Factors Associated with Severe Carotid Artery Stenosis in a Population with One of the Highest Incidences of Ischemic Stroke in Europe - Single National Center Analysis.

Introduction: Despite significant advances in its prevention and acute-phase treatment, stroke is still one of the leading causes of disability and death worldwide. Ischemic stroke accounts for 80 to 87% of all strokes, with 15-30% of cases being caused by extracranial carotid artery (CA) stenosis. Methods: This is an observational, cross-sectional, single-center, prospective, registry-based study. The current research presents the preliminary results after analyzing the demographic features, biological data, and cardio- and cerebro-vascular risk factors of the first 74 patients included in the first "Romanian registry for cervical and cerebral arterial stenosis." Results: In our group of patients, the severity of carotid artery stenosis was related to fibrinogen, total cholesterol, and triglyceride blood levels. Moreover, patients who underwent carotid artery stenosis were more prone to having peri-procedural complications if they had a low blood platelet count. Concerning the associated pathologies of patients with severe carotid atheromatosis, the risk of having lower cognitive abilities was higher in subjects with atrial fibrillation, regardless of the severity of carotid artery stenosis. Conclusions: The presented study brings essential information about a population more prone to cerebral ischemic events than that of most other countries. All data obtained until this moment and which will further result from analyzing the clinical, demographic, and biological features of patients included in this registry should be used for implementing populational strategies for preventing further strokes.

Decompressive Craniectomy: the Right Call at the Right Moment.

Introduction:Massive intracerebral hemorrhages and large internal carotid artery infarcts may cause early death due to severe cerebral edema with elevated intracranial pressure, despite maximal medical therapy. Decompressive craniectomy may be of benefit to these patients in terms of survival and even functional outcome. The aim of our paper is to present two cases that illustrate the use of decompressive craniectomy both in ischemic and hemorrhagic stroke, followed by a discussion on the indication and right timing of the intervention, but also on the outcome of these patients. Materials and methods: We present the cases of a 38-year-old man with a right lenticular and capsular hemorrhage who underwent decompressive craniectomy in the first 24 hours from onset of symptoms and a 64-year-old patient with an ischemic stroke in the territory of the left carotid artery with a decompressive craniectomy performed at more than 72 hours from the beginning. For each of the two cases, we analyzed the following parameters: neurologic status, Glasgow Coma Scale, aspect of the cerebral computed tomography before and after surgery, in-hospital complications and modified Rankin Scale at discharge. Outcomes: While the intervention was life-saving in both cases, the procedure had different functional outcomes. Conclusion: Decompressive craniectomy may be a life-saving procedure for patients with both hemorrhagic or ischemic strokes complicated with massive edema and increased intracranial pressure. When performed in the first 48 hours, especially in patients with ischemic stroke aged less than 60, it may also improve the functional outcome compared to conservative treatment.

Unruptured Giant Intracerebral Aneurysms: Serious Trouble Requiring Serious Treatment - Case Report and Literature Review.

Giant intracranial aneurysms (ICGA) represent 3 to 5% of all intracranial aneurysms in adults. They are defined as arterial dilatations, with more than 25 mm in diameter. Despite important advances in the research of endovascular techniques of treating giant intracranial aneurysms, the management of these vascular malformations still poses great difficulties for neurologists and interventional radiologists. In particular, these challenges arise from the difficult and modified cerebral anatomy of patients with ICGA. Choosing the best treatment for patients with ICGA involves not only finding the perfect balance between the potential risks and benefits of endovascular treatment, but also taking into consideration the patient's biological condition and associated diseases. The aim of this paper is to describe the decisional algorithm of treating patients with giant intracranial aneurysms and factors which could influence the choice of endovascular technique. We report a clinical case of a 63-year-old female with cardio-vascular risk factors (atrial fibrillation, high blood pressure), diagnosed with a symptomatic giant aneurysm of the right internal carotid artery and multiple cerebral micro-bleeds. Given the very large size of the aneurysm, its characteristics as well as patient's associated comorbidities, it was decided to exclude the ICA aneurysm from circulation by occluding the parent vessel (right internal carotid artery) by using endovascular techniques. Also, a review of the literature on the currently available endovascular methods for treating patients with giant intracranial aneurysms was performed in order to see the indications and possible long-term complications of each method. In selected cases, the risks of serious complications associated with occluding a large cervical-cerebral vessel (as the internal carotid artery) are far exceeded by the risk for rupture of giant aneurysms, which is fatal in many cases. Nevertheless, it is of utmost importance to mention that, although the use of endovascular methods leads to a significant increase in life expectancy, a severe decline in quality of life might be experienced by these patients.

