Periprocedural management of ruptured blister aneurysms treated with pipeline flow diversion.

Background: Blister aneurysms are high-risk intracranial vascular lesions. Definitive treatment of these lesions has been challenging. Severe disability or mortality rates are as high as 55% when these lesions are treated with open surgery. Recent data show that flow diversion is a safe and effective alternative treatment for blister aneurysms. Rerupture of the functionally unsecured lesion remains a concern as flow diversion does not immediately exclude the aneurysm from the circulation. Methods: A retrospective review was performed of any patients with ruptured blister aneurysms treated with a pipeline embolization device between 2010 and 2020 at the University of Colorado. Results: In this paper, we present the results of the intensive care management of ruptured intracranial blister aneurysms after flow-diverting stent placement. Conclusion: Despite the need for dual antiplatelet therapy and the delayed occlusion of blister aneurysms treated with flow diversion, we did not find an increase in periprocedural complications.

Neuroangiography: Review of Anatomy, Periprocedural Management, Technique, and Tips.

Neuroangiography (NA) is a minimally invasive procedure used to diagnose patients with neurovascular diseases. Noninvasive imaging has improved dramatically in recent years and is utilized more frequently; however, further evaluation with NA is still required in certain cases. NA indications include intracranial (cerebral aneurysms, arteriovenous malformations, dural arteriovenous fistula, cerebral vasculitis, cerebral vasospasm, ischemic stroke, nontraumatic subarachnoid hemorrhage, intracerebral hemorrhage, Moyamoya, vein of Galen malformation, intracranial tumors, and pseudotumor cerebri) and extracranial (internal and common carotid artery stenosis, vertebral artery stenosis, carotid artery blowout, vertebral artery blowout, epistaxis, oropharyngeal bleeding, and carotid body tumor) pathologies which can help with diagnosis and potential subsequent endovascular treatment. A thorough understanding of normal and variant cervical/cranial vascular anatomy is required. In addition, periprocedural management, catheter technique, equipment needed, and underlying disease pathology are paramount to successful and safe outcomes. This article will review basic neurovascular anatomy, periprocedural management, NA technique, and tips for safe and successful outcomes.

Idiopathic Intracranial Hypertension: Contemporary Management and Endovascular Techniques.

Idiopathic intracranial hypertension (IIH) is a disease process of abnormally increased intracranial pressure in the absence of a mass lesion. Medical management, optic nerve fenestration, and surgical shunting procedures have failed to produce consistently successful results. In an unknown percentage of cases, IIH is caused by dural venous sinus obstruction which can be cured by endovascular treatment with dural venous sinus stent placement. This helps prevent progressive vision loss and worsening papilledema caused by underlying increased intracranial pressure from venous outflow obstruction. Patients are required to have an established diagnosis of IIH, preferably made by a neuroophthalmologist, with clearly documented papilledema or at minimum visual disturbance along with lumbar puncture opening pressure greater than 25 cm H 2 O. Transverse to sigmoid sinus focal narrowing (intraluminal filling defect or extrinsic compression) must be seen during the venous phase of neuroangiography (NA) along with a pressure gradient of 10 mm Hg or greater across the focal narrowing during dural venous sinus pressure monitoring. A successful reduction is defined as a pressure gradient of less than 10 mm Hg after stent placement. Neuroophthalmologic follow-up occurs within 1 to 2 months to assess for changes in papilledema. If papilledema is unchanged or worsened, NA and hemodynamic evaluation is repeated for consideration of restenting. Appropriate patient selection criteria are required for IIH venous sinus stenting. The utilization of refined endovascular techniques along with postprocedure follow-up protocols can ultimately cure IIH for a select group of patients.

Comparative Analysis of Unruptured Cerebral Aneurysm Treatment Outcomes and Complications with the Classic versus Flex Pipeline Embolization Devices and Phenom versus Marksman Microcatheter Delivery System: The Role of Microcatheter Choice on Complication Rate.

