Association between draining vein diameters and intracranial arteriovenous malformation hemorrhage: a multicentric retrospective study.

PURPOSE: Intracranial arteriovenous malformations (AVMs) cause hemorrhage, and the role of draining vein diameters in rupture risk is controversial. The aims of the present study were to investigate the variables related with intracranial AVM rupture and to examine the association of draining vein diameters and AVM hemorrhage. METHODS: Two hundred three patients were included in this study, of which 117 (57%) had unruptured AVMs, and 86 (43%) had ruptured AVMs. RESULTS: In an adjusted (multivariate) analysis, the variables significantly associated with AVM hemorrhagic presentation were age (OR per year increase 0.97, 95%CI 0.95-0.99, p = 0.007), a deep nidus compared with superficial nidus (OR 3.21, 95%CI 1.13-9.06, p = 0.028), the nidus diameter (OR per each mm increase 0.95, 95%CI 0.92-0.97, p < 0.001), a single draining vein compared with multiple draining veins (OR 2.14, 95%CI 1.02-4.50, p = 0.044), the draining vein diameter (OR per mm increase 1.52, 95%CI 1.26-1.83, p < 0.001), and a draining vein diameter ≥ 5 mm compared with < 5 mm (OR 5.80, 95%CI 2.70-12.47, p < 0.001). CONCLUSION: In this study, after adjusted analysis, the variables associated with intracranial AVM hemorrhagic presentation were a young age, a small nidus diameter, a deeply located nidus, a single draining vein, and large draining vein diameters. A draining vein diameter cutoff ≥ 5 mm was positively associated with the risk of AVM rupture. A large and prospective study is now necessary to confirm if draining vein diameter is a risk factor for AVM hemorrhage.

Derivo Embolization Device for the Treatment of Intracranial Aneurysms.

Background and Purpose- Flow diverter technology improvements are necessary to provide safe and good results and enable the treatment of a larger variety of aneurysms. We report a nationwide experience with the Derivo Embolization Device in the treatment of intracranial aneurysms. Methods- BRAIDED (Brazilian Registry of Aneurysms Assigned to Intervention With the Derivo Embolization Device) is a multicenter, prospective, interventional, single-arm trial of the Derivo Embolization Device for the treatment of intracranial aneurysms. The primary effectiveness end point was total aneurysm occlusion at 6- and 12-month angiographies. The secondary safety end point was the absence of serious adverse events during follow-up. Univariable and multivariable logistic regression was performed to identify predictors of aneurysm persistence, periprocedural complications, and adverse events during follow-up. Results- Between December 2016 and October 2018, 146 patients harboring 183 intracranial aneurysms were treated in 151 interventions at 7 centers. Derivo Embolization Device placement was technically successful in all patients. Most aneurysms (86.9%) were located at the internal carotid artery, and the mean diameter was 6.7 mm. At 6 months, 113 of 140 (80.7%) aneurysms met the study's primary end point, and 74 of 83 (89.2%) met the study's primary end point at 12 months. Saccular morphology of the aneurysm (odds ratio, 5.66; 95% CI, 1.01-31.77) and the presence of a branch arising from the sac (odds ratio, 6.36; 95% CI, 2.11-22.36) predicted persistence. A long duration of follow-up (odds ratio, 0.86; 95% CI, 0.78-0.95) predicted total occlusion. Of the 146 enrolled patients, 138 (94.5%) were treated without serious adverse events during follow-up. In the multivariable analysis, aneurysms located at a sidewall were less likely to experience these events than those located at bifurcations (odds ratio, 0.07; 95% CI, 0.01-0.51). Conclusions- The Derivo Embolization Device is a safe and effective treatment for intracranial aneurysms. Clinical Trial Registration- URL: http://plataformabrasil.saude.gov.br/login.jsf. Unique identifier: CAAE 77089717.7.1001.5125.

Dual-lumen balloon to increase onyx venous penetration in the treatment of spinal dural arteriovenous fistulas.

PURPOSE: Spinal dural arteriovenous fistulas (sDAVF) are the most common spinal vascular lesions. The arterialization of the recipient vein results in venous hypertension and chronic ischemia. Intravascular injection of acrylic glue in order to occlude the draining vein is the principle of endovascular treatment, but a significant portion of embolization procedures do not succeed. We present our initial experience of endovascular balloon augmented embolization of sDAVF using a dual-lumen balloon. CLINICAL PRESENTATION: Three patients harboring sDAVF were submitted to endovascular treatment by onyx injection assisted by a double-lumen balloon as the sole therapy. Control angiography demonstrated complete obliteration of the fistula in all cases with clinical improvement. CONCLUSION: Dual-lumen balloon onyx embolization of spinal dural arteriovenous fistulas appears to be an acceptable and feasible alternative.

