Current management of symptomatic intracranial stenosis.

Intracranial arterial stenosis (IAS) is the cause of about 10% of all ischemic strokes in the United States, but may account for about 40% of strokes in some populations. After a stroke or transient ischemic attack due to IAS, patients face a 12% annual risk of recurrent stroke on medical therapy, with most strokes occurring in the first year. Warfarin is no better than aspirin in preventing recurrent strokes but poses a higher risk of serious bleeding and death. Groups with the highest risk of recurrent stroke are those with high-grade (≥ 70%) stenosis, those with recent symptom onset, those with symptoms precipitated by hemodynamic maneuvers, and women. Endovascular treatment of IAS is a rapidly evolving therapeutic option. Antiplatelet agents are currently recommended as the primary treatment for symptomatic IAS, with endovascular therapy reserved for appropriate high-risk cases refractory to medical therapy.

Use of a new double-lumen balloon catheter for single-catheter balloon-assisted coil embolization of intracranial aneurysms: technical note.

BACKGROUND: The prevalence of intracranial aneurysms is approximately 2% with an annual rupture rate of 0.7%. OBJECTIVE: We describe our initial feasibility experience using a new double-lumen balloon catheter for single-catheter balloon-assisted coil embolization of wide-neck intracranial aneurysms. METHODS: Two patients with large wide-neck intracranial aneurysms were referred for endovascular therapy. Endovascular treatment in the form of coil embolization alone was not feasible given the angioarchitecture of the aneurysms. Balloon-assisted coil embolization was planned. RESULTS: The patients underwent balloon-assisted coil embolization using the Ascent double-lumen balloon catheter (Micrus, San Jose, California). The balloon portion of the catheter was placed into the proximal neck of the aneurysm. The balloon was inflated and coil embolization performed through the inner lumen of the catheter. There were no procedural complications. CONCLUSION: Both aneurysms were successfully coiled by using the Ascent balloon occlusion catheter. The single-catheter balloon-assisted coil embolization technique can be performed safely and effectively with the Ascent double-lumen balloon catheter.

Onyx pulmonary artery embolization after treatment of a low-flow dural arteriovenous fistula: case report.

BACKGROUND AND IMPORTANCE: Endovascular management of dural arteriovenous fistulas (DAVFs) has become an accepted primary and often definitive therapy. We present the first documented case of Onyx pulmonary embolism after embolization of a low-flow DAVF. CLINICAL PRESENTATION: A 63-year-old man presented with subarachnoid hemorrhage secondary to a DAVF. Computed tomographic angiography, magnetic resonance imaging, and initial conventional angiogram were negative. A repeat angiogram demonstrated a DAVF, which was cured with Onyx embolization. A routine chest computed tomography after intervention revealed an asymptomatic Onyx embolization cast in a subsegmental pulmonary artery. CONCLUSION: Endovascular treatment options include transarterial embolization with microcoils, polyvinyl alcohol particles, n-butyl-2cyanoacrylate, and Onyx (ev3 Neurovascular, Irvine, California). Complications associated with the use of Onyx are low but include embolizate pulmonary embolism. Patients often remain asymptomatic, but for symptomatic patients, conservative treatment options usually result in resolution of symptoms.

Intracranial vertebrobasilar artery dissection associated with postpartum angiopathy.

Background. Cervicocephalic arterial dissection (CCAD) is rare in the postpartum period. To our knowledge this is the first reported case of postpartum angiopathy (PPA) presenting with ischemic stroke due to intracranial arterial dissection. Case. A 41-year-old woman presented with blurred vision, headache, and generalized seizures 5 days after delivering twins. She was treated with magnesium for eclampsia. MRI identified multiple posterior circulation infarcts. Angiography identified a complex dissection extending from both intradural vertebral arteries, through the basilar artery, and into both posterior cerebral arteries. Multiple segments of arterial dilatation and narrowing consistent with PPA were present. Xenon enhanced CT (Xe-CT) showed reduced regional cerebral blood flow that is improved with elevation in blood pressure. Conclusion. Intracranial vertebrobasilar dissection causing stroke is a rare complication of pregnancy. Eclampsia and PPA may play a role in its pathogenesis. Blood pressure management may be tailored using quantitative blood flow studies, such as Xe-CT.

Obstructive hydrocephalus from venous sinus thrombosis.

