Endovascular therapy of idiopathic cavernous aneurysms over 11 years.

PURPOSE: We report our experience with 42 patients with 48 cavernous carotid aneurysms, of whom 32 were treated with endovascular techniques and 10 were managed conservatively. METHODS: The 48 aneurysms were divided into two subgroups by location: 23 were at the C-3 portion of the carotid artery (small, saccular aneurysms with an epidural, partly intracavernous location) and 25 originated at the C4-5 segment (large or giant often fusiform aneurysms with a true intracavernous location). Morphologic features in both groups correlated well with differences in clinical presentation and also influenced therapy. Sixteen of the 25 C4-5 aneurysms (all large or giant) were treated by balloon occlusion of the parent artery, four (with narrow necks) were treated with Guglielmi detachable coils (GDCs), and five were not treated (asymptomatic or minimally symptomatic). Twelve of 13 C-3 aneurysms were treated with GDCs. Ten C-3 aneurysms were not treated. RESULTS: Ophthalmoplegia resolved or improved in nine of 12 patients treated with parent artery occlusion. All aneurysms treated by carotid occlusion thrombosed. Twelve of the 17 aneurysms treated with GDCs were 100% filled by the coils, four were 80% to 95% filled, and one was only 40% filled. Seven of the 100% filled aneurysms remained completely occluded, two showed slight coil compaction, and in three, follow-up angiography was not available. Among the incompletely filled aneurysms, two remained unchanged, one showed progressive thrombosis, a fourth revealed coil compaction, and in one, follow-up angiography was not available. One thromboembolic stroke and three transient ischemic attacks occurred perioperatively, for a permanent morbidity of 3.5% and a transient morbidity of 9%. There was no mortality. Mean clinical follow-up was 33 months; mean angiographic follow-up of patients treated with GDCs was 11 months. CONCLUSION: Surgically difficult cavernous aneurysms can be obliterated by embolization with excellent clinical results. Detachable coils have become an important endovascular tool, especially for narrow-necked cavernous aneurysms of the C-3 segment, which can be protected against rupture in the subarachnoid space in most cases.

Superselective indocyanine green angiography for selective revascularization in the management of peripheral cerebral aneurysms.

This report describes the management of a fusiform peripheral middle cerebral artery aneurysm by endovascular parent artery occlusion under bypass protection. Localization of the recipient cortical artery was accomplished after craniotomy by superselective injection of diluted ICG dye via a microcatheter positioned proximal to the aneurysm. This report demonstrates that superselective ICG angiography can be a beneficial alternative technique to identify the best anastomosis site intraoperatively.

Emergency Extracranial-to-Intracranial Bypass after Thromboembolic Occlusion of the Middle Cerebral Artery Following GDC Embolization of a Ruptured ACoA Aneurysm.

SUMMARY: We report a case of thromboembolic occlusion of the middle cerebral artery after endovascular treatment of a ruptured anterior communicating artery aneurysm. When fibrinolytic therapy failed to recanalize the occluded vessel, an emergency extracranial-to-intracranial bypass was performed. This intervention rescued our patient from cerebral infarction. This case demonstrates the importance of the offering this procedure at neurointerventional centers.

[The technique of stereotactic I125 brachytherapy (permanent implants) of brain tumors in Vienna]. / Technik der stereotaktischen J125-Brachytherapie (permanente Implantate) von Hirntumoren in Wien.

Methods of stereotactic target localisation are used in brachytherapy of brain tumors for many years. Since 1987 eight patients with inoperable astrocytomas grade I to III were treated at the Neurosurgical Clinic and Clinic for Radiotherapy of the University Vienna by permanent stereotactic I125-seed implantation. For that purpose a newly developed applicator was used. Preliminary results confine the low risk of operation, but the follow-up time is too short for evaluation of the treatment success. Principal problems of brain brachytherapy are discussed in the light of international data. In general, I125 brachytherapy is a useful and well tolerated way of treatment of low grade astrocytomas, the risk is low, which is especially important for children and old patients.

[Extra- and intracranial Doppler ultrasound. Evaluation of patients with surgical anastomosis of the arteria temporalis superficialis superficialis and arteria cerebri media]. / Extra- und intrakranielle Doppler-Sonographie. Beurteilung von Patienten mit operativen Anastomosen zwischen A. temporalis superficialis und A. cerebri media.

