In Sup Choi

Giant intracranial aneurysms: development, clinical presentation and treatment

The natural history of giant intracranial aneurysms are grave. More than 50% of patients suffer from rupture of these aneurysms and mortality is >60% in 2 years. Modern technology and advancement of knowledge in neurosurgery and interventional neuroradiology have altered its natural course for the better. As many reports have shown, the majority of these aneurysms can be treated either by surgery or by endovascular approach, even though morbidity is higher than when treating smaller aneurysms. Certain aneurysms are more suitable to direct surgical clipping and others may have better chances of good clinical outcome by endovascular treatment. It is imperative to analyse the location, morphology, hemodynamics and circulation of normal brain of each aneurysm before the mode of treatment is decided. Needless to say, the individual patients age, neurological and medical condition should be considered. For endovascular treatment, application of each technique, endosaccular occlusion or parent artery occlusion depends on the aneurysm location and geometry as well as its pathology. Several reports indicated that clinical outcome is better in patients treated by parent artery occlusion since it eliminates any blood flow to the aneurysm and it provides a more effective reduction of the mass effect. However, not all parent arteries can be sacrificed. In addition, endosaccular treatment is effective in preventing haemorrhage if the aneurysm is not re-canalised. It is also demonstrated that symptoms of mass effect can be reversed by endosaccular coiling. The patients who are treated this way should be closely monitored for re-canalisation.

The many faces of intracranial arterial dissections.

Intracranial arterial dissecting diseases are rare and challenging diseases with a high associated morbidity and mortality. Their common pathomechanic origin is related to blood entering the vessel wall via an endothelial and intimal tear. Depending on the fate of the thus established intramural hematoma, different symptoms may ensue including mass effect, subarachnoid hemorrhage or ischemia. If the mural hematoma ruptures all vascular layers of the intradural artery, a subarachnoid hemorrhagic will occur. If the intramural hematoma reopens distally into the parent vessel on the other hand, ischemic embolic events may happen following intramural clot formation. If the mural hematoma does neither open itself into the parent vessel nor into the subarachnoid space, the vessel wall may dilate leading to occlusion of perforator branches and local ischemia. Organization of the mural hematoma may result in a chronic dissecting process which may eventually lead to formation of a “giant partially thrombosed” aneurysm with thrombus of varying ages within the vessel wall, ingrowth of vasa vasorum and recurrent dissections with subsequent growth of the aneurysm from the periphery. Treatment strategies of these diseases should take the underlying pathomechanism into consideration and include, depending on the presentation medical treatment, parent vessel occlusion, flow reversal or diversion, surgical options or a combined treatment protocol.

Dissecting Aneurysms of the Distal Segment of the Posterior Inferior Cerebellar Arteries: Clinical Presentation and Management

BACKGROUND AND PURPOSE: Dissecting aneurysms of the distal segment of the PICA are rare. The purpose of this study was to evaluate the clinical presentations, imaging features, treatment options, and clinical outcomes of dissecting PICA aneurysms. MATERIALS AND METHODS: Six patients with dissecting aneurysms in the distal segments of PICA were found in the database of a single medical center, from November 1996 to December 2008, and retrospectively evaluated. Treatment mode and follow-up clinical outcomes were analyzed. RESULTS: Five patients with dissecting PICA aneurysms presented with acute intracranial hemorrhage and 1 patient presented with a large mass from an intramural hematoma. All 5 patients with intracranial hemorrhage were treated with endovascular occlusion of both the dissecting PICA aneurysm and the distal parent artery. The patient with the intramural hematoma underwent surgical trapping with end-to-end anastomosis. In 1 patient, the dissecting aneurysm recurred twice within a 5 year 3 month period, despite endovascular occlusion of both the aneurysm and the parent artery. The clinical outcome postprocedure was excellent in all patients, without permanent neurologic complication. CONCLUSIONS: For the endovascular treatment of dissecting aneurysms in the distal PICA segments, we recommend occlusion of both the dissecting aneurysm and the parent artery to avoid leaving the point of initial intimal tear untreated. All of our patients had excellent clinical outcomes; however, our experience with recanalization illustrates the need for close follow-up of patients.

Spinal Epidural Arteriovenous Fistula: a Unique Pathway into the Perimedullary Vein: A Case Report

Spinal dural arteriovenous fistulas (AVFs) are rare vascular malformations in the spinal dura, fed by dural branches of the radicular arteries, and drain primarily into intradural venous plexuses. They may cause elevated medullary venous pressure and produce a progressive myelopathy. We describe a case of AVF in the epidural space of the previous surgery site of L3 and it showed a unique complex venous pathway into the perimedullary vein, leading to classic clinical symptoms of venous congestion in the spinal cord. The shunt was draining into bilateral epidural venous plexus and then to the paravertebral veins at the level of L2. The venous outflow entered to the epidural space again and finally refluxed into the intradural perimedullary vein.

