Surgical access on the superior ophthalmic vein to the cavernous sinus dural fistula for embolization

BACKGROUND

Direct surgical exposure and cannulation (DSEC) of the superior ophthalmic vein (SOV) can be used as an alternative approach for the endovascular treatment of cavernous sinus dural fistulas (CSDF) that fail conventional endovascular access. The aim of this study was to report the techniques, effectiveness and safety of DSEC of the SOV in these cases.

METHODS

Between June 2007 and June 2011, nine CSDF in nine patients who presented with ocular signs and symptoms were embolized using DSEC of the SOV when the CSDF could not be treated via the transarterial or transfemoral venous route.

RESULTS

All nine patients were successfully treated by introduction of Onyx in conjunction with detachable coils through the catheterized SOV to the affected cavernous sinus. No exposure or catheterization of the SOV proved difficult. Symptoms and signs resolved completely in all patients after successful occlusion of the CSDF. There were no intraoperative complications. All patients underwent follow-up cerebral angiography at least 3 months after treatment, and none showed recurrence of the fistula.

CONCLUSION

DSEC of the SOV for embolization of a CSDF is a good alternative treatment when conventional venous routes are inaccessible. Surgical access to the SOV is direct and can be performed safely. The use of Onyx in conjunction with detachable coils is safe and effective for symptomatic CSDF.

Characteristics of brain arteriovenous malformations in patients presenting with nonhemorrhagic neurologic deficits

OBJECTIVE

To identify the specific angioarchitectural characteristics of arteriovenous malformations (AVMs) that are associated with a clinical presentation of nonhemorrhagic neurologic deficits.

METHODS

Between 1999 and 2008, 302 consecutive patients with AVMs were referred to our institution. Twenty-four patients (7.9%) presented with neurologic deficits without hemorrhage before treatment. We tested for statistical associations between angioarchitectural characteristics and neurological deficits at presentation.

RESULTS

When we compared the 24 (7.9%) patients with nonhemorrhagic neurological deficits with the 278 patients who did not experience neurologic deficits initially (total of 302 patients), female sex (P = 0.002), deep AVM location (P = 0.015), AVM size greater than 3 cm (P = 0.001), more than three arterial feeders present (P = 0.004), only perforating feeding artery (P = 0.007), the presence of more than three draining veins (P = 0.016), the presence of varices in the venous drainage (P = 0.013), and a Spetzler-Martin grade of III to V (P = 0.004) were statistically associated with neurological deficits. Patient age, eloquent location, deep venous drainage, venous drainage restriction, and coexisting aneurysms were not statistically associated with neurological deficits without hemorrhage.

CONCLUSION

The characteristics of AVM associated with nonhemorrhagic neurological deficits include female sex, deep AVM location, more than three arterial feeders, only perforating feeding artery, more than three draining veins, the presence of varices in the venous drainage, and a Spetzler-Martin grade of III to V.

Enterprise stent-assisted coiling of wide-necked intracranial aneurysms: clinical and angiographic follow-up

We evaluate and report our clinical and angiographic outcomes associated with stent-assisted coil embolization of wide-necked intracranial aneurysms using the Enterprise stent. One hundred sixty-nine patients diagnosed with 182 wide-necked intracranial aneurysms underwent placement of the Enterprise stent between April 2009 and October 2011. Demographic information, procedural data, procedure-related complications, angiographic results, and clinical outcomes were reviewed and evaluated. Stent deployment was successful in 166 out of 169 procedures (98.2%). Four patients had acute procedure-related complications, including th romboembolism in three patients and aneurysm perforation resulting in the death of one patient. Immediate angiographic results showed complete occlusion in 101 aneurysms (56.4%) and near-complete occlusion in 55 aneurysms (30.7%). Follow-up angiography was performed in 108 patients with 119 aneurysms at a mean of 8.1 months: complete occlusion was observed in 95 aneurysms (79.8%) and near-complete occlusion was found in 12 aneurysms (10.1%). Delayed intra-stent thromboses were observed in two patients, and asymptomatic in-stent stenosis was observed in one patient. Ten aneurysms (8.4%, 10/119) demonstrated recanalization, all of which were subsequently recoiled successfully. Clinical follow-up was obtained for 132 patients at a mean of 11.4 months, out of which 118 (89.4%) had favorable clinical outcomes as determined using a modified Rankin Scale (mRS) ≤ 1. The rates of procedure-related mortality and permanent morbidity were 0.6% (1/169) and 2.3%( 3/132), respectively. This study adds to the current body of evidence supporting the Enterprise stent as an effective and safe tool for the treatment of wide-necked intracranial aneurysms because it results in more complete occlusion and lower complication rates.

