[Case no. 5. Diagnosis: dural arteriovenous fistula of the posterior fossa with perimedullary venous drainage].
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Arteriovenous Fistula↗
Biomedical subjects
C Cognard
Publications and source records attributed to C Cognard.
Intracranial vascular involvement of brain pathologies and venous occlusions.
In this paper, the authors present the contribution of CT and MRI to the diagnosis of acute stroke caused by arterial or venous occlusion. The term "early" used in this context means within 6 h of the onset of symptoms. Signs of early ischemic edema are subtle and sometimes difficult to detect by CT or MRI. The purpose of this presentation is to familiarize the clinician and the radiologist with the subtle brain parenchymal changes seen within the first 6 h after onset of symptoms, in order to improve detection of early ischemic infarction and to improve patient care.
Acute Disease↗
Dural arteriovenous fistulas as a cause of intracranial hypertension due to impairment of cranial venous outflow.
OBJECTIVES: A retrospective study was carried out on 13 patients with intracranial dural arteriovenous fistulas (DAVFs) who presented with isolated or associated signs of intracranial hypertension. METHODS: Nine patients presented with symptoms of intracranial hypertension at the time of diagnosis. Ocular fundoscopy available in 12 patients showed bilateral papilloedema in eight and optic disk atrophy in four. Clinical evolution was particularly noticeable in five patients because of chronic (two patients) or acute (after lumbar shunting or puncture: three patients, one death) tonsillar herniation. RESULTS: Two patients had a type I fistula (drainage into a sinus, with a normal antegrade flow direction). The remaining 11 had type II fistulas (drainage into a sinus, with abnormal retrograde venous drainage into sinuses or cortical veins). Stenosis or thrombosis of the sinus(es) distal to the fistula was present in five patients. The cerebral venous drainage was abnormal in all patients. CONCLUSION: Type II (and some type I) DAVFs may present as isolated intracranial hypertension mimicking benign intracranial hypertension. Normal cerebral angiography should be added as a fifth criterion of benign intracranial hypertension. The cerebral venous drainage pattern must be carefully studied by contralateral carotid and vertebral artery injections to correctly evaluate the impairment of the cerebral venous outflow. Lumbar CSF diversion (puncture or shunting) may induce acute tonsillar herniation and should be avoided absolutely. DAVF may induce intracranial hypertension, which has a poor long term prognosis and may lead to an important loss of visual acuity and chronic tonsillar herniation. Consequently, patients with intracranial hypertension must be treated, even aggressively, to obliterate the fistula or at least to reduce the arterial flow and to restore a normal cerebral venous drainage. The endovascular treatment may associate arterial or transvenous embolisation and/or surgery. Patients in whom the fistula is not obliterated after an endovascular therapeutic procedure, need continuous clinical and angiographical follow up.
Adult↗
Intracranial berry aneurysms: angiographic and clinical results after endovascular treatment.
PURPOSE: To determine the types of aneurysm that may be treated endovascularly with platinum detachable coils. MATERIALS AND METHODS: Two hundred eight patients with 236 intracranial berry aneurysms underwent endovascular coil embolization; 150 patients had subarachnoid hemorrhage at the time of presentation. RESULTS: Treatment was performed in 182 patients with 203 (86%) aneurysms (86%). Follow-up angiograms were obtained at 3 months in 160 cases of aneurysm. A second procedure was performed in 18 (11%) of these cases, and a third was performed in one case. Final follow-up results in 152 aneurysms demonstrated total occlusion in 123 (81%) cases, subtotal occlusion in 26 (17%) cases, and incomplete occlusion in three (2%) cases. All patients with subtotally occluded aneurysm were scheduled for later angiographic follow-up and any indicated repeat treatment. Technique-related morbidity rate was 4% (seven patients with permanent neurologic deficits due to clotting). Technique-related mortality rate was 2% (perioperative rupture in two, hematoma due to urokinase perfusion in one, rebleeding of the initial hematoma after excessive uncontrolled anticoagulation in one). Rebleeding occurred in one patient after incomplete occlusion. CONCLUSION: Endovascular coil embolization seems to be a reliable technique, with good anatomic and clinical results, that provides protection against rebleeding of ruptured aneurysms.
