✓ Definitive endovascular treatment of dural arteriovenous fistulas (DAVFs) requires obliteration of the site of the fistula: either the diseased dural sinus or the pial vein. Access to this site is often limited by occlusion of the sinus proximal and distal to the segment containing the fistula. The authors describe a technique in which the mastoid emissary vein is used to gain access to a Borden–Shucart Type II DAVF in the transverse–sigmoid sinus. Recognition of this route of access, if present, may facilitate endovascular treatment of these lesions. Access to the transverse sinus via this approach can be straightforward and may be underused.
Dennis J. Rivet, James K. Goddard III, Keith M. Rich and Colin P. Derdeyn
Maria Mamalui-Hunter, Thomas Jiang, Keith M. Rich, Colin P. Derdeyn and Robert E. Drzymala
The effectiveness of Gamma Knife stereotactic surgery to obliterate brain arteriovenous malformations (AVMs) may be diminished by the preoperative adjunctive use of endovascular liquid embolic agents. The purpose of the present investigation was to determine if commercially available liquid embolic agents reduce the radiation dose to the target because of attenuation of the 60Co beam.
The apparent linear attenuation coefficients for 120- to 140-keV radiographs in embolized regions were retrieved from CT scans for several patients with AVMs who had undergone embolization procedures with liquid embolic agents to reduce nidal volumes. Based on these coefficients and a virtual model of Gamma Knife surgery (GKS) with basic ray tracing, the authors obtained the path lengths and densities of the embolized regions. The attenuation of 60Co beams was then calculated for various sizes and positions of embolized AVM regions and for the number of beams used for treatment. Published experiments for several high-atomic-number materials were used to estimate the effective 60Co beam attenuation coefficients for the N-butyl cyanoacrylate (NBCA, suspended in ethiodized oil) and ethylene vinyl alcohol copolymer (EVOH, with suspended micronized tantalum powder, Onyx) used in the AVM embolizations. Dose reductions during GKS were calculated for a theoretical model based on the CT-documented apparent linear attenuation coefficients and for the 60Co energy attenuation coefficient. Dose measurements were obtained in a phantom study with EVOH for comparison with the estimates generated from the two attenuation coefficients.
Based on CT (keV) apparent attenuation coefficients, the authors' theoretical model predicted that the cumulative effect of either of the embolic agents decreased the number of kilovoltage photons in an embolized nidus by −8% to −15% because of the increased atomic number and density of NBCA and Onyx. However, in using the effective attenuation coefficient for the 60Co energies as is used in GKS, the authors' theoretical model yielded only a 0.2% dose reduction per beam and a < 0.01%–0.2% dose reduction in total. These theoretical results were validated by measurements in a head phantom containing Onyx.
Dose reduction due to attenuation of the 60Co beam by the AVM embolization material was negligible for both NBCA and EVOH because of the high-energy 60Co beam.
David N. Loy, Keith M. Rich, Joseph Simpson, Ian Dorward, Lakshmi Santanam and Colin P. Derdeyn
This report demonstrates that time-of-flight (TOF) MR angiography is a useful adjunct for planning stereotactic radiosurgery (SRS) of large arteriovenous malformations (AVMs) after staged embolization with Onyx.
Onyx (ethylene vinyl copolymer), a recently approved liquid embolic agent, has been increasingly used to exclude portions of large AVMs from the parent circulation prior to SRS. Limiting SRS to regions of persistent arteriovenous shunting and excluding regions eliminated by embolization may reduce unnecessary radiation doses to eloquent brain structures. However, SRS dosimetry planning presents unique challenges after Onyx embolization because it creates extensive artifacts on CT scans, and it cannot be delineated from untreated nidus on standard MR sequences.
During the radiosurgery procedure, MR images were obtained using a GE Signa 1.5-T unit. Standard axial T2 fast spin echo high-resolution images (TR 3000 msec, TE 108 msec, slice thickness 2.5 mm) were generated for optimal visualization of brain tissue and AVM flow voids. The 3D TOF MR angiography images of the circle of Willis and vertebral arteries were subsequently obtained to visualize AVM regions embolized with Onyx (TR 37 msec, TE 6.9 msec, flip angle 20°).
