Coil embolization versus clipping for ruptured intracranial aneurysms: a meta-analysis of prospective controlled published studies.

BACKGROUND AND PURPOSE: Coil embolization is an alternative to clipping for intracranial aneurysms. However, controversy exists regarding the best therapeutic strategy in patients with ruptured aneurysms, and there is great center- and country-related variability in the rates of clipping versus coiling. We performed a meta-analysis of prospective controlled trials of clipping versus coil embolization for ruptured aneurysms. MATERIALS AND METHODS: We performed a search of the English literature for published prospective controlled trials comparing surgical clipping with endovascular coil embolization for ruptured intracranial aneurysms. Data were abstracted from the identified references. Outcomes of interest were the proportion of patients with a poor outcome at 1 year and episodes of rebleeding from the index treated aneurysm after the allocated treatment. RESULTS: There were 3 prospective controlled trials eligible for inclusion. These studies enrolled 2723 patients. Meta-analysis of these studies showed that the rate of poor outcome at 1 year was significantly lower in patients allocated to coil embolization (risk ratio, 0.75; 95% confidence interval, 0.65-0.87). This relative effect is consistent with an absolute risk reduction of 7.8% and a number needed to treat of 13. The effect on mortality was not statistically different across the 2 treatments. Rebleeding rates within the first month were higher in patients allocated to endovascular coil embolization. CONCLUSIONS: On the basis of the analysis of the 3 high-quality prospective controlled trials available, there is strong evidence to indicate that endovascular coil embolization is associated with better outcomes compared with surgical clipping in patients amenable to either therapeutic strategy.

Coiling for paraclinoid aneurysms: time to make way for flow diverters?

BACKGROUND AND PURPOSE: Paraclinoid aneurysms represent challenging lesions for which endovascular techniques have gained widespread application in their treatment. A new endovascular strategy, flow diversion, is gaining importance in the treatment of these aneurysms. Before embracing flow diversion in larger numbers of patients with paraclinoid aneurysms, it is important to know the safety and efficacy of "traditional" endovascular methods for these aneurysms. We review complications and outcomes of patients with unruptured paraclinoid aneurysms treated with coils, with or without balloon and stent assistance, over the past 12 years at our institution. MATERIALS AND METHODS: A retrospective review of 118 patients with 126 unruptured paraclinoid aneurysms, treated between 1999 and 2010, was performed. Clinical records, endovascular reports, angiographic results, and clinical outcomes were reviewed and analyzed. RESULTS: Fifty-nine percent of aneurysms were carotid-ophthalmic, 27% were hypophyseal, 9% were posterior carotid wall, 3% were carotid cave, and 2% were transitional. Twenty-one percent of aneurysms were symptomatic, and 3% were recurrent aneurysms after previous treatment. Fifty (40%) were treated with balloon assistance and 18 (14%) with stent assistance. Technical complications causing permanent morbidity occurred in 1 patient (0.8%), while early clinical complications causing transient morbidity occurred in 5 (4%) patients. Complete occlusion was achieved in 40% of aneurysms immediately after treatment and in 66 (62%) aneurysms during follow-up (mean 31.9 ± 28.4 months). Recurrences occurred in 18 patients (17%) and 10 (9%) patients were retreated. Clinical outcome was good in 95% and poor in 5% of the 107 patients with follow-up (mean 37.0 ± 33.7 months). Only in 1 patient was poor outcome related to the endovascular procedure. Transient ischemic attacks occurred in 4% of patients. No cases of rebleeding were observed during follow-up. CONCLUSIONS: Modern endovascular coil treatment of unruptured paraclinoid aneurysms appears safe, with satisfactory, although not ideal, rates of complete occlusion. The introduction of flow diverters will probably increase the rate of complete angiographic occlusion, but this must be achieved with low complication rates.

Endovascular treatment of ruptured paraclinoid aneurysms: results, complications, and follow-up.

