bluuebunny/crossref_metadata_2025 huggingface dataset:
Interdisciplinary Clinical Management of High Grade Arteriovenous Malformations and Ruptured Flow-Related Aneurysms in the Posterior Fossa
Authors: Mpotsaris A. , Loehr C. , Harati A. , Lohmann F. , Puchner M. , Weber W.
Published: January 2017

Posterior fossa arteriovenous malformations are rare entities and treatment modalities technically challenging. In recent years new therapeutic options have emerged through microsurgical and endovascular means. Based on a series of six cases we describe combined interdisciplinary treatment strategies and report the outcome in a midterm follow-up interval of 12 months. Clinical case data were collected during acute phase and follow-up including standardized angiographic control intervals during follow-up and assessment of the outcome. Treatment options included endovascular techniques as well as microsurgical techniques. All reported cases had SAH based on ruptured flow-related aneurysms in posterior fossa AVM; three out of six had multiple aneurysms. In one case we observed a de novo formation of two flow-associated distal aneurysms in an interval of ten years. Two patients were treated only endovascularly, one patient only surgically and three patients with combined methods. Five out of six patients had a good outcome (GOS 4 or 5). One died in the acute phase. Infratentorial AVMs are rare but characterized by a high risk of rupture and SAH, especially in conjunction with flow related aneurysms, which are predictors of poor outcome. The anatomic conditions of the posterior fossa may lead quickly to life-threatening complications due to mass effects. The present study indicates that treatment strategies in the acute phase should focus on flow-related aneurysms, followed by an elective AVM embolization and ectomy whenever possible. An experienced interdisciplinary team and the combination of techniques contribute to a reduction of complications and to a better outcome.
Endovascular Embolization of Distal Anterior Choroidal Artery Aneurysms Associated with Moyamoya Disease
Authors: Yang S. , Yu J.-L. , Wang H.-L. , Wang B. , Luo Q.
Published: January 2017

We evaluated the feasibility of endovascular embolization for the management of distal anterior choroidal artery (AChA) aneurysms associated with moyamoya disease and performed a literature review to summarize their clinical features and treatment. We describe two cases of moyamoya disease-associated distal AChA aneurysms treated by endovascular embolization. In both cases, a good outcome was observed. We performed a MEDLINE (1980–2010) search which identified 13 similar cases. Our analysis of the clinical data from these 15 cases led us to conclude that (i) endovascular embolization is an effective and feasible treatment for distal AChA aneurysms associated with moyamoya disease; (ii) aneurysm location and the preservation of the parent artery are two major prognostic factors for moyamoya disease-associated distal AChA aneurysms subjected to craniotomy or endovascular therapy; (iii) the parent artery should be preserved when the aneurysm is located in the temporal horn of the lateral ventricle, but sacrificed when it is located in the trigone of the lateral ventricle.
Pseudoaneurysm Formation following Intrasphenoid Rupture of an Idiopathic Intracavernous Carotid Artery Aneurysm: Coil Migration and Early Recurrence after Endovascular Treatment
Authors: De Blasi R. , Bracciolini E. , Chiumarulo L. , Salvati A. , Monetti C. , Federico F. , Carella A.
Published: January 2017

Intrasphenoid rupture of a non-traumatic aneurysm of the cavernous carotid artery is rare. We describe a patient in whom this condition manifested with epistaxis and led to the formation of a pseudoaneurysm occupying the right sphenoid sinus. The lesion recurred after repeated attempts at conservative endovascular therapy. Eventually the patient was treated with endovascular occlusion of the right internal carotid artery. Our report emphasizes the relapsing behaviour of a non-traumatic aneurysm of the cavernous portion of the internal carotid artery ruptured into the sphenoid sinus.
Successful Intravascular Ultrasound Thrombolysis of Dural Sinus Thrombosis with Pre-Existing Subarachnoid and Intraparenchymal Hemorrhages
Authors: Atherton M.E. , Culp W.C. , Brown A.T. , Erdem E.
Published: January 2017

A case of cerebral venous thrombosis with intraparenchymal and subarachnoid hemorrhages was initially treated unsuccessfully with mechanical and pharmacologic thrombolysis using intrathrombus tissue plasminogen activator (tPA) and angioplasty, and later successfully treated with an intravascular ultrasound tPA infusion catheter. This new microcatheter allowed direct infusion of tPA while using local therapeutic intravascular ultrasound to increase the thrombolytic effect. Flow was quickly restored. Our patient recovered from coma to discharge home without worsening of existing hemorrhages.
Adult Presentation of PHACES Syndrome
Authors: Arora S.S. , Plato B.M. , Sattenberg R.J. , Downs R.K. , Remmel K.S. , Heidenreich J.O.
Published: January 2017

A significant percentage of children with hemangiomas may have PHACES syndrome which refers to the association of posterior fossa malformations, facial hemangiomas, arterial cerebrovascular abnormalities, cardiovascular anomalies, eye abnormalities and ventral defects like sternal clefting or supraumbilical raphe. A variety of factors have led to under diagnosis of PHACES syndrome in the past including lack of awareness and limited imaging modalities. Also, patients with PHACES syndrome with arterial cerebrovascular abnormalities can present with acute ischemic stroke. However, these patients usually present before one year of age. We describe a 29-year-old woman with no history of cerebrovascular disease who initially presented with symptoms of a stroke and was subsequently diagnosed to have PHACES syndrome exhibiting an array of multiple unusual imaging findings. We also discuss the current literature and recommendations about PHACES syndrome.
Flow Diversion in Aneurysms Trial: The Design of the FIAT Study
Authors: Raymond J. , Darsaut T.E. , Guilbert F. , Weill A. , Roy D.
Published: January 2017

Intracranial aneurysms, particularly large and giant, fusiform or recurrent aneurysms are increasingly treated with flow diverters (FDs), a recently introduced and approved neurovascular device. While some rare cases may not be treated any other way, in most patients a more conventional, conservative, or validated approach such as coiling, parent vessel occlusion, or surgical clipping exists. Only a randomized clinical trial can answer the question of which treatment option leads to better patient outcomes.

