Endovascular treatment of dural arteriovenous fistulas with sinus drainage: Do we really need to protect the sinus?

BACKGROUND AND PURPOSE: Dural arteriovenous fistulas (DAVFs) with direct antegrade sinus drainage have a benign natural history but bruit can be disabling. Disconnection of the draining sinus is considered curative. We present the treatment results of 14 patients with a dural arteriovenous fistula with antegrade sinus return with emphasis on functionality of the involved sinus and the need for sinus patency. MATERIALS AND METHODS: Between January 2009 and January 2018, 14 patients with a DAVF with direct antegrade sinus drainage were treated in our institution. There were two men and 12 women (1: 6) with a mean age of 61 years (median 61, range 43-78). Clinical presentation was unbearable pulsatile bruit in all cases. Thirteen were draining in the sigmoid or transverse sinus and one drained into the inferior petrosal sinus. RESULTS: Twelve of 14 (86%) patients had a draining sinus non-functional for the brain. In ten of these 12 patients the sinus was occluded with liquid embolic or coils. In the two patients with a functional sinus, the fistula was successfully occluded without occluding the sinus. One patient with inferior petrosal sinus drainage required transvenous embolization. There were no permanent adverse events of treatment. CONCLUSIONS: Patients with DAVFs with direct antegrade sinus drainage were cured using a strategy of endovascular transarterial and transvenous embolization. Most patients had a non-functional sinus that could be occluded for cure.

The Woven EndoBridge (WEB) as primary treatment for unruptured intracranial aneurysms.

Purpose The intrasaccular flow disruptor Woven EndoBridge (WEB) device is developed for the treatment of wide-necked aneurysms without supportive devices. We used the WEB as primary treatment for unruptured aneurysms suitable for the device, regardless of neck size. Methods Between February 2015 and June 2017, 59 aneurysms in 51 patients were selectively treated with the WEB. There were 15 men and 36 women with a mean age of 59 years. Mean aneurysm size was 7.0 mm (range 3-22 mm). Of 59 aneurysms, 45 (76%) had a wide neck defined as ≥4 mm or dome-neck ratio ≤1.5. No stents or supporting balloons were used. Results Initial WEB position was judged good in all 59 unruptured aneurysms. One patient with a basilar tip aneurysm had a late thrombotic posterior cerebral artery occlusion by protrusion of the WEB over the artery. There were no procedural ruptures. Overall complication rate was 2.0% (1 of 51, 95% CI 0.01-11.3%). Imaging follow-up was available in 55 of 59 aneurysms (93%). At 3 months, 41 of 57 aneurysms (72%) were completely occluded, 12 (21%) had a neck remnant and 4 (7%) were incompletely occluded. Conclusion WEB treatment is safe and effective in selected unruptured aneurysms suitable for the device, regardless of neck size or location. There was no need for supportive devices. Three-quarters of all unruptured small aneurysms could be treated with the WEB. In our opinion, the WEB is a valuable alternative to coils, especially in wide-necked aneurysms.

Therapeutic internal carotid or vertebral artery occlusion using the WEB device.

The WEB device was used to occlude the internal carotid artery or vertebral artery as treatment for large aneurysms. The WEB could be placed accurately at the desired position inside the vessel. Two WEBs were sufficient to occlude the parent artery.

Endovascular treatment of intracranial aneurysms in the flow diverter era: frequency of use and results in a consecutive series of 550 treatments in a single centre.

Flow diverter devices became available in our department in 2009. We considered treatment with flow diverters only in patients with aneurysms not suitable for surgery or conventional endovascular techniques. This paper presents our preliminary experience with flow diverters in a consecutive series of 550 endovascular aneurysm treatments. Between January 2009 and July 2013, 550 endovascular treatments for intracranial aneurysms were performed. Of these, 490 were first-time aneurysm treatments in 464 patients and 61 were additional treatments of previously coiled aneurysms in 51 patients. Endovascular treatments consisted of selective coiling in 445 (80.8%), stent-assisted coiling in 68 (12.4%), balloon-assisted coiling in 13 (2.4%), parent vessel occlusion in 12 (2.2%) and flow diverter treatment in 12 (2.2%). Eleven patients with 12 aneurysms were treated with flow diverters. Two patients had ruptured dissecting aneurysms. One patient with a basilar trunk aneurysm died of acute in stent thrombosis and another patient died of brain stem ischaemia at 32 months follow-up. One patient had ischaemia with permanent neurological deficit. Two aneurysms are still open at up to 30 months follow-up. Flow diversion was used in 2% of all endovascular treatments. Both our own poor results and the high complication rates reported in the literature have converted our initial enthusiasm to apprehension and hesitancy. The safety and efficacy profile of flow diversion should discourage the use of these devices in aneurysms that can be treated with other techniques.

