Vein of Galen Malformations in adults.

OBJECTIVE: Vein of Galen Malformations (VoGM) are rare vascular malformations, typically seen in pediatric age groups. Even more rarely, VoGM's may be seen later in adulthood. In this case report and systematic review, we provide a thorough description of the current literature as well as provide a case example exploring the diagnosis, imaging, treatment, and management of VoGM in adults. METHODS: In accordance with PRISMA guidelines, we performed a systematic literature search for all relevant cases and case series of VoGM in adult patients. The reference list of all articles were reviewed for additional relevant cases. Articles were included if they described a VoGM of a patient over the age of 18 years old and published in English. 149 articles were originally identified and 26 described cases met our inclusion criteria. RESULTS: In our literature review we found 26 patients that met our inclusion criteria. We found 14 male patients and 12 female patients. The mean age at presentation was 37.2 years (median=34 years, SD= 13.6 years). The most common presenting symptoms of patient were headache (n = 9), seizure (n = 6), and vomiting (n = 4). Of the 12 cases which clearly reported the subtype of VoGM, the choroidal type was more frequently seen (n = 10) compared to the mural type (n = 2). In 3 patients, the VoGM was thrombosed at time of diagnosis. Of the 26 patients, endovascular treatment was performed most frequently (n = 8) but some received microsurgical treatment (n = 4) or were treated conservatively (n = 6). Other treatment modalities included (ventriculoperitoneal shunt, ventriculostomy) (n = 5). In 3 cases treatment was not specified. In comparison to VoGM seen in pediatric or neonatal populations, VoGM in adults generally resulted in more favorable outcomes with only 2 patients reported to have passed away following treatment. CONCLUSION: VoGM remains a rare finding amongst the adult population. Hence, we described the clinical presentation, treatment modalities, and outcomes of the cases described in the English literature. Perhaps due to the rate of thrombosis and the unique angioarchitecture seen in adult VoGM patients, outcomes were generally more favorable than those described in the literature in pediatric or neonate VoGM patients.

Evaluation of short- and long-term results of Y-stent-assisted coiling with Leo stents in endovascular treatment of wide-necked intracranial bifurcation aneurysms.

PURPOSE: This study aimed to evaluate the feasibility, safety, and efficacy of Y-stent-assisted coiling (Y-SAC) using LEO Baby® stents in treating of bifurcation aneurysms. METHODS: Patients who underwent Y-SAC using a braided stent (LEO Baby®, Montmorency, France) for wide-necked intracranial aneurysms between 2009 and 2019 and whose radiological and clinical follow-up data for at least 6 months could be obtained were evaluated. Data were obtained from patient records and analyzed retrospectively. RESULTS: We evaluated 111 patients with a mean age of 56.0 ± 10.8 years (range, 25-88 years). Most of the aneurysms were detected incidentally. Three patients had ruptured aneurysms. LEO Baby deployment and coiling were successful in all patients. Immediate aneurysm occlusion rates were determined as modified Raymond-Roy classification (mRRC) I 95.5% (n = 106), mRRC II 3.6% (n = 4), mRRC IIIa 0.9% (n = 1). In the sixth month, aneurysm occlusion rates were found to be complete and nearly complete in all patients (mRRC I 94.6%, n = 105 and mRRC II 4.5%; n = 5, respectively). Follow-up data of 91 patients for > 2 years were obtained. Of these, 88 had MRRCI obstruction and 3 had MRRC II obstruction. The overall complication rate was 4.8%, and one patient died during the post-procedural follow-up. CONCLUSION: The long-term follow-up results of Y-stenting with LEO Baby revealed that it provides stable closure of the aneurysm sac while preserving the main arterial structures. Therefore, it is a safe, durable, and effective method for treating wide-necked and complex bifurcation aneurysms.

