Ethmoidal dural arteriovenous fistulae: an assessment of surgical and endovascular management

OBJECTIVE

Endovascular treatment of ethmoidal dural arteriovenous fistulae (DAVFs) has become technically feasible, but its relative risks and benefits have not justified its use. We present a series of patients with ethmoidal DAVFs treated almost exclusively with surgery at an institution where expert endovascular therapy was available. Surgical risks, treatment efficacy, and patient outcomes were determined for comparison with published endovascular data.

METHODS

Sixteen patients with ethmoidal DAVFs were treated during a 17-year period from 1982 to 1999. In three patients, feeding arteries from the internal maxillary artery were embolized; no ophthalmic artery embolizations were performed. A low bifrontal surgical approach was used in most patients to expose, coagulate, and divide the fistulous site.

RESULTS

Ethmoidal DAVFs were occluded grossly and angiographically in all 16 patients. There was no treatment-associated neurological morbidity, and clinical outcomes were good in all but one patient who was comatose initially.

CONCLUSION

Review of our surgical experience with ethmoidal DAVFs as well as published endovascular results for these lesions suggests that endovascular management of ethmoidal DAVFs has a small but clinically significant risk to vision, is rarely effective in curing the fistula, and does not eliminate the need for surgery. In contrast, surgical management has no associated risk to vision, is highly effective at obliterating the fistula, and can contribute to good clinical outcomes in most patients. For these reasons, surgical management of ethmoidal DAVFs remains the treatment of choice.

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.

Endovascular therapy of traumatic injuries of the intracranial cerebral arteries

Traumatic intracranial arterial injuries represent uncommon complications of both closed-head injury and penetrating head trauma. These injuries include arterial dissections, pseudoaneurysms, and fistulas, both direct and indirect. Although these lesions may be identified while still asymptomatic, they usually present in a delayed fashion with intracranial hemorrhage, focal cerebral ischemia, or, occasionally, severe epistaxis. Endovascular therapy has assumed a major role in the management of this diverse group of lesions. Embolization of pseudoaneurysms with balloons or detachable coils, the use of embolic particles for small arterial injuries, and large vessel occlusion with detachable balloons represent current treatment strategies that have evolved over the past three decades. Angioplasty and stent deployment may have a future role to play in the management of arterial dissection. Principles of neurologic critical care that minimize secondary brain injury are essential adjuncts in the management of these patients before, during, and after endovascular treatment.

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.

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.

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.

Endovascular treatment of mural-type vein of Galen malformations

OBJECT

In this study the authors report on the results of endovascular treatment for mural-type vein of Galen malformations (VGMs) in a group of infants.

METHODS

Eight children (six infants and two neonates) who suffered from symptoms caused by a mural-type VGM were treated by means of endovascular therapy. Their age at the time of treatment ranged from 13 days to 19 months (mean 7.6 months). Two neonates and three infants who presented with hydrocephalus and increased head circumference, one of whom was stabilized with a shunt, underwent elective closure of the malformations 3, 4, 6, 6, and 13 months later, respectively. Two patients presented with hemorrhage; one had an intraventricular hemorrhage (IVH) on the 1st day of life and one, a 5-month-old infant, suffered a large parenchymal hemorrhage and an IVH; both patients were immediately cured by means of endovascular techniques. One child presented with a seizure and cortical venous drainage that were treated immediately. Eleven separate treatment sessions were conducted; eight via transarterial femoral access and the remaining three via a transvenous approach. Two patients were treated by using transfemoral transvenous embolization with fibered coils, and one patient required a transtorcular transvenous approach to permit complete closure of the fistula with electrolytically detachable coils. The embolic devices used included silk suture emboli (three patients), electrolytically detachable coils (three patients), and fibered platinum coils (seven patients). In seven patients, complete closure was demonstrated on postembolization arteriographic studies. The eighth patient had stagnant flow in a giant 6-cm varix treated with arterial and venous coils but has not yet undergone follow-up studies. Late follow-up arteriography was performed in four patients at times ranging from 11 to 24 months postprocedure. In one patient, thrombosis of the malformation and shrinkage of the varix were confirmed on follow-up computerized tomography scanning. The remaining three patients have not yet undergone follow-up angiographic examination. Two asymptomatic complications occurred, including separation of the distal catheter, which was removed with a snare device, and a single platinum coil that embolized to the lung, producing no symptoms in 101 months of clinical follow up. The follow-up period ranged from 3 to 105 months, with a mean of 52 months.

CONCLUSIONS

Endovascular therapy is the treatment of choice for mural-type VGMs and offers a high rate of cure with low morbidity.