Adjunct TOF MR angiography images demonstrated excellent contrast between nidus embolized with Onyx and regions of persistent arteriovenous shunting within a large AVM prior to SRS. Additional information derived from these sequences resulted in substantial adjustments to the treatment plan and an overall reduction in the treated tissue volume.
Colin P. Derdeyn, DeWitte T. Cross III, Christopher J. Moran, George W. Brown, Thomas K. Pilgram, Michael N. Diringer, Robert L. Grubb Jr., Keith M. Rich, Michael R. Chicoine and Ralph G. Dacey Jr.
Object. Ischemic stroke or transient ischemic attack (TIA) may occur after the treatment of intracranial aneurysms with Guglielmi detachable coils (GDCs). The purpose of the present study is to investigate possible risk factors for thromboembolic events and to determine their frequency and time course.
Methods. The records of 178 consecutive patients with 193 treated intracranial saccular aneurysms were reviewed. A total of 159 GDC procedures were performed to treat 143 aneurysms in 133 of those patients who were in good neurological condition, allowing clinical detection of postprocedure ischemic events (TIA or stroke). The association of clinical, anatomical, and pharmacological factors with intraprocedure intraarterial thrombus and with postprocedure ischemic events was investigated by using uni- and multivariate analyses.
Thrombus protruding into the parent artery was noted during six of 159 GDC procedures, resulting in a clinical deficit in one patient. No factor was associated with intraprocedure intraarterial thrombus. Ten postprocedure ischemic events occurred in nine patients. Seven events occurred within 24 hours, and three events occurred between 24 hours and 58 days. Aneurysm diameter and protruding coils were significant independent predictors of postprocedure ischemic events in multivariate analysis (both p = 0.02). The actuarial risk of stroke was 3.8%.
Conclusions. Larger aneurysm diameter and protruding loops of coils are associated with postprocedure ischemic events after GDC placement. It is unlikely that GDC-treated aneurysms retain thromboembolic potential beyond 2 months.
Manish N. Shah, James A. Botros, Thomas K. Pilgram, Christopher J. Moran, DeWitte T. Cross III, Michael R. Chicoine, Keith M. Rich, Ralph G. Dacey Jr., Colin P. Derdeyn and Gregory J. Zipfel
The goal of this study was to determine the clinical course of Borden-Shucart Type I cranial dural arteriovenous fistulas (DAVFs) and to calculate the annual rate of conversion of these lesions to more aggressive fistulas that have cortical venous drainage (CVD).
A retrospective chart review was conducted of all patients harboring DAVFs who were seen at the authors' institution between 1997 and 2009. Twenty-three patients with Type I DAVFs who had available clinical follow-up were identified. Angiographic and clinical data from these patients were reviewed. Neurological outcome and status of presenting symptoms were assessed during long-term follow-up.
Of the 23 patients, 13 underwent endovascular treatment for intolerable tinnitus or ophthalmological symptoms, and 10 did not undergo treatment. Three untreated patients died of unrelated causes. In those who were treated, complete DAVF obliteration was achieved in 4 patients, and palliative reduction in DAVF flow was achieved in 9 patients. Of the 19 patients without radiographic cure, no patient developed intracranial hemorrhage or nonhemorrhagic neurological deficits (NHNDs), and no patient died of DAVF-related causes over a mean follow-up of 5.6 years. One patient experienced a spontaneous, asymptomatic obliteration of a partially treated DAVF in late follow-up, and 2 patients experienced a symptomatic conversion of their DAVF to a higher-grade fistula with CVD in late follow-up. The annual rate of conversion to a higher-grade DAVF based on Kaplan-Meier cumulative event-free survival analysis was 1.0%. The annual rate of intracranial hemorrhage, NHND, and DAVF-related death was 0.0%.
