Endovascular treatment of carotid-cavernous fistulae: Long-term efficacy and prognostic factors.

INTRODUCTION: Carotid-cavernous fistulae are rare and affect visual prognosis. Their clinical presentation is varied and delayed diagnosis is common. They require rapid neuro-radio-ophthalmologic management. PURPOSE: The goal of this study was to evaluate the long-term efficacy and prognostic factors for treatment of carotid-cavernous fistulas by embolization. MATERIALS AND METHODS: A total of 60 patients with direct (10/60, 17%) or indirect (50/60, 83%) carotid-cavernous fistulae suspected during ophthalmological examination underwent cerebral angiography from December 2003 to October 2013. Of these, 59 (59/60, 98%) patients were treated with embolization. Treatment response was assessed with a follow-up angiogram confirming the exclusion of the fistula, and clinically by resolution of the initial symptoms. RESULTS: The diagnosis was suspected on the basis of proptosis in 45 patients (45/60, 75%), corkscrew episcleral vessels in 38 patients (38/60, 63%), chemosis in 37 patients (37/60, 61%), and diplopia in 30 patients (30/60, 50%). The median delay in diagnosis was 5 ± 5 months [0.5 to 24 months], and mean follow-up was 31 ± 31.5 months [0.5-118 months]. Eighteen patients (18/60, 30%) were lost to follow-up. Clinical response was complete in 24 patients (24/42, 57%) and partial in 14 patients (14/42, 33.5%). Symptoms were stable in one patient (1/42, 2.5%) and worsened in 3 patients (3/42, 7%). Morbidity per procedure was 3.3% and there was no postoperative mortality. Forty patients (40/60, 67%) had radiological follow-up and 39 patients (39/40, 97.5%) had a complete exclusion of the fistula. The presence of diplopia on initial examination was more frequently associated with an incomplete cure (P=0.04). CONCLUSION: The combination of proptosis, corkscrew episcleral vessels and diplopia should rapidly lead to head imaging to search for a carotid-cavernous fistula. Fistula embolization is a safe and effective treatment. The presence of diplopia on initial examination may be associated with a poorer outcome (P=0.044).

Endovascular treatment of posterior fossa arteriovenous malformations.

Infratentorial arteriovenous malformations (AVM) are rare, representing only 7-15% of cerebral AVM. The concentration of eloquent neurological structures and the high rate of bleeding presentation of AVM in this location complicate the management of such lesions. New therapeutic options, especially in endovascular therapy, have fundamentally modified the treatment strategy and also the outcome of posterior fossa AVM. Between 1999 and 2013, baseline, clinical and angiographic data of cerebral AVM were prospectively collected. We analyzed data from patients treated for a posterior fossa AVM, focusing on risk factors for bleeding, and clinical and angiographic outcomes. Sixty-nine patients (mean age 34 years, male to female ratio 2:1) were consecutively treated for an infratentorial AVM. Fifty-seven presented with hemorrhage, six with focal neurologic deficits, and the remaining six patients were diagnosed incidentally. The Spetzler-Martin grade was < 3 in 39 (56.5%) patients. Associated aneurysms were noted in 43.5% of patients. All patients were treated using endovascular procedures, associated with microsurgical resection in nine patients and with stereotactic radiosurgery in six. Mean follow-up was 28.5 months, with angiographic exclusion of the AVM in 72.5% of patients; 21.7% of patients presented a modified Rankin Score ⩾ 3 at follow-up. Endovascular embolization seems to be a secure approach for posterior fossa AVM although a large number of sessions are necessary to achieve complete obliteration. Multi-disciplinary discussion and management is crucial to obtain the best cure rate without increasing procedural risks.

Flow Diversion versus Standard Endovascular Techniques for the Treatment of Unruptured Carotid-Ophthalmic Aneurysms.

