Yves Pierre Gobin

Vascular anatomy of the spinal cord

In this article, a detailed description of the normal arterial supply and venous drainage of the spinal cord is provided, and the role of catheter angiography and MR angiography in depicting the vascular anatomy of the spinal cord is discussed.

Enucleation vs Ophthalmic Artery Chemosurgery for Advanced Intraocular Retinoblastoma: A Retrospective Analysis

IMPORTANCE Ophthalmic artery chemosurgery (OAC) has emerged as a primary treatment for advanced-stage retinoblastoma. To our knowledge, the incidence of orbital recurrence in eyes treated with OAC has not been described. OBJECTIVE To determine the incidence of orbital recurrence following enucleation or OAC as primary treatments for advanced-stage retinoblastoma. DESIGN, SETTING, AND PARTICIPANTS Single-institution cohort study with retrospective record review at an academic ophthalmic oncology practice. A total of 140 eyes in 135 patients who presented between February 14, 2006, and March 4, 2014, and were classified as having Reese-Ellsworth group 5 or International Classification of Retinoblastoma (Childrens Oncology Group) group D or E retinoblastoma were included; 63 patients (63 eyes) were primarily treated with enucleation and 72 patients (77 eyes) were primarily treated with OAC. This analysis was conducted between August 1, 2014, and March 1, 2015. MAIN OUTCOMES AND MEASURES Incidence of and time to orbital recurrence, metastasis, and death. RESULTS There were 5 orbital recurrences (incidence, 7.9%) in the primary enucleation group and 1 orbital recurrence (incidence, 1.3%) in the primary OAC group during median follow-up times of 42.6 months (range, 6.2-97.1 months) and 38.7 months (range, 9.0-104.3 months), respectively. The 24-month Kaplan-Meier estimate for orbital recurrence-free survival was worse for the enucleation group (92.1%; 95% CI, 82.0-96.7) than for the OAC group (100%) (log-rank test, P = .049). The enucleation group had 5 cases of metastatic disease (7.9%) and 2 deaths (3.2%). In the OAC group, there were 3 cases of metastatic disease (4.2%) and no deaths. Kaplan-Meier analysis of metastasis-free survival and overall survival yielded no differences between the 2 treatment groups. Analysis of a number of features of the 2 groups revealed more eyes with iris neovascularization in the enucleation group (25.4%) than in the OAC group (5.2%) and more eyes with group E retinoblastoma in the enucleation group (87.3%) than in the OAC group (29.9%), although neither of these factors was an independent predictor of orbital relapse in a Cox proportional hazards model. CONCLUSIONS AND RELEVANCE In this single-institution retrospective study of advanced intraocular retinoblastoma, there were more orbital recurrences in the group primarily treated with enucleation. Ophthalmic artery chemosurgery for advanced intraocular retinoblastoma was not found to increase the chance of orbital recurrence, metastatic disease, or death compared with primary enucleation.

Spinal intraarterial chemotherapy: interim results of a Phase I clinical trial.

OBJECT Despite advances in therapies using radiation oncology and spinal oncological surgery, there is a subgroup of patients with spinal metastases who suffer from progressive or recurrent epidural disease and remain at risk for neurological compromise. In this paper the authors describe their initial experience with a novel therapeutic approach that consists of intraarterial (IA) infusion of chemotherapy to treat progressive spinal metastatic disease. METHODS The main inclusion criterion was the presence of progressive, metastatic epidural disease to the spine causing spinal canal compromise in patients who were not candidates for the standard treatments of radiation therapy and/or surgery. All tumor histological types were eligible for this trial. Using the transfemoral arterial approach and standard neurointerventional techniques, all patients were treated with IA infusion of melphalan in the arteries supplying the epidural tumor. The protocol allowed for up to 3 procedures repeated at 3- to 6-week intervals. Outcome measures included physiological measures: 1) periprocedural complications according to the National Cancer Institutes Common Terminology Criteria for Adverse Events; and 2) MRI to assess for tumor response. RESULTS Nine patients with progressive spinal metastatic disease and cord compression were enrolled in a Phase I clinical trial of selective IA chemotherapy. All patients had metastatic disease from solid organs and were not candidates for further radiation therapy or surgery. A total of 19 spinal intraarterial chemotherapy (SIAC) procedures were performed, and the follow-up period ranged from 1 to 7 months (median 3 months). There was 1 serious adverse event (febrile neutropenia). Local tumor control was seen in 8 of 9 patients, whereas tumor progression at the treated level was seen in 1 patient. CONCLUSIONS These preliminary results support the hypothesis that SIAC is feasible and safe.

Retinal reattachment and ERG recovery after ophthalmic artery chemosurgery for advanced retinoblastoma in eyes with minimal baseline retinal function

