Long-Term Follow-Up Results following Elective Treatment of Unruptured Intracranial Aneurysms with the Pipeline Embolization Device

BACKGROUND AND PURPOSE

Numerous reports of treatment of wide-neck aneurysms by flow diverters have been published; however, long-term outcomes remain uncertain. This article reports the imaging results of unruptured aneurysms treated electively with the Pipeline Embolization Device for up to 56 months and clinical results for up to 61 months.

MATERIALS AND METHODS

One hundred nineteen aneurysms in 98 patients from 3 centers admitted between August 2009 and June 2011 were followed at 6-month, 1-year, and 2+-year postprocedural timeframes. Analyses on the effects of incorporated vessels, previous stent placement, aneurysm size, and morphology on aneurysm occlusion were performed.

RESULTS

The 1- and 2+-year imaging follow-ups were performed, on average, 13 and 28 months postprocedure. At 2+-year follow-up, clinical data were 100% complete and imaging data were complete for 103/116 aneurysms (88.8%) with a 93.2% occlusion rate. From 0 to 6 months, TIA, minor stroke, and major stroke rates were 4.2%, 3.4%, and 0.8% respectively. After 6 months, 1 patient had a TIA of uncertain cause, with an overall Pipeline Embolization Device-related mortality rate of 0.8%. An incorporated vessel was significant for a delay in occlusion (P = .009) and nonocclusion at 6 months and 1 year, with a delayed mean time of occlusion from 9.1 months (95% CI, 7.1-11.1 months) to 16.7 months (95% CI, 11.4-22.0 months). Other factors were nonsignificant.

CONCLUSIONS

The Pipeline Embolization Device demonstrates continued very high closure rates at 2+ years, with few delayed clinical adverse sequelae. The presence of an incorporated vessel in the wall of the aneurysm causes a delay in occlusion that approaches sidewall closure rates by 2 years.

Safety of the pipeline embolization device in treatment of posterior circulation aneurysms

BACKGROUND AND PURPOSE

The published results of treating internal carotid artery aneurysms with the PED do not necessarily apply to its use in the posterior circulation because disabling brain stem infarcts can be caused by occlusion of a single perforator. In this multicenter study, we assessed the safety of PED placement in the posterior circulation.

MATERIALS AND METHODS

A prospective case registry was maintained of all posterior circulation aneurysms treated with PEDs at 3 Australian neurointerventional centers during a 27-month period. The objective was to assess the complications and aneurysm occlusion rates associated with posterior circulation PEDs.

RESULTS

Thirty-two posterior circulation aneurysms were treated in 32 patients. No deaths or poor neurologic outcomes occurred. Perforator territory infarctions occurred in 3 (14%) of the 21 patients with basilar artery aneurysms, and in all 3, a single PED was used. Two asymptomatic intracranial hematomas were recorded. No aneurysm rupture or PED thrombosis was encountered. The overall rate of permanent neurologic complications was 9.4% (3/32); all 3 patients had very mild residual symptoms and a good clinical outcome. Aneurysm occlusion was demonstrated in 85% of patients with >6 months of follow-up and 96% of patients with >1 year of follow-up.

CONCLUSIONS

The PED is effective in the treatment of posterior circulation aneurysms that are otherwise difficult or impossible to treat with standard endovascular or surgical techniques, and its safety is similar to that of stent-assisted coiling techniques. A higher clinical perforator infarction rate may be associated with basilar artery PEDs relative to the internal carotid artery.

Cerebral hyperperfusion syndrome post-carotid artery stenting

Cerebral hyperperfusion syndrome is increasingly recognized as a complication in carotid artery stenting for severe internal carotid artery stenosis. This study reviews the cases of hyperperfusion syndrome occurring after this procedure. We reviewed our database of 170 cases of internal carotid artery stenting carried out at our hospital between January 1999 and June 2006. A radiology search was also carried out to identify those who had CT or MRI within 1 month of post-carotid artery stenting. We had four patients who developed cerebral hyperperfusion syndrome. One patient developed cerebral oedema, one patient had petechial intracerebral haemorrhage and two patients had large intracerebral haemorrhages, one of whom died. This gives a risk of 2.3% (95% confidence interval 2.27-2.323). All patients with cerebral haemorrhage presented within 6 h. Both patients with large intracerebral haemorrhage had carotid stenting within 3 weeks after presentation of symptoms and all had critically severe stenosis of 95% or more. In our series, large intracerebral haemorrhage has occurred only in patients who have been treated early. Cerebral hyperperfusion is an uncommon but serious complication post-carotid stenting. Further studies comparing early treatment of endarterectomy and carotid stenting are awaited.

Endovascular treatment of intracranial aneurysms with Guglielmi detachable coils: analysis of midterm angiographic and clinical outcomes

BACKGROUND AND PURPOSE

The previous decade has witnessed increasing application of Guglielmi detachable coils (GDCs) for the treatment of intracranial aneurysms. However, the midterm angiographic and clinical outcomes are not well documented. We report here the angiographic and clinical outcomes of patients treated with GDCs over an 8-year period.

METHODS

Between 1992 and 1998, 144 patients with 160 intracranial aneurysms were treated with GDCs. Clinical follow-up data were obtained from medical records, questionnaires, and telephone interviews. Angiographic studies were reviewed by 2 neuroradiologists to obtain consensus regarding the degree of aneurysm occlusion.