Causes and management of aneurysmal hemorrhage occurring during embolization with Guglielmi detachable coils

OBJECT

The purpose of this review is to describe the incidence, causes, management, and outcome of aneurysmal hemorrhage that occurred in patients during endovascular treatment with the Guglielmi detachable coil (GDC) system.

METHODS

At the authors' institution between September 1991 and August 1995, more than 200 patients were treated using GDCs for intracranial aneurysms. The first 200 patients treated in this fashion were reviewed and all who experienced new subarachnoid hemorrhage (SAH) during the procedure were identified. Angiographic studies were also reviewed and patients were contacted for longer-term follow up when possible. Four patients who experienced intraprocedural SAH were identified. The causes of hemorrhage were believed to be perforation of the aneurysm by the guidewire in one patient, perforation by the microcatheter in a second, and perforation by the delivery wire in a third. The fourth patient had a hemorrhage during injection of contrast material for control angiographic studies after placement of the final coil. One patient died, but the other three experienced no neurological symptoms or recovered without acquiring additional deficits. Overall a procedural hemorrhage rate of 2% was seen, with permanent morbidity and mortality rates of 0% and 0.5%, respectively.

CONCLUSIONS

Although SAH during endovascular treatment of intracranial aneurysms remains a significant risk, its incidence is low and a majority of patients can survive without serious sequelae.

Endovascular treatment of mural-type vein of Galen malformations

OBJECT

In this study the authors report on the results of endovascular treatment for mural-type vein of Galen malformations (VGMs) in a group of infants.

METHODS

Eight children (six infants and two neonates) who suffered from symptoms caused by a mural-type VGM were treated by means of endovascular therapy. Their age at the time of treatment ranged from 13 days to 19 months (mean 7.6 months). Two neonates and three infants who presented with hydrocephalus and increased head circumference, one of whom was stabilized with a shunt, underwent elective closure of the malformations 3, 4, 6, 6, and 13 months later, respectively. Two patients presented with hemorrhage; one had an intraventricular hemorrhage (IVH) on the 1st day of life and one, a 5-month-old infant, suffered a large parenchymal hemorrhage and an IVH; both patients were immediately cured by means of endovascular techniques. One child presented with a seizure and cortical venous drainage that were treated immediately. Eleven separate treatment sessions were conducted; eight via transarterial femoral access and the remaining three via a transvenous approach. Two patients were treated by using transfemoral transvenous embolization with fibered coils, and one patient required a transtorcular transvenous approach to permit complete closure of the fistula with electrolytically detachable coils. The embolic devices used included silk suture emboli (three patients), electrolytically detachable coils (three patients), and fibered platinum coils (seven patients). In seven patients, complete closure was demonstrated on postembolization arteriographic studies. The eighth patient had stagnant flow in a giant 6-cm varix treated with arterial and venous coils but has not yet undergone follow-up studies. Late follow-up arteriography was performed in four patients at times ranging from 11 to 24 months postprocedure. In one patient, thrombosis of the malformation and shrinkage of the varix were confirmed on follow-up computerized tomography scanning. The remaining three patients have not yet undergone follow-up angiographic examination. Two asymptomatic complications occurred, including separation of the distal catheter, which was removed with a snare device, and a single platinum coil that embolized to the lung, producing no symptoms in 101 months of clinical follow up. The follow-up period ranged from 3 to 105 months, with a mean of 52 months.

CONCLUSIONS

Endovascular therapy is the treatment of choice for mural-type VGMs and offers a high rate of cure with low morbidity.

Congenital cardiac anomalies with vein of Galen malformations in infants

Published reports and personal experience are reviewed relating to patients under 1 year of age diagnosed with a vein of Galen malformation and congenital heart disease. Including five patients from this institution, a total of 23 patients (12 neonates) with congenital heart disease and a vein of Galen malformation have been reported. Six of these had sinus venosus atrial septal defect and nine had aortic coarctation.

Endovascular treatment of pseudoaneurysms with electrolytically detachable coils

PURPOSE

We describe the clinical presentation, angiographic findings, and clinical outcome in a group of patients with pseudoaneurysms treated by a new endovascular technique using Guglielmi electrolytically detachable platinum coils (GDCs).

METHODS

We retrospectively reviewed the angiographic and clinical findings in a series of 11 patients with pseudoaneurysms occurring in a variety of locations: seven in the cavernous carotid artery, one in the petrous carotid artery, two in the anterior cerebral artery, and one in the cervical vertebral artery.

RESULTS

All aneurysms were cured with GDC embolization. The only complication was a branch occlusion, which resolved with heparinization and produced no clinical sequelae.

CONCLUSION

Pseudoaneurysms can be safely and effectively treated by embolization with GDCs. Consideration needs to be given to the anatomic location of the pseudoaneurysm and the acuity of onset. Treatment efficacy may by improved if there are bony confines around the aneurysm or if therapy takes place in the subacute period, when the wall of the pseudoaneurysm has matured and stabilized.

