Radiation dose reduction during intra-arterial chemotherapy for retinoblastoma: a retrospective analysis of 96 consecutive pediatric interventions using five distinct protocols.

BACKGROUND: Intra-arterial chemotherapy (IAC) represents a mainstay of retinoblastoma treatment in children. Patients with retinoblastoma are uniquely at risk for secondary malignancies and are sensitive to the ionizing effects of radiation. OBJECTIVE: To retrospectively review a single institution's experience with IAC for retinoblastoma and the effect of variable intra-procedural imaging techniques on radiation exposure. MATERIALS AND METHODS: Twenty-four consecutive patients, with a mean age of 30.8±16.3 months (range: 3.2-83.4 months), undergoing IAC for retinoblastoma between May 2014 and May 2020 (72 months) were included. No patients were excluded. The primary outcome was radiation exposure and secondary outcomes included technical success and procedural adverse events. Technical success was defined as catheterization of the ophthalmic or meningolacrimal artery and complete delivery of chemotherapy. Each procedure was retrospectively reviewed and categorized as one of five imaging protocol types. Protocol types were characterized by uniplanar versus multiplanar imaging and digital subtraction angiographic versus roadmap angiographic techniques. Radiation exposure, protocol utilization, the association of protocol and radiation exposure were assessed. RESULTS: During 96 consecutive interventions, 109 ocular treatments were performed. Thirteen of the 96 (15.5%) treatments were bilateral. Ocular technical success was 106 of 109 (97.2%). All three treatment failures were successfully repeated within a week. Mean fluoroscopy time was 6.4±6.2 min (range: 0.7-31.1 min). Mean air kerma was 36.2±52.2 mGy (range: 1.4-215.0 mGy). There were two major (1.8%) complications and four (3.7%) minor complications. Of the 96 procedures, 10 (10.4%), 9 (9.4%), 13 (13.5%), 28 (29.2%) and 36 (37.5%) were performed using protocol types A, B, C, D and E, respectively. For protocol type A, mean fluoroscopy time was 10.3±6.8 min (range: 3.0-25.4 min) and mean air kerma was 118.2±61.2 mGy (range: 24.5-167.3 mGy). For protocol type E, mean fluoroscopy time was 3.1±3.2 min (range: 0.7-15.1 min) and mean air kerma was 5.4±4.2 mGy (range: 1.4-19.5 mGy). Fluoroscopy time and air kerma decreased over time, corresponding to the reduced use of multiplanar imaging and digital subtraction angiography. In the first quartile (procedures 1-24), 8 (33.3%), 7 (29.2%), 2 (8.3%), 6 (25.0%) and 1 (4.2%) were performed using protocol types A, B, C, D and E, respectively. Mean fluoroscopy time was 10.5±8.2 min (range: 2.4-28.1 min) and mean air kerma was 84.2±71.6 mGy (range: 12.8-215.0 mGy). In the final quartile (procedures 73-96), 24 (100%) procedures were performed using protocol type E. Mean fluoroscopy time was 3.5±4.0 min (range: 0.7-15.1 min) and mean air kerma was 5.0±4.3 mGy (range: 1.4-18.0 mGy), representing 66.7% and 94.1% reductions from the first quartile, respectively. Technical success in the second half of the experience was 100%. CONCLUSION: Sequence elimination, consolidation from biplane imaging to lateral-only imaging, and replacing digital subtraction with roadmap angiography dramatically reduced radiation exposure during IAC for retinoblastoma without adversely affecting technical success or safety.

Surgery for very large and giant intracranial aneurysms: Results and complications.