Aim To report retinal function outcomes after ophthalmic artery chemosurgery (OAC) for advanced retinoblastoma (RB) in eyes with minimal pretreatment retinal function. Methods For 72 advanced RB eyes with baseline electroretinograms (ERGs) indistinguishable from noise (‘extinguished’) or flicker ERG amplitudes <25 µV (‘poor’), ERGs were obtained before OAC and at 3 months, 1 year and 2 years after OAC. Presence of baseline retinal detachments (RDs) and their subsequent resolution or persistence was also noted. Results At 3 months, 1 year and 2 years post-OAC, ‘extinguished’ eyes showed 9/15, 4/11 and 2/6 detectable ERGs, respectively, and ‘poor’ eyes showed 19/55, 14/30 and 8/18 ERGs exceeding 25 μV, respectively. Correlations between baseline and post-OAC ERGs were poor; however, good correlation (R2) existed between ERGs post-OAC at 3 months and 1 year (0.749), at 3 months and 2 years (0.773) and at 1 year and 2 years (0.771). Overall, 49/70 eyes presented with RD; 29 RDs resolved 3 months post-OAC, with an average ERG change of +20.6 μV. Eyes with persistent RD had an average ERG change of −2.2 μV. No eyes underwent ≥25 μV change without RD resolution. Conclusions Minimal baseline ERGs do not preclude significant recovery of retinal function after OAC. Good correlation exists between ERG outcomes at 3 months and those at subsequent follow-ups, suggesting that ERG amplitudes at 3-month post-OAC can prognosticate longer term retinal function, and that improvement is durable. For eyes presenting with RD, RD resolution is necessary but not sufficient for significant (≥25 μV) increases in ERG amplitudes.

Venous sinus stenting lowers the intracranial pressure in patients with idiopathic intracranial hypertension

Aims We report the cerebrospinal fluid opening pressure (CSF-OP) measurements obtained before and after venous sinus stenting (VSS) in 50 patients with idiopathic intracranial hypertension. Methods The CSF-OP was measured with a spinal tap 3 months before and 3 months after treatment. All data were prospectively collected and included patient demographics, weight (kg), body mass index (BMI), acetazolamide daily dosage (mg), procedural details, complications, venous sinus pressures (mm Hg), trans-stenotic pressure gradient (mm Hg), transverse sinus symmetry, and type of venous sinus stenosis. Results The average pretreatment CSF-OP was 37 cm H2O (range 25–77) and the average post-treatment CSF-OP was 20.2 cm H2O (range 10–36), with an average reduction of 16.8 cm H2O (P<0.01). The post-treatment CSF-OP was less than 25 cm H2O in 40/50 patients. The average acetazolamide daily dose decreased from 950 mg to 300 mg at the time of 3-month follow-up (P<0.01). No patient required an increase in acetazolamide dose 3 months after VSS. The average weight before treatment was 95.4 kg with an average BMI of 35.41. There was an average increase in body weight of 1.1 kg at the 3-month follow-up with an average increase in BMI of 0.35 (P=0.03). Conclusions We provide evidence that there is a significant decrease in CSF-OP in patients with idiopathic intracranial hypertension 3 months after VSS, independent of acetazolamide usage or weight loss.

P-022 Association of smoking with increased risk of stroke or transient ischemic attack in the treated vessel territory following angioplasty and stenting for intracranial atherosclerotic disease

Purpose Intracranial atherosclerotic disease (ICAD) is one of the leading causes of ischemic stroke worldwide. Percutaneous transluminal angioplasty (PTA) and stenting has emerged as a treatment for ICAD since there is a significant risk of recurrent ischemic stroke with medical management. We present data of our experience with PTA and stenting for ICAD and demonstrate an association between past or current smoking and risk of recurrent stroke or transient ischemic attack in the treated vessel territory. Materials and Methods A retrospective review was conducted of 29 patients with symptomatic ICAD >70% who failed medical management and underwent angioplasty and stenting between July 2005 and August 2010. Patients were classified as symptomatic or asymptomatic. Symptomatic patients were defined as having a recurrent ischemic stroke or transient ischemic attack in the vascular territory of the treated vessel. Rates of in-stent restenosis, hypertension, history of smoking or current smoking, diabetes, hyperlipidemia and location of stenosis were compared in symptomatic vs asymptomatic patients. The effects of past or current smoking, hypertension, diabetes and hyperlipidemia on rates of in-stent restenosis were also compared. Results 29 patients with symptomatic intracranial stenosis >70% underwent angioplasty and stenting of intracranial lesions; 26 returned for clinical follow-up. The procedural success rate, defined as more than 50% endoluminal revascularization of the stenotic lesion after stent deployment was 97%. There were no procedural complications. The average period of clinical and radiographic follow-up was 1.8 years. Three patients had strokes (11.5%) and two patients had a transient ischemic attack (7.7%) in the territory of the affected vessel over the follow-up period. The risk of ischemic stroke, transient ischemic attack, intracerebral hemorrhage or death at 30 days was zero. The incidence of ischemic stroke in the treated vessel territory was 7.7% at 6 months and 11.5% at 1 year. The incidence of ischemic stroke or TIA in the affected vessel at 1 year was 15.4%. From 1 year after the procedure to the end of the follow-up period there were no further strokes and only one TIA in the affected vessel territory. Of the modifiable risk factors, only past or current smoking had a statistically significant association with the symptomatic group (p=0.020). Diabetes, hypertension and hyperlipidemia were not associated with symptomatic patients. In-stent restenosis was also associated with the symptomatic group (p=0.028). There was no association of past or current smoking, hypertension, diabetes or hyperlipidemia with in-stent restenosis. Conclusions Of the vascular risk factors studied, past or current history of smoking was associated with recurrent ischemic stroke or transient ischemic attack in a treated vessel territory following successful PTA and stenting in ICAD. There was no association of smoking, hypertension, diabetes or hyperlipidemia with in-stent restenosis. Despite the relatively small number of patients, this study emphasizes the importance of smoking cessation in patients with ICAD undergoing angioplasty and stenting and also demonstrates that former smokers have higher risk of recurrent ischemia and should be risk-stratified accordingly.