[Treatment of an intracerebral mycotic aneurysm with embolisation]

We report the case of a patient with streptococcal mitral endocarditis discovered following an ischaemic cerebrovascular accident. The clinical evolution was marked by the progressive development of a mycotic aneurysm. Surveillance was performed with repeated angio-MRI which provided an indication for embolisation. We demonstrate the value and the current quality of angio-MRI for the diagnosis of mycotic aneurysms, and the value of active management of these lesions which present a high risk of rupture and which are associated with a significant excess mortality. Embolisation can allow earlier cardiac surgery for haemodynamically unstable patients and for those whose neurological state until now contra-indicated intervention.

[Spasmodic torticollis caused by metoclopramide: a rare etiology of C1-C2 rotatory pseudoluxation in children]

Torticollis in children must always instigate a search for trauma. Many other etiologies can be found. The authors report a case of postmedicinal atlantoaxial rotatory pseudoluxation (AARP) occurring in a child. This child had fallen down in the morning with head trauma followed by headache. Clinically, a stiff neck with an irreducible right rotation of his neck, and an osteotendinous hyperreflexia were noted. There was a C1-C2 rotatory dislocation with no traumatic lesion on the cervical CT scan. After a few hours, the torticollis spontaneously reduced and then reappeared on the left side. This clinical fluctuation and the absorption of metoclopramide (Primpéran) started in the morning for acute gastroenteritis provided the diagnosis of AARP. This entity was confirmed by the good clinical and radiological follow-up and was caused by the substantial ligament laxity of the craniovertebral junction encountered in children. The analysis of medical imaging and the systematic search for a medicinal cause helped make the right diagnosis.

A multicenter study of 705 ruptured intracranial aneurysms treated with Guglielmi detachable coils

BACKGROUND AND PURPOSE

The long-term durability of Guglielmi detachable coil (GDC) embolization of cerebral aneurysms is still unknown. The purpose of this study was to evaluate the stability of anatomic occlusion of aneurysms treated with GDCs and assess the rate of recanalization and re-treatment.

METHODS

A multicenter study involving 650 patients with 705 ruptured aneurysms treated with GDCs between January 1998 to May 2003 was conducted. During this period, 63% of ruptured aneurysms were treated by the endovascular technique. The morbidity and mortality associated with this technique, procedural feasibility, acute angiographic occlusion results, and long-term angiographic follow-up were assessed.

RESULTS

Overall technical feasibility of GDC treatment was 96.9%. Upon admission, 25% of patients were Hunt and Hess grade IV or V. Acute angiographic results in 683 aneurysms demonstrated total occlusion in 496 cases (72.6%), subtotal occlusion in 171 cases (25.%), and incomplete occlusion in 16 cases (2.4%). All patients were controlled by angiography and MR imaging at 3 months, 1 year, and subsequent yearly examinations post-treatment. A second treatment was performed in 27 cases (recanalization, 4.7%). Long-term follow-up angiograms (mean, 36 months) were obtained in 571 aneurysms (95%). Of them, 422 aneurysms (73.9%) demonstrated complete occlusion, 148 aneurysms (25.9%) demonstrated subtotal occlusion, and only 1 aneurysm was incompletely occluded. Overall mortality was 11.4% for all patients, with procedural mortality evaluated at 1.4%. Overall morbidity was calculated at 8.6%. Only one rebleeding occurred in our study, with a second procedure performed without vital consequences for the patient.

CONCLUSION

Our multicenter study confirms the stability of aneurysm embolization with GDC, with only 4.7% of aneurysms requiring re-treatment.

P-ANCA cranial pachymeningitis: a case report

Pachymeningitis is an inflammatory process that thickens the dura mater. This disease has various etiologies including infectious, neoplastic, or autoimmune diseases. We present the case of a patient who developed cranial pachymeningitis with a clinical and biological picture suggestive of a neurological form of vasculitis. A 51-year-old woman developed rhinitis, otitis media, headaches, and deterioration of her condition after a course of recombinant hepatitis B vaccine. After a booster dose of the vaccine, she developed unilateral visual loss and impairment of multiple cranial nerves. Blood analysis showed inflammation and presence of antimyeloperoxidase antineutrophil cytoplasmic antibody (MPO-ANCA). Cranial magnetic resonance imaging (MRI) showed pachymeningitis. A complete remission was obtained with immunosuppressive therapy. The initial clinical presentation and subsequent remission under immunosuppressive therapy were suggestive of a vasculitis with nervous system involvement. Though vasculitis was not proven histologically in this patient, we believe that MPO-ANCA-related autoimmunity provoked the patient's disease as already reported in similar cases. As pachymeningitis is a fibrosing process, early recognition and treatment of an autoimmune etiology, even in the absence of previous pulmonary or renal involvement, is required to prevent definitive neurological impairment.

