Gadolinium-enhanced MR imaging in the evaluation of uterine fibroids treated with uterine artery embolization.

OBJECTIVE: The purpose of this study was to determine whether tumor volume reduction can be predicted by the infarction rate of uterine fibroids as seen on gadolinium-enhanced MR images obtained immediately after uterine artery embolization. MATERIALS AND METHODS: In our study, 36 women with symptomatic uterine fibroids successfully underwent uterine artery embolization. Unenhanced and enhanced MR imaging was performed before the procedure and repeated at 1 week, 4 months, and 1 year after the procedure. We retrospectively reviewed enhanced MR images of uterine fibroids after uterine artery embolization. At 4 months after uterine artery embolization, we compared the rate of tumor volume reduction in patients with completely infarcted dominant fibroids with the rate of tumor volume reduction in patients with partially infarcted fibroids. RESULTS: Enhanced MR images obtained 1 week after uterine artery embolization revealed that 100% infarction rates of the dominant uterine fibroids were achieved in 33 women (92%), and 70--90% infarction rates were seen in the remaining three (8%). They also revealed that of a total of 204 fibroids in these patients, 100% infarction was achieved in 199 fibroids (98%). Enhanced MR images obtained 4 months after uterine artery embolization showed that tumor volume reduction of the completely infarcted dominant fibroids (n = 23) was 60% +/- 18%, whereas that of the partially infarcted fibroids (n = 5) was 35% +/- 27% (p = 0.0367). CONCLUSION: Gadolinium-enhanced MR imaging is a useful diagnostic technique for uterine fibroids after uterine artery embolization because it assesses the degree of infarction in the embolized fibroids, which corresponds to the subsequent tumor volume reduction.

False localization of rupture site in patients with multiple cerebral aneurysms and subarachnoid hemorrhage.

OBJECTIVE: Patients with subarachnoid hemorrhage and multiple intracranial aneurysms present a unique challenge to the neurosurgeon. Unless all aneurysms can be clipped through a single craniotomy, the surgeon must accurately determine which aneurysm has ruptured. Misjudgment may result in disastrous postoperative rebleeding from the untreated but true ruptured lesion. We assessed the risk of false localization of the rupture site and subsequent rebleeding and documented the problems in predicting the true rupture site when patients have multiple intracranial aneurysms. METHOD: We reviewed the records of a consecutive series of 93 patients treated over a period of 12 years who presented with their first subarachnoid hemorrhage and who had multiple intracranial aneurysms. The rupture site was determined on the basis of computed tomographic and angiographic findings, and the supposed ruptured aneurysm was clipped within 2 days of hemorrhage in each patient. Additional aneurysms that could not be accessed in the same surgical session were operated on at a later stage. All patients' records were reviewed, and all computed tomographic scans and angiograms, including repeat studies performed in some patients, were retrospectively reevaluated by the authors, who had no knowledge of the patients' clinical information. RESULTS: The location of the aneurysm that ruptured was verified at the time of surgery or during the autopsy in 76 patients (82%). The aneurysm that ruptured was the one predicted as ruptured by the surgeon before surgery in 69 patients (91%) and in retrospect in 72 patients (95%). Five of the 6 patients in whom the ruptured aneurysm was not correctly identified were thought to have only a single aneurysm. Four patients rebled after surgery, and 2 patients died as a result of the rebleeding. CONCLUSION: In the reported series, the most common cause of rebleeding soon after aneurysm surgery was failure to obliterate the ruptured aneurysm, usually because it was missed on the initial angiogram. The results support not only meticulous radiological investigation of all intracranial arteries before surgery but also thorough surgical inspection of the target aneurysm in all cases of subarachnoid hemorrhage even after one candidate lesion has been discovered.

An adult case of recurrent arteriovenous malformation after "complete" surgical excision: a case report.

BACKGROUND: Complete surgical excision of arteriovenous malformations (AVM) documented by postoperative angiography is considered a cure. However, recent reports have shown that AVMs in children may recur after negative postoperative angiograms, and some suggest that it may reflect the immaturity of their cerebrovasculature. This case report demonstrates that AVM in adults may also recur, despite postoperative angiograms confirming complete removal. CASE DESCRIPTION: This 28-year-old man presented in 1994 with a focal motor seizure and was found to have an AVM in the right frontal lobe. He underwent surgical excision of the AVM; postoperative angiograms taken immediately after surgery and 15 days later showed no residual AVM. He remained free of symptoms after surgery and it was considered that a complete removal had been achieved. In 1998 he developed a subarachnoid hemorrhage, and subsequent angiograms revealed a small AVM in an adjacent location. CONCLUSION: This is the oldest patient reported in the literature with a recurrence of AVM, despite postoperative angiograms confirming complete removal. Angiographically invisible immature vessels, which might have been left in the surgical field, might have formed a new malformation later. We still believe that such recurrence must be very rare after AVM surgery, but we now recommend follow-up angiography at yearly intervals to our patients.

Value of repeat angiography in patients with spontaneous subcortical hemorrhage.

BACKGROUND AND PURPOSE: Neuroradiological investigations do not disclose a source of bleeding in some patients with spontaneous subcortical hemorrhage. These patients may harbor undetected vascular malformations and may be at risk of rebleeding in the future. We investigated patients with subcortical hemorrhage with use of repeat angiography and MRI to determine the incidence of occult vascular malformations and the risk of bleeding during follow-up. METHODS: We reviewed a consecutive series of 137 patients with subcortical hemorrhage during a 10-year period (June 1987 through June 1997). If the patient was <65 years old and the first angiogram and/or MRI did not show a source of bleeding, repeat angiography was recommended. All angiographic and MRI studies were reviewed. The relationship between the identified bleeding source and clinical variables such as patient age, sex, and history of hypertension and the size and location of the hematoma were examined. RESULTS: One hundred seven patients (78%) underwent angiography on admission, 10 (7%) had immediate surgery for hematoma without angiography, and 20 (15%) had neither angiography nor surgery. Overall, an etiology for the hemorrhage was found in 55 cases (40%). Vascular malformations were common in young patients without preexisting hypertension. A second angiogram was obtained in 22 patients, and 4 arteriovenous malformations were demonstrated. Rebleeding at the site of the initial hemorrhage was not observed after a mean follow-up of 68 months. CONCLUSIONS: Angiography performed acutely after hemorrhage may not demonstrate vascular malformations. Consideration should be given to repeat angiography in patients who do not have a specific cause for hemorrhage.