Acute Renal Failure after Abdominal Trauma: Renal Artery Spasm Hypothesis in Ischemic Infarction in a 12-Year-Old Girl

Posttraumatic renal failure is often due to postischemic renal infarction, caused by identified vascular lesions. In our patient, a 12-year-old girl with acute anuric renal failure requiring hemodialysis after severe abdominal trauma, no vascular lesion or thrombosis was identified. Nevertheless, CT-scan and renal biopsy showed typical lesions of diffuse bilateral renal ischemic necrosis. The main hypothesis is a severe bilateral arterial vasospasm after a blunt abdominal trauma. The patient recovered only partially with persisting chronic renal failure.

DHE-Induced Peripheral Arterial Vasospasm in Primary Raynaud Phenomenon: Case Report

Dihydroergotamine (DHE) is primarily a serotonin 5HT1B and 5HT1D receptor agonist used for acute migraine treatment. It is associated with acute vasoconstriction mediated through the 5HT1B receptor and is contraindicated in patients with history of cardiac disease and peripheral vascular disease. We present a case of acute peripheral arterial vasospasm in a patient with primary Raynaud phenomenon while receiving inpatient treatment for status migrainosus with intravenous (IV) DHE. The patient is a 35-year-old female with a history of chronic migraine and primary Raynaud phenomenon. After 15 doses of IV DHE, the patient reported paresthesias of the right hand and was noted to have absent right radial and ulnar pulses to palpation. Portable arterial Doppler study demonstrated abnormal flat line pulse volume recordings (PVRs) in the right second, third, and fourth digits, with markedly dampened PVR in the right thumb and fifth finger along with no ulnar PVR detectable at the wrist. Duplex revealed bilateral severely diminished flow in the right ulnar and radial arteries without acute occlusions. Computed tomography angiogram of right upper extremity visualized arteries through the mid-forearm but not distally. Dihydroergotamine was discontinued, and the patient was started on oral amlodipine and aspirin. Repeat Doppler ultrasound 3 days later revealed normal arm and digital waveforms bilaterally consistent with resolution of vasospasm. This case highlights a potential complication of IV DHE therapy. Risk may be increased in patients with primary Raynaud phenomenon. We suggest cautious use of IV DHE in this population.

Surgical Treatment of Intracranial Aneurysms in Elderly

Introduction: Twenty years ago, elderly patients who had a diagnosis of intracerebral aneurysms were considered to have a poor prognosis and, thus, were excluded of any kind of treatment. With the rapid aging of the population, there was a consistent increase on the prevalence of subarachnoid hemorrhage and, consequently, all of its complications. Delayed neurological deterioration from cerebral arterial vasospasm is a major cause of morbidity and mortality. Thus, specific treatment strategy for intracranial aneurysms in the elderly has been developed. Materials and Methods: Analysis of medical records, office charts, and imaging studies of all elderly patients who underwent surgical treatment of intracerebral aneurysms, and review of literature. Data related to these patients, like gender, aneurysm location, rupture, and comorbidities, were recorded. Results: Between June 1996 and November 2009, among 152 patients with 209 ruptured and unruptured intracranial aneurysms treated surgically, 23 patients were 65 years of age or older. Discussion: Withholding aneurysm surgery merely because of the patient’s age is not necessarily the most appropriate decision. Early surgery, in order to avoid re-rupture, vasospasm and infection, still is the better decision, independently of the treatment modality - open surgery or endovascular.

Current Practices in the Management of Postoperative Arterial Vasospasm in Microsurgery

Background Postoperative microvascular arterial vasospasm is a rare clinical entity. There are no published management algorithms and also the pathophysiology of this phenomenon has not been elucidated. Methods An email survey of American Society for Reconstructive Microsurgery (ASRM) and World Society for Reconstructive Microsurgery (WSRM) members regarding their experiences with postoperative arterial vasospasm was conducted, returning 116 responses. A comprehensive literature search was conducted regarding the current body of knowledge on this entity. Results Sixty-five percent of respondents encountered cases where postoperative arterial vasospasm was clearly the cause of flap ischemia. The majority (62%) of surgeons believed a damaged segment of the artery was responsible for the spasm, with technical issues cited as the most likely cause. Sixty-two percent and 50% of surgeons used segmental resection of the recipient and donor vessels, respectively.Rated for proclivity to vasospasm, superficial inferior epigastric artery (SIEA) was the flap, superior thyroid artery (STA) the recipient vessel, and the lower limb the anatomic region most frequently mentioned.Most widely used management strategies were: topical vasodilators (91%), adventitial stripping (82%), and dilation of recipient and donor vessels (76%). Over 50% of surgeons used some type of vessel resection technique. Conclusions When flap ischemia is encountered without mechanical issues or thrombus, vasospasm can be the root cause. Certain vessels (SIEA, STA) and anatomic regions (lower limb) pose a higher risk for this phenomenon. When a vessel is affected, it is common practice to excise the questionable segment and use a graft as needed. Vessel resection as part of a multimodal approach can result in a reasonable salvage rate.

Sofia intermediate catheter and the SNAKE technique: safety and efficacy of the Sofia catheter without guidewire or microcatheter construct

BackgroundNeurointerventional surgeries (NIS) benefit from supportive endovascular constructs. Sofia is a soft-tipped, flexible, braided single lumen intermediate catheter designed for NIS. Sofia advancement from the cervical to the intracranial circulation without a luminal guidewire or microcatheter construct has not been described.ObjectiveTo evaluate the efficacy and safety of the new Sofia Non-wire Advancement techniKE (SNAKE) for advancement of the Sofia into the cerebral circulation.MethodsConsecutive patients who underwent NIS using Sofia were identified. Patient information, SNAKE use, and patient outcome were determined from electronic medical records. Sofia advancement to the cavernous internal carotid artery or the V2/V3 segment junction of the vertebral artery was the primary outcome measure. Secondary outcomes included arterial vasospasm and arterial dissection.Results263 Patients (181 females, 69%) who underwent a total of 305 NIS using Sofia were identified. SNAKE (SNAKE+) was used in 187 procedures (61%). Two hundred and ninety-three procedures (96%) were technically successful, which included 184 SNAKE+ NIS and 109 SNAKE− NIS. Primary outcome was achieved in all SNAKE+ procedures, but not in five SNAKE− procedures (2%). No arterial dissections were identified among 305 interventions. In the intracranial circulation, a single SNAKE+ patient (0.5%) had non-flow limiting arterial vasospasm involving the petrous internal carotid. Three SNAKE+ patients (1.6%) and one SNAKE− patient (0.8%) demonstrated external carotid artery branch artery vasospasm during dural arteriovenous fistula or facial arteriovenous malformation treatment.ConclusionSNAKE is a safe and effective technique for Sofia advancement. Sofia is a highly effective and safe intermediate catheter for a variety of NIS.