Endovascular embolization with radiopaque silk threads: a feasibility study in Swine

SUMMARY

Surgical suture endovascular embolization of brain arteriovenous malformations (AVMs) is an accepted method of preoperative treatment.A major drawback of AVM embolization with surgical sutures is that the sutures are not visible under fluoroscopy. An experimental study using swine is presented where surgical sutures were rendered radiopaque using platinum markers.

Medical surveillance of workers previously exposed to asbestos

According to current Italian law health surveillance of workers exposed to asbestos in the past must be maintained even after cessation of asbestos exposure (D.Lgs. 277/91). The law, however, makes no reference to timescales or time limits for clinical monitoring, nor to who is responsible. The main aims of health surveillance of individuals formerly exposed to asbestos can be summarized as follows: early diagnosis of the principal diseases associated with asbestos; counselling for workers; work-related disease certification; epidemiological studies. Medical check-ups entail a complete personal and work history, Chest X-Ray, respiratory function tests, TLCO. In all cases the worker must undergo a LDCT. We propose two new possible biological markers for the health surveillance of past-exposed patients: serum mesothelin and osteopontin.

Electrical models in the analysis of hemodynamic characteristics of arteriovenous malformations. Part 1: baseline measurements

SUMMARY

This paper describes the creation of two electric arteriovenous malformation (AVM) models where electric resistors simulate AVM vessels. The flow of electrons simulates the flow of blood. Using the models, it was possible to analyze the pressure and flow patterns in the nidus of a small, low-flow AVM and in the nidus of a large, high-flow AVM. "Normal" hemodynamic "physiologic" conditions of the two AVMs were studied, including the autoregulation of normal brain surrounding the AVMs. It is the first time that the hemodynamics within the different parts of the nidus (arterious, arteriolar, venular, venous) can be determined. The models will be utilized to assess AVM hemodynamic changes when different parameters (systemic blood pressure, embolization of arterial feeders, embolization of nidus, embolization of draining veins, surgical by-pass of the AVM) are changed. This will be the subject of part 2 of this paper.

[Experience of a centre for the study of occupational adjustment disorders referred to psychological harassment-related diseases at the workplace]

BACKGROUND

The rising awareness of psychological harassment at the workplace means that it is ever more important to collect clinical data and test tools to assess psychiatric disease connected with this phenomenon.

OBJECTIVES

The aim of the study was to assess the experience gained by the centre for work maladjustment of the University Hospital of Pisa on a sample of patients, using the methods proposed by the centre at the Clinica del Lavoro "Luigi Devoto".

MATERIALS AND METHODS

The patients were submitted to a diagnostic protocol consisting of work history, medical examination, psychological assessment, psychiatric examination, subjective questionnaires, mood scale and Neutest. The analysis was made in two phases in which 109 subjects were examined to check occupational stress effects in the period March 2002 - July 2004, after which 50 subjects were selected (45.9%) with the adaptation disorder and a history of adverse working conditions.

RESULTS

The data gathered showed a slight predominance of workers from the public administration sector. The most representative range of duration of the psychological violence varied from 6 months to 2 years (46%). From close examination of the causes of the maladjustment disorders, structural changes in organization appeared to be the most frequent (13 cases). Among patients with positive diagnosis of disorder caused by psychological violence at the workplace, three situations were prominent: attitude to being a social outcast, behaviour to ignore proposals, and professional declassing.

CONCLUSIONS

The multidisciplinary approach was culturally very stimulating and fundamental in reaching a final diagnosis of occupational disease: diagnosis of bullying at work and related disease was possible only thanks to the fact that three specialists agreed on the aetiological role of psychological harassment at the workplace. Our experience confirms that psychological harassment can cause health impairment and the most common diagnosis is maladjustment disorder.

Quantitative ultrasound of the hand phalanges in a cohort of monozygotic twins: influence of genetic and environmental factors

OBJECTIVE

Our objective was to evaluate the similarities and differences in bone mass and structure between pairs of monozygotic twins as measured by means of the quantitative ultrasound (QUS) technique.

DESIGN

A cohort of monozygotic twins was measured by QUS of the hand phalanges using the DBM sonic bone profiler (IGEA, Carpi, Italy). The parameters studied were amplitude-dependent speed of sound (AD-SoS), ultrasound bone profile index (UBPI), signal dynamics (SDy) and bone transmission time (BTT). Linear correlation coefficients, multivariate linear analysis and the ANOVA test were used to assess intrapair associations between variables and to determine which factors influence the intrapair differences in QUS variables.

PATIENTS

One hundred and six pairs of monozygotic twins were enrolled in the study, 68 females and 38 males in the age range 5 to 71 years.

RESULTS

Significant intrapair correlations were obtained in the whole population and separately for males and females, regarding height ( r =0.98-0.99, p <0.0001), weight ( r =0.95-0.96, p <0.0001), AD-SoS ( r =0.90-0.92, p <0.0001), BTT ( r =0.94-0.95, p <0.0001) and other QUS parameters ( r >0.74, p <0.0001). Multivariate analysis revealed that intrapair differences between AD-SoS, SDy, UBPI and BTT are significantly influenced by age in the whole population and in the female population. Furthermore, the ANOVA test showed, for the female group, a significant increase in the intrapair differences in SDy and UBPI above 40 years.

CONCLUSIONS

A relative contribution of genetic factors to skeletal status could be observed by phalangeal QUS measurement in monozygotic twins. A significant increase in the intrapair difference in QUS parameters with increasing age and onset of menopause also suggests the importance of environmental factors in the female twin population.

Percutaneous vertebroplasty: indications, contraindications, technique, and complications

Percutaneous vertebroplasty is emerging as one of the most promising new interventional procedures for relieving (or reducing) painful vertebra, with the injection of surgical polymethylmethacrylate or cement into vertebral bodies. This imaged-guided technique, originally used to treat vertebral hemangioma, has recently been extended to the treatment of metastases, osteoporotic compression fractures, and vertebral myeloma. It is increasingly being accepted as a main treatment of choice in the management of resistant back pain due to vertebral compression fractures, especially in the elderly individual who is not a candidate for surgery. In this article, we review indications, contraindications, technique, and complications of percutaneous vertebroplasty.

Effect of spinal degenerative changes on volumetric bone mineral density of the central skeleton as measured by quantitative computed tomography

PURPOSE

To evaluate the impact of degenerative changes due to osteoarthritis (OA) at the spine on volumetric bone mineral density (BMD) as measured by volumetric quantitative computed tomography (vQCT).

