bluuebunny/crossref_metadata_2025 huggingface dataset:
Intracranial Haemorrhage Probably Due to an Angiographically Occult AVM after Carotid Stenting
Authors: Berker M. , Ulus A. , Palaoglu S. , Soylemezoglu F. , Ay H. , Cekirge S.
Published: January 2017

Angiographically occult vascular malformations refer to cerebrovascular malformations that are not demonstrable on technically satisfactory cerebral angiography.

Authors herein present a very unusual intracranial bleeding complication related to an angiographically occult vascular malformation after extracranial carotid artery stenting procedure.

A 52-year-old male patient admitted to the hospital with 2 episodes of amaurosis fugax in the left eye. Cervical carotid angiography and bilateral carotid Doppler ultrasonography revealed a 98% stenosis of the left internal carotid artery just distal to the bifurcation. Post-stenting control cervical carotid angiography revealed neither any residual stenosis nor a developmental venous anomaly.

The patient developed left pupil dilatation with loss of consciousness two hours after the neurovascular intervention. Emergent cranial CT showed acute subdural haematoma, intracerebral and subarachnoid haemorrhage with massive midline shift. He underwent an emergent craniotomy with left temporal lobectomy. Abnormal cortical vascular structures with prominent engorgement were remarkable over the posterior temporal cortex. Histopathological studies confirmed the diagnosis of an occult AVM

Classically, these lesions are not visualized with angiography. Our patient's cerebral angiography and MR investigations were all normal. To our knowledge this is the first case in literature in which intracranial haemorrhage (acute subdural haematoma, intracerebral haematoma, SAH) occurred due to hyperperfusion of angiographically occult vascular malformation.
Combined Effects of Embolization and Hypofractionated Conformal Stereotactic Radiotherapy in Arteriovenous Malformations of the Brain
Authors: Lindvall P. , Wikholm G. , Bergström P. , Löfroth P. , Bergenheim A. T.
Published: January 2017

There are three major treatment options for cerebral AVMs; surgery, embolization and radiosurgery. Embolization may be effective to reduce the size and density but completely obliterates AVMs only in a minority of cases. Radiosurgery may be an alternative to resection, especially in smaller AVMs. Large AVMs have been considered difficult to treat safely and effectively with single fraction radiosurgery. Hypofractionated conformal stereotactic radiotherapy (HCSRT) alone or in combination with embolization may be an alternative treatment. Embolization may reduce the volume and density of AVMs, followed by HCSRT, allowing a safe delivery of a higher total dose of radiation than possible with a single fraction. Sixteen patients with AVMs were treated with embolization and HCSRT. Embolization was performed in 1–6 (median 2) sessions. HCSRT was delivered in 5 fractions with 6–7 Gy each to the total dose of 30–35 Gy. Cerebral angiographies before and after embolization were digitally compared for calculation of volume reduction and luminescence as a measure of AVM density. The mean AVM volume in 15 patients was reduced from 11.9 ± 2.1 (1–29, median 10.0) ml to 6.5 ± 2.0 (0.5–28, median 3) ml by embolization. The luminescence for all AVMs was significantly higher after than before embolization, indicating that all AVMs were less dense after embolization. Thirteen out of 16 patients (13/16, 81%) treated with embolization and HCSRT have so far shown obliteration of their AVMs 2–9 (median 4) years after HCSRT. Three patients experienced neurological sequele after embolization, and three patients developed radionecrosis after HCSRT. Using a new method to compare cerebral angiographies in AVMs we report reduction in density and volume after embolization. The obliteration rate of a combined treatment with embolization and HCSRT seems comparable with single fraction radiosurgery although the AVMs in our series are larger than reported in most series treated with single fraction radiosurgery.
Temporary Hidden Aneurysms during Pregnancy
Authors: Cho C. S. , Kim Y. J. , Cho K. T. , Lee S. K. , Park B. J. , Cho M. K.
Published: January 2017

There are a number of reports on cerebral aneurysmal ruptures during pregnancy. Although the cerebral aneurysmal rupture is quite rare during pregnancy, it leads to a high maternal mortality; which gives rise to a clinical significance.

We have encountered a number of multiple cerebral aneurysms during pregnancy, and the ruptured cases were successfully treated with the coiling procedures. The coiling is found to be a good treatment method for ruptured aneurysms during pregnancy.

The cerebral angiogram is the gold standard diagnostic method for detecting cerebral aneurysms. However, 1.8–20% of the cases are reported to be false negative in initial angiography, and only up to 20% can be diagnosed even with the additional angiographies. A special attention for a hidden aneurysm should also be required while managing the patients.
Intracranial Mechanical Recanalization and Fibrinolysis Using a Single Hyperglide Balloon Microcatheter
Authors: Reyes E. Castro , Gil F. Fortea , Medina F. Villoria , De Villoria J. Guzmán , Almazán L. Muñoz , Nuñez A. Gil , Allen P. Vázquez
Published: January 2017

Endovascular treatment of acute blockage of the middle cerebral artery may require a combination of mechanical recanalization and chemical fibrinolysis. Using a single microcatheter to perform both techniques helps shorten procedure time.
Endovascular Treatment of Cerebral AVM with Onyx - Initial Experience
Authors: Joseph S. , Chadaga H.C. , Murali K.
Published: January 2017

Five patients (M:2, F:3; Age range 9–51; N = 30 yrs) with cerebral AVM were managed with Onyx embolization through endovascular route in last three months. Two patients had complete occlusion of AVM following embolisation. In remaining three, one had 95% occlusion and other two had 70% and 50% occlusion respectively. No procedural related complications were observed immediately following procedure.
Brain AVM Embolization with Onyx®: Analysis of Treatment in 34 Patients
Authors: Leonardi M. , Simonetti L. , Cenni P. , Raffi L.
Published: January 2017

The endovascular approach to arteriovenous malformations (AVM) using different embolizing agents is a well-established treatment option.

