Traumatic Buccal and Inferior Alveolar Pseudoaneurysm Associated With Von Willebrand Disease: A Challenging Case Treated by Endovascular Approach.

ABSTRACT: Pseudoaneurysm resulting from the external carotid artery or its branches after trauma to the maxillofacial region is unlikely, even more so, in a patient with von Willebrand disease. This study aimed to report a challenging case of pseudoaneurysm of the buccal artery and inferior alveolar artery due to a mandible fracture in a traumatized patient with undiagnosed von Willebrand disease. This reported case was conducted by a multidisciplinary team, covering the departments of maxillofacial surgery, interventional neuroradiology, neurosurgery, and hematology. From a fracture of the lower jaw and the appropriate course of action, bleeding episodes followed until intervention with embolization therapy. To our knowledge, this is the first case reported in the literature of a patient with those conditions.

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.

Overt nickel and cobalt hypersensitivity after pipeline embolization device placement: A case report.

Nickel and cobalt are frequently found in metallic alloys used in the manufacture of aneurysm clips and endovascular prostheses, such as the pipeline embolization device (PED). Nickel hypersensitivity can affect up to 15% of the population, however, it is very rarely overt in patients who undergo endovascular stent placement. Here, we present the case of a 35-year-old woman who developed allergic symptoms after PED placement and was later confirmed to be allergic to both nickel and cobalt by patch testing. Fortunately, she responded well to pharmacologic treatment, rendering surgical intervention unnecessary. To the best of our knowledge, this is the first report of symptomatic nickel hypersensitivity, and the second report of symptomatic cobalt allergy caused by the PED. Despite its low prevalence, we believe that surgeons should actively inquire patients in the postoperative period about allergic symptoms, to facilitate early diagnosis and treatment.

Hydrocephalus Resolution with Third Ventriculostomy with Floor Stenting: Technical Note and Literature Review.

INTRODUCTION: The management of refractory obstructive hydrocephalus is a paramount neurosurgical challenge. The endoscopic third ventriculostomy (ETV) has been accepted as the procedure of choice for obstructive hydrocephalus, depending on the presence of certain risk factors, such as intracranial infections, young age, previous shunt failure and distorted anatomy of the ventricular floor, that predispose occlusion or obstruction of the CSF outflow through the stoma. CASE REPORT: A 20-year-old man with obstructive hydrocephalus due to primary aqueductal stenosis performed several neurosurgical procedures, including two previous ETV, without long term resolution. We performed another ETV, with stent placement at the stoma to prevent occlusion. After 25 months of asymptomatic follow-up, the patient presented with an enlarged fourth ventricle, and a new neuroendoscopic procedure showed a patent stoma and a well-placed stent. DISCUSSION: Stent placement on the third ventricular floor was already reported 19 times in the literature. Its success rate is about 94,7%, and complications happened in 2 cases, with functional impaired in only one of them. CONCLUSION: Third ventriculostomy with floor stenting proved to be an effective procedure in our case of complex hydrocephalus. It is a viable option in cases where there is a greater chance of stoma occlusion.

Casper stent in the treatment of pulsatile tinnitus in fibromuscular dysplasia: Therapeutic review and case report.

Fibromuscular dysplasia (FMD) is a known cause of pulsatile tinnitus that can, on rare occasion, evolve into an incapacitating condition. It is a noninflammatory and nonatherosclerotic arteriopathy of unknown cause that affects medium-sized vessels, such as the carotid and renal arteries, occurring mainly in women. We describe a 72-year-old woman suffering from pulsatile tinnitus refractory to medical treatment who was successfully treated with Casper stent in the carotid artery. The different treatment strategies published in the literature were reviewed.

Casper vs. Closed-Cell Stent : Carotid Artery Stenting Randomized Trial.

