Vasculitis del sistema nervioso central

La vasculitis primaria del Sistema Nervioso Central (VPSNC) se refiere a un grupo de enfermedades que resultan de la inflamación y destrucción de los vasos sanguíneos de la médula espinal, encéfalo y meninges, tanto en el sector venoso como arterial, esto puede conducir a la oclusión o formación de aneurismas, con las consiguientes alteraciones isquémico-hemorrágicas.1 La presentación es heterogénea y poco sistematizable. El diagnóstico se establece con un cuadro clínico compatible, una angiografía o biopsia del parénquima encefálico y/o meninges que evidencien vasculitis. Presentamos el caso de un paciente portador de retrovirus con probable VPSNC con clínica compatible, hallazgos imagenológicos sugestivos, con escasa alteración de LCR y EEG.2

Primary vasculitis of the Central Nervous System (VPSNC) refers to a group of diseases that result from inflammation and destruction of the blood vessels of the spinal cord, brain and meninges, both in the venous and arterial sector, this can lead to the occlusion or formation of aneurysms, with the consequent ischemic-hemorrhagic alterations.1 The presentation is heterogeneous and little systematizable. The diagnosis is established with a compatible clinical picture, an angiography or biopsy of the brain parenchyma and/or meninges that show vasculitis. We present the case of a patient with a retrovirus with probable NCPSV with compatible symptoms, suggestive imaging findings, with little CSF and EEG alteration.2

Analysis of risk factors associated with cerebral angiography headache / Análise de fatores de risco associados a cefaleia da angiografia cerebral

Abstract Background Despite previous studies indicating a moderate/high incidence of angiography headache (AH), there is still limited data about the risk factors associated with its occurrence. Objective The present study aimed to assess the associations among demographic, clinical, and technical characteristics of cerebral digital subtraction angiography (DSA) and the occurrence of AH. Methods Cross-sectional analytical observational study with a sample comprised of individuals with a recommendation for elective DSA. Clinical interviews were conducted to assess the occurrence of AH, using a standardized questionnaire. Results Among 114 subjects, the mean age was 52.8 (±13.8) years old, 75.4% (86/114) were women, 29.8% (34/114) had a history of migraines, and 10.5% (12/114) had chronic headaches. The overall frequency of AH was 45.6% (52/114). Of those, 88.4% (46/52) underwent 3D angiography, 7.7% (4/52) underwent aortography, and 1.9% (1/52) underwent both procedures. There was a statistically significant association between AH and previous history of migraine (odds ratio [OR]: 4.9; 95% confidence interval [CI] 1.62-14.7; p = 0.005) and 3D angiography (OR 6.62; 95%CI: 2.04-21.5; p = 0.002). Conclusions 3D angiography is strongly associated with the occurrence of AH, which has never been reported before. The association between a previous history of migraine and AH confirms the results of previous studies.

Resumo Antecedentes Apesar de estudos prévios indicarem uma incidência moderada/alta de cefaleia da angiografia (CA), os dados sobre os fatores de risco associados à sua ocorrência ainda são relativamente escassos. Objetivo O presente estudo teve como objetivo avaliar as associações entre as características demográficas, clínicas e técnicas da angiografia cerebral por subtração digital (ACSD) e a ocorrência de CA. Métodos Estudo observacional analítico transversal com uma amostra composta por indivíduos com indicação de ACSD em caráter eletivo. Entrevistas clínicas foram realizadas utilizando um questionário padronizado para acessar a ocorrência de CA. Resultados Entre os 114 indivíduos, a idade média foi de 52,8 (±13,8) anos, 75,4% (86/114) eram mulheres, 29,8% (34/114) tinham histórico de enxaqueca e 10,5% (12/114) tinham cefaleia crônica. A frequência geral de CA foi de 45,6% (52/114). Desses, 88,4% (46/52) foram submetidos à angiografia 3D, 7,7% (4/52), à aortografia e 1,9% (1/52), aos dois procedimentos. Houve associação estatisticamente significativa entre CA e histórico prévio de enxaqueca (odds ratio [OR] 4,9; intervalo de confiança [IC] 95%: 1,62-14,7; p = 0,005) e angiografia 3D (OR 6,62; IC95%: 2,04-21,5; p = 0,002). Conclusões A angiografia 3D está fortemente associada à ocorrência de CA, o que é inédito na literatura. A associação entre um histórico de enxaqueca e a CA confirma os resultados de estudos anteriores.

Utilidad de la angiografía intra-operatoria en el tratamiento quirúrgico de malformaciones arteriovenosas y aneurismas intracraneales

Objetivo: Determinar la utilidad de la angiografía intraoperatoria (AIO) para detectar lesiones residuales en casos de resección quirúrgica de malformaciones arteriovenosas (MAV) y aneurismas intracraneales. Material y métodos: Estudio observacional, descriptivo, tipo serie de casos. Entre noviembre de 1993 y abril de 2001, se diagnosticaron 778 pacientes con patología vascular cerebral, de los cuales 477 fueron sometidos a cirugía. Se empleó AIO en 119 casos y se analizaron las variables clínicas y radiológicas. Resultados: Se analizaron 119 casos, 105 (88,2%) con MAV y 14 (11,8%) con aneurisma. La edad promedio fue de 35 años (rango 6 - 69) y el sexo masculino representó el 52% de los casos. La asociación entre MAV y aneurisma se encontró en 17 casos (14,3%). El aneurisma más frecuente fue el paraclinoideo gigante (71,3%), mientras que las MAV supratentoriales y Spetzler-Martin grado 3 representaron el 83,8% y 73,3% de los casos, respectivamente. Se demostró lesión residual en 7 casos, de los cuales 5 fueron nido residual de MAV y 2 casos aneurisma remanente. Las complicaciones relacionadas a la AIO fueron del 3,4% y mortalidad del 2,5%. Conclusiones: La AIO es una técnica útil para detectar lesiones residuales en patología vascular cerebral sometidas a cirugía abierta.