This report assesses the results of our experience using a non “glueing” embolic material available for several years, commercially known as Onyx®.

We used Onyx to treat 34 consecutive patients in the last four years. All patients were treated in the same department by the same neuroradiological team, with a strictly repetitive technical strategy and procedural protocol.

All our patients presented AVMs with Spetzler Grade 3 or more, because in our Institution Grade 1 or 2 AVMs are directly treated by surgical approach. We adopt a multidisciplinary treatment approach (embolization, surgery, radiotherapy) by which embolization is construed as work in progress offering definitive treatment of AVMs without severe risks.

Embolization is mainly undertaken as the first step before surgery, to reduce flow and size of the AVM by a “targeted” technique. In addition to reducing lesion size, endovascular treatment aims to seal off AVM areas anatomically or haemodynamically complex for surgical treatment. Occasionally, the reduction in size allows a radiosurgical approach. Embolization seldom results in a definitive cure of AVMs.

At the end of multimodal approach, we obtained the complete and definitive cure of AVM in 21/34 patients (two complete obliteration with interventional technique, 19 in combination with surgery); to these were added 5/34 patients who received radiosurgical therapy.

No major complications arose during endovascular treatment. One patient had transitory (36 hour) impaired right arm pronation. The CT scan disclosed an asymptomatic mild SAH in the left sylvian fissure but no ischaemic areas.

One patient still in treatment died from fatal rebleeding (the clinical onset had been with haemorrhage two weeks before the session) 12 days after the embolization.

Excellent or good clinical outcome was obtained in 23/26 patients who completed the therapeutic protocol. Outcome was conditioned by focal symptoms present on admission in three patients due to haemorrhagic onset, but only one patient presented a severe disability on discharge.

In our view, the main problem of Onyx is that the apparently easier approach will probably lead to a wider diffusion of these procedures. AVMs are extremely difficult and dangerous to treat: this is not affected by the quality of the embolizing agents used and must be kept in mind at all times.
Temporary Balloon Occlusion during Giant Aneurysm Surgery
Authors: Petralia B. , Skrap M.
Published: January 2017

We propose this combined balloon occlusion and surgical technique to treat selected patients with large-giant aneurysms not suitable for a pure endovascular or surgical approach.

After an occlusion test a non detachable balloon catheter is positioned deflated proximally to the neck of the aneurysm under general anesthesia. The patient is then moved to the neurosurgical room. During the intervention the balloon is inflated and deflated when necessary to allow better surgical control of the aneurysmal sac. With this approach we achieve complete aneurysm occlusion and shorten the surgery time. Since January 2003 we have treated 13 giant aneurysms (ten paraclinoid and three vertebrobasilar) without significant complications related to balloon assistance and a good outcome in all patients.
Additional Rescue Stent Placement for Stabilization of a Prolapsed Coil during Stent-Assisted Coil Embolization of a Wide-Neck Intracranial Aneurysm
Authors: Sourour N. , Góngora-Rivera F. , Biondi A.
Published: January 2017

We report a case of a 55-year-old man carrying two unruptured internal carotid artery (ICA) wide-neck aneurysms.

In the same session, the smaller aneurysm was treated by coils using the remodeling technique and the large aneurysm was treated by stent-assisted coil embolization. During the stent-assisted procedure for the large aneurysm, the microcatheter tip moved from the aneurysm into the parent artery causing a prolapse of some coil loops into the vessel lumen.

The distal part of the coil was tangled within the stent's struts, therefore, in order to introduce the entire coil, an attempt was made to withdraw the prolapsed loops of the coil within the microcatheter and concomitantly repositioning the microcatheter into the residual aneurysm neck through the stent struts. However this maneuver was unsuccessful.

An attempt to retrieve gently the coil also failed and the coil prematurely detached. For maintaining the patency of the arterial lumen and to reduce the embolic risk, a second stent was used to pin the free coil loops. The rescue stent was positioned within the coil loops and its deployment allowed a circumferential expansion of some loops around the stent perimeter while other loops were flattened against the wall of the artery. The parent artery remained patent at one-year follow-up angiographic study. No clinical complications were observed.
Superselective Intracerebral Catheterization of a Branch of the Internal Carotid Artery Coupled with Magnetic Resonance Imaging
Authors: Pryor J. , D'Arceuil H. , Phil M. , Liu J. , He J. , Gonzalez R.G. , Duggan M. , De Crespigny A.
Published: January 2017

We used fluoroscopic guidance and over-the-wire techniques to superselectively place a microcatheter into a branch of the MCA of three macaques and MRI bolus tracking techniques to measure perfusion within the selected brain region. Such techniques are likely to be useful in the assessment and treatment of ischemic infarction, cerebral vasospasm, and monitoring local delivery of drugs into the brain.
The Current Status of Treatment Strategies for Cerebral Aneurysms in Nagoya University and Affiliated Hospitals Based on a Questionnaire Survey
Authors: Izumi T. , Miyachi S. , Hattori K. , Iizuka H. , Nakane Y. , Okamoto T. , Yoshida J.
Published: January 2017

