Cavernous sinus sampling is highly accurate in distinguishing Cushing's disease from the ectopic adrenocorticotropin syndrome and in predicting intrapituitary tumor location.

Inferior petrosal sinus sampling (IPSS) is used to distinguish pituitary Cushing's disease from occult cases of the ectopic ACTH syndrome, but is limited in that it requires the use of ovine CRH (oCRH) and is not highly accurate at predicting the intrapituitary location of tumors. This study was designed to determine whether cavernous sinus sampling (CSS) is as safe and accurate as IPSS, whether CSS can eliminate the need for oCRH stimulation, and whether CSS can accurately predict the intrapituitary location of tumors. Ninety-three consecutive patients with ACTH-dependent Cushing's syndrome were prospectively studied with bilateral, simultaneous CSS before and after oCRH stimulation. Prediction of a pituitary or ectopic ACTH source was based on cavernous/peripheral plasma ACTH ratios. Intrapituitary tumor location was predicted based on lateralization (side to side) ACTH ratios. These predictions were compared to surgical outcome in the 70 patients who had surgically proven pituitary (n = 65) or ectopic (n = 5) disease. CSS distinguished pituitary Cushing's disease from the ectopic ACTH syndrome in 93% of patients with proven tumors before oCRH administration and in 100% of patients with proven tumors after oCRH. It was as safe and efficacious as published IPSS results. CSS accurately predicted the intrapituitary lateralization of the tumor in 83% of all patients and 89% of those patients with good catheter position and symmetric venous flow. CSS is as safe and accurate as IPSS for distinguishing patients with pituitary Cushing's disease from those with the ectopic ACTH syndrome. In addition, CSS appears to be superior to IPSS for predicting intrapituitary tumor lateralization.

The use of electrolytically detachable coils in treating high-flow arteriovenous fistulas.

BACKGROUND AND PURPOSE: High-flow arteriovenous fistulas (AVFs) are commonly treated by using an endovascular approach with a variety of materials. The use of a Guglielmi electrolytically detachable coil (GDC) provides the ability to reposition or remove the coil if its position is not optimal and may minimize the risk of coil migration or distal embolization. This study reports our experience in using these coils alone or in combination with other materials in the treatment of intracranial and cervical high-flow fistulas. METHODS: Twelve patients with AVFs were treated with GDCs via the transvenous or transarterial-transfistulous routes. The six dural AVFs treated transvenously were also treated transarterially, and the GDCs were combined with fibered coils in three of these patients and in two other patients with pial AVFs. All patients have been clinically followed up for 12 to 48 months (mean, 28 months). RESULTS: Angiographic obliteration was obtained in all 12 patients. The fistulas have remained closed in 11 patients, as ascertained by angiographic confirmation in two patients and by clinical examination in nine patients. The one patient with recurrence experienced neurologic improvement and refused further treatment. GDCs required repositioning before detachment in seven patients, and no migration occurred after detachment. CONCLUSION: GDCs are useful for the treatment of high-flow AVFs. They afford more control in the placement of coils and may provide an anchoring point for more thrombogenic materials.

Foreign bodies in small arteries after use of an infusion microcatheter.

Over a 31-month period, we performed four neurointerventional procedures after which unexpected foreign bodies were noted in multiple arteries. All four procedures had in common the use of Fastracker-18 infusion microcatheters. Histologically, the intravascular debris looked strikingly similar to the hydrophilic coating on the catheter. An in vitro test mimicking clinical use of the microcatheter revealed that the hydrophilic coating can separate from the catheter. Until the coating is refined to make it more resistant to stripping, it may be advisable to reduce the amount of back-and-forth movement of these microcatheters if they have been positioned through guide catheters with small inner diameters and angled tips.

Clinical and angiographic outcomes, with treatment data, for patients with cerebral aneurysms treated with Guglielmi detachable coils: a single-center experience.

