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Meijer FJA, Van Der Vliet AM. Treatment of a traumatic carotid-cavernous fistula with a covered stent: some considerations. Case report. Interv Neuroradiol 2009; 15:191-6. [PMID: 20465898 DOI: 10.1177/159101990901500209] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2009] [Accepted: 04/05/2009] [Indexed: 11/15/2022] Open
Abstract
SUMMARY This article discusses some considerations concerning covered stent placement in a patient with a traumatic direct carotid-cavernous fistula. Our case supports recent reports in the literature that covered stent placement can be an acceptable alternative when detachable balloon occlusion or coil occlusion of a direct carotid-cavernous fistula fails or cannot be done. Positioning of a covered stent in the internal carotid artery can be technically challenging. No specific covered stents for neurovascular use have been designed or registered. Because of limited experience with covered stent placement in the carotid artery the optimal preventive and therapeutic strategies for thromboembolic complications are not known.
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Affiliation(s)
- F J A Meijer
- Department of Radiology, University Medical Center St. Radboud, Nijmegen, The Netherlands -
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52
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O'Connell JB, Darcy S, Reil T. Extracranial Internal Carotid Artery Mycotic Aneurysm: Case Report and Review. Vasc Endovascular Surg 2009; 43:410-5. [DOI: 10.1177/1538574409340590] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Mycotic aneurysms of the internal carotid artery (ICA) are rare and often difficult to diagnose. They can have nonspecific signs and symptoms, an unclear etiology, and can lead to severe morbidity and mortality if left untreated. We present a case of a 47-year-old woman with an apparent mycotic aneurysm of the extracranial ICA associated with Klebsiella pneumonia. We discuss the various clinical findings and radiographic imaging that lead to this unusual diagnosis and the details of our surgical treatment, which included excision of the mycotic aneurysm and reconstruction with a greater saphenous vein interposition graft. We also review the literature on mycotic aneurysms of the ICA, including the radiologic modalities available to diagnose this condition, epidemiology, pathophysiology, and treatment options.
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Affiliation(s)
- Jessica Beth O'Connell
- UCLA Gonda (Goldschmied) Vascular Center, David Geffen School of Medicine at University of California, Los Angeles, California,
| | - Sean Darcy
- UCLA Gonda (Goldschmied) Vascular Center, David Geffen School of Medicine at University of California, Los Angeles, California
| | - Todd Reil
- UCLA Gonda (Goldschmied) Vascular Center, David Geffen School of Medicine at University of California, Los Angeles, California
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53
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Zhu YQ, Cheng YS, Li MH, Zhang HX, Zhao JG, Wang YL. Comparison of Tissue Reaction with Three Different Endografts Used for Exclusion of Carotid Artery Aneurysm in a Dog Model. J Vasc Interv Radiol 2009; 20:791-8. [DOI: 10.1016/j.jvir.2008.12.417] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2007] [Revised: 12/09/2008] [Accepted: 12/10/2008] [Indexed: 11/27/2022] Open
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55
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Pathophysiology and treatment of brain AVMs. ACTA ACUST UNITED AC 2009; 19:82-90. [PMID: 19636681 DOI: 10.1007/s00062-009-8035-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2008] [Accepted: 11/09/2008] [Indexed: 10/20/2022]
Abstract
Cerebral arteriovenous malformations (AVMs) are a major source of intracerebral hemorrhage in younger adults. First, some basic ideas about AVM anatomy, the influences of pressure, macrovascular flow, perfusion and the "steal effect", and some recent observations in the field of inflammatory markers and genetics are briefly discussed. Then, some clinical aspects in the presentation and the natural course of AVMs are highlighted, with special emphasis on the prediction of hemorrhage. Finally, some problems of the current treatment options are mentioned, and future directions in diagnostics and therapy considered.
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56
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Wang C, Xie X, You C, Zhang C, Cheng M, He M, Sun H, Mao B. Placement of covered stents for the treatment of direct carotid cavernous fistulas. AJNR Am J Neuroradiol 2009; 30:1342-6. [PMID: 19342540 DOI: 10.3174/ajnr.a1583] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- C Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, PR China.
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57
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Nishi S, Nakayama Y, Ishibashi-Ueda H, Okamoto Y, Kinoshita Y. High-performance self-expanding stent graft: development and application to experimental aneurysms. J Artif Organs 2009; 12:35-9. [DOI: 10.1007/s10047-008-0437-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2008] [Accepted: 09/24/2008] [Indexed: 10/21/2022]
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58
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He M, Zhang H, Lei D, Mao BY, You C, Xie XD, Sun H, Ju Y, Zhang JM. Application of covered stent grafts for intracranial vertebral artery dissecting aneurysms. J Neurosurg 2009; 110:418-26. [DOI: 10.3171/2008.3.17470] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Endovascular stenting for the treatment of traumatic internal carotid injuries: expanding experience. ACTA ACUST UNITED AC 2009; 65:1561-6. [PMID: 19077655 DOI: 10.1097/ta.0b013e31817fd954] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The role of endovascular techniques in the treatment of traumatic vascular injuries, including injury to the internal carotid artery, continues to evolve. Despite growing experience with the usage of these techniques in the setting of artherosclerotic disease, published results in traumatic carotid injuries remain sporadic and confined to case reports and case series. METHODS We conducted a review of the medical literature from 1990 to the present date using the Pubmed and OVID Medline databases to search for all reports documenting the use of endovascular stenting for the treatment of carotid injuries. Thirty-one published reports were analyzed to abstract data regarding mechanism, location, and type of injury; use and type of anticoagulation used in conjunction with stenting; type and timing of radiographic and clinical follow-up; and radiographic and clinical outcomes. RESULTS The use of endovascular stenting for the treatment of internal carotid injuries was reported for only 113 patients from 1994 to the present date. Stenting was most commonly used after a blunt mechanism of injury (77.0%). The injury types treated by stenting included pseudoaneurysm (60.2%), arteriovenous fistula (16.8%), dissection (14.2%), partial transection (4.4%), occlusion (2.7%), intimal flap (0.9%), and aneurysm (0.9%). Initial endovascular stent placement was successful in 76.1% of patients. Radiographic and clinical follow-up periods ranging from 2 weeks to 2 years revealed a follow-up patency of 79.6%. No stent-related mortalities were reported. New neurologic deficits after stent placement occurred in 3.5%. CONCLUSION Endovascular treatment of traumatic internal carotid artery injury continues to evolve. Early results are encouraging, but experience with this modality and data on late follow-up are still very limited. A large prospective randomized trial is warranted to further define the role of this treatment modality in the setting of trauma.
