Long-term follow-up of 1036 cerebral aneurysms treated by bare coils: a multicentric cohort treated between 1998 and 2003.

BACKGROUND AND PURPOSE: The endovascular treatment (EVT) of cerebral aneurysms has experienced a revolution since 1991 with the introduction of platinum coil technology. During the past 10 years, there has been significant study of the feasibility of this technique, and clinical results of EVT have been published. The long-term durability of Guglielmi detachable coil (GDC) embolization of cerebral aneurysms still remains unknown. The purpose of this study was to evaluate the stability of anatomic occlusion of aneurysms and to assess the rate of recanalization and retreatment of these aneurysms. MATERIALS AND METHODS: Between January 1998 and December 2003, 1036 aneurysms (804 ruptured and 232 nonruptured) were treated consecutively with GDC coils in 5 neuroradiology centers. Procedural feasibility, acute angiographic occlusion results, morbidity, and mortality associated with this technique were assessed. All patients were regularly followed by digital subtraction angiography and MR imaging each year after treatment. RESULTS: Initial acute angiographic results in 1036 aneurysms demonstrated total occlusion in 731 patients (70.5%), subtotal occlusion in 252 (24.3%), incomplete occlusion in 20 (1.9%), and failures in 33% (3.3%) aneurysms. A remodeling technique was used in 10%. A second procedure was performed for 72 aneurysms (7%). The total aneurysm follow-up time was 49,923 months (4160.25 aneurysm-years). The retreatment period was either in the months following initial treatment in aneurysms incompletely occluded or in years due to recanalization or de novo aneurysms. Fewer than 5 patients rebled during 10 years of follow-up. Long-term follow-up angiograms were obtained in 899 aneurysms, with 646 total, 230 subtotal, and 23 incomplete results. CONCLUSIONS: Long-term follow-up of cerebral aneurysms is necessary to depict recanalization. Only 7% of the aneurysms were retreated. Use of bare coils gives a good long-term level of occlusion.

Feasibility, procedural morbidity and mortality, and long-term follow-up of endovascular treatment of 321 unruptured aneurysms.

BACKGROUND AND PURPOSE: The purpose of our study was to evaluate the technical feasibility, morbidity and mortality, and durability of occlusion of unruptured aneurysms treated with Guglielmi detachable coils (GDCs) with a long-term follow-up. MATERIALS AND METHODS: Between January 1998 and January 2005, we treated 321 unruptured aneurysms with GDCs in 5 neuroradiologic institutions. During this period, 63% of unruptured aneurysms were treated by endovascular technique. Procedural feasibility, technical complications, morbidity and mortality, and acute and long-term angiographic occlusion were assessed. RESULTS: Overall technical feasibility of coiling treatment was 94%; 302 aneurysms were treated by endovascular technique. At the end of the initial procedure, acute occlusion was classified as complete in 207 cases (70%), subtotal in 84 cases (26.1%), and incomplete in 11 cases (3.9%). Ischemic complications were observed in 28 patients (9%); 8 patients (2.6%) had perforation of their aneurysms. Treatment-related morbidity was 14.4%, and morbidity with clinical complications was evaluated at 7.7% (n = 23 patients). Five patients (1.7%) died as a result of aneurysm perforation. Final follow-up angiograms, after 9 secondary treatments, demonstrated complete occlusion in 193 patients (69.5%), subtotal in 80 aneurysms (28.5%), and incomplete occlusion in 5 (1.8%). Nineteen patients were lost to follow-up (6.3%). CONCLUSION: Endovascular coiling with detachable coils is an attractive option for treatment of unruptured aneurysms. This method of treatment is safe with a low rate of complications. Prospective studies with longer follow-up periods are needed to assess the long-term durability of occlusion in unruptured aneurysms.

Fibromuscular dysplasia may herald symptomatic recurrence of cervical artery dissection.

BACKGROUND: The prevalence of fibromuscular dysplasia (FMD) in patients with cervical artery dissection (CAD) is unknown. Our objectives were to assess the risk of CAD recurring as a stroke or a transient ischemic attack and the association of these events with FMD. METHODS: We prospectively included and followed 103 consecutive patients who had been admitted for a CAD. The median follow-up was 4 years (range 4 months to 10 years). The main criteria for inclusion were a mural hematoma demonstrated by cervical magnetic resonance imaging and/or signs suggesting CAD on 2 other investigations. FMD was diagnosed on the so-called string of beads pattern by digital subtraction angiography. RESULTS: Five patients had CAD recurrence (60% occurred late). Four of these 5 patients had FMD. In 4 patients, CAD recurrence involved another cervical artery. CONCLUSION: The rate of symptomatic CAD recurrence was 1% per year and was often related to FMD.