Safety and efficacy of flow diverter stents in the treatment of middle cerebral artery aneurysms: a single-center experience and follow-up data

PURPOSE: This study aims to evaluate the safety and efficacy of flow diverters (FDs) in the treatment of middle cerebral artery (MCA) aneurysms and share the follow-up (F/U) results. METHODS: The treatment and F/U results of 76 MCA aneurysms treated with the flow re-direction endoluminal device (FRED), FRED Jr., and pipeline embolization device (PED) FD stents were evaluated retrospectively. The aneurysm occlusion rates were compared between FDs, and the integrated and jailed branches were evaluated through follow-ups. The oversizing of the stent was compared between occluded/non-occluded aneurysms and integrated branches. RESULTS: The mean F/U duration was 32 ± 6.3 months, and the mean aneurysm diameter was 4.45 mm. A total of 61 (80.3%) aneurysms were wide-necked; 73 (96.1%) were saccular; 52 (68.4%) were located at the M1 segment; and 36 (45.6%) FREDs, 23 (29.1%) FRED Jr.s, and 19 (24.1%) PEDs were used for treatment. The overall occlusion rates for the 6-, 12-, 24-, 36-, and 60-month digital subtraction angiographies were 43.8%, 63.5%, 73.3%, 85.7%, and 87.5% respectively. The last F/U occlusion rates were 67.6% for FRED, 66.7% for PED, and 60.6% for FRED Jr. (P = 0.863). An integrated branch was covered with an FD during the treatment of 63 (82.8%) aneurysms. A total of six (10%) of the integrated branches were occluded without any symptoms at the last F/U appointment. The median oversizing was 0.45 (0-1.30) for occluded aneurysms, and 0.50 (0-1.40) for non-occluded aneurysms (P = 0.323). The median oversizing was 0.70 (0.45-1.10) in occluded integrated branches and 0.50 (0-1.40) in non-occluded branches (P = 0.131). In-stent stenosis was seen in 22 (30.1%) of the stents at the 6-month F/U and in only 2 (4.7%) at the 24-month F/U. Thus, none of the patients had any neurological deficits because of the in-stent stenosis. Severe in-stent stenosis was seen in two stents. CONCLUSION: MCA aneurysms tend to be complex, with integrated branches and potentially wide necks. FD stents are safe and effective in the treatment of MCA aneurysms, and the patency of the side and jailed branches is preserved in most cases. Higher occlusion and lower in-stent stenosis rates are seen with longer F/U durations.

Endovascular embolisation of a complex mandibular AVM: a hybrid transarterial and transvenous approach.

Mandibular arteriovenous malformations (AVMs) are rare lesions which can present with life-threatening haemorrhage. Endovascular embolisation can be life saving for these patients. We discuss a patient of mandibular AVM, who initially presented with reports of massive oral bleeding. The lesion was only partially embolised via transarterial route, as the nidus could not be penetrated completely. In view of rebleeding within 72 hours from the same site, a second embolisation procedure was done via combined, transarterial and transvenous approaches. Coils and onyx were used as embolising agents. Complete embolisation was achieved via combined approach. No further bleeding episodes were seen at 1-year follow-up. Endovascular embolisation of mandibular AVMs can be technically challenging and, hence, a sound knowledge of the anatomy as well as the possible modification of technique is essential to achieve complete obliteration of the lesion and to maximise the benefit of embolisation and to avoid major radical surgery.

Technical Challenges in Endovascular Treatment of Ruptured Aneurysm in a Patient with Body Mass Index >100.

BACKGROUND: Morbid obesity can pose unique challenges in the endovascular treatment of cerebrovascular diseases, particularly in the management of ruptured aneurysms. CASE DESCRIPTION: This technical report discusses the challenges faced during the treatment of a ruptured aneurysm in a morbidly obese patient with a body mass index of 101. The technical adaptations used included the utilization of Dyna CT for routine imaging, vacuum assist devices for patient transfer, and a transradial approach to avoid groin complications. The technical adaptations used in the management of the ruptured aneurysm in the morbidly obese patient were effective in overcoming the challenges posed by the patient's obesity. CONCLUSION: This technical report and literature review can serve as a guide for physicians treating morbidly obese patients with cerebrovascular diseases. Utilization of advanced technology and innovative approaches can aid in overcoming the challenges posed by obesity and improving patient outcomes.

Increased reliability of CT-imaging signs of bleeding into soft tissue in patients with COVID-19 for planning transarterial embolization.

