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Treatment of Intracranial Vascular Disorders with the Aid of Profound Hypothermia and Total Circulatory Arrest: Three Years' Experience

Collin S. MacCarty, John D. Michenfelder, and Alfred Uihlein

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Endovascular stent therapy for extracranial and intracranial carotid artery dissection: single-center experience

Clinical article

Hajime Ohta, Sabareesh K. Natarajan, Erik F. Hauck, Alexander A. Khalessi, Adnan H. Siddiqui, L. Nelson Hopkins, and Elad I. Levy

Object

The objective of this study was to evaluate endovascular stent therapy for carotid artery dissections (CADs).

Methods

Retrospective review of data at Millard Fillmore Gates Hospital identified 43 patients with 44 CADs (intracranial and/or extracranial) treated with carotid artery (CA) stent placement between January 2000 and June 2009.

Results

Thirty-two CADs were spontaneous and 12 were traumatic; 35 were symptomatic. Lesion locations included the extracranial internal CA (ICA; 24 cases), extracranial ICA with common CA involvement (4 cases), and extracranial ICA–intracranial ICA (16 cases). Carotid artery occlusion was 100% in 15 cases (34.1%), 99% in 6 cases (13.6%), 70%–98% in 13 cases (29.5%), and < 70% in 10 cases (22.7%). Five patients suffered pseudoaneurysms. Stent deployment was successful in 43 (97.7%) of 44 cases. The mean pretreatment score on the National Institutes of Health Stroke Scale was 6.2 ± 6.2. Recanalization (Thrombolysis in Myocardial Infarction Grade 2 or 3) was accomplished for 42 lesions (95.5%). Four patients demonstrated residual parent vessel stenosis (10%–50% in severity). Procedure-related complications occurred in 7 patients and included middle cerebral artery embolism (1 patient), intracranial hemorrhage (2 patients), worsening of dissection (1 patient), stent malpositioning (1 patient), embolic protection filter overload (1 patient), and filter retrieval device fracture (1 patient). Only 2 of these complications caused permanent deficits: the embolism caused a minor but permanent neurological deficit, and 1 intracranial hemorrhage was fatal. At discharge, 36 patients (83.7%) had modified Rankin Scale scores of 0–2 (favorable outcome). During the follow-up interval (mean 19.2 months, range 4–92 months), no patient suffered a new stroke and 1 patient died secondary to preexisting chronic renal failure. In 20 patients with angiographic follow-up, permanent resolution of the dissection was noted in 90.5%; 2 lesions (9.5%) required retreatment.

Conclusions

Endovascular stent-assisted repair of extra- and intracranial CAD was safe and effective in this experience and can be recommended for selected patients. In particular, patients with symptomatic CADs that are not responsive to medical therapy should be considered for interventional treatment.

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Endovascular treatment of brain arteriovenous malformations with prolonged intranidal Onyx injection technique: long-term results in 350 consecutive patients with completed endovascular treatment course

Clinical article

Isil Saatci, Serdar Geyik, Kivilcim Yavuz, and H. Saruhan Cekirge

Object

The purpose of this study was to present the authors' clinical experience and long-term angiographic and clinical follow-up results in 350 patients with brain arteriovenous malformations (AVMs) treated using prolonged intranidal Onyx injection with a very slow “staged” reflux technique described by the authors.

Methods

Three hundred and fifty consecutive patients with brain AVMs treated using Onyx between 1999 and 2008 and in whom definitive status for endovascular treatment was reached are presented. There were 206 (59%) male and 144 (41%) female patients, with a mean age of 34 years. There were 607 endovascular sessions performed. Onyx was the only agent used for intranidal injections in all patients, but in 42 patients high-concentration N-butyl cyanoacrylate glue was used adjunctively to close high-flow direct arteriovenous intra- or perinidal fistulas, or when a feeding vessel or nidus perforation and/or dissection occurred.