RESULTS

Eighty-one patients had ruptured aneurysms; 63 had unruptured aneurysms. Technical success was achieved in 91% of patients, with complete aneurysm occlusion in 46%, neck remnants in 16%, and residual body filling in 38%. Angiographic follow-up revealed that residual body filling in some aneurysms was resolved, small neck remnants were stable, and the recanalization rate decreased with time. All 63 patients with unruptured aneurysms were discharged from hospital with independent clinical status (Glasgow Outcome Score, 1 or 2). For patients with ruptured aneurysms, discharge clinical status correlated with the Hunt & Hess clinical grade at the time of treatment. Clinical follow-up for a minimum of 2 years was available in 98.5% of patients. Ninety-four percent of patients treated for unruptured aneurysms were independent at 2 years, and 82% of Hunt & Hess grade I to II patients were independent.

CONCLUSIONS

Coil embolization is a safe and effective treatment for both ruptured and unruptured aneurysms. Increasing angiographic stability is demonstrated in treated aneurysms up to 3 years from coil embolization. Therefore, follow-up angiography until this time is advisable.

Use of glycoprotein IIb-IIIa inhibitor for a thromboembolic complication during Guglielmi detachable coil treatment of an acutely ruptured aneurysm

Thrombotic occlusion of the anterior communicating and right anterior cerebral arteries occurred during embolization of an acutely ruptured aneurysm of the anterior communicating artery. Traditional management, including superselective infusion of a fibrinolytic agent, was unsuccessful in reestablishing normal vessel patency. Therefore, an intravenous dose of abciximab was administered. Serial angiography showed that normal vessel patency was reestablished within 10 min. There were no adverse events related to abciximab administration, and the patient recovered from the procedure without neurologic deficit.

Endovascular treatment of a ruptured dual aperture cavernous aneurysm

The authors describe the diagnosis and endovascular management of a multiaperture, ruptured cavernous internal carotid artery aneurysm causing a carotid cavernous fistula (CCF) using both transarterial and transvenous techniques. Although uncommon, recognition of the imaging characteristics of such a lesion will aide in successful management and improve treatment outcome. To the authors' knowledge, CCF due to a ruptured cavernous aneurysm with multiple shunts has not been previously reported.

Stent angioplasty for cervical carotid artery stenosis in high-risk symptomatic NASCET-ineligible patients

BACKGROUND AND PURPOSE

Although the North American Symptomatic Carotid Endarterectomy Trial (NASCET) has shown carotid endarterectomy (CEA) to be protective compared with medical therapy alone, its stringent eligibility criteria excluded patients with severe medical, angiographic, and neurological risk factors. We sought to determine the safety and efficacy of stent angioplasty in this high-risk subset for whom the perioperative morbidity and mortality of surgery are elevated.

METHODS

Twenty-eight consecutive symptomatic NASCET-ineligible patients (10 female; median age, 72.2 years) underwent microcatheter-based carotid stent angioplasty. Half of the patients had sustained a previous stroke. Classification of surgical risk by Sundt criteria yielded no patients in grade 1, 3 patients in grade 2 (10.7%), 8 in grade 3 (28.6%), and 17 (60.7%) in grade 4. Stratification of stroke risk for medical therapy according to the European Carotid Surgery Trial (ECST) 5-point score showed 8 patients with a score of 3 (28.6%), 12 with 4 (42.8%), and 8 with 5 (28.6%). Follow-up was obtained in all patients at a median of 14 months.

RESULTS

The procedure was technically successful in all cases (100%), with immediate stenosis reduction from a mean of 80.3% to 2.7%. There were no periprocedural deaths, 1 major stroke (3.6%), no minor strokes, and 3 transient ischemic attacks (10.7%). In-hospital complications included 2 nonfatal myocardial infarctions, 1 case of acute renal failure, and 1 groin hematoma requiring transfusion. There were 5 deaths during the follow-up period, all beyond 30 days after the procedure: 3 from cardiac causes, 1 from lung cancer, and 1 following unrelated surgery. The patient with major stroke died at 7.8 months during rehabilitation. No surviving patients had further strokes, and all except 1 (95.5%) remained asymptomatic. Anatomic follow-up in 20 patients showed occlusion in 2 (10%) (1 symptomatic, 1 asymptomatic) and intimal hyperplasia in 3 asymptomatic patients (15%).

CONCLUSIONS

The clinical results and sustained freedom from symptoms and stroke during the short available follow-up period suggest that stent angioplasty may be useful in the treatment of symptomatic cervical carotid stenosis in high-risk patients despite a notable incidence of restenosis.

Carotid artery stent placement for atherosclerotic disease: rationale, technique, and current status

Carotid arterial endarterectomy is considered to be the standard for the treatment of atherosclerotic carotid arterial occlusive disease. This has been validated with results of several randomized controlled trials in which its effectiveness has been demonstrated over that of the best nonsurgical therapy. In the past several years, however, carotid angioplasty with stent placement has emerged as a potential alternative to carotid endarterectomy. This article represents a critical examination of the rationale for carotid revascularization; the history of endovascular techniques for the treatment of carotid atherosclerosis, beginning with balloon angioplasty and evolving to the use of stents; and the evidence supporting the effectiveness of the endovascular approach. A brief description of the current technical aspects of carotid artery stent placement is presented. The future status of the endovascular approach will be determined with randomized trials in which carotid artery stent placement is directly compared with endarterectomy, as well as by the potential for further innovation and improvement in endovascular devices, technique, and safety.

Primary stenting for high-grade basilar artery stenosis

We report two patients with symptomatic high-grade stenosis of the basilar artery refractory to appropriate maximal medical therapy in whom endovascular stenting was performed successfully without preliminary balloon angioplasty. Excellent angiographic results were achieved and there were no procedural or periprocedural complications. The patients were asymptomatic and neurologically intact at a mean clinical follow-up of 6.5 months. Primary stenting of basilar artery stenosis may be an alternative to balloon angioplasty for patients with symptomatic lesions refractory to medical therapy or in whom anticoagulation is contraindicated.

