Riitta Rautio

Wide-necked intracranial aneurysms: treatment with stent-assisted coil embolization during acute (<72 hours) subarachnoid hemorrhage--experience in 61 consecutive patients.

PURPOSE To evaluate the safety and efficacy of stent-assisted embolization of ruptured wide-necked intracranial aneurysms during acute subarachnoid hemorrhage (SAH). MATERIALS AND METHODS Institutional review board approval for this retrospective study was obtained; the need to obtain informed consent was waived. Results in 61 consecutive patients (20 men, 41 women; mean age, 55.1 years; range, 26-83 years) with acutely ruptured wide-necked intracranial aneurysms who were treated with stent-assisted coil embolization were evaluated. The mean length of angiographic follow-up was 12.1 months (range, 0-52 months). Statistical analysis was performed to determine whether the features of the patient and the ruptured aneurysm affected the primary angiographic result or the patients clinical outcome. Categoric and dichotomous variables were examined with the chi(2) test or the Fisher exact test; the Mann-Whitney U test and Kruskal-Wallis one-way analysis were used to compare continuous-scale data for non-normally distributed variables. RESULTS The technical success rate was 72% (44 of 61). The technique-related complication rate was 21% (13 of 61), and the 30-day mortality rate was 20% (12 of 61). There was only one case of rebleeding, and clinical outcome was good for the majority of the patients (69% [42 of 61] had Glasgow Outcome Scale scores of 4 or 5 at the end of the study period). CONCLUSION Stent-assisted coil embolization is a feasible method for the endovascular treatment of wide-necked intracranial aneurysms that are difficult to treat surgically or with balloon-assisted embolization during acute SAH. The risk of subsequent rerupture of the aneurysm seems to be reduced for aneurysms treated early compared with that for nonsecured aneurysms.

Treatment of Lymphangiomas with OK-432 (Picibanil)

Purpose: To determine the efficacy of OK-432 sclerotherapy in the treatment of lymphangiomas. Methods: The treatment was begun for 14 patients with lymphangioma. The age range of the patients at the time of the first injection was from 10 months to 42 years. Eleven of the lesions involved the head and neck region, two the thorax and one was localized in the extremity. Prior to treatment all patients were investigated with either magnetic resonance imaging, computed tomography, ultrasound or a combination of these modalities. The injections were performed with ultrasound and/or fluoroscopic guidance. Eight patients received OK-432 as first-line treatment; five were treated after surgery and one after medical therapy. On average, 2.2 intracystic injections were performed per patient. Nine of the lesions were macrocystic and five were mixed lesions. Results: Eleven patients showed complete or marked response to the OK-432 sclerotherapy, two patients had moderate shrinkage of their lesions and only one patient showed no response to therapy. Macrocystic lesions showed the best response to therapy. Those patients who received OK-432 as first-line treatment showed complete or marked response. Conclusion: It was found that treatment of lymphangiomas with OK-432 was safe and effective.

OK-432 (Picibanil) therapy for lymphangiomas in children.

Abstract Lymphangiomas are benign, soft tumors that most often affect the head and neck area, usually causing marked cosmetic and functional problems. Treatment options include surgery and a large number of different sclerotherapy agents. Surgical treatment is challenging because of the need for complete excision. The risk of damage to surrounding structures or poor cosmetic results is high. Various sclerotherapy agents have been shown to have minimal effects on lymphangiomas. Their use has been associated with severe systemic, local and cosmetic side effects. OK-432 (Picibanil) is a new and promising form of sclerotherapy. An intracystic injection of OK-432 produces a local inflammatory reaction, which leads to resolution of the lesion. We have treated 11 pediatric lymphangioma patients with OK-432 with excellent results: complete regression in six, marked regression in four and no response in one case. Local swelling should be anticipated, especially when treating lesions near the upper airway. We found OK-432 injections to be safe and effective as a first line of treatment for lymphangiomas.

