Role of Transluminal Balloon Angioplasty for the Treatment of Vasospasm Due to Aneurysmal Subarachnoid Haemorrhage: A Multicentric Indian Experience.

Background Aneurysmal Subarachnoid Haemorrhage (aSAH) is a complex and critical neurological condition associated with significant mortality and morbidity. Apart from the initial insult due to the aneurysmal rupture itself, re-bleeding and severe cerebral vasospasm are some of the complications of aSAH that result in overall poor outcomes. Cerebral vasospasm in post-aSAH can result in delayed ischaemic neurological deficits. In the absence of timely interventions, it can lead to grave consequences for the patient. Management of cerebral vasospasm has been evolving over the years to prevent mortality and morbidity in aSAH patients. Materials and methods During 36 months from January 2018 to December 2020, 164 patients were admitted with aSAH in multiple Indian centres. Endovascular methods were used to treat all the aneurysms. Patients were observed for clinically symptomatic cerebral vasospasm. Patients with suspected vasospasm were further evaluated with a transcranial Doppler (TCD), brain computed tomography (CT) or magnetic resonance imaging (MRI) scan. In addition, digital subtraction angiography (DSA) of cerebral vessels was performed to evaluate vasospasm further. Twenty-two patients had clinically and angiographically significant vasospasm, and 20 patients were treated with transluminal balloon angioplasty (TBA). Results Satisfactory lumen dilation was achieved in 79 out of the 91 (86.81%) vasospastic segments, namely, distal internal carotid arteries (ICAs) 100%; middle cerebral arteries (MCA) 97.56% (M1=100%, M2=100%, M3=87.5%); vertebral arteries-100%; basilar arteries-100%; anterior cerebral arteries (ACA) 67.64% (A1=75%, A2=57.14%). The mean Modified Rankin Scale (mRS) score at 90 days was 0.75. 17 patients (85%) had an overall good outcome with no new neurological deficits. There were no cases of vessel rupture, dissection or thromboembolic complications. Conclusion TBA is a valuable, safe and effective option for managing clinically significant vasospasm caused by aSAH, adjuvant to medical management.

Experience with FRED junior flow diverter in treatment of cerebral aneurysms at or distal to the circle of Willis.

This retrospective study was aimed at assessing our results of endovascular management using the FRED junior flow diverter in cerebral aneurysms at or distal to the circle of Willis. 12 patients with 15 small cerebral vessel aneurysms at or distal to the circle of Willis underwent endovascular treatment using the FRED junior flow diverter at two tertiary care centres in Mumbai, India. 12 of the 15 aneurysms were unruptured, one was treated in an acutely ruptured setting, while two, which had presented with SAH were initially treated with balloon assisted coiling and later treated in a staged manner with a flow diverter. Technical success was 100% in all 15 deployments. Deployments were made across angles ranging from 45° to 180°. There was no stroke/TIA/death in any of the cases, which were unruptured. The O'Kelly-Marotta (OKM) staging was used to analyze angiographic follow up (at least one post procedure angiogram) which was available in 8 patients (10 aneurysms). OKM D & C was seen in 80% of the aneurysms on follow up angiograms. The treatment of small vessel cerebral aneurysms at or distal to the Circle of Willis using a dedicated flow diverter (FRED Jr.) is both technically feasible and highly efficacious.

Endovascular Management of Vein of Galen Aneurysmal Malformations: A Retrospective Analysis over a 15-Year Period.

OBJECTIVES: This retrospective study was aimed at assessing our results of endovascular management in vein of Galen aneurysmal malformation (VGAM). MATERIALS AND METHODS: This is a retrospective study of 26 patients of VGAM who underwent endovascular treatment between 1998 and 2012. All patients underwent trans-arterial embolization. Of 26 patients, 23 were treated using n-butyl cyano acrylate (Glue), while 3 out of 26 patients were treated using the ethylene vinyl alcohol (EVOH) copolymer. RESULTS: Ages of the treated patients ranged from 1 day to 18 years of age. Of the patients treated, 17 were males and 9 were females. Around 15 of the VGAMs were of the mural variety and 11 were choroidal in nature. A good outcome was seen in 22/26 (85%) of the patients. Complications were seen in total in 7/26 patients (26.92%) of which 3/26 (12%) has a fatal outcome. CONCLUSION: Endovascular embolization for VGAMs is highly efficacious and has helped create a population of VGAM survivors in this condition, which until only a few decades ago caused high mortality and morbidity.

