Endovascular treatment of intracranial aneurysms using the Pipeline Flex embolization device: a case series of 30 consecutive patients.

BACKGROUND: The Pipeline Flex embolization device has some peculiarities in comparison with the previous generation device. Despite recent reports of the modified delivery system, its safety is still unknown. OBJECTIVE: To illustrate the intraprocedural and periprocedural complication rate with this new device in 30 consecutive patients. MATERIAL AND METHODS: Clinical, procedural, and angiographic data, including aneurysm size and location, device or devices used, angiographic and clinical data were analyzed. RESULTS: 30 patients harboring 30 aneurysms were analyzed. 39 devices were placed properly. Multiple Pipeline embolization devices (PEDs) were used in 7 cases. In 28 devices the distal end opened fully from the beginning with a complete wall apposition. In the remaining 11 devices, distal-end opening of the devices was instant but partial, but fully opened easily after recapture. Among the 30 procedures, recapture and reposition of the Pipeline Flex was performed four times owing to proximal migration/malposition of the device during delivery. Four intraprocedural/periprocedural complications occurred, of which 2 resulted in major complications, with neurologic deficits persisting for longer than 7 days. The 30-day morbidity rate was 6.6%, with no deaths. No aneurysm rupture or parenchymal hemorrhage was seen. CONCLUSIONS: The Pipeline Flex embolization device allows more precise and controlled deployment than the first-generation device. The number of devices and the complication rate during the learning curve are lower than reported with the first-generation PED. The new delivery system and the resheathing maneuvers do not seem to increase the intraprocedural complication rate in comparison with the first-generation PED.

A collaborative system for endovascular treatment of acute ischaemic stroke: the Madrid Stroke Network experience.

BACKGROUND AND PURPOSE: The complexity and expense of endovascular treatment (EVT) for acute ischaemic stroke (AIS) can present difficulties in bringing this approach closer to the patients. A collaborative node was implemented involving three stroke centres (SCs) within the Madrid Stroke Network to provide round-the-clock access to EVT for AIS. METHODS: A weekly schedule was established to ensure that at least one SC was 'on-call' to provide EVT for all those with moderate to severe AIS due to large vessel occlusion, >4.5 h from symptom onset, or within this time-window but with contraindication to, or failure of, systemic thrombolysis. The time-window for treatment was 8 h for anterior circulation stroke and <24 h in posterior stroke. Outcomes measured were re-canalization rates, modified Rankin Scale (mRS) score at 3 months, mortality and symptomatic intra-cranial haemorrhage (SICH). RESULTS: Over a 2-year period (2012-2013), 303 candidate patients with AIS were considered for EVT as per protocol, and 196 (65%) received treatment. Reasons for non-treatment were significant improvement (14%), spontaneous re-canalization (26%), clinical worsening (9%) or radiological criteria of established infarction (31%). Re-canalization rate amongst treated patients was 80%. Median delay from symptom onset to re-canalization was 323 min (p25; p75 percentiles 255; 430). Mortality was 11%; independence (mRS 0-2) was 58%; SICH was 3%. CONCLUSIONS: Implementation of a collaborative network to provide EVT for AIS is feasible and effective. Results are good in terms of re-canalization rates and clinical outcomes.

Preliminary experience with the Pipeline Flex Embolization Device: technical note.

BACKGROUND: Clinical experience with the Pipeline Embolization Device (PED) has been widely described in the literature since it obtained its European CE and FDA approvals in 2008 and 2011, respectively. The new generation of PED, the Pipeline Flex Embolization Device, received the CE mark of approval in March 2014. While the implant composition has not changed, its new delivery system has some differences. One of the main changes from the previous generation is a new delivery system that makes the device resheathable until deployed over 90% of its length. We present our preliminary experience using this device. METHODS: Between May and June 2014, six patients with six aneurysms were treated with the Pipeline Flex device. RESULTS: All devices were placed properly, without technical difficulties. We successfully resheathed and repositioned the device in two cases. Minor and major intraprocedural or periprocedural events were noted. CONCLUSIONS: The Pipeline Flex device allows more precise and controlled deployment than the current PED device. Although this preliminary experience seems positive, multicenter larger series will be needed to confirm the safety and durability of this new device.

Pipeline endovascular device for the treatment of intracranial aneurysms at the level of the circle of Willis and beyond: multicenter experience.