We report the design of the FIAT study, a clinical care trial aiming to compare angiographic and clinical outcomes following treatment with a Flow-Diverter or with the best conventional treatment option.

The FIAT study will include both a randomized and a registry portion. Patients will be proposed randomization to either FD stenting or best conventional treatment option (observation, coiling, stenting, or clipping) as determined by the treating physician. FIAT will recruit a total of 338 patients, to show that i) FD stenting can be performed with an ‘acceptable’ immediate complication rate of less than 15% morbidity and mortality (defined as mRS > 2); ii) FD stenting can increase from 75 to 90% the proportion of patients with a “good outcome”, defined as complete or near-complete occlusion of the aneurysm AND a good clinical outcome (mRS ≤ 2) at one year, as compared to the best conventional option.

The FIAT study provides a scientific and ethical context to care for patients eligible for flow-diversion therapy.
Comparison of Cerebral Aneurysm Volumes as Determined by Digitally Measured 3D Rotational Angiography and Approximation from Three Diameters
Authors: Sadato A. , Hayakawa M. , Tanaka T. , Hirose Y.
Published: January 2017

This study compared digital measurement of aneurysm volume by 3D rotational angiography (3D-RA) with an approximation technique using three diameters of an aneurysm to re-interpret previously reported optimal packing densities (volume embolization ratio, VER) in coil embolization of intracranial aneurysms. Estimation of the volume of saccular aneurysms is important for calculation of the VER, which is in turn reported to be useful for prediction of coil compaction. The conventional formula for the volume estimation is V=4/3 π(A/2) (B/2) (C/2), where A, B, and C are the aneurysmal height, length, and width measured on 3D-RA image respectively.

Using 3D rotational angiography data from 74 aneurysms, the approximated volume generated using the conventional formula was directly compared with the digitally measured volume.

The digitally measured volume varied from 0.003 ml to 7.935 ml, and the dome-to-neck ratio (D/N) from 0.79 up to 4.62. We found that the conventional formula almost systematically underestimated the volume by up to 50 %, particularly when the neck was large relative to the dome (D/N<2). On average, digitally measured volume was 1.26!1.29 times larger than the approximated volume obtained using the conventional formula.

Conventional 2D angiography based aneurysm volume calculation tends to underestimate an aneurysm volume, so the so-called VER (volume embolization ratio) could be overestimated.
Mechanism of the Formation of Dural Arteriovenous Fistula — The Role of the Emissary Vein
Authors: Miyachi S. , Izumi T. , Matsubara N. , Naito T. , Haraguchi K. , Wakabayashi T.
Published: January 2017

Dural arteriovenous fistula (DAVF) can be separated into two types: DAVF which drains through an affected sinus (sinus type) and DAVF with direct reflux to the cortical vein (non-sinus type). The present report attempted to clarify the mechanism of formation and development of DAVF focusing on the emissary vein (EV) hypothesis.

First, inflammation occurs at the penetrating point of the EV on the dura due to idiopathic or secondary causes. Local inflammatory reactions induce vessel dilatation and neovascularization, and subsequently create arteriovenous (AV) connections on the arteriole level. Although EV communicating with dural arteries might play a role as draining routes at first, they start to degrade due to compression of enlarged emissary arteries or to a hemodynamic shift to the drainage pathway of least resistance. Following the occlusion of drainage pathway through EV into the sinus or cortical veins may form, resulting in clinically detectable DAVF. The AV shunt then expands to the surrounding dura associated with recruitment of feeders from distant sites induced by expression of angiogenetic factors and a shift in the hemodynamic balance. In sinus type DAVF, the sinus is progressively compartmentalized and finally occludes due to thrombogenesis with activated coagulopathy or to hemodynamic hypertrophy of the sinus wall. This progression results in the mature, aggressive DAVF with drainage impairments. Previous mechanistic hypotheses focusing on sinus hypertension and sinus thromboses cannot explain the pathogenesis of non-sinus type of DAVF. Although the etiology of DAVF may be concerned by the thrombo-occlusive change of sinus, the unique theory presented in this report may enable an understanding of the common etiology of both types of DAVF.
Arteriovenous Fistula in a Nerve Root of the Cauda Equina Fed by a Proximal Radiculo-Medullary Artery
Authors: Ohtonari T. , Ota S. , Nishihara N. , Suwa K. , Ota T. , Sekihara Y. , Tanaka A. , Koyama T.
Published: January 2017

While there have been a few reports on cases of intradural spinal arteriovenous fistula located on the filum terminale, no cases of its location in a nerve root of the cauda equina have been reported to date.

