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Alexis Victorien Konan, Jean Raymond and Daniel Roy

✓ The authors sought to show the feasibility and discuss the rationale of embolization of aneurysms associated with spinal cord arteriovenous malformations (SCAVMs). The authors reviewed the clinical presentation, magnetic resonance (MR) images, spinal angiograms, and clinical evolution of four patients treated for aneurysms associated with an SCAVM. Aneurysms were located on branches of the anterior spinal artery in three patients and on radiculopial arteries in two patients; one patient harbored two lesions. Treatment consisted of superselective bucrylate embolization of the branches harboring the aneurysms, with preservation of the arterial axis. Follow-up angiograms were obtained at 3 to 6 months postembolization in all patients.

All patients presented with hemorrhagic events. Hematomyelia was clearly related to a sulcocommissural or a vasa corona aneurysm in two patients. Another sulcocommissural aneurysm and multiple radiculopial aneurysms were presumed to be the cause of subarachnoid hemorrhage in two other patients. One patient harbored aneurysms on a sulcocommissural artery and on a radiculopial artery. All aneurysms were permanently obliterated. In one patient with a single fistula, the SCAVM was cured. The SCAVM was only partially obliterated (95, 50, and 20% in apparent volume) in three other patients. There were no complications or rebleeding episodes during a follow-up period of 17 to 37 months.

Aneurysms associated with SCAVMs can be eradicated by supraselective embolization, even on the anterior spinal artery territory. For patients presenting with hemorrhage and prohibitive risk of complete resection, embolization of aneurysms may decrease the risk of further rebleeding.

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Yves Lazorthes, Brigitte Sallerin-Caute, Jean-Claude Verdie, Raymond Bastide and Jean-Pierre Carillo

✓ Baclofen, the most effective drug for treating spasticity, is a specific agonist of gamma-aminobutyric acid-B receptors, and is very abundant in the superficial layers of the spinal cord. Given orally, baclofen does not easily penetrate the blood-brain barrier, and is distributed equally to the brain and spinal cord. Direct intrathecal administration was given in order to change the distribution of the drug by preferentially perfusing the spinal cord. Eighteen patients presenting a severe spastic syndrome were treated with chronic intrathecal infusion of baclofen in the lumbar cerebrospinal fluid. After clinical preselection, 38 patients were implanted with a lumbar access port allowing long-term trials in order to determine the efficacy of baclofen therapy and the effective 12-hour dose. The 18 patients selected for chronic administration were implanted with a programmable pump. The pathology in these cases was: multiple sclerosis (6 cases), posttrauma spastic syndrome (eight cases), and (one case each) cerebral palsy, ischemic cerebral lesion, spinal ischemia, and transverse myelitis. The mean follow-up period was 18 months (range 4 to 43 months).

The clinical results were evaluated according to muscular hypertony on Ashworth's scale (changed for occurrence of painful spasms) and functional improvement. Results were better for spastic syndrome secondary to traumatic medullary lesion than for demyelinating disease. Hypertonia was improved in all cases as confirmed by the registration of the Hoffman (H) reflex. Painful muscular spasms disappeared in 14 of the 16 affected patients. Significant functional improvement was noted in nine patients and was considerable in three. The risk of side effects secondary to overdose (such as excessive hypotonia or central depression) and the absence of a specific baclofen antagonist stresses the necessity for accurate determination of the efficient dose. After an initial titration period and adjustment of the therapeutic dose, the individual doses were from 21 to 500 µg/24 hrs (mean 160 µg/24 hrs). This new conservative method is very effective, perfectly reversible, and safe when administered in conditions favorable to its use.

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David F. Kallmes, Waleed Brinjikji and Alejandro A. Rabinstein

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Ignacio Arrese and Rosario Sarabia

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Mohamed Samy Elhammady and Roberto C. Heros

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Tim E. Darsaut and Jean Raymond

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Tim E. Darsaut and Jean Raymond

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Jean Raymond, Daniel Roy, Michel Bojanowski, Robert Moumdjian and Georges L'Espérance

✓ The surgical treatment of basilar bifurcation aneurysms is difficult and the need for an alternative approach is frequently stated. To assess the efficacy and safety of endovascular treatment of aneurysms located at the basilar bifurcation, the authors prospectively studied angiographic results, clinical results, and complications in 31 patients treated with Guglielmi detachable coils (GDCs). Patients treated acutely after subarachnoid hemorrhage (SAH) were graded according to the Hunt and Hess classification and clinical outcome was determined at 1- and 6-month intervals according to the Glasgow Outcome Scale (GOS).

