[A tumoral pitfall. What is your diagnosis? Diagnosis: Chordoid meningioma].
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Adult↗
Biomedical subjects
S Bracard
Publications and source records attributed to S Bracard.
[Recommendations for the use of intravenous thrombolytic therapy in cerebrovascular ischemic accident. French Society of Neurovascular Disorders].
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Brain Ischemia↗
Multivariate analysis of predictors of cerebral vasospasm occurrence after aneurysmal subarachnoid hemorrhage.
BACKGROUND AND PURPOSE: The role of type of treatment on cerebral vasospasm occurrence after aneurysmal subarachnoid hemorrhage (SAH) has not been studied. Through multivariate analysis we determined the independent prognostic factors of the occurrence of symptomatic vasospasm following aneurysmal SAH in a study cohort of 244 patients undergoing either surgical or endovascular treatment. The prognostic factors of sequelae after aneurysmal SAH were studied as well. METHODS: Symptomatic vasospasm was defined as the association of deterioration in a patient's neurological condition between 3 and 14 days after SAH with no other explanation and an increase in mean transcranial Doppler velocities of >120 cm/s. The prognostic factors were registered on admission and during the intensive care stay. RESULTS: Symptomatic vasospasm occurred in 22.2% surgical patients compared with 17.2% endovascular treatment patients (P=0.37). Multivariate analysis revealed that the probability of occurrence of symptomatic vasospasm decreased with age >50 years (relative risk [RR], 0.47 [0.25 to 0.88]) and severe World Federation of Neurological Surgeons (WFNS) grade measured on admission (RR, 0.43 [0.20 to 0.90]) and increased with hyperglycemia occurring during the intensive care stay (RR, 1.94 [1.04 to 3.63]). No difference in risk of symptomatic vasospasm could be identified between surgical and endovascular treatment. Symptomatic vasospasm (OR, 4.73 [CI, 1. 77 to 12.6]) as well as WFNS grade of >2 (OR, 8.95 [3.46 to 23.2]), treatment complications (OR, 8.39 [3.16 to 22.3]), and secondary brain insults were associated with an increased risk of 6-month sequelae. CONCLUSIONS: Age <50 years, good neurological grade, and hyperglycemia were all associated with an increased risk of cerebral vasospasm whereas treatment was not. This provides a basis for future clinical prospective randomized trials comparing both treatments.
Adult↗
[Endovascular treatment of vasospasm].
Cerebral vasospasm remains a leading cause of heightened morbidity and mortality rates following aneurysmal subarachnoid hemorrhage despite the apparent benefit of recent medical therapeutics. Successful resolution of medically refractory angiographically demonstrated vasospasm with concomitant reversal of delayed neurological deficit has been observed after balloon angioplasty. Subsequent reports confirmed these encouraging results but also emphasized the limitations of the technique and the risks of complications. Intraarterial papaverine infusion has been performed for the treatment of diffuse cerebral vasospasm with controversial results and has also been combined with angioplasty either to facilitate balloon navigation or to treat arteries inaccessible to balloon catheterization. All these different endovascular approaches explain the confusion existing about the indications, timing and efficacy of the endovascular treatments. This article reviews several clinical and experimental studies dealing with these questions.
Angioplasty, Balloon↗
[Management of vasospasm from subarachnoid hemorrhage. Attitude of French centers. French Society of Neuroradiology].
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Academic Medical Centers↗
[Cerebral ischemic accidents in young subjects. A prospective study of 296 patients aged 16 to 45 years].