How often is thunderclap headache caused by the reversible cerebral vasoconstriction syndrome?

BACKGROUND: Thunderclap headache (TCH) has a broad differential diagnosis that includes the reversible cerebral vasoconstriction syndrome (RCVS). It is believed to be caused by a dysregulation of vascular tone, which leads to reversible and segmental vasoconstriction and may cause permanent neurological deficits. One of the remaining mysteries is the incidence of the syndrome in a general hospital setting. METHODS: We recruited consecutive patients with TCH without evidence of aneurysmal subarachnoid hemorrhage on immediate computed tomography-scanning from the emergency room in a period of 12 months. Only those patients with an acute and severe onset of the pain were recruited; the peak of the pain had to be reached in less than 1 minute (verbal analog scale >8/10), and the minimum duration of the pain had to be 6 hours. All patients underwent lumbar puncture, magnetic resonance angiography, and serial transcranial Doppler sonography. RESULTS: Thirty-four patients fulfilled the inclusion criteria; 3 of those were diagnosed with the RCVS (8.8%; 95%confidence interval 3-23). CONCLUSIONS: We found the incidence of RCVS to be 8.8% (95% confidence interval 3-23) (3 patients) in patients presenting with TCH without evidence for severe illness. We believe that RCVS is an under recognized condition, and there fore additional imaging should be performed in every patient with TCH.

The donut sign: a new angiographic sign for partially thrombosed aneurysms with flow-induced intraluminal thrombus.

Three patients are described with unruptured large partially thrombosed aneurysms with a peculiar donut-shaped remaining lumen. Observations suggest that the flow geometry of the aneurysm and parent vessels induces a preferential circular laminar flow inside the aneurysm followed by partial intraluminal thrombosis leaving a donut-shaped lumen to accommodate the circular flow. This flow mechanism of thrombus formation inside aneurysms is different from the more common repeated intramural dissections and hemorrhages that cause growth in most large and giant partially thrombosed aneurysms.

[A child with convulsions of unknown origin: posterior reversible encephalopathy syndrome]. / Een kind met onbegrepen convulsies: posterieur reversibel encefalopathiesyndroom.

BACKGROUND: Posterior reversible encephalopathy syndrome (PRES) is a rare complication in children with post-streptococcal glomerulonephritis (PSGN). CASE DESCRIPTION: An 8-year-old boy was brought to the emergency department with seizures preceded by acute headache attacks and vomiting. On examination the boy was hypertensive with periorbital edema. Further investigation showed proteinuria, haematuria and intra-cerebral abnormalities. Recent history indicated streptococcal tonsillitis for which oral amoxicillin was prescribed in the preceding week. The diagnosis 'PRES consequent to PSGN' was made, following which the patient was treated successfully with anticonvulsants and antihypertensives and he recovered without remaining problems. CONCLUSION: PRES is a rare syndrome which can occur in children as a complication of PSGN. By early recognition and adequate treatment, permanent neurological damage and possible death can be prevented.

[Sudden severe headache not always harmless: thunderclap headache as a result of reversible cerebral vasoconstriction]. / Plotselinge ernstige hoofdpijn niet altijd onschuldig. 'Thunderclap headache' door reversibele cerebrale vasoconstrictie.