Complications caused by cerebral arteriovenous malformation embolization

We describe the complications of endovascular embolization for cerebral arteriovenous malformations (AVMs). 164 consecutive patients with AVMs treated by endovascular embolization between 1998 and 2003 were retrospectively reviewed. Over a five-year period, 292 embolization procedures were performed in 164 patients with embolization as the primary treatment modality (n=126) or as an adjunct to surgery (n =14) or radiosurgery (n=24). There were a total of 15 (9.1% per patient, 5.1% per procedure) complications in this series, of which 14 were clinically significant (8.5% of patients, 4.8% per procedure), and one was a technical complication (0.6% of patients, 0.3% per procedure). Excellent or good outcomes (Glasgow Outcome Scale ≥ 4) were observed in 136 (82.9%) patients at discharge. Neurological deficits (Glasgow Outcome Scale 1-4) as a direct result of embolization were 7.3% at discharge. In a single-center, retrospective, nonrandomized study, 82.9% of patients had excellent or good outcomes at discharge after AVM embolization, with a complication rate of 5.1%.

Potential proneness of fetal-type posterior cerebral artery to vascular insufficiency in parent vessel occlusion of distal posterior cerebral artery aneurysms

OBJECT

The purpose of this study was to report the potential proneness of a fetal-type posterior cerebral artery (PCA) to develop vascular insufficiency in parent vessel occlusion of distal PCA aneurysms.

METHODS

Between January 2005 and January 2011, 19 patients (9 females and 10 males) with 20 distal PCA aneurysms (16 dissecting and 4 saccular) were treated with endovascular parent vessel occlusion. The ages of the patients ranged from 5 to 71 years, with a mean age of 40.2 years. Of the 20 aneurysms, 4 were ruptured and 16 were unruptured. One of the unruptured aneurysms was additional to another ruptured aneurysm, and 15 were incidentally discovered. Five aneurysms were smaller than 10 mm, and the other 15 were 10 mm or larger.

RESULTS

All aneurysms were successfully treated with simultaneous coil occlusion of the aneurysm and the parent PCA. One patient had hemianopia at the initial presentation, and 2 patients had new persistent hemianopia due to insufficient leptomeningeal collateral circulation; in 16 patients with an intact visual field, no hemianopia developed because there was sufficient leptomeningeal collateral circulation. A fetal-type PCA was involved in all 3 patients with hemianopia, which was initially presented or caused by parent vessel occlusion. However, in the patients without hemianopia, an adult-type PCA was involved in all cases.

CONCLUSIONS

Endovascular treatment via coil occlusion of the aneurysm as well as the parent artery can be used to cure distal PCA aneurysms. A fetal-type PCA could be an important predictive factor for vascular insufficiency in parent vessel occlusion treatment.

Hemorrhage risk after partial endovascular NBCA and ONYX embolization for brain arteriovenous malformation

OBJECTIVE

To estimate for hemorrhage risk of partially endovascularly embolized brain arteriovenous malformation (BAVM).

METHODS

We retrospectively reviewed 147 consecutive patients with BAVM-treated mainly with endovascular N-butyl cyanoacrylate (NBCA) and ONYX embolization. In Kaplan-Meier survival analysis, the index date was the dated of initial endovascular embolization; cases were censored at time of subsequent intracranial hemorrhage (ICH), or loss to follow-up, and multivariate proportional-hazards regression models included age of presentation (≤30 years old), clinical presentations, and other potential confounders.

RESULTS

We reviewed 147 patients with BAVM (58.8% male; mean age±SD at treatment: 27.5±11.1 years) treated with endovascular embolization. One hundred and forty-four NBCA and 76 ONYX embolizations were performed. Complete obliteration of BAVMs was achieved in 29 patients (19.7%). Thirty-two (21.8%) patients were treated with additional Gamma-knife radiosurgery. During 499.5 years of follow-up, 15 partially treated patients suffered a further hemorrhage, which caused four deaths. The crude annual risk of hemorrhage was 3.0% and the annual death rate was 0.8%. Among partially treated patients with hemorrhage at initial presentation, the risk of hemorrhage was 3.8%, while the risk of hemorrhage for patients without hemorrhage at initial presentation was 2.5%. The annual rate of subsequent hemorrhage was 2.6% for non-ICH and 4.2% for ICH in the partial NBCA embolization group compared with 2.4% for non-ICH and 2.4% for ICH in the partial ONYX embolization group.

