Treatment of Extracranial and Intracranial Aneurysms and Arteriovenous Fistulae Using Stent Grafts

Placement of covered stents for the treatment of direct carotid cavernous fistulas

BACKGROUND AND PURPOSE

Endovascular detachable balloon occlusion and coil occlusion are 2 well-established options for the treatment of direct carotid cavernous fistulas (DCCFs). In recent years, covered stents have been applied in the treatment of neurovascular pathologies such as aneurysms, pseudoaneurysms, arterial dissections, and DCCFs. The purpose of this study was to investigate the clinical efficacy of covered stents for the treatment of DCCFs.

MATERIALS AND METHODS

Ten consecutive patients underwent covered-stent placement after failure of detachable balloon occlusion for the treatment of their DCCFs. Clinical and angiographic follow-up ranged from 5 to 48 months (mean, 18.2 months) after stent placement.

RESULTS

Stent placement was technically successful in all except 1 patient. In this patient, stent placement failed after multiple attempts because of rigidity of the Jostent GraftMaster Coronary Stent Graft and the tortuous anatomy of the internal carotid artery (ICA). Complete exclusion of the fistula was achieved in 6 patients immediately after stent deployment. Endoleak was observed in 3 patients. Re-dilation of the stent avoided the endoleak in 2 patients; in 1 of these 2 patients, formerly improved symptoms recurred the next morning and the ipsilateral ICA was occluded with detachable balloons. Spasm of the ICA was observed in most of the patients after stent placement; however, angioplasty was not required. Symptoms improved in all patients after treatment, without thromboembolic events. Follow-up cerebral angiography showed complete exclusion of all DCCFs and stent patency without intrastent stenosis in the 8 patients who had successful deployment of the stent.

CONCLUSIONS

Although a larger sample and expanded follow-up are needed, our series shows that covered stents can be used in the treatment of DCCFs with symptomatic relief.

Application of covered stent grafts for intracranial vertebral artery dissecting aneurysms

Object

Utilization of covered stent grafts in treating neurovascular disorders has been reported, but their efficacy and safety in vertebral artery (VA) dissecting aneurysms needs further investigation.

Methods

Six cases are presented involving VA dissecting aneurysms that were treated by positioning a covered stent graft. Two aneurysms were located distal to the posterior inferior cerebellar artery, and 4 were located proximal to the posterior inferior cerebellar artery. Aspirin as well as ticlopidine or clopidogrel were administered after the procedure to prevent stent-related thrombosis. All patients were followed up both angiographically and clinically.

Results

Five of the 6 patients underwent successful placement of a covered stent graft. The covered stent could not reach the level of the aneurysm in 1 patient with serious vasospasm who died secondary to severe subarachnoid hemorrhage that occurred 3 days later. Patient follow-up ranged from 6 to 14 months (mean 10.4 months), and demonstrated complete stabilization of the obliterated aneurysms, and no obvious intimal hyperplasia. No procedure-related complications such as stenosis or embolization occurred in the 5 patients with successful stent graft placement.

Conclusions

Although long-term follow-up studies using a greater number of patients is required for further validation of this technique, this preliminary assessment shows that covered stent graft placement is an efficient, safe, and microinvasive technique, and is a promising tool in treating intracranial VA dissecting aneurysms.

Diagnosis and Management of Traumatic Pseudoaneurysm of the Carotid Artery: Case Report and Review of the Literature

Injury to the carotid artery can occur in the setting of blunt and penetrating trauma. Such injury can result in pseudoaneurysm formation. We present a case of posttraumatic common carotid pseudoaneurysm (PTCP) that was diagnosed and treated 2 months after a motor vehicle accident and review the literature on the presentation, diagnosis, and management of PTCP.

Endovascular stent-graft treatment of a traumatic vertebral artery pseudoaneurysm and vertebrojugular fistula

An endovascular intervention is a feasible alternative to the technically challenging conventional surgery for the treatment of traumatic vertebral arterial lesions. This report describes a rare case involving a 22-year-old patient with a traumatic vertebral arterial pseudoaneurysm and multiple arteriovenous fistulas which were successfully sealed using the endovascular stent-graft technique.

