Endovascular management of spinal dural arteriovenous fistulas in 78 patients.

INTRODUCTION: The purpose of this study was the evaluation of the safety and efficiency of the endovascular treatment of spinal dural arteriovenous fistulas (SDAVFs). METHODS: Between May 1992 and August 2012, 78 patients (59 men) with an angiographically proven SDAVF with pial venous drainage were treated by endovascular embolization (n = 61) and/or surgery (n = 31) at three German hospitals by a single team of physicians and according to a uniform therapeutic concept. RESULTS: Endovascular treatment resulted in a complete occlusion of the fistula in 47 cases (77 %). After failed embolization with residual shunt, 14 DAVFs were surgically cured (23 % failure rate). We had one permanent and two minor complications after endovascular therapy. Within a postoperative period of 2 weeks, 73.6 % of patients improved in gait disability, 51.1 % in micturition function, and 70.5 % in paresthesia of the lower extremities. Long-term follow-up data showed further improvement of clinical symptoms confirmed by normalization or resolution of spinal changes on MRI. CONCLUSIONS: An interdisciplinary approach to the management of SDAVFs is mandatory. Patients without a common origin of arteries supplying the spinal cord and the dural fistula, and without a stenosis or occlusion of the concerning segmental artery are potential candidates for endovascular treatment (diluted n-butyl-2-cyanoacrylate). Only occlusion of the "nidus" and the proximal segment of the draining vein can lead to clinical improvement.

Endovascular coil occlusion of intracranial aneurysms assisted by a novel self-expandable nitinol microstent (neuroform).

SUMMARY: Endovascular treatment of wide neck intracranial aneurysms is technically difficult and leads to less favorable treatment results and long term outcome. We participated in a multicenter prospective study to evaluate the safety and performance of a new self-expandable nitinol micro stent (Neuroform) in stent assisted coil occlusion of wide neck intracranial aneurysms. Eighteen patients were enrolled in the study in a single center. The anatomy of the target aneurysm and the parent vessel, technical details of the procedure, device functionality, anatomic and clinical results were evaluated. All enrolled aneurysms were either wide necked or showed an unfavorable neck-to-fundus ratio. In 16 out of 18 patients the Neuroform device allowed stent assisted coil occlusion of the aneurysm. The occlusion rate was 95% in eight patients and 100% in eight patients. The two failures were both due to anatomic reasons. Flexibility of the stent, behavior during deployment and subsequent ability to retain coils within the aneurysmal sac were considered as good as or better than the properties of previous balloon expandable stents. No device-related adverse events were encountered. Procedure-related clinical complications occurred in seven patients but caused no severe permanent neurological deficit. The Neuroform neurovascular stenting system is a safe and effective adjunct for the stent-assisted coil occlusion of wide necked intracranial aneurysms. The major advantages of this device are its self-expanding property and very high flexibility which allows safe navigation, easy sizing, as well as accurate positioning of the stent while providing sufficient bridging of the aneurysm neck for subsequent coil placement.

Cure of a direct carotid cavernous fistula by endovascular stent deployment.

A 53-year-old woman underwent surgical thrombendarterectomy for treatment of artherosclerotic stenoses of her left internal carotid artery (ICA). A Fogarty catheter was used during this operation. The postoperative course was complicated by the development of a sixth cranial nerve palsy, protrusio, chemosis and ciliar injection of both eyes. Digital subtraction angiography showed a direct fistula between the cavernous segment of the left ICA and the cavernous sinus, with early and retrograde opacification of both superior ophthalmic veins. Endovascular occlusion of the fistula was achieved with preservation of the ICA by stent deployment over the rupture site of the ICA, as two detachable balloons could not obliterate the fistula while preserving the ICA patent. Follow-up angiography 7 months after the endovascular treatment confirmed persisting occlusion of the fistula with a patent ICA. Highly flexible porous coronary stents can easily be introduced into tortuous vessels, including the distal ICA. The haemodynamic effects achieved by stent deployment together with two balloons detached in the cavernous sinus may be sufficient to interrupt a direct carotid cavernous fistula.

