Combined Treatment of High-Flow Scalp Arteriovenous Malformations.

INTRODUCTION: Appropriate treatment of scalp arteriovenous malformations (SAVMs) remains largely unclear given the rarity of reported cases. This single-institution case series presents consecutive patients with extracranial SAVMs and long-term follow up.The primary aim of this study was to review treatment decisions, evaluate clinical outcomes, and compare our experience to available literature in order to better understand SAVMs and improve future outcomes. MATERIALS AND METHODS: A retrospective review of consecutive patients with extracranial SAVMs between January 2015 and December 2019 was performed. Treatment factors of interest included embolization method, embolic agents, and decision to proceed with surgical resection. Relevant clinical outcomes included recurrence rates, cure rates, and complications. RESULTS: Seven patients were included in the present series. Satisfactory outcomes were ultimately achieved for all 7 patients using embolization with or without combined surgical resection. Embolizations performed in combination with resection were curative in 4 of 4 cases (100%). Embolizations performed without resection were curative in 0 of 4 cases (0%), satisfactory in 2 of 4 cases (50%), and unsatisfactory in 2 of 4 cases (50%). DISCUSSION: All SAVM patients in this series were treated satisfactorily using embolization with or without operative resection. This study strongly suggests that embolization combined with surgical resection during the same admission yields the best treatment outcomes for SAVMs, specifically demonstrating lower rates of recurrence and embolization-related complications. Decisions on whether or not to proceed with resection should be made by the interventional radiologist, the plastic surgeon, and the patient together.

High Output Cardiovascular Physiology and Outcomes in Fetal Diagnosis of Vein of Galen Malformation.

Vein of Galen aneurysmal malformation (VGAM) is a rare anomaly associated with poor outcomes from high output cardiac failure and neurologic complications. Studies addressing fetal cardiovascular status and outcomes in this population are limited. A single-center retrospective review was conducted on patients with a prenatal diagnosis of VGAM who underwent a fetal echocardiogram between January 2015 and July 2019. Fetal echocardiographic data, brain magnetic resonance imaging (MRI) findings and outcomes were collected. Nine fetuses [median gestational age at echocardiogram 34 (1.1) weeks] were included. All patients had superior vena cava dilation and reversal of diastolic flow in the transverse aortic arch. Median cardiothoracic (CT) ratio was 0.39 (0.09). Right ventricular (RV) and left ventricular (LV) dysfunction was present in 66% and 11% fetuses, respectively. Four out of five patients that underwent postnatal endovascular neurosurgical interventions at our center were alive at follow-up (mean 2.7 years). Of the non-survivors (n = 5), 3 received comfort care because of severe brain damage and died in the neonatal period. Non-survivors more commonly had > mild tricuspid regurgitation (TR) (40% vs. 25%) and > mild RV dilation (60% vs. 25%). Combined cardiac index (CCI) was higher in non-survivors when compared to survivors (672.7 vs. 530.2 ml/kg/min, p = 0.016). Fetuses with significant parenchymal damage on brain MRI tended to have a higher CCI than those without (979.8 vs. 605.0 ml/kg/min, p = 0.047). RV dysfunction, TR and elevated CCI are more commonly seen in non-survivors with VGAM. A higher CCI is seen in those deemed untreatable due to significant parenchymal volume loss. Future multicenter studies are needed to assess for prenatal prediction of outcomes in this high-risk population.

National Trends in Utilization and Outcome of Endovascular Thrombectomy for Acute Ischemic Stroke in Elderly.