Stent graft treatment of cerebrovascular wall defects: intermediate-term clinical and angiographic results

OBJECTIVE

Endovascular stent graft (SG) deployment offers a useful vessel-preserving strategy for vascular wall lesions such as pseudoaneurysms and fistulae. Although deployment of expanded polytetrafluoro-ethylene-covered SGs within the carotid and vertebral arteries is technically feasible, data on long-term efficacy, safety, and patency rate remain sparse.

METHODS

Six patients with traumatic (n = 4), iatrogenic (n = 1), or spontaneous (n = 1) internal carotid and vertebral artery injuries (direct carotid-cavernous fistula, n = 2; pseudoaneurysms, n = 4) were treated with nine balloon-mounted coronary expanded polytetrafluoro-ethylene SGs. Angiographic (mean, 2.3 yr; range, 1.7-4.2 yr) and neurological follow-up (mean, 2.7 yr) was performed for all patients.

RESULTS

Complete angiographic exclusion of the lesion was achieved by the initial procedure in five of the six patients; one ruptured cavernous carotid aneurysm leading to a direct carotid-cavernous fistula showed persistent slow shunting despite tandem deployment of two SGs. All six patients revealed complete and persistent angiographic obliteration at delayed follow-up, with minimal in-stent stenosis (<20%) seen in two instances. Difficulty with SG navigation was encountered in five patients, resulting in one instance of guide catheter-induced intimal dissection. Type I endoleak was observed in five patients, requiring secondary angioplasty in four patients and deployment of an additional tandem SG in three.

CONCLUSION

Technical challenges in current-generation SG deployment include sizing, navigation, positioning, and propensity for endoleak. When managed successfully, stent grafting provides a valuable approach for the treatment of vascular wall defects for which vessel preservation is preferred. Intermediate-term safety is satisfactory, with no delayed complications and minimal in-stent stenosis in follow-up periods of more than 2 years.

Procedural Safety and Potential Vascular Complication of Endovascular Recanalization for Chronic Cervical Internal Carotid Artery Occlusion

Background— Patients with chronic cervical internal carotid artery occlusion (ICAO) and cerebral ischemia may benefit from revascularization. The feasibility of endovascular recanalization for chronic ICAO has been reported recently, but its safety is still unproven. We report the follow-up results of 54 chronic ICAO patients who underwent endovascular recanalization, focusing on potential vascular complications and corresponding management.

Methods and Results— Endovascular recanalization for chronic ICAO was attempted in 54 consecutive patients (48 men; 69.2�9.8 years old) with either recurrent neurological deficit or objective ipsilateral hemisphere ischemia. Mean duration from occlusion documentation to the procedure was 237�327 days (range, 56 to 1424 days). Adverse events while in the hospital and during the 3-month follow-up were recorded. Successful recanalization was achieved in 35 of 54 patients (65%). Three-month cumulative stroke and death rate was 4% (2 of 54), including 1 in-hospital fatal nonipsilateral stroke and 1 in-hospital minor ipsilateral stroke secondary to systemic hypotension. Vascular complications developed in 3 of 54 patients (6%), including 1 late pseudoaneurysm formation 3 months after recanalization, 1 immediate carotid-cavernous fistula after recanalization, and 1 minor extravasation at carotid bifurcation after failed recanalization. However, no clinical sequela was noted with close follow-up and adequate management.

Conclusion— Certain immediate or delayed vascular complications may develop during or after the endovascular recanalization for chronic ICAO. Although periprocedural death and stroke rate is limited in our study, further study combining neuroimaging tools and cognitive function evaluation is mandatory to assess its utility and appropriateness in patients with chronic ICAO.

Endovascular treatment of giant intracranial aneurysms with willis covered stents: technical case report

OBJECTIVE

To evaluate the efficacy of endovascular treatment of giant intracranial aneurysms with Willis covered stents (Micro-Port, Shanghai, China).

CLINICAL PRESENTATION

The endovascular treatment of two cases of giant intracranial aneurysm was successfully accomplished by the placement of Willis covered stents specially designed for intracranial use. Both patients presented with symptoms of cavernous mass effect that resulted from a giant aneurysm in the cavernous segment of the internal carotid artery.

