Rufus Corkill

Embolization of spinal intramedullary arteriovenous malformations using the liquid embolic agent, Onyx: a single-center experience in a series of 17 patients

OBJECT The aim of this study was to analyze the endovascular treatment results of using the Onyx liquid embolic system for spinal intramedullary arteriovenous malformations (AVMs). METHODS The clinical and radiological records of 17 patients with symptomatic spinal intramedullary AVMs treated exclusively by embolization with Onyx between 1999 and 2003 were retrospectively reviewed. There were 12 females and five males in the patient series (mean age 29 years). Four of these AVMs were located in the cervical spine, eight in the thoracic spine, and five in the lumbar spine. The clinical presentation of these AVMs included upper motor neuron signs and symptoms, and hemorrhage was the initial presentation in 12 patients. Neurological and functional evaluation was performed before and after treatment with Onyx in all patients. RESULTS Thirteen patients underwent a single endovascular treatment and four patients underwent two endovascular treatments (average 1.23 sessions per patient). Intraprocedural complications occurred on two occasions without neurological consequences. The mean follow-up duration was 24.3 months. Angiographic outcomes included total AVM obliteration in six patients (37.5%), subtotal obliteration in five patients (31.25%), and partial obliteration in five patients (31.25%). Improvement in neurological and/or functional status was noted in 14 patients, resulting in an 82% rate of overall good clinical outcome. CONCLUSIONS Embolization using the Onyx system is a promising treatment method for spinal vascular malformations, even for challenging intramedullary AVMs. Larger studies with longer follow-up durations will further enhance our knowledge on the safety and efficacy of this relatively new liquid embolic agent.

Endovascular treatment of very small intracranial aneurysms.

OBJECT Endovascular treatment of very small aneurysms poses a significant technical challenge for endovascular therapists. The authors review their experience with a series of patients who had intracranial aneurysms smaller than 3 mm in diameter. METHODS Between 1995 and 2006, 97 very small aneurysms (defined for purposes of this study as < 3 mm in diameter) were diagnosed in 94 patients who were subsequently referred for endovascular treatment. All patients presented after subarachnoid hemorrhage, which was attributed to the very small aneurysms in 85 patients. The authors reviewed the endovascular treatment, the clinical and angiographic results of the embolization, and the complications. RESULTS Five (5.2%) of the 97 endovascular procedures failed, and these patients underwent craniotomy and clip ligation. Of the 92 aneurysms successfully treated by coil embolization, 64 (69.6%) were completely occluded and 28 (30.4%) showed minor residual filling or neck remnants on the immediate postembolization angiogram. Complications occurred in 7 (7.2%) of 97 procedures during the treatment (3 thromboembolic events [3.1%] and 4 intraprocedural ruptures [4.1%]). Seventy-six patients were followed up angiographically; 4 (5.3%) of these 76 showed angiographic evidence of recanalization that required retreatment. The clinical outcomes for the 76 patients were also graded using the Glasgow Outcome Scale. In 61 (80.3%) cases the outcomes were graded 4 or 5, whereas in 15 (19.7%) they were graded 3. Seven patients (7.4%) died (GOS Grade 1), 2 due to procedure-related complications (intraoperative rupture) and 5 due to complications related to the presenting subarachnoid hemorrhage. CONCLUSIONS Endosaccular coil embolization of very small aneurysms is associated with relatively high rates of intraprocedural rupture, especially intraoperative rupture. With the advent of more sophisticated endovascular materials (microcatheters and microguidewires, soft and ultrasoft coils, and stents) endovascular procedures have become feasible and can lead to a good angiographic outcome.

Ruptured fusiform aneurysm of fenestrated A1 segment of the anterior cerebral artery : Case report and review of the literature

We present a case report of a 56-year-old woman with a ruptured fusiform aneurysm of a fenestrated A1 segment of the anterior cerebral artery (ACA). Fenestrated A1 segments are rare and only a few case reports have been published of a saccular type aneurysm formation. To the best of our knowledge, there have been no documented cases of fusiform aneurysms in these segments.

Non-invasive assessment of vasospasm following aneurysmal SAH using C-arm FDCT parenchymal blood volume measurement in the neuro-interventional suite: Technical feasibility.

Introduction Cerebral vasospasm is the leading cause of morbidity and mortality in patients with aneurysmal subarachnoid haemorrhage (SAH) surviving the initial ictus. Commonly used techniques for vasospasm assessment are digital subtraction angiography and transcranial Doppler sonography. These techniques can reliably identify only the major vessel spasm and fail to estimate its haemodynamic significance. To overcome these issues and to enable comprehensive non-invasive assessment of vasospasm inside the interventional suite, a novel protocol involving measurement of parenchymal blood volume (PBV) using C-arm flat detector computed tomography (FDCT) was implemented. Materials and methods Patients from the neuro-intensive treatment unit (ITU) with suspected vasospasm following aneurysmal SAH were scanned with a biplane C-arm angiography system using an intravenous contrast injection protocol. The PBV maps were generated using prototype software. Contemporaneous clinically indicated MR scan including the diffusion- and perfusion-weighted sequences was performed. C-arm PBV maps were compared against the MR perfusion maps. Results Distribution of haemodynamic impairment on C-arm PBV maps closely matched the pattern of abnormality on MR perfusion maps. On visual comparison between the two techniques, the extent of abnormality indicated PBV to be both cerebral blood flow and cerebral blood volume weighted. Conclusion C-arm FDCT PBV measurements allow an objective assessment of the severity and localisation of cerebral hypoperfusion resulting from vasospasm. The technique has proved feasible and useful in very sick patients after aneurysmal SAH. The promise shown in this early study indicates that it deserves further evaluation both for post-SAH vasospasm and in other relevant clinical settings.

More than meets the MRI: case report of a carcinoid tumour metastasis mimicking a meningioma

Abstract Cerebral metastases from carcinoid tumours are rarely reported and confer a much poorer prognosis than carcinoid metastases elsewhere in the body. We describe a case of carcinoid brain metastasis closely resembling a meningioma on magnetic resonance imaging (MRI), and review current treatment options.

Solitary Fibrous Tumour of the Face: A Rare Case Report

Solitary fibrous tumour is an uncommon neoplasm that arises predominantly from within the pleura. Extrapleural manifestation of solitary fibrous tumour, particularly in the head and neck area, is extremely rare. Here, we report a solitary fibrous tumour of the face in a 40-year old woman. The tumour was removed with a radiological combined approach, with embolisation of tumour blood vessels prior to excision. Eight months following surgery, the patient is well and free of disease.

Correction to: Stent placement in patients with acute subarachnoid haemorrhage: when is it justified?

In the original version of this article one author name was published incorrectly: Tanja Ddjurdjevic has been corrected to Tanja Djurdjevic.

Basic Principles and Simple Techniques

The incidence of spontaneous aneurismal subarachnoid hemorrhage is 6–10 per 100,000 patients per year, and the prevalence of intracranial aneurysms is between 1 and 5 % of the population. This suggests that 0.2–1 in 100 aneurysms rupture each year. One third of patients who have a subarachnoid hemorrhage will die before they get to a hospital, and another third will die within a month as a result of the damage done at the time of the bleed. Aneurismal rebleeding is the greatest risk to life. This has two peaks of increased risk: in the early and subacute phases within 24 h and at 7–10 days. If left unsecured, about 25 % will rebleed in the first 2 weeks and two-thirds within the first 2 months. Treatment options include supportive resuscitation, neurosurgical clipping, and endovascular therapy.