BACKGROUND AND PURPOSE: Paraclinoid aneurysms are an uncommon cause of aneurysmal SAH, and their treatment is challenging. To assess the effectiveness and safety of endovascular treatment of ruptured paraclinoid aneurysms, we performed a retrospective analysis of 33 patients. MATERIALS AND METHODS: Clinical and radiologic information on 33 patients undergoing endovascular therapy between 1999 and 2010 was retrospectively reviewed. Angiographic results were evaluated with the modified Raymond grading system, whereas clinical outcomes were evaluated with the mRS scale. RESULTS: Seventeen (52%) aneurysms were classified as clinoid segment aneurysms, and 16 (48%), as ophthalmic segment aneurysms. Twenty-six (79%) aneurysms were small, 6 (18%) were large, 1 was (3%) giant, and 39% were wide-neck. Coiling was done with balloon assistance in 36% of cases and stent-assistance in 6%. Technical complications occurred in 1 patient, contributing to death. Early clinical complications causing permanent disability occurred in 3% of cases. One patient (3%) had fatal rebleeding 18 days after treatment. Overall, procedure-related morbidity and mortality were, respectively, 3% and 6%. Complete occlusion of the aneurysm was achieved in 36% of patients after initial treatment and in 65% during follow-up (average, 29.3 months). Seven patients had recurrences requiring retreatment (30%). Clinical outcome (average, 32.9 months) was good in 75% of patients and poor in 25%. No delayed complications related to treatment and/or the aneurysm occurred. CONCLUSIONS: Ruptured paraclinoid aneurysms are challenging lesions from an endovascular and surgical point of view. Despite the high rate of recurrences, good clinical results and protection against rebleeding can be achieved with current endovascular techniques.

Levodopa effect on electromyographic activation patterns of tibialis anterior muscle during walking in Parkinson's disease.

Previous studies have reported that patients with Parkinson's disease (PD) show, in the "off medication" state, a reduced activation of tibialis anterior (TA) in the late swing-early stance phase of the gait cycle. In PD patients the pathophysiological picture may cause differences among the stride cycles. Our aims were to evaluate how frequently TA activity is reduced in the late swing-early stance phase and if there is a relationship between the TA pattern and the clinical picture. Thirty PD patients were studied 2 h after Levodopa administration ("on-med") and 12 h after Levodopa wash-out ("off-med"). They were evaluated by the Unified Parkinson's Disease Rating Scale (UPDRS III) and surface electromyography of TA and gastrocnemius medialis (GM). The root mean square (RMS) of the TA activity in late swing-early stance phase (RMS-A) was normalized as a percent of the RMS of the TA activity in late stance-early swing (RMS-B). RMS-A was reduced in 30% of patients in the "off-med" condition. Within these patients, the percentage of stride cycles with reduced RMS-A, ranged between 28% and 83%. After Levodopa intake, no stride cycle showed reduced RMS-A. Patients with reduced RMS-A had a lower UPDRS III total score in the "on-med" rather than in the "off-med" condition (p=0.02). Our data confirm and extend previous observations indicating that, in "off-med" the function of TA is impaired in those patients clinically more responsive to Levodopa. TA activation is reduced in a relatively high percent of gait cycles in the "off-med" state. Since the variability of TA activation disappears after Levodopa administration, this phenomenon could be the expression of an abnormal dopaminergic drive.

Spontaneous carotid-cavernous fistula supplied by the contralateral meningohypophyseal trunk: case report and literature review.

Carotid-cavernous sinus fistulas (CCF) are abnormal communications between the carotid artery and the cavernous sinus. Most spontaneous CCFs are low-flow fistulas, supplied by branches of the omolateral internal carotid artery or the external carotid artery. A 64-year-old man, with increasing diplopia, mild exophthalmos on the left side, blurred left vision and omolateral red eye, was admitted to our institution. The patient underwent a bilateral cerebral angiography that showed a left CCF fed by meningo-hypophyseal branches of the right internal carotid artery and draining from the cavernous sinus into a parahippocampal vein. A transarterial embolization of the carotid-cavernous fistula was performed, with complete obliteration of the fistula. Although anecdotal reports exist, there is a scarcity of well-documented cases of exclusively contralateral flow in the carotid-cavernous fistula. Most of the reported cases referred to contralateral flow into the carotid-cavernous fistula by the external carotid artery branches. To the best of our knowledge, there are no previous cases of a spontaneous CCF supplied by contralateral meningo-hypophyseal branches. A discussion of treatment options and a literature review are also performed.