Primary Treatment of Ruptured Blood Blister-Like Aneurysms with Stent-Assisted Coil Embolization: Report of Two Cases

Blood blister-like aneurysms (BBAs) are among the most hazardous cerebrovascular aneurysms to treat; microsurgical treatment of these small, wide-necked, and exceptionally fragile aneurysms place patients at significant risk of morbidity or mortality. We report two cases of ruptured BBAs attempted to be treated for the first time with stent-assisted coil embolization solely and review the current literature on treatment options. Our patients underwent stent-assisted coil embolization of the aneurysms in the acute stage of subarachnoid hemorrhage (SAH). One patient was successfully treated without procedure-related complications. The other patient died after surgical internal carotid artery (ICA) occlusion, carried out after intraoperative rerupture of the aneurysm during the endovascular treatment. In the successful case, 8-month and 19-month follow-up angiograms demonstrated incomplete (>90%) occlusion with residual filling of the aneurysm neck, which did not need additional coil embolization. Even though stent-assisted coil embolization of ruptured BBAs in the acute stage appears to be a technically feasible treatment option, the present stent-related endovascular technology has potentially hazardous drawbacks.

Endovascular Treatment of Venous Malformations in Extremities: Results of Sclerotherapy and the Quality of Life after Treatment

Purpose: To evaluate the long‐term results of endovascular sclerotherapy in treating venous extremity malformations and to assess the quality of life after treatment. Material and Methods: Twenty‐four patients were included who had completed treatment with ethanol sclerotherapy and a minimum of one year observation period. Nineteen patients attended a clinical control. To evaluate the quality of life after treatment, 23 patients filled in a questionnaire which included 20 multiple‐choice questions exploring four dimensions: psychological, physical and social functioning, and pain. Results: At the clinical control seven patients had no clinical symptoms related to the malformation, six had slight, four moderate, and two severe symptoms. In 16 patients the symptoms had diminished after treatment. No deterioration of the initial situation was observed. The results concerning quality of life showed that most patients did well after endovascular treatment. Pain was the most important injurious factor for state of health among the four different dimensions. The poorest outcome was found in malformations that filled the whole muscle or muscle compartment and in larger lesions. The patients whose malformation at the clinical control caused swelling to the extremity affected had poorer quality indices than others. Conclusion: Endovascular treatment for venous malformations is an effective treatment.

Long-term results and quality of life after endovascular treatment of venous malformations in the face and neck

Purpose: To evaluate the long-term results of endovascular sclerotherapy in treating venous and venocapillary malformations of the face and neck region, and to assess the quality of life after treatment. Material and Methods: Twenty consecutive patients with endovascularly treated venous and capillary-venous malformation of the face and neck were invited to attend for clinical control and magnetic resonance (MR) imaging. To evaluate the quality of life after treatment, patients were asked to fill in a questionnaire which included 20 multiple-choice questions exploring 4 dimensions: psychological, physical, and social functioning, and pain. Results: In 14 patients, symptoms and MR findings improved, while in 6 patients there was no improvement. Results concerning quality of life showed that most patients did well after endovascular treatment. Patients with venous malformations of the tongue had a worse outcome. Patients under the age of 16 at the beginning of the treatment and patients clinically followed by physicians specialized in vascular malformations had a better quality of life. Conclusion: Endovascular treatment for venous malformations is effective. Results and quality of life proved to be better when the endovascular treatment was begun before puberty and the patients had regular clinical controls after therapy.

Transcatheter Embolization of a Renal Artery Aneurysm Using Ethylene Vinyl Alcohol Copolymer

Our aim was to treat a clinically silent renal artery aneurysm. The patient was a 76-year-old man with elevated prostate-specific antigen and prostata biopsies with a gradus II–III adenocarcinoma who was incidentally found to have an aneurysm in his right renal artery. We performed a successful transcatheter embolization of the aneurysm using ethylene vinyl alcohol copolymer (Onyx). To avoid migration of the liquid material into the parent artery, a balloon was inflated in the orifice of the neck of the aneurysm while the liquid was injected. Five-month follow-up computed tomography (CT) imaging confirmed total occlusion of the aneurysm.

