Subclavian arteritis and pseudoaneurysm formation secondary to stent infection

Technically uncomplicated percutaneous angioplasty and stent placement of a left subclavian artery stenosis was performed in a 56-year-old man for treatment of subclavian steal syndrome and vertebrobasilar insufficiency. Six days later the patient was readmitted with Staphylococcus aureus bacteremia and stigmata of septic emboli isolated to the ipsilateral hand. Nine days later he had computed tomography (CT) evidence of a contrast-enhancing phlegmon surrounding the stent. Despite clinical improvement and resolution of bacteremia on intravenous antibiotic therapy, the phlegmon progressed, and at day 21 a pseudoaneurysm was angiographically confirmed. The patient underwent surgical removal of the stented arterial segment and successful autogenous arterial reconstruction. The possible contributory factors leading to stent infection were prolonged right femoral artery access and an infected left arm venous access. Although the role of prophylactic antibiotics remains to be defined, it may be important in cases where the vascular access sheath remains in place for a prolonged period of time.

Treatment of dural arteriovenous malformations and fistulas

Dural arteriovenous fistulas (DAVFs) or malformations consist of pathological vascular channels located within the substance of the dura mater and usually involve the walls of a dural sinus or adjacent cortical vein. DAVFs can affect a variety of cerebral venous structures and can present at various clinical stages. Although some fistulas can spontaneously thrombose, the clinical course usually involves progression from venous sinus pressurization to occlusion and retrograde cortical venous drainage. The spectrum of clinical presentation ranges from an irritating pulse-synchronous bruit to a disabling neurologic ischemic deficit or life-threatening intracranial hemorrhage from venous hypertension. The authors present their clinical experience in the radiographic diagnosis and endovascular treatment of these potentially dangerous lesions.

Carotid artery cavernous fistulas

The treatment of carotid cavernous fistulas has undergone a fundamental transformation during the preceding 30 years. Endovascular techniques have not only largely replaced surgical management of this disease, but have also resulted in substantially lower rates of procedure-associated morbidity and mortality. Percutaneous transarterial occlusion of direct cavernous carotid fistulas with preservation of the carotid artery using detachable balloons is now considered the current preferred therapeutic objective. Concurrent progress in percutaneous transvenous embolization techniques and materials has led to more effective and better-tailored therapies for indirect (dural) carotid cavernous fistulas. The current understanding of the clinicopathologic mechanisms associated with carotid cavernous fistulas and the endovascular therapies used in the contemporary management of this condition are reviewed.

Embolization of non-ruptured aneurysms

Options for treatment of intracranial aneurysms have expanded with the advent of the Guglielmi Detachable Coil (GDC) eight years ago. We have reviewed 435 cases of intracranial aneurysms treated at UCSF by endovascular means using the GDC system. Of these, 55% represent anterior circulation aneurysms, and 45% are located in the posterior circulation. Additionally, 55% of the aneurysms presented with subarachnoid hemorrhage (SAH) and 45% were unruptured. Factors which hindered optimal coiling include the following: wide aneurysm neck in relation to the overall aneurysm size, mural thrombus, giant aneurysm, arteries originating from the aneurysm sac, and middle cerebral location. After initial experience was gained, we tended to avoid these aneurysms especially in the non-ruptured group. This may be especially important in light of new epidemiological data suggesting that the natural history of unruptured aneurysms is significantly lower than previously thought. New technical developments which may reduce the risk of treating unruptured aneurysms include the two-dimensional coil, the three-dimensional coil, the balloon-assist technique for wide-necked aneurysms, and combined stent-coil procedures.

Acquired pial arteriovenous fistula following cerebral vein thrombosis

BACKGROUND

We report a unique case of an acquired pial arteriovenous fistula occurring after an asymptomatic thrombosis of a superficial cerebral vein.

CASE DESCRIPTION

A cerebral angiogram performed in a 51-year-old man with subarachnoid hemorrhage revealed a 10-mm ruptured anterior communicating artery aneurysm and a thrombosed left superficial middle cerebral vein. Coil embolization of the anterior communicating aneurysm was performed. Follow-up angiography 18 months later revealed a new, asymptomatic, pial arteriovenous fistula between the previously thrombosed left superficial middle cerebral vein and a small sylvian branch of the left middle cerebral artery.

