. 2014 Apr 4;20(2):155–232.
interv neuroradiol. 2014 Apr 4;20(2):155.
interv neuroradiol. 2014 Apr 4;20(2):157.
Objective: To show a novel application of the stent for the embolization of branch incorporated wideneck cerebral aneurysms that are not amenable to usual neck remodeling technique.
Methods: From March 2012 to October 2013, 8 patients with wide-neck aneurysms were treated with “modified Waffle-cone technique” at our institution. Solitaire AB Remodeling Device was used for this technique and we placing the distal end of the stent into the neck of the aneurysms for purpose of preservation of incorporated branch. The aneurysms were located at the middle cerebral artery bifurcation (n = 5), the P-com (n = 2) and the basilar- SCA (n = 1). Patient demographics, aneurysm morphology, procedures, and clinical and angiographic outcomes were reviewed.
Results: Successful deployment of the stent with preservation of the targeted artery and near complete occlusion was achieved in 7 of 8 patients. One patient with SCA aneurysm, we retrieved the devices and change the treatment plan because of preserving the branch was unsure. No procedure-related complication was occurred in all cases.
Conclusion: The modified waffle-cone technique may enhance the possibilities of the coil embolization of these selected cases. However, its safety and technical feasibility should be further evaluated by larger case series and long-term follow-up.
interv neuroradiol. 2014 Apr 4;20(2):157.
Objective: Aneurysms arising from pericallosal artery (PA) are uncommon and challenging to treat. The aim of this study was to report our experience with endovascular treatment of ruptured PA aneurysms.
Methods: From September 2003 through May 2012, 30 ruptured PA aneurysms in 30 patients were treated at our institution via endovascular approach. Procedural data, clinical and angiographic results were reviewed retrospectively.
Results: The immediate angiographic control showed complete occlusion in 21 (70.0%) patients and near-complete occlusion in 9 (30.0%). Procedure-related complication occurred, including procedure-related rebleeding in six and thromboembolic event in two. Preoperative contrast retention was most strongly associated with a increased risk of procedure-related rebleeding. At the end of the observational period, 18 patients were independent with a mRS score of 0-2, while the other 12 were dependent or dead (mRS score, 3-6). Adjacent hematoma was associated with a increased risk of poor clinical outcome. No neurologic deterioration or bleeding was seen during the follow-up period (mean, 32.7 months) in all survived patients. Seventeen of 23 surviving patients underwent follow-up conventional angiography (mean, 16.5 months). The result showed stable occlusion in 14 (82.4%), minor recanalization in two (11.8%), and major recanalization in one (5.9%), who had required recoiling.
Conclusion: Our preliminary experience demonstrates that endovascular treatment for ruptured PA aneurysms is feasible and effective. Procedure-related rebleedings occur far more often (20.0%) than has been generally suspected in other locations and were associated with a preoperative contrast retention. An existing adjacent hematoma was a predictor of poor clinical outcome.
interv neuroradiol. 2014 Apr 4;20(2):158.
Objective: The current treatment regimen for delayed cerebral ischemia (DCI) concomitant with vasospasm in subarachnoid hemorrhage (SAH) includes primary medical and secondary endovascular therapy. However, assessing an adequate response to medical therapy and its maintenance time remains difficult, and it can lead to delayed endovascular procedures. An analysis of 59 consecutive patients with aneurysmal SAH was carried out to assess the early endovascular approach for DCI concomitant with significant vasospasm, without prior medical treatment.
Design: Retrospective review of urgent endovascular intervention
Participants: Fivty nine aneurysmal SAH patients were included who underwent early angiographic assessment for clinical deterioration caused by DCI. All patients had prompt endovascular intervention for significant vasospasm (≥50% narrowing) mainly under local anesthesia. After urgent endovascular treatment, all patients were treated with hypervolemic-hypertension therapy.
Results: Endovascular treatments were performed on 422 vasospastic segments [(transluminal balloon angioplasty (TBA) for 107 segments , and intra-arterial nimodipine for 315 segments]. Regarding the distal arteries, TBA was conducted on 32 segments. Early neurological response was observed in 52 patients (89.5%). Fourty six patients (78.9%) showed good angiographic results. Repetitive intervention was conducted in eleven patients (18.6%) on 16 segments. Five cases of cerebral infarction were found; of these, three were symptomatic. Good outcomes (mRS ≤ 2) at 6 months were observed in 52 patients (89.5%).
Conclusions: Urgent endovascular treatment could be beneficial in aneurysmal SAH patients at high risk for DCI concomitant with significant vasospasm. However, the absence of a comparative analysis should be taken into consideration. Consequently, a larger comparative analysis could be justified to confirm the clinical validity of urgent endovascular intervention.
interv neuroradiol. 2014 Apr 4;20(2):158.
Objective: Larger aneurysm on distal intracranial artery (ICA) is one of the complicated aneurysm to treat. Segmental obliteration or neck clipping after by-pass surgery, regard as one of the standard treatment. But development of endovascular technique and devices, these aneurysms can be treated less invasive method. Authors report clinical outcomes of these aneurysm patients treated with endovascular technique.
Methods: 21 patients, large aneurysms at distal ICA who treated by endovascular method were included in this analysis. We retrospectively reviewed patient medical records and imaging files to analyses the aneurysm configurations, patient’s characteristics and clinical outcomes.
Results: The mean age of these patients was 61 years, 18 patients were female and 16 patients were ruptured. There was no prevalence of laterality. The patient clinical outcome was strongly depends on the initial neurologic status (p<0.05). On aneurysm anatomical configuration, 12 patients show saccular, 6 with wide-neck and 3 were fugiform shaped. In 6 patients, treated with stent assisted endovascular procedure and other 15 patients treated simple coiling. Overall mortality was 30% (7 out of 21) and fatal complication related with the endovascular procedure, delayed thrombosis occurred in two patient.
Conclusion: The development of 3 dimensional radiologic image and endovascular technique, the anatomical configuration of distal ICA large aneurysm can be evaluated accurately. And some of these aneurysms are good anatomical configuration enough to treat by endovascular management. Recent developed endovacular device and technique afford safe and less invasive treatment method to distal large or giant aneurysm patients.
interv neuroradiol. 2014 Apr 4;20(2):158–159.
Background: Endovascular internal trapping is an effective procedure for the treatment of acute vertebral artery dissection (VAD). However, the results of reconstructive treatment outcomes have not been reported.
Objective: To evaluate the long-term clinical and angiographic results of endovascular internal trapping or reconstructive treatment of acute VAD.
Methods: Between September, 2005 and August, 2013, 26 patients with acute VAD were treated by internal coil trapping (n=10), stent-assisted coiling (n=14), stent only (n=1) and proximal occlusion (n=1) in our hospital. Stent-assisted coiling include modified stent-assisted semi-jailing technique (n=10), balloon-in-stent technique (n=2), coiling followed by balloon mounted stent (n=2). All hemorrhagic type VADs were treated emergently within 12 hours from hospital arrival. All patients except three expired during acute stage were regularly followed-up by digital subtraction angiography (DSA) and clinical examination.
Results: Fourteen patients had hemorrhagic type VAD, and 12 had non-hemorrhagic type acute VAD. Clinical and angiographic follow-up at least 6 months data were obtained from 23 (88.5%) patients. There were 13 male and 13 female with a mean age of 49.5 years (age range, 34-70 years). The dominancy of relevant artery was dominant in 9, even in 12 and non-dominant in 5. All six dominant side ruptured VADs which were failed balloon test occlusion (BTO) and nine non-hemorrhagic type were treated with reconstructive technique. Clinical outcomes were favorable in 22 (84.6%), 1 had severe disability and 3 (11.5%) patients died due to poor initial clinical grade. Follow-up DSA results of 9 internal tapping and 1 proximal occlusion were all stable occlusion state. Among 15 cases of reconstructive treatment, 10 revealed stable occlusion of aneurismal dilatation and patent parent artery. Two developed regrowth of the coiled arterial wall in ruptured cases and successful retreatment was achieved. One in-stent parent artery occlusion occurred without symptom. There was no recurrent bleeding or ischemic symptom during the follow-up period.
Conclusion: The result of this study have proven that internal trapping is a stable and effective treatment for acute VAD and reconstructive treatment using stent and coils also could be feasible and safe alternative treatment modality even though it was hemorrhage type VAD. But close serial DSA follow up is mandatory.
interv neuroradiol. 2014 Apr 4;20(2):159–160.
Objective: Aneurysms arising from pericallosal artery (PA) are uncommon and challenging to treat. The aim of this study was to report our experience with endovascular treatment of ruptured PA aneurysms.
Objective and importance: Fusiform cerebral aneurysms have been particularly impossible or extremely difficult to treat using conventional coil or stent-assisted coil embolization. New concept, flow diversion with newly designed stent (flow diverters) has aroused great enthusiasm in treating giant or fusiform aneurysms. But their use has not been supported with high level of evidence. Modified stent-assisted semi-jailing technique could be feasible and effective alternative treatment technique for such fusiform aneurysms.
Clinical presentation: Between October, 2009 and August, 2013, 10 patients with acute vertebral artery dissection (VAD) were treated by modified stent-assisted semi-jailing technique in our hospital. Angiographic finding of all VAD was fusifrom shape. Four patients presented with subarachnoid hemorrhage and six patients had non-hemorrhagic type acute VAD. Clinical and angiographic follow-up at least 6 months data were obtained from 8 (80%) patients. There were 5 male and mean age of 49.4 years (age range, 38-69 years). The dominancy of relevant artery was dominant in 7, even in 1 and non-dominant in 2. The relationship between fusiform dissecting portion and posterior inferior cerebellar artery (PICA) was PICA distal type in 3, proximal in 1, PICA involved in 1 and absent PICA in 5. Follow-up DSA was performed in all patients except one who was expired early hospital day due to initial poor clinical grade. Seven patients revealed stable occlusion of aneurismal dilatation portion with coils and patent parent artery. One developed regrowth of the coiled arterial wall in ruptured PICA involved case and successful retreatment was achieved. One in-stent parent artery occlusion occurred without symptom. Clinical outcomes were favorable in 9 (90%) and 1 (10%) patient died. There was no recurrent bleeding or ischemic symptom during the follow-up period.
Intervention: Modified stent-assisted semi-jailing technique is as follows. We deliver Neuroform® stent using exchange microwire over the dissecting portion at first and then select the aneurismal portion with a microcatheter. Deploy the stent about one third which is so called semi-jailing technique for protection of distal coil migration and permission of microcatheter kick-back motion. After semi-jailing technique, put some additional coils loosely and circumferentially at aneurismal dilatation. When repeated angiography reveals slight distal flow compromise, deploy the stent completely. Finally second stent applied to stick unrecognized coil loops inside parent artery between two stents strut.
Conclusion: The result of this study have shown that reconstructive treatment named “modified stent-assisted semi-jailing technique” for fusiform dissecting aneurysms could be feasible and safe alternative treatment modality of VADs even though it was hemorrhage type. But close serial DSA follow up is mandatory in ruptured cases.
interv neuroradiol. 2014 Apr 4;20(2):160.
Purpose: The LUNA Aneurysm Embolization System (AES) is a new self-expanding ovoid device that serves as an intra saccular flow diverter as well as a scaffold for endothelization across the neck. The Objective of this prospective clinical study is to evaluate the long term ability of the LUNA AES device to occlude intracranial aneurysms while maintaining patency of the parent artery.
Materials and Methods: Immediate post-implantation occlusion grade (complete (complete obliteration of the aneurysm including the neck), near-complete (persistence of any portion of the original defect of the arterial wall), or incomplete (any opacification of the sac) compared to baseline), and parent vessel compromise were evaluated. Patients underwent neurological testing with the Modified Rankin Scale and the National Institute of Health Stroke Scale (NIHSS) at baseline and time of discharge. Follow-up included clinical assessment at one, 3, 6, 9 and 12 months, and angiographic follow-up at 6, 12 and 36 months.
Results: 63 patients (11 men) with 60 unruptured and 4 ruptured saccular aneurysms (49 bifurcation, 15 sidewall, median width 5.3 mm, height 6.0 mm and neck 3.4 mm) were enrolled in the study. LUNA device was implanted in 61 aneurysms, coils were implanted in 2 aneurysms and a stent was used for 1 aneurysm. 1 LUNA device was deployed per aneurysm. Device placement required assistance of a balloon microcatheter in 5 cases, and a stent in 2 case. Immediate complete/near complete occlusion was observed in 32.7% of the cases (20/61). Pre-discharge clinical follow up was uneventful in all but 2 patients (one sustained SAH from a contralateral MCA aneurysm, one had GI bleeding). 90.5% and 93.3% of patients had an event free follow up at 1 month and 3 months respectively. At 6 month follow-up, the following outcomes were noted: complete/near complete occlusion in 80% (40/50), no parent artery compromise in 96% (48/2), no distension of aneurysm wall in 96% (48/50), no rupture or (re)bleeding of the aneurysm in 100% (50/50), and no adverse events in 100% (50/50) of the treated patients.
Conclusion: Preliminary results demonstrate good safety profile. Angiographic follow up are promising.
For the authors: PSP; FOR (PI) Besançon, Limoges, Stockholm, Florence, Varsovie, Nancy, Brussels.
| Hopital Pitie salpetriere , Paris | Dr Nader-Antoine Sourour | 11 |
| Fondation Ophtalmologique Adolphe de Rothschild |
Dr Michel Piotin | 21 |
| CHU de Besançon | Pr Alessandra Biondi | 21 |
| Hôpital Dupuytren – CHU Limoges |
Pr Charbel Mounayer | 2 |
| Karolinska University Hospital in Solna |
Dr Tommy Andersson | 2 |
| Azienda Ospedaliero- UniversitariaCareggi |
Pr Salvatore Mangiafico | 2 |
| Medical University of Warsaw | Dr Maciej Jaworski | 2 |
| CHU Nancy | Pr Rene Anxionnat | 1 |
| Université Catholique de Louvain (UCL) Brussels |
Pr Pierre Goffette | 1 |
interv neuroradiol. 2014 Apr 4;20(2):160–161.
Background and Objective: Stent-assisted coil embolization is increasingly used to treat intracranial aneurysms especially with wide-neck to save the lumen of the normal branches. Several techniques using one or more stents have been described for the bifurcation aneurysms depending on the configuration of aneurysm and normal arteries. We will describe the long-term results of horizontal deployment technique of Enterprise stent via an antegrade approach for coil embolization of various bifurcation type aneurysms with wide neck.
Methods: For the protection of branch and more complete coverage of aneurysm neck with only one stent, we deployed the Enterprise stent from the distal segment of one branch to the ostium of another (counter) branch in an antegrade fashion. The neck of the aneurysm was covered by the proximal flared portion of the stent. Coil embolization using one or two microcatheters was followed.
Results: Eleven bifurcation type aneurysms with wide neck and considered to be suitable were treated using this technique so far. Aneurysm neck coverage of stent was sufficient for following coil packing in ten aneurysms (10/12). Among the six aneurysms with follow-up study (12-40 months), four aneurysms showed stable occlusion state while two basilar top aneurysms showed coil compaction.
Conclusion: Horizontal deployment of Enterprise stent via an antegrade approach followed by coil packing can be another option for the embolization of wide-necked bifurcation aneurysms.
interv neuroradiol. 2014 Apr 4;20(2):161.
Purpose: The evaluation of efficiency of endovascular embolization and follow-up of wide-neck aneurysms embolised with remodeling technique.
Material and Method:Retrospective study done with 32 patients having wide-neck intracranial aneurysms, including 24 ruptured aneurysms and 8 unruptuered aneurysms.
Result: Total occlusion acquired in 25 Pts (71.1%). Neck-remnant in 7 Pts (21.9%). No-one had saccular residual. Complications during the procedure taken place in 7 Pts (21.9%), most of them are thrombus-occluded and ruptured. Recovery was very high, mRS 0: 21 Pts (65.6%), 4 deads (12.5%), 2 Pts dependent (mRS 3,4). 10 Pts have been done MRI control after minimum 5 month, demonstrated 5 Pts having total occlusions. 4Pst have neck remnant and 1 recanalisation needed to be done second embolization.
Conclusion: Intravascular embolization for wide-neck intracranial aneurysms is feasible and efficient.
interv neuroradiol. 2014 Apr 4;20(2):157.
Purpose: The authors aims to report the result and experience in treatment of middle cerebral artery aneurysm by using coils and balloon.
Material amd Methods: Fifty one patients were included in the retrospetive study during the interval between January 2009 to December 2013 in Bach Mai hospital. A total of 51 middle cerebral atery aneurysms have been treated by using coils with assisted balloon or Stent. The group of the patients was comprised of 33 men and 18 women, aged 36 to 78 years (mean 56,33 ± 9,78 years). The sized of the aneurysm was in the range 2,0mm to 11,2 mm (mean 5,05 mm ± 2.13). The dome to neck ratio was range form 0,68 to 3,11. 6 patients was treated for unrupted aneurysm and the remaining 45 patients presented with a subarahnoid hemorrhage. The material used compose Matrix, Axium and Microvention coils with Hyperform or Hypergline baloon.
Results: In the 51 aneurysm treated, 36 cases by using the coils and 12 cases by assitted remodelling technique with Hyperform and 1 case by using Hyperglide balloons, 2 cases by Stent assiited, immediated angiographic result consisted of total occulsion 48 case (94,1%) and partial occlusion in 3 case. There was 3 procedure related complications with thombos post-operation and no fatal. Except this 3 patients, most of patient were successfully resolved without neurologic deffecit (18 cases – 94,1%). At follow up, 2 patients was with mRS 3 (3,9%), 1 patients was with mRS 4 and 48 case was were independent at follow up ( modified Rankin Scale score < or =2). Total 14 case was followed by MRA (6 months to 1 year after the procedure), 4 case presented with focal recanaliztion with coils compaction at the neck. 1 case was rehemorhage and treated repeatly by coils.
Conclusion: Using coils with assisted balloon or stents in endovascular treatment is a safe and effective for middle cerebral artery aneurysm.
interv neuroradiol. 2014 Apr 4;20(2):161–162.
Introduction: Aneurysms of the posterior cerebral artery (PCA) are rare, and most of the literatures reported in which the endovascular approach was applied. We retrospectively reported our some cases of PCA aneurysms for the treatment options and outcomes.
Materials and Methods: From March 2002 to December 2013, 11 patients (eight females and three male) with 11 PCA aneurysms (six saccular and five dissecting) were treated using the endovascular approach in two medical centers. Of the 11 patients, two presented with intracranial hemorrhage (ICH) with intraventricular hemorrhage (IVH), and five patients presented with subarachnoid hemorrhage. The aneurysms were asymptomatic in the remaining four patients.
Results: All 11 patients were successfully treated, with only one intraprocedural aneurysmal rupture. Coil embolization was used for saccular aneurysms to save parent arteries in seven cases, and coil embolization in combination with parent artery occlusion was used for dissecting aneurysms at above P2 segment in four cases. Eight patients got a score of the modified Rankin score 0, one patient got a score of 4; We lost two patient with lesion at the P3 segment was presented with ICH and IVH.
Conclusion: Posterior cerebral artery aneurysms can be treated safely with either occlusion of the aneurysm together with the PCA or with a selective coil embolization. Postoperative infarctions may be develop, but they are rarely presented a critical symptoms.
interv neuroradiol. 2014 Apr 4;20(2):162.
Background: The Enterprise stent is being increasingly used for endovascular treatment of complex intracranial aneurysms. The purpose of this study was to evaluate delayed thromboembolic complications after Enterprise stent-assisted embolization of unruptured intracranial aneurysms.
Methods: From December 2008 to May 2011, 125 patients with a mean age of 56.1 years underwent endovascular treatment of 126 unruptured intracranial aneurysms using the Enterprise stent. Clinical data and radiological findings were reviewed retrospectively to investigate delayed thromboembolic complications defined as ischemic stroke, transient ischemic attacks, and vessel occlusion that developed > 6 months of dual antiplatelet therapy.
Results: During a mean follow-up of 32.4 months, delayed thromboembolic complications occurred in 9 patients (7.2%) while on single antiplatelet therapy (n=5, 10-20 months after embolization) or after discontinuation of antiplatelet therapy (n=4, 6-14 months after embolization). Multivariate analysis showed that discontinuation of antiplatelet therapy (p<0.000; hazard ratio, 23.347; 95% CI 4.25-128.35) and smoking (p=0.030; hazard ratio, 11.372; 95% CI, 1.27-101.98) and were independent risk factors of delayed thromboembolic complications.
Conclusion: Enterprise stent-assisted embolization poses a significant risk of delayed thromboembolic complications, even after 6 months of dual antiplatelet therapy. The appropriate regimen and duration of antiplatelet therapy needs to be determined.
interv neuroradiol. 2014 Apr 4;20(2):162.
Background and Purpose: Peripheral cerebellar artery aneurysms are rare and difficult to treat surgically. The aim of this retrospective study is to report the clinical presentation, aneurysm etiology, and results of endvascular treatment.
Materials and Methods: Between 1998 and 2013, 13 patients with peripheral cerebellar aneurysms were referred to our department. The patients consisted of one man and 12 women with mean age of 55.9 years (range, 16-81years). Locations of aneurysms were as follows: superior cerebellar artery (SCA) in 2 cases, anterior inferior cerebellar artery (AICA) in 3 cases, and posterior inferior cerebellar artery (PICA) in 8cases.
Results: Twelve patients presented with subarachnoid hemorrhage with or without cerebellar hematoma. In one patient, the aneurysm was diagnosed incidentally. Etiology of these aneurysms were as follows: arterial dissection in 3 cases, arteriopathy in 3 cases, embryological factors in 3 cases, flow related aneurysm in 1 case, and unknown in 3 cases. Treatment of these aneurysms were as follows: selective aneurysm occlusion using coils in 4 cases, aneurysm with parent artery occlusion using coils / NBCA in 6 cases, and proximal occlusion using coils in 3 cases. In all cases, complete aneurysm occlusion was achieved.
Conclusion: The endovascular approach to treat peripheral cerebellar artery aneurysm by selective embolization or parent artery occlusion was feasible, safe and effective.
interv neuroradiol. 2014 Apr 4;20(2):162–163.
Purpose: Basilar artery (BA) dissections are rare lesions associated with significant morbidity and mortality.In a patient with hemorrhagic BA dissection, rebleeding rate is very high as much as 25% in the acute phase and the reported case fatality rate was about 20%. The treatment options for BA dissections would differ significantly from those for vertebral artery dissections and there are several treatment modalities including conservative management with BP lowering, open surgery with or without bypass, and endovascular treatment with stent(s) application with or without coiling. In dissecting aneurysms, stents have role of keeping the dissected intimal flap closed until healing with neointima.
Material and Methods: We reported 4 cases with hemorrhagic BA dissection. All cases was treated with endovascular treatment using stent(s) with or without coiling. Age (mean age:43), sex (2:2), cause (spont:3, trauma:1), rebleeding prior to treatment (1), and treatment modalities were reviewed. Two cases received stent only management and the remnant two cases was treated with stent application with coiling.
Results: All patients had clinical improvement compared with initial clinical symptom.One patient whose initial mentality is semicomatous, is quadriplegic status with drowsy mentality due to pontine infarction. In this patient treated with a stent with coiling, aneurysmal dilatation was recurred and additional coiling was done 2 months later. Rebleeding after treatment did not occurred in all cases. The patient with the longest F/U period (7 years) had a large amount of neointimal formation, causing mild compression of the brain stem.
Conclusion: Even though there are many controversies about the treatment of hemorrhagic BA dissection, endovascular treatment with stent(s) with or without coiling can be a good modality. Because the patients have a high rate of rebleeding in the acute phase, the treatment should be done as soon as possible.
interv neuroradiol. 2014 Apr 4;20(2):163.
Purpose: The purpose of our study is to report immediate and follow up angiographic and clinical results of endovascular treatment of 46 cases with intracranial vertebral artery dissecting aneurysms.
Material and Methods: Between July 2002 and September 2013, 46 cases in 42 patients with intracranial vertebral artery dissecting aneurysms were treated by endovascular approach. The patients were 23 males and 19 females and 36 to 80 years old (mean : 52.7 years old). 16 Cases were ruptured, 2 cases were symptomatic lesion without hemorrhage and 28 cases were incidental finding. Endovascular treatment strategies were consisted of internal trapping in 25 cases. stent-assisted coil embolization in 14 cases, coil embolization without stent in 2 cases and stent insertion without or failed coil embolization in 5 cases.
Results: Immediate angiography demonstrated parent artery occlusion by internal trapping in 25 cases, complete occlusion (7 cases), remnant sac (8 cases), remnant neck (1 case) by coil embolization with or without stent and stent insertion state with decreased flow into the aneurysmal sac in 5 cases. Post-procedural complications were developed in 8 cases. Lateral medullary infarction was noted in 3 cases, and embolic infarctions were noted in 2 cases. Unintentional occlusion of parent artery in 1 case, occlusion of PICA in 1 case and dissection of parent artery in 1 case were noted. Imaging follow up was obtained in 29 cases and revealed parent artery occlusion after internal trapping in 18 cases, antegrade recanalization after internal trapping in 2 cases, complete occlusion with vessel remodeling after coil embolization in 5 cases, recanalization after coil embolization in 2 cases and decreased sac size after stent insertion in 2 cases. Clinical follow-up at 3 month after embolization with modified Rankin Scale was obtained in 37 out of 42 patients. 23 patients had 0 point. 1, 3 and 5 point had 3 patients respectively. 2 and 4 point had 1 patient respectively. 3 patients were expired.
Conclusion: Endovascular treatment for intracranial vertebral artery dissecting aneurysms appears to be safe and effective. Follow up angiography revealed various changes after the initial endovascular treatment by the disease characteristics of dissection.
interv neuroradiol. 2014 Apr 4;20(2):163–164.
Background and Purpose: Management strategies for unruptured intracranial aneurysms (UIAs) are controversial. This study aimed to identify surrogate parameters that highly predict the rupture risk of small (<5 mm) UIAs.
Methods: Radiological data were collected from 854 patients with aneurysmal subarachnoid hemorrhages who were enrolled in the Sapporo SAH Study. They had a total of 854 ruptured intracranial aneurysms and 180 UIAs. The size, aneurysm-to-vessel size ratio, and distribution were precisely compared between ruptured intracranial aneurysms and UIAs.
Results: For all aneurysms, the size was significantly larger in ruptured intracranial aneurysms (7.0±1.3 mm) than in the UIAs (3.7±1.2 mm; P<0.001). Size ratio was also significantly higher in ruptured intracranial aneurysms (4.3±1.9) than in the UIAs (2.2±1.6; P<0.001). Multivariate logistic analysis showed that size and size ratio were correlated with aneurysm rupture. However, in small aneurysms, multivariate logistic regression revealed that only size ratio was associated with ruptured aneurysms (P=0.008; odds ratio, 9.1). There were no significant differences in size or aneurysm location. A receiver operating characteristic analysis was performed for size ratio in small aneurysms, and the threshold separating ruptured and unruptured groups was 3.12 and the area under the curve was 0.801.
Conclusions: This study revealed that the size ratio, and not the absolute size, may highly predict the risk of rupture in small UIAs. Size ratio measurements are very simple and provide useful information for determining treatment and follow-up strategies for patients with small UIAs.
interv neuroradiol. 2014 Apr 4;20(2):164.
Purpose: To report the results of patients with unruptured intracranial aneurysms undergoing endovascular embolization under conscious sedation.
Methods: Recent four years, the authors performed 245 procedures and treated 250 aneurysms. Sixty men and one-hundred eighty four women, average age was 61.0 years old. General anesthesia or procedural sedation and local anesthesia was selected according to the patient’s condition.
Results: One-hundred two procedures were performed under conscious sedation and local anesthesia (LA). The proportion of LA was increased from the year 2009 to 2013 (8.3%, 12.8%, 22.2%, 50.0%, 72.9% in each year). The proportion of LA in each location of aneurysms were 71.4%(VA), 54.5%(IC-anterior choroidal), 48.4% (IC-paraclinoid), 20.0% (MCA) and 15.4% (BA). The proportion of LA in each embolization techniques were 25.0% (balloon assist), 48.0% (stent assist), 54.5% (simple technique) and 88.9% (trapping and proximal artery occlusion). Peri-procedural ischemic events were observed in 2.9% (3/102) in the LA group and 3.5% (5/143) in the general anesthesia (GA) group. Morbidity at 6 months were 1.0% (1/102) in the LA group and 1.4% (2/143) in the GA group.
Conclusion: Endovascular embolization under conscious sedation (local anesthesia) can be effectively performed in most patients with unruptured intracranial aneurysms. Appropriate selection of the anesthesia is most important for safe treatment.
interv neuroradiol. 2014 Apr 4;20(2):157.
Purpose: Recently, platinum coil less than 1.5 mm (Target® NanoTM coil) has been used increasingly for finished or packing coils of the tiny aneurysms unfeasible to coiling with usual coils. According to the use of Nano coils, we evaluated radiological outcome and the packing density in tiny aneurysms (size <4 mm diameter) retrospectively.
Material and Methods: Between January 2012 and November 2013, coiling was perfomed in 132 patients with 137 tiny aneurysms. After March 2013, coiling with Nano coils was performed in 49 tiny aneurysms (31.6%).
Results: There was no symptomatic procedural complication except one lesion (thromboembolism, 0.7%). No procedural mortality developed. There were no statistical differences of the size of the aneurysms, locations of the aneurysms, age of the patients, procedural modalities, and radiological outcomes between two groups.
Packing density of coiling with Nano coils was 31.53% (SD, 9.68) higher than the packing density of coiling with no Nano coils (30.11% ± 7.46) without statistical significance.
Conclusion: In the tiny aneurysms, coiling with Nano coils resulted in no statistical benefits of radiological outcome or packing density.
interv neuroradiol. 2014 Apr 4;20(2):164–165.
Background: Stent-assisted coil embolization is useful for wide-necked, large and giant aneurysms, and is effective for avoiding coil herniation. However, the mobility of the microcatheter is often restricted, resulting in deviated or unbalanced coiling. In order to prevent this insufficient coiling, the authors devised a method for microcatheterization, the ‘one and a half round microcatheterization technique’. This technique is based on the formation of a one and a half round loop by the microcatheter along the aneurysmal wall. Furthermore, this technique can be supplemented with the double-catheter technique.
Methods: From July 2007 to July 2013, the authors used this technique for 25 aneurysms in 25 patients (8 men and 18 women; mean age 62.0 years). The one and a half round microcatheterization technique was used alone in 17 cases and was supplemented with the double-catheter technique in eight. The clinical and angiographic results were retrospectively evaluated.
Results: The average aneurysm size was 15.7 mm; 15 aneurysms (60%) were located at the internal carotid artery, 5 (20%) at the basilar artery and 5 (20%) at the vertebral artery. Immediate angiographic results showed complete obliteration in 10 aneurysms (40%) and residual neck in 11 (44%), leaving 4 residual aneurysms (16%). This technique was useful and acceptably safe for packing the aneurysmal sac entirely. During an average follow-up of 19.1 months, 10 of the 20 aneurysms (50%) were stable or had improved, although 3 (15%) required retreatment.
Conclusions: The one and a half round microcatheterization technique provides dense coil packing for stent-assisted embolization of large or giant aneurysms.
interv neuroradiol. 2014 Apr 4;20(2):165.
Objective: We used double catheter technique (DCT) for very-broad-neck ruptured aneurysms for which balloon neck plasty technique is inappropriate. We analyzed our clinical result and discussed the adequacy of our strategy which was to avoid stent assisted technique in acute phase of subarachnoid hemorrhage.
Material and Methods: Fifteen patients with 15 aneurysms underwent embolization with DCT between 2008 and 2013. The most frequent locations were IC-PC and BA tip. The mean size of aneurysms in maximum diameter was 10.8 (3-24) mm. The mean dome-neck ratio was 1.1 (0.65-1.4). We studied the occlusion grade, perioperative complication, mRS at 90 days and recurrence in follow-up.