Diagnosis and treatment of dural arteriovenous fistulas

Dural arteriovenous fistulas (DAVFs) are abnormal vascular connections located within the dura mater which are thought to be promoted by venous hypertension and venous sinus thrombosis. The symptoms associated with DAVFs depend on the direction and adequacy of venous drainage pathways, the amount of arteriovenous shunting and specific location of the fistula. Our experience over a period of eight years with 268 patients suffering from cranial DAVFs in the transverse, sigmoid, superior sagittal, ethmoidal, inferior and superior petrosal, cavernous, and marginal sinuses are presented. The clinical presentation, radiographic evaluation, and treatment modalities for DAVFs in each of these locations are summarized.

The effect of oestrogen on the development of arteriovenous fistulae induced by venous hypertension in rats

PURPOSE

Dural arteriovenous fistulae (AVF) represent abnormal communication between the meningeal arteries and the dural sinuses. Clinically, this condition appears more frequently in post-menopausal and pregnant women than in the general population. Oestrogen is believed to play an important role in the development of dural AVF; however, its exact role has not been clearly defined. We have previously reported that by surgically creating a carotid-jugular shunt in male rats, which then induces venous hypertension, spontaneous arteriovenous fistulae can result. To examine the specific role that oestrogen may have in the development of AVF induced by venous hypertension, we performed the following experimental procedure.

MATERIALS AND METHODS

Ninety-four Sprague-Dawley female rats (250-300 grams in weight) were randomly assigned to four different groups. Group 1 (n = 20): control (bilateral ovariectomy only). Group 2 (n = 19): bilateral ovariectomy and implantation of the oestrogen pellet (17-beta oestradiol 0.75 mg/pellet, 60 days release). Group 3 (n = 17): bilateral ovariectomy and venous hypertension (left carotid-jugular shunt with proximal jugular vein occlusion). Group 4 (n = 38): bilateral ovariectomy and oestrogen pellet implantation and venous hypertension. All of the groups were examined by angiography 60 days after treatment. In Groups 1 and 2, bilateral common carotid angiography was performed via a transfemoral route. In Groups 3 and 4, angiography was done after surgical ligation of the carotid-jugular shunt to examine for any newly developed AVF.

RESULTS

No newly developed AVF were found in either Groups 1, 2, or 3. In Group 4, 2 rats (5.3%) developed newly formed AVF which occurred in the nose and neck. Our previous study demonstrated that AVF appeared in 3 of 22 (13.6%) venous hypertensive male rats. Therefore, no statistical difference in the appearance rate of newly formed AVF was found among groups 1, 2, 3 or 4 and between our previously reported group of male venous hypertensive rats.

CONCLUSION

In this experimental study, ovariectomy with or without oestrogen did not affect the development of spontaneous AVF induced by venous hypertension.

Rapid development of giant fusiform cerebral aneurysms in angiographically normal vessels

Several reports have mentioned formation of new saccular aneurysms in previously normal-appearing vessels, but de novo fusiform aneurysms have not been reported. We describe three children who initially presented with giant fusiform aneurysms involving the cervical and petrous portions of the internal carotid artery and were treated with balloon occlusion. Between 2 and 6 years later, they were found to have new giant fusiform aneurysms in the vertebrobasilar system.

Preliminary experience with an electrolytically detachable fibered coil

We report our preliminary experience with a new embolic device, the electrolytically detachable fibered coil, in the treatment of four patients with high-flow arteriovenous shunting.

Neurologic manifestations of spinal epidural arteriovenous malformations

Eight patients with spinal epidural arteriovenous malformations presented with progressive myelopathy (3), hemorrhage (3), and tinnitus/bruits (2). MRI suggested a vascular malformation in four (of seven) patients. Spinal angiography was necessary for diagnosis. Treatment by endovascular embolic occlusion (with balloons, particles, or coils) (7 patients) or surgical resection (4 patients), or both, temporarily arrested progression of neurologic symptoms, but recurrence of symptoms in two patients was associated with development of collateral arterial supply to the malformation.

Epistaxis originating from traumatic pseudoaneurysm of the internal carotid artery: diagnosis and endovascular therapy

Posttraumatic pseudoaneurysm of the internal carotid artery (ICA) is an uncommon but potentially fatal cause of epistaxis. Because the onset of delayed bleeding from the time of injury is variable, prompt diagnosis of cavernous ICA pseudoaneurysm is often a clinical challenge. The relative urgency to evaluate for this disease is highlighted by the morbid nature of this entity. Optimal management demands rapid recognition and treatment to give the best functional outcome. The authors present a case series of six patients with skull base ICA pseudoaneurysm. A unifying feature in the majority of patients is the development of delayed, massive epistaxis. The time course for presentation of delayed life-threatening epistaxis ranged from 5 days to 9 weeks. Two patients exhibited the classic triad of unilateral blindness, orbital fractures, and massive epistaxis. All patients requiring intervention were successfully treated with endovascular embolization techniques that included detachable balloons and coils. The clinical and radiologic findings in this case series are presented. The relevant anatomy, diagnosis, and treatment of traumatic ICA pseudoaneurysm are reviewed. A contemporary treatment strategy is proposed.