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Bink A, Berkefeld J, Lüchtenberg M, Gerlach R, Neumann-Haefelin T, Zanella F, du Mesnil de Rochemont R. Coil embolization of cavernous sinus in patients with direct and dural arteriovenous fistula. Eur Radiol 2009; 19:1443-9. [DOI: 10.1007/s00330-008-1278-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2008] [Revised: 10/13/2008] [Accepted: 11/18/2008] [Indexed: 10/21/2022]
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Kuraishi K, Iwata H, Nakano S, Kubota S, Tonami H, Toda M, Toma N, Matsushima S, Hamada K, Ogawa S, Taki W. Development of nanofiber-covered stents using electrospinning:In vitroand acute phasein vivoexperiments. J Biomed Mater Res B Appl Biomater 2009; 88:230-9. [DOI: 10.1002/jbm.b.31173] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Lv X, Jiang C, Li Y, Lv M, Zhang J, Wu Z. Intracranial pseudoaneurysms, fusiform aneurysms and carotid-cavernous fistulas. Repair with percutaneous implantation of endovascular covered stents. Interv Neuroradiol 2008; 14:435-40. [PMID: 20557743 PMCID: PMC3313811 DOI: 10.1177/159101990801400409] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2008] [Accepted: 09/13/2008] [Indexed: 02/05/2023] Open
Abstract
The study assessed the effectiveness and safety of endovascular covered stents in the management of intracranial pseudoaneurysms, fusiform aneurysms and direct carotid-cavernous fistulas. Fourteen endovascular covered stents were used to repair three pseudoaneurysms, six fusiform aneurysms and six direct carotid-cavernous fistulas. Aneurysms were in the carotid artery in seven cases, in the vertebral artery two cases. It was not possible to treat two additional cases transcutaneously for technical reasons (2/15). Percutaneous closure of the lesions with an endovascular covered stent was successful in 13 of 15 cases. Initial follow-up showed good stent patency. No complications were observed after stent implantation. During follow-up, stent thromboses were detected in two of nine patients with follow-up digital subtracted angiography. One carotid-cavernous fistula of Barrow Type A transformed into Barrow Type D at nine month follow-up study was cured with a procudure of Onyx-18 injection. Endovascular covered stents may be an option for percutaneous closure of intracranial pseudoaneurysms, fusiform aneurysms and direct carotid-cavernous fistulas. Endoluminal vascular repair with covered stents offers an alternative therapeutic approach to conventional modalities.
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Affiliation(s)
- Xianli Lv
- Beijing Neurosurgical institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China -
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63
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Sancak T, Bilgic S, Ustuner E. Endovascular stent-graft treatment of a traumatic vertebral artery pseudoaneurysm and vertebrojugular fistula. Korean J Radiol 2008; 9 Suppl:S68-72. [PMID: 18607131 PMCID: PMC2627192 DOI: 10.3348/kjr.2008.9.s.s68] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
- Tanzer Sancak
- Department of Radiology, Ankara University Faculty of Medicine, Ibni Sina Hospital, Hasircilar Street, Sihhiye 06100 Ankara, Turkey.
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64
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Hoit DA, Schirmer CM, Malek AM. Stent graft treatment of cerebrovascular wall defects: intermediate-term clinical and angiographic results. Neurosurgery 2008; 62:ONS380-8; discussion ONS388-9. [PMID: 18596518 DOI: 10.1227/01.neu.0000326022.08973.b2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Daniel A Hoit
- Department of Neurosurgery, Cerebrovascular and Endovascular Division, Tufts-New England Medical Center and Tufts University School of Medicine, Boston, Massachusetts, USA
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65
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Fang C. Endovascular Treatment of a High-Flow Direct Traumatic Carotid Cavernous Fistula with a Two Year Follow-up. Interv Neuroradiol 2008; 14:297-301. [PMID: 20557727 PMCID: PMC3315356 DOI: 10.1177/159101990801400310] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2008] [Accepted: 07/01/2008] [Indexed: 11/16/2022] Open
Abstract
SUMMARY Endovascular treatment of high-flow direct traumatic carotid cavernous fistula (CCF) carries many difficulties. One of them is that carotid dissection may be associated with pseudo- aneurysm formation even when the CCF can be successfully embolized by detachable balloons. This article details a unique technique of treating pseudo-aneurysm by obstructing the lumen with preservation of the parent artery. The case presented here involves a 50-yearold man with a history of severe trauma. The angiography revealed that his bilateral highflow carotid cavernous fistula was successfully embolized by detachable balloons and control digital subtraction angiography at the end of the procedure demonstrated the fistula closed and the internal carotid artery preserved. But two months later, a pseudo-aneurysm formed in the right internal carotid artery. Under endovascular treatment along with other techniques including coils, stent-assisted and covered stent, the pseudo-aneurysm was excluded with preserved ICA. Two years later, the fistula and pseudo-aneurysm both disappeared quietly without patent foreign body reaction in the parent arterial wall.