Results

Angiographically confirmed obliteration was achieved in 179 patients (51%) with only endovascular treatment; 1 patient died due to intracranial hemorrhage after the treatment. Twenty-two patients underwent resection, and 136 patients were sent to radiosurgery after endovascular treatment. In 4 patients embolization therapy was discontinued, and 5 additional patients refused the suggested complementary surgery. In all 178 surviving patients who had angiographically confirmed AVM obliteration by embolization alone, 1–8 years of control angiography (mean 47 months) confirmed stable obliteration, except for 2 patients in whom a very small recruitment was noted in the 1st year on control angiography studies, despite initial apparent total obliteration (recanalization rate 1.1%). In the entire series, 5 patients died; the mortality rate was 1.4%. The permanent morbidity rate was 7.1%.

Conclusions

With the prolonged intranidal injection technique described herein, Onyx allows the practitioner to achieve higher rates of anatomical cures compared with the cure rates obtained previously with other embolic agents. More importantly, due to this technique's much more effective intranidal penetration, it allows high-grade AVMs to be made radiosurgically treatable in a group of patients for whom there has been no treatment alternative.

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Balloon-assisted Onyx embolization of cerebral single-channel pial arteriovenous fistulas

Technical note

C. Benjamin Newman, Yin C. Hu, Cameron G. McDougall, and Felipe C. Albuquerque

Object

Pial arteriovenous fistulas (AVFs) of the brain are rare vascular malformations associated with significant risks of hemorrhage and neurological deficit. Depending on their location and high-flow dynamics, these lesions can present treatment challenges for both endovascular and open cerebrovascular surgeons. The authors describe a novel endovascular treatment strategy that was used successfully to treat 2 pediatric patients with a pial AVF, and they discuss the technical nuances specific to their treatment strategy.

Methods

A single-channel high-flow pial AVF was diagnosed in 2 male patients (6 and 17 years of age). Both patients were treated with endovascular flow arrest using a highly conformable balloon followed by Onyx infusion for definitive closure of the fistula.

Results

Neither patient suffered a complication as a result of the procedure. At the 6-month follow-up in both cases, the simple discontinuation of blood flow had resulted in durable obliteration of the fistula and stable or improved neurological function.

Conclusions

Onyx can be delivered successfully into high-flow lesions after flow arrest to allow a minimally invasive and durable treatment for pial AVFs.

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Craniocervical arterial dissections as sequelae of chiropractic manipulation: patterns of injury and management

Clinical article

Felipe C. Albuquerque, Yin C. Hu, Shervin R. Dashti, Adib A. Abla, Justin C. Clark, Brian Alkire, Nicholas Theodore, and Cameron G. McDougall

Object

Chiropractic manipulation of the cervical spine is a known cause of craniocervical arterial dissections. In this paper, the authors describe the patterns of arterial injury after chiropractic manipulation and their management in the modern endovascular era.

Methods

A prospectively maintained endovascular database was reviewed to identify patients presenting with craniocervical arterial dissections after chiropractic manipulation. Factors assessed included time to symptomatic presentation, location of the injured arterial segment, neurological symptoms, endovascular treatment, surgical treatment, clinical outcome, and radiographic follow-up.

Results

Thirteen patients (8 women and 5 men, mean age 44 years, range 30–73 years) presented with neurological deficits, head and neck pain, or both, typically within hours or days of chiropractic manipulation. Arterial dissections were identified along the entire course of the vertebral artery, including the origin through the V4 segment. Three patients had vertebral artery dissections that continued rostrally to involve the basilar artery. Two patients had dissections of the internal carotid artery (ICA): 1 involved the cervical ICA and 1 involved the petrocavernous ICA. Stenting was performed in 5 cases, and thrombolysis of the basilar artery was performed in 1 case. Three patients underwent emergency cerebellar decompression because of impending herniation. Six patients were treated with medication alone, including either anticoagulation or antiplatelet therapy. Clinical follow-up was obtained in all patients (mean 19 months). Three patients had permanent neurological deficits, and 1 died of a massive cerebellar stroke. The remaining 9 patients recovered completely. Of the 12 patients who survived, radiographic follow-up was obtained in all but 1 of the most recently treated patients (mean 12 months). All stents were widely patent at follow-up.

