CT angiography versus 3D rotational angiography in patients with subarachnoid hemorrhage.

INTRODUCTION: CT angiography (CTA) is increasingly used as primary diagnostic tool to replace digital subtraction angiography (DSA) in patients with subarachnoid hemorrhage (SAH). However, 3D rotational angiography (3DRA) has substituted DSA as a reference standard. In this prospective observational study, we compare CTA with 3DRA of all cerebral vessels in a large cohort of patients with SAH. METHODS: Of 179 consecutive patients with SAH admitted between March 2013 and July 2014, 139 underwent 64- to 256-detector row CTA followed by complete cerebral 3DRA within 24 h. In 86 patients (62 %), 3DRA was performed under general anesthesia. Two observers from outside hospitals reviewed CTA data. RESULTS: In 118 of 139 patients (85 %), 3DRA diagnosed the cause of hemorrhage: 113 ruptured aneurysms, three arterial dissections, one micro-arteriovenous malformation (AVM), and one reversible vasoconstriction syndrome. On CTA, both observers missed all five non-aneurysmal causes of SAH. Sensitivity of CTA in depicting ruptured aneurysms was 0.88-0.91, and accuracy was 0.88-0.92. Of 113 ruptured aneurysms, 28 were ≤3 mm (25 %) and of 95 additional aneurysms, 71 were ≤3 mm (75 %). Sensitivity of depicting aneurysms ≤3 mm was 0.28-0.43. Of 95 additional aneurysms, the two raters missed 65 (68 %) and 58 (61 %). Sensitivity in detection was lower in aneurysms of the internal carotid artery than in other locations. CONCLUSION: CTA had some limitations as primary diagnostic tool in patients with SAH. All non-aneurysmal causes for SAH and one in ten ruptured aneurysms were missed. Performance of CTA was poor in aneurysms ≤3 mm. The majority of additional aneurysms were not depicted on CTA.

Pain course in conservatively treated patients with back pain and a VCF on the spine radiograph (VERTOS III).

OBJECTIVE: Little is known about the natural course of pain from vertebral compression fractures (VCF). In this study we evaluated the pain course in conservatively treated patients with back pain and a VCF on the spine radiograph. MATERIALS AND METHODS: Between May 2007 and November 2008, 169 patients with back pain referred by the general practitioner for spine radiographs and with a VCF were requested to participate in this follow-up study. Base line questionnaires about visual analogue scale (VAS) score, type of treatment and use of osteoporosis medication were filled in by 82 patients. Questionnaires were repeated at 6 weeks, and at 3, 6 and 12 months. Significant pain relief was defined as a decrease in VAS score of 50% or more from baseline. RESULTS: At baseline, mean VAS score in 82 patients was 6.9 (SD 2.0). Significant pain relief at 12 months was reported by 44 patients (54%) while in 38 patients (46%) pain relief was insufficient. No predictors for pain relief could be identified. Patients with insufficient pain relief at 12 months used significantly more analgesics and in these patients physiotherapy did better than other types of therapy. CONCLUSION: More than half of conservatively treated patients with back pain and VCF had sufficient pain relief at 12 months with most pain decrease in the first 3 months. However, a substantial proportion of patients still reported disabling pain. There were no predictors for the development of chronic pain. Patients with continuing pain ≥3 months after diagnosis of VCF may be candidates for vertebroplasty.

Endovascular treatment of brain arteriovenous malformations using a liquid embolic agent: results of a prospective, multicentre study (BRAVO).

