Multimodal management of ruptured cerebral micro-arteriovenous malformations: A retrospective series of 19 cases and a review of the literature.

BACKGROUND: Micro-arteriovenous malformations (micro-AVMs) are defined as AVMs just visible on angiography with a nidus size between 0.5 and 1cm. Their principal manifestation is intracranial hemorrhage and their diagnosis and therapeutic management are still unclear. METHODS: The aim of our work was to show the clinical presentation, treatment and outcome of ruptured cerebral micro-AVMs in a retrospective cohort study of 19 patients and a systematic review of the literature. RESULTS: We obtained a total of 20 micro-AVMs in 19 patients. The mean age was 47.3 years. Clinical presentation was acute bleeding. The mean volume of hematoma was 12.9 mm3 (0 - 60.4), with topographic distribution as follows: 64% cortical with supratentorial bleeding, 26% deep, and 10% in the posterior fossa. Among the 20 micro-AVMs of the series, 11 (55%) had endovascular management, 6 (30%) had surgical treatment and 3 (15%) had GK radiosurgery alone. All of our patients have been cured at the end of the follow up without re-permeabilization. In our series, clinical outcome showed good recovery with a mean score of 4.6 on Glasgow Outcome Scale (GOS). In the literature, 88% of patients had a GOS of 4 or 5. DISCUSSION: Intracerebral hematoma (ICH) was the main clinical manifestation. In the case of negative initial angiographic assessment, patients must have supraselective angiographic exploration. In the case of conservative treatment of hematoma, endovascular obliteration and microsurgical exclusion seems to be reasonable therapeutic options, according to our observations.

A randomized controlled study assessing outcome, cognition, autonomy and quality of life in over 70-year-old patients after aneurysmal subarachnoid hemorrhage.

BACKGROUND: Current aging of the population with good physiological status and the increasing incidence of subarachnoid hemorrhage (SAH) in elderly patients has enhanced the benefit of treatment in terms of independence and long-term quality of life (QoL). METHODS: From November 1, 2008 to October 30, 2012, 351 patients aged 70 years or older with aneurysmal SAH underwent adapted treatment: endovascular coiling (EV) for 228 (65%) patients, microsurgical clipping (MS) for 75 (29.3%) or conservative treatment for 48 (13.7%). Forty-one of these were randomized to EV (n=20) or to MS (n=21). The objectives were to determine the proportion of patients with modified Rankin Scale score≤2 (independence) at 1 year, and, secondarily, to compare cognitive function on the Mini-Mental State Examination (MMSE), autonomy on the Activities of Daily Living Index (ADLI) and Instrumental Activities of Daily Living scale (IADL), and QoL, in the prospective and randomized arms, at 1 year. RESULTS: At 1 year, with 1 loss to follow-up in the EV arm, 11 patients (55%) were independent after EV occlusion and 8 (38.1%) after MS exclusion, without significant difference (P=0.29). Mortality was higher after MS during the first 2 postoperative months, and thereafter the difference between MS and EV ceased to be significant. Cognitive function and autonomy scores were similar in both arms. CONCLUSION: In elderly patients treated for aneurysmal SAH, approximately 50% were independent at 1 year, with conserved cognition and autonomy. EV and MS are valid procedures in this population, with similar results at 1 year in terms of independence, cognition, autonomy, and QoL.

WEB Treatment of Intracranial Aneurysms: Clinical and Anatomic Results in the French Observatory.

BACKGROUND AND PURPOSE: Flow disruption with the WEB device is a new technique for the endovascular treatment of wide-neck bifurcation aneurysms. To obtain precise data regarding the safety and efficacy of this treatment with high-quality methodology, the prospective French Observatory study was conducted. Analysis of these data is presented, including 1-year follow-up. MATERIALS AND METHODS: Patients with bifurcation aneurysms for which WEB treatment was indicated were included in this prospective, multicenter Good Clinical Practice study. Clinical data, including adverse events and clinical status at 1 month and 1 year, were collected and independently analyzed by a medical monitor. An independent core laboratory evaluated the anatomic results at 1 year following the procedure. RESULTS: Ten French neurointerventional centers included 62 patients (39 women), 33-74 years of age (mean, 56.6 ± 9.80 years) with 63 aneurysms. Aneurysm locations were the middle cerebral artery in 32 aneurysms (50.8%), anterior communicating artery in 16 (25.4%), basilar artery in 9 (14.3%), and internal carotid artery terminus in 6 (9.5%). Morbidity and mortality at 1 month were, respectively, 3.2% (2/62 patients) and 0.0% (0/62). Morbidity and mortality (unrelated to the treatment) at 1 year were, respectively, 0.0% (0/59) and 3.4% (2/59 patients). At 1 year, complete occlusion was observed in 30/58 aneurysms (51.7%); neck remnant, in 16/58 aneurysms (27.6%); and aneurysm remnant, in 12/58 aneurysms (20.7%). CONCLUSIONS: This prospective French Observatory study showed very good safety of aneurysm treatment with the WEB, with a high rate of adequate aneurysm occlusion at 1 year (79.3%).