BACKGROUND AND PURPOSE: The aim of our study was to evaluate the safety and efficacy of the pipeline endovascular device for the treatment of anterior circulation aneurysms at the level of the circle of Willis and beyond. METHODS: A consecutive series of 25 patients (24 unruptured and one ruptured) with anterior circulation aneurysms treated with a pipeline endovascular device were included in the analysis. RESULTS: We found two minor clinical events (resolved within 7 days of the procedure), one major event (symptoms present after 7 days), and no mortality. There were no aneurysm ruptures or parenchymal hemorrhages during follow-up. The modified Rankin Scale (mRS) scores at 3 and 6 months did not change from the prior mRS score for all cases except 1. There was one asymptomatic periprocedural event. There were three intraprocedural complications which resolved without clinical consequences. Six month follow-up angiograms were obtained for 22 aneurysms, showing complete occlusion in 14 (64%) and significantly decreased residual filling in 8 (36%). The status of branches originating from the aneurysm sacs was evaluated in 14 angiograms: 11 were patent (79%), 2 had moderate reduction (14%) and 1 (7%) was occluded. We found six cases of in-stent stenosis (27%) on 6 month DSA, with only one symptomatic case. CONCLUSIONS: The pipeline embolization device provides a feasible and technically safe solution for aneurysms at and beyond the circle of Willis. Preliminary results are promising but larger series with longer term follow-up examinations are required to show the long term safety and durability of this treatment alternative.

Guidelines for the treatment of acute ischaemic stroke.

INTRODUCTION: Update of Acute Ischaemic Stroke Treatment Guidelines of the Spanish Neurological Society based on a critical review of the literature. Recommendations are made based on levels of evidence from published data and studies. DEVELOPMENT: Organized systems of care should be implemented to ensure access to the optimal management of all acute stroke patients in stroke units. Standard of care should include treatment of blood pressure (should only be treated if values are over 185/105 mmHg), treatment of hyperglycaemia over 155 mg/dl, and treatment of body temperature with antipyretic drugs if it rises above 37.5 °C. Neurological and systemic complications must be prevented and promptly treated. Decompressive hemicraniectomy should be considered in cases of malignant cerebral oedema. Intravenous thrombolysis with rtPA should be administered within 4.5 hours from symptom onset, except when there are contraindications. Intra-arterial pharmacological thrombolysis can be considered within 6 hours, and mechanical thrombectomy within 8 hours from onset, for anterior circulation strokes, while a wider window of opportunity up to 12-24 hours is feasible for posterior strokes. There is not enough evidence to recommend routine use of the so called neuroprotective drugs. Anticoagulation should be administered to patients with cerebral vein thrombosis. Rehabilitation should be started as early as possible. CONCLUSION: Treatment of acute ischaemic stroke includes management of patients in stroke units. Systemic thrombolysis should be considered within 4.5 hours from symptom onset. Intra-arterial approaches with a wider window of opportunity can be an option in certain cases. Protective and restorative therapies are being investigated.

[Neurovascular intervention in the acute phase of cerebral infarction]. / Intervencionismo neurovascular en la fase aguda del infarto cerebral.

BACKGROUND AND PURPOSE: Endovascular therapies in acute ischaemic stroke may offer benefits to patients that are not eligible for standard use of intravenous tissue activator plasminogen (iv t-PA) or when this is not effective. Our aim is to present the initial experience in with endovascular techniques in the Community of Madrid. METHODS: We present data from our registry of acute ischaemic strokes treated with endovascular re-perfusion therapies in five University Hospitals in Madrid (Spain) during the period 2005-2009. We recorded demographic data, vascular risk factors, risk severity with the NIHSS (National Institute of Health Stroke Scale), endovascular techniques, complications and mortality rates. Functional outcome and neurological disability at 90 days was defined by the modified Rankin scale (mRs). RESULTS: A total of 41 patients were treated with endovascular therapies. Mean age was 58.6 ± 19.9, and 56.1% were males. Of those 22 patients had an anterior circulation stroke and 19 had a posterior circulation stroke. Baseline NIHSS score was: median, 17 [range, 2-34]; 7 patients had previously received iv t-PA. The following endovascular techniques were performed: mechanical disruption (26 patients), intra-arterial infusion of t-PA (26 patients), angioplasty and stenting (5 patients), mechanical use of MERCI device (3 patients). Partial or total re-canalization was achieved in 32 patients (78%). Only one patient had a symptomatic cerebral haemorrhage. Three months after stroke, 53.6% of the patients were independent (mRs ≤ 2) and overall mortality rate was 19.5%. CONCLUSIONS: Acute ischaemic stroke is a potentially treatable medical emergency within the first hours after the onset of symptoms. Stroke endovascular procedures constitute an alternative for patients with iv t-PA exclusion criteria or when this is not effective.