OBJECTIVES: To evaluate the safety and efficacy of a new liquid embolic agent in brain arteriovenous malformation (bAVMs) embolisation. METHODS: A prospective, multicentre series was conducted at 11 interventional centres in Europe to evaluate embolisation of bAVMs with the new liquid embolic agent. Technical conditions, complications, clinical outcome and anatomical results were independently analysed. RESULTS: From December 2005 to December 2008, 117 patients (72 male; 45 female, aged 18-75 years) were included. Clinical presentation was mostly haemorrhage (34.2 %) and seizures (28.2 %). Most AVMs were located in the brain hemispheres (85.5 %). AVMs were <3 cm in 52.1 % of patients and ≥ 3 cm in 47.9 %. Morbidity was observed in 6/117 patients (5.1 %), related to haemorrhagic events in 2 cases and non-haemorrhagic complications in 4 cases. Five patients (4.3 %) died in relation to the treatment (bleeding in 4 patients and extensive venous thrombosis in 1). Complete occlusion of the AVM by embolisation alone was obtained in 23.5 % of patients. Complementary treatment was performed in 82.3 % of patients with partial AVM occlusion, mostly radiosurgery. CONCLUSIONS: In this prospective, multicentre, European, observational series, the new liquid embolic agent proved to be suitable for BAVM embolisation, with acceptable morbidity and mortality and good efficacy. KEY POINTS: • Numerous interventional techniques have been used to embolise brain arteriovenous malformations (AVMs). • This prospective multicentre study demonstrates the suitability of a liquid embolic agent. • The safety of treatment using Onyx is acceptable. • Such embolisation leads to complete AVM occlusion in 23.5 % of patients.

WEB Treatment of Ruptured Intracranial Aneurysms: Long-Term Follow-up of a Single-Center Cohort of 100 Patients.

BACKGROUND AND PURPOSE: The Woven EndoBridge device (WEB) was introduced for the intrasaccular treatment of wide-neck aneurysms without the need for adjunctive devices. We used the WEB as a primary treatment for 100 ruptured aneurysms regardless of neck size or location. In this study, we present the long-term follow-up of 78 surviving patients. MATERIALS AND METHODS: Between February 2015 and April 2017, one hundred ruptured aneurysms were treated with the WEB. For surviving patients, angiographic and clinical follow-up was scheduled at 3 months, and 3T MRA and clinical follow-up, at 6, 12, 36, and 60 months. Of 100 patients, 18 died during hospital admission, and in 4, the ruptured aneurysm was additionally treated. The remaining 78 patients had a mean follow-up of 51 months (median, 52 months; range, 5-84 months). There were 57 women and 21 men, with a mean age of 58.5 years (median, 59 years; range, 24-80 years). Of 78 aneurysms with long-term follow-up, 52 (66%) had a wide neck. RESULTS: Of 78 ruptured aneurysms, 56 (72%) remained completely occluded and 17 (22%) had a stable small neck remnant. Five of 78 aneurysms (6%; 95% CI, 2.4%-14.5%) reopened during follow-up and were additionally treated. There were no rebleeds during follow-up. CONCLUSIONS: Treatment of ruptured aneurysms with the WEB was safe and effective and has long-term results comparable with those of simple coiling of small-neck aneurysms. The WEB proved to be a valuable alternative to coils for both wide- and small-neck ruptured aneurysms without the need for stents, balloons, or antiplatelet therapy.

p64 flow diverter: Results in 108 patients from a single center.

BACKGROUND AND PURPOSE: Flow diverters are increasingly used to treat intracranial aneurysms. We report the safety and efficacy of the p64 flow diverter, a resheathable and detachable device for intracranial aneurysms. MATERIALS AND METHODS: We retrospectively reviewed 108 patients with 109 aneurysms treated with the p64 between March 2014 and July 2019. There were 87 women and 21 men, mean age 57 years. Of 109 aneurysms, 74 were discovered incidentally, 12 were symptomatic, 18 were previously treated, and five were ruptured dissection aneurysms. A total of 10 aneurysms were located in the posterior circulation. The mean aneurysm or remnant size was 8.1 mm. RESULTS: Hemorrhage by perforation with the distal guidewire occurred in two patients with permanent neurological deficits in one. In one patient, acute in-stent occlusion caused infarction with a permanent deficit. Permanent morbidity was 1.9% (2 of 108, 95%CI 0.1-6.9%); there was no mortality. During follow-up, three in-stent occlusions occurred, all asymptomatic. There were no delayed hemorrhagic complications. At six months, 77 of 96 aneurysms (80.2%) were completely occluded, and at last follow-up, this increased to 93 of 96 aneurysms (96.9%). In-stent stenosis at any degree occurred in 11 patients, progressing to asymptomatic complete occlusion in one. In the other patients, stenosis resolved or improved at further follow-up. CONCLUSION: The p64 offers an effective and safe treatment option. Aneurysm occlusion rate was 97% at last follow-up, mostly achieved with a single device. There were no delayed hemorrhagic complications. Delayed in-stent stenosis infrequently progresses to occlusion but remains a matter of concern.

