Collagen Crosslinking-assisted Treatment of a Bleb Leak: Enhancement of Vascularization around the Bleb.

AIM AND OBJECTIVE: To present a case with bleb leakage treated with collagen crosslinking (CXL). BACKGROUND: Bleb-related complications can cause serious problems even a long time after trabeculectomy. In this case report, we present a relatively unknown treatment method for bleb leakage which might be one of the long-term complications of trabeculectomy. CASE DESCRIPTION: A 60-year-old male patient was admitted to our clinic with a decrease in his left vision. The patient had a history of left trabeculectomy. The bleb leakage was observed. Autologous blood was injected into the bleb area as the first line of treatment. Collagen crosslinking was applied to the bleb area upon the recurrence of the leakage. In the 1st week after the CXL, CXL was repeated in the bleb area upon the observation that the leakage recurred. It was observed that the leakage did not recur and bleb vascularization was triggered after CXL. CONCLUSION: Conjunctival CXL might be a non-invasive, viable method in the management of bleb leakage. It might be applied in conjunction with bandage contact lenses for the treatment of late bleb leaks as an alternative treatment method before going into surgical intervention. CLINICAL SIGNIFICANCE: As a result of conjunctival CXL application, collagen permeability reduction and neovascularization secondary to CXL application might be effective in preventing bleb leakage. However, further studies are needed to prove this. HOW TO CITE THIS ARTICLE: Aktas Z, Aribas YK, Bilgihan K, et al. Collagen Crosslinking-assisted Treatment of a Bleb Leak: Enhancement of Vascularization around the Bleb. J Curr Glaucoma Pract 2021;15(1):36-39.

PARACENTRAL ACUTE MIDDLE MACULOPATHY IN PRIMARY CONGENITAL GLAUCOMA.

PURPOSE: To report a case of primary congenital glaucoma associated with paracentral acute middle maculopathy. METHODS: A case report. RESULTS: A 14-year-old girl with undiagnosed primary congenital glaucoma was referred for the evaluation of sudden vision loss a week after the initial symptoms. Visual acuity was counting fingers at 2 m in the right eye. Examination of her right eye revealed corneal stromal scar like Haab striae, splinter hemorrhage at the temporal border of the optic disk, perivenular hemorrhage, and fern-like white area at the macula. On optical coherence tomography of the right eye, hyperreflective plaques at the level of the inner nuclear layer/outer plexiform layer were present, corresponding to the opaque areas in fundoscopy. On optical coherence tomography angiography of the right eye, ischemic areas in deep capillary plexuses were present. These findings in optical coherence tomography angiography and optical coherence tomography were consistent with paracentral acute middle maculopathy. CONCLUSION: This is the first case of primary congenital glaucoma associated with paracentral acute middle maculopathy in the literature, and primary congenital glaucoma might be a predisposing factor.

Middle Cerebral Artery Bifurcation Aneurysms Treated by Extrasaccular Flow Diverters: Midterm Angiographic Evolution and Clinical Outcome.

BACKGROUND AND PURPOSE: Flow diverters have been increasingly used lately in off-label, distal intracranial aneurysm treatments. Our aim was to evaluate the effectiveness of flow diverters in the treatment of middle cerebral artery bifurcation aneurysms and to analyze midterm angiographic patterns of regional flow modifications for safety and clinical outcomes. MATERIALS AND METHODS: Consecutive patients treated from January 2010 to December 2014 by the authors by using endovascular flow-diverting stents for MCA bifurcation aneurysms were evaluated retrospectively with prospectively maintained data. All patients had been followed for at least 12 months after treatment, with at least 2 control angiograms; regional flow-related angiographic modifications were registered by using a new angiographic outcome scale for flow diverters. Data were analyzed with emphasis on procedure-related events, angiographic results, and clinical outcome. RESULTS: Fifty-eight patients were included in the study, with 63 MCA bifurcation aneurysms; 13 of these were large and giant. Pretreatment mRS was 0 for 12 patients (20.7%), 1 for 41 (70.7%), and 2 for 5 patients (8.6%). Six-month control revealed mRS 0-2 for 57 (98.3%) patients and 3 for 1 (1.7%) patient. Procedure-related morbidity and mortality were 8.6% (5/58) and 0%, respectively. From 95% of still circulating immediate postprocedure angiographic outcomes, 68% progressed to aneurysm occlusion at 6 months and 95%, to occlusion at 12 months, with a 0% aneurysm rupture rate. CONCLUSIONS: Flow diverters seem to be an effective treatment alternative for complex MCA bifurcation aneurysms, with reasonable complication rates. Longer angiographic follow-ups are needed to assess the morphologic outcome; immediate subtotal occlusions do not seem to be related to rupture.

