Atlas of Interventional Neurology

Atlas of Interventional Neurology Adnan I. Qureshi, MD, Editor Executive Director, Minnesota Stroke Initiative Asso...

Author: Adnan Qureshi

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Atlas of

Interventional Neurology

Adnan I. Qureshi, MD, Editor

Executive Director, Minnesota Stroke Initiative Associate Head, Department of Neurology Professor of Neurology, Neurosurgery, and Radiology Zeenat Qureshi Stroke Research Center University of Minnesota with

Alexandros L. Georgiadis, MD Associate Editor

Assistant Professor of Neurology, Zeenat Qureshi Stroke Research Center Minnesota Stroke Iniative University of Minnesota

Atlas of

Interventional Neurology

Visit our website at www.demosmedpub.com © 2009 Demos Medical Publishing, LLC. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher. Medicine is an ever-changing science. Research and clinical experience are continually expanding our knowledge, in particular our understanding of proper treatment and drug therapy. The authors, editors, and publisher have made every effort to ensure that all information in this book is in accordance with the state of knowledge at the time of production of the book. Nevertheless, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, express or implied, with respect to the contents of the publication. Every reader should examine carefully the package inserts accompanying each drug and should carefully check whether the dosage schedules mentioned therein or the contraindications stated by the manufacturer differ from the statements made in this book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Library of Congress Cataloging-in-Publication Data Atlas of interventional neurology / Adnan I. Qureshi with Alexandros L. Georgiadis. p. cm. ISBN-13: 978-1-933864-31-0 (alk. paper) ISBN-10: 1-933864-31-1 (alk. paper) 1. Cerebrovascular disease—Interventional radiology—Atlases. 2. Cerebrovascular disease—Endoscopic surgery—Atlases. I. Qureshi, Adnan I. II. Georgiadis, Alexandros L. RD594.2.A83 2009 617.4’810592—dc22

2008062550

Special discounts on bulk quantities of Demos Medical Publishing books are available to corporations, professional associations, pharmaceutical companies, health care organizations, and other qualifying groups. For details, please contact: Special Sales Department Demos Medical Publishing 386 Park Avenue South, Suite 301 New York, NY 10016 Phone:â•‡ 800–532–8663 or 212–683–0072 Fax:â•… 212–683–0118 Email:â•… [email protected]

08â•‡ 09â•‡ 10â•‡ 11â•…â•…â•… 5â•‡ 4â•‡ 3â•‡ 2â•‡ 1

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Dedications I dedicate this effort to my mother, Zeenat Qureshi, who taught me that one cannot place a price on education. It is worth every penny and all the effort; to my wife, Aasma, who always provided me with an objective and positive perspective of every situation; and to all my students who gave me a gift without parallel, the message of the future without bounds. Adnan Qureshi To my kids for inspiration, To my parents for support, To Viky for everything Alexandros Georgiadis

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Contents Foreword. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi Contributors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii List of Commonly Used Abbreviations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv

Chapter 1

Angioplasty and Stenting of the Extracranial Vessels. . . . . . . . . . . . 1

Chapter 2

Angioplasty and Stenting of the Intracranial Vessels. . . . . . . . . . . . 37

Chapter 3

Treatment of Acute Cerebral Ischemia. . . . . . . . . . . . . . . . . .å°“ . . . . . . 61

Chapter 4

Treatment of Aneurysms and Pseudoaneurysmal Lesions. . . . . . 105

Chapter 5

Treatment of Arterio-venous Malformations and Fistulas . . . . . . 157

Chapter 6

Treatment of Tumors. . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . . 193

Chapter 7

Treatment of Epistaxis. . . . . . . . . . . . . . . . . .å°“ . . . . . . . . . . . . . . . . . .å°“ . 207

vii

Chapter 8

Complications of Endovascular Procedures and Miscellaneous Cases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213

Appendix

List of Manufacturers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235

viii

Foreword

A dramatic change in the diagnostic capabilities and therapeutics of cerebrovascular diseases has evolved during the past two decades. Technology has now made it possible to safely and quickly image the brain and the neck and intracranial vessels that bring blood to and from the brain. Blood testing has also improved. Doctors can now tell the cause, localization, and extent of the cerebrovascular pathology in each patient they encounter, and can do so rapidly and urgently. The technology for intervening through patients’ blood vessels has also expanded greatly. It is now possible to treat many conditions through interventional techniques that in the past could be approached only by open intracranial surgery. Initially interventional treatments were pursued mainly by interventional radiologists and neurosurgeons. More recently neurologists trained and experienced in caring for patients with cerebrovascular diseases have entered the arena of interventional therapeutics. This makes good sense since they have had experience in the natural history of the various cerebrovascular conditions, and are well aware of alternatives to endovascular manipulations. Dr Adnan Qureshi has been one of the leaders in the development of the field of Interventional Neurology. He has herein edited a remarkable collection of cases that reflect the nature of the conditions encountered by interventionalists and the issues and problems involved in treating specific patients with various findings. Dr Qureshi has been able to attract the contributions in this atlas of many of the leaders in the burgeoning field of Interventional Neurology. Dr Miller Fisher was fond of remarking that one learns Neurology “stroke by stroke and case by case”. Qureshi has followed this dictum. Each patient is different. The atlas consists of extensive imaging and step-by-step instructions on treatment, outcome, and complications. This is a how-to book with fine details about treatment conundrums and techniques. The atlas consists of 150 cases. The opening chapter includes an analysis of 26 individual patients with lesions of the various arteries in the neck that were treated with angioplasty and/or stenting. Chapter 2 includes 15 patients whose intracranial occlusive lesions were treated with angioplasty and/or stents. Chapter 3 details the scenarios of 25 patients with acute, subacute, or progressive brain ischemia that were treated using a variety of interventional thrombolytic and mechanical techniques. Chapter 4 contains cases 67-105- patients with aneurysms and pseudoaneurysms. Chapter 5 considers 20 patients with various vascular malformations. Chapter 6 deals with 11 brain tumor cases, and Chapter 7 with the knotty issue of controlling severe epistaxis. The final chapter contains cases 137-150, a potpourri of miscellaneous conditions and complications. ix

The images are very well displayed, and the treatments are clearly reported as are the outcomes and complications. This is an extremely rich and rewarding atlas that will prove of great benefit to interventionalists as well as neurologists considering interventional treatment in specific situations, and to anyone interested in the diagnosis and treatment of patients with stroke and cerebrovascular disease. Louis R Caplan MD Beth Israel Deaconess Medical Center, Boston Harvard University

x

Preface

The Atlas of Interventional Neurology was prepared to provide a detailed, step-bystep approach to procedures performed in the practice of interventional neurology and its allied specialties, endovascular neurosurgery and interventional neuroradiology. The need for such an Atlas arose when neurovascular procedures matured from experimental treatment to standard of care for most indications. Several, essentially unrelated events played a major role in the evolution of Interventional Neurology. In 1941, Werner and colleagues (1) inserted silver wires into an intracranial aneurysm through a transorbital approach to prevent rupture by reducing blood-flow related mechanical stress. In 1958, Sussmann and Fitch (2) reported the successful recanalization of an acutely occluded internal carotid artery after injection of plasmin. In the early 1960’s, Luessenhop and Velasquez (3) showed that intracranial vessels could be catheterized with flow-directed balloon-tipped catheters, and in 1964, Serbinenko (4) performed temporary occlusion of the internal carotid artery using a flow- directed balloon. Concurrently, the field of cardiovascular medicine was undergoing an evolution as endovascular treatment of coronary artery disease became not only feasible, but responsible, prudent, and expected in most cases. Since then, neurovascular intervention has followed the precedent of cardiovascular intervention with rapid exploitation of the therapeutic opportunities afforded by this exquisitely invasive yet relatively safe and effective technique (5). In concert with the rapid development of techniques for neurovascular therapy, industry has been providing physicians with specialized and technologically sophisticated devices for interventional procedures. The Atlas of Interventional Neurology aspires to provide a convenient and responsible reflection of developments in the field, and a forum in which recognized experts in the field have discussed their insights and technical pearls. We chose to use a case-based approach in this Atlas. This approach was selected to provide readers a sense of real life experience in making decisions at each cross section within a procedure. Step by step illustrations were used to provide visual data that cannot be reproduced with text alone. The Atlas was organized into sections based on disease-specific interventional procedures. Experts from various disciplines including Neurological surgery, Neurology, and Neuroradiology contributed selected cases which represent a mixture of routine and technically

xi

challenging procedures. Special attention has been paid to highlight decision making based on available clinical, radiological, and angiographic information followed by an invaluable self-analysis by the experts on the strengths and weaknesses of the choices made. We hope that this Atlas will serve as a guide to any physician involved with the care of patients with cerebrovascular disease treated with interventional procedures. References 1. Werner SC, Blakemore AH, King BG. Aneurysm of the internal carotid artery within the skull: wiring and electrothermic coagulation, JAMA 1941;116:578–582. 2. Sussman BJ, Fitch TSP. Thrombolysis with fibrinolysis in cerebral arterial occlusion, JAMA 1958;167:1705–1709. 3. Luessenhop AJ, Velasquez AC. Observations on the tolerance of the intracranial arteries to catheterization, J Neurosurg 1964; 21:85–91. 4. Teitelbaum GP. Larsen DW. Zelman V. Lysachev AG. Likhterman LB. A tribute to Dr. Fedor A. Serbinenko, founder of endovascular neurosurgery. 5. Qureshi AI. Ten years of advances in neuroendovascular procedures. Journal of Endovascular Therapy 2004;11 Suppl 2:II1-4.

xii

Contributors Abou-Chebl, Alex, MD, University of Louisville, Louisville, KY

Janardhan, Vallabh, MD, University of Minnesota, Minneapolis, MN

Boulos, Alan S., MD, Albany Medical College, Albany, NY

Juravsky, Louis, MD, Centre Hospitalier de l’ Université de Montréal, Montreal, Canada

Dabus, Guilherme, MD, Massachusetts General Hospital, Boston, MA Edgell, Randall C., MD, Albany Medical College, Albany, NY Fitzsimmons, Brian-Fred, MD, Medical College of Wisconsin, Milwaukee, WI Georgiadis, Alexandros L., MD, University of Minnesota, Minneapolis, MN Guilbert, Francois, MD, Centre Hospitalier de l’ Université de Montréal, Montreal, Canada

Kim, Stanley H., MD, Saint David’s Medical Center, Austin, TX Kirmani, Jawad F., MD, University of Medicine and Dentistry of New Jersey, Newark, NJ Lynch, John R., MD, Medical College of Wisconsin, Miwaukee, WI Mahmoud, Mostafa, MD, PhD, Ain-Shams University, Cairo, Egypt Nguyen, Thanh, MD, Boston University, Boston, MA

Gupta, Rishi, MD, Cleveland Clinic Foundation, Cleveland, OH

Nogueira, Raul G., MD, Massachusetts General Hospital, Boston, MA

Hirsch, Joshua A., MD, Massachusetts General Hospital, Boston, MA

Pandya, Dhruvil J., MD, Medical College of Wisconsin, Milwaukee, WI

Hussein, Haitham M., MD, University of Minnesota, Minneapolis, MN

Patel, Anant I., MD, Saint David’s Medical Center, Austin, TX

Iancu-Gontard, Daniela, MD, Nancy Univerisy Hospital, Nancy, France

Prem, Kandiah, MD, Medical College of Wisconsin, Milwaukee, WI

xiii

Prestigiacomo, Charles J., MD, FACS University of Medicine and Dentistry of New Jersey, Newark, NJ

Suri, M. Fareed K., MD, University of Minnesota, Minneapolis, MN

Pryor, Johnny C., MD, Massachusetts General Hospital, Boston, MA

Szeder, Viktor, MD, PhD, Medical College of Wisconsin, Milwaukee, WI

Qureshi, Adnan I., MD, University of Minnesota, Minneapolis, MN

Taylor, Robert, A. MD, University of Minnesota, Minneapolis, MN

Raymond, Jean, MD, Centre Hospitalier de l’ Université de Montréal, Montreal, Canada

Tom, Ogunlene, PhD, Saint David’s Medical Center, Austin, TX

Rodriguez, Gustavo, J., MD, University of Minnesota, Minneapolis, MN Roy, Daniel, MD, Centre Hospitalier de l’ Université de Montréal, Montreal, Canada Shah, Qaisar A., MD, Abington Memorial Hospital, Abington, PA Silvaggio, Joseph A., MD, University of Manitoba, Winnipeg, Canada Soulez, Gilles, MD, Centre Hospitalier de l’ Université de Montréal, Montreal, Canada

Warren, Shannon, Saint David’s Medical Center, Austin, TX Weill, Alain, MD, Centre Hospitalier de l’ Université de Montréal, Montreal, Canada Wolfe, Thomas, MD, Medical College of Wisconsin, Milwaukee, WI Yoo, Albert, MD, Massachusetts General Hospital, Boston, MA Zaidat, Sam O., MD, Medical College of Wisconsin, Milwaukee, WI

xiv

List of Abbreviations AAA Abdominal aortic aneurysm ACA Anterior cerebral artery Acom Anterior communicating artery ACT Activated clotting (coagulation) time

FLAIR

Fluid-attenuated inversion recovery

FMD Fibromuscular dysplasia GP IIB/IIIA Glycoprotein IIB/IIIA IA Intra-arterial

ACTH Adrenocorticotropic hormone

ICA Internal carotid artery

AICA Anterior inferior cerebellar artery

ICH Intra-cerebral hemorrhage

AP Antero-posterior

IMAX Internal maxillary artery

AVF Arterio-venous fistula

IV Intravenous

AVM Arterio-venous malformation

LAO Left anterior oblique

CABG Coronary artery bypass graft surgery

MCA Middle cerebral artery

CAD Coronary artery disease CAS Carotid artery stenting CBV Cerebral blood volume CCA Common carotid artery

MRA Magnetic resonance angiography MRI Magnetic resonance imaging MRV Magnetic resonance venogram MTT Mean transit time

CEA Carotid endarterectomy

NASCET North American Symptomatic Carotid Endarterectomy Trial

CFA Common femoral artery

NBCA N-butyl cyanoacrylate

CFV Common femoral vein

NIHSS National Institutes of Health Stroke Scale

CT Computed tomography CTA CT angiography CTP CT perfusion DAVF Dural arterio-venous fistula DEPD Distal embolic protection device DMSO Dimethyl sulfoxide DWI Diffusion-weighted imaging ECA External carotid artery F French

OTW Over the wire PCA Posterior cerebral artery Pcom Posterior communicating artery PICA Posterior communicating artery PTCA Percutaneous transluminal coronay angioplasty PVD Peripheral vascular disease rCBF Regional cerebral blood flow RHV Rotating homostatic valve

xv

rt-PA Recombinant tissue plasminogen activator SAH Subarachnoid hemorrhage SCA Superior cerebellar artery SPECT Single photon emission computed tomography

SQ Subcutaneous STA Superficial temporal artery TIA Transient ischemic attack VA Verterbal artery WASID â•‡ Warfarin-Aspirin Symptomatic Intracranial Disease Study Group

xvi

CHAPTER 1

Angioplasty and Stenting of the Extracranial Vessels ICA D3 D2

D1

ECA

CCA D4

Measurements of the internal and common carotid arteries required prior to stent placement.

Distal marker

Design of a carotid stent.

Demonstration of subclavian steal syndrome. The red arrows indicate normal antegrade flow in the left vertebral artery. The blue arrows indicate “stolen” flow. The right vertebral artery fills in retrograde fashion and supplies the right subclavian and common carotid arteries with blood.

1

OVERVIEW OF CASES I

INTERNAL CAROTID ARTERY

Case 1

Distal embolic protection Angioplasty and stent placement Vessel measurements required for stenting Nascet-based calculation of stenosis Angioplasty and stent placement Angioplasty and stent placement Competitive filling of the anterior cerebral artery Severe tortuosity of the internal carotid artery

Case 2 Case 3

Case 4

Case 5 Case 6

Case 7

Case 8

Case 9

Case 10

CASES 1–10

Proximal and distal embolic protection Angioplasty and stent placement Tapered stent Post-stent angioplasty Angioplasty and stent placement CTA and CT perfusion studies Angioplasty Intraluminal clot Stenting deferred because of contraindication to dual antiplatlet treatment Heavily calcified lesions Angioplasty and stent placement Post-stent angioplasty Iatrogenic vasospasm Angioplasty and stent placement Multiple pre-stent angioplasties Stent trapped in lesion Intravascular ultrasound Radial artery approach Angioplasty and stent placement Allen test Medication protocol for radial and brachial artery procedures Angioplasty Cutting balloon Radiation-induced vasculopathy

II

COMMON CAROTID ARTERY

CASES 11–13

Case 11

Angioplasty and stent placement Subclavian steal syndrome

Case 12

Angioplasty and stent placement Radiation-induced stenosis Debris captured by a distal embolic protection device

Case 13

Subclavian steal syndrome

III

EXTERNAL CAROTID ARTERY

Case 14

Angioplasty and stent placement Brachial artery approach Stent placement without the use of a guide catheter External carotid artery and internal carotid artery collateral circulation

CASES 14–15

2

Case 15

Angioplasty and stent placement Treatment with Nitroglycerin for vasospasm

IV

BRACHIOCEPHALIC ARTERY

Case 16

Angioplasty and stent placement Transient ischemic attacks induced by orthostasis Balloon-mounted stents Placement of multiple stents

V

SUBCLAVIAN ARTERY

Case 17

Angioplasty and stent placement Subclavian artery occlusion Subclavian steal syndrome Dual arterial access (femoral and brachial artery) Microsnare device

VI

VERTEBRAL ARTERY ORIGIN

Case 18

Stent placement Balloon-mounted stent

Case 19

Distal embolic protection Stent placement Balloon-mounted stent Stent placement Balloon-mounted stent Iatrogenic vasospasm Use of a “buddy” wire Stent placement Balloon-mounted stent Retroperitoneal hematoma Stent placement Balloon-mounted stent Use of a “buddy” wire

Case 20

Case 21

Case 22

CASE 16

CASE 17

CASES 18–22

VII

VERTEBRAL ARTERY V-2 SEGMENT

Dynamic angiography Positional occlusion of the vertebral artery/Bow Hunter syndrome Stent placement Multiple posterior circulation strokes Brachial artery approach Uncinate spur Angioplasty and stent placement History of cervical discectomy Post-stent angioplasty

Case 23

Case 24

VIII

COMBINED SUBCLAVIAN ARTERY AND VA ARTERY ORIGIN

Case 25

Angioplasty and stent placement Subclavian steal syndrome Distal embolic protection Angioplasty and stent placement Stenting of the vertebral artery origin through a subclavian artery stent Arm claudication In-stent stenosis with fish-mouthing

Case 26

3

CASES 23–24

CASES 25–26

CASE 1 • Internal carotid artery angioplasty and stenting Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD

ICA

B AC KG R O U N D : â•‡ A 68-year-old man presented with a posterior circulation ischemic event. He was found to have proximal basilar artery occlusion and right ICA stenosis. The right ICA filled the posterior circulation through the Pcom. The decision was made to proceed with ICA stent placement to improve perfusion of the posterior circulation.

D3 D2

D1

ECA

CCA D4

1

Figure 1.â•‡ Measurements for stent placement. D1. Vessel diameter at the point of maximal stenosis D2. Distance from the ICA just distal to the stenosis to the CCA justâ•¯proximal to the stenosis D3. Diameter of the ICA distal to the stenosis D4. Diameter of the CCA proximal to the stenosis (1-D1/D3) 3 100 = % stenosis according to NASCET criteria D2 = Minimal stent length D3 = Approximate balloon size for post-stent angioplasty D4 = Minimal stent width

2C

2B

2A

2D

2E

Figure 2.â•‡ A through G. Stages of carotid stenting A. The guide catheter (6-French Cook Shuttle) is placed in the CCA. The arrow is pointing at the catheter tip. B. The DEPD (Filterwire EZ, arrow) is passed through the guide catheter, past the lesion into the distal cervical ICA. C. The balloon is in place across the lesion for pre-stent angioplasty. The white arrows show the proximal and distal balloon markings. D. ICA appearance after angioplasty with a 3.5 3 40 mm Savvy balloon catheter. E. The stent (7 3 40 mm self-expanding Precise stent) is in place. The white arrows indicate the position of the proximal and distal markers. F. ICA post-stent deployment. The arrows are pointing at areas of procedure-related vasospasm that resolved spontaneously. G. Unsubtracted image depicting the deployed stent (white arrows).

2F

2G

Post-stenting angioplasty is generally considered when there is residual stenosis of >30%. In this case, residual stenosis was 10% and therefore post-stent angioplasty was not performed.

4

CASE 2 • Internal carotid artery angioplasty and stenting Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD B ackground :â•‡ A 63-yearold man presented with a highgrade stenosis of the right ICA and occlusion of the left ICA.

1A

1C

1D

Procedure :â•‡ A 6-F Cook Shuttle system was introduced into the descending aorta and then positioned in the distal right CCA over a 5-F VTK catheter and a super-stiff Amplatz wire. A Filter EX DEPD was passed through the lesion and deployed at the level of the distal cervical ICA. Pre-angioplasty was performed with a Savvy balloon measuring 3.5 3 40 mm. The balloon was inflated to a pressure of 8 atmospheres.â•¯A Precise 7 3 30 mm self-expanding stent was then positioned across the lesion and deployed. Post-stenting images (Figure 1F) showed excellent resolution of the stenosis.

1B

1G

1E

1F

Figure 1.â•‡ A–D. Right CCA injections, lateral projection. A. The arrow points at the stenotic lesion. B . The DEPD has been deployed (arrow). C. The balloon is seen across the lesion. The arrows show the position of the proximal and distal balloon markers. D. Post-angioplasty images. Significant improvement of the lesion can be seen. E . Unsubtracted image. The stent is shown positioned across the lesion prior to deployment (arrows). F. Right CCA injection, lateral projection, post-stent placement. Minimal residual stenosis. G. Unsubtracted image. The deployed stent can be seen.

5

CASE 3 • Internal carotid artery angioplasty and stenting Alex Abou-Chebl, MD B AC KG R O U N D : â•‡ A 54-year-old man presented with a minor left MCA stroke while receiving therapy with aspirin and clopidogrel. The patient had a history of unstable angina, diabetes, hypertension, and hyperlipidemia. MRI revealed multiple punctate lesions in watershed territories. Carotid duplex revealed that the left ICA peak systolic velocity was 623 cm/s and the end diastolic velocity was 230 cm/s with an ICA/CCA ratio of 6.7. Clearly, in this relatively young patient, revascularization of the ICA was indicated, but CEA would carry a very high risk of MI and perioperative death. Based on the SAPPHIRE trial results, stent placement was considered to be the best choice.

Severe tortuosity of the ICA is a relative contraindication for stent placement. In general, such lesions should be treated with CEA. However, in cases of symptomatic ICA stenosis in the setting of multiple high-risk factors for CEA, endovascular therapy may be considered if revascularization is considered essential. In performing such interventions it is always important to keep in mind that the goal of therapy is stroke prevention, therefore any technical maneuver that puts a patient at risk for stroke should be avoided. Procedure : Figure 1. A. Left CCA injection, LAO projection. There is severe ICA stenosis (arrow). Note the 90-degree bend at the origin of the ICA, followed by a 100-degree bend just distal to the stenosis. B. Left CCA injection, AP intracranial projection. The flow-limiting effect of the stenosis can be deduced from two facts: The occipital artery (thick arrow) is filling as fast as the MCA branches, and there is competitive filling of the left ACA, i.e., the left ACA fills from the right ICA. Only the A1 segment (thin arrow) fills from the left.

1B

1A

Figure 2.â•‡ A and B. Unsubtracted images. A. Because of the tortuosity of the ICA, an 8-F H1 guide catheter (Cook Medical) (black arrow) was inserted via the typical telescoping technique into the distal CCA. A sheath catheter, although smaller, would not give adequate control nor allow for torquing of its tip toward the ICA to make it coaxial with the ICA take-off, as can be done with a shaped guide catheter. As expected, the DEPD (Angioguard) could not be advanced fully into the ICA. With every attempt, it would prolapse into the ECA (thick white arrow). A 0.014-inch coronary wire (BMW, thin white arrow) was instead placed in the ICA (functioning as a “buddy wire”) to straighten the vessel out. As can be seen (red lines outline the vessel), the ICA was not sufficiently straightened to allow delivery of the DEPD. B. The BMW was exchanged for a stiffer wire (Ironman) through an OTW balloon catheter (a balloon catheter is used instead of a microcatheter because it can be used to simultaneously predilate the lesion if needed). With the Ironman wire in place (arrow), the tortuosity of the ICA was effectively resolved (redâ•¯lines).

2A 2B

6

CASE 3 • (continued)

2C

2D

2E

Figure 2.â•‡ C–E. Unsubtracted images C,D.â•‡ The DEPD was then successfully passed into the ICA but would not advance fully (thick arrow) because of pseudo-stenosis and vasospasm (thin arrows) induced by the stiff wire, which causes the redundant curves of the ICA to fold up like a sleeve. For this reason, placement of a very stiff wire in the ICA is dangerous and should generally not be performed. In this case, the patient did not have many other options, and stenting without an DEPD is associated with a high risk of stroke. Therefore, adequate Heparinization was maintained (ACT’s ≈ 300 seconds) throughout the case, and nitroglycerin was given frequently directly into the carotid artery. To allow passage of the DEPD, the stiff wire was exchanged through the balloon catheter for the BMW, keeping the balloon catheter in place. This permitted delivery of the DEPD (circle). However the tortuosity returned, and stent placement was not possible, so the sequence was again repeated with replacement of the BMW with the Ironman wire. E. The stent was advanced over the DEPD wire into the stenosis, and the Ironman wire was again replaced with the BMW, which relieved the pseudo-stenosis, permitting full stent delivery without concern for causing dissection. If the stiff wire was kept in place, the stent could have been delivered, but advancing it could have easily torn the intima. After stent system delivery, the buddy wire was removed and the stent was deployed.