The p48 flow diverter: First clinical results in 25 aneurysms in three centers.

BACKGROUND: The novel low-profile p48 flow diverter has been designed to treat aneurysms on small vessels of 1.75-3mm. We report our first clinical experiences. METHODS: Between March 2018-January 2020, 22 patients with 25 aneurysms were treated with the p48 in 3 centers. One patient had 3 aneurysms covered by one p48 and one patient had 2 aneurysms. There were 5 men, 17 women, with a mean age of 55 years (median 59, range 29-73 years). RESULTS: In 25 aneurysms, 24 p48 flow diverters were placed. In 1 patient additional coils were placed in the aneurysm. Procedural vessel rupture by the micro guidewire occurred in 2 patients and vessel rupture during p48 balloon dilatation occurred in 1 patient. Overall, the permanent morbidity rate was 13.6% (3 of 22, 95%CI 3.9-34.2%) and mortality was 4.5% (1 of 22, 95%CI <0.01-23.5%). Most complications were procedure-related and not device-specific. Of 22 patients with 25 aneurysms treated with p48, 18 patients with 20 aneurysms had angiographic follow-up after 5-18 months. Of 19 aneurysms, 10 were occluded and 7 showed a remnant. Two aneurysms were open after 6 months. Three aneurysms were still not occluded after 12, 14, and 18 months and these 3 were retreated. Retreatment rate was 16% (3 of 19) and the adequate occlusion rate was 90% (17 of 19). CONCLUSIONS: Treatment of aneurysms in small-caliber vessels with the p48 is feasible and effective but is not without complications. More data is needed to establish indications, safety, and efficacy more accurately.

A systematic review and meta-analysis of Woven EndoBridge single layer for treatment of intracranial aneurysms.

BACKGROUND AND PURPOSE: The Woven EndoBridge is an intrasaccular device for the treatment of intracranial aneurysms. The first generation consisted of a high-profile double-layer braid. This review aims to evaluate the outcomes of the new generation low-profile Woven EndoBridge single layer device for intracranial aneurysm treatment. METHODS: A systematic review was conducted with Medline, Embase, and Web of Science Conference Proceedings databases. The search strategy provided 589 articles, 15 articles were included. RESULTS: Fifteen articles were identified reporting the use of Woven EndoBridge single-layer devices in 963 aneurysms, mostly wide-necked bifurcation aneurysms. Procedural aneurysm rupture was reported in 8 of 963 patients (0.83%; 95%CI 0.39-1.66%) and thromboembolic events in 54 of 963 patients (5.61%, 95CI 4.31-7.26%). Cumulative morbidity was 2.85% (27/949, 95%CI 1.95-4.12%) and mortality 0.93% (9/963, 95%CI 0.46-1.80%). The overall rate of adequate aneurysm occlusion at last follow-up was 83.3% (613/736; 95%CI 80.4-85.8%). Retreatment was reported in 38 aneurysms in eight studies with 450 aneurysms with follow-up (38/450; 8.4%, 95CI 6.2-11.4%). In 12 studies comprising 644 aneurysms with follow-up, rebleeds occurred in three patients in three studies with mean follow-up between 3.3 and 14.4 months (0.47%, 95%CI 0.09-1.43%). CONCLUSION: Woven EndoBridge single-layer is a promising new low-profile device especially for wide-neck bifurcation aneurysms, both ruptured and unruptured. No antiplatelet medication is needed which is a great advantage, especially in ruptured aneurysms. Efficacy and safety compare favorably with (stent-assisted) coiling. However, no direct comparison with other treatments is available as yet.

The Woven EndoBridge (WEB) for recurrent aneurysms: Clinical and imaging results.