We describe two such cases and describe the intraoperative findings. A 40-year-old man presented weakness of his left leg. Another 62-year-old man presented paraparesis dominantly in his left leg with urinary hesitation. In both cases, spinal T2-weighted magnetic resonance images showed edema of the spinal cord, indicating a flow void around it. Digital subtraction angiography disclosed an anterior radicular artery branching from the anterior spinal artery on the surface of the conus medullaris and a turnaround vein running in the opposite direction within the cauda equina.

In the first patient, while the feeding artery running along a nerve root was detected, the draining vein and the fistula were not identified at first sight. An incision into the respective nerve root exposed their location within it. In the second patient, unlike the first case, the feeding artery and the fistula were buried in a nerve root, while the draining vein was running along the nerve's surface. In both cases, permanent clips were applied to the draining vein closest to the fistula. The recognition of a hidden fistulous point in a nerve root of the cauda equina is essential for successful obliteration of the fistula.
Amplatzer Vascular Plug for Occlusion of Parent Artery in Carotid Blowout with Active Extravasation
Authors: Shankar J.J.S. , Maloney W.J. , Vandorpe R.
Published: January 2017

Carotid blowout is a devastating complication in patients with head and neck malignancy. Various treatments including high risk surgery, carotid stenting or carotid occlusion using either coils or detachable balloons have been described. The key for any treatment is the rapidity at which it can be performed. We describe treatment of common carotid blowout secondary to neoplastic infiltration using four Amplatzer vascular plugs deployed in less than ten minutes.
Early Single Center Experience with the Solitaire Thrombectomy Device for the Treatment of Acute Ischemic Stroke
Authors: Wehrschuetz M. , Wehrschuetz E. , Augustin M. , Niederkorn K. , Deutschmann H. , Ebner F.
Published: January 2017

We report the immediate technical and clinical outcome of a new self-expanding fully retrievable stent in the treatment of acute ischemic stroke.

Eleven consecutive patients with acute intracerebral artery occlusions were treated with a self-expandable fully retrievable intracranial stent (Solitaire AB). Four patients had an occlusion of the basilar artery, five had a middle cerebral artery occlusion and two had terminal carotid artery occlusions. Recanalization results were assessed by follow-up angiography immediately after the procedure. Neurologic status was evaluated before and after treatment (90-day follow-up) according to the National Institutes of Health Stroke Scale (NIHSS) and modified Rankin scales (mRS).

Successful revascularization (TICI 2a/b and 3) was achieved in 11 of 11 (100%) patients, a TICI 3 state was accomplished in two (18%) patients, and partial recanalization or slow distal branch filling with filling of more than two-thirds of the vessel territory (TICI 2a/2b) was achieved in nine (82%) patients. The stent was removed in all patients. The mean time from stroke symptom onset to recanalization was 339 minutes (+/– 114.3 minutes). NIHSS on admission was 16.09 (+/– 4.7). Almost two-thirds of the patients (61.2%) improved by >6 points on the NIHSS at discharge, and 30% showed a mRS of <2 at 90 days. Mortality was 9%. One patient with a BA occlusion had a massive brain stem infarction and died two days after the procedure. There were no intracranial hemorrhages.

The use of the Solitaire in ischemic stroke patients shows encouraging results. However, further prospective large randomized trials are mandatory to confirm these early results.
Drug Eluting Stents for Symptomatic Intracranial and Vertebral Artery Stenosis
Authors: Fields J.D. , Petersen B.D. , Lutsep H.L. , Nesbit G.M. , Liu K.C. , Dogan A. , Lee D.S. , Clark W.M. , Barnwell S.L.
Published: January 2017

The use of bare metal stents (BMS) to prevent recurrent stroke due to stenosis of the cerebral vasculature is associated with high rates of restenosis. Drug-eluting stents (DES) may decrease this risk. We evaluated the performance of DES in a cohort of patients treated at our institution.

Consecutive patients treated with DES were identified by a case log and billing records; data regarding procedural details, clinical outcome and angiographic follow-up was obtained by retrospective chart review.

Twenty-six patients (27 vessels; 14 vertebral origin (VO); 13 intracranial) were treated. Stenosis was reduced from mean 81% to 8% at the VO and 80% to 2% intracranially. No strokes occurred in the first 24 hours after stenting or at any time point in the VO group during a mean follow-up period of nine months. Among patients with intracranial stents, stroke with permanent disability occurred within 30 days in 1/12 (8%) and after 30 days in 1/11 (9%) with clinical follow-up (mean follow-up, 14 months). Follow-up catheter angiography was obtained in 14/14 (100%) in the VO group at mean eight months and in 8/11 surviving patients (73%) at a mean of ten months after stenting in the intracranial group. The restenosis rate was 21% at the VO (3/14) and 38% (3/8) for intracranial stents.

Restenosis at the VO was less frequent than might have been expected from reports utilizing BMS, however, overall restenosis rates appeared higher than previously reported for patients with intracranial DES and comparable with restenosis rates for intracranial BMS.
Oculomotor Nerve Palsy Caused by Posterior Communicating Artery Aneurysm: Evaluation of Symptoms after Endovascular Treatment
Authors: Ko J.H. , Kim Y-J.
Published: January 2017

