Razvan Buciuc

Transarterial balloon assisted Onyx embolization of pericallosal arteriovenous malformations

Summary Preliminary experience using a balloon assisted technique (BAT) for embolization of arteriovenous malformations (AVM) is reported. Two patients with large pericallosal AVMs were successfully embolized with Onyx under Scepter C balloon catheter flow arrest. Clinical presentation One patient presented with a large intraventricular hemorrhage and hydrocephalus. The second patient presented with a long history of seizures and a small intracerebral hemorrhage. Both patients demonstrated extensive interhemispheric AVMs with multiple arterial feeders, predominantly from the pericallosal arteries. Intervention A Marathon microcatheter was navigated into the target arterial feeders and a Scepter C occlusion balloon catheter was inflated immediately proximal. Under flow arrest, Onyx was injected via the microcatheter with excellent nidal penetration. In both cases, there was complete angiographic obliteration of the treated component of the AVM. Conclusions Onyx embolization under balloon catheter flow arrest allows for greater nidal penetration of embolic material and improved reflux control. The technique is limited by the current deliverability of balloon catheters and the potential risk for earlier embolization of dangerous anastomosis.

Carotid cavernous fistulae occurring after the use of the Fogarty catheter in carotid surgery: a review.

The Fogarty catheter represents a major advancement for the effective removal of distal thrombi during vascular surgery, including carotid endarterectomy (CEA). One complication related to its use is injury to the cavernous carotid artery with development of a carotid cavernous fistula (CCF). Including a recent case at our institution, 21 patients with a Fogarty-related CCF have been reported since 1967. We performed a detailed review of all Fogarty-related CCFs during the treatment of carotid occlusive disease. We suggest a management algorithm for post-CEA acute carotid occlusion.

Endovascular embolization of prominent intercavernous sinuses for successful transsphenoidal resection of Cushing microadenoma: case report.

BACKGROUND AND IMPORTANCE: Prominent intercavernous sinuses may result in vigorous bleeding during transsphenoidal resection of pituitary microadenomas and lead to incomplete or aborted tumor resection. We report the use of coil embolization of the intercavernous sinuses to prevent uncontrollable bleeding before transsphenoidal surgery is reattempted. CLINICAL PRESENTATION: A 40-year-old man with Cushing disease underwent an attempt for transsphenoidal resection of an adrenocorticotrophic hormone--producing pituitary microadenoma. This approach was aborted secondary to profuse intercavernous sinus bleeding. The patient underwent endovascular coil embolization of the anterior intercavernous sinuses with complete obliteration. Six weeks later, he underwent successful transsphenoidal resection of the microadenoma. CONCLUSION: To the best of our knowledge, this is the first report of successful coil embolization of the intercavernous sinuses to prevent uncontrolled bleeding before transsphenoidal resection of pituitary microadenomas. ABBREVIATION: ACTH, adrenocorticotrophic hormone

Percutaneous placement of an external drain of the cisterna magna using interventional magnetic resonance imaging in a patient with a persistent cerebrospinal fluid fistula: technical case report.

OBJECTIVECerebrospinal fluid diversion from the cisterna magna has been described previously but has largely been abandoned because of high complication rates and anatomic constraints. Situations still remain in which this may be the best or only alternative. We describe the use of interventional magnetic resonance imaging (iMRI) for the application of this largely forgotten procedure. PRESENTATIONA 28-year-old woman with a previously diagnosed malignant peripheral nerve sheath tumor of the thoracic spine presented with a refractory postoperative cerebrospinal fluid leak complicated by diffuse meningeal carcinomatosis. External lumbar drainage was unsuccessful because of complete tumor obliteration. An attempt at primary closure augmented with muscle flaps was also ineffective. Ventricular drainage was deferred because of concern for tumor seeding, thus necessitating a more aggressive approach. TECHNIQUEThe patient was intubated and placed in the open iMRI portal in a lateral decubitus position. Under direct image guidance, a closed-tip lumbar catheter was inserted into the cisterna magna through an iMRI-compatible biopsy needle and then connected for external drainage. CONCLUSIONTo our knowledge, this is the first described use of iMRI technology for catheterization of the cisterna magna for cerebrospinal fluid diversion. Moreover, iMRI technology should be considered in future applications of complex posterior fossa shunting procedures.