[GDC 18 treatment of ruptured and non-ruptured aneurysms: angiographic results and early and midterm follow-up of 115 aneurysms]. / Traitement par GDC 18 d'anévrismes rompus et non rompus: résultats angiographiques et suivi à court et moyen termes de l'occlusion anévrismale de 115 anévrismes.

OBJECTIVES: To demonstrate the technical feasibility, safety and results of intracranial aneurysm treatment by coils of 0.018-inch diameter wire (GDC 18) for ruptured and non-ruptured intracranial aneurysms. MATERIALS AND METHODS: From a commune database from five neuroradiological centers, we analysed endovascular technique with Gugliemi Detachable Coils (GDC) 18, complications of technique, acute angiographic occlusion results and long-term angiographic follow-up. Sixty-six percent of aneurysms were ruptured. The mean size of treated aneurysms was 13.7 mm. RESULTS: Overall feasibility of coil 18 treatments was 95%. Acute angiographic results in 110 aneurysms demonstrated total occlusion in 63 aneurysms (57.2%), subtotal occlusion in 37 cases (33.6%), and incomplete occlusion in 10 cases (9%). A second treatment was performed in 15 cases; follow-up demonstrated 60 (61%) total occlusions, 32 (33%) subtotal occlusion and 5 (5%) incomplete. Five patients were lost to follow-up, and 8 patients had died. Stability of occlusion with these coils was 61%. CONCLUSION: Coiling of intracranial aneurysms, ruptured or non-ruptured, using coils with a wire diameter of 0.018-inch is safe, with no more complications than standard coils. Remodelling technique is possible. This type of coils must be considered for treatment of large aneurysms.

Persistent carotid-vertebrobasilar anastomoses: how and why differentiating them?

The persistent carotid-vertebrobasilar anastomoses (PCVBA) can be explained by an interruption of the vertebrobasilar system (VBS) embryogenesis. We present two very rare cases of persistent anastomoses: a hypoglossal artery and a type I proatlantal artery, insisting on the angiographic criteria allowing differentiation. After a brief review of the embryogenesis of the VBS, we describe the different types of persistent anastomoses (hypoglossal, type I and II proatlantal, trigeminal and otic arteries). We will insist on the potential risks, not well-known, but typical of each anastomosis. PCVBA usually are incidental findings but imaging follow-up may be required since aneurysms may develop.

Double hepatomesenteric artery: a rare anatomical variant.

A case of a "double hepatomesenteric artery", i.e. two persisting hepatic arteries arising from the superior mesenteric artery, is reported. Also observed was a lack of systematisation of the pancreaticoduodenal arteries. The variant, which does not appear to have been previously reported in the literature, was observed when dissecting the vessels of the duodenal bulb in a preserved male cadaver injected with neoprene latex. Its embryological origin, as well as the clinical, radiological (diagnostic or interventional) and surgical implications, are discussed.

Accuracy of color-Doppler in the quantification of proximal vertebral artery stenoses.

BACKGROUND: Vertebrobasilar (VB) strokes appear to have the same causes as carotid strokes. Obstructive lesions of proximal vertebral arteries probably occur in about 30% of stroke patients. PURPOSE: Our aim was to assess the validity of color Doppler sonography compared to selective intra-arterial angiography in the quantification of proximal vertebral artery stenoses. MATERIALS AND METHODS: A prospective blind study of 316 vertebral arteries was undertaken between 1996 and 1998. One hundred and fifty-eight patients with cerebrovascular disorders without cerebral hemorrhage were studied consecutively by frequency or amplitude color Doppler flow imaging and intra-arterial angiography. The lesions were quantified by morphological and hemodynamic criteria and classified into 6 groups: 0% 207 arteries; 1-29% 32 arteries; 30-49% 29 arteries; 50-69% 13 arteries; 70-99% 23 arteries; 100% 12 arteries. RESULTS: Ten of the 12 occlusions were identified, the 2 false-negatives were due to 2 revascularized vessels. Moderate stenoses (<50%) were differentiated from tight stenoses (>50%) using hemodynamic criteria. The majority of false-negative stenoses (38) in the different groups were related to intrathoracic or very deep origin of the artery, anechogenic stenosis or a tortuous vessel. Stenoses greater than 70% were diagnosed in 71% of cases with a specificity of 99%. The kappa value was 0.80. CONCLUSION: Duplex sonography should be proposed first in VB attacks or stroke to detect and quantify vertebral artery stenoses for surgery and angioplasty.