Endovascular management of extracranial carotid artery dissection achieved using stent angioplasty

BACKGROUND AND PURPOSE

Dissection of the carotid artery can, in certain cases, lead to significant stenosis, occlusion, or pseudoaneurysm formation, with subsequent hemodynamic and embolic infarcts, despite anticoagulant therapy. We sought to determine the therapeutic value of stent-supported angioplasty retrospectively in this subset of patients who are poor candidates for medical therapy.

METHODS

Five men and five women (age range, 37-83 years; mean age, 51.2 years) with dissection of the internal (n=9) and common (n=1) carotid artery were successfully treated with percutaneous endovascular balloon angioplasty and stent placement. The etiology was spontaneous in five, iatrogenic in three, and traumatic in two. Seven of the treated lesions were left-sided and three were right-sided.

RESULTS

The treatment significantly improved dissection-related stenosis from 74+/-5.5% to 5.5+/-2.8%. Two occlusive dissections were successfully recanalized using microcatheter techniques during the acute phase. Multiple overlapping stents were needed in four patients to eliminate the inflow zone and false lumen and establish an angiographically smooth outline within the true lumen. There was one case of retroperitoneal hemorrhage, but there were no procedural transient ischemic attacks (TIAs), minor or major strokes, or deaths (0%). Clinical outcome at latest follow-up (16.5+/-1.9 months) showed significant improvements compared with pretreatment modified Rankin score (0.7+/-0.3 vs 1.8+/-0.44) and Barthel index (99.5+/-0.5 vs 80.5+/-8.9). One delayed stroke occurred in a treated patient with contralateral carotid occlusion following a hypotensive uterine hemorrhage at 8 months; the remaining nine patients have remained free of TIA or stroke.

CONCLUSION

In select cases of carotid dissection associated with critical hemodynamic insufficiency or thromboembolic events that occur despite medical therapy, endovascular stent placement appears to be a safe and effective method of restoring vessel lumen integrity, with good clinical outcome.

Cerebral hyperperfusion syndrome after percutaneous transluminal stenting of the craniocervical arteries

OBJECTIVE

Cerebral hyperperfusion syndrome is a recognized complication of carotid endarterectomy, with a reported incidence of 0.3 to 1.2%. The incidence of cerebral hyperperfusion after endovascular revascularization procedures of the craniocervical arteries remains unknown. We evaluated the incidence of cerebral hyperperfusion syndrome in our endovascular revascularization series. To our knowledge, there are no previous studies evaluating the incidence of hyperperfusion syndrome after percutaneous transluminal angioplasty/stenting.

METHODS

Between March 1996 and February 2000, 140 patients underwent percutaneous transluminal angioplasty/stenting of the craniocervical arteries at our institution. In all patients, selective bilateral arteriography of the carotid and vertebral arteries was performed to document the sites of craniocervical stenosis and collateral blood flow and the results of the endovascular revascularization procedure. We then reviewed all pertinent medical records, arteriographic films, and sectional imaging studies to determine the incidence of cerebral hyperperfusion in this series.

RESULTS

Seven patients (5.0%) developed clinical or radiological manifestations of cerebral hyperperfusion. In the target group, percutaneous transluminal stenting achieved a 90 to 100% reduction in stenotic lesions (mean stenosis, 91%) of the carotid (n = 5) and vertebral (n = 2) arteries. All seven patients remained neurologically stable immediately after treatment. There was delayed development of clinical and radiographic findings, suggestive of cerebral hyperperfusion. Six patients showed evidence of ipsilateral hemispheric edema, including two patients who developed intracranial hemorrhage (one parenchymal, one parenchymal and subarachnoid) documented by computed tomographic brain scans. Symptoms resolved within 72 hours in the four patients without hemorrhage. The two patients with hemorrhage recovered during a more protracted period (range, 3 wk to 6 mo). There were no long-term sequelae or deaths during a cumulative follow-up of 84 months (mean follow-up, 12 mo).

CONCLUSION

Hyperperfusion syndrome is an uncommon but potentially serious complication of extracranial and intracranial angioplasty and stenting procedures. The clinical manifestations are similar to hyperperfusion syndrome after carotid endarterectomy; however, the prevalence may be greater in the high-risk cohort commonly referred for endovascular treatment. Our findings suggest that patients undergoing endovascular stenting procedures should be closely monitored for evidence of hyperperfusion, with careful monitoring of blood pressure, heart rate, and anticoagulation. Further research is needed to confirm that cerebral hyperperfusion is the pathogenesis of this condition.

Endovascular treatment of cerebral artery aneurysms during pregnancy: report of three cases

Historically, surgical management of cerebral aneurysms during pregnancy has been controversial. Debate originally focused on early versus late intervention, before or after delivery of the fetus. More recently, treatment has centered on rapid intervention. We describe the endovascular treatment of cerebral artery aneurysms with Guglielmi detachable coils in three pregnant women.

Stent-supported coil embolization: the treatment of fusiform and wide-neck aneurysms and pseudoaneurysms

OBJECTIVE

We describe a consecutive series of patients treated with endovascular stent-supported coil embolization for symptomatic or enlarging wide-neck and fusiform aneurysms and pseudoaneurysms of the carotid and vertebrobasilar arteries.

METHODS

Seven stent-supported coil embolization procedures were performed for seven aneurysms in seven consecutive patients. There were five pseudoaneurysms, one dissecting aneurysm, and one berry aneurysm. Four aneurysms were located in the carotid artery, and three were located in the vertebrobasilar system. Three aneurysms were intracranial. Four patients were symptomatic, and three had angiographic evidence of increasing aneurysm size.

RESULTS

Technical success was achieved in six (86%) of seven patients. Entanglement of a coil with the stent struts necessitated partial coil delivery into the parent artery in one patient, but there were no neurological or other adverse sequelae. The 30-day rate of periprocedural stroke or mortality was 0%. At a mean clinical follow-up of 14.5 months, neurological status was at baseline or better in all patients. To date, all treated patients remain clinically asymptomatic with oral administration of aspirin only.