Figure 3.â•‡ A and B. Left CCA injection, LAO extracranial (A) and AP intracranial (B) projections following retrieval of the DEPD. A. There is only minimal residual stenosis. B. The absence of any filling defects excludes embolism of plaque material. The ACA now fills from the left ICA.

3A

3B

7

CASE 4 • Internal carotid artery angioplasty and stenting Randall C . Edgell, MD, Alan S. Boulos, MD B AC KG R O U N D :â•‡ A 64 year-old man presented with acute-onset right-sided weakness and dysarthria while hospitalized at an outside hospital where he had undergone coronary artery stent placement. CTA showed a critical left ICA stenosis. The patient arrived at our hospital at 6 hours after symptom onset.

Schematic depiction of proximal and distal protection devices used in carotid stenting. A. The distal protection device is deployed in a straight segment of the cervical ICA. B. The Concentric Balloon Guide catheter (Concentric Medical, Mountain View, CA) is the only available off-label balloon guide catheter, and is deployed within the distal common carotid artery.

The technique of proximal protection was developed for treating patients whose lesions were so severe that the distal protection device could not be positioned prior to angioplasty. It allows for reversal of flow during the pre-distal protection device angioplasty and thus reduces the risk of embolism. The pre-stent placement angioplasty creates room for the DEPD to pass through the lesion.

1A

1F

1B

1G

1C

1D

1E

P rocedure : Figure 1.â•‡ A through G. A. A Concentric balloon guide catheter (Concentric Medical, Mountain View, CA) is positioned in the distal CCA (arrow). The open arrow points at the ICA stenosis. B. A microwire and microcatheter OTW balloon system is used to cross the lesion (black arrow) with proximal protection (open arrow shows the inflated balloon). C. A 2 3 30 mm Maverick balloon is used for pre-stent angioplasty (arrow) with the proximal concentric balloon catheter inflated. At the same time, the operator is aspirating through the balloon catheter. D. Post-angioplasty, the filter device (EPI Filterwire) can traverse the lesion more safely and be deployed. E. The stent (6-8 mm Acculink tapered stent) is in place. The arrow points at the distal protection device. F. Post-stent angioplasty is performed with a 4 mm 3 20 mm ViaTrac balloon (arrow). G. Intracranial flow is greatly improved post-stent placement.

8

CASE 5 • Internal carotid artery angioplasty and stenting M. Fareed K. Suri, MD, Alexandros L. Georgiadis, MD, Vallabh Janardhan, MD B ackground :â•‡ A 78-year-old man presented with severe symptomatic right ICA stenosis (80%–99% by Doppler ultrasound). CT perfusion studies demonstrated decreased rCBF and increased MTT in the right hemisphere over the ICA territory. CTA confirmed the presence of severe ICA stenosis (Figure 1)

1

2C

2B

2A

Figure 2.â•‡ A and B. Right CCA injection, AP (A) and lateral (B) projections. There is severe stenosis of the proximal ICA (arrow). Figure C. Right CCA injection, AP intracranial projection. The ACA and the superior division of the MCA are not filling.

Procedure : â•‡ An 8-F Merci balloon guide catheter was advanced over a 5-F VERT 125 cm catheter into the right CCA (Figureâ•¯3A). The balloon was inflated for proximal protection and an Accunet 4.5-mm distal protection device was advanced through the lesion into the distal cervical ICA and deployed. A 4 3 30 mm ViaTrac balloon was then advanced over the distal protection device wire into the CCA and then across the lesion. Angioplasty was performed over two segments of the vessel at nominal pressure. This resulted in enough dilation of the lesion to allow passage of the stent (Figure 3B). A self-expanding tapered 6-8 3 40 mm Acculink stent was passed over the DEPD wire across the lesion and deployed. The final angiographic result is shown in Figure 3D. The patient tolerated the procedure well. Figure 3. A. Unsubtracted image. The balloon is inflated (circle) while the DEPD wire (arrow) is advanced from the CCA through the ICA stenosis. B. Right CCA run, AP projection. The DEPD is seen in the distal ICA (open arrow). The balloon markers are seen across the lesion (arrows). This is a post-angioplasty image. C. Post-stenting image. D. Right CCA, intracranial image. The superior division of the MCA and the ACAâ•¯are now filling (arrows).

3A

3B

3C

9

3D

CASE 6 • Internal carotid artery angioplasty Alex Abou-Chebl, MD B AC KG R O U N D : â•‡ A 78-year-old man presented with two left-hemispheric TIAs followed by a small infarct of the right ACA resulting in left-sided weakness greater in the arm than in the leg. The next day he had a myocardial infarction with congestive heart failure and progressive myocardial ischemia. Coronary angiography revealed severe four-vessel disease including the left main coronary artery and urgent CABG was contemplated. Noninvasive imaging revealed bilateral severe ICA stenosis. Inability to take aspirin and clopidogrel for a minimum of 4 weeks is an absolute contraindication to stenting. Primary angioplasty is considered when the underlying pathophysiology is FMD or arteritis, or when the patient can not take clopidogrel for the ideal duration of 4 weeks, such as in this case of a patient needing urgent CABG.

1C

1A

1B 1D

Procedure : Figure 1.â•‡ A–D. A. Right CCA injection, intracranial AP projection. There is a >90% stenosis of the petrous ICA (arrow). B. Left CCA injection, left anterior oblique view. There is a >80% ICA stenosis distal to the bulb (arrow). C. Left CCA injection, intracranial AP projection. The left ICA fills the right ACA (arrow) and is therefore the symptomatic vessel. D. Left CCA injection, lateral projection. There is a filling defect (arrow) suggestive of thrombus. Intraluminal clot is typically a contraindication for endovascular treatment, but in this patient, CEA was not feasible because of his poor medical condition (estimated near 40% stroke morbidity and mortality).

2A

2B

2C

10

Figure 2.â•‡ A–C. A. Left CCA injection, lateral projection. To safely permit passage of an embolic protection device, a Guardwire (arrow) was deployed in the proximal ECA through an 8-F Concentric Balloon Occlusion guide catheter. B. Unsubtracted image. The guide catheter balloon (white arrow) was inflated to occlude antegrade flow through the CCA and the Guardwire (black arrow) was inflated to prevent retrograde flow from the ECA into the ICA, permitting safe passage of a Filterwire EZ (black arrow top) into the ICA, without dislodging the luminal thrombus. C. Angioplasty with a 4 mm cutting balloon was performed, resulting in excellent reduction of the stenosis (arrow). A stent was not placed to permit immediate CABG on aspirin therapy. The luminal thrombus was caught in the Filterwire. The patient underwent an uneventful CABG.

CASE 7 • Internal carotid artery angioplasty and stenting Stanley H. Kim, MD B ackground :â•‡ A 64-year-old woman presented with episodes of dysarthria. She had a history of retinal artery occlusion, type 2 diabetes mellitus, hypertension, ischemic cardiomyopathy, congestive heart failure, CAD, 3-vessel CABG, and aortic valve replacement with residual severe aortic valve stenosis. The patient was on Warfarin. Ultrasound studies showed bilateral severe ICA stenosis. Diagnostic angiography revealed a 30% ICA stenosis on the right and an 80% calcified, irregular ICA stenosis on the left. Because of her multiple medical comorbidities she was referred for endovascular treatment. Warfarin was stopped and Enoxaparin was started at 1 mg/kg sq bid. Aspirin 325 mg daily and Clopidogrel 75 mg daily were also started one week prior to the procedure.

1A

1B

1C

Figure 1.â•‡ A–C. Diagnostic angiography. A. Left CCA injection, oblique projection. There is high-grade stenosis (arrow) in the ICA. The lesion is heavily calcified (circles). B. Magnified view of the calcifications (circles). C. Left CCA injection, AP projection, intracranial view. Filling of the intracranial circulation is slow.

2C

2A

2B

Procedure:â•‡ The procedure was performed under moderate conscious sedation. We administered 7000 units of Heparin intravenously to achieve an ACT of 315 seconds. A 6-F Cook Shuttle system was placed in the left CCA using the OTW exchange technique in the left ECA. A 5 mm Accunet depd was used to traverse the stenotic origin of the left cervical ICA. Then, angioplasty of the origin of the left cervical ICA was performed with a 4 3 30 mm ViaTrac balloon. This was followed by placement of a 6-8 3 30 mm tapered Acculink stent and post-stent angioplasty with a 4.5 3 30 mm ViaTrac balloon. O U TC O M E :â•‡ The patient tolerated the procedure well and was discharged home on aspirin, Clopidogrel, and Warfarin.

Figure 2.â•‡ A and B.â•‡ Left CCA injections, oblique projection, pre- (A) and post- (B) angioplasty and stenting. In A, the DEPD (arrow) has been positioned past the lesion. In B, mild to moderate ICA spasm is seen (arrow). The spasm resolved spontaneously. The residual stenosis is satisfactory in view of the heavy calcification. Final left CCA injection, intracranial AP projection. Intracranial flow is greatly improved. C. The presence of heavy calcification in a stenotic carotid lesion is a relative contra-indication for carotid angioplasty and stent placement. However, as illustrated by this case, some of these lesions may be amenable to carotid stenting. Preferably, stents with strong radial force should be used. The feasibility of pre-stent angioplasty of these calcified lesions provides some insight into how successful a revascularization can be achieved with stenting. 11

CASE 8 • Internal carotid artery angioplasty and stenting Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD B AC KG R O U N D : â•‡ A 75-year-old man presented with a highgrade symptomatic ICA stenosis. Surgery was not recommended due to multiple medical comorbidities.

1A

1B

Figure 1.â•‡ Diagnostic angiography. A. Right ICA injection, AP projection. There is a heavily calcified (arrow) severe stenosis. B. Unsubtracted image in lateral projection. The circle highlights the severely calcified plaque. Procedure :â•‡ A 6-F Cook Shuttle system was introduced through the right CFA and parked in the distal right CCA. An DEPD was passed through the lesion and deployed in the distal cervical ICA. A buddy wire was parked in the distal cervical CCA to add stability to the system. Figure 2.â•‡ A. Unsubtracted image. The deployed DEPD is seen (circle). B. Right CCA injection, AP projection. The injection confirms correct placement of the DEPD. There is no gap between the DEPD and the vessel wall. C. Unsubtracted image. The buddy wire (arrow) has been given a “J” shape to avoid disruption of the plaque in case it protrudes into the lesion.

2A

A balloon was passed through the lesion over the DEPD wire and deployed. The balloon catheter was then exchanged for a stent catheter. However, the stent could not be passed through the lesion and was therefore retrieved. A repeat angioplasty was performed. Aâ•¯second attempt to pass the stent was again unsuccessful.

2B

3A

2C

3B

3C

3D

Figure 3.â•‡ A–D. Unsubtracted lateral images. A and B.â•‡ The balloon is shown in position, pre- (A) and during (B) deployment. The arrows point at the balloon markers. C. The stent is trapped in the lesion and can not be advanced distally. The arrow points at the tip of the stent. D. Repeat angioplasty. The balloon is inflated. 12

CASE 8 • (continued) The buddy wire was then passed through the lesion in an attempt to straighten the vessel and facilitate passage of the stent. This maneuver was successful. The stent was brought in position for deployment, and the buddy wire was drawn back into the CCA. After the stent was deployed, an ultrasound probe (Volcano therapeutics, Rancho Cordova, California) was introduced over the DEPD wire and passed through the stent. The probe was then slowly pulled back via an automated mechanism, and ultrasound images of the stent and the vessel wall were obtained. There are no established indications for use of intravascular ultrasound in the cerebral vasculature. In this case, we wanted to see how well the stent abutted the vessel wall. Figure 3.â•‡ E–G. Unsubtracted lateral images. E. The buddy wire has been passed through the lesion. F. The stent has been positioned across the lesion. The buddy wire has been retrieved into the CCA. G. The stent has been successfully deployed.

3E

3F

3G

Ultrasound Probe

4B

4A

Figure 4. A. Unsubtracted lateral image. The ultrasound probe has been passed through the stent. B. Intravascular ultrasound image. The stent (arrow) is seen abutting the vessel wall (open arrow). Figure 5.â•‡ Right CCA injection, post-stent placement, AP projection. Only mild residual stenosis is present.

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5

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CASE 9 • (continued)

4B

4C

4A

Figure 4.â•‡ A–C. Right CCA injections. Lateral view. A and B are unsubtracted. Figure 5. A. Final right CCA injection, lateral projection. There is no residual stenosis. B. Unsubtracted image, AP projection. The stent and Cook Shuttle catheter are highlighted.

5A

5B

Table 1. Allen Test

Table 2. Protocol for angiographic procedures via radial arteryâ•¯access

For a description of the original Allen test, see Levy et al. as quoted in Table 2.

After sheath insertion, the following medications are administered through the sheath:

A commonly used modified test is performed as follows: Aâ•¯pulse oxymeter is attached to the index finger. Pressure is applied to the radial artery. There should be no change in waveform after 20 to 30 seconds of compression. Alternatively, both the radial and ulnar arteries are compressed until the waveform is abolished. Releasing the radial artery should re-establish a pulse-ox waveform.

Nitroglycerine Verapamil Heparin Lidocaine 2%

0.1 mg 2.5 mg 5000 units 1 mL

From: Levy AI, Boulos AS, Fessler RD, et al. Transradial cerebral angiography: an alternative route. Neurosurgery 2002; 51: 335–342. 15

CASE 10 • Internal carotid artery primary angioplasty for restenosis Qaisar A. Shah, MD, Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD B ackground :â•‡ A 79-year-old woman underwent radiotherapy for thyroid cancer in 1998. Four years later, she developed a symptomatic left ICA stenosis for which she was treated with stent placement. In 2006, she developed symptomatic re-stenosis.

2B

2C

1

2A

Figure 1.â•‡ CTA showing severe, in-stent restenosis (arrow). Figure 2. 2D A. Left ICA injection, lateral projection, unsubtracted. The arrow points at the stenosis. B. Left subclavian injection, AP projection. There is severe, diffuse disease in the left subclavian artery and the left VA is occluded at its origin. C. The left VA reconstitutes distally (arrow) from collaterals (circle) originating from the costocervical and thyrocervical trunks. D. Left ICA injection, AP intracranial projection. Cross-filling to the right hemisphere via the Acom. The underlying pathology is occlusion of the right cervical ICA. Procedure :â•‡ A 6-F Cook Shuttle system was introduced in the right CFA and advanced to the descending Â�aortic arch. A 5-F VTK catheter was passed through the Cook Shuttle into the aorta. Then the VTK was placed in the left CCA over a 0.035-inch super-stiff Amplatz guidewire. The Cook Shuttle was positioned in the distal CCA over the Vtk catheter which was then removed. A monorail 4 3 15 mm cutting balloon (Boston Scientific, San Diego, CA) was advanced over a 0.014-inch Allstar microwire. The microwire was parked in the distal cervical ICA. The balloon was positioned across the stenosis, then inflated three consecutive times at nominal pressure. Figure 3. A. Left CCA injection, lateral projection, unsubtracted. The balloon has been positioned across the stenosis. The arrows point at the balloon markers. B. Left CCA injection, lateral projection. Post angioplasty 3 3 there is improvement of the lesion. 3A

3B

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CASE 11 • Common carotid artery angioplasty and stenting Alex Abou-Chebl, MD B AC KG R O U N D : â•‡ A 50-year-old woman presented with a small left MCA cortical infarct. Carotid ultrasound revealed slow flow in both ICAs. Intra- and extracranial MRA was normal. A re-review of the ultrasound revealed that the left ICA velocities were very low, with a peak systolic velocity of 48 cm/sec and an end-diastolic velocity of 8 cm/sec. There was reversal of flow in the left VA. Angiography was performed.

In patients with cerebral ischemia, attention should be given to the origins of the great vessels especially when: • A history of cigarette smoking (especially in women) is present • A history of peripheral vascular disease is present • Asymmetric arm pulses or pressures are found • The search for the source of ischemia is negative or recurrent ischemia occurs in the same vascular territory with negative noninvasive studies

Figure 1.â•‡ A and B. A. Arch injection. The brachiocephalic artery is occluded (black arrow points at the stump). There is severe stenosis of the left CCA (white arrow). There is faint filling of the right VA and subclavian. There is no filling of the right CCA. B. Left subclavian injection. The left VA fills in antegrade fashion (red arrows). The right VA fills retrograde (steal, blue arrows) into the right subclavian and right CCA.

RVA LCCA LVA

1B

1A

2A

2B

The left CCA stenosis was presumed to be symptomatic. Therapeutic options included bypass to the left CCA from the left subclavian artery and endovascular treatment of the left CCA stenosis.

P rocedure :â•‡ The most important aspect of the procedure is choosing the correct guide catheter so as to have adequate support without cannulating the stenosis. An excellent choice is an Amplatz catheter that has been steamshaped to decrease its curvature and remove its primary curve, thus forming a tight “J” (circle, Figure 2B). In this case, traversing the lesion with an DEPD or even a coronary wire was not possible due to the severe degree and calcification of the stenosis. Therefore, a 5-F JR4 catheter (arrow, Figure 2A) was passed through the guide catheter to support wiring of the lesion with a long Whisper coronary wire. Predilatation with an over-the-wire coronary 2 3 9 mm balloon was then performed (Figure 2B, arrows point at the balloon markers). This allowed adequate contrast opacification of the carotid bifurcation and delivery of the DEPD.

17

CASE 11 • (continued)

2C

2E

2D

2F

The Whisper wire was exchanged, through the balloon catheter, for a more supportive wire (BMW), which was placed in the ECA (Figure 2C, black arrow). A Filterwire DEPD was then placed (Figure 2C, white arrow) in the ICA. A 7 3 15 mm Genesis stent was passed over the DEPD wire through the stenosis and deployed (Figure 2D) with about two struts of stent protruding into the aorta. To prevent restenosis, it is important that there is slight protrusion of the stent into the aorta. However, excessive protrusion would make future cannulation difficult. After deployment of the stent at nominal pressure, the balloon was withdrawn slightly and used to “flare” the proximal portion of the stent by inflation to 2 to 3 atmospheres above nominal (Figure 2E, the arrow marks the proximal tines of the stent). The buddy wire (BMW wire) was removed uneventfully, despite being trapped between the stent and vessel wall. This is often the case and is a helpful trick to maintain vessel access. After filter retrieval, a final angiogram revealed an excellent result (Figure 2F). The patient’s symptoms never recurred.

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CASE 12 • Common carotid artery angioplasty and stenting Stanley H. Kim, MD BACKGROUND:â•‡ An 81-year-old woman was found to have a 90% to 95% asymptomatic right carotid stenosis (Figures 1 A–C). She had a history of laryngeal cancer treated with radical neck dissection followed by radiation treatment.

1B

1A

2A

P rocedure :â•‡ A 6 F Cook Shuttle system was placed in the right CCA. A 5 mm Accunet distal protection device was used to traverse the stenosis. A tapered 6-8 3 30 mm Acculink stent was placed across the lesion and deployed. This was followed by angioplasty with a ViaTrac 4 3 30 mm balloon and then with a ViaTrac 5 3 30 mm balloon. The patient tolerated the procedure well. There were no complications. The final angiographic result is shown in Â�Figures 2 A and B.

2B

Figure 1.â•‡ A and B. Right CCA injections, AP (A) and lateral (B) projections. The arrows point at the area of stenosis. Figure 2.â•‡ A and B. Right CCA injections, APâ•¯(A) and lateral (B) projections, post-angioplasty and stenting. Only mild residual stenosis remains. Figure 3.â•‡ A significant amount of debris is shown caught in the distal protection device.

3

Radiation-induced stenosis CEA is considered by many to be relatively contraindicated in cases of radiation-induced carotid stenosis. Although surgery in those patients is not associated with higher rates of stroke, a number of problems have been reported: higher incidence of arterial damage, cranial nerve palsy, prosthetic infection, anastomotic breakdown, wound complications and vessel restenosis. Some studies have refuted the higher incidence of wound-healing problems and infections. However, restenosis rates after CEA do seem to be consistently high in this patient population. References: Protack CD, Bakken AM, Saad WA, et al. Radiation arteritis: A contraindication to carotid stenting? J Vasc Surg 2007; 45: 110–117. Leseche G, Castier Y, Chataigner O, et al. Carotid artery revascularization through a radiated field. J Vasc Surg 2003 Aug; 38(2):â•¯244–250.

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CASE 13 • Common carotid artery angioplasty and stenting Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD B ackground :â•‡ A 79-year-old woman presented with multiple transient episodes consisting of left-sided weakness and numbness.

1A

FRAME 14/42

1B

FRAME 23/42

Diagram 1â•‡ is meant to help explain the anatomy. There is stenosis of the origin of the left CCA (thin arrow), of the origin of the brachiocephalic artery (white arrow), and of the right VA (thick black arrow).

RCCA

2 2

1 2

1C

FRAME 37/42

3

1: Brachiocephalic 2: Left CCA 3: Left subclavian

DIAGRAM 1

MCA

FRAME 4/29

2A

Figures 1A through 1Câ•‡ are successive frames of an aortogram performed through a 5-F pig-tail catheter. A. The brachiocephalic artery is not seen. B. The brachiocephalic artery and right CCA are filling. There is severe stenosis at the origin of the brachiocephalic. C. The right VA and subclavian arteries are filling.

2B

FRAME 20/29

Figures 2A and 2B.â•‡ Perfusion angiogram, early arterial phase and early venous phase respectively. A. The right MCA fills through the Acom. The right ICA is not seen. B. The right ICA fills very late and is occluded intracranially (arrow). Figures 3A–3D.â•‡ Left subclavian artery injection, AP projection, four successive frames. The left VA fills the basilar artery. The right VA fills in a retrograde fashion and then fills the right subclavian artery.

S ynopsis of findings :â•‡ A severe proximal stenosis of the brachiocephalic artery is present. The right CCA fills in a delayed fashion, but is occluded intracranially. The right subclavian fills in a retrograde fashion from the right VA which steals flow from the basilar artery. The reason for this subclavian steal is the proximal brachiocephalic artery stenosis. There is severe stenosis at the origin of the left CCA. The left ICA fills the right MCA via the Acom. The right MCA is the presumed symptomatic vessel. Stenosis also is present at the origin of the left VA. Treating the brachiocephalic stenosis would diminish the steal phenomenon from the posterior circulation and increase flow to the right ICA. The right ICA however, is occluded intracranially. Treating the left CCA is the only way to increase flow to the symptomatic vessel (right MCA) through the Acom. The decision was therefore to proceed with angioplasty of the left CCA.

20

CASE 13 • (continued)

3C

3B

3A

3D

Figures 3.â•‡ A–D. Subclavian steal phenomenon. procedure : The left CCA was catheterized with a Simmons II catheter. The catheter was then parked in the left ECA. A 300-cm super-stiff Amplatz wire was introduced into the left ECA. Then, the Simmons II was exchanged over the wire to a 6-F Cook Shuttle system, which was parked in the aorta (Figure 4A, black arrow). An Amplatz wire was passed through the left CCA stenosis (Figure 4A, white arrow). The run shown in Figure 4B confirmed the presence of a high-grade stenosis (arrow). An ultra-thin balloon was positioned across the lesion and angioplasty was performed first at a pressure of 4 atmospheres and then at a pressure of 8 atmospheres. The post-angioplasty result is shown in Figure 4C. Excellent recanalization is apparent. In Figure 4D, extensive aortic atheroma can be seen (small arrows).

4B 4C 4A

21

4D

CASE 14 • External carotid artery angioplasty and stenting Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD B ackground :â•‡ A 64-year-old man presented with repeated episodes of blurred vision out of the right eye. Noninvasive imaging suggested occlusion vs. severe stenosis of the right ICA. The patient had severe bilateral PVD in the lower extremities that precluded a CFA approach. Catheterization of the right radial artery was not successful. The decision was made to catheterize the right brachial artery. A 20-gauge angiocath was placed and then exchanged for a 4-F sheath. A combination of medications was administered through the sheath to prevent vasospasm (see case 9). The diagnostic angiogram was performed with a 4-F Simmons I catheter.

1A

1B

1C

Figure 1.â•‡ A and B.â•‡ Unsubtracted images showing the reconstituted Simmons I catheter in the left subclavian artery (A) and in the brachiocephalic artery (B). C. Right CCA run. The ICA is occluded. There is severe stenosis of the ECA (arrow).

2A

The patient’s symptoms were interpreted as transient retinal ischemia owing to inadequate collateral flow through the ECA. There was also poor collateral flow through the Acom and Pcom. Therefore, the decision was made to perform angioplasty of the right ECA. 2B

2C

3C

3A

3B

Procedure :â•‡ The 4-F sheath was exchanged for a 6-F sheath and a 6-F MPD Envoy catheter was introduced. A 0.014 inch Sparta core wire was parked in the distal CCA (Figure 2A; the wire has reached the bifurcation and is curving back into the CCA). The MPD catheter was slowly advanced over the wire to the distal CCA (Figures 2 B, C). The wire was then brought across the stenosis and parked in the ECA (large arrow, Figure 3A).

