This paper summarizes the conclusions of the three working groups organized on behalf of the WFITN in Val d’Isère (France) during the ABC WIN meetings in 2010-2011 and 2012.
Atypical origin of the middle meningeal artery from the cervical internal carotid artery is a rare angiographic finding. We describe a case of the pharyngo-tympano-stapedial variant of the middle meningeal artery in a young patient. In this vascular variation the proximal segment of the middle meningeal artery, corresponding to an annexed inferior tympanic artery, originates from the cervical carotid artery. Then over the promontory it unites with the superior tympanic artery and continues with its intracranial course via the petrous branch.
middle meningeal artery, anatomic variation
Variations in vertebral artery origin and course are well-described in the literature. The origin of right vertebral artery from the right common carotid artery is an extremely rare variant. We describe a unique case of a child with Down syndrome with variant origins of bilateral vertebral artery, an aberrant right subclavian artery and concomitant Moyamoya disease of intracranial circulation. The presence of variations of the origin and course of craniocervical arteries might have profound implications in angiographic and surgical procedures and hence it is of great importance to be aware of such a possibility.
variant, vertebral artery, common carotid artery, Down syndrome, Moyamoya
Balloon test occlusion (BTO) of the internal carotid artery (ICA) combined with cerebral blood flow (CBF) study is a sensitive test for predicting the outcome of permanent ICA occlusion. However, false negative results sometimes occur using single photon emission tomography (SPECT). We have recently developed a rapid positron emission tomography (PET) protocol that measures not only the CBF but also the cerebral oxygen metabolism before and during BTO in succession. We measured acute changes in regional CBF and OEF/CMRO2 before and during BTO in three cases with large or giant cerebral aneurysms using the rapid PET protocol.
Although no patients showed ischemic symptoms during BTO, PET studies exhibited mildly to moderately decreased CBF (9∼34%) compared to the values obtained before BTO in all cases. The average OEF during BTO was significantly increased (21% and 43%) than that of before BTO in two cases. The two cases were considered to be non-tolerant for permanent ICA occlusion and treated without ICA sacrifice.
Measurement of the CBF and OEF/CMRO2 using a rapid PET protocol before and during BTO is feasible and can be used for accurate assessment of tolerance prediction in ICA occlusion.
balloon test occlusion, cerebral blood flow, cerebral oxygen metabolism, internal carotid artery, positron emission tomography
This study compared the accuracy of contrast-enhanced MR angiography (CE-MRA) to intra-arterial cerebral angiography (IA-DSA) for assessment of intracranial aneurysms after stent-assisted coiling and to check if the presence of a stent in the parent artery diminishes the accuracy of CE-MRA.
Consecutive patients with cerebral aneurysms treated by stent-assisted coiling were evaluated retrospectively. Matching follow-up CE-MRA and IA-DSA were evaluated separately. Evaluation included the presence of aneurysmal remnant, patency and stenosis of parent artery.
Twenty-seven patients with 28 aneurysms and 33 matched CE-MRA and IA-DSA studies were evaluated. Nineteen aneurysmal remnants were seen on CE-MRA and 16 on IA-DSA. CE-MRA diagnosed three aneurysmal remnants not appreciated on IA-DSA. Five other remnants were larger on CE-MRA than IA-DSA. None of the remnants were missed on CE-MRA.
Parent arteries were patent on both modalities. CE-MRA showed false stenosis of the stented artery in six cases and exaggerated stenosis in two. In 18 cases, CE-MRA showed a short focal “pseudo-stenosis” where the stent’s marker bands were located. This was noted whenever the stent’s marker bands were located in an artery with luminal diameter ≤2 mm and was called “marker band effect”.