SUMMARY Objective: To determine the utility of intraoperative angiography (IOA) to detect residual lesions after surgical repair of arteriovenous malformations (AVM) and intracranial aneurysms (ICA). Methods: This is a case series including 778 patients from November 1993 to April 2001; of which 477 underwent surgical intervention. IOA was used in 119 cases. Results: A total of 119 cases were analyzed, 105 patients with AVM (88.2%) and 14 with an aneurysm (11.8%). The mean age was 35 years (range 6 - 69) and males represented 52% of the cases. Both AVM and aneurysms occurred in 17 cases (14.3%). Giant paraclinoid aneurysm was the most common aneurysm (71.3%), whereas supratentorial and grade 3 Spetzler-Martin AVM represented 83.3% and 73.3% of the cases, respectively. A residual lesion was was detected in 7 cases, of which 5 were residual nidus of an AVM and 2 remnant aneurysms. IOA-related complications occurred in 3.4% and mortality was 2.5%. Conclusions: IOA is a useful technique to detect residual cerebro-vascular lesions after open surgeries

Signo de la arteria cerebral media hiperdensa e ictus isquémico con transformación hemorrágica / Hyperdense Middle Cerebral Artery Sign and Ischemic Stroke with Hemorrhagic Transformation

RESUMEN El signo de la arteria cerebral media hiperdensa es un patrón imagenológico que tiene una incidencia de un 30 a un 40 % de las oclusiones de esta arteria demostrada angiográficamente. Representa un signo temprano de ictus isquémico de mala evolución. Se presenta el caso de un paciente de 56 años de edad que comenzó con manifestaciones clínicas de afasia y hemiparesia derecha a predominio crural. En la tomografía al ingreso se observó hiperdensidad del trayecto de la arteria cerebral media izquierda que correspondió con un ictus isquémico extenso con conversión hemorrágica en escaneo evolutivo a las 72 horas. Se presenta el caso por lo poco frecuente que resulta realizar este diagnóstico a partir de los resultados hallados en la tomografía axial monocorte y porque hubo correlación entre las imágenes encontradas y el deterioro clínico posterior del paciente.

ABSTRACT The hyperdense middle cerebral artery sign is an imaging pattern that has an incidence from 30 to 40 % of occlusions of this artery demonstrated angiographically. It represents an early sign of poorly progressive ischemic stroke. A 56-year-old patient who began with clinical manifestations of aphasia and right hemiparesis, predominantly femoral it is presented. On admission tomography, hyperdensity of the left middle cerebral artery trajectory was observed, corresponding to an extensive ischemic stroke with hemorrhagic conversion in evolutionary scan at 72 hours. The case is presented because of how infrequent it is to make this diagnosis based on the results found in the single slice axial tomography and because there was a correlation between the images found and the subsequent clinical deterioration of the patient.

Síndrome de vasoconstricción cerebral reversible inducido por maniobra de Valsalva: Reporte de caso y revisión de la literatura / Valsalva maneuver induced-reversible cerebral vasoconstriction syndrome: Case report and literature review

RESUMEN El síndrome de vasoconstricción cerebral reversible es una entidad clínico-radiológica caracterizada por la presentación de cefalea severa de inicio hiperagudo tipo "trueno", con o sin signos y síntomas neurológicos adicionales en relación a una vasoconstricción arterial cerebral segmentaria que resuelve espontáneamente a los 3 meses. Por la superposición de las manifestaciones clínicas con otras entidades nosológicas, y por los múltiples factores etiológicos asociados, el diagnóstico se convierte en un reto; es imperativo realizarlo de forma temprana para la instauración de un tratamiento adecuado y la prevención de complicaciones. Se presenta el caso clínico de una paciente en quien se documentó como etiología la realización repetitiva de la maniobra de Valsalva sin otro factor concomitante, se exponen las intervenciones realizadas y se hace una revisión narrativa del tema con énfasis en el diagnóstico diferencial.

SUMMARY Reversible cerebral vasoconstriction syndrome is a clinical-radiological entity characterized by severe and hyperacute onset-thunderclap headache, with or without additional neurological signs and symptoms in relation to a segmental cerebral arterial vasoconstriction that resolves spontaneously at around 3 months. Its clinical manifestations are similar to other diseases, and additionally there are multiple associated etiological factors; early diagnosis becomes a challenge, but is essential to establish proper treatment and prevent complications. We present the case of a female patient in whom the repetitive performance of the Valsalva maneuver without another concomitant factor was documented as etiology, the interventions performed are presented and a narrative review of the topic is made with emphasis on differential diagnosis.

Residual lesions in patients who underwent microsurgical clipping of cerebral aneurysms

SUMMARY Microsurgical clipping is currently the main method of treating cerebral aneurysms, even with the improvement of endovascular therapy techniques in recent years. Treatment aims at complete occlusion of the lesion, which is not always feasible. Although appearing superior to endovascular treatment, microsurgical clipping may present varying percentages of incomplete occlusion. Such incidence may be reduced with the use of intraoperative vascular study. Some classifications were elaborated in an attempt to standardize the characteristics of residual lesions, but the classification criteria and terminology used in the studies remain vague and poorly documented, and there is no consensus for a uniform classification. Thus, there is also no agrément on which residual aneurysms should be treated. The aim of this study is to review the literature on residual lesions after microsurgery to treat cerebral aneurysms and how to proceed with them.