A 4 3 30 mm ViaTrac balloon was passed over the wire (markings indicated by small arrows in Figure 3A) and deployed (Figure 3B). Figure 3C shows the post-angioplasty result. Repeat vessel measurements after the initial angioplasty showed a larger ECA diameter. A second angioplasty was performed with a 4.5 3 30 mm ViaTrac balloon. However, there was still significant residual stenosis and it was decided to place a stent. 22

CASE 14 • (continued)

0.014” wire

FLEXIBLE TIP

PROXIMAL MARKER

carotid bifurcaton 0.035” wire

STENT

DISTAL MARKER

4B

4A

5

4C

4D

Stent placement would normally require a 7-F guide catheter or a 6-F Cook Shuttle system. Navigating a catheter of this stiffness and caliber into the CCA and stabilizing it there would pose a significant problem. Moreover, the chance of thrombotic complications in the brachial artery would increase too. The 0.014-inch wire was left in place in the ECA. A second wire (Amplatz super-stiff, 0.035-inch) was introduced through the MPD guide catheter and parked in the distal CCA (Figure 4A). The guide catheter was then removed, leaving both wires in place. The purpose of the additional wire was to straighten the vessels and thus increase system stability. A 6-8 mm tapered Acculink stent was advanced over the 0.014-inch wire (Figures 4 B, C) and deployed across the ECA lesion (Figureâ•¯4D). Figure 4.â•‡ A through D. Unsubtracted images, lateral (A, C, D) and AP (B) projection. B. The stent is being advanced distally. C. The parts of the stent are highlighted. D. The black arrows show the outline of the deployed stent. A post-stent placement CCA run (Figure 5) shows excellent resolution of the lesion. Figure 6.â•‡ A and B. Right CCA runs, lateral projection. Collateral circulation (A) pre- and (B) post- stent placement. There is great improvement in the filling of the MCA branches.

ICA OA

IMAX

6B

6A

23

CASE 15 • External carotid artery angioplasty and stenting Alex Abou-Chebl, MD B ackground :â•‡ A 62-year-old man presented with orthostatic right hemispheric TIAs 12 months following right CEA. Symptoms occurred despite treatment with aspirin and clopidogrel. Carotid ultrasound revealed bilateral ICA occlusion. Acetazolimide SPECT scan of the brain confirmed impaired cerebrovascular reserve in the right hemisphere. The therapeutic options were medical therapy, superficial temporal artery-MCA bypass, and endovascular therapy.

In patients with recurrent cerebral ischemia and internal carotid artery occlusion diagnosed by noninvasive studies, cerebral angiography is indicated to best define the anatomy and to: • Differentiate true ICA occlusion from pseudo-occlusion or string-sign • Define collateral flow • Search for treatable, flow-limiting lesions in collateral vessels

1A

2A

2D

1B

1C

2C

2B

2E

Figure 1.â•‡ A–C. Diagnostic angiography. A. An arch angiogram revealed left CCA occlusion (arrow). B. A right CCA angiogram, AP view, showed complete ICA occlusion at the bulb but reconstitution of the ICA via the ophthalmic artery (short arrow) and the vidian artery (longâ•¯arrow). VA injections (not shown) revealed a small Pcom supplying a small amount of collateral flow to the right ICA but a prominent Pcom on the left. C. Multiple views of the right ECA origin were obtained from different angles, and this LAO view revealed a 70% proximal ECA stenosis (arrow). Given that the bulk of right ICA flow was via collaterals from the ECA, the ECA stenosis was considered to be symptomatic. Endovascular therapy was considered for two reasons: 1) To improve collateral flow to the ICA for the presumed hemodynamic TIAs, and 2) to ensure adequate flow to the superficial temporal artery should the patient need bypass surgery. Procedure :â•‡ The decision on how to access the CCA in this case is an important one because the ECA is the target vessel, and it cannot be cannulated with stiff support wires to allow delivery of the sheath or guide catheter. Target lesions should only be crossed with the embolic protection device wire or a small treatment wire, never with larger “work-horse wires.” In this case because the patient had severe atherosclerotic disease of his femoral and iliac arteries, a 6-F sheath was chosen over an 8-F guide, even though a guide catheter would have been preferred because of the tortuosity of the ECA. A 6-F Shuttle Select sheath (Cook) was placed over the JB1 introducer and stiffangled glide wire carefully placed in the distal CCA.

Figure 2.â•‡ A–E. A. An Angioguard (Cordis) embolic protection device was placed with slow, cautious delivery because of the ECA tortuosity (arrows), the whole time ensuring that the sheath does not prolapse into the aorta. B. Preliminary angioplasty with a 3.5 3 9 mm coronary balloon was inadequate (arrow). C. A 6 3 30 mm Precise stent was deployed in the ECA. jailing the common facial-lingual trunk (dashed arrow). Following dilatation with a 4 3 12 mm balloon, there was poor flow through the ECA and filter (arrow). D. Nitroglycerin 200 mg was given through the sheath and multiple unsubtracted views were taken to search for dissection, but only vasospasm was seen (arrow). E. After filter retrieval a final angiogram revealed an excellent result (arrows). The patient’s symptoms have not recurred since. 24

CASE 16 • Brachiocephalic artery angioplasty and stenting Stanley H. Kim, MD B AC KG R O U N D : â•‡ A 60-year-old man presented with a 3-month history of attacks of numbness and weakness of the right side that were brought on by standing up. The patient had a history of occlusion of the left ICA accompanied by a left-hemispheric stroke 5 years prior to this event. Although he was found to have orthostatic hypotension, MRA revealed a high-grade stenosis of the innominate artery.

1B

1A

2

1C

The patient underwent a diagnostic cerebral angiogram that confirmed the severe stenosis of the origin of the innominate artery and the old left cervical ICA occlusion (Figure 1, A and B). The right ICA filled the ACA and MCA bilaterally (Figure 1C). The patient was loaded with 300 mg of Clopidogrel and 325 mg of Aspirin, and innominate artery angioplasty and stenting was performed. Procedure :â•‡ An 8-F sheath was placed in the right CFA. An 8-F multipurpose guide catheter was positioned just proximal to the origin of the innominate artery. A 6.5-mm Accunet DEPD was parked in the distal right CCA. A 10 3 30 mm Acculink stent was deployed across the stenosis. Post-stenting runs showed that the origin of the vessel had not been entirely covered as would be appropriate (to ensure that the proximal vessel is entirely covered, some protrusion of the stent into the lumen of the aorta is usually tolerated). Therefore, a second Acculink stent (10 3 20 mm) was deployed, slightly more proximally so as to cover the ostium. Post-stenting runs again showed that the ostium was not appropriately covered. It was felt that this was due to the propensity of the Acculink stents to migrate distally during deployment. Therefore, it was decided to deploy a balloon-mounted Herculink stent. A 7 3 18 mm stent was chosen and deployed. Post-stent angioplasty was performed with a 7 3 30 mm ViaTrac balloon, which was inflated to nominal pressure. Figure 2 shows the final angiographic result. O utcome :â•‡ The patient had no further episodes of right-arm weakness or numbness. He was discharged home the day after the Â�procedure.

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CASE 17 • Subclavian artery angioplasty and stenting M Fareed K. Suri, MD, Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD B AC KG R O U N D : â•‡ A 63-year-old woman presented with symptoms of posterior circulation ischemia. Diagnostic angiography demonstrated left subclavian origin occlusion with steal syndrome.

1B

Figure 1.â•‡ A and B.â•‡ Aortogram, early (A) and late (B) phase. A. The left subclavian artery is occluded (arrow). B. The left VA flows in retrograde fashion and fills the subclavian artery.

1A

Procedure : â•‡ A 4-F sheath was placed in the left brachial artery and a 6-F sheath was placed in the right CFA. A 4-F catheter was advanced through the brachial artery sheath into the left subclavian artery. The catheter was advanced over a 0.035-inch Terumo wire into the occluded segment of the subclavian artery. The plan had been to cross the occluded segment and then pass an exchange-length wire into the aorta. The next step would be to introduce a snare device through the femoral sheath, capture the wire, pull it out of the sheath, and perform the rest of the procedure over this wire through the femoral sheath. This technique has been developed because the guide catheter is usually not stable enough in the aorta or proximal subclavian stump to allow for a wire to cross the occlusion. However, the occlusion could not be crossed in this manner. The 6-F sheath was exchanged for a Cook Shuttle system that was parked in the subclavian artery stump. A 125 cm 5-F VERT catheter/stiff 0.035-inch glidewire combination was used to traverse the occlusion. The VERT catheter was parked distal to the occlusion, and the glidewire was removed. An exchange-length Nitrix 18 wire was introduced and parked in the axillary artery. A 2-mm microsnare device was introduced through the brachial artery sheath and was used to trap the Nitrix 18 wire and pull it back to the sheath (Figure 2E).

2A

2B

2C

Figure 2. A. Left subclavian artery injection. The 4-F catheter has been advanced to the site of the occlusion. B. Unsubtracted image. The Cook Shuttle has been parked in the stump (black arrow points at the tip). The glidewire (open arrow) has been extruded into the area of occlusion. The white arrow points at the 4-F catheter that has been introduced through the brachial sheath. C. Unsubtracted image. The VERT catheter (arrow) and glidewire (open arrow) have crossed the occlusion. D. Left subclavian artery injection. A small lumen has been created. 2D

26

CASE 17 • (continued)

2E

E. Unsubtracted image. The Nitrix 18 wire extends into the brachial artery, where it is held in place by the snare device (arrow). The open arrow shows the position of the tip of the brachial sheath. Angioplasty with a 6 3 40 mm balloon was followed by deployment of a Precise stent across the lesion.

3 4

Figure 3.â•‡ Unsubtracted image. The balloon is inflated for pre-stent angioplasty. Figure 4.â•‡ Left subclavian artery injection, post-angioplasty and stent placement. No residual stenosis is seen.

27

CASE 18 • Vertebral artery origin stenting Rishi Gupta, MD B AC KG R O U N D : â•‡ A 74-year-old woman presented with diplopia, ataxia, and dysarthria. She was found on MRI to have acute embolic-appearing ischemic infarcts in the cerebellum and occipital lobes. CTA revealed an ostial stenosis of the left VA. Figure 1.â•‡ Left subclavian artery injection. An eccentric, calcified plaque results in a high-grade stenosis (arrow).

1

2A

2B

Figure 2.â•‡ A and B. Left subclavian artery injections, (A) pre- and (B) post-stent placement. A. A 6-F Envoy guide catheter (arrow) was positioned in the subclavian artery just below the origin of the VA. Theâ•¯lesion was crossed with a 0.014-inch wire (open arrow). A 4.5 3 17 mm Liberte stent was then placed across the lesion. The balloon was inflated to nominal pressure, thus releasing the stent. B. Post-stent placement showing mild residual stenosis.

28

CASE 19 • Vertebral artery origin stenting Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD B ackground :â•‡ A 55-year-old woman presented with a symptomatic high-grade stenosis at the origin of the left VA (Figure 1, arrow).

1

2B

2A

3C 3A

3B

3D

Procedure :â•‡ A 6-F MPD Envoy catheter was positioned in the left subclavian artery. A Filter EX device was then advanced through the stenosis into the VA and deployed in the mid-cervical vessel (circle, Figures 2A and 2B). The position of the distal tip of the Filter EX wire is indicated by the arrow in Figure 2A. A 4 3 9 mm Vision Multilink balloon-mounted stent was then placed across the lesion (Figures 3A and B) and deployed (Figure 3C). The balloon catheter was removed and post-stenting images were obtained (Figure 3D), which showed excellent resolution of the lesion. All figures are projections obtained following left subclavian artery injections. Figure 1.â•‡ AP projection. Figure 2.â•‡ A and B. Lateral projection, B unsubtracted. Figure 3.â•‡ A–C. AP projection, B and C unsubtracted. The balloon is seen inflated in A and B (circle). In C, the balloon is deflated and the stent has been deployed (circle). D, Post-stent placement injection. The balloon has been removed, but the filter device is still in place. Figures 4A and Bâ•‡ are both unsubtracted, AP projections. The guidecatheter can be seen proximally (arrow). The filter-retrieval catheter is seen just proximal to the filter in A (open arrow). The wire is then held in position and the retrieval catheter is pushed forward. The filter collapses and is encased in the catheter (circle, 4B). Figure 5â•‡ (AP projection) shows the final angiographic result, after removal of the filter device.

4A

4B 5

29

CASE 20 • Vertebral artery origin stenting Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD BAC KG RO U N D :â•‡ A 71-year-old man presented with a symptomatic VA-origin stenosis (Figure 1, arrow).

4B

4A 1

6

5

2

3 7

Guide catheter used: 6-F MPD Envoy. For enhanced guide catheter stability, a V-18 wire (Figure 4A, arrows) was placed in the distal subclavian artery and left there for the duration of the procedure.

Procedure:â•‡ A Filter EX DEPD was passed through the lesion and deployed in the distal cervical VA (Figure 2, circle). The position of the distal wire is indicated by the black arrow in Figure 2. A Cypher 3.5 3 13 mm monorail stent system was introduced over the 0.014-inch Filter EX wire and positioned across the lesion (Figureâ•¯3, circle). The stent was near-occlusive for this lesion, as can be seen in in Figures 4A and 4B. There was excellent resolution of the stenotic lesion after the stent was deployed (Figures 5 and 6). Deployment was performed at a pressure of 14 atmospheres. After the filter device and V-18 wire were removed, an additional image was obtained that confirmed the success of the procedure (Figure 7).

Figures 1 through 7 are all AP projections. Figures 3 and 5 are unsubtracted. Figures 1, 2, 4, and 6 are left subclavian artery injections. In Figure 1, the stenotic lesion is highlighted by an arrow. In Figure 2, the white arrow points at a short segment of procedure-induced spasm. The deployed filter device is encircled, and the black arrow shows the distal end of the filter wire. Figure 3 shows the stent prior to deployment (circle). Figure 4A is an early arterial phase (frame 6/13). No flow can be seen past the stent in the VA. Figure 4B is a late arterial phase (frame 13/13). There is some minimal flow getting past the stent (arrow). Figure 5 shows the stent (circle). Figure 6 shows the immediate post-stenting result. The spasm has not resolved yet. After removal of the V-18 wire and the filter system, an additional left subclavian artery injection was obtained (Figure 7). The vasospasm had resolved. 30

CASE 21 • Vertebral artery origin stenting Stanley H. Kim, MD B AC KG R O U N D : â•‡ A 60-year-old woman presented with the complaint of several years of tinnitus and dizziness. MRI revealed no evidence of cerebral ischemia but MRA showed a severe stenosis at the origin of the left VA. The patient was started on Aspirin and Clopidogrel by her neurologist and was referred for angiography, which confirmed the severity of the lesion. The patient was scheduled for stent placement.

1

2A

2C

3A

2B

3B

Procedure : â•‡ The procedure was performed with the patient under moderate conscious sedation. Intravenous Heparin was administered at a dose of 4500 units to achieve an ACT of 380 seconds. A 6-F ENVOY guide catheter was navigated into the left subclavian artery just proximal to the origin of the left VA. A 5.5-mm Accunet DEPD was advanced through the left VA origin to the distal cervical left VA. Subsequently, a 4 3 14 mm balloon-mounted Herculink stent was deployed under fluoroscopy at the origin of the VA. Excellent revascularization of the VA origin was observed. The patient developed a small left retroperitoneal hematoma as confirmed by abdominal CT scan after closing the left femoral artery puncture site with a 6-F Angioseal (St. Jude Medical/Daig, Minnetonka, MN) device. Figure 1.â•‡ Left subclavian artery injection shows the VA origin stenosis. Figure 2.â•‡ A and B.â•‡ Left subclavian artery injections. The DEPD (arrow) has been positioned in the distal vessel. C. Unsubtracted image. The stent has been deployed. Figure 3.â•‡ A and B. Left subclavian artery injections, AP extracranial (A) and intracranial (B) projections post stent placement. O utcome :â•‡ The patient’s symptoms resolved after the procedure. She was discharged home four days later. Two weeks after discharge a repeat abdominal CT scan showed near-resolution of the left retroperitoneal hematoma. 31

CASE 22 • Vertebral artery origin stenting Rishi Gupta, MD B AC KG R O U N D : â•‡ An 86-year-old man presented with gait ataxia and clumsiness of the left hand. He was found on MRI to have a left cerebellar infarct. CTA revealed an occluded right VA and a high-grade stenosis of the left VA that was confirmed on cerebral angiography (Figure 1).

2

1

Figure 1.â•‡ Left subclavian artery injection. A high-grade stenosis at the origin of the left VA is seen (black arrow). A 6-F Envoy guide catheter (dashed white arrow) was placed in the left subclavian artery. At that time, intravenous Heparin was administered, aiming at an ACT of 250 seconds. P rocedure : â•‡ A 0.018-inch wire (“buddy” wire, white arrow) was positioned in the distal subclavian artery to provide support for the guide catheter. The lesion was then crossed with a 0.014-inch wire that was parked in the distal cervical VA (open arrow). A 3 3 12 mm Taxus stent was passed over the 0.014-inch wire and positioned across the lesion, completely covering the ostium of the VA. Figure 2.â•‡ Left subclavian artery injection, post-stent deployment. The VA origin is widely patent. In cases of asymptomatic VA origin stenosis, it is reasonable to maximize antiplatelet therapy prior to considering intervention. In case the lesion is symptomatic, there are essentially two options for intervention: endovascular treatment and surgery with bypass of the stenotic segment. Stent-placement is associated with lower restenosis rates than primary angioplasty. However, restenosis rates are significant even following stenting and may correlate with lesion length. Balloon-mounted stents have greater radial force and should be preferred over self-expanding stents. References: Lin YH, Liu YC, Tseng WY, et al. The impact of lesion length on angiographic restenosis after VA origin stenting. Eur J Vasc Endovasc Surg. 2006; 32(4): 379–385. Weber W, Mayer TE, Henkes H, et al. Efficacy of stent angioplasty for symptomatic stenoses of the proximal VA. Eur J Radiol 2005; 56(2): 240–247. Chastain HD, Campbell MS, Iver S, et al. Extracranial VA stent placement: in-hospital and follow-up results. J Neurosurg 1999; 91(4): 547–552.

32

CASE 23 • Vertebral artery V2-segment stenting Stanley H. Kim, MD B AC KG R O U N D : â•‡ A 61-year-old man presented with multiple posterior circulation ischemic strokes (Figures 1A and 1B). The patient was a poor historian and a history of symptoms related to head position could not be elicited reliably. MRA showed a hypoplastic or stenotic left VA and a right extracranial VA stenosis at C4–C5 (Figure 1C, arrow).

1B

1A

1C

2A

3

2B

2C

4

5

Cerebral angiography was performed for further evaluation of the posterior circulation. The left VA was hypoplastic. The right VA appeared normal in neutral head position (Figure 2A). Head turning to the left had no effect (Figure 2B). However, turning the head to the right beyond 45 degrees caused near-occlusion at the C4–C5 level (Figure 2C). Figures 2A–2C are AP projections following right subclavian artery injection. It was decided to attempt stent placement across the affected segment of the VA. P rocedure :â•‡ Because of excessive proximal tortuosity (Figure 3), the procedure was performed via a brachial artery approach. A 3 3 20 mm Taxus Express stent was successfully deployed across the affected segment of the vessel. Repeat angiography was performed 2 weeks after stent placement and showed no narrowing of the right VA on head turning to the right (Figure 4). The patient had no further neurologic symptoms. Computed Â�tomography of the cervical spine (Figure 5) showed an uncinate spur (dark arrow) abutting the stent (white arrow).

Positional occlusion of the VA is an established, albeit rare, cause of posterior circulation ischemia. It has been described following chiropractic manipulation, surgical positioning, trauma, or simple head rotation. It can be a benign phenomenon observed in asymptomatic individuals. Posterior circulation ischemia (often referred to as bow hunter’s syndrome) is typically associated with hypoplasia or disease of the contralateral VA. Compression of the VA can occur at three levels: at the V1 segment (caused by muscles), at the V2 segment (usually caused by osteophytes), or at the V3 segment (caused by muscles, the atlanto-occipital membrane, or trauma). The V3 segment seems to be the most common site of compression, especially at the atlanto-axial joint. Dynamic angiography, i.e. angiography of a vessel performed in different head positions, is the gold standard for diagnosis. So far, treatment, when deemed necessary, has always been decompression by means of surgery.

33

CASE 24 • Vertebral artery V2-segment angioplasty and stenting Stanley H. Kim, MD B AC KG R O U N D : â•‡ A 70-year-old woman presented with a history of 1 year of progressively worsening Â�dizziness and ataxia that were brought on by turning the head to the left. The patient had a history of anterior C5–C6 Â�discectomy and fusion.

1C

1B

1A

A dynamic left VA angiogram was performed. Figures 1.â•‡ A–C. Left subclavian artery injections, AP projection. A. The head is in neutral position. At the C5–C6 level, a focal stenotic lesion (arrow) is present. B. There is no change with the head turned to the right. C. With the head turned to the left, the lesion becomes occlusive. The patient became symptomatic every time she turned her head to the left. No evidence of intracranial stenosis was found.

2A

2B

2C

P rocedure:â•‡ A 5 3 20 mm Acculink stent was placed across the stenotic portion of the left VA (Figure 2B). Some extravasation of contrast was noted during a slow post-stent angioplasty with a 3.5 3 12 mm Maverick balloon (Figure 2C). Therefore, a second 5 3 20 mm Acculink stent was placed overlapping the upper portion of the first stent. On follow-up runs, a no further extravasation was observed.

2D

No immediate complications occurred and the patient remains asymptomatic at 3-month follow-up. Figure 2. A. Measurements for stent placement and angioplasty B. The stent is positioned across the lesion. C. Post-stent angioplasty. Unsubtracted image. The balloon is inflated. D. Final result post angioplasty and stenting 3 2 with head turned to the left.

34

CASE 25 • Combined Subclavian and Vertebral artery angioplasty and stenting Thomas Wolfe , MD, John R. Lynch, MD, Brian-Fred Fitzsimmons, MD, Osama O. Zaidat, MD MSc B ackground :â•‡ A 55-year-old woman developed intermittent left fingertip tingling, recurrent syncopal and pre-syncopal attacks, and orthostatic symptomatology. A tilt table test was positive. However, MRA demonstrated high-grade stenosis at the left subclavian artery origin. The left VA origin was difficult to assess on the MRA, due to artifact.

Figure 1.â•‡ Aortogram illustrating steal phenomenon (right to left) due to a high-grade stenosis (~ 90%) at the subclavian artery origin (white arrow). Retrograde flow is slow because of a stenosis at the origin of the left VA, estimated at >50% (black arrows). Treatment options for this lesion include angioplasty and stent placement using the femoral or brachial approach and bypass grafting between the diseased subclavian artery, and either the ipsilateral carotid or the contralateral subclavian artery or axillary artery. The chosen treatment was a transfemoral endovascular approach with intent to stent with distal embolic protection, if technically feasible. The femoral approach more easily accommodates the larger sheath required to support the subclavian stent, and it provides more direct access for treating tandem subclavian-VA lesions. Figure 2.â•‡ A–C.â•‡ Proximal left subclavian artery runs, AP projection. A. Prior to the procedure, severe subclavian artery stenosis and no antegrade VA flow is seen. B. Post-stent deployment in the subclavian artery and prior to angioplasty, significant residual stenosis is present. C. Post tandem subclavian-vertebral stent placement, there is significant improvement in distal antegrade subclavian artery and VA flow and <10% residual stenosis at both lesion sites. 2A

2B

2C

Procedure : â•‡ After fluoroscopically guided placement of a 90 cm 6-F Brite Tip sheath in the descending aorta, Heparin was administered intravenously and the ACT was maintained at 250 to 350 seconds throughout the procedure. The Brite Tip sheath was advanced to the left subclavian artery origin over a leading 6-F Bernstein catheter. Baseline subclavian artery runs were obtained (Figure 2A). Stent measurements were made, and a 4 mm Emboshield basket was successfully deployed in the mid-cervical VA. An XAct 8 3 20 mm stent was placed across the lesion (Figure 2B). Post-stent angioplasty was then performed using a 7 3 20 mm ViaTrac balloon inflated at 10 atmospheres. A Taxus 3.5 3 8 mm stent was then loaded over the Emboshield microwire and deployed across the left VA origin stenosis with Â�balloon inflation to 12 atmospheres. After demonstrating technical success of the tandem stenting (Figure 2C), the Emboshield was retrieved. Right VA angiography demonstrated normal left VA reflux wash-out, indicating resolution of the steal phenomenon with preservation of the distal posterior circulation. 35

CASE 26 • Combined Subclavian and Vertebral artery angioplasty and stenting Alex Abou-Chebl, MD B AC KG R O U N D : â•‡ A 53-year-old woman presented with recurrent posterior circulation TIAs and right-arm claudication while brushing her hair. The patient had a history of heavy cigarette smoking, hyperlipidemia, and diabetes mellitus, and had been treated at an outside institution with a right subclavian artery stent 6 months prior. The patient had not been instructed to stop smoking and to take lipid-lowering agents. Angiography was performed.

Stenting of the subclavian artery is an acceptable and effective means for treating arm claudication or the subclavian steal syndrome. However, subclavian artery interventions are often challenging because of the difficulty in maintaining system stability and the need to protect the origin of the vertebral arteries. As a rule, it is never appropriate to stent across the ostium of the VA. Also, the proximal great vessels are best treated with balloon expandable stents because placement is much easier. In this case, the treatment of the right subclavian artery was performed improperly, necessitating repeat treatment at our institution.

1A

1C

1B

Proximal stent marker

2A

3A

3B

2C

2B

Figure 1. A. Left subclavian injection. The left VA is occluded at the origin. B. Right subclavian injection. A selfexpanding Wallstent had been deployed covering the ostia of major branches including the VA. There is diffuse in-stent neointimal growth (notice the distance between the struts of the stent indicated by the black arrows and the actual vessel lumen). There is also severe stenosis at the origin of the VA (large white arrow) and at the distal end of the stent (small white arrow). C. Unsubtracted image. Notice the “fish-mouthing” at the distal end of the stent (circle), seen often with the braided Wallstent. Endovascular treatment was considered to be the best option for this patient since both the VA and Â�subclavian artery could be treated in the same setting.

