L. Thines

Management and clinical outcome of posterior fossa arteriovenous malformations: report on a single-centre 15-year experience

Objectives: Posterior fossa brain arteriovenous malformations (PFbAVMs) are rare lesions. Management is complicated by eloquence of adjacent neurological structures, multimodality treatment is often necessary, and obliteration is not always possible. We describe a 15-year experience in the management of posterior fossa brain AVMs with a focus on clinical outcome. Methods: From 1989 to 2004, prospectively collected information on 106 patients with diagnosis of a PFbAVMs was obtained. Clinical and angioarchitectural characteristics, management options and complications are described and reviewed to evaluate their impact on final outcome as measured by the Modified Rankin Score (mRS). Results: Ninety-eight patients were followed for an average of 3.3 years (1–14.6). The male-to-female ratio was 1:1. Ninety-five out of 98 patients (96.9%) were symptomatic at presentation, with 61 (62.2%) intracranial haemorrhages. Sixty-two patients were treated (46 cerebellar, 16 brainstem). Ten haemorrhages occurred in follow-up (4.1%/year). The mRS was obtained in 62 patients and was classified as low (good, mRS⩽2) or high (poor, mRS⩾3). Haemorrhage was the only predictor of poor mRS at presentation (pu200a=u200a0.0229). A poor clinical outcome was correlated with the presence of AA (pu200a=u200a0.0276), a poor initial mRS (p<0.0001) and the number of treatments needed (pu200a=u200a0.0434). Patients were significantly more likely to improve than to deteriorate over time (pu200a=u200a0.0201). Conclusion: The final clinical outcome in PFbAVMs relates directly with the presence of associated aneurysms, number of treatments needed to obliterate the AVM and mRS at presentation. Despite the fact that patients tend to improve after brain AVM haemorrhage, the relationship of MRS at presentation and final outcome suggests that an expedited, more definitive treatment is probably a better choice, especially in patients with good grades after the initial bleeding.

Postoperative assessment of clipped aneurysms with 64-slice computerized tomography angiography.

BACKGROUNDMultidetector computerized tomography angiography (MDCTA) is now a widely accepted technique for the management of intracranial aneurysms. OBJECTIVETo evaluate its accuracy for the postoperative assessment of clipped intracranial aneurysms. METHODSWe analyzed a consecutive series of 31 patients that underwent direct surgical clipping procedures of 38 aneurysms. A 64 slice MDCT scanner (Aquilion 64, Toshiba) was used and results were compared with digital subtraction angiographies (DSA). Two independent neuroradiologists analyzed the following data: examination quality, artifacts, aneurysm remnant, and patency of collateral branches. Interobserver agreement, sensitivity, and specificity were calculated. RESULTSSeventy-nine percent of the aneurysms were located in the anterior circulation. Significant artifacts were found with multiple and cobalt-alloy clips. According to DSA, remnants >2 mm were found in 21% of the cases, and 2 patients had one collateral branch occluded. Sensitivity and specificity of 64-MDCTA for the detection of aneurysm remnants were 50% and 100%, respectively. Sensitivity and specificity of 64-MDCTA for the detection of a significant remnant (>2 mm) and the detection of the occlusion of a collateral branch were, respectively, 67% and 100% and 50% and 100%. No relationship was found with the location, type, shape, size, or number of clips, but missed remnants tended to be larger with cobalt-alloy clips. CONCLUSIONS64-MDCTA is a valuable technique to assess the presence of a significant postoperative remnant in single titanium clip application cases and might be useful for long-term follow-up. DSA remains the most accurate postoperative radiological examination.

Direct imaging of the distal dural ring and paraclinoid internal carotid artery aneurysms with high-resolution T2 turbo-spin echo technique at 3-T magnetic resonance imaging.

OBJECTIVETo evaluate the feasibility of the direct visualization of the distal dural ring (DDR) and adjacent anatomic structures in patients with paraclinoid internal carotid artery aneurysms at 3-T magnetic resonance imaging (MRI). METHODSSix consecutive patients (1 man, 5 women; mean age, 45.5 years; age range, 34–51 years) who underwent a 3-T MRI examination for the evaluation of 7 paraclinoid carotid artery aneurysms were reviewed retrospectively. MRI scans were acquired using a T2 turbo-spin echo sequence with 2-mm thickness without gap on the coronal plane perpendicular to the diaphragma sellae. Identifications of the DDR, adjacent regional anatomic landmarks, and paraclinoid aneurysms were analyzed. The locations of the paraclinoid aneurysms were categorized into intradural (aneurysm neck and sac located above the DDR), transdural (aneurysm neck or sac were straddling the DDR), and extradural (aneurysm neck and sac located below the DDR). Interstudy agreement between computed tomographic angiography and 3-T MRI for the anatomic location of the paraclinoid aneurysms was assessed in 6 patients who underwent both examinations. RESULTSIn all cases, the DDR was clearly identified and the relationship between the DDR and the paraclinoid aneurysm was successfully determined on 3-T MRI. The aneurysm locations determined with 3-T MRI were 4 intradural and 3 extradural. A comparison between computed tomographic angiography and 3-T MRI revealed discordant anatomic locations in 3 aneurysms (3 of 6, 50%). CONCLUSIONDirect visualization of the DDR as well as precise evaluation of paraclinoid aneurysm location with high-resolution 3-T MRI is possible. This study shows that high-resolution 3-T MRI is an important means to determine the appropriate management for patients with paraclinoid aneurysms.

