Alexandre Cordeiro Ulhôa

Dural arteriovenous fistulas with direct cortical venous drainage treated with Onyx®: a case series

UNLABELLED Dural arteriovenous fistulas (DAVFs) may have aggressive symptoms, especially if there is direct cortical venous drainage. We report our preliminary experience in transarterial embolization of DAVFs with direct cortical venous drainage (CVR) using Onyx. METHOD Nine patients with DAVFs with direct cortical venous drainage were treated: eight type IV and one type III (Cognard). Treatment consisted of transarterial embolization using Onyx-18. Immediate post treatment angiographies, clinical outcome and late follow-up angiographies were studied. RESULTS Complete occlusion of the fistula was achieved in all patients with only one procedure and injection in only one arterial pedicle. On follow-up, eight patients became free from symptoms, one improved and no one deteriorated. Late angiographies showed no evidence of recurrent DAVF. CONCLUSION We recommend that transarterial Onyx embolization of DAVFs with direct cortical venous drainage be considered as a treatment option, while it showed to be feasible, safe and effective.

Preoperative embolization of choroid plexus papilloma with Onyx via the anterior choroidal artery: technical note

IntroductionTotal surgical resection is the treatment of choice for choroid plexus tumors. However, the hypervascular nature of such lesions imposes challenges to the surgical treatment. Preoperative embolization for intracranial tumors has been widely used in an attempt to reduce blood loss, but rarely with choroid plexus tumors.Case reportWe describe the first case of preoperative embolization of choroid plexus papilloma with Onyx via the anterior choroidal artery. The procedure underwent without any complications and surgical treatment was possible with minimal blood loss.DiscussionEmbolization of choroid plexus tumors via anterior choroidal artery is potentially dangerous, but following a meticulous technique, it can be used as a safe and effective preoperative procedure.

Endovascular treatment of a linguofacial trunk pseudoaneurysm after tonsillectomy

1 Medico (Fellow, neurorradiologia intervencionista, Hospital das Clinicas, Universidade Federal de Minas Gerais). 2 Medico (Neurorradiologista intervencionista, Hospital das Clinicas, Universidade Federal de Minas Gerais). 3 Medico (Residente, neurocirurgia, Hospital das Clinicas, Universidade Federal de Minas Gerais). Divisao de Neurorradiologia Intervencionista Hospital das Clinicas Universidade Federal de Minas Gerais Belo Horizonte Minas Gerais Brasil. Endereco para correspondencia: Felipe Padovani Trivelato. Rua Timbiras, no 3616. Barro Preto. Belo Horizonte MG. Brasil. CEP: 30140-062. E-mail: felipepadovani@yahoo.com.br Este artigo foi submetido no SGP (Sistema de Gestao de Publicacoes) do BJORL em 18 de maio de 2012. cod. 9212. Artigo aceito em 6 de outubro de 2012. CASE REPORT Braz J Otorhinolaryngol. 2013;79(4):524.

Endovascular treatment of a traumatic carotid artery aneurysm after endoscopic arachnoid cyst fenestration

Intracranial aneurysms are usually described in the adult population. They are rare in childhood, representing 1–5% of all intracranial aneurysms [5, 7, 10]. Aneurysms in this population exhibit features that differ significantly from those in adults, including a higher incidence of unusual anatomic locations, male predominance, and a higher incidence of uncommon etiologies, such as infection and trauma [4, 5, 7, 9, 10, 14]. Traumatic intracranial aneurysms are rare and constitute less than 1% of all aneurysms in large series [1–3, 9, 11, 12, 14–16, 18]. They may occur as the result of either blunt or penetrating trauma, including iatrogenic neurosurgical procedures [1–4, 11, 12, 14, 15, 18]. Direct surgical repair of intracranial traumatic aneurysms is challenging due to the lack of a true neck or aneurysm wall [1, 4, 13, 15, 16, 18]. The endoscopic management of hydrocephalus and intracranial cysts is a well-established and safe technique, but vascular lesions are potential complications of such interventions [6–8, 12, 15, 17]. We report a case of a traumatic supraclinoid carotid artery aneurysm after endoscopic middle fossa arachnoid cyst treatment that was successfully managed with selective endovascular occlusion. To our knowledge, this is the first report of selective endovascular treatment of a traumatic carotid aneurysm after endoscopic cystocisternostomy.

Endovascular treatment of pulsatile tinnitus associated with transverse sigmoid sinus aneurysms and jugular bulb anomalies

Pulsatile tinnitus of vascular origin may arise in arterial or venous structures. Many authors have reported the association of pulsatile tinnitus with anomalies of dural venous sinuses and the jugular bulb. In such circumstances, mainly concomitantly with disabling tinnitus, endovascular treatment has been successfully employed. We describe here a new case of jugular bulb diverticulum associated with transverse sigmoid sinus stenosis, in a patient presenting with disabling pulsatile tinnitus. She was treated with dural sinus stenting and selective embolization of the diverticulum. In addition, we performed a literature review aiming to identify possible risk factors for developing the symptoms, as well as the safety and results of endovascular treatment.