Balloon-assisted coiling of the proximal lobule of a paraophthalmic aneurysm causing panhypopituitarism: Technical case report

Background: We describe an intra-aneurysmal balloon-assisted technique to limit the coil volume in a large bilobulated paraophthalmic aneurysm. Our intent was to reduce the mass effect and presenting symptoms of diabetes insipidus (DI) with hypopituitarism. Case Description: A 32-year-old woman presented with symptoms of DI and her work-up demonstrated hypopituitarism and partial bitemporal visual field defects. Cerebral angiography revealed a large paraophthalmic aneurysm with two distinctive lobules, projecting toward the pituitary fossa. The patient declined craniotomy but consented for endovascular treatment. The plan was to limit the embolization to the proximal lobule only. Initially, we used a dual microcatheter technique with a microcatheter in each lobule. A framing coil in the distal lobule did not prevent coil migration from the proximal lobule. Instead, we elected to use a Hyperform balloon in the distal lobule and were able to successfully coil the proximal lobule only. Her 3-year follow-up angiogram revealed a completely occluded aneurysm. The patient experienced resolution of the DI and improvement of her visual fields. However, she remained in hypopituitarism. Conclusion: Intra-aneurysmal balloon-assisted coiling of proximal aneurysmal lobules might be an alternative for the reduction of mass effect related to the coil mass. Careful follow-up is needed because subtotal occlusion carries a future risk of growth, recanalization and rupture. Unruptured intracranial carotid aneurysms can present with reversible DI and usually permanent pituitary disturbances.

Advanced Imaging Assessment of Posterior Circulation Stroke Before and After Endovascular Intervention

BackgroundPerfusion-computed tomography (CTP) is a relatively new technique that allows rapid semiquantitative noninvasive evaluation of cerebral perfusion aiding in the diagnosis of cerebral ischemia and infarction. There is a paucity of data on its application within the posterior circulation, especially, the brainstem. We describe a case of basilar artery thrombosis with cerebellar and brainstem CTP mismatch and discuss possible future applications of CTP for acute posterior fossa circulation and infarction.MethodsCase report.ResultsSuccessful use of CTP to aid in decision to proceed with neurointervention in acute basilar artery occlusion and confirm its resolution after mechanical clot retrieval.ConclusionPerfusion-computed tomography can successfully be used to define cerebral ischemia and infarction within the posterior fossa and aid in decisions to proceed with neurointervention.

Aortic response to balloon-injury in the obese Zucker rat: a translational animal model for endovascular interventions

Background: The small diameter of the carotid balloon-injury (BI) model impedes the evaluation of available endovascular devices. We developed an endovascular BI model in the rat’s descending aorta that is compatible with available endovascular instruments. This study also tested the hypothesis that neointimal formation is enhanced in the aorta of obese Zucker (OZ) rats. Methods: Left external carotid arteriotomies and BI of the thoracic and abdominal aorta were performed using a Gateway balloon catheter. Aortograms and aortic pathology were examined at 2, 4 and 10 weeks. Results: Ten weeks after BI the OZ abdominal aorta narrowed 8.34 ± 1.10 % vs. an expansion of 2.36 ± 2.24 % in the lean rat (LZ) (p < 0.001). Simultaneously, the LZ thoracic aorta expanded 9.50 ± 4.27 % vs. a stenosis of 2.78 ± 1.65 % in the OZ (p = 0.003). A significant increase in neointimal formation, as measured by the intima to media (I:M) ratio, was observed in the OZ descending aorta (p <0.001). Conclusions: This is a minimally invasive BI model to the rat’s descending aorta compatible with available endovascular instruments. Following BI the OZ descending aorta demonstrates enhanced neointimal formation and constrictive vascular remodeling.

P-022 Endovascular revascularization of carotid artery using a flow reversal device

Introduction Surgical carotid revascularization has been described with various degrees of technical and clinical success. Currently, carotid revascularization is not recommended, based on the high potential for embolic stroke during the procedure. The data is however limited to only surgical cases. One series of endovascular revascularization for occluded carotids of unknown length of time has already been communicated. The authors present a similar series using a flow reversal device. Method During the period of February 2009 to November 2011 a total of 13 patients underwent endovascular revascularization of either single or both occluded carotid arteries. The procedure was done in all cases using a flow reversal system (the Gore flow reversal) In three cases the procedure had to be aborted due to the fact that the occluded segment included part of the supraclinoid carotid. In the rest of cases the procedure was technically feasible succesfully. After revascularization all patients underwent stenting of their extracranial carotids. Two patients had either bilateral occlusions or presented with a non-disabling stroke due to a severe stenosis on one side and a chronic occlusion on the other. In these cases the revascularizations have been performed in stages with a 2–3 month interval in between interventions. Results There were no neurologic complications related to the procedure either in the successful or in the aborted cases. Two patients developed large inguinal hematomas and had to be transfused. Conclusion The endovascular revascularization of carotid artery occlusion of unknown duration is feasible using a flow reversal device. Addditional information regarding clinical and imaging indications for the procedure is necessary in order to proper select patients that might benefit. Long term follow-up will also be necessary in order to assess the viability of re-opened carotids as well as risks for stroke in patients after this procedure. Competing interests None.