. 2013 Oct 29;19(Suppl 1):185–187.
interv neuroradiol. 2013 Oct 29;19(Suppl 1):185.
Background and Purpose: During embolization of meningiomas, intratumoral hemorrhagic complications may occur, especially with the use of small particle sizes. We compared the rate of hemorrhagic complications in 55 patients embolized with 400-μm calibrated microspheres (Embozene) with a historical cohort of 198 patients embolized with smaller PVA particles.
Materials and Methods: Between September 2009 and February 2012, fifty-five patients with 55 meningiomas were embolized with 400-μm calibrated microspheres. Indications for embolization were preoperative in 47 and before radiosurgery in 2 patients; and in 6 patients, embolization was offered as sole therapy. There were 35 women and 20 men with a mean age of 60.3 years. Mean meningioma diameter was 53 mm (range, 23�97 mm). Hemorrhagic complications were recorded.
Results: There were no hemorrhagic complications in the 55 embolized patients (0%; 95% CI, 0.0%�7.8%). The difference in complication rates between 400-μm calibrated microspheres in this study (0 of 55, 0%) and small PVA particles (45�150 μm) in the historical cohort (9 of 108, 8.3%) was just short of significance (P = .066). The difference in complication rates between 400-μm calibrated microspheres (0 of 55, 0%) and larger PVA particles (150�250 μm) in the historical cohort (1 of 93, 1.1%) was not significant (P = .8).
Conclusions: In this series, embolization of meningiomas by using large (400-μm) calibrated microspheres did not result in any hemorrhagic complications.
interv neuroradiol. 2013 Oct 29;19(Suppl 1):185.
Background and Purpose: Particle embolization is widely used in the treatment of meningiomas. We assessed the frequency and outcome of complications of embolization of meningiomas and tried to identify risk factors.
Materials and Methods: Between 1994 and 2009, a total of 198 patients with 201 meningiomas underwent embolization. Indication for embolization was preoperative in 165 and adjunctive to radiosurgery in 8. In the remaining 28, embolization was offered as a sole therapy. There were 128 women and 70 men with a mean age of 54.4 years (median 54 years; range, 15�90 years). Complications were defined as any neurologic deficit or death that occurred during or after embolization. Logistic regression was used to identify the following possible risk factors: age above median, female sex, tumor size above median, meningioma location in 5 categories, use of small particle size (45�150 μm), the presence of major peritumoral edema, and arterial supply in 3 categories.
Results: Complications occurred in 11 patients (5.6%; 95% confidence interval [CI], 3.0%�9.8%). Ten complications were hemorrhagic, and 1 was ischemic. Six of 10 patients with hemorrhagic complications underwent emergency surgery with removal of the hematoma and meningioma. Complications of embolization resulted in death in 2 and dependency in 5 patients (7/198, 3.5%; 95% CI, 1.6%�2.0%). The use of small particles (45�150 μm) was the only risk factor for complications (odds ratio [OR], 10.21; CI, 1.3�80.7; P = .028).
Conclusions: In this series, particle embolization of meningiomas had a complication rate of 5.6%. We believe that the use of small polyvinyl alcohol (PVA) particles (45�150 μm) should be discouraged.
interv neuroradiol. 2013 Oct 29;19(Suppl 1):185–186.
Purpose: Embolization of paragangliomas is a well-known pre-operative technique aimed at reducing surgical morbidity and mortality. We report our experience in either pre-operative or palliative transarterial embolization of head and neck paragangliomas (HNP) with ethylene vinyl alcohol (Onyx).
Materials and Methods: We retrospectively analyzed 29 pts with HNP: 18 jugulotympanic, 7 vagal and 4 carotid body tumors. Main symptoms at clinical presentation were lower cranial nerves (CN) paresis/palsy, tinnitus, hypoacusis and laterocervical mass. Trans-arterial embolization with Onyx was performed in all cases: 13 pts(45%) were embolized pre-operatively; 16 pts(55%) received palliative embolization, five of which underwent radiotherapy afterwards. Clinical and MR imaging follow-up data were recorded.
