✓ The authors assessed the reliability of magnetic resonance (MR) imaging contrast enhancement for the detection and follow-up evaluation of dissecting aneurysms of the vertebrobasilar circulation. Twenty consecutively admitted patients who underwent both gadolinium-enhanced MR imaging and conventional angiography were reviewed. Enhancement of the dissecting aneurysm was seen in all but one of the 20 patients, including 10 (71%) of 14 patients examined in the chronic phases, when the T1-hyperintensity signal that corresponded to the intramural hematoma was unrecognizable. The enhanced area corresponded to the “pearl sign” or aneurysm dilation noted on the comparable angiogram. On follow-up MR studies enhancement had spontaneously disappeared in four patients at a time when comparable vertebral angiograms revealed disappearance of the aneurysm dilation. The enhancement persisted in five of nine patients examined more than 24 weeks after symptom onset; in all five patients the aneurysm dilation remained on comparable angiograms. Dynamic MR studies showed rapid and remarkable enhancements with their peaks during the immediate dynamic phase after injection of the contrast material. The authors conclude that gadolinium-enhanced MR imaging is useful for the detection and follow-up evaluation of dissecting aneurysms of the vertebrobasilar circulation.
Shinji Nagahiro, Jun-ichiro Hamada, Yuji Sakamoto and Yukitaka Ushio
Jun-Ichiro Hamada, Shinji Nagahiro, Chikara Mimata, Takayuki Kaku and Yukitaka Ushio
✓ Two techniques of revascularizing the posterior inferior cerebellar artery (PICA) during aneurysm surgery are presented. One involves transposition of the PICA to the vertebral artery proximal to the aneurysm using a superior temporal artery (STA) as a graft. This is used in cases in which the PICA has branched off from the wall of the giant vertebral artery aneurysm. The other technique involves end-to-end anastomosis of the PICA after excision of a giant distal PICA aneurysm located at the cranial loop near the roof of the fourth ventricle. The reconstructions of the PICA described here are surgical procedures designed to preserve normal blood flow in the PICA in patients treated for giant aneurysms involving that artery.
Jun-ichiro Hamada, Isao Kitamura, Masahito Kurino, Nobuyuki Sueyoshi, Shozaburo Uemura and Yukitaka Ushio
✓ The case of a 64-year-old woman with multiple intracranial aneurysms and abnormal ophthalmic arteries arising from the bifurcation of the internal carotid artery is described. It is believed that this type of anomaly of the ophthalmic artery has not previously been reported. The neuroradiological and operative findings of this case are presented.
Jun-ichiro Hamada, Tatemi Todaka, Shigetoshi Yano, Yutaka Kai, Motohiro Morioka and Yukitaka Ushio
Object. In patients with aneurysms that require occlusion of the posterior inferior cerebellar artery (PICA), revascularization of this artery should be performed. A novel surgical method for revascularization of the PICA is presented.
Methods. After a segment of the superficial temporal artery (STA) was harvested, the aneurysm was treated by trapping, followed by placement of a vertebral artery (VA)—PICA bypass in which the STA segment was used as a graft. When the length of the proximal PICA was inadequate, the distal end of the STA was anastomosed to the proximal PICA in an end-to-side fashion. When the length of the proximal PICA was adequate, the STA was anastomosed to the proximal PICA in an end-to-end fashion. In either case, the proximal end of the STA was anastomosed to the VA in an end-to-side fashion. This procedure was used in nine patients whose aneurysms involved the PICA. Although partial lateral medullary syndrome developed in one of them, follow-up evaluation revealed graft patency in all patients. There were no instances of recurrent hemorrhage or ischemia.
Conclusions. Although this procedure requires harvesting of an STA graft and two anastomoses, it facilitates anterograde flow to the PICA territory. It also involves minimal mobilization of brainstem perforating vessels and the proximal PICA.
