Chuhan Jiang

Results and complications of transarterial embolization of intracranial dural arteriovenous fistulas using Onyx-18.

OBJECT Use of the Onyx liquid embolic system has become an option for treating dural arteriovenous fistulas (DAVFs) because of its advantageous nonadhesive and cohesive properties. However, the complication rates associated with the use of this system have not been reported. The authors present their initial experience of the risks related to transarterial embolization using this system. METHODS Between February 2005 and February 2007, 31 patients with DAVFs were treated at Beijing Tiantan Hospital. Transarterial embolization using Onyx-18 was performed as a preoperative adjunct or as definitive therapy. The demographic characteristics, angiographic features, clinical presentation, treatment, and outcome of the patients were reviewed. Clinical follow-up status was supplemented by telephone interviews to determine Glasgow Outcome Scale scores. RESULTS In 19 patients (61.3%) there was complete angiographic evidence of elimination of the shunts and resolution of the symptoms. The remaining 12 patients were treated successfully but did not attain complete embolization and had residual shunting. Adverse events occurred in 5 of 31 patients, with 3 DAVFs located at the tentorium, 1 at the inferior petrosal sinus, and 1 at the cavernous sinus. Complications included trigeminocardiac reflex in 2 patients (6.5%), hemifacial hypesthesia in 3 patients (9.7%), hemifacial palsy in 2 patients (6.5%), jaw pain in 1 patient (3.2%), posterior fossa infarction in 1 patient (3.2%), and microcatheter gluing in 1 patient (3.2%). At the last follow-up examination, all patients had returned to an independent clinical status. CONCLUSIONS Although a complete resolution of symptoms can be achieved with transarterial embolization using the Onyx liquid embolic system, the potential for serious complications exists with this procedure, necessitating the participation of a skilled neurointerventionalist.

The Incidence of Trigeminocardiac Reflex in Endovascular Treatment of Dural Arteriovenous Fistula with Onyx

This paper reports the incidence of trigeminocardiac reflex (TCR) in endovascular treatment of dural arteriovenous fistulas (DAVFs) with Onyx. The consecutive case histories of 45 patients with DAVFs, treated with Onyx transarterially and transvenously, from February 2005 to February 2008 at Beijing Tiantan Hospital, China, were retrospectively reviewed. The time period was limited as the anesthetic and intravascular procedure was performed under the same standardized anesthetic protocol and by the same team. The TCR rate was subsequently calculated. Of the 45 patients, five showed evidence of TCR during transarterial Onyx injection and transvenous DMSO injection. Their HR fell 50% during intravascular procedures compared with levels immediately before the stimulus. However, blood pressure values were stable in all cases. The TCR rate for all patients was 11.1% (95% CI, 4 to 24%), 7.7% (95% CI, 2 to 21%) in patients treated intraarterially and 33.3% (4 to 78%) in patients treated intravenously. Once HR has fallen, intravenous atropine is indicated to block the depressor response and prevention further TCR episodes. TCR may occur due to chemical stimulus of DMSO and Onyx cast formation under a standardized anesthetic protocol and should be blunted by atropine.

Angioarchitectural Characteristics of Brain Arteriovenous Malformations with and without Hemorrhage

OBJECTIVE To explore angioarchitectural features of brain arteriovenous malformations (AVMs) manifesting with hemorrhage and without hemorrhage. METHODS During the period 1999-2008, 302 consecutive patients with AVMs were retrospectively reviewed. Univariate and multivariate logistic analysis was used to assess AVM characteristics in patients who presented with hemorrhage and patients who presented without hemorrhage. Annual and cumulative incidence rates of AVM rupture were analyzed using Kaplan-Meier life-table analyses. RESULTS The annual risk of hemorrhage from AVMs in this study was 1.9%. In the comparison of 159 patients with AVM with hemorrhage at initial presentation with 143 patients who did not experience hemorrhage initially (total 302 patients), deep and infratentorial AVM location, AVM size<3 cm, single arterial feeder, single draining vein, combined deep and superficial drainage, presence of varices in the venous drainage, and coexisting aneurysms were statistically associated with hemorrhage presentation (P=0.000, P=0.000, P=0.007, P=0.000, P=0.000, P=0.000, and P=0.003) in univariate analysis. Deep and infratentorial AVM location, single draining vein, presence of varices in the venous drainage, and coexisting aneurysms were statistically associated with hemorrhage occurrence (P=0.007, P=0.008, P=0.018, and P=0.002) in multivariate logistic analysis. CONCLUSIONS The angioarchitectural characteristics of AVM associated with hemorrhage include deep and infratentorial AVM location, AVM size<3 cm, single arterial feeder, single draining vein, combined deep and superficial drainage, presence of varices in the venous drainage, and coexisting aneurysms.