Conclusions

Chiropractic manipulation of the cervical spine can produce dissections involving the cervical and cranial segments of the vertebral and carotid arteries. These injuries can be severe, requiring endovascular stenting and cranial surgery. In this patient series, a significant percentage (31%, 4/13) of patients were left permanently disabled or died as a result of their arterial injuries.

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Do statins reduce the risk of aneurysm development: a case-control study

Clinical article

Serge Marbacher, Janine-Ai Schläppi, Christian Fung, Jürg Hüsler, Jürgen Beck, and Andreas Raabe

Object

Recent studies in rats have demonstrated that statins may have an inhibitory effect on intracranial aneurysm (IA) development. The purpose of this study was to assess whether long-term statin use is associated with a reduced risk of IA formation in humans.

Methods

This was a single-center case-control study that included consecutive patients admitted to the authors' institution between January 1, 2005, and December 31, 2008. A case was defined as a patient with a cerebral angiography–confirmed diagnosis of IA. Three controls were matched to each case based on age, sex, and index year of hospital admission. The primary exposure of interest was cumulative statin use. Conditional logistic regression was used to assess the relationship between statin intake and incidence of IA.

Results

In total, 1200 patients were included in the study. No overall association was found between statin use and incidence of IA formation (OR 1.08, 95% CI 0.69–1.69), nor when dichotomized into hydrophilic and lipophilic user, or between short (≤12-month) and long (≥36-month) duration of intake. Hypertension and smoking significantly increased the risk of IA development (OR 4.02, 95% CI 2.49–6.45, and OR 1.67, 95% CI 1.02–2.72, respectively).

Conclusions

In contrast to recent experimental reports of the association between statins and a reduction of IA formation, the authors' findings suggest that in humans statins may have no significant beneficial effect on IA suppression.

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Filum terminale arteriovenous fistulas: the role of endovascular treatment

Clinical article

Ekachat Chanthanaphak, Sirintara Pongpech, Pakorn Jiarakongmun, Chai Kobkitsuksakul, Cuong Tran Chi, and Karel G. TerBrugge

Object

The authors describe the clinical presentation, imaging features, and management of patients presenting with filum terminale arteriovenous fistulas (FTAVFs) and the role of transarterial treatment in their management.

Methods

The authors retrospectively reviewed data obtained in 10 patients with FTAVFs diagnosed between January 1990 and December 2011.

Results

Most patients (70%) were male, and the age of the population ranged from 31 to 72 years (mean 58.2 years). Clinical presentation was progressive paraparesis and sensory loss in the lower extremities in 9 cases, back pain in 7, radicular pain in 3, bowel/bladder disturbance in 5, and impotence in 1. The duration of symptoms varied between 2 and 24 months. Initial MRI studies showed intramedullary increased T2 signal, swollen cord, and dilated perimedullary veins in all patients. One patient had syringomyelia, presumably caused by venous hypertension transmitted by the perimedullary venous system. Embolization was attempted in 7 patients and was curative in 6 patients. Surgery was performed in the other 4 patients in whom embolization was unsuccessful or deemed not feasible. There was no treatment-related complication in either group. Symptoms, venous congestion in the cord, and syringomyelia improved on follow-up in all patients.

Conclusions

Embolization should be considered the treatment of choice for FTAVFs and can effectively treat the majority of patients presenting with an FTAVF. In a smaller group of patients in whom the angioarchitecture is unfavorable, open surgery is recommended.

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Asymptomatic spinal dural arteriovenous fistulas: pathomechanical considerations

Clinical article

Kenichi Sato, Karel G. TerBrugge, and Timo Krings

Object

Spinal dural arteriovenous fistulas (SDAVFs) consist of a shunt with converging feeding vessels arising from radiculomeningeal arteries and draining retrogradely via a radicular vein into the perimedullary veins, thereby causing progressive myelopathy due to venous hypertension in the spinal cord. The purpose of this study was to evaluate the hypothesis that the obstruction of radicular venous outlets could be an additional factor inducing symptomatic venous hypertension due to a decreased outflow in SDAVFs.

