Incidence of fibrosing colonopathy with pancreatic enzyme replacement therapy in patients with cystic fibrosis

BACKGROUND

High daily doses of pancreatic enzyme replacement therapy (PERT) were historically associated with risk of fibrosing colonopathy (FC) in people with cystic fibrosis (pwCF), leading to development of PERT dosing guidelines and reformulated products. This study quantified incidence of FC in pwCF treated with PERT following those measures.

METHODS

This large prospective cohort study included eligible pwCF enrolled in the Cystic Fibrosis Foundation Patient Registry with ≥1 clinic visit in 2012-2014 and follow-up through 2020. Data on PERT exposure, demographics, and medical history were collected. Clinical data, imaging, and histopathology of suspected cases were examined by an independent adjudication panel of physicians familiar with this complication.

RESULTS

Base Study Population included 26,025 pwCF who contributed 155,814 person-years [mean (SD) 6.0 (2.0) years] of follow-up. Over 7.8 years, 29 pwCF had suspected FC; three cases were confirmed by adjudication, 22 cases were confirmed as not FC, and four cases were indeterminate. There were 22,161 pwCF exposed to any PERT, with mean PERT use time of 5.583 person-years and mean daily dose of 8328 U lipase per kg per day. All three confirmed cases and four indeterminate cases of FC occurred during current use of PERT. Incidence rates per 1000 person-years exposed were 0.0242 (95 % CI [0.0050, 0.0709]) for confirmed FC and 0.0566 (95 % CI [0.0227, 0.1166]) for indeterminate or confirmed FC.

CONCLUSIONS

The incidence of FC in pwCF is very low in the era of current treatment guidelines and more stringent quality standards for PERT products.

Intraoperative Angiogram Using C-Arm Fluoroscopy and Direct Common Carotid Artery Puncture During Surgical Treatment of Paraclinoid Aneurysms

BACKGROUND

Intraoperative angiography (IOA) has been shown to be a useful adjunct in surgical treatment of cerebral aneurysms. However, its use can be limited by hybrid operating room availability. On the other hand, the use of C-arm fluoroscopy can add challenges to IOA during navigation of the aortic arch and selection of the great vessels. We aimed to describe a simple method of IOA that can be applied during surgery of paraclinoid aneurysms and can be performed in a normal operating room without the need to navigate the aortic arch.

METHODS

In patients undergoing surgery for paraclinoid aneurysms with need for cervical carotid artery exposure, IOA was performed using a single plane C-arm fluoroscopy unit after direct puncture of the carotid artery.

RESULTS

Five patients were included: 2 with subarachnoid hemorrhage, 2 with unruptured aneurysm and history of subarachnoid hemorrhage, and 1 with unruptured aneurysm. There were 2 internal carotid blister aneurysms, 2 ophthalmic artery aneurysms, and 1 superior hypophyseal artery aneurysm. IOA was performed using direct carotid puncture through the neck incision required for proximal control. In all cases, intraoperative images were of sufficient quality to determine the completeness of aneurysm occlusion as well as parent and branching vessel patency. There were no postoperative infarctions and no complications related to IOA.

CONCLUSIONS

IOA using direct carotid puncture can be performed in a standard operating room with the use of a C-arm, eliminating the need to catheterize the great vessels of the aortic arch.

Patient and family experience of telehealth care delivery as part of the CF chronic care model early in the COVID-19 pandemic

Background

During the COVID-19 pandemic, CF centers shifted to a telehealth delivery model. Our study aimed to determine how people with CF (PwCF) and their families experienced telehealth and assessed its quality and acceptability for future CF care.

Methods

The CF Patient and Family State of Care Survey (PFSoC) was fielded from August 31-October 30, 2020. The PFSoC explored themes of overall telehealth quality, ease of use, desirability, and preference for a future mix of in-person and telehealth care. Demographic covariates considered included: gender, age, CFTR modulator status, and region of residence.

Results

424 PwCF and parents of PwCF responded (47% parents). Most (81%) reported a telehealth visit which included a MD/APP and nurse team members. 91% found telehealth easy to use, and 66% reported similar/higher quality than in-person care. One-third (34%) reported the highest desire for future telehealth care, with 45% (n =212) desiring 50% or more of visits conducted via telehealth. Adults were more likely than parents to report highest desire for future telehealth (64% vs. 36%). Respondents who perceived telehealth as similar/higher quality were more likely to desire future telehealth compared to those who perceived telehealth as lower quality (96% vs. 50%). Mixed methods analysis revealed themes affecting perceptions of telehealth.

