Stefan Brew

Endovascular Coil Occlusion of 1811 Intracranial Aneurysms: Early Angiographic and Clinical Results

OBJECTIVEWe sought to evaluate the early angiographic and clinical outcomes of the first session of endovascular coil occlusion of a large number of patients with intracranial aneurysms treated by five neurointerventionalists during a decade at a single center. METHODSWe performed retrospective analyses of pre- and postprocedural angiographic studies and early clinical outcomes. Enrolled patients underwent endovascular treatment of intracranial aneurysms with detachable coils. RESULTSA total of 1811 aneurysms in 1579 patients were treated with coil occlusion. Of these, 90 to 100% occlusion of 86.5% of the aneurysms was achieved. In 82.3% of the procedures, no complications occurred. The clinical outcome profile at primary discharge according to the Glasgow Outcome Scale was as follows: Grade V, 74.6%; Grade IV, 6.7%; Grade III, 11.1%; Grade II, 3.1%; and Grade I, 4.5%. In patients with large aneurysms with wide necks, a lower occlusion rate and an increased complication rate were encountered. The use of three-dimensional and fibered coils resulted in higher occlusion rates. Balloon remodeling and stent deployment increased the complication rate. Previous aneurysm rupture, procedural complications, and vasospasm correlated with poor outcome. Of the patients in poor grade after aneurysm rupture, 42% recovered to Glasgow Outcome Scale Grade IV or V, as opposed to 90% of patients who were treated for unruptured aneurysms. The ischemic complication rate was 9%, and the hemorrhagic complication rate was 3%. The early procedural morbidity rate was 5.3%, and the procedural mortality rate was 1.5%. The management mortality rate was 4.4%. CONCLUSIONThese data confirm the safety and efficacy of endovascular coil occlusion for patients with intracranial aneurysms.

Treatment of extracranial and intracranial aneurysms and arteriovenous fistulae using stent grafts.

OBJECTIVE:Treatment of 11 patients with aneurysms or arteriovenous fistulae of the craniocervical arteries with stent grafts. METHODS:Peripheral stent grafts were deployed in two extracranial internal carotid arteries. Coronary stent grafts were used to treat two giant aneurysms, five direct carotid-cavernous fistulae, one vertebrojugular fistula, and two dissecting aneurysms of the vertebral artery (V2 and V4). RESULTS:Stent grafts were used successfully in two extracranial internal carotid and two extracranial vertebral arteries, one dissecting aneurysm of the intracranial vertebral artery, one giant aneurysm and one pseudoaneurysm of the cavernous internal carotid artery, and five direct carotid-cavernous sinus fistulae. Angiographic follow-up examinations (available in nine patients; obtained at 3 mo to 5 yr; average, 24 mo) revealed normal vessel caliber, and the stent grafts in all 9 of 11 initial patients were patent. There was a recurrent saccular aneurysm adjacent to the stent graft in the patient with the intracranial vertebral artery aneurysm. The following five complications were encountered: transient hemiparesis (n = 2), increased hemiparesis, post-procedural management-related fatality, and ICA dissection. In six patients, stent graft deployment was accomplished without any technical or clinical complication. There were no permanent neurological deficits consequent to stent graft placement. CONCLUSION:Stent grafts are a useful tool for the endovascular treatment of head and neck aneurysms and direct arteriovenous fistulae in selected patients. The major disadvantage of the currently available stent grafts is their lack of mechanical flexibility. Maneuvering stent grafts in the intracranial arteries carries the risk of iatrogenic vessel dissection and may require supportive measures and protection of the target site by conventional stents.

Efficacy and Complications of Super-selective Intra-ophthalmic Artery Melphalan for the Treatment of Refractory Retinoblastoma

PURPOSE To report the efficacy of super-selective intra-ophthalmic artery melphalan (IAM) for the treatment of refractory retinoblastoma and any associated complications of this treatment. DESIGN A prospective case series. PARTICIPANTS Eyes with retinoblastoma that had been treated with systemic chemotherapy or local therapy and had a relapse of their condition. METHODS All patients receiving IAM between May 2009 and September 2010 were included in the study. Intra-ophthalmic artery melphalan was offered to patients who had failed to respond adequately to systemic chemotherapy and local treatment where appropriate or because of a new recurrence of retinoblastoma that could not be treated with local therapies. None of the patients were excluded because of central nervous system abnormalities. Patients received 2 treatments of IAM given 4 weeks apart. All patients received an orthoptic assessment 3 weeks after each treatment and an examination under anesthesia (EUA). A third treatment was given if an unsatisfactory response was observed on EUA after 2 treatments. MAIN OUTCOME MEASURES The response of the retinoblastoma tumor(s) and any associated local side effects from the treatment. RESULTS A total of 15 eyes in 14 patients were treated with IAM during the study period. The mean age at the time of IAM was 31.5 months (median 17.3, range 11.2-150.7 months), and the mean follow-up was 8.7 months (3-16.3 months). Tumor control was achieved in 12 eyes (80%), and 12 eyes (80%) had local side effects that included third cranial nerve palsy in 6 (40%), orbital edema in 3 (20%), permanent retinal detachment in 1 (7%), and vitreous hemorrhage in 4 (27%). Seven eyes (47%) developed significant retinal pigment epithelium changes. CONCLUSIONS Intra-ophthalmic artery melphalan is an effective treatment for retinoblastoma, achieving a high level of remission in refractory tumors. It can be associated with significant local side effects that can result in loss of vision and possible amblyogenesis. Clinicians and parents need to consider the benefits and potential local side effects before embarking on treatment.