Extracranial aneurysms of the posterior inferior cerebellar artery. Literature review and report of a new case.

Aneurysms arising from the extracranial portion of the posterior-inferior cerebellar artery (PICA) are considered extremely rare. To date, only ten cases have been reported in the literature. The authors report a case of a 29 year-old male patient admitted comatose in Hunt-Hess grade IV because of an subarachnoid haemorrhage predominantly involving the left cranio-vertebral junction up to C2 rather than the posterior fossa and the fourth ventricle. Angiography showed an extracranial aneurysm at left vertebral artery-PICA junction a few millimetres superior to the dural entry point of the vertebral artery (VA). A left extreme-lateral approach was performed and the aneurysm was successfully clipped. On first year follow-up the patient had completely recovered with no neurological deficits. This paper analyzes the literature review about these rare aneurysms and the technical notes regarding the cranio-vertebral junction approach to these lesions. Factors affecting the neurological outcome of these aneurysms are also reported.

[The optimization of the treatment and timing of the intervention by a nephrologist in pre-dialytic chronic renal insufficiency]. / L'ottimizzazione delle cure e il "timing" dell'intervento del nefrologo nell'insufficienza renale cronica pre-dialitica.

BACKGROUND: Early referral to nephrologists of patients with chronic renal failure (CRF) reduces morbidity and mortality in dialysis. Aim of this work is to evaluate the condition of early and late referral, and whether the two different conditions can affect the treatments. MATERIALS AND METHODS: This is a prospective study with a 12-month follow-up period. During this time, we verified the prevalence of patients with serum creatinine > 1.5 mg/dL (CRF patients) and the condition of early or late referral, defined as referral to nephrologists for > or < 3 times during follow up, respectively. Diagnosis of diabetes mellitus and/or arterial hypertension, and the use of antihypertensive drugs, insulin, hypoproteic diet and erythropoietin was recorded in each patient. RESULTS: CRF (mean serum creatinine value = 2.11+/-1.52 mg/dL) was observed in 190 patients aged 72.05+/-11.62 years. The prevalence of CRF was 4718 pmp. Diabetes and hypertension were diagnosed in 107 subjects (56.3%) and 152 subjects (80%), respectively. Only 74.2% (no. 141) of the patients with CRF was habitually followed by the nephrologist and the frequency was directly correlated to the degree of CRF: 100% of the patients with Creatinine Clearance (Cr Cl) < 25 mL/min, 70% with Cr Cl >25 < 50, and 0% with Cr Cl >50 < 80 mL/min. Early referral was coupled with a wider use of a hypoproteic diet, erythropietin, and the association ACE-I + Angiotensin II receptor antagonists. CONCLUSION: In conclusion, our data show a prevalence of CRF that is at least 5 times greater than that of dialysis patients. The condition of late referral is present in about 30% of the CRF population from the time of the initial phases of renal disease. Referral time affects the modalities of the treatment.

Custom cranioplasty using stereolithography and acrylic.

Numerous methods of cranioplasty have been described. Customization and prefabrication have been reported to reduce operating time and improve cosmesis. An original technique for the manufacture of customized cranioplastic implants has been developed and tested in 30 patients.Thirty patients requiring cranioplasties were selected. Data acquired from computed tomography (CT) were used to manufacture exact plastic replicas (biomodels) of craniotomy defects and master cranioplastic implants using the rapid prototyping technology of stereolithography (SL). The three-dimensional (3D) imaging techniques of mirroring and interpolation were used to extrapolate on existing anatomy to design the master implants. The master implants were hand finished to fit the defect in the corresponding cranial biomodel exactly and were then used to create a cavity mould. The mould was used to cast thermally polymerised custom acrylic implants. The surgeons reported that the customized implants reduced operating time, afforded excellent cosmesis and were cost effective. The patients reported that the opportunity to see the biomodel and implant preoperatively improved their understanding of the procedure. Two complications were noted, one infection and one implant required significant trimming. The simultaneous manufacture of the master implant (male) and biomodel (female) components from SL allowed custom accurate implants to be manufactured. Disadvantages identified were the time required for computer manipulations of the CT data (up to 2 h), difficulty in assessing the accuracy of the computer generated master as a 3D rendering, the potential for SL parts to warp, manufacturing time (minimum 2 days) and the cost of approximately $1300 US per case ($1000 for the SL biomodel and $300 for the acrylic casting).

