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Noel F. Fanning, Robert A. Willinsky, and Karel G. terBrugge

Object

Symptomatic local inflammation, aseptic meningitis, and hydrocephalus are reported in a group of patients treated with second generation/modified platinum coils. The purpose of this study was to define the frequency and determinants of magnetic resonance (MR) imaging findings of aneurysm wall enhancement, perianeurysmal edema, and hydrocephalus in a cohort of coil-embolized intradural cerebral aneurysms treated with bare platinum or modified platinum coils (Matrix or HydroCoils).

Methods

The authors retrospectively reviewed 359 Gd-enhanced MR follow-up studies of 181 treated aneurysms (125 ruptured) for mural enhancement. Univariate and multivariate logistic regression analyses were used to define mural enhancement associations with demographic, clinical, angiographic, treatment, and follow-up data. Embolization-related edema and hydrocephalus were defined in 95 MR imaging studies of 56 unruptured aneurysms.

Results

Asymptomatic wall enhancement was observed in lesions treated with all coil types, occurring in 21 (18.6%) of 113 bare platinum coil–treated aneurysms. Independent associations were HydroCoil treatment (odds ratio [OR] 9.75, 95% confidence interval [CI] 3.45–30.75) and increasing aneurysm size (OR 3.58, 95% CI 1.99–6.95). Five (8.9%) unruptured aneurysms had asymptomatic de novo edema, and 3 (5.3%) demonstrated hydrocephalus; all had been treated with HydroCoils. Hydrocephalus presentation was delayed (8–31 months) and symptomatic in 2 patients.

Conclusions

Asymptomatic aneurysm wall enhancement occurred in 18.6% of embolizations performed with bare platinum coils, and probably represents a normal healing response. Perimural edema and hydrocephalus were observed only in patients treated with HydroCoils, but have been reported in patients treated with other modified platinum coils. These symptoms appear to represent an exaggerated inflammatory response during aneurysm healing. Increased vigilance for delayed hydrocephalus is required. Judicious clinical use of modified platinum coils is warranted until results of randomized trials are published.

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Giuseppe Scotti, Karel Terbrugge, Denis Melançon, and Gary Bélanger

✓ The computerized tomography (CT) scans of 50 patients with surgically proven subdural hematomas were subdivided into three groups on the basis of the attenuation coefficients of the subdural fluid collections: 28% were more dense, 24% isodense, and 48% less dense than the surrounding brain. The 42 patients with the available data were then subdivided into three groups; acute, subacute, and chronic, according to the time interval between trauma or duration of symptoms and date of CT scanning. Subdural hematomas were found to be hyperdense in 100% of acute patients, isodense in 70% of the subacute group, and hypodense in 76% of the chronic group.

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Kenichi Sato, Karel G. TerBrugge, and Timo Krings

Object

Spinal dural arteriovenous fistulas (SDAVFs) consist of a shunt with converging feeding vessels arising from radiculomeningeal arteries and draining retrogradely via a radicular vein into the perimedullary veins, thereby causing progressive myelopathy due to venous hypertension in the spinal cord. The purpose of this study was to evaluate the hypothesis that the obstruction of radicular venous outlets could be an additional factor inducing symptomatic venous hypertension due to a decreased outflow in SDAVFs.

Methods

The authors compared the clinical and imaging findings in patients with asymptomatic SDAVFs identified incidentally at the upper thoracic region with the findings in symptomatic patients who harbored SDAVFs at the same level.

Results

All symptomatic patients presented with medullary dysfunction. The mean age of patients with asymptomatic SDAVF was 51.5 years, approximately 10 years younger than the patients with symptomatic SDAVF (64.1 years old). Despite the existence of dilated perimedullary vessels in the dorsal side of the spinal cord in all patients, the spinal cord edema seen in symptomatic patients was not detected on the MR images obtained in patients with asymptomatic SDAVF. The spinal angiograms of the asymptomatic patients distinctively demonstrated early radicular venous outflow from affected perimedullary veins to the extradural venous plexus as a potential alternate route for the venous hypertension to be released.

Conclusions

Obstruction of the radicular venous outflow could be an important factor in inducing spinal congestive edema due to venous hypertension, as well as subsequent clinical symptoms of SDAVFs.

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Giuseppe Lanzino and Philipp Taussky

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J. Marc C. Van Dijk, Karel G. TerBrugge, Robert A. Willinsky, and M. Christopher Wallace

Object. Dural arteriovenous fistulas (AVFs) are a well-known pathoanatomical and clinical entity. Excluding bilateral involvement of the cavernous sinus, multiple dural AVFs are rare, with isolated reports in the literature. The additional risk associated with multiplicity is unknown, although it has been claimed that there is a greater risk of hemorrhage at presentation. In a group of 284 patients with dural AVFs consecutively treated at a single center, the occurrence of multiplicity is investigated and its risk factors for hemorrhage are identified.

Methods. Among the 284 patients with both cranial and spinal dural AVFs, 20 patients with multiple fistulas were found. Nineteen (8.1%) of 235 patients with cranial AVFs had multiple cranial fistulas, and one (2%) of 49 patients with spinal AVFs harbored two spinal fistulas. Twelve patients were found to have a lesion at two separate sites, seven patients had them at three locations, and one patient had four fistulas, each at a different site.