Preoperative localization of an insulinoma: selective arterial calcium stimulation test performance.

PURPOSE: Preoperative localization of an insulinoma is recommended to improve the cure rate, but non-invasive procedures can fail to detect the tumour. The objective of the study was to assess the performance of a selective arterial calcium stimulation test in the preoperative localization of insulinomas that were not detected by conventional imaging procedures. METHODS: We conducted a monocenter retrospective case review of 13 patients who had endogenous hyperinsulinism and were treated between 1994 and 2013. Patients were selected on the basis of negative or doubtful non-invasive preoperative imaging. A selective arterial calcium stimulation test was performed by pancreatic and hepatic arteriography with selective intra-arterial calcium stimulation and hepatic venous sampling in order to obtain the plasma insulin measurement. We evaluated the efficacy of the test by comparing the results with an endoscopic ultrasound. RESULTS: Twelve of the 13 patients underwent surgery, and the presence of an insulinoma was proven in 11 patients by pathological analysis of the tumour. An endoscopic ultrasound was consistent with surgery in 71.4 % of cases, while selective arterial calcium stimulation was consistent with surgery in 90.9 % and allowed detection of an insulinoma in two additional patients with a negative endoscopic ultrasound. One false-negative and one false-positive arterial calcium test were observed. No adverse events were recorded except transient skin flush following calcium injection in one patient. CONCLUSION: The selective arterial calcium stimulation test is a sensitive diagnostic procedure for localizing insulinomas and may be considered when non-invasive radiological imaging does not allow the detection of an occult insulinoma.

WEB Treatment of Intracranial Aneurysms: Feasibility, Complications, and 1-Month Safety Results with the WEB DL and WEB SL/SLS in the French Observatory.

BACKGROUND AND PURPOSE: Safety analyses in the French Observatory have shown that treatment of intracranial aneurysms by using flow disruption with the Woven EndoBridge Device (WEB) is safe, with low morbidity and no mortality. The objective of this study was to analyze treatment feasibility, complications, and safety results in patients treated with the Woven EndoBridge Device Dual-Layer (WEB DL) and Woven EndoBridge Device Single-Layer/Single-Layer Sphere (WEB SL/SLS) in the French Observatory. MATERIALS AND METHODS: Patients with bifurcation aneurysms were included in this prospective, multicenter good clinical practices study. A medical monitor independently analyzed procedural and clinical data. The study started with the WEB DL, and secondarily, the WEB SL/SLS was authorized in the study. RESULTS: Between November 2012 and January 2014, 10 French centers included 62 patients with 63 aneurysms. Thirty patients with 31 aneurysms were treated with the WEB DL, and 32 patients with 32 aneurysms, with the WEB SL/SLS. The percentage of anterior communicating artery aneurysms treated with WEB SL/SLS was significantly higher (37.5%) compared with WEB DL (12.9%) (P = .04). The WEB SL/SLS was more frequently used in aneurysms of <10 mm than the WEB DL (respectively, 96.9% and 67.7%; P = .002). Morbidity was similar in both groups (WEB DL, 3.3%; WEB SL/SLS, 3.1%), and mortality was 0.0% in both groups. CONCLUSIONS: This comparative study shows increased use of WEB treatment in ruptured, small, and anterior communicating artery aneurysms when using WEB SL/SLS. There was a trend toward fewer thromboembolic complications with the WEB SL/SLS. With both the WEB DL and WEB SL/SLS, the treatment was safe, with low morbidity and no mortality.

