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Objective: Despite dramatic advances in all medical era, cerebral vasospasm is still the major complication in patients with subarachnoid hemorrhage (SAH). The purpose of this study was to assess the influence of intraarterial (IA) nimodipine in the treatment of symptomatic vasospasm and in preventing neurological disabilities. Materials and Methods: We retrospectively reviewed 10 patients of SAH who received IA nimodipine in 15 procedures. The decision to perform angiography and endovascular treatment was based on the neurological examination, brain computed tomography (CT) and CT-angiography. The procedure reports, anesthesia records, neurological examination before and after the procedure, brain imaging and short- and long-term outcome were studied. Results: The average dose of nimodipine was 2 mg. The median change in mean arterial pressure at 10 min was -10 mmHg. No significant change of heart rate was observed at 10 min. There was radiological improvement in 80% of the procedures. Neurological improvement was noted after eight out of 12 procedures when nimodipine was used as the sole treatment and after 10 out of 15, overall. Six patients clinically improved after the treatment and had good outcome. In one patient, an embolus caused fatal anterior and middle cerebral arteries infarction. There was no other neurological deficit or radiological abnormality due to the nimodipine treatment itself. Conclusion: Low-dose IA nimodipine is a valid adjunct for the endovascular treatment of cerebral vasospasm. Beneficial effects are achieved in some patients, prompting a prospective control study. [ABSTRACT FROM AUTHOR]

Our aim was to assess the clinical outcome of patients who were subjected to long-axis sacroplasty for the treatment of sacral insufficiency fractures. Nineteen patients with unilateral (n = 3) or bilateral (n = 16) sacral fractures were involved. Under local anaesthesia, each patient was subjected to CT-guided sacroplasty using the long-axis approach through a single entry point. An average of 6 ml of polymethylmethacrylate (PMMA) was delivered along the path of each sacral fracture. For each individual patient, the Visual Analogue pain Scale (VAS) before sacroplasty and at 1, 4, 24 and 48 weeks after the procedure was obtained. Furthermore, the use of analgesics (narcotic/nonnarcotic) along with the evolution of post-interventional patient mobility before and after sacroplasty was also recorded. The mean pre-procedure VAS was 8±1.9 (range, 2 to 10). This rapidly and significantly (P<0.001) declined in the first week after the procedure (mean 4±1.4; range, 1 to 7) followed by a gradual and significant (P<0.001) decrease along the rest of the follow-up period at 4 weeks (mean 3±1.1; range, 1 to 5), 24 weeks (mean 2.2±1.1; range, 1 to 5) and 48 weeks (mean 1.6±1.1; range, 1 to 5). Eleven (58%) patients were under narcotic analgesia before sacroplasty, whereas 8 (42%) patients were using nonnarcotics. Corresponding values after the procedure were 2/19 (10%; narcotic, one of them was on reserve) and 10/19 (53%; non-narcotic). The remaining 7 (37%) patients did not address post-procedure analgesic use. The evolution of post-interventional mobility was favourable in the study group as they revealed a significant improvement in their mobility point scale (P<0.001). Long-axis percutaneous sacroplasty is a suitable, minimally invasive treatment option for patients who present with sacral insufficiency fractures. More studies with larger patient numbers are needed to explore any unrecognised limitations of this therapeutic approach. [ABSTRACT FROM AUTHOR]

Abstract Background To identify patients with spontaneous subarachnoid hemorrhage for whom CT angiography alone can exclude ruptured aneurysms. Methods An observational retrospective review was carried out of all consecutive patients with non-traumatic subarachnoid hemorrhage who underwent both CT angiography and catheter angiography to exclude an aneurysm. CT angiography negative cases (no aneurysm) were classified according to their CT hemorrhage pattern as "aneurismal", "perimesencephalic" or as "no-hemorrhage." Results Two hundred and forty-one patients were included. A CT angiography aneurysm detection sensitivity and specificity of 96.4% and 96.0% were observed. All 35 cases of perimesencephalic or no-hemorrhage out of 78 CT angiography negatives also had negative angiography findings. Conclusions CT angiography is self-reliant to exclude ruptured aneurysms when either a perimesencephalic hemorrhage or no-hemorrhage pattern is identified on the CT within a week of symptom onset.