Obliteration of a metameric spinal arteriovenous malformation (Cobb syndrome) using combined endovascular embolization and surgical excision

Cobb syndrome represents the concurrent findings of a metameric spinal vascular malformation and a cutaneous vascular malformation within several dermatomes of each other. This rare entity engenders many difficult decisions with respect to appropriate therapeutic management. Historically, surgical excision carried a high morbidity, and conservative management without intervention was preferred. More recently, several cases of endovascular embolization have been reported with good success. The authors describe the case of a 17-year-old boy who presented with a right gluteal angioma and was found to have a spinal arteriovenous malformation. Multiple embolizations failed to prevent neurological deterioration, and the patient eventually became wheelchair dependent. Surgical excision of the malformation led to partial recovery of neurological function, and at the latest follow-up, 52 months postoperatively, the patient was able to ambulate independently. This case demonstrates the successful treatment of a patient with Cobb syndrome with surgical excision after multiple refractory embolizations. A multidisciplinary approach, which balances the patients current neurological function against the risks and potential gains from any interventional and surgical procedure, is recommended.

Combined surgical and endovascular management of a giant fusiform PCA aneurysm in a pediatric patient. A case report.

Treatment of intracranial giant aneurysms presents is challenging. In the case of pediatric giant aneurysm, more challenges arise. We describe our experience with a 17-year-old pediatric patient who presented with severe headache. She was diagnosed as having a giant fusiform aneurysm at the right P1-P2-Pcom junction. The aneurysm was treated with superficial temporal artery-posterior cerebral artery bypass and subsequent coil embolization of the aneurysm with parent artery occlusion. The patient had an excellent outcome at one-year follow-up. Our case suggests a combined approach of surgical and endovascular management may yield a better outcome than surgery or endovascular management alone in the treatment of pediatric giant aneurysm.

«Interventional Neuroradiology: a Neuroscience sub-specialty?»

Interventional Neuroradiology (INR) is not bound by the classical limits of a speciality, and is not restricted by standard formats of teaching and education. Open and naturally linked towards neurosciences, INR has become a unique source of novel ideas for research, development and progress allowing new and improved approaches to challenging pathologies resulting in better anatomo-clinical results. Opening INR to Neurosciences is the best way to keep it alive and growing. Anchored in Neuroradiology, at the crossroad of neurosciences, INR will further participate to progress and innovation as it has often been in the past.

Standards of Practice in Interventional Neuroradiology or Endovascular Neurosurgery: WFITN Site Conditions and Technical Operational Guidelines

with the working group composed of: S. Bracard, J. Byrne, L. Feng, O. Flodmark, A. Goulao, M. Leonardi, M. Mawad, J. Mishra, J. Moret, M. Negoro, R. Piske, B. Richling, G. Rodesch, J. Ruscalleda, K. terBrugge, A.Valavanis.

Retrospective Review of Procedural Parameters and Outcomes of Percutaneous Vertebroplasty in 673 Patients

Percutaneous vertebroplasty (PVP) is a minimally invasive procedure to treat back pain secondary to osteoporotic vertebral compression fractures (VCF). This study aims to review our techniques and outcomes in patients with VCF. Outcomes of all patients who underwent PVP at our institution from 1998 to 2014 were retrospectively collected from medical records and follow-up telephone interviews. 1174 PVP procedures for VCF in 673 patients were identified to have complete follow-up data. Patients with inadequate data were excluded from the analysis. Procedural aspects such as unipedicular or bipedicular access, vertebral region treated, amount of cement injected into vertebrae, number of levels treated at a single session, refracture rates and location, presence of a necrotic cavity, and pain outcomes were examined. Excellent rates of improvement of back pain for both single level and multilevel PVP were achieved in 92% of patients. Unipedicular or bipedicular approach, cement volume, vertebral region treated, cement extravasation, and presence of a necrotic cavity did not affect pain outcomes or refracture rates. Fractures that did develop after PVP were often adjacent and occurred earlier than distant level fractures. Lumbar vertebrae required more cement than thoracic vertebrae. PVP provides excellent rates of pain relief in both single and multilevel procedures. The procedural aspects evaluated did not affect pain outcome or refracture rates. Adjacent refractures tended to occur sooner than distant ones.

Spinal Arteriovenous Metameric Syndrome: Angioarchitecture and their Prognosis

The term “spinal arteriovenous metameric syndrome” (SAMS) is relatively new and is derived from craniofacial arteriovenous metameric syndrome (CAMS),[1][1] which was introduced to designate a rare form of vascular malformation involving both brain and face. SAMS includes all spinal vascular