WEB intrasaccular flow disruptor-prospective, multicenter experience in 83 patients with 85 aneurysms.

BACKGROUND AND PURPOSE: The safety and efficacy of WEB flow disruption have been analyzed in small, retrospective series. The object of this study was to evaluate the safety and efficacy of WEB flow disruption in a large, multicenter, prospectively collected population. MATERIALS AND METHODS: Data from all patients treated with the WEB-DL device between June 2011 and October 2013 in 11 French neurointerventional centers were prospectively collected and retrospectively analyzed. Complications occurring during and after treatment were analyzed as well as morbidity and mortality at 1 month. Aneurysm occlusion status at the last follow-up was analyzed. RESULTS: Eighty-three patients with 85 aneurysms were included in this series. Technical success was achieved in 77 patients with 79 aneurysms (92.9%). Periprocedural complications were observed in 9 patients (10.8%), leading to permanent neurologic deficits in 3 (3.9%). Morbidity and mortality at 1 month were 1.3% and 0.0%, respectively. Angiographic follow-up was performed for 65/79 aneurysms (82.3%) 3-24 months after treatment (mean, 5.3 months). Complete aneurysm occlusion was observed in 37/65 aneurysms (56.9%); neck remnant, in 23/65 (35.4%); and aneurysm remnant, in 5/65 (7.7%). CONCLUSIONS: In this large prospective series of patients, WEB flow disruption was a safe and efficient technique.

Five-Year Longitudinal MRI Follow-up and (1)H Single Voxel MRS in 14 patients with Gliomatosis Treated with Temodal, Radiotherapy and Antiangiogenic Therapy.

Gliomatosis cerebri (GC) is a challenging tumor, considered to have a poor prognosis and poor response to treatments. The purpose of this study is to better understand glial tumor metabolism and post chemotherapy, radiotherapy and antiangiogenic variations in a longitudinal study to determine cerebral variation in MRS area, amplitude, and ratios of metabolites and spectral profiles during a five year longitudinal follow-up in 14 patients with gliomatosis without initial hyperperfusion and treated with chemotherapy (Temozolomide (Temodal(®))), radiotherapy and subsequent antiangiogenic therapy. The study also aimed to detect changes in infiltration, proliferation, lipids or glycolytic metabolism, as these changes could be monitored longitudinally in humans with glial brain tumors (low and high grade) after therapy, using conventional magnetic resonance imaging (MRI), spectroscopy (MRS) and MR perfusion. Most patients had first initial clinical and MRS improvement and stable MRI. After 12 to 24 chemotherapy treatment cycles MRS usually showed an increase in the Cho/Cr ratio (proliferation) and sometimes contrast enhancements. Later, the patients showed clinical deterioration and radiotherapy was started. There was an improvement with radiotherapy that lasted nine to 18 months. This was followed by a worsening that led to try antiangiogenic therapy. Later in the evolution for three patients with hyperperfusion this symptom disappeared, but proliferation, infiltration and glycolytic metabolism remained at a high level. Spectroscopic and metabolic changes often occur well before clinical deterioration and sometimes before improvement. Therefore, MRS could be more sensitive and could detect changes earlier than MRI and is sometimes predictive. Despite the difficulty, the variability and unknown factors, these repeated measurements give us a better insight into the nature of the different processes, tumor progression and could lead to better understanding of therapeutic response.

Percutaneous treatment of cervical disk hernias using gelified ethanol.

This study investigates the efficacy of chemonucleolysis using RGE in the treatment of cervical disk hernias in a small sample of patients who had cervical diskogenic or radicular pain secondary to disk herniations. Results were satisfactory in 89.5% patients, with no adverse events recorded during the procedure or after. The use of RGE shows promising results and might be a feasible and safe alternative in the treatment of cervical disk hernias.

[Place of local thrombolytic therapy in the treatment for cerebral venous thrombosis]. / Thrombolyse in situ dans la thrombose veineuse cérébrale.