RESUMO A clipagem microcirúrgica é, atualmente, o principal método de tratamento dos aneurismas cerebrais, mesmo com o aprimoramento das técnicas de terapia endovascular nos últimos anos. O tratamento visa à oclusão completa da lesão, o que nem sempre é factível. Apesar de parecer superior ao tratamento endovascular, a clipagem microcirúrgica pode apresentar porcentagens variadas de oclusão incompleta. Tal incidência pode ser reduzida com utilização de estudo vascular intraoperatório. Algumas classificações foram elaboradas na tentativa de padronizar as características das lesões residuais, mas os critérios de classificação e a terminologia utilizados nos trabalhos mantêm-se vagos e pobremente documentados, não havendo consenso para uma classificação uniforme. Dessa forma, não há também concordância sobre quais aneurismas residuais devam ser submetidos a tratamento. O objetivo do presente estudo é realizar uma revisão da literatura a respeito das lesões residuais após microcirurgia para tratamento dos aneurismas cerebrais e como proceder diante dessas.

Experiencia de embolización de malformaciones arterio-venosas cerebrales en Hospital de Especialidades Carlos Andrade Marín, 2016-2017 / Experience of embolization of cerebral arteriovenous malformations in Carlos Andrade Marín Specialties Hospital, 2016-2017

INTRODUCCIÓN. La morbimortalidad de las malformaciones arterio-venosas cerebrales se encuentra dada principalmente por hemorragias. OBJETIVO. Conocer la situación de la embolización de malformaciones arterio-venosas en el Hospital de Especialidades Carlos Andrade Marín. MATERIALES Y MÉTODOS. Estudio observacional, retrospectivo en pacientes con diagnóstico de malformaciones arterio-venosas cerebral que fueron sometidos a intervención radiológica, durante el período de enero 2016 a diciembre 2017, en el Hospital de Especialidades Carlos Andrade Marín. RESULTADOS. 17 pacientes con criterios de inclusión, la mayoría con malformaciones arterio-venosas única y clasificación Spetzler Martin tipo I y II. El 52,9% fue sometido al procedimiento con antecedente de hemorragia intracerebral. Luego del procedimiento se alcanzó el 61,5% de obliteración en promedio, con 5,8% de pacientes que tuvo hemorragia intracerebral postprocedimiento. DISCUSIÓN. El uso de la embolización permite la oclusión del nido vascular displásico y del flujo de arterias nutricias profundas, disminuyendo la hemorragia intracerebral como complicación, siendo un tratamiento precursor de complementos quirúrgicos o como tratamiento único. El promedio de obliteración se encuentra dentro del rango reportado en la literatura, con un solo caso que tuvo complicación post procedimiento. Son necesarios estudios complementarios donde se especifiquen las variables de los tratamientos post procedimiento y un seguimiento para valorar supervivencia. CONCLUSIÓN. Resultados similares a los reportados en la literatura, se consideró la embolización como una alternativa del tratamiento, principalmente como precursor a la cirugía en malformaciones arterio-venosas con clasificación Spetzler Martin mayor a III.

INTRODUCTION. The morbidity and mortality of cerebral arteriovenous malformations is mainly due to hemorrhages. OBJECTIVE. To know the situation of the embolization of arterio-venous malformations in the Carlos Andrade Marín Specialties Hospital. MATERIALS AND METHODS. Observational, retrospective study in patients with a diagnosis of cerebral arteriovenous malformations who underwent radiological intervention, during the period from January 2016 to December 2017, at the Carlos Andrade Marín Specialties Hospital. RESULTS 17 patients with inclusion criteria, most with single arteriovenous malformations and Spetzler Martin type I and II classification. 52,9% underwent the procedure with a history of intracerebral hemorrhage. After the procedure, 61,5% of obliteration was achieved on average, with 5,8% of patients having post-procedural intracerebral hemorrhage. DISCUSSION. The use of embolization allows the occlusion of the dysplastic vascular nest and the flow of deep nutritional arteries, decreasing intracerebral hemorrhage as a complication, being a precursor treatment of surgical complements or as a single treatment. The average of obliteration is within the range reported in the literature, with only one case that had post procedure complication. Complementary studies are needed where the variables of the post-procedure treatments and a follow-up to assess survival are specified. CONCLUSION. Results similar to those reported in the literature, embolization was considered as an alternative treatment, mainly as a precursor to surgery in arteriovenous malformations with Spetzler Martin classification greater than III.

Síndrome de Moyamoya: una respuesta defensiva al daño crónico de un gran vaso cerebral Reporte de una serie de casos y revisión de la literatura / Moyamoya syndrome: a defensive response to the chronic damage of a large cerebral vessel. Cases report and review of the literature

RESUMEN OBJETIVOS: Presentar algunos casos de pacientes con síndrome de Moyamoya secundario a etiologías diversas y con base en ellos revisar aspectos generales del cuadro; de acuerdo con dos de los casos se propone una nueva hipótesis. MATERIALES Y MÉTODOS: Se describen cuatro casos clínicos de síndrome de Moyamoya, identificados en la ciudad de Medellín, Colombia, con sus respectivas imágenes y la evolución de su cuadro. Con base en dos de los casos, en los cuales el síndrome se desencadenó posteriormente a la implantación de un stent diversor de flujo, se propone una nueva etiología. RESULTADOS: En dos casos se identificó la implantación de un stent diversor de flujo como el desencadenante del cuadro de Moyamoya. En uno de los casos la enfermedad primaria fue una neurofibromatosis tipo 1; en el cuarto caso no fue posible identificar la causa del síndrome. Ninguno de los pacientes presentó compromiso neurológico a pesar del grave daño arterial. CONCLUSIONES: El síndrome de Moyamoya (SMM), más que una entidad independiente, debería ser entendido como un mecanismo compensatorio y defensivo secundario a la deprivación del flujo sanguíneo en la circulación cerebral anterior, el cual protege a los pacientes de eventos cerebrovasculares isquémicos con consecuencias devastadoras. La implantación de stents diversores de flujo como método de tratamiento de algunos aneurismas cerebrales, se proyecta en el tiempo como una de las causas más importantes del síndrome.