CONCLUSIONS

The effect of partial AVM embolization with liquid embolic agents may still be unclear as for risk reduction of annual hemorrhage rate of cerebral AVM.

Results of endovascular treatment for intracranial wide-necked saccular and dissecting aneurysms using the Enterprise stent: a single center experience

OBJECTIVE

The aim of the present retrospective study is to compare outcome of the endovascular treatment using the Enterprise stent in intracranial wide-necked saccular and dissecting aneurysms.

METHODS

Forty-six patients with 50 complex intracranial aneurysms admitted between June 2009 and November 2010 were treated using Enterprise stents. Thirty-one aneurysms were wide-necked saccular, 19 aneurysms dissecting. In 48 cases, aneurysms were occluded by stent-assisted coiling; in 2 cases, by stent alone.

RESULTS

Among the aneurysms treated with the Enterprise stent, patient sex, aneurysm location, hypertension history and the immediate angiographic results differed significantly between the saccular and dissecting aneurysm groups. However, recurrence rate, clinical follow-up outcomes did not differ significantly between the saccular and dissecting groups. There was 1 (2%) procedure-related complication, which caused death in the saccular group. At mean 9.1-month follow-up, the result was good in all dissecting cases and good in 30 saccular cases. There was 1 recurrence in each group.

CONCLUSIONS

Enterprise stent is very useful for endovascular embolization of intracranial wide-necked saccular and dissecting aneurysms because it is easy to navigate and place precisely. The overall morbidity and mortality rates were low.

Endovascular treatment of cerebral aneurysms associated with arteriovenous malformations

BACKGROUND AND PURPOSE

In univariate survival analysis, coexisting aneurysms was associated with a significantly increased risk of hemorrhage in AVMs. We report here on our clinical experience with AVMs associated with arterial aneurysms that were managed by endovascular treatment.

METHODS

To determine the incidence of associated aneurysms, the authors reviewed 366 consecutive patients with AVMs managed between 1999 and 2009. In 86 (23.5%) of these 366 patients, 55 intranidal aneurysms and 40 proximal aneurysms were observed. Targeted endovascular treatment with coils, n-butylcyanoacrylate(NBCA) and Onyx was performed for patients in this series, using a standard protocol. We reviewed the treatment plans, radiological findings and clinical courses of 86 patients suffering AVM associated with aneurysm.

RESULTS

Ninety-five aneurysms in 86 patients with AVMs were enrolled in this study. Hemorrhage was the most frequent presenting symptom (69 patients, 80.2%). Bleeding was caused by an AVM nidus in 44 cases, aneurysm rupture in 20 and an undetermined origin in 5. Four patients were treated for associated aneurysm with coils followed by AVM embolization and 82 patients were treated with NBCA or Onyx embolization. There were total of 3 complications (3.5%) clinically significant complications in this series. Excellent or good outcomes (Glasgow Outcome Scale ≥ 4) were observed in 63 (73.3%) patients at discharge. Neurological deficits (Glasgow Outcome Scale 1-4) were 16.6% at discharge.

CONCLUSION

Endovascular treatment can be adequately used for cerebral aneurysms associated with AVMs as an adjunct to microsurgery and radiosurgery.

Stent-assisted coil embolization of intracranial aneurysms using Solitaire stent

OBJECTIVE

To report patients with intracranial wide-necked or complex aneurysms who underwent Solitaire stent-assisted coil embolization.

MATERIALS AND METHODS

Retrospective analysis of 28 patients with intracranial wide-necked or complex aneurysms. Eighteen of the patients presented with an acute subarachnoid hemorrhage. Thirty-one aneurysms were treated with the support of different applications (n = 32) of the Solitaire AB stents followed by the standard coiling procedure (n = 30).

RESULTS

Successful positioning of the remodeling device was obtained in all the cases. One stent required repositioning after full deployment. There were four thromboembolic complications (12.5%) and two hemorrhagic complications (6.25%), which caused three deaths. No permanent procedural morbidity was observed in the surviving patient. Angiographic results included 26 complete occlusions (83.9%), three neck remnants (9.7%) and two incomplete occlusions (6.4%).

