bluuebunny/crossref_metadata_2025 huggingface dataset:
Diagnosis and Endovascular Treatment of Vertebral Arteriovenous Fistulas in Neurofibromatosis Type 1
Authors: Hori Y. , Goto K. , Ogata N. , Uda K.
Published: January 2017

We present diagnostic problems, strategies, techniques and material selection for endovascular treatment of high flow arteriovenous fistula (AVF) of tortuous and fragile vertebral artery (VA) with neurofibromatosis type 1 (NF1).

Diagnosis of NF1 was easy in four of our cases because of neurofibromatosis, skin pigmentation and various skeletal abnormalities. These stigmas of NF1 were lacking in one case, and the only clue to the diagnosis was ovoid bone defects of the skull vault. Diagnosis was made by performing biopsy of scalp neurofibromas incidentally found on CT. In two initial cases, venous varix were packed with coils by transvenous approach after the transarterial embolisation failed to completely cure the fistula. In three recent cases, blood flow through the fistula was markedly reduced as an initial step by placing detachable coils into the distal and proximal stumps of the afferent VA. Then a liquid adhesive was injected under systemic hypotension to completely occlude the fistula.

Control angiography revealed that the AVFs were completely occluded in all cases. Long-term angiographical and clinical status have been stable in all cases.

Trying to attain complete occlusion of fistulas using detachable balloons is not an appropriate treatment option for high flow fistulas situated on markedly dilated, tortuous and fragile VAs of patients with NF1. Also, trapping of fistulas is not justified because of the numerous potential feeding pedicles, and makes the following procedure difficult.
Guidewire-Induced Carotid Cavernous Fistula
Authors: Kim T.-S. , Ezura M. , Takahashi A. , Nishimura S. , Yoshimoto T.
Published: January 2017

A rare case of carotid cavernous fistula occurring during endovascular embolization of the left carotid cave aneurysm in a 48-year-old female is reported. It was thought to be caused by the tear of a small branch derived from the intracavernous internal carotid artery while the guidewire was passing the sharp posterior bend of the intracavernous internal carotid artery. The left carotid cave aneurysm was completely occluded with five Guglielmi detachable coils assisted by neck plasty technique. It was decided to follow-up the carotid cavernous fistula since it was asymptomatic. Follow-up angiogram performed two weeks later revealed spontaneous obliteration of the carotid cavernous fistula.
Giant Aneurysm of the Cervical Internal Carotid Artery Treated by Proximal Coil Embolization under Temporary Balloon Occlusion
Authors: Uchino A. , Takase Y. , Koizumi T. , Kudo S.
Published: January 2017

We report a patient with a giant aneurysm on the left cervical internal carotid artery (ICA) treated successfully by proximal coil occlusion. Fibered platinum coils were delivered via a 5-F catheter under temporary balloon occlusion of the proximal ICA and without complications. MR imaging ten months after the procedure showed the aneurysm to be reduced in size and subtotally thrombosed. Retrograde partial filling of the aneurysmal lumen was present, however. We describe the case in detail and discuss the ideal treatment of the cervical ICA aneurysm.
Moyamoya Disease is a Progressive Occlusive Arteriopathy of the Primitive Internal Carotid Artery
Authors: Komiyama M.
Published: January 2017

The purpose of this literature review is to disclose the relationship between the temporal profile of steno-occlusive changes in the cerebral arteries in moyamoya disease and the embryological evolution of the cerebral arteries. Steno-occlusive changes and progression occur in the sequence of embryological evolution of the primitive internal carotid artery in the early embryological stage. In other words, steno-occlusive changes in the cerebral arteries occur primarily near the bifurcation of the cranial and caudal divisions of the primitive internal carotid artery, evolve from the cranial division to the caudal one, and progress from the bifurcation centrifugally. Steno-occlusive changes do not occur essentially in the distal cortical branches of the primitive internal carotid artery, in any arteries in the external carotid system, which are derived from ventral pharyngeal system and primitive stapedial system, or in any cerebral arteries in the vertebrobasilar system, which are derived from the longitudinal neural arteries. These facts suggest that moyamoya disease is strongly related to the vasculogenesis of the primitive internal carotid artery and genetic factors play a major role in the clinical manifestations of moyamoya disease.
“Protected” Wallstenting of Atheromatous Stenoses at the Carotid Bifurcation
Authors: Théron J.G. , Guimaraens L.J. , Casasco A.E. , Courtheoux P.G. , Beaujeux R.L. , Rufenacht D.A. , Coskun O. , Sola M.T. , Constans J.-M. , Martin J.-B.
Published: January 2017

Atheromatous stenoses at the carotid bifurcation were treated by angioplasty and Wallstenting with cerebral protection obtained in most cases by temporary occlusion of the internal carotid artery. 287 carotid stenoses were treated in 233 patients. The stenosis was symptomatic in 79% of cases. All patients presented either a stenosis of >70% with significant impairment of the cerebral circulation (281 cases) or a symptomatic ulcerated plaque (six cases). A self-mounted protection system was used in 177 cases, the Percusurge Guardwire protection device in 98 cases an EPI filter in 12 cases. There was a contralateral internal carotid occlusion in 13% of cases. A combined stenting (vertebral, siphon, subclavian) was performed in 14% of cases. A Rolling membrane Wallstent was used in 84 patients, a first generation Easy Wallstent in 38 cases, a “Carotid” Easy Wallstent 35 in 55 cases and monorail 14 in 110 cases.