Cavernous internal carotid artery aneurysms treated with electrolytically detachable coils

OBJECTIVES

To report the results of treatment of aneurysms involving the cavernous segment of the internal carotid artery treated with a new device, the electrolytically detachable platinum coil.

MATERIALS AND METHODS

Between 1991 and 1995, 220 patients with intracranial aneurysms were treated with the electrolytically detachable platinum coils. Thirty-five patients (16%) harbored aneurysms involving the cavernous segment of the internal carotid artery and are the subject of this report. The presenting symptoms were cranial nerve palsies in 19 (54%), epistaxis in 4 (11%), and subarachnoid hemorrhage in 3 (9%). The age ranged from 31 to 80 years, with a mean of 58 years, and included 26 women and 9 men. The aneurysm size ranged from 5 to 22 mm, with an average of 11.6 mm.

RESULTS

Of the seven patients who presented with bleeding (epistaxis in four, subarachnoid bleeding in three), none had bleeding after treatment. Of patients who presented with cranial nerve palsy, 58% had complete resolution of signs and symptoms and 38% showed dramatic improvement. Only one patient who presented with severe visual loss and optic atrophy was slightly worse after treatment. Two patients died from causes unrelated to their cavernous aneurysms or their endovascular treatment.

CONCLUSIONS

In patients who harbor a symptomatic aneurysm arising from the cavernous segment of the internal carotid artery with a definable neck, electrolytically detachable coils offer an excellent treatment modality that permits aneurysm closure with preservation of flow in the carotid artery.

Intravascular stent and endovascular coil placement for a ruptured fusiform aneurysm of the basilar artery. Case report and review of the literature

The authors demonstrate the technical feasibility of using intravascular stents in conjunction with electrolytically detachable coils (Guglielmi detachable coils [GDCs]) for treatment of fusiform, broad-based, acutely ruptured intracranial aneurysms and review the literature on endovascular approaches to ruptured aneurysms and cerebral stent placement. A 77-year-old man presented with an acute subarachnoid hemorrhage of the posterior fossa. A fusiform aneurysm with a broad-based neck measuring 12 mm and involving the distal vertebral artery (VA) and proximal third of the basilar artery (BA) was demonstrated on cerebral angiography. The aneurysm was judged to be inoperable. Six days later a repeated hemorrhage occurred. A 15-mm-long intravascular stent was placed across the base of the aneurysm in the BA and expanded to 4 mm to act as a bridging scaffold to create a neck. A microcatheter was then guided through the interstices of the stent into the body and dome of the aneurysm, and GDCs were deposited for occlusion. The arteriogram obtained after stent placement demonstrated occlusion of the main dome and body of the aneurysm. The coils were stably positioned and held in place by the stent across the distal VA and BA fusiform aneurysm. Excellent blood flow to the distal BA and posterior cerebral artery was maintained through the stent. There were no new brainstem ischemic events attributable to the procedure. No rebleeding from the aneurysm had occurred by the 10.5-month follow-up evaluation, and the patient has experienced significant neurological improvement. Certain types of intracranial fusiform aneurysms may now be treated by combining intravascular stent and GDC placement for aneurysm occlusion via an endovascular approach. This is the first known clinical application of this novel approach in a ruptured cerebral aneurysm.

Dural arteriovenous fistulas of the marginal sinus

PURPOSE

To investigate the clinical presentation, angiographic findings, endovascular management and clinical outcome in dural arteriovenous fistulas (DAVFs) of the marginal sinus.

METHODS

Fourteen patients with DAVFs of the marginal sinus were identified from angiographic studies and medical records of all patients treated for DAVFs at our institution between July 1990 and August 1995. The endovascular treatment and clinical outcomes of these patients are reported.

RESULTS

Eleven patients had pulse-synchronous bruit, two had intracranial hemorrhage, and one had ataxia. Thirteen patients were cured with endovascular techniques alone and one was cured by a combination of preoperative embolization followed by surgical obliteration of the fistula. The sole complication of treatment was a partial left hypoglossal nerve palsy, which resolved spontaneously.

CONCLUSION

DAVFs of the marginal sinuses are potentially life-threatening lesions that can be treated with endovascular techniques for a high rate of cure and a low rate of morbidity.