INTRODUCTION: The Woven EndoBridge (WEB) device is a novel intrasaccular flow disrupter designed for wide-necked aneurysms. We present our results of WEB treatment in previously treated and reopened aneurysms. MATERIALS AND METHODS: Between February 2015 and December 2017, 17 patients with reopening of previously treated aneurysms were treated using the WEB device. Initial treatment was clipping in one, WEB in five and coiling in 11 aneurysms. Six aneurysms had two or three previous treatments. Mechanism of aneurysm reopening was clip remnant in one, compaction without regrowth in three, focal regrowth in five, reopening in partially thrombosed aneurysms in three and WEB compression in five aneurysms. RESULTS: Endovascular treatment of the recurrent aneurysm was possible in all 17 patients with good WEB position obtained. Additional devices were used in three of 17 patients (18%): coils in two and stent in one patient. No technical, hemorrhagic or thromboembolic complications occurred (0%, 97.5% confidence interval 0-22%). Overall imaging result at latest follow-up was complete occlusion in five (29%), neck remnant in six (35%), aneurysm reopening in six (35%) and persistent WEB filling in one aneurysm (6%). After retreatment with the WEB, two aneurysms were again additionally treated and three aneurysms are scheduled for additional treatment. Worst results were in partially thrombosed aneurysms. CONCLUSION: The WEB device for recurrent aneurysms may be a feasible and safe option, especially in wide-necked, shallow aneurysm recurrences. Results were poor in partially thrombosed recurrent aneurysms.

Current Hospital Demographics of Subarachnoid Hemorrhage Based on CT Angiography and 3D Rotational Angiography in a Neurosurgical Center.

BACKGROUND AND PURPOSE: Aneurysmal subarachnoid hemorrhage is an important cause of mortality and morbidity. Modern hospital demographics are scarce. We evaluated the diagnosis and treatment of patients with SAH in a neurosurgical referral center. MATERIALS AND METHODS: Between March 2013 and April 2015, two hundred eighty-four patients with SAH diagnosed on CT or lumbar puncture were admitted. All patients underwent 64- to 128-detector row CT angiography. Additional imaging was with 3D rotational angiography of all vessels. In patients with aneurysms, characteristics and mode of treatment were recorded. RESULTS: In 197 of 220 patients with an aneurysmal bleeding pattern, we found a cause of the bleeding: One hundred ninety-five patients had a ruptured aneurysm (98%); 1 patient, a micro-AVM; and 1 patient, reversible vasoconstriction syndrome. Of 195 ruptured aneurysms, 6 were dissecting aneurysms and 3 were AVM-associated flow aneurysms. In 23 of 204 patients (11%) with an aneurysmal bleeding pattern and 3D rotational angiography performed, no cause was found. In 8 of 9 patients (89%) with lumbar puncture positive for SAH but CT negative for it, no cause was found. Of 180 patients with a ruptured aneurysm eligible for treatment, 147 (82%) were treated endovascularly and 30 aneurysms (17%) were clipped. Of 204 patients with an aneurysmal bleeding pattern and 3D rotational angiography, 72 (35%) had multiple aneurysms. These 72 patients had, altogether, 117 additional aneurysms, of which 24 (21%) were treated by either coiling or clipping. CONCLUSIONS: This study provides robust data on hospital demographics of SAH in a neurosurgical referral center, based on CTA and 3D rotational angiography of all vessels.

Coiling of basilar tip aneurysms: results in 154 consecutive patients with emphasis on recurrent haemorrhage and re-treatment during mid- and long-term follow-up.

