High-resolution magnetic resonance imaging-based radiomic features aid in selecting endovascular candidates among patients with cerebral venous sinus thrombosis.

OBJECTIVES: Cerebral venous sinus thrombosis (CVST) can cause sinus obstruction and stenosis, with potentially fatal consequences. High-resolution magnetic resonance imaging (HRMRI) can diagnose CVST qualitatively, although quantitative screening methods are lacking for patients refractory to anticoagulation therapy and who may benefit from endovascular treatment (EVT). Thus, in this study, we used radiomic features (RFs) extracted from HRMRI to build machine learning models to predict response to drug therapy and determine the appropriateness of EVT. MATERIALS AND METHODS: RFs were extracted from three-dimensional T1-weighted motion-sensitized driven equilibrium (MSDE), T2-weighted MSDE, T1-contrast, and T1-contrast MSDE sequences to build radiomic signatures and support vector machine (SVM) models for predicting the efficacy of standard drug therapy and the necessity of EVT. RESULTS: We retrospectively included 53 patients with CVST in a prospective cohort study, among whom 14 underwent EVT after standard drug therapy failed. Thirteen RFs were selected to construct the RF signature and CVST-SVM models. In the validation dataset, the sensitivity, specificity, and area under the curve performance for the RF signature model were 0.833, 0.937, and 0.977, respectively. The radiomic score was correlated with days from symptom onset, history of dyslipidemia, smoking, fibrin degradation product, and D-dimer levels. The sensitivity, specificity, and area under the curve for the CVST-SVM model in the validation set were 0.917, 0.969, and 0.992, respectively. CONCLUSIONS: The CVST-SVM model trained with RFs extracted from HRMRI outperformed the RF signature model and could aid physicians in predicting patient responses to drug treatment and identifying those who may require EVT.

Endovascular Treatment of the Huge Dissecting Aneurysms Involving the Basilar Artery by the Internal Trapping Technique: Technical Note.

BACKGROUND: The endovascular strategy of the huge dissecting aneurysms involving the basilar artery (BA) is controversial and challenging. This study was to investigate the clinical and angiographic outcomes of the treatment of the huge dissecting aneurysms involving the BA by the internal trapping (IT) technique. METHODS: We retrospectively studied 15 patients with the huge dissecting aneurysms involving the BA treated by the IT technique between September 2005 and September 2014 in Department of Interventional Neuroradiology of Beijing Tiantan Hospital. Clinical and angiographic data were reviewed and evaluated. RESULTS: All patients were treated by the IT technique. That meant the dissecting artery and aneurysm segments were completed occlusion. After the procedure, the angiography demonstrated that all the dissecting artery and aneurysm segments were completed occlusion. Follow-up angiography was performed at 3-6 months or 12-18 months after the endovascular treatment (median 8 months), 14 patients had a good recovery. Re-canalization occurred in one patient whose aneurysm involved in bilateral vertebral arteries and the two third of the middle-lower BA. After the second treatment, the patient died by the ventricular tachycardia. CONCLUSIONS: The IT technique is a technically feasible and safe alternative for the treatment of BA dissecting aneurysms, but it is not necessarily the safest or most definitive treatment modality. The ideal treatment of the huge dissecting aneurysms involving the BA remains debatable and must be investigated on a case-by-case basis.

Clinical effectiveness of preoperative embolization for cerebellar hemangioblastoma.

