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Background and Purpose: Conventional angioplasty of cerebral vasospasm combines proximal balloon angioplasty (up to the first segment of cerebral arteries) with chemical angioplasty for distal arteries. Distal balloon angioplasty (up to the second segment of cerebral arteries) has been used in our center instead of chemical angioplasty since January 2015. We aimed to assess the effect of this new approach in patients with aneurysmal SAH., Materials and Methods: The occurrence, date, territory, and cause of any cerebral infarction were retrospectively determined and correlated to angioplasty procedures. Delayed cerebral infarction, new angioplasty in the territory of a previous angioplasty, angioplasty complications, 1-month mortality, and 6- to 12-month modified Rankin Scale ≤ 2 were compared between 2 periods (before-versus-after January 2015, from 2012 to 2017) with adjustment for age, sex, World Federation of Neurosurgical Societies score, and the modified Fisher grade., Results: Three-hundred-ninety-two patients were analyzed (160 before versus 232 after January 2015). Distal balloon angioplasty was associated with the following: higher rates of angioplasty (43% versus 27%, P < .001) and intravenous milrinone (31% versus 9%, P < .001); lower rates of postangioplasty delayed cerebral infarction (2.2% versus 7.5%, P = .01) and new angioplasty (8% versus 19%, P = .003) independent of the rate of patients treated by angioplasty and milrinone; and the same rates of stroke related to angioplasty (3.6% versus 3.1%, P = .78), delayed cerebral infarction (7.7% versus 12.5%, P = .12), mortality (10% versus 11%, P = .81), and favorable outcome (79% versus 73%, P = .21)., Conclusions: Our study suggests that distal balloon angioplasty is safe and decreases the risk of delayed cerebral infarction and the recurrence of vasospasm compared with conventional angioplasty. It fails to show a clinical benefit possibly because of confounding changes in adjuvant therapies of vasospasm during the study period., (© 2019 by American Journal of Neuroradiology.)

Fibro-osseous benign lesions rarely affect the sinonasal tract and are divided into 3 different entities, namely osteoma, fibrous dysplasia and ossifying fibroma. They share several clinical, radiological and histological similarities, but have different behaviours. Ossifying fibroma, and in particular the "juvenile" histological subtype, may have a locally aggressive evolution and a high risk for recurrence if removal is incomplete. The purpose of the present study is to compare the clinical behaviour of ossifying fibroma with the other benign fibro-osseous lesions; highlight different behaviour between the histological subtypes; compare the advantages, limitations and outcomes of an endoscopic endonasal approach with reports in the literature. We retrospectively reviewed 11 patients treated for sinonasal ossifying fibroma at a tertiary care centre. All patients underwent CT scan, and MRI was performed in cases of cranial base involvement or recurrence. Pre-operative biopsy was performed in cases where it was possible to use an endoscopic approach. One patient underwent pre-operative embolisation with ipsilateral visual loss after the procedure. Depending on its location, removal of the tumour was performed using an endoscopic (n = 7), or an external (n = 3) or combined (n = 1) approach. Histopathologically, 5 patients presented the conventional type, 5 the juvenile psammomatoid variant, which was associated in 1 case with an aneurismal bone cyst, and 1 case presented the trabecular juvenile variant. Three patients affected by the juvenile psammomatoid histological variant presented invasion of the skull base and underwent a subtotal removal that subsequently required, due to the regrowth of the remnant, a transbasal approach. Clinical, radiological and histological findings should all be considered to establish differential diagnosis among fibrous osseous lesions. More studies are necessary to conclude if the localisation and extension of the disease at the time of diagnosis is more important than the histological variant. An endoscopic approach is the first choice in most of cases even if an external open approach may be necessary in selected patients.

Background and Purpose: Parent artery occlusion has long been considered the reference treatment for large/giant or fusiform aneurysms of the carotid siphon. However, meager recent data exist on this technique, which tends to be replaced by stent-assisted reconstructive techniques. In our department since 2004, we have assessed the safety, efficacy, and complication risk factors of parent artery occlusion by using coils for trapping these aneurysms., Materials and Methods: We determined retrospectively the complication rate, factors associated with the occurrence of an ischemic event, changes in symptoms of mass effect, evolution of the aneurysmal size, and the growth of an additional aneurysm after treatment., Results: Fifty-six consecutive patients were included, with a median age of 54 years (range, 25-85 years; 92% women), 48% with giant aneurysms and 75% with infraclinoid aneurysms. There was a permanent morbidity rate of 5% exclusively due to ischemia, a zero mortality rate, an aneurysmal retraction rate of 91%, and an improvement rate for pain of 98% and for cranial nerve palsy of 72%, with a median follow-up of >3 years. Para-/supraclinoid topography of the aneurysm (P = .043) and the presence of cardiovascular risk factors (P = .024) were associated with an excessive risk of an ischemic event, whereas the presence of a mural thrombus had a protective role (P = .033)., Conclusions: In this study, parent artery occlusion by using coils to treat large/giant or fusiform aneurysms of the carotid siphon was safe and effective, especially for giant infraclinoid aneurysms. According to recent meta-analyses, these results suggest that the validation of stent-assisted reconstructive treatments for these aneurysms requires controlled studies with parent occlusion artery., (© 2015 by American Journal of Neuroradiology.)

