Endovascular treatment of cerebral aneurysms using the hydrocoil embolic system.

HydroCoils are platinum helical coils coated with a layer of hydrophilic acrylic polymer (hydrogel), which on contact with blood causes disentanglement of polymer chains and expansion. We retrospectively reviewed a series of 29 patients harboring 29 cerebral aneurysms treated with the Hydrocoil Embolic System in the period 2004-2005, discussing the results of endovascular procedures in terms of safety and efficacy. The immediate post-procedure angiographic control demonstrated complete aneurysm occlusion in 21 cases (72.4%), near-complete occlusion in seven cases (24.1%), whereas in one case (3.4%) there was a procedure failure with major perfusion of the sac. Five patients (17.2%) experienced thromboembolic complications, including an asymptomatic lacunar stroke of the head of the caudate nucleus, a thalamic infarct following hypotension secondary to pulmonary edema, temporal ischemia secondary to vasospasm and a small right occipital ischemic lesion. Only one patient (3.4%) suffered a major ischemic accident. No other procedure-related complication occurred. Three-month follow-up control with MR angiography and 12-month follow-up angiography demonstrated no recurrence of aneurysms. Overall, after a mean follow-up of 12 months, the clinical outcome was good recovery in 26 patients (89.6%), moderate disability in three patients (10.3%) and no vegetative status or death. Our HydroCoil series supports the safety and midterm durability of hydrogel-coated aneurysm coils in the treatment of cerebral aneurysms.

Comparison of otoplasty results using different types of suturing techniques.

BACKGROUND: Prominent ears are a common congenital deformity. Numerous techniques have been developed for the treatment of protruding ears, indicating that there is no single widely-accepted procedure. Modern otoplasty techniques fall into of two main surgical categories, (1) cartilage sparing (Mustardé & Furnas), and (2) cartilage cutting (Chongchet & Stenström). This study compares an antihelixmastoid suture technique with the normal Mustardé & Furnas technique. METHODS: Within a 5-year period (between 2005 and 2009), 78 patients (mean age 27 years; range 7 to 46) underwent otoplasty performed by the senior author (in a private plastic surgery center), employing the posterior suturing technique (Mustardé & Furnas). Of these 78 patients, 44 underwent otoplasty which combined the usual posterior suturing technique with modification we have developed (antihelixmastoid sutures). Depending on the suture technique used, the patients were divided into two groups: Group 1 (Mustardé & Furnas sutures), Group 2 (Mustardé & Furnas sutures with extra modification). Patients were invited for follow-up examinations 1 month and 1 year after surgery, and all of them attended both these follow-up checks, where recurrence and suture extrusion were evaluated. RESULTS: Group 1: the clinical recurrence rate was 4.55% (3 ears). The suture extrusion rate was 7.6% (5 ears). Group 2: the clinical recurrence rate was 1.25% (1 ear). The suture extrusion rate was 7.5% (6 ears). Patients were generally satisfied with the results in terms of shape and symmetry. There were no complications such as haematoma, ear deformity and skin necrosis. CONCLUSIONS: Posterior suturing with conchomastoid and modification of Mustardé sutures is a simple operation which can be performed quickly. It appears to be effective in terms of recurrence rate (especially in the upper segment) and patient satisfaction.

Lateral lumbar interbody fusion via a unilateral true percutaneous approach associated with minimally invasive pedicle screw fixation for degenerative disc disease and lumbar instability. A technical note.

In recent years, minimally invasive surgical techniques for lumbar fusion and fixation procedures gained worldwide popularity. Herein we describe a personal technique for percutaneous lumbar interbody fusion associated with minimally invasive posterior fixation for patients affected by degenerative disc disease and lumbar instability. The procedure is described in a step-by-step way and early results are presented. Although the present data reflect only an early experience, we believe that this is a straightforward procedure which may be more advantageous in terms of surgical invasiveness, potentially saving operative and recovery time and reducing risks compared to posterior or anterior approaches for lumbar interbody fusion.

Anatomical study and colour Doppler assessment of the skin perforators of the anterior tibial artery and possible clinical applications.

