Preventive treatment of unruptured intracranial aneurysms in adult patients with sickle cell anemia: A cohort study.

BACKGROUND AND PURPOSE: Intracranial aneurysms are frequent in patients with sickle cell anemia, while subarachnoid hemorrhage is a major cause of death and disability in young adult patients. Several characteristics, such as younger age and smaller size at rupture, may incline therapeutic decision towards exclusion treatments. Clinical guidelines on treatment of unruptured intracranial aneurysms in this population are still missing. We aimed to assess the safety and efficacy of the treatment of unruptured intracranial aneurysm in patients with sickle cell anemia, using an adapted hematological preparation regimen. PATIENTS AND METHODS: Adult patients with sickle cell anemia and treated unruptured aneurysms by endovascular therapy or neurosurgery were included in this retrospective cohort study. Treatment decision was reached after multi-disciplinary assessment. A pre-operative blood transfusion protocol was undertaken targeting a HbS below 30%. Demographic data, hematological preparation parameters and clinical and radiological outcomes were documented. RESULTS AND CONCLUSIONS: Twenty-five procedures were performed in 18 patients encompassing 19 aneurysms treated by embolization and 6 by surgery. Median age at treatment was 34 years-old and median aneurysm dome size was 4.4 mm. Immediate aneurysm exclusion rate was 85.7% after endovascular therapy and 100% after neurosurgery. Median follow-up was 6 months, with all patients being asymptomatic at last follow-up. Two transitory ischemic neurological deficits, as well as four cases of iodine-induced encephalopathy were identified after embolization. No complication occurred after surgery. Endovascular therapy by coiling and neurosurgical treatment of unruptured intracranial aneurysms appears to be safe in patients with sickle cell anemia and should be considered given the specific hemorrhagic risk observed in this population. A rigorous hematological preparation, associated with a dedicated peri­operative protocol and an adequate therapeutic strategy are essential prerequisites.

Quality of life after hemifacial spasm surgery: French versions of the HFS-8 and HFS-30 questionnaires.

OBJECTIVES: The aim of the present study was to assess quality of life before and after surgery for hemifacial spasm, in order to validate two specific quality of life scales translated in French. Surgical results and complications were reported. MATERIAL AND METHODS: Twenty-three patients with hemifacial spasm treated by microvascular decompression were retrospectively included. The HFS-8 and HFS-30 quality of life scales were translated from English into French using a forward-backward method and implemented on patients at least one year after surgery. RESULTS: Median HFS-8 and HFS-30 values were respectively 16±12.5 (range: 8-20.5) and 38±38.5 (range: 23-61.5) before surgery and 0.5±4.5 (range: 0-4.5) and 5±17.5 (range: 1-18.5) after surgery, showing significant improvement in quality of life (P<0.001). The internal consistency of both scales was excellent (Cronbach's alpha>0.9), and they were significantly correlated (Pearson coefficient=0.95; 95% CI [0.91; 0.98]; P<0.0001). Success rates were 83% and 91%, respectively, after primary and revision surgeries. Complications were transient with minor consequences in 80% of cases, but could impact quality of life when lasting. CONCLUSIONS: These results support the validity of the French versions of HFS-8 and HFS-30. Microvascular decompression is a safe and effective treatment for hemifacial spasm, and these scales are reliable tools to assess postoperative quality of life.

Clinical Impact of Flat Panel Volume CT Angiography in Evaluating the Accurate Intraoperative Deployment of Flow-Diverter Stents.