A method for the resection of cranial tumours and skull reconstruction.

A new technique for the resection of cranial tumours and subsequent reconstruction using stereolithographic (SL) biomodelling and customized cranioplastic implants has been developed. The technique is based on a custom model of the tumour and surrounding skull from which the resection of the tumour and shape of the cranioplasty can be determined. A patient with a hyperostotic fronto-orbital meningioma was selected. CT was performed and SL biomodels manufactured. The surgeon marked the resection margin on the biomodel and a customized resection template was fashioned. The tumour was then resected from the biomodel and a customized acrylic implant was manufactured to reconstruct the defect. At surgery the tumour was exposed in a routine fashion and the template used to mark the resection margin. Once resected, the defect was reconstructed with the custom cranioplastic implant. The technique facilitated accurate surgical resection of the tumour and subsequent reconstruction. The surgeon reported several advantages of the technique including increased confidence, reduced operating time (at least 1 h), excellent cosmetic results, accuracy, and simplicity. The patient reported that the opportunity to see the biomodel, template and implant improved her understanding of the procedure.

Cerebrovascular biomodelling: a technical note.

BACKGROUND: Recently computed tomographic angiography (CTA) and MR angiography (MRA) have been used to image cerebrovascular structures. Although CTA and MRA are accurate and sensitive imaging modalities, limitations have been identified in relation to image interpretation. Stereolithographic (SL) biomodelling is a new technology that allows three-dimensional (3D) CT and MR data to be used to accurately manufacture solid plastic replicas of anatomical structures. A prospective trial of SL biomodelling in cerebrovascular surgery has been performed to investigate the feasibility and clinical utility of this new display medium. METHODS: Fifteen patients with cerebral aneurysms and 1 patient with a cerebral arteriovenous malformation (AVM) were selected. 3D CT and/or MR angiograms were acquired and 19 solid anatomical biomodels manufactured using the rapid prototyping technology of stereolithography. The biomodels were used for patient education, diagnosis, operative planning and surgical navigation. RESULTS: The biomodels replicated the CTA and MRA source data. The accuracy of one biomodel was verified by comparison with a post mortem specimen, which corresponded exactly in the x and y planes but differed by 2 mm in the z plane. The ability to closely study an overview of complex cerebrovascular anatomy from any perspective on a solid biomodel was reported to enhance the surgeon's understanding, particularly when conventional images were equivocal. Cerebrovascular biomodels were found to be useful when positioning the patient's head for surgery, for selecting the best aneurysm clip and for the simulation of clipping. Patient informed consent was anecdotally improved. Disadvantages of the technology were the cost and manufacturing time. CONCLUSIONS: Cerebrovascular biomodelling may have utility in complex cases or when the standard imaging is felt to be equivocal.

Spinal biomodeling.

