Intracranial percutaneous transluminal angioplasty for arteriosclerotic stenosis.

BACKGROUND: Patients with intracranial arteriosclerotic disease have significant morbidity and mortality rates, and some are unresponsive to medical treatment and have unacceptable surgical risks. Percutaneous transluminal angioplasty of the intracranial vessels is a possible alternative to surgery. OBJECTIVES: To present our experience with percutaneous transluminal angioplasty and to summarize our data. PATIENTS AND METHODS: Sixteen patients underwent intracranial percutaneous transluminal angioplasty for high-grade arteriosclerotic stenosis based on strict inclusion and exclusion criteria. All patients had symptoms referable to the stenosis except one. Angioplasty was performed in 6 intracranial vertebral arteries, 3 basilar arteries, 5 middle cerebral arteries, and 3 distal internal carotid arteries. One patient had concomitant stent placement. RESULTS: There was 1 treatment failure secondary to tortuous vascular anatomy. Vessel caliber was increased to more than 80% of normal in 6 patients and to 50% to 70% of normal in 6 patients, with a reduction of symptoms. Three intimal dissections occurred during angioplasty; one of these, in a precavernous segment of the internal carotid artery, was stented. One patient restenosed within 1 month of treatment. The remaining treated arteries remained patent during follow-up of 3 months to 2 years. Stroke as a complication occurred in 2 patients, 1 mild and 1 severe. There was no mortality. CONCLUSIONS: Occlusive arteriosclerotic disease involving the intracranial cerebral vessels can be managed medically with antiplatelet and anticoagulant drug therapy or surgically. However, in patients who are unresponsive to medical therapy or who have unacceptable surgical risks, percutaneous transluminal angioplasty is an attractive alternative that can be performed in selected patients with relatively low risk and good clinical outcome.

Guglielmi detachable coiling for intracranial aneurysms: the story so far.

Spontaneous rupture of cerebral aneurysms typically results in subarachnoid hemorrhage. The primary goal of treatment of cerebral aneurysms is to prevent future rupture. Surgical clipping had been the mainstay of treatment of both ruptured and unruptured cerebral aneurysms. In 1991, Guglielmi detachable coil (GDC) embolization was introduced as an alternative method for treating selected patients with aneurysm. The goal of the treatment is prevent the flow of blood into the aneurysm sack by filling the aneurysm with coils and thrombus. Theoretically, there are several advantages of GDC over surgery. These procedures are performed under general anesthesia with the standard transfemoral approaches used in diagnostic angiography. Since its inception, GDC embolization has evolved as a result of both clinical experience and the introduction of technological improvements. We are now better at selecting aneurysms appropriate for coiling, which also have wide necks. Advances in GDC technology have also improved this method of treatment. Over the last several years, the number of coil sizes has been increased, multidimensional coils allowing safer initial coil placement have become available, and, more recently, softer coils have been introduced. Our current approach is to have both surgical and endovascular options for patients.

Treatment of carotid-cavernous sinus fistulas using a detachable balloon catheter through the superior ophthalmic vein.

Four consecutive patients with carotid-cavernous sinus fistulas that could not be treated by the standard techniques of endoarterial balloon occlusion or embolization were successfully treated by advancement of a detachable balloon catheter through the ipsilateral superior ophthalmic vein. Under angiographic monitoring, the balloon was passed into the cavernous sinus, inflated to close the fistula, and detached. Three of the patients had a spontaneous fistula, and one had a traumatic fistula that had previously been trapped unsuccessfully. All patients had complete resolution of symptoms and signs after occlusion of the fistula. There were no intraoperative or postoperative complications. The transvenous approach to the cavernous sinus through the superior ophthalmic vein is a safe, effective treatment of carotid-cavernous sinus fistulas, whether they are direct or dural in nature.

Treatment of traumatic carotid-cavernous fistula using detachable balloon catheters.

The goal of therapy in patients with traumatic carotid-cavernous fistulas is to occlude the fistula, preferably while maintaining the carotid blood flow. Surgical techniques that treat the fistula remote from the cavernous sinus often cannot maintain carotid patency. Various interventional techniques using detachable balloons have been developed. The most common technique uses the endarterial route, introducing the balloon catheter in the neck or the groin. If the balloon is detached in the cavernous sinus, the carotid blood flow will be preserved. A second approach uses the venous retrograde route through the jugular vein, inferior petrosal sinus, and cavernous sinus. Elegant and safe, this method is appropriate when the fistula drains posteriorly. A third approach involves surgical exposure of the cavernous sinus and direct introduction of the balloon. This is sometimes the only recourse when the fistula has been previously treated with internal carotid ligation.