Full opening of the stenosis was obtained in 98% of patients with correction of the arterial curve and improvement of the cerebral vascular supply. There were 0.7% cases with transient symptomatic neurological complications and 2% with permanent sequelae mainly related to avoidable inadequacy in flushing or to the insufficient radial force of the first generation Easy Wallstent. There were no per and one post-procedural cardiac complication (0.6%) in the s165 cases performed with the “Carotid” Easy Wallstent. Follow-up angiograms showed O.7% of restenoses. Still in evolution, endovascular treatment of atheromatous stenoses at the carotid bifurcation with cerebral protection and stenting is a promising alternative technique to surgery. The association of Carotid Easy Wallstent 14 monorail and Percusurge Guardwire appears to be currently satisfactory.
Secondary Spontaneous Thrombosis of a Giant Aneurysm Located Distally on a Feeding Artery after Embolization of an Associated Arteriovenous Malformation
Authors: Poon W.L. , Alvarez H. , Lasjaunias P.
Published: January 2017

Giant aneurysm located in the distal part of the feeding artery associated with a cerebral arteriovenous malformation is rare and the treatment is clinically challenging.

We report the spontaneous and complete thrombosis of a flow-related giant aneurysm immediate up-stream to a cerebral arteriovenous malformation by embolization of that malformation alone in a patient presenting with complex partial seizure and no history of intracranial haemorrhage. We obviated the need to directly intervene on the giant aneurysm, thus reducing unnecessary procedure related risks to the patient. Follow up one year later confirms the thrombosis and show shrinkage of the mass. The patient is asymptomatic.
Regression of a Flow-Related Ophthalmic Artery Aneurysm after Treatment of a Frontal DAVS
Authors: Andersson T. , Kihlström L. , Söderman M.
Published: January 2017

We report a case of a frontal dural arteriovenous shunt or fistula (DAVS) adjacent to the left side of the cribriform plate, with bilateral supply from multiple arteries, the most prominent being the dural branches originating from the anterior ethmoidal artery coming from the left ophthalmic artery. Before treatment there was an eight mm flow-related arterial aneurysm proximally on the left ophthalmic artery. After transarterial embolization of the DAVS with N-butyl cyanoacrylate and polyvinyl alcohol, minimal shunting still remained. At follow-up angiography six months after the treatment, the shunt was obliterated and the ophthalmic artery aneurysm had regressed completely. Our case illustrates that complete obliteration of a DAVS may be achieved even though arteriovenous shunting remains at the end of the procedure. Furthermore, a flow-related arterial aneurysm, may not warrant any specific treatment. Elimination of the high flow situation can lead to complete regression of these aneurysms.
Accuracy of Voxel-Based and Algebraic Formula-Based Methods in Quantifying Cerebral Aneurysm Volume by 3D-Rotational Digital Subtraction Angiography
Authors: Fanning N.F. , O'Dwyer H.M. , Bowden J.A.B. , Brennan P.R. , Thornton J.
Published: January 2017

Accurate knowledge of cerebral aneurysm volume would be valuable in guiding the volume of embolized material required for optimal filling of an aneurysm sac and recording percentage volume filling. Algebraic volumes are frequently estimated by algebraic volume formulae. 3D digital subtraction angiography (DSA) aids endovascular treatment planning and yields volumetric data. Our aim was to define the accuracy of 3D-DSA in quantifying aneurysm volume using an automated voxel-based volumetric method (voxel volume method) and compare results to volumes calculated by ellipsoid and cylindrical algebraic formulae (algebraic volume method).

We constructed 13 latex aneurysm moulds and measured their true volumes using a micro-pipette in-vitro. 3D-DSA was performed on contrast filled moulds and experimental volume estimated by both voxel and algebraic methods. In our in-vivo study we quantified the voxel and algebraic volumes from the 3D data sets of 75 cerebral aneurysms. The linear regression test provided correction values between voxel and algebraic methods.

The in-vitro study showed that the voxel volume method was the most accurate (mean percentage deviation from true volume 3.7 ± 3.5%; p = 0.9). The ellipsoid method significantly underestimated −11.2 ±13.6%; p<0.05) and the cylindrical method overestimated (42.6 ±35.7%; p<0.05) true aneurysm volume. Similar results were obtained in-vivo. While algebraic measurements could be corrected by an equation, the clinical usefulness of this equation is questionable due to the large volume range to achieve a 95% confidence interval.

The voxel volume method is accurate in quantifying aneurysm volume. Aneurysms in-vivo do not conform to simple algebraic geometry. Aneurysm volume on 3D-DSA should be calculated by the voxel-based method and not by algebraic formulae.
Endovascular Coiling of Aneurysm Remnants after Clipping in Patients with Follow-up
Authors: Mangiafico S. , Cellerini M. , Villa G. , Ammannati F. , Paoli L. , Mennonna P.
Published: January 2017

The vast majority of intracranial aneurysms can be obliterated completely with surgical clipping. However, postoperative remnants occur in about 4 to 8% of patients who undergo postoperative angiography.

Endovascular embolization has been successfully performed in patients with postoperative aneurysm remnant and it may represent a therapeutic alternative to surgical reintervention.