OBJECTIVE: The second-generation pipeline embolization device (PED), flex, has improved opening and resheathing ability compared to the first-generation classic PED device. A previously reported single-institutional study suggests that the PED flex devices are associated with lower rates of complications. However, there was limited discussion regarding the complication rate with respect to microcatheter choice for PED delivery and deployment. The present study aims to evaluate outcomes of aneurysm treatment with PED flex versus classic along with the Phenom microcatheter versus Marksman microcatheter. METHODS: A retrospective, IRB-approved database of all patients who received a PED classic or PED flex device between January 2012 and July 2018 was analyzed. Microcatheter choice, patient demographics, medical comorbidities, aneurysm characteristics, treatment information, and outcome data were analyzed using univariate analyses. RESULTS: A total of 75 PED procedures were analyzed. There was no significant difference in major complications between the PED classic and PED flex. However, those treated using the Marksman microcatheter were more likely to have a major complication (periprocedural hemorrhage or ischemic event; 16.6% vs. 0%, p = 0.0248) than those treated with the Phenom microcatheter. Within the PED flex cohort, all major complications were associated with the Marksman microcatheter (p = 0.0289). CONCLUSIONS: The present study does not replicate significantly fewer complications with PED flex but demonstrates a significant reduction in complications with the Phenom microcatheter. Ultimately, this suggests multiple factors are involved in achieving positive outcomes and low complication rates in PED treated unruptured cerebral aneurysms.

Intraosseous Cannulation of a Calvarial Diploic Vein for Embolization of a Symptomatic Dural Arteriovenous Fistula: A Technical Case Report.

BACKGROUND AND IMPORTANCE: Dural arteriovenous fistulas (DAVFs) may present unique challenges for treatment depending on the anatomy and pattern of venous drainage. If endovascular techniques are to be employed, the DAVF must be amenable to transvenous or transarterial therapy. When access of peripheral vasculature does not provide a straightforward path, less conventional options may be available. This case highlights a novel, technically simple, and effective approach for the treatment of a subset of DAVFs, with venous drainage through calvarial diploic veins, that would make endovascular treatment otherwise challenging or impossible. CLINICAL PRESENTATION: We present a case of a 66-yr-old female patient who was diagnosed with a symptomatic DAVF located along the sphenoid ridge with a large intraosseous channel containing the draining vein of the fistula. This lesion was successfully treated with transcranial endovascular embolization via direct intraosseous cannulation of the calvarial diploic vein. This novel approach obviated the need for a full-thickness craniotomy, afforded only minimal bone loss, and preserved the integrity of the dura. A 3-mo follow-up angiogram confirmed complete cure of the DAVF with no residual arteriovenous shunt. At 20 mo postembolization, the patient was symptom free, with no reported neurologic deficits. Complete diagnostic work-up, treatment planning in a multidisciplinary environment, and a novel approach for endovascular embolization utilizing a hybrid operating suite played key roles in the successful implementation of this technique. CONCLUSION: This is the first report of direct intraosseous cannulation of a calvarial diploic vein for successful transcranial endovascular embolization of a symptomatic DAVF.

Use of the PulseRider Device in the Treatment of Ruptured Intracranial Aneurysms: A Case Series.

BACKGROUND: Wide-necked intracranial aneurysms present unique treatment challenges in the setting of subarachnoid hemorrhage. New generations of endoluminal devices (stents) have expanded our ability to treat complex aneurysms. The PulseRider Aneurysm Neck Reconstruction Device (PulseRider [Cerenovus, Irvine, California, USA]) is new to the U.S. market after receiving Food and Drug Administration approval in June 2017. Official recommendation for use of the PulseRider is with dual antiplatelet therapy (DAPT). Its design has been hypothesized to carry a lower risk of thromboembolic complications in the circumstance that DAPT needs to be discontinued. METHODS: Between March and June 2018, we treated 4 cases of ruptured wide-necked basilar tip aneurysms at the University of Colorado Hospital, Aurora, Colorado, with PulseRider-assisted coil embolization. Imaging and chart reviews were performed retrospectively on each of these patients. RESULTS: All 4 aneurysms were successfully treated with PulseRider-assisted coil embolization. There were no periprocedural hemorrhages and no postprocedural reruptures. Two patients developed nonocclusive thrombi in the posterior cerebral arteries at the time of coiling, which was resolved with intra-arterial glycoprotein IIb/IIIa receptor antagonists. Two patients developed external ventricular drain-associated hemorrhages, only one of which developed after the administration of DAPT. All patients were eventually discharged to home. CONCLUSIONS: The PulseRider device represents a novel design for stent-assisted coil embolization. We report a small but promising series of its successful use in the acute treatment of wide-necked, ruptured basilar artery aneurysms. Additional experience is needed to determine if this device has a place in our armamentarium for treatment of ruptured aneurysms.