CONCLUSIONS

This case provides evidence that pial arteriovenous fistulas may develop as acquired lesions and furthermore may rarely follow cerebral vein thrombosis. Several cases of dural arteriovenous fistulas, as well as a single case of a mixed pial-dural arteriovenous fistula, occurring after dural sinus thrombosis have been reported previously. However, to our knowledge, this is the first report of an acquired pial arteriovenous fistula following a cerebral vein thrombosis.

Clinical use of stents for carotid artery disease

Over the last 5 years, the clinical use of intravascular stents for treatment of carotid artery pathology has become more prevalent and the spectrum of potential indications has widened. Endovascular stenting is providing an alternative to surgical endarterectomy for treatment of cervical carotid artery atherosclerotic disease. This has prompted a North American, randomized, controlled clinical trial directly comparing these two therapies. In this article we review the major surgical endarterectomy trials that currently provide the scientific rationale for revascularization of carotid artery occlusive disease, critically evaluate the evidence supporting the application of endovascular stenting procedures for the treatment of occlusive and nonocclusive disease of the extracranial and intracranial carotid artery, consider the current clinical indications for use of stents in the carotid artery, and discuss current equipment, technique, and potential procedure-related complications.

Treatment of posterior circulation ischemia with extracranial percutaneous balloon angioplasty and stent placement

BACKGROUND AND PURPOSE

Vertebrobasilar territory ischemia (VBI) leads to disabling neurological symptoms and poses a risk for stroke by an embolic or flow-related mechanism. We present our clinical experience in the endovascular treatment of patients with symptomatic VBI from severe atherosclerosis or dissection of the vertebral and subclavian arteries that was unresponsive to medical therapy.

METHODS

Twenty-one patients (9 female, 12 male) with a mean age of 65.7 years (range 47 to 81 years) underwent treatment with percutaneous endovascular balloon angioplasty and stent placement. Sixteen patients (76.2%) had evidence of contralateral involvement, and 9 (42.8%) demonstrated severe anterior-circulation atherosclerosis. Nine patients had a previous infarct in the occipital lobe, cerebellum, or pons before treatment. Follow-up was available for all patients.

RESULTS

Balloon angioplasty with intravascular stent placement was performed in 13 vertebral artery lesions (10 at the origin, 3 in the cervical segment) and in 8 subclavian lesions. The prestenting stenosis was 75% (50% to 100%) and was reduced to 4.5% (0% to 20%) after stenting. Six of the patients with proximal subclavian stenosis demonstrated angiographic evidence of subclavian steal, which resolved in all cases after treatment. All patients showed improvement in symptoms after the procedure except for 1 who developed a hemispheric stroke after thrombotic occlusion of an untreated cavernous carotid artery stenosis (rate of major stroke and mortality=4.8%). One patient (4.8%) had a periprocedural transient ischemic attack (TIA), and none had minor stroke. At long-term follow-up (mean=20.7+/-3.6 months) of the surviving 20 patients, 12 (57.1%) remained symptom-free, 4 (19%) had at most 1 TIA over a 3-month period, 2 (9.5%) had at most 1 TIA per month, and 2 (9.5%) had persistent symptoms. There were no clinically evident infarcts during the follow-up period.

CONCLUSIONS

Endovascular treatment using balloon angioplasty with intravascular stent placement for symptomatic stenotic lesions resulting in VBI that is unresponsive to medical therapy appears to be of benefit in this high-risk subset of patients with poor collateral flow.

Tandem intracranial stent deployment for treatment of an iatrogenic, flow-limiting, basilar artery dissection: technical case report

OBJECTIVE AND IMPORTANCE

Intimal dissection constitutes one of the complications associated with angioplasty of intracranial vessels. We present a case of iatrogenic dissection of the entire basilar artery, which was induced by angioplasty and stenting of symptomatic, focal, intracranial vertebral artery stenosis, and its successful treatment with tandem deployment of a downstream stent.