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Affiliation(s)
- C Fang
- 6th People Hospital, Jao Tong University, Shanghai, China
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66
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Stents for intracranial wide-necked aneurysms: more than mechanical protection. Neuroradiology 2008; 50:991-8. [PMID: 18807024 DOI: 10.1007/s00234-008-0460-0] [Citation(s) in RCA: 116] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2007] [Accepted: 09/02/2008] [Indexed: 10/21/2022]
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67
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Ring Around the Carotid: An Illustration of the Surgical Approach to the High Carotid Artery Injury. ACTA ACUST UNITED AC 2008; 65:E28-31. [DOI: 10.1097/01.ta.0000197603.33566.06] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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68
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Liu HM. Current Status of Interventional Neuroradiology (Neurointerventional Surgery). Tzu Chi Med J 2008. [DOI: 10.1016/s1016-3190(08)60033-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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69
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Huai RC, Yi CL, Ru LB, Chen GH, Guo HH, Luo L. Traumatic carotid cavernous fistula concomitant with pseudoaneurysm in the sphenoid sinus. Interv Neuroradiol 2008; 14:59-68. [PMID: 20557787 PMCID: PMC3313707 DOI: 10.1177/159101990801400108] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2007] [Accepted: 02/29/2008] [Indexed: 11/16/2022] Open
Abstract
SUMMARY This study was designed to elucidate the generating mechanism, diagnosis and treatment of traumatic carotid cavernous fistula (tCCF) concomitant with pseudoaneurysm in the sphenoid sinus. Six cases of tCCF concomitant with pseudoaneurysm in the sphenoid sinus were analyzed in this study. Clinical history, neurological examination, CT and MRI scans, pre- and postembolization cerebral angiograms and follow-up data were included. All patients presented with massive epistaxis and symptoms of tCCF. The pseudoaneurysms and fistulas were occluded with detachable balloons, and preservation of the parent artery in two cases. One patient also had indirect carotid cavernous fistula (CCF) on the contralateral side embolized by transfacial vein approach with microcoils. Complete symptom resolution was achieved in all cases, without procedure related complications. During the follow-up period all patients returned to work. Falling from a high speed motorcycle without wearing a helmet may be one of the main causes of this disease. The site of impact during the accident mostly localizes in the frontal and lateral of the orbit. Intracavernous sinus hypertension of tCCF combining with fracture of the lateral wall of the sphenoid may lead to the formation of a pseudoaneurysm in the sphenoid sinus. MRI scan is very helpful in the diagnosis of this disease before the patient receives angiography. Detachable balloon occlusion of the pseudoaneurysm and fistula is a safe and efficient treatment.
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Affiliation(s)
- R C Huai
- Department of Neurosurgery, Changzheng Hospital, the Shanghai Neurosurgical Institute, Shanghai China -
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70
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Lv XL, Li YX, Liu AH, Lv M, Jiang P, Zhang JB, Wu ZX. A complex cavernous sinus dural arteriovenous fistula secondary to covered stent placement for a traumatic carotid artery-cavernous sinus fistula: case report. J Neurosurg 2008; 108:588-90. [PMID: 18312107 DOI: 10.3171/jns/2008/108/3/0588] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Authors present the case of a patient with a direct carotid artery-cavernous sinus fistula caused by head trauma in whom a self-expanding covered stent was successfully used to obliterate the fistula. However, at the 9-month follow-up an angiogram revealed a complex caroticocavernous fistula that was completely obliterated with Onyx 18 transarterially.
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Affiliation(s)
- Xian-Li Lv
- Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
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71
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Eddleman CS, Surdell D, Miller J, Shaibani A, Bendok BR. Endovascular management of a ruptured cavernous carotid artery aneurysm associated with a carotid cavernous fistula with an intracranial self-expanding microstent and hydrogel-coated coil embolization: case report and review of the literature. ACTA ACUST UNITED AC 2007; 68:562-7; discussion 567. [DOI: 10.1016/j.surneu.2006.10.074] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2006] [Accepted: 10/30/2006] [Indexed: 10/22/2022]
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72
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Gomez F, Escobar W, Gomez AM, Gomez JF, Anaya CA. Treatment of carotid cavernous fistulas using covered stents: midterm results in seven patients. AJNR Am J Neuroradiol 2007; 28:1762-8. [PMID: 17885249 PMCID: PMC8134221 DOI: 10.3174/ajnr.a0636] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2006] [Accepted: 03/23/2007] [Indexed: 01/11/2023]
Abstract
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.
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Affiliation(s)
- F Gomez
- Department of Radiology, Centro Medico Imbanaco, Cali, Colombia.
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73
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Feiz-Erfan I, Horn EM, Theodore N, Zabramski JM, Klopfenstein JD, Lekovic GP, Albuquerque FC, Partovi S, Goslar PW, Petersen SR. Incidence and pattern of direct blunt neurovascular injury associated with trauma to the skull base. J Neurosurg 2007; 107:364-9. [PMID: 17695391 DOI: 10.3171/jns-07/08/0364] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Skull base fractures are often associated with potentially devastating injuries to major neural arteries in the head and neck, but the incidence and pattern of this association are unknown.
Methods
Between April and September 2002, 1738 Level 1 trauma patients were admitted to St. Joseph's Hospital and Medical Center in Phoenix, Arizona. Among them, a skull base fracture was diagnosed in 78 patients following computed tomography (CT) scans. Seven patients had no neurovascular imaging performed and were excluded. Altogether, 71 patients who received a diagnosis of skull base fractures after CT and who also underwent a neurovascular imaging study were included (54 men and 17 women, mean age 29 years, range 1–83 years). Patients underwent CT angiography, magnetic resonance angiography, or digital subtraction angiography of the head and craniovertebral junction, or combinations thereof.
Results
Nine neurovascular injuries were identified in six (8.5%) of the 71 patients. Fractures of the clivus were very likely to be associated with neurovascular injury (p < 0.001). A high risk of neurovascular injury showed a strong tendency to be associated with fractures of the sella turcica–sphenoid sinus complex (p = 0.07).
Conclusions
The risk of associated blunt neurovascular injury appears to be significant in Level 1 trauma patients in whom a diagnosis of skull base fracture has been made using CT. The incidence of neurovascular trauma is particularly high in patients with clival fractures. The authors recommend neurovascular imaging for Level 1 trauma patients with a high-risk fracture pattern of the central skull base to rule out cerebrovascular injuries.
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Affiliation(s)
- Iman Feiz-Erfan
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona 85013, USA
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74
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Maras D, Lioupis C, Magoufis G, Tsamopoulos N, Moulakakis K, Andrikopoulos V. Covered stent-graft treatment of traumatic internal carotid artery pseudoaneurysms: a review. Cardiovasc Intervent Radiol 2007; 29:958-68. [PMID: 16897263 DOI: 10.1007/s00270-005-0367-7] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
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.
