Total occlusion of a conus medullaris pial arteriovenous malformation obtained with one session of superselective embolization.

The authors report about a case of the endovascular treatment of a pial arteriovenous malformation (AVM). The lesion was located on the conus medullaris. This injury is a rare spinal AVM. The diagnostic management and surgical treatment was chosen with a collaboration between neurosurgeons and neuroradiologists. The diagnostic management was based on clinical validation and magnetic resonance with angiographic technique as a gold standard. With regard to the surgical treatment of spinal AVM, endovascular and radiotherapy is a decision which should be taken multidisciplinarily. The treatment is crucial in resolving this lesion. The authors describe the case of a 38-year-old girl with clinical findings of progressive radiculomedullary ischemic process caused by the presence of spinal AVM. The angiographic images showed a pial AVM of the conus medullaris fed by an anterior radiculomedullary artery (Adamckiewiz artery) originated from a left T11 dorsospinal artery and by a posterior radiculopial artery originated from the left L1 artery. The draining veins were posterior pial veins, and accessory anterior subpial veins. Even if the first treatment of a pial arteriovenous malformation (AVM) of conus medullaris can be the surgical treatment for posterior localization, a neurointerventional angiographic and modern materials make it possible to reach pial AVMS of conus medullaris avoiding surgery. The authors describe a successful treatment of conus medullaris arteriovenous malformation with a one session of superselective embolization.

Endovascular treatment of a cavernous sinus dural arteriovenous fistula by transvenous embolisation through the superior ophthalmic vein via cannulation of a frontal vein.

We describe a new approach for transvenous embolisation of cavernous sinus dural arteriovenous fistulae through the superior ophthalmic vein (SOV), i.e., via percutaneous cannulation of a frontal vein. Modern neurointerventional angiographic materials make it possible to reach the SOV in this way without puncturing it in the orbit or a surgical exposure. Orbital phlebography should still be in the repertoire of interventional neuroradiology units in large centres.

"Protected" wallstenting of atheromatous stenoses at the carotid bifurcation.

SUMMARY: Atheromatous stenoses at the carotid bifurcation were treated by angioplasty and Wallstenting with cerebral protection obtained in most cases by temporary occlusion of the internal carotid artery. 287 carotid stenoses were treated in 233 patients. The stenosis was symptomatic in 79% of cases. All patients presented either a stenosis of >70% with significant impairment of the cerebral circulation (281 cases) or a symptomatic ulcerated plaque (six cases). A self-mounted protection system was used in 177 cases, the Percusurge Guardwire protection device in 98 cases an EPI filter in 12 cases. There was a contralateral internal carotid occlusion in 13% of cases. A combined stenting (vertebral, siphon, subclavian) was performed in 14% of cases. A Rolling membrane Wallstent was used in 84 patients, a first generation Easy Wallstent in 38 cases, a "Carotid" Easy Wallstent 35 in 55 cases and monorail 14 in 110 cases. Full opening of the stenosis was obtained in 98% of patients with correction of the arterial curve and improvement of the cerebral vascular supply. There were 0.7% cases with transient symptomatic neurological complications and 2% with permanent sequelae mainly related to avoidable inadequacy in flushing or to the insufficient radial force of the first generation Easy Wallstent. There were no per and one post-procedural cardiac complication (0.6%) in the s165 cases performed with the "Carotid" Easy Wallstent. Follow-up angiograms showed 0.7% of restenoses. Still in evolution, endovascular treatment of atheromatous stenoses at the carotid bifurcation with cerebral protection and stenting is a promising alternative technique to surgery. The association of Carotid Easy Wallstent 14 monorail and Percusurge Guardwire appears to be currently satisfactory.

Selective endovascular treatment of 71 intracranial aneurysms with platinum coils.

Seventy-one intracranial aneurysms were treated by endovascular techniques, with the placement of minicoils inside the aneurysmal sac. Most aneurysms were manifest by hemorrhage (67 cases), and 43 of these were treated within the first 3 days after presentation. At the 1-year follow-up examination, the outcome was scored as good in 84.5% of cases, but the morbidity and mortality rates were 4.2% and 11.3%, respectively. Twenty-nine aneurysms in the anterior circulation and 42 in the posterior circulation were treated. In this series, 23 patients were classified as Hunt and Hess neurological Grade I, 27 as Grade II, 12 as Grade III, nine as Grade IV, and none as Grade V. Thirty-three aneurysms were less than 10 mm in diameter, 28 were 10 to 25 mm, and 10 were larger than 25 mm. The preliminary results from this study appear to justify the emergency treatment of aneurysms by this approach. Aneurysms in the posterior circulation are particularly well suited for this type of surgery.