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Amir R. Dehdashti, Bénédict Rilliet, Daniel A. Rufenacht, and Nicolas de Tribolet

Object. This study was designed to determine whether the frequency of shunt-dependent hydrocephalus in patients suffering from aneurysmal subarachnoid hemorrhage (SAH) differs when comparing surgical clip application with endovascular obliteration of ruptured aneurysms.

Methods. In this prospective nonrandomized study, 245 patients with aneurysmal SAH treated using either surgical clip application or endovascular coil embolization were studied at our institution between September 1997 and March 2003. One hundred eighty patients underwent clip application and 65 had coil embolization. In those patients who underwent clip application of anterior circulation aneurysms, the lamina terminalis was systematically fenestrated.

The occurrence of acute, asymptomatic, and shunt-dependent hydrocephalus was analyzed in both treatment groups. A subgroup analysis of patients with good clinical grade (World Federation of Neurosurgical Societies [WFNS] Grades I–III) and better Fisher Grade (1–3) and of patients with Fisher Grade 4 hemorrhage was performed.

Acute hydrocephalus was observed in 19% of surgical cases and 46% of endovascular ones. The occurrence of asymptomatic hydrocephalus was similar in both treatment groups (p = 0.4). Shunt-dependent hydrocephalus occurred in 14% of surgical cases and 19% of endovascular cases. This difference did not reach statistical significance (p = 0.53). Logistic regression models controlling for patient age, WFNS grade, Fisher grade, and acute hydrocephalus in patients with good clinical grade and better Fisher grade revealed no significant difference in the rate of shunt-dependent hydrocephalus in both therapy groups (odds ratio [OR] 0.8, 95% confidence interval [CI] 0.2–2.65). Results of similar models indicated that among patients with intraventricular hemorrhage (IVH), surgical clip application carried a lower risk of shunt-dependent hydrocephalus (OR 0.32, 95% CI 0.14–0.75) compared with that for endovascular embolization.

Conclusions. Shunt-dependent hydrocephalus was comparable in the two treatment groups, even in patients with better clinical and radiological grades on admission. Only patients in the endovascular therapy group who had experienced IVH showed a higher likelihood of shunt-dependent hydrocephalus.

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Kenji Sugiu, Jean-Baptiste Martin, Beatrix Jean, and Daniel A. Rüfenacht

✓ In this article the authors describe a rescue balloon procedure for coil implantation in three cases. In each patient, the coil seemed likely to unravel. The coils stretched when attempts were made to remove the partially implanted but trapped device. The inflation of a nondetachable microballoon in front of the aneurysm orifice allowed the surgeons to complete implantation of the coil and to avoid a more forceful and potentially harmful retrieval. This rescue balloon method may be useful for emergency situations, such as coil stretching with or without migration.

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Michael D. Partington, Daniel A. Rüfenacht, W. Richard Marsh, and David G. Piepgras

✓ The authors report a series of seven patients with myelopathy who were found to have spinal dural arteriovenous (AV) fistulas in which the nidus was located at some distance from the spinal cord. The nidus was intracranial in three cases and involved a sacral nerve root sheath in the other four, in each case, the arterialized draining vein led into the coronal plexus of medullary veins. A lack of normal draining radicular veins was noted in all cases. Magnetic resonance images were obtained in four patients and demonstrated spinal cord tissue changes only in the lower thoracic cord in three cases and in the cervical cord in one, all consistent with an ischemic process secondary to venous hypertension. Five patients were managed surgically by division of the draining vein, with improvement of the neurological deficit in all. One patient was treated by embolization alone and had stabilization of her deficit. The remaining patient in the series died of unrelated systemic disease before the spinal dural AV fistula could be treated.

These cases support the theory that venous hypertension is the dominant pathophysiological mechanism involved in spinal dural AV fistulas independent of their location. In patients with a suspected spinal dural AV fistula, lumbar and thoracic spinal angiography will reveal the site of the fistula in the majority of cases (88% in this series). In the remaining patients, the possibility of a remote fistula must be considered. The lack of normal venous drainage of the cord following injection in the artery of Adamkiewicz is the most reliable indicator of venous hypertension in the cord and can be helpful in making the decision to proceed with a search for a cranial or sacral arterial supply.

