Neurovascular radiosurgery.

SUMMARY: This article focuses on the treatment of neurovascular diseases, in particular brain arteriovenous malformations (BAVMs), with radiosurgery. The target group for this review is physicians who manage patients with neurovascular diseases, but are not actively engaged in radiosurgery. Radiosurgery for BAVMs is an established treatment with clearly defined risks and benefits. The efficacy of radiosurgery for dural arteriovenous shunts (DAVSs) is probably similar but the treatment has not yet gained the same acceptance. Radiosurgical treatment of cavernomas (cavernous hemangiomas) remains controversial. Well founded predictive models for BAVM radiosurgery show: * The probability of obliteration depends on the dose of radiation given to the periphery of the BAVM. * The risk of adverse radiation effects depends on the total dose of radiation, i.e. the amount of energy imparted into the tissue. The risk is greater in centrally located lesions. The risk of damage to brainstem nucleii and cranial nerves must be added to the risk predicted from current outcome models. * The risk of hemorrhage during the time span before obliteration depends on the BAVM volume, the dose of radiation to the periphery of the lesion and the age of the patient. Central location is a probably also a risk factor.

Combined endovascular/neurosurgical therapy of blister-like distal internal carotid aneurysms.

OBJECTIVE: To describe a novel therapeutic strategy for the treatment of "blister-like" aneurysms of the distal internal carotid artery (ICA). Direct surgical treatments of these fragile lesions have been associated with generally poor outcomes. METHODS: Two consecutive patients presenting with acute subarachnoid hemorrhage from "blister-like" aneurysms were treated with preliminary balloon occlusion of the ICA, followed by surgical trapping of the ICA beyond the aneurysm. RESULTS: The treatment resulted in complete thrombosis of both aneurysms with no clinical complications. CONCLUSION: This combined endovascular-neurosurgical approach offers a controlled, safer alternative to primary surgical therapy of "blister-like" aneurysms.

Carotid stenting without angioplasty.

BACKGROUND: Carotid angioplasty and stenting is gaining popularity as an alternative to carotid endarterectomy for the treatment of carotid bifurcation stenosis. The major concern with the procedure is the risk of embolic stroke which may be initiated by balloon angioplasty of friable atherosclerotic plaque. Elimination of angioplasty may result in a lower incidence of embolic complications. METHOD: We describe a case in which a self-expanding stent alone, without balloon angioplasty, was used to successfully dilate an atherosclerotic stenosis of the carotid bifurcation. RESULTS: A moderate increase in vessel diameter, from 75% to 50%, was immediately observed after stent placement alone. No embolic complications were observed and follow-up plain film and ultrasound examinations showed progressive stent enlargement with excellent anatomic and hemodynamic results. CONCLUSIONS: In this case of severe carotid stenosis, the use of a self-expanding stent alone, without balloon angioplasty, resulted in excellent anatomic and hemodynamic improvement.

Endovascular therapy of a large vertebral artery aneurysm using stent and coils.

BACKGROUND: Endovascular therapy is becoming an increasingly popular treatment for cerebral aneurysms. Total angiographic occlusion of small-necked aneurysms (<4 mm) can be obtained in a high percentage of cases. The endovascular treatment of wide-necked or fusiform aneurysms remains a challenge with complete angiographic occlusion reported in <15% of cases. CASE REPORT: We describe the combined use of a flexible coronary stent and platinum coils to treat a wide-necked aneurysm of the distal left vertebral artery, in a patient with Grade IV subarachnoid hemorrhage. RESULTS: The procedure was technically successful as the parent artery was protected by the stent while coils were deposited in the aneurysm lumen. Although angiographic aneurysm occlusion was incomplete, the dome was packed with coils. No further hemorrhage has occurred. CONCLUSION: Combined endovascular stent and coil therapy is a promising technique for the treatment of wide-necked cerebral aneurysms.

Carotid angioplasty and stenting: current status.

Carotid angioplasty and stenting has recently emerged as a popular alternative to endarterectomy for the treatment of carotid atherosclerosis. Carotid endarterectomy has been scientifically validated, but many believe carotid angioplasty and stenting to be a less invasive, less expensive and equally safe and effective method of treatment. The evidence for and against the use of each procedure will be discussed.

Clinical presentation and management of giant anterior communicating artery region aneurysms.

OBJECT: The authors reviewed their 20-year experience with giant anterior communicating artery aneurysms to correlate aneurysm size with clinical presentation and to analyze treatment methods. METHODS: In 18 patients, visual and cognitive impairment were quantitated and clinical outcome was categorized according to the Rankin scale. Statistical analysis was performed using Fisher's exact test. CONCLUSIONS: At least 3.5 cm of aneurysm mass effect was required to produce dementia in the patient (p = 0.0004). Dementia was usually caused by direct brain compression by the aneurysm rather than by hydrocephalus. Optic apparatus compression occurred with smaller aneurysms (2.7-3.2 cm) when they pointed inferiorly. Aneurysm neck clipping was possible in half of the cases. Special techniques, including temporary clipping, evacuation of intraluminal thrombus, tandem and/or fenestrated clipping, and clip reconstruction were often required. Occlusion of or injury to the anterior cerebral artery (ACA) was the main cause of poor outcome or death. Proximal ACA occlusion, even of dominant A1 segments with small or no contralateral A1 artery, was an effective treatment alternative and was well tolerated as a result of excellent leptomeningeal collateral circulation.

Cavernous aneurysm rupture with balloon occlusion of a direct carotid cavernous fistula: postmortem examination.

We present a unique case of a patient with a symptomatic carotid cavernous fistula treated successfully with balloon embolization. Her subsequent death from other disease processes allowed direct visualization of the balloon occlusion in situ at postmortem examination.

Thromboembolic events associated with the treatment of cerebral aneurysms with Guglielmi detachable coils.

BACKGROUND AND PURPOSE: The purpose of this study was to document the prevalence, radiologic appearance, and treatment of thromboembolic events related to GDC embolization of cerebral aneurysms. METHODS: The clinical and radiologic records of all patients undergoing GDC treatment of intracranial aneurysms at our institution were reviewed. All cases in which unexpected complications occurred were selected. Those complications related to presumed thromboembolic events were analyzed. RESULTS: Of 59 patients (60 aneurysms) treated with GDCs, 17 (28%) experienced thromboembolic events. Seven patients had transient ischemic attacks and 10 had strokes. In 10 patients, the deficits occurred during or immediately after the procedure; in the rest, the complications were delayed. In six patients, all radiologic investigations were negative for infarction and in seven patients, CT scans showed new ischemic lesions. In four patients, MR imaging alone showed infarcts, and in four of nine patients who underwent subsequent angiography, acute ischemic findings were demonstrated. Eight patients were treated with volume expansion, eight with full heparinization, and one patient underwent intraarterial thrombolysis. Clinical outcome was excellent or good in 14 of 17 patients, with only three patients (5%) incurring permanent neurologic deficits. CONCLUSION: Thromboembolic events related to GDC treatment may be more common than has been reported in the literature. In our experience, this rate was 28%, with persisting deficits in 5%. These events can occur after uncomplicated procedures and may be unaccompanied by radiologic findings. Clinical outcome is usually favorable.