Endovascular and surgical approaches of ethmoidal dural fistulas: a multicenter experience and a literature review.

Ethmoidal dural arteriovenous fistulae are rare vascular malformations associated with a high risk of bleeding. We present a multicenter contemporary series of patients treated with microsurgical and endovascular techniques. Sixteen consecutive patients were evaluated and/or treated between 2008 and 2015 at four centers with large experience in the endovascular and surgical treatment of cerebrovascular diseases. We analyzed demographic and clinical data, risk factors for dural fistulas, treatment type, peri- and post-operative morbidity, clinical and radiological outcomes, rates of occlusion, and long-term neurological outcome. Sixteen patients (81 % men, mean age of 58 years) with ethmoidal dural fistulas were included in the analysis. Seven patients had suffered an intracranial hemorrhage; the remaining presenting with neurological signs and symptoms or the fistula was an incidental finding. Three patients were managed conservatively. Among patients who underwent intervention (n = 13), 46.1 % were treated with endovascular therapy and 53.9 % were treated surgically. Complete angiographic obliteration was achieved in 100 % immediately after treatment and at last follow-up evaluation. All patients experienced a favorable neurological recovery (mRS 0-2) at the last follow-up visit (12 months). Ethmoidal dural AVFs are found mostly in male patients. Nowadays, due to wider use of non-invasive imaging, AVFs are discovered with increasing frequency in patients with minimal or no symptoms. Traditionally, these fistulas were considered "surgical." However, in the modern endovascular era, selected patients can be effectively and safely treated with embolization although surgical ligation continues to have an important role in their management.

Endovascular treatment of pulmonary and cerebral arteriovenous malformations in patients affected by hereditary haemorrhagic teleangiectasia.

Hereditary Haemorrhagic Teleangiectasia (HHT) is a vascular disorder of angiogenesis transmitted in an autosomal dominant pattern, characterised by heterogeneity in clinical manifestations. One of the most important organ involved is lung, including pulmonary arteriovenous malformations (PAVM). PAVM occur in 20 to 30% of the HHT population and recently are considered a marker of disease. PAVM are direct artery-to-vein connections with low pressure and without an interveining capillary bed. PAVM are classified as simple (supplied by one feeding artery) or complex (receiving blood supply from two or more feeding artery). According to the international reports, treatment it's recommendable for all PAVM with feeding vessels 3mm or larger, in order to reduce the risk of cerebral ischaemia and neurologic manifestations frequently attributed to paradoxical embolisation. Transcatheter embolotherapy of PAVM is a form of treatment based on occlusion of the feeding artery to a PAVM by using platinum coils or detachable balloons. The technique of coil embolisation involves the exact localisation of PAVM by pulmonary angiography followed by superselective percutaneous caheterisation of feeding artery obtained by using a dedicated 7F guiding catheter, which coaxially allocates a 5F hydrophilic catheter advanced in order to perform both superselective angiography of feeding artery and embolisation itself. Inside the 5F catheter the platinum coils are advanced using a .035'' guide-wire and released until an optimal occlusion of feeding artery is achieved. At the end of the procedure angiographic control is performed in order to verify the occlusion of feeding artery. The use of platinum coils is preferable over detachable balloons when feeding artery are greater than 7 mm in diameter and have irregular anatomical configuration. On the other hand, the principal advantage of using detachable balloons is that the balloon itself can be deflated and repositioned if necessary. Transcatheter embolotherapy is technically safe and clinically effective and may represent the primary choice of treatment in HHT patients. On the other hand the most common complications of this treatment (pleurisy and air embolism) can be prevented by using some tips during the embolisation procedure like "anchor technique," "scaffold technique" and "balloon assisted technique." Cerebral arteriovenous malformations (CAVM) are present in 10-20% of patients with HHT and multiple in 50% of cases. Cortical surface is the most frequent localisation. Angiography is needed to diagnose all CAVM and to clarify the angioarchitecture of the lesion. In HHT CAVM are usually either micro-AVM, with a nidus not bigger than 1 cm, or small AVM, with a nidus between 1 and 3 cm. Quite frequently there are lesions characterised by arteriovenous fistulas. In the three patterns of CAVM usually found in HHT, small AVM are the most risky for bleeding although the risk is lower than that associated with sporadic ones. It is estimated from 0.38 to 0.69% per year in spite of the general incidence of bleeding in sporadic CAVM that ranges from 2 to 4% per year. In HHT patients, at present, the precise indications and timing of treatment are not established. Trend is to treat small AVM and AVF and to follow-up micro-AVM with MRI and angiography. As for sporadic CAVM, treatment of small AVM is usually referred to stereotactic radiosurgery. Endovascular embolisation is proposable if the lesion is easily reachable by microcatheterism and the position of the microcatheter is safe. Glue is used for embolisation and the technique is briefly discussed.

[Percutaneous mechanical revascularization of chronic iliac artery occlusion with "first intention" stent placement]. / Rivascolarizzazione meccanica percutanea delle occlusioni croniche dell'arteria iliaca mediante posizionamento "di prima intenzione" di stent.