CLINICAL PRESENTATION

A 61-year-old, hypertensive, renal transplant recipient presented with orthostatic vertebrobasilar insufficiency that was refractory to medical management, including anticoagulation therapy. Angiography revealed an occluded right vertebral artery and focal, high-grade, left intracranial vertebral artery stenosis. Magnetic resonance imaging showed multiple posterior fossa infarctions. The left intracranial vertebral artery stenosis was successfully treated with primary stent deployment and balloon angioplasty, with symptom resolution. On postprocedure Day 2, the patient noted worsening right hemiparesis.

INTERVENTION

Subsequent angiography revealed a flow-limiting, windsock-type, basilar artery dissection beginning at the distal end of the left vertebral artery stent and extending to the origin of the left posterior cerebral artery. A tandem stent was navigated intracranially and deployed past the first one, successfully sealing the dissection inflow zone and reconstituting normal flow to the top of the basilar artery. A clinical follow-up examination at 3 months revealed no further orthostatic symptoms and only mild residual right-sided weakness.

CONCLUSION

This is the first description of iatrogenic stent-induced dissection of the entire basilar artery that was successfully treated by inflow zone control via tandem intracranial stent deployment.

Intraventricular contrast medium leakage during ethanol embolization of an arteriovenous malformation

We report the unusual phenomenon of abrupt intraventricular contrast medium leakage from the choroid plexus occurring during ethanol embolization of a periventricular arteriovenous malformation. There was no evidence of any associated intraventricular hemorrhage to suggest that leakage arose from a vessel perforation, as was first suspected. Intraventricular contrast medium leakage has been reported previously in the setting of ependymitis, and it is likely that similar pathogenetic mechanisms apply in this case. To our knowledge, this is the first reported case of intraventricular contrast medium leakage occurring during an embolization procedure.

Embolization of the meningohypophyseal trunk as a cause of diabetes insipidus

We present an unusual case of diabetes insipidus occurring after selective embolization of 50% dextrose and pure ethanol into an enlarged left meningohypophyseal trunk (MHT) supplying a dural carotid cavernous fistula. The inferior hypophyseal artery was not opacified during the selective preembolization MHT injection; however, diabetes insipidus developed abruptly a few hours after the procedure. The patient required intranasal 1-deamino-(8-D-arginine)-vasopressin for approximately 3 months, after which his symptoms resolved. The hazards of using liquid embolic agents, especially ethanol, in the cavernous branches of the internal carotid artery should always be borne in mind.

Simultaneous subarachnoid hemorrhage and carotid cavernous fistula after rupture of a paraclinoid aneurysm during balloon-assisted coil embolization

We describe an iatrogenic perforation of a paraclinoid aneurysm during balloon-assisted coil embolization that resulted in simultaneous subarachnoid contrast extravasation and a carotid cavernous fistula. The causative factors specifically related to the balloon-assisted method that led to aneurysm rupture are discussed as well as strategies for dealing with this complication.

Post-procedure migration of Guglielmi detachable coils and Mechanical detachable spirals

We describe a previously unreported complication of the use of Guglielmi detachable coils and Mechanical detachable spirals in endovascular treatment of intracranial aneurysms. We document four cases in which migration of part of a coil into the parent artery occurred after completion of the procedure. Possible mechanisms are discussed.

Treatment of an intracranial aneurysm using a new three-dimensional-shape Guglielmi detachable coil: technical case report

OBJECTIVE AND IMPORTANCE

Coil embolization of wide-necked aneurysms is currently difficult, when using a conventional endovascular approach without resorting to complex adjunctive techniques.

CLINICAL PRESENTATION

A 41-year-old woman with a history of systemic lupus erythematosus and hypertension refractory to treatment presented with an unruptured right ophthalmic segment aneurysm of the internal carotid artery having an unfavorable neck-to-fundus ratio.

INTERVENTION

A new type of Guglielmi detachable coil (Target Therapeutics, Fremont, CA), consisting of a series of omega loops, spontaneously forms a three-dimensional cage after deployment and was used to successfully treat the aneurysm, which was angiographically stable at the 3-month follow-up.

