Safety and effectiveness of the LVIS and LVIS Jr devices for the treatment of intracranial aneurysms: Final results of the LEPI multicenter cohort study

BACKGROUND

The Low profile visualized intraluminal support (LVIS)/LVIS Jr is a self-expanding braiding stent for the treatment of intracranial aneurysm. This study is to determine the safety and effectiveness of the LVIS/LVIS Jr for the treatment of intracranial aneurysms in a real-world setting.

METHODS

This prospective, observational, multicenter study enrolled patients with unruptured, ruptured and recanalized intracranial aneurysms treated with the LVIS stents, between February 2018 to December 2019. Primary endpoint was the cumulative morbidity and mortality rate (CMMR) assessed at 12 months follow-up (FU).

RESULTS

A total of 130 patients were included (62.3 % women, mean age 55.9 ± 11.4) on an intention-to-treat basis. Four patients (3.1 %) had 2 target aneurysms; 134 total aneurysms were treated. The aneurysms were mainly located on the middle cerebral artery (41/134; 30.6 %) and the anterior communicating artery (31/134; 23.1 %). The CMMR at 1 year linked to the procedure and/or device was 4.6 % (6/130). The overall mortality was 1.5 % (2/130), none of these deaths adjudged as being linked to the procedure and/or device. All aneurysms (134/134, 100 %) were successfully treated with LVIS stent and/or other devices. At a mean FU of 16.8 months post-procedure, complete/nearly complete occlusion was achieved in 112 aneurysms (92.6 %), and only 3 patients (2.5 %) required aneurysm retreatment.

CONCLUSION

This study provides evidence that the LVIS/LVIS Jr devices are safe and effective in the treatment of complex intracranial aneurysms, with very high rates of adequate occlusion at FU. These angiographic results are stable over time with an acceptable complication rate.

TRIAL REGISTRATION

ClinicalTrial.gov under NCT03553771.

Longitudinal radiological follow-up of individual level non-ischemic cerebral enhancing lesions following endovascular aneurysm treatment

BACKGROUND

Non-ischemic cerebral enhancing (NICE) lesions following aneurysm endovascular therapy are exceptionally rare, with unknown longitudinal evolution.

OBJECTIVE

To evaluate the radiological behavior of individual NICE lesions over time.

METHODS

Patients included in a retrospective national multicentric inception cohort were analyzed. NICE lesions were defined, using MRI, as delayed onset punctate, nodular, or annular foci enhancements with peri-lesion edema, distributed in the vascular territory of the aneurysm treatment, with no other confounding disease. Lesion burden and the longitudinal behavior of individual lesions were assessed.

RESULTS

Twenty-two patients were included, with a median initial lesion burden of 36 (IQR 17-54) on the first MRI scan. Of the 22 patients with at least one follow-up MRI scan, 16 (73%) had new lesions occurring mainly within the first 200 weeks after the date of the procedure. The median number of new lesions per MRI was 6 (IQR 2-16). Among the same 22 patients, 7 (32%) had recurrent lesions. The median persistent enhancement of a NICE lesion was 13 weeks (IQR 6-30). No factor was predictive of early regression of enhancement activity with lesion regression kinetics mainly being patient-dependent.

CONCLUSIONS

The behavior of individual NICE lesions was found to be highly variable with an overall patient-dependent regression velocity.

Non-ischemic cerebral enhancing lesions after intracranial aneurysm endovascular repair: a retrospective French national registry

BACKGROUND

Non-ischemic cerebral enhancing (NICE) lesions are exceptionally rare following aneurysm endovascular therapy (EVT).

OBJECTIVE

To investigate the presenting features and longitudinal follow-up of patients with NICE lesions following aneurysm EVT.

METHODS

Patients included in a retrospective national multicentre inception cohort were analysed. NICE lesions were defined, using MRI, as delayed onset punctate, nodular or annular foci enhancements with peri-lesion edema, distributed in the vascular territory of the aneurysm EVT, with no other confounding disease.

RESULTS

From a pool of 58 815 aneurysm endovascular treatment procedures during the study sampling period (2006-2019), 21/37 centres identified 31 patients with 32 aneurysms of the anterior circulation who developed NICE lesions (mean age 45±10 years). Mean delay to diagnosis was 5±9 months, with onset occurring a month or less after the index EVT procedure in 10 out of 31 patients (32%). NICE lesions were symptomatic at time of onset in 23 of 31 patients (74%). After a mean follow-up of 25±26 months, 25 patients (81%) were asymptomatic or minimally symptomatic without disability (modified Rankin Scale (mRS) score 0-1) at last follow-up while 4 (13%) presented with mild disability (mRS score 2). Clinical follow-up data were unavailable for two patients. Follow-up MRI (available in 27 patients; mean time interval after onset of 22±22 months) demonstrated persistent enhancement in 71% of cases.