We report the outcome of endovascular treatment in a series of patients presenting with posterior communicating artery aneurysm causing ocular motor nerve palsy. A retrospective study was made of ten patients who were treated by coil embolization of posterior communicating artery aneurysm caused by oculomotor nerve palsy. The assessed parameters were as follows: patient's age, presence of subarachnoid hemorrhage, aneurysm size, preoperative severity of symptoms, and timing of treatment after onset of symptoms. Improvement of oculomotor nerve palsy after treatment was noted in eight patients (80.0%). Complete recovery was noted in seven patients (70.0%), partial recovery in one patient (10.0%), and no recovery in two patients (20%). Clinical presentations with early management (≤2 days) were significant in influencing recovery. Complete recovery from ocular motor nerve palsy was significantly higher in patients with initial incomplete palsy compared with initial complete palsy patients (6/6 versus 1/4). Early treatment and initial partial palsy are relevant to improving prognoses. Endovascular treatment is favored method for treating oculomotor palsy.
Endovascular Management in Patients with Acute Basilar Artery Obstruction: Low-Dose Intra-Arterial Urokinase and Mechanical Clot Disruption
Authors: Yun J.S. , Kwak H.S. , Hwang S.B. , Chung G.H.
Published: January 2017

Mechanical clot disruption for the treatment of acute basilar artery occlusion (BAO) is known to provide a benefit. We aimed to determine the safety, recanalization rate and time-to-flow restoration of mechanical clot disruption and low dose urokinase (UK) infusions for the treatment of patients with acute BAO.

Between June 2006 and June 2010, 21 patients with acute BAO underwent endovascular treatment that included angioplasty or stent placement. The time to treatment, duration of the procedure, dose of urokinase (UK), recanalization rates and symptomatic hemorrhages were analyzed. Clinical outcome measures were assessed at admission and at the time of discharge using the National Institutes of Health Stroke Scale (NIHSS) score and at three months after treatment using the modified Rankin Score (mRS).

On admission, the median NIHSS score was 13.2. Median time from symptom onset to arrival at hospital was 356 minutes, and median time from symptom onset to intraarterial thrombolysis (IAT) was 49 minutes. We used the following interventional treatment regimens: Intraarterial (IA) UK and a minimal mechanical procedure (n=14), IA UK with angioplasty (n=1), IA UK with angioplasty and stent placement (n=3) and IA UK with HyperForm (n=3). The recanalization (thrombolysis in cerebral ischemia grade II or III) rate was 90.5% (19/21). There was symptomatic hemorrhage in one patient (4.8%). The median NIHSS score at discharge was 6.3. The three-month outcome was favorable (mRS: 0–2) for 14 patients (66.7%) and poor (mRS: 3–6) for seven patients (33.3%). The overall mortality at three months was 14.3% (three patients died).

Low-dose IAT with mechanical clot disruption is a safe and effective treatment for treatment for acute BAO.
Intra-Arterial Tirofiban Infusion for Partial Recanalization with Stagnant Flow in Hyperacute Cerebral Ischemic Stroke
Authors: Baik S.K. , Oh S.J. , Park K-P. , Lee J-H.
Published: January 2017

Early reocclusion is a major concern associated with poor clinical outcomes in patients with an ischemic cerebral stroke. This occurs most frequently in patients with partial initial recanalization. This study focuses on partial recanalization with stagnant antegrade flow after intravenous (IV) tPA or spontaneously, treated with the administration of intra-arterial (IA) tirofiban. Three patients with initial M1 occlusion on diagnostic studies had an occluded segment that was recanalized with stagnant flow after IV tPA or spontaneously. In all cases, IA tirofiban was administrated. We evaluated the distal blood flow and the degree of vascular narrowing in the pre and post-procedure angiography and at follow-up in addition to the clinical status. In all patients, severe vascular narrowing with stagnation of blood flow was detected in the initial M1. After infusion of IA tirofiban, improvement of the distal blood flow was achieved rapidly within 40 minutes in all patients. The severe vascular narrowing resolved rapidly in two patients without residual stenosis. In one patient, moderate vascular narrowing was still present. The median baseline National Institutes of Health Stroke Scale (NIHSS) scores were 18 and the median post-procedural NIHSS scores were 2 at two weeks. No intracerebral hemorrhage occurred in any of the patients. Treatment with IA tirofiban was safe and effective in patients with partial initial recanalization. It can be suggested that detection of any partial recanalization is time for administration of glycoprotein IIb-IIIa receptor inhibitor in hyperacute ischemic stroke.
Super-Selective Basilar Artery Infusion of Bevacizumab and Cetuximab for Multiply Recurrent Pediatric Ependymoma
Authors: Rajappa P. , Krass J. , Riina H.A. , Boockvar J.A. , Greenfield J.P.
Published: January 2017

Ependymoma is a central nervous system tumor associated with a poor prognosis due to limited efficacy of current medical treatment modalities, often resulting in multiple surgical re-resections with each tumor recurrence. As traditional chemotherapeutic regimens have proved unsuccessful in long-term control of subtotally resected ependymoma, other agents targeting the tumor microenvironement including the angiogenic factors supplying neovascularization have recently been used.

