Giant aneurysms have been treated with endovascular approaches like general, balloon-assisted and stent-assisted coiling, and flow diverter stent-assisted techniques. Few cases have been reported to be treated with both normal and large coils. Despite the mass effect, an adequate revascularization has been reported. An initial use of these coils is being reported in the current study. This is a case which has been successfully treated using a stent-assisted coiling with both small and large coils i.e., Penumbra Coil 400 (Penumbra, Inc., Alameda, California)

Cortes Lozano, William

Lobelo García, Nelson Oswaldo

Ordoñez Rubiano, Edgar Gerardo

Von Diemling, Christian

English

LAReferencia - Red Federada de Repositorios Institucionales de Publicaciones Científicas Latinoamericanas

Received 07/03/2016 Review began  07/07/2016 Review ended  08/17/2016 Published 08/31/2016© Copyright 2016Ordónez-Rubiano et al. This is an openaccess article distributed under the termsof the Creative Commons AttributionLicense CC-BY 3.0., which permitsunrestricted use, distribution, andreproduction in any medium, provided theoriginal author and source are credited.Stent-assisted Embolization of a Giant Aneurysmof the Middle Cerebral Artery Using Small andLarge Coils (Penumbra Coil 400)Edgar Gerardo Ordónez-Rubiano  , Christian Von-Diemling  , William Cortes-Lozano  , Nelson OswaldoLobelo-Garcia 1. Fundación Universitaria de Ciencias de la Salud, Hospital de San Jose/Hospital Infantil Universitario de San José 2.Department Allg. Innere Medizin, Klinik Hirslanden 3. Neurosurgery, Fundación Universitaria de Ciencias de la Salud,Hospital de San Jose/Hospital Infantil Universitario de San José 4. Neuroradiology, Fundación Universitaria de Cienciasde la Salud, Hospital de San Jose/Hospital Infantil Universitario de San JoséCorresponding author: Edgar Gerardo Ordónez-Rubiano, edgar_o88@hotmail.comAbstractGiant aneurysms have been treated with endovascular approaches like general, balloon-assisted and stent-assisted coiling, and flow diverter stent-assisted techniques. Few cases have been reported to be treatedwith both normal and large coils. Despite the mass effect, an adequate revascularization has been reported.An initial use of these coils is being reported in the current study. This is a case which has been successfullytreated using a stent-assisted coiling with both small and large coils i.e., Penumbra Coil 400 (Penumbra, Inc.,Alameda, California). Categories: NeurosurgeryKeywords: endovascular, giant aneurysm, stent, embolization, large coils, coilingIntroductionThe middle cerebral artery (MCA) is the most common location for giant aneurysms. About 15% of all MCAaneurysms are giant aneurysms [1]. A giant aneurysm is defined as an aneurysm with a diameter of morethan 25mm. Large giant aneurysms of the MCA are rare lesions. Their natural history, as well as theetiopathogenesis, do not remain completely elucidated. The incidence of a giant aneurysm is reported to be6.1% [2]. There is still a controversial discussion if clipping or coiling MCA aneurysms are superior or betterfor the patient, and often there is no ideal solution. Some authors prefer clipping the aneurysm because ofthe possibility of intraoperative hematoma evacuation if needed [3]. Lately, published studies have shownbetter outcomes when treating an aneurysm with a Penumbra 400 Coil in comparison to other conventionalcoils because of its higher packing density and lower number of coils per aneurysm, while achieving similarocclusion rates. Another advantage of these coils seems to be the cost-effectiveness [4, 5]. We describe thecase of a giant aneurysm of the MCA, which was treated successfully at our institute with Penumbra Coil400. Case PresentationA 27-year-old woman presented to the emergency department with nausea, vomiting, and global headache.The admission of non-contrast CT of the head showed a rounded hyperdense lesion in the left Sylvianfissure, without evidence of acute hemorrhage or associated hydrocephalus. A subsequent magneticresonance angiogram (MRA) was performed showing a giant aneurysm of the left MCA. A catheterangiography was further performed which demonstrated a giant aneurysm of the M1 segment of the leftMCA, with a distant flow to M3 and M4 segments, and collaterals coming from the left anterior cerebralartery (ACA). Before deciding whether to occlude the vessels or not, a balloon-assisted occlusion test (BOT)with a Scepter balloon in the proximal ostium of the aneurysm was performed, which resulted in a transitoryfacial paralysis. The parent vessel occlusion could not be performed. Therefore, it was decided to performstent-assisted coil embolization of the aneurysm using both small and large coils. (Figure 1) A right femoralartery entry was used with an 8F-introducer, through which a 0.88 Neuronmax catheter was entered up tothe right internal carotid artery (ICA). Subsequently, a distal support Vasco microcatheter was catheterizedwith a 0.014 microwire to the segment of the artery distal to the aneurysm. A Slim-px microcatheter wasused to