We demonstrate the value of high-resolution magnetic resonance imaging (MRI) in diagnosing, staging, and follow-up of retinoblastoma during eye-saving treatment. We have included informative retinoblastoma cases scanned on a 3T MRI system from a retrospective retinoblastoma cohort from 2009 through 2013. We show that high-resolution MRI has the potential to detect small intraocular seeds, hemorrhage, and metastatic risk factors not visible with fundoscopy (e.g., optic nerve invasion and choroidal invasion), and treatment response. Unfortunately, however, the diagnostic accuracy of high-resolution MRI is not perfect, especially for subtle intraocular seeds or minimal postlaminar optic nerve invasion. The most important application of MRI is the detection of metastatic risk factors, as these cannot be found by fundoscopy and ultrasound., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose: Postmortem computed tomography angiography (PMCTA) was introduced into forensic investigations a few years ago. It provides reliable images that can be consulted at any time. Conventional autopsy remains the reference standard for defining the cause of death, but provides only limited possibility of a second examination. This study compares these two procedures and discusses findings that can be detected exclusively using each method., Materials and Methods: This retrospective study compared radiological reports from PMCTA to reports from conventional autopsy for 50 forensic autopsy cases. Reported findings from autopsy and PMCTA were extracted and compared to each other. PMCTA was performed using a modified heart-lung machine and the oily contrast agent Angiofil® (Fumedica AG, Muri, Switzerland)., Results: PMCTA and conventional autopsy would have drawn similar conclusions regarding causes of death. Nearly 60 % of all findings were visualized with both techniques. PMCTA demonstrates a higher sensitivity for identifying skeletal and vascular lesions. However, vascular occlusions due to postmortem blood clots could be falsely assumed to be vascular lesions. In contrast, conventional autopsy does not detect all bone fractures or the exact source of bleeding. Conventional autopsy provides important information about organ morphology and remains the only way to diagnose a vital vascular occlusion with certitude., Conclusion: Overall, PMCTA and conventional autopsy provide comparable findings. However, each technique presents advantages and disadvantages for detecting specific findings. To correctly interpret findings and clearly define the indications for PMCTA, these differences must be understood.

Objectives: The role of angioplasty/stenting procedures, neurointerventionist experience, vascular risk factors, medical treatment and blood flow velocities were analysed to identify possible causes of intra-stent restenosis (ISR) following stenting of cervical and/or intracranial arteries, assuming progressive atherosclerosis to be the shared mechanism in both territories. Patients. 26 cerebrovascular patients subjected to stenting of severe (≥85%) symptomatic or asymptomatic carotid stenoses or moderate-to-severe (≥50%) intracranial or vertebral stenoses were included., Methods: Clinical, radiological and ultrasonographic follow-up data were analysed retrospectively., Results: Overall, stenting of the internal carotid artery (ICA) induced significant reductions in peak systolic velocities at 2 years (96±31 cm/s vs. 358.2±24.9 cm/s at baseline). The procedure-related ischemic complications rate was 7.4% (one hemispheric stroke and one TIA). The rate of ISR≤50% was 8% in the ICA at 2 years; was 50% in the common carotid artery (CCA) at 1 year, with concomitant distal ICA stenosis in 75% of CCA stenting, but all ISR were asymptomatic. Patients with ISR of the ICA were significantly younger (56.8±4.5 vs. 71.3±3.6 years, P=0.042) and had significantly more risk factors (5.5±0.9 vs. 3±0.3, P=0.012). No ISR≥70% was detected., Conclusions: ISR is relatively infrequent and, when present, it is mild and asymptomatic. Restenosis is more frequent in younger patients and those with several risk factors, and it may also be related to stenting of previous carotid endarterectomy., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Introduction: Currently, there is no reliable method to differentiate acute from chronic carotid occlusion. We propose a novel CTA-based method to differentiate acute from chronic carotid occlusions that could potentially aid clinical management of patients., Methods: We examined 72 patients with 89 spontaneously occluded extracranial internal carotids with CT angiography (CTA). All occlusions were confirmed by another imaging modality and classified as acute (imaging <1 week of presumed occlusion) orchronic (imaging >4 weeks), based on circumstantial clinical and radiological evidence. A neuroradiologist and a neurologist blinded to clinical information determined the site of occlusion on axial sections of CTA. They also looked for (a) hypodensity in the carotid artery (thrombus), (b) contrast within the carotid wall (vasa vasorum), (c) the site of the occluded carotid, and (d) the "carotid ring sign" (defined as presence of a and/or b)., Results: Of 89 occluded carotids, 24 were excluded because of insufficient circumstantial evidence to determine timing of occlusion, 4 because of insufficient image quality, and 3 because of subacute timing of occlusion. Among the remaining 45 acute and 13 chronic occlusions, inter-rater agreement (kappa) for the site of proximal occlusion was 0.88, 0.45 for distal occlusion, 0.78 for luminal hypodensity, 0.82 for wall contrast, and 0.90 for carotid ring sign. The carotid ring sign had 88.9% sensitivity, 69.2% specificity, and 84.5% accuracy to diagnose acute occlusion., Conclusion: The carotid ring sign helps to differentiate acute from chronic carotid occlusion. If further confirmed, this information may be helpful in studying ischemic symptoms and selecting treatment strategies in patients with carotid occlusions.

