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1.
Neurosurg Focus ; 32(5): E12, 2012 May.
Artigo em Inglês | MEDLINE | ID: mdl-22537121

RESUMO

Endovascular embolization with Onyx has been increasingly used to treat intracranial and spinal dural arteriovenous fistulas (DAVFs). Several case series have been published in recent years reporting high DAVF cure rates with this technique. Although it is seldom reported, DAVF recurrence may occur despite initial "cure." The authors present 3 separate cases of a recurrent DAVF after successful transarterial Onyx embolization. Despite adequate Onyx penetration into the fistula and draining vein, these cases demonstrate that DAVF recanalization may reappear with filling from previous or newly recruited arterial feeders. Other published reports of DAVF recurrence are examined, and potential contributory factors are discussed. These cases highlight the need for awareness of this possible phenomenon and suggest that follow-up angiography should be considered in patients treated with catheter embolization.


Assuntos
Malformações Vasculares do Sistema Nervoso Central/terapia , Embolização Terapêutica/métodos , Polivinil/uso terapêutico , Idoso , Malformações Vasculares do Sistema Nervoso Central/diagnóstico , Angiografia Cerebral , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Medula Espinal/irrigação sanguínea , Medula Espinal/cirurgia , Resultado do Tratamento
2.
Neurosurg Focus ; 26(5): E15, 2009 May.
Artigo em Inglês | MEDLINE | ID: mdl-19408993

RESUMO

OBJECT: Spinal dural arteriovenous fistulas (DAVFs) are the most common spinal vascular malformations and can be a significant cause of myelopathy, yet remain inefficiently diagnosed lesions. Over the last several decades, the treatment of spinal DAVFs has improved tremendously due to improvements in neuroimaging, microsurgical, and endovascular techniques. The aim of this paper was to review the existing literature regarding the clinical characteristics, classification, and endovascular management of spinal DAVFs. METHODS: A search of the PubMed database from the National Library of Medicine and reference lists of all relevant articles was conducted to identify all studies pertaining to spinal DAVFs, spinal dural fistulas, and spinal vascular malformations, with particular attention to endovascular management and outcomes. RESULTS: The ability to definitively treat spinal DAVFs using endovascular embolization has significantly improved over the last several decades. Overall rates of definitive embolization of spinal DAVFs have ranged between 25 and 100%, depending in part on the embolic agent used and the use of variable stiffness microcatheters. The majority of recent studies in which N-butyl cyanoacrylate or other liquid embolic agents were used have reported success rates of 70-90%. Surgical treatment remains the definitive option in cases of failed embolization, repeated recanalization, or lesions not amenable to embolization. Clinical outcomes have been comparable to surgical treatment when the fistula and draining vein remain persistently occluded. Improvements in gait and motor function are more likely following successful treatment, whereas micturition symptoms are less likely to improve. CONCLUSIONS: Endovascular embolization is an increasingly effective therapy in the treatment of spinal DAVFs, and can be used as a definitive intervention in the majority of patients that undergo modern endovascular intervention. A multidisciplinary approach to the treatment of these lesions is required, as surgery is required for refractory cases or those not amenable to embolization. Newer embolic agents, such as Onyx, hold significant promise for future therapy, yet long-term follow-up studies are required.


Assuntos
Malformações Vasculares do Sistema Nervoso Central/diagnóstico , Malformações Vasculares do Sistema Nervoso Central/terapia , Dura-Máter/anormalidades , Embolização Terapêutica/métodos , Medula Espinal/anormalidades , Adesivos/uso terapêutico , Malformações Vasculares do Sistema Nervoso Central/fisiopatologia , Dura-Máter/irrigação sanguínea , Dura-Máter/fisiopatologia , Embolização Terapêutica/tendências , Humanos , Microinjeções/métodos , Microinjeções/tendências , Reoperação/métodos , Reoperação/estatística & dados numéricos , Prevenção Secundária , Medula Espinal/irrigação sanguínea , Medula Espinal/fisiopatologia , Resultado do Tratamento
3.
Neurosurg Clin N Am ; 16(3): 561-8, vii, 2005 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-15990045

RESUMO

Interventional neuroradiology procedures of the spine are being performed with increasing frequency. These therapies complement and, in some cases, replace more conventional operations of the vertebral column and its contents. This article surveys the background, present application, and future horizons of several minimally invasive spinal interventions, including vertebroplasty and kyphoplasty, microcatheterization of the cervical epidural space via lumbar puncture for drug delivery, percutaneous intraspinal navigation, and percutaneous spinal fixation.


