Intra-arterial tissue plasminogen activator and abciximab in patients with acute basilar artery occlusion.

Acute basilar artery occlusion has a poor prognosis and best treatment has not been assessed yet; as for intra-arterial treatment, no "gold standard" exists. We evaluated a series of ten patients treated with intra-arterial combination of recombinant tissue plasminogen activator (rtPA) and abciximab. Partial/complete recanalisation was achieved in all patients and good outcome (1 month Modified Rankin Scale 0-2) in eight cases, while one patient had symptomatic intracranial haemorrhage and died. Such outcome appears significantly better if compared with the results of Basilar Artery International Cooperation Study, suggesting that intra-arterial administration of rtPA and abciximab may be a promising option in patients with acute basilar artery occlusion undergoing endovascular treatment.

Pulmonary embolism caused by cement leakage during percutaneous vertebroplasty. A case report of successful conservative management.

Percutaneous vertebroplasty (PV) is considered a minimally invasive procedure, yet cement leakage into the circulation may result in serious complications. Here, we are reporting a case of pulmonary embolism following PV for treatment of osteoporotic compression vertebral fracture.

Stenting and coil embolization of a ruptured dissecting basilar artery aneurysm associated with coil embolization of a pericallosal artery aneurysm. A case report.

We describe the case of a 54-year-old woman who underwent endovascular treatment in the setting of a massive subarachnoid haemorrhage due to rupture of a dissecting basilar trunk aneurysm treated with stent implantation and coiling. A further saccular aneurysm in the left pericallosal artery disclosed by four-vessel angiography was treated with coiling during the same procedure. Follow-up DSA performed after six months confirmed complete occlusion of both aneurysms and patency of the stent.

Spontaneous arteriovenous fistula of the vertebral artery. Three case reports.

Three cases of spontaneous arteriovenous fistulas of the vertebral artery (VAF) are reported. In one case the only symptom was a cervical bruit; in the other two cases, symptoms of multiple cervical radiculopathy were also observed. Definitive diagnostic findings were obtained by Doppler ultrasonography, computed tomography, magnetic resonance imaging, and angiography. Clinical signs of radiculopathy disappeared after endovascular balloon occlusion of the fistula, in about 1 month. In one case the vertebral artery was occluded without clinical consequences.

Contrast-enhanced three-dimensional MR angiography of neck vessels: does dephasing effect alter diagnostic accuracy?

The aim of this study was to evaluate diagnostic accuracy of contrast-enhanced MRA (CEMRA) compared with digital subtraction angiography (DSA) in studying neck vessels of 48 patients. In three groups of patients, we used three MRA protocols differing for voxel size to assess if intravoxel dephasing effects could modify accuracy of CEMRA. Accuracy and correlation with DSA results were calculated in all patients and separately in the three groups. A qualitative analysis of the likeness between morphology of the stenosis in CEMRA and DSA images was also assessed. In all patients accuracy and agreement with DSA were 96% and k=0.85 in subclavian arteries, 96% and k=0.84 in vertebral artery, 97% and k=0.88 in common carotid arteries, and 94% and k=0.86 in internal carotid arteries. In the three groups accuracy and agreement with DSA did not show any significant difference. Qualitative analysis of CEMRA and DSA images revealed a better agreement in depicting the morphology of stenosis using a smaller voxel size. The CEMRA represents a powerful tool for the non-invasive evaluation of neck vessels. Overestimation trend of CEMRA is confirmed and the reduction of voxel size, decreasing the dephasing intravoxel effect, allows to have a better overlapping of stenosis morphology on CEMRA compared with DSA, but it does not yield diagnostic gain in the stenosis grading.

Rebleeding and ischemia after acute endovascular treatment of ruptured dissecting subarachnoid vertebral artery aneurysms.

SUMMARY: Dissection aneurysms of the vertebral artery represent 3.2% of all cerebral aneurysms and 28% of intracranial dissection aneurysms. Dissection of the vertebral artery in its intracranial segment (V4) usually causes a subarachnoid hemorrhage (SAH) from subadventiatial extension of the vessel wall hematoma. Rarely (one case in seven), the symptomatology is characterized by brain stem ischemia from the vertebral artery and/or postero-inferior cerebellar artery occlusive dissection. The high rebleeding (18-33% with a 10+/-5 day interval between the first and the second bleeding) and mortality (> 45%) rates 1, 13 of this disease prompt emergency treatment usually consisting in endovascular coiling of the dissection aneurysm and/or the dissected segment of the parent vessel. Herein we report our experience in endovascular coiling of acutely ruptured dissecting aneurysms of the vertebral artery dissection in V4 segment. We focus the discussion on the risk of rebleeding and the ischemic complications that my occur after endovascular or surgical treatment.

