Endovascular therapy of direct dural carotid cavernous fistulas - A therapy assessment study including long-term follow-up patient interviews

Purpose Endovascular embolization nowadays is a well-established treatment option for direct carotid cavernous fistulas (dCCF, Barrow Type A). There are many publications on the complication and success rates of this method. However, little is known on the patients' opinion on the treatment result after several years. We report on this issue also including the "pioneer patients" treated almost two decades ago. Methods We retrospectively reviewed the records of all patient (n = 25) with a more than 24 months follow-up interval after endovascular treatment of a dCCF at our institution from 01/1999 to 08/2018. We determined primary therapy success, complication rate, state of the fistula in the last imaging follow-up and quoted the patient's subjective perception of the long-term treatment success using a standardized interview form. Results Occlusion rate in the last imaging follow up was 96% (24/25) with a complication rate of 8% (2/25). The response rate on our interview request was 96% (24/25) with a rate of considered feedback of 84% (21/25 patients). Duration of our observation interval for the patient reported outcome was 143 months / 11 years (median, range: 35-226 m/2-18 y). Most of them (21/25,84%) felt they benefited from the treatment. Conclusions Endovascular supply of dCCF is a highly effective treatment method leading to a sustainable therapy success with long-lasting stable subjective benefit even to our "pioneer patients" treated almost two decades ago

Pseudo-subarachnoid haemorrhage due to chronic hypoxaemia: case report and review of the literature

Background: The specificity of computed tomography (CT) for subarachnoid haemorrhage (SAH) is very high. However, physicians should be aware of rare false positive findings, also referred to as "pseudo-SAH". We present an unusual case in which such a finding was caused by chronic hypoxaemia. Case presentation: A 37-year-old male patient presented with headaches. His CT-scan showed multiple confluent subarachnoid hyperattenuations, which mimicked SAH. However, the headache was chronic and had no features typical for SAH. The patient suffered from severe chronic hypoxaemia due to congenital heart failure. On CT-angiography diffuse intracranial vessel proliferation was found and laboratory results revealed a highly raised level of haematocrit, which had both probably developed as compensatory mechanisms. A combination of these findings explained the subarachnoid hyperdensities. Magnetic resonance imaging (MRI) showed no signs of SAH and visualized hypoxaemia in cerebral veins. A diagnosis of pseudo-SAH was made. The patient's symptoms were likely due to a secondary headache attributed to hypoxia and/or hypercapnia. Therapy was symptomatic. Conclusions: Severe chronic hypoxaemia should be recognised as a rare cause of pseudo-SAH. Clinical evaluation and MRI help differentiate SAH from pseudo-SAH

Uncomplicated Pregnancy and Delivery after Previous Severe Postpartum Cerebral Angiopathy

Postpartum cerebral angiopathy (PCA) is a cerebral vasoconstriction syndrome developing shortly after delivery, without signs of preceding eclampsia. The risk for recurrence of PCA is unknown. Here, we report on a closely monitored, uneventful pregnancy of a woman with a previous severe episode of PCA. In summary, this case report demonstrates that PCA does not necessarily recur in following pregnancies, even after previous severe episodes

Early treatment of complex located pediatric low-grade gliomas using iodine-125 brachytherapy alone or in combination with microsurgery

To analyze efficacy, functional outcome, and treatment toxicity of low-dose rate I-125 brachytherapy (SBT) alone or in combination with best safe resection (in case of larger tumor volumes) as first-line treatment for pediatric low-grade gliomas (PLGGs) not suitable for complete resection. Consecutively treated (2000-2014) complex located circumscribed WHO grade I/II PLGGs were included. For small tumors (4cm in diameter) SBT alone was performed;for larger tumors best safe resection and subsequent SBT was chosen. Temporary Iodine-125 seeds were used (median reference dose: 54Gy). Treatment response was estimated with the modified MacDonald criteria. Analysis of functional outcome included ophthalmological, endocrinological and neurological evaluation. Survival was analyzed with the Kaplan-Meier method. Prognostic factors were obtained from proportional hazards models. Toxicity was categorized according to the Common Terminology Criteria for Adverse Events. Fifty-eight patients were included treated either with SBT alone (n=39) or with SBT plus microsurgery (n=19). Five-year progression-free survival was 87%. Two patients had died due to tumor progression. Among survivors, improvement/stabilization/deterioration of functional deficits was seen in 20/14/5 patients, respectively. Complete/partial response had beneficial impact on functional scores (P=0.02). The 5-year estimated risk to receive adjuvant radiotherapy/chemotherapy was 5.2%. The overall early (delayed) toxicity rate was 8.6% (10.3%), respectively. No permanent morbidity occurred. In complex located PLGGs, early SBT alone or combined with best safe resection preserves/improves functional scores and results in tumor control rates usually achieved with complete resection. Long-term analysis is necessary for confirmation of these results

Patient reported long-term outcome after endovascular therapy of indirect dural carotid cavernous fistulas.