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Koji Tokunaga, Krisztina Barath, Jean-Baptiste Martin, and Daniel A. Rüfenacht

✓ Transarterial particulate embolization is indicated for benign intracranial dural arteriovenous fistulas (DAVFs) that have no dangerous venous reflux. This treatment, however, does not cure these lesions. In this case report the authors describe a spontaneously occurring DAVF that was treated by implanting coils through a transarterial microcatheter into the affected venous channel. The channel was separate from the normal dural sinuses. The pathological architecture of the fistula and the usefulness of this approach are discussed.

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Jacques Théron, Léopoldo Guimaraens, Oguzman Coskun, Thérésa Sola, Jean-Baptiste Martin, and Daniel A. Rüfenacht

The authors report the complications that occurred in their experience with performing recanalization procedures in the internal carotid artery and present their treatment strategies. The complications can be classified into those that were periprocedural and those that were postprocedural. The former include complications related to the vascular-approach access site of and those associated with the dilation and stenting procedure. Other complications observed included embolic events, dissection, vascular spasm, bradycardia, inappropriate dilation, occlusion of the external carotid artery, and rare, unusual complications such as the occurrence of iatrogenic cavernous carotid fistula. Postprocedure complications occurred in the hours and days following the procedure in the form of embolic and occlusive events, and hypotension and bradycardia were seen as late complications in the months following the procedure. The authors discuss how such complications occur and provide suggestions on how to avoid them. The role of stent placement and the potential use of protective devices are explored. Overall, adequate use of currently available systems allows for safe application of endovascular treatment techniques that avoid altogether or treat these potential complications. A reduced incidence of complications related to the initial individual learning curve may be obtained with preclinical training, in which use of invitro models should be considered. Surgical standby no longer seems required; however, early posttreatment surveillance in intensive care unit is mandatory to avoid the remaining primary complications.

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Philippe Bijlenga, Sandrine Morel, Sven Hirsch, Karl Schaller, and Daniel Rüfenacht

The disease resulting in the formation, growth, and rupture of intracranial aneurysms is complex. Research is accumulating evidence that the disease is driven by many different factors, some constant and others variable over time. Combinations of factors may induce specific biophysical reactions at different stages of the disease. A better understanding of the biophysical mechanisms responsible for the disease initiation and progression is essential to predict the natural history of the disease. More accurate predictions are mandatory to adequately balance risks between observation and intervention at the individual level as expected in the age of personalized medicine. Multidisciplinary exploration of the disease also opens an avenue to the discovery of possible preventive actions or medical treatments. Modern information technologies and data processing methods offer tools to address such complex challenges requiring 1) the collection of a high volume of information provided globally, 2) integration and harmonization of the information, and 3) management of data sharing with a broad spectrum of stakeholders.

Over the last decade an infrastructure has been set up and is now made available to the academic community to support and promote exploration of intracranial disease, modeling, and clinical management simulation and monitoring.

The background and purpose of the infrastructure is reviewed. The infrastructure data flow architecture is presented. The basic concepts of disease modeling that oriented the design of the core information model are explained. Disease phases, milestones, cases stratification group in each phase, key relevant factors, and outcomes are defined. Data processing and disease model visualization tools are presented. Most relevant contributions to the literature resulting from the exploitation of the infrastructure are reviewed, and future perspectives are discussed.