BACKGROUND: Traumatic or trophic defects of the soft tissue of the lower leg are quite often very difficult to manage, especially in the distal third of the leg. Fasciocutaneous flaps are a relatively simple option for covering small- and medium-sized defects of the lower leg. The aim of this study is to investigate the distribution of septocutaneous perforators of the anterior tibial artery and their possible clinical applications. METHODS: An anatomical study was performed on 50 fresh adult cadaveric lower extremities. Using coloured contrast materials, the location of septocutaneous perforators, originating from the anterior tibial artery, were mapped. These findings were then compared with colour Doppler imaging (CDI) data in 20 living volunteers. RESULTS: The septocutaneous perforators of the anterior tibial artery follow a reproducible pattern all over the lower leg (septa I, II and III). In the distal segment, we found relatively few perforators. There was a marginal difference between cadaveric and CDI data for perforators with diameter >or=1mm. The average number of anterior tibial artery septocutaneous perforators in anatomical dissections was 6.6+/-2.4, while CDI revealed 8.2+/-3.2 perforators in living volunteers (P=0.053). In five areas of the lower leg, there is a >50% chance that a septocutaneous perforator with diameter >or=1mm is coming off the anterior tibial artery. Anatomical dissections for a cutaneous territory 5 cm above the lateral maleollus, and 10 cm in width, revealed 6.1+/-2.2 septocutaneous perforators (range 4 to 12). CONCLUSIONS: CDI, paired with knowledge of anatomical details, is a reliable tool for preoperative identification of septocutaneous perforators of 1mm or larger outer diameter, thus providing critical information for planning and harvesting safe fasciocutaneous flaps of the lower leg. Additionally, according to our anatomical study, a new transverse fasciocutaneous flap (Type B according to the Nahai-Mathes classification), located over the distal anterolateral third of the lower leg and based on perforators of the anterior tibial artery, may be successfully used for covering selected defects of the distal third of the lower leg.

The effect of nifedipine on the patency of microvascular anastomosis in rats.

Despite advances in microsurgical technique and experience in clinical microvascular surgery, there remains the possibility of vessel thrombosis. Factors that may contribute to vascular pedicle thrombosis include operative trauma, pedicle malposition, kinking, hypercoagulability and arterial vasoconstriction. The purpose of this study was to evaluate the effect of intravenous administration of nifedipine on the patency of the microvascular anastomosis of the femoral artery in rats. A total of 60 rats were used and divided into three groups. The first group (A) was used as a control group with no medical agent, the second group (B) was medicated with heparin, and the third group (C) was medicated with nifedipine. Patency was assessed with the distal empty refill test, one hour (1) and forty-eight hours (48) after completion of the anastomosis. The nifedipine and heparin treated groups (B & C) did not show higher patency rate compared to the control group (A). There was no statistically significant difference of patency percent after 1 hour and 48 hours among the three groups (p = 0.231/p = 0.480). Intravenous administration of nifedipine does not improve the patency of microvascular anastomosis. Surgical technique remains the most important factor for successful microvascular anastomosis.

Vertebroplasty in the treatment of osteoporotic vertebral fractures: results and functional outcome in a series of 175 consecutive patients.

Osteoporosis is the most common cause of vertebral collapse, which significantly impairs mobility and quality of life. Primary management consists of conservative therapeutic measures such as analgesics, bed rest, external bracing and rehabilitation. Percutaneous vertebroplasty for the treatment of osteoporotic compressive fractures has gained popularity during the last decade. The limited invasiveness and encouraging results of vertebroplasty obtained in the treatment of patients with symptomatic osteoporotic compression fractures have favored an extensive use of the procedure for the management of patients with disabling pain refractory to conservative therapy. In the present paper, the authors provide procedure results and functional outcomes in a series of 175 consecutive patients with 242 symptomatic osteoporotic vertebral compression fractures treated by means of percutaneous polymethylmethacrylate vertebroplasty.

Aggressive eosinophilic granuloma of the parietal bone. An immunohystochemical study of Ki-67 expression.