Aneurysm, Ruptured↗
Antisense oligonucleotides against 'cardiac' and 'skeletal' DHP-receptors reveal a dual role for the 'skeletal' isoform in EC coupling of skeletal muscle cells in primary culture.
Two dihydropyridine receptor mRNA isoforms (cardiac and skeletal) are expressed in rat skeletal muscle cells in primary culture. The progressive changes in excitation-contraction coupling mode from dual mode ('skeletal' and 'cardiac') to predominant 'skeletal' one during in vitro myogenesis are thought to be linked to the developmental changes in the relative expression of the two types of molecular entity previously observed in this preparation. In order to test this hypothesis, myotube cultures (5- to 7-day-old) were treated with antisense phosphorothioated oligodeoxynucleotides against cardiac or skeletal alpha1 subunit of L-type calcium channel. The oligodeoxynucleotide uptake by cells was checked by means of imaging of fluorescent oligodeoxynucleotide derivatives within the cells. Optimum concentration used (10 microM in the extracellular medium) and incubation time (70 hours) were empirically determined. Antisense directed against the cardiac type led to a 54% decrease in the averaged L-type calcium current peak density at -10 mV. The same type of experiment was performed with antisense against the skeletal isoform and led to a same order of inhibition (46%). This result clearly shows that the two isoforms can work as a calcium channel. Conversely, analysis of the shape of T-V (relative contractile amplitude versus membrane potential) curves shows that the treatment with 'skeletal' antisense depressed the contractile response in the medium membrane potential range whereas treatment with 'cardiac' antisense had no effect. This and other results taken together suggest that the skeletal isoform of dihydropyridine receptor is involved in both 'cardiac' and 'skeletal' types of EC coupling mechanisms at work in early stages of myotubes in vitro development. The type of coupling probably depends on the proximity of the skeletal dihydropyridine receptor and the ryanodine receptor.
Animals↗
Giant aneurysms of the middle cerebral artery trifurcation treated with extracranial-intracranial arterial bypass and endovascular occlusion. Report of two cases.
Giant middle cerebral artery (MCA) trifurcation aneurysms that cannot be excluded directly can be treated by flow inversion achieved by creation of an extracranial-intracranial bypass distal to the aneurysm, followed by occlusion of the parent vessel proximal to the aneurysm. As opposed to surgical occlusion, endovascular occlusion avoids dissection of the aneurysm area, and the site of occlusion can be chosen according to the flow distribution demonstrated on angiography performed during test occlusions. Two patients with giant aneurysms of the MCA trifurcation benefited from flow inversion treatment. Forty-eight hours after an MCA-superficial temporal artery bypass had been created, the M1 segment was occluded by inserting a coil in the first patient and the internal carotid artery was occluded with balloons in the second patient (there was no communicating artery in the latter case). Both occlusions were performed immediately after a clinical test of occlusion tolerance. The patients were clinically intact during the postoperative course. Follow-up angiography performed 11 and 4 months, respectively, after vessel occlusion showed that the aneurysm occlusion was stable.
Adult↗
Rescue of K562 cells from MDM2-modulated p53-dependent apoptosis by growth factor-induced differentiation.
The wild-type human MDM2 protooncogene was tested for its ability to modulate apoptotic activity of the de novo expressed p53 tumor suppressor gene in K562 cells. We also studied the role of some cytokines in this phenomenon. K562, a human myeloid leukemia cell line, does not express p53 at the mRNA or protein level. In this study, we stably transfected K562 with eukaryotic vectors containing either normal p53 cDNA (pC53-SN3) or mutated p53 (143Val-->Ala) cDNA (pC53-SCX3). Transfectants expressing WT p53 or those expressing mutant p53 are called K562 SN and K562 SM respectively. Many leukemic cell lines undergo apoptosis when de novo WT p53 is expressed alone. In contrast, while the resulting clones (K562 SN and K562 SM) expressed p53, they did not undergo apoptosis. However, when treated with MDM2 mRNA antisense (MDM2 AS) oligodeoxynucleotides (ODNs), K562 SN demonstrated apoptotic features at both molecular and morphological levels. No change was observed when the other clones (K562 and K562 SM) were treated with MDM2 AS. Apoptosis induced in this manner was associated with a relatively small increase in intracellular calcium [Ca2+]i. Cells cultured in medium previously supplemented with recombinant human (rh) interleukin (IL)-3 and rh-erythropoietin (Epo) did not undergo apoptosis. Moreover, K562 SN cells were induced to differentiate. This differentiation was evaluated by measuring hemoglobin (Hb) level in cellular extracted proteins and by analyzing erythroid colony number and morphology. High Hb synthesis was obtained when K562 SN cells were cultured with cytokines (IL-3 + Epo) combined with MDM2 AS. Our results are consistent with the hypothesis that the function of the proto-oncogene MDM2 is to provide a 'feedback' mechanism for the p53-dependent pathway of apoptosis that could be shunted toward differentiation.