Utility of balloon-assisted Guglielmi detachable coiling in the treatment of 49 cerebral aneurysms: a retrospective, multicenter study.

BACKGROUND AND PURPOSE: The management of wide-necked aneurysms or aneurysms with a neck-to-body ratio close to 1 is a difficult challenge for the interventional radiologist because of the risk of coil migration or coil protrusion into the parent vessel. Our objective was to evaluate the efficacy and safety of balloon-assisted coiling as well as the follow-up results of occlusion for those difficult aneurysms in which conventional treatment with Guglielmi detachable coils (GDCs) had failed. METHODS: A nondetachable balloon was used in 49 procedures performed in 44 patients (35 women and nine men) who underwent GDC coiling of aneurysms. Every aneurysm had either a wide neck or a sac diameter/neck size ratio (SNR) of 1.5 or less. RESULTS: In four (8%) of the procedures, balloon placement failed, leaving a total of 45 aneurysms treated with balloon-assisted coiling. Final results consisted of total occlusion in 30 cases (67%), subtotal occlusion in 11 cases (24%), and incomplete occlusion in four cases (9%). We found a correlation between the diameter of the sac and the occlusion rate, but not between the size of the neck or the SNR and the occlusion rate. Two thromboembolic complications occurred, but neither had clinical consequences. No aneurysmal rupture was observed during treatment. Final angiographic follow-up time ranged from 3 months to 5 years (mean, 16 months). CONCLUSION: Balloon-assisted coiling is an important adjunct in the treatment of aneurysms with a wide neck or low SNR. In our experience, this technique allowed safe and efficient treatment of aneurysms when conventional GDC treatment had failed.

A novel flexible endovascular stent for use in small and tortuous vessels.

We assessed in vivo the mode of delivery, short-term patency and cellular response to a prototype endovascular stent. The stent is designed for delivery through a modified microcatheter and is retrievable with detachment from a delivery wire effected by electrolysis. We successfully deployed 12 stents in a range of sizes from 3-4 mm in straight and angled arteries of pigs. At control angiography 3 and 6 weeks later, nine arteries were patent, two occluded and one narrowed; patency was not related to vessel or stent size. The device shows promise as a stent for intracranial arteries since it can be delivered through microcatheters small enough for intracranial navigation and provides the operator with greater control than currently available self- or balloon-expanded stents.

Reductionism in the pursuit of nursing science: (in)congruent with nursing's core values?

Within nursing scholarship a critique has developed around the philosophy and approaches of traditional science. The central theme of this critique is that the approaches of traditional science are antithetical to nursing's commitment to a humanistic philosophy, as reflected in the premise that reductionism is incongruent with nursing's core values. Several nurse scholars, believing that nursing's humanistic philosophy should guide the research efforts of the discipline, have advocated abandonment of the reductionistic approaches of traditional science. The authors contend that adoption of such a position will have serious consequences for knowledge development in nursing and subsequently will be detrimental to the advancement of nursing practice and the discipline of nursing. They refute the premise that reductionism is incongruent with nursing's core values, argue for reductionism in nursing science, and conclude that without the pursuit of epistemological holism, the actualization of nursing's core values is in jeopardy.

Descriptive anatomic study of the fourth perforating artery of the femoral system.

The existence of the fourth perforating artery of Paturet [7], a collateral branch of the superficial femoral artery in its lower third, is the subject of much debate. This artery has so far only been the subject of radio-anatomic descriptions based on arteriographies carried out within the context of arteriopathy of the lower limbs. We present a descriptive anatomic study of this artery based on 14 observations on 32 dissections. Three types of approach were carried out: exposure of the artery of the femoral quadriceps muscle up to its ending in the vastus lateralis; a lateral "orthopaedic" approach to the lower third of the femur; and a "vascular" approach by a medial incision to the femoro-popliteal axis in the lower third of the thigh. Its main relations are described, passing in front of the superficial femoral vein and then behind the femur before ending at the vastus lateralis muscle. These relations explain the possibility of anastomoses with collateral or terminal branches of the deep femoral artery (vastus lateralis artery, third perforating artery). The fourth perforating artery of Paturet [7] must be protected in traumatologic and vascular surgery. It is the main collector of vascular anastomoses between the deep femoral artery and the femoro-popliteal axis in the event of proximal occlusion of the superficial femoral artery. Its removal, in such a case, can aggravate an underlying arteriopathy.

Subclavian steal syndrome and flow-related aneurysm. Another reason to treat.