CE-MRA is an accurate technique for follow-up of aneurysms post stent-assisted coiling with excellent depiction of remnants in spite of the presence of a stent. Apparent stenosis of the stented parent artery on CE-MRA is often false or exaggerated. “Marker band effect” should be recognized as an artifact that appears when stent’s marker bands are in a small artery.
stent-assisted coiling, MR angiography, MRA, follow-up, aneurysmal remnants, parent artery stenosis, cerebral angiography, DSA, marker band effect
The balloon remodeling technique (BRT) was designed for endovascular treatment of wide-necked intracranial aneurysms. To date, the balloon catheters available have had a single lumen and suitable guidewires ranging from 0.010 to 0.012 inches. We describe the first case of aneurysm embolization using the BRT with the new double-lumen balloon catheter, Scepter C®, navigable on a 0.014-inch wire, and discuss the benefit of such a device.
balloon-assisted coil embolization, intracranial aneurysm, double lumen balloon, new device
During endovascular revascularization of subacute and chronic occlusion of the cervical internal carotid artery (ICA) it may be difficult to penetrate the lesion. Selecting the appropriate “true lumen”, a remnant of what had been the arterial lumen, at the initial step may facilitate the procedure. Because plaque at the carotid bifurcation is known to propagate from the posterior wall, a gateway to this “true lumen” should exist in the anterior side of the occluded stump. This hypothesis was studied retrospectively in our series of revascularizing ICA subacute and chronic occlusion.
Eleven patients underwent endovascular revascularization for symptomatic cervical ICA occlusion. Procedures were performed by initially penetrating the occluded stump with a guidewire, followed by supporting catheter advancement through the occluded segment to secure the distal normal arterial lumen. Cases were analyzed with regard to the location of initial guidewire penetration.
Eight patients underwent successful revascularization. In five cases, the entry point to the occluded stump was located at the anterior side, and in three, at the posterior side. Two posterior stump penetration cases were met with resistance in guidewire advancement, whereas penetration was smooth in the anterior cases. In addition, two posterior stump penetration cases resulted in contrast stasis in the posterior ICA wall.
In our series of revascularizing cervical ICA subacute and chronic occlusion, initially targeting the anterior side of the occluded stump resulted in favorable results. This may be the result of selecting the “true lumen” at the beginning of the procedure.
carotid occlusion, endovascular, revascularization
Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by acute severe headache with or without additional neurological symptoms and reversible cerebral vasoconstriction. Unruptured aneurysms have been reported in some cases with RCVS. We describe a severe case of a 50-year-old woman with RCVS presenting as cortical subarachnoid hemorrhage. Cerebral angiogram demonstrated the typical angiographic findings of RCVS and two very small unruptured aneurysms of the left internal carotid artery. The patient was treated with calcium channel blockers and the two aneurysms were successfully treated endovascularly. On day 16 the patient developed new focal neurological symptoms (severe paraparesis) and was successfully treated with intraarterial nimodipine and angioplasty in multiple sessions.
reversible cerebral vasoconstriction syndrome, subarachnoid hemorrhage, nimodipine, angioplasty
Transient contrast enhancement on computed tomography following endovascular treatment of stroke is a recognized entity that has been previously reported. Technological advances in brain imaging now have the potential to explore and refine its proposed etiology. We describe three patients in whom the location of contrast enhancement correlates with decreased cerebral blood volume on pre-therapeutic CT perfusion studies and with restricted diffusion on MRI. In this regard, contrast enhancement demarcated areas of completed cerebral infarction. The diagnostic and etiological implications are discussed.
stroke, endovascular treatment, contrast enhancement
Cerebral proliferative angiopathy (CPA) is a rare vascular abnormality with several angiomorphological features that are distinct from brain arteriovenous malformations (AVMs). The natural history of CPAs indicates a lower risk for hemorrhage compared to brain AVMs. A 62-year-old woman presented with gait instability and dysarthria. MRI and angiography revealed a diffuse vascular network involving the tectum and cerebellar vermis with intermingled brain parenchyma. This lesion had no dominant feeder, high-flow arteriovenous shunt, flow-related aneurysm or highly dilated veins on angiogram. These findings were consistent with a diagnosis of CPA. During follow-up, she developed progressive gait instability and eye movement abnormalities, but no remarkable change was detected on the repeated MRI and angiography. Nine years later, she died of mesencephalic hemorrhage originating from the CPA. To the best of our knowledge, this is the first description of a patient with CPA who died as a result of the initial hemorrhage. It is important to recognize that a part of CPAs is aggressive and can be more vulnerable to critical hemorrhage.
arteriovenous malformation, cerebral proliferative angiopathy, intracerebral hemorrhage
Multifocal cerebral venous sinus thrombosis (CVST) has a high mortality rate especially when patients present with stupor or coma. Medical treatment including anticoagulation raises concerns about the associated high risk of intracerebral hemorrhage. Treatment of multifocal CVST with mechanical thrombectomy devices and local tPA infusion have previously been reported. However, these devices may have technical limitations. Success of the new-generation aspiration thrombectomy device like the Penumbra system has been reported in few cases of isolated CVST without the use of chemical thrombolysis.
