Development of bilateral subdural hematoma after endovascular embolization of a dural sinus malformation.

INTRODUCTION: Dural sinus malformation is a rare congenital malformation characterized by a remarkable dilated dural sinus pouch. We described the development of bilateral subdural hematoma after endovascular embolization of a dural sinus malformation in an infant. CASE DESCRIPTION: A 32-day male infant was observed to have a fever and enlarged head circumference. A dural sinus malformation with giant dural sinus pouch thrombosis was established by magnetic resonance imaging and digital subtraction angiography. The patient developed bilateral subdural hematoma after endovascular embolization of the dural fistula. His neurological outcome was normal at 3-year follow-up. CONCLUSION: We report a case of development of bilateral subdural hematoma after endovascular embolization of a dural sinus malformation and had a normal neurological outcome.

Endovascular treatment for dural arteriovenous fistulas in the petroclival region.

Petroclival region dural arteriovenous fistulas (DAVFs) are rare and difficult lesions to manage. They often have very complex anatomical structures and can be further divided into the superior petrosal sinus, petrous apex, inferior petrosal sinus, upper clival, and upper clival epidural-osseous DAVFs. Most petroclival region DAVFs should be treated due to their high Cognard grades. Currently, endovascular treatment (EVT) has become the first-line therapeutic option for petroclival region DAVFs. But not all the petroclival region DAVFs could be cured with EVT. When the arterial feeders are large or the DAVF is adjacent to the venous sinus, the success rate may be higher. In petroclival region DAVFs, if EVT can be performed successfully, satisfactory outcome can be anticipated. However, there are some inadvertent complications, which include cranial nerve palsy, subsequent sinus thrombosis, and migration embolization of the internal carotid artery and vertebral artery. Currently, a review of the EVT of petroclival region DAVFs is lacking. In this article, we performed a review of the relevant literature on this issue. In addition, some illustrative cases would be provided to elaborate these specific entities.

Endovascular embolization of dural arteriovenous fistula in a child presented with slight conjunctival hyperemia.

BACKGROUND: Dural arteriovenous fistulas (DAVFs) are rare in pediatrics. A case of DAVF diagnosed because of a slight conjunctival hyperemia and endovascular coil embolization at 2 years old is reported. CASE DESCRIPTION: The 2-year-old boy presented with a slight conjunctival hyperemia of the left eye for 1 month. Magnetic resonance imaging (MRI) examination of the head showed abnormal blood flow in the left middle cranial fossa. On digital subtraction angiography, a DAVF with a dural feeder shunt and a venous varix at the middle cranial fossa was confirmed. After transarterial coil embolization, shunt blood flow disappeared. CONCLUSIONS: This report describes a case of DAVF with a slight conjunctival hyperemia treated by coil embolization in a child.

Training residents and fellows in the procedure of diagnostic cervicocerebral angiography: Techniques to avoid complications.

We examine the problems arising when training residents/fellows (RFs) initiate the learning of diagnostic cervicocerebral angiography (DCCA) and describe the steps on how to facilitate the learning process while avoiding complications. The risk of permanent neurological deficit as a result of DCCA ranges from 0.3-0.5%. Factors that correlated with complications include the following: the history of cerebral infarction, infusion of a large amount of contrast medium, a prolonged fluoroscopic time (>80 min) and the efficiency of training received. These findings suggest that the neurological morbidity depends largely upon the technique of catheterization of the patient. In order to reduce the complications arising from the lack of training, a personalised mentorship with a careful supervision of trainees is necessary. To ensure a good patient outcome, a decreased procedural time, awareness of complications at every step of the procedure and their avoidance, as well as the provision of good quality images is necessary. A mentorship program with a close supervision of the RFs is also one of the prerequisites for obtaining a good result.

Parent artery sacrifice for ruptured aneurysms in acute and chronic phases: A systematic review.

