. 2009 Jun 2;15(Suppl 1):43–257.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):45.
Tuesday, June 30th, 2009 · Room 517 · 13.30-14.50
interv neuroradiol. 2009 Jun 2;15(Suppl 1):45.
Purpose: Broad neck aneurysms may be treated by various techniques including 3D coils, balloon remodelling, trispan or stent. If none of these techniques are applicable, surgical clipping is usually achieved. An alternative may be the kissing balloon technique with the combined used of two remodelling ballons. The purpose of this study is to determine the efficacy of this technique.
Materials and Methods: A treatment by kissing balloon technique was attempted in 100 aneurysms harbouring a very broad neck. The aneurysms were unruptured (n=59), recanalized (n=30) or ruptured (n=11). The aneurysms were located at the MCA bifurcation (n=64), anterior communicating artery (n=15), posterior communicating artery (n=7), basilar artery (n=12) and carotid bifurcation (n=2). Different remodelling balloons were used (Hyperform, Eclipse, Hyperglide, Copernic).
Results: Placement of both balloons was possible in 98 cases, allowing total or sub-total occlusion of the aneurysm. Failure to place both balloons occured in 2 procedures. Postcoiling stenting was achieved in 5 patients, due to coil instability in 3 patients or thrombus extension in 2. Further thrombus extension was seen in 5 patients requiring a treatment with Reopro to restore a normal flow. Hemorrhagic complications occured in 4 patients, due either to aneurysmal perforation during coiling (n=2) or to perforation of a distal branch with a microguidewire (n=2). The one month mortality and morbidity is respectively of 1% and 3%.
Conclusion: The kissing balloons technique enables treatment of very wide necked aneurysms with a complication rate similar to the standard coiling technique.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):45–46.
Purpose: The purpose of this study was to compare intracranial aneurysm coiling procedural complications with and without the use of balloon assistance.
Materials and Methods: Six hundred forty three consecutive intracranial aneurysms were embolized between June 2002 and July 2008; 481 with balloon assistance (143/481 ruptured aneurysms) and 162 without (99/162 ruptured aneurysms). Three different interventionalists participated from a single center. High compliant Hyperglide (25.8%) and Hyperform (73.8%) (eV3 Corporation) were used. Procedural thromboembolic complications and intra-operative perforations were reviewed retrospectively and categorized as with and without clinical sequelae.
Results: Procedural thromboembolic events with clinical sequelae occurred in 11 (2.3%) of aneu-rysms treated with balloon assistance and 11 (6.8%) of aneurysms treated with out (p = 0.03). In ruptured aneurysms: 5 (3.5%) with balloon assistance and 11 (11.1%) with out (p = .033) and in unruptured aneurysms: 6 (1.8%) with balloon assistance and 0 (0.0%) with out (p = .014). Intra-operative perforations with clinical sequelae occurred in 7 (1.46%) with balloon assistance and 1 (0.62%) with out (p = .310).
Conclusions: The use of balloon assistance during embolization of intracranial aneurysms does not increase procedure related thromboembolic events or intra-operative perforations compared coil embolization without the use of balloon assisted technique.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):46.
Objective: Our aim is to present an early experience, with a new self-expanding flow diverter device designed for wide neck aneurysms treatments and to evaluate the occlusion rate at mid-term follow-up.
Method: 84 patients with 110 intracranial wide-necked aneurysms with or without previous treatment or with aneurysm recanalization, proximal to ICA bifurcation or vertebral-basilar junction were selected. The new device consists of a self-expanding, flow diverter, chromo-cobalt alloy, 48 wires broided design and 2,7 French microcatheter compatibility. All patients were treated with double antiplatelet aggregation at least 72 hours before surgery and 12 months post-treatment. Follow-up with control digital subtraction angiography (DSA) was performed at 1, 3, 6 and 12 months.
Results: 84 patients were enrolled with 110 aneurysms, 66 % female, median age was 57(7-79) years. As a result, fifty two were small aneurysms, thirty three large, fifty giant and eleven dissecting aneurysms. Aneurysms were coiled at: a) previous treatment (15), b) during the procedure (6). With PED the diseased parent artery was primarily reconstructed in the majority our patients: at 3 mo. 58%, 93 % at 6 mo. and 95.6% at year.
Conclusion: Although longer term follow up is needed, in this early experience, this new flow diverter device, Pipeline, was safe for proximal intracranial aneurysms treatment. Artery reconstruction at mid-term follow-up was acceptable. PED achieves a definitive endovascular reconstruction of cerebral aneurysm. PED provides durable treatment: no documented deterioration of long-term angiographic outcome (no recurrences).
interv neuroradiol. 2009 Jun 2;15(Suppl 1):46.
Purpose: To report our experience in stent-assisted coiling of cerebral aneurysms.
Materials and Methods: Clinical and angiographic outcomes of 1108 patients (1325 aneurysms) treated with coils from January 2002 to January 2009 were retrospectively analyzed.
Results: There were 1109 aneurysms (83.5%) treated without and 216 (16.5%) treated with stents. For those treated without stent, mean sac and neck sizes, volume and dome over neck ratio, ratio of ruptured aneurysms were 7.1 and 3.7 mm, 175 mm3 and 2.0, 49.5% respectively. For those treated with stents, mean sac and neck sizes, volume and dome over neck ratio, ratio of ruptured aneurysms were 9.3 and 5.6 mm, 406 mm3 and 1.7, 16.2% respectively. Balloon-expandable stents were used in 6.9% while self-expandable stents were used in 93.1% of aneurysms. Stents were delivered after coiling in 55.1% and before coiling in 44.9%. Neurological procedure-related complications occurred in 16.8% of patients (10.5% related to stent placement) in patients treated with stents versus 7.0% in patients treated without stent (P=0.1263). Procedure-induced mortality occurred in 6.8% of patients (5.3% related to stent placement) in patients treated with stents versus 2.5% in patients treated without stent (P=0.0762). 52.7% of aneurysms treated with stents had been followed (mean: 14 months) versus 69.8% of aneurysms treated without stent (mean: 22 months), disclosing angiographic recurrence in 14.9% versus 33.5% (P=0.0001).
Conclusion: Stent-assisted coiling conferred a statistically significant decreased of angiographic recurrence but at the price of more procedural complications.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):46–47.
Purpose: Stent-assisted coiling is a therapeutic alternative for the endovascular treatment (EVT) of wide-necked intracranial aneurysms. The necessity of dual antiplatelet therapy in the use of stent in ruptured aneurysms increases the risk of intracranial hemorrhage. Recently, the first completely retractable self-expandable stent has been developed.We propose a new technical approach using temporary placement of the stent during the coiling without the use of antiplatelets.
Methods: Between April 2008 and December 2008, eight patients with ruptured aneurysm have been treated with this technique. In all cases, previous attempts with EVT with the remodeling technique failed or were technically judged difficult. Aneurysms location was Pcom (n=3), carotid ophtalmic (n=1), vertebral artery (n=1), MCA (n=1), Acom (n=1), basilar artery (n=1). Aneurysms diameter varied from 3 to 15 mm. Clinical outcome was assessed with the modified Rankin Scale.
Results: In all patients, EVT combining stent placement (Solitaire AB, EV3, Irvine, Ca) across the aneurysm neck, subsequent coiling of the sac and stent retrieval was successfully performed. Immediate angiographic results consisted of 5 complete occlusions and 3 subtotal occlusions. No device-related complication occurred. In the course of the SAH, four patients required ventricular drainage after EVT. Six patients had excellent outcome, one patient died and one patient was mRS 5; both evolutions due to the natural course of the SAH.
Conclusion: Temporary stent-assisted coiling using Solitaire without antiplatelet therapy was feasible and safe in this limited series. It should be considered for challenging ruptured aneurysms.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):47.
Purpose: The long term follow-up of cerebral aneurysms is not well know, we wanted analyse clinical results of Guglielmi detachable bare coils embolisation of intradural saccular aneurysms and angiographic about our data base of five neuroradiological centers.
Materials and Methods: Since January 1998, we had collected all aneurysms treated in five neuroradiological centers. During 1998 and 2002, 929 patients with 1034 aneurysms were treated in our centers. 804 aneurysms were ruptured and 230 no ruptured. We have performed very regurlarly follow-up of theses patients with digital substract angiography and MRI and medical examination.
Results: Stability of occlusion was determined at 82%. Last angiographic control was excellent for 656 aneurysms (72%), subtotal for 230 (25%) and incomplete for 16. The proportion of aneurysms with reopening and second treatment was 6.5% (72 aneurysms). We obtained follow up for 902 aneurysms, mean time of follow-up was 58 months, (min 24 months, max 120 months). 50% of patients were reviewed at five years, 25% at seven years. The rate of rebleeding was very low, less than 5 patients rebled during this follow-up.
Conclusion: Long term follow-up of cerebral aneurysms is necessary to determine morphological deterioration. Only 6.5% of these were retreated; others were stabilized: use of bare coils is a very safe technic with good long term obliteration.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):47–48.
Object: To review the changes in the endovascular treatment (EVT) of aneurysmal subarachnoid hemorrhage (SAH) in Japanese top centers, we have been doing Retrospective Study of Endovascular Subarachnoid Aneurysm Treatment (RESAT) and compare the ISAT results.
Methods: We selected experienced board certified senior trainer as investigator of RESAT and send questionnaire to collect each EVT results. RESAT-1: to collect the data from 1997, GDC launched to Japan, to 2002. Then RESAT-2 to 6 (2003-2007): showed Japanese status after ISAT.
Results: 11,762 cases with intracranial aneurysm treated with EVT in this study group, and 4,194 cases were saccular aneurysms treated with aneurysmal embolization of 4,846 anrurysmal SAH. The cohort consisted of 2,792 women (66.4%) and 1,152 ACAs (28.1%), 321 MCAs (7.8%), 1,333 ICAs (32.5%), 944 BAs (23.1%), 311 VAs (7.6%). 1,877 cases were treated on day-0, and 1,741 cases were treated on day 1 to 3. 29.3% of the patients had a WFNS Grade IV or V. Good outcome (mRS 0 to 2) at discharge was achieved in 74.5% of patients. Procedure related complication is 2.9% of morbidity and 0.95% of mortality, and 2.1% of patients have re-bleeding and 4.2% of patients receive re-treatment.
Conclusions: This RESAT study showed the changes in the management of aneurysmal SAH in Japan, that more number of cases, located in anterior circulation, good conditioned patients treated with EVT. Outcome in RESAT is better than ISAT and previous report with surgical clipping for aneurismal SAH in Japan. Patients undergoing EVT will increase following the ISAT and RESAT study.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):48.
Purpose: To determine clinical outcomes at discharge & 6 months in patients with SAH from ruptured aneurysm enrolled in the HELPS & the Cerecyte coil trials compared with outcomes in matched patients in ISAT.
Materials and Methods: >550 patients randomised in HELPS and CCT trials were treated post acute SAH. These trials have ascertained outcomes associated with treating patients with current expertise and technologies. Only patients in good clinical grade at time of treatment were eligible for enrolment. Patient demographics & aneurysm characteristics were collected & outcomes determined at discharge & 6 month follow-up by validated self reported modified Rankin Scale of dependency. Pooled data will be analysed to examine, procedural complications, discharge outcomes & dependency at 6 months. This will be compared to matched dataset of ISAT patients to provide a direct comparison. This will enable robust assessment of whether there has been any change in clinical outcomes compared with the ISAT enrolment (1994-2002).
Results: Patient & aneurysm characteristics, procedure related complications together with discharge & 6 month clinical outcomes will be analysed; a multi-variant analysis of predictors of adverse outcomes will be presented. Combined available data will contain complete discharge outcome data and more than 95% of the 6 month outcome data.
Conclusion: Combined dataset from the 2 trials will provide accurate and up to date estimates of the clinical outcomes of coiling in good grade patients with acutely ruptured cerebral aneu-rysms across a wide range of high volume centres using current technologies & compared with pre-existing trial data.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):49.
Tuesday, June 30th, 2009 · Room 517 · 15.20-16.40
interv neuroradiol. 2009 Jun 2;15(Suppl 1):49.
Purpose: Thrombotic events are a common and severe complication of endovascular aneurysm treatment with significant impact on patients' outcome. This study assesses the efficacy and safety of abciximab for clot dissolution.
Material and Methods: All patients treated with abciximab during (41 patients) or shortly after (22 patients) intracranial aneurysm coil embolization were retrieved from the institutional database (2000 to 2007, 1250 patients). 63 patients (mean age: 55.3 years ±12.8) had received either intra-arterial or intra-venous abciximab. Risk factors for clot formation were assessed and the angiographic and clinical outcome was evaluated.
Results: Two patients died of treatment related intracranial hemorrhages into preexisting cerebral infarcts. Two patients developed a symptomatic groin hematoma. No aneurysm rupture occurred during or after abciximab application. The intra-procedural rate of total recanalisation was 68.3%.
Conclusions: Abciximab is efficacious and safe for thrombolysis during and after endovascular intracranial aneurysm treatment in the absence of preexisting ischemic stroke.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):49.
Background: The optimal management of very large (>20 mm) and giant (>25 mm) intracranial aneurysms remains obscure.
Methods: The authors retrospectively identified 205 aneurysms measuring 20 mm or greater treated at Stanford Hospital between 1983 and 2008. Clinical data including patient age, presentation, and baseline modified Rankin Score (mRS) were recorded, along with aneurysm size, location and morphology. Type of treatment and treatment method were recorded, and clinical outcomes were measured using mRS at discharge and at final follow-up. Angiographic outcomes were available in 88% of cases.
Results: 121 aneurysms were treated surgically, and 61 were treated with endovascular methods alone. Eleven aneurysms were treated with combination therapy, while 12 were followed conservatively. SAH was the mode of presentation in 131 (64%) of patients. The mean mRS score at final follow-up (mean 5.2 years) was 2.23 for surgically treated aneurysms, compared to 2.98 for endovascularly treated aneurysms. Univariate and multivariate statistical analyses are pending.
Conclusions: Preliminary results suggest that patients with very large and giant aneurysms treated with endovascular methods fared worse at final follow-up compared to surgically treated patients. Factors related to these outcomes will be better defined following statistical analysis.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):49–50.
Purpose: To compare the costs, clinical outcomes and length of stay for patients who underwent neurosurgical clipping versus endovascular coiling of ruptured and unruptured aneurysms over a one-year fiscal period (2007-2008).
Materials and Methods: A retrospective review was completed for inpatients with diagnosis of aneurysmal subarachnoid hemorrhage (SAH) and unruptured cerebral aneurysm for fiscal period 2007-2008. Length of stay and modified Rankin score were obtained at discharge. The cost of treatment related to equipment, nursing care and location (ICU/ward), operating room staff, and diagnostic imaging staff were abstracted.
Results: Of the 113 aneurysmal SAH admitted, 51 patients had their aneurysms treated - 37 were surgically clipped and 14 were coiled using endovascular treatment with a mean length of stay(mLOS) of 20 days and 12 days, respectively. The average cost of surgical clipping for ruptured SAH aneurysms was $67,720 / case versus at $48,494/case for coiling. Modified Rankin score averaged at 3. Forty-one inpatients with unruptured cerebral aneurysms were admitted, of which 16 patients were clipped and 25 coiled, with mLOS of 8 days and 2 days, respectively.
Conclusion: Even with the high procedural cost of endovascular coiling in patients with ruptured aneu-rysms, overall cost of coiling was approximately $20,00 less than the total costs of surgical clipping due to increased use of human resource and mLOS in surgically clipped patients. The cost for treatment of unruptured cerebral aneurysms is similar, but the mLOS is 6 days less with coiling which is significant given increasing patient numbers and current bed limitations.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):50.
Purpose: To evaluate if a negative CTA is reliable to exclude underlying vascular pathology in patients presenting with acute subarachnoid hemorrhage (SAH).
Materials and Methods: Retrospective analysis of consecutive negative CTAs performed for patients with SAH compared to the gold standard cerebral angiography (DSA). CTAs were performed using a 64-slice MDCT and included multi-planar MIP reconstructions and 3D reconstructions. The results of CTA are as interpreted prior to DSA.
Results: 188 patients with SAH and negative CTA were identified, 179 had a DSA. The distribution of blood on unenhanced CT was: Perimesencephalic (PMH) in 87 patients, diffuse aneurysmal pattern in 44, no blood on CT but positive LP in 31 and peripheral sulcal blood in 17. All patients with PMH distribution had a negative DSA. 1 (1/31, 3.2%) patient with no blood on CT but positive LP was diagnosed on DSA with vasculitis. 6 (6/17, 35.3%) patients with peripheral distribution of blood had DSA positive for vasculitis. All of the vasculitides are retrospectively seen on CTA. All patients with diffuse aneurysmal distribution of blood had a negative first DSA. However, repeat delayed DSA performed in 25 of these patients revealed a small aneurysm in 3 (3/25, 12%). 5 patients suffered a complication of DSA (2.8%): 1 stroke (0.6%), 1 asymptomatic vessel occlusion and 3 asymptomatic dissections.
Conclusion: Negative CTA is reliable for SAH and can replace the need for DSA especially in patients with PMH. In diffuse aneurysmal pattern of SAH, repeat delayed imaging is indicated. When there is no blood on CT or when blood is peripherally located, CTA should be carefully scrutinized for vasculitis.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):50–51.
Purpose: To assess diagnostic accuracy of magnetic resonance angiography (MRA) as a non-invasive alternative to digital subtraction angiography (DSA) used for follow-up of coiled intracranial aneurysms.
Materials and Methods: Of 417 consecutive patients with coiled aneurysms, 311 patients with 343 aneurysms were included. Time-of-flight [TOF] and contrast-enhanced [CE] MRA at 3.0-Tesla or 1.5-Tesla were performed in addition to follow-up DSA. Aneurysm occlusion on DSA and MRA was independently assessed with a treatment advice for incompletely occluded aneurysms. We calculated test characteristics of MRA, compared the area under the receiver operating characteristic curve (AUROC) for 3.0-Tesla versus 1.5-Tesla MRA, and for TOF-MRA alone versus TOF- plus CE-MRA, and compared treatment decisions.
Results: The prevalence of incomplete occlusion on DSA was 23% (95%CI:19-27%). The negative predictive value of MRA was 94% (95%CI:91-97%), positive predictive value 69% (95%CI:60-78%), sensitivity 82% (95%CI:72-89%), and specificity 89% (95%CI:85-93%). The AUROCs were similar for 3.0-Tesla (0.90, 95%CI:0.86-0.94) versus 1.5-Tesla MRA (0.87, 95%CI:0.78-0.95), and for TOF-MRA alone (0.86, 95%CI:0.81-0.91) versus TOF- plus CE-MRA (0.85, 95%CI:0.80-0.91). Six more patients were recoiled based on DSA and six patients would be recoiled merely based on MRA (difference 3% (95%CI:2-5%)).
Conclusion: Diagnostic accuracy of TOF-MRA alone for follow-up of coiled aneurysms is good at both 1.5- and 3.0-Tesla, and yields similar treatment decisions as DSA.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):51.
Purpose: To assess the value of outcome predictors in 'Grade 5' World Federation of Neurological Surgeons (WFNS) subarachnoid hemorrhage (SAH) patients.
Methods: We retrospectively evaluated 126 consecutive patients with grade V SAH at two (independent) institutions by evaluating the GCS (total Eye Motor Verbal score) and Glasgow Motor Score (GMS) during the first ten days of hospitalization. Among other factors, the impact of extra ventricular drainage (EVD) and rebleeding was analyzed. Outcome was determined at 6 months using the extended Glasgow Outcome Scale.
Results: Favorable outcome for the total group of patients was 19%. Forty-five patients (36%) were not treated because of absent brainstem reflexes. In one institution, 46% of patients with improvement of GCS > 8 at day '3' showed a favorable outcome, 9% of patients without improvement had a favorable outcome (P=0.005). Numbers for the other institution, 33% and 29% respectively (P=0.77), did not confirm these findings. Twenty-seven out of 73 patients showed improvement of GMS > 4 within 24 hours after EVD. Of these 27, eight (30%) showed a favorable outcome. Fifteen out of 33 patients (45%) without such a positive EVD response but with improvement of GMS > 4 at day two showed a favorable outcome. None of the 13 patients with a GMS < 4 at day two showed a favorable outcome. Rebleeding occurred in 19% of patients.
Conclusion: Patients who present or improve to a GMS > 4 at day 2 after SAH have a significant better outcome than patients who fail to do so; none of these have a favorable outcome. Patients with a GMS > 4 should be treated urgently to prevent unfavorable outcome due to rebleeding.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):51.
Purpose: Cerebrovascular complications of AIDS have been reported as high as 34% in post mortem series. Most patients suffer from ischaemic strokes but there are a number of reports of patients presenting with subarachnoid haemorrhage (SAH) related specifically to aneurysm rupture. Although these aneurysms may be co-incidental berry aneu-rysms the possibility exists that there may be direct arterial wall HIV infection and injury. We undertook a review of HIV infected patients presenting with SAH focusing on angiographic vessel appearance and vessel wall histology where available.
Materials and Methods: In four patients the clinical presentation, radiological findings and treatment were reviewed. In one patient post mortem findings and histology of the arterial wall were also examined.
Results: All patients presented with fairly typical features of SAH. The angiographic appearance was that of a dilating arteriopathy with dissection. Hi-stology confirmed the presence of intramural haematoma characteristic of dissection as well as peri-adventitial neovascularisation, internal elastic lamina disruption and intimal proliferation.
Conclusion: Advanced HIV infection can be associated with arteriopathy and arterial dissection. The histological findings offer two possibilities for the occurrence of dissection from either the adventitial side or the endothelial side.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):51–52.
Purpose: The durability of coil embolization may relate to local anatomical factors. Optimal timing of imaging follow-up is undetermined. This prospective historical cohort study analyzed factors that may affect recurrence of coiled anterior communicating artery (ACoA) aneurysms.
Methods: 329 patients had ACoA aneurysms coiled over a 10 year period. Patients were routinely imaged, usually with MRA, 6 months and 2 years post-procedure. Two clinicians reviewed the images and extracted data on the ACoA complex anatomy, aneurysm size and morphology, relationship of the aneurysm neck to the complex and the angle of inflow to the aneurysm. The post-procedural coiling result, and the appearance at follow-up, was recorded using the Montreal classification. Patients who died or for whom imaging was unavailable were excluded from analysis.
Results: Almost 40% of patients had an absent or hypoplastic A1. Inflow was acute in 85%. Complete aneurysm closure was obtained in 42%, with residual aneurysm present in 25%. Many aneurysms that were classified as incompletely closed based on a slight degree of interstitial filling improved to complete closure (36%) or a neck remnant (32%) at 6 months. Aneurysms that were completely closed initially were unlikely to develop recurrent aneurysm by 2 years; in 2 cases that did, change was seen on the 6 month follow-up scan. The presence of an anatomical variant increased the risk of recurrence at 6 months, as did increasing aneurysm size.
Conclusion: MRA 6 months post-coiling is able to predict recurrence at 2 years. Small aneurysms in patients with a normal ACoA complex, that remain closed at 6 months, may not require further follow-up.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):53.
Tuesday, June 30th, 2009 · Room 524 · 13.30-14.50
interv neuroradiol. 2009 Jun 2;15(Suppl 1):53.
Purpose: To evaluate individual factors that influence recanalization rates, time to reperfusion, periprocedural adverse events, postprocedural and long term clinical outcome in patients experiencing ischemic stroke that have been treated by endovascular means.
Materials and Methods: Over two years,130 ischemic stroke patients have been treated in two enrolled centers by a constant team of interventional neuroradiologist. In the majority of patients mechanical thrombectomy was performed with a combination of LIF and phenox clot retrievers, penumbra, merci, and a variety of stents and balloons including temporary stenting with the fully retrievable solitaire stent. Available data were collected with special focus on procedural specificities and postprocedural clinical path. and long term results.
Results: The average time from beginning of the procedure to first angiographic reperfusion was 55 min (min. 11, max. 308 minutes, unless the procedure terminated without success). Reperfusion rates and time-to-reperfusion improved with growing experience. Multimodality in mechanical thombectomy increased the reperfusion rates - TICI 2/3 reaches 90%, TICI 2b/3 70% vs. 82% and 60% with the use of only a single type of thromebctomy device. The rate of adverse events was low despite the increasing variety of devices. An extremely promising approach is the use of stent-type devices, as they have shown to achieve the highest rate of full reperfusion in our series.
Conclusion: Mechanical thrombectomy can achieve TICI 2/3 reperfusion rates as high as 90%. Success and effectiveness depend of eperience. Multimodality MTE increases reperfuion rates over single device approaches.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):53.
Purpose: To evaluate different endovascular techniques in the treatment of acute stroke.
Materials and Methods: We evaluated 151 patients presenting with symptoms consistent with acute stroke, who underwent inta-arterial or mechanical recanalization with either micro-wire manipulation, the Penumbra System (Penumbra Inc. Alameda, CA); or the Phenox Clot Retriever (pCR) (Phenox GmbH; Essen) from January 2005 to April 2008.
Results: Mechanical recanalization led to significantly higher recanalisation rates than i.a.lysis or combined i.v.and i.a. lysis. Here complete recanalization (TIMI 3) was achieved in 73% of patients and partial recanalization (TIMI 2) was achieved in 12%. In the i.a. group the rates were 55 and 17.95 % respectively.
Conclusion: Mechanical recanalization has the potential of exercising a significant impact in the interventional treatment of stroke in the future.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):53–54.
Purpose: The Penumbra System is a novel mechanical thrombectomy device recently approved for ischemic stroke in the US and Europe. The purpose of this retrospective study was to assess its safety and effectiveness in a post-market setting.
Materials and Methods: Case review was performed in 139 patients treated by the Penumbra System in accordance with the approved labeling, ie., NIH Stroke Scale (NIHSS) score ≥8, presentation ≤8 hrs from symptom onset, and large vessel occlusion (TIMI 0-1).
Results: Mean age of these patients was 63.9 years, baseline NIHSS score was 16, time from symptom onset to puncture and revascularization were, 4.5hrs and 48mins., respectively. After treatment, 84% of the patients were revascularized to TIMI 2 (46%) or 3 (38%) with 34.4% having a NIHSS score of 0-1 or ≥10 points improvement at Discharge. There were 7 procedure- or device-related serious adverse events, 2 cases of catheter fracture, and one case of separator tip detachment. A total of 18 patients (13%) were found to have ICH at 24 hours of which 10 (7.25%) were symptomatic. All cause mortality was 22% (30/139). Of the 95 patients who have reached ≥90 days follow-up, 40% had a mRS ≤2. Successfully revascularized patients tended to have a better outcome than those who failed: mRS ≤2: 46.2% vs. 18.8%; all cause mortality: 16.2% vs.42.9%. Similarly, patients with a baseline NIHSS score ≤20 fared better than those with >20; mRS ≤2: 52.5% vs. 35%; all cause mortality: 12.2% vs. 26.1%.
Conclusion: These post-market results suggest that the Penumbra System is safe and effective in reducing clot burden in acute stroke and patients who were successfully treated tended to have more favorable outcomes.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):54.
Purpose: Vessel recanalization constitutes a key issue in acute stroke treatment and is strongly associated with improved functional outcome and reduced mortality. The purpose of this study was to evaluate the Penumbra System [PS], a novel thrombus aspiration device which has recently shown promising results.
Methods: Patients presenting within 6 hours of symptom onset with a stroke attributable to acute occlusion of a major cerebral vessel confirmed by angiography were included in this retrospective study. They underwent thrombus aspiration using PS as first line endovascular treatment. IV thrombolysis (bolus and 1/2 infusion) was administered in patients presenting within 3 hours of symptom onset as well as IA t-PA at the discretion of the operator, during or after PS aspiration.
Results: 33 patients (mean age 67+/-13.9, 18M) were enrolled. Baseline mean NIHSS was 14+/-6.3 and 30% had 3 or more risk factors. Main stroke etiology was cardioembolic (70%) or LAA (15%). All target vessels (5 ICA & T, 21 M1-MCA, 2 M2-MCA, 5 BA) were accessible to PS. Complete (17) or partial (13) recanalization was achieved in 30 cases (91%). The median onset to recanalization time was 5 hr 57 with a median procedure time of 1hr 37. 15 subjects (45%) exhibited a favorable outcome and four (12%) died at 3 months. One symptomatic ICH occurred and 48% had asymptomatic intracranial hemorrhage. We observed 4 device-related SAE, 3 SAH and one device tip rupture.
Conclusion: These preliminary results confirm the very successful recanalization rate achieved by the Penumbra System but also suggest its potential effectiveness and safety in association with thrombolytic therapy within a 6 hours time window.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):54.
Purpose: To analyze short term efficacy of combined mechanical-chemical recanalization in acute stroke.
Materials and Methods: The Penumbra™ thrombaspiration system was used in combination with local and/or systemic thrombolysis in 28 consecutive acute stroke patients. The morphological results were rated as complete or incomplete recanalization of the target vessel with or without persisting occlusion of distal branches.
Results: Seven 'carotid T', 7 basilar and 15 MCA occlusions were treated. Procedures were started at a mean of 3:34 hours and finished at a maximum of 7 hours. Additional local thrombolysis (mean 19 mg rtPA) was applied in 24 patients and systemic in 16 cases (mean of 48 mg rtPA). Complete recanalization was achieved in 5 and partial in 9 cases. Distal branch occlusion persisted in 10, and the procedure failed in 4 cases. Nine patients had hemorrhagic transformation and 4 had parenchymal clot with mass effect. The initial mean NIH score of 19 dropped to 15 in 24 hours. Six patients died and the survivors had a mean modified Rankin score (mRS) of 3,6 at 30 days. Patients with complete recanalization had no mortality and a mean of 2,6 mRS outcome while partial recanalization resulted in 11% mortality and a mean outcome of mRS 3,4. Persistent distal branch occlusion lead to 40% mortality and 4,2 mean mRS, failure resulted in 25% mortality and a mean outcome of mRS 4,5.
Conclusion: Thrombaspiration is an effective adjunct in recanalization. The initial recanalization rate was the key determining factor of outcome. This suggests that to achieve better results it might be worthwhile to extend procedure time limit beyond 7 hours.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):55.
Purpose: The Penumbra Stroke System (PSS) was cleared for use in patients with ischemic stroke in January 2008. However, there are no published results on the efficacy and safety of the system in daily routine practice. Therefore, our aim was to describe our experience with this new system in acute vessel occlusions following thrombolysis.
Methods: We captured single-center data of 15 consecutive patients with acute ischemic stroke treated with the PSS after lysis therapy. All patients presented with TIMI 3 prior to use of the PSS. For early recognition of haemorrhage, intraprocedural flat-detector computed tomography (FD-CT) was used. Neurologic evaluation was performed using NIHSS score and mRs score.
Results: Mean patient age was 60 years. Initial median NIHSS score in 12 patients with occlusions in the anterior circulation was 15, three patients with basilar artery occlusion presented with coma. In the anterior circulation 9 of 12 target vessels were recanalised successful (TIMI 2 and 3). Rate of patients with independent clinical outcome (mRS ≤2) was 42%. Basilar artery occlusions could be recanalised in all cases to TIMI 3. Clinical result after 90 days was mRS 4 in 2 and mRs 5 in 1 case. Symptomatic haemorrhage did not occur, but contrast extravasation was noticed in 7 cases by FD-CT and subsequent conventional CT.
Conclusion: The PSS can safely be used for recanalisation in patients with acute ischemic stroke due to large vessel occlusion, treated prior with thrombolysis. Recanalisation rate was 80%. Symptomatic haemorrhage did not occur. Randomized trials are needed to demonstrate that endovascular mechanical thrombectomy improves patient outcome.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):55.
Purpose: Stent placement has been advocated as a rescue therapy in combination with thrombolytic agents, thrombectomy and percutaneous balloon angioplasty in acute stroke treatment. After an initial in-vivo study to evaluate the working principle, a clinical study was performed to evaluate feasibility, efficacy, and safety of intracranial artery recanalization for acute ischemic stroke using a self-expandable stent.
Material and Methods: All patients treated with an intracranial stent for acute cerebral artery occlusion were included. Treatment comprised intraarterial thrombolysis, thrombectomy, PTA, and stent placement. Recanalization result was assessed by follow-up angiography immediately after stent placement. Complications related to the procedure and outcome at 3 months were assessed.
Results: A total of twelve patients (median NIHSS 14, mean age 63 years) were treated with intracranial stents for acute ischemic stroke. Occlusions were located in the posterior vertebrobasilar circulation (n=6) and in the anterior circulation (n=6). Stent placement was feasible in all procedures and resulted in partial or complete recanalization (TIMI 2/3) in 92%. No vessel perforations, subarachnoid, or symptomatic intracerebral hemorrhages occurred. One dissection was found after thromboaspiration and PTA. Three patients (25%) had a good outcome (mRS 0 to 2), 3 (25%) a moderate outcome (mRS 3), and 6 (50%) a poor outcome (mRS 4 to 6). Mortality was 33.3%.
Conclusion: Intracranial placement of a self-expandable stent as a rescue procedure for acute ischemic stroke is feasible and seems to be safe to achieve sufficient recanalization.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):56.
Purpose: To show our experience using stenting as recanalization technique in acute ischemic stroke.
Material and Methods: In the last 2 years we have treated 11 patients with ischemic stroke using stenting in the acute phase. Only two patients have received intravenous fibrinolitics. In all cases we performed parenchimograpgy pre and post procedure to evaluate cerebral circulation. Occlusion site was at the carotid bifurcation in 2 cases, left MCA bifurcation in 1, vertebral artery in 2, carotid siphon in 1, vertebrobasilar junction in 1 and basilar trunk in 4 cases..
All cases received intraarterial urokinase (between 200,000 and 600,000 UI) except for the MCA case because the patient was taking acenocumarol. All procedures were done with systemic heparinization which was continued 24 hrs after and with aspirin and clopidrogel after the procedure.
Results: All stents were successfully deployded, 2 autoexpandable stents at the carotid bifurcation and 9 balloon expandable stents for the rest of the cases. The normal arterial circulation was recovered in all cases. 1 patient with a basilar trunk occlusion presented a perprocedure hemorrhage controlled with balloon inflation but the patient died 24 hrs after. In the rest of the cases there was no complications, they recovered from the initial deficit and there have been no new ischemic episodes.
Conclusions: In some cases, the use of stenting combined with intraarterial fibrinolitics is a feasible alternative to the use of thrombus extraction devices.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):56.
Purpose: Symptomatic internal carotid artery occlusion has a poor prognosis and intravenous fibrinolysis appears of limited efficiency. We report intra-arterial desobstruction of symptomatic carotid occlusions in 5 cases in the acute phase.
Materials and Methods: Retrospective study of a consecutive series of 5 cases (2 females, 3 males), mean age 52, with an NIH between 10 and 28, managed with a mean time of 5 hours after the first appearance of symptoms. Cervical vessels exploration showed cervical internal carotid occlusion. Brain perfusion revealed an acute stroke with an important hypoperfusion in total carotid territory. An endovascular desobstruction in the acute phase was attempted.
Results: Desobstruction on ICA was achieved in 4 cases, by stenting in 3 cases (2 dissection, 1 bifurcation stenosis), clot retrieval in one (C4 siphon stenosis), intraarteriel fibrinolysis was associated in 2 cases with M1/M2 occlusion. These 4 cases showed a clear clinical amelioration or recovery. In 5th case, angiography showed an extensive thrombosis in the ICA with failure of mechanical desobstruction. In the 4 efficient cases, tiny back flow by meningeal anastomosis into C5 to C3 segments of carotid siphon on late phase of CT or digitalized angiography predicted absence of extensive thrombosis.
Conclusion: Acute endovascular treatment by desobstruction of symptomatic occlusions of the ICA with hemodynamic component is safe and efficient when causing factor is a short stenosis (dissection or atheroma) without extensive thrombosis.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):56–57.
Purpose: We describe a method using a microcatheter to inject autologous arterial blood into the thrombus for recanalization of the artery.
Materials and Methods: We developed a technique to use autologous arterial blood alone or in combination with low dose pharmacologic thrombolysis to achieve thrombolysis in patient with acute ischemic infarcts. In the last 3 years, a total of 30 patients were encountered. All had pre-procedure NECT for rule out hemorrhage. The average time from symptom to needling was 333 minutes (SD=1151 minutes). Seven patients received treatment more than 6 hours after ischemic attach; six had large infarction on CT scan. The NISS was 15.4 in average (SD=7.9). Using a microcatheter, we repeatedly injected autologous arterial blood aspirated from femoral sheath into the thrombi. We limited the working time in 30 minutes.
Results: We successfully recanalized occluded arteries in 15 patients (TIMI3=5, TIMI2=8, TIMI1=2). No hemorrhage in patients without successful recanalization. Reperfusion hemorrhage occurred in 2 patients. No extracranial hemorrhage. However, long-term follow-up revealed 27 patients had TIMI3 flow on CTA follow-up.
Conclusion: Autologous blood thrombolysis for acute ischemic stroke may be an alternative for those patients with time window of 6 hours or more.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):58.
Tuesday, June 30th, 2009 • Room 524 • 15.20-16.40
interv neuroradiol. 2009 Jun 2;15(Suppl 1):58.
Purpose: To report long-term clinical and angiographic follow-up results of stenting for symptomatic atherosclerotic intracranial artery stenosis.
Materials and Methods: Between May 1998 and Sep. 2008, stent-assisted angioplasty was performed on 179 patients (Age range: 41-80, mean: 64.3years) with 196 symptomatic intracranial artery stenoses (MCA:61, ICA:75, VBA:60). Stent-assisted angioplasty was technically successful in 188 of 196 symptomatic intracranial artery stenoses. We retrospectively analyzed the procedure-related complications, clinical and angiographic outcomes of long-term follow-up.
Results: The mean pre-and post-stent stenosis degree decreased from 79.9% to 3.44%. The 30day periprocedural stroke or death rate was 3.7%.
On clinical follow-up of 172 patients (range: 3-107 months, mean: 45.1 month), nine transient ischemic attack,three minor strokes,one thalamic hemorrhage, one subarachnoid hemorrhage,one myocardiac infarct and one death were developed (ipsilateral stroke or death rate: 2.33%, overall vascular event or death rate: 8.72%). No other patients showed symptom related to the intracranial artery stenosis.
Angiographic follow-up (range: 3-55 months, mean: 12.1 month) was obtained in 94 of 188 intracranial stenoses. Significant stenosis (>50%) was observed in 13 of 94 lesions (13.8%).
There was no perforator or sidebranch occlusion in all follow-up cases.
Conclusion: Stent-assisted angioplasty for symptomatic atherosclerotic intracranial artery stenosis is feasible and safe. Long-term clinical and angiographic follow-up results could be favorable. Randomized clinical trial should be necessary.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):58–59.
Purpose: For carotid stenting to reach its full potential, an acceptable risk of periprocedural complications, particularly in low-risk patients, must be ensured. This presentation provides special emphasis on the process of risk stratification pertaining to clinical, anatomic, and procedural considerations necessary to optimize procedural safety and patient outcomes.
Materials and Methods: In between June 2003 up to October 2007 704 patients (764 arteries) underwent CAS performed using coaxial system with 6F ' 90 cm sheath, protection device placement, pre-dilatation, placement of the stent, stent dilatation and retrieval of the protection device. There were 142 patients (153 vessels) over 80 years old. Patients were stratified not by high surgical risk, but by high stenting risk taking in consideration patient's age, cerebral reserve and anatomical conditions - vessel tortuosity and calcifications.
Results: Overall complication rate was 2.5% (minor stroke 1.3%, major stroke ' hemorrhage 1.2%, all death 0.4%). In patients over 80 years old the complication rate was 3.2% (minor stroke 1.3%, major stroke 1.3%, all death 0.6%). There was no statistical difference for age, gender and symptomatic status.
Conclusion: Key to avoid complications is to recognize situations where complications can be expected. The results using algorithm when patients undergoing CAS are selected not whether the patient is high or low risk for CEA, but instead if the patients is high or low risk for CAS, are encouraging.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):59.
Purpose: We reported the long-term prognosis and the incidence of in-stent restenosis among the patients after carotid artery stenting (CAS).
Material and Methods: Two hundred forty-one patients underwent CAS between August 2000 and April 2008 for symptomatic or asymptomatic carotid severe stenosis in our institutions. Eleven cases which experienced major complication within 30 days were excluded. Finally, 230 patients, including 200 men and 30 women, mean age of 69.2 year old were included. They were retrospectively reviewed from clinical records. Twenty-nine patients were treated bilaterally. Mean follow-up period was 29.0 months (maximum 90 months).
Results: The freedom from 50% and 80% or greater in-stent restenosis after CAS at 36 months was 96.4% and 99.4%, respectively. Two ipsilateral cerebrovascular accidents and two amaurosis fugax were observed and the freedom rate at 12 and 36 months was 99.6% and 99.1%. There were only 15 patients who died after 30 days, because of pneumonia in 6 patients, neoplasm in 3, myocardial infarction in 2 and intracranial hemorrhage in 1. According to the Kaplan-Meier analysis, 3-year survival rate of the patients after CAS in our study was equal to that of Japanese 70-year-old male calculated based on life table published by welfare facilities (93.3% vs. 93.0%).
Conclusion: Our study showed that cervical carotid artery stenting strongly prevented cerebral infarction and caused rarely in-stent restenosis. Although carotid artery stenosis is one aspect of severe generalized arteriosclerosis, even high-age patient seem to have the time to receive preventive benefit of stroke under enough medical management.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):59.
Purpose: Presentation of an evolution of the cerebral protection system "TwinOne" whose relative limitation is that it implies an adaptation to the type of stent used by the operator. The goal of the new system to free the operator of this constraint and to make the carotid stenting more simple.
Method: An "integrated system" has been made that includes in only one tool
1) an autoexpandable stent
2) a cerebral protection balloon of modulable positioning
3) a post-dilation balloon.
Result: This still experimental system allows one to get an efficient cerebral protection by temporary occlusion of the distal internal carotid and to limit drastically the material exchange maneuvers
Conclusion: This system allows one to perform carotid stenting simply, rapidly and with an efficient cerebral protection.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):59–60.
Purpose: Thrombosis and occlusion of the internal carotid artery may acutely cause brain ischemia or stroke. Some individuals develop a chronic symptomatic perfusion insufficiency. These patients may be treated with an arterial bypass. Recently, endovascular recanalization of the internal carotid artery has been proposed as a treatment alternative. We here report our very preliminary results with this technique.
Materials and Methods: The material consists of five patients with symptomatic cerebral hypoperfusion, as proven with conventional angiography and CT perfusion. All five were offered treatment. Four were subjected to endovascular recanalization of the chronically occluded internal carotid artery, responsible for the hypoperfusion.
Results: One patient refused treatment and later developed a cerebral infarction and died.
One patient had complete, probably subintimal, recanalization of the internal carotid artery, but it was not possible to re-enter the true lumen.
Three patients were successfully treated with recanalization and stenting of the internal carotid artery. One patient had a large cerebral infarction prior to treatment, developed additional infarctions despite sufficient arterial flow after treatment, two days later suffered from a subarachnoid hemorrhage and died.
The remaining two patients are doing clinically well. One has a progressive stenotic process in a long segment of the ICA distal to the C1 segment. The second patient had a 50% in stent stenosis at six months follow up.
Conclusion: Endovascular recanalization of the chronically thrombosed internal carotid artery is technically feasible. The technique is still immature and further experience is necessary.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):60.
Background: Acute occlusion of internal Carotid Artery (ICA) is a clinical catastrophic entity with mortality.as high as 50%. With innovative devices and technology, we want to clarify the benefit and risk of interventional treatment for those patients
Methods and Results: From 2005 to 2009, 42 patients were enrolled and 7 patients were diagnosed as total ICA occlusion and underwent interventions ( 5 had intra-arterial thrombolysis and 3 had balloon/stenting with/without angioplasty). Compared with previous reports, our protocol precludes intervention in the patient with good contra-lateral collaterals.
Three patients had symptomatically hemorrhagic transformation and one developed severe brain edema after procedure. Decompressive craniotomy has been conducted in 3, who survived thereafter. Our patient No. 2 expired because the family refused surgery. The other patients had significant decrease of NIHSS more than 4 scores, and they had mRS <=3. All of our patients had tandem lesions at middle cerebral artery area, and delayed recanalization was noted in 4 of 7 .
Conclusions: Endovascular therapy was promising as a hyperacute management for patients of ICA total occlusion leading to survival rate more than 80% and significant neurological recovery in 50% of our patients. Tandem lesions were common in patients of total carotid occlusion. Although the mechanism was not clear, delayed recanalization was not uncommon in such patients.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):60.
Purpose: Complete or near occlusion of the carotid artery is different from carotid artery stenosis. There are some difficulties in revascularization of this disease. Experience with endovascular treatment is presented and discussed.
Materials and Methods: Nine patients with complete occlusion and nineteen with near occlusion were treated with endovascular procedures. External and common carotid arteries were occluded with balloons. Passing through the lesion, distal balloon protection was added. After sequential angioplasty carotid stent or coronary stent was deployed.
Results: Technical success was obtained in 19 of 19 cases with near occlusion and in 6 of 9 cases with complete occlusion. Complication occurred in 2 with near occlusion and in 1 with complete occlusion. No cerebral stroke after treatment was observed in 6-36 months follow-up.
Conclusion: Endovascular treatment is promising for complete or near occlusion of the carotid artery. Short-term results of this small series are satisfactory.
Accumulation of cases and long-term follow-up are necessary to validate this treatment.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):60–61.
Purpose: The hyperperfusion syndrome is a recognized complication of carotid artery stenting (CAS). Preoperative analysis of cerebral vasoreactivity could help to identify patients at risk for hyperperfusion. The aim of this study was to predict hyperperfusion using intraoperative CT perfusion, immediately after CAS. Relationship between parameters obtained from CT perfusion (cerebral blood flow; CBF, cerebral blood volume; CBV and time to peak; TTP) and hyperperfusion state of post CAS was analyzed.
Materials and Methods: Between April 2007 and July 2008, 41 consecutive patients underwent CAS, 32 of whom was performed the following imaging examinations and entered the present study. Thirty-two of the 24 patients were male, and 8 were female. Mean age was 69.5 years old. All procedures were performed at "Brain OR" where neurointervention was achieved in combination with neurosurgical operations with multidetector CT. CTP was done before and after stenting. CBF and CVR were investigated before and 1 month after CAS, with resting and acetazolamide-challenge SPECT.
Results: A significant change was observed in ΔTTP (= postoperative TTP - pre- operative TTP) between ipsilateral (26.5±32) and contralateral (3.4±11.4) side of CBF. A significant association of reduced CVR with hyperperfusion on the CTP immediately after stenting was also observed. TTP changes after stenting significantly correlated with CBF increase in the reduced CVR group but to in the normal group. The threshold of ΔTTP for hyperperfusion was estimated to be 36 sec.
Conclusion: Intraoperative CTP can identify patients at risk for hyperperfusion after CAS.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):61.
Purpose: To show our experience performing carotid angioplasty by direct puncture using Angioseal as an haemostatic closure device.
Material and Methods: 2 patients with carotid artery stenosis that have previously undergone attempts to performed angioplasty by femoral and radial approaches were programmed for angioplasty using a direct carotid approach.
Results: Both patients were successfully treated with angioplasty and stent placement. For haemostatic purposes we used Angioseal as closure device to avoid complications derived from carotid puncture. There were no peri or postprocedure complications. The patients remain asymptomatic 2 years after the procedure.
Conclusion: Although direct carotid puncture is not used today as it was in the past, it still remains a feasible and safe approach in experienced hands when other approaches (femoral or radial) have proven unsuccessful due to very tortuous anatomy. Main complications of carotid puncture were derived from haemostatic problems at the puncture site which can be overcome with the use of closure devices (AngioSeal) without complications.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):61.
Purpose: To compare the results of CAS using closed cell stents (Wallstent) with balloon protection device (Guardwire) and open cell stents (Precise) with filter protection device (Angioguard).
Materials and Methods: CAS has been indicated for 122 patients with symptomatic moderate to severe stenosis and asymptomatic severe stenosis with high risk for carotid endoarterectomy from 2005 to 2008. We have performed CAS using the combination of Wallstent/Guardwire (W/G) for 72 patients and Precise/Angioguard (P/A) for 36 patients in this period.
Results: Ipsilateral stroke and death within 30 days were reached in 4/72 patients (5.5%) using W/G and in 3/36 (8.3%) patients using P/A. Ischemic symptom during CAS appeared in 13 (18%) patients using W/G and in 1 (2.8%) patient in P/A. Symptomatic embolism during CAS occurred in 2 (2.7%) patients using W/G and in 1 (2.7%) patient using P/A. Symptomatic embolism after CAS only occurred in 2 (5.5%) patients using P/A. Plaque protrusion in the stents were confirmed in 1 (1.4%) patients using W/G and 6 (16.7%) patients using P/A.
Conclusion: There is higher tendency to have symptomatic embolism after CAS procedure in open cell stents with filter protection comparing to closed cell stents with balloon protection due to plaque protrusion.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):62.
Tuesday, June 30th, 2009 • Room 520ab • 13.30-14.50
interv neuroradiol. 2009 Jun 2;15(Suppl 1):62.
Purpose: In order to re-classify pediatric choroid fissure arteriovenous fistulas (PCFAVFs) including vein of Galen aneurysmal malformation (VGAM) and vein of Galen aneurysmal dilatation (VGAD).
Materials and Methods: We retrospectively reviewed 57 PCFAVFs with a dilated Galenic system which were treated in our institution from 1996 to 2008. Lesions were classified into VGAM (choroidal and mural types) and VGAD (choroidal, quadrigeminal, combined, and mural types). All cases that had visualization of ICV or cortical venous reflux were classified as VGAD.
Results: There were 24 VGAMs (5 mural and 19 choroidal). Mural VGAMs presented between newborn and 11 months of age with mild congestive heart failure (CHF), or macrocephaly / hydrocephalus. All choroidal VGAMs except for 2 cases presented with CHF within 2 weeks of life. There were 33 VGADs (11 quadrigeminal, 9 choroidal, 5 combined, and 8 murals). They presented with variety of symptoms. The age of presentation widely ranged from fetus to 19 years old. Three mural and 3 choroidal type VGADs had the same angiographic findings as mural and choroidal VGAM, respectively, except for visualization of ICV or cortical venous reflux.
Conclusion: PCFAVFs have various degrees of development of the vein of Galen ranging from the median prosencephalic vein without connection to the cerebral veins to the fully developed vein of Galen. Occlusion of the draining vein should not be performed as the initial treatment even for the apparent VGAM, because connection of the draining vein to the cortical veins may not be angiographically visualized due to high flow shunts and can cause delayed hemorrhage after occlusion.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):62–63.
Purpose: To characterize clinical, imaging, treatment, and outcome data associated with patients under 19 years old diagnosed with intracranial aneurysms at a tertiary care institution.
Materials and Methods: Retrospective medical record, imaging, and angiogram review from all pediatric patients examined at our university hospital over the last 27 years.
Results: Between 1981 and 2008, our institution evaluated 77 patients (mean age=12 years, 40 female, 37 male) with 103 intracranial aneurysms. At the time of initial presentation, patients reported headache (45%), cranial neuropathies (16%), nausea/vomitting (15%), vision changes (13%), trauma (13%), seizure (4%), or sensory changes (3%). Aneurysms were discovered incidentally in 6 patients. Of 103 total aneurysms, 11% measured greater than 25 mm. Thirty-one fusiform aneurysms occurred in 25 patients. Forty-seven saccular aneurysms occurred in 35 patients. Twelve infectious aneurysms occurred in 6 patients. Fifteen traumatic aneurysms occurred in 12 patients. Overall, subarachnoid hemorrage occured in 25 patients. A total of 60 patients underwent treatment of their aneurysms (endovascular, surgical, or both); 17 patients were managed conservatively with clinical follow-up and serial imaging. Overall mortality was 1.3%. Morbidity included 5% infarction and 1.3% new onset seizure disorder.
Conclusion: Intracranial aneurysms in children differ in distribution and etiology as compared to those in adults. Complex aneurysm morphologies, underlying vasculopathies, and the long expected lifespans of patients warrant a comprehensive multidisciplinary approach to both acute and chronic management of aneurysmal disease in children.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):63.
Purpose: To utilize the Youth Quality of Life Instrument - Facial Differences Module (YQOL-FD) to establish baselines for subjects undergoing endovascular treatments of head and neck vascular malformations (VMs) and compare these baseline results with those of historical controls.
Materials and Methods: Subjects between the ages of 11 and 18 who underwent endovascular treatments of their head and neck VMs at our institution were recruited. All participants completed the YQOL-FD during the peri-operative period. The YQOL-FD is validated for adolescents aged 11 to 18 and consists of 48 questions that address the domains of stigma, negative self-image, positive consequences, negative consequences, and coping.
Results: Twenty-one subjects (mean age 14.3 years, 57% women, 57% White) with mild to severe facial deformities completed the YQOL-FD. Fifteen had prior endovascular treatments (71%). Historical controls from the mild severity group (n=250) of the YQOL-FD original validation study were used for comparison. Our subjects' mean scores for the domains of stigma, negative self-image, negative consequences, and coping were not significantly different from those of historical controls. The domain of positive consequences, however, was significantly different (p<.05).
Conclusion: Our subjects with mild to severe facial differences have an equal, if not better, quality of life than the historical controls with only mild severity. We speculate that our comprehensive team approach with specialization in endovascular treatments of VMs improves our patients' outcomes, outlooks, and thus, quality of life.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):63.
Purpose: This case series shows how we successfully treat paediatric vascular anomalies which have Doppler proven arteriovenous high flow properties and unreachable positions.
Materials and Methods: Over the past decade our unit has treated 800+ paediatric patients that presented with vascular malformations or haemangiomas. Vascular malformations are correlated mostly to familial genetic disorders whilst 1% of haemangiomas are thought to be inherited. Haemangiomas occur in 10-12% of newborns and is caused by an over expression of molecules that promote angiogenesis, including VEGF and bFGF. Sixty percent of vascular anomalies occur in the head and neck area. Due to the cartilaginous nature of the cranial bones in young children, deformities tend to develop around haemangiomatous lesions. Because these lesions can cause disfigurement, we advocate early diagnosis and active treatment.
Results: We have attained good results with intralesional Bleomycin injection (IBI). However, there is a risk of haemorrhage. Consequently, once ultrasound shows fistulous flow via the super-selective arterial route, we perform particle embolization before IBI. In addition, the systemic administration of Indiral (a non-selective beta-blocker) improves results. Bleomycin was shown to inhibit neovessel growth via an, as yet, unidentified pathway, whereas Indiral is thought to downregulate the genes responsible for the expression of VEGF and FGF. Treatment and outcomes of patients will be discussed.
Conclusion: Vascular anomalies in young children can be treated successfully with a combination of IBI, prior arterial embolization and systemic administration of Indiral.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):63–64.
Purpose: This case report shows how the transcranial placement of an Amplatzer device controlled intractable cardiac failure in an infant born with a vein of Galen arteriovenous fistula. This was a life-saving procedure, and as far as we could establish, a world first.
Summary of case: A three week old infant, with a vein of Galen anomaly, was referred to our neuro-interventional unit. We performed trans-arterial embolization of the posterior choroidal arteries with glue under general anaesthesia. The procedure was limited by the amount of contrast we could safely inject. This procedure was repeated three times, but the infant's condition improved only marginally. The baby had massive cardiomegaly as well as early hepatic and renal failure. We decided to approach treatment from the venous side. However, the vein of Galen anomaly showed a morphological widening on the posterior side which is contra-indicated for the use of coils. A micro-catheter and guide wire was coiled into the vein of Galen aneurysm and left in situ for 24 hours. This was done to slowly reduce the flow of blood. Then an Amplatzer device, normally used for patent foramen ovale anomalies, was surgically inserted into the mesh of the micro-catheter. Over the next 24 hours the fistula stabilized and we could remove the guide wire. The baby's condition improved considerably.
Conclusion: The use of Amplatzer devices are well known in pulmonary arteriovenous fistulas. As far as we know this is the first ever use of such a device for a vein of Galen arteriovenous fistula after failed arterial embolization. With this procedure we reversed the terminal cardiac failure with which the infant presented.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):64.
Purpose: The purpose is to report our experience in the endovascular treatment of 7 cases of Vein of Galen aneurysm.
Material and Methods: The author presents 7 cases of Vein of Galen aneurysm presented between the age of 9 month and 6 years with variable clinical presentation. 5 children were presented with hydrocephalus, was presented with brain stem venous stroke due to associated absence of the two transverse sigmoid venous system. 1 case presented with epilepsy and associated with multiple venous malformations.
Results: The endovascular treatment has been conducted successfully in 5 hydrocephalic patients and resulted in arrest of head growth. The other two patients were not treated because the aneurysmal dilatation is not related to their symptoms. Angiographic details are discussed.
Conclusion: The endovascular treatment of vein of Galen must be carefully correlated with patient symptomatology.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):64.
Purpose: Katz et al.1 and Bisdorff et al.2 confirmed a strong association between periorbital lymphatic malformations and noncontiguous intracranial vascular anomalies. An association of orbital lymphatic malformation (LM) and vein of Galen (VOG) malformation has not been reported in the literature. We present a case of a 3 year-old boy with a right orbital LM as well as a VOG malformation treated at our institution.
Summary of case: At birth the patient was noted to have swelling of his right eyelid which increased in size over time, prompting evaluation with an MRI. The MRI scan showed multiple cysts with fluid-fluid levels involving the eyelid and intraconal and extraconal tissues of the right orbit, compatible with a LM. In addition, the MRI scan revealed a VOG malformation with a persistent falcine sinus. The patient underwent cerebral angiography and successful transarterial coil embolization of the VOG malformation at 11 months of age. The patient underwent surgical excision of the right orbital lesion at 3 years of age. Pathology, including immunohistochemical stains, was consistent with the diagnosis of LM.
Conclusion: We present an unusual case of an orbital LM and VOG malformation; a first report of this distinct association. This case is similar to prior reports on periorbital LM and intracranial vascular anomalies, and again suggests a genetic link between these entities, and emphasizes the need for prompt imaging of the brain in children diagnosed with a periorbital LM.
References
- Katz SE, et al. Ophthalmology. 1998 Jan;105(1):176–84. doi: 10.1016/s0161-6420(98)92058-9. [DOI] [PubMed] [Google Scholar]
- Bisdorff A, et al. Am J Neuroradiol. 2007 Feb;105(1):335–41. [PMC free article] [PubMed] [Google Scholar]
interv neuroradiol. 2009 Jun 2;15(Suppl 1):64–65.
Purpose: This is the first case report that endoglin abnormality confirmed by genetic analysis in vein of Galen aneurysmal malformation (VGAM).
Summary of case: This child, the first born to his family, delivered vaginally at 39 weeks and 5 days after a normal pregnancy. Initial symptoms were cardiac failure and pulmonary hypertension. Diagnosis of choroidal type VGAM was done by MRI/MRA and US at 3 days of age. His symptoms were uncontrollable by medications, progressed gradually. Patient was treated by transarterial mono-pedicle pure glue embolization at 11 days of age. His symptoms improved dramatically after intervention. Marked diminished of the median prosencephalic vein detected by MRI/MRA. The boy discharged at day 44 without medication. The patient is now 2 years old, developing normally. He has family history of HHT, his mother and grandmother have past history of uncontrollable nasal bleeding. The genetic analysis of the boy demonstrated on locus 9q33-34, mutated gene Endoglin. Endoglin is a component of the receptor complex for transforming growth factor (TGF) β1-β3, which is the gene mutated in Hereditary Hemorrhagic Teleangiectasia (HHT). Two cases of VGAM were reported recently caused by RASA1 mutation. However, there is no previous report of VGAM link with HHT. Therapeutic management and genetic analysis are included in this report on VGAM.
Conclusion: Reduced endoglin is one of the etiological factors in VGAM. Accumulation of the further clinical investigations should be planned.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):65.
Purpose: To illustrate that giant pial AVMs can be inapparent on screening prenatal sonography yet present in the neonatal period with heart failure that can be treated with endovascular embolization.
Materials and Methods: Review of a single neonatal giant AVM case.
Summary of Case: A full term boy was born via spontaneous vaginal delivery to a healthy 29-year old woman. Prenatal sonograms performed at 20 and 26 weeks gestational age were normal, including the brain. On delivery, the patient developed respiratory distress. CTA showed a right frontotemporoparietal AVM with multiple large AV fistulae involving the right anterior, middle and posterior cerebral arteries and concomitant massive dilatation of the dural venous sinuses.
The patient was transferred to our hospital in severe cardiac failure with anasarca, encephalopathy, diffuse hypotonia, and minimal withdrawal to pain. On days of life 6 and 9, a total of 5 MCA and 3 PCA shunts were embolized using detachable coils and n-BCA, with excellent angiographic shunt reduction. The patient became arousable. He was extubated at one month. Due to persistent pulmonary hypertension, a third embolization was performed at 6 weeks, with coil occlusion of the right M1 MCA and right anterior choroidal artery and n-BCA occlusion of the right A2 ACA. The patient's pulmonary hypertension improved and he was discharged home. Cardiac medications and oxygen were stopped 6 months later.
At 20 months of age, the patient was speaking several words, had a left hemiparesis, and no visual field deficit, heart failure, seizures, nor headaches. He required no medications. MRI demonstrated right hemispheric atrophy and a residual rim of AVM.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):65.
Purpose: To present our strategy in treating a pial fistula in the pediatric age group.
Case presentation: We present a case of pial fistula with two arteriovenous shunts and two large venous varices in a 2 year old girl who presented with seizures. MRI showed right side posterior fossa large signal void pouches with tortuous draining veins, pial fistula was the provisional diagnosis.
Conventional angiogram confirmed the diagnosis and showed two pial fistula shunts supplied by the posterior parietal and parieto occipital arteries draining into two large venous pouches. Embolisation was uneventful using NBCA concentrated at 50% occluding the fistulous shunts as well as the beginning (The foot) of the draining veins.
Six month follow up MRI and conventional angiogram confirmed total exclusion of the fistula. The patient remains asymptomatic with no epileptic fits encountered.
Conclusion: High concentrate NBCA permitted angiographic cure of the pial fistulous communication with no evidence of recurrence at 6 month follow up.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):66.
A 6-year-old boy developed sudden onset left hemiparesis, vertigo and dysarthria. He was taken to a local community hospital within 30 minutes of symptom onset where a CT head was performed, interpreted as normal. He was transferred to our institution six hours post-ictus with a clinical examination demonstrating mutism, drooling, a weak gag, left hemiparesis, and additional right-sided pyramidal signs. Review of his outside CT revealed a hyperdense basilar artery. Emergency MRI, including DWI and ADC imaging, demonstrated an acute brainstem infarct involving the pons and midbrain. CTA confirmed BAT and an extracranial left vertebral artery dissection. Clinical exam ten hours post-ictus revealed significant deterioration, with internuclear ophthalmoplegia, no tongue protrusion, drooling, left hemiplegia, right hemiparesis and bilateral extensor plantar responses. The child underwent balloon angioplasty-assisted IA thrombolysis, with complete basilar recanalization achieved at 12 hours post-ictus. A total of 12 mg (0.5 mg/kg) of rt-PA was required. CT brain obtained immediately post-intervention showed contrast staining in the pons with no hemorrhage. He was started on aspirin 81 mg daily, 24 hours post procedure. The boy made a very rapid recovery, such that two weeks following admission, he was transferred to a rehabilitation facility with normal speech, full extraocular movements, and minimal word finding difficulties. Although he was able to ambulate without assistance, mild limb weakness remained, as did significant emotional lability and dysphagia, requiring nasogastric tube feeds. At 3 months he had no residual neurological deficits.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):67.
Tuesday, June 30th, 2009 • Room 520ab • 15.20-16.40
interv neuroradiol. 2009 Jun 2;15(Suppl 1):67.
Purpose: The purpose of this report is to review the presentation and therapy of patients with traumatic vascular injuries of the head and neck.
Materials and Methods: 124 patients were diagnosed and endovascular treatment procedure was performed in our center from 2005-2008. The mechanisms of injury included motor vehicle accident in more than 95%, stab wound and aggravated assault in the others. There were 114 direct CCF, pseudoaneurysm and severe epistaxis in 4, SAH in 2, extra-cranial internal carotid progressive dissection presented with ischemic stroke in 2, external carotid lesion in 2 cases. Especially, we experienced 11 patients with difficult CCFs, who underwent initial treatment by muscle embolization (2 cases) or ligation of the carotid artery: 3 ICA, 6 CCA.
Results: Among 124 cases, the lesions were treated using detachable balloon in 91.1%, detachable coils in 8%, stenting and coilling in 0.08% (1 case). The using of material depends on the characteristic lesion especially the size of orifice. In subgroup treated CCF, we performed direct punture the ICA at the neck in 6, Pcom approach in 2, ophthalmic vein in 1, and 1 patient required direct surgery to expose the ICA in 1 case. The fistulas were successfully occluded in 10 cases. Over all, the lesions were cured in 96.7%, parent vessel were reserved in 78%. Hemiparesis complication was found in 0.8%, mortality rate was 0.8%.
Conclusion: Endovascular therapy provides a feasible treatment for head and neck traumatic vascular lesion with low complication rate. In this series, direct carotid cavernous fistula is the most common lesion and detachable balloon were used successfully in most of these cases.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):67–68.
Introduction: Meningioma (MNG) embolization is often performed with particles before surgery. In our institution, it is performed whenever possible with acrylic glue deposited into the MNG capillary bed. This technique has allowed to avoid surgical resection in certain MNG. We assess the indications, safety and efficacy of this treatment, emphasizing the stability of the results at follow up (mean: 18,3 months).
Material and Methods: 98 MNG have been selectively embolized with glue. Among them, 10 shrunk and / or disappeared, and were not operated (10,2 %). The localisation of the lesions, clinical symptoms, angioarchitecture, therapeutic management and results obtained have been analyzed.
Results: There were 7 convexity MNG, 1 falcorial, 1 clival, and 1 tentorial. Symptoms were seizures (3 cases) or progressive neurological deficits (4 cases); three patients were neurologically asymptomatic, except for headaches in 2 of them. These MNG measured less than 5 cm and were exclusively vascularized by dural feeders. Total devascularisation was obtained in 8 cases. Post angiographic MRI realised at 48 hours revealed tumor necrosis and follow up was decided. MRI at 6 months showed a tumoral shrinkage of more than 90% in 2 patients, of more than 50% in 8 cases. No morbidity occurred. Clinical improvement occurred in each case with normalization of the symptoms in 5 patients. The follow up is 48 months (1 case), 24 months (4 cases), 12 months (2 cases), 6 months (2 cases) and 3 months (1 case).
Conclusion: If properly selected and embolized, some MNG can benefit from therapeutic embolization. This technique could be included in the therapeutic strategy of these tumors.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):68.
Purpose: Some intraaxial brain tumors, such as hemangioblastoma, are highly vascular and may benefit from preoperative embolization. Embolization of intraaxial tumor can be challenging because these tumors are typically supplied by small distal parenchymal branches. This study reviews our preliminary experience of using Onyx and mannitol to treat intraaxial brain tumors.
Materials and Methods: Six patients with hypervascular intraaxial tumor were embolized preoperatively at a tertiary care center in the last three years. The angiographic results, periprocedural complication, estimated intraoperative blood loss and subjective assessment of surgical difficulty by the operating neurosurgeons were retrospectively reviewed.
Results: The six patients included three patients with posterior fossa hemangioblastomas, one patient with renal cell metastasis to the frontal lobe, one patient with small cell lung cancer metastasis to cerebellar hemisphere and one patient with supratentorial primitive neuroectodermal tumor. On average, 79% of tumor vascular supply was obliterated by embolization. There is no periprocedural complication. Estimated blood loss was lower than expected and the surgery was made easier by the embolization in all six patients.
Conclusion: It is feasible and safe to use a combination of liquid embolic agents to embolize hypervascular intraaxial brain tumors.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):68.
Purpose: Few reports have described the embolization of head and neck lesions using percutaneous techniques. We report our preliminary experience in the percutaneous embolization of hypervascular head and neck tumors and vascular malformations using liquid embolic agents.
Materials and Method: Retrospectively studied 18 patients (8 F: 10 M, mean age: 35, range 12 - 60) (Jan 03 - Dec 08). 19 hypervascular lesions of the head and neck were treated endovascularly. Percutaneous injection of liquid embolic agents (Onyx/n-BCA) was performed under ultrasound and/or fluoroscopic guidance and utilized in tumor compartments incompletely devascularized with endovascular embolisation. 10 paragangliomas, 4 juvenile angiofibromas (JNA), 4 AVMs of the face, and a venous malformation of face were treated. 14 tumors underwent surgery within 24 - 48 hours post-embolization. Documented intraoperative blood loss obtained in 12 patients.
Results: Homogenous intratumoral penetration was achieved during each injection. Mean 2 (20 gauge x 3.5 inch) spinal needles placed percutaneously into the tumors (range 1 - 4). The mean intraoperative blood loss was 390 cc (range 40 cc - 1700 cc, < 100 cc in 6). Following percutaneous technique, complete angiographic devascularization was achieved in 10 of 14 tumors. There were no related local complications or neurological deficits.
Conclusion:Percutaneous embolization of hypervascular lesions of the head and neck with liquid embolic agents is technically robust. Reduced intra-operative blood loss from endovascular techniques alone may allow safer and complete surgical resection.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):68–69.
Objective: Our purpose is to describe our experience with endovascular treatment of acute carotid blow-out syndrome with active and profuse bleeding by using stent graft.
Summary of cases:
Case 1: The patient was a 44 years old male with diagnosis of squamal cell carcinoma of tongue with metastasis to neck. He presented to the emergency room with profuse internal and external bleeding from right carotid blow-out secondary to a mass infiltrate in the carotid vessel. Covered stent graft was used to stop bleeding.
Case 2: The patient is a 69 years old female with the history of carotid endarterectomy. The patient had expansive pulasatile neck mass afterwards. The patient came with skin erosion and sudden active bleeding from the neck. She was selected to have an endovascular repair with stent graft.
Case 3: The patient was a 20 years old male who was brought to the ER for the stab wound to the neck. Primarily, the neck wound was closed with sutures and the bleeding from the carotid artery was contained with the use of Heparin. The patient had a hemorrhagic stroke afterwards, which made us to discontinue Heparin. Therefore, the patient became a candidate for carotid stenting.
Case 4: The patient was a 57 years old male with the history of squamal cell carcinoma treated with radiation and chemotherapy. He came to the ER with sudden bleeding. After cerebral angiogram, internal carotid artery stenting was done.
Conclusion: The placement of stent graft in patients with active bleeding from carotid blow-out is a feasible and successful approach to stop the acute bleeding with little morbidity in comparison to carotid artery ligation.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):69.
Purpose: To report the results of percutaneous sclerotherapy for facial venous malformations (VMs) using subjective clinical assessment and objective changes on MRI.
Materials and Methods: In the last 5 years, 56 patients (ages 16 to 75 years, 24 males, 32 females) with facial VMs were treated. Of these, 33 patients with 35 lesions had pre and post-treatment MRI. Percutaneous sclerotherapy was performed using alcohol (n= 8), bleomycin (n = 25) or both (n = 2). Patients received between 1 and 9 sclerotherapy sessions (average 3.31). MR findings and clinical results of treatment were retrospectively reviewed. Clinical results included patient satisfaction and clinician evaluation, and were classified as unchanged, worse or better. Objective results on MRI were classified as no change, worse, minor improvement (<50% decrease in size), marked improvement (> 50% decrease in size) or cured.
Results: 26 of 35 lesions (74.3%) showed objective improvement on MRI. Of these, 9/35 (25.7%) showed minimal decrease in size and 17/35 (48.6%) showed marked decrease. 9/35 (25.7%) lesions showed no change on MRI. No VMs were worse or completely cured. Subjectively, 32 of 35 (91.4%) patients and 33/35 (94.3%) clinicians felt that the lesions improved. 3/33 patients suffered facial nerve palsy after treatment, all of them treated with alcohol.
Conclusion: Percutaneous sclerotherapy is a useful technique to decrease the size and symptoms of facial VMs using both subjectively and objective measures. A subjective clinical post-procedural improvement is not always associated with visual reduction in size on MRI. Alcohol harbours higher risk for complications than bleomycin.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):69.
Purpose: Bleomycin is a cytotoxic glycopeptide antibiotic produced by the bacterium Streptomyces verticillus, first discovered in 1962, and has been used primarily for cancer. Bleomycin acts by induction of DNA strand breaks, believe to result in inhibition of DNA synthesis. The most serious complication of bleomycin is pulmonary fibrosis and impaired lung function. Past history of treatment with bleomycin should therefore always be disclosed to the anaesthetist prior to undergoing a procedure requiring general anesthesia. Other side effects include fever, rash, dermatographism, hyperpigmentation, alopecia, and Reynaud's phenomena. We report our early experience in the use of image guided sclerotherapy with Bleomycin in lower eyelid venous malformations (VMs).
Materials and Methods: We retrospectively reviewed 3 patients with mucosal involvement of the lower eyelid, and treated with Bleomycin. The maximum dose per procedure was 15 mg, and the maximum life dose should not exceed 400 mg.
Results: Complete disappearance clinically as well as based on MRI occurred in 2 patients, and significant improvement in the 3rd, that is still undergoing further treatment. No complications occurred.
Conclusion: We believe that the minimal inflammatory response, the fact that if extravascular injection(s) occurred there is much less risk of tissue necrosis; make it the sclerotherapy of choice in mucosal, and other sensitive locations. The effect on DNA may result in more stable treatments, with lower incidence of recurrence.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):69–70.
Purpose: Percutaneous treatment of venous malformations.
Method: Direct injection of a radio-opaque mixture of ethylcellulose and ethanol. 30 patients have been treated. All patients have been treated under general anesthesia. Radio opacity was modulated depending of the cases. The consistence of the substance and its radio opacity allow a precise control of its progression on fluoroscopy. Less than 1 cc was injected in each punctured spot of the malformation.
Results: After a phase of transient increase volume, a significant reduction of volume of the malformation was obtained in all cases. In 3 cases the treatment required two sessions. There has been no general complication. There has been in one case a transient ulceration of the skin that cured without sequelae.
Conclusion: This new substance represents a progress in the treatment of the venous malformations.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):71.
Wednesday, July 1st, 2009 • Room 517 • 13.30-14.50
interv neuroradiol. 2009 Jun 2;15(Suppl 1):71.
Objective: To detail the pathophysiological cascade giving rise to contralateral cavernous syndrome and posterior fossa symptoms in a ruptured intracavernous aneurysm.
Case report: A 55 year old lady complained since several weeks of headaches that suddenly completed with left VI nerve palsy. CT suspected a left intracavernous giant aneurysm. Acute clinical worsening occured with right proptosis and left cerebellar syndrome. MR showed dilatation of the right cavernous sinus, brain stem suffering and left cerebellar hematoma. Angiography disclosed an left ruptured intracavernous aneurysm draining into the controlateral cavernous plexus and superior ophthalmic vein, as into ipsilateral posterior fossa veins. Sacrifice of the carotid artery was performed and well tolerated, but the clinical evolution was marked by episodes of cerebellar hematoma, brain stem dysfunction, locked in syndrome, all related to posterior fossa venous ischemia, infarction and thrombosis. The patient improved under anticoagulation.
Conclusion: Although rare, rupture of an intracavernous aneurysm can have devastating consequences mostly due to the venous congestion and related disorders of the cavernous sinus itself and to its venous contributors.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):71.
Purpose: To present 3 interesting case studies which highlight the technique of curative embolisation of dural AV fistulas and subsequent resolution of parenchymal brain changes and associated neurological deficits.
Summary of cases: We present 3 cases of symptomatic dural AV fistulas with venous hypertension treated by liquid embolisation.
Case 1: 52yo F presented obtunded, with bilateral thalamic oedema, masquerading as straight venous sinus thrombosis. Formal cerebral angiography demonstrated a deep dAVF supplied by distal branches of the right anterior inferior cerebellar artery.
Case 2: 72yo F had progressive neurological deterioration resulting in her requiring nursing home care. She then presented with a right subdural haematoma and white matter changes in the right hemisphere. These changes were secondary to a right transverse sinus dAVF.
Case 3: 45yo F presented with worsening headache, MRI demonstrated a Chiari malformation and associated cervical syrinx. A sagittal sinus dAVF was also demonstrated, with associated dilated cortical veins.
The 3 cases of dAVF were embolised, the first with glue, the latter two with Onyx. All three cases were technically successful. There was clinical improvement in all three patients. Radiologically, the bilateral thalamic oedema in the first patient, the hemispheric changes in the second patient and the Chiari malformation with cervical syrinx in the third patient resolved.
Conclusion: Embolisation of dAVF is technically feasible, with curative intent. Secondarily there is capacity for reversal of the radiological parenchymal changes of venous hypertension associated with this condition and clinical improvement of neurological deficits.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):72.
Purpose: Compromised venous outflow may affect cerebral blood flow dynamics and brain perfusion. The primary pathology could be outside the standard imaging field and not included in the study. We present a series of patients with similar findings on CT brain perfusion studies resulting from different etiologies and levels of venous pathology.
Materials and Methods: Three patients treated at our hospital over 2 months presented with altered states of consciousness, ischemic and hemorrhagic infarcts resulting from (1) superior vena cava (SVC) syndrome; (2) dural venous sinus thrombosis (DVST); and (3) arteriovenous fistula (AVF) between the subclavian artery and internal jugular vein with retrograde flow within the internal jugular vein, sigmoid and transverse sinuses because of brachiocephalic vein occlusion.
Results: CT brain perfusion demonstrated abnormality with similar perfusion maps, resulting from venous outflow compromise in all patients; however, the etiologies and levels of venous pathology were different. Clinical improvement and normalization of CT brain perfusion findings after interventional treatment, including angioplasty/stenting of SVC, thrombolysis of DVST, and occlusion of AVF were observed.
Conclusion: Abnormal venous outflow due to stenosis, thrombosis or high pressure within venous system may significantly affect brain perfusion. Findings on CT brain perfusion studies may appear quite similar even when the underlying etiologies are different. These characteristic perfusion maps may suggest venous outflow compromise even when the primary pathology is not included in the study.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):72.
Objective: Discuss the cause of subarachnoid hemorrage in a patient with a thrombosed giant aneurysm.
Case report: 38-year old woman presenting with sudden onset of right hemiplegia and rapid progression into coma. CT scan revealed a subarachnoid hemorrage and a hematoma in the left sylvien fissure associated with a round lower density lesion. Angiography was performed and showed an occlusionof the left middle cerebral artery at the level of M2. The patient went to the operating room for hematoma ressection. During surgery, a completely thrombosed aneurysm of the middle cerebral artery measuring more than 3 cm was found. The angiographic follow-up at days 1 and 3 after surgery showed a progressive recanalization of the left MCA. Unfortunately, she developped a large left sylvien infarct nonetheless and died a month later from respiratory complications.
Discussion and conclusion: We seem unable to explain the relationship between the hemorrage, the thromobosed giant aneurysm and the occlusion of the MCA by any other theory than that of a dissection that progressively healed spontaneously. But if the actual cause of the bleeding is the dissection itself, possible though rare at this site, or the 'thrombosed' aneurysm remains a riddle.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):72–73.
Objective: To discuss the clinical course of juvenile dural arterio-venous fistulas (dAVf) in the pediatric population, focusing on the treatment strategy in relation to the developmental status.
Case Report: A two year old boy presented with a macrocrania, but no other neurological abnormalities. A multiple dAVf at the level of the superior sagittal sinus (SSS) was diagnosed with additional shunts at the tentorium and falx cerebri. Neurological development over time was closely followed, and showed only mild disturbances, minor motor developmental disorders were acknowledged. At seven years of age, recurrent headaches and behavior problems occurred. At that time the venous drainage of the brain is impaired, as both the brain and the dAVf have to drain through the enlarged superior ophthalmic vein in relation to bilateral jugular vein stenoses.
Discussion and Conclusion: Staged arterial embolization enabled hemodynamic and developmental control during the first six years. Because of extensive revascularization, additional embolization was not performed. In view of the symptoms a more aggressive approach was chosen: partial occlusion of the SSS, resulting in significant improvement of the venous drainage. The clinical course was highly favorable, headaches were cured, and his behavior changed for the better.
With respect to the additional (asymptomatic) shunts close to the falx and tentorium, no treatment was performed. From an anatomical point of view, it is questioned whether these are secondary dural or pial AV shunts due to the sump effect. Finally, as the dural AV fistula is not yet cured, the need for additional treatment will be discussed.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):73.