Conclusions

PwCF desire for future telehealth was influenced by perception of quality and age. Several themes emerged that need to be explored as telehealth is adapted into the CF chronic care model, especially when thinking about integration into pediatric care.

Design and methods for understanding the state of cystic fibrosis care amid the COVID-19 pandemic

Background

Novel therapies have dramatically changed cystic fibrosis (CF) and innovative care delivery systems are needed to meet future patient needs. Telehealth has been shown to be an efficient and desirable form of care delivery. The COVID-19 pandemic caused a rapid shift to telehealth, and this presented a unique opportunity to study facilitators, barriers, and satisfaction with this mode of care delivery. We aim to report survey methods, demographics and telehealth use among CF care programs, patients, and families during the pandemic.

Methods

CF programs completed two surveys between July 29 and September 18, 2020, and between April 19 and May 19, 2021. Patients and families completed a similar survey between August 31 and October 30, 2020. The surveys addressed topics assessing the pandemic's financial impact, telehealth modes and experiences, licensure and reimbursement issues, health screening, and remote monitoring. Quantitative data were analyzed with descriptive statistics and were compared to the CF Foundation Patient Registry.

Results

Most programs (278 at timepoint one and 274 at timepoint two) provided telehealth during the pandemic. The percent of visits containing either telephone or video components changed from 45% to 25% over the time periods. Additionally, 424 patients and families from various ages and backgrounds responded to the survey and 81% reported having a telehealth visit.

Conclusions

The pandemic accelerated telehealth adoption and these datasets are a valuable source for exploring telehealth barriers and facilitators, the quality-of-care experience, financial and workforce implications, the impact on underrepresented populations, and implications for coverage and reimbursement.

Remote monitoring in telehealth care delivery across the U.S. cystic fibrosis care network

BACKGROUND

Cystic fibrosis (CF) programs and people with CF (PwCF) employed various monitoring methods for virtual care during the COVID-19 pandemic. This paper characterizes experiences with remote monitoring across the U.S. CF community.

METHODS

The CF Foundation (CFF) sponsored distribution of home spirometers (April 2020 to May 2021), surveys to PwCF and CF programs (July to September 2020), and a second program survey (April to May 2021). We used mixed methods to explore access, use, and perspectives regarding the use of remote monitoring in future care.

RESULTS

By October 2020, 13,345 spirometers had been distributed, and 19,271 spirometers by May 2021. Programs (n=286) estimated proportions of PwCF with home devices increased over seven months: spirometers (30% to 70%), scales (50% to 70%), oximeters (5% to 10%) with higher estimates in adult programs for spirometers and oximeters. PwCF (n=378) had access to scales (89%), followed by oximeters (48%) and spirometers (47%), often using scales and oximeters weekly, and spirometers monthly. Over both surveys, some programs had no method to collect respiratory specimens for cultures associated with telehealth visits (47%, n=132; 41%, n=118). Most programs (81%) had a process for phlebotomy associated with a telehealth visit, primarily through off-site labs. Both PwCF and programs felt future care should advance remote monitoring and recommended improvements for access, training, and data collection systems.

CONCLUSIONS

PwCF and programs experienced unprecedented access to remote monitoring and raised its importance for future care. Improvements to current systems may leverage these shared experiences to augment future care models.

Evaluating barriers to and promoters of telehealth during the COVID-19 pandemic at U.S. cystic fibrosis programs

BACKGROUND

Cystic fibrosis (CF) care programs in the United States rapidly adopted telehealth during the COVID-19 pandemic. Understanding factors that promote or impede telehealth will inform planning for future telehealth-enabled care models.

METHODS

Adult, pediatric, and affiliate CF care programs in the United States (n = 287) were surveyed twice eight months apart in 2020-2021 about telehealth use. Programs were asked to describe barriers to and promoters of telehealth.

