Balloon-Assisted Coiling of Intracranial Aneurysms: Technical Details and Evaluation of Local Complications.

Background: Wide-neck intracranial aneurysms need additional devices like balloons or stent for management. Balloon-assisted coiling has evolved both with interventionalist experience and device modifications. Objective: We discussed our experience, evolution, and complications with this novel technique. Materials and Methods: Data of 2014-2019 was retrospectively reviewed for type of balloon used along with complications in intracranial aneurysm coiling. Two hundred five aneurysms were detected in 188 patients, of which balloon-assisted coiling was planned for 198 aneurysms. Both single and double-lumen balloons were used. Aneurysms were divided into bifurcation and sidewall aneurysms. The complications were compared between bifurcation and sidewall aneurysms, and between single and double lumen balloons. Results: Balloon-assisted coiling was planned for 198 aneurysms but successfully done for 195 (98.5%) cases. Single-lumen balloons were used in 56 aneurysms (28.3%), and double-lumen balloons were used in 142 cases (71.7%). Procedural thromboembolism within parent vessel was seen in 28 cases (14.1%); however symptomatic were encountered in 5 cases (2.5%). Intraprocedural rupture of the aneurysmal sac was seen in 9 cases (4.5%). The procedure-related mortality in our series was 1.6% (3/188 patients), and morbidity was 4.3% (8/188 patients). The complications among bifurcation and sidewall aneurysms compared between single- and double-lumen balloons showed a greater number of symptomatic thromboembolic complications in sidewall aneurysms with the use of single lumen balloons. Conclusions: There are significant symptomatic thromboembolic complications in sidewall aneurysms with the use of single-lumen balloons which decreased as interventionalist experience evolved and better hardware developed.

Paraclinoid Segment Aneurysms of the Internal Carotid Artery: Surgical Clipping.

BACKGROUND: Paraclinoid segment aneurysms arise from the internal carotid artery (ICA) between the distal dural ring and the origin of the posterior communicating (PComm) artery. OBJECTIVE: This pictorial study presents videos showing clipping of paraclinoid segment aneurysms. MATERIALS AND METHODS: The various subtypes of these aneurysms, the nuances in the technique of clinoidectomy, and methods of proximal control are presented. RESULTS: Cavernous ICA is designated as C4, clinoidal segment (between the proximal and distal dural rings) as C5, and supraclinoid segment (between the distal dural ring up to the PComm artery as C6 segment. The techniques used for clipping various aneurysms are based upon their subtypes and location. In the first case, in a giant superior hypophyseal artery aneurysm directed toward the suprasellar region, an intradural clinoidectomy helped in accessing the neck of the aneurysm encroaching into the clinoidal segment of ICA. In the second case, concurrent bilateral "kissing" paraclinoid segment aneurysms were clipped using a unilateral approach. In the third case, clipping of a dissecting paraclinoid segment aneurysm is demonstrated. CONCLUSIONS: Surgery still represents the most definitive form of treatment. It may also be used to evacuate an intracerebral hematoma, with an extremely tortuous proximal vessel or in an aneurysm with complex anatomy, with blister aneurysms, or following aneurysm regrowth following a failed endovascular procedure. Assessing the three-dimensional anatomy of various segments of ICA is an important step.

Spinal Epidural Fistulas-A Separate Entity to Dural Fistulas with Different Angioarchitecture and Treatment Approach.

OBJECTIVE: Spinal epidural arteriovenous fistulas (SEAVFs) are the rarest variety of spinal vascular malformation and are often misdiagnosed as type 1 spinal dural fistula. This retrospective study highlights the salient anatomic differentiating points of these entities and also highlights the importance of a planned endovascular treatment approach using different routes of access. Efficacy of the endovascular treatment at 3 months follow-up was also studied. METHODS: We retrospectively reviewed 11 treated patients with SEAVF. Existence of epidural arteriovenous fistula in all these patients was confirmed by spinal angiography. The Aminoff-Logue Scale score was assigned both before and after the procedure. The statistical results were expressed as percentages, and the preprocedure scale was compared with the postprocedure scale at 3 months by using a nonparametric Wilcoxon signed-rank test. RESULTS: The patients ranged in age from 7 to 53 years, with male predominance. Paraparesis was the commonest symptom, and 1 patient had congestive cardiac failure caused by a large fistula. Location was mostly dorsolumbar with intradural venous reflux into the perimedullary venous system (Castilla type A) noted in 3/11(27%) patients, and the remaining 73% patients had Castilla type B1 with an enlarged epidural venous sac. Therapeutic embolization was performed from arterial, venous, or combined routes. The 3-month postprocedure clinical assessment showed statistically significant (P < 0.004) improvement in the Aminoff-Logue Scale score. CONCLUSIONS: The differentiating points between SEAVF compared with type 1 spinal dural fistula are emphasized. The study also highlights the importance of a good angiographic assessment to best access the fistula by arterial, venous, percutaneous, or combined routes. Endovascular treatment resulted in statistically significant clinical improvement at 3 months follow-up.

