Clinical and imaging outcomes of 100 patients with cerebrospinal fluid-venous fistulas treated by transvenous embolization.

BACKGROUND: Cerebrospinal fluid-venous fistulas (CSFVF) are a common cause of spontaneous intracranial hypotension (SIH). Transvenous embolization has emerged as a reliable treatment option. We review the clinical presentation, imaging, and clinical outcomes of 100 consecutive CSFVF patients who underwent embolization over 2 years. METHODS: Baseline clinical characteristics, imaging findings (including Bern SIH score), technical outcomes, and long-term imaging and clinical outcomes were collected. All patients had at least 3 months of clinical follow-up and had baseline MRI. 99/100 patients underwent follow-up imaging at ≥3 months post-treatment. RESULTS: 100 patients were included. Mean imaging and clinical follow-up duration was 8.3±7.7 months and 15.0±6.8 months, respectively. The mean duration of symptoms before embolization was 40.9±52 months. Mean baseline Bern SIH score was 5.9±3.3. The most common baseline symptoms were headache (96 patients), tinnitus (55 patients), and cognitive dysfunction (44 patients). Technical success rate was 100%. Mean post-treatment Bern SIH score was 0.9±1.6 (P<0.0001). Following treatment, 95% of patients reported significant improvement or resolution in symptoms (58 patients reporting resolution and 37 reporting improvement). 5 patients reported no improvement. There were no major procedural or periprocedural complications. 10 patients had minor procedural complications that did not result in any change in management (Onyx emboli, venous perforation). 19 patients had rebound intracranial hypertension requiring acetazolamide therapy. 7 patients had recurrent fistula at the initially treated level. CONCLUSIONS: Transvenous embolization of CSFVF in SIH patients is safe and effective with a 95% treatment response, significant improvement in imaging outcomes, and a very low rate of complications.

Utility of CT venography in monitoring stent patency in idiopathic intracranial hypertension: retrospective single-center study.

BACKGROUND: Cerebral venous sinus stenting is an established treatment for patients with idiopathic intracranial hypertension (IIH), refractory to medical management and with stenotic venous sinus on conventional cerebral venography. Currently, there are no clear guidelines on optimal noninvasive imaging modality for routine post-stenting follow-up. We investigated diagnostic yield of CT venography (CTV) for evaluation of stent patency. METHODS: We reviewed our clinical database of patients with a diagnosis of IIH, who underwent stenting of stenotic transverse or transverse/sigmoid sinus junction. Patients who had follow-up CTVs after more than 30 days were included in the final study group. All CTVs were reviewed by two readers for in-stent thrombosis, extrinsic stent compression, juxta-stent stenosis, and new contralateral venous sinus stenosis. Inter-observer agreement and association of stent patency with clinical outcomes (headache and papilledema) were assessed. RESULTS: In all 36 included patients with 38 cerebral venograms for stenting, follow-up CTVs demonstrated adequate opacifications of the venous sinuses and stents for confident evaluation for in-stent thrombosis, extrinsic stent compression, juxta-stent stenosis, and new contralateral venous sinus stenosis, with inter-observer agreement coefficient of 0.7, 1.0, 0.8, and 1.0 respectively. Association between abnormal CTV and higher rates of persistent headache and lower rates of headache improvement/resolution was statistically significant (P-value of 0.01). CONCLUSION: CTV is a reliable noninvasive imaging modality for evaluation of cerebral venous sinuses and stent patency following treatment of idiopathic intracranial hypertension with venous sinus stenting and could be used as a routine follow-up study.

Sclerotherapy for low-flow vascular malformations of the orbital and periocular regions: Systematic review and meta-analysis.

Percutaneous sclerotherapy is an alternative strategy for the treatment of vascular malformations of the orbital and periorbital regions. The safety and efficacy of sclerotherapy in this setting have not been fully established. We present the results of a systematic review and meta-analysis examining the safety and efficacy of percutaneous sclerotherapy for the treatment of vascular malformations of the orbit. We searched PubMed, MEDLINE, and EMBASE from 2000 to 2018 for studies evaluating the safety and efficacy of percutaneous sclerotherapy for orbital and periorbital vascular malformations. Two independent reviewers selected studies and abstracted data. The primary outcome of this study is the efficacy of sclerotherapy which includes complete response, partial response, or no response to sclerotherapy. Data were analyzed using random-effects meta-analysis. Thirteen studies reporting on 154 patients were included. The rate of complete cure after percutaneous sclerotherapy was 54.9% (95% confidence interval [CI] = 34.2%-75.7%). The rate of emergent decompressive surgery was 3.4% (95% CI = 0.5%-6.2%), and the rate of vision loss was 2.7% (95% CI = 0.1%-5.3%). I2 values were above 50% for most outcomes indicating substantial heterogeneity. Our systematic review and meta-analysis of 13 studies and over 150 patients found that percutaneous sclerotherapy is a safe and effective treatment modality for the treatment of low-flow vascular malformations of the orbit.

Radiation dose reduction during neuroendovascular procedures.