INTRODUCTION: Spontaneous bleeding into the soft tissues of the abdominal and thoracic wall is described as complication of anticoagulant therapy. Computed tomography (CT) allows to detect the presence of extravasation of the contrast agent into a hematoma, which is indicated as a sign of ongoing bleeding. Other specific CT signs of such coagulopathic bleeding have been described earlier. AIM OF THE STUDY: To evaluate the significance of specific coagulopathic CT signs for predicting the dynamics of spontaneous bleeding into soft tissues in patients with COVID-19. MATERIALS AND METHODS: A retrospective study included 60 patients with COVID-19 with spontaneous bleeding into soft tissues and extravasation of a contrast agent on CT. In addition to extravasation, a "hematocrit effect" was detected in 43 patients on CT. Of these, 39 had extravasation in the form of a "signal flare." All patients underwent transarterial catheter angiography (TCA). To assess the prognostic value of CT signs, the results of CT and TCA compared. The absence of extravasation on the TCA more often corresponded to stopped bleeding. RESULTS: Extravasation on TCA found in 27 (45%) patients. The presence of the "hematocrit effect" or the combination of this sign with the phenomenon of a "signal flare" on CT (n = 43) led to more frequent confirmation of extravasation on TCA than in their absence (n = 17): 23.5% vs. 53.4% (p = 0.028). CONCLUSION: The presence of a fluid level and the phenomenon of a "signal flare" on CT in the structure of spontaneous hematomas of the soft tissues of the abdominal and thoracic wall in COVID-19 patients more often corresponded to ongoing bleeding on the TCA. The absence of coagulopathic CT signs more often corresponded to stopped bleeding.

[Computed tomography and endovascular occlusion in diagnosis and treatment of spontaneous bleeding into soft tissues of abdominal, chest wall and retroperitoneal space in patients with COVID-19]. / Komp'yuternaya tomografiya i rentgenendovaskulyarnaya okklyuziya v diagnostike i lechenii spontannykh krovotechenii v myagkie tkani bryushnoi, grudnoi stenok i zabryushinnogo prostranstva u bol'nykh COVID-19.

OBJECTIVE: To investigate the results of therapeutic and prophylactic endovascular hemostasis of spontaneous bleeding into soft tissues of abdominal, chest wall and retroperitoneal space in patients with COVID-19. MATERIAL AND METHODS: We retrospectively studied 35 patients with COVID-19 complicated by spontaneous bleeding into soft tissues of abdominal, chest wall and retroperitoneal space. According to CT data, the volume of hematoma was 1193.4±706.1 ml. In all patients, CT signs of ongoing bleeding were detected. Moreover, contrast agent extravasation in all phases of examination was established in 15 patients. In other ones, extravasation was detected in late phases or study phase was not identified. All patients underwent angiography. Ongoing bleeding was detected in 12 (34.3%) patients (group 1). They underwent embolization of the target vessel. In 23 patients, bleeding was not established during angiography. Of these, 13 ones underwent prophylactic embolization (group 2). No embolization was carried out in 10 patients (group 3). All groups differed in hematoma localization and COVID-19 severity. RESULTS: Fourteen (40%) patients died in postoperative period. Mortality was similar in all groups. The most common cause of death was progressive respiratory failure following pneumonia. The last one was established by autopsy in 10 (71.4%) patients. CONCLUSION: Angiography confirmed MR signs of contrast agent extravasation in 34.3% of patients. In case of extravasation in all CT phases, ongoing bleeding was confirmed in 66.7% of patients. Endovascular embolization is effective for arterial bleeding into soft tissues. However, large-scale studies are needed to assess the effect of this technique on survival.

Safety and Efficacy of the Off-Label Use of Pipeline Embolization Device Based on the 2018 Food and Drug Administration-Approved Indications for Intracranial Aneurysms: A Single-Center Retrospective Cohort Study.

