Breve historia de la neurorradiología española / A brief history of neuroradiology in Spain

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Hallazgos radiológicos de la arteria trigeminal persistente sintomática y asintomática / Radiological findings in symptomatic and asymptomatic persistent trigeminal artery

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Embolia gaseosa cerebral secundaria a la retirada de una vía venosa central / Cerebral gas embolism secondary to withdrawal of a central venous line

Objetivo. Presentar un caso de embolia gaseosa cerebral secundaria a la retirada de una vía venosa central en un paciente recientemente operado de cirugía abdominal. Caso clínico. Varón de 82 años que presenta súbitamente mioclonías en la extremidad superior derecha y disminución brusca del nivel de consciencia. Se le realiza una tomografía computarizada (TC) que pone de manifiesto burbujas de aire en la circulación intracraneal e infarto hemisférico derecho asociado. El paciente evoluciona clínicamente mal y fallece días más tarde. Conclusiones. El diagnóstico de la embolia gaseosa cerebral se realiza mediante TC craneal si ésta se realiza inmediatamente después de la entrada de aire en la circulación intracerebral. En fases tardías, los hallazgos son inespecíficos y difíciles de distinguir de un infarto isquémico o de la leucoencefalopatía difusa. El tratamiento se basa en medidas de soporte y, en algunos casos, oxígeno hiperbárico, aunque su eficacia real se discute. La embolia gaseosa cerebral es una complicación potencialmente mortal y evitable en pacientes con una vía venosa central u otros procedimientos yatrogénicos que puedan introducir aire en la circulación arterial o venosa

Aim. To report a case of cerebral gas embolism secondary to the withdrawal of a central venous line in a patient who had recently undergone abdominal surgery. Case report. An 82-year-old male who suddenly presented myoclonias in the right upper extremity and a sharp drop in the level of consciousness. A computerised tomography (CT) scan revealed air bubbles in the intracranial circulatory system and associated infarction in the right hemisphere. The patient’s clinical progression was poor and he died some days later. Conclusions. Cerebral gas embolism can be diagnosed using a CT scan of the head if it is performed immediately after the entrance of air into the bloodstream inside the brain. In later phases, findings are unspecific and difficult to distinguish from ischaemic infarction or from diffuse leukoencephalopathy. Treatment is based on supportive measures and, in some cases, hyperbaric oxygen, although their true effectiveness is a controversial issue. Cerebral gas embolism is a potentially fatal and avoidable complication in patients with a central venous line or other iatrogenic procedures that can allow air to enter the arterial or venous circulatory systems

[Cerebral gas embolism secondary to withdrawal of a central venous line]. / Embolia gaseosa cerebral secundaria a la retirada de una vía venosa central.

AIM: To report a case of cerebral gas embolism secondary to the withdrawal of a central venous line in a patient who had recently undergone abdominal surgery. CASE REPORT: An 82-year-old male who suddenly presented myoclonias in the right upper extremity and a sharp drop in the level of consciousness. A computerised tomography (CT) scan revealed air bubbles in the intracranial circulatory system and associated infarction in the right hemisphere. The patient's clinical progression was poor and he died some days later. CONCLUSIONS: Cerebral gas embolism can be diagnosed using a CT scan of the head if it is performed immediately after the entrance of air into the bloodstream inside the brain. In later phases, findings are unspecific and difficult to distinguish from ischaemic infarction or from diffuse leukoencephalopathy. Treatment is based on supportive measures and, in some cases, hyperbaric oxygen, although their true effectiveness is a controversial issue. Cerebral gas embolism is a potentially fatal and avoidable complication in patients with a central venous line or other iatrogenic procedures that can allow air to enter the arterial or venous circulatory systems.

Early Experience Studying Cerebral Aneurysms with Rotational and Threedimensional Angiography and Review of CT and MR Angiography Literature.

