Massimo Rollo

Diagnosis of traumatic carotid-cavernous sinus fistula by monitoring venous oxygen saturation in the jugular bulb: report of two cases.

OBJECTIVE AND IMPORTANCE A traumatic carotid-cavernous sinus fistula (CCF) is rarely diagnosed early and may sometimes be missed until clinical signs and symptoms appear. The continuous monitoring of cerebral venous oxygen saturation may reveal the presence of a CCF by means of a fiberoptic catheter that records very high oxygen saturation values when positioned in the jugular bulb. CLINICAL PRESENTATION We report two cases of early diagnosis of CCFs unexpectedly revealed by monitoring the jugular bulb for venous oxygen saturation values that approximated arterial saturation values. One case was diagnosed on Day 3 after admission, and the other was diagnosed shortly after cannulation of the ipsilateral jugular bulb. INTERVENTION Confirmation of the diagnosis of CCF was obtained by angiography. Intravascular treatment was performed in one case. CONCLUSION These cases add another diagnostic role to cerebral venous oxygen saturation monitoring. When high cerebral venous oxygen saturation values rapidly or abruptly reach arterial oxygen saturation, the presence of a CCF must be considered and confirmed by arterial angiography.

3D rotational angiography for the diagnosis and preoperative assessment of intracranial aneurysms: preliminary experience

PurposeThe aim of this study was to assess the value of the systematic use of 3D rotational angiography (3DRA) in the diagnosis and preoperative evaluation of cerebral aneurysms with a view to planning endovascular embolisation.Materials and methodsThirty-five consecutive aneurysms (20 incidental and 15 after subarachnoid haemorrhage) were studied and treated by means of 3DRA over a 1-year period. All rotational studies were conducted by selective cannulation of the vessel supplying the lesion (internal carotid artery or vertebral artery) with a single injection of 20 cc of contrast agent after diagnostic angiography in anterior-posterior (AP) and laterolateral (LL) views. Three-dimensional reconstructions were generated within a mean time of 5 min, and coil embolisation was performed on the basis of the 3D images.ResultsThree-dimensional RA enabled accurate definition of site, orientation, morphology and size of the sac and its relationship with the parent arteries and helped us choose the most appropriate angulation of the C-arm for guiding and controlling the embolisation procedure. Furthermore, the technique allowed us to detect six aneurysms for which conventional imaging had yielded equivocal results.ConclusionsBased on our experience before RA equipment became available and in agreement with the literature, we believe that 3DRA improves the identification of all lesions and helps refine the choice of the most suitable embolisation material and technique. Three-dimensional RA requires substantially fewer projections and thus reduces radiation dose and volume of contrast material to the patient. The use of 3DRA most likely results in a shorter procedure time and fewer risks and complications for the patient.RiassuntoObiettivoValutare l’utilità dell’impiego sistematico dell’angiografia rotazionale 3D (3DRA) nella diagnostica preliminare al trattamento endovascolare degli aneurismi cerebrali, ai fini della pianificazione della procedura.Materiali e metodiSono stati studiati e trattati consecutivamente 35 aneurismi (20 occasionali e 15 dopo emorragia subaracnoidea) con 3DRA in 32 pazienti in un anno. Lo studio rotazionale è stato sempre eseguito mediante cateterizzazione selettiva del vaso afferente (carotide interna o arteria vertebrale) con singola iniezione di 20 cc di MdC dopo angiografia diagnostica nelle due proiezioni ortogonali. Sono state effettuate ricostruzioni 3D con tempi di post-processing mediamente di 5 minuti, e sulla base di queste è stata eseguita l’embolizzazione con spirali.RisultatiMediante la 3DRA in ogni caso è stato possibile definire in maniera accurata la sede, l’orientamento, la morfologia e le dimensioni della sacca, il rapporto con i vasi parenti e la scelta dell’idonea angolazione dell’arco a C ai fini della guida e del controllo dell’embolizzazione. La tecnica ha permesso inoltre di individuare 6 aneurismi di dubbia interpretazione alla diagnostica tradizionale.ConclusioniIn base alla nostra esperienza precedente alla disponibilità di un angiografo rotazionale, e in accordo con i dati della letteratura, riteniamo che la 3DRA consenta di individuare con maggiore accuratezza tutte le lesioni e di scegliere con maggiore precisione il materiale più idoneo per la procedura, la tecnica di embolizzazione, nonché di ridurre sensibilmente il numero di proiezioni e quindi la dose di esposizione e di mdc al paziente, con una verosimile riduzione dei tempi di trattamento, dei rischi e delle complicanze.

