Objectives
Preoperative embolization of hypervascular spinal metastases (HSM) is efficient to reduce perioperative bleeding. However, intra-arterial digital subtraction angiography (IA-DSA) must ...confirm the hypervascular nature and rule out spinal cord arterial feeders. This study aimed to evaluate the reliability and accuracy of time-resolved contrast-enhanced magnetic resonance angiography (TR-CE-MRA) in assessing HSM prior to embolization.
Methods
All consecutive patients referred for preoperative embolization of an HSM were prospectively included. TR-CE-MRA sequences and selective IA-DSA were performed prior to embolization. Two readers independently reviewed imaging data to grade tumor vascularity (using a 3-grade and a dichotomized “yes vs no” scale) and identify the arterial supply of the spinal cord. Interobserver and intermodality agreements were estimated using kappa statistics.
Results
Thirty patients included between 2016 and 2019 were assessed for 55 levels. Interobserver agreement was moderate (κ = 0.52; 95% CI 0.09–0.81) for TR-CE-MRA. Intermodality agreement between TR-CE-MRA and IA-DSA was good (κ = 0.74; 95% CI 0.37–1.00). TR-CE-MRA had a sensitivity of 97.9%, a specificity of 71.4%, a positive predictive value of 95.9%, a negative predictive value of 83.3%, and an overall accuracy of 94.6%, for differentiating hypervascular from non-hypervascular SM. The arterial supply of the spine was assessable in 2/30 (6.7%) cases with no interobserver agreement (κ < 0).
Conclusions
TR-CE-MRA can reliably differentiate hypervascular from non-hypervascular SM and thereby avoid futile IA-DSAs. However, TR-CE-MRA was not able to evaluate the vascular supply of the spinal cord at the target levels, thus limiting its scope as a pretherapeutic assessment tool.
Key Points
• TR-CE-MRA aids in distinguishing hypervascular from non-hypervascular spinal metastases.
• TR-CE-MRA could avoid one-quarter of patients referred for HSM embolization to undergo futile conventional angiography.
• TR-CE-MRA’s spatial resolution is insufficient to replace IA-DSA in the pretherapeutic assessment of the spinal cord vascular anatomy.
Background and Purpose
Cangrelor is a P2Y12 inhibitor that presents the advantage of having a short half-life. Its use may be helpful in the management of antiplatelet therapy for patients with ...intracranial aneurysms treated by stent-assisted coiling or flow-diverter stents. The purpose of this study was to report early experiences in using cangrelor for such indications.
Material and Methods
From October 2017 to November 2018, 7 consecutive patients (5 females, 2 males, mean age = 56 years) were managed with cangrelor as antiplatelet therapy, combined with aspirin, for stent-assisted coiling embolization and flow-diverter embolization of challenging intracranial aneurysms. Anti-aggregation protocols, including cangrelor, were systematically recorded. Treatment-related complications (minor/major hemorrhagic complications, ischemic complications) as well as clinical and angiographic outcomes (evaluated at 8.7 ± 4.2 and 8.75 ± 10 months, respectively) were retrospectively analyzed.
Results
Of the aneurysms 71.4% (5 out of 7) were ruptured and treated in the acute phase. In one case cangrelor was used as an alternative to clopidogrel in an asymptomatic hemorrhagic complication after stent-assisted coiling for better control of a possible worsening of the intracranial bleeding. Of the patients, 1 (14%) with a complex ruptured MCA aneurysm treated with a flow-diverter stent experienced a severe intracranial hemorrhage, which occurred after switching the cangrelor to ticagrelor and eventually led to death. No hemorrhagic complications under cangrelor were recorded for the six remaining patients. No mRS worsening was observed at discharge, except for the patient who died and six out of the seven patients had a mRS ≤2 at follow-up.
Conclusion
Cangrelor is a new antiplatelet therapy with a P2Y12 inhibiting effect, with a rapid onset and offset of action, owing to its short half-life. This cases series presents a pilot experience with promising results in terms of antiplatelet management for challenging intracranial aneurysms treated by stent assisted coiling or flow-diverter stents.
Objective
To evaluate the incidence and risk factors for ICE during a PV.
Materials and methods
Single-center retrospective analysis of 1512 consecutive patients who underwent 1854 PV procedures for ...osteoporotic (34 %), malignant (39.9 %) or other cause (26.1 %) of vertebral compression fractures (VCFs)/spine tumor lesions. Only thoracic or lumbar PVs were included. PVs were performed with polymethylmethacrylate (PMMA) low-viscosity bone cement under fluoroscopic guidance. Chest imaging (X-ray or CT) was performed the same day after PV in patients with high clinical suspicion of ICE. All post-procedural chest-imaging examinations were reviewed, and all ICEs were agreed upon in consensus by two radiologists.