OBJECTIVE: Octogenarians were excluded and/or underrepresented in the major endovascular thrombectomy (EVT) randomized controlled trials, but continue to make up a growing proportion of stroke patients. To evaluate real-world trends in utilization and outcome of EVT in patients ≥80 years in a large nationally representative database. METHODS: Using the Nationwide Inpatient Sample (2014-2016), we identified patients admitted to United States hospitals with acute ischemic stroke (AIS) who also underwent EVT. The primary endpoint was good outcome (discharge to home/acute rehabilitation center). Poor outcome (discharge to skilled nursing facility or hospice and in-hospital mortality), intracerebral hemorrhage and in-hospital mortality were secondary outcome measures. RESULTS: In 376,956 patients with AIS, 6,230(1.54%) underwent EVT. 1,547(24.83%) were ≥80. The rate of EVT in AIS patients ≥80 more than doubled from 0.83%(n = 317) in 2014 to 1.83%(n = 695) in 2016. The rate of good outcome in patients ≥80 was 9%, significantly lower than younger patients (26%, p<0.001). In-hospital mortality was 19% in patients ≥80 compared to 13% in the younger cohort (p < 0.001). There was no difference in the rate of hemorrhagic transformation between octogenarians and younger patients (18.52% vs 17.01%, p=0.19). In patients ≥80 years of age, decreasing baseline comorbidity burden independently predicted good outcome (OR 0.258, 95% CI [0.674- 0.935]). CONCLUSIONS: A two-fold increase in the utilization of EVT in patients ≥80 years of age was seen from 2014 to 2016. While the comparative rate of good outcome is significantly lower in this age group, elderly patients with fewer comorbidities demonstrated better outcomes after EVT.

Emergent Large Vessel Occlusion Stroke During New York City's COVID-19 Outbreak: Clinical Characteristics and Paraclinical Findings.

BACKGROUND AND PURPOSE: The 2019 novel coronavirus outbreak and its associated disease (coronavirus disease 2019 [COVID-19]) have created a worldwide pandemic. Early data suggest higher rate of ischemic stroke in severe COVID-19 infection. We evaluated whether a relationship exists between emergent large vessel occlusion (ELVO) and the ongoing COVID-19 outbreak. METHODS: This is a retrospective, observational case series. Data were collected from all patients who presented with ELVO to the Mount Sinai Health System Hospitals across New York City during the peak 3 weeks of hospitalization and death from COVID-19. Patients' demographic, comorbid conditions, cardiovascular risk factors, COVID-19 disease status, and clinical presentation were extracted from the electronic medical record. Comparison was made between COVID-19 positive and negative cohorts. The incidence of ELVO stroke was compared with the pre-COVID period. RESULTS: Forty-five consecutive ELVO patients presented during the observation period. Fifty-three percent of patients tested positive for COVID-19. Total patients' mean (±SD) age was 66 (±17). Patients with COVID-19 were significantly younger than patients without COVID-19, 59±13 versus 74±17 (odds ratio [95% CI], 0.94 [0.81-0.98]; P=0.004). Seventy-five percent of patients with COVID-19 were male compared with 43% of patients without COVID-19 (odds ratio [95% CI], 3.99 [1.12-14.17]; P=0.032). Patients with COVID-19 were less likely to be White (8% versus 38% [odds ratio (95% CI), 0.15 (0.04-0.81); P=0.027]). In comparison to a similar time duration before the COVID-19 outbreak, a 2-fold increase in the total number of ELVO was observed (estimate: 0.78 [95% CI, 0.47-1.08], P≤0.0001). CONCLUSIONS: More than half of the ELVO stroke patients during the peak time of the New York City's COVID-19 outbreak were COVID-19 positive, and those patients with COVID-19 were younger, more likely to be male, and less likely to be White. Our findings also suggest an increase in the incidence of ELVO stroke during the peak of the COVID-19 outbreak.

COVID-19 and Decompressive Hemicraniectomy for Acute Ischemic Stroke.

BACKGROUND AND PURPOSE: Young patients with malignant cerebral edema have been shown to benefit from early decompressive hemicraniectomy. The impact of concomitant infection with coronavirus disease 2019 (COVID-19) and how this should weigh in on the decision for surgery is unclear. METHODS: We retrospectively reviewed all COVID-19-positive patients admitted to the neuroscience intensive care unit for malignant edema monitoring. Patients with >50% of middle cerebral artery involvement on computed tomography imaging were considered at risk for malignant edema. RESULTS: Seven patients were admitted for monitoring of whom 4 died. Cause of death was related to COVID-19 complications, and these were either seen both very early and several days into the intensive care unit course after the typical window of malignant cerebral swelling. Three cases underwent surgery, and 1 patient died postoperatively from cardiac failure. A good outcome was attained in the other 2 cases. CONCLUSIONS: COVID-19-positive patients with large hemispheric stroke can have a good outcome with decompressive hemicraniectomy. A positive test for COVID-19 should not be used in isolation to exclude patients from a potentially lifesaving procedure.