BACKGROUND: Results of and the complications encountered during surgery for very large and giant intracranial aneurysms are illustrated. OBJECTIVE: To analyze a consecutive series of patients with very large and giant aneurysms treated with microsurgery. METHODS: This retrospective study included seventy six very large and giant aneurysms which were managed by clipping and bypass technique. Sixty two (82%) aneurysms were located in anterior circulation, and 14 (18%) aneurysms were located in posterior circulation. The bypasses performed included local bypasses, extra-intracranial bypasses, double bypasses and combination techniques of external carotid-internal carotid (EC-IC) bypass and local bypasses. RESULTS: 73 patients with 76 aneurysms were treated over 13 years. There were 44 very large and 32 giant aneurysms. Twenty-four patients presented with subarachnoid hemorrhage [SAH] (32%) while forty nine patients with 52 aneurysms (68%) were unruptured. These 73 patients underwent 63 bypass procedures with aneurysm occlusion and 13 clipping procedures. Out of 62 anterior circulation aneurysms, bypass surgery was performed in 49 patients while 13 underwent clipping. In posterior circulation aneurysms, all patients were treated with bypass procedures with proximal occlusion or trapping. In the ruptured group, 16 (67%) patients had postoperative modified Rankin Scale (mRs) 0-2, six patients (25%) had mRs 3-5, and two patients (8.4%) died. In the unruptured group, 45 patients (87%) had mRs 0-2, 3 patients (6%) had mRs 3-5, and four patients (7.6%) died. CONCLUSIONS: In this large series of very large and giant aneurysms treated with microsurgical clipping and bypasses, excellent results were obtained in the long term, in regards to aneurysm occlusion, functional status, and graft patency. Our experience will be very useful to other neurosurgeons who treat these complex lesions.

Natural History and Management of Blunt Traumatic Pseudoaneurysms of the Internal Carotid Artery: The Harborview Algorithm Based Off a 10-Year Experience.

OBJECTIVE: To define the natural history of, and treatment strategy for, blunt traumatic internal carotid artery (ICA) pseudoaneurysms. BACKGROUND: The natural history and management of traumatic ICA pseudoaneurysms is controversial. METHODS: We retrospectively identified all traumatic ICA pseudoaneurysms diagnosed on head/neck computed tomographic angiography at a high-volume trauma center over a 10-year period. Radiographic and clinical data were recorded, and a treatment algorithm was derived. RESULTS: Forty-three pseudoaneurysms were diagnosed in 39 patients. All patients were treated with daily aspirin unless contraindicated, and 82% underwent daily transcranial Doppler ultrasonography with embolic monitoring. A rate of 8 or more emboli per hour was predictive of embolic stroke (P = 0.0076). Acute ischemic or embolic stroke was seen in 7 patients (16%) with an overall mortality in this subpopulation of 42% (n = 3). Four patients (9%) underwent acute surgical treatment (parent vessel sacrifice and/or arterial bypass) for ongoing ischemia. Long-term radiographic and clinical follow-up was obtained for 36 surviving patients (mean = 8 months; range: 1 week-5 years), all of whom were maintained on daily aspirin. No delayed ischemic or embolic events were reported. For ICA pseudoaneurysms treated with aspirin and observation alone, 9 (28%) increased in size, 17 (53%) decreased or stabilized, and 6 (19%) resolved. Enlargement of 5 mm or more in maximal diameter underwent delayed endovascular treatment with a 100% obliteration rate and no complications. CONCLUSIONS: Traumatic ICA pseudoaneurysms are safely treated with daily aspirin, embolic monitoring, and radiographic surveillance. Acute stroke or hemorrhage, or delayed radiographic progression, are indications for endovascular or surgical treatment.

Current Indications, Trends, and Long-Term Results of 233 Bypasses to Treat Complex Intracranial Aneurysms: A Location-Specific Analysis.

BACKGROUND AND OBJECTIVES: Advances in endovascular flow diverters have led to a secular shift in the management of brain aneurysms, causing debate on current bypass indications. We therefore sought to investigate the long-term results, current indications, and trends of bypasses for brain aneurysms. METHODS: We retrospectively reviewed bypasses performed between 2005 and 2022 to treat brain aneurysms. Demographic, clinical, and radiological data were collected till the most recent follow-up. Aneurysm occlusion and graft patency was noted on cerebral angiogram in the immediate postoperative, 3-month, and most recent follow-up periods. Clinical outcomes (modified Rankin scores) and complications were assessed at 3 month and most recent follow-up. Trends in bypass volume and graft patency were assessed in 5-year epochs. Results were dichotomized based on aneurysm location to generate location-specific results and trends. RESULTS: Overall, 203 patients (mean age 50 years, 57% female patients) with 207 cerebral aneurysms were treated with 233 cerebral bypasses with a mean follow-up of 2 years. Fusiform morphology was the most common bypass indication. Aneurysm occlusion on immediate postoperative and final follow-up angiogram was 89% (184/207) and 96% (198/207), respectively. Graft patency rate in the immediate postoperative period and most recent follow-up was 95% (222/233) and 92% (215/233), respectively. Of 207 aneurysms, 5 (2%) recurred. Of 203 patients, 81% (165) patients had modified Rankin scores of 0-2 at the 3-month follow-up and 11 patients died (mortality 5%). Although there was a steady decrease in the bypass volume over the study period, the proportion of bypasses for recurrent aneurysms increased serially. Posterior circulation aneurysms had lower rates of aneurysm occlusion and significantly higher incidence of postoperative strokes and deaths (P = .0035), with basilar artery aneurysms having the worst outcomes. CONCLUSION: Bypass indications have evolved with the inception of novel flow diverters. However, they remain relevant in the cerebrovascular surgeon's armamentarium, and long-term results are excellent.