P rocedure :â•‡ A torquable, nonhydrophilic 0.035-inch wire was placed in the axillary artery. A JR4 8-F guide catheter was passed over the wire and positioned in the proximal subclavian artery (Figure 2A, white arrow). Then, a hydrophilic 0.014-inch coronary wire (Figure 2A, black arrow) was passed into the VA and parked at the C2 level. Predilation of the VA ostium was then performed with a 2â•¯3 9 mm coronary balloon. This step was crucial because passing a stent through the struts of another stent can be difficult and there is a risk of shearing and embolization of the stent off of the balloon. In this case, since the Wallstent struts are braided rather than welded together, it was not difficult, to dilate through the stent even with a Â�noncompliant Â�balloon. Then, a 3 3 8 mm Cypher stent was placed across the lesion. The reason for this was that VA-origin lesions have very high restenosis rates and that this specific patient seemed to be prone to neointimal growth. To achieve adequate stability, the guide catheter had to be brought very close to the VA ostium (Figure 2B, white arrow). Because of the shape of the JR4 catheter, the stent and wire are in line with the VA (Figure 2B). Note that the stent is positioned lower than usual in order to cover the neointimal growth within the subclavian artery stent. Following successful stenting of the VA origin, a self-expanding Smart Control stent was deployed over the 0.035-inch wire at the edge of the preexisting subclavian artery stent and post-dilated with a 6-mm balloon (Figure 2C shows the final angiographic results). A self-expanding stent was chosen for this part of the subclavian artery, which may be compressed against the clavicle because it is more resistant to crushing and deformation. Post-stenting, the filling of the basilar was significantly improved (Figure 3, A [pre] and B [post]). 36

CHAPTER 2

Angioplasty and Stenting of the Intracranial Vessels

2

1

BALLOON

STENT

3

4

POST-STENT ANGIOPLASTY

6

5

37

A severe right vertebral artery stenosis is seen on CTA (1) and conventional angiography (2). Angioplasty (3), stenting (4) and post-stent angioplasty (5) are required before satisfactory recanalization is achieved (6).

OVERVIEW OF CASES I

INTRACRANIAL INTERNAL CAROTID ARTERY

Case 27

Angioplasty Stenting not feasible

Case 28

Bilateral angioplasty Grave’s disease Moya Moya

II

MIDDLE CEREBRAL ARTERY

Case 29

Angioplasty and stent placement Measurements required for intracranial stenting

Case 30

Angioplasty of the superior division Near-occlusive stenosis

III

INTRACRANIAL VERTEBRAL ARTERY

Case 31

Stent placement

Case 32

Angioplasty and stent placement Severe proximal tortuosity

Case 33

Angioplasty and stent placement Bilateral vertebral artery disease

Case 34

Angioplasty Thrombotic complication Intra-arterial thrombolysis Brachial artery approach

IV

BASILAR ARTERY

Case 35

Angioplasty Stenting not feasible latrogenic vasospasm

Case 36

Angioplasty, scheduled staged procedure Stenting deferred at follow-up

Case 37

Angioplasty Clot propagation Coil occlusion of the intracranial vertebral

CASES 27–28

CASES 29–30

CASES 31–34

CASES 35–40

38

Case 38

Angioplasty and stent placement

Case 39

Staged angioplasty and stenting Calculation of balloon and stent size Technique used to deploy the Wingspan stent

Case 40

Stent placement Balloon-mounted stent Facts on intracranial atherosclerosis

V

POSTERIOR CEREBRAL ARTERY

Case 41

Angioplasty and stent placement

39

CASE 41

CASE 27â•… •â•… Intracranial Internal carotid artery angioplasty Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD B AC KG R O U N D :â•‡ A 66-year-old man presented with symptomatic left ICA intracranial stenosis refractory to medical treatment. Procedure : â•‡ A 6-F sheath was placed in the right CFA. A 6-F MPD Envoy catheter was then advanced into the left CCA. The guide catheter was parked in the mid-cervical ICA. A Taxus 3 3 9 mm balloon-supported stent was advanced over a Transend-14 floppy wire into the intracranial ICA. The guide catheter was not adequately stable for the stent to traverse the area of stenosis (Figure 2A). More distal placement of the guide catheter did not add enough stability (Figure 2B). A V-18 wire was therefore passed through the guide catheter into the distal cervical ICA and was left there to provide support for subsequent stent positioning maneuvers (Figure 2C). Still the stent could not be advanced distally enough, and the stenting procedure was therefore aborted. The stent was pulled back into the guide catheter under direct visualization to prevent accidental dislodging of the stent (Figure 2D). A Maverick 3.5 3 9 mm balloon was brought into position and deployed once at nominal pressure (6 atmospheres). Follow-up images showed mild residual stenosis (Figure 3).

Figure 1.â•‡ Left ICA injection, oblique projection. The arrow points at the area of stenosis.

2A

1

2B

Figure 2.â•‡ A and B. Unsubtracted images, AP projection. A. The arrow points at a guide catheter loop that prolapsed proximally during attempts to advance the stent. B. The guide catheter has been parked more distally in an attempt to stabilize the system (the arrow points at the catheter tip). C. Left ICA injection. The arrow points at the V-18 wire. D. Unsubtracted image. The arrow points at the stent as it is being retrieved into the guide catheter. Figure 3.â•‡ Left ICA injection, oblique projection, post-angioplasty. There is mild residual stenosis.

2D 3 2C

40

CASE 28â•… •â•… Intracranial Internal carotid artery angioplasty Stanley H. Kim, MD, Anant I. Patel, MD B ackground :â•‡ A 33-year-old woman with history of Grave’s disease presented with right-sided weakness and numbness that lasted for a week. MRI showed left parieto-occipital ischemic changes.

1B 1C

1A

A diagnostic cerebral angiogram revealed severe bilateral supraclinoid ICA stenoses with net-like basal and cortical collateral vessels in the anterior and less so in the posterior circulation, consistent with moyamoya disease. The patient had a normal sedimentation rate. Figure 1. A. Left ICA injection, AP projection. The arrow indicates the site of stenosis. The engorged lenticulostriate arteries are encircled. B. Left ICA injection, lateral projection. The arrow again points at the stenotic lesion. C. Right ICA injection, AP projection. Severe stenosis is seen at the ICA terminus (arrow). Typical moyamoya small-vessel changes are not seen. Procedure : â•‡ It was decided to treat the symptomatic left ICA lesion. Angioplasty of the supraclinoid ICA was performed with a Maverick 2 3 9 mm balloon under conscious sedation. There were no complications. The angiographic result was good and sustained at follow-up at 7 months (Figure 2, A and B). At the same session, angioplasty of the right ICA was performed, again with a 2 3 9 mm Maverick balloon. The patient has remained asymptomatic for 3 years following the procedures.

2B

2A

Figure 2. A. Left ICA injection, oblique projection. There is minimal residual stenosis at 7 months post-angioplasty. Notice the regression of the abnormal vascular network seen in Figure 1A. B. Right ICA injection, AP projection. Minimal residual stenosis immediately postangioplasty.

An association between Grave’s disease and moyamoya has been described in multiple case reports and small case series. Â�Angioplasty has been recently proposed as an effective treatment alternative for early moyamoya. References: Sasaki T, Nogawa S, Amano T. Co-morbidity of moyamoya disease with Grave’s disease. Report of three cases and review of the literature. Intern Med 2006; 45(9): 649–653. Rodriguez GJ, Kirmani JF, Ezzeddine MA, Qureshi AI. Primary percutaneous transluminal angioplasty for early moyamoya disease. J Neuroimaging 2007; 17(1): 48–53.

41

CASE 29â•… •â•… Middle cerebral artery angioplasty and stenting Randall C . Edgell, MD, Alan S. Boulos, MD B AC KG R O U N D :â•‡ A 54-year-old woman presented with an acute fronto-temporal stroke. CTA revealed a high-grade MCA stenosis. MRI revealed a large area of perfusion/diffusion mismatch. Her clinical symptoms were also more severe than would have been predicted based on the MRI diffusion-weighted lesion, i.e., a clinical diffusion mismatch was also present.

D2

Measurements for stenting. D1. Vessel diameter at the point of maximal stenosis. D2. Diameter of pre-stenosis straight MCA segment. Used to size stent. (1-D1/D2) 3 100 = % stenosis according to WASID criteria. D3. Diameter of post-stenosis MCA. Used to size pre-stent angioplasty balloon. D4 = minimal stent length. Allow 2-4 mm on either side of the lesion. Keep in mind that longer stents are less navigable.

D1 D3

D4

1

2C 2A

2D

2B

P rocedure : 1. The guide catheter (6-F MPC Envoy) was placed in the ICA. 2. Because of the severity of the stenosis a 0.008-inch wire (Mirage) was required to cross the lesion. 3. An Echelon 10 microcatheter was then used to cross the lesion and was positioned in an M3 division. 4. A 0.014-inch Agility 350 cm wire was then used to exchange the microcatheter for a 1.5 3 15 mm semicompliant OTW Maverick balloon. A slow inflation and deflation was performed (Figure 2A, unsubtracted image). 5. There was moderate post-angioplasty residual stenosis (Figure 2B, ICA injection, AP projection). 6. The balloon catheter was then exchanged for a 2 3 8 mm balloon-mounted OTW coronary stent (MiniVision). A slow inflation and deflation was performed (Figure 2C, unsubtracted image). 7. A post-stent angiogam revealed excellent revascularization of the MCA (Figure 2D, ICA injection, AP projection).

42

CASE 30 • Middle cerebral artery angioplasty M. Fareed K. Suri, MD, Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD B ackground :â•‡ A 79-year-old man presented with repeated stereotypical TIAs. Diagnostic Â�angiography demonstrated a high-grade stenosis of the superior M2 segment of the right MCA. Figure 1. A and B.â•‡ Right ICA injection, AP Â�projection, early arterial (A) and capillary (B) phase. There is near-occlusion of the superior division of the MCA (arrow). In the capillary phase there is paucity of superior Â�division branches and pial collaterals can be seen arising from the inferior division and the ACA.

1B

1A

Procedure : â•‡ A Prowler Plus microcatheter was advanced over a Transend 14 platinum wire into the right MCA, just proximal to the stenosis. A microcatheter injection (Figure 2, A and B) confirmed the severity of the lesion. The lesion could not be traversed with the platinum wire, and a Transend 14 floppy was used instead. Angioplasty was then performed with a Maverick 1.5 3 15 mm balloon. This resulted in excellent recanalization, as shown in Figure 3.

2B

2A

Figure 2. A and B.â•‡ Microcatheter injection, AP projection, frames 7/17 (A) and 8/17 (B). There is diminished and delayed filling of the superior division of the MCA (arrows). Figure 3.â•‡ Right ICA injection, AP projection. Excellent recanalization occurred post angioplasty.

3

43

CASE 31 • Stenting of the intracranial Vertebral artery Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD BACKGROUND:â•‡ 63-year-old man presented with multiple ischemic events in the posterior circulation. The patient was found to have lesions in multiple vessels. The most significant lesion was a 63% (WASID criteria) right VA stenosis (Figure 1, arrow). Procedure : The guide catheter was parked in the right distal cervical VA. The stent was advanced across the lesion over the microwire, which was parked in the basilar artery. The stent was deployed, leading to complete resolution of the lesion (Figure 4). Guide-catheter used: 6-F MPC Envoy Microcatheter: None Stent: Cypher 2.5 3 8 mm, balloon-mounted, monorail Microwire: Transend 14

1

2

4

3

Figuresâ•‡ 1, 2, and 4 are AP projection images acquired following right VA injections. Figureâ•‡ 3 is an unsubtracted image in AP projection. 1. The arrow points at the area of stenosis. 2. The microwire has been passed through the stenosis. 3. The undeployed stent has been positioned across the lesion (arrow). 4. Post-stenting shows excellent resolution of the lesion.

44

CASE 32 • Angioplasty and stenting of the intracranial Vertebral artery Alex Abou-Chebl, MD B ackground :â•‡ An 82-year-old man presented with recurrent dysarthria and ataxia despite therapy with Aspirin. MRA revealed that he had bilateral intracranial VA stenosis. He was not considered to be a candidate for Warfarin therapy due to the presence of an expanding 7 cm AAA, which required surgery. Endovascular therapy was believed to be the best option because it would allow for AAA repair 30 days post stenting. The intracranial posterior circulation is generally easier to access than the anterior circulation because of the lack of sharp angulations that are often found in the cavernous ICA. However, the origins of the VA can be tortuous, making stent delivery difficult. In such cases, self-expanding stents may be more easily delivered, but for lesions that are severely calcified, they may not provide adequate radial force. Balloon-expandable stents are preferable in such cases but their delivery requires more proximal and wire support.

1A

1B

Aortic arch injection (not shown) revealed a type III arch. Figure 1.â•‡ A and B. Left subclavian artery angiogram, extracranial AP (A) and intracranial (B) lateral projection. There is severe Â�tortuosity of the VA origin (circle, Figure 1A). There is also severe stenosis of the intracranial VA distal to the origin of the PICA (arrow, Figure 1B).

1C

1D

Figure 1.â•‡ C and D. Right subclavian artery angiogram extracranial (C) and intracranial (D) AP projection. There is again severe, S-shaped tortuosity of the proximal VA (circle, Figure 1C). Intracranially, a severe, ulcerated stenosis of the VA is seen distal to the origin of the PICA.

Since both lesions were severe, it was reasonable to treat either of them. Although the right-sided stenosis was ulcerated and may therefore have been the culprit lesion, the severe angulation of the aortic arch and the tortuosity of the proximal right VA rendered treatment technically Â�difficult and risky. Access to the left VA is generally easier than to the right, and it was decided to treat this vessel.

2A

2B

P rocedure :â•‡ The conventional technique of passing a hydrophilic 0.035-inch wire through the ostium to allow guide catheter placement was briefly attempted but not pursued aggressively because of the risk of VA dissection.

Figure 2. A. A less ideal approach was to place a 0.035-inch wire (black arrow) distally in the axillary artery, over which an 8-F guidecatheter (arrowhead) could be placed in the subclavian artery just proximal to the VA origin. Keeping the 0.035-inch wire in place for support, a Synchro wire (white arrow) was used to cautiously wire the VA with additional support from a 2 3 9 mm Maverick OTW balloon catheter (thin black arrow). In such cases, only OTW balloons and stent delivery systems are chosen since they track better and they allow for the exchange of wires if needed. B. With the balloon as support, the VA lesion was crossed and the wire placed in the right PCA (black arrow). The balloon wasâ•¯then slowly inflated in the lesion, which was resistant to the angioplasty (white arrow shows a “waist” on the balloon). Predilation is performed in most cases to facilitate stent delivery, determine the resistance of the lesion to dilation and therefore help guide stent selection, and to assess how well the patient tolerates angioplasty. If a severe headache develops with angioplasty with such an undersized balloon (the VA measured 3.5 mm), then a more conservative approach is taken with stent sizing and inflation pressures to avoid vessel rupture. 45

CASE 32 • (continued)

2C

3

C. Left subclavian artery injection, AP projection. The immediate post-angioplasty angiogram revealed significant lesion recoil (arrow) with almost no change in the lesion. In such cases when there is severe residual stenosis, stent placement is essential to prevent acute or subacute thrombosis. Furthermore, since the lesion was resistant to angioplasty, a drug-eluting stent may not have been the ideal stent to use since such devices are at greater risk of thrombosis if not fully deployed and opposed to the vessel wall. In this case, a 3.5 3 9 mm Zeta stent was deployed very slowly (over 2 minutes). Although a longer stent would have been more ideal to cover the ballooned segment fully from “normal” artery to “normal” artery, the lack of a guide catheter within the VA itself would have made a longer stent difficult to deliver. Figure 3.â•‡ Left subclavian artery injection, lateral projection. The final angiographic result was excellent. There were no clinical complications.

46

CASE 33 • Angioplasty and stenting of the intracranial Vertebral artery Alexandros L. Georgiadis, MD, Qaisar A. Shah, MD, Vallabh Janardhan, MD B ackground :â•‡ A 65-year-old man presented with acute left-sided hearing loss. No abnormalities were noted on MRI. One month later, he presented with bilateral PICA territory strokes and was found to have occlusion of the left intradural VA. The patient was started on anticoagulation.

1A

1B

Figure 1. A. MRI DWI shows bilateral areas of diffusion restriction in PICA territory. B. On MRA, the left VA is not visualized. C. CTA shows severe focal stenosis of the intradural right VA (arrow). The left VA (not shown) wasâ•¯found to be occluded.

1C

A month later, the patient was readmitted with progressive dysphagia, nausea and, vomiting.

2B

2A

Figure 2. A. MRI DWI shows new lesions in the cerebellum and lateral medulla. B. On intracranial MRA, the left ICA and the entire posterior circulation are not visualized. C. Extracranial MRA with gadolinium. There is a flame-shaped occlusion of the left ICA past the bulb suggestive of a possible dissection. Both vertebral arteries are patent extracranially.

2C

The patient was referred for diagnostic angiography with possible intervention. Figure 3. A. Right CCA injection, AP projection. Robust cross-filling into the left ACA and MCA is seen.

R CCA

3A

47

CASE 33 • (continued)

L CCA

R CCA

3B

3C

L CCA

L VA

3D

RVA

RVA

3E

3F

3G

Figure 3. B. Right CCA injection, lateral projection. The CCA contributes to the posterior circulation (arrow) via a small Pcom (open arrow). C and D.â•‡ Left CCA injection, AP projections. The ICA tapers off after the bulb and appears to be occluded (arrow, Figure 3C). However, there is slow flow, as seen in the late arterial phase (Figure 3D), which terminates approximately at theâ•¯level of the cavernous segment (arrow). E. Left VA injection, lateral projection. The VA is occluded at the level of the distal V3 segment (arrow). F and G. Right VA injection, lateral (F) and AP (G) projections. There is signal drop-out at the level of the intracranial right VA (arrows). There is, however, some distal flow, indicating that the lesion is only near-occlusive. P rocedure : â•‡ In deciding which artery to treat, it is important to assess which is the symptomatic vessel. Based both on the clinical findings and the DWI-MRI, the symptomatic vessel is the right VA. The left ICA occlusion is also subacute or acute, and treating that would arguably augment flow to the posterior circulation. Treating the cervical lesion (possibly a dissection) would be feasible. However, a tandem occlusive lesion is present intracranially, which would be too technically difficult and hazardous to treat. Figure 4. A. Through an Envoy 6-F MPD guide catheter that was parked in the distal right cervical VA, an SL 10 microcatheter was advanced into the intracranial VA over an Agility 0.014 inch microwire. Runs were obtained. B. The microwire was then exchanged for a 300 cm Transend 14, which was parked in the right PCA.

4B

4A

48

CASE 33 • (continued)

4C

4D

4E

C and D.â•‡Unsubtracted images in AP (C) and lateral (D) projection. A Gateway 2 3 9 mm balloon was advanced to the site of stenosis (Figure 4C, arrow) and inflated to nominal pressure (Figure 4D, arrow). Following the first angioplasty, there was inadequate recanalization. The balloon was then exchanged for a 2.75 3 9 mm Gateway, and a second angioplasty was performed. This resulted in sufficient recanalization for the stent to pass. The larger balloon size was based on repeat measurements of the vessel. E. Right VA injection, AP projection following the second angioplasty.

5B

5A

5C

5D

5E

Figure 5.â•‡ Unsubtracted image. A. The balloon catheter was exchanged over the Transend-14 wire for a Wingspan stent (arrows point at the proximal and distal markers). B. Unsubtracted image. The stent was then deployed. The arrows point again at the markers. C. Right VA injection, AP projection, post-stent placement. Significant residual stenosis is still present. It was therefore decided to perform post-stent angioplasty. D. Unsubtracted image. The balloon (arrow) was positioned across the area of maximal residual stenosis and inflated. The white arrows point at the stent markings. E. Final right VA injection, AP projection. Despite of the presence of residual stenosis, very good distal flow is now seen.

49

CASE 34 • Angioplasty of the intracranial Vertebral artery Stanley H. Kim, MD B AC KG R O U N D :â•‡ A 68-year-old man presented with acute exacerbation of chronic dizziness and intermittent blurred vision and transient left-side numbness lasting 40 minutes. He had a history of hyperlipidemia and pituitary adenoma. MRI revealed no acute ischemic changes on DWI. However, MRA suggested a high-grade right intracranial VA stenosis. The patient was referred for diagnostic angiography. Arch injection revealed a very tortuous innominate artery bifurcation and tortuous origin of the right VA off the right subclavian artery (Figure 1A). Intracranial views following right subclavian artery injection revealed about 75% stenosis of the intracranial right VA (Figure 1B). The left VA was found to end in the left PICA. In view of those clinical and angiographic findings, right VA angioplasty and possibly stent placement were recommended. On the day prior to the procedure the patient was given 300 mg of Clopidogrel and 325 mg of Aspirin. Figure 1. A. Aortogram. Excessive tortuosity of the rightsided cerebral vessels is seen. B. Right VA injection, lateral projection. A high-grade intracranial stenosis (circle) is apparent. 1A

1B

P rocedure : â•‡ The procedure was carried out under moderate conscious sedation. The Allen test was performed to verfify adequate collateral supply from the ulnar artery. A micropuncture needle was used to access the right radial artery (Figure 2A) and a 4-F dilator was advanced over a wire into the radial artery. A solution containing a mixture of Heparin (5000 units), Verapamil (2.5 mg), Lidocaine (2%, 1 mL), Sodium bicarbonate (42 mg), and Nitroglycerine (2 mg) was injected through the 4-F dilator over a minute. The 4-F Â�dilator was then replaced by a 6-F sheath (Figure 2B).

2A

2B

A 6-F Envoy guide catheter was navigated over a glidewire under fluoroscopy into the right VA (Figure 2D) via the brachial (Figure 2C) and subclavian arteries. Additional 3000 units of Heparin were administered intravenously to achieve an ACT level of 320 seconds. A Prowler 14 microcatheter was navigated over a 0.014 inch Synchro microwire across the stenotic portion of the right VA and then the microwire was exchanged for a BMW exchange wire, which was parked in the left PCA (Figure 2E). A Maverick balloon (2.5 3 12 mm) was introduced over the BMW wire and angioplasty was performed. Total inflation time for the balloon was 20 seconds. Mild improvement in the luminal diameter of the vessel was seen (not shown). It was then attempted to navigate a Taxus stent (3 3 12 mm) over the BMW wire, but the stent could not be brought past the cervical C1-C2 level and thrombosis of the VA occurred (Figure 2F). The stent catheter was removed, and the Prowler microcatheter was advanced to the occlusion site over the BMW wire (Figure 2F).

50

CASE 34 • (continued)

2C

2D

2F

2E

Figure 2. C. Unsubtracted image shows the guide catheter (arrow points at the tip) as it is being advanced into the brachial artery. D. Right VA injection. The guide catheter has been placed in the proximal VA. It was then advanced to the distal cervical portion of the vessel. E. Right VA injection, oblique projection. The BMW wire is parked in the left PCA. F. Right VA injection, oblique projection. The microcatheter (arrow points at the tip) has been advanced to the site of occlusion. Six units of Reteplase were injected through the microcatheter, and complete recanalization of the right VA was achieved (Figure 3). The procedure was terminated. The patient did not develop any neurologic deficits. Antiplatelet treatment with Aspirin and Clopidogrel was continued. Figure 3.â•‡ Final right VA injection in AP projection shows completely recanalized posterior circulation.

3

outcome :â•‡ The patient was discharged home 2 days after the procedure with no neurologic deficits. At one-year follow-up, no new stroke or TIA had occurred. The Wingspan stent was not available at the time. conclusion :â•‡ Symptomatic VA stenosis is associated with high incidence of recurrent stroke. In cases where transfemoral approach to the VA is not feasible, radial approach is a viable alternative. Still, highly flexible stents such as the Wingspan may be required to access a tortuous VA.

51

CASE 35 • Basilar artery angioplasty Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD B AC KG R O U N D :â•‡ A 53-year-old man presented with hemiparesis and was found to have a pontine stroke (Figure 1A). MRA showed a mid-basilar artery stenosis (Figure 1B), which was confirmed by angiogram (Figure 1C).

1A

1B

1C

Figure 1. A. MRI DWI shows a pontine infarct (arrow). B. MRA. Signal drop-out in the mid-basilar artery (arrow) is seen. C. VA injection, lateral projection. The arrow points at the area of stenosis.

Procedure :â•‡ A 6-F sheath was placed in the right CFA. A 6-F Envoy MPD guide catheter was positioned in the distal extracranial left VA. The catheter caused significant vasospasm (Figure 2A) and was therefore repositioned more proximally. It was felt that the guide catheter could not provide enough support for a stent at this position, and it was therefore decided to proceed with primary angioplasty. A 3 3 9 mm Maverick balloon was advanced over a Transend-14 floppy microwire into the left VA. Due to inadequate system Â�stability with proximal positioning, the guide catheter had to be readvanced into the distal extracranial VA despite the vasospasm. For added stability, the microwire was parked distally in the left PCA in a P2 branch, and the balloon was advanced into the basilar artery (Figure 2B) and through the stenotic lesion. The balloon was then inflated to a pressure of 6 atmospheres (Figure 2C). Post-angioplasty runs (Figure 2D) showed only mild residual stenosis so that further angioplasty was deemed unnecessary.

P2 P1

F 2A

2B

2C

2D

Figure 2. A. Left VA injection. The rectangle highlights an area of multifocal vasospasm beginning just distal to the tip of the catheter (arrow). B and C.â•‡ Unsubtracted images. (B) The microwire is positioned in a P2 segment of the left PCA. The arrow shows the balloon, which is being advanced distally. (C) The balloon has been inflated to its nominal pressure of 6 atmospheres (arrow). D. Left VA injection, lateral projection. There is only mild residual stenosis post-angioplasty.

52

CASE 36 • Basilar artery angioplasty Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD B ackground :â•‡ A 59-year-old man was found wandering the streets confused.

1A

1B

1C

1D

1E

1F

Figure 1.â•‡ A–F.â•‡A xial MRI, DWI. Multiple posterior circulation ischemic foci are seen. G. MRA shows a proximal basilar stenosis (arrow).