Apoptosis↗
Local intraarterial fibrinolysis of thromboemboli occurring during endovascular treatment of intracerebral aneurysm: a comparison of anatomic results and clinical outcome.
PURPOSE: We describe our therapeutic strategy and correlate the anatomic results and clinical outcomes in patients who received immediate fibrinolytic therapy for thromboembolic complications occurring during endovascular treatment of an intracerebral aneurysm. METHODS: The medical records and angiographic examinations of 19 patients were reviewed. All endovascular procedures were performed with the patients under general anesthesia and fully heparinized. Thirteen patients received an intravenous bolus injection of aspirin. Thromboemboli occurred during catheterization or insertion of embolic material (Guglielmi detachable coils or mechanical detachable spirals) or in the first hours after the intervention. Clot distribution was within the MCA territory in 14 patients, the ACA in three patients, and the basilar trunk in two patients. A continuous intraarterial injection of urokinase was administered immediately, either superselectively distal to the thrombus or selectively within or closely proximal to the thrombus. In nine cases, chemical lysis was combined with mechanical clot fragmentation. Initial anatomic recanalization as well as clinical outcome at 3 months were evaluated. RESULTS: Ten patients showed complete recanalization and nine patients showed partial recanalization. Fourteen patients had a good clinical recovery. One patient was moderately disabled and two were severely disabled according to their scores on the Glasgow outcome scale. Two patients died, one as a consequence of the preexisting subarachnoid hemorrhage and the other because of a large intracerebral hematoma that developed after fibrinolysis. Of the 14 patients with a good clinical outcome, nine exhibited complete recanalization and five partial recanalization. CONCLUSION: Pharmacological thrombolysis seems to be a safe and efficient therapy that facilitates the natural fibrinolytic process, increasing the rate of recanalization in thromboembolic events. Clot fragmentation and superselective drug infusion appear to improve the rate of recanalization. Complete recanalization increases the chance of a better clinical outcome; however, clinical outcome does not always correspond to recanalization and vice versa.
Adult↗
Embolization of an orbital varix after surgical exposure.
We report a case of primary orbital varix treated by embolization with coils after surgical exposure and puncture of the venous ectasia. This method of treatment has the advantage of limiting traumatic dissection and avoiding difficult venous catheterization.
Adult↗
Endovascular treatment of basilar tip aneurysms after direct puncture of the vertebral artery.
Basilar aneurysms that are not amenable to standard endovascular treatment via the femoral approach because catheterization is difficult pose a rare but serious problem. We present two cases of basilar tip aneurysms successfully treated by the endovascular route after direct puncture of the right vertebral artery. In both patients, the left vertebral artery was tortuous, small, and irregular, and the ostium of the right vertebral artery was not accessible by the femoral approach.
Catheterization, Peripheral↗
Long-term changes in intracranial dural arteriovenous fistulae leading to worsening in the type of venous drainage.
