Long-term follow-up after treatment of intracranial aneurysms with the Pipeline embolization device: results from a single center.

BACKGROUND AND PURPOSE: Stent-like, self-expandable devices, the so-called flow diverters, are increasingly used for the treatment of wide-neck cerebral aneurysms. The immediate and short-term results are promising, but no long-term results are available. The purpose of our research was to report the long-term angiographic and cross-sectional imaging results after placement of a PED in 12 patients with wide-neck intracranial aneurysms. MATERIALS AND METHODS: Twelve wide-neck or otherwise untreatable cerebral aneurysms in 12 patients were treated with the PED. Angiography was performed at 6 and 24 months after treatment. Additional MR and CT angiograms were acquired. RESULTS: In all patients, angiographic or cross-sectional imaging follow-up of at least 27 months demonstrated complete occlusion of the aneurysms treated with the PED. There were no cases of aneurysm recurrence. Angiography at around 6 months showed complete occlusion in all cases, except 1 that showed complete occlusion at the 29-month follow-up. In 1 patient, a clinically asymptomatic 75% in-stent stenosis was seen on the angiography at 6 months but was resolved completely by balloon dilation. Device placement was successful in all patients. Distal embolization had occurred in 1 patient, but the clot was resolved completely without clinical sequelae. Almost immediate angiographic occlusion was achieved in 2 aneurysms and flow reduction in 10 aneurysms. CONCLUSIONS: Treatment of wide-neck intracranial aneurysms by PED placement led to successful and durable occlusion in all cases, without severe complications. Endovascular treatment for in-stent stenosis should be considered cautiously, because the underlying stenosis may be transient and disappear within 12 months after treatment.

Diagnostic accuracy of 3D time-of-flight MR angiography compared with digital subtraction angiography for follow-up of coiled intracranial aneurysms: influence of aneurysm size.

BACKGROUND AND PURPOSE: 3D time-of-flight MR angiography (3D TOF MRA) may be used as noninvasive alternative to digital subtraction angiography (DSA) for the follow-up of patients with intracranial aneurysms treated with Guglielmi detachable coils (GDCs). We aimed to determine the influence of aneurysm size and location on diagnostic accuracy of 3D TOF MRA for follow-up of intracranial aneurysms treated with GDCs. MATERIALS AND METHODS: Two hundred and one 3D TOF MRAs in 127 consecutive patients with 136 aneurysms were compared with DSA as standard of reference. Sensitivity and specificity of 3D TOF MRA for detection of residual or reperfusion of the aneurysms was calculated with regard to aneurysm size and location. RESULTS: Overall sensitivity and specificity of MRA was 88.5% and 92.9%, respectively. Sensitivity was lower for aneurysms

[Three-dimensional ultrasound (3DUS) of the neonatal brain: clinical application in patients of the neonatal intensive care unit (NICU)]. / Dreidimensionaler Ultraschall (3DUS) des neonatalen Gehirns: klinische Anwendbarkeit bei intensivgepflegten Neugeborenen.

AIM: To prospectively evaluate the potential role of 3DUS of the neonatal brain. METHOD: 60 patients from the NICU (gestational age: 25-42 weeks, mean: 31.6 weeks, age: 0 to 90 days, median: 10 days) underwent 2D- and 3D-neurosonography. Both studies were evaluated independently by two observers for comparison. Inter- and intraobserver variability were calculated. RESULTS: All 3DUS were of diagnostic quality and could be performed without sedation. 3DUS missed no essential diagnosis as established by conventional ultrasound (2DUS). Diagnosis included normal or physiologically immature neonatal brains (n = 21), plexus cysts (n = 4), plexus bleedings (n = 10), intraventricular haemorrhages grade I-III (n = 8), periventricular pathology such as periventricular echodensities (n = 4) and periventricular haemorrhages or cerebral infarctions (n = 6), hydrocephalus (n = 4), widened subdural spaces (n = 2) and one suprasellar midline tumour. 3DUS imaging time at the patient (4.8 +/- 2.6 min) was significantly shorter than for 2DUS (9.1 +/- 6.1 min). The additional axial plane provided by 3DUS improved the sonographic potential for differential diagnosis. 3DUS allowed an improved standardisation and documentation potentially valuable for follow-up. No statistically significant differences in intra- and interobserver variability were noted compared to 2DUS. Restrictions of 3DUS were the lack of directional Doppler data and the lower resolution particularly of the purely reconstructed plane. CONCLUSION: Bedside neonatal 3D-neurosonography at the NICU is feasible with diagnostic quality without sedation. 3DUS improves comparison during follow-up, as well as standardisation and documentation, and can be considered a useful adjunct in neonatal 2D-neurosonography.

