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Fernando Viñuela, Gary Duckwiler, and Michel Mawad

✓ From December 1990 to July 1995, the investigators participated in a prospective clinical study to evaluate the safety of the Guglielmi detachable coil (GDC) system for the treatment of aneurysms. This report summarizes the perioperative results from eight initial interventional neuroradiology centers in the United States. The report focuses on 403 patients who presented with acute subarachnoid hemorrhage from a ruptured intracranial aneurysm. These patients were treated within 15 days of the primary intracranial hemorrhage and were followed until they were discharged from the hospital or died.

Seventy percent of the patients were female and 30% were male. The patients' mean age was 58 years old. Aneurysm size was categorized as small (60.8%), large (34.7%), and giant (4.5%); and neck size was categorized as small (53.6%), wide (36.2%), fusiform (6%), and undetermined (4.2%). Fifty-seven percent of the aneurysms were located in the posterior circulation and 43% in the anterior circulation.

Eighty-two patients were classified as Hunt and Hess Grade I (20.3%), 105 Grade II (26.1%), 121 Grade III (30%), 69 Grade IV (17.1%), and 26 Grade V (6.5%). All patients in this study were excluded from surgical treatment either because of anticipated surgical difficulty (69.2%), attempted and failed surgery (12.7%), the patient's poor neurological (12.2%) or medical (4.7%) status, and/or refusal of surgery (1.2%).

The GDC embolization was performed within 48 hours of primary hemorrhage in 147 patients (36.5%), within 3 to 6 days in 156 patients (38.7%), 7 to 10 days in 71 patients (17.6%), and 11 to 15 days in 29 patients (7.2%). Complete aneurysm occlusion was observed in 70.8% of small aneurysms with a small neck, 35% of large aneurysms, and 50% of giant aneurysms. A small neck remnant was observed in 21.4% of small aneurysms with a small neck, 57.1% of large aneurysms, and 50% of giant aneurysms. Technical complications included aneurysm perforation (2.7%), unintentional parent artery occlusion (3%), and untoward cerebral embolization (2.48%). There was a 8.9% immediate morbidity rate related to the GDC technique. Seven deaths were related to technical complications (1.74%) and 18 (4.47%) to the severity of the primary hemorrhage.

The findings of this study demonstrate the safety of the GDC system for the treatment of ruptured intracranial aneurysms in anterior and posterior circulations. The authors believe additional randomized studies will further identify the role of this technique in the management of acutely ruptured incranial aneurysms.

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Fernando Viñuela, Gary Duckwiler, and Michel Mawad

✓From December 1990 to July 1995, the investigators participated in a prospective clinical study to evaluate the safety of the Guglielmi detachable coil (GDC) system for the treatment of aneurysms. This report summarizes the perioperative results from eight initial interventional neuroradiology centers in the United States. The report focuses on 403 patients who presented with acute subarachnoid hemorrhage from a ruptured intracranial aneurysm. These patients were treated within 15 days of the primary intracranial hemorrhage and were followed until they were discharged from the hospital or died.

Seventy percent of the patients were female and 30% were male. The patients' mean age was 58 years old. Aneurysm size was categorized as small (60.8%), large (34.7%), and giant (4.5%); and neck size was categorized as small (53.6%), wide (36.2%), fusiform (6%), and undetermined (4.2%). Fifty-seven percent of the aueurysms were located in the posterior circulation and 43% in the anterior circulation.

Eighty-two patients were classified as Hunt and Hess Grade I (20.3%), 105 Grade II (26.1%), 121 Grade III (30%), 69 Grade IV (17.1%), and 26 Grade V (6.5%). All patients in this study were excluded from surgical treatment either because of anticipated surgical difficulty (69.2%), attempted and failed surgery (12.7%), the patient's poor neurological (12.2%) or medical (4.7%) status, and/or refusal of surgery (1.2%).