SUMMARY OBJECTIVES: To present some cases of patients with Moyamoya syndrome secondary to diverse etiologies, and, based on them, to review general aspects of the clinical picture. Supported on two cases, the hypothesis of a new mechanism is proposed. MATERIALS AND METHODS: Four clinical cases of Moyamoya syndrome are described, identified in the city of Medellín, Colombia, with their respective images and the evolution of their condition. Based on two of the cases, in which the syndrome was triggered after the implantation of a flow-diverter stent, a new etiology is proposed. RESULTS: In two cases, the implantation of a flow-diverter stent was identified as the trigger of the Moyamoya picture. In one case the primary disease was type 1 neurofibromatosis; in the fourth case it was not possible to identify the cause of the syndrome. None of the patients presented neurological compromise despite severe arterial damage. CONCLUSIONS: Moyamoya syndrome (MMS), rather than an independent entity, should be understood as a compensatory and defensive mechanism in response to the deprivation of blood flow in the anterior cerebral circulation, which protects patients from ischemic cerebrovascular events. Implantation of flow-diverter stents, as a method of treatment of some cerebral aneurysms, is projected in time as an important cause of this syndrome.

Aneurysm of the Fenestrated Basilar Artery: Case Report and Literature Review

Introduction Aneurysms of the vertebrobasilar junction are rare, but when present, they are often associated with fenestration of the basilar artery. Frequently, the endovascular treatment is the first choice due to the complex anatomy of the posterior fossa, which represents a challenge for the open surgical treatment alternative. Case Report A 47-year-old man was admitted to the emergency unit with headache, diplopia, neck pain and mental confusion. The neurological exam showed: score of 15 in the Glasgow coma scale (GCS), no motor or sensitivity deficit, palsy of the left sixth cranial nerve and Hunt-Hess grade III. The computed tomography (CT) scan showed subarachnoid hemorrhage (Fisher III) and hydrocephalus. The patient was submitted to ventricular-peritoneal shunt. A diagnostic arteriography was performed with 3D reconstruction, which showed evidence of fenestration of the basilar artery associated with aneurysm in the right vertebrobasilar portion. An aneurysm coil embolization was performed without complications. The patient was discharged 19 days later maintaining diplopia, with paralysis of the left sixth cranial nerve, but without any other complaints or neurological symptoms. Discussion Fenestration of the basilar artery occurs due to failure of fusion of the longitudinal neural arteries in the embryonic period, and it is associated with the formation of aneurysms. The endovascular treatment is the first choice and several techniques are described, including simple coiling, balloon remodeling, stent-assisted coiling, liquid embolic agents and flow diversion devices. The three-dimensional rotational angiography (3DRA) is an extremely helpful tool when planning the best treatment course. Conclusion Fenestrated basilar artery aneurysms are rare and complex vascular diseases and their treatment improved with the advent of the 3D angiography and the development of the endovascular techniques.

Introdução Aneurismas da junção vertebrobasilar são raros, mas quando presentes, geralmente estão associados à fenestração da artéria basilar. Frequentemente, o tratamento endovascular é a primeira opção devido à complexidade da anatomia da fossa posterior, o que representa um obstáculo para a alternativa de tratamento com cirurgia aberta. Relato de Caso Um homem de 47 anos de idade deu entrada na unidade de emergência com cefaleia, diplopia, dor no pescoço e desorientação. O exame neurológico mostrou: 15 pontos na escala de coma Glasgow (ECG), ausência de déficit motor ou de sensibilidade, paralisia do sexto nervo craniano I esquerdo, Hunt-Hess grau III. A tomografia computadorizada apresentou hemorragia subaracnoidea (Fisher grau III) e hidrocefalia. O paciente foi submetido a shunt ventricular-peritoneal. A arteriografia diagnóstica foi feita com reconstrução 3D, que comprovou fenestração da artéria basilar associada a aneurisma na porção vertebrobasilar direita. Realizamos embolização do aneurisma com molas, sem complicações. O paciente recebeu alta 19 dias depois, mantendo diplopia, paralisia do sexto nervo craniano esquerdo, sem outras complicações ou sintomas neurológicos. Discussão A fenestração da artéria basilar ocorre devido à falência da fusão das artérias neurais longitudinais no período embrionário e está associada à formação de aneurismas. O tratamento endovascular é a primeira opção e várias técnicas são descritas, incluindo simples embolização, remodelagem por balão, embolização assistida com stent, agentes embólicos líquidos e dispositivos de desvio de fluxo. Para planejar o melhor tratamento, angiografias rotacionais 3D são extremamente úteis. Conclusão Aneurismas de artéria basilar fenestrada são doenças vasculares raras e complexas, e seu tratamento foi aprimorado com o advento de angiografias 3D e desenvolvimento de técnicas endovasculares.

Cranial venous sinus dominance: what to expect? Analysis of 100 cerebral angiographies / Dominância dos seios venosos cranianos: o que esperar? Análise de 100 angiografias cerebrais

ABSTRACT We report an analysis of the cranial venous sinuses circulation, emphasizing morphological and angiographic characteristics. Methods Data of 100 cerebral angiographies were retrospectively analyzed (p = 0.05). Results Mean age was 56.3 years, 62% female and 38% male. Measurements and dominance are shown in the Tables. There was no association between age or gender and dominance. Right parasagittal division of the superior sagittal sinus was associated with right dominance of the transverse sinus, sigmoid sinus and internal jugular vein; and left parasagittal division of the superior sagittal sinus was associated with left dominance of the transverse sinus, sigmoid sinus and internal jugular vein. Conclusion A dominance pattern of cranial venous sinuses was found. Age and gender did not influence this pattern. Angiographic findings, such as division of the superior sagittal sinus, were associated with a pattern of cranial venous dominance. We hope this article can add information and assist in preoperative venous analysis for neurosurgeons and neuroradiologists.

