Transvenous embolization of intracranial dural arteriovenous shunts through occluded venous segments: experience in 51 Patients.

BACKGROUND AND PURPOSE: DAVFs with cortical venous reflux carry a high risk of morbidity and mortality. Endovascular treatment options include transarterial embolization with a liquid embolic agent or transvenous access with occlusion of the involved venous segment, which may prove difficult if the venous access route is thrombosed. The aim of this article is to describe the technique and results of the transvenous approach via thrombosed venous segments for occlusion of DAVFs. MATERIALS AND METHODS: Our study was a retrospective analysis of 51 patients treated with a transvenous approach through an occluded sinus that was reopened by gentle rotational advancement of a 0.035-inch guidewire, which opened a path for a subsequently inserted microcatheter. RESULTS: Of 607 patients with DAVFs, the transvenous reopening technique was attempted in 62 patients in 65 sessions and was successful in 51 patients and 53 sessions. Immediate occlusion was seen in 42 patients; on follow-up, occlusion was seen in 49 patients, whereas 2 patients had reduced flow without cortical venous reflux. No permanent procedure-related morbidity was noted. CONCLUSIONS: The reopening technique to gain access to isolated venous pouches or the cavernous sinus for the treatment of DAVFs is a safe and effective treatment, which should be considered if transarterial approaches fail or are anticipated to result only in an incomplete anatomic cure.

Endovascular management in children with vein of Galen aneurysmal malformation.

BACKGROUND: A vein of Galen aneurysmal malformation (VGAM) is a relatively rare vascular malformation, often resulting in high morbidity and mortality. While surgical arterial clipping has been reported for decades, results in the literature have recently favored endovascular treatment. METHODS: During a 10-year period, all children who were diagnosed with VGAM were included in our follow-up study. Clinical and radiological records of 5 consecutive patients were reviewed. RESULTS: 5 children (4 infants and 1 child) who suffered from symptoms caused by VGAM were treated by means of transarterial embolization with N-butyl cyanoacrylate (NBCA) alone. Their age at the time of diagnosis ranged from 4 months to 3 years. 4 of the 5 patients presented with macrocranium, and 3 of those 4 patients were infants. The fifth patient presented with seizures. None of the patients presented with hemorrhage. 2 of the 5 VGAM patients were classified as the mural type, while the others 3 were of the choroidal type. Both mural type patients achieved total obliteration of lesions with good outcomes. One of the remaining 3 patients exhibited autistic behavior during late follow-up, whereas the other 2 had good outcomes. 2 patients suffered from asymptomatic ruptured arterial feeders during embolization, which were treated immediately with glue embolization. CONCLUSION: Our purpose in treating a patient with VGAM is to achieve normal brain development using minimally invasive interventions. Our treatment strategies were influenced by each patient's clinical status, their ages, and varying radiographic features. We achieved considerable successful in treating our patients by means of transarterial embolization alone.

Dangerous extracranial-intracranial anastomoses and supply to the cranial nerves: vessels the neurointerventionalist needs to know.

Transarterial embolization in the external carotid artery (ECA) territory has a major role in the endovascular management of epistaxis, skull base tumors, and dural arteriovenous fistulas. Knowledge of the potential anastomotic routes, identification of the cranial nerve supply from the ECA, and the proper choice of embolic material are crucial to help the interventionalist avoid neurologic complications during the procedure. Three regions along the skull base constitute potential anastomotic routes between the extracranial and intracranial arteries: the orbital, the petrocavernous, and the upper cervical regions. Branches of the internal maxillary artery have anastomoses with the ophthalmic artery and petrocavernous internal carotid artery (ICA), whereas the branches of the ascending pharyngeal artery are connected to the petrocavernous ICA. Branches of both the ascending pharyngeal artery and the occipital artery have anastomoses with the vertebral artery. To avoid cranial nerve palsy, one must have knowledge of the supply to the lower cranial nerves: The petrous branch of the middle meningeal artery and the stylomastoid branch of the posterior auricular artery form the facial arcade as the major supply to the facial nerve, and the neuromeningeal trunk of the ascending pharyngeal artery supplies the lower cranial nerves (CN IX-XII).