Assessment of extracranial–intracranial bypass patency with 64-slice multidetector computerized tomography angiography

IntroductionExtracranial–intracranial (EC/IC) bypass is a useful procedure for the treatment of cerebral vascular insufficiency or complex aneurysms. We explored the role of multidetector computed tomography angiography (MDCTA), instead of digital subtraction angiography (DSA), for the postoperative assessment of EC/IC bypass patency.MethodsWe retrospectively analyzed a consecutive series of 21 MDCTAs from 17 patients that underwent 25 direct or indirect EC/IC bypass procedures between April 2003 and November 2007. Conventional DSA was available for comparison in 13 cases. MDCTA used a 64-slice MDCT scanner (Aquilion 64, Toshiba). The proximal and distal patencies were analyzed independently on MDCTA and DSA by a neuroradiologist and a neurosurgeon. The bypass was considered patent when the entire donor vessel was opacified without discontinuity from proximal to distal ends and was visibly in contact with the recipient vessel.ResultsMDCTA depicted the patency status in every patient. Bypasses were patent in 22 cases, stenosed in one, and occluded in two. DSA always confirmed the results of the MDCTA (sensitivityu2009=u2009100%, 95% CIu2009=u20090.655–1.0; specificity 100%, 95% CIu2009=u20090.05–1.0).ConclusionsMDCTA is a non-invasive and accurate exam to assess the postoperative EC/IC bypass patency and is a promising technique in routine follow-up.

Multidisciplinary management of intracranial aneurysms: The experience of Lille university hospital center

BACKGROUNDnIn recent years, the multidisciplinary approach has become an important concern for the management of intracranial aneurysms.nnnOBJECTIVEnThis study aims to evaluate the functional outcomes of patients treated for an intracranial aneurysm (ruptured or unruptured), when the treatment modality was defined in a multidisciplinary fashion.nnnMATERIALS AND METHODSnIn this retrospective study, we included all patients (n=209) treated for an intracranial saccular aneurysm at Lille university hospital between January 2009 and December 2009. There were 70 men and 139 women with a mean age of 50.5 years (range 24 to 73 years). The clinical data were recorded before treatment including the American Society of Anesthesiology (ASA) and the World Federation of Neurosurgical Societies (WFNS) scores. Microsurgical approach was performed in 110 patients whereas 99 patients underwent an endovascular procedure. A modified Rankin Scale (mRS) was reported at 3 months after treatment. Intracranial vascular imaging was performed before and immediately after the treatment and then renewed at 3 years in all patients to detect any recurrence.nnnRESULTSnAmong the 121 patients with ruptured aneurysm, the functional outcomes were similar between patients who underwent microsurgery and patients who had an endovascular treatment. In the 88 patients with an unruptured aneurysm, functional outcomes were also similar between the two treatment modalities. Among the 99 patients treated by the endovascular approach, 4 had a significant aneurysm reopening on follow-up imaging leading to additional treatment (3 clipping, 1 coiling). No aneurysm recurrence was reported among the 110 patients who underwent microsurgical treatment.nnnCONCLUSIONnIn a trained team, the multidisciplinary approach appears to be a valuable strategy in the management of intracranial aneurysms, to achieve good functional outcomes.

Compression optochiasmatique par un clip refoulé par une hydrocéphalie chronique après traitement chirurgical d’un anévrisme rompu de l’artère communicante antérieure

Chronic hydrocephalus is a classic and recognized complication that affects 6 to 37% of patients with aneurysmal subarachnoid haemorrhage. The diagnosis is often mentioned due to the delayed onset of gait disturbance and slower psychomotor performance. The CT-scan confirms the diagnosis by showing an enlargement of the ventricles. In case of symptomatic hydrocephalus, a ventriculo-peritoneal shunt is often required. The authors report a rare case of chronic hydrocephalus presenting with visual symptoms, due to the delayed mobilisation of a surgical clip with direct mass effect over the anterior optic pathways. The treatment of hydrocephalus led to a rapid and complete regression of symptoms.

Intrasellar Rupture of a Paraclinoid Aneurysm With Subarachnoid Hemorrhage: Usefulness of MR Imaging in Diagnosis

SUMMARY: Characterization of paraclinoid aneurysms may be difficult because of the complexity of anatomic structures involved, and differentiation between intradural and extradural lesions is crucial. We report a case of a patient with a unique presentation of a paraclinoid aneurysm with intrasellar hemorrhage in which the presence of intrasellar blood and the relationship of the paraclinoid aneurysmal neck and sac to the dural rings were elegantly demonstrated on MR imaging and were critical in choosing the target lesion for treatment.

Selective microsurgical treatment of giant intracranial aneurysms.

Giant intracranial aneurysms are defined as greater than 25mm in diameter. They share the same surgical challenges and strategies as so-called complex aneurysms, sometimes smaller in size but presenting with similar complex anatomy. The surgical difficulties arise from the size of the sack, the presence of intraluminal thrombus, the thickness of the arterial wall, and the complexity of arterial branching on the neck. Preoperative imaging gathers complementary information from magnetic resonance imaging, computed tomographic angiography, and rotational catheter-based angiography with three-dimensional reconstruction including balloon-test occlusion. The therapeutic decision-making needs a multidisciplinary approach including endovascular, neurosurgical and anesthesiological expertises. The microsurgical treatment needs a step-by-step preoperative planning with anticipation of possible pitfalls and alternative strategies. Classical principles of aneurysm surgery have to be tailored to face the difficulties arising from the size of the sack and from the arterial wall calcifications.