Chao-Bao Luo

Patients with head and neck cancers and associated postirradiated carotid blowout syndrome: Endovascular therapeutic methods and outcomes

PURPOSE This study retrospectively evaluated the technical and hemostatic outcomes of reconstructive and deconstructive endovascular management in patients with head and neck cancers associated with carotid blowout syndrome (CBS). METHODS Twenty-four patients with head and neck cancers with CBS involving the main trunk of carotid artery underwent endovascular therapy. This included reconstructive management with self-expandable stent grafts to preserve the diseased carotid artery in 11 patients and deconstructive management with balloons, coils, or acrylic adhesives to occlude the diseased carotid artery in 13 patients. Based on clinical severity and therapeutic priority, we classified CBS in our patients into two groups: acute or impending and threatened. The angiographic severity was graded from 0 to 3. Evaluation of technical outcome included technical success, initial and delayed complications, and patency of stent graft in the reconstructive group. The hemostatic outcome was evaluated by immediate hemostatic result, rebleeding, and duration of hemostasis. Sex, age, clinical and angiographic severities, local wound complications, and location of the pathologic lesion were examined as predictors of the technical and hemostatic outcomes of endovascular management by using Cox regression method. RESULTS Technical success and immediate hemostasis were achieved in all patients of both groups. Initial complications during the procedures were encountered in four patients (36.4%) who underwent reconstructive management and in one patient (7.7%) who underwent deconstructive management (P = .142). Delayed complications during the follow-up were seen in one patient (9.1%) with reconstructive management and one patient (7.7%) with deconstructive management (P > .99). Rebleeding occurred in five patients (45.5%) in the reconstructive management group and in three patients (23.1%) in the deconstructive management group (P = .659). The mean duration of hemostasis after initial reconstructive and deconstructive management was 4.0 +/- 8.1 and 8.5 +/- 10.1 months, respectively (P = .249). Rebleeding was noted in 7 of 11 patients (63.6%) with acute CBS and in 1 of 13 patients (7.7%) with impending and threatened CBS (P = .008). CONCLUSION There is no significant difference in technical and hemostatic outcomes between the reconstructive and deconstructive endovascular management methods. Hemostatic results were influenced by clinical severity. The rebleeding rate is higher in patients with advanced and acute clinical severity.

Monitoring Peri-Therapeutic Cerebral Circulation Time: A Feasibility Study Using Color-Coded Quantitative DSA in Patients with Steno-Occlusive Arterial Disease

BACKGROUND AND PURPOSE: Intracranial hemodynamics are important for management of SOAD. This study aimed to monitor peri-stent placement intracranial CirT of patients with SOAD. MATERIALS AND METHODS: Twenty-five patients received stent placement for extracranial ICA stenosis, and 34 patients with normal CirT were recruited as controls. Their color-coded DSAs were used to define the Tmax of selected intravascular ROI. A total of 20 ROIs of the ICA, OphA, ACA, MCA, FV, PV, OV, SSS, SS, IJV, and MCV were selected. rTmax was defined as the Tmax at the selected region of interest minus Tmax at the cervical segment of the ICA (I1 on AP view and IA on lateral view). rTmax of the PV was defined as intracranial CirT. Intergroup and intragroup longitudinal comparisons of rTmax were performed. RESULTS: rTmax values of the normal cohorts were as follows: ICA-AP, 0.12; ICA-LAT, 0.10; A1, 0.28; A2, 0.53; A3, 0.81; M1, 0.40; M2, 0.80; M3, 0.95; OphA, 0.35; FV, 4.83; PV, 5.11; OV, 5.17; SSS, 6.16; SS, 6.51; IJV, 6.81; and MCV, 3.86 seconds. Before stent placement, the rTmax values of arterial ROIs, except A3 and M3, were prolonged compared with values from control subjects (P < .05). None of the rTmax of any venous ROIs in the stenotic group was prolonged with significance. After stent placement, the rTmax of all arterial ROIs shortened significantly, except A1and M3. Poststenting rTmax was not different from the control group. CONCLUSIONS: Without extra contrast medium and radiation dosages, color-coded quantitative DSA enables real-time monitoring of peri-therapeutic intracranial CirT in patients with SOAD .