CONCLUSION

Although the initial technical and clinical results of Solitaire stent-assisted coiling of aneurysms was reported to be encouraging in recent reports, we had encountered higher thromboembolic and hemorrhagic complications in our patients.

Endovascular embolization for symptomatic perimedullary AVF and intramedullary AVM: a series and a literature review

INTRODUCTION

Perimedullary arteriovenous fistula (AVF) has shunt on the spinal cord surface and it can be treated with surgery, or endovascular embolization. Intramedullary arteriovenous malformation (AVM) has its nidus in the cord and is difficult to treat either by surgery or endovascular technique. We report our experience with endovascular embolization in the treatment of perimedullary AVF and intramedullary AVM.

METHODS

Four consecutive cases of spinal perimedullary AVF and six intramedullary AVM were retrospectively reviewed. These cases were evaluated and treated at Beijing Tiantan Hospital, China, over a 2-year period. A review of previously reported cases was also performed.

RESULTS

There was no significant difference in the presentations (P = 0.348), level of lesions (P = 0.350), arterial suppliers (P = 0.801), and associated vascular anomalies between perimedullary AVF and intramedullary AVM, except for age (P = 0.014) and treatment modalities (P = 0.003). The patients with perimedullary AVFs were younger in our cases; the age at onset of symptoms averaged 25.8 years compared to 31.7 years for intramedullary AVMs. There was a significant male predominance for both lesions, and a significantly higher incidence of subarachnoid hemorrhage than in spinal dural AVFs. Regarding treatment, endovascular coil embolization is frequently used in perimedullary AVF and liquid embolic agent is an effective therapeutic choice in intramedullary AVM.

CONCLUSION

Perimedullary AVF and intramedullary AVM are dissimilar with dural AVF in clinical characteristics. Our experience suggests that the endovascular treatment of spine perimedullary AVFs and intramedullary AVMs is feasible and effective. Endovascular treatment for intramedullary AVMs is still challenging, the main problem is acute ischemia injury of the spinal cord.

Brain AVM characteristics and age

OBJECTIVE

To explore angioarchitectural features of brain arteriovenous malformations (BAVMs) in ages.

METHODS

302 Consecutive patients with BAVMs between 1999 and 2008 were retrospectively reviewed. Univariate analysis was used to test initial presentation and BAVM characteristics in different ages.

RESULTS

Patients ranged in age from 5 to 65 years (mean±SD, 28.3±12.8). One hundred and eighty-eight were male and 113 female. Clinical presentations were hemorrhage (52.6%), seizure (24.5% of patients), headache (12.6%), focal neurological deficit (6.3%), or other clinical events, including incidental BAVM diagnoses (4.0%). Increasing age correlated positively with coexisting arterial aneurysms (P=0.044). No differences were found for sex, initial presentation, BAVM size, BAVM location, arterial feeders and venous drainage pattern between each age groups.

CONCLUSION

Increasing age correlated positively with coexisting arterial aneurysms. No statistical significance was observed for clinical presentations, and BAVM characteristics among age groups.

Endovascular management of direct carotid-cavernous sinus fistulas

To evaluate the single-centre experience with endovascular management of direct carotid-cavernous sinus fistulas (DCCF). Between November 2008 and November 2010, a total of 14 patients (11 males) with direct carotid-cavernous sinus fistula underwent 16 transarterial treatment sessions. The patient files and angiograms were analysed retrospectively. Clinical signs and symptoms included exophthalmos [n=12, (85.7%)], pulsatile tinnitus [n=9, (64.3%)], cranial nerve III or VI palsy [n=2, (14.3%)], and impaired vision [n=1, (7.1%)]. Angiography revealed in addition cortical drainage in five patients (35.7%). Transarterial embolization was performed using detachable balloon in nine sessions (56.2%), detachable coils in three sessions (18.8%) and a combination with Onyx in four sessions (25%). Complete interruption of the arteriovenous shunt was achieved in all patients. There was a tendency for ocular pressure-related symptoms to resolve rapidly, while cranial nerve palsy and diplopia improved slowly (7.1%) or did not change (7.1%). The patient with visual impairment recovered within the first two weeks after endovascular treatment. After complete interruption of the arteriovenous shunt, two (12.5%) recurrences were observed in balloon treatment and retreatment was given. Transarterial management is a highly efficient and safe treatment in DCCFs. In the majority of patients a significant and permanent improvement in clinical signs and symptoms can be achieved.