BACKGROUND: Cerebral venous sinus thrombosis (CVST) is a rare form of stroke. Although increased intracranial pressure is a well-described complication of CVST, hydrocephalus has rarely been reported. CASE: We present the case of a 49-year-old woman who presented with one week of headache, vomiting, and progressive neurologic deterioration leading to coma. Head CT and MRI identified extensive CVST and accompanying hydrocephalus. She was treated with systemic anticoagulation as well as mechanical and pharmacologic endovascular thrombolysis. An external ventricular drain (EVD) was not inserted given the potential bleeding risk while anticoagulated. Subsequently, she made an excellent recovery and had a normal neurologic exam at long-term follow up. CONCLUSION: Hydrocephalus is a rare complication of cerebral venous sinus thrombosis. Treatment of hydrocephalus with an EVD may not be necessary if interventions are undertaken to urgently recanalize thrombosed venous sinuses.

Endovascular and surgical treatment of ruptured cerebral aneurysms in pediatric patients.

OBJECTIVE: Pediatric cerebral aneurysms are rare. There are very few recent studies that focus on the multidisciplinary treatment of ruptured aneurysms. We reviewed our pediatric endovascular and surgical experience with ruptured cerebral aneurysms. METHODS: Pediatric patients aged 16 years and younger who were admitted with a diagnosis of aneurysmal subarachnoid hemorrhage and treated at the Children's Hospital of Philadelphia were included in this analysis. RESULTS: Twelve patients with 13 aneurysms (4 male patients and 8 female patients; age range, 4 months-16 years; mean age, 5.1 years), were admitted with subarachnoid hemorrhage during the past 12 years. The majority of patients were admitted in good clinical condition; 31% were in Hunt and Hess Grade II, and 31% were in Hunt and Hess Grade III. The remaining patients were in poor clinical condition and were in Hunt and Hess Grade IV (23%) or Grade V (15%). Computed tomography revealed that 15% of the patients were in Fisher Grade 2, 23% were in Fisher Grade 3, and 62% were in Fisher Grade 4. Endovascular techniques were used in the treatment of 5 aneurysms, and microsurgery was used in the treatment of 8 aneurysms. In the endovascular group, aneurysm sizes ranged from 2 to 35 mm (mean, 12.6 mm); 3 aneurysms were in the anterior circulation, and 2 were in the posterior circulation. In the microsurgery group, 6 aneurysms were in the anterior circulation, and 2 were in the posterior circulation; sizes ranged from 3 to 15 mm (mean, 6.8 mm). Sixty-nine percent of the patients were independent at follow-up. CONCLUSION: Contemporary endovascular and microsurgical techniques can be used effectively to treat ruptured cerebral aneurysms in pediatric patients. In the time period studied, the techniques were equally effective when used in the appropriate patients.

Neurovascular emergencies in the elderly.

Neurovascular diseases are major causes of disability and death in the elderly; many present as medical emergencies. With the continuing growth of the geriatric population, there has been increasing interest in the impact of aging on the cerebrovascular system. Recent advances in the clinical neurosciences have demonstrated that neurovascular emergencies in the elderly often are amenable to treatment; neuroimaging plays a critical role in diagnosis and neurointerventional techniques are becoming increasingly important therapeutic options. This article provides an overview of some of the common neurovascular disorders in the elderly that require urgent evaluation and treatment, with an emphasis on the expanding role for interventional neuroradiology in their management.

Rheolytic thrombectomy for cerebral sinus thrombosis.

INTRODUCTION: Cerebral venous and sinus thrombosis (CVST) is an uncommon cause of stroke that is associated with poor outcomes in high-risk patients who present with stupor or coma, rapidly progressive neurologic deficits or progressive neurologic deficits during therapeutic anticoagulation. METHODS AND RESULTS: We report the rapid treatment of CVST in six patients at high risk for poor outcomes (death or dependency) using rheolytic thrombectomy combined with locally administered low-dose recombinant tissue plasminogen activator (rt-PA), and review the literature on rheolytic thrombectomy for CVST. All of the procedures were technically successful. No complications occurred. Two patients experienced partial rethrombosis following rheolytic thrombectomy requiring a second treatment. Preexisting hemorrhagic infarcts in two patients remained stable. Two of six patients experienced excellent clinical outcomes. Two had good outcomes. There were two deaths from irreversible cerebral injury caused by extensive CVST that had occurred prior to the endovascular treatments. In 24 cases of rheolytic thrombectomy for CVST that were reviewed from this series and previously published reports, the large majority of patients experienced good to excellent clinical outcomes. CONCLUSIONS: Extensive CVST in high-risk patients can be rapidly fatal. Rheolytic thrombectomy combined with locally administered, low-dose recombinant tissue plasminogen activator (rt-PA) is a safe and effective endovascular method to rapidly recanalize the intracranial dural sinuses in high-risk patients with CVST.

Admission angiographic cerebral circulation time may predict subsequent angiographic vasospasm after aneurysmal subarachnoid hemorrhage.