Solitary eosinophilic granuloma (EG) of the skull is a rare lesion, the natural history of which is still to be defined. We report a case of a 26-year-old female who presented with progressive headache and nausea accompanied by a painful firm mass in her left parietal region, which grew very rapidly during the last two weeks before admission. Computed tomography scan showed an osteolytic lesion, which on magnetic resonance imaging appeared hyperintense on both T1- and T2-weighted images, with marked and heterogeneous enhancement after gadolinium administration. Total surgical excision of the lesion was performed and histopathological diagnosis was compatible with eosinophilic granuloma. Immuno-histochemical study of Ki-67 antigen expression was also performed with a labelling index of 10%. In a review of the pertinent literature, we found one case report showing a Ki-67 labelling index of 6.2% in a patient harboring EG of the occipital bone. These two relatively high percentages of proliferative activity suggest a role of local Langerhans'cell proliferation, along with that of inflammatory response, in the aggressive clinical course and rapid expansion observed in some rare cases of solitary eosinophilic granuloma.

Stent implantation for treatment of symptomatic spontaneous cervical internal carotid artery dissecting aneurysm. A case report.

Cervical internal carotid dissections are rare. Approximately one third of the cases are associated with pseudoaneurysm. The first-choice management of cervical carotid dissecting aneurysms consists in anticoagulation or antiplatelet therapy. Surgery is typically indicated in cases of failure of conservative therapy with recurrent cerebral ischemic attacks. In recent years, stent implantation has been also employed for the management of patients with carotid dissecting aneurysms whose neurological conditions were refractory to medical treatment. In the present case we describe the treatment of a patient with a carotid dissecting aneurysm, by means of endovascular stent application and provide angiographic control 24 months after the intervention.

Lymphoplasmacyte rich meningioma. A case report and review of the literature.

A peculiar type of meningioma with conspicious plasma-cell components is described. In accordance with the World Health Organization's Histological Typing of Tumours of the Central Nervous System, this rare clinical entity is recently designed as lymphoplasmacyte rich (LPR) meningioma. This type of meningioma is usually accompanied by prominent peripheral blood abnormalities, anemia and/or policlonal gammophaty, that disappear after surgical removal of the tumor. Actually, the origin (neoplastic or inflammatory) of this tumor is unclear; its biological behavior and clinical course are anomalous so it is considered closer to intracranial inflammatory masses rather than typical meningioma. In this paper, a new case of intracranial LPR meningioma occurring in a woman, is reported and a review the literature is made.

An unusual case of vertebral arteriovenous fistula treated with electrodetachable coil embolization.

Vertebral arteriovenous fistulas (VAF) are rare clinical entities. Most are post-traumatic in origin, following direct injury, or iatrogenic. Treatment options include endovascular occlusion or direct surgical closure. We present a rare case of a spontaneous VAF, presenting with cervical and upper limb pain in a patient with previous chiropractic manipulations, successfully treated with electrodetachable coil embolization. While the natural history of the VAFs is still to be settled, endovascular occlusion appears to be a safe and reliable method to deal with such lesions, mainly in symptomatic cases. The use of electrically detachable coils may be considered as an effective alternative for the endovascular occlusion of these fistulas.

Endoscopic release in carpal tunnel syndrome: analysis of clinical results in 200 cases.

Carpal tunnel syndrome is the most common peripheral neuropathy. Conventional carpal tunnel surgery has been performed as a primary procedure for the decompression of the median nerve at the wrist in patients who have idiopathic carpal tunnel syndrome. While the results have been excellent, this surgical procedure has been reported to be related to high postoperative morbidity and extended length of recovery time. Over the past decade, endoscopic release of the transverse carpal ligament has been developed as a new, alternative method to the open procedures. Endoscopic carpal tunnel release has been reported to ensure less postoperative morbidity, more rapid recovery of strength, with earlier return to work, reduced disability time and a better cosmetic result. The authors present a surgical series of 200 hands in 164 patients (36 bilaterals) with idiopathic carpal tunnel syndrome, who underwent a single-portal endoscopic carpal tunnel release (Agee technique), with regards to the clinical outcome and complications occurred after 4-months follow-up.

