Headache response after CT-guided fibrin glue occlusion of CSF-venous fistulas.

OBJECTIVE: To assess headache response and patient perception of improvement after computed tomography (CT)-guided fibrin glue occlusion of cerebrospinal fluid-venous fistulas (CVFs) in a large sample size and with a long clinical follow-up. BACKGROUND: CVFs are an increasingly identified type of spinal leak in patients with spontaneous intracranial hypotension (SIH), and CT-guided fibrin glue occlusion has been introduced as a treatment option in a prior small series. METHODS: Retrospective case series review of medical records from a single institution was performed for all patients with CVFs that were treated with CT-guided fibrin glue occlusion between August 2018 and April 2022 in an outpatient or inpatient setting. Pre- and posttreatment Headache Impact Tests (HIT-6) were administered to patients, and a change in scores was evaluated. In some patients, pretreatment HIT-6 tests were not obtained prior to the fibrin glue procedure, and the patient was asked to fill out the pretreatment test based on personal recall of their symptoms prior to treatment. Patients completed a Patient Global Impression of Change (PGIC) scale after treatment. Pre- and posttreatment brain imaging was compared using Bern SIH scores. RESULTS: Thirty-five patients (19 females, 16 males; mean age 60 years) with CVFs treated with CT-guided fibrin glue occlusion met the inclusion criteria. Mean pretreatment and posttreatment HIT-6 scores were 64.7 ± 10.2 and 43.4 ± 9.9 (p < 0.001), respectively. The posttreatment HIT-6 questionnaires were completed on average 10.3 months after treatment, and 20 patients filled out the pretreatment HIT-6 form after their treatment. The mean PGIC score was 6.1 ± 1.3. Mean pretreatment and posttreatment Bern SIH scores were 5.9 ± 2.5 and 1.5 ± 1.5 (p < 0.001), respectively. CONCLUSIONS: We report a large series of patients who underwent CT-guided fibrin glue occlusion of CVFs. We showed that headache scores decreased after treatment, and the majority of patients had high PGIC scores. Posttreatment brain MRIs also showed improved Bern SIH scores.

Management of a ruptured and unruptured pial arteriovenous fistula during and after pregnancy.

We present the case of a 16-week pregnant 19-year-old female who presented with hemiplegia due to a ruptured right frontal pial arteriovenous fistula (PAVF). She was also found to have an unruptured right temporal PAVF and a family history of brain hemorrhage. The patient was managed with Onyx embolization of the ruptured fistula, followed by surgical excision and hematoma evacuation. At 35 weeks gestation, she underwent cesarean section to prevent rupture of the second fistula in the setting of peripartum hypervolemia and increasing headaches. The child was delivered healthy. Subsequently, the right temporal AV fistula, supplied by a middle cerebral artery and posterior cerebral artery branch, underwent staged embolization resulting in complete occlusion. The patient recovered to a modified Rankin score of two, with a left foot drop as only persistent significant motor deficit.

Ethylene vinyl alcohol copolymer to treat an intracranial arteriovenous malformation in a dog.

A 6-year-old neutered male German shepherd dog was evaluated for obtundation, blindness, and bilateral exophthalmos. A magnetic resonance imaging scan of the brain was performed and identified an arteriovenous malformation (AVM) with several feeding arterial branches, and venous drainage through the cavernous sinus. Venous vessels rostral to the AVM were severely distended and extended into the retrobulbar spaces. Liquid embolization by injection of ethylene vinyl alcohol copolymer was performed from access points in the maxillary arteries and internal carotid arteries. No intraprocedural complications were encountered, and the dog was discharged the next day. Bilateral enucleation eventually was performed because of exposure keratopathy. At 31 months post-embolization, owners reported that the dog was doing very well clinically with high activity level and normal appetite, and the dog also appeared to be pain free. Although intracranial AVMs are very rare in companion animals, successful treatment using liquid embolization is possible and should be considered.

Mechanical Thrombectomy for Sequential Bilateral Middle Cerebral Artery Occlusions in a Patient With Recurrent Cryptogenic Strokes: A Case Report.