The cerebellar hemangioblastoma (CHB) has an abundant blood supply and deep anatomical location. Complete surgical resection is generally very difficult. This study investigated the safety and effectiveness of preoperative embolization followed by surgical resection of CHB in a large cohort of patients. A database of 125 CHB patients with surgical resection in Beijing Tiantan Hospital between July 2006 and July 2012 was reviewed. Of those, 46 cases (experimental group) received preoperative embolization, 79 cases (control group) underwent surgery without embolization. Patient demographics, tumor size, duration of surgery, blood loss, blood transfusion, complications and follow-up results were collected and analyzed retrospectively. In the experimental group, the Kamofsky score (KS) was 80-100 in 40 cases (86.9%), 40-70 in 4 cases (8.7%), and below 40 in 2 cases (4.3%). Among 31 cases with follow-up, KS was 80-100 in 27 cases (87.1%), 40-70 in 2 cases (6.5%), and 0 in 2 cases (6.5%). In control group, KS was 80 -100 in 65 cases (82.2%), 40-70 in 6 cases (7.6%), 10-30 in 3 cases (3.8%), and 0 in 3 cases (3.8%). Among 53 cases with follow-up, KS was 80-100 in 44 cases (83.0%), 40-70 in 4 cases (7.5%), 10-30 in 1 case (1.9%), and 0 in 4 cases (7.5%). There were statistically significant differences between the experimental and control groups in tumor size, duration of surgery, amount of intraoperative blood loss and transfusion (p <0.01). However, complications (p = 0.31) and follow-up results (p = 0.76) showed no significant differences between groups. Selective preoperative embolization of those CHB patients with richer blood supply, higher hemorrhage risk, is safe and effective, and is a reliable adjuvant therapy for complete surgical resection of CHB.

[Multiple factors related with intracranial hemorrhage of dural arteriovenous fistula: clinical analysis].

OBJECTIVE: To discuss the relevant predicative factors of dural arteriovenous fistula (dAVF) in intracranial hemorrhage. METHODS: A total of 144 consecutive patients with dAVFs were recruited for a retrospective analysis from 1996 to 2006. The relevant factors of gender, age, fistula flow rate, arterial supply, lesion and venous drainage pattern were analyzed to evaluate the outcome of intracranial hemorrhage. RESULTS: Univariate analysis showed that gender, lesion and venous drainage pattern were statistical significant for intracranial hemorrhage of DAVF (P < 0.05). However, only venous drainage pattern was significant in the predication of intracranial hemorrhage (P < 0.05). CONCLUSION: Only venous drainage pattern is significant in the predication of dural arteriovenous fistulas in intracranial hemorrhage. Both gender and lesion may be confounding factors.

Transvenous embolization with a combination of detachable coils and Onyx for a complicated cavernous dural arteriovenous fistula.

BACKGROUND: Treatment of cavernous dural arteriovenous fistulas (DAVF) is usually made by a transarterial approach. However, in many complicated patients, treatments via transarterial approaches can not be achieved, and only an operation via a transvenous approach is feasible. We aimed to study the feasibility of transarterial embolization of cavernous dural arteriovenous fistulas with a combination detachable coils and Onyx to embolize a complicated cavernous DAVF via a transvenous approach. METHODS: From August 2006 to August 2007, six cases of complicated cavernous DAVF were embolized with a combination of detachable coils and Onyx via a transvenous approach. Three cases were male and the other three were female. Their ages ranged from 36 to 69 years old. The fistula was in the right lateral cavernous sinus in one case, in the left lateral cavernous sinus in another, and in the bilateral cavernous sinus in 4 cases. One fistula was fed by the right internal carotid artery and its meningohypophyseal trunk; one was fed by the branches of the left internal carotid artery and left external carotid artery; four were fed by the branches of the bilateral internal carotid artery and/or the bilateral external carotid artery. One case was drained via one lateral inferior petrosal sinus; three were drained via bilateral inferior petrosal sinuses; one was drained via one lateral ophthalmic and facial veins; one was drained via the inferior petrosal sinus and the ophthalmic and facial veins. Four were embolized via the inferior petrosal sinus, and two were embolized via the ophthalmic and facial veins. RESULTS: Among six cases of complicated cavernous DAVF, four were fully embolized with Onyx by a single operation, and two cases were fully embolized with Onyx following two operations. Transient headache was found after operation in all patients, but was cured after several days by the symptomatic treatments. In one case, the first operation via the inferior petrosal sinus was a failure; the feeding branches of the external carotid artery were embolized, and transient facial palsy was appeared after operation. The fistula was fully embolized with Onyx via the inferior petrosal sinus after two months with no complications. One bilateral cavernous sinus DAVF was embolized with Onyx via the inferior petrosal sinus by two operations, and transient abducens nerve palsy occurred after embolization. CONCLUSIONS: Because Onyx may be injected via a transvenous approach and the microcatheter is easily withdrawn, cavernous sinus via transvenous catheterization and embolization is a safe and efficient way to treat complicated cavernous dural arteriovenous fistulas, especially those for which operations via transarterial approaches have failed, or spontaneous cavernous dural arteriovenous fistulas.