Bilateral chronic subdural hematoma associated with meningioma. Case report and review of the literature.

Gross intracranial hemorrhage associated with brain tumor has been reported to range from 3.6-10%. Brain metastases and malignant glioma are the most frequent underlying pathologies. Intracranial hemorrhage related to meningioma is a rare condition. Subarachnoid hemorrhage, acute subdural hematoma, intratumoral and intraparenchymal hematomas are the most common forms of bleeding associated with meningioma. By contrast, chronic subdural hematoma (cSDH) and intraventricular hemorrhage are seen less frequently. The authors report a very rare case of left fronto-parietal convexity meningioma associated with bilateral cSDH in a patient with history of recent minor head trauma and review the literature on hemorrhage associated with meningiomas.

Paravertebral retropleuric microsurgery approach to the treatment of thoracic disc herniation. Personal experience and consideration of unsatisfactory results.

AIM: The authors report their experience on the paravertebral retropleuric microsurgery approach to the treatment of thoracic disc herniation. The paper describes both the approach and its result and it further expands on the reason behind the few cases of unsatisfactory results. METHODS: Twenty-three patients were operated upon for thoracic disc herniation between 1994 and 2000. The paravertebral retropleuric microsurgery approach was used in each. RESULTS: The results were very satisfactory in 20 cases, with all symptoms completely disappearing. In only 3 cases we had unsatisfactory results. CONCLUSION: We think that the postero-lateral retropleuric approach is a correct method for the treatment of thoracic disc herniation because it did not cause any significant bone intervention.

Neurocysticercosis. Case report.

In the present review we report a case of a 53-year-old woman affected with a cyst solitary cerebral hemispheric lesion causing acute generalized seizure. Clinical and neuroradiologic diagnosis of cystic astrocytoma was performed and the patient was operated. Microscopic analysis of the surgical specimen led to a diagnosis of parasitic infection, consistent with neurocysticercosis (NCC). NCC is the most frequent parasitosis of the central nervous system (CNS) in the world. The infective agent is taenia solium larvae. It is endemic in Latin America, Africa and some Asiatic countries, such as India. In Europe, many cases have been reported in Portugal, Spain, Poland and Romania. In Italy NCC is a rare disease. In recent years no cases have been described, but with high rate of immigration from endemic areas (Africa and East Europe) this parasitosis will be found in our country too, particularly affecting communities where hygienic conditions are poor. In conclusion we briefly analyze the relationship between pathogenesis of this parasitosis and its clinical symptoms.

Conversion of hip arthrodesis to total hip arthroplasty.

With the predictably good outcome now found with THA, hip arthrodesis has limited indications today. The procedure still has a role in the case of the young, heavy demand male with an isolated arthritic hip condition, and developments such as the Cobra head plate have considerably improved success rates. However, a long-term hip arthrodesis can have profound effects on a patient's daily function and activities of daily living. In addition, gait pattern is considerably affected as well as other joints such as the lower back, ipsilateral knee, and contralateral hip. Many patients with a hip arthrodesis will eventually require a takedown of the fused hip and conversion to a THA. The primary indications include fusion in malposition, pseudarthrosis, or severe pain in other joints. The surgeon undertaking such a task must be familiar with the arthrodesis techniques that have been used in the past as well as the equipment that may be required to extract the fixation hardware. Clinical assessment with particular attention to leg-length discrepancy, position of the arthrodesis, and function of the abductors is of paramount importance. The surgeon must carefully review preoperative radiographs to plan the procedure. The surgeon must also be aware of the presence of pathology in other joints. After takedown of a hip arthrodesis and conversion to a THA, patients cannot expect the result to equal the success rates of primary THA. Patients generally can expect an improvement in function and mobility. Back pain and ipsilateral knee pain are usually improved postoperatively, but the effect on contralateral hip pain is less predictable. Many patients will continue to show a positive Trendelenburg sign, but further improvement in strength of the hip abductors can be expected with time. Leg-length discrepancy is generally improved substantially after THA. However, a substantial number of patients will require a walking aid postoperatively. Overall, the risk of complications and the rates of revision after converting an arthrodesed hip to a THA are quite high. The procedure can be complex. Consideration should be given to referring these patients to a specialized center under the care of an experienced arthroplasty surgeon if preoperative planning suggests that the conversion will not be straightforward.