Haemangiopericytoma of the nasal cavity.

Haemangiopericytomas (HPC) are rare vascular tumours originating from a pericytes, a term coined by Zimmermann to refer to the main location of this cell line in the pericapillary connective tissue. HPC may arise in any part of the body. We report a 29-year-old man with a histologically proven nasal haemangiopericytoma-like tumour. The lesion was embolised through the ophthalmic artery before it was removed surgically. The main symptoms of nasal HPC are epistaxis and obstruction of the nose. Malignant and benign clinical courses have been described. Local recurrence and metastases may be observed years after initial diagnosis.

Intracranial vertebrobasilar stenosis: angioplasty and follow-up.

BACKGROUND AND PURPOSE: When medication fails to improve symptoms of atherosclerotic stenosis of the intracranial vertebral and basilar arteries, percutaneous transluminal angioplasty (PTA) is considered. However, because investigators disagree on the usefulness of this procedure, we conducted a retrospective study to evaluate the indications, efficacy, and safety of PTA. METHODS: Twenty patients underwent PTA of the vertebral (n = 14) or basilar (n = 6) artery, 18 for neurologic signs and symptoms of arterial stenosis that recurred or progressed despite pharmacotherapy and two prophylactically. Neurologic examinations were performed before and after the procedure and arterial patency was evaluated at follow-up by digital subtraction angiography and/or MR angiography. Imaging follow-up was available for 14 (70%) of the 20 patients, neurologic follow-up for 15 (75%). RESULTS: The stenosis was successfully dilated in all patients, and on follow-up neuroradiologic examinations, vessel patency could be seen in 12 (86%) of 14 patients. Only one (7%) of 15 patients who returned for a follow-up neurologic examination had new symptoms (caused by occlusion of the vertebral artery 4 months after the procedure). One patient had a reversible neurologic deficit and one had hemiparesis after PTA. No patient died as a result of PTA. CONCLUSION: In our study, PTA of intracranial vertebrobasilar arteries was associated with a low mortality and morbidity rate and with a high degree of patency. This technique may therefore be regarded as an effective means of improving the patency of stenotic arteries. In selective cases, it might be considered for use prophylactically.

Long-term outcome after local intra-arterial fibrinolysis of basilar artery thrombosis.

Thrombolytic therapy of acute basilar artery (BA) thrombosis has been shown to reduce mortality and avoid a fatal outcome. Objective of this study was to investigate the long-term clinical outcome following intra-arterial fibrinolysis of occlusions of the BA. We retrospectively analyzed the clinical records and neuroradiologic results of 20 consecutive patients who had intra-arterial fibrinolysis of acute occlusions of the BA between 1982 and 1990. All patients were followed neurologically for a period of up to 12 years, including assessment of the Barthel index (BI) and brain CT or MRI studies. At the time of treatment, 6 patients were somnolent and 14 comatose, and tetraparesis was present in 15. The time between the onset of symptoms and treatment ranged from 1 to 48 h. The mortality rate was 35% (7/20 patients). Functional outcome was excellent in 9, 78%, of 13 survivors (BI <85). During the cumulative follow-up period (125 patient years) there was 1 death from myocardial infarction and 1 death from pneumonia. Vascular events during follow-up were myocardial infarction (n = 3) and a single cerebral transient ischemic attack. Despite the fact that our series was biased towards patients with severe symptoms, 65% (13/20) survived, and 78% of the survivors reached independence in daily life. These results provide evidence that local fibrinolysis of BA occlusion reduces mortality, and the long-term prognosis of the survivors is better than previously thought. None of our patients had a further stroke during the follow-up period, which indicates that acute BA occlusion is not a strong indicator for advanced arteriosclerotic disease.

[Pseudoaneurysm of the extracranial internal carotid artery. Treatment by stent and coil implantation]. / Pseudoaneurysmen der extrakraniellen A. carotis interna. Behandlung durch Stent- und Coil-Implantation.