OBJECTIVE: The aim of this trial was to compare the efficacy of closed-cell stents with Casper stents during carotid angioplasty stenting (CAS). METHODS: This was a randomized superiority trial in which 88 patients were enrolled. The primary end points were the incidence, number, and size of new ischemic brain lesions after CAS under distal embolic protection devices (EPD). The secondary end points included stroke, transient ischemic attack (TIA) and myocardial infarction (MI). Ischemic brain lesions were assessed by a diffusion-weighted magnetic resonance image (DW-MRI). Neurological outcomes were evaluated by means of the National Institutes of Health scale score (NIHSS) and the modified Rankin scale (mRS). RESULTS: Compared with closed-cell stents (n = 47), Casper stents (n = 41), resulted in no significant reduction in the incidence (44.7% versus 39%, P = 0.592), number (1.3 ± 1.8 versus 0.9 ± 1.5, p = 0.444), and size (3.9 ± 5.8 mm versus 2.8 ± 4.1 mm, p = 0.353) of new ischemic brain lesions. The global rate of stroke/TIA/MI was (2/88, 2.3%). Two TIA occurred during the hospitalization period, one in each group (1/41, 2.4% vs 1/47, 2.1%). One patient of the Casper group had an asymptomatic in-stent thrombosis. One patient of the control group had a MI (1/47, 2.1%) after discharge. CONCLUSION: The Casper stents did not show superiority in the rate of incidence, number and size of new silent ischemic brain lesions detect by DW-MRI when compared to close cell stents during CAS under distal EPD.

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 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.

Stent infection after carotid angioplasty - Treatment with dual layer stent.

Stent infection is extremely rare, especially in stents placed in the internal carotid artery (ICA). Treatment in these cases remains controversial and no consensus has been reached, resulting in high mortality in all cases. We report the case of a 78-year-old man undergoing stent placement in the left ICA who, 20 days later, presented with infection at the stent site and a large pseudoaneurysm. The primary infectious focus was the teeth. The patient was treated with antibiotics and placement of a Casper stent, a dual layer braided metal stent with micro-mesh, intended to determine flow diversion and arterial wall reconstruction. Although the procedure was able to reduce the pseudoaneurysm, the patient eventually died of sepsis. We believe that the use of dual layer stents, with a flow-diverting effect, may be a treatment option in selected cases. However, further studies are needed to confirm this hypothesis.

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.

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.

The use of balloon-expandable stents in the management of intracranial arterial diseases: a 5-year single-center experience.

BACKGROUND AND PURPOSE: Although stent-assisted intracranial procedures are becoming a routine clinical practice, there have been relatively few large studies published in the literature regarding the application of the balloon-expandable stent technology in the treatment of intracranial arterial diseases. In this report, the authors reviewed their experience with 75 cases at a single center. METHODS: From 1998 to 2003, 75 patients underwent percutaneous transluminal intracranial stent placement as a treatment for wide-necked intracranial aneurysms and atherosclerotic stenoses. The anatomy of the target lesions, technical details of the procedures, device functionality, procedure-related complications, and short-term outcomes were reviewed in a retrospective fashion. RESULTS: The clinical indications included wide-necked intracranial aneurysms (59) and atherosclerotic stenoses (16). The stent was successfully deployed in 92% of the patients (69 of 75 cases). In the remaining 6 cases, the causes of failed stent deployment included arterial tortuosities (2), stent migration (2), fracture of the stent (1), and arterial perforation (1). The short-term outcome (mean follow-up, 7.5 months; range, 3-12 months) was evaluated by using the modified Rankin scale (MR spectroscopy 0-6). Fifty-three patients (70.6%) had excellent outcomes (MR spectroscopy 0-1), 12 (16%) had good outcomes (MR spectroscopy 2), and 5 (6.7%) had poor outcomes (MR spectroscopy 4-5). Five patients (6.7%) died. CONCLUSION: The use of BES is associated with a high rate of hemorrhagic and ischemic complications, more specifically when used in the anterior circulation. Cases of large-necked aneurysms not treatable with balloon remodeling technique and atheromatous sclerosis could be eligible for this treatment.

Venous phase timing during balloon test occlusion as a criterion for permanent internal carotid artery sacrifice.