Objective and Importance: This is the first report of an aggressive dural arteriovenous fistula presenting with rhinorrhea. It demonstrates the importance of recognizing raised intracranial pressure, and its underlying cause, as the predisposing factor to a 'spontaneous' cerebrospinal fluid leak, as this carries implications for management.
Clinical presentation: Ten years after minor trauma and directly following an intercontinental flight, a 43 year-old female presented with rhinorrhea. A rightsided pulsatile tinnitus had been present for the last nine years. Imaging demonstrated an intracranial dural arteriovenous fistula of the right transverse sinus, with cortical venous reflux. Magnetic resonance imaging findings indicated longstanding raised intracranial pressure.
Intervention: The fistula was treated by endovascular means, using both transvenous and transarterial approaches, which led to immediate relief of the tinnitus and resolution of the rhinorrhea within four days.
Conclusion: A dural arteriovenous fistula should be included in the differential diagnosis of underlying causes of raised intracranial pressure, when examining a patient with a cerebrospinal fluid leak. Treatment of the fistula should precede attempts to treat the rhinorrhea, especially if the fistula has cortical venous reflux.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):73.
Objectives:
1. To understand the persistent embryological vascular connections between anterior and posterior circulations.
2. Illustrate the invasive imaging to determine the causative relationship of persistent trigeminal artery (PTA) to trigeminal neuralgia (TN) and to demonstrate whether PTA can be sacrificed safely.
3. To discuss various treatment options and to describe the endovascular management of PTA causing TN.
Background: PTA is an embryological connection between carotid and basilar artery which usually involutes soon after birth. It is seen in 0.02 to 0.6% of all cerebral angiograms and is found in 2.2% of patients presenting with TN. Treatment of PTA poses a challenge to the neurosurgeons due to its course through the Meckel's cave. Permanent endovascular occlusion of PTA has shown encouraging results in patients with TN.
Methods: We illustrate the CT / MR imaging, angiographic findings of PTA and describe balloon test occlusion to determine the causative relationship of PTA to TN and to assess the safety of permanent occlusion. We also describe the procedure of permanent occlusion of PTA.
Conclusion: Understanding the normal anatomy of trigeminal nerve and nearby structures is crucial to identifying the cause of TN. We describe the embryology and course of PTA with a detailed illustration of endovascular approach for treatment.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):74.
Wednesday, July 1st, 2009 • Room 517 • 15.20-16.40
interv neuroradiol. 2009 Jun 2;15(Suppl 1):74.
Purpose: Distal embolism is still one of the most significant problems to solve in carotid artery stenting (CAS). Although the periprocedural complication rate has decreased after introduction of distal brain protection devices, CAS for patients with vulnerable plaque is thought to be risky. The purpose of the present study was to investigate the feasibility of various plaque images including conventional carotid ultrasonography (US), black-blood MRI, virtual histology on intravascular ultrasonography (VH-IVUS), angioscopy and 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) to detect vulnerable plaque which creates large amount of atheromatous debris during CAS.
Materials and Methods: Among 300 procedures from 285 patients, echo-density less than 35 in gray scale median, high signal intensity on T1 weighted image (more than 1.3 in ratio to sternocleidmastoideus muscle), less calcified plaque in IVUS were all statistically significant factors. High-grade stenosis rate and long segment lesion were also associated with plaque vulnerability significantly. Angioscopy was very useful to evaluate the plaque surface stability after CAS. FDG-PET was a unique image and supposed to express the active inflammation in the plaque. FDG-PET with 3D-CT angiogram could depict the rough location of the inflammatory components.
Conclusion: The authors could perform CAS safely based on combination of these images with no mortality and low morbidity rate of 2.3%. Carotid plaque imaging can provide important information as to treatment indication as well as devices and techniques to choice, and is essential to improve the clinical results of CAS.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):74–75.
Purpose: We studied carotid plaque morphology using CTA in TIA/stroke to identify additional factors that may predict plaque activity.
Materials and Methods: Patients presenting with hemispheric TIA/stroke and who also had a caro-tid CTA within 24 hrs were studied retrospectively. Scans were interpreted by two blinded readers studying plaque length, width, density, shape, surface and calcification as well as intraluminal thrombus (ILT) in addition to stenosis. An ILT was defined as a pedunculated defect projecting into the vessel lumen.
Results: 673 patients (408 male, age 18-91; Mean= 65.8) with good scans and who also had a hemispheric event were included. The ipsilateral carotids served as cases (n=673) and the contralateral as controls. Univariable logistic regression showed that occlusions [p=0.01], severe stenosis (70-99%) [p=0.06] and ILT [p=0.01] were predictive of symptomatic side. Some features were seen more with the control side such as smooth plaque [p=0.01] and extensive calcification [p=0.03]. There was no correlation between hypodense plaque [p=0.7] or ulceration [p=0.74] in predicting symptomatic side. In a multivariable logistic regression model, accounting for age, gender and stenosis, ILT was still found to be significant [p=0.048] and extensive calcification seen more with the control side [p=0.047]. It also showed a graded increase in odds ratios as stenosis increased towards occlusion.
Conclusion: In addition to higher stenosis grades, presence of ILT is highly predictive of sym-ptomatic side in carotid disease. Smooth plaque and severe calcification seems to be protective. This may be useful in radiological risk stratification in carotid disease in addition to stenosis.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):75.
Purpose: In-stent filling defects (ISFD) are often observed on multidetector-row CT angiography (CTA) after carotid artery stenting (CAS), and may lead to restenosis. The rate of occurrence and serial changes in ISFD have not been reported. We investigated the frequency and serial changes in ISFD following CAS.
Materials and Methods: 82 carotid arteries in 77 patients were examined by serial CTA at 7 days, one month, 6 months, and every 6 months after CAS. The occurrence and location of ISFD at early (7 days), mid (1–12 months), and late (> 12 months) phases, and serial changes of the ISFD in each phase were analyzed. The mean follow-up period after CAS was 1.5 years (8 days–7 years).
Results: ISFD with a median axial diameter of 1.2 mm (0.6–2.9 mm) were observed in 32 (39%) lesions on the 7th day, and all were located at the primary lesion. At one month, 29 of the 32 lesions were examined, and the median axial diameter of the ISFD was 0 mm (0–2.5 mm), with 25 lesions disappeared or diminished. In the mid phase, new ISFD, median axial diameter 0.9 mm (0.5–1.6 mm), developed in 36 of 69 lesions (52%), with 28 located at the primary lesion and 8 at the stent edges. The ISFD were enlarged in 11, and unchanged or diminished in 18. In the late phase, new ISFD, median axial diameter 1.0 mm (0.5–2.4 mm), developed in 8 of 39 lesions (20%), and 7 were located at the stent edge. Three ISFDs were enlarged.
Conclusion: ISFD developed in 39%, 52% and 20% of cases at the early, mid-term and late phases, respectively. The ISFD occurred at different phases showed different reaction, and may reflect different pathogenic responses after CAS.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):75.
Purpose: ASPECT scores completed on admission non-contrast CT (NCCT) following acute stroke may identify patients who could benefit from thrombolysis treatment. Contrast staining on the NCCT after intra-arterial (IA) thrombolysis can be classified as enhancement, extravasation, or hemorrhage. The objective of our study was to define the relationship between admission ASPECT scores and contrast staining on NCCT after IA thrombolysis for acute stroke.
Materials and Methods: Forty-eight patients with acute ischemic stroke (AIS) in the anterior circulation treated with IA thrombolysis were included in this study. Contrast staining on post-IA thrombolysis NCCT scans was classified as enhancement (no contrast present at 24 hours), extravasation (contrast > 90 HU present at 24 hours) or hemorrhage (contrast < 90 HU present at 24 hours). The ASPECTS template was used by a trained neuroradiologist to score areas of contrast staining.
Results: Contrast staining was present on 93% (40/43) of the NCCTs. Of these, 21 showed evidence of extravasation or hemorrhage and 19 showed enhancement. Extravasation and hemorrhage were evident in the deep grey matter in 93% of cases, whereas only 73% of cases with enhancement showed contrast in the deep grey matter, with the remainder showing enhancement only in the cortical grey matter. Admission ASPECT scores were not significantly different between patients demonstrating enhancement (7.5 ± 1.5) and those with extravasation or hemorrhage (7.3 ± 1.5).
Conclusion: Admission ASPECT scores are not different between patients demonstrating contrast enhancement and those with extravasation or hemorrhage on NCCT following IA thrombolysis treatment for acute stroke.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):76.
Purpose: The authors assessed cerebral hemodynamics by using perfusion CT (PCT) and SPECT with same protocol (including acetazolamide challenge) in patients with cerebrovascular stenotic disease.
Materials and Methods: Thirteen patients were diagnosed as cervical carotid stenosis and 5 patients as intracranial ICA stenosis the other 13 patients as MCA stenosis. All patients except only one patient underwent PCT with acetazolamide challenge, and among these, 21 patients underwent SPECT at the same period. ROI values of MCA territory were obtained at MTT, CBF, and CBV in PCT, and count of ROI of SPECT before and after acetazolamide challenge.
Results: The mean stenosis rate was 76.6±11.9 %. Significant decrease in CBF (13.1±17.6, P=0.000) and CBV (10.5±14.9, P=0.001) and significant increases in MTT (37.4±41.1, P=0.000) were found after acetazolamide challenge in MCA territories of stenotic side. However, count of ROI of SPECT were not changed significantly (1.4±5.6, P=0.252). Meantime, linear correlations were found between the stenosis rate and so-called basal MTT, CBF, and so-called Diamox MTT, CBF, CBV. Besides, the ratio differences between ROI values of basal PCT and diamox PCT were also correlated with stenosis rate (MTT: Y=-94.3+1.7X, r2=0.228, p=0.004, CBF: Y=-34.8+0.6X, r2=0.153, p=0.019, CBV: Y=-30.4+0.5X, r2=0.157, p=0.017). However, no correlations were found between the stenosis rate and basal SPECT or Diamox SPECT.
Conclusion: Parameters obtained from PCT with acetazolamide challenge may be more valuable and correlated well with the cerebrovascular stenosis than diamox SPECT.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):76.
Purpose: Ischemic stroke patients presenting within 12-24 hours who have a clinical diffusion mismatch, may be at increased risk for neurological worsening and infarct growth. We sought to study the feasibility and safety of reperfusion in a series of 16 consecutive patients, triaged after 8 hours, according to these criteria.
Methods: Patients with National Institutes of Health Stroke Scale score (NIHSSS) of 8 or more points and diffusion weighted imaging abnormality of 25 cc3 or less were identified. Rates of early neurological deterioration (END, increase of NIHSSS by 4 or more points) and early neurological improvement (ENI, decrease in NIHSSS by 4 or more points) at one week were determined. Follow-up imaging was obtained to evaluate for intracranial hemorrhage (ICH).
Results: Sixteen patients were identified, 11 of whom underwent attempted revascularization. The average age and time to treat was 60 years and 34 hours, respectively. The mean initial, 24 hour, and one week NIHSSS were 13, 10, and 7, respectively, with lower scores at one week amongst patients successfully revascularized (4 vs 10, p=0.040). None of the revascularized patients experienced END while 2 of the untreated patients did (40%, p<0.001). Eight of the treated patients (72% of total, 100% of those successfully revascularized) experienced ENI, compared with 2 (40%) of the untreated patients (p<0.001). No patient suffered ICH.
Conclusions: Endovascular treatment for acute ischemic stroke beyond 8 hours is feasible and may confer ENI and prevent END in patients fulfilling the criteria of a "clinical-diffusion mismatch." A prospective study is planned.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):76–77.
Purpose: We aimed to assess whether a new 320 slice CT scanner, capable of time-resolved vascular imaging (4D-CTA), can replace digital subtraction angiography (DSA) for treatment decision making and follow-up evaluation in cerebral arteriovenous malformations (AVMs).
Materials and Methods: We included patients with a cerebral AVM, either newly diagnosed or treated with radiosurgery. Each patient was subjected to a DSA and 4D-CTA. The 4D-CTA was performed using a scanner with 320 parallel detectors, each 0.5 mm in width (Acquilion One, Toshiba, Japan). With the gantry rotating at 1 Hz, 24 CTA volumes were acquired. Each volume was reconstructed from a full rotation with 640 overlapping images at 0.25 mm intervals. Time-resolved maximum intensity projection series were generated at different viewing angles. One neuroradiologist and one neurosurgeon were asked to review each data set independently.
Results: In this ongoing study, the first 10 recruited patients, analyzed at the time of writing this abstract, showed full concordance between DSA and 4D-CTA imaging with regard to the treatment choice of newly diagnosed lesions and existence of residual shunting in irradiated lesions. Small feeding arteries and draining veins, which were detected with DSA, were not always mentioned in the reviewers' 4D-CTA report.
Conclusion: 4D-CTA is a promising new adjunct in the neuroradiological diagnostic armamentarium. It enables noninvasive treatment planning of cerebral AVMs. Furthermore, it allows for noninvasive follow-up of radiosurgically treated lesions. Our first results suggest that the value of this new tool may increase as neuroradiologists grow more accustomed to its evaluation.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):77.
Purpose: To prospectively test the hypothesis that time-resolved CT angiography (TR-CTA) on a Toshiba 320-slice CT scanner enables the same characterisation of cerebral vascular malformation (CVM) including arteriovenous malformation (AVM), dural arterio-venous fistula (DAVF), pial arterio-venous fistula (PAVF) and developmental venous anomaly (DVA) compared to digital subtraction angiography (DSA).
Materials and Methods: In a prospective comparative study, 15 (7 Male; 8 Female) consecutive patients (10 AVM, 2 DAVF, 1 PAVF, and 2 DVA) underwent 16 TRCTA (Aquillion one, Toshiba) for suspected CVM diagnosed on routine CT or MRI. One patient with a dural AVF underwent TRCTA and DSA twice before and after treatment. Of the 16 patients, 11 were followed with DSA (Artis, Siemens) within 2 months of TRCTA. 20 sequential volume acquisitions of whole head were acquired after injection of 50 ml contrast at the rate of 4 ml/sec. 2 patients with DVA did not undergo DSA. Two TRCTA were not assessed due to technical problems.
TRCTA were independently reviewed by two neuroradiologists and DSA by two other neuroradiologists and graded according to the Spetzler-Martin classification, Borden classification, overall diagnostic quality, and level of confidence. Weighted kappa coefficients(K) were calculated to compare reader 's assessment of DSA vs TRCTA.
Results: There was excellent (k=0.83 and 1) to good (k= 0.56, 0.61, 0.65 and 0.67) agreement between the different possible pairs of neuroradiologists for the assessment of vascular malformations.
Conclusion: The TRCTA technique is a promising technique for noninvasive imaging of intracranial vascular malformations.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):77–78.
Purpose: To compare flat-detector computed tomography (FD-CT) to multisclice CT (MSCT) in the visualization of ICH, SAH, ventricular blood and ventricular drainages to evaluate the diagnostic quality of the new imaging modality of FD-CT.
Methods: 65 cases with intracranial haemorrhage (SAH, ICH, ventricular haemorrhage) including 24 cases with ventricular drainages were reviewed by two independent reviewers. All patients were investigated with FD-CT and MSCT. Numbers of ICH and SAH slices positive were counted. In ICH diameters and area of the lesion were measured. Drainages were assessed to be correctly positioned, displaced or images not suitable for evaluation. Ventricular blood was assessed to be visible or not. Statistical analysis was carried out by Graph Pad Prism 4 and SPSS 14.0 with calculation of Pearsoʼns correlation coefficient (r) and linear regression analysis to evaluate the level of inter- and intraobserver agreement.
Results: We found a high interobserver agreement regarding the number of slices with evidence of ICH (r= 0.89 MSCT, 0.78 FD-CT) and SAH (0.88 MSCT, 0.9 FD-CT). Small ventricular bleedings were not detected in FD-CT in 36.4 % of cases. 6 of 7 perimesencephalic SAH were not visible on FD-CT. Drainages could be assessed in both modalities in 83.3 % while in 16.7 % (4 cases) FD-CT was inappropriate to delineate positioning of the drainage.
Conclusion: FD-CT is a helpful tool in the management of emergency patients with intracranial haemorrhage. Despite limited contrast resolution haemorrhages and external drainages can be visualized reliable. Perimesencephalic SAH and small blood amounts within the occipital horns may not be discovered using FD-CT.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):78.
Purpose: To determine the diagnostic properties of MRA respect DSA as method of estimate occlusion grade of coiled cerebral aneurysms.
Materials and Methods: We performed a prospective diagnostic test study on a sample of 147 treated aneurysms, which met inclusion criteria and signed informed consent. Standardized protocols of DSA and unenhanced 3D-TOF MRA at 1.5T were performed within a week. Three masked and independent neuroradiologists evaluated MRAs and DSAs using Raymond's scale. Gold standard was defined as the agreed diagnosis of 2 or 3 DSA evaluations. Residual flow was defined to have Raymond class of 2 or 3. The Coheʼns Kappa statistics was used to evaluate the agreement.
Results: 147 DSA/MRA examinations were performed in 122 patients harboring 130 aneurysms treated (85.7% only coils, 14.3% stent+coils). Using the Raymond's scale a moderate agreement within pairs of MRA was found (Î 0.53-0.60). Validity of MRA as independant evaluation for residual flow determination had 91.5% an average sensitivity, ranging from 88 to 94%; mean average specificity was 58.5% (66-65%). Combining the results of the raters, result positive when either positive, the sensitivity was 98% and specificity 36.7%. Considering as positive when all three results positive, sensitivity was 83.7% and specificity 77.6% Grouping by size, MRA of aneurysms <10 mm had 89.2% sensitivity and 60.7% specificity, but those were 98.6% and 38.9% in >10 mm respectively.
Conclusions: We found razonables agreement and validity values for MRA, but lower than we expected. A better sensitivity in aneurysms >10mm and combined MRA evaluations. DSA should remain as the gold standard in follow-up.
Supported by grant FONIS SA07i20023
interv neuroradiol. 2009 Jun 2;15(Suppl 1):78.
Purpose: Magnetic Resonance Angiography (MRA) is increasingly used as a non-invasive alternative to angiography for follow-up of coiled intracranial aneu-rysms. One unresolved issue of MRA is the need for contrast enhancement. The aim of our study was to compare 3D time-of-flight (TOF-MRA) with contrast enhanced (CE-MRA) at 3T with angiography as the reference standard.
Methods: Seventy-two aneurysms were imaged with TOF-MRA, CE-MRA and angiography at the same day 6 months after coiling. Occlusion status on MRA was classified as adequate (complete and near complete) or incomplete. For TOF-MRA and CE-MRA, inter-observer agreement, inter-modality agreement and correlation with angiography was assessed by '-statistics. Test characteristics of TOF-MRA and CE-MRA were calculated and the areas under the receiver operating characteristic curve (AUROC) were compared.
Results: Inter-observer agreement was good for CE-MRA and very good for TOF-MRA. Correlation of TOF-MRA and CE-MRA with angiography was good. All 5 incompletely occluded aneurysms that were additionally treated were correctly identified with both MRA techniques. AUROC for TOF-MRA and CE-MRA was 0.90 (95%CI: 0.79-1.02) and 0.91 (95%CI: 0.79-1.02). Inter-modality agreement between TOF-MRA and CE-MRA was very good ('=0.83 95%CI 0.65-1.00) with full agreement in 66(96%) of 69 aneurysms.
Conclusion: TOF-MRA and CE-MRA at 3T are equivalent in evaluating the occlusion status of intracranial aneurysms after coiling. Since TOF-MRA does not involve contrast administration, this method is preferred over CE-MRA. TOF-MRA may replace angiography in the majority of patients for the follow-up of coiled intracranial aneurysms.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):78–79.
Purpose: To compare the performance of Contrast Enhanced MR Angiography (CEMRA) with CT Angiography (CTA) in the work up of patients presenting with a subarachnoid hemorrhage (SAH).
Materials and Methods: In 76 consecutive patients with a non traumatic SAH a CEMRA was performed in addition to a CTA, which is our standard protocol for detection of an cerebral aneurysm. In all these patients a digital subtraction angiography (DSA) was performed: as a diagnostic procedure in case of an initially negative CTA or when uncertainty remained about the preferred treatment after the CTA, or as part of the endovascular treatment procedure. This DSA served as the standard of reference.
The CEMRA and CTA data were post processed and interactively evaluated by two independent observers. They both evaluated both modalities with an interval of at least twelve months between the evaluation of the first and second modality.
The DSA data were evaluated by two other independent observers.
Scoring criteria were: quality of images, presence of an aneurysm, location, size and configuration of the aneurysm, feasibility of endovascular treatment and confidence.
Sensitivity and specificity for the detection of an aneurysm were calculated as well as the interobserver agreement for both modalities.
Results: 56 of 76 patients (74%) had one or more aneurysms.
Sensitivity and specificity for the detection of an aneurysm were 96,4 % and 70,0 % respectively for CEMRA, and 92,9 % and 82,5 % respectively for CTA.
Interobserver agreement (Kappa) for CEMRA and CTA were 0,84 and 0,90 respectively.
Conclusion: CEMRA can be used in the work up of patients presenting with a SAH and its performance is as good as CTA.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):80.
Wednesday, July 1st, 2009 • Room 524 • 13.30-14.50
interv neuroradiol. 2009 Jun 2;15(Suppl 1):80.
Purpose: The purpose of this study was to find factors related thromboembolic events during coil embolization for unruptured intracranial aneurysms and to evaluate role of clopidogrel (CPG) premedication in preventing them.
Materials and Methods: Clinical and angiographic data of 556 patients harboring 644 unruptured aneurysms were included in a retrospective cohort study. Since March 2006, CPG (with or without aspirin) was administered to patients with unruptured aneurysms before coil embolization (CPG group) in our institution. CPG group included 416 patients with 485 aneurysms, and control group (no antiplatelet premedication) included 140 patients with 159 aneurysms. Various factors (age, gender, CPG premedication, maximal aneurysm diameter, aneu-rysm volume, aneurysm location, treatment modality, packing attenuation) were analyzed in relation to development of procedure-related thromboembolism.
Results: Procedure-related thromboembolic ev-ents tended to occur less frequently in CPG group (7.4% vs. 12.6%; p=0.0657) and there was 41% of relative risk reduction in CPG group. Aneurysm perforation during the procedure did not occur more commonly in CPG group (0.8% vs. 1.3%; p=0.6403). Thromboembolism tended to reduce in the female patients taking CPG premedication (5.2% vs. 11.1%; p=0.0549). Multiple logistic regression analysis identified gender and clopidogrel premedication as significant factors related to thromboembolism.
Conclusion: Clopidogrel premedication seems to have a beneficial effect in reducing procedure-related thromboembolism during the coil embolization, especially in female patients.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):80–81.
Purpose: Onyx HD500 is a new liquid embolic agent which recently received Humanitarian Use Device (HUD) approval in the U.S. for treatment of wide-necked sidewall intracranial aneurysms. The data submitted for HUD approval was a subset of the randomized clinical trial (RCT) patients who met the HUD criteria. We present an analysis of these data.
Materials and Methods: Inclusion was limited to de novo, unruptured, saccular aneurysms with a dome:neck ratio <2, or a neck diameter >4 mm but <10 mm (HUD criteria). The primary endpoint was >90% aneurysm occlusion without major adverse events (AEs). An independent core lab determined angiographic results immediately after the procedure and at 6 months. A Data Safety Monitoring Board (DSMB) adjudicated complications as major or minor, and if device related.
Results: Twenty Onyx patients and 34 GDC patients meet the HUD criteria. Incidence of major, minor, and device related complications were similar between the two groups. Using intention to treat (ITT) analysis, immediate angiographic results (>90% occlusion without AEs) were superior with Onyx HD500 compared to GDC (90% versus 52.9%, p=.007). The primary endpoint at 6 months using ITT revealed a trend of improved outcome with Onyx HD500 compared to GDC (88.2% versus 59.4%, p=0.0522). With an analysis by actual treatment received, Onyx HD500 was superior to GDC immediately (100% versus 55%, p=0.001), and at 6 months (100% versus 69.0%, p=0.018).
Conclusion: Onyx HD500 aneurysm embolization may result in improved angiographic results, lower rates of recanalization, and a similar safety profile, compared to GDC embolization for aneurysms that meet the HUD criteria.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):81.
A prospective randomized trial of unruptured aneurysms is preferable to produce unbiased groups yielding comparisons between preventive intervention and observation. However, the design and conduct of a trial is difficult due to differing practice patterns and changing intervention methods.
The International Study of Unruptured Intracranial Aneurysms was designed as a prospective cohort study. Patients were subdivided into cohorts based upon observation or treatment practices from 1991-1998. The data was grouped together and analyzed to determine treatment decisions. Using propensity analysis equivalent probability groups were constructed. Similar main predictors of treatment and outcome were observed. Analysis of hemorrhage, mortality and short-term and long-term morbidity and mortality were assessed. Also risk-benefit ratios were calculated.
The results show comparability of groups in the propensity-based subset. There was short-term benefit of observation versus intervention. However this reversed and indicated that gains in benefit of treatment were evident only long-term.
While a clinical comparison can be done through propensity based methods, drawbacks are evident including reduced sample size, unmeasured confounders and lack of control of study procedures. A clinical trial is preferable and may yield similar results with more confidence.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):81.
Purpose: To examine clinical outcomes at discharge & 6 months in patients enrolled in the Hydrocoil endovascular aneurysm packing study (HELPS) and the Cerecyte coil trial (CCT) to provide accurate & objective assessment of complication rate of coiling unruptured aneurysms & to examine predictors of poor outcome.
Materials and Methods: Over 400 patients treated for a previously unruptured aneurysm were enrolled in the HELPS and CCT randomised trials. Clinical outcomes & any differences in outcome between the allocated groups were examined. The patient demographics & aneurysm characteristics were prospectively collected & clinical outcomes were determined at discharge and 6 month follow-up by a validated self reported modified Rankin Scale of dependency. These large multi-national trials have provided the ideal environment to examine clinical outcomes associated with treating patients with current technologies. The pooled data of the trials will be analysed to examine procedural complications, discharge outcomes and dependency at 6 months.
Results: Patient & aneurysm characteristics will be analysed with the discharge and six month clinical outcomes, procedure related complications and adverse events and a multi-variant analysis of the predictors of adverse outcomes. Combined available data, which will contain complete discharge outcome data and more than 95% of the 6 month outcome data, will be analysed & presented.
Conclusion: Combined data from the 2 studies provide, for the first time, large randomized trial dataset on the complication rate of coil treatment of unruptured cerebral aneurysms with data from a wide range of high volume centres utilising current technologies.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):81–82.
Purpose: To analyze the modalities of treatment, the rate of adverse events, the morbidity and mortality rates, and the length of hospital stay for patients treated for unruptured intracranial aneurysms by endovascular approach in relation to the volume of patients treated in the centers in ATENA.
Materials and Methods: The centers of ATENA study were classified in two groups according to the number of patients included during the study period. In group A were included 13 centers in which 20 patients or less were treated, and in group B, 14 centers in which more than 20 patients were treated. Both groups of patients and aneurysms were not significantly different.
Results: Modalities of endovascular treatment were significantly different in both groups with a more frequent use of the standard coiling technique in group A and of the stenting in group B.
The global rate of adverse events was not significantly different in groups A and B (respectively 16.0% and 14.4%). Similarly the rate of specific adverse events (Thromboembolism + intraoperative rupture + device related problem) was not significantly different in groups A and B (respectively 12.8% and 12.5%). Only intraoperative rupture was significantly more frequent in group A than in group B (respectively 3.7% and 2.1%; p=0.03).
One month mortality and morbidity rates were not significantly different in groups A (respectively 2.3% and 1.8%) and B (respectively 1.0% and 1.7%). The length of hospital stay was not significantly different in both groups.
Conclusion: In this subgroup analysis of ATENA series, the safety of the endovascular treatment of unruptured intracranial aneurysms is similar in low and high-volume centers.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):82.
Purpose: It is controversial whether unruptured aneurysms incidentally found on brain check-up should be treated or observed. We reviewed our unruptured aneurysms series to clarify the benefit and safety of the endovascular treatment.
Materials and Methods: We successfully treated 729 aneurysms in 671 patients with embolization in Nagoya University and affiliated hospitals these 9 years. The treatment period was divided to two periods, before and after 2005, according to the difference of the treatment environment. Also we reviewed the almost same term follow-up data of 159 patients with 176 untreated aneurysms.
Results: The technical complication occurred in 33 patients including 6 perforations, 18 ischemic events due to embolism or branch occlusion, 9 other causes concerning with approach and devices. Of these 9 resulted in unfavorable outcome (mRS>2) including one expired case. By periods, 23 accidents in 386 cases were experienced in the former period, while only 10 in 343 cases in the latter one. During the follow-up after the embolization (mean 4.5 years), there is one patient with rupture of PICA aneurysm, and 7 recurrence including 5 cases requiring the retreatment. While, 3 ruptures and 5 enlargements occurred in the series of untreated aneurysms during the same follow-up period.
Conclusion: Endovascular treatment of unruptured aneurysm is found to be significantly effective to prevent rupture despite the remaining question whether to contribute the prevention of enlargement. Technical safety of the latter period may be yielded by the install of the newest bi-plane machine, line-up of various and refined coils and routine preoperative anti-platelet management.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):82–83.
Purpose: To decide the management of intracranial unruptured aneurysms, it is very important to investigate the natural history of them. A prospective study has done at 12 Japanese national hospitals to determine the surgical standards for small unruptured intracranial aneurysm (SUAVe Study, Japan). The concept of this study is observing the natural history of all small unruptured aneurysms (under 5mm in diameter) without surgical procedure.
Materials and Methods: Since September 2000, 540 Aneurysms (446 patients) with 92 aneurysms (89 patients) excluded by film judgment committees have been registered. 448 aneurysms (373 patients) have been followed up for a mean of 22. 8 months (824. 5 aneurysm-years).
Results: Five aneurysms have already ruptured (two of 249 Aneurysms in single type and three of 199 aneurysms in multiple types). The annual rupture rate is 0. 46% with Kaplan-Meier Method (0% in single type and 1. 1% in multiple types). Six aneurysms were operated due to the enlargement of the aneurysm size. Considering these findings, the annual rupture rate might rise slightly. The important factors were the multiple types, female, over 70 years old, and anterior communicating artery aneurysm without a significant difference.
Conclusion: These findings show that the surgical standards for unruptured aneurysm under 5mm are not set, especially in single type.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):83.
Purpose: We report prospective analysis of risk of rupture and treatment outcome for unruptured intracranial saccular aneurysm (UIA).
Materials and Methods: Between January 2003 and April 2008, a total of 876 patients with 1111 UIAs were referred to our institution. Aneurysms larger than 5 mm were considered candidates for treatment. When the patient elected conservative management, 3D CTA follow-up were obtained every 6 months. Of these, 370 UIAs were treated by endovascular or surgical treatment (Treated group) and 603 patients with 741 UIAs were conservatively observed (Observed group).
Results: Twenty-six UIAs ruptured during observation resulting in a 1.8% rupture rate per year. The mean follow up duration was 1405.6 person-years. The annual rupture rate of small aneurysms (<5mm) and non-small aneurysms (>=5 mm) were 0.7% and 4.1% (hazard ratio [HR] 4.96, 95% confidence interval [CI], 2.1-12.0, P<0.001), respectively.
In comparison of all sized UIAs, there was no significant difference in the clinical outcome between two groups during 5-years. In comparison of clinical outcome in more than 10mm groups, clinical outcome in treated group was significantly better than in observed group.
Conclusion: UIAs larger than 10mm should be considered to treat. A boundary of effectiveness of treatment might be found around 7mm of UIAs suggested as ISUIA.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):84.
Wednesday, July 1st, 2009 • Room 524 • 15.20-16.40
interv neuroradiol. 2009 Jun 2;15(Suppl 1):84.
Purpose: To evaluate the long-term clinical and angiographic follow-up of patients with ruptured cerebral aneurysms treated with coiling, focusing on re-hemorrhage and changes in aneurysm morphology.
Materials and Methods: 377 patients with ruptured aneurysms that were treated using endovascular approaches at our institution between 1994 and 2008 were reviewed. Clinical and angiographic data was analyzed from a prospectively collected database.
Results: There were 377 patients with 391 ruptured aneurysms treated over 14 years. Good outcome (GOS = 5) was achieved in 74% of patients, moderate disability or poor outcome in 18%, and 8.8% died. Permanent morbidity or mortality from procedural complications occurred in 2.9%. Complete follow-up was available for 85% of surviving patients, with mean follow-up of 22.3 months. Re-treatment was required in 11% (31 patients). Eight (2.1%) patients re-bled, 6 (1.6%) in hospital within 30 days of treatment, 5 in the first 48 hours. Follow-up imaging was available in 276 aneurysms in 270 patients. Recanalization occurred in 56 of 276 aneurysms (20.3%) regardless of the initial angiographic result, but the risk was higher if a body remnant was left (Chi-square = 11.791, p = 0.0006).
Conclusion: Long-term clinical and angiographic follow-up demonstrates the efficacy of endovascular treatment of ruptured intracranial aneurysms. Re-bleeding after treatment is rare, with the greatest risk during the first 48 hours after treatment. Initial angiographic results are not a useful predictor of clinical outcome or re-hemorrhage.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):84–85.
Background and Purpose: Controlled detachment coils have been available since 1991 and proven superior to clipping in terms of clinical outcomes. However their use in middle cerebral artery aneurysms remains controversial. We are undertaking a systematic review of the available literature on this aneurysm subgroup.
Methods: We performed a systematic review of the literature from 1992 to end of 2007. Medline, Embase and bibliographic searching were employed; search was limited to studies having an English abstract, being on human adult subjects and with at least 20 coiled MCA aneurysms included. A standardised data extraction proforma was developed. Pre-specified quality criteria were used to critically appraise studies. Data extraction was limited to reports with an acceptable quality score, defined as > 50%.
Results: 609 studies of potential relevance were identified by the intial search. The collation and data extraction process is ongoing at present. The results of this systematic review will be presented for the first time at WFITN.
Conclusion: The available literature is of mixed quality, but middle cerebral artery aneurysms are clealry underrepresented. We will critically examine whether the evidence for coiling MCA aneurysms is equivalent to that for aneurysms as a whole. We aim to therefore be able to conclude whether clipping or not should be the first choice treatment modality for this group.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):85.
Purpose: Evaluation of the clinical outcome at discharge and at 6 months after endovascular treatment of cerebral aneurysms in 237 patients aged 65 years and older.
Materials and Methods: From October 1992 to April 2008, 237 patients aged 65 years or more presenting with 246 cerebral aneurysms, were treated by endovascular coil embolization in our institute. 194 (78.9%) aneurysms were ruptured. 103 patients (53%) presented with Hunt and Hess (HH) grade III or more.
Results: Complications were encountered in 17.5 % (43/246) of cases, most were of thrombo-embolic origin. Three patients (1.3%) rebled during the initial phase. Overall procedural related mortality was 1.2%, permanent and transient morbidity was 2.8 % and 2.4 % respectively. At discharge, favorable clinical outcome (Glasgow outcome score (GOS) I-II), was obtained in 90.6 % (39/43) of patients with unruptured aneurysm, 86.8% (79/91) with ruptured aneurysms and initial HH I-II and only 36.9% (38/103) with HH grade III or more. Thirty four deaths occurred (14.7%). At six months, among 18 patients with GOS III-IV at discharge, 61% (11/18) showed clinical improvement to GOS I-II. No rebleeding occurred.
Conclusion: Despite of a relatively higher rate of thrombo-embolic complications in the elderly people, endovascular treatment of cerebral aneurysms presents an acceptable morbi-mortality rate, and may be proposed as a first line of treatment. The clinical outcome depends on the clinical status on admission.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):85.
Purpose: Anterior choroidal artery (AChA) aneurysms are difficult to treat and the clinical outcome of patients is occasionally compromised by ischemic complications after clipping operations. The purpose of this study was to document the outcome and follow-up results of the use of endovascular coil embolization in patients with AChA aneurysms.
Materials and Methods: From July 1999 to March 2008, 88 patients with 90 AChA aneurysms (31 ruptured and 59 unruptured) were treated with coil embolization in 91 sessions. There were 87 small (less than 10 mm) and three large aneurysms. Preprocedural oculomotor nerve palsy associated with AChA aneurysms was noted in eight patients.
Results: The degree of angiographic occlusion of the aneurysms was complete for 15 aneurysms (17%), near complete for 69 (77%) and partial for six (7%). There were four (4.5%) symptomatic procedure-related complications (three thromboembolic events and one procedural bleed). The procedural bleed resulted in mortality; however, the thromboembolic events only caused transient deficits. A favorable outcome of GOS 5 or GOS 4 was achieved in 90% (79/88) of the patients at the time of discharge. No case showed bleeding or rebleeding during the follow-up period (mean, 25 months). AChA aneurysm-associated oculomotor nerve palsy tended to become aggravated transiently after coil embolization, and then completely recovered over a period from two to nine months.
Conclusion: Coil embolization is a safe and effective treatment modality in cases of AChA aneurysms. Coil embolization enables procedural recognition of arterial compromise and immediate reestablishment of flow, thus contributing to a favorable outcome.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):85–86.
Purpose: To report the immediate and mid term follow up angiographic and clinical results in a retrospective consecutive series of 96 patients with basilar artery (BA) trunk aneurysms treated by endovascular occlusion.
Materials and Methods: 96 BA aneurysms were treated in 96 patients (58 women and 38 men) with a mean age of 51 years. 73 aneurysms (76%) were ruptured. 80 were located at upper end of the basilar trunk, 8 at its side wall and 8 were on top of fenestration. Sac occlusion was achieved with simple coiling in 78 cases and with adjunctive techniques in 15, using balloon remodeling in 6, coil Trispan in 4 and stenting in 5 cases. 3 aneurysms were treated with flow reversal.
Results: Thromboembolic complications were encountered in 9 patients. Procedural related mortality, transient and permanent morbidity were 3.3%, 2.2% and 1.1% respectively. Satisfactory occlusion was obtained in 71 cases (74%). During average follow-up period of 4.2 years, 6 minor (6.3%) and 23 major (24%) recanalizations were encountered, 21 of them occurred during the first year. 16 second treatments (16.7%) were performed. 2 late rebleeding occurred at 3 and 5 years (0.48% / year).
Conclusion: The endovascular occlusion of basilar artery trunk aneurysms appears to be effective in preventing rebleeding with an acceptable morbid-mortality rate. However, in our experience, the rate of recanalization is high, justifying a more frequent second treatment than in other locations.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):86.
Purpose: CLARITY is a multicentre consecutive controlled series of ruptured aneurysm embolization. The goal was: - in the GDC arm, to analyze the feasibility, morbi-mortality, and immediate and long term results in a consecutive series of ruptured aneurysms treated in first intention by embolization and to describe the actual place of clipping, - in the Matrix arm, to compare those clinical issues when Matrix is use consecutively.
Methods: In Clarity GDC study, 401 patients were treated in 19 French centers. In Matrix study, 377 coiled patients were treated in 16 Centers. Inclusion criteria were: Every patient with a ruptured aneurysm (< 1 week after SAH), aneurysm < 15 mm, patient age from 18 to 80 YO.
Results: Clarity GDC/Matrix results were respectively: - Embolization failure: 1.5 and 0.5%, - GDC or Matrix embolization failure: 1.5 and 3.5%, - Balloon remodelling was used in 20 and 23%, - Stent were used in 0.5 and 3.2%. Thrombo-embolic events occurred in 13.6 and 13.3%, leading to permanent deficit in 3.4% in both arms and death in 1 and 0.7%. Intra-operative rupture occurred in 3.9 and 3.7% leading to permanent deficit in 0.5 in both arms and death in 0.2 and 0%.
Conclusions: This study shows that nowadays in France, 80% of ruptured aneurysms are treated by embolization. Results of embolization concerning clinical evolution in a non selected consecutive population of ruptured aneurysms are almost similar to those of ISAT study. There is no difference between GDC and Matrix in term of treatment feasibility and morbi-mortality.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):86.
Purpose: To evaluate differences concerning recanalization in ruptured and unruptured aneurysms.
Materials and Methods: We performed a retrospective analysis of 210 ruptured and 151 unruptured aneurysms. Initial occlusion rate, packing density and recanalization rate were determined. Recanalization rates and the need for retreatment were evaluated based on follow-up angiographies (DSA) over a period of up to four years.
Results: In the ruptured aneurysms group, younger patients recanalized more frequently (p = 0.016). Higher packing density led to less recanalization (p = 0.015).
In the unruptured aneurysms group, age did not influence recanalization, but aneurysm volume (p = 0.027). Aneurysms treated with 3D coils tended towards higher recanalization rates (p = 0.035).
Conclusion: Different factors will influence recanalization in ruptured and unruptured aneurysms. This should be considered during endovascular treatment.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):86–87.
Purpose: To analyze the long term angiographic results and clinical outcome after endovascular treatment with bare Guglielmi Detachable Coils (GDCs) in a consecutive single-center series of Patients with Intracranial Aneurysms (IAs).
Materials and Methods: Between 1996 and 1999, 318 consecutive patients underwent aneurysm embolisation with bare GDCs, for a total of 357 IAs treated. Lesions were divided into two distinct subsets in relation to subarachnoid hemorrhage: 78.6% were ruptured and 21.4% were unruptured. No stent-assisted coiling technique was employed. All patients were prospectively entered into a database and subsequently followed over time. Clinical outcome was assessed according to the modified Rankin Scale. Imaging Follow-Up (FU) was carried out by means of digital subtraction angiography (DSA) and/or MR angiography including the last ten-year DSA FU.
Results: The analysis is currently ongoing. Final data concerning overall clinical outcome, rebleeding rate, angiographic aneurysm changes, retreatment and clinical-angiographic correlations will be presented.
Conclusion: Our study may contribute to the evaluation of the long term efficacy and safety of GDC embolisation of IA. This information can be used as background knowledge in the evaluation of series of patient treated with newer techniques including bioactive coils and stenting procedure.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):88.
Wednesday, July 1st, 2009 • Room 520c • 13.30-14.50
interv neuroradiol. 2009 Jun 2;15(Suppl 1):88.
The aim is to determine the optimal endovascular method in the treatment of arteriovenous malformations (AVM) of the spinal cord (SC).
Methods: Over 500 patients with AVM of SC cord were treated in period over 30 years. Among them were men −68%, women −32%, including 178 (35%) children. The endovascular occlusions of afferent vessels using the different methods – balloon-occlusion method by F. Serbinenko (2%), PVA-emboli (56%) and Hystoacryl (37%) embolization, combined methods (4%), coils (1%) were performed.
Results: Occlusion of cervical spinal afferent vessels and AVM's nidus was mainly performed by using PVA-emboli, Hystoacryl. These methods were used for cases with AVMs supplied by anterior spinal and radicular arteries. AVM fistulae localized on the posterior cervical SC surface had great extension and slow blood velocity. Endovascular occlusion for this type of AVMs consists in direct injection of the glue. When dealing with endovascular occlusion of the AVM supplied by the artery of Adamkiewicz and anterior spinal artery it is necessary first to extinct accessory sources of blood supply and only then if possible to extinct an aneurysm from the Adamkiewicz artery system by using glue or coils. The technique used resulted in outcome improvement in 90% of cases, 4% of patients revealed no dynamics, and 6% showed neurological impairment.
Conclusion: The choice of using of method of endovascular occlusion should be based on analysis of DSA and MRI data, haemodynamic characteristics of the AVM and SC. Areas of the SC particularly vulnerable to ischemia and their extension size are also of special importance.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):88–89.
Purpose: Cobb's syndrome, cutaneous vertebral medullary angiomatosis, is a part of spinal arteriovenous metameric syndromes (SAMs), comes from the vascular malformation triad of skin, bone, and spinal cord involvement. It is hardly cured with current treatment modalities. We have accumulated some experience in improvement of spinal function with multiple combined therapeutic techniques.
Materials and Methods: 61 cases of Cobb's syndrome with spinal cord dysfunction had been treated in our department from Feb, 2003 to Dec, 2007. The treatment had been followed the same strategy: 1st step - investigating the pathogenic mechanisms with symptom onset, MRI, angiography and the response to the first treatment, 2nd step ' treating the trouble-making parts of the lesions with embolisation only, surgery only or combination of the both. All the patients were followed up regularly.
Results: Among these 61 cases, the pathogenic mechanisms were found as hemorrhage, mass effect, ischemia and venous hypertensive myelopathy. Two or more mechanisms could coexist in the same patient. 48 cases were embolized, 3 cases were treated with surgery and 10 cases were treated with combination. More than 1-year's spinal cord function follow up showed: excellent in 9, good in 26, fair in 23 and worse in 3 cases.
Conclusion: Not all the lesion in Cobb's syndrome can be or should be cured anatomically. Pathogenic mechanism should be analyzed carefully and the treatment should focus on the special targets that affect the cord. Long term improvement or stabilization could be achieved.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):89.
Purpose: To demonstrate the author's method of management of Spinal cord AVM's fed by anterior spinal artery.
Materials and Methods: Five cases of spinal cord AVM's fed mainly by anterior spinal artery were embolized through ASA. All but one of the cases had intramedullary hemorragge previously. Magic 1.2 was navigated through ASA into sulcocomissural artery and NBCA was injected gently into the nidus, so that false aneurysm was obliterated and that the ASA was not disturbed. The whole procedure was performed under general anesthesia and injection of glue was done under apnea. Systemic heparinization was kept four 24 hours after the procedure in order to avoid further thrombosis of draining veins and corticosteroid was administrated intravenously to prevent inflammatory reaction of the spinal cord.
Result: In all cases we could not achieve complete obliteration but obliteration of false aneurysm or reduction of venous congestion. ASA was confirmed to be preserved in all cases. None of the patient deteriorated postoperatively, but four of them neurologically improved immediately after embolizatiom.
Conclusion: Spinal cord AVM's can be embolized through ASA. Targeted partial embolization of the spinal cord AVM may stabilize the lesion even if it is not totally obliterated and may help neurological improvement of the patient. In this procedure it is most important to avoid reflux of glue into the ASA.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):89.
Purpose: Arterio-venous shunts at the level of the Filum Terminale are one of the rarest location within the group classification of Spinal arterio-venous shunts.They are usually subgroup within the extension of Spinal cord (intramedullary) arteriovenous shunt. Diagnosis from clinical presentation and imaging modalities are rather different from other location of spinal cord shunts and can mimicking the Spinal Dural arterio-venous shunts.
Material and Methods: Within our 125 total spinal arterio-venous shunts during 1995-2008; there were six cases located at the Filum Terminale which four of them were proper Filum Terminale fistulas and two were the shunts at the dural attachment of the Filum terminale. Clinical and MRI presentation of all are similar which are long segment of subacute to chronic cord venous congestion surrounded by dilated vessels both ventral and dorsal to the congested cord. None presented with hemorrhage in any spaces. Final diagnosis were made by selective spinal angiogram for the propose of treatment.
Results: Five out of the six Filum Terminale shunts were treated successfully be endovascular embolization;the one that was failed was treated by surgery. Smallest flow related microcatheter were navigated via the Anterior Spinal Artery to reach the level of the shunts ;followed by permanent liquid embolic material injection covering the proximal venous segment. All of the six patients had immediate clinical recovery and long term stable follow up.
Conclusion: Proper diagnosis and treatment of Spinal Filum Terminale arteriovenous shunts are crucial ; update endovascular treatment could be the curative option with good results.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):89–90.
Purpose: Film terminale is a anatomical structure in the end of spinal cord. Only a few cases have been reported of dural arteriovenous malformation (DAVMs) at the film terminale. We retrospectively analyzed the angiographic features, MR findings and clinical manifestations of spinal DAVM in film terminale.
Materials and Methods: From 1992 to 2008, 4 patients (2 female, 2 male; mean age, 56yrs) of spinal DAVMs in film terminale were evaluated
Results: Clinical manifestations were bowel and/or bladder dysfunction (3/4, 75%), progressive paraparesis (3/4, 75%), buttock pain (2/4, 50%), and sensory changes of lower extremities (2/4, 50%). Feeders of spinal DAVMs in film terminale were anterior spinal artery (4/4, 100%) and L4 radiculomedullary artery (1/4, 25%). MR findings were enhancing vascular structures around conus (4/4, 100%), and high signal intensity in lower spinal cord (2/4, 50%). Endovascular treatment was attempted in 2 patients (2/4, 50%) and achieved complete occlusion. Surgical treatment was performed in 2 patients (2/4, 50%). Neurologic symptoms of 4 patients with treatment were improved in all patients.
Conclusion: Our results show spinal DAVMs in film terminale is rare lesion. They are exclusively supplied by the anterior spinal artery. Clinical manifestation and MR findings are similar with other type of spinal DAVMs. Neurologic symptoms can be improved by endovascular treatment or surgery.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):90.
Purpose: We present a case of a perimedullary AV fistula in a patient with Hereditary Hemorrhagic Telangiectasia (HHT), treated using Onyx.
Summary of case: A 28 year old female presented with a slow onset weakness involving both lower limbs. An MRI of the spine showed a vascular lesion involving the lower thoracic cord. She has a family history of HHT and in the past has had several episodes of epistaxis. A subsequent MR angiogram revealed a perimedullary AV fistula of the lower thoracic cord. Spinal angiography revealed a high flow perimedullary arterio-venous fistula being predominantly supplied by the left T11 and L1 segmental arteries. Numerous radiculopial feeders were seen supplying a relatively large sized venous pouch. There was no sizeable contribution to the anterior or posterior spinal axis. A DMSO compatible microcatheter, (Marathon, ev3) was negotiated into the inferior portion of the venous pouch over a 0.08 '' microwire, (Mirage, ev3) from the left L1 segmental artery and subsequently into the superior aspect of the pouch. We used Onyx-18 (ev3) to embolize the venous pouch under fluoroscopic guidance, withdrawing the microcatheter inferiorly as injection proceeded. The final Onyx cast filled the venous pouch, disconnecting the arterial input and final control angiograms confirmed satisfactory obliteration of the fistula. On follow-up the patient made a slow recovery with improvement of lower extremity power over time.
Conclusion: Trans-arterial venous disconnection of spinal perimedullary fistulas may be a feasible option in lesions with suitable anatomy. Special attention should be paid to the angiogram to look for the arterial cord supply as well as drainage.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):90.
Purpose: Extradural spinal arteriovenous malformations and fistulas restricted to the epidural space are so rare that they are excluded in the common classification system of spinal vascular malformations.
These lesions have the potential to cause serious neurological symptoms that can lead to significant neurological morbidity sometimes irreversible.
The role of Onyx to treat spinal epidural AVF has not been established.
We report our initial experience with Onyx embolization in the treatment of spinal epidural AVFs.
Materials and Methods: We report 8 patients with 9 cases of spinal epidural AVFs causing progressive myelopathy treated with Onyx embolization material. In all cases Onyx was the only embolization material used except in one case where coils were used as adjuvant treatment.
Results: All spinal epidural AVFs except 2 cases had perimedullary venous drainage presenting with progressive myelopathy secondary to venous hypertension. One of the other 2 cases presented with mass effect and the other was an incidental finding.
Onyx caused occlusion of the epidural component and the intradural draining vein in 8 of 9 cases. In the other not enough penetration to the fistula site was obtained and the patient was sent for open surgery.
No technical or clinical complication related to the onyx was observed.
Conclusions: We were successful treating 8 of 9 epidural AVFs using onyx embolization material.
Our initial experience suggest that the endovascular treatment of epidural AVF's with Onyx is feasible, safe and highly effective as it allows for a controlled penetration of the embolic agent into the epidural component and intradural draining vein.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):90–91.
Purpose: We present a case of spinal osteodural AVF with unusual features of multiple arterial feeders converging onto a venous sac that was treated by transvenous coil embolisation resulting in complete obliteration of the fistula and symptom relief.
Materials and Methods: A 68 year old lady presented with progressive lower limb weakness and bladder incontinence. MR scan showed thoraco-lumbar intradural flow voids and cord high signal. Dilated venous sacs causing posterior vertebral scalloping were seen at L1 and L3 levels. Spinal angiography revealed bilateral feeders from L1, L3, L5 and internal iliac levels converging at L1 and L3 levels onto dilated venous sacs. Intradural reflux was noted at L1 level. The fistulae were treated by transvenous coil embolisation of the venous sacs achieving complete obliteration. Delayed MR scans showed obliteration of cord high signal and intradural flow voids. At 6 months, the patient was continent and independently mobile.
Summary: Spinal osteodural fistula is located in epidural space involving the vertebral body adjacent to the dilated venous sac into which the osteodural feeders of segmental arteries converge. Symptoms are due to intradural venous reflux causing cord venous hypertension. Obliteration of the venous sac via venous route seems to be the treatment of choice, although arterial embolization or surgical resection may be possible. Thorough analysis of the azygos, hemiazygos, paraspinal and the epidural venous anatomy is essential before treatment. As incomplete coil packing may result in recurrence, dense packing of the venous sac is critical for the cure of the lesion.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):91.
Purpose: To report 2 cases of giant perimedullary arteriovenous fistulas treated by direct percutaneous puncture and embolization of the draining vein.
Material and Methods: 2 patients with giant perimedullary AV fistulas, one cervical and one lumbar, that were preaviously treated by endovasuclar arterial and venous approaches without success, underwent direct puncture of a venous pouch and retrograde catheterization of the fistulos point.
Results: Both patients were succesfully embolized with dissapearence of the giant perimedullary fistulas. There were no complications during the procedure or at 30 day follow-up.
Conclusions: The management of giant PMAVF by direct percutaneous venous puncture is feasible and can be another alternative of minimally invasive treatment in cases where arterial or retrograde venous approaches are not possible or are very risky. This technique should be performed by highly trained specialists in the treatment of spinal arteriovenous malformations. Only experience will tell us if this technique could in the future replace or be safer than traditional techniques for the treatment of giant PMAVF.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):91.
A 61 year old female was referred to our hospital with a presumed diagnosis of a giant sacral chordoma. She had been experiencing profound deep-seated pelvic discomfort, exacerbated by crouching or sitting for extended periods of time. Percutaneous biopsy of this ll x ll x 9 cm mass confirmed a diagnosis of a rare giant sacral intraosseous hemangioma. Conventional angiography demonstrated marked vascularity of this benign tumor, with dominant supply by the right lateral sacral artery. Sessional sclerotherapy with dessicated alcohol was done as a minimally invasive means of lesion control and therapy, as the sacral tumor was not felt to be suitable for surgical resection. Initially, four intra-arterial sclerotherapy procedures were performed, after microcatheter access to the dominant lateral sacral supply. Although followup imaging had suggested interval healing of the hemangioma, with stabilization in size, the patient still was experiencing significant discomfort. A CT-guided epidural steroid injection was performed at L5/S1, with the patient having marked pain relief, as measured by Visual Analog Scale (2-3/10 versus 6-7/10 pre-procedure). The last four treatments have been direct intra-lesional alcohol sclerotherapy. Followup CT reveals significant new bone formation, with the patient expressing further improvement in her baseline discomfort after the last session, associated with improved functional outcome as well. She is now maintained on periodic epidural steroid injections, with only oral acetominophen required for additional analgesia. This report presents an extremely difficult management issue of a patient with a rare giant sacral intraosseous hemangioma.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):92.
Purpose: By investigating the x-ray radiation dosage of patient and physician in the interventional examination and embolization in vascular malformation of spinal cord to analysis the factors which influence x-ray radiation dosage as well as the ways to decrease the dosage.
Materials and Methods: Thermoluminescence was used to measure the x-ray radiation dosage of patient and physician in the interventional examination and embolization in vascular malformation of spinal cord with 100 cases in our department from 2006.3 to 2007.9.
Results: The dosage of skin in the patients who accepted spinal angiography is: 0.009~2.032Gy; while the dosage of skin in the physicians is: 0.225~1.601 mGy. The dosage of skin in the patients who accepted interventional embolization is: 2.131~9.874 Gy; while the dosage of skin in the physicians is: 0.307~2.462 mGy.
Conclusion: Not only being the golden standard of vascular malformation of spinal cord Spinal angiography can also provide a great quantity of information for both operation and embolization. Meanwhile interventional embolization is now looked upon as a important therapeutic tool for spinal cord vascular malformation. However, while in the interventional examination and embolization both the patients and physicians exposed to too much x-ray radiation. Even some of them appeared acute radiate erythema or alopecia. So some more effective protection should be taken to decrease the x-ray radiation dosage accepted by patients and physicians.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):93.
Wednesday, July 1st, 2009 • Room 520c • 15.20-16.40
interv neuroradiol. 2009 Jun 2;15(Suppl 1):93.
Purpose: To illustrate our preliminary experience about a new synthetic ceramic bone substitute -Cerament™ Spine Support- in the treatment of Vertebral Compression Fracture(VCF) showing our clinical results at 3 months short term follow-up.
Material and Methods: 15 patients (9F, 6M, ages means 55 years) affected by osteoporotics VCFs (13/15) and by traumatic VCFs (2/15). All pts. were studied by MRI protocol (Sagital T2W,STIR,T1W). VCF distribution was: 5 at level L2, 6 L4, 2 T12, 2T11. All procedures were performed under local anesthesia with trans-peduncolar approach. A new synthetic ceramic bone substitute -Cerament™ Spine Support- was used to intend for augmentation of the vertebral body. It's constituted by 60% alpha-calcium sulfate ('-CaS) and 40% hydroxyapatite (HA). A clinical short term follow-up at 3 months was performed with VAS and ODS.
Results: VP was successfully performed and led to an excellent outcome in all pts with clinical improvement. No vascular,extraforaminal or epidural leakage or other adverse events were observed. At 3 months VAS and ODS decreased about of 40% from pre-treatment to post treatment in all pts with complete cement reabsorption and complete bone's substitution.
Conclusions: VP for osteoporotic or traumatic VCF was archived. Ceramic bone substitute -Cerament™ Spine Support - is new cement safe and effective to use for osteoporotic and traumatic cement. A long term follow-up is recommended.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):93–94.
Purpose: To determine the effectiveness of pain relief and the incidence of new related fractures as the long term outcome of percutaneous vertebroplasty (PV) in the treatment of painful vertebral compression fractures (VCF).
Materials and Method: Retrospectively review of 120 patients with 220 painful VCFs who were treated by VP during 8 year period at Siriraj Hospital, Bangkok, Thailand was performed. The clinical outcomes were assessed by telephone follow-up, medical records and the imaging follow-up study. The visual analog-scale for pain was used to assess each patient at 24 hours, 3 months, 6 months and 1 year after PV. The new fractures were evaluated from the imaging follow-up.
Results: Of the 220 VCFs, the L1 and T12 vertebrae were the most frequency levels (23.6 % and 20% respectively), the others were from T6 to L5 levels. The visual analog scale for pain was averaged at 8 before PV, 4.21 at 24 hours after PV, 3.37 at 3 months, 2.17 at 6 months and 1.73 at 1 year, and for overall periods was 2.27.The intraprocedural complications occurred in 2 patients, 1 from leakage of cement compressing the exiting nerve root and 1 from intrathecal hematoma. Of the 120 patients,14 (11.7%) had 34 new vertebral fractures (15.5%), whereas 13 of 34 vertebrae were adjacent to the treated levels.
Conclusion: PV is long-term effective for the treatment of painful VCFs. Only one-third of subsequent fracture occurred in levels adjacent to the treated level.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):94.
Purpose: To evaluate the effectiveness and security of percutaneous vertebroplasty in the cervical spine (CPV).
Materials and Methods: We evaluated 75 patients (mean age, 51.3 years) who underwent CPV (n=101) for malignancies (n=69) and vertebral hemangiomas (n=6) between January 1994 and October 2007. Follow-up (mean time of 8.8 months) was avaible in 57 (76 %) patients: 48 of them had CPV indicated for pain control and nine for spinal stabilization. Data were analysed by means of univariate and multivariate analysis.
Results: Pain improvement was observed in 37 (77.1%) out of 48 followed patients and was correlated in multivariate analysis with cement volume (P=0.011) and with vertebral filling (P=0.007). Spinal stabilization was observed in 55 (96.5%) of 57 followed patients and was related with none of the evaluated variables. The ROC curve identified the vertebral filling as a good predictor of pain improvement (P=0.008). The best cut-off point to discriminate pain improvement was 50% of vertebral filling (78.0% sensitivity and 62.5% specificity). Clinical complications were detected in 13 (17.3%) patients: local complications in 10 (13.3%) patients and systemic clinical complications in three (4.0%) patients. Posterior wall disruption (P=0.026) and transverse venous PMMA leakage (P=0.023) were significantly associated with clinical complications. Long-term morbidity and mortality rate was 1.3% (one patient) and 1.3% (one patient).
Conclusion: CPV is a safe and efficacious procedure, but the potential for local and systemic complications must be considered. Cement volume and vertebral filling were associated with pain improvement but not with spinal stability.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):94.
Purpose: To evaluate height restoration of fractured vertebrae post operatively and after 6 months after cyphoplasty using a permanent intravertebral implant combined with PMMA.
Materials and Methods: 23 patients were prospectively included after a spinal traumatic event and CT scan showing evidence for thoracolumbar compression fracture without osteoporotic background. All fracture types were A-1 to A3-1 according to MAGERL classification. No patient had posterior arch involvement. All patients were treated before within 10 days post trauma. 2 implants were used at each level. CT scan were performed after surgery and 6 months later. Several quality of life questionnaires were performed before treatment and 6 month later. All data were collected and analyzed in an external statistical unit.
Results: 26 vertebrae have been treated in 23 patients. Mean height restoration at anterior part of vertebra was 2,2 mm and 2,3 mm at the mid portion. No complications have been observed. All patients could stand up the day after treatment Mean time to discharge without brace was 3,2 days. Vertebral pain assessment showed reduction from 7,1/10 to 2,1 at day 1. All quality of life indicators showed dramatic improvements during all the follow up.
Conclusion: The use of SPINE JACK implant in burst fractures allows quick discharge of patient and satisfying restoration of vertebral height after 6 months. The safety of procedure must lead to a comparative study versus orthopedic and/or surgical treatment.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):94–95.
Purpose: Balloon Kyphoplasty (BKP) is a safe and efficient method in treatment of traumatic vertebral body fractures. This study report short term results and its ability to restore the height of vertebrae.
Materials and Methods: We retrospectively reviewed a series of 80 vertebral traumatic fractures in 68 patients managed between july 2005 and february 2009. 79 compression fractures Magerl A type without neurological symptoms underwent BKP and one Magerl B2 fracture was additionally managed by posterior osteosynthesis. All patients underwent preoperative and day 1 postoperative CT scan to measure anterior, midline and posterior body heights of the fractured vertebra. Vertebral kyphosis angle was measured on pre and post-operative CT images and in three successive stages of the procedure: before, ballons inflated, and cement injected. Student test was used to assess comparison results.
Results: We recorded significant restoration of vertebra body anterior heights (+4.2 mm) and significant decrease of kyphosis angle (-5.5°). Kyphosis angle reduction was significantly less important after cement was injected than when ballons were inflated (-1.4°). Preoperatively, 12% of compression fractures were more than 50% of the normal vertebral body height and 68% were more than 25%. After BKP no more compression fractures over 50% subsisted and 21% were above 25%. No complication was recorded. Asymptomatic cement leakages were observed in 14% of cases.
Conclusion: BKP proves to be safe and efficient treatment for pain relief in traumatic vertebral body fractures. Height restoration is constantly present specifically in severe compression fractures.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):95.
The advent of percutaneous material delivery has provided a viable treatment option that quickly improves the quality of life in patients with vertebral compression fractures. Injection of the material stabilizes the fracture thus preventing micro motion at the fracture site. PMMA bone cement has been the material of choice to date, but adjacent segmental fractures have been as high as 20% within the first year leading to further surgical intervention . A cement of altered modulus that represents the properties of trabecular bone may reduce this risk. Presented here is the first clinical series of vertobroplasty with a bi-phasic ceramic bone substitute with mechanical properties similar to cancellous bone.
The bi-phasic material (Cerament™, Bone Support AB) comprises a powder of synthetic calcium sulfate (60% by weight) and a balance of sintered hydroxyapatite, mixed with a radio-opacity enhancing component which contains iohexol to produce a flowable and injectable paste. The calcium sulfate resorbs with time producing porosity which allows for new bone ingrowth through occupation of osteoprogenitor cells and osteoblasts, while the hydroxyapatite acts as a long term osteoconductive matrix.
The material provides the appropriate mechanical environment for stability of the VCF and pain prevention. Its construction delivers a compressive strength similar to that of cancellous bone when implanted and this restores initial strength to aid pain prevention. The stiffness is also similar to that of cancellous bone to help prevent additional fractures in adjacent vertebrae.
The early clinical results shall be discussed.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):95.
Purpose: To demonstrate the efficacy and safety of the percutneous treatment of cervical disk hernias using nucleolysis with gelified ethanol.
Methods: From January 2004 to May 2008, patients with an intervertebral disk hernia at the cervical level in whose conventional treatment have failed, were offered percutaneous treatment with nucleolysis of the disk using gelified ethanol.
Results: A total of 56 consecutive patients were treated using nucleolysis with gelified ethanol. 14 men (25%) and 42 women (75%) ,ages between 25 and 80. Results were categorized according to MacNab scale (Excellent, Good, Fair, Poor), in 12 cases the result was excellent, in 38 good, fair in 5 and poor in 1.
Conclusions: The use of gelified ethanol for the treatment of cervical disk hernias is safe and provides good results, allowing patients with failure to conventional treatments to improve their symptomatology without having to undergo surgical procedures.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):95–96.
Purpose: Aim of this study is to compare percutaneous fixation of lumbar instability to the standard open technique, and to assess if advantages are significant enough to consider this operation for the cath lab.
Material and Methods: Patients with chronic severe back pain from lumbar instability are randomized to open stabilization with posterior lumbar interbody fusion (PLIF) or percutaneous transforaminal lumbar interbody fusion (TLIF).
Outcome measures are blood loss, length of surgery time, need for first assistant, post-op analgesic needs, length of hospital stay, incidence of infection, wound healing complications, total length of incision(s).
Results: To date, a total of 11 patients underwent either open (n=6) or percutaneous (n=5) surgery. The percutaneous group had significant reduction in: blood loss, need for surgical assistance, postop analgesic needs, length of hospital stay, and incision length. No significant change was seen in surgery time, infection rate, and wound complications.
Conclusion: Reduction in blood loss and minimal need for surgical assistance make percutaneous TLIF well suited for the cath lab, where superior equipment is expected to result in better visualization, higher accuracy and shorter operating times.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):96.
Purpose: To describe the usefulness of the combined endovascular and direct percutaneous treatment as therapy option for aneurismal bone cyst of the spine. (ABC)
Material and Methods: 6 pts (4M, 2F, age mean 18 years) with symptomatic ABCs at cervical, thoracic and lumbar spine with this distribution: 2 only posterior arch of L5, 3 at arch and body of T9, 1 at arch and body of C7. All pts were studied by MRI protocol and MDCT with MPR and 3D reconstructions. The procedure was performed under general anaesthesia for all pts. An angiographic control was performed in all pts, before any treatment. Percutaneous treatment was performed by direct injection of Glubran® diluted at 30% with Lipiodol®, while endovascular treatment was performed by Onyx® injection. Clinical and x-ray long term follow-up was performed at 1 year.
Results: Combined endovascular and percutaneous treatment for the ABCs was successfully performed and led to an excellent outcome in all pts with clinical improvement. There were no peri-procedural or subsequent clinical complications and the glue resulted in successful selective permanent occlusion with intralesional penetration. Direct sclerotherapy resulted in immediate thrombosis of 80% of the volume of the malformation with no progression of symptoms. At follow-up at 12 months, the symptoms had completely resolved and x-ray control showed total ossification of the lesion in all pts.
Conclusions: Combined surgical and percutaneous treatment or just direct percutaneous sclerotherapy with glue are an important,safe,effective therapy option for symptomatic aneurismal bone cyst. Results are stable and confirmed by clinical and x-ray long term clinical follow-up.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):96.
Purpose: Chronic painful pathology is frequent and multi-factorial. Percutaneous or surgical treatments often consider only one of the anatomical components the painful pathology which is actually 'regional'. We present our therapeutic concept to solve this problem.
Method: The following tools are used in association or successively according to the result obtained after each therapeutic step :
1) percutaneous treatment of all symptomatic discal levels at discographyography. This number being frequently of 2 but often also 3 or even 4 levels.
2) bilateral systematic steroids injections in the facet joints at the level of the treated disks,
3) systematic consideration of the harmony of the para-spinal muscles and correction by various techniques of stimulation,
4) lumbo sacral percutaneous liposuction to improve the active muscle support of the vertebral column,
5) CT sacro-iliac steroid infiltration after clinical determination of its responsibility in the residual symptomatology.
Results: Routinely used in the chronic painful lumbar pathology this concept of 'regional' suffering brought numerous and often spectacular good results in majority of the cases.
Conclusion: This new therapeutic concept respects the spine anatomy and is efficient in one of the most frequent human pathologies.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):97.
Thursday, July 2nd, 2009 • Room 517 • 13.30-14.50
interv neuroradiol. 2009 Jun 2;15(Suppl 1):97.
Purpose: To report long-term clinical and angiographic outcomes of stenting for patients with symptomatic intracranial stenosis using drug-eluting stent (DES) versus bare metal stent (BMS).
Materials and Methods: Between May 1998 and Sep. 2008, stent-assisted angioplasty was performed on 179 patients (mean age: 63.2 years) with 196 symptomatic intracranial stenosis (MCA:61, ICA:75, VBA:60). DES was used in 33 of the total 196 cases (MCA:17, ICA:4, VBA:12).
The DES sizes used were 2.25mm in six, 2.5mm in 24, and 2.75mm in three cases. We retrospectively analyzed the technical success, procedure-related complications, clinical and angiographic outcomes between two groups.
Results: Technical success was achieved in 100% for the DES and in 95.1% for the BMS. The 30 day periprocedural complication rate was 9.1% in the DES and 4.5% in the BMS. Angiographic follow-up was available in 19 of 33 cases for the DES (range: 3-37, mean: 10.7months) and in 75 of 155 cases for the BMS (range: 3-55, mean: 13.3months). Restenosis rate was 0% in the DES and 17.3% in the BMS (28.6% in cases less than 3mm in diameter and 7.5% in cases equal to or more than 3mm in diameter). Clinical follow-up was available in 33 patients for the DES (range: 3-42, mean: 18.4 months) and 139 patients for the BMS (range: 3-107, mean: 41.8 months). Ipsilateral stroke or death rate was 0% in the DES and 2.88% in the BMS. Overall vascular events or death rate was 3% in the DES group and 10.1% in the BMS group.
Conclusion: Stent-assisted angioplasty for symptomatic atherosclerotic intracranial artery stenosis is feasible and safe with favorable longterm outcomes. Drug-eluting stent could be recommended for the stenotic vessel less than 3mm in diameter.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):97–98.
Purpose: To compare perioperative outcomes of treatment of intracranial atherosclerosis with balloon expandible drug-eluting (DES) and self expanding (SE) stents.
Materials and Methods: Retrospective review of patients with intracranial stenosis, excluding vertebral origin stenosis and non-atheromatous lesions, treated with DES or SE where one of the authors was the primary operator between 2003 and November 2008.
Results: A total of 92 arterial segments were treated in 87 patients with a self-expanding stent. There were no treatment failures. In this group there were 11 ischemic (TIA or stroke) and 2 hemorrhagic events, 1 symptomatic groin hematoma and 1 cervical dissection related to the procedure resulting in a procedural complication rate of 14.1 %. In 8 other patients hyperacute thrombus was noted in the stented segment and was managed conservatively with intravenous Reopro administration without additional morbidity. DES placement was attempted in 24 cases and was successful in 22. There was no evidence of hyperacute thrombosis. In DES group there were 2 periprocedural TIAs, 1 acute stent occlusion on day 1 resulting in stroke, one cervical dissection and a procedural complication rate of 16.1 %. 3 DES placements were for the treatment of symptomatic SE restenosis. Follow-up angiograms/ CTAs available in 41 SE and 9 DES cases yielded restenosis rates of 24 % and 33 % respectively (excluding 1 DES placed for target vessel revascularization after bare stent placement). All occlusions occurred in arteries with diameters of 3 mm or less.
Conclusions: Stenting of intracranial atherosclerosis had similar perioperative outcomes with either SE or DES.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):98.
Background: The US Wingspan Study is a prospective registry of 158 patients with intracranial stenosis treated with the Gateway-Wingspan System. We present the long term angiographic and clinical follow up data for these patients.
Methods: 158 consecutive patients with 168 treated intracranial atherostenoses (50-99%) were enrolled between 11/2005 and 8/07 at five participating institutions. Patients were followed for a minimum of 1 year. Any stroke or death within 30 days or ipsilateral stroke between 30 days and last follow up was counted as a 'primary endpoint'. Patients typically underwent follow up angiography or CTA at 3-6 months and 8-15 months after treatment. In-stent restenosis was also evaluated.
Results: Stent placement could be achieved more than 95% of the time. The average pre-treatment stenosis was 75.2% and was reduced to 42.7% after angioplasty, improving further to 27.3% after placement of the Wingspan (with or without post-dilation). Nine peri-procedural complications were encountered (5.4% per lesion, 5.7% per patient complication rate). 143 of 147 eligible patients (97.3%) had at least 3 months of clinical follow up. There were 13 ipsilateral strokes after 30 days (average interval of 14.2 months, 9%). An additional 9 patients experienced TIA. The majority of these delayed ischemic events could be attributed to either early anti-platelet interruption or in-stent restenosis (ISR).
Conclusions: The treatment of symptomatic intracranial stenosis can be accomplished with the Wingspan system with a high rate of technical success and a reasonable rate of peri-procedural complications (~5%). The rate of delayed ipsilateral stroke observed in our population was 9%. The cumulative rate of 'primary endpoint' for all patients was 14%. These data support the concept of equipoise between medical therapy and PTAS with Wingspan for patients with high grade, symptomatic intracranial stenosis.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):98.
Purpose: Intracranial stenosis is an important cause of cerebral ischemia. Endovascular approaches using angioplasty and stenting have been developed to decrease the rate of recurrent stroke. Preliminary experience with drug eluting stents in the cerebral circulation has suggested a reduction in restenosis rate We therefore retrospectively reviewed the experience at our institution with drug-eluting stents.
Material and Methods: Twenty-six patients were treated with 27 drug-eluting stents. Combination antiplatelet therapy was administered to all patients. In most cases, pre-stent angioplasty was followed by placement of Tacrolimus, or Sirolimus eluting balloon-mounted stents. Post-stent dilation was not performed. Follow-up clinical and angiographic evaluation at six months was scheduled for all patients.
Results: DES placement was successful in 100% of patients and was generally well tolerated. The degree of stenosis before and after intervention was reduced from mean±SD 80%±8% to 5%±9%. There were no major perioperative complications. In the thirty days after stent placement, three ischemic events occurred-one TIA and two strokes.
Overall restenosis rate, defined as stenosis of > 50% of the vessel lumen, was 27% during angiographic follow- at a mean±SD of 8.5±5.9 months. The rate of symptomatic restenosis was 33% . The risk of stroke between 30 days after stenting and last follow-up was 8% and the risk of TIA was 12%.
Conclusion: The procedure can be performed with a high degree of technical success, a relatively low complication rate, and that the risk of recurrent stroke appears favorable compared with what might be expected based on medical therapy alone.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):98–99.
Purpose: The combination of undersized balloon dilatation and deployment of oversized self-expanding stents for the treatment of intracranial stenoses has increased the procedural safety. Available stents are notorious for frequent (30%) recurrent stenoses. This might be due to an excessive radial force of the implanted stents (e.g., WingSpan). We used a stent with less radial force (Enterprise, Cordis) together with undersized balloon dilatation.
Materials and Methods: 54 patients (37 male) with 56 intracranial arterial stenoses. Stenoses locations: distal ICA (n=6), MCA (n=23), ACA (n=2), distal VA (n=11), BA (n=13), PCA (n=1). Treatment was performed after dual antiaggregation under general anesthesia. The most frequently used balloon was Ryujin. The stents were either 14 or 22 mm long with a nominal diameter of 4 mm. Follow-up DSA was performed 6 and 12 weeks as well as 6 and 12 months after the treatment. All patients remained under a continued medication with ASA and Clopidogrel.
Results: A sufficient vessel dilatation with less then 50 % residual stenosis was achieved in all patients. There was no access failure. Procedural complications were encountered in 5 patients (2 pontine ischemia with minor deficit, 2 basal ganglia ischemia with transient deficit, 1 early stent thrombosis without permanent deficit). 36 stenoses were evaluated with follow-up DSA. Significant re-stenoses were observed and re-treated in 4 patients (11 %), in 2 of them using drug eluting balloons.
Conclusion: The use of self-expanding stents with closed cell design and less radial force yields improved follow-up results after the stent-PTA of intracranial arterial stenoses.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):99.
Purpose: The purpose of this study was to report feasibility and safety data after clinical use of monorail balloon expandable stents dedicated for treatment of intracranial stenoses.
Patients and Methods: Between 2006 and 2009 n = 34 patients with high grade > 70 % symptomatic intracranial stenosis were scheduled for endovascular treatment with PHAROS or PHAROS-Vitesse. We performed 25 elective procedures and 9 interventions in cases with acute strokes. The patients clinical status was assesed by an independent neurologist before and after the intervention. All patients were included in a regular neurologic follow up programme.
Results: Stenting was technically successful in 31 out of 34 cases. In three patients we switched to selfexpanding stents. One minor, one major periprocedural stroke and no deaths occurred in the 25 elective cases accounting for a 30 d stroke and death rate of 8 %. There were no further strokes during a mean follow-up period of 12 months. There was no requirement for retreatment of high grade in-stent-restenosis. Two out of nine patients with acute strokes showed new neurologic deficits after the procedure or during follow-up. Two of these patients died due to nonneurologic disease.
Conclusions: The use of the PHAROS and PHA-ROS- Vitesse for treatment of intracranial stenoses shows high technical success rates and meets current safety standards. There was no evidence of increased ischemic events or restenosis rates during follow-up.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):99.
Aims: To describe our expierence with patients with stroke secundary to intracranial stenosis refractary to the medical treatment agreements with angioplasty with or without stent.
Patients and Methods: We to perform a retrospective study where 27 patients enlisted during the period between January 1997 and Januery 2009. The studied changeables went age, sex, factor of risk, clinical presentatio, percentage and location of the stenosis and morbimortality.
Results: Of 27 enlisted patients there realized 29 procedures (27 angioplsty with stent and 2 without stent). Obtained exelents clinical results and angiography with a morbimortality of 7,4%.
Conclusions: The angioplasty with or without stent it is a safe and effective for the treatment intracranial stenosis. We believe that the suitable selection of the patients and the experience of the team of doctors neurovascular are fundamental to obtain the best results.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):99–100.
Purpose: Stenting is the preferred treatment of symptomatic intracranial dissection refractory to medical therapy. We present 3 cases of intracranial dissection treated with placement of a self-expanding Enterprise stent.
Methods: Records of patients with intracranial dissection treated at our institution with placement of an Enterprise stent were reviewed.
Results: Three patients with intracranial dissection were treated with Enterprise stent placement. Two patients presented with spontaneous dissection and MCA territory stroke. Both patients remained symptomatic on medical management. The first patient was successfully treated with placement of an Enterprise stent in the supraclinoid ICA and M1 segment with excellent angiographic result post procedure and on 6 month follow up. The second patient demonstrated a > 90% stenosis of the left M1 secondary to spontaneous dissection. An Enterprise stent was successfully placed across this lesion with 70% residual stenosis. Six week follow up demonstrated 50% residual stenosis. The patient was clinically asymptomatic and no further intervention was performed. The third patient presented with traumatic injury and dissection involving the supraclinoid ICA. This was also successfully treated with placement of an Enterprise stent with no residual stenosis post procedure and on follow up angio-gram.
Conclusion: The Enterprise stent is a self expanding stent which is easily navigable into the intracranial circulation. It has the ability to be repositioned which allows for accurate deployment. It is safe and appears to be effective in treatment of intracranial dissections though larger series of patients with longer term follow up is required.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):101.
Thursday, July 2nd, 2009 • Room 517 • 15.20-16.30
interv neuroradiol. 2009 Jun 2;15(Suppl 1):101.
Purpose: Atherosclerotic disease of the intracranial vertebrobasilar system carries a high stroke risk despite medical treatment. Technologic advances and increasing experience have allowed a relatively safe procedure with fewer periprocedural complications.