Rete mirabile associated with pial arteriovenous fistula: imaging features with literature review.

A rete mirabile is a vascular network of intercommunicating small arteries or arterioles that replace the definitive adult artery supplying the brain. It supplies the brain in lower mammals but is not seen in normal human embryological development. A 26-year-old man presented with worsening tinnitus that was interfering with his sleep. On CT and digital subtraction angiography he was found to have a temporal lobe pial arteriovenous fistula with bilateral carotid and vertebral rete mirabile. The patient was offered open surgical and endovascular treatment options for pial arteriovenous fistula but he refused both and opted for conservative medical management. At 6-month follow-up he continued to have pulsatile tinnitus but was otherwise neurologically normal. We present the first described association of rete mirabile with pial arteriovenous fistula and discuss its clinical presentation and imaging features, with a review of the literature for bilateral carotid and vertebral rete mirabile.

Rete mirabile associated with pial arteriovenous fistula: imaging features with literature review.

A rete mirabile is a vascular network of intercommunicating small arteries or arterioles that replace the definitive adult artery supplying the brain. It supplies the brain in lower mammals but is not seen in normal human embryological development. A 26-year-old man presented with worsening tinnitus that was interfering with his sleep. On CT and digital subtraction angiography he was found to have a temporal lobe pial arteriovenous fistula with bilateral carotid and vertebral rete mirabile. The patient was offered open surgical and endovascular treatment options for pial arteriovenous fistula but he refused both and opted for conservative medical management. At 6-month follow-up he continued to have pulsatile tinnitus but was otherwise neurologically normal. We present the first described association of rete mirabile with pial arteriovenous fistula and discuss its clinical presentation and imaging features, with a review of the literature for bilateral carotid and vertebral rete mirabile.

Bilateral carotid and vertebral rete mirabile with vein of Galen aneurysmal malformation: an unreported association.

Rete mirabile is a fine meshwork of anastomosing vessels that replace the parent artery. A 30-year-old woman complained of slurring of speech, right eye proptosis, recurrent vomiting, and loss of bladder and bowel control, followed by drowsiness lasting 30-40 min, for the past 6 months. On cross sectional imaging and angiography, the patient was found to have a vein of Galen aneurysmal malformation, with bilateral carotid and vertebral rete mirabile. The patient was offered both endovascular and open surgical options but she refused any form of surgical treatment and opted for conservative management. At the 6 month follow-up, she continued to have occasional episodes of headache and vomiting but was otherwise normal. We describe the clinical, cross sectional, and angiographic features of this patient. A comparison with other patients with bilateral carotid and vertebral rete mirabile is also reported.

Crouzon's Syndrome with Life-Threatening Ear Bleed: Ruptured Jugular Vein Diverticulum Treated by Endovascular Embolization.

Crouzon's syndrome is the commonest variety of syndromic craniosynostosis. Life-threatening ear bleed due to ruptured jugular venous diverticulum in Crouzon's syndrome has not been described previously. In patients with syndromic craniosynostosis, definitive repair of jugular diverticulum by open surgery is fraught with high risk of bleeding, poor functional outcomes, and even death. A 24-year-old woman with Crouzon's syndrome presented with conductive hearing loss and recurrent episodes of torrential bleeding from her left ear. On computed tomography, a defect in the roof of jugular fossa containing jugular venous diverticulum immediately inferior to the bony external auditory canal was seen. The clinical presentation, imaging features, and endovascular management of Crouzon's syndrome due to a ruptured jugular venous diverticulum is described.

Acute subarachnoid hemorrhage in posterior condylar canal dural arteriovenous fistula: imaging features with endovascular management.