Anti-neutrophil cytoplasmic antibody associated central nervous system vasculitis with brain and spinal cord subarachnoid hemorrhage: A rare case report and review of the literature.

This case report describes a 48-year old female who presented with altered mental status, lower extremity weakness, low back pain and a recent history of subjective fevers and night sweats found to have posterior parieto-occipital and spinal subarachnoid hemorrhage on imaging. Further work-up revealed vasculitic changes in the intracranial vasculature and the external carotid artery on angiography. She also demonstrated positivity for perinuclear anti-neutrophil cytoplasmic (p-ANCA) antibodies overall consistent with ANCA associated central nervous system vasculitis (AAV). The present case describes a rare and new presentation of AAV that caused both a cerebral and spinal subarachnoid hemorrhage. There has been no documentation of spinal subarachnoid hemorrhage associated with primary or secondary vasculitis in the literature. Ultimately, this case demonstrates the important finding that AAV can have spinal cord manifestations and cervical vasculature involvement along with the more classic intra-cranial vasculitis findings.

Nationwide analysis of hospital-to-hospital transfer in patients with aneurysmal subarachnoid hemorrhage requiring aneurysm repair.

OBJECTIVEAneurysmal subarachnoid hemorrhage (aSAH) has devastating consequences. The association between higher institutional volumes and improved outcomes for aSAH patients has been studied extensively. However, the literature exploring patterns of transfer in this context is sparse. Expansion of the endovascular workforce has raised concerns about the decentralization of care, reduced institutional volumes, and worsened patient outcomes. In this paper, the authors explored various patient and hospital factors associated with the transfer of aSAH patients by using a nationally representative database.METHODSThe 2013 and 2014 years of the National Inpatient Sample (NIS) were used to define an observational cohort of patients with ruptured brain aneurysms. The initial search identified patients with SAH (ICD-9-CM 430). Those with concomitant codes suggesting trauma or other intracranial vascular abnormalities were excluded. Finally, the patients who had not undergone a subsequent procedure to repair an intracranial aneurysm were excluded. These criteria yielded a cohort of 4373 patients, 1379 of whom had undergone microsurgical clip ligation and 2994 of whom had undergone endovascular repair. The outcome of interest was transfer status, and the NIS data element TRAN_IN was used to define this state. Multiple explanatory variables were identified, including age, sex, primary payer, median household income by zip code, race, hospital size, hospital control, hospital teaching status, and hospital location. These variables were evaluated using descriptive statistics, bivariate correlation analysis, and multivariable logistic regression modeling to determine their relationship with transfer status.RESULTSPatients with aSAH who were treated in an urban teaching hospital had higher odds of being a transfer (OR 2.15, 95% CI 1.71-2.72) than the patients in urban nonteaching hospitals. White patients were more likely to be transfer patients than were any of the other racial groups (p < 0.0001). Moreover, patients who lived in the highest-income zip codes were less likely to be transferred than the patients in the lowest income quartile (OR 0.78, 95% CI 0.64-0.95). Repair type (clip vs coil) and primary payer were not associated with transfer status.CONCLUSIONSA relatively high percentage of patients with aSAH are transferred between acute care hospitals. Race and income were associated with transfer status. White patients are more likely to be transferred than other races. Patients from zip codes with the highest income transferred at lower rates than those from the lowest income quartile. Transfer patients were preferentially sent to urban teaching hospitals. The modality of aneurysm treatment was not associated with transfer status.

Patterns, Predictors, and Outcomes of Postprocedure Delayed Hemorrhage Following Flow Diversion for Intracranial Aneurysm Treatment.