Intervencionismo neurovascular en la fase aguda del infarto cerebral / Endovascular treatment for acute stroke: an open field to begin

Introducción: La evidencia de que la recanalización y la reperfusión del lecho vascular distal de pacientes adecuadamente seleccionados son fundamentales para lograr un buen pronóstico funcional ha disparado el interés y la investigación sobre el tratamiento endovascular del ictus isquémico agudo. Desarrollo: La fibrinólisis intravenosa (i.v.) es el tratamiento de elección en pacientes con ictus isquémico agudo, aunque presenta ciertas limitaciones. El tratamiento endovascular supone una alternativa prometedora con ventajas teóricas sobre el tratamiento i.v., como una mayor frecuencia de recanalización y mayor ventana terapéutica. Las estrategias de reperfusión endovascular incluyen fibrinólisis intraarterial con fármacos o tratamiento mecánico con dispositivos que permiten extracción, aspiración, disrupción o atrapamiento del trombo en la pared. El ideal del tratamiento integral del ictus agudo sería aportar especificidad al paciente individual: tratar una oclusión arterial con unas colaterales y con una fisiología de la isquemia cerebral aguda determinadas. Con todos estos datos, ante cualquier paciente podremos decidir la mejor estrategia terapéutica y pasar de un enfoque del paciente basado únicamente en el tiempo a un enfoque basado también en la fisiopatología; por lo tanto, distintos pacientes tendrían diferentes ventanas terapéuticas. La situación del tratamiento endovascular en España es heterogénea y precisa de recursos materiales y humanos para conseguir su implantación en todo el territorio. Conclusiones: El tratamiento endovascular del ictus supone una nueva herramienta terapéutica para lograr la reperfusión de una forma segura en los pacientes no candidatos a alteplasa o que no han conseguido reperfundir con el fibrinolítico i.v (AU)

Introduction: The evidence that recanalization and reperfusion of the distal vascular bed in appropriately selected patients is crucial to achieve good functional outcome has triggered interest and research into endovascular treatment of acute ischemic stroke.Development: Intravenous (iv) thrombolytic therapy is the treatment of choice in patients with acute ischemic stroke, however, it has certain limitations. Endovascular treatment is a promising alternative with theoretical advantages over iv therapy, such as an increased frequency of recanalization and longer therapeutic windows. Endovascular reperfusion strategies include intra-arterial fibrinolysis with drugs, or endovascular mechanical devices for thrombectomy or thrombus disruption, thromboaspiration, or thrombus entrapment in the vessel wall. The ideal of comprehensive treatment of acute stroke would provide specificity to treat an individual patient: with specific arterial occlusion and collaterals and a determined physiology of acute cerebral ischemia. With all this information, we would decide the best therapeutic strategy for the patient, and move from just a time-based approach to include a pathophysiology approach as well, and thus different patients could have different therapeutic windows. The endovascular treatment situation in Spain is heterogeneous and requires human and material resources to enable it to be implemented throughout the country. Conclusions: Endovascular treatment of stroke is a new therapeutic tool for achieving reperfusion safely in patients ineligible for Alteplase or who have failed reperfusion with an iv fibrinolytic (AU)

Diagnóstico y tratamiento del insulinoma: nuestra experiencia en 10 casos / Diagnosis and treatment of insulinoma: review of 10 patients