MATERIAL AND METHODS

Eighty-four elderly women (mean age 73 +/- 6 years), comprising 33 with vertebral fractures assessed by radiographs and 51 without vertebral fractures, were studied. Trabecular, cortical, and integral BMD were examined at the spine and hip using a helical CT scanner and were compared to dual X-ray absorptiometry (DXA) measurements at the same sites. OA changes visible on the radiographs were categorized into two grades according to severity. Differences in BMD measures obtained in the two groups of patients defined by OA grade using the described radiologic methods were compared using analysis of variance. Standardized difference (effect sizes) was also compared between radiologic methods.

RESULTS

Spinal trabecular BMD did not differ significantly between OA grade 0 and OA grade 1. Spinal cortical and integral BMD measures showed statistically significant differences, as did the lumbar spine DXA BMD measurement (13%, P = 0.02). The QCT measurements at the hip were also higher in OA 1 subjects. Femoral trabecular BMD was 13-15% higher in OA grade 1 subjects than in OA grade 0 subjects. The cortical BMD measures in the CT_TOT_FEM and CT_TROCH ROI's were also higher in the OA 1 subjects. The integral QCT BMD measures in the hip showed difference between grades OA 1 and 0. The DXA measurements in the neck and trochanter ROI's showed smaller differences (9 and 11%, respectively). There were no statistically significant differences in bone size.

CONCLUSION

There is no evidence supporting that trabecular BMD measurements by QCT are influenced by OA. Instead, degenerative changes have an effect on both cortical and integral QCT, and on DXA at the lumbar spine and the hip. For subjects with established OA, assessment of BMD by volumetric QCT may be suggested.

Superficial inflammatory and primary neoplastic lymphadenopathy: diagnostic accuracy of power-doppler sonography

OBJECTIVE

To evaluate the sensitivity, specificity and diagnostic accuracy of a cut-off of the resistive index of 0.5 for the differentiation between inflammatory and neoplastic primary lymphadenopathies.

SUBJECTS AND METHODS

We measured the resistive index of superficial enlarged lymph nodes in a total of 50 patients (29 males and 21 females; age range 12-72 years, mean age 41.6 year) using an ATL 5000 HDI. A resistive index greater than or equal to 0.5 indicated an inflammatory lymph node and a resistive index <0.5 was consistent with neoplastic primary lymphadenopathies. The gold standard was either surgical biopsy or lymph-node reduction seen with ultrasound examination after antibiotic therapy.

RESULTS

The sensitivity of the resistive index for distinguishing inflammatory from neoplastic lymphadenopathy was 84.6%, the specificity 100% and the diagnostic accuracy 95.7% (P < 0.001, statistically significant).

CONCLUSION

The results of this study indicate that power-Doppler using a resistive index cut-off of 0.5 was a valid technique for distinguishing between inflammatory and primary neoplastic lymph nodes in patients with superficial lymphadenopathies.

Extracts from St John's Wort and their antimicrobial activity

In an effort to carry out a more in-depth investigation on the antimicrobial properties of H. perforatum, we have assayed different extracts (MeOH; petroleum ether; CHCl(3) and EtOAc) from the aerial parts of the plant against selected microorganisms. Growth inhibition was observed only for Gram-positive bacteria, B. subtilis and B. cereus being the most susceptible to the tested drugs. The Hypericum extract obtained with EtOAc was the most active. The main constituents of this extract, as determined by HPLC analysis, were flavonoids, hypericins and hyperforins. Incubation of the selected microorganisms with the pure chemicals resulted in a significant inhibition of their growth by hypericin, hyperforin and its stable dicyclohexilammonium salt. Flavonoids appeared inactive at all.

[Quantitative bone ultrasonography: state of the art and perspectives]

Quantitative Ultrasound (QUS) is a relatively new method of bone assessment that measures the velocity of sound and the broadband ultrasound attenuation at different skeletal sites: heel and phalanges. This is a mobile, inexpensive, easy to perform and radiation-free technique, capable of assessing not only bone density, commonly measured by means of Single Energy X-ray Absorptiometry, SXA, Dual Energy X-ray Absorptiometry, DXA and Quantitative Computed Tomography, QCT, but also its elasticity and structure. QUS has been validated for diagnosis of osteoporosis and prevention of hip fractures. Very recently, QUS was also been applied to the study of uremic osteodistrophy, of female premenopausal osteoporosis, male osteoporosis and in paediatric population. Moreover, many studies in the dialysis population has also shown the effectiveness of QUS at the phalanges site in evaluating bone turn-over and bone osteopenia. QUS may be an useful tool for the nephrologist in the day by day monitoring of uremic osteodistrophy and secondary hyperparathyroidism.

Bone densitometry in children: a critical appraisal

Due to the introduction of new therapeutic regimen aimed at increasing and maintaining bone mass, bone densitometry in children has gained interest. As in all new fields of medicine we expect the interest in bone densitometry in children to increase in the coming years. Children pose a unique problem for those involved in the field of bone densitometry, because as time progresses the measured subject changes in shape and volume. It is therefore of importance that radiologists and clinicians gain insight in the available techniques. It is also important to keep in mind that all bone densitometry techniques have been exclusively designed, developed and validated for use in an adult population. In this article we give an overview of the available techniques and discuss the specific problems that can be expected when these techniques are used in children. In the discussion section general problems regarding bone densitometry in children are presented.

Palangeal quantitative ultrasound, phalangeal morphometric variables, and vertebral fracture discrimination

The aim of this study was to evaluate the association among phalangeal morphometric parameters, amplitude-dependent speed of sound (AD-SOS), ultrasound bone profile index (UBPI), and spinal bone mineral density (BMD) and fracture status. One hundred women (controls, mean age 53 +/- 12 years) and 40 osteoporotic women (mean age 59 +/- 7 years) with atraumatic fractures, diagnosed by spinal radiographs, were investigated. Quantitative ultrasound (QUS) assessment was performed using the DBM Sonic 1200. Morphological properties of the phalanges were measured from a digitized X-ray image of the hand acquired using industrial film. Spinal BMD was assessed by dual X-ray absorptiometry (DXA) and quantitative computed tomography (QCT). An increase in medullary canal width and a decrease in cortical thickness with aging were observed from the morphometric analysis of the hand radiographs. This phenomenon can be attributed mainly to endosteal resorption. QUS measurements at the phalanges were not significantly related to finger thickness (r <0.20, n.s.). They were significantly correlated to medullary canal ratio (r = -0.57, P <0.0001, for AD-SOS and r = -0.64, P <0.0001, for UBPI) and to cortical thickness (r = +0.52, P <0.0001 for AD-SOS and r = +0.59, P <0.0001 for UBPI). In the discrimination analysis between nonfractured and atraumatic vertebral fracture subjects we found that cortical thickness at the level of the phalanges were similar to lumbar spine BMD. The age and BMI-adjusted odds ratio ranged from 2.0 to 3.1 for QUS, 4.28 for BMD by QCT, 4.1 for BMD by DXA, and 4.1 for cortical thickness. We conclude from these data that phalangeal QUS is related to cortical thickness, which in turn is influenced by endosteal bone resorption occurring in association with spinal osteoporosis.