INTERVENTION

Three Willis covered stents were successfully placed in two patients. Immediate postprocedure angiograms demonstrated some endoleak of the aneurysms. In one patient, the endoleak was eliminated and complete exclusion of the aneurysms was confirmed with follow-up angiography. However, the other patient required the placement of a new Willis covered stent.

CONCLUSION

The use of covered stents in intracranial vascular structures is a feasible method to treat selected cases of intracranial giant aneurysms. It is suggested that patients who present with compressive mass effect caused by large or giant aneurysms are the best candidates for covered stent placement, but potential complications should be considered carefully before the stenting procedure.

Combined covered stent and onyx treatment for complex dural arteriovenous fistula involving the clivus and cavernous sinus

BACKGROUND

Complex DAVFs involving both the clivus and cavernous sinus are rare, especially when associated with brainstem compression from a large varix. In this report, we describe the use of a covered stent in combination with a liquid embolic agent to cure a complex clival-cavernous DAVF.

METHODS

A 46-year-old man presented with 6 months of dizziness, dysphagia, and progressive dysarthria. Magnetic resonance imaging showed tortuous and enlarged right cavernous and preclival flow voids. There were also bilateral prepontine varices compressing the ventral pons, which led to marked dorsal pontine edema. A cerebral angiogram revealed a clival DAVF supplied by multiple branches of the right ECA, as well as the MHT of the right ICA.

RESULTS

An endovascular cure was achieved by deploying a covered stent in the right cavernous ICA, followed by transarterial embolization of the feeding arteries originating from the ECA with Onyx (ev3, Irvine, Calif). This combined approach resulted in complete occlusion of the fistula. His 1-month follow-up angiogram confirmed persistent occlusion of the fistula and preserved patency of the right ICA. The patient made a full recovery without any new symptoms, and he remained neurologically intact at 18-month follow-up.

CONCLUSION

The combined technique of covered stent placement and Onyx transarterial embolization is valuable for the management of complex DAVFs supplied by branches of both the external and internal carotid arteries.

Endovascular treatment of giant intracranial aneurysms with willis covered stents: technical case report

OBJECTIVE

To evaluate the efficacy of endovascular treatment of giant intracranial aneurysms with Willis covered stents (Micro-Port, Shanghai, China).

CLINICAL PRESENTATION

The endovascular treatment of two cases of giant intracranial aneurysm was successfully accomplished by the placement of Willis covered stents specially designed for intracranial use. Both patients presented with symptoms of cavernous mass effect that resulted from a giant aneurysm in the cavernous segment of the internal carotid artery.

INTERVENTION

Three Willis covered stents were successfully placed in two patients. Immediate postprocedure angiograms demonstrated some endoleak of the aneurysms. In one patient, the endoleak was eliminated and complete exclusion of the aneurysms was confirmed with follow-up angiography. However, the other patient required the placement of a new Willis covered stent.

CONCLUSION

The use of covered stents in intracranial vascular structures is a feasible method to treat selected cases of intracranial giant aneurysms. It is suggested that patients who present with compressive mass effect caused by large or giant aneurysms are the best candidates for covered stent placement, but potential complications should be considered carefully before the stenting procedure.

Endovascular embolization of intracranial aneurysms

Intracranial aneurysm (ICA) is a common condition but with a high mortality rate when rupture occurs. The treatment of ruptured or unruptured ICA, especially with an endovascular approach, has been evolving rapidly. The current generally accepted opinion suggests that endovascular embolization is an effective technique for preventing the recurrence of aneurysm rupture, but the rebleeding rate after endovascular embolization is found to be higher than that after surgical clipping. In addition, long-term follow-up data are required for the evaluation of the effectiveness of endovascular treatment in unruptured ICA. This review presents the current understanding of ICA, the selection of optimal treatment approaches, and in particular, the advances in endovascular embolization in the treatment of ICA, including embolic materials, therapeutic and assisting techniques, long-term effectiveness, and limitations.