Results: Devascularization was of at least 60%; in 6 cases(20%) a second embolization was needed. Two distal migrations of Onyx occurred without clinical consequences. Eight pts(28%) had procedure related complications: 8 new CN palsies (VII, X and XII CN) and 4 worsening of preexisting palsy. All deficits had partial or complete regression at follow-up (mean 31M, range 3-86M), except for 2 stable X CN palsies(6%). No complications due to Onyx mass effect were observed. Surgical procedure was facilitated by pre-operative embolization; 54% of operated pts were cured, 46% showed tumor stability. Long-term follow-up of palliative embolizations resulted in tumor volume stability (69%) or increase in intracranial or tympanic compartments.
Conclusion: Arterial embolization with Onyx of HNP is a feasible and efficient pre-operative or palliative treatment with promising long-term results.
interv neuroradiol. 2013 Oct 29;19(Suppl 1):186.
Introduction: Interventional radiology is experiencing significant progress with success in treating various diseases. Increased number of angiography procedures raises proportion of this subspecialty on population medical radiation dose. Interventional procedures place the greatest burden on the patient and the staff in the terms of radiation dose.
Material and Methods: Presented work examined group of 141 patients, who underwent various endovascular procedures. We used three basic measures of radiation exposure: dose area product (DAP), surface dose and effective dose. The DAP was measured by DAP-meter during the procedure, other measures were calculated. We compared radiation burden of different procedures.
Results: The measured values show significant difference between diagnostic and therapeutic procedures. The diagnostic procedures do not pose significant radiation risk for patient. Conversely, the dose in the therapeutic procedures is not low, although it does not reach level for deterministic effects. In one case, interventional procedure on abdominal aorta reached surface dose of 1.5 Gy. In the case of brain aneurysm or AVM embolization the surface dose averaged 1 Gy. If the patient undergoes several such sessions, the dose can easily exceed the limit of 2 Gy. Nontheless such case was not recorded in our department.
Conclusion: All angiography procedures have concomitant risk of exposing the patient and staff to ionizing radiation. In several published cases the surface dose reached the limit for deterministic effects. Understanding principles influencing radiation burden of patients and staff during can help reduce the doses and can prevent radiation emergencies.
interv neuroradiol. 2013 Oct 29;19(Suppl 1):186.
Background: Carotid Balloon Test Occlusion (CBTO) and Parent artery sacrifice (PAS) in malignant head and neck tumor patients is challenging since positioning of patient is difficult due to neck contractures and verbal communication with patients is very limited during CBTO since most patients have tracheostomy.
Materials and Methods: We retrospectively reviewed 28 consecutive malignant head and neck tumor patients (M:F=20:8, mean age=61.5 years) who had CBTO from 2006 to 2013. Indications for CBTO included tumor invasion to carotid artery (n=19) and pre-operative assessment (n=9). The CBTO protocols included various combinations of clinical examination, angiography (delayed venous phase more than 2 seconds), hypotension challenge, electroencephalography (EEG) and Nuclear Medicine (SPECT). PAS was performed with either surgical ligation or endovascular occlusion for whom passed CBTO.
Results: CBTO and PAS were technically successful in all patients. The combination of clinical examination, angiography and EEG were the most frequently employed CBTO protocol (32.1%, 9/28) followed by the combination of clinical examination, angiography, hypotension challenge and SPECT (25%, 7/28). Among 21 patients who passed CBTO (75%, 21/28), PAS was performed in 16 patients (surgical ligation: 5, endovascular occlusion:11). One patient (3.6%, 1/28) developed acute ischemic stroke after CBTO procedure. One patient developed hemodynamic stroke after PAS (1/16, 6.25%) who successfully passed CBTO.
Conclusion: CBTO procedure in malignant head and neck tumor patients is feasible and reasonably safe. Post PAS stroke risk in malignant head and neck tumor patients who passed CBTO is low.
interv neuroradiol. 2013 Oct 29;19(Suppl 1):186–187.
Background: Cranio-cervical vascular injuries comprise a heterogeneous group with differing mechanisms of injury and pathological lesions. Endovascular intervention has changed the way that these lesions can be approached, however little information is available aside from case reports as to the role that endovascular treatment may have.
Purpose: To assess if endovascular treatment of cranio-cervical vascular trauma is an effective treatment strategy which lowers morbidity and mortality.