CONCLUSION

Stent-supported coil embolization represents an emerging therapeutic alternative to surgery for the treatment of symptomatic or enlarging wide-neck and fusiform aneurysms and pseudoaneurysms of the cervical and vertebrobasilar arteries, which are not amenable to conventional unsupported coil embolization. Experience with greater numbers of patients and long-term follow-up are required to further validate this technique.

Balloon-assist technique for endovascular coil embolization of geometrically difficult intracranial aneurysms

OBJECTIVE

The balloon-assist or neck-remodeling technique is an adjunctive method devised for the endovascular coil embolization of aneurysms characterized by a wide neck or unfavorable geometric features. Since its initial description, there have been few data to corroborate its utility, efficacy, and safety in aneurysm embolization.

METHODS

Twenty patients (19 female patients and 1 male patient) with 22 aneurysms (19 unruptured aneurysms and 3 ruptured aneurysms) underwent balloon-assisted coil embolization. The balloon-assist technique was performed in the same treatment session after conventional coil embolization had failed in 55% of cases (12 of 22 cases) and was the primary treatment in 45% of cases. The majority of aneurysms were located in the supraclinoid carotid artery (13 paraophthalmic and 3 superior hypophyseal aneurysms). The mean angiographic measurements included a fundus of 8.7 +/- 3.7 mm, a neck of 5.3 +/- 2.2 mm, and a comparatively unfavorable fundus/neck ratio of 1.33 +/- 0.23.

RESULTS

Technical success was achieved in 77% of cases (17 of 22). The rate of aneurysm obliteration at the end of the procedures was 97 +/- 3.8%. Angiographic follow-up data (mean follow-up period, 10.3 mo) obtained for 89% of the treated aneurysms (15 of 17) confirmed stable mean occlusion of 97.8 +/- 3.8%. Technical complications included two cases of asymptomatic distal vessel thromboembolism, which resolved angiographically within 24 hours, and one case of intraprocedural rupture of an arteriovenous malformation-related feeder artery aneurysm, which resulted in no neurological deficits and required no further treatment (transient complication rate, 13.6%; 3 of 22 cases). There were no deaths and no procedure-related 30-day or permanent morbidity.

CONCLUSION

The balloon-assist method of coil embolization is characterized by promising intermediate-term angiographic and clinical outcomes and acceptable morbidity and mortality rates. Although this adjunctive method requires the use of an additional microcatheter and consequently involves a higher level of technical complexity, it extends the range of aneurysms that can be successfully treated with electrolytically detachable coils via an endovascular approach.

Endovascular stenting for carotid artery stenosis: preliminary experience using the shape-memory- alloy-recoverable-technology (SMART) stent

We describe our initial clinical experience using the newly available self-expanding, Nitinol, shape-memory-, alloy-recoverable-technology (SMART) stent in treating carotid artery occlusive disease. Five stents were used in four carotid arteries in four consecutive patients with carotid stenosis of at least 70%. Technical success (<20% residual stenosis) was achieved in all cases. No procedural complications specifically related to use of the SMART stent were encountered. All patients remained symptom-free, with no evidence of transient ischemic attacks or new strokes during an average follow-up period of 6 months. Excellent performance of the SMART stent for the endovascular treatment of carotid artery stenosis has been shown based on our early experience. Validation with greater numbers and longer-term follow-up is required. The specific technical characteristics, potential advantages, and disadvantages of this stent are discussed and compared with other currently used carotid artery stents.

Endovascular treatment of noncarotid extracranial cerebrovascular disease

The last two decades have witnessed a growing application of endovascular techniques for the treatment of atherosclerotic disease of the extracranial vertebral arteries, subclavian arteries, and brachiocephalic artery. Beginning with simple balloon angioplasty, these minimally invasive techniques have now progressed to the use of stent-supported angioplasty. Stent-supported angioplasty is currently providing a therapeutic alternative to traditional methods of open surgery for revascularization of these vessels and increasing the therapeutic options available for patients who have failed maximal medical therapy. Additionally, endovascular techniques are also being used successfully to treat a variety of nonatherosclerotic diseases affecting the noncarotid extacranial arteries, such as inflammatory, radiation, and anastomotic-graft strictures; acute intimal dissection; traumatic and spontaneous arteriovenous fistulas; and aneurysms or pseudoaneurysms. Continued innovation and refinement of endovascular devices and techniques will inevitably improve technical success rates, reduce procedure-related complications, and broaden the endovascular therapeutic spectrum for extracranial cerebrovascular disease.

Patient presentation, angiographic features, and treatment of strangulation-induced bilateral dissection of the cervical internal carotid artery. Report of three cases

Domestic violence leading to strangulation by an abusive spouse can cause carotid artery dissection. This phenomenon is rare and has been described in only three previous instances. The authors present their management strategies in three additional cases. Three young women aged 24 to 43 years were victims of manual strangulation committed by their spouses 3 months to 1 year before presentation. Two of the patients suffered delayed cerebral infarctions before presentation and angiography demonstrated focal, mirror-image severe residual stenoses in the high-cervical internal carotid artery (ICA), which were characteristic of a healed chronic dissection; there was no evidence of fibromuscular dysplasia. One of these patients underwent unilateral percutaneous angioplasty with stent placement, and the other underwent bilateral percutaneous angioplasty. Both patients have recovered from their strokes and remain clinically stable at 8 and 20 months posttreatment, respectively. The third patient presented with bilateral ischemic frontal watershed infarctions resulting from an occluded left ICA and a severely narrowed right ICA. Given the extent of the established infarctions, this case was managed with a long-term regimen of anticoagulation medications, and the patient remains neurologically impaired. These cases illustrate the susceptibility of the manually compressed ICA to traumatic injury as a result of domestic violence. They identify bilateral symmetrical ICA dissection as a consistent finding and the real danger of delayed stroke as a consequence of strangulation. Endovascular therapy in which percutaneous angioplasty and/or stent placement are used can be useful in treating residual focal stenoses to improve cerebral perfusion and to lower the risk of embolic or ischemic stroke.