Multiple symptomatic cerebral arteriovenous malformations in a patient with HIV.

This brief case report describes an unusual presumed association of chronic HIV infection with multiple cerebral arteriovenous malformations. An adult male patient presented with recurrent spontaneous brain intracranial hemorrhages and neurologic deficits requiring surgical evacuation. The diagnosis was delayed because of lack of a high index of suspicion of this unexpected and previously unrecognized association.

Clinical characteristics of dural arteriovenous shunts in 446 patients of three different ethnicities.

SUMMARY: Dural arteriovenous shunts (DAVSs) developing in either the ventral, dorsal or lateral epidural spaces (VE, DE and LE-shunts) predictably drain in either cranio/spino-fugal or -petal directions. Associated conditions like venous outflow restrictions (VOR) may be responsible for changes in this drainage pattern. The goal of this study was to compare demographic, angiographic and clinical characteristics of different types of DAVS in Europe, South America, and Asia to find out whether the same clinical profile is present in different ethnicities. Charts and angiographic films of 446 patients with DAVS from three hospitals in Europe, Asia and South America were retrospectively evaluated. Clinical symptoms were separated into benign and aggressive and the presence or absence of cortical venous reflux (CVR) and VOR was noted. LE-shunts were present in elderly men and were always associated with CVR resulting in aggressive symptoms. VE-shunts were present in females and almost always had benign symptoms. There were no differences among the three populations for these shunts. DE-shunts in the Asian population were more aggressive secondary to a higher rate of VOR with associated CVR. VE-shunts rarely lead to CVR even in the presence of VOR, whereas LE-shunts invariably lead to CVR, irrespective of the population investigated. CVR in DE-shunts is not related to the primary disease (i.e. the shunt itself) but to associated factors that led to VOR. Since the occurrence of these varied between different ethnicities, DE-shunts were aggressive in the Asian population and benign in the European and South American populations.

Trigeminal fistula treated by combined transvenous and transarterial embolisation.

Trigeminal cavernous fistulae are rare, compared to other types of carotid-cavernous fistulae with only about 17 examples previously reported in English literature. The aetiology can be either post-traumatic or spontaneous, and in the latter group either due to a ruptured trigeminal aneurysm or postulated intrinsic weakness of the artery itself. The treatment goal is to close the fistula while preserving the parent artery and this can be done either by surgical or endovascular methods. We present a 35-year-old woman with a spontaneous trigeminal fistula treated by combined trans-venous and trans-arterial embolisation.

PHACES syndrome: a review of eight previously unreported cases with late arterial occlusions.

PHACE and PHACES are acronyms for a syndrome of variable expression comprising posterior cranial fossa malformations, facial haemangiomas, arterial anomalies, aortic coarctation and other cardiac disorders, ocular abnormalities and stenotic arterial disease. We review five girls and three boys aged 1 month-14 years with disorders from this spectrum. Six had large facial haemangiomas but recent reports suggest that small haemangiomas may occur; hence our inclusion of two possible cases. We also focus on the recently recognised feature of progressive intracranial arterial occlusions, present in four of our patients, later than previously recognised, from 4 to 14 years of age. We suggest that many elements of this disorder could reflect an abnormality of cell proliferation and apoptosis.

Ruptured anterior spinal artery aneurysm associated with coarctation of aorta. Case report and literature review.