Background and Purpose: Recently some series have been published about the use of Onyx for the treatment of DAFVs with satisfactory results. Our aim was to describe the treatment of different types of intracranial DAVFs with transcatheter injection of Onyx through an arterial approach., Materials and Methods: At the Department of Interventional Neuroradiology, Hospital Lariboisière Paris, between January 2005 and January 2010, we treated 44 DAVFs in 42 patients. All patients were initially treated by arterial injection of Onyx. The average patient age was 56 years (range, 27-86 years), and there were 17 women and 25 men treated., Results: A total of 58 arterial pedicles were catheterized, with the middle meningeal artery representing the most common site (n = 38). The average time of injection was 30 minutes (range, 15-60 minutes), and the average amount of Onyx was 2.5 mL (range, 0.6-6.5 mL). Of the 20 fistulas with direct venous drainage into a dural sinus (types I and II), we achieved the preservation of the sinus in 7 patients. Of the 44 fistulas embolized, 8 required a second embolization treatment and 1 fistula required a third treatment. In 9 cases, a complementary treatment was performed via transvenous embolization with coils and/or open surgery. Early complications were observed in 6 patients: Four had nerve injury (facial palsy, n = 2, and neuralgia, n = 2), and 2 had complications related to extension of venous thrombosis postembolization. All 6 patients had partial or complete resolution of these symptoms., Conclusions: The treatment of DAVFs by intracranial arterial injection of Onyx is safe, and, in most cases, results in the occlusion of the arterial venous shunt. In DAVFs with direct sinus drainage, sinus preservation was only possible in 7 of 20 patients (35%).

We report the case of an early ISR that was due to platelet aggregation despite correct observance of a standard antiplatelet regimen. Biologic testing showed clopidogrel inefficiency, and ISR disappeared on angiography after a loading dose of clopidogrel. This result suggested that the arterial lumen reduction was due to platelet aggregation rather than in-stent myointimal hyperplasia. This observation emphasizes the importance of verifying the efficacy of clopidogrel before placing a stent.

Summary: Three cases of spontaneously closing dural arteriovenous fistulas (AVFs) are presented, and 11 previously published cases are reviewed. On the basis of clinical and angiographic data, two types of spontaneously regressing dural AVFs are distinguished: posttraumatic and spontaneous. In all cases, the explanation for spontaneous closure is unknown. Some authors have hypothesized that the thrombosis of the draining sinus could be involved. We report three cases of spontaneous dural AVF closure with conservation of sinus patency.

Respiratory effects of nitrous oxide and isoflurane were studied in 13 children (mean age 45.6 +/- 19.3 months, mean weight 14.9 +/- 4.8 kg) during surgery under continuous extradural anaesthesia. Three different anaesthetic states were studied: isoflurane 0.5 MAC in oxygen (27 study periods), isoflurane 0.5 MAC with 50% nitrous oxide (32), isoflurane 1 MAC in oxygen (25). End-tidal carbon dioxide (PE' CO2) and isoflurane, respiratory indices (tidal volume, VT; minute ventilation, VE; mean inspiratory flow, VI; respiratory frequency f, effective inspiratory timing TI/Ttot were measured. The addition of nitrous oxide (comparison of respiratory variables obtained in 25 successive periods at (1) and (2)) produced a significant increase in PE' CO2' significant decreases in VT, VE and VI, a significant increase in f. The increase in alveolar concentration of isoflurane ((1) compared with (3) in 25 successive periods) was associated with a significant increase in PE' CO2' significant decreases in VT, VE, VI and a significant increase in f. The equipotent anaesthetic states (2) and (3) were compared in 21 successive periods. In children, the net result of substituting nitrous oxide for an equal MAC fraction of isoflurane was to produce a smaller decrease in VT responsible for a smaller decrease in VE without significant change in respiratory rate.