Multimodal endovascular intervention is becoming more commonplace for the acute intervention of ischemic stroke. Hyperdensity in a portion of the treated territory is a common finding on postthrombolytic noncontrast CT (NCCT), but its significance is poorly understood. The authors conducted a single-institution, retrospective chart review of patients who had intraarterial thrombolysis of the anterior circulation between 2010 and 2011 with evidence of hyperdensity on NCCT following recanalization. Eighteen patients had evidence of postoperative contrast stasis causing hyperdensity on NCCT. One hundred percent of the patients had MR imaging evidence of completed strokes postoperatively in the same distribution as the stasis. Stasis on NCCT after intervention had a sensitivity and specificity of 82% and 0% for predicting stroke, respectively. Furthermore, the positive predictive value was 100%. The presence of contrast stasis on postthrombolytic NCCT correlates well with stroke seen on subsequent MR imaging.
George M. Ghobrial, Anil K. Nair, Richard T. Dalyai, Pascal Jabbour, Stavropoula I. Tjoumakaris, Aaron S. Dumont, Robert H. Rosenwasser and L. Fernando Gonzalez
Nohra Chalouhi, Aaron S. Dumont, Stavropoula Tjoumakaris, L. Fernando Gonzalez, Jurij R. Bilyk, Ciro Randazzo, David Hasan, Richard T. Dalyai, Robert Rosenwasser and Pascal Jabbour
Endovascular therapy is the primary treatment option for carotid-cavernous fistulas (CCFs). Operative cannulation of the superior ophthalmic vein (SOV) provides a reasonable alternative route to the cavernous sinus when all transvenous and transarterial approaches have been unsuccessful. The role of the liquid embolic agent Onyx in the management of CCFs has not been well documented, especially when using an SOV approach. The purpose of this study is to assess the safety and efficacy of Onyx embolization of CCFs through a surgical cannulation of the SOV.
The authors retrospectively reviewed all patients with CCFs who were treated with Onyx through an SOV approach between April 2009 and April 2011. Traditional endovascular approaches had failed in all patients.
A total of 10 patients were identified, 1 with a Type A CCF, 5 with a Type B CCF, and 4 with a Type D CCF. All fistulas were embolized in 1 session. Onyx was the sole embolic agent used in 7 cases and was combined with coils in 3 other cases. Complete obliteration was achieved in 8 patients and a significant reduction in fistulous flow was achieved in 2 patients, which later progressed to near-complete occlusion on angiographic follow-up. All patients experienced a complete clinical recovery with excellent cosmetic results and were free from recurrence at their latest clinical follow-up evaluations.
Onyx embolization is an excellent therapy for CCFs in general, and through an SOV approach in particular. Direct operative cannulation of the SOV followed by Onyx embolization may be the best treatment option in patients with CCFs when all other endovascular approaches have been exhausted.
Richard T. Dalyai, George Ghobrial, Issam Awad, Stavropoula Tjoumakaris, L. Fernando Gonzalez, Aaron S. Dumont, Nohra Chalouhi, Ciro Randazzo, Robert Rosenwasser and Pascal Jabbour
Cavernous malformations (CMs) are angiographically occult vascular malformations that are frequently found incidentally on MR imaging. Despite this benign presentation, these lesions could cause symptomatic intracranial hemorrhage, seizures, and focal neurological deficits. Cavernomas can be managed conservatively with neuroimaging studies, surgically with lesion removal, or with radiosurgery. Considering recent studies examining the CM's natural history, imaging techniques, and possible therapeutic interventions, the authors provide a concise review of the literature and discuss the optimal management of incidental CMs.