Extracranial carotid artery pseudoaneurysm presenting with embolic stroke in a pediatric patient. Case report

Extracranial carotid artery (CA) aneurysms are rare in the pediatric population and are usually the result of connective tissue disorders, traumatic dissection, or infection. The authors present the case of a large calcified internal carotid artery pseudoaneurysm of obscure origins presenting with embolic stroke in a child. Aneurysm excision and CA reconstruction would have been extremely difficult due to the distal location of the lesion, and CA ligation was contraindicated due to a failed balloon test occlusion. Therefore, after anticoagulation therapy, the patient was treated endovascularly with a covered stent and complete exclusion of the aneurysm from the circulation. The patient recovered all neurological function and has remained in excellent condition. A follow-up angiogram performed at 6 months showed no recurrence or stenosis.

Treatment of carotid cavernous fistulas using covered stents: midterm results in seven patients

BACKGROUND AND PURPOSE

Carotid cavernous fistulas (CCF) can be effectively treated by using different therapeutic alternatives such as detachable balloons and detachable coils, alone or in combination with N-butyl-2-cyanoacrylate (n-BCA) or Onyx. Stents have also been used in an attempt to improve preservation of the parent artery while still occluding the fistula. We present our experience using balloon-expandable covered stents to treat CCF, focusing on arterial wall reconstruction. To our knowledge, this is the first series with midterm follow-up between 3 months and 3.5 years.

MATERIALS AND METHODS

From the 46 CCF treated at our institution between November 1998 and September 2006, a total of 7 posttraumatic direct CCF were treated using polytetrafluoroethylene (PTFE)-covered stents between April 2003 and September 2006. Five were treated with covered stents alone. One patient with transection of the internal carotid artery (ICA) first underwent bare stent placement to provide support for the covered stent. One patient had to be treated with coils and n-BCA.

RESULTS

Control angiograms obtained in the 7 patients demonstrated occlusion of the fistula and preservation of the ICA in all cases. There was no mortality and no immediate postprocedural morbidity. There was 1 case of morbidity identified at 1-month follow-up with asymptomatic occlusion of the ICA; the other 6 patients had angiographic follow-up between 3 and 42 months (mean, 18.4 months), with persistent occlusion of the fistulas, patent stent grafts, and no significant intimal hyperplasia.

CONCLUSIONS

PTFE-covered stents are evolving as a promising intracranial therapeutic alternative to treat CCF and preserve the parent artery by reconstructing the arterial wall. They should be considered in patients in whom fistulas cannot be successfully occluded with detachable balloons or detachable coils. More investigation is required to further develop their specifications and indications.

A new covered stent designed for intracranial vasculature: application in the management of pseudoaneurysms of the cranial internal carotid artery

BACKGROUND AND PURPOSE

The management of intracranial pseudoaneurysms is controversial. The purpose of this study was to provide a preliminary evaluation of the clinical efficacy of a Willis covered stent specially designed for the intracranial vasculature in the management of a pseudoaneurysm of the cranial internal carotid artery (CICA).

MATERIALS AND METHODS

Eight patients with pseudoaneurysms of the CICA were treated with use of the Willis covered stent. The flexibility of the entire stent system was gauged from the resistance met when reaching the target lesion and was categorized as no resistance, no apparent resistance, or resistance that could be overcome. The apposition of the Willis stent after deployment was scored as excellent with no endoleak, good with a small endoleak, or bad with an apparent endoleak. Follow-up angiography was performed 3 to 12 months after placement of the stent, and angiographic assessments were categorized as endoleak, stenosis of the covered segment of vessel, or occlusion of parent arteries. Follow-up clinical evaluations were also performed, and outcomes were graded as full recovery, improvement, unchanged, and aggravation.

RESULTS

Endovascular treatment was technically successful in all aneurysms without procedural-related complications, and all of the stents were easily navigated to the targeted lesions in the CICA. Complete resolution of the pseudoaneurysm was observed in 6 patients immediately after the procedure, and a minimal endoleak into the aneurysm persisted in 2 patients. No morbidity or mortality and no technical adverse event occurred. A follow-up angiogram confirmed complete reconstruction of the internal carotid artery, with no recurrent aneurysmal filling and no occurrence of stenosis in the area of the stent. By the final follow-up visit, 4 patients had fully recovered, 3 had improved, and 1 patient's condition was unchanged.