Jun-ichiro Hamada, Yutaka Kai, Motohiro Morioka, Shigetoshi Yano, Tatemi Todaka and Yukitaka Ushio
Object. The goal of this study was to implement an algorithm for and assess the multimodal (endovascular and microsurgical) treatment of patients with ruptured dissecting aneurysms of the vertebral artery (VA) during the acute stage.
Methods. During a 4-year period, the authors treated 19 ruptured dissecting aneurysms of the VA during the acute stage, within 3 days after the hemorrhage. Factors guiding management decisions were tolerance of the test occlusion and the site of the dissection. The algorithm takes into account these factors to select among treatment options, that is, trapping of the VA with Guglielmi Detachable Coils (GDCs); trapping of the VA and revascularization of the posterior inferior cerebellar artery (PICA); trapping of the VA and VA—posterior cerebral artery (PCA) anastomosis; and trapping of the VA, VA—PCA anastomosis, and revascularization of the PICA. Of the 15 aneurysms without PICA involvement, 14 were treated by trapping of the VA with GDCs and one by trapping of the VA and a VA—PCA bypass. The other four aneurysms with PICA involvement were treated by VA trapping and PICA revascularization. There was no episode of recurrent hemorrhage or ischemia during the posttreatment follow-up period. Although lateral medullary syndrome developed as a permanent complication in one patient, a good recovery was made by the other 18 patients by 6 months after the ictus.
Conclusions. The factors that determine the appropriate treatment for ruptured dissecting aneurysms of the VA are tolerance of a test occlusion and the site of dissection. Favorable patient outcomes can be achieved when this algorithm is used.
Yutaka Kai, Jun-ichiro Hamada, Motohiro Morioka, Shigetoshi Yano, Kiyotoshi Hamasaki and Yukitaka Ushio
✓ Dissecting basilar artery (BA) aneurysms in patients presenting with subarachnoid hemorrhage are life threatening, especially in those who experience subsequent bleeding or progressive dissection, and immediate surgical or endovascular intervention may be necessary. The authors report on a 52-year-old woman whose dissecting BA aneurysm was treated successfully with proximal occlusion and flow reversal. Clipping of the proximal BA above the level of the anterior inferior cerebellar arteries facilitated retrograde flow from a radial artery graft placed between the left vertebral artery and the left posterior cerebral artery, thereby providing continuous perfusion of the BA and its branches. Postoperative angiograms obtained 1 year later revealed good retrograde flow through the BA and dilation of the radial arterial graft. There were no episodes of recurrent hemorrhage.
Jun-Ichiro Hamada, Shigetoshi Yano, Yutaka Kai, Kazunari Koga, Motohiro Morioka, Yasuji Ishimaru and Yukitaka Ushio
Object. Of all intracranial dural arteriovenous fistulas (DAVFs), those with cortical venous drainage associated with cortical venous ectasia or varices are predisposed to an aggressive course and produce progressive neurological symptoms or hemorrhages. The authors undertook a histological examination of venous aneurysms and arterialized veins in the proximity of these aneurysms that had been surgically removed in patients with DAVFs.
Methods. Surgical specimens were obtained in eight patients. The excised venous aneurysms and the arterialized veins in their proximity were stained using hematoxylin and eosin, van Gieson's elastic, and Masson's trichrome stain. Immunostaining was also performed for alpha smooth-muscle actin, desmin, and factor VIII antigen. Five of the patients had presented with venous hypertension, and three had intracranial hemorrhages. The arterialized vein obtained in the proximity of the venous aneurysm exhibited local irregular intimal thickening; the internal elastic lamina (IEL) was grossly preserved. All venous aneurysms in patients with venous hypertension manifested medial thickening and local intimal thickening with loss of IEL; the thickness of the wall was relatively uniform. In contrast, the wall thickness of venous aneurysms in patients with hemorrhage was extremely irregular and there was no clear delineation between the media and the intima. In media with complete disappearance of IEL, there was scant muscle tissue.