Endovascular treatment of hemifacial spasm associated with a petrosal DAVF using transarterial Onyx embolization. A case report

This paper reports that decompression of the facial nerve by transarterial Onyx embolization may relieve hemifacial spasm (HFS) caused by dilated veins due to a right petrosal dural arteriovenous fistula (DAVF). A 56-year-old man suffered severe chronic right HFS associated with a dilated right petrosal vein lying in the vicinity of the facial nerve. The right petrosal DAVF was reached through the middle meningeal artery using a transfemoral arterial approach and was occluded with Onyx 18 (M.T.I.- ev3, Irvine, CA, USA). There was complete remission of HFS without recurrence after two months of follow-up. This case supports vascular compression in the pathogenesis of HFS and suggests that facial nerve injury caused by a DAVF could be treated with transarterial Onyx embolization.

Dural arteriovenous fistula of crianiocervical junction: Four case reports

The clinical characteristics of aggressive craniocervical junction dural arteriovenous fistula (CCJDAVF) and effect treatment was studied in four patients and all four patients were treated endovascularly with liquid embolic agents. Post-embolization angiography documented complete obliteration in one patient and partial obliteration in the other three patients. All patients had good recovery without any procedure-related complications. Endovascular embolization can be used to reduce the rate of flow through CCJDAVFs or as a definitive treatment when the fistula is accessible endovascularly.

Characteristics of Brain Arteriovenous Malformations Presenting with Seizures without Acute or Remote Hemorrhage

We report on the predictors of seizure presention in unruptured brain arteriovenous malformations (AVMs). Between 1999 and 2008, 302 consecutive patients with AVMs were referred to our institution for endovascular treatment. Seventy-four patients (24.5%) experienced seizures without hemorrhage before treatment. We tested for statistical associations between angioarchitectural characteristics and seizure presentation. When we compared the 74 patients with seizures without hemorrhage with the 228 patients who did not experience seizures initially (total of 302 patients), male sex, cortical AVM location, AVM size of more than 3 cm, superficial venous drainage and presence of varices in the venous drainage were statistically associated with seizures (P=0.016, P=0.002, P=0.022, P=0.005, and P=0.022, respectively). Posterior fossa and deep locations and coexisting aneurysms were statistically associated with no seizures. The angioarchitectural characteristics of AVM associated with seizure presentation include male sex, cortical AVM location, AVM size of more than 3 cm, superficial venous drainage and presence of varices in the venous drainage.

The limitations and risks of transarterial Onyx injections in the treatment of grade I and II DAVFs

BACKGROUND AND OBJECTIVE

Embolization of grade III-V intracranial DAVFs using Onyx is feasible with promising results, indicating stability at the time of mid-term follow-up. This article is to evaluate the role of transarterial Onyx embolization in the treatment of grade I and II intracranial dural arteriovenous fistulas (DAVFs), including its limitations and risks.

METHODS

We retrospectively studied consecutive 26 patients (8 women and 18 men) treated for an grade I and II intracranial DAVF since 2006 in whom a transarterial approach was attempted with Onyx-18 embolization. There were 18 transverse-sigmoid sinus, 4 cavernous sinus, 2 superior sagittal sinus, 1 inferior petrosal sinus and 1 intradiploic fistulas. Five fistulas were Type I, 8 were Type IIa, and 13 were Type IIa+b, according to the Cognard classification. The mean clinical follow-up period was 15.6 months.

RESULTS

Anatomic cure was proven in 13 patients (50%) and clinical cure was obtained in 17 cases (65.4%). These 13 cures were achieved after a single procedure. All these 13 patients underwent a follow-up angiography, which has confirmed the complete cure. Partial occlusion was obtained in 13 patients. Complications were as follows: 2 cardiac Onyx migration, 2 reflexive bradyarrythmia, 1 transient visual hallucination, 2 transient fifth nerve palsies and 1 permanent seventh nerve palsy in inferior petrosal sinus DAVF.

CONCLUSIONS

Based on this experience, grade I and II intracranial DAVFs may be treated with transarterial Onyx embolization to reduce the shunted blood flow and to facilitate subsequent transvenous embolization or surgery.

Transarterial Onyx packing of the transverse-sigmoid sinus for dural arteriovenous fistulas

OBJECTIVE

To report transarterial Onyx packing of the transverse-sigmoid sinus for dural arteriovenous fistulae (DAVFs).