Endovascular Management of Direct Carotid-Cavernous Fistula: Evolution of Cost Effective Sandwich Technique.

Objective There is a direct fistulous connection between the cavernous segment of the internal carotid artery and cavernous sinus in cases of direct carotid-cavernous fistula (CCF). Endovascular embolization is the mainstay of management in this condition. This study is about the evolution of endovascular treatment methods and the development of a cost-effective technique for embolization of direct CCF at a tertiary care center. Materials and Methods A retrospective analysis was performed of all the cases of direct type CCF embolized by endovascular techniques in our department from 2008 to 2018.Clinical follow-up of these patients was done at 1 week, 3 months, and 6 months. Results A total of 45 patients with 40 having a prior history of head trauma were included in this study. All cases were treated with a transarterial route except one which was treated with the transvenous approach. Detachable balloon s were used in 12 (26.67%) patients, only detachable coils in 14 cases (31.11%), both detachable balloons and coils in 9 cases (20%), and both detachable and push coils, that is, sandwich technique in 8 cases (17.78%). Parent arterial occlusion was performed in 10 patients (22.22%). There was complete resolution of chemosis and bruit in all the patients. Conclusion Endovascular treatment is the mainstay of management in direct CCF. Using more fibered thrombogenic coils in a sandwich manner decreases the cost of the treatment significantly.

Endovascular biopsy in Takayasu arteritis.

Takayasu arteritis is a chronic inflammatory arteriopathy of the large vessels, mainly the aortic arch and its branches. The disease progression varies, ranging from a rapid progression to quiescence reached within 2 years. The activity of the disease is evaluated by biochemical markers, but at times, there is a discrepancy between the clinical picture and biochemical markers. Histopathology helps in assessing the disease activity, but it is not included in the antemortem diagnosis because of the invasiveness of the procedure and the availability of noninvasive vascular imaging. However, it may be performed simultaneously with angioplasty. Here we present a case of endovascular aortic biopsy conducted to detect active inflammation in the aortic wall.

Dynamic magnetic resonance imaging parameters for objective assessment of the magnitude of tethered cord syndrome in patients with spinal dysraphism.

BACKGROUND: Dynamic magnetic resonance imaging (MRI)-based criteria for diagnosing magnitude of tethered cord syndrome (TCS) in occult spinal dysraphism are proposed. METHODS: In this prospective, case-control design study, MRI lumbosacral spine was performed in 51 subjects [pilot group (n = 10) without TCS (for defining radiological parameters), control group (n = 10) without TCS (for baseline assessment), and study group (n = 31) with spinal dysraphism (thick filum terminale [n = 12], lumbar/lumbosacral meningomyelocoele [n = 6], and lipomyelomeningocoele [n = 13])]. The parameters compared in control and study groups included oscillatory frequency (OF), difference in ratio, in supine/prone position, of distance between posterior margin of vertebral body and anterior margin of spinal cord (oscillatory distance [OD]), with canal diameter, at the level of conus as well as superior border of contiguous two vertebrae above that level; delta bending angle (ΔBA), difference, in supine/prone position, of angle between longitudinal axis of conus and that of lower spinal cord; and sagittal and axial root angles, subtended between exiting ventral nerve roots and longitudinal axis of cord. An outcome assessment at follow-up was also done. RESULTS: In the study group (cord tethered), significantly less movement at the level of conus (OF0, p = 0.013) and one level above (OF1, p = 0.03) and significant difference in ΔBA (p = 0.0) were observed in supine and prone positions, compared to controls. Ventral nerve root stretching resulted in sagittal/axial root angle changes. Median OF (0.04) in the lipomyelomeningocoele group was significantly less than that in control group (0.23). Median OF was also lesser in patients with thick filum terminale or meningomyelocele. Difference in median sagittal and axial root angles among the study and control groups was statistically significant (p = 0.00). CONCLUSION: New dynamic MRI-based parameters to establish the presence and magnitude of TCS have been defined. OF measured the extent of loss of translational cord displacement in supine and prone positions; ΔBA defined the relative angulation of conus with lower spinal cord, and sagittal and axial root angles represented ventral nerve root stretching. The difference in OF or ΔBA was minimum in the group with thick filum terminale and progressively increased in the groups with lipomyelomeningocele and meningomyelocele.