CONCLUSIONS

The clinical spectrum of NICE lesions following aneurysm EVT therapy spans a wide range of neurological symptoms. Clinical course is most commonly benign, although persistent long-term enhancement is frequent.

Greater occipital nerve MR tractography: Feasibility and anatomical considerations

BACKGROUND AND PURPOSE

To assess the feasibility of greater occipital nerve (GON) tractography using a fully automated tractography technique on the whole-neck volume, in comparison with anatomical knowledge.

METHODS

Healthy subjects were consecutively included in this study if they had no history or symptoms of headache or brain disorder. A 3T MRI scanner with a 32 channel head coil was used. The following parameters for Diffusion Weighed (DWI) were used: b value of 1000 s/mm², 32 directions, acquired voxel size: 2 mm isotropic. High-Order tractography with the Constrained Spherical Deconvolution (CSD) model was generated. Track-Weighted Imaging (TWI) maps were generated with MRTrix. Two radiologists performed blind evaluations of the GON pathways on TWI maps.

RESULTS

A total of 20 healthy subjects were included (12 males and eight females, mean age 53.8 years old). In comparison with anatomical atlas, GON complete visualization (from C1-C2 origin to muscular emergence) was possible in 18 out of 20 healthy subjects. In two cases, GON was not visible in the cervical spine foramen.

CONCLUSION

Tractography through TWI is a feasible technique to accurately depict GON. This technique may appear as a promising technique for therapeutic management of patients with occipital neuralgia.

Patient eligibility for thrombectomy after acute stroke: Northern French Alps database analysis

BACKGROUND

Since 2015, the emergence of mechanical thrombectomy as standard care in acute stroke has involved organizational changes not only for stroke centers, but also for entire emergency regional networks. The aim of our study was to assess the proportion of ischemic stroke patients, admitted to stroke units in the Northern French Alps within the first 6h of onset, eligible for thrombectomy.

METHODS

This study retrospectively analyzed the clinical and radiological data of all acute stroke patients hospitalized at three stroke units of the Northern French Alps Emergency Network (RENAU) in 2014. Eligible patients had proximal arterial occlusions of the anterior and posterior cerebral circulation, as confirmed by brain imaging, which could be treated by thrombectomy within 6h of symptom onset.

RESULTS

Of the 435 cases of acute ischemic stroke, 152 patients were treated by intravenous thrombolysis (IV rtPA). Of these patients, 83 (55%) had intracranial occlusions and were eligible for combined thrombectomy. Of the 283 patients not treatable by IV rtPA, 32 patients (11%) were eligible for primary thrombectomy.

CONCLUSION

Thrombectomy could be performed in 26% of our acute ischemic stroke patients (n=115/435), and a large increase in endovascular procedures is expected over the next few years that will require close collaboration among all partners in the emergency networks. Using our RENAU stroke database, it will be possible to compare various factors contributing to effective activity.

Reduced CMRO₂ and cerebrovascular reserve in patients with severe intracranial arterial stenosis: a combined multiparametric qBOLD oxygenation and BOLD fMRI study

Multiparametric quantitative blood oxygenation level dependent (mqBOLD) magnetic resonance Imaging (MRI) approach allows mapping tissular oxygen saturation (StO2 ) and cerebral metabolic rate of oxygen (CMRO2 ). To identify hemodynamic alteration related to severe intracranial arterial stenosis (SIAS), functional MRI of cerebrovascular reserve (CVR BOLD fMRI) to hypercapnia has been proposed. Diffusion imaging suggests chronic low grade ischemia in patients with impaired CVR. The aim of the present study was to evaluate how oxygen parameters (StO2 and CMRO2 ), assessed with mqBOLD approach, correlate with CVR in patients (n = 12) with SIAS and without arterial occlusion. The perfusion (dynamic susceptibility contrast), oxygenation, and CVR were compared. The MRI protocol conducted at 3T lasted approximately 1 h. Regions of interest measures on maps were delineated on segmented gray matter (GM) of middle cerebral artery territories. We have shown that decreased CVR is spatially associated with decreased CMRO2 in GM of patients with SIAS. Further, the degree of ipsilateral CVR reduction was well-correlated with the amplitude of the CMRO2 deficit. The altered CMRO2 suggests the presence of a moderate ischemia explained by both a decrease in perfusion and in CVR. CVR and mqBOLD method may be helpful in the selection of patients with SIAS to advocate for medical therapy or percutaneous transluminal angioplasty-stenting.