CONCLUSION

On the basis of our preliminary experience, the Willis covered stent specially designed for the intracranial vasculature can manage a CICA pseudoaneurysm safely and effectively, but longer follow-up and expanded clinical trials are needed.

Endovascular treatment of giant or very large intracranial aneurysms with different modalities: an analysis of 20 cases

INTRODUCTION

The aim of this retrospective study was to evaluate the clinical efficacy and limitations of different endovascular modalities in the treatment of very large and giant intracranial aneurysms.

METHODS

A group of 20 patients with very large and giant intracranial aneurysms treated by endovascular approaches were retrospectively analyzed. Of the 20 patients, 9 had been treated by parent artery occlusion, 8 by coil embolization, and 3 with an intracranial covered stent. Two recurrent aneurysms initially treated with coil embolization were retreated with an intracranial covered stent. Patients were followed for 9-83 months after the procedure.

RESULTS

Endovascular treatment was technically feasible in all 20 patients. One patient died 7 days after the procedure from rebleeding caused by incomplete aneurysmal occlusion. Immediate postprocedural angiograms showed that complete occlusion was achieved in 11 aneurysms, subtotal occlusion in 7, and incomplete occlusion in 2. The final angiographic results in the other 19 surviving patients confirmed complete occlusion of 15 aneurysms, subtotal occlusion in 3, and incomplete occlusion in 1. Clinical evaluations performed at the final follow-up visit showed an excellent outcome in 11 patients and a good outcome in 8.

CONCLUSION

Endovascular treatment of giant intracranial aneurysms with coil embolization is often associated with a low complete occlusion rate and a high recanalization rate, and parent artery occlusion remains a practical option in selected patients. Based on our limited experience, the use of an intracranial covered stent appears to be a relatively simple and safe procedure for occluding very large and giant aneurysms while still maintaining the patency of the parent artery.

Treatment of a giant vertebrobasilar artery aneurysm using stent grafts

✓This 65-year-old man presented to the authors' institution reporting neck swelling. Stage IIIA Hodgkin disease was diagnosed, and a computed tomography scan of the neck revealed a vertebrobasilar artery aneurysm. His medical history was significant for subarachnoid hemorrhage and coma 2 years earlier. Subsequent digital subtraction angiography demonstrated a giant fusiform vertebrobasilar junction aneurysm with associated basilar artery (BA) fenestration. Endovascular treatment of the giant aneurysm was performed by left vertebral artery (VA) occlusion and placement of two Jo-stent coronary stent grafts from the right VA to the BA. The postprocedure course was uneventful. Follow-up angiography performed 1 week postoperatively demonstrated complete exclusion of the aneurysm. This unique case is described and a review of the relevant literature is presented.

Endovascular Treatment of Extracranial Internal Carotid Aneurysms Using Endografts

Aneurysms of the extracranial internal carotid artery (EICA) are infrequent. They are difficult to treat with conventional surgery because of their distal extension into the skull base. We report three cases of EICA aneurysms in two symptomatic patients successfully treated with polytetrafluoroethylene self-expanding endografts using an endovascular approach. The aneurysms were located distal to the carotid bifurcation and extended to the subpetrous portion of the internal carotid artery.

Covered stent-graft treatment of traumatic internal carotid artery pseudoaneurysms: a review

OBJECTIVE

To review the literature concerning the management with placement of covered stent-grafts of traumatic pseudoaneurysms of the extracranial internal carotid artery (ICA) resulting from penetrating craniocervical injuries or skull base fractures.

METHOD

We have reviewed, from the Medline database, all the published cases in the English literature since 1990 and we have added a new case.

RESULTS

We identified 20 patients with traumatic extracranial ICA pseudoaneurysms due to penetrating craniocervical injuries or skull base fractures who had been treated with covered stent-graft implantation. Many discrepancies have been ascertained regarding the anticoagulation therapy. In 3 patients the ICA was totally occluded in the follow-up period, giving an overall occlusion rate 15%. No serious complication was reported as a result of the endovascular procedure.