Percutaneous vertebroplasty: optimizing the procedure after treatment of 250 vertebral levels under fluoroscopic guidance

PurposePercutaneous vertebroplasty (PVP) is a minimally invasive treatment for symptomatic vertebral compression fractures (VCFs). The aim of this study was to assess the effectiveness, complications and progress of results of PVP optimized in terms of technique, costs, time and strategic protocol after 3 years of procedures performed under fluoroscopic guidance alone.Materials and methodsWe treated 250 VCFs in 120 consecutive patients after assessing clinical and radiological indications. The effectiveness of the procedure was determined by statistical analysis of numerical scores for pain, mobility and drug consumption before and after treatment.ResultsNo major complications and only three minor complications occurred. Clinically relevant improved mobility and reduction of pain and analgesics were observed, with overall significant results (p<0.0001) in all patients at 24 h after PVP and in 83 available patients at 6 months. A total of five asymptomatic refractures of cemented vertebrae and 14 new symptomatic vertebral fractures at different levels were observed between 1 and 10 months after the procedure.ConclusionsPVP is a safe, rapid, effective and costeffective therapy for VCFs, requiring only brief hospital admission and with long-lasting clinical results, when performed under good-quality radiological guidance, when correct indications are respected and when it is associated with rehabilitation therapy in the follow-up. It is a valid alternative to conservative therapy, which is burdened by high healthcare costs and often requires long-term immobilisation of frail and elderly patients at risk of clinical complications.RiassuntoObiettivoLa vertebroplastica percutanea (VPP) è un trattamento mininvasivo per le fratture vertebrali sintomatiche da compressione (FVC). Scopo del presente lavoro è quello di valutare l’efficacia, le complicanze e la progressione dei risultati della VPP ottimizzata in termini di tecnica, costi, tempi e protocollo strategico dopo 3 anni di procedure effettuate sotto esclusiva guida fluoroscopica.Materiali e metodiSono state trattate 250 FVC in 120 pazienti consecutivi dopo valutazione delle indicazioni cliniche e radiologiche. L’efficacia della procedura è stata determinata attraverso l’analisi statistica di score numerici per il dolore, la mobilità e l’uso di farmaci antalgici prima e dopo il trattamento.RisultatiNon si sono verificate complicanze maggiori e solo 3 complicanze minori. È stato osservato un miglioramento della mobilità e riduzione del dolore e dell’uso di farmaci antalgici clinicamente rilevanti con risultati significativi (p<0,0001) in tutti i pazienti a 24 ore dalla VPP e, in 83 pazienti reperibili, a distanza di 6 mesi. Sono stati rilevati 5 nuovi cedimenti asintomatici in vertebre precedentemente trattate e 14 nuove fratture sintomatiche su livelli differenti da 1 a 10 mesi dopo la procedura.ConclusioniLa VPP costituisce un trattamento sicuro, rapido, efficace, poco costoso, che richiede solo un ricovero breve e con risultati clinici duraturi qualora sia impiegato un sistema di guida radiologica di buona qualità, siano rispettate le corrette indicazioni e venga associata una terapia riabilitativa nel follow-up. Rappresenta una valida alternativa alla terapia conservativa, quest’ultima gravata da elevati costi sanitari e che richiede spesso l’immobilizzazione prolungata di pazienti fragili e anziani, a rischio di complicanze cliniche.

Three-dimensional rotational angiography for craniotomy planning and postintervention evaluation of intracranial aneurysms