PURPOSE: The purpose of this study is to report mid- and long-term clinical and angiographic results of coiling of basilar tip aneurysms. MATERIALS AND METHODS: Between January 1995 and August 2006, 154 basilar tip aneurysms were coiled. A total of 114 (74%) had ruptured and 40 (26%) were unruptured. There were 42 men and 112 women taking part in this study, with a mean age of 50.5 years (median, 50; range, 25-73 years). The mean aneurysm size was 11.1 mm (median, 10; range, 2-30 mm) and 71 (46%) were large or giant. Of 154 aneurysms, 40 (26%) were primarily coiled with a supporting device. RESULTS: Initial occlusion was (near) complete in 144 (94%) and incomplete in 10 (6%) aneurysms. The combined procedural mortality and morbidity was 3.8% (6 of 154, 95% CI 1.4-8.3%). The mean clinical follow-up of 144 surviving patients was 53 months (range, 3-144 months; 637 patient-years). The annual incidence rate for recurrent haemorrhage was 0.3% (2 in 637 patient years, 95% CI 0.04-1.1%). During angiographic follow-up of mean 34 months (range, 6-122 months) in 138 patients (96%), 27 basilar tip aneurysms (17.5%) re-opened over time and were additionally coiled. Of these, 11 repeatedly re-opened and were repeatedly coiled. An aneurysm size of median >10 mm was the only significant predictor for re-treatment at follow-up (OR 7.0, 95% CI 2.5-19.7). CONCLUSION: Coiling of basilar tip aneurysms is safe and effective in preventing recurrent haemorrhage. Follow-up angiography is mandatory to timely detection of re-opening, especially in large and giant aneurysms.

Mid-term 3T MRA follow-up of intracranial aneurysms treated with the Woven EndoBridge.

INTRODUCTION: Angiography is the standard follow-up modality for treated aneurysms with the Woven EndoBridge (WEB), and magnetic resonance angiography (MRA) is useful for extended follow-up. We present the results of WEB-treated aneurysms with angiographic follow-up at three months and at least 18 months' 3T MRA follow-up. MATERIALS AND METHODS: Included were 52 patients with 53 aneurysms treated with the WEB between February 2015 and July 2016. There were 29 women and 23 men with a mean age of 60 years (median 62, range 23-76). Mean aneurysm size was 6.2 mm (median 6, range 3-16 mm). RESULTS: 3T MRA follow-up was mean 19.6 months (median 18, range 18-36 months). One patient had an aneurysm remnant at three-month angiography that was additionally coiled and with stable complete occlusion at 18 months' 3T MRA follow-up. At three-month follow-up angiography, 44 aneurysms were completely occluded and eight had a neck remnant. At latest 3T MRA, stable complete occlusion was present in 43 aneurysms and stable neck remnant in eight. One posterior cerebral artery (PCA) dissection aneurysm was stable at three and six months but was enlarged and reopened at 18 months, confirmed with angiography. Focal signal loss by the proximal marker of the WEB was apparent in four patients without compromising diagnostic evaluation. CONCLUSION: WEB-treated aneurysms with adequate occlusion at three-month angiography remained stable during serial 3T MRA follow-up of 18-36 months. One PCA aneurysm reopened during the 6- to 18-month interval. Once the WEB-treated aneurysm is adequately occluded in the short term, later reopening is uncommon.

The New Low-Profile WEB 17 System for Treatment of Intracranial Aneurysms: First Clinical Experiences.

BACKGROUND AND PURPOSE: The Woven EndoBridge (WEB) is an intrasaccular flow diverter intended to treat wide-neck aneurysms. The latest generation WEBs needed a 0.021-inch microcatheter in the small sizes. Recently, a lower profile range of WEBs compliant with a 0.017-inch microcatheter (WEB 17) has been introduced. We present the first clinical results of treatment of both ruptured and unruptured aneurysms with the WEB 17. MATERIALS AND METHODS: Between December 2016 and September 2017, forty-six aneurysms in 40 patients were treated with the WEB 17. No supporting stents or balloons were used. Twenty-five aneurysms were ruptured (54%). There were 6 men and 34 women (mean age, 62 years; median, 63 years; range, 46-87 years). The mean aneurysm size was 4.9 mm (median, 5 mm; range, 2-7 mm). RESULTS: There were 2 thromboembolic procedural complications without clinical sequelae and no ruptures. The overall permanent procedural complication rate was 0% (0 of 40; 97.5% CI, 0%-10.4%). Imaging follow-up at 3 months was available in 33 patients with 39 aneurysms (97.5% of 40 eligible aneurysms). In 1 aneurysm, the detached WEB was undersized and the remnant was additionally treated with coils after 1 week. This same aneurysm reopened at 3 months and was again treated with a second WEB. One other aneurysm showed persistent WEB filling at 3 months. Complete occlusion was achieved in 28 of 39 aneurysms (72%), and 9 aneurysms (23%) showed a neck remnant. CONCLUSIONS: The WEB 17 is safe and effective for both ruptured and unruptured aneurysms. The WEB 17 is a valuable addition to the existing WEB size range, especially for very small aneurysms.