Twelve aneurysm remnants after surgical clipping were treated with endovascular embolization using GDC. All aneurysms were located in the anterior circulation. Our experience confirms the feasibility and relative safety of this treatment strategy that may be considered a valid alternative to reintervention.
Endovascular Treatment with Platinum Coils
Authors: Raymond J. , Ogoudikpe C. , Metcalfe A. , Salazkin I. , Gevry G. , Robledo O.
Published: January 2017

Recanalization after coil occlusion is a concern for long-term results of endovascular treatment. Knowledge of molecular events following coil occlusion and recanalization could help design specific strategies to promote permanent occlusion.

Platinum coils were implanted into canine maxillary, vertebral or lingual arteries. Coil occlusion (treatment 1), routinely followed by recanalization was compared with two strategies to prevent recanalization: beta radiation using 32P coils (treatment 2) and endothelial denudation, using an endovascular device, followed by coil occlusion (treatment 3).

The evolution of initial complete occlusions was followed by angiography and pathology at three months. Levels of messenger RNA of vWF (von Willebrand factor), SMA (smooth muscle actin), CD14, CD31 (or PECAM-1: Platelet Endothelial Cell Adhesion Molecule-1), PDGFBB (platelet-derived growth factor), TGF-b1 (transforming growth factor), MCP-1 (macrophage chemoattractant protein), Angiopoietins, Metalloproteinases-9, 14 and inhibitors (TIMP-2, 4) were followed by Reverse Transcription and Polymerase Chain Reaction (RT-PCR). Analyses were performed one, four, seven and 14 days after coiling, and levels of expression after the three treatments were compared using ANOVA s.

Intact arteries treated with platinum coils routinely recanalize (100%), but arteries treated by denudation and coiling or with radioactive coils recanalize in only 17% and 4% respectively (P<.001). Recanalization was associated with increased levels of vWF mRNA at seven days, a finding that was not observed with denudation or radiation (P=.015). There was no other significant difference.

Recanalization is associated with early vWF expression, perhaps reflecting the development of endothelialized channels through thrombus formed after coil occlusion.
Treatment of a Recurrent Internal Carotid Artery Pseudoaneurysm with the Wallgraft Endoprosthesis
Authors: Sibtain N. , Shah J. , Johnson D. , Clifton A.
Published: January 2017

The use of covered stents to treat traumatic carotid artery pseudoaneurysms is increasingly being documented. Adjunctive antiplatelet therapy is mandatory. We present a case of bilateral traumatic carotid artery pseudoaneuryms in which antiplatelet therapy was contraindicated at presentation, thereby dictating alternative treatment with coil embolization alone. Subsequent aneurysmal recurrence was successfully treated with the Wallgraft prosthesis. The literature on the use of the Wallgraft prosthesis for the treatment of carotid artery pseudoaneurysms is also reviewed.
Analysis of Supplemental Surgical or Endovascular Treatment for Cerebral Aneurysms in the Endovascular Performed Cases
Authors: Fukui K. , Watanabe M. , Inoue N. , Wakabayashi K. , Kato T. , Tanei T.
Published: January 2017

In the 150 endovascular performed cases from May 1997 to Dec 2004, supplemental combination of endovascular and surgical treatments were performed in 46 cases. Characteristics of the treatments were combination for multiple aneurysms, surgical clipping for failed endovascular attempt, embolization for recurrence after clipping, bypass surgery before endovascular parent artery occlusion, surgery for recurrent aneurysms after embolization, and embolization for failed surgical attempt. Sixty seven percent of ruptured and 87% of unruptured cases showed satisfactory clinical outcome (modified Rankin scale = 0 to 2). Supplemental combination of each treatment will support the disadvantage of another treatment, and which improve the clinical outcome of cerebral aneurysm.
Balloon or Stent-Assisted Coil Embolization for Acutely Ruptured Wide-Necked Aneurysms
Authors: Matsumoto H. , Tsuji N. , Fujita K. , Miki J. , Terada T. , Tsumoto T. , Yamaga H.
Published: January 2017

In this paper, we report five cases with acutely ruptured wide-necked aneurysms, which were treated with coil embolization using a balloon or stent-assisted technique. Balloon-assisted coil embolization using Equinox balloon, Commodore balloon, and Hyperform balloon were performed for four patients and stent-assisted coil embolization using BX velocity for one patient. We discuss problems of coil embolization for acutely ruptured wide-necked aneurysms with a balloon or stent-assisted technique.
Experience of Y-Configured Stents for Small Basilar Tip Aneurysms
Authors: Cho Chun-Sung , Kim Young-Joon , Kim Jin Kyung , Kim Young Jin , Lee Sang Koo , Cho Maeng Ki
Published: January 2017

Among posterior circulation aneurysms, basilar tip aneurysm is the most difficult to treat. Because of their deep location in front of the brainstem and their intimate relationship to perforating vessels, morbidity and mortality rates associated with direct exposure used to be daunting.

Complex intracranial aneurysms are not uncommonly encountered in cerebrovascular practice. Often their complexity can render standard treatment either impossible or exceedingly hazardous. Although endovascular therapy is an available alternative to surgical clipping, it is not without risks.

The Neuroform stent represents a significant advance in the endovascular treatment of intracranial aneurysms. The Y-configured reconstruction method of the Neuroform stent may represent a variable therapeutic option especially in the case of terminal type including bifurcation aneurysms.

