Microsurgical Clipping after Failed Contour Device Embolization of an Anterior Communicating Artery Aneurysm: Technical Note

BACKGROUND

 Endovascular therapy has revolutionized the treatment of cerebral aneurysms in recent years and decades. So-called intrasaccular devices (i.e., Woven EndoBridge [WEB], MicroVention, Aliso Viejo, California, United States; or Contour, Cerus Neurovascular, Fremont, California, United States) are a promising endovascular technology, especially for wide-based aneurysms. However, long-term outcome data are currently particularly scarce for Contour and strategies for failed Contour cases are lacking. Here, we report the feasibility of microsurgical clipping after failed Contour device embolization.

METHODS

 Feasibility of microsurgical clipping after failed aneurysm embolization with a Contour intrasaccular device was assessed in a patient.

RESULTS

 We present the case of a 36-year-old male patient diagnosed with Hunt and Hess grade 1 subarachnoid hemorrhage from an anterior communicating artery aneurysm. The ruptured aneurysm was initially treated with the Contour device. After 3 months, angiographic imaging showed a clear aneurysm residual deemed not endovascularly accessible. The patient was then successfully clipped using microsurgical techniques. The patient was discharged with no neurologic abnormalities.

CONCLUSION

 After thorough bibliographical research, this presents the first published case report of microsurgical clipping after failed embolization with Contour. The main insights gained after clipping were that the Contour does not significantly disturb or hinder clipping. In contrast to coils in aneurysms to be clipped, the Contour can be easily compressed by the clip blades and does not have to be removed. In addition, the Contour had not migrated into the subarachnoid space and there was no abnormal scarring. Clipping appears to be a reasonable treatment strategy for failure of embolization with Contour if endovascular means are not suitable.

Middle cerebral artery aneurysm surgery after stent misplacement: A case report

Stent misplacement during endovascular treatment of middle cerebral artery (MCA) aneurysms can cause challenges and be problematic, if clipping becomes necessary. This article reports on a 56-year-old woman with an unruptured, multi-lobulated MCA aneurysm, whom primarily refused surgery; therefore, she was scheduled for stent-assisted coiling. After successful deployment of the stent, it unfortunately then became snagged by the microcatheter and was pulled backwards. The subsequent surgical procedure (i.e. clipping of the MCA aneurysm) was challenging, due to the position of the dislodged stent. Such as misplacement of the stent is rarely documented: It resulted in the difficult handling of a MCA aneurysm. Aneurysms of the MCA should primarily be considered for surgical clipping. In conclusion, an increased risk for eventual surgery should be considered, in cases where endovascular treatments with stents are performed.

Computerized Angiographic Occlusion Rating for Ruptured Clipped Aneurysms is Superior to Subjective Occlusion Rating

BACKGROUND AND PURPOSE

The computerized occlusion rating to estimate angiographic occlusion of embolized aneurysms is superior to the subjective occlusion rating. In this study, we compared the 2 methods in the analysis of aneurysms clipped after subarachnoid hemorrhage.

MATERIALS AND METHODS

The pre- and postoperative angiographic images (DSA) of 95 selected patients were analyzed and stratified in 4 grades (grade 0 for 100%, grade I for <99%-90%, grade II for <89%-70%, grade III for <70% occlusion) by using the subjective (angiographic) occlusion rating and the computerized (angiographic) occlusion rating. For the subjective occlusion rating, the occlusion rate was estimated; for the computerized occlusion rating, the "occluded" and "nonoccluded" aneurysm areas were automatically calculated in square millimeters after outlining the ideal occlusion line.

RESULTS

With the subjective occlusion rating, 75 (78.9%), 12 (12.6%), 7 (7.4%), and 1 (1.1%) and with the computerized occlusion rating 45 (47.4%), 24 (25.3%), 20 (21.0%), and 6 (6.3%) patients had aneurysms stratified to grades 0, I, II and III, respectively. The interobserver variation was significant with the subjective occlusion rating but not with the computerized occlusion rating. The subjective occlusion rating overestimated aneurysm occlusion in 30 (31.6%) patients. Mean values were the following: subjective occlusion rating of 97.5 ± 6.3% and computerized occlusion rating of 93.5 ± 9.7%; P = < .001. No patient rebled, and 4 patients underwent retreatment during 36 ± 38.9 months; the predictive value (log-rank, Kaplan-Meier) of the subjective and computerized occlusion ratings with respect to retreatment was highly significant for both methods (subjective occlusion rating: χ(2), 29.65; P < .001; computerized occlusion rating: χ(2), 35.57, P < .001).