BACKGROUND: Experience with respect to parent vessel sacrifice (PVS) for unclippable/uncoilable ruptured aneurysms is limited. OBJECTIVE: The aim of the present systematic review was to evaluate the risk of PVS for unclippable/uncoilable ruptured aneurysms. MATERIALS AND METHODS: The PUBMED and SCIENCEDIRECT databases were searched using "parent vessel occlusion OR parent artery occlusion" AND "acute subarachnoid hemorrhage" till December 27, 2015, and 1 journal was searched from November 1995 to April 2016 for relevant results. RESULTS: Out of a total of 19 eligible studies, 104 patients with 104 ruptured aneurysms were treated by PVS with or without bypass surgery. Unfavorable outcome [modified Rankin Score (mRS) 4-6] was reported in 14 (13.4%) acute phase patients, with a 9.6% mortality rate. Thirty (28.8%) patients developed ischemic complications and 3 (2.9%) developed bleeding complications. The complication rate was higher for PVS in the acute phase (38.0% vs. 12.0%; P= 0.015). The unfavorable clinical outcome was found to be significant in acute phase versus chronic phase (17.7% vs. 0%; P= 0.024). The risk of morbidity associated with distal vessel [posterior cerebral artery (PCA) + superior cerebellar artery (SCA) + posterior inferior cerebellar artery (PICA)] sacrifice was not lower than that associated with major vessel [internal carotid artery (ICA) + basilar artery (BA) + vertebral artery (VA)] sacrifice (P = 0.961). CONCLUSION: Complication and unfavorable outcome rates associated with PVS for acutely ruptured aneurysms are high. The risk of distal vessel sacrifice was not lower than major vessel sacrifice in the acute phase.

A systematic review of pipeline embolization device for giant intracranial aneurysms.

The experience with respect to the treatment of giant intracranial aneurysms with flow-diversion devices is limited. The aim of the present systematic review was to evaluate the effect of the pipeline embolization device (PED) on giant intracranial aneurysms. Eligible related articles were identified by searching the PubMed, Web of Science, Springer, ScienceDirect, and OVID databases using "giant aneurysm" and "pipeline" as the search items. The date of the last search was November 20, 2015. This systematic review adopted the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. In a total of 9 eligible studies with 200 patients and 215 aneurysms, 40 (18.6%) giant (aneurysm diameter >25mm) intracranial aneurysms treated with PED were analyzed. During a 6 to 34 month follow-up, complete occlusion was achieved in 23 (57.5%) cases. Seven patients (17.5%) developed intracranial hemorrhage, 5 developed ischemic attack (12.5%), and 13 (32.5%) developed a mass effect after PED treatment. The complication rate was 77.8% in PED for giant vertebrobasilar artery aneurysms. The cumulative mortality rate for giant paraclinoid carotid artery and middle cerebral artery aneurysms was 13.3% and increased up to 50% for giant vertebrobasilar artery aneurysms. The complete obliteration rate of PED for giant intracranial aneurysms was approximately 60%. Mass effect is the most mechanism of complications. Complication and mortality rates associated with PED for giant vertebrobasilar artery aneurysms are still extremely high.

Hemorrhagic Moyamoya Disease in Children: Clinical, Angiographic features, and Long-Term Surgical Outcome.

BACKGROUND AND PURPOSE: Here, we describe the clinical, angiographic characteristics, and long-term surgical outcome of hemorrhagic moyamoya disease in children. METHODS: We retrospectively collected 374 consecutive children with moyamoya disease (hemorrhagic 30 and ischemic 344) between 2004 and 2012 in our hospital. The clinical and radiological characteristics of the hemorrhagic patients were retrospectively described and analyzed. All the hemorrhagic patients underwent encephalo-duro-arterio-synangiosis procedure. Digital subtraction angiography was performed to evaluate the efficacy of vascularization. Clinical follow-up outcomes were obtained through clinical visits, telephone, or letter interview. RESULTS: In our study, the ratio of female to male patients in the hemorrhagic group was significantly higher than the ischemic group (2:1 versus 0.9:1; P<0.05). The most frequent hemorrhagic location was intraventricular hemorrhage (n=22, 73%). In addition, significantly greater dilatation of the anterior choroidal artery and the posterior communicating artery were seen in the hemorrhagic group (P<0.05). Good or fair vascularization were observed in all the 15 children with digital subtraction angiography follow-up. Clinical outcomes showed that 25 of 30 (83%) patients had no disability (modified Rankin scale score, 0 and 1); 1 patient (3.3%) died of recurrent hemorrhagic stroke. CONCLUSIONS: The presence of anterior choroidal artery and posterior communicating artery dilation may be associated with the bleeding episode in the children with hemorrhagic moyamoya disease. The encephalo-duro-arterio-synangiosis surgery can effectively increase the cerebral blood flow in children, which may decrease the incidence of recurrent hemorrhage.