BACKGROUND: The pipeline embolization device (PED; ev3/Covidien) has proven safe and effective for treating selected intracranial aneurysms. This device's versatility and popularity have driven increased interest in expanding the latest 2018 Food and Drug Administration-approved indications. OBJECTIVE: To compare "off-label" and "on-label" PED treatment. METHODS: Retrospective analysis of aneurysms treated with PED at a single center from 2013 to 2019. Comparisons were made based on the 2018 Food and Drug Administration-approved indications. RESULTS: A total of 492 treated aneurysms were included (65.2% on-label and 34.8% off-label). Aneurysm complete and near-complete occlusion rate was nonsignificantly lower in the off-label group (80.9% vs 85.7%; P = .19). Off-label treatment had higher rate of poor functional outcomes (modified Rankin Scale [mRS] >2: 10.3% vs 3.5%; P = .002). Although pretreatment mRS was already higher in the off-label group (5.3% vs 0.3%; P < .001) and there were no differences in mRS worsening during follow-up (5.5% vs 2.9%; P = .15). We also found a trend to a higher rate of intracranial hemorrhagic complications in the off-label group (4.7% vs 1.6%; P = .05), but there were no differences in hemorrhages requiring surgical intervention (1.8% vs 1.3%; P = .65). There were no differences in retreatment, thromboembolic complications, and mortality rates. CONCLUSION: Off-label PED treatment may be considered for select aneurysms, which are challenging to treat with other techniques. These cases have similar complete and near-complete occlusion rates compared with on-label cases. There are, however, higher risks of poor functional outcomes despite similar rates of thromboembolic and hemorrhagic complications. This is partly explained by the significantly higher pretreatment mRS score in the off-label group.

Complete robotic intervention for acute epistaxis in a patient with COVID-19 pneumonia: technical considerations and device selection tips.

The use of robot-assisted technology is expanding in interventional laboratories with an increasing number of reports of effective treatment delivery in neurointerventional procedures. Here we report the feasibility of complete robot-assisted neurointervention including the guide catheter and microcatheter manipulations with subsequent embolization of the arterial source of hemorrhage in a patient hospitalized with severe COVID-19 complicated by acute epistaxis.

Transvenous Onyx Embolization of a Type D Carotid-Cavernous-Fistula: Operative Video.

Carotid-cavernous fistulas (CCFs) are acquired pathologic shunts between the carotid circulation and the cavernous sinus that result in venous congestion.1 They often present with ocular symptoms, such as chemosis, proptosis, and blurry vision. Cranial nerve deficits and increased intraocular pressure are often seen on the neuro-ophthalmologic examination.2 If left untreated, they can lead to cortical venous reflux and intracranial hemorrhage. A cerebral angiogram is the gold standard to diagnose these lesions. The hallmark of dural CCF is opacification of venous structures in the arterial phase of the angiogram. Dependent on carotid branches contributing to the fistula, 4 types are classically defined by Barrow et al.3 When the fistula is indirect (types B-D), the goal of treatment is obliteration via the transvenous route.4 We present the case of a patient who had chemosis and proptosis of the left eye with imaging findings concerning for dural CCF (Video 1). An informed consent was obtained and the patient underwent a cerebral angiogram and treatment of the CCF. In the operative video, we showcase the treatment of a type D CCF using transvenous embolization with Onyx (Covidien, Irvine, CA) and achieve angiographic cure of the fistula. We were able to use Onyx for embolization since the superselective injection did not show cortical venous drainage. This is important as obliteration of cortical veins with liquid embolisate could cause venous infarcts. To our knowledge, this is the first video article that illustrates the endovascular embolization of a CCF and highlights the angiographic findings pre- and post-embolization.

Hemodynamic differences by increasing low profile visualized intraluminal support (LVIS) stent local compaction across intracranial aneurysm orifice.