Adult onset ornithine transcarbamylase deficiency: an unusual cause of semantic disorders

Ornithine transcarbamylase deficiency (OTCD) is the most common urea cycle disorder. This condition usually presents in neonates or children. This report describes the clinical case of a 21 year old woman who was diagnosed in adulthood during the course of an unexplained coma. After recovery from the coma, she presented very unusual neuropsychological disorders involving memory and the meaning of certain words, suggesting a semantic deficit. The discovery of OTCD in adulthood is rare and the neuropsychological consequences may be unique.

[Management of cerebrospinal fluid fistulae: physiopathology, imaging and treatment]

Cerebrospinal fluid (CSF) fistulae can produce leakage through a defect in the bony skull and meninges into the contiguous air-filled cavities at the base of the skull. The major risk is central nervous system infection. When abundant clear rhinorrhea or otorrhea is present, the diagnosis is obvious and imaging is used to localize the fistula. Computed tomography (CT) with millimetric slices and magnetic resonance imaging (MRI) are the most effective diagnostic tools. CT cisternography, an invasive procedure, should only be used when the diagnosis remains uncertain following CT scan and MRI. When CSF leakage is sparse or intermittent, the diagnosis can be made by measuring beta-2 transferrine in the escaping fluid. CT scan followed by MRI are also useful for making the diagnosis and locating the fistula when exterior leakage is absent. CT scan alone is effective for assessing isolated otorrhea. If the diagnosis remains uncertain after all these studies have been used, the patient should be closely followed clinically and isotopic study or surgery should be considered.

Sclérose percutanée des malformations veineuses superficielles : étude rétrospective de 68 cas

PURPOSE

To evaluate the efficacy of percutaneous sclerotherapy for the treatment of venous malformations (VMs) with regards to cosmetic and functional outcome as a function of their size and to review the complications.

MATERIALS AND METHODS

A retrospective study was performed between January 1997 and January 2002 on 68 patients (45 females and 23 males) ranging in age from 3 to 60 Years at the CHRU of Tours.

RESULTS

Percutaneous sclerotherapy was a very effective treatment for small and medium-size VMs, for which the aim was to achieve cure. Aetoxisclerol and Ethibloc are the sclerosing agents used. They were associated with minimal side effects and no major complication. For larger lesions, the treatment was more complex and combined stronger and also more dangerous agents like absolute ethanol and Histoacryl. The aim was then a decrease of cosmetic and functional problems.

CONCLUSION

Percutaneous sclerotherapy with Aetoxisclerol, Ethibloc, absolute ethanol or Histoacryl, either alone or before surgery, is a safe and effective method of managing soft-tIssue venous malformations.

Follow-up of intracranial aneurysms treated with detachable coils: comparison of plain radiographs, 3D time-of-flight MRA and digital subtraction angiography

All patients with aneurysms treated with Guglielmi detachable coils (GDC) are undergo angiography to assess long-term stability of aneurysm exclusion or to show recurrence of the aneurysm sac, which may require further treatment. We prospectively compared the plain-film appearance of the coil-mass, 3D time-of-flight MR angiography (TOF MRA) and digital subtraction angiography (DSA) for the detection of aneurysm recanalisation during follow-up. We studied 60 patients with 74 intracranial aneurysms treated with Guglielmi detachable coils. We used the unsubtracted image of the angiograms performed at the completion of any embolisation procedure and at follow-up as the plain radiographs. Recanalisation was considered if loosening, compaction or reorientation of the coil mass was apparent. TOF MRA was performed to assess the presence and size of a neck remnant. DSA was regarded as the definitive investigation. Comparison of the techniques showed good agreement as regards aneurysm recanalisation. MRA was more accurate than plain radiography and could replace DSA for long term follow- up. The initial follow-up examination should, however, include both modalities. In cases of contraindications or limitations to MRA, the interval between follow-up angiographic examinations could be increased if there is no change in the plain-film coil-mass appearances.

Intracranial aneurysms treated with Guglielmi detachable coils: is contrast material necessary in the follow-up with 3D time-of-flight MR angiography?