[SV40: a possible co-carcinogen of asbestos in the pathogenesis of mesothelioma?]

BACKGROUND

The etiopathogenic role of asbestos in causing malignant mesothelioma of the pleura is clearly supported by an impressive amount of data. Despite the frequent association with previous exposure to asbestos, only a relatively small fraction of those exposed develop malignant mesothelioma. The long latency period between initial exposure and onset of the tumor suggests that human mesothelioma, like many other tumors, has a multi-stage evolution with the occurrence of many mutating events involving various tumorigenic agents, probably in part initiating and in part promoting development. Recently this has raised great interest in the scientific world, in an attempt to identify possible factors which together with asbestos may have a role in developing this rare malignant tumor. Ionizing radiations and genetic susceptibility have occasionally been identified as the culprits. A virus called SV40 has been gaining increasing scientific credibility since the mid 1990's as a potential co-carcinogen of asbestos.

OBJECTIVES

The aim of this article was to examine the supposed interaction between asbestos and SV40 in the pathogenesis of mesothelioma and the way this simian virus has become a human virus.

METHODS

All biomolecular and epidemiological data available from medical literature along with the results of the experiments performed during the last 7 years in our department laboratories were reviewed and compared.

RESULTS

The first two pieces of experimental evidence of the presence of SV40-like DNA sequences in mesothelioma samples were obtained in 1994 in the United States, and one year later in our laboratories. After these two studies many research groups started carrying out similar experiments, obtaining comparable results in most cases. Moreover, beyond the mere detection of viral DNA sequences large amount of biomolecular data has recently been added in favour of its role in the pathogenesis of mesothelioma. Epidemiological studies published to date were unable to provide similar unanimous results. Data regarding the source of human infection are still debatable, even if the inadvertent administration of contaminated poliovaccines to millions of people in Europe and the United States between 1955 and 1963 remains one of the most reasonable hypotheses.

CONCLUSIONS

On the basis of all the biomolecular data reviewed and partially on the basis of epidemiological studies, SV40 seems to be the best candidate as a cofactor with asbestos in the development of human mesothelioma.

Osteo-articular, mammographic and thoracic films: clinical evaluation of digital view box versus conventional view box

PURPOSE

To compare in a clinical setting a conventional view box with a digital view box (Smart Light 2000 Digital Film Viewer System, Smart Light, Israel) in the identification of osteo-articular, mammographic and thoracic lesions.

MATERIALS AND METHODS

Six radiologists (two for each imaging procedure), experts in osteo-articular, mammographic and thoracic diseases, independently, compared 600 plain films (100 patient with two projections for each imaging procedure). The radiologists evaluated the films by filling-out a multiple choice questionnaire containing questions concerning the type of pathology seen and the technical quality of the radiography in terms of exposure along with specific questions concerning each of the imaging procedures.

RESULTS

We observed a higher sensitivity of the digital view box for lesion identification (p<0.05); furthermore, we analyzed a greater number of radiographs, recovering technically unsuitable films, because of over or under-exposure (high or low optical density). The interreader agreement was also good (> 0.75). The better lesion perception derived from the increase luminance of the digital view box in the evaluation of higher film densities, such as in overexposed films. DISCUSSION. The technical characteristics of the digital view box reduce or eliminate negative factors that reduce perceptional performance, and often permit the recovery of films that would have otherwise been considered technically unreadable.

Diagnostic utility of an echo-contrast agent in patients with synovitis using power Doppler ultrasound: a preliminary study with comparison to contrast-enhanced MRI

The purpose of this study was to first evaluate Levovist (Schering, Berlin, Germany), an echo-contrast agent, during power Doppler sonography (PDS) in patients with synovitis using asymptomatic joints as controls. Then we evaluated the accuracy of this technique against contrast-enhanced MRI. Forty patients (19 men and 21 women; mean age 40 years) were enrolled on the basis of clinical signs, laboratory tests, and radiographic findings positive for articular inflammatory disease. They were examined with conventional ultrasonography (US) and PDS techniques before and after intravenous contrast medium injection. Fourteen patients then underwent MRI with and without contrast medium 8-14 days after PDS studies. Three expert readers independently evaluated each examination. After contrast medium, synovium in inflammatory arthritis enhanced on PDS compared with normal joints in the same patient. Power Doppler sonography after contrast medium and MRI were concordant in all cases. Power Doppler sonography with contrast medium showed a qualitative increase in signal from synovial vessels, the first sign of synovial changes in inflammatory diseases.

Measurement of bone mineral density at the spine and proximal femur by volumetric quantitative computed tomography and dual-energy X-ray absorptiometry in elderly women with and without vertebral fractures

The goal of this study was to determine the effect of vertebral fracture status on trabecular bone mineral density (BMD) measurements obtained in the proximal femur and spine by helical volumetric quantitative computed tomography (vQCT). The study population consisted of 71 Italian women (average age 73 +/- 6) years. This group included 26 subjects with radiographically confirmed atraumatic vertebral fractures and 45 controls. The subjects received helical CT scans of the L1 and L2 vertebral bodies and the hip. The three-dimensional CT images were processed using specialized image analysis algorithms to extract measurements of trabecular, cortical, and integral BMD in the spine and hip. To compare the vQCT results with the most widely used clinical BMD measurement, dual X-ray absorptiometry (DXA) scans of the anteroposterior (AP) spine and proximal femur were also obtained. The difference between the subjects with vertebral fractures and the age-matched controls was computed for each BMD measure. All BMD measurements showed statistically significant differences, which ranged from 7% to 22% between subjects with fractures and controls. Although, given our small sample size, we could not detect statistically significant differences in discriminatory power between BMD techniques, integral BMD of the spine measured by vQCT and DXA tended to show stronger associations with fracture status (0.001 < p < 0.004). Measurements by QCT and DXA at the hip were also associated with vertebral fracture status, although the association of DXA BMD with fracture status was explained largely by differences in body weight between subjects with vertebral fractures and controls.

