Cloft, Harry J.

Osteosarcoma is an aggressive primary bone tumor. It is currently treated with multimodality therapy including en bloc resection, which has been demonstrated to confer a survival benefit over intralesional resection. The authors present the case of an 8-year-old girl with a C-1 lateral mass osteosarcoma, which was treated with a 4-stage en bloc resection and spinal reconstruction. While technically complex, the feasibility of en bloc resection for spinal osteosarcoma should be explored in the pediatric population.

Background Although rare, spinal arteriovenous malformations (AVMs) are thought to be more prevalent in the hereditary Hereditary Hemorrhagic Telangiectasia (HHT) population. Methods We report a case of a spinal AVM in a 37-year-old female with HHT treated with endovascular embolization. In addition, we report findings from a systematic review of the literature on the clinical characteristics, angioarchitecture, and clinical outcomes of HHT patients with spinal AVMs. Results The patient is a 37 year-old female with definite HHT who presented with a one-year history of progressive gait difficulty. The spinal fistula was incidentally detected on chest computed tomography (CT). Spinal angiography demonstrated a large perimedullary arteriovenous fistula was supplied by a posterolateral spinal artery. The fistula was treated with detachable coils. The patient made a complete neurological recovery. Our systematic review yielded 25 additional cases of spinal AVMs in HHT patients. All fistulae were perimedullary (100.0%). Treatments were described in 24 of the 26 lesions. Endovascular-only treatment was performed in 16 cases (66.6%) and surgical-only treatment was performed in five cases (20.8%). Complete or near-complete occlusion rates were 86.7% (13/15) for endovascular treated cases, 100.0% (4/4) for surgery and 66.6% (2/3) for combined treatments. Overall, 80.0% of patients (16/20) reported improvement in function following treatment, 100.0% (5/5) in the surgery group and 84.6% (11/13) reported improvement in the endovascular group. Conclusions Spinal fistulae in HHT patients are usually type IV perimedullary fistulae. Both endovascular and surgical treatments appeared to be effective in treating these lesions. However, it is clear that endovascular therapy has become the preferred treatment modality.

OBJECT Flow-diversion treatment has been shown to be associated with high rates of angiographic obliteration; however, the treatment is relatively contraindicated in the acute phase following subarachnoid hemorrhage (SAH) as these patients require periprocedural dual antiplatelet therapy. Acute coiling followed by flow diversion has emerged as an intriguing and feasible treatment option for ruptured complex and giant aneurysms. In this study the authors report outcomes and complications of patients with ruptured aneurysms undergoing coiling in the acute phase followed by planned delayed flow diversion. METHODS This case series includes patients from 2 institutions. All patients underwent standard endovascular coiling in the acute phase after SAH with the intention and plan to proceed with flow diversion at a later date. Outcomes studied included angiographic occlusion, procedure-related complications, and long-term clinical outcome as measured using the modified Rankin Scale. RESULTS A total of 31 patients underwent coiling in the acute phase with the intention to undergo flow diversion at a later date. The mean aneurysm size was 15.8 ± 7.9 mm. Of the 31 patients undergoing coiling, 4 patients could not undergo further flow-diverter therapy: 3 patients (9.7%) died of complications of subarachnoid hemorrhage and 1 patient had permanent morbidity as a result of perioperative ischemic stroke (3.1%). Twenty-seven patients underwent staged placement of flow diverters after adequate recovery. The median time to treatment was 16 weeks. There was one case of aneurysm rebleeding following coil treatment. There were no cases of permanent morbidity or mortality resulting from flow-diverter treatment. Twenty-four patients underwent imaging follow-up; 18 of these patients had aneurysms that were completely or nearly completely occluded (58.1% on an intent-to-treat basis). At last follow-up (mean 18.3 months), 25 patients had mRS scores ≤ 2 (80.6% on an intent-to-treat basis). CONCLUSIONS Staged treatment of ruptured complex and giant intracranial aneurysms with coiling in the acute phase and flow-diverter treatment following recovery from SAH is both safe and effective. In this series, no cases of rebleeding occurred during the interval between coiling and flow diversion. This strategy should be considered as a valid option in patients presenting with these challenging ruptured aneurysms.

