Alex Berenstein

Transvascular treatment of giant aneurysms of the cavernous carotid and vertebral arteries: Functional investigation and embolization

Functional angiographic investigation and percutaneous embolization using detachable balloons in nine carotid cavernous aneurysms, three petrous aneurysms, one vertebral artery aneurysm, and one posterior inferior cerebellar aneurysm are reported. A double-lumen balloon catheter is used to evaluate acute tolerance to occlusion of the carotid or vertebral arteries. Occlusion is tested under systemic heparinization. Local perfusion of heparinized saline, proximal as well as distal, to the balloon occlusion is used. The procedure was successful in all but one cavernous aneurysm. The arterial lumen was sacrificed in all cases. Clinical improvement occurred in all successful cases. Retro-orbital pain was relieved in all. Ocular cranial nerve palsies improved or resolved in most. One delayed ophthalmic episode that improved represents the only complication. No such embolic problems occurred in any case in which the cavernous carotid artery was occluded by balloon trapping. The delayed embolic complications after carotid artery occlusion are related to the collateral vessels to the C-4 and C-5 segments of the artery. Balloon trapping decreases the length of the thrombosed segment and prevents retrograde filing of the aneurysm.

Catheter and material selection for transarterial embolization: technical considerations. II. Materials.

In this second part of the report, the authors discuss the advantages and disadvantages of several embolization agents. These include Gelfoam, silicone spheres, polyvinyl alcohol foam (PVA), isobutyl-2-cyanoacrylate (IBCA), silicone fluid mixtures, and tantalum powder. The techniques employed and conditions under which these materials should be used are discussed.

Neuroophthalmologic Abnormalities and Intravascular Therapy of Traumatic Carotid Cavernous Fistulas

Traumatic fistulas were successfully embolized using various transvascular approaches in 33 of 34 lesions. Complete superselective angiographic demonstration of the exact site of the shunt and possible collaterals was necessary to choose the appropriate embolization techniques. Improvement in the signs of orbital congestion was seen in all cases. Embolization, which directly occludes the fistula, precludes recurrences via collateralization and restores the normal arteriovenous gradient to the eye and optic nerve.

Normal Functional Anatomy of the Facial Artery

The functional anatomy of the facial artery consists of a group of constant arterial pedicles nourishing a specific territory and supplied by a variable facial trunk. There is a hemodynamic balance with other variable connecting trunks such as the transverse facial and internal maxillary arteries. Every type of variant, irrespective of its origin, may be understood based on the constant relationships and anastomoses involved. Knowledge of this functional anatomical system is crucial to an understanding of the blood supply to the face.

The Clinical Importance of the Inferolateral Trunk of the Internal Carotid Artery

The inferolateral trunk (ILT) of the internal carotid artery (ICA) is a branch that arises inferiorly from the C4 segment of the cavernous ICA. It provides blood supply to the 3rd, 4th, and 6th cranial nerves, as well as to the gasserian ganglion. The ILT anastomoses to branches of the internal maxillary artery, providing collateral circulation between the external carotid artery and the ICA systems. Retinal and cerebral emboli can arise from the external carotid artery system and travel via the ILT to the ICA. Cranial nerve palsies may result after occlusion of the ILT. We present the cases of four patients who had iatrogenic neurological dysfunction subsequent to intravascular procedures that involved the ILT. These cases provide further clinical confirmation of the importance of this blood vessel. A 5th case involving iatrogenic occlusion of the ILT and no neurological deficit is also presented, demonstrating that the ILT is not the sole blood supply of the cranial nerves in the cavernous sinus.

Percutaneous transvascular treatment of giant carotid aneurysms Neuro‐ophthalmologic findings

Twelve of 17 patients with cavernous carotid aneurysms had balloon embolization directed through a percutaneous double lumen catheter for progressive pain, ophthalmoplegia, or visual loss. Functional angiography was carried out with systemic heparinization and double-lumen balloon catheters to test tolerance to carotid occlusion. Eleven were successfully treated, though two patients with initial preservation of the ipsilateral carotid artery had unplanned deflation of the balloon, necessitating re-embolization. No serious permanent neurologic complications occurred. All patients had complete resolution of pain, and nine had improvement in the extraocular eye muscle and lid function. Balloon trapping of the cavernous carotid artery, rather than placing the balloon directly into the aneurysm, resulted in involution of the aneurysm and decompression of the involved cranial nerves.

Transumbilical Catheterization of Cerebral Arteries

OBJECTIVE AND IMPORTANCE For neonates requiring cerebral endovascular procedures, an alternative route of arterial access, the umbilical artery, is described. Transfemoral catheterization, with its attendant risks, can thus be avoided. CLINICAL PRESENTATION Six neonates with severe cardiac failure secondary to aneurysmal malformations of the vein of Galen underwent transarterial embolization in an effort to reduce flow through the intracranial arteriovenous malformations and therefore improve control of the high output cardiac failure. TECHNIQUE The transumbilical route was used in each case, with successful devascularization of some of the malformations in all patients. The femoral arteries were preserved for future staged embolizations. No complications related to the umbilical artery catheterization were encountered. CONCLUSION Femoral artery cannulation in neonates is technically challenging and may result in stenosis or thrombosis of the vessel. The umbilical artery provides an alternative route of vascular access for cerebral artery catheterization and embolization in these patients, preserving the femoral arteries for future interventions.