RESULTS

Ninety-seven percent of programs provided telehealth services. In the first CF Care Program State of Care Survey (SoC1), programs estimated that 57% of patients exclusively received in-person care, 36% of patients received telehealth by phone/computer with video, and 8% of patients received telephone-only care. In the second CF Care Program State of Care Survey (SoC2), programs estimated that 80% of visits were in-person and 15% were via audio and video telehealth. Pediatric programs (21%) were less likely than adult (37%) or affiliate (41%) programs to recommend telehealth (p = 0.007). All programs ranked lack of internet access as the highest barrier to patient engagement with telehealth. Promoters of telehealth were increased accessibility and avoidance of infection transmission. Top ranked changes to improve telehealth were expanded provision of remote monitoring devices and technology access. Similar proportions of program types anticipated institutional telehealth expansion.

CONCLUSION

During the COVID-19 pandemic, CF programs in the United States identified factors to improve future care delivery via telehealth. Targeting specific barriers and promoters will improve the use and quality of telehealth throughout the care center network.

Barriers and facilitators to implementing telehealth services during the COVID-19 pandemic: A qualitative analysis of interviews with cystic fibrosis care team members

Background

The COVID-19 pandemic forced cystic fibrosis (CF) care programs to rapidly shift from in-person care delivery to telehealth. Our objective was to provide a qualitative exploration of facilitators and barriers to: 1) implementing high-quality telehealth and 2) navigating reimbursement for telehealth services.

Methods

We used data from the 2020 State of Care CF Program Survey (n=286 U.S. care programs) administered in August-September to identify two cohorts of programs, with variation in telehealth quality (n=12 programs) and reimbursement (n=8 programs). We conducted focus groups and semi-structured interviews with CF program directors and coordinators in December 2020, approximately 9 months from onset of the pandemic. We used the Consolidated Framework for Implementation Research to identify facilitators and barriers of implementation, and inductive thematic analysis to identify facilitators and barriers of reimbursement.

Results

Factors differentiating programs with greater and lower perceived telehealth quality included telehealth characteristics (perceived advantage over in-person care, cost, platform quality); external influences (needs and resources of those served by the CF program), characteristics of the CF program (compatibility with workflows, relative priority, available resources); characteristics of team members (individual stage of change), and processes for implementation (engaging patients and teams). Reimbursement barriers included documentation to optimize billing; reimbursement of multi-disciplinary team members, remote monitoring, and telephone-only telehealth; and lower volume of patients.

Conclusions

A number of factors are associated with successful implementation and reimbursement of telehealth. Future efforts should provide guidance and incentives that support telehealth delivery and infrastructure, share best practices across CF programs, and remove barriers.

Segmental overgrowth and aneurysms due to mosaic PDGFRB p.(Tyr562Cys)

Activating variants in the platelet-derived growth factor receptor β gene (PDGFRB) have been associated with Kosaki overgrowth syndrome, infantile myofibromatosis, and Penttinen premature aging syndrome. A recently described phenotype with fusiform aneurysm has been associated with mosaic PDGFRB c.1685A > G p.(Tyr562Cys) variant. Few reports however have examined the vascular phenotypes and mosaic effects of PDGFRB variants. We describe clinical characteristics of two patients with a recurrent mosaic PDGFRB p.(Tyr562Cys) variant identified via next-generation sequencing-based genetic testing. We observed intracranial fusiform aneurysm in one patient and found an additional eight patients with aneurysms and phenotypes associated with PDGFRB-activating variants through literature search. The conditions caused by PDGFRB-activating variants share overlapping features including overgrowth, premature aged skin, and vascular malformations including aneurysms. Aneurysms are progressive and can result in morbidities and mortalities in the absence of successful intervention. Germline and/or somatic testing for PDGFRB gene should be obtained when PDGFRB activating variant-related phenotypes are present. Whole-body imaging of the arterial tree and echocardiography are recommended after diagnosis. Repeating the imaging study within a 6- to 12-month period after detection is reasonable. Finally, further evaluation for the effectiveness and safety profile of kinase inhibitors in this patient population is warranted.

Determining the Suitability of Registries for Embedding Clinical Trials in the United States: A Project of the Clinical Trials Transformation Initiative

BACKGROUND

Patient registries are organized systems that use observational methods to collect uniform data on specified outcomes in a population defined by a particular disease, condition, or exposure. Data collected in registries often coincide with data that could support clinical trials. Integrating clinical trials within registries to create registry-embedded clinical trials offers opportunities to reduce duplicative data collection, identify and recruit patients more efficiently, decrease time to database lock, accelerate time to regulatory decision-making, and reduce clinical trial costs. This article describes a project of the Clinical Trials Transformation Initiative (CTTI) intended to help clinical trials researchers determine when a registry could potentially serve as the platform for the conduct of a clinical trial.