We investigated differences in the treatment strategies for ruptured aneurysms among 26 hospitals affiliated with Nagoya University and any changes in those strategies based on responses to a questionnaire. We also surveyed the data concerning patients with a ruptured aneurysm collected from our affiliated hospitals between 2001 and 2002. In half of the institutes, angiography is performed immediately after an urgent medical examination, there are only five hospitals (20%) which have a basic policy of terminating the angiography within three to six hours after onset. In half of the institutes, the timing of the treatment also depends on the location of the aneurysm. In particular, the treatment for vertebro-basilar aneurysms tends to be done the next day or later. Low-grade subarachnoid hemorrhage (SAH) patients with mild symptoms tended not to be given any sedative drugs (46%), while patients with SAH in some institutes were sedated without informed consent regardless of the severity. The main treatment method for most anterior circulation aneurysms was clipping. Concerning aneurysms located in the posterior circulation and the origin of the ophthalmic artery, clipping and coiling were equally selected. Almost all the hospitals (92%) responded that their treatment strategy had not changed even after the report of the International Subarachnoid Aneurysm Trial (ISAT). There is a great deal of difference in treatment strategies and indications among institutions. In particular, institutions without neuroendovascular interventionists (NETists) frequently persist in the conventional policy, making it urgently necessary to bring NETists up-to-date on the latest advance in endovascular treatment.
Direct Superficial Temporal Vein Approach for Dural Carotid Cavernous Fistula
Authors: Matsubara S. , Kazekawa K. , Aikawa H. , Onizuka M. , Tsutsumi M. , Ikou M. , Kodama T. , Nii K. , Nagata S. , Tanaka A.
Published: January 2017

We present an alternative endovascular approach to treat dural carotid cavernous fistulae (dural CCF) that drain only into the superior ophthalmic vein. Four cases of cavernous dural AVFs that could not be treated via the inferior petrosal vein were accessed via the direct superficial temporal vein approach through the superior ophthalmic vein. Successful embolization was documented radiographically and clinically in all patients. The trans-superficial temporal vein approach is safe and useful for inaccessible dural CCFs through the inferior petrosal sinus.
Treatment of Cerebral Aneurysms: Surgical Clipping and Coil Embolization
Authors: Kaku Y. , Watarai H. , Kokuzawa J. , Tanaka T. , Andoh T.
Published: January 2017

The present series provides a balanced overview of the treatment of aneurysms in surgical clipping and coil embolization.

Between January 2004 and March 2006, 76 consecutive patients with cerebral aneurysms underwent endovascular embolization and/or surgical clipping. Of these, 42 patients suffered an aneurysmal subarachnoid hemorrhage (SAH), while the remaining 34 patients had nonruptured cerebral aneurysms.

Of the 23 surgically treated patients, 17 (73.9%) achieved a favorable outcome. Of the 19 patients who underwent endovascular embolization, 12 (63.2%) achieved a favorable outcome. Three patients (15.8%) who underwent endovascular embolization needed to undergo re-treatments, while no re-treatment was needed in the surgically treated patients. Of the 34 nonruptured aneurysms, 12 (35.3%) were treated using surgical clipping, while 22 (64.7%) underwent endovascular embolization. The complication rates of the two treatment modalities demonstrated no significant difference.

A combined microsurgical-endovascular team approach is thus considered to provide the most effective means to achieve favorable outcomes for patients with cerebral aneurysms.
Extracranial Vertebral Artery Aneurysm Associated with Neurofibromatosis Type 1
Authors: Hiramatsu H. , Negoro M. , Hayakawa M. , Sadatou A. , Irie K. , Uemura A. , Kanno T. , Sano K.
Published: January 2017

Extracranial vertebral artery aneurysm associated with neurofibromatosis (NF1) is very rare. The aneurysm was successfully treated by endovascular trapping of the aneurysm and proximal vertebral artery with coils.
Evaluation of Carotid Artery Plaque Using IVUS Virtual Histology
Authors: Tamakawa N. , Sakai H. , Nishimura Y.
Published: January 2017

Currently carotid artery stenting (CAS) as well as carotid endoarterectomy (CEA) have become widely accepted forms of treatment for carotid artery stenosis, although complications associated with distal embolism remain problematic. Therefore it is important to have an accurate understanding of the properties of carotid plaque before undertaking CAS in order to ensure the safety of such a therapeutic treatment. This study was undertaken to determine the efficacy of using IVUS Virtual Histology TM (VH-IVUS) to evaluate the pathological properties of plaque contained within carotid artery stenosis.

VH-IVUS was performed for six cases undergoing CAS during the period of July to December, 2005. VH-IVUS displays plaque composition under four color mappings of fibrous, fibro-fatty, calcification and necrotic core, being able to offer detailed tissue characterization of soft to hard plaque components. Plaque evaluation by VH-IVUS is both reproducible and objective, and is considered to be an effective method for evaluating the risk complications associated with CAS.
Combination Therapy Using tPA and Edaravone Improves the Neurotoxic Effect of tPA
Authors: Kano T. , Harada T. , Hirayama T. , Katayama Y.
Published: January 2017

In acute ischemic stroke patients, administration of tissue plasminogen activator (tPA) was proven to improve clinical outcome. On the other hand, neurotoxic effects of tPA have been reported in animal experimental studies. Using a rat thromboembolic stroke model, we examined whether or not the free radical scavenger, edaravone, could attenuate such neurotoxic effect of tPA administered for the purpose of fibrinolysis. Even when early recanalization was induced by administering tPA at 30 minutes after the onset of ischemia, significant amount of tPA was extravasated through the cerebral vessels. Edaravone significantly attenuated extravasation of tPA. Combination therapy using tPA and edaravone appears to be a promising strategy for diminishing the negative effects of tPA.
Stenting for Chronic Total Occlusion of the Proximal Subclavian Artery
Authors: Sakai C. , Sakai N. , Kuroiwa T. , Ishihara H. , Adachi H. , Morizane A. , Yano T. , Kajikawa R. , Yamagami H. , Kobayashi J. , Kondo K. , Kikuchi H.
Published: January 2017