An acute ischemic stroke secondary to sphenoid sinusitis

Acute isolated sphenoid sinusitis is a relatively uncommon entity. Because its symptoms and clinical findings are nonspecific, it can be easily misdiagnosed. Left unrecognized and untreated, it can lead to several well-known and severe complications, including meningitis, cerebral abscess, cavernous sinus thrombosis, and epidural or subdural empyema. We report the case of a 28-year-old woman with acute sphenoid sinusitis complicated by ischemic stroke in the left caudate nucleus, lentiform nucleus, and posterior part of the internal capsule. The stroke was diagnosed on magnetic resonance imaging. Also, magnetic resonance angiography showed a narrowing of the internal carotid artery and a narrowing of the first part of the left anterior and middle cerebral arteries (A1 and M1 segments). The patient was treated with medical therapy, including antibiotics, and surgical drainage of the sphenoid sinus via an endoscopic approach. Her outcome was good, and she experienced minimal neurologic sequelae. We discuss the possible explanations for this rare complication.

Giant osteoma of the maxillary sinus--diagnosis and management

Osteomas are rare, slow-growing, benign bone tumors that preferentially develop in the paranasal sinuses. We report a case of a giant osteoma of the left maxillary sinus in a 29-year-old man which was diagnosed by imaging and endoscopy and treated surgically because of the patient's symptoms and maxillary sinus distortion. Given the large volume and location of the osteoma, resection was performed through an external sublabial approach, according to the Rouge-Denker technique. There were no postoperative complications. There was no sign of recurrence at 5 years follow-up. A review of the literature for maxillary sinus osteomas was performed. Indications for surgery and the different surgical approaches available are discussed.

[Diffuse cervical cellulites and descending necrotizing mediastinitis]

OBJECTIVES

To give a report on the progress in physical examination, investigations and treatment of diffuse cervical cellulites (DCC) associated with descending necrotizing mediastinitis.

MATERIALS AND METHODS

A Retrospective study (1995-2005) of patients presenting DCC with mediastinitis was made. All had a cervical and thoracic Computed tomography (CT) scan. The references were collected by a Medline search.

RESULTS

Six men and 2 women, average ages 53 years were treated. Four had an immunodeficient status. Two had had an anti-inflammatory drug treatment without antibiotic treatment. The average for diagnosis and treatment was 4 days. In 2 cases we found a dental origin and in 6 cases a pharyngeal origin. The most frequently identified germs were streptococcus beta haemolytic group A and Prevotella. In 4 cases, no physical sign of mediastinitis was noted. The diagnosis of mediastinitis was made thanks to the thoracic CT scan. All the patients were treated by broad-spectrum antibiotic therapy. All had cervical and thoracic surgical drainage. Mediastinal drainage was made by cervical way in 3 cases and by thoracotomy in 5 cases. One patient died.

CONCLUSIONS

The DCC with mediastinum extension are serious infectious emergencies with a high mortality rate. Clinical diagnosis of mediastinitis is difficult. A thoracic CT scan should be performed systematically. Performing thoracotomy best controls mediastinal drainage.

Syndrome de Lemierre : apport de l’imagerie

Lemierre syndrome is a septic thrombosis of the internal jugular vein with pulmonary abscesses secondary to untreated pharyngotonsillitis due to anaerobic bacteria. It occurs in young, previously healthy patients and leads to life-threatening consequences if not treated. We illustrate the value of imaging and particularly cervical and thoracic CT in a report of three recent cases.

[Dehiscence of the anterior semicircular canal and otosclerosis: a case report]

The dehiscence of the anterior semicircular canal is a new clinical entity, it is necessary to consider this when a gusher occurs during stapedial surgery.

CASE REPORT

We report a rare case of dehiscence of the anterior canal associated with otosclerosis. This was revealed by a gusher during the initial stapedectomy. At 3 months, an obliteration of the dehiscence was necessary by middle cranial fossa approach (persistant vestibular symptoms), seven months later. Revision stapedial surgery resulted in complete closure of the air-bone-gap.

CONCLUSION

High resolution CT scans of the temporal bone are the key to diagnosis. It is necessary to appreciate this pathology with advances in canal and vestibular surgery.

[Sphenoid sinus mucocele of unusual aetiology and location]

Mucoceles of the sphenoid sinnus are rare. 140 cases have been reported in the literature.

PURPOSES

We review a case and discuss: 1) pathophysiology and diagnosis of mucoceles; 2) etiologies, anatomical variants, clinical manifestations and treatment of sphenoidal mucoceles.