We report the results of our experience in two small basilar tip aneurysms using stent-assisted coiling.
Selective Transvenous Embolization of Dural Arteriovenous Fistulas Involving the Hypoglossal Canal
Authors: Okahara M. , Kiyosue H. , Tanoue S. , Sagara Y. , Hori Y. , Kashiwagi J. , Mori H.
Published: January 2017

The hypoglossal canal contains a venous plexus that connects the inferior petrous sinus, condylar vein, jugular vein and paravertebral plexus. The venous plexus is one of the venous drainage routes of the posterior skull base. Only a few cases of dural arteriovenous fistulas (AVFs) involving the hypoglossal canal have been reported.

We describe three cases (a 62-year-old female, a 52-year-old male, and an 83-year-old male) of dural AVFs involving the hypoglossal canal. Symptoms were pulse-synchronous bruit in two cases and proptosis/chemosis in one. All dural AVFs were mainly fed by the ipsilateral ascending pharyngeal artery. Two of three dural AVFs involving the hypoglossal canal mainly drained through the anterior condylar confluence into the inferior petrosal sinus retrogradely with antegrade drainage through the lateral condylar vein. The other one drained through the lateral and posterior condylar veins into the suboccipital cavernous sinus. All dural AVFs were completely occluded by selective transvenous embolization without any complications, and the symptoms disappeared within one week in all cases.

Dural AVFs involving the hypoglossal canal can be successfully treated by selective transvenous embolization with critical evaluation of venous anatomy in each case.
Extracranial Vertebral Artery Involvement in Neurofibromatosis Type I: Report of Four Cases and Literature Review
Authors: Pereira V.M. , Geiprasert S. , Krings T. , Caldas J.G.M.P. , Toulgoat F. , Ozanne A. , Mercier P. , Lasjaunias P. L.
Published: January 2017

Neurofibromatosis type 1 (NF-1) is one of the most common inherited diseases and as an autosomal dominant genetic disorder results from NF-1 gene mutation with 100% penetration and wide phenotypic variability.

The disease can involve a wide variety of tissues derived from all three embryonic layers. NF-1 vasculopathy has been described primarily in peripheral arteries, but arteries supplying the CNS may also be involved. Of those, extracranial vertebral involvement is the commonest and most important. A series of four patients with NF-1 and vascular disease of the vertebral artery is described with a review of the pathophysiology, vascular phenotypes, their management and the pertinent literature.
Endovascular Treatment of Huge Dissecting Aneurysms Involving the Basilar Artery
Authors: Yang X. , Mu S. , Lv M. , Li L. , Wu Z.
Published: January 2017

Dissecting aneurysms involving the basilar artery (BA) are lesions with significant morbidity and mortality. Their management is controversial and often difficult. There is no generally approved strategy.

Two cases of huge dissections involving the BA presented with subarachnoid hemorrhage in one case and mass effect in both cases. The dissection of case 1 involved the upper two thirds of the BA distal to the anterior inferior cerebellar arteries (AICA). Another dissection of case 2 involved the bilateral vertebral arteries (VA) distal to bilateral PICA and extended to upper third of the BA. After making a basket with coils inside the pseudoaneursym, proximal dissection was totally occluded in case 1. Dissection on the bilateral VA distal to the bilateral PICA and proximal BA was occluded in case 2 with a small residual dissection on the left VA. Case 1 had an excellent recovery with a durable image and clinical result. But recanalization and regrowth occurred in case 2, which might have originated from the residual dissection on the left VA, induced acute mass effect and sudden coma six weeks after the initial treatment. The residual and regrown dissection had to be occluded in a second intervention. The patient died two days later.

BA occlusion is safe and efficient for dissections involving the BA as in our case and the literature. Proximal occlusion might be enough for huge and long lesions like ours. It seems that completely dense packing of proximal dissection is the key point to prevent recanalization.
A Rete Mirabile of the Posterior Cerebral Artery
Authors: Zheng L. , Metcalfe R. , Bhattacharya JJ
Published: January 2017

We present the case of a 41-year-old man with a vascular network associated with the left posterior cerebral artery (PCA). Although initially considered to be a brain AVM, further investigation showed no arteriovenous shunting and a rete mirabile of the PCA was diagnosed. A well known but rare occurrence mainly in the anterior circulation, rete mirabile has not previously been described in the PCA.

The PCA is a composite vessel, developmentally. Its proximal portion derives from the posterior division of the ICA while its cortical territories are annexed from the anterior choroidal artery adjacent to the lateral geniculate body. We propose that this rete (or network) represents a persistence of the embryonic anastomosis between the AChA and the PCA.
Endovascular Treatment of a Ruptured Aneurysm at a Very Rare Location
Authors: Sarikaya B. , Oksuz E. , Deniz F.E. , Firat M.M.
Published: January 2017

We describe a patient with a small ruptured azygos anterior cerebral artery aneurysm located at a non-bifurcation distal site on the artery treated successfully with simple coiling.
Microsurgical Clipping of Intracranial Aneurysms following Unsuccessful Endovascular Treatment
Authors: Yu J.-L. , Xu K. , Wang H.-L. , Wang B. , Luo Q.
Published: January 2017