Anti-angiogenic agents such as bevacizumab are routinely used in adult patients with recurrent glioma. Selective intra-arterial cerebral infusion (SIACI) of biological agents within tumor-supplying cerebral vasculature has recently been re-examined as a means to avoid the systemic side-effects associated with intravenous use of bevacizumab. This technical paper describes the first reported use of SIACI for delivery of two targeted biologic agents, bevacizumab and cetuximab in a pediatric patient utilizing the basilar artery to selectively administer the drugs to the tumor microenvironment. We believe this method for therapeutic delivery will both broaden treatment options and better refine treatment methodology as the multi-modality treatment approach often required to treat patients with pediatric ependymomas and other intracranial malignancies evolves.
Direct Endoscopic Intratumoral Injection of Onyx for the Preoperative Embolization of a Recurrent Juvenile Nasal Angiofibroma
Authors: Hira A. , Chao K.
Published: January 2017

Percutaneous injection of embolization material within head and neck tumors is being described as an alternative or adjunct to transarterial embolization. Access in these reports is by computed tomography (CT) guidance, which is cumbersome given the need to transport the patient from the CT scanner to angiography suite. We describe a case of direct percutaneous onyx embolization of juvenile nasal angiofibroma following endoscopic access in the angiography suite including self-sustained onyx combustion during surgical electrocautery.
Spontaneous Post-Partum Cervical Carotid Artery Dissection in a Patient with Reversible Cerebral Vasoconstriction Syndrome
Authors: Soltanolkotabi M. , Ansari S.A. , Shaibani A. , Singer T.B. , Hurley M.C.
Published: January 2017

Post-partum cervicocephalic artery dissection (pp-CAD) is a rare and poorly understood condition. To our knowledge, only 21 cases have been reported. Reversible cerebral segmental vasoconstriction (RCSV) was first described by Call and Fleming in 1988, and its association with pp-CAD has only been reported in three cases. However, in those cases it is unclear whether the pp-CAD may have been caused by straining during labor and therefore merely coincidental to the intracranial arteriopathy. We describe a 41-year-old right-handed African-American woman who developed the syndrome of pp-CAD (headaches, trace subarachnoid hemorrhage and diffuse cerebral arteriopathy on angiogram) two weeks after delivery. In this unique case, the patient had fortuitously undergone an MR study twice over a four day period which included the carotid bifurcations. During that time the patient was an inpatient, on bed rest and subject to continuous cardiac monitoring. The interval studies documented a true spontaneous right internal carotid artery dissection occurring without obvious cause. The patient had noted moderate right neck pain developing between the two MR studies but experienced no neurological deficits. Subsequent conventional angiography confirmed the presence of postpartum cerebral arteriopathy and the cervical dissection. The patient was managed conservatively with antiplatelet medication and had an otherwise uneventful course. We hypothesize whether transient arterial wall abnormalities, postpartum hormonal changes or subtle connective tissue aberrations play a similar role in the pathogenesis of these two associated conditions.
Coronaric Stent-Graft Deployment in the Treatment of Carotid Blowout
Authors: Pampana E. , Gandini R. , Stefanini M. , Fabiano S. , Chiaravalloti A. , Morosetti D. , Spano S. , Simonetti G.
Published: January 2017

“Carotid blowout syndrome” is defined as a hemorrhage caused by rupture of the carotid artery and its branches, and may be a severe complication of rhinopharyngeal carcinoma.

This study aimed to highlight the usefulness and versatility of endovascular stent-graft placement as a rescue treatment in life-threatening carotid blowout syndrome.

We describe the unconventional use of a 6×5 mm balloon-expandable coronaric covered stent in a patient with a diagnosis of spinocellular rhinopharyngeal carcinoma, followed by carotid blowout syndrome. Although long-term follow-up is needed to assess the eventuality of bleeding recurrence, the immediate clinical results were satisfactory.
Use of an Angiographic Catheter in Place of the Racz Epidural Catheter in the Lysis of Epidural Space Adhesions
Authors: Impiombato F. Ambesi , Lunghi V. , Gambacorta D. , Babili C. , Zocchi M.
Published: January 2017

This technical note describes lysis of adhesions in the epidural space with the use of a 5F vascular catheter inserted on a 0.35-inch guide passed through the sacral foramen. Commonly employed in the administration of anesthetics, a vascular catheter can be advantageously used in place of the Racz epidural catheter, with a potential reduction in damage to the nerve structures of the sacral canal.
Five to Ten Years Follow-up after Coiling of 241 Patients with Acutely Ruptured Aneurysms
Authors: Consoli A. , Renieri L. , Mura R. , Nappini S. , Ricciardi F. , Pecchioli G. , Ammannati F. , Mangiafico S.
Published: January 2017

Endovascular treatment has assumed a role of first choice in the management of ruptured intracranial aneurysms. We describe the clinical and morphological data after the treatment of 258 ruptured intracranial aneurysms in 241 patients, in order to evaluate the safety and the efficacy of the endovascular treatment.

Two hundred and forty-one patients with saccular ruptured aneurysms were treated at our institution between 2000 and 2005. After the endovascular treatment a clinical and angiographic follow-up was conducted. The clinical follow-up was carried out with a medical examination and telephonic interviews and mRS was used for evaluation.

Two hundred and forty-nine acutely ruptured aneurysms were successfully treated and immediately after the endovascular procedure 81.9% of the aneurysms resulted completely occluded, 12.1% had a residual neck and 6% revealed a residual sac. The evolution of each grade was evaluated at six months and two years. During the follow-up we observed five early and one late re-bleedings. Twenty-four patients underwent a second procedure. After the discharge and up to ten years 73.1% of patients had a good clinical outcome (mRS0–1), 8.9% died and the remainder showed moderate-severe disability (mRS2–3).