A small number of Type I DAVFs will convert to more aggressive DAVFs with CVD over time. This conversion to a higher-grade DAVF is typically heralded by a change in patient symptoms. Follow-up vascular imaging is important, particularly in the setting of recurrent or new symptoms.
Chad W. Washington, Gregory J. Zipfel, Michael R. Chicoine, Colin P. Derdeyn, Keith M. Rich, Christopher J. Moran, DeWitte T. Cross and Ralph G. Dacey Jr.
The purpose of aneurysm surgery is complete aneurysm obliteration while sparing associated arteries. Indocyanine green (ICG) videoangiography is a new technique that allows for real-time evaluation of blood flow in the aneurysm and vessels. The authors performed a retrospective study to compare the accuracy of ICG videoangiography with intraoperative angiography (IA), and determine if ICG videoangiography can be used without follow-up IA.
From June 2007 through September 2009, 155 patients underwent craniotomies for clipping of aneurysms. Operative summaries, angiograms, and operative and ICG videoangiography videos were reviewed. The number, size, and location of aneurysms, the ICG videoangiography and IA findings, and the need for clip adjustment after ICG videoangiography and IA were recorded. Discordance between ICG videoangiography and IA was defined as ICG videoangiography demonstrating aneurysm obliteration and normal vessel flow, but post-IA showing either an aneurysmal remnant and/or vessel occlusion requiring clip adjustment.
Thirty-two percent of patients (49 of 155) underwent both ICG videoangiography and IA. The post-ICG videoangiography clip adjustment rate was 4.1% (2 of 49). The overall rate of ICG videoangiography–IA agreement was 75.5% (37 of 49) and the ICG videoangiography–IA discordance rate requiring post-IA clip adjustment was 14.3% (7 of 49). Adjustments were due to 3 aneurysmal remnants and 4 vessel occlusions. These adjustments were attributed to obscuration of the residual aneurysm or the affected vessel from the field of view and the presence of dye in the affected vessel via collateral flow. Although not statistically significant, there was a trend for ICG videoangiography–IA discordance requiring clip adjustment to occur in cases involving the anterior communicating artery complex, with an odds ratio of 3.3 for ICG videoangiography–IA discordance in these cases.
These results suggest that care should be taken when considering ICG videoangiography as the sole means for intraoperative evaluation of aneurysm clip application. The authors further conclude that IA should remain the gold standard for evaluation during aneurysm surgery. However, a combination of ICG videoangiography and IA may ultimately prove to be the most effective strategy for maximizing the safety and efficacy of aneurysm surgery.
Anderson Chun-On Tsang
Josser E. Delgado Almandoz, Bharathi D. Jagadeesan, Daniel Refai, Christopher J. Moran, DeWitte T. Cross III, Michael R. Chicoine, Keith M. Rich, Michael N. Diringer, Ralph G. Dacey Jr., Colin P. Derdeyn and Gregory J. Zipfel
The yield of CT angiography (CTA) and MR angiography (MRA) in patients with subarachnoid hemorrhage (SAH) who have a negative initial catheter angiogram is currently not well understood. This study aims to determine the yield of CTA and MRA in a prospective cohort of patients with SAH and a negative initial catheter angiogram.
From January 1, 2005, until September 1, 2010, the authors instituted a prospective protocol in which patients with SAH—as documented by noncontrast CT or CSF xanthochromia and a negative initial catheter angiogram— were evaluated using CTA and MRA to assess for causative cerebral aneurysms. Two neuroradiologists independently evaluated the noncontrast CT scans to determine the SAH pattern (perimesencephalic or not) and the CT and MR angiograms to assess for causative cerebral aneurysms.