BACKGROUND: The Low-profile Visualized Intraluminal Support device (LVIS) has been successfully used to treat cerebral aneurysm, and the push-pull technique has been used clinically to compact the stent across aneurysm orifice. Our aim was to exhibit the hemodynamic effect of the compacted LVIS stent. METHODS: Two patient-specific aneurysm models were constructed from three-dimensional angiographic images. The uniform LVIS stent, compacted LVIS and Pipeline Embolization Device (PED) with or without coil embolization were virtually deployed into aneurysm models to perform hemodynamic analysis. Intra-aneurysmal flow parameters were calculated to assess hemodynamic differences among different models. RESULTS: The compacted LVIS had the highest metal coverage across the aneurysm orifice (case 1, 46.37%; case 2, 67.01%). However, the PED achieved the highest pore density (case 1, 19.56 pores/mm2; case 2, 18.07 pores/mm2). The compacted LVIS produced a much higher intra-aneurysmal flow reduction than the uniform LVIS. The PED showed a higher intra-aneurysmal flow reduction than the compacted LVIS in case 1, but the results were comparable in case 2. After stent placement, the intra-aneurysmal flow was further reduced as subsequent coil embolization. The compacted LVIS stent with coils produced a similar reduction in intra-aneurysmal flow to that of the PED. CONCLUSIONS: The combined characteristics of stent metal coverage and pore density should be considered when assessing the flow diversion effects of stents. More intra-aneurysmal flow reductions could be introduced by compacted LVIS stent than the uniform one. Compared with PED, compacted LVIS stent may exhibit a flow-diverting effect comparable to that of the PED.

Pipeline Embolization Device Versus Stent-Assisted Coiling for Intracranial Aneurysm Treatment: A Retrospective Propensity Score-Matched Study.

BACKGROUND: Pipeline embolization device (PED; Medtronic) and stent-assisted coiling (SAC) are established modalities for treatment of intracranial aneurysms. OBJECTIVE: To comparatively assess the efficacy of these techniques. METHODS: We conducted a retrospective analysis of patients with aneurysms treated at our institution with either PED from 2013 to 2017 or SAC from 2009 to 2015. All large (>10 mm), ruptured, fusiform, anterior communicating artery, posterior circulation aneurysms, and patients with no available follow-up imaging were eliminated before running the propensity score matching (PSM). Patients were matched using nearest neighbor controlling for: age, gender, smoking, exact location, maximal diameter, and presence of multiple aneurysms. Total hospital costs for equipment and implants were calculated from procedure product and hospital billing records, and compared between the propensity-matched pairs. RESULTS: Out of 165 patients harboring 202 aneurysms; 170 (84.2%) were treated with the PED, and 32 (15.8%) were treated using SAC. PSM resulted in 23 matched pairs; with significantly longer follow up in the SAC group (mean 29.8 vs 14.1 mo; P = .0002). Complete occlusion rates were not different (82.6 vs 87%; P = .68), with no difference between the groups for modified Rankin Scale on last clinical follow-up, procedural complications or retreatment rates. Average total costs calculated from the hospital records, including equipment and implants, were not different between propensity-score matched pairs (P = .48). CONCLUSION: PED placement and SAC offer equally efficacious occlusion rates, functional outcomes, procedural complication rates, and cost profiles for small unruptured anterior circulation saccular aneurysms which do not involve the anterior communicating artery.

Renal angiomyolipoma rupture in a young female with COVID-19.

While primarily a respiratory illness, infection with the novel coronavirus (COVID-19) is associated with pathologic changes in coagulation, characterized by both thromboembolic and bleeding events. We present the case of a 22-year-old female diagnosed with renal angiomyolipoma (AML) rupture 2 weeks after COVID-19 infection, ultimately requiring admission for hemorrhage control via endovascular embolization. Emergency medicine physicians should maintain a high index of suspicion for renal AML rupture and other spontaneous bleeding events in patients with recent COVID-19 infection due to a possible correlation between the two.

Contribution of Interventional Radiologist in the Management of Pseudoaneurysm and Neck Hemorrhages in COVID-19 patients.

Patients with severe coronavirus disease 2019 (COVID-19) may have endothelial inflammation, pseudoaneurysm, and an increasing risk of bleeding, especially during surgical procedures. In this article, we reported 2 cases of COVID-19 patients with neck vascular lesions. The first patient had pseudoaneurysm of the cricothyroid artery, which was treated by percutaneous glue injection through ultrasonography guidance. The second patient presented lateral neck hematoma in front of the left superior thyroid artery, which was managed by coil endovascular embolization. In the context of pandemic, the management of vascular lesions may be performed through interventional radiological procedures that may reduce the risk of virus aerosolization and health care provider contamination.