RESUMO Relatamos uma análise da circulação dos seios venoso cranianos, enfatizando características morfológicas e angiográficas. Métodos Dados de 100 angiografias cerebrais foram retrospectivamente analisados (p = 0,05). Resultados Média de idade 56,3 anos, 62% feminino e 38% masculino. Medições e dominância expostos em tabelas. Sem associação entre idade ou sexo e dominância. Divisão parassagittal direita do Seio Sagital Superior (SSS) foi associada com dominância direita do Seio Transverso (ST), Seio Sigmóide (SS) e Veia Jugular Interna (VJI), e divisão parassagittal esquerda do SSS foi associada com dominância esquerda do ST, SS e VJI. Conclusão Um padrão de dominância dos seios venosos do crânio foi encontrado. Idade e sexo não influenciaram esse padrão. Achados angiográficos, como divisão do SSS, foram associados com o padrão de dominância venoso cerebral. Esperamos que este artigo acrescente informações e auxilie na análise venosa pré-operatória para neurocirurgiões e neuroradiologistas.

Endovascular Treatment for Idiopathic Intracranial Hypertension Improves Clinical Symptoms and Signs

Introduction New physiopathological concepts regarding idiopathic intracranial hypertension (IIH) recommend the endovascular treatment in refractory patients with transverse sinus stenosis. Objectives To assess the role of the transverse sinus stenting treatment in the symptomatology of patients with IIH. Method Clinically refractory patients with impaired venous drainage of the transverse sinus were submitted to cerebral angiographies. Patients with pre and poststenotic pressure gradients > 8 mmHg were submitted to endovascular treatment. Results Seven patients underwent cerebral angiography with manometry. Stenting was performed in six cases after pressure gradient assessment. All cases showed improvements in headache and resolution of papilledema. Discussion and Conclusion Although the role of endovascular therapy should be further studied, our data suggest it may improve the clinical symptoms and signs of IIH in selected patients.

Introdução Novos conceitos fisiopatológicos a respeito da hipertensão intracraniana idiopática (HII) propõem, em casos refratários, o tratamento endovascular em pacientes com estenose no seio transverso. Objetivos Avaliar o efeito do tratamento endovascular, realizado pela implantação de um stent no seio transverso, em pacientes com HII. Método Pacientes refratários clinicamente com alterações da drenagem venosa no seio transverso foram submetidos a angiografia cerebral. Diante de gradientes pressóricos pré e pós-estenóticos maiores do que 8 mmHg, foi feito o tratamento endovascular. Resultados Sete pacientes realizaram angiografia cerebral com manometria. A colocação de stent foi realizada em seis após avaliação do gradiente pressórico. Todos apresentaram melhora da cefaleia, com resolução do papiledema. Discussão e Conclusão Apesar de o papel do tratamento endovascular para HII necessitar de mais estudos, nossos dados sugerem que ele pode melhorar sinais e sintomas relacionados à HII em pacientes selecionados.

Spontaneous Resolution of a Traumatic Intracranial Aneurysm

Traumatic intracranial aneurysms are rare, and normally result from blunt or penetrating head traumas. Carotid angiography is considered the gold standard and reliable exam to detect this aneurysm. There are specific angiography features that mark the contrasts between a traumatic aneurysm and a common saccular aneurysm. Most authors agree that once the diagnosis is made, surgery is the ideal treatment. This article presents a case of a successful expectant treatment based on the clinical findings of the patient and combined with a constant evaluation of her case. The clinical findings depend on the location and direction of growth of the aneurysm. Traumatic aneurysms of the internal carotid artery (ICA) are unusual, and occur predominantly in the intracavernous portion of that vessel.

Aneurismas traumáticos intracranianos são raros, e normalmente resultam de um traumatismo craniano fechado ou penetrante. O exame considerado padrão ouro para detectar esse tipo de aneurisma é a angiografia da circulação carotídea. Existem características específicas das angiografias que diferenciam o aneurisma traumático do aneurisma sacular comum. A maioria dos autores acredita que, quando realizado o diagnóstico, o melhor tratamento é a cirurgia. O artigo apresenta um caso de tratamento conservador que evolui com sucesso, baseado nos achados clínicos da paciente, e combinado com avaliação constante do caso. Os achados clínicos na paciente dependem da localização e da direção de crescimento do aneurisma. Aneurismas traumáticos da artéria carótida interna (ACI) são raros, e ocorrem predominantemente na sua porção intracavernosa.

Angiografía cerebral por abordaje transradial. experiencia inicial y resultados / Cerebral angiography by transradial approach. initial experience and results

Introducción: El abordaje transradial es utilizado en forma rutinaria para la realización de angiografías coronarias y en menor medida cerebrales. El objetivo de este trabajo es presentar la experiencia inicial de este abordaje realizado en un centro. Material y métodos: Realizamos una revisión de todas las angiografías cerebrales diagnósticas realizadas en forma consecutiva en el Hospital El Cruce, entre julio y diciembre de 2015, y los resultados obtenidos mediante el abordaje transradial. Se calculó la proporción de estudios realizados por esta vía, el tiempo de estadía hospitalaria de los pacientes y la ocurrencia de complicaciones asociadas al mismo. La elección del abordaje se realizó de acuerdo a la decisión del operador. Resultados: Entre julio y diciembre de 2015, se realizaron 89 angiografías cerebrales en pacientes de 14 a 80 años. Los abordajes realizados por punción de la arteria radial fueron 45 (50,56%) y en todos los casos se logró el diagnóstico adecuado de la anatomía vascular. No se observaron complicaciones asociadas al abordaje. La estadía del paciente luego de la angiografía fue en promedio de 75 min. Conclusiones: El abordaje transradial permitió el estudio de todas las arterias cerebrales en todos los pacientes sometidos al mismo. No hubo limitaciones para realizar este abordaje en relación a sexo ni edad. El tiempo de estadía posterior al procedimiento fue similar al promedio descripto en la literatura con este abordaje. No se observaron complicaciones severas asociadas a esta vía.

