Endovascular treatment of intracranial aneurysms using the Derivo Embolization Device: a multicenter experience.

BACKGROUND: Flow diversion is the first-line treatment for several types of intracranial aneurysms. We report on a large series of patients treated with the Derivo Embolization Device who underwent a 1-year angiographic control follow-up. METHODS: We performed a multicenter retrospective analysis of prospectively collected data, designed to evaluate the clinical and angiographic results of treatment of intracranial aneurysms with the Derivo Flow Diverter. The primary endpoint was complete occlusion of the aneurysm within 12 months, which was evaluated using DSA. The secondary endpoint was the absence of any serious adverse events. Univariate and multivariate logistic regression analyses were performed to analyze the data. RESULTS: The study was conducted from December 2016 to September 2019 and enrolled 127 patients with 177 intracranial aneurysms, treated at three different centers. Efficacy at 6 months was 70.1% (122/174) for total occlusion and 87.3% (152/174) for favorable occlusion and, at 12 months, it was 83.3% (145/174) for total occlusion and 97.7% (170/174) for favorable occlusion. Regarding safety concerns, 97.6% (124/127) of patients did not experience severe adverse effects during the follow-up period of 12 months, and there was no procedure-related mortality. CONCLUSIONS: The Derivo Embolization Device, achieving a total occlusion rate of 83.3% and a favorable occlusion rate of 97.7% in a 1-year angiographic control study of 174 aneurysms with minor morbidity and no intervention-related mortality, is a safe and effective treatment for intracranial aneurysms.

Correlation between angioarchitectural characteristics of brain arteriovenous malformations and clinical presentation of 183 patients / Impacto das características angioarquiteturais das malformações arteriovenosas cerebrais na apresentaçáo clínica: análise de 183 pacientes

ABSTRACT Background: The correlation between angioarchitecture and clinical presentation of brain arteriovenous malformation (bAVM) remains a subject of debate. Objective: The main purpose of the present study was to assess the correlation between angioarchitectural characteristics of bAVM and clinical presentation. Methods: A retrospective review of all consecutive patients presenting a bAVM who underwent a cerebral angiography at Beneficencia Portuguesa Hospital in São Paulo between January 2006 and October 2016 was carried out. Patients were divided in five groups: group 1 - hemorrhage; group 2 - seizure; group 3 - headache; group 4 - progressive neurological deficits (PND); group 5 - incidental). Results: A total of 183 patients were included, with group 1 comprising 56 cases, group 2 49 cases, group 3 41 cases, group 4 28 cases, and group 5 9 cases. Regarding hemorrhage presentation, a statistical correlation was observed with female gender (P < 0.02), Spetzler-Martin 3B (P < .0015), and lesions with low flow (P < 0.04). A positive association was found between group 2 and age less than 36 years (P < 0.001), male sex (P < 0.018), presence of superficial lesions not classified as SM 3B (P < 0.002), presence of venous ectasia (p <0.03), and arterial steal phenomenon (P < 0.03). Group 4 was associated with older age (P < 0.01). Conclusions: Angioarchitectural characteristics can be correlated with some clinical presentations as well as with some clinical data, making it possible to create predictive models to differentiate clinical presentations.