Figure 2.â•‡ A and B. Left VA injection, AP (A) and lateral (B) projections. A proximal basilar artery stenosis (arrows) is seen. The length of the lesion can be best appreciated in the lateral projection. P rocedure :â•‡ The decision was made to perform primary angioplasty acutely, to be followed by stent placement 1â•¯to 2 months later. Angioplasty was performed three times, from distal to proximal, covering more than half the length 2B of the basilar artery. A Maverick 2.5 3 10 mm balloon was used. A 5-F MPD Envoy guide catheter was used initially but did not provide adequate support. Therefore, a 6-F MPD was used in conjunction with a V-18 support wire. Both devices were parked in the distal cervical VA. Figures 3â•‡ A and B show the microwire (arrow) and balloon (circle) in one of the angioplasty procedures (unsubtracted images). The balloon is inflated in 3B. Figure 4.â•‡ A and B. Left VA injection, AP (A) and lateral (B) projection. Final injections post-angioplasty.

2A

3B

3A

The patient returned for stent placement 2 months later. Stent placement was deferred for the following reasons: • Great discrepancy between the size of the proximal basilar (1.57 mm) and the size of the vessel at the vertebro-basilar artery junction (3.82 mm) (see Figure 5B). A 3.5-or 4-mm stent might have caused injury to the proximal basilar artery. • Long segment of diseased vessel that could not be covered by a stent • Mild maximal residual stenosis (30%, see Figure 5A) • The patient had been asymptomatic

4B

4A

1G

Left VA Injection AP Projection

Left VA Injection AP Projection

5B

5A

53

CASE 37 • Basilar artery angioplasty Guilherme Dabus, MD, Raul G. Nogueira, MD B AC KG R O U N D :â•‡ A 73-year-old woman presented with acute onset of vertigo. CTA demonstrated an extensive non-occlusive basilar artery thrombus (Figure 1, arrowhead) and complete occlusion of the right VA (Figure 1, arrow). Brain MRI performed at that time did not reveal any infarcts. The patient was subsequently started on intravenous infusion of Heparin. A few hours later, she suddenly developed right hemiparesis, facial numbness and weakness, as well as nausea, vomiting, dysarthria, right-gaze paralysis, and downbeat nystagmus. Intravenous infusion of Eptifibatide was began after a head CT ruled out hemorrhage, and the patient was emergently taken to the neurointerventional suite. Initial angiogram showed complete occlusion of the basilar artery (Figure 2, A and B), presumably due to additional clot propagation from the right VA.

2A

2B

2C

1

2D

Procedure Part 1:â•‡ Angioplasty and thrombolysis. A left VA injection is shown in Figure 2, A (AP projection) and B (lateral). There was complete occlusion of the proximal basilar artery (white arrow). Note the PICA-SCA collateral circulation (black arrows, Figure 2B). 2G 2E

2F

A Hyperglide 4 3 10 mm balloon was navigated into the basilar artery over an 3-pedion 10 guidewire. Gentle balloon angioplasty was sequentially performed in the basilar artery, proximally to distally, under continuous road-mapping visualization by using a hand-held device (Cadence syringe, ev3, Inc.).

Figures 2, C-G.â•‡ The arrows in Figures 2C-2F demonstrate the balloon positioned in different locations within the basilar artery during sequential angioplasty. During the procedure, the microwire was occasionally removed and Urokinase was infused through the balloon microcatheter at different locations, for a total of 250,000 units. Final angiogram (Figure 2G) demonstrated complete recanalization of the basilar artery and all of its major branches except for the right SCA (arrow).

3A

3B

4A

4B

Procedure Part II:â•‡ Right VA coil occlusion. This was performed as an attempt to prevent stump emboli or clot propagation from the right VA into the basilar artery. Figure 3A demonstrates complete occlusion of the distal right VA with flow stagnation (arrows). Figure 3B demonstrates the successful coil occlusion of the right VA. The arrows point at the coil mass. follow- up : MRI performed 24 hours later demonstrated small infarcts affecting the right PICA and bilateral SCA territories (arrows – Figures 4 A and B) without any brainstem involvement. The patient made an excellent functional recovery and was discharged home with her family. 54

CASE 38 • Basilar artery angioplasty and stenting Raul G. Nogueira, MD, Joshua A. Hirsch, MD B ackground :â•‡ A 72-year-old man presented with medically refractory recurrent posterior circulation ischemic events. CTA showed critical basilar artery stenosis.

1A

1B

2A

3A

1C

2B

2C

3B

4B

4A

5A

Figure 1. A. DWI MRI. The arrow points at an area of restricted diffusion. B. DWI MRI obtained 3 weeks later shows new areas of ischemia (arrow). C. CTA shows severe stenosis of the proximal basilar artery (arrow). It was decided to proceed with balloon angioplasty and stenting of the basilar artery stenosis. The patient’s warfarin was discontinued and he was started on clopidogrel and Aspirin. Diagnostic angiography showed mild to moderate narrowing and tortuosity just distal to the left VA origin (arrow, Figure 2A). There was severe stenosis of the basilar artery at the level just distal to the take-off of the AICAs (arrow, Figures 2B and 2C). Procedure : A Prowler 14 microcatheter was navigated across the stenotic segment with the aid of a Transend 300 platinum-tip microwire. The wire was parked in the left PCA (white arrow, Figure 3A). The microcatheter was removed and a 3 3 20 mm Cross-Sail rapid-exchange balloon was introduced. It was advanced over the Transend wire and centered across the stenosis (circle, Figure 3A). The balloon was inflated to a pressure of 3 atmospheres at a rate of 1-2 Â�atmospheres per minute. Postangioplasty showed significant improvement of the lesion (Figure 3B). The balloon was then exchanged for a Cypher Rx 3.5 3 23 mm drug-eluting stent, which was Â�positioned across the lesion and deployed by inflating its Â�balloon to a pressure of 6 atmospheres at a rate of 1-2 atmospheres per minute (Figure 4B). Balloon and microwire were removed, and a final angiogram was performed that showed no evidence of Â�significant residual stenosis or embolic complications (Figures 5 A and B).

5B

Figure 2. A. Left subclavian run, AP projection. The arrow points at an area of stenosis at the origin of the left VA. B and C.â•‡ Left VA injection, AP (A) and lateral (B) projection. The arrow points at the severe basilar artery stenosis. Figure 3.â•‡ A and B. Left VA injection, AP projection, A unsubtracted. Figure 3A shows the partially inflated balloon positioned across the stenotic lesion (circle). The microwire is parked in the left PCA (arrow). Figure 3B is a post-angioplasty run. Significant resolution of the stenosis is apparent. Figure 4.â•‡ A and B. Left VA injection, AP projections. The stent is seen in position (circle). In Figure 4B, the stent has been deployed. Figure 5.â•‡ A and B. Left VA injection, AP (A) and lateral (B) projection. There is very good resolution of the lesion.

55

CASE 39 • Staged angioplasty and stenting of the Basilar artery Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD B AC KG R O U N D :â•‡ A 62-year-old man presented with signs of progressive posterior circulation ischemia. He was out of the window for intravenous and intra-arterial thrombolysis. Noninvasive imaging revealed a mid-basilar stenosis.

1A

1B

Right VA injection, AP projection

Diagnostic angiography was performed urgently. It confirmed the Â�presence of a significant, focal, mid-basilar artery stenosis (arrow, Figure 1A). The decision was made to perform urgent angioplasty, to be followed by stent placement 4 to 6 weeks later. The patient was started on intravenous Eptifibatide to avoid the time loss associated with loading of Clopidogrel. Figure 1B shows the final result after initial angioplasty with a Maverick 3 3 9 mm balloon. The patient was started on Aspirin and Clopidogrel following the procedure, and the Eptifibatide infusion was discontinued 6 hours later. The patient’s condition stabilized with no further neurologic events. The stenting procedure followed 5 weeks later.

Pre-stent angioplasty recommended with a Â�balloon 80% the size of the smallest diameter of the involved segment of the vessel 2 mm 2.4 mm 3 mm

AICA 3.4 mm

Recommended balloon and stent length: Length of lesion + 3 mm margin on either side

Recommended stent size: Equal to or marginally exceeding the largest diameter of the involved vessel 3.5 mm

Figure 2Aâ•‡ shows an AP projection following a left VA injection. This was obtained prior to the second intervention to assess if pre-stent angioplasty would be necessary and to determine the size of the stent and balloon to be used. In this case, the residual lumen was felt to be adequate, and no pre-stent angioplasty was performed. The origin of the AICA was in close proximity to the lesion (Figure 2A, arrow). Preserving this vessel was a significant outcome measure for this procedure.

9 mm

2A

P rocedure : The procedure was performed via a 6-F short sheath. A 6-F MPD-Envoy guide catheter was used. Before the guide catheter was brought in SCA PCA position in the distal left cervical VA, 70 Units/Kg of intravenous Heparin were administered, to achieve an ACT between 300-350 seconds. AICA AICA After the ACT was confirmed to be in this range, the guide catheter was parked in the distal cervical vertebral. A 45’ SL-10 microcatheter was introduced over a Transend floppy exchange-length (300-mm) micro2B wire. The microcatheter was positioned just proximal to the site of the stenosis in the basilar artery, and Roadmap obtained to help navigate the the microwire was navigated across the lesion into microwire into the PCA. The arrows 3 the distal basilar artery, then parked in the left PCA point at the microwire. The location of the AICA, SCA, and PCA is indicated. (Figure 2B). The microcatheter was removed while the microwire was kept in place. A 3.5 mm 3 9 mm Wingspan stent was prepared and introduced over the Transend microwire into the basilar artery. The stent was brought in position across the lesion. Correct positioning was confirmed by acquisition of contrast images. The stent was then deployed. The final result post stenting is shown in Figure 3.

56

CASE 39 • (continued)

PRE-DEPLOYMENT (SEE FIG. 5A)

DEPLOYMENT (SEE FIGS. 5B-5G) HOLD STABLE

HOLD STABLE INNER BODY

4A

4B

NON-RADIOPAQUE DOUBLE-TAPER TIP A

A A

B

B

C D

C B

D 5A

5B

AB B A

C C D

D

C D

4C

5C

5D

B

B

B

B

A C D

AC D 5E

5F

C

C

D A

D

5G

5H

Figures 4A-C and 5A-Hâ•‡ are meant to elucidate the steps involved in deploying the stent. Figure 4C shows the distal end of a Wingspan stent-catheter. The distal-most part is not radio-opaque. The catheter consists of an inner body and an outer body (sheath). The tip of the sheath is radio-opaque (marked as A in Figure 4C and in Figures 5A through G). The actual stent extends from B to C in Figures 4C and 5A through H. The stent lies distally to the inner body of the catheter, which ends at point D in Figures 4C and 5A through H. Prior to deployment, the inner body must be pushed forward so that it abuts the stent (Figures 4A and 5A). In the subsequent figures, points C and D lay in close proximity. Subsequently, it is important to confirm that the stent has not lost its position. After correct position is reconfirmed, the stent can be deployed. As shown in Figure 4B, the inner body of the catheter is held stable, while the outer body (sheath) is pulled by the Y-connector. Figures 5B-G show the tip of the sheath (A) moved downward. Once A is past B (Figures 5D and 5E), the stent starts to deploy. The stent markers are highlighted in a circle in Figures 5E-G. Once A moves past C (Figure 5G), the stent is entirely deployed. Figure 5H shows the final result. 57

CASE 40 • Basilar artery stenting Rishi Gupta, MD B AC KG R O U N D :â•‡ A 54-year-old man presented with right-sided hemiparesis, diplopia, and right-sided visual field loss. MRI revealed acute infarcts in the pons and left occipital lobe. Angiography showed a high-grade stenosis (Figure 1) in the mid-basilar segment at the level of the pontine perforators.

Some facts on intracranial artery atherosclerosis: •â•… The risk of stroke on medical therapy is 25% in the first year if stenosis is >70%. •â•… There is no difference between Warfarin and Aspirin in reducing the risk of stroke. •â•… Stenting and angioplasty are reserved for patients refractory to medical therapy. •â•… The rate of restenosis after stent placement is not adequately known. •â•… The rate of stroke maybe higher if hemodynamic impairment is demonstrated ipsilateral to the stenosis. •â•… The Wingspan stent is currently the only FDA-approved self-expanding stent approved under Humanitarian Device Exemption provisions for intracranial stenting. Figure 1.â•‡ Left VA injection, AP projection. There is a high-grade stenosis at the mid-basilar artery level (arrow).

2A

1

2C

2B

3

Figures 2 (A-C) and 3.â•‡ Left VA injections, AP projection. Figures 2A-C are intra-procedural, Figure 3 is post-procedural. Figure 2C is unsubtracted.

Procedure : â•‡ A 6-F Envoy guide catheter was placed in the left VA. Intravenous Heparin was administered to achieve an ACT of ≥250 seconds. Under road map guidance a microcatheter was navigated over a 0.014-inch microwire into the left PCA. The microcatheter was exchanged over a 300-cm, 0.014-inch microwire that remained in the left PCA (arrow, Figure 2A). A 3.5 3 12 mm Taxus stent was navigated over the microwire to the stenotic segment. Control angiographic injections showed that the stent was occlusive (Figure 2B). Figure 2C shows the stent in position (arrow) prior to balloon inflation to 9 atmospheres. The stent was undersized by 10% compared to the measured luminal diameter. Post-stent placement injections (Figure 3) showed wide patency of the basilar artery.

58

CASE 41 • Posterior cerebral artery angioplasty and stenting Thomas Wolfe , MD, John R. Lynch, MD, Brian-Fred Fitzsimmons, MD, Osama O. Zaidat, MD B ackground :â•‡ A 65-year-old woman presented with fluctuating right-sided sensory and motor symptoms. MRI revealed a left thalamo-capsular ischemic stroke, and MRA showed a high-grade stenosis of the left PCA. The patient was started on antiplatelet medications but continued to have fluctuating symptoms. Diagnostic four-vessel cerebral angiography was obtained to evaluate the degree and extent of left PCA stenosis in preparation for possible endovascular therapy.

1A

1B

Figure 1. A. Coronal FLAIR MRI shows a thalamic stroke (arrow). 1C 1D B. MRA shows a tandem left PCA stenosis (arrows). Angiography revealed a tandem stenosis of the left PCA. The proximal lesion caused ~ 50% narrowing, whereas the distal lesion was estimated at 65%-70%. Distal flow was slow. The length of the vessel affected by the lesions was 11.6 mm. C and D.â•‡Left VA injection, lateral projection. The arrows indicate the site of the stenotic lesions. The left PCA is shown in higher magnification in the middle of Figure 1D. It was felt that the patient’s symptoms were due to hypoperfusion. She was started on dual antiplatelets and asked to return in 4â•¯weeks for intervention. Procedure : â•‡ After placement of a 6-F introducer sheath, a Heparin bolus of 80 units/kg was administered intravenously. ACT was maintained between 250 and 300 seconds throughout the procedure. A 90-cm 6-F Envoy XB guide catheter was placed in the proximal right VA under fluoroscopic and roadmap guidance. Initial images were obtained to identify the best working view to obtain vessel measurements (Figure 1, C and D). The stenotic PCA lesions were crossed with an Excelsior SL-10 microcatheter over a Synchro microwire. The Synchro microwire was then exchanged for a Transend floppy-tip 300-cm, 0.014-inch microwire, which was placed in the distal left P3-PCA. The microcatheter was removed. A Gateway 2.5 3 15 mm angioplasty balloon was prepared with 2:1 contrast:saline solution and passed across the lesions. After correct positioning was confirmed, the balloon was inflated to a pressure of 8 atmospheres (Figure 2, A and B). Angiography showed some improvement of flow after angioplasty. A Wingspan intracranial (3 3 15 mm) stent was then deployed successfully across the lesion (Figure 2, C and D). After confirming that there was no evidence of acute in-stent thrombosis, the guide catheter was removed.

2A

2B

2C

2D

Figure 2. A and B.â•‡ Left VA injection, lateral (A) and AP (B) projections. The arrows point at the inflated balloon. C and D.â•‡ Left VA injection, s/p stent placement, AP (C) and lateral (D) projections. The arrows point at the stent Â�markings. The stented PCA segment is shown in higher magnification (inset). 59

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CHAPTER 3

Treatment of Acute and Subacute orâ•¯Progressive Cerebral Ischemia

1

The Qureshi grading system for vascular lesions. LSA—Lenticulostriate LMC—Leptomeningeal collaterals BA—Basilar artery 2

Figure 1â•‡ shows a case of occlusion of the MCA (arrow). Following multimodal thrombolysis, complete recanalization ofâ•¯the MCA is seen (Figure 2). 61

OVERVIEW OF CASES I

TREATMENT OF ACUTE CEREBRAL ISCHEMIA

Treatment of isolated intracranial lesions

Case 42

Middle cerebral artery occlusion Embolic complications during cardiac catheterization Combination of intravenous antiplatelet agents and thrombolytics

Case 43

Middle cerebral artery occlusion Intravenous antiplatelet agents for prevention of rethrombosis

Case 44

Middle cerebral artery occlusion Hyperdense Middle cerebral artery sign Treatment past the 6-hour time window

Case 45

Middle cerebral artery occlusion Unknown time of onset Clinical-diffusion mismatch

Case 46

Middle cerebral artery occlusion MERCI clot retrieval device

Case 47

Middle cerebral artery near-occlusion Unknown time of onset Clinical/perfusion-diffusion mismatch Presumed Middle cerebral artery dissection

Case 48

Distal Anterior cerebral artery branch occlusion Intravenous antiplatelet agents for prevention of rethrombosis

Case 49

Intracranial Internal carotid artery occlusion Multimodal thrombolysis Lack of recanalization

Case 50

Intracranial Internal carotid artery occlusion MERCI clot retrieval device

Case 51

Basilar artery occlusion

Treatment of combined extra- and intracranial lesions

Case 52

Tandem Internal carotid artery/Middle cerebral artery occlusion Delayed recanalization

Case 53

Tandem Internal carotid artery/Middle cerebral artery occlusion Suction thrombectomy

Case 54

Tandem Internal carotid artery/intracranial occlusions Hyperdense Middle cerebral artery sign

Case 55

Tandem Internal carotid artery/Middle cerebral artery occlusion Suction thrombectomy Delayed recanalization

Case 56

Tandem Internal carotid artery/Middle cerebral artery occlusion Angioplasty and stenting of contralateral Internal carotid artery stenosis Thrombolysis from the contralateral side through the Anterior communicating artery

62

CASES 42–56

II

TREATMENT OF SUBACUTE OR PROGRESSIVE/FLUCTUATING CEREBRAL ISCHEMIA

Treatment of Internal carotid artery stenosis of presumed atherosclerotic origin

Case 57

Watershed ischemia CT perfusion studies

Case 58

Progressive ischemia CT perfusion studies

Case 59

Progressive ischemia Multiple angioplasties Placement of multiple stents

Treatment of Internal carotid artery dissection

Case 60

Dissection resulting in severe stenosis Watershed infarcts Placement of multiple stents

Case 61

Dissection resulting in severe stenosis Bilateral Internal carotid artery dissections Fibromuscular dysplasia Watershed infarcts

Case 62

Dissection resulting in occlusion Fluctuating ischemia Conservative management of dissections Severe vessel tortuosity

Treatment of subacute Internal carotid artery occlusion

Case 63

Tandem intra-/extracranial Internal carotid artery occlusion SPECT studies

Stenting of an Internal carotid artery to improve collateral flow to the posterior circulation

Case 64

Bilateral vertebral artery occlusion Internal carotid artery stenosis CT perfusion studies

Treatment of intracranial lesions

Case 65

Basilar artery stenosis Fluctuating ischemia Aggressive thrombosis

Case 66

Bilateral intracranial vertebral artery dissection Head trauma Retrograde flow in the basilar artery Lack of recanalization

63

CASES 57–66

CASE 42 • Acute Middle cerebral artery occlusion Alex Abou-Chebl, MD B AC KG R O U N D : â•‡ A 59-year-old man was undergoing a left heart catheterization when he suddenly developed aphasia and right hemiplegia. The patient had a history of cigarette smoking, hypertension, and hyperlipidemia. Neurologic assessment revealed an NIHSS score of 22. The patient had not received Heparin and was only taking Aspirin. An ischemic etiology was presumed, and cerebral angiography was performed immediately.

Figure 1.â•‡ Left ICA injection, AP projection. There is an abrupt cutoff of the MCA at mid-vessel (thick arrow) with pial collaterals (thin arrows). P rocedure :â•‡ Heparin (4500 units) was immediately administered intravenously and a 6-F Envoy guide catheter was inserted into the distal cervical ICA over a floppy glidewire using road-mapping technique. A long sheath was not inserted first into the CCA because of the lack of tortuosity and the high probability that a simple pharmacologic approach would achieve full recanalization because of the “freshness” of the thrombus.

1

2A

2B

Figure 2.â•‡ A and B. Left ICA injections, AP intracranial projections. A. A Synchro 0.014-inch wire was advanced through a 2.3-F Rapid Transit microcatheter into the MCA and gentle wire manipulation was performed. This resulted in thrombus migration into the superior division of the MCA (arrow), restoring flow to the lenticulostiates and most of the inferior division. B. The superior division was then cannulated with the wire and microcatheter (arrow). One unit of Reteplase was injected into the thrombus. Microcatheter contrast injections were not performed. Repeat angiography 5 minutes later revealed no change. One mg of Abciximab was injected directly into the thrombus. C and D.â•‡ Left ICA injections, AP (C) and lateral (D) projections.

2D

2C

Five minutes after the Abciximab injection, there was partial recanalization of the proximal superior division (Figure 2, C and D) but there was still significantly reduced flow in the distal branches with a large area of cortex not being perfused (Figure 2D, circle). An additional unit of Reteplase followed by 5 mg of Abciximab (total of one-fourth of the standard bolus dose) were administered.

64

CASE 42 • (continued)

Ten minutes later, angiography revealed complete recanalization of all of the MCA branches (Figure 3, A and B). The patient began to recover language almost immediately. The procedure was terminated 1 hour after onset. The Heparin was not reversed, but no additional pharmacologic therapy was given. CT performed the next day (Figure 4) was normal, consistent with the patient’s neurological exam.

3A

3B

4

Figure 3.â•‡ A and B. Left ICA injections, AP (A) and lateral (B) projections.

The approach in this case highlights the benefits of rapid administration of a combination of low-dose fibrinolytics and GPIIb/IIIa antagonists. Drug delivery over 1 to 2 hours is too slow. By giving small doses in rapid succession directly into the thrombus, the risk of ICH may be minimized.

65

CASE 43 • Acute Middle cerebral artery occlusion Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD B AC KG R O U N D : â•‡ A 69-year-old man was admitted with left hemiparesis. NIHSS score was 8, and the time of onset was between 3–6 hours prior to admission. The patient was taken to the angiography suite for endovascular intervention after a CT scan excluded ICH. Procedure : Figure 1.â•‡ A and B. A. A 6-F sheath was placed in the right CFA and a 6-F MPD Envoy catheter was advanced to the aortic arch. A 20-degree Caldwell AP projection (perfusion) showed paucity of right MCA branches (circle). B. Right ICA injection revealed an occlusion of the inferior division of the right MCA (arrow, AP projection). P erfusion

2A

2C

2B

2E

2F

1B

1A

2G

2D

2H

Figure 2.â•‡ A–H. A 2.3-F Prowler Plus microcatheter was advanced into the right proximal MCA. A, B.â•‡ AP projection, early phase subtracted and late phase unsubtracted views show the inferior division oclusion (Qureshi grade II, arrows). C. Lateral projection, unsubtracted. The microcatheter is passed through the occlusion into the inferior division of the MCA. D. AP projection, microcatheter injection. MCA inferior division branches are filling. E. AP projection, double injection (i.e., simultaneous guide catheter and microcatheter injection). The proximal arrow shows where the MCA filling from the guide catheter injection stops. The distal arrow points at the tip of the microcatheter. The filling defect between the arrows is caused by a clot, which measured 9 mm in length. Reteplase was administered into and proximal to the clot. F. AP projection, guide catheter run after administration of Reteplase. Occlusion of the MCA M1 segment (arrow) is present. Following this run, additional Reteplase was administered and angioplasty was performed with a Maverick 2.5 3 9 mm balloon, which was inflated to nominal pressure three times. G. AP projection, guide catheter run. This final run shows good right MCA flow (Qureshi grade I) inspite of some residual stenosis. The patient was placed on an Eptifibatide drip for 20 hours to prevent rethrombosis after a post-procedure CT scan showed no ICH. H. Follow-up MRA 3 days later shows preserved patency of both MCA divisions.

66

CASE 44 • Acute Middle cerebral artery occlusion Stanley H. Kim, MD B ackground :â•‡ A 71-year-old woman presented with acute onset of aphasia and right hemiparesis 6 hours from onset of symptoms. Initial NIHSS score was 9. A CT scan of the head revealed a hyperdense MCA sign on the left (arrow, Figure 1A). Diagnostic angiography revealed occlusion of the left MCA-M1 segment (arrow, Figure 1B).

1A

1B

2

4

3

5

Figures 2 and 3.â•‡ Unsubtracted images, AP projection. Figures 4 and 5.â•‡ Left ICA injection, AP projection. Procedure : â•‡ A microcatheter was passed through the clot (Figure 2, arrow points at the tip). Ten units of Reteplase were administered intra-arterially in and around the M1-clot. No recanalization ensued. Next, mechanical thrombolysis was performed using a MERCI X 6 clot-retrieval device. Again, there was no recanalization. A 2.5 3 12 mm Maverick balloon was then passed through the lesion and deployed (arrow, Figure 3). This led to partial recanalization of the MCA, as seen in Figure 4. A follow-up run performed 5 minutes later showed near-complete recanalization (Figure 5). At the time of recanalization, the patient was at 12 hours post symptom onset. The patient was discharged home 3 days after the procedure. NIHSS score was 1. Hyperdense MCA sign The hyperdense MCA sign refers to a linear hyperdensity, which follows the course of the MCA and is seen typically on axial CT scan slices. It is supposed to indicate the presence of thrombus in the MCA. However, there is disagreement regarding the specificity of this finding.Patients with hyperdense MCA sign are more likely to have severe deficits at onset and a poorer outcome a 3 months. Although they may benefit from intravenous thrombolysis, these patients are good candidates for intra-arterial intervention. References: Rauch RA, Bazan 3rd C, Larsson EM, Jinkins JR. Hyperdense middle cerebral arteries identified in CT as a false sign of vascular occlusion. Am J Neuroradiol 1993; 14(3): 669–673. Tomsick T, Brott T, Barsan W, at el. Prognostic value of the hyperdense middle cerebral artery sign and stroke scale score before ultraearly thrombolytic therapy. Am J Neuroradiol 1996; 17: 79–85. Qureshi AI, Ezzeddine MA, Nasar A, et al. Is iv tissue plasminogen activator beneficial in patients with hyperdense artery sign? Neurology 2006; 66: 1171–1174.