Complete myelography with metrizamide.

Thorough myelography of the entire spinal cord including the foramen magnum region can be accomplished consistently and promptly after metrizamide injection via lumbar or lateral cervical puncture. When lumbar puncture is used the patient's torso is oblique, but the neck is prone and straight and the table is tilted 20 degrees head-down to allow direct cervical filling with contrast material. Each region is filmed in several projections, the patient being turned gently from the prone cervical to the supine thoracic position. Of 100 cases without block studied in this way, all had adequate cervical and foramen magnum films. In only five was the contrast material too dilute to show the edges of the spinal cord well and the subarachnoid sac adequately in the thoracic region. In 29 patients, there were mild side effects not requiring medication, while 20 had side effects of a more moderate to severe nature. No seizures were encountered. Metrizamide proved a convenient, efficient, and acceptable contrast medium for myelography when a study of the entire spinal cord is indicated.

Preembolization superselective angiography: role in the treatment of brain arteriovenous malformations with isobutyl-2 cyanoacrylate.

Transfemoral and intraoperative embolization of arteriovenous malformations (AVMs) of the brain with isobutyl-2 cyanoacrylate may achieve complete and permanent occlusion of the AVMs. The preembolization superselective angiogram is an important source of information to decrease potential technical or clinical complications while seeking that goal. The information obtained from the angiogram of each individual feeder may be classified as anatomical, dynamic, and functional. This angiogram is performed either through a calibrated-leak balloon glued to a Silastic tubing, which is capable of negotiating cortical arterial curves, or through a short catheter directly placed into a feeder at surgery. In 64 patients, 175 preembolization superselective angiograms were obtained. Of those, 105 were obtained using the transfemoral technique, and 70 were obtained by direct catheterization after a craniotomy. Complications occurred in eight patients with only one permanent injury. Transient neurologic deficit occurred in five patients. One patient developed a permanent left monoplegia and one patient a subarachnoid hemorrhage without permanent neurologic deficit. In one patient, a delayed intracerebral hemorrhage produced a right hemiplegia and aphasia. The patient fully recovered in 6 months.

Two different calibrated-leak balloons: experimental work and application in humans.

Two different types of latex calibrated-leak balloon catheters have been developed. One consists of a Teflon catheter with a detachable latex balloon and is used to embolize branches of the external carotid artery. The other consists of a Silastic catheter with a nondetachable latex balloon and is used to embolize brain arteriovenous malformations. An experimental model and animal experiments have determined the best conditions for safe and reproducible embolization with isobutyl-2 cyanoacrylate (IBC-2). Selective catheterization of branches of external carotid, middle cerebral, anterior cerebral, and posterior cerebral arteries in humans is facilitated, and embolization with IBC-2 has been achieved with these balloon catheters.

Hyperintense thrombus on GRASS MR images: potential pitfall in flow evaluation.

Gradient-recalled acquisition in the steady state (GRASS) MR images, obtained in four patients with angiographic evidence of successful occlusion of cerebral arteriovenous malformations, demonstrated hyperintense signal intraluminally. Although this was initially mistaken as evidence of persistent blood flow in the arteriovenous malformation, the short TR/TE spin-echo images showed hyperintense signal rather than flow void, thereby indicating the presence of subacute thrombus. GRASS images alone should not be used to determine the success of embolotherapy of cerebral arteriovenous malformations or to determine aneurysm patency, since the hyperintense signal is a potential pitfall that may mislead the radiologist in the absence of corroborative images, particularly the short TR/TE spin-echo sequences.

Stenosis of afferent vessels of intracranial arteriovenous malformations.

Four women are described with stenoses of the feeding arteries to cerebral arteriovenous malformations. These stenoses were hemodynamically significant in that the nidus malformations filled late in the arterial phase of angiography and the draining veins did not fill much earlier than the usual venous phase. In two of these patients, who were referred for possible embolization, the stenosis served as an impediment to balloon navigation in the feeding vessel in one and served as a partial contraindication to embolization in the other. It is possible that if these stenoses progress, they may lead to thrombosis of the arteriovenous malformations.

Angiographic follow-up of large cerebral AVMs incompletely embolized with isobutyl-2-cyanoacrylate.