PurposeThe authors evaluated the usefulness of three-dimensional rotational angiography (3DRA) in surgical planning and postoperative evaluation of cerebral aneurysms.Materials and methodsA total of 111 consecutive aneurysms in 100 patients (32 emergency referrals due to haemorrhage) were evaluated with 3DRA over a period of 3 years. The rotational study was always performed with a single injection of 20 cc of contrast agent in the afferent vessel after diagnostic cerebral angiography in the two orthogonal projections. Three-dimensional reconstructions were obtained for the pre- and postoperative assessment.ResultsThree-dimensional RA provides a virtual view of the surgical field with the same orientation required for the surgical approach and, compared with surgical findings, reliably defined location, orientation, morphology and relationship with parent vessels of the aneurysm in all cases. Postoperatively, it allowed better assessment of any residual lesion and of the relationship between surgical clips and parent vessels, compared with standard 2D angiography.Conclusions3DRA is a reliable method for preliminary assessment of cerebral aneurysms undergoing surgery. It provides multiple projections with a preview of the surgical field and study of lesion characteristics, which can help achieve faster and safer surgery. Compared with 2D angiography, the 3D model, with its multiple views, allows better assessment of postoperative outcomes. The method also significantly reduces the number of angiographic projections and therefore radiation and contrast-medium dose to the patient.RiassuntoObiettivoScopo del presente lavoro è stato valutare l’utilità dell’angiografia rotazionale 3D (3DRA) per la pianificazione del trattamento chirurgico degli aneurismi cerebrali e per la valutazione post-operatoria.Materiali e metodiSono stati valutati 111 aneurismi con 3DRA in 100 pazienti (32 in urgenza dopo emorragia) in 3 anni. Lo studio rotazionale è stato sempre eseguito consingola iniezione di 20 cc di mezzo di contrasto (MdC) del vaso afferente alla lesione dopo panangiografia cerebrale diagnostica nelle due proiezioni ortogonali. Sono state cosÌ ottenute ricostruzioni 3D nel work-up pre- e postoperatorio.RisultatiLa 3DRA ha permesso la visualizzazione virtuale del campo operatorio con l’orientamento necessario per l’approccio chirurgico e, confrontata con i reperti chirurgici, in tutti i casi ha definito con estrema affidabilità la sede, l’orientamento, la morfologia e il rapporto con i vasi parenti dell’aneurisma. Nel post-operatorio, rispetto all’angiografia standard 2D, ha permesso una migliore valutazione di eventuali residui della lesione e dei rapporti delle clip chirurgiche con i vasi parenti.ConclusioniLa 3DRA è una metodica affidabile per la valutazione preliminare degli aneurismi cerebrali candidati ad intervento chirurgico in termini di previsualizzazione del campo operatorio e studio delle caratteristiche della lesione, utili per interventi più rapidi e sicuri. Rispetto all’angiografia 2D, grazie alla multiproiettività del modello 3D, permette una migliore valutazione degli esiti post-operatori. La metodica inoltre consente di ridurre significativamente il numero di proiezioni angiografiche e quindi la dose di esposizione e MdC al paziente.Purpose. The authors evaluated the usefulness of threedimensional rotational angiography (3DRA) in surgical planning and postoperative evaluation of cerebral aneurysms. Materials and methods. A total of 111 consecutive aneurysms in 100 patients (32 emergency referrals due to haemorrhage) were evaluated with 3DRA over a period of 3 years. The rotational study was always performed with a single injection of 20 cc of contrast agent in the afferent vessel after diagnostic cerebral angiography in the two orthogonal projections. Three-dimensional reconstructions were obtained for the pre- and postoperative assessment. Results. Three-dimensional RA provides a virtual view of the surgical field with the same orientation required for the surgical approach and, compared with surgical findings, reliably defined location, orientation, morphology and relationship with parent vessels of the aneurysm in all cases. Postoperatively, it allowed better assessment of any residual lesion and of the relationship between surgical clips and parent vessels, compared with standard 2D angiography. Conclusions. 3DRA is a reliable method for preliminary assessment of cerebral aneurysms undergoing surgery. It provides multiple projections with a preview of the surgical field and study of lesion characteristics, which can help achieve faster and safer surgery. Compared with 2D angiography, the 3D model, with its multiple views, allows better assessment of postoperative outcomes. The method

Utilizzo dell'angiografia rotazionale 3D per la strategia d'approccio chirurgico craniotomico e nel controllo post-operatorio degli aneurismi intracranici