Occult middle meningeal artery to middle cerebral artery anastomosis associated with prior trauma.

The report describes a patient who presented with traumatic right temporoparietal calvarial fracture with chronic right subdural haematoma who underwent right middle meningeal artery embolisation with n-BCA during which direct filling of an anterior temporal branch of the middle cerebral artery was observed.

Vein of Galen Malformations.

Significant efforts have been made over the last few decades to improve the diagnosis and management of patients with vein of Galen malformations (VOGMs). The mainstays of treatment remain focused on primary endovascular management by staged transarterial embolizations with adjunctive use of transvenous embolization, medical therapy, and neurosurgical intervention for symptom control in select patients. Innovation in endovascular technology and techniques as well as promising new genomic research elucidating potential therapeutic targets hold significant promise for the future of VOGM treatment.

Endovascular therapy for asymptomatic unruptured intracranial aneurysms: JR-NET and JR-NET2 findings.

BACKGROUND AND PURPOSE: National registration studies (the Japanese Registry of Neuroendovascular Therapy [JR-NET] and JR-NET2) have determined the current status and outcomes of neuroendovascular therapy (neuro-EVT). We analyzed short-term outcomes of EVT for asymptomatic unruptured intracranial aneurysms (UIAs). METHODS: We extracted periprocedural information about EVT for 4767 asymptomatic UIAs from 31,968 registered procedural records of all EVT in the JR-NET and JR-NET2 databases. We assessed the features of the aneurysms and procedures, immediate radiographic findings, procedure-related complications, and clinical outcomes at 30 days after the procedures. RESULTS: We located 80.0% of UIAs in the anterior circulation, and the most frequent were paraclinoid. The diameter of 2.5%, 32.9%, 51.9%, 12.0%, and 0.7% of the UIAs was <3, 3 to 4, 5 to 9, 10 to 19, and >20 mm, respectively. EVT failed in only 2.1%. Adjunctive techniques were applied in 54.8% of procedures. Pre- and postprocedural antiplatelet agents were prescribed in 85.6% and 84.0%, respectively, of the procedures. The immediate radiographic outcomes of 57.7%, 31.9%, and 10.0% of the UIAs comprised complete occlusion, residual necks, and residual aneurysms, respectively. Complications that were associated with 9.1% of procedures comprised 2.0% hemorrhagic and 4.6% ischemic, and the 30-day morbidity and mortality rates were 2.12% and 0.31%, respectively. CONCLUSIONS: The radiographic results of EVT for asymptomatic UIAs in Japan were acceptable, with low mortality and morbidity rates.

Evolution of transvenous embolization in vein of Galen malformation: case series and review of the literature.

BACKGROUND: Treatment of vein of Galen malformations (VOGMs) has improved greatly since the inception of endovascular treatment. Transvenous embolization (TVE) is an attractive option to achieve complete obliteration. OBJECTIVE: To review the literature on TVE of VOGM and then analyze our practice's unique experience and evolving treatment strategies over 30 years. METHODS: A retrospective review of our clinical database for patients with the diagnosis of VOGM treated between January 2004 and August 2021 was performed. A literature review of 49 relevant articles was also carried out. RESULTS: TVE in VOGM has evolved with initial introduction as a transtorcular (TT) approach, which then lost favor to transarterial embolization (TAE). TAE has been considered the more favorable approach in most high-volume centers. In more recent times, the transvenous embolization (TVE) approach has been revisited as a last treatment to achieve a cure after a series of TAE treatments. We presently favor beginning treatment with staged TAE to reduce flow to the lesion and, importantly, shrink the draining vein. This then allows for the performance of TVE with the Chapot pressure cooker technique (CPCT) with coils and liquid embolic embolization. CONCLUSIONS: TT TVE itself carries a high degree of risk and is most highly associated with long-term morbidities and mortality. Traditional transfemoral/transjugular TVE approaches are safe and effective in simple fistulas with a small venous pouch; however, we believe that the CPCT is the safest technique as a last-stage treatment for its security in avoiding reflux and obtaining occlusion of the small perforators.