PURPOSE: The purpose of this study was to evaluate the reliability of angiography-based balloon test occlusion (BTO) criteria to decide whether to perform internal carotid artery (ICA) permanent occlusion. METHODS: From March 1999 to August 2004, 60 patients underwent therapeutic ICA occlusion. Angiographic BTO was performed systematically in all patients under general anesthesia (GA). No clinical examination test was performed. After balloon inflation, contralateral carotid and vertebral arteries angiograms were obtained. The symmetry of the venous phases of each hemisphere was assessed. Occlusion was considered to be feasible when the delay between the venous drainage of the injected and the occluded hemisphere was not >2 seconds. Venous drainage delay >4 seconds was considered as contraindication to ICA permanent occlusion. In patients with venous drainage delay of 2-4 seconds, the occlusion was performed only in selected cases. RESULTS: From a total of 60 patients, 44 had exact symmetry of the venous phase, 10 had delay of 1 second, and 3 other patients had 2-second delays. Clinical outcome for these 57 patients was uneventful. Three patients had venous drainage delay of 3 seconds. One of them had delayed watershed area infarction without clinical consequences at the time of hospital discharge. No periprocedural complications were observed. CONCLUSION: Venous opacification symmetry in the tested and control vascular territories was a reliable predictor of a subject's ability to tolerate carotid occlusion without developing neurologic deficit. Carotid sacrifice was found to be possible when the delay was <3 seconds.

Bilateral Transverse Sinus Angioplasty for the Treatment of Idiopathic Intracranial Hypertension ­ Case Report and Literature Review

Idiopathic intracranial hypertension (IIH) is a disease characterized by an increase in intracranial pressure, without presence of parenchymal lesions or hydrocephalus that justify it. Over 90% of cases there is association with stenosis of the dural venous sinuses. It is characterized by headache, tinidus, nausea, vomiting and visual disturbances. Initial treatment is clinical and when it fails there is indication of invasive procedures, among them shunts and fenestration of the optic nerve sheath. Angioplasty of dural venous sinuses, when indicated, has shown an alternative with better results and less complications. We report a case of a female patient, with 27 years old, diagnosed with IIH and bilateral transverse sinus stenosis, which was treated by bilateral stenting and total resolution of symptoms. Besides describing the case we review the literature about the subject.

Cavernous Carotid Artery Giant Aneurysm: Case Report and Literature Review

The giant aneurysm of the cavernous internal carotid artery is an uncommon event. In the case of giant aneurysmal formation, the patient presents with some signs or symptoms, reported or observed on physical examination,which reveal a possiblemass effect with neurovascular compression of the aneurysm, or even a subarachnoid hemorrhage due to the rupture of the aneurysm. We report the case of a 69-year-old patient who was admitted to the emergency department, referred by the basic health unit (BHU) of her locality for neurosurgical evaluation after suffering a mild traumatic brain injury (TBI). The patient, who was asymptomatic, carried with her a tomographic computerized examination of the skull, performed one day after the incident, evidencing left nodular parasellar lesion involving the cavernous sinus, discovered at random. After more specific clinical, laboratory and imaging exams, she was diagnosed with a giant aneurysm of the cavernous segment of the left internal carotid artery (LICA) and was submitted to endovascular embolization for correction.

Endovascular Neurosurgery in the Northern Macro-Region of Rio Grande do Sul: Part I