Endovascular treatment of middle cerebral artery aneurysms with flow modification with the use of the pipeline embolization device.

BACKGROUND AND PURPOSE: The Pipeline Embolization Device was reported to be safe and effective in the treatment of sidewall aneurysms, preserving the patency of the vessels covered by the construct. However, to date, the safety and efficacy of this device in treating bifurcation aneurysms remains unknown. We report our preliminary experience with the use of the Pipeline Embolization Device in the management of MCA aneurysms located at the bifurcations, including mid- and long-term follow-up data. MATERIALS AND METHODS: Wide-neck MCA aneurysms, which give rise to a bifurcating or distal branch in which other endovascular techniques are thought to be unfeasible or more risky, were included. Data including demographics, aneurysm features, antiplatelet therapy, complications, and angiographic follow-up results for up to 30 months were recorded. RESULTS: Twenty-five aneurysms located at the MCA bifurcation (n = 21) or distal (n = 4) were treated. Of these, 22 were small and 3 were large. A single device was used in all but 2. No deaths occurred in the series. All patients had at least 1 control angiographic study, 21 of which were DSA (3-30 months), which showed that 12 of the rising branches were patent whereas 6 were filling in reduced caliber and 3 were occluded asymptomatically. According to the last angiographic follow-up, complete occlusion was revealed in 21 of 25 aneurysms (84%). CONCLUSIONS: The Pipeline Embolization Device provides a safe and effective treatment alternative for wide-neck MCA aneurysms that give rise to a bifurcating or distal branch when other endovascular techniques are thought to be unfeasible or more risky.

Stent-assisted coiling in endovascular treatment of 500 consecutive cerebral aneurysms with long-term follow-up.

BACKGROUND AND PURPOSE: Stent-assisted coil embolization has become one of the most preferred techniques in the treatment of wide-neck intracranial aneurysms; however, long-term patency and safety of the self-expanding neurostents and their role in durability of the endovascular treatment has remained ambiguous. We sought to retrospectively examine the long-term results of self-expanding stent usage in conjunction with coil embolization in treatment of wide-neck cerebral aneurysms. MATERIALS AND METHODS: We coiled 500 wide-neck cerebral aneurysms with different types of self-expanding neurostent assistance in 468 patients. Patient and aneurysm characteristics, pharmacologic therapy protocol, complications, and initial occlusion grades were analyzed. Patients underwent angiographic follow-up at 6 months to 7 years after treatment. DSA or MRA images of all patients were analyzed to assess the occlusion rate of aneurysms and patency of the parent artery. RESULTS: Enterprise (n = 340), Solitaire (n = 98), Wingspan (n = 41), LEO (n = 16), and Neuroform (n = 5) stent systems were used in this series. Stent-related thromboembolic events occurred in 21 patients and intraoperative rupture occurred in 4 patients. Initially, complete occlusion was achieved in 42.2% of the aneurysms, and, according to the last follow-up data, the rate had progressed to 90.8%. Recanalization rate at 6 months was 8%, whereas the late recanalization rate was 2%. CONCLUSIONS: The use of stents in endovascular treatment provides high rates of complete occlusion and low rates of recurrence at a long-term follow-up study.

Double stent-assisted coil embolization treatment for bifurcation aneurysms: immediate treatment results and long-term angiographic outcome.

BACKGROUND AND PURPOSE: The goal of endovascular treatment of cerebral bifurcation aneurysms is to achieve safe coiling of the sac along with preserving patency of the diverging branches. Our purpose was evaluate procedural safety and efficacy as well as the long-term durability of endovascular treatment of bifurcation aneurysms with double stent-assisted coiling. MATERIALS AND METHODS: One hundred ninety-one consecutive patients with bifurcation aneurysms were included in this series. Technical failure occurred in 3 aneurysms (1.5%); 188 patients with 193 aneurysms treated with double stent-assisted coiling were retrospectively evaluated; 113 aneurysms were located at middle cerebral artery bifurcation, 42 at the anterior communicating artery, 22 at the basilar artery bifurcation, and the remaining 16 at the internal carotid artery bifurcation; 132 were small (<10 mm), 56 were large (10-25 mm), and 5 were giant (>25 mm). RESULTS: The technical success rate of double-stent application was 98.5% (193 aneurysms). In total, there were 5 procedural complications with an associated rate of 2.7%, one of which led to death (0.5%). Delayed ischemic stroke occurred in 2 patients (1.1%). Overall, permanent morbidity occurred in 2 patients, with associated rate of 1.1%. Follow-up was obtained in 186 aneurysms (96.4%), and recanalization occurred in 4 aneurysms (2.2%). In subgroup analysis, the recanalization rate was 3.8% for large aneurysms and 40% for giant aneurysms. No recanalization occurred in small aneurysms. CONCLUSIONS: Dual stent-assisted coiling of cerebral aneurysms is a feasible and safe procedure. It may offer a curative solution with long-term durability for treatment of wide-neck small and large aneurysms.