There were 18 women and 13 men, ranging in age from 34 to 67 years (mean age 48 years). Twenty-three were treated acutely after SAH. Clinical Hunt and Hess grades at presentation were as follows: Grade I, six patients; Grade II, three; Grade III, 11; Grade IV, two; and Grade V, one. The GOS score for the group of patients treated acutely was: GOS I, 18 patients; GOS II, III, and IV, one patient each; and GOS V, two patients. There were seven technical complications in this group, most often asymptomatic, but one patient died after aneurysm rupture during treatment and one had residual diplopia at 4 months. Eight patients were treated for incidental basilar bifurcation aneurysms. One technical complication with no neurological deficit occurred in this group of patients with incidental aneurysms.

Immediate angiographic results were considered to be satisfactory in 94% of patients, with complete obliteration in 42% and residual neck and dog ears in 52%. There was no bleeding episode after treatment during clinical follow-up periods ranging from 3 to 42 months (mean 15.5 months in 29 surviving patients). Angiographic results were available for 27 patients at 6 months and were as follows: 30% of the lesions were completely obliterated, 59% presented some residual neck, and 11% showed some opacification of the aneurysm sac. During the follow-up period of up to 42 months, a total of seven recurrences were noted, necessitating retreatment with GDCs in five patients.

Endovascular treatment of basilar bifurcation aneurysms prevented rebleeding and could be performed without clinically significant complications in 94% of patients. Clinical results after SAH compared favorably with surgical series. Morphological results appear less satisfactory, and long-term angiographic follow-up review is mandatory to detect recurrences.

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Robert Fahed, Tim E. Darsaut, Igor Salazkin, Guylaine Gevry and Jean Raymond

OBJECTIVE

The Medina embolization device (MED) is a novel, braided self-expanding endovascular device designed to occlude aneurysms by constructing an in situ intrasaccular flow diverter. Although a single device can be positioned at the neck of simple spherical in vitro aneurysms, the best way to occlude more complex in vivo aneurysms (using multiple MEDs or a combination of MEDs and platinum coils) is currently unknown.

METHODS

Fifty-two aneurysms of 3 different types were created in 31 canines, yielding 48 patent aneurysms. Treatments were randomly allocated by drawing lots: group 1, MEDs alone (n = 16); group 2, MEDs plus standard platinum coils (n = 16); and group 3, control aneurysms treated with coils alone (n = 16). Angiographic results were scored and compared immediately following treatment completion and at 3 months. Specimens were photographed and the extent of neointimal closure of the aneurysmal neck scored, followed by histopathological analyses.

RESULTS

Angiographic scores of 0 or 1 (occlusion or near occlusion) were initially obtained in 2 of 16 (12.5%, 95% CI 1.6%–38.3%) group 1 (MEDs alone), 3 of 16 (18.7%, 95% CI 4%–45.6%) group 2 (MEDs plus coils), and 10 of 16 (62.5%, 95% CI 35.4%–84.8%) group 3 (coils alone) aneurysms (p = 0.005). At 3 months, scores of 0 or 1 were found in 11 of 16 (68.7%, 95% CI 41.3%–89.0%) group 1, 9 of 16 (56.2%, 95% CI 29.9%–80.2%) group 2, and 8 of 16 (50%, 95% CI 24.7%–75.3%) group 3 aneurysms (p = 0.82). Neointimal scores were similar for the 3 treated groups (p = 0.66).

CONCLUSION

Endovascular treatment of experimental aneurysms with MEDs or MEDs and coils showed angiographic occlusion and neointimal scores at 3 months that were similar to those achieved with standard platinum coiling.

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Michel W. Bojanowski, Elsa Magro, Tim Darsaut and Jean Raymond