Intracranial Endovascular Balloon Test Occlusion—Indications, Methods, and Predictive Value

Proximal Internal Carotid Artery Occlusion and Extracranial-Intracranial Bypass for Treatment of Fusiform and Giant Internal Carotid Artery Aneurysms

OBJECTIVE

To discuss the treatment of intracranial fusiform and giant internal carotid artery (ICA) aneurysms via revascularization based on our institutional experience.

METHODS

An institutional review board-approved retrospective analysis was performed of patients with unruptured fusiform and giant intracranial ICA aneurysms treated from November 1991 to May 2020. All patients were evaluated for extracranial-intracranial (EC-IC) bypass and ICA occlusion.

RESULTS

Thirty-eight patients were identified. Initially, patients failing preoperative balloon test occlusion were treated with superficial temporal artery (STA)-middle cerebral artery (MCA) bypass and concurrent proximal ICA ligation. We then treated them with STA-MCA bypass, followed by staged balloon test occlusion, and, if they passed, endovascular ICA coil occlusion. We treat all surgical medically uncomplicated patients with double-barrel STA-MCA bypass and concurrent proximal ICA ligation. The mean length of follow-up was 99 months. Symptom stability or improvement was noted in 85% of patients. Bypass graft patency was 92.1%, and all surviving patients had patent bypasses at their last angiogram. Aneurysm occlusion was complete in 90.9% of patients completing proximal ICA ligation. Three patients experienced ischemic complications and 4 patients experienced hemorrhagic complications.

CONCLUSIONS

Not all fusiform intracranial ICA aneurysms require intervention, except when life-threatening rupture risk is high or symptomatic management is necessary to preserve function and quality of life. EC-IC bypass can augment the safety of proximal ICA occlusion. The rate of complete aneurysm occlusion with this treatment is 90.9%, and long-term bypass graft-related complications are rare. Perioperative stroke is a major risk, and continued evolution of treatment is required.

An algorithm for the treatment of concurrent pituitary adenoma and cavernous sinus aneurysm: A systematic review & case report

BACKGROUND

Rarely, Pituitary adenomas (PA) can co-occur with intrasellar or intracavernous aneurysms. There is currently no clear guidance for the management of this dual pathology. We attempt to provide an algorithm to help guide clinical decision making for treatment of PAs co-occurring with adjacent cerebral aneurysms.

METHODS

A comprehensive literature search was conducted following PRISMA guidelines using various databases. Search terms included "(Pituitary Adenoma OR Prolactinoma OR Macroadenoma OR Adenoma) AND (ICA OR Internal Carotid Artery OR paracliniod OR clinoid) Aneurysm AND (Intra-cavernous OR intracavernous OR intrasellar OR Cavernous)."

RESULTS

A total of 24 studies with 24 patients were included. Twelve (50%) patients experienced visual symptoms. Ten patients (42%) had an aneurysm embedded within the adenoma. Fourteen patients (58%) had an aneurysm adjacent to the adenoma. Embedded aneurysms were significantly associated with rupture events.

CONCLUSION

Vision loss is the most pressing determinant of treatment. In the absence of visual symptoms, the aneurysm should be treated first by coil embolization. If not amenable to coiling, place flow diverting stent followed by six months of anticoagulation and antiplatelet therapy. If visual loss is apparent, the adenoma-aneurysm spatial relationship becomes critical. In cases of an adjacent aneurysm, the adenoma should be removed transsphenoidally with extreme care and aneurysm rupture protocols in place. If the aneurysm is embedded within the adenoma, then a BTO is favored with permanent ICA occlusion followed by transsphenoidal resection if adequate collateral supply is demonstrated. If there is inadequate collateral supply, then an open-approach for amenable aneurysms with transcranial adenoma debulking should be performed.

Preoperative percutaneous Onyx embolization of carotid body paragangliomas with balloon test occlusion

Objectives

The study aims to analyze our first experience with direct percutaneous embolization of carotid body tumors (CBTs) using ethylene-vinyl alcohol copolymer (Onyx) along with balloon test occlusion (BTO).

Methods

A retrospective preliminary single-center study was conducted at the Otorhinolaryngology and Head and Neck Surgery Department and the Medical Imaging Department of the University Teaching Hospital. A consecutive series of three patients with CBTs was treated at the local institution between October 2018 and June 2019. All three patients underwent preoperative percutaneous embolization using ethylene-vinyl alcohol copolymer (Onyx 18) with the addition of BTO. Outcome measures were the percentage of tumor devascularization, intraoperative blood losses, and operation times. BTO was evaluated by clinical neurological examination and neurosonological transcranial Doppler examination of the middle cerebral artery (MCA).

