Assessment of CE-MRA for the rapid detection of supra-aortic vascular disease.

BACKGROUND: Contrast-enhanced MR angiography (CE-MRA) using a combined head and neck coil permits non-invasive imaging of the vasculature from the aortic arch through to the Circle of Willis in less than 2 minutes. OBJECTIVE: To determine the accuracy of CE-MRA for the detection of vascular pathology, in particular vascular stenoses, using digital subtraction angiography (DSA) as the gold standard. METHODS: In a prospective study of 81 patients referred for DSA, CE-MRA and DSA studies were performed within 72 hours of each other. CE-MRA was performed on a 1.5 Tesla clinical MRI scanner using a five-channel neurovascular array (head and neck coil), with dynamic tracking of the IV gadolinium bolus. CE-MRAs and DSA films were read by two interventional neuroradiologists blinded to the clinical presentation of the patient. RESULTS: On DSA, there were 77 vascular stenoses > or =50% identified, 51 extracranial and 26 intracranial. The overall sensitivity of CE-MRA using the neurovascular array for the detection of vascular stenoses > or =50% was 57% (95% CI: 46 to 68%) with a specificity of 98% (97 to 99%). The sensitivity for the detection of extracranial vascular stenoses > or =50% was 82% (72 to 93%) with a specificity of 97% (96 to 98%). However, the sensitivity for the detection of intracranial vascular stenoses > or =50% was only 8% (0 to 18%), with a specificity of 99% (98 to 100%). CONCLUSIONS: At this stage Contrast-enhanced MR angiography using a neurovascular coil shows promise as a rapid, specific, and noninvasive screening method for extracranial vascular disease, but not for intracranial vascular disease.

Management of Zone III Missile Injuries Involving the Carotid Artery and Cranial Nerves.

Carotid and cranial nerve injuries from zone III (high cervical/cranial base) missile injuries are rare and difficult to treat. We have treated five patients with such injuries. We present our management scheme, and compare it to the management of the same injuries in other reports. Five consecutive zone III missile injuries presented to our institution. Trauma assessment by the trauma team, followed by detailed neurological assessment and radiographs (angiogram and computed tomography) were obtained on admission. All patients presented with dysphagia and carotid artery injury with good collateral flow, documented by angiogram. Two patients had facial nerve injury, one had trigeminal nerve injury, one patient presented with tongue weakness, and one patient suffered conductive hearing loss. No patient had evidence of stroke clinically or radiographically. Carotid artery injury was managed with bypass (3 of 5) or ligation (2 of 5). Cranial nerve injuries were documented and treated aggressively with surgery if needed. All patients were discharged to home. Patients presenting with zone III missile injuries should receive an expeditious neurological exam and four-vessel angiogram after initial trauma survey and resuscitation. Bypass of the injured portion of carotid artery is a valid treatment in the hemodynamically stable patient. The unstable patient should undergo ligation to stop hemorrhage and protect against immediate risk for stroke, with the option to bypass later. Cranial nerve injuries should be pursued and aggressively treated to minimize morbidity and prevent mortality.

Combined supra/infratentorial-transsinus approach to large pineal region tumors.

OBJECT: The authors sought to confirm that the combined supra/infratentorial-transsinus approach offers a safer means of resecting large pineal region tumors than other approaches currently being used. The aforementioned method provides a wider exposure of the pineal region with less brain retraction than the infratentorial-supracerebellar or the occipital-transtentorial approach alone and is applicable to some large and giant tumors of this area. This combined approach was used in six patients to remove large pineal region tumors including four tentorial meningiomas, one pineocytoma, and one epidermoid cyst. METHODS: The transverse sinus and tentorium were sectioned after review of preoperative angiographic studies, after taking intraoperative measurements of the venous pressure in the nondominant transverse sinus before and after clipping and while monitoring the somatosensory evoked potentials. The occipital lobe cortex and cerebellum were retracted slightly along the tentorium. Deep veins of the galenic system, the quadrigeminal area, and the tumor were well exposed. Before it was used for tumor resection the approach was studied in five cadaveric head specimens, and the projection of different approaches was compared radiologically. The tumors were removed in a gross-total manner in all patients, and none of the major veins of the galenic system was injured. Resuturing of the nondominant transverse sinus was performed postoperatively in one patient. One of the six patients experienced transient visual loss, and another suffered mild right sixth cranial nerve paresis; however, both recovered in 3 weeks. The wide exposure of the combined approach was also confirmed on radiological and anatomical studies. CONCLUSIONS: The combined supra/infratentorial-transsinus approach is preferred for the resection of certain large pineal region tumors.