From 1990 to 1997, June, 296 patients (156 males and 140 females), aged 16 to 45 years, admitted in the Neurology Department of the University Hospital of Nancy (F) for ischemic stroke, were prospectively evaluated according to a standardized analysis of anamnestic and clinical data, angiography (90 p. 100 of cases), TEE (78 p. 100), hemostasis. Women were younger (mean age = 34.82 y) than men (36.87 y; p = 0.003), with a peak in the 4th decade. Clinical event was a TIA in 14.2 p. 100, a stroke in 51.7 p. 100; it concerned the anterior circulation in 64.5 p. 100, posterior circulation in 25 p. 100, multiple territories in 10.5 p. 100. History of TIA, cervical-cranial pain or Horner syndrome suggestive of dissection, pregnancy or post-partum were found respectively in 60 (20.3 p. 100), 34 (11.1 p. 100) and 13 (9.3 p. 100) cases. Risk factors concerned 87.2 p. 100 of patients, mainly smoking (55.1 p. 100), oral contraceptive (53 p. 100), hyperlipemia (35 p. 100), and were more frequent in case of atheroma and lacunar stroke (p < 0.0000). Etiology, according to TOAST classification, was: atheroma (8.4 p. 100), cardioembolism (8.7 p. 100), small-artery disease (7.1 p. 100), dissection (15.5 p. 100), other determined causes (11.1 p. 100), multiple causes (5.7 p. 100), undetermined cause (34.8 p. 100). Septal pathology was found 34 times. Patients whose stroke remained unexplained were younger (33.7 y vs 37.7, p = 0.002), had less risk factors (p < 0.0000), had more TIA (p = 0.005), more often in the carotid territory (p = 0.008), had a better prognosis (p = 0.01), and showed more often emboli at angiography (p = 0.001). During a mean follow-up of 33 months (median = 19), 21 recurrent strokes occurred and 6 patients died. 134 (46 p. 100) patients had no sequelae, 101 (34.7 p. 100) minor disability, 42 (14.4 p. 100) major sequelae. These results, compared to the main studies of the literature, suggest the interest of common definition criteria and classification of etiologies. In practice, hierarchisation of investigations may be proposed, and vascular risk factors should be tracked in young patients. In patients whose stroke remains unexplained, further studies, as atrial vulnerability, are needed.
Adolescent↗
[Diffusion imaging in asymptomatic focal vasospasm. Apropos of a case].
We report a case of an asymptomatic vasospasm with a focal, reversible apparent diffusion coefficient (ADC) decrease after a middle cerebral artery aneurysm rupture. This isolated decrease of ADC has not yet been reported in this pathological situation. It could be interesting to predict the risk of ischemic delayed complications of vasospasm.
Adult↗
3D angiography. Clinical interest. First applications in interventional neuroradiology.
3D angiography is a true technical revolution that allows improvement in the quality and safety of diagnostic and endovascular treatment procedures. 3D angiography images are obtained by reconstruction of a rotational angiography acquisition done on a C-arm (GE Medical Systems) spinning at 40 degrees per second. The carotid or vertebral selective injection of a total of 15 ml of non-ionic contrast media at 3 ml/sec over 5 seconds allows the selection of the "arterial phase". Four hundred sixty 3D angiographic studies were performed from December 1996 to September 1998 on 260 patients and have been analyzed in MIP (Maximum Intensity Projection) and SSD (Shaded Surface Display) views. The exploration of intracranial aneurysms is simplified and only requires, for each vascular axis, a biplane PA and Lateral run followed by a single rotational angiography run. The 3D angiography image is available on the workstation's screen (Advantage Workstation 3.1, GE Medical Systems) in less than 10 minutes after the acquisition of the rotational run. It therefore allows one to analyze, during the intervention, the aneurysm's angioarchitecture, in particular the neck, and select the best therapeutic technique. When endovascular treatment is the best indication, 3D angiography allows one to define the optimal angle of view and accurately select the microcoils dimensions. 3D angiography replaces the multiple oblique views that used to be required to analyze the complex aneurysms and therefore allows a reduction of the total contrast medium quantity, the patient X-ray dose and the length of the intervention time which is a safety factor. Also, in particular for complex cases, it brings additional elements complementing the results of standard 2D DSA and rotational angiograms. In the cervical vascular pathology, 3D angiography allows for a better assessment of the stenosis level and of dissection lesions. Our current research activities focus on the matching without stereotactic frame between 3D X-ray angiography and volumetric MR acquisition, which should allow us to improve the treatment of intracerebral arterio-venous malformations (AVMs).