Endovascular therapy for the carotid artery

Endovascular therapy is well established as the preferred method of treatment for surgically inaccessible lesions of the carotid artery. Its role in the treatment for cavernous carotid fistulas and aneurysms of the cervical, petrous, and cavernous carotid arteries is discussed. Angioplasty is under investigation in the management of symptomatic atherosclerotic disease. The evolving role of angioplasty and stenting in the treatment of these lesions is reviewed.

The role of angiogenic factor bFGF in the development of dural AVFs

PURPOSE

Dural arteriovenous fistulas (dAVFs) are known to be acquired disorders. Angiogenic stimulants, such as basic fibroblast growth factor (bFGF), may be involved in the evolution of this disorder. We examined the appearance and localization of bFGF, in human dAVF sinuses, versus a control using immunohistochemical techniques, to evaluate these qualitative differences.

PATIENTS AND METHODS

Four human dural sinuses from dAVF patients, and one control dural sinus were removed at surgery or autopsy and used for this study. Immunohistochemistry for bFGF was performed in all five specimens to identify its appearance and localization. Immunohistochemistry for alpha smooth muscle actin, factor VII related antigen, and macrophage (CD-68) were done in all tissues to identify the bFGF positive cell types.

RESULTS

In the control dural sinus, there was negative staining by bFGF immunohistochemistry. However, in all four sinuses of the dAVF patients, smooth muscle cells, endothelial cells, and meningeal cells were stained positively in various degrees by bFGF immunohistochemistry.

CONCLUSION

bFGF may be significant in the development of dAVFs, judging from its strong immunoreactivity in the sinuses of dAVF patients.

Endovascular surgical approach to intracranial vascular diseases

PURPOSE

The endovascular surgical approach to complex disorders of the central nervous system has made rapid and significant advancements over the past decade. Patients with intracranial arterial aneurysms, traumatic carotid and vertebral artery lesions, including fistulas and pseudoaneurysms, hemodynamically significant atherosclerotic lesions, vasospasm, and acute stroke are now being approached and treated by newer and less invasive techniques, including cerebral angioplasty and thrombolytic therapy.

METHODS

All procedures are usually performed from a transfemoral approach utilizing a variety of occlusion devices, including detachable silicone balloons, microcoils, electrolytic detachable coils, liquid tissue adhesives, and particulate emboli for vessel occlusion. For dilatation and reperfusion of vessels, balloon angioplasty catheters, stents, and thrombolytic drugs are being used.

RESULTS

For the treatment of traumatic vascular injuries, such as carotid cavernous sinus fistulas and vertebral arteriovenous fistulas and pseudoaneurysms, endovascular therapy has become the treatment of choice. The endovascular approach for intracranial aneurysms is emerging as a therapeutic option in selected cases. For occlusive disorders in patients presenting with acute cerebral ischemia, extracranial angioplasty and cerebral thrombolysis techniques are currently under investigation.

CONCLUSIONS

As these techniques continue to evolve, the field of interventional neuroradiology will expand the therapeutic options for managing complex cerebrovascular disorders and improve patient outcome in acute stroke therapy.

Transluminal angioplasty for arteriosclerotic disease of the distal vertebral and basilar arteries

OBJECTIVE

Percutaneous transluminal angioplasty (PTA) for the distal vertebral and basilar artery is now being performed in selected patients with haemodynamically significant lesions of the posterior cerebral circulation. Its effect and overall results were examined.

PATIENTS AND METHODS

A balloon dilatation catheter specifically developed for these procedures, with a 2.0-3.5 mm balloon diameter, at 6 atmospheres of pressure, was used. Angioplasty was performed in 12 patients (including six whose initial results have been reported) with angiographically documented stenotic lesions involving either the intracranial vertebral artery (C1-C2 portion) or the basilar artery, and satisfying the following criteria: (1) clinical symptoms suggestive or consistent with a transient ischaemic attack refractory to medical treatment, or small infarction of the posterior circulation; and (2) angiographically documented stenosis greater than 70%. Two of 12 patients had complete thrombosis of the distal vertebral and basilar artery and PTA was performed after successful intra-arterial thrombolysis.

RESULTS

Successful results, without complications, were obtained in eight patients, with complete resolution of vertebrobasilar ischaemic symptoms. Immediate complications occurred in four patients including two with vessel dissection, and two with thromboembolism. The two patients with acute arterial dissection were reoperated but developed small infarctions with permanent neurological deficits. The two patients with thromboembolic complication showed transient neurological deficit. The overall stenosis ratio decreased from a mean of 84% pretreatment to 44% after the angioplasty procedure. Restenosis occurred in two patients. Long term clinical follow up in 11 patients who survived more than six months showed resolution of ischaemic symptoms after PTA in all except for one with a restenosis who had recurrent transient ischaemic attacks.