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MESH Headings
- Adult
- Aneurysm, False/diagnostic imaging
- Aneurysm, False/etiology
- Aneurysm, False/surgery
- Anticoagulants/therapeutic use
- Blood Vessel Prosthesis Implantation
- Carotid Artery Injuries/diagnostic imaging
- Carotid Artery Injuries/etiology
- Carotid Artery Injuries/surgery
- Carotid Artery, Internal/diagnostic imaging
- Carotid Artery, Internal/surgery
- Coated Materials, Biocompatible/therapeutic use
- Combined Modality Therapy
- Graft Occlusion, Vascular/diagnostic imaging
- Graft Occlusion, Vascular/etiology
- Head Injuries, Penetrating/complications
- Head Injuries, Penetrating/diagnostic imaging
- Head Injuries, Penetrating/surgery
- Humans
- Male
- Polytetrafluoroethylene/therapeutic use
- Radiography
- Skull Fracture, Basilar/complications
- Skull Fracture, Basilar/diagnostic imaging
- Skull Fracture, Basilar/surgery
- Stents
- Vascular Patency
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Affiliation(s)
- Dimitrios Maras
- Department of Vascular Surgery, The Red Cross Hospital of Athens, Athens, Greece
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75
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Gjertsen O, Nakstad PH, Pedersen HK, Josefsen R. Traumatic aneurysm of the superior cerebellar artery. Interv Neuroradiol 2007; 13:167-71. [PMID: 20566145 DOI: 10.1177/159101990701300207] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2007] [Accepted: 04/30/2007] [Indexed: 11/15/2022] Open
Abstract
SUMMARY Following a head trauma in a 40-year-old male, massive subarachnoid hemorrhage and fractures of the skull base/clivus was found at CT. CT angiography demonstrated an aneurysm on the proximal part of the right superior cerebellar artery. The aneurysm was successfully coiled without any complication and the patient improved clinically during the following three months. The decline in use of angiography in head trauma patients during the last two decades may lead to a lower detection of traumatic aneurysm than in previous times. The value of angiographic procedures in patients suffering head traumas with SAH and skull base fractures is therefore emphasized.
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Affiliation(s)
- O Gjertsen
- Department of Neuroradiology, Ullevål University Hospital and University of Oslo, Norway -
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76
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Abstract
Atherosclerotic occlusive lesions of the common carotid artery (CCA), the internal carotid artery (ICA), and the intracranial branches are amenable to angioplasty and stenting. Non atheromatous occlusive lesions caused by fibromuscular dysplasia, arteritis, or trauma may also be treated by image guided intervention in selected patients. Aneurysmal lesions of the CCA, ICA and the intracranial branches of degenerative, mycotic or traumatic etiologies, as well as carotid cavernous fistulae are mostly best treated by embolization. Technological developments continuously expand the indications of interventional treatment in these vascular territories.
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Affiliation(s)
- George Magoufis
- Department of Interventional Neuroradiology, Metropolitan Hospital, Voula, Greece
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77
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Treatment of an iatrogenic vertebral artery laceration with the Symbiot self expandable covered stent. Clin Neurol Neurosurg 2007; 109:512-5. [PMID: 17412492 DOI: 10.1016/j.clineuro.2007.02.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2006] [Revised: 02/23/2007] [Accepted: 02/28/2007] [Indexed: 10/23/2022]
Abstract
Vertebral artery laceration is difficult to treat surgically. Endovascular treatment with balloon expandable covered stents often fails due to their rigidity and poor navigability. We present a case of iatrogenic vertebral artery laceration where endovascular treatment with a balloon expandable covered stent failed. Eventually a self expandable symbiot covered stent was deployed over the laceration, securing hemostasis and preserving the vessel patency. The newer self expandable covered stents seem promising in the treatment of vertebral artery injury.
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78
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van Hensbroek PB, Ponsen KJ, Reekers JA, Goslings JC. Endovascular treatment of anterior tibial artery pseudoaneurysm following locking compression plating of the tibia. J Orthop Trauma 2007; 21:279-82. [PMID: 17414557 DOI: 10.1097/bot.0b013e3180500371] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Less invasive surgery and interventional radiology are relatively new techniques. This case report describes a patient with a distal tibial fracture that was stabilized using minimally invasive osteosynthesis consisting of a precontoured metaphyseal Locking Compression Plate (LCP). Postoperative radiographs showed good alignment of the bone, and the initial postoperative course was uneventful. At the sixth-week follow-up visit after surgery, the patient presented with a pulsating and tender mass on the lower leg that was palpable subcutaneously. Arteriography showed a pseudoaneurysm of the anterior tibial artery. At the same procedure an endovascular stent was placed, thereby excluding the pseudoaneurysm from the main circulation while keeping the vessel lumen patent. At the time of the last visit, 6 months after the operation, the patient was fully weightbearing with normal function of the ankle but with a nonhealing fracture on the x-ray. The dorsalis pedis pulse was equally strong as on the right side. Endovascular treatment with a covered stent proved to be an effective treatment for the described posttraumatic pseudoaneurysm of the anterior tibial artery. This case illustrates a risk of less invasive fracture surgery and at the same time underlines the value of a multidisciplinary approach to complications in trauma surgery.
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79
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Ray CE, Spalding SC, Cothren CC, Wang WS, Moore EE, Johnson SP. State of the art: noninvasive imaging and management of neurovascular trauma. World J Emerg Surg 2007; 2:1. [PMID: 17212833 PMCID: PMC1796545 DOI: 10.1186/1749-7922-2-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2006] [Accepted: 01/09/2007] [Indexed: 11/10/2022] Open
Abstract
Neurotrauma represents a significant public health problem, accounting for a significant proportion of the morbidity and mortality associated with all traumatic injuries. Both blunt and penetrating injuries to cervicocerebral vessels are significant and are likely more common than previously recognized. Imaging of such injuries is an important component in the evaluation of individuals presenting with such potential injuries, made all the more important since many of the vascular injuries are clinically silent. Management of injuries, particularly those caused by blunt trauma, is constantly evolving. This article addresses the current state of imaging and treatment of such injuries.