Risk Score for Neurological Complications After Endovascular Treatment of Unruptured Intracranial Aneurysms.

BACKGROUND AND PURPOSE: Procedure-related neurological complications are common after endovascular treatment of unruptured intracranial aneurysms. We aimed to develop a score to quantify individual patient risk. METHODS: We retrospectively analyzed consecutive patients who underwent endovascular treatment for unruptured intracranial aneurysms between January 2012 and September 2015. After excluding those who lost to follow-up and those with fusiform unruptured intracranial aneurysms, included patients were randomly divided into a derivation group (60%) and a validation group (40%). A neurological complication was defined as any transient or permanent increase in the modified Rankin Scale score after aneurysm embolization. A risk score for neurological complications was derived from multivariable logistic regression analyses in the derivation group and validated in the validation group. RESULTS: Overall, 1060 patients were included (636 in the derivation group and 424 in the validation group). The incidence of neurological complications was 5.5% (95% confidence interval, 3.8%-7.4%). A 3-point risk score (S-C-C) was derived to predict neurological complications (size [≥10 mm=1], core areas [yes=1], and cerebral ischemic comorbidity [yes=1]). The incidence of neurological complications varied from 2.2% in 0-point patients to 25.0% in 3-point patients. The score demonstrated significant discrimination (C-statistic, 0.714; 95% confidence interval, 0.624-0.804) and calibration (McFadden R(2), 0.102) in the derivation group. Excellent prediction, discrimination, and calibration properties were reproduced in the validation group. CONCLUSIONS: One in 20 patients will develop neurological complications after endovascular treatment of unruptured intracranial aneurysms. The S-C-C score may be useful for predicting these adverse outcomes based on variables in daily practice.

Endovascular Treatment of 147 Cases of Cavernous Carotid Aneurysms: A Single-Center Experience.

BACKGROUND: Cavernous carotid aneurysms (CCAs) are characterized by pain and neuro-ophthalmologic deficits. The optimal treatment remains unclear, especially for asymptomatic CCAs. This study investigated the efficacy of endovascular treatment for CCAs in our center. METHODS: Data obtained from patients who underwent endovascular treatment for CCAs from July 2011 to July 2014 were reviewed. A retrospective analysis was conducted regarding the general condition, clinical presentation, aneurysm characteristics, therapeutic strategy, and prognosis of CCA patients. RESULTS: One hundred forty-seven patients who exhibited 155 CCAs were included, which comprised 46 asymptomatic and 101 symptomatic CCA cases. Forty-eight cases presented with headache, 5 cases presented with subarachnoid hemorrhage, 20 cases presented with diplopia, 38 cases presented with cranial nerve palsy, and 27 cases presented with ischemic stroke. The mean aneurysm sizes were 15.3 ± 12.2 and 8.1 ± 7.1 mm in the symptomatic and asymptomatic groups, respectively. Different treatments were administered: coil occlusion (n = 15), stent/balloon-assisted coil occlusion (n = 123), and parent artery occlusion (PAO) (n = 17). The PAO-treated group exhibited the highest aneurysm occlusion rate. Follow-up data were available for 131 cases, which included 86 symptomatic and 45 asymptomatic cases. There were no deaths. Among the symptomatic patients, 40.7% improved, 58.1% remained stable, and 1.2% worsened; 12 patients exhibited regrowth and 6 patients had repeated endovascular treatment. The asymptomatic patients remained stable, including 5 patients who exhibited regrowth and 2 patients who had repeated endovascular treatment. CONCLUSION: Endovascular treatment is safe and effective for CCAs and should be considered in patients with minimal complications, as well as in asymptomatic patients with stable symptoms.

Endovascular treatment of A1 aneurysms of the anterior cerebral artery.