SUMMARY: From september 2000 to september 2001, 32 consecutive patients with ruptured intracranial aneurysms were examined with rotational and 3D reconstruction angiography using an Integris V5000 Philips Medical System: 39 aneurysms were detected. After a selective cerebral artery was catheterized with a 5F or 4F-catheter, 35 ml of contrast medium was intra-arterially administered at a rate of 4 ml/s and a 180 degrees rotational angiography was performed in eight seconds. This information was transferred to a computer (Silicon Graphics Octane) with software (Integris 3DRA, Philips Integris Systems) and a three-dimensional reconstruction was made. The information provided by Angio-3D was useful for evaluating the parent artery, aneurysmal sac, aneurysmal neck and arterial branches. It was also very useful in selecting the therapeutic method. For open surgery, this technique provides preoperative images that are useful for planning microsurgical approaches, especially in cases of large aneurysm showing complex surrounding arteries. For endovascular embolization, various anatomic characteristics of the aneurysm such as neck and sac size, shape, lobularity, parent artery and arterial branches adjacent to the aneurysmal neck must be demonstrated. This is very important to determine the best projection for embolization and to avoid multiple series. This is also essential in the choice of the first coil to create a good basket producing total occlusion. Microaneurysms are demonstrated well with this technique whereas this is difficult to do with conventional arteriography. The Angio-RM and Angio-CT literature show a lower sensitivity and specificity in comparasion with our experience with 3D IA-ROT-DSA. For this reason, we believe that 3D IA-ROTDSA is now the gold standard for patients presenting intracranial aneurysms.

[Intra-arterial fibrinolysis in vertebrobasilar system]. / Fibrinólisis intrarterial en el territorio vertebrobasilar.

INTRODUCTION: The acute vertebrobasilar occlussion is usually a life-treatening disease leading to death or major disability. The treatment with heparin and the selective fibrinolysis no show good results, for this reason the local intra-arterial fibrinolysis appear as the choice treatment in patients with stroke and a agiography with basilar artery occlussion or intracranial vertebral artery occlusion. This tecnique has been proved to be effective treatment for selected patients with acute thromboembolic occlusion of the middle cerebral artery, ophthalmic artery and vertebrobasilar system, reducing the mortality in the vertebrobasilar system from 90% to 40%. CLINICAL CASE: We present a 63 years-old man with a vertebrobasilar thrombosis of a probable cardioembolic origen. He was treated with r-TPA local intra-arterial fibrinolysis, to get a recanalization of vertebrobasilar system. In the control TC we see a haemorragic sufusion in the brain stem. The follow-up see a patient with tetraparesis and palsy of the low cranial nerves and normal superior cerebral functions. CONCLUSIONS: The local intra-arterial fibrinolysis is the choise treatment in the vertebrobasilar thrombosis because the high morbimortality of this patology and the inefficacy of the others therapeutics. The result depend of many factors as the thrombo location, the neurologic state, the evolution time, the start of treatment, the colateral circulation, the nervous tissue reserve, etc, that have dificult predict the result, but it is best of the natural history of the disease. Is necesary, change the concept of emergency and the attitude front the isquemic cerebral disease at the sanitary leaders, the doctors, and the general population, for dispose of more means to cofront this pathology, which permit diminish the morbimortality and reduce the grade of incapacity.

[Preocclusive stenosis of the extracranial vertebral artery. Treatment by percutaneous transluminal angioplasty and insertion of endoprosthesis]. / Estenosis preoclusiva de la arteria vertebral extracraneal. Tratamiento mediante angioplastia transluminal percutánea y colocación de endoprótesis.

INTRODUCTION: Atherosclerotic occlusive disease of the extracranial portion of the vertebral artery is relatively frequent and is usually related to vertebrobasilar ischemia. Due to the lack of a noninvasive diagnostic technique, at present it is often not diagnosed. Surgical treatment is difficult and risky. Percutaneous transluminal angioplasty (PTA) is only partly useful due to a high rate of restenosis. The recent development of stenting has led to an evident improvement of PTA results, reducing restenosis and offering an effective treatment with low morbidity and mortality. CLINICAL CASE: Sixty year old male patient, smoker and moderate drinker, who is hospitalized due to repeated ischemic strokes (cerebellar stroke in the left posterior and interior inferior cerebellar arteries, and cerebral stroke at occipito-parietal and ipsilateral capsulo-thalamic levels) in spite of antithrombotic treatment. Angiography showed: a) occlusion of the left vertebral artery; b) preocclusive stenosis of the right vertebral artery in the ostium; c) fetal origin of the right posterior cerebral artery, and d) left hypoplasic posterior communicating artery. PTA and stent placement at the right vertebral artery is performed with an excellent angiographic result, a partial recovery of neurological symptomatology and absence of new episodes of cerebral ischemia during a three-month follow-up. CONCLUSION: Percutaneous transluminal angioplasty and stent placement is an effective low morbidity-mortality treatment in occlusive atherosclerosis of the vertebral artery, although further randomized multicenter studies are required in order to validate this conclusion.