PurposeThe authors evaluated the usefulness of three-dimensional rotational angiography (3DRA) in surgical planning and postoperative evaluation of cerebral aneurysms.Materials and methodsA total of 111 consecutive aneurysms in 100 patients (32 emergency referrals due to haemorrhage) were evaluated with 3DRA over a period of 3 years. The rotational study was always performed with a single injection of 20 cc of contrast agent in the afferent vessel after diagnostic cerebral angiography in the two orthogonal projections. Three-dimensional reconstructions were obtained for the pre- and postoperative assessment.ResultsThree-dimensional RA provides a virtual view of the surgical field with the same orientation required for the surgical approach and, compared with surgical findings, reliably defined location, orientation, morphology and relationship with parent vessels of the aneurysm in all cases. Postoperatively, it allowed better assessment of any residual lesion and of the relationship between surgical clips and parent vessels, compared with standard 2D angiography.Conclusions3DRA is a reliable method for preliminary assessment of cerebral aneurysms undergoing surgery. It provides multiple projections with a preview of the surgical field and study of lesion characteristics, which can help achieve faster and safer surgery. Compared with 2D angiography, the 3D model, with its multiple views, allows better assessment of postoperative outcomes. The method also significantly reduces the number of angiographic projections and therefore radiation and contrast-medium dose to the patient.RiassuntoObiettivoScopo del presente lavoro è stato valutare l’utilità dell’angiografia rotazionale 3D (3DRA) per la pianificazione del trattamento chirurgico degli aneurismi cerebrali e per la valutazione post-operatoria.Materiali e metodiSono stati valutati 111 aneurismi con 3DRA in 100 pazienti (32 in urgenza dopo emorragia) in 3 anni. Lo studio rotazionale è stato sempre eseguito consingola iniezione di 20 cc di mezzo di contrasto (MdC) del vaso afferente alla lesione dopo panangiografia cerebrale diagnostica nelle due proiezioni ortogonali. Sono state cosÌ ottenute ricostruzioni 3D nel work-up pre- e postoperatorio.RisultatiLa 3DRA ha permesso la visualizzazione virtuale del campo operatorio con l’orientamento necessario per l’approccio chirurgico e, confrontata con i reperti chirurgici, in tutti i casi ha definito con estrema affidabilità la sede, l’orientamento, la morfologia e il rapporto con i vasi parenti dell’aneurisma. Nel post-operatorio, rispetto all’angiografia standard 2D, ha permesso una migliore valutazione di eventuali residui della lesione e dei rapporti delle clip chirurgiche con i vasi parenti.ConclusioniLa 3DRA è una metodica affidabile per la valutazione preliminare degli aneurismi cerebrali candidati ad intervento chirurgico in termini di previsualizzazione del campo operatorio e studio delle caratteristiche della lesione, utili per interventi più rapidi e sicuri. Rispetto all’angiografia 2D, grazie alla multiproiettività del modello 3D, permette una migliore valutazione degli esiti post-operatori. La metodica inoltre consente di ridurre significativamente il numero di proiezioni angiografiche e quindi la dose di esposizione e MdC al paziente.Purpose. The authors evaluated the usefulness of threedimensional rotational angiography (3DRA) in surgical planning and postoperative evaluation of cerebral aneurysms. Materials and methods. A total of 111 consecutive aneurysms in 100 patients (32 emergency referrals due to haemorrhage) were evaluated with 3DRA over a period of 3 years. The rotational study was always performed with a single injection of 20 cc of contrast agent in the afferent vessel after diagnostic cerebral angiography in the two orthogonal projections. Three-dimensional reconstructions were obtained for the pre- and postoperative assessment. Results. Three-dimensional RA provides a virtual view of the surgical field with the same orientation required for the surgical approach and, compared with surgical findings, reliably defined location, orientation, morphology and relationship with parent vessels of the aneurysm in all cases. Postoperatively, it allowed better assessment of any residual lesion and of the relationship between surgical clips and parent vessels, compared with standard 2D angiography. Conclusions. 3DRA is a reliable method for preliminary assessment of cerebral aneurysms undergoing surgery. It provides multiple projections with a preview of the surgical field and study of lesion characteristics, which can help achieve faster and safer surgery. Compared with 2D angiography, the 3D model, with its multiple views, allows better assessment of postoperative outcomes. The method

Three-dimensional rotational angiography for craniotomy planning and postintervention evaluation of intracranial aneurysms Utilizzo dell'angiografia rotazionale 3D per la strategia d'approccio chirurgico craniotomico e nel controllo post-operatorio degli aneurismi intracranici

