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ABSTRACT: : Delayed ipsilateral parenchymal hemorrhage has been observed following aneurysm treatment with the Pipeline Embolization Device (PED). The relationship of this phenomenon to the device and/or procedure remains elusive. We present the histopathological analysis of brain sections from three patients who suffered fatal parenchymal hemorrhages (PHs) after initially uneventful PED treatments.
: Three patients with paraclinoid carotid aneurysms were treated electively with PED. All patients were pre-treated with aspririn and clopidrogel. All three cases were performed under general anesthesia, with the use of a tri-axial access system. One (n = 2) or two (n = 1) PEDs were used for parent artery reconstruction. Two cases required balloon angioplasty to achieve device apposition.
: Average age was 66.3 years. Average aneurysm size was 10.2 mm (range 5-13.3 mm). All patients were at their neurological baseline immediately after the procedure and for at least 72 hours thereafter. All three patients presented with a precipitous neurological deterioration related to spontaneous ipsilateral PH, between 3 and 14 days after the procedure (average 7.7 days). No patient experienced any preceding neurological sequela. In all three patients, autopsy confirmed a large PH distributed within the hemisphere ipsilateral to the reconstructed artery. Hemorrhages were anatomically remote from the aneurysm and reconstructed parent vessel. In all cases, histopathological analysis revealed basophilic, granular, non-polarizable foreign material completely occluding the lumen of the affected vessels in the region surrounding the observed hemorrhage. Vessels in the unaffected regions of the brain were spared of these foreign body emboli.
: Delayed ipsilateral parenchymal hemorrhage can be observed following aneurysm treatment with the PED. The identification of embolized foreign material in the distribution of the hemorrhages in all three autopsy specimens suggests a potential relationship between intra-procedural foreign material emboli and delayed ipsilateral parenchymal hemorrhage after PED reconstruction.
Neurosurgery 08/2012; 71(2):E551-2. · 2.79 Impact Factor
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ABSTRACT: BACKGROUND: Cerebral venous sinus thrombosis (CVT) is an uncommon cause of stroke that is usually treated medically with intravenous heparin therapy followed by long-term anticoagulation therapy. A series of patients with CVT who underwent rheolytic thrombectomy with the AngioJet as a first-line adjunctive treatment in addition to standard anticoagulation therapy is presented. METHODS: Prospectively maintained endovascular databases at two institutions were retrospectively reviewed. The available clinical and imaging data were compiled at each institution and combined for analysis. RESULTS: Over 18 months, 13 patients (seven women and six men; age range 17-73 years, median age 45 years) with CVT were treated with rheolytic thrombectomy. Immediate (partial or complete) recanalization of the thrombosed intracranial sinuses was achieved in all patients. At a median radiographic follow-up of 7 months there was continued patency of all recanalized sinuses. Clinical follow-up was available on nine patients: modified Rankin score of 0 in four patients, 1 in three patients and 6 in two patients. CONCLUSION: This series demonstrates the feasibility of performing mechanical thrombectomy as a first-line treatment for acute CVT. This technique facilitates the prompt restoration of intracranial venous outflow, which may result in rapid neurological and symptomatic improvement.
Journal of neurointerventional surgery 12/2011; · 0.92 Impact Factor
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ABSTRACT: 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.
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.
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 V(4) 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.
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.
Journal of Neurosurgery 09/2011; 115(6):1197-205. · 2.96 Impact Factor
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ABSTRACT: Intracranial venous hypertension is known to be associated with venous outflow obstruction. We discuss the diagnosis and treatment of mechanical venous outflow obstruction causing pseudotumor cerebri.
We report 2 patients presenting with central venous outflow obstruction secondary to osseous compression of the internal jugular veins at the craniocervical junction. The point of jugular compression was between the lateral tubercle of C1 and a prominent, posteriorly located styloid process. In both cases, catheter venography showed high-grade jugular stenosis at the level of C1 with an associated pressure gradient. The dominant jugular vein was decompressed after the styloid process was resected. Postoperative imaging confirmed resolution of the jugular stenosis and normalization of preoperative pressure gradients. In both cases, the symptoms of intracranial hypertension resolved.
Intracranial venous hypertension may result from extrinsic osseous compression of the jugular veins at the skull base. Although rare, this phenomenon is important to recognize because primary stenting not only is ineffective but also may actually exacerbate the outflow obstruction. The osseous impingement of the dominant jugular vein can be relieved via a decompressive styloidectomy, and the clinical results can be excellent.
