Purpose
Different embolization techniques and materials are available for the pre-operative embolization of carotid body paragangliomas. In this study, we report the first experience of the direct ...percutaneous puncture technique under fluoroscopic guidance using the low-viscosity formula of SQUID-12. The additional use of a transitory balloon-blockage at the origin of the external carotid artery aims to confer higher protection by limiting the risk of non-target embolization and subsequent neurological sequelae.
Materials and Methods
We retrospectively reviewed all cases of carotid body paragangliomas that have undergone pre-surgical embolization with a direct puncture technique and balloon-assistance at our institution between 2019 and 2020. The use of the liquid EVOH-based SQUID-12 as the sole embolic agent was the main inclusion criteria.
Results
A total of 9 patients with 9 carotid body paragangliomas were enrolled in this case series. The mean volume of the lesion was 309 mm3. The mean embolization-session time amounted to 88 min. The average number of needles inserted was 2, and the mean volume of SQUID-12 used per case was 23 ml. Successful total devascularization was obtained in all cases. No long-term sequelae due to the embolization procedure occurred.
Conclusions
Pre-operative paraganglioma embolization with SQUID-12 using a direct puncture and balloon-assisted technique is a safe and efficient method with few complications.
Background
The pressure cooker technique (PCT) was developed to enable safer and more extensive embolization of hypervascular lesions by simultaneously minimizing backflow of liquid embolic materials ...and thus reduce the risk of non-target embolization of adjacent healthy vessels. We report our experience in applying the PCT to cerebral arteriovenous malformations (AVMs) and dural arteriovenous fistulas (DAVFs) and additionally suggest our technical adjustments.
Methods
We retrospectively reviewed all patients suffering from AVMs or DAVFs that were treated with the PCT between 2018 and 2020 in two university hospitals. The endpoints of the study were clinical safety and the technical efficacy.
The endpoints of the study were clinical safety and the technical efficacy. Clinical safety was the absence of death, major or minor symptomatic stroke, TIA and procedure-related intracranial bleeding (SAH) in the peri-procedural period until dismission. Good clinical outcome was defined as no deterioration of the modified Rankin Scale (mRS) score (comparing the pre- and post-procedural mRS evaluated by a trained neurologist at admission and dismission).
The technical efficacy was considered as the complete embolization occlusion of the target vessels of the lesion documented on the final control angiogram. Long-term follow-up evaluation was not intended for this study as it was not available for all patients.
Results
Fifteen consecutive patients (6 women; mean age 55 y; range 20–82 y) with seven AVMs and eight DAVFs met the inclusion criteria. The primary clinical safety end point was obtained in all cases as no intraprocedural complications were encountered. All patients had a good clinical outcome with no difference between the pre- and post-mRS scores. The primary efficacy end point was reached in all cases.
Conclusion
The PCT is a safe and effective technique in the treatment of cerebral AVMs and DAVFs. Adding an easy and fast step to the procedure, namely the injection of contrast media to test the complete obstruction by the plug, the risk of reflux seems to additionally be reduced.
Objectives
To investigate the clinical meaning of brain parenchymal computed-tomography hyperdensities (CTHD) in patients treated of anterior circulation acute stroke with reperfusion therapy.
...Methods
Patients were retrospectively enrolled from three different hospitals. Brain CT scans were assessed at four time points: We recorded ASPECT scores of pre-treatment CTs, assessed ASPECT scores and the presence of CTHD on post-treatment CTs acquired within 24–30 h and 24–72 h, and examined a one-month CTs follow-up to determine the ischemic evolution of CTHD. We correlated the presence of CTHD with clinical and radiological data to define its predictive and prognostic factors.
