Wojciech Beuth

Methods and time schedule for follow-up of intracranial aneurysms treated with endovascular embolization: a systematic review.

BACKGROUND AND PURPOSE To review the diagnostic value of angiographic methods and the optimal timetable for follow-up imaging of patients after endovascular treatment of intracranial aneurysms. MATERIAL AND METHODS A comprehensive computer-aided search for relevant primary papers was performed using the MEDLINE, PubMed, Embase, and Cochrane Collaboration database from January 1991 to March 2011. Original papers were included that reported either diagnostic value of angiographic modalities for follow-up vs. digital subtracted angiography (DSA) or comparison of aneurysm occlusion rate in delayed vs. early follow-up. RESULTS The systematic review identified 35 relevant studies: 3 on the diagnostic value of three-dimensional (3D) DSA, 30 on the performance of magnetic resonance angiography (MRA), and 3 on time schedules for follow-up. 3D DSA had sensitivity of 100%, and specificity of 58.3-94.7%. Magnetic resonance angiography had sensitivity of 28.4-100%, and specificity of 50.0-100%. The proportion of aneurysms that recanalized between the early follow-up examination at 6 months and the delayed imaging at 1.5-6.0 years was 0-2.5%. CONCLUSIONS Magnetic resonance angiography seems to be the best imaging method for the follow-up. In selected cases, when invasive angiography is necessary, 3D DSA should be considered to improve the diagnostic accuracy. Most patients who present with stable and adequate aneurysm occlusion at 6 months after coiling may not require further follow-up. Key words: intracranial aneurysm, embolization, coils, digital subtracted angiography, magnetic resonance, computed tomography.

Follow-up of cerebral aneurysm embolization with hydrogel embolic system: Systematic review and meta-analysis

BACKGROUND Hydrogel embolic system (HES) for endovascular treatment of cerebral aneurysms was developed to reduce the risk of aneurysm recurrence and the rate of retreatment. The aim of this systematic review was to verify the efficacy of HES, also in comparison to bare platinum coils (BPC). MATERIAL AND METHODS A systematic literature search was performed by two independent reviewers for articles published until January 31st, 2013 on the follow-up recurrence rate of intracranial aneurysm embolization with hydrogel-coated coils. RESULTS Thirteen articles on the use of HES for embolization of cerebral aneurysms were included in this study, for a total of 1683 embolized aneurysms. Significant heterogeneity was found regarding patient populations, methods of aneurysm coiling, follow-up schedules, and recurrence definitions. The pooled rate of initial complete aneurysm occlusion was 55% (95%CI, 38-70%); 59% (95%CI, 43-74%) in the subgroup of aneurysms treated with the use of HES. The pooled total recurrence rate was 19% (95%CI, 15-24%); 17% (95%CI, 14-22%) in the HES-treated subgroup. The pooled major recurrence rate was 12% (95%CI, 8-18%); 11% (95%CI, 7-16%) in the HES-treated subgroup. Comparing both types of coils, the pooled odds ratio for total recurrence was 0.63 (95%CI, 0.45-0.88; p=0.008) in favor of HES. CONCLUSIONS Embolization of cerebral aneurysms using HES seems to result in a lower rate of recurrence than that obtained using BPC, which is in line with the only randomized controlled trial. High-quality prospective studies are needed to define specific indications for the use of hydrogel-coated coils.

Predictors of residual flow in embolized intracranial ruptured aneurysms at early follow-up.

BACKGROUND The possibility of recanalization and the need for retreatment are the most important drawbacks of intracranial aneurysm embolization. The purpose of the study was to prospectively analyze the results of early follow-up angiography of embolized ruptured aneurysms in an attempt to determine factors predicting the presence of residual flow. MATERIAL/METHODS Evaluation included 72 patients with 72 aneurysms, which were followed-up 3 months after the treatment. Analysis of residual flow predictors included: age and gender, clinical state in Hunt-Hess scale, aneurysm localization, aneurysm three dimensions and volume, neck width, sac-to-neck ratio, initial result of embolization, number of coils used and the use of hydrogel coils and stents. RESULTS Mean sac diameter was 6.5±3.9 mm, and mean neck width was 2.9±1.4 mm. Follow-up angiography presented residual flow in 26 aneurysms (36.1%): class 2 in 8 aneurysms (11.1%), and class 3 in 18 cases (25.0%). Stable aneurysm filling was observed in 45 cases (62.5%), progression of residual flow in 25 cases (34.7%), and regression in 2 cases (2.8%). According to ROC analysis independent predictors of residual flow were aneurysm neck diameter (AUC 0.857, 95% CI: 0.755-0.928, p<0.0001) and sac-to-neck ratio (AUC 0.817, 95% CI: 0.708-0.898, p<0.0001). Cut-off point of the ROC curve was established at 2.8 mm for neck diameter, and 1.73 for sac-to-neck ratio. CONCLUSIONS Aneurysm neck diameter and sac-to-neck ratio are independently related to the residual flow in embolized ruptured aneurysms at early follow-up.