AIM: The aim of this study was to present the clinical and angiographic outcomes of A1 aneurysms treated by coil embolization. MATERIALS AND METHODS: We retrospectively evaluated 38 consecutive patients with A1 aneurysm (20 ruptured and 18 unruptured; mean age, 53.8 ± 11.9 years) from 2011 to 2014 treated by an endovascular approach in our hospital. Follow-up angiography was obtained in 30 patients. Clinical outcomes were evaluated by modified Rankin Scale (mRS) over telephone. RESULTS: Among the 38 patients, 24 were treated with single-catheter technique, 8 with stent-assisted coiling (Enterprise 3; Solitaire 5), 5 with parent vessel obliteration, and 1 with balloon-assisted coiling. Initial angiographic results revealed that complete occlusion was achieved in 21 aneurysms (55.3%), near-complete occlusion in 16 (42.1%), and partial occlusion with contrast agent filling the aneurysm sac in 1 (2.6%). Procedure-related complications were observed in 6 patients (15.8%). Follow-up angiographic imaging evaluation after coil embolization was performed in 32 aneurysms (mean interval, 22.6 ± 6.7 months), which showed that 31 (96.9%) aneurysms remained stable or improved without regrowth, while minor recanalization was found in 1 aneurysm (3.1%), which was treated by parent vessel occlusion. Clinical follow-up evaluation was excellent in 37 of the 38 patients (mRS score 0 in 34, and mRS score 1 in 3) at a mean duration of 26.6 ± 7.7 months. CONCLUSIONS: Endovascular treatment is feasible and effective for A1 segment aneurysms. The current treatment selections, including single-catheter embolization, balloon-assisted coiling, stent-assisted coiling, and parent vessel occlusion, should be performed according to the characteristics and morphology of A1 aneurysms.

Stent-assisted coiling of ruptured wide-necked intracranial aneurysms: A single-center experience of 218 consecutive patients.

BACKGROUND: Stent-assisted coiling (SAC) in the treatment of ruptured intracranial aneurysms (RIAs) remains controversial. AIMS: In this study, we report our experience of SAC of wide-necked RIAs and evaluate the risk factors contributing to periprocedural complications. MATERIALS AND METHODS: 218 patients underwent SAC for ruptured, wide-necked saccular intracranial aneurysms at our center between 2011 and 2014. Multivariate logistic regression analysis was performed to evaluate the risk factors contributing to the periprocedural complications. Follow-up angiography was available in 178 (84.8%) patients. Clinical outcome was measured using the Glasgow Outcome Scale (GOS) through telephonic interviews. RESULTS: Periprocedural complications occurred in 33 (15.1%) patients out of which 17 were thromboembolic (7.8%) and the remainder were hemorrhagic complications (n = 16, 7.3%). Multivariate logistic regression analysis showed that a positive history of hypertension (odds ratio [OR] 4.899, 95% confidence interval [CI] 1.266-18.951; P = 0.021), and daughter blebs (OR 12.165, 95% CI 3.247-45.577; P = 0.0001) were the major risk factors for the periprocedural hemorrhagic complications, but not for the thromboembolic complications. Angiographic follow-up (mean, 19.5 ± 11.9 months) showed Raymond scale (RS) 1 in 158 (88.8%) patients and RS2 in 20 (11.2%) patients without any angiographic recurrence. At a mean clinical follow-up of 29.1 ± 16.2 months, 201 out of the 210 surviving patients had a good functional outcome (GOS score of 4 or 5). CONCLUSIONS: SAC is an effective treatment option for selected ruptured wide-necked aneurysms, especially in patients who do not require external ventricle drainage for acute hydrocephalus. The periprocedural hemorrhagic complications tend to be more common in the hypertensive patients and in those with daughter blebs in the aneurysm sac.

The influence of age and the initial clinical presentations of patients with an arteriovenous malformation on the risk of hemorrhage.