The long-term stability of the anatomical result is a critical issue of this approach because eventual re-bleedings may occur even after several months or years. A careful clinical and radiological follow-up for up to two years after the embolization may prevent recurrences but may not be sufficient.
Endovascular Treatment of Recurrent Coiled Aneurysms: Assessment of Complications and Rebleeding during a Decade in a Single Center
Authors: Sedat J. , Chau Y. , Moubarak K. , Vargas J. , Lonjon M.
Published: January 2017

Recurrence is the main drawback of aneurysmal coiling. Additional coiling must sometimes be considered in patients with reopened aneurysms and expose the patient to the risk of a new procedure. Our purpose was to assess the procedural complications of additional endovascular treatments in patients with previously coiled but recurrent aneurysms treated by two neurointerventionalists during a decade in a single center.

Between 1999 and 2009, 637 intracranial aneurysms were coiled and had a clinical and angiographic follow-up at our institution. Following the first embolization, 44 aneurysms were retreated with coils and 11 were retreated a second time. Retreatment was decided when a recurrence showed at angiographic follow-up. Early retreatments, performed in the first month after an incomplete or failed initial coiling, were excluded.

We retrospectively analysed the procedural complications, rebleeding, clinical and angiographic outcomes of the retreatments. No death or bleeding occurred in these 55 additional procedures. We had three periprocedural thromboembolic complications and the procedural permanent morbidity was 1.8%. Clinical and angiographic follow-ups ranged from six months to nine years (mean: 37 months, median: 36 months). Thirty-seven of the 44 retreated aneurysms (84%) showed a stable occlusion at follow-up. Seven showed a recurrence but were not retreated due to the stability of the packing. No rebleeding was observed during the follow-up period. Our results show that endovascular treatment of recurrent aneurysms is associated with a low procedural risk.
Direct Vertebral Artery Access for the Endovascular Treatment of Basilar Artery Aneurysms
Authors: Vanzin J.R. , Manzato L. Bambini , Slaviero F. , Strzelecki M. , Annes R. D'Agostini
Published: January 2017

The femoral approach has been considered the preferred technique for the endovascular treatment of intracranial aneurysms. Occasionally, aneurysms are not amenable to the standard femoral approach. We describe four cases of basilar artery aneurysm that were treated by the direct vertebral artery access of V1 at the cervical region. The direct vertebral artery access technique can provide an alternative route in selected cases for the treatment of basilar artery aneurysms.
Persistent Neurological Deficit from Iodinated Contrast Encephalopathy following Intracranial Aneurysm Coiling
Authors: Leong S. , Fanning N.F.
Published: January 2017

Neurotoxicity from iodinated contrast agents is a known but rare complication of angiography and neurovascular intervention. Neurotoxicity results from contrast penetrating the blood-brain barrier with resultant cerebral oedema and altered neuronal excitability. Clinical effects include encephalopathy, seizures, cortical blindness and focal neurological deficits. Contrast induced encephalopathy is extensively reported as a transient and reversible phenomenon. We describe a patient with a persistent motor deficit due to an encephalopathy from iodinated contrast media administered during cerebral aneurysm coiling. This observation and a review of the literature highlights that contrast-induced encephalopathy may not always have a benign outcome and can cause permanent deficits. This potential harmful effect should be recognised by the angiographer and the interventionalist.
Measurement of Blood Flow in Arteriovenous Malformations before and after Embolization Using Arterial Spin Labeling
Authors: Suazo L. , Foerster B. , Fermin R. , Speckter H. , Vilchez C. , Oviedo J. , Stoeter P.
Published: January 2017

The assessment of shunt reduction after an embolization of an arteriovenous malformation (AVM) or fistula (AVF) from conventional angiography is often difficult and may be subjective.

Here we present a completely non-invasive method using magnetic resonance imaging (MRI) to measure shunt reduction. Using pulsed arterial spin labeling (PASL), we determined the relative amount of signal attributed to the shunt over 1.75 s and 6 different slices covering the lesion. This amount of signal from the shunt was related to the total signal from all slices and measured before and after embolization.

The method showed a fair agreement between the PASL results and the judgement from conventional angiography. In the case of a total or subtotal shunt occlusion, PASL showed a shunt reduction between 69% and 92%, whereas in minimal shunt reduction as judged by conventional angiography, the ASL result was −6% (indicating slightly increased flow) to 35% in a partially occluded vein of Galen aneurysm. The PASL method proved to be fairly reproducible (up to 2% deviation between three measurements without interventions). On conclusion, PASL is able to reliably measure the amount of shunt reduction achieved by embolization of AVMs and AVFs.
Balloon-Expandable Stent Placement in Patients with Immediate Reocclusion after Initial Successful Thrombolysis of Acute Middle Cerebral Arterial Obstruction
Authors: Lee H.K. , Kwak H.S. , Chung G.H. , Hwang S.B.
Published: January 2017

We present the results of our approach for treating 12 consecutive cases of acute middle cerebral artery (MCA) stroke by performing balloon-expandable stent (BES) placement after immediate reocclusion due to the underlying stenosis after intra-arterial thrombolysis (IAT).

We retrospectively reviewed the clinical outcomes of 12 patients with acute MCA stroke who underwent recanalization by BES placement in an underlying stenosis after IAT. The time to treatment, urokinase dose, duration of the procedure, recanalization rates and symptomatic hemorrhage were analyzed. Clinical outcome measures were assessed on admission and at discharge (the National Institutes of Health stroke scores [NIHSS]) as well as three months after treatment (modified Rankin scales [mRS]).