We report the results of 26 patients who underwent stent deployment for chronic total occlusion of proximal subclavian artery. From January 1998 to October 2005, 26 patients (18 male; mean age, 62.7 years, range 22 to 83 years), 28 lesions, underwent 29 procedures of stenting for chronic total occlusion of the proximal subclavian artery. Twenty-three patients had symptoms of claudication in their arm, no patients had subclavian steal syndrome. A brachial approach was used in 21 procedures, a femoral approach was used in five procedures, and combined femoral-brachial approach was required in three procedures. Primary stent deployment was success in 24 lesions (85.7%), and secondary procedure was success in one patient, totally 25 lesions (89.3%) were successfully treated by stenting. Procedure related complication occurred in four cases, including stent migration without symptoms in two procedures, hemianopsia on next day in a case, and TIA on unclear reason in one case. Permanent morbidity rate is 3.4% in procedure. Target lesion re-treatment required in three lesions, caused by subacute thrombosis, in-stent-restenosis, and dissection of the vessel by stent edge. The cases of subacute thrombosis and in-stent-restenosis were treated by re-PTA, and the case of dissection was treated by additional stenting. Secondary patency was 100%.

We conclude that stenting for chronic total occlusion of subclavian arteries appears feasible and safe.
Incidence of Ischemic Complications after Endovascular Treatment for Ruptured Dissecting Vertebral Artery Aneurysms
Authors: Kudo T. , Iihara K. , Satow T. , Murao K. , Miyamoto S.
Published: January 2017

We analyzed the incidence of ischemic complications after internal trapping for ruptured VA dissecting aneurysms.

Between April 2001 and August 2005, nine cases of ruptured VA dissecting aneurysms, five in women, “proximal” or distal (distal type) to the origin of the PICA, were treated by internal trapping in the acute stage after SAH. There were four cases of proximal type and five of distal type. The demographics of the patients were reviewed in the medical charts and radiological findings were evaluated by neuroradiologists. The dissected site was completely obliterated and PICA was preserved in all cases. Follow-up angiography performed five to 19 days after treatment revealed complete obliteration of the aneurysm and patency of the PICA. The incidence of perioprocedural ischemic complications for the PICA-distal type (75%) was higher than that for the PICA-proximal type (20%).

Here we retrospectively analyzed and discussed the incidence and mechanisms of ischemic complications.
Early Embolization for Ruptured Aneurysm in Acute Stage of Subarachnoid Hemorrhage with Neurogenic Pulmonary Edema
Authors: Meguro T. , Terada K. , Hirotsune N. , Nishino S. , Asano T. , Manabe T.
Published: January 2017

Four cases of ruptured aneurysmal subarachnoid hemorrhage (SAH) presented with severe neurogenic pulmonary edema (NPE). On admission, two patients were grade IV and two were grade V according to Hunt and Hess grading. All patients needed respiratory management with the assistance of a ventilator. Three of them underwent endovascular treatment for the ruptured aneurysms within three days from onset after ensuring hemodynamic stability. Immediately after the endovascular treatment, lumbar spinal drainage was inserted in all the patients. The pulmonary edema findings disappeared rapidly after the respiratory management. The results were good recovery in two, and moderate disability in two. We concluded that early embolization of ruptured aneurysm and placement of spinal drainage is a satisfactory option for severe SAH with NPE.
Emergency Stenting of an Acute Internal Carotid Artery Occlusion from Spontaneous Dissection
Authors: Leong S. , Abbas S. , Galvin L. , Moroney J , Brennan P. , Thornton J.
Published: January 2017

Internal carotid artery (ICA) dissection is an important cause of stroke in the younger population. Carotid stenting with or without angioplasty is usually the preferred treatment for symptomatic patients who have failed medical therapy. We report a case of a symptomatic internal carotid artery dissection at the petrous segment of the ICA initially treated conservatively with anticoagulation and antiplatlet agents. Due to early clinical deterioration from near complete carotid occlusion without adequate cross over flow, the patient underwent emergency stenting of the ICA.

Post procedure angiography demonstrated no residual stenosis of the ICA. The patient progressively improved and at six months follow-up, the patient had no further symptoms, a normal neurological examination and improvement in the imaging findings.

The successful clinical result in our case of ICA stenting for dissection as a ‘hemispheric rescue’ contributes to the growing literature of endovascular management of carotid dissection. The excellent mid term follow-up confirms the efficacy of this treatment for a dominant ICA.
Morphological Study of Aneurysms at the Junction of the Superior Cerebellar Artery
Authors: Iizuka H. , Miyachi S. , Ohshima T. , Izumi T. , Tsurumi A. , Yoshida J.
Published: January 2017

Superior cerebellar artery (SCA) aneurysms sometimes involve the origin of the SCA making treatment difficult. We focused on the morphological characteristics of SCA aneurysms and adjacent vascular structures to apply clinical decision-making for the treatment strategy. Sixty-nine SCA aneurysms, including 34 ruptured and 35 unruptured ones, had been treated for over 12 years. Multiple aneurysms were associated in 30 patients. The pattern of the neck position of aneurysms was classified into three types: Type A: no SCA-involved type; Type B: half involved type with SCA originating from the aneurysmal neck; Type C: pure SCA aneurysm with all the neck mounting on SCA. Morphological and clinical analysis was done between ruptured and unruptured aneurysms and among the three types.