Therapeutic approaches in pelvic bleeding of neoplastic origin.

OBJECTIVES: The aim of this study is to present the main - surgical and non-surgical - therapeutic approaches (or methods) used in the treatment of pelvic bleeding of neoplastic origin. MATERIALS AND METHODS: analysis of the materials found in the literature on this subject. RESULTS: Among the surgical methods used, hypogastric artery ligation is the oldest therapeutic approach in cervical bleedings of neoplastic origin. Due to the frequent recurrence of haemorrhages, mere ligation has been proven not to be sufficient, but necessitating the concomitant ligation of the lumbo-ovarian, round and uterosacral ligaments. In the case of severe bleedings, difficult to control, direct embolization of the hypogastric artery below the level of ligation is usually practiced. As for the non-surgical methods used, we chose to present uterine artery embolization and the application of haemostatic Mohs' paste. Uterine artery embolization consists in the permanent occlusion of the uterine arteries in neoplastic abundant haemorrhages, when the intervention includes the use of permanent embolic material. Stopping the bleeding within the first 24 hours from the embolization means that the intervention has been a success, and provides the patient with the possibility to continue the therapy protocol according to her stadialization. Recent studies of the Japanese researchers have indicated the possibility to use the Mohs' paste for haemostatic purposes on patients with cervical bleedings of medium intensity, in cases of advanced cervical cancer. CONCLUSIONS: With severe haemorrhages - occurring spontaneously or during surgery - the emergency haemostatic intervention consists in the bilateral hypogastric artery ligation. With long-lasting haemorrhages of medium intensity, we usually resort to uterine artery embolization, since this is a minimally invasive method and may also be performed with abundant bleeding under emergency pressure. The application of the Mohs' paste for haemostatic purposes is a new therapeutic method, whose efficiency cannot be yet estimated.

Transarterial embolization of renal vascular lesions after percutaneous nephrolithotomy.

INTRODUCTION: Percutaneous nephrolithotomy (PCNL) represents a safe and efficient procedure in the surgical management of renal lithiasis. Nevertheless, surgeons have to face specific complications during and after the procedure, hemorrhage being one of the most common. In most cases the injuries are self-limited and do not need a surgical intervention. Renal arteriography with selective angiographic embolization is needed in patients with massive hemorrhage or continuous hematuria. Our objective was to evaluate the effectiveness of percutaneous transarterial embolization for the treatment of renal arterial post-PCNL bleeding. MATERIAL AND METHOD: This retrospective study was performed between March 2007 and October 2012 and included 22 patients who had undergone renal embolization due to significant post-PCNL renal artery bleeding. The site, number, and type of bleeding lesions, and the result of the embolization procedure were recorded. We report on the incidence, treatment, radiological and clinical results of these serious vascular injuries at our institution. RESULTS: Our study has included a large group of patients, the 95.45% angiographic success rate confirming that percutaneous transcatheter embolization is a valuable treatment for most renal vascular injuries. Renal angiography revealed pseudoaneurysm in 15 patients, arteriovenous fistula in 5 and arterial laceration in 2 patients. Significant risk factors on univariate analysis for severe hematuria requiring superselective angiography were multiple staghorn calculi, upper calix puncture and history of pyelonephritis. The severity of the hematuria after PCNL is influenced by many factors, including mean stone size and mean operative time and is correlated with duration of hospitalization and mean hemoglobin drop. CONCLUSIONS: Percutaneous transarterial embolization of the injured vessel is an effective, minimally invasive and relatively easy procedure in experienced centers, with high rate of success and immediate benefits, thus saving the patient from the morbidity that results from severe renal bleeding.

Why antiplatelet treatment in spontaneous internal carotid dissection?