In the subgroup with multiple AVFs the percentage of hemorrhage at presentation was three times higher than in the entire group (p = 0.01). Cortical venous drainage in cranial fistulas was present in 84% of patients with multiple lesions compared with 46% of patients with solitary lesions (p < 0.005).

Conclusions. Multiple dural AVFs are not rare. In this group of 284 patients it was found in 8.1% of all patients with cranial dural AVFs. Multiplicity was associated with a higher percentage of cortical venous drainage, a pattern of drainage reportedly yielding a higher risk for hemorrhage.

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J. Marc C. van Dijk, Karel G. TerBrugge, Robert A. Willinsky, and M. Christopher Wallace

Object. A single-institution series of 119 consecutive patients with a dural arteriovenous fistula (DAVF) and cortical venous reflux was reviewed to assess the overall clinical outcome of multidisciplinary management after long-term follow up. The selective disconnection of the cortical venous reflux compared with the obliteration of the entire DAVF was evaluated.

Methods. Dural arteriovenous fistulas in patients in this series were diagnosed between 1984 and 2001, and treatment was instituted in 102 of them. The outcome of adequately treated patients was compared with that of a control group consisting of those with persistent cortical venous reflux and with data found in the literature. In cases of combined dural sinus drainage and cortical venous reflux, a novel treatment concept of selective disconnection of the cortical venous reflux that left the sinus drainage intact, and thus converted the aggressive DAVF into a benign lesion, was evaluated.

Endovascular treatment, which was instituted initially in 78 patients, resulted in an obliteration or selective disconnection in 26 (25.5%) of 102 cases. In 70 cases (68.6%) the DAVFs were surgically obliterated or disconnected. In six cases (5.9%), patients were left with persistent cortical venous reflux. No lasting complications were noted in this series. Follow-up angiography confirmed a durable result in 94 (97.9%) of 96 adequately treated cases, at a mean follow up of 27.6 months (range 1.4–138.3 months).

Selective disconnection was performed in 23 DAVFs with combined sinus drainage and cortical venous reflux. These patients' long-term outcomes were equal to those with obliterated DAVFs, and the complication rate was lower.

Conclusions. Considering the ominous course of DAVFs with patent cortical venous reflux, multidisciplinary treatment of these lesions is highly effective and the complication rate is low. Selective disconnection provides a valid treatment option of DAVFs with combined dural sinus drainage and cortical venous reflux, as has been shown in cranial DAVFs with direct cortical venous reflux.

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Ronit Agid and Karel Terbrugge

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Stanley Tchang, Guiseppe Scotti, Karel Terbrugge, Denis Melançon, Gary Bélanger, Curt Milner, and Romeo Ethier

✓ Computerized tomography (CT) is shown to be very helpful in demonstrating the presence and extent of supratentorial gliomas, particularly in combination with intravenous injection of contrast material. Certain specific density patterns were found to exist and enabled us to differentiate with confidence the low-grade gliomas from the glioblastomas. Overlapping did occur, however, as was to be expected, since histological proof was sometimes obtained by needle biopsy with its inherent doubt as to true tumor representation. Future CT techniques such as sequential scanning after intravenous injection of contrast material may further increase the usefulness of CT scans in the diagnosis and therapeutic approach to the patient with a suspected glioma.

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Ai-Hsien Li, Derek Armstrong, and Karel G. terBrugge

Object

The treatment of vein of Galen aneurysmal malformation (VGAM) is among the most challenging of all the neurovascular disorders.

Methods

Between 1984 and 2005, 26 consecutive patients with VGAMs were treated by the authors' group, and their data were prospectively collected; 12 patients presented with congestive heart failure (CHF) and 10 had hydrocephalus. Five patients did not undergo endovascular treatment because of minimal symptoms or severe comorbidities. Twelve patients underwent embolization for refractory CHF requiring ventilation: 7 of these 12 patients had the procedure in the neonatal stage (5 survived), and 5 were treated in infancy or childhood following successful aggressive medical treatment (4 survived). The other 9 patients underwent endovascular surgery to treat a progressively enlarging head circumference; there was imaging evidence of ventricular enlargement and/or signs of developmental delay (6 underwent surgery in infancy and 3 in childhood; 1 patient died).

Results

The survival rate in this series was 76.9% (20 of 26). Fourteen (66.7%) of 21 patients who underwent endovascular treatment had no developmental delay. An analysis of various factors demonstrated that comorbidities and embolization effect (procedure success and long-term effect) were prognostic factors of survival. In addition, the patient's age at embolization was significantly higher in those with developmental delay than in those without (559.86 ± 535.43 days vs 94.83 ± 95.77 days, respectively; p = 0.028).

Conclusions

The authors conclude that neonatal VGAMs can be treated successfully with a strategic approach integrating antenatal diagnosis, endovascular surgery, treatment at intensive care facilities, and the cooperative efforts of different specialties. In the authors' experience, patients in whom VGAM was diagnosed and managed in infancy or childhood had more than 90% long-term survival.