There was no difference in patient profile between ruptured and unruptured aneurysms. The angle formed by the posterior cerebral artery and SCA on the aneurysm side was obtuse in 62 (90%) patients. From the morphological point of view the SCA-involved type (types B + C) was significantly more prevalent in ruptured aneurysms (77%). Bleb formation was particular in ruptured aneurysms. As for the treatment, the risk of SCA occlusion and incomplete and attempted operation was particularly high in cases with SCA-involved type.

Although SCA aneurysms may grow due to the hemodynamic stress at the opened bifurcation between the PCA and SCA, the neck shifting to the origin of SCA, particularly in ruptured lesions, may suggest some other etiological mechanism. SCA-involved type aneurysms had a high treatment risk of SCA occlusion and tended to incomplete treatment to avoid such ischemic complications.
Accidental Transtumoral Microparticle Embolization of Eloquent Brain Areas in a Case of Large Temporofrontal Meningioma
Authors: Celedin S. , Rabitsch E. , Hausegger K.A. , Richling B.
Published: January 2017

We report a case of transtumoral diapedesis of microparticles during preoperative embolization of a large symptomatic temporofrontal meningioma, resulting in severe neurological deficit. In retrospective analysis of angiographic images, the pattern of supply to the tumour was found to be predictive for wide anastomotic channels connecting the dural and pial supply, thereby increasing the risk of the procedure. Recognising this pattern can prevent this rare cause of complication in a still controversial procedure.
3D Road-Mapping in the Endovascular Treatment of Cerebral Aneurysms and Arteriovenous Malformations
Authors: Rossitti S. , Pfister M.
Published: January 2017

3D road-mapping with syngo iPilot was used as an additional tool for assessing cerebral aneurysms and arteriovenous malformations (AVMs) for endovascular therapy. This method provides accurate superimposition of a live fluoroscopic image (native or vascular road-map) and its matching 2D projection of the 3D data set, delivering more anatomic information on one additional display. In the endovascular management of cases with complex anatomy, 3D road-mapping provides excellent image quality at the intervention site. This method can potentially reduce intervention time, the number of DSA runs, fluoroscopy time and the amount of contrast media used in a procedure, with reservation for these factors being mainly operator-dependent. 3D road-mapping probably does not provide any advantage in the treatment of cerebral aneurysms or AVMs with very simple configuration, and it should not be used when acquisition of an optimum 3D data set is not feasible.
Onyx Migration in the Endovascular Management of Intracranial Dural Arteriovenous Fistulas
Authors: Wang H. , Lv X. , Jiang C. , Li Y. , Wu Z. , Xu K.
Published: January 2017

Onyx migration in the endovascular treatment of dural arteriovenous fistulas (dural AVFs) is uncommon. We describe five cases of Onyx migration to the heart and draining vein and its avoidance.

Between February 2007 and August 2008, Onyx migration was encountered in five patients with dural AVFs treated endovascularly at our institute. Procedures performed under general anesthesia consisted of two arterial approaches and three venous approaches.

Two patients with dural AVFs involving the transverse-sigmoid sinus were treated by transarterial embolization using Onyx-18 via the occipital artery and the posterior branch of the middle meningeal artery, respectively. A piece of Onyx was found in the right ventricle on post-embolization chest X-ray film in both patients, one developed tricuspid valve dysfunction requiring thoracic surgery and one was asymptomatic. The other three patients were treated with a combination of Onyx (34 or 18) and coils transvenously with venous Onyx migration leading to draining vein occlusion, one with dural AVF involving the tentorium died from venous rupture, two patients with bilateral dural AVFs of the cavernous sinus (one with deterioration of ocular symptoms and one without symptoms). Postoperative digital subtraction angiography confirmed the elimination of dural AVF in one patient, and residual fistulae in three patients. The follow-up study ranging from two to nine months (average, 4.5 months). Three patients recovered to their full activities, while one had visual disturbance.

Although Onyx has been considered a controllable embolic agent, its migration to other locations causing clinical deterioration can occur. This problem should be noted and prevented.
Ozone Nucleolysis for Management of Pain and Disability in Prolapsed Lumber Intervertebral Disc
Authors: Das G. , Ray S. , Ishwarari S. , Roy M. , Ghosh P.
Published: January 2017

The prevalence rate of low back pain in a number of studies ranged from 22% to 65% in one year, and lifetime prevalence ranged from 11% to 84%. Over the years many percutaneous minimally invasive therapeutic modalities have evolved. Intradiscal oxygen-ozone therapy has also showed promising results. We undertook a prospective cohort study to evaluate the therapeutic outcome of oxygen-ozone therapy on patients with lumber disc herniation in the Indian population.

After obtaining ethical committee and investigational review board permission, 53 consecutive patients complying with selection criteria were treated with a single session of oxygen-ozone therapy. All presented with clinical signs of lumber nerve root compression supported by CT and MRI findings. All patients received 3–7 ml of ozone-oxygen mixture at an ozone concentration of 29–32 mc/ml of oxygen. Therapeutic outcome was assessed after three weeks, three months, six months, one year and two years on a visual analog scale and Oswestry low back pain disability questionnaire.