Materials and Methods: A total of 24 patients with 24 intracranial atherosclerotic lesions of the vertebral or basilar artery were treated by means of stent-assisted angioplasty in our institution between October 2001 and October 2008. 14 patients presented with stenosis in basilar artery and 10 had stenosis in the intracranial vertebral artery. The mean age was 65 ± 7.5 years. We calculated the degree of stenosis on angiograms before and immediately after PTA and at a follow-up to compare the diameter of the vessel at the site of greatest narrowing with the diameter of a normal artery distal to the lesion. Significant restenosis was defined as stenosis of greater than 50%.
Results: In all cases deployment of the stent was technically successful and control angiography demonstrated elimination of stenoses. Only a residual stenosis of 10-25% was left in four cases (% 17). One patient died due to hemorrhagic transformation of the pons infarct that developed 2nd day of the procedure and the other patient developed immediate postprocedural dizziness, diplopia and swallowing problems.
Conclusion: This study supports the safety and the potential efficiency of stent-assisted angioplasty in patients with symptomatic vertebrobasilar artery stenosis.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):101–102.
Purpose: Stroke mechanism depends on multiple factors. We compared ACHC distal to severe M1 stenosis according to the presenting symptoms and infarct patterns, perfusion status, and outcome after recanalization.
Materials and Methods: ACHC in 60 patients (M:F = 41:19, mean age = 55) was divided into three types: normal type with normal sized MCA branches and no shift of the vascular watershed zone (n = 17); shift type with decreased size of MCA branches and shift of ACA - MCA watershed zone down to MCA side (n = 14); and dilatation type with dilated MCA branches with slow flow and minimal shift of watershed zone (n = 29). We compared ACHC with presenting symptoms (stroke vs TIA), MRI ischemic changes (border-zone, perforator, and wedge-shaped cortical infarcts), perfusion studies, and outcome. Bivariate analysis was performed using Fisher's exact test.
Results: Dilatation type was the most common ACHC. Shift type was more common in females than in males (P = 0.001). In the order of dilatation, shift, and normal types, there was a greater tendency toward stroke than TIA (P= 0.002) and more frequent border-zone infarct (P = 0.003). Perfusion was more decreased in the dilatation type (P = 0.042). The outcome did not reveal any difference due to the low event rate (4/60, 6.7%).
Conclusion: ACHC is related to presenting symptoms, infarct pattern, and perfusion status. Angiographic changes beyond stenosis may represent a spectrum between the development degree of anatomic variation at the border zone and the hypoperfusion status. Plaque status leading to artery-to-artery embolism possibly remains the last variable.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):102.
Purpose: Intracranial atherosclerosis is considered a possible cause of stroke. Endovascular treatment is currently indicated in recurrence of symptoms despite best medical therapy. The authors present their own experience.
Materials and Methods: Since March 2001, 29 patients (24 male, mean age 64 years old) with intracranial atherosclerosis and recurrent transient ischemic attacks (TIA) despite maximal medical therapy (two platelet-active drugs, statins and control of vascular risk factors) were treated. 14/29 patients refer to the beginning of authors'experience when dedicated devices (balloons, stents) were not available and cardiologic material was mainly used. In the last few years both dedicated balloons and self expandable stents were made available and 15/29 patients were treated with them. 20/29 stenoses (69%) were located in anterior circulation (16/20 in the intracranial carotid artery, 4/20 in the middle cerebral artery). 9/29 (31%) stenoses were in posterior circulation (5/9 in the basilar artery, 4/9 in the intracranial portion of vertebral artery).
Results: Technical success was achieved in 25/29 patients (86%). Three major complications (10%) occurred (2 major strokes, 1 death due to cerebral hemorrhage).
Conclusions: In symptomatic patients despite best medical therapy, endovascular treatment of intracranial atherosclerotic stenoses by angioplasty and stent implantation is effective and safe. Technical feasibility has been improving much since dedicated devices are available.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):102.
Purpose: To report our experience with revascularization of chronically occluded cerebral arteries.
Materials and Methods: 6 patients underwent endovascular revascularization of chronically occluded intracranial. The occlusion time ranged from 3 days to 24 months. All patients were incapacitated due to cerebral hypoperfusion. One patient failed EC-IC bypass surgery, 1 patient refused the surgical option, and 4 were too sick to undergo EC-IC bypass. Follow'up diagnostic cerebral angiogram (DCA) at 3 months and clinical follow-up at 1 year were reviewed.
Results: The wire was unable to cross the lesion safely in 1/6 patients (technically unsuccessful, 16.6%). In the other 5 patients, the wire crossed the lesion easily and angioplasty was performed. DCA post balloon angioplasty revealed reconstitution of the true lumen in 4/5 (80%). In the 5th case, DCA demonstrated vessel rupture, and the patient expired. Of the residual 4 patients, 3 had Wingspan™ placed at the site of the angioplasty. The 4th patient with angioplasty of the intracranial vertebral artery received a balloon mounted stent at the vertebral ostium. Complication rate in the first 30 days for the 5 surviving patients was 1 TIA. The 4 patients with successful recanalization underwent follow-up DCA at 3 months, demonstrating perfect patency of the vessels. No clinical complication was recorded at the 1 year follow-up. All 4 patients reported marked clinical improvement.
Conclusion: In selected patients, recanalization of chronically occluded cerebral vessels is feasible and beneficial. In our series 5/6 patients either remarkably improved or were stable (83.3%).
interv neuroradiol. 2009 Jun 2;15(Suppl 1):102–103.
Purpose: To evaluate the prevalence, risk factor, clinical and radiographic outcomes of clopidogrel resistance in patients with stenting for atherosclerotic cerebrovascular disease.
Materials and Methods: Between Sep. 2006 and June 2008, clopidogrel resistance test was performed on 43 patients who underwent stenting for atherosclerotic cerebrovascular disease. Clopidogrel resistance test was performed about 12 hours after drug administration(loading dose: 300 mg, maintanance dose: 75 mg). 41 patients were included(range: 41-79, mean: 65.9 years). Among 41 patients, 18 patients showed intracranial lesions, and 23 patients had extracranial lesions. We evaluate the prevalence, risk factors and complications related to clopidogrel resistance.
Results: 21 patients (51.2%) presented clopidogrel resistance(intracranial: 10 patients (55.6%), extracranial: 11 patients (47.8%)) with no clopidogrel resistance in 20 patients. Stent-assisted angioplasty was technically successful in all patients, but acute instent thrombosis occurred in 5 patients with intracranial lesion (four patients with clopidogrel resistance and one patient without clopidogrel resistance). Acute thrombi were completely lysed after IA infusion of abciximab. Patients with clopidogrel resistance showed relatively higher incidence of dyslipidemia than non-resistance patients.
Conclusion: There is high prevalence of clopidogrel resistance in patients with atherosclerotic cerebrovascular disease. Acute instent thrombosis is more frequently seen in the clopidogrel resistant group. So, clopidogrel resistance test should be necessary to avoid thromboembolic complications related to acute instent thrombosis.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):103.
Purpose: To demonstrate the role of vertebral artery ostium (VAO) atherosclerotic lesions as a source of posterior circulation stroke.
Materials and Methods: 91 patients underwent VAO stenting (100 stents), and data were collected prospectively and analyzed retrospectively. Patients were divided in 4 groups: group 1 presented with transient ischemic attack (TIA) followed by stroke (5), group 2 stroke (30), group 3 TIA (44) and group 4 incidentally found (12). Cerebral angiographies were reviewed. Clinical follow-up at 1 year post-stenting was evaluated for recurrent symptoms.
Results: 4 variables seen on angiogram appear to correlate with clinical presentation: BUET
1. Bilateral VAO stenosis incidence decreased from group 1 to 3, (100%, 60%, 43.3% respectively). This trend became more pronounced if we include that at least one VA is occluded (100%, 53.3%, 34.09% respectively).
2. Ulceration at the VAO was seen only in patients with TIAs (1/8 in group 1, 7/8 in group 3).
3. Angiographic VA Embolus was found in symptomatic vessels only in all 3 affected patients (1 with VA occlusion, 2 with VA critical stenosis).
4. Tandem lesion incidence decreased from group 1 to 3 (60%, 50%, 15.6% respectively).
Clinical follow-up was available on 73/91 patients at a mean of 14.14 months. There were only 2 TIAs in-territory and 6 in different territories.
Conclusion: The direct relationship between the morphologic abnormalities at the VAO and clinical presentation and the low stroke/TIA rate following stenting suggest that VAO is a significant source of posterior circulation stroke. The presence of the BUET variable correlates with symptomatic lesions and may help in treatment decisions.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):103.
Purpose: The primary objective is to explore the usefulness of Magnetic Resonance Imaging (MRI) and Magnetic Resonance Angiography (MRA) in determining which vertebral artery is responsible for the posterior circulation stroke.
Materials and Methods: 91 patients underwent vertebral artery ostium stenting (100 stents). Data were collected prospectively and analyzed retrospectively. The posterior circulation was divided into 3 parts on MRI: Proximal (P) consisting of the medulla and the inferior cerebellum in the distribution of the posterior inferior cerebellar artery, Middle (M) comprising the pons and the distribution of the anterior inferior cerebellar artery, and Distal (D) containing the superior cerebellar and posterior cerebral arteries territory. Available MRIs were reviewed to determine the location of diffusion abnormalities (P, M, D). MRAs were compared to DCA to assess its efficacy in detection vertebral artery ostium stenosis.
Results: 51/91 patients had MRIs available. 25/51 had DWI abnormalities in the posterior circulation.17/25 patients (68%) had DWI in the P region. 17/17 (100%) had an abnormal ipsilateral vertebral artery, including artery occlusion in 12/17 (70.58%) and stenosis in 5/17 (29.41%).
A total of 47 MRAs without contrast (MRAwo) were found. 13/47 (27.65%) agreed with DCA findings. However, MRAs with contrast (MRAw) agreed with DCA findings in 8/11 cases found (72.72%).
Conclusion: DWI abnormalities in the PICA territory have a high localization value for the ipsilateral vertebral artery as a source/conduit of stroke. MRAw is superior to MRAwo, but both are insufficiently sensitive.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):104.
Thursday, July 2nd, 2009 • Room 520ab • 13.30-14.50
interv neuroradiol. 2009 Jun 2;15(Suppl 1):104.
Purpose: Dural arteriovenous fistulas (DAVFs) with leptomeningeal venous reflux pose a high risk of aggressive manifestations including hemorrhage. Among DAVFs, there is a peculiar type that demonstrates direct drainage into the bridging vein, and not into the dural venous sinus. The purpose of this study was to investigate the characteristics of DAVFs which drain directly into the petrosal vein or the bridging vein of the medulla oblongata.
Materials and Methods: Eleven consecutive cases of DAVFs which drained directly into the petrosal vein, and six cases of DAVFs which drained directly into the bridging vein of the medulla were retrospectively reviewed. These cases were evaluated and/or treated at our institute over a 27-year period. Review of previously reported cases was also performed.
Results: Both of these "extrasinusal" type DAVFs revealed very similar characteristics. There was a significant male predominance (p < 0.001) and a significantly higher incidence of aggressive neurological manifestations including hemorrhage or venous hypertension than DAVFs developed in the transverse-sigmoid or cavernous sinus (p < 0.001), which were considered to be attributable to leptomeningeal venous reflux. Regarding the treatment, endovascular embolization, either transarterial or transvenous, is frequently difficult, and surgery may be an effective therapeutic choice in many instances.
Conclusions: Embryologically, both the petrosal vein and the bridging vein of the medulla are cranial homologies of the spinal cord emissary bridging veins. We believe that these DAVFs may be included in a single category with spinal DAVFs which show similar clinical characteristics.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):104–105.
Purpose: Dural Arteriovenous Fistulas (dAVFs) with exclusive leptomeningeal venous drainage (cortical and non-cortical) are lesions associated with poor prognosis and treatment is mandatory. The purpose of our study was to report our experience in transarterial embolisation using Onyx in these lesions.
Materials and Methods: Retrospective evaluation was carried out in 14 patients with a DAVF with leptomeningeal venous drainage treated transarterially using Onyx. There were 10 men and 4 women ranging in age from 46 to 67 years. Clinical findings included hemorrhage in 8 patients, symptoms of raised intracranial pressure in 3, bruit and headache in 1 and in 2 patients the dAVF was diagnosed by chance. The DAVFs were located at the transverse sinus (n=3), at the superior sagittal sinus (n=2), at the superior petrosal sinus (n=1), in the tentorial region (n=6) and in the posterior fossa (n=2). Endovascular treatment was performed using only onyx in 12 cases, onyx and glue in 1 and onyx and coils in another one.
Results: Occlusion of the DAVF was complete in 10 cases, subtotal in 3 and failed in one. In 8 cases, the complete occlusion of the fistula was obtained in one session. After embolization, 10 patients (including 8 who recovered from the hemorrhage) remained asymptomatic. Four patients with symptoms of raised intracranial pressure and/or bruit and headache were clinically cured. No clinical complications were observed in this series.
Conclusion: In our experience, Onyx is a safe and effective tool in the treatment of DAVFs with a leptomeningeal venous drainage. At the present time, transarterial embolization with Onyx is the elective treatment in most of these lesions.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):105.
Introduction: Transvenous (TV) embolization as additional method in treatment of difficult vascular pathology has gained more attention during recent years. However small experience is collected in this direction. We summarized experience of the single clinic.
Material and Methods: From 2002 till 2008 we performed 168 interventions in 99 patients with different neurovascular pathology in which TV approach was used. 48 male and 51 female patients, aged from 1y. 3m. to 78 y.o., were operated. Distribution of pathology was following: DAVF – 56 pts (56,6%), direct fistulas (CCF, AVF of vertebral artery, pial AVF) – 22 pts (22,2%), vein Galen AVMs – 3 pts (3%), sinuses thrombosis – 9 pts (9,1%), hemangiomas – 6 (6,1%), other (sinus stenosis, orbital varix) – 3 pts (3%). 69 patients underwent only TV procedures, in other cases we used combined embolization – TV and transarterial (TA). In 93 pts transfemoral TV approach was performed, in 6 cases – direct approach (via SOV, facial vein, sigmoid sinus).
Results: Angiografically confirmed total occlusion of AV lesions was achieved in 73.6% of cases. Subtotal occlusion was displayed in 17.5% of cases, partial occlusion in other cases. In cases of sinuses thrombosis and stenosis full recanalization was achieved by selective TV thrombolytic therapy and balloon sinusoplasty. Orbital varices were closed totally. Morbidity and mortality were 1% equally.
Conclusions: TV occlusion is effective method in treatment of DAVF. Combination of TV and TA embolization allows to increase efficacy of operations in AVF. This method demands further perfection and wider introduction in clinical practice.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):105.
Purpose: Embolization with transarterial (TAE) and transvenous approach (TVE) is the standard treatment fashion for the dural arteriovenous fistula (DAVF). We verify the efficacy and pitfall of these two modalities by reviewing our case series of 10 years and by analyzing the questionnaire results of Japanese qualified neurointerventionalists.
Object: We treated 237 patients with DAVF in the 304 sessions including by 155 TAE with particles or glue, by 99 TVE with coils and by 46 both methods. The location of DAVF is cavernous in 108, transverse in 81, and tentorial sinus in 17 patients. Staged combination therapy was performed in 30 patients. Further, we conducted a survey of Japanese neurointerventionalists about the treatment strategy for DAVF and obtained 394 replies.
Results: DAVFs with TAE using particles in the early periods mostly remained or recanalized. Of 51 patients with TAE using glue for the isolated sinus 32 cured in the single session, however 8 patients required second treatments. Ischemic complications occurred in 2 patients. Of 99 patients with TVE 85 patients angiographically cured. Three patients developed hemorrhagic complications. Total morbidity rate was 2.1% and mortality rate was 0%. According to the survey TVE is selected for the first choice treatment for DAVF in 70 % of respondents. However, Half of these experienced various complications in TVE.
Conclusion: Although TVE may be an ideal and standard treatment method for DAVF because of its high cure rate, however, remaining venous reflux should have high risk of complications. TAE with liquid material should be focused particularly for the cases with cortical drainage.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):105–106.
Background and Purpose: An increasing number of intracranial dural arteriovenous fistulas (DAVFs) are amenable to endovascular treatment with Onyx (ev3, Irvine, Calif). However, reports on complications caused by this technique have been limited. We present the initial Beijing Tiantan Hospital experience with adverse events related to transarterial Onyx embolization for DAVFs.
Materials and Methods: Between September 2005 and February 2008, a total of 40 patients with DAVFs were treated at our institute with Onyx-18. There were 11 women and 29 men with a mean age of 43.15 years (age range, 23'60 years). We reviewed the clinical presentation, angiographic features, treatment, and outcome.
Results: In 40 patients, total obliteration was achieved in 25 DAVFs (62.5%), with the remaining 15 patients not cured with residual shunts. Complications occurred in 9 patients, 5 DAVFs were located at tentorium, 2 were located at the transverse-sigmoid sinus, one was found at the inferior petrosal sinus, and one was found at the cavernous sinus, leading to permanent disability in 3 patients (morbidity, 7.5%). Complications included reflexive bradyarrhythmia in 3 (7.5%) patients, hemifacial hypoesthesia in 3 (7.5%) patients, hemifacial palsy in 2 (5%) patients, posterior fossa infarction in 2 (5%) patients, jaw pain in 1 (2.5%) patient, microcatheter gluing in 1 (2.5%) patient, hallucinations in 1 (2.5%) patient, and Onyx migration in 1 (2.5%) patient.
Conclusion: Although complete cure can be achieved by transarterial embolization with Onyx, the potential for serious complications exists with this procedure.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):106.
Purpose: Intracranial dural arteriovenous shunts (ICDAVSs) with cortical venous reflux (CVR) are best treated by embolization (E°). New embolic materials as Onyx are often considered to be some kind of 'gold standard' for E° of these lesions. The purpose of this study is to emphasize the importance of transarterial E° using acrylic glue in the therapeutic management of ICDAVS with CVR, and to compare our results obtained with those available in the literature with Onyx in the same type of ICDAVSs.
Methods: We reviewed the clinical and radiological files of 53 consecutive patients suffering from ICDAVS with CVR, treated homogeneously with the same angiographic and therapeutic protocol.
Results: Fourteen ICDAVSs were located at the superior sagittal sinus and/or convexity veins, 13 at the transverse and sigmoid sinus, 12 at the tentorium, 5 in the anterior cranial fossa, 4 at the foramen magnum, 3 at the torcular, 2 at the straight sinus, and 1 at the vein of Galen. One patient presented with an infantile ICDAVS with multiple shunts. Thirty six percent of patients had bled. Forty four patients underwent transarterial E° (1 failure, 42 with glue). In 38 patients, only glue was used for E°. Cure of the fistula was obtained in 35 patients (92%). Partial occlusion of the main shunt with suppression of the CVR was achieved in all other patients. No mortality or permanent morbidity was seen our series.
Conclusion: ICDAVS are safely managed by transarterial E°. Glue allows a cheap, fast and effective treatment with high rates of cures that compare favourably to those obtained with Onyx.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):106.
Purpose: We report our experience in the treatment of 24 dural fistulae of the lateral sinus or superior sagittal sinus sinus by venous remodelling allowing cure of the fistula and preservation of the sinus.
Patients and Methods: 24 dural fistulae were treated by this technique from june 2006 to january 2009 in our institution. The fistulae located at the lateral sinus (n=15), sagital sinus (n=4), torcular (n=3) and occipital sinus (n=2). A single procedure was achieved in 22 patients, 2 patients underwent 2 procedures and 1 patient 3 procedures. Onyx was injected under temporary balloon inflation after distal selective catheterization of a meningeal feeder in 22 patients and retrograde venous navigation in 2 patients.
Results: Complete cure of the fistula could be obtained in 22 and subtotal occlusion in 2 patients. The sinus could be preserved in 22 patients. Complementary coiling with sacrifice of the sinus was necessary in 2 cases. A cure could be obtained even in the dural fistulae located at the torcular. A cochlear nerve ischemia occured in one patient.
Conclusion: The combined use of a venous remodelling balloon and arterial injection of Onyx allows cure of dural fistulae with preservation of the sinus. This technique seems to be specifically indicated when normal cortical veins drain into the impaired segment of sinus.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):107.
Thursday, July 2nd, 2009 • Room 520ab • 15.20-16.30
interv neuroradiol. 2009 Jun 2;15(Suppl 1):107.
Objective: The aim of this study is to describe the technique and results of the transvenous approach for occlusion of cavernous dural arteriovenous fistulas (DAVFs) with Onyx.
Methods: Eleven patients presenting with clinically symptomatic DAVFs, were treated between August 2005 and February 2007 at Beijing Tiantan Hospital. We were able to navigate small hydrophilic catheters and microguidwires through the facial vein or inferior petrosal sinus (IPS) into the ipsilateral cavernous sinus. After reaching the fistula site the cavernous sinus was packed with Onyx or combining with detachable platinum coils.
Results: We were able to reach the fistula site and to achieve a good packing of Onyx or combining with coils within the arteriovenous shunting zone in 10 patients. The final angiogram showed complete occlusion of the arteriovenous fistula. Two (18.2%) patients developed a bradycardia during DMSO injection. No complications related to the approach were observed.
Conclusions: Transvenous occlusion of cavernous DAVFs is a feasible approach, even via facial vein or via IPS. Onyx may be another option for cavernous packing other than detachable platinum coils.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):107.
Purpose: Our experience with Onyx treatment of dural AVFs and CCFs is very encouraging. However, hemodynamic instability during embolization was observed in some of our patients.
Summary of cases: Nine patients with DAVFs were treated in our department over the last 18 months: 2 with Barrow type B and D dural CCFs, 7 with Cognard type III and IV DAVFs. Durable results have been achieved without any recurrences or permanent complications in our small series.
We have observed severe bradycardia in 4 cases with a brief asystole in two of our patients during transarterial and transvenous Onyx delivery into cavernous sinus and orbital vessels which resolved promptly with interruption of injection and administration of atropine.
Possible explanation of this phenomenon could be an irritation by Onyx or DMSO of the trigeminal nerve or its branches within the cavernous sinus, which produces a vagal reflex through trigeminocardiac reflex, or oculocardiac reflex (Aschner phenomenon) during injection into ophthalmic arteries and veins.
Conclusion: Treatment of DAVF and some types of CCF with Onyx is an effective and a relatively safe technique.
Hemodynamic instability may be observed during Onyx injection, especially within cavernous sinus and orbits.
Proposed measures to prevent this complication include pretreatment with atropine, or prophylactic placement of transvenous pacemaker in patients with underlying heart block and patients with contraindication to atropine use.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):107–108.
Purpose: The tentorial dural arteriovenous fistula (DAVF) is an uncommon disease with poor nature history.
Management of tentorial DAVF remains controversial. The study reports the technique and results of transarterial embolization by using Onyx in the treatment of a series of 14 patients with tentorial DAVF.
Materials and Methods: We retrospectively reviewed the clinical and radiological data of 14 patients with tentorial DAVFs, who were treated by transarterial embolization using Onyx in Shanghai Changhai Hospital between 2005 and 2008.
Results: Twelve patients presented with subarachnoid or intraventricular hemorrhage. Complete cure was achieved in 11 patients after 1 procedure and one patient after 2 procedures.
Incompleted cure was obtained in the other two cases. One patient experienced vessel perforation and one had microcatheter retention. All the patients recovered well, except for one patient died of severe infection caused by ventricular drainage. Clinical follow-up showed no rebleeding or worsen. Follow-up angiography in 8 patients with total occlusion demonstrated no recurrence.
Conclusion: These results suggest that transarterial embolization using Onyx is feasible and effective for management of tentorial DAVFs.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):108.
Purpose: In treating cavernous sinus dural arteriovenous fistulas (CSdAVFs), transvenous embolization of the whole affected sinus has been widely performed. This method, however, may result in the disturbance of the normal venous drainage or permanent cranial nerve palsy.
In this report, we describe the superselective shunt occlusion of the CSdAVFs, especially in technical details.
Methods: From January 2003 to December 2008, we experienced 17 consecutive cases of CSdAVFs. In all cases, we could detect the locus of the arteriovenous shunts by way of 3-dimensional rotational angiography (3-D RA) and/or superselective arteriography. After navigating the microcatheter to the shunt segment by transvenous approach, consecutive arteriovenous superselective angiography was very useful to confirm the location of the microcatheter at the proper position. The shunt segment was obliterated with bare platinum coils.
Results: In 11 out of 17 cases (64.7%), coiling only in the small venous pouch or segment, which was just downstream of the shunt point, had led to complete disappearance of the shunt and resolution of the symptoms without obliterating the entire sinus.
Conclusion: This technique, which enables both preservation of the normal venous drainage as well as complete resolution of the ocular symptoms with small amounts of coils, is a feasible and cost effective way to treat CSdAVFs. Accurate understanding of the angioarchitecture by 3-D RA and superselective angiography and gentle catheter navigation in the affected sinus is necessary.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):108.
Purpose: The endovascular treatment of the spontaneous dural fistula of cavernous sinus can be achieved by arterial access, with relief of symptoms or the venous access through the inferior petrous sinus, ophthalmic vein, intercavernous sinus and facial vein. The presentation of this case suggests access to the cavernous sinus through the puncture of the foramen ovale as an alternative when the failure of venous access conventionally described.
Summary of the case: Female patient, 76 years old, evolving in six months with right conjunctive hyperemia, exophthalmia, increased intraocular pressure and visual deficit. Angiographic diagnosis of spontaneous and isolated FAVD from the right cavernous sinus, Barrow Type C, with venous drainage through the superior ophthalmic vein. Procedure with general anesthesia. Selective catheterization of the right common carotid artery to control blood. Try to access the cavernous sinus via the inferior petrous sinus and intercavernoso contra lateral and ipsilateral facial vein, and the dissection of the superior ophthalmic vein, without success. Cavernous sinus catheterization performed by puncture of the foramen ovale, guided by the points of HARTEL, followed by occlusion with microcoils. Regression symptomatic with gradual normalization of intraocular pressure, the exophthalmia and conjunctive hyperemia in 3 months.
Conclusion: Access to the cavernous sinus through the foramen ovale is exception and should be considered in cases of FAVD spontaneous isolated and unable to access by conventional treatment.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):109.
Purpose: Onyx is nowadays recognised as a good tool in the treatment of cranial Dural Arterio Venous Fistulae (DAVF). Most of the time it is possible to reach a complete occlusion of the fistula or to reduce it up to be operated on. We want to share our experience and discuss technical aspects of endovascular infusion of Onyx concerning our first twelve patients.
Materials and Methods: From October 2007 to January 2009 we used Onyx for cranial DAVF treatment in twelve patients: nine patients were male and three female; age ranging from 22 to 80 years old. Clinical presentation was: sudden onset of bruit after car accident in one patient, haemorrhagic presentation (one patient), seizures and hemiplegia (one), headache and intracranial hypertension (two), asymptomatic (one), spontaneous sudden onset of tinnitus in the other six patients. Cognard classification was used: type I was diagnosed in seven patients, type II in 4 patients, type III in one patient.
Results: Complete occlusion was achieved in ten patients, small remnant was left in one, one patient will need further treatment.
All patients cured had complete relief of symptoms. One patient will need additional treatment. One patient has recovered from haemorrhagic presentation. One patient is recovering from seizures and other neurological symptoms.
Conclusion: The preliminary results we achieved with Onyx are very promising since we reached complete occlusion with a single treatment in the majority of the cases. Endovascular injection in external carotid branches is safe and relatively easy to perform.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):109.
Purpose: Our purpose was to present our experience in embolizing dural arteriovenous fistulas (DAVFs) of lateral sinus using Onyx-18.
Materials and Methods: From 2008-1 to 2009-2 in our center, 7 patients (6 men and 1 woman) with a mean age of 48 years old (range 21-66) with intracranial DAVFs of lateral sinus were embolized only with Onyx-18. 5 patients presented with severe consciousness impairment or hemiplegia.
Results: All patients underwent endovascular treatment with Onyx-18. 4 in 5 patients with sinus thrombosis underwent antithrombotic therapy. Complete resolution of the DAVFs on immediate postoperation angiography was achieved in 5 patients. The remaining 2 patients had residual shunting and acquired complete elimination after the second emblization 2 months later. Venous drainage pattern of 5 patients with Cognard classification IIA+B and 1 patient with IIB was converted from reflux to normal drainage pathway. At the clinical follow up, 6 patients had excellent outcomes (modified Rankin score, 0 or 1) including 2 patients with impaired consciouness and 1 patients with severe unconsciousness and epilepsy improved remarkably at 2 months follow up (modified Rankin score, 3). There was no significant morbidity or mortality.
Conclusion: In our experience, the endovascular treatment of intracranial DAVFs in the region of lateral sinus with Onyx-18 alone is feasible, safe, and highly effective.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):109–110.
Purpose: To report the results of endovascular treatment of intracranial dural arterio-venous fistulae (DAVF) using onyx (ethylene vinyl alcohol) in series of 11 cases.
Materials and Methods: Retrospective study of a series of 11 patients (5 females, 6 males), mean age 54 (16-71) presenting DAVF treated by Onyx. According to Borden classification: 2 cases were type 1, 2 cases type 2 and 7 type 3. Type 1 were revealed by pulsatile tinnitus, type 2 by pulsatile tinnitus and brain hematoma, type 3 by brain hematoma in 4, subarachnoid hemorrhage in 2 and confusion in 1. Follow up with MR angiography or digitalized angiography range from 3 month to 10month (mean 8 month).
Results: In 8 cases Onyx was used as exclusive embolic agent with a complete occlusion in one procedure. In two cases, complete fistula occlusion was achieved with additional Glue injection during the same procedure in 1 case and with coil sigmoid sinus occlusion in a second procedure in another case. In one case Onyx was used as a second session of a type 3 fistula previously incompletely treated by Glue resulting in a small residual fistula filling. No clinical complication occurred. A symptomatic trapping of the microcatheter occurred in a case. No recanalization of the fistula was observed on follow up..
Conclusion: Endovascular treatment of Dural Arteriovenous fistulas using Onyx allowed in this short series a complete cure in 91% of the cases and a partial result in one.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):110.
Purpose: Dural arteriovenous fistulae (DAVF) of the anterior cranial fossa are rare lesions that may cause intracranial hemorrhage.
Previous reports mostly describe treatment by open surgery.
The purpose of this study was to describe our experience with this specific type of fistulae including endovascular treatment.
Materials and Methods: We retrospectively identified all patients with anterior cranial fossa DAVF diagnosed and treated in three separate institutions during the last 23 years. Clinical charts, imaging studies and procedural notes were evaluated.
Results: We found 24 patients with 24 DAVF in the anterior cranial fossa; 22 males and 2 females aged 3 to 77 years. Eleven patients were primarily treated by surgical disconnection and 2 by radiosurgery.
Eleven patients were treated endovascularly. Seven (63.6%) of these were cured. In the 4 cases of failed embolization final disconnection was achieved by surgery. Surgery was effective in disconnecting the fistula in 100% of cases. All endovascular procedures were transarterial injections of diluted glue (NBCA). There were no complications from the endovascular treatment. One surgically treated patient developed brain edema around the venous pouch and confusion post venous disconnection. No patient suffered from a hemorrhage during the follow up period.
Conclusion: Disconnection of anterior cranial fossa DAVF by transarterial catheterization through the ophthalmic artery and subsequent injection of NBCA is possible with a reasonable success rate and a low risk for complications.
In patients with good vascular access this could be the treatment of choice, to be followed by open surgery in case of failure.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):110.
Purpose: Dural arteriovenous fistula (DAVF) at the foramen magnum is rare.
We retrospectively analyzed the angiographic features, clinical manifestation and endovascular treatment of DAVF at the foramen magnum.
Materials and Methods: From 1992 to 2008, 10 patients (10 male, mean age, 53.5yrs) of DAVF at the foramen magnum were evaluated.
Results: Clinical manifestations were related with intracranial hemorrhage (SAH, IVH, vermian hemorrhage) (5/10, 50%), congestive myelopathy (6/10, 60%). Feeders of DAVF at the foramen magnum were ascending pharyngeal artery (8), occipital artery (5), vertebral artery (5), middle meningeal artery (2). Draining vein was caudal direction through anterior, posterior spinal vein (5/10, 50%), cranial direction through intracranial veins (4/10, 40%) and both direction (1/10, 10%).
The location of the DAVF was lateral rim (8/10, 80%, 6 in right side, 2 in let side) and dorsal rim (2/10, 20%) of the foramen magnum.
Endovascular treatment was attempted in all patients and 8 patients achieved complete occlusion (8/10, 80%), and 2 patients had small residual shunt (2/10, 20%). 3 patients showed complete recovery from their neurologic symptoms and 7 patients were markedly improved with residual neurologic deficits.
Conclusion: Clinical manifestation and image findings are related with intracranial hemorrhage or/and congestive myelopathy. For the patients with congestive myelopathy, venous drainage of DAVF was caudal direction through anterior and posterior spinal vein, and for intracranial hemorrhage, cranial direction through intracranial veins.
Neurologic symptoms can be improved by endovascular treatment.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):110–111.
Purpose: Transvenous embolization (TVE) has become a standard technique for the treatment of dural arteriovenous fistulas (DAVFs).
For effective TVE, it is important to place coils at the shunting venous pouch in initial stage of procedure. However, it is often difficult to navigate a microcatheter to the shunting venous pouch due to difficult anatomical relationship of approach routes with targeted pouches.
We demonstrate a simple technique of the turn-back embolization technique developed for successful TVE for such cases.
Materials and Methods: Three transverse-sigmoid sinus (TSS) DAVFs and 3 cavernous sinus (CS) DAVFs were treated by TVE using the turn-back embolization technique.
The TSSDAVFs showed ipsilateral sigmoid sinus occlusion, and. the AVFs involved the proximal parts of the transverse sinuses in two, and involved transverse sinus and torcular in one.
The CSDAVFs showed the shunting pouches localized at the posteromedial portion of the cavernous sinus in two and posteromedial and posterolateral portion in one.
Results: The microcatheters were advanced through the occluded sigmoid sinuses in TSSDAVF cases and inferior petrosal sinus in CSDAVF cases, which could be turned back within the involved sinuses into the target pouches in all cases.
Coils were placed at the shunting pouches in initial stage. Complete occlusion or marked regression of AVF with disappearance of cortical reflux was obtained in TSSDAVFs. All CSDAVFs disappeared, in which two could be treated by selective embolization alone. No complications were observed.
Conclusion: Turn-back embolization technique is a simple and useful technique for effective transvenous embolization of DAVFs.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):111.
Purpose: We present our experience with endovascular treatment of tentorial dural arteriovenous fistula (TDAVF).
Material and Methods: Clinical files of 8 patients with TDAVF in our institution between 1995-2008 were reviewed based on clinical manifestations, typing of TDAVFs, feeding arteries, venous draining pattern, endovascular approach, clinical outcome and follow-up results.
Results: There were seven male and one female with age ranging between 6-79 year (mean: 50 yr). Clinical manifestations were hemorrhage in six patients, headache in three and tinnitus in one patient. According to cognard classification there were five patients in type 4, one in type 5, one in type 2a+2b and one in type 1. Fistulas were marginal in four cases, medial and lateral types with two patients in each group. Middle meningeal artery and meningohypophyseal trunk were the most feeder artery and lateral or sigmoid sinus, galenic and cerebellar veins were the most drainage channels. Endovascular approach was transarterial embolization mostly via middle meningeal artery in 7 patients and transvenous embolization including transcavernous approach in 3 patients. Total embolization with complete elimination of fistula was achieved in 7 patients. One patient referred to surgery because the proximal part of the meningohypophyseal branch was unaccessible by microcatheter. Conversely one patient had history of incomplete treatment by neurosurgery. One patient died one week later due to secondary thrombose and venous occlusion.
Conclusion: Endovascular management makes treatment possible of TDAVFs with reasonable results. Neurosurgical approach is complementary treatment in some cases.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):112.
Thursday, July 2nd, 2009 • Room 524 • 13.30-14.50
interv neuroradiol. 2009 Jun 2;15(Suppl 1):112.
Purpose: We present our experience in the treatment and the follow-up of 25 aneurysms treated with a flow-diverting stent.
Materials and Methods: 25 aneurysms were treated in 24 patients using the Silk stent (Balt) in our institution from October 2007 to february 2009. The aneurysms were fusiform (n=22) or sacciform (n=3), and mostly unruptured (n=24). They were located at the internal carotid artery (n=10), middle cerebral artery (n=5), basilar artery (n=4), anterior cerebral artery (n=2), vertebral artery (n=2), PICA (n=1) and posterior cerebral artery (n=1). Premedication with plavix was achieved in all patients and intravenous aspirin and heparin were administered during the procedure.The treatment was achieved with Silk alone (n=22), Silk + coils (n=1), Silk + coils + Onyx (n=2). A follow-up examination from 3 to 12 months is available in all patients.
Results: Placement of the Silk could be achieved in all procedures. No hemorrhagic complication occured. Occlusion of a vessel covered by the stent occured in 3 cases, leading to ischemia in one. The one month morbidity and mortality are 4% and O%. Three asymptomatic in-stent stenoses were found on the 6 weeks follow-up angiography, two of them being rever-sible on the later controls.
Conclusion: The treatment of giant and fusiform aneurysms is an interesting therapeutic alternative using the Silk, allowing a possible endovascular treatment in fusiform aneurysms and a stable treatment in giant aneurysms.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):112–113.
Contributing centre representatives: E. Akgul, S. Bakke, A. Bonafe, P. Brouwer, R. Chapot, P. Fourie, G. Gal, T. Goddard, R. Juszkat, K. Kupcs , M. Leonardi, , L. Lemme-Plaghos, O. Levrier, S. Margus, L. Remonda, I. Saatci, W. Weber.
Purpose: A company sponsored registry was established to assemble performance data on a new stent device.
Methods: Over an 8 month period, data were collected centrally on all SILK (Balt) flow diverters deployed in 18 centres. These included: complications and outcomes (angiographic and clinical). 70 procedures (68 aneurysms) were performed; 55 (78%) using SILK alone and 15(22%) with adjuvant coils. Aneurysms were: 73% giant or large, 43% symptomatic and 6% recently ruptured. Follow up (FU) imaging was performed at 1-4 months.
Results: Poor deployment was reported in 14 (20%) procedures; causing 7 no sequelae, 1 abandonment, 2 repeat procedures and 4 arterial occlusions (1 transient). At 30 days, 7/68 patients were clinically worse: 3 new neurological deficits (4%), 2 transient symptoms after aneurysm thrombosis and 2 deaths due to pneumonia. Available FU imaging in 38; showed initially: 7 (18%) complete occlusions, 3 neck remnants and 28 (74%) residual sacs, and delayed: 19 (50%) complete occlusions, 5 neck remnants and 14 residuals. There were 7 arterial occlusions and 2 late in-stent stenoses.
Conclusion: The flow diverter effectively induced aneurysm thrombosis in half the aneurysms with delayed improvements in all but 4 aneurysms. Increasing experience reduced initial stent deployment difficulties.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):113.
Purpose: To analyze mid term efficacy of flow modification for aneurysm treatment.
Materials and Methods: Nineteen aneurysms (including 4 giants, 10 large and 5 small) in 18 patients were treated using the Pipeline™ Embolization Device (PED). The PED was used alone in 10, and additional loose coil packing was applied in 9 aneurysms. A single device was used in 7, and multiple (2-5) in 12 cases.
Results: Immediate complete occlusion was achieved in 4 cases. One patient treated with PED and coils, suffered a small visual field deficit. Subacute in-stent thrombosis occurred in one case that cleared completely, one patient had a transient contrast reaction, and one patient died due to rupture of a coexisting, untreated aneurysm. Angiographic follow up was obtained on 18 aneurysms and demonstrated complete aneurysm occlusion in 17, and small residual filling in 1 case. Asymptomatic, nonsignificant parent vessel narrowing was seen in one case. In those aneurysms that had coil packing, the mean volumetric packing density was 14,7%. There was no difference between occlusion of aneurysms treated with PED alone or with additional coil packing. A total of 27 side branches were covered by one or more devices. One immediate and two late ophthalmic artery occlusions occurred. All 4 giant aneurysms were collapsed on crossectional imaging at 6-18 months.
Conclusion: Flow modification is a highly effective method in producing stable occlusion of aneurysms, including those that are otherwise difficult to treat. Additional aneurysm packing with coils does not seem to be necessary. Due to the necessity of perioperative antiplatlet medication, coexisiting aneurysms may need to be secured.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):113.
Purpose: We present our experience with Cordis Enterprise stent-assisted coiling of cerebral aneurysms.
Methods: Records of patients treated with Enterprise stent-assisted coiling were analyzed prospectively, including clinical history, indication for stent use, aneurysm size, difficulties with stent placement or deployment, degree of aneurysm occlusion, procedure-related complications, and post treatment follow up results.
Results: A total of 45 stents have been deployed for treatment of cerebral aneurysms. Indications for stent use included wide aneurysm neck (n=39) and fusiform aneurysm (n=6). The Enterprise stent was deployed satisfactorily in all 45 cases. In 6 cases, the distal or proximal tines of the stent did not open completely; however in only one case did this require delayed coiling of aneurysm for fear of inadequate vessel apposition. One patient developed partial visual field deficit and retinal ischemia immediately after stent-assisted coiling, possibly related to the proximal tines of the stent situated near the ophthalmic artery origin. Thirty two aneurysms demonstrating complete angiographic occlusion and 13 aneurysms demonstrating small neck remnant. Six month follow-up angiographic follow up is available for 15 aneurysms. In all cases, the Enterprise stent demonstrated no in-stent stenosis and none of the aneurysms demonstrated recanalization requiring further treatment.
Conclusion: The Enterprise stent is a useful device for stent-assisted coiling of complex cerebral aneurysms. The stent is easily navigable and can be repositioned if needed allowing for accurate placement. The closed cell design allows for satisfactory coil packing density of the aneurysm.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):113–114.
Purpose: The flow diverter devices are gaining wide acceptance in the treatment of intracranial aneurysms. The aim of this study was to evaluate the safety and efficacy of Leo Plus stent implantation without coiling in aneurysms in the posterior circulation.
Methods: Between 2004 and 2008, 13 patients with aneurysms in the posterior circulation were treated with Leo Plus stent implantation without coiling. There were 5 females and 8 males, aged 17-66, mean: 48,8. There were 7 saccular basilar artery (BA) trunk aneurysms, 3 fusiform BA aneurysms, 2 fusiform vertebral artery (VA) aneurysms and one saccular VA aneurysm. Prior to the procedure, all patients were preloaded with 2 antiplatelet drugs: acetylsalicylic acid and clopidogrel.
Results: All procedures were performed without complications. Due to the decreased inflow into the aneurysm after stent implantation, further coiling was abandoned.
Follow-up angiography after 12 months were performed in 8 patients and revealed complete aneurysm thrombosis in 6 cases (2 saccular BA aneurysms, 2 fusiform BA aneurysms, 1 saccular VA aneurysm, 1 fusiform VA aneurysm) and incomplete/almost complete aneurysm thrombosis was observed in 1 saccular BA aneurysm. In one case, control angiography revealed enlargement of aneurysm and partial instent thrombosis (1 fusiform BA aneurysm). The remaining 5 aneurysms are to be followed-up.
Conclusions: In some cases of intracranial aneurysms of the posterior circulation (those localized in the vessel trunk and fusiform aneurysms) Leo Plus stent implantation without coiling may be an efficient final treatment.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):114.
Purpose: The incidence, significance and management of in-stent thrombosis and stenosis are undefined for newer devices. This exhibit describes early in-stent complications in 3 patients treated with Enterprise stents.
Materials and Methods: Chart review of patients treated with Enterprise stent determined technical success, aneurysm occlusion and complications. Barthel Index (BI), modified Rankin Score (mRS) and Glasgow Outcome Score (GOS) were noted.
Results: 15 patients received Enterprise stents for elective treatment of wide necked aneurysm over 18/12. All were pretreated with clopidogrel and aspirin, continued for >3/12 post-procedure. Two patients experienced delayed in-stent thrombosis 3 weeks and 2 months following stenting: one sustained symptomatic thromboembolism (BI 100, mRS 2, GOS 1), the other complete stent thrombosis, resulting in disabling motor and cognitive deficits (BI 50, mRS 4, GOS 3). Both patients were smokers, non-compliant with antiplatelet therapy and suffered mental illness. A third patient displayed asymptomatic in-stent stenosis at 6 months despite treatment compliance (BI 100, mRS 0, GOS 1). Platelet function testing in one patient demonstrated impaired ADP-induced aggregation >1 week following clopidogrel cessation. Rates of delayed in-stent thrombosis and stenosis in our series were 13.3% (2/15) and 6.7% (1/15) respectively.
Conclusion: Noncompliance, mental illness and smoking have been previously linked to increased rates of adverse vascular events The interventionalist should consider possible patient non-compliance when assessing suitability for stent-assisted coiling procedures.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):114–115.
Purpose: To evaluate the frequency of silent thromboembolic events associated with stent-assisted endovascular procedures of intracranial aneurysms using 3 Tesla (3T) diffusion-weighted (DW) MR imaging.
Materials and Methods: A consecutive and prospective series of eighteen patients with aneurysms treated with stent-assisted coil placement (16 cases) or stenting alone (2 cases) was included. Stents used were 12 Neuroform3, 2 Enterprise and 4 Silk.
In order to assess the result of the stent-assisted procedure, a 3T MR study with our standard stroke protocol (DW, T2*, Flair and 3D TOF MRA) is performed from 24 to 72 hours after the treatment in patients without clinical complications. Parameters of the DWI were: 5 mm slices thickness, a 280x210 mm FOV, 160x128 matrix, TE = 60.8 ms, TR = 7000 ms and b factor 1000 s/mm2. Two neuroradiologists independently reviewed MR studies. Diagnosis of procedure-related infarctions was based on visualization of hyperintense area on DWIs, confirmed on ADC maps. Small hyperintensity with normal ADC were also rated as ischemic lesions since diminution of ADC in small lesions can be missed on ADC maps because of partial volume effect.
Results: embolic lesions were noted on the DW images of 3 of 18 patients (17%). All lesions were located ipsilateral to the side of the aneurysm. Two patients had one lesions and one patients had three. No lesions were observed in 3 cases treated with balloon-assisted coil placement before the deployment of the stent.
Conclusion: The use of stents in treating aneu-rysms does not appear to increase the frequency of silent thromboembolic events even on a 3 T MR unit allowing higher resolution DW images.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):115.
Purpose: To report our preliminary experiences with the SILK (BALT Extrusion), a new, 'semi covered', self-expanding intracranial stent in the treatment of cerebral aneurysms.
Materials and Methods: Between March and December 2008, 16 intracranial aneurysms in 16 patients were treated with a recently developed stent that has so tight mesh that it can cause thrombosis of the aneurysm sac without placing any additional embolic agent in it. All but one of the aneurysms were large or giant, with extremely wide or partially/fully fusiform neck. All but one of the patients had progrediating mass effect. The patients were adequately premedicated with Clopidogrel and ASA. They were treated under general anaesthesia and full Heparinisation.
Results: 14 stents were delivered and deployed at the desired location. The immediate control angiograms after the detachment showed good alignment of the stents to the vessel walls and considerably reduced flow in the sacs. The patients were left on Clopidogrel in 2 and ASA in 3 months. 3 months follow up angiograms showed total or nearly total occlusion of the sac, except one case. The mass-effect has initially progrediated, and then successively diminished by the time.
Conclusion: This new device is a promising tool in the treatment of this group of cerebral aneurysms that caused major difficulties both for the surgeons and the interventional neuroradiologists. Further evaluation of the results concerning the mass-effect is necessary to define its role in the management of these, otherwise difficult-to-treat aneurysms.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):116.
Thursday, July 2nd, 2009 • Room 524 • 15.20-16.30
interv neuroradiol. 2009 Jun 2;15(Suppl 1):116.
Purpose: The aim of this study was to evaluate the outcome of endovascular coiling of ruptured anterior communicating artery (AcomA) aneurysms followed by intracerebral hematoma (ICH) evacuation with burr hole trephination and catheterization.
Materials and Methods: Twelve patients treated by coiling with subsequent ICH drainage with burr hole trephination and catheterization were recruited from 290 patients with ruptured AcomA aneurysm in our hospital between January 2001 and December 2007. The clinical and radiographic characteristics and outcomes of the 12 patients were retrospectively analyzed.
Results: All 12 patients were male aged from 29 to 62 years, and had ICHs with 16 mL to 45 mL volumes and nine (75%) of them had frontal ICHs on the opposite side of dominant A1. Admission Hunt-Hess (HH) grade was 4 in 8 patients, 3 in 2, and 5 in 2. The treatment outcomes in 8 of the 12 patients were good recovery or moderately disabled (Glasgow outcome scale; GOS 5 or 4), and functionally dependent (GOS 3 or 2) in other 4 patients at 6-month clinical follow-up. There was no rebleeding during the follow-up (mean 22.9 months, ranged from 7 to 68 months).
Conclusion: The result of our series suggests that coiling with subsequent evacuation of ICH with burr hole trephination and catheterization may be an alternative treatment option for ruptured AcomA aneurysm with ICH requiring evacuation in the opposite side of dominant A1.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):116–117.
Purpose: We report the ophthalmologic outcome following endovascular treatment (EVT) of 20 consecutive patients with third nerve palsy (TNP) caused by posterior communicating artery (PcomA) aneurysms.
Materials and Methods: The third nerve function before and after EVT was assessed and studied retrospectively. Predictive recovery factors known from literature including treatment timing, degree of pre-operative nerve deficit, and association with subarachnoid hemorrhage, coil type, cardiovascular risk factors and age were analyzed.
Results: Eight patients presented with complete nerve palsy (40%) and twelve with partial palsy (60%). Eleven patients had SAH. The mean aneurysm size was 7.14 mm; there were no partially thrombosed aneurysms. Recovery was complete in seven patients (35%), partial in twelve patients (60%), and one patient remained unchanged (5%). The mean duration of follow-up was 24.7 months. One patient with complete TNP recovered completely 5 months after EVT. One case of late complete nerve recovery was observed at 20 months. No cases of reoccurrences or worsening of the partial TNP was observed, including patients who developed recanalisation of the aneurysmal sac. Clinical presentation with SAH and early management were statistically significant factors that positively influenced nerve recovery (p=0.006549) and (p= 0.015718) respectively.
Conclusion: EVT of PcomA aneurysms is associated with high rates of third nerve function recovery. Complete recovery can be expected even after long periods and in cases of initial complete nerve palsy. The early treatment and the association with SAH seem to promote the nerve recovery.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):117.
Purpose: Ischemic event is a rare type of clinical symptomatic presentation of unruptured aneurysms. The purpose of this study is to investigate correlation between localisation of aneurysm and ischemic territory, to analyze aneurismal architecture and the risk of new ischemic or hemorrhagic accident and to work out a therapeutic strategy for this type of unruptured symptomatic aneurysm.
Patients and Method: A retrospective review of all patients with ischemic events distal to intracranial aneurysms reviewed over 2 years period.
Of 5 patients, all had anterior circulation aneu-rysm. Endovascurar treatment of the aneurysm was performed in 4 cases. One patient programmed for endovascular treatment died before intervention from massive hemorrhage.
Characteristics of aneurysm, coexisting vascular cranial or extra cranial pathology, endovascular ma-nagement and complications were analyzed.
Results: Endovascular treatment were well tolerated. One patient had transient neurological worsening. Mortality was 0%. None of the patients experienced any additional ischemic or hemorrhagic events during follow up period.
Conclusion: Thromboembolism originating from unruptured aneurismal sac might be an important indicator of aneurysms morphology evolution. The endovascular treatment of unruptured aneurysm responsible for ischemic episodes is effective for the prevention of subsequent ischemic or hemorrhagic complication. However the idea of creating homogenous management strategy for this heterogeneous group of patients remains always a therapeutic decision dilemma.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):117.
Purpose: Recently, the de-novo perianeurysmal edema after coil embolization of intracranial aneurysm has been reported. It is speculated that inflammatory reaction or pulsation of the aneurysm induce the edema, but exact mechanism is still unknown. In some reports, the effects of bioactive coils were related to the edema. Although only bare platinum coils were available in our institute, de-novo perianeurysmal high signal intensity lesions on MRI T2WI/FLAIR sequences were detected in several cases. In this study, we defined the incidence of the high signal intensity lesion, which had developed after the embolization with bare platinum coils. We also evaluated the pathophysiology of the lesion with utilizing MR spectoroscopy.
Materials and Methods: From January 2003 to May 2008, 331 intracranial unruptured aneurysms were embolized with bare platinum coils in our institute. Follow-up MRI/MRA scans were obtained in the next day, 3, 6 and 12 months. If de-novo perianeurysmal high signal intensity lesion was detected on T2WI/FLAIR sequences, MR spectoroscopy was performed.
Results: The perianeurysmal high signal intensity lesions were detected in nine aneurysms (2.7%). The average size of the aneurysms was 11.8 mm. The average duration from the embolization to the detection of the lesion was 62 days. Recanalization was detected in six aneurysms and re-embolization was undergone in three. On MRS, no specific abnormal peak such as lactate or lipids was detected. Overall, the results of MRS were compatible with vasogenic edema.
Conclusion: Even with bare platinum coils, de-novo perianeurysmal edema was observed to a certain degree after the coil embolization.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):117–118.
Purpose: To evaluate whether intravenous administration of Reo-ProR (abciximab) is effective and safe in dissolving thrombi formed during endovascular coiling of ruptured intracranial aneurysms.
Material and Methods: Patients coiled, with or without balloon remodelling, for ruptured intracranial aneurysms at our institution between January 1st 2006 and November 30th 2008 were included. Stented patients were excluded. Procedure data and immediate results from the embolizations were retrospectively reviewed together with chart data from the initial hospitalization and 3-8 months follow-up.
Results: 163 patients were identified. In nine patients (5.5 %) a thrombus was formed at the aneurysm neck or in the nearby branches despite full heparinization. Seven patients were treated with intravenous Reo-ProR. There was significant improvement in flow for all those treated patients 40 minutes after administration of the drug. No aneurysmal rebleed occurred. Three patients had limited groin hematomas. One patient had a transient left arm weakness but did not develop a manifest infarct. At 3-8 months follow-up, there were no persistent complications related to Reo-ProR administration.
Conclusion: Acute treatment of periprocedural thrombosis when coiling ruptured intracranial aneu-rysms may include GPIIb/IIIa inhibitors such as Reo-ProR (abciximab). In this limited series, intravenous administration of Reo-ProR for clot dissolving during embolization of ruptured aneurysms seems to be effective and safe with no long term drug-related complications.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):118.
Purpose: To evaluate the risk factors for thrombus formation during aneurysm coil embolization and also to evaluate outcome, and safety of IA thrombolysis.
Materials and Methods: We retrospectively reviewed aneurysm coil embolizations back to 2004. The etiology of thrombus formation, thrombolytic agent used, time for thrombus resolution, and presence of stroke was noted. Outcome at discharge was recorded with the Glasgow Outcome Scale (GCS) and the Modified Rankin Score (MRS).
Results: Thrombus formation was noted in 13/225 aneurysm coiling procedures. The mean aneurysm dimension was 9.3 mm, neck to dome ratio 0.6, and aspect ratio was 1.5. Intracranial stenting occurred in 2 cases. The etiology of thrombus formation was secondary to 'minimal' coil loop herniation in 3 cases, 'mild to moderate' coil loop herniation in 9 cases and moderate to severe coil loop herniation in one case. Mean time for thrombus resolution was 23 minutes (7-45 minutes). Nine patients were treated with IA tPA only (mean dose 10.0 mg), one with abciximab only (17 mg), and 3 had a combination of 10 mg IA tPA and 6 mg IA eptifibatide. Flow was restored to TIMI score of 3 in all but one. One SAH patient experienced aneurysmal rebleed during thrombolysis. 9/13 patients had no evidence of stroke. On discharge, the mean GOS was 4.4 (0-5), and the mean MRS was 0.6 (0-5). There was one death. All survivors had a MRS of 2 or less on discharge.
Conclusion: Wide neck aneurysms and coil loop herniation (even minimal) is a risk factor. IA thrombolysis restores flow with a low risk of hemorrhage. On discharge, all survivors had a good outcome.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):118–119.
Purpose: Evaluate efficacity of dual microcateterization in association with 3D coil and stent in the treatment of cerebral aneurisms with different anatomical aspects.
Casuistic and Method: 25 patients with 25 aneu-rysms were treated by dual microcateterization using 3D coil and auto expandable stent. Patients were divided into 03 groups: Group I - patients with lobated aneurysms ; Group II and Group III were differentiated according to sac/neck ratio. Group II included aneurysms with sac/neck ratio >2 and group III with aneurysms with sac/neck ratio<2.Endovascular technique consisted in dual microcatheterization of aneurismal sac. By one microcatheter we put the first 3D coil to frame the aneurysm to obtain a basket shape. It was not detached until Further coils used through the second microcatheter filled aneurismal sac. Multilobated lesions were treated with selective lobule embolizations. In cases which was not possible stabilize the coils into aneurismal sac we associated auto expandable stent to place the coils.
Results: Selective embolization of each aneurysmal lobe in group I allowed complete occlusion of aneurysms. Group II furthered satisfactory occlusion using dual microcatheterization and 3D coil. In group III was necessary associate self expandable stent to cover aneurismal neck. In this group, including smaller aneurysms with 2 to 3 mm diameter we did simultaneous aneurismal coiling by dual microcatheterization to avoid coils migration.
Conclusion: Dual microcatheterization in association with 3D coil and stent is an alternative technique to treat complex aneurysm. Aneurismal sac/ neck ratio was an important landmark to choose the optimal technique.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):119.
Objective: The purpose of this study is to evaluate the mid-term follow-up of patients with symptomatic vasospasm after SAH, treated with NeurofloTM.
Material and Methods: A non-randomized single center prospective study was carried out in 94 consecutive patients with symptomatic vasospasm who were treated with Neuroflo between June 2002 and June 2008. We analyzed the following variables: age, sex, Hunt & Hess grade, Fisher grade, size and location of the aneurysm, midterm follow up and procedural morbimortality. All cases were evaluated with NIHSS and modified Rankin Scale.
Results: All ruptured aneurysms were secured with coiling technique before Neuroflo treatment.
30 patients (32%) controlled with DSA showed distal vasospasm and 64 (68%) had combined (proximal/distal) vasospasm. All patients with distal vasospasm received nimodipine and were treated with super selective chemical angioplasty. Mean procedural time was 1.5 hour before Neuroflow treatment. No patient had an increase in NIHSS score during the procedure. 72% of the p had mRs < than 3 at mid therm follow up. There were 9 deaths within two weeks of the procedure, 6 (67%) due to hemispheric brain infarcts in the MCA territory and 3 (33%) due to infections. There were two deaths one month after the procedure due to pneumonia and septicemia respectively.
Conclusions: We demonstrated that partial aortic obstruction controlled with balloon for treatment of symptomatic vasospasm using Neuroflo was a safe and a simple method. Clinical improvement could be achieved in 72% of the survivor patients at mid-term follow-up. Further randomized studies are required to demonstrate the efficacy of this method.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):119.
Purpose: Anterior communicating artery is the most frequent aneurysms. Stenting is particularly difficult and of limited use for AcomA aneurysm. We report our experience on stent-assisted embolization for wide-necked AcomA aneurysms in 21 patients. Particular attention was given to the morphological characteristics and strategy of stent deployment.
Materials and Methods: Between January 2005 and February 2008, stent-assisted coiling was performed in 21 patients with wide-necked anterior communicating artery aneurysms. The information on patient demographics, aneurysm morphology, procedures, and clinical and angiographic outcomes were retrospectively reviewed.
Results: Successful deployment of the stent in the target artery was achieved in all patients. Nineteen Neuroform 2 or Neuroform 3 stents and two LEO stents were used. The distal segment of stent was positioned in ipsilateral A2 in 12 cases, in controlateral A2 across AcomA in 5 cases, and into aneurysm sac in 4 cases. Complete occlusion was achieved in 18 cases, near complete occlusion in 2 cases and partial occlusion in one case. Intraoperative rupture of aneurysm developed in one patient, which was secured by subsequent coiling. Angiographic follow-up in 14 cases for 8.7 months showed one recanalization.
Conclusion: Our preliminary results suggest that stent-assisted embolization for wide-necked AcomA aneurysm is technically feasible, effective and safety. The morphological analysis should be performed to guide the selection of the best modality of treatment. Further follow-up is needed for long-term efficacy of stenting.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):119–120.
Purpose: Small intracranial aneurysms are difficult to treat by coiling due to a high incidence of procedural rupture. Modifications to bare platinum coils have not enhanced our success rate or reduced complication rates. Successful experience with hydrocoil in larger aneurysms led us to employ it in small aneurysms and it is now our coil of choice even in very small (<4 mm) acutely ruptured aneurysms. In this retrospective series we review our experience with the device looking at safety and efficacy.
Materials and Methods: We reviewed all patients who had endovascular treatment of ruptured intracranial aneurysms from January 2005 to December 2008, using 1, 2 or 3 coils, at least one of which was hydrocoil. 91 patients were identified: 23 patients with 1 coil, 39 Patients with 2 and 29 patients with 3 coils. Post procedural and 6 month follow angiograms were compared to determine occlusion and re-canalization rates. Initial packing was analysed looking at percentage filling and the presence of hydrocoil at the neck. Complication rates including technical, thromboembolic and procedural rupture have been calculated.
Results: Technical complications without clinical sequel occurred in 2 cases. Procedural rupture occurred in 2 (2.2%) patients. Clinical outcomes and occlusion rates at 6 months will be presented.
Conclusion: In this case series we demonstrate that the use of hydrocoil to treat small ruptured aneurysms is as safe as the use of bare platinum coils. Analysis of occlusion rates and factors that predict complete occlusion will be discussed.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):120.
Purpose: To present our experience with a direct transcervical/brachial puncture approach in endovascular procedures, in which cranial access via the percutaneous transfemoral route was impossible due to tortuous angioarchitecture.
Methods: Since 1992 21 interventions have been performed in 19 patients via a direct puncture approach. In 12 patients a surgical cut down and cannulation of the targeted artery (carotid: n=8; vertebral: n=4) was done. A percutaneous puncture of either the carotid (n=5) or brachial artery (n=2) was executed in 7 patients. The intended interventions were as follows: 14 embolizations in aneurysms including one stent-assisted coiling and one internal carotid balloon occlusion, 4 glue embolizations for AVM's and one embolization of a carotid cavernous fistula.
Results: In 17 of 19 patients (89.5%) having a direct puncture introduction of the microcatheter endovascular surgery could be successfully executed. Neither any complications related to the technique in the percutaneous nor in the surgical cut down group were encountered. A favourable clinical outcome (mRS 0-2) could be reached in 15 of 19 patients (78.9%). The remaining 4 poor graded patients (21.1%) did not recover satisfyingly.
Conclusion: The transcervical or transbrachial direct puncture either accomplished percutaneously or by surgical cut down is an effective and safe access route in patients, in whom interventions cannot be done transfemorally. In cases, where extensive perioperative anticoagulation is mandatory, bleeding at the puncture site maybe controlled more effectively by closing the arterial hole with sutures under visual control than by percutaneous maneuvers alone.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):120.
Purpose: Patients with intracranial aneurysms are at risk for future development of new aneurysms and growth of additional untreated aneurysms. Because in previous long-term studies duration of follow-up varied widely, the time interval after which screening could be effective remains largely unknown. The purpose of this study was to assess the incidence of de novo aneurysm formation and the growth of additional untreated aneurysms in patients with coiled aneurysms followed up with MR angiography (MRA) after a fixed period of 5 years.
Materials and Methods: In 65 patients with coiled intracranial aneurysms, high-resolution 3T MRA was performed 5.1-0.2 years after coiling. MRA follow-up imaging was compared with MRA or CT angiography at the time of coiling. Additional aneurysms detected at MRA follow-up were classified as unchanged, grown, de novo, or incomparable with previous imaging.
Results: In 13 of 65 patients (20%), 24 additional aneurysms were found. Four aneurysms were incomparable with previous imaging and 2 of these were clipped. Of the remaining 20 additional aneurysms, 1 was de novo, 1 had grown slightly, and 18 were unchanged. The incidence of de novo aneurysm formation after 5 years was 1.54% (95% confidence interval, 0.01–9.0%). For additional aneurysms known at the time of initial coiling and for the 1 de novo aneurysm, no treatment was indicated.
Conclusions: MRA screening 5 years after coiling for detection of de novo aneurysms and growth of additional untreated aneurysms has a low yield in terms of finding aneurysms that need to be treated.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):121.
Friday, July 3rd, 2009 • Room 517 • 13.30-14.50
interv neuroradiol. 2009 Jun 2;15(Suppl 1):121.
Background: Brain AVMs are diagnosed mainly in young adults with the most serious complication being intracranial hemorrhage. The goal of this study was to determine morphological AVM characteristics associated with intracranial hemorrhage after initiation of embolization therapy.
Methods: Overall, 195 consecutive AVM patients underwent endovascular embolisation therapy using NBCA. Univariate and multivariate statistical models were used to test the effect of age, sex, AVM size, AVM brain localization (lobar, deep, infratentorial, borderzone), venous drainage pattern (superficial and/or deep), venous ectasia, and the presence of associated arterial aneurysms on intracranial hemorrhage after AVM embolisation.
Results: A total of 26 patients experienced AVM hemorrhage during the follow-up period. The risk of post-embolization hemorrhage was higher in the first week after intervention (HR 6.87; 95% CI 1.05-45.2; p = 0.045) as compared to subsequent follow-up beyond 7 days. Overall, hemorrhage after initiation of endovascular therapy was independently associated with increasing age (HR 1.03; 95% CI 1.00-1.06; p=0.024), AVM borderzone location (HR 6.09; 95% CI 1.82-20.4; p=0.003) and feeding artery aneurysms (HR 2.33; 95% CI 1.04-5.24; p=0.04). No effect was seen for sex, AVM size, anatomic location, venous drainage pattern, intranidal aneurysms, and initial hemorrhagic presentation.
Conclusion: In this uncontrolled observational study, AVM borderzone location, the presence of feeding artery aneurysms, and increasing age independently predicted AVM hemorrhage during post embolisation follow-up. The results may be tested in independent datasets using different embolic agents.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):121–122.
Purpose: Although cure of cerebral AVMs (Arteriovenous Malformations) is the ideal goal it is often only possible with smaller sized lesions. This is certainly true if surgery or radiotherapy is used as treatment strategies. Endovascular treatment however allows the possibility of partial treatment directed at specific areas of AVM architecture. With this in mind we retrospectively reviewed our cohort of AVMs to establish which morphological areas we had identified as targets and how the treatment of the AVM influenced the clinical picture.
Materials and Methods: Over a 36-month period 42 AVMs were treated. These patients were retrospectively analysed.
Results: In 22 of the patients who presented with a haemorrhage an intranidal aneurysm was identified as a target and treated in 9 patients. Other patients presented with headaches (2), neurological deficit (4) and seizures (16) with two patients having their AVM picked up co-incidentally. Targets identified included high flow fistulas (12), decreasing venous flow (17) and cure of the AVM (8).
Results of targeted treatment showed a lower rehaemorrhage rate than anticipated by the natural history. Patients cured did best and targeted embolisation improved seizures in 9 patients, neurological deficit in 4 patients and headache in 20 patients.
Conclusion: Until safer methods exist to cure large AVMs the use of targeted embolisation is acceptable as it protects patients against rehaemorrhage and translates into an improvement in their clinical picture.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):122.
Purpose: We present our experience with Onyx in brain AVM with emphasis on results and morbidity/mortality.
Material and Methods: We treated by embolization 133 patients with brain AVM, 29 of them with Onyx. 17 (59%) male, 12 female. 6 (21%) presented with hemorrhage,15 (57%) with epilepsy and 7 with headaches. 27 were supratentorial (9 frontal, 5 parietal, 8 temporal, 4 occipital), 1 deep thalamus, 1 vermian and 1 left cerebellar hemisphere lesion. The therapeutic protocol was curative embolization in 10 patients (34%), pre radiosurgery in 11 cases (38%) and presurgical in 8 (28%).
Results: Until now, complete exclusion of the AVM was obtained in 10 patients (100%) with curative embolization and in all 8 patients (100%) that did pre surgical embolization. Complete exclusion was also seen in 5 cases of preradiosurgery embolization group (45%). The remaining are waiting for control angiograms. Hemorrhagic complications occurred in 3 patients (10%).
Conclusions: Onyx embolization alone or associated to radiosurgery and surgery can be highly effective in the cure of brain AVM. Until now, in our series a complete AVM obliteration was obtained in 23 patients (79%) in a total of 29 – 10 curative embolization, 8 presurgical embolization, 5 preradiosurgery embolization. However, these results are obtained with high morbidity/mortality rates (10%) - the learning curve is slow and we need to understand better the mechanism/behaviour of this embolic material, identify vascular structures in Onyx cast; also, in giant AVM we should consider several embolization sessions instead a single session treatment.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):122.
Purpose: To evaluate the safety and the efficacy of Onyx in the endovascular treatment of brain arteriovenous malformations (AVMs).
Methods: BRAVO is a European, prospective, multicenter series conducted in 11 centers in 5 European countries. Patients were consecutively enrolled on an intention-to-treat basis. The final goal was to include 100 patients. Clinical and anatomical results were evaluated by an independent core lab.
Results: From May 2006 to December 2008, 122 patients were enrolled (Females: 38%, Males: 62%; mean age: 42 years). Clinical presentation was intracranial haemorrhage (31%), epilepsy (37%), progressive neurological deficit (14%), and other (18%). Anatomical characteristics of brain AVMs were analyzed in 108 cases. Associated aneurysm was present in 28% of cases, and direct fistulas in 36% of cases. AVMs were located in the cerebral hemispheres (95 cases), in the corpus callosum (3 cases), in the basal ganglia (2 cases) and in the cerebellum (8 cases). Modalities of treatment, adverse events, and clinical complications are analyzed.
The final degree of occlusion and the complementary treatments, when needed, are described.
Conclusion: The preliminary results of the first prospective, multicenter, European series dealing with the endovascular treatment of AVMs with Onyx are presented and will be analyzed in light of the literature.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):122–123.
Purpose: To show our experience with combined management of cerebral AVM's using embolization followed by surgical resection.
Material and Methods: In the last 3 years, 14 out 65 patients treated with embolization for a cerebral AVM, have been treated also with surgical resection. Hemorrhage was the presentation symptom in 9 patients and in 4 were seizures. Spetzler classification was 1 case with grade 5, 7 cases with grade 4, 3 cases with grade 3 and 3 cases with grade 2. Nidus size was larger than 5 cms in 10 cases and 8 of them were supratentorial (3 frontal, 1 temporal, 3 parietooccipital and 1 occipital). 11 cases were successfully embolized (1-3 sessions) in 3 cases Onyx was used. These 14 patients underwent surgical resection between 4 days and 3 weeks post embolization, 1 patient required a second surgery. All patient have been controlled with angiography.
Results: In all embolization cases the size of the AVM was reduced between a 40 and 60%. In 2 of the 4 occipital AVM a campimetric deficit was present after embolization. There was no hemorrhagic complication.
Surgery was completed in 13 cases. There was 2 CSF fistulas, 1 patient with a cerebellar AVM presented transient ataxia and 3 patients with an occipital AVM worsened the campimetric deficit.
Control angiography showed complete excision in all cases.
Conclusions: Embolization prior to surgery helps reduce the size of the AVM, reducing complications during surgical resection. No major complications were recorded in our series after embolization but it is important to have an appropriate selection of the AVM before embolization. Occipital AVM's have an important risk of visual field deficit after treatment.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):123.
Purpose: We report our experience in the treatment of brain AVMs using a meningeal approach
Materials and Methods: 85 patients were treated in our institution from january 2007 to june 2008 for a brain AVM. A meningeal supply was systematically checked and found in 18 patients, which led to systematic selective distal catheterization of the meningeal feeder and injection of Onyx.
Results: An intranidal injection of 2,8 ml to 8,5 ml of Onyx was possible in 17 patients. Onyx could not reach the nidus in one patient. A cure of the AVM could be achieved by the meningeal approach in 6 cases and led to significant reduction of volume of the nidus in the other patients, allowing further treatment by surgery or radiation therapy.
Conclusion: The meningeal approach allows an intranidal diffusion of Onyx in nearly all cases despite the small size of the feeding arteries. This complementary approach is specifically indicated in situations where there is no endovascular access through the anterior or posterior circulation.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):123.
Purpose: To analyze the outcome of 96 consecutive cases of temporal Brain AVM, managed in our center between 1988 and 2004 with a mean follow-up of 8,7 years per patient.
Patients and Methods: The patients are part of a prospective, single center registry of 722 patients managed for a Brain AVM. The presentation mode, the morphologic characteristics, the treatment strategy and outcomes for each patient with a temporal Brain AVM were recorded. Peritreatment permanent morbidity and mortality, the rate of spontaneous hemorrhage during the treatment and follow-up period as well as the final anatomical cure rate were also recorded.
Results: Hemorrhagic presentation was significantly associated to a medial location and a single draining vein of the temporal Brain AVM (p<0,05). Embolization as the only or as an adjunctive treatment modality was chosen in 79% of patients and had a peritreatment permanent morbidity of 6% and a peritreatment mortality of 4,9%. All cases of peritreatment death occurred during the first 3 embolization sessions. The mean treatment time was 3,8 years with a rate of spontaneous bleeding of 1,6% and a spontaneous death rate of 0,7% per patient years. No cases of spontaneous bleeding or death occurred in the group of patients who had finished their treatment during a mean follow-up time of 3,2 years.
Conclusion: In our study temporal Brain AVMs presented a relatively high rate of periembolization morbidity of 6% and a mortality of 4,9% compared to the rest of our treated Brain AVM population were the mortality rate is less than 2%.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):123–124.
Background and Purpose: We reviewed the experience in our endovascular treatment of patients with BAVFs.
Materials and Methods: From March 2006 to March 2008, a total of 9 consecutive patients with nontraumatic BAVFs were treated at Beijing Tiantan Hospital. Dural arteriovenous fistulas (AVFs) and Galen aneurysmal malformations were excluded from this study. We retrospectively reviewed the medical records, cerebral angiograms, and endovascular reports for each patient. Radiographic outcome was assessed by posttreatment angiography. Clinical outcome was assessed for every patient.
Results: There were 9 patients with a total of 11 BAVFs. The mean age at presentation was 17.8 years. The clinical presentations were intracranial hemorrhage in 4 patients, headaches in 2 patients, and seizure in 1 patient, with 2 patients diagnosed incidentally. All lesions were supratentorial, and a venous varix was found on angiographic examination. Seven patients were treated with coils, 1 with Onyx-34 (ev3, Irvine, Calif), and 1 with a combination of coils and glue. All 9 lesions were completely obliterated as demonstrated on follow-up angiographic examination. With a mean follow-up of 5.7 months (range, 3–12 months), all patients were neurologically excellent with no symptoms (modified Rankin Scale, 0).
Conclusions: BAVFs are more frequent in younger patients and frequently lead to intracranial hemorrhage. Staged endovascular coil embolization of BAVFs may be a good appropriate treatment technique.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):125.
Friday, July 3rd, 2009 • Room 517 • 13.30-14.50
interv neuroradiol. 2009 Jun 2;15(Suppl 1):125.
Purpose: To introduce the efficacy of endovascular treatments of ICA blood blister–like aneurysm (BBA).
Material and Methods: Ten patients with ICA BBAs who presented with subarachnoid hemorrhage, a total number of 15 endovascular treatments were performed, including seven endosaccular coil embolizations including conventional, stent-assisted and balloon-assisted procedures and 8 endovascular ICA trapping procedures. Three underwent after failure of surgical treatment (two cases of rebleeding after clip placement and one aneurysmal regrowth after wrapping). Repeated endovascular treatments were undertaken in four patients after failure of endosaccular coil embolization.
Results: All patients treated by endosaccular coil embolization showed aneurysmal regrowth. Neither stents nor balloons prevented the regrowth. ICA trapping was performed successfully without complication in 8 patients, and they showed excellent outcomes except 2 who already had severe neuralgic deficit before the trapping. The patients are doing good in clinical and radiological long-term follow-up.
Conclusion: Based on the authors' experiences, we suggest that ICA trapping including the lesion segment should be considered as an option for definitive treatment if a BOT reveals satisfactory results.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):125.
Purpose: Blood blister-like aneurysms, BBA, are uncommon and most fragile and hazardous to treat both surgically and endovascularily. We present our endovascular results and antiplatelet regime in eigth patients with BBA.
Methods: All patients presented with SAH, Fisher grad 2-4, four had ICH. H&H at presentation was 2-3/4 and 4/4 patients. Five BBA was not evident on the initial angiograms but evolved within the following days. Five BBA had typically supraclinoid and posterior location ICA. Angiographic and clinical outcome is presented
Results: Seven were treated acutely, one 2 months after ictus. Stent alone and stent + coils in one and seven patients respectively. Occlusion rate was; complete in three, almost complete in five patients.
Clopidogrel was given to all, four had a bolus of 150mg just before and 150mg after stent and coil placement, four had 150mg after the procedure only. Clopidogrel was pursued for three months. Six patients had angiographic follow-up before discharge. Complementary treatment before discharge was done due to early regrowth in two cases. Permanent artery occlusion was necessitated in one with a clinically silent but increasing ICH.
No early ischemia or late haemorrhage occurred. MRS was 0-2 in six patients, 3 in two. Two BBA showed late regrowth with an uneventful complementary treatment.
Conclusion: BBA are often overseen on initial CTA or DSA. Early follow-up angiography seems advisable. BBA can be treated with stents alone or in combination with coils. Although not recommended it seems justified and safe to use antiplatelets to a reduced dose and out of normal practice in individual cases if needed. Early revascularization may occur.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):126.
Purpose: Blood Blister'Like (BBL) Aneurysms of the supraclinoid Internal Carotid Artery (ICA) are rare and extremely dangerous lesions. According to pathological studies, these aneurysms seem to be dissecting in origin. The purpose of our study was to analyze the angiographic findings, treatment and outcome in these lesions.
Materials and Methods: 12 patients presenting with subarachnoid hemorrhage due to a BBL aneurysm were included in the study. There were 10 women and 2 men ranging in age from 20 to 67 years (mean age: 41.5 ys.). Six patients were treated by endovascular approach (coiling in 1 patient, ballon-assisted coiling in 2, stenting/coiling in 3), 4 patients were treated by surgery and in 2 patients the endovascular treatment was performed after failure of surgery. In 3 patients, repeated angiographies sho-wed changes of the aneurysm morphology .
Results: Good clinical and anatomic results were obtained in 4 patients (endovascular treatment in 2 and surgical in 2). Good clinical outcome was observed in 2 patients despite residual lesion. Mild/poor clinical outcome in 3 patients. In 2 patients, angiography after treatment (1 endovascular /1 surgical) showed progression of dissecting phenomena. Three patients died.
Conclusion: The optimum treatment of BBL aneurysms is still not known. Despite different therapeutic strategies, these lesions are often associated with high morbidity and mortality rates. Limitations of the endovascular treatment, including stenting and parent artery occlusion, are also due to acute hemorrhagic presentation. Better understanding and careful analysis of these lesions is needed in order to improve clinical and angiographic results.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):126.
Introduction: Blister-like aneurysms (BA) are unusual lesions. These pseudoaneurysms originate at non-branching sites of the internal carotid artery, present a fragile wall and a poorly defined neck. Given these characteristics, direct clipping is challenging and is reported to be associated with a significant rate of morbidity and mortality.
Method: Retrospective study of patients with ruptured BA that were treated surgically at Hôpital Notre Dame from January 2005 to March 2009. A detailed analysis of the surgical approach adapted for BA is presented as well as an assessment of post-operative angiographic results.
Results: Five patients, 2 male and 3 female, with a BA documented in the acute setting of a subarachnoid hemorrhage were treated during the study period. In two patients, the initial angiography was interpreted as normal. The surgical technique took into consideration the specific characteristics of BAs.with particular attention to initial dissection and clip placement. No intra-operative rupture occurred in this series. Blood flow in the supraclinoid carotid artery distal to the aneurysm clip was assessed intraoperatively in all patients. No infarction was documented on post-operative CTs. DSA performed within 24 hours following surgery confirmed the exclusion of the BA in all cases. All patients evolved favourably.
Conclusion: Recognition of the BA entity pre-operatively is important to adapt the surgical strategy in light of the characteristics of these aneurysms. Appropriate neurosurgical sequences is expected to reduce perioperative aneurysm rupture and enable satisfactory clipping of BA.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):126–127.