BACKGROUND AND PURPOSE: The major determinants of hemorrhage in an arteriovenous malformation (AVM) include its angioarchitecture, as well as the patient's age and clinical presentation. The aim of this study was to determine whether or not the risk of hemorrhage in an AVM differs based on the different clinical presentations and the initial age at diagnosis. METHODS: A consecutive case series of 496 patients having a brain AVM was retrospectively analyzed. The radiological evidence of hemorrhage was established in 84 of these cases after the initial diagnosis of AVM had been made. These cases were analyzed using univariate analysis and Kaplan-Meier curves with respect to age at diagnosis, the clinical presentation of patients harboring the AVM as well as the Spetzler-Martin grade of the AVM. RESULTS: Hemorrage occurred in 84 patients with an AVM during a mean duration of 2.5 years (range, 1month-28 years). In univariate analysis, a subsequent hemorrhage within an AVM was associated with the following factors: When the patients initially presented with a hemorrhage, and, had a younger age (<30 years), female gender, and Spetzler-Martin III and IV grades. By analysis of the Kaplan-Meier curves, it was estimated that the annual hemorrhage rate was 12.3% in those cases who initially presented with hemorrhage, compared with 3.5% for those cases whose initial presentation was not associated with AVM bleed. In the latter category (i.e., patients who did not have hemorrhage as the initial presentation), the annual rate of subsequent hemorrhage was lower for those patients who initially presented with seizures than those who had other initial presentations (such as those having neurological deficits, headaches, or those incidentally detected to be having an AVM) (with the bleeding rate being 1.9% in those with seizures as the initial presentation vs. 4.6% for the other presentations or those with incidentally detected AVMs, P = 0.002). CONCLUSIONS: The subsequent occurrence of hemorrhage in an AVM was associated with the initial presentation of hemorrhage, a younger patient's age (<30 years), the female gender, and Spetzler-Martin grades III and IV. The risk of subsequent hemorrhage in patients with an initial presentation of a seizure was lower than the risk of hemorrhage that occurred with other presentations. Patients with an AVM who present with recurrent headaches, and those in whom the AVM has been detected incidentally, should also be kept under surveillance as they too manifest a risk of a subsequent hemorrhage.

A challenging entity of unruptured giant saccular aneurysms of vertebrobasilar artery.

PURPOSE: Giant intracranial aneurysms commonly cause poor clinical outcome and few studies focus on them. This study is to retrospectively report the angiographic and clinical presentations in unruptured giant saccular vertebrobasilar aneurysms with and without endovascular treatment. METHODS: Out of 400 patients who had unruptured posterior circulation aneurysms in a single center, we found 10 unruptured giant (>25mm) saccular vertebrobasilar aneurysms. Clinical and angiographic presentations as well as their clinical outcomes were assessed. RESULTS: Of the 10 giant aneurysms in 10 patients, three were left untreated. During 6 months follow-up, all 3 of these patients died from aneurysm rupture. The remaining 7 patients were treated by endovascular procedure, 5 received stent-assisted coiling, 1 was treated by parent artery occlusion (PAO), and 1 was treated by conventional coiling. Of these treated patients, only one survived during a 22 month period of follow-up. CONCLUSIONS: Patients with giant saccular aneurysms of vertebrobasilar artery presenting mass effect may have extremely poor clinical outcomes and may not benefit from endovascular treatment.

Endovascular management of giant aneurysms: An introspection.

AIMS: To evaluate the outcome of giant intra-dural aneurysms managed with endovascular techniques. MATERIALS AND METHODS: We retrospectively reviewed a series of 39 consecutive giant intra-dural aneurysms. The technical feasibility of endovascular treatment, its complications, the angiographic results and the clinical outcome were assessed. Logistic regression analysis was performed to evaluate for predictors of a poor outcome. RESULTS: Nine patients were left untreated. During a 30 month follow-up, four of them (44.4%) died and two (22.2%) deteriorated. Thirty aneurysms (12 located in the anterior circulation and 18 located in the posterior circulation) were treated using endovascular methods. Of these, 11 were treated by parent vessel occlusion, 11 by stent-assisted coiling, one using only coils, six using solely a stent, and, one using both coils and onyx. During a 28 month follow-up, seven (23.3%) patients died and two (6.7%) patients experienced permanent neurological deficits. The mortality and morbidity in the endovascular group seemed lower than that in the untreated group (P = 0.045, 30% vs. 66.7%). There was no difference in the results of endovascular treatment between giant intra-dural aneurysms located in the posterior and the anterior circulation. CONCLUSIONS: Giant intra-dural aneurysms, whether treated or not, may have a poor clinical outcome. The outcome following endovascular treatment of these lesions is better than its natural history when left untreated. However, endovascular treatment may often be associated with high complication rates and a low chance of cure.

Classification of anterior communicating aneurysms on a basis of endovascular treatments.