Methods and Materials: A retrospective review of all patients undergoing a Digital Subtracted Angiogram (DSA) following traumatic injury to the head or the cervical region at Groote Schuur Hospital from 1st January, 2006 to 31st December, 2010.
Results: 633 patients had Digital Subtraction Angiograms for trauma to the Cranio-cervical region at Groote Schuur Hospital for the period from 1st January 2006 to 31st December 2010. Of these, 74 patients had lesions on DSA that could be treated by endovascular intervention. 82 injuries were diagnosed and 79 injuries were treated. On angiography, patients were either classified as having vessel lacerations, false aneurysms (FAs), Fistulas or vessel occlusions. All patients were successfully treated. There were 3 procedure related technical complications and 1 neurological complication as a result of the endovascular treatment.
Conclusion:Traumatic cranio-cervical injuries are associated with severe morbidity and mortality if left untreated especially in the setting of blunt trauma where the clinical presentation is delayed. Though the injuries have traditionally been treated surgically, endovascular treatment offers a viable and safe treatment alternative.
interv neuroradiol. 2013 Oct 29;19(Suppl 1):187.
Purpose: To determine the safety of intra-arterial Abciximab injection in the management of thromboembolic complications during endovascular treatment of ruptured cerebral aneurysms.
Materials and Methods: In a consecutive series of 783 patients with ruptured aneurysm, we prospectively recorded 42/783 (5.3%) patients who received ReoPro to treat a thromboembolic event during or immediately after embolization. Subarachnoid Hemorrhage (SAH), WFNS grade, hematoma, shunting, complications and clinical outcomes were retrospectively analyzed.
Results: SAH WFNS grade were as follow: I 14, II 11, III 10, IV 5, V 2. 15/42 patients had a shunt installed less than 24h prior Abciximab injection; one shunt was inserted 24h post injection. 10/42 patients had hematoma of various size additionally to the SAH prior to embolization. In all cases Reopro was injected only after the ruptured aneurysm was secured. 4/42 patients (9.5%) suffered a new intracranial hemorrhage define as "any new blood on Ct or MR in the 48hrs following ReoPro administration", however only one was clinically relevant and superior to 1.5cm in long axis. 2 patients (4.8%) experienced significant peripheral bleeding define as "requiring any specific imaging test or treatment" but none were associated with long term disabilities. At three-to six month follow up, 31patients (74%) achieved a modified Rankin Scale score (mRS) of 2 or less, 6 patients (14%) had mRS of 3 to 5, 3 were dead (7%), 2 were lost at follow-up.
Conclusion: When the aneurysm is secured, intra-arterial ReoPro injection is a low complication rate treatment modality for thromboembolic events during embolization of cerebral ruptured aneurysm.
interv neuroradiol. 2013 Oct 29;19(Suppl 1):187.
We present cases associated with mortality and morbidity due to change in the morphology of the implanted devices following treatments with various flow diverters.
interv neuroradiol. 2013 Oct 29;19(Suppl 1):187.
Introduction: Increasing evidence exists that treatment of complex medical conditions in high volume centers is found to improve outcome. We aimed to determine, based on published literature, whether this holds true for aneurysmal subarachnoid hemorrhage treatment.
Methods: We identified studies up to September 28th, 2012, who evaluated outcome in high versus low volume centers in patients with SAH either by clipping or endovascular coiling. Compared outcome measure was in hospital mortality.
Results: Four articles were included in this analysis, representing 36600 patients totally. Meta-analysis showed a decrease in hospital mortality (odds ratio [OR], 0.77; 95% CI, 0.60 to 0.97; P=0.00; I2=91%) in high volume hospitals treating SAH patients. Definition of hospital volume differed between studies. Cut-offs and dichotomizations were used as well as division in quartiles. Low volume is defined as nine or less patients yearly to less than 30. High volume is defined from more than 20 patients annually to more than 50 patients a year. For comparability between studies recalculation was done with dichotomized data if available and revealed an OR of 0.85 (0.72-0.99; P=0.00; I2=87%)
Conclusions: Despite the shortcomings of this study, the mortality rate was lower in hospitals with a larger caseload. Limitations of the meta-analysis are the not uniform cutoff values and uncertainty about case mix.