Role of electrothrombosis in aneurysm treatment with Guglielmi detachable coils: an in vitro scanning electron microscopic study.

BACKGROUND AND PURPOSE: In the 1990s, the introduction of the Guglielmi detachable coil (GDC) system in clinical practice was followed by extensive clinical use of this endovascular device in the treatment of brain aneurysms. This technology is based on electrothrombosis and electrolytic detachment of platinum coils. Despite the extensive use of this treatment technique, the role of electrothrombosis has not been fully investigated and clarified. An in vitro electron microscopic study of human blood was performed to elucidate the role that electrothrombosis might play in triggering the biologic response of thrombosis of the aneurysmal sac. METHODS: Human blood from five patients was used to fill plastic containers in which GDCs had been deposited. These five patients had subarachnoid hemorrhage and were similar in age and clinical presentation. Electron microscopic studies were performed on GDCs that had been electrically charged and on GDCs that had not. RESULTS: All electron microscopic studies revealed that the electrically charged GDCs were covered by blood elements and fibrin adherent to the surface of the coil. Noncharged GDCs did not have deposits or adhesions of these blood constituents. CONCLUSION: These findings demonstrated that passage of electric current through the GDC induces attraction of blood constituents. This attraction may trigger a thrombotic reaction on the surface of the coil. The greater the time of current application, the more pronounced the cellular reaction and the deposition of fibrin and blood cells on the GDC.

Characteristics of cerebral microembolism during carotid stenting and angioplasty alone.

BACKGROUND: Cerebral microembolism has often been documented by transcranial Doppler imaging during carotid angioplasty and stenting. However, few data are available about its characteristics during the 2 different kinds of procedure. OBJECTIVES: To compare the incidence of microemboli occurring during angioplasty alone with that during stenting in the different phases of the procedures and to relate it to periprocedural cerebrovascular complications. PATIENTS AND METHODS: Thirty-eight patients underwent 41 procedures (15 angioplasty alone and 26 stenting) for symptomatic carotid stenoses of 70% or more. Transcranial Doppler monitoring was performed to detect microemboli in the middle cerebral artery during 3 phases of the procedure: (1) guidewire crossing, (2) first dilatation in case of angioplasty alone or stent release with predilatation if performed, and (3) further dilatation. RESULTS: Microemboli occurred in all cases in phase 1 of the procedure but less frequently in the arteries treated with stenting when compared with those treated with angioplasty alone in phase 2 and particularly (P<.02) in phase 3. The mean number of microemboli was highest in phase 2, predominant (P<.05) during angioplasty alone, and particularly reduced (P<.02) in phase 3 during the stenting procedures. During 2 (5%) of the 41 procedures, cerebrovascular complications occurred in phase 1, with the number of microemboli being higher than mean values. CONCLUSIONS: Cerebral microembolism is a very common event, especially during guidewire crossing and angioplasty alone compared with stenting. Further studies concerning the prognostic significance of this are advisable.

Plaque surface and microembolic signals in moderate carotid stenosis.

We performed Transcranial Doppler Monitoring to detect microembolic signals (MES) in 47 patients with moderate (30%-69%) carotid stenosis proven by selective angiography. We compared the occurrence of MES with the clinical characteristics of stenosis (symptomatic or asymptomatic) and the angiographic plaque features (nonulcerated, deep ulceration, superficial ulceration, ulceration with flap, or ulceration without flap). For these cases there was no indication for endarterectomy, nevertheless we thought it would be useful to identify risk subgroups that might benefit from surgical treatment. MES were detected in 17.9% of the stenoses with a prevalence (p <. 01) in symptomatic cases (25%) compared to asymptomatic cases (14. 3%). There was a significant correlation of MES with plaque ulceration (p <.01) and particularly with ulceration without flap (p <.01). No difference between deep and superficial ulceration was observed. The availability of prospective data on this topic might be useful to select subgroups of patients with moderate carotid stenosis at risk for embolism.

Superselective intraarterial fibrinolysis in central retinal artery occlusion.

Intraarterial fibrinolysis was performed in three patients with acute central retinal artery occlusion using recombinant tissue plasminogen activator as a fibrinolytic agent. In two cases the ophthalmic artery was selectively catheterized, and in the other a thrombolytic drug was infused into the ophthalmic artery by way of the meningeal collaterals. All patients experienced visual improvement. Fibrinolysis can produce better results than obtained from conservative treatment. A good prognosis can be achieved if the treatment starts within the first 4 to 5 hours after occlusion.

Acute histologic and ultrastructural study in one case of human basilar tip aneurysm embolised with guglielmi detachable coils.