Objetivo Revisión de la presentación clínica, la sensibilidad y la especificidad de las diferentes técnicas de localización utilizadas y de los tratamientos empleados en pacientes con insulinoma. Pacientes y métodos Estudio restrospectivo y descriptivo de pacientes con diagnóstico de insulinoma intervenidos en nuestro centro durante el período de 1992 a 2004. Se evaluaron la edad, el sexo, la clínica, los valores de insulina y de glucosa, los resultados de estudios de localización, la técnica quirúrgica, las características anatomopatológicas y la morbimortalidad. Resultados Se estudió a 10 pacientes, un 60% mujeres, con una edad de 58 ± 14 años. La clínica fue de neuroglucopenia en el 90% y síntomas simpatoadrenérgicos en el 50%. En todos los casos se demostró una relación insulina/glucosa elevada. Las tasas de detección del tumor fueron, para la ecografía transabdominal del 22%, para la tomografía computarizada del 50%, para la resonancia magnética del 33% y para la gammagrafía con octreótido marcado del 25%; con estas técnicas se localizó el 50% de los tumores. La arteriografía con inyección de calcio y la ecografía intraoperatoria identificaron el tumor en todos los casos en los que se realizaron. Dos pacientes tenían insulinomas malignos con metástasis ganglionares. La cirugía fue la enucleación en 5 casos, resección distal del páncreas en 3 y duodenopancreatectomía cefálica en 2. En ningún caso el insulinoma se asoció a neoplasia endocrina múltiple tipo 1. No existió mortalidad postoperatoria. Todos los pacientes estaban asintomáticos, al menos, 6 meses tras la cirugía. Conclusiones La arteriografía con inyección intraarterial de calcio es la prueba de localización preoperatoria más sensible, pero debido a su complejidad debe reservarse para pacientes con insulina sin diagnóstico de localización previo. La alta sensibilidad y el bajo coste de la ecografía intraoperatoria la convierten en una técnica sencilla y muy útil durante el procedimiento quirúrgico, tanto para la localización del tumor como para la valoración de su extensión (AU)

Objective To evaluate clinical features, the sensitivity and specificity of preoperative imaging techniques, and treatment in patients with insulinoma. Patients and methods All patients treated in our institution for surgically proven insulinoma between 1992 and 2004 were retrospectively reviewed. Age, sex, symptoms, insulin and glucose levels, imaging studies, surgical technique, pathological results, morbidity and mortality were analyzed. Results Ten patients with pancreatic insulinomas were included. The mean age was 58 ± 14 years and 60% were women. Clinical findings included neuroglycopenia in 90% and/or sympathoadrenal symptoms in 50%. In all patients, a high insulin/glucose ratio was demonstrated. The detection rates were 22% for transabdominal ultrasonography, 50% for computed tomography (CT), 33% for magnetic resonance imaging and 25% for 111-In-octreotide imaging. Using these techniques, 50% of the tumors were detected. Selective arterial calcium stimulation with hepatic venous sampling and intraoperative ultrasonography identified the tumor in all patients who underwent these techniques. Two patients had malignant insulinomas with nodal metastases. Surgical procedures included enucleation of insulinoma in five patients, partial distal pancreatectomy in three patients and the Whipple procedure in two patients. None of the patients had associated multiple endocrine neoplasia type 1. There was no postoperative mortality. All patients were symptom-free for at least 6 months after surgery. Conclusions Selective arterial calcium stimulation is the most sensitive preoperative test but, due to its complexity, it should be reserved for difficult cases. Because of its high sensitivity and low cost, intraoperative ultrasonography is a very useful intraoperative technique to evaluate localization and/or extension of the insulinoma (AU)

Arteriovenous fistula after temporomandibular joint arthroscopy successfully treated with embolization.

Temporomandibular joint arthoscopy is a minimal invasive surgical procedure commonly used to effectively treat some internal derangement of the TMJ. However, this method is not free of complications. Arteriovenous fistula (AVF) is a lesion that communicates the high flow arterial system and the low flow venous network. We describe a new case of preauricular traumatic AVF successfully treated with external carotid embolization, along with a review of the medical literature.

[Fusiform aneurysm of the middle cerebral artery]. / Aneurisma fusiforme de la arteria cerebral media.