This study evaluated the long-term angiographic results in large cerebral arteriovenous malformations (AVMs) partially embolized with isobutyl-2-cyanoacrylate. Preembolization, immediate postembolization, and long-term follow-up angiograms were performed in 30 large, partially embolized brain AVMs. Particular attention was paid to the relative size of the residual AVM nidus and the embolized arterial feeders, to recruitment of new feeders, to the size of residual draining veins, and to the speed of arteriovenous shunt. Nine cases with less than 50% AVM nidus obliteration showed no significant morphologic changes. In 18 cases with 50-75% obliteration of the AVM nidus, 11 (61.1%) showed no significant changes, six (33.3%) showed enlargement of the AVM nidus, and one (5.5%) evolved to complete angiographic obliteration. In three cases with 75-99% AVM nidus obliteration, one remained unchanged, one showed an increase in the size of the AVM nidus, and one evolved to complete obliteration. Evaluation by plain film, CT, and cerebral angiography of the isobutyl-2-cyanoacrylate deposits showed that when the polymer was positioned predominantly in arterial feeders there was invariably reconstitution of the AVM nidus through leptomeningeal, deep medullary, and/or dural collaterals. This phenomenon did not occur when the isobutyl-2-cyanoacrylate was deposited mainly in the AVM nidus.

Superselective injection of BCNU through a latex calibrated-leak balloon.

Carmustine (BCNU) has been used extensively to treat glioblastomas by injection through a catheter placed in the cervical internal carotid artery. The technique causes severe pain to the eye and has resulted in ipsilateral blindness. The use of a latex calibrated-leak balloon positioned above the ophthalmic artery in the internal carotid artery or in one of its branches appears to circumvent the ocular complications mentioned. At an infusion rate at 125 ml/hr the balloon does not inflate and does not occlude the artery. This new technique has been used to treat 10 patients without complications.

Treatment of carotid cavernous fistulae or cavernous aneurysms associated with a persistent trigeminal artery: report of three cases.

One case of traumatic carotid cavernous fistula and two cases of cavernous aneurysm associated with a persistent trigeminal artery are reported. Since a significant rate of infarctions or hemorrhages in the vertebrobasilar territory is associated with PTA, we prefer to permanently occlude the PTA during treatment of a carotid cavernous fistula or a cavernous aneurysm if the trigeminal artery can be sacrificed without jeopardizing the basilar circulation. These three patients were cured without complications. The internal carotid artery could be preserved in only one case.

Arteriovenous malformation nidus catheterization with hydrophilic wire and flow-directed catheter.

Arteriovenous malformation nidus catheterization with a flow-directed catheter at times can be difficult owing to tortuosity of the intracranial vasculature and distal location of the nidus. Since January 1995, hydrophilic wire has been used in conjunction with the 1.8F flow-directed microcatheter in over 150 vessel embolizations with cyanoacrylate glue for brain and spinal arteriovenous malformations at our institution. This technique has improved our success rate in achieving superselective catheterization of the nidus and has shortened the overall procedure time. To date, only one complication has occurred that was directly related to wire manipulation.

Giant unclippable aneurysms: treatment with detachable balloons.

Nine cases of giant unclippable aneurysms treated with the detachable balloon technique are reported. Adjunctive surgical bypass procedures and arterial ligation were also carried out in four and one cases, respectively. All the patients tolerated occlusion of the carotid artery (eight cases) or of both vertebral arteries (one case). Three patients developed neurologic complications: two transient and one permanent (blindness in one eye). The complications occurred when attempts were made to occlude the aneurysm lumen only to preserve the carotid blood flow. Permanent occlusion of the carotid artery appears safer than aneurysm obliteration. Surgical procedures are necessary if the patient does not tolerate permanent occlusion of the artery or if occlusion of the artery is insufficient to obtain thrombosis of the aneurysm.

Progressive thrombosis of brain arteriovenous malformations after embolization with isobutyl 2-cyanoacrylate.

Embolization of brain arteriovenous malformations (AVMs) with isobutyl 2-cyanoacrylate (IBCA) is an alternative to surgical treatment when dealing with large AVMs with multiple arterial feeders. The deposition of IBCA in the nidus of the AVM may produce an active and progressive thrombosis that may lead to complete occlusion of the nidus and/or to progressive thrombosis of the draining veins. Four clinical examples of progressive thrombosis after IBCA embolization are demonstrated, including two cases in which late follow-up angiography showed complete obliteration of a partly embolized AVM.

Dominant-hemisphere arteriovenous malformations: therapeutic embolization with isobutyl-2-cyanoacrylate.