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Affiliation(s)
- Charles E Ray
- Diagnostic and Interventional Radiology, Denver Health Medical Center, 777 Bannock St, Denver, CO80204, USA
- Diagnostic and Interventional Radiology, University of Colorado Health Sciences Center, 4200 East Ninth Street, Denver, CO80220, USA
| | - Shaun C Spalding
- Diagnostic and Interventional Radiology, University of Colorado Health Sciences Center, 4200 East Ninth Street, Denver, CO80220, USA
| | - C Clay Cothren
- Surgery, Denver Health Medical Center, 777 Bannock St., Denver, CO80204, USA
- Surgery, University of Colorado Health Sciences Center, 4200 East Ninth Street, Denver, CO80220, USA
| | - Wei-Shin Wang
- University of Colorado School of Medicine, 4200 East Ninth Street, Denver, CO80220, USA
| | - Ernest E Moore
- Surgery, Denver Health Medical Center, 777 Bannock St., Denver, CO80204, USA
- Surgery, University of Colorado Health Sciences Center, 4200 East Ninth Street, Denver, CO80220, USA
| | - Stephen P Johnson
- Diagnostic and Interventional Radiology, University of Colorado Health Sciences Center, 4200 East Ninth Street, Denver, CO80220, USA
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80
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Li MH, Gao BL, Wang YL, Fang C, Li YD. 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. Neuroradiology 2006; 48:841-6. [PMID: 16944121 DOI: 10.1007/s00234-006-0127-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2006] [Accepted: 06/12/2006] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Ming-Hua Li
- Department of Radiology, Shanghai Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200233, People's Republic of China
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81
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Chan AW, Yadav JS, Krieger D, Abou-Chebl A. Endovascular repair of carotid artery aneurysm with Jostent covered stent: initial experience and one-year result. Catheter Cardiovasc Interv 2006; 63:15-20. [PMID: 15343562 DOI: 10.1002/ccd.20094] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Treatment for symptomatic extracranial carotid artery aneurysm is evolving and we describe two cases of successful endovascular treatment of distal internal carotid aneurysm using Jostent, a balloon-expandable coronary polytetrafluoroethylene-covered stent. Both patients remained symptom-free at 1 year after the procedure and patency of the stents was maintained. We conclude that endovascular treatment of carotid artery aneurysm with Jostent is feasible and safe and may be more preferable than conventional strategies.
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Affiliation(s)
- Albert W Chan
- Department of Cardiology, Royal Columbian Hospital, New Westminster, British Columbia, Canada
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82
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Hauck EF, Nauta HJW. Spontaneous spinal epidural arteriovenous fistulae in neurofibromatosis type-1. ACTA ACUST UNITED AC 2006; 66:215-21. [PMID: 16876638 DOI: 10.1016/j.surneu.2006.01.018] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2005] [Accepted: 12/29/2005] [Indexed: 11/16/2022]
Abstract
BACKGROUND NF-1 is one of the most common autosomal-dominantly inherited genetic disorders with an incidence of approximately 1:3500. We report a case and review the literature to characterize spontaneous spinal AVF that occur in neurofibromatosis (NF-1). CASE REPORT A 51-year-old woman presented with NF-1 and progressive radiculomyelopathy. Angiography revealed an AVF terminating in a giant intraspinal epidural varix extending paraspinally through the C3/4 neural foramen. Trapping of the AVF attempted 18 years earlier prevented endovascular access for embolization, and vigorous bleeding made direct surgical resection impossible. Therefore, as palliation, arterial feeding collaterals were occluded, and surgically exposed tortuous veins were packed with coils. Laminectomies and partial resection of the epidural varix resulted in subtotal occlusion with clinical improvement. CONCLUSION The spinal AVF associated with NF-1 appears to show dominant venous drainage to the intraspinal extradural and paraspinal venous plexus without evidence of intradural drainage. The vertebral artery is typically the origin of the fistula. A giant venous varix and numerous collateral feeders to the vertebral artery may give an AVM-like appearance. Clinically, the fistulae produce a syndromic triad including symptoms of NF-1, progressive radiculomyelopathy, and a bruit. Treatment is direct attack on the fistula by either surgery or embolization. If, however, a direct approach cannot be chosen, occlusion of feeding vessels combined with laminectomies can result in long-term symptomatic improvement.
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Affiliation(s)
- Erik F Hauck
- Division of Neurosurgery, University of Texas Medical Branch at Galveston, Galveston, TX 77555-0517, USA.
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83
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Kurt A, Tanrivermiş A, Ipek A, Tosun O, Gümüş M, Yazicioğlu KR, Taş I. A challenging problem. Vertebral pseudoaneurysm and arteriovenous fistula involving vertebral artery and ipsilateral internal jugular vein due to craniocervical penetrating trauma. Interv Neuroradiol 2006; 12:171-5. [PMID: 20569571 DOI: 10.1177/159101990601200213] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2006] [Accepted: 05/15/2006] [Indexed: 11/16/2022] Open
Abstract
SUMMARY Vertebral pseudoaneurysm and arteriovenous fistulas are very rare and are commonly due to penetrating trauma to craniocervical region. A 20-year-old man was presented with progressive swelling and pulsatile mass on the left side of his face. He had been stabbed two weeks ago on the left side of his face. Doppler Ultrasound revealed large left vertebral pseudoaneursym and arteriovenous fistulisation with the ipsilateral internal jugulat vein. MR Angiography and conventional angiography confirmed arteriovenous fistula between left vertebral artery and ipsilateral internal jugular vein and large pseudoaneurysm formation on vertebral artery. Arteriovenous fistula was closed surgically and embolized with surgicell. But the pseudoaneurysm was treated with endovascular covered stent placement.
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Affiliation(s)
- A Kurt
- Ankara Atatürk Education and Research Hospital Department of Radiology, Ankara-Turkey Assistant, Radiology Department, Instructor, Radiology Department -
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84
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Madan A, Mujic A, Daniels K, Hunn A, Liddell J, Rosenfeld JV. Traumatic carotid artery-cavernous sinus fistula treated with a covered stent. Report of two cases. J Neurosurg 2006; 104:969-73. [PMID: 16776343 DOI: 10.3171/jns.2006.104.6.969] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The authors describe the cases of two patients with unilateral traumatic caroticocavernous fistulas in whom a self-expanding covered stent was successfully used to obliterate the fistula after failed occlusion with detachable balloons and coils. They discuss this option as a primary therapeutic modality in cases in which detachable balloons or coils, with or without a bare stent, have failed to obliterate the fistula. The placement of a covered stent to occlude the lesion from the outset may represent a new therapeutic approach to the treatment of these lesions.
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Affiliation(s)
- Anoop Madan
- Department of Radiology, Alfred Hospital and Monash University, Melbourne, Australia.