RESUMO Antecedentes: A correlação entre a angioarquitetura e a apresentação clínica da Malformação Arteriovenosa do cérebro (MAVc) permanece um assunto de debate. Objetivos: Correlacionar as características angioarquiteturais das MAVc com a apresentação clínica. Métodos: Estudou-se pacientes consecutivos atendidos no Hospital Beneficência Portuguesa-SP, entre 2006 a 2016. Após análise geral, criaram-se cinco grupos de acordo com a apresentação clínica: 1- Hemorragia; 2 - Epilepsia; 3 - Cefaléia; 4 - Déficit Neurológico Progressivo (DNP) e 5 - Incidental. Características epidemiológicas (clínica e topografia) e angioarquiteturais (Classificação de Spetzler-Martin Modificada - SMM; Fluxo intranidal; Aneurismas arteriais, intranidais e venosos; Ectasia venosa; Congestão venosa; "Roubo" arterial; Vascularização dural; Drenagem Venosa Profunda) foram analisadas. Resultados: 183 pacientes foram incluídos e analisados globalmente. Após essa etapa, foram divididos nos grupos: 1 - 56 casos (30,6%); 2 - 49 casos (26,7%); 3 - 41 casos (22,4%); 4 - 28 casos (15,3%) e 5 - 9 casos (4,9%). Principais achados foram referentes a apresentação hemorrágica, na qual observamos correlação estatística positiva com o sexo feminino (P<0,02), lesões classificadas como SMM 3B (P<0,0015) e baixo fluxo (P<0,04). Relacionado à epilepsia, encontramos significância estatística que possibilitou a correlação com pacientes com idade inferior a 36 anos (P<0,001), sexo masculino (P<0,018), lesões superficiais (P<0,002), presença de ectasia venosa (P<0,003) e "roubo" arterial (P<0,01). Pacientes com DNP se apresentam com idade superior aos demais (P<0,01). Conclusões: Após análise multivariada, foi possível separar as MAV em grupos de acordo com as características angioarquiteturais, comprovando que algumas dessas características estão fortemente relacionadas a determinada manifestação.

Correlation between angioarchitectural characteristics of brain arteriovenous malformations and clinical presentation of 183 patients.

BACKGROUND: The correlation between angioarchitecture and clinical presentation of brain arteriovenous malformation (bAVM) remains a subject of debate. OBJECTIVE: The main purpose of the present study was to assess the correlation between angioarchitectural characteristics of bAVM and clinical presentation. METHODS: A retrospective review of all consecutive patients presenting a bAVM who underwent a cerebral angiography at Beneficencia Portuguesa Hospital in São Paulo between January 2006 and October 2016 was carried out. Patients were divided in five groups: group 1 - hemorrhage; group 2 - seizure; group 3 - headache; group 4 - progressive neurological deficits (PND); group 5 - incidental). RESULTS: A total of 183 patients were included, with group 1 comprising 56 cases, group 2 49 cases, group 3 41 cases, group 4 28 cases, and group 5 9 cases. Regarding hemorrhage presentation, a statistical correlation was observed with female gender (P < 0.02), Spetzler-Martin 3B (P < .0015), and lesions with low flow (P < 0.04). A positive association was found between group 2 and age less than 36 years (P < 0.001), male sex (P < 0.018), presence of superficial lesions not classified as SM 3B (P < 0.002), presence of venous ectasia (p <0.03), and arterial steal phenomenon (P < 0.03). Group 4 was associated with older age (P < 0.01). CONCLUSIONS: Angioarchitectural characteristics can be correlated with some clinical presentations as well as with some clinical data, making it possible to create predictive models to differentiate clinical presentations.

Safety and Effectiveness of the Pipeline Flex Embolization Device With Shield Technology for the Treatment of Intracranial Aneurysms: Midterm Results From a Multicenter Study.

BACKGROUND: The safety and efficacy of the first generation of the Pipeline Embolization Device (PED; Medtronic Inc) have been proven in large case series. Ischemic events are one of the most common complications following treatment of aneurysms with flow diverters. The new PED Flex with Shield technology (PED Shield; Medtronic Inc) was introduced to minimize the rate of complications. OBJECTIVE: To evaluate the outcomes of patients harboring aneurysms treated with the PED Shield. METHODS: This was an observational, prospective, single-arm multicenter study of patients treated with the PED Shield. The primary safety endpoint was the absence of major neurological complications and death. The secondary effectiveness endpoint was angiographic occlusion at 6 and 12 mo. Technical complications were also reported. RESULTS: Between November 2017 and December 2018, 151 patients from 7 centers with 182 aneurysms were enrolled. The mean aneurysm size was 7.0 mm; 27 (14.8%) aneurysms were large, and 7 (3.8%) were giant. In 141 of 151 patients (93.4%), the primary endpoint was reached. The overall rate of periprocedural complications was 7.3%. Of the aneurysms, 79.7% met the study's secondary endpoint of complete occlusion at 6 mo and 85.3% at 12 mo. CONCLUSION: The PED Shield is a safe and effective treatment for intracranial aneurysms. The results regarding total occlusion and ischemic complications did not differ from those obtained in case series using previous versions of the PED. Long-term follow-up and comparative studies are required to provide stronger conclusions regarding the reduced thrombogenicity of this device.