METHODS

We retrospectively studied consecutive 5 patients (2 female and 3 male) treated for a transverse-sigmoid sinus DAVF since 2008 in whom transverse sinus packing was attempted with a transarterial approach Onyx embolization. The mean clinical follow-up period was 6.2 months.

RESULTS

Of the five lesions, 2 fistulas were type IIa, 3 were type IIb, according to the Cognard classification. Five Onyx embolizations were all performed via the middle meningeal artery. Cure was obtained in all cases after completion of direct sinus packing. No complications were revealed.

CONCLUSIONS

Transarterial Onyx packing of transverse-sigmoid sinus for DAVFs via the meningeal arterial system is a safe therapeutic alternative in selected cases.

Complication risk of endovascular embolization for cerebral arteriovenous malformation

OBJECTIVE

The embolic agents currently used for the treatment of AVMs are n-butyl cyanoacrylate (NBCA) and ethylene-vinyl alcohol copolymer (ONYX). The purpose of this study was to examine the overall NBCA and ONYX embolization-related complication rate.

METHODS

We retrospectively reviewed 147 consecutive patients with cerebral AVMs treated mainly with endovascular NBCA and ONYX embolization. Demographics, including age, sex, presenting symptoms, and angiographic factors including AVM size, deep venous drainage, and involvement of eloquent cortex were recorded. Number of pedicles embolized, the obliteration rate, and any complications were recorded. Complications were classified as the following: bleeding and ischemic complications. The ischemic complications were also classified as transient neurologic deficit, and permanent deficits. Modified Rankin Scale (mRS) scores were collected pre- and postembolization on all patients. Univariate regression analysis of determinants of complications was performed.

RESULTS

We reviewed 147 patients with BAVM (58.5% male; mean age±SD at treatment: 27.5±11.1 years) treated with endovascular embolization. Two hundred twenty embolization, 144 NBCA and 76 ONYX embolizations were performed. Complete obliteration of BAVMs were achieved in 29 patients (19.7%). Additional gamma-knife radiosurgery were performed for 32 (21.8%) patients. There were 5 Spetzler-Martin grade I (3.4%), 20 grade II (13.6%), 54 grade III (36.7%), 44 grade IV (30%), and 24 grade V (16.3%) AVMs. There were a total of 7 (4.8% per patient, 3.2% per procedure) complications. There were bleeding complications in 2 patients (1.4% per patient, 0.9% per procedure), transient neurologic deficits in 4 (2.7% per patient, 1.8% per procedure) and 1 permanent deficit (0.7% per patient, 0.5% per procedure). Of the 147 patients, 141 (95.9%) were mRS 0-2, 6 (4.1%) were mRS=3 at discharge. Univariate analysis of risk factors for embolic agent showed that ONYX was not significantly associated with complications (X2=0.3, P>0.5).

CONCLUSIONS

Embolization of brain AVMs is safe, 95.9% of patients had excellent or good outcomes at discharge after AVM embolization using liquid embolic agents, with a complication rate of 4.8%. ONYX embolization was not associated a higher rate of complications comparing with NBCA embolization.

Cerebral arteriovenous malformations associated with flow-related and circle of Willis aneurysms

BACKGROUND

To evaluate the characteristics of brain arteriovenous malformations (AVMs) with coexisting flow-related and Willis circle aneurysms.

METHODS

The 302 consecutive retrospectively reviewed patients from the Beijing Tiantan Hospital were analyzed in this study. The presence of cerebral aneurysms was confirmed by pretreatment selective and superselective angiography. Univariate and multivariate analyses were performed for patient age, sex, history of rupture, associated aneurysms, AVM size, and deep and superficial venous drainage.

RESULTS

Of the 302 patients, 41 (13.6%) had AVMs associated with intranidal aneurysms, and 33 (10.9%) had AVMs associated with extranidal aneurysms. Of the 33 patients, 24 (72.7%) had a flow-related and 9 (27.3%) had a Willis circle aneurysm. Flow-related and Willis circle aneurysms correlated positively with intracranial hemorrhage (P = 0.003), patient age (P = 0.003), and infratentorial AVMs (P = 0.040) in multiple univariate analysis.

CONCLUSIONS

Flow-related and Willis circle aneurysms coexisting with cerebral AVMs frequently are associated with initial hemorrhage presentation, patient age, and infratentorial AVM location.