Bypass combined with embolization via a venous graft in a patient with a giant aneurysm in the posterior communicating artery and bilateral idiopathic occlusion of the internal carotid artery in the neck

The authors describe the case of a patient with a symptomatic giant aneurysm of the posterior communicating artery (PCoA) associated with bilateral idiopathic occlusion of the internal carotid artery (ICA). The presence of severe tortuosity of the vertebral arteries (VAs), both at their origin from the subclavian artery and at the level of the third segment, impeded navigation of the catheter for embolization of the aneurysm with Guglielmi detachable coils (GDCs). A direct surgical approach was considered to be a high-risk procedure because of the bilateral occlusion of the ICAs and the size of the aneurysm. The following therapeutic strategy was therefore adopted: 1) balloon occlusion test of the left VA; 2) vertebro-vertebral bypass with saphenous vein graft to provide a pathway for subsequent embolization; 3) ICA-left middle cerebral artery bypass to ensure blood flow in the event that embolization resulted in closure of the PCoA; and 4) GDC embolization of the aneurysm via the posterior circulation graft to ensure complete exclusion of the lesion from the arterial circulation and preservation of the PCoA. At 3-month follow-up review the patient did not present with any neurological deficits; at 1-year control examination, magnetic resonance (MR) imaging and MR angiography both confirmed complete exclusion of the aneurysm and patency of the two bypasses.

Bone loss rate in adrenal incidentalomas: a longitudinal study

Although by definition patients with adrenal incidentalomas (AI) do not have evident clinical syndromes, they may frequently suffer from subclinical hypercortisolism (SH). This is of some importance because of evidence that SH may lead to clinical complications, including bone loss. Thus, the understanding of bone involvement due to SH may be extremely important in the management of AI. Unfortunately, the available data on bone mineral density (BMD) in AI patients come from cross-sectional studies, which, to further complicate our understanding, are also conflicting, probably due to a different selection of patients and/or the variability in cortisol secretion (CS) often described in AI. To gain further insight about this topic, we performed a longitudinal study evaluating the rate of spinal and femoral bone loss levels in 24 females with AI. AI subjects were subdivided in two groups on the basis of the median of urinary cortisol secretion (UFC): group I (n = 12; UFC, <140.4 nmol/24 h) and group II (n = 12; UFC, >140.4 nmol/24 h). Spinal BMD was measured by both single energy quantitative computed tomography (L1-L4) and dual energy x-ray absorptiometry (DXA; L2-L4), and femoral BMD was determined by DXA. Bone loss rate was expressed as the change in z-score per yr. The spinal bone loss rate was higher (P < 0.005) in group II than in group I when measured by both quantitative computed tomography (-0.19 +/- 0.14 vs. 0.00 +/- 0.15) and DXA (-0.19 +/- 0.17 vs. 0.00 +/- 0.11). Moreover, CS and spinal bone loss rate were significantly correlated when patients were considered together. In conclusion, our data show that 1) AI patients with higher CS have increased lumbar trabecular bone loss rate than those with lower CS; and 2) the degree of spinal bone loss rate is related to the degree of CS. Thus, lumbar spine (LS) BMD has to be evaluated for well balanced decision-making on the treatment of choice for AI female patients.

Role of electrothrombosis in aneurysm treatment with Guglielmi detachable coils: an in vitro scanning electron microscopic study

BACKGROUND AND PURPOSE

In the 1990s, the introduction of the Guglielmi detachable coil (GDC) system in clinical practice was followed by extensive clinical use of this endovascular device in the treatment of brain aneurysms. This technology is based on electrothrombosis and electrolytic detachment of platinum coils. Despite the extensive use of this treatment technique, the role of electrothrombosis has not been fully investigated and clarified. An in vitro electron microscopic study of human blood was performed to elucidate the role that electrothrombosis might play in triggering the biologic response of thrombosis of the aneurysmal sac.

METHODS

Human blood from five patients was used to fill plastic containers in which GDCs had been deposited. These five patients had subarachnoid hemorrhage and were similar in age and clinical presentation. Electron microscopic studies were performed on GDCs that had been electrically charged and on GDCs that had not.

RESULTS

All electron microscopic studies revealed that the electrically charged GDCs were covered by blood elements and fibrin adherent to the surface of the coil. Noncharged GDCs did not have deposits or adhesions of these blood constituents.

CONCLUSION

These findings demonstrated that passage of electric current through the GDC induces attraction of blood constituents. This attraction may trigger a thrombotic reaction on the surface of the coil. The greater the time of current application, the more pronounced the cellular reaction and the deposition of fibrin and blood cells on the GDC.

Current methods and advances in bone densitometry

Bone mass is the primary, although not the only, determinant of fracture. Over the past few years a number of noninvasive techniques have been developed to more sensitively quantitate bone mass. These include single and dual photon absorptiometry (SPA and DPA), single and dual X-ray absorptiometry (SXA and DXA) and quantitative computed tomography (QCT). While differing in anatomic sites measured and in their estimates of precision, accuracy, and fracture discrimination, all of these methods provide clinically useful measurements of skeletal status. It is the intent of this review to discuss the pros and cons of these techniques and to present the new applications of ultrasound (US) and magnetic resonance (MRI) in the detection and management of osteoporosis.

Pitfalls of GDC Embolisation of Intracranial Aneurysms

SUMMARY

We present a critical analysis of the cerebral aneurysm GDC embolisation technique and its numerous possible pitfalls with the experience of 448 aneurysms in 401 patients performed during a seven year period at UCLA's Division of Interventional Neuroradiology. A "pitfall" is defined as any hidden or not easily recognized danger or difficulty. We review pitfalls related to micro-catheterization, GDC coil delivery, complex vascular anatomy, post-embolisation management, and pre-existing patient's clinical condition. The possible associated technical and clinical complications include aneurysm rupture, parent artery occlusion, thrombo-embolic stroke, coil stretching/rupture, coil migration, incomplete embolisation or embolisation failure. Lastly we present a discussion of our experience and suggestions of how to avoid some of these pitfalls.

From porous media to trabecular bone relaxation analysis: spatial variation of marrow 1H relaxation time distributions detected in vitro by quasi-continuous distribution analysis

Quasi-continuous distributions of T(1) and T(2) of 1H nuclei were analyzed in vitro at 20MHz on some twenty fresh bone samples of pig femur. Large numbers of data points allowed a detailed investigation. Relaxation data were inverted by UPEN (Uniform PENalty inversion). In all samples the widths of the distributions, covering more than two decades, are not even close to being compatible with single exponential components. Moreover, the T(1) and T(2) distributions show enough character to distinguish the samples. We observe a spatial variation of these characteristics and in particular a second peak centered at 500-600 ms appearing in some proximal femur samples. The quasi-continuous distribution allows one to correlate the water content of the sample with parts of the distributions in specific time ranges. The signal fraction with T(1) values longer than a cutoff time of about 170 ms is in very good agreement with the water content of the samples and is significantly larger in the group of samples cored from proximal femur. Also T(2) distributions differentiate the samples, and the signal fraction with T(2) shorter than about 30 ms is significantly larger in the group of distal femur samples.