The median NIHSS score on admission was 8.6. Four patients received IV rtPA. The median time from symptom onset to IAT was 236 minutes and the median duration of IAT was 62 minutes. The median dose of urokinase was 140,000 units. Initial recanalization after stent deployment (thrombolysis in cerebral ischemia attack grade of II or III) was achieved in all patients. Two patients died in the hospital due to aspiration pneumonia during medical management. In two patients, in-stent reocclusion occurred within 48 hours after stent deployment. At discharge, the median NIHSS score in ten patients (including the patients with reobstruction) was 2.4. The three-month outcome was excellent (mRS, 0–1) in eight patients.

In this study, BES deployment was safe and effective in patients with an immediately reoccluded MCA after successful IAT.
Treatment of Progressive Cerebral Sinuses Thrombosis with Local Thrombolysis
Authors: Mohammadian R. , Sohrabi B. , Mansourizadeh R. , Mohammadian F. , Nazempour A. , Farhoudi M. , Pashapour A. , Aghdam A.A. Taher , Hashemzadeh A. , Pourkakrodi M.
Published: January 2017

Cerebral venous thrombosis (CVT) is a potentially serious disease, with nonspecific clinical symptoms and an unpredictable outcome. Despite adequate anticoagulation, a patient's clinical condition can rapidly deteriorate. The aim of this study was to evaluate the efficacy of local thrombolysis in these patients.

Consecutive patients with progressive cerebral venous thrombosis between October 2008 and January 2011 were enrolled prospectively. Progressive CVT was defined as the persistence of neurologic findings (headache, blurred vision, and visual field defects) despite at least four days (or 48 hours in patients with involvement of more than one sinus) on full anticoagulation therapy with heparin and development of focal neurologic deficits or cortical hemorrhage. We excluded patients with large hematomas and predisposing malignancies like leukemia. All patients underwent local thrombolysis with 30 mg recombinant tissue plasminogen activator (rtPA).

Overall, 26 patients were enrolled with a mean age of 35.5 years (range 18 to 56 years). Six patients (23%) were male and twenty patients (77%) were female. The most common presenting feature was headache and the most common neurologic finding was papilledema, which was present in all patients. Eighty-five percent of women had a history of oral contraceptive pill consumption. Successful recanalization was achieved in all patients except one (96.2%). Neurological examinations and follow-up assessments were based on a modified Rankin scale (mRS). Favorable outcome and recovery was defined as a mRS score of 0–1. Follow-up assessments at the third week showed that 25 out of 26 recovered, with 18 having a mRS score of 0 and 7 with a mRS score of 1. There were no procedure-related neurological complications.

Our results show that local thrombolysis is a safe and effective treatment modality for patients suffering from progressive CVT.
Short-Term Clinico-Radiographic Response to Super-Selective Intra-Arterial Cerebral Infusion of Bevacizumab for the Treatment of Vestibular Schwannomas in Neurofibromatosis Type 2
Authors: Riina H.A. , Burkhardt J-K. , Santillan A. , Bassani L. , Patsalides A. , Boockvar J.A.
Published: January 2017

Neurofibromatosis type 2 (NF2) is an autosomal dominant syndrome with a prevalence of approximately 1 in 30,000. NF 2 is characterized by bilateral vestibular schwannomas, as well as meningiomas, ependymomas and gliomas. Currently, surgical resection and radiotherapy represent the mainstay of treatment, although new studies suggest a role for certain chemotherapeutic agents. Intravenous administration of Bevacizumab (Avastin, Genetech Pharmaceuticals) has been shown to be active in the treatment of vestibular schwannomas. The IV route of administration, however, carries a risk of known systemic side-effects such as bowel perforation, wound dehiscence and pulmonary embolism. In addition, the percentage of drug that reaches the tumor site may be restricted by the blood tumor barrier. This report describes the super-selective intra-arterial infusion of Bevacizumab following blood brain barrier disruption for the treatment of vestibular schwannomas in three patients with Neurofibromatosis type 2. It represents the first time such a technique has been performed for this disease. Additionally, this method of drug delivery may have important implications in the treatment of patients with vestibular schwannomas associated with Neurofibromatosis type 2.
Y-Stent-Assisted Coil Embolization of Anterior Circulation Aneurysms Using Two Solitaire AB Devices: A Single Center Experience
Authors: Martínez-Galdámez M. , Saura P. , Saura J. , Martinez A. , De Campos J.M. , Pérez A.
Published: January 2017

Wide-neck intracranial aneurysms remain a challenge to endovascular treatment. We describe our experience in repairing wide-neck aneurysms of the anterior circulation located at arterial branch points using coil embolization assisted by Y-stenting using two Solitaire® stents.

Six wide-neck intracranial aneurysms located on the middle cerebral artery bifurcation 3, pericallosal artery 1, and anterior communicating artery 2 were repaired by Y-stent-assisted coil embolization using two Solitaire® stents. Four cases were incidental findings of aneurysm and two cases were previously treated ruptured aneurysms that had undergone recanalization.

All the cases were successfully treated without complications. Follow-up by digital subtraction angiography and magnetic resonance angiography at six months showed the stents to be patent with no recanalization of the aneurysm sacs.

Repairing wide-neck aneurysms of the anterior circulation by Y-stent-assisted coil embolization using two Solitaire® stents is a simple and safe method of treating complex aneurysms. While the results are promising, larger series with longer term follow-ups are needed to corroborate that this treatment method is superior to other techniques.
Treatment of Post-Traumatic Carotid-Cavernous Fistulas with the Willis Covered Stent
Authors: Wang Y-L. , Ma J. , Ding P-X. , Li Y-D. , Han X-W. , Wu G.
Published: January 2017

We describe our preliminary experience on the feasibility of using the Willis covered stent in patients with carotid-cavernous fistulas (CCFs).