CONCLUSIONS

The 2 methods showed remarkable differences in the estimation of the angiographic occlusion rates of clipped aneurysms. The clearly lower interobserver variation of the computerized versus subjective occlusion rating may indicate a superiority of the computerized occlusion rating.

Osteoporosis and skeletal fractures in chronic liver disease

In order to determine the prevalence and severity of hepatic osteodystrophy by non-invasive means we compared 115 consecutive ambulant patients with histologically proven chronic liver disease to 113 age and sex matched control subjects. Methods used included the assessment of fracture prevalence rates, spinal radiography, and measurements of bone mineral density in the spine and the forearm. Spinal and peripheral fractures were more prevalent in the patients than in the control subjects (p less than 0.03 and p less than 0.01 respectively). The type of the underlying liver disease did not significantly affect the fracture prevalence rates, but alcoholic patients sustained more peripheral fractures than patients with other hepatic disorders (p less than 0.05). The bone mineral densities of the spines and the forearms were significantly reduced in male patients of all age groups and in female patients aged 60 years or more (p less than 0.001 for men and p less than 0.01 for women for both measurements). The prevalence rates of spinal and forearm osteoporosis were twice as high among patients with liver disease than in control subjects regardless of the definitions used. The presence of cirrhosis and hypogonadism were major risk factors for development of both spinal (Beta coef = 0.190 and 0.176; SE = 0.079 and 0.086 respectively) and forearm osteoporosis (Beta coef = 0.20 and 0.29; SE = 0.073 and 0.80 respectively). Spinal bone density was the predominant determinant of spinal fractures (Beta coef = -0.007; SE = 0.001), while hypogonadism (Beta coef = 0.363; SE = 0.075) and cirrhosis (Beta coef = 0.185; SE = 0.068) were the major predictors of peripheral fractures. The concentrations of serum calcium and serum vitamin D metabolites and the use of corticosteroids were apparently without effect on the prevalence of skeletal fractures or bone density.

Ethanol reduces bone formation and may cause osteoporosis

INTRODUCTION

The etiology of ethanol-associated osteopenia is not fully understood. In order to define the role of ethanol in the pathogenesis of hepatic osteodystrophy, we compared two groups of alcoholic patients with histologically established alcoholic liver disease.

PATIENTS AND METHODS

Twenty-eight patients currently drinking ethanol ("drinkers") and 12 claiming not to have consumed any ethanol for at least six months ("abstainers") were enrolled in the study. In addition, 35 non-alcoholic control subjects without clinical or biochemical evidence of liver disease were also studied. Bone mineral density and various biochemical and hormonal values were measured in each subject; iliac crest biopsies were taken under local anesthesia in the patients and under general anesthesia in the control subjects.

RESULTS

Forearm bone mineral densities, spinal bone mineral densities, and iliac crest cancellous bone areas were significantly lower in the alcoholic patients compared with control subjects (p less than 0.01 for all measurements), but these values did not differ between the drinkers and the abstainers. The drinkers, however, had significantly less osteoblastic activity than the abstainers, as assessed by dynamic bone histomorphometry (p less than 0.001). Serum bone Gla-protein concentrations were higher in the abstainers than in the drinkers (p less than 0.001). No differences were seen relating to histologic parameters of bone resorption, although the alcoholic patients who had lower serum free testosterone concentrations than the control subjects also had higher urinary hydroxyproline excretion rates.

CONCLUSION

These data suggest that ethanol may be responsible for osteoblastic dysfunction resulting in diminished bone formation and reduced bone mineralization.

