Superselective indocyanine green angiography for selective revascularization in the management of peripheral cerebral aneurysms.

This report describes the management of a fusiform peripheral middle cerebral artery aneurysm by endovascular parent artery occlusion under bypass protection. Localization of the recipient cortical artery was accomplished after craniotomy by superselective injection of diluted ICG dye via a microcatheter positioned proximal to the aneurysm. This report demonstrates that superselective ICG angiography can be a beneficial alternative technique to identify the best anastomosis site intraoperatively.

Ruptured carotid artery aneurysms of the ophthalmic (C6) segment: clinical and angiographic long term follow-up of a multidisciplinary management strategy.

BACKGROUND: The management of ruptured C6 aneurysms remains controversial. Detailed long-term outcome data are still lacking. Thus the present study provided a detailed long term follow-up for a multidisciplinary approach combining microsurgical clipping, endovascular embolisation and parent artery occlusion with/without bypass protection. METHODS: In our single centre analysis of 64 consecutive patients, indications for microsurgery were: superior aneurysm projection, giant/large or wide necked aneurysms and aneurysms at branching sites. Indications for embolisation were: narrow necks, neck calcification, close aneurysm relation to the clinoid process or adhesion to the distal dural ring, and aneurysm location in the concavity of the carotid siphon curve. RESULTS: 23 patients (35.9%) underwent microsurgery, 38 patients (59.4%) embolisation and three patients (4.7%) parent artery occlusion under bypass protection. Retreatment was required in 20.9% (surgery 8.7%, endovascular 31.6%). Procedure related transient complications occurred in 10.9% (surgery 13.0%, endovascular 10.5%). Procedure related permanent morbidities occurred in 6.3% (surgery 8.7%, endovascular 5.3%), including visual deficits in 4.7% (surgery 4.4%, endovascular 5.3%). One endovascular patient died. Angiographic follow-up (29.2 (SD 31.9) months) revealed total aneurysm occlusion in 94.4% of the surgical and 82.9% of the endovascular patients. Clinical follow-up (58.7 (SD 47.6) months) showed 73.4% of the population reaching Glasgow Outcome Scale 4-5, these data being equivalent to the International Subarachnoid Aneurysm Trial (ISAT) outcomes. CONCLUSIONS: Based on favourable neuroradiological and ophthalmological outcomes, microsurgery is recommended for superiorly projecting aneurysms, especially aneurysms involving the ophthalmic artery, and for giant/large or wide necked aneurysms. Based on stable aneurysm occlusion and excellent clinical outcomes, embolisation can be recommended for inferiorly/medially projecting small, narrow necked aneurysms.

Computerized assessment of angiographic occlusion rate and coil density in embolized human cerebral aneurysms.

BACKGROUND AND PURPOSE: Computerized methods have been introduced for more objective quantification of angiographic occlusion rate and coil density as parameters of successful embolization. This study aimed 1) to evaluate this new computerized method for angiographic occlusion rating and coil density calculations by comparison with corresponding histometric parameters from retrieved human aneurysms, and 2) to compare the new computerized method with the present standard of subjective angiographic occlusion rating. MATERIALS AND METHODS: From 14 postmortem-retrieved human aneurysms, angiographic occlusion rate was determined by contrast medium attenuation-gradient distinction on digital subtraction angiographs after Guglielmi detachable coil (GDC) embolization. Angiographic coil density was calculated, approximating aneurysms as ellipsoid and coils as cylindric volumes. On surface-stained histologic ground sections of the respective aneurysms, the occluded aneurysm area and coil area were measured. Then, we calculated and compared the histometric occlusion rates and coil densities with the corresponding angiographic parameters by using the Wilcoxon paired signed-rank test and the Spearman rank correlation. RESULTS: Computerized angiographic occlusion rates (75%-100%) showed good correlation (r = 0.799; P < .01) with histometric occlusion-rates (61%-100%), resulting in no statistically significant differences (P = .2163). With 5.1% (+/-3.8), the mean difference between computerized angiographic occlusion rates and histometry was substantially lower compared with 10.7% (+/-8.7) mean difference between subjective angiographic estimations and histometry. Calculated angiographic coil density (13%-32%) significantly differed from histometric coil density (8%-35%; P < .05). CONCLUSIONS: For recanalized aneurysms, computerized angiographic occlusion rating showed better correspondence with histometry compared with subjective angiographic occlusion rating. Clinical application of this new tool may lead to more objective cutoff values for re-embolization indications. The value of coil density calculations seems limited by the approximation of the aneurysms as ellipsoid volumes.