Pipeline embolization device for the treatment of a traumatic intracranial aneurysm in a child.

INTRODUCTION: Traumatic intracranial aneurysms in children are rare and may occur as the result of closed or penetrating head trauma. Their natural history seems to be more aggressive. Most traumatic aneurysms have complex shape, tending to have a large neck or even a fusiform morphology. CASE REPORT: We present a case of a traumatic carotid artery aneurysm in a 9-year-old girl that was successfully treated with pipeline embolization device. DISCUSSION: Due to its dissecting nature, wall friability and lack of a substantial neck can make surgical clipping and selective coiling difficult and risky. Although endovascular parent artery occlusion is the best approach in the acute phase, in some situations it is not possible or very risky. In such scenario the use of flow diverter devices would be an alternative approach. Additionally, we discuss the potential advantages and risks of flow diverter deployment inside a developing vessel.

Preoperative embolization of choroid plexus papilloma with Onyx via the anterior choroidal artery: technical note.

INTRODUCTION: Total surgical resection is the treatment of choice for choroid plexus tumors. However, the hypervascular nature of such lesions imposes challenges to the surgical treatment. Preoperative embolization for intracranial tumors has been widely used in an attempt to reduce blood loss, but rarely with choroid plexus tumors. CASE REPORT: We describe the first case of preoperative embolization of choroid plexus papilloma with Onyx via the anterior choroidal artery. The procedure underwent without any complications and surgical treatment was possible with minimal blood loss. DISCUSSION: Embolization of choroid plexus tumors via anterior choroidal artery is potentially dangerous, but following a meticulous technique, it can be used as a safe and effective preoperative procedure.

The use of dual-lumen balloon for embolization of peripheral arteriovenous malformations.

PURPOSE: We aimed to evaluate the safety and feasibility of the embolization of peripheral arteriovenous malformation (AVM) with non-adhesive liquid agents (NALA) injected by dual-lumen balloons (DLB). METHODS: We conducted a multicenter retrospective study between January 2017 and June 2019, including patients with peripheral AVM embolized with NALA by DLB. Fourteen patients were included. The AVM classification, technical and clinical success were evaluated, as were nidus size, liquid agent used, volume and time of injection in DLB, complications, follow-up and need of surgical intervention. RESULTS: The mean age of the patients was 37±22.5 years (range, 6-82 years). The mean nidus size was 5.2±2.4 cm (range, 3.0-12.0 cm). By Schobinger classification, 11 AVMs were classified in stage 3 and 3 AVMs were classified in stage 2. By Cho's classification, 2 AVMs were in stage II, 4 AVMs were in stage I, 4 AVMs were in stage IIIa and 4 AVMs were in stage IIIb. Onyx was used in 11 patients (78.6%), while Squid, PHIL, and both Onyx and Squid were used in one patient each (7.1%). Seven patients (50%) required one session of embolization, 4 patients (28.6%) required two, 2 patients (14.3%) required three and 1 patient (7.1%) required four sessions. Complete nidus exclusion was achieved in 11 patients (78.6%), optimal clinical response in 12 patients (85.7%). Four patients (28.6%) exhibited minor complications, all controlled. No major complications were seen. Four patients underwent surgical intervention (28.6%). CONCLUSION: The embolization of peripheral AVM with NALA in DLB appears to be safe and feasible, achieving high rates of technical and clinical success.

Endovascular Treatment of Tentorial Dural Arteriovenous Fistulas Using the Transarterial Approach as a First-Line Strategy.

BACKGROUND: In recent decades, endovascular approaches have become the standard treatment for most tentorial dural arteriovenous fistulas (TDAVFs). Although endovascular treatment (EVT) is associated with better clinical outcomes, the angiographic occlusion rates are lower than those of surgical or combined approaches. OBJECTIVE: To evaluate the efficacy and safety of EVT for TDAVFs using the transarterial approach (TAA) as a first-line strategy. METHODS: Clinical and radiological data from 45 consecutive patients with TDAVFs who underwent EVT at 2 centers were retrospectively reviewed. Patient demographics and clinical and angiographic data were registered. Postprocedural and 6-mo follow-up angiographic and clinical results were evaluated. Univariable and multivariable logistic regression were performed to identify angiographic occlusion predictors after the first session and predictors of clinical complications. RESULTS: An isolated TAA was used for 40 TDAVFs (88.9%). A total of 37 (82.2%) TDAVFs were completely occluded after a single EVT session, and 44 TDAVFs (97.8%) were completely occluded after the last procedure. The presence of fewer than 5 arterial feeders was a predictor for total occlusion after the first treatment session (odds ratio [OR], 18.9; 95% CI 2.06-173.57; P = .01). Six-month angiographic control was performed in 42 patients, and all TDAVFs were occluded. Good long-term neurological outcomes were observed in 41 patients (91.1%). Clinical complications occurred in 7 (15.6%) patients. They were related to the number of accessed arteries to perform TAA (odds ratio, 2.53; 95% CI 1.10-5.86; P = .03). The procedure-related mortality rate was 2.2%. CONCLUSION: TAA is a safe and effective treatment for TDAVFs.