Results
In total, 165 patients were evaluated. At post-treatment CTs acquired within 24–30 h, 68 (41%) patients showed the presence of CTHD. On post-treatment CTs acquired within 24–72 h, 43 (63%) of the CTHD showed hemorrhagic transformation. Sixty-five (95%) out of the 68 CTHD evolved in a final ischemic brain area. Multivariate statistical analysis identified puncture to recanalization time to be the only independent factors predicting the presence of CTHD (
p
= 0.045). The presence of CTHD at the first post-treatment CTs was an independent factor for clinical outcome determined with mRS scores at 3-month follow-up (
p
= 0.05). Outcomes were worse for hemorrhagic transformation at follow-up CTs compared to the ischemic evolution of the CTHD (
p
= 0.01).
Conclusions
The presence of CTHD at CTs imaging acquired within 24–30 h after reperfusion therapy is an independent prognostic factor of a worse clinical outcome, regardless of its ASPECT score at baseline CTs and of its hemorrhagic evolution.
Spindle cell oncocytomas are extremely rare neoplasms of the sellar, parasellar, and suprasellar regions that can frequently mimic pituitary adenomas. Fewer than 50 cases have been ever reported in ...the literature, and there is no consensus on best treatments to be provided.
We hereby present a challenging case of sellar and suprasellar spindle cell oncocytoma in a patient of 64 years. The patient, who presented with hydrocephalus, hypopituitarism, and visual deficit, underwent urgent transsphenoidal (TNS) resection of the mass, which was aborted for massive life-threatening bleeding. The patient received ventriculoperitoneal shunt with relief of symptoms. An endovascular embolization of tumor feeders from the distal portion of the right internal maxillary artery, in particular the sphenopalatine artery, was then performed and a second-look TNS surgery was feasible. The patient was discharged in optimal clinical condition, recovered both endocrinologic and visual deficits, and is now in follow-up.
We found that the oncocytoma was radiologically and clinically comparable with a pituitary adenoma, except for higher representation of vasculature. According to our recent experience and review of the literature, we believe that surgery (transsphenoidal or transcranial approach) is the recommended treatment in those who are symptomatic and preoperative embolization might be a suitable option to reduce intraoperative bleeding and increase radicality.
Lumbar puncture (LP) is rarely complicated by cerebral vein thrombosis (CVT), especially if other risk factors coexist. We describe the case of a 28‐year‐old woman who developed CVT after ...corticosteroid treatment and LP performed for suspected multiple sclerosis. The day after LP, she developed intense headache and on Day 8 generalized tonic‐clonic seizures. A brain computed tomography scan showed thrombosis of the superior sagittal sinus and cortical veins. Thrombophilia screening showed heterozygous G20210A prothrombin mutation. Anticoagulant therapy with low molecular weight heparin and then warfarin was administered until Day 16 after LP, when a brain magnetic resonance imaging showed a subdural hematoma. Warfarin was interrupted and dabigatran was started. The patient recovered completely, both from the initial thrombotic event and the hemorrhagic complication. This case highlights the importance to keep in mind CVT in the differential diagnosis of post‐LP headache not responsive to standard therapy, and suggests that dabigatran can be considered an effective and safe treatment of CVT.
Aim
To compare clinical success and patient satisfaction of percutaneous cervical nucleoplasty (PCN) and percutaneous cervical discectomy (PCD) in contained cervical disc herniation treatment.
...Materials and methods
We retrospectively identified 50 consecutive patients in our institution: 24 underwent the PCD treatment and 26 patients were treated by the PCN procedure. All patients complained of radicular pain with or without neck pain; diagnosis of contained cervical disc herniation was obtained by MRI; all patients had received conservative therapy which did not result in symptom improvement. Exclusion from our series consisted of patients who had undergone previous surgery at the indicated level, or those with myelopathy, or those in whom more than a sole herniation was treated in the same session. Overall procedure time, fluoroscopy time, radiation dose and complications were recorded. The MacNab scale score was used to assess clinical success in terms of pain relief at 2- and 6-month follow-up. After 4–6 months, a cervical MRI was obtained in 24 patients.