Emergency Extracranial-to-Intracranial Bypass after Thromboembolic Occlusion of the Middle Cerebral Artery Following GDC Embolization of a Ruptured ACoA Aneurysm.

SUMMARY: We report a case of thromboembolic occlusion of the middle cerebral artery after endovascular treatment of a ruptured anterior communicating artery aneurysm. When fibrinolytic therapy failed to recanalize the occluded vessel, an emergency extracranial-to-intracranial bypass was performed. This intervention rescued our patient from cerebral infarction. This case demonstrates the importance of the offering this procedure at neurointerventional centers.

Posthemorrhagic hydrocephalus in preterm infants: long-term follow-up and shunt-related complications.

INTRODUCTION: A retrospective analysis of 42 preterm infants with intraventricular hemorrhage was performed in order to evaluate shunt-related problems in neonates with posthemorrhagic hydrocephalus. PATIENTS AND METHODS: Within the last 15 years, 76 infants with intraventricular hemorrhage were treated primarily by external ventricular drainage, and 42 needed permanent shunting. Shunting was performed 28-101 days after the patients' birth, ventriculoatrial shunts being placed in 10 patients and ventriculoperitoneal shunts in 32. RESULTS: The mean number of shunt revisions per patient was 1.57. The main reasons for shunt revision were infection (7.1%) and blockage (45.2%). Primary ventriculoperitoneal and ventriculoatrial shunts differed only insignificantly in revision rate and length of shunt survival, whereas ventriculoperitoneal shunts used in shunt revisions required significantly fewer further revisions. CONCLUSIONS: The neurological outcome was not related to the necessity for or to complications of a shunt. Programmable valve systems and neuroendoscopy appear to be helpful in the overall management and in the treatment of complications.

Electronic database for documentation of microsurgical and endovascular treatment of intracranial aneurysms: technical note.

The authors present an electronic database for the documentation and inter-group comparison of patients subjected to microsurgical and/or endovascular therapy of ruptured and unruptured intracranial aneurysms.

A lateral mass fracture of C1 associated with left vertebral artery and mid-basilar artery occlusion.

Extreme acceleration and deceleration forces as well as axial loading are exerted at the occipito-cervical junction of drivers involved in high-velocity motor vehicle accidents, especially with fastened seatbelts. Injury at this level, usually lethal, can go unrecognized despite modern emergency management of the unconscious patient. A precise neurologic and radiographic workup of damage to this area is often not possible or overlooked in the initial phase of such severe trauma. We describe a patient with multiple injuries who sustained a left vertebral artery occlusion associated with a left-sided lateral mass fracture of C1 and a basilar artery occlusion resulting in a locked-in syndrome after an automobile accident.

Treatment of dural arteriovenous fistulae (dAVF's) at the superior sagittal sinus (SSS) using embolisation combined with micro- or radiosurgery.

DAVF's at the SSS are extremely rare and usually present with intracranial haemorrhage (ICH) or a progressive neurological deficit. Due to their midline location and multiple arterial supply, endovascular treatment alone often fails in eliminating the fistula. Therefore, endovascular, combined with neurosurgical and/or radiosurgical treatment is often needed to cure the patient. We summarized our experience with three male patients over a ten-year period who suffered from dAVF's involving the middle and posterior third of the SSS. Two of them presented with an ICH during the clinical course. Despite multiple transarterial embolisations, complete fistula occlusion could not be achieved in any of them. Nevertheless, neurological symptoms improved in all cases. One patient refused further treatment and died six years later due to an ICH. Another patient was finally cured by microsurgical coagulation of the fistula. In the remaining patient stereotactic radiosurgery (SRS) was performed after nearly complete endovascular occlusion. We strongly recommend microsurgery and/or radiosurgery as adjunctive measures, if embolisation alone fails to eliminate these dangerous fistulae.