Pseudoaneurysms of the extracranial internal carotid artery (ICA) can be caused by external injury or may be due to spontaneous dissection. Pseudoaneurysms bear an increased risk of arterio-arterial embolism. Treatment of pseudoaneurysms is influenced by the location and the type of injury, associated injuries, collaterals to the ipsilateral hemisphere, neurological signs and symptoms, growth of the lesion and patient age. Potential treatment regimen include conservative and medical approaches with anticoagulation and antiplatelet therapy, extra-intracranial bypass, resection of the pseudoaneurysm with vessel reconstruction, ligation or endovascular balloon occlusion of the ICA. Pseudoaneurysms of the ICA adjacent to the skull base require a major surgical procedure. If there are contra-indications for vessel occlusion conservative or medical treatment used to be the only therapeutic alternatives. We report the treatment of two patients with extracranial ICA pseudoaneurysms after blunt injury with stent placement (in one case combined with coil embolization) as a further treatment option.

Endovascular therapy of brain AVMs prior to radiosurgery.

The purposes of this study were to determine the safety and efficacy of embolization of brain AVMs prior to radiosurgery and to evaluate the total obliteration rate achieved. The brain AVMs of 64 patients were subselectively embolized mainly with NBCA, platinum microcoils and/or PVA. The aim of embolization was the reduction of the target volume and/or the elimination of vascular structures bearing an increased risk of hemorrhage. Presenting symptoms were intracranial hemorrhage in 33 patients, a seizure disorder in 21 patients, and headache in 6 patients. Four AVMs had been detected as an incidental finding. The initial AVM volume was in the range of 0.5 to 84 cc (mean 17 cc). Grading of the AVMs according to the Spetzler-Martin scale showed the following distribution: grade I, 3x; II, 13x; III, 11x; IV, 17x; V, 4x; VI, 16x. A total of 300 endovascular procedures including 47 subselective catheterizations without and 253 with embolization were performed. A size reduction of the AVMs between 10% and 95% (mean 63%, median 70%) was achieved. Neurological symptoms due to treatment complications were transient in 12 patients, of minor clinical significance but permanent in 4 patients. Following radiosurgery, one patient died due to recurrent intracerebral hemorrhage. Three patients are doing well but refused final follow-up angiography. A total of 30 patients is currently within the latency interval after radiosurgery. Radiosurgery failed to obliterate the embolized AVMs in 16 patients. Angiography confirmed complete nidus obliteration in 14 patients. The endovascular treatment of brain AVMs prior to radiosurgery proved safe and effective and may be considered in either high grade or incidental AVMs. AVM obliteration after embolization and radiosurgery is less frequently achieved than after stereotactic irradiation of primarily small AVMs.

Percutaneous transluminal angioplasty of intracranial artery stenosis: clinical results in 24 patients.

Circumscribed stenotic lesions of the intracranial arteries can cause cerebral ischemia by hemodynamic and/or thromboembolic mechanisms. Anticoagulation therapy, antiplatelet therapy, and bypass surgery are treatment strategies that have no direct impact on the underlying lesion. This study summarizes the experience of a single institution at which percutaneous transluminal angioplasty (PTA) of intracranial atherosclerotic stenoses was performed. The authors performed a retrospective analysis of 24 consecutive patients. Their medical histories (cardiovascular risk factors, current clinical signs and symptoms and their duration, previous stroke[s], and medical treatment) were evaluated together with findings from previous imaging studies. The site and degree of the stenoses to be treated (target lesion) were identified with the use of ultrasound and angiography studies. Additional vascular stenoses were noted. Percutaneous transluminal angioplasty was performed using single-lumen balloon microcatheters with appropriate diameters. The results of PTA were correlated with angiographic and ultrasound findings and the clinical outcome. Significant cardiovascular risk factors and clinical signs and symptoms related to the target lesion that persisted despite medical treatment were identified in all patients except one. The duration of symptoms varied from several days to 8 months. Previous stroke had occurred in four patients. The degree of stenosis was classified as "high grade" in 10 patients and as "subtotal" in 14. The target lesion (stenosis) was located in the anterior circulation in eight patients (four in the internal carotid and four in the middle cerebral arteries). Stenoses of posterior circulation vessels were treated in 16 patients (nine vertebral, six basilar, and one posterior cerebral arteries). Recanalization was rated "complete" in 15 patients and sufficient in six patients. In three patients residual stenosis remained. Complications were encountered in seven patients: two asymptomatic dissections, one transient vessel occlusion, one vessel occlusion with subsequent stroke, and three ischemic lesions likely due to thromboembolism, two of which caused only transient neurological symptoms. Percutaneous balloon dilation proved effective in the treatment of intracranial atherosclerotic stenosis. There are, however, potential complications and experience with this procedure is only limited. Long-term results need to be determined. The authors conclude from their preliminary results that PTA may be an alternative to bypass surgery and conservative management and may be considered for patients in whom ischemic neurological symptoms persist despite medical treatment.