Introduction. The main objective of the treatment of intracranial aneurysms is to isolate them from the cerebral blood circulation. A fusiform aneurysm, because of its shape, cannot be treated using the usual techniques and usually requires techniques of arterial reconstruction and revascularization using by pass. Currently it is possible to find the vascular territories with the greatest risk of causing neurological defects and where revascularization is necessary. CASE REPORT. A 20 year old man with no previous history of illness who had several transient ischaemic episodes. Emergency laboratory tests, ECG and plain chest Xray were all normal. Imaging investigations showed the presence of a fusiform aneurysm of the anterosuperior division of the right middle cerebral artery. No associated systemic disease was detected. Wada s test showed the vascular territory with the greatest risk of neurological deficit. Extra intra cranial by pass was done from the right superficial temporal artery to the distal portion of the anteriorsuperior branch of this artery. The operation was done using a right pterion approach with dissection of the superficial temporal artery, and the aneurysm, trapping and termino lateral anastomosis. Cerebral protectors and mild hypothermia were used during the operation. The post operative course was uneventful. Anatomo pathological diagnosis was of an atherosclerotic fusiform aneurysm with osseous and chondroid metaplasia. After six months follow up the patient remains asymptomatic. Discussion and conclusions. Treatment of fusiform cerebral aneurysms is complex and usually requires procedures for cerebral revascularization. Correct pre operative evaluation is essential to identify the vascular territory with the greatest risk of causing neurological deficit. Wada s test is useful for this, since it permits selective evaluation of the different vascular territories safely and quickly. High or low flow by pass of these territories prevents cerebral ischaemia and permits the treatment of choice for these aneurysms.

Aneurisma fusiforme de la arteria cerebral media / Fusiform aneurysm of the middle cerebral artery

Introducción. El objetivo principal del tratamiento de los aneurismas intracraneales es su aislamiento de la circulación sanguínea cerebral. El aneurisma fusiforme, por su morfología no puede tratarse con las técnicas habituales y suele requerir técnicas de reconstrucción arterial y revascularización mediante by-pass. Actualmente podemos conocer los territorios vasculares que tienen mayor riesgo de producir déficit neurológico y donde es necesaria la revascularización. Caso clínico. Varón de 20 años de edad sin antecedentes personales de interés que sufre varios episodios de accidentes isquémicos transitorios. La analítica de urgencias, el ECG y la radiografía simple de tórax fueron normales. Las pruebas de imagen demostraron la presencia de un aneurisma fusiforme en la división anterosuperior de la arteria cerebral media derecha. No se demostraron otras enfermedades sistémicas asociadas. El test de Wada demostró el territorio vascular con mayor riesgo de déficit neurológico. Se realizó un by-pass extraintracraneal desde la arteria temporal superficial derecha a la porción distal de dicha rama anterosuperior. La intervención se realizó mediante un abordaje pterional derecho junto con disección de la arteria temporal superficial, disección del aneurisma, atrapamiento y anastomosis termino lateral. Durante la intervención se utilizaron protectores cerebrales e hipotermia ligera. El postoperatorio transcurrió sin complicaciones. El diagnóstico anatomopatológico fue de aneurisma fusiforme ateroesclerótico con metaplasia ósea y condroide. A los seis meses de evolución el paciente se encuentra asintomático. Discusión y conclusiones. El tratamiento de los aneurismas fusiformes cerebrales es complejo y suele requerir un procedimiento de revascularización cerebral. Es fundamental una correcta evaluación preoperatoria que identifique los territorios vasculares con mayor riesgo de producir déficit neurológico. El test de Wada es útil en este sentido, ya que permite evaluar de forma selectiva los diferentes territorios vasculares de forma segura y rápida. El by-pass de alto o bajo flujo en dichos territorios previene la isquemia cerebral y resulta el tratamiento de elección en este tipo de aneurismas (AU)

[The rupture of a cardiac hydatid cyst located in the right ventricle]. / Rotura de un quiste hidatídico cardíaco situado en ventrículo derecho.

Heart involvement in echinococcal disease is rare, but it is more infrequent the location of cysts in the right ventricle. We report a case of a male 35 years old with hydatid cysts located in the right ventricle. The condition was diagnosed by two-dimensional echocardiogram performed after the rupture of the cysts leading to massive pulmonary embolism and subsequently right heart failure. Early diagnosis appears mandatory in an attempt to modify, applying the appropriate therapy, the natural evolution of this potentially lethal condition.

[Cranio-orbital neurofibrosarcoma]. / Neurofibrosarcome cranio-orbitaire.

We present a type 1 neurofibromatosis case with sarcomatous degeneration of a cranio-orbital neurofibroma, its surgical evolution and the cytogenetics and cellular proliferative potential features (CMF, Ki-67 antibody).