BACKGROUND AND PURPOSE: The anterior communicating artery (Acoma) aneurysms are difficult to understand because of their anatomical variations. This study reported a new classification of Acoma aneurysms on a basis of endovascular treatments. METHODS: This retrospective study enrolled consecutive 94 patients harbored 100 Acoma aneurysms treated with coil embolization. All Acoma aneurysms were classified into 5 orientations (straight, superior, inferior, anterior, and posterior) based on the axis connecting A1 origin and the base of the aneurysm. Aneurysm characteristics, endovascular treatments, angiographic, and clinical outcomes were evaluated using this classification. RESULTS: According to this classification, there were 64 (64%) straight, 16 (16%) inferior, 16 (16%) superior, 2 (2%) anterior, and 2 (2%) posterior projection aneurysms. There were significant differences between different groups in aneurysm height (p=0.009) and aneurysm neck size (p = 0.003), and in endovascular treatments (p=0.006). There was a significant difference in the proportion of rupture presentation among the three groups of straight, inferior, and superior (p = 0.019). There was no difference in the results of postoperative angiography (p = 0.090). An excellent functional outcome with an mRS ≤1 was achieved in 91 (96.8%) patients. CONCLUSIONS: This classification of Acoma aneurysms based on the axis connecting A1 origin and the base of the aneurysm is associated with aneurysm height, aneurysm neck size, and in need for stent-assisted therapy. Endovascular embolization can provide the same effective treatment for aneurysms in all directions.

Predicting postinterventional rupture of intracranial aneurysms using arteriography-derived radiomic features after pipeline embolization.

Background and purpose: Postinterventional rupture of intracranial aneurysms (IAs) remains a severe complication after flow diverter treatment. However, potential hemodynamic mechanisms underlying independent predictors for postinterventional rupture of IAs remain unclear. In this study, we employed arteriography-derived radiomic features to predict this complication. Methods: We included 64 patients who underwent pipeline flow diversion for intracranial aneurysms, distinguishing between 16 patients who experienced postinterventional rupture and 48 who did not. We performed propensity score matching based on clinical and morphological factors to match these patients with 48 patients with postinterventional unruptured IAs at a 1:3 ratio. Postinterventional digital subtraction angiography were used to create five arteriography-derived perfusion parameter maps and then radiomics features were obtained from each map. Informative features were selected through the least absolute shrinkage and selection operator method with five-fold cross-validation. Subsequently, radiomics scores were formulated to predict the occurrence of postinterventional IA ruptures. Prediction performance was evaluated with the training and test datasets using area under the curve (AUC) and confusion matrix-derived metrics. Results: Overall, 1,459 radiomics features were obtained, and six were selected. The resulting radiomics scores had high efficacy in distinguishing the postinterventional rupture group. The AUC and Youden index were 0.912 (95% confidence interval: 0.767-1.000) and 0.847 for the training dataset, respectively, and 0.938 (95% confidence interval, 0.806-1.000) and 0.800 for the testing dataset, respectively. Conclusion: Radiomics scores generated using arteriography-derived radiomic features effectively predicted postinterventional IA ruptures and may aid in differentiating IAs at high risk of postinterventional rupture.

Transvenous onyx embolization of a direct carotid-cavernous fistula via the prevertebral vein at the level of the atlanto-occipital membrane: Technical note.

The inferior petrosal sinus (IPS) is the most commonly used transvenous approach to obliterate the carotid-cavernous fistula (CCF). We presented a case of direct CCF was successfully embolized through contralateral jugular vein via the prevertebral vein at the level of the atlanto-occipital membrane. Because of the confluence of the caudal end of the IPS and the prevertebral vein at the medial side of the hypoglossal canal, the transvenous route through the ipsilateral jugular vein was failed. Transcirculation approach via the prevertebral vein at the level of the atlanto-occipital membrane seems to be the choice when venous access is available.

Transarterial embolization of sinus dural arteriovenous fistula using non-adhesive liquid embolic material.