Neurosurgery 08/2011; 70(3):E795-9. · 2.79 Impact Factor
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ABSTRACT: 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.
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.
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.
Onyx can be delivered successfully into high-flow lesions after flow arrest to allow a minimally invasive and durable treatment for pial AVFs.
Journal of Neurosurgery Pediatrics 06/2011; 7(6):637-42. · 1.53 Impact Factor
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ABSTRACT: Unfavorable anatomy can preclude embolization of intracranial aneurysms. Transcirculation techniques, in which a catheter is navigated from one side of the brain to the other or from the anterior to the posterior circulation, are alternative pathways for primary or balloon- or stent-assisted coiling.
We report the largest experience in coil embolization of aneurysms using transcirculation techniques.
We reviewed our endovascular database from 2006 to 2009 and identified 18 patients who had aneurysms treated with transcirculation techniques.
Eight patients had anterior and 10 had posterior circulation aneurysms. Overall, 8 patients were treated with stent-assisted coiling and 9 with balloon-assisted coiling, including 1 patient treated with a "kissing balloon" technique. Of the 9 patients treated with balloon-assistance, 1 also was stented at the conclusion of aneurysm coiling. One patient with a left fourth vertebral artery (V4) aneurysm was treated with coiling alone via a bilateral vertebral artery (VA) approach. In 14 patients, the anterior communicating and posterior communicating arteries were used as conduits. In 4 patients, both VAs were traversed to treat 2 V4 aneurysms and 2 posterior inferior cerebellar artery aneurysms. One patient died as a result of treatment and was the only permanent complication (5.6%). Complete or near-complete (>95%) embolization was achieved in all patients.
Transcirculation techniques are effective pathways for embolization of complex aneurysms. Although technically challenging, these techniques are associated with an acceptably low rate of complications when compared to the natural history of the treated lesion.
Neurosurgery 03/2011; 68(3):820-9; discussion 829-30. · 2.79 Impact Factor
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ABSTRACT: Traditional endovascular treatment of cranial dural arteriovenous fistulas (DAVFs) consists of a transarterial approach with n-butylcyanoacrylate (nBCA) or a transvenous approach with coil embolization. The advent of Onyx in the endovascular arsenal potentially offers a high probability of obliteration of these vascular lesions through a purely transarterial route.
A retrospective review of the Barrow Neurological Institute endovascular database between October 2005 and November 2009 highlighted 50 patients with 63 cranial DAVFs that were treated with transarterial Onyx, with and without adjuvant embolysates, for a total of 76 embolization procedures. Hospital records, cerebral angiography and other diagnostic imaging and clinical visits were reviewed.
At a median follow-up of 5 months (range 0-25 months), complete angiographic cure was obtained in 41 patients with 50 (79%) DAVFs after transarterial embolization using Onyx combined with other embolysates. When Onyx was used as the sole embolic agent, 32 of 37 DAVFs (87%) in 29 (of 33) patients achieved angiographic cure. Subgroup analysis showed that by using the middle meningeal artery (MMA) as a conduit for primary Onyx embolization, angiographic cures were achieved in 27 of the 37 DAVFs (73%). Periprocedural complications occurred in six (7.9%) sessions in one patients (8%). Only one patient had a permanent complication (2%) with unimproved cranial nerve palsies.
Transarterial Onyx embolization of cranial DAVFs, particularly using the MMA as a conduit, is a safe and effective curative therapy.
Journal of neurointerventional surgery 03/2011; 3(1):5-13. · 0.92 Impact Factor
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ABSTRACT: Coccidioidomycosis is secondary to infection with fungal species Coccidioides immitis or Coccidioides posadasii. One consequence of extrapulmonary coccidioidomycosis dissemination is meningitis, which is associated with high rates of morbidity and mortality if left untreated. Intracranial vasospasm, although rarely described, can occur and may be a result of vasculitic or subacute fibrotic changes. We describe a case of successful percutaneous transluminal angioplasty (PTA) in a patient with severe vasospasm related to coccidioidal meningitis. This is the first report of this endovascular treatment used to treat coccidioidal vasospasm.
A patient with a history of pulmonary coccidioidomycosis presented with acute confusion, blurry vision and headache. Serology confirmed basilar meningitis and magnetic resonance angiography demonstrated severe symptomatic vasospasm.