A 43-year-old man presented with acute subarachnoid hemorrhage. He was investigated and found to have a rare posterior condylar canal dural arteriovenous fistula (DAVF). DAVFs of the posterior condylar canal are rare. Venous drainage of the DAVF was through a long, tortuous, and aneurysmal bridging vein. We describe the clinical presentation, cross sectional imaging, angiographic features, and endovascular management of this patient. The patient was treated by transarterial embolization of the fistula through the ascending pharyngeal artery. This is the first report of an acutely bled posterior condylar canal DAVF treated by transarterial Onyx embolization with balloon protection in the vertebral artery. The patient recovered without any neurological deficit and had an excellent outcome. On 6 month follow-up angiogram, there was stable occlusion of the dural fistula.

Bilateral carotid and vertebral rete mirabile with vein of Galen aneurysmal malformation: an unreported association.

Rete mirabile is a fine meshwork of anastomosing vessels that replace the parent artery. A 30-year-old woman complained of slurring of speech, right eye proptosis, recurrent vomiting, and loss of bladder and bowel control, followed by drowsiness lasting 30-40 min, for the past 6 months. On cross sectional imaging and angiography, the patient was found to have a vein of Galen aneurysmal malformation, with bilateral carotid and vertebral rete mirabile. The patient was offered both endovascular and open surgical options but she refused any form of surgical treatment and opted for conservative management. At the 6 month follow-up, she continued to have occasional episodes of headache and vomiting but was otherwise normal. We describe the clinical, cross sectional, and angiographic features of this patient. A comparison with other patients with bilateral carotid and vertebral rete mirabile is also reported.

Cerebral and spinal vascular involvement in Hereditary Hemorrhagic Telengiectasia: Report of two cases.

INTRODUCTION: We present two cases of Hereditary Hemmorhagic Telengiectasia (HHT), one pediatric and the other adult, with a view to highlight the myriad cerebral and spinal vascular manifestations of this disease. The syndrome and its various findings will be reviewed including the utility of angiography in assessing the various vascular abnormalities of the cerebral and spinal vasculature. METHODS: A review of literature regarding various developmental abnormalities including brain and spinal cord arterio-venous malformations (AVMs), arterio-venous fistulae (AVFs), micro AVMs, micro-fistulae, aneurysms and cavernomas that occur in pediatric and adult population subsets of HHT. Both patients underwent thorough clinical and laboratory evaluation. The pediatric patient underwent a contrast enhanced computed tomography (CECT) of the chest; cerebral, Pulmonary & celiac angiography. The adult patient underwent cerebral and spinal angiography. CONCLUSION: The spectrum of vascular malformations in Hereditary Hemorrhagic Telengiectasia (HHT) is varied.The incidence and manifestations of brain and spinal cord AVMs, AVFs, micro AVMs, micro-fistulae, aneurysms and cavernomas are different in the pediatric and adults affected by the disease. Cerebral and spinal angiography are necessary in characterising the various developmental vascular abnormalities in order to guide further management.

Acute subarachnoid hemorrhage in posterior condylar canal dural arteriovenous fistula: imaging features with endovascular management.

A 43-year-old man presented with acute subarachnoid hemorrhage. He was investigated and found to have a rare posterior condylar canal dural arteriovenous fistula (DAVF). DAVFs of the posterior condylar canal are rare. Venous drainage of the DAVF was through a long, tortuous, and aneurysmal bridging vein. We describe the clinical presentation, cross sectional imaging, angiographic features, and endovascular management of this patient. The patient was treated by transarterial embolization of the fistula through the ascending pharyngeal artery. This is the first report of an acutely bled posterior condylar canal DAVF treated by transarterial Onyx embolization with balloon protection in the vertebral artery. The patient recovered without any neurological deficit and had an excellent outcome. On 6 month follow-up angiogram, there was stable occlusion of the dural fistula.

Retromandibular vein diverticulum: unique imaging findings with a novel therapeutic strategy.

Diverticula of the vascular system are rare. A diverticulum involving the retromandibular vein has not been described to date. We describe the imaging findings and a novel therapeutic strategy for the management of this rare diverticulum. A 25-year-old male presented with complaints of swelling behind the angle of mandible that enlarged on straining. On imaging, a retromandibular vein diverticulum was seen. The diverticulum was punctured percutaneously with the patient performing Valsalva maneuver and injected with sclerosant microfoam. There was no sclerosant reflux into the normal neck veins. At 6-month follow-up, the patient had complete resolution of his symptoms. We also have done a review of literature for patients with venous diverticula in the head and neck region treated by endovascular techniques.