OBJECTIVE: The purpose of this report is to provide the most detailed treatment and outcome data currently available in the literature, to allow for the further evaluation of Guglielmi detachable coils (GDC) as an appropriate treatment option for patients with cerebral aneurysms. METHODS: During a period of 4.5 years, 74 patients with intracerebral aneurysms were treated with GDC in the Department of Neurosurgery at Oregon Health Sciences University. A comprehensive retrospective and prospective analysis of these patients was performed, to assess the overall angiographic and clinical outcomes for these patients. RESULTS: Seventy-seven aneurysms were treated, with an average angiographic follow-up period of 1.4 years. Initially, 40% of aneurysms exhibited complete (100%) occlusion, 52% near complete (90-99%) occlusion, and 8% incomplete (<90%) occlusion. The average clinical follow-up period was 2.2 years. For unruptured aneurysms, 85% of patients returned to independent status. Of patients of Hunt and Hess Grade I/II status, 81% were independent; of patients of Grade III status, 100% were independent; and, of patients of Grade IV/V status, 50% were independent. The procedure-related morbidity rate was 9.1%, with a 7.8% risk of death from aneurysm perforation, stroke, or delayed hemorrhage. No completely occluded aneurysm hemorrhaged after GDC treatment (follow-up period, 1.9 yr). Of near complete occlusions, 2.6% hemorrhaged after embolization, at a rate of 1.4%/yr (follow-up period, 1.9 yr). CONCLUSION: This study details long-term clinical outcomes after GDC treatment and describes factors affecting the need for retreatment. Although complete anatomic cure was not obtained in all cases and the long-term protection from subarachnoid hemorrhage remains to be determined, these data indicate that GDC are a safe and efficacious treatment for cerebral aneurysms.

Traumatic indirect carotid-cavernous fistula: report of two cases.

UNLABELLED: OBJECTIVE AND CLINICAL IMPORTANCE: We present two cases of post-traumatic indirect carotid-cavernous fistulas. Trauma produces the direct type of carotid-cavernous fistula in almost all cases, and recognition that trauma may induce the indirect type has been rarely reported. CLINICAL PRESENTATION: Both patients presented with signs and symptoms of direct carotid-cavernous fistulas, including bruit, proptosis, and chemosis, after trauma to the head. INTERVENTION: The two patients were treated by transarterial embolization, resulting in immediate and permanent occlusion of the fistula. CONCLUSION: Trauma may rarely induce an indirect type of carotid-cavernous fistula. This posttraumatic, indirect carotid-cavernous fistula was, in these two cases, successfully and permanently cured by transarterial embolization because of the large fistulous connection between the branches of the external carotid artery and the cavernous sinus.

Embolization as treatment for spinal cord compression from renal cell carcinoma: case report.

OBJECTIVE AND IMPORTANCE: Metastatic renal cell carcinoma may involve the vertebrae, resulting in acute spinal cord compression. Embolization has been used to reduce operative blood loss during surgical decompression, but it has not been considered as an alternative that may eliminate the need for open debulking. CLINICAL PRESENTATION: A case is presented of a 30-year-old woman with renal cell carcinoma who developed increasing severe back pain, lower extremity weakness, and sensory loss. Magnetic resonance evaluation revealed a T5 metastasis, resulting in significant spinal cord compression. INTERVENTION: Transarterial embolization was performed with polyvinyl alcohol particles and platinum microcoils. One month after embolization, the patient's lower extremity strength and sensation had improved, and magnetic resonance imaging demonstrated a dramatic response with a significant reduction of cord compression. She deteriorated again 4 months later, and a new sacral mass was embolized. She again improved after treatment. CONCLUSION: This report illustrates that embolization may be used as palliative treatment for spinal cord compression and obviate the need for open surgical decompression.

Endovascular treatment of traumatic dural sinus thrombosis: case report.

OBJECTIVE: Dural sinus thrombosis has rarely been associated with closed head injury. We present a unique case involving the use of endovascular thrombolysis in the treatment of traumatic dural sinus thrombosis, which has not been reported. CLINICAL PRESENTATION: A 20-year-old male patient suffered a severe closed head injury while skiing. He developed refractory elevated intracranial pressure requiring barbiturate coma. Angiography demonstrated thrombosis of the dominant right transverse and sigmoid sinuses, with partial thrombosis of the superior sagittal sinus. Urokinase was administered via a microcatheter within the thrombus as a bolus of 250,000 units and then as a continuous infusion of 60,000 to 100,000 units per hour for 48 hours. The patient was maintained in a barbiturate coma and heparinized. Serial angiography was performed to assess the sinus patency and efficacy of thrombolysis. RESULTS: After 48 hours of thrombolysis, angiography demonstrated normal patency of the superior sagittal, right transverse, and right sigmoid sinuses. The intracranial pressure decreased after thrombolysis and was manageable with conventional techniques. Within 48 hours of the completed thrombolysis, the barbiturates were withdrawn and the patient's neurological status rapidly improved until the time of discharge 2 weeks later. DISCUSSION AND CONCLUSION: This case documents a rare instance of traumatic dural sinus thrombosis resulting from a closed head injury. In addition, endovascular thrombolysis resulted in subsequent opening of the dural sinuses and effective intracranial pressure management, despite the presence of a hemorrhagic contusion. Heparin was effective in maintaining sinus patency and was used safely in conjunction with urokinase in this setting of head injury.