Dural arteriovenous fistula with spinal perimedullary venous drainage

The purpose of this study was to investigate the characteristics of six patients with dural arteriovenous fistula (DAVF) with drainage directly into the perimedullary venous system. In five patients with subarachnoid hemorrhage (SAH), cerebral angiography revealed a DAVF with spinal venous drainage located at the petrosal sinus in one, at the tentorium in one, and at the craniocervical junction in four. In the patient with myelopathy, angiographic exploration began with a spinal angiogram. Bilateral vertebral angiography initially failed to demonstrate the fistula, and a tentorial DAVF was established with carotid artery angiography. Patients had no myelopathy when the venous drainage was limited to the cervical cord; myelopathy was present when the venous drainage descended toward the conus medullaris. Diagnosis of a DAVF presenting with myelopathy is more challenging than of those presenting with SAH.

Endovascular treatment of ruptured and unruptured vertebral artery aneurysms

This paper analyzes the success of endovascular management of ruptured and unruptured vertebral artery aneurysms. Sixty-three patients with 65 vertebral (both acute dissection and chronic larger aneurysms are included) treated at our hospital form the basis of the analysis. Clinical outcome was evaluated using the modified Rankin Scale. Angiographic follow-up data was obtained for 44 patients (69.8%) for periods ranging from three to 16 months (mean, eight months). Based on the Hunt and Hess grading scale, the patient population included 34 patients (54.0%) with unruptured aneurysms, 28 (44.4%) with Grade 1 aneurysms, one (1.6%) with Grade 2 aneurysms. The locations of the aneurysms included 25 (38.5%) at the distal to posterior inferior cerebellar artery (PICA), 22 (33.8%) at the proximal to PICA and 18 (27.7%) at the vertebral artery-posterior inferior cerebellar artery (VA-PICA). Of the 63 patients, 12 (19%) were women and 51 (81%) were men. The mean age at treatment was 41.7 years (range, six-77 yrs). Follow-up angiograms were obtained in 44 (69.8%) out of 63 patients. Complete or virtually complete thrombosis was confirmed on early posttreatment angiography in 39 (88.6%) out of 44 patients. A slight reduction in the size of the lesion was noted in three patients and there was a significant residual lesion in two (4.5%) patients. Clinical follow-up revealed 90.5% patients in the mRS 0-2 category, 4.8% patients in the mRS>2 category, and 4.8% patients had died (mRS 6). Three patients died of rebleeding (n=1) or progressive mass effect/brainstem ischemia (n=2). Ruptured and unruptured aneurysms of the vertebral artery can be well treated using endovascular techniques, overall long-term results were good in 90.5% of patients.

Characteristics of arteriovenous malformations associated with cerebral aneurysms

OBJECTIVE

To analyze the characteristics of brain arteriovenous malformations (AVMs) associated with cerebral aneurysms.

METHODS

A total of 302 consecutive, retrospectively reviewed patients from the Beijing Tiantan Hospital were analyzed in this study. The presence of cerebral aneurysm was confirmed by pretherapeutic selective and superselective angiography. Clinical presentation was categorized as intracranial hemorrhage or nonhemorrhagic presentation. Univariate and multivariate statistical models were applied to test the effect of age, sex, AVM size and location, and venous drainage pattern.

RESULTS

Of the 302 patients, 74 (24.5%) had AVMs associated with cerebral aneurysms. AVMs coexisting with aneurysms were significantly associated with hemorrhage at initial presentation (2.27; 95% confidence interval 1.31-3.95; P = 0.003). Infratentorial AVM location was significantly associated with AVMs coexisting with aneurysms (2.31; 95% confidence interval 1.02-5.24; P = 0.040). Deep or superficial venous drainage, female sex, or AVM size were not significantly associated with AVMs coexisting with aneurysms. The regression model showed significant effect was found for initial presentation with hemorrhage (P = 0.003), age (P = 0.003), and infratentorial AVM location (P = 0.040).

CONCLUSIONS

Our findings suggest that AVMs associated with cerebral aneurysms are frequently associated with initial hemorrhage presentation and infratentorial AVM location.

Potential advantages and limitations of the Leo stent in endovascular treatment of complex cerebral aneurysms

OBJECTIVE

The Leo self-expandable stent is a new retractable stent that is delivered via a conventional catheter. The aim of this study was to evaluate the use of this stent for endovascular treatment of complex aneurysms.