Web Vessels: Literature Review and Neurointerventional Management.

OBJECTIVE: The aim of this study was to describe 27 patients with 32 web vessels (WVs) from our practice and provide a review of the literature regarding imaging diagnostics, clinical presentation, and treatment of WVs. METHODS: A MEDLINE search was performed using combinations of the following terms: "stroke in young adults," "web," "recurrent stroke," "diaphragm-like," "atypical fibromuscular hyperplasia," "atypical fibromuscular dysplasia," "septal fibromuscular dysplasia," "septa," "diaphragms," "pseudovalvular folds," and "carotid diaphragm." Our series was added in this review. RESULTS: According to location, there were 88 carotid WVs (91.66%), 7 vertebral WVs (7.3%), and 1 subclavian WV (1.04%). According to clinical presentation, the reported WVs caused stroke in 81 cases (84.38%). Treatment was supportive care in 46 cases (47.91%), surgery in 33 cases (35.41%), and an endovascular procedure through angioplasty and stenting in 17 cases (17.7%). Variables such as age (P = 0.7565), sex (P = 0.6912), and location (P = 0.7993) were not shown to be risk factors for stroke in these patients. CONCLUSIONS: Although few cases have been reported in the literature, the stroke rate in patients with WVs is high. Endovascular treatment is presented as an effective form of treatment with no associated morbidities or recurrences of ischemic events.

Dissecting spinal aneurysms: conservative management as a therapeutic option.

OBJECTIVE: Isolated dissecting spinal aneurysms are rare lesions that pose a therapeutic challenge. We report our experience in the management of four patients with dissecting spinal aneurysms. METHODS: After institutional review board approval was obtained, the neurointerventional databases of the two participating institutions were retrospectively reviewed. Aneurysms in the anterior spinal artery, posterior spinal artery, or in a radiculomedullary artery were included in the analysis. Flow-related aneurysms were excluded. Data on clinical presentation, hemorrhage location, aneurysm size, location, angiographic follow-up, re-hemorrhage, and clinical outcome were obtained and analyzed. RESULTS: Four patients with five spinal dissecting aneurysms met the inclusion criteria. There were two women and the mean age was 63 years (range 36-64). All patients presented with hemorrhage. Three radiculomedullary arteries in two different patients had one lesion each; the other two involved the anterior spinal artery and a posterior spinal artery in different patients. All four patients were managed conservatively. Follow-up angiography (5.5 months) demonstrated occlusion of all five aneurysms. There was no re-hemorrhage and all patients had a good outcome at the last follow-up (modified Rankin Scale score 0-2). CONCLUSIONS: Conservative management of ruptured spontaneous dissecting spinal aneurysms is a reasonable therapeutic option capable of achieving favorable angiographic and clinical outcomes.

Flow Diverters for Treatment of 160 Ophthalmic Segment Aneurysms: Evaluation of Safety and Efficacy in a Multicenter Cohort.