BACKGROUND AND PURPOSE

Three-dimensional time-of-flight (TOF) MR angiography has been evaluated in the follow-up of intracranial aneurysms treated with Guglielmi detachable coils (GDCs) with good results. Some of the studies used contrast material in addition to the 3D TOF MR technique and others did not. We assessed the usefulness of contrast material with 3D TOF MR angiography by comparing this sequence before and after contrast material injection.

METHODS

Fifty-eight patients harboring a total of 71 cerebral aneurysms previously treated with GDCs were included in the prospective study. MR angiography (at 1.5 T) was performed with a 3D TOF sequence before and after injection of gadolinium-based contrast material. Features evaluated were presence and size of a neck remnant, parent and adjacent vessel patency, and venous overlap. Digital subtraction angiography was the standard of reference.

RESULTS

Comparison of the techniques showed a good agreement in the detection of residual flow. Six cases of small residual neck were not detected with either the 3D TOF or the contrast-enhanced 3D TOF sequence. In one case of giant aneurysm, the extent of recanalization was more evident after contrast material administration. The use of contrast material did not help to show the parent and adjacent arteries. Venous overlap on contrast-enhanced 3D TOF angiograms did not affect image interpretation.

CONCLUSION

In this series, the use of intravenous contrast material did not improve the ability of 3D TOF MR angiography to depict the presence of residual or recurrent aneurysms previously treated with endovascular coiling. In one giant aneurysm, use of intravenous contrast material did result in improved visualization of a residual aneurysm.

Uterine necrosis after arterial embolization for postpartum hemorrhage

BACKGROUND

Selective embolization is an effective and reputedly safe method of managing pregnancy-related bleeding. However, we report an ischemic uterine necrosis after arterial embolization.

CASE

The patient had heavy postpartum bleeding treated by embolization of the uterine arteries using polyvinyl alcohol particles (diameter 150-250 and 300-600 microm) and gelatin sponge pledgets. Her postoperative recovery was complicated by menorrhagia and pelvic pain. Because of the persistent menorrhagia and risk of infection, a hysterectomy was performed. Histopathology of the hysterectomy specimen revealed massive ischemic myometrial necrosis.

CONCLUSION

This complication is most likely related to the small size of the particles used. In the management of postpartum bleeding by arterial embolization, the material of choice is gelatin sponge pledgets, and the use of small particles should be avoided.

MRI morphometric study and correlation with cognitive functions in young adults shunted for congenital hydrocephalus related to spina bifida

We studied the morphometric MRI findings and their correlation with cognitive functions in a population of 10 young adults shunted for congenital hydrocephalus related to spina bifida. Morphometric MRI analysis included measurement of the ventricular dilatation index, frontal and occipital parenchymal thickness and the size of the corpus callosum. The neuropsychological status was evaluated, notably to look for a discrepancy between verbal and performance skills, a finding which has previously been described in hydrocephalic children. We also investigated whether there was a correlation between cognitive function and cerebral morphometric indexes. In each case, MRI demonstrated the structural changes associated with the Chiari II malformation. The size of the lateral ventricles varied, ranging from important dilatation to small ventricles. Six patients had only partial development of the corpus callosum. All patients had a normal global IQ. In our population of young adults, we did not observe any discrepancy between verbal and visuospatial performances as has been described in children with hydrocephalus. We found no relationship between cognitive function and ventricle dilatation or parenchymal thickness or between the size of the corpus callosum and callosal transfer.

Prospective sonographic assessment of uterine artery embolization for the treatment of fibroids

OBJECTIVES

To evaluate sonographic features following uterine artery embolization and to assess using ultrasound the efficacy of embolization as the primary treatment of fibroids.

DESIGN

Fifty-eight women (mean age, 44.5 years; range, 33-65 years) suffering from symptoms due to fibroids (menometrorrhagia, bulk-related symptoms, pelvic pain) were followed-up after uterine artery embolization by ultrasound examination at 3 months, 6 months, 1 year and 2 years with assessment of volume and vascularization of fibroids as well as uterine vascularization.

RESULTS

Fifty-eight patients were examined at 3 months, 46 at 6 months, 36 at 1 year and 19 at 2 years. Most patients were improved or free of symptoms at 3 months (90%), 6 months (92%) and 1 year (87%) and all monitored patients were free of symptoms at 2 years. Clinical failure of treatment occurred in only two cases (3%). Progressive significant reduction in fibroid size with reference to the baseline was demonstrated during follow-up from 3 months (-29%) to 24 months (-86%). Absence of intrafibroid vessels was observed in all except three cases as early as 3 months, whereas perifibroid vessels persisted in 21 cases. No changes in uterine vascularization or uterine artery resistance were noted.