Recurrent sequential mechanical thrombectomy for cryptogenic large vessel occlusion (LVO) can lead to excellent clinical outcome. A 68-year-old right-handed male presented with an acute proximal right middle cerebral artery (MCA) ischemic syndrome and underwent successful revascularization by mechanical thrombectomy with normal functional recovery. He was treated with dual antiplatelet therapy for 2 months following discharge, however later discontinued clopidogrel due to side effects. He then developed a recurrent, contralateral MCA occlusion 16 months later and once again received emergent endovascular reperfusion therapy with excellent neurological outcome. He has remained on off-label empiric oral anticoagulation since and has not had recurrent stroke nor evidence of cerebral ischemia. Favorable clinical outcomes can be achieved in patients despite recurrent LVO who underwent emergent mechanical thrombectomy. Optimal antithrombotic secondary stroke prevention strategies following embolic stroke of unknown source remains uncertain as recent evidence does not support rivaroxaban or dabigatran over aspirin. The benefit of apixaban over aspirin for the prevention of recurrent cerebral ischemia is under current investigation.

Ruptured Fisher grade 3 blister aneurysms have a higher incidence of delayed cerebral ischemia than ruptured Fisher grade 3 saccular aneurysms.

BACKGROUND: Blister aneurysms are a rare subclass of aneurysms, which remain challenging to treat both with open cerebrovascular and endovascular techniques, and clinicians continue to see poor outcomes in some cases despite improvements in technology. Based on our clinical observations, we hypothesized that patients with a Fisher grade 3 subarachnoid hemorrhage (SAH) from a ruptured anterior circulation blister aneurysm are significantly more likely to develop poor outcome due to delayed cerebral ischemia than patients with a Fisher grade 3 SAH from a ruptured anterior circulation saccular aneurysm. METHODS: In this consecutive case series, we reviewed management, outcomes, and rates of delayed cerebral ischemia for all ruptured anterior circulation blister aneurysms from 2012 to 2018 at our institution and compared them to a concurrent cohort of ruptured saccular anterior circulation aneurysms. A blister aneurysm was defined as an aneurysm that arises from a nonbranching point and demonstrates hemispherical anatomy on diagnostic angiography. RESULTS: We identified 14 consecutive ruptured anterior circulation blister aneurysms. Thirteen aneurysms were treated operatively- 5 with clip remodeling and 8 with flow diversion embolization. While clip remodeling had a high intraoperative rupture rate (80%), there was only one (12.5%) intraoperative rupture with flow diversion embolization. Outcomes were worsened by delayed cerebral ischemia from vasospasm in patients with Fisher 3 hemorrhages from blister aneurysms (86%). The rate of delayed cerebral ischemia from vasospasm was significantly higher for ruptured blister aneurysms than for a concurrent cohort of ruptured saccular aneurysms (8.6%, P = 0.0001). CONCLUSION: Ruptured Fisher grade 3 anterior circulation blister aneurysms have a significantly higher incidence of delayed cerebral ischemia from vasospasm compared to saccular aneurysms, regardless of the treatment modality.

Three-dimensional aneurysm volume measurements show no correlation between coil packing density and recurrence.

OBJECTIVE: Endovascular treatment is the mainstay therapy for brain aneurysms. About 15% of patients need re-treatment within six months due to early recanalization. In this study, we investigate risk factors associated with treatment failure. METHODS: This retrospective cohort study includes endovascularly treated aneurysm cases between July 2012 and December 2015 at the University of California Davis Medical Center with pre-treatment and early post-treatment imaging. Thin cut 3D aneurysm volume rendering was used for morphologic analyses. Univariate and bivariate analyses were conducted to evaluate differences between patients and clinical factors by treatment failure. RESULTS: Of the 50 patients who met the inclusion criteria, 41 (82.0%) were female, with an average age of 61 years. Most aneurysms were on the anterior communicating artery (40%) or posterior communicating artery (22.0%), and 34 (68%) aneurysms were ruptured. Early treatment failure was observed in 14 (28.0%) of endovascularly treated patients. Raymond-Roy class (RRC) was significantly associated with treatment failure (p = 0.0052), with 10 out of the 14 cases (71.4%) with early recanalization having an RRC of 3. Coil packing density did not associate with aneurysm recanalization (p = 0.61). CONCLUSION: In our single institution series, patient characteristics, aneurysm characteristics, or coil packing density did not affect early aneurysm recanalization. RRC was the best predictor of early recanalization; however, further confirmation with additional studies are required. Although this study focused on early treatment failure, late recanalization has been shown with longer follow up. Further investigation into factors associated with late treatment failure will need further investigation. New intrasaccular devices and flow diverters will also likely play a role in reducing recurrence in the future as these treatments gain usage.