Spinal dural arteriovenous fistula associated with syringomyelia.

The previously undescribed association of a spinal dural arteriovenous fistula with syringomyelia was found in a 60-year-old male, who developed increasing paresis, numbness of both lower extremities and sphincteric dysfunction. Symptoms and signs were attributed to a syringomyelia at T5-L1 and an arteriovenous spinal dural fistula at L1. The fistula was successfully immobilised with N-butyl-cyano-acrylate. Six months after the procedure, all abnormalities had nearly disappeared. Whether the relation between the fistula and the syringomyelia was coincidental or causative could not be determined.

Preoperative embolization of hypervascular skull base tumors.

The purpose of the present study is to review the results and complications of preoperative embolization of hypervascular skull base tumors at a neurosurgical center with a team of neurosurgeons cross-experienced in the application of both microsurgery and endovascular techniques. One hundred and twenty-eight endovascular approaches were performed in 66 patients treated for skull base meningiomas (n = 41), paragangliomas of the temporal bone (n = 18), and juvenile nasopharyngeal angiofibromas (n = 7). One death and 2 permanent disabilities were attributable to endovascular therapy. These complications occurred early in our experience (1982-1989) and were related to thromboembolic events rather than complications of transcatheter embolization itself. Our current standard is to perform transfemoral superselective embolizations with either finely corpuscular embolizing substances (PVA particles) or cyanoacrylates (NBCA) under local anesthesia. Using this protocol no embolization-related complications have occurred over the last 9 years. We thus conclude that preoperative embolization of hypervascular skull base tumors can be accomplished safely with the endovascular techniques now available.

Preoperative embolization of intracranial meningiomas: a 17-years single center experience.

The purpose of the present report is to review the evolution of endovascular therapy at our center as utilized for the preoperative embolization of intracranial meningiomas over a 17-years period (1982-1998). This study is based upon a consecutive series of 63 patients who underwent preoperative embolization of intracranial meningiomas. Total or subtotal angiographic devascularization of the tumor parenchyma was accomplished in 38 patients (60.3%) who had tumors with either an external carotid artery supply only (n = 30) or with contributions from the cavernous carotid artery, ophthalmic artery, vertebral artery, or pial feeders which were feasible for selective embolization (n = 8). Partial tumor embolizations were attained in the remaining 25 patients (39.7%) because 1. the remanent feeders were considered easily accessible to surgical control in the early stages of dissection, 2. the feeding branches were inaccessible for a microcatheter approach, or 3. superselective microcatheter positions allowing for safe embolization without reflux of embolic material into physiological branches were not achieved. Overall, 97 of 126 tumor feeders identified angiographically were catheterized to selective embolization (77%). Three embolization related complications occurred early in our experience (1982-1989) using techniques which no longer meet standards of treatment. In light of the remarkable evolution of endovascular techniques over the 17-years study period, however, we conclude that preoperative embolization of intracranial meningiomas can be performed safely with the endovascular tools currently available.

Intra-arterial thrombolysis for the treatment of perioperative childhood cardioembolic stroke.

Local intra-arterial lysis using recombinant tissue plasminogen activator (rTPA) was performed in a 6 and 2/3-year-old patient with major cardioembolic ischemic stroke 48 hours after intracardiac surgery. Selective application of 2.5 mg rTPA (0.11 mg/kg body weight) resulted in recanalization of the occluded cerebral vasculature with good neurologic recovery.

Clinical and angiographic results of endosaccular coiling treatment of giant and very large intracranial aneurysms: a 7-year, single-center experience.