A comparison of computed tomography angiography and digital subtraction angiography for the diagnosis of penetrating cerebrovascular injury: a prospective multicenter study.

OBJECTIVE: In this research, the authors sought to characterize the incidence and extent of cerebrovascular lesions after penetrating brain injury in a civilian population and to compare the diagnostic value of head computed tomography angiography (CTA) and digital subtraction angiography (DSA) in their diagnosis. METHODS: This was a prospective multicenter cohort study of patients with penetrating brain injury due to any mechanism presenting at two academic medical centers over a 3-year period (May 2020 to May 2023). All patients underwent both CTA and DSA. The sensitivity and specificity of CTA was calculated, with DSA considered the gold standard. The number of DSA studies needed to identify a lesion requiring treatment that had not been identified on CTA was also calculated. RESULTS: A total of 73 patients were included in the study, 33 of whom had at least 1 penetrating cerebrovascular injury, for an incidence of 45.2%. The injuries included 13 pseudoaneurysms, 11 major arterial occlusions, 9 dural venous sinus occlusions, 8 dural arteriovenous fistulas, and 6 carotid cavernous fistulas. The sensitivity of CTA was 36.4%, and the specificity was 85.0%. Overall, 5.6 DSA studies were needed to identify a lesion requiring treatment that had not been identified with CTA. CONCLUSIONS: Cerebrovascular injury is common after penetrating brain injury, and CTA alone is insufficient to diagnosis these injuries. Patients with penetrating brain injuries should routinely undergo DSA.

Embolization and Resection of Epidural Spinal Arteriovenous Malformations: Case Report.

BACKGROUND AND IMPORTANCE: Spinal vascular malformations (sVMs) are relatively uncommon, accounting for 5% to 10% of all spinal cord lesions. Spetzler and Kim developed a paradigm to classify sVMs based on a variety of characteristics into 1 of 6 types, including a subcategory for exclusively epidural sVMs. There is a paucity of literature focused on this category, specifically sources describing the clinical manifestation and management of these lesions. CLINICAL PRESENTATION: We report 2 cases of purely epidural spinal arteriovenous fistula, with an emphasis on the radiographic features and combined endovascular and microsurgical treatment. We report 2 patients known to have epidural spinal arteriovenous fistula who underwent both embolization and surgical resection between May 2019 and August 2020 at our institution. Data collected included demographic, clinical, and operative course, including age, sex, medical history, presenting symptoms, and preoperative and postoperative imaging. Both of these patients were managed with a combination of an endovascular approach for embolization of feeding arterial source and surgical exploration/resection. In both cases, no residual vascular malformation was identified, and the patients went on to be symptom free after 6 weeks. CONCLUSION: This report describes the use of a combination of endovascular and surgical approaches to achieve maximal benefit for 2 patients. These cases reinforce the value of a staged multimodal treatment approach in achieving good functional outcomes for patients with these rare and challenging entities.

Safety and radiologic clearance of chronic subdural hematoma after endovascular embolization using SQUID 18 in patients older than 80 years.

The aim of the study was to evaluate radiographic clearance and clinical outcomes in patients over age 80 who undergo SQUID 18 embolization of the middle meningeal artery (MMA) for the management of chronic subdural hematoma (cSDH). From April 2020 to October 2021, data were obtained from patients with cSDH who underwent MMA embolization at our institution. Clinical and radiological data including pre-operative and last follow-up CT scans were analyzed. Six embolization procedures were performed in five patients using SQUID 18, a liquid embolic agent. The median age was 83 years, and three subjects were female. Two of the six cases were recurrent hematomas. MMA embolization was achieved in 100% of cases. The median diameter of the hematoma at admission was 20 mm and at last follow-up was 5.3 mm, demonstrating statistically significant radiographic clearance (P = 0.043). There were no intra or post-operative complications. Mortality was not noted during observation period. SQUID MMA embolization safely and significantly reduced the hematoma diameter and offers an alternative treatment in patients older than 80 years with cSDH.