Quality of life after endovascular sclerotherapy of low-flow venous malformations: the efficacy of polidocanol compared with ethanol

Background Limited information is available on mid-term results and quality of life (QOL) after endovascular sclerotherapy of venous malformations. Purpose To compare two agents—polidocanol and ethanol—with a focus on the influence on QOL after sclerotherapy. Material and Methods Forty-one consecutive patients with a venous malformation in the head and neck area or in the extremities were treated with polidocanol between 2008 and 2013. Pre- and post-treatment magnetic resonance imaging (MRI) scans were compared. All patients completed a self-evaluation form on symptoms as well as a QOL questionnaire. The results were compared with previously obtained material during 1991–2001, comprising 44 consecutive, similarly located venous malformation patients subject to ethanol sclerotherapy. Results No significant clinical complications were observed. Subjectively, 19 (46%) of the patients benefitted from the treatment. QOL results showed that 85% of patients had an index < 39 – where 0 represents the highest and 100 the lowest QOL. Patients in the ethanol group had marginally better overall post-treatment QOL results. Post-treatment MRI in 35 patients showed the size of the malformation unchanged in 19 (54%) patients, in ten (29%) there was a decrease (<50%) while in six (17%) the decrease was more significant (>50%). Post-treatment MRI results did not correlate with either subjective symptoms or QOL results. Conclusion Polidocanol sclerotherapy were found to be an effective, safe, and well tolerated treatment option for low flow venous malformations. Routine MRI for follow-up appears redundant and may be omitted.

Left cerebral hemisphere hydrophilic polymer embolism associated with endovascular WEB treatment of a ruptured aneurysm of the anterior cerebral artery

Hydrophilic polymer embolism (HPE) is a rare, likely under-recognized iatrogenic complication, caused by fragmentation of surface materials used on endovascular medical devices. The organs most often involved in HPE are the brain and lungs, resulting in both local and systemic reactions. We present the case of a cerebral HPE associated with WEB treatment of a ruptured aneurysm of the anterior cerebral artery, and involving diffusely the left cerebral hemisphere. The patient developed pneumonia and status epilepticus, and died 24 days after the endovascular procedure, most likely as a result of the sequelae of the aneurysm rupture. The precise role of HPE in the sequence of events leading to death can remain, as in this case, a matter for speculation. However, the potential role of HPE in the events leading to death following diagnostic and therapeutic procedures should be appropriately assessed, especially when recovery does not progress as expected.

Single-center experience with six-month follow-up of FRED Jr® flow diverters for intracranial aneurysms in small arteries

Background The flow-diverter stent (FD) has been proven to be a safe and efficient device in the treatment of large and giant wide-necked proximal internal carotid artery aneurysms. Purpose To report the outcomes using Flow Re-Direction Endoluminal Device Junior (Fred Jr) flow diverters in the treatment of aneurysms in or distal to the circle of Willis with parent artery diameter < 2.5 mm. Material and Methods All electively treated aneurysms with this FD at our institution between September 2015 and December 2016 were retrospectively reviewed. Technical issues, immediate and follow-up radiological findings, and clinical outcomes were assessed. Fifteen patients with 15 aneurysms were included in the study. Results No technical difficulties or complications were encountered during the FD procedure. No FD-related post-procedural complications or mortality occurred. The patients were discharged with unaltered National Institute of Health Stroke Scale (NIHSS) or modified Ranking Scale (mRS). Complete occlusion was reached in 13/15 aneurysms (87%) as assessed from the most recent radiological follow-up (6–24 months). Conclusion Our preliminary results show that the device worked technically well with no complications for aneurysms located on small intracranial arteries. The occlusion rates are comparable to those of other FDs that have been used in small arteries. The device offers a good choice in treating aneurysms that are unmanageable with conventional endovascular techniques or surgery.