OBJECTIVE: To evaluate patterns, predictors, and outcomes of postprocedure delayed hemorrhage (PPDH) following flow diversion therapy for intracranial aneurysm treatment. METHODS: From 2012 to 2016, 50 patients with 52 aneurysms were treated with the Pipeline embolization device. Device placement was performed as a standalone therapy or with adjunctive coil embolization. Patients underwent dual antiplatelet therapy for 6 months after treatment. Medical comorbidities; aneurysm traits; and treatment factors, including platelet function testing, were studied. Statistical analysis was performed using cross-tabulation. RESULTS: Six PPDHs (12%) occurred 2-16 days (mean 6.8 days) after Pipeline placement, manifesting as 1 of 2 distinct patterns: convexity subarachnoid hemorrhage (cSAH) (n = 4) or lobar intraparenchymal hemorrhage (IPH) (n = 2). All PPDHs occurred ipsilateral to the device; 1 IPH occurred ipsilateral but in a different arterial territory. PPDH occurred in both treated anterior communicating artery aneurysms. Cases of PPDH demonstrated on average lower P2Y12 reaction unit values at the time of treatment. Platelet function testing at the time of hemorrhage was consistently hypertherapeutic. Patients with cSAH had only minimal worsening of modified Rankin Scale score at the time of discharge, whereas the 2 patients with IPH experienced significant deterioration. CONCLUSIONS: PPDH is a poorly understood complication following flow diversion therapy that can result in significant morbidity. In our experience, nonaneurysmal cSAH does not result in poor clinical outcomes, whereas IPH leads to long-term deficits or death. As previously suggested, there appears to be a correlation between low P2Y12 reaction unit values and PPDH.

Embolization of Head and Neck Vascular Malformations using Serial Arterial Embolization Followed by Dominant Arterial Embolization with Two Microcatheter Technique.

PURPOSE: Head and neck arteriovenous malformation (AVM) and fistulae treatment without reflux and with nidal penetration are challenging. We describe a case series including adult and pediatric patients utilizing a specific two-microcatheter technique using Onyx with strategic embolization of small feeding branches prior to dominant branch embolization. We aim to demonstrate the safety and efficacy of this technique. PATIENT SELECTION: Head and neck vascular malformation cases were reviewed from 2010 to 2017. 11 patients between 2010 and 2017 were treated with serial embolization along with Onyx embolization utilizing a two-microcatheter technique. Five patients had cerebral AVMs, three had dural arteriovenous fistulae, two had mandibular AVMs, and one had a posterior neck AVM. Vascular anatomy, location, and procedural details were recorded. TECHNIQUE: During procedures 1-4, smaller arterial feeders were embolized first to maximally decrease the intranidal pressure at the time of the embolization of the major residual feeder. The dominant residual feeder was then embolized using two catheters. Coils followed by Onyx were initially deployed through the proximal catheter to form a dense plug. The plug was allowed to solidify for 30 min. Aggressive embolization of the nidus was then performed through the distal catheter. RESULTS: All 11 patients had excellent treatment results with complete (6) or near-complete (5) obliteration of the vascular malformation nidus. No procedural complications were noted, specifically no strokes, hemorrhages, or unintentionally retained catheter fragments occurred. CONCLUSION: AVMs and fistulae are challenging to treat. A two-microcatheter technique for Onyx embolization with prior embolization of smaller arterial feeders is a safe and efficacious treatment option. This technique allows for maximal nidus penetration while minimizing the risk of nontarget embolization/reflux. In all cases, we achieved excellent results with complete or near-complete obliteration of the vascular malformation nidus.

Dural sinus stenting for idiopathic intracranial hypertension: factors associated with hemodynamic failure and management with extended stenting.

BACKGROUND: Some patients undergoing dural sinus stenting for idiopathic intracranial hypertension (IIH) develop clinical and hemodynamic failure (recurrence of the pressure gradient) owing to stent-adjacent stenosis. OBJECTIVE: To characterize factors associated with hemodynamic failure, and to describe outcomes of patients after repeat stenting. MATERIALS AND METHODS: We reviewed the initial and follow-up clinical, venographic, and hemodynamic data in 39 patients with IIH treated over 17 years with stenting. Thirty-two had follow-up angiographic and hemodynamic data at 1-99 months (mean 27.6, median 19.5 months). Eight patients were treated with 12 repeat stenting procedures, including extended stenting into the superior sagittal sinus (SSS). RESULTS: All patients had an initial successful hemodynamic result with the pressure gradient reduced from 10-43 to 0-7 mm Hg. 10/32 patients (31.3%), all women, developed new stenoses in the transverse sinus or posterior SSS above the stent with a recurrent pressure gradient. 7/9 patients with pure extrinsic stenosis of the transverse-sigmoid junction pre-stenting developed new stenoses and hemodynamic failure. All patients with hemodynamic failure who were restented had early and mid-term documented hemodynamic success at 1.7-50 months. They were free from papilledema at 3.8-50 months after the last restenting, and 11.5-99.5 months after initial stent placement (mean 45.3, median 38.5 months). CONCLUSIONS: Pure extrinsic compression of the transverse-sigmoid junction and female gender were strongly associated with hemodynamic failure. Eight patients with hemodynamic failure who were restented had successful control of papilledema, including 4/4 who had extended stenting into the SSS.