Five-year outcome of a staged giant Shamblin type III carotid body tumor excision.

Giant carotid body tumors, defined as those >8 cm in size, are extremely rare. Definitive surgical management is a complex undertaking because these large tumors tend to have grown to envelop cranial nerves and the carotid artery, and few data exist regarding the long-term outcomes for these patients. We present the case of a patient with bilateral giant carotid body tumors who underwent staged embolization and excision of a >10-cm carotid body tumor. After 5 years of follow-up, we demonstrated that elective open repair can provide long-term symptomatic relief. We describe and illustrate the crucial steps and considerations regarding the excision of complex Shamblin type III carotid body tumors.

Balloon test occlusion with the Doppler velocity guidewire.

Transcranial Doppler ultrasonography is the most commonly used method of cerebrovascular blood flow velocity measurement, but it is subject to certain technical and anatomic limitations. The Doppler velocity guidewire measures blood flow velocity within any vessel during cerebral angiography, overcoming these limitations. We report the first use of this guidewire in the measurement of blood flow velocity during balloon test occlusion, with results similar to simultaneously measured transcranial Doppler ultrasonography. Velocity measurement by Doppler guidewire could be useful in balloon test occlusion for vertebrobasilar circulation, where transcranial Doppler ultrasonography is limited, and provide anatomically specific blood flow velocity measurements in the diagnosis and treatment of stroke and other cerebrovascular diseases.

Embolization of carotid-cavernous fistula via direct percutaneous puncture of the inferior ophthalmic vein.

Carotid-cavernous fistulas (CCFs) are anomalous connections between the carotid circulation and the cavernous sinus, and may cause significant morbidity. Endovascular treatment of these lesions can be challenging if typical transvenous routes are inaccessible. We describe a case of a Barrow type D carotid-cavernous fistula in which transvenous embolization was attempted via the inferior petrosal sinus (IPS). No connection was found to the fistula, and the superior ophthalmic vein (SOV) was thrombosed. A novel direct percutaneous puncture of the IOV was performed with ultrasound guidance showing that this is a safe alternative route of CCF access and embolization when the IPS and SOV are inaccessible.

Persistent Stapedial Artery Resulting in Direct Communication Between the Middle Meningeal and Basilar Arteries: Clinical Image.

A persistent stapedial artery originates from the petrous segment of the internal carotid artery due to failure of the regression of the embryonic stapedial artery. During embryologic development, the stapedial artery supplies the middle meningeal artery through the ventral pharyngeal artery. The presence of a persistent stapedial artery can result in direct communication between the basilar and middle meningeal arteries. We present a cerebral angiogram image of an adult patient that shows a right-sided persistent stapedial artery with communication between the right middle meningeal and basilar arteries. It is important to recognize such rare anatomic variants during endovascular interventions to avoid catastrophic complications such as nontarget embolization of the posterior circulation.

Endovascular treatment of medium and large intracranial aneurysms with large volume coils: A single-center experience.

BACKGROUND: Large volume coils are an alternative to conventional coils for the treatment of intracranial aneurysms. However, there are no published reports documenting occlusion and complication rates in medium and large intracranial aneurysms. Therefore, we present our results in this subgroup of aneurysms. METHODS: A single-center, retrospective analysis of consecutive patients treated with Penumbra coils 400 in aneurysms ≥7 mm was performed. Demographics, aneurysm features, procedural details, intraoperative complications, clinical outcomes, and occlusion rates were analyzed. RESULTS: Thirty-three patients were included for analysis, and a total of 33 intracranial aneurysms were analyzed. Mean age was 57.6 years (SD ± 12.4) and 85% of the patients were women. Large aneurysms represented 46% of cases. Paraclinoid (55%) followed by posterior communicating (30.3%) aneurysms was the most frequently treated. Ruptured and saccular aneurysms were found in 49% and 63% of the cases, respectively. The mean aneurysmal dimensions were 14.2 mm width, 11.9 mm length, 5.4 mm neck, and 2.4 dome-to-neck ratio. A dome-neck ratio <2 was identified in 39% of cases. The mean number of coils per aneurysm was 4.8. Immediate modified Raymond-Roy Grades 1, 2, and 3A were achieved in 15%, 21%, and 64%, respectively. Twenty-six patients were evaluated at a mean follow-up period of 11 months, with an adequate occlusion of 92% and a good clinical outcome (modified Rankin score ≤2) in 96% of patients. CONCLUSION: Endovascular treatment with PC400 coils is an effective and safe option for medium and large intracranial aneurysms with high occlusion rates, few complications, and good clinical outcomes at follow-up.