access the proximal M1 segment of the right MCA. A 3D-DSA reconstruction was performed andused as a railroad map. 1 2 34 Open Access CaseReport  DOI: 10.7759/cureus.762How to cite this articleOrdónez-Rubiano E, Von-Diemling C, Cortes-Lozano W, et al. (August 31, 2016) Stent-assisted Embolization of a Giant Aneurysm of the MiddleCerebral Artery Using Small and Large Coils (Penumbra Coil 400). Cureus 8(8): e762. DOI 10.7759/cureus.762FIGURE 1: Pre-embolization Catheter Angiography Images(A) There is a 5x5x5cms giant Middle Cerebral Artery aneurysm, with flush-filling to the superolateral wall.Perforating arteries are denoted proximal to the aneurysm. (B) The ballon for the Ballon-assisted OcclusionTest is depicted (arrow).Posteriorly, an Enterprise stent was successfully introduced, and a complete recanalization was achieved.After the placement of the stent, a total of 36 coils (26 conventional and seven large coils) were used.Subsequent one and two-year follow-up MRAs and angiograms showed adequate packaging (Figure 2). Thepatient presented occasional headaches, but there was no hemorrhage or other complications related to thetreatment of the aneurysm.FIGURE 2: Post-embolization MRI and Catheter Angiography Images(A) Catheter angiography and (B) Susceptibility-Weighted Magnetic Resonance Imaging post-coiling one-year-control demonstrating adequate embolization with thrombosis and without partial filling of theaneurysm.DiscussionWhen the BOT is tolerated, the parent vessel occlusion is the primary therapy for a large and giant aneurysmwith the exception of the basilar tip. Surgical bypass should be reserved only for cases where an aneurysm islocated intradurally and has a high potential of re-rupture and cannot be treated by parent arterial occlusionor endovascular approaches [2]. Here we describe the treatment of a giant right middle cerebral arteryaneurysm using small and large coils (Penumbra 400 coil). An estimation of how many conventional coilswould be needed is challenging and depends on the size and length of coils used. We chose this coil becauserecent studies in comparison with conventional coils have shown that the  Penumbra Coil 400 provides ahigher packing density with a lower number of coils per aneurysm while achieving similar occlusion rates.Furthermore, it seems to be more cost-effective [4, 5]. Achieving adequate packing density during aneurysmtreatment is often challenging. We know from studies which investigated the packing attenuation (inserted2016 Ordónez-Rubiano et al. Cureus 8(8): e762. DOI 10.7759/cureus.762 2 of 3coil volume/aneurysm volume), that the majority of aneurysms that are packed more than 25% stay stable[6], therefore it is critical to achieve a high packing density. ConclusionsThis case demonstrates an adequate treatment of a giant MCA aneurysm with a stent-assisted coiling withPenumbra Coil 400. However, the mass effect of embolization material could be a cause of the residualheadaches. Additional InformationDisclosuresHuman subjects: Consent was obtained by all participants in this study. Comité de Ética de la FundaciónUniversitaria de Ciencias de la Salud issued approval. Conflicts of interest: In compliance with the ICMJEuniform disclosure form, all authors declare the following: Payment/services info: All authors havedeclared that no financial support was received from any organization for the submitted work. Financialrelationships: All authors have declared that they have no financial relationships at present or within theprevious three years with any organizations that might have an interest in the submitted work. Otherrelationships: All authors have declared that there are no other relationships or activities that could appearto have influenced the submitted work.References1. Sughrue ME, Saloner D, Rayz VL, et al.: Giant intracranial aneurysms: evolution of management in acontemporary surgical series. Neurosurgery. 2011, 69:1261–1270. 10.1227/NEU.0b013e31822bb8a62. Mortimer AM, Bradley MD, Mews P, et al.: Endovascular treatment of 300 consecutive middle cerebral arteryaneurysms: clinical and radiologic outcomes. AJNR Am J Neuroradiol. 2014, 35:706–714. 10.3174/ajnr.A37763. Mascitelli JR, Polykarpou MF, Patel AA, et al.: Initial experience with Penumbra Coil 400 versus standardcoils in embolization of cerebral aneurysms: a retrospective review. Journal of neurointerventional surgery.2013, 5:573–576. 10.1136/neurintsurg-2012-0104834. Milburn J, Pansara AL, Vidal G, et al.: Initial experience using the Penumbra coil 400: comparison ofaneurysm packing, cost effectiveness, and coil efficiency. Journal of. 2014, 6:121–124. 10.1136/neurintsurg-2012-0105875. van Rooij WJ, Sluzewski M: Endovascular treatment of large and giant aneurysms. AJNR Am J Neuroradiol.2009, 30:12–18. 10.3174/ajnr.A12676. Sluzewski M, van Rooij WJ, Slob MJ, et al.: Relation between aneurysm volume, packing, and compaction in145 cerebral aneurysms treated with coils. Radiology. 2004, 231:653–658. 10.1148/radiol.23130304602016 Ordónez-Rubiano et al. Cureus 8(8): e762. DOI 10.7759/cureus.762 3 of 3

