Preliminary experience with Precipitating Hydrophobic Injectable Liquid (PHIL) in treating cerebral AVMs.

OBJECTIVE: To describe our early experience in treating cerebral arteriovenous malformations (AVMs) with the new Precipitating Hydrophobic Injectable Liquid (PHIL) embolic material. MATERIALS AND METHODS: Between June and August 2015 five patients with cerebral AVMs were treated at two tertiary university hospitals. PHIL was used as complementary treatment to Onyx liquid embolic material or as the sole endovascular treatment. RESULTS: Five patients (average age 39 years (range 19-73)) with ruptured plexiform AVMs were treated. The group included one patient with Spetzler-Martin grade II AVMs, three grade III, and one grade IV. One grade II and two grade III AVMs were cured. A total of nine pedicles were embolized with an average of two pedicles per session. There were no procedural complications. One patient had a seizure after embolization but a brain CT scan showed no hemorrhage. CONCLUSIONS: PHIL is a new embolic agent that can be used for the treatment of cerebral AVMs.

Treatment of direct carotid-cavernous fistulas with a double lumen balloon.

OBJECTIVE: To describe the treatment of direct high flow carotid-cavernous sinus fistulas (dCCFs) with the double lumen balloon Scepter C. MATERIALS AND METHODS: 7 patients with dCCFs were identified and treated with a double lumen balloon Scepter C. 5 patients had post-traumatic dCCFs and two patients had spontaneous dCCFs due to a ruptured cavernous-carotid aneurysm. The double lumen balloon was used in characterizing the angioarchitecture of the fistula in all patients. The best treatment option was then decided based on the characteristics of the carotid wall tear. Embolization of the cavernous sinus was achieved with coils and injection of Onyx liquid embolic material in three patients and with coils alone in four patients. One patient required stent assisted coiling to reconstruct the internal carotid artery. RESULTS: 7 patients with dCCFs were treated with transarterial embolization. All patients had immediate angiographic and clinical cure. The Scepter C balloon was used for balloon assisted coiling and injection of Onyx liquid embolic material. On follow-up, all patients had clinical symptom resolution. CONCLUSIONS: The Scepter C balloon is a useful tool for the transarterial treatment of dCCFs.

Endovascular treatment of PICA aneurysms with a Low-profile Visualized Intraluminal Support (LVIS Jr) device.

OBJECTIVE: To describe the treatment of posterior inferior cerebellar artery (PICA) aneurysms with the Low-profile Visualized Intraluminal Support Device (LVIS Jr) stent. MATERIALS AND METHODS: The databases of three institutions were retrospectively reviewed. Patients who underwent endovascular treatment of PICA aneurysms using a reconstructive technique where the LVIS Jr stent was totally or partially deployed into the PICA were included in the analysis. Clinical presentation, aneurysm and PICA sizes, procedural complications, and clinical and angiographic follow-up information was recorded and analyzed. RESULTS: Seven patients who underwent endovascular treatment of PICA aneurysms with an LVIS Jr stent were identified. Four aneurysms were treated in the acute phase of subarachnoid hemorrhage (SAH). There were no symptomatic complications. One patient had spasm distal to the stent as a result of mechanical straightening of the vessel. One patient was treated in the acute phase of SAH and required a gycoprotein IIb/IIIa inhibitor after the stent was implanted. This patient needed to be re-treated to complete embolization. All patients had good clinical outcomes (Glasgow Outcome Scale 5). No in-stent stenosis or occlusion was seen on short-term angiographic follow-up and the aneurysms were occluded. CONCLUSIONS: This small series suggests that the use of a reconstructive technique with the LVIS Jr stent for the treatment of PICA aneurysms is feasible, safe and effective in the short term.

Automated cement segmentation in vertebroplasty.

Vertebroplasty is a minimally invasive procedure with many benefits; however, the procedure is not without risks and potential complications, of which leakage of the cement out of the vertebral body and into the surrounding tissues is one of the most serious. Cement can leak into the spinal canal, venous system, soft tissues, lungs and intradiscal space, causing serious neurological complications, tissue necrosis or pulmonary embolism. We present a method for automatic segmentation and tracking of bone cement during vertebroplasty procedures, as a first step towards developing a warning system to avoid cement leakage outside the vertebral body. We show that by using active contours based on level sets the shape of the injected cement can be accurately detected. The model has been improved for segmentation as proposed in our previous work by including a term that restricts the level set function to the vertebral body. The method has been applied to a set of real intra-operative X-ray images and the results show that the algorithm can successfully detect different shapes with blurred and not well-defined boundaries, where the classical active contours segmentation is not applicable. The method has been positively evaluated by physicians.