OBJECTIVE: To evaluate whether the objectives of surgical treatment, i.e., prevention of aneurysmal rebleeding, relief of aneurysmal mass effect, and prevention of embolic complications, are met by endosaccular coiling treatment applied to giant and very large wide-necked aneurysms. METHODS: Thirty patients with 31 giant or very large aneurysms were considered to show unacceptable risk/benefit ratios for open surgery and were treated using the Guglielmi detachable coil (GDC) method between 1992 and 1998. RESULTS: With endosaccular GDC treatment, 73.3% of the population experienced excellent to good recoveries (Glasgow Outcome Scale scores of 4 or 5), with a 13.3% procedure-related morbidity rate and a 6.7% procedure-related mortality rate. Two hemorrhaging episodes occurred after GDC treatment (annual bleeding rate, 2.5%; 2 hemorrhaging episodes/79.2 patient-yr). Symptoms related to aneurysmal mass effect were improved for 45.5% of the patients presenting with signs of neural compression. Among 23 patients with 24 aneurysms who were available for angiographic follow-up assessment, complete or nearly complete occlusion was observed for 17 aneurysms (71%; angiographic follow-up period, 24.3 +/- 19.6 mo, mean +/- standard deviation). A single total embolization served as definitive treatment for only 12.5% of the giant aneurysms and 31% of the very large aneurysms. CONCLUSION: Endosaccular GDC treatment of giant and very large aneurysms was accomplished with procedure-related morbidity and mortality rates comparable to those for open surgery performed by experts. However, because coil stability was unsatisfactory, we suggest that the GDC method should currently be reserved for individuals who are considered poor candidates for open surgery.

Variant arteriovenous fistula of the superior sagittal sinus--case report.

A 57-year-old male presented with a rare variant of dural arteriovenous fistula, located in the wall of an unobstructed superior sagittal sinus. Drainage occurred through a cortical vein no longer connected to its parent sinus, which filled up a cluster of transmedullary running veins, one of which was the presumed site of hemorrhage. Arterial blood was supplied via the external carotid artery branches. This type of fistula seriously increases the risk of hemorrhage in the patient and therefore requires complete obliteration. Attempts to embolize the fistula failed. The draining vein was isolated and coagulated resulting in permanent occlusion of the fistula. The fistula probably developed through a process of thrombophlebitis and revascularization via arterioles of the vein rather than previous occlusion of the sinus.

Gross and microscopic histopathological findings in aneurysms of the human brain treated with Guglielmi detachable coils.

OBJECT: The histopathological characteristics of aneurysms obtained at autopsy or surgery 3 days to 54 months after being treated with Guglielmi detachable coils (GDCs) were assessed. METHODS: Seventeen aneurysms were obtained at autopsy and one was removed at surgery. Fourteen were examined histologically with the coils in situ. Naked coils embedded in an unorganized thrombus were found in those aneurysms that had been treated with coils within 1 week earlier. An incomplete replacement of the intraluminal blood clot by fibrous tissue and a partial membranous covering at the aneurysm orifice were observed in those aneurysms that had been treated with coils between 2 and 3 weeks prior to examination. One small aneurysm treated 6 weeks before harvesting showed formation of an endothelium-lined layer of connective tissue at the orifice. Collagen-rich vascularized tissue surrounding the coils was found in an aneurysm removed at surgery 54 months after coil implantation. Interestingly, six (50%) of 12 aneurysms (two small, three large, and one giant) that had been deemed 100% occluded on initial angiography showed tiny open spaces between the coils at the neck on gross examination. CONCLUSIONS: Endothelialization of the aneurysm orifice following placement of GDCs can occur; however, it appears to be the exception rather than the rule. In large aneurysms the process of intraaneurysm clot organization seems to be delayed and incomplete; tiny open spaces between the coils and an incomplete membranous covering in the region of the neck are frequently encountered. Further longitudinal studies are required to establish the spectrum of healing profiles that may direct our efforts in modifying the GDC system to produce a more stable long-term result.

Prognostic factor analysis for multiple brain metastases after gamma knife radiosurgery: results in 97 patients.