METHODS

Through a review of registry-embedded clinical trials and commentaries, semi-structured interviews with experts, and a multi-stakeholder expert meeting, the project team addressed how to identify and describe essential registry characteristics, practices, and processes required to for conducting embedded clinical trials intended for regulatory submissions in the United States.

RESULTS

Recommendations, suggested practices, and decision trees that facilitate the assessment of whether a registry is suitable for embedding clinical trials were developed, as well as considerations for the design of new registries. Essential registry characteristics include relevancy, robustness, reliability, and assurance of patient protections.

CONCLUSIONS

The project identifies a clear role for registries in creating a sustainable and reusable infrastructure to conduct clinical trials. Adoption of these recommendations will facilitate the ability to perform high-quality and efficient prospective registry-based clinical trials.

Abstract 198: Endovascular Biopsy: in vivo Brain Aneurysm Endothelial Cell Sampling and Gene Expression Analysis

Introduction: Cerebral aneurysms affect 1-6% of the population and their rupture carries significant mortality and morbidity. The paucity of data related to histopathological features of aneurysms stems largely from the risks associated with aneurysm tissue collection. We set out to establish a feasible technique to isolate viable endothelial cells (EC) and to characterize the differences in genetic expression (GE) between iliac arterial cells vs. aneurysm cells and non-ruptured vs. ruptured aneurysm cells.

Methods: 10 patients (5 non-ruptured and 5 ruptured) undergoing aneurysm treatment were enrolled under IRB approval. ECs from aneurysms and iliac arteries were sampled using an appropriately sized coil and a 0.035 “J” wire respectively. Coils and wires were processed via FACS and single cell qPCR to quantify expression of 48 genes implicated in EC function and aneurysm pathogenesis. Mixed models were performed using each GE level as the outcome with multiple predictors. Unsupervised cluster analysis including: hierarchical heat-map clustering, K-medoids, principle components, cART, and self-organizing maps (SOM) were used to find cell clusters based on coordinately expressed GE.

Results: 437 FACS-sorted cells were collected and 319 demonstrated CD31, CD34 and CD105 triple-positive expression. Of these, 94 were aneurysmal cells. The average number of extracted aneurysm cells per patient was 9.4 (1-24, median 6.5) with a trend for higher cell yields from ruptured aneurysms (p = 0.116). Mixed model analyses revealed a history of smoking showed the strongest associations with GE (median p-value 0.104 with 11/48 analyses p < 0.05); 5 genes significantly predicted rupture status (median p-value 0.363 with 5/48 analyses p < 0.05); and one gene significantly differentiated cell type (median p-value 0.557, with 1/48 analyses p < 0.05). SOM analysis revealed clustered GE profiles suggestive of distinct functional EC sub-populations.

Conclusion: Cerebral endovascular sampling is a safe and reliable means for targeted cell collection for genetic analysis. Smoking was strongly associated with GE levels. Our analysis provides evidence that GE levels may be associated with cell type and rupture status.

Abstract 51: Degree of Clot Enhancement on Admission CT Predicts Revascularization Efficacy in Acute Ischemic Stroke

Background: Thrombi in the setting of acute ischemic stroke have been classified in pathology studies as “red clots” (erythrocyte rich) versus “white clots” (platelet/fibrin rich). Current strategies in lysing these clots include pharmacological agents and mechanical devices. Despite these treatment options, thrombolysis fails in a significant portion of patients and may lead to hemorrhagic complications. Having insight into the clot composition may provide clinicians with a way to triage patients to the appropriate treatment. The purpose of the study was to investigate whether the lysability of thrombi in acute ischemic stroke can be predicted by measuring the Hounsfield (HU) on the admission non-contrast CT (NCT), post-contrast enhanced CT (CECT) and CTA.