[Vertebral morphometry: evaluation of osteoporosis-caused fractures]

PURPOSE

To compare visual reading of spine radiographs and quantitative morphometric approach for assessing the prevalence of vertebral fractures in postmenopausal osteoporosis.

MATERIAL AND METHODS

In 473 postmenopausal women afferent to our Centre of Osteoporosis under-went lateral thoracic and lumbar spine radiograph to identify vertebral fractures and dual energy X-ray absorptiometry (DXA) to measure bone mineral density (BMD) of the lumbar spine (L1-L4). Osteoporosis was defined according to the World Health Organization (WHO) guidelines. To identify vertebral fractures the radiographs were visually analyzed by two radiologists; a woman was judged as fractured only if both readers independently found at least one vertebral fracture on her films. Then the spine radiographs were digitized by means of a scanner to perform quantitative vertebral morphometry (QVM) using specific software. An expert operator manually located the calipers on the vertebral bodies from T4 to L5 and the computer automatically calculated the anterior, middle and posterior vertebral heights and their ratios. A vertebral fracture was defined by morphometry as a reduction by at least 20%, with an absolute decrease of at least 4 mm, in one of three height ratios of any vertebral body compared to the corresponding reference ratio for fertile women.

RESULTS

Visual reading by radiologists detected 9.5% (45/473) women with vertebral fractures and QVM detected 13.7% (65/473) with statistical significance (p < 0.001). In the 75-80 years age group the prevalence of vertebral fractures reaches the maximum value, 26.3% by visual reading and 36.8% by QVM. Among fractured women, 34 were osteoporotic by DXA; 11 women found fractured by visual reading and 21 by QVM were osteopenic women, with bone mineral densities between -1 and -2.5 SD of the T-score.

CONCLUSION

This study showed that quantitative assessment of spine radiographs by vertebral morphometry is an objective method that allows to identify a larger number of vertebral fractures compared to visual inspection. This is very important not only for epidemiological studies, but also for clinical use because a previous vertebral fracture increases the risk of subsequent fractures significantly. Therefore, to improve the risk assessment of vertebral fractures for osteoporotic patients it is necessary to combine the use of QVM and BMD.

Continuous distribution analysis of marrow 1 H magnetic resonance relaxation in bone

Longitudinal and transverse NMR relaxation of 1H nuclei were studied in vitro on fresh animal femur samples. A large number of data points were taken, starting at 100 micros for T(1) by inversion-recovery, at 200 micros for T(2) by single-echo sequences, and at 600 micros for T(2) by CPMG echo-trains. Quasi-continuous distributions of relaxation times were computed, giving wide distributions for all samples. Bulk marrow removed from the medullary cavity showed T(2) distributions from about 20 ms to 600 ms and T(1) distributions from about 40 ms to 2 s. The 1H nuclei in trabecular bone samples, where marrow is confined, may show long tails for T(2) at relaxation times down to 250 micros, the origin of which is still not known. These tails are absent in bulk marrow from the medullary cavity. The differences observed in T(1) distributions among trabecular bone samples are in accordance with the different marrow compositions. Discrete exponential fits were computed also, and in most cases four discrete exponential components were required to fit the experimental data adequately. However, the discrete components do not seem to correspond to any physically distinguishable separate compartments.

Endovascular treatment of basilar tip aneurysms using Guglielmi detachable coils: anatomic and clinical outcomes in 73 patients from a single institution

OBJECTIVE

Seventy-three consecutive patients with 75 basilar tip aneurysms were treated with Guglielmi detachable coil (GDC) technology. Their anatomic and clinical outcomes are discussed.

METHODS

Seventy-five basilar tip aneurysms were treated with the GDC system at the University of California, Los Angeles Medical Center from 1990 to 1999. The average age of the population was 48.3 years (range, 28-82 yr). Forty-two patients (57.5%) presented with acute subarachnoid hemorrhage, 8 patients (10.9%) had unruptured aneurysms with mass effect, and 23 patients (31.5%) had incidental aneurysms. Thirty-one aneurysms (41.3%) were small with a small neck, 18 (24%) were small with a wide neck, 16 (21.3%) were large, and 10 (13.3%) were giant aneurysms.

RESULTS

Immediate anatomic outcomes demonstrated complete or near-complete occlusion in 64 aneurysms (85.3%) and incomplete occlusion in 7 aneurysms (9.3%). Four aneurysms (5.3%) could not be embolized because of anatomic difficulties. Of the 69 patients treated with GDCs, 63 patients (91.3%) remained neurologically intact or unchanged from their initial clinical status. Procedure-related morbidity and mortality were 4.1% and 1.4%, respectively. Long-term follow-up angiograms were obtained in 41 patients with 42 aneurysms. Thirty aneurysms (71.4%) demonstrated complete or near-complete occlusion. One incompletely embolized giant aneurysm ruptured during the follow-up period.

CONCLUSION

In contrast to surgical clipping of basilar tip aneurysms, the main technical challenge of the Guglielmi detachable coiling procedure depends on the shape of the aneurysm, not its location. The results of this study indicate that endovascular GDC technology is an appropriate therapeutic alternative in ruptured or unruptured basilar tip aneurysms regardless of patient age, clinical presentation, clinical status, or timing of treatment.

Natural history of the neck remnant of a cerebral aneurysm treated with the Guglielmi detachable coil system

OBJECT

The long-term durability of Guglielmi detachable coil (GDC) embolization of cerebral aneurysms is still unknown. The purpose of this study was to evaluate the anatomical evolution of neck remnants in aneurysms treated with GDCs.