OBJECTIVE: Angiographic cerebral vasospasm occurs in approximately 70% of patients hospitalized after aneurysmal subarachnoid hemorrhage (SAH) and is associated with poor outcome. In this study, we examined whether or not cerebral circulation time (CCT) measured with digital subtraction angiography was associated with angiographic vasospasm. METHODS: Patients who underwent cerebral angiography within 24 hours of SAH were analyzed. Contrast dye transit time from the arterial to the venous phase was measured to obtain CCT (supraclinoid internal carotid artery to parietal cortical veins) and microvascular CCT (cortical middle cerebral artery to parietal cortical veins). Patients with ruptured anterior circulation aneurysms and vasospasm on follow-up angiography (Group A) were compared with patients with SAH without vasospasm (Group B) and with normal control subjects (Group C). RESULTS: There were 20 patients in Group A (mean age, 51 +/- 13 yr), 17 patients in Group B (56 +/- 12 yr), and 98 patients in Group C (52 +/- 12 yr). CCT in patients in Group A (7.7 +/- 1.9 s) was significantly longer than those in Groups B (6.6 +/- 1.2 s; P = 0.005) and C (5.9 +/- 1 s; P < 0.001). Microvascular CCT in patients in Group A (7.1 +/- 1.8 s) was significantly longer than those in Groups B (6.1 +/- 1.2 s; P = 0.003) and C (5.4 +/- 0.9 s; P < 0.001). CONCLUSION: Prolonged CCT, a measurement of increased small vessel resistance, can be identified within 24 hours after SAH and is associated with subsequent angiographic vasospasm. These results suggest that microcirculation changes may be involved in vasospasm.

Reversible cerebral vasoconstriction syndrome associated with subarachnoid hemorrhage.

INTRODUCTION: Reversible cerebral vasoconstriction syndrome (RCVS) is a rare vasculopathy of unknown etiology. Ischemic stroke and intracerebral hemorrhage are well-documented sequelae, but subarachnoid hemorrhage is an uncommon complication of RCVS. METHODS AND RESULTS: We report six cases of RCVS associated with subarachnoid hemorrhage. Two cases occurred in postpartum women, two in women with a history of migraines, one in a woman who recently stopped taking her anti-hypertensive medications, and one in a man after sexual intercourse. All six patients presented with the classic thunderclap headache. Two patients experienced generalized tonic-clonic seizures, and two patients had small ischemic infarcts. Segmental vasoconstriction was demonstrated on cerebral angiography in all six cases. Aneurysmal subarachnoid hemorrhage and other etiologies were excluded. Reversibility of the segmental vasoconstriction was confirmed by follow-up angiography in four patients and by transcranial Doppler sonography in two patients. All six patients had an excellent neurological outcome. CONCLUSIONS: Reversible cerebral vasoconstriction syndrome may be associated with subarachnoid hemorrhage. RCVS should be included in the differential diagnosis of non-aneurysmal subarachnoid hemorrhage.

Lumbar vertebral hemangioma presenting with the acute onset of neurological symptoms. Case report.

Vertebral hemangiomas are common entities that rarely present with neurological deficits. The authors report the unusual case of a large L-3 vertebral hemangioma with epidural extension in a 27-year-old woman who presented with hip flexor and quadriceps weakness, foot drop, and leg pain. The characteristics of the mass on magnetic resonance imaging suggested an aggressive, hypervascular lesion. The patient underwent embolization of the lesion followed by direct intralesional injection of ethanol. Significant resolution of clinical symptoms was observed immediately after the procedure and at her follow-up visits. Follow-up imaging studies obtained 9 months after the procedure also documented a considerable reduction in the size of the hemangioma with minimal loss of vertebral height and a mild kyphosis at the affected level. On repeated imaging studies obtained 21 months postoperatively, the size of the hemangioma and the degree of vertebral body compression were stable. As demonstrated in this case, patients with vertebral hemangiomas can present with acute nerve root compression and signs and symptoms similar to those of disc herniation. Vertebral hemangiomas can be treated effectively with interventional techniques such as embolization and ethanol injection.

De novo aneurysm formation and regression after brain arteriovenous malformation embolization: case report.