CONCLUSION

Transluminal angioplasty may be an effective procedure to treat vertebrobasilar ischaemia secondary to high grade arteriosclerotic disease affecting either the distal vertebral or basilar artery regions that do not respond to medical treatment.

Endovascular treatment of basilar tip aneurysms using electrolytically detachable coils

Preliminary experience using electrolytically detachable coils to treat basilar tip aneurysms in 33 patients is described. The most frequent presentation was subarachnoid hemorrhage (SAH) in 23 patients. All patients were referred after neurosurgical assessment and exclusion as candidates for surgical clipping of their aneurysms. At the time of initial treatment complete aneurysm occlusion was achieved in seven (21.2%) of 33 patients. In 17 of the patients (51.5%), greater than 90% but less than 100% aneurysm occlusion was achieved. Angiographic follow up (mean 11.7 months) was available in 19 patients. At follow- up angiography four (21%) of 19 aneurysms were 100% occluded and 12 (63.2%) of 19 were more than 90% but less than 100% occluded. The mean clinical follow-up time in treated patients surviving beyond the initial treatment period is 15 months. One patient suffered major permanent morbidity from thrombosis of the basilar tip region a few hours after coil placement. One patient treated following SAH experienced further hemorrhage 6 months later. No other patient suffered direct or indirect permanent morbidity as a consequence of this method of treatment. The authors believe that this technique is a reasonable alternative for patients who are not candidates for conventional surgical treatment or in whom such treatment has failed. This study's follow-up period is brief and greater experience with long-term follow-up study is mandatory.

Treatment of massive posterior epistaxis by detachable coil embolization of a cavernous internal carotid artery aneurysm

We present a case of massive posterior epistaxis caused by a cavernous internal carotid artery aneurysm. This lesion was treated with endovascular placement of electrolytically detachable platinum embolization coils. The treatment resulted in cessation of epistaxis until the patient's death 3 months following embolization. We discuss aspects of using these above coils for this condition.

Endovascular management of biopsy-related posterior inferior cerebellar artery pseudoaneurysm

We present a case of a posterior inferior cerebellar artery pseudoaneurysm with subarachnoid hemorrhage resulting from a transoral head and neck tumor biopsy. The pseudoaneurysm was managed using transcatheter coil embolization.

Spinal dural arteriovenous fistulas supplied by branches of the internal iliac arteries

Spinal dural arteriovenous fistulas are abnormal arteriovenous connections on the surface of the dura. They are supplied by branches of intercostal, lumbar, vertebral, middle sacral, or subclavian arteries and rarely by branches of the internal iliac arteries. We present four cases of spinal dural arteriovenous fistulas supplied exclusively by branches of the internal iliac artery in which the clinical and magnetic resonance presentation were not suggestive of this unusual supply. In our experience, internal iliac artery supply was observed in 12.5% of cases of spinal dural arteriovenous fistulas. We recommend that selective internal iliac arteriography be included in the angiographic evaluation of patients suspected of having a spinal dural arteriovenous fistula.

Interventional neurovascular techniques in the treatment of stroke--state-of-the-art therapy

Interventional neurovascular techniques for the treatment of patients presenting with symptoms of acute or impending stroke, are now being utilized with increasing frequency in three major areas. (i) For patients presenting with cerebrovascular ischaemic symptoms due to haemodynamically significant stenosis from atherosclerosis, vasculitis, intimal hyperplasia, and dissection, cerebral percutaneous transluminal angioplasty has been shown to be beneficial for both extracranial and intracranial disease. (ii) Patients with acute, embolic occlusion of the internal carotid, middle cerebral, distal vertebral, and basilar arteries have been successfully treated by placement of microcatheters directly into the thrombus with successful thrombolysis, recanalization, and reperfusion to the distal ischemic brain. (iii) Acute arterial vasospasm secondary to subarachnoid haemorrhage is now being managed by balloon angioplasty in those instances where conventional medical therapy has failed. These techniques are altering our current management and broadening the therapeutic alternatives for patients who present with acute cerebrovascular insufficiency and stroke in evolution. As wider experience is gained in these techniques, the clinical indications for their use will also broaden.