BACKGROUND AND PURPOSE: Over the past few years, flow diversion has been increasingly adopted for the treatment of intracranial aneurysms, especially in the paraclinoid and paraophthalmic carotid segment. We compared clinical and angiographic outcomes and complication rates in 2 groups of patients with unruptured carotid-ophthalmic aneurysms treated for 7 years by either standard coil-based techniques or flow diversion. MATERIALS AND METHODS: From February 2006 to December 2013, 162 unruptured carotid-ophthalmic aneurysms were treated endovascularly in 138 patients. Sixty-seven aneurysms were treated by coil-based techniques in 61 patients. Flow diverters were deployed in 95 unruptured aneurysms (77 patients), with additional coiling in 27 patients. Complication rates, clinical outcome, and immediate and long-term angiographic results were retrospectively analyzed. RESULTS: No procedure-related deaths occurred. Four procedure-related thromboembolic events (6.6%) leading to permanent morbidity in 1 case (1.6%) occurred in the coiling group. Neurologic complications were observed in 6 patients (7.8%) in the flow-diversion group, resulting in 3.9% permanent morbidity. No statistically significant difference was found between complication (P = .9) and morbidity rates (P = .6). In the coiling group (median follow-up, 31.5 ± 24.5 months), recanalization occurred at 1 year in 23/50 (54%) aneurysms and 27/55 aneurysms (50.9%) at the latest follow-up, leading to retreatment in 6 patients (9%). In the flow-diversion group (mean follow-up, 13.5 ± 10.8 months), 85.3% (35/41) of all aneurysms were occluded after 12 months, and 74.6% (50/67) on latest follow-up. The retreatment rate was 2.1%. Occlusion rates between the 2 groups differed significantly at 12 months (P < .001) and at the latest follow-up (P < .005). CONCLUSIONS: Our retrospective analysis shows better long-term occlusion of carotid-ophthalmic aneurysms after use of flow diverters compared with standard coil-based techniques, without significant differences in permanent morbidity.

"Y" and "X" stent-assisted coiling of complex and wide-neck intracranial bifurcation aneurysms.

BACKGROUND AND PURPOSE: Stent-assisted coiling with two stents has been described in some series for the treatment of complex and wide-neck bifurcation aneurysms. Our aim was to report our experience of a stent-assisted coiling technique with double stents in "Y" and "X" configurations, with emphasis on safety, feasibility, and efficacy. MATERIALS AND METHODS: Clinical and angiographic outcomes of patients for whom the strategic therapeutic option was the stent-assisted coiling technique in a Y or X configuration for neck scaffolding from June 2006 to June 2013 were retrospectively analyzed. RESULTS: One hundred five aneurysms in 97 patients were treated during 100 consecutive procedures. There were 54.2% (57/105) MCA, 28.6% (30/105) anterior communicating artery, 16.2% (17/105) basilar tip, and 1.0% (1/105) ICA termination aneurysms. A Y stent placement was used to treat 87 aneurysms in 85 procedures; an X stent placement was used to treat 7 aneurysms in 6 procedures, while 9 procedures failed for 11 aneurysms. There were 10.0% (10/100) procedure-related permanent neurologic deficits and 1.0% (1/100) death. The immediate angiographic controls showed a complete occlusion in 47.6% (50/105) of the aneurysms and a partial (neck or sac remnant) occlusion in 52.4% (55/105). To date, 81.0% (85/105) of the aneurysms have been followed up (mean, 17 months) with angiography, disclosing a recanalization in 5.9% (5/85) and an improvement in 42.4% (36/85). At discharge and follow-up, the mRS score was 0 in 83.5% (81/97) of patients, 1 in 4.1% (4/97), 2 in 3.1% (3/97), 3 in 4.1% (4/97), 4 in 3.1% (3/97), and 6 in 2.1% (2/97). CONCLUSIONS: Y and X stent-assisted coiling of complex and wide-neck intracranial bifurcation aneurysms is an effective technique.

Hemorrhagic complications after endovascular treatment of cerebral arteriovenous malformations.

BACKGROUND AND PURPOSE: Intracranial hemorrhage is the most severe complication of brain arteriovenous malformation treatment. We report our rate of hemorrhagic complications after endovascular treatment and analyze the clinical significance and potential mechanisms, with emphasis on cases of delayed hemorrhage after uneventful embolization. MATERIALS AND METHODS: During a 10-year period, 846 embolization procedures were performed in 408 patients with brain AVMs. Any cases of hemorrhagic complications were identified and divided into those related or unrelated to a periprocedural arterial tear (during catheter navigation or catheter retrieval). We analyzed the following variables: sex, age, hemorrhagic presentation, Spetzler-Martin grade, size of the AVM, number of embolized pedicles, microcatheter used, type and volume of liquid embolic agent injected, and the presence of a premature venous occlusion. Univariate and multivariate multiple regression analyses were performed to identify risk factors for hemorrhagic complications. RESULTS: A hemorrhagic complication occurred in 92 (11%) procedures. Forty-four (48%) complications were related to a periprocedural arterial perforation, and 48 (52%) were not. Hemorrhagic complications unrelated to an arterial perforation were located more commonly in the cerebral parenchyma, caused more neurologic deficits, and were associated with worse prognosis than those in the arterial perforation group. Only premature venous occlusion was identified as an independent predictor of hemorrhagic complication in the nonperforation group. Premature venous occlusion was significantly related to the ratio of Onyx volume to nidus diameter. CONCLUSIONS: Higher injected volume of embolic agent and deposition on the venous outflow before complete occlusion of the AVM may account for severe hemorrhagic complications.