Background: Superselective ophthalmic artery chemotherapy (SOAC) has recently been proposed as an alternative to intravenous chemoreduction for advanced intraocular retinoblastoma. Preliminary results appear promising in terms of tumor control and eye conservation, but little is known regarding ocular toxicity and visual prognosis. In this study, we report on the vascular adverse effects observed in our initial cohort of 13 patients., Methods: The charts of 13 consecutive patients with retinoblastoma who received a total of 30 injections (up to 3 injections of a single agent per patient at 3-week interval) of melphalan (0.35 mg/kg) in the ophthalmic artery between November 2008 and June 2010 were retrospectively reviewed. RetCam fundus photography and fluorescein angiography were performed at presentation and before each injection. Vision was assessed at the latest visit., Results: Enucleation and external beam radiotherapy could be avoided in all cases but one, with a mean follow-up of 7 months. Sectoral choroidal occlusive vasculopathy leading to chorioretinal atrophy was observed temporally in 2 eyes (15%) 3 weeks to 6 weeks after the beginning of SOAC and retinal arteriolar emboli in 1 eye 2 weeks after injection. There was no stroke or other clinically significant systemic side effects except a perioperative transient spasm of the internal carotid artery in one patient. Vision ranged between 20/1600 and 20/32 depending on the status of the macula., Conclusion: Superselective ophthalmic artery chemotherapy was effective in all patients with no stroke or other systemic vascular complications. Unlike intravenous chemoreduction, SOAC is associated with potentially sight-threatening adverse effects, such as severe chorioretinal atrophy secondary to subacute choroidal occlusive vasculopathy or central retinal artery embolism, not to mention the risk of ophthalmic artery obstruction, which was not observed in this series. Further analysis of the risks and benefits of SOAC will define its role within the therapeutic arsenal. Meanwhile, we suggest that SOAC should be given in one eye only and restricted to advanced cases of retinoblastoma, as an alternative to enucleation and/or external beam radiotherapy.

Background: To identify patients with spontaneous subarachnoid hemorrhage for whom CT angiography alone can exclude ruptured aneurysms., Methods: An observational retrospective review was carried out of all consecutive patients with non-traumatic subarachnoid hemorrhage who underwent both CT angiography and catheter angiography to exclude an aneurysm. CT angiography negative cases (no aneurysm) were classified according to their CT hemorrhage pattern as "aneurismal", "perimesencephalic" or as "no-hemorrhage.", Results: Two hundred and forty-one patients were included. A CT angiography aneurysm detection sensitivity and specificity of 96.4% and 96.0% were observed. All 35 cases of perimesencephalic or no-hemorrhage out of 78 CT angiography negatives also had negative angiography findings., Conclusions: CT angiography is self-reliant to exclude ruptured aneurysms when either a perimesencephalic hemorrhage or no-hemorrhage pattern is identified on the CT within a week of symptom onset.

Pedicle screw insertion in spinal surgery is a demanding technique with potential risks to neurological structures, for example, within the spinal canal. Assessing screw placement in clinical practice has been performed using plain radiographs and/or mainly axial computed tomography (CT) images. Screw placement using CT image reconstructions in multiple planes has been described, but its reliability has yet to be studied. This study aimed at addressing the clinical issue of interobserver and intraobserver reliability in the use of axial and coronal CT images for the assessment of pedicle screw placement. Fifty nine pedicle screws were studied by two experienced radiologists on two separate occasions. Screw placement was classified as "in", "out" or "questionable". On average, 88% and 92% of the screws were classified as "in" by the first and second radiologist, respectively. Intraobserver agreement strength was almost perfect for both observers using either axial or coronal images. Interobserver agreement strength was almost perfect (axial) and substantial (coronal) in the first reading and substantial (axial, coronal) in the second reading. Assessing screw placement in more than one CT imaging plane is not only useful but reliable. Routine use may enhance reporting quality of screw placement by surgeons and radiologists.

We present the case of a young man with compression of both renal arteries by the crura of the diaphragm. Correct diagnosis of renal artery entrapment is difficult but crucial. The investigations rely on an high index of suspicion and include Doppler ultrasound and spiral computed tomography angiography, which permits visualization of the diaphragm and its relationships with the aorta. This pathology, unlike common renal artery stenoses, requires surgical decompression and sometimes aortorenal bypass graft.