Result: At initial treatment, 7 aneurysms resulted in complete occlusion or neck remnant. Although the remaining 8 aneurysms were recognized slow body filling, re-bleeding was not found. In 2 cases, asymptomatic infarction due to coiling was found. The ratio of mRS 0-2 was 88% and 29% among the patients with Hunt & Hess grade 2-3 and 4-5. Among 3 basilar aneurysms, recurrence was found and 2 aneurysms were retreated with stent-assisted coiling resulted in 1 further recanalization.
Conclusion: The embolization with DCT for ruptured very-broad-neck aneurysms was effective and safe. Although stent-assisted coiling for recurrent aneurysm in chronic stage was effective, the large thrombosed aneurysm need parent vessel occlusion or the application of flow-diverting stent.
interv neuroradiol. 2014 Apr 4;20(2):165–166.
Objective. To evaluate primary results of flow diverter stent in treating intracranial aneurysms.
Material and Method:7 patients with unruptured wide neck saccular or fusiform intracranial aneurysms were treated with Pipeline flow diverter stent (Covidien, USA). Immediate results and follow up were evaluated with clinical symptom, MRI and DSA.
Results: 7 patients (3 male and 4 female), aged from 34 to 63 (average 51.4, SD 8.8), with 8 unruptured aneurysms in which 7 are wide neck saccular (87.5%) and 1 is fusiform (12.5%). Diameter of aneuryms ranges from 6.5 to 15.8 mm (average 10.6 mm, SD 4.2). There are 7 lesions (87.5%) locating at internal carotid system and 1 lesion (12.5%) at vertebrobasilar system.
Pipeline stent was the unique device used for all aneurysms. Pipeline stent length ranges from 16 to 25 mm, diameter from 4.0 to 4.75 mm. Technical success gained in 100% of cases without complications. Contrast medium stagnation inside aneurysms were observed in all 8 lesions. 1 patient suffered from ipsilateral mild ischemic stroke at the 3rd day post intervetion due to cessation of antiplatelet drugs, totally recoverd with intensive medical treatment. During follow up time from 2 to 24 months (average 9.1 months), there are no complications occurred. Post-intervention MRI and DSA were done for 5 patients showed total occlusion in 4 aneurysms (80%) at 3 months and in all 5 aneurysms (100%) with normal flow in parent arteries, no distal emboli, no ipsiletaral infarction evidence.
Conclusion: Primary results of using flow diverter stent Pipeline shows high efficacy and safety in treating unruptured intracranial aneurysms.
interv neuroradiol. 2014 Apr 4;20(2):166.
Those two presentation are about the usage of braided stent (regular one and the flow diverter) in the treatment of brain aneurysm. Our one year of experience with the new Baby Leo stent in the treatment of brain aneurysms, mainly complex, will be given with data concerning the stent, its pro and cons and the complication rate - permanent deficit nearly zero at that period. Short term imaging follow-up in part of the group shows promising results with protected aneurysm in most of cases. Example cases will be shown with explanation about the stent and the technique. The second part will be on the mid and long term experience with flow diverter the Silk.
Our experience with near 60 cases of patient harboring 67 aneurysms treated with silk for different type and size of aneurysm will be given. Those cases were treated in the last 5 years mainly for big and giant aneurysms. Type of aneurysms, location, and rate of clinical and technical complications will be given and follow up. This series is one of the largest concerning that flow diverter from a single institution.
interv neuroradiol. 2014 Apr 4;20(2):166.
Background and Purpose: Endovascular treatment is a method to prevent aneurysms from re-rupturing. Our aim in this study was to assess the efficacy of endovascular treatment on cerebral ruptured aneurysms.
Method: A prospective analysis of 64 hemorrhagic stroke with 69 aneurysms. Angiographic follow-up at 3; 6; and 12 months after treatment.
Results: Complete occlusion 67.6%; good outcome 78%; recurrence 5.9%. Conclusion: endovascular treatment was a effective method for cerebral aneurysm.
interv neuroradiol. 2014 Apr 4;20(2):166.
Background and Purpose: Endovascular treatment has been widely recommended as a standard treatment for cerebral aneurysm. However, the experience in Vietnam is still limited. We report the prospective case series of endovascular treatment at 2 military hospitals.
Method: A prospective analysis of all patients with endosaccular coil occlusion aneurysms collected from June 2008 to April 2011. Long-term follow-up angiograms for 36 months.
Results: There were 110 patients with 127 aneurysms. Clinical characteristics: severe headache 96.4%, nausea and vomiting 95.5%, conscious disorder 65.5%, Warning leak 48,2%. Complete occlusion 89.7%, incomplete occlusion 8.4%. Outcome (12 months after discharge): good 94.8%, bad 5.2%, death 8.4%. Rebleeding 40%. Recurrence 13%.
Conclusion: Endovascular treatment was safe and effective.
interv neuroradiol. 2014 Apr 4;20(2):166–167.
In treating ruptured vertebral artery dissecting aneurysms (VADA), neuroendovascular therapy (NET) represented by coil obliteration is considered to be a reliable intervention. However, there has been no multi-center based study in this setting so far. In this article, results of NET for ruptured VADA obtained from JR-NET (Japanese registry of neuroendovascular therapy) 1 & 2 were assessed to elucidate the factors associated with favorable outcome. A total of 213 in JR-NET 1 and 381 patients in JR-NET 2 with ruptured VADA were included, and they were separately analyzed because several important datasets such as vasospasm and site of dissecting aneurysms in relation to the PICA were only collected in JR-NET 1. The ratio of poor WFNS grade (4 and 5) was 48.8% and 53.9%, and the ratio of favorable outcome (modified Rankin scale 0 to 2) at 30 days after onset was 61.1 % and 49.1% in JR-NET 1 and 2, respectively. In both studies, poor WFNS grade and procedural complication were independently correlated as negative factors for favorable outcome. In JR-NET 1, PICA-involved lesion was also designated as a negative factor while elderly age and absence of postprocedural antithrombotic therapy was detected as other negative factors in JR-NET 2. The ratios of favorable outcome in poor grade patients were 25.4% in JR-NET 1 and 31.3% in JR-NET 2, which seemed compatible with the previous studies. These results may provide a baseline data for the NET in this disease and could be useful for validating the benefits of novel devices.
interv neuroradiol. 2014 Apr 4;20(2):167.
Unruptured intracranial aneurysms (UIAs) in elderly patients are increasingly diagnosed due to the development of less invasive and high-quality neuroimaging modalities. The purpose of this study was to report the treatment results of endovascular therapy of asymptomatic UIAs in patients aged 80 or older. From August 2003 through November 2013, a total of 1057 patients with 1133 asymptomatic UIAs underwent endovascular therapy at Juntendo University Hospital and affiliated hospitals. Among those, 27 patients with 29 aneurysms comprised the patients of this study. Twenty-five aneurysms were located in the anterior circulation. Frequent locations were the internal carotid and anterior cerebral arteries. The sizes of the aneurysms ranged from 2.0 to 10.5 mm in maximum diameter, with a mean size of 5.4 ± 2.3 mm. All procedures were completed. Immediate angiographic outcomes were complete occlusion (12), residual neck (1), and residual aneurysm (16). Procedure-related complications with clinical modification occurred in 1 patient, who suffered from aneurysm rupture on the day of treatment. Eleven patients underwent anatomic follow-ups with magnetic resonance angiography or conventional angiography >179 days after endovascular therapy. Their mean anatomic follow-up period was 20.5 ± 18.1 months, and the radiological follow-up results were: unchanged (3), improved (7), and minor recurrence (1). The overall mean clinical follow-up period was 23.9 ± 30.7 months (range: 10 days – 10.2 years). No patients underwent retreatment. In conclusion, endovascular therapy for patients aged 80 or older is safe and feasible.
interv neuroradiol. 2014 Apr 4;20(2):167–168.
Introduction: Traditional stent-assisted embolization of intracranial aneurysms required delivery catheters typically larger than the coiling and balloon catheters, which are also more difficult to access distal circulation.
Objective: We assessed the application of a low profile stent system for stent-assisted embolization of ruptured distal intracranial aneurysms.
Methods: We retrospectively reviewed and identified these patients over the past three months from our hospital records.
Results: Five patients underwent stent-assisted embolization of ruptured distal intracranial aneurysms using a low profile stent system (LVISTM Jr. Device, Microvention). The aneurysm locations were anterior cerebral artery (2), middle cerebral artery (2), and posterior cerebral artery (1). All aneurysms were completely occluded at the time of treatment and last radiological follow up. One patient developed intracerebral hemorrhage at a vascular territory different from the offending vessel. All patients achieved favorable neurological outcome at last follow-up (mRS 0-2).
Conclusions: A low profile stent system provided a safe and feasible way for stent-assisted embolization of ruptured distal intracranial aneurysms.
interv neuroradiol. 2014 Apr 4;20(2):168.
Aim: To study the angiographic results of using PipelineTM embolization device (PED) as a primary treatment option for intracranial aneurysm
Method: Patients with intracranial aneurysms treated with PED from January 2008 to August 2013 in the Department of Neurosurgery, Queen Mary Hospital, HKSAR, PRC were included. The medical records and angiograms were studied retrospectively. Aneurysm obliteration was the primary end point. Procedural related complications were studied, too. Factors related to rate of complete obliteration and complications were analyzed.
Results: 55 consecutive patients with 61 PED insertion procedures were identified in the study period. The mean age was 58.1 (32-83) years old. 17 out of 55 patients were men. The mean follow-up duration was 27 (1-27) months. Complete aneurysm obliteration was achieved in 41/61 (67.8%) of patients by early angiogram within 6 months. An addition of 7 complete obliterations was achieved in late follow-up imaging, resulted in long term obliteration rate of 78.7%. There were 14/61 (22.6%) procedural related complications, of which 4/61 (6.6%) resulted into permanent deficit. One procedural related mortality was found.
Conclusion: PED is an effective treatment option for intracranial aneurysm. Knowing the factors related to complete obliteration and complications helps to select patient for the procedure.
interv neuroradiol. 2014 Apr 4;20(2):168.
Purpose: Carotido-ophthalmic aneurysms (COA) are challenging lesions often prone to recanalisation after endovascular treatment. Flow diversion (FD) is emerging as a new endovascular strategy for the treatment of these aneurysms, its goal being virtually to achieve a stable aneurysm occlusion on a long term basis. We sought to compare angiographic outcome and complication rates in two groups of patients treated by standard coiling (SC) or FD at our institution over 6 years.
Methods: From February 2006 to December 2012, 40 unruptured COA’s subdivided into 2 consecutive cohorts, were treated endovascularly in 38 patients, 9 of which were symptomatic. Twenty-six COA’s were treated by SC. Balloon-assisted technique was employed in 8 cases, stent-assistance in 5 cases. Flow diverters were deployed in 18 previously untreated unruptured aneurysms starting June 2009. Additional coiling was performed in 4 cases. Imaging follow-up was carried out by 3D TOF MRA and DSA at 6 months at 12 months respectively, then 3D TOF MRA on a yearly basis.
Results: Mean follow up was 59.2+/–35.6 months.. No death or permanent morbidity was observed. One thromboembolic event (3.8%) causing transient neurologic motor deficit occurred in the SC group within 6 hours after the procedure. One homolateral intra-parenchimal hemorrhage (5.6%) was observed 10 days after procedure in the FD group, causing transient aphasia and contralateral monoplegia. Clinical outcome was good in all patients. No statistical significance was found in term of difference in complication rates (p=0.08). No cases of rebleeding were observed during follow-up. Partial recanalisation was observed during follow-up (mean 65.3+/-27.1 months) in 12 (46.3%) COA’s treated by SC (6 neck remnants and 6 residual sacs), leading to re-treatment in 5 (19.2%). Of the 5 aneurysms coiled by stent-assisted technique, 2 recanalised at 1 year. One incompletely treated aneurysm didn’t show any increase in the size of the circulating portion over 38 months. In the FD group (mean follow up time 37.2+/–25.4), 10 COA’s showed complete thrombosis within 6 months, 15 within 12 months. No recanalisation was observed after thrombosis had occurred. One small (5mm) wide-necked aneurysm remained patent at 24 months and required re-treatment by a second flow diverter. The difference between the two groups in term of recanalisation at follow-up was statistically significant (p=0.0004) even when considering only sac remnants in the SC group (p=0.002).
Conclusion: Though conducted on a small sample and in a particular subset of aneurysms, this retrospective analysis shows better stability of aneurysmal thrombosis after use of FD compared to SC. The introduction of flow diverters may probably increase the rate of long-lasting complete angiographic occlusion in COA’s. However, larger samples and long term follow-up for FD are needed to better assess complication rates and stability of treatment results.
interv neuroradiol. 2014 Apr 4;20(2):168–169.
Purpose: To evaluate the results and complications of a relatively recent flow diverter stent in the treatment of intracranial aneurysms.
Materials & Methods: Twenty-five Surpass stents deployed in 20 patients with 24 unruptured or recanalized aneurysms. Angiographic, clinical and MR results were evaluated immediately after the procedure, at 3-6 months and at 1 year Follow-Up
Results: Succesful deployment of the device was observed in all cases. No morbidity was observed in this series. One patient with a giant aneurysm died from the aneurysm rupture five days after the treatment. At this time, follow-up data at 1 year FU are under analysis. Xper-CT or DynaCT were performed in all cases showing the correct deployment of the stent.
Conclusion: Although more experience and follow-up are needed in order to evaluate the Surpass stent, this device appears efficient and relatively safe for the treatment of aneurysms in which the use of a flow diverter stent is indicated.
interv neuroradiol. 2014 Apr 4;20(2):157.
Purpose: pCONus is a self-expanding, completely retrievable, electrolytically detachable device with a proximal shaft (similar to stents) and four distal petals with a nylon cross in the distal end of the shaft allowing a safe deployment of coils. In case of wide neck intracranial bifurcation aneurysms, this device is an alternative to Y or X stenting or remodeling technique using two balloons. The device looks like a “waffle cone” stent and intraneurysmal part is similar to the no longer available TriSpan Neck Bridging Device. The extraneurysmal stent portion is similat to the solitaire stent. The purpose of this study was to evaluate the safety and efficacy of this new device for the treatment of intracranial wide neck bifurcation aneurysms.
Materials & Methods: Our series include 18 consecutive patients with an unruptured aneurysm treated using the pCONus device. Four cases were recanalized aneurysms.
Results: Succesful deployment of the device was observed in all cases. No hemorrhagic or ischemic complications were observed. One patient had a groin hematoma. After the initial embolization procedure, a 90 to 100% occlusion rate was achieved in all cases but a neck remnant was evident in 3 patients. Follow-up data at 6 months showed good results in all case except in one recanalized aneurysm.
Conclusion: The pCONus device allows a safe coil occlusion of wide neck bifurcation aneurysms. Although more experience and longer follow-up are needed in order to evaluate the pCONus System, this device is an interesting alternative in the treatment of wide neck intracranial aneurysms.
interv neuroradiol. 2014 Apr 4;20(2):169–170.
Purpose: Endovascular coil embolization is a prompt and effective treatment of ruptured cerebral aneurysms patients. But until now there is no report, immediate surgical decompression craniectomy (DC) after endovascular coiling is as effect treatment modality compared with DC with surgical clipping, for poor grade subarachnoid hemorrhage (SAH; Hunter Has grade 4~5) patients. Authors tried to compare the therapeutic effect of the decompression surgery after clipping and endovascular coiling.
Materials and Methods: We analysis our SAH due to intracranial aneurysm ruptured patients’ data retrospectively. From April 2003 to March 2012, DC after endovascular coiling undertook in 22 patients (coiling group) and after surgical clippings undertook in 21 patients (clipping group) were included in this study. All these patients undertook ventricular puncture and DC as an initial treatment, and monitored intracranial pressure (initial and post-operation 72 hours). The clinical outcomes of the patients were complications.
Results: Patients demographic features such as sex, age, initial Hunter-Hass and Fisher score distribution were statistical no significant difference (p<0.05), between two groups. Patients outcomes, such as mortality, unfavorable (mRS 1-3) and favorable outcomes (mRS 5~4) were show no statistical difference (p>0.05). And total anesthesia time (in coiling group: coiling time plus surgery time) was also similar (p<0.05).
Conclusion: This study results shows that in poor grade SAH patients, final clinical outcomes of the DC after endovascular coiling or surgical clipping, was similar therapeutic results. Authors would like to propose that DC after endovascular coiling in poor grade SAH patients could be a another therapeutic option.
interv neuroradiol. 2014 Apr 4;20(2):170.
Background and Purpose: Delayed intraparenchymal haemorrhage is a poorly understood complication of treatment of intracranial aneurysms by flow-diverter stents. Stroke with subsequent haemorrhagic trans-formation has been suggested as a potential aetiology. This exploratory study aimed to assess the rate of new susceptibility Weighted imaging (SWI) lesions identified on magnetic resonance imaging after flow-diverter stent treatment and the association with asymptomatic brain infarction identified on diffusion weighted imaging (DWI).
Material and Methods: We performed a single centre retrospective review of clinical and radiology databases to identify all intra-cranial aneurysms treated electively with flow-diverter stents between March 2009 and December 2013. Additional inclusion criteria were pre and post treatment MRI, including immediate day 1 post-treatment MRI with DWI and SWI sequences. New SWI lesions were identified on both immediate and delayed (up to12 month) post-treatment MRI and categorized into stented and non-stented vascular territories. The relationship between a new SWI lesion occurring in a stented or non-stented territory was analyzed using Fisher’s two-tailed exact test. SWI lesions occurring after the immediate post-treatment MRI were also compared to immediate post-treatment DWI to determine whether these had occurred in areas of previous asymptomatic infarction.
Results: A total of 12 treatments in 10 patients satisfied all inclusion criteria. All were treated with the SILK flow-diverting stent (Balt Extrusion, Montmorency, France); all received pre and post-treatment aspirin and clopidogrel. A single stent was placed in the majority of treatments (n=10; 83%). Two patients received bilateral stents. At least one new post –treatment SWI lesion was identified after 8 (67%) treatments. There was a significant difference in the rate of new SWI lesions in the stented vascular territory compared to the non-stented vascular territory (67% vs 17%; p=0.036). In three treatments (25%), at least one SWI lesion had occurred in an area of previous asymptomatic infarction on DWI; all occurred in stented vascular territories.
Conclusions: Our exploratory study suggests that new post-treatment SWI lesions are common after elective treatment of intracranial aneurysms by flow-diverter stents, particularly in the stented vascular territory. Some may relate to haemorrhagic conversion of asymptomatic brain infarction. To better understand the occurrence and pathophysiology of these post-treatment SWI lesions, a larger prospective study is warranted.
Correspondence: Ronil V. Chandra, Neurovascular Surgery, Department of Radiology, Monash Health Department of Surgery, Monash University; Melbourne, Australia
interv neuroradiol. 2014 Apr 4;20(2):170–171.
Introduction: Flow diverters enable intracranial aneurysmal repair without the need to enter the aneurysm sac. Concerns however have been raised regarding the cost compared to coiling techniques. The aim of this study was to evaluate the relative costs for different aneurysm sizes to ascertain if different sizes are more cost-effectively treated by a particular method.
Methods: Patients undergoing aneurysmal repair at two neurovascular referral centres between September 2005 and August 2010 were included, bar patients who underwent coiling for recurrences of prior microneurosurgical clipping. These aneurysms were stratified into three size groups. The average and median number of coils or flow diverters and the average and median costs of treatment of each size category was calculated.
Results: 429 aneurysms were treated. Of these, 409 were coiled with or without assist devices. 48% fell under Group A (<7 mm), 36% under Group B (7-12mm) and 16% under Group C (>12 mm). 20 aneurysms were flow diverted. Of these 14 were treated de novo, 5 previously coiled, and one previously clipped. 20% belonged in Group A, 25% in Group B and 55% in Group C. The highest procedural costs in the coiling group were Group C aneurysms requiring stent assistance with an average of $ 24,563 (median $ 23,860). Using flow diversion, the average was $ 24,650 (median $ 16490).
Conclusion: Given the price parity threshold crossed for aneurysms >12mm requiring stent assistance and the relative ease of the flow diverter technique, we suggest that flow diversion should be considered the first-line treatment for aneurysms in this category.
interv neuroradiol. 2014 Apr 4;20(2):171.
Background: Endovascular treatment of intracranial aneurysms via flow diversion has become increasingly popular over the past several years. The flow redirection endoluminal device (FRED; Microvention, Tustin, California, USA) system is a next generation closed cell paired stent flow diversion device.
Objective: Our initial clinical experience with the FRED system is described. We believe this series to be the first use of the FRED system in South East Asia.
Methods: 10 aneurysms were treated utilizing the FRED system in patients. Post-deployment angiography and fluoro CTs were obtained in all cases.
Results: Immediate post-treatment angiography demonstrated reduced flow into all aneurysms although no long term angiographic data are yet available. The device proved technically easy to deploy and recapture after partial deployment if needed. One technical complication was encountered which illustrated an important characteristic of the device. No other complication technical or otherwise, were encountered. Radiographic visibility and ability to maintain its internal cylindrical shape in tortuous arteries, as demonstrated by fluoro CT, was at least as good as the pipeline embolization device.
Conclusions: The FRED system was technically easy to deploy with only one procedural complication occurring in this first reported series of 10 aneurysms. The ability of the FRED system to be recaptured after partial deployment and to maintain its internal shape in tortuous vessels was demonstrated well.
Long term clinical and angiographic follow-up along with prospective studies are now needed to ascertain the role of the FRED in intracranial aneurysm treatment.
interv neuroradiol. 2014 Apr 4;20(2):172.
Purpose: In order to evaluate clinical influence of posterior fossa dural sinus occlusion in the patients with a vein of Galen aneurysmal malformation (VGAM), and the effect of embolization on its natural course.
Materials and Methods: We retrospectively reviewed 61 consecutive patients (33 males and 28 females including 19 newborns, 34 infants, and 8 children) with VGAM who were referred to our center between 2005 and 2012 and performed angiography.
Results: Twenty patients (32.8%) demonstrated unilateral or bilateral occlusion or severe stenosis of the posterior fossa dural sinuses, especially the sigmoid sinus. It was not observed in neonates and initially found during infancy in 13 patients and during childhood in 7 patients. All patients had signs of the hydrovenous disorder. Dural sinus occlusion / stenosis were seen on the initial angiogram in 13 patients and during angiographic follow up in 7 patients. After total or subtotal obliteration of the VGAM by trans-arterial glue embolization, no progression of the sinus stenosis was observed with 7cases of partial recanalization. On the follow up, 7 patients had varying degree of developmental delay, but remaining 13 patients were neurologically normal.
Conclusions: Dural sinus occlusion / stenosis are common observation for VGAM, which cause aggravation of the hydrovenous disorder. Early endovascular intervention with subtotal occlusion of the VGAM seems to prevent progressive dural sinus occlusion and improve clinical outcome.
interv neuroradiol. 2014 Apr 4;20(2):172.
Background:Vein of Galen aneurysmal malformation (VGAM) is a spectrum of disease in the subarachnoid space in the choroid fissure with varying maturation of the vein of Galen. We attempted to create a new classification of this disease.
Materials and Methods: Eighty-seven cases of VGAM were retrospectively analyzed and classified by its location of shunting and flow. They were classified into Choroidal 1 (C1), Choroidal 2 (C2), Quadrigeminal(Q), and Mural (M) types. C1 and C2 are high flow (C1) and relatively low flow (C2) fistulas respectively in the velum interpositum cistern supplied mainly by choroidal arteries. Q is fistulas in the quadrigeminal cistern mainly supplied by quadrigeminal arteries. M are mural fistulas and further classified into choroidal M (CM) and quadrigeminal M (QM) depending on the shunt location either in the velum interpositum cistern (CM) or quadrigeminal cistern (QM), respectively.
Results: There were 32 C1, 13 C2, 18 Q, and 24 M cases. C1 tended to present with neonatal high flow congestive heart failure and was associated with high frequency of residual embryonic falcine sinus. C2, Q, and M tended to present with the hydrovenous disorder after neonatal period, after 1 year old, and during infancy, respectively. Connections of the draining venous pouch with the cerebral veins were observed in 15 cases (47%) in C1, 12 cases (92%) in C2, 18 cases (94%) in Q, and 15 cases (63%) in M.
Conclusions: New classification correlates with vascular anatomy, timing and mode of presentation, frequency of cerebral vein connection, and seem to be helpful to better understand the disease and plan treatment.
interv neuroradiol. 2014 Apr 4;20(2):173.
Purpose: To clarify neuroradiological manifestations of hereditary hemorrhagic telangiectasia (HHT).
Methods: There were 54 men and 49 women, aged 2 to 78 with a mean of 41.1 years old. Diagnosis of HHT was based on either genetic analysis (endoglin or ALK-1) or definite clinical diagnosis of Curacao. There were 53 HHT1 patients, 27 HHT2 patients, 2 patients with definite clinical diagnosis, but without identifiable gene, and 21 clinically definite HHT without genetic confirmation. All patients underwent MR examination at 1.5 or 3.0T without contrast enhancement. Recent patients also underwent contrast MR study. Their MR images were retrospectively reviewed.
Results: Variety of abnormalities were found: vascular malformation (20, HHT1 14, HHT2 1, multiple 12, pial AVF 7, small AVM 7, capillary telangiectasia 13), aneurysm (2), infarction (16), spontaneous hemorrhage (1), abscess (3), brain mal-developmental (1), brain tumor (2), and Mn accumulation in the basal ganglia (39, HHT1 7, HHT2 21). Only 1 spinal AVM was noted among them.
Conclusion: HHT presents with a variety of neuroradiological manifestations, including vascular malformations, infarctions, and brain abscesses. To avoid adverse events, vigorous screening and periodic MR examinations of the brain are warranted.
interv neuroradiol. 2014 Apr 4;20(2):173.
Objectif: To evaluate the Predictive factors for neurological evolution of patients presenting intracerebral hematoma secondary to a brain arteriovenous malformation rupture .
Material and Methods: Retrospective single center study on 59 consecutive patients ( 29 females, 30 males , mean age =41.3 years ) hospitalized in neurosurgical ICU from january 2005 to december 2010 for a ICH secondary to a brain AVM rupture (documented by cerebral angiography , brain CT or MRI or anatomopatholgy). The neurological evolution was evaluated by the mRS (modified Rankin Scale) and GOS (Glasow outcome scale) at more than 1 year ( mean time of follow up =2.9 years). The tested predictive factors were: age, sex, admission GCS (Glascow score), initial CT: location of the hematoma (supra/infra tentorial),volume of the hematoma, presence of intraventricular blood, presence of brain herniation ( uncal and cingulate), level of PS100 at admission, at D7 and the mean PS100 during the hospitalization period.
Results: 16 patients (27,1%) presented a favorable clinical evolution (mRS ≤ 2); 27 patients (45.8%) presented an unfavorable clinical evolution (mRS > 3) and 16 were lost of sight (27.1%). 13 (22.2%) patients deceased during hospitalisation. The factors stastisticaly associated with an unfavorable clinical evolution were : the lowest GCS score before first sedation (P=0.0338 IC 95% [0.23 ; 5.57] ) , the mean PS100 level at admission (P=0.0038, IC95% [0.512 ; 2.448]) and presence of intraventricular blood (P=0.033 OR 5.0731 IC95% [1.0236;28.849]).
Conclusion: The presence of intraventricular blood, the lowest GCS score before intubation , initial PS100 and the mean PS 100 during hospitalisation are significantly associated with a bad clinical prognosis (mRS>2) in patients with ICH following a brain AVM rupture .
interv neuroradiol. 2014 Apr 4;20(2):173–174.
Purpose: Ateriovenous malformations ( AVMs) are the most common variety of intracarnial vascular malformations. The Onyx liquid embolic system (ev3 Neurovascular, Irvine, CA) was recently approved for the treatment of intracranial AVMs.We report the initial experience by using Onyx for embolization of brain arteriovenous malformations (AVMs).
Material and Methods: Between January 2008 and December 2013, 83 patients with brain AVMs were embolized with Onyx at Bach Mai Hopital. There were 34 women and 49 men with a mean age of 25, 56 years (, range 14-71 years). Clinical presentation included seizures in 34 patients (40,91%), hemorrhage from the AVM in 51 patients (61,44%), visual disturbances in 6 patient (7,22%), and in 1 patient (1,2%) the AVM was an incidental finding. Mean estimated size of the AVM was 31,33 cm ± 11,37 (median 4, range 10–55 mm). The Micro Catheters which we used were Sonic, Ultraflow and Apollo.
Results: In 83 patients, 92 embolization procedures were performed with 121 feeding pedicles embolized, ranging from 1 to 4 per patient. Average estimated size reduction was 78,9 ± 24,3 ( range 10%–100%). Total obliteration was achieved in 34 AVMs (40,9 %), and partial embolization was achieved in 49 patients. Complications occurred in 12 patients, leading to death in 3 patient (mortality 2.3%).
Conclusion: Our initial experience suggests that the endovascular treatment of intracranial AVM with the Onyx is feasible, safe, and highly effective, as it allows for a controlled penetration of the embolic agent into the draining vein.
interv neuroradiol. 2014 Apr 4;20(2):174.
Purpose: The purpose of this report is to review our experience for treatment of direct and very high flow intracranial AV fistulas by disconnecting at the AV junction.
Materials and Methods: From 2006 to 2013 among the 180 cerebral AVMs there are six cases with direct and very high flow intracranial AV fistulas. Two males: the first one is 15 years-old and the second is 2 years-old; four females: the first one is 18 years-old, the second is 14 years-old, the third is 10 years-old and the fouth case is 49 years-old. The main symptoms of these patients were seizures and fainting. The direct AV shunt was located in posterior cerebral artery in 2 cases the others two in anterior cerebral artery and one case from dural branch of occipital artery. The draining vein was connected to the vein of Galen in two and draining to the superficial cerebral vein in three and one to tranverse sinus. The first case was treated in 2006 by injection pure glue but failed to stop the AV shunt because of enlargement of the feeder artery and very high flow AV shunt. Then the AV junction was approached with 2 microcatheters and deployed two coils to work together against coil migration to the huge venous pouch. The first coil is play a role of prevention the following coils fly to the venous pouch. When the second deployed coil was stable; it was detached. And then, we continue with next coils using the second microcatheter until we can low down or stop the AV shunt. If coiling alone cannot control the AV shunt; we will inject diluted glue to fix the coils mass and finally the first distal coil was detached.
Results: Six cases of direct and very high flow intracranial AV fistulas were treated successfully by using the double coils technique without any related procedure complication. Clinical symptoms after the procedure had improved dramatically. Follow up clinical is no more seizures and fainting. Follow up angiograms reveal the AV fistulas were cured in all 6 cases and draining venous pouches shrunk themselves.
Conclusions: In our experience, double catheters technique can be performed safely to disconnect the very high flow intracranial AV fistulas. The benefit of this technique is to reduce the amount of coils and eliminate the risks of mass effect or recanalization because we don’t coiling the venous pouch.
interv neuroradiol. 2014 Apr 4;20(2):174–175.
Objectives: The authors analyzed the clinical, neuroimaging outcomes and complications that occur in 6 years of patient with AVM after GKRS, focusing on the analysis of the oblitergation rate depending on the AVM volume and long – term complications.
Methods: Between 2007 and 2012, 730 patients AVMs were treated Gamma Knife radiosurgery (GKRS) at our unit, 401 prospective patients with cerebral AVMs were treated GKRS more than 20 months and follow up by Microsoft Office Access, R tatistical analysis. Of these patients,. Grading depend on diameter: small, medium and large are 250, 142 and 9. The mean age was 30,476 ± 13,48 years (6-76), the mean volume 8,957 ± 13,257 cm3 (0,0187- 135,00 cm3), the mean marginal dose was 21,379 ± 3,04 Gy (13-26), and the mean follow up duration was 41,829 ± 13,59 moths (21,43-72,67).