Conclusions. Degenerative changes in venous aneurysms in patients with hemorrhage were much greater than in patients with venous hypertension, possibly because hemorrhages result from a more complicated interplay of anatomical, hemodynamic, and degenerative factors.
Jun-Ichiro Hamada, Yutaka Kai, Motohiro Morioka, Kiyoshi Kazekawa, Yasuji Ishimaru, Hiroo Iwata and Yukitaka Ushio
Object. The authors have developed a mixture of ethylene vinyl alcohol copolymer (EVAL) and iopamidol, which is dissolved in ethanol, as an alternative solvent to provide a safe means of embolizing arteriovenous malformations (AVMs).
Methods. A two-stage delivery technique is required to prevent premature precipitation in the catheter when using this material: the catheter is first infused with 30% ethanol and this is followed by the delivery of the EVAL—ethanol mixture. Acute angiographic changes were analyzed after superselective delivery of dimethyl sulfoxide (DMSO) and 30% ethanol into the renal artery of rabbits. Histological changes following the embolization of the renal artery achieved using the EVAL—ethanol mixture were recorded at 1 hour and at 2 and 16 weeks after the procedure. Although DMSO always produced severe, rapidly progressive vasospasm in the renal artery during a 1- to 60-minute postinfusion, 30% ethanol did not. Microscopically, the lumens of embolized vessels examined 1 hour after embolization with EVAL—ethanol appeared to be filled with EVAL sponges, leaving almost no open spaces. The space between the EVAL sponges and the inner surface of the vessels was filled with fresh thrombus. In the vessel walls of specimens examined 2 weeks after embolization there was no or a slight inflammatory reaction. Scattered in the EVAL sponges were almost equal numbers of neutrophilic granulocytes and mononuclear cells, indicative of a mild inflammatory response. In specimens examined 16 weeks postembolization, the changes noted at 2 weeks were intensified. There was no definite histopathological evidence of mural hemorrhage, perivascular extravasation of the mixture, or perivascular hemorrhage in any specimen that was examined.
Conclusions. Although the degree of permanence of this embolization material is yet unknown, the mixture was easy to handle, and appeared safe and effective for AVM embolization. Its nonadhesive characteristic and its ability to be infused by repeated injections make it an attractive alternative to currently available materials. The good results obtained in this study led us to undertake a clinical trial, the results of which are contained in a companion article in this issue of the Journal of Neurosurgery.
Jun-Ichiro Hamada, Yutaka Kai, Motohiro Morioka, Kiyoshi Kazekawa, Yasuji Ishimaru, Hiroo Iwata and Yukitaka Ushio
Object. The authors report their clinical experience with their new nonadhesive liquid embolic agent, an ethylene vinyl alcohol copolymer (EVAL)/ethanol mixture, to treat arteriovenous malformations (AVMs).
Methods. Between June 1995 and April 2001, 57 patients with confirmed AVMs underwent embolization of their lesions with the EVAL/ethanol mixture. In 87 procedures consisting of one to three stages, the authors embolized 185 feeding arteries to occlude as much of the AVM as possible. Repeated injections under fluoroscopic control could be performed smoothly without encountering cementing of the catheter to the vessel wall. Among the 87 embolizations undertaken in 57 patients, seven procedures (8%) in six patients produced new postembolization symptoms. Resolution of these symptoms occurred within hours or days after four of the seven procedures; permanent neurological deficits remained after the other three procedures (3.4%). Of the 57 patients, three underwent postembolization radiosurgery, and 54 underwent radical treatment with microsurgical extirpation. Histopathological examination of the 54 specimens disclosed mild inflammation within the embolized lumen without inflammatory reactions in the media or adventitia. Follow-up angiograms obtained 3 years after radiosurgery was administered showed that in all three patients treated in this fashion the nidus had completely disappeared.
Conclusions. The EVAL/ethanol mixture is handled easily and appears to be an effective and safe agent for preoperative embolization of AVMs.