INTRODUCTION: Cerebral venous thrombosis (CVT) is uncommon with a variable clinical presentation and an unpredictable outcome. Heparin is used for first-line treatment in association with symptomatic and etiologic management. Despite adequate anticoagulation, the condition may deteriorate in some patients warranting the use of local thrombolysis (LT) known for good efficacy and safety. But there are few cases and trials upon which to base guidelines for the use of LT. METHODS: A retrospective review of the medical and radiological records of patients with CVT was managed in the Caen hospital over a six-year period. We compared clinical factors of poor prognosis and radiological findings according to treatment delivered. RESULTS: Thirty-six patients are treated for CVT. LT was performed in eight of them; dose-adjusted intravenous heparin was the only treatment in the 28 others. Good outcome was achieved in two thirds of the patients with functional sinus patency in all cases. Based on an analysis of the radiological data of the 36 patients, we propose a summary of radiological risk factors associated with a worsening condition despite adequate anticoagulation. DISCUSSION/CONCLUSION: Based on our experience and a review of the literature which includes 98 previous cases, LT appears to be a relative effective end safe procedure even in the presence of a hemorrhagic infarct. The treatment by LT should be considered in patients who present clinical criteria of gravity and radiological risk factors associated with failure of heparin treatment. The usefulness of LT remains to be determined in a randomized trial comparing heparin alone and heparin associated with LT.

Radial approach in the treatment of supraaortic arterial lesions.

SUMMARY: Radial approach (mainly right) has been used in the treatment of 67 supraaortic lesions including 56 carotid, nine vertebral and two subclavian artery stenoses. This approach offers new possibilities and solves most of the remaining technical difficulties or impossibilities encountered in the endovascular treatment of supraaortic lesions. The current technique is described. The results of this first series have been very satisfactory without complication. MR angiography allows selection of patients suitable for radial approach.

[Quantitative relationships between ADC and perfusion changes in acute ischemic stroke using combined diffusion-weighted imaging and perfusion MR (DWI/PMR)]. / Relation quantitative des modifications de la diffusion et de la perfusion au sein du parenchyme cerebral au cours de l'accident ischémique aigu.

UNLABELLED: MR-based diffusion- and perfusion-weighted imaging (DWI/PWI) has become the standard imaging technique to assess the individual brain pathophysiological status in acute ischemic stroke. The finding of a "mismatch" with larger PWI than DWI abnormality is thought to reflect the presence of tissue at-risk of infarction, i.e., penumbra. However, there has been no detailed study of the quantitative relationships between perfusion and diffusion changes in stroke patients. According to the experimental concept of penumbra, the ADC would be expected to remain unchanged despite decreasing perfusion until a critical threshold is reached. We have tested this hypothesis directly in man. METHODS: DWI/PWI was performed in 7 patients with MCA territory stroke within 4-10 hrs from onset. Mismatch was defined on diffusion and rMTT maps, and circular ROIs were positioned within the ADC lesion (D), the mismatch area (M), and the normal appearing cortex (N); mirror ROIs were also obtained, and affected/unaffected ratios for ADC and rCBF were computed for each ROI. RESULTS: The mean (+/-1 SD) ADC ratios were 0.60 +/- 0.09, 0.95 +/- 0.10 and 1.02 +/- 0.04 in L, M and N, respectively; the corresponding rCBF ratios were 0.32 +/- 0.12, 0.75 +/- 0.14 and 0.97 +/- 0.09, respectively. The relationship was non-linear, with the rCBF but not the ADC ratio for M being significantly lower (p < 0.01) than that for N. A threshold for decline in ADC was apparent around 0.50 rCBF ratio. COMMENT: These results directly document in man that the ADC declines only after hypoperfusion has reached a certain degree (about 50%), consistent with the concept of the ischaemic penumbra.

[Diffusion MR imaging of the central nervous system: clinical applications]. / IRM de diffusion du système nerveux central: applications cliniques.

Diffusion-weighted MR imaging is a technique in which image contrast is determined by the motion of water molecules within tissues. This motion is characterized by the apparent diffusion coefficient (ADC). This technique is particularly useful for the early detection of cerebral infarction but many other diseases of the central nervous system are associated with a change in water diffusion and may be assessed by diffusion-weighted MR imaging. This is an easy and fast pulse sequence providing useful data for early diagnosis and prognosis as well as information about underlying pathophysiology. After an overview of the basic concepts of diffusion imaging and the knowledge required for image interpretation, we will assess the potential value of this technique for the diagnosis of the main diseases of the central nervous system.