Pain intensity was significantly reduced following treatment (VAS baseline 7.58 ± 0.86, after three weeks 2.75 ± 1.42 and after two years 2.64 ± 2.14). Similarly the Oswestry disability index showed a remarkable improvement in the functional status of the patients (p<0.05). No major complication was observed in this case series. Oxygen-ozone treatment is highly effective in relieving low back pain due to lumber disc herniation.
Endovascular Biopsy: Evaluating the Feasibility of Harvesting Endothelial Cells Using Detachable Coils
Authors: Cooke Daniel L. , Su Hua , Sun Zhengda , Guo Yi , Guo Diana , Saeed Maythem M. , Hetts Steven W. , Higashida Randall T. , Dowd Christopher F. , Young William L. , Halbach Van V.
Published: January 2017

The absence of safe and reliable methods to harvest vascular tissue in situ limits the discovery of the underlying genetic and pathophysiological mechanisms of many vascular disorders such as aneurysms. We investigated the feasibility and comparable efficacy of endothelial cell collection using a spectrum of endovascular coils.

Nine detachable coils ranging in k coefficient (0.15–0.24), diameter (4.0 mm–16.0 mm), and length (8.0 cm–47.0 cm) were tested in pigs. All coils were deployed and retrieved within the iliac artery of pigs (three coils/pig). Collected coils were evaluated under light microscopy. The total and endothelial cells collected by each coil were quantified. The nucleated cells were identified by Wright-Giemsa and DAPI stains. Endothelial and smooth muscle cells were identified by CD31 and α-smooth muscle actin antibody staining.

Coils were deployed and retrieved without technical difficulty. Light microscopy demonstrated sheets of cellular material concentrated within the coil winds. All coils collected cellular material while five of nine (55.6%) coils retrieved endothelial cells. Coils collected mean endothelial cell counts of 89.0±101.6. Regression analysis demonstrated a positive correlation between increasing coil diameter and endothelial cell counts (R2 = 0.52, p = 0.029).

Conventional detachable coils can be used to harvest endothelial cells. The number of endothelial cells collected by a coil positively correlated with its diameter. Given the widespread use of coils and their well-described safety profile their potential as an endovascular biopsy device would expand the availability of tissue for cellular and molecular analysis.
Feasibility Study of Perfusion Imaging Using Flat Detector CT with an Intra-Arterial Injection Protocol Compared to Conventional Multi-Slice Perfusion CT with an Intravenous Injection Protocol
Authors: Zhang Qiang , Wang Bin , Han Jingfeng , Zhang Zhiqiang , Sun Qi , Beilner Janina , Shen Chunsen , He Zijun , Dai Yiwu , Xu Ruxiang
Published: January 2017

This study investigated the feasibility of using intra-arterial injection-based cerebral blood volume (CBV) imaging with flat detector computed tomography (CT, IAFD-CBV). It is proven that this new method could provide comparable physiologic information as standard intravenous injection-based multi-slice computed tomography CBV imaging (IVCT-CBV).

Twelve patients were examined using both IAFD-CBV and IVCT-CBV. An experienced neuroradiologist read both sets of generated CBV maps. If a physiologic perfusion disorder was detected in standard IVCT-CBV, the focus was to check whether IAFD-CBV indicated the same disorder or not. Otherwise, if no disorder was detected, relative CBV (rCBV) values at different basal ganglia regions were measured for both CBV maps and then compared.

For three patients with lesions, IAFD-CBV and IVCT-CBV showed similar perfusion disorders in the corresponding regions. For nine patients without lesions, both CBV maps showed good symmetry of contrast agent (CA) distribution for left/right hemisphere, the total average of rCBV was found to be 0.94 –/+0.18 and 1.01 –/+0.14 (1.0 for perfect symmetry) in IAFD-CBV and IVCT-CBV, respectively. However, compared to IVCT-CBV, IAFD-CBV imaging required 70% less contrast agent (CA).

In general, a good correlation between IAFD-CBV and IVCT-CBV was found for all 12 patients. Minor deviations of IAFD-CBV were only detected at regions supplied by the middle cerebral artery. IAFD-CBV imaging, which can be directly performed in a catheterization laboratory, was proven to be technically feasible for real-time CBV assessment of the whole brain with good accuracy, and minimized CA usage.
Vertebral Artery Position in the Setting of Cervical Degenerative Disease: Implications for Selective Cervical Transforaminal Epidural Injections
Authors: Fitzgerald Ryan T , Bartynski Walter S , Collins Heather R
Published: January 2017

Cervical transforaminal epidural injections (C-TfEI) are commonly performed in patients with cervical radiculopathy/pain. C-TfEIs are typically performed without incident but adverse events can occur. Using CT-fluoroscopy-guided C-TfEI, we commonly observe the vertebral artery in proximity to the target injection site. The purpose of this study was to assess the position of the vertebral artery relative to the typical C-TfEI injection point.

CT-fluoroscopy-guided C-TfEIs were performed at 70 levels in 68 patients with radiculopathy/neck pain (age range 19–83 yrs, mean 50.6 yrs). Degenerative neural foraminal narrowing at each level was characterized (normal-to-mild, moderate, severe). Vertebral artery position was categorized as: anterior (normal), partially covering neural foramen, complete/near-complete covering the neural foramen. Additional measured variables included angle of needle trajectory, foraminal angle, and whether or not needle trajectory intersected with the vertebral artery.

Foraminal vertebral artery covering correlated with severity of foraminal degenerative narrowing (p=0.003). Complete/near-complete covering was seen in: 65% severely narrowed foramina, 30% moderately narrowed foramina and 10% normal/mildly-narrowed foramina. Needle trajectory intersected with the vertebral artery in 30 of 70 injections (46%) by CT-fluoroscopy, frequently associated with shallow (lateral) approaches. Foraminal angle, approximating oblique fluoroscopic technique, suggests needle trajectory intersection with the vertebral artery in 27 of 70 foramina (39%).