Aortic Dissection↗
[MRI aspects of spinal cord abscesses. Report of 5 cases and review of the literature].
The spinal canal is an uncommon site for abscess formation resulting from bloodstream disseminated infection. Prognosis is often unfavorable. Rapid treatment is essential for satisfactory neurological recovery. Abscesses within the spinal canal are thus diagnostic and therapeutic emergencies. The neuro-infectious and inflammatory manifestations and laboratory findings vary considerably and are insufficient for diagnosis. MRI plays a decisive role. The most commonly reported signs are the presence of an intramedullary collection giving a low-intensity signal on T1-weighted images and a high-intensity signal on T2-weighted images with peripheral contrast uptake and generally extended adjacent medullary edema. We report here five cases of spinal canal abscesses diagnoses with MRI at different stages of development (pre-suppurative myelitis in two cases, constituted abscess in three cases). For each case we reviewed the clinical course and describe the details of the imaging findings. In our series, the collected abscesses presented as round lesions within the canal with contrast uptake. It is noteworthy that the periependymal gray matter adjacent to the lesion also took up the contrast agent in all patients with a collected abscess. This sign has not been described previously and appears to be a going argument orienting the diagnosis towards an infectious rather than tumoral formation.
Abscess↗
X-ray angiography in stereotactic conditions: techniques and interest for interventional neuroradiology.
This paper reports work in progress on X-ray angiography acquired under stereotactic conditions. The objective is to be able to match multimodality images (typically MRI and X-ray) without a stereotactic frame but with stereotactic precision. We have identified potential problems and have studied them in detail. We conclude that, although the overall application is feasible, much work remains to be done on the estimation of the X-ray system conic projection and on automatic matching based on vascular structures.
Angiography, Digital Subtraction↗
[An exceptional variety of medulloblastoma: melanotic medulloblastoma].
We report a new case of melanotic medulloblastoma of the vermis in a 3 1/2 year old boy. This tumor showed a typical histological appearance with pseudoepithelial pigmented structures immunoreactive for S100 protein and vimentin. The tumor did not recur after total surgical removal and post operative radiation. However, after a 10 year follow-up, imaging demonstrated that a second tumor occurred in the left cerebellar hemisphere, which, on histological examination, was a typical glioblastoma. Hypothesis concerning the histogenesis of the second tumor, as well as a causal association with radiation therapy and possible contribution of growth hormone therapy are discussed.
Cerebellar Neoplasms↗
Pontine veins. MRI cross-sectional anatomy.
The pons is covered by a rich venous network offering numerous vascular landmarks in MRI and during surgery. We present an original study of the veins as they appear on MR multiplanar scans after gadolinium IV injection. This prospective study is based on 40 consecutive patients with normal posterior fossa structures. One of the major venous collectors follows the pons: the superior petrosal v. was identified on MRI in 95% of our cases. Its hooklike extremity drains into the superior petrosal sinus. The inferior petrosal v. was never identifiable. The superficial pontine venous network are identified in 72.5% of cases in the axial plane and were organised in longitudinal and transverse collectors, whose MR aspects are presented here.
Humans↗
Endovascular occlusion of intracranial aneurysms of the posterior circulation: comparison of balloons, free coils and detachable coils in 38 patients.