Purpose: Intracranial Dissecting Aneurysms are uncommon lesions in contrast to saccular aneurysms arising at arterial bifurcations. According to pathological studies, most of spontaneous aneurysms along arterial trunks are related to dissection. We evaluated the endovascular treatment options and results in a consecutive series of trunkal dissecting aneurysms.
Materials and Methods: Retrospective evaluation was carried out in 68 patients. Both proximal and distal locations were included. Aneurysms were separated into acute or chronic,, thrombosed and non-thrombosed. Treatment included parent artery occlusion (PAO), selective treatment using coils and/or stenting.
Results: Trunkal dissecting aneurysms presenting acutely are usually small and non thrombosed. Selective treatment using coils/stent is feasible in many cases. However the PAO is indicated in some instances. 'Chronic' trunkal aneurysms, usually large or giant and thrombosed, often present with mass effect. Minor bleedings arising from the arterial wall, and not from the vessel lumen, can also occur. Because the pathological process involves the arterial wall, selective treatment is usually ineffective with high rate of aneurysmal recanalization and the PAO remained the best treatment. In some cases stenting was performed with good results. In this series, the so-called "extension of thrombosis" after endovascular treatment was observed more frequently in trunkal aneurysms than in bifurcation aneurysms.
Conclusion: Careful evaluation and understanding of the underlying pathological mechanisms of these aneurysms is useful in order to plan the appropriate endovascular treatment.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):127.
Purpose: Analyze evolution of alternatives in endovascular treatment of intracranial dissecting aneurysms.
Material and Methods: Retrospective analysis of a series of 48 cases (26 female and 22 male) treated by endovascular approach between 2002 and 2008. Clinical presentation was SAH in 41 cases (85.4%), ischemia in 3 (6.2%), headaches in 2 (4.1%), seizures in 1 (2%) and incidental finding during treatment of another aneurysm in 1 (2%). Twenty cases (41.6%) were located in the anterior circuit and 28 (58.3%) in the posterior.
Results: At the beginning of the series conventional deconstructive treatment was performed by local and/or proximal parent vessel and aneurysm occlusion using detachable balloons in 4 cases (8.3%) and detachable coils in 36 (75%). More lately reconstructive treatment with coils was performed in 2 cases (4.1%), coils and stent in 5 cases (10.4%) and only stenting in 1 (2%) with good results. Intra procedural complications were observed in 8% of the cases: transitory ischemia in 2, SAH bleeding with no side effects in one and a major stroke with death due to cerebellar infarct in a vertebral artery dissection PICA occlusion. Only one SAH case which had been treated by proximal occlusion bled one month later and required retreatment; another case was retreated because of recurrence of the aneurysm detected in the follow up angiogram.
Conclusions: Due to new devices and skills the treatment of dissecting intracranial aneurysms has nowadays more endovascular therapeutic options other than proximal vessel occlusion and reconstructive stent assisted treatment should be accomplished when possible.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):127.
Objective: To present our initial experience, with a new self-expanding flow diverter device for dissecting aneurysms treatment.
Method: Twelve patients with twelve intracranial dissecting aneurysms with or without previous treatment were selected, located from the ICA extracranial bifurcation or the vertebro-basilar junction.
The PED consists of a self-expanding, flow diverter, chromo-cobalt alloy, and 48 wires broided design.
All patients were treated with double antiplatelet aggregation at least 72 hours before surgery and 12 months post-treatment.
Results: Twelve patients were enrolled with 12 dissecting aneurysms (63.6 % female, median age was 52 (7-79) years. Ten patients had vertebro-basilar aneurysms, 1 had ICA extracranial bifurcation and 1 had ICA intracranial bifurcation aneurysm.
The clinical presentation was: 4 mass effect, 3 SAH, 2 traumatic and 3 incidental. Five patients received only 1 stent each, 4 patients received 2 each, 1 patient received 3 and the last two, 4 stents each one. Aneurysms were coiled as a previous treatment in 2 cases; during the stenting procedure in 3 cases; and after the stenting procedure in the other 3 cases.
Conclusion: In our initial experience, this new flow diverter device (Pipeline™) represents a safe and effective technique in the treatment of intracranial dissecting aneurysms. It also showed an acceptable result in terms of artery reconstruction. Further studies are needed to evaluate the long term durability of stent-assisted aneurysm occlusion and tolerance to the stent.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):127–128.
Purpose: Dissecting aneurysms of the peripheral posterior inferior cerebellar artery (PICA) are rare and management is controversial.
The purpose of this study was to assess the clinical characteristics of dissecting peripheral PICA aneurysms and to evaluate the angiographic and clinical results of the patients who underwent endovascular treatment in a single center.
Materials and Methods: The six consecutive patients with 6 peripheral PICA aneurysms included in data base from November 1992 to December 2008 were retrospectively evaluated.
Pre and posttreatment CT or MR images, endovascular treatment, follow-up angiograms and clinical outcomes were analyzed.
Results: Five of the aneurysms presented with an acute intracranial hemorrhage (4 of SAH, 3 of intraventricular hemorrhage, 1 of intracerebellar hemorrhage).
Five aneurysms were treated by endovascular coiling by occlusion of dissecting aneurysm and proximal dissected PICA segment.
One patient underwent surgery. One aneurysm needed retreatment on follow-up. Procedure related complications were not occurred. There was no rebleeding in all patients. The clinical outcome was good in 5 patients.
Conclusions: Endovascular occlusion of dissected aneurysm and dissected proximal PICA segment was safe and the patients were tolerated.
However, strict follow-up was needed especially for the patients having clinical symptoms related with arterial dissection or showing recanalization of occluded PICA segment on follow up angiography.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):129.
Friday, July 3rd, 2009 • Room 520ab • 13.30-14.50
interv neuroradiol. 2009 Jun 2;15(Suppl 1):129.
Objectives: To evaluate the dural venous sinus disease as a cause of pseudotumor cerebri and the possibility of endovascular treatment depending on the causal factor.
Summary of cases:
Case 1: Patient Female, 66 years, chronic headaches, tinnitus the right, brain MRI of normal in 2004 and 2006. Sudden diplopic and paresis of the right VI°nerve in with normal MRI in 07/2008. Edema of right optical nerve. Cerebral angiography with stenosis within the right lateral and bilateral cortical venous hypertension. Procedure with general anesthesia. Sigmoid sinus catheterization to Guider 6F. Measurement of venous pressure in pre(16 mm H2O) and post(10 mm H2O) stenosis. Angioplasty with stent implantation Sinus ® 7x40 mm.
Case 2: Patient Male 67 years, TCE with occipital fracture in 2004. Developments with daily headache, tinnitus, bilateral edema of optical nerves and loss of visual acuity. Normal MRI. Angiography with arterial venous fistula of the left lateral dural sinus, nourished by branches of the carotid and vertebral. Treatment with endovascular occlusion of the lateral sinus using microcoils with regression of symptoms. In both cases there was clinical improvement in control of headache and tinnitus and the regression of the visual deficit.
Conclusion: Cerebral digital angiographic is necessary in the arsenal of diagnostic pseudotumor cerebri syndrome, to evaluate the dural venous drainage. The dural sinus stenosis or FAVD as causal factor of venous hypertension, may be more common than currently measured. The alternative is treatment with endovascular technical for these pathologies.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):129–130.
Purpose: To evaluate the use of self expanding nitinol stents for the treatment of dural sinus stenosis causing elevated venous pressures associated with peusdotumor cerebri.
Material and Methods: From Febuary 2005 to September 2008, eight patients were treated. All patients were female and symptomatic with debilitating headaches (HA), 3 had visual changes, one with blindness.
Seven had papiledema on fundoscopic exam. All had failed medical therapy, 3 had undergone optic fenestration procedures, and one had previous ventriculO pertioneal (VP) shunt.
Diagnostic angiography with direct dural sinus venography and pressure measurements was performed.
All patients dural sinus stenosis were treated by predilation (6 mm diameter) followed by self expanding nitionol stent placement (10 mm diameter).
Results: All patients had venous stenosis, (either bilateral transverse sinus n=7, superior saggital sinus n=1) by venography. Pressure gradients across the lesions measured 14 to 26 mm Hg (mean=20 mm).
Venous gradients after stent placement measured 1 to 6 mm Hg, (mean=3 mm Hg)
Headaches resolved in all patients. Visual disturbances resolved in all patients. Papilledema resolved in 7 of 7 patients, (single patient with superior saggital sinus stenosis did not have papilledema).
All patients were maintained on aspirin (forever) and plavix therapy (x 6 months). Follow up angiography at 6 months has demonstrated widely patent stents. Clinical follow up has been from 1 to 42 months with resolution of symptoms in all patients.
Conclusion: Treatment of Pseudotumor cerebri due to venous obstruction in selected patients maybe effectively treated by stent placement in the dural sinuses.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):130.
Purpose: Retrospective analysis of pre-treatment finding, endovascular procedures and clinical outcome in patients with pseudotumor cerebri who underwent balloon dilatation and stent deployment of stenotic segments of transverse / sigmoid sinus.
Materials and Methods: 8 patients (11-64 years old, 3 male, 5 female), presented with headache, papilledema, visual loss, visual obscurations, high CSF opening pressure. After transarterial angiography including extended phlebographic runs, an 8 F sheath was inserted into the internal jugular vein. Using pressure measurement in the superior sagittal sinus and direct biplane and rotational phlebography, the stenotic segment(s) was determined. Balloon angioplasty of this sinus was followed by the deployment of a self-expanding stent. All patients remained under dual antiaggregation and low molecular heparinization for at least 3 months. Follow-up DSA was performed 6 months after treatment.
Results: All patients improved significantly or became asymptomatic as related to the signs and symptoms of pseudotumor cerebri. There were neither procedural nor post-procedural complications. All deployed stents were widely patent at angiographic follow up.
Conclusion: Balloon angioplasty and stent deployment is safe and efficient for the treatment of stenoses of the intracranial sinuses. Adequately selected patients may expect improvement of both headache and visual obscuration from improved cerebral venous drainage.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):130.
Introduction: Idiopathic ICH are seen in young obese women presenting with Headaches, Visual obscuration and visual loss, Papilledema and CSF increased pressure at lumbar puncture. Treatment is based on weight loss, Acetazolamide and ventricular shunting. We discuss indication of sinus pressure manometry and sinus stenting in severe forms of IICH
Material and Method: We report a two years experience in 10 patients (9 female), mean age of 34 YO (21 to 57), patient weight was from 70 to 129 kg, CSF pressure measured by lumbar puncture was 25 to 90 cm H20. Repeated CSF lumbar subtractions were previously performed in 4 cases, ventricular shunting in 3. Duration of symptoms before sinus manometry ranged from 1 month to 14 years. Eight patients were stented because of a pressure gradient > 10 (from 11 to 35) and 2 patients were not stented (gradient< 10). Post-stent gradient significantly decreased in all cases. Five patients were rendered asymptomatic, two improved and one unchanged. In two patients symptoms recurred during follow up. One patient was retreated (on both sides). Two patients were not retreated despite recurrence of symptoms but because repeated manometry did not show a gradient > 10.
Conclusion: In patients with sinus stenosis and medical treatment failure, sinus stenting seems to be an interesting alternative to classic surgical approaches.
However, papilledema, CSF pressure measurements, MR and MR venography, sinus pressure gradient have to be precisely evaluated before deciding for sinus stenting. Larger studies are required to better determine sinus stenting results and indication.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):130–131.
Purpose: Evaluate the safety and assess the efficacy of intra-arterial super-selective transplantation of autologous stem cells in the treatment refractory temporal lobe epilepsy.
Materials and Methods: 20 patients with temporal lobe epilepsy resistant to medical therapy and neuroimaging compatible with hippocampal sclerosis. Punction of the iliac bone with marrow aspiration followed by separation of the stem cells fraction. In the same day a cerebral catheter angiography of the vertebral artery is performed followed by a superselective catheterization of the P1-P2 segment of the posterior cerebral artery related to the lesion. Clinical evaluation with the Engel scale, video- EEG and neuropsicological examination up to 6 months.
Results: The trial is on going and most of the patients are seizure free with no complications during the procedures.
Conclusion: The results so far have shown that the immediate morbidity was zero and the neurological evolution of the treated patients have been superior in comparison to patients with medical therapy.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):131.
JSNET has been working not only for the academic field but also the educational system of the specialist. There are lots of medical societies in Japan and their specialty systems are diverse and lack reliability. In this respect, JBMS is now adjusting and consolidating the various specialty systems. There are 66 medical societies who are the members of JBMS. The year 2007, JSNET was allowed to be a member of JBMS. Also the Ministry of Health, Labor and Welfare allows certain medical society to advertise their specialty title to the public. To require the allowance from the Ministry, medical society has to establish the specialty system according to the certain guideline. JSNET adjusted the specialty system and got approval of the Ministry in 2008.
The relationship of JBMS, Ministry advertising system and JSNET are presented.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):131.
Purpose: Variable phenotypic expression of central nervous arteriovenous malformation have already been described in HHT. The aim of this study is to review them regarding their genotype HHT1 versus HHT2.
Material and Methods: Nine patients refered for embolization of a cerebral or spinal arteriovenous malformation had a genetic analysis with a diagnosis of HHT1 or HHT2. We reviewed the angiographic and clinical charts of these patients. Cerebral arteriovenous fistula (CAVF), cerebral micro arteriovenous malformation (microCAVM) of nidus type, cerebral AVM larger than 1 cm, spinal arteriovenous fistula (SAVF) and cerebral dural arteriovenous shunt (CDAVS) were the different neurovascular phenotypes held up.
Results: Six patients were HHT1, from 13 months to 27 years at presentation: CAVF, CAVM, microCAVM, SAVF and CDAVS were identified.
Three patients were HHT2, from 8 months to 32 years at presentation: SAVF and CAVM were identified.
Conclusion: Nor HHT1 nor HHT2 is specifically dealing with one of the neurovascular lesion type. Moreover both HHT1 and HHT2 patients, children and adults, may present symptomatic CNS arteriovenous malformations which need to be treated by embolization.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):131–132.
Objective: To study the reasons, the clinical features and the prognosis of the subarachoid hemorrhage (SAH) patients who have negative DSA examination.
Methods: Clinical data were respectively compared and analyzed in 163 patients with spontaneous SAH, including 37 patients with negative DSA examinations and 126 patients with positive DSA examinations.
Results: Compared to patients with positive DSA examinations, patients with negative DSA examinations have many own features including older age (59.8 Vs 47.3 yrs), more hypertension (51.4% Vs 28.6%), more hyperlipidemia (45.9% Vs 23.0%), more diabetes (27.0% Vs 8.7%) and more smoking (24.3% Vs 15.9%), less bleeding amount (modified CT Fisher grade I: II: III: IV = 67.6% Vs 27.0% : 16.2% Vs 33.3% : 16.2% Vs 24.6% : 0% Vs 15.1%), more cases belong to perimesencephalic nonaneurysmal subarachnoid hemorrhage(PNSH) as showed by CT(24.3% Vs 0%), lower Hunt-Hess grades at admission (I : II : II : IV : V = 67.5% Vs 4.7% : 24.3% Vs 40.4% : 8.1% Vs 31.7% : 0% Vs 15.0% : 0 Vs 8.7%), shorter duration of unconsciousness (0.3 days Vs 3.6 days), less rebleeding (2.7% Vs 20.6%), less hydrocephalus (2.7% Vs 14.3%), less symptomatic cerebral vascular spasms (0 % Vs 34.1%), less deaths (0% Vs 8.7%), and less NIHSS scales at discharge (0.3 Vs 3.5).
Conclusions: Patients with negative DSA examination are usually old adults with atherosclerosis. SAH in those patients usually cause less bleeding volume, mild symptoms and good prognosis.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):132.
Purpose: Symptomatic cerebral vasospasm (SCVS) is still lack of reliable early warning methods and often diagnosed after clinical deterioration of neurological function, making prevention and treatment passive. Through retrospective case analysis, this study investigates the risk factors relevant to SCVS in order to provide useful information for clinical work.
Methods: Clinical data of 211 cases with SAH was reviewed in this study. Cases with worsened clinical symptoms presented within 3 weeks of onset and could not be explained by other reasons were diagnosed as SCVS.16 risk factors such as age, sex, history of hypertension, diabetes, modified Fisher CT grade, Hunt-Hess grade, intraventricular hemorrhage and so on were separately analyzed , including univariate analysis and logistic analysis.
Results: There were 81 SCVS cases with a mean age of 60.07 yrs, accounting for 38.4% (81/211), and 130 non-SCVS cases with a mean age of 53.50yrs, accounting for 61.6 % (130/211). Univariate analysis showed that age, history of hypertension, Hunt-Hess grade at admission, modified Fisher grade, aneurysm location, fever and intraventricular hemorrhage reached statistical significance, suggesting that they might be risk factors to SCVS.
However, logistic analysis showed that only age (OR=1.027, 95% CI=1.002-1.053, P<0.05) and modified Fisher grade (OR=2.985, 95% CI=2.048-4.352, P<0.05) entered the equation, suggesting both were independent risk factors. But history of hypertension, Hunt-Hess grade at admission, aneurysm location, fever and intraventricular hemorrhage didʼnt enter the equation.
Conclusions: Age and modified Fisher grade are independent risk factors for SCVS.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):133–134.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):135.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):135.
The Problem: The prevalence of unruptured brain arteriovenous malformations (BAVMs) is now known to be almost twice that of BAVMs discovered because of hemorrhage. The management issue for those unruptured requires reassessment of the natural history, the frequency and severity of any hemorrhage, and the clinical outcomes from intervention. To date, increasing age, deep brain location, associated aneurysms, and exclusive deep venous drainage are associated with increased hemorrhage risk, borderzone location less, isolated small lesions the least. Compared with traditional estimates, current studies suggest the frequency and severity of hemorrhage are lower, and complications of intervention higher. BAVMs being embedded in brain tissue, interventions intended to eradicate the lesion carry understandable risks, even in the most experienced hands, risks which should justify the undertaking.
The Clinical Trial Plan: NIH is sponsoring A Randomized trial of Unruptured Brain Arteriovenous malformations (ARUBA), a controlled clinical trial comparing any form(s) of intervention (e.g., endovascular embolization, radiosurgery, microneurosurgery) vs. medical management for symptoms (e.g., seizure, headache). Eligible patients have an unbled BAVM deemed suitable for attempted eradication; those not considered safe for the attempt are ineligible The endpoint is a composite event of death from any cause or stroke (hemorrhage or infarction confirmed by imaging). Secondary outcomes include risk of death or clinical impairment (Rankin Score ≥ 2) at a minimum of 5 years post-randomization (possibly up to 10 years). Clinical outcome status will be measured by the Rankin Scale, NIHSS, and EuroQual (EQ-5D).
The Progress: The trial has been enrolling since late spring 2007, slowly accumulating the current 64 centers with an additional 29 in varying stages of completion of paperwork. To date 597 patients have been screened, 226 found eligible and 69 (30%) randomized from 64 centers on 3 continents, 35 in Europe alone. The investigators are blinded to the outcome for the trial overall. An NIH-appointed Data and Safety Monitoring Board reviews the progress semi-annually.
The Outcome: Should traditional risk estimates be demonstrated, the net benefit of intervention should be demonstrable well within a 5-year timeframe and justify an intervention plan for unruptured BAVMs. Should current risk estimates apply, conservative management may have a lower incidence of hemorrhage and morbidity, and require far longer follow-up to determine if the intervention compares favorably with the natural history.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):136.
Rationale: The goal of this investigator-initiated trial is to compare the long-term outcomes of patients who receive medical management for symptoms (e.g., headache, seizures) associated with an unruptured AVM to those who receive medical management and invasive therapy to eradicate the brain AVM.
Design: ARUBA is an international, multicenter, randomized, controlled, open, prospective clinical trial.
Sample size: 800 patients (1:1 random assignment).
Population studied: Patients aged ≥18 years, diagnosed with an unruptured brain AVM considered treatable by the local investigators.
Outcome measures: The primary outcome measure is the composite endpoint of death from any cause or stroke (clinically symptomatic hemorrhage or infarction confirmed by imaging). The secondary outcome measure is long-term clinical status by Rankin Scale, NIHSS, SF-36, and EuroQol.
Interventions: Patients will be randomly assigned to invasive therapy (endovascular, surgical, and/or radiation therapy) versus medical management alone. The study protocol will not modify any routine treatment strategies in either arm. Patients will be followed for 10 years from randomization.
Trial status: Patient enrollment has started in 2007 with a current recruitment rate of 1-2 patients/week. Participating sites currently include multidisciplinary treatment centers in the US, Australia, Austria, Brazil, Canada, Finland, France, Germany, Italy, Netherlands, Spain, Switzerland, and the UK.
Funding: NIH/NINDS.
Registered: http://clinicaltrials.gov/ct2/show/NCT0038918
interv neuroradiol. 2009 Jun 2;15(Suppl 1):136.
Purpose: To report patient and aneurysm characteristics, discharge and 6-month clinical outcomes in patients with ruptured and unruptured cerebral aneurysms enrolled in the trial.
Methods: The Cerecyte Coil Trial is a prospective randomised clinical trial of 500 patients undergoing endovascular coiling of cerebral aneurysms. The primary outcome is to determine whether the use of Cerecyte polymer loaded coils improves the angiographic outcome at 6-months as assessed by the core lab. The secondary outcome is to compare safety in the two groups and report the current clinical outcomes at discharge and 6-months of patients undergoing endovascular coiling.
Results: The trial completed recruitment in January 2009 with 500 patients from 23 centres in six countries and enrolled 236 patients with ruptured and 264 patients with unruptured aneurysms.
Clinical data available to date: in patients with ruptured aneurysms, two died before and one after discharge, 194 of 202 had a good WFNS score at discharge and 154 of 157 alive at 6-months had a modified Rankin score (mRS) of 0-2. In those with unruptured aneu-rysms, there were no deaths in hospital and 198 of 202 were discharged home. At 6-months one patient had died, 135 of 136 patients were mRS 0-2 and one was mRS 3. Complete discharge data and available 6-month clinical outcome data will be analysed prior to the meeting.
Conclusion: The safety profile of modern coil techniques appear good and the trial will provide reliable clinical outcome data for patients with ruptured and unruptured aneurysms. It remains to be seen if Cerecyte polymer loaded coils improve angiographic outcomes.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):136–137.
Purpose: To present the final angiographic results from the randomized control trial of hydrocoil versus bare platinum in endovascular aneurysm treatment [HELPS] .
Materials and Methods: HELPS is a multicenter international randomized controlled trial with concealed allocation. Primary outcome is angiographic outcome in hydrocoil vs bare platinum arms. Groups are matched using appropriate minimization criteria. Angiographic analysis is performed by an independent core lab blinded to the patient allocation (CHUM, Montreal). Secondary outcomes include independently assessed clinical outcome [Modified Rankin Score], coil lengths used, packing density achieved, rebleed and retreatment rates. Analysis of results is on an intention to treat basis. The funders (Microvention Inc. and UK NHS) and trial sponsor (Lothian Health on behalf of UK NHS) have no control over the running of the trial and no access to the trial data. HELPS is currently in the final stages of angiographic follow-up analysis.
Results: Data from HELPS on periprocedural outcomes have previously been published as well as congress presentations on some of the secondary outcome measures. The primary outcome angiographic data are nearing completion by core lab and these will be collated, analysed and presented.
Conclusion: HELPS is the first randomized control trial examining coated- coil technology for cerebral aneurysm treatment. The primary outcome results will be presented for the first time to the profession at WFITN.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):137.
Purpose: Proliferation of new endovascular devices and therapeutic strategies calls for a prudent and rational evaluation of clinical benefit. Evaluation must be done in an effective manner and in collaboration with industry. Such a research initiative requires organizational and methodological support to survive and thrive in a competitive environment. We propose the formation of an international consortium committed to the pursuit of effective neurovascular therapies through design and execution of basic science, device development and clinical trials.
Design:The Consortium is owned and operated by its members who are international leaders in neurointerventional research and practice. The Consortium brings competency, knowledge, and expertise to industry as well as to its membership across a spectrum of research initiatives such as: expedited review of clinical trials, protocol development, surveys and systematic reviews; laboratory expertise and support for research design and grant applications. Once objectives and protocols are approved, the Consortium provides a stable network of centers capable of timely realization of clinical trials or preclinical investigations in an optimal environment. The Consortium is a non-profit organization. The potential revenue generated from client sponsored financial agreements will be re-directed to the academic and research objectives of the organization. The Consortium wishes to work in concert with industry, to support emerging trends in therapeutic development.
Conclusion: The Consortium is a realistic endeavor optimally structured to promote excellence through scientific appraisal of treatments, and to accelerate technical progress.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):137–138.
Martin M Brown on behalf of the ICSS investigators.
Background: Stenting is an alternative to endarterectomy for the treatment of carotid stenosis but equivalent safety and efficacy of stenting versus endarterectomy has not been shown. We therefore started a large multicentre randomised trial to compare the two procedures in 2001.
Methods: ICSS is an international trial in which patients with recently symptomatic carotid artery stenosis suitable for either procedure were randomised in equal proportions between carotid stenting and endarterectomy. Strict criteria were applied to ensure that experienced surgeons and interventionalists carried out the procedures at fully enrolled centres.
Less experienced investigators could join at probationary centres but were required to treat patients under the supervision of an experienced proctor. Independent neurologists carried out follow up 30 days after treatment, at then at 6 months, 12 months and yearly after randomisation. Outcome events were adjudicated independently. An independent data monitoring committee oversaw trial safety. Analysis was planned by intention-to-treat and per-protocol.
Results: Recruitment of the planned sample size was completed from 50 centres in Europe, Australia, Canada and New Zealand in 2008. 1713 patients (1512 from fully enrolled centres) were randomised. Safety data will be presented including the rates of any stroke, myocardial infarction or death within 30 days of treatment and treatment-related cranial nerve palsy or haematoma. Proportions of outcome events within 30 days of treatment will be compared between randomised treatment groups. Estimated absolute risk differences and risk ratios will be reported. Relative risks will be compared for predefined subgroups.
Conclusions: The results will play a major role in determining the role of stenting versus endarterectomy for symptomatic carotid stenosis. However, the aim of treatment is to prevent long-term stroke and the analysis of the primary outcome measure of long term survival free of disabling stroke will require further follow up.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):138.
Purpose: Even though vertebroplasty is widely applied for treatment of painful, osteoporotic fractures, there are no published placebo-controlled, randomized, blinded trials. The INvestigational Vertebroplasty Efficacy and Safety Trial (INVEST) compared patients undergoing standard vertebroplasty with patients undergoing a simulated vertebroplasty to determine the efficacy of vertebroplasty in achieving improved function and pain relief.
Materials and Methods: We randomly assigned patients presenting with painful, osteoporotic fractures 1:1 to either a normal vertebroplasty procedure or to a "control intervention." The control intervention included injection of local anesthetic as in vertebroplasty but without placement of the bone biopsy needle or PMMA. Patients and clinical coordinators conducting outcomes interviews remained blinded to procedure type. The primary outcomes included changes in the Roland Morris Disability Scale (RMDS) and a 10-point pain visual analogue scale (VAS) at one month. Secondary outcome measures included the modified Deyo-Patrick Pain Frequency and Bothersomeness Scale, the SF-36, the Strength of Function and Activities of Daily Living, the EQ-5D, and the Osteoporosis Assessment Questionnaire body image domain. We also measured outcomes at days 1, 2, and 3 and months 3, 6, and 12. We obtained radiographs at 12 months. We allowed crossover after the one month time point. Our study will have greater than 80% power to detect a 3-point difference on the RMDS and greater than 80% power to detect a 1.5 point difference on the pain VAS.
Results: The trial completed enrollment in August, 2008 with 131 patients enrolled.
Conclusion: Outcomes of vertebroplasty and control groups at 3 months will be presented.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):138.
On behalf of the ISAT Collaborators.
Purpose: To report the long-term the risk of death, disability and re-bleeding in patients randomised to clipping or endovascular coiling following rupture of an intracranial aneurysm.
Methods: 2143 patients were enrolled in 43 neurosurgical centres. The one-year clinical outcomes have been previously reported and should significant benefit in patients allocated to coiling. All UK and some non-UK centres continued long-term follow up of enrolled patients, representing 2004 of the original cohort. Annual follow-up has performed for a minimum of six and a maximum of 14 years (mean nine years). All deaths and re-bleeding events are recorded.
Results: A total of 24 re-bleeds have occurred after one year. Of these 13 were from the treated aneurysm, 10 in the coiling group and three in the clipping group (p = 0.06 log rank). There were 8447 and 8177 person-years of follow-up in coiling and clipping groups respectively. Four re-bleeds occurred from a pre-existing aneurysm and six from new aneurysms. At 5 years there was a significant mortality difference 10.7% of the endovascular and 13.8% of the neurosurgical patients had died respectively (p=0.03 log rank) but the proportion of independent survivors was the same.
Conclusion: There is a small increased risk of recurrent bleeding from a coiled aneurysm in the first 5 years compared with a clipped aneurysm but the risks are small, and do not outweigh the earlier improved clinical outcome. The risk of death is significantly lower in the coiled group at five-years RR 0.77 (0.61 - 0.98. P = 0.03).
interv neuroradiol. 2009 Jun 2;15(Suppl 1):139.
Purpose: The Matrix and Platinum Science (MAPS™) Trial, a prospective, randomized, multicenter trial will:
• Investigate outcomes of subjects with ruptured and unruptured aneurysms suitable for treatment with either Matrix2® Coils or GDC® Coils [Boston Scientific Neurovascular, Fremont, CA].
• Establish Target Aneurysm Recurrence (TAR) rates for Matrix2® and GDC® coils (defined as clinically relevant recurrence resulting in target aneurysm reintervention, rupture/re-rupture, and/or neurologic death)
• Correlate defined angiographic endpoints with TAR rates and assess their predictive value
Materials and Methods:
• 630 subjects (315 each treatment arm) undergo endovascular embolization to ensure 500 subjects with complete 12-month follow-up. Data collected at procedure, 48 hours, 30 ±7 days, 12 ±3 months and 2, 3, 4 and 5 years post procedure.
• Non-inferiority test for TAR rates between two groups at 1-sided significance level (α) of 0.05
• Anticipated 20% TAR rate in the GDC® arm in non-inferiority testing.
• Superiority test for Matrix2® over GDC® in reducing TAR performed using 2-sided α=0.05 upon demonstration of non-inferiority of the two treatments.
Results: 428 patients enrolled from 43 sites: 27 US sites with 260 subjects; 16 international sites with 168 subjects. Sites in United States, Australia, Canada, China, France, Germany, Mexico, Norway, Spain, Turkey and the United Kingdom.
Conclusions:
• Currently recruiting participants
• Study Start date: March 2007
• Estimated Patient Enrollment Completion: December 2009
• Estimated Study Completion date: March 2015
Disclosure: Boston Scientific Corporation is the trial sponsor.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):139.
Background and Purpose: To present the protocol of a randomised trial comparing mechanical revascularisation of occluded intracranial vessels in acute stroke with best medical therapy.
Methods: Trial objectives are to determine if mechanical re-vascularisation reduces the risk of death or dependence at 3 months based on mRs of 0-2 vs 3-5 or death (primary). Secondary objectives include 1) Immediate recanalisation rates; 2) Early neurological improvement (NIHSS score at 24h) 3) Angiographic patency at 7 days (Core lab assessed). 4) Infarct volume in the 2 groups at follow up 7 days and/or 3 months in patients with prior perfusion diffusion imaging. 5) Days spent at home between stroke and final follow-up. 6) Rankin Shift analysis using Cochrane-Mantel-Haenszl approach.
Main Inclusion Criteria are: 1) Patients with acute ischaemic stroke (no haemorrhage on plain CT); 2) NIH stroke score of ≥11; 3) Occlusion of the main middle cerebral trunk, MCA bifurcation or intracranial internal carotid artery demonstrated on CTA or MRA; 4) Interventional treatment can be commenced within 6 hours of onset of the stroke; 5) Consent of patient or assent of relatives as determined by UK MREC or IRB; 6) Previously independent prior to the stroke; 7) Predicted large Infarct volume; 8) CT (or MRI) perfusion is required in enrolled patients, but the findings will not be used for eligibility.
Interventions are either 1. Mechanical thrombus removal or vessel revascularisation by endovascular means with or without the use of intra-arterial rTPA OR 2. Best medical therapy including i.v. thrombolysis when indicated and routine stroke care Devices used in the Trial: The operator determines the choice of device. Devices with regulatory approval (CE mark, FDA approval) for use in stroke and approved by the Trail steering committee may be used in the trial.
Conclusion: It is essential and timely to conduct a high quality randomised trial using the latest imaging CT and/ or MRI angiogram and perfusion scanning and the available devices to determine if patients with acute ischaemic stroke benefit from intra-arterial intervention.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):139–140.
Purpose: Angiographic recurrence after endovascular coiling is a significant problem in two circumstances that we label "aneurysms with a high Propensity for Recurrence after Endovascular Treatment" (PRET): 1) patients with large aneurysms; 2) patients in whom platinum coil embolization has already been followed by an angiographic recurrence. New coils have been designed to preserve the safety of embolization while improving on long-term efficacy but evidence for their benefit is lacking. The PRET trial therefore aims at comparing hydrogel to platinum coils in patients with large aneurysms (≥10mm; PRET-1) or in patients with a major recurrence after previous coiling (PRET-2).
Design: PRET is a multi-centre randomized, controlled trial. A total of 500 participants will be enrolled. PRET is designed as 2 parallel trials; thus PRET-1 (250) and PRET-2 (250) cases will be randomized separately to platinum or hydrogel coils. The duration of the study is five years, three years for patient recruitment plus 18 months of follow-up.
Outcome measures and analysis: The primary endpoint is recurrence rate; the primary hypothesis is that hydrogel coils decrease the recurrence rate from 50% to 30% (range: 40-50% to 21-30%) at 18 months as compared to platinum coils. Recurrence rates will be compared with a z-test for independent proportions at 6 months and 18 months. Secondary endpoints include procedural complications, clinical outcome, safety of hydrogel coiling and overall morbidity and mortality.
Conclusion: The PRET trial will determine the relative safety and efficacy of hydrogel vs platinum coils in two groups of patients who stand to benefit the most from the newer coils.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):140.
Background: Atherosclerotic stenosis of the major intracranial arteries is an important cause of stroke worldwide. The Warfarin Aspirin Symptomatic Intracranial Disease (WASID) trial showed that patients with severe stenosis (70% - 99%) and TIA or stroke within 30 days had a 22.9% rate of ischemic stroke in the territory of the symptomatic artery at 1 yr (5% CI 15.4% - 30.4%). Stenting has emerged as a promising treatment but the efficacy of this procedure remains to be proven.
Design, Objective, and Primary Endpoints: SAM- MPRIS is an NIH funded, randomized clinical trial that will determine whether intracranial stenting (using the Wingspan stent) and aggressive medical therapy is superior to aggressive medical therapy alone for preventing the primary endpoint (any stroke or death within 30 days after enrollment, any stroke or death within 30 days after any revascularization procedure done during follow-up, or stroke in the territory of the symptomatic intracranial artery beyond 30 days after enrollment) in patients with 70-99% symptomatic stenosis of a major intracranial artery (MCA, carotid, vertebral, basilar). The anticipated sample size is 764 subjects. Aggressive medical therapy in all patients consists of aspirin 325 mg per day for entire follow-up, clopidogrel 75mg per day for 90 days after enrollment, and intensive risk factor management primarily targeting systolic blood pressure < 140 mm Hg (< 130 if diabetic) and LDL < 70 mg/dl.
Trial Status: Sixty sites in the USA have been selected to participate. Enrollment began at 6 sites in November 2008 and as of March 31, 2009, forty four patients have been enrolled at 35 active sites.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):140–141.
Purpose: Reperfusion in ischemic stroke can be pursued by either systemic intravenous thrombolysis (IVT) or intra-arterial thrombolysis (IAT). However, IVT with Alteplase within 3 h of symptom onset in selected patients, remains the only approved medication for the treatment of acute stroke. No randomized controlled trials (RCT) have so far been published to compare the two modalities. To explore this, we started the SYNTHESIS pilot trial.
Material and Methods: SYNTHESIS is a multicenter, open-label, randomized controlled trial, with blinded follow-up, whose purpose is to determine whether IAT compared to IVT, in patients randomized within 3 h of ischemic stroke, increases the proportion of independent survival, as expressed by a modified Rankin Scale (mRS) score of 1 or less, at 90 days.
Eligible patients were randomized to receive either 0.9 mg/kg (max 90 mg) IV Alteplase (control arm) or up to 0.9 mg/kg IA Alteplase (max 90 mg) over 60 minutes into the thrombus, if necessary associated with clot mechanical disruption and/or retrieval devices.
Results: This pilot phase (4 years with 4 centres working) was terminated in 2008. Fifty-four patients, out of 161 eligible, were randomized. Almost twice as many patients on IAT as those on IVT survived without residual disability (48% vs. 28%; P=0.097) .
Conclusion: Patients on IAT displayed a clear trend toward a long-term more favorable clinical outcome compared to those who underwent IVT. The SYNTHESIS EXPANSION Trial was therefore started in 2008 to confirm these findings and is actually ongoing.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):141.
Purpose: To determine whether the best endovascular treatment (experimental arm) compared to iv Alteplase in accordance with the current European labelling (control arm), is effective and safe in patients with acute ischemic stroke.
Materials and Methods: Non-profit, ongoing, multicenter randomized controlled trial, open-label, with blinded follow-up aiming to determine whether endovascular treatment (i.e. intra-arterial thrombolysis with alteplase alone, associated to, or substituted by mechanical recanalization maneuvers), compared with iv Alteplase, increases the proportion of independent survivors at 3 months. The study is pragmatically based on the "uncertainty principle" between endovascular treatment and iv thrombolysis for patients eligible to iv Alteplase. There is not any pre-specified clinical (such as NIHSS cut-off) or instrumental criteria (such as the demonstration of arterial occlusion with non invasive procedures) to further select a patient already eligible for iv Alteplase, although investigators are left free to use them. Eligibility applies to patients with symptomatic, acute ischemic stroke, seen within 4.5 h of onset, being able to initiate iv Alteplase immediately and endovascular treatment as soon as possible and, in any case, not later that 6 h of stroke onset. Enrollment will be completed with 350 randomized patients.
Results: 18 centers are participating in Italy and 20% of the sample has been enrolled. Recruitment is proceeding at a rate of 8-10 patients per month.
Conclusion: A clinical and practical approach to assess the efficacy of endovascular treatment is feasible.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):141.
Purpose: The management of patients with unruptured aneurysms is controversial. A randomized trial may be the only way to demonstrate the potential benefits of endovascular management over conservative management.
Design: TEAM is an international, randomized, controlled trial comparing conservative with endovascular management over a period of 10 years. Participants are candidates for endovascular treatment of one or more unruptured aneurysms (size 3-25 mm), recently discovered or prevalent. 2,002 patients equally divided between the two groups will be enrolled, a size sufficient to achieve 80% power at a 0.0167 significance level to detect differences in disease versus treatment-related poor outcome from 7-9% to 3-5% and overall mortality from 16 to 11%.
Outcome measures and analysis: Primary endpoint is mortality and morbidity from intracranial haemorrhage (mRS ≥3). Secondary endpoints include incidence of hemorrhagic events, morbidity related to coiling, morphological results, overall clinical outcome and quality of life. The analyses will be performed on two populations: intent-to-treat and per protocol. Main statistical tests compare between the 5- and 10-year probabilities of 1/ poor outcome from haemorrhage related to the lesion; 2/ mortality from haemorrhage or from complications of treatment; 3/combined disease or treatment related mortality and morbidity in the absence of other causes of death or disability. A committee unaware of group assignment will adjudicate the relation to disease or treatment.
Trial status: Recruitment started in June 2006. The trial is now underway in about 50 centers in Canada, the US and Europe, and about 76 participants have been enrolled.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):142.
Purpose: Posterior circulation strokes account for 20% stroke. About one quarter of these are due to stenoses in the vertebral and/or basilar arteries.
There is little data on either recurent stroke risk or optimal management. Primary stenting for proximal vertebral stenosis is considered safe but there is limited data describing and comparing the recurrent stroke risk in patients with vertebral stenosis on best medical therapy.
Materials and Methods: The study aim is to compare the risks and benefits of vertebral stenting for symptomatic vertebral stenosis compared with best medical treatment.
A feasibilty phase/trial is now underway in the Uk to determine the feasibilty of and barrier to recruitment, an estimate of the frequency of outcome events to allow adequate power calculations for a main trial and restenosis in the stented patients.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):142.
Evidenced-based evaluations of surgical procedures for long-term prevention are needed. A trial of unruptured intracranial aneurysm intervention was planned and designed. Several unique aspects of the trial design became apparent as the trial was developed and are applicable to other preventive surgery trials. First, there needed to be evidence for a subset of patients with unruptured intracranial aneurysms for there to be equipoise between observation and treatment in long-term outcome. Data from the International Study of Unruptured Intracranial Aneurysms was analyzed to determine where equivalence existed. Second, the treatment composition and treatment morbidity and mortality may have changed from the time period of the observational evidence. Procedures in the 1990's were analyzed for risk and efficacy in preventing hemorrhage but the procedures may have improved since then. Third, as with most procedure-based trials the peri-procedure morbidity and mortality effects one arm of the study and the observational arm need to surpass the outcome over time. Data suggests that this may be 5-10 years. Hence an adaptive design utilizing outcome rates but also rate of change may be considered. Fourth, for safety monitoring, adverse events are more likely to be peri-procedural. Hence a critical level of adverse event needs to be pre-specified. Fifth, in addition to the primary global endpoint the study would need to consider competing risks for other causes of neurological change and causes of mortality, e.g. only 10% of the mortality could be attributed to the aneurysm. The design of the trial will be discussed and how these challenges were addressed. Recommendations for preventive procedural trials in the design and analysis will be presented.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):143–144.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):145.
Tuesday, June 30th, 2009 • Room 519a • 13.30-16.40
interv neuroradiol. 2009 Jun 2;15(Suppl 1):145.
Background: Perianeurysmal inflammatory reaction is a well described phenomenon that can occur following aneurysm coiling and can lead to symptomatic lesions of adjacent structures. This is far more common when modified coils are used. However, it can also be seen after conventional coiling with bare platinum coils. Other types of inflammation affecting the brain can also be seen, especially if MRI is used in the follow-up of such procedures. We intend to discuss four different patients that developed delayed inflammatory reactions with blood-brain-barrier breakdown following coiling.
Brief description of the complication, management, and outcome: Among approximately 250 aneurysms coiled between 2006 and 2008 in our Institution we were able to detect 4 patients that developed a delayed inflammatory reaction following a coiling procedure. As opposed to the common perianeurysmal inflammation, these patients developed a more spread inflammatory reaction involving the hemisphere of the treated vessel. These reactions were symptomatic in the 2 patients with unruptured aneurysms. One of the 2 patients with ruptured aneurysms developed vasospasm. The reactions started from 2 days after the procedure and persisted for months. MRI was performed in 3 of the patients and the findings included significant vasogenic edema and contrast-enhancement of nodular areas of the affected hemisphere. All patients were treated with corticosteroids with significant clinical and radiological improvement.
Lessons to take home: Patients submitted to coiling also have to be followed by parenchymal imaging methods in order to survey for complications that are not depicted by angiographic tests.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):145–146.
Background: Perianeusymal inflammatory reaction can be induced after endovascular coiling of cerebral aneurysms. All of the post embolization inflammatory edema encountered in the literature are induced whether by bioactive coils or by aneurysmal regrowth.
We present our experience with a special type of delayed inflammatory edema related to a non ruptured aneurysmal embolization with bare platinum coils appeared 1 month later without neither hydrocephalus nor aneurysmal regrowth.
Description: We report a case of a 46 year old female patient presented with dysesthesia of the chin, MRI examination showed incidentally two aneu-rysms (at the supraclinoid portion of the right ICA measuring 12 mm and at the A1 segment of the right anterior cerebral artery measuring 2.5 mm) with no perianeurysmal edema. The internal carotid aneu-rysm was treated with different types of bare platinum coils. One month after the embolization the patient suffered from neurological symptoms (Epilepsy and olfaction disorders). MRI examination showed de-novo perisneurysmal edema in the right internal temporal region diagnosed on MRI. The perianeurysmal edema showed regression with corticoids and the neurological symptoms were controlled by anti-epileptic drugs.
Lessons to take home: Perianeurysmal inflammatory edema can result from the use of bare platinum coils. Symptoms are related to the site of the inflammatory reaction.
Medical treatment is effective in treating both the inflammatory reaction and its symptoms.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):146.
Background: Dissection caused by remodeling technique can cause intraoperative hemorrhage and later can be the cause of newly developed aneu-rysms. Flow diversion stents are suitable for the treatment of these types of complications.
Complication, Management and Outcome: We present a case of a 50 years old female patient presented with a ruptured small right internal carotid aneurysm and treated with remodeling technique. The balloon caused dissection and intraoperative hemorrhage of the internal carotid artery which was controlled by balloon inflation and reversal of heparin, with no neurological deficits afterwards. The follow up after 9 months showed the formation of a new aneurysmal sac on this previously dissected part. After balloon occlusion tests verifying the vascularisation of the anterior choroidal artery's territory by collateral circulation, a Silk stent was deployed over the two aneurysms covering the whole diseased segment with preservation of the anterioir choroidal artery and marked stagnation of contrast inside the aneurysm.
Lessons to take home: Intraoperative bleeding caused by dissection from remodeling technique can be through the parent artery and not from the aneu-rysmal sac.
Rapidly growing aneurysms can develop over the dissected zone.
Flow diversion stents are efficient for the treatment of such complications with preservation of the permeability of stent covered important branches.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):147.
Wednesday, July 1st, 2009 • Room 519a • 13.30-16.40
interv neuroradiol. 2009 Jun 2;15(Suppl 1):147.
A 57-yearold female was admitted for embolization of a 2x1.5x1 cm left frontal opercular AVM. During embolization, the feeding artery, a branch of the middle cerebral artery which was quite tortuous, was selected and the AVM nidus was accessed. Onyx 18 injection was started. After about 12 minutes of injection, there had already been approximately 10-15 mm of reflux within the small distal feeder. Due to the tortuosity and expected difficulty in catheter withdrawal, an early attempt was made to retrieve the Marathon catheter. However, at about half an hour of the prolonged pullback effort, the patient's blood pressure suddenly increased. Due to vasospasm, distal territory was not adequately visualized and it was thought that the reason for the hemodynamic change was a cerebral hematoma secondary to feeder transection. A decision was made to inject further and embolize the possibly ruptured feeder artery totally together with as much remaining AVM as possible. After some feeder filling with relatively higher pressure injection, the catheter burst at cavernous segment and Onyx laminated the cavernous carotid artery. Catheter was left in place. An emergent CT showed no hematoma. Patient was heparinized. There were no clinical sequela. The remaining AVM was surgically removed later. A 15-month follow-up angiogram showed no residual AVM and patency of the carotid artery.
Learning points: It is not straightforward to predict catheter entrapment with Onyx. Risks of leaving a microcatheter in patient may be lower than those efforts in recapturing it.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):147.
Background: The use of ONYX in the endovascular treatment of cerebral AVMs has resulted in a higher number of completely cured lesions. Though, the more it penetrates inside the nidus, the higher the risk of severe hemorrhagic complications.
Case: Man, 60 yo. No neurologic symptoms apart from seizures for many years. Since he wants to stop therapy, TC and MR are performed, discovering a left inferior parietal AVM with a huge ectatic vein along the drainage. Decision is made to treat. A first procedure is performed with ONYX and roughly 50% of the AVM is excluded. Mild slowdown of the flow in the big vein is observed, so that we do not insist in occluding more. Patient wakes up well but at night a sudden headache arises and he becomes confused, aphasic, hemiparetic. A hemorrhage is evident on CT and he is quickly operated removing just the hematoma. There is a very slow recovery from aphasia and hemiparesis in the following days. He is not really oriented, but improves day by day. After 5 days he goes again in a coma because of a new hemorrhage. Eventually he is operated and the AVM is resected. After 1 year the patient has still some degree of aphasia and hemiparesis and other more subtle but very disturbing deficits.
Lesson to take home: ONYX is more efficient in the treatment of brain AVM but also may be very harmful. According to other similar complication that we had, early surgery is mandatory even after a small hemorrhage.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):148.
Background: This otherwise healthy female had her first drop attacks and seizures at the age of 25. She developed an externally audible pulse synchronous bruit when 54 years old. An angiography one year later disclosed a very large DAVS in a malformed left transverse sinus. The major blood supply came from dural arteries but there was a significant contribution from pial arteries. There was also what appeared to be AV shunts from pial arteries to pial veins draining into the DAVS region and substantial pial venous reflux.
She was clinically stable with occasional drop attacks and strong bruit.
At the age of 60 she was treated by transarterial embolization of the dural supply. She had then an obvious cerebellar congestion. After the embolization she suffered some temporal lobe seizures and the bruit diminished. She still had drop attacks.
At the age of 68 she was subjected to gamma knife treatment of the DAVS.
Two years later the bruit disappeared and she developed headaches and a feeling of "pressure inside the head". An MRI disclosed cerebellar oedema. The DAVS was still present.
Procedure: Transvenous embolization of the left transverse sinus with detachable coils.
The patient woke up after the procedure and responded well. She complained of headache.
Complication: Four hours later she rapidly deteriorated and lost unconsciousness. A CT scan disclosed ICH and SDH.
Outcome: The SDH was evacuated and she had a ventricular drainage. However, the patient died four days after the procedure.
Lessons: Significant pial blood supply or pial arteriovenous shunts to a DAVS may constitute a contraindication to transvenous embolization.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):148.
Background: 52 year-old female presenting with headache and vertigo. During investigation she underwent a brain CT scan that showed a right occipital mass evoking either a meningioma or a vascular lesion. Angiography was performed and a tentorial dural fistula was found. This fistula was fed by petrosal branches of the middle meningeal and occipital arteries wich drained into a huge venous pouch that later emptied into the right sygmoid sinus. An embolisation was subsequently performed with Onyx via both middle meningeal and occipital arteries. A complete occlusion of the fistula was achieved with almost no contamination of the huge pouch. The patient woke up well, without any focal deficit.
Complication, management and outcome: In the 5th day after treatment she went into an abrupt coma. CT scan showed thrombosis of the venous pouch surrounded by edema. The patient suffered a surgical ressection of the thrombosed malformation and progressively recovered, although she still keep some paresis of the left arm and a left hemianopsy.
Lesson: In such cases should we predict a surgical act after embolisation or simple anti-coagulation post-treatment should be enough to prevent this acute venous thrombosis situation?
interv neuroradiol. 2009 Jun 2;15(Suppl 1):149.
Thursday, July 2nd, 2009 • Room 519a • 13.30-16.30
interv neuroradiol. 2009 Jun 2;15(Suppl 1):149.
Background: To present a case of type A aortic dissection presenting as acute ischemic stroke and initial stent placement as a treatment of symptomatic treatment.
Brief description of the complication, management, and outcome: A 68-year-old woman was found fallen. She had hypertension, but did not take medicine. Initial brain computed tomographic angiography (CTA) revealed decreased density of right internal carotid artery (ICA), middle cerebral artery (MCA), and its branches as acute ischemic stroke. Transfemoral angiography showed flow disturbance in innominate artery and right ICA. We suspected aortic dissection at that time and performed stent placement to improve blood flow of right ICA. After completion of procedure, follow-up MRA showed normalization of blood flow in right ICA and follow-up perfusion image showed normalization of perfusion of right cerebral hemisphere. However, she waiting for operation died with abrupt hypotension and comatose mentality maybe due to rupture of aortic dissection in 10 admission day.
Lesson(s) to take home: Aortic dissection might be missed in acute stroke of elderly hypertensive patient. It's our mistake that we did not think the possibility of aortic dissection. But, we don't think that stent placement in innomiate artery is malpractice.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):149.
Background: Posterior circulation angioplasty and stenting was recently proposed to be an effective measure against recurrent posterior circulation stroke related to intracranial vertebrobasilar stenosis. However, possible complications associated with the procedure should be carefully monitored.
Complication, management and outcome: Delayed (more than 24 hours after procedure) bilateral vocal cord palsies after basilar artery angioplasty and stenting presented with stridor followed by cardiorespiratory arrest. She was successfully resuscitated and airway was protected with temporary tracehsotomy. Her vocal cord palsies completely recovered in three weeks' time and tracheostomy tube was weaned off.
Lessons to take home: Noisy respiration and dyspnoea after intracranial angioplasty and stenting should be promptly evaluated for causes. In the case of stridor, consideration of airway protection with intubation or tracheostomy should be of paramount importance and could save the patient from rapid deterioration.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):150.
Friday, July 3rd, 2009 • Room 519a • 13.30-14.50
interv neuroradiol. 2009 Jun 2;15(Suppl 1):150.
Case report: A 50-year-old woman with a previous right MCA territory infarct presented with acute headache, positive lumbar puncture for blood, Grade I. MRA revealed a right MCA aneurysm. Approximately 18 cc of air were accidentally injected into the right carotid artery at the time of 3D angiography. The air-angiogram included both carotid artery territories as well as the basilar and posterior cerebral arteries through communicating arteries. The patient was comatose for 72 hours despite 3 sessions of hyperbaric oxygen therapy. Discouraged and in despair by no clinical improvement after 48 hours an MRA examination, however, was surprisingly reassuring with bitholamic edema, but very little infarction. The patient fully recuperated on day 4 and treatment of her aneurysm the following week was uneventful.
Lesson to take home: The prognosis after air embolization can be surprisingly good despite a devastating clinical syndrome for 72 hours.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):150.
Background: Retained microcatheters have not been described in infant transarterial embolizations, a setting where luminal compromise may result.
We report the case of a microcatheter tip that stretched, during retrieval from an Onyx cast, from the facial artery to the common femoral artery, where it sheared.
Description: The patient presented at one day of life with a cervicofacial skin stain, beneath which a mass rapidly grew; imaging suggested a lymphatic malformation. Sclerotherapy at three months was complicated by massive lesional bleeding. Continued growth led to attempted resection at seven months, which was subtotal, due to copious blood loss. Pathology revealed infantile myofibromatosis. The tumor regrew, prompting attempted complete excision preceded by preoperative embolization. Onyx 18 was delivered via an Ultraflow microcatheter. Increased resistance during catheter retrieval was overcome after injection of NTG and further traction. Decreased pulses several hours later led to anticoagulation. Imaging demonstrated a retained catheter tip extending continuously from the CFA to the facial artery, still embedded in an Onyx cast at the tumor. The catheter was removed surgically by exposing the cast with fluoroscopic assistance, and manually delivering the attached catheter. The fragment was retrieved intact, stretched thread-like, measuring 54 cm. Imaging showed no further catheter or thrombus, and the patient recovered fully. Four days later, he underwent total excision of the mass, with minimal blood loss. He has no untoward effects.
Lessons: A low threshold for CT imaging is appropriate, in treatment planning for stretched, retained microcatheters.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):151–152.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):153.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):153.
Objective: To report the clinical outcome obtained in treatment of giant intracranial aneurysms (GAs).
Methods: Between 2005 and 2007, 51 patients with 51 GAs were presented to our hospital. Twenty-nine were treated with primary parent vessel occlusion without distal bypass and ten underwent treatment with preserving parent artery. Twelve patients could not be treated endovascularly.
Results: Selective embolization (including two remodeling techniques and two stent-coil embolizations) resulted in only one cure. Two patients died as a result of subarachnoid hemorrhage periprocedurely. Twenty-nine patients treated primarily with parent vessel occlusion and three patients treated with covered stent were considered cured after their treatments. Only one patient treated with parent vessel occlusion experienced ischemia during follow-up period, which result in a mild neurological deficits. Of the twelve patients who could not be treated endovascularly, one succumbed to surgery, four died while being treated conservatively, and three were lost to follow-up monitoring.
Conclusion: Parent artery occlusion, covered stent, coil occlusion provide effective protection against bleeding. In treatment of paraclinoid GAs of internal carotid artery, the use of stent, stent assisted coil embolization may be a pitfall.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):153.
Purpose: Evaluation of the outcome in a series of 23 thrombo-embolic complications related to aneurismal coil embolization treated with Combined Intra-arterial and Intra-venous administration of Abciximab.
Methods: Twenty three patients were retrospectively identified who had thromboembolic complications related to their aneurismal coiling procedure and for which, Abciximab was used as the first line of treatment. Abciximab was administered intrarterially followed by intra-venous Infusion over 12 hours period. Modified Rankin Scale (mRS) was used to evaluate neurological outcome of patients at follow-up. Thrombolysis in myocardial infarction (TIMI) flow grade was adopted to characterize thromboembolic incidence and outcome.
Results: Amelioration on TIMI flow grade was achieved in 19/23 patients (82%) while persistence of flow grade was noted in 4/23 patients (17.4%), TIMI Grade 3 was obtained in 15/23 patients (65.2%). Higher response to abciximab was noted for thrombi at the Coil parent artery interface in 81.2% of cases (TIMI Grade 3 in 9/11 cases) while lower response to abciximab was noted in 60% of distal thrombi (TIMI Grade 3 in 6/10 cases). No postprocedural hemorrhagic complications were noted in the series while 11 ischemic sequelae (47.8%) were identified. mRS of 2 or less was achieved in 73.9% (17/23 patients) of cases and of 3 or more in 26.1% (6/23 patients).
Conclusion: High Dose Combined Intra arterial / intra venous administration of Abciximab is safe and effective in treatment of thromboembolic complications occurring during aneurismal coil embolization with no hemorrhagic complications and with better effect on thrombi at the coil parent artery interface.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):153–154.
Objective: To explore the therapeutic efficacy of using induced embolization for intracranial giant aneurysms.
Methods: There are 13.1% (26/198 ) of the patients were treated from January 2000 to July 2008 in our hospital. 21 cases were treated by induced embolization (Implanted 1 or 2 microcoils into the near heart terminal of parent artery, which lead to 50% decrease in blood supplement. After that, anti-coagulation therapy was adopted for 3 months). 4 cases were clipped or removed by operation; one patient was treated with conservative methods.
Results: Embolization is induced in 21 patients. In 10 cases aneurysm were embolized completely, and embolized more than 50% in 8 cases. In 3 cases aneurysms were embolized less 50%, and one patient died 9 days after procedures. The mean follow-up period was 24 .2 months (1 month to 6 years) after the induced embolization. 20 patients were follow-up by the DSA (16 cases) or CTA (3 cases). 90% (18/20) aneurysms can not display in DSA after the initial induced embolization. In 1 case still show partial aneurysms in CTA, but the patient's symptom disappeared. 1 patient was died during follow-up period.
Conclusions: Induced embolization lead to aneurysms embolized completely in 3 months when compensatory circulation could be established. So complications of embolization will decreased significantly. Both short and long-term efficacy of induced embolization for intracranial giant aneurysms is good. Induced embolization should be one of therapy strategy and be helpful to decreas mass effect for intracranial giant aneurysms.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):154.
Purpose: To analyze the safety of the remodelling technique compared to the standard coiling technique in a large multicenter series concerning the endovascular treatment of unruptured intracranial aneurysms (ATENA).
Materials and Methods: In the ATENA series, performed in 27 institutions, 547 patients (383 females and 164 males; age: 22-83 years, mean: 51.0 ± 11.1 years) having a total of 572 aneurysms were treated by coiling alone in 325 patients, and by the remodelling technique in 222 patients. For each patient group, we recorded aneurysms characteristics, rate of adverse events related to the treatment, and patient outcome.
Results: The overall rate of adverse events related to the treatment ' regardless of whether they lead to clinical consequences or not - was 10.8% (35/325) for coiling, and 11.7% (26/222) for remodelling. Thromboembolic events, intraoperative rupture, and device related problems were encountered in 6.2% (20/325), 2.2% (7/325), and 2.5% (8/325) in the coiling group, and 5.4% (12/222), 3.2% (7/222), and 3.2% (7/222) in the remodelling group, respectively. The morbidity and mortality rates did not differ significantly between groups: 2.2% (7/325) and 0.9% (3/325) in the coiling group and 2.3% (5/222) and 1.4% (3/222) in the remodelling group, respectively.
Conclusion: In this large prospective, multicenter study, the remodelling technique was associated with a similar rate of adverse events and morbimortality compared to the standard coiling technique.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):154.
Purpose: We studied endovascular surgery for distal anterior cerebral artery (DACA) aneurysms.
Materials and Methods: Between April 2002 and December 2008, we treated 42 patients (64.6±10.8 years, 66.8% female) with a DACA aneurysm including 18 subarachnoid hemorrhage (SAH) patients. Six aneurysms were detected as associated lesions of other ruptured aneurysms. Basically, the simple technique was performed, but adjunctive techniques were used when the simple technique was suspect. Guglielmi detachable coils were mainly used. Immediate angiographic results were categorized as complete occlusion (CO), residual neck (RN) and residual flow (RF). Radiological follow-ups by angiography or magnetic resonance angiography were categorized as unchanged, recurrence (subdivided into major and minor) and improved.
Results: Of 18 SAH patients, 7 demonstrated good recovery, 4 had moderate disability, 3 severe disability, a vegetative state in 2 and death in 2. All non-SAH patients had a good clinical outcome. Complications occurred in 8 patients. Two ischemic events and 2 arterial perforations occurred without any consequences. Two rebled from the coiled aneurysms, of which one died. One groin pseudoaneurysm requiring surgical repair and one carotid artery dissection occurred. Overall the permanent morbidity and mortality rate was 2.4%. Immediate angiographic results were CO 26, RN 7 and RF 9. Radiological follow-ups over 3 months showed 13 unchanged, 2 minor and 4 major recurrences and 3 improved.
Conclusion: Endovascular surgery for DACA aneurysms achieved good short-term clinical outcomes. Recurrences and posttreatment bleeding remained significant concerns.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):155.
Background and Purpose: Stent placement is increasingly used for the complex intracranial aneurysms. But its sa-fety and efficacy is not well established.
Methods: We searched seven databases, including Pubmed, Embase, SCI-expanded, Cochrane Library, ISI Proceedings, BIOSIS Preview, ProQuest Dissertations & Theses for the concerning studies with multiple key words from December 1997 to August 2008.
Results: Twenty-seven studies were finally included in this systematic review, eight of which were prospective and consecutive. A total of 806 patients with 851 intracranial aneurysms were analyzed, the overall initial complete occlusion rate was 51.7% (399/772, 95% CI, 48.17%-55.23%), the overall complication rate was 12.6% (108/857, 95% CI, 10.38%- 14.82%), during the angiographic follow-up, the improving rate was 25.7% (101/393, 95% CI, 21.38%- 30.02%). After performing chi-square test between the subgroups of unruptured and ruptured aneurysms, balloon-expandable and self-expandable stents, statistical significances were reached in three tests, including rate of dependence between unruptured and ruptured aneurysms (χ2=14.84, p=0.0001), rate of initial complete occlusion (χ2=8.541, p=0.003) and rate of procedure related complications (χ2=28.373, p=0.0000) between self-expandable and balloon-expandable stents.
Conclusions: Stent is a safe and efficacious assisting tool in embolizing complex intracranial aneurysms. And self-expandable stents is much easier and significantly safer in navigating and deploying through the tortuous cerebral vasculature than balloon-expandable stents.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):155.
Purpose: Clinical course of intradural aneurysms onset from oculomotor nerve palsy treated by endovascular-endosaccular coil embolization were reviewed.
Materials and Methods: We have had 6 cases of intradural aneurysms onset from oculomotor nerve palsy since 1997. They were 4 cases of SAH and 2 cases of non-ruptured aneurysms. Locations of the aneurysms were 5 cases at ICA 'Pcom and one case of BA-SCA. The size of the aneurysms ranged from 5.8 to 8.7mm. Four cases were complete oculomotor nerve palsy and 2 cases were incomplete oculomotor nerve palsy.
Results: All cases were treated by endovascular-endosaccular coil embolization. Considering the recovery of the oculomotor nerve palsy, intentional loose packing of the nerve contact portion was performed in selected cases. Clinical recovery of the oculomotor nerve palsy was 4 cases recovered completely and 2 cases recovered incompletely. Two cases with preoperative incomplete oculomotor nerve palsy were recovered completely.
Conclusion: In spite of conservative anatomical contact or close position of the aneurysm and oculomotor nerve, endovascular-endosaccular coil embolization of ruptured or non-ruptured aneurysms onset from oculomotor nerve palsy is effective methods of treatment in comparison with previous reported surgical clipping series. Not only the contact and initial damage at SAH but also the pulsation to the nerve plays an important role for the onset of oculomotor nerve palsy. Endovascular-endosaccular coil embolization may reduce the pulsation from the aneurysm to the nerve for the recovery.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):155–156.
Purpose: We retrospectively collected and analyzed the clinical data of endovascular treatment modalities and results of this particular lesion in single institution.
Materials and Methods: Seventeen patients with ruptured wide-necked tiny intracranial aneurysms were treated endovascularly. The locations were PcomA in 10, intradural paraclinoid ICA in 3, AchoA in 2, BA in 1, and dorsal wall internal carotid artery in 1. Patient demographics consisted of 10 females and 7 males, with an age range of 35 to 63 years (mean 51.8 years).
Results: All 17 aneurysms were treated with stent-assisted coiling (10 aneurysms) or stent placement alone (7 aneurysms). Seventeen stents were successful deployed, including 5 balloon-expandable coronary stents in the early period and 12 self-expanding intracranial stents in later period. Of the 10 aneurysms treated with stent-assisted coiling, 5 were densely packed while another 5 were loosely packed with coils. Nine patients were angiographically followed ranged from 4 to 30 months (mean: 9.3 mos). The result showed complete obliteration of aneurysms in all patients. Seven aneu-rysms were treated by stent placement alone. Follow-up conventional angiographic examinations availa-ble for 4 out of 7 patients treated with stent placement alo-ne (mean: 11.6 mos), showed complete obliteration of aneurysm in 3 patients and significant reduction of aneurysm size in another patient. In one case, short-term follow-up (1 mo) demonstrated no significant change.
Conclusion: Very small ruptured wide-necked intracranial aneurysm is not uncommon and can be safely treated by endovascular method with stent-assisted coiling or stent placement alone.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):156.
Purpose: To assess the value of a new retrievable self-expanding stent system (LEO) in aneurysm treatment.
Materials and Methods: Forty-three patients with aneurysms, with forty-four aneurysm involved, were treated using LEO stent. Sixteen aneurysms were treated with single-stent deployment, twenty-five with stent-assisted technique, two with double-stent deployment and one with double-stent assist coils. Also the imaging and clinical results were followed up.
Results: The stent was easily to reposition and all the stent delivered successfully. One stent with unsatisfactory position, one cases with acute in-stent thrombus. During follow up, one case was with chronic in-stent thrombus and one with hyperplasia of endothelium. Twenty-two (50.5%) aneurysms got tight coiled during procedure. Among twenty two cases with follow up results, 72.4% aneurysms got cured or improved, 13.8% were stable, three dissection aneurysms enlarged in short period and two patients died.
Conclusion: The new retrievable self-expanding stent (LEO), with the advantage of controlled delivery, easily deployment and various types for choosing, was a valuable system for vessel reconstruction during aneurysm embolization.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):156.
Purpose: Definite angiographic or MR findings for cerebral arterial dissection, such as double lumen, intimal flap or intramural hematoma, are not always detected by the examinations in acute phase. We report a case of an anterior cerebral artery (ACA) dissection, in which MR cisternography revealed a transient dilatation of the vascular outer diameter at the affected segment in acute phase.
Materials and Methods: The case is a 42-year-old male patient with an abrupt severe headache. Initial CT revealed a faint subarachnoid hemorrhage in the frontal region. He admitted to our hospital and was treated conservatively as the suspicion of right ACA dissection. Repeat cerebral angiography and MRI/MRA performed.
Results: Initial angiograms showed tapering stenosis at the right A2. It was difficult to confirm the ACA dissection by the initial examination, because intramural hematoma, intimal flap or double lumen was not detected on MRI/MRA. ACA dissection was confirmed by the resolution of right A2 stenosis on the follow up angiograms of day 14. On the other hand, initial MR cisternography revealed a fusiform dilatation of the vascular outer contour at the right A2, which resolved on the MR cisternography of day 14. Vascular inner luminal abnormality with dilatation of the outer diameter may be a sign of arterial dissection.
Conclusion: Fusiform dilatation of the vascular outer contour at the affected segment, revealed by the MR cisternography, may be helpful to diagnose arterial dissection in the acute phase.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):156–157.
Purpose: To compare the quality of immediate anatomical results after the endovascular treatment of ruptured aneurysms using GDC and Matrix coils in CLARITY series.
Methods: Postoperative anatomical results were evaluated on DSA, anonymously and independently by two experienced neuroradiologists. Two different scales were used: the Montreal scale and a new scale specifically designed for the present study (Clarity scale).
Results: 401 aneurysms were treated using GDC coils and 373 using Matrix coils. Immediate anatomical results (Montreal scale) were not significantly different with GDC or Matrix coils. In GDC group, result was complete occlusion for 197 aneurysms (49.1%), neck remnant for 155 aneurysms (38.7%), and aneurysm remnant for 49 aneurysms (12.2%). In Matrix group, result was complete occlusion for 168 aneurysms (44.9%), neck remnant for 171 aneurysms (45.7%), and aneurysm remnant for 35 aneurysms (9.4%). Similar results were obtained using Clarity scale. The factors affecting the quality of aneurismal occlusion have been studied in both GDC and Matrix groups.
Conclusions: The postoperative occlusion after endovascular treatment of ruptured aneurysms is satisfying with a high percentage of complete occlusion or neck remnant in both GDC (87.8%) and Matrix (90.6%) groups.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):157.
Purpose: Peripheral cerebellar arteries aneurysms are rare and difficult to treat surgically because of the intimate relation with the brainstem and cranial nerves. The conventional treatment of these lesions requires technically demanding cranial base approaches with considerable morbidity. We report a series of 9 patients treated by embolization.
Materials and Methods: Between 1999 and 2007, 260 aneurysms were treated in our Institution, 9 of which were peripheral cerebellar arteries aneurysms (3.4%). Aneurysm location was superior cerebellar artery (SCA) in 3 cases, anterior-inferior cerebellar artery (AICA) in 2 cases and posterior-inferior cerebellar artery (PICA) in 4 cases. Seven patients presented with subarachnoid hemorrhage (77%), one patient with a cranial nerve deficit (11%), and in the remaining case the aneurysm was incidental (11%). In all cases, selective embolization of the aneurysmal sac was performed using platinum coils.
Results: Endovascular treatment resulted in seven complete occlusions, one neck remnant, and one case of intraoperative rupture of the aneurysm followed by death. The ruptured aneurysm was a giant (25 mm.) left PICA lesion. Glasgow outcome scale score was 5 (excellent) in 7 patients (77%), 4 (good) in one patient (11%), and 1 (bad) in one patient. Imaging follow-up at 6 months and 1 year revealed persistent occlusions in eight patients.
Conclusion: The endovascular approach to treat peripheral cerebellar arteries aneurysms by selective embolization was safe and effective, and lacked the significant morbidity associated with conventional surgery. Imaging follow-up showed excellent anatomic results in accordance with clinical recovery.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):157.
Objective: Silk Stent (Balt Extrusion, Montmorency, France) is a nitinol, flexible, specifically designed with microcell, self-expanding device, recently available in Argentina for embolization of wide necked large and giant aneurysms. We report our experience with Silk stent with emphasis on evolving treatment strategies and occlusion durability at short term follow-up.
Methods: All patients were registered in a prospectively maintained database. We assessed clinical history, indications for stent use, aneurysm dimensions, procedure technical details, degree of aneurysm initial occlusion, angiographic and clinical findings at follow-up, and complications.
Results: Over a 7 month period, 9 aneurysm cases were treated; 5 previous to rupture and 4 previously treated with coils or coils and stent. Indications were: broad aneurysm neck (5), giant aneurysm (3), and fusi-form/dissecting morphology (1). Stent placement was technically possible and successfully done in 8 cases, while in other one distal stent segment did not expand and originated transitory arterial occlusion with no clinical deficit. Patients continued three month antiplatelet medication and follow-up angiogram was performed at the fourth: total occlusion in 1 patient, progressive thrombosis in 3, and no change in one (case with not expanding distal stent segment).
Conclusion: The Silk stent is a new device which may facilitate adequate embolization of complex cerebral aneurysms not amenable to coiling therapy. Initial follow-up data indicates favorable progressive thrombosis takes place but more experience and longer term follow-up are required to establish final occlusion rates and evolution of stented aneurysms.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):157–158.
Objectives: The aim of the present study was to clarify the safety margin of the coil mass for endovascular embolized aneurysms, which was not disturbed blood flow in branching arteries, using computational fluid dynamics.
Methods: We picked up an unruptured VA-PICA aneurysm, of which the flow impairment in the PICA was strongly feared during endovascular coiling. A three-dimentional model was built from a solid voxel on the computer. We also made 6 models of final coil configuration in this aneurysm. The Case-0 was pretreatment. The Case-1 was imagined natural round coil mass. The Case-2, 3 and 4 were intentionally designed as a neck-remnant. The Case-5 and 6 were made with balloon neck remodeling techniques. Computational fluid dynamics were applied with Fujitsu alpha-flow (Fujitsu, Tokyo, Japan). We analyzed flow amount in the PICA in each models. The imported blood flow condition was gotten from 4D-FLOW by a 3-tesla MRI in the same patient in order to enhance the accuracy.
Results: The higher average of out flow amount to the PICA was Case-0, 5, 4, 6, 1, 3, and 2 in order. The preservation of the flow in PICA was more balloon neck remodeling models than intentional neck-remnant ones.
Conclusions: We found much differences of out flow to the branching artery even if little gaps of the coil configuration for endovascular coil embolization. It is very important for preventing thromboembolic events that serious consideration of the final coil configuration.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):158.
Purpose: Superior cerebellar artery (SCA) aneu-rysms sometimes involve the origin of SCA, and it may make the treatment difficult. We focused on the morphological characteristics of SCA aneurysms and adjacent vascular structures to apply the clinical decision making for the treatment strategy.
Method: Sixty-nine SCA aneurysms, including 34 ruptured and 35 unruptured ones, had been treated for over 12 years. Multiple aneurysms were associated in 30 patients. The pattern of the neck position of aneurysms was classified into three:
Type A: no SCA-involved type;
Type B: half involved type with SCA originating from the aneurysmal neck;
Type C: pure SCA aneurysm with all the neck mounting on SCA.
Morphological and clinical analysis was done between ruptured and unruptured aneurysms and among three types.
Result: There was no difference of patient profile between ruptured and unruptured aneurysms. The angle formed by posterior cerebral artery (PCA) and SCA on the aneurysm side was obtuse in 62 (90%) patients. On the morphological point of view SCA-involved type (type B + C) was significantly more in ruptured aneurysms (76%). Bleb formation is particular in ruptured aneurysms. As for the treatment, the risk of SCA occlusion and incomplete and attempted operation was particularly higher in cases with SCA-involved type.
Conclusion: Although SCA aneurysms may grow due to the hemodynamic stress at the opened bifurcation between the PCA and SCA, the neck shifting to the origin of SCA, particularly in ruptured ones, may suggest some other etiological mechanism. SCA-involved type aneurysm had high treatment risk of SCA occlusion and tends to incomplete treatment.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):158.
Purpose: Endovascular treatment of intracranial aneurysms using platinum coils is effective, but uncommonly aneurysms recur. This study examines the safety and efficacy of this technique in small single center series.
Materials and Methods: Between June 2002 and Dec 2008, we treated 148 unruptured aneurysms with platinum coils in our center. During this period, 70% of unruptured aneurysms were treated by endovascular technique. Procedural feasibility, technical complications, morbidity and mortality, and short and mid-term angiographic occlusion were assessed.
Results: Overall technical success rate of coiling treatment was 133 cases (90.0%). At the end of the initial procedure, acute occlusion was classified as complete (grade 1) in 105 cases (78.9%), neck remnant >90% and body filling >90% (grade 2) in 27 cases (20.3%), and imcomplete <90% in 1 cases (0.8%). Treatment'related morbidity was 1.5%, and mortality was none. Analysis of the follow-up angiograms and MRA showed 90.0(%) had stable occlusion, 4.0(%) had improved occlusion, and 6.0(%) had worsening occlusion.
Conclusion: Endovascular treatment with detachable coils is an effective option for treatment of unruptured aneurysms. This method of treatment is safe with a low rate of complications. Prospective studies with long-term follow-up are needed to assess the long-term durability of occlusion in unruptured aneurysms.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):159.
Purpose: To show our experience and results in the treatment of intracranial aneurysms using stents.
Patients and Methods: Retrospective study of patients with cerebral aneurysms treated with intracranial stents at our institution between March 1999 and December 2008. We analyzed the demographic data, angiographic results, clinical presentation, technique, results and follow up.
Results: We treated 980 aneurysms (915 patients) of which 107 aneurysms (104 patients) were treated with stents. The mean age at presentation was 49.1 years old (range 8 to 76 years old). The main presentation at diagnostic was headache (31%), other treated aneurysm (15%) and cavernous sinus syndrome (10%). 32% of the cases were ruptured aneurysms. Classified by size, we treated 40 big, 27 giants and 36 small aneurysms. Their main localizations were at the anterior circulation (77/107) principally at the carotid ophthalmic segment (35/77) and the cavernous portion of the internal carotid artery (29/77). We used 27 cardiological stents, mainly in the first period and from December 2002 we started using neurostents that diminished our rate of technical difficulties and complications. We used coils in 89/104 of treated patients and in 15/104 patients we used only stent for aneurysm treatment. We presented 16 technical complications and 10 patients clinical complications. Four patients died. At discharge 93.5% presented a favorable outcome with a mean follow up of 32 months.
Conclusion: In the last 10 years we have succesfuly used intracranial stents for the treatment of cerebral aneurysms. We have gain experience by the hand of the technical and technological advances of neuro stents.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):159.
Purpose: To present our 11 years of experience in the endovascular treatment of intracranial aneurysms.
Patients and Methods: Retrospective study between April 1997 to January 2009 .We studied the demographic data, clinical presentation, angiographic characteristics, short and long term results and follows up.
Results: We treated 980 aneurysms (915 patients) with 61,9% of ruptured aneurysms. Mean age was 51 years-old (3-86) with 77,7% of women. Headache was the main symptom at presentation (57.3%), followed by consciousness disturbances and neurological deficits. In subarachnoid hemorrhage (SAH) group the Hunt-Hess score was 1 (24,7%), 2 (32,8%), 3 (28,6%), 4 (13,1%) and 5 (0,9%). The most frequent localizations were carotid ophthalmic segment (20%), posterior communicating artery (19.3%) and anterior communicating artery (14,7%). Main aneurysms size (size/neck) were small and narrow neck (59,1%), small and broad neck (15,8%) and big and broad neck (11,8%). Treatment was done in the acute phase in 45,6% of patients with SAH. 91,0% of aneurysms were treated only with coils, 7,4% with stent and coils, 1% with only stent and 0,6% with others endovascular techniques. Post embolization occlusions rates were complete (33,9%), subtotal (40,9%) and partial (24,3%). There were 11,5% intra-procedure complications. At discharge, 73,8% of patients presented good outcome (mRS ≤2) with 1,7% of mortality secondary to treatment. We have a 50% of follow up with 26,4% of recanalization.
Conclusion: Endovascular treatment is a well-validated therapeutic modality for ruptured and unruptured aneurysms. In our 11 years experience we have showed good results with low morbi-mortality.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):159–160.
Purpose: There was a rapid change from surgical to endovascular aneurysm treatment at our institution which requires outcome audit to support this.
Design: Retrospective cross-sectional study on patients treated the year before and after the introduction of a coiling service (Groups 1 and 2 respectively).
Variables were assessed for normality with the Shapiro-Wilks test and with Chi-square and non-paired t-test for nominal and parametric data respectively.
Subjects: 139 patients (108 F, 31M). Mean age 52.4 yrs. Mean time to follow-up is 699 days (729 Group 1 [95% CI 709-749], 664 group 2 [95% CI 642-686]). No significant differences in age, WFNS grade or aneurysm location were noted in the 2 groups.
Results: Surgical, endovascular and no treatment were recorded in 78.7%, 10.7% & 10.7% of group 1 & 29.7%, 65.7% and 4.7% in group 2. Poor outcomes (MRS 3-6) were seen in 30.7% and 24.0% of groups 1 &2 (NS).