Superselective vesical artery embolization in the management of intractable hematuria secondary to hemorrhagic cystitis.

PURPOSE: To evaluate the efficacy and outcome of superselective vesical arterial embolization in the management of severe intractable hematuria secondary to hemorrhagic cystitis. MATERIALS AND METHODS: We retrospectively reviewed the medical records of nine patients with severe intractable hematuria treated with superselective vesical artery embolization at our institution between March 2003 and February 2015. There were six males and three females with a mean age of 56.1 years. Seven patients had transitional cell carcinoma (TCC) of urinary bladder and had undergone transurethral resection of bladder tumor and pelvic radiotherapy. One patient had synchronous renal pelvis and bladder TCC. One patient had aortoarteritis and was receiving cyclophosphamide therapy and another patient had carcinoma cervix post-pelvic radiotherapy. Following the failure of conservative management, superselective vesical artery catheterization and embolization was performed with 300-500-µ PVA particles in all patients. Coil embolization of inferior gluteal artery followed by particle embolization of vesical arteries was done in one patient in whom superior, inferior vesical and inferior gluteal arteries were arising as a trifurcation. RESULTS: The technical success rate was 100% with complete cessation of hematuria within 48 h in all patients. No significant complications were noted, except for post-embolization syndrome in one patient, which improved on symptomatic treatment. During a mean follow-up period of 14.45 months (ranging from 3-28 months), one patient had mild recurrent hematuria (at 2 months) which resolved spontaneously. CONCLUSIONS: Superselective vesical artery embolization is a safe and effective procedure in controlling intractable life-threatening hematuria in a select group of patients who have failed conventional treatment protocols. This procedure may be considered as the treatment of choice since it usually obviates the need for emergency surgery in these severely ill patients.

Three-dimensional visualization of intracranial tumors with cortical surface and vasculature from routine MR sequences.

The simultaneous three-dimensional (3D) visualization of intracranial tumors, brain structures, skull, and vessels is desired by neurosurgeons to create a clear mental picture of the anatomical orientation of the surgical field prior to the surgical intervention. Different anatomical and pathological components are usually visualized separately on different magnetic resonance (MR) sequences; however, during surgery, they are tackled simultaneously. Another problem is that most present day MR workstations enable review of two-dimensional (2D) slices only with limited postprocessing options. With recent software developments, a simultaneous 3D visualization simulating the real surgical field is possible using commercial or open source softwares. The authors have reviewed the important concepts and described a technique of interactive 3D visualization from routine 3D T1-weighted, MR angiography, and MR venography sequences using open source FSL (Functional MRI of the brain software library) and BrainSuite softwares.

The "focus on aneurysm" principle: Classification and surgical principles of management of concurrent arterial aneurysm with arteriovenous malformation causing intracranial hemorrhage.