67

CASE 45 • Acute Middle cerebral artery occlusion Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD

1A

1B

1C

1D

1E

1F

Figure 1.â•‡ A–F. MRI DWI.

2

B AC KG R O U N D : â•‡ A 64-year-old woman presented with right-sided weakness and Â�dysarthria. Time of onset was unknown. Initial NIHSS score was 10. The patient deteriorated while in the emergency department. At that time, an MRI was obtained. The DWI seen in Figures 1A–F shows fairly limited abnormalities compared to the patient’s clinical deficits, i.e.,â•¯there was a clinical-diffusion mismatch. In essence, the size of underperfused brain tissue is extrapolated from the clinical deficit, and thus the clinical-diffusion mismatch is a rough estimate of the perfusion-diffusion mismatch, i.e.,â•¯penumbra, or salvageable tissue. On that basis, the decision was made to offer the patient intra-arterial treatment. A perfusion angiogram was performed initially (Figure 2). This showed occlusion of the left MCA (arrow). A 6-F MPD Envoy was positioned in the left CCA. The proximal ICA was found to be without disease (Figure 3, left CCA injection, lateral projection). The Envoy was advanced into the mid-cervical left ICA and contrast was injected. Figure 4A shows again the MCA occlusion. Figure 4B (late arterial phase) shows extensive collateralization from the ACA (Qureshi grade 3). Procedure : â•‡ A Prowler Plus/Transend 14 microcatheter/microwire system was brought to the ICA bifurcation (arrow, Figure 5). Reteplase was administered into the proximal MCA at a dose of 0.5 units. Partial recanalization was seen. A Maverick 2 3 9 mm balloon was introduced over a Transend 14 microwire. The microwire was parked in the superior division, and the balloon was positioned across the lesion (Figures 6 and 7, circle) and inflated. Complete recanalization ensued (Figure 8). AP

AP

4A

4B

3 5

7

6

Figure 5.â•‡ Left ICA injection, AP projection. Post-thrombolysis, irregularity in the proximal MCA is still seen, likely secondary to residual intraluminal clot (see arrow). Figure 6.â•‡ Unsubtracted. The balloon (circle) has been positioned across the lesion. Figures 7 and 8.â•‡ Left ICA injections, AP projection, pre- (7) and post- (8) angioplasty. Complete restoration of flow post-angioplasty is seen.

68

8

CASE 46 • Acute Middle cerebral artery occlusion Gustavo J. Rodriguez, MD, Vallabh Janardhan, MD B ackground :â•‡ A 79-year-old man presented with acute-onset aphasia and right-sided hemiplegia. NIHSS score was 20 on admission. The patient was given intravenous rt-PA at 2 hours after symptom onset. CTA showed occlusion of the proximal left MCA. CTP findings were consistent with a large area of viable hypoperfused tissue.

CB V

CBF

MT T

1

Figure 1.â•‡ CTA. The arrow points at the proximal left MCA occlusion. Figure 2.â•‡ CTP. The finding of increased rCBV, decreased rCBF, and prolonged MTT over a large part of the left MCA territory indicates a large area of hypoperfused but likely viable tissue.

2

The patient was taken to the angiography suite for possible intra-arterial intervention. A 4-F sheath was introduced into the right CFA using a micropuncture kit. This was exchanged for a 6-F sheath. Diagnostic angiography was performed with a 125-cm 5-F VERT catheter. The CTA findings were confirmed.

3B

3A

Figure 3.â•‡ A–C. Left ICA injection, lateral projection, early (A), mid- (B), and late (C) arterial phase. The left MCA is occluded proximally. Pial collaterals from the ACA fill some of the MCA branches in the later frames (Qureshi grade 3A). In B, a small AVM is visible, fed by MCA branches. The AVM venous outflow can be seen best in C (the arrow points at the early draining vein). The nidus is highlighted by a circle in B and C.

3C

69

CASE 46 • (continued)

Procedure :â•‡ Since the patient had received full-dose intravenous thrombolysis and in the presence of the small AVM (although there are no data regarding thrombolysis and rupture of asymptomatic AVMs), it was decided to perform mechanical thrombolysis. The 6-F sheath was exchanged for an 8-F sheath. An 8-F MERCI balloon guide catheter was advanced over a 0.035-inch exchangelength glidewire and a 5-F 125-cm VERT catheter into the proximal left ICA. The MERCI microcatheter was advanced to the area of the clot over an Agility 0.014-inch microwire. Using the technique described in detail in Case 50, two clots were retrieved. Follow-up injections revealed full recanalization of the MCA (Qureshi grade 0). Recanalization was achieved at 4 hours and 45 minutes after symptom onset. Figure 4.â•‡ A and B. Left ICA injection postprocedure, AP projection, early (A) and mid- (B) arterial phase. There is complete recanalization of the MCA. The arrow 4B points at the AVM.

4B

4A

Figure 5.â•‡ A–C. MRI DWI performed the day following the procedure. The cortical MCA territories have been almost entirely spared. The arrows point at deep infarcts and a punctate cortical stroke.

5A

5B

O utcome :â•‡ At the time of discharge, the patient had a NIHSS score of 5.

70

5C

CASE 47 • Acute Middle cerebral artery near-occlusion, likely secondary to dissection Gustavo J. Rodriguez, MD, Rober t A. Taylor, MD B ackground :â•‡ A 29-year-old man woke up with right-sided weakness, dysarthria, and mild aphasia. MRI DWI showed very small areas of diffusion restriction, whereas CTP showed a large area of hypoperfusion in the left MCA territory and CTA showed a thrombus in the proximal MCA. Based on the perfusion and clinical/diffusion mismatch, it was decided to proceed with intra-arterial treatment.

CBV

1A

1B

1C

Figure 1.â•‡ A–C. Axial MRI DWI showing small areas of diffusion restriction along the left MCA territory. Figure 2.â•‡ CTP showing perfusion deficits over virtually the entire left MCA territory.

CBF

MTT

Procedure : â•‡ A microcatheter was positioned in the proximal MCA and a total of 2 mg of rt-PA was administered. Excellent distal flow was achieved, despite the presence of some residual thrombus. Follow-up angiography the next day showed again improved flow in the proximal MCA with a linear filling defect that resembled a dissection flap.

2

Figure 3. A. Initial left ICA injection, AP projection. There is a large filling defect in the proximal MCA. A string of flow (arrow) provides some distal perfusion. B. Double injection in AP projection. The circle highlights the filling defect.

3A 3B

Figure 4.â•‡ Left ICA injection, AP projection, post-thrombolysis. â•›There is excellent distal flow despite some residual filling defects (arrow). Figure 5.â•‡ Follow-up angiography at 24 hours. Left ICA injection, AP projection. Distal flow is normal. There is a linear filling defect (arrows) that resembles a dissection flap. 4

5

71

O utcome :â•‡ The patient had complete neurologic recovery by the time of discharge.

CASE 48 • Acute distal Anterior cerebral artery occlusion Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD B ackground :â•‡ A 53-year-old man presented within 3 hours of symptom onset with left-leg weakness. NIHSS score wasâ•¯2. It was felt that symptoms were too mild to warrant treatment with intravenous rt-PA. The patient agreed to intra-arterial Â�treatment.

P rocedure :â•‡ A 6-F MPD Envoy catheter was placed in the right ICA. Images that were obtained demonstrated a distal ACA occlusion (arrows, Figure 1, A and B). A Prowler Plus microcatheter was introduced into the ACA over a Transend 14 microwire and placed in the A2 segment (Figure 2). Reteplase was administered through the microcatheter at a dose of 0.5 units in a 5 mL solution with normal saline. There was recanalization with complete restoration of distal flow (Figure 3). However some residual clot (circle, Figure 3) remained. Therefore, to prevent rethrombosis, the patient was treated with intravenous Eptifibatide for 20 hours. 1A

1B

Figure 1.â•‡ A and B. Right ICA injections, lateral (A) and AP (B) projections. The arrows point at a distal ACA occlusion.

Eptifibatide protocol for prevention of rethrombosis in patients treated with thrombolytics: Bolus 135 mg/kg Followed by: Drip @ 0.5 mg/kg/min For total of 20 hours

2

3

4

Figure 2.â•‡ Microcatheter injection, AP projection. The arrow points at the site of occlusion. Figure 3.â•‡ Right ICA guide catheter run post-thrombolysis, lateral projection. The recanalized ACA segment is highlighted in aâ•¯circle. Figure 4.â•‡ MRI DWI obtained after treatment. There is a small focal abnormality (arrow) corresponding to the vascular occlusion visualized earlier. 72

CASE 49 • Acute intracranial Internal carotid artery occlusion Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD B ackground :â•‡ A 49-year-old man presented with a severe right-hemispheric deficit at 3 to 6 hours after symptom onset. NIHSS score was 27. CT scan excluded ICH.

P rocedure :â•‡ A 6-F sheath was introduced through the right CFA. A 6-F Envoy MPD guide catheter was advanced to the right CCA. The proximal ICA was found to be widely patent. The guide catheter was then advanced into the right ICA. The ICA was occluded just distal to the origin of the Pcom (arrow, Figure 1). The decision was made to place a stent across the lesion. A ProwlerPlus microcatheter was advanced over a Transend floppy microwire past the occlusion into the right MCA (arrow, Figure 2A). The microcatheter was then withdrawn. A Taxus 2.5 3 9 mm balloon-supported stent was introduced over the microwire into the clot (Figure 2B), and the balloon was inflated to deploy the stent. Post-deployment runs showed no recanalization (Figure 2C). The balloon was advanced past the stent and redeployed (circle, Figure 2D) without significant effect. The balloon was therefore repositioned more distally (Figure 2E) and deployed again. No significant recanalization (Figure 2F) occurred.

Right ICA AP

1

2C

2B

2A

2E

2F

73

2D

Figure 2.â•‡ A and B.â•‡Unsubtrtacted images. The arrows in B point at the stent markings. C. Right ICA injection, AP projection. There is no recanalization post-stent placement. D and E. Unsubtracted images. The circle in D highlights the balloon as it is inflated past the stent. The white arrows in E indicate the position of the balloon prior to the second angioplasty, whereas the black arrows indicate the stentâ•¯position. F. Right ICA injection, AP projection post-stent placement and angioplasty 3 2. No recanalization is seen.

CASE 49 • (continued)

A Prowler Plus microcatheter was advanced over a Transend floppy microwire (Figure 2G) into the right MCA past the clot (Figure 2H) and 0.5 units of Reteplase were administered. The catheter was retracted back into the clot (Figure 2I). Additional 0.5 units of Reteplase were administered. Follow-up runs showed no recanalization. Attempts to remove the clot with a snare device (2-mm Microvena snare) (Figure 2J) were also unsuccessful. The end-result is shown in Figure 2K.

2G

2H

2I

G. Unsubtracted image. The tip of the microwire has been given a J-shape (circle) to facilitate passage through the stent. H. Microcatheter injection past the clot. I. More proximal microcatheter injection. The arrow indicates the position of the microcatheter tip. The rectangle highlights the stretch of intraluminal clot. J. Unsubtracted image post-thrombolysis. A snare device has been introduced (rectangle). K. Final right ICA injection, AP projection.

2J

2K

Follow-up angiogram the following day showed recanalization of both the MCA and ACA (Figure 3). However, the patient was deteriorating clinically. CT scan showed a large infarction with hemorrhagic transformation and midline shift (Figure 4).

3

74

4

CASE 50 • Acute intracranial Internal carotid artery occlusion Alexandros L. Georgiadis, MD, Rober t A. Taylor, MD B ackground :â•‡ A 50-year-old woman presented with right-sided weakness and aphasia; NIHSS score was 22. The patient received full-dose intravenous rt-PA and a CTP was performed as an attempt to assess if she would profit from intraarterial treatment.

1B

1A

Figure 1.â•‡ A–C. CT perfusion study. MTT is prolonged over the entire left MCA distribution (C) indicating that it is likely that the patient has proximal vessel occlusion. The most severely affected region is the superior division MCA distribution. The same pattern of abnormalities is seen on the rCBF map. CBV is severely reduced in the superior MCA division territory (arrow, Figure 1A) indicating that that tissue may not be viable. Based on this CTP study, it was presumed that there was still a large area of salvageable tissue, mainly in the posterior MCA division distribution. The patient was therefore taken to the angiography suite for intra-arterial treatment.

1C

Figure 2. A. A 5-F pigtail was positioned in the proximal aortic arch and a machineinjection was performed. The left ICA was not visualized. B. Left CCA injection. A cut-off in the intracranial left ICA (arrow) is apparent.

2A

2B

75

CASE 50 • (continued)

3A

3B

3C

Procedure : â•‡ Following the diagnostic angiogram, it was attempted to place a 6-F guide catheter in the distal cervical ICA to support a microcatheter that was to be advanced to the site of occlusion. A Simmons II Envoy was chosen because the left CCA had a bovine origin and could not be selected with a straight catheter. Due to extreme proximal vessel tortuosity, however, the guide catheter prolapsed repeatedly back into the arch. A softer, 5-F Simmons II diagnostic catheter was then used to select the left CCA over an exchange-length glidewire. This catheter was successfully advanced distally. The glidewire was then parked in the distal ECA, and the 5-F catheter was exchanged for a 6-F MPD Envoy guide catheter. This was advanced to the distal cervical left ICA without difficulty. A microcatheter was then introduced and placed in the area of the carotid bifurcation (Figure 3A, unsubtracted image, the arrow points at the microcatheter tip). A microcatheter injection (Figure 3B, AP projection) showed minimal filling of the ACA and MCA. Two sequential small doses of rt-PA were infused through the microcatheter. As shown in Figure 3C (microcatheter injection, lateral projection), no significant recanalization was noted. At this stage, since it was not considered safe to administer more thrombolytics, the decision was made to perform mechanical thrombolysis with help of a MERCI L5 device. The 6-F CFA sheath was exchanged over wire for an 8-F sheath that could accommodate the MERCI guide catheter.

0.6 m L sy ringe w ith 1 :1 contrast saline solution for balloon inflation 1 :1 contrast saline solution

suction

microcatheter

merci guide catheter (8 - F or 9 -F) 4A

me Rci device introducer

merci micro C atheter

4B

76

The MERCI system consists of an 8-F or 9-F guide catheter, a microcatheter, the actual MERCI device, and an Â�introducer. Figure 4. A. The guide catheter has two ports. An RHV is connected to the first port. The side-port of the RHV is used to attach a large syringe with which suction can be applied. The side-port of the guide catheter is connected via a three-way connector to a syringe with a 1:1 contrast:saline mix. For greater precision, a 1 mL syringe is used to actually inflate the balloon of the guide catheter with 0.6 mL of solution. B. The introducer and the MERCI microcatheter.

CASE 50 • (continued)

4C

4D

4F

4E

C. The MERCI guide catheter is passed through the sheath with help of an introducer (open arrow). The guide catheter is equipedâ•¯with a balloon (thick arrow), which is located at the catheter tip and inflated during clot retrieval to block antegrade flow and the distal embolization that could result from device maneuvers. The balloon should be free of air (thin arrow). Small amounts of air will permeate through the wall of the balloon and dissipate. The guide catheter should be preferably placed in the ICA as far distal as is deemed safe. In this case, the proximal ICA was very tortuous, and the catheter was therefore parked in the distal CCA. D. The MERCI L5 device consists of five loops. Multiple filaments are attached to it to maximize the chance of capturing and trapping the clot. E. The introducer has a hub that can be moved toward the microcatheter and attached to it to facilitate passage of the device. F. A device can be used for two passes. To use it again, it has to be back-fed into the introducer. After the wire has been passed, the device is stretched and then pulled into the introducer.

5B

5A

77

5C

CASE 50 • (continued)

5E

5D

5G

5H

5F

5I

Figure 5.â•‡ A–I. Description of technique. Images A–H were obtained from a flow model by means of fluoroscopy. A. The MERCI microcatheter is introduced over a 0.014-inch microwire and passed through the clot. The microwire is removed. The arrow points at the microcatheter tip. B. The MERCI device is made of nitinol, which is not radio-opaque. However, the distal part that includes the loops is coated with platinum and is therefore radio-opaque (arrows, Figure 5B). C. The device’s five loops are extruded. It is important that the proximal radio-opaque segment remain in the microcatheter (arrow). To minimize the risk of damage to the vessel, after the first two loops are extruded, it is advisable to pull the microcatheter back instead of pushing the wire in. D. The microcatheter and the MERCI device are pulled back together. Stretch starts to develop when the device traps the clot (arrow). E. When stretch is seen, the guide catheter balloon is inflated with 0.6 mL of 1:1 contrast:saline solution (arrow). The microcatheter and device are pulled back slowly. Suction is applied. F. If the loops start to unwind (arrow), the device can be torqued in counter-clockwise direction. G. The torqueing maneuver results in a “phone-cable”-type configuration of the device (arrow), which helps trap the clot. H. The microcatheter and device are withdrawn into the guide catheter. I. Clots often break loose from the device. Suction should therefore still be applied until the device reaches the rotating hemostatic valve which should at that time be unscrewed. The catheter should be backbled or (preferably) suction should be applied in order to retrieve clot fragments that may be still in the catheter. The balloon can then be deflated and an injection can be obtained.

78

CASE 50 • (continued)

6A

6B

Figure 6. A. Left CCA injection following the first pass with the MERCI device. The ICA appears occluded just past the bulb. B. Left CCA injection, intracranial lateral projection, following the second pass. The ICA has recanalized. The open arrow pointsâ•¯at the superior division of the MCA, which remains occluded. The black arrow points at some residual clot. The patient was started on Aspirin following the procedure to prevent rethrombosis. Intravenous antiplatelet medications could not be used because the patient had received full dose rt-PA.

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Figure 7.â•‡ A and B. Some clot fragments were attached to the device (A), while others (B) were aspirated from the guide catheter. Figure 8.â•‡ CT performed 24 hours later showed a relatively small infarct, essentially restricted to the area that was presumed to be nonviable based on the CTP study of the previous day. References: Smith WS, Sung G, Starkman S, et al. Safety and efficacy of mechanical embolectomy in acute ischemic stroke: results of the MERCI trial. Stroke 2005; 36(7): 1432–1438. Smith WS. Safety of mechanical thrombectomy and intravenous tissue plasminogen activator in acute ischemic stroke. Results of the multi Mechanical Embolus Removal in Cerebral Ischemia (MERCI) trial, part I. AJNR Am J Neuroradiol 2006; 27(6): 1177–1182.

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CASE 51 • Acute Basilar artery occlusion M. Fareed K. Suri, MD, Alexandros L. Georgiadis, MD, Vallabh Janardhan, MD B AC KG R O U N D :â•‡ A 75-year-old man developed difficulty in swallowing and nausea and suddenly collapsed. CTA showed basilar artery occlusion. MRI demonstrated bilateral cerebellar infarcts with sparing of the brainstem (Figure 1, A and B). Diagnostic angiography, performed emergently, confirmed the lack of antegrade flow to the basilar artery.

pica

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Figure 1.â•‡ A and B. DWI MRI demonstrating multiple posterior circulation infarcts. Figure 2. A. Left VA injection, AP projection. The VA terminates at the PICA level. B. Right VA injection, AP projection. The VA is occluded just past the origin of the PICA (white arrow). Procedure : â•‡ For stability a 7-F Guider Softip XF 40-degree was advanced into the origin of the left VA. An Echelon-14 45-degree microcatheter was advanced into the basilar artery across the occlusion over a Transend-EX 14 microwire. A microcatheter injection demonstrated patency of the distal basilar artery (Figure 3A). The Transend 14 microwire was removed and an X-Celerator 10 microwire was advanced through the mirocatheter into the left PCA (Figure 3B). It is possible to inject through the microcatheter around this smaller microwire. A dose of 250,000 units of Urokinase was diluted in 20 mL of solution. With the microcatheter placed distal to, inside, and proximal to the clot, 50,000, 100,000 and 50,000 units of Urokinase were administered in sequence. Guide catheter injections demonstrated recanalization of the basilar artery (Figure 3C).

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Figure 3.â•‡ A and B. Microcatheter injections, AP (A) and lateral (B) projections. C is a guide catheter injection into the right VA in AP projection. The arrows in A–C indicate the position of the microcatheter tip. A. The clot extends of clot before the origin of AICAs. B. The microwire can be seen parked in the PCA (white arrow). C. Following the administration of Urokinase, the basilar is widely patent.

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CASE 52 • Acute tandem Internal carotid artery-Middle crebral artery occlusion Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD B ackground :â•‡ A 59-year-old man presented with acute-onset left hemiparesis, NIHSS score was 16. The patient was outside the window for treatment with intravenous rt-PA.

Procedure : â•‡ A 6-F short sheath was placed in the right CFA. A 6-F Envoy MPD guide catheter was advanced into the proximal ascending aorta and a 20-degree cranial AP shot (perfusion image) was obtained (Figure 1). The right ICA was entirely absent. The catheter was then brought into the right CCA, and the right ICA was found to taper off in a flame-like shape (arrows, Figure 2A). Figure 2B (same injection, late arterial phase) shows some late filling of the distal cervical ICA and an intracranial occlusion. It was presumed that the underlying pathology was a dissection of the cervical ICA. The decision was made to administer Reteplase into the intracranial clot. A J-shaped Transend floppy microwire was advanced into the right ICA. An image was obtained to confirm placement of the microcatheter in the true lumen (Figure 3A). The microwire was then moved distally through the area of occlusion and a Prowler Plus 2.3-F microcatheter was advanced into the ICA (Figure 3B). A microcatheter injection was performed to reconfirm placement in the true lumen (Figure 3C). The microcatheter was advanced further into the MCA (Figure 3D). Reteplase was administered through the microcatheter into the MCA. Figure 1.â•‡ Arch injection, intracranial perfusion image. There is no filling of the ICA. Figure 2.â•‡ A and B. Right CCA injection, lateral projection, early (A) and late (B) arterial phase. There is delayed flow in the distal ICA, which is occluded intracranially.

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Figure 3. A. Right ICA injection, AP projection. The wire (arrow) is in the true lumen. B. Unsubtracted image.The J-shaped wire is seen near the ICA terminus. The J shape reduces the likelihood of entering the pseudolumen and extending the dissection. C. Microcatheter injection, lateral projection, distal ICA. The microcatheter is confirmed to be in the true lumen. D. Microcatheter injection, AP projection, proximal MCA. Reteplase was administered at this site.

CASE 52 • (continued) Follow-up injections showed no recanalization (Figure 3E). At that time, it was decided to proceed with stent placement. A 300-cm Transend floppy wire was advanced through the microcatheter and parked in the distal intracranial ICA (Figure 3F). The microcatheter was then exchanged for a 5.5 3 4.7 mm Magic Wall stent. The stent was advanced as far as possible into the clot and deployed (Figure 3G). No significant recanalization ensued (Figure 3H). Follow-up angiography 8 days later revealed a widely patent ICA with restored normal intracranial circulation (Figure 4, A and B).

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E. Right ICA injection, lateral projection, postthrombolysis. There is no recanalization. F. Unsubtracted image. The black arrow points at the tip of the microwire. The white arrows point at the stent markings. G. Unsubtracted image, post-stent deployment. The outline of the stent can be seen. H. Final right ICA injection, AP projection. There is no improvement in flow.

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Figure 4.â•‡ A and B. Follow-up angiography, 8â•¯days post-procedure, right CCA injections. A. Extracranial lateral projection. The ICA has fully recanalized. B. Intracranial AP projection. Normal intracranial flow is apparent.

CASE 53 • Acute tandem Internal carotid artery-Middle cerebral artery occlusion Stanley H. Kim, MD B ackground :â•‡ A 47-year-old man presented with a right-hemispheric deficit, NIHSS score of 15, at 3 hours after symptom onset. A CT scan of the head revealed a hyperdense MCA sign on the right. Diagnostic angiography showed occlusion of the right cervical ICA. Figure 1. A. Right CCA injection. The ICA is occluded (arrow). B. Right CCA injection, intracranial. No filling of the right MCA is seen.

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There was also no cross-filling to the right MCA from the left anterior circulation upon left CCA injection. P rocedure :â•‡ Next, an 8-F guide catheter was advanced to the area of occlusion and suction thrombectomy was performed. This was done by connecting the guide catheter to a 60-mL syringe and aspirating. Partial recanalization of the ICA was achieved (Figure 2A). The right MCA remained occluded (arrow, Figure 2B)

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Attempts to recanalize the MCA were made with a MERCI L6 clot-retrieval device (circle, Figure 3) but were not successful. Subsequently, a total of 15 units of Reteplase were administered through a microcatheter to the site of the occlusion, again without success.

Angioplasty with a 2.5 3 12 mm Maverick balloon (Figure 4A shows the inflated balloon) achieved partial recanalization (the arrow in Figure 4B points at a residual filling defect). â•›A right CCA cervical run was then performed (Figure 5A). It showed a 70% residual stenosis of the proximal ICA. It was felt that treating this lesion would augment flow and thus counter rethrombosis.