MATERIAL AND METHOD

Case report and literature review.

CASE REPORT

An 18-year-old female, with no past medical history was hospitalized for right fluctuating monocular blindness. MRI and CT scan facilitated the diagnosis of right clinoid mucocele with compression of the optic nerve. Imagery also revealed fibrous dysplasia of the anterior skull base which probably induced the mucocele formation. The mucocele was successfully decompressed during endoscopic sinus surgery. Postoperative course was unremarkable. At four months post surgery there was no recurrence of ophtalmological symptoms.

DISCUSSION-CONCLUSION

The pathophysiology of mucoceles remains uncertain. Diagnosis is based on imagery (CT scan, RMI). Imagery allows accurate location of the mucocele, defines any concomitant pathology and oulines important anatomical structures necessary for safe endoscopic sinus surgery. The association of fibrous dysplasia and an anterior clinoidal mucocele is exceptional. To our knowledge this is the only report in the literature. Ophtalmologic symptoms with a risk of blindness require urgent surgical treatment. Surgery involves decompression, ideally endoscopically.

Long-term control of vestibular schwannoma after a translabyrinthine complete removal

OBJECTIVE

The goal of this study was to determine the rate of recurrent vestibular schwannoma after a total removal via the translabyrinthine approach.

PATIENTS

Between 1973 and 1995, 346 patients were operated on by a translabyrinthine approach. Ninety-one patients were included in a retrospective study for follow-up of 5 years or longer.

RESULTS

The mean follow-up period for magnetic resonance imaging (MRI) examination was obtained after mean of 11 years in 91 patients. None of the 91 patients experienced a recurrent vestibular schwannoma on MRI.

CONCLUSION

The translabyrinthine approach is a safe procedure for total definitive removal of a vestibular schwannoma and permitted the absence of tumoral recurrence in our series of 91 patients. A single gadolinium-enhanced MRI scan 5 years after surgery is advised in case of total removal. In case of any doubt about the quality of the tumoral removal, a proposed MRI follow-up schedule within 2 years and 5 years of surgery is an initial baseline pattern, and possibly thereafter repeated MRI examinations on clinical grounds.

[Nasopalatine canal cyst: 4 cases and a review of the literature]

OBJECTIVES

Nasopalatine cyst (NPC) is the most common epithelial and non-odontogenic cyst arising in the maxilla. It is nevertheless generally underestimated by ENT surgeons. The purpose of our report was to provide details about the pathophysiology, diagnosis and treatment of NPC.

MATERIAL AND METHODS

Our study was based on a retrospective analysis of four cases and a review of the literature.

RESULTS

From January 2002 to March 2003, four patients (3 males and 1 female, mean age 43 Years) were treated for NPC at the ENT Department of Grenoble University hospital. One patient had received prior treatment. Symptoms were a palatine mass on the midline of the hard palate behind the central maxillary incisors in two patients, and a superior vestibular mass in the two others. Diagnosis was established on the basis of the CT-scan and histological findings. Excision was performed under general anesthesia in all four patients. Median hospital stay was four days (3-5 days). There was no post-operative complication. Median follow-up was 10 Months.

CONCLUSION

NPC is arises from embryological tIssue. It must be differentiated from radicular cyst. Diagnosis is based on radiographic and histological results. Treatment consists in enucleation. Surgical access depends on the size of the cyst and its anterior or posterior extension. Excision must be total to avoid relapse which may occur after five Years. Long-term follow-up is essential.

Nasopalatine duct cyst (NPDc): one case report

OBJECTIVES

NPDc arises from embryological tissue. It is classified among the epithelial non-odontogenic cysts according to the 1992 WHO histological typing of odontogenic tumors. The purpose of our report was to provide details about the pathophysiology, diagnosis and treatment of NPDc.

CASE REPORT

A 25 year-old male was referred by his practitioner regarding to an intermittent palatal swelling for 6 months. Diagnosis of NPDc was suggested on the basis of computed tomography (CT-scan). Excision was performed under general anaesthesia. There was no post-operative complication. Histological features confirmed an inflamed NPDc. Follow up was 22 months, without relapse.

CONCLUSION

NPDc occurs in approximately 1% of the population and forms approximately 12% of all jaw cyst tumors. NPDc may occur at any age, but main cases are seen between 40 and 60 years old. It has a slight male predilection. Black and white people are equally involved. NPDc is normally asymptomatic, unless it is infected. The most common symptom is swelling, usually in the anterior part of palate's midline. Diagnosis is based on radiographic and histological results. Treatment of choice is enucleation.

