Transarterial Treatment of Cranial Dural Arteriovenous Fistulas: The Role of Transarterial and Transvenous Balloon-Assisted Embolization.

BACKGROUND AND PURPOSE: Treatment of dural arteriovenous fistulas can be performed by transarterial or transvenous accesses. For those fistulas located at a dural sinus wall, obliteration of the sinus might lead to a substantial risk of complications if the occluded sinus impairs normal venous drainage. For those fistulas with direct leptomeningeal venous drainage, navigation to reach the arteriovenous shunting point of a leptomeningeal vein is usually technically demanding. We report the outcomes of patients with dural AVFs treated by transarterial injection of liquid embolic agents assisted by transarterial double-lumen balloon catheters and/or transvenous balloon catheters. MATERIALS AND METHODS: This was a retrospective, 3-center study including patients with dural AVFs treated with a balloon-assisted technique in at least 1 treatment session. Angiographic follow-up was performed at 6 months. Clinical assessment was performed at admission and discharge and was reassessed at 30-day and 6-month follow-ups. RESULTS: Forty-one patients with 43 dural AVFs were treated. Thirty-four fistulas were located at a dural sinus wall. Treatment was performed using only a transarterial approach in 42 fistulas. Only 1 session was needed for complete obliteration of the fistula in 86% of the patients. Immediate complete angiographic occlusion was achieved in 39 fistulas. Of the 41 controlled fistulas, 40 (97.6%) were completely occluded at 6 months. Thirty-nine fistulas (95.1%) were cured without any report of major neurologic events or death during follow-up. CONCLUSIONS: Transarterial balloon-assisted treatment of dural AVFs with or without transvenous balloon protection was shown to be safe and effective.

Performance of rapid prescreening and 100% rapid review as internal quality control methods for cervical cytopathology.

BACKGROUND: An objective of quality control for cervical cytopathology is reducing high rates of false-negative results of laboratory tests. Therefore, methods to review smears such as rapid prescreening and 100% rapid review, which have shown better performance detecting false-negative results, have been widely used. The performance of rapid prescreening and the performance of 100% rapid review as internal quality control methods for cervical cytology examinations were evaluated. METHODS: For 24 months, 9318 conventional cervical cytology smears underwent rapid prescreening and routine screening. The 100% rapid review method was performed for 8244 smears classified as negative during routine screening. Any discordant results underwent detailed review to define the final diagnosis. This was considered the gold standard for evaluating the performance of rapid prescreening and 100% rapid review. RESULTS: Routine screening showed increases of 13.3% and 11.5% in the detection of abnormal smears with rapid prescreening and 100% rapid review, respectively. The relative percentage variation showed a 38.1% increase in the diagnosis of atypical squamous cells of undetermined significance with routine screening and rapid prescreening and a 12.5% increase in the diagnosis of atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion with both rapid prescreening and 100% rapid review. Sensitivity rates of rapid prescreening and routine screening were 48.2% and 83.2%, respectively. Sensitivity rates of rapid prescreening and 100% rapid review were 65.7% and 57.8%, respectively, for detecting false-negative results. CONCLUSIONS: Inclusion of rapid prescreening and/or 100% rapid review improved the diagnostic sensitivity of the cervical cytology examination and reduced false-negative results of routine screening and can provide good quality control.

A Novel Configuration of Pipeline Embolization Device for Internal Carotid Bifurcation Region Aneurysms: Horizontal Deployment.

PURPOSE: To describe a novel configuration of pipeline embolization device for internal carotid bifurcation region aneurysm, named horizontal stenting. CLINICAL PRESENTATION: A 64-year-old woman, with visual deficit, harboring a large wide-necked aneurysm located at the junction between left internal carotid artery and left A1 segment of anterior cerebral artery, was submitted to endovascular treatment. As she had pre-existing occlusion of left internal carotid, approach from the contralateral internal carotid was used to advance the pipeline embolization device through the anterior communicating artery and place the flow diverter horizontally across the neck (from M1 to A1). Coil embolization was also performed through a microcatheter navigated via posterior communicating artery. The intervention was uneventful, with total aneurysm occlusion. Patient presented with visual improvement on follow-up. CONCLUSION: Horizontal deployment of pipeline embolization device appears to be an acceptable and feasible alternative to treat internal carotid bifurcation aneurysms. Long-term follow-up and a greater number of cases are mandatory to establish the safety of this strategy.