Endovascular treatment of high-risk tentorial dural arteriovenous fistulas: clinical outcomes

IntroductionAn increasing number of intracranial dural arteriovenous fistulas (DAVFs) are amenable to endovascular treatment with Onyx-18. We reviewed our experience with the endovascular management of tentorial dural arteriovenous fistulas (TDAVFs) treated transarterially and transvenously.Materials and methodsClinical records for 19 consecutive patients (three women, 16 men) with TDAVFs treated endovascularly between 2005 and 2008 were reviewed to determine their presenting symptoms, angiographic features, endovascular treatments, and clinical outcomes. Most patients (78.9%) presented with intracranial hemorrhage (ICH). All patients had high-risk angiographic features such as leptomeningeal venous varix.ResultsTransarterial embolization was performed in 19 patients. Transvenous embolization was additionally performed in two patients and caused one death. At the time of the last follow-up evaluation, 16 (84.2%) patients had good or excellent outcomes (modified Rankin score, 0 or 1) and one (5.3%) was deceased. Six patients had a residual fistula and were treated with gamma knife radiosurgery. The overall morbidity and mortality rate was 10.5%.ConclusionHigh-risk TDAVFs can be successfully managed with good outcomes. When anatomic features can be accessed endovascularly, endovascular treatment is indicated. Patients with residual filling of the DAVF should be considered for adjuvant therapy, including further radiosurgery.

Results of endovascular treatment for intracranial wide-necked saccular and dissecting aneurysms using the Enterprise stent: A single center experience

OBJECTIVE The aim of the present retrospective study is to compare outcome of the endovascular treatment using the Enterprise stent in intracranial wide-necked saccular and dissecting aneurysms. METHODS Forty-six patients with 50 complex intracranial aneurysms admitted between June 2009 and November 2010 were treated using Enterprise stents. Thirty-one aneurysms were wide-necked saccular, 19 aneurysms dissecting. In 48 cases, aneurysms were occluded by stent-assisted coiling; in 2 cases, by stent alone. RESULTS Among the aneurysms treated with the Enterprise stent, patient sex, aneurysm location, hypertension history and the immediate angiographic results differed significantly between the saccular and dissecting aneurysm groups. However, recurrence rate, clinical follow-up outcomes did not differ significantly between the saccular and dissecting groups. There was 1 (2%) procedure-related complication, which caused death in the saccular group. At mean 9.1-month follow-up, the result was good in all dissecting cases and good in 30 saccular cases. There was 1 recurrence in each group. CONCLUSIONS Enterprise stent is very useful for endovascular embolization of intracranial wide-necked saccular and dissecting aneurysms because it is easy to navigate and place precisely. The overall morbidity and mortality rates were low.

Endovascular treatment of paraclinoid aneurysms: 142 aneurysms in one centre

Background Current endovascular techniques have been widely used to treat paraclinoid aneurysms. Methods From January 2009 to December 2011, 126 consecutive patients with 142 saccular paraclinoid aneurysms were treated with endovascular embolization at our institute. A retrospective review of the clinical and imaging data was performed. Results Of the 142 aneurysms, 121 (86.2%) had small while 21 (14.8%) had large fundus size. 83 aneurysms (58.5%) were narrow necked and 59 (41.5%) were wide necked. The dome–neck ratio was favorable in 26 aneurysms (18.3%) and unfavorable in 116 (81.7%). 24 aneurysms (16.9%) were managed with coil embolization and 118 (83.1%) with a stent assisted coiling technique. Immediate angiography demonstrated complete occlusion in 62 (43.7%), neck remnant occlusion in 47 (33.1%), and residual aneurysm occlusion in 33 (23.2%) aneurysms. The overall recurrence rate in the 112 aneurysms with angiographic follow-up (8.88±3.40 months, mean±SD) was 12.5%. Of the 14 recurrent aneurysms, 10 were managed with endovascular treatment (six by stent assisted coiling, four by coiling) while four are under observation. There were six (4.3%) procedural complications during 137 procedures. Clinical follow-up was available for 119 patients (94%) with a follow-up time of 16.6±13.6 months, and the majority (98%) had a modified Rankin scale score of 0–1. Conclusions The stent assisted coiling technique is effective for the treatment of paraclinoid aneurysms. Small paraclinoid aneurysms (≤10 mm) are suitable for endovascular treatment, with a low rate of recurrence. In contrast, large paraclinoid aneurysms (>10 mm) treated with current endovascular techniques exhibited a high rate of recurrence.

Hemorrhage risk after partial endovascular NBCA and ONYX embolization for brain arteriovenous malformation.

