Evaluation of angiographic computed tomography in the follow-up after endovascular treatment of cerebral aneurysms—a comparative study with DSA and TOF-MRA

Following coil embolization of intracranial aneurysms, many centers perform at least one digital subtraction angiography (DSA) continuing with time-of-flight magnetic resonance angiography (TOF-MRA). Angiographic computed tomography (ACT) provides high-resolution data from a rotational acquisition of a c-arm-mounted flat panel detector. This study evaluates possible advantages of applying ACT in aneurysm follow-up. In 22 patients DSA examinations with a rotational acquisition were performed. Rotational data were processed into an isotropic high-resolution volume. TOF-MRA was performed the day before DSA. Three experienced neuroradiologists performed a rating of the occlusion rate and a subjective method comparison. Weighted κ statistics were calculated to assess the level of interobserver agreement. Compared to DSA, the diagnostic value of ACT as well as of TOF-MRA was rated to be inferior, although the sensitivity of detecting residual necks was higher with both techniques. Compared to TOF-MRA, ACT achieves favorable ratings only in aneurysms after stent-remodeling. Interobserver agreement was high for all techniques. Ratings of the occlusion rate correlated highly between all observers (r > 0.85, p < 0.001, respectively). In selected patients ACT can add valuable diagnostic information to DSA. TOF-MRA remains a highly sensitive method for aneurysm follow-up.     

Flat detector CT and its applications in the endovascular treatment of wide-necked intracranial aneurysms—A literature review

Flat detector CT (FDCT) provides cross sectional imaging within an angiographic suite and is increasingly gaining popularity in various areas of interventional radiology, as an alternative imaging modality. Its relatively high spatial resolution improves visualization of intraluminal devices such as intracranial stents or flow-diverters. Device deployment and positioning, in relation to the parent vessel and surrounding structures, are easily assessible with FDCT. Furthermore, with contrast agent administration, it expands the diagnostic capabilities of this new imaging tool. However, beam-hardening artifacts is a major limitation in some cases. The examination can be performed both during the endovascular procedure and for pre- and post-treatment imaging. Intravenous contrast agent injection reduces the risk of complications, making it possible to perform this examination in the outpatient settings. The aim of this paper is to present an overview of published studies reporting experience with FDCT in the field of endovascular neurosurgery and in particular, FDCT's contribution in treatment of wide-necked intracranial aneurysms. The authors have focused specifically on stent-assisted coiling and flow-diverter implantation, since obtaining proper parent vessel wall apposition of these devices is essential for short- and long-term procedural outcomes.     

Stent-assisted coil embolization of intracranial aneurysms using the Solitaire™ AB Neurovascular Remodeling Device: initial and midterm follow-up results

Introduction

The purpose of this retrospective review was to present our experience in using the Solitaire? AB Neurovascular Remodeling Device in the stent-assisted treatment of intracranial aneurysms, focusing on midterm results. To date, this is the largest series using the Solitaire? AB Neurovascular Remodeling Device.

Methods

From February 2008 to December 2010, 102 patients harboring 104 wide-necked or complex intracranial aneurysms were consecutively enrolled. Forty-five patients presented with an acute subarachnoid hemorrhage. Stent implantation was combined with a standard coiling procedure in 100 patients; in 13 of them, by bailout stenting. On average, at least one clinical and angiographic follow-up was available in 63 patients after 6.3 months. Forty-nine patients were followed for up to 13.6 months.

Results

Of the stents, 98.4 % could be deployed successfully. A Raymond class 1 occlusion was obtained in 51 % of the aneurysms, a Raymond class 2 occlusion in 44 %, and in the remaining 5 % a Raymond class 3 occlusion was obtained. Procedure-related morbidity was 3.9 % (n?=?4) and procedure-related mortality was 2.9 % (n?=?3). During the follow-up period, 39.2 % of the aneurysms showed further thrombosis, 45.1 % remained unchanged, and 15.7 % recanalized. In the follow-up clinical examination according to the modified Rankin Scale, 16.3 % of all patients presented with clinical improvement, 73.5 % were unchanged, and 10.2 % of patients deteriorated.

Conclusion

Considering that stent-assisted coiling is indicated in unfavorable aneurysms, which are not amenable to standard coiling procedures, the Solitaire AB stent proved to be an efficient and safe device in midterm angiographic and clinical follow-up results.     