Endovascular treatment of residual or recurrent intracranial aneurysms after surgical clipping.

OBJECTIVE: Total aneurysm occlusion is crucial for the prevention of rebleeding of a ruptured aneurysm or to avoid rupture of an unruptured lesion. Both surgical and endovascular embolization fail to achieve complete aneurysm occlusion in all the cases. The objective of the study was to establish the safety and efficacy of endovascular treatment for previously clipped residual or recurrent aneurysms. METHODS: This was an observational, retrospective study of patients harboring incompletely occluded intracranial aneurysms after clipping who underwent endovascular treatment. Patients were treated using 4 different techniques: (1) simple coiling, (2) balloon remodeling, (3) stent-assisted coiling, and (4) flow diversion. Analyses were performed to identify predictors of total aneurysm occlusion, recanalization and complications. RESULTS: Between May 2010 and September 2018, 70 patients harboring incompletely occluded intracranial aneurysms after clipping met the inclusion criteria in 5 centers. The mean residual aneurysm size was 7.5 mm. Fifty-nine aneurysms were unruptured. Total aneurysm occlusion was achieved in 75.3% of the aneurysms after 1 year. All aneurysms treated with flow diversion revealed complete occlusion according to control angiography. Recanalization was observed in 14.5%. Permanent morbidity and mortality occurred in 2.9% and 1.4% of the patients, respectively. CONCLUSIONS: Endovascular treatment of recurrent or residual aneurysms after surgical clipping was safe and efficacious. Flow diversion seems to be associated with better anatomical results. A more rigid study, a larger group of patients, and longterm follow-up are required to provide stronger conclusions about the best approach for residual clipped aneurysms.

Safety and Effectiveness of the Pipeline Flex Embolization Device With Shield Technology for the Treatment of Intracranial Aneurysms: Midterm Results From a Multicenter Study.

BACKGROUND: The safety and efficacy of the first generation of the Pipeline Embolization Device (PED; Medtronic Inc) have been proven in large case series. Ischemic events are one of the most common complications following treatment of aneurysms with flow diverters. The new PED Flex with Shield technology (PED Shield; Medtronic Inc) was introduced to minimize the rate of complications. OBJECTIVE: To evaluate the outcomes of patients harboring aneurysms treated with the PED Shield. METHODS: This was an observational, prospective, single-arm multicenter study of patients treated with the PED Shield. The primary safety endpoint was the absence of major neurological complications and death. The secondary effectiveness endpoint was angiographic occlusion at 6 and 12 mo. Technical complications were also reported. RESULTS: Between November 2017 and December 2018, 151 patients from 7 centers with 182 aneurysms were enrolled. The mean aneurysm size was 7.0 mm; 27 (14.8%) aneurysms were large, and 7 (3.8%) were giant. In 141 of 151 patients (93.4%), the primary endpoint was reached. The overall rate of periprocedural complications was 7.3%. Of the aneurysms, 79.7% met the study's secondary endpoint of complete occlusion at 6 mo and 85.3% at 12 mo. CONCLUSION: The PED Shield is a safe and effective treatment for intracranial aneurysms. The results regarding total occlusion and ischemic complications did not differ from those obtained in case series using previous versions of the PED. Long-term follow-up and comparative studies are required to provide stronger conclusions regarding the reduced thrombogenicity of this device.

Republished: Recurrence of a totally occluded aneurysm after treatment with a pipeline embolization device.

Treatment with a pipeline embolization device (PED) is widely accepted as an excellent option for patients harboring giant, wide neck, saccular intracranial aneurysms. It has been shown to be safe and very effective. We describe a previously unreported case of a large middle cerebral artery aneurysm, related to the carotid tip, that was treated with a PED and coils. The 6 month follow-up angiogram demonstrated complete occlusion of the aneurysm. However, the 9 month angiogram revealed recurrent filling of the aneurysm sac. To our knowledge, this is the first report to describe recanalization of an aneurysm totally occluded on the control angiography after treatment with a PED. Unanswered questions include the mechanism of recanalization and the need for additional control angiograms and MRI following a previous examination revealing total aneurysm occlusion.