Reconstruction of the Ascending Reticular Activating System with Diffusion Tensor Tractography in Patients with a Disorder of Consciousness after Traumatic Brain Injury

Repositorio Digital de la Fundación Universitaria de Ciencias de la Salud

Received 07/20/2017 Review began  08/08/2017 Review ended  09/27/2017 Published 09/28/2017© Copyright 2017Ordóñez-Rubiano et al. This is an openaccess article distributed under the termsof the Creative Commons AttributionLicense CC-BY 3.0., which permitsunrestricted use, distribution, andreproduction in any medium, provided theoriginal author and source are credited.Reconstruction of the Ascending ReticularActivating System with Diffusion TensorTractography in Patients with a Disorder ofConsciousness after Traumatic Brain InjuryEdgar Gerardo Ordóñez-Rubiano  , Jason Johnson  , Cesar O. Enciso-Olivera  , Jorge H. Marín-Muñoz  ,William Cortes-Lozano  , Pablo E. Baquero-Herrera  , Edgar G. Ordóñez-Mora  , Hernando A. Cifuentes-Lobelo 1. Neurosurgery Department, Fundación Universitaria De Ciencias De La Salud, Hospital de San Jose/Hospital InfantilUniversitario de San José 2. Neuroradiology, MD Anderson 3. Critical Care and Intensive Care Unit. Hospital InfantilUniversitario De San José. Bogotá, Colombia, Hospital Infantil Universitario de San José - Fundación Universitaria deCiencias de la Salud 4. Neuroradiology. Hospital Infantil Universitario De San José. Bogotá, Colombia., Hospital InfantilUniversitario de San José - Fundación Universitaria de Ciencias de la Salud 5. Neurosurgery, Fundación Universitaria DeCiencias De La Salud, Hospital de San Jose/Hospital Infantil Universitario de San José 6. Neurosurgery Department.Hospital Infantil Universitario De San José. Bogotá, Colombia, Hospital Infantil Universitario de San José - FundaciónUniversitaria de Ciencias de la Salud 7. Neurosurgery Department. Hospital Infantil Universitario De San José. Bogotá,Colombia., Hospital Infantil Universitario de San José - Fundación Universitaria de Ciencias de la SaludCorresponding author: Edgar Gerardo Ordóñez-Rubiano, edgar_o88@hotmail.comAbstractThis work describes the reconstruction of the ascending reticular activating system (ARAS) with diffusiontensor tractography in three patients with altered consciousness after traumatic brain injury. A diffusiontensor tractography was performed in three patients with impaired consciousness after a severe traumaticbrain injury. A 1.5 T scanner was used to obtain the tensor sequences; axial tensors were acquired. Post-processing was performed, and the mean fractional anisotropy (FA) values were recorded. The FA maps wereused to do a manual tracing of the following regions of interest (ROIs): the ventromedial midbrain, theanterior thalamus, and the hypothalamus. Case 1 presented destruction of the right dorsal and ventraltegmental tracts as well as destruction of the right middle forebrain bundle, case 2 had destruction of theright dorsal tegmental tract, and case 3 had destruction of the bilateral ventral and dorsal tegmental tracts,as well as destruction of the right middle