Michael Horowitz

Transluminal Stent-assisted Angioplasty of the Intracranial Vertebrobasilar System for Medically Refractory, Posterior Circulation Ischemia: Early Results

OBJECTIVE Symptomatic vertebrobasilar artery stenosis portends a poor prognosis, even with medical therapy. Surgical intervention is associated with considerable morbidity, and percutaneous angioplasty alone has demonstrated mixed results, with significant complications. Recent advances in stent technology have allowed for a novel treatment of symptomatic, medically refractory, vertebrobasilar artery stenosis. We report on a series of patients with medically refractory, posterior circulation stenosis who were treated with transluminal angioplasty and stenting at two medical centers in the United States. METHODS A retrospective analysis of data for 11 consecutive patients with symptomatic, medically refractory, intracranial, vertebral or basilar artery stenosis was performed. All patients were treated with percutaneous transluminal angioplasty and stenting. Short-term clinical and angiographic follow-up data were obtained. RESULTS Among 11 patients who were treated with stent-assisted angioplasty of the basilar or vertebral arteries, there were three periprocedural deaths and one delayed death after a pontine stroke. Other complications included a second pontine infarction, with subsequent residual diplopia. The remaining seven patients (64%) experienced symptom resolution and have resumed their preprocedural activities of daily living. Angiographic follow-up examinations demonstrated good patency of the stented lesions for five of seven survivors (71%); one patient exhibited minimal intrastent intimal hyperplasia, and another patient developed new stenosis proximal to the stent and also developed an aneurysm within the stented portion of the basilar artery. The last patient exhibited 40% narrowing of the treated portion of the vessel lumen. CONCLUSION Recent advances in stent technology allow negotiation of the proximal posterior circulation vasculature. Although the treatment of vertebrobasilar artery stenosis with angioplasty and stenting is promising, long-term angiographic and clinical follow-up monitoring of a larger patient population is needed.

Posteroinferior cerebellar artery aneurysms: Surgical results for 38 patients

OBJECTIVE Posteroinferior cerebellar artery aneurysms have an incidence of approximately 0.49%. Reports in the literature are sparse concerning outcomes in this patient population. We report our results for 38 consecutive patients who were treated during the last 6.5 years. METHODS All patients (n = 38) with posteroinferior cerebellar artery aneurysms that were surgically treated at Zale-Lipshy University Hospital between January 1990 and May 1997 were retrospectively reviewed. Data were collected and analyzed relating to demographics, condition at presentation, lesion characteristics, associated medical problems, postsurgical complications, and outcome. RESULTS Sixty-six percent of the patients (n = 25) experienced neurological sequelae, which included symptomatic vasospasm, hydrocephalus, dysarthria, paresis, diplopia, ataxia, and facial paralysis. Many, however, showed significant improvement during their hospitalization and during the course of the ensuing year. Seventy-four percent of the patients had a Glasgow Outcome Scale score of 1 or 2 at the time of discharge, 91% at 6 months after surgery, and 89% at 1 year after surgery. CONCLUSION This review summarizes the presentations and outcomes of 38 consecutive surgical cases during a 6.5-year period and concludes that posteroinferior cerebellar artery aneurysms are not benign entities. The study does, however, also demonstrate that patients have significant recuperative potential after the treatment of these lesions.

Percutaneous transluminal angioplasty and stenting of midbasilar stenoses: three technical case reports and literature review.

OBJECTIVE AND IMPORTANCE Symptomatic basilar artery stenosis is a highly morbid disease process. Recent technological and pharmaceutical advances make endovascular treatment of this disease process possible. CLINICAL PRESENTATION We report three cases of patients with a symptomatic basilar artery stenosis despite anticoagulation. INTERVENTION All patients were successfully treated with a flexible coronary stent and perioperative antiplatelet medications without incident. Poststenting angiography demonstrated a normal-caliber artery with patent perforators. In one case, a poststenting cerebral blood flow study revealed improved perfusion. CONCLUSION A new generation of stents and balloons makes access to intracranial intradural arterial pathological abnormalities possible. Such devices may well revolutionize the management of ischemic and hemorrhagic intracranial cerebrovascular disease.