Assuntos
Discotomia Percutânea/métodos , Doenças da Coluna Vertebral/cirurgia , Extravasamento de Materiais Terapêuticos e Diagnósticos/diagnóstico , Extravasamento de Materiais Terapêuticos e Diagnósticos/diagnóstico por imagem , Humanos , Radiografia , Radiologia Intervencionista , Doenças da Coluna Vertebral/diagnóstico por imagem , Fraturas da Coluna Vertebral/cirurgia
4.
Neurosurgery ; 53(2): 380-2; discussion 383, 2003 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-12925255

RESUMO

OBJECTIVE: Percutaneous kyphoplasty is postulated to have several advantages over percutaneous vertebroplasty for the treatment of vertebral compression fractures and is gaining increased popularity. However, cement delivery with the KyphX kit (Kyphon, Inc., Santa Clara, CA), the only commercially available device for percutaneous kyphoplasty, is relatively problematic. This kit uses a series of "bone filler device" (BFD) tubes. Each BFD must be loaded manually with cement, which is then injected into the kyphoplasty cavity by manually depressing an inner stylet. The high profile of the BFD cannulas and their stylets requires frequent repositioning of the image intensifier tube and table. Because each accommodates only a small volume, the BFDs must be exchanged frequently. This delivery method also places the operator's hands directly in the field of radiation. We sought to overcome these limitations. METHODS: Dissatisfied with the shortcomings of the BFDs, we substituted the EZflow screw-syringe injector (Parallax Medical, Mountain View, CA) we use to deliver cement during conventional percutaneous vertebroplasty. This amalgam of the KyphX kit and the screw-syringe injector has been used for kyphoplasty treatment of 26 thoracolumbar compression fractures in 17 patients. RESULTS: The screw-syringe injector allows controlled volumetric delivery of large boluses of high-viscosity cement without having to refill the reservoir. It minimizes radiation exposure and does not require repositioning of the x-ray tubes. It may theoretically allow decompression should cement extrusion occur. Also, it delivers cement to the interstices of bony trabeculae outside the kyphoplasty cavity, thus combining the mechanical benefits of percutaneous kyphoplasty and percutaneous vertebroplasty. CONCLUSION: The use of a screw-syringe injector has several merits over the customary means of cement delivery during kyphoplasty.


Assuntos
Cimentos Ósseos/uso terapêutico , Parafusos Ósseos , Fixação Interna de Fraturas/métodos , Vértebras Lombares/lesões , Vértebras Lombares/cirurgia , Compressão da Medula Espinal/etiologia , Compressão da Medula Espinal/cirurgia , Fraturas da Coluna Vertebral/complicações , Fraturas da Coluna Vertebral/cirurgia , Seringas , Vértebras Torácicas/lesões , Vértebras Torácicas/cirurgia , Humanos , Vértebras Lombares/diagnóstico por imagem , Radiografia , Compressão da Medula Espinal/diagnóstico por imagem , Fraturas da Coluna Vertebral/diagnóstico por imagem , Vértebras Torácicas/diagnóstico por imagem
5.
Neurosurgery ; 51(1): 247-52; discussion 252-3, 2002 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-12182427

RESUMO

OBJECTIVE: The use of a covered stent-graft to repair disruptions of the cervical carotid and vertebral arteries is described. This device maintains vessel patency while effectively excluding pseudoaneurysms, arteriovenous fistulae, and other breaches in the integrity of the arterial wall. METHODS: Patient 1 bled from a large rent in the proximal common carotid artery as a result of tumor invasion. Patient 2 developed a vertebral arteriovenous fistula after a stab injury to the neck. Patient 3 developed cerebral infarction and an enlarging pseudoaneurysm of the internal carotid artery, also after a stab wound to the neck. RESULTS: All three patients were treated with the Wallgraft endoprosthesis (Boston Scientific, Watertown, MA). In each case, the vessel wall defect was repaired while antegrade flow through the artery was preserved or restored. No neurological complications occurred as a result of stent-graft deployment. CONCLUSION: Covered stent-grafts offer an alternative to endovascular occlusion of the parent vessel, thereby expanding the therapeutic options for patients with extracranial cerebrovascular disease. These three cases highlight the usefulness and versatility of these devices for endoluminal reconstruction of the brachiocephalic vasculature.