Conclusion: The change to coiling has improved outcomes in line with that seen in ISAT. The lack of statistical significance reflects the relatively small numbers. Continued audit is mandatory as endovascular practice expands further.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):160.
Purpose: Aneurysms arising from the non-branching sites in the internal carotid artery (ICA), or so-called anterior wall (AW) aneurysms, have been reported. The surgical management of these aneurysms poses technical challenges, and such patients are frequently referred for endovascular coil embolization(CE). The purpose of this study was to report the clinical presentation, endovascular treatment and outcome of ICA AW aneurysms.
Material and Methods: From 2003 to 2008, we treated 17 patients M:F=2:15, age, 37-72 years, mean 56.6) with ICA AW aneurysms. Two patients presented with subarachnoid haemorrhage, 3 patients presented with visual disturbance and the remaining 12 patients were asymptomatic.
Results: Although 16 of the 17 patients were treated with an adjunctive balloon remodelling technique, all aneurysms could be treated with aneurismal CE. Angiographic results were complete occlusion in 9, small neck remnant in 5 and dome filling in 2 patients. We experienced minor bleeding in 1 patient. In the post-operative course, we experienced neurological deterioration in 2 patients. One patient with a large aneurysm developed an embolic cerebral infarction within 24h. Another patient with a large symptomatic aneu-rysm showed deterioration of ipsilateral visual acuity 2days after CE. Although none of the patients showed rupture or re-rupture of the treated aneurysm in the follow-up period, 1 patient with a ruptured ICA AW aneurysm who showed aneurysmal recanalization underwent re -CE.
Conclusion: The results of this study indicate that endovascular CE is a safe and effective therapeutic alternative for ruptured and unruptured ICA AW aneurysms.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):160.
Purpose: To present endovascular technique for treatment of broad – neck aneurysms.
Materials and Methods: 171 patients (F: 96, M: 75) with broad neck aneurysms from 3 - 15 mm, F/NR < 2, sac diameter from 3 - 35 mm. 82 (48%) patients were after SAH. Qualification to procedure was done after angio CT by team neuroradiologyst and neurosurgeon. We planed to use 3D coils, intracranial stents and balloon remodeling. Subsequent filling of aneurysmal sac was done with GDC, Matrix and Hydrocoils.
Postprocedure angiographic control was done: 3/6 and 12 months.
Results: In 43 (25%) cases we used only 3D coils, in 60 (35%) cases intracranial stents, in 68 (40%) we used also balloon remodeling. In group with remodeling and 3D coils embolization were done: 100% n=31, 90-99% n=12. In group with intracranial stents: 100% n=46, 12 cases > 90%, in two cases only stent was implanted, without embolization (aneurysms disappeared during procedure).
Recanalization and subsequent embolization were done in 21 (12%) cases, in this group 2 cases after 100% embolization with stent.
Complications were observed in 8 case: after implanting the stent started thromboembolic event, in 4 cases resolved after abciximab (ReoPro) with no neurological sequel. In one case parent artery were occluded.
Conclusion: 3D coils, intracranial stents and balloon remodeling are important tools in endovascular therapy, improving endovascular occlusion of wide-neck aneu-rysms with protecting proper lumen of patent parent artery. Using intracranial stents increasing risk of tromboembolic complications and needs proper therapy.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):160–161.
Purpose: We present our experience with flow diverting stenting in the treatment of intracranial aneurysms. With this technique we try to promote aneurysm thrombosis preserving the collaterals of the parent artery.
Material and Methods: In the last 6 months we treated 8 patients with cerebral aneurysms using a high density nitinol stent – SILK (Balt) - 5 women and 3 males (37 to 71 years old). Five patients presented with headaches and 3 with SAH, mass effect and ischemic stroke. Regarding aneurysm location, 2 were located in V4 segment of vertebral artery, 4 in cavernous carotid, 1 in carotid ophthalmic segment and 1 was a PCom aneurysm. All patients were under double antiaggregant platelet therapy (maintained during 3 months, followed by monotherapy) and during the surgery a full heparin protocol was done.
In one patent a transitory worsening of mass effect was noted with progressive neurological recovery. In other case the patient developed one hour after the procedure a severe left cerebral ischemic stroke caused by intra stent thrombosis with distal embolism – intra arterial ReoPro protocol was immediately done with an excellent neurological recovery.
Results: The immediately post stent angiography showed 1 complete aneurysm exclusion and reduction of sac size and flow in 7. Until now 3 patients performed late control angiography (3-6 months) that showed complete aneurysm exclusion.
Conclusions: These preliminary results seems to support flow diverting stenting as an alternative therapeutic option in some intracranial aneurysms.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):161.
Purpose: The terms "dissecting" and "fusiform" are used to describe non-saccular aneurysms. Their pathogenesis, intriguing location and treatment options remain a subject of debate. We wished to analyze our experience with the treatment of non-saccular/non-fusiform aneurysms of the posterior circulation.
Materials and Methods: Retrospective analysis of medical records and imaging studies of all posterior circulation aneurysms referred to the neuro-endovascular clinic at the MNI for consideration of treatment, between 2003 and 2008. All giant, fusiform, basilar tip, berry like and posterior communicating artery aneurysms were excluded.
Results: Twelve patients (nine females, average age of 51 years) were identified. Nine patients presented with acute SAH and the remaining with progressive focal localizing symptoms. The location of the aneurysms was: side wall of the basilar artery and PICA (33% respectively), P2 (8%), SCA (8%), VA (8%) and AICA (8%). According to the Neurovascular team's prediction of best results ten cases received initial endovascular treatment and one surgery. In one patient endovascular treatment was unsuccessfully attempted and clipping was required. There were no procedure-related complications. The outcome was satisfactory in all cases at follow up angiography and/or clinical evaluation. One out of 10 patients (10%) treated endovascularly needed re-coiling 12 months later and eventually surgery.
Conclusion: Endovascular treatment of posterior circulation non-saccular aneurysms is a feasible and successful approach. In spite of the challenging features of these lesions, complete endovascular treatment was achieved in all but one case.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):161.
Purpose: To retrospectively analyze features of ACh thrombosis syndrome after ACh aneurysm embolization, and to propose preventive measures.
Methods: 33 ACh aneurysms presented as SAH in 32 cases were treated with coil embolization from June 1996 to June 2007.
Results: Of 33 ACh aneurysms, 26 were less than 10 mm (78.8%), and 7 were larger than 10 mm (21.2%). 18 parent arteries come from aneurysm dome or body, and 15 ACh arteries stem directly from internal carotid artery. 14 aneurysms were of compact embolization (42.4%), subtotal embolization was performed in 18 aneurysms (54.6%), and residual embolization in 1 aneurysm (3.0%). Of all 32 patients, 29 recovered to status of modified Rankin scale 0-2, and one patient died. Follow-up averages 49 months, ranging from 6-102 months with no rebleeding. 31 aneurysms in 30 patients were followed by DSA and regrowth occurred in 5 aneurysms (16.1%), where there is no need for re-embolization and they remained stable in subsequent follow-ups. 3 patients harbored ACh thrombosis syndrome 6 hours after interventional therapy, and 2 patients recovered back to normal within 1 week, while contralateral hemiparesis was the only complication in one patient after 2 weeks of rehabilitation. Ipsilateral anterior choroidal arteries originated directly from dome or body in all the 3 patients with ACh thrombosis syndrome.
Conclusions: Coil embolization of ACh aneurysm yield promising outcomes, but patients with ipsilateral anterior choroidal arteries stemming from aneurysm dome or body may be vulnerable to ACh thrombosis syndrome, which may be prevented using subtotal embolization of aneurysm.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):161–162.
Purpose: To evaluate the best magnetic resonance angiography (MRA) technique to follow-up brain aneurysms treated by coiling.
Materials and Methods: 770 brain aneurysms were embolized with platinum coils in the last 10 years. In 83/770, coiling was assisted by stent because of aneurysm's wide neck. MRA follow-up was strict in order to detect possible recurrences in time. It was performed one month after the embolization and every six months thereafter for following 5 years. Time of flight (TOF) technique was always used. In patients treated by stenting and in those ones embolized because of large aneurysms, Phase Contrast (PC) technique was also used. In the last 30 MRA follow-up, contrast enhanced (CE)-MRA was added in order to evaluate possible false negatives of both TOF and PC techniques.
Results: Recurrence was observed in 81 aneurysms (10%) using TOF and PC techniques. Conventional digital subtraction angiography (DSA) confirmed it in 76/81. In the last 30 embolized aneurysms studied by CE-MRA too, one recurrence was registered but it had been already previously detected by both TOF and PC techniques. TOF technique registered pitfalls in aneurysms treated by stenting and in large ones, because of flow suppression induced by magnetic susceptibility artifacts produced by metal. These pitfalls were solved by PC technique addition.
Conclusions: MRA performed with TOF technique is efficacious to follow-up coiled brain aneurysms. Nevertheless, PC technique is necessary in both aneurysms treated by stenting and in large ones. According to our initial experience, CE-MRA does not seem to add significative data.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):162.
Purpose: Treatment of wide-necked basilar tip aneurysms with detachable coils is technically challenging. We present our experience in treatment of basilar tip aneurysms using balloon-assisted coil embolization method.
Materials and Methods: From February 2000 to November 2008, 36 balloon-assisted coiling procedure of basilar tip aneurysms were performed in 35 patients (one patient had 2 aneurysms). Clinical files of patients were reviewed based on aneurysm neck size, pre-treatment rupture and hunt-hess score, occurrence of intraprocedural complications, technical success, procedure related morbidity and glasgow outcome scale.
Results: There were 25 female and 10 male patients with neck width ≥4 mm in 31 and <4 mm in four cases.Ruptured aneurysms observed in 18 patients with hunt-hess grade1 in 15 and grade2 in 3 cases. Intraprocedural complication occurred in 5 patients including thromboembolic events in 4 cases and rupture in one case. Complete obliteration was achieved in 97.2% of aneurysms with dog ear remnant in one case (2.8%). No procedure related morbidity was evident in 89% of aneurysms although PCA territory infarct and post coiling perianeurysmal edema occurred in 2 cases (5.5%). Two patients had died as a result of basilar thrombose and related to aneurysm rupture during embolization. Glasgow outcome scale was a score of 5 in 88.5%, 4 in 5.7% and 1 in 5.7%. Initial follow up studies were obtained in 54.3% with a mean of 16.3 months and showed a 89.5% cure rate. Neck regrowth (≤3mm) was observed in 2 patients.
Conclusion: Balloon-assisted technique makes embolization possible of wide necked basilar tip aneurysms with reasonable safety and efficacy.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):162–163.
Aim: Treatment of posterior circulation aneu-rysms poses a great technical challenge. The advent of endovascular techniques has made such treatment more feasible. We report our experience with the endovascular management of ruptured and unruptured posterior circulation aneurysms during the past 8 years.
Materials and Methods: This retrospective study was conducted at our institute between January 2000 and August 2008. Thirty-five patients (16 males; 19 females) age range - 24 to 65 years (mean- 46.75 years) were included. Endovascular treatment was based on the configuration of the aneurysm. Attempt was made to completely occlude the aneurysms. In vertebral artery dissecting aneurysms, flow modification technique was used to treat the aneurysm by using stents.
Result: A total of 35 ruptured and unruptured aneurysms in the posterior circulation were treated. Out of them 23 were in the basilar top, 4 in the basilar trunk, 2 in distal PCA and 6 were in V4 segment. All the cases were technically successful. We have encountered only three complications. In cases of ruptured aneurysms the pre and post procedure (at the time of discharge) mean modified Rankin scores in the patients were 4.6 (SD 0.51) and 1.7 (SD 1.98). This improvement in Rankin score after endovascular treatment was statistically significant.
Conclusion: Endovascular management of these lesions is safe and effective mode of treatment and gives adequate protection from rebleeds.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):163.
Purpose: The aim of this study was to review our experience in coil embolization of anterior communicating artery aneurysms with balloon remodelling method during last 10 years.
Materials and Methods: From june 1999 to December 2008, 66 balloon assisted coiling procedure of A.co. A aneurysms were performed in our institution. Clinical files of patients were reviewed based on aneurysm neck size, pre-treatment rupture, occurrence of intraprocedural complications, technical success, procedure related morbidity and glasgow outcome scale.
Results: There were 32 female and 34 male patients with neck width ≥4 mm in 38 and <4 mm in 28 cases. Ruptured aneurysms observed in 40 patients with hunt-hess grade1 in 36, grade 2 in three and grade 3 in one case. Intraprocedural complication occurred in 17 patients including thrombus formation in 14 and rupture in six cases.Complete obliteration was achieved in 90.9% of aneurysms while dog ear, neck remnant and aneurysm filling observed in three(4.5%), two(3%) and one(1.5%) case respectively. No procedural morbidity was evident in 89.4% of aneurysms although cerebral infarct and symptoms related to secondary hydrocephalus occurred in 6 cases(9%). One patient had died because of pre-procedural rupture of aneurysm and related hematoma. Glasgow outcome scale was a score of 5 in 84.8%, 4 in 13.6% and 1 in 1.5%. Initial follow up studies were obtained in 53.8% with a mean of 12.8 months and showed a 80% cure rate. Neck regrowth was observed in five patients and aneurysm filling in two patients.
Conclusion: Balloon-assisted technique makes embolization possible of wide necked anterior communicating aneurysms with reasonable safety and efficacy.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):163.
We reported a bilateral spontaneous atherosclerotic occlusion of primitive carotid artery associated to basilar tip aneurism. A 54 yo female suffered subarachnoid hemorrhage due to aneurysm rupture. Cerebral angiography showed a comunication between vertebral and external carotid arteries without proximal carotid common artery conection to braquicefalic tronc or aortic arch. Both vertebral arteries were increased in size. The blood flow to anterior circulation was provided exclusively by anastomosis between posterior communicating artery and vertebro carotid anastomosis like "pro atlantal type II". The embryological vascular anastomosis between carotid and vertebral basilar arterial system, allow the imbalance and exchange of blood flow to supply the brain parenquima. In this case the atherosclerotic disease associated to hypertension have promoted the occlusion of both primitive carotid artery leading to high flow in vertebro basilar system and opened the collateral anastomosis. In our opinion the vertebral high flow was responsible for the hemodynamic stress leading to aneurysm formation.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):163–164.
Purpose: The proportion of incompletely occluded aneurysms after coiling varies widely between studies. We conducted a systematic review to determine initial occlusion, reopening and retreatment rates of coiled aneurysms.
Materials and Methods: We searched Pub-Med and EMBASE (January 1999-September 2008) for studies of more than 50 coiled intracranial aneurysms. We extracted data on initial occlusion-, reopening- and retreatment rates. We grouped studies reporting on solely ruptured aneurysms, posterior circulation aneurysms and studies with a large proportion of aneurysms >10 mm to assess possible risk factors for incomplete occlusion, reopening and retreatment.
Results: 46 studies reporting on 8161 coiled aneurysms met inclusion criteria. Immediately after coiling, 91.2% (95% CI: 90.6-91.9%) of the aneurysms were adequately occluded. Aneurysm reopening occurred in 20.8% (95% CI: 19.8-21.9%) and retreatment was performed in 10.3% (95% CI: 9.5-11.0%).
Retreatment rate was higher in studies with a large proportion of aneurysms >10 mm and reopening rate was higher in studies dedicated to posterior circulation aneurysms, compared to studies containing all aneur-ysms. Since overall quality of descriptions was poor, no statistic evaluation was possible concerning risk factors.
Conclusion: Immediately after coiling, 91% of aneu-rysms were adequately occluded. At follow-up, 21% showed reopening and 10% were retreated. In order to asses possible risk factors for reopening and retreatment of coiled aneurysms, results from the current studies are insufficient. Long term follow-up studies with fixed follow-up intervals and individual patient descriptions are needed.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):164.
Purpose: Despite the widespread adoption of endovascular treatment of aneurysms with bare platinum coils, questions about efficacy and outcomes of bioactive detachable coils remain unanswered. From January 2006 through December 2007 we treated a total of 284 ruptured and un-ruptured aneurysms.
Materials and Methods: Patients were divided into 2 groups. Group 1 consisted of 191 patients treated with either Matrix coils alone or a combination of Matrix and GDC (>70% Matrix by total coil length) coils. Group 2 consisted of 93 patients treated with GDC coils only. Initial post-procedural and mid-term digital subtraction angiograms (DSAs) were evaluated and defined using the Modified Raymond Scale by a non-associated blinded reviewer.
Results: Patient age, female to male ratio, anterior to posterior distribution of aneurysms, rupture status, and use of adjunctive devices was recorded. Comparative acute and mid-term angiographic outcomes for both patient groups will be reported. A total of 6 procedural-related complications occurred for a total rate of .02% with no statistical difference between Matrix and GDC.
Conclusions: There was no statistical difference in the likelihood of complications associated with the use of bioactive coils compared with the use of bare platinum coils. In addition, we will provide critical and objective angiographic evaluation of patients treated with Matrix and compare against our own series of GDC patients to determine any differences in acute and mid-term occlusion rates.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):164.
Purpose: Hydrocoils are expansile coils designed to improve aneurysm occlusion and decrease recurrences for a smaller length of coil. In this study we report the efficacy and follow up of hydrocoils from a single centre
Materials and Methods: We performed a retrospective single centre review of all aneurysms coiled either partially or wholly with the use of hydrocoils over a 5 year period. End points included morbidity, mortality, initial rate of occlusion and follow up angiographic occlusion and recurrence rates. Inter group comparison was made between aneurysm containing varying percentages of hydrocoil.
Results: Of 320 patients there was an overall recurrence rate of 13.9%, with 3.8% requiring further treatment. There was direct correlation between percentage filling by hydrocoils and rate of complete occlusion on follow up and indirectly with recurrence rate. Direct procedural mortality was 1.5% with a further 2% with permenant disability. In comparison with published literature on bare platinum coils, the results compare favourably with a trend towards fewer recurrences.
Conclusion: Hydrocoils can be effectively deployed in aneurysms with comparable complication rate to bare platinum coils. There was lower recurrence rates compared to bare platinum coils on follow up angiopgraphy depending on the percentage hydrocoil placed in the aneurysm.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):164–165.
Purpose: Endovascular treatment of of very small (≤ 3 mm) aneurysms remains controversial because of high risk of complications and technical difficulties. Our purpose was to evaluate the feasibility and results of endovascular treatment of aneurysms not exceeding 3 mm.
Material and Method: Between 2005 and 2008, total 811 aneurysms were treated by coil embolization (n=345) and surgery (n=476). The numbers of aneu-rysms not exceeding 3mm was 171 and 31 aneurysms were treated by coil embolization. Of 31 aneurysms, 5 (16%) were ruptured and 26 (84%) were unruptured cases. We evaluated immediate post-procedural angiographic results, follow up MR angiography (MRA), clinical outcomes including procedure-related morbidity and mortality.
Result: Complete and near-complete occlusion was achieved in 25 aneurysms (80.6%) and 6 aneurysm (19.4%), respectively. Stent assist coil embolization was done in 5 cases because of wide neck aneurysm. In 3 patients balloon remodeling technique was used. Intra-arterial administration of abciximab due to suspicious in-stent thrombosis was performed in one patient. Clinical outcomes of 5 ruptured were good (GOS≥4). Follow-up MRA obtained with 1 month to 34 months later (mean, 10 months) was available in 27 of 31 patients, and recanalization of aneurysm was not found. There were no procedure-related morbidity and mortality and clinical evidence of neurologic deficit was not seen during the follow-up period (mean: 10 months, range: 1month to 34 months) in all patients.
Conclusion: Endovascular treatment of very small aneurysm was technically feasible with good results. It may be alternative modality of treatment in very small aneurysm.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):165.
Purpose: Large aneurysms (≥10 mm) carry a poor natural history, whether ruptured or unruptured. Their treatment remains challenging, with more endovascular techniques being utilized. We report our experience over a 6-year period.
Methods: A retrospective analysis was conducted of aneurysms ≥10 mm in size treated by endovascular coiling between 2002 and 2008. Patient, aneu-rysm, and treatment characteristics as well as adverse events were reviewed in 51 patients.
Results: There were 33 (64.7%) ruptured and 18 (35.3%) unruptured aneurysms measuring ≥10 mm. The mean (± standard deviation) age was 55 ± 10 years and follow up was 19 ± 16 months. 25 (49.0%) patients had more than one aneurysm. Recanalization occurred in 20 (39.2%) patients, 11 (21.6%) major and 9 (17.7%) minor. Two patients rebled, in both cases from previously clipped and ruptured anterior communicating artery aneurysms, one which underwent successful embolization and the other unable to achieve adequate occlusion thus undergoing a second surgical clipping procedure. Two patients developed communicating hydrocephalus requiring CSF diversion and 4 patients had symptomatic peri-aneurysmal edema with delayed onset of focal neurological deficits and headache.
Conclusion: This study suggests that aneurysms ≥10 mm in size may present greater challenges to clinicians that include a potentially higher incidence of adverse events and recanalization post endovascular treatment. This supports the importance of multicenter data collection in gaining further statistical power to determine the nature and sequelae of these events in an attempt to optimize the treatment of large intracranial aneurysms.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):165.
Purpose: To illustrate that after coiling of a pseudoaneurysm and sacrifice of the parent vessel, reconstitution and remodeling of that vessel may occur without aneurysm recurrence at least in the short term.
Summary of case: A 50 year-old woman with a Hunt and Hess Grade 4 subarachnoid hemorrhage underwent coil occlusion of a 4mm right vertebral artery dissecting aneurysm. Primary coiling with vessel sacrifice was feasible due to aneurysm anatomy. Immediate cessation of proximal flow was observed and sacrifice was well tolerated without PICA compromise due to AICA/PICA configuration. The vessel segment was not trapped. At three and six month follow-up, complete reconstitution of a normal appearing vertebral artery was observed, with stable obliteration of the aneurysm. The patient is being followed closely to undergo immediate vessel segment trapping for any evidence of aneurysm recurrence.
Conclusion: Parent vessel reconstitution with stable aneurysm obliteration was observed after endovascular coil occlusion and parent vessel sacrifice of a ruptured dissecting intracranial vertebral artery aneurysm.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):165–166.
Purpose: The use of self expandable stents for the treatment of intracranial aneurysms has widened the therapeutic options for aneurysms that would not have had an endovascular treatment alternative. The Enterprise® self expandable stent was recently approved for use in Canada.
Materials and Methods: Between January 2008 and January 2009, 8 patients underwent 9 endovascular stent assisted coiling with the Enterprise stent at the Hamilton General Hospital. All patients were pre-loaded with Plavix and Aspirin. We reviewed the technical and peri-procedural complications as well as clinical and radiological outcomes. All patients had follow-up imaging with DSA, CTA or MRA.
Results: Even though navigation of the microcatheter was difficult in some cases, all stents were deployed satisfactorily. No intra-procedural complications occur. In one patient with a giant partially thrombosed aneurysm, bilateral small thalamic strokes were detected on MRI post procedurally. No vessel occlusion or stenosis was observed on follow-up imaging.
Conclusion: The Enterprise stent has shown to be a reliable endovascular tool for stent assisted techniques. In our experience this device is easier to navigate and deploy compared to previously available intracranial stents approved for aneurysm treatment.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):166.
Purpose: Parent vessel occlusion for treatment of intracranial aneurysms can be achieved with detachable balloon or coils. The use of HydroCoil® may allow rapid and effective occlusion of the artery.
Materials and Methods: 4 patients (3 females and 1 male) with 2 large and 2 giant aneurysms were treated by scarifying the parent artery with HydroCoil. All aneurysms were unruptured but symptomatic. Two aneurysms were on the internal carotid artery (supraclinoid and cavernous segments), one on the A2 segment of the anterior cerebral artery and one on the P2 segment of the posterior cerebral artery. Clinical and neuro-imaging finding were reviewed.
Results: Parent vessel occlusion was achieved in all patients. All patients tolerated procedures well with no new neurological deficits. One patient had a hematoma at the puncture side that resolved with no intervention or clinical consequences. Follow up neuro-imaging in 3 patients showed no evidence of aneurysmal filling with good supply from collateral circulation. In one case there was partial aneurysm filling in a giant aneurysm.
Conclusion: The use of HydroCoil for parent vessel occlusion is effective for complete and rapid sacrifice of the artery in a short segment. This technique is useful in treating aneurysms when conventional coiling is not feasible.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):166.
Purpose: To know the outcome of unpredicted events during coiling of intracranial aneurysm.
Materials and Methods: We performed retrospective analysis of total of 129 aneurysms that were treated by coil embolization between July 2003 and July 2007 in our institution. Out of 129 cases, 19 unpredicted events such as thromboembolism (7), coil protrusion into parent vessel (5), intraprocedural rupture (6), or device related complication (1) were noted. We investigated the modified Rankin scale of these unpredicted events at discharge.
Results: Eight patients out of 19 had Modified Rankin scale of 0, three patients had 1 or 2, and four patients were 3 or 4. Four patients expired. In expired patients, preprocedural Hunt and Hess grade was 3 (one patient), 4 (two patient), and 0 (one patient).
Conclusion: Unpredicted events resulted in somewhat worse outcome, but that result is mitigated by the preprocedural morbidity. And furthermore, proper and timely corrective procedures such as infusion of antiplatelet agents or thrombolytics, prompt coil packing, and removal of the coil from the parent vessel with a snare usually resulted in a favorable outcome. We also found that a mere observation of the patients during the unpredicted events played an integral part in reducing adverse outcome.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):166–167.
Purpose: The management of posterior circulation aneurysms especially in certain locations and aneurysmal morphology (such as fusiform basilar artery aneurysms) is a tremendous challenge. In this presentation, we report our experience in the endovascular treatment of posterior circulation aneurysms.
Material and Methods: Our review includes 42 patients with distal vertebral and basilar artery aneurysms. Twenty-five patients had basilar aneurysms (19 basilar tip, 6 midbasilar), 5 posterior inferior cerebellar artery aneurysms, 4 vertebral artery aneurysms, 5 superior cerebellar aneurysms, 2 posterior cerebral artery aneurysms and 1 persistent trigeminal artery aneurysm.
Results: We will discuss the treatment indications, endovascular methods including coiling, stenting and parent vessel occlusion with associated risks and complications and technical challenges in this subset of patients. Twenty patients presented with subarachnoid hemorrhage and were treated within 24 hours from admission. Eight patients had fusiform aneurysms and were treated with parent vessel occlusion (n=4) or stent assisted coiling (n=4). Treatment was incomplete in one patient. Of the 34 patients with saccular aneurysms, 27 were treated with coils alone, 5 with stent assisted coiling and 1 with balloon assisted coiling. Total morbidity in the elective group was 4% and mortality was 0%. In the ruptured aneurysm group, morbidity related to the procedure was 5% and mortality was 20%.
Conclusion: In this presentation we show our institutional experience with a spectrum of posterior circulation aneurysms and the various endovascular treatment methods, with their risks and complications.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):167.
Introduction: We presented our initial results with PED in treating large and giant intracranial aneurysm, focused in clinical and angiographic results, as complications and midterm follow up.
Methods: Over a period of 34 months (March 2006-B February 2009) 43 patients (6 male/ 37 female) average age 62.1 years (7-85) with 47 large and giant aneurysms were treated with PED. Clinical presentation in 42 aneurysms was mass effect (with 1 or more neurological deficit) and 5 with non acute subarachnoid hemorrhage. All aneurysm were located in a main proximal artery. In anterior circulation was presented 39 aneu-rysms and 8 in posterior circulation. Thirty aneurysm were treated with only 1 PED, ten with 2 PED, three patients with 3 PED, three aneurysm required 4 and 1 patient more than 4 devices.
Results: Angiogram follow up range between 1 to 30 months. At 6 months FU occlusion rate was 93 %, and 6 to 12 months FU all aneurysms registered total occlusion. All patients with an initial mRS of 1 or zero, were unchanged at 3-6 month follow-up. No major (stroke or death) complications were encountered during the study period. Three patients, all with giant's aneurysms, experienced transient exacerbations of pre-existing cranial neuropathies and headache after the PED treatment. All of them were managed with corticosteroids and these symptoms resolved within 1 month.
Conclusion: These initial technical and clinical results are highly encouraging, and this technique (IER) may significantly improve the endovascular treatment of intracranial complex large and giant aneurysms.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):167–168.
Purpose: In a retrospective review from 1996 to 2004, we detected a risk for re-haemorrhage during embolization of acute subarachnoid hemorrhaged (SAH) aneurysms of a 4.4% (eight ruptures in 180 patients). We have reviewed the next 130 patients embolized in the acute stage of SAH between 2005 and 2009 to evaluate our current risk of bleeding.
Material and Methods: Embolization provoked re-rupture of the aneurysm in three patients among the 130 recent SAH cases. One of the patients died in the operating room. In the other two cases, intraprocedural haemorrhage resulted in few clinical changes.
Results and Conclusion: Among our initial cases (before 2005), one incident was due to microguide perforation of the aneurysm, another rehaemorrhage was related to the use of urokinase after coiling, and the remaining six complications occurred during coil placement (three cases in the first coil, and one of each during the second, third and forth coil). Mortality in this series was 1.6% (3 out of 8 patients). Among our recent cases, haemorrhage was due to difficult stent progression in one case, to first coil placement in another patient and to unknown causes in a third one.
The bleeding rate in this study has decreased in the last five years to 2.3%, yielding an intraoperative mortality of 0.7%. Reasons for bleeding in the recent series of treatments differ from the old cases.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):168.
Background and Purpose: Whether incidental aneu-rysms should be treated preventively remains controversial. A better knowledge of the morbidity and the long term effectiveness of endovascular treatment (EVT) is mandatory, since approximately 2% of adults harbor an unruptured aneurysm (UA).
Materials and Methods: The medical literature on EVT of UA was reviewed through a variety of databases. Searches were run by 2 of the reviewers using PubMed (including MEDLINE and Pre-MEDLINE), EMBASE.com, The Cochrane Controlled Trials Register database. Eligibility criteria were (1) the presentation of data included explicitly reported percentage of at least either case-fatality or permanent morbidity rate or crude data allowing an independent recalculation into crude numbers; (2) at least 10 patients; (3) UAs were saccular, non fusiform, strictly intradural, non dissequant, without concurrent arteriovenous malformation; (4) study published in a peer-reviewed journal; (5) original study and (6) publication in English or French between January 2003 and July 2008. Safety end points included procedural mortality, defined as any death caused by a complication occurring during the embolization procedure and unfavourable outcome at one month, defined as a mRS of 4 to 6; a GOS score of 3 or 4; a WFNS score of 3-6; a discharge site type 2.
Results: From 16 000 papers, 75 studies met all inclusion criteria and were included in the analysis. None of the studies scored positively on all the items of high methodological quality assessment. Cumulative unfavourable outcome at one month, including death, was found in 257 of 5791 patients (5.8%, 95%CI, 5.1-6.5 Q-value: 118.2, I2=40%). Thromboembolic event (9.0%, 95%CI, 8.2-9.9%; Q-value: 185.6, I2=68.2%), device problem (3.0%, 95%CI, 2.5-3.6%; Q-value: 74.2, I2=20.5%) and UA rupture (2.7%, 95%CI, 2.3-3.2%; Q-value: 27.1, I2=11.8%) were the three main procedural complications. There was a significant association between mortality and posterior location (RR=2.9 [95%CI=1.4-6.1], p=0.04). Patients with unfavourable outcome were significantly older (p = 0.01). A residual UA at the end of the procedure was found in 11.2%. Retreatment frequency was 11.3% (95%CI, 9.8-13.0%; Q-value: 78.1, I2=62.9%). The annual risk of bleeding after EVT was 0.2% (95%CI, 0.1-0.3%; Q-value: 17.5, I2=88.6%) but follow-up was limited.
Conclusion: The level of evidence regarding coiling of unruptured aneurysms is weak. Efficacy in the prevention of ruptures remains unproven. This systematic review highlights the importance of initiating a systematic enterprise to provide more reliable knowledge.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):169.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):169.
Background: Brain arteriovenous malformations (AVMs) often present with epileptic seizures, but prospective data on the risk of seizures by morphologic AVM characteristics are scarce. To address this issue, we analyzed demographic and morphological factors in patients with seizures at initial AVM presentation.
Subjects and Methods: We studied 155 consecutive AVM patients from a prospective referral center database. Univariate analysis and multivariate logistic regression models were used to test the effect of demographic (age, sex) and morphologic characteristics (AVM size, anatomic and arterial location, venous drainage pattern) on seizures as initial presentation in patients with unruptured brain AVM.
Results: Overall, 45 AVM patients initially presented with seizures (29%). By univariate comparison, male sex (p=0.02), increasing AVM size (p<0,006), frontal lobe localization (p<0.0001), arterial borderzone location (p<0.0006), superficial venous drainage (p=0.0002) and presence of venous ectasia (p=0.003) were statistically associated with seizures. The multivariate analysis confirmed an independent effect of male sex, frontal lobe AVMs and arterial borderzone location on seizure occurrence. All patients with seizures showed presence of a superficial venous drainage component.
Conclusions: Our study suggests seizures mainly occur in AVMs with superficial drainage. Other predisposing factors include male sex, increasing AVM size, frontal lobe and arterial borderzone location. Whether or not interventional treatment has an effect on the long-term risk of epilepsy remains to be determined.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):169.
Background: Hemorrhage constitutes the most feared complication in the natural history of untreated brain AVMs. Recent data suggest that the clinical deficit after AVM hemorrhage may be mild in some cases, but no studies exist on morphological AVM characteristics that may predict disabling deficits.
Methods: Of the 200 patients from the prospective Lariboisière AVM Database, we analyzed 80 cases who initially presented with intracranial hemorrhage. Univariate and multiple logistic regression models were used to determine the effect of demographic and morphological variables (AVM size, anatomic and eloquent location, feeding artery and venous drainage pattern) on disabling neurological deficits after acute AVM rupture (mRS >2).
Results: Among cases with initial AVM rupture, n=54 (68%) had intracerebral, n=17 (21%) subarachnoid, and n=29 (36%) intraventricular hemorrhage. The median mRS was 2 (IQR 1-4). Univariate comparisons showed significantly more disabling neurological deficits among AVMs with intracerebral hemorrhage (p=0.003), exclusive venous drainage (p=0.045). The multivariate model confirmed the independent effect of intracerebral bleeding location (OR 4.77, 95% CI 1.73 -13.17; p=0.003) and exclusive deep venous drainage (OR 2.85, 95% CI 1.17 - 6.94; p=0.021).
Conclusion: Disabling neurological deficits due to AVM rupture seem to occur more frequently in malformations with exclusive deep venous drainage and those bleeding into the brain parenchyma. The concept of eloquent brain locations does not seem to predict neurological outcome in AVM natural history. The potential role of the actual hematoma size and location merits further investigation.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):170.
Aim: To study the efficacy of Onyx Embolization in cerebral AVMs.
Materials and Methods: Between March 2006 and Aug 2008, 45 patients with brain AVMs were embolized with Onyx. Patients included 24 males and 21 females with mean age of 28 yrs (range 10 - 52 yrs). Clinical presentation included intractable seizures in 30 patients, parenchymal and intraventricular hemorrhage in 8, SAH from concomitant aneurysm in 1, motor aphasia in 1 and intractable headache in 5 patients. Average Spetzler-Martin grade and AVM volume at presentation was 3 and 18cm3 respectively.
Results: Fifty nine Onyx embolisation procedures were performed in these patients. Total of 138 feeding pedicles were embolized, averaging 2-3 pedicles per patient. Intranidal fistulas were embolized with varying concentration of NBCA. Average estimated size reduction was 75% (range 10 - 100%). Total angiographic obliteration was achieved in 8, partial embolisation followed by radiosurgery in 25 (90 - 95% obliteration in 10 and 80 - 90 % obliteration in 15 patients), partial embolisation followed by surgery in 1, and 11 patients have been advised additional sittings of embolization. Complications occurred in 10 patients, 4 had transient neurological deficits, one each had intraventricular and small parenchymal haema-toma, cortical vein thrombosis and 3 had post embolisation parenchymal haematoma that was surgically evacuated. No mortality was documented.
Conclusion: Onyx is a safe new liquid embolic agent for the embolisation of brain AVMs. Complete obliteration can be achieved in small AVMs. Large AVMs can be adequately reduced in size for additional surgical / radiosurgical treatment.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):170.
Purpose: In order to better define AVM nidal angioarchitecture 3D rotational acquisitions (3D-RA) on interventional flat panel angiographic X-ray equipement (Allura series, Philips Healthcare, the Netherlands) were performed to assess 3D vessels reconstructions of the malformations.
Material and Methods: 50 patients harbouring an intracranial arteriovenous malformation without prior treatment have been studied by conventionnal an 3D rotational angiography (3DRA). A serie of 120 images is acquired at a rate of 30fr/s, over an angle of 240° with a 512x512 pixel matrix detector. Selective injections are made using a nonionic contrast material. To have complete filling of the nidus and the draining veins, a delay for X-ray arrival time is applied (3s) for a full acquisition cycle of 7s. During the propeller acquisition move, the dataset is transferred to the 3D workstation (Xtravision, Philips Healthcare, the Netherlands). The volume is reconstructed and handled in a 3D space environment and can be studied with multiplanar reconstruction and a specified thickness, varying from 0.7 mm to 10 mm.
Results: Inter and intraobserver variabilty of this technique of AVM visualisation was superior to conventionnal angiograms for assesment of intra and perinidal aneurysms and venous morphology.
Conclusion: This new technique of brain AVM nidus allows for more precise assessment of the angioarchitecture of the nidus before treatment decision.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):170–171.
Purpose: To present the technical aspects of endovascular treatment of palpebral AVMs (pAVMs) and to expose the clinical and angiographic results.
Materials and Methods: Ten patients (6 females, 4 males) with a mean age of 22.7 y-o (range 12-35) were treated in our department from December 1992 to April 2007 for superficial pAVMs. Seven patients presented isolated pAVMs, while 3 had hemifacial AVM. Eight patients underwent absolute alcohol or Ethibloc injection by direct puncture (DP) in 11 procedures; ten transarterial embolisation (TAE) procedures, using glue or Onyx, were performed in 8 patients. Clinical and angiographic follow up (FU) were performed with a mean delay of 4 years.
Results: Two patients had a single endovascular treatment. Iterative procedures (from 2 to 4 procedures) were performed in 8 patients.
In one patient, endovascular treatment failed because of the risk of occlusion of the central retinal artery. No complication occurred except one case of transitory palpebral haematoma.
No decrease of visual acuity related to endovascular procedure was reported. Exclusion of the AVMs at the end of the procedure was > 80 % in 9/10 cases and total in half of the cases. All the patients underwent at least one surgical procedure after the embolization. Good clinical regression of the mass was obtained in 8 patients.
Conclusion: Associated with surgery, endovascular management for pAVMs is an efficient and safe technique with a clinical success rate of 80 %.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):171.
Background and Purpose: AVM embolization material reduce the radiation dose by shielding effect, proportionally to the radioopacity and the thickness of the material. Consequently embolization material might reduce the radiation dose delivered to an embolized AVM.
Purpose: Evaluate the impact of embolization material on radiation dose, by measuring and comparing the dose delivered in the center of an AVM model, prior and after embolization with onyx 18.
Material and Method: A cylindric (4cm length, 2cm diameter) embolized AVM model was created digging little channels in a water density material and filling them with onyx 18. X rays of the model were taken to ensure that onyx filled all the channels. A measurement film was positionned in the center of the model. The AVM embolized model was then positionned in the center of a brain phantom and irradiated (250 cgay) in stereotactic conditions using multiple radiation beams. The experiment was repeated twice.
Results: Measurement films showed that 245,6 et 247,2 cGy were delivered in the center of the AVM model filled with onyx compared to 247,3 and 240,1 cGy in the center of the AVM model without onyx.
Conclusion: It is unlikely that embolization material reduce the radiation dose delivered to an AVM in clinical conditions. This annihilation of the shielding effect is most likely explained by rebound effect and by the fact that the radiotherapy is delivered using multiple beams in different axes.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):171.
Purpose: Although onyx is a good tool in regard to DAVF and AVM embolization, in some cases it doesn't fulfill prior expectations. We wish to open a discussion on a situation where we found a limitation of this technique.
Material and Methods: We introduced onyx technique in our routine practice in 2006. Since then, out of 31 cases of AVM and DAVF we have treated 11 AVM and 6 DAVF with onyx. Median age for AVM patients has been 28 years old (15-45), and median age for DAVF has been 59 (53-67).
Results: In three patients, the embolization through the external carotid artery has been considered suboptimal despite achieving what was considered an adequate catheter tip location. In all three cases of insufficient onyx, penetration involved meningeal arteries.
Conclusion: We hypothesize that, when distal meningeal arteriolar bed is composed of very thin branches, onyx cannot be suitable for completely occluding the malformation. Diluted glue may be a better alternative.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):172.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):172.
Purpose: To present our experience using Onyx in the treatment of intracranial dural arteriovenous malformations (DAVF).
Material and Methods: Descriptive retrospective study of patients with DAVF treated with Onyx-18 (ev3) between September 2005 and December 2008.
Results: Of 35 patients with DAVF that diagnosis were made during the mentioned period, 13 were treated with Onyx-18 (10 males and mean age of 48 years-old). Patients presented with a mean of 33 months of symptoms history, mainly tinnitus (4/13), seizures (2/13) and cognitive deficit (2/13). Location at the transverse dural sinus was the most frequent (8/13) followed by the petrous sinus. Using the Rothschild Foundation classification there were distributed in osteo-dural (10/13), duro-dural (2/13) and duro-pial (1/13). With Merland classification they were distributed in type 2a+b (6/13), 3 (4/13), 4 (2/13), 2b (1/13) and 1 (1/13). They presented external carotid supply in 9/13 cases and mixture in 4/13. In 6/13 patients Onyx was used as the only therapy. In the remaining group, onyx was used together with other material (3/7) and after treating de DAVF with surgery, coils, gelfoam, microparticles or Histoacryl (4/7). Complete occlusion was achieved in 9/13 cases and 3 cases were retreated. Eight patients were controlled (mean: 7 months after embolization) with 6 complete exclusions. We did not have any complication or secondary morbidity in all the series.
Conclusion: The treatment of DAVF with Onyx is a safe and efficient option for the management of this disease. Long-term controls are follow up are needed to establish the real cure rates.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):172.
Purpose: This study aimed to define the patterns of basal cerebral venous drainage (BCVD) from cavernous sinus dural arteriovenous fistulas (CSDAVFs).
Materials and Methods: Forty sets of selective angiographic data from 36 patients with spontaneous CSDAVFs (age range, 53-79 years) were retrospectively analyzed for their drainage patterns. Three types of BCVD were observed, i.e., superolateral type, BCVD via the deep middle cerebral vein or uncal vein; posterolateral type, BCVD via the superior petrosal sinus and petrosal vein; and posteromedial type, BCVD via the bridging vein and the anterior pontomesencephalic vein. MR images and/or 3D-DSA images were also reviewed when available.
Results: BCVD from CSDAVF was found in 12 patients (30%), and the other drainage routes included the superior ophthalmic vein in 25 (63%), the inferior petrosal sinus in 17 (43%), the superficial middle cerebral vein in 17 (43%), intercavernous sinus in 15 (38%), the superior petrosal sinus in 7 (18%), and pterygoid plexus in 2 (5%), respectively.
In 12 patients with BCVD, superolateral type was found in 4 (33%), posterolateral type in 5 (42%), and posteromedial type in 7 (58%). Four cases of posteromedial type were associated with other types of BCVD.
Conclusion: CSDAVFs are often associated with BCVD via three different pathways. The posteromedial type via the bridging vein is the most frequent type of BCVD.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):173.
Purpose: To report our experience in treatment of dural AVF at superior sagittal sinus (SSS) in last 3 years.
Materials and Methods: Since 2006 till January 2009, we encountered 3 cases of dural AVF at SSS. They were 2 men and 1 woman and aged 66, 46, and 56 years old respectively. The clinical symptoms included dysphasia (n= 1), frequency attach of black out with spontaneous recovery (n=1), tinnitus (n=2), and headache (n=2).
Results: First patients treated with balloon angioplasty for the severe stenosis at transverse sinus, clincial symptom free for 3 years (no more black out). For the 2nd patient , we performed transvenous embolization throught the occluded SSS. For the 3rd patient, we performed fistula occlusion through trans-arterial approach. The dural AVF at SSS were occluded completely in the last 2 patients with no evidence of recurrence in short- or mid-term follow-up. The SSS was kept patent in the 3rd patient.
Conclusion: All the dural AVF especially at SSS should be treated individualizedly according to the lesion anatomy, patient's condition and experience of operator.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):173.
Purpose: To review cases of dural arteriovenous fistulae of cavernous sinus, treated with transvenous approaches through occluded or stenosed IPV by reopening technique in Ramathibodi hospital.
Method: We retrospectively review DAVFs of cavernous sinuses with occluded or stenosed IPV, between January 2007 to December 2008, approaching through occluded IPV.
Results: Among our 28 cases of cavernous DAVFs with stenosed IPV and underwent INR, including 20 females and 8 males, age varies between 27-79 years old. There are 16 DAVFs with intracranial venous reflux, with 9 cases of MCV, 3 cases of deep cerebral venous reflux and 4 cases of posterior fossa venous reflux. Transvenous approach through thrombosed ipsilateral (19 cases) and contralateral IPV (1 case), and through facial vein (1 case) are done then embolizing by fibered coils, GDC and NBCA, in serial fashion of disconnection. We experient 1 case of immediate complication with posterior fossa reflux.
Conclusion: DAVFs of cavernous sinus are relatively rare disease and pattern of venous drainage determines symptoms, leading to dangerous venous congestion with intracranial venous infarction and the malignant DAVFs usually occurs with venous obstruction. Transvenous approach to cavernous sinus can achieve best result with low morbidity & motality. Transvenous mechanical reopening of occluded inferior petrosal sinus with large guidewire, followed by microcatheter is useful technique to be discussed. Serial embolization of complex septated cavernous sinuses in order to obliteration of the dangerous reflux using technique of transcatheter selection will be shown.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):173–174.
Purpose: Sinus confluence (SC) is a sinus junction of the superior sagittal sinus (SSS), straight sinus (StS), and transverse sinuses (TS). Variation of the SC and adjacent sinuses can affect the cerebral venous return in dural arteriovenous fistulas (DAVFs). We analyzed variations of SC and adjacent sinuses by MDCT angiography, and demonstrate cases of DAVFs associated with sinus variations.
Methods: Axial and reconstructed images of CT angiography in 65 cases without lesion affecting sinus drainage was reviewed with a special interest in SC and associated sinuses. Angiography of 86 cases of DAVFs was reviewed to evaluate their relationship with the sinus variations.
Results: SC was classified into 7 types based on patterns of junction of SSS, StS, and bilateral TSs. Type A (n=19), Single terminations of the SSS and StS joining to the TS confluence ; Type B (n=4), bifurcated termination of the SSS; Type C (n=12), bifurcated termination of the StS; Type D (n=12), bifurcated terminations of both SSS and StS; Type E (n=6), Type D with TS confluence; Type F (n=9), single termination of the SSS and StS without TS confluence; Type G (n=3), aplasia of unilateral TS. Variations of adjacent sinuses included intrasinus septation (n=45), primitive tentorial sinus (n=2), developed occipital sinus (n=5), communication between medial and lateral tentorial sinuses (n=12), and falcine sinus (n=5). Among 86 DAVFs, some of TSSDAVFs and SSSDAVF were associated with intrasinus septation. Types of the SC are associated with cortical reflux from TSSDAVFs.
Conclusion: SC and adjacent sinuses frequently showed various variations. The knowledge would be important in the treatment of DAVFs.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):174.
A 76-year-female presented with a two months duration of mild exophthalmos and chemosis on the right side. Cranial CT and MRI remained inconclusive, but DSA demonstrated a slow-flow Type D fistula in the posterior part of the right cavernous sinus, with supply coming from the right meningeohypophyseal trunk and from the right accessory meningeal artery.
Intervention: A 1.5 F UltraFlow™ microcatheter was navigated into the internal maxillary artery over a SilverSpeed™ 0,010 microguidewire, and further advanced into the AMA, supplying the AV shunt. Temporary indirect flow control was achieved using a 20 mm HyperGlide™ balloon catheter navigated to the level of the MHT origin and inflated during the slow injection of Onyx®. Control angiograms of the right ECA and ICA showed complete occlusion of the fistula. After the procedure, the patients exophthalmos and chemosis improved steadily. Her visual acuity improved from 0.1 on both sides to 0.3 in the right and 0.5 in the left eye. The patient was discharged on the fifth postoperative day.
Discussion/Conclusion: In conclusion, this case demonstrates that using indirect flow control is a valuable adjunctive technique to increase the safety of transarterial Onyx® embolization. The combination of different modern occlusion techniques, further expands the possibilities of endovascular management using a non-adhesive liquid embolic for effective obliteration of DCSFs.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):175.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):175.
Purpose: To evaluate the accuracy of CT angiography and MR angiography (3D Time-of-Flight (TOF) and contrast-enhanced methods) in measuring intracranial atherosclerotic stenosis compared with digital subtraction angiography (DSA).
Materials and Methods: Between January 2007 and December 2007, forty one of 164 patients who underwent DSA in our hospital have intracranial atherosclerotic stenosis. All of 41 patients had undergone 3D TOF and contrast-enhanced MR angiography and ten patients had undergone CT angiography also. Seventy one arteries were assessed independently by 2 observers using DSA as the reference standard.
Results: In comparing CT and MR angiography with DSA of 21 arteries in 10 patients, repeated measured ANOVA showed that the degree of stenosis on CT angiography and TOF MR angiography was not different from on DSA but on contrast-enhanced MR angiography was significantly different from on DSA. In comparing TOF and contrast-enhanced MR angiography with DSA of 71 arteries in 41 patients, repeated measured ANOVA showed that the degree of stenosis of TOF MR angiography was not different from on DSA but the degree of stenosis on contrast-enhanced MR angiography was measured significantly higher than that on DSA.
Conclusion: CT angiography and TOF MR angiography can be used as reliable diagnostic and follow-up tool for the estimation of the degree of intracranial atherosclerotic stenosis.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):175.
Objective: The efficacy and pitfalls of endovascular recanalization were evaluated in cases of internal carotid artery occlusion in subacute to chronic stage.
Methods: Fourteen cases (15 lesions) of symptomatic internal carotid occlusion with hemodynamic compromise or recurrent symptoms were treated at the subacute to chronic stage using endovascular techniques. Parodi's anti-embolic system was used during the recanalization procedure to prevent embolic stroke.
Results: Recanalization of the occluded ICA was achieved in 14/15 lesions. The occlusion points were cervical ICA in 10, and petrous - cavernous ICA in 4 in successfully recanalized cases. The patient's ischemic symptoms disappeared completely after the treatment, and new ischemic symptoms did not appear related to the treated lesion. Single photon emission computed tomography findings demonstrated the improvement of hemodynamic compromise in all cases. One case caused right middle cerebral artery branch occlusion during the procedure, but his neurological symptoms were stable due to preexisting hemiparesis. Endovascular recanalization was possible and effective in improving hemodynamic compromise. However, there still several problems, such as hyperperfusion syndrome after recanalization, cerebral embolism during treatment, durability after treatment, and identification of the occlusion point before the treatment.
Conclusion: Endovascular recanalization using an embolic protection device can be considered as an alternative treatment for symptomatic internal carotid occlusion with hemodynamic compromise or refractory to antiplatelet therapy, even in the subacute to chronic stage.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):176.
Purpose: Patients with carotid occlusion and inadequate cerebral perfusion via collateral vessels are at high risk of subsequent stroke. In this group of patients, surgical options have failed to show benefit. We report our experience on 13 patients treated with carotid angioplasty and stenting (CAS) for symptomatic internal carotid (ICA) occlusion.
Materials and Methods: We retrospectively reviewed all of the cases of carotid occlusions that underwent cerebral angiography with the intent to revascularize over a 2-year period. Inclusion criteria were: angiographic demonstration of an ICA occlusion and the presence of clinical features suggestive of hemodynamic impairment, despite intensive medical treatment.
Results: Thirteen patients with a mean age of 72 years were selected for endovascular ICA recanalization. Ten patients (77 %) were successfully revascularized. Two clinically insignificant intraprocedural complications were noted: 1 flow limiting dissection treated by endovascular means and an acute thrombosis of an intracranial stent treated with abciximab. One patient in which recanalization failed, suffered a TIA after the procedure. There were no new ischemic events or reestenosis during a mean follow up of 18 months.
Conclusion: In patients with ICA occlusion and hemodynamic compromise, endovascular recanalization appears to show promising results in terms of efficacy and safety. In this group of patients, restoration of flow in the occluded ICA is associated with clinical stabilization. Future prospective studies are necessary to determine which patients are most likely to benefit from this form of therapy.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):176.
Purpose: To validate the usefulness of high resolution (HR) MRI in evaluation of intracranial artery stenosis.
Materials and Methods: Eight intracranial arteries (middle cerebral artery (n=4), basilar artery (n=3) and internal carotid artery (n=1)) from 6 patients who had significant intracranial artery stenosis on prior MR angiogram were enrolled and undertook HR MRI. The HR MRI was based on pre- and postcontrast proton density-weighted images of transaxial and coronal plane with parameters of TR/TE = 2500/30 msec, FOV = 120x105 mm, matrix size = 320x220, reconstructed voxel size = 0.23x0.23x2 mm.
Results: The cause of stenosis was atherosclerosis (n=7) or dissection (n=1). In a patient with proximal MCA dissection, intimal flap was clearly demonstrated only on HR MRI. The shape of atheromatous plaques were either eccentric (n=5) or circumferential (n=2).
Eccentric plaque had two layers; inner intermediate signal intensity layer (enhanced on postcontrast study) and outer low signal intensity layer. In two patients, the location of eccentric atheromatous plaques of basilar artery correlated with perforator occlusion leading to pontine infarction.
Conclusion: HR MRI is very useful method in revealing the cause of intracranial stenosis and the different characteristics of atheromatous plaques which may influence the stroke risk or treatment strategy.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):176–177.
Background and Purpose: We studied the efficacy and safety of additional neuroendovascular treatment (A-NET) for patients who are refractory to intravenous (IV) recombinant tissue plasminogen activator (rt-PA) in a retrospective manner.
Subjects and Method: The study subjects comprised consecutive 35 patients between Dec 2005 and Aug 2008; they had been treated with 0.6 mg/kg IV rt-PA (alteplase). The patients with major arterial occlusion who presented with a NIHSS score of ≥10 after the completion of rt-PA infusion were considered eligible for A-NET. A good outcome was defined when the mRS score was ≥2 at 3 months. Technique: A basket-shaped microguidewire (Soutenir) was placed on the distal side of the clot. The clot was removed by sandwiched between the Soutenir and the microcatheter. If the thrombectomy using Soutenir failed, percutaneous angioplasty using balloon catheter was attempted.
Results: A total of 13 patients with major arterial occlusion had a neurological deficit with an NIHSS score of ≥10 after the completion of rt-PA infusion. Of these 13 patients, 9 were treated with A-NET. Successful recanalization (TIMI score of ≥2) was achieved in 3 (33%) patients and a good prognosis was obtained in 2 (22%) patients. Five (56%) patients had a thin subarachnoid hemorrhage after the procedure, however, no special treatment was required. Symptomatic intracranial hemorrhage was not observed in any of the 9 patients. In contrast, all the 4 patients who did not receive A-NET had a poor prognosis.
Conclusion: A-NET using Soutenir can achieve a good outcome in patients unresponsive to rt-PA.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):177.
Purpose: Acute stroke from occlusion of the internal carotid artery (ICA) and proximal middle cerebral artery (MCA) generally has a poor prognosis and respond poorly to intravenous thrombolysis. Intra-arterial pharmacological and mechanical thrombolysis was used as an alternative procedure.
Materials and Methods: We retrospectively analyzed 10 consecutive patients (mean age 68 years, range 48 - 86 years) with an occluded ICA or proximal MCA treated with intra-arterial thrombolysis and balloon angioplasty. Eight patients had an ICA occlusion (siphon = 3, terminal = 5, including 2 concomitant cervical ICA occlusion), and 2 patients proximal MCA occlusion. Mean NIHSS score was 16 (range, 9 - 21). Mean time to treatment was 213 minutes (range, 120 - 330 minutes). Angiograms were graded according to Qureshi classification scheme. Recanalization was defined as grade 0 - 2. Hemorrhagic transformation was evaluated with CT scan on next day and 1 week after procedure.
Results: Immediate recanalization was achieved in 4 patients. There was no procedure-related complication. Hemorrhagic transformation occurred in 4 patients. One patient had recurrent stroke on contra-lateral hemisphere after procedure. Outcomes at discharge were dependent (modified Rankin Scale score 3 - 5) in all patients. There was no death case.
Conclusion: Recanalization of occluded vessel is an important factor for favorable outcome. Balloon angioplasty combined with intra-arterial pharmacological thrombolysis can be an effective technique to achieve recanalization, but it is difficult to recanalize ICA and proximal MCA occlusion with large amount of clots.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):177.
Purpose: It is well known about cerebral ischemic complications related to emboli during or after carotid artery stenting(CAS). However, hemodynamic ischemia in the other vascular territories related to hypotension after CAS has not been reported. We report three cases of cerebral ischemia appeared after CAS in the other vascular territories in 840 CAS series treated from 1997 to 2008 .
Cases and Methods: The first case had the right internal carotid artery(ICA) stenosis and left ICA occlusion. The right ICA was treated with CAS and the patient caused left cerebral infarction. Single photon emission computed tomography(SPECT) demonstrated stage II ischemia in the left middle cerebral arterial(MCA) territory. The left ICA was recanalized using endovascular technique. The second case had occlusion of the right anterior cerebral artery(ACA) and that area, showing stage II ischemia, was supplied from the leptomeningeal anastomosis via the right MCA. CAS was performed for the right ICA stenosis and hypotension caused cerebral infarction in the ACA territory. The third case had bilateral ICA stenosis and right ICA side was symptomatic. SPECT demonstrated stage II ischemia in the left MCA territory. A few days after CAS, he had left cerebral ischemia and treated with CAS for the left ICA.
Discussion: All cases had stage II cerebral ischemia and hypotension after CAS caused symptomatic cerebral ischemia in the preexisting subclinical ischemic area.
Conclusion: In cases with stage II cerebral ischemia, the risk of cerebral infarction is high after CAS in the affected territory. The control of the blood pressure is very important in these cases after CAS.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):178.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):178.
Purpose: The objective of this paper is to describe the clinical spectrum and treatment of the direct carotid cavernous fistulae (DCCF).
Materials and Methods: From January 2006 to January 2009, we prospectively evaluated ten patients with DCCF, regarding the clinical presentation, etiology, the duration of disease, Barrow subtype, the pattern of venous drainage, the flow of the shunt, the treatment option, as well as clinical and angiographic outcomes.
Results: In our study, all cases had type A fistulae. The time to diagnosis ranged from three days to two years from the onset of symptoms. DCCF was traumatic in eight cases (80%) and spontaneous in two cases (20%). Four (40%) cases had high-flow DCCF - all the blood from the internal carotid artery (ICA) entered the fistula without filling of intracranial vessel -; four (40%) cases had intermediate-flow DCCF - both the fistula and intracranial vessels received blood from the ICA), two (20%) cases had low-flow DCCF (only slow and sluggish filling of the cavernous sinus was apparent). Two patients with low-flow DCCF had spontaneous occlusion, but eight (80%) patients were submitted to endovascular treatment with coils by selective arterial approach of the cavernous sinus. Two (20%) cases had recanalization in less than three months after the treatment, requiring permanent occlusion of the ICA.
Conclusion: Selective occlusion of the cavernous sinus by arterial route is the first treatment option for intermediate and high-flow DCCF, in case of recanalization, definitive occlusion of the ICA may be considered a viable and safe form of treatment.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):178–179.
Purpose: We demonstrate utility of 3D rotational digital subtraction angiography (DSA) and DynaCT in the localization of intracranial arteriovenous fistulae (AVF).
Materials and Methods: We utilized a biplane flat-planner detector angiographic suite where 3D rotational DSA or cone-beam volume CT can be obtained interchangeably with the same FD C-arm. Our first case was a symptomatic dural AVF with cortical venous reflux (CVR) and multiple arterial feeders from the left occipital artery draining into an isolated left transverse sinus. The burr hole site was accurately localized with fiducials on the MPR workstation images generated from the rotational DSA. Placement of the burr hole was intended to avoid drilling into the adjacent mastoid air cells and to target the site of CVR, first. We also used 3D DSA and DynaCT with fiducials for precise localization of superficial pial AVF and tentorial AVF only visible at DSA. The lesions were not seen on CTA or MRA thereby preventing utilization of standard neuronavigation during surgical treatment.
Results: With the precise localization of the target lesion, we were able to perform relatively small craniotomies allowing for full access to the lesion. By correlating 3D DSA/DynaCT with CT images, the treating physician could use neuronavigation in cases of AVF not appreciated on cross sectional imaging.
Conclusion: 3D DSA and DynaCT allowed precise localization of intracranial AVF with fiducials which helped in treatment planning. These techniques are particularly useful when the AVF is beyond the resolution of cross sectional imaging.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):179.
Purpose: The purpose of this study is to report on the use of Dual-Volume-technique (DVT) and contrast enhanced ACT (DynaCT) for the visualization of small arteries in the pterygopalatine and middle cranial fossa.
Materials and Method: In five patients ACT and DVT were obtained using AXIOM Artis dBA (Siemens) and the following parameters 1) DVT: 10 sec, 2.5 cc/sec, total of 28ml (300mg Iodine). 2) ACT: 20sec. rotations, 0.4 increment, 220° total angle, 1024 matrix, 543 projections, 20% (50%) dilution (300mg Iodine), 2cc/sec and total of 40 ml. Image post-processing was performed in volume rendering technique (VRT) and maximum intensity projections (MIPs) using a commercially available workstation (Leonardo).
Results: ACT and DVT provided superior visualization of small branches of the internal maxillary and pterygopalatine artery, such as the accessory meningeal artery, artery of the foramen rotundum, vidian artery and pterygovaginal artery while demonstrating their precise courses through the foramina and osseous canals of the skull base and middle cranial fossa.
Conclusion: DVT in combination with ACT provide detailed anatomical information in neurovascular imaging previously not obtainable using other imaging modalities. It improves understanding of regions with complex vascular anatomy such as the pterygopalatine fossa and the parasellar and cavernous sinus region. This knowledge is valuable for interventional neuroradiologists when performing endovascular occlusions of arteriovenous shunting lesions supplied by arteries in this territory.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):179.
Background and Purpose: The purpose of this study is to report on the use of Dual-Volume-technique (DVT) and contrast enhanced ACT (DynaCT) for the visualization of venous anatomy in the cavernous sinus region.
Material and Method: In six patients, ACTs and DVTs were obtained using AXIOM Artis dBA (Siemens) and the following parameters 1) DVT: 10 sec, 2.5 cc/sec, total of 28ml (300mg Iodine). 2) ACT: 20 sec. rotations, 0.4 increment, 220° total angle, 1024 matrix, 543 projections, 20% (50%) dilution (300 mg Iodine), 2 cc/sec and total of 40 ml. Image post-processing was performed in volume rendering technique (VRT) and maximum intensity projections (MIPs) using a commercially available workstation (Leonardo).
Results: Visualization of major and minor venous structures using ACT was excellent and superior to 2D-DSA. ACT visualized in great detail small venous structures such as the internal carotid artery venous plexus (Rektorzik), the inferior petroclival vein and the anterior condylar confluens, commonly obscured on standard 2D-DSAs. DVT facilitated the understanding of the relationships between venous and adjacent osseous structures, not readily obtainable with other currently available imaging techniques.
Conclusion: DVT in combination with ACT provides a high level of three-dimensional information in complex anatomical areas that is of high value for interventional neuroradiologists when performing endovascular treatment and neurosurgeons when performing open surgery. The quality of image information obtained has become comparable to plastic casts obtained from cadaver studies, currently the reference method when studying vascular anatomy in this area.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):179–180.
Objective: Parasagittal meningiomas are one of the most challenging meningiomas for neurosurgeons due to high rate of recurrence and involving the parasagittal sinus. The purpose of this study was to determine the effect of Gamma Knife Radiosurgery on recurrence and size of parasagittal me-ningiomas.
Material and Methods: We treated 125 patients with parasagittal meningiomas using Leksell Gamma Knife model C system. 94% of patients had undergone microsurgery between 1 to 3 times due to tumor recurrence, and the reminder were new cases of parasagittal meningiomas. The tumors volume were between 0.636 to 58.7 cm3 and Gamma Knife treatment was performed by means of 10 to 15.5 grays and 35 to 70% marginal isodose.
Results: There was 91% tumor control rate as indicated by unchanged or reduced tumor volume with 2 years mean follow up. Major complication has been peritumoral brain edema, most likely due to venous problems.There was no mortality associated with treatment.
Discussion and Conclusion: The finding of our study shows that Gamma Knife could be considered as an effective treatment in parasagittal meningiomas.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):180.
Purpose: To report a very rare case with spinal intraosseous epidural AV fistula with perimedullary vein reflux causing myelopathy symptoms. With Onyx embolization, the intraosseous fistula tracts are totally obliteration.
Summary of case: A 57-year-old male with T12 and L2 compressive fracture with low back pain for more than 1 year. An accident happened few days before and acute deterioration of back pain with paresthesia, bil. lower legs paraparesis, urine and feces incontinence are noted. MR revealed cord edema with abnormal dilated vessels indicated spinal dural AV fistula with primedullary venous drainage. Spinal angiography showed epidural AV fistula fed by left T12 lumbar artery with intraosseous fistula tracts connecting to basivertebral vein and draining to anterior internal vertebral venous plexus than reflux into perimedullary veins. Embolization was performed by selective catheterization into the fistula and 0.6ml Onyx injected. The origin of drainage vein and all the intraosseous fistula tracts are totally occluded. Follow-up MR revealed complete recovery of cord signal intensity and disappear of the dilated vessels. The CT confirms the intraosseous communication of fistua. The patient discharged 1 week later with completely recovery.
Conclusion: Spinal intraosseous epidural AV fistula into epidural venous plexus with reflux into intradural perimedullary vein is a extremely rare finding causing myelopathy. Onyx is feasible, safe and allowing for a controlled penetration to achive complete obliteration. Furthermore, imaging studies of this case may be the first report to prove the possible correlation between trauma and spinal extradural AV fistula.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):180.
Purpose: Paraspinal AVFs are characterized as extradural AV shunts (AVSs) along the spinal column and this type of AVS are relatively rare among all spinal AVSs. We report 4 cases of Paraspinal AVF.
Summary of cases: From 1990 to 2009, 4 cases of paraspinal AVF were identified among a series of 141 spinal AVSs in our institute. There were 2 men and 2 women and the mean age was 55.5 yr (range 47-61). The AVFs were located at cervical area In 3 of 4 cases and found at T7 spinal level in 1 case. All patients presented with progressive myelopathy. All AVSs had multiple feeders and large ectatic drainers and varix. 3 of 4 AVSs were extremely high flow. 2 patients presented marked boney destruction. 1 patient had adjunctive tiny perime-dullary AVF and 1 patient had intracranial dAVF. No definite perimedullary venous reflux was revealed with DSA in all cases except one. All patients were treated with several times of transarterial embolization (TAE) with NBCA. Among them, 2 patients received subsequent transvenous coil embolization and 1 patients received surgical decompression and vertebral fixation followed by stereotactic radiotherapy after TAE. 1 patient was cured and 1 patient had marked shrinkage of the lesion. Perimedullary venous reflux was diminished but AVS was remaining in 1 patient. Another 1 patient is undergoing treatment. Clinical symptoms were markedly improved in 2 patients and the remaining 2 patients were unchanged.
Conclusion: Giant paraspinal AVFs are challenging lesions. A clear understanding of the anatomy and pathophysiology is necessary to plan treatment. To achieve better results, properly combined multimodal approaches are required in many cases.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):180–181.
Object: In an endovascular coil embolization for an intracranial aneurysm, the excessive pressure during the coil insertion into an aneurysm may cause a catastrophic rupture or dislodge a microcatheter tip from the aneurismal dome, resulting in insufficient embolization. Such undue mechanical pressure can only be subjectively detected by the subtle tactile feedback the surgeon experiences. Therefore, we developed a new sensor device measuring the coil-insertion pressure via an optical system. We introduce this novel sensor device.
Methods: This system is comprised of a haemostatic valve connected to the proximal end of a microcatheter (Y-connector). The sensor principle is based on an optical system consisting of an LED and line sensor. The latter measures how much the coil-delivery wire slightly bends in response to the insertion pressure by detecting the wire shadow. That information is translated into a given force level. The experimental aneurysm embolization was performed using this optical sensor. A silicone aneurysm and an in vivo (artificial swine bifurcation aneurysm) model were used. The sensor continuously monitored the mechanical force during the insertion.
Results: The sensor adequately recorded the coil-insertion pressure during the embolization. The presence of the sensor did not hinder the procedure in any way. In the silicone aneurysm model, the record showed a repeated peak-pattern change in pressure that reflected the actual clinical experience. In in vivo study, the record showed similar results.
Conclusion: This new sensor device adequately measures coil insertion pressure. This system provides potential for safer and more reliable aneurysm embolizations.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):181.
Purpose: Pre-operative tumor embolization has been shown to allow safe and complete resection of hypervascular head and neck tumors. However, endovascular embolization of hypervascular tumors in the head and neck may be challenging. We present a technique for the direct devascularization of a right carotid body tumor using percutaneous embolization with Onyx.
Case report: A 33-year-old gentleman presented with left-sided neck mass. Imaging revealed bilateral carotid body tumors. We were requested to perform pre-operative embolization to allow safe and complete right tumor resection.
A 6 Fr guide catheter was placed in the right common carotid and external carotid artery. Initially, a microcatheter was placed into the spinomuscular branch of the ascending pharyngeal artery and embolization with 100-300 particles was attempted. However, the catheter was occlusive with poor antegrade flow and endovascular embolization was terminated. Under fluoroscopic and ultrasound guidance, 3 3.5 inch x 20 gauge spinal needles were localized into the right tumor. Intra-tumoral angiography confirmed its position within the tumor vascular bed. Subsequently, embolization was accomplished under with slow infusion of 3.5 ml of Onyx 18. Less than 50 ml of blood loss was documented after surgical resection.
Conclusion: This case illustrates the value of percutaneous embolization with Onyx in the devascularization of head and neck tumors not amenable to particle embolization. In our limited experience, direct percutaneous tumor embolization appears to be safe and effective by independently reducing intra-operative blood loss.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):181–182.
We present a case of large pseudoaneurysm in sphenoid sinus associated with concomitant traumatic carotid-cavernous fistula (CCF). A 44-year-old male developed right carotid-cavernous fistula after head injury. MDCT angiography (CTA) not only depicted the presence of fistula, but also showed large pseudoaneurysm protruding to sphenoid sinus via fractured bony defect. Transarterial embolization by using detachable balloon could not occlude the connection between CCF and pseudoaneurysm completely. The lesion was occluded with Guglielmi Detachable Coils (GDC). Recurrent CCF and recurrent sac of pseudoaneurysm were noted one month later and were treated again with GDC. After the procedure, the CCF and pseudoaneurysm were completely obliterated, and the symptoms were cured. The importance of a cerebral angiography or CTA to know the status of the CCF and the possible formation of pseudoaneurysm is emphasized. The management options are also discussed.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):182.
Aim: To review the endovascular management of various cervical arterio - venous fistulae & analyse the outcome.
Materials and Methods: We retrospectively reviewed the angiographic data over the last 8 years to search for cervical arterio-venous fistulae. We encountered 4 cases, 2 males & 2 females, age range from 13 to 40 years. There were 2 vertebro-jugular fistulae (both spontaneous), one vertebro-vertebral fistula (spontaneous) & one carotico-jugular fistula (post traumatic). The patient with vertebro-vertebral fistula was a case of NF-1. The symptoms included humming sound over left side of the neck, radicular pain in left upper limb, paraesthesia and progressive weakness of both upper and lower limbs, more so on left side in paitent with VVF, While the other three noted swelling over the neck incidentally.
All patients underwent a complete angiogram to delineate the angioarchitechture of the fistula. Subsequently the fistulae were occluded by the transarterial route using balloons & coils. Number of embolisations per patient were 2 (3 patients) & 4 (1 patient). The patient with VVF underwent 4 sittings & was treated with a combined transarterial & percutaneous approach.
Results: All the fistulae showed complete closure after the final sitting of embolisation. Clinically all patients showed remarkable recovery. No recurrence was noted after total occlusion of the fistulae.
Conclusion: Arterivenous fistulae of the cervical vessels are uncommon lesions. They may be spontaneous (may be associated with neurocutaneous syndromes) or post traumatic. Endovascular management stays the mainstay of treatment with high success rates.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):182.
Purpose: Carotid body tumors are highly vascularized tumors. Surgical removal is often associated with a significant intraoperative bleeding rate because of the vascular nature of the tumor.The traditional technique for preoperative devascularization performed by most interventional radiologists is superselective catheterization of the supplying branches and transarterial embolization with particulate agent. However, because of the complex angioarchitecture with multiple, small feeding branches, involvement of branches arising from ICA and ECA, complete devascularization of the tumor is frequently not achieved. We report our experience in two cases of carotid body tumor treated by means of direct puncture and intratumoral injection of glue.
Materials and Methods: Two cases (62Y/O,24Y/O) of carotid body tumors (7 cm and 4 cm) presenting with palpable mass. Preoperative tumor embolization were performed under general anaesthesia. At preoperative treatment, detailed angiography was performed in each patient. The study included selective series of the external and internal carotid arteries and the vertebral arteries. All patients underwent surgery, which was performed one day after these procedure. The degree of devascularization was determined by angiography and blood loss was determined intraoperatively.
Result: Almost complete obliteration of the tumor stain in these two patients and minimal intraoperative bleeding.
Conclusion: Direct puncture of carotid body tumors with the intralesional injection of glue is a feasible, safe, and effective technique for achieving presurgical devascularization.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):182–183.
Purpose: The petroclival area is located behind the internal carotid artery in its intrapetrosal portion, which thus represents a potential danger for a percutaneous access. We present a case of transjugal percutaneous biopsy of the clivus using 3D angiography and 3D flatpanelCT in a biplane angio suite to delineate and avoid petrosal portion of internal carotid artery.
Summary of case: A 34-year-old patient is followed after surgery for a midline craniopharyngioma. A de novo osteolytic process of the right petroclival area independent from the residual craniopharyngioma is discovered on a control MRI. A biopsy is needed before radiosurgery.
In a biplane flatpanel angio suite and under general anesthesia, a percutaneous trans jugal bone trocars biopsy set is introduced to the petroclival fissure under fluoroscopic control. The petrosal portion of the internal carotid artery is identified by fusion images of 3D angiography and 3D CT. Progression of trocars into the osteolytic process is controlled by 3DCT, 3D angiography and fluoroscopic roadmap. Once in place an intratumoral soft tissue biopsy is realized. No complication occured. Biopsy analysis confirmed chondrosarcoma of low rank.
Conclusion: Percutaneus transjugal biopsy of the clivus and petrous apex is possible if a precise control of the petrous portion of the internal carotid artery is done by 3D angiography and 3D CT with rotational angiography.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):183.
Objective: To review three recent cases of symptomatic unilateral vertebral artery injury (VAI). We discuss how these cases have affected our facility's current screening protocol for cervical vascular injury in patients who present with cervical spine fractures due to blunt trauma.
Materials and Methods: A review of cross-sectional imaging and digital subtraction angiographic images of three patients. Clinical information was obtained by a retrospective chart review.
Summary of cases: Three patients with unilateral VAI developed posterior circulation infarction. All three patients were involved in high speed motor vehicle collisions, and sustained cervical spine fractures. Two cases were treated with endovascular vertebral artery sacrifice after persistent antegrade flow was demonstrated distal to the injured segment. Unfavourable anatomy in the third patient precluded an intervention, and the patient was treated medically. This unusual cluster of cases provided a dramatic display of the rare but potentially devastating morbidity associated with VAI. In light of these cases and a review of the literature, we have included CT angiography much more frequently at our facility in patients with high risk cervical spine fractures. Because of the relatively rare incidence of symptomatic VAI, we believe that it remains under-recognized, especially in smaller trauma centers such as ours. These cases have resulted in increased screening for VAI in our facility. Prompt diagnosis allows for early consideration of medical and/or interventional therapy with the intention of preventing adverse neurological outcomes.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):183.
Purpose: To present a patient with intercavernousinternal carotid anastomosis (ICA). Approximately 20 cases of this anomaly was described in the literature accompanying unilateral internal carotid agenesis.
Materials and Methods: A 57 year-old male was admitted to our hospital after a transient ischemic attack. He was otherwise in good health and was not diabetic. A CT angiogram was not able to reveal a cause for the cerebrovascular event but demonstrated a vascular structure within the anterior part of the sella and absence of the right carotid canal. An MR angiogram was suggestive of an interconnection between two carotid circulations within sella (TCA) and right internal carotid agenesis. The findings were verified by an arteriogram, the patient was also noted to have an incidental right middle cerebral aneurysm, aplas ia of right A1 segment and early bifurcation of the A2 segments from the left A1. 6 months after discharge, several weeks following a motor vehicle accident, the patient presented again with left retroorbital pain. On exam anisocoria was noted. A repeat angiogram to exclude Horner's syndrome due to left carotid dissection showed no interval change with regard to the previous arteriogram. Further clinical evaluation of the patient disclosed that the patient had Cranial Nerve III palsy. He was discharged on conservative management.
Conclusion: Many vascular lesions, including aneurysms, within sella may lead to Cranial Nerve III palsy. To our knowledge, this is the first TCA presenting with a third nerve palsy, possibly secondary to compression of the nerve by the anastomotic artery.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):183–184.
Background and Purpose: Patients with coiled ruptured aneurysms with incomplete occlusion at 6 months are not only at risk for rebleeding during further follow-up, but also for complications of retreatment and angiographic follow-up, and for progressive mass effect by aneurysm growth in selected cases. In this study we assessed frequency and outcome of all these events in 124 patients with a mean follow-up of 3.3 years.
Methods: Between November 1994 and January 2008, 901 ruptured aneurysms were coiled and 713 (79%) had 6 months angiographic follow-up. Of the 713 aneurysms, 589 were adequately occluded and 124 (17%) were incompletely occluded. These 124 patients were followed for mean 3.3.years (median xx, range).
Results: Of 124 aneurysms, 88 were retreated (71%, 95%CI 63-79%). During further follow-up, 15 of 88 patients were retreated more than once. Altogether, 115 retreatments were performed and no complications occurred (0%, 95% CI 0.0-3.9%). Also, in 307 follow-up angiograms there were no complications. During follow-up, 4 aneurysms rebled, causing death in 2. Another 4 patients had progressive mass effect caused by growth of the coiled aneurysm causing death in 1. Annual event rate was 1.9% and annual mortality was 0.7% (8 and 3 in 413 patient-years).
Conclusion: In patients with coiled ruptured aneurysms with incomplete occlusion at 6 months, a strategy of imaging follow-up and retreatment when possible leads to a low risk of events leading to morbidity or mortality. Recurrent hemorrhage and progressive mass effect of the aneurysm were responsible for these events, not complications from treatment or angiographic follow-up.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):185.
*The following posters have also been presented during the Technological Fair on Monday June 29th, 2009 (during the Satellite Symposium on Innovations and Progress in Neuro-Endovascular Therapies).
interv neuroradiol. 2009 Jun 2;15(Suppl 1):186.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):186.
Purpose: Neck plasty technique is useful for embolization of a wide neck aneurysm. Utilizing this technique for an ICA aneurysm, a neck plasty balloon sometimes moves during inflation because of the high pressure of ICA flow. To overcome this disadvantage, we introduce tandem balloon method, which is a modification of neck plasty technique for intraaneurysmal embolization of an ICA aneurysm using a balloon catheter as a guiding catheter. Here, we evaluated embolization of ICA aneurysms using a balloon catheter as a guiding catheter.
Materials and Methods: The smallest diameter of the balloon catheter that allows two microcatheters, a 2-marcker microcatheter and a balloon microcatheter, was 9F until recently, so now we developed a 8F balloon catheter which accepts two microcatheters. We used a 8F (or 9F) balloon catheter in 14 patients with ICA aneurysm, 12 of unruptured, one of acutely ruptured, and one of chronic ruptured.