CONCLUSIONS

Uterine artery embolization is a valuable endovascular method for the treatment of fibroids, resulting in marked reduction in fibroid size and disappearance of intrafibroid vessels without reduction in uterine vascularization which is well depicted by sonography.

Quantitative analysis of striatal dopamine D2 receptors with 123 I-iodolisuride SPECT in degenerative extrapyramidal diseases

123I-Iodolisuride has high specific affinity for binding on dopamine D2 receptors in the striatum and has been used in a few single photon emission computed tomography (SPECT) studies of extrapyramidal disorders. The diagnosis of Parkinson's disease (PD) is very difficult in the first 5 years of evolution, with 15-25% false positive diagnoses. The aim of this study was therefore to determine the value of iodolisuride SPECT in discriminating Parkinson's from the most frequent Parkinson-plus syndromes (PPS). Seventeen patients with an extrapyramidal syndrome had a SPECT examination 1 h after injection of 180-185 MBq of 123I-iodolisuride. They were followed under dopaminergic treatment for at least 2 years. After 2 years, they were separated in two groups according to specific clinical criteria and sensitivity to dopaminergic treatment: nine patients had PD (age = 59.8+/-8.8 years; Hoehn and Yahr = 1.8+/-0.7; evolution = 4.3+/-3 years) and eight had PPS (age = 71.6+/-7.3 years; Hoehn and Yahr = 2.9+/-2.0; evolution = 4.1+/-1.5 years). The binding potential of iodolisuride in the striatum was assessed by considering the striatum (S)/occipital lobe (O) ratio at the pseudo-equilibrium 1 h after injection. The S/O ratio was statistically different between PD and PPS (1.97+/-0.3 vs. 1.65+/-0.2 (P<0.02)). Iodolisuride SPECT could differentiate both groups with a sensitivity of 88.8% and a specificity of 75%. Iodolisuride is a good specific D2 receptor ligand for SPECT and complements specific clinical criteria for the diagnosis of Parkinson's disease and differentiation between different extrapyramidal disorders.

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.

Uterine artery embolization in the primary treatment of uterine leiomyomas: technical features and prospective follow-up with clinical and sonographic examinations in 58 patients

OBJECTIVE

The purpose of this study was to analyze the technical features of uterine artery embolization and to evaluate the effectiveness of this method as the primary treatment of uterine leiomyomas in a series of 58 patients monitored by clinical and sonographic examinations.

SUBJECTS AND METHODS

Fifty-eight women (age range, 33-65 years; mean age, 44.5 years) with symptoms caused by uterine leiomyomas (abnormal bleeding, bulk-related symptoms, pelvic pain) were included in this prospective study. We performed embolization with a single catheter using the single-femoral artery approach, injection of particles (150-250 mm), and an absorbable gelatin sponge. Postprocedural pain was assessed using a visual analog scale. Systematic follow-up included clinical and sonographic examinations at 3 months for 58 patients, at 6 months for 46 patients, at 1 year for 27 patients, and at 2 years for seven patients.

RESULTS

Embolization was performed without problems in 84% of the patients. Post-procedural pain control was excellent in 90% of the patients. In most patients, symptoms were improved or had resolved at 3 months (90%), 6 months (92%), and 1 year (93%), and all patients were symptom-free at 2 years. Clinical failure of treatment occurred in only two patients (3%). Progressive reduction in leiomyoma size was revealed during sonographic follow-up, and new leiomyomas were seen in one patient at 2 years.

CONCLUSION

Uterine artery embolization is an endovascular method for the treatment of uterine leiomyomas that is clinically effective in most patients and that induces a progressive reduction in the size of the largest leiomyomas.

[MRI diagnosis of cavernous sinus invasion by pituitary adenomas]

Several MRI signs are helpful for the preoperative MRI diagnosis of cavernous sinus invasion by an adenoma. The first step is to analyse the percentage of encasement of the intracavernous ICA by the adenoma. If this percentage is greater than or equal to 66%, the cavernous sinus is invaded. If the percentage of encasement of intracavernous CA is less than 25%, the cavernous sinus is not invaded. If the percentage of encasement is between 25 and 66%, the analysis of the cavernous venous compartment, the drawing of intercarotid lines and the analysis of the shape and venous compartments of the cavernous sinus are necessary. The cavernous sinus invasion remains very likely if the carotid sulcus venous compartment is obliterated, or if the lateral intercarotid line is crossed. Conversely, if the median intercarotid line is uncrossed, the superior venous compartment is visible, the cavernous sinus is of normal size, or there is no bulging of its lateral dural wall, invasion of the cavernous sinus space can reliably be excluded.