PurposeThe authors evaluated the usefulness of three-dimensional rotational angiography (3DRA) in surgical planning and postoperative evaluation of cerebral aneurysms.Materials and methodsA total of 111 consecutive aneurysms in 100 patients (32 emergency referrals due to haemorrhage) were evaluated with 3DRA over a period of 3 years. The rotational study was always performed with a single injection of 20 cc of contrast agent in the afferent vessel after diagnostic cerebral angiography in the two orthogonal projections. Three-dimensional reconstructions were obtained for the pre- and postoperative assessment.ResultsThree-dimensional RA provides a virtual view of the surgical field with the same orientation required for the surgical approach and, compared with surgical findings, reliably defined location, orientation, morphology and relationship with parent vessels of the aneurysm in all cases. Postoperatively, it allowed better assessment of any residual lesion and of the relationship between surgical clips and parent vessels, compared with standard 2D angiography.Conclusions3DRA is a reliable method for preliminary assessment of cerebral aneurysms undergoing surgery. It provides multiple projections with a preview of the surgical field and study of lesion characteristics, which can help achieve faster and safer surgery. Compared with 2D angiography, the 3D model, with its multiple views, allows better assessment of postoperative outcomes. The method also significantly reduces the number of angiographic projections and therefore radiation and contrast-medium dose to the patient.RiassuntoObiettivoScopo del presente lavoro è stato valutare l’utilità dell’angiografia rotazionale 3D (3DRA) per la pianificazione del trattamento chirurgico degli aneurismi cerebrali e per la valutazione post-operatoria.Materiali e metodiSono stati valutati 111 aneurismi con 3DRA in 100 pazienti (32 in urgenza dopo emorragia) in 3 anni. Lo studio rotazionale è stato sempre eseguito consingola iniezione di 20 cc di mezzo di contrasto (MdC) del vaso afferente alla lesione dopo panangiografia cerebrale diagnostica nelle due proiezioni ortogonali. Sono state cosÌ ottenute ricostruzioni 3D nel work-up pre- e postoperatorio.RisultatiLa 3DRA ha permesso la visualizzazione virtuale del campo operatorio con l’orientamento necessario per l’approccio chirurgico e, confrontata con i reperti chirurgici, in tutti i casi ha definito con estrema affidabilità la sede, l’orientamento, la morfologia e il rapporto con i vasi parenti dell’aneurisma. Nel post-operatorio, rispetto all’angiografia standard 2D, ha permesso una migliore valutazione di eventuali residui della lesione e dei rapporti delle clip chirurgiche con i vasi parenti.ConclusioniLa 3DRA è una metodica affidabile per la valutazione preliminare degli aneurismi cerebrali candidati ad intervento chirurgico in termini di previsualizzazione del campo operatorio e studio delle caratteristiche della lesione, utili per interventi più rapidi e sicuri. Rispetto all’angiografia 2D, grazie alla multiproiettività del modello 3D, permette una migliore valutazione degli esiti post-operatori. La metodica inoltre consente di ridurre significativamente il numero di proiezioni angiografiche e quindi la dose di esposizione e MdC al paziente.Purpose. The authors evaluated the usefulness of threedimensional rotational angiography (3DRA) in surgical planning and postoperative evaluation of cerebral aneurysms. Materials and methods. A total of 111 consecutive aneurysms in 100 patients (32 emergency referrals due to haemorrhage) were evaluated with 3DRA over a period of 3 years. The rotational study was always performed with a single injection of 20 cc of contrast agent in the afferent vessel after diagnostic cerebral angiography in the two orthogonal projections. Three-dimensional reconstructions were obtained for the pre- and postoperative assessment. Results. Three-dimensional RA provides a virtual view of the surgical field with the same orientation required for the surgical approach and, compared with surgical findings, reliably defined location, orientation, morphology and relationship with parent vessels of the aneurysm in all cases. Postoperatively, it allowed better assessment of any residual lesion and of the relationship between surgical clips and parent vessels, compared with standard 2D angiography. Conclusions. 3DRA is a reliable method for preliminary assessment of cerebral aneurysms undergoing surgery. It provides multiple projections with a preview of the surgical field and study of lesion characteristics, which can help achieve faster and safer surgery. Compared with 2D angiography, the 3D model, with its multiple views, allows better assessment of postoperative outcomes. The method

The Neuroradiological Approach to Patients in Coma

Coma is rightly considered to be the one of the most commonly occurring neurological emergency conditions. Coma can be the consequence of an entire spectrum of pathological conditions and thus requires equally varied but quite specific treatment (8, 15, 16). Neuroradiological studies are often the only real practical option for initial diagnostic patient investigation, as the clinician may have access to little or no information when the patient is admitted. In such situations, it is almost always Computed Tomography (CT) that assumes the leading role in the initial diagnostic, prognostic and therapeutic approach. The fundamental question is whether or not there are documentable intracranial neuroanatomical alterations, which, if present, can be subsequently monitored after the patient is admitted to the intensive care suite. We will not deal in detail here with the entire spectrum of the intracranial pathology responsible for causing coma, as they are dealt with separately in the various chapters of this volume; instead, we will briefly outline the optimal neuroradiological approach to be utilized in patients in coma including: a) the modes of investigation; b) the related technical variables; c) conditions causing acute focal lesions (9), and d) conditions causing diffuse brain impairment.