Packing performance of helical Guglielmi detachable coil (GDC) 18 in intracranial aneurysms: a comparison with helical GDC 10 coils and complex Trufill/Orbit coils.

BACKGROUND AND PURPOSE: The purpose of this study was to retrospectively compare the packing performance of helical Guglielmi detachable coil (GDC) 18 (thickness, 0.0135-0.015 inch) with the packing performance of both helical GDC 10 (thickness, 0.010 inch) and complex Trufill/Orbit coils (thickness, 0.012 inch). MATERIALS AND METHODS: From our data base, we selected aneurysms that were exclusively coiled with GDC 18 coils. For every aneurysm treated with GDC 18 coils, we tried to identify a volume-matched control aneurysm treated with exclusively GDC 10 coils or exclusively Trufill/Orbit coils. This process resulted in 32 aneurysm pairs treated with either GDC 18 or GDC 10 coils and 35 aneurysm pairs treated with either GDC 18 or Trufill/Orbit coils. RESULTS: The mean packing of 24.2% of aneurysms treated with GDC 18 was significantly higher than the mean packing of 18.3% of aneurysms treated with GDC 10 (P<.0001). The mean packing of 23.1% of GDC 18 coils was not different from the mean packing of 25.1% of Trufill/Orbit coils (P=.15). CONCLUSION: In aneurysms of 4 mm or larger, packing performance of helical GDC 18 coils is superior to that of helical GDC 10 coils and equal to that of complex Trufill/Orbit coils.

Coiling of very large and giant basilar tip aneurysms: midterm clinical and angiographic results.

BACKGROUND AND PURPOSE: The purpose of this study was to report the midterm clinical and angiographic results of coiling of very large (>15 mm) and giant basilar tip aneurysms. MATERIALS AND METHODS: Between January 1995 and October 2005, 44 very large and giant basilar tip aneurysms in 44 patients were coiled. There were 13 men (30%) and 31 women (70%) with a mean age of 51.4 years (median, 51 years; range, 34-72 years). Mean aneurysm size was 19.6 mm (range, 15-30 mm). Of 44 aneurysms, 33 (75%) had ruptured. Of 11 unruptured basilar tip aneurysms, 7 were incidentally discovered, 1 was additional to another ruptured aneurysm, and 3 were symptomatic by mass effect. RESULTS: Procedural mortality was 2/44 (4.6%, 95% confidence interval (CI), 0.4%-16%) and morbidity 1/44 (2.3%, 95% CI, 0.01%-13%). Of 33 patients with ruptured aneurysms, mean clinical follow-up was 5.2 years (range, 0.5-11.5 years). Two patients had a rebleeding from the coiled basilar tip aneurysm leading to death in 1 patient and to dependency in the other patient (annual rebleeding rate, 1.1%) One other patient died 2 years later of progressive brain stem compression. Mean angiographic follow-up in 41 of 42 surviving patients was 3.1 years. Nineteen aneurysms reopened and were coiled for a second time. Of these, 9 repeatedly reopened with time and were repeatedly coiled up to 6 times. Additional treatments were without complications. CONCLUSION: Coiling of very large and giant basilar tip aneurysms is associated with reasonably low morbidity. Although additional treatment during follow-up is frequently necessary, rebleeding is uncommon.

Packing performance of GDC 360 degrees coils in intracranial aneurysms: a comparison with complex orbit coils and helical GDC 10 coils.