SUMMARY: Histologic findings after Guglielmi detachable coils endovascular embolisation have been studied in experimental aneurysms. Few reports describe histopathologic reactions to platinum coils in humans. In this report we describe gross, light microscopic pathology and scanning electron microscopy study of a ruptured basilar tip artery aneurysm in a patient who died 16 hours following coiling.

Epidural spinal cavernous hemangioma.

STUDY DESIGN: Five cases of epidural spinal cavernous hemangioma submitted to magnetic resonance imaging and surgery were reviewed. OBJECTIVE: To correlate different magnetic resonance imaging appearances of epidural spinal cavernous hemangioma with histologic findings. SUMMARY OF BACKGROUND DATA: Cavernous hemangioma is an uncommon vascular malformation that may occur anywhere in the central nervous system. Purely epidural lesions are very rare. Accurate correlation between magnetic resonance imaging appearances and histologic findings have not been reported in the literature. METHODS: Five cases of epidural spinal cavernous hemangioma that had undergone magnetic resonance imaging evaluation followed by microsurgical removal, were retrospectively reviewed. Conventional spin-echo T1-, proton density- and T2-weighted magnetic resonance images were obtained in all cases, and gadolinium was used in all but one. Two cases have also been evaluated with computed tomography. RESULTS: In two cases, magnetic resonance imaging showed mixed low- and high-signal intensity components in all sequences and pathologic examination showed degenerative phenomena and hemosiderin pigments. In the remaining three cases, magnetic resonance imaging showed low- or intermediate-signal intensity on T1-weighted and high-signal intensity on proton density- and T2-weighted images. In those cases, pathologic examination showed an absence of degenerative phenomena and no signs of hemorrhage. All patients underwent surgery by laminectomy and microsurgical resection. In all, significant improvement was obtained. CONCLUSIONS: Epidural spinal cavernous hemangioma has a different magnetic resonance imaging appearance probably because of the presence or absence of the degenerative phenomena and hemosiderin pigments. As in cerebral locations, mixed signal intensity in all sequences on magnetic resonance images might be indicative of cavernous hemangioma. Presumptive preoperative diagnosis of the lesion may render the surgical approach less invasive.

Bilateral medial frontal infarction in a case of azygous anterior cerebral artery stenosis.

We describe the unusual case of a 63-year-old woman with a history of arterial hypertension who presented a sudden weakness of the lower limbs followed by mutism, akinesia and dyspraxia. Magnetic resonance images showed a bilateral medial frontal infarction. Digital subtraction angiography documented a right azygous anterior cerebral artery with severe stenosis in its sub-callosal tract; the left anterior cerebral artery showed mild hypoplasia with only sub-frontal and fronto-polar branches. No embolic source was documented. Afterwards the patient presented a gradual and partial recovery of both motor and cognitive functions.

Carotid plaque features on angiography and asymptomatic cerebral microembolism.

We studied 110 carotid arteries of 55 patients with unilateral or bilateral carotid stenosis diagnosed with selective angiography, by using Transcranial Doppler to detect high intensity transient signals (HITS) in the middle cerebral arteries (MCAs). HITS identified as embolic signals were prevalent (P < 0.05) in the MCAs on the same side as severe (70-99%) stenosis (22 of 51 = 43.1%) compared to moderate (30-69%) stenosis (5 of 37 = 13.5%). No HITS were observed in the MCA on the same side as normal control carotid arteries (n = 17) [occluded arteries (n = 5) were not considered]. HITS were more prevalent (P < 0.05) in the MCAs on the same side as ulcerated plaques (14 of 23 = 60.9%) compared to non-ulcerated plaques (13 of 65 = 20%), and all moderate stenoses producing HITS presented ulceration of the plaque. Ulcerated plaque groups showed a higher mean number of HITS than non-ulcerated plaque groups and no significant difference was noted between moderate and severe stenosis, between superficial or deep ulcerations and between ulcerations with flap or without flap. Therefore, severe carotid stenosis and moderate stenosis with plaque ulceration result in angiographic findings most frequently associated with HITS. Further studies are necessary to evaluate the clinical significance of this finding.

MRI and MR angiography of vertebral artery dissection.