Background and Purpose: We investigated the association of multisection CT angiography (MSCTA) and perfusion CT (PCT) for the characterization of vasospasm secondary to aneurysmal subarachnoid hemorrhage., Materials and Methods: Among 27 patients with symptomatic cerebrovascular vasospasm investigated by digital subtraction angiography (DSA), 18 underwent both cerebral PCT and MSCTA. For the remaining 9, only PCT or MSCTA could be performed. MSCTA was compared with DSA for the detection and characterization of vasospasm on 286 intracranial arterial segments. PCT maps were visually reviewed for mean transit time, relative cerebral blood flow, and relative cerebral blood volume abnormalities and were qualitatively compared with the corresponding regional vasospasm detected by DSA., Results: Vasospasm was grouped into 2 categories: mild-moderate and severe. The depiction of vasospasm by MSCTA showed the best sensitivity, specificity, and accuracy at the level of the A2 and M2 arterial segments (100% for each), in contrast to the carotid siphon (45%, 100%, and 85% respectively). The characterization of vasospasm severity by MSCTA showed a sensitivity, specificity, and accuracy of 86.8%, 96.8%, and 95.2%, respectively, for mild-moderate vasospasm, and 76.5%, 99.5%, and 97.5%, respectively, for severe vasospasm. The PCT abnormalities were related to severe vasospasm in 9 patients and to mild-to-moderate vasospasm in 2. The sensitivity, specificity, and accuracy of PCT in detecting vasospasm were 90%, 100%, and 92.3%, respectively, for severe vasospasm, and 20%, 100%, and 38.5%, respectively, for mild-moderate vasospasm., Conclusion: MSCTA/PCT can assess the location and severity of cerebrovascular vasospasm and its related perfusion abnormalities. It can identify severe vasospasm with risk of delayed ischemia and can thus guide the invasive treatment.

Sacral insufficiency fractures constitute clinical challenges because no effective surgical techniques can be applied and only a conservative treatment is currently performed. Sacroplasty is increasingly used to treat sacral insufficiency fractures. A computed tomography (CT)-guided technique concerning the placement of the sacroplasty needles within the sacral wings by using a laser alignment light guidance associated with a CT gantry tilt in a plane parallel to the sacral bone is presented. This method allowed a fast and precise placement of the needle in and along the sacral wings, thus preventing the use of multiple needles to reach the fracture sites.

Sacral insufficiency fracture is a debilitating injury for which no active treatment is currently available. It frequently causes significant pain and limits activities of daily living in patients with osteoporosis. Percutaneous vertebroplasty is a common procedure to alleviate the pain associated with thoracic and lumbar vertebral compression fractures. The sacral percutaneous cimentoplasty procedure (sacroplasty) has recently been introduced as an alternative to medical management of osteoporotic sacral insufficiency fractures. The purpose of this article is to illustrate the effectiveness and the utility of percutaneous sacroplasty in this kind of pathology and to show how this procedure can provide symptom relief without having major complications.

Object: In this study the accuracy of multislice computerized tomography (MSCT) angiography in the postoperative examination of clip-occluded intracranial aneurysms was compared with that of intraarterial digital subtraction (DS) angiography, Methods: Forty-nine consecutive patients with 60 clipped aneurysms (41 of which had ruptured) were studied with the aid of postoperative MSCT and DS angiography. Both types of radiological studies were reviewed independently by two observers to assess the quality of the images, the artifacts left by the clips, the completeness of aneurysm occlusion, the patency of the parent vessel, and the duration and cost of the examination. The quality of MSCT angiography was good in 42 patients (86%). Poor-quality MSCT angiograms (14%) were a result of the late acquisition of images in three patients and the presence of clip or motion artifacts in four. Occlusion of the aneurysm on good-quality MSCT angiograms was confirmed in all but two patients in whom a small (2-mm) remnant was confirmed on DS angiograms. In one patient, occlusion of a parent vessel was seen on DS angiograms but missed on MSCT angiograms. The sensitivity and specificity for detecting neck remnants on MSCT angiography were both 100%, and the sensitivity and specificity for evaluating vessel patency were 80 and 100%, respectively (95% confidence interval 29.2-100%). Interobserver agreements were 0.765 and 0.86, respectively. The mean duration of the examination was 13 minutes for MSCT angiography and 75 minutes for DS angiography (p < 0.05). Multislice CT angiography was highly cost effective (p < 0.01)., Conclusions: Current-generation MSCT angiography is an accurate noninvasive tool used for assessment of clipped aneurysms in the anterior circulation. Its high sensitivity and low cost warrant its use for postoperative routine control examinations following clip placement on an aneurysm. Digital subtraction angiography must be performed if the interpretation of MSCT angiograms is doubtful or if the aneurysm is located in the posterior circulation.