[Methods of identification and localization of ethmoid and sphenoid osteomeningeal breaches]

The accurate localization of cerebrospinal fluid (CSF) fistula presenting as rhinorrhea is an essential requirement for successful dural repair, in order to eliminate unsuccessful surgical exploration, and to achieve a definitive closure of the osteo-dural defect. The authors report their experience in 22 patients, and propose a simplified attitude: realization of high resolution CT scan in all cases, in first choice, and a MRI with MR cysternography sequences, in second choice, in case of negative CT scan.

A persistent pharyngohyostapedial artery: embryologic implications

A 3-year-old child was examined because of otorrhagia. CT scans showed an unusual vessel, confirmed by angiography, related to a persistent pharyngohyostapedial artery. This embryonic persistent artery associated with the normal internal carotid artery would explain the "duplication" aspect of the internal carotid artery.

[Gadolinium and contrast medium MRI of the acoustic nerve in patients with meningeal neuritis and acoustico-facial syndrome]

Twelve cases of vestibular neuritis were investigated in gradient echo MRI with gadolinium. Only 3 severe cases associated with an acoustico facial syndrome (2 cases of herpes zoster oticus and one case after influenzae) demonstrated focal enhancement within the internal auditory canal on post contrast T1 weighted images. This enhancement involved at least 2 differents nerves. These 3 severe cases associating sensory neural hearing loss and facial palsy revealed a meningeal reaction after cerebrospinal fluid examination. The enhancement lasted a long time (up to 10 months) in one case of RAMSAY HUNT syndrome associated with a chronic lymphocytic leukemia. The MRI was able to confirm the anatomical reality of the vestibular neuritis and more precisely of the meningoneuritis and gave arguments for the theory of the polyneuropathy of Adour. Enhancement at MRI seems correlated with the severity of the affection (permanent vestibular areflexia in 3 cases and permanent hearing loss in 1 case).

[Benign vertebral osteoblastoma. Report of 6 cases]

We present six cases of benign spinal osteoblastoma. This localization of this uncommon benign bone tumor occurring in young subjects is rare. The patients were explored with radiotomography, computed tomography, myelography and medullo-spinal angiography. These benign tumors may appear radiographically as pure bone lysis mimicking malignancy. The size of these tumors often leads to widening search for extension, particularly in recurrent, aggressive, multifocal forms which require wide resection, and sometimes total vertebrectomy. Medullo-spinal angiography can confirm the vascular involvement of the tumor nidus and is require to identify arteries supplying the spinal canal which would modify operative strategy.

Direct emergence of the dorsospinal artery from the aorta supplying the anterior spinal artery: report of two cases

We report two cases of an isolated dorsospinal artery that emerged directly from the aorta to supply the anterior spinal artery, which in one case had another blood supply on the opposite side, in a lower position. It is important to identify this anatomic variant, otherwise spinal angiography might be incomplete, especially when the isolated dorsospinal artery supplies the anterior spinal artery.

[MRI aspects of cerebellar hemangioblastomas. Apropos of 9 cases]

Nine patients with haemangioblastoma of the posterior cerebral fossa were explored by computerized tomography (CT), then by magnetic resonance imaging (MRI) with enhancement by gadolinium in 4 cases. Following a review of clinical and laboratory data, the radiological images are detailed and distributed into three forms: cystic with mural nodule, solid, and annular. The usefulness of the different imaging techniques is specified, and the stress it put on the need to look for multiple sites in the entire central nervous system.

[Computed tomographic aspects of secondary cholesteatomas of the middle ear and petrous bone]

The authors present their experience of secondary cholesteatomas of the middle ear explored by computerized tomography (CT). Following a brief anatomicopathological description of secondary petrous bone cholesteatomas, and of the CT technique used for their exploration, they describe and illustrate the classical "bag-shaped" internal or external attical forms usually extended to the antrum and the mastoid process, and the less common locations often due to relapse or postoperative recurrences (anterior hypotympanic or posterior mastoidal). The holotympanic forms, usually due to "lamellar" cholesteatomas, create diagnostic problems with other opacities in the cavity, as also do certain forms that are evacuated spontaneously or by aspiration. One of the qualities of CT lies in the preoperative extension assessment. The lesion may extend towards the internal wall of the cavity (lateral semicircular canal, second portion of the facial nerve), towards the labyrinth to the petrosal apex and/or the geniculate ganglion, and above all towards the inferior labyrinth which might bring the cholesteatoma into contact with large vessels (e.g. jugular vein bulb for postero-inferior extensions, carotid canal for antero-inferior extensions). Extension into anfractuosities of the cavity walls (sinus tympani, subratubal fossette) must be systematically looked for in order to avoid postoperative recurrences.