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Therapeutic options for endovascular therapy for intracranial aneurysms

Rocco A. Armonda, Jeffrey E. Thomas, and Robert H. Rosenwasser

Endovascular surgical technology is in the early stages of evolution. A critical phase of this development has been microcatheter technology, which has permitted sufficiently precise intravascular navigation to safely engage the lumen of the aneurysm itself. Digital subtraction angiography, rapid filming techniques and image acquisition, and simultaneous multiplanar imaging capability are indispensable tools that are constantly being refined in the setting of ever-improving computer technology. The marriage of these different technologies has allowed effective endovascular treatment of difficult-to-access aneurysms in medically compromised patients for whom open microsurgery has inherently higher risks.

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Early and aggressive treatment of medically intractable cerebral vasospasm with pentobarbital coma, cerebral angioplasty and ICP reduction

Rocco A. Armonda, Jeffrey E. Thomas, and Robert H. Rosenwasser

The authors present the unique experience of one neurovascular service under the direct supervision of the senior author, for which surgical, endovascular, and intensive care treatments were conducted in a select group of 32 patients with aneurysmal subarachnoid hemorrhage who had medically intractable symptomatic vasospasm.

A protocol of early and aggressive treatment was instituted using pentobarbital coma, cerebral angioplasty, and intracranial pressure (ICP) reduction. The patient population consisted of 25 women and seven men, whose ages ranged from 34 to 60 years (average 47 years). The patients' Hunt and Hess grades on presentation were as follows: Grade 0 (one); Grade I (three); Grade II (two); Grade III (nine); Grade IV (10); Grade V (seven). Microsurgical clipping alone was performed in 15 of 32 patients, endosaccular occlusion was performed in 17 of 20 patients, and two patients underwent combined treatment. Subsequent angioplasty was performed in 26 of 32 patients. Additionally, all 32 patients underwent treatment of increased ICP with ventriculostomy placement, removal of the bone flap (11), evacuation of associated intracranial hematoma (five), and decompressive obectomy (four).

Twenty-one patients survived and 11 died. Of the 21 survivors, seven have returned to work, live independently, and have no neurological deficits; eight require minimal assistance at home; four are in rehabilitation with moderate deficits at 3 months; and two remain in a persistent vegetative state.

In this group of aggressively treated patients who received pentobarbital cerebral protection, successful treatment of medically intractable cerebral vasospasm was related to time of treatment (< 2 hours), expeditious reduction of elevated ICP, and angioplasty.

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Incidence and management of traumatic vertebral artery injuries: wartime experience in Ukraine

Andrii Sirko, Yurii Cherednychenko, Ehsan Dowlati, Vadym Perepelytsia, and Rocco A. Armonda

OBJECTIVE

Modern combat–related vertebral artery (VA) injuries are increasingly being diagnosed, but the management of such injuries remains controversial. The authors report the frequency and characteristics of combat-related penetrating VA injuries and the indications for endovascular treatment, as well as analyze their treatment outcomes.

METHODS

A 1-year prospective study was completed at a civilian medical center in Dnipro, Ukraine, in all patients with VA injuries sustained during the Russian invasion in the 1st year of war. The authors evaluated the location, type, and severity of the VA injuries and concomitant injuries, as well as the type of intervention and outcomes at 1 month.

RESULTS

In total, 279 wounded patients underwent cerebral angiography and 30 (10.8%) patients had VA injuries. All patients were male. There were 28 soldiers and 2 civilians with a mean age of 37.5 years. Four (13.3%) patients had Bissl grade I injuries, 4 (13.3%) had grade II injuries, 4 (13.3%) had grade III injuries (pseudoaneurysm), and 18 (60.0%) had grade IV injuries (occlusion). Four (13.3%) patients underwent emergency open surgical intervention. Fourteen (46.7%) patients underwent endovascular intervention. There was a significant relationship between the anatomical level of the VA injury and surgical intervention (p < 0.05). Endovascular intervention was correlated with the severity of vascular injury to the VA, with 12.5% of the patients receiving intervention for grade I and II lesions and 59.1% receiving intervention for grade III and IV lesions (p < 0.05). The overall mortality in the study group was 6.7% (n = 2), and both died of ischemic complications.

