Packing Density Necessary to Reach a High Complete Occlusion Rate in Circumferential Unruptured Intracranial Aneurysms Treated with Stent-Assisted Coil Embolization.

BACKGROUND AND PURPOSE: This study is a homogeneous series of circumferential unruptured intracranial aneurysms with large necks treated with stent-assisted coil embolization. Our purpose was to demonstrate which value of packing density is required to produce a durable occlusion. MATERIALS AND METHODS: We retrospectively evaluated all patients with unruptured intracranial aneurysms who were treated with stent-assisted coil embolization having late angiographic control between 2004 and 2014, in a single large cerebrovascular referral center. To calculate the packing density, aneurysm volume, and coil volume, we used an on-line system. RESULTS: In 49 circumferential unruptured intracranial aneurysms treated with stent-assisted coil embolization, 38.7% (n = 19) had complete occlusion in the immediate control. Of those with incomplete occlusion, 80% (n = 24) progressed to complete occlusion in the late angiographic follow-up. At late angiographic control, 87.7% (n = 43) of aneurysms were completely occluded. All aneurysms with a packing density of ≥19% were completely occluded. Packing density was the only statistically significant predictor of complete occlusion. None of the aneurysms with complete occlusion at immediate control or at late angiographic control had recurrence. CONCLUSIONS: In circumferential aneurysms treated with stent-assisted coil embolization, packing density is the main predictor of complete occlusion. In this type of aneurysm, a packing density of ≥19% was enough to reach complete occlusion; knowing this is important to avoid higher packing densities that have more risk.

Traumatic carotid-cavernous fistula: endovascular treatment with onyx and coils.

SUMMARY: Carotid cavernous fistulas (CCF) are mostly post-traumatic and are due to a tear of the internal carotid artery (ICA) inside the cavernous sinus. The improvement of endovascular techniques with venous approach enables the preservation of internal carotid artery patency in most cases when detachable balloons fail in order to reconstruct and repair the tear in the ICA. The case described here has a giant aneurysmatic dilatation of the cavernous sinus and inferior petrosal sinus. We associate coils and Onyx to occlude the lesion preserving and repairing the large hole of the fistula.

Internal carotid artery pseudoaneurysm after tonsillectomy treated by endovascular approach. A case report.

SUMMARY: Surgery on the head and neck region may be complicated by vascular trauma, caused by direct injury on the vascular wall. Lesions of the arteries are more dangerous than the venous one. The traumatic lesion may cause laceration of the artery wall, spasm, dissection, arteriovenous fistula, occlusion or pseudoaneurysm. We present a case of a child with a giant ICA pseudoaneurysm after tonsillectomy, manifested by pulsing mass and respiratory distress, which was treated by endovascular approach, occluding the lesion and the proximal artery with Histoacryl. We reinforce that the endovascular approach is the better way to treat most of the traumatic vascular lesions.

Spontaneous Resolution of a Ruptured Dissecting PICA Aneurysm. Report of Two Cases.

SUMMARY: Spontaneous dissecting aneurysms (SDAs) seldom involve the intradural vertebral artery VA, the posterior cerebral, basilar or postero inferior cerebellar arteries (PICAs), where they produce subarachnoid haemorrhage and/or ischaemia. These lesions may develop spontaneously or occasionally after minor trauma and occur in young people in whom there is no underlying abnormality to explain the appearance of the dissection in most cases. Spontaneous dissecting aneurysm of the PICA is rare and its natural history is not well understood. Surgery or endovascular treatment for PICA dissection remain controversial because they suggest vessel occlusion. Only in a few cases is the bypass between the occipital artery and the PICA possible with trapping of the dissected segment. Reinforcement of the arterial wall does not seem efficient and the surgical approach per se with sole exclusion of the aneurysm may be disastrous. We describe two cases of SDA of PICA that presented with subarachnoid haemorrhage (SAH), treated conservatively, with spontaneous cure of the lesions, angiographically confirmed at mid-time follow-up of five and four months. These favourable spontaneous thromboses, like 11 other similar case reported in the literature, did not show any rebleed. The possibility of a benign clinical course of this lesion exists; clinical and angiographic management of the patient before a decision for a aggressive treatment is proposed.

Sinus skeletonization: a treatment for dural arteriovenous malformations of the tentorial apex. Report of two cases.

Two cases of dural arteriovenous malformation of the tentorial apex are presented. Both were treated surgically by means of a sinus skeletonization technique. The operative technique included a combined bioccipital and median suboccipital craniotomy in which the posterior third of the superior sagittal and the straight and bilateral transverse sinuses were skeletonized by incising the falx and the tentorium along the sinuses. Endovascular embolization was used prior to the surgical approach in one case. Clinical and angiographic cure was achieved in both patients, with a follow up of 4 years in the first case and 1 year in the second one. The surgical technique is described in detail.

Treating complications of subclavian vein puncture by embolization of the internal mammary artery.