Results
ICEs were detected in 72 patients (92 cement embolisms). In 86.1 % of the cases, concomitant pulmonary artery cement leakage was detected. Symptomatic ICEs were observed in six cases (8.3% of all ICEs; 0.32% of all PV procedures). No ICE led to death or permanent sequelae. Multiple levels treated during the same PV session were associated with a higher ICE rate OR: 3.59, 95% CI: (1.98-6.51);
p
< 0.001; the use of flat panel technology with a lower ICE occurrence OR: 0.51, 95% CI: (0.32-0.83);
p
= 0.007.
Conclusion
Intracardiac cement embolism after PV has a low incidence (3.9 % in our study). Symptomatic complications related to ICE are rare (0.3%); none was responsible for clinical sequelae in our series.
Key Points
• The incidence of intracardiac cement embolism (ICE) during PVP is low (3.9%).
•
Having a high number of treated vertebrae during the same session is a significant risk factor for ICE.
•
Symptomatic intracardiac cement embolisms have a low incidence (8.3% of patients with ICE).
Hemangioblastoma is a rare tumor of vascular origin, most commonly located in the posterior fossa, which presents with severe symptoms and usually very hard to resect without remarkable operative ...blood loss.1–2 Pre-operative embolization may decrease the amount of intra-operative bleeding, but the endovascular treatment of such tumor may be very challenging due to the high risk of infarction of the surrounding tissues. Direct puncture embolization has been developed to overcome many of the limitations of endovascular techniques for many hypervascular lesions, also hemangioblastomas.3–5 We present in this Technical Video (video 1) a direct puncture embolization with balloon-protection of a hemangioblastoma of the medulla oblongata using Onyx 18 (Medtronic, inc.) as sole liquid embolic agent.
Endovascular embolization of brain arteriovenous malformations (AVMs) is sometimes intentionally partial, in the case of staged treatment for instance. Residual AVMs may be prone to ...angioarchitectural modification during follow-up. The objective of this work is to evaluate the nature and extent of these modifications.
We performed a retrospective monocentric study on a cohort of adult patients treated by incomplete endovascular embolization for ruptured and unruptured AVMs with an available angiographic follow-up, without any intervening confounding event between the 2 angiographic examinations. AVM angioarchitectural modifications (arterial, nidal, and venous) were analyzed. Clinical and radiological data were tested in univariate analyses for association with the occurrence of AVM regression or progression.
Eighty-two partial embolization sessions in 57 patients were included in the study. A 40% (33/82) rate of modification was found on follow-up, with 23/82 (28%) controls showing at least one angioarchitectural regression feature and 15/82 (18.3%) showing at least one angioarchitectural progression item. Nidal growth was the most frequent modification occurring after 12/82 (14.6%) embolizations. The only factor associated with nidal volume growth was a longer time interval between embolization and follow-up (median IQR: 190 250 days vs 89.5133 days in the subgroup without nidal growth; P = .02). Specific modifications of arterial supply, nidal anatomy, and venous drainage were identified and documented.
Angioarchitectural modifications (both progression and regression) of brain AVMs are frequent findings after partial embolization. Nidal volume growth is associated with longer time intervals between embolization and follow-up.
Objectives
To describe a novel long-axis multimodal navigation assisted technique — the so-called Eiffel Tower technique — aimed at integrating recent technological improvements for the routine ...treatment of sacral insufficiency fractures.
Materials and methods
The long-axis approach described in the present study aimed at consolidating the sacral bone according to biomechanical considerations. The purpose was (i) to cement vertically the sacral alae all along and within the lateral fracture lines, resembling the pillars of a tower, and (ii) to reinforce cranially with a horizontal S1 landing zone (or dense central bone) resembling the first level of the tower. An electromagnetic navigation system was used in combination with CT and fluoroscopic guidance to overtop extreme angulation challenges. All patients treated between January 2019 and October 2021 in a single tertiary center were retrospectively reviewed.
Results
A description of the technique is provided. Twelve female patients (median age: 80 years range: 32 to 94) were treated for sacral insufficiency fractures with the “Eiffel Tower” technique. The median treatment delay was 8 weeks (range: 3 to 20) and the initial median pain assessed by the visual analogue scale was 7 (range: 6 to 8). Pain was successfully relieved (visual analogue score < 3) for 9 patients (75%) and persisted for 2 patients (17%). One patient was lost during the follow-up. No complication was noted.