BACKGROUND: Treatment of ophthalmic segment aneurysms (OSA) remains challenging. Flow diverter stents (FDS) have evolved as a promising endovascular treatment option for aneurysms of the internal carotid artery and are associated with high occlusion rates and a favorable morbidity and mortality profile. OBJECTIVE: To determine safety and efficacy of FDS for OSA in a large, multicenter cohort. METHODS: A retrospective analysis of prospectively maintained databases of 127 consecutive patients harboring 160 OSA treated with FDS was performed. Aneurysms were classified based on location and morphology. Follow-up with digital subtraction angiography (DSA) was performed 6 to 18 months after treatment. RESULTS: Follow-up DSA was available for 101 (63.1%) aneurysms with a mean follow-up of 18 months. Complete occlusion was observed in 90 aneurysms (89.1%), near-complete occlusion (>95%) in 3 (3%), and incomplete occlusion (<95%) in 8 aneurysms (7.9%). One aneurysm was retreated with another FDS (0.9%). No risk factors for incomplete occlusion were identified. The OA was occluded at the latest follow-up in 6 cases (7.1%). Permanent morbidity occurred in 4 patients (3.1%), and there was no mortality related to the FDS procedure. CONCLUSION: Treatment of OSA with FDS was found to be safe and effective. The retreatment rate was extremely low and aneurysms that occluded did not reanalyze.

Neurovascular reconstruction with flow diverter stents for the treatment of 87 intracranial aneurysms: Clinical results.

BACKGROUND: Flow diverter stents represent a new endovascular tool to treat complex aneurysms, such as giant, large, wide-necked and fusiform. The highly dense mash of these stents reduces inflow and outflow inside the aneurysm, resulting in intra aneurysmal thrombosis and stent endothelialization. OBJECTIVES: To present the results of treatment of intracranial aneurysms with flow diverter stents in a single center. METHODS: Retrospective review of 77 patients with 87 aneurysms treated using two different types of flow diverter stent, the Pipeline Embolization Device and SILK stent, between October 2010 and September 2013 in an interventional neuroradiology center. RESULTS: Flow diverter stent placement was successful in 98% of the lesions and resulted in an immediate major stasis within most of the treated aneurysms. The overall aneurysm occlusion rate at six months and 18 months was 80% and 84% respectively. Symptomatic complications occurred in 11 patients (14.3%) with morbidity in eight (10.4%) and mortality in three patients (3.9%). CONCLUSION: Flow diversion is a promising technique for treatment of challenging intracranial aneurysms with acceptable morbidity. A high rate of complete occlusion for small large necked aneurysms, a low morbidity and mortality rate and no recanalization encourage their use in these aneurysms. Further studies accessing long-term aneurysm occlusion and recanalization are required.

Carotid rete mirabile associated with subarachnoid hemorrhage from intracranial aneurysm: A case report and systematic review.

Carotid rete mirabile (CRM) is a rare physiological vascular network in humans that is most often found in Eastern populations. This paper describes a CRM associated with an aneurysmal subarachnoid hemorrhage (aSAH) and discusses the details of the patient's treatment. A 28-year-old woman was admitted to our service with clinical signs and symptoms of a spontaneous aSAH. Computed tomography revealed a diffuse and extensive SAH (Fisher group IV), while an angiogram showed an abnormal collateral network in the right carotid system and a hypoplastic aspect to the internal carotid artery (ICA) on the same side. In addition, a saccular aneurysm with a diameter of 9.5 mm was present in the ophthalmic segment of the left ICA. This case is extremely uncommon. To avoid rebleeding in the patient, we successfully treated the patient by clipping the aneurysmal lesion. No procedure was performed for the CRM.

Editorial: «Interventional Neuroradiology: a Neuroscience sub-specialty?¼.

Interventional Neuroradiology (INR) is not bound by the classical limits of a speciality, and is not restricted by standard formats of teaching and education. Open and naturally linked towards neurosciences, INR has become a unique source of novel ideas for research, development and progress allowing new and improved approaches to challenging pathologies resulting in better anatomo-clinical results. Opening INR to Neurosciences is the best way to keep it alive and growing. Anchored in Neuroradiology, at the crossroad of neurosciences, INR will further participate to progress and innovation as it has often been in the past.

«Interventional Neuroradiology: a neuroscience sub-specialty?¼.