Hepatic osteodystrophy. Static and dynamic bone histomorphometry and serum bone Gla-protein in 80 patients with chronic liver disease

To study the pathogenesis of osteoporosis in patients with chronic liver disease, we performed dynamic bone histomorphometry and measured serum bone Gla-protein in 80 patients with various types of chronic liver disease. These results were compared with results obtained in 40 healthy controls. Mean trabecular bone volume and mean trabecular thickness were significantly reduced in both men and women with chronic liver disease (p less than 0.001 for both measurements in men and p less than 0.01 for both measurements in women). Osteoporosis as defined by histologic parameters was present in 17 (21%) patients with no significant differences in prevalence rates among the various hepatic disorders. No patient had histologic evidence of osteomalacia, although mineralization lag times were prolonged (p less than 0.01 for men and women). Bone formation rates were significantly reduced in 46 (57%) patients, and unlike the static measurements, were related to the type and severity of the underlying liver disease. Patients with alcoholic liver disease, hemochromatosis, and cholestatic liver disease had lower bone turnover rates and osteoblastic surfaces (p less than 0.001 and p less than 0.05, respectively) than patients with chronic active hepatitis. Furthermore, the presence of hepatic cirrhosis was associated with diminished bone formation and lower osteoblast surfaces. Serum bone Gla-protein levels were significantly correlated with bone formation rates and osteoblast surfaces (r = 0.585 and r = 0.434, respectively). A reduction in osteoblast surfaces has not previously been demonstrated in liver disease. This reduction and the associated impairment of osteoblastic activity may contribute to the pathogenesis of osteoporosis and can be assessed by the measurement of serum bone Gla-protein.

Comparative sensitivity of serum cholylglycine concentration and bromsulphalein retention in patients with early and late alcoholic liver disease

Measurement of serum bile acids has been claimed to be a sensitive and specific biochemical test of hepatic function. We have prospectively measured post-prandial serum glycocholate (cholylglycine) concentrations in 31 patients with alcoholic liver disease and compared these measurements with those of bromsulphalein (BSP) retention, prothrombin time, and serum albumin. In the patients with early (non-cirrhotic) alcoholic liver disease (N = 14) BSP retention was abnormal significantly more frequently than was serum cholylglycine concentration (100% vs 29%, p less than 0.001). In contrast, amongst patients with late (cirrhotic) alcoholic liver disease, BSP retention and serum cholylglycine were abnormal with equal frequency (94%). In both groups of patients BSP retention and serum cholylglycine were abnormal significantly more often than were prothrombin time and serum albumin concentrations. We conclude that moderately severe hepatocellular dysfunction is required before serum cholylglycine can become a reliable biochemical indicator of liver disease.

Serum bile acid concentrations during pregnancy and their relationship to obstetric cholestasis

We have prospectively studied changes in serum postprandial cholylglycine (CG) concentration during 297 pregnancies. We found an increase in CG concentration from 0.3 mumol/L at 15 weeks' pregnancy to 0.6 mumol/L at 40 weeks' pregnancy. Although this increase was statistically significant (p less than 0.005), median concentrations of CG remained well within the normal range (0-1.5 mumol/L). However, 10% of the group showed markedly elevated serum CG concentrations at 30 weeks' pregnancy, and the CG level in this group continued to rise during the third trimester. Pruritus was significantly more common in the group with elevated CG concentrations (48%) than in the group with normal CG levels (20%) (p less than 0.005). Serum CG was a much more sensitive predictor of pruritus during pregnancy than other biochemical liver tests. Elevated CG levels were found more commonly in Mediterranean and Asian patients than patients of other ethnic origins (p less than 0.025). No statistically significant associations were found between elevated CG concentrations and maternal age, number of previous pregnancies, pruritus during previous pregnancies, contraceptive-induced cholestasis, and fetal maturity. We conclude that obstetric cholestasis is probably much more common than previously suspected and that consideration should be given to the measurement of serum bile acids in all pregnant individuals with unexplained pruritus.

Fulminant hepatic failure due to allopurinol

A 58-year-old Chinese woman was admitted to hospital with a presumed hypersensitivity reaction to allopurinol. Her illness was characterised by high fever, eosinophilia, exfoliative dermatitis and jaundice. She developed fulminant hepatic failure and septicemia with a fatal outcome. Clinical details are presented and the possible relationship of allopurinol hypersensitivity to renal impairment is discussed.