Results
Neither major nor minor complications were reported. Regarding patient satisfaction, overall median modified MacNab score was excellent both at 2 and 6 months after treatment. No significant statistical difference was found in mean modified MacNab score at 2 and 6 months among patients grouped by treatment choice (
p
= 0.319 and 0.847, respectively); radiation dose was inferior in PCN group than in PCD, with no significant statistical difference.
Conclusion
PCD and PCN were found to be safe and effective in terms of pain relief in contained cervical herniation treatment.
Chronic hepatitis C virus (HCV) infection is associated with numerous extra-hepatic complications, including neurological and renal manifestations. We describe the case of a 67-year-old Caucasian man ...with HCV-associated cryoglobulinemic glomerulonephritis, cirrhosis, and hepatocellular carcinoma. The early posttransplant course was complicated by fibrosing cholestatic hepatitis due to recurrent HCV in the graft (HCV RNA up to 44,944,438 IU/mL). Proliferative glomerulonephritis (nephritic and nephrotic syndrome) with mixed cryoglobulinemia (purpura) was also recorded. Seventy-two days after surgery, the patient presented with seizures and arterial hypertension; brain magnetic resonance imaging indicated the diagnosis of posterior reversible encephalopathy syndrome (PRES). PRES responded well to medical treatment with complete resolution of neurological changes. Antiviral therapy (sofosbuvir and ribavirin, six months) gave a sustained viral response with the improvement of cryoglobulinemic symptoms (including glomerular disease). Repeat liver biopsy revealed the regression of cholestatic damage and perisinusoidal fibrosis. The current follow-up shows stable chronic renal failure (serum creatinine: 1.4 mg/dL) and mild nephritic syndrome. The impact of extrahepatic manifestations of HCV on patient outcomes is highlighted from novel observational studies reporting a relationship between HCV cure (as expressed by the sustained viral response) and a decrease in both liver-related and renal complications. Clinical trials evaluating the efficacy and tolerance of novel direct-acting antiviral agents for the management of HCV-associated glomerular diseases are underway.
•Direct oral anticoagulants as alternative treatment for cerebral vein thrombosis•No significant difference has been observed for the risk of recurrent thrombosis•The risk of bleeding was higher on ...direct oral anticoagulants than on warfarin
Plaque protrusion through stent struts represents one of the principal causes of cerebral embolisation during carotid artery stenting (CAS) and the stent healing period. The aim of this study was to ...evaluate the safety (technical success) and efficacy (clinical success) of the CGuard stent system – a new nitinol stent covered by a closed-cell polyethylene terephthalate mesh designed to prevent embolic events.
Eighty-two consecutive patients who underwent CAS with CGuard from June 2015 were included in this study. The same surgeon performed all procedures. Primary endpoints included technical and clinical success. Clinical success was considered to be absence of death, major or minor stroke. The incidence of new ischaemic brain lesions was also evaluated by diffusion weighted magnetic resonance imaging (DW-MRI) in a subgroup of patients as a secondary endpoint.
In this study, 82 patients (73.8 ± 8.5 years, 75% male, 19% symptomatic) underwent CAS procedures. Immediate technical success was 100%, with the stenosis diameter reduced from 81.4 ± 4.9% to 11.0 ± 3.5%. There was peri-operative technical and clinical success in 100% of symptomatic patients, and in 98.5% of asymptomatic patients, because of the occurrence of one acute stent thrombosis 4 hours post-CAS followed by a minor stroke. In the post-operative period (30 days), no new events were registered. The most recent 21 patients (24%) underwent DW-MRI in the peri-operative period: new ischaemic brain lesions were recorded in 23.8% of patients and the average lesion volume per patients was 0.039 ± 0.025 cm3.
The technical and clinical outcomes of this single centre study suggest that the CGuard may be a safe and effective device for endovascular treatment of symptomatic and asymptomatic subjects, independent of aortic arch anatomy. Further larger comparative studies are needed to confirm these benefits.
PDF