CONCLUSION

The new Guglielmi detachable coil may be useful in the embolization of aneurysms having an unfavorable geometry, which would otherwise not be amenable to endovascular treatment without adjunctive techniques.

Application of a rheolytic thrombectomy device in the treatment of dural sinus thrombosis: a new technique

We present a novel application of a transvascular rheolytic thrombectomy system in the treatment of symptomatic dural sinus thrombosis in a 54-year-old woman with somnolence and left-sided weakness. The diagnosis of bilateral transverse and superior sagittal sinus thrombosis was made and the patient was treated with anticoagulant therapy. After an initial period of improvement, she became comatose and hemiplegic 8 days after presentation. After excluding intracerebral hemorrhage by MR imaging, we performed angiography and transfemoral venous thrombolysis with a hydrodynamic thrombectomy catheter, followed by intrasinus urokinase thrombolytic therapy over the course of 2 days. This technique resulted in dramatic sinus thrombolysis and near total neurologic recovery. Six months after treatment, the patient showed mild cognitive impairment and no focal neurologic deficit. Our preliminary experience suggests that this technique may play a significant role in the endovascular treatment of this potentially devastating disease.

Endovascular recanalization with balloon angioplasty and stenting of an occluded occipital sinus for treatment of intracranial venous hypertension: technical case report

OBJECTIVE AND IMPORTANCE

Dural sinus thrombosis can lead to intracranial venous hypertension and can be complicated by intracranial hemorrhage. We present a case report of a patient who underwent endovascular recanalization and stenting of a thrombosed occipital sinus.

CLINICAL PRESENTATION

A 13-year-old patient with a history of chronic sinus thrombosis refractory to anticoagulant therapy presented with acute onset of aphasia and hemiparesis. Computed tomography and magnetic resonance imaging revealed hydrocephalus and cerebral edema. Angiography delineated multiple dural arteriovenous fistulae and persistent occlusion of the posterior sagittal, occipital, and bilateral transverse dural sinuses with retrograde cortical venous drainage.

INTERVENTION

After embolization of the dural arteriovenous fistulae, a transvenous approach was used to recanalize and perform balloon angioplasty of the right internal jugular vein and the occipital and left transverse sinuses, resulting in subsequent clinical improvement. The patient's condition deteriorated 3 days later with reocclusion of both balloon-dilated sinuses. Repeat angioplasty and then deployment of an endovascular stent in the occipital sinus were performed, and reestablishment of venous outflow was achieved, resulting in a decrease of intracranial venous pressure from 41 to 14 mm Hg and neurological improvement. At the 3-month follow-up examination, the stented occipital sinus remained patent and served as the only conduit for extracranial venous outflow; the patient remained neurologically intact at the 12-month follow-up examination.

CONCLUSION

This is the first report of mechanical recanalization, balloon angioplasty, and stent deployment in the occipital sinus to provide sustained venous outflow for the treatment of venous hypertension with retrograde cortical venous drainage in a patient with dural pansinus thrombosis refractory to anticoagulant therapy.

Spinal dural arteriovenous fistula with an associated feeding artery aneurysm: case report

OBJECTIVE AND IMPORTANCE

A case of a spinal dural arteriovenous fistula (DAVF) with two associated feeding artery aneurysms is reported. Intradural spinal arteriovenous malformations have been associated with aneurysms that present with subarachnoid hemorrhage and with venous varices that produce mass effect, but spinal DAVFs have not previously been described in association with feeding artery aneurysms.

CLINICAL PRESENTATION

A 71-year-old man presented with progressive spastic paraparesis, constipation, and overflow incontinence. Magnetic resonance imaging demonstrated a spinal vascular lesion and venous ischemia in the lower spinal cord. Diagnostic spinal angiography revealed a DAVF originating from the left T11 radicular artery and having the unusual feature of two proximal feeding artery aneurysms.

INTERVENTION

The patient deteriorated neurologically after undergoing angiography, prompting emergent surgery. The DAVF was resected through a T11 transpedicular approach. One aneurysm was dolichoectatic and therefore unclippable, requiring proximal occlusion of the parent artery after establishing tolerance of test occlusion using somatosensory evoked potentials; the second aneurysm was adjacent to the fistula and was resected with the DAVF.