Assuntos
Falso Aneurisma/cirurgia , Fístula Arteriovenosa/cirurgia , Implante de Prótese Vascular , Doenças das Artérias Carótidas/cirurgia , Estenose das Carótidas/cirurgia , Materiais Revestidos Biocompatíveis , Stents , Artéria Vertebral/lesões , Ferimentos Perfurantes/cirurgia , Adulto , Falso Aneurisma/diagnóstico por imagem , Falso Aneurisma/etiologia , Fístula Arteriovenosa/diagnóstico por imagem , Fístula Arteriovenosa/etiologia , Doenças das Artérias Carótidas/diagnóstico por imagem , Doenças das Artérias Carótidas/etiologia , Artéria Carótida Interna/diagnóstico por imagem , Artéria Carótida Interna/cirurgia , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/etiologia , Angiografia Cerebral , Feminino , Humanos , Desenho de Prótese , Técnica de Subtração , Artéria Vertebral/diagnóstico por imagem , Artéria Vertebral/cirurgia , Ferimentos Perfurantes/diagnóstico por imagem , Ferimentos Perfurantes/etiologia
6.
Neuroimaging Clin N Am ; 12(2): 249-69, 2002 May.
Artigo em Inglês | MEDLINE | ID: mdl-12391635

RESUMO

Traumatic vascular injury to the intracranial and extracranial circulation can be sequelae of blunt, penetrating, or iatrogenic insults to the head, face, or neck. Treatment options include conservative medical management, or more invasive surgical or endovascular therapy. The appropriate treatment depends on the risk-benefit ratio of each option considering the natural history of each. Injuries include mild intimal irregularities, intimal flaps, pseudoaneurysms, fistulas, and occlusions. Need for treatment is partly determined by the collateral circulation to the brain, and the degree to which the lesion is thrombogenic. Advances in endovascular devices and techniques provide us with less invasive alternatives to surgery intervention or allow the interventionalist to treat lesions not treatable by any other modality.


Assuntos
Lesões das Artérias Carótidas/diagnóstico , Artérias Cerebrais/lesões , Artéria Vertebral/lesões , Angiografia , Lesões das Artérias Carótidas/terapia , Angiografia Cerebral , Face/irrigação sanguínea , Traumatismos Faciais/diagnóstico , Traumatismos Faciais/terapia , Humanos , Angiografia por Ressonância Magnética , Lesões do Pescoço/diagnóstico , Ultrassonografia Doppler Dupla , Fístula Vascular/diagnóstico , Fístula Vascular/etiologia , Fístula Vascular/terapia
7.
Neurosurgery ; 62(5 Suppl 2): ONSE412-3; discussion ONSE413-4, 2008 May.
Artigo em Inglês | MEDLINE | ID: mdl-18596535

RESUMO

OBJECTIVE: Several different methodologies for proximal occlusion and retrograde suction decompression of large paraclinoid aneurysms have been reported previously. In this article, we describe the novel use of an endovascular embolectomy device (F.A.S.T. funnel catheter; Genesis Medical Interventional, Inc., Redwood City, CA) for temporary internal carotid artery occlusion and suction decompression of an intracranial aneurysm to facilitate surgical clip ligation. The combination of atraumatic occlusion technology and large lumen size makes this technique safer and easier. CLINICAL PRESENTATION: A 53-year-old woman with progressive headaches underwent computed tomographic angiography, which revealed an unruptured large left paraclinoid aneurysm. Cerebral angiography confirmed the diagnosis. The patient did not tolerate a balloon test occlusion for therapeutic Hunterian internal carotid occlusion. The patient was subsequently taken to the operating room for a craniotomy and clip ligation of the aneurysm. INTERVENTION: A standard left pterional craniotomy was performed with opening of the sylvian fissure and exposure of the left paraclinoid aneurysm. Intraoperative angiography with introduction of a new endovascular embolectomy device was performed. The device was deployed to achieve temporary occlusion of the cervical internal carotid artery, and aspiration through the central lumen allowed for retrograde suction decompression of the aneurysm. Collapse of the aneurysm through this technique permitted visualization of the aneurysmal neck with successful clip ligation. CONCLUSION: A new endovascular embolectomy device can be used to safely perform suction decompression of large paraclinoid aneurysms to facilitate clip ligation.


Assuntos
Descompressão Cirúrgica/instrumentação , Embolectomia/instrumentação , Aneurisma Intracraniano/cirurgia , Ligadura/instrumentação , Sucção/instrumentação , Desenho de Equipamento , Feminino , Humanos , Pessoa de Meia-Idade , Resultado do Tratamento
8.
Neurosurgery ; 63(1 Suppl 1): ONS55-61; discussion ONS61-2, 2008 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-18728604