Comparison of 3D TOF MR angiographic accuracy in predicting Raymond grade of flow-diverted versus coiled intracranial aneurysms.

The accuracy of 3D time of Flight Magnetic Resonance Angiography (TOF MRA) has been studied extensively for following coiled intracranial aneurysms. It is used by many clinicians for non-invasive follow-up because of its adequate sensitivity in predicting aneurysmal recanalization compared to diagnostic cerebral angiography. The data on the accuracy of 3D TOF MRA for the Pipeline™ Embolization Device (PED) are sparse. In a retrospective chart review, we compared the accuracy of 3D TOF MRA of PED to coil embolization at our institution. 3D TOF MRA had a lower sensitivity and positive predictive value in detecting aneurysmal filling in PED-treated versus coiled aneurysms (57% versus 87% and 80% versus 100%, respectively). Analysis of discrepancies between conventional diagnostic angiography and 3D TOF MRA revealed that 3D TOF MRA was inaccurate in the setting of small residual necks and slow residual filling of the dome with fluid-fluid layers. Therefore, contrasted studies such as contrast-enhanced MRA may be preferred for non-invasively following PED-treated aneurysms to increase accuracy.

Management and outcome of spontaneous cerebral venous sinus thrombosis in a 5-year consecutive single-institution cohort.

BACKGROUND: Cerebral venous sinus thrombosis (CVST) is an uncommon form of stroke with a variable presentation, ranging from headaches, to coma and death. Although the American Stroke Association has developed guidelines for the treatment of CVST, data are sparse on the outcome after treatment with anticoagulation, thrombolysis, and thrombectomy. METHODS: In this retrospective review, we describe the 5-year UC Davis experience with spontaneous CVST. RESULTS: Forty-one patients (mean age 37.5±23.1, range 0-96 years; 29 female) were identified with CVST. The majority of cases involved the transverse sinus (75.6%), sigmoid sinus (58.5%), and superior sagittal sinus (29.3%). The most common form of treatment was anticoagulation or antiplatelet therapy (n=35), while six patients were managed by observation alone. The overall 1-year modified Rankin score (mRS) was 1.4±1.5. Male patients and patients with a poor admission mRS had a worse outcome. Outcome was unaffected by hypercoagulable state, number of dural sinuses involved, the presence of intracranial hemorrhage, or seizures. Two patients who underwent anticoagulation therapy also required endovascular thrombectomy; both patients had a 1-year mRS of ≤2. Two patients underwent direct open surgical canalization of the superior sagittal sinus with varying outcomes (mRS 2 vs mRS 6). CONCLUSIONS: In our series, the majority (92.9%) of patients with spontaneous dural sinus thrombosis had a favorable clinical outcome as defined by a mRS ≤2. Further prospective studies are needed to study the impact of anticoagulation on the clinical course of the disease.

The transclival artery: a variant persistent carotid-basilar arterial anastomosis not previously reported.

During embryological development, primitive anastomoses exist between the carotid and vertebrobasilar arteries. These anastomoses typically regress or are incorporated into the developing vasculature. Persistence beyond fetal development, however, results in vascular anomalies that alter haemodynamic flow with a predisposition for aneurysm formation. The carotid-vertebrobasilar anastomoses mirror the primitive communications and include (from most to least common) the trigeminal, hypoglossal, proatlantal and otic arteries. The hypoglossal and proatlantal variants extend through the hypoglossal canal or foramen magnum, respectively. We present a previously undescribed variant of these persistent fetal anastomoses, the 'transclival artery', which courses through its own transclival skull base canal/foramen.

Surgical and Nonsurgical Treatment of Vascular Skull Base Trauma.

Vascular trauma is associated with blunt skull base fractures and penetrating injuries. We review the contemporary management of cranial vascular trauma, including blunt and penetrating cerebrovascular injury as well as refractory epistaxis from facial trauma.

The transclival artery: a variant persistent carotid-basilar arterial anastomosis not previously reported.