The routes for embolization of dural carotid cavernous fistulas when the endovascular approach is indicated as a first-line strategy.

INTRODUCTION: Multiple ways to access the dural carotid cavernous fistula have been described. The aim of the present study was to assess the results of embolization of a dural carotid cavernous fistula via different routes using endovascular accesses as a first-line strategy. METHODS: A retrospective data analysis of a consecutive series of 63 patients presenting with dural carotid cavernous fistula was performed. RESULTS: The dural carotid cavernous fistula was accessed by an endovascular approach in 58 patients (92.1%) and by direct puncture in five patients (7.9%). The inferior petrosal sinus was the main route accessed (65%). A recanalization of an occluded inferior petrosal sinus was obtained in 20.6% of cases. The access via either facial ophthalmic veins or the superior petrosal sinus was obtained in 20.6% and 3.1% of cases, respectively. Complete angiographic occlusion of a dural carotid cavernous fistula immediately after treatment was achieved in 53 patients (84.1%), whereas 10 patients (15.9%) displayed a partial occlusion. Treatment-related complications were observed in two patients (3.2%). CONCLUSIONS: In this study, the endovascular approach allowed dural carotid cavernous fistula embolization in most patients. The inferior petrosal sinus, even when thrombosed, was the main route used to access the dural carotid cavernous fistula, followed by the facial vein, direct cavernous sinus puncture, and the superior petrosal sinus.

Preliminary Experience with the TransForm Occlusion Balloon Catheter: Safety and Potential Advantages.

PURPOSE: Balloon-assisted coiling (BAC) has made the treatment of aneurysms with complex shape and broad neck possible, especially during the acute phase of hemorrhage. The authors present a prospective series of their preliminary experience with the TransForm occlusion balloon catheter (TOBC). METHODS: Between September 2015 to February 2016 a total of 20 patients underwent endovascular treatment assisted by TOBC of which 19 had 20 untreated aneurysms and 1 patient harboring a meningioma was submitted to balloon test occlusion (BTO). The TOBC was used to perform BAC and BTO for the treatment of vasospasms and to cross the neck of giant aneurysms (anchor technique). All data regarding the feasibility and safety of treatment with the device were collected prospectively. RESULTS: All patients completed treatment according to the modality previously chosen. The balloon was employed solely for remodeling in 17 patients, for anchor technique in 2, for both remodeling and vasospasm angioplasty in 1 and for BTO in 1 patient. The balloon could be navigated to the target aneurysm in all cases. Evaluation of postoperative anatomical results indicated total occlusion in 13 (72.2 %) aneurysms, neck remnants in 4 (22.2 %) and residual sac filling in 1 (5.5 %). There were two (9.5 %) complications related to treatment, all thromboembolic. No technical complications were observed. CONCLUSION: The TOBC was shown to be safe and effective for the treatment of intracranial aneurysms with BAC. In addition, it was successfully employed to perform angioplasty for vasospasm and BTO. Finally, it was used in the balloon anchor technique for the first time.

Recurrence of a totally occluded aneurysm after treatment with a pipeline embolization device.

Treatment with a pipeline embolization device (PED) is widely accepted as an excellent option for patients harboring giant, wide neck, saccular intracranial aneurysms. It has been shown to be safe and very effective. We describe a previously unreported case of a large middle cerebral artery aneurysm, related to the carotid tip, that was treated with a PED and coils. The 6 month follow-up angiogram demonstrated complete occlusion of the aneurysm. However, the 9 month angiogram revealed recurrent filling of the aneurysm sac. To our knowledge, this is the first report to describe recanalization of an aneurysm totally occluded on the control angiography after treatment with a PED. Unanswered questions include the mechanism of recanalization and the need for additional control angiograms and MRI following a previous examination revealing total aneurysm occlusion.

Transorbital Cavernous Sinus Direct Puncture : Alternative to treat dural arteriovenous fistula.