Results: The navigation of the balloon guiding catheter was smooth and easy enough in every patient. We started with single catheter technique first and succeeded in 8 patients, but not in 6 patients. A HyperForm balloon microcather was introduced if single catheter technique was failed. Balloon guiding catheter was inflated just before inflation of the HyperForm. The HyperForm balloon was stable in all the 6 patients. There was one complication of femoral hemoatoma at the puncture site in the case used 9F balloon catheter.
Conclusion: The tandem balloon method is useful technique for intraaneurysmal embolization of an ICA aneurysm. A 8F balloon catheter is practicable as a standard guiding catheter for intraaneurysmal embolization of an ICA aneurysm.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):186.
Purpose: To quantitatively assess the effect of coil material, pulse sequence, and field strength on artifact induced by coils used for occlusion of intracranial aneurysms.
Materials and Methods: Three coil phantoms, 6mm in diameter, were constructed of bare platinum/tungsten alloy, covered platinum/tungsten alloy, and platinum/iridium alloy with a nitinol core. The phantoms were scanned at 3.0-Tesla according to a 3D time-of-flight magnetic resonance angiography (MRA) protocol as used in clinical practice. Additional 2D gradient echo scans with variation of echo time and read-out bandwidth, expressed in the water fat shift (WFS), were acquired at 1.5-Tesla and 3.0-Tesla. We measured artifact volume in 3D time-of-flight MRA and divided the artifact volume by the actual coilmesh volume, expressed in an overestimation factor. The proportional change in artifact diameter in the 2D gradient echo scans was calculated for variation in echo time, WFS, and field strength.
Results: The overestimation factor for artifact volume at 3.0-Tesla was 4 for bare platinum/tungsten alloy coils, 3 for covered platinum/tungsten alloy coils, and 10 for platinum/iridium alloy coils with a nitinol core. The artifact diameter enlarged with 31% for an increase in echo time from 2.3 to 6.9 ms, reduced with 2% for a decrease in WFS from 4 to 2 pixels, and reduced with 13% at 1.5-Tesla.
Conclusion: Platinum/iridium coils with a nitinol core produce larger artifacts than platinum/tungsten alloy coils. The echo time influenced artifact production more than field strength and read-out bandwidth, so choosing the shortest possible echo time is essential for artifact reduction.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):187.
Purpose: A new coil material for brain aneurysm was developed with novel bioactive design. Histologic analysis of biological change after deployment of the coil material was performed using experimental aneurysm model in swine.
Method: A total of 16 sidewall aneurysms were surgically created in 8 swine. 8 aneurysms were embolized using the coil materials with new bioactive design. As a reference, 4 aneurysms were embolized with clinically available 90/10 PGLA coils (Matrix coil®) and 4 aneurysms were embolized with platinum coils (Guglielmi Detachable Coil). All animals were kept alive for 14 days after the procedure. Histologic as well as immunohistochemical analyses were performed on each harvested sample.
Results: The coil material with new bioactive design induced similar inflammatory reaction when compared to the PGLA coil and stronger reaction than that of platinum coil. However, quantitative histological analysis showed that the most intense collagen deposition was observed in the new coil material group followed by PGLA coil group and platinum group. Furthermore, intensive macrophage expression as well as prominent invasion of myofibroblast was also observed in the new coil material group. The granulation tissue induced by the new coil material was characterized by its intensive invasion of multinuclear giant cells, profound microvascular proliferation and the advanced fibrosis around the coil materials.
Conclusion: Given the histologic findings observed in this study, the coil material with novel bioactive design seems to induce more potent biological effect, e.g. granulation tissue formation, than currently available coil materials for aneurysm treatment.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):187.
Purpose: In order to estimate the risk of aneu-rysm's rupture, a high efficient computational hemodynamic simulation system was introduced to simulate the blood flow in aneurysms. 20 IC-PC (Internal Carotid Posterior Communicating) and 10 MCA (Middle Cerebral Artery) aneurysms were selected with similar size and locations; seven pre-rupture-aneurysms (ruptured, on average, in five months after angiography), and 23 unrupture-aneurysms.
Energy loss (EL) has been proposed to approximate the hemodynamic lesion inside of the aneurysms.
Materials and Methods: CFD (Computational Fluid Dynamics) was as a calculation tool, and a transfer system was developed to convert the clinical image into available vessel geometries. The EL was calculated by the difference of the EL from with-aneurysm to non-aneurysm (removed aneurysm by visualization software). To confirm the accuracy of simulation, the results were validated by in-vitro and in-vivo. The validations showed good agreements.
Results: The flow inside the pre-rupture-aneu-rysms appeared higher speed; with stronger crashed into aneurysm surfaces compared with the unrupture cases. Blood passed through the pre-rupture-aneurysms was calculated to lose about 5 times more energy than the unrupture-aneurysms. The results indicated that the EL may be a significant parameter to estimate aneurysm rupture.
Conclusion: The research found that flows appeared more complex - with higher disturbances in the pre-rupture-aneurysms. Flow EL at aneurysms indicates a clear differentiation between pre-rupture and unrupture aneurysms. The simulation system has been systematically developed to be compacted within 30 minutes per case.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):187–188.
Purpose: Detachable coils are one of the standard embolic materials for the treatment of cerebral aneurysm. Recently the progress of invent the new coils are obvious such as bioactive coils and hydro coils. But still it is necessary to pack coils in the aneurysm very tightly. We would like to introduce newly invented made-in-Japan bare coils called ED COIL®. It is very soft and might be suitable for using as filling and finishing coils.
Materials and Methods: From January 2007, we have experienced 214 aneurysms treated by endovascular procedure using detachable coils. In these cases, we used ED COIL® for 153 cerebral aneurysms for embolization. ED COIL® is very soft bare coil made by Kaneka Medics which is genuine Japanese company. Platinum coil is connected with pusher wire using polyvinyl alcohol tube which is detached by electrically. ED COIL® is almost the same quality as regular 0.010"bare coils and it might be softer. We used ED COIL® as filling or finishing coils with other detachable coils except for very small aneurysm which we used it from the framing coil till finishing coil.
Results: Within 153 treated aneurysm using ED COIL®, inserted coils were detached safely in all cases except for a case of extravasetion. The case of extravation, we recovered using inflation of balloon catheter and packing coils very tight quickly. After detachment, distal migration of the coils occurred in one case, and in this case, migrated coil mass was retrieved with snare retriever successfully. No obvious clinical complication during these cases.
Conclusion: ED COIL® is useful for tight packing of aneurysm safely. We will show more about ED COIL® in the report.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):188.
Purpose: Real-time, intra-operative tools for minimizing aneurysm re-canalization may prove useful during endovascular treatment of intracranial aneurysms. This study aims to identify a volume occlusion percentage threshold above which aneurysm re-canalization is significantly reduced.
Methods: A retrospective analysis of 207 aneurysms treated by endovascular coiling in 191 patients between 2002 and 2008 was conducted. Initial volume occlusion percentages were calculated using an online calculator (Angiocalc©, Hanley et al.) that incorporates aneurysm characteristics. Re-canalization was defined as any angiographic increased filling from baseline.
Results: 146 (70.5%) ruptured and 61 (29.5%) unruptured aneurysms were reviewed. There was a mean (± standard deviation) follow-up of 18 ± 13months, size of 7.7 ± 3.9 mm, patient age of 53 ± 11, and initial occlusion percentage of 27 ± 10% (median 25%). Re-canalization occurred in 49 (23.7%) of 207 aneurysms, including 18 (8.7%) major and 31 (15.0%) minor cases. Initial volume occlusion <25% was a significant predictor of any re-canalization in univariate analysis (odds ratio [OR] 2.73 [95% confidence interval (CI) 1.39,6.89], p=0.003) and of major re-canalization in univariate analysis (OR 4.10 [95%CI 1.30,12.92], p=0.01). Adjusted multivariate analysis found that initial occlusion <25% significantly predicted any re-canalization (OR 2.35 [95%CI 1.15,4.81], p=0.02).
Conclusion: This suggests an initial volume occlusion threshold of <25% is significantly associated with aneurysm re-canalization. Real-time, intra-operative tools may be useful to reduce the risk of re-canalization by striving for >25% volume occlusion at the time of treatment.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):188–189.
Purpose: To investigate the capacity of a new liquid embolization device in reconstructing the surface of the parent artery at the aneurysm orifice resulting in reconstruction of laminar flow within its lumen.
Materials and Methods: Seven aneurysms in 7 patients were treated under an EC approved protocol. Indications included recurrence, acute subarachnoid hemorrhage (SAH) and incidental findings. Neucrylate AN, a new generation cyanoacrylate based embolic material was injected into aneurysms under flow control provided by temporary balloon occlusion across the aneurysm orifice with a total injection time ranging from 0:45 s to 2:30 minutes.
Results: Three parophthalmic carotid and 2 basilar tip aneurysms were completely occluded. Small residual filling was observed in another two aneu-rysms. Reconstruction of laminar flow was confirmed by flow simulation studies in 3, and by microcatheter injection angiography in 2 cases. Technical complications resulting in balloon rupture occurred in 3 cases without any clinical sequalae. No distal or proximal migration of the embolic material was observed. One patient died from SAH induced vasospasm 10 days following procedure, one had a temporary visual field deficit and another one suffered temporary aggravation of a preexisiting mass effect due to a giant basilar tip aneurysm.
Conclusion: In our limited experience, the Neucrylate AN liquid aneurysm embolic device proved to be safe and effective in reconstructing both the morphology and flow of the parent artery across aneurysms. Technical improvements of the protection balloons are needed to increase safety. Further follow up is being conducted to investigate long term efficacy.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):189.
Purpose: Despite current advancement of endovascular cerebral aneurysm therapy, universal measurement system of aneurysm size and volume has not yet been established. To conduct uniform evaluation of cerebral aneurysm occlusion and recurrence, we developed an analytical measurement software, Neuro VisionTM (KGT) for cerebral aneurysms.
Materials: This new software can be installed on a personal computer (PC) from a web-site. After installation, DICOM 3D data of pre and post aneu-rysm embolization images can be easily loaded to the PC. The aneurysm size (height, width, neck) and volume can be calculated automatically within 2 minutes. We retrospectively evaluated 73 unruptured aneurysms treated in 2006 using this software.
Results: All measurements were conducted in easy, fast and user friendly way. Of the 73 unruptured aneurysms, 15 (21%) showed recanalization. Average volume embolization rate (VER) of recanalized and not recanalized aneurysms were 24.2% and 19.5% respectively (P<0.01). Moreover, we found that recanalization tendency even with appropriate values of volume embolization rate (VRE) is higher in "bifurcation" type, compared to "side wall" type.
Of the 73 unruptured aneurysms, 6 (8.2%) required re-treatment. Average VER of stable occluded and retreatment requiring aneurysms were 23.5% and 19% respectively (P<0.05).
Conclusion: This software can be used for scientific and eventually clinical evaluation of cerebral aneurysm treatment.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):189.
Purpose: Endovascular treatment (EVT) of intracranial aneurysms requires highly trained physicians and careful pre-therapeutic evaluation of the aneurysm morphology. A realistic interventional neuroradiology simulator would provide procedural and skill training for either educational purpose or pre-therapeutic simulation in complex cases. This work aims at evaluating the clinical realism of a computer-based simulator for the EVT of aneurysms.
Material and Methods: A prototype computer-based EVT simulation system was developed and implemented. A silicon vascular phantom (Elastrat, Geneva, Switzerland) as well as two patient data sets were used for the evaluation. A coil adapted to the aneurysm was deployed under fluoroscopy. Then, a simulation was done with the same, as well as larger and smaller coils under the same viewing incidence and was visually assessed and compared to fluoroscopic images. The maximum of coil pressure onto the aneurysm sac was recorded during all simulations.
Results: In all cases, simulation with the correct coil showed a realistic coil behaviour and aneurysm filling. As expected, full and stable coiling of the aneurysm was impossible to simulate with too small coils. Protrusions outside the sac were observed with too large coils. In this latter case, the pressure onto the aneurysm wall dramatically increased as compared with the correct coil.
Conclusion: A preliminary evaluation of a computer-based EVT simulation system was made on both phantom and patient data. Our report emphasizes the clinical realism of the simulated deployment of coils, in particular with regard to potential hazards related to an inadequate choice of coil.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):189–190.
Purpose: To evaluate the long-term patency in elastase-induced saccular aneurysm models in rabbits.
Materials and Methods: Thirteen elastase-induced aneurysms were created. Serial intra-arterial digital subtractive angiography (IADSA) was performed 1 month and 5 years after creation. Aneurysm shape and dimensions, including neck diameter, aneurysm width and height, were evaluated from IADSA images.
Results: All the 13 aneurysms showed patent of aneurysm lumen 1 month after creation. Aneurysm shape remained the same 5 years after creation in 12 (92%) of 13 aneurysms, with 1 (8%) narrow necked aneurysm showed partial thrombosis within aneurysm cavity (neck size 1.9 mm, width 4.4mm, ratio of width/ neck 2.3).
Conclusion: Long-term patency of elastase-induced saccular aneurysm model in rabbits is excellent. There is occasional thrombus formation in aneurysm with narrow neck.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):190.
Purpose: To visualise intracranial arteries in cases of hemorrhagic strokes such as subarachnoid haemorrhage by time of flight (TOF) MR angiography. With this technique, vasospasms should be detected by non invasive MRA.
Materials and Methods: The scanner was Achiva 1.5 T HP Nova Dual Gradient (Philips Medical Systems Nederland B.V.) with its 16 channels neurovascular coil. After routine TOF MRA, mask images were acquired giving presaturation slabs both of cranial and caudal side. Subtacted this mask image from routine MRA, subtracted MRA images were obtained. This subtracted TOF MRA was performed for patients with subarachnoid hemorrhage and other hemorhagic strokes.
Results: Background noise was erased by this subtraction and brain arteries were clearly visualised. Even routine TOF could not detect vasospasm, subtracted TOF could detect them. Acquisition time for routine TOF was two minutes 55 seconds for 130 slices. For acquisition of mask, it took also two minutes and 55 seconds, which was thought beneficial to pay. Based on subtraction, patients' motion remarkably disturbed image quality.
Conclusion: Subtracting background from routine TOF MRA, brain vesels could be clearly visialised even in cases of hemorrhagic stokes. Vasospasms could be detected by this technique. Subtracted TOF may be beneficial for treatment of subarachnoid hemorrhage.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):190.
Purpose: Aspect ratio (AR) is a factor in aneurysm rupture. We examined the impact of AR on wall remodeling using rabbit elastase induced aneurysms.
Materials and Methods: 10 aneurysms were harvested at 12 weeks and defined as high (≥2.4) and low (≤1.6) ARs (n=5 for each group). Staining with H&E, VVG and CD31 immunohistochemistry was performed. We evaluated specific aneurysm sites including upper and lower aspects of the outflow and inflow walls. Wall and neointimal hyperplasia thicknesses were measured and compared.
Results: High AR group. Histologically, the 3 layers of the artery wall were absent, replaced by fibrotic tissue. Both neointimal hyperplasia and CD31 staining were absent on the inflow wall. In contrast, all 3 layers in the outflow wall remained; there was neointimal hyperplasia and CD31 staining along the entire outflow wall. The inflow wall was significantly thinner than the outflow wall (0.1 ± 0.03 vs 0.3±0.08, p=.0006) near the neck.
Low AR group. Fibrotic tissue replaced both outflow and inflow walls in 4 of 5 aneurysms. Neointimal hyperplasia was absent along both walls in these aneurysms. There were no differences in outflow and inflow wall thickness.
The lower portions of the high AR inflow wall were thinner than that of low AR group (0.06 ± 0.03vs0.11 ± 0.05, p=0.1 NS).
Conclusion: Aneurysm wall remodeling is different in low vs high AR aneurysms. Marked thinning was noted along the high AR inflow wall only. We are now correlating these same aneurysm findings with computational flow dynamics to study whether specific hemodynamic features might explain these findings; with an end goal of better understanding risk of rupture in saccular aneurysms.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):190–191.
Purpose: To analyse the hemodynamic characteristics in bifurcation cerebral aneurysms, simulated by computer fluid dynamics (CFD).
Material and Methods: We analysed the real data of 5 patients with 5 cerebral aneurysms (4 ruptured and 1 unruptured) of the middle cerebral artery (MCA) bifurcation. Data was obtained using a Philips Allura monoplane angiograph with 3D rotational acquisition. Images were exported in VRML mode. Then were segmentated with several softwares to create a volume and a meshed geometry. Hemodynamic characteristics were obtained using Fluent®. We determined the vortex structure, wall shear stress (WSS), effective stress (or pressure) and the degree of centre displacement between the dome and the neck.
Results: We found 2 centred (C) aneurysms and 3 non-centred (NC) aneurysms. All NC aneurysms were ruptured. In the C group there was a ruptured and an un-ruptured aneurysm. In C aneurysms the maximum pressure forces were at the fondus with significant higher values (148,45 vs 10,47 kPA). The same aneurysms also showed higher WSS values comparing the ones with non-aligned axis (3,4 vs 0,58 PA). We found no differences between ruptured and unruptered aneurysms.
Conclusion: WSS have been determined to be critical in the origin of aneurysm rupture. Although we found no differences in the ruptured and unruptured group of our small series, we were able to determine that bifurcation anatomic characteristics could lead to specific hemodynamic significant differences. Their relation to aneurysm rupture must be confirmed or not with larger series.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):191.
Purpose: Although hemodynamic stress is thought to play a role in growth and rupture of intracranial aneurysms, limited information is available about actual pressure (P) and blood flow velocity (BFV) in intracranial vessels. We aimed to simultaneously measure BFV and P using a guidewire with a pressure and Doppler velocity sensor at the tip.
Materials and Methods: We included 4 patients scheduled for elective coiling of unruptured intracranial aneurysms. Pulsatile BFV and P were recorded at 4 locations in the inlet and outlet vessels and within the aneurysm, if possible.
Results: Two aneurysms were located at the ophthalmic artery and two at the posterior communicating artery with a mean size of 6.8mm, range 5-9mm. High-fidelity BFV and P measurements were feasible in 10 (63%) and 14 (88%) of 16 locations, respectively. Systolic BFV ranged from 45-95 cm/s in the proximal internal carotid arteries (ICA) and was 42.8 cm/s (range 12-74 cm/s) higher in the inlet vessels in all patients. Complex flow fields limited capture of good BFV waveforms within the aneurysms. ICA systolic P ranged from 117-141 mmHg and declined by 10.7mmHg (range 3-26 mmHg) within aneurysms. Pulse pressure declined by 7.0 mmHg (range 6-10 mmHg) at more distal locations.
Conclusion: We have shown the feasibility of a novel method of simultaneous local pressure and blood flow velocity measurements in intracranial aneurysms and surrounding vessels using a dual-sensor guidewire. Local BFV can serve as boundary conditions for computational fluid dynamics, while P recordings provide direct information on the mechanical load imposed upon the aneurysm. Both measurements may thus add to patient-specific rupture risk assessment.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):191–192.
Purpose: The purpose of this study was to assess the usefulness of geometrical features of internal carotid artery (ICA) aneurysms in predicting the risk of rupture.
Materials and Methods: From an internal data base 39 consecutive ICA aneurysms were studied. Analysis of the aneurysm volume (V), ostium area (O area), the V/O area ratio, the ostium shape (width, breadth and ellipticity), parent artery and adjacent branch diameters and the aspect ratio were studied. All measurements were made from 2D and 3D DSA studies obtained using commercially available software (Leonardo, Siemens Healthcare, Forchheim, Germany).
Results: Aneurysms with the V/O area ratio > 12.0 and the ostium area < 13.0 had a statistically significant higher incidence of rupture (p =0.004 and p = 0.03 respectively). These two parameters were measured with high reproducibility. Aneurysms with an elliptical ostium and a smaller parent artery also had a higher incidence of rupture although these were not statistically significant (p=0.26 and p=0.12 respectively). Aneurysms with an aspect ratio > 1.3 also had a higher incidence of rupture than those with an aspect ratio < 1.3. This was not, however, statistically significant (p=0.21). The aspect ratio was found to be highly dependent on the projection chosen for measurement and varied considerably from measurements made on 2D and 3D acquisitions.
Conclusion: The V/O area ratio, the ostium area and its shape were helpful predictors of the risk of rupture in ICA aneurysms. Furthermore, the V/O area ratio seems to be a more reliable index than the aspect ratio because of its high reproducibility. The full value of these parameters requires further study.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):192.
Purpose: The purpose is to determine the capabilities of the Toshiba Aquilion One 320 CT scanner in detecting residual/recurrent cerebral aneurysm after coiling or clipping.
Material and Methods: 12 patients with one aneu-rysm each had either clipping (7) or coiling (5). All had CT Angiography performed by dynamic multiple volume acquisitions of the entire skull in an axial fashion i.e. no table movement and covering 16cm of z-axis volume. 60 mls of 370 contrast with 50 ml saline flush was used. Optimal arterial phase images of the anterior and posterior circulation were generated around the AP and SI planes in both Volume Render and Maximum Intensity Projections. The following were determined: 1) Residual aneurysm on the CTA. CTA interpretations were blinded to the subsequent Digital Subtraction Angiography performed within 4 days. 2) The amount of clip or coil artefact on the CTA. This is defined as the length (mm) of artery obscured by artefacts adjacent to the clip/coil in all three planes (axial, coronal and sagittal) in both VR and MIP projections. Averages for each plane and an overall average measurements were obtained for clipped and coiled aneurysms.
Results: For clipped aneurysms, the overall average artefact was 2.1 mm (MIP) and 2.7 mm (VR). For coiled aneurysms, the overall average artefact was 3.1 mm (MIP) and 4.2 mm (VR). The CTA did not detect any residual aneurysm. DSA detected a 6.4 x 2.3 mm residue in a clipped aneurysm and a 3 x 3 mm residue in a coiled aneurysm.
Conclusion: Volume acquisitions with 320 slice CT are still associated with small volume of artefact that may prevent detection of residual aneurysms that are similar in size to the volume of artefact.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):192.
Purpose: We report 10 consecutive patients treated with new Ascent remodelling balloon used in treating wide-necked intracranial aneurysms.
Materials and Methods: Between September 2008 and February 2009, 10 wide necked aneurysms were treated with remodelling technique using Ascent Balloon (Micrus Endovacular Corporation). The sites were: Anterior communicating-3, Internal carotid bifurcation-1, Carotico-ophthalmic-1, Basilar termination-3, Middle cerebral artery trifurcation-1 and Anterior cerebral artery-1. There were 6 good grade, 2 poor grade patients and 2 incidental aneurysms. The balloon was placed via 6F system using 0.014" microwire and flushed with heparinised saline. Coiling was performed using bare platinum coils.
Results: Embolisation was successful in all cases. In 9 cases the balloon could be placed at the desired site. In 1 case the balloon failed to track and coiling was performed without any protective device. An exchange technique for balloon placement was not required in any patient. The balloon wire can be withdrawn for reshaping without clot formation in balloon. The balloon Inflation-Deflation was rapid, predictable and stable. There were no thromboembolic complications, arterial dissections or ruptures. Angiograms showed complete occlusion in 8 aneurysms and 2 small neck remnants. All patients remained in similar WFNS grade post treatment.
Conclusion: The Ascent balloon is safe and easy to use for treating wide necked aneurysms. The choice of 0.014" wire allows tortuous vessel access without needing exchange technique. The coaxial design minimises contrast loss allowing better balloon opacification and minimising thromboembolic complications.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):192–193.
Purpose: To compare the packing densities achieved with novel soft coil designs, the Cashmere-014 and Deltapaq-010 coils, compared to each other and to a standard platinum, Helipaq-010 coil.
Methods: Twenty one identical silicone aneurysms were manufactured with sac and neck diameters of 8mm and 4mm respectively. The aneurysms were divided into 3 groups by coil type and coiled in a randomised, blinded fashion. Aneurysm models were connected to a pulsatile flow pump, catheterized and coiled under fluoroscopic control with a Siemens Neurostar system using single plane working angle projection. An identical Courier 90° tip catheter and Watusi guidewire were used for each model. Endpoint definition was catheter dislodgement from the coiled aneurysm, inability to insert the final coil due to resistance or parent vessel intrusion. Allowance was made for inadvertent catheter dislodgement in underpacked aneurysms, in which case the catheter was reinserted into the aneurysm over guidewire. Packing densities were calculated as a function of coil length x bore / aneurysm volume. Mean packing densities were compared across the groups for statistically significant differences using the Student T-test.
Results: Mean packing densities (percentage) were 32.2±3.3 (Helipaq), 35.2±2.8 (Cashmere) and 38.5±2.2 (Deltapaq). The greater packing achieved with the Deltapaq coil was statistically significant compared to the Helipaq (p = 0.001) and Cashmere (p = 0.012). The Cashmere tended to have greater packing than the Helipaq but did not achieve statistical significance (p = 0.096).
Conclusion: New, more compliant, coil design technologies allow higher packing densities in an aneurysm model.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):193.
Purpose: Durability of embolization of cerebral aneurysms has been hypothesized to result from greater packing density during the initial treatment. Coil development has been directed toward this goal through modifications in the coil properties. Deltapaq (Micrus, San Jose, CA) filling coils have been manufactured with a unique primary wind to allow increased coil breaking during deployment and softness to allow greater packing of aneurysms.
Methods: Case logs were reviewed for embolizations with the Deltapaq coil. We report the initial multi-center procedural experience with these coils.
Results: Forty nine patients with 51 aneurysms were identified. Mean age was 56 years, and aneurysms were treated electively in 33 (65%). The mean largest diameter of the aneurysm was 6.8 +/- 3.2 mm. Packing density (PD) achieved in these aneurysms was 40.8 +/- 19.6%. Balloon-assist was used for 25 aneurysms and resulted in greater mean PD, while stent-assist was used for 8 with no difference in PD. Immediate procedural results achieved were; 25 aneurysms were completely occluded (Raymond class 1), 18 had filling at the neck (Raymond class 2) and 8 had persistent filling of the aneurysm (Raymond class 3). Procedural complications were not associated with degree of PD. Minor complications (neurologic symptoms resolving within 24 hours or resolving angiographic thrombus) occurred in 5 patients. Major complications occurred during four embolizations (rupture, carotid dissection, cranial neuropathy and neurologic deficit lasting longer than 24 hours).
Conclusion: Initial experience with the Deltapaq coil is encouraging, with higher PD achieved without increased procedural complications.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):193.
Purpose: Assess the 3D position, apposition and deployment of intracranial stents by high resolution stent reconstruction with flat panel detector systems (Allura series, FD20, Philips Healthcare, The Netherlands).
Materials and Methods: On 100 patients acquisitionswere performed based on 120 kV X-ray control settings of a sequence of 620 images at a frame rate of 30 fr/s, over an angle of 240° using a 1024*1024 pixel matrix detector within a 43 cm maximum field of view. The 3D spatial resolution can go down to 30 μm (0.4 mm) with a contrast resolution of 5 Hounsfield Units at a slice thickness of 10 mm. The volume is reconstructed into a 256^3 pixel matrix box.
Results: We report our initial experience of in vivo assesment of intracranial stents used for intracranial aneurysm or intracranial stenosis treatment We assesed the ability of this technique to evaluate the deployment of stent intravascularly despite their poor radioopacity. Coils beam hardening artifacts are an important limitation to the analysis.
Conclusion: This technique in vivo is able to evaluate the stent deployment depending on the arterial curvature and confirm results of former in vitro experiences. It provides pertinent informations that modified the indications and techniques of intracranial stenting.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):194.
Purpose: The treatment of cerebral arteriovenous malformations (AVMs) by endovascular techniques is an invaluable tool in the management, pre-operative, pre-radiosurgical, and in certain cases definitive, of these lesions. Provocative testing before embolization has shown to be a predictor of a successful endovascular treatment without neurological deficit on patients. It has been traditionally used to establish area eloquence in patients undergoing neurointerventional embolization procedures. Pro-pofol has been used priorly as an alternative agent in Wada testing with adequate results. The pur-pose of this study is to establish the use of propofol as a safe and effective alternative to barbiturate provocative testing in AVM embolization procedures.
Materials and Methods: A series of 20 patients, undergoing 37 embolization sessions, were treated for cerebral AVMs between November, 2007 and January, 2009 by endovascular methods. All of the patients were treated under conscious sedation. Pre-embolization neurological assessment was evaluated with provocative testing using propofol at 7 mg doses intra-arterial after microcathether placement near the AVM nidus.
Results: Among these 37 embolization sessions, three provocative tests resulted with transient neurological deficits precluding further embolization. One of the patients passing the provocative test developed slight paresis as a result of embolization with n-BCA.
Conclusions: Propofol can be a safe and effective alternative to barbiturate testing on patients undergoing embolization of AVMs under conscious sedation.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):194.
Purpose: To assess the feasibility, safety, and effectiveness of the intracranial stenting with Zotarolimus-Eluting-Stent for symptomatic intracranial atherosclerotic stenosis
Materials and Method: From Jan. 2007 to Dec. 2007, 29 patients (29 lesions) with symptomatic intracranial atherosclerotic stenosis underwent primary stenting (Endeavor, Medtronic, Zotarolimus-eluting stent). Male-to-female ratio was 16:13 and mean age was 61.5 (41-76). Treated lesions were as follows: MCA - 13, Cavernous and distal ICA - 10, basilar artery - 3, V4 - 3. Mean stenosis was 72.8%.
Results: 27 stents were deployed successfully (93%). There were 3 minor infarcts, 1 mortality with vessel dissection, and 1 inadvertant detachment of stent. Follow-up angiography was available in 15 patients (range: 6-13 months, mean 8.7 months). Significant stenosis (>50%) was revealed in 2 patient. On clinical follow-up of 25 patients (range:1-22 months, mean: 12.9 month), one death with major infarct were developed. No other patients showed symptom related to the intracranial artery stenosis.
Conclusion: In selected patients, endovascular revascularization of intracranial arteries with stent-assisted angioplasty is technically feasible. But In the beginning, the physician must consider that potentially fatal complications may occur, and prepare for the worst.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):194.
Purpose: To assess the difference of embolic events by guiding catheter system in carotid stenting.
Materials and Methods: Among the patients underwent carotid stenting for 2 years (2007-2008), we chose 31 patients underwent pre- and post-procedural diffusion-weighted MR imaging (DWI). Among 31 patients, we positioned 8-F guiding catheter by assisting of a 0.035-inch guidewire conventionally (conventional method) in prior 16 patients. In the latter 15 patients, we positioned 8-F guiding catheter by assisting of a 5-F headhunter catheter and a 0.035-inch guidewire (assisted method). We analyzed newly developed diffusion-prolonged signals after procedure by site and number of the signals on DWI.
Results: New diffusion-prolonged signals after procedure were developed in 12 of 16 patients used conventional method (75%) and 7 of 15 patients used assisted method (46.7%). Among 16 patients used conventional method, the new diffusion-prolonged signals after procedure were in ipsilateral territory in 5 patients (31.3%), other territory in 1 patient (6.3%) and ipsilateral and other territories in 6 patients (37.5%). All seven patients with new diffusion-prolonged signals after procedure in 15 patients used assisted method had the lesions in only ipsilateral territory. The occurrence rate of new diffusion-prolonged signals after procedure in other territory is significantly lower in the group of assisted method than the group of conventional method (p=0.002).
Conclusion: The softness, size and shape of guiding catheter affect embolic events during carotid stenting. 5-F headhunter-assisted positioning of guiding catheter may be useful to prevent embolic event from the proximal vessel.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):195.
Object: To report new clot retrieval system for acute ischemic stroke treatment and results of experimental study of this system.
Methods: This new clot retrieval system was consisted of double reverse spiral fine nitinol wires, made by Wellfind Co, Saitama, Japan. Profile of this system is 0.014 inches from tip to proximal end of system, and could navigate with any usual microcatheter system. Once this system advances distally, double reverse spiral wire open in vessel and catch clot. Then, control arterial flow with balloon guiding system and pull back this system to withdraw clot, as Merci system. To confirm performance of this system and mechanical influence to artery, we completed animal experimental study and histopathological evaluation.
Results: At first, established embolic occlusion model of cervical arteries of pig with clot and successfully retrieved embolic materials with endovascular procedure using this system. And no pathological damages were shown in histopatological evaluation from extracted arteries after clot retrieval procedure.
Conclusions: This new clot retrieval system may work for acute stroke treatment. Clinical study is recommended to confirm efficacy and safety of this system.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):195.
Purpose: Periprocedural hypotension, which frequently occurs during carotid artery stenting (CAS), is an important risk factor for complications such as stroke or death after CAS.
Methods: In order to determine if a scoring model can be established to predict periprocedural hypotension (systolic blood pressure < or = 90 mm Hg) and prolonged periprocedural hypotension (requiring vasopressor for > 3 hours) in CAS, the authors conducted a prospective cohort study of patients undergoing interventional treatment of cervical carotid artery stenosis.
Results: Forty-eight stenotic lesions in 45 consecutive patients, treated with CAS, were included in the study. Multivariate analysis showed three independent risk factors of periprocedural hypotension; "fibrous plaque on Virtual Histology" (P = 0.029), "stenotic lesion involving both the common carotid artery and internal carotid artery on angiogram" (P = 0.004), and "patients without history of diabetes mellitus" (P = 0.020). Further, "distance between carotid bifurcation and point of minimum lumen size < or = 10 mm on angiogram" (P = 0.003) was an independent risk factor of prolonged periprocedural hypotension. Carotid morphologic autonomic pathologic score (carotid MAPS), determined by adding one point for each of those risk factors (total 0 to 4), had good discrimination for both periprocedural hypotension (area under receiver operating characteristic curve: ROC AUC = 0.876; SE 0.053) and prolonged periprocedural hypotension (ROC AUC = 0.811; SE 0.066).
Conclusion: Carotid MAPS is useful for predicting periprocedural hypotension and prolonged periprocedural hypotension during CAS.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):195–196.
Purpose: We aim to validate a large animal stroke model with the final goal of investigating mechanical recanalization.
Materials and Methods: Autologous clot (2.4x15 mm) was injected into the ICA of 8 mongrel dogs. DSA and 3T MRI imaging was performed before and after thromboembolism of the MCA. After 3 hours of MCA occlusion, thrombectomy devices were navigated to the occluded MCA. TTC staining of excised brains were performed to confirm MCA territory infarct.
Results: MR imaging revealed the development of a diffusion lesion ipsilateral to the occluded MCA in 6 of 8 dogs. MR and catheter angiography demonstrated that failure to produce diffusion lesions in 2 dogs was due to 1. autolysis of the clot and 2. A1 to distal M1 anastomosis. Postmortem TTC stained brain sections correlated to the observed diffusion lesions. Due to the tortuosity of the ICA, device delivery through a 2.3 Fr catheter into the MCA was performed from the dorsal approach. This approach was successful in 2 of 8 experiments. Delivery of 1.7 Fr systems into the MCA was successful; however they are too small to deliver the thrombectomy device.
Conclusion: The canine thromboembolic cerebral ischemia model produces repeatable brain infarction, 75% in our series. Autolysis of the clot or anatomical variants leading to collateral supply of the affected area may interfere with infarct evolution. Existing thrombectomy devices are not amendable to this model. This gyrencephalic model of stroke may be considered as an alternative to the rat MCA occlusion model for the development of thrombolysis or neuroprotection strategies.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):196.
Background and Purpose: To create an animal model to simulate human aneurysms, we modified the elastase-induced aneurysm model by use of a simple surgical technique in rabbits.
Methods: 33 New Zealand white rabbits were divided into three groups: in group 1 (n=23), a temporary arcuated aneurysm clip was placed at the origin of the right common carotid artery (RCCA) and part of right subclavian artery (RSCA), and the elastase-induced aneurysm procedure undertaken; in group 2 (n=5), elastase was replaced by saline; and in group 3 (n=5), the temporary arcuated aneurysm clip was located 3 mm above the location of the clip in group 1. Intravenous digital subtraction angiography (IVDSA) was performed at 3 weeks, 8 weeks, 4 months, and 6 months after the procedure, and two animals from group 1, and one each from groups 2 and 3, were euthanized for pathology after angiography. In group 1, aneurysm sizes were compared over time by analysis of variance.
Results: At every time point, saccular aneurysms were displayed in group 1 animals, but retrograde residuals were diplayed in all remaining animals of the other groups. Pathologic analysis showed that aneurysms had a thin wall and absence of elastin in group 1, no aneurysm and retrograde thrombosis in group 2, and aneurysms with thrombosis at 3 weeks that were absorbed after 2 months in group 3. In group 1, mean aneurysm dimensions, and diameter of parent vessel were not significantly changed over time (P>0.05).
Conclusion: Elastase and location of the temporary arcuated aneurysm clip are important to the success of this aneurysm model.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):196.
Purpose: To improve and value the establishing method of carotid side-wall aneurysm model in canine.
Materials and Methods: Bilateral multiple side-wall aneurysm models were surgically established on the carotid arteries of 15 dogs. The dogs were randomized to 3 groups: A: to be heparinized during procedure, B: after procedure, and C: not to be heparinized. Angiography was performed 2w and 1m later to evaluate the hemodynamic characteristics. Histopatholgic study was performed 2w in one dog from each group and 1m in random two dogs.
Results: Thirty-seven experimental aneurysms were confirmed. Angiograms showed whirl-like, vortex flow of blood within the dome of the aneurysms. 1 and 6 aneurysms were obliterated with thrombus in group A and C respectively. There's no significant difference in thrombosis rate between group A and B (Nemenyi: P>0.5). Histopatholgic study showed aneurysms became stable with the reduced inflammations after 1m.
Conclusion: To heparinize post-procedure and intra-procedure during model establishment could get the same anti-coagulation effects. To establish multiple aneurysms with surgical technique was well controlled. This model was useful in study the therapy technique of aneurysm for its possibility of realizing self-contrast and blank contrast.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):196–197.
Purpose: The advances in imaging technologies have improved our abilities to reveal the anatomical three-dimensional orientation of cerebral ANs, with a positive effect on their therapeutic management. Better understanding of the correlation between intra-aneurysmal flow dynamics and the natural history of cerebral ANs would lead to better therapeutic decisions. It has been suggested that hemodynamic factors such as intra-aneurysmal pressure and fluid-induced wall shear stress may be responsible for the development and growth of aneurysms.
Material and Methods: 6 Simple models of variable shapes of anterior communicating artery aneurysm have been made using computational flow dynamic methods based upon changes in the diameter of the A1 arteries. The relative distribution of stresses among the aneurysms have been studied and correlated with each others.
Results: The variations in the diameter of both A1 anterior cerebral arteries have significant impact on the stresses among the normal or aneurismal anterior communicating artery. Aneurysms located on geometries of equal A1 arteries have less dynamic stresses for formation than those located on dominant A1 on one side.
Conclusion: The variation in diameters of the parent vessels harboring the ACOM aneurysms will probably have an impact n their risk of rupture.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):197.
Purpose: To visualise flow at parent arteries and aneurysms by computational fluid dynamics (CFD). By this visualisation, specific flow pattern at bleb was considered.
Materials and Methods: Three dimensional (3D) structures of aneurysms were obtained by 3D DSA or 3D time of flight MR angiography. The 3D structure was given to our home brew voxcel based CFD system, which did not need manual segmentation nor mesh generation. The calculation model had solid wall, at present, and flow pattern was pulsatile, whose pattern was gotten by Dopper wire. The results were visualised by home brew visualisation application.
Results: To calculate at 128 x 128 x 128 voxcel model, it took about 7 or 10 days for 3 or 4 cycles using Xeon 5160 quad core system. For preparation, it took only a few hours as no need of mesh generation. Most of bleb had poor flow into themselves. Well-preparated DSA could confirm slow flow at bleb by slow contrast filling.
Conclusion: CFD for aneurysm with bleb showed decreased flow at bleb. Relatively slow flow was thought to a possible risk factor of rupture, also low share probably.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):197.
Purpose: Therapeutic neurointervention has become the main therapy for cerebrovascular diseases. However, tortuous arteries require certain interval of training before neurointerventionists could manipulate the devices with adequate skills. The present study attempts to produce the simulator for neurointerventional training using vascular model based on clinical cases.
Materials and Methods: Rapid production technique of an in vitro model of the human cerebral arteries based on MRI or CT scan was invented. 3D images of blood vessels were obtained and a solid wax model was rapid-prototyped with heat- and solvent- materials, and embedded within liquid silicone elastomer solidifying into solid block. After the evacuation of the wax a hollow reproduction of the wax model within the silicone block is obtained. Afterwards, soft vascular models were obtained with liquid silicone.
Results: The arterial model obtained was anatomically accurate for each arterial structure. The minimal attainable diameter was 300 micron in size and physical characteristics reproduced human blood vessels such as elastic modulus, Poison's ratio and friction coefficient within respectively 5 % errors. It is transparent and gives human-like elasticity. And models of carotid arteries and aorta were connected to cerebral arterial models. Normal saline with pulsatile flow was circulated using mechanical pump. Finally a complete model of human arteries related to neurointervention was created and was used as simulator for training.
Conclusion: Our vascular models could contribute to train young doctors as a simulator for neurointervention with its accurate reproducibility.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):198.
Purpose: The goal of this study is to build a population-representative silicone arterial model with lubricated lumen for easy deployment and testing of neuro-endovascular devices.
Materials and Methods: To evaluate the accessibility for neurovascular device delivery to the anterior intracranial circulation, a small-batch manufacturing method by infusing silicone into a core-shell structure was used to create an internal carotid artery (ICA)-middle cerebral artery (MCA) bifurcation replica with representative ICA siphon geometry. The 3D vasculatures from 20 patients were segmented and constructed from the MRA dataset, respectively, and centerline of each vasculature was extracted for vascular characterization. The ICA siphon with median average curvature (AC), length, and diameter was selected as a representative model. To provide lubricity to the devices, the luminal surface of the Sylgard 184 and LIM 6030 replica were treated with LSR topcoat. The coefficient of friction (COF) of the silicone replica was measured by a friction rig designed according to ASTM 1894 for evaluation of the effect of the surface modification.
Results: The median AC, length and curvature of the left ICA siphon from 20 patients are 4.37 mm, 21.42 mm and 0.30 mm-1, respectively. For right ICA siphon, they are 4.18 mm, 22.91 mm and 0.30 mm-1, respectively. A 54 % of COF reduction is achieved for the Sylgard 184 replica with one layer of LSR topcoat. For LIM 6030 replica, repeating the coating procedure for 3 times results in a 46 % COF reduction.
Conclusion: A silicone cerebrovascular replica with representative ICA siphon geometry and smooth luminal surface is fabricated for endovascular research in vitro.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):198.
Purpose: To investigate the impact of hemodynamic factors on the rupture of intracranial aneurysms with 3D model computational fluid dynamic simulation.
Materials and Methods: Rotation angiography was performed in three couples of internal carotid artery mirror aneurysms. Each couple was divided into two groups, one was symptomatic or ruptured aneurysm and the other was asymptomatic one. 3D reconstruction and computational fluid dynamic (CFD) simulation were obtained and the hemodynamic factors in the parent artery and aneurysm were compared.
Results: The average shear stress of the neck and the close parent artery of asymptomatic group was 5.54±2.89Pa, 6.6±3.47 Pa, while symptomatic group was 3.82±3.14 and 6.69±2.78. The low shear stress region of asymptomatic group was 0.53±0.50% and symptomatic group was 8.67±9.07%(P=0.05).
Conclusion: Ruptured intracranial aneurysms has a wider range of the low wall shear stress region compared with unruptured ones.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):198–199.
Purpose: Accurate evaluation of post-stent deployment characteristics such as wall malapposition, strut misalignment, and strut prolapse into the lumen has been limited by the resolution of current clinical imaging modalities. In our study, ultra-high resolution MicroCT was used to accurately visualize and assess deployment characteristics of four different intracranial stents.
Materials and Methods: A Neuroform Treo stent (NF3), a Enterprise stent, a Leo stent, and a Pharos stent were deployed in a straight polytetrafluoroethylene (PTFE) tube. MicroCT images were acquired using an eXplore Locus SP scanner. Image processing was performed using volume renderings with Amira 4.1 and additional unwrapping of the datasets in Matlab.
Results: The NF3 stent exhibited cell vertex misalignments at the distal end, uniform cell area, and intraluminal strut prolapse. The Enterprise stent showed no strut prolapse in the midsection but the struts carrying the markers prolapsed into the lumen due to the flaring of the stent ends. The Leo stent showed minor strut prolapse in every cell due to the braiding design, while major strut malapposition was present where the struts and the markers cross. The Pharos stent exhibited irregular cell alignments and skewed connectors but no strut prolapse.
Conclusion: Ultra-high resolution MicroCT provide highly accurate visualizations of stent deployment characteristics and adverse mechanics, such as cell misalignment, strut malapposition, and intraluminal strut prolapse. Detection and evaluation of minimal strut asymmetries is of potentially significant importance as they have been shown to have a strong influence on the stents' hemodynamic performance.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):199.
Purpose: The purpose of our study was to evaluate the quality and spatial resolution in stent visualization provided by a currently available state of the art 64 slice CT (Multislice CT) scanner in comparison with a clinical high resolution imaging modality (C-arm CT) and two pre-clinical imaging modalities: Flat Panel-CT (FP-CT) and ultra-high resolution MicroCT.
Material and Methods: A 2.3 x 23 mm Cypher stent was deployed in a polytetrafluoroethylene tube. MS-CT was acquired using VCT (GE Healthcare), C-arm CT using Artis dBA (DynaCT, Siemens), FP-CT using a pre-clinical research CT scanner (GE Global Research), and MicroCT using eXplore Locus SP (GE Healthcare).
Results: Due to blooming effects and partial volume averaging, the volume rendering generated from MS-CT showed artificially increased strut dimensions with no clear distinction between the regular struts and connector struts. The shape of the stent surface differed remarkably from the actual stent shape. C-arm CT and FP-CT derived volume renderings were superior to MS-CT, but also exhibited exaggerated strut dimensions compared to MicroCT. Basic geometric features of struts and connectors were visible, while finer details, as identified by MicroCT, were inconsistently visualized.
Conclusion: The spatial resolution of 64 slice CT scanners is inferior to C-arm CT and FP-CT. All of these modalities are currently insufficient to accurately visualize structural details of small metallic stents as are elucidated by MicroCT. Substantial increase in the spatial resolution of current and future clinical imaging modalities, especially MS-CT, is necessary for reliable and accurate assessment of stent deployment and patency.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):199.
Purpose: Coil embolization of intracranial aneu-rysms may be followed by recurrences. Radiofrequency ablation (RFA) of the endothelium may prevent recanalization after coil embolization.
Methods: We compared angiographic and pathological results of coil embolization (n=8) with coil embolization preceded by RFA (n=7) using a cardiac RF probe in the coil arterial occlusion model in 6 dogs at 1 month. Standard platinum coils, as potential RF probes and a dedicated constructed RF probe, for neurovascular applications in the absence or presence of a platinum coil or of a mass of coils, are tested for their ability to generate reproducible lesions in vitro, using egg white or chicken meat as substrates. A mathematical model was designed to predict perianeurysmal isotherm lesions during RFA.
Results: Coil embolization of arteries led to occlusion followed by recanalization (n=8), while RFA (20-30watts for 60 seconds) prevented recanalization in all coil-occluded arteries (P<0.001; X2 test). Current coils offer high impedance (400 ohms) at high current frequencies and are damaged by RF transmission. A dedicated probe generated reproducible lesions, but contact with coils interferes with lesion reproducibility. When the coil mass was used as a RF probe, a uniform RF lesion that conformed to the coil mass shape was produced. The mathematical model predicted a uniform heat distribution within 1mm from the periphery of the coil mass.
Conclusion: RFA can prevent recanalization after coil occlusion at least in the arterial model. Modifications of coils, dedicated neurovascular probes, and technique optimization remain necessary before considering a clinical application.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):200.
We proposed a canine T-type bifurcation aneu-rysm, surgically created between the 2 common carotid arteries. We assessed its value for training in endovascular techniques and testing both embolic and stenting devices.
The experimental aneurysm described herein mirrors human bifurcation aneurysms, in particular basilar tip aneurysm, and with this model, we sought to reproduce endovascular technical difficulties for stenting. The lesions created in this canine model did not show angiographic or histologic evidence of aneurysmal occlusion, after stenting. It has also been shown to recur after coiling in 2/2 animals. We conclude that this model may be useful for training in endovascular techniques and, because of sufficient aneurismal recurrence, is suitable for evaluating stenting devices.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):200.
Purpose: Neuroendovascular technology now allows routine access to distal cerebral vessels but there are cases where vessel tortuosity may not permit stable guide catheter position for placement of a microcatheter into the distal cerebral vasculature. The 6F Neuron delivery catheter has been developed to overcome this difficulty. We describe our preliminary experience with this delivery catheter, in overcoming tortuous vascular anatomy enabling safe microcatheter access into the distal cerebral vasculature.
Materials and Methods: Retrospective review of patient records treated at our institute (Jan 07 - Oct 08). In all cases, initial attempt at placement of a standard guide catheter was unsuccessful due to vascular tortuosity. However, the Neuron delivery catheter was able to be easily advanced into a stable distal position allowing for advancement of the microcatheter to the lesion. Demographics were 5 F and 2 M. Age; mean 53 years (range 15-67). 3 carotid cavernous fistulas, 2 M1 stenoses, one supraclinoid ICA dissection, and one SAH (HH III) from a ruptured left V4 aneurysm were treated.
Results: The Neuron delivery catheter was placed into the supraclinoid ICA in 3 cases, left V4 in 1 case, distal IMAX artery in 1 case, superior orbital vein in 1 case, and angular vein in 1 case, enabling successful endovascular treatment of the intracranial pathology with no related neurological complications.
Conclusion: All lesions were successfully treated through a microcatheter coaxially advanced through the Neuron delivery catheter. This catheter allows treatment of intracranial pathology previously not thought possible with traditional guide catheter technology.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):200.
Purpose: Neuro IVR requires precise information of the lesion with DSA. Three Dimensional Rotation Angiography (3D-RA) is now essential for Neuro IVR procedure. Development of flat panel technology also enables us to get intraoperative cone beam CT with 3D-RA. We evaluated usefulness of 3D-RA cone beam CT for Neuro IVR.
Materials and Methods: 3D-RA cone beam CT (DynaCT) was performed during various situation during Neuro IVR with Axiom artis dBA (Siemens) from May 2005 in our institution. Scan time for DynaCT was set to 8 seconds to reduce image processing time. Diluted contrast medium (10-20% in concentration) was used for enhanced DynaCT study.
Results: a) Aneurysm embolization: Using enhanced DynaCT, neck information was better visualized compared to 3D-RA. Enhanced DynaCT was also useful for precise positioning and placement of intracranial stents. b) Intaracranial PTA: In case of sever vessel stenosis, lesion crossing with guidewire was secured by enhanced DynaCT image and followed by safe PTA procedure. c) Carotid stentig: Enhanced DynaCT showed precise relation of vessel wall and stent. It also visualized accurate landing of protection filter.
Conclusion: Enhanced DynaCT showed useful information which could not be seen by 3D-RA only. Cone beam CT with contrast medium could be essential modality to achieve more accurate and safe neuro IVR procedure.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):201.
Purpose: Safety and gentleness to a vascular wall are required for a guiding catheter, especially in neuroendovascular treatment. Therefore, the new guiding catheter with a highly efficient silicone made balloon has been developed. Here we introduce a feature of this new instrument.
Materials and Methods: As compared with other balloon-catheters, on account of the silicone made balloon, our new catheter called CELLO (Fuji Systems Corporation, Tokyo, Japan) can provide a lot of usefulness; high conformability for fitting to a vascular wall gently, no fragmentation in case of burst although a balloon can be inflated to 16mm-diameter, easy and certain removing the air. Also there will be a low risk of catheter-induced damage on the vascular wall, because the tip of the catheter is covered fully with a silicon made balloon.
Results: We are developing a various sizes of catheter from 5 to 10Fr. The shaft of smaller catheter, such as 5 or 6Fr, is softer and more flexible to be used for occlusion of internal carotid artery and vertebral artery. The larger catheter, such as 9 or 10 Fr, which has more stability and trackability for the case such a carotid artery stenting needed proximal common carotid artery occlusion. Moreover, it will be applicable to the case of percutaneous transluminal angioplasty and thrombectomy.
Conclusion: Our new balloon-catheter, CELLO can be used for wide range of neuroendovascular treatment. This will provide us more surefire and safer procedure.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):201.
Purpose: The authors describe initial clinical experience of Robotic Digital subtraction angiography system in the Hybrid operation room (OR).
Materials and Methods: A newly designed robotic DSA system, Artis zeego (Siemens, Germany) was installed in the Hybrid OR. The system consists of a multi-axis robotic C-arm and surgical OR table. In addition to conventional neuroendovascular procedures, the system was used as intra-operative imaging tool for various neurosurgical procedures such as aneurysm clipping or spine instrumentation.
Results: Endovascular procedures including conventional endovascular treatment, open surgery and pre surgical cerebral/spinal angiography with/without subsequent surgical procedures were successfully performed using Robotic DSA. Newly developed 3D roadmap (i-pilot) was utilized as real time catheter navigation tool. During surgical procedures such as aneurysm clipping or Arteriovenous fistula treatment, intra-operative 2D and 3D angiography was easily performed without moving OR table. For surgical procedures, Robotic C-arm provided not only fluoloscopic images but also C-arm based CT images (DynaCT) and surgical OR table allowed surgeons to conduct image-guided surgery without moving the patients.
Conclusions: Newly developed Robotic DSA system provides safe and systemic treatment in the field of Endovascular Treatment and Neurosurgery.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):201–202.
Purpose: Drug eluting stents were devised as an answer to restenosis, but research has shown the eluting drug can interfere with the blood vessel's healing process, increasing the risk of stent thrombosis. A stent coated with Polyzene®-F, is a novel solution which promises to reduce in-stent restenosis and tackle the risk of thrombosis. Aim of the present study was to address late neointima and stent strut coverage in a consecutive subgroup of patients.
Materials and Methods: Fifty-five patients were enrolled in the ATLANTA FIM registry, addressing the follow-up results of the CATANIA™ stent with Polyzene®-F. As a part of the protocol, 15 patients were randomly assigned to optical coherence tomography (OCT) examination at 6-month follow up.
Results: A total of 1,904 cross-sectional images with 19,028 struts were analyzed. The rate of covered struts was 99.5%, whereas malapposed struts accounted for 0.15%. Area measurements were performed in 476 cross-sections. Neointimal (NIH) area and percentage of NIH area were 3.2±1.4 mm2 and 38±17%, respectively. Percentage of NIH area was comparable between diabetics and non diabetics. Qualitative assessment of OCT images demonstrated neither occurrence of stent fractures nor thrombus.
Conclusion: OCT assessment of the Polyzene®-F covered stent at follow up showed mild percentage of neointima. Also, almost complete stent strut coverage was revealed by OCT. These figures indicate that the CATANIA™ stent with Polyzene®-F is a promising solution for reducing late stent restenosis and preventing thrombosis.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):202.
Purpose: To test the reliability of non-invasive cerebral oximetry monitoring by Near-Infrared Spectroscopy (NIRS) in predicting neurologic intolerance to blood flow disturbance in patients treated by Carotid Artery Stenting (CAS) with either distal or proximal cerebral protection.
Materials and Methods: Between October 2003 and September 2008 109 patients, for a total of 123 stenotic lesions, were treated by protected CAS under NIRS monitoring of the relative oxygen saturation in the cortical vascular bed (rSO2). Three subgroups, based on type of protection used, were identified: distal filters in 67 cases, distal occlusive balloon in 12, proximal occlusion with MoMA system in 44. An rSO2 decrease of 20% from baseline was tested as a cut-off to predict clinical intolerance. Overall decrease of rSO2 was compared between subgroups.
Results: No major or minor cerebral or cardiac events occurred. Transient neurologic intolerance was reported in 4 cases with proximal protection and in 1 case protected with distal filter (p=0,046) Clinical intolerance was always anticipated by a decrease of rSO2 greater than 20% (PPV =55,6%, NPV= 100%). Statistically significant difference in rSO2 value decrease was found between filter/MoMA (p=0,00006) and distal occlusion/MoMA (p=0,024) subgroups respectively. No significant difference emerged between distal occlusion and filters (p=0,64).
Conclusions: NIRS monitoring during protected CAS is feasible and safe. A decrease in rSO2 lower than 20% from baseline was highly predictive of clinical tolerance to flow-blockage. NIRS may help improve safety of CAS procedures with proximal protection, by allowing a more confident handling of procedural steps.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):202–203.
Introduction: Since the loss of detachable balloons in the US in 2003, there has been no single-deployment device for ICA or vertebral artery parent vessel occlusion (PVO). Detachable coils can accomplish PVO, but are a time-consuming and expensive solution at best. The Amplatzer Plug, a self-expanding mesh device, recently has been introduced for peripheral vessel occlusion, but lacks the flexibility and regulatory approval for neuro indications. In the canine, an animal model frequently utilized for it's aggressive thrombolytic system, the Amplatzer Plug has previously been shown superior to coils for vascular occlusion.
The purpose of this study was to evaluate the efficacy of the Acta Vascular Occlusion System (VOS), a new Nitinol braided occlusion device seeking regulatory clearance - as compared to the currently-marketed Amplatzer Plug control device. in a canine model.
Methods: Using standard catheter based angiographic techniques either an Amplatzer Vascular Plug or an Acta VOS was implanted in either the subclavian or carotid artery in 12 canines. Accuracy, placement ease, vessel and device measurements were recorded. Occlusion effectiveness of each device was measured angiographically at 10min (+/- 2 min.) post-deployment and reassessed at 20min if not occluded. Occlusion was graded as: 1 complete occlusion; 2 near-complete; 3 incomplete or slow-flow; 4 no sign of stasis. Four animals were survived to 1 month and 3 animals to 2 months when angiography was performed followed by euthanasia, necropsy and vessel harvest for histopathology.
Control Device: Amplatzer Vascular Plug (AGA Medical, Golden Valley, MN), a self-expanding, cylindrical Nitinol wire mesh with platinum markers, 6mm diameter x 7mm long (9-PLUG-006), with 30-50% oversizing according to manufacturer's instructions.
Test Device: Acta VOS (Nfocus Neuromedical, Palo Alto, CA) a novel self-expanding ball comprised of two layers of high-density Nitinol braid with proximal and distal platinum markers. The unconstrained saucer-shape of the device is 10 mm x 1 5mm.
Results: All devices were implanted at the desired position. The Acta VOS resulted in more rapid occlusion with 92% achieving total occlusion at 10min vs Amplatzer with only 33% occluded at 10min. The Acta device produced total vessel occlusion on average in 10.4 min compared to the Amplatzer at 17.0 min. At follow-up angiography, recanalization was seen in all (100%) of the animals treated with the Amplatzer device compared to 5 of 7 (71%) of animals treated with the Acta VOS. Histologic data are pending.
Conclusions: Both vessel occlusion devices were simple and accurate to deploy. The Acta VOS device produced more rapid complete occlusion. The Acta VOS achieved more durable occlusion results compared to the Amplatzer in this animal model.
Disclosures: This study was sponsored by Nfocus Neuromedical, Inc., Palo Alto, CA
interv neuroradiol. 2009 Jun 2;15(Suppl 1):203.
Purpose: We describe the development of an interventional stroke unit in which MR and X-Ray angiography are integrated. The ability of MRI to determine tissue viability in acute stroke and in identifying patients who may benefit from early intervention is well established. In addition to IV tPA, intra-arterial therapies such as IA tPA and mechanical devices are available. However, tight coordination of schedules is required and cumbersome patient transportation between imaging modalities results in loss of precious time.
Materials and Methods: The integrated Angio-MR suite is comprised of a wide-bore 3T MR scanner suspended on rails mounted on the ceiling in combination with a biplane angiography system. A specialty radiolucent and MR compatible angiography table retains all the functionality of a "surgical" angiography table.
Results: Integration of both imaging modalities was successfully achieved and a two-room configuration was designed and built. One room was designed as diagnostic MR and the other as a standard, neuro-interventional lab. Modifications were made to both systems (collectively, the "RF-Quiet Design"), to the angiography tabletop and accessories. Switching between imaging modalities can be achieved in times as low as 90s, excluding other workflow aspects.
Conclusion: An integrated suite where both MRI and angiography can be performed on a stationary patient has been developed and demonstrated functional. Such integration may provide improvements in diagnosis of acute stroke, time-to-intervention, and its evaluation in a time-sensitive manner.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):203.
Background: Report our experimental work on rabbit elastase model of a new flow disrupting device.
Materials and Methods: 18 animals with aneurysm on the sub-clavian artery have been treated primarily by this stent (3.5 mm diameter/ 10-20 mm length) without coils. Stents have also been implanted in the abdominal aorta for evaluation of collateral patency. Dual Antiplatelet therapy was given for 1 month. The primary criteria studied was angiographic aneurismal occlusion at time points of 1,3 and 6 months. Secondary criteria's as complications on parent vessel, stent delivery and collateral branches patency inside the stent were aso studied. Histological electronic microscopy and was performed.
Results: Angiographic, histological and electronic microscopy caracteristics of aneurismal exclusion correspond to progressive thrombosis of the sac and neoendothelialization of the stents.
Conclusion: This type of stent allows for progressive occlusion or near complete exclusion of the aneurysm with preservation of parent vessel artery and collateral branches patency.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):203–204.
Background: Standalone devices targeted at endoluminal reconstruction for treatment of intracranial aneurysms have been developing. Such an endoluminal device may offer substantial advances over endosaccular therapies. The Silk stent (Balt, Montmorency, France) is one of this new developed endoluminal reconstructive devices designed to disrupt flow in the aneurysm but keep intact laminar flow of the parent artery. Even though this breakthrough device has been developed, the morphology after deployment has not yet to be studied especially in tortuous vessels.
Materials and Methods: Two sets of different size Polytetrafluoroethylene tubes (PTFE) tubes were used. To simulate the aneurysm neck, the tubes were punched through two opposite walls. Two similar sets of different size Silk stents were deployed in each tube. Each PTFE tube was curved and fixed in different angles. The tube also was curved in two different positions. Data collection was done after performing each position using flat-panel angiographic computed tomography (xperCT, Philips Healthcare) and macroscopic photography.
Results: Good conformability and deployment characteristics is observed under xperCT. Slippage of the wires is observed in a curved vessel model considerably, depending on the size and angle. Reduced interlaced diamond area occurred on lesser curvature. On the other hand, the area was larger on the greater curvature.
Conclusion: Because the wires can basically slide onto each other, braided wires design affects the interlaced diamond area in different curved vessel models. Detail of the morphology will likely enhance the ability to use this device clinically more safely and effectively.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):204.
Purpose: The aim of this paper is to explore the feasibility of road mapping techniques with fusion of pre-acquired Computer Tomography Angiography (CTA) images and real-time fluoroscopy for caheterization of supra-aortic trunk.
Material and Methods: We used a C-arc angiographic unit connected to a 3D workstation to create the dynamic road mapping. The volume datasets of isotropic CTA axial images (secondary dataset) were loaded into the workstation prior to the beginning of the examination. The protocol of rotation angiography of the thorax and neck without contrast injection was done to produce a primary dataset. Thereafter we created an overlay road mapping with the primary volume dataset and the secondary volume dataset. The navigation of the guide wires or catheters with the real-time fluoroscopy can start as soon as the registration between the 3D volumes is performed and follow the position of the C-arm.
Results: Three cases of diagnostic cerebral angiography (6 internal carotid arteries and 3 vertebral arteries) were performed using this technique. The mean consumption of contrast media was less than the control group (43 vs. 76 ml). The mean operative time is about the same (33 vs. 36 minutes). No complication was observed during or after the angiograms.
Conclusion: Road mapping combining pre-acquired CTA isotropic datasets with fluoroscopy from aortic arch level to proximal internal carotid arteries is feasible. The accuracy of registration was considered satisfactory in clinical practice.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):205–206.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):207.
Purpose: This study analyses advantages and shortcomings of Indocyanin Green (ICG) angiography in comparison to standard intraoperative digital subtraction angiography (DSA) during cerebral aneurysm surgery.
Materials and Methods: In 61 aneurysm patients, intraoperative DSA and ICG angiography were performed simultaneously for assessment of aneurysm occlusion and parent artery patency. Patient demographics, clinical data, and intraoperative findings were prospectively collected.
Results: Intraoperative ICG angiography was performed pre- and post aneurysm clipping using 50mg of ICG dye (PULSION Medical Systems, Munich, Germany) intravenously. The fluorescent dye was detected in the operative field through the operation microscope. The quality of ICG angiograms was negatively affected by cisternal blood, deep aneu-rysm location, and atheromatous plaques.
Results of DSA and ICG angiography differed in two cases: parent artery occlusion was not detected by ICG angiography in one case; misclipping and aneurysmal ICG filling was detected after surgical manipulation of the aneurysm during ICG angiography in another case. ICG angiography does not provide information about arteries outside the operative field and vessels embedded in brain tissue ICG provides information about important vascular structures, e.g. patency of perforating arteries after aneurysm clipping, as seen from the surgical viewpoint.
Conclusion: ICG angiography is a non invasive technique providing information about critical aspects of aneurysm surgery, e.g. aneurysm occlusion and parent artery patency. The limited field of view, restricted to the operation field, remains a significant shortcoming of the procedure.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):207.
Purpose: Endovascular embolization for very small cerebral aneurysm is still controversial. It may be difficult to do coil embolization and assiociated with high risk of procedure-related ruptured. We report the result of our experience in endovascular coil embolization for these lesions and assess the feasibility and effectivity.
Materials and Methods: We conducted an review of our experience and results of endovascular treatments for a series of 19 patients with 20 very small cerebral aneurysms. Among these patients, 14 women and 5 men, ranging age from 38-63 years. The very small aneurysms were located at supraclinoid segment of ICA in 7, cavernous segment of ICA in 3, AcomA in 5, Vertebral artery-posterior inferior cerebellar artery (VA-PICA) in 2, bifurcation of MCA in 1, pericallosal artery in 1, P2 segment in 1. The WFNS classification before treatment was Grade I in 14 patients and Grade II in 5 patients. The strategy of endovascular treatment included coil occlusion, balloon-assisted coiling and stent-assisted coiling.
Results: All patients were successfully treated with coil embolization, immediate angiography determined occlusion of aneurysm, including total occlusion in 5, subtotal occlusion in 9 and partial occlusion in 6. During 1 to 2 years follow-up, all aneurysms were confirmed complete occlusion by control angiography. No recurrence and coil compaction occurred. No rehemorrhage and neurologic systemic stroke occurred.
Conclusion: Endovascular coil embolization for very small cerebral aneurysm is effective and feasible. Initial subtotal or partial aneurysm occlusion might progress to total occlusion.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):208.
Purpose: Evaluating the effective and safety of using cover stent for recurrent intracranial large aneurysms which had been embolized with Neuroform stent assisted coiling.
Materials and Methods: 5 cases with cerebral large aneurysm had been treated by conventional endovascular embolization with Neuroform stent assisted coiling at an earlier date (over 6 months), recanalization was showed by control angiographic follow-up. Patient's age ranged from 32 to 64 years. Among these patients, aneurysms were located at cavernous segment of the ICA in 3 patients, supraclinoid segment in 1 patient and vertebrobasilar junction in 1 patient. 4 patients had mass effect symptoms.
Cover stents were navigated through the neuroform stent and deployed to cover the aneurysm neck. In 2 cases, there were two cover stents deployed in parent artery.
Results: Control angiography showed all aneurysms were excluded from the circulation and parent artery was preserved. No technical adverse event occur. 1 to 2 years follow up, the clinical symptome showed complete resolution in 3 patients, partial resolution in 1 patient, and complete reconstruction of the parent artery in all patients with no recurrent aneurismal filling and hemodynamic stenosis revealed.
Conclusion: The treatment of using cover stent for reopened large and giant aneurysm that had been embolized by neuroform stent assisted coiling is feasible. The technique of cover stent could be a effective strategy for management recanalization of the large and giant aneurysm.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):208.
Background: Dissecting aneurysms of the PCA are difficult to treat with preservation of the parentarteries. We report the clinical and angiographic outcome for 8 patients with dissecting aneurysmslocated at the P2 segment of the PCA.
Methods: In the past 5 years, 8 patients, 2 female and 6 male, presented to our institution with P2 dissecting aneurysms of the PCA and were treated endovascularly. The age of our patients ranged from 4 to 58 years, with a mean age of 34.4. Of the 8 patients, 5 had subarachnoid and/or intracerebral hemorrhage upon presentation.
Two patients with P2 dissecting aneurysms presented with mild hemiparesis and hypoesthesia; 1 patient with a large dissecting aneurysm complained of headaches.
Results: Eight patients with P2 aneurysms of the PCA underwent PVO. Parent vessel occlusions were performed with detachable coils. No patient developed neurologic deficits.
Conclusion: P2 dissecting aneurysms can be treated with PVO in the cases in which selective embolization of the aneurismal sac with detachable platinum coils or surgical clipping cannot be achieved.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):208.
Background: We present the results of our initial experience in using the Leo stent to treat patients with wide-necked cerebral aneurysms.
Methods: We assessed the clinical history, aneurysm dimensions, and technical details of the procedures, including any difficulties with stent deployment, degree of aneurysm occlusion, and complications.
Results: During a year period, 15 patients with 17 broad-necked aneurysms (n=13; average neck length, 6.1 mm; average aneruysm size, 9 mm) were treated with the Leo stent. Fifteen stents were deployed successfully with two failed. Of the coiled aneurysms, complete or subtotal (more than 95%) occlusion was achieved in 11 aneurysms, and partial occlusion was achieved in 2. One patient had multiple stents placed. One patient had ruptured aneurysm at the time of treatment. Technical problems included difficulty in deploying the stent (n=2).
Two periprocedural thromboembolic complications occurred. One patient had palsy after thrombolysis was attempted.
The other patient made an excellent functional recovery after undergoing successful thrombolysis of a thrombosed internal carotid artery stent.
Conclusion: Preliminary data demonstrated that the Leo stent is useful device for the treatment of patients with wide-necked aneurysms.
In cases with tortuous cerebral vasculature, delivery and deployment may be technically challenging. Clinically significant complications are uncommon.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):209.
Purpose: The recent advances in stent design have provided the ability to treat wide-necked intracranial aneurysms while keeping the parent vessel patent. We present the results of our initial experience in using the Enterprise stent (Cordis Neurovascular, Inc. Miami Lakes, FL) to treat patients with wide-necked cerebral aneurysms, with an emphasis on potential applications and associated intra-procedural complications.
Materials and Methods: A retrospective study of 15 patients with 15 wide-necked cerebral aneurysms enrolled in a single-center registry of patients treated using Enterprise stents, was performed. Three of 15 aneurysms were unruptured aneurysms, nine were acutely ruptured and 3 patients had SAH in their anamnesis. Four aneurysms were recanalized after previous endovascular treatment. 13 aneu-rysms were located in the anterior and two in the posterior circulation. Mean aneurysm size was 9.4 mm. The balloon remodeling technique for coiling before stenting was performed in one-third of all patients.
Results: Fifteen stent sessions were performed. In fourteen sessions successful deployment was obtained. In 15 aneurysms treated with stent-assisted coiling, angiographic results showed 7 (46%) aneurysm occlusions, 6 (40%) neck remnants, one (7%) residual aneurysms and one (7%) procedure failed. Procedural morbidity was not observed and one patient died.
Conclusion: These results indicate that Enterprise stent-assisted coil embolization is a safe and effective technique for lumen remodeling and treatment of wide-necked cerebral aneurysms. Further studies are needed to evaluate the long-term durability of stent-assisted aneurysm occlusion and tolerance to the stent.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):209.
Introduction: Fusiform vertebrobasilar aneurysm has an annual rupture rate of 2.3%. Involvement of the origin of posterior inferior cerebellar artery poses a technical challenge to treatment. We described here the endovascular treatment of an unruptured fusiform vertebral artery aneurysm involving the origin of posterior inferior cerebellar artery with flow remodeling.
Case report: A 47 year old gentleman presented with sudden onset of right-sided numbness, which resolved within a week. Magnetic resonance imaging showed right vertebral artery fusiform aneurysm (2 cm long) involving the origin of posterior inferior cerebellar artery, with a dome over superior part. The right vertebral artery aneurysm was treated by insertion of Neuroform stent (4.0mm x 30mm), followed by loose GDC coil packing of the aneurysm dome. Post-procedural angiography showed persistent flow into the embolized part of aneurysm. Follow-up angiography at 7 months showed the aneurysm dome occluded with trimming down of the fusiform aneurysm.
Discussion: Neuroform stent (Boston Scientific, Fermont, CA), a nitinol self-expanding open cell microstent, had the advantage of improved flexibility to negotiate to distal vessels and had low procedural morbidity. The concept was that local hemodynamics could be altered by placing an intravascular microstent. The coil loops together with the flow stasis induced by the microstent could promote the formation of a stable thrombus. Moreover, the porous microstent could serve as a substrate for neointimal growth and induce a remodeling of the diseased arterial segment, with preservation of important branch. This was successfully illustrated by the case described above.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):209–210.
Purpose: We aim to describe our tentatively established strategies for early endovascular treatment of hemorrhagic intradural vertebral artery dissection and the efficacy in prophylaxis of rebleeding and long term therapeutic effect.
Materials and Methods: Between January 2005 and January 2008, 14 patients with hemorrhagic intradural vertebral artery dissection were treated as our strategies no more than 1 week after SAH. Six patients received stent-assisted coiling, four received double stents placement and the other four received dissection and parent artery occlusion. Within follow-up, DSA at 6th to 12th month was required to evaluate effect of endovascular treatment and mRS (modified Rankin Scale) was used to assess recently clinical status.
Results: Among endovascular treatment, all procedures were relatively successful and no ischemic and rebleeding episodes occurred. Images from follow-up DSA confirmed that, for six stent-assisted coiling treated patients, three dissection was complete occlusion, two were nearly complete and one were incomplete; for double stents placement patients, two of them were cured completely while contrast material remained filled partially in other two cases; for the occlusion treatment patients, all dissection aneurysm disappeared completely. Besides one case among occlusion group died due to the AIND, there are neither severe morbidities (mRS 0-3) nor rebleeding or ischemia episodes after endovascular treatment hitherto.
Conclusion: Accordingly, our endovascular treatment for vertebral artery dissection have shown effective and promising potency in prophylaxis of rebleeding and curing these lesions.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):210.
Purpose: We sought to determine the long-term efficacy of aneurysm obliteration using CTA as the sole diagnostic test to determine ruptured aneurysm coilability.
Materials and Methods: A retrospective review of patients with ruptured aneurysms who had a CTA performed between 2004-2006 was performed. The follow-up contrast-enhanced MRA(CEMRA) reports were reviewed.
Results: A total of 189 aneurysms were coiled during the study period. 92 patients presented with SAH (48%). The median aneurysm size = 7 mm. 69/92 (75%) of aneurysms were deemed coilable on CTA alone. Patients were directly booked for endovascular treatment under general anesthesia without an intervening diagnostic catheter angiogram. The median time to coiling=19 hours. Long-term follow-up CEMRA was available in 56 (81%) of these patients. 51 of 56 (91%), with a mean follow-up of 20.6 months, had stable results; 5/56 (9%) required retreatment.
Conclusion: Decision-making regarding coilability of ruptured aneurysms based solely on CTA results in long-term durable aneurysm obliteration.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):210.
Purpose: We like to report the experience in 294 aneurysms treated endovascularly in 281 patients over a period of 13 years by the same interventional neuroradiologist .
Materials and Methods: 210 females and 71 males with 294 cerebral aneurysms presented with subarachnoid hemorrhage in 72% of cases, 89 patients had an unruptured lesion. The assessment of the occlusion of the aneurysm was based on the modified Raymond scale at the time of the treatment, in the mid term and lond term follow up. The procedure related complications, the number of surgery required after failed endovascular treatment and the final pati
Results: At the time of the treatment 187 cases were totally occluded;a small neck remnant was noted in 50 cases and a residual aneurysm in 25. In 32 cases the procedure was unsuccessful, 21 of these patients went on to surgical clipping. There were a total of 6 patients (2%) who bled after coiling, 4 of them within 24 hours. Procedure related complications with permanent sequelae occurred in 5 patients. The latest follow up exams were available in 136 cases: 55.8% of cases were totally occluded, 34.5% of cases had a stable small residual neck, finally in 13 cases a residual aneurysm was present but since it appeared stable, treatment was not deemed necessary.
Conclusion: The endovascular treatment of intracranial aneurysms is a relative safe modality with stable long term result: 90% of patients have either total occlusion or small residual neck. The fact that the same interventional neuroradiologist has performed all the interventions in this series offers a very homogeneous cohort which is rare to observe.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):210–211.
Purpose: The purpose of this retrospective study was to report the morphological characteristics and results of surgical and endovascular treatment of basilar artery (BA) trunk saccular aneurysms.
Materials: Twenty-two patients with 22 BA trunk saccular aneurysms underwent surgery including endovascular intervention.
Results: In this series, BA trunk aneurysms showed characteristic features such as so-called lateral aneurysm (41%), multiple aneurysms (32%), including two de novo aneurysms, and various vascular anomalies. Eleven craniotomies for neck clipping were performed for 11 ruptured aneurysms. However, in one of these cases, we abandoned neck clipping because of concern for neck tearing and embolized it later. Five ruptured and five unruptured aneurysms were successfully treated by endovascular surgery. Another one incompletely embolized aneurysm had grown to huge size, and the patient underwent a Hunterian ligation with a flow reconstruction.
Conclusion: The unusually high incidence of various associated vascular anomalies suggests that focal wall weakness must be based on the mechanism of aneurysm initiation. Most patients presented with subarachnoid hemorrhage. The pretreatment neurological state was predictive for clinical outcome. And clinical outcomes in this series were not affected by the choice of treatment. However, considering that three of 11 surgical cases needed subsequent treatment, endovascular surgery should be considered as a first choice.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):211.
Purpose: The aim of this study was to evaluate the safety and efficacy of Neuroform Stent when facing wide neck aneurysms and to compare the results considering the different types of coils used.
Material and Methods: We retrospectively analysed our database concerning 68 patients, harbouring 76 wide neck unruptured aneurysms, treated with Neuroform® stents and coils. Fifty aneu-rysms were treated in first intention and 26 retreated after partial recanalization. Coiling was performed with bioactive coils (53.9%), Hydrocoils (31.6%) or platinum coils (14.5%). Clinical, anatomical and technical results were reviewed.
Results: No mortality related to the treatment was recorded. Acute permanent morbidity was observed in 2 patients. After the treatment, complete occlusion was achieved in 31.6% of the aneurysms, neck remnant in 26.3 % and aneurysm remnant in 42.1% of them.
At mid term follow-up (20.2 ± 10.4 months) the patients were investigated with AMR (43) or DSA (33). A five months delayed ischemic stroke due to a in-stent thrombosis was observed. Three cases of clinically silent in-stent stenosis were also been observed 6 and 15 months after the embolization. Compared to the acute angiographic results, midterm evaluation showed stable occlusion in 32.9% of aneurysms, improved outcome in 52 % and worsening in 14.5 % of them.
Conclusion: The data of our study, in term of clinical and anatomical results, were comparable to the others in literature. We did not substantiate any difference comparing the results of aneurysms treated with different types of coils.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):211.
Object: Application of coil embolization for microaneurysm (less than 3mm in maximum diameter) has been considered a technically difficult method due to increased risk of potential aneurysm perforation during procedure. We present our experience and evaluation feasibility and limitations.
Material and Methods: Twenty patients with microaneurysms which were performed with coil embolization, visited our hospital between August 2003 and February 2008, were reviewed. They were unruptured aneurysms in 6, Hunt & Hess grade I in 1, grade II in 6, grade III in 4, grade IV in 2, and grade in 1.
Results: Eighteen patients were successfully performed without a complications(90%). Only two patients had a complications during or after procedures. One of them had a transient aphasia after procedure, which was stent related thromboembolic complication. The other patient had a delayed hemorrhages after procedure, which were related to incomplete embolization of aneurysm.
Conclusion: To prevent rupture or delayed hemorrhages during or after coil embolization of microaneurysm, selection of patients and, understanding of structural and technical characteristic of microcatheter is essential.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):211–212.
Purpose: Micrus Presidio coils are a combined framing and early filling coil. We present our initial 1 yr experience.
Materials and Methods: 48 patients with 48 aneurysms were treated with Presidio; 31 F & 16 M with 30 ruptured & 18 unruptured lesions. In 43 patients, Presidio was the framing coil. In 5 it was used for parent artery occlusion. Aneurysm location was: A Com 7; P Com 11; MCA 9; Posterior 7; Ophth 2; other 10. Patients were WFNS: 0 18; I 11; II 7; III 2; IV 7; V 2.