METHODS

Of 455 aneurysms treated with GDCs from 1990 to 1998 at the University of California at Los Angeles Medical Center, 178 aneurysms (39%) had residual necks postembolization. Long-term follow-up angiograms were obtained in 73 of these aneurysms in 71 patients. The mean duration of angiographic follow up was 17.3 months. Twenty-four of the aneurysms were small with small necks, 24 were small with wide necks, 15 were large, and 10 were giant aneurysms. In small aneurysms with small necks, postembolization angiography revealed 12 aneurysms (50%) with progressive thrombosis, eight (33%) unchanged, and four (17%) with recanalization. In small aneurysms with wide necks, six (25%) had progressive thrombosis, eight (33%) remained unchanged, and 10 (42%) had recanalization. In large aneurysms, two (13%) were unchanged and 13 (87%) had recanalization. Of the giant aneurysms only one (10%) remained unchanged and nine (90%) had recanalization. Overall, 18 aneurysms (25%) exhibited progressive thrombosis, 19 (26%) remained unchanged, and 36 (49%) displayed recanalization on follow-up angiography. During the last 2 years of the study, the recanalization rate decreased and a higher rate of progressive thrombosis was noted in aneurysms with small necks. These positive changes are related to important new technical developments.

CONCLUSIONS

Treatment with GDCs appears to be effective and the results permanent in most small aneurysms with small necks. However, there are important technical limitations in the current GDC technology that prevent recanalization in wide-necked or large or giant aneurysms.

Age-related changes assessed by peripheral QCT in healthy Italian women

The purpose of this study was to describe the normal cross-sectional pattern of radial bone loss associated with aging in healthy women and to generate a normative database using peripheral quantitative computed tomography (pQCT). Subjects with suspected conditions affecting bone metabolism or receiving any drugs affecting bone mineralization were excluded. The trabecular bone mineral density (BMD) and the total bone density of the ultradistal radius at the nondominant forearm was measured using the Norland-Stratec XCT-960 pQCT scanner in 386 healthy pre-, peri-, and postmenopausal females aged 15-81 years. The long-term in vivo precision error was 1.6 % CV (coefficient of variation) for trabecular and 0.8% CV for total BMD measurements. The highest value of trabecular and total BMD measured was observed at the age group 15-39 years. Beyond these ages both trabecular and total BMD showed a linear decline with aging, decreasing by an overall slope of -1.28 and -0.55 mg/cm3 per year for total and trabecular BMD measurements, respectively. The test of parallelism between the regression slopes of the peri- and postmenopausal women showed a statistically significant difference for total BMD measurement (p = 0.003). Measurement of total and trabecular BMD was not influenced by weight, height or body mass index, but it was correlated with natural logarithm of years since menopause. We conclude that pQCT of the ultradistal radius is a precise method for measuring the true volumetric BMD and for detecting age-related bone loss in the trabecular and total bone of female subjects encompassing the adult age range and menopausal status.

[Comparison of mammographic and industrial films in dialysis patients]

PURPOSE

To optimize the technique for radiographic studies of bone and joint damage in renal osteodystrophy.

MATERIAL AND METHODS

Sixty-four patients with chronic renal failure on dialysis for 0-10 years, were divided into two homogeneous groups and submitted to two different radiographic examinations of the nondominant hand. Group A patients were examined with a conventional radiological unit and an industrial film and a conventional radiological unit with a mammographic film with a dedicated screen, while group B patients with a mammographic with an industrial film and a conventional radiologic unit with a mammographic film with a dedicated screen. The examinations were evaluated by three radiologists in a double-blind fashion.

RESULTS

Bone conditions such as osteoporomalacia, trabecular rarefaction, channel enlargement and intracortical absorption were equally demonstrated by mammographic films and the mammograph with industrial films. The mammographic film was superior to the mammograph with an industrial film in 8 cases, comparable in 25 and inferior in 6, but when compared with the conventional radiological unit with an industrial film it was superior in 19 cases, comparable in 2 and never inferior.

CONCLUSIONS

The industrial film without a screen combined with a mammograph is considered the gold standard to study fine bone alterations in renal osteodystrophy. However the conventional radiological unit with a mammographic film with a dedicated screen provides the same results with lower irradiation doses and can therefore be considered a good alternative.

SV40 can be reproducibly detected in paraffin-embedded mesothelioma samples

We studied tissue sections from 18 paraffin embedded mesothelioma specimens diagnosed by the Pathology Department of S. Chiara Hospital of Pisa. Using PCR analysis and Southern blot hybridization we examined the specimens for the DNA regulatory region of the virus. 10/18 (55.5%) of the samples tested contained SV40 DNA regulatory sequences, and of these positive samples, 80% were found to contain Tag sequences by PCR and Southern Blot hybridization. These results confirm that SV40 can be amplified and detected in paraffin embedded mesothelioma samples.

Imaging in degenerative disease of the lumbar spine

Degenerative disease involves all spinal components. Conventional radiology and digital radiology are the procedures of first choice in order to establish the diagnosis. CT and MRI should be considered of second choice, based on precise indications. The physiologic aspects of the spine during aging are differentiated from the degenerative alterations and relative complications specific of arthrosis with modern available imaging procedures.

The lumbar spine: imaging in rheumatic disease

Seronegative inflammatory spondyloarthropathies include ankylosing spondylitis, psoriatic arthritis, Reiter syndrome, juvenile chronic arthritis and colitic arthritis. These diseases share some characteristics among which the most important is the presence of the histocompatibility antigen HLA B27; moreover the frequent overlapping of the various inflammation patterns have accounted for their classification in a single group. Diagnostic imaging can differentiate among the different forms only if the diagnostic algorithm, based on clinical history and laboratory findings is followed, considering the advantages and limitations of each method. In this respect, it should be kept in mind that the findings relative to the spine and sacroiliac joints allow to establish a definitive diagnosis.

Combined imaging in spondylodiscitis

At present, in spite of the advancement in antibiotic therapy no significant decrease in the incidence of spinal infections is observed: most likely, this is correlated to the increased immigration flows, high risk behaviors (drug addiction, alcoholism), immunosuppressive diseases (AIDS, leukemia, lymphoma), interventional procedures (iatrogenic causes). Early diagnosis, at times difficult and often misunderstood, is facilitated by the use of a correct diagnostic algorithm, supported by blood culture, needle aspiration and biopsy. Aim of this report was to evaluate the role of the different imaging procedures, CT and MRI in particular, for prompt correct therapeutic management.

Primary bone tumors and pseudotumors of the lumbosacral spine

Primary tumors of the spine are relatively infrequent lesions compared with metastatic disease, multiple myeloma, and lymphoma which are the more frequent neoplasms of the spine and usually manifest with multifocal lesions and thus pose little diagnostic dilemma. However, in the presence of a solitary spinal lesion, the more uncommon primary tumors of the spine represent an important group of entities for diagnostic consideration. The most common benign and malignant primary tumors of the spine are enostosis, osteoid osteoma, osteoblastoma, giant cell tumor, aneurysmal bone cyst, osteochondroma, chordoma, chondrosarcoma, Ewing sarcoma, primitive neuroectodermal tumor, and osteosarcoma. The imaging features of these lesions are often characteristic. Radiologists should be aware of the appearance of these unusual tumors in order to provide a complete differential diagnosis.