Fibrinólisis intrarterial en el territorio vertebrobasilar / Intra-arterial fibrinolysis in vertebrobasilar system

Introducción. La oclusión vertebrobasilar aguda es una patología grave con una historia natural que suele terminar en muerte o gran incapacidad. El tratamiento médico con heparina y la fibri nólisis selectiva no han mostrado buenos resultados, por lo que la fibrinólisis local intrarterial aparece como el método terapéutico de elección en aquellos pacientes con un ictus en evolución y una angiografía que demuestra la oclusión de la arteria basilar o de ambas vertebrales a nivel intracraneal. Esta terapia ha probado su eficacia en el tratamiento de pacientes seleccionados con oclusión aguda tromboembólica de la arteria cerebral media, arteria oftálmica y sistema vertebrobasilar, reduciendo la mortalidad, en este último, de un 90 a un 40 por ciento. Caso clínico. Presentamos el caso un paciente varón de 63 años con una trombosis vertebrobasilar de probable origen cardioembólico que tratamos mediante fibrinólisis intrarterial con r-TPA, lográndose la recanalización del sistema vertebrobasilar. En la TC de control se apreció una sufusión hemorrágica en el bulbo y protuberancia. El paciente después del tratamiento quedó con una tetraparesia y afectación de pares bajos, con funciones cerebrales superiores normales. Conclusiones. La fibrinólisis local intrarterial es el tratamiento de elección en la trombosis vertebrobasilar dada la elevada morbimortalidad de esta patología y la ineficacia de otros tratamientos. Los resultados dependen de muchos factores como la localización del trombo, el estado neurológico, el tiempo de evolución, el inicio del tratamiento, la circulación colateral, la reserva del tejido nervioso, etc., que hacen difícil predecir el resultado pero que es mejor que la evolución natural de la enfermedad. Se debe realizar un esfuerzo para cambiar el concepto de urgencia y la actitud frente a la enfermedad isquémica cerebral en los dirigentes sanitarios, en los médicos y en la población general, para poder disponer de más medios para afrontar esta patología, lo que permitiría disminuir la morbimortalidad y reducir el grado de incapacidad (AU)

Estenosis preoclusiva de la arteria vertebral extracraneal.Tratamiento mediante angioplastia transluminal percutánea y colocación de endoprótesis / Pre-occlusive stenosis of the extracranial vertebral artery. Treatment by percutaneous transluminal angioplasty and insertion of stent

Introducción. La enfermedad oclusiva aterosclerótica de la arteria vertebral extracraneal es relativamente frecuente y está relacionada con la isquemia vertebrobasilar, aunque infradiagnosticada por no disponer en la actualidad de un método de diagnóstico no invasivo. El tratamiento quirúrgico es difícil y con alto riesgo. La angioplastia transluminal percutánea (PTA) aislada tiene una utilidad limitada dado el alto índice de reestenosis. El desarrollo de endoprótesis (stent) ha permitido mejorar de forma ostensible los resultados de la PTA al reducir la reestenosis y ofrecer un tratamiento eficaz y de baja morbimortalidad. Caso clínico. Presentamos el caso de un varón de 60 años, fumador y enólico moderado, que ingresa por infartos isquémicos de repetición (cerebelosos en los territorios de las arterias cerebelosas inferiores anterior y posterior izquierdas y cerebrales a nivel occipitoparietal y capsulotalámico ipsilaterales) a pesar de tratamiento antiagregante. La angiografía mostró: a) oclusión de la arteria vertebral izquierda; b) estenosis preoclusiva de la arterial vertebral derecha en el ostium; c) origen fetal de la cerebral posterior derecha, y d) arteria comunicante posterior izquierda hipoplásica.Se practica una PTA+endoprótesis de la arteria vertebral derecha, tras la cual se obtiene un excelente resultado angiográfico, la recuperación parcial de la sintomatología neurológica y la ausencia de nuevos episodios de isquemia cerebral en tres meses de seguimiento. Conclusión. La angioplastia transluminal percutánea y la colocación de endoprótesis son un tratamiento eficaz y de baja morbimortalidad en la aterosclerosis oclusiva de la arteria vertebral, aunque se requieren estudios aleatorizados multicéntricos para validar esta apreciación (AU)