Aneurysms were: small (<10 mm) with small neck (<4 mm) 11; small with wide neck (>4 mm) 18; large (10-25 mm) with small neck 2; large with wide neck 11; 3 giant aneurysms; 32 wide (balloons in 13 [40%]) & 13 narrow-necked lesions. 25 were regular, 16 irregular. Aspect ratios were: <2 n=20; >2 n=23. 2 stents were deployed.
Results: 22 patients received ≥1 Hydrogel coil; 8 ≥1 platinum coil; and 47 ≥1 Cercecyte coil. Initial occlusion was: Complete 26 (50%); neck remnant 11 (24%); Interstitial filling 6 (13%); residual aneurysm 5 (11%); abandoned 1 (2%).
There were no procedural ruptures or parent artery occlusions. 1 coil knotted & 1 patient re-bled & died on heparin despite complete occlusion.
WFNS grades post procedure were: 0/I (GCS 15/15) 26 (59%); II 7 (15.5%); III 2 (5%); IV 7 (15.5%); V 2 (4%).
Conclusion: Presidio provides excellent neck-coverage and stability if one is prepared to re-deploy several times without significantly increasing rupture risk. The long lengths have advantages in parent vessel occlusions.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):212.
Purpose: For endovascular-endosaccular coil embolization for ruptured aneurysms, one of the important prognostic factors is recurrence of aneurysm. We analyzed recurrence pattern of ruptured aneurysm in order to prospect recurrence and to perform additional treatment in proper stage.
Materials and Methods: We have had 101 ruptured aneurysms treated by endosaccular coil embolization since 1998.2 to 2008.12. There was no case using stent assist technique in this series. These cases were followed by plain skull films at 3M and cerebral angiography at 6M. Angiographical follow-up was performed in 69 cases. We evaluated follow-up angiographical results and the pattern of the recurrence.
Results: Angiographical recurrence was found 38% in class 1 result, 17 cases out of 45 cases, and 28% in class 2 result, 10 cases out of 36 cases and 25% in class 3 result, 5 cases out of 20 cases. The patterns of recurrence were classified into simple coil compaction, intra-frame coil compaction, regrowth of neck remnant, mixed these patterns, inflow side recurrence and coil migration into thrombus or intracerebral hematoma. There were two cases of recurrent SAH in this series and additional coil embolization was performed in 6 cases.
Conclusion: Nearly one-third of ruptured aneu-rysms presented recurrence including minimal simple coil compaction. Early detection of coil compaction or coil migration is very important for proper timing of additional treatment before the recurrent SAH. Introduction of stent assisted technique with or without using surface modified coils is expected to reduce recurrence.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):212–213.
Purpose: To evaluate the aneurysms after coil embolization with three dimensional angiographic apparatuses.
Materials and Methods: From February 2008 to January 2009 at the University of Tokyo Hospital, 62 aneurysms after coil embolization in 57 patients were evaluated with 3dra reconstruction images. 47 at the end of treatment session and 15 at the time of midterm follow up (mean 16 Months). To make detailed images of three dimensional neck-aneurysm remnants, we made 'inverted translucent' or 'inverted volume rendering' images. Subtle adjustment of opacity and threshold for the reconstructed images on the work-station gave us more information about the angiographic results.
Results: With three dimensional estimations, less than 15% of aneurysms were evaluated as complete obliteration, while most aneurysms were evaluated as incomplete obliteration (Dog Ear; 9.7%, Residual Neck; 48%, Residual Aneurysm; 29% according to the Roy and Raymond Classification). We found it difficult to make the residual neck and branches visible for large and giant aneurysms due to the platinum artifact. For these cases, combination of reconstruction image and conventional angiography at the same C-arm angle were of great help for precise information.
Conclusion: Compared with conventional two dimensional angiographic images, three dimensional reconstruction images showed more precise morphology of the residual part of the aneurysms with platinum coils. 'Inverted Translucent' or 'Inverted Volume Rendering' images in combination with conventional angiography would be one of the best method for the three dimensional estimation of aneurysms after coil embolization.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):213.
Purpose: MicroVention Hydrosoft coils combine limited expansion, softness & similar histological characteristics to standard Hydrogel coils. We present our initial 1 yr experience.
Materials and Methods: 195 patients with 217 aneurysms (1 dural AVF) were treated with Hydrosoft; 152 F & 43 M with 147 ruptured & 70 unruptured lesions. Aneurysm location was: A Com 48; P Com 46; MCA 38, basilar 18; Ophth 7; ICA termination: 17; other 43. Hydrosoft only were used in 19, otherwise combined with Cerecyte or bare platinum coil. 19 aneurysms were re-treatments. Over 90% were good WFNS grade (0-II). 27 procedures were balloon assisted and 7 stents were deployed.
Results: Initial occlusion was: complete 127 (58%); neck remnant 75 (34%); Interstitial filling 10 (5%); residual aneurysm 3, failed in 2 cases. There were 2 aneurysm ruptures and one vessel rupture during manipulation for parent vessel occlusion. One permanent MCA branch occlusion although ReoPro was used on 8 occasions due to thrombus accumulation. Four patients died of vasospasm and one due to procedure related complications. Of the patients that had 6 month follow up angiography, 81% of aneurysms were stably occluded and 19% developed small neck recurrences or true re-growth; 3 patients are planned for re-treatment and the rest are under surveillance; 3 showed improved occlusion at f/u.
Conclusion: Hydrosoft coils are easy to deploy and do not have the time penalty of standard Hydrogel coils. In this early two centre series initial occlusion and stability is comparable to or slightly better than bare platinum coils alone but larger series and longer f/u is required while results from randomised controlled trials are awaited.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):213.
Purpose: The Enterprise stent is the new nitinol intracranial stent designed for treatment of wide-necked intracranial aneurysms. The purpose of our study was to evaluate the feasibility and initial results of employing this stent in patients with complex cerebral arterial anatomy.
Method and Materials: We collected all clinical data from our first twenty-one Enterprise stent placements. Stents were placed in ruptured and unruptured wide neck aneurysms unamenable to treatment with other available intracranial stent types. Decision to treat with the Enterprise stent was based on existing anatomical complexity or presentation of the aneurysm by means of acute subarachnoid hemorrhage with intricate arterial anatomy. All aneurysms were located in the anterior or posterior circulation.
Results: A total of twenty-two (28) stents were used in the study. Twenty-one (27) stents were successfully deployed; one stents became trapped inside the microcatheter. This stents was easily removed and a new one was placed. All stents were accurately positioned in the desired location. Two complications occurred (watershed incfarcts) after used Stent above 28 mm long both patients improve after three days to base line.
Conclusion: With introduction of the Enterprise stent, a new tool is available for the treatment of wide-necked intracranial aneurysms in patients with complex cerebral arterial anatomy which were previously untreatable with other stent types. Long term results of the stents for this application are still to be assessed.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):213–214.
Purpose: Aneurysms of the posterior cerebral artery (PCA) are rare. Endovascular embolization of PCA aneurysms has evolved rapidly because surgery of PCA aneurysms is technically challenging. The purpose of this study was to report the clinical presentation, endovascular treatment, and outcome of PCA aneurysms.
Materials and Methods: From 1998 to 2007, we treated 13 patients (F:M = 9:4, Age: 37-78 years, mean: 58.7) with PCA aneurysms. Nine patients presented with subarachnoid hemorrhage (SAH), one presented with a symptomatic temporal lobe seizure and the remaining three were asymptomatic. Eleven aneurysms were located on the P2 segment and another three aneu-rysms were located on the P3 segment of the PCA.
Results: Ten aneurysms were treated with aneurysm embolization, two with embolization of the aneurysm and the parent PCA and another with proximal PCA occlusion. Three aneurysms were treated with balloon remodelling technique and a another was treated with the double catheter technique. Angiography indicated that seven of the ten aneurysms treated with aneurysm embolization were complete and there was a small neck remnant in three. One patient treated for aneurysm and a parent PCA showed temporal lobe infarction. Two patients died from sequelae of SAH and one suffered from a small thalamic infarction due to delayed occlusion of PCA 7 months after treatment.
Conclusion: Although PCA typically has a rich anatomical collateral, occlusion of PCA hasn a risk of cerebral infarction. Therefore, aneurysm embolization sparing parent PCA flow should be selected for PCA aneurysm.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):214.
Purpose: An aneurysm on a persistent trigeminal artery variant itself is seldom and its treatment is still not well reported.
Summary of case: A 48-year-old man suffered from spontaneous subarachnoid hemorrhage. Emergent Right internal carotid angiography revealed a persistent trigeminal artery variant, and a fusiform aneurysm on its proximal segment as its branching from the ICA. Intraluminal occlusion of the aneurysm together with the variant artery was performed with detachable coils. The patient recovered without any neurologic deficits. Related literatures and possible embryologic pathogenesis were reviewed.
Conclusion: We proposed that a defect harboured the persistent embryonic vessel might be the possible causes of the fusiform aneurysm and occlusion of a PTAV aneurysm together with the parent artery was a safe and effective treatment for this rare clinical circumstance.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):214.
Purpose: To illustrate our preliminary experience about the combined treatment of stenting and coiling for complex cerebral aneurysm(AA) by news stents (Enterprise®, Leo Plus ®, Solitare®, Wingspan®, Silk®).
Material and Methods: 18 patients, 20 AA, were treated by stenting and coiling. Same pts. were affected by sacciform wide-necked partially thrombosed aneurysms, others by fusiforms. 6 ruptured AA were treated on early treatment, while others 14 on election's day. For 4/20 coiling was performed by Jailing technique and in 3 cases also a remodelling technique was performed. Pts with ruptured AA were previously administrated with heparin's protocol during and post-treatment more ASA (500mg) after stenting. Pts with unruptured AA were previously administrated with plavix for 7 days before. Post-intervention medical therapy was plavix and aspirin for 5 months, then aspirin (100mg). MRA and DSA at 6-12 months were performed.
Results: Treatment was successfully performed. The stent could be navigated within cerebral arteries without any exchange procedure, and thanks to its retractability, it was precisely positioned. No procedure-related complication occurred. Complete occlusion aneurysm was observed in 14/20 AA, partial occlusion with residual sac in 2/20. At 4 months collect's rest was observed in 4/20 with a increase of residual sac at one year in one case, treated by coiling. At 1 year, MRA showed reduction of the rest in one case and a stable collect' rest in other one.
Conclusions: Stenting + coiling for sacciform wide-necked, or fusiform aneurysms is safe procedure without complication. Medical-therapy pre-post procedure associated to follow-up are necessary to establish occlusion rate.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):214–215.
Objective: Matrix and Matrix2 (Boston Scientific, Boston, USA) are bio absorbable polymer coated coils developed to promote intra aneurysmal clot organization and fibrosis. We evaluated recanalization and re-treatment rates in a continuous series treated with them.
Methods: Retrospective review of a procedural database of aneurysms treated between July 2004 until December 2008 was performed. Recanalization and re-treatment rates were analyzed in relationship with neck and sac size, and ruptured or non ruptured aneurysms.
Results: From 388 aneurysms treated, 3 and 12 months follow up angiograms of 189 were available: 68 (35.9%) aneurysms demonstrated progressive occlusion, 60 (31.7%) stabilization and 61 (32.2%) some degree of recanalization. Recanalization rate was 38% in ruptured and 26.8% in non ruptu- red aneurysms; 28% in small neck and 39.7 % in wide neck; 29.4 % in small, 41.6 % in large and 42.8 % in giant.
Re-treatment was performed in 26 (13.7%) of 189 aneurysms when considered insufficiently occluded in the follow up. It was performed in 10 (10.3%) of 97 non ruptured aneurysms and 16 (17.3%) of 92 of ruptured ones; 14 (11.5%) of 121 small neck aneurysms and 12 (17.6%) of 68 of wide neck. The small and large aneurysms re-treatment rate was 11.6% and 22% respectively.
Conclusions: Sufficient and stable occlusion was observed mainly in none ruptured, small neck and small aneurysms as observed in bare platinum coil series although recanalization and re-treatment rates were lower than in previously reported Matrix coil series.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):215.
Purpose: To detect the pulsation of unruptured or ruptured cerebral aneurysm blebs by ECG-GR with 320-row area detector CT (ADCT).
Materials and Methods:
Subjects: 40 patients with 53 cerebral aneurysms (ruptured: 7 patients (7 aneu-rysms), unruptured: 32 patients (46 aneurysms)) who underwent ECG-gated 320-row ADCT examination between November 2007 and Jan. 2009.
Methods: Scanning was performed 5 s after the contrast medium was observed on the monitor using the SureStart function. The tube voltage, tube current and tube rotation speed were set to 120 kV, 220 mA, and 0.35 s/rot., respectively. Scanning was performed for 2 cardiac cycles.
Results: Satisfactory images were obtained in all patients. The accuracy of the images was significantly improved as compared to those obtained by ECG-gated reconstruction with helical scanning. Pulsation of the bleb could be detected in 5/7 with ruptured cerebral aneurysms. Aneurysmal pulsation could be detected in 15/46 with unruptured cerebral aneurysms, including 6 that pulsation of the bleb could be detected.
Conclusion: We previously reported the detection of pulsation of the bleb at the rupture point of cerebral aneurysms by ECG-GR with helical scanning (Am J Neuroradiol: 26, 1366-1369, 2005). For unruptured cerebral aneurysms, however, it is difficult to detect pulsation. ECG-GR with 320-row ADCT significantly improves the accuracy of images as compared to those obtained with helical scanning, making it possible to detect pulsation of the bleb in some patients with unruptured cerebral aneurysms. This finding may be a risk factor for future rupture, and follow-up observation is therefore required.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):215.
Purpose: Balloon test occlusion of the carotid has low morbidity and mortality. A case is presented to illustrate the importance of a comprehensive imaging review prior to undertaking this investigation.
Case: A 65 yr old F with a giant left carotid aneu-rysm was referred for investigation and treatment. She underwent CT angiography, catheter angiography and subsequent balloon test occlusion. A 5F Boston Guider Soft-tip® was navigated into the left internal carotid artery. Initial angiography showed the aneu-rysm but no other definite abnormality. Heparin was administered and table-side ACT increased to 2.5 times baseline. An EV3 Hyperglide® balloon was navigated into the petrous carotid artery and inflated to occlude the vessel. Immediately the patient became confused and dysphasic. The balloon was deflated within 20 seconds. The patient did not improve and a right hemiparesis was noted. Immediate angiography was performed which showed left middle cerebral artery occlusion. Subsequent review revealed calcification of the left middle cerebral artery trifurcation on CTA. Angiographic images were reviewed and a tight middle cerebral artery stenosis was seen retrospectively. This was the point of occlusion of the vessel. 3D angiography was not available at the time. The patient and images improved with thrombolysis but angioplasty proved impossible due to difficulty navigating the balloon past the aneurysm. She improved over the ensuing few days with supportive management but has been left dysphasic.
Conclusion: This case illustrates the importance of reviewing all imaging data prior to this investigation: the target pathology, the inflow, crossflow but also the ouflow.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):216.
Purpose: Remodelling technique is widely considered very helpful for coiling of wide neck aneurysms. However a not negligible amount of them recur. Stenting after remodelling assisted coiling might help to stabilize coils'packing reducing the chance of recurrence.
Materials and Methods: Out of 103 wide neck aneurysms treated by remodelling assisted coiling, 21 were completed with secondary stenting in order to stabilize the neck region preventing possible recurrence. All treated aneurysms originated from carotid siphon. 9/21 were ruptured ones. Stents (20 Neuroform, 1 Wingspan) were implanted after both successful remodelling assisted coiling and administration of antiplatelet therapy. Before stenting, the chance of following neurosurgical intervention was considered and the possible candidates were not treated by stenting, considering the need of double antiplatelet therapy after it. Follow-up was performed by MRA after one month and every six months thereafter.
Results: 17/21 (81%) procedures were completed without any technical complication. In 4/21 (19%) thrombotic complications occurred, but just 1/21 (5%) stenting related. MRA follow-up showed persistence of complete aneurysm occlusion in 18/21 (86%) and recurrence in 2/21 (10%) that required further treatment. One patient with ruptured aneurysm died because of stent related thrombotic complication (4%).
Conclusions: According to authors' experience, stenting after remodelling assisted coiling of wide neck aneurysms is useful in stabilizing coiling, reducing the rate of recurrence during follow-up. Caution is needed in ruptured aneurysms that might require following neurosurgical intervention.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):216.
Purpose: Third nerve paresis may occur because of external compression by a posterior communicating artery (PCA) aneurysm or delayed appearance of a mass effect after embolization. This is the first report of an oculomotor nerve (OMN) compression by an endovascular coil herniating outside the aneurismal pouch.
Summary of case: A 23-year old female patient was successfully treated in our department for a ruptured right PCA aneurysm by endovascular coiling. Immediate and long-term angiographic control at 24 months showed complete occlusion of the aneurysm (outcome class 1) and initial follow-up period was clinically uneventful. Subsequently, the patient presented with diplopia of progressive onset over a 6 month period. Neurological assessment found partial right OMN palsy and angiography confirmed a shift of the coils with one coil herniated outside the aneurysm pouch with a still completely occluded aneurysm. High field (3 Tesla) magnetic resonance imaging findings indicated that this herniated coil exerted a mass effect on the OMN. The aneurysm was surgically clipped and the herniated coil was removed. Two month after surgery the patient had almost recovered normal eye movements.
Conclusion: After total occlusion of PCA aneurysms, delayed coil dislocation and extravascular coil herniation can occur during long-term follow-up and compromise specific cranial nerves. In this case, surgical decompressive treatment may lead to recovery.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):216–217.
Purpose: We report a single-center experience of selective endovascular treatment of 402 consecutive cerebral aneurysms over a 12-year period.
Material and Methods: From 1996 to 2008 534 patients (mean age 45.7 years, 37% male) were referred to Interventional Radiology Department of Strasbourg University Hospital for treatment of intracranial aneurysm. Data were available for 384 patients with 402 aneurysms. Medical files were reviewed and procedure-related mortality and morbidity were assessed as well as immediate and long-term angiographic outcomes. All aneurysms were electively treated with Guglielmi and/or Matrix Detachable Coils (Boston Scientific Neurovascular, Natick, MA).
Results: Aneurysms were acutely ruptured (72,1%) or unruptured (27,9%). Eighty-nine percent were located in the anterior circulation. Overall procedure related morbidity and mortality were respectively 10,9% and 0,0%. Most untoward events were minor as groin haematoma (6,4%). Major complications (4,5%), mostly thromboembolic phenomena (2,4%) or intra-procedural aneurysm rupture (1,5%), led only in three cases a permanent morbidity but no major handicap. Two patients (0,5%) died during post-operative period because of re-bleeding. Immediate successful angiographic occlusion was obtained in 95,7% (complete obliteration in 27,4% and small neck remnant in 68,4%). Over 89% complied to angiographic follow-up with a mean follow-up period of 57 months (3-164). Progressive aneurysm thrombosis was observed in 40,5% of cases and recanalization was observed in 31,6%.
Conclusion: Our study confirms that selective endovascular occlusion of cerebral aneurysms is efficient and has a favourable benefit to risk ratio.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):217.
Purpose: We present our experience with balloon and stent assisted coiling in treatment ofwide neckcerebral aneurysm.
Materials and Methods: We treated 314 patients with cerebral aneurysm by coiling in101 (32%) with a combined remodeling technique. Baloons were used in 80 (79%) and stents in 21 (21%). 67 presented with SAH (66%), accidental diagnosis in 27 (27%), ischemic stroke in 5 and mass effect in 2. In balloon remodeling technique group, 14 were carotid ophthalmic/paraophthalmic, 3 hypophyseal, 1 cavernous, 22 PCom, 7 ACh, 4 ICA bifurcation, 2 ACom, 1 M1, 4 MCA bifurcation, 2 V4, 2 PICA, 2 SCA, 15 basilar tip and 1 PCA-P1. Stenting cases included 1 cervical ICA, 3 cavernous, 4 ophthalmic, 3 PCom, 1 ACh, 3 V4, 1 PICA, 2 vertebral-basilar junction and 1 basilar. Full heparinizatition (all) anddouble antiplatelet therapy (stent cases) were done.
Results: In balloon remodeling technique: 67 total aneurysmal sac occlusion (84%), 7 residual neck (8%) and 6 subtotal occlusion (8%). In stenting cases: 16 (76%) total aneurysm occlusion, 1 residual neck and in 4 cases (19%) of dissecting aneurysms remained a residual sac (proposed to a second stent). Intrastent thrombosis occurred in one patient (reverted with IA ReoPro); thrombus formation adjacent to the balloon was seen in 3 patients, treated with IA ReoPro (1 resulted in minor ischemia). We had 2 ruptures not related with the balloon (1 death). Mortality directly correlated with balloon manipulation happened in one PICA aneurysm (1%).
Conclusions: The remodeling balloon and stenting technique allow us to treat in better conditions with a low risk the wide neck sacular and fusiform/dissecting aneurysms.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):217.
Purpose: Middle cerebral artery (MCA) aneurysms often have features that may be unfavorable to coil embolization. However, endovascular treatment of MCA aneurysms is growing trend due to improvements of the devices and new technique. The aim of this study was to report our experience of coil embolization of MCA aneurysms.
Materials and Methods: From April 2007 to December 2008, 120 consecutive patients underwent endovascular treatment at out institute; Nine (7.5%) of them had MCA aneurysms. We retrospectively reviewed of these nine patients to determine the angiographic feature, technical result and clinical outcome.
Results: Of nine MCA aneurysms, eight (88.9%) were unruptured and one patient presented with subarachnoid hemorrhage (SAH). The mean age was 67.3 years. In two patients, embolization was failed due to its complex angiographic geometry. Treatment of the remaining seven patients was technically successful (77.8%). Surgical clipping was followed in one patient after failed coil embolization. Adjunctive endovascular techniques were used in four patients to protect branch vessels at the neck. There were no procedure related complications and complete or near complete occlusion was achieved in all seven patients.
Conclusions: Coil embolization of MCA aneurysms can be carried out with high rates of technical success with acceptable morbidity.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):217–218.
Purpose: Our use of hydrocoil in small acutely ruptured aneurysms led us to develop a new technique for catheter withdrawal. The safe use of this coil requires sizing the first coil to the minimum diameter of the aneurysm and consequently the stability of the coil mass during catheter withdrawal is of concern.
Materials and Methods: The technique was derived from first principles. The tip of a microcatheter will move away from its target during advancement of a microguidewire.
We utilize this phenomenon to cause the tip of a catheter to exit an aneurysm as a result of forward movement of the detached delivery wire rather than traction of the catheter. After detachment the delivery wire is placed close to the tip of the catheter. The tension in the catheter is removed incrementally. The wire is advanced to a 'crossed' position. The wire is then withdrawn to its previous position and the procedure repeated until the catheter tip exits the aneurysm.
We have validated the technique in vitro using a perfused flow model.
Results: Under the same conditions of flow, aneurysm and coil size we were able to cause a coil to dislodge and embolize using a standard catheter withdrawal technique but remain stable using the new technique.
Conclusion: The technique allows a gradual separation of the tail of the last coil from the catheter with the minimum disturbance of the coil mass. The catheter exits the aneurysm slowly and in a controlled fashion rather than the sudden exit of a catheter withdrawn in the conventional manner. Successful experience in vivo persuades us of the merit of the technique.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):218.
A 73 year old female presented with aneurysmal SAH and collapse. CTA performed emergently demonstrated of a 6 mm relatively wide-necked basilar tip aneurysm. An EVD was placed for management of hydrocephalus and endovascular coiling of the aneurysm was performed the following day. Tortuosity of the vertebral arteries did not allow for balloon-remodeling techniques or concurrent stent placement during aneurysm coiling, with post-coiling angiography demonstrating mild downward migration ofa couple of coil loops into the neck of the aneurysm. The patient was maintained on a low PTT target Heparin infusion, to prevent potential thrombotic complications. Approximately, 24 hours post-coiling, she deteriorated neurologically, with emergent CT head demonstrating interval development of bilateral posterior fossa subdural hematomas, and a hematoma along the right frontal EVD tract. Mass effect infratentorially had markedly worsened, with evidence of upward and downward transtentorial herniation, and obliteration of the fourth ventricle, perimesencephalic cisternsand cerebellar sulci. Bilateral PCA infarcts were also evident. CTA demonstrated complete lack of contrast opacification beyond the dural penetration of both vertebral arteries, with no opacification of the intracranial posterior circulation. Although anterior circulation flow was also markedly attenuated, contrast filling was seen of both M1 segments. At this time, the patient had no brainstem reflexes, with decision made to withdraw care. The patient died shortly thereafter. This case represents a unique compartmental ICP elevation, with consequent cessation of brainstem and posterior circulation blood flow.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):218.
Purpose: To detect residual flow in the coil mass and deformity of coil mass after coil embolization for brain aneurysms by high resolutional magnetic resonance angiography.
Materials and Methods: High resolutional time of flight angiography was examined by Achiva 1.5 T HP Nova Dual Gradient (Philips Medical Systems Nederland B.V.) with its 16 channels neurovascular coil. The spacial resolution was set at 0.25 x 0.25 x 0.25 mm. This high resolutional TOF wes performed as follow up study for those patients who underwent coil embolization for brain aneurysms.
Results: It took 11 minutes and 26 seconds to acquire 100 slices, 2.5 cm. In cases of coil compaction after embolization of giant aneurysms, each strut of coils could be visualised. Even densely packed regular sized aneurysms, concave deformity could be observe occasionally at the neck area of the coil masses. This kind of concave deformity should be difficult to observe by X ray based imaging because coils were extremely radiopaque.
Conclusion: High resolutional TOF could visualise possible flow in coil mass, which should very useful for follow up of coil embolisation.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):219.
Purpose: To report the technical feasibility and outcomes of a series of 34 aneurysms with size less than 4 mm treated by endovascular approach in our Institution.
Materials and Methods: Retrospective analysis of all aneurysms with size less than or equal to 4mm treated by endovascular approach in our institution between January 2003 and November 2008. All measurements were based on the 3D reconstructed images of the rotational angiograms (RA) or from the computed tomography angiography (CTA) if RA was unavailable. All demographic, anatomical and technical variables were analyzed.
Results: 34 aneurysms were smaller or equal to 4 mm. CTA was performed in 30 patients and demonstrated the aneurysm in 28. The patients were predominantly female and 26 aneurysms were ruptured. Embolization was technically possible in all cases although requiring advanced skills and difficult maneuvering and "tricks" for completion. Mean volume of the aneurysms was 16.7 mm3 and the mean packing volume was 36%. Intraprocedural rupture occurred in 4 patients but not correlated with poor outcome (p:0.5). Balloon assistance was used in 8 aneurysms and stenting in 3. Three patients died from causes unrelated to coiling. Poor outcome was associated with age older than 60 years (p:0.03). Most patients had an excellent outcome and were independent. On follow-up 14 aneurysms were completely occluded and minimal neck remnant observed in 15. One patient was retreated.
Conclusions: CTA is a reliable and sensitive method in the detection and treatment planning of small intracranial aneurysms. Endovascular treatment of small cerebral aneurysms is feasible resulting in long-term durability.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):219.
Purpose: Aneurysmal rupture during endovascular treatment is one of the most feared complications of endovascular aneurysm therapy. The purpose of this study was to determine the frequency, causes, management, and outcome of aneurysmal rupture that occurred during treatment with GDCs in an unselected series of patients with ruptured cerebral aneurysms.
Materials and Methods: Between July 1999 and October 2008, we treated 150 acutely ruptured cerebral aneurysms with GDCs. All charts were reviewed, and patients with aneurysmal rupture occurring during embolization were identified.
Results: Four patients had an intraprocedural aneurysmal rupture. In one patient, rupture was due to guidewire perforation of the wall . In one patient, the microcatheter itself perforated the aneurysm. In one patient, rupture occurred during placement of the first coil. Endovascular packing was continued in one patient. In another patient ,rupture occurred during placement of the last coil. Last coil detaching was continued in one patient .Two patients died as a result of the aneurysmal rupture. No negative long-term effects were observed in the remaining two patients. In summary, we observed intraprocedural aneurysmal rupture in 2.7% of our patients, with a mortality rate of 50% and no long-term morbidity.
Conclusion: Aneurysmal rupture during endovascular treatment with GDCs is a rare event; clinical severity may be variable. Embolization of the aneurysm can be continued in most cases, and 50% of patients with treatment-related subarachnoid hemorrhage survive without serious sequelae.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):219.
Purpose: Aneurysms located at the vertebrobasilar junction are rare (the angiographic frequency is 0.022% to 0.6%). Surgery of such aneurysms are difficult due to the limits in obtaining the adequate surgical exposition. We present a basilar artery fenestration aneurysm successfully treated with axium detachable coils.
Summary of case: A 43 year old man was presented with sudden severe headache, vomiting, nausea and stiff neck. His condition was graded Hunt and Hess grade II. To demonstrate the subarachnoid hemorrhage CT and CT angiography were performed. Two kissing aneurysms at the basilar artery fenestration were diagnosed. DSA and 3D DSA were performed and the large aneurysm of 17 mm diameter was immediately and completely embolized using axium detachable coils. The second one of 4 mm diameter without neck was not treated. Control MRA performed at the third month of treatment showed no residual neck formation and the untreated aneurysm was stable. Final neurological examination was normal.
Conclusion: Coil embolization of basilar artery fenestration aneurysms seems to be an effective and safe treatment. Axium detachable coil system provides a quick tool for intracranial aneurysm treatment.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):220.
Purpose: To show our experience with the use of self expandable stent SOLITAIRE (EV3) for the treatment of middle cerebral artery wide neck aneurisms.
Material and Methods: 4 patients with unruptured aneurism of the middle cerebral artery, one of them with mirror aneurisms, were treated using coils + stent using self expandable, fully retrievable stent SOLITAIRE.
Results: A total of 5 stents where placed (2 in one patient), with total exclusion of the aneurisms and no peri or post procedure complication.
Conclusion: This new stent is safe and easy to use with the added advantage of being fully retrievable which allows us to reposition the stent once completely deployed and maybe to be used as a remodeling material in the future without the disadvantage of stopping flow that remodeling ballons have.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):220.
Purpose: Aggressive venous thrombosis (AVT) has been advocated as major causes for sub-acute or late delayed complications especially haemorrhage, after endovascular embolization of cerebral arteriovenous malformations (AVM). We retrospectively reviewed our results with special emphasise on patients given heparin iv or subcutaneously after embolization.
Methods: 43 patients, mean age 44 (range 14-67) were included. 21 had presented with haemorrhage, 10 with seizure and 12 with other symptoms. Spetzler-Martin grading was 1/5, 2/10 3/15 and 4-5/13. 23 AVM were high-flow or had single drainage. Angiographic results, complications and control-CT or -MR were evaluated. Outcome was graded using mRS.
Results: 88 procedures were done. A bolus of 2000-4000IU of iv heparin was given in 52 and subcutaneous enoxiparine used after 44 procedures (bolus 40-80mg followed by 20-40mg/5-7 days). Three procedural extravasations occurred. Surgical evacuation of an acute, slowly progressive ICH from a vascular tear was done in one patient. Transient symptoms were seen in 6 patients. No subacute or late deterioration developed. CT or MR revealed no venous thrombosis or late haemorrhage. MRS scores were 0-2 in 39 and 3 in two patients. 13 patients had complete occlusion after embolization; three showed spontaneous occlusion at follow up, the others were sent to Radiosurgery or surgery.
Conclusion: Procedural and post-procedural anticoagulation therapy seems to reduce subacute or late ICH and neurological complications by preventing AVT. Our anticoagulation regime does not seem to increase the risk of early bleedings or to reduce the chance of spontaneous AVM occlusion, rather the opposite.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):220–221.
Purpose: Our objective was to analyze technical, clinical and angiographic results for non-surgical berryintracranial aneurysms treated by endovascular approach at Ribeirão Preto Medical School - University of São Paulo - Brazil, and compare to the current literature.
Materials and Methods: Between August 2005 and November 2008, 137 aneurysms were treated in 106 patients, 101 aneurysms in 75 patients were unruptured and 36 aneurysms in 31 patients were ruptured. The data were prospectively included and demographic information, type of treatment, complications, clinical and angiographic results were evaluated. Statistical analyses were performed.
Results: Sixty three aneurysms (45.99%) were treated with coils alone, 52 (37.96%) with balloon remodeling, 15 (10.95%) with stent remodeling, and 7 (5.11%) with therapeutic occlusion of the internal carotid artery. Technical complications occurred in 9 aneurysms (6,57%), 3 (2.19%) symptomatic and 6 (4.38%) asymptomatic. Six clinical complications (5.66%) were related to the procedures, 3 (2.83%) transitory and 3 (2.83%) permanent. Angiographic follow-up was performed for 97 aneurysms, clinical monitoring for 77 patients and telephone interview for 97 patients. Retreatment was required for 8 aneurysms, 8.25% of the controlled aneurysms.
Conclusion: The results in this series are similar to those found in the literature, proving that the embolisation for intracranial aneurysms in a brazilian public hospital is possible and safe. Different treatment optionshad similar complication risks. Large and giant aneurysms treated by stent remodeling and therapeutic occlusion were more stable over time.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):221.
Purpose: To present the first case of intrameatal AICA aneurysm treated with coil.
Case: A 60-years-old man with a history of hypertension, presented with acute headache, nausea and vomiting. CT showed subarchnoid hemorrhage in the right cerebellopontine angle. Selective DSA showed a sacular aneurysm at the right AICA situated inside de internal auditive canal. After DSA, on day 12th he presented a right facial paresis and hypoacussia. Endovascular occlusion was performed on day 30th. We used a 6 French introducer in the right femoral artery. A 6F Guider™ catheter was positioned in the left vertebral artery. The aneurysm was microcatheterized and filled with GDC coils. A complete occlusion of the aneurysm was achieved. The patient was discharged with no neurological deficit. After the 1st year, control DSA showed the complete and stable occlusion of the aneurysm.
Conclusion: Only 7 cases of intrameatal aneu-rysms have been reported since 1948. The lesions were all managed surgically. We showed a ruptured aneurysm successfully treated with coils with complete symptoms regression.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):221.
Purpose: Few studies have directly compared 3D time-of-flight (TOF) MRA with contrast-enhanced (CE) MRA for surveillance of coiled intracranial aneurysms. Even less has been reported on the relative efficacy of these two MR angiographic techniques in depicting recurrent aneurysms following stent-assisted coiling. We report the findings of 3D TOF MRA and CE MRA in a small case series of patients who developed recurrent aneurysms following stent-assisted coiling.
Materials and Methods: Between January and September 2008, recurrent aneurysms were detected on follow-up (mean time interval since procedure: 20.3 months, range: 10-27 months) of four patients (mean age: 48.5 years, range: 39-59 years) who had previously undergone stent-assisted coiling. The 3D TOF MRA and CE MRA of these patients were compared and evaluated. Correlations with digital subtraction angiography (DSA) were also made.
Results: In two patients, recurrent aneurysms were convincingly demonstrated on the CE MRA but not on the 3D TOF MRA. In the other two patients, refilling of aneurysm was detected on both forms of MRA but was more superiorly depicted with the CE MRA. The aneurysm necks and the lumens of the stented parent arteries were consistently better visualized on CE MRA. DSA of two of the patients were noted to significantly underestimate the recurrent aneurysms when compared with the CE MRA.
Conclusion: CE MRA is potentially superior to 3D TOF MRA in the follow-up of aneurysms that have been treated with stent-assisted coiling, with improved visualization of the aneurysm necks. DSA, the conventional "gold standard" technique for surveillance of recurrent aneurysms, is also not infallible.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):221–222.
Background: Surgical treatment of aneurysm localized in basilar artery (BA) is difficult and cause high mortality and numerous neurological deficits. Endovascular embolization of these aneurysms gives possibility of treatment of such aneurysm in a safer way. We want to share our experience by presenting long term results in order to identify factors that might be important in predicting success of treatment.
Aim and Methods: From 1994 to 2005 in our department over 1000 patients were treated due to intracranial aneurysms, among them 120 patients underwent endovascular embolisation of aneurysms localized in basilar artery. All patients had angiography after the treatment and radiological investigation in a long term follow-up. In cases, were recanalisation appeared, patients were qualified to second endovascular procedure. We assessed clinical result in Glasgow Outcome Scale (GOS) and quality of life using modified EuroQoL form.
Results: In 104 cases total and subtotal occlusion of the aneurysm was obtained. 90 patients were discharged from the hospital in a good clinical state (GOS 4 and 5). Long term clinical results were good in 64 cases. Nine early deaths and 25 in a long term follow-up were found. In 4 cases recanalisation appeared and second procedure was performed with good radiological effect. Good result at follow-up correlated significantly with: aneurysm size, initial treatment success.
Conclusion: Best long-term angiographic results are obtained when the primary treatment is successful. Endovascular embolisation in our observation is a good and safe method of treatment in aneurysms located in basilar artery.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):222.
Purpose: To share our early experience of using different intracranial stents to manage blood blister-like aneurysms (BBLA) in the internal carotid artery (ICA) presented as acute subarachnoid haemorrhage (SAH).
Materials and Methods: In the past 6 months, we had 2 patients with BBLA in the dorsal supraclanoidal segment of ICA and bled. Both patients presented as grade I SAH and we treated them both solely by intracranial stenting by a Neuroform or a Pipeline stents. The interventions were carried 2 weeks after the acute presentation under general anaesthesia. Post-operatively, the patients were put on Plavix for 6 weeks.
Results: Both patients recovered well from the procedures without complication and post-operative angiogram in 3 months showed complete obliteration of the aneurysms.
Conclusion: BBLA has long been a very difficult pathology to be managed as its fragile wall makes surgical clipping of these aneurysms very challenging. Conventional endovascular coiling of them are many times impossible owing to their small sizes and wide necks. With the introduction of several new intracranial stents and our early encouraging results of applications of them onto these BBLA, we may eventually reach a better solution in BBLA management. Of course, a larger series or a control study between other treatment alternatives and longer follow up are required before any definite management recommendation can be determined.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):222.
Purpose: Giant serpentine aneurysms (GSA) are rare, fusiform aneurysms greater than 2.5 cm. They have a typical serpiginous course through a partially thrombosed vascular lumen. These aneurysms may rarely rupture and more typically cause neurologic insult from mass effect and edema.
We present a case of a ruptured GSA involving the anterior cerebral artery successfully treated with endovascular parent artery occlusion. MRI, TCD, CT perfusion, 3D DSA, endovascular treatment and follow up imaging of this huge aneurysm were discussed.
Summary of case: A 66 year old man was presented with headache and dizziness. MRI, MRA and cerebral angiography showed a GSA of the right anterior cerebral artery. Transcranial doppler showed high resistance flow. On CT perfusion, CBV was normal and CBF and MTT revealed hypoperfusion in anterior cerebral artery territory.
The patient refused the treatment. Five months later he presented with a severe headache, nausea, vomiting, and stiff neck (Hunt & Hess grade 2). Cranial CT showed subarachnoid hemorrhage. The aneurysm and the parent artery were immediately embolized using GDC coils without any occlusion test.
Immediate control angiography showed anterior cerebral artery filled retrogradely via pial collaterals. Hydrocephalus due to SAH and the compression of the foramen of monroe was treated by placing a ventriculoperitoneal shunt. The patient has been discharged without any neurological deficit.
Conclusion: Endovascular coil occlusion of the parent artery seems to be the first choice in the treatment of GSA. Meticulous consideration of DSA, transcranial doppler and cerebral perfusion imaging are of great value for therapeutical decision.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):222–223.
Purpose: To show an extreme example of altered flow patterns along collaterals in Moyamoya contributing to aneurysm formation and early rupture.
Summary of case: A 24 year-old woman presented with a Hunt & Hess grade 3 subarachnoid hemorrhage. Angiography revealed complete right and left internal carotid artery occlusions with robust collateralization from the vertebrobasilar system. At the basilar apex, a 3mm aneurysm was identified and repaired endovascularly. The patient recovered fully and is being closely followed for coil compaction or aneurysm recurrence, as the aneurysm neck continues to be exposed to the entire cerebral blood flow.
Conclusion: A 24 year-old woman with Moyamoya was found to direct her entire cerebral blood flow across the vertebro-basilar system, which may explain formation and early rupture of a flow related basilar tip aneurysm in this young patient.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):223.
Purpose: Intravascular stents are increasingly used in neurointervention. Usually the stent is used as an aid to coil aneurysms with a large neck, to avoid coil protrusion into the parent vessel. It has been observed that stents that have been placed in a preexistent vascular angle, have a significant effect in changing this angle. Vascular geometry is important in hemodynamics, a change in a local geometry can change local blood flow patterns and shear stresses profoundly. The purpose of this study was to quantify vascular angle change due to intracranial stent placement.
Materials and Methods: Seven patients with an intracranial aneurysm, treated with stent-assisted coiling (Leo stent, Balt, Montmorency, France) underwent imaging (3DRA, MRA or CTA) before and after stenting. Locations of the aneurysms were, anterior cerebral artery (n=2) , cavernous internal carotid artery (n=2) and basilar tip (n=3).
Centerlines of the parent vessels were calculated before and after stenting using the Vascular Modeling ToolKit.. Using the distance of the stent from identifiable structures in the vascular tree it was possible to accurately measure the change in vascular curvature caused by the stent.
Results: In all patients, the stent caused a change in geometry of the parent vessel. Stent-related vascular angle change ranged from -16 to 43 degrees, with an average of 14 degrees. In 5 cases the parent vessel was straightened (n=5), in two cases the local angle sharpened.
Conclusion: Stents have a substantial effect on the vascular geometry, changing vascular angles with up to 43 degrees. This change in geometry could change local hemodynamics.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):223.
Purpose: To describe the angiographic results and procedural morbidity in patients with small aneurysms less than 3.5 mm in maximum diameter treated by endovascular coil embolization.
Materials and Methods: During a 2-year-period a total of 194 aneurysms were embolized by detachable coils. Of these 194 aneurysms, we attempted to treat 38 small aneurysms (<3.5 mm) by coil embolization. Of these 38 small aneurysms, 17 had ruptured and 21 had not ruptured aneurysm. 22 aneurysms were less than 3 mm in maximum diameter. Mean age was 57.4 years (38-87 years old). We evaluated the technical success rate and post embolization angiographic results (complete; no contrast media filling/almost; small amount contrast media filling without neck remnant /partial; remained neck) including coil packing density. We also evaluated the procedural morbidity and mortality.
Results: Technical success rate was 94.7% (36 aneu-rysms). Of these 36 aneurysms, postembolization results were complete in 11, almost in 11, and partial in 14. The mean packing density is 30.6%, and the number of inserted coils was 2.2 (mean length; 6.85 cm). There was one case of procedure related hemorrhage distal artery from aneurysm possibly from microguide wire. There was no thromboembolism and aneurysm rupture. Overall procedure-related rate for permanent morbidity and mortality was 2.6 % (n = 1) and 0 %, respectively.
Conclusion: Coil embolization of very small aneu-rysms was technically feasible with good angiographic results. Although coil embolization of very small aneurysms is struggling procedures, there is relatively lower rate of overall procedure related morbidity and mortality than expected.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):223–224.
Purpose: Enterprise stent (Cordis Neurovascular, Miami, FL) is frequently used to assist coiling of wide neck aneurysms. The stent is very flexible and has a close cell design. This report describes delayed migration of Enterprise stent after initial appropriate deployment in two patients, its possible mechanisms and prevention of such dislodgement.
Summary of cases: A 40 year-old-female was treated for a 4.2 mm recurrent wide neck basilar tip aneurysm with a 4.5 x 14 mm Enterprise stent deployed from the right PCA to the basilar artery. An angiogram performed 6 weeks later for coiling showed the stent dislodged proximally in the basilar artery. The distal end of the stent was lying in the aneurysm just distal to the origins of both PCA's, similar to a waffle cone, protecting both PCA's during coiling.
A 59 year-old-female underwent stent assisted coiling of a wide neck, unruptured, 4.5 mm basilar tip aneurysm. A 4.5 x 22 mm Enterprise stent was deployed from the left PCA to the mid-basilar artery followed by coiling of the aneurysm. A left vertebral angiogram done 6 months later showed proximal migration of the stent with the distal end of the stent barely lying in the proximal left P1 segment. The proximal end of the stent reached the vertebrobasilar junction. Further proximal migration of the stent did not occur due to the spread of the strut over the confluence of both vertebral arteries.
Conclusion: These cases describe that delayed migration of Enterprise stent can occur specially if a shorter stent is used and the distal end is in a curved small diameter branch artery. Despite the displacement we were able to coil the aneurysm successfully in one patient.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):224.
Purpose: Our purpose was to determine the value of the maximum ostium angle (MOA) of internal carotid artery (ICA) aneurysms as a predictor of the need for the use of stents in endovascular treatment.
Materials and Methods: 55 consecutive ICA aneurysms were identified in a retrospective review of an internal database. 31 of these were treated with endovascular techniques and the other 24 were either not treated or clipped. The angle from the parent artery center-line to the margins of the ostium was measured from 3D acquisition using commercially available software and the maximum angle (MOA) was then correlated with the use of stents in endovascular treatment. For the untreated or clipped aneurysms, three experienced neuroradiologists blinded as to the MOA reviewed the 3D studies as to whether or not stents would have been required for endovascular treatment.
Results: Aneurysms with a MOA of more than 120 degrees required much more frequent use of a stent than those with a MOA of smaller than 120 degrees (91.3 % vs. 33.3 %). The average MOA of aneurysms requiring the use of stents was 132.5±44.4 degrees while the average MOA of ones not requiring the use of stent was 96.3±28.8 degrees; this difference was statistically significant (p=0.003). Ruptured aneurysms had a smaller MOA than unruptured ones (p=0.17) but 2 of them (15.4%), which were clipped, were considered to need stents for endovascular treatment.
Conclusions: In this study the MOA was an accurate predictor of the need for the use of stents in endovascular treatment of ICA aneurysms. Additional studies are ongoing to determine the impact of this parameter on the treatment outcome after endovascular therapy.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):224.
Purpose: Truncal cerebral aneurysms include fusiform, dissecting and serpentine aneurysms. When presenting with bleeding or mass effect, the natural evolution is unfavourable. Despite latest advances in endovascular reconstruction techniques, in many occasions endovascular parent vessel sacrifice is the unique therapeutic alternative. In this context, test occlusion is mandatory and sometimes difficult to apply with balloons. We report our experience on 10 patients treated with parent artery occlusion after test occlusion with coils.
Materials and Methods: We retrospectively revie-wed all of the cases of truncal cerebral aneurysms treated with coiling at the parent vessel. We included all the symptomatic truncal aneurysms with a positive test occlusion (visualization of collaterals and no clinical deficits before detaching the coil). Follow up was carried out until complete occlusion of the aneurysm was achieved.
Results: Ten patients with a mean age of 53 years were selected for endovascular parent vessel occlusion with coils. Four were located in the anterior circulation and six were in the posterior circulation. All of them were successfully treated. No clinically significant intraprocedural complications were noted. There were no new clinical events during a mean follow up of 18 months.
Conclusion: In patients with fusiform, dissecting or serpentiform aneurysms which can not be treated with assisted endovascular techniques (remodeling, stenting) or balloon occlusion, coiling of the aneu-rysm and / or the main artery, after realizing a coil test occlusion is effective and safe with low morbidity and mortality.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):225.
Purpose: The purpose of this study was to determine if the GDC® 360° complex-shaped coil design provides greater angiographic occlusion at follow-up compared to GDC 2D and 3D coils for the embolization of intracranial aneurysms.
Materials and Methods: Three hundred and fifty consecutive intracranial aneurysms were treated with GDC coils; 205 with GDC 360° and 145 with GDC 3D and 2D coils. Angiographic occlusion was retrospectively and prospectively reviewed. Procedural images were compared to follow-up catheter digital subtraction angiograms performed <12 months post-procedure and >12 months post-procedure. Occlusion was classified as complete occlusion, residual neck (filling at aneurysm neck but no room for additional coils), and residual aneurysm (room for additional coils). Aneurysms greater than 2.5cm were excluded.
Results: There is no statistically significant difference in procedural and <12 month angiographic occlusion between aneurysms embolized with GDC 360° and aneurysms embolized with GDC 2D and 3D coils. Angiographic occlusion at >12 months showed 66.3% (53/80) complete occlusion and 10% (8/80) residual aneurysm in aneurysms embolized with GDC 360° coils, and 50.8% (33/65) complete occlusion and 26.25% (17/65) residual aneurysm in aneurysms embolized with GDC 2D and 3D coils.
Conclusion: Intracranial aneurysms embolized with GDC 360° coils show greater angiographic occlusion greater than one year post-coiling compared to aneurysms embolized with GDC 2D and 3D coils.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):225.
Purpose: To investigate the effectiveness and safety of LEO stent-assisted embolization for wide-necked aneurysms of intracranial internal carotid artery (ICA).
Methods: 14 cases with 17 wide-necked aneu-rysms were involved in this study. 2 cases were male and 12 were female, aged 45-60 yrs with a mean of 52.7 yrs. 3 cases with two aneurysms in the ipsilateral or contralateral ICA were treated endovascularly at the same time. 7 aneurysms were ruptured and 10 unruptured. The aneurysms sized 2mm ' 15 mm, with a mean of 7.6 mm. 15 Leo stents were used for the embolization of 17 aneurysms, sized 3.5 x 25mm to 4.5 x 30 mm. 2 aneurysms were embolized using standard technique, i.e. the microcatheter was inserted into the aneurysm sac through the stent mesh after discharge of the LEO stent. However, other 15 were embolized using different technique, i.e. the microcatheter was inserted into the aneurysm sac directly before discharge of the LEO stent. Different coils were used for the embolization of aneurysms.
Results: 15 Leo stents were placed successfully. 16 aneurysms were embolized successfully using stent-assisted techniques, including complete embolization in 13 aneurysms and partial embolization in 3 aneu-rysms. 1 small aneurysm (2x3mm) was failed to embolize due to displace of the discharged stent when the microcatheter was inserted into the aneurysm sac through the stent mesh. No other complications happened relevant to the procedures such as outside discharge of the stent, intra-stent thrombosis, or protrusion of the coils into the parent ICA.
Conclusions: LEO stent-assisted embolization of wide-necked ICA aneurysms is effective and safe.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):225–226.
Purpose: To study the safety and efficacy of embolisation of complex/giant intracranial aneu-rysms.
Methods and Materials: From November, 1993 to November 2008, 35 giant (>25 mm)/complex aneu-rysms were embolized at our centre (AIIMS). 18 males & 17 females, from 14-75 yrs (mean age-55 years) were studied. 14 patients had mass effect, 14 headache, 6-SAH, & one each with stroke and epistaxis. 24 aneurysms were un-ruptured, 11-ruptured: 6 presented with SAH, & one pseudoaneurysm had epistaxis. 20 aneurysms were in the anterior circulation & 15 in the posterior circulation. 30 aneurysms had a broad (>4 mm) neck and 5 aneurysms had a narrow neck, 24 aneurysms were sacular, 5 dissecting, 5 serpiginous and 1 flow-related.
Results: Indications for treatment was difficult surgery (28 cases: 5 cases, surgery failed, 1 case had an AVM-associated aneurysm, and 1 had multiple aneurysms. 9 cases had detachable coils only, 9 balloon parent vessel occlusion, 3 by parent vessel occlusion through coils, 3 with balloon assistance, 10 by stent-assisted coiling, and in one case, aneurysm had thrombosed by itself.
Complete aneurysm occlusion was achieved in 12 (33%) cases, >90% occlusion in 12 (33%) cases, 70-90% occlusion in 6 cases (20%), 50-70% in 2 cases (4%) and less than 50% occlusion in 3 cases (10%). Hence, complete/near-total occlusion was achieved in 24 (70.3%) cases.
Complications: Procedure-related morbidity was encountered in 3 cases (9%), with thromboembolism in 2 cases, & parent vessel occlusion with infarcts in one case. One patient died (mortality-3%) due to aneurysm perforation.
Conclusions: Giant/complex aneurysms can be safely treated by endovascular route.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):226.
Case report: We report a 57 year old man with a ruptured left posterior frontal AVM. The patient presented with a large infra-opercular parenchymal hematoma, with an angiographically demonstrated pseudoaneurysm and single draining vein. Due to unsuccessful efforts at transarterial embolization of en-passage arterial feeders, the patient was primarily treated with transvenous Onyx embolization. Follow-up angiography at 1 month revealed durable angiographic cure of the AVM. Our case illustrates that in patients with ruptured AVM secondary to pseudoaneurysm with a single draining vein, transvenous treatment can be utilized to achieve occlusion of the pseudoaneurysm and AVM cure. To our knowledge, this is the first description of a transvenous approach for endovascular therapy of ruptured AVM.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):226.
Purpose: We aimed to present glue treatment of arterial perforations occuring during endovascular embolization of intracranial arteriovenous malformations (AVMs) and fistulas (AVFs).
Materials and Methods: In seven (23.3%) of 30 patients, 9 (6.3%) arterial perforations occurred during 142 intracranial AVM nidus or AVF microcatheter/microguidewire manipulations of 52 sessions. They were 13 women and 17 men (mean age: 36.4 years). Of 30 patients, 26 were AVMs and 4 were AVFs. In all patients, onyx was planned for embolization. Glue (cyanoacrylate) with 25% concentration was prepared to use for occluding the perforated artery before starting the catheterization. In every suspect of arterial perforation, control angiography was performed to show the extravasation.
Results: In all patients, succesful management of arterial perforation with glue injection was obtained. No serious early or late complication was seen after the procedure due to subarachnoid hemorrhage or occluding the vessel.
Conclusion: Glue injection for the treatment of arterial perforations during microcatheter manipulations of intracranial AVM or AVF embolization is a safe and effective method.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):226–227.
Background: Stereotactic radiosurgery is an important treatment technique for cerebral AVMs. Delayed radiation-induced complications remain a significant problem in some patients treated with radiosurgery. The majority of these adverse events occur within 3 years of radiosurgical treatment. Radiation necrosis has been reported with a frequency of 1.7 to 7.6% for AVMs.
Method: We present 2 cases of delayed cystic necrosis post stereotactic radiosurgery for AVM. The AVM in the first patient was treated with embolization, surgical resection & stereotactic radiosurgery whereas the AVM in the second patient was treated with embolization & stereotactic radiosurgery.
Result: The 2 patients developed the radiation-necrosis 12 & 3 years post radiosurgery respectively. In both cases the radionecrosis had a "pseudo-tumoral" appearance characterized by an inner component iso-intense to CSF in all MRI sequences, a thin capsule partially enhancing and perilesional vasogenic edema. The posterior fossa lesion was resected due to the significant mass effect on the IV ventricle.
Conclusion: Radiation necrosis can occur more than a decade after stereotactic radiosurgery, necessitating patient follow up during a longer period of time than currently practiced. Furthermore, there is a need for more careful reporting on the natural history of such cases to clarify the pathogenesis of late radiation necrosis after radiosurgery and to define patient groups with a higher risk for these entities. A cooperative multicenter database of the outcomes of stereotactic radiosurgery is needed to better define patient risk factors and to decrease the incidence of late radiation necrosis.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):227.
We present a case of a symptomatic venous aneu-rysm that developed in the drainage network of a deep seated basal ganglia and thalamic Arterio-Venous Malformation (AVM). The venous aneurysm was treated selectively with platinum coils using a venous approach whithout jeopardizing the venous drainage of the AVM. Treatment of symptomatic venous aneurysms by decreasing the intensity of blood flow through the AVM might be theoretically achieved by arterial embolization. When not feasible,a selective venous endovascular treatment could be an alternative. Caution in regard to AVM drainage has to be taken in consideration prior to treatment.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):227.
Purpose: We present our experience with the use of a percutaneous closure device with a collagen bloc for securing an intracranially retained microcatheter to a common carotid artery (CCA) after transarterial treatment of an arteriovenous malformation (AVM).
Summary of case: A 56-year old female patient was referred to our department for additional endovascular treatment of a right-brain frontotemporal artériovenous malformation. Since previous transfemoral embolization attempts had failed because of major tortuousity of right internal carotid artery (ICA) a right CCA puncture was performed for access. Embolization with ethylene vinyl alcohol copolymer 6% (Onyx® 18) was successful but at the end of the procedure the microcatheter remained trapped in the cast. Removing the device by forced traction was judged too dangerous by the authors because of the risk of rupture of the malformation. The microcatheter was left in the anterior cerebral artery and a percutaneous closure device with a collagen bloc (Angio-Seal®) was used to secure its proximal part to the right CCA wall in order to prevent embolic complications. Finally, the catheter was sectioned at skin level. Post-procedure period was uneventful and neurological status was normal on hospital discharge one week later.
Conclusion: A percutaneous closure device assisted securing of an microcatheter to a CCA can be performed safely and may be worth being evaluated as treatment option in patients with tortuous vessels and/or difficult-to-reach AVMs in whom CCA puncture is necessary.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):227–228.
Purpose: We present an interesting case of a complex cerebral vascular malformation manifesting 17 years following a road traffic accident.
Summary of Case: A 42 year old lady presented with a 2 month history of recent deteriorationof memory, worsening of ataxia and urinary incontinence. She was in a road traffic accident in 1985, where she sustained severe head trauma and was in a coma for 16 weeks. She has had a right eye proptosis since; this has worsened in the past year. CT and MR imaging demonstrated a large vascular malformation with very prominent veins occupying the right middle cranial fossa. Catheter angiography demonstrated a complex vascular malformation which appeared to arise from a complete blowout of the P1 segment of the posterior cerebral artery on the right feeding into a massively dilated vein. The fistula fed from the vertebro-basilar circulation and from a hugely hypertrophied posterior communicating artery on the right. She also had a right paraclinoid aneurysm and a left P1 segment aneurysm. She underwent four interventional procedures initially using GDC coiling and subsequently glue embolisation of the fistula, with marked improvement in her symptoms. Final angiogram showed no residual filling of the fistula or the P1 segment aneurysm; she had a residual right paraclinoid aneurysm which was subsequently coiled 2 years later.
Conclusion: We demonstrate the successful management of a complex vascular malformation which necessitated multiple interventional procedures which included GDC coiling and glue embolisation.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):228.
Purpose: To demonstrate the hemodynamic relationship between the two arteriovenous fistulas (AVF) located at anatomically different regions.
Summary of case: A 57-year-old man admitted with a 2-month history of tinnitus in the left ear. Digital subtraction angiogram revealed AVFs at left preauricular region (fed by superficial temporal artery) and right frontalscalp (fed by middle meningeal artery). Because left one was symptomatic and had much higher flow on angiogram, transarterial embolization was performed at the left superficial temporal artery with NBCA and coils to reduce shunt flow. Follow-up angiogram after 1 month showed significant change of AVF in the right frontalscalp, which were gaining another feeding artery (superficial temporal artery), remarkably increased shunt flow and change of venous drainage course (from anterior direction to posterior direction). Transarterial embolization of this AVF was performed with NBCA.
Conclusion: The hemodynamics of facial AVF can be affected by manipulation of another facial AVF located at anatomically different regions.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):228.
Purpose: We assessed the predictive value of MRI with the golden standard, digital subtraction angiography (DSA), for complete obliteration of brain arteriovenous malformations (bAVM) after radiosurgery.
Materials and Methods: Examinations of 65 patients with a single bAVM were analyzed. Inclusion criteria were a visible nidus on both MR- and DSA-images before radiosurgery, and follow-up MR- and DSA-examinations performed after radiosurgery. DSA was obtained with a frame rate of 3'6 s-1 in at least 2 projections. MR-images were obtained at 1.5T using a standard polarized head coil. Imaging protocol included T2-weighted images, slice thickness of 3mm 3000/20/90° (TR/TE/flip-angle), as well as Time-of-Flight (TOF) MRA 39/6.5/20° with a slice thickness of 1 mm and in-plane resolution of 0.4 mm. Data presented in this abstract are preliminary and based on initial radiology reports.
Results: The mean follow-up after radiosurgery was 54 ± 25 months. The mean interval between follow-up MRI and DSA was 3.1 ± 1.9 months. Onfollow-up examination complete bAVM obliteration was observed on DSA in 39 patients, MRI was positive for obliteration in 26 patients. Sensitivity and specificity of MRI for obliteration were 67% and 85%, respectively. Positive and negative predictive value for predicting complete angiographic obliteration with MRI was 87% and 63%, respectively.
Conclusion: In comparison to DSA MRI is 87% reliably able to predict obliteration when using only T2-weighted and non contrast enhanced TOF-MRA. Therefore, when using the above mentioned MRI-sequences DSA remains necessary in order to prevent both under- and over-estimation of complete AVM obliteration.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):228–229.
Purpose: The altered brain perfusion associated with cerebral arteriovenous malformations(AVMs) has previously been challenging using CT perfusion (CTP) due to limited coverage. Our study was conducted to assess the altered perfusion in AVMs using whole brain CTP on a 320 slice volume scanner.
Materials and Methods: Whole brain CTP (Toshiba) was performed in 8 patients with AVM and 3 patients with AVFs. CTP study was performed as part of the time-resolved CT angiograms (TRCTA) performed for clinical reasons. The cerebral blood volume (CBV), cerebral blood flow (CBF), and mean transient time (MTT) were assessed. Regions of interest (ROIs) placed over the following AVM target sections were defined as follows: N, AVM nidus; P, immediately posterior to the nidus; A, immediately anterior to the nidus; Ar, anterior remote; Pr, posterior remote; Cbm, cerebellum; BG, basal ganglia for the rest of the brain. Similar ROIs in the contralateral hemisphere (N1, P1, A1, Pr1, Ar1, Cbm1 and BG1) served as internal references. Perfusion parameters were compared to the opposite side. Paired t test was used for statistical analysis. P value <0.05 was considered significant.
Results: Three types of perfusion disturbance pattern were observed in cases of AVM. CBF and CBV was very markedly high (p=0.0002 and 0.0026) within the nidus; low (p=0.038 and 0.056) in anterior perilesional parenchyma; and low in the opposite cerebellar hemisphere in 2 patients with hemispheric AVMs. The perfusion parameters were not affected in the 3 cases of AVF.
Conclusion: This study emphasizes the role of whole brain perfusion studies in cases of AVM. Data is now readily available for processing as an adjunctive study to TRCTA.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):229.
Purpose: Arteriovenous malformations in the neck are rare, however they need to be considered in the differential diagnosis of patients presenting with hoarseness, since they can be treated readily with current endovascular techniques. We present an unusual case of hoarseness caused by paralysis of the right true vocal cord from an arteriovenous malformation in the neck that resolved after endovascular treatment.
Summary of case: A 61 year old female presented to our institute in January 2005 with hoarseness from a true vocal cord paralysis. On clinical examination a vascular mass was present in the right side of the neck, expansile with respiration, with an audible bruit and paralysis of the right true vocal cord in its lateral position. An MRI, MRA, and diagnostic angiogram revealed an arteriovenous malformation in the right side of the neck mainly supplied by the superior and inferior thyroidal arteries. Endovascular treatment with liquid embolic agents (combination of Alcohol and n-BCA) was performed in three stages eight weeks apart with resolution of the patient's hoarseness and vocal cord paralysis.
Conclusion: Arteriovenous malformation of the neck must be included in the differential diagnosis of a patient presenting with hoarseness. Resolution of the patient's hoarseness and vocal cord paralysis can be seen after endovascular treatment.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):229.
Background: We present the cases of Onyx migration to heart and draining vein and its avoidance.
Methods: Between February 2007 and August 2008, Onyx migration was encountered in 5 patients with dural AVFs treated endovascularly at our institute. Procedures performed under general anesthesia consist of 2 arterial approaches and 3 venous approaches.
Results: Two patients with dural AVFs involving the transverse-sigmoid sinus was treated with transarterial embolization, using Onyx-18, via the occipital artey and the posterior branch of the middle meningeal artery, respectively. A piece of Onyx in right ventricle was found on post-embolization chest X-ray film in both patients, one developed the tricuspid valve dysfunction requring thoracic surgery and one was asymptomatic. The other 3 patients were treated with a combination of Onyx (34 or 18) and coils transvenously with venous Onyx migration leading to draining vein occlusion, 1 with dural AVF involving tentorium died of venous rupture, 2 patients with bilateral dural AVFs of the cavernous sinus (1 with deterioration of ocular symptoms and 1 without symptoms). Postoperative digital subtraction angiography confirmed the elimination of dural AVF in 1 patient, residual fistulae in 3 patients. The follow-up study ranging from 2 to 9 months (average, 4.5 mo) three patients recovered to their full activities with one visual disturbance.
Conclusion: Although Onyx has been considered a controllable embolic agent, its migration to other location causing clinical deterioration can occurred actually. This problem should be noted and prevented.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):229–230.
Purpose: We evaluate cortical venous reflux induced by arterio-venous fistula using susceptibility weighted imaging { SWI }.
Materials and Methods: SWI is high-resolusion, three dimensional, fully compensated gradient-echo sequence that uses both magnitude and phase imaging. Postprocessing is applied to the magnitude image by means of a phase mask to increase the conspicuity of veins and other sources of susceptibility effects. This sequence was used for the 13 patients with dural arterio-venous fistula involved with cortical venous reflux. For all patients, another sequence of MRI and the angiography were performed. We compared about the detection of cortical venous reflux between SWI and the other imaging of MRI.
Results: SWI gave the information of cortical venous reflux for all cases. SWI showed the extended vein with cortical venous reflux more attractively than T2 imaging. Especially extended vein located at cerebral white matther was showed significantly. But venous structure nearby skull base representing superior opthalamic vein and sphenoparietal sinus was not detected. There are three cases of manifestation with venous infarction. SWI of venous infarction showed strongly low signal intensity. However, the white matter nearby venous infarction showed high signal intensity. This high signal area had no detection with other imaging. It means the SWI will have high sensitivity for venous stasis.
Conclusion: In the evaluation of dural arterio-venous fistula accompanied with cortical reflux, SWI is useful imaging.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):230.
There are different techniques of endovascular treatment for direct carotid cavernous fistulas (CCFs) and most of them use detachable balloons. We present 1 case of type 1 CCFs treated by the placement of two covered stents, with a 1-year clinical and angiographic follow-up. A limited number of traumatic CCFs have been reported in the literature and the coronary covered stent grafts have been sporadically used in the intracranial arteries. There is also poor information about the long-term evolution. The patient with post-traumatic CCF was treated by positioning two covered stents, with minimal superposition, in the intracranial internal carotid artery (ICA) to occlude the fistula. At the end of the procedure a minimal residual filling of the CCF was present. She received periodic clinical and angiographic follow-up to evaluate the patency and the stability of clinical results. We noticed the regression of the symptoms related to the CCF after treatment and no recurrence of the symptoms during the follow up period. The angiographic follow-up revealed a good patency of the ICA. The covered stent grafts can be used as an efficient treatment of CCFs if a standard treatment fails.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):230.
We encountered a case of middle cranial fossa dural arteriovenous fistula (DAVF) with direct cortical venous drainage which was treated completely by a transarterial approach.
Summary of case: A 44-year-old man presented with sudden onset headache. Cerebral angiography revealed a left middle cranial fossa DAVF (Cognard type4, Borden type3) fed by the inferolateral trunk (ILT) of the left internal carotid artery, the artery of the foramen rotundum (AFR), the middle meningeal artery (MMA), the accessory meningeal ar-tery (AMA) and the deep temporal artery (DTA). Venous drainage proceeded through refluxed temporal cortical veins toward the left transverse sinus. After flow reduction by coil embolization for ILT, MMA and DTA, low concentration n-butyl-cyanoacrylate (NBCA) injection was performed by wedging the microcatheter into the branches of AFR and AMA. The NBCA permeated the arteriovenous shunt, perifistulous network, and proximal draining vein. No complication occurred and the postoperative and follow-up angiogram confirmed complete obliteration of the DAVF.
Conclusion: This is the first case report of middle cranial fossa DAVF with direct cortical venous drainage treat by transarterial NBCA embolization. Transarterial glue embolization with the aid of a wedged microcatheter in flow-arrest conditions is a safe and an effective treatment for intracranial DAVFs.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):230–231.
Purpose: To present our experience of 5 cases of sDAVF treated with Onyx.
Material and Methods: Retrospective study of sDAVF treated with Onyx-18 (ev3) at our institution from January 2007 to December 2008.
Results: We treated 5 patients with ages between 31 and 61 years old, all males and one with an operated lumbar lypoma. All patients presented with progressive paraparesis, with associated hypoesthesia and sphincter dysfunction. Two patients arrived with paraplegia. Clinical presentation and MRI leads to suspect the diagnostic. Typical MRI findings were hyperintense spinal cord, flow void at perimedullary vessels and pial enhancement after gadolinium injection. Diagnostic was done using selective digital subtraction angiography. After arterial super selective micro-catheterization all sDAVF were completely excluded with Onyx-18. Three of five patients got clinically better after embolization even one patient with paraplegia. None of the cases worsened their symptoms. Patients that did not get better with embolization were those with more than 1 year of clinical manifestations.
Conclusion: Onyx treatment for sDAVF is a valid and safe therapeutic option that allows complete embolizations with satisfactory preliminary results. Its rate of success may be due to their capacity of reaching the venous side of the fistula.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):231.
Purpose: Catheterization of cavernous sinus for treatment of arteriovenous fistulae is difficult in some patients. We describe a navigation technique we used to catheterize cavernous sinus in a 19 year-old male patient using a novel flexible tip guide catheter.
Summary of case: The patient was referred to our department for endovascular treatment of a traumatic right carotid cavernous sinus fistula. Complete occlusion of right cavernous sinus with detachable coils was achieved in several steps: After femoral vein puncture an ordinary 6F guide catheter was placed in internal jugular vein and inferior petrous sinus was catheterized with the microcatheter to accede lateral part of the sinus. Catheterization of medial part via facial and angular vein failed when using the same coaxial system. We decided to navigate with a novel compliant 6F guide catheter (Neuron ' Penumbra Inc.) through facial veins until the superior ophthalmic vein within the right orbit. Then a microcatheter was successfully advanced in an coaxial fashion until the medial part of cavernous sinus.
Subsequent arterial control showed no more venous drainage but persistence of a pseuo-aneurysmal pouch of right carotid siphon which was embolized using a classical transarterial access with coaxial system of a guide and a microcatheter. No complications occurred during the procedure.
Conclusion: Intra-orbitary positioning of a specially designed, compliant guide catheter in the superior ophthalmic vein after femoral vein puncture can be performed safely and may improve access and microcatheter stability in treatment of difficult-to-reach cavernous sinus lesions.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):231.
Purpose: We present unusual venous approach in embolization of Dural AV Fistulae (DAVF)in two patients.
Material, Methods and Result: In our institution we treated by venous approach 32 patients (38%) in a total of 84 cases of DAVF - cavernous sinus region in 16 patients, 13 in the lateral sinus and the others 3 in superiorsagital sinus (SSS), middle cranial floor and skull base involving the condilian canal. In two of those patients we used an unusual technique. One patient presented with progressive dementia caused by SSS DAVF with multiple shunts. The other one was a patient with dementia and a high risk type IV lateral sinus DAVF.
The SSS DAVF was treated by microcatheterism of the sinus and total occlusion with coils. Regarding the type IV lateral sinus AV shunt an osteolytic lesion was noted in the adjacent skull. In this case we performed direct puncture and venous pouch coiling. No complications occurred, both patients improved and the follow-up angiograms showed complete exclusion of both DAVF.
Conclusions: The venous approach to treat DAVF remains indicated in several patients. Even in the SSS DAVF, if the sinus is excluded from the venous drainage of normal parenchyma, it is possible its occlusion for treatment of the shunt. In superficial lesions adjacent to the skull it is important to analyse the bone structure as embolization may be possible by direct puncture of the shunt.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):231–232.
Background: Treatment of cavernous dural arteriovenous fistulas (DAVF) is usually made by a transarterial approach. However, in some complicated patients, treatment via transarterial approach might not be complete and the transvenous approach is mandatory for the completion of treatment. We present a case of combined trans arterial and transvenous approach using Onyx and detachable coils in a DAVF fed by multiple different branches of the bilateral internal carotid artery and the right external carotid artery.
Summary: A 60 years-old woman presented proptosis, chemosis and pulsatile tinitus of the right side for 1 year. The IRM and angiography showed a single cavernous dural arteriovenous fistulas of the cortical venous dranaige with persistence a of shunt of the level cavernous sinus. The lesion was endovasculary treated by transarterial approach through right middle me-ningeal artery with onyx liquid embolic agent, that resulted in a complete occlusion of the frontal corticals venous drainage. In second time, via transvenous approach, the right cavernous sinus was accessed via the right inferior petrosal sinus and treated by a combination of detachable coils and onyx. In this case, a complete angiographic closure of the fistula was achieved with full recovery from neuro-ophthalmologic symptoms.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):232.
Purpose: To report our experience in treatment of different dural AVF through paraspinal venous plexus (PVP) approach.
Materials and Methods: In the last 5 years, we used the PVP approach for the treatment of 7 different dural AVF. They were 4 man and 3 women and aged 47 to 65 years old. The location of the lesion were cavernous sinus (n=2), hypoglossal canal (n=2), foramen magnum (n=1), inferior petrosal vein (n=1), and cervicomedullary junction (n=1). The embolic materials were detachable coils and NBCA.
Results: All the procedure were sucessful and no adverse event occurred. The long-term (mean follow-up time= 3.3 years, SD=0.6 years) outcome were good and no evidence of local recurrence.
Conclusion: in selective cases, PVP approach is a safe and easy in treating dural AVF.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):232.
Purpose: We present the first case of pulmonary artery embolization of Onyx during a dural arteriovenous fistula (DAVF) treatment.
Case: A 49 years-old male presented with a 3 years history of generalized seizures. Digital subtraction angiography (DSA) showed multiple DAVFs of the right transverse and sigmoid sinus (Merland IIb), and two fistulas at the dorsal portion of the superior sagital sinus (Merland III and IIb). Embolization of the right transverse and sigmoid sinus DAVF was decided. The middle meningeal artery was distally microcatheterized with a Marathon 1.3F and Mirage microguidewire (EV3, Plymouth, MN). We injected 0.27ml of DimetylSulfoxide (DMSO) followed by 1.5ml of Onyx-18 (EV3, Plymouth, MN). The material reached the fistula and the sigmoid sinus. The fistula was controlled, but suddenly the material was mobilized in to the jugular vein and to the pulmonary arteries. The procedure was ended and the patient transferred to the ICU with mechanical ventilation. Initially high FIO2 was needed but in the following hours it was progressively decreased. Chest radiography and chest angioCT showed Onyx material mainly in the left pulmonary arteries (approximately 20% of the pulmonary vascular territory). The patient was extubated 12 hours latter with no pulmonary insufficiency. He was kept under full heparinization for 4 days and then tapered. He presented no further pulmonary symptoms.
Conclusions: Systemic complications during Onyx embolization of brain vascular malformations have been rarely reported. There is only one previous case of Onyx pulmonary embolization during a brain vascular malformation in a newborn with a non-galenic AV fistula.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):232–233.
Purpose: We report our early experience in a small clinical series on embolization of cavernous sinus dural arteriovenous fistulae via direct percutaneous transorbital punctures, using Onyx (ethylene vinyl alcohol copolymer) as the sole embolic agent. To the best of our knowledge, percutaneous transorbital injection of Onyx for obliteration of cavernous sinus dural arteriovenous fistulae has never been published in the literature.
Materials and Methods: Between April and August 2008, three patients (mean age: 65.3 years, range: 61-72 years) with cavernous sinus arteriovenous fistulae underwent Onyx embolization through direct percutaneous transorbital punctures of the cavernous sinuses. In each patient, the ipsilateral inferior petrosal sinus was thrombosed and could not be traversed via the conventional transfemoral venous approach. The technical application, angiographic and clinical results were evaluated, and the patients were prospectively followed up.
Results: In each case, complete obliteration of the cavernous sinus dural arteriovenous fistula was achieved in a single session using Onyx as the sole embolic agent, with significant alleviation of the patient's orbital and neuro-ophthalmologic symptoms within 24 hours. No procedural complication was encountered. Subsequent follow-up at 6 months showed complete resolution of all three patients' initial clinical complaints.
Conclusion: Direct percutaneous transorbital puncture, coupled with the unique physical properties of Onyx, provides a safe and effective alternative approach to embolize cavernous sinus dural arteriovenous fistulae, particularly when the conventional transfemoral venous routes are inaccessible.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):233.
We report a case of dural arteriovenous fistula (dAVF) of the anterior condylar confluent (ACC) presented with left ptosis, exophthalmos and chemosis.
Case: In 1996, 69 years-old female presented with left chemosis, which was diagnosed as carotid-cavernous fistula and transvenous embolization of the left superior ophthalmic vein (SOV) was performed. Her symptom wascompletely resolved. A few weeks after the first operation, she noticed weakness of the left side of the tongue and pulsative tinnitus. She did not tell the doctor, because she could not imagine the symptoms had related to her disease. She dropped off the follow-up studies. In 2008, she went to another doctor due to exacerbation of palsative tinnitus. Brain checkup revealed dAVF around ACC. The angiograms of the first treatment were carefully reviewed. The fistula point was located around the ACC, which was not precisely interpreted in 1996.
Preoperative angiography showed that the main drainage route was the external vertebral plexus via lateral condylar veins and the internal jugular vein via connecting emissary veins. This time we completed transvenous embolization of the fistula, with updated understanding of this entity.Three dimentional-digital subtraction angiography (3D-DSA) could clarify the angioarchitecture of the fistula point. Multi Planar Reformat (MPR) images obtained fromthe 3D-DSA was also useful to show the exact route of the microcatheter.
Conclusion: The dAVFs around the ACC have various potential drainage routes. Although the dAVF of the ACC draining into the ipsilateral SOV is thought to be very rare, the knowledge of this entity is essential for the diagnosis and proper treatment.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):233.
Purpose: Carotid artery stent placement has been accepted as an effective alternative to carotid endarterectomy, especially in patients at high risk for carotid endarterectomy. The purpose of this study was to determine potential clinical risk factors for the development of postprocedural neurologic deficits after carotid artery stent placement.
Materials and Methods: The clinical characteristics of 58 patients (49 men, 9 women; 41 at high risk for carotid endarterectomy, 17 at low risk for carotid endarterectomy; median age, 70 years) who underwent carotid artery stent placement with distal balloon protection for 65 hemispheres/arteries (31 asymptomatic lesions and 34 symptomatic lesions) and the combined 30-day complication rates (transient ischemic attack (TIA), minor stroke, major stroke, or death) were analyzed.
Results: Six patients (9.0%) experienced a TIA and one patient (1.5%) had a major stroke (1.5%) within 30 days of the procedure. There were no deaths, so the overall 30-day combined stroke and death rate was 1.5%. The chi-square test revealed that advanced age (>75 years) was a significant clinical predictor of the 30-day combined neurological complication and major adverse effect rate (P<0.01). In addition, a symptomatic lesion was marginally associated with the 30-day neurological ischemia rate on the ipsilateral side (P=0.049).
Conclusions: Our data suggest that carotid artery stent placement with distal balloon protection can be performed with similar periprocedural complication rates to those of carotid endarterectomy. Carotid endarterectomy should be the first-line treatment in the management of patients older than 75 years.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):233–234.
Purpose: In patients who underwent endovascular angioplasty and stenting for treating occlusive carotid diseases, iatrogenic artery dissection is not a rare phenomenon. But feasible treatment strategies for this complication have not been established. Here we report a patient who developed dissection after recanalization of the occluded carotid. The complication was resolved with implantation of two tandem bare metal stents.
Case Description: A 63-year-old female experienced repeated right extremities weakness and left amaurosis fugax despite antiplatelet treatment. Magnetic resonance imaging revealed multiple infarctions in the left cerebral hemisphere. Digital subtraction angiography confirmed the occlusion of the left carotid at bifurcation. Endovascular recanalization of the occluded carotid was performed under local anesthesia. After probing with a guidewire and dilation with an over-the-wire balloon, the occluded left carotid was opened, but a long dissection across bifurcation was developed. Considering the profiles of the dissection, two tandem stents were implanted. The post-stenting angiography demonstrated that the true lumen was enlarged and the false lumen of dissection was eliminated. The patient improved progressively and no further TIA or stroke was observed during the following 3 months.
Conclusion: The results indicated that angioplasty and stenting may provide a feasible alternative treatment for iatrogenic carotid dissection related to endovascular intervention. When applying endovascular strategies for occluded carotid especially chronically occluded carotid, any manipulation should be handled with extra caution.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):234.
Purpose: To determine whether endovascular treatment is as safe and effective as medical treatment for symptomatic middle cerebral artery stenosis.