Ruptured Distal Posterior Inferior Cerebellar Artery (PICA) Aneurysms Associated with Cerebellar Arterial Venous Malformations (AVMs): A Case Series and Review of the Literature Demonstrating the Need for Angiographic Evaluation and Feasibility of Endovascular Treatment.

OBJECTIVE: The characteristics, diagnosis, and preferred management strategies for distal posterior inferior cerebellar artery (PICA) aneurysms associated with cerebellar arteriovenous malformation (AVMs) are poorly understood. We present a case series with attention to aneurysm angioarchitecture, diagnostic imaging, treatment approaches, and a thorough review of the literature. With this information, we demonstrate a specific anatomical pattern for these aneurysms, an underreported need for conventional digital subtraction angiography (DSA) during evaluation, along with the utility of endovascular treatment with liquid embolic agents. METHODS: Neurosurgical patients from 2005 to 2016 were reviewed to identify PICA aneurysms along with distal PICA aneurysms. Details of their presentation, imaging studies, associated AVMs and treatment were recorded. A thorough literature search of previous case series and case reports of distal PICA aneurysms with and without associated small cerebellar AVMs was performed with PubMed and Google Scholar. RESULTS: Thirty-four patients with PICA aneurysms were identified at our institution, 12 of which were in a distal segment. All 12 of these patients underwent DSA as a part of their evaluation. Of the 12 patients with distal PICA aneurysms, 9 presented with subarachnoid hemorrhage and intraventricular hemorrhage. Five of these patients had a small occult cerebellar AVM. All nine patients presenting with a ruptured distal PICA aneurysm had a Fischer grade 4 subarachnoid hemorrhage. Of the five patients with a small occult cerebellar AVM, the AVM nidus was missed on computed tomography angiogram (CTA) interpretation but easily visualized with DSA. CTA followed by DSA with concurrent endovascular treatment was performed in 9 of the 12 patients with distal PICA aneurysms. Two of the 12 patients were treated with microsurgical clip ligation, and one mycotic aneurysm was identified and treated with antibiotics. Parent vessel sacrifice was used distal to the aneurysm in all 5 associated AVM cases with liquid embolic agents as well as AVM embolization in 3 of the 5 cases. Fifty-one well-described case reports of distal PICA aneurysms associated with small cerebellar AVMs have been reported in the literature. A total of 12 well-described case series of distal PICA aneurysms that comment on associated AVMs describe an associated small cerebellar AVM incidence of 4%-50%. In our case series, the incidence of an associated small cerebellar AVM with a distal PICA aneurysm was 42%. CONCLUSIONS: In cases of distal PICA aneurysms, there is a frequent association of a small cerebellar AVM. In our series, CTA was an inadequate diagnostic study to identify the associated AVM, and DSA was necessary to definitely visualize the AVM nidus. Endovascular treatment of the aneurysm and AVM with the use of liquid embolic agents was a feasible and useful management strategy.

Anomalous Right Vertebral Artery Originating from the Aortic Arch Distal to the Left Subclavian Artery: A Case Report and Review of the Literature.

OBJECTIVE: Present a case report of an anomalous origin of the right vertebral artery originating from the aortic arch distal to the left subclavian along with a review of cases reported to date in the literature. METHODS: Provide background information on this rare anomaly, present the case report, review the literature using PubMed, summarize previously reported cases to date, and discuss the underlying embryologic development of this anomaly along with its significance. RESULTS: We report a 54-year-old man presenting with a subarachnoid hemorrhage referred for diagnostic cerebral arteriography who was found to have an anomalous origin of the right vertebral artery originating from the aortic arch distal to the left subclavian artery in conjunction with a bovine arch. We also report 13 previously reported cases along with their other associated variant anatomy. CONCLUSIONS: Based upon our present case and previously documented cases to date, this anomaly is a rare finding. An understanding of aberrant anatomy and its embryologic basis is paramount to avoiding inadvertent vascular injury during diagnostic cerebral angiography. Therefore, this abnormality must be considered if selective vertebral artery catheterization is difficult or unsuccessful.

Acute Posterior Multifocal Placoid Pigment Epitheliopathy Associated with Stroke: A Case Report and Review of the Literature.