METHODS

Twenty-eight complex cerebral aneurysms (27 saccular and 1 fusiform) in 28 patients were treated electively. They were located at the internal carotid artery (17), basilar trunk (3), anterior cerebral artery (1), anterior communicating artery (3), vertebral artery (2) and middle cerebral artery (2). One aneurysm exhibited recanalization after primary endovascular treatment without stent. Clinical outcome was assessed with the modified Glasgow Outcome Scale.

RESULTS

Deployment of Leo stent was successful in 26 lesions, and difficulties in stent positioning due to tortuous cerebral circulation in 2 cases, which were treated with Neuroform stent. Additional coil embolization was performed in 26 lesions. No permanent neurological deficits were encountered consequent to endovascular procedure. Complete or partial occlusion immediately after stent deployment was achieved in all aneurysms. There was no immediate coil embolization was chosen in 3 cases because of subsequent reduced filling of the aneurysms with contrast agent on angiograms. There were 3 asymptomatic parent artery occlusion related to the deployment of the Leo stent, one stent migration. Follow-up revealed patent stents in the remaining cases. No angiographic recurrences arose.

CONCLUSION

The Leo stent is very useful for endovascular treatment of complex cerebral aneurysms because it is easy to navigate and place precisely. A drawback is that in-stent thrombosis caused by stent placement and stiffer delivery catheters to place larger stents.

Angioarchitectural characteristics of brain arteriovenous malformations with and without hemorrhage

OBJECTIVE

To explore angioarchitectural features of brain arteriovenous malformations (AVMs) manifesting with hemorrhage and without hemorrhage.

METHODS

During the period 1999-2008, 302 consecutive patients with AVMs were retrospectively reviewed. Univariate and multivariate logistic analysis was used to assess AVM characteristics in patients who presented with hemorrhage and patients who presented without hemorrhage. Annual and cumulative incidence rates of AVM rupture were analyzed using Kaplan-Meier life-table analyses.

RESULTS

The annual risk of hemorrhage from AVMs in this study was 1.9%. In the comparison of 159 patients with AVM with hemorrhage at initial presentation with 143 patients who did not experience hemorrhage initially (total 302 patients), deep and infratentorial AVM location, AVM size<3 cm, single arterial feeder, single draining vein, combined deep and superficial drainage, presence of varices in the venous drainage, and coexisting aneurysms were statistically associated with hemorrhage presentation (P=0.000, P=0.000, P=0.007, P=0.000, P=0.000, P=0.000, and P=0.003) in univariate analysis. Deep and infratentorial AVM location, single draining vein, presence of varices in the venous drainage, and coexisting aneurysms were statistically associated with hemorrhage occurrence (P=0.007, P=0.008, P=0.018, and P=0.002) in multivariate logistic analysis.

CONCLUSIONS

The angioarchitectural characteristics of AVM associated with hemorrhage include deep and infratentorial AVM location, AVM size<3 cm, single arterial feeder, single draining vein, combined deep and superficial drainage, presence of varices in the venous drainage, and coexisting aneurysms.

Endovascular treatment for cerebral perforating artery aneurysms

OBJECTIVE

Cerebral perforating artery (CPA) aneurysms are rarely reported in the literature, making management decisions challenging. This study is to report neurological outcomes in a single institution experience of perforating artery aneurysms treated endovascularly.

METHODS

All cases involving patients with CPA aneurysms who presented to Beijing Tiantan Hospital between September 2006 and September 2009 were reviewed retrospectively.

RESULTS

Over 3 years, four patients with four CPA aneurysms were treated. The Hunt and Hess grade on admission ranged from 0 to IV, with intracranial hemorrhage in three of the four patients. Conventional angiography confirmed the presence of the aneurysms, and all patients underwent endovascular embolization using liquid embolic materials with parent artery sacrifice. Associated risk factor in our series of patients was brain arteriovenous malformation. The locations of aneurysm were lenticulostriate artery, anterior choroidal artery and medial posterior choroidal artery. The mean size of the aneurysms was 2.5 mm. The mean modified Rankin scale score at follow-up was 1.25. Three patients in whom the perforating artery was sacrificed had good outcomes, suggesting that loss of the artery is clinically well tolerated.

CONCLUSIONS

This case series reveals that endovascular treatment of CPA aneurysms may be an appropriate, effective, and safe therapy.