Results: The angiographic obliteration rate was 77,2% overall, and it was 88,8%, 59,7%, and 22% for small, medium and large AVMs. Respectively, obliterated time 17,186 ± 7,63 (10-48) months. For small, medium AVMs, the obliterated time are 13,863 ± 4,52 months (10-36), 24,649 ± 7,49 months (12-48) months. Have 9 patients hemorrhage, the overall bleeding rate was 2,25%. The bleeding rate was1,2%, 2,7% and 11,1% for small, medium and large AVMs. Have 11 patients with severe brain edema, the brain edema rate overall is 2,7%, this is 1,2%, 6,3% and 0% for small, medium and large AVMs, 2 patient need open surgery to remove severe brain edema.
Conclusions: Gamma Knife radiosurgery is a safe and effective treatment for selected patients with AVMs, and it carries a low risk of first hemorrhage from brain arteriovenous malformations and damaging adjacent critical vascular structures. Complications are acceptable. However, need follow up along time to appreciate obliteration rate and complications.
interv neuroradiol. 2014 Apr 4;20(2):175–176.
Objectives: • Cases demonstration and quiz show; • Brief overview & classification of vascular anomalies; • Spectrum, pathogenesis, genetics & natural history; • Diagnosis & evaluation; • Treatment options and outcomes
Natural history: • Congenital abnormalities; • Dysmorphogenesis; • Present at birth but may not be evident until month or years later; • No gender predilection; • Slow steady growth, no involution; • May expand rapidly secondary to sepsis, trauma or hormonal changes; • Some lesions proliferate and do not fit classification scheme
Clinical manifestation: • Wide spectrum of presentation & anatomic location – Localized or diffuse – Solitary or multiple – Cutaneous and subcutaneous – Involves muscle, joints or bones – Visceral; • Combined with other vascular malformations; • Some types of lesions associated with syndromes or gene mutations
Venous Malformations: Can occur in any location. May be deep or superficial and involve one anatomic region; Seem to enlarge around puberty.
Veno-lymphatic Malformations: Can be huge, deforming & cause severe functional problems; • Venous and lymphatic malformations frequently occur together even though one component dominates.
Lymphatic vesicles: Vascular Malformations: Known Mutations; Glomovenous Malformation (GVM VMCM) Glomulin TIE2 1p21-22 9p21; Mucocutaneous Venous Malformation; Cerebral Cavernous Malformation (CCM 1 2 3); Angiokeratoma Corporis Diffusum; Fabry’s CM-AVM; Blue Rubber Bleb Nevus Syndrome; Maffucci Syndrome; Klippel-Trenaunay and Parkes Weber Syndromes; • Klippel-Trenaunay – Low Flow; – Capillary, venous and lymphatic malformations; – Overgrowth and asymmetry of extremities & trunk; – May show overlap with Proteus Syndrome; • Parkes Weber; – High Flow; Capillary, venous, lymphatic and arterial malformations; Somatic overgrowth common; • Both present difficult therapeutic challenges:
Hematological Complications: • Venous and veno-lymphatic malformations are at an increased risk for hematological and thrombotic complications; – Presumed to be secondary to abnormal blood flow; – Abnormal vascular endothelium leading to abnormalities in coagulation; • Case reports of sudden death due to pulmonary embolism in children and adolescents; • Increased risk of complications after surgical or invasive radiological procedures; • The pathogenesis is poorly understood & incidence is not well-documented; – PTT; – Fibrinogen; – D-dimer; Antiphospholipid Antibody Assessment; Thrombotic Genetic Polymorphisms.
Hematologic Evaluation: 1. Labs; – CBC & Platelet count; – evaluation of blood smear; 4. Thrombotic Profile; • Protein S; 2. Coagulation Labs – PT; Protein C; Antithrombin III; Plasminogen; Modified APC Resistance; Plasminogen Activator Inhibitor; Anti-cardiolipin antibody Lupus anticoagulant.
Genetic Polymorphisms: Thrombosis Risk: It has not been definitively demonstrated that these polymorphisms increase risk of thrombotic complications in children and adolescents with vascular malformations.
Abnormal Thrombotic Risk: • More than 50% of our patients had evidence of abnormal clotting parameters (PT, PTT, D-dimers and FSP), May benefit from anti-thromboembolic prophylaxis treatment with LMWH.
Spontaneous Hemorrhage
Poorly-healing Venous Stasis Ulcers
Pain - Infection
Treatment of Venous and Veno-lymhatic Malformations: • Supportive Treatment, – Compression garments 30mmHg; – Low molecular weight heparin; Aspirin better for arterial lesions; – Avoid estrogen containing oral contraceptives; – Judicious use of systemic antibiotics; – Topical antibacterial soaps; • Sclerotherapy; – Doxicycline; macrocystic lymphatic malformations; Sodiumtetradecylsulfate–venousmalformations; – Bleomycin; • Surgical excision; – Total; – Subtotal; Multiple debulking procedures; • Laser treatment of cutaneous component: selective.
Indications for LMWH: • Hemolytic anemia with elevated d-dimers >1; • Painful recurring thrombotic episodes; • Multiple lesions: deep & cutaneous venous lesions; • Pre and post-operative prophylaxis in patients with elevated d-dimers; – Hemolytic anemia; – ↓ fibrinogen, d-dimer; – Treated with sclerotherapy; – Low molecular weight heparin.
Sclerotherapy; Outcome: • Permanent relief - 1 treatment 21% • Decreased symptoms 58% • Repeat sclerosis required & effective 26% ; • Complications – ulceration, pain 21%; MRI of pelvis showing venous malformation:
Indications for Surgical Excision or Debulking Procedures: • Life threatening lesions not amenable to non- surgical debulking; • Significant disfigurement; • Impairment of normal functions including wearing shoes, clothes etc...; • Lesions causing repetitive infection; • pain that can be significantly improved by total/partial excision; • Localized lesions amenable to curative resection without compromising function.
Conclusions: • Extensive venous and veno-lymphatic malformations remain a challenge for patients and their physicians; • Coagulopathy more common in diffuse and multiple lesions; • Recognizing thromboembolic risk enables effective prevention strategies to be utilized - LMWH prevents complications; • Although cure is not possible for many patients most can lead a satisfactory life with supportive care and tailored management; • Multimodal therapy including sclerotherapy, surgical debulking, laser therapy and pharmacotherapy provide the foundation for successful treatment today; • These patients are often best managed by an interdisciplinary team.
interv neuroradiol. 2014 Apr 4;20(2):176.
Purpose: To review technical aspect in treatment of a case of young man with orbito-maxillary AVMs using simple co-axial system in Ramathibodi Hospital, whom present with bloody tear from bleeding per left eye.
Material and Methods: We retrospectively review a 18-year-old man, with history of abnormal pulsatile mass at nasal side of the left orbit, with occasional bloody tear in his adolescent period. We were consults on January 2014, for pre-operative embolization, using combined endovascular and direct puncture by coaxial technique. The procedure following by surgery is done successfully.
Result: The patient was found to have high flow AVMs at floor of the left orbit and left maxillary region with multiple arterial feeders from branches of left internal maxillary arteries, left facial artery and left ophthalmic artery. There are large draining veins, with the largest venous pouch of the left angular vein before draining toward the contralateral right angular and draining to left superficial temporal veins and bilateral facial vein. Transarterial embolization was unable to cure the AVMs, but help to decrease the flow. Prophylatic IV antibiotic was administered before further direct puncture using coaxial system with 11G short IV needle was securely apply to the venous ouch and connecting to pressurized dripping fluid, then 2.3fr microcatheter was used to superselection further to the proper position before injecting 33% diluted NBCA(glue) until achieve obliteration of the flow within the pouch showed in control angiography of the potential feeders. After 5minutes, the coaxial system was removed. The patient underwent reconstructive surgery within 48hours, with minimal perioperative blood loss.
Conclusion: Craniofacial AVMs can be challenging and bringing concerns not only functional and hemodynamic results but also cosmetic aspect. Intracranial investigation must be aware to exclude condition such as cerebrofacial arteriovenous metameric syndrome (CAMS) before treatment approach. Transarterial embolization alone usually fail to completely cure the lesion with goal achieving. While multidisciplinary team approach with surgical option can do better. Conventional direct puncture with sclerosing agent or fluid adhesive injection is useful in slow flow lesion such as venolymphatic malformation, while in high flow lesion i.e. AVMs, the blood reflux into the needle can cause early polymerization of the adhesive fluid in the needle prior to achieve the complete result. Coaxial system approach can protect those reflux and allow multiple catheters injection in order to cure the disease. Protection of venous exit can be done easily by cookies cutter technique or manual compression of the venous outlet. Reconstructive surgery should be done within 72 hours after injection, to avoid excessive perioperative blood loss. No serious complication is demonstrated in our experience.
interv neuroradiol. 2014 Apr 4;20(2):177.
Background: In patients with symptomatic carotid artery stenosis, long-term effects of carotid artery stenting (CAS) on blood pressure (BP) changes have not been documented well. We evaluated the effects of CAS on BP and found out its predisposing factors in patients with symptomatic carotid artery stenosis.
Methods: Between January 2003 and June 2012, a total of 107 patients were recruited and all subjects met the following inclusion criteria: (1) patients underwent CAS with symptomatic carotid artery stenosis > 50%; (2) patients had clinical and radiographic data for at least one year of follow-up after CAS; and (3) patients had BP measurements at four different time points: pretreatment, posttreatment, one-month follow-up, and one-year follow-up. We evaluated the significance of the BP changes between the pretreatment BP and follow-up BPs, and found out its predisposing factors.Results: Compared to the mean systolic/diastolic BP value (141.0/87.4 mmHg) at the pretreatment BP, the follow-up BPs were significantly decreased after CAS (120.5/74.5, 126.2/76.9, and 129.2/79.0 mmHg at the posttreatment, the one-month follow-up, and the one-year follow-up, respectively [p < 0.01]). The location of the stenosis (odds ratio = 1.856, 95% confidence interval, 1.388 to 5.589; p = 0.003) and hypertension (odds ratio = 1.627, 95% confidence interval, 1.101 to 3.757; p = 0.014) were independent predisposing factors for BP-lowering effects of CAS on multivariate analysis.
Conclusion: For patients with symptomatic carotid artery stenosis, CAS might have BP-lowering effect at the one-year follow-up especially in patients with hypertension or the stenosis at body lesions.
interv neuroradiol. 2014 Apr 4;20(2):177.
Objective: Patients with internal carotid stenosis (ICA) with pseudoocclusion is supposed to be high risk lesion for neurosurgeons performing carotid endoarterectomy as well as carotid artery stenting (CAS). We present our clinical results in our series.
Cases and Methods: Total 61 pseudoocclusion of the ICA in 1200 CAS cases were treated within these 10 years and all CAS procedures were performed using various types of protection system such as distal balloon protection system, distal filter protection system, or flow reversal method. After introduction of flow reversal method, almost all cases with pseudoocclusion were treated under this method.
Results: The treatment success rate for pseudoocclusion was 98% (60/61 lesions). Morbi/mortality rate at 30 days was 5 % and restenosis greater than 50% at 6 month was also 5%.
Conclusion: CAS using a meticulous protection system is safe and useful even for lesions with pseudoocclusion.
interv neuroradiol. 2014 Apr 4;20(2):157–178.
Purpose: To evaluate the clinical follow-up results of carotid artery stenting (CAS) for carotid artery stenosis in patients over 70 year of age.
Material and Method:We performed CAS 48 patients between June 2006 to July 2013. Among them, we evaluated 28 patients over 70 years old (71-90, mean 76.8 ). CAS for re-stenosis after carotid endarterectomy was excluded. 17 of 28 cases were symptomatic.
Result: All patients were successfully treated with CAS using protection devices. Two minor complications encountered due to this procedure; one patient experienced decreased visual acuity due to embolism of ipsilateral opthalmic artery, the other had minor cerebral infarction. Mean follow-up period was 46.4 months (3.2-69.9). There was no stroke during this period. 3 patients died because of pneumonia within 1 year after CAS.
Conclusion: CAS is acceptable treatment to prevent stroke in patients over the age of 70 years.
interv neuroradiol. 2014 Apr 4;20(2):178.
Background: Previous studies (including CREST studies) have shown that the complications following CAS increases as the patient’s age advances. We select tailored CAS or CEA for each clinical case mainly in accordance with plaque profile in order to avoid high-risk cases for CAS. We analyzed the outcome of such selected CAS cases specifically in elderly patients (≥70).
Method: Of the 205 surgical treatments (149 CAS; 56 CEA) for carotid artery stenosis at our institution between April 2010 and May 2013, we examined 126 cases (92 CAS; 34 CEA) with patients over 70. In principle, tailored CAS was performed as a first-line therapy for carotid artery stenosis with the suitable selection of embolic protection device(EPD). In addition, CEA was performed to avoid high-risk cases for CAS, including those with high-volume soft plaque or calcification. Of the selected 92 tailored CAS cases, the use of EPD is as follows: 53 filter (F), 39 balloon (B).
Result: Of the 92 CAS treatments, there were no cases of intraoperative complications and 2 cases (2.2%) of symptomatic post-operative complications (temporary mild paralysis in 1 case (F), and temporary aphasia in 1 case (B)). Both cases were accompanied by ischemic complications with micro embolism.
Conclusion: Evaluation of risk factors before operative procedures to exclude high-risk cases and to apply tailored CAS adequately can improve the safety of CAS for elderly patients and clinical outcomes for carotid artery stenosis in general.
interv neuroradiol. 2014 Apr 4;20(2):178–179.
Carotid endoarterectomy (CEA) is the standard treatment for the patients with carotid artery stenosis. Recently, there are several radomised clinical trials of carotid artery stenting (CAS) to know its safety and efficacy, comparing with CEA. SAPPHIRE and CREST (North America) are the positive study to reveal the non inferiority of CAS, while the EVA-3S, SPACE, and ICSS (Europe) are the negative study to CAS. We have to think about the various bias of these studies and evaluate them in a fare fashion. Several important points are discussed to perform the safer and efficacious CAS.
Patient’s demography: age and gender, symptomatic or asymptomatic, associated risk factor (hypertension, diabetes, coronary disease, hyperlipidemia).
Plaque diagnosis: Find the soft and fragile (=dangerous) paques: ultrasonography, MRI (BB, MPRAGE, TOF). Find the circumferencial calcified plaque: plain CT.
Access route: Evaluate the vascular abnormalities (ASO, aortic aneurysm/dissection, type of the aorta) in the access routes: CT angio, MR angio.
Cerebral perfusion: Evaluate the cerebral blod flow and hemodynamic compromise and Predict the possibility of postoperative hyperperfusion: CBF study with a diamox challenge.
Chose the approach route: 1) transfemoral approach; 2) transbrachial approach; 3) trandcarotid approach.
Chose the cerebral protection device: 1) distal filter (Filterwire, Angioguard, etc); 2) distal balloon (Percuserge); 3) proximal balloon (Parodi’s system, etc).
Chose the stent: 1) open cell stent; 2) closed cell stent.
Premedication: 1) dual antiplatelet; 2) statin?
Complication of treatment: thromboembolic complication (cerebral ischemia), bradycardia and hypotension, hyperperfusion syndrome (inracranial hemorrhage), groin/retroperitoneal hematoma.
Nationwide survey of carotid revascularization in Japan: Japan Atherosclerosis Study (JCAS) is the prospective registry of patients with carotid artery stenosis, which was conducted from 2002 to 2006. The patients with carotid stenosis of 50% or more were enrolled in a prospective fashion from 53 centers. The patients were treated either by medical therapy (MT), carotid endarterectomy (CEA), or carotid artery stenting (CAS) according to each center’s indication. Endpoint is either ipsilateral stroke, acute myocardial infarction, or death. 1164 patients were enrolled between the initial 3 years. 87% of the patients were men. Mean age was 69.8 years. 51% of the patients had a symptomatic and 49% had an asymptomatic stenosis. 45% of the patients were treated by CEA, 34% by CAS, and 21% by MT. Major adverse events at 30 day occurred in 3.2% of CEA and 3.6% of CAS group (ns). 746 patients were followed-up for 847 days (mean). Restenosis ratio was 10.7% in CEA and 5.4%(p=0.016) in CAS group. In the follow-up period, ipsilateral stroke occurred in 0.54% of CEA, 0.39% of CAS, and 6.09% (p<0.001) of MT group. 4.8% of the patients in CEA group, 5.8% in CAS, and 10.4% in MT died. Cardiovascular events occurred in 3.5% of the 746 patients.
interv neuroradiol. 2014 Apr 4;20(2):179.
Vertebral artery dissection is not a common condition. The incidence is around 1-1.5 per 100,000. The peak age is in the fourth decade. The diseased VA segment can be intracranial or extracranial. About 10% subarachnoid hemorrhage is caused by intracranial VA dissection. Ruptured intracranial VA dissection is associated with high rebleeding risk (37-57%) and high mortality rate (46%).
Open surgical treatment involves trapping or proximal ligation of VA if the diseased VA is non-dominant. For dominant VA or PICA involved in diseased segment, wrapping is the preferred treatment. Bypass followed by trapping in an acute setting with a swollen brain is technically challenging. With the good result of Flow Diverter’s use in non-rupture condition, there is a question whether it can be used in acute rupture setting.
Since 2009, there were 7 patients undergoing Pipeline stenting of Ruptured Intracranial VA Dissection (dominant VA or PICA / AICA involved) in our centre. Only the first case which is a complicated vertebrobasilar artery dissection of a previously irradiated nasopharngeal carcinoma patient, suffered from a minor rebleeding 2 weeks after stenting and needed addition of one more pipeline stent. This patient died 8 months later due to food aspiration at home. There was a minor PICA territory infarct in another patient with dissection involving PICA origin despite post-stenting control CTA showed patent PICA. There were 2 patients suffering from extracranial bleeding episodes (epistaxis and bleeding pile) and needed blood transfusion. The result is satisfactory in this group of patients with difficult vascular anatomy-perfusion characteristics. The use of antiplatelet agents in this group of acute SAH patients needs to be carefully monitored.
interv neuroradiol. 2014 Apr 4;20(2):179–180.
Objectives: To analyze the result of endovascular treatment for severe and symptomatic cerebral arteries stenosis by angioplasty and stenting at University Medical Center HCM city.
Population: The research population is including patients who have extra or intracraninal cerebral artery stenosis: carotid artery, middle cerebral artery M1 segment, vertebral artery, basilar artery, anterior cerebral artery A1 segment. The level of arterial stenosis is at least 70% and arterial diameter from 2mm with related symptoms: ischemic stroke, repeated TIA (transient ischemic attach) which failure of medical management.
Methods: This is the case series report study. The clinical symptoms before and after treatment will be analyzed, long term follow up symptoms including new stroke or TIA which is related to the interventional artery. Endovascular procedure will be performed with reopen up the vessel by angioplasty (dilation with the balloon) and stenting (implant of Stent device). After carotid stenting follow up protocol will be applied by Doppler Ultrasound after 1 month, 6 months and 1 year. While intracranial stenosis stenting will be followed up by clinical examination, MRI, MRA after 6 month. Cerebral Digital Subtraction Angiography (DSA) follow up will be indicated when the patient has symptoms (stroke or TIA) which are related to treated vessel.
Results: From 2006 to June -2013 at University Medical Center HCM, we had performed 100 cases with extra or intracraninal cerebral artery stenosis by angioplasty dilation and stent deployment. Among this series, carotid stenosis is 49%, middle cerebral artery M1 segment 28%, origin of vertebral artery 9%, basilar artery 11%, and anterior cerebral artery A1 segment in 2%. Endovascular procedure technical success in 98%. Restenosis rate after carotid stenting detected by Doppler Ultrasound is 4%, mostly no symptoms and can be re-dilated by balloon in severe cases. The longest follow up time is more than 4 years there is no repeated stroke case. The severe complication rate after procedure is 6% including cerebral bleeding after stenting suggested by hyper reperfusion syndrome in 3%, mortality rate is 3%.
Conclusions: Endovascular treatment for severe and symptomatic cerebral arteries stenosis by angioplasty and stenting has indicated that this is quite safe and effective procedure for prevention of repeated stroke caused by large extra or intracraninal cerebral artery stenosis with low restenosis rate.
interv neuroradiol. 2014 Apr 4;20(2):180.
Introduction: The cause of pseudotumor cerebri, or idiopathic intracranial hypertension(IIH), is controversial. We report our results from 13 cases of venous sinus stenting
Methods: A retrospective chart review of patients with medically refractory IIH, who underwent intracranial venous sinus stenting from March 2008 to June 2011, was performed.
Results: 13 patients have a focal stenosis at the Intracranial venous sinus with a pressure gradient ≥10 mm Hg (mean -16.9 mm Hg, range 10-26 mm Hg). The mean age of the patients was 38.3 years. All patients reported headaches, visual symptoms and had abnormal ophthalmological examination with evidence of papilledema and/or visual field or visual acuity deficits. The mean duration of symptoms was 5.7 years. All patients had failed medical management. All patients underwent intracranial venous sinus stenting. The pressure gradient across the stenosis resolved immediately after stent placement. No periprocedural complications were noted in this study. The mean follow-up was 12 months. 10 of 13 patients reported improvement in their symptoms.
Conclusions: These findings indicate a role for transverse sinus stent placement in the management of selected patients with IIH
interv neuroradiol. 2014 Apr 4;20(2):180–181.
Purpose: Intracranial magnetic resonance (MR) angiography is widely used to diagnose cerebrovascular diseases such as infarction, vasculitis, and moyamoya disease. MR angiography noninvasively shows luminal narrowing of the intracranial arteries. However, most vascular diseases, especially atherosclerosis, do not show luminal narrowing in early stage. Recently, high-resolution (HR) intracranial arterial wall imaging is used to demonstrate intracranial arterial wall abnormality. In our institution, HR intracranial arterial wall imaging have been performed in patients with stroke, TIA, or moyamoya disease. HR intracranial arterial wall imaging clearly showed arterial wall pathologies such as wall thickening or enhancement at the stenotic portion detected on MR angiography. Moreover, HR intracranial arterial wall imaing showed hidden arterial wall pathologies in the arteries which were not stenotic on MR angiography. The aim of this study was to evaluate the frequency of bilateral arterial wall pathologies in patients with normal or unilateral intracranial artery stenosis detected on the MR angiography and the pattern of enhancing wall thickening was also evaluated.
Material and Methods: Bewteen March 2012 and April 2013, there were 129 patients with HR intracranial arterial wall imaging in our institution. Of them, 44 patients who showed normal (n=5) or unilateral stenosis (n=39) on conventional time-of-flight (TOF) MR angiography were included in this study (21 males; ages, 30-86 years; mean, 54 years). Magnetic resonance imaging was performed at 3.0 T (Achieva, Philips Medical Systems, Best, The Netherlands) with an 8-channel sensitivity-encoding (SENSE) head coil. Three-dimentional (3D), TOF MR angiography was performed with following parameters: repetition time (TR), 25 msec; echo time (TE), 3.5 msec; flip angle, 20°; matrix, 880x332; slice thickness, 0.6 mm; field of view (FOV), 250 mm. T1-weighted volumetric isoptopic TSE acquisition (VISTA) image was acquired after intravenous injection of contrast material [Dotarem (Gadoterate Meglumine), Guerbet, Aulnay-sous-Bois, France, 0.1 mmol/kg body weight by power injector] with the following parameters: TR/TE, 350/23 ms; flip angle, 90°; matrix, 360x360; slice thickness, 0.5 mm; field of view (FOV), 180 mm. Black-blood contrast was acquired by applying saturation band below the imaging slap. The frequency, location (distal ICA, M1, M1/M2 junction and M2 segment), and type (concentric or eccentric) of enhancing wall thickening were analyzed. If the lesion showed eccentric enhancement, the most thickened positions of enhancing wall (anterior/posterior/medial/lateral wall for distal ICA and M2, anterior/posterior/superior/inferior wall for M1 and M1/M2 junction) were described.
Results: The clinical diagnoses were atherosclerosis (n=29), moyamoya disease (n=7), vasculitis (n=2), dissection (n=1), and indeterminate (n=5) (Fig.1-3). 86.4% (38/44) showed bilateral wall enhancement. Five patients who had unilateral MCA infarction showed no stenosis on MR angiography, however, all of them showed bilateral arterial wall enhancement. On the ipsilateral side (lesion or symptomatic side), 70.5% of distal ICA, 81.8% of M1, 59.1% of M1/M2 junction, 27.3% of M2 segment showed wall enhancement. On the contralateral side, 38.6% of distal ICA, 52.3% of M1, 65.9% of M1/M2 junction, 9.1% of M2 segment showed wall enhancement. Atherosclerosis showed eccentric wall enhancement more likely (82.8%), however, stenosis with other etiologies showed concentric enhancement (60%) more likely (P=0.007). In case of atherosclerosis, lateral wall of distal ICA (57.9%), anterior wall of M1 (60.9%), posterior wall of M1/2 junction (94.1%) and anterior wall of M2 (57.1%) were most frequently involved positions on the ipsilateral side (Fig. 4). On the contralateral side, lateral wall of distal ICA (46.7%), anterior wall of M1 (77.8%), posterior wall of M1/2 junction (84.2%) were most frequently involved positions of each vessel (Fig. 5).
Conclusion: High-resolution intracranial arterial wall imaging may reveal subclinical pathologic changes of vessel wall even the stenosis is not evident on the MR angiography. Atherosclerosis showed eccentric wall enhancement more likely than other etiologies. In case of atherosclerosis, there were preferred positions of vessel wall involvement and it may suggest the underlying pathophysiologies of atherosclerosis, such as low wall shear stress area.
interv neuroradiol. 2014 Apr 4;20(2):181.
Purpose: The use of antiplatelet therapy has shown to decrease the incidence of thromboembolic events during stenting procedures (coil assisted stenting, flow diverters and for intracranial atherosclerosis diseases). But the risk of hemorrhagic complications remain an important risk to consider when prescribing these drugs. Newest antithrombotic agents may play a better role among individuals who are recognized to be at a higher risk of non-response or low response. Pharmacodynamics response to clopidogrel varies among individuals. Several factors contribute to inter-individual variability in clopidogrel response including genetic and environmental influences on P2Y12 receptor density and function. This variability is driven in large part by polymorphisms in the CYP2C19 enzyme, which plays a key role in the biotransformation of the prodrug to the active metabolite and by variable kinetics impairments emit by concomitant drug uses.
Materials and Methods: A review of recent literature pertinent to neuroendovascular procedures will be presented. A literature search was conducted (1966–January 2014) using MEDLINE including in-process and other non-indexed citations, as well as Current Contents, EMBASE Drugs Pharmacology, and the International Pharmaceutical Abstract databases.
Conclusion: Patients with high platelet reactivity on clopidogrel therapy may be suitable candidates for either ticagrelor or prasugrel for long-term therapy. However, large-scale studies will be needed to validate the utility and safety of more potent P2Y12 inhibitors in patients undergoing intracranial stenting procedures. New drugs (like cangrelor) and newer devices are still in development but would offer advantages, in a very near future to the neurointerventionalist.
interv neuroradiol. 2014 Apr 4;20(2):182.
Purpose: In treating dural arteriovenous fistulas (dAVFs), the goal of embolization is occlusion of the dural vein close to the shunt point; We have recently reported the efficacy of superselective shunt occlusion (SSSO) in which coiling only the small venous pouch or compartment just downstream of the shunt point. Thus, detection of the shunt point is crucial in performing this method. The purpose of this study is to establish a more intelligible technique to detect shunt point compared with conventional DSA images and 3D-RA images.
Materials and Methods: We have developed a new technique named circular color coding (CCC): in which arrival time of contrast media was determined by time-density curve obtained from conventional DSA pixel by pixel, followed by converting the arrival time to circular color phases. By this technique, blood flow is demonstrated as sequential color imaging. CCC was applied to 18 dAVFs, and neuroradiologists/neurosurgeons assessed the shunt points with CCC, conventional DSA, and 3-D RA images separately.
Results: SSSO were available in 6 of 18 cases, and CCC showed more accuracy and required shorter time in determining shunt points in all 6 cases than either conventional DSA or 3-D RA images alone.
Conclusion: CCC achieved easier and better understanding of the shunts by coloring blood flow compared with conventional DSA in which density of contrasts should be stared at. By complementary use of 3-D RA which has better spatial solution, CCC would be a very useful technique in the treatment for dAVFs.
interv neuroradiol. 2014 Apr 4;20(2):182.
Background: Transvenous target embolization of cavernous sinus dural arteriovenous fistula (CSdAVF) has some benefits such as shorter procedure time and necessity of less amount of coil. However, curability of target embolization has not been clear yet.
Objective: To verify the curability of the transvenous target embolization of CSdAVF. [Patients &Methods] Patients who underwent initial catheter intervention of CSdAVF in our institute for the duration of 2005-2013 were included. The strategy of transvenous embolization (TVE) was devided into 4 groups: target embolization of shunt points (S), embolization of shunt points and retrograde venous drainage (S+D), cavernous sinus packing (CSP), and occlusion of retrograde venous drainage only (D). The primary end point defined as additional treatment.
Results: 39 cases of CSdAVF underwent initial catheter intervention in this period including 36 cases of transvenous embolization. The strategy of TVE included 8 cases of S, 15 of S+D, 6 of CSP and 7 of. Complete obliteration of shunts was achieved in 75% of S, 46.7% of S+D, 33.3% of CSP, 42.9% of D. Additional treatment was performed in 4 cases including 3 of S and 1 case of CSP. The rate of additional embolization of S group was significantly high in univariate analysis (P=0.03). Complete obliteration after initial embolization has not correlation with the necessity of additional treatment (P=0.61).
Conclusion: Transvenous target embolization of CSdAVF tends to need additional treatment later.
interv neuroradiol. 2014 Apr 4;20(2):183.
Background: Cognitive impairment is one of the symptoms of dural arteriovenous fistulas (AVF) with cortical venous reflux.
Purpose: We aimed to evaluate of impaired cerebral perfusion in patients with dural AVF presenting with cognitive impairment using perfusion MRI.
Methods: In all, 19 patients with dural AVF underwent perfusion MRI before and after treatment between January 2008 and October 2013. We examined the correlation between cognitive impairment and the parameters of perfusion MRI.
Results: The dural AVF location was transverse-sigmoid in eight patients, cavernous sinus in five, superior sagittal sinus in four, tentorial in two. There were 14 patients (74%) with cortical venous reflux, including five patients (26%) with cognitive impairment. The mean transit time was prolonged in all of the patients who presented with cognitive impairment.
Conclusion: Impaired cerebral perfusion in patients with dural AVF presenting with cognitive impairment can be evaluated by the mean transit time.
interv neuroradiol. 2014 Apr 4;20(2):183.
Objective: Tentorial dural arteriovenous fistulas (DAVFs) are rare, have a high risk of hemorrhage, and require urgent treatment. This study aimed to summarize and discuss our strategies and results of endovascular and surgical treatment for tentorial DAVFs.
Patients and Methods: Between 1980 and 2013, 216 consecutive cases underwent endovascular and/or surgical treatment for intracranial DAVFs. We reviewed the data of 8 patients (3.7%) with tentorial DAVFs retrospectively, including their illness history, neuroimaging, treatment modalities and their results.
Result: There were 7 male and 1 female patients, aged between 50 and 65 (mean 59.4). Clinical manifestations were headache in 3 cases, subarachnoid hemorrhage, tinnitus and visual disturbance in each one case. Two patients had no symptoms. Seven patients had the lateral type (superior petrosal sinus) fistula and 2 had the medical type (falcotentorial) fistula. Five cases were Cognard type-IV (non-sinus type) and 3 cases were type-IIa or IIb lesion. The venous drainage was retrograde leptomeningeal fashion in 7 patients including deep veins in one. Eight patients underwent feeder embolization with glue from feeding external carotid branches. One patient underwent successful transvenous embolization. The complete obliteration by means of embolization was achieved in one patient, and subtotal obliteration in 4. Two patients underwent successful surgical clipping of the draining petrosal veins after arterial embolization. There were no episodes of rebleeding or marked recurrence during follow-up period.