CONCLUSION

Feeding artery aneurysms in association with spinal DAVFs have not been previously reported. They present additional risk to patients and, with simple modifications of the standard operative approaches, can easily be treated as part of the surgery for the DAVF.

Endovascular stenting of an acutely thrombosed basilar artery: technical case report and review of the literature

OBJECTIVE AND IMPORTANCE

The goal of this report was to describe the successful percutaneous endovascular use of a Gianturco-Roubin-2 coronary stent in the treatment of an acute atherothrombotic occlusion of the basilar artery. To our knowledge, the percutaneous endovascular deployment of an intra-arterial stent for the treatment of an acute atherothrombotic occlusion of the basilar artery and the percutaneous endovascular placement of a Gianturco-Roubin-2 stent in the basilar artery have not been previously reported.

CLINICAL PRESENTATION

An 83-year-old man presented with a recurrent, transient, locked-in syndrome resulting from a lower basilar artery occlusion caused by vertebrobasilar thrombosis superimposed on severe proximal basilar artery atheromatous stenosis.

INTERVENTION

After successful superselective intra-arterial thrombolysis of the vertebrobasilar clot, balloon angioplasty of the underlying basilar artery stenosis was performed, without significant angiographic improvement. Percutaneous endovascular deployment of a Gianturco-Roubin-2 coronary stent of 4-mm diameter was subsequently performed, with excellent angiographic results.

CONCLUSION

The patient made a very good neurological recovery but unfortunately died as a result of cardiogenic shock and sepsis. Detailed neuropathological follow-up results are presented; stent patency was revealed in the postmortem examination. The anatomic and pathophysiological considerations of basilar artery stent placement for the treatment of acute basilar artery occlusion related to atherosclerotic stenosis are discussed.

Hypertrophic olivary degeneration: case report in a child

We report a case of hypertrophic olivary degeneration (HOD) detected by MRI, in a 14-year-old girl, 13 months after surgical excision of a brainstem cavernous malformation. As in vivo diagnosis of this condition has only become possible with the advent of MRI, the number of reported cases remains relatively small and they are almost exclusively in adults. Many radiologists and particularly paediatric radiologists, may therefore be unfamiliar with this entity. To our knowledge, this is the first specific report of HOD diagnosed by MRI in a child.

Improved imaging of the spinal cord in multiple sclerosis using three-dimensional fast spin echo

We report assessment of a new three-dimensional fast spin echo (3D FSE) sequence in ten patients with clinically definite multiple sclerosis, comparing it with standard 2D FSE, and in ten normal controls. We saw 29 focal lesions on the 2D images and 53 on the 3D FSE images (P = 0.05); none were seen in controls. Lesion length was significantly smaller on the 3D FSE than on to the 2D FSE images (3D: 1.36; 2D 2.0; P = 0.03). This may relate in part to separation into several lesions on the 3D images of confluent abnormal signal seen on 2D and in part to detection of small lesions missed by the thicker 2D FSE slices (3 mm compared to 1.5 mm). The 3D FSE sequence looks promising in improving spinal cord imaging.

Transmural migration of an intracavernous carotid detachable balloon used to control surgically induced haemorrhage

We report a case in which a balloon detached in the carotid siphon for control of iatrogenic bleeding migrated to the oesophagus. We discuss the pathophysiology.

How much now to tell? Patients' attitudes to an information sheet prior to angiography and angioplasty

A prospectively controlled pilot study of 100 patients undergoing an invasive radiological procedure was undertaken to test patients' acceptance of risk disclosure and whether this increases anxiety and rate of procedure cancellation. Two sheets with differing amounts of information on adverse outcome were randomly allocated and patients provided a graded response to statements following the procedure. Eighty-one completed questionnaires were received (brief sheet n = 40; long sheet n = 41). There were 19 non-compliers with main causes either due to lack of interest or problems such as language difficulties, visual impairment and dementia. There were no significant differences between the two groups with respect to subjective anxiety caused by the information or risk of procedure cancellation. This preliminary work has shown that information sheets are well accepted and provide a simple, standardized format for risk disclosure.