STUDY DESIGN: A prospective trial of stereolithographic biomodeling in complex spinal surgery. OBJECTIVES: To investigate the use of stereolithographic biomodeling as an aid to complex spinal surgery. SUMMARY OF BACKGROUND DATA: Of the array of imaging methods available to assist the spinal surgeon, no single method provides a complete overview of the anatomy, although three-dimensional imaging has been shown to have advantages. METHODS: Stereolithographic biomodeling is a new technology that allows data from three-dimensional computed tomographic scans to be used to generate exact plastic replicas of anatomic structures. Five patients with complex deformities were selected: two children with congenital deformities, a patient with an osteoblastoma, a patient with basilar invagination caused by osteogenesis imperfecta, and a patient with a failed lumbar fusion. Computed tomographic scanning was performed and stereolithographic biomodels generated. The stereolithographic biomodels were used for patient education, operative planning, and surgical navigation. RESULTS: The surgeons reported that biomodeling was useful in complex spinal surgery and was an effective technology. Stereolithographic biomodels were found to be particularly useful in morphologic assessment, in the planning and rehearsal of surgery, for intraoperative navigation, and for informing patients about surgical procedures. CONCLUSIONS: Stereolithographic biomodeling allows imaging data to be displayed in a physical form. This intuitive medium may improve data display and allows surgical simulation on a proxy of the surgical site. Draw-backs of the technology were a minimum 24 hours' manufacturing time and the cost.

Biomodel-guided stereotaxy.

OBJECTIVES: To simplify the practice of stereotactic surgery by using an original method, apparatus, and solid anatomic replica for trajectory planning and to validate the method and apparatus in a laboratory and clinical trial. METHODS: The patient is marked with fiducials and scanned by using computed tomography or magnetic resonance imaging. The three-dimensional data are converted to a format acceptable to stereolithography. Stereolithography uses a laser to polymerize photosensitive resin into a solid plastic model (biomodel). Stereolithography can replicate blood vessels, soft tissue, tumor, and bone accurately (<0.8 mm). A stereotactic apparatus is referenced to fiducials replicated in the biomodel. The trajectory for the intervention is determined and saved. The apparatus is attached to the patient fiducials, and the intervention is replicated. RESULTS: Three types of apparatus (template, Brown-Roberts-Wells frame, and D'Urso frame) were tested on phantoms and patients requiring the excision/biopsy of tumors. The localization errors determined from the phantom studies were template, 0.82 mm; Brown-Roberts-Wells frame, 1.17 mm; and D'Urso frame, 0.89 mm. The surgeons reported that clinical use of the template and D'Urso frame was accurate and ergonomic. The Brown-Roberts-Wells frame was more difficult to use and somewhat inaccurate. CONCLUSION: Biomodel-guided stereotaxy has significant advantages. It is performed quickly; it is based on simple, intuitive methodology; it enhances visualization of anatomy and trajectory planning; it enhances patient understanding; it uses inexpensive equipment; it does not require rigid head fixation; and it has greater versatility than known techniques. Disadvantages are biomodel cost and a manufacturing time of 12 to 24 hours.

Stereolithographic modelling as an aid to orbital brachytherapy.

PURPOSE: This paper describes the technique of stereolithographic biomodelling and its application to a patient who was treated using orbital brachytherapy. METHODS AND MATERIALS: The process uses a moving laser beam, directed by a computer, to draw cross-sections of the model onto the surface of photo-curable liquid plastic. Using a stereolithographic apparatus (SLA), solid or surface data is sliced by software into very thin cross-sections. A helium cadmium (HeCd) laser then generates a small intense spot of ultraviolet (UV) light that is moved across the top of a vat of liquid photo monomer by a computerised optical scanning system. The laser polymerises the liquid into a solid where it touches, precisely printing each cross-section. A vertical elevator lowers the newly formed layer, and a recoating and levelling system establishes the next layer's thickness. Successive cross-sections (0.25 mm thick), each one adhering to the one below, are built one on top of the other, to form the part from the bottom up. The biomodel allowed the implant to be planned in detail prior to the surgery. The accurate placement of brachytherapy catheters was assured, and the dosimetry could be determined and optimised prior to the definitive procedure. CONCLUSIONS: Stereolithography is a useful technique in the area of orbital brachytherapy. It allows the implant to to be carried out with greater accuracy and confidence. For the patient, it minimises the risk to the eye and provides them with a greater understanding of the procedure.

Stereolithographic biomodelling in cranio-maxillofacial surgery: a prospective trial.