Placement of an intrasaccular flow diverter in an intracranial sidewall aneurysm using the Bendit articulating microcatheter.

Intrasaccular flow diversion is a new endovascular option for managing unruptured intracranial aneurysms.1-6 However, catheter ejection can occur during placement of an intrasaccular flow diverter, especially in tortuous vasculature that creates unfavorable angles between the aneurysm neck and the parent vessel.5 The Bendit steerable microcatheter (Bendit Technologies, Petah Tikva, Israel) can dynamically change its tip angle and may mitigate these placement concerns.7-9 Here, we report the placement of an intrasaccular flow diverter for the treatment of an unruptured internal carotid artery sidewall aneurysm at an unfavorable neck angle using the Bendit microcatheter (video 1). The Bendit was navigated around the 180° turn of the carotid siphon and held a stable position during device delivery. The device was sequentially deployed as the Bendit was progressively straightened and was successfully placed within the aneurysm. No neurological complications were experienced and the patient was asymptomatic on follow-up 3 months later.neurintsurg;jnis-2023-020529v1/V1F1V1Video 1Placement of an intrasaccular flow diverter in an intracranial sidewall aneurysm using the Bendit articulating microcatheter.

Percutaneous sclerotherapy of microcystic lymphatic malformations: the use of an innovative gravity-dependent technique.

BACKGROUND: In the last few decades there has been development of innovative therapies for the treatment of craniofacial lymphatic malformations. Percutaneous sclerotherapy has demonstrated efficacy in the management of macrocystic lymphatic lesions, but it is less suitable for microcystic lesions given their size. The gravity-dependent technique is a novel augmentation of standard percutaneous sclerotherapy: the technique enables a sclerosing agent to permeate the small microchannels seen in microcystic lesions that would otherwise be difficult to treat. METHODS: Between 2005 and 2021, 124 patients with microcystic or mixed lymphatic malformations were treated using a novel gravity-dependent sclerotherapy technique. Bleomycin at a maximum dose of 15 IU per session was used as the main sclerosing agent. Fluoroscopy and ultrasound were used to ensure proper positioning of the catheter prior to injecting the sclerosing agent. The response to treatment was assessed clinically and with cross-sectional imaging. RESULTS: Nearly all cases showed significant improvement after the gravity-dependent technique. There have been no permanent complications from sclerotherapy treatment. There was a mild transient adverse effect from bleomycin in one case of erythema and tenderness that lasted several weeks then ameliorated. CONCLUSIONS: The gravity-dependent sclerotherapy technique is a suitable treatment option for microcystic lymphatic malformations.

Safety and efficacy of dual lumen balloon catheters for the Treatment of cerebral vascular malformations: A systematic review, pooled analysis, and meta-analysis.