The purpose of the current study was to examine the reasons for failed endovascular aneurysm coiling and to determine the outcome of immediate microsurgical clipping. From July 2006 to July 2008, 198 patients underwent endovascular coiling at our institute; among them, ten cases were unsuccessful. All of the patients were diagnosed with intracranial aneurysms (ICAs) by cranial computed tomography angiography (CTA), and all underwent endovascular treatment without digital subtraction angiography (DSA). When endovascular coiling failed, the patients were immediately transferred to the operating room for microsurgical clipping under the same anesthetic. The ten patients were divided into three groups based on the cause of endovascular failure and associated clinical features. The clinical follow-up period was between 6–12 months, and all 10 patients had good outcomes following the surgery. Taken together, the results of this study suggest that immediate microsurgical clipping after failed endovascular coiling is efficient and may provide improved outcomes by preventing rebleeding.
A Novel Grading Scale for the Angiographic Assessment of Intracranial Aneurysms Treated Using Flow Diverting Stents
Authors: O'Kelly C.J. , Krings T. , Fiorella D. , Marotta T.R.
Published: January 2017

Flow diverting stents are emerging as a treatment option for difficult intracranial aneurysms. Current grading scales for assessment of angiographic outcomes following aneurysm treatment do not apply to aneurysms treated by flow diversion. We propose a novel grading scale based on the degree of angiographic filling and contrast stasis. This scale will facilitate communication and standardize reporting of outcomes following flow diversion treatments.
Angiographic Pitfall: Duplicated Tapered A1 Segment of the Anterior Cerebral Artery Mimicking an Anterior Communicating Artery Aneurysm
Authors: Weil A.G. , Bojanowski M.W. , Scholtes F. , Darsaut T.E. , Signorelli F. , Weill A.
Published: January 2017

We describe a misleading case of a partially occluded A1 segment duplication that mimicked an ACoA aneurysm on computed tomography angiography and conventional angiography and led to surgical intervention. The location of such an anomaly at the ACoA on the side of least hemodynamic stress may provide a clue to recognizing this variant.
Sinus Thrombosis in a Patient with Intracranial Hypotension: A Suggested Hypothesis of Venous Stasis
Authors: Yoon K-W. , Cho M-K. , Kim Y.J. , Cho C.S. , Lee S-K.
Published: January 2017

We describe the case of a 26-year-old man with orthostatic headache. Cerebral angiography revealed thrombosis in the sagittal sinus. Spine MRI showed cerebrospinal fluid collection at the C1–2 level. We performed blood patch and the symptoms disappeared. We report a rare case of intracranial hypotension caused by CSF leak and describe our hypothesis that SIH can change the velocity of cerebral blood flow and cause thrombosis.
Stretched and Sheared Microcatheter Retained after Onyx Embolization of Infantile Myofibromatosis
Authors: Puri A.S. , Rahbar R. , Dearden J. , Graham R.J. , Lillehei C. , Orbach D.B.
Published: January 2017

We describe a rare neurointerventional complication, namely a stretched and sheared microcatheter, extending 52 cm from its point of retention within an Onyx cast in an infant patient's neck mass, to the groin. The tumor was an unusual manifestation of infantile myofibromatosis and prior attempts at resection had proven impossible due to bleeding. Recommendations regarding microcatheter selection, diagnostic workup, and management of the ensuing complication are given.
Endovascular Treatment of Unruptured Intracranial Aneurysms
Authors: Yue W.
Published: January 2017

We report the clinical and angiographic results of endovascular treatment of unruptured intracranial aneurysms.

Over a three-year period, 80 unruptured aneurysms in 74 patients were electively treated with endovascular management. One aneurysm was diagnosed during investigations for a second ruptured aneurysm, 54 aneurysms were incidentally discovered, 18 aneurysms presented with symptoms of mass effect and seven aneurysms presented with symptoms of brain stem ischemia. Mean size of the 80 unruptured aneurysms was 12.5±8.0 mm (range, 2–39 mm). Thirty-six aneurysms (45%) were small (<10 mm), 38 aneurysms (47.5%) were large (10–25 mm), and six aneurysms (7.5%) were giant (25–39 mm). Forty-eight wide-necked aneurysms (60%) were coiled with the aid of a supporting device.

The mortality rate was 1.25%, and the overall morbidity was 1.25%. Of these, one of the patients suffered a stroke, leading to severe disability (1.25%). In one patient, the aneurysm ruptured during treatment, resulting in death. Initial aneurysm occlusion was complete (100%) in 76.25% aneurysms, nearly complete (90%–98%) in 10% aneurysms and incomplete (60%–85%) in 13.75% aneurysms. Follow-up angiography was available in 67 patients with 73 treated aneurysms (91.25%) from one to 36 months (mean 9.3 months); partial reopening occurred in 7.5%, mainly large and giant aneurysms (5.5%). Additional coiling was performed in four aneurysms. There were no complications in additional treatments. At 14.1-month clinical follow-up (range, 2 to 36 months), mRS score was 0 in 78.75% patients, 1 in 10% patients, 2 in 8.75% and 3 in 1.25%. There was no aneurysmal rupture during the follow-up period. Endovascular treatment of unruptured intracranial aneurysms has low procedural mortality and morbidity rates.
Endovascular Treatment of Hemifacial Spasm Associated with a Petrosal DAVF Using Transarterial Onyx Embolization
Authors: Li T. , Lv X. , Wu Z.
Published: January 2017

This paper reports that decompression of the facial nerve by transarterial Onyx embolization may relieve hemifacial spasm (HFS) caused by dilated veins due to a right petrosal dural arteriovenous fistula (DAVF).

A 56-year-old man suffered severe chronic right HFS associated with a dilated right petrosal vein lying in the vicinity of the facial nerve.

The right petrosal DAVF was reached through the middle meningeal artery using a transfemoral arterial approach and was occluded with Onyx 18 (M.T.I.- ev3, Irvine, CA, USA). There was complete remission of HFS without recurrence after two months of follow-up.