We review seven patients with intracranial dural arteriovenous fistulae (ICDAVF), each altering the initial type of venous drainage to one with a higher grading during long-term follow-up. Five were discovered due to symptoms of intracranial hypertension, two due to changes in tinnitus and one case following subarachnoid haemorrhage. In five cases, cortical venous drainage developed during the follow-up period. Three different mechanisms were observed: stenosis or thrombosis in the draining veins in 4 cases: increased arterial flow in 2; and the appearance o a new fistula site or extension of the initial shunt in 2. Type I and type II a fistulae which are not completely cured, require both close clinical observation and Doppler examinations in the follow-up period. Any charge in the clinical pictures indicates a repeat angiogram. Stenosis of the venous drain-age, forecasting later worsening in the venous outlet, requires more thorough angiographic follow-up.
Adult↗
Contrast enhancement of the facial nerve on MRI: normal or pathological?
We prospectively analysed the normal contrast-enhanced MRI features of the facial nerve and determined criteria for pathological contrast enhancement. We studied 31 patients with clinically normal facial nerves with T1-weighted images before and after contrast medium. The intensity, thickness and right-left symmetry of enhancement were assessed in each segment and correlated with MRI features observed in abnormal facial nerves. Enhancement along at least one segment of the facial nerve was seen in 98% of cases, but only within the facial canal: labyrinthine segment: 78.2%; geniculate ganglion: 96.9%; tympanic: 88.4%; mastoid: 66.6%. Marked (+2) to intense (+3) enhancement was seen in the labyrinthine segment in 17.4%, the geniculate ganglion in 36.3%, and the tympanic (25.6%) and mastoid (7.1%) segments, whereas intense enhancement was only seen in the geniculate ganglion (6%) and the tympanic segment (11.6%). A right-left asymmetry was noted in 69% of cases. No correlation was found between enhancement and the thickness of the nerve. No enhancement of the eighth nerve was seen. We suggest three criteria for pathological enhancement: enhancement outside the facial canal; extension of enhancement to the eighth nerve; and intense enhancement in the labyrinthine and/or mastoid segments.
Adolescent↗
Reversal of the relative expression of cardiac and skeletal alpha1 subunit isoforms of L-type calcium channel during in vitro myogenesis.
Cardiac and skeletal type of excitation-contraction coupling (ECC) are quite different. Those differences could be explained by structural ones in the molecular entities involved in ECC, ie dihydropyridines (DHP) receptors (alpha1 subunit of L-type calcium channels) of the sarcolemma or ryanodine receptors of the sarcoplasmic reticulum membrane. As previously demonstrated by means of electrophysiology, the two types of ECC coexist during the first stages of in vitro development of skeletal muscle, whereas the skeletal type predominates at the later ones. In order to see whether evolution of ECC could be correlated with the one of alpha1 subunit expression, we determined by Northern Blotting which isoforms of alpha1 subunit are expressed during the in vitro myogenesis. mRNA corresponding to the cardiac isoform are present in myoblasts (before fusion), but patch-clamp experiments showed that they are not functional. After fusion, skeletal and cardiac mRNA are coexpressed in myotubes, with different intensities: whereas expression of skeletal mRNA (which are the more intensive) stabilized at the later stages tested, cardiac mRNA decreased. We conclude that evolution in mRNA alpha1 subunit isoforms expression could partly explained evolution of ECC features during in vitro myogenesis.
Animals↗
Intracranial aneurysms: endovascular treatment with mechanical detachable spirals in 60 aneurysms.
PURPOSE: To evaluate preliminary results with endovascular treatment (EVT) of intracranial aneurysms with mechanical detachable spirals. MATERIALS AND METHODS: EVT with spirals was attempted in 57 patients with 60 aneurysms (47 berry, nine large, and four giant aneurysms). Thirty-seven patients had subarachnoid hemorrhage (three of whom were also treated for associated aneurysm), nine were asymptomatic, six had headache, three had mass effect, and two had neurologic deficits. RESULTS: EVT with the spirals was achieved in 55 (92%) of the 60 aneurysms. Of 42 treated berry aneurysms and 13 treated large and giant aneurysms, 33 berry and nine large and giant aneurysms underwent 3-month angiographic follow-up. Complete occlusion was attained in 23 berry and four large and giant aneurysms, subtotal occlusion (doubtful or obvious small neck remnant) was obtained in eight berry and four large and giant aneurysms, and incomplete occlusion was obtained in two berry aneurysms and one giant aneurysm. These results were obtained after one procedure in 21 patients, after two procedures in 19 patients, and after three procedures in two patients. Seven patients had complications that necessitated infusion of urokinase. Permanent neurologic deficits were found in three. There were no deaths. CONCLUSION: Good results were obtained with EVT of intracranial aneurysms with mechanical detachable spirals. These spirals are characterized by rapid detachment and low cost.