GDC 360° for the endovascular treatment of intracranial aneurysms: a matched-pair study analysing angiographic outcomes with GDC 3D Coils in 38 patients

Introduction  The purpose of this study was to determine whether coil embolisation with a new complex-shaped Guglielmi Detachable Coil (GDC 360°; Boston Scientific Neurovascular, Fremont, CA, USA) has any effect on the stability of aneurysm occlusion. Materials and methods  Fifty-one consecutive patients with intracranial aneurysms treated with GDC 360° were included. Angiographic results and adverse neurological events during the follow-up period were recorded. For 38 patients treated with GDC 360° with available follow-up data, a corresponding patient treated with GDC 3D was identified from our database. Matches were sought for rupture status, location, aneurysmal size, and neck size. The angiographic outcome of these matched controls at 6 months was compared to aneurysms treated with GDC 360°. Results  Initial angiographic controls for 38 patients treated with GDC 360° showed complete occlusion in 32 aneurysms, and a neck remnant in six. At 6-month follow-up, complete occlusion was found in 29, a neck remnant in eight, and a residual aneurysm in one. One patient treated with GDC 360° needed retreatment for a major recanalisation. In 38 matched patients treated with GDC 3D, initial angiographic controls found complete aneurysmal occlusion in 30 aneurysms and a residual neck in 8. At 6-month follow-up, 24 aneurysms were completely occluded, ten showed a neck remnant, and residual aneurysms were seen in four. Four patients, treated with GDC 3D, were retreated for major aneurysm recanalisations. Conclusion  Our data suggests that endovascular coil embolisation with GDC 360° might improve long-term stability of coiled aneurysms when compared to GDC 3D.     

Treatment of a wide-necked aneurysm of the anterior cerebral artery using two Enterprise stents in “Y”-configuration stenting technique and coil embolization: a technical note

The endovascular treatment of wide-necked aneurysms remains challenging. The “Y”-stenting technique has been used for stent-assisted coil embolization of wide-necked bifurcation aneurysms. So far, this technique has been described for aneurysms of the basilar apex or the middle cerebral artery bifurcation and only for open stent systems using the Neuroform stent. We report a 52-year-old woman with recurrence of a wide-necked aneurysm of the anterior cerebral artery that was successfully retreated by stent-assisted coiling using the “Y”-stenting technique with the Enterprise stent system.     

Does stent type impact coil embolization outcomes in extended follow-up of small-sized aneurysms (&lt; 10 mm)?

Purpose

Self-expandable stents have enabled endovascular treatment of wide-necked aneurysms (ordinarily viewed as technically prohibitive), with favorable outcomes. However, the impact of stent type on occlusive stability has not been adequately investigated. In small-sized unruptured saccular aneurysms, we generated estimates of stent-assisted coil embolization outcomes during follow-up monitoring. Stent type and other risk factors linked to recanalization were analyzed.

Methods

A cohort of 286 patients harboring 312 small-sized unruptured aneurysms (<?10 mm) was subjected to mid-term and extended follow-up monitoring after stent-assisted coiling. Three types of stents (Enterprise, 192; Neuroform, 27; LVIS, 93) were deployed in this population; all medical records and radiologic data of which were reviewed. Mid-term recanalization rates and related risk factors were assessed using binary logistic regression analysis.

Results

A total of 49 aneurysms (15.7%) displayed recanalization at 6 months postembolization, with 34 and 15 instances of minor and major recanalization, respectively. Multivariate analysis indicated that wide-necked aneurysms (>?4 mm) (HR?=?2.362; p?=?0.017), incomplete occlusion at time of coiling (HR?=?2.949; p?=?0.002), and stent type (p?=?0.048) were significant factors in mid-term recanalization, whereas hypertension (p?=?0.095) and packing density ≤?30% (p?=?0.213) fell short of statistical significance. Compared with Enterprise (HR?=?2.828) or Neuroform (HR?=?4.206) stents, outcomes proved more favorable with use of LVIS.

Conclusions

Above findings demonstrate that in addition to occlusive status at time of coil embolization and neck size, stent type may affect follow-up outcomes of stent-assisted coil embolization in small-sized aneurysms. LVIS (vs Enterprise or Neuroform stents) performed best during follow-up monitoring in terms of limiting recanalization.

     

Dissecting aneurysms of the vertebral artery—angiographic patterns at the dissecting site on balloon test occlusion

Introduction

At present, the risk of future hemorrhage or ischemic insult from vertebral artery (VA) dissection cannot be estimated from available imaging data. We investigated the relationship between symptoms and the angiographic patterns of the dissecting site on balloon test occlusion (BTO) to develop guidelines for clinical decision-making.

Methods

We retrospectively reviewed 18 patients with unilateral VA dissection who presented with subarachnoid hemorrhage (SAH) or cerebral infarction. We analyzed the angiographic findings at the dissecting site on contralateral VA angiograms during BTO of the affected VA, classified the angiographic patterns into two types, and compared the symptoms they presented.