Stereotactic radiosurgery (SR) is being used with increasing frequency in the treatment of brain metastases. This study provides data from a clinical experience with radiosurgery in the treatment of cases with multiple metastases and identifies parameters that may be useful in the proper selection and therapy of these patients. From January 1993 to April 1997, 97 patients (43 women and 54 men; median age 58 years) suffering from multiple brain metastases (median 3; range 2-4) in MRI scans, received SR with the Gamma Knife. The median dose at the tumor margin was 20 Gy (range 17-30 Gy). Median tumor volume was 3900 cmm (range 100-10,000). Different forms of hemiparesis, focal and generalized seizures, cognitive deficit, headache, dizziness and ataxia had been the predominant neurological symptoms. Major histologies included lung carcinoma (44%), breast cancer (21%), renal cell carcinoma (10%), colorectal cancer (8%), and melanoma (7%). The median survival time was 6 months after SR. The actual one-year survival rate was 26%. In univariate and multivariate analysis, a higher Karnofsky performance rating and absence of extracranial metastases had a significantly positive effect on survival. Local tumor control was achieved in 94% of the patients. Complications included the onset of peritumoral edema (n = 5) and necrosis (n = 1). SR induces a significant tumor remission accompanied by neurological improvement and, therefore, provides the opportunity for prolonged high quality survival. We conclude that radiosurgical treatment of multiple brain metastases leads to an equivalent rate of survival when compared to the historic experience of patients treated with whole brain radiotherapy. Patients presenting initially with a higher Karnofsky performance rating and without extracranial metastases had a median survival time of nine months. Each such case should therefore be evaluated based on these factors to determine an optimal treatment regimen.

Treatment of basilar artery bifurcation aneurysms by using Guglielmi detachable coils: a 6-year experience.

OBJECT: The authors retrospectively analyzed the results of their 6-year experience in the treatment of basilar artery (BA) bifurcation aneurysms by using Guglielmi detachable coils (GDCs). METHODS: This analysis involved 45 BA tip aneurysms in 16 men and 29 women who ranged in age from 23 to 78 years (mean 50 years). Seventy-five percent of the aneurysms had ruptured and 25% remained unruptured. Of the group whose aneurysms hemorrhaged, 14 patients were Hunt and Hess Grade I or II and 20 were Hunt and Hess Grades III to V; 32 patients were treated within 2 weeks of their subarachnoid hemorrhage (SAH). Initially, treatment with GDCs was limited to poor-grade high-risk patients who refused surgery or patients in whom surgery proved unsuccessful. Later in the study, good-grade patients with narrow-necked aneurysms were also treated using GDCs. The length of clinical follow up ranged from 1 to 72 months (average 27.4 months) in the 37 surviving patients. In 33 of the 45 aneurysms treated with coil placement, good to excellent results were achieved. There were 12 poor results (27%) including one in a patient from the non-SAH group who suffered a thrombotic complication due to an underlying vasculitis. Eight deaths were recorded in this group of 45 patients. One of these deaths was caused by a complication related to anesthesia, one by unknown causes, and six resulted from complications of the disease. One patient rebled on the 2nd day after the endovascular procedure. The mortality and permanent morbidity rates directly related to the intervention were 2.2% and 4.4%, respectively. Angiographic studies obtained immediately postintervention demonstrated 99 to 100% occlusion in 30 (67%) of the aneurysms; nine (20%) were more than 90% occluded; and six (13%) were less than 90% occluded by the GDCs. Follow-up angiograms were obtained in 31 patients between 2 and 72 months after coil placement. Nineteen (61%) of the follow-up angiograms revealed stable results (that is, no change from initial treatment). Twelve of the 31 showed coil compaction, but only eight of these lesions could accept additional coils. In large aneurysms recanalization was seen in 57%, and some of the larger lesions required as many as four embolizations (mean 1.7) to achieve optimal occlusion. When small-necked aneurysms were analyzed as a subset, a stable angiographic result was seen in 92%. CONCLUSIONS: Use of GDCs led to excellent clinical and angiographic results in the majority of patients with BA tip aneurysms included in this limited follow-up study. Rebleeding was encountered in one of the 34 previously ruptured BA aneurysms treated with GDCs, and no hemorrhages have been documented in the 11 unruptured aneurysms treated with GDCs in this series. Long-term follow-up studies are necessary before it is possible to compare adequately the treatment of aneurysms with coil placement to the gold standard of aneurysm clipping.