This case supports vascular compression in the pathogenesis of HFS and suggests that facial nerve injury caused by a DAVF could be treated with transarterial Onyx embolization.
Juvenile Pilocytic Astrocytoma in Association with Arteriovenous Malformation
Authors: Soltanolkotabi M. , Schoeneman S.E. , Dipatri A.J. , Hurley M.C. , Ansari S.A. , Rajaram V. , Tomita T. , Shaibani A.
Published: January 2017

Pilocytic astrocytomas are highly vascular, relatively common primary brain tumors in the pediatric population, but their association with a true arteriovenous malformation (AVM) is extremely rare. We describe an eight-year-old girl with a right supratentorial juvenile pilocytic astrocytoma (WHO grade I) with an angiographically documented AVM entangled in the tumor mass who presented with intracranial hemorrhage due to a ruptured anterior choroidal artery pseudoaneurysm encased in the lesion. The AVM nidus as well as the hemorrhage site was embolized with Onyx. A literature review revealed only one previous report of a true intermixture of these two lesions. We hypothesize whether the association of vascular malformations and primary brain tumors are merely coincidental or if they point to the existence of a distinct entity and/or a common etiologic factor.
Anomalous Origins of Bilateral Vertebral Arteries in a Child with down Syndrome and Moyamoya Disease
Authors: Mishra A. , Pendharkar H. , Jayadaevan E.R. , Bodhey N.
Published: January 2017

Variations in vertebral artery origin and course are well-described in the literature. The origin of right vertebral artery from the right common carotid artery is an extremely rare variant. We describe a unique case of a child with Down syndrome with variant origins of bilateral vertebral artery, an aberrant right subclavian artery and concomitant Moyamoya disease of intracranial circulation. The presence of variations of the origin and course of craniocervical arteries might have profound implications in angiographic and surgical procedures and hence it is of great importance to be aware of such a possibility.
Cerebral Blood Flow and Metabolism Measurement Using Positron Emission Tomography before and during Internal Carotid Artery Test Occlusions: Feasibility of Rapid Quantitative Measurement of CBF and OEF/CMRO2
Authors: Kawai N. , Kawanishi M. , Shindou A. , Kudomi N. , Yamamoto Y. , Nishiyama Y. , Tamiya T.
Published: January 2017

Balloon test occlusion (BTO) of the internal carotid artery (ICA) combined with cerebral blood flow (CBF) study is a sensitive test for predicting the outcome of permanent ICA occlusion. However, false negative results sometimes occur using single photon emission tomography (SPECT). We have recently developed a rapid positron emission tomography (PET) protocol that measures not only the CBF but also the cerebral oxygen metabolism before and during BTO in succession. We measured acute changes in regional CBF and OEF/CMRO2 before and during BTO in three cases with large or giant cerebral aneurysms using the rapid PET protocol.

Although no patients showed ischemic symptoms during BTO, PET studies exhibited mildly to moderately decreased CBF (9∼34%) compared to the values obtained before BTO in all cases. The average OEF during BTO was significantly increased (21% and 43%) than that of before BTO in two cases. The two cases were considered to be non-tolerant for permanent ICA occlusion and treated without ICA sacrifice.

Measurement of the CBF and OEF/CMRO2 using a rapid PET protocol before and during BTO is feasible and can be used for accurate assessment of tolerance prediction in ICA occlusion.
CE-MRA for Follow-up of Aneurysms Post Stent-Assisted Coiling
Authors: Agid R. , Schaaf M. , Farb Ri.
Published: January 2017

This study compared the accuracy of contrast-enhanced MR angiography (CE-MRA) to intraarterial cerebral angiography (IA-DSA) for assessment of intracranial aneurysms after stent-assisted coiling and to check if the presence of a stent in the parent artery diminishes the accuracy of CE-MRA.

Consecutive patients with cerebral aneurysms treated by stent-assisted coiling were evaluated retrospectively. Matching follow-up CE-MRA and IA-DSA were evaluated separately. Evaluation included the presence of aneurysmal remnant, patency and stenosis of parent artery.

Twenty-seven patients with 28 aneurysms and 33 matched CE-MRA and IA-DSA studies were evaluated. Nineteen aneurysmal remnants were seen on CE-MRA and 16 on IA-DSA. CE-MRA diagnosed three aneurysmal remnants not appreciated on IA-DSA. Five other remnants were larger on CE-MRA than IA-DSA. None of the remnants were missed on CE-MRA.

Parent arteries were patent on both modalities. CE-MRA showed false stenosis of the stented artery in six cases and exaggerated stenosis in two. In 18 cases, CE-MRA showed a short focal “pseudo-stenosis” where the stent's marker bands were located. This was noted whenever the stent's marker bands were located in an artery with luminal diameter ≤2 mm and was called “marker band effect”.

CE-MRA is an accurate technique for follow-up of aneurysms post stent-assisted coiling with excellent depiction of remnants in spite of the presence of a stent. Apparent stenosis of the stented parent artery on CE-MRA is often false or exaggerated. “Marker band effect” should be recognized as an artifact that appears when stent's marker bands are in a small artery.
Use of the Penumbra System 054 plus Low Dose Thrombolytic Infusion for Multifocal Venous Sinus Thrombosis
Authors: Siddiqui F.M. , Pride G.L. , Lee J.D.
Published: January 2017

Multifocal cerebral venous sinus thrombosis (CVST) has a high mortality rate especially when patients present with stupor or coma. Medical treatment including anticoagulation raises concerns about the associated high risk of intracerebral hemorrhage. Treatment of multifocal CVST with mechanical thrombectomy devices and local tPA infusion have previously been reported. However, these devices may have technical limitations. Success of the new-generation aspiration thrombectomy device like the Penumbra system has been reported in few cases of isolated CVST without the use of chemical thrombolysis.