Conclusion
The “Eiffel Tower” multimodal cementoplasty integrates recent technological developments, in particular electromagnetic navigation, with the purpose of reconstructing the biomechanical chain of the sacral bone.
Key Points
• Sacral insufficiency fractures are common and can be efficiently treated with percutaneous sacroplasty.
• The long axis sacroplasty approach can be challenging given both the shape of the sacral bone and the angulation to reach the target lesion.
• The “Eiffel Tower” technique is a novel approach using electromagnetic navigation to expand the concept of the long axis route, adding a horizontal S1 landing zone.
Objectives
Pelvic bone pathological lesions and traumatic fractures are a considerable source of pain and disability. In this study, we sought to evaluate the effectiveness of reinforced ...cementoplasty (RC) in painful and unstable lesions involving the pelvic bone in terms of pain relief and functional recovery.
Methods
All patients with neoplastic lesion or pelvic fracture for whom a pelvic bone RC was carried out between November 2013 and October 2017 were included in our study. All patients who failed the medical management, patients unsuitable for surgery, and patients with unstable osteolytic lesions were eligible to RC. Clinical outcome was evaluated with a 1-month and 6-month post-procedure follow-up. The primary endpoint was local pain relief measured by the visual analogue scale (VAS).
Results
Twenty-two patients (18 females, 4 males; mean age of 65.4 ± 13.3 years range 38–80) presenting with painful and unstable pelvic lesions were treated by RC during the study period. Among the 22 patients, 8 patients presented with unstable pelvic fractures (3 patients with iliac crest fracture, 3 with sacral fractures, and the remaining 2 with peri-acetabular fractures). No procedure-related complications were recorded. All patients had significant pain relief and functional improvement at 1 month. One patient (4.5%) had suffered a secondary fracture due to local tumour progression.
Conclusions
Reinforced cementoplasty is an original minimally invasive technique that may help in providing pain relief and effective bone stability for neoplastic and traumatic lesions involving the pelvic bone.
Key Points
• Reinforced cementoplasty is feasible in both traumatic fractures and tumoural bone lesions of the pelvis.
• Reinforced cementoplasty for pelvic bone lesions provides pain relief and functional recovery.
• Recurrence of pelvic bone fracture was observed in 4.5% of the cases in our series.
Objectives
Cement leakages in soft tissues are a common occurrence during cementoplasty. They may cause chronic pain, and thus treatment failure. Spindle malposition during reinforced cementoplasty ...may cause vascular, nerve or cartilage injury. Our goal was to evaluate the rate of cement leakage/spindle extraction and describe the techniques used.
Methods
This retrospective monocentre study included 104 patients who underwent reinforced cementoplasty and 3425 patients who underwent cementoplasty between 2012 and 2020. Operative reports and fluoroscopic images were reviewed to identify extraction attempts and their outcomes.
Results
Six patients (5.8%) had a malpositioned spindle, and all of them underwent spindle extraction during reinforced cementoplasty, with an 80% success rate. A total of 7 attempts were performed, using 2 different techniques. One thousand one hundred thirty patients (32%) had a cement leak in soft tissues, and 7 (0.6%) underwent cement leakage extraction during cementoplasty, with a 100% success rate. A total of 10 attempts were performed, using 3 different techniques. No major complication related to the extraction procedures occurred.
Conclusions
Spindle malpositions and soft tissue cement leakages are not uncommon. We described 5 different percutaneous techniques that were safe and effective to extract spindles and paravertebral cement fragments.
Key Points
•
Soft tissue cement leakages or spindle malpositions are a non-rare occurrence during cementoplasty, and may cause technical failure and/or chronic pain.
•
Most soft tissue cement fragments and malpositioned spindles can easily be extracted using simple percutaneous techniques.
Cangrelor is a P2Y12 inhibitor antiplatelet agent, with a rapid onset and offset. The available literature only reviews short-term administration over a few hours. We describe 5 patients who received ...cangrelor for >1 month in a neurosurgical intensive care unit due to a very high likelihood of requiring emergency revision surgery. Despite multiple therapeutic interruptions for surgical procedures, no hemorrhagic events occurred, and there was only one transient ischemic event, which occurred during transition from cangrelor to ticagrelor. Cangrelor can be a therapeutic option for patients with a high likelihood of requiring revision neurosurgery after intracranial stenting.
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