CONCLUSIONS

In modern armed conflicts, VA injuries are much more common than reported for previous wars. With the available modern endovascular technology, cerebral angiography is warranted for suspected VA injury and allows for both the diagnosis and treatment of these injuries. Whether endovascular intervention is performed depends on the level and severity of VA injury, severity of concomitant injuries, and presence of collateral circulation.

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Carotid angioplasty and stenting for recurrent and radiation-induced stenosis: preliminary experience

Ronald P. Benitez, Rocco A. Armonda, James Harrop, Jeffrey E. Thomas, and Robert H. Rosenwasser

Carotid endarterectomy for atherosclerotic occlusive disease has become the standard of care for the treatment of symptomatic and asymptomatic occlusive disease of the carotid bifurcation, based on the results of the North American Symptomatic Carotid Endarterectomy Trial, as well as the Asymptomatic Carotid Atherosclerosis Study. For surgical treatment to be of benefit, the perioperative complication rate for neurological events should be 6% or less in the symptomatic population and 3% or less in the asymptomatic group. The performance of carotid endarterectomy for recurrent stenosis and radiation-induced stenosis has reported neurological events ranging from 4 to 10%. It is in this particular population that carotid angioplasty and stent placement may play a role.

The authors performed a retrospective analysis of 11 patients who underwent carotid angioplasty and stent placement for recurrent or radiation-induced stenosis. One patient in whom endarterectomy was performed by the vascular surgery service had a critical stenosis distal to the endarterectomy site and awoke with a neurological deficit. This patient underwent reexploration and placement of a stent in the artery distal to the arteriotomy site.

The follow-up period ranged from 7 to 12 months. Patient age ranged from 65 to 77 years (mean 75 years). Five of eight patients underwent angioplasty and stent placement for recurrent atherosclerotic disease. Two patients had radiation-induced stenosis, and one patient had a stent placed intraoperatively. All patients, with the exception of the one who underwent intraoperative stent placement, had posttreatment stenoses of less than 15%. The surgical patient had a 30% residual stenosis distally. There were no intra- or postoperative transient ischemic attacks, major or minor strokes, or deaths.

Patients who have recurrent or radiation-induced stenosis are potential candidates for angioplasty and stent placement. Before this can be recommended as an alternative to surgical correction, a longer follow-up period is required.

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Delayed detection of carotid–cavernous fistulas associated with wartime blast–induced craniofacial trauma

Report of 2 cases

Sudhakar Vadivelu, Randy Scott Bell, Ben Crandall, Tom DeGraba, and Rocco A. Armonda

Blast-induced neurotrauma is a leading cause of military casualties. Its effects on cerebrovascular structures are not well understood. Vascular injury resulting from overpressure shock wave impact may have a delayed presentation and detection. The authors present the cases of 2 patients who sustained blast-induced craniofacial trauma and brain injury. Detection of a cervical dissection was delayed in one patient, and detection of carotid-cavernous fistulas was delayed in both patients. The authors report the successful obliteration of both the dissection and the carotidcavernous fistulas via an endovascular approach. Endovascular management provides both a reasonable and effective therapeutic option to blast-induced cerebrovascular injuries.

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Toward a rational treatment of Chiari I malformation and syringomyelia

Richard G. Ellenbogen, Rocco A. Armonda, Dennis W. W. Shaw, and H. Richard Winn

In patients with Chiari I malformation with and without associated syringomyelia, aberrant cerebrospinal fluid (CSF) dynamics and a spectrum of posterior fossa pathological findings are demonstrated. In this study, the authors test the validity of using prospective cardiac-gated phase-contrast cine-mode magnetic resonance (MR) imaging to define the malformation, delineate its pathophysiology, and assist in implementing a rational treatment plan.

Eighty-five cases were prospectively analyzed using cine MR imaging. Sixty-five patients, adults and children, with symptomatic Chiari malformation, with and without syringomyelia, were surgically treated from 1990 to 1999. All patients underwent pre- and postoperative cine MR evaluation. Ten patients were treated after a previous surgical procedure had failed. To establish CSF flow characteristics and normative CSF profiles, 20 healthy volunteers were examined.

