Brachial artery approach for endovascular treatment of posterior circulation intracranial vascular disease: technique and application in 5 cases.

Although the transbrachial artery approach has been well described as an alternative for percutaneous coronary interventions and diagnostic cerebral arteriography, little has been reported regarding the use of this technique for therapeutic neuroendovascular procedures. We highlight the technical applications of this technique during 5 procedures. Three women (age 68, 69, and 83 years) and 1 man (age 79 years) were treated using brachial artery access. Two of the women with complex posterior circulation aneurysms were treated with stent-assisted coil embolization. The third woman presented with a symptomatic occlusion of the basilar artery and underwent intra-arterial thrombolysis and angioplasty, followed at a later date by a second intra-arterial thrombolysis procedure. The male patient presented with recurrent, intractable posterior circulation ischemic events and underwent balloon angioplasty and stenting of a high-grade stenosis of the right vertebral artery. All patients had failed treatment via a transfemoral route and demonstrated significant thoracoaortic and/or iliofemoral tortuosity. Appropriate intracranial vascular access was achieved in all patients, and there were no intraprocedural complications. We conclude that a transbrachial approach may be successfully used for a variety of therapeutic neuroendovascular interventions when a transfemoral route is not available.

Onyx-HD 500 Embolization of a Traumatic Internal Carotid Artery Pseudoaneurysm after Transsphenoidal Surgery.

BACKGROUND AND PURPOSE: Traumatic intracranial pseudoaneurysms present a challenge for treatment. Traditionally these lesions have required a deconstructive approach consisting of vessel sacrifice since their fragile nature often makes direct microsurgical repair or coil embolization hazardous. As a high-viscosity liquid embolic agent that results in immediate, vessel sparing aneurysm occlusion, Onyx-HD 500 represents a uniquely efficacious tool for this clinical situation. CASE SUMMARY: We report the case of a 56-year-old right-handed gentleman who suffered a vascular injury to the ICA during revision transsphenoidal surgery for a recurrent pituitary macroadenoma. The patient was initially treated with nasal packing, but after recurrent episodes of epistaxis and a CT angiogram demonstrating a large traumatic ICA pseudoaneurysm, the patient was referred for invasive treatment. Given the presumed fragility of the lesion, embolization with Onyx-HD 500 was chosen in order to safely achieve immediate aneurysm occlusion without the need for vessel sacrifice. After an early recurrence due to incomplete initial embolization, the patient went on to complete occlusion without further hemorrhage. CONCLUSION: This case illustrates the utility of a high-viscosity liquid embolic agent in providing immediate protection from rehemorrhage by occluding a large ruptured pseudoaneurysm of the proximal intracranial ICA, while sparing the parent artery.

Development and spontaneous regression of a de novo posterior communicating artery aneurysm in a child following gamma knife stereotactic radiosurgical obliteration of a cerebral AVM: Case report and review of the literature.

Reports of the development of true intracranial aneurysms after radiosurgery are exceedingly rare and unconvincing. We report the case of a young boy who developed a posterior communicating artery aneurysm after the Gamma Knife radiosurgical treatment of a thalamic AVM. This ten year-old presented with left upper extremity tremors. MRI/MRA revealed a right thalamic AVM. No intracranial aneurysms were found on initial angiography. The patient underwent two-stage endovascular embolization of his AVM followed by Gamma Knife radiosurgical treatment (18 Gy delivered to the 50% isodose line). Follow up angiogram at 38 months confirmed obliteration of the AVM, but revealed a new 2.2 x 1.5 mm aneurysm located at the origin of the right posterior communicating artery. A MRA obtained 5 months later (43 months after treatment) demonstrated regression of the aneurysm. This is the first report of the development of an intracranial aneurysm after Gamma Knife radiosurgery in a child and the first description to include pre and post-treatment angiography that clearly demonstrates interval aneurysm development. Although the aneurysm showed subsequent regression during continued follow-up, this report illustrates the critical importance of post-treatment angiography for patients with intracranial AVM treated in this manner.