Transvenous embolization of cavernous dural arteriovenous fistula: report of 28 cases.

BACKGROUND: Usually, cavernous dural arteriovenous fistula can be treated via transarterial approaches. However, in many complicated patients, transvenous approaches are superior to the transarterial ones because of the difficulties during a transarterial operation. In this study, we retrospectively analyzed the outcomes of 28 patients with cavernous dural arteriovenous fistula treated by transvenous embolization. METHODS: From September 2001 to December 2005, 28 patients with 31 cavernous dural arteriovenous fistulae were treated with transvenous embolization in Beijing Tiantan Hospital. The involved cavernous sinuses were catheterized via the femoral vein-inferior petrosal sinus approach or the femoral-facial-superior ophthalmic vein approach, and embolized with coils (GDC, EDC, Matrix, Orbit or free coil) or coils plus silk. The patients were followed up for 3 to 26 months. RESULTS: All the 31 cavernous sinuses in the 28 patients were successfully embolized. Complete angiographic obliteration of the fistulae was achieved immediately in 25 patients. Residual shunting was observed in the other 3, who had drainage through the pterygoid plexus (2 patients) or the inferior petrosal sinus (1) after the operation. Headache and vomiting were the most common symptoms after the embolization. In 3 patients, who achieved complete angiographic obliteration immediately, the left oculomotor nerve palsy remained unchanged after the operation. Transient abducens nerve palsy was encountered in 1. In 1 patient, the occular symptoms were improved after the operation, but recurred 4 days later, and then disappeared spontaneously after 5 days. During the follow-up, no patient had recurrence. Three months after the operation, angiography was performed on the 3 patients with residual shunting. Two of them had angiographic cure, the other had residual drainage through the pterygoid plexus. CONCLUSIONS: Transvenous catheterization and embolization of the cavernous sinus is a safe and efficient way to treat complicated cavernous dural arteriovenous fistulae. It is an alternative to the patients with spontaneous cavernous dural arteriovenous fistulae or those in whom transarterial embolization failed.

[Endovascular treatment of posterior cerebral artery aneurysm: analysis of 21 patients].

OBJECTIVE: To investigate the effect of endovascular treatment on posterior cerebral artery (PCA) aneurysm. METHODS: The clinical data of 21 patients with PCA aneurysm, 12 males and 9 females, aged 3 - 60, totally 22 aneurysms, 3 located in the P1 segment, 16 (in 15 patients) on the P2 segment, and 3 being serpentine aneurysms and involving P2-3 segment, were analyzed. One patients gave up treatment, 6 patients, with 7 aneurysms, underwent aneurysm sac occlusion, and 14 patients underwent parent vessel occlusion. RESULTS: Complete aneurysm sac occlusion was achieved in 5 patients with 6 aneurysms, and incomplete occlusion was achieved in 1 patient who died of bleeding of aneurysm the next day after the operation. All 14 patients undergoing parent vessel occlusion survived without aneurysm detected by angiography, among which 3 presented hemianesthesia of the contralateral side and 2 recovered completely. CONCLUSION: Endovascular treatment is safe and effective for PCA aneurysm.

[Transvenous embolization in treatment of refractory carotid-cavernous sinus fistula].