Traumatic indirect carotid cavernous fistulas: angioarchitectures and results of transarterial embolization by liquid adhesives in 11 patients

BACKGROUND The angioarchitectures of traumatic indirect CCFs and the effectiveness and safety of transarterial liquid adhesive embolization for these fistulas remain to be evaluated. METHODS A total of 276 consecutive patients with traumatic craniofacial arteriovenous fistula were referred for embolization in the past 15 years. Eleven had traumatic indirect CCFs and were managed with transarterial liquid adhesive embolization. This group was composed of 8 men and 3 women ranging from 15 to 46 years of age. The most frequently observed symptoms were neuro-ophthalmic, followed by bruit and headache. All lesions were single fistula and fed exclusively by meningeal artery. The accessory meningeal artery was involved most often (n = 7), followed by the middle meningeal artery (n = 4). Venous drains were the ophthalmic vein (n = 11) and/or inferior petrous sinus (n = 8). No cortical vein drainage was observed. Liquid adhesives (60%) were used to obliterate all fistulas; 2 patients were also treated with detachable coils. RESULTS All fistulas were totally occluded with resolutive fistula-related symptoms. Asymptomatic migration of liquid adhesives into the nearby arterial branch was observed in 1 patient. One patient had partial ocular choroidal infarction. No recurrent or residual fistula was found upon clinical follow-up. CONCLUSIONS Angioarchitecture and treatment of traumatic indirect CCFs differed from the spontaneous type of fistulas. By transarterial liquid adhesive embolization, treatment of all fistulas was safe, with effective occlusion and associated low peri-procedural risk. This procedure may be considered as the primary treatment for these traumatic fistulas.

MR imaging of giant intracranial aneurysm.

We reviewed the clinical features and findings of magnetic resonance imaging (MRI) in 17 cases of giant intracranial aneurysm (GIA). All were confirmed by digital subtraction angiography (DSA). Seven were non-thrombosed and 10 were partially thrombosed.All thrombosed parts showed no enhancement. The majority of the lumen showed good enhancement in the post-contrast study (89%). About 80% of the partially thrombosed aneurysms had an onion skin appearance on non-contrast T1WI. On T2WI about 80% of partially thrombosed aneurysms had a low signal inside the thrombus or its wall from the susceptibility effect of blood elements such as haemosiderin. Flow void sign was noted in 88% on non-contrast T1WI and T2WI. Flow artifacts along the phase-encoding direction from the lumen of the aneurysm were noted in 41% of non-contrast T1WI, 56% of contrast-enhanced T1WI, and 29% of T2WI.Non-enhancement inside the thrombus and an onion skin appearance were important signs of thrombosis of the aneurysm. Flow artifacts along the phase-encoding direction from the lumen of the aneurysm provided an important clue of a patent lumen inside an aneurysm. The following signs provided clues to the diagnosis of patency lumen instead of thrombosis with high sensitivity and specificity: flow void sign on noncontrast T1WI (sensitivity 88%, specificity 100%), enhancement on contrast-enhanced T1WI (sensitivity 89%, specificity 100%), presence of either flow void sign or enhancement on contrast-enhanced T1WI (sensitivity 100%, specificity 100%).

Stent Management of Coil Herniation in Embolization of Internal Carotid Aneurysms

BACKGROUND AND PURPOSE: Coil herniation into the parent artery after detachment is an uncommon complication of embolization of the intracranial aneurysm. We report our experience with stent reconstruction of the lumen and flow of the internal carotid artery (ICA) after coil herniation during embolization for intracranial ICA aneurysms and the possible mechanisms of coil herniation. MATERIALS AND METHODS: A series of 216 consecutive patients was treated by endovascular coil embolizations for intracranial aneurysms. Of these patients, there were 9 (4 men, 5 women; 32–68 years of age) complicating with coil herniation into the ICA and undergoing stent deployment to reconstruct the ICA lumen (n = 8) or both lumen and flow (n = 1). Wide-neck aneurysms were found in 8 and narrow-neck, in 1. Aneurysms were in the posterior communicating artery (n = 5) and the paraophthalmic (n = 3) and cavernous portions (n = 1) of the ICA. Self-expandable stents were deployed in the ICA in 6; balloon-mounted stents were selected in 3. RESULTS: The causes of coil herniation appeared to be coil instability after detachment (n = 6), excessive embolization (n = 1), microcatheter-related problems (n = 1), or being pushed by subsequent coil embolization (n = 1). Endovascular stent placement to reconstruct the lumen and/or flow of the ICA was technically successful in all 9 patients; 1 needed a second stent due to further coil migration. No significant procedure-related complications were found. Clinical follow-up was 8–35 months. CONCLUSION: Coil herniation occasionally occurs during endovascular embolization of ICA aneurysms because of coil instability after detachment, excessive embolization, microcatheter-related problems, or pushing by subsequent coil embolization. In this small series, stent placement was safe and effective in the reconstruction of the arterial lumen and/or restoration of flow past a herniated coil mass.