Management and outcome of vein of Galen malformation

Objective To describe our experience of treating children with vein of Galen aneurysmal malformation (VGM) in a single UK centre between 2003 and 2008. Method Retrospective review of case notes and neuroimaging. Results 33 children were seen (26 neonates, seven infants), of whom 28 underwent endovascular treatment. Four were not offered treatment as they had evidence of severe diffuse brain injury at presentation; treatment was deferred in another who subsequently died. Seven children died (two of whom had endovascular treatment). Of the survivors (all treated), 13 (39%) are neurodevelopmentally intact, seven (21%) have mild neurodevelopmental impairment and the remaining six (18%) have significant neurological impairment. The authors were not able to identify clinical or radiological parameters which strongly predicted outcome. Of note, two children with initially low Bicêtre scores were neurologically intact after successful embolisation. Conclusion The outlook for children with VGM is significantly better since the advent of endovascular treatment. Decisions about the appropriateness and timing of treatment should be taken by an experienced multidisciplinary team.

Preoperative Particle and Glue Embolization of Meningiomas: Indications, Results and Lessons Learned from 117 Consecutive Patients.

BACKGROUND: Preoperative embolization of meningiomas remains contentious, with persisting uncertainty over the safety and efficacy of this adjunctive technique. OBJECTIVE: To evaluate the safety of presurgical embolization of meningiomas and its impact on subsequent transfusion requirement with respect to the extent of embolization and technique used. METHODS: One hundred seventeen consecutive patients between 2001 and 2010 were referred for embolization of presumed intracranial meningioma before surgical resection. Glue and/or particles were used to devascularize the tumor in 107 patients, all of whom went on to operative resection. The extent and nature of embolization-related complications, degree of angiographic devascularization, and the intraoperative blood transfusion requirements were analyzed. RESULTS: Mean blood transfusion requirement during surgery was 0.8 units per case (range, 1-14 units). Blood transfusion was significantly lower in patients whose meningiomas were completely, angiographically devascularized (P = .035). Four patients had complications as a direct result of the embolization procedure. These included intratumoral hemorrhage in 2, sixth cranial nerve palsy in 1, and scalp necrosis requiring reconstructive surgery in 1 patient. CONCLUSION: The complication rate was 3.7%. No relationship between the embolic agent and the degree of devascularization was observed. Achieving a complete devascularization resulted in a lower blood transfusion requirement, considered an indirect measure of operative blood loss. This series demonstrates that preoperative meningioma embolization is safe and may reduce operative blood loss. We present distal intratumoral injection of liquid embolic as a safe and effective alternative to more established particle embolization techniques.

Arterial Ischemic Stroke in Children

Acute ischemic stroke affects 3.3 of 100,000 children per year. The causes of AIS in children can be broadly divided into the following 6 categories: cardiac disese, sickle cell disease, moyamoya, arterial dissection, other arteriopathies, and other causes. Approximately 24% of the cases are classified as idiopathic. Magnetic resonance imaging (MRI) and cerebral angiography play an important role in the determining the causes of an AIS in children. Medical approaches, including anticoagulation, anti-inflammatories, and antiplatelet therapies, surgical revascularization and endovascular approaches may have a role in the management of AIS in children.

Spinal Dural Arteriovenous Fistulas: Clinical Experience with Endovascular Treatment as a Primary Therapy at 2 Academic Referral Centers