Adult↗
[Reconstruction technic in the treatment of wide-neck intracranial aneurysms. Long-term angiographic and clinical results. Apropos of 56 cases].
PURPOSE: The main factor limiting endovascular treatment of intracranial aneurysms is the shape of the aneurysmal sac, particularly the width of the neck. In this study we present a new technique to occlude wide neck aneurysms that involves the temporary inflation of a non-detachable balloon in front of the aneurysm neck during each coil placement. The aim of the study is to present the feasibility, efficacy and safety of this "remodeling technique" (RT) as compared to that of "normal" GDC treatment. MATERIAL AND METHOD: 56 aneurysms in 54 patients were selected for treatment with the RT. Thirty-seven (70%) of the patients presented with subarachnoid hemorrhage. Twenty-five (45%) of the aneurysms were located at the vertebrobasilar artery, 24 (43%) at the internal carotid artery, and seven at the level of smaller arteries. RESULTS: Treatment was achieved in 52 aneurysms in 50 patients. Two aneurysms which were initially not completely occluded underwent a second treatment using the RT. Final results (i.e. the last follow-up angiography or results at the end of the treatment for the cases that have not yet had follow-up) consisted of total occlusion in 40 cases (77%), sub-total occlusion in nine cases (17%), and incomplete occlusion in three cases (6%). Angiographic evidence of clotting was observed during the procedure in three cases, resulting in one permanent deficit (quadranopia). Rupture of the aneurysmal sac occurred during the procedure in three cases, all of which were asymptomatic in the follow-up. Thus, morbidity due to the technique was 1/52 (0.5%) and mortality was 0/56 patients. CONCLUSION: The remodeling technique allowed the treatment of 52 wide neck or badly shaped aneurysms that were not treatable without this technique. The results of occlusion with the RT seem better than those in our series of normal GDC treatment, and complications related to the technique are fewer. This technique thereby extends the spectrum of treatable aneurysms without increasing the risk incurred by treatment.
Adolescent↗
Posttraumatic spinal subarachnoid cyst.
A case of posttraumatic compressive subarachnoid cyst of the thoracic spine studied by MR myelography, and myelo-CT is reported. This cyst was surgically confirmed and treated by shunting.
Adolescent↗
Acrylic vertebroplasty in symptomatic cervical vertebral haemangiomas: report of 2 cases.
We report two cases of acrylic vertebroplasty in symptomatic cervical vertebral haemangiomas. In both cases significant improvement of symptoms was rapid. One patient was able to return to work.
Adult↗
The role of CT in evaluation of the effectiveness of embolisation of spinal dural arteriovenous fistulae with N-butyl cyanoacrylate.
A failed embolisation of a spinal dural arteriovenous fistula (AVF), because a pedicular injection has not reached the initial venous compartment, must be identified immediately, to allow prompt surgery and thus avoid clinical deterioration. The purpose of our study was to determine the role of CT in confirming a complete cure just after embolisation with N-butyl cyanoacrylate (NBCA). Seven patients embolised for spinal dural AVFs with perimedullary venous drainage had an immediate postembolisation CT scan. In six patients a complete cure was achieved, with a normal postembolisation angiogram in five cases. Just after injection of NBCA, we were unable to determine on plain films whether or not the glue had reached the draining vein in six of seven cases. The postembolisation CT showed various patterns: in two cured patients, the glue was visible in the inner surface of the dura mater and therefore on the venous side. In five cases, the glue was approaching the dura mater around the cord or seemed to reach its surface: in the four patients cured, the glue column was 7-18 mm high, whereas it was less than 2 mm high in the patient with angiographic proof of recurrent fistula. The follow-up angiogram remains the only way to confirm a durable cure. We suggest that immediate postembolisation CT may help in assessing endovascular treatment of spinal dural AVFs.
Adult↗