BACKGROUND: The formation of de novo aneurysms is a known complication of vessel occlusion (Wright RL, Sweet WH. Carotid or vertebral occlusion in the treatment of intracranial aneurysms: value of early and late readings of carotid and retinal pressures. Clin Neurosurg 1962:9;163-192). Aneurysms most commonly develop on newly formed primary collateral routes as a result of increased flow through these collaterals. Development of aneurysms is not commonly seen in vessels whose flow has been directly decreased by therapeutic or natural occlusion. CASE DESCRIPTION: A 53-year-old woman with an intracerebral hemorrhage underwent cerebral angiography which demonstrated a right parietal AVM. An enlarged right ACA gave rise to 3 direct feeding pedicles. Leptomeningeal collaterals from the right MCA as well as the right PCA also gave collateral supply to the AVM. The lesion had superficial drainage into the superior sagittal sinus and deep venous drainage into the right posterior pericallosal vein. No feeding artery aneurysms or intranidal aneurysms were present. Treatment plan included preoperative embolization followed by surgical resection. CONCLUSION: To our knowledge, this is the first reported case of a de novo aneurysm forming and regressing in an artery hemodynamically related to an embolized AVM. The short timescale of its development (6 weeks) is also noteworthy. The spontaneous regression suggests that at least some aneurysms forming in vessels after abrupt decrease in distal runoff may have a self-limited course. Such lesions may do best if not subjected to direct endovascular or surgical treatment.

Current management of symptomatic intracranial stenosis: medical versus endovascular therapy.

Approximately 8% to 10% of all ischemic strokes are caused by intracranial arterial stenosis (IAS). After a stroke or transient ischemic attack due to IAS, patients face a 12% annual risk of recurrent stroke on medical therapy, with most strokes occurring in the first year. Warfarin has been shown to be no better than aspirin in preventing recurrent strokes but poses a higher risk of serious bleeding and death. Groups with the highest risk of recurrent stroke are those with high-grade (> or = 70%) stenosis, those with recent symptom onset, and women. Endovascular treatment of IAS is a rapidly evolving therapeutic option. Antiplatelet agents are currently recommended as the primary treatment for symptomatic IAS, with endovascular therapy reserved for appropriate high-risk cases refractory to medical therapy.

Stroke associated with Barth syndrome.

Barth syndrome is an inherited disorder characterized by dilated cardiomyopathy, neutropenia, growth retardation, and skeletal myopathy. We describe a case of acute stroke owing to Barth syndrome that required intra-arterial thrombolysis. This case suggests that cardiovascular complications can be observed in patients with Barth syndrome. Stroke prevention measures, including the use of antithrombotic agents, might be warranted.

Intra-arterial papaverine used to treat cerebral vasospasm reduces brain oxygen.

INTRODUCTION: Intra-arterial papaverine (IAP) is used to treat symptomatic cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH). IAP, however, can increase intracranial pressure (ICP). In this study we examined whether IAP alters brain oxygen (BtO2). METHODS: Poor clinical grade (Hunt & Hess IV or V) SAH patients who underwent continuous ICP and BtO2 monitoring during IAP infusion for symptomatic cerebral vasospasm were evaluated as part of a prospective observational study. RESULTS: Data are available for five patients (median age 58) who received IAP for cerebral vasospasm 4 to 7 days after SAH. In each patient, angiographic vasospasm was improved on postinfusion angiogram. Mean ICP before IAP was 23.04 +/- 1.18 mmHg; it increased immediately after IAP infusion and remained elevated (29.89 +/- 1.18 mmHg; p < 0.05) during IAP and for approximately 10 minutes after IAP ended. Baseline mean arterial pressure (MAP) was 110.55 +/- 1.36 mmHg. During IAP treatment MAP remained stable (110.90 +/- 2.00 mmHg; p = 0.31). Mean BtO2 before IAP was 32.99 +/- 1.45 mmHg. There was a significant BtO2 decrease in all patients during IAP to a mean of 22.96 +/- 2.9 mmHg (p < 0.05). BtO2 returned to baseline within 10 minutes after IAP ended. There was a modest relationship between the ICP increase and BtO2 decrease (R2 = 0.526). CONCLUSION: IAP infusion to treat cerebral vasospasm following SAH can increase ICP and reduce BtO2. The IAP-induced reduction in BtO2 may help explain why IAP, although it reverses arterial narrowing, does not improve patient outcome.

Otologic manifestations of petrous carotid aneurysms.