Embolization treatment of 16 patients with dominant-hemisphere arteriovenous malformations (AVMs) is described. This group was selected from 50 patients with brain AVMs embolized with isobutyl 2-cyanoacrylate (IBC-2) over a period of 3 years. All 16 AVMs were cortical in location; six involved the rolandic and speech areas, and four had a deep component. Ten AVMs were embolized through a transfemoral approach, an intraoperative approach was used for four cases, and a combined transfemoral/intraoperative approach was used in two cases. Complete obliteration of the AVM was obtained in one case. Partial obliteration and complete surgical resection was obtained in three cases. Obliteration of 70%-95% of the AVM was obtained in six cases and 45%-70% of the AVM was obliterated in six cases. IBC-2 embolization of the venous drainage was observed in three cases. After embolization, eight patients remained neurologically unchanged. Three patients had mild neurologic deficits that resolved completely within 48 hr; one had a deficit that cleared up 1 week later; and one had a deficit that disappeared within 6 months. In three patients a mild permanent neurologic deficit was evident 6 months after embolization.

Treatment of dural carotid-cavernous fistulas via the superior ophthalmic vein.

Symptomatic patients with dural carotid-cavernous fistulas often require treatment. Traditional therapies, which often are not completely successful, include manual common carotid artery compression and embolization via transarterial routes. This report describes four symptomatic patients with spontaneous dural carotid-cavernous fistulas who were treated unsuccessfully with transarterial embolotherapy and subsequently treated successfully by having a detachable balloon introduced into the cavernous sinus via the superior ophthalmic vein, which was surgically exposed. The fistulas resolved without complications. Treatment of dural carotid-cavernous fistulas by means of the transvenous approach via the superior ophthalmic vein may be of benefit in selected patients.

Giant serpentine aneurysms: a review and presentation of five cases.

We present five cases of giant serpentine aneurysms (large, partially thrombosed aneurysms containing tortuous vascular channels with a separate entrance and outflow pathway) and review 28 cases reported in the literature. Giant serpentine aneurysms should be considered as a subgroup of giant aneurysms, distinct from saccular and fusiform varieties, given their unique clinical presentation and radiographic features.

Bilateral simultaneous cavernous sinus sampling using corticotropin-releasing hormone in the evaluation of Cushing disease.

PURPOSE: To determine whether bilateral, simultaneous, cavernous sinus sampling after corticotropin-releasing hormone (CRH) stimulation offers as accurate detection and lateralization of Cushing disease as inferior petrosal sinus sampling does. METHODS: Seventeen consecutive patients with hypercortisolism and with high-dose dexamethasone suppression test results suggesting Cushing disease underwent bilateral cavenous sinus sampling with CRH stimulation. The diagnosis of Cushing disease was established in all patients by histologic examination or, if no tumor was found at surgery, by subtotal resection of the gland or radiation therapy resulting in eventual hypocortisolism or normal adrenal function and clinical remission. RESULTS: The sensitivity of cavenous sinus sampling with and without CRH in detecting Cushing disease was 94% and 71%, respectively. The abnormal side of the pituitary was correctly identified in all patients who had criteria for lateralization, yielding a positive predictive value of 100%. CONCLUSIONS: This small series suggests that cavernous sinus sampling with CRH is as accurate as inferior petrosal sinus sampling in detecting Cushing disease and perhaps more accurate in lateralizing the abnormality within the pituitary gland.

High-flow angiopathy: cerebral blood vessel changes in experimental chronic arteriovenous fistula.

Profound vascular damage secondary to high-flow extracranial states has been well characterized. However, changes in cerebral vasculature secondary to high-flow states have not been studied. To determine changes related to high-flow states in cerebral vessels, a rabbit model was developed in which torrential flow was created in the vertebrals, carotids, basilar, and vessels of the circle of Willis by means of a carotid-jugular shunt after ligation of the proximal carotid. The clinical, angiographic, and histologic changes noted in the animal model include: abrupt clinical deterioration after a variable interval with some animals developing ptosis, afferent vessel dilatation and the development of prominent anastomotic channels, variable cerebral vessel histopathology--related to duration and relative proximity to the shunt--affecting all three vessel layers, plump, irregular, and clumped endothelium, denuded with adherent platelets, irregular, duplicated, and thinned internal elastic membrane, frayed with invasion of the intima by mesenchymal cells, vacuolization and necrosis of the media muscle, and invasion of adventitia by foreign cells and small blood vessels. The high-flow angiopathy seen in this model may help explain vascular changes associated with high-flow cerebral vascular lesions, as well as other types of vascular damage.