We treated 38 patients with 39 aneurysms of the posterior circulation by an endovascular technique using balloons, free coils or Guglielmi detachable coils (GDC) from 1986 to May 1993. The patients ranged in age from 10 to 71 years. Subarachnoid haemorrhage was the most frequent presentation (29 patients), followed by mass effect (5 patients) and epilepsy (2 patients). Treatment consisted of embolisation of the aneurysm with preservation of the parent vessel (in 29) or occlusion of the parent vessel (in 5). Multiple procedures were performed in 12 patients (32%, maximum 3 embolisations, total 17 treatments), because of incomplete initial aneurysm occlusion (in 8 cases) or re-opening of the aneurysm (in 9). Treatment could not be achieved in 5 patients. Good to excellent aneurysm occlusion was obtained in 28 patients (72%). Little or no neurological impairment occurred in 31 patients (82%). Complications related to treatment (11 patients, 29%) included 4 cases of transient cerebral ischaemia, 7 of stroke resulting in minimal neurological impairment (in 5), severe impairment (in 1) and one death. There were 6 patients who died, of rebleeding from the same aneurysm (2), basilar stroke (1) and unrelated causes (3). Comparison of the different occlusion techniques showed that the best angiographic results were obtained with balloons (good to excellent aneurysm occlusion was obtained in 17 of 22 patients treated) and the GDC (12 of 13 patients), and that less good results were given by free coils (4 of 9 patients). Complications related to treatment were fewest in patients treated with GDC (1 of 16 treatments, including multiple procedures) or free coils (2 of 12 treatments) and were more frequent with balloons (6 of 27 treatments). All five treatment failures occurred with balloon embolisation, whereas treatment was possible in all cases treated with free coils or GDC.
Adolescent↗
The veins of the medulla oblongata: MRI cross-sectional anatomy.
Magnetic resonance imaging (MRI) has progressively become the major or even the only imaging procedure for displaying the vascular relationships of the brainstem in the context of infra-tentorial lesions. In order to assess the MR sectional anatomy of the bulbar vv. 40 normal patients were examined in the MR axial, frontal and sagittal planes after gadolinium i.v. injection. The bulbar venous networks were inconstantly visualised: anterior vv. (16%). posterior (3%), lateral (8%). The vein of the lateral recess of the fourth ventricle was constant in the three planes; the inferior petrosal sinus could be seen in 82% of cases. Their relation with the posterior fossa structures are emphasised and discussed.
Contrast Media↗
[Subarachnoid hemorrhage caused by aneurysm rupture. Surgery or embolization?].
Traditionally the aneurysms of the circle of Willis have been an indication for neurosurgery. New technologies of endovascular treatment with electrically detachable coils resulted in a different therapeutical concept since four years. A series including 140 patients has been treated in our institution from 1 January 1992 to 31 December 1994, 94 of them presenting with a subarachnoid haemorrhage. Out of these 140 patients, 84 were treated with surgery, 51 with the endovascular technique, five with surgery after incomplete or unsuccessful endovascular treatment. Surgery was indicated in patients presenting early after bleeding, devoid of vasospasm, with a favourable Hunt and Hess grading and in aneurysms located in the anterior part of the circle of Willis. Endovascular treatment was indicated in patients admitted with delay, with severe vasospasm, a poor Hunt and Hess grading and in all aneurysms of the vertebrobasilar arterial network. Age was of less importance in comparison to the status of the vessels for selection of the method of treatment. Giant aneurysms are difficult to treat as surgery is faced with the size of the aneurysmal itself and endovascular technique with the width of the aneurysmal neck.
Aneurysm, Ruptured↗
[Endovascular treatment of intracranial aneurysms].
