Xiaodong Xie

Traumatic Carotid-Cavernous Fistulas Treated with Covered Stents: Experience of 12 Cases

OBJECTIVE Covered stents have recently become available for intracranial use, such as aneurysms, arterial dissections and carotid-cavernous fistulas (CCFs). However, there have been few reports of the successful application of covered stents for the treatment of traumatic CCFs (TCCFs). The purpose of this study is to investigate the efficacy and safety of endovascular treatment of TCCFs with covered stent. METHODS Twelve consecutive patients with TCCFs treated with covered stent after initial failure of traditional techniques are presented. All the patients were followed up both clinically and angiographically for a mean of 22.5 months. RESULTS Eleven of the 12 patients had covered stents placed successfully. In one case, the covered stent placement failed after multiple attempts because of the tortuous anatomy of the internal carotid artery (ICA). Complete occlusion was achieved in nine cases immediately after stent deployment. Endoleak was observed in case 4 and redilation was performed to avoid the endoleak. In case 8, improved symptoms recurred the next morning, and cerebral angiogram revealed a small endoleak; redilation was performed to eliminate the endoleak successfully. Spasm of the ICA was observed in six cases, but angioplasty was not required. Symptoms improved in all cases after stent placement. Angiographic follow-up demonstrated complete occlusion of the TCCFs and patency of ICA, and no intra-stent stenosis or embolization occurred in the 11 patients who received successful stent placement. CONCLUSION Although larger sample and long-term follow-up are required, our series shows that covered stent is an effective, safe, and microinvasive method to treat TCCFs.

Application of covered stent grafts for intracranial vertebral artery dissecting aneurysms

OBJECT Utilization of covered stent grafts in treating neurovascular disorders has been reported, but their efficacy and safety in vertebral artery (VA) dissecting aneurysms needs further investigation. METHODS Six cases are presented involving VA dissecting aneurysms that were treated by positioning a covered stent graft. Two aneurysms were located distal to the posterior inferior cerebellar artery, and 4 were located proximal to the posterior inferior cerebellar artery. Aspirin as well as ticlopidine or clopidogrel were administered after the procedure to prevent stent-related thrombosis. All patients were followed up both angiographically and clinically. RESULTS Five of the 6 patients underwent successful placement of a covered stent graft. The covered stent could not reach the level of the aneurysm in 1 patient with serious vasospasm who died secondary to severe subarachnoid hemorrhage that occurred 3 days later. Patient follow-up ranged from 6 to 14 months (mean 10.4 months), and demonstrated complete stabilization of the obliterated aneurysms, and no obvious intimal hyperplasia. No procedure-related complications such as stenosis or embolization occurred in the 5 patients with successful stent graft placement. CONCLUSIONS Although long-term follow-up studies using a greater number of patients is required for further validation of this technique, this preliminary assessment shows that covered stent graft placement is an efficient, safe, and microinvasive technique, and is a promising tool in treating intracranial VA dissecting aneurysms.

Giant cavernous aneurysm associated with a persistent trigeminal artery and persistent otic artery.

Primitive trigeminal artery (PTA) and primitive otic artery (POA) is a very rare entity in adult life. We present a case of PTA and POA associated with a giant unruptured cavernous aneurysm in a 54-year-old woman. The PTA and the POA arose from the sac of the aneurysm directly, which greatly complicated endovascular therapy management.

Embolization of a bleeding maxillary arteriovenous malformation via the superficial temporal artery after external carotid artery ligation.

We report a new approach of embolization in a 15-year-old boy that presented with a massive hemorrhage from a maxillary arteriovenous malformation. Rebleeding occurred after emergent ligation of the external carotid artery. The bleeding was successfully controlled by embolization via the superficial temporal artery.

Congenital Pial Arteriovenous Fistula in the Temporal Region Draining into Cavernous Sinus: A Case Report

This report concerns a 4-month-old infant with progressive prominent and redness of his left eye since birth. This report concerns a 4-month-old infant with progressive prominent redness of his left eye since birth. Angiography revealed a congenital pial arteriovenous fistula between the temporal branch of the left posterior cerebral artery and left cavernous sinus through the sphenoparietal sinus, a condition not reported in the literature. The fistula was successfully occluded with two micro-coils by vertebrobasilar approach.

Transcatheter Embolization of a Ruptured Internal Pudendal Artery Pseudoaneurysm in a Patient with Neurofibromatosis Type 1

Neurofibromatosis type 1 (NF-1) is an autosomal dominant disorder. Pseudoaneurysms formation and rupture is an unusual complication of neurofibromatosis. To date, pseudoaneurysm of the internal pudendal artery associated with NF-1 has not been reported. In this article, we present a 62-yr-old man with NF-1 suffering from spontaneous hematoma of the perinea and scrotum. A digital substraction angiography disclosed a ruptured pseudoaneurysm of the right internal pudendal artery, which was successfully managed with transcatheter embolization.