Endovascular palliation of AVM-associated intractable trigeminal neuralgia via embolization of the artery of the foramen rotundum.

OBJECTIVE: Trigeminal neuralgia is rarely caused by arteriovenous malformations of the posterior fossa. Embolization of aberrant vessels can provide symptomatic relief; however, embolization is not always technically possible, and its effects can be temporary. Embolization of the nerve's blood supply could reduce its excitability and provide pain relief. SETTING: The study was set in an academic tertiary care center. STUDY DESIGN: The study was designed as a report of a clinical case. SUMMARY: The authors report the case of a 13-year-old girl with a large, unruptured posterior fossa arteriovenous malformation (AVM) presented with left-sided V2-division trigeminal neuralgia. She had undergone multiple previous embolizations of feeding vessels from the anterior inferior cerebellar artery with temporary relief of her symptoms. Embolization of the middle meningeal artery was attempted, but the vessel's tortuosity precluded safe catheterization. Instead, the artery of the foramen rotundum, which had minimal contribution to the AVM nidus, was embolized with Onyx copolymer. The patient had immediate cessation of her neuralgia, with a small area of hypesthesia above her left cheek. Complete pain relief lasted for 8 months, followed by a return of mild dysesthesia episodes not requiring intervention. CONCLUSION: This case may represent a new method of palliative treatment for AVM-associated trigeminal neuralgia, or potentially trigeminal neuralgia of other etiologies. Based on this case's success, a prospective study using additional provocative testing with intraarterial lidocaine is proposed.

A rare case of ruptured intracranial aneurysm arising from the retro-mastoid branch of the occipital artery.

BACKGROUND: Aneurysms of the occipital artery (OA) are rare, with few cases published in the literature. The pathophysiology is unknown, and the presentation is variable. We present a case of a ruptured intracranial aneurysm arising from a branch of the OA. CASE DESCRIPTION: A 36-year-old male with a history of ankylosing spondylitis presented with altered mental status after an assaulted. On examination, he was intubated, with a Glasgow coma scale of 9, and imaging of the head and neck revealed a subdural hematoma of the posterior fossa and the cervical spine. The patient underwent suboccipital craniectomy and C1-5 laminectomy with the evacuation of the subdural hematoma. Postoperative cerebral angiography showed an intracranial aneurysm arising from the retromastoid branch of the OA on the left side. Furthermore, the parent vessel of the aneurysm supplied the left lower half of the cerebellar hemisphere. The aneurysm and the parent vessel were embolized using platinum coils. The patient tolerated the procedure well, and magnetic resonance imaging of the brain showed a minor left-sided cerebellar infarct, which was asymptomatic. The patient was discharged home with a modified Rankin scale of 2. There were no outpatient follow-up data available because the patient lost to follow-up. CONCLUSION: Intracranial OA aneurysms are extremely rare with no clear consensus concerning the management of these aneurysms. They can be treated using endovascular and or open surgical techniques depending on the aneurysm characteristics, patient condition, rupture status, and others.

Distal Basilar Artery "Umbrella Aneurysm" Treated by Radial Artery Graft Bypass From the External Carotid Artery to Posterior Cerebral Artery and Clip Trapping: 2-Dimensional Operative Video.

A 71-yr-old woman was discovered to have an incidental distal basilar artery (BA) fusiform aneurysm 7 × 5 mm in dimension, shaped like an "umbrella handle" with critical stenosis distal to the aneurysm. The right posterior cerebral artery (PCA) P1 segment was small; the left posterior communicating artery (PComA) was miniscule. Because the natural history of fusiform BA aneurysms is poorly defined, this was equated to a saccular aneurysm, with an estimated 10-yr rupture rate of 29%.1-8 After discussion of alternative treatments, the patient decided upon surgery. Because of inadequate collateral circulation, a bypass to the left PCA was deemed necessary. The aneurysm was exposed by an extended trans-sylvian approach, and the left PCA P2 segment was visualized subtemporally. The left radial artery (RAG) was extracted, and pressure distended to prevent vasospasm. The RAG bypass was sutured first to the P2, and then to the cervical external carotid artery (ECA); the BA aneurysm was then clipped. The proximal anastomosis of the bypass needed revision because of poor flow; a 4-mm punch hole was made to widen the arteriotomy on the ECA. The patient was discharged home with mild memory loss and partial left cranial nerve III palsy. After discharge, she developed a severe left hemicrania, resolved with gabapentin. At 6-wk follow-up, she was asymptomatic, and computed tomography (CT) angiogram demonstrated patency of the bypass. The patient gave informed consent for surgery and video recording. All relevant patient identifiers have been removed from the video and accompanying radiology slides.