Introduction: The transradial approach is routinely used to perform both coronary and, to a lesser extent, cerebral angiographic studies. The aim of this study was to review our experience with this approach.Methods: We review all diagnostic cerebral angiographies performed consecutively in the El Cruce Hospital between July and December 2015 and the results obtained using the transradial approach. The proportion of studies conducted in this way, the length of hospital stay of patients and the occurrence of complications associated with it are calculated. The choice of approach was performed according to the decision of the operator.Results: Between July and December 2015, 89 cerebral angiograms were performed in patients between 14 and 80 years old. Of these, 45 (50.6%) were performed utilizing a transradial approach. No complications were observed associated with this technique. The patient's mean stay post angiogram was 75 minutes. Moreover, all the studies performed via the transradial approach allowed for the adequate diagnosis of cerebral vessels anatomy.Conclusions: In our experience performing cerebral angiographies, the transradial approach is associated with complete studies, a negligible complication rate and a short stay post-procedure. No important complications were observed with this approach.

Diagnóstico de muerte cerebral: uso de la angiografía por tomografía axial computarizada como herramienta diagnóstica no invasiva al alcance de todos / Diagnosis of Brain Death: Use of Computed Tomography Angiography as a Non-invasive Diagnostic Tool Available to Everyone

Introducción: La muerte cerebral (MC) se define como la pérdida irreversible de la función cerebral y la ausencia de reflejos del tallo cerebral y de movimientos respiratorios. Objetivo: Describir los hallazgos en la angioTAC cerebral en pacientes con signos clínicos de MC, para evaluar su aplicabilidad como método diagnóstico. Métodos: Se realizó un estudio retrospectivo, entre septiembre de 2013 y abril de 2015; se incluyeron pacientes entre 21 y 60 años, a quienes se les practicó angioTAC para verificar MC. El diagnóstico clínico de MC se realizó mediante el examen neurológico y el test de apnea. Adicionalmente se realizó una angioTAC con tomógrafo multicorte de cuatro detectores, con tres adquisiciones, mediante cortes axiales de 2 mm desde el cuerpo vertebral de C6 hasta 5 cm arriba. El diagnóstico escanográfico de MC se hizo basado en criterios de ausencia completa de circulación intracraneal con una escala de 6 puntos. Resultados: Se identificaron 12 pacientes que cumplían con los criterios de inclusión (5 hombres y 7 mujeres), con edad media 46,6 años (21-60). Los diagnósticos de base fueron: neurovascular (n=8), trauma craneoencefálico (n=2), meningioma (n=1) y paro cardiorespiratorio (n=1). Solo un paciente no cumplió con los 6 puntos de los criterios propuestos para la evaluación con angioTAC. Conclusiones: La angioTAC puede suministrar información suficiente para realizar el diagnóstico confirmatorio imaginológico de MC en los pacientes con duda diagnostica clínica; sin embargo, es necesario compararlo en el futuro con la angiografía por catéter.

Introduction: Brain death (BD) is defined as an irreversible loss of brain function, and the absence of reflexes of the brain stem and of respiratory movements. Objective:To describe the brain CT angiography findings in patients with clinical signs of brain death (BD) and to evaluate its applicability as a diagnostic method of BD as well. Methods: A retrospective study was performed between September 2013 and April 2015, which included patients between the ages of 21 and 60, who underwent CT angiography with BD protocol. The clinical diagnosis of BD was made by neurological examination and with an apnea test. Additionally, a multi-slice CT angiography was performed with a 4-detectors tomograph, with three acquisitions, with 2mm axial slices from the vertebral body of C6 to 5 cm above. The BDscan diagnostic criteria was performed based on criteria of complete absence of intra-cranial circulation with a 6 point scale. Results: 12 patients that met the inclusion criteria (5 males and 7 females), with a mean age of 46.6 years (21-60) were identified. The initial diagnosis of the patients were neurovascular (n = 8), head trauma (n = 2), meningioma (n = 1) and cardiopulmonary arrest (n = 1). Only one patient did not meet the 6 points of the proposed criteria for the evaluation with CT angiography. Conclusions: CT angiography could provide enough information to perform confirmatory diagnostic imaging of BD in patients with clinical doubts of diagnosis of BD, however it is necessary in the future to compare it with catheter angiography.

Incidencia de lesiones vasculares intracraneales posteriores a trauma craneoencefálico / Incidence of Intracranial Vascular Lesions after Head Injury

Objetivo: Evaluar la incidencia de lesiones vasculares intracraneales traumáticas y determinar las formas más frecuentes de su presentación. Metodología: Mediante un estudio observacional descriptivo de corte transversal se seleccionaron los pacientes identificados con trauma craneoencefálico que requirieron estudio angiográfico en el Hospital Universitario del Valle. Resultados: Entre abril de 2012 y diciembre de 2013 se registraron 52 pacientes que requirieron angiografía en el contexto de trauma craneoencefálico; de ellos, 36,53 % presentaron algún hallazgo positivo para lesión vascular intracraneal traumática. El tipo de lesión más prevalente fue la trombosis de senos venosos (52,6 %); la fistula arteriovenosa se presentó en el 26,31 % de los pacientes; en el 13,8 % se documentaron disecciones arteriales; el 10,5 % presentó pseudoaneurismas; y en solo un caso se describió una compresión extrínseca. Conclusiones: Las lesiones vasculares intracraneales postraumáticas son frecuentes en nuestra población. La trombosis de seno venoso tenía la mayor incidencia, contrario a la literatura revisada referente al tema, donde la fistula arteriovenosa es habitualmente la lesión más frecuente. Además de brindarnos un panorama de la incidencia de determinadas lesiones, este estudio nos demuestra la necesidad de contar con datos obtenidos en instituciones colombianas, porque es evidente la divergencia con estudios publicados en otros países.