Search for occult secondary osteoporosis: impact of identified possible risk factors on bone mineral density.

OBJECTIVES: To determine whether the use of more elaborate diagnostic tests can identify possible risk factors for secondary osteoporosis and to evaluate the impact of these possible risk factors on the severity of bone disease in the study population. DESIGN: Cross-sectional study. SETTING AND PARTICIPANTS: We have investigated 377 subjects (285 females, 92 males) with osteoporosis (T-score less than -2.5 in dual energy X-ray absorption) or nontraumatic lumbar vertebral fractures; these patients were referred to our hospital, a secondary care centre, for evaluation and treatment of osteoporosis. RESULTS: Osteoporosis without attributable risk factor was diagnosed in 106 women (37%) and 30 men (33%). In 241 patients (179 women, 62 men) one or more possible risk factors for osteoporosis (in this paper also called subclinical disease) were revealed. The most common were lactose malabsorption, disturbed exocrine pancreatic function and renal tubular disturbances, including renal hypercalciuria, incomplete renal tubular acidosis and mild phosphate diabetes. The number of possible risk factors in the individual patient was significantly related to the severity of osteoporosis as assessed by Z-scores (Spearman correlation r = -0.43, P < 0.001, n = 172 for females; r = -0.28, P < 0.05, n = 65 for males). CONCLUSIONS: All the identified subclinical diseases would have remained undetected if the currently accepted guidelines for the investigation of patients with osteoporosis were applied. The statistically significant correlation between the number of identified possible risk factors and the severity of bone disease in the individual patient strongly suggests the pathogenetic significance of the identified subclinical diseases. It is yet to be shown, whether specific treatment of these subclinical diseases yields additional improvement of bone mass as compared with standard treatment of osteoporosis.

Placement of Hemobahn stent-grafts in femoropopliteal arteries: early experience and midterm results in 18 patients.

PURPOSE: To determine the outcome of a new polytetrafluoroethylene (PTFE)-covered stent-graft in the treatment of occlusive lesions of the femoropopliteal arteries. MATERIALS AND METHODS: Eighteen patients with intermittent claudication (Fontaine stages IIb-IV; Rutherford classes I/2-III/5) and occlusive lesions of the superficial femoral and/or popliteal artery were treated with use of a new PTFE-covered stent-graft (Hemobahn). Indication for stent-graft insertion was an unsatisfactory result after balloon dilation. RESULTS: Successful stent-graft placement was achieved in 17 patients (94%). In one patient, additional insertion of a Palmaz stent was necessary because of a stent-graft wrinkle. Mean ankle-brachial index increased from 0.72 +/- 0.15 preoperatively to 0.94 +/- 0.17 postoperatively (P =.028). Fifteen patients (83%) experienced an initial improvement of at least one clinical stage. Primary patency was 61% +/- 11% at 3 months and 49% +/- 12% at 6 months. Stent-graft occlusion was observed in 13 patients (72%). In four patients, the stent-graft was reopened percutaneously by balloon angioplasty (n = 2) and/or rotational thrombectomy (n = 2). Therefore, the secondary patency rate was 67% +/- 11% at 3 months and 61% +/- 11% at 6 months. Patency rates proved to be significantly lower for stent-grafts longer than 10 cm (P =.03). Intimal hyperplasia at the proximal or distal end of the stent-graft was observed in seven patients (39%). Complications such as access site hematoma (n = 3), distal thromboembolism (n = 2), and abscess formation around the stent-graft (n = 1) were observed. CONCLUSION: Despite excellent initial angiographic results, the patency rate in lesions treated with the Hemobahn stent-graft in this small study was unsatisfactory. Use of stent-grafts longer than 10 cm and the occurrence of intimal hyperplasia proved to be major factors in the reduction of long-term patency rates.

Complications in endoluminal repair of abdominal aortic aneurysms.

In this review the technical and systemic complications occurring during endoluminal repair of abdominal aortic aneurysms are summarized. According to the data in the literature the technical success-rate of the endoluminal procedure should be >90% and the overall complication-rate <10%. It should be differentiated between complications which have an adverse effect on the outcome of the procedure, and technical problems, which complicate the procedure but do not affect the outcome. The majority of the technical problems can be solved endoluminally. The 30-day mortality rate should be in the same range as elective open surgical repair. One major factor influencing the immediate results is the experience of the interventional team.