We describe two cases in which mechanical thrombectomy were used in conjunction with intra-sinus tPA infusion. Both cases were complicated and failed initial anticoagulation. Penumbra 054 was used in both cases. The Penumbra 054 is a novel device that has a bigger lumen which provides compatibility with other microcatheters, if additional therapies are required. The larger internal diameter of this catheter also allows for stronger thrombo-aspiration, potentially effecting more rapid sinus recanalization. Both cases showed remarkable clinical recovery without any major complications.

This is the first reported simultaneous use of the Penumbra system 054 along with tPA infusion. New devices such as the Penumbra system may offer additional therapeutic options in the treatment of multifocal CVST.
Intraprocedural Angiographic CT as a Valuable Tool in the Course of Endovascular Treatment of Direct Sinus Cavernous Fistulas
Authors: Gölitz P. , Struffert T. , Saake M. Arc , Knossalla F. , Doerfler A.
Published: January 2017

This investigation aimed to demonstrate the potential of intraprocedural angiographic CT in monitoring complex endovascular coil embolization of direct carotid cavernous fistulas.

Angiographic CT was performed as a dual rotational 5 s run with intraarterial contrast medium injection in two patients during endovascular coil embolization of direct carotid cavernous fistulas. Intraprocedural angiographic CT was considered helpful if conventional 2D series were not conclusive concerning coil position or if a precise delineation of the parent artery was impossible due to a complex anatomy or overlying coil material. During postprocessing multiplanar reformatted and dual volume images of angiographic CT were reconstructed.

Angiographic CT turned out to be superior in the intraprocedural visualization of accidental coil migration into the parent artery where conventional 2D-DSA series failed to reliably detect coil protrusion. The delineation of coil protrusion by angiographic CT allowed immediate correct coil repositioning to prevent parent artery compromising.

Angiographic CT can function as a valuable intraprocedurally feasible tool during complex coil embolizations of direct carotid cavernous fistulas. It allows the precise visualization of the cerebral vasculature and any accidental coil protrusion can be determined accurately in cases where conventional 2D-DSA series are unclear or compromised. Thus angiographic CT might contribute substantially to reduce procedural complications and to increase safety in the management of endovascular treatment of direct carotid cavernous fistulas.
Cement Embolization of a Segmental Artery after Percutaneous Vertebroplasty: A Potentially Catastrophic Vascular Complication
Authors: Matouk C.C. , Krings T. , Ter Brugge K.G. , Smith R.
Published: January 2017

Serious complications related to percutaneous vertebral augmentation procedures, vertebroplasty and kyphoplasty, are rare and most often result from local cement leakage or venous embolization. We describe an adult patient who underwent multi-level, thoracic percutaneous vertebral augmentation procedures for painful osteoporotic compression fractures. The patient's percutaneous vertebroplasty performed at the T9 level was complicated by the asymptomatic, direct embolization of the right T9 segmental artery with penetration of cement into the radicular artery beneath the pedicle. We review the literature regarding the unusual occurrence of direct arterial cement embolization during vertebral augmentation procedures, discuss possible pathomechanisms, and alert clinicians to this potentially catastrophic vascular complication.
Resolution of Clinical Symptoms after Reopening of an Occluded Inferior Petrosal Sinus in a Patient with a Cavernous Sinus Dural Arteriovenous Fistula
Authors: Kojima A. , Onozuka S. , Kinoshita Y.
Published: January 2017

We describe a rare case with a cavernous sinus (CS) dural arteriovenous fistula (DAVF) in which the clinical symptoms disappeared after the patient underwent reopening of an occluded inferior petrosal sinus (IPS). A 66-year-old woman presented with increased intraocular pressure, chemosis, and proptosis on the left side. Angiography demonstrated a left CS DAVF supplied by the dural branches of bilateral internal carotid arteries. The shunt flow was directed to the superior and inferior ophthalmic veins, while the bilateral IPSs were not opacified. Accordingly, a transvenous embolization of the fistula was attempted. Although the microcatheter was navigated to the cavernous sinus through the occluded left IPS, obliteration of the fistula was unsuccessful because of the failure of superselective catheterization at the fistulous point. However, the final image demonstrated the development of an antegrade shunt flow through the left IPS to the internal jugular vein and disappearance of the retrograde reflux to the superior and inferior ophthalmic veins.

The patient's clinical symptoms immediately resolved after the operation, and the symptoms have not recurred during a one-year follow-up period. Inappropriate transvenous embolization of CS DAVFs can result in vascular complications arising from the unintentional redistribution of shunt flow. The present case illustrates that the disappearance of retrograde shunt flow to the ophthalmic veins after reopening of the occluded IPS may be sufficient if a superselective approach fails or is anticipated to result only in an incomplete embolization of the fistulous point.
CT Angiography in an Acute Stroke Protocol: Correlation between Occlusion Site and Outcome of Intravenous Thrombolysis
Authors: Porelli S. , Leonardi M. , Stafa A. , Barbara C. , Procaccianti G. , Simonetti L.
Published: January 2017

Thrombolysis with intravenous rt-PA is the current therapy for acute ischemic stroke. Unlike other outcome factors, relatively little is known about the prognostic value of the occlusion site on treatment outcome. We compared the effectiveness and safety of intravenous thrombolysis in patients with different levels of occlusion identified by CT angiography (CTA) in anterior circulation stroke, and analyzed the influence of the occlusion site on treatment outcome in relation to other outcome factors.