Rotational vertebral artery occlusion: a mechanism of vertebrobasilar insufficiency.

OBJECTIVE: Symptomatic dynamic changes in blood flow secondary to vertebral artery compression with rotational head motion are evaluated in a series of patients as a cause for posterior circulation transient ischemic attacks. These cases are classic examples of rotational vertebral artery occlusion and allow for the discussion of the anatomic basis, angiographic features, and treatment options. ILLUSTRATIVE CASES: In our series, symptoms of vertebrobasilar insufficiency were reproducible with rotational head movement. Compression of the vertebral artery was demonstrated angiographically. The correct site of occlusion of the vertebral artery was apparent only by dynamic angiography with progressive head rotation. All of the patients presented in the illustrative cases had occlusion at the C2 level; however, one patient had been previously misdiagnosed and another had an additional site of occlusion. The anatomic course of the vertebral artery is described in addition to the sites of rotational occlusion. CONCLUSION: Rotational vertebral occlusion is an important cause of vertebrobasilar symptoms, which may lead to permanent neurological deficit if left undiagnosed. Dynamic angiography is the established method of diagnosis. Great care must be taken to avoid misdiagnosing the site of occlusion or missing a second occlusive site. For this reason, it is crucial to have a thorough understanding of the anatomic course of the vertebral artery and the muscular and tendinous insertions, which may cause rotational occlusion. The decision for treatment must be based on the site of occlusion as well as the assessment of the patient as a surgical candidate. A review of the literature reveals that surgical treatment is effective and must be considered to avoid further morbidity.

The role of angioplasty in the treatment of cerebrovascular disease.

Percutaneous transluminal angioplasty (PTA), an established treatment of arterial stenosis in coronary, renal, and other peripheral sites, is being applied to the cerebrovascular territory with greater frequency. Early results suggest that PTA may be safe and efficacious in the treatment of extracranial arterial stenosis secondary to atherosclerosis and fibromuscular dysplasia. PTA is also being used with promising results in treating symptomatic intracranial arterial stenosis from atherosclerosis. This review examines PTA in the treatment of cerebrovascular disease, current indications, and results.

Direct carotid cavernous fistula after trigeminal balloon microcompression gangliolysis: case report.

OBJECTIVE AND IMPORTANCE: Percutaneous gangliolysis procedures may rarely be associated with vascular complications. There are three reported cases of carotid cavernous fistulas occurring after percutaneous microcompressive trigeminal gangliolysis. This is the only reported case of this complication associated with microcompression gangliolysis. CLINICAL PRESENTATION: A 78-year-old woman was referred to our institution with a history of abrupt onset of left-sided bruit, proptosis, chemosis, and diplopia after a percutaneous retrogasserian microcompression. INTERVENTION: Cerebral angiography revealed a large left direct carotid cavernous fistula. Attempts at balloon embolization were unsuccessful, and the lesion was ultimately cured by transarterial and transvenous coil embolization. CONCLUSION: Follow-up examination revealed no evidence of bruit or neurological deficit. This report highlights a unique complication of balloon gangliolysis and describes coil embolization of the fistula as the mode of treatment.

Intracranial intraarterial thrombolysis facilitated by microcatheter navigation through an occluded cervical internal carotid artery.