Methods: We studied 53 patients with acute anterior and posterior circulation large vessel ischemic strokes treated at our institution with IV tPA, IA tPA, and/or mechanical thrombectomy devices (Merci). The HU of the clot was measured on NCT, CECT and CTA. The HU of the homologous contralateral cerebral artery was also measured for standardization purposes. The obtained HU was corrected for hematocrit by using an accepted correction formula HUclot/HUcontralateral. The volume of the clot was calculated using the formula for a cylinder with an elliptical base (π x R x r xH). Recanalization was assessed by TICI grade (0-3).

Results: There is a strong correlation between the HU of the thrombus on preintervention NCT and postintervention TICI grade among all patients regardless of pharmacological or mechanical treatment ( Table 1 ). Patients with TICI≥2 demonstrated higher HU on NCT compared to patients with TICI<2 among all treatment modalities. On CECT and CTA, patients with higher TICI scores tended to have a lower HU, however, this did not reach statistical significance. There was no correlation between clot volume and lysability.

Conclusion: Thrombi with lower HU on NCT appear to be more resistant to pharmacological and mechanical thrombectomy and likely represent “white clots.” While thrombi with higher HU are less resistant to acute stroke therapies and likely represent “red clots.” Measuring the HU of the thrombus on the admission NCT provides the stroke team with a rapid method to analyze the clot composition, a potentially useful discriminator in selecting the most appropriate reperfusion strategy for an individual patient.

Zygomatico-orbital intra-arterial melphalan infusion for intraocular retinoblastoma

Retinoblastoma is a rare and curable malignancy affecting the pediatric population. For advanced stage intraocular retinoblastoma, enucleation remains the primary treatment modality, although the use of laser photocoagulation, cryotherapy, radiotherapy and chemotherapy are frequently used, particularly in the setting of bilateral disease. Intravenous chemotherapy is the long-standing method of delivery, but local administration (subtenon, intravitreal or intra-arterial) is gaining in popularity because of the reduced side effects related to systemic administration. Of these newer methods, intra-arterial infusion has demonstrated technical feasibility, few procedural complications and robust tumor response. A case is described where a collateral supply to the affected ophthalmic artery was via the zygomatico-orbital branch of the ipsilateral superficial temporal artery. Melphalan infusion was performed via this pathway without incident.

Transvenous embolization of a pediatric pial arteriovenous fistula

Pial arteriovenous fistulas (AVFs) are a rare, although clinically significant, vascular anomaly affecting the pediatric population. There are few retrospective case series describing their epidemiological, clinical and radiographic characteristics as well as technical elements of treatment. Combined transarterial and transvenous embolization of a 12 month old female with a multi-hole pial AVF is described. The patient underwent treatment in a staged fashion and without neurological complication.

Clinical characteristics and management of vascular anomalies: findings of a multidisciplinary vascular anomalies clinic

OBJECTIVE

To describe the scope of the University of California, San Francisco (UCSF), Vascular Anomalies Clinic (VAC), including the types of diagnoses, characteristics, and management of patients seen in the clinic.

DESIGN

Case series.

SETTING

Referral, outpatient, multidisciplinary clinic in a university system.

PATIENTS

Consecutive sample of 175 patients seen in the VAC at UCSF from January 2001 to July 2003.

MAIN OUTCOME MEASURES

Diagnosis before and after clinic visit, symptoms, treatment recommendations, age of onset, age at clinic visit, location of lesion, sex, and type of referring physician.

RESULTS

A total of 96% of patients had cutaneous involvement, 71% of patients had vascular malformations, and 14% had infantile hemangiomas. Fifty-eight percent of patients were referred from outside the UCSF system. Of the patients who had not been previously seen by members of the VAC team or UCSF dermatologists, only 22% had been assigned correct specific diagnoses before coming to the VAC, and 13% had incorrect specific diagnoses before coming to the VAC. Fifty-six percent of vascular malformations were first noted at birth and 17% were noted at later than 10 years of age. Eighty-seven percent of patients were symptomatic from their vascular lesion. Sixty-six percent of patients underwent prior magnetic resonance imaging of their lesion. Further diagnostic workup was recommended in 43% of cases, and treatment recommendations were made in 83% of cases.

CONCLUSIONS

Significant confusion still exists regarding the appropriate terminology, diagnosis, and management of vascular anomalies. Multidisciplinary clinics effectively address these complicated and troubling disorders by providing accurate diagnoses, clear treatment recommendations, and counseling from a team of specialists.