DSA volumetric 3D reconstructions of intracranial aneurysms: A pictorial essay.

Summary A gold standard of cerebral vessel imaging remains the digital subtraction angiography (DSA) performed in three projections. However, in specific clinical cases, many additional projections are required, or a complete visualization of a lesion may even be impossible with 2D angiography. Three-dimensional (3D) reconstructions of rotational angiography were reported to improve the performance of DSA significantly. In this pictorial essay, specific applications of this technique are presented in the management of intracranial aneurysms, including: preoperative aneurysm evaluation, intraoperative imaging, and follow-up. Volumetric reconstructions of 3D DSA are a valuable tool for cerebral vessels imaging. They play a vital role in the assessment of intracranial aneurysms, especially in evaluation of the aneurysm neck and the aneurysm recanalization.

Time-resolved imaging of contrast kinetics does not improve performance of follow-up MRA of embolized intracranial aneurysms.

Summary Background The use of contrast media and the time-resolved imaging of contrast kinetics (TRICKS) technique have some theoretical advantages over time-of-flight magnetic resonance angiography (TOF-MRA) in the follow-up of intracranial aneurysms after endovascular treatment. We prospectively compared the diagnostic performance of TRICKS and TOF-MRA with digital subtracted angiography (DSA) in the assessment of occlusion of embolized aneurysms. Material/Methods Seventy-two consecutive patients with 72 aneurysms were examined 3 months after embolization. Test characteristics of TOF-MRA and TRICKS were calculated for the detection of residual flow. The results of quantification of flow were compared with weighted kappa. Intraobserver and interobserver reproducibility was determined. Results The sensitivity of TOF-MRA was 85% (95% CI, 65–96%) and of TRICKS, 89% (95% CI, 70–97%). The specificity of both methods was 91% (95% CI, 79–98%). The accuracy of the flow quantification ranged from 0.76 (TOF-MRA) to 0.83 (TRICKS). There was no significant difference between the methods in the area under the ROC curve regarding both the detection and the quantification of flow. Intraobserver reproducibility was very good with both techniques (kappa, 0.86–0.89). The interobserver reproducibility was moderate for TOF-MRA and very good for TRICKS (kappa, 0.74–0.80). Conclusions In this study, TOF-MRA and TRICKS presented similar diagnostic performance; therefore, the use of time-resolved contrast-enhanced MRA is not justified in the follow-up of embolized aneurysms.

Stimulation of the human auditory nerve with optical radiation

A novel, spatially selective method to stimulate cranial nerves has been proposed: contact free stimulation with optical radiation. The radiation source is an infrared pulsed laser. The Case Report is the first report ever that shows that optical stimulation of the auditory nerve is possible in the human. The ethical approach to conduct any measurements or tests in humans requires efficacy and safety studies in animals, which have been conducted in gerbils. This report represents the first step in a translational research project to initiate a paradigm shift in neural interfaces. A patient was selected who required surgical removal of a large meningioma angiomatum WHO I by a planned transcochlear approach. Prior to cochlear ablation by drilling and subsequent tumor resection, the cochlear nerve was stimulated with a pulsed infrared laser at low radiation energies. Stimulation with optical radiation evoked compound action potentials from the human auditory nerve. Stimulation of the auditory nerve with infrared laser pulses is possible in the human inner ear. The finding is an important step for translating results from animal experiments to human and furthers the development of a novel interface that uses optical radiation to stimulate neurons. Additional measurements are required to optimize the stimulation parameters.