Radiation carotid blowout syndrome in nasopharyngeal carcinoma: Angiographic features and endovascular management

Objective To report clinical manifestations, angiographic features, and outcomes of endovascular management in 14 patients with 15 radiation carotid blowout syndromes of nasopharyngeal carcinomas. Study Design and Subjects Retrospective chart review of 14 patients with nasopharyngeal carcinomas (mean age 49 years) with 15 radiation carotid blowout syndromes who had undergone endovascular embolization to manage oronasal bleeding in the past 10 years. Results Average radiation dose to affected carotid artery was 73 gray units (latent period: 33 months). Radiation carotid blowout syndrome was detected in internal (n = 10), external (n = 4), or common carotid artery (n = 1). Detachable balloons were used in 11 affecting arteries for vascular occlusion; 4 were treated by liquid adhesives or coil. Endovascular treatment was successful in all 15 radiation carotid blowout syndromes with cessation of hemorrhage. One patient had hemiparesis after embolization. Mean clinical follow-up was 21 months. Conclusion Radiation carotid blowout syndrome in nasopharyngeal carcinoma may occur in various periods or arteries. Endovascular embolization provides both safe and effective management.

The current role of 1.5T non-contrast 3D time-of-flight magnetic resonance angiography to detect intracranial steno-occlusive disease

BACKGROUND/PURPOSE This study was performed to evaluate the role of non-contrast 3D time-of-flight (TOF) magnetic resonance angiography (MRA) to detect and quantify intracranial steno-occlusive disease. METHODS Between April 2004 and January 2006, 45 patients with both 1.5T TOF MRA and digital subtraction angiography (DSA) performed within a 30-day interval were included. We evaluated the following intracranial arterial segments: petrous internal carotid artery (ICA), cavernous ICA, supraclinoid ICA, M1 of middle cerebral artery, A1 of anterior cerebral artery, P1 of posterior cerebral artery, basilar artery, and distal vertebral artery. In total, 675 arterial segments were evaluated and categorized as negative, moderate-1 (3049% stenosis), moderate-2 (5069%), severe (7099% stenosis, including gap sign on MRA), and occlusion. RESULTS The sensitivity and specificity of TOF MRA for > 29% stenosis and > 49% stenosis were 94%, 96% and 95%, 96%, respectively; while sensitivity and specificity for occlusion lesions were both 100%. However, 44 segments (37% of diseased segments) were overestimated by MRA, including 20 false-positive stenoses (which occurred in 10 [22%] patients) and 24 overestimated stenosis degree. The gap sign as severe stenosis only showed about 21% sensitivity and 41% specificity. Seven lesions were underestimated by MRA: three arterial segments were out of the field of MRA examination, and four were moderate-1stenosis on DSA. CONCLUSION TOF MRA has high sensitivity and specificity in detecting all categories of stenosis degree and occlusion. However, it tends to overestimate lesions. Therefore, MRA can be considered as a screening study. Confirmation with other studies is recommended in doubtful cases.

Endovascular treatment of intracranial high-flow arteriovenous fistulas by Guglielmi detachable coils.