Five year results of LINAC radiosurgery for arteriovenous malformations: outcome for large AVMS

PURPOSE

For radiosurgery of large arteriovenous malformations (AVMs), the optimal relationship of dose and volume to obliteration, complications, and hemorrhage is not well defined. Multivariate analysis was performed to assess the relationship of multiple AVM and treatment factors to the outcome of AVMs significantly larger than previously reported in the literature.

METHODS AND MATERIALS

73 patients with intracranial AVMs underwent LINAC radiosurgery. Over 50% of the AVMs were larger than 3 cm in diameter and the median and mean treatment volumes were 8.4 cc and 15.3 cc, respectively (range 0.4-143.4 cc). Minimum AVM treatment doses varied between 1000-2200 cGy (median: 1600 cGy).

RESULTS

The obliteration rates for treatment volumes < 4 cc, 4-13.9 cc, and > or = 14 cc were 67%, 58%, and 23%, respectively. AVM obliteration was significantly associated with higher minimum treatment dose and negatively associated with a history of prior embolization with particulate materials. No AVM receiving < 1400 cGy was obliterated. The incidence of post-radiosurgical imaging abnormalities and clinical complications rose with increasing treatment volume. For treatment volumes > 14 cc receiving > or = 1600 cGy, the incidence of post-radiosurgical MRI T2 abnormalities was 72% and the incidence of radiation necrosis requiring resection was 22%. The rate of post-radiosurgical hemorrhage was 2.7% per person-year for AVMs with treatment volumes < 14 cc and 7.5% per person-year for AVMs > or = 14 cc.

CONCLUSION

As AVM size increases, the dose-volume range for the optimal balance between successful obliteration and the risk of complications and post-radiosurgical hemorrhage narrows.

Embolization of neurosurgical lesions involving the ophthalmic artery

OBJECTIVE

A number of anteriorly located cranial base and extracranial lesions receive their vascular supply wholly or in part from the ophthalmic artery, and embolization of the ophthalmic artery can be helpful in the management of these lesions, either as the primary treatment or as an adjunct to surgery. We present situations in which the embolization of lesions involving the ophthalmic artery was performed to effect a partial or total cure of the lesion.

METHODS

Twelve patients underwent a total of 15 embolization attempts on lesions involving the ophthalmic artery. Four patients had arteriovenous malformations of the orbit, four had dural arteriovenous fistulae, two had orbital meningiomas, one had a planum sphenoidale meningioma, and one had a juvenile nasal angiofibroma. In each case, a Tracker No. 18 microcatheter (Target Therapeutics, Inc., Fremont, CA) was navigated into the ophthalmic artery using a steerable guidewire and digital road mapping. Embolic agents included polyvinyl alcohol particles ranging from 350 to 1500 microm in diameter, 2-mm platinum microcoils, and n-butyl-cyanoacrylate. In 12 of 15 cases, lidocaine and amytal provocation tests were conducted before any attempt at embolization to assess the role of the ophthalmic artery in vision.

RESULTS

Embolization was successfully performed in the 14 situations in which it was attempted. Positive results of two lidocaine/amytal tests were noted. In one case, embolization was not attempted. In the other case, a larger caliber embolic agent (2-mm platinum coils) was used. A single transient decrease in visual acuity lasting 4 days was the only embolization-related complication.

CONCLUSION

Proper case selection, judicious use of embolic agents, and use of provocative testing can result in safe embolization of lesions supplied by the ophthalmic artery.

Mathematical cognitive style and arithmetic sign comprehension: a study of EEG alpha and theta activity

The localization of arithmetic sign comprehension was investigated using EEG spectral parameters as indicators of cortical engagement. Right-handed male subjects were selected on the basis of scores on the Mathematics Cognitive Style Survey and assigned to 2 groups, a 'left hemisphere oriented (LHO)' (N = 9) and 'right hemisphere oriented (RHO)' (N = 9) group. Subjects were presented with 4 conditions, a motoric baseline condition, two arithmetic fact retrieval tasks employing either a sign operator or verbal operator and a sign comprehension task which required subjects to fill in a missing sign (e.g. 6 ? 4 = 24). Both across subject correlational analysis of EEG alpha 1 asymmetry and performance as well as within subject analysis of condition means indicated a somewhat unique contribution of the right hemisphere to sign comprehension. LHO subjects exhibited greater relative left mid-temporal lobe activation than RHO subjects but less relative left frontal activation (theta band) than RHO subjects during the verbal operator task. It was tentatively concluded that this frontal lobe asymmetry difference was due to a mismatch in strategy preference and coding requirements among RHO subjects.