BACKGROUND: Present a case report of acute posterior multifocal placoid pigment epitheliopathy (APMPPE) associated with stroke along with the serologic findings, diagnostic findings, and treatment in addition to presenting a review of other case reports to date in literature. With this information, we are attempting to identify key diagnostic features and appropriate treatment options for patients with this disease. METHODS: Presentation of case report, background on APMPPE, review of the literature and previous case reports, and discussion of diagnostic workup and treatment options for these patients. RESULTS: There are 28 well-described case reports in the literature to date, not including our case report; 23 had documented radiographic findings consistent with parenchymal injury, ischemic stroke, hemorrhagic stroke, or cerebral venous thrombosis. We report a 23-year-old right-handed man with left hemiparesis, ischemic strokes, and angiographic findings characteristic of cerebral vasculitis 4 months after he was diagnosed with APMPPE. CONCLUSIONS: Based on our present case and previously documented cases to date, corticosteroid therapy with potential escalation of care to immunomodulatory treatment appears to benefit clinical outcomes.

Embolization of bronchial artery-supplied ectopic parathyroid adenomas located in the aortopulmonary window.

Ectopic parathyroid adenomas in the aortopulmonary window (APW) are extremely rare, constituting only 1% of ectopic mediastinal adenomas and 0.24% of all parathyroid adenomas. The authors have encountered three patients with ectopic adenomas in the APW. In each case, the primary arterial supply to the APW adenoma arose from the bronchial artery. In addition, there was a small anastomotic arterial channel connecting the bronchial artery supplying the adenoma to the left inferior thyroid. All three adenomas were treated with transcatheter embolization, with control of hyperparathyroidism in two of three patients. One patient required thoracoscopic removal of the adenoma. It is critical that the interventionalist be aware of this arterial supply pattern to allow successful embolization of an APW ectopic adenoma.

Juvenile nasopharyngeal angiofibroma: vascular determinates for operative complications and tumor recurrence.

OBJECTIVES/HYPOTHESIS: Operative complications and tumor recurrence in juvenile nasopharyngeal angiofibroma (JNA) are measurable and meaningful outcomes. This study aimed to assess the association of these two outcomes to various clinical indices and in particular, vascular determinates. STUDY DESIGN: Retrospective cohort study. METHODS: An 18-year retrospective chart review of an academic tertiary center was undertaken. Data from clinical notes, imaging studies, and arteriograms were analyzed. RESULTS: Thirty-seven male (mean age, 14.4 years) patients were included in the study. Tumor stages included: IA (three), IB (three), IIA (14), IIB (three), IIC (five), IIIA (five), and IIIB (four). Four complications (cerebrospinal fluid leak, cerebral vascular accident, and two transient ocular defects) occurred. Eight recurrences occurred within 24 months following surgery. Complications were associated with estimated intraoperative blood loss (EBL) (P = .045). Tumor recurrence was associated with feeding vessels from the contralateral internal carotid artery (ICA) (P = .017). EBL was significantly associated with surgical technique used. EBL, tumor stage, and tumor vascular supply were significantly associated with each other. CONCLUSIONS: Vascular factors were associated with JNA complication and tumor recurrence. EBL might affect complications, and contralateral ICA as a feeding vessel might affect recurrence. EBL was influenced by procedure choice and was interrelated to size and vascular supply of the tumor. This study bolsters the need to decrease intraoperative blood loss by preoperative embolization and use of endoscopic removal techniques. Furthermore, when branches of the ICA are found to be feeding vessels, greater surgical attention for a dry surgical field is encouraged.

Dural sinus stent placement for idiopathic intracranial hypertension.