Percutaneous cementoplasty in multiple myeloma: a valuable adjunct for pain control and ambulation maintenance.

GOALS OF WORK: Bone pain and functional impairment are major concerns for multiple myeloma (MM) patients. The goal of this study was to better define the role of percutaneous cementoplasty (PC) in improving their quality of life. MATERIALS AND METHODS: This retrospective analysis included 28 consecutive heavily pretreated MM patients managed at our institution between 1996 and 2002. They underwent a total of 34 PC procedures for the treatment of 117 vertebrae and 2 iliac sites and were evaluated at 1 month. MAIN RESULTS: Significant pain reduction of >50% was obtained after 83% of the procedures, with a mean visual analogous score decreasing from 7.48/10 to 2.1/10 (p < 0.001). It resulted in a complete interruption of opiate analgesic consumption after 59.3% of the procedures, with a mean decrease of 70.4% in the opiate dose. Functional impairment was evaluated with the Eastern Cooperative Oncology Group (ECOG) performance status scale, with mean scores improving from 1.9 to 0.86 after the procedures (p = 0.001). There was no major complication. CONCLUSION: PC is a safe, feasible, and efficient approach for the treatment of bone pain and disability in MM patients.

Subtracted vortex centers path line method with cinematic angiography for measurement of flow speed in cerebral aneurysms.

BACKGROUND AND PURPOSE: The assessment of blood flow speed by imaging modalities is of increasing importance for endovascular treatment, such as stent implantation, of cerebral aneurysms. The subtracted vortex centers path line method (SVC method) utilizes image post-processing for determining flow quantitatively. In current practice, intra-aneurysmal flow in an in vitro model is visualized by laser sheet translumination and digitally recorded. In this study, we applied this method to cinematic angiography (CA), which is the preferred imaging method for endovascular interventions, to analyse hemodynamic changes. The SVC method was applied to the images and compared with results of the slipstream line method with colored fluid. METHODS: A transparent tubular model was constructed of silicone which included an aneurysm 10 mm in diameter and having a 5 mm neck on a straight parent artery with a diameter of 3.5 mm. The model was integrated into a pulsatile circulation system. By CA, successive images at 25 frames/s with injection of contrast were obtained. RESULTS AND CONCLUSION: Rotating vortexes of contrast, which advanced along the wall of the aneurysm, were observed in successive images of the aneurysm cavity. This phenomenon was also observed in the successive images with the slipstream line method. The speed of the vortex center was calculated and the results show that the vortex speed of CA was the same as that under the slipstream line method. This indicates the possibility of applying the SVC method to medical imaging equipment for analysis of the flow in aneurysms containing stent.

Preclinical testing of a new clot-retrieving wire device using polyvinyl alcohol hydrogel vascular models.

INTRODUCTION: Cerebral embolism is the principal cause of cerebral infarction. Recently, mechanical embolectomy has been proposed as an effective method. We performed a preclinical evaluation of a new mechanical clot-retrieving wire. METHODS: This clot-retrieving wire consisted of three nitinol loops at the tip of a microguidewire. These three loops could be collapsed into a 0.018-inch wire compatible microcatheter. Each loop was 8 mm long and 3.5 mm wide. For simulation, polyvinyl alcohol (PVA) vascular anatomical models of the human carotid (eight models) and vertebrobasilar (three models) circulation were constructed. A pulsatile flow circulation system was used. Embolic clots were produced using pig blood plasma. The microcatheter and the microguidewire were advanced beyond the clot. The wire was then exchanged for the retrieving wire. The microcatheter was then pulled slightly back to open the loops. The clot was then caught by withdrawal of the system. Once caught, the clot was retrieved to the guiding catheter tip. We investigated the following points: ease of device deployment, clot capture ability, clot removal against blood flow and removal of the clot out of the introducer system. RESULTS: A total of 104 procedures were performed in 11 PVA models and evaluated. The drop rate was 19%. We succeeded in partial and total recanalization in 51.0% of the procedures (53/104) within 30 minutes. CONCLUSION: This new clot-retrieving wire could be useful for mechanical clot extraction in stroke.