Objectives: To evaluate the incidence of traumatic intracranial vascular lesions, as well as to determine the most frequent forms of their presentation. Methodology: An observational, descriptive, cross-sectional study identified patients with cranioencephalic trauma who required angiographic study at the Hospital Universitario del Valle. Results: Between April 2012 and December 2013, there were identified 52 patients requiring angiography in the context of a traumatic brain injury; 36.53 % of them had a positive finding for traumatic intracranial vascular injury. The most prevalent type of lesion was venous sinus thrombosis (52.6 %); arteriovenous fistula was present in 26.31 % of the patients; 13.8 % had arterial dissections; 10.5 % had pseudoaneurysms, and extrinsic compression (5.3 %) was described in only one case. Of the patients evaluated 2 cases of concomitant lesions. Conclusions: Posttraumatic intracranial vascular lesions are common in our population. Venous sinus thrombosis had the highest incidence, contrary to the literature on the subject, where arteriovenous fistula is usually the most frequent lesion. Besides providing an overview of the incidence of certain injuries, this study demonstrates the need for data from Colombian institutions, due to the evident divergence from studies published in other countries.

Effects of iodinated contrast media in a novel model for cerebral vasospasm / Efeitos do meio de contraste iodado em um novo modelo de vasoespasmo cerebral

Objective We developed an in vitro model for vasospasm post subarachnoid hemorrhage that was suitable for investigating brain vessel autoregulation. We further investigated the effects of iodinated contrast medium on the vascular tone and the myogenic response of spastic cerebral vessels. Method We isolated and perfused the superior cerebellar arteries of rats. The vessels were pressurized and studied under isobaric conditions. Coagulated blood was used to simulate subarachnoid hemorrhage. The contrast medium iodixanol was applied intraluminally. Results Vessels exposed to blood developed significantly stronger myogenic tone (65.7 ± 2.0% vs 77.1 ± 1.2% of the maximum diameter, for the blood and the control group, respectively) and significantly decreased myogenic response, compared with the control groups. The contrast medium did not worsen the myogenic tone or the myogenic response in any group. Conclusion Our results show that deranged myogenic response may contribute to cerebral blood flow disturbances subsequent to subarachnoid hemorrhage. The contrast medium did not have any negative influence on vessel tone or myogenic response in this experimental setting. .

Objetivo Desenvolvemos um modelo in vitro para vasoespasmo subsequente à hemorragia subaracnóide que foi adequado para investigar a autorregularão dos vasos cerebrais. Em seguida investigamos os efeitos o meio de contraste iodado no tônus vascular e na resposta miogênica dos vasos cerebrais espásticos. Método Isolamos e perfundimos as artérias cerebelares superiores de ratos. Os vasos foram pressurizados e estudados em condições isobáricas. Sangue coagulado foi utilizado para simular hemorragia subaracnóide. O meio de contraste iodixanol foi aplicado intraluminarmente. Resultados Os vasos expostos ao sangue desenvolveram aumento significativo do tônus miogênico (65.7 ± 2.0% vs 77.1 ± 1.2% do maior diâmetro, para o grupo de sangue e o grupo controle, respectivamente) com resposta miogênica significativamente menor do que aquela dos controles. O meio de contraste iodado não piorou o tônus miogênico ou a resposta miogênica em nenhum dos grupos. Conclusão Nossos resultados mostram que uma resposta miogênica pode contribuir para as alterações de fluxo sanguíneo cerebral subsequentes à hemorragia subaracnóide. O meio de contraste iodado não teve nenhuma influência negativa no tônus vascular ou na resposta miogênica neste modelo experimental. .

Cerebral Proliferative Angiopathy­Description of a Rare Clinical Entity / Angiopatia cerebral proliferativa ­ descrição de uma entidade clínica rara

The cerebral proliferative angiopathy (CPA) is an uncommon vascular malformation of the brain, representing approximately 3.4% of arteriovenous malformation (AVM) cases, with complex morphology and poorly understood origin. Thus, we present the case of a woman patient aged 27 years, who performed magnetic resonance imaging (MRI) of the brain because of a headache. Extensive malformation was identified vascular right frontoparietal, with the presence of the brain tissue mixed with the vessel. CPA identified multiple feeder arteries, with the absence of nidus and slowing the flow into the venous system, confirming that it was CPA. During evaluation at another hospital she underwent partial embolization of the lesion, without success. Currently, the patient is progressing with left hemiparesis. CPA has distinct characteristics, such as large dimensions, presence of functional brain tissue intermingled with the vessels, no nidus, multiple nourishing vessels, and small veins. It does not present well-defined nidus or flow-related aneurysms. These characteristics classify it as a disease itself within the group of AVMs. This case clinically presents with seizures, refractory headaches, focal neurologic deficits, and low risk of bleeding. Alternatives for curative treatment imply significant neurologic deficits and the most accepted options aimed at easing the symptoms and the partial embolization alternative that is best associated with risks and benefits.

A angiopatia cerebral progressiva (ACP) é uma malformação vascular encefálica incomum, representando cerca de 3,4% dos casos de malformações arteriovenosas (MAV's), com morfologia complexa e origem pouco compreendida. Assim, apresentamos o caso de uma paciente de 27 anos, que realizou RNM de crânio para investigação etiológica de cefaleia, tendo sido identificado extensa malformação vascular frontoparietal direita, com a presença de tecido cerebral entremeado aos vasos. Exame de angiografia cerebral identificou múltiplas artérias nutridoras, com ausência de nidus e lentificação do fluxo para o sistema venoso, confirmando tratar-se de Angiopatia Cerebral Proliferativa. Durante avaliação emoutro serviço foi submetida à embolização parcial da lesão, sem sucesso. Atualmente a paciente vem evoluindo com hemiparesia dimidiada à esquerda. A ACP apresenta características distintas como a presença de tecido cerebral funcionante entremeado aos vasos, ausência de nidus, múltiplos vasos nutridores e pequenas veias, sendo uma lesão de grandes imensões. Não apresenta nidus bem definido ou aneurismas relacionados ao fluxo. Estas características a classificam como uma doença própria dentro do grupo das malformações arteriovenosas. Clinicamente cursa com crises epilépticas, cefaleias refratárias e déficits neurológicos focais. Apresenta baixo risco de sangramento. As alternativas para tratamento curativo implicam em importantes déficits neurológicos e as opções mais aceitam visam à atenuação da sintomatologia, sendo a embolização parcial a alternativa que melhor associa riscos e benefícios.

