Angel Lee

Roles and rules of Syngo iFLOW in neuroendovascular procedures

Abstract The authors present 2 patients who underwent neuroendovascular procedures in syngo iFLOW produced that use the dynamic of fluid in several types of intracranial pathologies. As part of a combined CT/angiography suite, iFLOW offered the major advantage of immediate detection or exclusion of intracranial complication without patient transfer. The study of fluid dynamics constitutes a cornerstone for the evaluation of various intracranial vascular pathologies. These applications include the isolation of cerebral aneurysms by embolization and clipping, embolisation of malformations, as well the evaluation of vasooclussive diseases. The emergence of techniques such as syngo iFLOW, which give a comprehensive picture of angiography, constitute a element that can to contribute to the decision of conduct clinics. Siemens has developed a novel based system which is able to reconstruct in achieving angiography techniques colors define intracranial flow characteristics in a single image. With this technique, is possible to obtain a comprehensive picture of cerebral angiography.

Intra-arterial chemotherapy for retinoblastoma: a practical review

Abstract The use of chemotherapy for retinoblastoma constitutes a promising treatment strategy. Retinoblastoma is the most common eye cancer in the childhood.. Treatment depends on the laterality, intraocular location and tumor extension. Radiation therapy became an important element in the management of this type of injury risk of extraocular secondary tumor development. Eye salvage is mandatory when vision preserved. The current neuroendovascular techniques constitute a therapeutic tool for these tumors. We present a practical review of current concepts in the management of these tumors.

Endovascular management of intracranial pial arteriovenous fistulas: Experience of largest series at a single center over six years

Introduction: Intracranial pial fistulas are an extremely uncommon type of vascular pathology consisting of one or multiple arterial connections to a single venous drainage channel without the presence of an intervening nidus. Due to its typical location and high-flow dynamics, its management is difficult and options include endovascular treatment and open surgical treatment. The arterial supply of these lesions is usually derived from pial or cortical vessels, and commonly such lesions are not localized in the dura mater. Materials and Methods: Authors report the experience of consecutive ten cases managed at the Instituto Nacional de Neurología y Neurocirugía “Manuel Velasco Suárez” of México extending from 2007 to 2012 with endovascular technique, constituting one of the largest series in the Western literature. Discussion: Pial fistulas are associated with a poor natural history, and the selection of individualized therapeutic strategies can provide good outcomes. Conclusion: The neuroendovascular intervention is currently considered as safe, low cost, and effective management modality for such lesions.

Extracranial internal carotid artery aneurysm: case illustration

Abstract Extracranial internal carotid artery aneurysms (EICAA) are uncommon lesion. These aneurysms can be classified as true or false aneurysms, atherosclerotic, dysplastic, infectious, posttraumatic and iatrogenic aneurysms. The most common presentation is central neurologic dysfunction, either a stroke or a transient ischemic attack. The rupture of these aneurysms can lead to severely impairment and can affect the quality of life of the patients or even may lead to death. Management of these lesions is required in most cases to prevent complications, however there is no treatment guideline or expert consensus for the management. We present a case of an unusual EICAA, associated with kinking of the affected vessel and review the literature.

When flow diverters fail: short review and a case illustration of a device failure

Abstract The ultimate aims of treatment of the intracranial aneurysms are reconstruction the vessel wall and correcting the hemodynamic disturbance. A flow diverter (FD) is a stent placed inside lumen of the parent artery with aim to blood flow reduction into the aneurysms sac to the extent of almost stagnation leading to gradual onset of progressive thrombosis and neointimal lining of arterial wall remodeling to maintain blood outflow into perforators the side and branches. Flow diverter is considered as an effective treatment for fusiform, wide-necked, large and giant intracranial unruptured aneurysms. However, FD implantation may also be associated with growth and rupture of residual aneurysms. The most frequent complication of endovascular aneurysms management is thromboembolic events and less common are intra and postoperative hemorrhagic aneurysmal rupture. Authors report a case where a lack of operation of the device as illustration is presented to demonstrate the shortcomings of this new type of devices.

Flat panel detector -CT with endovenous injection. Description of a novel technique for obtaining cerebral arteries imaging: Technical note

Introduction The diagnosis and management of cerebral vascular disease has improved due to the constant development of imaging techniques. Digital subtraction angiography (DSA) is the gold standard, but still involves high cost and risk (1). The certainty of the images obtained by noninvasive methods currently has facilitated the identification of therapeutic surgical or endovascular decisions in many centers of the world regardless of the ASD. At other times, the CT angiography is useful as a tool for control and monitoring in patients already treated (2–6), however it is still ineffective for proper evaluation of intra-stent stenosis (7–9). The flat-panel detector CT (FPDCT) is a relatively new technology that provides extremely useful images in cerebral vascular disease, especially for its ability to show relationships between soft tissue and bone, detect complications during the procedure, display of intra and extracranial coils and stents, however it require the intraarterial injection of contrast material (10–12). There are few articles that show the intravenous injection technique for FPDCT. n this paper we show a novel technique developed at the National Institute of Neurology and Neurosurgery for imaging with intravenous injection. Equipment: We used a biplane system C-arm with flat detector angiography, AXIOM Artis dBA (Siemens, Erlangen, Germany) with a system of dynamic imaging plane detector with high spatial resolution and contrast resolution of 14 bits, detector input plane 30 x 40 (48 cm diagonal) with a pixel size of 154 um and input level detector 20 x 20 (25 cm diagonal) with a pixel size of 184 um, with acquisition of DSA images in real time with up to 7.5 imag./s, 10, 15, January 30 imag. / s in biplane in 1024 x 1024 matrix

