Early outcomes and periprocedural complications of transarterial embolization of brain arteriovenous malformations with Onyx®

Background Brain arteriovenous malformation (BAVM) is a rare pathology diagnosed mostly in young adults. However, due to its hemorrhagic complications, it constitutes an important clinical problem. Treatment modalities available include endovascular, surgery and radiosurgery. The aim of the study was to assess the efficacy and safety of endovascular treatment of BAVM with Onyx® by reporting one-center experience. Material and methods Between 2006 and 2013, 54 patients with BAVM were embolized with Onyx. The group consisted of 24 males and 30 females, aged 10 to 65 years (mean 42.6±15.4). Clinical manifestations of BAVMs were: hemorrhage in 27 (50.0%), headaches in 12 (22.2%), seizures in 7 (13.0%) and focal neurologic deficits in 2 (3.7%) patients. Six (11.1%) patients were asymptomatic. A majority of BAVMs were of II and III grade in Spetzler-Martin scale (19 and 22 cases respectively). Results A total number of 108 endovascular procedures were performed (mean 2.00±0.98 sessions/patient). Complete obliteration of malformation was achieved in 25 (46.3%) patients, mostly with grade II and III BAVMs. In 29 (53.7%) patients, embolization led to a decrease in size of BAVM that made it feasible for other treatment modality. Morbidity and mortality rates were 5.6% and 1.8% respectively. The rate of hemorrhagic complications was 9.3%. Conclusion Embolization of BAVM with Onyx® is an effective and safe method of treatment. However, regarding type and consequences of complications, the technique needs further improvement

Significance of aneurysm wall enhancement on high-resolution vessel wall magnetic resonance imaging in clinical management of patients with intracranial aneurysms

Introduction. The prevalence of intracranial aneurysms is estimated to be around 3% in the general population. Although these are often incidental findings, they potentially carry the risk of rupture, with all of the devastating consequences of SAH. State of the art. Several risk factors of aneurysm rupture have been identified, including aneurysm size, irregular shape, and location. Although it is widely accepted that the risk of rupture increases with size, small aneurysms remain the cause of a significant percentage of aneurysmal SAH. Up to 30% of patients with acute aneurysmal SAH have multiple aneurysms. Determining the site of rupture in these patients can be challenging, given that the results of imaging studies and clinical symptoms are sometimes inconclusive. It would be extremely useful to identify new imaging biomarkers of aneurysm instability which could have an impact on patient management and qualification for treatment. High-resolution vessel wall magnetic resonance imaging (HR-VW MRI) opens up new possibilities for improved characterisation of intracranial vasculature. One of the most promising clinical applications of this new imaging tool is the evaluation of intracranial aneurysms. Clinical implications. Aneurysm wall enhancement (AWE) on HR-VW MRI is believed to be a marker for wall inflammation and, potentially, for aneurysm instability. In this article, we summarise the published literature on AWE with special emphasis on its use in determining the site of rupture in the setting of acute SAH in patients with multiple aneurysms, as well as its role in identifying unruptured aneurysms which are at the greatest risk of rupture. Future directions. More and larger studies are needed to definitively establish the role of AWE on HR-VW MRI in the diagnostic workup of patients with intracranial aneurysms

Przezskórne leczenie krytycznego niedokrwienia kończyn dolnych u pacjentów z niedrożnością tętnic podudzi

Background: This article describes the application of percutaneous transluminal angioplasty (PTA) in the treatment of crural artery obstruction in patients with critical lower limb ischemia. Material/Methods: In 17 patients, 24 PTAs of crural artery obstructions were performed. The clinical material consisted of 9 men and 8 women, whose mean age was 72 years (range 54-85 years). 11 patients were classified in clinical stage Fontaine IV, and 6 in stage III. The obstructions were from 3 to 21 cm (mean 6 cm). In 8 cases, PTA of the femoropopliteal segment was also carried out. The risk factors and comorbidities included diabetes 10 cases (58.8%), hypertension 9 cases (56%), ischemic heart disease 8 cases (50%), hyperlipidemia 7 cases (43.8%), cerebrovascular diseases 3 cases (18.8%), and cigarette smoking 6 cases (37.5%). Technical success was defined as restoration of the artery along its whole length to the foot. Pain relief at rest and healing of trophic lesions at 30-day follow-up were recognized as a good outcome. Results: Technical success was achieved in 12 patients (70.6%). In 2 cases the patency was only restored in the proximal part of the artery (12.5%). In 3 cases (17.6%) the procedure failed. In one case acute occlusion of the artery occurred. In 2 cases the obstruction was not successfully passed with a guidewire. In 4 cases hematoma was found at the puncture site, without clinical consequences. In 13 patients (76.4%) clinical success was achieved. Conclusions: Percutaneous transluminal angioplasty is an effective and relatively safe method of treatment of patients with critical limb ischemia caused by obstruction of the crural arteries