Seventy-seven patients were included, with a mean age of 52.8 years (median 54 years, range 19–88 years). Fifty patients were female (64.9%) and 27 male (35.1%). Forty-three patients had nonperimesencephalic SAH (55.8%), 29 patients had perimesencephalic SAH (37.7%), and 5 patients had CSF xanthochromia (6.5%). Computed tomography angiography demonstrated a causative cerebral aneurysm in 4 patients (5.2% yield), all of whom had nonperimesencephalic SAH (9.3% yield). Mean aneurysm size was 2.6 mm (range 2.1–3.3 mm). Magnetic resonance angiography demonstrated only 1 of these aneurysms. No causative cerebral aneurysms were found in patients with perimesencephalic SAH or CSF xanthochromia.
Computed tomography angiography is a valuable adjunct in the evaluation of patients with nonperimesencephalic SAH who have a negative initial catheter angiogram, demonstrating a causative cerebral aneurysm in 9.3% of patients.
Ananth K. Vellimana, Yasha Kadkhodayan, Keith M. Rich, DeWitte T. Cross III, Christopher J. Moran, Allyson R. Zazulia, Jin-Moo Lee, Michael R. Chicoine, Ralph G. Dacey Jr., Colin P. Derdeyn and Gregory J. Zipfel
The aim of this study was to define the optimal treatment for patients with symptomatic intraluminal carotid artery thrombus (ICAT).
The authors performed a retrospective chart review of patients who had presented with symptomatic ICAT at their institution between 2001 and 2011.
Twenty-four patients (16 males and 8 females) with ICAT presented with ischemic stroke (18 patients) or transient ischemic attack ([TIA], 6 patients). All were initially treated using anticoagulation with or without antiplatelet drugs. Eight of these patients had no or only mild carotid artery stenosis on initial angiography and were treated with medical management alone. The remaining 16 patients had moderate or severe carotid stenosis on initial angiography; of these, 10 underwent delayed revascularization (8 patients, carotid endarterectomy [CEA]; 2 patients, angioplasty and stenting), 2 refused revascularization, and 4 were treated with medical therapy alone. One patient had multiple TIAs despite medical therapy and eventually underwent CEA; the remaining 23 patients had no TIAs after treatment. No patient suffered ischemic or hemorrhagic stroke while on anticoagulation therapy, either during the perioperative period or in the long-term follow-up; 1 patient died of an unrelated condition. The mean follow-up was 16.4 months.
Results of this study suggest that initial anticoagulation for symptomatic ICAT leads to a low rate of recurrent ischemic events and that carotid revascularization, if indicated, can be safely performed in a delayed manner.
Terrence F. Holekamp, Matthew E. Mollman, Rory K. J. Murphy, Grant R. Kolar, Neha M. Kramer, Colin P. Derdeyn, Christopher J. Moran, Richard J. Perrin, Keith M. Rich, Giuseppe Lanzino and Gregory J. Zipfel
Nonhemorrhagic neurological deficits are underrecognized symptoms of intracranial dural arteriovenous fistulas (dAVFs) having cortical venous drainage. These symptoms are the consequence of cortical venous hypertension and portend a clinical course with increased risk of neurological morbidity and mortality. One rarely documented and easily misinterpreted type of nonhemorrhagic neurological deficit is progressive dementia, which can result from venous hypertension in the cortex or in bilateral thalami. The latter, which is due to dAVF drainage into the deep venous system, is the less common of these 2 dementia syndromes. Herein, the authors report 4 cases of dAVF with venous drainage into the vein of Galen causing bithalamic edema and rapidly progressive dementia. Two patients were treated successfully with endovascular embolization, and the other 2 patients were treated successfully with endovascular embolization followed by surgery. The radiographic abnormalities and presenting symptoms rapidly resolved after dAVF obliteration in all 4 cases. Detailed descriptions of these 4 cases are presented along with a critical review of 15 previously reported cases. In our analysis of these 19 published cases, the following were emphasized: 1) the clinical and radiographic differences between dAVF-induced thalamic versus cortical dementia syndromes; 2) the differential diagnosis and necessary radiographic workup for patients presenting with a rapidly progressive thalamic dementia syndrome; 3) the frequency at which delays in diagnosis occurred and potentially dangerous and avoidable diagnostic procedures were used; and 4) the rapidity and completeness of symptom resolution following dAVF treatment.