Cerebral hyperperfusion syndrome after endovascular reconstruction of carotid artery in high-flow carotid-jugular fistula.

We describe the occurrence of cerebral hyperperfusion syndrome (CHS) in a case of long-standing carotid-jugular fistula (CJF) treated by endovascular reconstruction of the carotid artery. A 43-year-old male with a high-flow CJF between the internal carotid artery (ICA) and internal jugular vein underwent endovascular reconstruction of the carotid artery using a stent graft. After treatment, the patient developed CHS. The patient succumbed to a large intracranial bleed in the left external capsule and parietal lobe on the fifth postoperative day. CHS following endovascular reconstruction of carotid artery is rare. We present the first reported case of CHS following endovascular reconstruction of ICA. A review of literature for patients treated by endovascular rerouting of blood flow to the cerebral parenchyma associated with hyperperfusion syndrome has been performed.

Recurrent cerebral hyperperfusion syndrome after intracranial angioplasty and stenting: case report with review of literature.

Cerebral hyperperfusion syndrome (CHS) describes a syndrome of sudden onset focal neurological features, unilateral headache, and systemic hypertension. Recurrent CHS in the same patient has not been described to date. We describe a 55-year-old woman who first developed CHS post intracranial stenting with sudden-onset right focal seizures and associated acute focal edema on imaging. After one and half years, the patient developed symptomatic in-stent restenosis and underwent repeat angioplasty with stenting. Postprocedure, the patient had another episode of CHS in the form of acute bleed in the basal ganglia and died. A review of literature of patients for CHS postintracranial angioplasty and stenting also was performed. The present case describes a rare clinical scenario where the patient had recurrent CHS with different clinical and imaging features.

Endovascular management of giant intracranial aneurysms of the posterior circulation.

BACKGROUND: Large size, and location in posterior circulation, both individually portend high risk in the endovascular management of intracranial aneurysms. AIM: The purpose of this study was to investigate the outcome of endovascular management of giant posterior circulation aneurysms at our centre. MATERIALS AND METHODS: This is a retrospective analysis of 22 consecutive patients with giant posterior circulation aneurysms, who were managed by endovascular techniques between 1997 and 2009. The aneurysms included: Vertebral-6 (27%), basilar or vertebrobasilar - 7 (32%) and nine posterior cerebral artery (PCA) - 9 (41%). RESULTS: There were 14 males and eight females with a mean age of 37 years. Treatment modalities included: Parent vessel sacrifice (PVS), coil embolization, flow reversal, stent-assisted coiling, and telescopic stent placement. Angiographic cure or stasis was achieved in 21 (95%) patients and no recurrence was observed in 17 of the 18 patients who had follow-up. Complications occurred in 9 (41%) patients, death in 4 and morbidity in 5 (3 with good eventual outcome). Overall, good clinical outcome was noted in 16 (73%) patients. The majority of the poor outcomes were observed in the management of basilar/vertebrobasilar aneurysms and flow reversal. Parent vessel sacrifice showed the best outcomes with stable results. CONCLUSIONS: Our results suggest that PVS remains the procedure of choice wherever possible and is relatively safe, particularly for giant vertebral and PCA aneurysms. When PVS is not feasible, stent-assisted coiling is a reasonable and safe option and requires follow-up. Management of basilar or vertebrobasilar aneurysms is complicated and still evolving.

Endovascular treatment for bilateral vertebral arteriovenous fistulas in neurofibromatosis 1.

We report a rare case of a 36-year-old woman with neurofibromatosis 1 (NF1) with bilateral vertebro-vertebral arteriovenous fistulas. The patient presented with quadriparesis and had neck pain. Angiography revealed vertebral arteriovenous fistulas bilaterally with dilated epidural venous plexuses compressing the cervical cord resulting in quadriparesis. Endovascular treatment using coils and balloons resulted in successful occlusion of both fistulas. At 6-months postembolization, the patient had improved significantly and is now able to walk with support.