We describe two cases in which mechanical thrombectomy were used in conjunction with intra-sinus tPA infusion. Both cases were complicated and failed initial anticoagulation. Penumbra 054 was used in both cases. The Penumbra 054 is a novel device that has a bigger lumen which provides compatibility with other microcatheters, if additional therapies are required. The larger internal diameter of this catheter also allows for stronger thrombo-aspiration, potentially effecting more rapid sinus recanalization. Both cases showed remarkable clinical recovery without any major complications.
This is the first reported simultaneous use of the Penumbra system 054 along with tPA infusion. New devices such as the Penumbra system may offer additional therapeutic options in the treatment of multifocal CVST.
venous sinus thrombosis, angiography, mechanical thrombectomy
A 54-year-old man with symptomatic internal carotid artery stenosis with absence of the common carotid artery (CCA), who had been treated with surgery and postoperative radiotherapy for tonsillar carcinoma, underwent direct percutaneous carotid artery stenting (CAS). To our knowledge, this is the first report of direct percutaneous carotid artery stenting (CAS) for a patient with absent CCA.
absent common carotid artery, endovascular treatment, direct percutaneous carotid artery stenting, internal carotid artery stenosis, radiation-induced stenosis, cerebral protection
This investigation aimed to demonstrate the potential of intraprocedural angiographic CT in monitoring complex endovascular coil embolization of direct carotid cavernous fistulas.
Angiographic CT was performed as a dual rotational 5 s run with intraarterial contrast medium injection in two patients during endovascular coil embolization of direct carotid cavernous fistulas. Intraprocedural angiographic CT was considered helpful if conventional 2D series were not conclusive concerning coil position or if a precise delineation of the parent artery was impossible due to a complex anatomy or overlying coil material. During postprocessing multiplanar reformatted and dual volume images of angiographic CT were reconstructed.
Angiographic CT turned out to be superior in the intraprocedural visualization of accidental coil migration into the parent artery where conventional 2D-DSA series failed to reliably detect coil protrusion. The delineation of coil protrusion by angiographic CT allowed immediate correct coil repositioning to prevent parent artery compromising.
Angiographic CT can function as a valuable intraprocedurally feasible tool during complex coil embolizations of direct carotid cavernous fistulas. It allows the precise visualization of the cerebral vasculature and any accidental coil protrusion can be determined accurately in cases where conventional 2D-DSA series are unclear or compromised. Thus angiographic CT might contribute substantially to reduce procedural complications and to increase safety in the management of endovascular treatment of direct carotid cavernous fistulas.
carotid cavernous fistula, endovascular approach, transarterial coil embolization, intraprocedural angiographic CT
We describe a case of dural arteriovenous fistulas (DAVFs) involving the superior sagittal sinus (SSS) successfully treated with stent placement for an occluded sinus and transarterial embolization.
A 61-year-old man who had been treated with anticoagulation for a known SSS thrombosis presented with a sudden onset of headache. CT scan revealed an intraventricular hemorrhage and cerebral angiography revealed DAVFs involving the SSS which had severe venous congestion and sinus occlusion. We treated this case with a staged endovascular approach which consisted of stent placement for the occluded sinus and transarterial intravenous embolization resulting in complete eradication of DAVFs.