Vertebral artery position is commonly displaced into the foramen in patients with advanced cervical degenerative disease. Operator awareness of altered vertebral artery position is important for determination of optimal needle trajectory and tip placement prior to injection in patients undergoing C-TfEI.
Onyx Embolization of an Intracranial Hemangiopericytoma by Direct Transcranial Puncture
Authors: Ding Dale , Kreitel Derek , Liu Kenneth C.
Published: January 2017

Intracranial hemangiopericytomas are uncommon but highly vascular dural-based tumors which commonly derive arterial blood supply from both intracranial and extracranial circulations. Microsurgical resection of these lesions may result in excessive blood loss without the aid of pre-operative embolization. We describe a case of a large tentorial hemangiopericytoma for which initial resection was aborted due to excessive blood loss. After failed endovascular access, we performed a direct transcranial puncture of the hemangiopericytoma through the craniotomy defect and successfully embolized the tumor with Onyx. Post-embolization gross total resection was achieved with a limited amount of operative blood loss. Direct puncture embolization provides several advantages over traditional endovascular embolization including decreased procedural duration, circumventing challenging arterial anatomy, and a lower risk of stroke in the presence of extracranial-to-intracranial anastamoses. While direct puncture embolization has been described for tumors of the neck and skull base, this is the first reported case of an intracranial hemangiopericytoma successfully devascularized by direct transcranial puncture Onyx embolization.
Prevention of Complications during Endovascular Surgery on the External Carotid Arteries, with Special Reference to Use of Nitropaste and the Lidocaine Test
Authors: Kurata A. , Miyasaka Y. , Tanaka C. , Tokiwa K. , Saegusa H. , Fujii K. , Kan S.
Published: January 2017

Purpose

To examine all complications of endovascular procedures on the external carotid arteries and to ascertain how to reduce their number.

Methods

In 93 consecutive patients, 137 endovascular procedures on the external carotid arteries were performed during the last 6 years.

Results

We encountered no neurologic complications in these patients. In eight (9%) of the 93 patients who underwent lidocaine tests of the external carotid branches, nine transient cranial nerve palsies occured, seven of 67 vessels (10%) involving the middle meningeal artery and two of 18 vessels (11%) the ascending pharyngeal artery. However, they soon disappeared and successful embolisations were achieved. Vasospasm that prevented endovascular procedures occurred in only two cases of this series as a result of the application of isosorbide dinitrate.

Conclusions

The lidocaine test effectively provoked cranial nerve palsies without false negatives. The complication rate of endovascular surgery will decrease as long as awareness of complications such as cranial nerve palsy is maintained.
Intra-Arterial Chemotherapy with Carboplatin (CBDCA) and Vepesid (VP16) in Primary Malignant Brain Tumours
Authors: Clocchiatti L. , Cartei G. , Lavaroni A. , Vigevani E. , Fabris G. , Tommasini G. , Leonardi M.
Published: January 2017

Twenty three patients (18 males) were followed from January 1993 to July 1996 for primary central nervous system malignancy: glioblastoma multiforme (GM) (15 patients), anaplastic astrocytoma (AA) (8 patients). Ninety one cycles (average 4 cycles per patient) of intraarterial chemotherapy (IACH) were administered.

The IACH included: Carboplatin (CBP) 250 mg/m2 and Vepesid (VP16) 150 mg/m2 infusion; both drugs in normal saline, 100 ml and 250 ml, were infused over 15 and 30 min respectively. IACH was repeated every two weeks four or six times according to response to chemotherapy. IACH was preceded by i.v. methylprednisolone 40mg and pure anti-emetic (5HT3 serotonin uptake inhibitors) and subcutaneous daily doses of G-CSF following IACH to prevent neutropenia. The whole treatment required a 24h hospital admission.

The IACH was well-tolerated and toxicity (Miller's grade, WHO) included: two cases of reversible pulmonary embolism (8.6%) three and ten days respectively after therapy (one patient had atrial fibrillation, two cases grade 2 vomiting, two grade 1 anaemia and three grade 3 thombocytopenia (13%).

Response to therapy was evaluated in 21 out of 23 patients, two having not yet received at least four IACH cycles: 4 PRO (3 GM, 1 AA), 15 SD (10 GM, 5 AA) and 2 PR (AA). Seventeen patients responded to IACH (SD + RO) (74%), and the PRs belonged to the AA group. Survival duration was from 16 + to 108 weeks.

IACH with CP and VP16 warrants further studies focussing on drug dose and schedule. A prospective randomized multicentric trial evaluating radiotherapy and systemic chemotherapy plus/minus IACH is currently underway.
Predictibility of the Cervical Origin of the Anterior Spinal Artery
Authors: Mercier P. , Brassier G. , Fournier D. , Hentati N. , Pasco-Papon A. , Papon X.
Published: January 2017

The anatomic study (under a surgical microscope) of 25 brains that had previously been injected with colored latex confirmed the fact that in the majority of cases, the anterior spinal artery results from the merging of two arterioles which both derive from two vertebral arteries.

This bilateral nature is determined by the symmetric origin of the posterior inferior cerebellar arteries.

When the conformation is asymmetrical, a single anterior spinal artery branches off from the vertebral artery that supplies the closest posterior inferior cerebellar artery.
The Natural History and Management of Intracranial Dural Arteriovenous Fistulae
Authors: Davies M.A. , Saleh J. , ter Brugge K. , Willinsky R. , Wallace M.C.
Published: January 2017

The recently proposed classification scheme of Borden, Wu, and Shucart (Borden*) should have the ability to identify those intracranial dural arteriovenous fistulae (ICDAVF) which will continue to behave in a benign fashion. We examine for the first time the natural history of benign ICDAVF, including the predictive ability of this grading scale, and the implications for lesion management.