The GDC embolization was performed within 48 hours of primary hemorrhage in 147 patients (36.5%), within 3 to 6 days in 156 patients (38.7%), 7 to 10 days in 71 patients (17.6%), and 11 to 15 days in 29 patients (7.2%). Complete aneurysm occlusion was observed in 70.8% of small aneurysms with a small neck, 35% of large aneurysms, and 50% of giant aneurysms. A small neck remnant was observed in 21.4% of small aneurysms with a small neck, 57.1% of large aneurysms, and 50% of giant aneurysms. Technical complications included aneurysm perforation (2.7%), unintentional parent artery occlusion (3%), and untoward cerebral embolization (2.48%). There was a 8.9% immediate morbidity rate related to the GDC technique. Seven deaths were related lo technical complications (1.74%) and 18 (4.47%) to the severity of the primary hemorrhage.

The findings of this study demonstrate the safety of the GDC system for the treatment of ruptured intracranial aneurysms in anterior and posterior circulations. The authors believe additional randomized studies will further identify the role of this technique in the management of acutely ruptured incranial aneurysms.

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Spinal intramedullary ependymal cyst

Report of three cases

Daniel P. Robertson, Joel B. Kirkpatrick, Richard L. Harper, and Michel E. Mawad

✓ Three cases of spinal intramedullary ependymal cyst, two at the thoracolumbar junction and one in the cervical spinal cord, are reported in women in their fifth to seventh decades. Neurological signs and symptoms were extremity dysesthesias, paresthesias, and weakness. Plain cervical and lumbothoracic x-ray films were normal for the patients' age. Magnetic resonance (MR) imaging demonstrated a rounded cystic intramedullary mass at the thoracolumbar junction in two cases and at C3–7 in one case. The signal intensity of the cyst contents approximated that of cerebrospinal fluid on T1- and T2-weighted images. Upon administration of gadolinium-diethylenetriaminepenta-acetic acid (Gd-DTPA), MR imaging showed no enhancement in the cyst wall or cavity. Myelotomy and cyst drainage were performed in each case, and the neurological status of each patient improved. The lining of the cyst was biopsied in one of the three patients undergoing surgery and was composed of a single layer of cuboidal cells supported by glial tissue. Periodic acid-Schiff staining of the tissue did not reveal a basement membrane. The findings in these cases suggest that the Gd-DTPA-enhanced MR imaging appearance of intramedullary spinal ependymal cyst is consistent and allows for accurate preoperative diagnosis with or without biopsy.

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Michel E. Mawad, Saruhan Cekirge, Elisa Ciceri, and Isil Saatci

Object. The aim of this study was to test the feasibility, safety, and efficacy of a new endovascular method for the treatment of giant intracranial aneurysms. This new method consists of combining a metallic stent with a liquid polymer; the stent is first placed across the neck of the aneurysm to reconstruct a tubular arterial lumen, followed by obliteration of the fundus of the aneurysm with an ethyl vinyl alcohol polymer. During its injection, the liquid polymer is contained within the aneurysm by temporarily inflating an occlusion balloon in the parent artery.

Methods. Eleven patients harboring a giant aneurysm were successfully treated using this procedure. All aneurysms were excluded from the circulation, with preservation of the parent artery. In nine of the 11 patients, the 6-month follow-up angiogram demonstrated no recanalization of the aneurysm. In one patient who had a giant and partially clotted internal carotid artery bifurcation aneurysm, the follow-up angiogram demonstrated minimal recanalization. The complications in this series of patients included one death and one case of transient hemiparesis caused by watershed ischemia.

Conclusions. The initial anatomical results and the clinical outcome in this small series of patients are very encouraging. The mortality and morbidity rates associated with this new endovascular treatment are superior to those associated with surgical clipping of giant aneurysms.

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Roukoz B. Chamoun, Michel E. Mawad, William E. Whitehead, Thomas G. Luerssen, and Andrew Jea

Object

Currently, no diagnostic or treatment standards exist for extracranial carotid artery dissection (CAD) in children after trauma. The purpose of this study was to review and describe the characteristics, diagnosis, and treatment of this rather uncommon sequelae of pediatric trauma.