BACKGROUND: Thunderclap headache may be a symptom of a severe underlying disorder. CASE DESCRIPTION: A 41-year-old man had recurrent episodes of thunderclap headache triggered by Valsalva-like manoeuvres. His medical history reported cannabis exposure. Angiography showed segmental vasoconstriction of cerebral arteries. He stopped using cannabis and tried to avoid intracranial pressure increasing activities. 3 months later he was no longer experiencing any symptoms and the vascular anomalies had clearly improved. We concluded that reversible cerebral vasoconstriction syndrome (RCVS) was the underlying cause of the thunderclap headache. CONCLUSION: In contrast with primary thunderclap headache and primary headache due to sex, cough and exertion, RCVS is not harmless, since the characteristic cerebral vasoconstriction can lead to life-threatening neurologic complications. The increasing quality of diagnostic imaging techniques will probably lead to such primary headaches being diagnosed less frequently and, more specifically, to more frequent diagnosis of severe underlying pathology. Because of the differences in prognosis and treatment, proper diagnostic imaging should be performed in all patients with thunderclap headache.

Late reopening of adequately coiled intracranial aneurysms: frequency and risk factors in 400 patients with 440 aneurysms.

BACKGROUND AND PURPOSE: In aneurysms that are adequately occluded 6 months after coiling, the risk of late reopening is largely unknown. We assessed the occurrence of late aneurysm reopening and possible risk factors. METHODS: From January 1995 to June 2005, 1808 intracranial aneurysms were coiled in 1675 patients at 7 medical centers. At 6 months, 1066 aneurysms in 971 patients were adequately occluded. At mean 6.0 years after coiling, of the 971 patients, 400 patients with 440 aneurysms underwent 3 Tesla magnetic resonance angiography to assess occlusion status of the aneurysms. Proportions and corresponding 95% CI of aneurysm reopening and retreatment were calculated. Risk factors for late reopening were assessed by univariate and multivariate logistic regression analysis, and included patient sex, rupture status of aneurysms, aneurysm size≥10 mm, and aneurysm location. RESULTS: In 11 of 400 patients (2.8%; 95% CI, 1.4-4.9%) with 440 aneurysms (2.5%; 95% CI, 1.0-4.0%), late reopening had occurred; 3 reopened aneurysms were retreated (0.7%; 95% CI, 0.2-1.5%). Independent predictors for late reopening were aneurysm size≥10 mm (OR 4.7; 95% CI, 1.3-16.3) and location on basilar tip (OR 3.9; 95% CI, 1.1-14.6). There were no late reopenings in the 143 anterior cerebral artery aneurysms. CONCLUSIONS: For the vast majority of adequately occluded intracranial aneurysms 6 months after coiling (those<10 mm and not located on basilar tip), prolonged imaging follow-up within the first 5 to 10 years after coiling does not seem beneficial in terms of detecting reopened aneurysms that need retreatment. Whether patients might benefit from screening beyond the 5- to 10-year interval is not yet clear.

De novo aneurysm formation and growth of untreated aneurysms: a 5-year MRA follow-up in a large cohort of patients with coiled aneurysms and review of the literature.

BACKGROUND AND PURPOSE: Rates of development of de novo intracranial aneurysms and of growth of untreated additional aneurysms are largely unknown. We performed MRA in a large patient cohort with coiled aneurysms at 5-year follow-up. METHODS: In 276 patients with coiled intracranial aneurysms and 5±0.5 years of follow-up MRA (totaling 1332 follow-up patient-years), additional aneurysms were classified as unchanged, grown, de novo, or incomparable with previous imaging. We calculated 5-year cumulative incidence of de novo aneurysm formation and growth of untreated aneurysms. We searched PubMed and EMBASE databases for studies assessing aneurysm development, and growth. RESULTS: In 50 of 276 patients (18%), 75 additional aneurysms were present at follow-up MRA. Of these 75, 2 were de novo (both 3 mm), 58 were unchanged, 5 had grown from 1 to 3 mm (7.9% of 63 known additional aneurysms; 95% CI, 1.3%-14.6%), and 10 were incomparable. Five-year cumulative incidence for a de novo aneurysm developing was 0.75%. Four additional aneurysms in 3 patients were treated. Ten previous studies reported annual incidences of growth of additional aneurysms ranging from 1.51% to 22.7%, and 5 studies reported annual incidences of de novo aneurysm formation ranging from 0.3 to 1.8%. CONCLUSIONS: MRA screening of patients with coiled aneurysms within the first 5 years after treatment has a low rate of de novo aneurysm development and growth of additional aneurysms, and an even lower treatment rate.