Endovascular treatment of ruptured posterior circulation cerebral aneurysms. Clinical and angiographic outcomes

BACKGROUND AND PURPOSE

We sought to describe the clinical outcome and angiographic results obtained in the endovascular therapy of ruptured posterior circulation cerebral aneurysms using Guglielmi detachable coils (GDC) over a 7-year period.

METHODS

A retrospective analysis was performed of 112 patients evaluated at the University of California at San Francisco Medical Center between June 1991 and August 1998. The Hunt-Hess grade at presentation of treated patients was I in 26 patients (24%), II in 24 (22%), III in 27 (25%), IV in 24 (22%), and V in 8 (7%). Clinical follow-up for the total population was achieved in 104 of 109 patients (96%), with a mean duration of 13.1 months. Angiographic follow-up for the subset excluding parent vessel occlusion cases was obtained in 93% of cases, with a mean duration of 7.2 months.

RESULTS

Technical success, defined as the ability to catheterize and embolize the aneurysm with GDC, was achieved in 109 of 112 of cases (97%). The mean angiographic occlusion rate, or projected area of the aneurysm occluded by the coils, for all 110 successfully treated aneurysms was 94.6%. At latest clinical follow-up, 81 of 109 patients (74%) achieved good recovery with Glasgow Outcome Scale (GOS) score of I, 10 of 109 (9%) were moderately (GOS II) and 5 of 109 (5%) were severely (GOS III) disabled, 1 of 109 (1%) remained in a vegetative state (GOS IV), and 12 of 109 (11%) were dead. Of the subset of 77 patients with Hunt-Hess grades I to III, 68 (88%) achieved a good clinical outcome (GOS I). A statistically significant correlation was demonstrated between Hunt-Hess grade at presentation and final GOS outcome score (chi(2)=41.4, P<0.0005). Procedure-related permanent morbidity was 2.8% (3/109 patients). Repeated hemorrhage was observed in a single patient (0.9%) with a partially treated aneurysm.

CONCLUSIONS

The observed favorable outcome and low morbidity in this group of high-risk patients point to GDC embolization as an effective method for the endovascular management of patients with ruptured posterior circulation aneurysms.

Subclavian arteritis and pseudoaneurysm formation secondary to stent infection

Technically uncomplicated percutaneous angioplasty and stent placement of a left subclavian artery stenosis was performed in a 56-year-old man for treatment of subclavian steal syndrome and vertebrobasilar insufficiency. Six days later the patient was readmitted with Staphylococcus aureus bacteremia and stigmata of septic emboli isolated to the ipsilateral hand. Nine days later he had computed tomography (CT) evidence of a contrast-enhancing phlegmon surrounding the stent. Despite clinical improvement and resolution of bacteremia on intravenous antibiotic therapy, the phlegmon progressed, and at day 21 a pseudoaneurysm was angiographically confirmed. The patient underwent surgical removal of the stented arterial segment and successful autogenous arterial reconstruction. The possible contributory factors leading to stent infection were prolonged right femoral artery access and an infected left arm venous access. Although the role of prophylactic antibiotics remains to be defined, it may be important in cases where the vascular access sheath remains in place for a prolonged period of time.

Treatment of dural arteriovenous malformations and fistulas

Dural arteriovenous fistulas (DAVFs) or malformations consist of pathological vascular channels located within the substance of the dura mater and usually involve the walls of a dural sinus or adjacent cortical vein. DAVFs can affect a variety of cerebral venous structures and can present at various clinical stages. Although some fistulas can spontaneously thrombose, the clinical course usually involves progression from venous sinus pressurization to occlusion and retrograde cortical venous drainage. The spectrum of clinical presentation ranges from an irritating pulse-synchronous bruit to a disabling neurologic ischemic deficit or life-threatening intracranial hemorrhage from venous hypertension. The authors present their clinical experience in the radiographic diagnosis and endovascular treatment of these potentially dangerous lesions.

Carotid artery cavernous fistulas

The treatment of carotid cavernous fistulas has undergone a fundamental transformation during the preceding 30 years. Endovascular techniques have not only largely replaced surgical management of this disease, but have also resulted in substantially lower rates of procedure-associated morbidity and mortality. Percutaneous transarterial occlusion of direct cavernous carotid fistulas with preservation of the carotid artery using detachable balloons is now considered the current preferred therapeutic objective. Concurrent progress in percutaneous transvenous embolization techniques and materials has led to more effective and better-tailored therapies for indirect (dural) carotid cavernous fistulas. The current understanding of the clinicopathologic mechanisms associated with carotid cavernous fistulas and the endovascular therapies used in the contemporary management of this condition are reviewed.

Embolization of non-ruptured aneurysms

Options for treatment of intracranial aneurysms have expanded with the advent of the Guglielmi Detachable Coil (GDC) eight years ago. We have reviewed 435 cases of intracranial aneurysms treated at UCSF by endovascular means using the GDC system. Of these, 55% represent anterior circulation aneurysms, and 45% are located in the posterior circulation. Additionally, 55% of the aneurysms presented with subarachnoid hemorrhage (SAH) and 45% were unruptured. Factors which hindered optimal coiling include the following: wide aneurysm neck in relation to the overall aneurysm size, mural thrombus, giant aneurysm, arteries originating from the aneurysm sac, and middle cerebral location. After initial experience was gained, we tended to avoid these aneurysms especially in the non-ruptured group. This may be especially important in light of new epidemiological data suggesting that the natural history of unruptured aneurysms is significantly lower than previously thought. New technical developments which may reduce the risk of treating unruptured aneurysms include the two-dimensional coil, the three-dimensional coil, the balloon-assist technique for wide-necked aneurysms, and combined stent-coil procedures.

