William Sorby

Combined Endovascular Stent Implantation and Endosaccular Coil Placement for the Treatment of a Wide-necked Vertebral Artery Aneurysm: Technical Case Report

OBJECTIVE AND IMPORTANCE We describe a case in humans of the combined application of endovascular stent placement and Guglielmi detachable coil packing in the management of a wide-necked intracranial aneurysm. CLINICAL PRESENTATION A 56-year-old woman suffered a subarachnoid hemorrhage secondary to a large wide-necked left vertebral artery aneurysm. Because of the size of the neck of the aneurysm and the extent of its calcification evident on computed tomographic scans, it was deemed unsuitable for surgical intervention or for conventional endovascular coiling. Instead, a combined surgical and endovascular therapy was instituted. INTERVENTION The left vertebral artery was surgically exposed and cannulated to allow for the placement of an endovascular stent across the neck of the aneurysm to act as a buttress against which Guglielmi detachable coils could be packed. The patient suffered no ill effects as a result of this procedure and made a slow but steady recovery. CONCLUSION This report describes a case of a wide-necked intracranial artery aneurysm treated using a combination of endovascular stent implantation across an aneurysm neck and endosaccular coil placement to obliterate the aneurysm. The technique described provides another treatment to better manage the difficult entity of wide-necked intracranial aneurysms that may be unsuitable for clipping.

Angioplasty and Stenting in the Posterior Cerebral Circulation

Purpose: To report initial experience with intracranial vertebral artery (VA) and basilar artery (BA) percutaneous transluminal angioplasty (PTA) and stenting. Methods: Eleven patients (10 men; mean age 66 years, range 56–75) with intracranial 14 VA and 3 BA stenoses were managed from December 1997 through November 1999. All patients presented with vertebrobasilar ischemia (VBI) despite antiplatelet and anticoagulant therapy. Clinical presentations included visual disturbance (n = 8), dysarthria/dysphasia (n = 5), and vertigo (n = 5). Results: Five patients underwent PTA only of 7 lesions with a mean preprocedural stenosis of 80% (range 50%–90%) that was reduced to 54% (range 30%–70%) after dilation. Six patients received 9 stents, 2 for VA dissections, 3 for tandem lesions, and 1 for a BA lesion. There were no embolic strokes. Patients were followed by clinical evaluation and personal or telephone interviews. Over a mean 18-month follow-up (range 12–35), 8 (73%) patients remained asymptomatic, while 3 (27%) had permanent deficits, 2 related to the procedure and 1 owing to distal disease Conclusions: Intracranial VA or BA angioplasty and stenting alleviated symptoms in patients with vertebrobasilar ischemia despite best medical management and may prevent stroke.

Outcome of aneurysmal subarachnoid haemorrhage following the introduction of papaverine angioplasty

This is a prospective study reporting the impact of angiographic vasospasm on the outcome following aneurysmal subarachnoid haemorrhage utilising a common regimen that includes nimodipine and angioplasty. The first 100 patients suffering an aneurysmal subarachnoid haemorrhage treated by surgery and this angioplasty driven protocol are reviewed. Angiography was performed if the Glasgow Coma Score (GCS) fell by two, a focal neurological deficit developed, hyponatraemia was detected, or routinely on days 5-7 following the subarachnoid haemorrhage. Angioplasty with papaverine was administered intra-arterially in all patients with significant angiographic vasospasm. Neurological deficits on admission were not present in 49% and associated with a GCS less than 14 in 38%. Angiographic vasospasm was detected in 48% of patients (all of whom received papaverine). Overall 3 month outcome was normal in 60%, neurological deficit but independence with regard to activities of daily living in 18%, loss of independence in 17%, and death in 5% of cases. Analysis of admission neurological condition (GCS < vs GCS > 13), presence of angiographic vasospasm, aneurysm size (less than or greater than 1.5 cm), and aneurysm circulation (anterior vs posterior) on outcome (normal vs abnormal) found that only admission neurological condition significantly influenced outcome (P < 0.0001). The results suggest that with the protocol of nimodipine and angioplasty the impact of vasospasm on outcome is far less significant than the clinical severity of the initial haemorrhage. This is in contradistinction to the experience with aneurysmal subarachnoid haemorrhage prior to this regimen (nimodipine and angioplasty) where vasospasm was the most significant determinant of a poor outcome.