BACKGROUND AND PURPOSE: The purpose of this study was to compare obtained packing densities of aneurysms treated with the newly introduced GDC 360 degrees coils with packing densities of aneurysms treated with either complex Orbit/Trufill coils or helical GDC 10 coils. PATIENTS AND METHODS: Twenty-two aneurysms in 20 patients were coiled with GDC 360 degrees coils. For each of the 22 aneurysms coiled with GDC 360 degrees coils, 2 volume-matched controls treated with either complex Orbit/Trufill coils or helical GDC coils were identified from our data base. The packing of these matched controls was compared with the calculated packing of the 22 aneurysms treated with GDC 360 degrees coils. RESULTS: There was no difference in mean aneurysm volume between aneurysms treated with any of the 3 types of coils (P = .9). Mean packing of 22.1% of aneurysms treated with GDC 360 degrees coils was significantly lower than mean packing of 30.3% of aneurysms treated with complex Orbit/Trufill coils (P = .0015). Mean packing of 22.1% of aneurysms treated with GDC 360 degrees coils was not different from mean packing of 21.6% of aneurysms treated with helical GDC 10 coils (P = .81). CONCLUSION: The use of complex-shaped GDC 360 degrees coils does not lead to increased packing in comparison with that of helical GDC 10 coils. The use of complex Orbit/Trufill coils results in significantly higher packing than that of both GDC 360 degrees coils and helical GDC 10 coils.

Brain AVM embolization with Onyx.

BACKGROUND AND PURPOSE: To report the initial experience by using a new liquid embolic agent (Onyx) for embolization of brain arteriovenous malformations (AVMs). METHODS: Between May 2000 and December 2005, 44 patients with brain AVMs were embolized with Onyx. There were 18 women and 26 men with a mean age of 42.4 years (median 44, range 14-71 years). Clinical presentation included seizures in 26 patients (59%), hemorrhage from the AVM in 13 patients (30%), subarachnoid hemorrhage from a concomitant aneurysm in 3 patients (7%), visual disturbances in 1 patient (2.3%), and in 1 patient (2.3%) the AVM was an incidental finding. Mean estimated size of the AVM was 3.9 cm (median 4, range 2-7 cm). RESULTS: In 44 patients, 52 embolization procedures were performed with 138 feeding pedicles embolized, ranging from 1 to 7 per patient. Average estimated size reduction was 75% (median 80%, range 40%-100%). Total obliteration was achieved in 7 AVMs (16%), and partial embolization was followed by surgery in 10 patients and by radiosurgery in 20 patients. Complications occurred in 6 patients, leading to death in 1 patient (mortality 2.3%) and to permanent disability in 2 patients (morbidity 4.6%). CONCLUSION: Onyx is feasible and safe in the embolization of brain AVMs. Complete obliteration can be achieved in small AVMs. Large AVMs can be adequately reduced in size for additional surgical or radiosurgical treatment.

Intracranial dural fistulas with exclusive perimedullary drainage: the need for complete cerebral angiography for diagnosis and treatment planning.

Three patients are presented with slowly progressive tetraparesis caused by an intracranial dural arteriovenous fistula with exclusive perimedullary venous drainage. MR imaging showed a swollen cervicothoracic cord with central myelopathy and dilated perimedullary veins. Bilateral vertebral angiography initially failed to demonstrate the fistulas, and diagnosis was established with external carotid angiography. All 3 patients were successfully treated with glue embolization, 1 after failed surgical exploration. Angiographic cure of the fistula resulted in clinical cure in 1 patient and stabilization in 2 patients.

Dural arteriovenous fistulas with cortical venous drainage: incidence, clinical presentation, and treatment.

BACKGROUND AND PURPOSE: Our purpose was to report our experience with intracranial dural arteriovenous fistulas (DAVFs) with cortical venous drainage during a 12-year period. PATIENTS AND METHODS: Between January 1994 and January 2006, 91 patients with intracranial DAVFs presented at our institution, and 29 (32%) had cortical venous drainage. There were 5 women and 24 men (mean age, 53.9 years; range, 24-77). Clinical presentation was intraparenchymal or subarachnoid hemorrhage in 18 patients (62%), seizures in 4 patients (14%), visual symptoms in 2 patients (7%), pulsatile bruit in 1 patient (3%), and the DAVF (14%) was incidentally discovered in 4 patients. RESULTS: In 2 patients, the DAVF had been obliterated spontaneously at the time of scheduled embolization 10 and 2 months after hemorrhage, respectively. Five patients with an anterior fossa DAVF underwent successful surgery. In 14 patients, the DAVF was completely occluded with embolization alone, and in 7 patients, embolization was followed by surgery. Altogether, complete occlusion was angiographically confirmed in 28 of 29 DAVFs; the result of radiosurgery of 1 DAVF is pending. There were no complications of surgery; embolization was complicated by postembolization hemorrhage in 1 patient (3%). CONCLUSION: Most DAVFs with cortical venous drainage have an aggressive clinical course. Treatment by a neurovascular team by using surgery, embolization, or a combination resulted in cure in all cases, with a very low complication rate.