Acquired pial arteriovenous fistula following cerebral vein thrombosis

BACKGROUND

We report a unique case of an acquired pial arteriovenous fistula occurring after an asymptomatic thrombosis of a superficial cerebral vein.

CASE DESCRIPTION

A cerebral angiogram performed in a 51-year-old man with subarachnoid hemorrhage revealed a 10-mm ruptured anterior communicating artery aneurysm and a thrombosed left superficial middle cerebral vein. Coil embolization of the anterior communicating aneurysm was performed. Follow-up angiography 18 months later revealed a new, asymptomatic, pial arteriovenous fistula between the previously thrombosed left superficial middle cerebral vein and a small sylvian branch of the left middle cerebral artery.

CONCLUSIONS

This case provides evidence that pial arteriovenous fistulas may develop as acquired lesions and furthermore may rarely follow cerebral vein thrombosis. Several cases of dural arteriovenous fistulas, as well as a single case of a mixed pial-dural arteriovenous fistula, occurring after dural sinus thrombosis have been reported previously. However, to our knowledge, this is the first report of an acquired pial arteriovenous fistula following a cerebral vein thrombosis.

Clinical use of stents for carotid artery disease

Over the last 5 years, the clinical use of intravascular stents for treatment of carotid artery pathology has become more prevalent and the spectrum of potential indications has widened. Endovascular stenting is providing an alternative to surgical endarterectomy for treatment of cervical carotid artery atherosclerotic disease. This has prompted a North American, randomized, controlled clinical trial directly comparing these two therapies. In this article we review the major surgical endarterectomy trials that currently provide the scientific rationale for revascularization of carotid artery occlusive disease, critically evaluate the evidence supporting the application of endovascular stenting procedures for the treatment of occlusive and nonocclusive disease of the extracranial and intracranial carotid artery, consider the current clinical indications for use of stents in the carotid artery, and discuss current equipment, technique, and potential procedure-related complications.

Treatment of posterior circulation ischemia with extracranial percutaneous balloon angioplasty and stent placement

BACKGROUND AND PURPOSE

Vertebrobasilar territory ischemia (VBI) leads to disabling neurological symptoms and poses a risk for stroke by an embolic or flow-related mechanism. We present our clinical experience in the endovascular treatment of patients with symptomatic VBI from severe atherosclerosis or dissection of the vertebral and subclavian arteries that was unresponsive to medical therapy.

METHODS

Twenty-one patients (9 female, 12 male) with a mean age of 65.7 years (range 47 to 81 years) underwent treatment with percutaneous endovascular balloon angioplasty and stent placement. Sixteen patients (76.2%) had evidence of contralateral involvement, and 9 (42.8%) demonstrated severe anterior-circulation atherosclerosis. Nine patients had a previous infarct in the occipital lobe, cerebellum, or pons before treatment. Follow-up was available for all patients.

RESULTS

Balloon angioplasty with intravascular stent placement was performed in 13 vertebral artery lesions (10 at the origin, 3 in the cervical segment) and in 8 subclavian lesions. The prestenting stenosis was 75% (50% to 100%) and was reduced to 4.5% (0% to 20%) after stenting. Six of the patients with proximal subclavian stenosis demonstrated angiographic evidence of subclavian steal, which resolved in all cases after treatment. All patients showed improvement in symptoms after the procedure except for 1 who developed a hemispheric stroke after thrombotic occlusion of an untreated cavernous carotid artery stenosis (rate of major stroke and mortality=4.8%). One patient (4.8%) had a periprocedural transient ischemic attack (TIA), and none had minor stroke. At long-term follow-up (mean=20.7+/-3.6 months) of the surviving 20 patients, 12 (57.1%) remained symptom-free, 4 (19%) had at most 1 TIA over a 3-month period, 2 (9.5%) had at most 1 TIA per month, and 2 (9.5%) had persistent symptoms. There were no clinically evident infarcts during the follow-up period.

CONCLUSIONS

Endovascular treatment using balloon angioplasty with intravascular stent placement for symptomatic stenotic lesions resulting in VBI that is unresponsive to medical therapy appears to be of benefit in this high-risk subset of patients with poor collateral flow.

Tandem intracranial stent deployment for treatment of an iatrogenic, flow-limiting, basilar artery dissection: technical case report

OBJECTIVE AND IMPORTANCE

Intimal dissection constitutes one of the complications associated with angioplasty of intracranial vessels. We present a case of iatrogenic dissection of the entire basilar artery, which was induced by angioplasty and stenting of symptomatic, focal, intracranial vertebral artery stenosis, and its successful treatment with tandem deployment of a downstream stent.

CLINICAL PRESENTATION

A 61-year-old, hypertensive, renal transplant recipient presented with orthostatic vertebrobasilar insufficiency that was refractory to medical management, including anticoagulation therapy. Angiography revealed an occluded right vertebral artery and focal, high-grade, left intracranial vertebral artery stenosis. Magnetic resonance imaging showed multiple posterior fossa infarctions. The left intracranial vertebral artery stenosis was successfully treated with primary stent deployment and balloon angioplasty, with symptom resolution. On postprocedure Day 2, the patient noted worsening right hemiparesis.

INTERVENTION

Subsequent angiography revealed a flow-limiting, windsock-type, basilar artery dissection beginning at the distal end of the left vertebral artery stent and extending to the origin of the left posterior cerebral artery. A tandem stent was navigated intracranially and deployed past the first one, successfully sealing the dissection inflow zone and reconstituting normal flow to the top of the basilar artery. A clinical follow-up examination at 3 months revealed no further orthostatic symptoms and only mild residual right-sided weakness.