Intracranial aneurysm stenting: follow-up with MR angiography.

Intracranial stenting is increasingly being used to treat intracranial aneurysms and stenoses. We wanted to assess the utility of magnetic resonance angiography (MRA) in the follow-up of patients treated with various types of intracranial stents and to assess the utility of performing gadolinium-enhanced MRA. A total of 19 patients having undergone intracranial stenting for aneurysms were imaged by MRI at 1.5T. A total of 20 stents were placed in 19 patients. In addition to conventional T2- and diffusion-weighted MRI, 3D time-of-flight MRA was performed before and after contrast administration. In the case of metallic INX stents (N = 7), there was a signal drop at the level of the vessel. which did not allow to evaluating the parent vessel, whereas this was visible in Nitinol stents (N = 8). Additionally a stent with a wire had a small artifact (N = 3). Contrast administration also improved vessel lumen visualization. In the case of Nitinol stents, MRA can be used to reliably demonstrate the vessel lumen after intracranial stenting. The use of postcontrast 3D time-of-flight imaging helps improve the intraluminal definition.

Volume determination of intracranial aneurysms using 16-row multislice computed tomography angiography: a systematic in vitro analysis of different reconstruction methods.

OBJECTIVE: To assess multislice computed tomography (CT) angiography for volume determination of intracranial aneurysms. METHODS: Submillimetric 16-row multislice CT angiography was performed with optimized scan parameters on precision spheres and a soft carotid artery model harboring 3 aneurysms connected to a pulsatile circuit. The CT angiography images were produced using optimized techniques for axial, multiplanar reformation, maximum intensity projection, surface-shaded display, and volume-rendered images. Measurements were made with electronic precision calipers by segmentation according to the method of Cavalieri and by the use of automated volumetric analysis software. RESULTS: Segmentation resulted in precise and accurate volume estimates of aneurysms, but small volumes were underestimated and evaluation time was long (36:44 minutes). Automated volume evaluation from volume-rendered reconstructions also resulted in low measurement error, although the evaluation process was significantly faster (3:25 minutes; P < 0.0001). CONCLUSIONS: The use of an automated volume analysis tool on volume-rendered reconstructions is recommended for time-efficient volume assessment of intracranial aneurysms.

Arterialization of cerebral veins on dynamic MDCT angiography: a possible sign of a dural arteriovenous fistula.

OBJECTIVE: MDCT angiography allows fast imaging of the cerebral vessels, and its potential as a noninvasive technique to detect vascular abnormalities on the basis of morphologic changes is well established. We analyzed vascular enhancement patterns of cerebral venous structures on MDCT angiography, which enabled us to diagnose dural arteriovenous fistula. CONCLUSION: MDCT angiography performed during an early arterial phase showed asymmetrically higher contrast intensity in the transverse or sigmoid sinus, or both, in five patients. In all patients, digital subtraction angiography confirmed the presence of a dural arteriovenous fistula on the side on which the higher contrast intensity appeared. Radiologists should actively look for this sign in the imaging workup of patients presenting with nonspecific symptoms that might be related to a dural arteriovenous fistula.

Cavernous sinus thrombosis elicited by a central retinal vein venous stasis retinopathy.

BACKGROUND: Central retinal vein occlusion is a relatively common retinal disorder in the elderly, and those with cardiovascular or thrombophilic risk factors are at increased risk. Although still unsatisfying, some treatments for the acute and chronic phases have been established based on randomized studies. However, for rare conditions mimicking central retinal vein occlusion, treatment of the acute phase should be targeted at etiology. A rare condition mimicking central retinal vein occlusion in a 70-year-old man is presented and discussed. METHODS: A 70-year-old man was admitted to the hospital for isovolemic hemodilution related to a central retinal vein occlusion of the elderly, after a sudden decrease in visual acuity to 0.1. RESULTS: Clinical and laboratory work-up demonstrated a venous stasis retinopathy, related to an atypical cavernous sinus thrombosis of undetermined origin. The patient had experienced in the past 6 months intermittent diplopia and an irreducible conjunctival hyperemia. Hemodilution was dismissed. Soon after initiation of anticoagulation therapy, the patient's clinical signs and symptoms improved. Final visual acuity was 0.8. CONCLUSION: Venous stasis retinopathy secondary to cavernous sinus thrombosis is rare. However, careful clinical examination and extensive laboratory work-up is needed to exclude central retinal vein occlusion not associated with common vascular pathologies of the elderly.