Basilar Artery Fenestration Aneurysms: Endovascular Treatment Strategies Based on 3D Morphology.

PURPOSE: Basilar artery is the second most common site of fenestration, after the anterior communicating region. It is believed this variation predisposes a patient to posterior aneurysm formation and increases the complexity of the surgical anatomy. Endovascular management has become the first option to treat these aneurysms. We retrospectively evaluated eight patients, who underwent endovascular treatment for fenestrated basilar artery related aneurysms (fBA-AN). Additionally, based on our findings and on literature review, we developed a treatment strategy based on a proposed classification of fBA-AN. METHODS: Between June 2010 and September 2012, eight patients harboring nine basilar artery fenestration aneurysms were consecutively treated. Based on aneurysm morphology (neck size) and its relationship to the fenestration (sparing or not one channel) characterized by 3D-DSA, we proposed a simple classification and treatment strategies. Additionally, a literature review was performed. RESULTS: All patients received endovascular treatment. Most aneurysms involved the vertebrobasilar junction and both channels of the fenestration. A total of 5 aneurysms had wide neck while 4 had narrow neck. Overall, 5 (55.5 %) aneurysms were treated with stent assisted coiling, 3 (33.3 %) aneurysms with selective coiling, and 1 (11.1 %) aneurysm with balloon assisted coiling. We had only 1 (11.1 %) complication, named aneurysm rupture. CONCLUSION: Basilar artery fenestration aneurysms are rare and complex lesions. Endovascular treatment appears to be safe and efficient. The detailed understanding of the aneurysm morphology and its relation to the fenestration is strongly recommended to treatment planning. Further studies are necessary to validate the utility of the proposed classification and treatment strategy.

Endovascular treatment of isolated posterior inferior cerebellar artery dissecting aneurysms: parent artery occlusion or selective coiling?

PURPOSE: Isolated posterior inferior cerebellar artery dissecting aneurysms are rare lesions. Their underlying pathology, presentation, and natural history are poorly understood. Their treatment is controversial, and few data are available regarding the best treatment. We conducted the first study comparing selective coiling and parent artery occlusion for the treatment of isolated PICA dissecting aneurysms. METHODS: All patients harboring isolated PICA dissecting aneurysms treated between January 2006 and October 2012, in a single center, were retrospectively evaluated. Patients were consecutively submitted either to selective coiling or parent artery occlusion. The safety and durability (recanalization and rebleeding rates) of each treatment were established. In order to compare the results of both treatment modalities, we also performed a literature search of all cases of isolated PICA dissecting aneurysms endovascularly treated. RESULTS: Fourteen patients harboring isolated PICA dissecting aneurysms were assigned to endovascular treatment in our center (eight to selective coiling vs six to parent artery occlusion). There was no statistical difference between both groups regarding complications. No patient experienced rebleeding. One recanalization was observed in the selective coiling group. Based on literature review (83 cases), selective coiling and parent artery occlusion showed similar success rate in preventing rebleeding. Parent artery occlusion was significantly associated with a higher risk of ischemic complication (p = 0.013). CONCLUSIONS: Both selective coiling and parent artery occlusion are highly effective in preventing rebleeding in isolated PICA dissecting aneurysms. Although total complication rate is similar between both modalities, parent artery occlusion is significantly associated to a higher risk of ischemic events.

Endovascular treatment of tentorial dural arteriovenous fistulae.

Tentorial dural arteriovenous fistula (DAVF) is a rare vascular disease, which accounts for less than 4% of all cases of intracranial DAVF. Because of the high risk of intracranial hemorrhage, patients with tentorial DAVF need aggressive treatment. Management approaches are still controversial, and endovascular treatment has emerged as an effective alternative. In the current work, we describe our experience with the endovascular approach in the treatment of these deep and complex DAVF of the tentorium. Eight patients were treated between January 2006 and July 2009. Six patients (75%) presented with intracranial hemorrhage related to the DAVF rupture. Four patients (50%) had subarachnoid bleeding and two had intraparenchymal hematoma. Endovascular treatment was performed via the transarterial route alone in five cases (62.5%), by the transvenous approach in two cases (25.0%) and in a combined procedure using both arterial and venous routes in one patient (12.5%). Complete obliteration of the fistula was achieved in all cases. The outcome at 15 months was favorable (modified Rankin scale 0-3) in seven (87.5%) patients. Complete cure of the lesion was confirmed in these cases. This paper reports on the effectiveness of endovascular treatment in tentorial DAVF management. The choice of the venous versus the arterial approach is determined by regarding different anatomical dispositions.