Conclusion: It is difficult to obliterate the tentorial dAVF completely only by endovascular treatment. But subtotal obliteration provided an acceptable clinical prognosis. Combined surgical treatment is a potential therapy for the tentorial dAVF.
interv neuroradiol. 2014 Apr 4;20(2):183–184.
Purpose: Transarterial embolization with n-butyl cyanoacrylate (NBCA) is a highly effective technique especially for non-sinusal type dural arteriovenous fisutulas (AVFs). It is important to penetrate the NBCA into the venous side through the fistulas for curative intent. However, it is often difficult to obtain sufficient penetration of NBCA due to early polymerization and fragmentation of NBCA caused by ionic collateral blood flow from other feeders. To prevent early polymerization of NBCA, we combined the simultaneous 5% glucose solution injection from another feeding pedicle with transarterial NBCA embolization via the main feeding pedicle. We demonstrate this technique with illustrative cases.
Materials and Methods: Seven cases of dural / epidural AVFs, including two superior sagittal sinus (SSS) dural AVF, one ethmoidal dural AVF, one superior petrosal sinus dural AVF, one frontal dural AVF, and two spinal epidural arteriovenous fistula (EDAVF) were treated by this technique. All cranial AVFs showed Borden type III and 2 spinal epidural AVFs showed perimedullary drainage alone. Two microcatheters were advanced into two different feeding pedicles with bilateral femoral approach. NBCA at low concentration (17-20%) was injected through the microcatheter closer to the shunting point while 5% glucose solution was injected through another microcatheter.
Results: All except one showed complete disappearance of AVFs with the sufficient NBCA penetration into draining veins. The remaining one case showed marked regression of AVFs. No procedure-related complication was observed. In all cases no recurrence was observed during 8 month mean follow-up periods
Conclusion: Transarterial NBCA embolization with simultaneous 5% glucose solution injection from another feeding pedicle is an effective technique for the curative treatment of dural / epidural AVFs.
interv neuroradiol. 2014 Apr 4;20(2):184.
Background: Carotid-Cavernous fistula is a direct connection between carotid artery and cavernous sinus. This connection made a high pressure on veins that drain the venous blood to the cavernous sinus, and sometime retrograde flow. This venous hypertension and retrograde flow will cause neurologic deficit. The most frequent sign and symptoms are on the eye. The others are: epistaxis, intracerebral hemorrhage and weakness. In some progressive cases an urgent treatment is necessary.
Purpose: To share some experience in treating CCF with endovascular and surgery procedures.
Material: In our series we have treat 12 cases of CCF. The symptoms are : ocular problem 9 cases, epistaxis 2 cases, and ICH one case.
Result: Our treatment are : balloon embolization 9 cases , coil embolization 2 cases, surgery one case. In two cases carotid artery was sacrifice, one by coiling and the other one by surgery
Discussion: CCF is a progressive disease and cause permanent neurologic deficit. The target is to close the fistula which reduce the venous pressure and restore the neurologic deficit.
Conclusion: There are many method to stop the fistula and if the fistula can be stopped, the symptom will improve.
interv neuroradiol. 2014 Apr 4;20(2):184.
Dural Arterio-Venous Fistula (DAVF) is indicated for treatment when there is any reflux in the venous system (from type II to type V based on Cognard classification). However, total occlusion may be not achievable in certain cases, in which partial occlusion has to be considered. For such cases, measuring venous sinus pressure may be helpful in quantifying the treatment results; and venous sinus angioplasty to make a better drainage way for the fistula may have a role in making the fistula less aggressive.
Method :we describe a case with type II DAVF (Cognard’s classification) at the right sigmoid sinus, in which venous sinus angioplasty give a surprisingly amazing impact on the nature of the fistula. Also, we evaluate the treatment result by measuring the venous sinus pressure at different locations, by which we can quantify the effect of each treatment steps.
Result: the location of venous sinus stenosis is right at the site of fistula (middle of the sigmoid sinus). Venous sinus pressure is around 55mmHg at the whole dural venous system that is distal to the stenosis (Superior Sagittal Sinus, Torcular, Right Transverse Sinus, distal end of the Sigmoid Sinus), and drops dramatically to 15mmHg at the proximal end of the Sigmoid Sinus. After venous angioplasty, venous pressure is balanced to around 25-30 mmHg in the whole intracranial venous sinus system, and the fistula is changed to type I (Cognard’s classification).
Conclusion: Venous Sinus Angioplasty may play a more-important-than-we-thought role in treating DAVF, especially in cases when total occlusion cannot be achieved. Also, Venous Sinus Pressure might be an Objective way to measure the results of treating DAVF.
interv neuroradiol. 2014 Apr 4;20(2):184–185.
Transvenous Embolization is a high effective method for managing dural arteriovenous fistula especially cavernous sinus position. In almost patient we can approach cavernous sinus by inferior petrosal sinus, however when not accessible through it, there are some other venous ways. We report 5 cases with CSDAVF treated by coils embolization with different accessible ways. 1 case with inferior petrosal sinus, 1 case with superior petrosal sinus, 2 case with retrograde approach from external jugular vein to superior ophthalmic vein (SOV), 1 case with direct puncture in to SOV. Resuls were complete embolization in 4 cases and the remaining case with superior petrosal sinus changes from progressive to benign type. There were no complication during and post procedures. Conclusion, There are lots of venous ways to access cavernous sinus effectively and safety in treating CSDAVF.
interv neuroradiol. 2014 Apr 4;20(2):185.
Objectives: The purpose of this study was to assess the efficacy and safety of Gamma Knife surgery (GKS) for the treatment of cavernous sinus dural arteriovenous fistulas (CSDAVFs).
Methods: Among the 94 GKS procedures performed for CSDAVFs in the authors’ institute, 82 cases were clinical followed up more than 3 months, formed the database from which the authors determined clinical outcome and the incidence of untoward events, follow up by Microsoft Office Access, R tatistical analysis
Results: A symptomatic cure was observed in one patient with CSDAVFs as early as 6 weeks. The cumulative cure rate based on follow-up angiography of CSDAVFs approached 90% at 6 months, A neuroimaging-based cure lagged behind that of the clinical symptoms, the mean obliterated time: 11 ± 4 (8-22) weeks. Overall, there were no nonfatal intracerebral hemorrhages during the follow-up period. No neurological status without hemorrhage was noted with ODAVFs. There were no cranial nerve neuropathies.
Conclusion: Gamma Knife surgery provides a safe and effective option for treatment of intracranial DAVFs with a low risk of complications. In cases of DAVFs with benign clinical presentation, GKS can serve as a primary treatment. In some cases of aggressive DAVFs in which there is extensive retrograde cortical vein drainage, combined treatment with embolization or surgery is suggested.
interv neuroradiol. 2014 Apr 4;20(2):186–187.
Background: Basilar artery occlusion (BAO) is a rare (1%) but very severe subtype of stroke, with a very high mortality and disability rate. IV thrombolysis is a poorly effective treatment, explaining the rise of endovascular treatment, which has gained acceptance in this indication. But even though recanalization rate is higher in endovascular treatment of BAO, a favorable neurological outcome, defined by a modified Rankin scale (mRS) = 0-2 at 3 months follow-up, remains low (30 %). Our study aimed to evaluate the effectiveness and safety of endovascular treatment of basilar artery occlusion, and to identify clinical and radiological prognostic factors that may help predicting the clinical outcome.
Methods: We retrospectively analyzed the charts of 29 consecutive patients (21 males, 8 females; mean age/SD = 61.1 ± 14.1 y, range: 29-88) who presented BAO (diagnosed with a positive MRI with 3D time-of-flight angiography or brain CT with CT angiography) and underwent endovascular treatment between April 2006 and June 2013 in our institution. Clinical data (including National Institute of Health Stroke Scale [NIHSS] at admission/day1/day7, delay between symptoms and beginning of endovascular procedure), radiological data (including prognostic scores on initial MRI and follow-up MRI within 48 hours after the procedure: Bern score1, Cho et al. score2, Renard et al. score3, DWI-pc-ASPECTS4), angiographic data (including duration of the procedure, vascular anatomy, drugs and devices used during the procedure, recanalization rate using the following scales: Thrombolysis In Cerebral Ischemia [TICI] score, Thrombolysis In Myocardial Ischemia [TICI] score and Arterial Occlusive Lesion [AOL] score) were retrospectively assessed. Patients were divided in two groups: good outcome was defined by a mRS=0-2 at 3 months follow-up, whereas poor outcome was defined by a mRS=3-6 at 3 months follow-up.
Results: 9/29 patients (31%) had a good outcome, and 20/29 patients (69%) had a poor outcome, including 8/29 deceased patients (27.6 %). There was a statistically significant difference between the groups regarding NIHSS at day 1 and day 7 (p<0.0001), all four prognostic scores on initial and/or follow-up MRI (p<0.05 for each score), thalamic infarction on follow-up MRI (p=0.04), AOL score (p=0.02). There was no significant difference between the groups regarding delay from symptoms to endovascular procedure (p=0.272), TIMI score (p=0.2), TICI score (p=0.22).
Conclusion: Endovascular treatment of BAO is a safe and effective treatment. Recanalization seems to be a necessary but not sufficient prognostic factor for a good outcome. Further studies need to identify other clinical and/or radiological prognostic factors.
Abbreviations: Basilar Artery Occlusion (BAO) – modified Rankin Scale (mRS) - National Institude of Health Stroke Scale (NIHSS) - Arterial Occlusive Lesion (AOL) - Thrombolysis In Myocardial Ischemia (TIMI) - Thrombolysis In Cerebral Ischemia (TICI) - Diffusion Weighted Imaging (DWI).
References
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interv neuroradiol. 2014 Apr 4;20(2):187.
In this investigation, a nano-sized protein-encapsulated polymeric micelle was prepared by selfassembling human serum albumin (HSA) as a model protein and degradable block copolymer methoxy poly(ethylene glycol)-poly(b-amino ester) (PEG-PAE) with piperidine and imidazole rings 1-2. The albumin encapsulated polymeric micelle maintained a stable micellar state at physiological pH 7.4 with a particle size of around 56.0 nm in water. In the 0.15 M NaCl solution, moreover, the particle size would increase from 56.0 nm to 65.7 nm. From the zeta potential results, when the pH is lower than pH 7.0, the albumin-encapsulated polymeric micelle bears a gradually increasing net positive charge due to the ionized amino groups in the PAE chain. As a result, the albumin encapsulated PEG-PAE-API can be used as a pH-triggered targeting agent and an effective drug delivery system in cerebral ischemia models. We found a gradual increase in fluorescence signals of the brain ischemic area, indicating that the pH-tuning positively charged protein-encapsulated polymeric micelle could be effective for targeting the acidic environment and diagnostic imaging. Owing to its unique ability of simultaneous acid-triggered targeting and effective delivery of proteins, this strategy may be utilized in the design of general platforms for delivering other proteins in biomedical applications. Moreover, we expect that the polymeric micelle can be globally applicable for diseases that undergo tissue acidosis such as tumors, inflammation, and ischemia.
Figure 1.
In vivo near-infrared fluorescence (NIRF) images and signal quantification. Coronal cross-sectional NIRF images of rat brains injected with (A) polymer-albumin and (B) albumin. (C) Quantitative analysis of the NIRF signal intensity in the ischemic area of the brain reveals at 30 min and 3 h after injection
References
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interv neuroradiol. 2014 Apr 4;20(2):187.
Background and Purpose: Intravenous flat-detector CT (IV FDCT) angiography is an emerging technology for the detection of intracranial vascular disease. The study was conducted to determine the feasibility of IV FDCT in estimating major atherosclerotic intracranial arteries stenosis with digital subtraction angiography (DSA) as the reference.
Methods: DSA and IV FDCT were performed simultaneously in patients with transient ischemic attack or acute cerebral infarction. The degree and length of stenosis were measured. The stenotic vessels were categorized into four groups by the grade of stenosis: normal (<30%), mild (30-49%), moderate (50-69%) or severe (>70%). The vessels of the normal group were excluded from analysis to reduce spectrum bias. Measurement of vessels was recorded using an electric ruler by a qualified endovascular neurosurgeon and a neuroradiologist.
Results: A total of sixty-nine patients with 842 vessel segments were calculated. Mild (n=56), moderate (n=47) and severe stenosis (n=46) groups were analyzed. IV FDCT had a sensitivity of 97.6%, specificity of 96.9%, and a negative predictive value of 96.9% for detecting ≥50% stenosis and respective values of 91.9%, 98.2%, and 97.4 % for depicting ≥70% stenosis. The difference of stenotic length between two tests was not significantly difference as an increase in the severity of stenosis (Spearman’s rank test; r = - 0.12, p=0.13)
Conclusion: IV FDCT can be a feasible alternative as a noninvasive method for evaluating stenosis of the major intracranial arteries.
interv neuroradiol. 2014 Apr 4;20(2):187–188.
Background and Purpose: Amount of perfusion and diffusion mismatching (P/D mismatch) in acute stroke imaging study is a good prognostic factor for the patients who undertook intraarterial thrombolysis (Ia-Tx). And recent introduced SEDAN score is well correlated with hemorrhageic complication, in patients with intravenous tissue plasminogen administration (i.v.-tPA). Authors tried to evaluated the validity of the SEDAN score of the hemorrhagic complication rate and prognostic values, in patients who undertook IA-Tx.
Methods: 100 patients out of 121, who undertook acute stroke MRI before the IA-Tx, were included in this analaysis. SEDAN score were evaluated retrospectively by review of medical records and radiologic images. Incidence of the hemorrhagic complication, patient initial neurologic status and neurologic outcomes and recanalization rate were evaluated.
Results: SEDAN score was not correlated with the hemorrhagic complication, rather it was correlated well with the recanalization, initial neurologic status and neurologic outcomes (p<0.05).
Conclusions: In treatment of IA-Tx, P/D mismatch is much significant than SEDAN score, not only incidence of hemmorrhagic complication but also patient outcomes. But on a emergency situation for management of acute stroke patients, knowledge about SEDAN score may help for physicians to decision making.
interv neuroradiol. 2014 Apr 4;20(2):188.
Background and Objective: The standard treatment modality in acute stroke patients is intravenous tissue plasminogen activator (IV-tPA) administration, but its therapeutic results on large-artery intracranial occlusive disease (LAICOD) are questionable. Authors analyzed the recanalization rate of IV-tPA therapy in LAICOD patients.
Methods: A total of 202 patients with infused IV-tPA were included in this retrospective analysis. All patients, underwent brain CT-angiography as an initial image study and after IV-tPA administration, MRI was performed. And in 40 patients with failure of recanalization after IV-tPA, additional IA-Tx was attempted if the patient was within 6 hours from the symptom attack. Clinical outcomes were compared by recanalization rate, modified Rankin Scale (mRS), and hemorrhagic complication rate.
Results: 119 patients were defined with LAICOD, 79 patients received IV-tPA only and 40 patients were given IV-tPA and additional IA-Tx. The recanalization rate of LAICOD patients after IV-tPA was 13.4% (16 out of 119 patients). Patient outcomes of recanalized patients after IV-tPA, showed a more favorable outcome (mRS=0~2, 73.3%) than non-recanalized patients (favorable outcome = 31.3%). Patients who underwent additional IA-Tx, showed 87.5% recanalization rate and these patients’ mortality was significantly low than non-recanalized after IV-tPA administration (31.3% vs. 17.1%, p<0.05).
Conclusion: From this study, the recanalization rate after IV-tPA on LAICOD patients was very low and non-recanalized patients’ clinical outcomes were also poor. Authors would like to propose that IA-Tx might be considered as an additional treatment modality for LAICOD patients who didn’t recanalized after IV-tPA administration.
interv neuroradiol. 2014 Apr 4;20(2):188–189.
Purpose: Mechanical thrombectomy using solitaire stent has been an emerging treatment of choice in acute arterial occlusion irrespective of the location of the lesion. However, unpredicted detachment of Solitaire stent is one of the fatal events during the procedure of mechanical Solitaire thrombectomy. The purpose of this study is to evaluate the propensity of the unexpected detachment of the Solitaire stent retrospectively.
Material and Method:During January 2012 to June 2013, we conducted a retrospective study of consecutive patients presenting with acute ischemic stroke treated with mechanical Solitaire thrombectomy in 3 experienced stroke centers. Nine cases of the unexpected detachment of the solitaire stent developed during mechanical Solitaire thrombectomy.
Result: Median Age of the patients was 76 years old (range, 57~85). The occlusion site of the unexpected stent detachment included the proximal middle cerebral artery in 7 and the internal carotid artery in 2. Stent size of unexpected detachment included 6 mm*30 mm in 7,5 mm*30 mm in 1, and 4 mm*20 mm in 1 lesion. Unexpected detachment was occurred in 4 patients at first retrieval, 1 patient at second, 3 patients at third, 1 patient at fifth. Stent deploy site of the cases that unexpected detachment occurred at first retrieval were proximal MCA lesions in all cases. After detachment, proximal marker of Solitaire was seen in 3 patients. However, that was not seen in the other 6 patients.
Conclusion: Unexpected detachment of solitaire stent should be considered in the first time of the stent retrieval with a relative large diameter, especially in the elderly patients with MCA occlusions.
interv neuroradiol. 2014 Apr 4;20(2):189.
Background and Purpose: Prognosis of acute internal carotid occlusion(AICAO) is well known to be poor however, a minority of those AICAO patients shows relative fair initial NIHSS.Aggressive endovascular treatment is deferred in those cases due to potential risk and complication.
Material and Method:From Jan. 2009 to Dec 2013, there are six patients with initial fair NIHSS among 60 patients with AICAO in our institute. Fair NIHSS defined less than 6. Those six patients did not undergo emergent endovascular treatment for not severe clinical symtoms. Instead, they were treated intensive medical treatment (IV-tPA, IV heparinization with volume expander therapy, dual antiplatlet medication). We retrospectively analyzed clinical course and coutcome of those pateints.
Results: All (6/6) patients showed neurologic detoriation(Increse in NIHSS more than 4) between 3 hours and 70 hours in spite of all possible mecial treatment. Initial angiography presented abundant cross filling through anterior communicating artery (A-com) and/or Posterior communuicating artery (P-com) in all patients (6/6). Intracranial artery occlusion due to secondary thromboembolism developed in three patients (3/6). Middle cerebral artery (MCA) occlusion happened in three patients and both anterior cerebral artery (ACA) occlusion and MCA occlusion occurred in one patient. The patients underwent secondary embolic event showed more steep increase of NIHSS than the rest 3 patient did not have secondary attack.
Conclusion: Preemptive endovascular treatment of acute ICA occlusion patients with initial fair NIHSS can be considered.
interv neuroradiol. 2014 Apr 4;20(2):189–190.
Backgrounds: Despite collateral flow plays an important role in maintaining tissue viability in acute ischemic stroke with large vessel occlusion, collateral flow at angiography are not used for decision-making in endovascular therapy or assessment of clinical outcomes after endovascular therapy. The relationship among the angiographic baseline collateral flow, recanalization and clinical outcomes after endovascular therapy remains unknown. We aimed to assess relationship among the baseline angiographic collateral flow, recanalization and clinical outcomes after endovascular therapy.
Method: We assessed patients presenting with acute anterior circulation ischemic strokes to undergo endovascular therapy from January 2011 to May 2013. Eighty three patients were performed baseline cerebral angiography. We assessed baseline characteristics, National Institutes of Health Stroke Scale(NIHSS) score on admission, prior use of intravenous tissue plasminogen activator (Combined IV-tPA), and site of occlusion, first found abnromal time to arrival times (FAT to arrival times), baseline angiographic collateral flow, recanalization (Thrombolysis in Cerebral Infarction[TICI] scale) and clinical outcome (modified Rankin scale [mRS] score). We divided 4 clinical outcome categories to Good outcome (mRS 0, 1, 2), Fair outcome (mRS 3, 4), and Poor outcome (mRS 5, 6). To assess baseline angiographic collateral flow (BACF) was used Angiographic Collateral Flow Grading System by the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology. TICI scale was designed as Good recanalization (TICI 3, 2b), Partial recanalization (TICI 2a) and Bad recanalization (TICI 1, 0).
Results: Among 83 patients, the mean age was 69.0 years, and female was 46 (55.4%). BACF grade 4 and grade 3 were showed the 10 patients (12.0%) and 47 (56.6%). BACF grade 2 and 1 were showed 19 (22.9%) and 7 (8.4%). Good recanalization was achieved in 43 (51.8%). Partial recanalization was achieved in 15 (18.1%). Bad recanalization was achieved in 25 (30.1%). Good outcome was showed in 39 (46.9%). Fair outcome was showed in 19 (22.9%). Poor outcome was showed in 25 (30.1%). Clinical outcome was significantly associated with BACF. Good outcome occurred in 33 (57.9%) of 57 patients with BACF grade 3 and 4. On the other hand, good outcome occurred in 6 (23.1%) of 26 with BACF grade 0, 1 and 2. Good recanalization was significantly related with BACF. Good recanalization achieved in 35 (61.4%) of 57 patients with BACF grade 3 and 4, whereas good recanalization occurred in 8 (30.7%) of 26 with BACF grade 1 and 2.
Conclusions: Good baseline angiographic collateral flow may help to predict better clinical outcome and to achieve successful recanalization after endovascular treatment in acute ischemic stroke.
interv neuroradiol. 2014 Apr 4;20(2):190.
Background & Purpose: Mechanical thrombectomy with many devices has improved recanalization rates when compared to clot disruption with a wire and microcatheter alone. Among the many devices, the Solitaire stent retriever and forced arterial suction thrombectomy (FAST) with Penumbra reperfusion catheter were introduced recently. The aim of this study was to compare our immediate recanalization rates with these two available mechanical devices and switch technique of these devices.
Materials and Methods: A retrospective review from March 2010 to November 2013 was performed on patients who underwent mechanical thrombectomy for large vessel occlusion. Cases where IATPA and/or balloon angioplasty and/or stenting performed without mechanical thrombectomy were excluded from the study. Recanalization rates were assessed immediately post-procedure by follow-up angiography. TIMI and TICI scores were used to quantify the extent of recanalization and the residual clot burden.
Results: Forty eight procedures were performed on 46 patients using Solitaire-FR (SOL):28 and FAST:20. Nine cases underwent thrombectomy using both FAST and Solitaire devices. The M:F ratio was 1.1:1. The most common vascular territory involved was the right MCA (13/48) followed by left MCA (10/48), basilar top (9/48), Rt. ICA (8/48), left ICA (7/48), and left posterior cerebral arteries (1/48). The average needle to recanalization time was 61 minutes (SOL: 54 and FAST: 71). Additional procedures were performed in 23% (11/48) of the cases [SOL: 7% (2/28) and FAST: 45% (9/20)]. The number of Solitaire stent passes was 1.6 (range 1-6) in solitaire only cases, but the number of FAST was 2.3 (rage 1-3) in FAST only cases. Complete recanalization was achieved in 59.1% (13/22) [SOL: 64.3% (18/28) and FAST: 50% (10/20)]. The rate of complete recanalization was statistically significant for the Solitaire group vs. the FAST group (<0.05).
Conclusions: The study reveals a higher rate of angiographic recanalization using the Solitaire-FR device, requiring a lesser number of passes and other associated procedures as compared to FAST. Thus, Stent retrievers (Solitaire-FR) are advantageous in faster device delivery and quick flow restoration. In difficult cases, switch technique from Solitaire stent to the FAST was more effective than vise versa. However, future prospective randomized large trials are required to confirm these early results.
interv neuroradiol. 2014 Apr 4;20(2):191.
Purpose: To compare radiation doses for various flat panel DSA acquisitions with varying parameters using a cerebral aneurysm phantom.
Materials and Methods: A homemade silicone aneurysm phantom was immersed in a water container (20(h)x21(w)cm). Measurement of radiation dose in terms of dose area product (DAP), air kerma (AK), and peak skin dose (PSD) were performed simulating a 16 sec DSA exposure, 16 sec fluoroscopy, DSA perfusion, 3D angiography, vasoCT, and XperCT acquisitions using a flat panel DSA machine (Philips Allura Xper FD 20/20). Radiation doses were compared by varying parameters such as the SID, FOV, collimation, filtration for DSA, patient type, fluoro mode with reference to the phantom images.
Results: A single DSA AP/lateral run (110/6/31cm, 16secs, 20 frames) resulted in AK, PSD, and DAP of 129.7/152.5 mGy, 122.3/163.5 mGy, and 47.36 Gycm2. Addition of 0.1 mmCu+1 mmAl resulted in 34.9% reduction of DAP on AP/Lat DSA runs. The AK and PSD also showed 30.9/44.0% and 20.9/65.5% reductions. Decrease of AP/lateral SID from 120/112 cm to 110/102 cm did not show a significant increase in DAP (0.4%) but the AK and PSD decreased 21/7.2% and 19.4/5.2%, meanwhile the fluoroscopic DAP, AK and PSD showed 4.2%, 13.3/22.7%, 11/21.1% decrease. Enlargement of FOV from 15cm to 19 cm resulted in 6.5/7.0% and 4.5% decrease of AK and PSD, however an 32.4% increase of DAP. Addition of collimation (AP 0.8/1.4 cm, Lat 3.0/0.9 cm) after FOV enlargement resulted 2.9/-0.4%, 5.3/-1.0%, and 38.4% decrease of AK, PSD, and DAP. Similar trends were seen for fluoroscope. Changes of patient type from very small adult to baby resulted in 78/69.8%, 75.5/52.2% and 69.6% decrease in AK, PSD, and DAP. Change of fluoroscope mode from normal to low resulted in 25.4/43.2%, 27.2/40.7%, and 34.4% decrease in AK, PSD, and DAP. Increase of 3D rotational angiogram FOV from 15 to 19 resulted in 4.0% reduction in AK but 33.0% increase in DAP. 3D rotational angiogram (15 cm), DSA perfusion AP view, vasoCT, and XperCT resulted in AK/PSD/DAP of 36.485 (AK) /1413 (DAP), 161.5/171.1/26.911, 141.6/28.0/8.765, and 65.19 mGy/43.4 mGy/23.076 Gycm2, respectively.
Conclusion: Adjusting DSA parameters (filtration, minimizing detector distance from patient, demagnification with collimation, choice of DSA & fluoro modes, minimizing special acquisitions) may allow reduction in radiation dose for cerebral angiograms. Proper radiation dose reduction protocols should be implemented with regards to image quality.
interv neuroradiol. 2014 Apr 4;20(2):191–192.
Objective: By showing the fate of radial artery after TRCA, we discuss about feasibility and safety of routine TRCA.
Methods: From January 2011 to November 2013, retrospective analysis of data, which was collected in prospectively, was performed for the patients who underwent transradial routine cerebral angiography. 490 procedures of cerebral angiography of 408 patients were performed. TRCAs were performed in 441 cases of 361 patients. In all of the cases, pre-procedure Doppler ultrasonography was carried out. And 228 cases of 177 patients got early follow-up Doppler ultrasonography on 7th day after procedure and were enrolled in this study, Ultrasonographic findings such as diameter and any vascular complications were evaluated and analyzed by a blinded neuroradiologist.
Results: All the patients showed negative Allen’s test (normal collateral palmar circulation) before procedure. The mean pre-procedure radial artery diameter was 2.48 mm (1.2-3.6, median 3.05) and the post-procedure mean radial artery diameter was 2.51 mm (0.8-4.7, median 2.5). In 23 radial arteries (10.1%), there were asymptomatic vascular complications on the follow-up Doppler ultrasonography; 2 cases of marked intimal hyperplasia with obstructive flow pattern in 1 case, suspicious arteriovenous fistula in 1 case, 2 cases of local hematoma with one case compressing radial artery to 0.8 mm, 4 cases of stenosis with 3 near occlusion, one case of occlusion which was found resolved in 7 month follow-up Doppler, 2 cases of pseudoaneurysm, 7 cases of thrombus formation, 2 cases of fusiform aneurismal dilation and 2 cases of dissection. Only 6 cases of them (2.6%) showed change of flow pattern in flowmetry. All of the findings of above mentioned were asymptomatic. Thirty four patients got multiple procedures of TRCA on same radial artery, 2 patients with 4 procedures, 8 with 3 procedures and 24 with 2 procedures. All of their radial arteries were kept patent and only one case showed thrombus formation which resolved after 2 weeks.
Conclusion: High rate of vascular complications without any clinical symptoms were noted by early follow up Doppler ultrasonography. The fate of the complicated radial artery should be more evaluated by late follow-up Doppler ultrasonography.
interv neuroradiol. 2014 Apr 4;20(2):192.
Zeego (Siemens, Germany) is the multi-axial C-arm interventional angio-machine and can be used in the operation room as the hybrid operating system for combined surgical and neuroendovascular treatment. It allows us to do not only simple percutaneous neurointerventions, but also surgical neuroendovascular treatment, like a craniotomy and catheter intervention or a neck dissection and catheter intervention. We treated 300 patients with cerebrovascular diseases using Zeego, and present representative cases treated using this kind of surgical catheter-interventional approach instead of the difficult percutaneous approach, including patients with dural AV fistulas and intracranial aneurysms.
interv neuroradiol. 2014 Apr 4;20(2):192.
Purpose: To evaluate the safety and feasilility of the cerebral tumor biopsy and aspiration cerebral abcess technique under CT scanner guidance
Material and Method:The procedure was perfomed under sedation anesthesia and controlled by many consecutive slide with and without contrast material on the Siemens two barette machine. The specimens acquised through 14 or 16 Gause needle.
Result: Four patients have been done cerebral biopsy and abcess drainage with aspiration technique. Three patients have result of cerebral tumor, including one fibrilairy astrocytoma, one glioblastoma multiform and the other show cerebral metastasis with adenomatous cell (lung tumor). The fouth patient has been done two different time for pus aspiration due to cerebral abcess (clinical symptom improved after aspiration). All of four patients have no intracranial haemorrhage complication.
Conclusion: cerebral biopsy and sspiration abcess under CT scanner guidance is the feasible and safe technique. It is usefull in the cas needed to know pathologique of intracranial tumor to planning the strategy treatment.
interv neuroradiol. 2014 Apr 4;20(2):192–193.
Purpose: To evaluate the efficacy of Gasserian ganglion neurolysis in the treatment of tic douloureux using absolute alcohol injected percutaneously while monitoring needle placement with fluoroscopic and DSA guidance.
Materials and Methods: a prospective descriptive study. DSA was used to confirm the good position of the needle’s tip and to verify the absence of leakage of contrast media. Then, 2ml absolute alcohol was injected in the Gasserian fossa only when no leakage was detected.
Results: from April 2012 to August 2013, the procedure was performed in 23 patients having an average age 63.5 ± 10 y/o with the oldest one being 83 y/o. A complete disappearance of the pain was observed in 96% of the cases. However facial numbness was noted as a side effect in 82% of the cases. All patients much preferred the numbness to the pain. No other significant complications were seen.
Conclusion: The percutaneous Gasserian neurolysis with absolute alcohol under DSA monitoring seems to be a safe, cheap, easy and effective means to treat trigeminal neuralgia.This procedure is useful particularly where economics is a factor.
interv neuroradiol. 2014 Apr 4;20(2):193.
Purpose: to present our first experiences in the celiac plexus neurolysis under CT guidance in order to reduce the abdominal pain due to unresecable cancer of the stomach, pancreas, liver or chronic pancreatitis.
