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)