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A 6-8 3 40 mm Acculink stent was placed in the cervical ICA. This was followed by angioplasty with a 4.5 3 30 mm Viaâ•¯Trac balloon. A 5-mm Accunet distal-protection device was used. Figure 5B shows the final result post-angioplasty and stenting. Figure 6 is the final intracranial run. The MCA has fully recanalized.

CASE 54 • Acute tandem Internal carotid artery-intracranial occlusions Thanh Nguyen, MD, Jean Raymond, MD, Alain Weill, MD B AC KG R O U N D :â•‡ A 62-year-old man presented with acute aphasia and right hemiplegia, NIHSS score of 15, at 3 hours from onset of symptoms. There was a hyperdense left MCA sign on CT (arrow, Figure 1). Angiography revealed occlusion of the ICA.

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Figure 2.â•‡ A and B. A. Left CCA injection, AP projection. The proximal cervical ICA is occluded. B. Left CCA injection, AP intracranial projection. Reconstitution of the ICA (small arrow) through the ophthalmic artery (long arrow).

Figure 1.â•‡ CT with hyperdense left MCA sign (arrow).

Procedure :â•‡ A 6-F guide catheter was placed in the left CCA. The occlusion was traversed with a 0.035-inch wire, followed by a 4-F catheter. Injection distal to the left ICA origin occlusion revealed a left A1 cut-off and clot in the left MCA bifurcation. Twenty mg of rt-PA were injected intra-arterially at 3 hours and 30 minutes from symptom onset through the 4-F catheter. A microcatheter injection immediately afterwards showed no significant change (Figure 3). A 0.014-inch exchange-length microwire was navigated through the 4-F catheter and parked in the left MCA. A stent (8 3 40 mm) was deployed at the level of the internal carotid occlusion (Figure 4, A and B), with good revascularization of the left ICA and intracranial circulation or TIMI 2 flow (Figure 4C).

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Figure 3.â•‡ Distal left ICA microcatheter injection after 20 mg IA rt-PA showing persistent occlusion of the left A1 (black arrow) and left M2 superior branch (white arrow).

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Figure 4.â•‡ A–C. A. Unsubtracted image showing the stent as it is positioned across the lesion. B. Left CCA run post-stent placement, lateral projection. C. Left ICA run, intracranial AP projection post-stenting shows significantly improved intracranial flow. Figure 5.â•‡ CT post-stenting shows a small hypodensity in the area of the left insular cortex. Clinical course: The patient had remarkable improvement with complete return of right-sided motor function and only mild residual aphasia. CT showed small hypodensities in the left insular cortex (Figure 5). He was discharged home with an NIHSS score of 1. 5

Reference: Jovin T, Gupta R, Uchino K et al. Emergency stenting of extracranial internal carotid artery occlusion in acute stroke has a high revascularization rate. Stroke 2005;â•›â•›36:â•›â•›2426–2430.

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CASE 55 • Acute Tandem Internal carotid artery-Middle cerebral artery occlusion Stanley H. Kim, MD B ackground :â•‡ A 75-year-old woman presented with acute-onset left hemiplegia and dysarthria. She was seen at 3 hours after the onset of symptoms. Initial NIHSS score was 15. CT scan showed no hypodensity or ICH. The patient underwent diagnostic angiography with the goal of performing intra-arterial mechanical and/or pharmacological thrombolysis. Figure 1. A. Aortic arch injection, intracranial AP projection. Complete occlusion of the right ICA. There is a proximal cut-off in the MCA (arrow). The right ACA fills via the Acom. B. Left ICA injection, AP projection. Some delayed collateral supply to the right MCA territory occurs via the right ACA (highlighted). 1B

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Procedure :â•‡ The intervention was carried out under general anesthesia. Right CCA injections (not shown) revealed occlusion of the ICA just distal to the bulb. After completion of the diagnostic angiogram, 2000 units of intravenous Heparin were administered to achieve an ACT value around 200 seconds. A 5-F angle-tip diagnostic catheter was advanced over a 300-cm supercoil exchange wire into the right CCA. Over the exchange wire, the diagnostic catheter was exchanged for an 8-F guide catheter. Suction thrombectomy was performed by aspirating the 8-F catheter with a 60 mL syringe. The tip of the guide catheter was positioned at the occlusion site of the right cervical ICA. Suction thrombectomy produced minimal recanalization of right cervical ICA (Figure 2A).

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Right ICA angioplasty was performed with a 4 3 30 mm ViaTrac balloon over a Tran-send EX 0.014-inch microwire Â�without distal protection. Then, the Â�balloon and microwire were removed and a 5.5-mm Accunet distal-protection device was introduced into the distal cervical ICA. Over the Accunet filter wire, a tapered 8-6 3 40 mm Acculink stent (Figure 2C) was deployed, resulting in significant recanalization of the vessel (Figure 2D). Follow-up CCA injections showed Â�persistant occlusion of the MCA (Figureâ•¯2E).

Figure 2. A. Right CCA injection post suction thrombectomy, lateral projection. Minimal flow is seen (arrow) past the carotid bulb. B. Right CCA injection post-angioplasty shows some recanalization of the ICA. C. Unsubtracted image. The stent is in place (arrows point at the markers). D. Right CCA injection post-ICA angioplasty and stent placement. Good flow has resumed despite moderate residual stenosis. E. Right CCA injection post-ICA angioplasty and stent placement, intracranial lateral projection. The MCA remains oclcuded (arrow).

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CASE 55 • (continued)

To reperfuse the MCA, balloon angioplasty was undertaken using a 2.5 3 12 mm Maverick balloon with subsequent intra-arterial thrombolysis with 10 units of Reteplase. Partial recanalization of the right MCA was achieved (not shown). The procedure was completed at ~7 hours after the onset of stroke symptoms. Post-stent angioplasty of the ICA was not done because follow-up injections showed only minimal residual carotid stenosis (Figure 2G). The patient tolerated the procedure well. Immediately post-intervention, the patient’s NIHSS score had improved from 15 to 8. Figure 2. F. Unsubtracted image. The balloon has been positioned in the proximal MCA and inflated. G. Final right CCA injection shows only mild residual ICA stenosis.

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A 24-hour post-procedure CT scan showed no ICH and minimal hypodensity in the right parietal region. The patient was placed on daily Aspirin (325 mg) and Clopidogrel (75 mg). Six days later, repeat angiography demonstrated complete recanalization of the right MCA (Figure 3). Figure 3.â•‡ Repeat angiogram, right ICA injection, AP projection. Complete recanalization of the MCA is apparent. O utcome : The patient was discharged home after 7 days of hospitalization. NIHSS score at the time of discharge was 2.

3

Acute stroke in the setting of complete cervical ICA occlusion with minimal to no collateral blood supply is associated with high mortality. Expeditious cervical ICA and intracranial artery recanalization is necessary for a good functional recovery. Carotid angioplasty and stent placement are often required prior to intracranial thrombolysis. Although clot retrieval devices can be used for intracranial mechanical thrombolysis, this case illustrates that a combination of intracranial angioplasty and intra-arterial pharmacological thrombolysis can also lead to complete intracranial arterial recanalization. Intra-arterial infusion of thrombolytic agents such as Reteplase has been at times associated with recanalization followed by reocclusion. However, this case also illustrates that delayed complete recanalization can be observed. Although endovascular recanalization of a completely occluded cervical ICA may be technically challenging, the outcome of successful versus failed recanalization can translate into the difference between life or death.

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CASE 56 • Acute tandem Internal carotid artery-Middle cerebral artery occlusion Alexandros L. Georgiadis, MD, Jawad F. Kirmani, MD B ackground :â•‡ A 76-year-old man presented with a severe left-hemispheric deficit outside the window for treatment with intravenous thrombolysis. A 6-F Simmnons II Envoy catheter was positioned in the ascending aortic arch and a perfusion view was obtained (Figure 1). No filling of the left intracranial ICA was observed. Figure 2.â•‡ A and B. Left CCA injection, lateral projection, early (A) and late (B) arterial phase. The ICA is occluded.

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Figure 3. A. Right CCA run. Lateral projection. There is significant stenosis of the distal CCA and proximal ICA (arrows). The ICA stenosis was estimated to be 70%. B. Right CCA run, AP projection, intracranial view. The left ACA and MCA fill through the Acom. The MCA is occluded at the M1-segment (arrow). C. Extensive pial collaterals (rectangle) supply the left MCA territory.

Intra-arterial thrombolysis could be performed in one of two ways: Right ICA access. The proximal stenosis needs to be first treated with angioplasty/stenting because it would otherwise possibly cause embolic complications. This procedure would also augment collateral flow to the left side. The left MCA can then be accessed from the right carotid circulation through the Acom. Left ICA access. A microwire-microcatheter system is introduced through the occluded portion of the vessel to obtain an image. This is necessary so that a tandem occlusion of the intracranial vessel can be ruled out. If there is no intracranial occlusion, angioplasty/stenting can be performed. In the long run, revascularization of the occluded ICA might be best for the patientâ•¯(1). However, it is not clear if there is any short-term benefit in this approach (2,3). In this case, it was felt that access through the right ICA might save time, and this approach was therefore chosen. After completion of the diagnostic angiogram, the 6-F sheath was exchanged for a 6-F Cook Shuttle system over an Amplatz 300 cm super-stiff wire that had been parked in the right ECA. The Cook Shuttle system was advanced to the distal right CCA. 87

CASE 56 • (continued)

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Procedure , S tage 1:â•‡ Angioplasty/stenting of the right ICA. Figure 4.â•‡ A–E. Right CCA injections, lateral (A and B) and AP (E) projections. C and D are unsubtracted. A. A 9 3 40 mm Precise stent was positioned across the lesion over a BMW wire. The wire was positioned in the distal extracranial ICA. The arrows point at the stent markings. B. There is significant residual stenosis (arrow) post stent placement. C. A Savvy 4.5 3 40 mm balloon is positioned inside the stent for angioplasty (arrows: stent markers). D. The balloon is inflated inside the stent to a pressure of 7 atmospheres (supra-nominal). E. Only minimal residual stenosis is seen.

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Procedure , S tage 2 :â•‡ Attempted thrombolysis across the Acom. A Prowler Plus/Transend 14 system was introduced but could not be passed through the Acom into left the A1. The Transend 14 was removed and replaced by a Synchro 14 microwire. With this wire, the Acom was crossed (Figure 5A) and the microcatheter was positioned in the proximal MCA (Figure 5B). At that time, symptom onset was over 6 hours ago and thrombolytics were therefore not administered. Mechanical thrombolysis was performed with the microcatheter-microwire system. Attempts to pass a Microvena snare device into the left MCA failed. Final runs revealed excellent recanalization of the M1 and superior M2 segments with diminished flow in the inferior M2.

5C

Figure 5. A. Unsubtracted image. The microwire has been passed through the Acom into the left MCA. B and C.â•‡ Right ICA injection, AP projection (B) pre- and (C) post- thrombolysis. The large clot burden in the MCA is highlighted in a circle in B. In C, good flow is seen in the M1 and superior division M2. There is no flow in the inferior division.

References: 1. Grubb RL Jr, Derdeyn CP, Fritsch SM, et al. Importance of hemodynamic factors in the prognosis of symptomatic carotid occlusion. J Am Med Assoc 1998; 280:â•¯1055–1060. 2. Jovin TG, Gupta R, Uchino K, et al. Emergent stenting of extracranial carotid artery occlusion in acute stroke has a high revascularization rate. Stroke 2005; 36: 2426–2430. 3. Qureshi AI. Endovascular revascularization of symptomatic acute extracranial internal carotid artery occlusion. Stroke 2005;â•›â•›36:â•›â•›2335–2336.

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CASE 57 • Subacute ischemia resulting from Internal carotid artery stenosis Qaisar A. Shah, MD, Alexandros L. Georgiadis, MD, Vallabh Janardhan, MD B ackground :â•‡ A 47-year-old-man was admitted after an episode of right-arm dysmetria and sensory loss, which resolved partially. The patient had a history of myocardial infarction, hypercholesterolemia, hypertension, PTCA, and CABG.

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Figure 1.â•‡ A–C. MRI DWI images show areas of diffusion restriction distributed over the left hemisphere in a pattern suggesting ischemia in the MCA-ACA watershed territory.

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Figure 2. A. MRA shows signal drop-out in the proximal left ICA (arrow) suggesting a >80% stenosis. B. There is signal drop-out on CTA also (arrow). Figure 3.â•‡ A–C. There is increased CBV (A), diminished rCBF (B), and prolonged MTT (C) over the left hemisphere.

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Procedure : Figure 4. A. Left CCA injection, AP projection. A high-grade ulcerated lesion in the proximal ICA (arrow) is seen. An 8-F MERCI guide catheter was placed in the distal CCA and the balloon was inflated to block flow while an Accunet DEPD was passed through the lesion (not shown). B. The DEPD wire is in place (arrow). C. Unsubtracted image. A ViaTrac balloon has been advanced across the lesion over the DEPD wire and inflated. 89

CASE 57 • (continued)

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D. Left CCA injection, AP projection, post-angioplasty. The balloon has been exchanged over the DEPD wire for an Acculink stent, which is seen positioned across the stenosis (arrows point at the markers). Note the increase in lumen post angioplasty. E. Unsubtracted image. The stent has been deployed. Figure 5.â•‡ A and B. Final left CCA injection, lateral (A), and AP (B) projection. Only mild residual stenosis is seen.

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Figure 6.â•‡ A–C. CTP performed after the procedure. CBV (A), CBF (B), and MTT (C) have normalized.

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CASE 58 • Progressive ischemia resulting from Internal carotid artery stenosis Alexandros L. Georgiadis, MD, Rober t A. Taylor, MD B ackground :â•‡ A 72-year-old man presented with acute-onset of left-sided weakness, NIHSS score was 5. He received intravenous rt-PA at an outside hospital and was transferred for further management. At ~9 hours after symptom onset, he deteriorated significantly. A CT scan was negative for hemorrhage. CTP showed a large area of hypoperfusion over the right hemisphere (Figure 1, A–C), while CTA showed a significant right ICA stenosis (Figure 1D). MRI was performed urgently to assess the degree of irreversible ischemia. DWI showed a small infarct in the territory of the posterior MCA (Figure 2A). Because of the significant clinical- and perfusion-to-diffusion mismatch, and assuming that hypoperfusion due to the high-grade ICA stenosis was the cause, the patient was given 600 mg of Clopidogrel and 325 mg of Aspirin and taken to the angiographic suite for emergent stening.

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Figure 1.â•‡ A–D. CTP (A–C) and CTA of the right ICA (D). A. Mean transit times are prolonged in the entire MCA distribution, most severely in the posterior division (arrow). B. The same distribution of abnormal findings is seen in rCBF. C. CBV is increased over most of the MCA territory with the exception of the area highlighted in Figure 1A. This indicates nonviable tissue in that region (confirmed by MRI DWI). D. There is significant stenosis of the right ICA (arrow). Figure 2.â•‡ A and B.â•‡ MRI DWI (A) and ADC map (B). A small focus of diffusion restriction is apparent in the posterior parietal area (Figure 2A, arrow). A corresponding lesion is seen on the ADC map (Figure 2B, arrow).

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CASE 58 • (continued)

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Figure 3.â•‡ Diagnostic angiogram. Right CCA injection, oblique projection. There is severe stenosis (80% by NASCET criteria) of the right ICA (arrow). The left ICA (not shown) had a 65% proximal stenosis. P rocedure Figure 4.â•‡ A–C. Angioplasty and stenting. A. A DEPD is placed in the distal cervical ICA (arrow). B. A balloon is positioned across the lesion (arrows point at the markers). C. The stent is ready to be deployed (arrows point at the markers). D. Final right CCA run. Only minimal residual stenosis is seen post-angioplasty and stent placement.

4D

The patient improved clinically following the procedure. A repeat CT and CTP were performed the following day (Figure 5, A–D).

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Figure 5.â•‡ A–C.â•‡Repeat CTP performed the day following the procedure. The hypoperfusion noted in the previous study has resolved. D. CT performed at the same time showed a small posterior-parietal stroke corresponding with the area of decreased CBV and diffusion restriction seen in the scans obtained on the previous day.

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CASE 59 • Progressive ischemia resulting from Internal carotid artery stenosis M. Fareed K. Suri, MD, Alexandros L. Georgiadis, MD, Rober t A. Taylor, MD B ackground :â•‡ A 63-year-old man presented with an episode of left-sided hemiparesis and was found to have an infarct in the right caudate region. CTA showed a right ICA string sign. During hospitalization, the patient had another episode of left hemiparesis after which he was found to have a new infarct in the right corona radiata. Diagnostic angiography confirmed the CTA findings. There was minimal flow in the right cervical ICA with intracranial reconstitution via the ophthalmic artery.

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Figure 1.â•‡ A and B. Right CCA injection, lateral projection, extracranial (A) and intracranial (B) view. A. There is a severe proximal ICA stenosis with minimal antegrade flow (arrow). B. The red arrows show the flow of blood from the ECA branches into the ICA (circle). In the ICA, there is antegrade flow toward the MCA and retrograde flow. The black arrow points at an area of stenosis in the cavernous ICA. C. Right CCA injection, intracranial AP projection. The ICA fills the MCA but not the ACA. D. Left CCA injection, intracranial AP projection. Cross-filling to the right ACA is seen, but not to the MCA. The contribution to the right ICA territory from the posterior circulation was not significant (not shown). Procedure , S tage 1:â•‡ A Cook Shuttle system was placed in the distal right CCA. The lesion was traversed with an SL-10 microcatheter over a Transend 14 microwire. The wire was then exchanged for a 300-cm Transend 14, which was parked in the right proximal MCA. The microcatheter was exchanged for a Maverick 3 3 20 mm balloon catheter, which was positioned in the cavernous ICA, where the first angioplasty was performed. Six more angioplasty procedures were performed along the entire ICA from the cavernous segment to the carotid bulb. Balloon inflation was achieved by direct injection of a 1:1 contrast:saline solution from a 20 mL syringe into the balloon catheter, without use of a manometer. The injection was stopped when adequate balloon inflation was visualized, and the solution was then aspirated.

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Figure 2.â•‡ A–G. Unsubtracted images of the seven sequential angioplasty procedures. The balloon is shown inflated.

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Figure 3.â•‡ Right CCA injection, AP projection following angioplasty. There Is now antegrade flow in the ICA. 2E

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CASE 59 • (continued)

Procedure , S tage 2 : â•‡ A Wingspan 4.0 3 20 mm stent was deployed in the ICA cavernous segment. An Xpert 4.0 3 30 mm stent was deployed in the petrous segment with its distal end overlapping the proximal end of the Wingspan stent. Multiple angioplasty procedures along the entire cervical ICA were then performed with a ViaTrac 4.0 3 20 mm balloon, using the Â�technique that was described above. Figure 4.â•‡ A and B. Unsubtracted images. A. The overlapping stents are seen. B. The entire cervical ICA was treated again with angioplasty. The balloon is shown inflated during the first angioplasty.

Wingspan stent

Recanalization was still not satisfactory. Therefore, the decision was made to place stents across the cervical ICA.

Xpert stent

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Procedure , S tage 3 :â•‡ An Xpert 5.0 3 60 mm stent was deployed in the cervical ICA with its distal end overlapping the proximal end of the previous stent. An Acculink 6-8 3 40 mm tapered stent was deployed in the carotid bulb so that its distal end overlapped with the proximal end of the previous stent. A ViaTrac 5.0 3 20 mm balloon was advanced over the microwire to the high cervical segment of the right ICA, and a final angioplasty was performed using a balloon insufflation device. The patient had an episode of asystole that resolved following balloon deflation. Final injections demonstrated complete recanalization of the vessel.

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Figure 5.â•‡ Final injections. A. Right CCA injection, lateral projection. There is complete recanalization of the ICA. Some residual stenosis is noted in the bulb. B. Right CCA injection, AP intracranial projection. Good filling of the MCA and ACA is seen.

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CASE 60 • Fluctuating ischemia resulting from Internal carotid artery dissection Stanley H. Kim, MD B ackground :â•‡ A 40-year-old man presented with sudden onset of aphasia, right-sided neglect, and right-sided hemiparesis. He was seen in the emergency room 3 hours after the onset of stroke symptoms. CT scan revealed no ICH or hypodensity. CTA showed a left cervical ICA dissection. He was admitted to the neurology service and placed on intravenous Heparin. An MRI of the brain revealed a small focal area of ischemia in the left fronto-parietal region on DWI. The patient improved with near resolution of aphasia and right hemiparesis except for mild right-hand weakness and a subtle right peripheral field visual cut. However, 2 days after admission, follow-up MRI of the brain revealed worsening ischemic changes in the left frontol-parietal and left occipital regions. In view of the interval increase in ischemic changes in the left hemisphere, the patient underwent diagnostic angiography to evaluate the left cervical ICA dissection and intracranial circulation. The cerebral angiogram revealed a long (about 7 cm) dissection starting from the proximal left cervical ICA and extending to the petrous segment with near occlusion at that level. The patient was given 300 mg of Clopidogrel and 325 mg of Aspirin 2 hours prior to the intervention.

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Figure 1.â•‡ A–C. MRI DWI from the day of admission (A) and 2 days later (B and C). The arrows point at areas of diffusion restriction. Extensive new lesions are seen in B and C. Figure 2.â•‡ Left CCA injection, lateral projection. A long dissected segment in the ICA is apparent.

2

1C

Procedure: â•… The procedure was performed under moderate conscious sedation. Heparin was administered intravenously (4000 units) to achieve an ACT value of 315 seconds. A 6-F Cook Shuttle system was placed in the left CCA over a wire that had been parked in the left ECA. A DEPD could not be used because the dissection extended to the petrous segment of the ICA. An SL-10 microcatheter was advanced over a 0.014-inch Synchro microwire into the true lumen of the ICA under road-map guidance. The microcatheter was placed into the M1 segment of the left MCA. The microwire was exchanged for a BMW wire, which was parked in the MCA. The microcatheter was then removed. A 5 3 20 mm Acculink stent was advanced over the BMW wire, positioned so as to cover the most distal part of the dissection, and deployed. 3A

3B

Figure 3. A. The wire is placed in the ECA. B. The Cook Shuttle is advanced into the CCA over the wire. 95

CASE 60 • (continued)

Subsequently, two more Acculink stents (7 3 30 mm, 6 3 10 mm) were deployed more distally, partly overlapping each other. Complete recanalization of the ICA was achieved on follow-up runs. The patient tolerated the procedure well. Figure 3.â•‡ C and D. Unsubtracted images. C. The first stent is shown at the beginning of deployment. D. All three stents have been deployed. The arrows mark theâ•¯proximal and distal ends of the stented vessel segment.

3C

3D

4B

5

Figure 4.â•‡ A and B. Post-procedure left CCA injections, (A) extra- and (B) intra-cranial projections. The ICA is widely patent. There is good intracranial flow with no evidence of distal embolism. Figure 5.â•‡ The stent is seen on post-procedure follow-up CT (open arrow). O utcome : The patient was discharged home 3 days after the procedure on 325 mg of Aspirin and 75 mg of Clopidogrel daily. He had minimal right-hand weakness and a subtle right peripheral visual field cut. 4A

C onclusion : The management of spontaneous ICA dissection can be challenging. Conservative treatment with intravenous Heparin can possibly aggravate intramural hemorrhage within the dissected carotid artery, thus causing further compromise of the ICA lumen. In cases of progressively worsening neurological symptoms or radiological evidence of new ischemic changes during conservative medical therapy, carotid stenting should be considered.

96

CASE 61 • Progressive ischemia resulting from bilateral Internal carotid artery dissections John R. Lynch, MD, Thomas Wolfe , MD, Brian-Fred Fitzsimmons, MD, Osama O. Zaidat, MD B ackground :â•‡ A 53-year-old woman presented with a right MCA watershed region ischemic stroke. Cerebral angiography revealed complete occlusion of the right ICA 2 cm distal to the carotid bulb, consistent with dissection. Fibromuscular dysplasia (FMD) involving the cervical segment of the left ICA (Figure 1B) and the left VA was observed. Ten days later, the patient had a left parietal ischemic stroke. CTA revealed narrowing of the left ICA just distal to the carotid bulb with a dissection extending all the way into the petrous portion intracranially. It was feared that progression of the new lesion to occlusion would likely cause bilateral cortical ischemia. The decision was therefore made to proceed with urgent stent placement in

1A

1B

1C

Figure 1.â•‡ A–C. A. CTA following the first insult shows occlusion of the right ICA just distal to the bulb (arrow). B. Left CCA injection, first angiographic image. Note the FMD-type changes in the distal cervical ICA (circle). C. MRI DWI following the second stroke. The original watershed ischemic lesion is seen in the right hemisphere (white arrows). Aâ•¯posterior parietal lefthemispheric ischemic stroke (black arrow) also is shown.

P rocedure : • The patient was loaded with 325 mg of Aspirin and 300 mg of Clopidogrel 1 day prior to the procedure. Intravenous Heparin was given to maintain an ACT value between 250–300 throughout the procedure. • A 6-F 90-cm Shuttle Sheath was placed over a Bernstein 6-F 110-cm catheter and a 0.035-inch glidewire into the distal CCA under fluoroscopic images using road-map guidance. • Contrast stagnation occurred in the false lumen. After measuring the ICA distal to the stenosis, the dissected left ICA true lumen was crossed with a 190-cm EZ Filterwire DEPD that was deployed in the petrous portion of the vessel. • A 4.5 3 20 mm Wingspan stent was advanced to the distal cervical/pre-petrous portion of the ICA until the distal end of the stent touched the proximal end of the Filterwire and could not be advanced any further. The Wingspan stent was then deployed successfully across the lesion. • Next, three Xact stents were deployed serially, each overlapping the previously placed stent. The stents used were: 7 3 30 mm, 10-8 tapered 3 40 mm, and 10-8 tapered 3 30 mm. The final stent extended into the carotid bulb. Thus, the entire length of the vessel was reconstructed. After confirming that there was no evidence of acute in-stent thrombosis, the guide catheter was removed. •

Figure 2.â•‡ A–C. Left CCA runs during the procedure (A and B) and post-procedure (C). Figure 2A is unsubtracted. A. The black arrows indicate the position of the DEPD. The circle highlights the area of the ICA where the dissection originated. B. The arrow points at the DEPD. C. The ICA is entirely reconstructed following placement of four consecutive stents. No appreciable residual stenosis is seen.