Imaging of sacroiliac joints

The early diagnosis of inflammatory and degenerative disease of sacroiliac joints is markedly difficult because the clinical pattern is not dissimilar from that of diseases involving the lumbar spine and sciatic nerve. Furthermore as in inflammations in general, when only structural changes in the synovial membrane and cartilage are involved, the findings of conventional radiology are often nondiagnostic. CT is now considered the gold standard procedure because in spite of its nonnegligible limitations, single lesions in the synovial and ligamentous compartments can be distinctively evidenced. MRI, unlike other procedures, affords the early nonspecific documentation of intrinsic and/or reactive alterations in the subchondral bone, therefore it appears to fill the gap between the onset of symptoms and the imaging visualization of sacroiliitis.

Degenerative disease of the lumbosacral spine: disk herniation and stenosis

Degeneration of the intervertebral disk complex begins early in life and is a consequence of a variety of environmental factors as well as of normal aging. Degeneration of bone and soft tissue spinal elements is the most common cause of spinal stenosis. The term "degeneration" as commonly applied to the spine covers such a wide variety of clinical, radiological and pathological manifestations that the word is really only a symbol of our ignorance. Computed tomography and myelography have long been used for diagnosing the effects of degenerative diseases' of the lumbar spine. Despite the continuous improvement in magnetic resonance scanning for this purpose, computed tomography can provide excellent screening for disk herniation and spinal stenosis.

Imaging of trabecular bone structure in osteoporosis

Osteoporosis is a metabolic bone disorder that is characterized by reduced bone mass and a deterioration of bone structure which results in an increased fracture risk. Since the disease is preventable, diagnostic techniques are of major importance. Standard techniques determine bone mineral density, whereas some of the newer techniques focus on trabecular structure. This article reviews structure analysis techniques in the diagnosis of osteoporosis. Imaging techniques applied to the assessment of trabecular bone structure include conventional radiography, magnification radiography, high-resolution CT (HRCT) and high-resolution MR imaging (HRMRI). The best results were obtained using high-resolution tomographic techniques. The highest spatial resolutions in vivo were achieved using HRMRI. The most common texture analysis techniques that have been used are morphological parameters (analogous to bone histomorphometry). Fractal dimension, co-occurrence matrices, mathematical filter techniques and autocorrelation functions are more complex techniques. Most of the studies evaluating structure analysis show that texture parameters and bone mineral density both predict bone strength and osteoporotic fractures, and that combining both techniques yields the best results in the diagnosis of osteoporosis.

GDC in Ruptured versus Unruptured Aneurysms

We have treated 581 aneurysms in 510 patients from August 1990 to November 1998. In 247 patients the presentation was acute rupture. In 141 patients the aneurysm treated was incidental. Complications in the acute group was 10.1% morbidity with 2.8% procedure related mortality. The corresponding rates were 4.2% and 0% in the incidental group.

In the incidental group all complications occurred up to 1995. In our last 91 patients there has been no morbidity or mortality. Anatomic outcomes were dependent upon aneurysm geometry in both groups. This low rate of complications when compared to the natural history for both ruptured and unruptured aneurysm favors treatment if the long-term follow-up confirms reduced longitudinal hemorrhage rates, and the aneurysm has a favorable geometry.

Phalangeal US velocity discriminates between normal and vertebrally fractured subjects

The purpose of this study was to evaluate the diagnostic sensitivity of phalangeal bone ultrasound velocity of the hand in the diagnosis of osteoporosis and to compare this technique to bone mineral density (BMD) measurement at the lumbar spine assessed by dual X-ray absorptiometry (DXA) and quantitative computed tomography (QCT). We investigated US velocity at the distal metaphysis of the proximal phalanx and spinal BMD in 101 women. Fifty-nine were healthy (mean age 50 +/- 11.6 years) and 42 were osteoporotic (mean age 65 +/- 6.6 years) with documented vertebral fractures. In the healthy population the relation with age was, respectively, r = -0.73 (p < 0. 0001) for quantitative US (QUS), r = -0.74 (p < 0.0001) for QCT and r = -0.48 (p < 0.01) for DXA. Both US and DXA were correlated with QCT: r = 0.74 and r = 0.77 (p < 0.0001), respectively. Correlation of QUS and DXA was r = 0.56 (p < 0.0001). Phalangeal US velocity and spinal BMD (QCT and DXA) values discriminate healthy from osteoporotic women. Age-adjusted logistic regression analysis of the data showed standardized odds ratios (OR) for vertebral fracture to be similar for US and DXA (OR = 1.8 and 1.5, respectively) and stronger for QCT (OR = 2.9). Phalangeal US velocity reflects age-related bone loss and differentiates between healthy and osteoporotic subjects.

[Digital film viewer versus conventional view boxes in the identification of bone and joint disorders]

PURPOSE

To compare the diagnostic accuracy of a digital film viewer (Smartlight 2000 Plus) versus a conventional view box for the identification of bone and joint disorders.

MATERIAL AND METHODS

In order to evaluate the qualitative and quantitative differences of digital and conventional film viewers, 100 plain films of patients with bone and joint disorders taken in an emergency room January through May 1998 were reviewed utilizing both types of view boxes. Three radiologists expert of bone and joint disorders, independently compared the films, filled a form about the qualitative and quantitative analysis of the lesions depicted for each patient, and reported a few notes on the technical quality of the plain films in terms of exposure. The results were compared using the chi-square test (p < 0.005).

RESULTS

Data analysis showed that the digital film viewer permitted a quicker reading of the film while decreasing the perception threshold for elementary lesions and ocular fatigue. All the radiographs read with the digital film viewer were considered technically adequate: the film quality was considered good in 10 cases and sufficient in 2. Two of the same radiographs read with the conventional view box were considered of good quality, nine were considered sufficient and one was considered insufficient due to overexposure. There were six cases of agreement and six of disagreement for the diagnosis: four were due to overexposure of the radiograph and two to better conspicuity provided by the digital film viewer.

DISCUSSION

Correct image illumination is the first element a radiologist evaluates when reading a radiograph. A conventional view box may, when it is not properly maintained or when the radiograph is overexposed, decrease the radiologist's visual capacity. This increases the time required to read the radiograph and, therefore, physical and ocular fatigue, which in turn increases the risk of missing or misevaluating a lesion. A digital film viewer emits light with a variable intensity which is proportional to the optical density of the film. This increases the visual capacity of the radiologist and the lesion contrast, while reducing the factors which affect the radiograph reading.