Materials and Methods: a prospective descriptive study discribing the celiac plexus neurolysis using 22G Chiba needle and 30ml absolute alcohol to inject in the antecrural space under CT guidance after the block test with Lidocaine.
Results: From April to November 2013, sevent patients with uncontrolable upper abdomen pain due to cancer or chronic pancreatitis were treated by the celiac plexus neurolysis. 4 (/7) patients got a good relief with tha VAS score reduced by 5 right after the procedure. Once case got a result limited and two patients did not get any improvement so continue to be treated with medicaments. There was no grave complication except diarrhea (4-5 times per day) was observed in 6 (/7) patients.
Conclusion: The celiac plexus neurolysis with absolute alcohol under the CT guided could bring a good relief for the upper abdomen pain due to advanced stage cancer in this region or due to chronic pancreatitis. This prodedure could help to improve the quality of life and bring a human value.
interv neuroradiol. 2014 Apr 4;20(2):194.
Background: The Authors have experienced twenty cases of spinal dural fistulae (SDAVFs) since 1997. We discuss the strategy and technique of the treatment of SDAVFs according to the result of embolization.
Material and Method:The patients consisted of 18 males and one female. Their age ranged from 39 to 81 y.o. (mean 63). Location of the lesion was as follows; six craniocervical junction (CCJ), two cervical, 10 thoratic, two lumber and one sacral. presented with haemorrhage and 13 presented with venous congestion. Six cases presented with hemorrhage; five of them were CCJ and one was cervical lesion.
Results: All lesions except for CCJ and sacral lesions were successfully embolized without complication. No recurrence was experienced in these cases. Two cases of CCJ and one of sacral lesions could not be cured by embolization because of failure of catheterization or incomplete embolization. Two of CCJ lesions and one of cervical lesion were not even tried to be embolized. These seven cases were successfully treated by surgery.
Discussion: Surgery is the most reliable way of disconnecting SDAVFs. Many neurosurgeons say that surgery should be the first choice of the treatment of SDAVFs because of its reliability. Neuroradiologists suggest that embolization can be the first choice because of its minimal invasiveness and low risk. According to our results, embolization should be the first choice for thoratic and lumber SDAVFs. Treatment option for cervical and sacral SDAVFs should be decided depending on the result of diagnostic angiography. CCJ lesions are not good candidate for embolization and should be considered to be treated by surgery.
Conclusions: Embolization can be the first choice of the treatment of SDAVF, except for CCJ lesons. Surgery should be considered for CCJ lesions.
interv neuroradiol. 2014 Apr 4;20(2):194–195.
Objective: to study the effect of endovascular treatment on sinal arteriovenous malformations (SAMVs).
Method: We prospectively studied patients who were diagnosed with spinal AVMs and treated endovascularly with NBCA glue at the University Medical Center_HCM City from January 2009 to September 2013. The Aminoff-Logue disability scale was used to evaluate clinical features of the patients.
Results: Seventy-five SAVM patients were treated by endovascular occlusion. 40% were type 1, type 2 and type 3 together made up 20%, and 40% were type 4. Endovascular treatment deemed effective with absolute occlusion achieved in 97% of type 1 and 63% of type 4 patients. Failure rate was 7%, and recanalization occurred in 15%. Complications existed in 10.6% of cases, 2 of which is severe with 1 death due to subarachnoid hemorrhage and 1 tetraplegia after treating a type 2 cervical SAVM. After the mean following time of 19 ± 9.7 months (from 2 to 37 months), clinical recovery was achieved in 80% of cases. 5 patient (7%) was worse during follow-up, mostly in type 2 and 3. Only the patients’ clinical presentation before treatment was found to be statistically related with clinical outcome.
Conclusion: Endovascular treatment for spinal AVMs were found to be effective, with some minor limitation.
interv neuroradiol. 2014 Apr 4;20(2):195.
Background: Vertebroplasty and kyphoplasty are effective technique for vertebral hemangiomas or spinal fractures. This study reports the applying that technique in EXSON center for 5 years with the aim to provide an insight of situation of vertebroplasty and kyphoplasty in our country.
Material and Method:Retrospective study on all patients, who got vertebroplasty or kyphoplasty in EXSON center from June 2008 to August 2013.
Results: There were 1035 patients with 1130 times underwent vertebroplasty or kyphoplasty procedures affected on 2023 vertebral bodies. There were 45 patients (4%) with spinal traumatic fractures, 28 patients (2.5%) with vertebral hemangiomas including 15 patients with both vertebral hemangiomas and spinal osteoporotic fractures. In 1130 times of applying procedures, before 1062 times (93,9%), patients could not neither sit nor stand nor walk. 977 patients with spinal osteoporotic fractures carried out 1085 procedures of vertebroplasty and kyphoplasty, in that 21 patients were applied kyphoplasty. In osteoporotic series, there were 836 women (85,6%) and 141 men (14,4%), mean age of that series was 72.5. 778 patients (79.8%) got bone density assessment with DXA bone densitometer, T-score ranged from -3.1 to -6.8. There were 1950 osteoporotic vertebral body fractures, from T3 to L5, carried out the procedures, most frequently was L1 (433 vertebral body, 22.2%). In 278 patients (28.5%), cement leaked out into adjacent tissue but it was not any complication. In 23 patients, cement leaking to lung was found out by chest x-ray after procedures but it was not any infarctus detected. There were 1091 cases (96.5%) patients could easily move during 24 hours after procedures. 719 patients (74.7%) underwent osteoporotic treatment after vertebroplasty and kyphoplasty.
Conclusion: Vertebroplasty and kyphoplasty is a minimally invasive technique providing high efficacy of pain relief in treatment of spinal fractures, especially osteoporotic fractures.
interv neuroradiol. 2014 Apr 4;20(2):195.
Objective: FVH Pain Clinic, the first Pain Clinic in Vietnam, has done interventional technique in Pain Management from 2006. We take time to learn, so now we would like to review our result in 3 last years (2010-2013) to get experience and improve our protocol.
Material and Methods: This is a prospective study. 120 patients were chosen by chance in 860 patients who were done injection from 1/2010 to 12/2013 at Pain Clinic of FV hospital.
Result: 120 patients with 164 injections - Age: 26-93 years old - Category of injection: - Number of injection: - + 1 injection: 80 cases - + 2 injections: 28 cases - + 3 injections: 10 cases - Kind of injection: Epidural injection: 50 cases (31%) - LMB injection: 81 cases (49%) - Foraminal injection: 9 cases (4%) - Foraminal RF: 11 cases (7%) - LMB RF: 11 cases (7%) - Epidurolysis: 4 cases (2%) - The Ratio of Effective Pain Management: Successful Epidural cases: >70% (within 3 months until 3 years). If the patient also has facet pain, LMB injection will be added in treatment. Successful LMB cases: > 80% (within 3 months until 3 years).
Some experiences: - LMB techniques are very useful in cervical and lumbar facets pain treatment for the old patients and osteoporosis. - Unsuccessful cases often happen to the youth with anxiety disorder or depression. - Radio frequency is only asked for effective injection in short time. - If the injection is not totally effective or the patient recur quickly, re-estimating diagnostic, redoing MRI may be requested.
Conclusion: Injection techniques are really effective in pain management. However, choosing the patient as well as the technique is very important. It is better to have good cooperation between Pain Specialists and Neurosurgeon. In addition, patients with psychology and depression matters have to be controlled well before deciding do injection. Finally, diagnostic injection also has an important role in determining facet joint and radicular pain.
interv neuroradiol. 2014 Apr 4;20(2):196.
Objectives: We report our experience in treatment of traumatic direct carotid cavernous fistula (CCF) via endovascular intervention. We hereof recommend an additional classification system for type A CCF and suggest respective treatment strategies.
Methodology: Only type A CCF patients (Barrow’s classification) would be recruited for the study. Based on the angiographic characteristics of the CCF, we classified type A CCF into three subtypes including small size, medium size and large size fistula depending on whether there was presence of the anterior carotid artery (ACA) and/or middle carotid artery (MCA). Angiograms with opacification of both ACA and MCA were categorized as small size fistula. Angiograms with opacification of either ACA or MCA were categorized as medium size fistula and those without opacification of neither ACA nor MCA were classified as large size fiatula. After the confirm angiogram, endovascular embolization would be performed im-promp-tu using detachable balloon, coils or both. All cases were followed up for complication and effect after the embolization.
Results: A total of 172 direct traumatic CCF patients were enrolled. The small size fistula was accountant for 12.8% (22 cases), medium size 35.5% (61 cases) and large size fistula accountant for 51.7% (89 cases). The successful rate of fistula occlusion under endovascular embolization was 94% with preservation of the carotid artery in 70%. For the treatment of each subtype, a total of 21/22 cases of the small size fistulas were successfully treated using coils alone. The other single case of small fistula was defaulted. Most of the medium and large size fistulas were cured using detachable balloons. When the fistula sealing could not be obtained using detachable balloon, coils were added to affirm the embolization of the cavernous sinus via venous access. There were about 2.9% of patient experienced direct carotid artery puncture and 0.6% puncture after carotid artery cut-down exposure. About 30% of cases experienced sacrifice of the parent vessels and it was associated with sizes of the fistula. Total severe complication was about 2.4% which included 1 death (0.6%) due to vagal shock; 1 transient hemiparesis post-sacrifice occlusion of the carotid artery but the patient had recovered after 3 months; 1 acute thrombus embolism and the patient was completely saved with recombinant tissue plaminogen activator (rTPA); 1 balloon dislodgement then got stuck at the anterior communicating artery but the patient was asymptomatic.
Conclusion: Endovascular intervention as the treatment of direct traumatic CCF had high cure rate and low complication with its ability to preserve the carotid artery. It also can supply flexible accesses to the fistulous site with various alternative embolic materials. The new classification of type A CCF based on angiographic features was helpful for planning for the embolization. Coil should be considered as the first embolic material for small size fistula meanwhile detachable balloons was suggested as the first-choice embolic agent for the medium and large size fistula.
interv neuroradiol. 2014 Apr 4;20(2):196–197.
We are reporting a 51-year-old female patient having a history of direct carotid cavernous fistula (CCF) which was treated by internal carotid artery (ICA) ligation 17 year ago. She presented to Ho Chi Minh City University Medical Center with symptoms of recurrent CCF. The recurred CCF was supplied by multiple feeders coming from anterior, posterior communicating artery and the recanalized left ICA. Her CCF was not plausible for another surgical ligation and was referred for endovascular treatment. The fistula was eventually occluded by percutaneous embolization via the right ICA approach. Through this case, we would like to discuss about the treatment strategies of those having recurrent CCF with preexisted ICA ligation.
In Vietnam, previously carotico-cavernous fistula was mainly treated with muscle occlusion, carotid artery ligation or combinations of these methods. There were reported good outcomes for treatment of CCF surgically. However, surgical repairs had carried, not only complication, but a risk of recurrence due to recanalization of the previously ligated ICA.
Since the emergence of endovascular intervention, the treatment of direct CCF has evolved from surgical ligation to angiographic embolization using balloon or coils via artery route or venous access. This endovascular method currently is the treatment of choice for traumatic CCF due to its ability to preserve the carotid artery and flexibility in treatment strategy with various approaches to the fistula.
interv neuroradiol. 2014 Apr 4;20(2):197.
We are presenting a case of a young male patient having a carotid cavernous fistula (CCF) after a head injury. He presented to the other hospital and was embolized with a detachable balloon. After being discharged, his proptosis became worse and his cognition became sluggish. He was referred to us for repeating the assessment of his CCF which was still present. It had become worsened with a huge aneurysmal dilatation of the cavernous sinus and refluxes into the cortical cerebellar and spinal veins. The balloon was seen within the cavernous sinus which was not working. We decided to repeat the embolization using detachable balloons again. Totally 6 balloons were used and the fistula was sealed. He was discharge well with improvement of his Glasgow comma scale. Dangerous venous drainage had occasionally happened in CCF cased in which there was reflux into cortical and spinal veins. It is associated with intracranial venous hemorrhage. Detachable balloon was demonstrated as an effective embolic material even in complicated case with largely dilated cavernous sinus.
interv neuroradiol. 2014 Apr 4;20(2):197.
Background: Carotid-Cavernous fistula is a direct connection between carotid artery and cavernous sinus. This connection made a high pressure on veins that drain the venous blood to the cavernous sinus, and sometime retrograde flow. This venous hypertension and retrograde flow will cause neurologic deficit. The most frequent sign and symptoms are on the eye. The others are: epistaxis, intracerebral hemorrhage and weakness. In some progressive cases an urgent treatment is necessary.
Purpose: To share some experience in treating CCF with endovascular and surgery procedures.
Material: In our series we have treat 12 cases of CCF. The symptoms are: ocular problem 9 cases, epistaxis 2 cases, and ICH one case.
Result: Our treatment are : balloon embolization 9 cases , coil embolization 2 cases, surgery one case. In two cases carotid artery was sacrifice, one by coiling and the other one by surgery
Discussion: CCF is a progressive disease and cause permanent neurologic deficit. The target is to close the fistula which reduce the venous pressure and restore the neurologic deficit.
Conclusion: There are many method to stop the fistula and if the fistula can be stopped, the symptom will improve.
interv neuroradiol. 2014 Apr 4;20(2):197–198.
Carotid cavernous fistula (CCF) is an abnormal communication between cavernous portion of internal carotid artery and cavernous sinus. These are classified as direct and indirect CCF. Direct CCF is direct communication of ICA with cavernous sinus. Indirect CCF is communication of dural branches of ECA and ICA with cavernous sinus. The most common cause of direct CCF is rupture of aneurysm into cavernous sinus and Trauma. The common cause of indirect CCF is thrombosis of sinus with development of fistula.There are various Methods of treating direct and indirect CCF by endovascular means. CCF can be treated endovascularly by balloon occlusion of cavernous sinus, coiling of cavernous sinus, stent graft , Onyx alone or Onyx with coils and parent vessel occlusion. We present a case of indirect CCF which was treated endovascularly through venous route from inferior petrosal sinus. Patient recovered from the symptoms completely.
interv neuroradiol. 2014 Apr 4;20(2):199.
interv neuroradiol. 2014 Apr 4;20(2):200.
Introduction: The management of patients with ruptured cerebral aneurysms and severe vasospasm is subject to considerable controversy. Described herein is an endovascular technique to simultaneously address both aneurysmal rupture and vasospasm, demonstrating the efficacy of treatment.
Methods: A series of 11 patients undergoing simultaneous endovascular treatment of ruptured aneurysms and vasospasm were reviewed. After placement of a guiding catheter within proximal internal carotid artery for coil embolization, an infusion line of nimodipine is wired to one hub, and of a microcatheter is advanced through another hub (to select and deliver detachable coils). Nimodipine is then infused continuously during coil embolization.
Results: This technique was applied to 11 ruptured aneurysms accompanied by vasospasm (anterior communicating artery, 6 patients; internal carotid artery, 2 patients; posterior communicating and middle cerebral arteries, 1 patient each). Aneurysmal occlusion by coils and nimodipine-induced angioplasty were simultaneously achieved, resulting in excellent outcomes for all patients, and there were no procedure-related complications. Seven patients required repeated nimodipine infusion.
Conclusions: Our small series of patients suggests that the simultaneous endovascular management of ruptured cerebral aneurysms and vasospasm is a viable approach in patents presenting with subarachnoid hemorrhage and severe vasospasm.
interv neuroradiol. 2014 Apr 4;20(2):200.
A boy 10 year-old, neither history of infection nor congenital heart diseases, suddenly had severe headache, vomiting, and mild fever for two days. His head CT Scan revealed subarachnoid hemorrhage in the frontal interstice. And subsequent transfemoral cerebral angiography (DSA) revealed that there were two aneurysms from the distal branch of the Right anterior cerebral artery. These others cerebral arteries were normal. After diagnostic a few days, he underwent microsurgery for clipping aneurysm, but the surgery was unsuccessful because of the brain oedema. The neurosurgeon did only craniotomy for decompression. After the surgery, his GCS was 15 points. Then, he was treated by endovascular therapy after 7 days onset. During the second angiogram, the second new aneurysm was found nearby and distal to the 1st one. We suggested mycotic aneurysm and deployed two coils sacrificed two aneurysms segment. After embolization the patient had no deficit and no fever, he was treated with dual antibiotic agent. By the 20th day, he suddenly had seizures, and unconsciousness rapidly. His GCS was 6 points and head CT Scan revealed a massive parenchymal hemorrhage in the Left occipital, where is not related to both aneurysms. Emergency surgery was performed with hematoma removal and decompressed craniotomy. After the surgery 6 months, he is conscious, can sit firmly but he can’t walk himself. He is treating by physiotherapy and rehabilitation. Intracerebral mycotic aneurysm is rare and difficult to treat.
interv neuroradiol. 2014 Apr 4;20(2):200–201.
Object: Intradural internal carotid artery (ICA) aneurysms may grow closer to anterior optic pathways, causing mass effect over these anatomical structures, including visual deficit. In this study, we report the outcomes of patients presenting with visual field deficit attributed to optic pathway compression.
Methods: The authors retrospectively reviewed data of 19 patients who harbored unruptured ICA aneurysm presenting with visual field deficit caused by mass effect over the anterior optic pathways between 2010 and 2012. Statistical analysis was performed to identify the variables related to partial or total recovery of the visual symptoms. Aneurysm location was ICA cavernous in 1, ICA ophthalmic in 5, ICA paraclinoid in 13. Fifteen aneurysms were greater than 10 mm in diameter including 4 giant aneurysms.
Results: Direct neck clipping of the aneurysm was performed in 10 aneurysms, EC/IC bypass + endovascular trapping in 3, coil embolization in 5 and proximal artery occlusion in 1. After a mean follow-up of 8.7 months, the visual outcomes were as follows: 2 patient (10.5%) worsened, 7 (36.8%) unchanged, 3 (15.8%) improved and 7 (36.8%) experienced complete recovery from visual deficits. The variables that influenced the visual outcomes were the duration of the visual symptoms (p = 0.028) and severity of symptoms (p=0.035). The treatment modalities were not significantly associated with the visual outcomes.
Conclusions: It is difficult to achieve sufficient decompression of the optic pathway when the aneurysm is large or giant. The authors found that endosaccular embolization therapy may be benefit vision. The duration and the severity of the visual symptoms were clinically correlated with the outcome of anterior optic pathway compression by ICA aneurysm.
interv neuroradiol. 2014 Apr 4;20(2):201.
We report an unusual case of cerebral aneurysmal subarachnoid hemorrage (SAH) with Fabry‘s disease. A 42-year-old woman presented with aneurysmal SAH which is originated a saccular aneurysm of the right posterior communicating artery. This patient was treated by an endovascular coil embolization of aneurysm. Postoperatively, the patient recovered well without neurological deficit. During an admission, patient had a sign of proteinuria in urine analysis. In kidney needle biopsy, pathologic findings showed the suggestive of nephrosialidosis (mucolipidosis of lysosomal stroage disease) which is consistent with a Fabry‘s disease. Fabry‘s disease presented with aneurysmal SAH, especially in middle-aged is uncommon, but could be a clinical concern. Further investigation to reveal risk factors, vascular anatomy, and causative mechanisms of a Fabry‘s disease with aneurysmal SAH.
interv neuroradiol. 2014 Apr 4;20(2):201–203.
Introduction: Coiling of intracranial aneurysms has become the treatment of choice and has partly replaced neurosurgical clipping in most neurosurgical institutions. However, in difficult aneurysms with a very complex neck configuration, primary bypass of the aneurysm neck using any kind of microguidewires or microcatheters may also fail. The Neuroform stent is a device specifically designed for use in cerebral vessel and is increasingly being used in the embolization of wide-necked aneurysms, but complication and long-term patency are unsatisfactory. Recently, the use of stent-assisted coiling with preservation of the parent vessel lumen has been described in some series. Most studies have shown that with the advances in device technology intracranial stenting is feasible. lntracranial epidural hematoma (EDH) is usually a consequence of head injury. But, spontaneous epidural hematoma can occur in patients with paracranial infections, bleeding or coagulation disorder, vascular malformation, and neoplastic disorder. We present first case report demonstrates delayed spontaneous EDH occurring as a complication of stent assisted coiling of a ruptured intracranial aneurysm.
Case presentation: This 59-year-old woman was transferred from a local hospital due to symptoms of severe headache and decrease mentality. Brain CT scan revealed a subarachnoid hemorrhage with blood clot in basal cistern (Figure 1). On the first day in the hospital, three dimensional (3D) - CT angiography and diagnostic cerebral angiography performed. 3D CT and TFCA revealed a large wide-necked aneurysm of the left ICA (Figure 2). After a discussion of management options, vessel preservation was attempted by means of stent-assited coiling of the aneurysm. The patient was not pretreated with antiplatelets medication due to no time in emergency state. Following induction of intravenous sedation with propofol, a 6-French Envoy guiding catheter was placed in the ICA. The patient was anticoagulated with I.V. administered heparination maintaining the activated clotting time at 2.5 times the basal level. After successful stent placement, coil embolization was performed with detachable coils through a microcatheter (Excelsior SL-10; Target Therapeutics) placed in the aneurysm through the interstices of the stent (Figure 3). Heparinization was not reversed at the end of the endovascular procedure. The patient was maintained on daily aspirin and clopidogrel after stenting. Follow-up CT scan was performed at 10 days revealing a epidural hematoma within left frontal side (Figure 4). And then we are performed to craniotomy with hematoma removal (Figure 5).
Figure 1.
Figure 2.
Figure 3.
Figure 4.
Figure 5.
Discussion: Spontaneously occurring EDH is now a well-known entity. However, the spontaneous occurrence of an EDH after coil embolization has far never been reported in the literature. The etiology of spontaneously occuring EDH can involve three mechanisms. The first is neighboring infection, which is usually located in the paranasal sinuses and the middle ear. Two theories have been proposed to explain this mechanism. The first theory is that infection-related arteritis may weaken meningeal vessel walls, resulting in bleeding into the extradural space. The second theory is that accumulation of exudate, pus, or air in the extradural space causes progressive detachment of the dura mater from the inner table, and this process leads to diffuse extradural venous bleeding.
An elegant hypothesis advanced by Gordon specifies that dura mater detachment and subsequent bleeding may be enhanced by intracranial hypotension resulting from an occult cerebrospinal fluid fistula, a common finding in patients who present with spontaneously occurring EDH caused by otorhinolaryngological infection. Second possible mechanism for the spontaneous occurrence of hemorrhage in the extradural space is an iatrogenic, acquired, or congenital coagulation disorder. Our patient had not undergone anticoagulant or antiaggregate therapy, and complete blood coagulation analysis revealed no hematological abnormality. The third potential underlying mechanism of spontaneously occurring EDH is vascular malformation, including dural AVM, hemangioma of the dura mater or diploe , and middle meningeal artery aneurysm
Conclusion: The occurrence of an EDH after coil embolization is rare. Given the patient’s clinical history and the absence of both coagulation abnormalities and pericranial infection, the most likely explanation would be bleeding from an occult dural or extradural vascular malformation. However, more clinical data with longer follow-ups are needed to help establish the this event after coil embolization
interv neuroradiol. 2014 Apr 4;20(2):203.
Background and Purpose: Protective/remodeling techniques for treating wide-necked intracranial aneurysms are constantly sought. However, their utility may be limited in lesions that incorporate the mouths of acute-angled efferent branch vessels. Furthermore, passage of a protective microcatheter may be challenging if a small branch is extremely tortuous. This study was conducted to explore a novel method of treating wide-necked aneurysms, utilizing microguidewire protection.
Methods: A microcatheter is first passed into parent artery (proximal to aneurysm) to position a microguidewire proximally in the involved branch. A second microcatheter is then inserted into aneurysmal sac. Advancement of the protective microcatheter forces the microguidewire to shift, thus covering aneurysmal neck.
A framing coil may then be placed within aneurysmal sac, under microguidewire protection. After completing initial coil insertion, easing of tension on the microcatheter allows separation of protective microguidewire and frame coil, confirming stability of the initial coil.
Results: This technique was applied to 11 intracranial saccular aneurysms of M1 segment (n=6), MCA bifurcation (n=4), and AcomA (n=1) with success, combining stent protection in two patients. Coil embolization was thus facilitated, resulting in excellent outcomes for all patients. No morbidity or mortality was directly related to microguidewire protection.
Conclusion: Our small study suggests that microguidewire protection may be a safe alternative, if traditional remodeling or protective options are infeasible due to intrinsic vascular properties. This technique is particularly suited for treatment of wide-necked aneurysms where passage of protective microcatheters into involved branches is not achievable.
interv neuroradiol. 2014 Apr 4;20(2):203–204.
Purpose: Cerebral aneurysms may enlarge due to various factors and situations, such as hypertension, size, shape, projection and location. It is well known that larger aneurysm have a higher tendency to rupture. Therefore the prediction of the enlargement of an aneurysm is important to define the future outcome. We focused on the inflow energy into the aneurysmal sac based on computational fluid dynamics (CFD) method to identify the relationship with the enlargement from the long-term follow-up aneurysms.
Methods: CFD study was performed for 5 basilar aneurysms follow-up for a long time (3.6y-9.4y: average 7.3y). 3D reconstruction images were obtained from 3DCT angiography. CFD analysis was performed by the non-stationary finite volume method (Toyota Communication System Co., Ltd.). We investigated wall shear stress (WSS), inflow energy (IE) and pressure energy (PE) of the aneurysmal neck and studied the relationship between these parameters and the volume enlargement rate (VR) and the surface enlargement rate (SR).
Results: IE and PE were found to have a strong correlation with VR (correlation coefficient: IE 0.905, PE 0.922) and SR (correlation coefficient: IE 0.950, PE 0.979). Other factors including WSS did not a show definite relationship.
Conclusions: In our study, the higher IE or PE may have caused the enlargement of the aneurysm. In fact, WSS, the famous factors have influencing the rupture, had less relationship with enlargement. Even in the limited study situations of specific aneurysms, IE and PE may become a predictor of aneurysmal enlargement.
interv neuroradiol. 2014 Apr 4;20(2):204.
Five patients with ruptured vertebra basilar dissecting aneurysms, to which parent artery occlusion can not be applied, were treated by using Enterprise VRD. Thelocation of the dissecting aneurysms was vertebral artery in three patients and basilar artery in two. In all patients, Enterprise VRD was successfully deployed in the dissecting segment, and the coils were inserted in the aneurysmal dilatation by semi-jailing technique. Ischemic complication occurred in two patients and rebleeding occurred in one patient 4 months after the treatment. Favorable outcome was obtained in four of the five patients.
Enterprise VRD iseasy to access to the lesion, less stressful to the parent artery in the deployment, conformable to the tortuous parent artery, and available for semi-jailing technique. Stent-assisted coil embolization using Enterprise VRD can be a feasible and effective treatment in selected patients with ruptured vertebrobasilar dissecting aneurysmsnot suitable for parent artery occlusion.
interv neuroradiol. 2014 Apr 4;20(2):204.
The saccular aneurysms of vertebrobasilar junction are rare, but when present they are often associated with a fenestration of basilar artery. Basilar artery fenestration is reported in 0.6% of angiograms and in about 5% of some autopsy series. The complex anatomy of this region, such as multiple small perforators to the brain stem and multiple lower cranial nerves, makes surgical clipping difficult. Recently, it has been suggested that endovascular coiling is a treatment alternative to surgically difficult aneurysms. We present 2 cases of vertebrobasilar junction aneurysms associated with fenestration of basilar artery in four patients, which were treated with endovascular coiling with stents.
interv neuroradiol. 2014 Apr 4;20(2):204–205.
Objective: Aneurysms located at the distal portion of the posterior inferior cerebellar artery (PICA) are rare, and their clinical features are not fully understood. We report 4 cases and analyze their clinical characteristics and outcomes from three different treatment strategies.
Material and Methods: We retrospectively reviewed 4 cases with a distal posterior inferior cerebellar artery (PICA) aneurysm among 368 cases of intracranial aneurysms rupture that were surgically treated during the period from November 2008 to October 2013. The following data were analyzed: age, sex, aneurysm size, Hunt-Hess grade at presentation, angiographic characteristics, and clinical treatment outcome determined by Glascow outcome scores (GOS). Treatments performed included 2 endovascular sacrificing the parent arteries of the aneurysms, 1 selective coiling, and 1 clipping after failure of endovascular treatment.
Results: Four patients (4 all females; mean age: 58 years; mean aneurysm size: 4.7 mm) presented at our facility with subarachnoid hemorrhage (SAH) caused by aneurysm rupture. Two patients presented with Hunt-Hess grades 5; two others were in Hunt-Hess grades 2 or 3. The location of the aneurysm was telovelotonsillar in 3 cases and cortical in 1 cases. The angiographic findings were 1 fusiform dissecting aneurysm and 3 saccular aneurysms. One patient with fusiform dissecting aneurysm died because of no procedural related Rt. MCA infarction after endovascular sacrificing the parent arteries. The surviving three patients had GOS of 5.
Conclusion: Treatment decisions were based on the individual clinician’s experience, without a standardized approach to treatment. Endovascular sacrificing the parent artery of the distal PICA aneurysm result in permanent occlusion of the lesion. But selective coiling with parent artery preservation can be considered whenever the anatomy allowed the coils to be retained in the aneurysm sac. The type of parent artery and particularly the collateralization of its distal part should be considered as an essential factor to take into consideration when choosing a treatment strategy.
interv neuroradiol. 2014 Apr 4;20(2):205.
Purpose: A1 aneurysms (A1A) are rare, forming less than 1% of all intracranial aneurysms, and a few information is known about anatomical and clinical characteristics of A1 aneurysms. The aim of this study was to analyze the anatomical and clinical characteristics by their locations.
Material and Methods: In 27 patients with diagnosed pure A1 aneurysms, representing 1.4% of 1890 aneurysm patients to 2011, angiographical figures, clinical presentation, surgical or endovascular treatments and outcome were retrospectively analyzed. Twelve patients (44.4%) presented with subarachnoid hemorrhage (SAH), other fifteen patients were found incidentally during the evaluation for headache or stroke symptoms.
Results: Of 27 patients, proximal A1A were 15 and distal A1A were 12. 44.4% (12 of 27) of A1A occurred at proximal end and 29.6% (8 of 27) at distal end. ICA-A1 angle of proximal A1A were more narrow than distal A1A (83.3° ± 14.0 vs. 97.3° ± 14.3) (P = 0.017). 14 aneurysms (93.3%) projected posteriorly at proximal A1A but 2 aneurysms (16.6%) at distal A1A (P = 0.000), and 11 aneurysms (73.3%) projected superiorly at proximal A1A but 4 aneurysms (33.3%) at distal A1A (P = 0.039). Ruptured aneurysms were more frequently at distal A1A. (13.3% vs. 50%, P = 0.039) Proximal A1A was happened 1 seizure and 1 infarction, but at distal A1A 1 thrombus and 2 deaths.
Conclusion: Almost of A1A had arisen at both ends, and their characteristics were differ each other. Proximal A1A had short distance from ICABF and directed to posterior, appropriate micro-catheter shaping and neck-remodeling technique will be needed especially in endovascular treatment. And distal A1 aneurysms are carefully select treatment strategy because of vulnerable to rupture.
interv neuroradiol. 2014 Apr 4;20(2):205–206.
Background: A wide neck aneurysm in the vertebrobasilar junction is difficult to treat especially in a patient presented with SAH and there is no opposite vertebral artery.
Case report: A 61-year-old man presented with severe headache one day before and came to hospital with GCS 13 points and subarachnoid hemorrhage on his head CT scan. A wide neck aneurysm was found on the CTA at the right vertebrobasilar artery. On the angiogram showed the wide neck aneurysm 5x6mm at the right vertebrobasilar and there is no contralateral vertebral artery on the left side. Endovascular treatment was performed after 10 days of SAH with the “jailing” technique: 1 Leo Stent (BALT) and 3 coils were used. The aneurysm was cured with keeping the normal flow from the right vertebrobasilar artery. The patient had a good recovery and discharged 4 days after procedure without any deficits.