Analysis of complications and recurrences of aneurysm coiling with special emphasis on the stent-assisted technique.

BACKGROUND AND PURPOSE: Stent-assisted coiling has expanded the treatment of intracranial aneurysms. With the use of continuously compiled data, we reviewed the role and drawbacks of stent-assisted coiling. MATERIALS AND METHODS: We compiled data from consecutive patients from 2003-2012 who underwent coiling, with or without stent assistance. Clinical and angiographic results were analyzed retrospectively. RESULTS: Of 1815 saccular aneurysms in 1505 patients, 323 (17.8%) were treated with stents (299 procedures) and 1492 (82.2%) without stents (1400 procedures). Procedure-related complications occurred in 9.4% with stents versus 5.6% without stents (P = .016, relative risk 1.5; 95% CI, 1.1-2.7). Ischemic complications were more frequent in the stent group than in the no-stent group (7.0% versus 3.5%; P = .005; relative risk, 1.7; 95% CI 1.2-2.5), as were hemorrhagic complications (2.3% versus 1.9%, P = .64). Procedure-induced mortality occurred in 2.7% (8/299) with stents versus 1.1% (15/1400) without stents (P = .029; relative risk, 2.0; 95% CI, 1.1-3.5). Logistic regression analysis identified wide-neck aneurysms as the most significant independent predictor of complications. A total of 64.1% (207/323) of aneurysms treated with stents and 70.3% (1049/1492) treated without stents have been followed, disclosing angiographic recurrence in 15.5% (32/207) versus 35.5% (372/1049), respectively (P < .0001). Logistic regression analysis showed that the presence of a stent was the most important factor for the reduction of angiographic recurrence (P < .0001; relative risk, 2.3; 95% CI, 1.6-3.3). CONCLUSIONS: The stent-assisted coiling technique is associated with a significant decrease in recurrences but a significant increase in complications. The treatment of wide-neck aneurysms remains hazardous.

[Family pediatricians and obstructive sleep disorders]. / Il pediatra di famiglia e i disturbi respiratori ostruttivi nel sonno.

UNLABELLED: BREATHING: Problems related to the Obstructive Sleep Disordered Breathing (OSDB) are so many: 1) a noso- graphic setting has still to be defined and this leads to contrasting results concerning the prevalence of the OSDB; 2) the absence of a single pathogenetic trigger which can explain the sudden increase of the number of cases of the OSDB since the 1980's; 3) a poor integration between clinical and diagnostic tests; 4) a not well defined role of the family pediatrician in approaching the OSDB. OBJECTIVES: From the above introduction we can deduce four objectives of the study: 1) verifying the prevalence of the OSDB; 2) studying if an early development of the adenotonsillar tissues can influence the on-set of the OSDB; 3) a better definition of the clinical diagnosis; 4) knowing what decisions the family pediatrician do take as concerns the diagnostic tests and therapy. MATERIAL AND METHOD: This study was carried out on questionnaires completed by 8 family pediatricians which consisted of two parts: the first section regarded the whole population interviewed (2.271 children) and the second more specific was reserved only to the 42 children classified as affected by the OSDB. These 42 children presented at least 3 of the following 4 features during sleep: (1) the parents are worried about the way their child breaths (2) snoring (3) apnea (4) paradoxical rib cage movement in inspiration. RESULTS: The prevalence of the OSDB was 1.8%. However considering how suggested by some authors even those children who snored and also presented oral respiration, the prevalence increased to 10.3%. These values are similar to the international results with a prevalence of 2-3% for the more severe forms defined as Obstructive Sleep Apnea Syndromes (OSAS) and of 8-11% considering all the forms of the OSDB. Grouping these patients according to their ages, it resulted that the highest incidence of the OSDB was in children between 3-5 years. This observation supports the hypothesis that at the base of the OSDB is an early development of the adenotonsillar tissues, thus in constrast which the classical course which identifies the peak of adenotonsillar hypertrophy between 4 and 6 years of age. The frequency of the single signs and symptoms in the various ages permits the improvement of the clinical diagnosis: in particular snoring, oral respiration and tonsillar hypertrophy are less frequent in the first three years of life, while in the older children the percentage of growth inhibition decreased and it becomes more difficult observing paradoxical rib cage movement in inspiration. Concerning the diagnostic tests, the family pediatrician asks only exceptionally specific test during sleep (5% of the patients). Concerning therapy, many were the indications for adenotonsillectomy even during the first three years of age (82% of the patients) proving that the family paediatrician has overcome the old attitude of not indicating operation in the first 4-5 years of age. CONCLUSION: The confirmed high prevalence of the OSDB, the possibility of further improving the clinical diagnosis, the good capacity of the family pediatrician concerns diagnosis and therapy are all factors which favour the direct management of most of the children with adenotonsillar hypertrophy by the family pediatrician. The diagnosis and therapeutic choice can find support in sleep tests when necessary. These tests have to be carried out in a specialized laboratory and the results be interpreted together with the clinical signs and symptoms. Patients who have to be managed by Pediatric sleep laboratory are: 1) children with OSDB due to organic and functional alterations on genetic basis; 2) children in whom adenotonsillectomy presents a high risk such as a severe respiratory insufficiency and the young age of the patient (less 12-18 months of life).