OBJECTIVE: To investigate the effects of transvenous embolization in treatment of refractory carotid-cavernous sinus fistula (CCF). METHODS: Twenty-five patients of refractory CCF with 28 foci underwent transvenous embolization, femoral vein-inferior petrosal sinus approach was used in 12 of which, and femoral vein-facial vein-superior ophthalmic vein approach was used in 12 of which. The embolizing materials included controllable coils (GDC, EDC), free coil, and silk. Three to twenty-four months after the treatment angiography was conducted on 10 patients and telephone follow-up was conducted on the other 15 patients. RESULTS: Immediate complete angiographic obliteration of the fistula was achieved in 20 patients. Residual shunting was left in 5 patients, 2 with pterygoid drainage and 3 with inferior petrosal sinus drainage. Headache and vomiting were the common symptoms after embolization. The angiography during follow-up showed that there were residual shunting in 4 patients, residual inferior petrosal drainage in 1 patient, and residual pterygoid drainage in 1 patient, and that no reoccurrence was found in the 6 patients with complete angiographic obliteration. The patients undergoing telephone follow-up reported that they had not any symptom. CONCLUSION: Safe and effective, transvenous embolization can be the first choice after the failure in treatment of the carotid-cavernous sinus fistula.

[Endovascular stent implantation in treatment of intracranial wide-necked aneurysms].

OBJECTIVE: To evaluate the effectiveness and feasibility of treatment of intracranial wide-necked aneurysms with a new technique of Neuroform self-expanding stent combined with detachable coil. METHODS: A retrospective analysis of thirty patients with intracranial wide-necked aneurysms, 14 males and 16 females, aged 48 (18-68), wide-necked aneurysms, underwent occlusion of aneurysms using Neuroform self-expanding stent combined with detachable coil. RESULTS: 21 of the 30 aneurysms were completely occluded (70%) and 9 of the 30 aneurysms were incompletely occluded (30%) after initial coils embolization. Thromboembolic events were found in one case and migration of stent in two cases. Clinical follow-up performed in 29 patients showed that only one patient had permanent mild hemi-paralysis. Twenty-one patients were followed up for 6-12 months, 7 of which needed second treatment and 4 of which showed complete occlusion. CONCLUSION: A flexible device, Neuroform self-expanding stent can be safely maneuvered through tortuous intracranial vessels, enabling the endovascular treatment of complex wide-necked aneurysms. The new technique of Neuroform stent combined with detachable coil increases the early outcome of intracranial wide-necked aneurysm.

[Transvenous occlusion of carotid cavernous fistula].

OBJECTIVE: To evaluate the treatment of carotid cavernous fistula with the transvenous approaches. METHODS: Seventeen patients (14 males and 3 males) with carotid cavernous fistula (CCF) were retrospectively analyzed. RESULTS: Totally 18 cavernous sinus of 17 patients were occluded. Nine operations were performed via inferior petrosal sinus approaches and 6 via the facial vein. One patient (bilateral fistula) received both two approaches. The fistula were completely occluded immediately after the procedures in 12 patients. Small shunts remained in four of other patients (2 pterygoid drainage and 2 inferior petrosal sinus, respectively). Facial vein catheterization failed because of vein vasospasm in one patient; his symptoms relieved 5 days later and angiography showed the CCF disappeared another 2 days later. CONCLUSION: Transvenous embolization of CCF is effective, safe, and easy to perform.

Endovascular treatment of cerebral arteriovenous malformations with Onyx embolization.

BACKGROUND: In the past 5 years, new treatment materials and techniques offering a different concept in endovascular treatment have been described for cerebral arteriovenous malformations (CAVMs). The aim of this study was to assess the endovascular treatment of CAVMs by using a liquid embolic material, Onyx (Micro Therapeutics. Inc., Irvine, CA, USA). METHODS: From September 2003 to September 2004, Onyx was used to treat 22 patients with CAVMs. Ten AVMS were located in functional areas, 8 in deep cerebral areas, and 4 in the cerebellar hemisphere. The size of CAVMs was about 3 cm in diameter in 5 patients, 3-6 cm in 11, and more than 6 cm in 6. RESULTS: In the 22 patients, Onyx embolization was successful. Nidus occlusion was complete in 3 patients, > 90% in 8, > 80% and < 90% in 6, and > 50% and < 80% in 5. Complications included transient neurological deficits in 2 patients, and adherence of microcatheter to the site of injection in 2. CONCLUSIONS: Being non-adhesiveness, Onyx is a safe and satisfactory embolic material in the treatment of CAVMs. But its long-term efficacy awaits further follow-up.