Intracranial aneurysms associated with a double origin of the posterior inferior cerebellar artery.

The posterior inferior cerebellar artery (PICA) frequently has a variable course and target territory. However, double origin PICA is a rare finding. Its significance is uncertain, but it has been associated with intracranial aneurysms localized at the PICA proper or at a distant site. The presence of this variation imposes specific challenges. We describe two cases of double origin PICA, one of them associated with an ipsilateral PICA aneurysm. The role of this finding was critically reviewed. A literature search identified 23 cases of double origin PICA, including both cases reported in this paper. Intracranial aneurysms were strongly associated with double origin PICA (71% in 21 detailed cases of double origin PICA). The current patient harboring a PICA aneurysm was successfully treated by endovascular trapping. In the setting of double origin PICA aneurysms, this variation beneficially affects the treatment choice once the two limbs enable the safe sacrifice of the channel involved, with preservation of blood flow through the other channel.

In situ correlative immuno-identification of mononuclear infiltrates and invasive bacteria in diseased gingiva.

The purpose of this study was to identify and quantify mononuclear cells and invasive bacteria in consecutive histological sections in diseased gingiva. Gingival biopsies were obtained from sites displaying evidences of severe periodontitis (pocket depth greater than 5 mm, bleeding on probing) in six patients. Specimens were frozen and serially sectioned at 8 micron in a cryostat. Monoclonal antibodies (mAb) directed against membrane markers of mononuclear infiltrate cells and rabbit polyclonal sera against specific bacteria shown to be invasive in association with an immunoperoxidase technique and specific point quantification were used. The mAb panel included Leu 1 (Pan T), Leu 2a (T suppressor/cytotoxic), Leu 3a (T helper/inducer), Leu 6 (Langerhans/dendritic), Leu 7 (NK/K), Leu M3 (monocyte/macrophage), and B7 (B cell). This methodology allows for in situ per cent quantification of mononuclear cell subsets along with identification and quantification of invasive bacteria in the same gingival tissue site. This may be a practical approach to establish the relationship between bacterial invasion and cellular immune response by the host. This technique enabled the characterization of the mononuclear infiltrate in relationship to specifically identified invasive bacteria in diseased gingiva.

Bacterial invasion in experimental gingivitis in man.

Gingival biopsies of the mesial papilla area of the first molar were obtained from each patient at 0-, 14- and 21-day intervals during plaque formation. The biopsies were fixed, serially sectioned, and Gram-stained. The incidence and distribution of the bacteria-like structures were studied by microscopy. In all the specimens the bacterial nature of Gram-stained material was substantiated. In the epithelium the highest number of bacteria was found at the outer layer of marginal oral epithelium, sulcular epithelium and apical oral epithelium along with a decreasing pattern of penetration progressing deeper into the layers of tissue. For junctional epithelium the situation was just the opposite. Each subject had significantly higher counts at Day 21 than at Day 14 for both epithelium and connective tissue. Also significantly higher counts were found in connective tissue compared with epithelium. The higher bacterial density of intragingival bacteria was associated with the higher gingival and plaque indices. This study suggests that early stages of gingival inflammation may be mediated by invasion of bacteria.

The presence of bacteria in the oral epithelium in periodontal disease. III. Correlation with Langerhans cells.

Langerhans cells (LC) are cell types found in the skin and gingiva. LC have immunological functions as phagocytic cells and as antigen-presenting cells for T and B lymphocytes. Sections from biopsies of the gingiva in cases of periodontal disease were found to have increased numbers of LC. These biopsies also contained intragingival bacteria. Serial sections of frozen specimens of human gingiva were prepared for staining. Hematoxylin and eosin were used for tissue survey, the Gram stain for assessment of bacterial invasion, anti-Leu-6 monoclonal antibody associated with peroxidase technique (PAP) to identify LC, antibacterial sera to Bacteroides gingivalis and Actinobacillus actinomycetemcomitans associated with peroxidase to specifically identify these two common periodontopathogenic bacteria. Additional positive identification of bacteria was performed by preparing the same histological section containing gram-stained particles for scanning electron microscope and transmission electron microscope LC confirmation. The results suggest that the increased number of LC seen in diseased sites of oral epithelium containing intragingival microorganisms may be one of the host immune mechanisms to penetration by bacteria.