Coiling of recurrent and residual cerebral aneurysms after unsuccessful clipping.

We treated four patients with 3 recurrent and 1 residual aneurysm after surgical clipping by using Guglielmi detachable coils (GDCs). Three subjects presented after a second subarachnoid hemorrhage (SAH) occurring between 10 and 25 years after the first bleeding. Early postoperative angiography of the fourth patient showed an incompletely clipped aneurysm. In three poor grade patients we observed one good outcome, one fair result and one death due to the sequelae of SAH. One good grade patient remained in excellent condition postoperatively. Three aneurysms were totally occluded and in one a more than 90% occlusion was achieved with GDCs. We consider the treatment with GDC a viable alternative to reoperation in all patients with recurrent or residual aneurysms following failed attempt at surgical obliteration.

Chronic shunt-dependent hydrocephalus after early surgical and early endovascular treatment of ruptured intracranial aneurysms.

OBJECTIVE: The goal of this study was to document the influence of the treatment method (early surgery versus early endovascular treatment) on the development of chronic shunt-dependent hydrocephalus in a series of 242 patients treated within 7 days after aneurysmal subarachnoid hemorrhage (SAH). METHODS: The following parameters were prospectively recorded in a computerized database and retrospectively analyzed for association with chronic shunt-dependent hydrocephalus: 1) Hunt and Hess grade, 2) Fisher computed tomographic grade, 3) incidence of repeat SAH, 4) aneurysm location, and 5) treatment method (early surgery versus early endovascular treatment). RESULTS: Forty of 187 patients (21.4%) who survived the SAH and its neurological and/or medical sequelae underwent definitive shunting for treatment of chronic hydrocephalus. The rate of shunt dependency was positively correlated with a higher Hunt and Hess grade (P < 0.001), a higher Fisher computed tomographic grade (P = 0.003), the occurrence of intraventricular hemorrhage (P < 0.001), repeat SAH (P = 0.003), and aneurysms arising at the anterior communicating artery (P < 0.001). CONCLUSION: The results of the present study indicate that the treatment method used does not affect the risk of the later development of chronic shunt-dependent hydrocephalus (early surgery, 23.2% [29 of 125]; early endovascular treatment, 17.7% [11 of 62]; P = 0.45).

Histopathological findings in experimental aneurysms embolized with conventional and thrombogenic/antithrombolytic Guglielmi coils.

We studied the short- and long-term histological responses induced by conventional and modified electronically detachable coils (GDCs) in experimental aneurysms. Eighteen carotid bifurcation aneurysms were produced microsurgically in rabbits. Six animals each were treated either with conventional or with GDCs coated with a mixture of tissue-thromboplastin to enhance intra-aneurysmal thrombus formation and of plasminogen activator inhibitor type-1 (PAI-1) in inhibit intra-aneurysmal clot fibrinolysis. Six served as untreated controls. Follow-up angiograms were obtained immediately and at 3, 6, 9, 12, 17, and 24 weeks after embolization prior to sacrifice of the animals. All aneurysms were studied macroscopically and histopathologically with the coils in situ. Five of six control aneurysms remained patent. Endovascular occlusion rates between > 90% and 100% were achieved in nine of twelve coiled aneurysms. Follow-up angiography demonstrated recanalization and coil compaction in 5 of them. Gross and microscopic histopathological examination revealed a membrane covering the orifice, intra-aneurysmal scar formation, and development of a neo-intima in both treatment groups at 17 and 24 weeks postembolization. The granulation tissue response appeared to be equally distributed in aneurysms treated with either uncoated or coated coils. Further quantitative morphometric studies are needed to prove if a thrombogenic/antithrombolytic coil-coating might be of value in providing a more enduring anatomic result after GDC-treatment of human brain aneurysms.