Interventional Neuroradiology (INR) is not bound by the classical limits of a specialty, and is not restricted by standard formats of teaching and education. Open and naturally linked towards neurosciences, INR has become a unique source of novel ideas for research, development and progress allowing new and improved approaches to challenging pathologies resulting in better anatomo-clinical results. Opening INR to Neurosciences is the best way to keep it alive and growing. Anchored in Neuroradiology, at the crossroad of neurosciences, INR will further participate to progress and innovation as it has often been in the past.

Anatomia arterial intracraniana: avaliação por angiotomografia computadorizada: [revisão] / Intracranial arterial anatomy: evaluation by computed tomography angiography: [review]

Durante muitos anos, o estudo arterial intracraniano foi realizado, exclusivamente, por meio daangiografia convencional, em que há cateterização seletiva das artérias. Hoje em dia, com a evoluçãotecnológica da tomografia computadorizada por meio de multidetectores permitindo aquisições com fatias de corte cada vez mais finas, maior velocidade e melhor resolução espacial, surgiucomo nova modalidade de investigação a angiotomografia, menos invasiva e com menor morbidade que a arteriografia convencional. Muitos estudos na literatura vêm analisando a sensibilidade deste novo método na detecção de aneurismas intracranianos e comparando seus resultados com aqueles obtidos pela arteriografia convencional. Para tal, percebe-se a necessidade doreconhecimento da anatomia arterial intracraniana normal e suas variações a partir de imagenscom reformações multiplanares, objetivando o fornecimento de importantes informações paradefinição de estratégias nas abordagens cirúrgicas, tais como calcificações parietais, posição docolo aneurismático e relações com estruturas anatômicas circundantes.

By many decades, the intracranial arteries study was realized exclusively by angiography through selective arterial catheterization.Nowadays, with the technologic evaluation of computerized tomography devices with multidetectors allowing acquisitions with even more thinner slices, higher speed and better resolution, it had appeared a new modality of investigation: the computed tomography angiography, less invasive and with minor morbidity than conventional arteriography. Many studies in the literature have been analyzing the sensibility of the new method for the detection ofintracranial aneurisms and comparing them with the conventional arteriography. There is a necessity to recognize the normal intracranial arterial anatomy and its variations using images obtainedfrom multiplanar reformations, in order to give important informationfor surgeries strategies, such as wall calcifications, aneurismatic neck position and relationships with surrounding anatomical structures.

Malformação arteriovenosa medular: tratamento cirúrgico, enfatizando a importância da discussão multidisciplinar para decisão / Spinal arteriovenous malformation: surgical treatment, with emphasys in the importance of the multidisciplinary disccussion for therapeutic

MAVs medulares são lesões complexas que podem se apresentar como nidus ou mais frequentemente como fistulas. O diagnóstico é realizado através de arteriografia e o tratamento de eleição é geralmente a embolização, ficando a cirurgia reservada para casos selecionados. Neste artigo são discutidos as formas de classificação dessas lesões e seu tratamento. Apresenta-se ainda um caso onde foi realizado o tratamento cirúrgico. Embora geralmente tratadas por embolização, a cirurgia evidenciando a necessidade da discussão multidisciplinar no processo de decisão terapêutica.

Evaluation of Onyx HD-500 embolic system in the treatment of 84 wide-neck intracranial aneurysms.