Ecografía músculotendinosa del retropié: patología traumática / Ultrasonography of ankle

La ecografía nos brinda una ayuda importante en el diagnóstico de la patología inflamatoria-traumática de los tendones del retropié, en especial Aquiles y tibial posterior. Es nuestro objetivo en este trabajo hacer una demostración correlativa de la clínica y la imagen, en las enfermedades que afectan a estos tendones, proponiendo una clasificación que sea útil para la terapéutica de esta afecciones (AU)

Ecografía músculotendinosa del retropié: patología traumática / Ultrasonography of ankle

La ecografía nos brinda una ayuda importante en el diagnóstico de la patología inflamatoria-traumática de los tendones del retropié, en especial Aquiles y tibial posterior. Es nuestro objetivo en este trabajo hacer una demostración correlativa de la clínica y la imagen, en las enfermedades que afectan a estos tendones, proponiendo una clasificación que sea útil para la terapéutica de esta afecciones

Tumores musculoesqueléticos de la pelvis y la cadera / Soft tissue and bone tumores of the hip and pelvis

El tratamiento actual de los tumores musculoesqueléticos cuya filosofía es la reducción de la magnitud de la cirugía con reservación de los miembros y de ser posible de la función, ha provocado una gran demanda de los métodos del diagnóstico por imágenes. Cuando las lesiones asientan en la pelvis al tema etiológico se suma la dificultad en su detección debido a la particular anatomía del área. Con el objeto de analizar la incidencia de los tumores musculoesqueléticos y el aporte de divesos métodos diagnósticos se estudió una población constituída por 214 pacientes con tumores o lesiones seudotumorales pelvianas comprobados histológicamente. Se detectaron 19 lesiones seudotumorales, 27 tumores benignos, 6 tumores o células gigantes y 162 tumores malignos. Dos tercios de las lesiones seudotumorales y de los tumores benignos ocurrieron por debajo de los 30 años de edad. Los tumores malignos fueron mayoría (75 por ciento) destacándose las metástasis (70 por ciento de todos los tumores malignos). El tumor primario más frecuente fue el condrosarcoma. El diagnóstico por imágenes juega en la actualidad un rol significativo en el diagnóstico y estadificación de los tumores muescoesqueléticos. Junto con la clínica y la anatomía patológica constituyen el trípode indispensable para arribar al diagnóstico definitivo e instituir la terapéutica adecuada (AU)

Tumores musculoesqueléticos de la pelvis y la cadera / Soft tissue and bone tumores of the hip and pelvis

El tratamiento actual de los tumores musculoesqueléticos cuya filosofía es la reducción de la magnitud de la cirugía con reservación de los miembros y de ser posible de la función, ha provocado una gran demanda de los métodos del diagnóstico por imágenes. Cuando las lesiones asientan en la pelvis al tema etiológico se suma la dificultad en su detección debido a la particular anatomía del área. Con el objeto de analizar la incidencia de los tumores musculoesqueléticos y el aporte de divesos métodos diagnósticos se estudió una población constituída por 214 pacientes con tumores o lesiones seudotumorales pelvianas comprobados histológicamente. Se detectaron 19 lesiones seudotumorales, 27 tumores benignos, 6 tumores o células gigantes y 162 tumores malignos. Dos tercios de las lesiones seudotumorales y de los tumores benignos ocurrieron por debajo de los 30 años de edad. Los tumores malignos fueron mayoría (75 por ciento) destacándose las metástasis (70 por ciento de todos los tumores malignos). El tumor primario más frecuente fue el condrosarcoma. El diagnóstico por imágenes juega en la actualidad un rol significativo en el diagnóstico y estadificación de los tumores muescoesqueléticos. Junto con la clínica y la anatomía patológica constituyen el trípode indispensable para arribar al diagnóstico definitivo e instituir la terapéutica adecuada