Left atrial and left atrial appendage functional abnormalities in patients with cardioembolic stroke in sinus rhythm and idiopathic atrial fibrillation.

Thrombogenesis in the left atrial appendage (LAA) has been related to the special morphology of this cavity and to its size and degree of dysfunction. However, no study has focused on LAA function in conjunction with left atrial (LA) function in both sinus rhythm (SR) and nonrheumatic idiopathic atrial fibrillation (AF) in relation to clinical status (cardioembolic stroke). Forty-three patients in SR (14 patients with stroke, 29 control subjects) and 45 patients in AF (27 patients with stroke, 18 control subjects) were examined by transthoracic and transesophageal echocardiography. Baseline clinical characteristics and standard transthoracic and transesophageal measurements of the LA and LAA (size, fractional area change, flow measurements, spontaneous echo contrast, and thrombus) were recorded and compared in relation to cardiac rhythm. Patients in the stroke-SR group showed a significant decrease of fractional area change in the LA (32%+/-15%) and LAA (34%+/-15%) in relation to control subjects (43%+/-10%, p = 0.035, 49%+/-13%, p = 0.006, respectively). Patients in the stroke-AF group showed significant reduction of appendage flow measurements (outward velocity = 22+/-13 vs 33+/-19 cm/sec, p = 0.036), whereas no differences were detected in the center of the LA. In multiple regression analysis, the presence of cardioembolic stroke was positively associated with the presence of spontaneous echo contrast (p = 0.0253) and spontaneous echo contrast negatively associated with appendage inward flow velocity (p<0.001). Cardioembolic stroke in patients in SR is associated with a global decrease of shortening in both cavities and in patients with AF, with a reduction of LAA flow parameters. Patients with spontaneous echo contrast, thrombus, or both showed further reduction of shortening and flow velocities in both cavities, indicating a more advanced stage of dysfunction.

Myeloradicular damage in traumatic cervical disc herniation.

BACKGROUND: The literature on pure traumatic disc herniation is now voluminous but diversity of opinion exists regarding frequency, pathogenesis and management of this type of lesion. As a further contribution to the solution of the question it is thus justified to report our series of cervical traumatic disc herniation. METHODS: During the period from January 1986 to December 1994, 41 patients (25 males and 16 females, between the ages of 24 and 51 years) with traumatic cervical disc herniations were operated on by anterior approach. Twenty-six (63.4%) patients presented with radicular syndrome, 3 (7.3%) with medullary symptoms and signs, and 12 (29.3%) with myeloradiculopathy. Disc herniation was at the C3/4 level in 4 (9.7%) cases, at the C4/5 level in 7 (17.1%) cases, at the C5/6 level in 24 (58.5%) cases, and at the C6/7 level in 8 (19.5%) cases. In 6 (40%) patients suffering from myelopathy (with or without radiculopathy) an area of high MR signal intensity was observed within the cervical cord on T2-weighted images; such area corresponded at the level of cord compression by disc and was not demonstrated on T1-weighted images. All patients underwent discectomy without bone grafting. RESULTS: Among patients with radiculopathy, 27 (71%) experienced complete relief of preoperative symptomatology, and 11 (29%) minor pain and/or neurological deficits without interference with work activities. The myelopathy completely disappeared in 11 (73.3%) cases whereas remained unchanged in 3 (20%); 1 patient with myelopathy experienced amelioration of preoperative specific symptoms and signs. CONCLUSIONS: The results of surgery for cervical radiculopathy due to traumatic disc herniation are satisfactory since 92 to 100% of the patients postoperatively regain prior activities, an observation we have confirmed with our own series. The results in cases of myelopathy are less satisfactory: although approximately 73% of our patients with myelopathy reported total relief of preoperative symptomatology, published reports indicate that a significant postoperative improvement is seen in 33 to 56% of patients.