Spontaneous spinal cerebrospinal fluid venous-fistula treated with transvenous embolization: A case report.

BACKGROUND: Spinal cerebrospinal fluid venous fistula (CVF) is a recognized cause of chronic positional headache and spontaneous intracranial hypotension (SIH). It occurs due to an aberrant connection formed between the spinal subarachnoid space and an adjacent spinal epidural vein. The diagnosis of CVF can be difficult to establish but can be documented utilizing advanced imaging techniques (e.g., enhanced MR myelography/digital subtraction myelography). Their treatment involves surgical ligation of the involved nerve root, imaging-guided epidural blood patching, and/or endovascular embolization. Here, we report a 40-year-old male who presented with a symptomatic lumbar CVF successfully treated with transvenous embolization. CASE DESCRIPTION: A 40-year-old male presented with several months of positional headaches. The MRI of the brain showed diffuse pachymeningeal enhancement consistent with the diagnosis of SIH. Although the MR of the lumbar spine was unremarkable, the MR myelogram with digital subtraction imaging showed a CVF at the L2 level. Following transvenous embolization (i.e., through the Azygous vein), the patient's symptoms fully resolved. CONCLUSION: Spinal CVF are rare and may cause chronic headaches and symptoms/signs of SIH. In this case, an MR myelogram with digital subtraction images demonstrated the anomalous connection between the spinal subarachnoid space and an adjacent spinal epidural vein at the L2 level. Although open surgical ablation of this connection may be feasible, less invasive techniques such as endovascular embolization should become the treatment of choice for the future management of CVF.

Three strikes? Failed vascular access in mechanical thrombectomy.

Anatomic variability in the posterior circulation and small, fragile, or otherwise treacherous origins of vertebral arteries can create a challenge to acute endovascular intervention. We report a case of unsuccessful reperfusion due to inability to access the posterior circulation in a patient with acute basilar artery occlusion.

Endovascular strategies for stroke management after subacute in-stent thrombosis.

Subacute in-stent thrombosis is a rare but potentially fatal condition that can occur after treatment for intracranial aneurysms or stenosis. While immediate and late thromboembolic post-stent complications are well-described, subacute (2-30 days post-intervention) thrombosis is unusual. The administration of peri-operative dual anti-platelet therapy (DAPT) has significantly reduced the risk for thrombosis, but questions remain as to the choice of agents and treatment of thromboembolic complications in this setting. We present our acute endovascular management strategies for three patients who suffered thromboembolic complications.

Spasm, stenosis and shelves: balloon-assisted tracking techniques in endovascular interventions.

The technique of balloon-assisted tracking (BAT) has been demonstrated in transradial cardio-angiographic procedures. Using three commonly encountered clinical scenarios, we outline the technical details of BAT for managing peripheral and cerebral interventions with challenging vascular access. We describe methods used to overcome vasospasm, stenosis and vascular shelves during interventions for acute ischemic stroke, but these issues are not unique to neuroendovascular cases and the techniques can be applied across all endovascular interventions. We present three acute stroke interventions where anatomic challenges were overcome with the use of endovascular BAT. This article describes a novel application for BAT techniques in endovascular interventions to assist with access in peripheral, cervical and intracranial vessels. These methods can also be used to improve access during diagnostic cerebral angiography. BAT is a useful adjunct when navigating catheters through vasospasm, tortuous anatomy, vascular step-offs or intraluminal plaques.

Republished: Successful treatment of direct carotid-cavernous fistula in a patient with Ehlers-Danlos syndrome type IV without arterial puncture: the transvenous triple-overlay embolization (TAILOREd) technique.

We report successful transvenous treatment of direct carotid-cavernous fistula in a patient with Ehlers-Danlos syndrome type IV using a novel triple-overlay embolization (TAILOREd) technique without the need for arterial puncture, which is known to be highly risky in this patient group. The TAILOREd technique allowed for successful treatment using preoperative MR angiography as a three-dimensional overlay roadmap combined with cone beam CT and live fluoroscopy, precluding the need for an arterial puncture.