Objective: The objective is to report our experience of transarterial embolization of sinus dural arteriovenous fistula (DAVF) using non-adhesive liquid embolic material.Materials and methods: In 3 cases of Borden type II sinus DAVFs, a Copernic balloon was used to protect sagittal sinus in one patient, palliative Onyx embolization was performed to protect transverse sinus in one patient and EVAL/DMSO/ethanol mixture (EVAL, SUCCESS, Shandong, China) was used in the last patient.Results: Two Borden type II DAVFs were changed into type I DAVF and one was cured. The dural sinus was patent after successful Onyx embolization in 3 cases resulting in well patient recovery. There were no treatment-related events.Conclusion: Transarterial embolization of sinus DAVF using non-adhesive liquid embolic material could be effective and safe with sinus protection techniques.

The use of SNAP and T1-weighted VISTA in cervical artery dissection.

BACKGROUND AND PURPOSE: Some cervical artery dissection (CAD) can't be easily confirmed by commonly used angiography techniques in clinical practice. We aimed to compare the abilities of the vessel wall magnetic resonance imaging (MRI) techniques including simultaneous noncontrast angiography and intraplaque hemorrhage (SNAP) sequence and T1-weighted volumetric isotropic turbo spin echo acquisition (T1-w VISTA) sequence alone for evaluating CAD. MATERIALS AND METHODS: From July 2017 to October 2020, 59 patients underwent MRI examinations including SNAP and T1-w VISTA sequences for cervical artery pathologies. SNAP and T1-w VISTA images were retrospectively and independently reviewed to evaluate their diagnostic performances of CAD by using the final diagnosis as the reference standard which was established by clinical history, physical examination, and all available images. The agreement between T1-w VISTA and SNAP in the identification of the imaging features of CAD, including intramural hematoma (IMH), intimal flap, and double lumen, were compared. The IMH-wall contrasts by T1-w VISTA and SNAP were also compared. RESULTS: CAD was confirmed in 43 of the 59 patients. T1-w VISTA and SNAP showed the same diagnostic performance, and their consistencies with the final diagnosis were good (κ = 0.776, p < 0.001). The sensitivity and specificity in CAD diagnosis were 0.978 and 0.750 for T1-w VISTA and SNAP. The IMH, intimal flap, and double lumen observed on SNAP were also determined by T1-w VISTA (κ = 1.000, p < 0.001 for all). The SNAP sequence showed higher IMH-wall contrast than T1-w VISTA (7.34 ± 4.56 vs. 3.12 ± 1.17, p < 0.001). CONCLUSIONS: SNAP and T1-w VISTA sequences had the same performance in CAD diagnosis, thus they were both recommended. In addition, SNAP showed better IMH-wall contrast than T1-w VISTA.

Endovascular embolization for symptomatic perimedullary AVF and intramedullary AVM: a series and a literature review.

INTRODUCTION: Perimedullary arteriovenous fistula (AVF) has shunt on the spinal cord surface and it can be treated with surgery, or endovascular embolization. Intramedullary arteriovenous malformation (AVM) has its nidus in the cord and is difficult to treat either by surgery or endovascular technique. We report our experience with endovascular embolization in the treatment of perimedullary AVF and intramedullary AVM. METHODS: Four consecutive cases of spinal perimedullary AVF and six intramedullary AVM were retrospectively reviewed. These cases were evaluated and treated at Beijing Tiantan Hospital, China, over a 2-year period. A review of previously reported cases was also performed. RESULTS: There was no significant difference in the presentations (P = 0.348), level of lesions (P = 0.350), arterial suppliers (P = 0.801), and associated vascular anomalies between perimedullary AVF and intramedullary AVM, except for age (P = 0.014) and treatment modalities (P = 0.003). The patients with perimedullary AVFs were younger in our cases; the age at onset of symptoms averaged 25.8 years compared to 31.7 years for intramedullary AVMs. There was a significant male predominance for both lesions, and a significantly higher incidence of subarachnoid hemorrhage than in spinal dural AVFs. Regarding treatment, endovascular coil embolization is frequently used in perimedullary AVF and liquid embolic agent is an effective therapeutic choice in intramedullary AVM. CONCLUSION: Perimedullary AVF and intramedullary AVM are dissimilar with dural AVF in clinical characteristics. Our experience suggests that the endovascular treatment of spine perimedullary AVFs and intramedullary AVMs is feasible and effective. Endovascular treatment for intramedullary AVMs is still challenging, the main problem is acute ischemia injury of the spinal cord.