SUMMARY: A 39-year-old man presented with acute headache and neck pain, followed by quadriparesis and quadriparesthesia, accompanied by urinary and bowel incontinence. Lumbar puncture showed subarachnoid haemorrhage. Angiogram via a right axillary approach revealed severe coarctation of the aorta, between the left common carotid artery and left subclavian artery. Multiple collateral circulation including an enlarged anterior spinal arterial axis bridging the stenosed arch provided collateral circulation to the abdominal aorta. A small lobulated aneurysm was seen at the radiculomedullary-anterior spinal artery junction from the right ascending cervical artery. This patient underwent successful surgical clipping of the aneurysm. Pathogenesis of the spinal arterial aneurysm associated with coarctation of the aorta is likely to result from the haemodynamic stress from collateral circulation through the anterior spinal axis rather than segmental arterial disease or angiodysplastic disease. Aneurysms of the spinal artery are rare but can be unusually found in association with SCAVMs, coarctation of aorta, Klippel-Trenaunay syndrome or more rarely with aortic arch interruption.

Early neurological complications after stereotactic radiosurgery/radiotherapy.

OBJECTIVE: To evaluate the neurological complications after stereotactic radiosurgery (SRS) and stereotactic radiotherapy (SRT). MATERIAL AND METHOD: The Ramathibodi Radiosurgery Unit started its service in August 1997, using the linear-accelerator based system. There were 144 patients treated from August 1997 to October 1999. Single fraction SRS was performed in 56 cases consisting of 46 arteriovenous malformations (AVMs), 4 cranial nerve (CN) schwannomas, 3 pituitary adenomas, 2 meningiomas, and 1 multiple hemangioblastomas. Eighty eight patients received multifractionated SRT, including 27 meningiomas, 17 pituitary adenomas, 13 benign and malignant gliomas, 8 brain metastasi(e)s, 5 CA nasopharynx, 5 craniopharyngiomas, 5 CN schwannomas, 2 AVMs, 2 chordomas, and 4 others. After treatment the patients were clinically evaluated every 1-6 months and MRI was scheduled at 6 or 12-month interval or when there were abnormal clinical signs/symptoms. The complications included any new neurological complaints or findings during and after treatment. RESULTS: Median follow-up time was 9.5 (0-20) months. Of 138 patients with available follow-up data, there were 23 (13 SRS and 10 SRT) cases who experienced new neurological symptoms at 3 weeks - 20 months (median = 3 months) from the time treatment started. Symptoms included headache, seizure, weakness, decreased vision, vertigo with/without ataxia, diplopia, dizziness, impaired memory, hemifacial spasm, decreased sensation and facial palsy. Three AVM patients had intraventricular hemorrhage from the patent nidi. After symptomatic treatment there were 15 cases with complete recovery (including seizure control) and 6 with partial recovery. There were 2 deaths from ruptured AVM and progressive metastatic brain lesion. There were 79 patients who had at least 1 follow-up MRI, and changes were detected in T2-weighted images in 19 cases at 3-18 months after treatment. Ten cases had symptoms corresponding to the image changes, the other 9 patients were asymptomatic. CONCLUSIONS: Longer follow-up time is needed to fully evaluate the complications after SRS/SRT, however, preliminary results showed that most of the complications were mild and transient. There was a tendency of a higher complication rate in the SRS group. Not all patients with post treatment image changes developed symptoms.

Multifocal and metameric spinal cord arteriovenous malformations. Review of 19 cases.

SUMMARY: We describe 19 (16.0%) multiple vascular malformations (AVMs) in 119 spinal cord arteriovenous malformations (SCAVMs). The associated lesions were eight vertebral vascular malformations, two cutaneous, four limbs, four radicular AVMs, three bifocal SCAVMs; one patient had a bifocal cord lesion associated with vertebral and limb localisations. Various syndromic associations were seen: nine Cobb, two Klippel-Trenaunay-Weber, one Parkes Weber. An additional subgroup of unclassified associations is constituted by seven cases with bifocal intradural uni or multimetameric lesions. In our SCAVMs series, the incidence ofmultipie vascular lesions is high, in particular multifocal intradural malformations. Metameric distribution is the most frequent type of multiplicity. Identification of the myelomeric level involved in SCAVM allows segmental link between various lesions of mesodermal or neural crest origin to be discussed.