CONCLUSION

Preliminary results suggest that placement of stent-grafts is a safe and effective method of treating ICA traumatic pseudoaneurysms resulting from penetrating craniocervical injuries or skull base fractures. The immediate results are satisfactory when the procedure takes place with appropriate anticoagulation therapy. The periprocedural morbidity and mortality and the early patency are also acceptable. A surveillance program with appropriate interventions to manage restenosis may improve the long-term patency.

[Endovascular treatment of epistaxis of the internal carotid artery. Vessel occlusion and vessel preservation]

Epistaxis can become an ENT emergency situation. In most patients the bleeding source are branches of the external carotid artery. Hemorrhage of the internal carotid artery is very rare and can be due to inflammatory disease, trauma, or iatrogenic laceration of the ICA during endonasal surgery. Depiction of the bleeding source with radiological methods (computed tomography with contrast enhancement and conventional angiography) is crucial to avoid fatal complications. We report three cases with life-threatening epistaxis in whom bleeding was stopped with endovascular treatment alone.

Management of pseudoaneurysms in the intracranial segment of the internal carotid artery with covered stents specially designed for use in the intracranial vasculature: technical notes

Vascular diseases like aneurysms, pseudoaneurysms and direct high-flow carotid-cavernous fistulas on the intracranial segment of the internal carotid artery are usually managed through transarterial embolization with detachable coils or balloons. Utility of covered stents has been reported with good results in the treatment of selective cases. But the current generation of covered stents for coronary use is rather stiff and difficult to navigate in tortuous vessels particularly in the intracranial vasculature. Herein, we report on the use and technical respects of balloon-expanded covered stents specially designed for intracranial vasculature in the treatment of two pseudoaneurysms secondary to the successful obliteration of direct CCFs on the intracranial segment of the internal carotid artery. This is the first report of covered stents specially developed for use in intracranial vasculature.

Carotid and vertebral artery dissections: clinical aspects, imaging features and endovascular treatment

Extracranial arterial dissections are a recognised cause of stroke, particularly in young adults. Clinical diagnosis may be difficult, and the classical triad of symptoms is uncommon. Imaging plays a pivotal role in the diagnosis of extracranial arterial dissections, and this review provides a detailed discussion of the relative merits and limitations of currently available imaging modalities. Conventional arteriography has been the reference standard for demonstrating an intimal flap and double lumen, which are the hallmarks of a dissection, and for detecting complications such as stenosis, occlusion or pseudoaneurysm. Noninvasive vascular imaging methods, such as ultrasound (US), magnetic resonance angiography (MRA) and computed tomography angiography (CTA) are increasingly replacing conventional angiography for the diagnosis of carotid and vertebral dissections. Ultrasound provides dynamic and "real-time" information regarding blood flow. Source data of MRA and CTA and additional cross-sectional images can provide direct visualisation of the mural haematoma and information about the vessel lumen. Anticoagulation to prevent strokes is the mainstay of medical treatment, but randomised trials to define the optimal treatment regime are lacking. Surgery has a limited role in management of dissections, but endovascular procedures are gaining importance for treatment of complications and if medical management fails.

Treatment of a middle cerebral artery giant aneurysm using a covered stent

✓ The authors report the case of a 60-year-old man harboring a wide-necked giant aneurysm of the M1 segment of the left middle cerebral artery (MCA); his symptoms included transient ischemic attacks characterized by right hemiparesis and aphasia. The aneurysm was treated by placing a covered stent across the orifice of the aneurysm. The 18-month follow-up examination showed a very good outcome, with perfect left MCA patency, no new ischemic lesion, and minor residual aphasia and right hemiparesis. This is the first report in the literature of an MCA aneurysm treated using a covered stent.

Vertebral artery injury after blunt cervical trauma: an update

BACKGROUND

Vertebral artery injury (VAI) after blunt cervical trauma has been considered to be rare. The incidence of VAI has increased dramatically within the last decade after a heightened awareness of this entity on the part of spine surgeons. Diagnostic or therapeutic guidelines for VAI have not been established fully, however.

METHODS

A review of the literature published between 1990 and 2004 was conducted.