BACKGROUND AND PURPOSE: Spinal dural arteriovenous fistulas are a rare entity that, if left untreated, can lead to considerable morbidity with progressive spinal cord symptoms. The aim of this study was to evaluate the clinical outcome of patients with spinal dural arteriovenous fistulas that were primarily treated with endovascular embolization. MATERIALS AND METHODS: A retrospective review was performed of all patients from 1997–2010 who underwent treatment at 2 academic referral centers for a spinal dural arteriovenous fistula. Follow-up was performed by clinical examination, and functional status was measured by use of the Aminoff-Logue Disability Scale, McCormick classification grading, and mRS scores. The nonparametric Wilcoxon signed rank test was used to compare pretreatment and posttreatment Aminoff-Logue Disability Scale gait and micturition scores, McCormick classification grading, and mRS scores. P values < .05 were considered significant. RESULTS: A total of 38 patients were included. Five patients (2 endovascular, 3 surgical) were lost to follow-up and therefore were excluded from the analysis, 29 patients were initially treated from an endovascular approach (9 Onyx, 20 cyanoacrylate), and 4 patients were treated from a standard surgical approach. Five patients in the endovascular group subsequently underwent surgery for various reasons. The clinical improvements in the Aminoff-Logue Disability Scale gait and micturition scores, McCormick classification grading, and the mRS scores were statistically significant (P < .05, Wilcoxon signed rank test). CONCLUSIONS: We conclude that endovascular treatment of spinal dural arteriovenous fistulas can result in good clinical outcomes. Surgery remains the treatment of choice when safe embolization of the proximal radicular draining vein cannot be obtained or because the shunting artery of the spinal dural arteriovenous fistula also supplies the anterior spinal, posterior spinal, or a radiculomedullary artery.

Pediatric Cerebral Aneurysms

Childhood intracranial aneurysms differ from those in the adult population in incidence and gender prevalence, cause, location, and clinical presentation. Endovascular treatment of pediatric aneurysms is the suggested approach because it offers both reconstructive and deconstructive techniques and a better clinical outcome compared with surgery; however, the long-term durability of endovascular treatment is still questionable, therefore long-term clinical and imaging follow-up is necessary. The clinical presentation, diagnosis, and treatment of intracranial aneurysms in children are discussed, and data from endovascular treatments are presented.

Subarachnoid haemorrhage as the first clinical manifestation of Churg-Strauss syndrome

Sirs: We report a case of a 37-year old woman with spontaneous subarachnoid haemorrhage (SAH) and elevated p-ANCA titres, who developed systemic features of ChurgStrauss syndrome (CSS) a year later. The patient presented with sudden onset, severe headache. Past medical history included mild treated hypertension (average reading 150/80 over the preceding year). There was no family history of SAH. On admission, the patient was fully conscious without focal deficit. CT scan showed subarachnoid blood in the right sylvian fissure, suggestive of a middle cerebral artery source. Four vessel catheter angiography (Fig. 1) was performed. Chest radiograph was normal. Full blood count, including differential, clotting and renal function, was normal. Erythrocyte sedimentation rate (ESR) was raised at 82 mm/h (normal 1–20 mm/h) and raised C-reactive protein (CRP) 42 g/L (0–5 g/L). A vasculitic screen revealed positive pANCA with MPO titre of 626 units (normal range 0–100). Urine analysis showed microscopic haematuria, 24 hour urine analysis showed decreased creatinine excretion 59 (70–145 ml/min) and increased protein excretion 360 mg/24 h (normal < 150 mg/24 h), other vasculitic screening including renal ultrasound were normal. Echocardiogram showed left ventricular hypertrophy. An initial diagnosis of p-ANCA positive vasculitis was made and a 3 day course of intravenous methylprednisolone was administered and ESR fell from 82 mm/h to 20 mm/h two months later. Repeat angiography three months after presentation showed improvement in the calibre of all affected vessels. The patient re-presented eight months later with cough, dyspnoea and chronic rhinitis. ESR was 25 mm/h, pANCA (MPO) 294 units. There was an eosinophilia of 17.4 % (normal range 1–6 %). Chest X-ray showed a new 2 cm infiltrate in left lower zone. Pulmonary function tests showed severe reversible obstructive deficit. A diagnosis of CSS was made according to the American College of Rheumatology Criteria [6] at month 14 after presentation with headache. There was a very good response to further immunosuppression with prednisolone and azathioprine. We think it likely that the SAH was the first clinical manifestation but the search for vasculitis was made on the basis of angiography that has been variably interpreted. The appearances of reversible narrowing of the basal arteries with variable alteration of calibre of more peripheral arteries is nonspecific and has a wide differential diagnosis, including vasospasm from SAH. Peripheral neurological involvement in CSS is common with a neuropathy present in 53 %–78 % of patients [3, 9]. CNS manifestations in CSS are less frequent and characterised by cerebral infarctions in 6–8 % of cases [3, 9]. Intracerebral haemorrhage is rarely associated with CSS [4]. SAH in association with CSS is exceptional, with only six cases of CSS associated with SAH reported [1, 2, 5, 7, 8, 10]. CNS LETTER TO THE EDITORS

Autonomic cardio‐respiratory reflex reactions and superselective ophthalmic arterial chemotherapy for retinoblastoma

To describe our experience with superselective ophthalmic artery chemotherapy (SOAC) in retinoblastoma and to report the serious adverse cardio‐respiratory reactions we have observed.