CONCLUSION

This is the first description of iatrogenic stent-induced dissection of the entire basilar artery that was successfully treated by inflow zone control via tandem intracranial stent deployment.

Intraventricular contrast medium leakage during ethanol embolization of an arteriovenous malformation

We report the unusual phenomenon of abrupt intraventricular contrast medium leakage from the choroid plexus occurring during ethanol embolization of a periventricular arteriovenous malformation. There was no evidence of any associated intraventricular hemorrhage to suggest that leakage arose from a vessel perforation, as was first suspected. Intraventricular contrast medium leakage has been reported previously in the setting of ependymitis, and it is likely that similar pathogenetic mechanisms apply in this case. To our knowledge, this is the first reported case of intraventricular contrast medium leakage occurring during an embolization procedure.

Embolization of the meningohypophyseal trunk as a cause of diabetes insipidus

We present an unusual case of diabetes insipidus occurring after selective embolization of 50% dextrose and pure ethanol into an enlarged left meningohypophyseal trunk (MHT) supplying a dural carotid cavernous fistula. The inferior hypophyseal artery was not opacified during the selective preembolization MHT injection; however, diabetes insipidus developed abruptly a few hours after the procedure. The patient required intranasal 1-deamino-(8-D-arginine)-vasopressin for approximately 3 months, after which his symptoms resolved. The hazards of using liquid embolic agents, especially ethanol, in the cavernous branches of the internal carotid artery should always be borne in mind.

Simultaneous subarachnoid hemorrhage and carotid cavernous fistula after rupture of a paraclinoid aneurysm during balloon-assisted coil embolization

We describe an iatrogenic perforation of a paraclinoid aneurysm during balloon-assisted coil embolization that resulted in simultaneous subarachnoid contrast extravasation and a carotid cavernous fistula. The causative factors specifically related to the balloon-assisted method that led to aneurysm rupture are discussed as well as strategies for dealing with this complication.

Post-procedure migration of Guglielmi detachable coils and Mechanical detachable spirals

We describe a previously unreported complication of the use of Guglielmi detachable coils and Mechanical detachable spirals in endovascular treatment of intracranial aneurysms. We document four cases in which migration of part of a coil into the parent artery occurred after completion of the procedure. Possible mechanisms are discussed.

Treatment of an intracranial aneurysm using a new three-dimensional-shape Guglielmi detachable coil: technical case report

OBJECTIVE AND IMPORTANCE

Coil embolization of wide-necked aneurysms is currently difficult, when using a conventional endovascular approach without resorting to complex adjunctive techniques.

CLINICAL PRESENTATION

A 41-year-old woman with a history of systemic lupus erythematosus and hypertension refractory to treatment presented with an unruptured right ophthalmic segment aneurysm of the internal carotid artery having an unfavorable neck-to-fundus ratio.

INTERVENTION

A new type of Guglielmi detachable coil (Target Therapeutics, Fremont, CA), consisting of a series of omega loops, spontaneously forms a three-dimensional cage after deployment and was used to successfully treat the aneurysm, which was angiographically stable at the 3-month follow-up.

CONCLUSION

The new Guglielmi detachable coil may be useful in the embolization of aneurysms having an unfavorable geometry, which would otherwise not be amenable to endovascular treatment without adjunctive techniques.

Application of a rheolytic thrombectomy device in the treatment of dural sinus thrombosis: a new technique

We present a novel application of a transvascular rheolytic thrombectomy system in the treatment of symptomatic dural sinus thrombosis in a 54-year-old woman with somnolence and left-sided weakness. The diagnosis of bilateral transverse and superior sagittal sinus thrombosis was made and the patient was treated with anticoagulant therapy. After an initial period of improvement, she became comatose and hemiplegic 8 days after presentation. After excluding intracerebral hemorrhage by MR imaging, we performed angiography and transfemoral venous thrombolysis with a hydrodynamic thrombectomy catheter, followed by intrasinus urokinase thrombolytic therapy over the course of 2 days. This technique resulted in dramatic sinus thrombolysis and near total neurologic recovery. Six months after treatment, the patient showed mild cognitive impairment and no focal neurologic deficit. Our preliminary experience suggests that this technique may play a significant role in the endovascular treatment of this potentially devastating disease.

Endovascular recanalization with balloon angioplasty and stenting of an occluded occipital sinus for treatment of intracranial venous hypertension: technical case report

OBJECTIVE AND IMPORTANCE

Dural sinus thrombosis can lead to intracranial venous hypertension and can be complicated by intracranial hemorrhage. We present a case report of a patient who underwent endovascular recanalization and stenting of a thrombosed occipital sinus.

CLINICAL PRESENTATION

A 13-year-old patient with a history of chronic sinus thrombosis refractory to anticoagulant therapy presented with acute onset of aphasia and hemiparesis. Computed tomography and magnetic resonance imaging revealed hydrocephalus and cerebral edema. Angiography delineated multiple dural arteriovenous fistulae and persistent occlusion of the posterior sagittal, occipital, and bilateral transverse dural sinuses with retrograde cortical venous drainage.

INTERVENTION

After embolization of the dural arteriovenous fistulae, a transvenous approach was used to recanalize and perform balloon angioplasty of the right internal jugular vein and the occipital and left transverse sinuses, resulting in subsequent clinical improvement. The patient's condition deteriorated 3 days later with reocclusion of both balloon-dilated sinuses. Repeat angioplasty and then deployment of an endovascular stent in the occipital sinus were performed, and reestablishment of venous outflow was achieved, resulting in a decrease of intracranial venous pressure from 41 to 14 mm Hg and neurological improvement. At the 3-month follow-up examination, the stented occipital sinus remained patent and served as the only conduit for extracranial venous outflow; the patient remained neurologically intact at the 12-month follow-up examination.