Spontaneous dissection of the internal carotid artery is a leading cause of stroke and TIA, particularly in young patients. The antithrombotic treatment with or without an interventional procedure is a unanimously accepted indication for the prevention of the ischemic events in these patients. Whether anticoagulants or antiplatelets as antithrombotics are a better option is a matter of debate. The authors, based on clinical and pathophysiological data in the published studies and their own experience argue in favour of antiplatelets in most cases, without excluding the need of anticoagulants in some cases, due to the lack of objective proofs for the superiority of anticoagulants in this pathology and at the same time, a better safety profile of antiplatelets. To have a clear-cut answer to this debate, a large comparative randomized clinical trial between the two types of treatment is desirable.

Uterine artery embolization for leioyomas, ultrasonography and angiography aspects.

OBJECTIVE AND RATIONALE: The purpose of this study is to evaluate the degree of fibroid shrinkage which well correlates with symptom regression, and thus to assess the effectiveness of the procedure. METHOD: 31 patients were included in the trial after selection. All the patients were thoroughly evaluated before embolization, the following day and at a month after but also at 3 months for 10 of them. A certain protocol was followed passing through well established steps. The purpose was to discover and rule out any associated possible disease and to assess and grade the symptoms, ultrasound and angiographic aspects. RESULTS: Regarding the uterus, its volume evolution registered a descending trend, the mean decrease at 30 days being of 25% (-81,6 cm³) and at 90 days of 52%(-173,15 cm³). The fibroids also decreased statistically, the mean global variation at 30 days registering a decrease of -17,66 cm³(27%) and 61% at day 90. The mean global reduction at 30 days was of 44% (-33,18 cm³) and of 62% (-60,85 cm³) at 90 days. Absence of uterine anastomoses lead to proper fibroid decrease whereas their presence diminished the chances. CONCLUSIONS: The uterine and fibroid volumes registered a statistical volume decrease at 30 and 90 days in comparison with the volumes before embolization. Absence of uterine anastomoses led to proper fibroid decrease. Longer evaluation time is needed for an accurate evaluation of volume reduction degree.

[Management for pseudoaneurysm of cystic artery with an arterio-biliary fistula after laparoscopic cholecystectomy: a rare case of hemobilia]. / Managementul pseudoanevrismului de artera cistica cu fistula arterio-biliara dupa colecistectomie laparoscopica: cauza rara de hemobilie.

Although laparoscopic cholecystectomy is considered to be the gold standard for treatment for symptomatic cholelithiasis, it is associated with an increased risk of biliary and vascular injury compared to the traditional technique. Massive hemobilia is a rare but potentially life-threatening cause of upper gastrointestinal hemorrhage. Arterio-biliary fistula is an uncommon cause of hemobilia. We describe a case of cystic artery pseudo-aneurysm causing arterio-biliary fistula and presenting as severe melaena and cholangitis that occurred 7 months after laparoscopic cholecystectomy. Gastroduodenoscopy failed to establish the exact source of bleeding and hepatic artery angiography and selective embolization of the pseudo-aneurysm successfully controlled the bleeding. Pseudo-aneurysm of the hepatic artery is mostly iatrogenic due to biliary intervention, as demonstrated in this case. Transarterial embolization is considered the first line of intervention to stop the bleeding for most causes of hemobilia. Hemobilia is a rare complication that should be considered when managing patients with bleeding or jaundice even several months after laparoscopic cholecystectomy.

Combined endovascular and surgical therapy of uterine fibroma.

Since the first description of uterine artery embolisation for the treatment of symptomatic fibroids of the uterus in 1994, this minimally invasive procedure has been increasingly performed in many countries. Transcatheter embolisation of the uterine arteries feeding large fibroids is a minimally invasive technique. This paper presents the combined endovascular and surgical therapy in the treatment of uterine fibroma. The purpose of this therapy is saving the reproductive function of the uterus even in cases with very large fibromas or located in areas with difficult access, in which hysterectomy would have been needed. The therapy has a high rate of success, it is accompanied by disappearance of the symptoms and it has a low risk of intra- and postoperatory complications. The first step is the embolisation of uterine arteries--a safe therapy of uterine fibroma. The procedure eliminates the risk of post-miomectomy relapse through the symultaneous devascularisation of all fibroma nodules, even of the very small ones which are unapparent clinically or imagistically. The post-embolisation surgical intervention is undertaken in conditions of operative comfort, with minimal bleeding; it eliminates the need for blood transfusions and diminishes the duration of intervention. Three representative cases where this therapy has been successfully applied are presented in this article. The embolisation of the uterine arteries represents an efficient therapy of the uterine fibroma, with very good results noted in the speciality literature.