Distal aneurysms of cerebellar arteries: incidence, clinical presentation, and outcome of endovascular parent vessel occlusion.

BACKGROUND AND PURPOSE: The aim of this retrospective study was to report the incidence, clinical presentation, and midterm clinical and imaging results of endovascular parent vessel occlusion of 11 patients with 13 distal cerebellar artery aneurysms. MATERIALS AND METHODS: Between January 1995 and December 2006, 2201 aneurysms were treated in our institution. Thirteen aneurysms in 11 patients were located on distal cerebellar arteries (incidence, 0.6%), 8 of them arising from vessels feeding small arteriovenous malformations. There were 6 men and 5 women, ranging from 44 to 70 years of age. One patient with a superior cerebellar artery aneurysm presented with isolated trochlear nerve palsy. Ten patients presented with subarachnoid and intraventricular hemorrhage, and most patients were in poor clinical condition on admission. Aneurysm location was the superior cerebellar artery in 3, the anterior inferior cerebellar artery in 5, and the posterior inferior cerebellar artery in 5. Two patients had 2 aneurysms each. RESULTS: Eleven aneurysms were treated by simultaneous coil occlusion of the aneurysm and parent artery or occlusion of the parent artery just proximal to the aneurysm. Clinical follow-up was at a mean of 16.5 months (range, 2-40 months). Infarction in the territory of the occluded vessel was apparent on follow-up imaging in 5 of 11 patients, all without functional impairment. CONCLUSION: Distal cerebellar artery aneurysms are rare. Most patients present with poor-grade hemorrhage. Endovascular parent vessel occlusion is effective in excluding the aneurysm from the circulation. In most patients, adequate collateral circulation prevents infarction in the territory of the occluded vessel. In this series, when infarction did occur, the clinical consequences were limited.

Aneurysms of the vertebrobasilar junction: incidence, clinical presentation, and outcome of endovascular treatment.

BACKGROUND AND PURPOSE: The aim of this retrospective study was to report the incidence, clinical presentation, and midterm clinical and imaging results of endovascular treatment of 10 aneurysms of the vertebrobasilar junction. MATERIALS AND METHODS: Between January 1995 and January 2007, 2112 aneurysms were treated in our institution. Ten aneurysms in 10 patients were located on the vertebrobasilar junction and 7 aneurysms (70%) were associated with proximal basilar fenestration. There were 5 men and 5 women, ranging from 29 to 75 years of age. Nine aneurysms presented with subarachnoid hemorrhage, and one was a giant partially thrombosed aneurysm with mass effect on the brain stem. RESULTS: Nine ruptured aneurysms were treated by primary coil occlusion. One giant unruptured aneurysm was initially treated with bilateral vertebral artery occlusion, 2 months later followed by selective coil occlusion of the remaining aneurysm lumen via the posterior communicating artery. At imaging follow-up of 6-30 months in 7 patients, all aneurysms were adequately occluded. In 2 patients, the vertebrobasilar junction and distal vertebral arteries (including the aneurysm) thrombosed completely on follow-up without clinical sequelae. CONCLUSION: Vertebrobasilar junction aneurysms are rare, with an incidence of 0.5% of treated aneurysms at our institution. Vertebrobasilar junction aneurysms are frequently associated with proximal basilar fenestration. Most patients present with subarachnoid hemorrhage. Endovascular treatment is effective and safe in excluding the aneurysms from the circulation.