Results

Devascularization of all three tumors was complete or near complete. All three tumors were surgically extirpated with excellent surgical outcomes. The blood losses were minimal, and the average operation time was 2 h and 8 min. BTO was positive in one patient, which was valuable additional information on carotid branches ligation limitations. The other two patients showed negative BTOs with the result of safety of eventual carotid arteries ligations.

Conclusion

Preoperative direct percutaneous embolization of CBT with Onyx is a highly effective procedure that significantly facilitates surgery. BTO provides valuable additional information on the most appropriate and safe surgical approach.

Endovascular treatment of anterior inferior cerebellar artery trunk aneurysms

BACKGROUND

The anterior inferior cerebellar artery (AICA) is a very slender and anatomically variable artery that gives off many important perforating arteries that feed the brainstem and nerve-related arteries that feed the inner ear and labyrinth. AICA trunk aneurysms are rare entities that are also difficult to manage. At present, endovascular treatment (EVT) is the preferred choice; however, the understanding of EVT for AICA trunk aneurysms is limited.

METHODS

In this article, we present a literature review on EVT for AICA trunk aneurysms. To promote understanding, we would also provide some illustrative educational cases of our institute.

RESULTS

Aneurysms along the AICA trunk can occur alone (isolated AICA aneurysm) or secondary to cerebrovascular shunts (flow-related AICA aneurysm). According to their anatomical location, they can also be divided into proximal and distal types. At present, EVT is the mainstream treatment, mainly including selective coiling with parent artery preservation and parent artery occlusion. Both coils and liquid embolization materials can be used.

CONCLUSIONS

For AICA trunk aneurysms, EVT is a reasonable choice and should be based on the specific anatomical location, pathology, and collateral circulation. However, there is still controversy as to the specific type of treatment that should be chosen.

Balloon-Assisted Roadmap Technique to Enable Flow Diversion of a High-Flow Direct Carotid-Cavernous Fistula

BACKGROUND

The use of flow diverters as a first-line treatment for direct carotid cavernous fistula (CCF) is a relatively new approach in the neurointerventional field which allows obliteration of the fistula with less mass effect from coils in the cavernous sinus. Safe and successful deployment of a flow diverter requires adequate imaging of the parent vessel, which may be challenging in the setting of high-flow CCF without antegrade flow.

OBJECTIVE

To facilitate adequate parent vessel imaging in the setting of high-flow CCF to enable the safe development of a flow diverter device.

METHODS

Here we present the case of a patient with delayed presentation of post-traumatic direct CCF after a motor vehicle accident, with no antegrade flow past the fistulous connection. We used temporary balloon occlusion of the fistulous connection to enable road-map imaging of the parent vessel and flow-diverter placement. "Drag and drop" device opening in the middle cerebral artery facilitated better deployment of the flow-diverter against retrograde cavernous flow through the fistula.

RESULTS

Temporary balloon occlusion of the fistulous connection was used to acquire a roadmap to facilitate safe deployment of a flow diverter and subsequent treatment of the CCF with transvenous coil embolization, with complete resolution of symptoms.

CONCLUSION

Balloon-assisted roadmap use is a novel means of visualizing the parent vessel in direct CCF to facilitate safe flow diverter deployment.

Management of Cutaneously Exposed Carotid Stents in Recurrent and Unresectable Head and Neck Cancer

Objective Carotid blowout syndrome (CBS) is a rare but potentially life-threatening complication of head and neck cancer (HNC) treatment. Patients with CBS are managed with covered stents, limited published information exists regarding the management of delayed complications, specifically cutaneous exposure of stents. Here, we present our experience managing cutaneously exposed carotid artery stents (CAS) in patients with recurrent and unresectable HNC.

Methods A single-institution retrospective analysis was performed to identify recurrent HNC patients who underwent CAS placement for CBS and complicated with cutaneous exposure of the stent between 2014 and 2016. Medical records were reviewed with attention to treatment history, pre-, intra-, and postoperative courses, anticoagulation needs, and durability of the reconstruction.