Extracavernous arteriovenous fistulae. Report of five cases.

SUMMARY: We report five cases of arteriovenous fistulae (AVFs) of the carotid system. Two were traumatic non penetrating injuries and involved the subarachnoid, extracavernous part of the intracranial internal carotid artery; two were spontaneous and involved the internal carotid artery in its extracranial portion; one was a spontaneous AVF of the ascending pharyngeal artery. All the symptoms due to these AVFs were not related to the location of the fistula, but to the congestive venous drainage. The revealing symptoms regressed and/or improved after transarterial detachable balloon embolisation that led to complete occlusion of the AVFs.

Interventional neuroradiology in Thailand: 1989-1997.

SUMMARY: In 1979 the Siriraj team in Bangkok began exploring a field that was then new in Thailand, i.e. interventional neuroradiology. This first phase consisted mostly in self-training and foreign exposure. It included experimental work with animal models, as well as early clinical trials designed to assess our skills in particle embolisation and the ligated and detachable balloon techniques. In 1990 a new phase started. Essential techniques were acquired in collaboration with the neurovascular unit of Bidtre Hospital in France during a three year training programme. Throughout this period, the support of the Association Medicale Franco-Asiatique (AMFA) and the French foreign affairs department proved vital. Our department progressively became a referral centre for the different techniques used in embolisation (balloons, glue...) and for various vascular lesions of the brain, the head and neck region, and spinal cord diseases. Within Mahidol University, the Ramathibodi and Prasat Hospital centres started the same interventional neuroradiology training program in 1995; they benefited from the same tutors and connections as Siriraj. In 1996, the newly acquired biplane DSA machines in both centres enabled us to improve the treatment of arteriovenous malformations - using the glue technique -, intracranial aneurysm - using GDC-coils-, clot lysis, angioplasty...ete. According to international recommendations, the critical mass we reached in 1997 in terms of number of patients and interventions, allows us to offer training in endovascular techniques to junior neuroradiologists at Mahidol university.

Spinal Cord Arteriovenous Malformations in a Pediatric Population Children below 15 Years of Age The Place of Endovascular Management.

SUMMARY: Among a global group of 164 spinal arteriovenous shunts, a series of 16 spinal cord arteriovenous malformations (SCAVMs) were diagnosed in a pediatric population below 15 years of age. The majority of the lesions affected the male population; 6 were located in the cervical spine and 10 at the thoracolumbar level. Hemorrhage was the most frequent symptom encountered (63%). Half of the bleeds occurred only in the subarachnoid spaces. Neurological deficits (acute or progressive) revealed the SCAVM in 31 % of patients. The lesion was an incidental finding in one patient (6%). All the diagnoses (except one) were made by MRI. Selective angiography confirmed the diagnosis and identified the type of the lesion (nidus or fistula) and its angioarchitecture, stressing that the veins and their related features are the key point in the clinical eloquence of SCAVMs. All the treatments performed were endovascular; no patient was deemed a surgical candidate. Therapeutic abstention was decided in 37% of cases, mainly for anatomical reasons. All the patients in this group improved (50% being normal and 50% presenting slight non-handicapping deficits due to the initial accidents). Embolisation was indicated in 10 patients (63%) and was performed with fluid agents (histoacryl(*)) except in the first patient who had been treated with particles. Twelve percent of patients were cured (fistula), the remaining 88% having their lesion controlled to more than 50%. This partial treatment was always targetted towards the angioarchitectural weak points of the lesion. All patients improved after embolisation, 45% of them being neurologically normal. Follow-up in this group ranges from 1.5 to 13 Years. No complications occurred after embolisation. No bleed, rebleed or clinical worsening has occurred after endovascular treatment. The results in this series suggest that endovascular treatment (even partial but targetted) represents a safe and stable therapeutic alternative in the management of SCAVMs in this population.