Recanalization of an occluded sinus by stent placement can reduce venous congestion and transarterial intravenous embolization can obliterate dural arteriovenous shunts. This staged strategy is feasible and should be considered a first option of treatment, especially for DAVFs which presented with intracranial hemorrhage and aggressive venous hypertension.
superior sagittal sinus, dural arteriovenous fistulas, stent placement, transarterial embolization
Neurofibromatosis type 1 (NF-1) is an autosomal dominant disorder characterized by cutaneous pigmentations, neurofibromas, Lisch nodules and neuroectodermal tumors. Supra-aortic vessel aneurysms may affect patients with NF-1 and can be associated with rupture, ischemic complications and compression symptoms. We describe a 48-year-old woman with NF-1 and an extracranial 3×5 cm right internal carotid artery aneurysm. After balloon test occlusion the patient was treated with parent artery sacrifice which led to significant shrinkage on follow-up MR and reduction of compression symptoms. The literature concerning internal carotid artery aneurysms associated with NF-1 is reviewed evaluating the possible therapeutic options.
neurofibromatosis type 1, internal carotid artery aneurysm, parent artery occlusion
Pseudoaneurysms of the neck arteries are rare lesions usually traumatic and less frequently infectious in origin. They are often described as case reports. We describe here an unusual occurrence of pseudoaneurysms in the common carotid and vertebral artery in a four-year-old child victim of a stab wound in the neck treated by parent artery occlusion of the vertebral and common carotid arteries.
pseudoaneurysms, balloon occlusion, parent artery occlusion
External carotid artery (ECA) pseudoaneurysm is a known complication of treatment for head and neck cancer. We report a case of facial artery pseudoaneurysm arising after irradiation and salvage surgery for advanced tonsillar cancer, that was treated with endovascular embolization. The case was complicated by delayed transcutaneous extrusion of embolization coils through the skin of the anterior neck. We review the literature for related cases of coil extrusion in the head and neck, and discuss the implications for pseudoaneurysm surveillance.
pseudoaneurysm, embolization, coils, head and neck cancer, external carotid artery
Serious complications related to percutaneous vertebral augmentation procedures, vertebroplasty and kyphoplasty, are rare and most often result from local cement leakage or venous embolization. We describe an adult patient who underwent multi-level, thoracic percutaneous vertebral augmentation procedures for painful osteoporotic compression fractures. The patient’s percutaneous vertebroplasty performed at the T9 level was complicated by the asymptomatic, direct embolization of the right T9 segmental artery with penetration of cement into the radicular artery beneath the pedicle. We review the literature regarding the unusual occurrence of direct arterial cement embolization during vertebral augmentation procedures, discuss possible pathomechanisms, and alert clinicians to this potentially catastrophic vascular complication.
vertebroplasty, vascular complications, cement embolization, artery of Adamkiewicz
Intracranial aneurysm is a fairly common (often asymptomatic) condition. Subarachnoid hemorrhage associated with aneurysmal rupture is a potentially lethal event with a mortality rate as high as 50 percent and a high rate of disability among those who survive the initial hemorrhage, such that recently published guidelines support treatment of intracerebral aneurysms. The current treatment options include surgical clipping and endovascular treatment, but these are not without significant problems. Despite the trend toward endovascular treatment the rate of recurrence and complications is high. Current published evidence of the use of covered stent is limited to stents covered with polytetrafluoroethylene. It is now recognized that mammalian extracellular matrix represents an excellent scaffold material suitable for many therapeutic applications and glutaraldehyde treated pericardium has been widely used for many years due to its desirable features such as low immunogenicity and durability. This report describes the first published experience with the Aneugraft Pericardium Covered Stent (ITGI Medical, OR Akiva, Israel) in the treatment of internal carotid and vertebral artery aneurysms in three patients. In all three cases, the implantation of this novel device has resulted in successful closure of aneurysms.
covered stent, pericardium covered stent, aneurysm, vertebral artery, internal carotid artery
Neurofibromatosis type 2 (NF2) is an autosomal dominant syndrome with a prevalence of approximately 1 in 30,000. NF 2 is characterized by bilateral vestibular schwannomas, as well as meningiomas, ependymomas and gliomas. Currently, surgical resection and radiotherapy represent the mainstay of treatment, although new studies suggest a role for certain chemotherapeutic agents. Intravenous administration of Bevacizumab (Avastin, Genetech Pharmaceuticals) has been shown to be active in the treatment of vestibular schwannomas. The IV route of administration, however, carries a risk of known systemic side-effects such as bowel perforation, wound dehiscence and pulmonary embolism. In addition, the percentage of drug that reaches the tumor site may be restricted by the blood tumor barrier. This report describes the super-selective intra-arterial infusion of Bevacizumab following blood brain barrier disruption for the treatment of vestibular schwannomas in three patients with Neurofibromatosis type 2. It represents the first time such a technique has been performed for this disease. Additionally, this method of drug delivery may have important implications in the treatment of patients with vestibular schwannomas associated with Neurofibromatosis type 2.