CONCLUSIONS

The use of a digital film viewer increased the visual capacity of the radiologist and eliminated the negative elements which complicated the radiograph reading and permitted the use of radiographs that would otherwise have been considered of poor quality due to overexposure. This, combined with the experience of the radiologist, decreased of the risk of missing or misevaluating a lesion.

Osteochondroma of the L-5 vertebra: a rare cause of sciatic pain. Case report

Solitary or multiple osteochondromas, which are benign bone tumors that usually occur in the long bones, are rarely found in the vertebral column. When present in the spine, however, they have a predilection for the cervical or upper thoracic regions. The authors present the case of a solitary osteochondroma arising from the left L-5 articular process that contributed to sciatica; complete cure was achieved following its removal. It is possible to speculate that the cartilage of secondary ossification centers can be the origin of aberrant islands of cartilaginous tissue that cause the osteochondroma to form. The more rapid the ossification process of these centers, the greater the probability that aberrant cartilage will form. Therefore, the fact that osteochondromas are more frequently located in the higher segments of the vertebral column could be explained by the different durations of the ossification processes in these centers, which increase gradually below the cervical segments.

Ballonn-assisted Guglielmi detachable coiling of wide-necked aneurysma: Part II--clinical results

OBJECTIVE

To demonstrate the indications and efficacy of balloon-assisted Guglielmi detachable coiling (BAGDC).

METHODS

BAGDC was used for 23 patients (19 women and 4 men; mean age, 55 yr) (17%) of a series of 136 consecutive patients who underwent Guglielmi detachable coiling of aneurysms. Every aneurysm had a wide neck, and 57% were large (11-25 mm in diameter). In each case, a nondetachable silicone balloon was advanced in the parent artery and inflated to occlude the neck of the aneurysm and stabilize the Guglielmi detachable coil delivery microcatheter at the aneurysm neck. Guglielmi detachable coils were then deposited. The balloon was then deflated to verify appropriate coil placement and stability, and finally, the Guglielmi detachable coils were detached. This process was repeated until the aneurysm was suitably embolized.

RESULTS

One hundred percent aneurysm embolization was achieved in 19 patients (83%), and 95 to 100% embolization was achieved in 4 patients (17%). Twenty-two patients (96%) were at their preprocedure neurological baseline after the procedure. There were three complications in the study. One patient died after sustaining subarachnoid hemorrhage-induced vasospasm followed by a hemorrhagic infarction. She had undergone an unsuccessful clip ligation of her aneurysm. A second patient developed an intra-arterial thrombus at the site of balloon deployment. She sustained ischemic events that were treated with thrombolysis and anticoagulation. She made a complete recovery. A third patient developed an intra-arterial thrombus that was noted during the procedure. She was treated with intra-arterial thrombolysis and experienced no clinical sequelae. No permanent complications could be attributed to the BAGDC technique. The median clinical follow-up time was 10 months. No patient required additional treatment or developed a recurrent aneurysm neck or lumen.

CONCLUSION

BAGDC is a promising adjunct to the treatment of wide-necked aneurysms. The balloon serves two purposes: it stabilizes the microcatheter in the aneurysm during coil delivery, and it forces the coil to assume the three-dimensional shape of the aneurysm without impinging on the parent artery.

Altered bone mass and turnover in female patients with adrenal incidentaloma: the effect of subclinical hypercortisolism

The strategy of treatment for patients with adrenal incidentalomas (AI) may depend upon the presence of hormonal hypersecretion. Although alterations of bone turnover have been recently reported, data on bone mineral density (BMD) are not available in AI patients. We evaluated bone turnover and BMD in 32 female AI patients and 64 matched controls. Spinal and femoral BMD were similar in patients and controls. Serum bone GLA protein (6.8+/-3.5 vs. 8.8+/-3.2 ng/mL; P<0.005) and PTH (48.8+/-15.1 vs. 37.2+/-10.9 pg/mL; P<0.0001) were different in patients and controls. Patients were then subdivided into 2 groups: with (n = 8; group A) or without (n = 24; group B) subclinical hypercortisolism. PTH was higher (P<0.05) in group A than in group B and in both groups than in controls (57.1+/-13.6, 46.0+/-14.8, and 37.2+/-10.9 pg/mL, respectively), and bone GLA protein was lower in group A than in group B and controls (3.8+/-2.3, 7.5+/-3.1, and 8.8+/-3.2 ng/mL, respectively; P<0.05). Serum type I cross-linked C telopeptide and fasting urinary deoxypyridinoline/ creatinine were not different in the three groups. BMD at each site was lower (P<0.05) in group A than in group B and controls. Bone mass and metabolism are altered in AI patients with subclinical hypercortisolism and should be taken into account, therefore, when addressing the treatment of choice for these patients.

Endovascular treatment of multiple intracranial aneurysms by using Guglielmi detachable coils

OBJECT

The purpose of this paper is to present the authors' experience with Guglielmi detachable coil (GDC) embolization of multiple intracranial aneurysms and to evaluate the results of this therapy in single-stage procedures.

METHODS

Clinical and angiographic evaluations were performed in 38 consecutive patients with multiple intracranial aneurysms treated by GDC embolization between March 1990 and October 1997. Twenty-nine patients presented with subarachnoid hemorrhage (SAH), four with mass effect, and five were asymptomatic. These 38 patients harbored 101 aneurysms, 79 of which were treated with GDCs, 14 by surgical clipping, and eight were left untreated. Of the GDC-treated lesions, a complete endovascular occlusion was achieved in 55 aneurysms (70%), and 24 (30%) presented neck remnants. Twenty-five patients (66%) underwent GDC embolization of more than one aneurysm in the first session. Eighteen (86%) of 21 patients with acute SAH underwent treatment for all aneurysms within 3 days after admission (15 of 21 in one session). Follow-up angiographic studies in 30 patients demonstrated an unchanged or improved result in 94% of the aneurysms (59 lesions) and coil compaction in 6% (four lesions). The overall clinical outcome was excellent in 34 patients (89%), good in one (3%), fair in one (3%), and death in two (5%).

CONCLUSIONS

Endovascular treatment of multiple intracranial aneurysms, regardless of their location, with GDCs was performed safely in one session, even during the acute phase of SAH. Treatment of all aneurysms in one session protected the patient from rebleeding and eliminated the risk of mistakenly treating only the unruptured aneurysms.