Observations on metal concentrations in three species of shark (Deania calcea, Centroscymnus crepidater, and Centroscymnus owstoni) from southeastern Australian waters

Deep sea dog sharks (Deania calcea, Centroscymnus crepidater, and Centroscymnus owstonii) were captured from the waters off western Victoria, Australia, in April and May 1998. The elements As, Ca, Cd, Cu, Fe, Hg, K, Mg, Mn, Na, Sr, and Zn were detected in the muscle tissue. The concentrations of Al, Ba, Be, Cr, Mo, Ni, Pb, and V were below the detection limits of the instrumental techniques employed (ICP-ES and GF-AAS). However, significant concentration differences between species were detected for As, Cd, Hg, and Zn. C. owstoni contained the highest concentrations of each of these elements. The concentrations of Cu, Pb, and Zn in each species were below the maximum levels permitted in food by the Australian Food Standards Code. The maximum permitted concentrations of As and Hg were exceeded in all species, and weekly consumption of 400 g of any of these sharks would result in intake of more than the FAO's provisional tolerable weekly intake. Although C. crepidator and D. calcea have strong relationships between length and mercury concentration, C. owstoni does not. Placing C. crepidator and C. owstoni in the same genus, therefore, is worth re-examination as the mechanisms for controlling mercury in C. owstoni appear to differ from that used by both C. crepidator and D. calcea.

Cavernous sinus invasion by pituitary adenoma: MR imaging

PURPOSE

To define magnetic resonance (MR) imaging criteria for the diagnosis of cavernous sinus invasion by pituitary adenoma.

MATERIALS AND METHODS

The MR images obtained in 106 patients (86 female, 20 male; age range, 16-71 years) were reviewed retrospectively by two physicians. The standard-of-reference criteria for invasion were the surgical findings. A chi(2) analysis was performed, and the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for nine groups of MR imaging signs were computed.

RESULTS

Invasion of the cavernous sinus was certain (PPV, 100%) if the percentage of encasement of the internal carotid artery (ICA) by tumor was 67% or greater. It was highly probable if the carotid sulcus venous compartment was not depicted (PPV, 95%) or the line joining the lateral wall of the intracavernous and supracavernous ICAs was passed by the tumor (PPV, 85%). It was definitely not invaded (NPV, 100%) if the percentage of encasement of the intracavernous ICA was lower than 25% or the line joining the medial wall of the intracavernous and supracavernous ICAs was not passed by the tumor.

CONCLUSION

The radiologic diagnosis of cavernous sinus invasion by pituitary adenoma remains difficult, but the above-mentioned criteria may be of assistance.

[Amyotrophic lateral sclerosis manifesting as cognitive disorders. Value of brain perfusion scintigraphic tomography in intensive care]

BACKGROUND

Cognitive disorders have been described in amyotrophic lateral sclerosis, but usually after the diagnosis has ben established.

CASE REPORT

A 57-year-old man was intubated for acute respiratory distress subsequent to pneumonia and diaphragm palsy. He had a 2-year history of drug-resistant depression and deterioration of cognitive functions. A pyramidal syndrome associated with biopsy-proven chronic neurogenic atrophy led to the diagnosis of amyotrophic lateral sclerosis. The electromyogram did not contribute to diagnosis. Brain MRI only evidenced moderate bilateral frontal-temporal atrophy. Brain SPECT demonstrated major perfusion defects in the frontal lobes.

DISCUSSION

This patient had amyotrophic lateral sclerosis and frontal-temporal dementia with an unusually late onset clinical presentation: cognitive disorder was the inaugural sign. Brain SPECT and muscle biopsy enabled us to identify the cortical and peripheral motor neurone involvement in this uncooperative intensive care patient totally dependent on mechanical ventilation.

Hemianopsia related to dissection of the internal carotid artery

Spontaneous dissection of the internal carotid artery is typically associated with cerebral vascular infarction along the anterior and middle cerebral distribution, whereas occipital infarction is usually related to posterior circulation abnormalities. Hemianopsia with occipital infarction related to carotid artery dissection has therefore rarely been reported. A 40-year-old woman in whom acute-onset hemianopsia developed, related to occipital infarction secondary to internal artery dissection, is described. This atypical association is explained by anatomic variations of the posterior part of the circle of Willis. Neuroimages showed occipital infarction related to internal carotid artery dissection associated with hypoplasia of the proximal portion of the cerebral posterior artery (P1). The anatomic correlation of this atypical association and a review of the literature are presented.