PURPOSE:Patient-reported long-term follow-up after endovascular treatment of indirect carotid cavernous fistulas is important, but rarely addressed in literature. We report on this issue with a special focus on the patient's view and its impact on the indication evaluation process. METHODS:We retrospectively reviewed the records of all patients (n = 33) with a minimum follow-up interval of at least 36 and up to 166 months after endovascular treatment of an indirect carotid cavernous fistula (Barrow B-D) at our institution (treated from 01/2003 to 06/2015). We determined treatment details including primary therapy success and complication rate and quote the patient's subjective perception of the long-term treatment success using a standardized interview form. RESULTS:As a primary result the fistula was completely occluded in 25/33 cases (76%), while a downgrading was achieved in 8/33 (24%) of the cases. Secondary occlusion was observed in three out of eight patients (38%). In the long-term interview (response rate: 91%, median follow-up interval: 114 months) 87% of the patients reported high satisfaction with the long-term therapy result. Endovascular treatment achieved a sustainable relief from all eye-related symptoms in 89% and from pulsatile tinnitus in 57% of the cases. CONCLUSIONS:In addition to good results in terms of angiographic and clinical cure, endovascular treatment is also perceived as beneficial by most of the patients. This is another important argument in favor of an endovascular treatment

Endovascular stroke treatment now and then-procedural and clinical effectiveness and safety of different mechanical thrombectomy techniques over time

Background: The most essential development in endovascular stroke treatment (EST) was the shift from intra-arterial thrombolysis to endovascular thrombectomy with dedicated thrombectomy devices, most notably the introduction of stent-retrievers. We evaluated procedural and clinical effectiveness and safety of different EST techniques over time. Methods: We retrospectively analyzed EST cases that were treated by the same interventionalist before (n=36) and after (n=50) stent-retrievers were established as the treatment device of first choice. EST techniques in the first cohort comprised intra-arterial thrombolysis (n=24), manual thrombus aspiration (n=15), the use of the Penumbra thrombectomy system (n=13) and the Phenox clot retriever (n=3), intracranial stenting (n=10), and EST with stent-retrievers as a salvage procedure (n=11). In the second cohort, EST with stent-retrievers was the treatment option of first choice (n=47). Intra-arterial thrombolysis (n=15) and stenting of the occluded vessel (n=1) were performed, whenever EST with stent-retrievers failed. Results: In both cohorts, revascularization rates (TICI ≥2b) were high (91.7% and 86.0%, respectively). A significantly lower number of interventional techniques per case were required in the second cohort (mean ± SD, 1.4±0.5 vs. 2.1±0.9, P<0.001). Recanalization was achieved almost twice as fast in the second cohort (85 vs. 163 minutes on average, P<0.001). The rate of patients achieving good functional outcome (mRS ≤2) was higher in the second cohort (40.0% vs. 22.2%, P=0.083). Conclusions: Our findings imply that when stent-retrievers were established as first-line the treatment device a significantly lower number of interventional techniques per case were required and recanalization was achieved almost twice as fast

Incidental Findings in Neuroimaging Research: Ethical Considerations

Neuroimaging-especially functional MR imaging (fMRI)-opens the door to non-invasively map cortical processing and to understand how our brain works. fMRI evolved from basic (Ogawa et al., Proc Natl Acad Sci U S A 87: 9868-9872, 1990; Ogawa et al., Biophys J 64: 803-812, 1993; Kwong et al., Proc Natl Acad Sci U S A 89: 5675-5679, 1992) and clinical applications in the 1990s (Yousry et al., Radiology 195: 23-29, 1995) to become a powerful and ubiquitous tool in neurocognitive research. Because fMRI can be used to answer clinical questions, the more the research conducted, the greater the potential for clinical translation and subsequent patient benefit. This book focuses on the clinical applications of fMRI; however, prior to any routine clinical use, there is a need to test its reliability in healthy controls. The focus of this chapter is on ethical questions raised by incidental findings (IF) in fMRI in healthy volunteers and the conclusions to be drawn. Considering ethical issues is important in patient care but should be taken even more serious in healthy volunteers. Ethical issues relevant to fMRI concern how the requirements of voluntary participation and privacy are handled by the researchers (Carli et al., J Med Ethics 38: 127-129, 2012), how harm is prevented and whether appropriate information and decisional aids are offered to the subjects or patients before obtaining informed consent (Reiter-Theil and Stingelin Giles, Screening and preventive diagnosis with radiological imaging, Springer, Berlin 2007). Because an IF can have a major impact on the subject’s life, the management pertaining to such a discovery should be analysed thoroughly (Ulmer et al., AJNR Am J Neuroradiol 30: E55, 2009)