During embryological development, primitive anastomoses exist between the carotid and vertebrobasilar arteries. These anastomoses typically regress or are incorporated into the developing vasculature. Persistence beyond fetal development, however, results in vascular anomalies that alter haemodynamic flow with a predisposition for aneurysm formation. The carotid-vertebrobasilar anastomoses mirror the primitive communications and include (from most to least common) the trigeminal, hypoglossal, proatlantal and otic arteries. The hypoglossal and proatlantal variants extend through the hypoglossal canal or foramen magnum, respectively. We present a previously undescribed variant of these persistent fetal anastomoses, the 'transclival artery', which courses through its own transclival skull base canal/foramen.

Resolution of third nerve palsy despite persistent aneurysmal mass effect after flow diversion embolization of posterior communicating artery aneurysms.

Posterior communicating artery (PCOM) aneurysms may cause third nerve palsies. The optimal treatment with clipping versus coiling remains controversial. Here we report on two cases of resolution of third nerve palsy after flow diversion embolization of large and giant PCOM aneurysms without adjuvant coil placement. The resolution of third nerve palsy was not preceded by significant shrinkage of the aneurysmal sac on MRI. However, one patient showed resolution of T2-weighted signal abnormalities in the midbrain and mesial temporal lobe despite a similar size of the aneurysm. Therefore, flow diversion embolization of a PCOM aneurysm may resolve oculomotor nerve palsies through decreasing arterial pulsations against the nerve or midbrain.

Contrast encephalopathy after coiling in the setting of obstructive sleep apnoea.

Obstructive sleep apnoea (OSA) is increasingly recognised as a source of perioperative morbidity and mortality. We describe a patient with severe OSA who developed transient contrast encephalopathy after elective coiling of an anterior communicating artery aneurysm. Contrast extravasation led to cerebral oedema, seizures and delirium, which eventually completely resolved. OSA is known to be associated with a proinflammatory state that leads to hypertension, impaired endothelial repair capacity and endothelial dysfunction. Further studies are needed to clarify whether OSA increases the risk of endovascular procedures.

Antegrade rheolytic thrombectomy and thrombolysis for superior sagittal sinus thrombosis using burr hole access.

Superior sagittal sinus (SSS) thrombosis has high morbidity and mortality, and urgent recanalization is critical for severe cases. Standard endovascular techniques for thrombolysis and thrombectomy use retrograde venous access, an approach that may be unsuccessful in cases with extensive firm clot burden involving the dural sinuses distal to the SSS. An anterior open transcranial approach to the SSS for catheter sheath placement to facilitate antegrade mechanical thrombectomy and thrombolysis of the SSS and more distal sinuses has not been previously described. Here we describe a case in which multiple unsuccessful attempts at retrograde endovascular access were attempted. Thus, a burr hole over the anterior SSS was performed for daily endovascular antegrade procedures using the Angiojet rheolytic catheter device and chemical thrombolysis. Near-complete recanalization of the SSS was achieved with venous outflow via dilated left transverse and left sigmoid sinuses, along with significant collateral flow in multiple cerebral veins.

Antegrade rheolytic thrombectomy and thrombolysis for superior sagittal sinus thrombosis using burr hole access.

Superior sagittal sinus (SSS) thrombosis has high morbidity and mortality, and urgent recanalization is critical for severe cases. Standard endovascular techniques for thrombolysis and thrombectomy use retrograde venous access, an approach that may be unsuccessful in cases with extensive firm clot burden involving the dural sinuses distal to the SSS. An anterior open transcranial approach to the SSS for catheter sheath placement to facilitate antegrade mechanical thrombectomy and thrombolysis of the SSS and more distal sinuses has not been previously described. Here we describe a case in which multiple unsuccessful attempts at retrograde endovascular access were attempted. Thus, a burr hole over the anterior SSS was performed for daily endovascular antegrade procedures using the Angiojet rheolytic catheter device and chemical thrombolysis. Near-complete recanalization of the SSS was achieved with venous outflow via dilated left transverse and left sigmoid sinuses, along with significant collateral flow in multiple cerebral veins.

Delayed complication after embolotherapy of a vertebral arteriovenous fistula: spinal cord ischemia.

Previous reports suggest a generally successful experience with embolotherapy of vertebral arteriovenous fistulas of the neck. However, potential complications do exist, as shown by this report documenting spinal cord ischemia secondary to compromise of a dominant spinal artery arising from the proximal aspect of the right vertebral artery.