BACKGROUND: There is little evidence in scientific literature assessing the safety and efficacy of dual-lumen balloon catheters (DLBCs) and their performance compared to single-lumen catheters (SLCs). METHODS: In this PROSPERO-registered, PRISMA-compliant systematic review, we identified all MEDLINE and EMBASE single-arm (DLBCs) and double-arm (DLBCs vs SLCs) cohorts where DLBCs were used for the treatment of cerebral arteriovenous malformations (AVMs) or dural arteriovenous fistulas (dAVFs). Immediate angiographic outcome, vascular complications, technical failures, reflux episodes and entrapment were the primary outcomes. A meta-analysis of the double-arm studies summarized the primary outcomes of total procedural time and immediate angiographic outcome. RESULTS: The authors identified 18 studies encompassing 209 treated lesions with reported outcomes. Complete occlusion was achieved in 108/132 treated dAVFs (81.8%, 95% CI: [74-87.8%]) and in 45/77 treated AVMs (58.4%, [46.7-69.4%]). The proportion of completely occluded dAVFs was statistically significantly higher than that of AVMs, p < .001. There were eight reported vascular complications (3.8%, [1.8-7.7%]), five technical failures (2.4%, [0.9-5.8%]), 14 reflux events (6.7%, [3.9-11.2%]), two entrapment events (1%, [0.2-3.8%]) and 0 deaths (mortality rate 0%, [0-2.3%]). In a meta-analysis for the treatment of dAVFs, the total procedural time was significantly less for DLBCs compared to SLCs (64.9 vs 125.7 min, p < .0001). The odds of complete immediate occlusion were significantly higher with DLBCs compared to SLCs (odds ratio (OR) 4.6, [1.5-14.3], p = .008). CONCLUSION: Dual-lumen balloon catheters are safe and effective for the embolization of cerebral AVMs and dAVFs and can achieve faster and potentially superior results compared to SLCs. REGISTRATION-URL: https://www.crd.york.ac.uk/prospero/ Unique Identifier: CRD42021269096.

Transvenous balloon-assisted approach to anterior fossa dural arteriovenous fistula using retrograde pressure cooker technique.

Endovascular embolization is the first-line therapy for dural arteriovenous fistulas (dAVFs). Transarterial embolization (TAE) may be limited by poor anatomical access. Transvenous embolization avoids this, but carries a risk of hemorrhage, venous redirection, and neurologic deterioration. Dual-lumen balloon microcatheters like the Scepter Mini (Microvention, Aliso Viejo, CA, USA) provide flow arrest and prevent reflux during TAE with liquid embolic agents (LEAs), but use in the distensible veins may be challenging. In this video, we use a Scepter Mini in a transvenous approach to a Cognard type IV anterior ethmoidal dAVF as a safe alternative to surgery, transvenous pressure cooker, and trans-ophthalmic TAE (video 1). The Scepter Mini was navigated transvenously to the anterior superior sagittal sinus. LEA was injected with excellent penetration to the venous pouch and further penetration into the network of tortuous feeders. No neurologic complications were experienced, and follow-up angiogram 9 months later demonstrated cure of the dAVF. Video 2 describes procedural considerations in transvenous approaches, steps of the procedure, and includes references1-10 which are relevant to this topic.neurintsurg;jnis-2023-020530v1/V1F1V1Video 1 neurintsurg;jnis-2023-020530v1/V2F2V2Video 2 .

Low-memory shape coils for intracranial aneurysm coiling: Initial and single-center experience with the i-ED coil.

Background: Endovascular aneurysmal coiling is a preventative alternative to clipping to avoid aneurysmal rupture. In the literature and our own experience, some common coiling challenges which arise include: (1) microcatheter kickback, (2) detachment zone rigidity, (3) intrasaccular compartmentalization of coils on deployment, and (4) attainability of high-density and effective packing with as few coils as possible. Methods: We retrospectively reviewed a consecutive case series of 15 intracranial aneurysm patients who received Kaneka i-ED Coils since their initial use in our practice (December 2020) till May 2022. Results: Of the 14 saccular aneurysm patients treated with i-ED coils, 2/14 (14.3%) achieved a Raymond-Roy (RR) score of 3A (internal remnant), 4/14 (28.6%) achieved RR 2 (slight neck remnant) and 8/14 (57.1%) achieved RR 1. One MoyaMoya patient (5.9%) with a fusiform aneurysm also achieved a complete occlusion by parent artery takedown in this series. Aneurysm volumes ranged from 8.15 mm 3 to 315.5 mm 3 with an average packing density of 36.23% and a standard deviation 8.87%. At 30 days, most of our cohort scored a 0 on the modified Rankin scale (mRS) (11/15), with two patients scoring at an mRS score of 1, one at an mRS score of 4, and one at an mRS score of 6. Low-memory shape, coil cases achieved a significantly higher packing density (P < 0.01) and PD/Coils-used ratio (P < 0.05) than other cases in our practice. Conclusion: Our initial experience with i-ED coils has shown that they are a feasible strategy in a number of differently sized and shaped aneurysms. While fewer coils overall were not a statistically significant finding in this study, the future studies with larger cohorts are necessary and in progress.