Embolization therapy is reported in 2 patients who had vascular complications following percutaneous subclavian vein catheterization. One had an arteriovenous fistula between the right internal mammary artery (IMA) and the brachiocephalic vein. The other patient presented with a pseudo-aneurysm of the IMA with life-threatening hemorrhage and a large thoracic hematoma. A detachable latex balloon was used for occlusion of the arteriovenous fistula in the first patient and a steel spring coil was used to embolize the IMA and the pseudo-aneurysm in the second patient. The lesions were successfully treated on follow-up of 30 months for the first patient and 37 months for the other.

Hemobilia: transcatheter occlusive therapy and long-term follow-up.

Eight patients with life-threatening hemobilia were treated by percutaneous transcatheter occlusive therapy. The bleeding was caused by a traumatic pseudoaneurysm of the hepatic artery in 6 cases (auto accident in 4, surgery in 1, biliary drainage in 1) and a true aneurysm of the hepatic artery in 2 (unknown etiology in 1 and mycotic in 1). Arterial catheterization was used in all cases except for one in which a direct percutaneous puncture was performed. Gelfoam alone was used as embolic material in 3 patients. In 1 patient each, the material used was gelfoam plus coils, coils alone, blood clot, n-butyl-cyanoacrylate and an occluding balloon catheter. In all cases the bleeding stopped and did not recur during the follow-up period which ranged from 9 months to 14 years. This experience indicates that transcatheter occlusive therapy is an effective method for the treatment of severe hemobilia.

Lipiodol retention within hepatic cavernous hemangioma.

Intraarterial injection of Lipiodol has been recommended to differentiate hepatocellular carcinoma from benign lesions such as cavernous hemangioma, because uptake and prolonged retention of the contrast medium is a characteristic of the malignant tumors. In two cases of cavernous hemangioma of the liver in which we injected Lipiodol, uptake and retention up to 3 months was demonstrated. We conclude that the intraarterial injection of Lipiodol may not be reliable in differentiating hepatocellular carcinoma from cavernous hemangioma of the liver.

Percutaneous transhepatic biliary drainage: alternatives in left hepatic duct obstruction.

The left-lobe subxiphoid approach has been the standard way to drain left hepatic duct occlusion. A new, right-side biliary drainage approach is described. Five patients, among 25 patients with bilateral biliary obstruction, were treated by an internal-internal drainage system. Three types of internal-internal drainage techniques are described: internal-internal luminal, type 1; internal-internal luminal, type 2; and internal-internal transductal, type 3. All 5 patients succeeded in biliary drainage. The internal-internal biliary drainage technique, performed from the right-side approach, is effective, avoids additional liver puncture and tract dilatation, and allows the combination of several biliary drainage techniques, adding greatly to the flexibility when treating intrahepatic obstruction. No complications were observed in our small series but special precaution should be taken with the transductal technique due to the possibility of bleeding.

Extrasinusal dural arteriovenous malformations. Report of three cases.

Of 60 cases of dural arteriovenous malformations (DAVM) explored and treated in the Vascular Neuroradiology Unit of the Hospital of Bicêtre between 1980 and 1986, 3 presented in an extrasinusal location: intraorbital, middle cerebral fossa and the region of the superior orbital fissure. We have not found any prior description of DAVMs in these regions in the literature. The classic concept that DAVMs arise in direct relationship with the dural sinuses is limited. We believe that these lesions may also develop in relationship with the venous drainage system of the sinuses and the venous drainage of the peripheral nervous system. We note that the superior ophthalmic vein which drains DAVMs of the orbit and the olfactory vein which drains DAVMs of the anterior cranial fossa and other veins that accompany the cranial nerves through the skull base have the characteristics of emissary veins. It may be that DAVMs can develop wherever veins follow a transosseous trajectory.

Chronic portosystemic encephalopathy: embolization of portosystemic shunts.

Operative ligation of portosystemic shunts is effective in controlling chronic portosystemic encephalopathy (CPSE) but is associated with significant mortality. Review of the records of five patients with CPSE treated with radiologic occlusion procedures showed that these are suitable alternatives to surgery. Three patients had alcoholic cirrhosis, one had hepatic fibrosis from schistosomiasis, and one had post-necrotic cirrhosis. All had CPSE with progressive, severe cerebral impairment refractory to clinical treatment. Four patients had a spontaneous splenorenal shunt, and one had a surgically created mesocaval shunt (MCS). Partial splenic embolization was performed in two patients, direct shunt embolization was performed via percutaneous transhepatic portography in two other patients, and an MCS embolization was performed in one patient through the inferior vena cava. In four patients embolization controlled the CPSE. In the remaining patient it could not be evaluated because of his premature death from intraabdominal bleeding, a late complication of the procedure. Interventional radiologic procedures are effective in the control of CPSE in selected patients.

Carotid-cavernous fistulas: embolization through the superior ophthalmic vein approach.

Five patients aged 17-33 years with traumatic carotid-cavernous fistulas (CCFs) were treated by antegrade embolization through a superior ophthalmic vein approach, using cutdown technique on the upper eyelid. CCFs had recurred after prior treatment by multivessel ligation in three patients. Embolization through the ophthalmic vein resulted in long-term cure in three patients. The remaining patients were successfully treated by embolization through the arterial approach after failure of the ophthalmic vein technique. This is a new and rewarding technique to treat patients with CCFs, especially when there has been carotid ligation, provided the ophthalmic vein is thickened and arterialized.