Urinary coproporphyrin excretion in Rotor's syndrome: a family study

A family of seven is described in which a teenage boy and two siblings were found to have Rotor's syndrome. Total urinary coproporphyrin excretion was found to be significantly elevated in the patients with Rotor's syndrome (mean 59 . 0 mumol/mol creatinine), when compared with control subjects (mean 16 . 3 mumol/mol creatinine) (p less than 0 . 005). Similarly, urinary excretion of both coproporphyrin isomer I and coproporphyrin isomer III was greater in the subjects with Rotor's syndrome than in controls (p less than 0 . 005). Coproporphyrin I comprised 60 . 2% of total urinary coproporphyrin excretion in the subjects with Rotor's syndrome, compared with 38 . 6% in the controls, but the difference was not significant. In the parents and clinically unaffected siblings neither total urinary coproporphyrin excretion (13 . 3 and 19 . 3 mumol/mol creatinine respectively) nor percentage coproporphyrin I excretion (36 . 8 and 30 . 4%) differed from controls. Thus, although we have confirmed the previous finding of increased urinary coproporphyrin excretion in subjects with Rotor's syndrome, we have not found the previously noted intermediate increase in coproporphyrin I excretion amongst phenotypically normal relatives of subjects with this autosomal recessive disorder.

Jaundice due to carbimazole

On three occasions, a 63 year old housewife with hyperthyroidism developed a reaction which included fever, pruritus, malaise, and, on one occasion, jaundice one to 17 days after taking carbimazole. Challenge with carbimazole was followed within 12 hours by abdominal pain, pruritus, and increased serum transaminase levels. Light microscopy of a liver biopsy showed increase of portal zone cellularity over the control and the electron microscopy revealed fine structural changes compatible with drug-related liver injury.

Cognitive deficits associated with chronic hepatic encephalopathy and their response to levodopa

A battery of computer-based psychological tests given to seven patients with chronic hepatic encephalopathy showed them to be intellectually impaired, particularly on speed-based measures, as compared with general hospital patients and with patients with cirrhosis but without clinical or electroencephalographic evidence of encephalopathy. Two of the seven patients in the latter group also showed evidence of cognitive impairment on some tests. The effects of levodopa were also evaluated by sequential assessment with these tests. Although there was some improvement in speed of performance on certain tasks and a suggestion of deterioration on other measures, there was little overall change. It is concluded that levodopa has an 'arousing' or antidepressant action and that its effect on intellectual functions is secondary to this alerting effect and is consequently dependent on the emotional and attentional status of the patient.

Treatment of chronic hepatic encephalopathy with levodopa

Three of six patients with chronic hepatic encephalopathy treated with levodopa showed a significant improvement. One patient was probably improved whilst the remaining two patients failed to show any benefit. Serial electroencephalography did not demonstrate significant changes. Treatment with levodopa was associated with an improvement in ;speed-based' tasks as assessed by computerized psychometry. A significant rise in cerebral oxygen consumption was found during levodopa therapy. Gastrointestinal side effects were dose limiting. It is concluded that a therapeutic trial of levodopa in patients with chronic hepatic encephalopathy is indicated when the response to conventional therapy has been poor.

Skeletal muscle blood flow and neurovascular reactivity in liver disease

There was no significant difference in forearm muscle blood flow, measured by the clearance of (133)Xenon when 38 patients with liver disease were compared with 38 normal subjects. Patients with a clinically hyperdynamic circulation, finger clubbing, and previous portocaval anastomoses were included in the study. The changes in forearm skeletal muscle blood flow and pulse rate caused by a head-up tilt of 70 degrees were measured in 15 patients with chronic liver disease and 15 age-matched controls. Head-up tilting resulted in significantly less peripheral vasoconstriction and tachycardia in the group with liver disease than in the control group. These results suggest an impairment of baroreceptor-mediated sympathetic reactivity in liver disease. Such a defect might explain the relative rarity of hypertension in patients with cirrhosis.