Results

Patients with dissection opacified from the distal to the proximal side are more likely to present with cerebral infarction than SAH. Conversely, patients with dissection opacified from the proximal to the distal side had a significantly higher incidence of SAH.

Conclusions

Angiographic findings at the dissecting site on contralateral VA angiograms during BTO of the affected VA are helpful for considering the treatment and prognosis of patients with VA dissecting aneurysms.     

The venous hinge—an objective sign for the diagnosis and follow-up of treatment in patients with intracranial hypotension syndrome

Introduction  In patients with Intracranial Hypotension Syndrome (IHS), we observed reduction of the angle between vein of the Galen (VOG) and internal cerebral vein (ICV), which returns to the baseline after treatment. We coin the term “venous hinge” to describe this dynamic process and discuss its importance in IHS. Methods  A midsagittal T1W image showing both VOG and ICV in the same plane was reterospectively analyzed by three different neuroradiologists in 17 patients with IHS. The angle between the lines drawn along the main axis of VOG and ICV (venous hinge angle (VHA)) was measured and documented. This angle measured from the magnetic resonance imaging (MRI) of the 50 normal controls was also recorded. Paired t tests were used to compare the VHA between male and female controls and between patients of IHS and normal controls. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) were calculated. The VHA was also calculated after treatment of these patients and paired t test was done to look for significant change in the VHA after treatment. Results  The mean VHA formed by the veins in the IHS and control groups were 65° (35–98°) and 91° (76–124°) respectively (P < 0.0001). At a VHA of 79°, the sensitivity, specificity, PPV, and NPV for diagnosis of IHS were 88.24%, 92%, 78.95%, and 95.83% respectively. In ten patients, follow-up MRI demonstrated normalization of the collapsing angle following appropriate treatment (p = 0.003). Conclusion  We report a previously undescribed imaging finding in patients with IHS. Recognition of this sign may aid in the diagnosis of IHS.     

Three-dimensional time-of-flight MR angiography at 3 T compared to digital subtraction angiography in the follow-up of ruptured and coiled intracranial aneurysms: a prospective study

Introduction Since digital subtraction angiography (DSA) carries a low risk of morbidity, and is associated with patient discomfort and higher cost, our objective was to determine whether high-resolution 3-D time-of-flight MR angiography (TOF-MRA) at 3 T may replace DSA in the follow-up of patients after coiling of an intracranial aneurysm. Methods This prospective study included 50 consecutive patients with a ruptured and subsequently coiled intracranial aneurysm. All patients were followed up at a mean of 14 months after coiling with DSA and high-resolution 3-D TOF-MRA at 3 T generating 0.02 mm³ isotropic voxels. One examiner used DSA and TOF-MR angiograms to assess the need for and risk of retreatment; these data were used to calculate intermodality agreement. Another two examiners independently assessed aneurysm occlusion by DSA and TOF-MRA according to the Raymond scale; these data were used to calculate interobserver agreement. Results Discrepancies between DSA and TOF-MRA were found in three patients (intermodality agreement κ = 0.86). While DSA indicated complete aneurysm occlusion, TOF-MRA showed small neck remnants in the three patients. Coils on all DSA projections obscured these three neck remnants. Interobserver agreement was higher for DSA (κ = 0.82) than for TOF-MRA (κ = 0.68), which was in part due to the complexity of the information provided by TOF source images and reconstructions. Conclusion 3-D TOF-MRA at 3 T is not only an adjunctive tool but is ready to replace DSA in the follow-up of patients with previously coiled intracranial aneurysms. Additional DSA may only be performed in complex and not clearly laid out aneurysms.     

Clinical experience with the pREset stent retriever for the treatment of acute ischemic stroke—a review of 271 consecutive cases

Introduction

The purpose of this study was to evaluate the safety and efficacy of the pREset stent retriever in a real-world clinical setting.

Methods

Patients treated with pREset were selected from a prospectively maintained single-center database. A TICI score ≥2b after ≤3 passes was regarded as successful recanalization. All device-related complications and their clinical significance were reported. Parenchymal hematomas (PH) were classified according to ECASS, adding focal and diffuse subarachnoid hemorrhage (SAH) as categories. A 90-day mRS of 0–2 was defined as favorable outcome. In addition, we separately analyzed patients treated with >3 pREset passes and patients receiving other rescue maneuvers.