AI software detection of large vessel occlusion stroke on CT angiography: a real-world prospective diagnostic test accuracy study.

BACKGROUND: Artificial intelligence (AI) software is increasingly applied in stroke diagnostics. However, the actual performance of AI tools for identifying large vessel occlusion (LVO) stroke in real time in a real-world setting has not been fully studied. OBJECTIVE: To determine the accuracy of AI software in a real-world, three-tiered multihospital stroke network. METHODS: All consecutive head and neck CT angiography (CTA) scans performed during stroke codes and run through an AI software engine (Viz LVO) between May 2019 and October 2020 were prospectively collected. CTA readings by radiologists served as the clinical reference standard test and Viz LVO output served as the index test. Accuracy metrics were calculated. RESULTS: Of a total of 1822 CTAs performed, 190 occlusions were identified; 142 of which were internal carotid artery terminus (ICA-T), middle cerebral artery M1, or M2 locations. Accuracy metrics were analyzed for two different groups: ICA-T and M1 ±M2. For the ICA-T/M1 versus the ICA-T/M1/M2 group, sensitivity was 93.8% vs 74.6%, specificity was 91.1% vs 91.1%, negative predictive value was 99.7% vs 97.6%, accuracy was 91.2% vs 89.8%, and area under the curve was 0.95 vs 0.86, respectively. Detection rates for ICA-T, M1, and M2 occlusions were 100%, 93%, and 49%, respectively. As expected, the algorithm offered better detection rates for proximal occlusions than for mid/distal M2 occlusions (58% vs 28%, p=0.03). CONCLUSIONS: These accuracy metrics support Viz LVO as a useful adjunct tool in stroke diagnostics. Fast and accurate diagnosis with high negative predictive value mitigates missing potentially salvageable patients.

Use of a mini balloon microcatheter to facilitate penetration of fine vascular networks and curative embolization in vein of Galen malformations.

Background Patients with vein of Galen malformations (VOGMs) can develop fine angiogenic networks with fistulous connections to the precursor of the vein of Galen. In these cases, transarterial embolization (TAE) with liquid embolic agents (LEAs) is challenging due to reflux in the pedicle leading to the network, causing poor penetration. Transvenous approaches carry a risk of hemorrhage from pathologic vasculature. Dual-lumen balloon microcatheters like the Scepter Mini (Microvention, Aliso Viejo, CA) improve distal pedicle access, preventing reflux.Objective Here, we report on the use of the Scepter Mini for TAE of angiogenic VOGM.Methods A single-institution retrospective chart review identified all VOGMs treated with Scepter Mini microcatheters. Clinical data, angioarchitecture, and technical parameters were reviewed.Results 17 Scepter Mini catheters were used in 12 embolization procedures of 7 patients with VOGM at a median age of 2.1 years. Patients presented with hydrocephalus (100%) and gross motor and speech delays (57.1%). Networks developed extra-axially into the subependymal zone fed by posterior choroidal, posterior cerebral, and thalamoperforator arteries. Posterior choroidal branches (n=7/17, 41.2%) were most frequently catheterized to achieve distal access to the network. Embolization with Onyx-18 and significant network penetration occurred in 17/17 uses. Near tip entrapment with LEA cast displacement occurred in 1/17 uses. Another patient experienced postprocedural intraventricular hemorrhage requiring a third ventriculostomy without permanent neurologic deficit.Conclusion The Scepter Mini provided excellent distal access with penetration to the fistula and extra-axial network reduction with few complications. The Scepter Mini provides a means for successful treatment of technically challenging angiogenic VOGM.

Lethal subarachnoid haemorrhage in a patient with rete mirabile network of the posterior circulation with associated aneurysm.