Emergent cerebral angiography confirmed severe vasospasm in the right middle cerebral artery and moderate vasospasm in the left middle cerebral artery. Successful PTA was performed under general anesthesia. The patient demonstrated postprocedural angiographic and clinical improvement.
We report the first case of successful PTA performed to treat vasospasm related to coccidioidal meningitis. When vasospasm is clinically symptomatic, PTA is a safe and feasible procedure.
Journal of neurointerventional surgery 03/2011; 3(1):62-5. · 0.92 Impact Factor
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ABSTRACT: To report a successful transarterial Onyx embolization of a highly vascularized sacral chordoma.
A 74-year-old patient presented with progressive lower back pain and anorectal and urogenital dysfunction complicated by excessive intraoperative blood loss requiring emergent endovascular intervention.
Emergent pelvic angiography demonstrated a highly vascularized sacral chordoma. Transarterial embolization with Onyx was performed successfully via a single arterial pedicle, the median sacral artery. Surgical extirpation was achieved with the expected amount of intraoperative blood loss without further complications.
Preoperative transarterial Onyx embolization can be performed safely and effectively to assist in the surgical resection of sacral chordomas.
Journal of neurointerventional surgery 03/2011; 3(1):85-7. · 0.92 Impact Factor
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ABSTRACT: Transient cortical blindness (TCB) is reported as a rare complication of coronary and cerebral angiography. Angiography of the vertebral arteries carries the highest incidence of causing TCB. The etiology of this phenomenon is unknown.
A 42-year-old woman underwent treatment for an enlarging pseudoaneurysm of her vertebral artery. The patient had a brief complex seizure during angiography. Following the procedure, she experienced TCB. During this time, an electroencephalogram (EEG) showed seizure activity. This case represents the first recorded instance of abnormal EEG during angiography-associated TCB.
The patient was immediately given intravenous lorazepam and phenytoin sodium. Her EEG returned to normal in the ensuing hours and subsequently her vision returned to normal.
We present the first reported case of abnormal EEG activity during angiography-associated TCB. We hypothesize that seizure activity is a possible underlying cause of angiography-induced TCB.
World Neurosurgery 01/2011; 75(1):83-6. · 0.68 Impact Factor
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ABSTRACT: Cerebral cavernous malformations (CMs) are angiographically occult neurovascular lesions that consist of enlarged vascular channels without intervening normal parenchyma. Cavernous malformations can occur as sporadic or autosomal- dominant inherited conditions. Approximately 50% of Hispanic patients with cerebral CMs have the familial form, compared with 10 to 20% of Caucasian patients. There is no difference in the pathological findings or presentation in the sporadic and familial forms. To date, familial CMs have been attributed to mutations at three different loci: CCM1 on 7q21.2, CCM2 on 7p15-p13, or CCM3 on 3q25.2-q27. The authors summarize the current understanding of the molecular events underlying familial CMs.
Neurosurgical FOCUS 02/2006; 21(1):e2. · 2.87 Impact Factor
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ABSTRACT: The cause of pseudotumor cerebri, or benign intracranial hypertension (BIH), is controversial. We report our results from 18 cases of venous sinus stenting (VSS), the largest series in the literature, with specific focus on the rate of technical success, amelioration of the subjective symptom of headache, attendant complications, and radiographic patency on follow-up.
Review of our prospectively maintained database identified 18 patients who had undergone 19 VSS procedures for the placement of 30 stents in the past 2.5 years. Indications for treatment included a clinical diagnosis of BIH with venographic demonstration of stenosis.
VSS was technically successful in all patients (100%). No patient suffered a permanent complication. Three patients were lost to follow-up. The remaining 15 patients were followed clinically and asked to rate their headache severity on a scale of 1 to 10 both before and after VSS. Overall, 12 patients (80%) qualified their headaches as better after VSS, two stated that they were the same, and one patient said that they were worse. Of 14 patients who underwent follow-up angiography, all demonstrated normal patency of the stented segments. In one of these patients, stenosis was detected on follow-up in the unstented segment of the sigmoid sinus and jugular bulb.
VSS is highly effective (80%) in ameliorating headache associated with BIH. The procedure is associated with a high rate of technical success (100%), a low rate of permanent complications (0), and a high rate of stent patency on follow-up angiography (100%).
World Neurosurgery 75(5-6):648-52; discussion 592-5. · 0.68 Impact Factor