Results

We included 271 patients. Successful recanalization was achieved in 76.4 %. Device-related complications occurred in 9.2 % of which 2.2 % were clinically significant. PH I, PH II, focal SAH, and diffuse SAH was observed in 5.2, 4.8, 12.2, and 2.2 %, respectively. A total of 39.5 % of patients had favorable clinical outcome. Considering treatments with >3 pREset passes or other rescue procedures, an additional 8.5 and 9.3 % of target vessels were recanalized. The chance of favorable clinical outcome decreased significantly with any kind of rescue therapy. In addition, the rate of PH I was significantly higher in patients treated with >3 pREset passes, whereas all other types of hemorrhage showed no difference.

Conclusion

In terms of safety and effectiveness, pREset performed comparably to other stent retriever devices. To avoid futile recanalization and potential additional harm, escalation of therapy beyond three thrombectomy passes should only be performed after careful individual consideration of each case.     

Pott’s puffy tumor,intracranial, and orbital complications as the initial presentation of sinusitis in healthy adolescents,a case series

Pott’s puffy tumor (PPT) and intracranial complications of sinusitis are considered rare in the post-antibiotic era. We present a series of pediatric patients who were diagnosed with these complications. The purpose of this study is to discuss the clinical presentations and imaging findings in order to increase awareness of pediatricians and radiologists. A computer search identified nine pediatric patients who were admitted to our hospital between October 2006 and July 2009. The patients’ charts and imaging studies were reviewed. There were eight males (11–16 years old) and one female (9 years old). All patients presented with significant headache and fever. Only two patients had sinusitis symptoms. CT and MRI revealed sinusitis in seven patients. These patients were diagnosed with epidural abscess (six), subdural empyema (one), PPT (five), focal meningitis (six), and orbital cellulitis (four). Two patients did not have sinusitis on the day of admission, but were treated recently for sinusitis. These two patients presented with frontal epidural abscess, PPT, thrombosis of the superior sagittal sinus, and frontal bone osteomyelitis. All patients were treated with a multidisciplinary approach and had good outcome with no residual neurologic deficits. Complications of sinusitis are not rare in the studied population. The presentation may be misleading. Therefore, a high index of suspicion is needed, particularly in adolescent males who present with significant headache and fever. Evaluation with contrast-enhanced CT of the brain, sinuses, and orbits should be done first, followed by MRI examinations.     

Driving under the influence of synthetic cannabinoids (“Spice”): a case series

Recreational use of synthetic cannabinoid receptor agonists—so-called “Spice” products—became very popular during the last few years. Several reports on clinical symptoms and poisonings were published. Unfortunately, most of these reports do not contain any analytical data on synthetic cannabinoids in body fluids, and no or only a limited number of cases were reported concerning driving under the influence (DUI) of this kind of drugs. In this article, several cases of DUI of synthetic cannabinoids (AM-2201, JWH-018, JWH-019, JWH-122, JWH-210, JWH-307, MAM-2201 (JWH-122 5-fluoropentyl derivative), and UR-144) are presented, focusing on analytical results and signs of impairment documented by the police or the physicians who had taken the blood sample from the suspects. Consumption of synthetic cannabinoids can lead to impairment similar to typical performance deficits caused by cannabis use which are not compatible with safe driving. These deficits include centrally sedating effects and impairment of fine motor skills necessary for keeping the vehicle on track. Police as well as forensic toxicologists and other groups should become familiar with the effects of synthetic cannabinoid use, and be aware of the fact that drug users may shift to these “legal” alternatives due to their nondetectability by commonly used drug screening tests based on antibodies. Sophisticated screening procedures covering the complete range of available compounds or their metabolites have to be developed for both blood/serum and urine testing.     

Serial MRI of olivary hypertrophy: Long-term follow-up of a patient with the “top of the basilar” syndrome

We describe a patient with the top of the basilar syndrome, in whom MRI documented the appearance and regression of olivary hypertrophy.     

Metastatic calcification of floor of the mouth secondary to chronic renal failure—report of a rare case with atypical presentation

Soft-tissue calcification is always pathological. Metastatic calcification is calcification of soft tissues owing to hyperphosphataemia with or without hypercalcaemia. Metastatic calcification of oral cavity is extremely rare. A case report of metastatic calcification of the floor of the mouth with atypical radiologic and clinical picture is presented here along with a review of earlier reports. A chance finding of the granular oral mucosa on palpation led to a radiographic examination revealing granular calcifications of the floor of the mouth. Blood chemistry and hormone analysis revealed chronic renal failure and hyperparathyroidism. A diagnosis of metastatic calcification secondary to renal failure was made and the treatment was aimed at correcting the renal failure without any intervention for the asymptomatic calcifications. Key differences between the present case and other cases reported in the literature are outlined.     