Compared with normal volunteers, in Chiari I malformation patients with and without syringomyelia, uniformly abnormal craniocervical junction CSF flow profiles were revealed. After intradural exploration, nearly all patients with Chiari I malformation experienced clinical improvement and CSF flow profiles, paralleling those of normal volunteers, were shown. In all patients in whom treatment had failed, abnormal preoperative CSF flow profiles, which correlated with suspected physiological abnormalities and the pathological findings noted at reoperation, were demonstrated.

Symptomatic Chiari I malformation is a dynamic process characterized by the impaction of the hindbrain in an abnormal posterior fossa. This compression obstructs the normal venting of CSF in and out of the craniocervical sub-arachnoid space, throughout the cardiac cycle. Therefore, decompression or enlargement of the posterior fossa to establish normal CSF pathways should be the primary goal of surgical intervention. Aberrant CSF flow appears to be only one aspect of the pathological condition found in patients with Chiari I malformation. Arachnoid scarring in the posterior fossa and selective vulnerability of the spinal cord may also be factors in the pathogenesis and maintenance of associated syringomyelia. Phase-contrast cine MR imaging is a useful tool in defining physiological and anatomical problems in patients with Chiari I and syringomyelia, and it can help guide an appropriate primary or salvage surgical therapy.

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The shipboard Beirut terrorist bombing experience: a historical account and recommendations for preparedness in events of mass neurological injuries

Zachary S. Hubbard, Fraser Henderson Jr., Rocco A. Armonda, Alejandro M. Spiotta, Robert Rosenbaum, and Fraser Henderson Sr.

On a Sunday morning at 06:22 on October 23, 1983, in Beirut, Lebanon, a semitrailer filled with TNT sped through the guarded barrier into the ground floor of the Civilian Aviation Authority and exploded, killing and wounding US Marines from the 1st Battalion 8th Regiment (2nd Division), as well as the battalion surgeon and deployed corpsmen. The truck bomb explosion, estimated to be the equivalent of 21,000 lbs of TNT, and regarded as the largest nonnuclear explosion since World War II, caused what was then the most lethal single-day death toll for the US Marine Corps since the Battle of Iwo Jima in World War II. Considerable neurological injury resulted from the bombing. Of the 112 survivors, 37 had head injuries, 2 had spinal cord injuries, and 9 had peripheral nerve injuries. Concussion, scalp laceration, and skull fracture were the most common cranial injuries.

Within minutes of the explosion, the Commander Task Force 61/62 Mass Casualty Plan was implemented by personnel aboard the USS Iwo Jima. The wounded were triaged according to standard protocol at the time. Senator Humphreys, chairman of the Preparedness Committee and a corpsman in the Korean War, commented that he had never seen such a well-executed evolution. This was the result of meticulous preparation that included training not only of the medical personnel but also of volunteers from the ship’s company, frequent drilling with other shipboard units, coordination of resources throughout the ship, the presence of a meticulous senior enlisted man who carefully registered each of the wounded, the presence of trained security forces, and a drilled and functioning communication system.

Viewed through the lens of a neurosurgeon, the 1983 bombings and mass casualty event impart important lessons in preparedness. Medical personnel should be trained specifically to handle the kinds of injuries anticipated and should rehearse the mass casualty event on a regular basis using mock-up patients. Neurosurgery staff should participate in training and planning for events alongside other clinicians. Training of nurses, corpsmen, and also nonmedical personnel is essential. In a large-scale evolution, nonmedical personnel may monitor vital signs, work as scribes or stretcher bearers, and run messages. It is incumbent upon medical providers and neurosurgeons in particular to be aware of the potential for mass casualty events and to make necessary preparations.

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Neurological sequelae from brachiocephalic vein stenosis

Report of 2 cases

David W. Herzig, Andrew B. Stemer, Randy S. Bell, Ai-Hsi Liu, Rocco A. Armonda, and William O. Bank

Stenosis of central veins (brachiocephalic vein [BCV] and superior vena cava) occurs in 30% of hemodialysis patients, rarely producing intracranial pathology. The authors present the first cases of BCV stenosis causing perimesencephalic subarachnoid hemorrhage and myoclonic epilepsy.

