Selection of Patients for Treatment of Brain Arteriovenous Malformations by the Transvenous Approach: Relationship with Venous Anatomy and Risk of Hemorrhagic Complications

BACKGROUND AND PURPOSE:Intracranial hemorrhage represents a severe complication of brain arteriovenous malformation treatment. The aim of this cohort was to report the rate of hemorrhagic complications after transvenous endovascular embolization and analyze the potential angioarchitectural risk factors as well as clinical outcomes.MATERIALS AND METHODS:During an 11-year period, 57 patients underwent transvenous endovascular embolization. All cases of hemorrhagic complications were identified. We analyzed the following variables: sex, age, hemorrhagic presentation, Spetzler-Martin grade, size of the AVM before the transvenous treatment, number of venous collectors, pattern of drainage, presence of dilated veins, and technical aspects. Univariate and multivariate multiple regression analyses were performed to evaluate the potential risk factors for procedure-related hemorrhagic complications.RESULTS:Hemorrhagic complications (either intraprocedural or periprocedural) unrelated to a perforation due to micronavigation occurred in 8 (14.0%) procedures. Significant (mRS > 2) and persistent neurologic deficits were present in 2 (3.5%) patients at 6-month control. Larger nidi, especially >3 cm (P = .03), and a larger number of venous collectors have shown a statistically significant correlation with hemorrhagic complications. Only the number of venous collectors was identified as an independent predictor of hemorrhagic complications in the multivariate analysis (OR, 8.7; 95% confidence interval, 2.2–58.2) (P = .006).CONCLUSIONS:Larger nidus sizes and an increased number of venous collectors may increase the risk of hemorrhagic complications when implementing transvenous endovascular treatment of AVMs. The technique is effective and promising, especially with small nidi and single venous collectors.

Endovascular treatment for brain arteriovenous malformations (bAVMs) was traditionally focused on targeting the nidus through an intra-arterial approach, whether as a means of curative treatment or targeted embolization as an adjunctive or emergency treatment. In an attempt to target parts of the nidus that lie in the deep brain areas or that are supplied by very thin or perforating arterial branches, transvenous endovascular embolization (TVE) has emerged and is becoming a new tool to target otherwise incurable brain AVMs.^1-3Even though TVE has several advantages, including a very high rate of angiographic cure up to 92.6%³ and a means of curing otherwise incurable bAVMs,^4,5 it still needs to be used very selectively, to reduce hemorrhagic complications (HC).Nevertheless, the technique is not exempt from intraprocedural or periprocedural complications. Hemorrhagic complications represent the most important and challenging procedure-related issues with this technique, which may lead to poor clinical outcomes.^6-9A greater understanding of the frequency and risk factors for HC may optimize patient selection for TVE. The aim of this study was to estimate the rates of intraprocedural and periprocedural hemorrhage after TVE for bAVMs, to assess the morbidity and mortality associated with bleeding, and to analyze the angioarchitectural risk factors linked with such complications.     

Primary adrenal lymphoma presenting as Addison’s disease: case report and review of the literature

Primary adrenal lymphoma (PAL) is an extremely rare entity and adrenal insufficiency is a common complication. Bilateral enlargement of adrenal glands should raise the suspicion of lymphoma, especially in patients with clinical or laboratory features of adrenal insufficiency. Most of these cases are highly aggressive tumors and should be treated with multiagent chemotherapy. The role of bilateral adrenalectomy and/or radiotherapy cannot be estimated. Our patient with PAL was an 80-year-old man who presented with clinical and laboratory features of adrenal insufficiency. Combination chemotherapy plus rituximab was unsuccessful and our patient died from progressive disease.     

Pectoralis major transfer for the treatment of irreparable anterosuperior rotator cuff tears

The purpose of this study was to evaluate the outcome of subcoracoid pectoralis major transfer for the treatment of irreparable anterosuperior rotator cuff tears. This type of tear involves complete rupture of the subscapularis in combination with either the supraspinatus alone or the supraspinatus and infraspinatus. These ruptures are characterised by a poor quality of the rotator cuff that does not allow for a direct tendon-to-bone reconstruction. Between 2000 and 2006, 15 patients were treated using a deltopectoral approach and transfer of the clavicular part of the pectoralis major to the lesser tuberosity and to the anterior part of the greater tuberosity. After an average follow-up (follow-up rate 100%) of 37 months the average functional rating using the Constant and Murley score (CS) increased from 51.73 ± 16.18 to 68.17 ± 8.84 points (p = 0.005). The mean subcategories of the Constant score for pain (p = 0.005), activities of daily living (p = 0.008) but not for range of motion (p = 0.9), significantly improved. At follow-up 13 patients (87%) were available for magnetic resonance imaging (MRI) of the shoulder. Nine patients (70%) had an intact transferred pectoralis major muscle, two (15%) had one that was thin but intact and two patients a rupture (one complete). Two patients had postoperative haematoma and one patient developed cuff tear arthropathy. The good results confirm that pectoralis major transfer is a reliable treatment option for irreparable anterosuperior rotator cuff injuries with significant improvement in pain and function.     

Quality of life in endometrial cancer survivors

Objective: The aim of this study was to evaluate the health-related quality of life in survivors of endometrial cancer (EC), and to identify common problems that they may encounter, in the hope of paving the way to improving their quality of life. Study design: We investigated and compared the health conditions and quality of life between EC survivors and the general population as a control group. There were 61 EC patients who were at clinical stage I–III and survived for 5–7 years after the primary treatments. The control group was composed of 527 healthy postmenopausal women. All of them completed a self-evaluated questionnaire pertaining to personal conditions, medical surveillance, individual well-being and quality of life. Results: The EC survivors were divided into two groups: an older group (n=34) and a younger group (n=27). The latter was compared with the controls. In general, most of the EC survivors were old, low-educated women. The majority of them were in a poor condition. They were inactive, received medical surveillance and had regular medication. The distribution of various complications was higher in the older EC group while the climacteric symptoms were more common in the younger EC group. In both EC groups, the quality of life was lower than in the controls. The prevalence of somatic symptoms was higher in the older EC survivors and psychological problems were a common complaint of the younger EC survivors. Conclusion: The quality of life was poor in the EC survivors. To improve their life quality, earlier psychological counseling should be offered to EC survivors, in particular to younger and single women, and hormone replacement therapy (HRT) should be recommended, but on a selective basis, to those patients at low risk of cancer recurrence.