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Charles B. Wilson and Grant Hieshima

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Wesley A. King, Grant B. Hieshima, and Neil A. Martin

✓ An attempt at transfemoral transarterial balloon occlusion of a high-flow spontaneous carotid-cavernous fistula was unsuccessful because the carotid artery rent was too small for this approach. During a subsequent transvenous approach to the cavernous sinus through the jugular vein, the inferior petrosal sinus was perforated. A minor subarachnoid hemorrhage occurred before the tear could be sealed by the deposition of three Gianturco coils in the vein. The patient was taken to the operating room for emergency obliteration of the fistula and petrosal sinus in order to remove the risk of further hemorrhage. Under the guidance of intraoperative digital subtraction angiography, isobutyl-2-cyanoacrylate was injected directly into the surgically exposed cavernous sinus. Successful obliteration of the fistula was achieved with preservation of the carotid artery, and the angiography catheter was removed safely from the petrosal sinus. Although initially after surgery the patient had nearly complete ophthalmoplegia, at her 1-year follow-up examination she had normal ocular motility and visual acuity. The transvenous approach to the cavernous sinus and alternative methods of treatment of carotid-cavernous fistulas are discussed.

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Milton D. Heifetz, Grant B. Hieshima, and C. Mark Mehringer

✓ A doughnut-shaped balloon has been designed that can be inserted intravascularly by catheter to occlude the orifice of an intracranial berry or giant aneurysm or arteriovenous fistula. The blood in the parent artery can continue to flow uninterrupted through the hole in the balloon. In a preliminary study, an arteriovenous fistula was successfully obliterated in a dog. The technique for placing the balloon is described.

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Kevin T. Foley, Leslie D. Cahan, and Grant B. Hieshima

✓ A portable digital subtraction unit has been used in the operating room as an important improvement in obtaining high-quality intraoperative angiograms. This digital subtraction system offers several advantages over previously described techniques for intraoperative studies. Not only are the images of good quality, but also the dose of contrast medium is reduced and a real-time imaging capability allows the surgeon to visualize the passage of contrast agent dynamically. Arterial injections may be performed by selective femoral cerebral catheterization, puncture of the cervical carotid artery, retrograde catheterization via the superficial temporal artery, or puncture of an intracranial vessel at the time of surgery.

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Isabelle M. Germano, Richard L. Davis, Charles B. Wilson, and Grant B. Hieshima

✓ Embolization with polyvinyl alcohol (PVA) is an accepted method of rendering complex arteriovenous malformations (AVM's) more amenable to surgery, but its effects on human vascular tissues have not been adequately documented. The authors reviewed the histopathology of 66 intracranial AVM's resected 1 to 76 days after embolization with PVA. The mean age of the patients was 36 years, and their AVM's were located in the cerebral hemispheres (92%), the cerebellum (6%), or the corpus callosum (2%). In 79% of cases, at least one vessel contained PVA particles; in most cases, the vessel was filled with sharp, angular PVA particles in a serpiginous pattern. Polyvinyl alcohol particles indented the endothelium in 69% of cases but were rarely found subendothelially. Clotted blood and fibroblasts were present among the particles, and abundant intraluminal mononuclear and polymorphonuclear inflammatory cells were found in all vessels containing PVA particles. Foreign-body giant cells appeared 2 to 14 days after embolization in the majority of cases. Patchy mural angionecrosis and necrotizing vasculitis were found in 39% of the cases. Recanalized lumina were seen in 18% of PVA-embolized vessels. Foreign materials resembling cotton fibers and other particulate substances, which were probably contaminants of the contrast solution or the embolic material, were found in 65% of the cases. These findings suggest a specific chain of events in the interaction between PVA and vessel wall components and may explain some important sequelae of embolization therapy.

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Leslie D. Cahan, Randall T. Higashida, Van V. Halbach, and Grant B. Hieshima

✓ In recent years, it has become evident that the most common form of arteriovenous malformation to involve the spinal cord in adults is a low-flow fistula with its nidus located on the dura in relation to the dorsal nerve root. This lesion, termed “radiculomeningeal fistula” (RMF), is drained by the intradural coronal venous system and most likely causes neurological deficits due to raised venous pressure within the spinal cord. The therapy that was formerly recommended was multilevel laminectomy with microsurgical stripping of the intradural vessels. However, that procedure focused on the draining veins rather than the nidus, and it has been replaced by direct treatment of the nidus or by disconnecting the nidus from the coronal venous system. This paper reports variants of RMF's that show a wider spectrum of the clinical and radiological findings than has been previously reported. Three patients presenting with extradural venous drainage, intraspinal hemorrhage, and/or sudden non-hemorrhagic neurological decline are reported. A more complete understanding of RMF facilitates the radiological and clinical evaluation of these patients and enables the surgeon to modify the therapy in a significant way.

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Griffith R. Harsh, Charles B. Wilson, Grant B. Hieshima, and William P. Dillon

✓ A patient with trigeminal neuralgia and hemifacial spasm was evaluated using multiplanar magnetic resonance (MR) imaging with gadolinium enhancement. Preoperative images demonstrated massively ectatic vertebral and basilar arteries and their distortion of the brain stem and the trigeminal and facial nerves. Surgical manipulation included selective trigeminal rhizotomy, cushioning of the residual nerve at the point of maximal distortion by the underlying basilar artery, and microvascular decompression of the seventh nerve from the anterior inferior cerebellar artery which was being pushed dorsomedially by the vertebral artery. Postoperatively, the patient had neither trigeminal neuralgia nor facial spasm. Gadolinium-enhanced MR imaging not only excludes other etiologies such as tumor or arteriovenous malformation, but also demonstrates cranial nerve compression by ectatic vertebral and basilar arteries. The choice of preoperative imaging modality is discussed and the literature concerning the etiology of tic convulsif is reviewed.

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Charles M. Strother, Sigurd Lunde, Virgil Graves, Steven Toutant, and Grant B. Hieshima

✓ A fatal rupture of a large paraophthalmic aneurysm 11 months following treatment with detachable balloons is described. This case illustrates the potential consequences of incomplete aneurysm obliteration with endovascular techniques and emphasizes the need for adequate posttreatment evaluation when this method is used for aneurysm therapy.