High incidence of nephropathy in neurosurgical patients after intra-arterial administration of low-osmolar and iso-osmolar contrast media

Background Percutaneous endovascular examinations and interventions require significant amounts of iodinated contrast media (CM) and have been reported to be complicated by an increased incidence of post-contrast nephropathy. Purpose To evaluate renal function, the incidence of post-contrast nephropathy, and risk factors after interventional procedures in neurosurgical patients after intra-arterial administration of a low-osmolar contrast medium (LOCM) versus an iso-osmolar contrast medium (IOCM). Material and Methods This single-center, prospective, randomized, double-blinded study included 92 patients in its final analysis (mean age 49.6 ± 12.6 years, 29.3% men, mean eGFR 97.8 ± 26.3 mL/min/1.73 m2). LOCM was used in 48 patients (52.2%) and IOCM in 44 patients (47.8%). The patients were given an average of 151.2 ± 52.1 mL of contrast medium intra-arterially. Serum creatinine (SCr), urinary N-acetyl-β-glucosaminidase (NAG) excretion, and creatinine clearance (CCr) were measured at baseline, and on days 1 and 3 after the procedure. Results Baseline risk factors, renal functional parameters, and average CM doses were not statistically different between the two groups. SCr, NAG, and CCr values did not differ significantly between the LOCM and IOCM groups on days 1 and 3 after CM administration. Nephropathy developed in 21 cases (22.8%): 13 (27.1%) after LOCM use and 8 (18.2%) after IOCM; (P = NS). The only significant risk factors of CIN were the diabetes (P = 0.0466) and atherosclerosis (P = 0.0498). Conclusion We found a high incidence of nephropathy in neurosurgical patients after intra-arterial CM administration. The renal function values and incidence of nephropathy following LOCM administration were not statistically different from those following IOCM administration.

Functional Capacity Scale as a new tool for early functional assessment in patients after surgical treatment of intracranial aneurysms: A prospective study involving 128 patients

Summary Background Functional assessment of a patient focuses on the assessment of independence in activities of daily living. The aim of the study was to verify the usefulness of a new tool (Functional Capacity Scale – FCS) for early functional assessment of patients after surgical treatment of an intracranial aneurysm. Material/Methods The study was conducted in the Neurosurgical Department and Clinic, CM in Bydgoszcz, NCU, within a group of 128 patients after surgical treatment of an intracranial aneurysm. Direct observation and measurement were used in the study. In clinical assessment, the Hunt and Hess Scale was applied. For the final functional assessment, the Functional Capacity Scale (FCS), the Glasgow Outcome Scale, the Functional Index “Repty”, the Barthel Index, and the Rankin Scale were used. Results The study shows that on the day of discharge almost 60% of patients are independent or slightly dependent on others for functional capability, and 15% are significantly or totally dependent. FCS significantly correlates with FIR (0.93, p<0.001), GOS (0.89, p<0.01), RS (−0.88, p<0.01) and BI (0.82, p<0.001). Conclusions 1. Fifty percent of patients with intracranial aneurysm assessed at the early postoperative stage leave the ward as functionally capable of performing everyday activities. 2. There are significant correlations between FCS and the other scales used for functional assessment. 3. There is a significant relationship between functional capacity of the patient on the day of discharge and clinical condition before the surgical treatment.

Dostęp czaszkowo-twarzowy w leczeniu guzów zatok przynosowych z zajęciem przedniego dołu czaszki

Summary Introduction Craniofacial resection is a treatment of choice for paranasal malignant and benign tumors invading the skull base. The aim of the study In this article the authors present the experience in craniofacial resection for malignant tumors invading the anterior skull base. Material and methods The material consisted of four patients operated in the Department of Otolaryngology and Laryngological Oncology CM UMK between 2007 and 2010. The patients were treated for malignant neoplasms of the paranasal sinuses with anterior skull base involvement. The age range of the group were between 60 and 75 years. Of these patients three were females and one male. Results We performed a lateral rhinotomy for laryngological acces for the tumor. The neurosurgeon performed anterior skull base osteotomy at an appropriate site above. The patients recovered uneventfully. The follow up period ranged between 13 and 42 months. The overall 3-year survival for all patients in our series was 66,6%. Conclusions Combined craniofacial resection of tumors of the anterior skull base is an effective approach for the management of these pathologies. This type of approach in elderly patients over 70 years old could be associated with increased mortality and complications leading to poorer outcome.