OBJECTIVE: We report our results using Onyx HD-500 (Micro Therapeutics, Inc., Irvine, CA) in the endovascular treatment of wide-neck intracranial aneurysms, which have a high rate of incomplete occlusion and recanalization with platinum coils. METHODS: Sixty-nine patients with 84 aneurysms were treated. Most of the aneurysms were located in the anterior circulation (80 of 84 aneurysms), were unruptured (74 of 84 aneurysms), and were incidental. Ten presented with subarachnoid hemorrhage, and 15 were symptomatic. All aneurysms had wide necks (neck >4 mm and/or dome-to-neck ratio <1.5). Fifty aneurysms were small (<12 mm), 30 were large (12 to <25 mm) and 4 were giant. Angiographic follow-up was available for 65 of the 84 aneurysms at 6 months, for 31 of the 84 aneurysms at 18 months, and for 5 of the 84 aneurysms at 36 months. RESULTS: Complete aneurysm occlusion was seen in 65.5% of aneurysms on immediate control, in 84.6% at 6 months, and in 90.3% at 18 months. The rates of complete occlusion were 74%, 95.1%, and 95.2% for small aneurysms and 53.3%, 70%, and 80% for large aneurysms at the same follow-up periods. Progression from incomplete to complete occlusion was seen in 68.2% of all aneurysms, with a higher percentage in small aneurysms (90.9%). Aneurysm recanalization was observed in 3 patients (4.6%), with retreatment in 2 patients (3.3%). Procedural mortality was 2.9%. Overall morbidity was 7.2%. CONCLUSION: Onyx embolization of intracranial wide-neck aneurysms is safe and effective. Morbidity and mortality rates are similar to those of other current endovascular techniques. Larger samples and longer follow-up periods are necessary.

Radiosurgery with a linear accelerator in cerebral arteriovenous malformations.

OBJECTIVE: To evaluate results achieved with radiosurgery and complications of the procedure when treating arteriovenous malformations with linear accelerator. METHODS: This retrospective study was conducted between October 1993 and December 1996. Sixty-one patients with arteriovenous malformations were treated with radiosurgery utilizing a 6MV energy linear accelerator. Ages of the 32 female and 29 male patients ranged from 6 to 54 years (mean: 28.3 years). The most frequent initial symptom was cephalea (45.9%), followed by neurological deficit (36.1%). Cerebral hemorrhage diagnosed by image was observed in 35 patients (57.3%). Most arteriovenous malformations (67.2%) were graded Spetzler III and IV. Venous stenosis (21.3%) and aneurysm (13.1%) were the most frequent angioarchitecture changes. The dose administered varied from 12 to 27.5Gy in the periphery of the lesion. RESULTS: Out of twenty-eight patients that underwent conclusive angiography control, complete obliteration was achieved in 18 (72%) and treatment failed in 7 (absence of occlusion with more than 3 years of follow-up). Four were submitted to a second radiosurgery, and one of these has shown obliteration after 18 months of follow-up. DISCUSSION: Several factors were analyzed regarding the occlusion rate (gender, age, volume, localization, Spetzler, flow, embolization, total of isocenters, prescribed dose and chosen isodose) and complications (total of isocenters, localization, volume, maximum dose, prescribed dose and chosen isodose). Analyzed variables showed no statistical significance for obliteration of the vessel, as well as for treatment complications. The largest diameter of the arteriovenous malformation, its volume and the dose administered did not influence time of obliteration. CONCLUSION: Radiosurgery is effective in the treatment of arteriovenous malformations and can be an alternative for patients with clinical contraindication or with lesions in eloquent areas. In the studied variables no statistically significant correlation was observed between occlusion and treatment complications.

Radiosurgery with a linear accelerator in cerebral arteriovenous malformations / Radiocirurgia com acelerador linear em malformações arteriovenosas cerebrais