[Endovascular treatment of a cervical vertebral artery pseudoaneurysm using covered stents. One case report]. / Traitement par endoprothèses couvertes d'un faux anévrysme de l'artère vertébrale cervicale. A propos d'un cas chez une adolescente.

Covered stents have been successfully used in the treatment of fusiform aneurysms and post dissection aneurysms in peripheral arteries as well as in post-traumatic arteriovenous fistulas. We report a case where a pseudoaneurysm of the cervical vertebral artery was excluded by placement of two covered stents, preserving patency of the parent artery, in a 15-year-old patient.

[Serious cerebral venous thrombosis: can we use fibrinolytic?]. / Thrombophlébite cérébrale grave: peut-on fibrinolyser ?

We report a case of thrombosis of superior sagittal and cavernous sinuses treated by direct instillation of fibrinolytic agents via selective catheterization. Despite risk of bleeding related to the pathology and treatment, no adverse side-effect occurred. This report is unusual regarding the poor initial clinical patient's condition with dilated and unreactive pupil. The good neurologic outcome warrants aggressive treatment in the most severe forms of cerebral venous thrombosis.

"Protected" wallstenting of atheromatous stenoses at the carotid bifurcation.

SUMMARY: Atheromatous stenoses at the carotid bifurcation were treated by angioplasty and Wallstenting with cerebral protection obtained in most cases by temporary occlusion of the internal carotid artery. 287 carotid stenoses were treated in 233 patients. The stenosis was symptomatic in 79% of cases. All patients presented either a stenosis of >70% with significant impairment of the cerebral circulation (281 cases) or a symptomatic ulcerated plaque (six cases). A self-mounted protection system was used in 177 cases, the Percusurge Guardwire protection device in 98 cases an EPI filter in 12 cases. There was a contralateral internal carotid occlusion in 13% of cases. A combined stenting (vertebral, siphon, subclavian) was performed in 14% of cases. A Rolling membrane Wallstent was used in 84 patients, a first generation Easy Wallstent in 38 cases, a "Carotid" Easy Wallstent 35 in 55 cases and monorail 14 in 110 cases. Full opening of the stenosis was obtained in 98% of patients with correction of the arterial curve and improvement of the cerebral vascular supply. There were 0.7% cases with transient symptomatic neurological complications and 2% with permanent sequelae mainly related to avoidable inadequacy in flushing or to the insufficient radial force of the first generation Easy Wallstent. There were no per and one post-procedural cardiac complication (0.6%) in the s165 cases performed with the "Carotid" Easy Wallstent. Follow-up angiograms showed 0.7% of restenoses. Still in evolution, endovascular treatment of atheromatous stenoses at the carotid bifurcation with cerebral protection and stenting is a promising alternative technique to surgery. The association of Carotid Easy Wallstent 14 monorail and Percusurge Guardwire appears to be currently satisfactory.

[Rotational vertebro-basilar insufficiency secondary to a fibrous band of the longus colli muscle: value of CT spiral angiography diagnosis]. / Insuffisance vertébro-basilaire rotationelle par une bande fibreuse du muscle longus colli: apport de l'angioscanner spiralé

A CASE REPORT: The authors report a case of rotational vertebro-basilar insufficiency causing "drop-attacks". To our knowledge, it is the first case of extraluminal vertebral artery compression caused by a fibrous band of the longus colli muscle, demonstrated by spiral computed tomographic angiography with volume rendering reformation.

[Pseudotumoral presentation of cat scratch disease]. / Maladie des griffes du chat de présentation pseudotumorale.

BACKGROUND: A frequent cause of chronic benign lymphadenopathy, cat-scratch disease (CSD) occurs mainly in children and young adults. Bartonella henselae is the agent responsible for CSD. The most common symptoms of the disease are regional lymphadenopathy and fever. Atypical forms occur in about 10% of patients; among them, CSD may initially present as a tumor. CASE REPORT: A 4-year-old child developed a 'tumor' of the arm with fever. The values of white blood cell count and CRP were normal. Ultrasonography, MRI and arteriography did not contribute to the diagnosis, which was established on histologic examination and serologic test for infection with B. henselae. The outcome was favorable with antibiotic treatment. CONCLUSION: In case of tumor of the limbs, cat-scratch disease should be searched for.