Coiling of intracranial aneurysms: a systematic review on initial occlusion and reopening and retreatment rates.

BACKGROUND AND PURPOSE: The proportion of incompletely occluded aneurysms after coiling varies widely between studies. To assess overall outcome of coiling, we systematically reviewed the literature to determine initial occlusion, reopening, and retreatment rates of coiled aneurysms according to predefined criteria and subgroups. METHODS: We searched PubMed and EMBASE (January 1999 to September 2008) for studies of >50 coiled aneurysms. Two reviewers independently extracted data. We grouped studies reporting on only ruptured aneurysms, posterior circulation aneurysms, and studies with large proportions of aneurysms >10 mm to assess possible determinants for incomplete occlusion, reopening, and retreatment. RESULTS: Forty-six studies totalling 8161 coiled aneurysms met inclusion criteria. Immediately after coiling, 91.2% (95% CI, 90.6% to 91.9%) of the aneurysms were adequately occluded. Aneurysm reopening occurred in 20.8% (95% CI, 19.8% to 21.9%) and retreatment was performed in 10.3% (95% CI, 9.5% to 11.0%). Reopening rate was lower in studies reporting on ruptured aneurysms only compared with all studies (11.4% versus 20.8%; relative risk, 0.55; 95% CI, 0.47 to 0.64) and higher in studies focusing on posterior circulation aneurysms compared with studies with >85% anterior circulation aneurysms (22.5% versus 15.5%; relative risk, 1.5; 95% CI,1.2 to 1.7). Regression analysis showed higher retreatment rates with increasing proportion of aneurysms >10 mm (beta=0.252; 95% CI, 0.073 to 0.432). We could not find a relation between reopening and type of coils used. CONCLUSIONS: At follow-up, one fifth of all coiled intracranial aneurysms shows reopening of which half is retreated. Possible risk factors for aneurysm reopening are location in the posterior circulation and size >10 mm. To confirm our findings, a meta-analysis on individual well-reported patient data is desirable.

Iatrogenic lumbar pseudoaneurysm causing dural sac compression after spine surgery.

A 69-year-old man presented 3 months after lumbar spine surgery with progressive paraparesis and bladder and sphincter dysfunction caused by a lumbar artery pseudoaneurysm compressing the dural sac. After embolization with glue, the thrombosed pseudoaneurysm substantially decreased in size and the patient's neurological symptoms improved.

Long-term recurrent subarachnoid hemorrhage after adequate coiling versus clipping of ruptured intracranial aneurysms.

BACKGROUND AND PURPOSE: Coiling is increasingly used as treatment for intracranial aneurysms. Despite its favorable short-term outcome, concerns exist about long-term reopening and inherent risk of recurrent subarachnoid hemorrhage (SAH). We hypothesized a higher risk for recurrent SAH after adequate coiling compared with clipping. METHODS: Patients with ruptured intracranial aneurysms coiled between 1994 and 2002 with adequate (>90%) aneurysm occlusion at 6-month follow-up angiograms were included. We interviewed these patients about new episodes of SAH. By survival analysis, we assessed the cumulative incidence of recurrent SAH after coiling and compared it with the incidence of recurrent SAH in a cohort of 748 patients with clipped aneurysms by calculating age and sex-adjusted hazard ratios. RESULTS: Of 283 coiled patients with a total follow-up of 1778 patient-years (mean, 6.3 years), one patient had a recurrent SAH (0.4%) and 2 patients had a possible recurrent SAH. For recurrent SAH within the first 8 years after treatment, the cumulative incidence was 0.4% (95% CI, -0.4 to 1.2) after coiling versus 2.6% (95% CI, 1.2 to 4.0) after clipping (hazard ratio, 0.2; 95% CI, 0.03 to 1.6). For possible and confirmed recurrent SAH combined, the cumulative incidence was 0.7% (95% CI, 0.3 to 1.7) after coiling versus 3.0% (95% CI, 1.3 to 4.6) after clipping (hazard ratio, 0.7; 95% CI, 0.2 to 2.3). CONCLUSIONS: Patients with adequately occluded aneurysms by coiling at short-term follow-up are at low risk for recurrent SAH in the long term. Within the first 8 years after treatment, the risk of recurrent SAH is not higher after adequate coiling than after clipping.