Conclusion: The ‘jailing’ technique can be used to treat wide neck aneurysms. This technique will be more difficult and dangerous when the artery is small and much more attention when the parent artery with no collateral circulation.
interv neuroradiol. 2014 Apr 4;20(2):206.
We have already developed Masamune balloon microcatheter. We recently developed “Super-Msamune”, a new type of Msamune, in which the balloon is modified into more compliant. The balloon itself is very compliant. It is more compliant than HyperForm, but is not single lumen but double lumen. It easily herniates to free space and makes better neck protection possible. Because of double lumen, it can be used only for neck plasty balloon, but also for the catheter for coil insertion. We will show initial experiences of this balloon in this presentation. The balloon is still immature now and further modification would be necessary. It would become commercially available within 1 year.
interv neuroradiol. 2014 Apr 4;20(2):206.
Objective: Distal cerebral aneurysms associate with various mechanisms for their formation and their surgical treatment are often difficult because of their difficulty of operative orientation. We report nine patients with distal cerebral aneurysm treated by embolization using n-butyl cyanoacrylate with or without coil.
Methods: Between 2007 and 2013, nine patients with ruptured distally located cerebral aneurysm were treated with n-butyl cyanoacrylate. We performed the embolization of aneurysmal sac and proximal parent vessels; endovascular internal trapping different from only proximal parent artery occlusion. The etiology and location of aneurysm were as follows: mycotic aneurysm (n=1), arteriovenous malformations (n=4), dissection (n=1), unverified etiology (n=3), choroidal segment of anterior choroidal artery (n=2), posterior inferior cerebellar artery (n=2), superior cerebellar artery (n=1), posterior cerebral artery (n=2) and middle cerebral artery (n=1), anterior cerebral artery (n=1). One case is a salvage therapy using glue for intraoperative aneurysmal rupture during coil embolization. Mean clinical and imaging follow-up duration was 18 months. (range, 8-32months).
Results: : In all 9 patients, embolization using glue resulted in complete obliteration confirmed by angiography and no recurrence during follow-up period. Complication related to the procedure occurred in 2 cases; one is occipital lobe infarction due to parent artery occlusion in P3 aneurysm, another is rebleeding in cerebellar arteriovenous malformation with flow related aneurysm.
Discussion: Rapid injection of n-butyl cyanoacrylate for distal aneurysms with or without low-flow arteriovenous malformations is not required. A careful continuous injection and appropriate catheter positioning may result in successful embolization. We suggested that the adhesion of catheter was rare even if remarkable reflux to proximal vessels in the treatment using low concentration of n-butyl cyanoacrylate.
Conclusion: Endovascular internal trapping of distal cerebral aneurysm using n-butyl cyanoacrylate was feasible, safe, and effective.
interv neuroradiol. 2014 Apr 4;20(2):206–207.
Unusually an aneurysm is the cause of hemorrhage in patients with moyamoya disease (MMD). We present a case of a ruptured thalamoperforator artery aneurysm treated with n-butyl cyanoacrylic acid (nBCA) embolization in a patient with MMD.
A 51-year-old female presented with suddenly decreased mentality and left side 3rd cranial nerve palsy. Initial brain computed tomography and angiography showed subarachnoid hemorrhage, both distal internal carotid arterial occlusion and strong enhancing nodule at left side posterior communicating artery. Digital subtraction angiography reveals occlusion at the terminal portion of the both internal carotid artery with development of moyamoya vessels and aneurysm like vascular pouch at left side P1 portion. A 50% solution of nBCA and ethiodol was injected into the aneurysm. Postembolization angiography demonstrated no evidence of residual aneurysm. There were no procedural complications and at 1 year follow-up she remained neurologically normal. One year follow-up magnetic resonance angiography showed no residual aneurysm.
In MMD associated with intracranial aneurysms, coil embolization was performed for saccular aneurysms whereas endovascular parent artery occlusion with glu was conducted for pseudoaneurysms. The endovascular occlusion of aneurysms on the collateral vessel in MMD with nBCA might be an effective treatment option.
interv neuroradiol. 2014 Apr 4;20(2):207.
This case report describes an aneurysm arising from the lateral spinal artery. Spinal artery aneurysms that are not associated with other vascular abnormalities or other entities are exceptionally rare. Especially isolated lateral spinal artery (LSA) aneurysm is extremely rare with only one case of isolated LSA aneurysm rupture reported to date. We report a case of LSA aneurysm presenting with subarachnoid hemorrhage (SAH).
A 67-year-old man presented with sudden onset of headache and neck pain. A computed tomography (CT) scan showed perimesencephalic and perimedullary SAH and subdural hematoma extending caudally to upper cervical spinal cord. A conventional angiogram demonstrated a right LSA aneurysm. Onyx embolization of the aneurysm was performed. During procedure, the patient developed sudden cardiac arrest. After resuscitation, the patient developed “lock-in-syndrome”. Retrospective angiography review revealed Onyx migration to distal posterior inferior cerebellar artery and contralateral LSA. We describe the first treatment example of an isolated LSA aneurysm using Onyx with a catastrophic complication. This extremely rare case illustrates how knowledge of the angiography and super-selective microangiography aids the correct diagnosis, choice of treatment modality and the prevention of endovascular or surgical treatment complications.
interv neuroradiol. 2014 Apr 4;20(2):207.
Purpose: The purpose of this study was to evaluate clinical results in the patients with severe subarachnoid hemorrhage (Hunt and Hess Grade V) treated with aggressive ICP control and brain protection using Hypothermia therapy (HT) subsequent to aneurysmal coil embolization (CE.)
Material and Methods: From 2003 Jan to 2013 Dec, we have treated 36 patients (F:M=24:12) with Hunt Grade V (GCS3:7, 4:19, 5:3, 6: 5) were treated with HT subsequent to CE. From the initial CT scan, Fisher’s CT group were G3 in 34 and G4 in 21. The location of aneurysm were ACA in 16, MCA in 3, ICA in 5, B-V in 8.
Results: From 2003 to 2009, we treated 22 patients with 35°C mild hypothermia for 72hours. 8 (36%) patients had good outcomes (Glasgow Outcome Scale: GOS 1 and 2). 7 patients took the GOS5 (spasm 4, brain injury 2, pulmonary embolism 1). From 2010 to 2013, we treated 12 patients with 36°C hypothermia for 72 hours. 5(41%) patients had good outcomes. 3 patients took the GOS 5(spasm 1, brain injury 2). Pneumonia was found as complications frequently, but the death due to pneumonia was not found. In our institution, outcome of severe subarachnoid hemorrhage gradually become good. Endovascular CE and HT contributes to the improvement of Results:Conclusion: Severe subarachnoid hemorrhage has many cases having difficulty in treatment and outcome is very poor. But we can expect some better outcome by CE and HT.
interv neuroradiol. 2014 Apr 4;20(2):207–208.
Background: Isolated dissecting aneurysms of the posterior inferior cerebellar artery (PICA) are rare, but have a high risk of re-bleeding. Recently, endovascular treatment has been proposed as an alternative to surgery, but still they present a therapeutic challenge. We report results of various endovascular treatments in patients with isolated PICA dissecting aneurysms.
Methods: Eleven patients (mean age: 44.4 years, range: 15-58, M:F=5:6) with isolated PICA dissecting aneurysms were treated by endovascular techniques (graft stent insertion in three, coiling of aneurysmal sac in four, stent assisted coiling of aneurysmal sac in two, and occlusion of parent artery by coil in two) in our institution between March 2005 and May 2012 and followed for up to 45 months. Clinical presentations were acute subarachnoid hemorrhage in seven patients, ischemia in two, severe headache in one and an incidental aneurysm of PICA in a ruptured anterior choroidal artery aneurysm. Preprocedural occlusion test performed in five patients. We carefully examined the presence of contrast filling of the PICA by collaterals during parent artery occlusion
Results: On immediate follow-up angiograms, dissecting aneurysms were successfully occluded in all patients. PICA flow was well preserved in nine of eleven patients by collaterals and sluggish PICA flow in remaining two with parent artery occlusion. One patient developed ipsilateral PICA territory infarction two days after parent artery occlusion, but fully recovered at discharge. There were two procedure-related thrombo-embolic complications, but no neurologic sequela occurred. Angiographic follow-up (mean: 18 month, range: 3-45 months) was available in all patients. Follow-up angiograms showed total aneurysmal occlusion with well preserved PICA flow by collaterals in all patients. There was no newly developed neurologic event or re-bleeding in all patients during clinical follow-up periods (mean: 40.3month, range: 6 - 60 months).
Conclusions: Various endovascular techniques are feasible and relatively effective, safe treatment modality of the isolated PICA dissecting aneurysm.
interv neuroradiol. 2014 Apr 4;20(2):208.
Background and Purpose: The aim of this study was to evaluate the safety and effectiveness of one-stage coiling for multiple intracranial aneurysms.
Methods: All patients who underwent one-stage coiling for two or more aneurysms were identified from a prospectively registered neurointerventional database over 10 years. The patient characteristics and clinical and angiographic outcomes at discharge and follow-up were retrospectively evaluated.
Results: A total of 167 patients (M:F=30:137; mean age, 58 years) with multiple aneurysms (a total of 418 aneurysms; mean, 2.5 aneurysms/patient) underwent attempted one-stage coiling for two or more aneurysms (a total of 359 aneurysms; mean, 2.1 aneurysms/patient). In 131 patients (78.4%), all detected aneurysms were treated with coiling only. Treatment-related morbidity and mortality at discharge were 1.8% and 0.6% per patient, respectively. Of the 132 patients without subarachnoid hemorrhage, favorable outcomes (modified Rankin scale score, 0–2) at discharge were 129 (97.7%), and of the 35 patients with subarachnoid hemorrhage, 27 (77.1%) had favorable outcomes at discharge. Of the 162 patients (97%) for whom clinical follow-up was available (mean, 35.8 months), 154 patients (95.1%) had favorable outcomes. Immediate post-treatment angiography showed complete occlusion in 186 (51.8%) aneurysms, neck remnants in 134 (37.3%), sac remnants in 33 (9.2%), and failure in 6 (1.7%). Of the 262 (73.9%) aneurysms that underwent follow-up imaging (mean, 24.8 months), 244 (93.1%) showed a stable or improved state, with 12 (4.6%) minor and 6 (2.3%) major recurrences.
Conclusions: One-stage coiling of multiple aneurysms seemed to be safe and effective, with low morbidity and mortality.
interv neuroradiol. 2014 Apr 4;20(2):208–209.
Introduction: Stent-assisted coiling on intracranial aneurysm has been considered as an effective technique. But dual antiplatelet therapy when a stent is placed for assistance in the treatment of ruptured aneurysms is of concern. A case of ruptured basilar tip large aneurysm was treated with endovascular techniques and is described here.
Case: A 71-year-old woman with a history of hypertension had a sudden onset double vision and a severe headache, which the brain CT showed diffuse subarachnoid hemorrhage (SAH), Fishergroup 3 and Hunt & Kosnic grade II.The diagnostic cerebral angiography revealed a basilar tip aneurysm that measured 19 mm×15 mm of aneurysm body with a 14mm neck, sharing bilateral posterior cerebral artery (PCA) origin.We decided to deploy Y-configured stents using enterprise VRD 28mm with double microcatheter technique. For a preparation of stenting, dual antiplatelet therapy was performed. Body filling of the aneurysm was showed immediately after coiling, which was possible maintaining patency of bilateral PCA. A week later, follow up angiography showed neck remnant without body filling. The patient was no neurological deficit and got a good recovery.
Conclusion: It is difficult and challenging to treat of ruptured basilar tip large aneurysm with wide neck, and is necessary to use stents to keep patency of PCAs. Dual antiplatelet therapy for stenting is necessary to prevent ischemic events, but there is a risk of a hemorrhage and re-rupture of aneurysm. We considered how to use stenting and antiplatelet therapy for ruptured basilar tip large aneurysm.
interv neuroradiol. 2014 Apr 4;20(2):209.
Background and Purpose: Direct surgical clipping for aneurysm with underlying moyamoya disease is difficult and the morbidity is high due to the extensive collaterals, as well as the already compromised cerebral blood flow. We report here on a case of a ruptured basilar tip aneurysm that was successfully treated with coil embolization in the bilateral cervical internal carotid arteries ( ICA) occlusion with abnormal vascular networks which mimicked moyamoya disease.
Material and Methods: A 43-year-old man with familial history of moyamoya disease presented with subarachnoid hemorrhage. Digital subtraction angiography demonstrated complete occlusion of bilateral ICAs at the proximal portion and a ruptured aneurysm at the basilar artery bifurcation. Aneurysm size was 4.3mm width x 6.1mm height x 3.0mm neck with ruptured bleb on dome. Each meningeal artery supplied the anterior cranial base, but most of both hemispheres were supplied with blood from the basilar artery and the posterior cerebral arteries through a large number of collateral vessels to the ICA bifurcation and the anterior cerebral and middle cerebral arteries. Perfusion CT with acetazolamide(ACZ) injection revealed no reduction of cerebral blood flow and normal reactivity to ACZ.
Results: We performed coil embolization for ruptured basilar tip aneurysm under the general anesthesia. Two GDC-10 360 coils and two 10 hydrosoft helical coils were successfully deployed and tightly packed. Balloon and stent-assisted coiling was not used. The post-intervention course is uneventful.
Conclusion: It seems that a proximal stenosis of ICAs of patients with moyamoya disease can progress into complete occlusion and this may be another characteristic morphologic feature of moyamoya disease. Neurointerventional coil embolization for basilar tip aneurysm associated with moyamoya disease is safe and useful even without assistance of balloon or stent. Regular follow up angiograms is essential and additional embolization may be needed even though there was no perfusion defect seen on the perfusion CT.
interv neuroradiol. 2014 Apr 4;20(2):209.
Case 1: A 42-year-old woman with grade IV SAH according to the World Federation of Neurological Surgeons (WFNS). Initial cerebral angiography showed spontaneously occluded vertebral artery dissection. Serial angiography 7 days after the onset of subarachnoid hemorrhage revealed that the affected artery was recanalized, and we performed parent artery occlusion of right vertebral artery.
Case 2: A 49-year-old woman presented with a ruptured vertebral artery dissecting aneurysm manifesting as subarachnoid hemorrhage (WFNS grade IV) followed by acute occlusion and early recanalization (1 day after the onset) of the affected artery. Therefore, we performed parent artery occlusion for the affected artery.
Discussion: Spontaneous occlusion is a rare manifestation of ruptured vertebral artery dissection. In cases where hemorrhage occurs, occlusion of the lesion is effective in reducing the risk of re-bleeding. However, deciding on treatment is difficult in uncommon cases in which occlusion occurs immediately after hemorrhage. We will provide 2 case reports, that we experienced ruptured vertebral artery dissecting aneurysm followed by spontaneous acute occlusion and early recanalization. The progressive angiographic changes of the ruptured vertebral artery dissection and the endovascular treatment of such arterial dissections will be discussed.
interv neuroradiol. 2014 Apr 4;20(2):210.
Objective: Aneurysms arising from pericallosal artery (PA) are uncommon and challenging to treat. The aim of this study was to report our experience with endovascular treatment of ruptured PA aneurysms.
Methods: From September 2003 through May 2012, 30 ruptured PA aneurysms in 30 patients were treated at our institution via endovascular approach. Procedural data, clinical and angiographic results were reviewed retrospectively.
Results: The immediate angiographic control showed complete occlusion in 21 (70.0%) patients and near-complete occlusion in 9 (30.0%). Procedure-related complication occurred, including procedure-related rebleeding in six and thromboembolic event in two. Preoperative contrast retention was most strongly associated with a increased risk of procedure-related rebleeding. At the end of the observational period, 18 patients were independent with a mRS score of 0-2, while the other 12 were dependent or dead (mRS score, 3-6). Adjacent hematoma was associated with a increased risk of poor clinical outcome. No neurologic deterioration or bleeding was seen during the follow-up period (mean, 32.7 months) in all survived patients. Seventeen of 23 surviving patients underwent follow-up conventional angiography (mean, 16.5 months). The result showed stable occlusion in 14 (82.4%), minor recanalization in two (11.8%), and major recanalization in one (5.9%), who had required recoiling.
Conclusion: Our preliminary experience demonstrates that endovascular treatment for ruptured PA aneurysms is feasible and effective. Procedure-related rebleedings occur far more often (20.0%) than has been generally suspected in other locations and were associated with a preoperative contrast retention. An existing adjacent hematoma was a predictor of poor clinical outcome.
interv neuroradiol. 2014 Apr 4;20(2):210.
Object: In cases of fetal type artery incorporated on aneurysm or broad necked appearance, it could be very difficult to treat posterior communicating artery (PcomA) aneurysms endovascularly. With intracranial stenting increasing in recent years, and the improvement of stent-assisted coiling, several techniques have been developed for broad neck PcomA aneurysms in which the aneurysms are incorporating the origins of the branches. The authors introduce the retrograde navigation of stent and further coiling in second stage for ruptured PcomA aneurysm.
Materials and Methods: Fifty two year old female with SAH (H&H grade 3) was shown broad neck right PcomA anerysm with fetal type PcomA incorporated to the aneurysm neck. The distal internal carotid artery (ICA) and PcomA angle was acutely curved. In the beginning waffle cone stent technique was applied and the coiling was successfully deployed without any complication. However 18 months after follow up angiography revealed recanalization. Retrograde stenting consisted of series of technical steps: 1) stent catheter navigation from contralateral left ICA, left A1. 2) Through Acom artery, the stent was navigated to right A1, right ICA in a retrograde fashion. 3) The stent catheter introduced into the aneurysm sac recanalized and selected to the PcomA reversely. 4) The stent was deployed from the right PcomA to right ICA. 5) A microcatheter for coiling was introduced through right ICA and further coiling was performed.
Results: The aneurysm was almost completely coiled by the second stage stent assisted coiling. One year after follow up, the aneurysm was secured.
Conclusion: The authors successfully treated one patient with ruptured broad neck ICA-PcomA aneurysms using retrograde stenting through the narrow Acom artery approach. It may constitute a viable alternative treatment option for PcomA aneurysms with difficult configurations and acute ICA-Pcom artery angle.
interv neuroradiol. 2014 Apr 4;20(2):210–211.
Introduction: Aneurysms of the internal carotid artery (ICA) bifurcation are uncommon and qualify as T-bifurcation lesions that bear high hemodynamic stress. Herein, we present the clinical and radiologic results of coil embolization in ICA bifurcation aneurysms (ICA-BA).
Methods: Records of 65 patients harboring 66 ICA-BA were retrieved from data prospectively accrued between September, 1999 and July, 2013. Clinical and morphologic outcomes of the aneurysms were assessed, including technical aspects of treatment.
Results: The aneurysms under study were directed either superiorly (41/66, 62.1%), anteriorly (24/66, 36.4%), or posteriorly (1/66, 1.5%), and all were devoid of perforators. Aneurysmal necks were situated symmetrically at terminal ICA (37/66, 56.1%) or slightly deviated to proximal A1 segment (29/66, 43.9%). Steam-shaped S microcatheter (73.8 %) was most commonly used to select the aneurysms, and the single microcatheter technique was most commonly applied (56.1%) to perform coil embolization, followed by balloon-remodeling (21.2%), multiple microcatheter (15.1%), and stent-protection (7.6%). Successful aneurysmal occlusion was achieved in 100%, with no procedure-related morbidity or mortality. Imaging performed in the course of follow-up (mean duration, 27.3 months) confirmed stable occlusion of most lesions (47/53, 88.7%).
Conclusion: Through tailored technical strategies, ICA bifurcation aneurysms are amenable to safe and effective endovascular coil embolization, with a tendency for stable occlusion long-term.
interv neuroradiol. 2014 Apr 4;20(2):211.
Background and Purpose: The purpose of the present study was to report our experience with endovascular treatment of 17 patients with ruptured intradural vertebral dissecting aneurysm.
Method and materials: Between November 2007 and November 2013, 20 patients with ruptured intradural vertebral dissecting aneurysms were treated with endovascular modalities, which consisted of internal coil trapping, stent-assisted coil embolization and multiple stents overlapping placement. Post-procedural complications including infarction and recurrent hemorrhage were retrospectively reviewed and clinical outcomes were evaluated at discharge and follow-up clinics 6 months later using mRS.
Results: Seventeen patients with ruptured vertebral dissecting aneurysm were enrolled in the present study. Internal coil trapping was performed 13 patients and stent-assisted coil embolization was applied to 2 patients. Multiple stents placement and combined surgical bypass with coil trapping were used for managing the other 2 patients. Post-procedural infarction was developed in 12 of 17 patients and recurrent hemorrhage was reported on 3 patients who underwent stent-assisted coil embolization and internal trapping. Nine patients with sole infarction showed excellent or favorable clinical outcome of mRS from 0 to 3. Three patients with rebleeding and concomitant infarction were revealed poor outcomes of mRS 4 or 6. Imaging follow up was obtained in 14 survived patients, which revealed complete obliteration of the dissecting aneurysm.
Conclusions: Even high frequency of post-procedural infarction, clinical outcome of endovascular treatment for ruptured vertebral dissecting aneurysms was favorable. Poor clinical outcome was associated with recurrent hemorrhage. Therefore prevention of recurrent SAH outweighs the risk of ischemia in the PICA territory and lateral medulla.
interv neuroradiol. 2014 Apr 4;20(2):211–212.
Background and Purpose: Antiplatelet resistance is known to be associated with symptomatic ischemic complication after endovascular coil embolization. The purpose of our study was to evaluate the relationship between antiplatelet resistance and clinically silent thromboembolic complications using DWI in patients who underwent coil embolization for unruptured intracranial aneurysm.
Methods: Between October 2011 and May 2013, 58 patients with 62 unruptured aneurysms who were measured for antiplatelet response using VerifyNow assay and underwent elective coil embolization for unruptured aneurysm with posttreatment DWI were enrolled. Diffusion positive lesions were classified into three groups according to the number of lesions (n = 0 (grade O), n < 6 (grade I) and n ≥ 6 (grade II)). The relationship between antiplatelet resistance and diffusion positive lesions was analyzed.
Results: Sixty-two endovascular coiling procedures were performed on 58 patients. Clopidogrel resistance was revealed in 22 patients (37.9%) and diffusion positive lesions were demonstrated in 28 patients (48.3%); these consisted of 19 (32.8%) grade I and 9 (15.5%) grade II lesions. Clopidogrel resistance was not relevant to the development of a diffusion positive lesion (grade I and II, p = .589) but associated with the development of grade II lesions (p = .001). In the logistic regression prediction model, clopidogrel resistance was significantly associated with the development of grade II lesions (p = .001).
Conclusions: Multiple diffusion positive lesions (≥6 in number) occurred more frequently in patients with clopidogrel resistance after endovascular coiling for unruptured aneurysm.
interv neuroradiol. 2014 Apr 4;20(2):212.
Objective: Coil embolization has become a major modality of treatment for intracranial aneurysms. However, small intracranial aneurysms are now thought to represent a higher risk of procedure-related rupture compared to larger aneurysms. This situation poses technical challenges and treatment dilemmas. Our aim in this study was to evaluate the safety and effectiveness of the double-microcatheter technique for small intracranial aneurysm with wide necks.
Materials and Methods: Between January 2012 and November 2013, 19 small unruptured intracranial aneurysms with wide necks (defined as maximum diameter <4mm and dome to neck ratio ≤1.5) in 19 patients (mean age, 53.2 years, range, 26-70; 8 men and 11 women) were treated with the double-microcatheter technique. Clinical and radiologic outcomes were retrospectively evaluated.
Results: All the aneurysms (middle cerebral artery: 1, anterior communicating artery: 5, anterior choroidal artery: 1, ophthalmic artery: 2, posterior communicating artery: 5, basilar artery: 2, posterior inferior cerebellar artery: 1, and superior cerebellar artery: 2), except for one patient, were successfully treated with the double-microcatheter technique only. A stent was needed in just one case, where the aneurysm was located at the top of the basilar artery. Only one case had a complication during the procedure: A thrombus occurred around the embolized aneurysm, but was dissolved completely without symptoms. Immediate post-embolization angiographies demonstrated complete occlusion in 10 patients, and a minimal residual neck in 9 patients. The mean packing density was 35% (range, 19-67). During the clinical follow-up period (mean, 4.4 months; range: 0-11), all patients reported an mRS score of 0. Follow-up MR angiography was available for 13 aneurysms at 0-9 months. All aneurysms showed complete occlusion except for 1 minimal residual neck that required no further treatment.
Conclusion: The double-microcatheter technique appears to be feasible and effective in the treatment of small unruptured intracranial aneurysms with wide necks.
interv neuroradiol. 2014 Apr 4;20(2):212–213.
A 56-year-old man presented with sudden bursting headache and slight mentality change. The brain CT angiography showed prepontine SAH and a small saccular aneurysm from the perforating artery of the right side mid basilar artery. Cerebral angiography revealed a ruptured brain stem perforating artery (BPA) aneurysm associated with an arteriovenous malformation (AVM).
A brain stem perforating artery (BPA) aneurysm was located on Rt. mid-portion perforating artery of basilar artery. It’s 3-mm sized very small aneurysm. An arteriovenous malformation (AVM) was located in Rt. Cerebellopontine area, less than 3 cm sized ( Spetzler- Martin Grade 3). Initial procedure was done to aneurysm due to SAH. Successful incomplete obliteration of aneurysm rupture was done by intravascular coiling. And follow up embolization by Onyx was done to Rt. mid-portion perforating artery of basilar artery. But The AVM was not obliterated. After then 100days of 2nd embolization of AVM by onyx, We treated radiosurgery (1500 cGy/1 time). We don’t evauation of AVM situation of post SRS, because of patient had other personal cause. On recent, We studied for follow up TFCA. It’s showed nearly removed of AVM nidus on Rt. Brain stem area. This case is very rare. We have been treated several various treat ment modalities.
interv neuroradiol. 2014 Apr 4;20(2):213.
Object: In cases of fetal type artery incorporated on aneurysm or broad necked appearance, it could be very difficult to treat posterior communicating artery (PcomA) aneurysms endovascularly. With increasing of the intracranial stenting in recent years, and the improvement of stent-assisted coiling, several techniques have been developed for broad neck PcomA aneurysms in which the aneurysms are incorporating the origins of the branches. The authors introduce the retrograde navigation of stent and further coiling in second stage for ruptured PcomA aneurysm.
Materials and Methods: Fifty two year old female with SAH (H&H grade 3) was shown broad neck right PcomA anerysm with fetal type PcomA incorporated to the aneurysm neck. The distal internal carotid artery (ICA) and PcomA angle was acutely curved. In the beginning waffle cone stent technique was applied and the coiling was successfully deployed without any complication.
However 18 months after follow up angiography revealed recanalization. Retrograde stenting consisted of series of technical steps: 1) stent catheter navigation from contralateral left ICA, left A1. 2) Through Acom artery, the stent was navigated to right A1, right ICA in a retrograde fashion. 3) The stent catheter introduced into the aneurysm sac recanalized and selected to the PcomA reversely. 4) The stent was deployed from the right PcomA to right ICA. 5) A microcatheter for coiling was introduced through right ICA and further coiling was performed.
Results: The aneurysm was almost completely coiled by the second stage stent assisted coiling. One year after follow up, the aneurysm was secured.
Conclusion: The authors successfully treated one patient with ruptured broad neck ICA-PcomA aneurysms using retrograde stenting through the narrow Acom artery approach. It may constitute a viable alternative treatment option for PcomA aneurysms with difficult configurations and acute ICA-Pcom artery angle.
interv neuroradiol. 2014 Apr 4;20(2):213.
Introduction: Subclavian artery dissecting aneurysms are uncommon. The most common causes of dissecting aneurysm are trauma and infection.
Case: A 52 year-old man, known case of cirrhosis child C with E.coli peritonitis was admitted for antibiotic treatment. During admission, the doctor examined the right supraclavicular lymph nodes, then needle aspiration was done with fresh blood from injected into right subclavian artery. So, patient was refered to Ramathibodi hospital for evaluation this injury. The CTA showed a right subclavian artery dissecting aneurysm with partially thrombosed peripheral and inferior portion, covering the left sided of origin of right vertebral artery(VA), measuring about 4.6 x 5.5 x 6.2 cm. in AP, transverse and vertical diamention, respectively. This patient was sent to treat with vascular stent graft covering the origin of dissecting aneurysm. About 1 week later, the CTA showed stable dissecting aneurysm. We planned to embolized this dissecting aneurysm. The conventional angiogram showed minimally reduction of the size of aneurysm with partially contrast filling to the aneurysm from right subclavian artery and retrograde from right VA. We inserted the microcatheter from left VA through vertebrobasilar junction into the origin of right VA and dissecting aneurysm. Transarterial embolization of this dissecting aneurysm and the origin of right VA was successfully done using detachable coils. The control angiogram showed nearly complete obliteration.
Conclusion: The subclavian artery dissecting aneurysm is rare but potentially serious. The chance of ruptured dissecting aneurysm is high, that related to the sized of dissecting aneurysm.
interv neuroradiol. 2014 Apr 4;20(2):214.
A 60-year-old male presented with sudden onset of deterioration of the consciousness for 1 hour. Glassgow Coma Score (GCS) is E1V1M5. Patient was sent for immediate CT scan demonstrating a large hematoma at the right basal ganglion with spillage to the ventricular system. After contrast administration, there was contrast leakage within the hematoma that spilled to the ventricle. Furthermore, a tiny enhanced outpouching vascular lesion was found at the inferior aspect of the hematoma, indicating pseudoaneurysm. Emergency cerebral angiogram was subsequently done that showed a 5.3x4.0-mm pseudoaneurysm at the right anterior choroidal artery with active angiographic contrast extravasation. A 1.2Fr Magic microcatheter was inserted in the right internal carotid artery for attempt embolization but not success to select the origin of the right anterior choroidal artery. Neurological signs was reevaluated after cerebral angiogram demonstrating dropping of GCS (E1VTM1) and loss of brainstem signs. After discussed with patient relatives, we decided for no further definitive treatment.
Conclusion: Cerebral angiogram should be done urgently for detecting and eradicating source of bleeding in case of active contrast leakage within intracerebral hemorrhage demonstrating in CT scan.
interv neuroradiol. 2014 Apr 4;20(2):214.
Purpose: We demonstrate the successful single session endovascular embolization for the parenchymal AVM of the temporal lobe through a small feeder of MMA by using liquid embolic materials and detachable delivery catheter.
Methods: A 42-year old man complained of repeat syncope and seizure for several months. We diagnosed the parenchymal AVM with main feeders from pial branches of the right MCA and a small feeder from posterior division of the right middle meningeal artery (MMA) and deep/superficial venous drainages by MR and DSA. We chose the route through the a minor feeder from MMA and selected the Onyx as a embolic materials for multiple injections and good penetration into the larger nidus, mainly supplied through the right MCA, and used the detachable microcatheter (Apollo, EV3/Covidian, ) as a onyx delivery for the longer margin of reflux during push-wait-plug technique.
Results: We successfully performed the embolization for the high flow parenchymal AVM through posterior division of the MMA, which was a minor arterial feeder, by using total 6 ml of Onyx 18 and a 3cm-detachable tip Apollo microcatheter via single catheterization and single session under general anesthesia. Total time of procedure was 50 minutes from introduction of guiding catheter to final onyx cast. Small amount of residual AVM with early venous drainage were still noted on post-procedural angiograms, but scanty or little residual AVM on 3 month-follow-up conventional angiograms. There were no immediate and intermediate complications, nor recurred neurologic symptoms.
Conclusion: We illustrate the case of effective and safe endovascular management for the symptomatic parenchymal AVM through a minor MMA feeder by using Onyx and Apollo in a single catheterization.
interv neuroradiol. 2014 Apr 4;20(2):214–215.