Microsurgical versus Endovascular Treatments for Blood-Blister Aneurysms of the Internal Carotid Artery: A Retrospective Study of 83 Patients in a Single Center

BACKGROUND Blood-blister aneurysms (BBAs) of the internal carotid artery (ICA) are challenging lesions with high morbidity and mortality. Both surgical and endovascular approaches have been used to treat BBAs; however, little is known about their safety and efficacy. OBJECTIVE To review our experience with the treatment of BBAs and explore the optimal treatment strategy. METHODS A total of 83 patients with BBAs were reviewed retrospectively. The characteristics of the patients and the aneurysms, treatment results, and follow-up outcomes were analyzed. RESULTS The cohort comprised 52 females and 31 males with a mean age of 46.6 years; 33 patients were assigned to the microsurgical therapy. Subsequently, 27/33 patients underwent surgical clipping, 4/33 underwent trapping without bypass, 2/33 underwent wrapping, and 50 patients underwent endovascular therapy, including stent-assisted coiling (49 patients) and coiling (1 patient). Intraoperative rupture occurred in 14 and 4 patients in the microsurgical and endovascular groups, respectively. Ischemic events occurred in 16 and 8 patients in the microsurgical and endovascular groups, respectively. At 1-year follow-up, a favorable clinical outcome was achieved in 18 (54.5%) and 38 (76.0%) patients in the microsurgical and endovascular groups, respectively. The multivariate regression model showed that the treatment strategies, Fisher grade, and vasospasm contributed significantly to the prediction of outcome for 1 year. CONCLUSIONS BBAs are challenging vascular lesions with poor prognosis. Endovascular treatment may be more effective and safer with better outcomes than surgical approaches.

Rupture of vertebral artery dissection aneurysm during 3D DSA

A 60-year-old man with a history of headache and vomiting had a subarachnoid hemorrhage on CT scan. On 2-dimensional (2D) digital subtraction angiography (DSA), a possible dissection aneurysm of the vertebral artery was seen (video 1 on the Neurology® Web site at Neurology.org). During 3D DSA, the aneurysm suddenly ruptured (video 2), with intracranial hemorrhage. The pressure of contrast was 200 psi, the rate was 2 mL/s, with a total volume of 12 mL. The patient was transferred to the intensive care unit but died of brain herniation and vasospasm. Few dissection aneurysms rupture during 3D DSA, but the risk is likely attributable to continuous contrast hyperperfusion at high pressure.

The application of the Willis covered stent in the treatment of carotid-cavernous fistula: a single center experience

BACKGROUND The purpose of the present study was to describe our single-institutional experience of treating direct carotid-cavernous fistulas (DCCFs) with Willis covered stents (WCSs). METHODS Of a total of 31 DCCFs, 10 were treated with WCSs (Microport, Shanghai, China) at West China Hospital from January 2015 to December 2016. The indications for treatment, perioperative findings, and postoperative and follow-up results were collected and analyzed. RESULTS All 10 patients had successful deployment of WCSs. Complete exclusion of the fistula was achieved in 6 patients immediately after deployment of 1 stent. Endoleak was observed in 4 patients (patients 2, 4, 5, and 9). Thus, repeat dilation of the stent with greater pressure was performed, which resolved the endoleak in 2 patients (patients 2 and 9). The endoleak of the other 2 patients persisted after repeat dilation of the balloon. Hence, a second stent was deployed in these 2 patients (patients 4 and 5), which eliminated the endoleak in patient 4. However, patient 5 continued to have a minimal endoleak. Nine patients had fistulas successfully occluded by WCSs during the follow-up period. One patient experienced recurrence of a DCCF at the 10-day follow-up point. We chose coil embolization to address this DCCF. No stenosis of the internal carotid artery or DCCF recurrence, except that in the abovementioned patient, was observed. CONCLUSIONS WCS was proved to be an alternative treatment method for complex DCCFs through reconstruction and preservation of the internal carotid artery. Our study also confirmed the safety, efficacy, and midterm durability of WCSs for complex DCCFs without any serious delayed complications.

Angiographic Appearance of Pulsatile Blister Aneurysm

A male with detected subarachnoid hemorrhage was admitted to our center. During the first angiography, a pulsatile blister aneurysm was revealed and the aneurysm was also noticeably enlarged during the surveillance angiography. The patient accepted balloon-assisted clipping successfully. Blister aneurysms are at a high risk of rupture, high risk of regrowth, and need for multimodal management.