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85
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Mourikis D, Chatziioannou A, Doriforou O, Skiadas V, Koutoulidis V, Katsenis K, Vlahos L. Endovascular Treatment of a Vertebral Artery Pseudoaneurysm in a Drug User. Cardiovasc Intervent Radiol 2006; 29:662-4. [PMID: 16502178 DOI: 10.1007/s00270-005-0105-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
A 26-year-old drug abuser who presented with sepsis was found to have a pseudoaneurysm in the left vertebral artery. This aneurysm was presumed to be post-traumatic, since the patient reported multiple attempts to inject drugs in the left jugular vein 15 days prior to admission. The pseudoaneurysm was treated effectively with stent-graft placement.
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Affiliation(s)
- Dimitrios Mourikis
- Department of Radiology, Areteion Hospital, University of Athens, Vas Sofias 76, Athens, Greece
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86
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Katayama S, Fujita K, Takeda N, Okamura Y. Stent graft placement for the treatment of giant aneurysm at the proximal cavernous internal carotid artery. A case report. Interv Neuroradiol 2006; 12:117-20. [PMID: 20569614 DOI: 10.1177/15910199060120s118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2005] [Accepted: 12/15/2005] [Indexed: 11/16/2022] Open
Affiliation(s)
- S Katayama
- Department of Neurosurgery, Nishi-Kobe Medical Center, Kobe, Japan
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87
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Abstract
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.
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MESH Headings
- Aneurysm, False/diagnosis
- Aneurysm, False/diagnostic imaging
- Angiography/methods
- Angiography, Digital Subtraction/methods
- Blood Vessels/injuries
- Carotid Artery, Internal, Dissection/diagnosis
- Carotid Artery, Internal, Dissection/diagnostic imaging
- Craniocerebral Trauma/diagnosis
- Craniocerebral Trauma/diagnostic imaging
- Diagnosis, Differential
- Humans
- Intracranial Arteriovenous Malformations/diagnosis
- Intracranial Arteriovenous Malformations/diagnostic imaging
- Magnetic Resonance Angiography/methods
- Magnetic Resonance Imaging/methods
- Neck/blood supply
- Neck Injuries/diagnosis
- Neck Injuries/diagnostic imaging
- Tomography, X-Ray Computed/methods
- Vertebral Artery Dissection/diagnosis
- Vertebral Artery Dissection/diagnostic imaging
- Wounds, Penetrating/diagnosis
- Wounds, Penetrating/diagnostic imaging
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Affiliation(s)
- M J B Stallmeyer
- Division of Diagnostic and Interventional Neuroradiology, Department of Diagnostic Radiology, University of Maryland School of Medicine, Baltimore, MD 21208, USA.
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88
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Inoue T, Tsutsumi K, Iijima A, Shinozaki M, Ishida J, Yako K. Urgent treatment of severe subarachnoid hemorrhage caused by ruptured traumatic aneurysm of the cavernous internal carotid artery using coil embolization followed by superficial temporal artery-middle cerebral artery anastomosis: A case report. ACTA ACUST UNITED AC 2005; 64:450-4; discussion 454-5. [PMID: 16253699 DOI: 10.1016/j.surneu.2004.12.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2004] [Accepted: 12/29/2004] [Indexed: 11/21/2022]
Abstract
BACKGROUND Traumatic aneurysm of the cavernous internal carotid artery (ICA) with extension into the subarachnoid space is associated with increased risk of fatality especially when it is accompanied by severe subarachnoid hemorrhage (SAH). Only cases of patients who survived the acute stage and who were treated in a delayed setting have been reported. There has been no successfully treated case immediately after an injury. CASE DESCRIPTION We encountered a 48-year-old man who presented with dense SAH immediately after being involved in a motor vehicle accident. Emergent angiography revealed traumatic aneurysm of the left cavernous ICA with extension beyond the superior wall of the cavernous sinus into the subarachnoid space and concomitant direct high-flow carotid cavernous fistula. Detachable platinum coil occlusion of the cavernous ICA followed by superficial temporal artery-middle cerebral artery anastomosis on day 0 and aggressive therapy to SAH, including ventriculocisternal irrigation and drainage, was performed. The patient eventually made a good recovery. CONCLUSION Considering the extremely poor prognosis and unstable nature of a ruptured traumatic aneurysm with extensive SAH in the acute stage, definitive and immediate prevention of rebleeding in conjunction with proper revascularization would be warranted, such as in the present case.
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Affiliation(s)
- Tomohiro Inoue
- Department of Neurosurgery, Showa General Hospital, Tokyo 187-8510, Japan
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89
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O'Shaughnessy BA, Bendok BR, Parkinson RJ, Shaibani A, Batjer HH. Transarterial coil embolization of a high-flow vertebrojugular fistula due to penetrating craniocervical trauma: case report. ACTA ACUST UNITED AC 2005; 64:335-40; discussion 340. [PMID: 16182005 DOI: 10.1016/j.surneu.2004.11.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2004] [Revised: 10/25/2004] [Accepted: 11/08/2004] [Indexed: 11/23/2022]
Abstract
BACKGROUND Vertebrojugular fistulas after penetrating cervical trauma (gunshot or stab wounds) are rarely reported. Successful endovascular coil embolization of an acute fistulizing vertebral artery pseudoaneurysm involving an obstructed internal jugular vein is presented and the various treatment strategies for such a lesion are described. CASE DESCRIPTION A 23-year-old man presented from an outside institution after sustaining 2 gunshot wounds in a civilian conflict. Neuroimaging revealed a right vertebral artery pseudoaneurysm, which formed a fistulous connection with the internal jugular vein. Because venous outflow obstruction was present just below the fistula, a high-flow shunt was directed intracranially. Both the pseudoaneurysm and arteriovenous fistula were accessed percutaneously via a transfemoral route and coil embolization was performed. Perfusion of the basilar artery circulation was assumed by the contralateral vertebral artery. The ipsilateral posteroinferior cerebellar artery filled through retrograde flow down the vertebral confluence. CONCLUSIONS Coil embolization is a safe and reliable strategy by which to obliterate an acute traumatic vertebrojugular fistula as well as pseudoaneurysm. Serial angiographic follow-up is mandatory to document a persistent cure.