A 48-year-old woman presented with a symptomatic right subclavian steal syndrome due to proximal subclavian artery stenosis. Anatomically the innominate artery was absent. Collateral circulation followed the vertebro-vertebral pathway with reversal of blood flow in the ipsilateral vertebral artery. There was also multiple dilated intervertebral collaterals and an associated saccular aneurysm on one of them. Surgical carotid-subclavian transposition permitted relief of clinical symptoms, disappearance of collateral circulation and subtotal regression of the aneurysm. This spontaneous evolution confirmed the role of high-flow in the pathogenesis of some aneurysms and the habitually good prognosis of flow-related aneurysms with correction of the cause. Arteriography still appears essential in diagnosis, pretherapeutic assessment and sometimes post-treatment evaluation in subclavian steal syndrome.

Optimizing the hemodynamic performance of the DDD pacemaker: impact of the atrioventricular delay on the pulmonary venous flow pattern.

UNLABELLED: This study evaluated the impact of the atrioventricular delay (AVD) on the pulmonary venous flow pattern (PVFP). METHODS: Transthoracic Doppler PVFP were obtained during atrial and ventricular pacing at a fixed rate of 70 beats/min in 20 patients equipped with a DDD pacemaker, diastolic dysfunction linked to an impaired relaxation, a mean ejection fraction of 49%, and AV block. Two subgroups were analyzed equally: group I: seven patients with a normal ejection fraction and group II: 13 patients with decreased ejection fraction. Three different AVDs were studied: short (50 ms), intermediate (150 ms), and long (250 ms). RESULTS: As the AVD increased, the diastolic filling time and the peak atrial reverse flow wave decreased (P < 0.001). There was a decreasing D wave and no significant change in the peak velocity of the S wave. The S wave became biphasic in all patients at the longest AVD of 250 ms. The systolic (S) velocity time integral (VTI) of the pulmonary wave and the systolic/total PVF-VTI ratio increased significantly (P < 0.001). A similar response was seen in both group of patients. CONCLUSIONS: These data correlated the AVD with PVFP, supplying critical systolic information completing the diastolic data obtained from mitral Doppler patterns. These systolic measurements were especially useful for patients with heart failure and a DDD pacemaker, in order to obtain the longest diastolic filling time at the lowest atrial pressure.

[Cervical deficit radiculopathy in 3 cases of vertebral artery dissection]. / Radiculopathie cervicale déficitaire au cours de trois cas de dissection de l'artère vertébrale.

Three cases of extracranial vertebral artery dissections with upper limb peripheral motor deficit (C5-C6) are reported. Six similar cases were also found in the literature. Central neurological symptoms occurred in five of these nine cases, suggesting the diagnosis of dissection. The peripheral motor or sensorial deficit was strictly isolated in the four other cases, simulating radicular neuralgia due to discopathy or foraminal compression. In case of dissections, a precise analysis of pain is helpful to guide diagnosis; sharp, unbearable, continuous and extended neck pain without nocturnal paroxysms and posterior neck stiffness is typical. Analgesics or anti-inflammatory drugs are ineffective. Peripheral motor deficit is more common than sensory deficit. Recovery was complete in this series. In most cases, the radiculopathy appears to be due to cervical root compression in its extraforaminal course due to the dissection hematoma and rarely to radicular ischemia.

[In situ thrombolysis in the treatment of venous thrombosis of effort in the arm]. / Thrombolyse in situ dans le traitement des thromboses veineuses d'effort du membre supérieur.

From March 1989 to March 1993, six athletic patients were treated in our institution by thrombolytic therapy for acute effort axillary-subclavian vein thrombosis in thoracic outlet syndrome. Mean age of these patients was 20 (range 14 to 27). An in situ infusion with urokinase (2,500 U/kg/h) and Heparin (100 U/kg/12 hours) was given during 64 hours (Range 14 to 72). Phlebography showed a complete reperfusion in three cases (the treatment began within an average period of 5.6 days), partial reperfusion in two cases (the treatment began within an average period of 8.5 days). In one case there was no reperfusion on phlebography: treatment began within an average period of 15 days. For this patient, a venous axillo-jugular bypass graft was performed. In all cases, there was no bleeding complication. A trans-axillary first rib resection was done three months later. Mean follow up was 31 months (range: two to 51 months). All patients recovered their previous physical status. Echo-Doppler exam showed normal subclavian vein flow in four cases, partial occlusion in one case and a total occlusion of the subclavian vein flow in one case. In this last case, the thrombolytic therapy failed to restore the permeability of the subclavian vein. Bypassgraft was patent. Axillary-subclavian vein thrombosis seen within a period of seven days should be treated by local thrombolytic therapy using urokinase and heparin.