INTRODUCTION: The authors present a retrospective series of their clinical experience in the treatment of cavernous dural arteriovenous fistulas (DAVF) by direct transorbital puncture of the cavernous sinus as an alternative to the endovascular approach. METHODS: Between October 2012 and September 2014, eight patients harboring cavernous DAVF underwent percutaneous treatment by direct transorbital puncture of the cavernous sinus at three institutions. All patients presented with ocular symptoms. Standard endovascular approaches, including transvenous and transarterial routes, were primarily attempted without success in all cases. Direct puncture was performed through two different approaches, namely inferolateral and superomedial. The entry point was the inferior and superior eyelid, respectively. Embolization was performed with coils or Onyx (Covidien, Irvine, CA). Immediate and late angiographies were used to evaluate the occlusion of the fistula. RESULTS: Of the patients seven had complete occlusion of the cavernous DAVFs noted on the immediate and follow-up angiograms and one patient had residual filling but reduction of the shunt resulted in clinical improvement. None of the patients had worsening of neurological function. One case was complicated by inadvertent internal carotid puncture but without clinical manifestations. One patient experienced postoperative superior ophthalmic vein thrombosis. CONCLUSION: In very specific cases, when endovascular access is not possible or fails to occlude cavernous DAVF, direct transorbital puncture of the cavernous sinus was shown to be feasible, safe and very effective.

Occlusion rates of intracranial aneurysms treated with the Pipeline embolization device: the role of branches arising from the sac.

OBJECTIVEThe aim of this study was to compare the clinical and angiographic outcomes of intracranial aneurysms with and without branches arising from the sac after Pipeline embolization device (PED) treatment.METHODSThis retrospective 2-center comparative study included 116 patients with 157 aneurysms that were treated with PEDs. Aneurysms were divided into 2 groups: one group had branches arising from the sac and the other group did not. Study end points included total aneurysm occlusion assessed by angiography at 6 and 12 months, death or stroke, technical complications, in-stent stenosis, patency of covered branches, and transient ischemia.RESULTSOne hundred fifty-one aneurysms (96%) were located in the internal carotid artery. A branch arising from the sac was observed in 26 aneurysms. Complete occlusion was found in 120 of 156 aneurysms at 6 months (76.92% [95% CI 69.71%-82.84%]) and in 136 of 155 aneurysms at 12 months (87.74% [95% CI 81.28%-92.27%]). Total occlusion was more frequently observed in the group without a branch arising from the sac (84% vs 40% at 6 months, p < 0.001; 93.10% vs 60% at 1 year, p < 0.001). There were 4 (3.45% [95% CI 1.11%-9.12%]) cases of death or major stroke. Amaurosis fugax occurred in 3 patients. One patient experienced worsening of mass effect after treatment. No occlusion of branches arising from the aneurysm was observed. In-stent stenosis greater than 50% was observed in 1 case.CONCLUSIONSAneurysms treated with PEDs are less likely to be totally occluded if they have a branch arising from the sac than are aneurysms without these branches.

Transvenous embolization of dural carotid cavernous fistulas: the role of liquid embolic agents in association with coils on patient outcomes.

INTRODUCTION: Transvenous embolization is the standard treatment for dural carotid cavernous fistulas (DCCF). Although various embolic materials have been used, the best embolic material for the treatment of DCCF is still unknown. OBJECTIVE: To assess the safety and efficacy of different embolic materials used for the endovascular treatment of DCCF. METHODS: A retrospective data analysis of a consecutive series of 62 patients presenting DCCF was performed. Clinical and radiological data from patients were assessed, and the embolic material used-coils or liquids-were compared between two groups of patients. RESULTS: Complete angiographic occlusion of DCCF after treatment was achieved in 83.9% of the patients (52/62). We found a higher rate of complete occlusion of DCCF when liquids were associated with coils than with coils alone (96.5% vs 71.8%, p=0.01), and no differences in complication rates or clinical outcomes were seen between the two groups. At the 6-month follow-up, we found a higher rate of improvement in ocular symptoms compared with cranial nerve palsy improvement (94.7% vs 77.7%, p=0.02). Two patients (3.2%) had treatment-related complications without clinical symptoms. CONCLUSION: In this study, in comparison with the use of coils alone, the association of transvenous embolization with liquid embolic agents for DCCF treatment resulted in higher rates of complete occlusion without increasing complication rates. The clinical outcome at the 6-month follow-up showed significant improvement in ocular symptoms over cranial nerve palsy regression, which was independent of the embolic agent chosen for treatment.

Endovascular treatment of pulsatile tinnitus associated with transverse sigmoid sinus aneurysms and jugular bulb anomalies.

Pulsatile tinnitus of vascular origin may arise in arterial or venous structures. Many authors have reported the association of pulsatile tinnitus with anomalies of dural venous sinuses and the jugular bulb. In such circumstances, mainly concomitantly with disabling tinnitus, endovascular treatment has been successfully employed. We describe here a new case of jugular bulb diverticulum associated with transverse sigmoid sinus stenosis, in a patient presenting with disabling pulsatile tinnitus. She was treated with dural sinus stenting and selective embolization of the diverticulum. In addition, we performed a literature review aiming to identify possible risk factors for developing the symptoms, as well as the safety and results of endovascular treatment.