OBJECT The association between age and outcomes following aneurysm treatment with flow diverters such as the Pipeline Embolization Device (PED) have not been well established. Using the International Retrospective Study of the Pipeline Embolization Device (IntrePED) registry, the authors assessed the age-related clinical outcomes of patients undergoing aneurysm embolization with the PED. METHODS Patients with unruptured aneurysms in the IntrePED registry were divided into 4 age groups: ≤ 50, 51–60, 61–70, and > 70 years old. The rates of the following postoperative complications were compared between age groups using chi-square tests: spontaneous rupture, intracranial hemorrhage (ICH), ischemic stroke, parent artery stenosis, cranial neuropathy, neurological morbidity, neurological mortality, combined neurological morbidity and mortality, and all-cause mortality. The association between age and these complications was tested in a multivariate logistic regression analysis adjusted for sex, number of PEDs, and aneurysm size, location, and type. RESULTS Seven hundred eleven patients with 820 unruptured aneurysms were included in this study. Univariate analysis demonstrated no significant difference in ICH rates across age groups (lowest 1.0% for patients ≤ 50 years old and highest 5.0% for patients > 70 years old, p = 0.097). There was no difference in ischemic stroke rates (lowest 3.6% for patients ≤ 50 years old and highest 6.0% for patients 50–60 years old, p = 0.73). Age > 70 years old was associated with higher rates of neurological mortality; patients > 70 years old had neurological mortality rates of 7.4% compared with 3.3% for patients 61–70 years old, 2.7% for patients 51–60 years old, and 0.5% for patients ≤ 50 years old (p = 0.006). On multivariate logistic regression analysis, increasing age was associated with higher odds of combined neurological morbidity and mortality (odds ratio 1.02, 95% confidence interval 1.00–1.05; p = 0.03). CONCLUSIONS Increasing age is associated with higher neurological morbidity and mortality after Pipeline embolization of intracranial aneurysms. However, the overall complication rates of PED treatment in this group of highly selected elderly patients (> 70 years) were acceptably low, suggesting that age alone should not be considered an exclusion criterion when considering treatment of intracranial aneurysms with the PED.

Background and purpose Carotid blowout is a life threatening complication of invasive head and neck cancers and their treatments. This is commonly treated with endovascular embolization and carotid stenting. Using the Nationwide Inpatient Sample, we report the immediate clinical results of patients receiving embolization and/or stenting for treatment of carotid blowout associated with head and neck cancer. Materials and methods Using the Nationwide Inpatient Sample from the period 2003–2011, we defined carotid blowout patients as those with head and neck malignancies receiving carotid stenting and/or endovascular embolization without open surgery. Outcomes studied included mortality, acute ischemic stroke, hemiplegia/paresis, and other post-operative neurologic complications. Outcomes for the endovascular embolization and carotid stenting group were compared. Results A total of 1218 patients underwent endovascular treatment for carotid blowout. Of these, 1080 patients (88.6%) underwent embolization procedures and 138 patients (11.4%) underwent carotid stenting. The mortality rate of endovascular embolization patients was similar to that of carotid stenting patients (8.0%, 95% confidence interval (CI) = 6.5%–9.7% versus 10.2%, 95% CI=6.0%–16.4%, p = 0.36). Stroke rate was similar between embolization patients and stenting patients (2.3%, 95% CI=1.6%–3.4% vs. 3.4%, 95% CI=1.3%–8.4%, p = 0.43). Hemiplegia rates were significantly higher rate in stenting patients compared with endovascular occlusion patients (3.8%, 95% CI=1.3%–8.4% vs. 1.4%, 95% CI=1.4%–2.4%, p = 0.05). The rate of post-operative neurologic complications was higher in stenting patients compared with embolization patients (6.5%, 95% CI=3.3%–12.1% vs. 1.4%, 95% CI=0.9%–2.4%, p < 0.0001). Conclusions Given the natural history of carotid blowout, carotid stenting and endovascular embolization are acceptable means of treating this disease. Endovascular embolization remains the most common treatment among patients with head and neck cancers with lower overall rates of post-operative neurologic complications, including hemiplegia/paresis and stroke.

The relative safety of unruptured aneurysm treatment with coiling versus flow diversion therapy is unknown. Most data available on flow diversion reflect highly focused patient groups and very experienced operators. We evaluated a national, multihospital patient database to examine periprocedural morbidity and mortality in patients treated with endovascular flow diversion therapy. The Premier Perspective database was used to identify patients hospitalized between May 2011 and March 2013 for unruptured aneurysm who underwent flow diversion therapy with a Pipeline embolization device. The risk of in-hospital mortality and morbidity was determined using ICD 9 codes. A total of 279 unruptured aneurysm patients at 18 medical centers underwent endovascular therapy with a Pipeline device. Adverse outcomes included in-hospital mortality in two cases (0.7%), discharge to long-term care in 22 cases (7.9%), ischemic complications in 14 cases (5.0%), hemorrhagic complications in four cases (1.4%), and postoperative neurological complications in nine cases (3.2%). This study of a large cohort of patient hospitalizations in the United States provides preliminary data on flow diversion in a “real world” scenario and demonstrates that the periprocedural morbidity and mortality is not negligible and must be considered in the context of the natural history of the aneurysms that are being treated.