AIM: To describe the impact of steps towards reduction of procedural doses of radiation during neuroendovascular procedures. METHODS: Phantom exposures under controlled circumstances were performed using a Rando-Alderson adult-sized head phantom. Customized imaging protocols were devised for pediatric and adult imaging and implemented in clinical use. Outcome data for estimated skin doses (ESD) and dose-area product (DAP) following pediatric and adult diagnostic and interventional procedures over 4.5 years were analyzed retrospectively. RESULTS: Dose estimates were reduced by 50% or more after introduction of customized imaging protocols in association with modification of personnel behavior compared with doses recorded with previously used vendor-recommended protocols. DISCUSSION: Substantial reductions in radiation use during neuroendovascular procedures can be achieved through a combination of equipment modification and operator behavior.

Occult dural arteriovenous fistula causing rapidly progressive conus medullaris syndrome and paraplegia after lumbar microdiscectomy.

BACKGROUND CONTEXT: A spinal dural arteriovenous fistula (DAVF) is a known cause of venous congestive myelopathy. These lesions are thought to be acquired. There exist two prior reports that describe DAVF presenting with slowly progressive myelopathy years after lumbar disc surgery. PURPOSE: We report the first case of a preexistent, asymptomatic DAVF that became acutely symptomatic after lumbar microdiscectomy causing rapidly progressive conus medullaris syndrome and paraplegia. STUDY DESIGN: Case report. METHODS: A 53-year-old Caucasian male presented with urinary retention, fecal incontinence, and progressive loss of function in bilateral lower extremities less than 3 months after a lumbar discectomy at an outside facility. The patient underwent microdiscectomy at L4/L5 and L5/S1 for left-sided radicular symptoms and evidence of herniated discs on magnetic resonance imaging (MRI). The patient's preoperative pain improved after the discectomy, but his bowel, bladder, and lower extremity function deteriorated steadily after discharge. Postoperative MRI showed salient serpentine vessels in the region of L1 and L2 with an enlarged T2 bright conus medullaris. Retrospective review of preoperative MRI revealed the presence of similar but less pronounced findings. A spinal arteriogram confirmed concerns of an arteriovenous malformation. The patient was transferred to our facility for definitive management of his DAVF via catheter embolization. RESULTS: Complete fistula obliteration was confirmed at the time of embolization and at 8 weeks follow-up with selective spinal angiography. The appearance of the conus medullaris normalized on follow-up MRI. The patient made a slow but significant recovery in rehabilitation. He regained the ability to independently ambulate but remains significantly disabled secondary to residual lower extremity weakness and spasticity. He continues self-catheterization for persistent neurogenic bladder dysfunction. CONCLUSIONS: This represents the first case of an occult spinal DAVF becoming acutely symptomatic after lumbar disc surgery. Although the etiology of the lesion and its symptomatic progression remains unknown, an alteration of blood flow through the DAVF as a result of surgery may have resulted in progressive venous congestive myelopathy. The present case highlights the importance of considering a spinal DAVF in the differential diagnosis of any patient with signs of myelopathy or conus medullaris syndrome after lumbar discectomy. In addition, this case underscores the gravity of recognizing subtle features that suggest the presence of an occult vascular malformation on preoperative imaging, as symptomatic progression of these lesions carries significant potential morbidity.

Endovascular management of vertebrobasilar dissecting aneurysms.

BACKGROUND AND PURPOSE: Several approaches to the treatment of dissecting aneurysms of the vertebrobasilar system have been used. We evaluated our endovascular experience, which includes trapping and proximal occlusion. METHODS: Thirty-five patients with intradural vertebrobasilar dissecting aneurysms presented to our institution between 1992 and 2002. Twenty-six were treated by endovascular means and two with surgery. In the endovascular group, 14 were in a supra-posterior inferior cerebellar artery (PICA) location, and three of these extended to the vertebrobasilar junction on the initial angiogram. Ten were located in an infra-PICA location, or no antegrade flow was seen in the PICA or anterior spinal artery. Two were located at the PICA with antegrade flow preserved in the branch. Twelve lesions were treated with trapping; another 14 were initially treated with proximal occlusion techniques, two of which eventually required trapping procedures. Follow-up images were obtained within 1 year of initial treatment in 24 patients. Mean follow-up for these patients was 3.5 years. RESULTS: Initial treatments were technically successful and without complication in all 26 patients. Follow-up examinations showed complete cure in 19 of 24 patients. One patient died of global ischemia after presenting as Hunt and Hess grade 5 with subarachanoid hemorrhage. Two recurrent hemorrhages occurred in patients in the proximal occlusion group; one died, and the other underwent a trapping procedure. One patient developed contralateral vertebral dissection 24 hours after occlusion of a dissecting aneurysm of the dominant vertebral artery and died of a brain stem infarct. Another died of probable vasospasm, and the last died of an unknown cause 1 month after treatment. Two patients had recanalization despite an initial trapping procedure, both underwent further treatment. Mortality rate was 20% in the treated group (including the two patients treated surgically), with four of five deaths occurring during the initial hospital course. Mortality rate was 50% in the six patients in the untreated group who were available for follow-up. CONCLUSION: Dissecting aneurysms of the vertebrobasilar system remain high-risk lesions because of their natural history. They can be managed by endovascular methods according to aneurysm location, configuration, collateral circulation, and time of presentation. Trapping results in better prevention of rehemorrhage. Proximal occlusion can achieve occlusion without manipulation of the affected segment when more direct endovascular occlusion or stent placement cannot be performed.