Transitory Brain Stem Edema Following Successfully Transvenous Embolization of a Posterior Fossa Arteriovenous Malformation

The best management of brain arteriovenous malformations (BAVMs) remains controversial, since the annual risk of hemorrhage must be balanced against the significant morbimortality associated with the treatment [2]. The treatment of BAVMs includes different modalities such as microsurgery, embolization, and radiosurgery, either alone or in combination [1, 8]. regarding endovascular therapy, this is no longer reserved exclusively for preoperative embolization. Instead, it is becoming a curative procedure in an increasing proportion of cases [1, 8]. Technological advances, including the development of softer flow-directed microcatheters and mainly the advent of onyx are responsible for the increase in the cure rates [1, 5, 8, 10]. However, it has also been associated with considerable rates of complications [1, 8]. Although one of the most feared complications is the inadvertent occlusion of the draining veins of the arteriovenous malformation (AVM) before the complete exclusion of the nidus, transvenous approach can be used in very selected cases [1, 5, 9]. We report a case of a ruptured posterior fossa AVM that was successfully treated by transvenous approach. And moreover, a flow-related aneurysm shrinkage occurred in few days without specific treatment. Case Report

Occlusion rates of intracranial aneurysms treated with the Pipeline embolization device: the role of branches arising from the sac

OBJECTIVEThe aim of this study was to compare the clinical and angiographic outcomes of intracranial aneurysms with and without branches arising from the sac after Pipeline embolization device (PED) treatment.METHODSThis retrospective 2-center comparative study included 116 patients with 157 aneurysms that were treated with PEDs. Aneurysms were divided into 2 groups: one group had branches arising from the sac and the other group did not. Study end points included total aneurysm occlusion assessed by angiography at 6 and 12 months, death or stroke, technical complications, in-stent stenosis, patency of covered branches, and transient ischemia.RESULTSOne hundred fifty-one aneurysms (96%) were located in the internal carotid artery. A branch arising from the sac was observed in 26 aneurysms. Complete occlusion was found in 120 of 156 aneurysms at 6 months (76.92% [95% CI 69.71%-82.84%]) and in 136 of 155 aneurysms at 12 months (87.74% [95% CI 81.28%-92.27%]). Total occlusion was more frequently observed in the group without a branch arising from the sac (84% vs 40% at 6 months, p < 0.001; 93.10% vs 60% at 1 year, p < 0.001). There were 4 (3.45% [95% CI 1.11%-9.12%]) cases of death or major stroke. Amaurosis fugax occurred in 3 patients. One patient experienced worsening of mass effect after treatment. No occlusion of branches arising from the aneurysm was observed. In-stent stenosis greater than 50% was observed in 1 case.CONCLUSIONSAneurysms treated with PEDs are less likely to be totally occluded if they have a branch arising from the sac than are aneurysms without these branches.

Pipeline embolization device for the treatment of a traumatic intracranial aneurysm in a child

IntroductionTraumatic intracranial aneurysms in children are rare and may occur as the result of closed or penetrating head trauma. Their natural history seems to be more aggressive. Most traumatic aneurysms have complex shape, tending to have a large neck or even a fusiform morphology.Case reportWe present a case of a traumatic carotid artery aneurysm in a 9-year-old girl that was successfully treated with pipeline embolization device.DiscussionDue to its dissecting nature, wall friability and lack of a substantial neck can make surgical clipping and selective coiling difficult and risky. Although endovascular parent artery occlusion is the best approach in the acute phase, in some situations it is not possible or very risky. In such scenario the use of flow diverter devices would be an alternative approach. Additionally, we discuss the potential advantages and risks of flow diverter deployment inside a developing vessel.

Trombólise intra-arterial associada a angioplastia adjunta na fase aguda do acidente vascular cerebral isquêmico

BACKGROUND: Early reperfusion of an occluded artery responsible for an acute ischemic stroke is associated to the salvage of the hypoperfused zone adjacent to the central ischemic area. Our objective was to analyze the efficacy of intra-arterial thrombolysis in reestablishing flow in the treated vessel during the acute phase of ischemic stroke in a retrospective series of patients and evaluate the degree of disability using the modified Rankin scale (mRS) in a minimum follow-up period of three months, identifying prognostic variables. METHODS: Series of 30 patients with acute ischemic stroke [time from the onset of symptoms and beginning of thrombolysis (Δt) 18 (P = 0.01), advanced age (P = 0.01) and higher doses of recombinant tissue plasminogen activator (rt-PA) (P = 0.08). CONCLUSIONS: Intra-arterial thrombolysis in the acute phase of ischemic stroke and associated to adjunct intracranial angioplasty has proven to be an effective method with a high percentage of complete recanalization and favorable outcome in appropriately selected patients.

Anestesia em paciente portadora de doença de moyamoya: relato de caso

JUSTIFICATIVA E OBJETIVOS: A doenca de moyamoya e uma vasculopatia cerebral progressiva rara, mais frequentemente diagnosticada em populacoes asiaticas, mas que tambem vem sendo identificada no Brasil. Durante a sua vida, pacientes portadores desta doenca podem ser submetidos aos mais variados tipos de procedimentos cirurgicos. O anestesiologista deve entender a fisiopatologia da doenca e instituir as medidas peri-operatorias mais adequadas, no intuito de melhorar o prognostico destes pacientes. RELATO DO CASO: Paciente do sexo feminino, 22 anos, com insuficiencia renal cronica, portadora da doenca de moyamoya, submetida a intervencao cirurgica para instalacao de fistula arteriovenosa. A anestesia foi induzida com fentanil, propofol e atracurio e mantida com sevoflurano. Durante o procedimento, a paciente foi mantida em normocapnia e normotermia. A extubacao foi realizada e a paciente transferida a sala de recuperacao pos-anestesica sem complicacoes. CONCLUSOES: Este artigo apresenta os cuidados anestesicos dispensados a uma paciente portadora da doenca de moyamoya.