Interventional neurovascular techniques for cerebral revascularization in the treatment of stroke

Recent advances in interventional neurovascular radiology have altered the management of cerebrovascular diseases by providing alternative treatments in three areas. (1) Cerebral percutaneous transluminal angioplasty is being used more often as an alternative to surgical endarterectomy or bypass grafting for patients with high-grade vascular stenosis of the innominate, subclavian, carotid, vertebral, and intracranial blood vessels. To date, the success rate has been greater than 90%, with less than 10% morbidity. (2) Transluminal angioplasty and local infusion of antispasmodic drugs are being used to treat patients with severe angiographic vasospasm unresponsive to conventional medical therapy. Intracranial arterial vasospasm due to subarachnoid hemorrhage has remained a leading cause of delayed morbidity and mortality. Neurologic improvement, defined as improvement in the Hunt and Hess neurologic grading scale, has been shown in 60-80% of the patients so treated. (3) Local intraarterial fibrinolysis has been beneficial for patients with acute thromboembolic occlusion in both intracranial arteries and the cerebral dural sinuses. Preliminary studies indicate that early revascularization is associated with improved neurologic outcome. This review delineates the current state of the art in interventional neurovascular techniques for treating patients with stroke in evolution and patients with signs and symptoms of impending stroke due to vascular stenosis or occlusion. These techniques for cerebral revascularization are under investigation as potential life-saving therapy when conventional medical or surgical treatment has failed. As more experience is gained, the results of controlled clinical trials become available, and technical improvements evolve, these procedures will decrease the morbidity and mortality associated with strokes.

Thrombolytic therapy in acute stroke

PURPOSE

To report the safety and efficacy of local, direct, intra-arterial and intravenous fibrinolysis treatment in selected cases of clinically symptomatic patients with acute occlusion of the intracranial cerebral arteries and dural sinuses.

METHODS

Patients with acute progressive neurological deterioration, in spite of systemic anticoagulation and/or antiplatelet medications, presenting with occlusion of a major intracranial cerebral artery or dural sinus were tested. From a transfemoral approach through a guiding catheter, a 2.5F microcatheter was guided directly into the intracranial cerebral circulation and embedded within the clot. Infusion of urokinase was then performed directly into the thrombus until lysis was attained.

RESULTS

In 36 total patients, 27 cases were treated for an acute arterial occlusion in 45 vascular territories. Clinically, there was neurological improvement in 18 (66.7%) cases. Complications directly related to therapy included symptomatic intracranial hemorrhage in three cases (11.1%), which included 1 case (3.7%) of vessel perforation. In 8 (29.6%) patients, there was no evidence of clinical improvement, and in long-term follow-up there were 9 (33.3%) patient deaths. Nine patients were treated for an intracerebral dural sinus thrombosis in ten vascular territories by local urokinase infusion. In 7 (77.8%) cases, there was angiographic evidence of clot lysis and clinical improvement of the patient's neurological condition. Minor complications including infection and noncerebral sites of bleeding occurred in 3 (33.3%) patients, requiring adjustment in urokinase infusion therapy.

CONCLUSION

Local, direct intra-arterial or intravenous infusion of thrombolytic drugs for treatment of stroke patients may improve overall patient morbidity and mortality related to acute thromboembolic disease in the central nervous system. Further clinical studies are warranted to evaluate this form of therapy.

Intracranial aneurysms. Evolution and future role of endovascular techniques

Treatment of patients with an intracranial aneurysm by interventional neurovascular techniques has made tremendous advances over the past decade. Innovative occlusion devices have included detachable latex and silicone balloons, liquid polymers, intravascular lasers, and stents. As this technology continues to evolve, treatment options will expand and morbidity will continue to decline. The indications for treatment using minimally invasive surgical techniques will alter current management for these difficult and challenging vascular disorders.

Treatment of dural sinus thrombosis by urokinase infusion

PURPOSE

To gain a preliminary understanding of the role of thrombolytic therapy for the thrombosed dural sinus, we retrospectively reviewed our initial experience.

METHODS

Seven patients, ages 25 to 71, who presented with symptomatic dural sinus thrombosis and who failed a trial of medical therapy were treated with direct infusion of urokinase into the thrombosed sinus. Patients received urokinase doses ranging from 20,000 to 150,000 U/h with a mean infusion time of 163 hours (range 88 to 244 hours).

RESULTS

Patency of the affected dural sinus was achieved with antegrade flow in all patients. Six patients either improved neurologically over their prethrombolysis state or were healthy after thrombolysis; one of them required angioplasty. The other patient improved after surgical repair of a residual dural arteriovenous fistula. The only complications were an infected femoral access site which resolved after treatment with antibiotics and hematuria which cleared after discontinuation of anticoagulation.

CONCLUSIONS

Thrombolysis of the thrombosed dural sinus shows promise as a safe and efficacious treatment. The results of this study should provide the impetus for further research.