Background: This study reports our experience in performing transarterial Guglielmi detachable coil (GDC) embolization for intracranial high‐flow arteriovenous fistulas (AVFs) and evaluates its efficacy and safety. Methods: Over 3 years, 13 patients with 14 intracranial high‐flow AVFs had been managed by transarterial GDC embolization in our institution. There were 6 men and 7 women, with a mean age of 27 years. Of these 14 AVFs, 8 were traumatic carotid‐cavernous fistulas (TCCFs); 5 were AVFs at the frontal, temporal, parieto‐occipital lobes, or associated with arteriovenous malformation (n = 3); 1 was a tentorium AVF. Results: All of these high‐flow AVFs were successfully occluded by a single session of transarterial GDC embolization. In 8 patients with TCCFs, the nearby parent arteries were preserved. The average number of coils was 8 and the average length was 126 cm. All AVF‐related symptoms resolved immediately or gradually on clinical follow‐up. No significant procedure‐related neurologic complication or recurrent AVF was seen. All 13 patients were followed up clinically for an average of 16 months (range, 6–25 months). Conclusion: Transarterial GDC embolization is a useful method in the treatment of intracranial high‐flow AVFs. GDC affords more control in the placement of coils and proved both efficient and safe in the management of intracranial high‐flow AVFs.

Role of CT and endovascular embolization in managing pseudoaneurysms of the internal maxillary artery.

Background: The purpose of this study was to evaluate the role of computed tomography (CT) and endovascular embolization in managing 10 patients with 11 internal maxillary arterial pseudoaneurysms (IMPAs) with acute oronasal hemorrhage. Methods: A series of 10 patients with 11 IMPAs presenting with profuse oronasal hemorrhage, all treated with endovas‐cular embolization, were reviewed. There were 9 males and 1 female ranging in age from 10 to 56 years (mean, 38 years). The predisposing factors of IMPA were trauma (n = 6) or head and neck carcinomas (HNCs) after surgical treatment and/or postradiation therapy (n = 5). Before embolization, all patients had CT of maxillofacial regions to evaluate the extension of trauma or to evaluate the treatment outcome for HNCs. Endovascular embolization was employed to occlude the IMPAs by delivering the embolic agents of liquid adhesives (n = 9) or microcoils (n = 2) to the IMPAs. Results: On the lesion side, CT revealed maxillofacial fractures in all 5 trauma patients and recurrent or residual tumors in 3 patients with HNCs. In the other 2 patients with HNCs, CT showed no significant finding and contributed little to the catheter angiography in detecting the IMPAs. Endovascular treatment was technically successful in all 11 IMPAs, ceasing hemorrhage immediately after embolization. No recurrence of bleeding was observed. No patient developed neurologic deficit, skin, or mucosal necrosis at the maxillofacial region. Clinical follow‐up was 2‐36 months (mean, 14 months). Two patients with advanced carcinoma died during follow‐up because of disease progression. Conclusion: CT is a useful tool for guiding catheter angiography to localize the majority of IMPAs. Endovascular embolization can succeed in managing IMPAs, and should be performed as soon as the IMPA is depicted.

Verifying complete obliteration of carotid artery-cavernous sinus fistula: role of color Doppler ultrasonography.

The purpose of this study was to evaluate the role of color Doppler ultrasonography in verifying obliteration of carotid artery‐cavernous sinus fistula before and after therapeutic embolization or gamma knife radiosurgery. Before treatment, carotid artery‐cavernous sinus fistula showed the following data on color Doppler ultrasonography: (1) increased blood flow in the common carotid artery (220 to 1264 ml/min with mean+/‐SD of 728+/‐378 ml/min); internal carotid artery (435 to 1097 ml/min with mean+/‐SD of 834+/‐216 ml/min) in fistulas of the direct type; and external carotid artery (85 to 257 ml/min with mean+/‐SD of 170+/‐75 ml/min) in fistulas of the indirect type in comparison to the contralateral side; (2) reverse pulsatile flow or spiculated wave form with turbulent flow in the engorged superior ophthalmic vein on the lesion side in all patients. All of the above abnormal hemodynamic changes became normal in six patients immediately after first embolization, in two patients with balloon embolization combined with subsequent direct embolization by direct puncture through the superior orbital fissure or internal carotid artery embolization, and in five patients after gamma knife radiosurgery at 4, 4, 8, 9, and 9 months, respectively. Color Doppler ultrasonography might be a good modality in long‐term follow‐up of carotid artery‐cavernous sinus fistula after gamma knife radiosurgery and embolization.