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Affiliation(s)
- Brian A O'Shaughnessy
- Department of Neurological Surgery, The Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
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90
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Cho KH, Shin YS, Yoon SH, Kim SH, Ahn YH, Cho KG. Poor surgical technique in cervical plating leading to vertebral artery injury and brain stem infarction—case report. ACTA ACUST UNITED AC 2005; 64:221-5. [PMID: 16099249 DOI: 10.1016/j.surneu.2004.09.042] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2004] [Accepted: 09/13/2004] [Indexed: 11/23/2022]
Abstract
BACKGROUND Lateral mass plating is a safe fixating system for lower cervical fractures. Brain stem infarction after cervical lateral mass screw plating has not been reported in previous literature. We report a case of poor surgical technique leading to vertebral artery injury and brain stem infarction after cervical lateral mass plating. CASE DESCRIPTION A 41-year-old male patient was transferred to our hospital because of hemiparesis and dysarthria immediately after lateral mass plating for fracture and dislocation of the fifth and sixth cervical vertebrae. Brain magnetic resonance imaging showed infarction of the left posterior inferior cerebellar artery territory, and the vertebral artery angiography showed complete occlusion of the left vertebral artery. The cervical computed tomography revealed a left screw of the fifth and sixth cervical vertebrae penetrating the central portion of the transverse foramen. The patient was managed with anticoagulant and supportive therapy only, with subsequent improvement of hemiparesis and dysarthria. CONCLUSIONS Poor surgical technique of lateral mass plating in the cervical spine could lead to vertebral artery injury and even brain stem infarction. Postoperative brain infarction in cervical fusion could be a complication of the usually safe lateral mass plating of the cervical spine.
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Affiliation(s)
- Ki Hong Cho
- Department of Neurosurgery, Ajou University School of Medicine, Suwon, Republic of Korea 443-721
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91
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Lanzino G, Kanaan Y, Perrini P, Dayoub H, Fraser K. Emerging Concepts in the Treatment of Intracranial Aneurysms: Stents, Coated Coils, and Liquid Embolic Agents. Neurosurgery 2005; 57:449-59; discussion 449-59. [PMID: 16145523 DOI: 10.1227/01.neu.0000170538.74899.7f] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
ABSTRACT
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.
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Affiliation(s)
- Giuseppe Lanzino
- Department of Neurosurgery, Illinois Neurological Institute, University of Illinois College of Medicine, Peoria, IL 61637, USA.
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92
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Abstract
Traumatic brain injury (TBI) is a common and potentially devastating clinical problem. Because prompt proper management of TBI sequelae can significantly alter the clinical course especially within 48 h of the injury, neuroimaging techniques have become an important part of the diagnostic work up of such patients. In the acute setting, these imaging studies can determine the presence and extent of injury and guide surgical planning and minimally invasive interventions. Neuroimaging also can be important in the chronic therapy of TBI, identifying chronic sequelae, determining prognosis, and guiding rehabilitation.
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Affiliation(s)
- Bruce Lee
- Department of Medicine, University of Pennsylvania Health System, Philadelphia, Pennsylvani 19104, USA
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93
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Robinson DH. Vascular Lesions of the Skull Base: Endovascular Prospective for the Otolaryngologist. Otolaryngol Clin North Am 2005; 38:737-71. [PMID: 16005729 DOI: 10.1016/j.otc.2005.03.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
With continual advances being made in endovascular equipment and techniques, the role that these image-guided, minimally invasive therapies play in the multidisciplinary management of vascular lesions of the skull base will probably continue to expand. The introduction of emerging technologies, including the development and implementation of implantable bioactive devices such as drug-eluting stents, bioactive embolic coils, and bioactive particulate embolic materials, will provide an increasing array of options for these patients. This article has reviewed the basic concepts of embolization and revascularization for vascular lesions of the skull base encountered by the practicing otolaryngologist. These concepts can provide a framework for collaboration between the otolaryngologist and neuroendovascular operator in a cooperative approach to these patients. The importance of detailed knowledge of the vascular anatomy of the skull base when dealing with these lesions, the concept of dangerous anastomoses, several clinically useful classification schemes for these lesions, and basic endovascular techniques of embolization and revascularization have been highlighted.
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Affiliation(s)
- David H Robinson
- Vascular Center, Section of Interventional Radiology, Department of Radiology, Virginia Mason Medical Center, 1100 Ninth Avenue, Seattle, WA 98101, USA.
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94
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Marden FA, Sinha Roy S, Malisch TW. A novel approach to direct carotid cavernous fistula repair: HydroCoil-assisted revision after balloon reconstruction. ACTA ACUST UNITED AC 2005; 64:140-3; discussion 143. [PMID: 16051006 DOI: 10.1016/j.surneu.2004.09.040] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2004] [Accepted: 09/20/2004] [Indexed: 11/16/2022]
Abstract
BACKGROUND Direct carotid cavernous fistulae (CCF) are commonly treated by endovascular deployment of a detachable balloon into the cavernous sinus to reconstruct the sidewall of the carotid artery and preserve flow in that vessel. Relatively few reports exist describing revisions using constructive, transarterial approaches when this technique fails. METHODS We describe a novel method using expandable hydrogel-coated platinum coils to revise a failed balloon reconstruction in which the balloon had migrated within the cavernous sinus away from the rent in the carotid wall. RESULTS This new technique to buttress the balloon back into the desired position using expandable coils proved to be effective, safe, and durable. CONCLUSIONS As endovascular treatments for direct CCF continue to evolve, techniques for revision will likely follow. This report adds a novel approach to our therapeutic armamentarium.
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Affiliation(s)
- Franklin A Marden
- Department of Radiology, University of Illinois at Chicago, Chicago, IL 60612, USA.