Treatment of intracranial aneurysms using the pipeline flow-diverter embolization device: a single-center experience with long-term follow-up results.

BACKGROUND AND PURPOSE: Flow-diverting devices now offer a new treatment alternative for cerebral aneurysms. We present the results of a large single-center series of patients treated with the PED, including long-term follow-up. MATERIALS AND METHODS: Between November 2008 and September 2011, sidewall aneurysms with a wide neck (≥4 mm) or unfavorable dome-neck ratio (≤1.5); large/giant, fusiform, dissecting, blister-like, and recurrent sidewall aneurysms; aneurysms at difficult angles; and aneurysms in which a branch was originating directly from the sac were treated with the PED. Patients were premedicated with dual antiplatelet medications. Data, including demographics, aneurysm features, clinical presentation, complications, results, and follow-up information, for up to 2 years are presented. RESULTS: Two hundred fifty-one aneurysms in 191 patients were treated. Of these, 96 (38.3%) were large or giant (≥10 mm). In 34/251 (13.5%), PEDs were used for retreatment. Adjunctive coiling was performed in 11 aneurysms (2.1%). The mean number of devices per aneurysm was 1.3. One aneurysm ruptured in the fourth month posttreatment (0.5%), and symptomatic in-construct stenosis was detected in 1 patient (0.5%) treated with percutaneous transarterial angioplasty. Any event rate was 27/191 (14.1%), with a permanent morbidity of 1% and mortality of 0.5%. Control angiography was available in 182 (95.3%) patients with 239 (95.2%) aneurysms. In 121 aneurysms (48.2%), 1- to 2-year control angiography was available. The aneurysm occlusion rate was 91.2% in 6 months, increasing to 94.6%. CONCLUSIONS: Use of the PED is safe, efficacious, and durable in cerebral aneurysm treatment, with low morbidity-mortality and high occlusion rates as confirmed with mid- to long-term control angiography.

Etiologic factors in falls from height in pediatric cases.

OBJECTIVE: In this study, factors causing falls from height and precautions taken for their prevention were investigated. METHODS: The study was carried out prospectively between June 2009 and June 2010. Patients under 18 years of age presenting at the emergency department of a university hospital, for whom the primary reason for admission was an accidental fall from a height of at least one meter, were included in the study. The demographic characteristics of the patients, the characteristics of the falls, and clinical features were recorded. RESULTS: Data for 133 patients were evaluated. Among these patients, 72 (54.1%) were male; the median age was 4 (IQR 2-7). The most common fall site was a balcony (38%). Falls frequently happened in the spring and the summer. The mean fall height was 2.9 ± 2.5 m, the median GCS score was 15 (IQR 14-15), and the median PTS was 10 (IQR 9-11). The fall heights was higher in patients who lost consciousness (p < 0.001). Among the 95 patients who were 0-6 years old, it was found that about 55% were unaccompanied by their parents. The most common pathology in the patients was head trauma (63%), while 17.3% had multiple traumas. CONCLUSION: Since the vast majority of the fall cases were in the pre-school age group, most were due to falls from a balcony, and more than half of the cases were unaccompanied by parents or caregivers, there are two issues that need to be addressed in relation to pediatric falls from height: family education and legal regulations considering child safety in the design of doors, windows, and balconies of buildings.

A novel "Y" stent flow diversion technique for the endovascular treatment of bifurcation aneurysms without endosaccular coiling.