What the Neurosurgeon needs to know about Cerebral Developmental Venous anomalies

Abstract Venous Angiomas or Developmental venous anomalies (DVA) are extreme variations of normal transmedullary veins that are necessary for the drainage of white and gray matter, also are one type of cerebrovascular malformation (CVM), sharing category with capillary telangiectesias, cavernous malformations (CM), and arteriovenous malformations (AVM), each of which may also be associated with a DVA. DVA are the most commonly encountered CVM, accounting for up to 60% of all CVM. We present a review of the literatura

Vein of Galen malformation: What to do when vascular access is not feasible?

Abstract Background: The vein of Galen aneurysmal malformation (GVAM) is a rare congenital vascular lesion, with high morbidity and mortality without treatment, endovascular management is the best alternative available today. Aim: The purpose of this work is to report the case of a female patient with imaginological and angiographical diagnosis of GVAM, which was difficult for endovascular managent alone, due to this was decided an alternative endovascular direct access guided by stereotactic assistance. Case report: We report the case of an infant with imaging and angiographic diagnosis of GVAM, with absence of the vein access through classical embolization could be done, complicating and making difficult for endovascular management alone, hence was decided an alternative endovascular direct access guided by stereotactic assistance, ensuring total embolization of the lesion with coils. The patient progressed satisfactorily. Discussion: VGAM generally represents only 1% or less of total cerebral vascular malformations, but in pediatrics may be as high as 30%. The malformation is occupying the subarachnoid space of the velum interpositum and the quadrigeminal cistern. It is characterized by the presence of the vein embryonic precursor of the vein of Galen, and abnormal arterial shunts from arteries normally developed but extremely dilated. Mortality rate is high in these patients without treatment, developing hydrocephalus and cerebral complications related to the occupying mass that could drive to epilepsy, serious cognitive sequelae, intracerebral emorrhage and death within the possibilities. Heart failure is often a common complication. To our knowledge this is the first report of the use of stereotactic assistance in the endovascular therapeutic management of VGAM. Conclusions: In cases where clasical venous access cannot be achieved as in the case we report, further technical assistance can be obtained with stereotactic guidance, making easier the procedure, remembering that without therapy, VGAM result in lifethreatening hydrocephalus and/or intracranial hemorrhage, rapidly driving to death.

Endovascular management of dural fistulas into the cavernous sinus. A systematic review

Abstract Background: Dural fistula to the cavernous sinus (DFCS) is an infrequent pathology that consists in the anomalous communication between the meningeal branches of the internal carotid artery (ICA) and/or the external carotid artery (ECA) and the cavernous sinus. Aim: To perform a systematic review to evaluate clinical and imaging findings in DFCS, and current indications for treatment. Methods: A literature search was performed in several medical databases using the keywords “intracranial dural fistula”, “carotid-cavernous fistula”, “endovascular treatment”, associated with “outcome”; resulting articles were assessed by considering factors such as: number of patients treated, type of material used, complications, and type of image technique used for diagnosis. Results: 33 articles were selected, yielding: clinical and imaging: The symptoms are basically related to the type of venous drainage of the fistula. The combination of ocular symptoms and tinnitus is highly suggestive of DFCS. Ocular symptoms are found in 80-97% of patients, while the tinnitus is present in up to 50% of cases. The imaging method for initial assessment of the DFCS is the magnetic resonance imaging. Digital subtraction angiography is the method of choice to determine adequately the precise angioarchitecture of the injury and its drainage. This data is of vital importance in future decision making. Treatment: Currently are considered as indications for the management of DFCS: 1) rapidly progressive deterioration of visual function, 2) angiographic evidence of abnormal cortical venous drainage, 3) the hypoxic consequences in retina and optic nerve, and 4) ischemic keratitis; the most suitable materials for embolization of the DFCS are CA and PAP. Conclusion: DFCS stills being an uncommon cerebrovascular condition, with good outcomes from endovascular treatment.

Indications and practical application of strategies in the endovascular management of intracranial aneurysms

Abstract The occlusion of intracranial aneurysms is more successful and stable by properly planning the approach and application of endovascular techniques. The next step is a relentless analysis of the different indications of endovascular treatment, tailoring a strategy suitable for the specific case, and making more rational choices for the management of aneurysms. Indications and strategies according to the analysis of the aneurysmal complex are given, as well as pros and cons of the endovascular technique according to different anatomical locations