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95
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Joo JY, Ahn JY, Chung YS, Chung SS, Kim SH, Yoon PH, Kim OJ. Therapeutic Endovascular Treatments for Traumatic Carotid Artery Injuries. ACTA ACUST UNITED AC 2005; 58:1159-66. [PMID: 15995463 DOI: 10.1097/01.ta.0000171550.01402.ed] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The diagnosis and management of traumatic carotid vessel injuries continue to be controversial, with direct surgical repair with parent artery preservation still presenting difficulties. The purpose of this report is to review the endovascular therapy of patients with traumatic carotid vessel injuries for preservation of the parent artery, and to determine the safety and efficacy of endovascular therapy. METHODS Ten patients with traumatic carotid lesions were treated using therapeutic endovascular methods. Endovascular therapy was accomplished by implanting balloons, porous or polytetrafluoroethylene-covered stents, and/or embolic materials including coils or glue. RESULTS All fistulas and pseudoaneurysms were successfully embolized with no periprocedural complications including vessel disruption/rupture, distal embolization, or new neurologic deficits. The parent arteries of all patients except one were preserved. The reason for the parent artery sacrifice was a thrombus formation due to coil migration into the parent artery. No additional surgical procedures for vascular lesions were required. There were no delayed neurologic or vascular complications, and no lesions recurred during the follow-up periods (mean 20.3 months). CONCLUSION The goal of endovascular therapy is the selective elimination of the vascular pathology with the normal patency of the cerebral arteries. The authors' experience demonstrates that endovascular therapy using stents, balloons, and coils is both feasible and safe for treatment of traumatic carotid injuries. Of these endovascular methods, the stent can be used to exclude the aneurysm or fistula from the circulation and preserve the parent artery in selective cases. Long-term follow-up review of these repairs will be necessary to provide a full evaluation of the safety and efficacy of these devices.
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Affiliation(s)
- Jin Yang Joo
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, South Korea
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96
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Krings T, Hans FJ, Möller-Hartmann W, Brunn A, Thiex R, Schmitz-Rode T, Verken P, Scherer K, Dreeskamp H, Stein KP, Gilsbach J, Thron A. Treatment of Experimentally Induced Aneurysms with Stents. Neurosurgery 2005; 56:1347-59; discussion 1360. [PMID: 15918952 DOI: 10.1227/01.neu.0000159887.03290.d1] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2004] [Accepted: 12/02/2004] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Although Guglielmi detachable coil systems have been widely accepted for treatment of intracranial aneurysms, primary stenting of aneurysms using porous stents, stent grafts, or implantation of coils after stent placement constitute emerging techniques in endovascular treatment. The aim of the present study was to use an animal model to investigate these different approaches to treat cerebral aneurysms with regard to the rate of closure and the histopathological changes within the aneurysm cavity and the parent vessel after stent placement. METHODS We created aneurysms in 30 rabbits by distal ligation and intraluminal incubation of the right common carotid artery with elastase. Ten animals were treated with porous stents alone, 10 animals with stent grafts (covered stents), and 10 animals with stents and additional coiling via the interstices of the stent, which enabled dense packing of the coils. Five animals in each group were observed for 1 month and the other animals for 3 months. Histological analyses were performed, including immunohistochemical investigations for estimating the proliferation of the intima and possible inflammatory infiltration. RESULTS Covered stents led to a complete and stable aneurysm occlusion with only minimal proliferative carrier vessel wall changes. One covered stent was completely occluded with old thrombus, and the other 9 remained patent. Porous stents occluded two of five aneurysms in the 1-month follow-up group and four of five after 3 months. However, progressive sprouting of neointima inside the carrier vessel that resulted in a stenosis of up to 40% was present. In the Stent + Coil group, one aneurysm showed recanalization after 1 month, and three of five aneurysms were recanalized after 3 months after coil compaction. Moreover, in-stent stenosis of up to 30% was present. CONCLUSION This study demonstrates the possible shortcomings and problems of emerging stent techniques to treat intracerebral aneurysms, shows where technical advances have to be made, and describes in which cases of aneurysm morphology caution has to be exercised when considering an endovascular approach using stents.
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Affiliation(s)
- Timo Krings
- Department of Neuroradiology, University Hospital, University of Technology, Aachen, Germany.
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97
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Lee B, Newberg A. Neuroimaging in traumatic brain imaging. Neurotherapeutics 2005. [DOI: 10.1007/bf03206678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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98
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Garcia Alzamora M, Rosahl SK, Lehmberg J, Klisch J. Life-threatening bleeding from a vertebral artery pseudoaneurysm after anterior cervical spine approach: endovascular repair by a triple stent-in-stent method. Case report. Neuroradiology 2005; 47:282-6. [PMID: 15789201 DOI: 10.1007/s00234-005-1343-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2004] [Accepted: 11/16/2004] [Indexed: 10/25/2022]
Abstract
The incidence of injury to the cervical vertebral artery during surgery for stenosis of the cervical neuroforamina is very low. We present a case in which bleeding during microforaminotomy at the level C6/7 occurred. The bleeding could be controlled intraoperatively. Two days later, a life-threatening cervical hematoma required urgent bedside evacuation. A false aneurysm of the left cervical vertebral artery was successfully occluded by a modified triple stent-in-stent technique, maintaining the flow in the vessel.
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Affiliation(s)
- Meritxell Garcia Alzamora
- Section of Neuroradiology, Neurocenter, University of Freiburg, Breisacher Str. 64, 79106 Freiburg, Germany.
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99
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Akiyama Y, Nakahara I, Tanaka M, Iwamuro Y, Hayashi J, Harada K, Fujimoto M. Urgent Endovascular Stent-Graft Placement for a Ruptured Traumatic Pseudoaneurysm of the Extracranial Carotid Artery. ACTA ACUST UNITED AC 2005; 58:624-7. [PMID: 15761362 DOI: 10.1097/01.ta.0000096662.79685.ea] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Yasuhiko Akiyama
- Department of Neurosurgery, Kokura Memorial Hospital, Fukuoka, Japan.
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100
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O'Shaughnessy BA, Getch CC, Bowman RM, Batjer HH. Ruptured traumatic vertebral artery pseudoaneurysm in a child treated with trapping and posterior inferior cerebellar artery reimplantation. J Neurosurg 2005; 102:231-7. [PMID: 16156237 DOI: 10.3171/jns.2005.102.2.0231] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors present the case report of a pediatric patient with a ruptured traumatic pseudoaneurysm of the intracranial vertebral artery (VA) from which the posterior inferior cerebellar artery (PICA) emerged. After considering multiple therapeutic options, the patient was treated surgically by trapping of the aneurysm segment and direct reimplantation of the PICA distal to the rupture site. In addition to presenting this unique case, the authors discuss the treatment of VA pseudoaneurysms and the various techniques for PICA revascularization. A review of the literature on PICA reimplantation is provided as an adjunct in the treatment of complex VA aneurysms.
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Affiliation(s)
- Brian A O'Shaughnessy
- Department of Neurological Surgery, The Feinberg School of Medicine, McGaw Medical Center, Children's Memorial Hospital, Northwestern University, Chicago, Illinois 60611, USA
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