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Joon K. Song, Joseph M. Eskridge, Eun-Chul Chung, Lindsey C. Blake, J. Paul Elliott, Lisa Finch, Cyrus Niakan, Kenneth R. Maravilla, and H. Richard Winn

Object. The aim of this study was to determine the incidence and clinical significance of complications related to preoperative embolization of cerebral arteriovenous malformations (AVMs) with silk sutures as documented on postprocedure computerized tomography (CT) scans.

Methods. The CT scans were obtained within 12 to 24 hours after 221 (96%) of 230 consecutive embolizations in 70 patients. These CT scans were evaluated for the presence of ischemia, infarction, hemorrhage, or contrast agent extravasation. Adverse patient outcomes were determined after each embolization and were correlated with CT findings. New abnormalities demonstrated on CT scans were also correlated with the Spetzler—Martin AVM grade, degree of arteriovenous shunting, and location. New abnormalities, the majority of them infarcts, resulted from 29 (13%) of 221 embolization procedures. In 11 (38%) of 29 cases of new CT findings, patients were asymptomatic, including 10 with new infarcts on CT scans. New neurological deficits occurred in 20 (8.7%) of 230 total embolization procedures in 19 patients, including one death. Permanent deficits occurred in nine patients (3.9% per embolization procedure, 12.8% per patient). Of the patients with new neurological deficits, 18 (90%) of 20 embolization procedures resulted in new abnormalities on CT scans. Two patients with new transient neurological deficits had no new findings on CT scans. Spetzler—Martin grade, AVM location, degree of arteriovenous shunting, and higher numbers of procedures were not statistically associated with a higher incidence of abnormalities on CT scans or new permanent neurological deficits.

Conclusions. Silk sutures are an effective and relatively safe embolic agent. After brain AVM embolization with silk sutures, new abnormalities were found on CT scans obtained in one of eight procedures. When a new CT finding occurred, the patient had roughly equal chances of having no new symptoms, having new transient neurological deficits, or having new permanent neurological deficits.

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Joseph M. Eskridge, Joon K. Song, J. Paul Elliott, David W. Newell, M. Sean Grady, and H. Richard Winn

✓ The authors describe a new endovascular technique that improves catheterization and balloon angioplasty of the A1 segment of the anterior cerebral artery after it has been narrowed by vasospasm. The technical results of using this method in seven patients are presented.

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Joon K. Song, Joseph M. Eskridge, Cyrus Niakan, and H. Richard Winn

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Toru Fukuhara, Guy M. McKhann II, Paul Santiago, Joseph M. Eskridge, John D. Loeser, and H. Richard Winn

✓ The authors describe a patient with right-sided central pain resulting from a left parietal arteriovenous malformation (AVM). The AVM was treated with staged embolization and stereotactic radiosurgery, and its obliteration was documented on follow-up angiographic studies. Surprisingly, the patient noted complete resolution of her pain syndrome after embolization, which is an extremely rare result. Central pain and its proposed mechanisms are discussed.

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J. Paul Elliott, David W. Newell, Derek J. Lam, Joseph M. Eskridge, Colleen M. Douville, Peter D. Le Roux, David H. Lewis, Marc R. Mayberg, M. Sean Grady, and H. Richard Winn

Object. The purpose of this study was to test the hypothesis that balloon angioplasty is superior to papaverine infusion for the treatment of proximal anterior circulation arterial vasospasm following subarachnoid hemorrhage (SAH). Between 1989 and 1995, 125 vasospastic distal internal carotid artery or proximal middle cerebral artery vessel segments were treated in 52 patients.