Introduction: In endovascular embolization of intracranial arteriovenous malformation(AVM) intracranial blood flow, AVM itself and surrounding brain tissues, change significantly. Often hemorrhagic event occurs and results in fatal. To avoid hemorrhagic event it is necessary to detect real-time intracranial blood flow change. Single Photon Emission Computed Tomography (SPECT),that is major modality to detect intracranial blood flow change,can not detect real-time change. Regional Saturation of Oxygen (rSO2) monitoring is simple, non-invasive and able to detect real-time intracranial blood flow change continuously. There are some reports of effectiveness of rSO2 monitoring in carotid endarteriotomy (CEA) and carotid artery stenting (CAS),but there are few of reports in endovascular embolization of AVM. This study evaluated the effectiveness of rSO2 monitoring in endovascular embolization of AVM.
Methods: Between January 2011 and September 2013, bilateral rSO2 was monitored for 25 patients, 36 cases in our facility, from the start of endovascular embolization of AVM to the next day continuously. We investigated correlations between rSO2 values and hemorrhagic events with following two parameters. - rSO2 ratio: rSO2/baseline rSO2 - ◿rSO2: affected side rSO2 ratio/not affected side rSO2 ratio
Results: Hemorrhagic events were observed in 3 cases (8%). In one case postoperative CT revealed intracranial hemorrhage (ICH), it was guessed due to hyperperfusion. In the other two cases hemorrhagic events were due to intraoperative procedure. In the case, ICH due to hyperperfusion, affected side rSO2 was 1.09 and ◿rSO2 was 1.11 at the end point of embolization. In other 7 cases affected side rSO2 ratios were more than 1.1 and ◿rSO2 were less than 1.1 at the end point of embolization, no hemorrhagic events were observed.
Discussion: It is not easy to interpret rSO2 change because often the value is fluctuating. There are individual differences of normal rSO2 and the values fluctuate by O2 administration and blood pressure change and so on. It is important that monitoring bilateral rSO2 and note the laterality of rSO2 change. We considered that hemorrhagic complication was high risk when ◿rSO2 increased more than 1.1 in endovascular embolization of AVM.
Conclusion: To reduce complications rSO2 monitoring is very effective in endovascular embolization of AVM.
interv neuroradiol. 2014 Apr 4;20(2):215.
Arteriovenous malformations, Onyx embolization, Microcatheter
The treatment of intracranial arteriovenous malformations (AVMs) is a multidisciplinary approach including embolization, microsurgical resection and radiosurgery. In recently, embolization using liquid emboliant such as n-butyl cyanoacrylate (n-BCA) and Onyx (EV3, Irvine, USA) can be more effective deceasing AVMs size and increasing curative embolized rate. Especially, the Onyx can be more long procedural time, more penestration and more controllable.
The recent development of a new mircocatheter with a detachable tip, Apollo (EV3, Irvine, USA) and Sonic (Balt, Montmorency, France), helps to easy navigation, easy retrieving the microcatheter and prolong procedual time. But this adventage affected a bad influence on unintented disconnection of microcatheter like our case. We report that detachable microcatheter early unintended disconnected at detach zone during embolization of AVM using Onyx and Apollo microcatheter.
interv neuroradiol. 2014 Apr 4;20(2):215–216.
Endovascular closure of high-flow arteriovenous (AV) shunts in intracranial AV malformations (AVMs) is technically challenging. With the use of liquid embolic agents, the high flow through the shunt may cause migration of the embolic agent to the venous outflow tract with possible devastating consequences. ED coils (Kaneka Medix Co, Osaka, Japan) are useful for the preoperative embolization of high-flow feeders of AVMs via the transarterial routes before n-butyl cyanoacrylate (NBCA) injection. Detachable coils may be inserted at the fistula site to decrease the flow and may provide an anchoring point for the injection of NBCA. ED coils are compatible with one marker Marathon™ Flow Directed Micro Catheter (Irvine CA, Covidien), because the detachment point between the coil and the delivery wire is detected electrically and the tip of the delivery wire is very flexible enough to navigate coils through long tortuous vessels. ED coils are also useful for transvenous approach of dural arteriovenous fistula located in the middle fossa that drains via the frontal cortical vein into superior sagittal sinus (SSS). The lesion was treated by ED coil embolization of the draining vein just distal to the shunt through Marathon catheter introduced from SSS into the frontal cortical vein. Different types of high-flow AV shunts can safely be occluded with endovascular techniques tailored to the specific anatomical configuration of the shunt.
interv neuroradiol. 2014 Apr 4;20(2):216.
Backgrounds: There is controversy about treatment timing or modalities for a relative deep seated tiny brain arteriovenous malformation (AVM) presented with huge intracerebral hematoma (ICH). We presented our treatment strategy in the two patients with relative deep seated ruptured AVMs concomitantly with huge temporal ICH.
Case report: Case 1: A 19-year-old young man presented with decreased consciousness. Brain computed tomography (CT) angiography revealed huge left temporal ICH with subcortical temporal tiny AVM. The patient underwent decompressive craniectomy with hematoma evacuation and underwent embolization using onyx for ruptured tiny AVM immediately after surgery. Control and followed angiogram showed complete occlusion of nidus. The patient underwent cranioplasty one month after endovascular treatment and discharged without any neurologic deficit except right hemianopsia.
Case 2: A 40-year-old woman suffered from decreased consciousness. Brain CT angiography showed huge left temporal ICH with subcortical tiny AVM. Decompressive craniectomy with hematoma evacuation was performed followed by embolization of ruptured tiny AVM using Onyx. Control angiogram showed residual nidus. The patient underwent resection of residual nidus and cranioplasty under navigation 1 month after endovascular treatment. Followed angiogram showed no residual nidus. The patient discharged with the speech disturbance (Wernecke’s aphagia).
Conclusion: In the cases of ruptured relative deep tiny AVMs presented with huge temporal ICH, it may be reasonable that urgent embolization using onyx as a curative or bridge therapy for resection of nidus can be performed after decompressive surgery.
interv neuroradiol. 2014 Apr 4;20(2):216.
Introduction: Ruptured brain arteriovenous malformations (bAVMs) are at increased risk of rehemorrhage but management has been conservative. We report our case in the treatment of ruptured bAVMs on large intracerebral hemorrhage (ICH) with Onyx embolization.
Case report: A 59-year-old male had arrived emergency room due to altered mentality. His mentality was semicoma. The brain computed tomography (CT) and CT angiography revealed ICH in right temporooccipital lobe, intraventricular hemorrhage, mildline deviation and AVM in right occipital lobe. First, because of hematoma removal and intracranial pressure control, decompression craniectomy was conducted. Conventional angiography revealed large AVM in right occipital lobe, supplied by multiple branch of right posterior cerebral artery (PCA) and right ascending pharyngeal artery. His Spezler-Martin Grade was 3. Onyx embolization was conducted for obliteration of ruptured AVM. After 6 days, follow up conventional angiography revealed residual fine AVM in right occipital lobe, supplied by a few branches from right MCA, PCA, ascending pharyngeal artery and left occipital artery. He was transferred to other hospital on only mild confusion in neurologic examination, 11 days after embolization, to take radiosurgery for residual AVM.
Discussion: In unruptured bAVMs, a recent study showed that medical management alone is superior to medical management with interventional therapy for the prevention of death or stroke in patients with followed up for 33 months. But approximately half of all bAVMs present with a hemorrhage. The treatment of ruptured bAVMs is challenging based on a multidisciplinary approach involving neurosurgery, radiosurgery, and interventional neuroradiology. A recent study, complete occlusion was obtained with Onyx embolization alone in a high percentage of cases (23.5% of all cases and 36.7% of AVM smaller than 3cm). And also, radiosurgery has good result, but disadvantage of radiosurgery is long latency period until obliteration about 3 years. Onyx could be prefered to be used as the first line embolization agent for the treatment of ruptured bAVMs.
interv neuroradiol. 2014 Apr 4;20(2):216–217.
Purpose: This study is to evaluate the association of the age of patient and the rate of stenosis with the development of emboli and acute infarcts in carotid artery stenting (CAS) with embolic protection device (EPD).
Materials and Methods: Forty-eight consecutive patients (49-81 years old, mean; 68.2), who underwent CAS with EPD due to proximal internal carotid artery stenosis were included. All of them received oral aspirin (100mg) and clopidogrel (75mg) daily for a minimum 5 days prior to the procedure, and initial intravenous bolus injection of heparin of 1500-3000 IU with 1000 IU at 1 hour later. Pre-stenting balloon dilatation was performed in the stenotic area under EPD placement before CAS. Diffusion weighted MR imaging was performed one day after CAS. Patients were classified into three groups with no, small and large emboli captured within EPD, which were compared with medical and radiological information.
Results: No, small and large emboli are identified within EPD in each 20, 12 and 16 patients. The older age and the more severe stenosis are associated with the development of emboli and acute infarcts (P value < 0.1).
Conclusions: In patients treated with CAS under EPD, older age and the rate of stenosis tend to be related with the development of emboli and acute infarcts. Therefore in the patients with risk factors, it’s essential to carefully manage the procedure of CAS with EPD.
interv neuroradiol. 2014 Apr 4;20(2):217.
Introduction: Infections involving endovascular devices are rare, although they present with increased frequency. In 2007, Hogg et al. reported that there were only 35 cases of infection to the stent inserted various body parts from 1991 to 2007 after review of literatures. Among those infections, the infection to stent inserted in carotid artery is seldom to find, especially. To our knowledge, only one prior case of infection to carotid stent was reported.
Case report: A 68-year-old man with both common carotid plaques for 8 years had developed sudden-onset dysarthria. He visited our hospital and diagnosed acute lacunar infarction on right basal ganglia. On the brain MRA scan, the severe stenosis was observed on left proximal internal carotid artery. Carotid artery stenting (CAS) to left proximal ICA was successfully performed 7 days after stroke onset using Carotid Wall stent. On the 2 days after CAS, the patient developed right side weakness with high fever. On the follow up MRI, newly developed multiple acute infarctions were observed on the left hemisphere. Infective endocarditis was suspected but, on the transesophageal echocardiogram, the evidence of infective endocarditis was not observed.
The phlebitis of left forearm was regarded as focus of fever. But, the fever was persistent despite of antibiotics therapy and additional epididymo-orchitis of scrotum was developed 2 days later. At that time, the patient complained about his left neck swelling. On the blood culture, methicillin resistant staphylococcus aureus was detected. The neck swelling of the patient progressed despite of vancomycin therapy as time went by. The neck CT was performed 9 days later CAS.
Inflammatory changes with abscess formation were observed on the lower portion of inserted stent. The patient transferred to division of infectious disease for proper treatment. The condition of the patient stabilized rapidly. But one follow up neck CT taken on the 25 days after CAS, the impending rupture sign with pseudoaneurysm formation on the left common carotid artery was observed. The patient transferred to another hospital for stent removing operation. The patient underwent resection of the left carotid bifurcation, including the indwelling stent and reconstruction with a saphenous vein interposition graft. The patient was fully recovered without any neurological sequelae.
Conclusion: The exact pathology of stent infection is not fully understood. But on the animal studies, the stents act as a nidus for colonization or a vector for iatrogenic introduction. During the procedure, arterial trauma inducing the denudation of endothelial lining and exposing the arterial media. And also, the stent acts as a bacterial medium and sequesters bacteria beneath the struts and the infection to the stent spreads to the arterial wall. The resulting inflammation causes necrosis and destruction of the arterial wall, which can lead to pseudoaneurysm formation and subsequent rupture and promote platelet adherence and thrombus formation resulting in septic emboli.
To prevent further sequelae from the infection, early recognition of the possibility of infection to the stent is mandatory.
interv neuroradiol. 2014 Apr 4;20(2):218.
Purpose: The purpose of this study is to assess the factors which influence intolerance in the use of proximal balloon occlusion embolic protection device for carotid artery stenting (CAS).
Materials and Methods: From sep. 2012 to Oct. 2013, 27 patients (mean age: 70.3±7.2 years) with proximal internal cerebral artery (pICA) stenosis were treated with proximal balloon occlusion embolic protection system. Fifteen patients presented with acute infarction and the other 12 patients with transient ischemic attacks (TIAs). Mean stenosis rate was 82.3±6.6% (70~95%). Nine patients had the lesion at the left side (33.3%). Contralateral ICA occlusion or severe stenosis was observed in 12 patients (44.4%). Clinical data, angiographic findings, occlusion time, periprocedural medications including intravenous injection, and procedure-related complications were analyzed according to the presence or absence of intolerance.
Results: All cases were treated successfully and no peri-procedural untoward events occurred. All 3 steps i.e. prestent ballooning, stenting, and poststent ballooning were done in 24 of 27patients (88.9%) and, in the other 3 patients, only stenting and poststent ballooning were done. Intolerance was observed in 6 patients (22.2%) and the mean duration of intolerance is 21.7±20.4 seconds (10~60 seconds). There was no statistically significant difference between two dividing groups according to the presence or absence of intolerance in the comparison of clinical and angiographic factors including age, sex, presenting symptoms, stenosis rate, lesion side, occlusion time, and the presence of contralateral occlusion or flow compromising stenosis.
Conclusion: The proximal balloon occlusion embolic protection system seems to be useful in CAS, and the intolerance does not appeared to be necessary restrictive consideration even when the patient does not have eligible collateral system in conventional terms.
interv neuroradiol. 2014 Apr 4;20(2):218.
Objective: The main concern regarding transfemoral carotid artery stenting (CAS) is the possible dislodgement of cerebral emboli during the procedure. CAS with endovascular proximal flow blockage is deemed able to reduce the cerebral embolization observed during filter-protected CAS. We evaluated clinical outcome and intraoperative embolization rates in a series of patients undergoing CAS with filter-protected device and proximal flow blockage.
Method: During 2 year, a series of 26 consecutive patients with symptomatic or asymptomatic internal carotid artery stenosis ≥70% were included to undergo CAS with filter-protected device and proximal flow blockage, obtained with the MoMa system. All patients underwent preoperative and postoperative DW-MRI in order to detect new ischemic lesions. We compared clinical outcome and postoperative embolization rates in each.
Result: CAS was successfully performed in all 26 patients. No deaths or neurological events occurred in the postoperative period with filter-protected device and proximal flow blockage. The filter-protected device was successfully used in 21 patients (technical success: 95%). Mean age was 68.4 year old and mean stenosis was 83%. Preoperative infarction was 47% (10/21). DW-MRI disclosed 94 new ischemic lesions in 15 patients (14/21, 67%). 11 lesions in 4 patients were contralateral to the treated carotid artery. Whereas, the MoMa system was successfully used in 5 patients (technical success: 84%). Mean age was 71.4 year old and mean stenosis was 90%. Preoperative infarction was 40% (2/5). No intolerance to balloon occlusion was observed. DW-MRI disclosed 6 new ischemic lesions in 1 patients (1/5, 20%). All lesions were ipsilateral to the treated carotid artery.
Conclusion: Transfemoral CAS with proximal flow blockage achieves good technical and clinical results while postoperative incidence of DW-MRI ischemic lesions is inferior to the one reported after transfemoral filter-protected CAS. However, CAS with proximal flow blockage is still accompanied by a non-negligible cerebral embolization. Further study, directly comparing the results of DW-MRI after CAS with distal filters and proximal occlusion devices, are needed to confirm this trend.
interv neuroradiol. 2014 Apr 4;20(2):218–219.
Objective: Stent placement with or without angioplasty on Carotid , vertebral , intracranial vessel aims to reduce the risk of recurrent ischaemic stroke. Although it is still not well-known, but the stent placement procedures has been started in some hospitals by neuro Interventionist. The purpose of this study is to shows the safety and succesfull rate of carotid , vertebral , intracranial artery stenting in ischaemic stroke.
Method: During January 2010 to November 2013, 40 patients with symptomatic carotid stenosis greater than 60% and asymptomatic greater than 70% based on cerebral Digital substraction angiography examination underwent urgent or deferred stenting with or without angioplasty (10 TIA, 30 minor stroke). Clinical and radiological data were reviewed. Outcomes were worsening stroke, new stroke, or stroke-related death up to 30 days after the procedure. Procedure-related complications were also documented
Result: For this study, it has been placed 45 stents in 40 stenosis patients ( 27 men and 13 women), the mean age was 59 +/- 12 years. Stent placement has been done in internal carotid artery, vertebral artery and intracranial vessels. There are 35 patients that has been performed single stent placement whereas another 5 patients had double stent.Successfull procedure rate was 100% (recidual stenosis <10%). There was 1 patient with consciousness deterioration preceded by hypotension. The consciousness was improved after 7days and there was no neurological deficit. All patients were alive during this study.
Conclussion: Stent placement procedure is a relatively safe procedure. Death rate of this procedure is 0% that is performed by neuro-interventionist in Indonesia.
interv neuroradiol. 2014 Apr 4;20(2):219.
Introduction: Ischemic stroke is a major cause of adult disability and the 3rd leading cause of death. Approximately 15-30% of ischemic strokes are caused by obstructive carotid atherosclerosis involving the carotid bifurcation The purpose of this study is to determine safety, short and mid-term outcomes of CAS (Carotid Artery Stenting) during the last 5 years in a single cerebrovascular disease specialized hospital.
Materials and Methods: Between January 2006 and December 2010, 101 successful CAS out of 103 attempted procedures in 89 patients were included in this study. The indications for CAS were symptomatic carotid-artery stenosis 60% and asymptomatic stenosis of at least 80%. There were 70 men and 19 women and their age range was 50-79 years (mean 71.1). Self expanding stents with cerebral protection devices were used in all cases. Acetylsalicylic acid (100mg/d) and clopidogrel (75mg/d) were applied for at least 4 to 5 days prior to procedure. Weight-adjusted (70U/kg) heparin was used. Atropine (1mg) was given intravenously, if needed, to reduce bradycardia and hypotension potentially associated with carotid dilation. Acetylsalicylic acid (100mg/d) and clopidogrel (75 mg/d) was continued for 3 months after the interventional procedure. Mono antiplatelet therapy (aspirin, clopidogrel, or ticlopidine) was continued indefinitely. One hundred one stents (50 Protégé, 37 Precise stent, 12 Wallstent, and 2 Acculink) and distal filters (89 Spider Rx, 9 Filter-wire, 3 Embo-shield) were used.
Results: There were one death (huge ICH), 4 minor strokes (4.2%), 9 bradycardia (9.4%), and 3 groin hematoma as peri-procedural complications. Follow-up angiography was done in 58 patients (61%) for 6-58 months (mean 17.3), there was only one restenosis (1%). Clinical follow-up was done for 84 patients (88%) for 6-60 months (mean 32), there were two deaths (2.3%, one myocardial infarction, one rectal cancer), one major stroke (basilar artery, 21 months), and one minor stroke (cerebellum, 10 months).
Conclusion: CAS is and effective treatment modality and as safe as CEA for carefully selected patients. Judicious selection of the procedure is made on a case-by-case after considering the patient (physiological), lesion, and access (anatomical) factors that increase the risk of CAS and CEA in that particular patient.
interv neuroradiol. 2014 Apr 4;20(2):219–220.
Background: Visual dysfunction due to carotid atherosclerotic disease is often improved after carotid reperfusion therapy such as carotid endarterectomy (CEA) and carotid artery stenting (CAS). However, a few reports showed CEA sometimes aggravated neovascular glaucoma. There has been no report at this situation after CAS. We experienced and report a case of acute deterioration of neovascular glaucoma after staged CAS.
Case report: A 74-year-old man developed sudden left hemiparesis and was admitted to our hospital. He had senile cataract with operation on the right eye 1month before admission. Brain MRI and MRA showed acute border-zone infarction in the right cerebral hemisphere, and severe stenosis on the right proximal internal carotid artery. Preoperative diamox SPECT showed markedly decreased vascular reserve on the right cerebral hemisphere. Therefore, we planned staged CAS due to high risk of hyperperfusion. Five days after first angioplasty, he complained of severe ocular pain on the right eye. Intraocular pressure (IOP) of the right eye was markedly elevated to 43 mmHg and new vessels at iris (rubeosis iridis) were shown. After active management including intravitreal lucentis injection, IOP was markedly decreased and ocular pain was subsided after at three days after diagnosis, but highly elevated IOP was maintained for two weeks. CAS was performed on 14 days after angioplasty. His ocular pain was recurred one day after CAS and maintained for two days. Although ocular pain subsided, highly elevated (>30 mmHg) IOP was maintained. No neurological progression or cardiac symptom appeared until the 30th post-stenting day.
Conclusion: We should be aware that CAS not only improves vision in patients with ischemic oculopathy, but can also rarely induce paradoxical visual deterioration such as aggravation of neovascular glaucoma.
interv neuroradiol. 2014 Apr 4;20(2):220.
Distal embolization resulting from carotid angioplasty and stenting (CAS) occurs mainly in the cerebral hemisphere. We report a case of ophthalmic artery occlusion after carotid revascularization. A 75-year old man received emergency CAS for cervical internal carotid artery occlusion. Two months later, the patient was readmitted for decreased visual acuity. We found ophthalmic artery occlusion that was not noticed soon after CAS. Although ophthalmic artery occlusion after CAS is rare, endovascular neurosurgeons should be aware of this potential complication.
interv neuroradiol. 2014 Apr 4;20(2):220.
Background: Impaired baroreflex function after carotid artery revascularization procedure is well known phenomenon.
However, long-term effect of blood pressure and heart rate parameters according to the method of revascularization has rarely been studied. In this study, we tried to study the association between blood pressure and heart rate variability and type of carotid revascularization procedure using within-individual visit-to-visit variability of blood pressure and heart rate.
Methods: Retrospective analysis of data of patients who underwent carotid revascularization was performed. Carotid revascularization procedure included carotid endarterectomy (CEA) and carotid artery stenting (CAS). We calculated mean of systolic blood pressure, diastolic blood pressure, and heart rate for each visit. And, we calculated mean of systolic blood pressure, diastolic blood pressure, and heart rate of readings taken over multiple follow-up visits and expressed within-individual visit-to-visit variability as standard deviation (SD), coefficient of variation (SD/mean), maximum value, and minimum value for systolic blood pressure, diastolic blood pressure, and heart rate. The association between procedure (CEA vs CEA) and derived parameters of systolic blood pressure, diastolic blood pressure, and heart rate was assessed by univariate and multivariate Logistic regression analyses and expressed as Odds ratio with 95% confidence interval.
Results: A total of 129 subjects were included in this study (22 female; mean age 66.01 ± 9.97 years; 85 carotid artery stenting, 44 carotid endarterectomy). Between CEA and CAS, there were significant difference of history of smoking, pre-procedural stenosis grade of target artery, and previous history stroke. Among the parameters of blood pressure and heart rate, mean systolic blood pressure (129.6 ± 11.07 for CAS, 124.4± 9.83 for CEA, p = 0.0095) and minimal systolic blood pressure (106.6 ± 11.82 for CAS, 100.6 ± 15.19 for CEA, p = 0.0136) were significant lower in CEA group than CAS group, respectively. After logistic regression analysis, the difference maintained after adjusting clinical and radiological covariates (OR 1.064, 95% CI 1.018 – 1.113 for mean systolic blood pressure; 1.036, 95%CI 1.003 – 1.071, p = 0.332 for minimal systolic blood pressure).
Conclusion: The impact of carotid revascularization was different according to the Methods of procedure. The underlying pathophysiological mechanism and the potential association between hemodynamic alteration and outcome should be focused on the future studies.
interv neuroradiol. 2014 Apr 4;20(2):221.
Background and Purpose: The timing for carotid artery stenting (CAS) in symptomatic patients is controversial. The earlier CAS is performed, the more recurrence of stroke may be prevented. However, some practitioners believe that they should wait at least several weeks after the onset of stroke so that possibly vulnerable plaque may become stable. The purpose of this study is to clarify the best timing for carotid artery stenting based upon a single center experience.
Methods: Consecutive 143 cases of symptomatic carotid artery stenosis were retrospectively reviewed in this study. The clinical periprocedural complication rates were statistically evaluated in association with duration between the onset and the stenting: 1) 0-2 week, 2) 2-4 week, 3) 4-12 week, and 4) not earlier than 12 weeks.
Results: CAS was performed at 0-2 weeks in 8 cases (75.4 years old on average), at 2-4 weeks in 30 cases (73.7 years old), at 4-12 weeks in 55 cases (73.6 years old), at not earlier than 12 weeks in 50 cases (71.1 years old). The periprocedural complications rate was 0%, 6.7%, 1.8%, and 6.0% retrospectively, which were not statistically different
Conclusion: The current study suggests that CAS may be performed safely and effectively in an acute stage of ischemic stroke.
interv neuroradiol. 2014 Apr 4;20(2):221.
Purpose: Complete occlusion of the internal carotid artery is not a good candidate for CEA or CAS. No definite treatment is available except for acute occlusion. Our experience with endovascular revascularization of these lesions is presented.
Material and Method:Endovascular revascularization was performed in 26 patients with chronic complete occlusion. A guide wire was advanced through the occluded internal carotid artery. With proximal and distal protection sequential angioplasty was performed. Carotid stents and coronary stents were deployed to the residual stenosis. Patients were followed up with angiography or 3DCT.
Results: Technical success was obtained in 22 out of 26. Complications were observed in three. One with retinal ischemia and two with transient hemiparesis. In the follow-up, patency of the vessel was confirmed in 21 of 22. Ischemic stroke occurred in one with reocclusion. Other patients were free from stroke after treatment.
Conclusion: Endovascular revascularization is promising for chronic complete occlusion of the internal carotid artery.
interv neuroradiol. 2014 Apr 4;20(2):221.
Introduction: Dural arteriovenous fistulas (dAVFs) around the anterior condylar confluent (ACC) and adjacent bone structure are relatively rare. A case of dAVFs around ACC with intraosseous vascular niuds in the clivus was treated with endovascular techniques and is described here.
Case: A 75 – year old man presented with an audible pulse - synchronous bruit. Angiogram showed dAVFs fed by the ascending pharyngeal artery and meningeal branch of vertebral artery with retrograde drainage to the inferior petrosal sinus (IPS). Source images of MR angiography showed abnormal flow signal in the region of the clivus with an intraosseous component. 3D-DSA showed the dAVFs in which an intraosseous arteriovenous fistula draining into the anterior condylar vein. Venous drainage routes were antegrade drainage to the jugular vein and the suboccipital cavernous sinus, and retrograde drainage into the cavernous sinus via the IPS. It was difficult to navigate microcatheter from IPS to ACC because the angle of IPS and ACC was sharp. But microcatheter was easily navigated to ACC by detaining occlusion balloon catheter “Scepter C” in IPS. The patient was successfully treated with selective transvenous coil embolization, with all symptoms disappearing.
Conclusion: dAVFs around the ACC is relatively rare. It is therefore important to assess the venous anatomy and the fistulous points for a safe and effective treatment.
interv neuroradiol. 2014 Apr 4;20(2):222.
We report an unusual case of dural arteriovenous fistula (AVF) of superior sagittal sinus (SSS) after tamoxifen treatment for breast cancer. A 30-year-old female presented as an emergency room with a sudden headache and left sided weakness and sensory loss. On past medical history, she was diagnosed with breast cancer 1 year ago, and subsequently underwent breast conserving mastectomy with whole breast radiation and adjuvant chemotherapy of tamoxifen 20 mg daily. At the time of admission, Computed tomography (CT) showed small acute right intracerebral hemorrhage at centrum semiovale, and magnetic resonance imaging (MRI) demonstrated that dural AVF at the SSS with a prominent and tortuous venous enhancement along centrum semiovale, left Sylvian vein and vein of Galen. Cerebral angiography showed that dural AVF at the mid-portion of SSS with a meningeal arterial feeding vessels entering the wall of the SSS, then draining through dilated cortical veins. Our patient had no signs of active malignancy nor any abnormalities in her coagulation profile, so it can be concluded that tamoxifen was the likely cause of SSS thrombosis and dural AVF. The dural AVF was treated by an endovascular coil embolization for SSS. The patient dramatically recovered favorably to normal with left side motor and sensory deficit. Future studies of women with breast cancer using tamoxifen should be designed to determine the stroke etiologies, the role of additional chemotherapy and existing stroke risk factors, and the potential mechanisms of venous thrombosis.
interv neuroradiol. 2014 Apr 4;20(2):222.
Intracranial dural arteriovenous fistulas (DAVFs) are abnormal connections between dural arteries and dural venous sinuses or leptomeningeal veins. It has been known that the clinical presentation depends on its drainage pattern from arterio-venous shunts and presence of leptomeningeal venous reflux correlates with seriousness of clinical status. Particularly, the type of DAVF that drain directly into the subarachnoid vein often poses a high risk of hemorrhage or venous ischemia due to venous hypertension. When leptomeningeal venous reflux occurs to spinal medullary veins via mesencephalic venous connection, intracranial DAVFs can cause spinal myelopathy that may be accompanied by symptoms and imaging abnormalities similar to those of the more classical spinal DAVFs. Despite being cautioned as a underdiagnosed entity due to the rarity and nonspecific clinical and imaging features, it is often unrecognized and leads to devastating morbidity with progressive spinal cord and brainstem symptoms. We are reporting a case of intracranial DAVF with extremely nonspecific spinal MRI findings without vascularity on the spinal cord.
interv neuroradiol. 2014 Apr 4;20(2):222.
Purpose: To clarify the optimal treatment of transverse-signoid sinus dural artetiovenous fistulas (T-S dAVF) with isolated sinus. Methods: Twenty-two patients (11 male and 11 female ranging from 45-78 years, mean 64.8 years) with isolated sinus of 53 patients with T-S dAVFs treated from 1996 to 2013 were retrospectively reviewed. Clinical presentations were intracerebral hemorrhage in 9, venous infarction in 9, increased intracranial pressure in 1, and tinnitus only in 3 patients. Initial treatments were sinus packing by transfemoral vein approach through the occluded sinus in 17 (TVE), sinus packing by direct sinus puncture in 3 (DSP) and transarterial embolization using NBCA in 2 patients (TAE).
Results: Complete obliteration was achieved in 11 of 17 patients treated with TVE (65%), 2 of 3 patients treated with DSP (67%) and 1 of 2 patients treated with TAE (50%). Of 8 patients who could not achieve complete obliteration by the initial treatments, curative treatments were performed in 5 patients by direct surgery and 2 patients by TAE.
Conclusion: TVE is a treatment of choice for the T-S dAVF with isolated sinus. TAE and direct surgery are considered for the patients with failed TVE.
interv neuroradiol. 2014 Apr 4;20(2):222–223.
Introduction: Intracranial dural arteriovenous fistulas (AVF) with pial feeders are rare vascular lesions of the brain and the unique type of dural AVF, which are composed of a single or multiple dural arterial and pial feeders to venous channels. They always are associated with a drainage to cortical veins and also different from typical AVF or other intracranial vascular lesions. We report on three cases with dural AVF with pial feeders to treat with endovascular options.
Materials and Methods: Case 1 is a 62-years-old man with tinnitus. A cerebral angiography showed a dural AVF with multiple dural feeders and pial feeder arising from the anterior inferior cerebellar artery and main drainage on basal vein with venous aneurysm.
Case 2 is a 47-years-old woman with a sudden bursting headache at occipital area and changed mental status. Computed tomographic scan showed subarachnoid hemorrhage and intracerebellar hemorrhage. The cerebral angiography showed multiple dural feeders and pial feeder from P2 segment of posterior cerebral artery and multiple cortical venous drainage with large varix. Case 3 is a 54-years-old male with incidental finding of pial AVF on left cerebellum. In this case, a cerebral angiography demonstrated dual cortical feeders of superior cerebellar artery and posterior inferior cerebellar artery and cortical drainages into transverse and sigmoid sinus with large venous aneurysm.
Results: A treatment strategy of flow disconnection was used with endovascular options in all three patients. Combined approach of transvenous coil and transarterial onyx embolization was performed in case 1.