CONCLUSION

This is the first report of mechanical recanalization, balloon angioplasty, and stent deployment in the occipital sinus to provide sustained venous outflow for the treatment of venous hypertension with retrograde cortical venous drainage in a patient with dural pansinus thrombosis refractory to anticoagulant therapy.

Spinal dural arteriovenous fistula with an associated feeding artery aneurysm: case report

OBJECTIVE AND IMPORTANCE

A case of a spinal dural arteriovenous fistula (DAVF) with two associated feeding artery aneurysms is reported. Intradural spinal arteriovenous malformations have been associated with aneurysms that present with subarachnoid hemorrhage and with venous varices that produce mass effect, but spinal DAVFs have not previously been described in association with feeding artery aneurysms.

CLINICAL PRESENTATION

A 71-year-old man presented with progressive spastic paraparesis, constipation, and overflow incontinence. Magnetic resonance imaging demonstrated a spinal vascular lesion and venous ischemia in the lower spinal cord. Diagnostic spinal angiography revealed a DAVF originating from the left T11 radicular artery and having the unusual feature of two proximal feeding artery aneurysms.

INTERVENTION

The patient deteriorated neurologically after undergoing angiography, prompting emergent surgery. The DAVF was resected through a T11 transpedicular approach. One aneurysm was dolichoectatic and therefore unclippable, requiring proximal occlusion of the parent artery after establishing tolerance of test occlusion using somatosensory evoked potentials; the second aneurysm was adjacent to the fistula and was resected with the DAVF.

CONCLUSION

Feeding artery aneurysms in association with spinal DAVFs have not been previously reported. They present additional risk to patients and, with simple modifications of the standard operative approaches, can easily be treated as part of the surgery for the DAVF.

Endovascular stenting of an acutely thrombosed basilar artery: technical case report and review of the literature

OBJECTIVE AND IMPORTANCE

The goal of this report was to describe the successful percutaneous endovascular use of a Gianturco-Roubin-2 coronary stent in the treatment of an acute atherothrombotic occlusion of the basilar artery. To our knowledge, the percutaneous endovascular deployment of an intra-arterial stent for the treatment of an acute atherothrombotic occlusion of the basilar artery and the percutaneous endovascular placement of a Gianturco-Roubin-2 stent in the basilar artery have not been previously reported.

CLINICAL PRESENTATION

An 83-year-old man presented with a recurrent, transient, locked-in syndrome resulting from a lower basilar artery occlusion caused by vertebrobasilar thrombosis superimposed on severe proximal basilar artery atheromatous stenosis.

INTERVENTION

After successful superselective intra-arterial thrombolysis of the vertebrobasilar clot, balloon angioplasty of the underlying basilar artery stenosis was performed, without significant angiographic improvement. Percutaneous endovascular deployment of a Gianturco-Roubin-2 coronary stent of 4-mm diameter was subsequently performed, with excellent angiographic results.

CONCLUSION

The patient made a very good neurological recovery but unfortunately died as a result of cardiogenic shock and sepsis. Detailed neuropathological follow-up results are presented; stent patency was revealed in the postmortem examination. The anatomic and pathophysiological considerations of basilar artery stent placement for the treatment of acute basilar artery occlusion related to atherosclerotic stenosis are discussed.

Hypertrophic olivary degeneration: case report in a child

We report a case of hypertrophic olivary degeneration (HOD) detected by MRI, in a 14-year-old girl, 13 months after surgical excision of a brainstem cavernous malformation. As in vivo diagnosis of this condition has only become possible with the advent of MRI, the number of reported cases remains relatively small and they are almost exclusively in adults. Many radiologists and particularly paediatric radiologists, may therefore be unfamiliar with this entity. To our knowledge, this is the first specific report of HOD diagnosed by MRI in a child.

Improved imaging of the spinal cord in multiple sclerosis using three-dimensional fast spin echo

We report assessment of a new three-dimensional fast spin echo (3D FSE) sequence in ten patients with clinically definite multiple sclerosis, comparing it with standard 2D FSE, and in ten normal controls. We saw 29 focal lesions on the 2D images and 53 on the 3D FSE images (P = 0.05); none were seen in controls. Lesion length was significantly smaller on the 3D FSE than on to the 2D FSE images (3D: 1.36; 2D 2.0; P = 0.03). This may relate in part to separation into several lesions on the 3D images of confluent abnormal signal seen on 2D and in part to detection of small lesions missed by the thicker 2D FSE slices (3 mm compared to 1.5 mm). The 3D FSE sequence looks promising in improving spinal cord imaging.

Transmural migration of an intracavernous carotid detachable balloon used to control surgically induced haemorrhage

We report a case in which a balloon detached in the carotid siphon for control of iatrogenic bleeding migrated to the oesophagus. We discuss the pathophysiology.

How much now to tell? Patients' attitudes to an information sheet prior to angiography and angioplasty

A prospectively controlled pilot study of 100 patients undergoing an invasive radiological procedure was undertaken to test patients' acceptance of risk disclosure and whether this increases anxiety and rate of procedure cancellation. Two sheets with differing amounts of information on adverse outcome were randomly allocated and patients provided a graded response to statements following the procedure. Eighty-one completed questionnaires were received (brief sheet n = 40; long sheet n = 41). There were 19 non-compliers with main causes either due to lack of interest or problems such as language difficulties, visual impairment and dementia. There were no significant differences between the two groups with respect to subjective anxiety caused by the information or risk of procedure cancellation. This preliminary work has shown that information sheets are well accepted and provide a simple, standardized format for risk disclosure.