Intra-arterial papaverine in the management of cerebral vasospasm following subarachnoid haemorrhage

Abstract Between July 1992 and January 1993 a prospective pilot study of the efficacy of intra-arterial papaverine in the management of clinically significant angiographically confirmed cerebral vasospasm arising as a consequence of aneurysmal subarachnoid haemorrhage was conducted. During this period 40 patients were managed with aneurysmal subarachnoid haemorrhage. All patients were treated with nimodipine from day of admission and carefully monitored in the neurosurgical intensive care unit. 11 of the 40 patients subsequently developed clinically significant angiographically confirmed cerebral vasospasm and underwent angiography with selective internal carotid or vertebral artery injection of papaverine in 12 to 40 mg boluses to a maximum of 450 mg. A good angiographic response was seen in all cases. Two patients underwent repeat procedures, in one case twice. Overall clinical outcome was good in 7 cases, moderate disability in 2 cases, severe disability in 1 case and death in 1 case. In patients who underwent the procedure in less than 4 hours from the onset of their deficits (n=8) a good outcome was seen to occur in 7 patients with one patient sustaining a moderate deficit. Complications from the procedure were seizures in 3 patients and a momentary locked-in-syndrome in one case. All complications were seen with a fast bolus of the higher volume papaverine and have not occurred with a slow infusion of the lower dose boluses. None of the patients developing these complications had them recur outside the angiogram suite. Our conclusion is that this form of treatment supplements the therapeutic regimens now available in the management of cerebral vasospasm.

Combined Endovascular and Open Surgery for Four-Vessel Cerebrovascular Occlusive Disease

Purpose: To report a case of bilateral simultaneous percutaneous transluminal angioplasty and stenting of the intracranial vertebral arteries prior to staged bilateral carotid endarterectomy. Case Report : A 68-year-old man presented with a 3-month history of recurrent, intermittent left-sided weakness and diplopia. Imaging defined bilateral 80% to 99% internal carotid artery stenoses and >90% stenoses of both distal vertebral arteries at the level of the foramen magnum. Bilateral intracranial vertebral artery stenting was performed, followed by staged carotid endarterectomies. No complications occurred, and the patient recovered uneventfully from all 3 procedures. He remains symptom- and event-free 20 months later. Conclusions: Our initial success in this case indicates a role for percutaneous transluminal angioplasty and stenting as an alternative to open surgery for intracranial vertebral artery stenosis.

Management of small arteriovenous malformations of the brain.

A consecutive series of arteriovenous malformations of the brain, no greater than 3 cm in diameter, referred to the author between January 1989 and October 1994 is reviewed. Of these 42 cases 39 underwent surgical excision of the lesion. The surgical group had mortality, 2.5% morbidity and 100% angiographic cure. Surgery in non-eloquent brain (n=21) resulted in no neurological morbidity and surgery in eloquent brain (n=18) resulted in a 5.5% neurological morbidity. The reason for not operating in three cases was elderly age in one, poor neurological condition in one, and involvement of the posterior limb of the internal capsule in one. Arteriovenous malformations with diameters no greater than 3 cm are considered by some to be suitable for treatment by focussed irradiation. However, surgery is likely to remain the more effective and safer mode of treatment for the majority of cases when factoring in the expected complications of focussed irradiation during the latency period. These risks are discussed.

Surgical management of dural arteriovenous malformations of the cranium

Ten patients undergoing surgical treatment of dural arteriovenous malformations of the cranium between June 1992 and June 1995 are presented. Indications for surgery were prevention of intracranial haemorrhage in eight cases and palliation of neurological deficits in two cases. The aim of surgery was attempted complete cure when considered technically feasible. Six patients underwent aggressive surgical resection in an ablation attempt and four underwent leptomeningeal venous disconnection only. In those undergoing aggressive surgical resection, one patient died, one was rendered disabled and angiographic cure was achieved in four without mishap. In those undergoing leptomeningeal venous disconnection, there was no mortality or morbidity but angiographic cure was achieved in only one of four patients. As a result of our experience our policy has changed. When the indications for surgery are to palliate leptomeningeal venous hypertension or as prophylaxis against future haemorrhage, interruption of the involved leptomeningeal venous drainage in the subarachnoid space without attempted cure is now the sole aim of surgery. The surgical technique employed should be based on the pathophysiological disturbance requiring correction rather than the resectability of the lesion.

Effective management of cerebral vasospasm with balloon angioplasty after failed papaverine angioplasty

A 37 year old male with symptomatic cerebral vasospasm complicating the rupture of a basilar tip aneurysm was initially treated with intra-arterial papaverine in conjunction with concomitant hypervolaemia and induced hypertension. However, the vasospasm was only moderately improved, with this effect lasting for less than 24 h. Following further administration of intra-arterial papaverine, without significant angiographic improvement, endovascular balloon dilatation of both vertebral arteries and basilar artery resulted in dramatic and sustained reversal of angiographic vasospasm. The patients clinical condition improved dramatically after this procedure, progressing from an unconscious state requiring ventilatory support, to a Glasgow Coma Score of 15 in the absence of focal neurological signs (with the exception of a right oculomotor palsy), within 9 days. This case suggests that there may be a role for balloon dilatation angioplasty, in patients who have cerebral vasospasm refractory to treatment with intra-arterial papaverine.