We selected 71 patients from a stroke database collected between June 2007 and December 2011 at our hospital. All of the studied patients had anterior circulation stroke with intracranial occlusion detected by CTA and were treated with intravenous rt-PA. They were divided into two groups according to the site of occlusion along the middle cerebral artery course: proximal (carotid “T”, complete M1 and mild M1 occlusions) and distal (M2/M3 occlusions). Treatment effectiveness was assessed by modified Rankin Scale (mRS) at three months, considering a positive outcome a mRS value ≤ 2. Treatment safety was assessed by evaluating the rate of hemorrhagic complications seen on unenhanced CT at 24 hours. Binary logistic regression was performed to evaluate the interaction between occlusion site and other variables such as sex, age, ASPECT score on admission and baseline NIHSS value in determining treatment outcome.

The degree of effectiveness and safety differed when considering patients with proximal and distal occlusions. The percentage of successfully treated cases was 28.6% in the first group compared to 72% in the second, and the rate of hemorrhagic complications was 28.6% and 6% respectively. After adjustment for sex, age, ASPECT score on admission and baseline NIHSS value, occlusion site was the only variable significantly influencing treatment safety and, together with baseline NIHSS value, the only valid predictor of treatment effectiveness.

We demonstrated a correlation between the site of arterial occlusion and outcome of intravenous thrombolysis. By helping the choice of the best therapeutic strategy depending on the identified occlusion site, CTA could be usefully added to the examinations included in the Stroke Protocol for the baseline evaluation of patients with suspected acute stroke.
Vascular Distribution of Glioblastoma Multiforme at Diagnosis
Authors: Yohay K. , Wolf D.S. , Aronson L.J. , Duus M. , Melhem E.R. , Cohen K.J.
Published: January 2017

Treatment of high-grade gliomas with selective intra-arterial (IA) administration of chemotherapies has been proposed, and utilized as a therapeutic modality. This approach offers the conceptual benefit of providing maximal delivery of the agent to the tumor bed, while potentially reducing systemic exposure to the agent. This retrospective study was designed to determine the vascular distribution of glioblastoma multiforme (GBM) at the time of diagnosis in an effort to determine what proportion of patients would likely be candidates for this approach. The preoperative MRI scans of 50 patients with GBM were analyzed and compared to published normative data of intracranial vascular distribution. Vascular distribution was determined by analyzing post-gadolinium axial and coronal T1 images, axial T2 images, and axial T2 images with an additional 1 cm margin (T2 + 1 cm) added in all dimensions. T1 analysis demonstrated 60% of tumors in a single vascular distribution. T2 analysis of these tumors reduced that number to 34%. When the T2 + 1 cm margin was utilized, only 6% of tumors were in a single vascular distribution. 66% of tumors were limited to the anterior circulation on T1 imaging but only 34% on T2 + 1 cm imaging. 30% of tumors were also within the distribution of the anterior choroidal artery. These findings suggest that the use of selective IA administration of agents is necessarily limited to a fraction of presenting patients or will require administration via multiple cerebral arteries.
Swine Hybrid Aneurysm Model for Endovascular Surgery Training
Authors: Namba K. , Mashio K. , Kawamura Y. , Higaki A. , Nemoto S.
Published: January 2017

The aim of this study was to develop a technically simple swine aneurysm-training model by inserting a silicone aneurysm circuit in the cervical vessels.

A silicone aneurysm circuit was created by designing multiple aneurysms in size and configuration on a silicone vessel. Five swine underwent surgical implantation of this circuit in the cervical vessels: one end in the common carotid artery and the other in the external jugular vein. Using this model, an aneurysm coiling procedure was simulated under fluoroscopic guidance, roadmapping and digital subtraction angiography.

Creating an aneurysm model for training purposes by this method was technically simple and enabled the formation of a wide variety of aneurysms in a single procedure. The quality of the model was uniform and the model was reproducible. Coiling training using this model resembled a realistic clinical situation.

The swine hybrid aneurysm-training model was advantageous from the standpoint of technical simplicity in the creation and variety of aneurysms it provided. The swine hybrid aneurysm model may be an additional option for aneurysm coiling training.
Endovascular Management of Pediatric High-Flow Vertebro-Vertebral Fistula with Reversed Basilar Artery Flow
Authors: Honarmand A.R. , Ansari S.A. , Alden T.D. , Soltanolkotabi M. , Schoeneman S.E. , Hurley M.C. , Rahman O. , Shaibani A.
Published: January 2017

Vertebral artery arteriovenous fistula (VAVF) is mostly known as a post-traumatic and/or iatrogenic arteriovenous complication. However, spontaneous high-flow VAVF associated with flow reversal in the basilar artery has not been reported in children. We describe a unique asymptomatic presentation of a spontaneous high-flow VAVF associated with flow reversal in the basilar artery in a pediatric patient. The literature for classification, pathophysiology, treatment strategies, and post-procedural complications is also reviewed.