Major improvements have been achieved in endovascular treatment of intracranial aneurysms during the last twenty years. Initial techniques of selective balloon occlusion were progressively replaced by the packing of the aneurysmal pouch with very small and soft metallic devices, named coils, with controlled detachment. In some rare cases, balloon occlusion is still used in order to occlude the parent vessel or to reverse the flow, especially in the vertebro-basilar system. Essential aims for the anaesthesiologist include: complete immobility of the patient throughout the endovascular procedure, systemic anticoagulation in order to avoid any thromboembolic complication during and after treatment, prevention and/or treatment of vasospasm, precise evaluation of fluid balance during the procedure. Our experience is based on 145 aneurysms in 135 patients, treated by endovascular route; 91 (63%) of them were revealed by a subarachnoid haemorrhage (SAH). Their main locations were: the carotid siphon (33.1%), the anterior communicating artery (19.3%), the basilar artery (17.2%) and the middle cerebral artery (17.2%). Thirty-seven of these aneurysms (25.5%) were very small in size with a diameter less than 4 mm. Total or sub-total (more than 90%) occlusion was achieved in 141 aneurysms (90.3%). Thromboembolic complications occurred in eight patients (5.9%), neurological sequelae in one. Other treatment-related complications included the migration of a coil outside the aneurysm in six cases (4.4%) without neurological deficit in one and five ruptures of the aneurysm (3.7%) during the procedure with one lethal issue due to the spontaneous bleeding of a controlateral arterio-venous malformation. Thirteen patients died (9.6%). The cause of the death was related on the initial SAH in 11 of them. The two others were both due to rupture: of a second untreated aneurysm in one case and of an associated arteriovenous malformation in the second one. At present the main indications of endovascular treatment are poor or non indications for neurosurgery. Due to the quality of results, endovascular therapy will be more and more used in case of ruptured or non ruptured aneurysms.
Cerebral Angiography↗
[Endovascular treatment of vasospasm].
Various therapeutic strategies have been recently proposed to prevent the vasospasm after subarachnoid haemorrhage, and to avoid its clinical consequences. Despite these progresses, mortality and morbidity of delayed ischaemic consequences of vasospasm remain important. Two endovascular treatments have been proposed. The successful use of transluminal angioplasty for vasospasm was first reported by Zubkov in 1984. Transluminal angioplasty is very effective with clinical improvement when the treatment is undertaken without delay after the onset of symptoms. Limitations of this technique are the inaccessibility of distal arteries and the risks (vascular rupture or occlusion). More recently, to overcome these limitations, a selective intraarterial infusion of papaverine has been proposed. These infusions are less risky and can be employed in distal vasospasm. However, clinical results seem to be less favourable and often transient. These two techniques are still used with slightly different indications. According to our experience, it seems reasonable to reserve transluminal angioplasty for symptomatic vasospasm, associated with papaverine or not, and to use papaverine alone in all other cases.
Angioplasty, Balloon↗
Aneurysm clipping after endovascular treatment with coils: a report of eight patients.
Between January 1990 and December 1994, patients with subarachnoid hemorrhage related to ruptured aneurysms who were referred to our institution were treated by neurosurgical and neuroradiological teams. In each patient, the respective indications for neurosurgical or endovascular treatment were discussed, taking into consideration patients' age and the morphological and topographical aneurysm features. We report eight cases of patients with subarachnoid hemorrhage who underwent operations after primary endovascular procedures (Hunt and Hess scores III, IV, and V). The indications for surgical treatment were as follows. First, deliberate partial occlusion of the aneurysm (two aneurysms of the internal carotid artery and one aneurysm of the anterior communicating artery) was performed to obtain only partial clotting of the aneurysm sac by free coils. However, this procedure was discontinued in favor of the use of Guglielmi detachable coils. The second indication was partial occlusion after an endovascular procedure (two aneurysms of the middle cerebral artery and one internal carotid artery aneurysm). The third indication was re-expansion of the aneurysm 1 year after the endovascular treatment (one middle cerebral artery aneurysm). The final indication was secondary rupture of the aneurysm sac and false aneurysm around the migrating coil (one aneurysm of the pericallosal artery). During surgery, the aneurysm sac appeared translucent. The coils bulged out and stretched the aneurysm sac. One ruptured the membrane leading to a subarachnoid hemorrhage during the endovascular procedure. No hemorrhage occurred during the surgical clipping. Aneurysm obliteration was easily performed, especially when the packing was partial, but was very difficult when the complete aneurysm closure led to a stenosis of the parent vessel. A giant sylvian aneurysm rest, visible only with angiography, was left untreated. This series illustrates an original experience, which led us to conclude that aneurysm surgery with coils in place is not as difficult as is often thought.
Adult↗