RESULTS

The incidence of VAI among total blunt trauma admissions ranged from 0.20% to 0.77%. Most VAI patients remained asymptomatic, but sudden unexpected deterioration was often reported. Distraction/extension, distraction/flexion, and lateral flexion injuries were the major mechanisms of injury. Dissection and occlusion were the frequent vascular injury patterns. Facet joint dislocations and the fractures extending into the transverse foramen were the spine injury patterns closely associated with VAI. Digital subtraction angiography was the most sensitive imaging study, but because of invasiveness, its role as a screening study remained questionable. Neuroradiological intervention was used successfully to treat hemorrhagic VAI and progressing vertebrobasilar stroke. Systemic anticoagulation with heparin was the preferred treatment for mild ischemia. Treatment of asymptomatic patients has been controversial because the natural history of VAI has not been elucidated. Prophylactic anticoagulation with heparin or the use of antiplatelet agents was advocated in recent studies.

CONCLUSIONS

Preemptive treatment may be reasonable in selected patients considering the devastating potentials of VAI. The potential risks of heparin or antiplatelet agents in relation to early cervical spine surgery have not been addressed fully, however, and spine surgeons have to weigh the risk and benefit of such treatment cautiously.

Endovaskulärer Verschluss der A. basilaris zur Behandlung dissektionsbedingter und dysplastischer fusiformer Aneurysmen

Dissecting aneurysms of the basilar artery trunk frequently affect young adults. Fusiform shape and narrowing of the proximal parent artery are typical features. Changes in aneurysm size and geometry may be observed more rapidly than in atherosclerotic or dysplastic aneurysms. Dissecting aneurysms carry a significant risk of rupture. Thrombotic or embolic occlusion of small pontine branches may cause ischemic symptoms. Sufficiently large aneurysms compress the adjacent brainstem. The operative treatment of these aneurysms is associated with unacceptable risks. At least one posterior communicating artery with normal calibre together with the ipsilateral P1 segment needs to provide adequate collateral flow to the upper basilar artery to allow endovascular coil occlusion of the segment that is affected by the dissection and/or fusiform aneurysmal dilatation. Four illustrative cases of endovascular coil occlusion of the basilar artery for the treatment of fusiform aneurysms are presented and discussed.

Imaging of Traumatic Neurovascular Injury

Traumatic injury to the major vessels of the head and neck can result in potentially devastating neurologic sequelae. Until recently, conventional angiography was the primary imaging modality used to evaluate these often challenging patients. Advances in cross-sectional imaging have improved the ability to screen for these lesions, which have been found to be more common than previously thought; however, accepted protocols of imaging evaluation have not yet been fully established. This article presents a general approach to the patient with suspected neurovascular injury. This includes a discussion of the histopathologic spectrum, clinical presentation, mechanisms, radiologic work-up, pertinent issues of the most common lesions, and some of the endovascular techniques used in their management.

Symptomatic internal carotid artery dissecting pseudoaneurysm: endovascular treatment by stent-graft

Dissecting pseudoaneurysm of the extracranial portion of the internal carotid artery (ICA) is a usually benign complication of spontaneous ICA dissection. We report a case in which pseudoaneurysm volume enlarged progressively and new clinical symptoms developed 9 months following disease onset. Placement of a coronary stent-graft resulted in immediate complete resolution of clinical symptoms and radiologic restoration of normal flow.

Endovascular Management of a Patient after SAH

Treatment of acute aneurysmal subarachnoid hemorrhages consists of occluding the aneurysm to prevent rebleed, attempting to prevent vasospasm, and maintaining blood flow to the brain through vessels in vasospasm. Endovascular treatment has been shown to be as safe as, or safer, than surgical clipping for patients with SAH. Engineering solutions to our clinical problems continue to improve endovascular outcomes. This article reviews the current state of endovascular therapy.