This report covers a series of four patients with acute cervical carotid occlusion and profound neurological deficits who were treated with intracranial intraarterial thrombolysis. All of the patients presented with arm plegia with variable leg involvement and two of them had global aphasia. Angiography identified occlusion of the proximal internal carotid artery (ICA) in each case and intracranial thromboembolus of the supraclinoid ICA and/or its branches. Catheter navigation through the occluded ICA segment was straightforward in three patients and somewhat difficult in one patient with an 80% ICA stenosis. Intraarterial urokinase infusion along with mechanical clot disruption was performed at the clot site in the middle cerebral artery, supraclinoid ICA, and/or anterior cerebral artery. All patients had recanalization of the treated artery after urokinase infusion. Antegrade flow through the ICA was reestablished in two patients, and good collateral filling across the anterior communicating artery was established in the other two. All patients had major pretreatment deficits (mean National Institutes of Health (NIH) Stroke Score 24 +/-4) with significant improvement noted at 3 months posttreatment (NIH Stroke Score 7 +/-6;p=0.03). Two patients made a dramatic early recovery. Postprocedure computerized tomography revealed no abnormality in one and asymptomatic basal ganglia high density from repeated local contrast injections in two patients. On the basis of their findings in this small study group the authors suggest that catheter navigation through a presumably occluded carotid artery is feasible and possibly effective in thrombolytic therapy of intracranial thrombolysis. Further study with clinical trials is necessary to determine the safety and efficacy of this technique.

Extensive arachnoid ossification with associated syringomyelia presenting as thoracic myelopathy. Case report and review of the literature.

The authors present the case of progressive thoracic myelopathy caused by the extensive ossification of the arachnoid membrane and associated intramedullary syrinx. Based on their findings and results of the literature search, they describe a pathological basis for this rare condition, discuss its incidence and symptomatology, and suggest a simple classification for various types of the arachnoid ossification. They also discuss the magnetic resonance imaging features of arachnoid ossification and associated spinal cord changes. The particular value of plain computerized tomography, which is highly sensitive in revealing intraspinal calcifications and ossifications, in the diagnostic evaluation of patients with a clinical picture of progressive myelopathy is emphasized.

Does reversal of ischemia on diffusion-weighted imaging reflect higher apparent diffusion coefficient values?

This study investigated whether ischemia on diffusion-weighted imaging (DWI) that reverses has higher apparent diffusion coefficients (ADCs). A patient treated with thrombolytics was evaluated with serial magnetic resonance imaging studies before treatment, at 3 and 14 days and at 4 weeks. A 100.01-cm3 left frontoparietal stroke on baseline DWI was only 18.11 cm3 (18%) on 4-week fluid attenuated inversion recovery. The mean ADC was 7.43 x 10(-3) mm2/s in the 6 regions that reversed and 7.31 x 10(-3) mm2/s in the 6 regions that persisted (P < .036). With thrombolytic treatment, large ischemic lesions on DWI may reverse, and these areas display higher mean ADCs.

Endovascular management of hemorrhage in patients with head and neck cancer.

OBJECTIVE: To present selective endovascular embolization as a therapeutic alternative to surgical ligation in the management of hemorrhage in patients with head and neck squamous cell carcinoma. DESIGN: Retrospective chart review of patients with head and neck cancer and significant hemorrhage who were treated with selective endovascular embolization. SETTING: A university medical center. PATIENTS: A total of 12 patients, aged 26 to 72 years, with 13 episodes of hemorrhage were treated at Oregon Health Sciences University, Portland, between November 1991 and January 1996. INTERVENTION: All patients underwent angiography with selective endovascular embolization at the interventional radiology suite using a combination of endovascular balloons, platinum coils, and microparticles. OUTCOME MEASURES: All charts were reviewed for diagnosis, treatment, factors that may have contributed to hemorrhage, bleeding site, therapeutic measures, control of hemorrhage, postembolization course, complications, and number of hospital days. RESULTS: The cause of the bleeding was tumor in 5 patients, pharyngocutaneous fistula in 4 patients, radiation necrosis in 3 patients, and postoperative complication in 1 patient. Bleeding arose from the common carotid artery in 4 patients, external carotid artery and its branches in 8 patients, and internal jugular vein in 1 patient. Hemorrhage was successfully controlled in all patients; a permanent left-sided hemiplegia and facial weakness developed in 1 patient. There were no recurrences of hemorrhage. All patients were discharged from the hospital. CONCLUSION: Angiography with selective embolization is a safe and effective alternative to surgical ligation for control of hemorrhage in patients with squamous cell carcinoma of the head and neck.