BACKGROUND AND PURPOSE: The deployment of flow-diverter stents may be difficult to analyse on regular DSA. The purpose of our study was to investigate the clinical impact of stent-dedicated flat panel volume CT angiography to evaluate intraoperatively the satisfactory deployment of flow-diverter stents. MATERIALS AND METHODS: From January 2009 to April 2015, 83 consecutive patients (mean age, 51 years; 62 women) were treated in our institution with flow-diverter stents. Eighty-seven aneurysms (82 unruptured, 5 ruptured; 77 anterior, 10 posterior circulation) were treated in these 83 patients (4 patients had 2 aneurysms, both treated by means of flow-diverter stents). One patient was treated for a traumatic carotid cavernous fistula. In 80% of the cases (68/85) a flat panel volume CT angiography was performed in the angiographic suite just after the flow-diverter stent deployment. Stent visualization was assessed by 2 independent reviewers. The clinical impact of stent malapposition was evaluated. RESULTS: Flow-diverter stent visualization was satisfactory in 73.5% of the cases. In 2 cases (2.9%) the flat panel volume CT angiography prompted the operator to perform an additional intrastent angioplasty for a condition that was previously underestimated. Four patients (4.7%) experienced acute thromboembolic complications; 3 others had delayed thromboembolic complications. Only 1 of these patients had thromboembolic complications (acute or delayed) related to stent misdeployment, which was easily managed intraoperatively with no clinical consequence. CONCLUSIONS: Flat panel volume CT angiography is an interesting tool to depict flow-diverter stent misdeployment and may encourage the operator to perform intrastent angioplasty (2.9% of the cases in our experience) to reduce the risks of thromboembolic complications.

Flow Diverter Stents for the Treatment of Anterior Cerebral Artery Aneurysms: Safety and Effectiveness.

BACKGROUND AND PURPOSE: Flow diverter stents (FDSs) are increasingly used for the treatment of intracranial aneurysms. Initially developed for the management of giant and large aneurysms, their indications have progressively expanded. The purpose of our study was to evaluate the safety and effectiveness of FDSs for the treatment of anterior cerebral artery (ACA) aneurysms. MATERIALS AND METHODS: Among the 94 consecutive patients treated for 100 intracranial aneurysms by means of FDSs in our institution from October 2010 to January 2015, eight aneurysms (8 %) in seven patients were located on the ACA. Three aneurysms were located on the A1 segment, three aneurysms on the anterior communicating artery (ACom) and two on the A2-A3 junction. In three cases, FDS was used for angiographic recurrence after coiling. Five patients were treated with a Pipeline embolization device, one with a NeuroEndograft and the last one with a Silk FDS. RESULTS: Treatment was feasible in all cases. No technical difficulty was reported. No acute or delayed clinical complication was recorded. Modified Rankin Scale was 0 for six patients and one for one patient. Mean angiographic follow-up was 9.7 ± 3.9 months (range 6-15). Total exclusion was observed in five aneurysms (71.4 %) and neck remnant in two (28.6 %) cases. One patient refused the control DSA. CONCLUSION: Our series shows the safety and effectiveness of FDSs for the treatment of ACA aneurysms.

[Intracranial dural arteriovenous fistula with perimedullary venous drainage: Anatomical, clinical and therapeutic considerations about one case, and review of the literature]. / Fistule durale intracrânienne à drainage veineux périmédullaire : considérations anatomiques, cliniques et thérapeutiques à propos d'un cas, et revue de la littérature.

Intracranial dural arteriovenous fistulae with perimedullary venous drainage are unusual type of vascular brain malformations. Patients may present with a rapidly progressive ascending myelopathy associated with autonomic dysfunction, which can cause a misdiagnosis and delay the therapeutic management. These clinical signs must be quickly recognized to avoid a poor outcome. The authors report the case of a 60-year-old woman presenting with a progressive myelopathy due to a dural arteriovenous fistula with perimedullary venous drainage. The diagnosis was suspected on brain-spinal MRI and confirmed by brain arteriography visualizing the arteriovenous shunt in the middle segment of the superior petrous sinus. MRI showed edema in the medulla oblongata. The treatment was performed early by endovascular glue embolization of the arteriovenous shunt and of the origin of the vein. Brain arteriography and clinical follow-up, one month later, showed complete disappearance of the dural fistula and regression of clinical symptoms. MRI control showed the reduction of the brain stem edema. Because of the early pejorative prognosis of these kinds of fistulae, early diagnosis and treatment are needed.