Emerging Concepts in the Treatment of Intracranial Aneurysms: Stents, Coated Coils, and Liquid Embolic Agents

ENDOVASCULAR TECHNIQUES FOR the treatment of intracranial aneurysms are rapidly evolving. Modifications of more traditional coils have been introduced. Such modifications include newer coils coated with various polymers to increase both coil thrombogenicity and degree of aneurysm packing. In addition, newer coil designs aimed at improving the conformability of the coil to the aneurysm have been used with promising preliminary results. The availability of a newer generation of stents specifically designed for intracranial navigation allows for more effective treatment of aneurysms with wide necks, which usually have been considered unsuitable for optimal endovascular treatment. Endovascular alternatives to coil embolization, such as liquid embolic materials, also have been explored for the treatment of intracranial aneurysms, with varying results. We summarize the rationale for use of these newer devices and early clinical experiences. Areas of current research and future directions of endovascular aneurysm treatment also are discussed.

Treatment of Intra- and Extracranial Arterial Dissections Using Stents and Embolization

PURPOSE

To evaluate the safety and efficacy of stent placement for extracranial and intracranial arterial dissections.

METHODS

Eighteen patients underwent endovascular treatment of carotid and vertebral dissections using intraluminal stent placement. Five patients with arterial dissection were treated, 2 using one insertion of a single stent and 3 using placement of two stents. Patients with a dissecting aneurysm were treated as follows: 7 patients with insertion of one stent, 4 with placement of two stents, and 2 by stent-assisted Guglielmi detachable coil embolization. In the 18 patients in whom stenting was attempted, the overall success in reaching the target lesion was 94.4%. Of the 17 patients treated with stents, stent release and positioning were considered optimal in 16 (94%) and suboptimal in one (6%). In patients who underwent a successful procedure, all parent arteries were preserved. There were no instances of postprocedural ischemic attacks, new neurologic deficits, or new minor or major strokes prior to patient discharge. In follow up, all patients were assessed, using the modified Rankin scale, as functionally improved or of stable clinical status. The reduction in dissection-induced stenosis or pseudoaneurysm, the patency rate obtained at follow-up, and the lack of strokes (ischemic or hemorrhagic) suggest that stent placement offers a viable alternative to complex surgical bypass or reconstructive procedures. The long-term efficacy and durability of stent placement for arterial dissection remain to be determined in a larger series.

Initial experience with intracranial stent-graft use. Technical notes

SUMMARY

We describe our initial experience with the placement of two premounted balloon expandable intracranial Jostent stent-grafts within the intracavernous internal carotid artery for the treatment of a symptomatic large intracavernous aneurysm in one case and a post-traumatic caroticocavernous fistula in the second. Among the initial technical complications we encountered were stent-graft migration and rapidly progressive intragraft thrombosis, with delayed sealing of the stent-graft coverings and exclusion of the pathologies relating to the use of abciximab in both cases. Despite these initial problems both cases had excellent short-term clinical outcomes with angiographic exclusion of both lesions by day three and good clinical and angiographic outcomes at one and two months respectively.

Endovascular management of intracranial vertebral artery dissecting aneurysms

Object

Intracranial vertebral artery (VA) dissecting aneurysms often present with severe subarachnoid hemorrhage (SAH) and dramatic neurological injury. The authors reviewed the management of 23 cases in an effort to evaluate treatment efficacy and outcomes.

Methods

The records of 23 patients who underwent endovascular treatment were reviewed to determine symptoms, type of therapy, complications, and clinical outcomes. All patients were evaluated using records kept in a prospectively maintained database.

Ten men and 13 women (age range 35–72 years; mean age 49 years) were treated over an 8-year period. Twelve patients presented with poor-grade SAH, five with good-grade SAH, three with headache, and two with stroke. The other patient's aneurysm was discovered incidentally. Treatment included coil occlusion of the artery at the aneurysm in 21 patients and stent-assisted coil placement in two. Parent artery sacrifice was successful in all cases, whereas both patients treated with stent-assisted coil insertion suffered recurrences. No patient sustained permanent complications as a result of treatment. Two patients died due to the severity of their original SAH. Findings were normal in 14 patients on follow-up review (including five of the 12 presenting with poor-grade SAH), five had fixed neurological deficits but were able to care for themselves, and one was permanently disabled.

Conclusions

Despite their often aggressive neurological presentation, intracranial VA dissecting aneurysms can be managed safely with coil occlusion of the lesion and/or parent artery. Even patients presenting in poor neurological condition may improve dramatically.