CONTEXT: Concurrent arterial aneurysms (AAs) occurring in 2.7-16.7% patients harboring an arteriovenous malformation (AVM) aggravate the risk of intracranial hemorrhage. AIM: We evaluate the variations of aneurysms simultaneously coexisting with AVMs. A classification-based management strategy and an abbreviated nomenclature that describes their radiological features is also proposed. SETTING: Tertiary care academic institute. STATISTICS: Test of significance applied to determine the factors causing rebleeding in the groups of patients with concurrent AVM and aneurysm and those with only AVMs. SUBJECTS AND METHODS: Sixteen patients (5 with subarachnoid hemorrhage and 11 with intracerebral/intraventricular hemorrhage; 10 with low flow [LF] and 6 with high flow [HF] AVMs) underwent radiological assessment of Spetzler Martin (SM) grading and flow status of AA + AVM. Their modified Rankin's score (mRS) at admission was compared with their follow-up (F/U) score. RESULTS: Pre-operative mRS was 0 in 5, 2 in 6, 3 in 1, 4 in 3 and 5 in 1; and, SM grade I in 5, II in 3, III in 3, IV in 4 and V in 1 patients, respectively. AA associated AVMs were classified as: (I) Flow-related proximal (n = 2); (II) flow-related distal (n = 3); (III) intranidal (n = 5); (IV) extra-intranidal (n = 2); (V) remote major ipsilateral (n = 1); (VI) remote major contralateral (n = 1); (VII) deep perforator related (n = 1); (VIII) superficial (n = 1); and (IX) distal (n = 0). Their treatment strategy included: Flow related AA, SM I-III LF AVM: aneurysm clipping with AVM excision; nidal-extranidal AA, SM I-III LF AVM: Excision or embolization of both AA + AVM; nidal-extranidal and perforator-related AA, SM IV-V HF AVM: Only endovascular embolization or radiosurgery. Surgical decision-making for remote AA took into account their ipsilateral/contralateral filling status and vessel dominance; and, for AA associated with SM III HF AVM, it varied in each patient based on diffuseness of AVM nidus, flow across arteriovenous fistula and eloquence of cortex. Follow up (F/U) (23.29 months; range: 1.5-69 months) mRS scores were 0 in 12, 2 in 2, 3 in 1 and 6 in 1 patients, respectively. CONCLUSIONS: Patients with intracranial AVMs should be screened for concurrent AAs. Further grading, management protocols and prognostication should particularly "focus on the aneurysm."

Spinal arteriovenous malformations: Is surgery indicated?

PURPOSE: To identify clinico-radiological distinguishing features in various types of spinal arteriovenous malformations (AVM) with an aim to define the role of surgical intervention. MATERIALS AND METHODS: Hero's modified Di Chiro classification differentiated four types of spinal AVMs on digital subtraction angiogram (DSA) in 74 patients: I. Dural arteriovenous fistulae (n = 35, 47.3%); II. Glomus/intramedullary (n = 13, 17.6%); III. Juvenile/metameric (n = 4, 5.4%); and, IV. Ventral perimedullary fistula (n = 21, 28.4%). A patient with extradural AVM remained unclassified. Demographic profiles, DSA features and reason for surgical referral were recorded. Statistical comparison of discrete variables like gender, spinal cord level, presentation and outcome was made using Chi-square test; and, continuous variables like age, feeder number, duration of symptoms and number of staged embolizations by one way analysis of variance with Boneferoni post hoc comparison. Embolization alone (n = 39, 52.7%), surgery alone (n = 16, 21.6%), and combined approach (n = 4, 5.4%) were the treatments offered (15 were treated elsewhere). RESULTS: Type I-AVM occurred in significantly older population than other types (P = 0.01). Mean duration of symptoms was 13.18 ± 12.8 months. Thoracic cord involvement predominated in type-I and III AVMs (P = 0.01). Number of feeding arteries were 1 in 59.7%; 2 in 29.0%; and, multiple in 11.3% patients, respectively. Staged embolization procedures in type-III AVM were significant (P < 0.01). Surgical referral was required due to: Vessel tortuosity/insufficient parent vessel caliber (n = 7); residual AVM (n = 4); low flow AVM (n = 3); and, multiple feeders (n = 2). Check DSA (n = 34) revealed complete AVM obliteration in 26 and minor residual lesion in eight patients. Neurological status improved in 26 and stabilized in 25 patients. CONCLUSIONS: Differentiating between Type I-IV AVMs has a significant bearing on their management. Surgical intervention should be considered as an important adjunct/alternative to therapeutic embolization.

Traumatic aneurysms of the intracranial and cervical vessels: A review.

Traumatic intracranial aneurysms (TICA) are rare in occurrence, constituting less than 1% of the total cases of intracranial aneurysms. Cervical posttraumatic aneurysms arising from major blood vessels supplying the brain are also extremely rare. Their variable locations, morphological variations and the presence of concomitant head injury makes their diagnosis and treatment a challenge. In this review, we discuss the epidemiology, etiology, classification and management issues related to TICA as well as traumatic neck aneurysms and review the pertinent literature.