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Jonathan E. Hodes, Armand Aymard, Y. Pierre Gobin, Daniel Rüfenacht, Siegfried Bien, Daniel Reizine, André Gaston, and Jean Jacques Merland

✓ Among 121 intracerebral aneurysms presenting at one institution between 1984 and 1989, 16 were treated by endovascular means. All 16 lesions were intradural and intracranial, and had failed either surgical or endovascular attempts at selective exclusion with parent vessel preservation. The lesions included four giant middle cerebral artery (MCA) aneurysms, one giant anterior communicating artery aneurysm, six giant posterior cerebral artery aneurysms, one posterior inferior cerebellar artery aneurysm, one giant mid-basilar artery aneurysm, two giant fusiform basilar artery aneurysms, and one dissecting vertebral artery aneurysm. One of the 16 patients failed an MCA test occlusion and was approached surgically after attempted endovascular selective occlusion. Treatment involved pretreatment evaluation of cerebral blood flow followed by a preliminary parent vessel test occlusion under neuroleptic analgesia with vigilant neurological monitoring. If the test occlusion was tolerated, it was immediately followed by permanent occlusion of the parent vessel with either detachable or nondetachable balloon or coils.

The follow-up period ranged from 1 to 8 years. Excellent outcomes were obtained in 12 cases with complete angiographic obliteration of the aneurysm and no new neurological deficits and/or improvement of the pre-embolization symptoms. Four patients died: two related to the procedure, one secondary to rupture of another untreated aneurysm, and the fourth from a postoperative MCA thrombosis after having failed endovascular test occlusion. The angiographic, clinical, and cerebral blood flow criteria for occlusion tolerance are discussed.

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Armand Aymard, Y. Pierre Gobin, Jonathan E. Hodes, Siegfried Bien, Daniel Rüfenacht, Daniel Reizine, Bernard George, and Jean J. Merland

✓ Twenty-one patients with aneurysms of the vertebrobasilar circulation underwent unilateral or bilateral endovascular occlusion of the vertebral artery. Six patients presented with subarachnoid hemorrhage (SAH), 10 with mass effect, four with mass effect and SAH, and one with ischemic symptoms. Thirteen patients had good outcomes with complete clinical and angiographic cure. Six patients had partial thrombosis of their aneurysms. There was one death and one treatment failure. One patient suffered transient stroke. It is concluded that endovascular occlusion of the vertebral artery following test occlusion is a safe and effective treatment for proximal aneurysms of the vertebrobasilar circulation.

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Francis H. Tomlinson, Daniel A. Rüfenacht, Thoralf M. Sundt Jr., Douglas A. Nichols, and Nicolee C. Fode

✓ Arteriovenous (AV) fistulas of cerebral and spinal arteries are characterized angiographically by an immediate AV transition without a capillary bed or “nidus” as occurs in AV malformations (AVM's). The clinical presentation, morphology, radiology, and treatment of 12 patients with cerebral AV fistulas and of 12 patients with spinal AV fistulas are reviewed. In the patients with cerebral lesions, headache and seizure disorders were the most common presentations followed by subarachnoid hemorrhage, cardiac failure, progressive neurological dysfunction, and incidental detection on prenatal ultrasound study. In patients with spinal AV fistulas, weakness and sensory disturbance in the lower extremities were the most frequent clinical presentations followed by back pain, disturbances of micturition, and grand mal seizure. The etiology of the symptom complex produced by AV fistulas in each of these locations differed, with venous hypertension being important in spinal cord lesions.

Of the patients with cerebral lesions, nine had a single AV fistula, one had two fistulas, and two had multiple fistulas. An AVM was observed in five patients with fistulas (two large, three small). Nine patients exhibited extramedullary AV fistulas of the spine, of whom eight had a single fistula and one had three fistulas; three patients had intramedullary spinal AV fistulas. An arterial aneurysm was found in association with two fistulas, one cerebral and one spinal. Venous ectasias or varices, frequently exhibiting mural calcification, were observed to be prominent in all AV fistulas involving cerebral arteries and in two involving spinal arteries. The location and size of the venous complexes reflected the diameter of the fistula. In addition to conventional imaging techniques (cerebral angiography, computerized tomography, and magnetic resonance (MR) imaging), MR angiography was a helpful adjunct in the evaluation of fistulas. Treatment strategies employed for AV fistulas in both locations included open surgical and endovascular procedures, frequently used in combination. A satisfactory outcome was observed in all patients.