Although vertebroplasty was initially a treatment of vertebral haemangioma or metastases, this procedure is now frequent option to the treatment of osteoporotic vertebral fractures. In this review article, we will discuss the indication, the techniques and the follow-up of the vertebroplasty. This is a risky procedure, which should be performed by experimented physicians working with high-resolution fluoroscopic equipments, by biplane fluoroscopy, to reduce the risk and irradiation to the patient. According to the available follow-up studies, there is clear evidence of a strong improvement of quality of life after vertebroplasty by rapid decreasing of back pain at least during the first six months. Other new studies will analyze the long-term follow-up after vertebroplasty.

Intracranial aneurysms, cervical carotid stenosis and acute cerebral ischemia constitute the three main and more frequent diseases in which the endovascular approach is considered a valuable alternative to the surgical or pharmacologic treatment. With the introduction of balloon assistance techniques, even intracranial large neck aneurysms can be currently suitable to endovascular treatment. Stent angioplasty is widely used in whole Europe in the treatment of cervical carotid artery stenosis. Mechanical endovascular embolectomy techniques are actually available to be used alone or in combination with pharmacologic thrombolysis in the treatment of acute cerebral ischemia. This article discuss on the new technical possibilities concerning the endovascular approach in these aforementioned diseases.

Object: The goal of this study was to assess the diagnostic accuracy of computerized tomography (CT) angiography performed with the aid of multislice technology (MSCT angiography) in the investigation of intracranial aneurysms, by comparing this method with intraarterial digital subtraction (IADS) angiography., Methods: Fifty consecutive adult patients, who successively underwent MSCT angiography (four rows) and IADS angiography of intracranial vessels, were prospectively identified. The MSCT angiography studies consisted of 1.25-mm slices, with 0.8-mm reconstruction intervals, a pitch of 0.75, and timing determined by a test bolus. Two neuroradiologists, who were blinded to the initial interpretation of the MSCT angiograms as well as to those of the IADS angiograms, independently reviewed the MSCT angiograms for the detection and characterization of intracranial aneurysms. Forty-nine intracranial aneurysms were identified in 40 patients; 33 of these lesions were responsible for subarachnoid hemorrhage. The sensitivity, specificity, and accuracy of MSCT angiography in the detection of intracranial aneurysms were 94.8, 95.2, and 94.9%, respectively, on a per-aneurysm basis and 99, 95.2, and 98.3%, respectively, on a per-patient basis. Interobserver agreement was 98%. There was an excellent correlation between aneurysm size assessed using MSCT angiography and that determined by IADS angiography (slope = 0.916, r = 0.877, p < 0.001); however, 2 mm stood as the cutoff size below which the sensitivity of MSCT angiography was statistically lower. That method displayed great accuracy in characterizing the morphological characteristics of the aneurysm., Conclusions: Multislice CT angiography is an accurate and robust noninvasive screening test for intracranial aneurysms. It performs better than that reported for single-slice CT angiography. Introduction of eight- and especially 16-row MSCT angiography will provide further progression through thinner slices, a lower pitch, and a purely arterial phase.

Purpose: To evaluate the role of computed tomography angiography (CTA) and magnetic resonance angiography (MRA) in the quantification of atherosclerotic stenosis of carotid artery bifurcation in comparison with digital substraction angiography (DSA) and Doppler sonography (DS)., Materials and Methods: Twenty-five patients with atherosclerotic disease of the carotid arteries with proven stenosis by DSA, had spiral CTA, MRA using two- and three-dimensional time-of-flight gradient echo techniques, and DS using Doppler flow signal recording (total 47 carotid artery bifurcations). The degree of stenosis was measured according to the North American Symptomatic Carotid Endarterectomy Trial criteria: total occlusion (100%), severe (70-99%), moderate (30-69%) and mild (0-29%). The degree of stenosis measured by CTA, MRA and DS was compared to DSA, used as the gold standard., Results: Ninety-seven percent of MRA measures were equivalent to DSA, and 3% were underestimated; 96% of CTA measures were equivalent to DSA, and 4% were underestimated; 77% of DS measures were equivalent to DSA, 21% were overestimated and 2% were underestimated., Conclusions: CTA and MRA are equally accurate methods in quantifying the degree of carotid bifurcation stenosis., (Copyright 2001 S. Karger AG, Basel)