Abstract Objective: To estimate for hemorrhage risk of partially endovascularly embolized brain arteriovenous malformation (BAVM). Methods: We retrospectively reviewed 147 consecutive patients with BAVM-treated mainly with endovascular N-butyl cyanoacrylate (NBCA) and ONYX embolization. In Kaplan–Meier survival analysis, the index date was the dated of initial endovascular embolization; cases were censored at time of subsequent intracranial hemorrhage (ICH), or loss to follow-up, and multivariate proportional-hazards regression models included age of presentation (⩽30 years old), clinical presentations, and other potential confounders. Results: We reviewed 147 patients with BAVM (58·8% male; mean age±SD at treatment: 27·5±11·1 years) treated with endovascular embolization. One hundred and forty-four NBCA and 76 ONYX embolizations were performed. Complete obliteration of BAVMs was achieved in 29 patients (19·7%). Thirty-two (21·8%) patients were treated with additional Gamma-knife radiosurgery. During 499·5 years of follow-up, 15 partially treated patients suffered a further hemorrhage, which caused four deaths. The crude annual risk of hemorrhage was 3·0% and the annual death rate was 0·8%. Among partially treated patients with hemorrhage at initial presentation, the risk of hemorrhage was 3·8%, while the risk of hemorrhage for patients without hemorrhage at initial presentation was 2·5%. The annual rate of subsequent hemorrhage was 2·6% for non-ICH and 4·2% for ICH in the partial NBCA embolization group compared with 2·4% for non-ICH and 2·4% for ICH in the partial ONYX embolization group. Conclusions: The effect of partial AVM embolization with liquid embolic agents may still be unclear as for risk reduction of annual hemorrhage rate of cerebral AVM.

Percutaneous transvenous packing of cavernous sinus with Onyx for cavernous dural arteriovenous fistula

OBJECTIVE The aim of this study is to describe the technique and results of the transvenous approach for occlusion of cavernous dural arteriovenous fistulas (DAVFs) with Onyx. METHODS Eleven patients presenting with clinically symptomatic DAVFs, were treated between August 2005 and February 2007 at Beijing Tiantan Hospital. We were able to navigate small hydrophilic catheters and microguidwires through the facial vein or inferior petrosal sinus (IPS) into the ipsilateral cavernous sinus. After reaching the fistula site the cavernous sinus was packed with Onyx or combining with detachable platinum coils. RESULTS We were able to reach the fistula site and to achieve a good packing of Onyx or combining with coils within the arteriovenous shunting zone in 10 patients. The final angiogram showed complete occlusion of the arteriovenous fistula. Two (18.2%) patients developed a bradycardia during DMSO injection. No complications related to the approach were observed. CONCLUSIONS Transvenous occlusion of cavernous DAVFs is a feasible approach, even via facial vein or via IPS. Onyx may be another option for cavernous packing other than detachable platinum coils.

Endovascular treatment of cerebral aneurysms with the use of stents in small cerebral vessels

Abstract Objective: To report the results of the Neuroform, Leo and Wingspan stents used to treat cerebral aneurysms in vessels of small caliber. Materials and methods: We reviewed 12 cases of wide-necked aneurysms treated with stent deployment into small cerebral vessels with diameter range from 1·0 to 2·5 mm. All stents were deployed for aneurysm treatment in combination with coiling. Aneurysm locations were as follows: A1 (n = 4), anterior communicating artery (n = 2), A2 (n = 1), M1 (n = 2), M2 (n = 1) and P1 (n = 2). Clinical follow-up ranged from 3 to 12 months. Imaging follow-up (range: 3-6 months) was performed with cerebral angiography. Results: Twelve self-expanding stents (six Neuroform stents, three Leo stents and three Wingspan stents) were deployed for 12 wide-necked cerebral aneurysms arising from vessels measuring 2·5 mm in diameter. Eleven procedures were successfully performed without immediate or delayed device-related complications with one stent misplacement. Intraprocedural thrombus developed within the stent in one patient. There were no clinical neurological symptoms related to the treated vessel territory at clinical follow-up. Conclusion: Development of newer small endovascular devices, such as Neuroform, Leo and Wingspan stents, allow access and ability to treat lesions farther out in the smaller cerebral vessels.

Embolization of intracranial dural arteriovenous fistulas with Onyx-18

BACKGROUND AND PURPOSE The use of Onyx in the treatment of AVMs has been reported in the literature, but experience in the treatment of DAVF is lacking. We report the clinical outcome obtained in the treatment of dural arteriovenous fistulas (DAVFs) using a new liquid embolic agent, Onyx-18. METHODS The present series included 21 patients; 9 had DAVFs draining directly into the cortical veins, 6 had DAVFs draining directly into the dural sinus, 4 had DAVFs draining through the ophthalmic veins and 2 had DAVFs involving the dural sinus with leptomeningeal retrograde venous drainage Clinical data were extracted from hospital files and all patients were followed. RESULTS In 14 patients (70%) there was complete angiographic elimination of the shunts and resolution of the symptoms. The remaining 7(30%) patients was not cured with residual shunts. Adverse events occurred in 6(30%) of 21 patients with 1 DAVF located at the transverse sigmoid sinus, 2 at tentorium, and 3 at the cavernous sinus. Cranial deficits occurred in 3(15%) patients, brain infarction in 1(5%) patient and microcatheter gluing in 1(3.2%) patient. At final follow up, 20 patients were asymptomatic with 1 showed clinical improvement. CONCLUSION Definitive cure may be attained effectively with Onyx in dural arteriovenous fistulas and adjunctive to surgery and radiotherapy. Location of the DAVFs affected the outcome of transarterial embolization.