Rete mirabile (RM), an arterial network normally existing in some vertebrate animals interconnecting the extracranial and intracranial arterial circulation, can rarely be found in humans whether asymptomatic or presenting with cerebral ischaemia or haemorrhage. Encompassing diverse angiographic characteristics and similarities with other arterial malformations, proper diagnosis and differential diagnosis is challenging. We hereby describe an unusual RM case variant, presenting to us with lethal subarachnoid haemorrhage owing to a ruptured small aneurysm associated with the RM network. Angiography disclosed an absent P1 segment of the posterior cerebral artery (PCA) and an RM network anastomosing the basilar apex with the normal distal PCA. Brain death was confirmed on the fifth day after admission and attributed to the severity of subarachnoid haemorrhage (SAH). This is an exceedingly rare case representing an intradural-to-intradural RM anastomosis in a patient presenting with lethal SAH. RM epidemiology, pathophysiology, presentation, angiographic findings and prognosis are reviewed.

Transvenous embolization of vein of galen aneurysmal malformations with coils as a final procedure for cure: A single-institution experience of 18 years.

INTRODUCTION: Staged, transarterial embolization (TAE) is currently considered the gold standard for the treatment of vein of Galen aneurysmal malformation (VGAM); however, as transarterial access becomes restricted, further staged TAE may become ineffective or carry an increased risk of hemorrhagic or ischemic stroke when attempting complete obliteration. OBJECTIVE: To describe the first consecutive, retrospective series of VGAM treated with transvenous embolization (TVE) with coils alone, as the final treatment in staged endovascular therapy, at a single institution between January 2004 and September 2021. RESULTS: A total of 10 patients with a median age of 5.5 (IQR: 9.25) years were treated with coiling TVE. Patients were treated with a median number of 5 (IQR: 2.75) TAEs prior to the final TVE treatment. Complete or near-complete immediate angiographic obliteration was achieved in eight patients. Immediate post-procedural (within 48 h) hemorrhagic complications were noted in two patients (20%), one of whom passed away while the second suffered from hemiparesis. Stereotactic radiosurgery was performed in two patients with incomplete obliteration after TVE. The median follow-up time after TVE was 17 (IQR: 9) months. At long-term follow up (17 months) for the remaining nine patients, all VGAMs were completely obliterated. Long-term clinical deterioration compared to pre-TVE was noticed in one case. CONCLUSION: Transvenous coil embolization is a technically feasible but risky option, as a final-stage treatment for cure of VGAMs with restricted trans-arterial access. Although TVE with coils remains an effective therapeutic modality, we recommend continuing investigation of safer TVE techniques to achieve cure.

Initial experience with the Scepter Mini catheter for the embolization of vascular malformations in the pediatric population.

BACKGROUND: Achieving distal access and flow control are of significant importance for the treatment of intracerebral arteriovenous shunting lesions. The Scepter Mini catheter is a low-profile, dual-lumen balloon catheter, designed to provide navigability in small-caliber, tortuous intracranial vessels. OBJECTIVE: To describe the initial experience of the Scepter Mini catheter in the treatment of pediatric arteriovenous malformations and fistulas. METHODS: A single-institution, retrospective chart review identified all consecutive uses of the Scepter Mini catheter for endovascular embolization of vascular malformations in the pediatric population. RESULTS: Three different arterial pedicles were embolized with the Scepter Mini catheter in two different patients. One patient was diagnosed with a vein of Galen malformation that had undergone multiple treatments and the other with a torcular dural arteriovenous fistula. All cases encompassed quite challenging tortuosity of small-caliber feeders which prevented the use of another microcatheter. The Scepter Mini catheter navigated into feeding arteries of diameters 0.65, 1.9, and 1.25 mm, and its balloon was inflated to achieve excellent blood flow control. Total obliteration (100%) of the shunting lesion was achieved in both cases. No reflux, pedicle rupture or other untoward effects were observed. Both patients had an uneventful recovery. CONCLUSION: The Scepter Mini catheter afforded fast and safe distal access, flow control, and treatment of arteriovenous malformations in this initial pediatric cohort. The catheter's low profile and easy navigability should support its use in tortuous and small arterial feeders, especially in the pediatric population.