Visual symptoms with dural arteriovenous malformations draining into occipital veins

Objective: To determine the cause of the visual dysfunction and effect of treatment on dural arteriovenous malformations (DAVMs) that secondarily involve the occipital lobe. Background: DAVMs are an infrequent cause of visual dysfunction that should be amenable to treatment if diagnosed before permanent visual field loss. Methods: The records of seven patients with cerebral visual disturbances associated with DAVMs were analyzed with attention to visual symptoms, visual field testing, and vascular anatomy. Results: Sudden visual loss occurred in five patients, two with a hemorrhage and one with a venous infarct in the occipital lobe. Fortification images occurred in three patients, two of whom had palinopsia (one with de novo formed visual hallucinations). Homonymous quadrantic or hemianoptic field defects, some fluctuating, were found in six patients. Angiography revealed each DAVM was supplied solely by dural arteries and drained into occipital pial veins due to retrograde blood flow through the sites near or in the wall or lumen of the dural venous channels that normally drain the occipital lobe. Unlike DAVMs in other locations, only two patients had occlusion of an adjacent venous sinus. These patients, particularly the two with posterior fossa DAVMs remote to the occipital lobe, clearly demonstrate the visual and neurologic dysfunction resulting from venous hypertension. In six patients, intra-arterial embolization of the arterial feeders and nidus (one patient required additional surgery) resulted in resumption of normal occipital venous emptying. No further visual episodes occurred in five of these six patients. The visual fields normalized in three patients and improved in one with venous infarct but were unchanged in both patients with a hemorrhage. Conclusions: DAVMs that drain into occipital veins cause field loss and other visual disturbances because of venous hypertension in the occipital lobe, which can be reversed by occluding the DAVM nidus. If a venous infarct or hemorrhage has not caused irreversible damage, visual recovery should be complete.

Balloon Catheters for Investigating Carotid Cavernous Fistulas

A simple and reliable technique is described for investigating the precise location of an arteriovenous fistulous communication and its hemodynamics by temporary and complete vessel occlusion with a double-lumen balloon catheter.

Embolization of Arteriovenous Malformations of the Spinal Cord

Arteriovenous malformations of the spinal cord (SCAVMs) are rare lesions of congenital origin (Hurth et al. 1978) that represent only about one-tenth of cerebral AVMs (Cogen and Stein 1983). Their natural history (Aminoff and Logue 1974a,b; Bailey and Sperl 1969; Hurth et al. 1978; Tobin 1976) and their physiopathology (Aminoff et al. 1974; Arseni and Samitca 1959; Gross and Ralston 1959; Hurth et al. 1978; Spetzler et al. 1989; Wyburn Mason 1943) are still poorly understood, and the treatment required is often difficult, controversial, and challenging (Ausman et al. 1977; Cogen and Stein 1983; Djindjian 1975, 1976; Djindjian and Merland 1978; Doppman et al. 1971; Horton et al. 1986; Houdart et al. 1974;Kito et al. 1983;Krayenbuhl et al. 1969; Latchaw and Gold 1979; Malis 1979; Margolis and Birchfield 1974; Margolis et al. 1979; Morgan et al. 1986; Newton and Adams 1968; Ommaya et al. 1969; Patterson and Voorhies 1978; Riche et al. 1983; Stein 1979; Theron et al. 1986; Yasargil et al. 1975). This lack of knowledge stems from the small size of the published series and the different classifications used by different authors, based on surgical (Rosenblum et al. 1987; Spetzler et al. 1989) or angiographic (Riche et al. 1983a,b, 1985) considerations. We believe that the distinction between intra- and extramedullary location, widely used in the literature and regarded as a determinant of further treatment, is anatomically inappropriate since all the lesions are subpial, as is also the case with their cerebral homologues (Hassler et al. 1989; Maillot 1991; Nicholas and Weller 1988). This distinction is relevant in respect of surgical data and concerns, but it cannot be applied to endovascular approaches. For example, SCAVMs fed by the anterior spinal axis and previously described as intramedullary may in fact be purely extramedullary, embedded in the anterior spinal sulcus without involvement of the spinal cord itself, like sulcal AVMs of the brain. We shall therefore concentrate our analysis primarily on the anatomic (Garcia-Monaco and Lasjaunias 1990; Lasjaunias and Berenstein 1990) and angioarchitectural aspects of SCAVMs (Berenstein and Lasjaunias 1992; Lasjaunias and Berenstein 1990; Rodesch et al. 1991). Spinal cord angiography at present remains the gold standard for evaluation of these lesions; MRI, although providing diagnostic indications in respect of SCAVMs and excellent information on the spinal cord itself, is unable to reveal the exact location and type of AV shunt involved (Di Chiro et al. 1985; Doppman et al. 1987; Masaryk et al. 1987; Modik et al. 1989; Rodesch et al. 1991). Currently MRI and MR angiographic study are unable to provide any of the answers required in order to reach decisions on therapy and technique.