Methods

The authors compared the clinical and imaging findings in patients with asymptomatic SDAVFs identified incidentally at the upper thoracic region with the findings in symptomatic patients who harbored SDAVFs at the same level.

Results

All symptomatic patients presented with medullary dysfunction. The mean age of patients with asymptomatic SDAVF was 51.5 years, approximately 10 years younger than the patients with symptomatic SDAVF (64.1 years old). Despite the existence of dilated perimedullary vessels in the dorsal side of the spinal cord in all patients, the spinal cord edema seen in symptomatic patients was not detected on the MR images obtained in patients with asymptomatic SDAVF. The spinal angiograms of the asymptomatic patients distinctively demonstrated early radicular venous outflow from affected perimedullary veins to the extradural venous plexus as a potential alternate route for the venous hypertension to be released.

Conclusions

Obstruction of the radicular venous outflow could be an important factor in inducing spinal congestive edema due to venous hypertension, as well as subsequent clinical symptoms of SDAVFs.

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Long-term social outcome in children with moyamoya disease who have reached adulthood

Clinical article

Ji Hoon Phi, Kyu-Chang Wang, Byung-Kyu Cho, Myung Sook Lee, Jong-Hwa Lee, Kyung-Sang Yu, Bong-Jin Hahm, and Seung-Ki Kim

Object

Although the reported surgical outcome is favorable, there is little information regarding the long-term quality of life in pediatric patients with moyamoya disease (MMD) when they grow to adulthood. The authors conducted a survey to provide details of social adaptation and satisfaction in adults who underwent revascularization surgery for MMD during childhood.

Methods

One hundred twenty-three patients with MMD who had undergone surgery during childhood and were older than 18 years of age were recruited for this study. The authors mailed self-administered questionnaires regarding each patient's education, employment, marriage, driver's license, physical condition, and satisfaction. Sixty-five patients (53%) responded.

Results

Compared with the general population, the patients showed a similar rate of attaining a higher education. Forty-nine (80%) of 61 patients who were not currently high school students had entered college or university. However, the presence of neurological deficits on preoperative examination was a negative predictor of entrance into a college or university, as well as employment. Some patients had difficulty in planning marriage because of physical handicaps, and the rate of acquiring a driver's license and actual driving were relatively low. Approximately 80% of the responders were satisfied with their treatment outcomes, but more than one-half reported subjectively assessed neurological problems.

Conclusions

In this study, pediatric patients with MMD showed favorable social adaptation in adulthood. The findings also indicated that early diagnosis and intervention before the establishment of neurological deficits are essential to children with MMD in becoming better socially adapted. Further, more thorough clinical examinations are required during follow-up in patients with MMD.

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Rupture of anterior communicating artery aneurysms during computed tomography angiography: description of the pathway for intraseptal and intraventricular hemorrhage

Report of 2 cases

Felix Scholtes, Francesco Signorelli, and Michel W. Bojanowski

Intraventricular hemorrhage is common after the rupture of anterior communicating artery (ACoA) aneurysms, although the anatomical pathway has not been described. Knowledge of the mechanism of hemorrhage may enhance understanding of its prognosis. Using CT angiography, the authors analyzed this pathway in 2 cases of ACoA aneurysm rupture associated with intraventricular hemorrhage. The initial hemorrhages created a hyperdense ventriculographic image on which the subsequent contrast medium ejection could be followed. The contrast medium entered the subarachnoid space of the anterior interhemispheric fissure and broke through the lamina rostralis into the septum pellucidum and into the frontal horns of the lateral ventricles. Thus, the authors provide an explanation for bleeding from ACoA aneurysms into the ventricular system in the presence of an intact lamina terminalis. The septum pellucidum may act as a buffer before extension of the bleeding into the ventricular system.