Methods: A prospective, randomized, controlled, single center clinical trial was conducted comparing standard endovascular treatment (stenting or balloon angioplasty) with medical treatment for symptomatic middle cerebral artery stenosis (≥50%). The endovascular group will receive stenting or balloon angioplasty, the medical group will receive standard medical treatment (acenterine 100mg plus plavix 75mg /day), and all the patients should control the risk factors. The endpoint was any stroke or TIA or death during the 1-year follow-up.
Results: 45 patients were enrolled from August 2007 to December 2008, of which 22 in endovascular group (16 man, mean age 51.64 years, range 31-74), 23 in medical group (19 man; mean age 46.83 years, range 27-70). There were 4 patients in endovascular group refused to have endovascular treatment. There were no significant difference in baseline patient characteristics between the two groups. The mean follow-up time was 312.397±28.185 day (range 3-365) for endovascular group, and 331.524±22.520 day (range 0-365) for medical group. During this period, there were one stroke and 4 TIAs occurred (3 vs. 2), and 3 periprecedural complications (6.67%, 1 external iliac artery pseudoaneurysm and 2 petechias), the endpoint events rates were 16.7% vs. 7.4%, p=0.375, no significant difference between the two groups.
Conclusion: The result didn't show the efficacy of endovascular treatment compared with medical treatment, more cases and longer follow-up should be involved into further study.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):234–235.
Purpose: To report a case of simultaneous spontaneous dissection of bilateral vertebral arteries with ischemic stroke and vertebrobasilar insufficiency treated successfully by stenting in one session.
Materials and Method: A 34 years-old male patient with migraine and hypertension history suffered from progressive headache and limbs weakness and then unconsciousness. Brain MRI showed acute ischemic stroke at left thalamus, left superior cerebellar peduncle and left side pons. MR angiography showed dissection at left vertebral artery (V4 segment) and right vertebral artery (V2 segment) with stenosis. Bilateral posterior communicating arteries can not be detected at the MR angigraphy. Transcranial Doppler revealed decreased blood flow in bilateral vertebral arteries. Under impression of bilateral vertebral arteries dissectiong with vertebrobasilar insufficiency, endovascular stenting with balloon expanded stents were performed for blood flow restoration. Two stents were placed covering left V4 segment (2x10 mm, 3x12 mm) and one stent in right V2 segment (3.5 mmx22 mm). The 3 stents were placed in the same session. Patient's consciousness recovered soon after the procedure without progression of the neurological deficit.
Summary of case: Simultaneous spontaneous dissection of bilateral vertebral arteries is a rare condition. Although treatment policy for arterial dissection with ischemic stroke is antiplatelet agents and anticoagulants, restoration of the arterial flow by stenting is mandatory in condition of vertebrobasilar insufficiency.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):235.
Purpose: We report carotid artery stenting using Angioguard XP and PRECISE.
Material and Methods: Subjects had a total of 41 lesions (40 cases) and a mean age of 73.8 (54-88) years old, and consisted of 35 men and 5 women. They had 28 symptomatic (21 TIAs and 7 MnCSs) and 13 asymptomatic lesions with a rate of stenosis of 50-90% (mean 81.6%). Carotid endarterectomies (CEAs) at high risk included 5 cases with complicated contralateral internal carotid and basilar arterial occlusions and 3 cases with a lesion high in the internal carotid artery. Coronary artery disease was observed in 22 cases. There were 22 subjects with an age of 75 years old or older. In principle, 2 antiplatelet agents were administered preoperatively and treatment was started after ACT was extended around 300 sec. using heparin.
Results: In all cases, the rate of stenosis was improved to 20% or less. Intraoperatively, 1 lesion showed no-flow and 3 lesions showed slow flow. Within 2 weeks of the operation, new DWI high lesions were detected in 18 of 24 cases (75%) that underwent MRI; however, no sequela of neurological deficit was observed postoperatively. Complications other than those observed in the cranial nerves included intraabdominal hematoma in 1 case that need arterial embolization.
Conclusion: Angioguard XP is relatively easy to handle and provided carotid artery stentin. No aggravation due to cerebral embolism was observed; however, the DWI-positive rate was high, calling attention to embolus that may pass through the filter.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):235.
Purpose: We evaluated the CBF changes on CT perfusion in 8 patients received carotid stenting by measurement of CBF data in the hemispheres.
Materials and Methods: Totally 10 arteries with 90% or more stenosis were treated, and their cerebral hemispheres were evaluated with CT perfusion. The prestent CT perfusion was performed within one week before stenting, and the poststent CT perfusion was performed within one week after stenting. We measured CBF values by drawing a big ROC at the bilateral hemispheres lateral to the lateral ventricle at two levels: high ventricular level, and supraventricular level. CBF value from each ROI was divided by average CBF of bilateral thalamus to obtain a ratio.
Results: The post-stent CBF showed hyperperfusion (CBF was more than 200% of the pre-stent status) in 3 hemispheres ipsilateral to the carotid artery received stenting, they were 226%, 224%, and 202% of the pre-stent status. Only one of these three had asymptomatic intracerebral hemorrhage on the same hemisphere. The hemisphere CBF relative to the thalamus varied from 29% to 82% prior to stenting. The prestent CBF's were 29%, 38%, and 49% of their thalamus in cases with poststenting hyperperfusion. For other cases with no poststent hyperperfusion, their present CBF's were 60% or more of the thalamus value.
Conclusion: The present hemisphere/thalamus CBF ratio on CT perfusion provides important value in predicting post-stent hyperperfusion.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):235–236.
Purpose: Stent thrombosis is an infrequent but severe complication after drug-eluting stents implantation. We describe a case of very late stent thrombosis after discontinuation of clopidogrel therapy, 16 months after placement of TAXUS stent.
Summary of Case: A 69-year-old man was admitted to our hospital with recurrent dizziness and diplopia. Cerebral angiography demonstrated 60% stenosis of the right vertebral artery and total occlusion of left vertebral artery. Stent-assisted angioplasy with a TAXUS stent was successful by using the "double-wire" technique. The patients experienced recurrent symptom one week after discontinuation of clopidogrel therapy at 16 months. DSA follow-up showed contrast filling defects at the distal stent edge. The patient recovered well when dual antiplatelet therapy and anticoagulation were reinitiated. No abnormality within the stent was confirmed in control angiogram 2 weeks later.
Conclusion: This case highlights the concerns about the duration of clopidogrel therapy following implantation of DES due to the very late stent thrombosis. It also suggests that optimal stent deployment is required for long-term result.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):236.
Purpose: We evaluated the safety and effectiveness of synchronous stenting and balloon angioplasty of multiple supraaortic stenoses in one session in patients with cerebral ischemic symptoms.
Materials and Methods: We treated 23 patients with multiple stenoses of supraaortic vessels in 24 sessions. Stenting and balloon angioplasty were performed syncronously in 4 lesions in one (4.3%) patient, 3 lesions in 3 (13.0%) and 2 lesions in 19 (82.6 %) patients. Stenting and balloon angioplasty were performed for 54 lesions; 11 in right internal carotid, 17 in left internal carotid, 4 in right common carotid, 7 in left common carotid, 7 in left vertebral, 2 in right subclavian, and 6 in left subclavian arteries. Angioplasty was performed for two lesions only in one patient. All patients were evaluated clinically and radiologically with CT and/or MRI one day later.
Results: Procedures were successful in all lesions (technical success: 100%). Patients were followed for 1-43 months. Death or stroke was not seen during the procedure, in early or late period. In five (21.7%) patients bradycardia and in one (4.3%) patient asystoly relieved with atropine developed during instent baloon dilatation. In three (13.0%) patients, hypotension lasting 2 days was seen. There was no additional embolic lesions clinically or on CT and/or MRI performed the following day. In two (8.7%) patients, stent restenosis after 12 months and baypass graft stenoses after 18 months were seen and relieved with balloon angioplasty.
Conclusion: Synchronous multiple stenting and angioplasty in patients with ischemic symptoms are safe and technically feasible methods in the treatment of supraaortic stenoses.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):236.
Purpose: Carotid stent implantation (CAS) has been applied clinically since about 12 years ago. Plaque behavior under the stent implantation is still unknown and report of pathological examination of carotid stent is very rare. We had a chance of autopsy examination of carotid stent case and pathological detailed examination was performed for the extract specimens.
Case: 77 year old male with TIA of right hemiparesis and the left side CAS was performed in 2004. 2 by using SMART stent (Cordis 8 mm x 40 mm). He had bilateral cervical carotid stenosis and his right side CAS was performed in 2005. 3 by using Presurge stent (EV3 9.0 mm x 40 mm). Forty one months after his left side CAS and 28 months after his right side CAS, he died by head trauma with acute subdural hematoma. Proposal of autopsy was accepted by his family, and bilateral cervical carotid artery extraction was done including implanted stents.
Pathological Examination: Specimens were fixed by 20% HCOH, resin embedding with making grinded section including metal of stent and stained by Cole's HE. Inside lumen of the stent was covered by the intimal cells and partial microscopic hemorrhage was found around the stent strut. New and old mixed hemorrhagic change was found outside the stent and the plaque was vanishing throughout the stent. No intimal hyperplasia was found inside and outside lumen of the stent.
Conclusion: Vanishing plaque findings after the stent implantation suggest not only mechanical remodeling but also stabilization or absorption of the plaque is expected by stent implantation for cervical carotid stenosis.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):236–237.
Purpose: We evaluated the feasibility of multi parametric CT perfusion (CTP) approach in guiding the decision to treat with an endovascular procedure a patient with Rendu Osler syndrome suffering for hyperacute stroke due to MCA occlusion.
Summary of case: We described a case of a 70 years old female with previous diagnosis of Rendu Osler syndrome who was admitted in our department with signs and symptoms indicating hemispheric stroke and underwent CT protocol within 3 hours of onset. The ASPECT score on unhenanced standard CT was 8 in left MCA territory, CT angiography demonstrated on occlusion of left M1 segment and CTP revealed a large mismatch between cerebral blood flow (CBF) and cerebral blood volume (CBV). Because Rendu Osler syndrome represents an absolute contraindication for systemic or local thrombolysis, mechanical reperfusion therapy was performed based on CTP findings. A successful recanalization was obtained by gently inflation of a hyperform balloon (Ev3) 4 mm x 7 mm through the thrombus. An immediate clinical improvement was observed after the angioplasty and persisted over time during the transition from the acute to the subacute phase. Follow-up CTP studies performed at 24h and 7 days after onset showed a progressive decrease in the volume of the hypoperfused area as measured on CTP maps.
Conclusion: This illustrative case suggests that CTP technology represents a useful tool for selecting the more appropriate therapy in patients with both hyperacute stroke and contraindication for thrombolysis. CTP analysis seems to be a promising method for a prospectively determination of ischemic lesion evolution.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):237.
Purpose: To present the experience and results of primary stent-assisted angioplasty in acute MCA occlusion.
Materials and Methods: We included two patients with stroke MCA occlusion, with less than 6 hours of evolution. The initial diagnosis study was CT angiography, followed by Diffusion MRI without evidence of cerebral hemorrhage. All of them were treated with mechnical thrombolysis and primary stent assisted angioplasty.
Result: Two patients underwent cerebral angiography and showed occlusion of MCA. Occlusion of left MCA in 1 patient and right MCA in 1 patient. Superselective catheterization and mechanical thrombolysis with agility microwire (Cordis Inc.) was performed. Post thrombolysis angiogram showed severe stenosis at the middle cerebral artery. Total recanalization achieved by stent assisted angioplasty. No complications were developed during procedure. No other patients have developed new or recurrent neurological symptoms over a period of 1 year.
Conclusion: Primary stenting for acute MCA occlusion by underlyingstenosis appears to be technically feasible. The treatment results seem to be sustained in the long term clinical and imaging study.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):237.
Purpose: Dissection of supra-aortic arterial trunks are the origin of about 2% of all ischemic stroke and of 10 to 25% of stroke in young individuals. The treatment of these dissections is essentially medical by way of systemic heparinotherapy. However, in certain cases endovascular treatment with stenting might be indicated.
Materials and Methods: From March 2004 to March 2008 thirteen patients and fifteen cervical dissections have been treated with stent.
Carotid: Post-traumatic = 7
Spontaneous = 2
Dissecting Aneurysm = 1
Vertebral = 5
The indication of endovascular treatment was proposed when faced with a stroke, permanent or not, due to cerebral hypoperfusion. For the lower cervical carotid dissections Carotid Wallstents were used, except for one case treated with a Silver Stent. The vertebral or higher carotid dissections were treated with Leo Stent in 4 cases and balloon detachable stents in other 4 cases.
All patients were kept under anti-platelet therapy for at least 3 months.
Results: The 6-month or 1-year angiographic follow-up showed a good evolution of all dissection, except for one case of a vertebral artery dissection (V2) in wich remained a moderate intra-stent stenosis
No complications were noted in this small series.
Conclusion: Endovascular treatment of cervical dissections is seldom indicated. However, the use of stents allows to obtain a rapid cure with no major complications.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):237–238.
Objective: To evaluate effect of angioplasty and stenting in patients with multiple stenoses of supra-aortic branches (SAB).
Material and Methods: We report 67 patients with multiple stenoses of supra-aortic vessels treated at our Institute from 2003 till 2008. 15 of them had CCA-ICA (12) and VA (3) occlusion with contralateral ICA stenosis. In 67 cases we used 86 stents: 64 CCA-ICA stenting, 20 ScA stenting and 2 extracranial VA stenting. Self-expandable stents were used in CCA-ICA stenosis; balloon-expandable stents were used in subclavian and vertebral artery stenosis. 61 pts had symptomatic stenoses (TIA, minor/major stroke, amaurosis fugax, steal-syndrome) and 6 ' asymptomatic multiple SAB stenoses. Degree of stenoses was reported as 50-100% (4 patients had occlusion ScA (3) and a. anonyma (1). In 53 cases it was accompanied by severe co-morbidity (stenocardia, arterial hypertension, diabetes mellitus) Angioplasty was performed according to indications. In all cases surgery was performed under TCD-control with embolodetection using different intravascular filters. Control examinations were performed in 1, 3, 6 and 12 months after surgery.
Results: Technical success was achieved in 66 of 67 cases. In 3 cases we observed macroembolia of the filter-wire. 4 patients had TIA within 24 hours after the operation. Catamnestic data (3-30 month) was collected from 45 patients (67%): morbidity/mortality - 0; TIA - 0; significant restenoses (>30%) - 0, occlusion of the stented ICA - 1.
Conclusion: Angioplasty and stenting with embolic protection devices in patients with multiple severe stenoses of SAB is considered as treatment of choice.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):238.
Purpose: Intracranial internal carotid artery (ICA) dissection manifesting as ischemic stroke is rare and the optimal treatment has not been established. We report two cases of this disease treated successfully by stent placement.
Summary of cases:
Case 1 was a 28-year-old man who presented with mild left hemiparesis after sudden onset of headache. Left hemiparesis rapidly deteriorated within 2 hours. Diffusion-weighted magnetic resonance imaging (MRI) showed infarcts in the territory of the right ICA. Angiography showed stenosis and double lumen of the supraclinoid segment of the right ICA. A balloon-expandable coronary stent was placed 4 hours after onset. Postprocedural angiography sho-wed complete resolution of the stenosis. Follow-up angiography 2 years later showed complete healing of the dissection and his neurological deficit had fully recovered.
Case 2 was a 29-year-old woman who presented with seizure and left hemiparesis after sudden onset of headache. Diffusion-weighted MRI revealed infarcts in the right basal ganglia and cortex of the right frontal lobe. Angiography showed pearl and string sign at the supraclinoid segment of the right ICA. Anticoagulant therapy was began and her symptoms resolved within a day. However, she again developed left hemiparesis 2 days after onset. MRI revealed new infarcts in the right middle cerebral artery territory. A balloon-expandable coronary stent was placed. Follow-up angiography 2 years later showed complete healing of the dissection and she had only mild monoparesis of the left upper extremity.
Conclusion: The present cases suggest that stent placement for intracranial ICA dissection presenting with ischemic stroke is effective.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):238.
Purpose: We tried to use segmental dilation and self-expanded stenting technique to treat long lesion of intracranial artery stenosis. By reviewing these cases, the efficacy and safety of this technique is evaluated.
Materials and Methods: In this series, there were 12 cases of intracranial artery stenosis, which including 5 cases of internal carotid artery terminal segment to M1 of middle cerebral artery, 2 cases of M1 to M2 segment of middle cerebral artery, and 5 cases of vertebral basilar artery. The stenotic length of arteries was all more than 10 mm. All patients were treated by segmental dilation of small balloon and long self-expended stent angioplasty.
Results: In all these cases, the average stenotic degree is 86.3%. After dilation, it decreased to 22.5%, and then improved by stenting angioplasty to 6.7%. All cases were succeeding with a good outcome. 1 case occurred a postoperative TIA, and other one occlusion of side branch. 9 cases were followed more than 3 months without any adverse effect or reste-nosis.
Conclusion: The segmental dilation and self-expanded stenting angioplasty technique is safe and effective to treat long lesion of intracranial artery stenosis.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):239.
Purpose: The correlation of cervicocerebral stenosis and coronary stenosis has never been proven by angiography, this study was designed to evaluate it.
Materials and Methods: 34 patients simultaneously accepting angiography of cervicocerebral and coronary arteries were retrospectively studied, which were divided into two subgroups based on the number of stenotic branches of coronary artery, respectively 16 cases in group A (≥2) and 18 cases in group B (≤2), then compared the incidences of stenotic branches of cervicocerebral arteries by chi square test.
Results: This study had 304 branches of cervicocerebral arteries in group A, respectively 176 branches of intracranial segments (IS) and 128 branches of extracranial segments (ES), moreover, had 342 branches of cervicocerebral arteries in group B, respectively 198 branches of IS and 144 branches of ES. The incidence of IS was higher in group B (35/198) than that in group A (18/176) (P=0.012), yet there was no statistical significance of ES between two subgroups (P=0.749). This study had 294 branches of cervicocerebral arteries in group A, respectively 192 branches in carotid artery system (CAS) and 102 branches in vertebrobasilar system (VBS), moreover, had 342 branches of cervicocerebral arteries in group B, respectively 216 branches in CAS and 126 branches in VBS. The incidence of CAS was higher in group B (38/216) than that in group A (20/192) (P=0.038), yet there was no statistical significance of VBS between two subgroups (P=0.682).
Conclusion: Along with the aggravation of coronary stenosis, there are dierct correlation with intracranial segments of cervicocerebral arteries, especially in carotid artery system.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):239.
Background: Spontaneous hemorrhage of collateral vessels during cerebral angiography is not common and requires immediate action. Treatment includes reversal of anticoagulation and micro-catheterization with usage of glue, coils or other embolic agents.
Case Description: A51 year-old female with history ofDM, HT, and A.Fib who experienced recurrent strokes of the brainstem - MRA demonstrated 99 percent occlusion of the right vertebral artery, 90 percent stenosis of the left vertebral artery and absent bilateral posterior communicating arteries. The patient underwent cerebral angiography for intracranial angioplasty and stenting. Upon the initial left vertebral artery catheterization, the angiogram revealed active hemorrhage from small indirect medullary pial collateral vessel originating from left vertebral artery, just proximal to high-grade vertebral stenosis. Emergent micro-catheterization of this tiny collateral hemorrhage branch was attempted. However, catheterization could only be achieved with the microwire and the microcathether was pinned against the orifice of the vessel. No embolic agents could be used. Within one hour, using the wire/microcatheter as temporary blockage along with emergent platelet transfusion and protamine administration, there was complete cessation of active hemorrhage. The patient made a dramatic recovery and underwent successful angioplasty and stenting of the intracranial right vertebral artery soon afterwards.
Conclusion: Spontaneous intracranial hemorrhage from a small pial collateral vessel is a rare occurrence. Temporary occlusion and vasospasm induction may be a life-saving alternative in these too small to catheterize vessels.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):239–240.
Introduction: Imaging techniques that allow early diagnosis are important, as treatment of stroke is currently dependent on the time elapsed since ictus and detection of potentially salvageable brain. CT perfusion is a highly sensitive modality that can determine the occurrence of acute infarction and help differentiate salvageable versus infarcted brain tissue. However, to date, the exact parametric values that correspond to ischemia and penumbra are not well defined.
Case Report: We present CT Perfusion data demonstrating the initial territory of at risk ischemic brain in a patient who awoke with an acute basilar stroke. The initial CT perfusion scan demonstrated a large ischemic region in the left cerebellar, pontine, temporal, and occipital territories. Based on these initial CTP findings and clinical presentation, intra-arterial thrombectomy was successfully performed. Follow-up non-contrast CT studies done 2 months post intervention demonstrated small areas of infarct, with large areas of at risk brain preserved. The complete imaging data set pre and post intervention allowed us to begin to interrogate the question of what parametric values ultimately result in infarcted tissue and which more accurately represent salvageable tissue in this acutely completely revascularized patient. To this end, a retrospective statistical image analysis was performed between the CBV, CBF, and MTT maps generated by CT perfusion, with the corresponding axial slices of the delayed non-contrast CT head.
Conclusion: Our early results suggest that CT perfusion imaging may be enhanced by utilizing revascularized patients in the calculation of thresholds of penumbra.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):240.
Introduction: Instent restenosis (ISR) is a known sequlae of carotid artery stenting (CAS). In this particular patient a high grade ISR occurred within 6-12 weeks after successful CAS. We hypothesize that this patient's history of extensive proliferate scar formation (PSF) after skin injury may be an important clinical risk factor for accelerated restenosis following endovascular stenting operations.
Case Description: This is a 59-year-old male a high grade 90 to 99% stenosis of the left internal carotid artery. We noted that all of his surgical incisions had generated significant hypertrophic scars. Percutaneous transluminal angioplasty and stenting of the left common carotid and internal carotid artery were performed successfully with no significant residual stenosis in August, 2007. On repeat angiography conducted 12 weeks after the PTA and stenting, however, approximately 70-80% in-stent restenosis of the previous stented segment of the left internal carotid artery was observed. Successful repeat angioplasty was performed with less than 30% residual stenosis on final control angiography.
Conclusion: In-vitro studies and one clinical report seem to support an association between proliferative scar formation and ISR. This may have several important clinical implications that may require further investigation. Patients with a history of a significant proliferative scar formation may need more intense vascular imaging followup. Perioperative oral or intravenous corticosteroids regimens may be considered to potentially prophylax against accelerated hypertrophic restenosis.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):240.
Intracranial atherosclerosis accounts for 5-10% of ischemic strokes in the United States. The locations most commonly affected include the middle cerebral, supraclinoid internal carotid, vertebral and basilar arteries. Lesions specifically located in the anterior cerebral artery (ACA) territory are infrequently reported. Patients who fail medical therapy are at a high natural history risk for recurrent ischemic events, in which case intracranial angioplasty or stenting may be a reasonable therapy. There is scarce literature describing angioplasty of fixed atherosclerotic lesions affecting the ACA territory.
We describe a 63 year old African American woman who underwent successful A2 segment balloon angioplasty for recurrent, symptomatic atherosclerotic disease treated initially with medical therapy. At 8 month follow-up, the patient remained without further clinical events and follow-up angiography demonstrated less than 30% residual stenosis of the treated A2 segment.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):240–241.
Background and Purpose: The best result in intra arterial trombolise are obtained when this technical is apply into 6 hours after stroke, however most of case arrive in hospital late.We discuss the possibility to apply the intra arterial thrombolysis in a select case after 6 hours.
Clinical case: A 55 yo man presented with left hemiparesia, normal conscience, NIHSS 8 and onset stroke 5h50min. CT scan hyperdensity sign in right meddle cerebral artery, without hemorrhage or isquemic image. At 7 hours after stroke onset, angiography presented with occlusion of M2 in right site, with collateral circulation from anastomoses leptomeningea and NIHSS 10. Moreover the time, the mechanic intra arterial thrombolysis was done and 4 mg of rtPA was injected in situ. The meddle cerebral artery was completely reopening. After 12 hours of thrombolysis the NIHSS was 2 and CT demonstrated asymptomatic small hemorrhage.
Discussion: When the intra arterial thrombolysis was done into 6 hours with the NIHSS <20, the results are better with hemorrhagic risk <4,7%. In our case, the collateral circulation maintain a relatively perfusion in cerebral tissue with the NIHSS 10, despite the occlusion of M2. The questions are: how long this collateral system maintains the good perfusion, without to progress in malign meddle cerebral infarct? What more import: the time of onset stroke (>7 hours) or analyze of NIHSS, collateral perfusion and CT scan. In our opinion, the low level in the NIHSS with a good collateral perfusion, normal CT, reflected a positive "mismatch "that allow do the intra arterial thrombolysis.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):241.
Purpose: Moyamoya is a progressive occlusive disease that affects the last segment of the internal carotid artery, the M1 and A1 segments. The revealing event may be cerebral ischemia or in adults haemorrhage. Almost all patients are diagnosed at a stage of the disease when the affected arteries have occluded.
Summary of case: The patient was a 28 year old previously healthy man with a history of alcohol abuse and drugs (cannabis). He was a moderate smoker.
He sudddenly noticed sensory disturbances in his left hand, followed by partial left sided hemiparesis. The motor symptoms disappeared within 15 minutes but the sensory disturbances migrated and persisted for another 24 hours.
CT-angiography disclosed subarachnoid blood over the right cerebral convexity. CT-perfusion showed a moderate increase in MTT and a slight increase in blood volume in the right hemisphere.
An angiography disclosed a 5mm long smooth occlusion or extremely tight stenosis of the first part of the right MCA. There was an approximately 70% stenosis at the origin of the right A1 and a slight narrowing of the top of the ICA. The left side was affected in a similar fashion but to a much lesser degree. Collateral flow was abundant.
We believed this to be a case of early diagnosis of Moyamoya and proposed balloon dilatation of the right MCA. This was performed a few days later with a Gateway® 2.25mm balloon (Boston Scientific). There were no complications. The flow in the right MCA was restored and was still normal at follow-up angiography three months later.
Conclusion: In patients with Moyamoya diagnosed before permanent arterial occlusion, balloon dilatation of the affected vessels can be a treatment option.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):241.
Introduction: Profound bradycardia and hypotension are well-recognized during carotid stent-assisted angioplasty operations. We describe two rare and severe cases of carotid sinus reactions in which patients experienced transient, reversible asystole (>15 secs) during carotid angioplasty.
Case descriptions: Patient 1 is a 77-year-old male presenting with recurrent syncope for six months. Catheter angiography confirmed 90'99 percent long segment stenosis of the origin and post bulbar segment of the cervical right internal carotid artery. Gradual post-stent angioplasty resulted in profound bradycardia progressing to asystole (approximately 20 secs), and hypotension, which were immediately treated with glycopyrrolate and atropine and immediate balloon deflation. Immediate restoration of sinus rhythm was observed with balloon deflation.
Second patient is a 59-year-old male who presented with accelerated high grade ISR of previously placed CAS. Gradual inflation of the balloon during repeat PTA resulted in profound bradycardia progressing to asystole (approximately 20 secs), and hypotension, which were immediately treated with glycopyrrolate and atropine and immediate balloon deflation. Immediate restoration of sinus rhythm was observed with balloon deflation.
Conclusion: Prolonged asystole (> 15 secs) may be rarely observed during carotid bulbar segment angioplasty. Immediate recognition and rapid, early balloon deflation coupled with IV atropine or glycopyrrolate may be sufficient to restore normal sinus rhythm quickly.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):241–242.
Purpose: To evaluate whether stenting of acute carotid dissections in patients with proven symptomatic hypoperfusion is safe and effective.
Material and Methods: Patients that were stented in the internal carotid artery at our institution between June 1st 2006 and September 30th 2008 were included. Procedure data and early radiological results were retrospectively reviewed together with chart data and images from 3-6 months follow-up.
Results: 53 patients were identified. In three patients, the indication for the procedure was acute dissection with neurological symptoms and hemodynamic impairment as shown by CT-perfusion related to internal carotid artery lumen impairment and an incomplete Circle of Willis. None of the patients had manifest infarcts. All three dissections were localized in the upper cervical and petrosal segments of the internal carotid artery and treated with 1-3 intracranial stents. There were no complications from the stenting procedures. In all three patients, the symptoms resolved almost completely and the CT-perfusion was normalized within 24 hours after the procedure. One patient developed small, asymptomatic infarcts in deep watershed areas. At 3-6 months follow-up, the stents were fully patent with normal brain perfusion and all patients had recovered completely (Modified Rankin Scale=0).
Conclusion: Acute dissection in patients with an incomplete Circle of Willis can cause symptomatic hypoperfusion that may develop into large hemispheric infarcts. In this small series, stenting was performed safely with excellent radiological and clinical long term results and may consequently be a treatment option for this limited patient category.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):242.
Objective: To investigate the relationship between cortical cerebral watershed infarction (CCWI) and carotid artery stenosis and evaluate the cantilever insertion operation.
Methods: After 23 CCWI patients diagnosed by CT or MRI received DSA detection, we supply cantilever insertion operation for 11 patients according to their voluntary, and conservation treatment for other 12 patients. All the patients were followed up 6 to 12 months.
Results: Among 23 CCWI patients, 22 were detected with carotid artery stenosis. According to statistic results, it showed that the degree of carotid artery stenosis was associated with clinical symptom and the volume of steal phenomenon, P<0.01.
The artery stenosis were improved over 90% with the cantilever inserted and dizziness, steal phenomenon disappeared. From 6 to 12 months followed up showed that the patients with cantilever insertion treatment got less new symptoms, steal phenomenon and artery stenosis, compared to the patients with conservation treatment, P≥0.05 or P≥0.01. The restenosis and deterioration of artery stenosis has no statistic difference between pre and post with cantilever insertion treatment 6 to 12 months later, P≥0.05.
Conclusions: CCWI was associated with carotid artery stenosis. The cantilever insertion could be useful for treatment of carotid artery stenosis and prevention of cortical cerebral watershed infarction.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):242.
Objective: To study the correlation between compensation by collateral circulation and the clinical nerve function damage degree in patients with severe stenosis or occlusion of ICA.
Methods: We analyzed NIHSS scores on hospital admission and clinical and arterigraphic findings of 52 consecutive patients with cerebral infarction.
Results: Of the 52 cases, DSA demonstrated ICA occlusion in 18 cases, unilateral ICA severe stenosis in 28 cases, bilateral ICA severe stenosis in 6 case. 14 cases have no collateral circulation pathway in the circle of Willis. ACoA was present in 18 cases, PCoA in 8 ,anterior and posterior communicating arteries at same time in 12. The average ranks of NIHSS in no collateral circulation pathway in the circle of Willis group and collateral circulation pathway in the circle of Willis groups were 35.75 and 23.09,respectively, with significant difference (P =0.006). The average ranks of NIHSS in collateral circulation pathway in the ACoA group and collateral circulation pathway in the PCoA groups were 12.42 and 15.94, respectively, with no significant difference (P =0.285).
Conclusions: Effective collateral circulation can be established spontaneously through multiple ways when ICA occlusion or severe stenosis takes place. There is a significant association of NIHSS scores and the compensation and location of a vessel occulusion. It is mandatory to investigate carefully the collateral circulation through DSA before treatment intervention.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):243.
Purpose: The time to recanalize the occluded artery is the most important factor for the outcome of the patient suffering acute ischemic stroke. To save the time and to improve the efficiency, we used double catheter technique. We experienced a case that the ccludedMCA branch was recanalized as soon as we started the procedure and recovered well.
Materials and Methods: A 66-year-old man presented with an NIHSS score 14 in30 minutes from the time of symptom onset. Initial diffusion MRI showed right MCA territory infarction. He receivedt-PA. But patient did not show any improvement 1 hour after t-PA injection.Perfusion/DiffusionMRI showed mistmatching on right MCA territory.The conventional angiogram showed the right distal M1 occlusion. One microcatheter was indwelled in the thrombus and urokinase injection was performed through the microcatheter. 400,000 units of urokinase was mixed by 50cc saline and that mixture was injected by 100cc per hour. The other microcatheter was placed just in the thrombus and mechanical clot disruption was done by a microwire under continuous injection of the urokinase.
Result: 5 minutes after the mechanical clot disruption, the occluded M1 was recanalized andTICI grade was change from 0 to 3. The patient showed good motor improvement of the motor power at 6 hours after the thrombolysis. He recovered independently after rehabilitation therapy with the modified Rankin scale 1.
Conclusion: Early recanalization of occluded artery improve clinical outcome of patient suffering acute ischemic stroke. This technique can reduce time to recanalize and improve the effeciency of mechanical disruption of the clot.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):243.
Purpose: We examined cognitive function before and after carotid artery stenting (CAS). Cerebral blood flow (CBF) and cerebral vascular reserve (CVR) were also measured using SPECT at the almost same interval, and relationship between cognitive abilities and cerebral perfusion was analyzed.
Material and Methods: Subjects were 27 patients having symptomatic severe carotid stenosis. Five of 27 patients were women, and mean age was 69.3 years. Neuropsychological testing was performed before CAS and at 1 month with a frontal assessment battery (FAB), Mini-mental state examination (MMSE), Raven's colored progressive matrices (RCPM), Kana-hiroi test, word fluency test, Wechsler Adult Intelligence Scale and Wechsler Memory scale. CBF and CVR were investigated before and 1 month after CAS, with resting and acetazolamide-challenge SPECT.
Results: A significant improvements after CAS were observed in the scores of FAB, verbal memory, general memory and delayed recall. In patients with right side carotid stenosis, after stenting, we found significant improvements of the scores from performance IQ. Furthermore, no differences were observed between the affected side of lesions and cognitive performances. There were no significant changes in CBF at pre and 1 month after CAS. In CVR 1 month after stenting, all cases improved significantly in patients with right side lesions.
Conclusion: In our study, some improvements were observed after CAS, however it is not enough to conclude that CAS can change neuropsychological function. CAS interventionists would be actively engaged in this development of the field to contribute to continue providing the high quality of patients' life.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):243–244.
Purpose: Embolic protection device, such as AngioGuard™ XP (Cordis, MI, USA), has been developed to reduce the embolic events following carotid artery stenting (CAS), and is currently considered the standard of care for CAS in Japan. However, it is sometimes difficult to retrieve this filter device with the tortuous situation of the placement with open-cell design stent (Pricise; Cordis, MI, USA). Thus, we produce a new rescue catheter with using a difficult situation to retrieve this device. The objective of this study is to assess the performance of this catheter.
Materials and Methods: The rescue catheter consists of coaxial system, which is made from 6F outer-catheter and 4F inner-catheter with adjusting 0.014-inch guide-wire of its tip.
We confirm the radiographic visualization of this catheter under fluoroscopy, and evaluate the usability and the crossing ability in the tortuous situation such as inward prolapsed of the stent with using a flow model.
Results: Characteristics of an ideal device would be easy to use, complete capture of AngioGuard™ XP in tortuous anatomy.
Conclusion: On the basis of this study, the rescue catheter seems to be well suited to use, if it is difficult to retrieve the AngioGuard™ XP. There will be an increasing used for specific tools to decrease the complications of the CAS procedure.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):244.
A 53 year-old male was found unresponsive, slumped over in his chair. He had been suffering from intermittent loss of vision and numbness in his right extremities for 2 weeks. He was brought to the emergency room and was intubated upon his arrival as his level of consciousness rapidly deteriorated (GCS 9/15 and NIHSS 29). On initial examination, there was weakness of all limbs, with motor power totally lost in his right extremities (muscle grade: left 3/5 and right 0/5).
Initial CT showed no bleeding, but severe atherosclerotic changes of bilateral vertebrobasilar arteries and suspected recent infarct in thalamus. Emergency cerebral angiography revealed total occlusion of bilateral vertebral arteries (V4) and basilar artery, and Urokinase 500,000 units was given. Patient temporarily regained partial motor power (3/5 on both sides) but his clinical condition deteriorated again 4 hours later in the same afternoon.
CT angiography after the first procedure showed an additional dissection of the distal segment of basilar artery. Perfusion defects were noted in the pons, bilateral middle cerebellar peduncles (worse on the left side), upper portion of bilateral cerebellar hemisphere and right occipital lobe. So we put 4 consecutive stents from basilar tip down to distal portion of left vertebral artery and restored TIMI III flow well.
He recovered well and was extubated on the 6 th day with complete restoration of perfusion defects. His mRS was 2 on 30th after onset.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):244.
Purpose: In addition to stenosis degree, plaque stability is known to be related with presenting symptom pattern in intracranial arteries. However, plaque status evaluation is limited in intracranial vessels due to the small caliber of the vessel. We evaluate feasibility of plaque status analysis in M1 by high resolution MRI.
Materials and Methods: We prospectively analyzed high resolution MRI before and after contrast enahncement in 10 patients who also underwent cerebral catheter angiography. Control was done in 5 patients in the opposite normal vessel in case the patient is tolerable to the study. Image protocol for vessel wall consisted of 3D TOF-MRA, pre- and post-contrast T1WI, pre-contrast T2WI, and pre- and post-contrast high resolution proton density weighted images (PDWI). Overall examination time was 7 minutes. Our hospital's institutional review board approved the prospective research protocols, and all patients gave us their informed written consents.
Results: Plaque status could be clearly demonstrated especially on PDWI. Contrast enhanced image revealed additional information of the plaque status. Plaque location on sagittal image was variably distributed. Coronal reconstruction image based on the tangential view of the sagittal cross sectional image was helpful to identify the plaque along the vessel wall and comparable with cerebral angiography. Plaque location along the M1 wall.
Conclusion: Plaque status could be well demonstrated by high resolution MRI. Coronal reconstructed image based on the sagittal view was useful to evaluate the plaque status in addition to contrast enhanced image.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):244–245.
Background and Purpose: We reported the comparison between PercuSurge occlusion balloon (PS) and Angioguard XP (AG) which were used as prime choice at each period.
Materials and Methods: Two hundred eighty-five patients, including 245 men and 40 women, mean age of 69.5 year old underwent carotid artery stenting (CAS) between October 2002 and December 2008 for symptomatic or asymptomatic cervical carotid artery stenosis in our institutions. Twenty-five patients were treated bilaterally. Major adverse event (MAE) within 30 days, ischemia on MRI-DWI and residual stenosis more than 30% was investigated. Risk factors correlated with MAE was analyzed among each group. In addition, flow impairment which is contributable to ischemic complication was also examined among F group.
Results: Sixty-one cases (19.7%) were partially or completely protected by AG. The 30-day rate of all death/any stroke was 4.2% among all cases, 2.0 and 13.1% among PS and AG group. Residual stenosis was observed among AG group more often than PS group (20.9% vs 11.1%). Single regression analysis showed MAE correlated with contralateral ICA occlusion or severe stenosis and history of diabetes mellitus among PS group, and with flow impairment and modified Rankin Scale at procedure among AG group significantly. Flow impairment occurred in 19 (33.3%), and correlated with near occlusion, higher necrotic core rate on intravascular ultrasound and left-side lesion significantly in multivariate analysis.
Conclusion: There is a possibility that PS is superior to AG for CAS. The appropriate case selection and development of skill seemed to be necessary to use AG.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):245.
Objective: Due to complicated symptoms and signs, glomus jugular tumor (GJT) may be easily misdiagnosed. This study aims at probing the clinical characters, image figures and therapeutic ways of GJT.
Methods: 4 cases with GJT finally diagnosed by DSA were retrospectively analyzed. Combined with relative literature, the clinic characters, image figures, diagnosis and differential diagnosis and therapeutic strategies of GJT were concluded and summarized.
Results: Patients with GJT are often the elder, generally above 40 and most frequently between 60-70 years old. With some heritability, GJT progresses slowly so that the course is usually long, generally lasting for more than 4 years and exceptionally for more than10 years. The main clinical manifestations are caused by auricular nerves and other cranial nerves involvement. As the tumor grows larger, the cerebellum and the brainstem may be involved and intracranial hypertension may appear. Characteristic MRI findings are the serpiginous appearance of signal void in tumor and the "salt & pepper" sign which is especially valuable to the diagnosis. DSA can demonstrate definitely the location, the size and the infringing range of the tumor, providing the evidence to the final diagnosis. The therapeutic ways of GJT include surgical excision, tumor-blood vessel embolization and radiation.
Conclusions: Typical clinical manifestations plus MRI findings contribute to the GJT diagnosis. DSA can give the final diagnosis and provide help to surgery therapy. Surgical resection is the most valuable way to cure it. Preoperative embolization is essential to reduce blood loss during operation.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):245–246.
Purpose: We propose a new therapeutic approach to low back pain consisting in a liposuction of the fat surrounding the atrophied lumbosacral paraspinal muscles. This study was originally based upon the observation that paraspinal muscular atrophy with fat deposits occurs near the region of intervertebral disk hernias. Our hypothesis was that reduction in the volume of the fat deposits would allow an expansion of the atrophied muscles and consequently improve the active contention of the lumbo-sacral spine.
Methods: We present our current experience on 103 patients. In all cases the symptoms had persisted for over one year. There were 68% females, mean age 58, lumbar pain 46,6% (48), lumbo-radicular pain 36% (37), diffuse pain of the lower extremities 8,7% (9), coccyx pain 5,8% (6), thoraco-lumbar pain 2,9% (3). Percutaneous intradiscal treatment had been performed previously (4 months to 13 years before liposuction) on 68 patients without meaningful recurrence of disk hernia. In 6 patients a second session of liposuction has been performed a few months or years after the first session.
Results: There has been no complication. Overall results showed 78% (80) of very good (11) or good results (69). Repeated liposuction has been bene- ficial on all the cases. The MR follow-up controls regularly showed an expansion of the para-spinal muscles.
Conclusion: It is, at our knowledge, the first time that liposuction is used to encourage muscular expansion. This pilot study has demonstrated safety and therapeutic efficiency.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):246.
Purpose: Born of the observation of a relation between the harmony of the para-spinal muscles and the distal muscular strength the paraspinal muscular harmonization method uses mainly original acupunctural and/or homeopathic stimulations of the paraspinal muscle. We present the imaging techniques used to document objectively the therapeutic effect of the method.
Material and Method: Paraspinal muscular harmonization method has been routinely used for several years in various indications including the painful pathologies of the spine with or without hernia, diffuse painful symptoms and scolioses. Four imaging techniques have been used before and after stimulation:
1) photography,
2) GDV bio-électrograhy (whole body digital projection of the Kirlian effect),
3) cerebral spectroscopy of the supra-thalamic areas,
4) thermography.
Results: Thermography and cerebral spectroscopy show immediate significant modifications:
a) thermography appears especially simple of use while showing an obvious cutaneous cooling after stimulation.
b) cerebral spectroscopy shows a (reduction) reversible decrease of the NAA / Cr ratio, glutamatergic (Glx) and Cho / Cr changes.
Photography as well as bio-électrography show constant modifications but sometimes more belated.
Conclusion: Imaging techniques document objectively the effect, otherwise clinically obvious, of the method.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):246.
Purpose: The purpose was to clarify the usefulness of and carotid ultrasonography for evaluation of cross-filling through the anterior communicating artery (ACoA) of the circle of Willis regarded as primary collateral pathway in patients with trial occlusion of the internal carotid artery (ICA).
Methods: Cross-filling was determined on the angiogram by contrast filling the ACoA following a carotid injection with temporary manual occlusion of the contralateral common carotid artery (Matas test). The appearance of the cross-filling was the graded on a 3-point scale: grade 1, no cross-filling was visualized on the angiogram; grade 2, small but definite collateral distribution, often with dilution, eg just to anterior cerebral artery or to anterior cerebral and some to middle cerebral arteries; grade 3, full cross-filling, eg to middle cerebral artery. In carotid ultrasonography, we measured the blood velocity of ICA (VICA) before and during Matas test. The correlation between the grades of cross-filling on the angiogram and the VICA in carotid ultrasonography was investigated in each case.
Results: In grade 3 patients, the VICA increased immediately during Matas test, while that of the other grade patients remained unaffected by occlusion test. Consequently, increasing VICA in carotid ultrasonography during Matas test is suggested that the cross-filling via ACoA is more effective pathway compared with unchanging VICA between before and during Matas test.
Conclusions: Ombined carotid ultrasonography and Matas test seems to be useful and less-invasive in predicting the cross-filling via the circle of Willis.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):246–247.
Purpose: The occurrente simultaneously to Aneurysm and AVM's are few common; in study in 1969 to 3,265 patients only 1% haven Aneurysm and AVM's combined. The theory to hemodinamic stress as predispose factor in occurrence of aneurysm in patient with AVM's is corroborate, because in 1 case the first Angiography with AVM haven't Aneurysm, and 3 years posterior, where finding 3 aneurysm in the same vascular territory to the AVM; and the spontaneous regression to the aneurysms posterior to AVM's .treatment. soport to the hemodinamic stress theory.
Materials and Methods: 3 patients were treated at our Unit, 2 females, 1 male, range 45-49 years old, mean age: 47.
Results: There were 3 cases combined aneurysm and AVM's to the 301 cases to endovascular terapy at our Unit., to 1 % , female 2 cases to 66.7 % and 1 male to 33.3 %. Mortality: zero in this serie. There were 2 cases to aneurysm and AVM in the same territory and 1 in diferent territory. We trate first the aneurysm. In Two cases and the AVM in 1 case. There were no complications.
Conclusions: Occlusion o the aneurysm previous to the AVM's was realized in two cases, and partial occlusion to the AVM. In 1 case. The question is wich trate firsts.
References
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interv neuroradiol. 2009 Jun 2;15(Suppl 1):247.
The role of the vasa vasorum in nutrition and in the pathologic development of carotid arteries is an evolving research focus. The vasa vasorum provides the arterial supply to the adventitia and the outer media of the carotid artery, where diffusion across the endothelial layer supplies oxygen and other nutrients to the endothelium and inner media. Cases in which a carotid artery becomes completely occluded because of advanced atherosclerotic disease and the distal internal carotid artery (ICA) is revascularized from small arterial channels have been observed occasionally. Some of these channels represent a hypertrophied vasa vasorum. Collateralization of a previously occluded ICA by the vasa vasorum has been the subject of several case reports on atherosclerotic occlusion and one previous case report on arterial dissection of the ICA. Herein we report the angiographic appearance of an apparently hypertrophied vasa vasorum of the cervical ICA, which was secondary to arterial dissection, and discuss its potential clinical implications.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):247.
Sigmoid sinus diverticulum, which is a rare dural sinus anomaly, is regarded as one of the very rare causes of pulsatile tinnitus and there are only a few international reports about their surgical or endovascular management. We experienced a 31-year-old female presented with a pulsatile tinnitus on her right ear for 3 years. Her tinnitus was decreased by compressing on her ipsilateral (right) jugular area, and increased by compressing on her contralateral (left) jugular area. Otoscopic and neurologic examination showed no abnormality. On the CT scan 7x6mm sized sigmoid sinus diverticulum with relatively narrow neck (4.5 mm) was found on the lateral aspect of the right proximal sigmoid sinus. We embolized the diverticulum with 2 detachable coils via transfemoral venous approach under local anesthesia and the tinnitus disappeared right away. We report this rare case with a review of a few related literatures.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):247–248.
Purpose: The incidence of the "non-union of the vertebral arteries" had been reported as 0.2% of cases on cerebral angiography. In our daily MR examinations, however, we frequently encounter MR angiograms (MRA) which do not demonstrate the distal portion of unilateral vertebral artery (VA). The purpose of this study was to calculate the frequency of aplastic unilateral distal VA by MR images performed for asymptomatic people.
Materials and Methods: In a time span of one year, 237 asymptomatic people (140 male, 97 female, 28-67, mean 54.4 years old) underwent brain MRI as "Brain check-up Examination" in our hospital. To identify an aplastic unilateral distal VA, we retrospectively compared three dimensional time-of-flight MRA with basi-parallel anatomic scanning (BPAS)-MRI which was designed for recognition of the arterial outer contour.
Results: Aplasia of the unilateral distal VA was confirmed in 11 persons (4.6%). According to our classification, hypoplastic distal VA in 12 (5.1%), and asymptomatic acquired unilateral distal VA occlusion was also proved in 2 (0.8%).
Conclusion: We found that the frequency of aplastic unilateral distal VA was 4.6% in asymptomatic people by using combination of MRA and BPAS-MRI for assessment of intracranial VA. Doctors who evaluate the brain MRI/MRA in daily work should know this percentage.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):248.
Background: Moyamoya disease (i.e., Japanese for "puff of smoke") is a progressive occlusive disease of the cerebral vasculature with particular involvement of the circle of Willis. Moyamoya is characterized on angiogram by the abnormal appearance of vascular collateral networks.
Case Description: Mr. RS is a 43-year-old Haitian male with past medical history of diabetes and borderline hypertension, who originally presented on 12/2007 with a left frontal lobe ischemic stroke in the watershed distribution. The initial cerebral angiogram demonstrated 60 percent stenosis of the clinoid segment of both internal carotid arteries (ICA). The diagnosis of Moyamoya disease was suspected based on the angiographic findings with exclusion of vasculitis and hypercoagulability. Nine months after the initial stroke, the patient presented with a right frontoparietal watershed ischemic stroke. On repeat cerebral angiogram, the patient had a complete occlusion of the right ICA at the previous stenotic clinoid segment. Successful revascularization of this subacute occlusion (approximately 10 days) was achieved with angioplasty and stenting.
The right ICA remained patent at the four-month follow-up angiogram. Additionally, there was progression of the left ICA stenosis to 80 percent. Revascularization of the left ICA with PTA/stent was also performed electively.
Conclusion: Along with our case, there are a few documented case reports from Europe and Japan that demonstrated successful neuroendovascular therapy for Moyamoya syndrome. However, successful revascularization of a subacute intracranial occlusion in Moyamoya disease has not yet been described.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):248.
Purpose: To show our experience using DynaCT in detecting hemorrhagic complications after neurovascular procedures.
Material and Methods: We performed a prospective study of all neuro-vascular procedures at our institution from June 2007 to December 2008. We used a Siemens Axiom Artis dBA biplane angiograph with flat panel detector and DynaCT. All treated patients were examined with DynaCT after endovascular treatment. We used a 20 second acquisition with 543 images without contrast media. We utilized a Leonardo Flash workstation and performed multiplanar reconstructions with soft tissue algorithm. Multidetector CT was done for each patient within 12 hours after treatment.
Results: We performed 353 post embolization DynaCT's mainly in arterio venous malformations (AVM) and aneurysms. Of 130 AVM we found 13 perinidal hemorrhages, 3 of which required urgency surgical evacuation. Of 142 cerebral aneurysms we detected 4 post-coiling bleedings that were clinically observed and medically managed, with no need for surgery. In others procedures (81/353) like occlusion test, angioplasty, dural fistula or tumors embolizations, we found no hemorrhagic complications. All hemorrhagic cases were confirmed with multidetector CT. We did not found positive hemorrhagic multidetector CT with negative DynaCT.
Conclusion: DynaCT is an excellent tool for detecting hemorrhagic complications after neuro-vascular procedures. It allows early therapeutic decisions that could lower associated morbi-mortality.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):248–249.
Purpose: Acute thromboembolism is a frequently encountered complication occurring during endovascular procedure. The abciximab was used as a rescue agent in the thromboembolic events complicating interventional procedure. We report our experience about intraarterial administration of abciximab during various clinical setting.
Materials and Methods: We retrospectively reviewed thirty-one cases (mean age: 60 years, range: 28-85) in which abciximab was intraarterially administered for the treatment of acute thrombosis during neurointervention in our institution between 2005 and 2008. 18 patients were treated with coiling/stent-assisted coil embolization(ruptured: 8, unruptured: 10) and 13 patients treated with elective stenting for atherosclerotic stenosis (four patients had underlying acute or subacute infarct).
Results: In all cases, successful recanalization of thrombotic artery were achieved. Complete angiographic improvement was seen during procedure in 25 cases or follow up angiography (mean days: 24.2 days, range: 4 - 90) in 6 cases. Mean dose of abciximab used was 9.52 mg; range of dose was 4-20 mg. One subdural hematoma was recognized on CT after procedure, which he had recent trauma. There was no parenchymal or subarachnoid hemorrhage in all patients.
Conclusion: Abciximab was safe and effective when used as a rescue agent for thromboembolic complications encountered during endovascular treatment, even though there is concomitant ruptured aneurysm or recent infarction.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):249.
Purpose: We report a case of a giant extracranial internal carotid artery aneurysm treated by stent-assisted coil embolization.
Summary of cases: A 55-year-old woman was referred with a pulsatile mass at Left neck area, not associated with any other problem. There was no history of cerebrovascular symptoms, neck pain, or cervical trauma. A CT scan showed a 35 mm-sized aneurysm of the internal carotid artery (ICA). Angiography demonstrated a saccular ICA aneurysm, with a lengthening and tortuosity of the ICA. We used Neuroform 3 stent to secure the neck portion of Aneurysm and 29 detachable coils to occlude aneutysm. After embolization, we did final angiography to confirm packing of aneurysm and intact ICA blood flow. Two months after the stent-assisted coil embolization, the patient showed a no neurological deficit and couldn't feel pulsatile & thrilling mass.
Conclusion: This case shows stent-assisted coil embolization can be a satisfactory therapeutic choice in the management of extracranial carotid artery aneurysms.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):249.
Purpose: We describe a case of a patient with persistent trigeminal artery and it's purposed to discuss anatomic aspects and the relationships between the aspect of this uncommon artery and its possible associated complications, like trigeminal neuralgia, aneurysms, haemorrhage.
Summary of case: A 42 yo patient, female, suffering from headache, dizziness, vertigo and hypoesthesia in her right arm and her right hemiface during 3 days. Fundoscopia revealed papilledema. On the brain CT it was observed diffuse brain edema and a thrombosis suspected image in the sinus confluence. Thus, she was submitted into a cerebral digital angiography that showed a right persistent trigeminal artery communicating the right internal carotid artery (cavernous segment ' C4) with the distal basilar artery segment. There was no sinus thrombosis evidence, buta right stenosis of lateral sinuswas found that suggests pseudotumor cerebri. She had a good outcome with no impairment and asymptomatic when discharged from hospital.
Conclusion: Through this case report we must concern about the presence of this artery and its possible associated complications. However in this particular case, it was encounteredno evidence associatedamongpersistent trigeminal artery, sinus thrombosis and pseudotumor cerebri.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):249–250.
Introduction: Traumatic or iatrogenic pseudoaneursym of superficial temporal artery is well known.
Treatment gold standard of pseudoaneurysm in superficial temporal artery is surgical ligation under local or general anesthesia. And, endovascular or ultrasonography guided embolization or conservative management (untrasonography guided compression) was other option. But, to our knowledge spontaneous regression of pseudoaneursym is rarely known. So, we report a case of iatrogenic pseudoaneurysm of the superficial temporal artery which spontaneously regressed.
Summary of case: 32 year old female visited our institute with sudden onset headache and left side weakness. CT scan showed large amount of intracerebral hematoma in right frontal subcortical area and intraventricular hemorrhage in both lateral, 3 rd and 4 th ventricles. Emergency ventricular drainage and hematoma evacuation were done. To rule out hidden vascular pathology, transfemoral cerebral angiography was done. On left external carotid artery angiography, there was 0.3 c m sized pseudoaneursym in superficial temporal artery adjacent to craniotomy site. Due to its small size and no associated symptom, we did not perform immediate removal of the lesion. We decide to treat the lesion after interval follow up. But, on compted tomographic angiography follow up, it regressed spontaneously.
Conclusion: Spontaneous regression of traumatic or iatrogenic pseudoaneurysm may occur. So, conservative magement maybe considered in treatment of superficial temporal artery pseudoaneurysm especially in small size.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):250.
Aim: To evaluate the long term results of endovascular management of carotico-cavernous fistulas.
Materials and Methods: We retrospectively & prospectively studied 129 patients of Carotico cavernous fistula who had undergone endovascular management at our institute over 21 years. Predominant presenting complaints were -swelling of eye, redness, diplopia, DOV restricted eye movements, headache, tinnitus, intracranial hemorrhage etc. After angiogram, the feeders & venous drainage was analysed. There were 77 males & 52 females, age range 6 - 72 years (mean 44.7 years). CCF was type A in 70 (57 post traumatic, 1 iatrogenic, 12 spontaneous), type B in 9 (1 post traumatic, 8 spontaneous), type C in 8 (all spontaneous), type D in 42 (39 spontaneous, 3 post traumatic).
Type A, 65 embolised (52-balloons &/or coils,11-ICA trapping, 1-spontaneous closure, 1 closed after attempted balloon passage & 2-carotid compression). In type B, 6-carotid compression, 1-spontaneous occlusion, one-transvenous coiling ,1-no access). Type C - all had transarterial embolisation. In type D, 26 embolised via arterial route, 3 via arterial and venous route while 5 via the venous route only. Seven were advised carotid compression.
Results: Patients were followed up at 1, 3 & 6 months & then yearly. At long term follow up, all the embolised fistulas remained closed. 2 patients with type D CCF had recurrence due to uncontrolled DM. We encountered 5 deaths (3 EDS) & 4 minor complications.
Conclusion: Endovascular treatment remains the mainstay of treating carotico-cavernous fistulas. Co-morbidities should be well controlled to prevent recurrence.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):250.
Aim: Angiographic identification of arterial dissections is essential to plan appropriate intervention & therapy. Our aim was to identify the varied imaging appearances of craniocervical arterial dissections.
Materials and Methods: This was a retrospective study over last ten years carried out at our institute. A total of 130 patients (100 males, 30 females) age range 2 - 80 years, underwent angiograms for evaluation of the suspected dissection. In these 130 patients, there were 134 dissections, 124 were spontaneous, 8 traumatic, 2 iatrogenic. Duration of symptoms varied from immediate to over one year. The symptomatology included neck pain (43), headache (55), weakness (67), TIA (24), loss of consciousness (8), seizures (6), vertigo (30), vomiting (35), Horner's (21), gait ataxia (20), lower cranial nerve palsy (20). Dissection was intracranial in 4 patients & bilateral in 4 patients. Seventy lesions were in the posterior circulation.
Results: The angiographic appearances included total occlusion (78), flame sign (10), string sign (30), flame & string (4), aneurysms (7) & intimal flap visualisation in one. None of the patients showed a double lumen sign. There were no recurrent dissections. Angiography could correctly depict the site & extent of dissection. The treatment was carried out with anti- coagulants & stenting (2 iatrogenic). The patients were followed up clinically & with neck vessel Doppler.
Conclusion: The angiographic appearances of arterial dissections varied. Ability to identify these lesions helps direct towards timely & correct treatment.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):250–251.
Aim: To evaluate the role of endovascular management in patients of neurocutaneous syndromes with vascular lesions.
Materials and Methods: We retrospectively analy-sed the data at our institute for patients of neurocutaneous syndromes who were refereed to us for management of their vascular lesions. There were seven patients - four with VHL (3 cranial & 1 spinal hemangioblastoma), 2 with NF-1 (1 cavernous ICA aneu-rysm, 1 vertebro- vertebral fistula), and one patient with HHT (intracranial pial dural AVF). The presenting complaints varied (as per the case) from headache, nausea, tinnitus, limb weakness, ptosis, diplopia & recurrent epistaxis. All patients underwent MRI followed by an angiogram. Subsequently they underwent particulate embolisation with PVA (150- 250 microns, for hemangioblastomas) coiling of ICA aneurysm, Trans-arterial & percutaneous embolisation of VVF (4 sittings) & coil & onyx embolisation of pial AVF.
Results: The vascular blush was obliterated in all hemangioblastomas aiding surgery. The ICA aneurysm & pial AVF showed total closure after single embolisation while VVF was obliterated completely after multiple sittings.
Conclusion: Endovascular therapy has an indispensable role in therapeutic management of various lesions. It can aid in reducing blood loss in vascular lesions associated with neuro- cutaneous syndromes.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):251.
Aim: Pediatric endovascular lesions behave differently than adult vascular lesions. They need careful evaluation & expert management. Our aim was to review the paediatric endovascular neuro- interventions carried out at our institute.
Materials and Methods: We retrospectively reviewed the data for paediatric patients who were treated at our institute over the last 10 years. There were 27 patients; 16 males, 11 females, age range 2-12 years (mean 9 years). The presenting symptoms varied as per the type & location of the lesion & included seizures, limb weakness, epistaxis, focal swelling etc. The lesions encountered in these patients were: 12 AVMs, 2 CCFs, 2 JNAs, 2 spinal vascular malformations, 2 intracranial aneurysms, 1 cheek hemangioma, 1 sinus pericranii, 1 skull base tumour, 1 vertebro- jugular fistula, 1 scalp AVM & 1 pial AV fistula. The patients were treated with glue, alcohol, onyx, coils, PVA particles alone or in combination. Percutaneous embolisation was also carried out in two cases.
Results: The embolisation resulted in complete obliteration of 23 lesions while 4 AVMs showed about 75% reduction. The cheek hemangioma recurred & was reembolised. There were 3 transient minor complications. At follow up patients showed significant improvement in their clinical symptoms.
Conclusion: Endovascular management of paediatric vascular lesions is a challenging arena. Dedicated team approach is helpful in managing them.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):251.
Aim: To evaluate the varied clinical manifestations, treatment strategy and the long term follow up in Vein of Galen malformations.
Material and Methods: Between October 1983 and August 2008, 31 patients with VOGMs were referred to our institute for evaluation and management. Thirteen children younger than 2 years of age presented with rapidly increasing head size. Among 14 children with age above 2 years, the most common presentation was chronic headache. Four patients who presented during adulthood had chronic headache for many years before presentation. Angiographic evaluation of the lesion was performed in 21 patients. The embolisation procedure was done under general anesthesia with induced systemic hypotension. Twenty-one patients were treated using endovascular techniques using coils and glue in all cases.
Results: Complete obliteration was achieved in 8 out of 9 cases of mural type and 5 out of 7 cases of choroidal type of vein of Galen malformation. In rest of the patients, near complete obliteration was achieved. Occlusion of the arteriovenous shunts and resolution of vein of Galen aneurysmal dilation could be achieved in two patients. All the patients were regularly followed up clinically .
Conclusion: VOGMs usually present with varied clinical manifestations in different age group and endovascular management provides an excellent and an effective way to treat such malformations.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):252.
Purpose: Simultaneous bilateral carotid stenting is considered unsafe because of the potential risks of both sudden cerebral reperfusion and bi-hemisferic thromboembolic complications. Treatments were reserved to selected patients when severe co-morbidities made the simultaneous bilateral procedures more advisable than delayed single ones.
Materials and Method: Out of 650 protected carotid stenting procedures, we simultaneously performed 76 in 38 patients (25 males, 13 females, mean age 71 yrs). Each patient had previously been scheduled for surgical by-pass because of severe coronary artery disease, but the presence of bilateral significative carotid stenosis (>70%) made it at high risk for stroke. We used different cerebral protection devices according to the vessel anatomy, characteristics of the stenosis and cerebral pattern flow. A neurological evaluation was obtained before, immediately after and 24 hours after the procedures. Follow-up was performed with Duplex scan at 1, 6, 12 months and every year thereafter.
Results: Technical success was achieved in 100%. The 30-day stroke/death rate was 1.3% because 1 episode of amaurosis fugax was registered during the intervention. No neurological complications occurred during the following scheduled surgical coronary by-pass.
Conclusions: According to our experience simultaneous bilateral protected carotid stenting proved to be feasible and safe in well selected cases.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):252.
Purpose: To report the 5-year results of CAS performed in a single center with Boston Scientific Symbiot Covered Stent (SCS).
Materials and Methods: Thirty-seven patients (range 32-85 years) were treated with 40 SCS from July 2002 to February 2006; main indications were ICA soft ulcerated plaque and pseudoaneurysm. Proximal (MoMA) and distal embolic protection devices were employed in 10 and 22 patients respectively. Follow up (range 34-72 months) was carried out by Duplex US or CTA every 3 months on the first year and every 6 months subsequently. Technical success, complications, early and late restenosis were retrospectively evaluated. Primary and secondary patency were calculated according to Kaplan-Meier statistical analysis.
Results: Technical success was achieved in all cases. No intraprocedural cerebral embolism was observed. Two acute complications occurred: one transient Horner syndrome and one incoercible jaw pain resolved by omolateral ECA stenting. One CAS procedure was prodromic to successful intracerebral fibrinolisis for acute stroke treatment.One asymptomatic stent thrombosis due to inappropriate antiplatelet therapy was observed at 1 month; 4 restenoses occurred between 11 and 33 months (3/4 retreated by CAS). Nine patients died for unrelated causes between 6 and 36 months. Primary and secondary patencies at 6, 12, 60 months were 97,2%, 94,2%, 83,4% and 97,3%, 97,3% and 93,4%, respectively.
Conclusion: CAS with SCS is feasible and safe.Our long term results show SCS patency to be not inferior to bare metal stent. In selected cases, the potential minor risk of cerebral microembolism by non-routinary use of covered stents might be not associated to worse patency.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):252–253.
We report a case where the initial lesion was insignificant without neurological deficit and a few days late became high flow cervical fistula between vertebral artery and jugular vein.
Clinical case: A 28 yo man presented one week after cervical trauma by knife, cervical pain, local tumor, tinnitus in right side and nauseas. Neurological exam is normal, except by retro auricular tumor and thrill. DSA and Doppler reveled signs for arteriovenous fistula between the right vertebral artery (V2 segment) and the right internal jugular vein with normal cerebral flow. Percutaneous coil embolization was achieved with occlusion proximal and distal fistula point, without neurological damage.
Discussion: In our case the small lesion promoted by knife and the anatomic position of vertebral, deeper in the neck involved by cervical muscle, maybe was responsible by late clinical sign. Fistulas between the vertebral artery and the internal jugular vein as a result of penetrating trauma are extremely rare lesions. The clinical sign of vertebral jugular fistula are related to flow rate, chronicity of the lesion, and venous drainage pattern. Thediagnosis is often difficult and includes evidences of penetrating injury alone, expanding hematoma, hemorrhage and cervical bruits. In our case the posterior communicant artery was present providing the good flow and the contra lateral vertebral artery was of good diameter. We conclude that in penetrating trauma of the neck, the angiographic study is mandatory to exclude this type of lesion therefore it's a rare lesion. The endovascular approach appears to be better than open surgery because these are deep lesions and treatment must be done.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):253.
Case report: The DSA was done for analyses of olfactory groove meningioma and we detect an anatomic variation of the main trunk of PICA. This artery comes, in our case, of de cervical segment of Internal Carotid Artery. We consider that the anastomoses is via hypoglossal artery, joining the vertebral territory with the pharyngeal ascendant artery, witch come from the carotid region that was in the early times the third aortic arch. This pattern of vascularization resembles that the carotid system is older than the vertebro-basilar one in the ontogenesis and in the phylogenies, and was the responsible for the irrigation of the metencephalon structures until the development of the longitudinal neural arteries.
Conclusion: This report is destinated to show the important relation of the two main systems that irrigates the cephalic segment. The ventral pharyngeal system, the third aortic arch and longitudinal neural arteries are connected by the territory of supply. In regions of transition like the cranio vertebral junction we observe some anatomoses between the carotid system and the vertebro- basilar. There are the proatlantal I, proatlantal II and the hypoglossal as the anastomotic arteries between the two systems, that originates from the third aortic arch. The knowledge of this communication between the territories of the external carotid artery and the territory of vascularization of the vértebro-basilar system is essential for endovascular neurosurgeons that work with micro spheres in the external carotid artery ramous. This understanding come to refined the state of the art of the of the endovascular technique, principal in treatment of meningeal tumors.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):253.
Purpose: A rare case of spontaneous intraorbital fistula between ophthalmic artery branch and superior ophthalmic vein managed by transvenous occlusion is demonstrated.
Materials and Methods: A 72 year old man presented with right eye proptosis. There was no preceding trauma. His vision was normal and there were no cranial nerve palsies. A CT angiogram demonstrated early opacification of a dilated superior ophthalmic vein with a normal sized cavernous sinus. Cerebral angiogram showed a fistula between a branch of ophthalmic artery and the superior ophthalmic vein. Selective ophthalmic artery angiograms showed that a branch just beyond the origin of central retinal artery fed the fistula. As safe distal catheter position was not possible, venous route was adopted. After venous cut down the superior ophthalmic vein was cannulated and the fistula was obliterated using bare platinum coils. At 4 weeks the patient had normal ocular appearances without any cranial nerve or visual deficits
Summary: Intraorbital AV fistulas have been reported secondary to trauma. In our patient this occurred spontaneously. Clinically they can be indistinguishable from caroticocavernous fistulae. CT Angiography may demonstrate the site of fistulation. Selective microcatheter angiography is essential to plan treatment and to exclude small orbital AVMs. The principle of management is to obliterate the fistula either by arterial or venous route. In our case we chose the venous route to protect the central retinal artery. With the venous approach close ocular assessment is essential to detect and prevent progressive venous thrombosis.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):253–254.
An 88 year old female with a port-wine stain involving the maxillary region (V2) of the left side of her face was referred with a history of a progressive non-traumatic left third nerve palsy. Cranial computerized tomography (CT) revealed a small left anterior frontotemporal subdural hematoma with no mass effect, and no evidence of subarachnoid hemorrhage. A CT angiogram revealed a large (11 mm x 14 mm) extradural saccular aneurysm of the cavernous portion of the left internal carotid artery and a 6 mm x 3 mm anterior choroidal artery aneurysm. The association of facial hemangiomas and intracranial aneurysms has been described previously in a single case report, however, without the discussion of a potential relation of both lesions. In our patient, two aneurysms were present on a segment of the ICA that is linked through the maxillary portion of the trigeminal nerve to the V2 facial region. Therefore, our case with the involvement of the left internal carotid artery in the context of a left maxillary facial hemangioma may represent a segmental arterial vulnerability. The association of craniofacial hemangiomas and intracranial arteriovenous malformations found within the same metamere has been well described as part of the Cerebrofacial Arteriovenous Metameric Syndrome (CAMS). While the findings in our patients may well be coincidental, our case may represent a variant of CAMS with the vulnerability targeted upon the arterial vasculature. In addition to presenting the clinical and radiological findings in this case, we will discuss the embryological, developmental, and pathophysiological links that may have lead to both the patient's aneurysms and her facial hemangioma.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):254.
Purpose: The aim of this work is to illustrate the multiple different uses of a portable CT Unit during endovascular intervention in the Neuroangiographic suite.
Material and Methods: Since April 2007 our Institution has acquired a Portable CT Unit (Ceretom, Neurologica).
The main use of the unit is in the Intensive care Unit; however we have been found this equipment very useful during endovascular procedures in the Neuroangiographic suite.
The CT portable is an 8 multislice scanner that enable also CT perfusion and CT angiogram of the Circle of Willis.
We have been using the Portable CT unit in the Neuroangiographic suite prior, during or following different endovascular procedures, i.e. coiling of aneurysms, embolization of AVMs.
Results: The quality of the images obtained is excellent with very good contrast and special resolution which enable evaluation of relative small lesion or minimal amount of extravased blood. Furthermore the unit is readily available for evaluation of brain perfusion prior or following Embolization of AVM.
This comparison demonstrates improvement of the cerebral perfusion with increase of CBF after the Embolization in areas remote from the AVM location.
Conclusion: The Portable CT enables an efficient and rapid acquisition of brain imaging in the Neuroangiographic suite. The possibility to obtain rapidly a CT during an endovascular procedure is very useful to assess a possible complication, the size of the ventricular system or /and the position of the ventricular drain. This of course facilitates taking decision during patient treatment avoiding transferring the patient in a different room.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):254–255.
Background: In the last 12 years, we have evaluate angiographically 55 cases of spontaneous dissection of the intradural VA and basilar arteries (28 hemorrhagic and 27 ischemic). Different modalities of endovascular treatment was performed depending of the angiographic aspect and the anatomy. We know that most of ischemic dissection had a good evolution to cure or thrombosis and that haemorrhagic cases need a quick treatment to avoid rebleeding, but we had 4 cases with an unexpected evolution.
Case 1: patient treated twice from a left VA dissection with 2 stents and coils, presents a right VA dissection with SAH 6 days after the last treatment. DSA show extensive dissection with 2 saccular aneurysms.
Case 2: Left VA dissection with double lumen presented by headache, no treated. DSA control 3 month after show thrombosis of the VA bellow the PICA, including the dissected segment, with retrograde filling. MRI control 3 month later show a mass on the dissected site. DSA show hypervascular mass. One month later the patient develop hemiparestesis and a new DSA show thrombosis of the left PICA and increase in the mass. Corticoid treatment with decrease in the mass 6 month later.
Case 3: Haemorrhagic left VA dissection involving PICA and AEA origins. Occlusion of the VA proximal to PICA. Control 3 month later show increase of the aneurysm. Surgical treatment with complete occlusion.
Case 4: Haemorrhagic right VA dissection treated by endovascular trapping. Rebleeding 28 days after by dissection of the right VA and PCoA.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):255.
Objective: Report a case of bilateral internal carotid artery agenesis associate with aneurysm of the basilar artery, treated for embolization.
Case report: The authors report the case of a 34 year-old woman, who presented with sudden headache and degradation of the conscience level. Tomography of skull showed subarachnoid hemorrhage, as well as, bilateral absence of the carotid canals on both sides. Cerebral angiography showed agenesis of bilateral internal carotid arteries and sacular aneurysm of the distal segment of basilar artery. This aneurysm was treated for embolization with coiling and remodeling.
Results: the aneurysm was embolized with good angiography result, without complication.
Discussion and Conclusion: Intracranial aneu-rysms occur in twenty-five percent of the patients with agenesis of the internal carotid artery. The diagnosis is arteriography associated with the CT that demonstrates absence of the carotid channels. This in case that it demonstrates this association for the presence of aneurysm in the distal segment of the basilar artery, that was treated for embolization with coils and remodeling. Agenesis and hipoplasia of internal carotid artery constitute abnormalitys vascular cerebral rare, and less frequent when bilateral, being able to be associates the cerebral aneurysm, which to be able treated for embolization.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):255.
Objective: Explaining the importance of anatomical knowledge of the cerebral venous system according to cerebral venous thrombosis (CVT) in context with clinical signs, symptoms and the significant role of neuroimaging.
Case report: We report on a young woman who collapsed. After 12 h without symptoms she suffered from progressive headache. Next day she turned to an external hospital with additional vomiting. NECT 3 days after fall showed hyperdense transverse and straight sinuses and blurred thalami. The patient was transferred to our hospital presenting amnesia, thalamic aphasia, fluctuating alertness, hyperalgesia and shivering. NECT demonstrated progressive bilateral thalamic blurring and edema of deep brain. Transverse and rectus sinus and deep cerebral veins were highly hyperdense. According to length of the diagnosed CVT and bad condition 24h-local-thrombolysis was performed using Alteplase. Control angiography demonstrated antegrad flow in deep venous system and recanalised sinuses. Hydrocephalus was treated with ventrikulostomy. Anticoagulation was continued using iv heparin. Next days patient became awake and orientated. Medical history revealed nicotin abuse, use of contraceptive and familial clustering of venous thrombosis. Thrombophilia could not be proven.
Discussion: CVT is a rare multifactorial cerebrovascular disease. Due to the typical but unspecific symptoms diagnose of CVT is based on neuroimaging, especially MR-venography. However NECT already can show typical signs. Prompt diagnosis can accelerate i.v. treatment and improve outcome of patients with CVT. Local thrombolysis should be reserved for special indications e.g. deep CVT, space occupying edema.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):255–256.
Objective: To describe a case of brachial plexus lesion due to venous hypertension caused by a subclavia AVF after thrombosis of its primary drainage.
Case report: This 40 years old man has been submitted to several jugular vein puncture to despite rejection of a heart transplant secondary to endocarditis. Two years before our consultation, he was submitted to a stent treatment of a subclavia AVF that drained only in the superior cave vein. Six month before our evaluation, he started a progressive right brachial plexus syndrome. MRI show hyper signal in the brachial plexus roots and DSA shows thrombosis of the subclavia vein, and drainage of the AFV toward cervical vein and epidural plexus. The venous reflux was producing the brachial plexus lesion and the AVF was occluded with some coils, with regression of the symptoms.
Discussion: Similarly to intracranial or spinal DAVS, this case shows the role of venous drainage in producing symptoms due venous hypertension.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):256.
Objective: to describe the improvement of behavior and cognitive functions in one patient with a giant frontal AVM by neuropsychological rehabilitation after endovascular partial treatment.
Case report: Neuropsychological assessments allow us to disclose impaired cognitive functions, and to draw strategies to improve it and also the quality of life. The patient is a 23 years old man who could no longer formulate plans because of an inability to take all aspects of a situation and with emotional liability. The aim of neuropsychological intervention was to improve psychological resource through psychotherapy, increasing acceptance and understanding his cognitive problems, provide with strategies and exercises to reduce cognitive problems and provision of vocational counseling.
Results: The patient became adapted to a new job, came back to school and improved his relationship with his family and colleagues.
Conclusion: Neuropsychological intervention can be useful when the function was identified correctly. Neuropsychological intervention can modify and reduce everyday problems or the patients and his or her relatives.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):256.
Case report: A five weeks infant presented a left hemiparesis.
He was admitted the day after in the emergency unit of the hospital.
Angioscanner revealed an intracerebral hemato-ma in the temporal lobe, subarachnoid hemorrage in the right laeral fissure, right subdural hematoma and a right middle cerebral aneurysm at a trifurcation.
MRI showed ichemia in the temporal, insular and frontal lobes. Angiography assessed the aneurysm. Embolization was performed, with sacrifying the parent angular artery with coils.
Angiographic and MRI follow-up demonstrated the collateral circulation and the absence of increase of the ischemic damages.
Discussion: We hypothesize the dissecting nature of the aneurysm in this infant, justifying the choice of occlusion of the parent artery.
The hemorraghe in three pial, sub arachnoid and subdural compartments is discussed, as well the associated ischemia.
Tolerance of the parent artery occlusion is discussed in newborns or infants.
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Objective: To show the natural history of an intracranial dissection of A2 with spontaneous occlusion and the clinical tolerance without neurological deficit due to the collateral circulation.
Case Report: We report the case of a 39 years old man presenting with inferior limb transitory paresis. He reported a pelvic traumatism 3 weeks earlier followed by persisting headaches.
Magnetic Resonance Imaging (MRI) showed a fusiform dissecting aneurysm of A2 segment of the left anterior cerebral artery, with mural hematoma and ischemia in the white matter of the left hemisphere, junctional between the anterior and the middle cerebral arteries circulations. Angiography assessed the diagnosis of dissecting aneurysm with intimal flap, fusiform ectasia. Anticoagulation then antiagreggant treatment were administred. Follow up with MRI and angiography showed the spontaneous occlusion of A2, decrease of the hematoma and collateral circulation from the middle cerebral artery.
Discussion: The authors discuss the nature of the arterial injury: the dissecting process, the arterial layers involved and the possible relationship with the traumatism as well as the role of the falx cerebri. The neurological deficit is considered as hemodynamic and not related to emboli from the dissection. The spontaneous occlusion is discussed regarding the risk of recurrence of bleeding. The therapeutic option of sacrifying the anterior cerebral artery and its possible morbidity is discussed. The capacity in young adults to develop collateral circulation is shown as the condition for the absence of neurological deficit.
interv neuroradiol. 2009 Jun 2;15(Suppl 1):257.
Objective: Spontaneous thrombosis of Dural Arteriovenous Fistulae (dAVF) is a well documented phenomenon. Research has been conducted suggesting a connection between non-O blood grouping and thrombus formation; however, this is the first report of the association in dAVF.
Material and Methods: Between October 2001 and July 2007, a total of 7 cavernous dAVF's were evaluated by our service for embolization treatment. Data collected included patient age, sex, presenting symptoms, blood group, and outcome.
Results: Spontaneous thrombosis was noted in 3 (43%) of the 7 cases identified. All 3 patients with blood type A underwent spontaneous thrombosis, while spontaneous thrombosis did not occur in 2 patients with type B and 1 with O. Blood type data was unavailable in one patient who did not thrombose. Each spontaneous thrombosis case had distinctive clinical management. One case underwent cerebral angiogram demonstrating complete spontaneous thrombosis following transfer from another institution. Embolization was attempted in one case, but was unsuccessful due to anatomical challenges. Angiogram of the subsequent day showed complete thrombosis of the dAVF. The final case received coil embolization with residual dAVF on the final run and at six months. One year follow-up angiography demonstrated complete spontaneous thrombosis of the dAVF. Statistical analysis of blood group distribution was conducted proving significance (p≤0.001).
Discussion and Conclusion: Given the distribution of ABO blood type prevalence in the US, A blood type appears to be a strong predictor of spontaneous thrombosis in patients with cavernous dAVF's in this small series of patients.