Aneurysm retreatment after Guglielmi detachable coil and nondetachable coil embolization: Report of nine cases and review of the literature

OBJECTIVE Guglielmi detachable coil embolization of cerebral aneurysms is becoming increasingly used to manage certain intracranial lesions based on aneurysm geometry, patient condition, and patient and surgeon preferences. Aneurysm recurrences or incomplete initial treatments are not uncommon, making repeat treatment necessary using either surgical or endovascular techniques. METHODS Between January 1993 and June 1998, 1025 cerebral aneurysms were managed by the authors at a single hospital. One hundred twenty-four of these lesions were treated using Guglielmi detachable coils, and one was managed with nondetachable coils. During the follow-up period, eight patients who underwent embolization at our institution and one who underwent embolization elsewhere received repeat treatment. Five were approached surgically, and four underwent re-embolization. All charts and films were reviewed retrospectively to determine patient outcome and clinical success. RESULTS No patient in the subgroup of this clinical study suffered a permanent complication from initial aneurysm coiling, no episodes of subsequent bleeding occurred, and no complications resulted from any subsequent therapies. The anatomic results were excellent, and all aneurysms were totally or near totally obliterated. CONCLUSION Subtotal initial coil embolization of aneurysms can be managed safely using a variety of surgical and endovascular techniques. Our approach to this predicament, lessons we have learned, and a review of the literature are herein discussed.

Multidisciplinary approach to traumatic intracranial aneurysms secondary to shotgun and handgun wounds

BACKGROUND Traumatic intracranial aneurysms (TICAs) may develop following gunshot injuries to the head. Management of these lesions often combines various aspects of microneurosurgical and endovascular techniques to safely repair or obliterate vessel defects. METHODS We reviewed our experience over the last 18 years and identified five cases of intracranial aneurysms following gunshot and handgun wounds that were treated surgically and/or endovascularly. RESULTS All patients had successful obliteration of their lesions using a variety of therapeutic modalities aimed at preserving neurologic function while at the same time eliminating the aneurysm from the circulation. CONCLUSION Both microneurosurgery and endovascular surgery have important roles to play in the management of TICAs. In some cases, both methods can be combined to eliminate lesions and maximize patient recovery in a safe, efficient, and effective fashion.

Intraarterial thrombolysis for thromboemboli associated with endovascular aneurysm coiling. Report of five cases.

With the rapidly developing applications of GDC endovascular aneurysm embolization, the recognition and treatment of potential intra-procedural complications is crucial to reducing the morbidity and mortality of this procedure. Thromboembolic complications occur with an incidence of 2–11% with endovascular aneurysm coiling. We describe five cases in which the intraarterial use of thrombolytics was applied to disrupt a fresh clot and recanalize the occluded vessels with variable angiographic and clinical success. Five cases are presented in which thromboembolic complications occurred during or shortly after GDC endovascular aneurysm occlusion. The complication was recognized while depositing coils in two cases, on post-embolization angiogram in one, and a few hours following embolization in two cases in which a new neurologic deficit developed in the ICU. In those cases recognized while the microcatheter was near the aneurysm site, immediate thrombolysis was performed at the site of occlusion. The patients who developed a new neurologic deficit were returned to the endovascular suite and the site of occlusion was noted to be distal to the coiled aneurysm. Clot disruption was performed with the microcatheter before delivering intraarterial thrombolytics. Thromboembolic complications of GDC aneurysm embolization are fortunately rare and can be managed with delivery of thrombolytic therapy at the site of occlusion. Intraarterial thrombolysis of fresh clot caused by GDC aneurysm occlusion can successfully open the occluded vessels but not without serious risk of hemorrhage.