A review of 4,500 angiograms yielded 11 patients with dissection of the vertebral arteries who had MRI and (in 4 patients) MR angiography (MRA) in the acute phase of stroke. One patient with incidental discovery at arteriography of asymptomatic vertebral artery dissection and two patients with acute strokes with MRI and MRA findings consistent with vertebral artery dissection were included. Dissection occurred after neck trauma or chiropractic manipulation in 4 patients and was spontaneous in 10. Dissection involved the extracranial vertebral artery in 9 patients, the extra-intracranial junction in 1, and the intracranial artery in 4. MRI demonstrated infarcts in the brain stem, cerebellum, thalamus or temporo-occipital regions in 7 patients with extra- or extra-intracranial dissections and a solitary lateral medullary infarct in 4 patients (3 with intracranial and 1 with extra-intracranial dissection). In 2 patients no brain abnormality related to vertebral artery dissection was found and in one MRI did not show subarachnoid haemorrhage revealed by CT. Intramural dissecting haematoma appeared as crescentic or rounded high signal on T1-weighted images in 10 patients examined 3-20 days after the onset of symptoms. The abnormal vessel stood out in the low signal cerebrospinal fluid in intracranial dissections, whereas it was more difficult to detect in extracranial dissections because of the intermediate-to-high signal of the normal perivascular structures and slow flow proximal and distal to the dissection. In two patients examined within 36 h of the onset, mural thickening was of intermediate signal intensity on T1-weighted images and high signal on spin-density and T2-weighted images. MRA showed abrupt stenosis in 2 patients and disappearance of flow signal at and distal to the dissection in 5. Follow-up arteriography, MRI or MRA showed findings consistent with occlusion of the dissected vessel in 6 of 8 patients.

Anterior fossa dural arteriovenous malformation discovered by means of PW-Doppler examination.

One case of dural arteriovenous malformation in the base of the anterior cranial fossa is reported. It was discovered by means of a PW-Doppler examination of angular branch of the ophthalmic artery in a patient under observation for hypertrophy of a superficial temporal artery. The nidus was located in the region of the cribriform plate and fed by the anterior ethmoidal arteries of both sides, draining into the superior sagittal sinus, via pial enlarged veins. The patient successfully underwent surgical treatment and a post-operative PW-Doppler confirmed normalization of the flow pattern in the angular branches of both ophthalmic arteries.

Spinal cavernous angioma producing subarachnoid hemorrhage. Case report.

A case of subarachnoid hemorrhage due to intramedullary cavernous angioma at the T9 level is presented. Literature dealing with subarachnoid hemorrhage due to intraspinal lesions is reviewed. The majority of cases of spinal subarachnoid hemorrhage are due to arteriovenous malformations, whereas bleeding by cavernous angioma is extremely rare. The subarachnoid hemorrhage is rare event (1.8%) in our series too. The clinical presentation of severe back pain with radicular component associated with signs of meningism (Fincher's syndrome) led us to carry out magnetic resonance imaging. This gave accurate diagnosis for surgical treatment. Laminectomy at T9-T10 level and total microsurgical removal of the vascular malformation were performed with total functional recovery.

White matter hyperintensities in Parkinson's disease. Clinical correlations.

OBJECTIVES: To verify recent preliminary data indicating that white matter hyperintensities on magnetic resonance imaging are more abundant in patients with Parkinson's disease (PD) than in healthy subjects and to examine possible correlation between these abnormalities and clinical features of PD. DESIGN: Magnetic resonance imaging data on patients with PD and normal subjects were compared as to frequency, extent, and topographic location of white matter hyperintensities; moreover, in the PD group, we studied the possible correlation of white matter hyperintensities with clinical features such as severity, disease duration, and therapy. SETTING: The outpatient clinic of the Institute of Clinical Neurology and the Neuroradiology Unit of the University of Pisa (Italy). PATIENTS: We studied 102 nondemented patients with idiopathic PD and 68 sex- and age-matched healthy controls, all screened for absence of cerebrovascular risk factors. OUTCOME MEASURES: White matter hyperintensities were classified as periventricular hyperintensities and deep hyperintensities. Frequency, extent, and topographic location of both periventricular and deep hyperintensities were evaluated. The clinical parameters examined were disease duration, treatment type, and disease severity (using Hoehn and Yahr staging and the Unified Parkinson's Disease Rating Scale), as well as disease progression index (ratio between Hoehn and Yahr stage and disease duration). RESULTS: The frequency and the extent of periventricular hyperintensities were significantly higher in patients with PD than in healthy subjects. Moreover, within the PD group, the patients who had periventricular hyperintensities had significantly shorter disease duration and greater disease severity, ie, a higher disease progression index, than those who did not. CONCLUSION: These data suggest that periventricular hyperintensities may represent a marker for a clinical subtype of PD characterized by a more rapid neurodegenerative process.

Spontaneous regression of intracranial arteriovenous malformation.

Spontaneous regression of an arteriovenous malformation is rare. When complete or partial regression occurs, an associated factor is usually involved, such as intracranial hemorrhage, surgery, radiation therapy, or a new neurological deficit. Another case in which the resolution was totally spontaneous is presented here. We discuss the importance of transcranial doppler revealing the hemodynamic changes in the cerebral arteries in the presence of an AVM and when the latter is thrombosed. Several mechanisms for regression are considered, and we focus on the dissection of the afferent vessel, pointing out the role of such an event in the natural history of AVM.