Eleven consecutive patients with post-traumatic CCFs referred for treatment with Willis covered stents were enrolled into this prospective study, and were subsequently followed-up at our hospital. Data on technical success, initial and final angiographic results, mortality, morbidity and final clinical outcome, was collected, with follow-up performed at one, three, six and 12 months, and yearly thereafter.

Deployment of the covered stents was technically successful in all patients. Angiographic results following stent placement showed a complete occlusion in eight patients with ten CCFs, and an incomplete occlusion in three. No adverse events occurred either during or after the procedure. Angiographic follow-up (mean 14.73 ± 6.77 months) revealed complete occlusion and no obvious in-stent stenosis in all patients. Clinical follow-up (mean 17.73 ± 6.48 months) demonstrated full recovery in ten patients, and improvement in one.

These preliminary results indicate that the use of the Willis covered stent is a feasible procedure, and that it may therefore serve as an alternative treatment for CCFs. Longer follow-up assessments and an expanded clinical trial are needed.
Coiling after Treatment with the Woven EndoBridge Cerebral Aneurysm Embolization Device
Authors: Wallner A.K. , Broussalis E. , Hauser T. , Trinka E. , Killer-Oberpfalzer M.
Published: January 2017

Retreatment options after the use of the newly launched Woven EndoBridge cerebral aneurysm embolization device (WEB II) are mostly unknown. Nine months after WEB II implantation, a 55-year-old female patient presented with regrowth of an MCA aneurysm. For the first time, standard balloon-assisted coiling was used to close the regrown aneurysm proximal to the WEB II implant. We report on the feasibility and safety of balloon-assisted coiling after implantation of the WEB II device.
Percutaneous Pediculoplasty for Traumatic Pedicle Fracture
Authors: Singh J. , Baker M.D. , Morris P.P. , Whitlow C.T.
Published: January 2017

The objective of this case is to illustrate a technique for performing fluoroscopically guided percutaneous pediculoplasty in the setting of traumatic or non-neoplastic pedicle fractures.

Pediculoplasty has been described in the literature as a complimentary technique performed during vertebroplasty. In this case, isolated pediculoplasty is demonstrated using existing vertebroplasty equipment, which may be utilized as a primary intervention for pedicle fractures in patients who are poor surgical candidates.
The Pharyngo-Tympano-Stapedial Variant of the Middle Meningeal Artery
Authors: Baltsavias G. , Kumar R. , Valavanis A.
Published: January 2017

Atypical origin of the middle meningeal artery from the cervical internal carotid artery is a rare angiographic finding. We describe a case of the pharyngo-tympano-stapedial variant of the middle meningeal artery in a young patient. In this vascular variation the proximal segment of the middle meningeal artery, corresponding to an annexed inferior tympanic artery, originates from the cervical carotid artery. Then over the promontory it unites with the superior tympanic artery and continues with its intracranial course via the petrous branch.
Wire-Probing Technique to Revascularize Subacute or Chronic Internal Carotid Artery Occlusion
Authors: Namba K. , Shojima M. , Nemoto S.
Published: January 2017

During endovascular revascularization of subacute and chronic occlusion of the cervical internal carotid artery (ICA) it may be difficult to penetrate the lesion. Selecting the appropriate “true lumen”, a remnant of what had been the arterial lumen, at the initial step may facilitate the procedure. Because plaque at the carotid bifurcation is known to propagate from the posterior wall, a gateway to this “true lumen” should exist in the anterior side of the occluded stump. This hypothesis was studied retrospectively in our series of revascularizing ICA subacute and chronic occlusion.

Eleven patients underwent endovascular revascularization for symptomatic cervical ICA occlusion. Procedures were performed by initially penetrating the occluded stump with a guidewire, followed by supporting catheter advancement through the occluded segment to secure the distal normal arterial lumen. Cases were analyzed with regard to the location of initial guidewire penetration.

Eight patients underwent successful revascularization. In five cases, the entry point to the occluded stump was located at the anterior side, and in three, at the posterior side. Two posterior stump penetration cases were met with resistance in guidewire advancement, whereas penetration was smooth in the anterior cases. In addition, two posterior stump penetration cases resulted in contrast stasis in the posterior ICA wall.

In our series of revascularizing cervical ICA subacute and chronic occlusion, initially targeting the anterior side of the occluded stump resulted in favorable results. This may be the result of selecting the “true lumen” at the beginning of the procedure.
Reversible Cerebral Vasoconstriction Syndrome: Treatment with Multiple Sessions of Intra-Arterial Nimodipine and Angioplasty
Authors: Ioannidis I. , Nasis N. , Agianniotaki E. , Katsouda E. , Andreou A.
Published: January 2017

Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by acute severe headache with or without additional neurological symptoms and reversible cerebral vasoconstriction. Unruptured aneurysms have been reported in some cases with RCVS. We describe a severe case of a 50-year-old woman with RCVS presenting as cortical subarachnoid hemorrhage. Cerebral angiogram demonstrated the typical angiographic findings of RCVS and two very small unruptured aneurysms of the left internal carotid artery. The patient was treated with calcium channel blockers and the two aneurysms were successfully treated endovascularly. On day 16 the patient developed new focal neurological symptoms (severe paraparesis) and was successfully treated with intraarterial nimodipine and angioplasty in multiple sessions.