OBJECTIVE: To evaluate results achieved with radiosurgery and complications of the procedure when treating arteriovenous malformations with linear accelerator. METHODS: This retrospective study was conducted between October 1993 and December 1996. Sixty-one patients with arteriovenous malformations were treated with radiosurgery utilizing a 6MV energy linear accelerator. Ages of the 32 female and 29 male patients ranged from 6 to 54 years (mean: 28.3 years). The most frequent initial symptom was cephalea (45.9 percent), followed by neurological deficit (36.1 percent). Cerebral hemorrhage diagnosed by image was observed in 35 patients (57.3 percent). Most arteriovenous malformations (67.2 percent) were graded Spetzler III and IV. Venous stenosis (21.3 percent) and aneurysm (13.1 percent) were the most frequent angioarchitecture changes. The dose administered varied from 12 to 27.5Gy in the periphery of the lesion. RESULTS: Out of twenty-eight patients that underwent conclusive angiography control, complete obliteration was achieved in 18 (72 percent) and treatment failed in 7 (absence of occlusion with more than 3 years of follow-up). Four were submitted to a second radiosurgery, and one of these has shown obliteration after 18 months of follow-up. DISCUSSION: Several factors were analyzed regarding the occlusion rate (gender, age, volume, localization, Spetzler, flow, embolization, total of isocenters, prescribed dose and chosen isodose) and complications (total of isocenters, localization, volume, maximum dose, prescribed dose and chosen isodose). Analyzed variables showed no statistical significance for obliteration of the vessel, as well as for treatment complications. The largest diameter of the arteriovenous malformation, its volume and the dose administered did not influence time of obliteration. CONCLUSION: Radiosurgery is effective in the treatment of arteriovenous malformations and can be an alternative for patients with clinical...

OBJETIVO: Analisar os resultados obtidos com radiocirurgia e as suas complicações do procedimento, no tratamento das malformações arteriovenosas com acelerador linear. MÉTODOS: Este é um estudo retrospectivo. Entre Outubro de 93 e Dezembro de 96, sessenta e um pacientes com malformações arteriovenosas foram tratados, utilizando um acelerador linear com 6MV de energia. As idades variaram de 6 a 54 anos (média: 28,3 anos), 32 pacientes mulheres e 29 pacientes homens. O sintoma inicial mais freqüente foi cefaléia (45,9 por cento), seguido de déficit neurológico (36,1 por cento). Hemorragia cerebral diagnostica por exame de imagem foi observada em 35 pacientes (57,3 por cento). A maioria das malformações arteriovenosas (67,2 por cento) eram graus III e IV de Spetzler. Estenose venosa (21,3 por cento) e aneurisma (13,1 por cento) foram as mais freqüentes alterações da arquitetura vascular. A dose administrada variou de 12 a 27,5Gy na periferia da lesão. RESULTADOS: Dos vinte e oito pacientes que se submeteram a controle angiográfico conclusivo, 18 tiveram obliteração completa (72 por cento) e 7 falharam ao tratamento (ausência de oclusão com mais de três anos de seguimento). Quatro pacientes foram submetidos a uma segunda radiocirurgia, e um paciente deste grupo apresentou obliteração em 18 meses de seguimento. DISCUSSÃO: Vários fatores foram analisados em relação ao grau de oclusão (sexo, idade, volume, localização, Spetzler, fluxo, embolização, total de isocentros, dose prescrita e isodose escolhida) e complicações (total de isocentros, localização, volume, dose máxima, dose prescrita e isodose escolhida). As variáveis analisadas não mostraram significância estatística para a obliteração do vaso, bem como para as complicações de tratamento. O maior diâmetro da malformação arteriovenosa, seu volume e a dose administrada não influenciaram no tempo de obliteração. CONCLUSÃO: Radiocirurgia é eficiente no tratamento das malformações arteriovenosas...

Avaliação radiológica imediata, aos seis meses e aos 18 meses, do uso do copolímero etileno vinil álcool (Onyx®) no tratamento endovascular de aneurismas saculares intracranianos de colo largo / Radiological evaluation on immediate, 6 and 18 month control on the use of Onyx® in the endovascular treatment of wide neck intracranial aneurysms