Case 2 underwent transarterial onyx embolization and case 3 was transvenous coil embolization. All three lesions were completely obliterated as demonstrated radiographically, including obliteration of the venous varices associated with three of lesions.
However, post-treatment massive ICH and brain swelling after successful obliteration of AVF was developed in case 2 and she died.
Conclusion: Intracranial dural AVF with pial feeders is similar to typical dural AVF in treatment method. However, it should pay attention to incompletely disconnect flow of pial feeders because alteration in flow might cause hyperemia in the adjacent normal brain tissue that interferes with the ability of autoregulation.
interv neuroradiol. 2014 Apr 4;20(2):223.
Learning Objective: To illustrate and to review usefulness of rotational DSA with dual volume visualization in endovascular management of intracranial dural arteriovenous fistula.
Summary: Rotational DSA are useful imaging tool in the evaluation of neurovascular disease. Between January 2010 and December 2013, 30 intracranial dural arteriovenous fistulas were treated endovascularly. We will illustrate usefulness of rotational DSA in depiction of shunted pouch during diagnosis, planning and monitoring the navigation of microcatheter and placement of embolic material during embolization. Emphasize will be given to the usefulness of dual rotational angiography with dual volume visualization befere and during the intervention.
Conclusion: After reviewing this exhibit, the participant will be able to demonstrated technical tips and advantage of rotational DSA with dual volume visualization in endovascular management of intracranial and spinal dural arteriovenous fistula.
interv neuroradiol. 2014 Apr 4;20(2):223–224.
Background and Purpose: Intracranial dural arteriovenous fistulas (DAVFs) can devided into two main types of sinus and nonsinus fistulas in a practical point of view. The purpose of the present study was to compare treatment outcomes of transarterial Onyx embolization in managing with DAVFs between sinus and nonsinus groups.
Method and Materials: From August 2008 to September 2013, 80 patients with intracranial DAVFs underwent endovascular treatment in our institution, and 13 (16.3%) patients had DAVF with pure leptomeningeal drainage. Among them 12 patients were treated with transarterial Onyx embolization. Forty-one of 67 patients with sinus fistula were managed with transarterial embolization using Onyx with or without other embolic agents including coils, n-BCA and contour PVA particles. Immediate post-procedural angiography was reviewed for evaluating treatment outcomes and categorized into the following two groups of complete and incomplete obliteration. Follow up MR angiography was checked for long-term follow-up results and was divided into complete and incomplete embolization.
Results: Twelve patients with pure leptomeningeal drainage underwent single session of transarterial Onyx embolization and complete obliteration was achieved in 8 patients (8/12, 66.7%). No mortality or permanent morbidity was observed in this series. A total of 55 procedures using transarterial Onyx with or without adjunctive agent was performed to 41 patients with sinus fistula and complete obliteration was confirmed in 17 procedures (17/55, 30.9%). Residual fistulous tract was detected on follow-up MRA in 3 patients (4/12, 33.3%) with pure leptomeningeal drainage and 12 patients (17/41, 41.5%) with sinus fistula.
Conclusions: Intra-arterial embolization of DAVFs with pure leptomeningeal drainage by using Onyx results in a high rate of complete obliteration (66.7%) with safe as compared with those with sinus fistula (30.9%).
interv neuroradiol. 2014 Apr 4;20(2):224.
Purpose: Transarterial embolization with n-butyl cyanoacryslate (NBCA) is a highly effective technique especially for non-sinusal type dural arteriovenous fisutulas (AVFs). It is important to penetrate the NBCA into the venous side through the fistulas for curative intent. However, it is often difficult to obtain sufficient penetration of NBCA due to early polymerization and fragmentation of NBCA caused by ionic collateral blood flow from other feeders. To prevent early polymerization of NBCA, we combined the simultaneous 5% glucose solution injection from another feeding pedicle with transarterial NBCA embolization via the main feeding pedicle. We demonstrate this technique with illustrative cases.
Materials and Methods: Seven cases of dural / epidural AVFs, including two superior sagittal sinus (SSS) dural AVF, one ethmoidal dural AVF, one superior petrosal sinus dural AVF, one frontal dural AVF, and two spinal epidural arteriovenous fistula (EDAVF) were treated by this technique. All cranial AVFs showed Borden type III and 2 spinal epidural AVFs showed perimedullary drainage alone. Two microcatheters were advanced into two different feeding pedicles with bilateral femoral approach. NBCA at low concentration (17-20%) was injected through the microcatheter closer to the shunting point while 5% glucose solution was injected through another microcatheter.
Results: All except one showed complete disappearance of AVFs with the sufficient NBCA penetration into draining veins. The remaining one case showed marked regression of AVFs. No procedure-related complication was observed. In all cases no recurrence was observed during 8 month mean follow-up periods
Conclusion: Transarterial NBCA embolization with simultaneous 5% glucose solution injection from another feeding pedicle is an effective technique for the curative treatment of dural / epidural AVFs.
interv neuroradiol. 2014 Apr 4;20(2):224–225.
Tentorial DAVFs with perimedullary venous drainage are rare lesions and could be misdiagnosed as spinal DAVFs. We report three cases of tentorial dural arteriovenous fistulas with perimedullary venous drainage, two cases with myelopathy and one case with no myelopathy. MR images showed cerebellopontine angle and perimedullary flow voids. Cerebral angiography showed tentorial DAVFs with spinal venous drainage. We conclude that DAVFs with spinal drainage cannot be ruled out when perimedullary flow voids are seen on MRI.
interv neuroradiol. 2014 Apr 4;20(2):225.
Carotid cavernous fistula (CCF) is an abnormal communication between cavernous portion of internal carotid artery and cavernous sinus. These are classified as direct and indirect CCF. Direct CCF is direct communication of ICA with cavernous sinus. Indirect CCF is communication of dural branches of ECA and ICA with cavernous sinus. The most common cause of direct CCF is rupture of aneurysm into cavernous sinus and Trauma. The common cause of indirect CCF is thrombosis of sinus with development of fistula.There are various Methods of treating direct and indirect CCF by endovascular means. CCF can be treated endovascularly by balloon occlusion of cavernous sinus, coiling of cavernous sinus, stent graft, Onyx alone or Onyx with coils and parent vessel occlusion. We present a case of indirect CCF which was treated endovascularly through venous route from inferior petrosal sinus. Patient recovered from the symptoms completely.
interv neuroradiol. 2014 Apr 4;20(2):225.
Objective: Mechanical thrombectomy was effective revascularization therapy for acute intracranial large vessel occlusion; however, it has a potential risk of arterial wall damage. The long-term patency of the recanalized vessel is unknown.
Methods: We retrospectively reviewed medical records of consecutive patients who had undergone endovascular treatment for IVtPA-failed/ineligible acute intracranial major vessel occlusion between October 2010 and April 2013 at our institution. MRA follow-up was performed at baseline and at 24 ± 6 hours and 3 months after endovascular therapy.
Results: Sixty-seven patients received endovascular treatment for acute ischemic stroke. Mean age was 69.7±11.5 years, baseline median National Institutes of Health Stroke Scale score was 15 (8 to 24). Occluded vessels were the internal carotid artery in 22 (32.8%), middle cerebral artery (MCA) in 33 (49.2%), and vertebro-basilar artery in 11 (16.4%) patients. Mechanical clot extraction devices were used for 49 (73.1%) patients. Successful recanalization, defined as Thrombolysis in Cerebral Infarction (TICI) grade 2B or 3, was obtained in 54 (80.5%) patients. Modified Rankin score 0,1 at 3-month was obtained in 27 (40.3%) patients. At 24-hour after the treatment, re-occlusion of the recanalized vessel was observed in 3 / 51 (5.9%) patients. None of 37 patients who received 3-month MRA follow-up had re-occlusion, but diffuse severe stenosis of recanalized vessels was developed in 5 (13.5%) patients. All of these patients had undergone treatment for MCA occlusion (OR 21.5, 95%CI 1.010-459.4, p<0.05).
Conclusion: In this study, re-occlusion or development of late stenosis in successfully recanalized vessels was observed. Our results suggest that mechanical thrombectomy is effective but has the potential risk of vessel damage.
interv neuroradiol. 2014 Apr 4;20(2):225–226.
Purpose: To compare the results of mechanical thrombectomy using stent retriever and Penumbra system in acute vertebrobasilar occlusion.
Material and Methods: 13 patients with vertebrobasilar occlusion were treated with mechanical thrombectomy. The mean age was 65.8 years (range, 50 – 89 years). 6 patients were treated by using stent retrievers and 5 patients treated by using the Penumbra system. 2 patient were treated by combined procedure.
Result: Recanalization rate after using the Penumbra system was 80% and after using stent retriever was 100%. However, mechanical thrombectomy by using the Penumbra system was superior to stent retrievers in NISS score improvement (80% versus 66.7%), modified Rankin scale =< 2 after 3 months (80% versus 50%).
Conclusion: In acute vertebrobasilar occlusion, mechanical thrombectomy using the Penumbra system and using stent retrievers both showed high recanalization rate and relatively good outcome. In spite of small cases, Penumbra system showed relatively better clinical outcome rate comparing with stent retriever. On the endovascular mechanical thrombectomy in VBO, Penumbra system could be better choice in the aspect of efficacy and safety.
interv neuroradiol. 2014 Apr 4;20(2):226.
Objective: Mechanical thrombectomy using solitaire stent (ev3 Inc, Irvine, CA, USA) has been introduced effective method in acute ischemic stroke. However, there were no consensuses on treatment strategies after the failure of the thrombectomy using solitaire stent. We described experiences about tirofiban injection after solitaire stent deployment as a rescue therapy after the failure of thrombectomy.
Material and Method:Data on 11 patients treated with mechanical thrombectomy using solitaire stent were collected, retrospectively. Solitaire stent was used as primary thrombectomy method in all 11 patients. If more two times thrombectomy with solitaire stent failed, we performed the tirofiban injection after solitaire stent deployment as rescue method.
Result: Median age and initial NIHSS was 68 years (range, 50-87) and 14 (range, 6-20). Female was 4 (36.3%). Mean time of FAT was 78.5 minutes. The vessel occlusions were 8 cases in the middle cerebral artery, 1 in distal internal carotid artery, and 2 in basilar artery. Successful recanalization (TICI grade 2b and 3) using rescue method was achieved in 9 (81.8%) of all 11 patients. In two patients with no successful recanalization after rescue method, angioplasty with stent insertion was performed and successful recanalization was achieved in all 2 patients. Periprocedural complications occurred in 3 patients (distal embolization, n=2; wire perforation, n=1). Mortality occurred in one patient. Eight patients experienced the neurological improvement.
Conclusion: We suggest that tirofiban injection after solitaire stent deployment may be effective and safe for successful recanalization after the failure of thrombectomy using solitaire stent in acute ischemic stroke.
interv neuroradiol. 2014 Apr 4;20(2):226.
For the intra-cranial thrombectomy using Stentriever, there’s an ongoing debate about the better method between conscious sedation and general anesthesia. For the thrombectomy under conscious sedation state, adequate patient immobilization is one of the most important prerequisites for the safer and efficient procedure. We have designed and revised our own patient immobilization solution for some intra-cranial procedures such as thrombectomy using Stentriever and chemical angioplasty for vasospasm under conscious sedation.
In this presentation, we will show you the developmental processes for the most updated version.
interv neuroradiol. 2014 Apr 4;20(2):227.
Background: Cerebral digital subtraction angiography (DSA) continues to be used for the examination of patients with cerebrovascular diseases.This study aims to determine the level of safety from of cerebral Digital Substraction Angiography ( Cerebral DSA ) procedures performed by Neuro interventionist.
Methods: A prospective study was conducted from January 2009 until November 2013. Recording data includes patient demographics, procedure’s details, and complications that occurred during and after the procedure. Neurological complications are classified based on the international classification: (a) transient, (b) reversible, (c) permanent. The complications were examined by a neurologist.
Results: The patients comprised 305 (38%) women and 495 (62%) men, ranging from 4 to 86 years of age. From 800 patients who underwent the procedure, reversible neurological complications were found in 3 (0.37 %) patient. Neither reversible nor transient neurological complications were found.
Conclusion: Cerebral DSA performed by a neuro intervention in Indonesia, it is safe to do. The results of the study show the number of complications that occur is very low. The study did not reveal both aspect of neurological and non-neurological complications, nor number of deaths.
interv neuroradiol. 2014 Apr 4;20(2):227.
Introduction: Idiopathic intracranial hypertension (IIH) is a disorder of elevated cerebrospinal fluid pressure of unknown cause. IIH occurs in women in the childbearing years. The symptoms of increased intracranial pressure are headache, pulse synchronous tinnitus (pulsatile tinnitus), transient visual obscurations and visual loss but that the patient maintains an alert and oriented mental state, but has no localizing neurologic findings. There is no evidence of deformity or obstruction of the ventricular system and diagnostic studies are otherwise normal except for increased cerebrospinal fluid pressure. Neuroimaging signs of increased intracranial pressure include empty sella syndrome, lateral sinus, flattened globes and fully unfolded optic nerve sheaths. In addition, no secondary cause of intracranial hypertension can be found. we were carried out to assess stenting to directed at reducing intracranial pressure in idiopathic cases or correcting associated conditions.
Case report: A 19-year-old woman who had severe headache and vomiting visited our clinic. Fourteen years ago, she was V-P shunt surgery due to hydrocephalus, and three years ago, was Decopmressive suboccuipital craniectomy and Cl laminectomy with duroplasty by Arnold-Chiari syndrome. The patient’s Lumbar puncture pressure was 400mHg and Magnetic resonance imaging revealed hydrosyrinx C1 to T12 Spinal cord. We performed Extended partial laminectomy on C1 with adhesiolysis on cerebellum, medullar, cervical cord. The patients had disappeared headache. But after 5 days, the patients had severe headache and vomiting. The patient’s Lumbar puncture pressure was 190mHg and Magnetic resonance venogram imaging reveal Rt. Transverse sinus severe stenosis ,we performed Rt. transverse stenting.
Result: The post-stenting course was uneventful, and patient’s headache is completely resolved.
Conclusions: Endovascular sinus stenting can be a useful tool for idiopathic intracranial hypertension complicated with sinus stenosis.
interv neuroradiol. 2014 Apr 4;20(2):227–228.
Background: We are increasing casese in intracranial stening and some increasing wire perforation in small arteries.How to solve the this problem? We embolized rabbit renal artery by microwire and RF generator. To prospectively evaluate the tissue reaction, the embolic effects and absorption of embolization effects of radiofrequency wire electrode method to comparing with PVA embolization method on rabbit renal artery (similar size in human M2)
Materials and Methods: This experiement was performed in accordance with regulations on the animal care and experiments. NewZealand white rabbits were divided into two groups according to the materials ( PVA.diameter 150-250um,4 rabbits) and RF ablation(8 rabbits) by 0.018 inch Tefron coated platinum Mandril guide Wire, Cook, Bjaeverskov, Denmark) used for embolization of right renal artery. A rabbit from each group was sacrificed 3 days, 1 week,2 weeks,4 weeks after embolization Gross and microscopic pathologic findings were examined with Hematoxylin and Eosin staining. RF generator (RF 3000, Boston Scientific Corporation, Boston,USA)
Results: Gross pathologic findings were examined and swelling of embolized kidney was observed 3 days after embolization,where as shrinkage of the kidney was consistently seen after 2weeks,with hard consistency and nodular spaces being noted. At the histologic analysis the PVA particles makes incomplete obstruction of the arterial lumen and no vascularitis is noted at 3 days later. The RF ablation shows full layer necrosis with thrombus formation of after three days later. The 4 weeks later, PVA group shows no remarkable change and the RF group shows no remarkable change and the RF group reveal generalized destruction of architecture of artery with thrombolysis
Conclusion: Embolization of radiofrequency wire electrode is a good candidate for embolic method shows more cell destruction in rabbit in comparison with PVA particle. We need long term follow up and safety study of RF ablation method.
interv neuroradiol. 2014 Apr 4;20(2):228–229.
Aim: To study the prevalence of pseudoaneurysm in post-radiotherapy patients with head and neck tumours, the various treatment options and the problems with flow diverters.
Method: This is a retrospective study including all consecutive patients attending our Radiology Department for emergency diagnostic and interventional cerebral angiographic services over the past 4 years. All the angiograms were retrieved and reviewed by two radiologists [KCL & RL] independently and agreement reached by consensus. Their medical records were retrieved and reviewed as well.
Results: 43 patients attended our Radiology Department for emergency diagnostic and interventional services between 2010 and 2013. One patient had profuse bleeding after tonsillectomy and was excluded. Another patient had no known head and neck tumour; subsequent imaging and clinical findings did not reveal any neck tumour. He was excluded as well. All except one patient presented with acute epistaxis. The other patient has increasing neck swelling after previous lymph node punch biopsy over supraclavicular region. Mean age at presentation was 43 years old [range 29-79] with 29 male and 12 female. 34 patients [83%] had nasopharyngeal carcinoma. Other head and neck tumours include carcinoma of the tongue, larynx, hypopharynx and ameloblastic fibrosarcoma. All of them had received previous neck chemoirradiation. Sixteen pseudoaneurysms were identified on angiographic studies, 11 [69%] from internal carotid artery (ICA), 4 from external carotid artery (ECA) and one from subclavian artery (SCA). Seven out of the 11 ICA pseudoaneurysms were located at laceral portion of the ICA. Nine of the 11 ICA pseudoaneurysms were treated with Pipeline Embolization Device (PED) (Covidien/ev3, Irvine, California) alone and two patients were treated with additional detachable platinum coils placed into the pseudoaneurysms sac. The number of PED deployed ranged from one to four. The other two ICA pseudoaneurysms were treated with parent artery trapping. Atrium covered stent was used to treat the SCA pseudoaneurysm. ECA pseudoaneurysms were seen arising from lingual artery, superior thyroid artery, internal maxillary artery. They were treated with parent artery occlusion either with coils or NBCA [n-Butyl cyanoacrylate]. Technical success was achieved in all 16 pseudoaneurysms. There is one 30-day mortality in one of the ICA pseudoaneurysms treated with PED in relation to aspiration pneumonia and sepsis.
Discussion: More than one in four patients presented to us with severe epistaxis requiring urgent angiographic service had underlying pseudoaneurysms. More and more ECA pseudoaneuysms were identified. We used to employ self expandable covered stent for the treatment of ICA pseudoaneurysms. It is however no longer available in our locality and we have switched to PED for acute treatment in recent years. PED treatment of bleeding pseudoaneurysm is off-labeled use and the problem with placement of PED is the need to administrate dual antiplatelet agents after stent placement. In theory, one PED will have coverage of more than 30% of the surface diameter of the parent vessel. Besides, side branch occlusion is not an issue in laceral ICA. We have placed in 3 PEDs in one of the laceral 3cm ICA pseudoaneurysm with significant stasis in the pseudoaneurysm by the end of the procedure. The pseudoaneurysm showed interval enlargement on D1 follow-up angiography and another PED was inserted. Serial follow up angiogram showed exclusion of the pseudoaneurysm from the circulation in about 1-week time. Placement of additional detachable coils into the sac of the pseudoaneurysm might be needed to enhance its thrombosis.
Conclusion: Pseudoaneurysm is common in patients with head and neck tumours with previous irradiation presented for acute angiographic service for epistaxis. PED is an option for treating ICA pseudoaneurysm, addition placement of detachable coils into the aneurysmal sac might be needed to enhance thrombosis.
interv neuroradiol. 2014 Apr 4;20(2):229.
Aim: An optimum flow diverter angle at the aneurysm neck enables its occlusion. This is accomplished by reducing the volume of blood flowing into the aneurysm. This study investigates the impact of different angle geometries of Flow Diverters on the hemodynamics at the aneurysm neck.
Method:We simulated 2 patients using patient specific imaging: Patient A with a relatively straight vessel geometry and Patient B with a highly curved geometry. The aneurysms are Internal Carotid Artery (ICA) aneurysms having a neck width of 4.1 mm and 5.3 mm respectively. 4 cases of flow diverter-aneurysm geometry were assembled using Creo Elements Direct Modelling Express 4.0 for each of the patient. The flow diverter angle across the neck was fixed at 0° (Case 2), 35° (Case 3) and 70° (Case 4). A no stent case was included as control (Case 1).
Results: In the curved stent cases (Case 3 and Case4) for Patient A, the volume flow reduction was 89% and 86% correspondingly. Patient B showed significantly higher flow rate reduction of about 91% for Case 4. In both patients, a difference of more than 50% flow reduction was observed in the curved stent cases (Case 3 & 4) compared to the straight flow diverter geometry (Case 2) where volume flow reduction was just above 41% for patient A and 20% for patient B. Higher EL% is observed with an increasing angle of curvature. In patient A, the Energy loss for Case 3 and 4 was calculated as 70% whereas for Case 2 it was 40%. In patient B, the Energy Loss for Case 3 and 4 was 51% and 58% and 30% for Case 2.
Discussions: The results showed that flow diverter angle across the neck significantly alter the hemodynamics inside the aneurysm. The greater angled Flow Diverter geometries reduces the flow more than straight ones. The geometry of the parent artery has less effect than the geometry of the Flow Diverters.
Conclusion: This study supports the crucial role played by flow diverter positioning for successful treatment of cerebral aneurysms. The study warrants further investigation of the effect of flow diverter deployment angle on aneurysm hemodynamics.
interv neuroradiol. 2014 Apr 4;20(2):229–230.
Introduction: Cerebral Angiogram is reserved as one of the important diagnostic modalities for stroke patients. However, its procedure could be more invasive than other modalities such as CT, MRI. Catheter / guidewire manipulation have a risk of damaging blood vessels causing dissection. We report 5 iatrogenic cerebral arterial dissection cases during angiogram performed in our institute with review of the literature.
Methods and Results: We retrospectively analyzed all of angiogram ( diagnostic angiogram and intervention ) over a period of 6 years (From 2006 to 2013) and 5 cerebral artery dissection was detected during procedure. 2 cases were detected during diagnostic Angiogram and 3 cases were detected during intervention. Date were reviewed with age, sex, catheter type, location of dissection, time of procedure, clinical outcome, usage of medical treatment. Location of dissection was : 3 in carotid artery and 2 in vertebral artery. Pattern of dissection were: 1 double lumen, 3 narrowing ,1 extravasation (CCF). Stent placement was performed only 1 out of 5 cases. All of 5 patients were followed up with antiplatelate therapy. No neurological change during follow up period and no ischemic change on MRI were detected. Vascular patency was also confirmed by MRA.
Conclusion: As previously reported on literature, iatrogenic cranial vessel dissection randomly occurs during manipulation of catheter / guidewire during angiogram procedure. Being more careful and well prepared when facing high risk cases prevent complication and result in good clinical course. Also it is important that operator should be technically well trained. Early detection of complication and appropriate treatment with long term follow up with less invasive modalities such as CT,MRI lead to good clinical outcome.
interv neuroradiol. 2014 Apr 4;20(2):230.
Background: Digital flat-panel detector cone-beam computed tomography (CBCT) is a new clinical application protocol to obtain volumetric CT images via a C-arm angiographic system for high resolution visualization of vessels, soft tissue, and bone at a free angle. The aim of this study was to evaluate the effectiveness of CBCT for the assessment of vertebral artery (VA) dissection.
Objective: We conducted a retrospective review of 12 patients with 14 lesions. 5 patients presented with headache, 3 with ischemia, and 1 with trauma. 3 patients was diagnosed with incidental findings. CBCT was performed subsequently to the conventional cerebral angiography. Images of CBCT was compared with that of 2D-DSA, 3D-DSA, MRI, and CT angiography (CTA) for the assessment of the morphology of the dissection.
Results: Shapes of the dissection were pearl and string sign in 4 lesions, dilatation in 7 lesions, string sign in 1 lesion, and occlusion in 2 lesions. CBCT identified more irregularity of the vascular lumen and the intimal flap/double lumen than other image modality. Especially, this characteristic was remarkable in the small diameter of the lesion. However, MRI was the best for the assessment of wall thickening and intramural hematoma in the lesions.
Conclusion: In our study, CBCT is possible to detect the actual morphology of vascular lumen in the dissection compared with 2D-DSA, 3D-DSA, MRI, and CTA. CBCT is useful in the diagnosis of VA dissection.
interv neuroradiol. 2014 Apr 4;20(2):230.
Objective: Presurgical embolization of hypervascular central nervous system tumors has been shown to reduce intraoperative blood loss and operating time. However, palliative embolization is not established for the treatment of tumors. Here, we present the first case of a patient with a hypervascular tumor who was successfully controlled with palliative tumor embolization at a 10-month image follow-up and a 20 months clinical follow up.
Method: A 78-year-old male patient presented with a 1-month history of headache and worsening gait disturbance. Gadolinium-enhanced magnetic resonance imaging showed hydrocephalus caused by a 3.9x3.6-cm strongly enhanced mass in the posterior fossa containing multiple cysts. Angiography demonstrated a highly vascular mass supplied by the superior cerebellar artery (SCA) and anterior inferior cerebellar artery (AICA). The image findings are compatible with hemangioblastoma
Result: After diagnostic angiography, a microcatheter was introduced superselectively to the right SCA and AICA, and Onyx was delivered into the tumor with excellent penetration of the tumor vessels. Postembolization angiography demonstrated nearly total obliteration of the vasculature. The patient refused open surgery for tumor resection after preoperative embolization. After 3 months of discharge, his initial symptoms were improved. Sequential follow up imaging studies showed continuous decreases in peritumoral edema and mass for 10 months.
Conclusion: Onyx embolization may be effective in treating inoperable patients with hypervascular intracranial tumors.
interv neuroradiol. 2014 Apr 4;20(2):230–231.
Purpose: To study the efficacy of endovascular treatment on intracranial vertebral dissections with subarachnoid hemorrhage
Material and Methods: We retrospectively analyzed patients who presented our hospital with ruptured VAD and underwent endovascular treatment between August 2005 and February 2013. Clinical and radiologic data were reviewed in all patients. Clinical outcome was evaluated with Glasgow outcome scale(GOS) at the last clinical follow up.
Results: Total of 25 patients were included in this study. There were 20 male and 5 female patients with a mean age of 49.7 years (age range, 36-82 years). Among 25 patients, 21 patients were treated by internal coil trapping and 4 patients were treated by stent assisted coiling to preserve the maternal artery. The mean preoperative Hunt and Hess grade was 3.48 and the mean WFNS grade was 3.24. 14 lesions were in the right vertebral artery and 11 lesions were in the left side. 7 lesions were located proximal to the PICA origin, 7 lesions involved the origin of PICA, and 11 lesions located distal to the PICA origin. Mean follow up period was 26.3 month, ranging 5 to 69 months. According to the Glasgow outcome scale, 9 patients showed good clinical outcome and 10 patients died. In the internal coil trapping group, 9 patients showed good outcome. In the stent assisted coiling group, all patients died.
Conclusion: Although only small numbers of patients were included in this study, we could confirm the high mortality in ruptured VAD. With endovascular treatment, internal coil trapping was effective in preventing recurrent hemorrhage.
interv neuroradiol. 2014 Apr 4;20(2):231.
A 18-year-old college american football player had been suffering from vague headache since he was tackled during exercise several weeks ago. He checked brain CT at a local hospital few days ago because his headache became worse and did not relieved by taking medicine.Initial brain CT revealed small amount of subdural hematoma on left cerebral convexity.It was considered as a simple traumatic hemorrhage and managed by conservative manners. Several days later, he felt more aggravating headache and experienced an episode of generalized partial seizure. On the CT taken immediate after the seizure episode, the amount of acute hematoma was markedly increased and a small modular mass was contrast-enhanced on the left cerebral convexity. Subsequent transfemoral cerebral angiography revealed that it was a 4mm sized aneurysmal dilatation of cortical branch of middle cerebral artery which is supplying posterior frontal region. Emergency craniotomy was proceeded to eliminate the aneurysm and lower the elevated intracranial pressure by removing the hematoma. The bone was widely opened and the subdural hematoma was removed by repeated gentle irrigations and suctions. When the dural flap was half turned over and the surface of the brain was clearly visualized, several irregular shaped hard nodules were encountered. They were buried in the sulcus and severely adhered to the surface of adjacent brain. In the middle of those nodules, located an organizing hematoma which was covering the cortical branch of middle cerebral artery.The artery was explored and trapped by clips along severely injured segment. The ischemic injury was minimized because retrograde flow filled the distal part of occluded artery. The patient recovered without sequelae and discharged soon. It was well known that the traumatic dissection usually occurs along the falx cerebri and tentorium. This is an unusual case that an dissection occurred by rubbing of calcified nodules to convexity artery. We presume that the repeated head contusion during football plays and subsequent minor hemorrhages contributed to both calcification of dura mater and injury of the cortical artery.
interv neuroradiol. 2014 Apr 4;20(2):231–232.
The treatment of traumatic carotid cavernous fistula by transarterial approach is known most effective treatment. Detachable balloon, graft stent, detachable or pushable coil can be used through transarterial approach. We tried treatment of CCF by balloon assistant coil embolization. After postembolization, shunt amount very much decreased, the symptoms of patient were relieved. But after 2 weeks postembolization, multiple embolic infarction occurred. Magnetic resonance angiogram showed heterogenous signal in cavernous internal carotid artery. We tried additional treatment of stent deploy in heterogenous singal portion. Thromboembolism didn’t occur no more. Balloon assistant coil embolization of carotid cavernous fistula had several advantages that especially, balloon could protect parent vessel lumens frome pushable or detachable coil. But our case showed that balloon wouldn’t protect the parent vessel. We report that rare complication occurred after treatment of carotid cavernous fistula.
interv neuroradiol. 2014 Apr 4;20(2):232.
We report a rare case of a combined traumatic pseudoaneurysm and arteriovenous fistula (AVF) of the middle meningeal artery (MMA) on a non-fractured site. A 24-year old man was admitted to our hospital with head trauma. He underwent a craniotomy and the removal of an epidural hematoma on the right side. Twenty-five days later, he complained of pulsatile tinnitus on the left non-fractured side. An angiography revealed a markedly dilated proximal MMA with flow shunting to the pterygoid plexus. We performed proximal occlusion on the proximal MMA for the traumatic pseudoaneurysm and the AVF of the MMA by using coils. Although an immediate angiography showed retrograde contrast filling from the collateral vessels into the distal part of the pseudoaneurysm, a follow-up angiography revealed that the lesion had successfully disappeared.
interv neuroradiol. 2014 Apr 4;20(2):157.
We are presenting an uncommon case of carotid cavernous fistula (CCF) sustained after a head trauma. He presented to our center with proptosis and bruit on the frontal region. Subsequently he experienced angiogram which showed an aneurysm distal to the fistulous ICA.
The present of the aneurysm make the treatment of the CCF risky due to the possibility of aneurysm rupture. The right CCF was decided to be treated with occlusion of the ICA. The CCF was sealed and the aneurysm was also embolized. In this article, the patient presentation was described and the technical issue of the embolization procedure was discussed.
interv neuroradiol. 2014 Apr 4;20(2):232.
Purpose: to present experiences in the management of intracranial vascular complications post head injury with endovascular techniques,
Materials and Methods: a descriptive study with 3 cases reported.
Results: Between April to October 2013, three cases with serious intracranial lesions of the carotid artery were treated in our institution by endovascular intervention. One patient had a ruptured pseudoaneurysm with dissection of the internal carotid artery and was successfully treated by coil placement. The second case involved a rupture of the carotid artery into the sphenoid sinuswith massive hemorrhage. which was successfully closed with ballons. The last patient had a CCF completely closed by percutaneous ballon placement. However, this patient presented 2 months later with a meningeal hemorrhage probably due to a new aneurysm.
Conclusion: Endovascular procedures may be used to treat intracranial vascular complications of trauma, which are often life threatening. These may be the only Methods available.