Methods. Blood flow velocities of the involved vessels were assessed by using transcranial Doppler (TCD) monitoring in relation to the day of treatment with balloon angioplasty or papaverine infusion. Balloon angioplasty and papaverine infusion cohorts were compared based on mean pre- and posttreatment velocity at 24 and 48 hours using the one-tailed, paired-samples t-test. Balloon angioplasty alone was performed in 101 vessel segments (81%) in 39 patients (75%), whereas papaverine infusion alone was used in 24 vessel segments (19%) in 13 patients (25%). Although repeated treatment after balloon angioplasty was needed in only one vessel segment, repeated treatment following papaverine infusion was required in 10 vessel segments (42%) in six patients because of recurrent vasospasm (p < 0.001). Seven vessel segments (29%) with recurrent spasm following papaverine infusion were treated with balloon angioplasty. Although vessel segments treated with papaverine demonstrated a 20% mean decrease in blood flow velocity (p < 0.009) on posttreatment Day 1, velocities were not significantly lower than pretreatment levels by posttreatment Day 2 (p = 0.133). Balloon angioplasty resulted in a 45% mean decrease in velocity to a normal level following treatment (p < 0.001), a decrease that was sustained.

Conclusions. Balloon angioplasty is superior to papaverine infusion for the permanent treatment of proximal anterior circulation vasospasm following aneurysmal SAH.

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J. Paul Elliott, David W. Newell, Derek J. Lam, Joseph M. Eskridge, Colleen M. Douville, Peter D. LeRoux, David H. Lewis, Marc R. Mayberg, M. Sean Grady, and H. Richard Winn

The authors used daily transcranial Doppler (TCD) evaluation to test the hypothesis that balloon angioplasty is superior to papaverine infusion for the treatment of proximal anterior circulation arterial vasospasm following subarachnoid hemorrhage (SAH). Between 1989 and 1995, 125 vasospastic distal internal carotid artery or proximal middle cerebral artery vessel segments were treated in 52 patients. Blood flow velocities of the involved vessels were assessed using TCD monitoring in relation to the day of treatment with balloon angioplasty or papaverine infusion. Balloon angioplasty and papavarine infusion cohorts were compared based on mean pretreatment velocity and mean posttreatment velocity at 24 and 48 hours using the one-tailed, paired-samples t-test. Balloon angioplasty alone was performed in 101 vessel segments (81%) in 39 patients (75%), whereas papaverine infusion alone was used in 24 vessel segments (19%) in 13 patients (25%). Although repeated treatment following balloon angioplasty was needed in only one vessel segment, repeated treatment following papaverine infusion was required in 10 vessel segments (42%) in six patients because of recurrent vasospasm (p < 0.001). Seven vessel segments (29%) with recurrent spasm following papaverine infusion were treated with balloon angioplasty. Although vessel segments treated with papaverine demonstrated a 20% mean decrease in blood flow velocity (p < 0.009) on posttreatment Day 1, velocities were not significantly lower than pretreatment levels by posttreatment Day 2 (p = 0.133). Balloon angioplasty resulted in a 45% mean decrease in velocity to a normal level following treatment (p < 0.001), which was sustained. The authors conclude that balloon angioplasty is superior to papaverine infusion for the permanent treatment of proximal anterior circulation vasospasm following aneurysmal SAH.

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Peter D. Le Roux, J. Paul Elliott, Lois Downey, David W. Newell, M. Sean Grady, Marc R. Mayberg, Joseph M. Eskridge, and H. Richard Winn

✓ Several significant diagnostic and therapeutic advances in the management of subarachnoid hemorrhage have emerged during the last 10 years. The present study was undertaken to determine whether these advances have improved overall outcome in patients of low surgical risk and what factors predict outcome. The authors retrospectively reviewed the management of good-grade patients seen at the Harborview Medical Center at the University of Washington, who suffered ruptured anterior circulation aneurysms between 1983 and 1993. The results in this series demonstrate that favorable outcomes occurred in 96.8% of patients designated Hunt and Hess Grade I, 88.3% of those assigned Grade II, and 81.3% of those deemed Grade III after rupture of anterior circulation aneurysms. On the basis of clinical and radiographic factors present at admission, correct prediction can be made about all favorable, but only 17% of unfavorable outcomes. During the decade under investigation, the authors observed a significant (p = 0.002) increase in the number of favorable outcomes: 74.5% of patients treated during the first management period (1983–1987); 87% of patients treated during the second period (1987–1990); and 93.5% of patients treated during the third management period (1990–1993) experienced favorable outcomes. Improvements in critical-care techniques and the management of vasospasm may be associated with the improved outcome observed during this series.