Development of acquired arteriovenous fistulas in rats due to venous hypertension

Dural sinus thrombosis has been hypothesized as a possible cause of dural arteriovenous fistulas (AVF's). The pathogenesis and evolution from thrombosis to actual development of an AVF are still unknown. To study dural fistula formation, a surgically induced venous hypertension model in rats was created by producing an arteriovenous shunt between the carotid artery and the external jugular vein. The external jugular vein beyond the anastomosis was ligated 2 to 3 months after surgery and angiography was performed to identify any new acquired AVF's. Forty-six male Sprague-Dawley rats, each weighing approximately 300 gm, were used for this study. In Group I, 22 rats underwent a common carotid artery anastomosis to the external jugular vein, which is the largest draining vein from the transverse sinus via the posterior facial vein, followed by proximal external jugular vein ligation. In Group II, 13 rats underwent the same surgical procedure, followed by contralateral posterior facial vein occlusion. Group III served as the control group, in which 11 rats underwent only unilateral external jugular vein occlusion with or without contralateral posterior facial vein occlusion. The shunts in Groups I and II were ligated at 2 to 3 months following surgery, and transfemoral angiography was performed immediately before and after occlusion. New acquired AVF's had developed in three rats (13.6%) in Group I, three rats (23.1%) in Group II, and no rats (0%) in Group III. One of these newly formed fistulas was located at the dural sinus, analogous to the human dural AVF. The other five were located in the subcutaneous tissue, including the face and neck. The dural AVF in the rat was present on follow-up angiography at 1 week after the bypass occlusion. It is concluded that chronic venous hypertension of 2 to 3 months' duration, without associated venous or sinus thrombosis, can induce new AVF's affecting the dural sinuses or the subcutaneous tissue.

The efficacy of endosaccular aneurysm occlusion in alleviating neurological deficits produced by mass effect

Endovascular obliteration of intracranial aneurysms with preservation of the parent artery (endosaccular occlusion) has been advocated for patients who fail or are excluded from surgical clipping and cannot undergo Hunterian ligation therapy. To clarify the effect that endosaccular occlusion has on the presenting neurological signs, 26 patients with aneurysms and symptoms related to mass effect who underwent this therapy were followed for a mean of 60 months. Only patients with objective neurological deficits who had not suffered a hemorrhage were included in this series. Response to therapy was classified into one of three groups: "resolved," if the patient had complete resolution of presenting signs; "improved," if significant and sustained improvement was recorded in the neurological examinations, and "unchanged," if no change was observed. Thirteen patients (50%) were classified as resolved, 11 (42.3%) as improved, and two (7.7%) as unchanged. A comparison of patients classified as resolved with those who were improved revealed that the former group had less wall calcification (30% vs. 60%) and a shorter duration of symptoms. Patients with neurological sign resolution (62%) were more likely to have totally occluded aneurysms on late follow-up arteriograms than those who had improvement (28%) or were unchanged (0%). This study suggests that endosaccular embolization therapy can improve or alleviate presenting neurological signs unrelated to hemorrhage or distal embolization in the majority of cases.

Endovascular platinum coil embolization of incompletely surgically clipped cerebral aneurysms

The natural history of incompletely clipped intracranial aneurysms is largely unknown. The authors present two cases of residual aneurysm filling after surgical clipping which were successfully managed by intravascular placement of platinum coils. Management of residual aneurysms and possible future role of transcatheter therapy are discussed.

Treatment of giant intradural (perimedullary) arteriovenous fistulas

Ten patients with giant intradural spinal arteriovenous fistulas (perimedullary Types II and III) were treated with embolization alone (three patients) or in combination with surgery (seven patients). Their ages at the time of treatment ranged from 2 to 40 years, with a mean of 19.5 years. The indications for treatment included progressive myelopathy in five patients, spinal subarachnoid hemorrhage in four, and acute paraplegia in one. Associated conditions included Rendu-Osler-Weber syndrome in two patients, and Cobb's syndrome in two patients. In one patient, the cause of the fistula may have been related to epidural anesthesia traumatizing a low tethered cord. Angiographically, the fistulas were subclassified in three groups: a single-hole fistula supplied by a single feeding medullary artery (three patients); a single-hole fistula supplied by multiple medullary arteries (three patients); and multiple separate fistulas supplied by multiple medullary arteries (four patients). Eight patients were classified as perimedullary Type III and two as perimedullary Type II. Embolic agents were delivered from transarterial routes in 14 procedures and transvenous routes in 2 procedures. A total of 16 embolizations and 8 operations were performed in 10 patients. Seven patients were cured of their fistula (as demonstrated by angiography), two patients had 5% residual filling and are scheduled for future therapy. One refused a follow-up angiographic examination. Complications related to embolization included rupture of the anterior spinal artery by a detachable balloon, resulting in transient worsening of paraplegia with recovery to baseline. Transient worsening of symptoms after surgery was common, but all patients returned to baseline or better. Dramatic improvement was observed in four patients.(ABSTRACT TRUNCATED AT 250 WORDS)