Treatment of massive posterior epistaxis by detachable coil embolization of a cavernous internal carotid artery aneurysm

We present a case of massive posterior epistaxis caused by a cavernous internal carotid artery aneurysm. This lesion was treated with endovascular placement of electrolytically detachable platinum embolization coils. The treatment resulted in cessation of epistaxis until the patient's death 3 months following embolization. We discuss aspects of using these above coils for this condition.

Endovascular detachable balloon embolization therapy of cavernous carotid artery aneurysms: results in 87 cases

Interventional neurovascular techniques for treating patients with intracranial aneurysms are now being performed in selected cases. In certain anatomical locations that are difficult to reach surgically, such as the cavernous portion of the internal carotid artery (ICA), this technique may be especially useful. The procedure is performed from a transfemoral approach, using local anesthesia, thus permitting continuous neurological monitoring. Between 1981 and 1989, 87 patients diagnosed as having an intracavernous aneurysm were treated with endovascular detachable balloon embolization techniques. The patients ranged in age from 11 to 84 years. The presenting symptom was mass effect in 69 cases (79.3%), rupture of a preexisting aneurysm resulting in a carotid-cavernous sinus fistula in eight cases (9.2%), trauma resulting in a cavernous pseudoaneurysm in seven cases (8.0%), and hemorrhage in three cases (3.4%). Therapeutic occlusion of the ICA across or just proximal to the aneurysm neck was performed in 68 patients (78.2%). Since 1984, with the development of a permanent solidifying agent (2-hydroxyethyl methacrylate) to fill the balloon, it is now feasible in some cases to guide the balloon directly into the aneurysm and preserve the parent artery; this was achieved in 19 cases (22%). Follow-up examination has demonstrated complete thrombosis with partial or total alleviation of symptoms in all patients with therapeutic occlusion of the parent vessel. Of the 19 patients with preservation of the parent artery, follow-up studies have demonstrated total exclusion in 12 cases (63%) and subtotal occlusion of greater than 85% in seven cases (37%), with clinical improvement in all cases. Complications from therapy included transient cerebral ischemia during or after therapy requiring volume expansion in seven cases, embolic symptoms requiring antiplatelet medication in two cases, and stroke in four cases; there were no deaths. Detachable balloon embolization therapy, particularly for large and giant symptomatic aneurysms of the cavernous ICA, can be an effective mode of treatment.

Treatment of intracranial aneurysms with preservation of the parent vessel: results of percutaneous balloon embolization in 84 patients

Treatment of intracranial arterial aneurysms by interventional neurovascular techniques is now being performed in selected cases. From a transfemoral approach, under local anesthesia, a detachable silicone microballoon can be guided through the intracranial circulation, directed into the aneurysm, inflated with a polymerizing agent for solidification, and detached. The goal is to exclude the aneurysm from the circulation and preserve flow through the parent artery. Since 1984, 84 patients have been treated by this technique. The patients ranged in age from 15 to 83 years (mean age, 48) and included 63 females and 21 males. The distribution of aneurysms included 59 in the anterior circulation and 25 in the posterior circulation. The presenting symptom or cause was mass effect in 45 patients (53.6%), subarachnoid hemorrhage in 31 patients (36.9%), carotid-cavernous sinus fistula resulting from rupture of an intracavernous aneurysm in six cases (7.1%), trauma in one case, and transient cerebral ischemia due to emboli in one case. Permanent complications directly related to therapy included 15 deaths and nine cases of stroke. Clinical and radiologic follow-ups were performed 1, 3, and 12 months after treatment; duration of follow-up ranged from 3 to 68 months (mean, 35.5 months). In 65 cases (77.4%) there was evidence of complete aneurysmal occlusion, and in 19 cases 922.6%) there was subtotal occlusion greater than 85%. Interventional techniques for treatment of intracranial aneurysms may be useful as a therapeutic alternative in those patients not amenable to standard surgical therapy.