Stereolithographic (SL) biomodelling is a new technology that allows three-dimensional (3-D) computed tomography (CT) data to be used to manufacture solid plastic replicas of anatomical structures (biomodels). A prospective trial with the objective of assessing the utility of biomodelling in complex surgery has been performed. Forty-five patients with craniofacial, maxillofacial, skull base cervical spinal pathology were selected. 3-D CT or MR scanning was performed and the data of interest were edited and converted into a form acceptable to the rapid prototyping technology SL. The data were used to guide a laser to selectively polymerize photosensitive resin to manufacture biomodels. The biomodels were used by surgeons for patient education, diagnosis and operative planning. An assessment protocol was used to test the hypothesis that 'biomodels in addition to standard imaging had greater utility in the surgery performed than the standard imaging alone'. Biomodels significantly improved operative planning (images 44.09%, images with biomodel 82.21%, P < .01) and diagnosis (images 65.63%, images with biomodel 95.23%, P < .01). Biomodels were found to improve measurement accuracy significantly (image measurement error 44.14%, biomodel measurement error 7.91%, P < .05). Surgeons estimated that the use of biomodels reduced operating time by a mean of 17.63% and were cost effective at a mean price of $1031 AUS. Patients found the biomodels to be helpful for informed consent (images 63.53%, biomodels 88.54%, P < .001). Biomodelling is an intuitive, user-friendly technology that facilitated diagnosis and operative planning. Biomodels allowed surgeons to rehearse procedures readily and improved communication between colleagues and patients.

Fetal biomodelling.

A study has been performed to determine if a stereolithographic (SL) biomodel of a fetal face could be created from 3 dimensional (3D) ultrasound (US). 3D ultrasound images were acquired by Diasonics Gateway 2D Array ultrasound systems (Diasonics Ultrasound, San Jose, CA, USA) using an electromagnetic localizer (Tomtec Free Hand Scanning Device, Tomtec Imaging Systems, Middle Cove, Australia). 3D volumetric reconstruction of the fetal face was performed and the data was prepared to guide the construction of an exact solid biomodel by stereolithography (SLA 250 3D Systems, Valencia, CA, USA). A faithful solid representation of the fetal face was produced within 12 hours of the US scan. The fetal biomodel seemed to improve the display of the 3D data. The user-friendly nature of biomodelling may have clinical utility for fetal morphological assessment and as an aid when counselling parents.

Stereolithographic (SL) biomodelling in craniofacial surgery.

BACKGROUND: Stereolithographic (SL) biomodelling allows 3D CT to be used to generate solid plastic replicas of anatomical structures (biomodels). Case reports in the literature suggest that such biomodels may have a use in craniofacial surgery but no large series or assessment of utility has been reported. A prospective trial to assess the utility of biomodelling in craniofacial surgery has been performed. METHODS: Forty patients with complex craniofacial abnormalities were selected and 3D CT scanning performed. The data of interest was used to guide a laser to selectively polymerise photosensitive resin to manufacture SL biomodels. The biomodels were used for patient education, diagnosis and operative planning. An assessment protocol was designed to test the hypothesis that biomodels in addition to standard imaging had greater utility in the surgery performed than the standard imaging alone. RESULTS: Anecdotally surgeons found biomodelling useful in 40 complex craniofacial operations. The formal assessment of the first 10 cases suggested biomodels improved operative planning (image 76%, image with biomodel 97%, P < 0.01) and diagnosis (image 82.5%, image with biomodel 99.25%, P < 0.01). Surgeons estimated that the use of biomodels had reduced operating time by a mean of 16% and were cost effective at a mean price of $1100 AUS. CONCLUSION: Biomodelling was reported as an intuitive, user-friendly technology that facilitated diagnosis, operative planning and communication between colleagues and patients. Limitations of the technology were manufacturing time and cost.

Maxillofacial biomodelling.

The authors report the clinical applications of biomodelling with the stereolithography apparatus, a computer-controlled manufacturing technique that builds anatomically accurate skeletal models from sectional radiological data. Reference to several individual cases demonstrates how pre-operative 3-D modelling can refine the accuracy of diagnostic information, facilitate preoperative planning and surgical technique, and reduce operating time.