Zastosowanie przezskórnej wewnątrznaczyniowej angioplastyki w leczeniu zwężeń i niedrożności tętnic podudzia

Background: The method of percutaneous transluminal angioplasty in the treatment of stenoses and obstruction of crural arteries was introduced. Material/Methods: In 51 patients aged 51-86 years (mean: 69 years), including 32 men and 19 women, 56 procedures of crural PTA were carried out. The patients were classified as Fontaine's clinical stages IIb-IV. The procedures involved stenoses in 40 cases and 16 artery occlusions. The average length of the lesion was 2.7±1.6 cm. In 22 cases, crural PTA was performed in combination with PTA of the femoropopliteal segment and in 34 cases only crural PTA was carried out. The angioplasty was performed with antegrade puncture through the ipsilateral common femoral artery in 48 patients and in 3 from retrograde puncture with the cross-over method. For the procedures of the crural arteries, guide wires and coronary balloons were used. The following risk factors were present in the patients: 49% diabetes, 48% cigarette smoking, 42% hypertension, and 23% hyperlipidemia. The comorbidity with the highest incidence was ischemic heart disease (51%). Results: Good primary arteriographic and clinical results were achieved in 50 cases (89.2%). The ankle-brachial index (ABI) increased on average by 0.26 (0.20-0.52). In one case, occlusion of an artery occurred as a complication, and in 5 the procedure failed without any serious clinical consequences. Conclusions: Percutaneous balloon angioplasty is an effective method of treatment of patients with stenoses and short obstructions of crural arteries

Comparison of 3D-CRT and IMRT techniques in radiotherapy for post-prostatectomy patients with a higher risk of nodal involvement

Background. Irradiation of a larger volume of the target may lead to an increase of the doses delivered to the surrounding organs at risk (OAR) for post-prostatectomy patients with a higher risk of nodal involvement. It was anticipated that IMRT significantly improved OAR sparing. The aim of this study was to provide a dosimetric comparison between conformal radiotherapy (3D-CRT) and intensity-modulated radiotherapy (IMRT) treatment plans for patients with prostate cancer irradiated to the prostate bed and pelvic lymph-nodal area. Materials and methods. The 3D-CRT and IMRT plans were created for ten patients after prostatectomy. The treatment plans were generated for the prostate bed (PTV1) and the pelvic lymph nodes (PTV2). The sum of PTV1 and PTV2 was irradiated to a mean dose of 46 Gy in 23 fractions, and additionally PTV1 was irradiated to a mean dose of 18 Gy in 9 fractions. Target coverage and the doses delivered to the pelvic bones, the rectum, the bladder, the bowel bag, and the femurs, were compared between techniques. The Wilcoxon signed-rank test was used to compare the dosimetric parameters. Results. The dosimetric quality of 3D-CRT and IMRT plans were comparable for target coverage (the mean value of PTV1 V95%, the mean value of PTV2 V95% all > 99%). The IMRT plans resulted in significant reductions in the pelvic bones V30[%], V40[%], the rectum V40[%], V50[%], V60[%], the bladder V40[%], V50[%], V60[%], the bowel bag V45[cc] and the femurs V40[%]. Conclusions. The analysis presented in this paper demonstrates that the IMRT technique reduces the delivered dose to the OARs. Most interesting was the possibility of reducing the delivered dose to the pelvic bones and the bowel bag. This allowed us to expect a decreased risk of acute hematologic toxicity and acute gastrointestinal toxicity

Comparison of 3D-CRT and IMRT techniques in radiotherapy for post-prostatectomy patients with a higher risk of nodal involvement

