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Muneer Eesa, Pranshu Sharma, Alim Pyarali Mitha, Garnette Roy Sutherland and Mayank Goyal

Intracranial dural arteriovenous fistulas (dAVFs) are commonly encountered in centers specializing in cerebrovascular diseases. Knowing the precise site of fistulous communication with the venous structures is essential in targeting the appropriate surgical or endovascular therapy once a decision to treat has been made. Such sites can usually be located with digital subtraction angiography alone. The authors describe a case in which localization was best performed using cone-beam volume CT in the angiography suite after selective microcatheterization of the feeding vessel and injection of a contrast agent in a dAVF related to the petrous temporal bone. Imaging studies showed the lesion was related to the inferior aspect of the tentorium, warranting a suboccipital surgical approach to treat the fistula.

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Michael B. Avery, Ahmed Alaqeel, Amy B. Bromley, Yong-Xiang Chen, John H. Wong, Muneer Eesa and Alim P. Mitha

OBJECTIVE

Reliable animal models are an important aspect of translational research, especially for relatively uncommon clinical entities such as fusiform aneurysms. While several animal models exist, very few are tailored to cerebral fusiform aneurysms, which have unique attributes compared to abdominal fusiform aneurysms. The authors aimed to build from previous models to create a cerebral fusiform aneurysm model that is simple to use and reliable.

METHODS

Twelve female New Zealand White rabbits were assigned to 3 groups: group E, elastase only; group C, CaCl2 only; group EC, elastase + CaCl2. All rabbits underwent surgical exposure of the right common carotid artery (CCA) and 20 minutes of peri-carotid incubation with their respective chemicals. Angiography was performed 6 weeks later for arterial dilation measurements, with 50% increase in diameter being defined as fusiform aneurysm formation. The arterial segments, along with the contralateral CCAs, were harvested and assessed histologically for wall component measurements and elastin semiquantification. A separate rabbit underwent aneurysm creation per the group EC protocol and was treated with an endovascular flow-diversion device.

RESULTS

All of the group EC rabbits developed fusiform aneurysms (mean dilation of 88%), while none of the group E or group C rabbits developed aneurysms (p = 0.001). Histological analysis revealed increased internal elastic lamina fragmentation in the group EC aneurysms, which also had less tunica intima hyperplasia. All aneurysms exhibited thinning of the tunica media and reduction in elastin content. The use of an endovascular flow-diverting stent was successful, with complete parent vessel remodeling, as expected, 4 weeks after deployment.

CONCLUSIONS

The peri-arterial application of combined elastase and CaCl2 to the CCA appears sufficient to reliably produce fusiform aneurysms after 6 weeks. Exposure to elastase or CaCl2 individually appears insufficient, despite the observed histological changes to the arterial wall. The proposed fusiform aneurysm model is able to accommodate endovascular devices, simulating the tortuous pathway experienced in using such devices in human cerebral aneurysms and thus is a satisfactory model to use in translational research.

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Aaron Hockley, Michael K. Tso, Mohammed A. Almekhlafi, Abhay K. Lodha, Robin Clegg, Jeremy Luntley, Muneer Eesa and John H. Wong

OBJECTIVE

Vein of Galen aneurysmal malformations (VGAMs) in infancy have a poor natural history if left untreated. Their high-flow nature can preclude safe and accurate therapeutic vessel occlusion and the risk of inadvertent pulmonary embolism is predominant. The authors describe the technique of rapid cardiac ventricular pacing for inducing transient hypotension to facilitate the controlled embolization of VGAMs.

METHODS

Initial transjugular venous access was obtained for placing temporary pacing leads for rapid cardiac ventricular pacing immediately prior to embolization. Definitive transarterial embolization procedures for the VGAMs were then performed in the same setting in which liquid embolic agents or coils were used.

RESULTS

Beginning in 2010, a total of five procedures were performed in three infants. Transvenous rapid cardiac ventricular pacing was successfully achieved to induce systemic transient flow arrest in all but two attempts, and facilitated partial embolization with n-butyl cyanoacrylate (n-BCA) and coils in all procedures. Ventricular fibrillation occurred twice in one patient and was successfully reversed with defibrillation on both occasions. One patient failed to improve and died from refractory heart failure. Two patients stabilized following staged embolization.

CONCLUSIONS

Rapid transvenous cardiac ventricular pacing can be considered to induce transient hypotension and facilitate controlled embolization in challenging high-flow VGAMs.

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Aaron Hockley, Michael K. Tso, Mohammed A. Almekhlafi, Abhay K. Lodha, Robin Clegg, Jeremy Luntley, Muneer Eesa and John H. Wong

OBJECTIVE

Vein of Galen aneurysmal malformations (VGAMs) in infancy have a poor natural history if left untreated. Their high-flow nature can preclude safe and accurate therapeutic vessel occlusion and the risk of inadvertent pulmonary embolism is predominant. The authors describe the technique of rapid cardiac ventricular pacing for inducing transient hypotension to facilitate the controlled embolization of VGAMs.

METHODS

Initial transjugular venous access was obtained for placing temporary pacing leads for rapid cardiac ventricular pacing immediately prior to embolization. Definitive transarterial embolization procedures for the VGAMs were then performed in the same setting in which liquid embolic agents or coils were used.

RESULTS

Beginning in 2010, a total of five procedures were performed in three infants. Transvenous rapid cardiac ventricular pacing was successfully achieved to induce systemic transient flow arrest in all but two attempts, and facilitated partial embolization with n-butyl cyanoacrylate (n-BCA) and coils in all procedures. Ventricular fibrillation occurred twice in one patient and was successfully reversed with defibrillation on both occasions. One patient failed to improve and died from refractory heart failure. Two patients stabilized following staged embolization.

CONCLUSIONS

Rapid transvenous cardiac ventricular pacing can be considered to induce transient hypotension and facilitate controlled embolization in challenging high-flow VGAMs.