OBJECT: The use of unilateral dural sinus stent placement in patients with idiopathic intracranial hypertension (IIH) has been described by multiple investigators. To date there is a paucity of information on the angiographic and hemodynamic outcome of these procedures. The object of this study was to define the clinical, angiographic, and hemodynamic outcome of placement of unilateral dural sinus stents to treat intracranial venous hypertension in a subgroup of patients meeting the diagnostic criteria for IIH. METHODS: Eighteen consecutive patients with a clinical diagnosis of IIH were treated with unilateral stent placement in the transverse-sigmoid junction region. All patients had papilledema. All 12 female patients had headaches; 1 of 6 males had headaches previously that disappeared after weight loss. Seventeen patients had elevated opening pressures at lumbar puncture. Twelve patients had opening pressures of 33-55 cm H(2)O. All patients underwent diagnostic cerebral arteriography that showed venous outflow compromise by filling defects in the transverse-sigmoid junction region. All patients underwent intracranial selective venous pressure measurements across the filling defects. Follow-up arteriography was performed in 16 patients and follow-up venography/venous pressure measurements were performed in 15 patients. RESULTS: Initial pressure gradients across the filling defects ranged from 10.5 to 39 mm Hg. Nineteen stent procedures were performed in 18 patients. One patient underwent repeat stent placement for hemodynamic failure. Pressure gradients were reduced in every instance and ranged from 0 to 7 mm Hg after stenting. Fifteen of 16 patients in whom ophthalmological follow-up was performed experienced disappearance of papilledema. Follow-up arteriography in 16 patients at 5-99 months (mean 25.3 months, median 18.5 months) showed patency of all stents without in-stent restenosis. Two patients had filling defects immediately above the stent. Four other patients developed transverse sinus narrowing above the stent without filling defects. One of these patients underwent repeat stent placement because of hemodynamic deterioration. Two of the other 3 patients had hemodynamic deterioration with recurrent pressure gradients of 10.5 and 18 mm Hg. CONCLUSIONS: All stents remained patent without restenosis. Stent placement is durable and successfully eliminates papilledema in appropriately selected patients. Continuing hemodynamic success in this series was 80%, and was 87% with repeat stent placement in 1 patient.

An 18-year-old man with fenestrated vertebral arteries, recurrent stroke and successful angiographic coiling.

Fenestration of vertebral arteries has been reported in association with thromboembolic brain infarctions. However, few cases have been reported in which recurrent infarction occurred in spite of adequate anticoagulation. We report a young man with fenestrated vertebral arteries and stroke who failed to respond to standard anticoagulation therapy but did well with angiographic coil obliteration of an abnormal vertebral segment. An 18-year-old left-handed man presented with acute onset of dizziness and headache. No trauma or other stroke risk factors were identified. Left cerebellar infarction was seen on CT, but the cause could not be identified by brain and neck MRI, MRA, or CTA. Bilateral fenestrated vertebral arteries were identified with conventional angiography. Although the patient recovered fully and was treated with anticoagulation, he suffered a recurrent stroke 1 month later involving the right cerebellum while he was on a therapeutic dose of warfarin. Repeat arteriography showed a spontaneous dissection within one of the fenestrated vertebral segments. Since receiving angiographic coil obliteration of the pathologic segment, he has been free of all symptoms. We conclude that the patient sustained recurrent thromboembolic events in his posterior circulation due to spontaneous dissection within a fenestrated vertebral artery segment. Conventional angiography and emergent interventional embolization were essential to his diagnostic evaluation and therapeutic intervention.

The effects of desflurane and propofol on portosystemic pressure in patients with portal hypertension.

UNLABELLED: Physicians perform hepatic venous pressure measurements to guide medical therapy aimed at reducing portal hypertension. These measurements are frequently performed during general anesthesia. Since most general anesthetic drugs reduce liver blood flow, it is likely that hepatic venous pressures will be altered. We therefore examined the effects of two frequently used anesthetic drugs on hepatic venous pressure in a prospective randomized study to determine if pressure measurements taken during general anesthesia were similar to awake values. We studied 21 patients with hepatitis C, excluding patients with hepatofugal flow and portal vein thrombosis. All patients had free and wedged hepatic venous pressures measured awake with sedation and after anesthesia with either propofol or desflurane. Desflurane significantly increased free hepatic venous pressure (11.9 +/- 4.4 to 23.5 +/- 4.1 mm Hg; P < 0.05) and decreased hepatic venous pressure gradient (21.6 +/- 7.4 to 14.7 +/- 5.2 mm Hg; P < 0.05), whereas propofol did not change these variables. We conclude that desflurane, but not propofol, alters hepatic venous pressure measurements from the awake state, significantly increasing free hepatic venous pressure and decreasing the hepatic venous pressure gradient, an indirect measure of portosystemic pressure. Changes in the hepatic venous pressure gradient must be interpreted with caution during desflurane general anesthesia. IMPLICATIONS: Desflurane reduces the blood pressure difference between the portal and systemic circulations. This can cause errors in assessment of the success of medical therapy of portal hypertension. Propofol has less effect on the difference between the portal and systemic circulation.