Revisão de literatura e relato de caso de fístula arteriovenosa craniana cutânea pós-traumática / Post traumatic cutaneous cranial fístula: case report and literature review

Os autores descrevem o caso de um doente de 34 anos que, após agressão sofrida em 2008, detectou o surgimento de tumoração no mesmo local em que sofrera a agressão, onde surgiu uma fístula arteriovenosa cutânea pós-traumática, documentada por meio de angiografia digital. Tanto o doente quanto a equipe médica optaram por conduta não cirúrgica, e o doente segue assintomático no seguimento ambulatorial, sem modificação da fístula desde seu diagnóstico.

The authors describe a 34 years old men with cutaneous vascular disorder after a cranial injury suffered three months ago. Subsidiary investigation by angiography showed a cutaneous arteriovenous malformation. The men asymptomatic, have a non-surgical conduct and he is very well after three years.

Evaluation of occupational and patient dose in cerebral angiography procedures / Avaliação da dose ocupacional e de pacientes adultos em procedimentos de angiografia cerebral

Objective The present study was aimed at estimating the doses received by physicians and patients during cerebral angiography procedures in a public hospital of Recife, PE, Brazil. Materials and Methods The study sample included 158 adult patients, and during the procedures the following parameters were evaluated: exposure parameters (kV, mAs), number of acquired images, reference air kerma value (Ka,r) and air kerma-area product (PKA). Additionally, the physicians involved in the procedures were evaluated as for absorbed dose in the eyes, thyroid, chest, hands and feet. Results The results demonstrated that the doses to the patients' eyes region were relatively close to the threshold for cataract occurrence. As regards the physicians, the average effective dose was 2.6 µSv, and the highest effective dose recorded was 16 µSv. Conclusion Depending on the number of procedures, the doses received by the physicians may exceed the annual dose limit for the crystalline lenses (20 mSv) established by national and international standards. It is important to note that the high doses received by the physicians are due to the lack of radiation protection equipment and accessories, such as leaded curtains, screens and protective goggles. .

Proteção cerebral em pacientes idosos durante implante de stent carotídeo / Cerebral protection in elderly patients during carotid stenting

INTRODUÇÃO: O tipo de proteção cerebral utilizado durante o implante de stent carotídeo é controverso em idosos. Nosso objetivo foi avaliar os resultados dos dispositivos de proteção embólica cerebral (PEC), proximal e distal, em pacientes > 70 anos de idade, por meio da ressonância magnética ponderada de difusão (RM-PD). MÉTODOS: Entre 2008 e 2011, 60 pacientes com indicação de stent carotídeo foram randomizados para PEC com Mo.Ma® ou Angioguard®, dos quais 26 tinham > 70 anos de idade. Os resultados da RM-PD realizada antes e 48 horas após o procedimento foram avaliados por neuro­logista independente e cego para o tipo de PEC utilizado. Foram analisados o número de novos focos isquêmicos, sua localização e o tamanho. RESULTADOS: Novos focos isquêmicos cerebrais foram encontrados em 8/12 (66,7%) pacientes do grupo Mo.Ma® e em 12/14 (85,7%) pacientes do grupo Angioguard® (P = 0,37). A maioria das lesões (> 90%) era ipsilateral à artéria tratada em ambos os grupos, e o tamanho das lesões foi < 0,5 cm na maioria dos casos. O número de lesões por paciente foi menor com o dispositivo Mo.Ma® (mediana [variação]: 3 [1 a 8] lesões vs. 15 [2 a 76] lesões; P < 0,001). Todos os pacientes que tiveram mais de 40 lesões pertenciam ao grupo Angioguard®. CONCLUSÕES: Mesmo utilizando PEC (proximal ou distal), novas lesões isquêmicas foram observadas em ambos os grupos em pacientes idosos. Proporcionalmente maior número de pacientes com Angioguard® teve novos focos isquêmicos se comparados aos pacientes do grupo Mo.Ma®. O dispositivo de PEC Mo.Ma® parece diminuir o número de lesões por paciente.

BACKGROUND: The type of cerebral protection used during carotid stenting in the elderly is controversial. Our objective was to evaluate the results of proximal and distal cerebral embolic protection devices (EPDs), in patients > 70 years through diffusion-weighted magnetic resonance imaging (DW-MRI). METHODS: Between 2008 and 2011, 60 patients with indication for carotid stenting were randomized to EPD with Mo.Ma® or Angioguard®, of which 26 patients were > 70 years of age. Results of DW-MRI performed before and 48 hours after the procedure were evaluated by an independent neurologist blinded to the type of EPD used. New ischemic lesions, their localization and size were analyzed. RESULTS: New cerebral ischemic lesions were found in 8/12 (66.7%) patients in the Mo.Ma® group and 12/14 (85.7%) patients in the Angioguard® group (P = 0.37). The vast majority of the lesions (> 90%) were ipsilateral to the treated artery in both groups and the size of the lesions was < 0.5 cm in most cases. The number of lesions per patient was lower with the Mo.Ma® device (median [variation]: 3 [1 to 8] lesions vs 15 [2 to 76] lesions; P < 0.001). All of the patients with more than 40 lesions were in the Angioguard® group. CONCLUSIONS: Despite the use of EPDs (proximal or distal), new ischemic lesions were observed in both groups in elderly patients. A proportionately larger number of patients with Angioguard® had new ischemic lesions when compared to those with Mo.Ma®. The Mo.Ma® device seems to decrease the number of lesions per patient.