[Treatment of acute stroke on the stroke unit. Initial experiences with an acute stroke unit in Germany]. / Behandlung des akuten Schlaganfalls auf der Stroke Unit. Erste Erfahrungen mit einer akuten Stroke Unit in Deutschland.

We studied the effects of stroke unit care in an acute Neurology department on the outcome and the length of hospital stay in acute stroke patients. After an emergency evaluation on admission including CCT, ultrasound studies and ECG the patients were treated on a specialist stroke unit for an average 3.9 days. For 48 +/- 24 h monitoring of blood pressure, ECG, pO2 and transcranial Doppler sonography was instituted. Stroke unit treatment reduced the length of hospital stay from an average 15.8 days in the time period before institution of the stroke unit to 12.9 days. This effect was especially marked in patients with acute occlusion of major intracranial arteries (before stroke unit treatment: n = 33; hospital stay 22.5 days; after stroke unit treatment: n = 54; hospital stay 13.9 days). Clinical deterioration in acute ischemic stroke was related to reduction of cerebral blood flow velocities due to blood pressure changes or space occupying effects. Monitoring on the stroke unit allowed immediate treatment of systemic hypotension, cerebral edema or cardiac arrhythmias. Transcranial Doppler sonography revealed HITS in 6/55 acute stroke patients without new clinical symptoms. Monitoring on the stroke unit improved the specific care for acute stroke patients. The length of hospital stay was reduced after stroke unit care.

Sticky Platelet Syndrome: a Cause of Neurovascular Thrombosis and Thrombo-embolism.

SUMMARY: Increased platelet aggregation induced by adenosine diphosphate and epinephrine and enhanced platelet activation response to surface contact are the key features of the "sticky platelet syndrome", in which the phenotype is transmitted with an autosomal dominant pattern. Two thirds of the patients with this syndrome have a positive family history of thrombo-embolic disease, which may be triggered by stress. We have seen two patients suffering from intracranial arterial and venous sinus thrombosis due to sticky platelet syndrome. Hyperaggregability of the platelets after stimulation with adenosine diphosphate and epinephrine was found in both. Case 1: A 43 year old man with a superior sagittal and right transverse venous sinus thrombosis developed subdural hygromas and a venous infarct of the parietal lobe. After burr hole evacuation of the hygromas, aspirin and phenoprocumone were prescribed. The patient made a good neurological recovery. Case 2: A 52 year old woman experienced spontaneous occlusion of a right MCA branch. The work-up revealed bilateral MCA and a basilar tip aneurysm. During the attempt to treat the basilar tip aneurysm by endovascular means, a thrombus formed within the left vertebral artery and was dislodged to both posterior cerebral arteries (PCAs). Local intra-arterial fibrinolysis yielded good recanalization of both PCAs. No new neurological deficit occurred. Continuous prophylaxis with aspirin was started. In sticky platelet syndrome stress and adrenaline release can trigger the thrombosis of intracranial arterial or venous vessels in otherwise healthy subjects. This is a potential cause of thromboembolic complications during endovascular procedures. Low-dose aspirin normalizes platelet hyperaggregability.