[Aspiration bronchopneumopathies]. / Le broncopneumopatie da aspirazione.

Diagnosis of pulmonary disease due to inhalation (PDI) is based on the assumption that not all paediatric pulmonary disease is attributable to infection. Moreover, an accurate investigation of all typical signs of PDI is necessary: drooling, pouring of food from the nose, choking, frequent vomiting and regurgitation. Specific aetiological diagnosis is not difficult when PDI represents only the epiphenomenon of well defined diseases which have disturbed deglutition (e.g. premature birth, cerebral palsy, muscle disease). It is difficult but more important to find the cause of dysphagia when dysphagia itself represents the first sign of dysfunction of the autonomic nervous system (e.g. familial dysautonomy). There are different PDI due to oesophageal dysphagia, e.g. the anomalous artery which presses the oesophagus against the trachea, oesophageal duplication, achalasia. The most frequent cause is gastro-oesophageal reflux, although recently its role in producing symptoms at night in the asthmatic child in much less. Gastro-oesophageal reflux is increased by the Beta2, agonists, the corticosteroids and theophylline. Therefore these drugs, especially theophylline, have to be used with discretion, also if gastro-oesophageal reflux is only suspected (e.g. frequent vomiting by the infant). Anomalous communication between the oesophagus and airways, particularly the laryngotracheo-oesophageal cleft and the isolated tracheoesophageal fistula, are rare diseases and difficult to diagnose. Therefore diagnosis can be delayed for months or even years. Prognosis is extremely variable: repeated inhalation will, however, cause diffuse interstitial fibrosis or, more rarely, a bronchiectasic lesion.

[Aerosol administration in antibiotic therapy of cystic fibrosis]. / La via areosolica nella terapia antibiotica della fibrosi cistica.

The aim of this research was to evaluate the response to aerosol antibiotic therapy in Cystic Fibrosis (CF) patients, who because of severe lung disease, were obligated to frequent hospitalizations to undergo intravenous antibiotic therapy. Ten patients, aged 2 to 20 years were submitted to 4 months cycles of aerosol antibiotic therapy for a total of 18 cycles. The daily treatment consisted of carbenicillin 1 g b.d. and gentamicin 80 mgs b.d. At the end of treatment there was a statistically significant improvement of the modified Huang score and of single clinical parameters such as body growth, apetite, physical activity, clinical thoracic evaluation, appearance of sputum. Almost all of the radiographic items remained unchanged: in only 4 cases there was an improvement of the atelectasis-broncopneumonia type lesions. Regarding lung function, there was a statistically significant increase of maximum midexpiratory flow rate (MMEF) from 40% predicted before treatment to 50% predicted after. The reduction of residual volume (RV) from 270% predicted before 170% predicted after treatment was quantitatively more important. Furthermore, the treatment brought about a drastic reduction in number of hospitalizations: from an average of 1,7 hospitalizations/year before to an average of 0,3 hospitalizations/year during treatment. The increased number of isolations of isolations of candida albicans is the only report which favors possible adverse effects, in particular the possibility that this type of treatment favors lung mycosis.