During a mean postoperative period of 16 months, 51 patients who had received an extracranial-intracranial (EC-IC) arterial bypass were examined by means of transcranial and extracranial Doppler ultrasound, with the following results: the flow velocities of the middle cerebral artery (MCA) are postoperatively significantly lower than in normal control subjects. No differences were seen if the MCA was supplied via the EC-IC bypass or via any "natural" collateral vessels. In 32 cases, blood supply of the MCA artery was provided via the EC-IC bypass. In another 13 cases the MCA was supplied via the contralateral carotid artery and in six further cases via other collateral vessels. In the extracranial area, an internalisation of the flow pattern of the superficial temporal artery was found if the bloodstream from the anastomosis passed through the MCA. Similar changes at the external carotid artery were mainly due to the changed haemodynamics resulting from the extracranial occlusion of the internal carotid artery. No correlation was found between the clinical neurological course and haemodynamic data. The only indication for the EC-IC bypass, as we see it at the moment, is prophylactic surgery, such as, for example, treatment of giant aneurysms and definitely insufficient crossflow. All other indications that have been suggested after the publication of the results of the EC-IC Bypass Study Group will have to be confirmed by further study.

Spontaneous subarachnoid hemorrhage with negative angiography: CT findings.

Computed tomography of 31 patients with spontaneous subarachnoid hemorrhage (SAH) but negative angiography was evaluated to find out whether the pattern of SAH as seen in CT offers indications for a possible reexamination with angiography. Based on the distribution and the amount of SAH, classification into three groups was possible: (a) 18 cases, normal CT (but blood in the CSF, gained by lumbar puncture) or SAH in the basal cisterns only; repeat angiography was negative in all these cases; (b) nine cases, SAH in the basal cisterns as well as in one or both Sylvian fissures; in addition, small amounts of blood in the interhemispheric fissure and/or in the sulci; repeat angiography revealed an aneurysm in one of these cases; (c) four cases, large quantities of blood in all subarachnoid spaces; in all but one of these cases a vascular lesion was visualized with repeat angiography or verified at autopsy. In conclusion, repeat angiography is mandatory in cases with SAH patterns that can be classified into group b or c, whereas it can be omitted in patients with small amounts of blood confined to the basal cisterns.

False aneurysms of the intracavernous carotid artery--report of 7 cases.

We present 7 cases of false intracavernous carotid artery aneurysms. Four occurred after trauma and three were caused iatrogenically. Two of the latter occurred in patients with pituitary adenomas, one after transsphenoidal microsurgery and the other after yttrium [YI90] seed implantation into the sella. The third iatrogenic aneurysm was seen shortly after transcavernous tumour surgery. In five of our seven patients massive, delayed, life-threatening epistaxis was the leading symptom. All traumatic cases were associated with immediate unilateral blindness or blurred vision and with skull base fractures. One of these had a concomitant carotid cavernous fistula. Treatment of choice of our 5 recent cases was permanent balloon occlusion of the intracavernous carotid artery at the level of the lesion. Collateral circulation was evaluated prior to definitive carotid occlusion using a balloon test occlusion. During the balloon test adequate collateral circulation was defined as symmetric angiographic filling of both hemispheres. Awake patients were neurologically examined continuously. In unconscious patients transcranial Doppler sonography, electroencephalographic and somatosensory evoked potential monitoring was used in addition. Intra-operative heparin administration was not reversed with protamin. A postoperative continuous heparin infusion was not found necessary. In our two early cases this technique was not available: In the first case we accomplished aneurysm occlusion by a surgically introduced Fogarty balloon catheter. Our second patient needed surgical trapping of the involved carotid after early unsuccessful attempts of selective aneurysm occlusion. After treatment no further epistaxis occurred. Follow-up angiography showed persistent aneurysm occlusion. The results were excellent in 5 cases and good in 1 case. One patient with bilateral lesions suffered a stroke after occlusion of the second, remaining carotid artery, despite functioning bilateral extra-intracranial bypasses. Four years later there is a mild dysphasia still present in this patient. The mean follow-up time was 75.6 months.