In the first case, a 73-year-old man on hemodialysis presented with headache and blurry vision, and was admitted with presumed idiopathic intracranial hypertension after negative CT studies and confirmatory lumbar puncture. The patient mildly improved until hospital Day 3, when he experienced a seizure; emergency CT scans showed perimesencephalic subarachnoid hemorrhage. Cerebral angiography failed to find any vascular abnormality, but demonstrated venous congestion. A fistulogram found left BCV occlusion with jugular reflux. The occlusion could not be reopened percutaneously and required open fistula ligation. Postoperatively, symptoms resolved and the patient remained intact at 7-month follow-up.

In the second case, a 67-year-old woman on hemodialysis presented with right arm weakness and myoclonic jerks. Admission MRI revealed subcortical edema and a possible dural arteriovenous fistula. Cerebral angiography showed venous engorgement, but no vascular malformation. A fistulogram found left BCV stenosis with jugular reflux, which was immediately reversed with angioplasty and stent placement. Postprocedure the patient was seizure free, and her strength improved. Seven months later the patient presented in myoclonic status epilepticus, and a fistulogram revealed stent occlusion. Angioplasty successfully reopened the stent and she returned to baseline; she was seizure free at 4-month follow-up.

Central venous stenosis is common with hemodialysis, but rarely presents with neurological findings. Prompt recognition and endovascular intervention can restore normal venous drainage and resolve symptoms.

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The evolution of the treatment of traumatic cerebrovascular injury during wartime

A review

Randy S. Bell, Robert D. Ecker, Meryl A. Severson III, John E. Wanebo, Benjamin Crandall, and Rocco A. Armonda

The approach to traumatic craniocervical vascular injury has evolved significantly in recent years. Conflicts prior to Operations Iraqi and Enduring Freedom were characterized by minimal intervention in the setting of severe penetrating head injury, in large part due to limited far-forward resource availability. Consequently, sequelae of penetrating head injury like traumatic aneurysm formation remained poorly characterized with a paucity of pathophysiological descriptions. The current conflicts have seen dramatic improvements with respect to the management of severe penetrating and closed head injuries. As a result of the rapid field resuscitation and early cranial decompression, patients are surviving longer, which has led to diagnosis and treatment of entities that had previously gone undiagnosed. Therefore, in this paper the authors' purpose is to review their experience with severe traumatic brain injury complicated by injury to the craniocervical vasculature. Historical approaches will be reviewed, and the importance of modern endovascular techniques will be emphasized.

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Early venous thromboembolism chemoprophylaxis in combat-related penetrating brain injury

R. Michael Meyer, M. Benjamin Larkin, Nicholas S. Szuflita, Chris J. Neal, Jeffrey M. Tomlin, Rocco A. Armonda, Jeffrey A. Bailey, and Randy S. Bell

OBJECTIVE

Traumatic brain injury (TBI) is independently associated with deep vein thrombosis (DVT) and pulmonary embolism (PE). Given the numerous studies of civilian closed-head injury, the Brain Trauma Foundation recommends venous thromboembolism chemoprophylaxis (VTC) after severe TBI. No studies have specifically examined this practice in penetrating brain injury (PBI). Therefore, the authors examined the safety and effectiveness of early VTC after PBI with respect to worsening intracranial hemorrhage and DVT or PE.

METHODS

The Kandahar Airfield neurosurgery service managed 908 consults between January 2010 and March 2013. Eighty of these were US active duty members with PBI, 13 of whom were excluded from analysis because they presented with frankly nonsurvivable CNS injury or they died during initial resuscitation. This is a retrospective analysis of the remaining 67 patients.

RESULTS

Thirty-two patients received early VTC and 35 did not. Mean time to the first dose was 24 hours. Fifty-two patients had blast-related PBI and 15 had gunshot wounds (GSWs) to the head. The incidence of worsened intracranial hemorrhage was 16% after early VTC and 17% when it was not given, with the relative risk approaching 1 (RR = 0.91). The incidence of DVT or PE was 12% after early VTC and 17% when it was not given (RR = 0.73), though this difference was not statistically significant.

CONCLUSIONS

Early VTC was safe with regard to the progression of intracranial hemorrhage in this cohort of combat-related PBI patients. Data in this study suggest that this intervention may have been effective for the prevention of DVT or PE but not statistically significantly so. More research is needed to clarify the safety and efficacy of this practice.