RESUMO

OBJECTIVE: A fetal variant posterior cerebral artery (fetal PCA) is an embryological remnant in which the PCA is primarily supplied via the anterior cerebral circulation. Internal carotid artery (ICA) aneurysms originating from the takeoff of fetal PCA vessels deserve special attention before surgical or endovascular obliteration because of a greater potential for ischemic injury. We present the first series of ICA-posterior communicating artery (PComA) aneurysms originating at the takeoff of fetal PCA vessels that were treated by surgical or endovascular intervention. METHODS: A retrospective chart review was conducted for all patients who underwent surgical and endovascular treatment of an ICA-PComA aneurysm at Los Angeles County-University of Southern California Medical Center during a 15-year period (1991-2006) to identify cases with aneurysms originating from fetal variant PCAs. Data were retrospectively reviewed and analyzed. RESULTS: During a 15-year period, 271 patients were treated for 273 ICA-PComA aneurysms. Aneurysms occurring at the origin of fetal PCAs were identified in 30 patients (11%). There were 23 women (77%) and seven men (23%) (sex difference, P = 0.0035). Twenty-four patients underwent surgical clipping, whereas six patients underwent endovascular coiling. The mean aneurysm size was 7 mm. The mean ischemia time with temporary clipping (12 cases) was 4.5 minutes. Intraoperative rupture occurred in four surgical cases (17%). Postoperative angiography demonstrated occlusion of the fetal PCA in one case after clip ligation (3%), with an ensuing occipital infarct yet no clinical symptoms. CONCLUSION: ICA-PComA aneurysms originating from fetal PCA vessels may pose a more substantial risk for infarction and subsequent neurological sequelae with surgical or endovascular obliteration. Fetal variant circulations were identified at the PComA origin in 11% of ICA-PComA aneurysm patients and were more commonly encountered in women. The decision of surgical versus endovascular treatment of fetal PCA aneurysms must be carefully considered, given the greater potential for ischemic injury with parent vessel occlusion.


Assuntos
Doenças das Artérias Carótidas/cirurgia , Artéria Carótida Interna/cirurgia , Aneurisma Intracraniano/cirurgia , Artéria Cerebral Posterior/anormalidades , Artéria Cerebral Posterior/cirurgia , Procedimentos Cirúrgicos Vasculares/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Doenças das Artérias Carótidas/diagnóstico por imagem , Artéria Carótida Interna/diagnóstico por imagem , Feminino , Seguimentos , Humanos , Aneurisma Intracraniano/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Artéria Cerebral Posterior/diagnóstico por imagem , Radiografia , Estudos Retrospectivos
9.
Neurosurgery ; 59(5 Suppl 3): S158-62; discussion S3-13, 2006 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-17053599

RESUMO

OBJECTIVE: Effective transarterial embolization of a dural arteriovenous fistula or pial arteriovenous malformation (AVM) requires penetration of a durable occlusive agent into the fistula or AVM nidus. Cyanoacrylate glue often cannot traverse the tortuous vessels that typically supply such malformations, leading to proximal occlusion and recruitment of collateral flow. Other embolic agents, such as polyvinyl alcohol particles, achieve better penetration, but their effects are short lived, often leading to recanalization. The authors sought to overcome these obstacles by developing a technique to enhance glue penetration into the fistula or AVM nidus itself. METHODS: After placing a guide catheter in the proximal feeding artery, a microcatheter is advanced coaxially to its limit. As glue is injected through the microcatheter, a column of 5% dextrose in water (D5W) is pushed manually through the guide catheter lumen to propel the glue forward. This technique has been bench tested in a standard flow model of vascular malformations, using a pump capable of delivering various rates of D5W. It has also been validated in treating 17 patients with cerebral dural arteriovenous fistulae or AVMs, with real-time adjustment of D5W flow according to the extent of glue penetration. RESULTS: In the bench model, the extent of glue penetration, as graded by a new scale of liquid agent embolization proposed by the authors, correlated directly with the rate of D5W flow (P = 0.5, analysis of variance). In vivo, this technique has enhanced the penetration of glue into the fistula or AVM nidus, resulting in longstanding embolization of these malformations. CONCLUSION: Coaxial injection of D5W through the guide catheter can propel cyanoacrylate glue through tortuous feeding arteries and can enhance its penetration into dural fistulae and AVMs, leading to more effective endovascular treatment of these malformations.


Assuntos
Malformações Arteriovenosas/diagnóstico , Malformações Arteriovenosas/terapia , Cateterismo/métodos , Cianoacrilatos/administração & dosagem , Embolização Terapêutica/métodos , Avaliação de Resultados em Cuidados de Saúde/métodos , Adesivos Teciduais/administração & dosagem , Malformações Arteriovenosas/classificação , Cateterismo/instrumentação , Embolização Terapêutica/instrumentação , Desenho de Equipamento , Humanos , Índice de Gravidade de Doença , Resultado do Tratamento
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