Sumatriptan: vasoactive effect on human dural vessels, demonstrated by subselective angiography.

Sumatriptan, a selective 5-hydroxytryptamine (5HT1D)-receptor agonist, has recently been introduced in the pharmacotherapy of acute migrane attacks. The potential vasoactive effect of sumatriptan on human dural vessels in vivo, however, is still a matter of controversy. We investigated the effects of sumatriptan on dural vessels after subcutaneous or intra-arterial injection. During interventional angiography, the middle meningeal artery (MMA) of nine patients was catheterized with a microcatheter using the transfemoral route. Three MMA were entirely normal, two supplied a dural arteriovenous fistula (AVF) and four were transdural feeders to a brain arteriovenous malformation (AVM). Sumatriptan was injected either into the subcutaneous tissue of the right shoulder (6 mg, two patients) or into the catheterized MMA (2 mg, six patients). The substance caused a marked vasoconstriction of the three normal MMA, visible angiographically and confirmed by intravascular Doppler ultrasonography. Vasoconstriction was still present in the last angiogram obtained 15 min post-injection. Slightly hypertrophied feeders to dural AVF and to brain AVM showed some vasoconstriction in one and four patients, respectively. In two patients with markedly hypertrophied dural feeders to a dural AVF and to a brain AVM, respectively, rapid shunting probably prevented obvious vasoactive effects of sumatriptan. The data obtained by angiography and intravascular Doppler ultrasonography provide strong evidence that sumatriptan has a vasoconstrictive effect on normal as well as hypertrophied dural vessels.

Endovascular laser detachment of platinum alloy microcoils: principle and initial experimental experience.

The aim of the investigation was the technical realization and approval of a new method for insertion and detachment of platinum alloy microcoils and other vascular implants via standard microcatheters. Flexible lightconducting fibers, 105 microns in diameter were connected to platinum alloy microcoils. It was examined whether an insertion wire, a lightconducting fiber and a platinum alloy microcoil could be advanced through a Tracker-18 (Target) microcatheter. The detachment of the attached coil from the lightconducting fiber was investigated. Platinum alloy microcoils can be attached to available lightconducting fibers in a reliable and reproduceable manner. Together with the fiber they can be advanced via a Tracker-18 microcatheter. Only extremely tortuous vessels may increase the friction to critical values. A Ho-YAG laser source was used. This allowed the instantaneous detachment of microcoils from laser fibers. In contrast to electrolytical detachment, no foreign substances are released to the blood stream. The detachment does not require waiting time and does not activate thrombus formation. Due to specific technical features, injuries of the vessel wall are avoided. After further miniaturization and adaption of the lightconducting fibers to the required characteristics, laster detachment may have the potential to replace current methods such as electrolytical and mechanical coil detachment.

[Cerebral arteriovenous malformations. Diagnosis, clinical aspects and therapy]. / Zerebrale arteriovenöse Malformationen (AVM). Diagnostik, Klinik und Therapie.

An overview of cerebral arteriovenous malformations is presented. These congenital lesions are classified according to volume, number of feeding arteries, type of venous drainage, and localization. Clinical manifestations are intracerebral or subarachnoidal hemorrhages, or symptomatic epileptic seizures. Most patients with AVM exhibit their first symptoms before the age of 40. Migraine-like headaches and "steal" phenomena are rarely the main symptoms. Diagnosis is obtained by means of MRI and selective angiography; the treatment of choice is a combination of interventional neuroradiological therapy, radiosurgery and/or microsurgery which is adjusted to the individual case.

Local thrombolytic therapy for thromboembolic occlusion of the middle cerebral artery.

We report on 10 patients with thromboembolic occlusion of the middle cerebral artery (MCA) who underwent local thrombolytic therapy. Six patients developed a MCA occlusion during long-standing interventional neuroradiological procedures, while four had a proven or suspected cardio-embolic stroke. Streptokinase or urokinase was applied by a microcatheter placed into the thrombus within six hours of clinical onset. Complete or partial revascularization was achieved in all patients. Recovery was complete in seven and partial in three of the patients. In two patients, minor haemorrhagic transformation of the infarct occurred, which did not lead to neurological deterioration. It is concluded that in a selected group of patients with MCA occlusion, local thrombolytic therapy represents a safe and effective therapy.