Left ventricular mass regression early after aortic valve replacement.

BACKGROUND: Regression of left ventricular hypertrophy is an important and well-recognized salutary effect of aortic valve replacement. The earliest evidence of left ventricular mass regression after aortic valve replacement and the influence of prosthesis type are not well known, and were the focus of this study. METHODS: Transthoracic echocardiography was used to measure left ventricular mass index preoperatively and before discharge in 57 consecutive patients undergoing isolated aortic valve replacement (with or without coronary artery bypass grafting). RESULTS: Three patients were excluded from the study because of inability to obtain accurate M-mode echocardiographic images for left ventricular mass measurement preoperatively (1) or postoperatively (2). Of the remaining 54 patients, mechanical bileaflet valves were used in 19, stented tissue bioprostheses were implanted in 15, and a stentless porcine bioprosthesis was chosen for 20. Postoperative echocardiograms were obtained 4.9 +/- 2.3 days after aortic valve replacement (range, 2 to 9 days). A two-way repeated-measures analysis of variance demonstrated a significant reduction of left ventricular mass index before discharge (preoperative 141.4 +/- 45.2 g/m2, postoperative 127.5 +/- 32.8 g/m2; p = 0.0005) but no differences between prostheses. CONCLUSIONS: Left ventricular mass regression begins early after aortic valve replacement, probably because of reduction of transvalvular gradients and left ventricular wall stress. At least in the very early postoperative period, the type of prosthesis does not influence the extent of mass regression.

Is body size the cause for poor outcomes of coronary artery bypass operations in women?

Although small body size and coronary artery diameter are recognized as major contributors to the increased risk of coronary artery bypass grafting in women, few studies have established the independent influence of body size and gender on outcome. We studied 7025 consecutive patients (5694 men, 1331 women) undergoing isolated coronary artery bypass grafting between 1990 and 1994. Women were older, had higher preoperative prevalences of urgent operation because of unstable angina, diabetes, peripheral vascular disease, hypertension, and single-vessel coronary artery disease (p < 0.0001), and a lower prevalence of left ventricular ejection fraction 40% or less (p < 0.0001). The prevalences of operative mortality (men, 1.8%; women, 3.5%), low-output syndrome (men, 6.6%; women, 14.8%), and myocardial infarction (men, 2.8%; women, 5.5%) were higher in women (p < 0.0001). Patients were divided into quartiles for body surface area, weight, height, and body mass index. For both men and women, there was no difference in operative mortality between the highest and lowest quartiles of body size. Women, however, had a higher prevalence of operative mortality than men in the lower quartiles of body surface area, height, and weight and in the higher quartiles of body mass index. Among men, the prevalence of low-output syndrome increased (p < 0.0001) with decreasing body surface area, weight, and body mass index, suggesting that body size did influence the prevalence of low-output syndrome. However, women had a higher prevalence of low-output syndrome than men in every category and quartile of body size (p < 0.0001). Multivariable analysis identified gender as a significant determinant of operative mortality (odds ratio 1.83, 95% confidence interval 1.27 to 2.64) and low-output syndrome (odds ratio 2.52, 95% confidence interval 2.05 to 3.11). When multivariable adjustments were made for body size and preoperative risk factors, gender remained a predictor of both operative mortality and low-output syndrome. Multivariable assessment of risk for men and women separately identified that urgent operation was a predictor of operative mortality (odds ratio 2.52, 95% confidence interval 1.32 to 5.61) and low-output syndrome (odds ratio 1.57, 95% confidence interval 1.14 to 2.17) in women but not men. In conclusion, the increased risk of coronary artery bypass grafting in women may be explained in part by dramatic differences in preoperative risk factors between men and women. In both men and women, small body size did not increase the risk of operative mortality, but may have contributed to the risk of low-output syndrome.(ABSTRACT TRUNCATED AT 400 WORDS)