Assessment of Complication Types and Rates Related to Diagnostic Angiography and Interventional Neuroradiologic Procedures A Four Year Review (1993–1996)

We determined the types and rates of complications related to diagnostic angiography and neuroradiologic interventional procedures at a centre that carries out the full spectrum of angiographic procedures. The occurrence of immediate and delayed complications in 1929 neuroangiographic procedures (1358 diagnostic and 571 interventional) performed between the years 1993–1996 was prospectively identified and recorded on a daily basis. A retrospective review of all charts of patients having procedures conducted during the study period was also carried out to ensure that no complications were missed. The overall complication rate for diagnostic cerebral angiography was 2.2%. Puncture site complications ranged from 0 – 0.1%. Vessel injury distal to the puncture site ranged from 0.2 – 0.6%. The temporary neurologic complication rate was 0.3%, while the permanent rate was 0.4%. There were no contrast reactions. The death rate was 0.1%. Interventional procedures had higher incidences of complications with overall rates ranging from 5.3 – 33%. Temporary and permanent neurologic deficits occurred at a rate of 0 – 10.5% depending upon the procedure involved. Individual complication and death rates and complication categories are provided for arteriovenous malformation embolisation, tumour embolisation, temporary balloon occlusion tests, detachable balloon vessel sacrifice, urokinase infusion, angioplasty, papavarine infusion, GDC embolisation, and carotid cavernous fistula embolisation. When carried out in experienced hands, neuroangiography and neurointervention are relatively safe with low incidences of neurologic and non-neurologic complications. Knowledge of these rates is important when counselling patients prior to treatments or deciding upon the risk-benefit ratio of preoperative procedures.

Intracavernous carotid artery aneurysms: the possible importance of angiographic dural waisting. A case report.

BACKGROUND Cavernous carotid aneurysms are generally benign entities. Certain indications exist for their treatment, however, including transient ischemic events, subarachnoid hemorrhage or risk of subarachnoid hemorrhage, epistaxis or its risk, ophthalmoplegia, pain, and progressive visual loss. We feel certain angiographic features may indicate a greater likelihood that cavernous carotid aneurysms extend into the subarachnoid space, thus making their rupture a life-threatening event. METHODS A case report of an intracavernous carotid aneurysm, which at surgery extended into the subarachnoid space, is described. RESULTS In this particular case, deformation of the aneurysm (waisting) as seen at angiography was in retrospect an indication that the cavernous carotid aneurysm extended into the subarachnoid space, either through the dural ring or through the eroded dural roof of the cavernous sinus. This finding was verified at surgery when the lesion was explored and trapped. CONCLUSION Angiographic waisting of a cavernous carotid aneurysm may indicate that the aneurysm extends into the subarachnoid space. Such extension means that rupture would be a life-threatening event. While deformation of the aneurysm may be secondary to compression against the optic nerve or anterior clinoid process with an intact layer of dura overlying the aneurysm, the neurosurgeon confronted with such findings should analyze such lesions carefully and consider surgical exploration.

Radiation dermatitis after spinal arteriovenous malformation embolization: case report

Few cases of radiation injury related to lengthy interventional neuroradiologic procedures have been reported, although concern has been heightened, as evidenced by a 1994 FDA Public Health Advisory. We report a case of radiation-induced dermatitis in a patient undergoing multiple diagnostic and embolization procedures for treatment of a spinal arteriovenous malformation.

Subarachnoid hemorrhage during arteriovenous malformation embolization as a result of vessel wall “sandblasting”

OBJECTIVE Preoperative selective particulate embolization of arteriovenous malformations can make subsequent surgical resection of such lesions safer for the patient and easier for the surgeon. Nevertheless, embolization carries intrinsic risks, which include subarachnoid hemorrhage. We report two cases of subarachnoid hemorrhage during particulate embolization that we think was attributable to catheter positioning near a vessel curve and subsequent denudation of the vessel wall to the degree that hemorrhage was induced.