BACKGROUND AND PURPOSE: Stent-assisted endovascular treatment and flow diversion techniques are increasingly used for the management of wide-neck intracranial aneurysms. We report our initial clinical experience using a new flow diversion technique for the endovascular management of bifurcation aneurysms. MATERIALS AND METHODS: Eight bifurcation aneurysms were treated by placing 2 stents in Y-configuration with no accompanying endosaccular packing. This treatment technique aimed at flow diversion was selected in these cases because 1) the aneurysm was giant and causing mass effect, 2) the emanating branches were incorporated within the sac, or 3) the aneurysm was too small. Aneurysms were located at middle cerebral (5 aneurysms) and basilar artery bifurcations (3 aneurysms). Five aneurysms were small, 1 was large, and 2 were partially thrombosed giant. Closed-cell stents were used in all Y-stent placement procedures. RESULTS: In all aneurysms, both stents could be placed at the intended locations without any procedural complication. Follow-up angiograms obtained at 3 months to 2 years demonstrated that all stents were patent except for one with asymptomatic P1 occlusion. Complete occlusion with remodelled bifurcation was observed in all middle cerebral artery bifurcation aneurysms and the large basilar tip aneurysm. Residual filling despite reduction in size was observed in both of the partially thrombosed giant aneurysms at 2-year and 3-month follow-up angiograms, respectively. CONCLUSIONS: Flow diversion with double stent placement in Y-configuration provided successful and stable aneurysm occlusion. The technical and clinical results achieved are highly encouraging that this technique may contribute to the endovascular treatment of these complex bifurcation aneurysms.

X-configured stent-assisted coiling in the endovascular treatment of complex anterior communicating artery aneurysms: a novel reconstructive technique.

Incomplete initial occlusion rates and relatively less long-term durability remain as major problems of endovascular treatment of cerebral aneurysms. Stent-assisted coiling is a well-established current solution to overcome these problems. Double-stent treatment with a Y-configuration has been previously reported to improve the application of coiling to wide-neck bifurcation aneurysms. Herein, a novel technique of X-configured stent-assisted coiling for treatment of wide-neck and complex AcomA aneurysms is described.

Comparison of Flexiblade and Macintosh laryngoscopes: cervical extension angles during orotracheal intubation.

SUMMARY: The Flexiblade(TM) is a new laryngoscope with a flexible blade, a handle and a lever, allowing gradual flexion over the distal half of the blade. In this study, we aimed to compare cervical vertebral movements during tracheal intubation with the Flexiblade and Macintosh laryngoscope in 32 patients undergoing elective surgery requiring general anaesthesia (n = 16 per group). Fluoroscopic images of cervical movement were captured before, during and after intubation and evaluated by a radiologist. C1-C2 cervical vertebral movement was significantly reduced during the intubation in the Flexiblade group (p < 0.0001). C2-C3 cervical movement was similar in both groups (p = 0.81). No significant differences were noted in success rates for intubation, oxygen saturation levels, haemodynamic variables or intubation-related injury. The decreased extension angle between C1-C2 during Flexiblade laryngoscopy compared with Macintosh laryngoscopy may be an advantage where neurological damage with cervical movement is a concern.

HyperForm balloon-assisted endovascular neck bypass technique to perform balloon or stent-assisted treatment of cerebral aneurysms.

We describe a technique to bypass aneurysm neck using the HyperForm balloon to perform balloon- or stent-assisted endovascular treatment of complex large or giant aneurysms with very wide neck in which other methods would fail to obtain an access distal to the aneurysm.

MR peritoneography in complications of continuous ambulatory peritoneal dialysis.

BACKGROUND: We evaluated the usefulness of magnetic resonance (MR) peritoneography for the examination of complications from continuous ambulatory peritoneal dialysis (CAPD). METHODS: MR peritoneography was performed in 20 patients who had suspected CAPD-related complications. Patients who had active peritonitis were not included in the study. Before MR imaging, a mixture of 2000 mL of peritoneal dialysis solution and 20 mL of gadopentetate dimeglumine was instilled into the peritoneal cavity. MR imaging was performed on a 1.0-Tesla system using a body coil. Axial, coronal, and sagittal fat-saturated fast spoiled gradient echo (repetition/echo times, 100/6.3 ms; flip angle, 90 degrees), axial fat-saturated T2-weighted fast spin echo (repetition/echo times, 6000/107 ms), and coronal fat-saturated T2-weighted fast spin echo (repetition/echo times, 3000/96.2 ms) images of the abdomen and the pelvis were obtained. After drain-age, triplanar fat-saturated fast spoiled gradient echo images were repeated with the same parameters. RESULTS: Homogeneous distribution of the dialysate in the peritoneal cavity was detected in 18 patients (90%). In 12 patients (60%), fluid leaks were discovered peripheral to the exit site, tunnel, and site of peritoneal entrance of the catheter. Fluid leaks through the abdominal wall in five patients (25%), retroperitoneum in one patient (5%), and a previous operation site in one patient (5%) were demonstrated. No abnormal finding was detected in three patients (15%) who had clinically suspected complications, whereas a dialysate leak was found in two patients (10%) who had no significant finding at physical examination. CONCLUSIONS: MR peritoneography provides detailed information about the anatomic distribution of dialysate leaks in patients treated with CAPD and poses no risks associated with ionizing radiation and nephrotoxic contrast medium.