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William McAuliffe, Murphy Townsend, Joseph M. Eskridge, David W. Newell, M. Sean Grady, and H. Richard Winn

✓ The authors reviewed the cases of 21 patients who received intraarterial infusions of papaverine to determine the drug's effects on intracranial pressure (ICP), mean arterial blood pressure, pulse rate, and cerebral perfusion pressure (CPP). The study focused on patients with aneurysmal subarachnoid hemorrhage who developed clinical signs and symptoms of vasospasm, which was documented by cerebral angiography. In 18 patients, an average dose of 300 mg papaverine was administered over 20 to 35 minutes using a No. 5 French catheter inserted into the high cervical internal carotid artery or vertebral artery. Two other patients received superselective infusions via a microcatheter placed in the anterior cerebral artery.

Sixteen patients (76%) experienced good angiographic results, and 11 (52%) obtained objective clinical improvement within 48 hours. Significant elevations in ICP, blood pressure, and pulse rate were noted during papaverine infusion. In contrast, no statistically significant sustained change in CPP was observed, although it tended to decrease during papaverine infusion. In one elderly patient, infusion of the common carotid artery resulted in profound bradycardia and hypotension with a subsequent significant increase in ICP and a marked decrease in CPP. The increase in ICP in these patients correlates well with changes seen in animal models and is probably related to increased cerebral blood flow.

A careful, titrated infusion of papaverine, with constant reference to the patient's ICP, blood pressure, and pulse rate, minimizes the transient increase in ICP while maintaining adequate blood pressure and CPP. Failure to monitor these parameters during the infusion, with appropriate modification of the rate of titration, could potentially produce an uncontrolled change in ICP or CPP.

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Robert C. Rostomily, Marc R. Mayberg, Joseph M. Eskridge, Robert Goodkin, and H. Richard Winn

✓ Percutaneous transluminal angioplasty is commonly used for treatment of peripheral vascular disease, but only recently has it been applied to craniocervical lesions. The successful use of percutaneous transluminal angioplasty for treatment of an isolated high-grade stenosis of the petrous internal carotid artery is described in a patient with progressive ischemic symptoms despite maximum medical management. At his 2-year follow-up examination, the patient remained asymptomatic with angiographic evidence of progressive resolution of the stenotic lesion and indirect evidence of improved hemispheric blood flow ipsilateral to the lesion. Percutaneous transluminal angioplasty may provide an effective means of treatment for selective intracranial atherosclerotic stenosis.

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Varun Laohaprasit, Daniel L. Silbergeld, George A. Ojemann, Joseph M. Eskridge, and H. Richard Winn

✓ Contrast-enhanced computerized tomography (CT) is frequently utilized immediately after surgery to determine the presence of residual tumor, but the response of nontumor brain tissue is unclear. Consequently, the authors investigated the postoperative CT contrast enhancement in six patients undergoing lobectomy for epilepsy. Preoperative CT scans were obtained in all cases and revealed no enhancing lesions. All patients underwent craniotomy with electrocorticography while awake, followed by lobectomy. Computerized tomography scans with and without administration of contrast material were obtained on postoperative Days 3, 7, and 30. Edema, artifact, and enhancement of the resection margins were seen on postoperative Days 3 and 7, but had resolved in all patients by Day 30. It is concluded that postoperative CT scans for assessment of residual tumor are best obtained at 30 days or thereafter, when normal brain does not enhance and edema and artifact have diminished.