Background. Irradiation of a larger volume of the target may lead to an increase of the doses delivered to the surrounding organs at risk (OAR) for post-prostatectomy patients with a higher risk of nodal involvement. It was anticipated that IMRT significantly improved OAR sparing. The aim of this study was to provide a dosimetric comparison between conformal radiotherapy (3D-CRT) and intensity-modulated radiotherapy (IMRT) treatment plans for patients with prostate cancer irradiated to the prostate bed and pelvic lymph-nodal area. Materials and methods. The 3D-CRT and IMRT plans were created for ten patients after prostatectomy. The treatment plans were generated for the prostate bed (PTV1) and the pelvic lymph nodes (PTV2). The sum of PTV1 and PTV2 was irradiated to a mean dose of 46 Gy in 23 fractions, and additionally PTV1 was irradiated to a mean dose of 18 Gy in 9 fractions. Target coverage and the doses delivered to the pelvic bones, the rectum, the bladder, the bowel bag, and the femurs, were compared between techniques. The Wilcoxon signed-rank test was used to compare the dosimetric parameters. Results. The dosimetric quality of 3D-CRT and IMRT plans were comparable for target coverage (the mean value of PTV1 V95%, the mean value of PTV2 V95% all > 99%). The IMRT plans resulted in significant reductions in the pelvic bones V30[%], V40[%], the rectum V40[%], V50[%], V60[%], the bladder V40[%], V50[%], V60[%], the bowel bag V45[cc] and the femurs V40[%]. Conclusions. The analysis presented in this paper demonstrates that the IMRT technique reduces the delivered dose to the OARs. Most interesting was the possibility of reducing the delivered dose to the pelvic bones and the bowel bag. This allowed us to expect a decreased risk of acute hematologic toxicity and acute gastrointestinal toxicity

Diagnostic value of non-enhanced computed tomography in identifying location of ruptured cerebral aneurysm in patients with aneurysmal subarachnoid haemorrhage

Background. In patients with SAH and multiple aneurysms, the ruptured lesion must be identified to prevent recurrent bleeding.Aim of the study. To assess the diagnostic value of non-enhanced computed tomography (NECT) in identifying the rupture site in patients with subarachnoid haemorrhage (SAH) and multiple aneurysms.Material and methods. We included patients with SAH revealed by NECT and multiple aneurysms detected on computed tomography angiography (CTA) in whom a ruptured aneurysm was identified during neurosurgery. Two radiologists predicted the location of the ruptured aneurysm based on the distribution of the SAH and location of intracerebral haematoma (ICH) by NECT.Results. Eighty-three patients with a mean age of 55.7 ± 14.4 years were included. Ruptured aneurysms were significantly larger (mean size 7.7 ± 4.7 mm) than unruptured aneurysms (mean size 5.9 ± 4.5 mm; p = 0.014). Interobserver agreement was 0.86 (p < 0.001). Overall sensitivity and specificity of radiological prediction were 78.3% (95% CI, 68.6%-87.1%) and 96.4% (95% CI, 94.3%-97.8%) respectively. Overall PPV and NPV were 78.3% (95% CI, 67.6%-86.3%) and 96.8% (95% CI, 94.8%-98.1%) respectively. The sensitivity and PPV for aneurysms in the anterior communicating, anterior, and middle cerebral arteries appeared to be significantly higher than in other locations (p = 0.015 and 0.019 respectively). Analysis of independent predictive factors of correct radiological location revealed that ICH predisposes to a correct radiological diagnosis with an odds ratio of 8.57 (95% CI, 1.07-68.99; p = 0.03).Conclusions. NECT has a high diagnostic value in identifying the source of bleeding in patients with multiple aneurysms for anterior circulation aneurysms, especially with coexisting ICH. For other locations, NECT is not reliable enough to base treatment decisions upon

The role of cultural practitioners in managing memories of disputed territories: a literature review

This literature review discusses the connections between space, memory and cultural practice from several standpoints. The first part on the Relationship between Memory, Territoriality and Cultural Practice brings to memory studies insights from the spatial turn in cultural and political geography. By the emphasis on ‘lived’ space, David Clarke raises the question of what is at stake in the memory of disputed territories, paying attention in particular to affect, embodiment and performance. By stressing individual, processual and open-ended engagements with place and memory, scholars working with affective and nonrepresentational approaches understand place as multiple and becoming, which works against dominant accounts of geographical location that seek to define and delimit both geographically and temporally by insisting on historical fixity and an exclusionary spatial ordering. The second part on Memory and Cultural Heritage: From Reconciliation and Peace Building to Pilgrimage and Tourism by Weronika Czyżewska-Poncyljusz, Umber bin Ibad and Joanna Wawrzyniak surveys recent scholarship on (i) reconciliation and peace building; (ii) heritage and reconciliation; (iii) and diasporas, pilgrimages and tourism. These fields offer insights to memory studies as it seeks to find ways in which cultural practices contribute to conflict transformation and post-conflict recovery. Recognition of the profound impact culture has on peace building and reconciliation processes leads to interdisciplinary efforts in creating models of art-based educational programs and socially engaged cultural practices on community levels that contribute to practice oriented approach to conflict resolution through culture. Special focus in this review is given to cultural practices at heritage sites which have potential to overcome antagonism and one-sidedness of memory practices, strategies, and forms in postconflict societies. The review shows that while it is widely recognized that cultural practices might become a resource for both reconciliation and for renewal of conflicts, it is still not clear what type of heritage management is decisive in peace building and reconciliation