[Neurologic and psychiatric disorders in vinyl chloride disease]. / Neurologische und psychiatrische Störungen bei der Vinylchlorid-Krankheit.

A literature review and an own case observation of neurological and psychiatrical disturbances in vinyl chloride disease are presented. In acute vinyl chloride intoxication, patients complain of vertigo, nausea and headache. At higher concentrations, vinyl chloride exerts a narcotic effect. In patients with chronic occupational exposure, neurological disturbances include sensory-motor polyneuropathy, trigeminal sensory neuropathy, slight pyramidal signs and cerebellar and extrapyramidal motor disorders. Psychiatric disturbances present as neurasthenic or depressive syndromes. Sleep disorders and disorders of sexual functions are frequently encountered. Pathological EEG alterations can be found in a high proportion of patients. The long term course and prognosis of the neurological and psychiatrical disorders in vinyl chloride disease are obscure. In an own case, a slight sensory polyneuropathy, bilateral hyposmia, a marked neurasthenic syndrome, typical EEG changes and computed tomography signs of cerebral atrophy were found in a 56-years-old patient as late as 16 years after the exposure to vinyl chloride.

[Clinical aspects and treatment of spontaneous carotid artery-cavernous sinus fistula]. / Klinik und Therapie spontaner Carotis-Sinus cavernosus-Fisteln.

21 patients, who fulfilled the clinical and angiographic criteria of a spontaneous carotid cavernous fistula (CCF), were studied at the Alfried Krupp Hospital, Essen, Germany, between 1980 and 1988. Of these patients, 4 had direct shunts between the internal carotid artery and the cavernous sinus and 17 patients had unilateral or bilateral dural shunts between meningeal branches of the internal and/or external carotid artery and the cavernous sinus. The most common initial symptoms were eye redness, bruit and headache. 6 of 12 patients with double vision had mechanical disorders of eye movement. A rapid irreversible loss of vision occurred in 2 patients. In 9 of 21 patients either progressive visual deterioration, proptosis or severe orbital pain necessitated prompt institution of treatment. All direct fistulas could be occluded by the use of the detachable balloon technique. 5 patients with dural CCF were successfully treated with particle embolization of the external carotid artery blood supply. In dural CCF not requiring emergent treatment, combined carotid artery and jugular vein compression was preferred and resulted in complete cure or sufficient improvement in all but one patient. We recommend this method as the first stage of treatment in dural CCF with uncomplicated course.

Monitoring of hemispheric or brainstem functions with neurophysiologic methods during interventional neuroradiology.

Interventional neuroradiology, sometimes requiring full anesthesia, is now performed in high-risk patients. The neurologic state of an anesthetized patient cannot always be sufficiently evaluated during the neuroradiologic examination. In such cases neurophysiological methods provide information about some aspects of the patient's cerebral condition. Three useful neurophysiological methods for monitoring hemispheric or brainstem functions during the neuroradiologic procedure are on-line or Fourier-transformed electroencephalographic (EEG) analysis; the monitoring of somatosensory-evoked potentials; and the monitoring of brainstem acoustic-evoked potentials. All methods can be done in the operating room with small, mobile equipment.

Evoked potential monitoring during acute occlusion of the basilar artery and selective local thrombolytic therapy.

Neurophysiological examinations of brainstem functions before, during and after selective interventional neuroradiology i.e. selective intraarterial thrombolytic therapy of an acute occlusion of the basilar artery are reported. The success of the therapy was demonstrated by the reappearance of normal somatosensory potentials and of the blink reflex immediately after the thrombolysis. The BAEPs were continuously recorded during the thrombolysis. Normalization of the latencies and of the interpeak latencies at a very early stage of the therapy indicated the improvement of brainstem functions.