Selective anteromedial bundle reconstruction in partial ACL tears: a series of 36 patients with mean 24 months follow-up

The purpose of this study was to describe an original technique of reconstruction of the anteromedial bundle preserving the posterolateral bundle and to report the results of a consecutive 36 patients series with mean 24 months follow-up. Our hypothesis is that this selective reconstruction of ACL partial tears could restore knee stability and function. In a consecutive series of 256, ACL reconstructions, 36 patients in which intact ACL fibers remained in the location corresponding to the posterolateral bundle were perioperatively diagnosed. These patients (21 women and 15 men) underwent isolated reconstruction of the anteromedial bundle while keeping the remaining fibers intact. AM bundle reconstructions were performed by the same surgeon using an outside-in technique. A quadrupled hamstring graft was used in 20 patients and a doubled semitendinosus graft in 16 patients. The mean age of the patients at the time of surgery was 32 years (min 15, max 53). The delay between injury and surgery was 6.6 months (min 2, max 35). Patients were assessed with the IKDC ligament evaluation form. Instrumented knee testing was performed with the Rolimeter arthrometer. Statistical analysis was performed to compare the preoperative and postoperative objective evaluation. Eleven concomitant meniscal lesions at the time of reconstruction were found. One patient who underwent a traumatic graft rupture at 4 months post surgery and two patients with previous contralateral ACL reconstruction were excluded, leaving 33 patients for final evaluation. Three reoperations were performed, including two arthrolysis for cyclops syndrome and one revision for a traumatic graft rupture. At last follow-up, 24 (73%) patients were graded A, 8 (24%) graded B and 1 C (3%) at IKDC objective evaluation. Mean side to side instrumented laxity was 4.8 mm (min 3, max 6) preoperatively and 0.8 mm (min 0, max 2) postoperatively. AM bundle reconstruction with an outside-in technique remains simple and reproducible. The preliminary results are encouraging with excellent side to side laxity. Graft size should probably be adapted to limit cyclops syndrome occurrence.     

A case of drowning linked to ingested sulfides — a report with animal experiments

An adult male was found dead beneath a pool of sewage in the pump room of a fish market. Autopsy revealed the cause of death to be suffocation after aspirating sewage into the respiratory tract. Since hydrogen sulfide gas was detected in the atmosphere at the scene of the accident, gas poisoning was suspected and toxicological analysis of sulfides in body tissues was performed. The concentrations of sulfides in the blood, lung and kidney were 0.95 mol/ml, 0.22 and 0.38 mol/g, respectively. These values were remarkably higher than those in previously reported cases involving exposure to hydrogen sulfide gas. Therefore, oral intake of sulfides was assumed and the distribution of sulfides in tissues following oral administration of sodium sulfide solution was examined by means of animal experiments using rats. The concentration of sulfides in the blood from rats following oral intake was much higher than that seen following gas exposure. Based on these results, we concluded that the victim had been exposed to hydrogen sulfide gas and had then collapse into a pool of sewage containing sulfides. The sulfides which were distributed throughout the body tissues had mainly issued from the alimentary tract prior to death by drowning.     

Repeated poisoning of the life partner by thallium — a case of questionable Munchausen by adult proxy syndrome with ensuing attempted murder

After the use of thallium as rat poison was banned, the knowledge about the severe and treacherous course of poisonings with this toxic metal has widely been lost. In the present case, the male victim sustained two insidious poisoning attacks in 2017 and 2020 by the perpetrator, his female life partner. In the first poisoning episode, he suffered from increasing heavy pain of the abdomen, stinging pain of both legs, persistent obstipation, hyperesthesia, and, after about 2 weeks, tuft-wise loss of hair as typical symptoms of the thallium poisoning. Within 7 weeks, he was successively examined in six hospitals with a wide variety of diagnostic methods, but a conclusive explanation of the complaints was not found. The possibility of a metal intoxication was then suggested by the perpetrator who privately arranged the analysis of a blood sample with the result of 175 µg/l thallium. Although a criminal poisoning was assumed, the perpetrator was not identified. After the victim left the perpetrator, she subtly executed a second poisoning attack with thallium sulfate (blood level 1230 µg/l after 1 day, urine level 4760 µg/l after 10 days, and hair concentrations 3.26–0.49 from proximal to distal in 9 segments). The perpetrator was sentenced to 10.5 years imprisonment for grievous bodily harm and attempted murder. Because of the behavior of the perpetrator, a Munchausen by proxy syndrome was discussed as a motivation of the first poisoning but was excluded by the psychiatric expert because of a missing antisocial personality disorder.