INTRODUCTION: Percutaneous treatment of chronic iliac artery occlusion has not yet gained complete acceptance as the method of choice. The reason of this widespread skepticism are the poor results achieved with angioplasty and/or lysis therapy. The introduction of stents seems to open new perspectives to percutaneous treatment and the latest follow-up studies report encouraging results. MATERIAL AND METHODS: We report our personal experience in percutaneous mechanical revascularization of chronic iliac occlusion with primary stent placement in 29 patients with 2 years' maximum follow-up. Clinically the patients had at least 3 months' claudication and were in Fontaine stages II to IV. The occlusion was passed mechanically using a hydrophilic guide wire, through the contralateral access in 19 cases and ipsilaterally in 10. The stents were primarily implanted in the last 12 patients; in the first 15 patients, after dilatation with undersized balloons, 25 Wallstent and 12 Palmaz stents were implanted. Each patient underwent color Doppler follow-up for 3-24 months. Nine patients underwent angiography too, after one year. RESULTS: The mechanical passage of the guide-wire through the occluded segment was successful in 27 of 29 (93.1%) patients referred for percutaneous revascularization of a chronic occlusion of the iliac artery. The stent was placed and immediate patency was achieved in 100% of these 27 patients. Clinical improvement was of two stages in 24 patients and of one stage in 3 patients. The follow-up showed neither reocclusions nor critical stenoses of the restored iliac segment. Five embolic complications (5%) occurred after angioplasty, all of them treated percutaneously; surgery was never necessary. DISCUSSION AND CONCLUSIONS: The follow-up studies published in the literature in the last few years and our personal experience encourage the percutaneous treatment of chronic iliac artery occlusions. Percutaneous mechanical revascularization with primary stent positioning can be proposed because it is a reliable and efficacious tool, particularly in young patients in whom a surgical aortoiliac or aortofemoral bypass might injure the pudendal plexis and cause sexual disturbances.

Magnetic resonance imaging of normal and pathologic fetal brain.

A total of 78 pregnant patients who had previously been studied by ultrasound (US) underwent magnetic resonance (MRI) because of suspected fetal abnormality. The first 20 cases were performed using fetal curarization. Even in the 27 cases in which the MR examination concerned other body regions, a brain study was always performed to analyze the normal anatomy at different gestational ages. There is a brief discussion on normal MRI anatomy of the fetal brain. There were 45 studies that concerned central nervous system pathology, and the most frequent malformative and neoplastic disorders were revealed. A comparison between MRI and US is proposed for each. In conclusion, MRI can be regarded as a complementary method that can be helpful in the rare cases when the US diagnosis is doubtful.

Neurophysiological abnormalities in adrenoleukodystrophy carriers. Evidence of different degrees of central nervous system involvement.

We studied 19 women, heterozygous for adrenoleukodystrophy (ALD) in whom the carrier status was demonstrated by abnormally high plasma levels of very-long-chain fatty acids. Clinical examination revealed slight neurological signs in two patients. Clear-cut neurological deficits in three, and it was fully normal in the remaining 14. All subjects underwent motor evoked potential (MEP) and somatosensory evoked potential (SEP) studies. Seventeen out of 19 subjects underwent brain MRI which demonstrated various degrees of abnormality in one asymptomatic and five symptomatic subjects; SEPs and MEPs revealed CNS involvement in 12 and 8 out of the 19 subjects, respectively. Symptomatic patients showed severe neurophysiological abnormalities, whereas milder but unequivocal EP abnormalities were found in seven of the 14 patients with normal clinical examination. Our data thus suggest CNS involvement in the majority of the ALD carriers, evident also in preclinical stages and progressively severe. The possibility of assessing different degrees of neurological involvement could be relevant for therapeutical purposes. Moreover, neurophysiological studies could provide the only objective marker of functional nervous system involvement, e.g. in order to monitor the efficacy of treatment, and in clinically and radiologically silent cases.

Doppler US in interventional neuroradiology.

Doppler ultrasonography and transcranial Doppler ultrasonography can be applied to the study of the hemodynamic aspects of cerebrovascular disease curable with intravascular therapy. There are three stages where Doppler ultrasonography is considered appropriate: 1) in the diagnosis of cerebrovascular disease to study its hemodynamics and support the therapeutic approach; 2) during the interventional procedure to assess the hemodynamic modifications while therapy is administered; 3) in posttreatment control and in follow-up. The role and findings of transcranial Doppler ultrasonography and Doppler sonography in cerebral arteriovenous malformations, in dural arteriovenous malformations, in arteriovenous fistulae of large vessels in cerebral aneurysms and in steno-obstructive disease, are considered.

CNS cryptococcosis in AIDS: spectrum of MR findings.

Cryptococcus is a ubiquitous saprophytic fungus that may become pathogenic, particularly in immunosuppressed patients. In the CNS of AIDS patients, the incidence of this fungal infection is 5% of all the opportunistic infections. In this study, we review the MR findings in nine AIDS patients affected by CNS cryptococcosis. All MR studies were performed before and after intravenous administration of a single dose of gadopentetate dimeglumine and again after an additional dose. Autopsy was performed in one case. Magnetic resonance imaging revealed evidence of meningitis or meningoencephalitis, dilated Virchow-Robin spaces, cyst-like structures (gelatinous pseudocysts), and granulomas (cryptococcomas) of the choroid plexuses. The last two findings (pseudocysts and choroidal ependymal granulomas) are relatively specific for cryptococcosis.