Results We identified three patients who presented with a right CAS fully exposed in a large, ulcerative wound. All patients underwent a right pectoralis major myocutaneous flap (PMMF) to cover the exposed stent within 30 days of presentation to our institution. Two of three patients attained adequate coverage of the stent for more than 30 days, while one experienced partial flap dehiscence within 12 days. Two patients developed postoperative chest hematomas, which were managed conservatively. Two of three patients were able to undergo further palliative adjuvant treatments within 60 days of the initial surgical procedure.

Conclusion In this small series, durable coverage of an exposed carotid artery with PMMF was successful in two of three patients with extensive disease burden and complex prior treatment history. No mortalities occurred within 30 days postoperatively.

Neurovascular Perfusion Study With DynaPBV During Preoperative Balloon Test Occlusion: A Feasibility Study on Aneurysm and Tumor Lesions

To report feasibility, safety, and technical advantages of flat-detector computed tomography perfusion (FD-CTP) during balloon test occlusion (BTO) angiography studies, 10 patients patients scheduled for BTO were evaluated. Cerebral blood volume maps were extracted from FD-CTP images acquired during the test. The FD-CTP perfusion combined with BTO is feasible and safe in intracranial tumor, and aneurysm cases in which vessel sacrifice should be considered.

Superficial temporal artery-middle cerebral artery bypass for the treatment of complex middle cerebral artery aneurysms

Objectives:

Direct microsurgical clipping for complex middle cerebral artery (MCA) aneurysms may require a long ischemic time. Sacrifice of the parent artery with trapping or endovascular coiling also may lead to ischemic stroke. We described our institutional experience with the treatment of complex MCA aneurysms using extracranial-intracranial (EC-IC) (superficial temporal artery [STA]-MCA) bypass.

Materials and Methods:

We retrospectively reviewed patients who had treatment of IC aneurysms with the assistance of STA-MCA bypass from July 2002 to December 2016. Six patients with complex MCA aneurysms were identified, and we reviewed their clinical characteristics.

Results:

There were three men and three women with age ranging from 27 to 59 (mean 49) years old. Image studies showed subarachnoid hemorrhage in three cases. All patients underwent STA-MCA anastomosis, and the follow-up period ranged from 2 to 116 months (mean 51.5 months). Two of the six MCA aneurysms were fusiform, two aneurysms had bizarre configurations, one was a dissecting saccular aneurysm, and one had a blister configuration. Three patients received direct vessel trapping, two patients received aneurysm clipping, and one received aneurysm coiling. The postoperative bypass patency rate was 100%. The modified Rankin scale showed good outcomes in the six patients.

Conclusions:

EC-IC bypass plays an important role as a salvage procedure in the treatment of complex MCA aneurysms which have a fusiform, bizarre, or blister configuration.

Treatment strategies for dissecting aneurysms of the posterior cerebral artery

BACKGROUND

Dissecting aneurysms of the posterior cerebral artery (PCA) are rare and difficult to treat because of their deep and unfamiliar locations and unusual shapes. Although several treatment modalities have been proposed, none have generated satisfying results. Our experiences with PCA-dissecting aneurysms are reviewed and the treatment strategies discussed.

METHODS

All consecutive patients with PCA-dissecting aneurysm who were treated in a tertiary referral hospital between January 1998 and March 2014 were identified by retrospective review. Their clinical characteristics, radiological findings, treatment modalities and outcomes were documented.

RESULTS

Of the 21 patients with 21 PCA-dissecting aneurysms, 9 had subarachnoid hemorrhage and 3 had acute infarction of the thalamus at presentation. The aneurysms involved P1 (n = 4), the P1-2 junction (n = 3), mid-P2 (n = 6), P2A (n = 3), P2P (n = 1) and the P2-3 junction (n = 4). The aneurysm shapes were as follows: fusiform (n = 12), partially thrombosed (n = 8) and blood blister-like aneurysms (n = 1). The mean size was 16.6 ± 9.7 mm. Parent artery occlusion (PAO) without bypass (n = 15), PAO with bypass (n = 2), stent-assisted endosaccular coiling (n = 3) and stent placement only (n = 1) were performed. All three patients who underwent stent-assisted endosaccular coiling and the single patient who underwent PAO without bypass developed aneurysm recurrence. Six of the ten patients who received a PAO without a balloon test occlusion (BTO) experienced PCA territory infarction, whereas only one of the five patients who received a PAO after passing the BTO experienced an infarction.

CONCLUSIONS

PAO for PCA-dissecting aneurysm was effective in preventing recurrence. In addition, BTO before PAO was helpful in identifying candidates who truly needed surgical revascularization.