BACKGROUND AND PURPOSE: The petrous and cavernous segments of the extradural internal carotid artery take a complex course through the skull base before entering the subarachnoid space distal to the cavernous sinus. Despite the protection from trauma afforded by the anatomy, the petrous and carotid internal carotid artery (ICA) segments of the vessel remains subject to disease, the most important of which are aneurysms. Aneurysms affecting the petrous portion of the vessel are extremely uncommon, and presentation with otologic symptoms is unusual. These symptoms include hearing loss, tinnitus, and life threatening hemorrhage. This article emphasizes the need for a high level of suspicion for aneurysm as a potential cause for otologic symptoms. We report and discuss three cases of petrous carotid aneurysms with otologic manifestations to increase the awareness and aid in the diagnosis and treatment of this uncommon disorder. METHODS: The medical records and imaging studies of three patients presenting to our institution with aneurysms involving the petrous internal carotid artery were reviewed. One presented with progressive bilateral sensorineural hearing loss. The next patient presented with pulsatile tinnitus. The last patient presented to the emergency room unresponsive with severe epistaxis. RESULTS: All three patients had imaging studies revealing petrous carotid aneurysms. Each patient had symptoms related to the aneurysms ranging from hearing loss, tinnitus, and life-threatening hemorrhage. CONCLUSION: Petrous carotid aneurysms are rare, and presentation with otologic symptoms is unusual. Awareness of these lesions as a cause of otologic symptoms, however, is highly important. These cases also illustrate the usefulness of endovascular treatments for aneurysms of the petrous portion of the internal carotid artery, which are extremely difficult to treat by using an open surgical approach.

Rapid cognitive decline following lumbar puncture in a patient with a dural arteriovenous fistula.

BACKGROUND: Dural arteriovenous fistulas (DAVFs) are frequently accompanied with raised intracranial pressure and clinical findings suggestive of pseudotumor cerebri. However, unlike pseudotumor cerebri, the clinical response to lumbar cerebrospinal fluid (CSF) removal can vary from beneficial to acute clinical deterioration leading to death. The criteria for the safe use of lumbar puncture (LP) in patients with a DAVF are not well established. METHODS: A 61-year-old man presented with visual difficulty. Magnetic resonance imaging (MRI) and angiography revealed a left transverse sinus DAVF. He underwent multiple embolizations of arterial feeders over 3 years. He was then noted to have cognitive deficits in short term memory, listening, and concentrating. Over several days after an LP he became increasingly lethargic but arousable. Within hours after a repeat LP there was a rapid deterioration in the patient's level of consciousness and he became unarousable. RESULTS: A brain MRI revealed extensive dilated cortical veins and left temporal lobe venous ischemia without tonsillar herniation. A cerebral angiogram showed an extensive left transverse sinus DAVF with an occluded lateral transverse sinus and increased retrograde venous drainage. Embolization of the arterial feeders in combination with trans-venous coil embolization of the left transverse sinus reversed the patient's neurologic decline. He was discharged neurologically intact except for his chronic visual acuity problems. CONCLUSION: We speculate that when a DAVF manifests retrograde venous flow sufficient to cause cognitive deficits, lumbar CSF drainage must be undertaken with extreme caution.

Outcomes for overlapping stents in the extracranial carotid artery.

Various diseases of the carotid artery are treatable by stenting. However, few reports of overlapping carotid stents exist. As a result, the indications, long-term outcomes, and potential complications of this technique remain largely unknown. We therefore present and examine a series of 11 patients treated by this unique stenting method. A retrospective single-institution review was performed for patients in whom overlapping carotid stents were placed. Only patients with imaging follow-up beyond 3 months were included. Of 38 patients who had extracranial carotid artery stents placed, 11 patients fulfilled the inclusion criteria for both overlapping stents and imaging follow-up greater than 3 months (range, 0.4-3 years; mean, 1.3 years). Clinical follow-up ranged between 0.4 and 3.6 years (mean, 2.1 years). Carotid pathology within this cohort included atheromatous stenosis (n = 3), recurrent stenosis following carotid endarterectomy (n = 2) or stenting (n = 1), postirradiation angiitis (n = 1), carotid artery kink created by initial stent placement (n = 2), and both traumatic (n = 1) and neoplastic (n = 1) carotid blowout syndrome. No permanent stroke or stenting-related death occurred. Focal stenosis or intimal hyperplasia resulting in 35% or less luminal narrowing developed in three patients (27%) after tandem stenting. Overlapping stents provide a durable treatment for a variety of extracranial carotid pathologies. Clinically and hemodynamically significant (> 50%) poststenting stenosis or intimal hyperplasia did not occur in this series.

Successful treatment of cerebral vasospasm by use of transdermal nitroglycerin ointment (Nitropaste).

To our knowledge, the use of transdermal nitroglycerin ointment (Nitropaste) in the setting of intracranial vasospasm has not been described in the peer-reviewed literature. Five patients with intracranial vasospasm induced by subarachnoid hemorrhage were evaluated angiographically both before and after application of Nitropaste. All cases exhibited mild to moderate improvement in the degree of vasospasm. We conclude that Nitropaste is a simple noninvasive technique to reduce intracranial vasospasm.