bevacizumab, superselective intra-arterial cerebral infusion, Neurofibromatosis type 2, vestibularis schwannoma
Meningiomas are often embolized before their surgical resection to reduce blood loss during surgery. Polyvinyl alcohol (PVA) particles have been the most frequently used material for embolization of meningiomas. We have used n-butyl cyanoacrylate (NBCA) as the first-choice material since 2001. Thirty-one meningiomas were embolized with NBCA. We report the result of embolization of meningiomas with NBCA in comparison with PVA particles.
meningioma, preoperative embolization, n-butyl cyanoacrylate
Pilocytic astrocytomas are highly vascular, relatively common primary brain tumors in the pediatric population, but their association with a true arteriovenous malformation (AVM) is extremely rare. We describe an eight-year-old girl with a right supratentorial juvenile pilocytic astrocytoma (WHO grade I) with an angiographically documented AVM entangled in the tumor mass who presented with intracranial hemorrhage due to a ruptured anterior choroidal artery pseudoaneurysm encased in the lesion. The AVM nidus as well as the hemorrhage site was embolized with Onyx. A literature review revealed only one previous report of a true intermixture of these two lesions. We hypothesize whether the association of vascular malformations and primary brain tumors are merely coincidental or if they point to the existence of a distinct entity and/or a common etiologic factor.
juvenile pilocytic astrocytoma, arteriovenous malformation, Onyx
Radiosurgery is a recognized safe form of treating and usually curing arteriovenous malformations (AVMs). Complications related to radiosurgery, especially late sequelae, are rare. Such sequelae may be secondary to incomplete treatment of the original lesion such as haemorrhage, or secondary to the radiation damage to the tissue, or both. Sometimes treatment may induce new lesions. We report a patient who had an AVM cured with radiosurgery, but developed hemisensory loss acutely and had changes on MRI in keeping with a haematoma. We discuss the possible differential diagnosis that should be considered.
arteriovenous malformation, radiosurgery, chronic encapsulating expanding haematoma, induced cavernoma
The clinical implications of venous cerebrovascular maldevelopment remain poorly understood. We report on the association of cerebrofacial venous anomalies (including sinus pericranii), ocular abnormalities and mild developmental delay in two children. In addition, one child had a seizure disorder. Complex cerebrofacial slow-flow vascular anomalies may herald an underlying developmental aberration affecting the cerebrofacial and orbital regions
sinus pericranii, seizure disorder, venous malformation, developmental delay
Wide-neck intracranial aneurysms remain a challenge to endovascular treatment. We describe our experience in repairing wide-neck aneurysms of the anterior circulation located at arterial branch points using coil embolization assisted by Y-stenting using two Solitaire® stents.
Six wide-neck intracranial aneurysms located on the middle cerebral artery bifurcation 3, pericallosal artery 1, and anterior communicating artery 2 were repaired by Y-stent-assisted coil embolization using two Solitaire® stents. Four cases were incidental findings of aneurysm and two cases were previously treated ruptured aneurysms that had undergone recanalization.
All the cases were successfully treated without complications. Follow-up by digital subtraction angiography and magnetic resonance angiography at six months showed the stents to be patent with no recanalization of the aneurysm sacs.
Repairing wide-neck aneurysms of the anterior circulation by Y-stent-assisted coil embolization using two Solitaire® stents is a simple and safe method of treating complex aneurysms. While the results are promising, larger series with longer term follow-ups are needed to corroborate that this treatment method is superior to other techniques.
wide-neck aneurysm, embolization, Y-stenting technique, closed-cells stent