A cohort of 55 Borden* grade I lesions was selected from a heterogeneous series of 102 consecutive ICDAVF seen at one institution between 1984 and 1995. Data were collected prospectively from 1991. Grade I lesions were those whose nidus drained directly into a dural venous sinus (DVS) or meningeal vein. The absence of retrograde leptomeningeal venous drainage (RLVD) was an important feature. Intracranial haemorrhage (ICH), non haemorrhagic neurological deficit (NHND), and death were considered aggressive features.

There were 23 cavernous sinus, 2 foramen magnum, 1 middle cranial fossa, and 29 transverse sinus lesions. One patient received obliterative surgical treatment. Thirty-two lesions were observed only, and 22 patients developed symptoms or signs requiring palliative embolisation.

Two minor complications occurred following embolisation: transient pulmonary aedema (1), and an asymptomatic pericallosal artery embolus (1). Follow-up was available on 48 (89%) patients for a total of 133 patient years (mean 33 months). This included 26 of the 32 patients observed and all 22 of the patients embolised. Aggressive interval behavior was seen in only one patient. Symptom improvement or resolution was observed in the majority of patients, whether observed only [21/26 (81%)], or whether they required embolisation for symptom palliation [19/22 (86%)]. Overall, 53 of the 54 (98%) of ICDAVF behaved in a benign fashion in the follow-up period.

The predictable benign natural history of patients identified as Borden* grade I at presentation mandates a conservative approach to these ICDAVF. In some patients, when symptom severity demands, palliative embolisation is an effective and safe therapy.
Giant Multilocular Fusiform Aneurysm of the Posterior Cerebral Artery
Authors: Kon H. , Ezura M. , Takahashi A. , Yoshimoto T.
Published: January 2017

A 60-year-old woman presented with a giant posterior cerebral artery aneurysm. Her visual field examination revealed right upper quadrantanopia. Because of the difficulty of the neck clipping, we performed parent artery occlusion using the Guglielmi detachable coils following balloon Matas test monitored with single photon emission computed tomography (SPECT) with 99mTc-d, l hexamethyl-propylene-amine oxime. Postoperative left internal angiography showed the left occipital region was supplied by a leptomenigeal collateral via left the middle cerebral artery. Six months after embolisation the aneurysm was completely thrombosed on MR imaging.

Her visual field deficits had also improved six months after embolisation. A combination of the balloon Matas test with SPECT followed by parent artery occlusion is an excellent method to treat such giant aneurysms.
Bilateral Thalamic Infarcts Complicating Basilar Tip Aneurysm Coil Embolisation
Authors: Cloft H.J. , Kallmes D.F. , Lanzino G. , Jensen M.E. , Dion J.E.
Published: January 2017

We report a case of bilateral thalamic infarcts with no apparent cause other than unilateral partial occlusion of the P1 segment of the posterior cerebral artery caused by Guglielmi detachable coils in a basilar tip aneurysm.

This case demonstrates that bilateral thalamic infarctions can result from a unilateral posterior cerebral artery stenosis or occlusion, and does not necessarily imply bilateral posterior cerebral artery abnormality.
Substance P: An Inflammatory Peptide
Authors: Katsanos G.S. , Anogeianaki A. , Orso C. , Tetè S. , Salini V. , Antinolfi P.L. , Sabatino G.
Published: January 2017

Substance P (SP) is involved in neurogenic inflammation and in the pathogenesis of several inflammatory diseases, demonstrating that there is a narrow interrelationship between the nervous system and immunity. Macrophage functions are altered in stress, therefore, since SP is a macrophage activator, its biological effect has been intimately linked to stress. In fact, SP enhances LPS-induced macrophage TNFα production from stressed animals and stimulates the production of IL-8 CXC chemokine response in a mast cell line in vitro. The stress-induced cytokines from macrophage also alter and contribute to inflammation. Understanding the pathophysiology of inflammation and the role of the chemical mediator SP may improve inflammation management.
Patients with Allergic Rhinitis Show an Allergen-Specific Interferon-Gamma Defect
Authors: Fenoglio D. , Ferrera A. , Ferrera F. , Sormani M.P. , di Gioacchino M. , Ciprandi G.
Published: January 2017

Allergic rhinitis (AR) is characterized by Th2 polarized immune response. Consequently, allergic patients have a defect in IFN-γ production. So far, however, all the experimental studies have investigated only the IFN-γ production induced by the causal allergen. The aim of this study is to investigate whether there is a difference in the in vitro IFN-γ production, using different allergens as stimuli, in patients presenting with rhinitis due to pollen allergy. Forty-one AR patients with pollen allergy were enrolled. IFN-γ-specific producing cells were stimulated with PHA, causal pollen, and House Dust Mite (HDM). IFN-γ production was assessed by cytokine ELISPOT. IFN-γ production of peripheral blood mononuclear cells (PBMC) stimulated by specific pollen was significantly lower than IFN-γ production of PBMC stimulated by HDM (p<0.001). IFN-γ production of PBMC stimulated by specific pollen was significantly lower than IFN-γ production of PBMC stimulated by PHA (p<0.001). Moreover, in the HDM-sensitized patients, there seems to be a trend for a different defect. The present study highlights that the defective IFN-γ production is allergen specific and that HDM sensitization may also affects this parameter.