forebrain bundle. The affected fibers of the ascending reticularactivating system with diffuse axonal injury and the FA values abnormalities in the ascending reticularactivating system in three patients with a disorder of consciousness (DOC) after traumatic brain injury aredescribed.Categories: NeurosurgeryKeywords: diffusion tensor imaging, arousal, consciousness, ascending reticular activating system, tractography,traumatic brain injury, neurosurgeryIntroductionThe arousal component of the consciousness is generated by the ascending reticular activating system(ARAS) [1]. It has been largely demonstrated that the ARAS is composed of groups of neurons that projectfrom different nuclei in the brainstem forming a diffuse and complex network that connect to the cortexthrough thalamic and extra-thalamic pathways. The ARAS integrates its reticular core and its nuclei in thebrainstem, as well as its rostral projections directed to the hypothalamus, the thalamus, the basal forebrain,and the cortex [1]. After the development of diffusion tensor imaging (DTI) and fiber tracking post-processing, the neuroanatomic connectivity of the ARAS and its relationship with altered consciousnessdisorders were carefully described [1]. Description of the ARAS in healthy subjects and in post-mortemformalin brains [1-2] have been reported, as well as some cases with diffuse axonal injury (DAI) aftertraumatic brain injury (TBI) [3-4]. Analysis of fractional anisotropy (FA) values of white matter tracts inpatients after anoxic brain injury [5] and patients after TBI [4] have been performed and a DTI predictionsystem for long-term neurological outcome in comatose patients has also been reported [6]. The objective ofthis manuscript is to describe the reconstruction of diffusion tensor tractography (DTT) of the ARASpathways in three patients with impaired consciousness after TBI.Case PresentationPatients and definitionsClinical and neuroimaging data of three Hispanic male patients with severe TBI, with a disorder ofconsciousness (DOC) following trauma, admitted at the intensive care unit (ICU) of the Hospital InfantilUniversitario de San José, Bogota, Colombia, between January 2015 and January 2017 are presented. The1 2 3 45 6 67 Open Access CaseReport  DOI: 10.7759/cureus.1723How to cite this articleOrdóñez-Rubiano E, Johnson J, Enciso-Olivera C O, et al. (September 28, 2017) Reconstruction of the Ascending Reticular Activating System withDiffusion Tensor Tractography in Patients with a Disorder of Consciousness after Traumatic Brain Injury. Cureus 9(9): e1723. DOI10.7759/cureus.1723

https://assets.cureus.com/uploads/case_report/pdf/3151/1613130285-20210212-15846-e4vea9.pdf

Reconstruction of the Ascending Reticular Activating System with Diffusion Tensor Tractography in Patients with a Disorder of Consciousness after Traumatic Brain Injury

Abstract

Similar works

Full text

Available Versions

LAReferencia - Red Federada de Repositorios Institucionales de Publicaciones Científicas Latinoamericanas

Repositorio Digital de la Fundación Universitaria de Ciencias de la Salud