Methods

A systematic review of the literature was performed to examine the pertinent studies of traumatic extracranial carotid artery (CA) injuries in children.

Results

No randomized trials were identified; however, 19 case reports or small case series consisting of 34 pediatric patients were found in the literature. The diagnosis of CAD was made in 33 of 34 patients only after the onset of ischemic symptomatology. Twenty-four of 34 patients underwent cerebral angiography to confirm diagnosis; MR angiography affirmed the diagnosis in 6 of 34 patients. There was little published experience with CA ultrasonography or CT angiography for diagnosis. Thirty of 34 patients were treated with medical therapy or observation; 2 of 4 patients treated with observation alone died. There was little experience with open surgical treatment of CAD in the pediatric population, and there were no studies on the endovascular treatment of traumatic CAD in children. The literature does not support anticoagulation therapy over antiplatelet therapy.

Conclusions

As a result of this review of the literature, the authors propose the algorithms for the evaluation and treatment of traumatic extracranial CADs in children. These recommendations include utilizing MR angiography as a screening tool in cases in which the clinical suspicion of CAD is high, using conventional cerebral angiography to confirm the diagnosis, implementing antiplatelet therapy as initial medical management, and reserving endovascular stenting in cases of failed medical treatment.

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Yuichi Murayama, Tim Malisch, Guido Guglielmi, Michel E. Mawad, Fernando Viñuela, Gary R. Duckwiler, Y. Pierre Gobin, Richard P. Klucznick, Neil A. Martin, and John Frazee

✓ Cerebral vasospasm is the most common cause of morbidity and mortality in patients admitted to the hospital after suffering aneurysmal subarachnoid hemorrhage (SAH). The early surgical removal of subarachnoid clots and irrigation of the basal cisterns have been reported to reduce the incidence of vasospasm. In contrast to surgery, the endovascular treatment of aneurysms does not allow removal of subarachnoid clots. In this study the authors measured the incidence of symptomatic vasospasm after early endovascular treatment of acutely ruptured aneurysms with Guglielmi detachable coils (GDCs).

Sixty-nine patients classified as Hunt and Hess Grades I to III underwent occlusion of intracranial aneurysms via GDCs within 72 hours of rupture. The amount of blood on the initial computerized tomography (CT) scan was classified by means of Fisher's scale. Symptomatic vasospasm was defined as the onset of neurological deterioration verified with angiographic or transcranial Doppler studies. Hypertensive, hypervolemic, hemodilution therapy, with or without intracranial angioplasty, was used to treat vasospasm after GDC placement.

Symptomatic vasospasm occurred in 16 (23%) of 69 patients. The clinical grade at admission and the amount of blood on the initial CT were both associated with the incidence of subsequent vasospasm. At 6-month clinical follow-up examination, 12 of these 16 patients experienced a good recovery, two were moderately disabled, and two patients had died of vasospasm.

In conclusion, the 23% incidence of symptomatic vasospasm in this series compares favorably with that found in conventional surgical series of patients with acute aneurysmal SAH. These results indicate that endovascular therapy does not have an unfavorable impact on cerebral vasospasm.

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Ryan S. Kitagawa, Michel E. Mawad, William E. Whitehead, Daniel J. Curry, Thomas G. Luersen, and Andrew Jea

Arteriovenous malformations (AVMs) within the spinal canal and in the paraspinal region are unusual. Spinal cord and dural AVMs or arteriovenous fistulas have been the subject of numerous reports, but paraspinal malformations causing venous congestion or hemorrhage in the spinal canal are rare and present special diagnosis and management challenges. The authors review previously published reports on 16 children with paraspinal AVMs. They also describe the 17th case of a child with a paraspinal AVM who presented with a spontaneous spinal epidural hematoma. To the best of the authors' knowledge, there has been no other case of a spinal epidural hematoma associated with a paraspinal AVM. In each of the 17 cases, the vascular lesion was successfully obliterated using endovascular therapy. Embolization with permanent occlusive agents is an effective treatment for these rare but potentially debilitating lesions.