The efficacy and safety of angioplasty for cerebral vasospasm after subarachnoid hemorrhage.

OBJECTIVE: Cerebral angioplasty is being increasingly used for symptomatic vasospasm secondary to subarachnoid hemorrhage. We attempted to determine the safety and efficacy of angioplasty for refractory vasospasm. We also looked at the influence of timing of angioplasty on outcome. METHODS: We retrospectively studied patients with subarachnoid hemorrhage who underwent angioplasty in our institution to determine the safety and the success rate achieved with this procedure. The study period extended from August 1993 until February 1997. Clinical and radiological data were collected, with emphasis on clinical improvement after angioplasty and its relationship with timing of intervention. Thirty-one patients with 43 aneurysms and one case of arteriovenous malformations were included. Their ages varied between 28 and 68 years, with an average age of 44 years. Five patients were assigned Hunt and Hess Grade IV, 15 were assigned Grade III, 7 were assigned Grade II, and 4 were assigned Grade I. All patients except two underwent angioplasty after aneurysm clipping or coiling. RESULTS: Angioplasty was performed an average of 6.9 days after the occurrence of subarachnoid hemorrhage, with a range from 1 to 14 days. It was performed early (within 24 h) after refractory clinical deterioration in 21 patients. A total of 81 vessels were dilated. Three angioplasty-related complications occurred: two femoral hematomas and one retroperitoneal hematoma. Clinical improvement was dramatic after 12 procedures, moderate after 11 procedures, and minimal or nonexistent after 9 procedures. There was a clear tendency toward more significant improvement in patients with earlier angioplasty (<24 h from onset of neurological deficit) (P=0.0038). At discharge, 8 patients had achieved good recoveries (Glasgow Outcome Scale score of 1), 11 had moderate disabilities (Glasgow Outcome Scale score of 2), and 10 had severe disabilities (Glasgow Outcome Scale score of 3). Two deaths were encountered, and they were unrelated to angioplasty. Follow-up was obtained for 27 patients: 25 had good outcomes, 1 was moderately disabled, and 1 died. There was no significant correlation between interval and outcome. CONCLUSION: Our results indicate that angioplasty is a safe and effective treatment for symptomatic vasospasm that is refractory to hyperdynamic hypervolemic therapy. When used early (<24 h), it leads to significant clinical improvement. However, the long-term outcome is good, even in cases of delayed angioplasty. The prevention of worsening of the cerebral ischemia and its extension to other territories may be the reason.

Rapid development of bilateral internal carotid artery aneurysm from sphenoid sinus aspergillosis.

The purpose of this case report is to familiarize the sinus surgeon with the possibility of the rapid development of internal carotid artery aneuryams from fungal infections of the sphenoid sinuses. A renal dialysis patient with progressive loss of vision was treated with high doses of steroids for the presumed diagnosis of temporal arteritis. Subsequent work-up included a magnetic resonance arteriogram (MRA) and computed tomography (CT) with contrast that failed to demonstrate aneurysmal changes of the carotid arteries but suggested the presence of a mycotic infection of the sphenoid sinuses. During a sphenoidotomy two days later, in addition to the anticipated aspergillus infection of the sinuses, an aneurysm extending from the left internal carotid artery into the sphenoid sinus was encountered. An emergency arteriogram immediately following the surgery revealed a second newly developed large mycotic aneurysm of the right internal carotid artery filling the right sphenoid sinus as well. This case report documents the rapidity with which mycotic aneurysms can develop from a sphenoid sinus infection secondary to aspergillosis in an immunocompromised host.

Nonhemorrhagic pituitary macroadenoma producing reversible internal carotid artery occlusion: case report.

Obstruction of the internal carotid artery by a pituitary tumor is a rare occurrence, particularly in the absence of pituitary apoplexy. A cas of occlusion of the right internal carotid artery caused by a nonhemorrhagic pituitary adenoma is reported. The patient presented with a 3-month history of headaches and a progressive loss of vision in his right eye, leading to sudden complete right-sided blindness on the day of admission. Except for the visual system, the patient's clinical examination revealed nothing remarkable. There was complete restoration of blood flow in the internal carotid artery after emergency transsphenoidal resection of the tumor was performed. The patient's vision also substantially improved shortly after the surgery. Neurodiagnostic correlation, using various imaging studies, is presented. This cas also demonstrates the importance of using magnetic resonance imaging with and without contrast to demonstrate complete occlusion or thrombosis in the affected vessel.