Introduction The city of Passo Fundo, in the north of the Rio Grande do Sul state, has been standing out in the health care field for many years. The state has become a reference in endovascular interventional neuroradiology. We will cover 10 years of experience in this area and divide our observations in 3 parts: cerebral angiograms (part I), carotid angioplasties (part II) and intracranial aneurysms (part III). The goal of part I is to statistically assess the cerebral angiograms, their indications, risks and complications, as well as to do a technical review. Materials and Methods A retrospective study from 2005 to 2015 with a total of 5,567 interventional neuroradiology procedures performed. A total of 4,114 angiograms, 639 embolizations of intracranial aneurysms, 414 carotid angioplasties, 143 embolizations of cerebral arteriovenous malformations, 32 embolizations of dural arteriovenous fistulas, 102 cerebral vasospasm treatments, 21 treatments of epistaxis, 36 embolizations of craniocervical tumor, 25 thrombolysis of ischemic stroke, 18 vertebroplasties and 13 embolizations of arteriovenous malformations of the face. Results A total of 4,084 procedures performed, 21,811 vessels studied, average vase 7.62/2.82 vessel and patient/procedure. Of these, 2,536 were diagnostic procedures and 1,548 angiographic controls. Of the total, 1,188 patients received only an angiogram, 27.14% of which were therapeutic procedures. We obtained a total of 3.89% complications: 2.33% reflection vasovagal, 0.56% allergic skin reaction, anaphylactic shock 0.07%, 0.27% femoral hematoma, 0.26% transient neurological deficit, 0.12% permanent neurological deficit and no case of death. Conclusion Cerebral angiography in adults, children and infants is a safe procedure with low risk of permanent neurological complications.

Arterial Embolization in the Treatment of Severe Epistaxis: A Case Report / Embolización Arterial en el Tratamiento de la Epistaxis Severa: Reporte de un Caso

ABSTRACT: Nasal hemorrhage or epistaxis is a common finding in the emergency department. The causes of epistaxis are varied and can be classified as local, systemic or a combination of both. The aim of this study was to report a case of embolization of branches of the maxillary artery for treatment of epistaxis secondary to facial trauma. A 43-year-old man suffered blunt trauma in the frontonasal area as a result of a bicycle accident. It presented with amnesia, severe epistaxis, panfacial edema and nasal deformity. The patient was hypotensive and hypothermic, with evidence of hemorrhagic intracranial. Orotracheal intubation was performed immediately to protect the airways and prevent aspiration of blood to the lower respiratory tract. The occlusion of the artery was successful and was immediately followed by cessation of oronasal bleeding. The patient was discharged after ten days. Arterial embolization should be the gold-standard treatment, which provides a safe and effective alternative for the control of epistaxis.

RESUMEN: La hemorragia nasal o epistaxis es un hallazgo común en el servicio de urgencias. Las causas de la epistaxis son variadas y pueden clasificarse como locales, sistémicas o una combinación. El objetivo de este estudio fuerelatar un caso de embolización de ramas de la arteria maxilar para el tratamiento de epistaxis secundaria a trauma facial. Um hombre de 43 años de edad sufrió traumatismo contuso en la zona frontonasal como consecuencia de un accidente de bicicleta. Se presentaba con amnesia, epistaxis grave, edema panfacial y deformidad nasal. El paciente fue hipotenso y hipotermático, con evidencia de hemorragia intracraneal. La intubación orotraqueal fue realizada inmediatamente para proteger las vías aéreas y evitar la aspiración de sangre para el tracto respiratorio inferior. La oclusión de la arteria fue exitosa y fue seguida inmediatamente por cesación de sangramiento oronasal. El paciente fue dado de alta después de diez días. La embolización arterial debe ser el tratamiento de elección, que proporciona una alternativa segura y eficaz para el control de la epistaxis.

Number of coils necessary to treat cerebral aneurysms according to each size group: a study based on a series of 952 embolized aneurysms.

OBJECTIVE: The Brazilian public health system determines a quantity of coils allowed to treat a cerebral aneurysm. The goal of this paper was to determine the number of coils necessary to treat an aneurysm based on size. METHODS: All patients harboring an aneurysm treated by endovascular approach between 1999 and 2003 were reviewed. RESULTS: There were 952 aneurysms included. Mean diameter sac was 8.2 mm with 7.9 coils per aneurysm. Out of 462 small aneurysms, mean size was 4.8 mm, with 4.6 coils/aneurysm used. A total of 315 medium aneurysms were treated, mean size was 8.6 mm, with 8.2 coils. Out of 135 large, mean size was 17 mm, with 16.1 coils. Forty giant aneurysms were treated with a mean size of 32 mm and 28.7 coils. CONCLUSIONS: We propose size as a reference to predict the number of coils necessary to treat each aneurysm: one coil for each millimeter of diameter.