Angiographic evaluation and correlative anatomy.

This article provides a brief description of cerebral arterial angiographic anatomy with special attention given to the deep nuclear structures and collateral supply as it relates to acute ischemic stroke. Illustrative angiography cases with the CT or MRI are provided. Illustrative cases of differential diagnoses of stroke are also discussed.

Intra-arterial thrombolysis for acute stroke.

Intra-arterial thrombolysis is a developing modality for the treatment of the acute stroke that shows promise in restoring cerebral arterial supply. The rationale for treatment via the intra-arterial route rather than intravenously rests on increased recanalization with preliminary evidence suggesting improved outcome. Successful treatment is due in part to selecting patients who are not at increased risk for unwanted sequelae, namely intracranial hemorrhage, based on clinical and imaging features. The authors describe some points of technique for the procedure with an emphasis on interpretation of findings to guide therapy and solve problems.

Other endovascular treatment strategies for acute ischemic stroke.

This article discusses the efforts being made to develop a safe, efficacious method of clot removal in the treatment of acute ischemic stroke. Four endovascular treatment strategies are discussed: mechanical clot disruption, endovascular thrombectomy, stents, and therapeutic carotid occlusion.

Current concepts on carotid artery-cavernous sinus fistulas.

With greater understanding of the pathophysiological mechanisms by which carotid artery-cavernous sinus fistulas occur, and with improved endovascular devices, more appropriate and definitive treatments are being performed. The authors define cartoid cavernous fistulas based on an accepted classification system and the signs and symptoms related to these fistulas are described. Angiographic evaluation of the risk the lesion may pose for precipitating stroke or visual loss in the patient is discussed. The literature on treatment alternatives for the different types of fistulas including transvenous, transarterial, and conservative management is reviewed.

Drug eluting stents for symptomatic intracranial and vertebral artery stenosis.

The use of bare metal stents (BMS) to prevent recurrent stroke due to stenosis of the cerebral vasculature is associated with high rates of restenosis. Drug-eluting stents (DES) may decrease this risk. We evaluated the performance of DES in a cohort of patients treated at our institution.Consecutive patients treated with DES were identified by a case log and billing records; data regarding procedural details, clinical outcome and angiographic follow-up was obtained by retrospective chart review.Twenty-six patients (27 vessels; 14 vertebral origin (VO); 13 intracranial) were treated. Stenosis was reduced from mean 81% to 8% at the VO and 80% to 2% intracranially. No strokes occurred in the first 24 hours after stenting or at any time point in the VO group during a mean follow-up period of nine months. Among patients with intracranial stents, stroke with permanent disability occurred within 30 days in 1/12 (8%) and after 30 days in 1/11 (9%) with clinical follow-up (mean follow-up, 14 months). Follow-up catheter angiography was obtained in 14/14 (100%) in the VO group at mean eight months and in 8/11 surviving patients (73%) at a mean of ten months after stenting in the intracranial group. The restenosis rate was 21% at the VO (3/14) and 38% (3/8) for intracranial stents. Restenosis at the VO was less frequent than might have been expected from reports utilizing BMS, however, overall restenosis rates appeared higher than previously reported for patients with intracranial DES and comparable with restenosis rates for intracranial BMS.

Femoral artery complications associated with the Mynx closure device.

BACKGROUND AND PURPOSE: Devices to close a femoral arteriotomy are frequently used after catheterization for interventional radiology and cardiac procedures to decrease the time to hemostasis and ambulation and, potentially, to decrease local complications. The Mynx vascular closure device uses a sealant designed to occlude the access tract, resulting in hemostasis. MATERIALS AND METHODS: We retrospectively reviewed all cases in which the Mynx device was used and for which follow-up angiography was available. A total of 146 devices were deployed in 135 patients. A follow-up vascular study visualizing the femoral artery was performed in 26 patients (27 studies). RESULTS: There were 5 (5/27, 18%) cases of intravascular Mynx sealant on follow-up vascular imaging. Three pseudoaneurysms (3/27, 11%) were identified. CONCLUSIONS: In this small study, intravascular sealant and pseudoaneurysms were found frequently after femoral arterial closure with the Mynx vascular closure device.