Introdução: A alta incidência de oclusão incompleta e recanalização dos aneurismas intracranianos de colo largo tratados por via endovascular levaram ao desenvolvimento de novas técnicas, entre elas o uso do Onyx ®. Objetivos: avaliar a eficiência do agente embólico líquido Onyx® em produzir oclusão completa dos aneurismas intracranianos de colo largo e avaliar a estabilidade do tratamento aos 6 meses e aos 18 meses, por meio de controles angiográficos. Casuística e métodos: Esta tese foi realizada na Seção de Neuroradiologia Intervencionista da Med Imagem, do Hospital São Joaquim da Real e Benemérita Associação Portuguesa de Beneficência de São Paulo, através da revisão de dados clínicos e radiológicos de 69 pacientes tratados pelo autor, com 84 aneurismas intracranianos de colo largo no período de julho de 2002 a fevereiro de 2006. Dez pacientes eram do sexo masculino e 59 do sexo feminino, com idade variando de 24 anos a 86 anos (mediana de 52 anos). Todos os aneurismas tinham origem lateral à artéria e apresentavam pelo menos um dos critérios usados para definir colo largo - colo maior que 4 mm de diâmetro e relação saco/colo menor que 1,5. Cinqüenta aneurismas eram pequenos, 30 grandes e quatro gigantes (diâmetro máximo menor que 12mm, de 12mm a 25mm e maiores que 25mm, respectivamente). As apresentações clínicas mais comuns foram: achado incidental em 34 pacientes, pós-hemorragia sub aracnóide e recanalização após tratamento com espirais destacáveis em 10. A maioria dos aneurismas era da artéria carótida interna (76 aneurismas). Controles angiográficos foram feitos ao final, aos seis meses e aos 18 meses do tratamento (controles I, II e III respectivamente), sendo analisados principalmente o grau de oclusão (completa ou incompleta), incidência de recanalização e complicações clínicas. Avaliação estatística foi feita pelo método de Kaplan-Meier para o percentual cumulativo de oclusão completa e percentual de recanalização e análise univariada e...

Introduction: The high rate of incomplete occlusion and intracranial large neck aneurysms recanalization lead to the development of new techniques, including the use of Onyx®. Purpose: to evaluate the efficacy of the liquid embolic system Onyx ® to produce completes occlusion of the intracranial large neck aneurysms and evaluates the stability of the treatment at 6 month and 18 month angiographic control. Materials and Methods: this thesis has been performed at Section of Interventional Neuroradiology of Med Imagem, at the Hospital São Joaquim da Real e Benemérita Associação Portuguesa de Beneficência de São Paulo, based on a review of clinical and radiological records of 69 patients treated by the author, harboring 84 large neck intracranial aneurysms between July 2002 and February 2006. Ten patients were male and 59 female, with age ranging from 24 to 86 years old. All aneurysms were lateral to the parent vessel and were wide neck (neck > 4 mm and/or domus to neck ratio < 1.5). Fifty aneurysms were small (<12 mm), 30 were large (12 to 25 mm) and 4 were giant (> 25 mm). Thirty four aneurysms were incidental, 10 were ruptured and 10 were recanalized after coil treatment and the majority was located in the internal carotid artery (76). Angiographic follow-up was done at the end of the procedure, at six month and at 18 month (controls I, II and III respectively), analyzing the rate of complete occlusion, recanalization and clinical complication. Statically analysis were done by Kaplan-Meier method for cumulative percentage of complete aneurysm occlusion and for recanalization, and univariate and multivariate analysis of predictive factors of immediate and late complete occlusion through logistic regression. Results: Complete aneurysm occlusion was achieved in 65.5% on immediate control, in 84.6% at 6 month, and in 90.3% at 18 month follow-up periods for all aneurysms. This rate was 74%, 95.1% and 95.2% for small and 53.3%, 70% and 80% for large aneurysms...

[Subperiosteal hematoma of the orbit: case report]. / Hematoma subperiosteal de órbita: relato de caso.

We describe a sixteen years old male patient that suffered a craniocerebral trauma and presented at the emergency room, with ocular pain, palpebral hematoma and left eye proptosis. Orbital computed tomography showed left subperiosteal orbital hematoma. A surgical drainage was performed. Subperiosteal hematoma of the orbit is a rare cause of proptosis; its early diagnosis must be made in order to avoid possible complications.