2A

2B

2C

97

CASE 62 • Fluctuating ischemia resulting from Internal carotid artery dissection Alex Abou-Chebl, MD B AC KG R O U N D :â•‡ A 42-year-old woman with no significant risk factors presented with left hemianesthesia of sudden onset and was diagnosed with carotid occlusion by duplex ultrasound. She was treated with Heparin, but on the second hospital day she began to fluctuate, with transient left hemi-neglect and hemiparesis. Induced hypertension was initiated with no improvement. Urgent MRI was performed to assess the degree of brain injury. There was a small to moderate right parietal infarct on DWI and a larger deficit on PWI. Angiography was performed. Spontaneous arterial dissection is reported to have a relatively benign course and conservative (i.e., medical) treatment is usually advocated. While this approach is effective in the majority of patients, not all patients with dissection have a benign course. This may be due to a large stroke at presentation, the development of a SAH due to intracranial extension, or continued ischemia due to ongoing embolization or poor collateral flow combined with a severe flow-limiting stenosis. In these patients, “aggressive” therapy may be warranted.

1A

2A

3B

3A

1C

1B

Figure 1.â•‡ A and B. Right CCA injection. There is retrograde filling of the ICA (black arrows) through the ophthalmic artery (arrowhead). There is a flame-shaped occlusion of the right ICA (white arrow). However, to demonstrate complete occlusion of the ICA, the catheter was advanced carefully into the stump. C. Right ICA injection. There is severe stenosis at the apex of the second of two 180 loops (arrow). The angiographic appearance, the presence of redundant loops, the location of the lesion, the patient’s age, and her lack of risk factors, all pointed towards dissection as the underlying etiology.

Since the patient was symptomatic and with most of the right MCA territory at risk, it was decided to treat the lesion. Endovascular therapy was the best option since surgical treatment of dissections is associated with mortality rates of ~9%. The major obstacle in this case would be advancing a stent through the extremely tortuous ICA. This requires adequate wire support and extremely stable guide/sheath access. A DEPD was not considered necessary since the lesion was not atherosclerotic and therefore, the risk of embolization due to plaque disruption was low. Furthermore, DEPD placement would not have been easy, may have had a higher risk of intimal injury and, most importantly, would not have provided sufficient support to advance a stent since it would have had to be placed in the cervical ICA. Procedure :â•… An 8-F Cook Shuttle system was placed in the 2B distal CCA and through it an 8-F H1 guide catheter was advanced into the bulb of the ICA (arrow, Figure 2A). A Synchro wire was used to cautiously cross the lesion and a 1.5-mm balloon was advanced into the distal cervical ICA. The wire was removed. A gentle injection of contrast was performed through the balloon catheter to ensure that the balloon was in the true lumen. The wire was readvanced into the MCA (white arrow, Figure 2A) and the balloon was advanced further to allow exchange of the soft wire for a BMW wire for more support. The BMW wire was parked in the same location. A 3-mm coronary balloon was then used to predilate the lesion. A 6 3 20 mm Precise stent was then advanced, with great difficulty but atraumatically with continuous forward pressure on the sheath and guide and careful attention on the tip of the wire, into the lesion (arrow, Figure 2B). The stent was deployed in the apex of the second loop followed by a second overlapping stent extending over the apex of the first loop. Both were post-dilated with a 4-mm balloon. The final angiograms (Figure 3, A and B) revealed excellent results, with complete restoration of intracranial flow. The patient began to improve promptly. She was given Aspirin 650 mg and Clopidogrel 600 mg immediately after the stent deployment and Heparin was discontinued. 98

CASE 63 • Subacute ischemia resulting from Internal carotid artery occlusion Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD B ackground :â•‡ A 48-year-old man woke up with severe right-sided weakness and global aphasia. NIHSS score was 22 upon initial evaluation. The patient was not a candidate for thrombolysis because of the unknown time of onset. Noninvasive imaging showed a high-grade left ICA stenosis versus occlusion.

1

Figure 1.â•‡ Brain perfusion study with SPECT. The patient was injected with 22 mCi of Tc-99m Neurolite. Image acquisition was performed 30 minutes later. The white arrows point at areas of decreased perfusion. Subacute ICA occlusive lesions can sometimes be revascularized. In many cases, however, a tandem intracranial occlusion is present, rendering revascularization too risky and difficult. In this patient, the decision to attempt stent placement was based on the large perfusion deficits by SPECT scan when compared to the stroke size identified CT scan. Ideally, a perfusion study should be coupled with a study of tissue metabolism to demonstrate a mismatch between blood supply and demand. The same approach can be used for patient selection for ECA-ICA bypass in cases of chronic carotid occlusion.

3A

FRAME 6/16

2A

FRAME 10/16

3B

2B

A 6-F sheath was placed in the right CFA. A 6-F MPD Envoy was then positioned in the left CCA. Following a contrast injection, the occlusion of the left ICA was confirmed (Figure 2, A and B, lateral projections, early and late phase). The occlusion has the typical flame shape that is commonly associated with ICA dissections. A 2.3-F Prowler Plus microcatheter was advanced over a Transend 14 microwire through the lesion into the distal ICA (Figure 3A, unsubtracted). A distal injection revealed a second occlusion of the ICA intracranially (arrow, Figure 3B). Revascularization was therefore not attempted.

99

CASE 64 • Progressive ischemia resulting from multivessel disease Alexandros L. Georgiadis, MD, Haitham M. Hussein, MD, Adnan I. Qureshi, MD B AC KG R O U N D :â•‡ A 69-year-old man presented with subacute right hemiparesis and a right partial VI nerve palsy. A few hours after admission, he started developing new left-side weakness. The patient underwent MRI/A (Figure 1A) and CTA (Figure 1B) and CT perfusion imaging. The studies revealed bilateral cervical ICA stenosis as well as a mid-basilar stenosis (arrow) and no visualization of the intracranial VAs. CTP showed decreased perfusion in the right MCA and bilateral PCA territories. It was decided that the patient should undergo angiography with the option of endovascular intervention. 1B

1A

3B

3A

2B

2A

LEFT VA

RIGHT VA EXTRACRANIAL

EXTRACRANIAL

INTRACRANIAL

INTRACRANIAL

Figure 3.â•‡ A and B. Left subclavian artery injection, AP (A) and lateral (B) projection. The vessel is occluded extracranially and is not seen in 3A. It reconstitutes distally (arrows) via collaterals (circle) but does not contribute flow to the basilar artery.

Figure 2.â•‡ A and B. Right VA injection, AP projection. The vessel is normal in its extracranial segments. It is however occluded intracranially (arrow).

5B 4A

4B

5A

RIGHT CAROTID EXTRACRANIAL

LEFT CAROTID INTRACRANIAL

EXTRACRANIAL

Figure 4.â•‡ A and B. Right CCA injection, AP (A) and lateral (B) projection. There is a high-grade, irregular stenosis at the bifurcation (arrow). Intracranially, the right ICA fills the basilar artery in retrograde fashion (circle) via the Pcom.

INTRACRANIAL

Figure 5.â•‡ A and B. Left CCA injection, AP (A) and lateral (B) projection. There is moderate stenosis at the bifurcation (arrow). The left CCA also fills the basilar, but to a lesser degree (circle).

The diagnostic angiogram revealed the findings shown in Figures 2A through 5B. The basilar artery received no antegrade flow. The main source of retrograde flow was the right ICA, which had significant stenosis and diminished perfusion of its own territory by CTP. It was therefore decided to treat the right ICA stenosis. 100

CASE 64 • (continued)

RCCA, AP RCCA, AP

6A

RCCA, LAT

6C

6B

6D

RCCA, LAT

6E

Procedure : A 6-F Cook Shuttle system was introduced into the descending aortic arch over a 300-cm Amplatz super-stiff wire. A 5-F 120-cm Simmons II catheter was introduced through the Cook Shuttle into the arch and then into the right CCA. The Cook Shuttle was advanced over the Simmons II into the distal CCA (Figure 6A). A 0.014-inch Stabilizer microwire was introduced into the right CCA and was then used to traverse the lesion. The microwire was placed in the distal ICA (Figure 6B, white arrow). A ViaTrac 5 3 30 mm balloon was positioned over the microwire across the lesion (Figures 6B and 6C, black arrows show the proximal and distal balloon markings). The balloon was then deployed at nominal pressure. The post-angioplasty injection showed suboptimal results. The decision was therefore made to proceed with stent placement. A 7-10 3 40 mm Acculink monorail stent was prepared and advanced over the Stabilizer microwire into the area of stenosis (Figure 6D, arrows point at the stent markers). The stent was deployed and post-stent injections (Figure 6E) showed <20% residual stenosis. rCBF

PRE

MTT

PRE

7B

7A

CBV

PRE

MTT

POST

Figure 7.â•‡ A–D. CT perfusion images. Map of rCBF (measured in mL/100 g A. cerebral tissue/min). B and D.â•‡ MTT measurements in seconds. C. Map of CBV (measured in mL/100 g cerebral tissue). Figures 7A–7C were obtained prior to the procedure. Figure 7D is part of a post-procedure follow-up study. Figure 7A shows that rCBF is decreased over the entire territory of the right MCA and both PCAs, indicating hypoperfusion. Figure 7B, shows the expected increase in MTT in exactly the same regions. Figure 7C shows fairly symmetrical values over the two hemispheres. This finding indicates that the hypoperfused tissue is still viable. CBV is decreased in regions of irreversible ischemic injury. Penumbra is characterized by normal to elevated CBV values secondary to vasodilatation. After the procedure, perfusion improved dramatically in the right MCA territory and moderately in the territories of the PCAs (Figure 7D).

7D

7C

Reference: Wintermark M, Sesay M, Barbier E, et al. Comparative overview of brain perfusion imaging techniques. Stroke 2005; 36: 83–99.

101

CASE 65 • Fluctuating ischemia resulting from Basilar artery disease Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD B AC KG R O U N D : â•‡ A 77-year-old man presented with fluctuating signs of posterior circulation ischemia.

1A

PERFUSION, FRAME 3

1B

1C PERFUSION, FRAME 7

Figure 1.â•‡ A–C. Initially an MRA was performed (A) that showed a signal dropout in the mid-basilar (arrow). Then the patient was taken to the angiographic suite.

A 6-F sheath was placed in the right CFA and a 6-F Envoy Simmons II catheter was introduced and advanced into the aortic arch. A 20-degree Caldwell AP projection (perfusion shot) was obtained. As seen in B and C, there is significant delay in the filling of the posterior circulation.

2A

POST ANGIOPLASTY 3 2

2C

2B

2E

POST ANGIOPLASTY 3 3

2F

2D

2G

2H

Procedure :â•… Figure 2.â•‡ A–H. Left VA injections, AP projection. A. Stenosis at the mid-basilar artery level (arrow). B. A follow-up injection 1 minute later reveals a complete occlusion of the basilar artery just distal to the take-off of the AICA. C. A Transend 14 microwire (arrow) was passed through the occlusive segment, and its tip was positioned in the right PCA. D. A 2 3 9 mm Maverick balloon was brought in position across the occlusive lesion (arrows: proximal and distal balloon markers). E. After angioplasty 3 2, significant residual stenosis was still observed. Because flow was increased through the basilar artery, repeat measurements were taken. These measurements revealed a larger vessel diameter. Therefore, the decision was made to perform another angioplasty with a larger balloon. F. A Maverick 3.5 3 9 mm balloon was brought in position and a third angioplasty was performed. There was still significant residual stenosis. G. This injection, which was performed prior to the fourth and final angioplasty showed re-occlusion of the basilar artery. H. Flow is restored after the fourth angioplasty. However, a large intra-luminal clot is seen (arrow). Follow-up one-vessel angiogram showed showed good patency of the basilar artery, but occlusion of the left PCA. The patient had significant deficits. He had right homonymous hemianopsia, gaze abnormalities, and a left-sided hemiparesis. Figure 3.â•‡ A–D. Follow-up MRI. There are multiple scattered DWI lesions in the posterior circulation. 3A

3B

3C

102

3D

CASE 66 • Progressive ischemia due to bilateral Vertebral artery dissections M. Fareed K. Suri, MD, Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD B ackground :â•‡ A 24-year-old man became unresponsive the next day following a motor vehicle accident. CTA demonstrated bilateral VA dissections.

RVA LVA

1A

1B

1C

Figure 1.â•‡ A–C. CTA, 3-D reconstruction. A, B.â•‡ Both vertebral arteries can be seen tapering off (circle). C. The basilar artery fills presumably in retrograde fashion, since both vertebrals can only be seen at the level of the vertebro-basilar junction.

2A

2B

2C

Figure 2.â•‡ A–C. Diagnostic angiography. A, B.â•‡ Left (A) and right (B) VA injection, AP projection. Both VAs are occluded at the C2 level (arrows). C. Left ICA injection, lateral projection, late arterial phase. The basilar artery (arrow) can be seen filling in retrograde fashion. Procedure : Considering the acute neurologic deterioration of the patient, the decision was made to attempt to recanalize the left VA. The vessels appeared to be co-dominant and access to the left VA was easier. A 6-F MPD Envoy catheter was placed in the left VA and a RapidTransit microcatheter was advanced over a Transend 14 microwire into the basilar artery. A microcatheter injection confirmed placement in the true lumen. A double injection (i.e., simultaneous microcatheter and guide catheter injection) was performed to assess the length of the occluded segment. The microwire was then exchanged for a 300-cm Transend 14, and the microcatheter was exchanged for a Neuroform 4 3 20 mm stent. The stent was positioned at the distal end of the dissection in the mid-basilar segment and deployed. There was limited expansion of the proximal end of the stent. It was therefore attempted to place a second stent, partly overlapping the initial one, but this was not possible. The second stent (Neuroform 4.5 3 20 mm) was deployed just proximal to the first one. Although it appeared that the entire length of the dissection had been covered, there was no flow in the vessel. A third stent (Neuroform 4.5 3 20 mm) was then placed proximally with partial overlap with the second stent. Again, no recanalization was observed. The procedure was terminated at that time.

103

CASE 66 • (continued) Figure 3. A. Microcatheter injection. The microcatheter (arrow points at the tip) is in the true lumen of the basilar artery. B. Double injection. The occluded segment extends between the two arrows. Figure 4. A. Unsubtracted image. The proximal struts of the stent have not expanded sufficiently (circle). B. Unsubtracted image, after placement of 2 stents. The arrows point at the stent markers. The 3A stents abut each other as it was not technically possible to achieve partial overlap. Note the stagnation of contrast from a previous run (white arrows). C. Left VA injection, AP projection, s/p placement of 2 stents. There is no distal flow. D. Unsubtracted image, after placement of 3 stents. The arrows point at the stent markers. There is again stagnation of contrast (white arrows). E. Final left VA injection, AP projection. No recanalization has been achieved.

4A

4B

4D

4C

4E

104

3B

CHAPTER 4

Treatment of Aneurysms and Pseudo-aneurysmal Lesions

1A

2A

1B

2B

3A

3B

Figures 1A through 3Aâ•‡ are photographs of an aneurysm flow model taken after deployment of one, two, and four coils respectively. Figures 2A through 2Câ•‡ are the corresponding fluoroscopic images. The figures illustrate the discordance between angiographic result and actual filling of the aneurysm. In coil embolization, the best possible balance between procedure safety and successful treatment of the aneurysm must be maintained. To this end, it is important to achieve optimal packing density, defined as: Packing density 5 Cumulative coil volume/Aneurysm volume. Excessive coiling may increase the risk of rupture, whereas placing an inadequate number of coils may be associated with a higher risk of recanalization of the aneurysm (coil compaction). Coil compaction in most cases occurs within 12 months following the procedure. In general, packing densities of >20% to 30% have been associated with low incidence of coil compaction. Poor correlation exists between angiographic occlusion and actual packing density. Packing density can be derived from the equation mentioned above. Approximate coil and aneurysmal volumes can be calculated as follows: Coil volume 5 p 3 (coil radius2) 3 coil length Aneurysm volume 5 (4/3) 3 p 3 (length/2) 3 (width/2) 3 (height/2)

105

OVERVIEW OF CASES I

COIL EMBOLIZATION

CASES 67–78

Case 67

Unruptured basilar apex aneurysm

Case 68

Ruptured Internal carotid artery aneurysm

Case 69

Unruptured Internal carotid artery aneurysm Hydrocoils

Case 70

Ruptured multilobed Internal carotid artery aneurysm

Case 71

Ruptured multilobed posterior inferior cerebellar artery aneurysm

Atypically located aneurysms

Case 72

Distal Anterior cerebral artery ruptured aneurysm

Case 73

Distal Posterior cerebral artery ruptured aneurysm

Embolization via Internal carotid artery access

Case 74

Ruptured Internal carotid artery aneurysm Excessive tortuosity of the proximal cervical vessels

Cases with complications

Case 75

Ruptured Internal carotid artery aneurysm Giant aneurysm Coil compaction

Case 76

Ruptured Internal carotid artery aneurysm Coil compaction

Case 77

Ruptured basilar apex aneurysm Coil compaction

Case 78

Ruptured Anterior communicating artery aneurysm Thrombo-embolic complications

II

BALLOON-ASSISTED COIL EMBOLIZATION

Case 79

Ruptured hypophyseal artery aneurysm

Case 80

Unruptured Anterior communicating artery aneurysm

Case 81

Ruptured Internal carotid artery aneurysm

Cases with complications

Case 82

Unruptured Internal carotid artery aneurysm Thrombo-embolic complications Treatment with intranenous abciximab Iatrogenic vasospasm

Case 83

Unruptured Internal carotid artery aneurysm Internal carotid artery occlusion Treatment with intra-arterial Reteplase

106

CASES 79–83

III

STENT-ASSISTED COIL EMBOLIZATION

Treatment in one session

Case 84

Unruptured Internal carotid artery aneurysm Aneurysm recurrence post clipping

Case 85

Unruptured Internal carotid artery aneurysm

Case 86

Unruptured distal cervical Internal carotid artery aneurysm Pseudo-aneurysmal lesion

Case 87

Unruptured cavernous Internal carotid artery aneursym Cranial nerve palsy

Case 88

Unruptured Internal carotid artery terminus aneurysm Stent placement following coil embolization In-stent stenosis Cerecyte coils

Treatment in two sessions

Case 89

Ruptured clinoid Internal carotid artery aneurysm Persistent hypoglossal artery

Case 90

Unruptured Internal carotid artery/Ophthalmic artery aneurysm Multiple aneurysms

Case 91

Unruptured Internal carotid artery aneurysm Balloon test-occlusion Iatrogenic vasospasm Intra-arterial nicardipine

Case with complication

Case 92

Ruptured posterior cerebral artery aneurysm Thrombo-embolic complication Treatment with intravenous Eptifibatide

IV

COIL EMBOLIZATION WITH PARENT-VESSEL OCCLUSION

Parent-vessel occulsion with coils

Case 93

Ruptured Internal carotid artery aneurysm Giant aneurysm Alcox and Mathis maneuvers

Case 94

Ruptured vertebral artery aneurysm Dissecting aneurysm

Parent-vessel occlusion with detachable balloons

Case 95

Unruptured Internal carotid artery aneurysm Traumatic pseudo-aneurysm Balloon test-occlusion

107

CASES 84–92

CASES 93–97

Cases with complications

Case 96

Unruptured Anterior cerebral artery aneurysm Ischemic complications

Case 97

Unruptured Basilar artery aneurysm Ischemic and hemorrhagic complications

V

ALTERNATIVE TECHNIQUES

Trispan device

Case 98

Unruptured Basilar apex aneurysm

Onyx embolization

Case 99

Unruptured Internal carotid artery/Ophthalmic artery aneurysm Coil compaction

Microcatheter deflection technique

Case 100

Unruptured Middle cerebral artery bifurcation aneurysm Unsuccessful balloon-assisted coil embolization Neuroform stent placement following coil embolization

VI

TREATMENT OF VASOSPASM

Case 101

Basilar artery and Posterior cerebral artery vasospasm Basilar artery angioplasty Intra-arterial papaverine

Case 102

Posterior cerebral artery vasospasm Intra-arterial nicardipine

VII

MISCELLANEOUS CASES

Case 103

Aneurysm not suitable for coiling Variations in posterior circulation anatomy

Case 104

Aneurysm regression following stent placement Pseudo-aneurysm

Case 105

Vertebral artery aneurysm Repeat stent-assissted coil embolization Coil compaction

CASES 98–100

CASES 101–102

CASES 103–105

108

CASE 67 • Unruptured Basilar artery apex aneurysm Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD B ac kg round :â•‡ A 56-year-old woman was found to have an unruptured, bilobed basilar artery apex aneurysm (Figure 1) Â�measuring >10 mm in its greatest dimension. Sheath used: 6-F, short Guide-catheter: Envoy MPC Microcatheter: SL-10 Microwire: Transend 14 Coils used: Matrix 2 360 10 mm 3 30 cm Matrix 2D Soft SR 6 mm 3 10 cm (two coils), 5 mm 3 8 cm Matrix 2 D Ultrasoft SR 3 mm 3 6 cm (two coils)

1

Coil#1

2A

Coil#6

2B

Figure 1.â•‡ Left VA injection, oblique projection. Figure 2.â•‡ A and B. Unsubtracted images. A. After placement of one coil. B. After placement of all six coils. Figure 3.â•‡ Left VA injection, AP projection. Final run showing complete angiographic obliteration of the aneurysm.

3

Treatment of unruptured aneurysms Significant controversy still exists regarding which patients with unruptured aneurysms should be treated (1-3). Based mainly on the data from two large prospective studies (4, 5), the general consensus is that asymptomatic aneurysms smaller than 7 mm should not be treated. Other factors that influence the risk of rupture and need to be considered include: location (posterior circulation aneurysms are more prone to rupture), patient’s age (procedural morbidity increases with age), history of previous SAH (increases the risk of rupture of an unrelated aneurysm). The patient’s preference must obviously be taken into consideration as well. References: 1. Donnan GA, Davis SM. Patients with small, asymptomatic unruptured intracranial aneurysms and no history of subarachnoid hemorrhage should be treated conservatively. Stroke 2005; 36: 407. 2.â•‡ Wiebers DO. Patients with small, asymptomatic unruptured intracranial aneurysms and no history of subarachnoid hemorrhage should be treated conservatively: For. Stoke 2005; 36: 408–409. 3. Weir B. Patients with small, asymptomatic unruptured intracranial aneurysms and no history of subarachnoid hemorrhage should be treated conservatively: Against. Stroke 2005; 36: 410–411. 4. International study of unruptured intracranial aneurysms investigators. Unruptured intracranial aneurysms: risk of rupture and risk of surgical intervention. N Engl J Med 1998; 339: 1725–1733. 5. Wiebers DO, Whisnant JP, Huston J 3rd, et al. International study of unruptured intracranial aneurysms investigators. Unruptured intracranial aneurysms: natural history, clinical outcome and risks of surgical and endovascular treatment. Lancet 2003; 362: 103–110.

109

CASE 68 • Ruptured Internal carotid artery aneurysm Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD B AC KG R O U N D : â•‡ The patient presented with SAH, Hunt & Hess Grade II. Diffuse blood in the cisterns was seen on the CT scan (Figure 1, A and B).

1A

1B

2A

Left Internal carotid artery injection,

2B

3A

Diagnostic angiography showed an irregular aneurysm, Â�measuring ~7 mm 3 7 mm (black arrow, Â�Figure 2A) in close proximity to the origin of the Pcom (white arrow, Figure 2A). Figure 2B (right VA injection, lateral view) shows that the PCAs do not fill from the basilar. The same finding was observed after left VA injection. The 3-D reconstruction shown in Figure 3A, shows a distinct origin for the aneurysm (small arrow) and the Pcom (large arrow). This is confirmed in the projection seen in Figure 3B. The curved arrows point at the neck of the aneurysm (upper arrow) and the origin of the Pcom (lower arrow).

3B

4B 4C

4A

4D

P rocedure : Figure 4Aâ•‡ (unsubtracted image) shows the first coil after it was completely introduced into the aneurysm: the coil marker (black arrow) has just crossed the proximal microcatheter marker (white arrow). The image obtained after the first coil was deployed is shown in Figure 4B, whereas Figures 4C and 4D show the final runs after placement of all six coils. Note that the Pcom is preserved. Coils used, listed in order of deployment: GDC 360 7 3 20, Matrix 2 360 ultrasoft 5 3 15, 4 3 8, 3 3 8, Matrix 2 helical ultrasoft 3 3 6, Matrix 2 2-D Soft 3 3 6

110

CASE 69 • Unruptured Internal carotid artery aneurysm Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD B ac kg round :â•‡ A 49-year-old woman was found to have an unruptured aneurysm at the ICA/Pcom junction that increased in size during follow-up. In May of 2005, the aneurysm measured 7 mm and had a neck of ~5 mm. Because of the wide neck, the decision was made to treat the aneurysm in two stages. In May of 2005, a VITA stent was placed across the neck of the aneurysm. In April of 2006, the patient returned for coil embolization through the stent. At that time, the aneurysm had regressed to a size of 4 mm. Figure 1.â•‡ Left Internal carotid artery injection, lateral projection. â•›The aneurysm (open arrow) has regressed to a size of 4 mm. â•›The white arrow points at the Pcom. â•›The black arrow shows the PCA that fills through the Pcom. A surgical clip that had been used to treat a previous aneurysm can also be seen (arrowhead).

1

Procedure : The guide catheter used for the procedure was a 5-F MPD Envoy (due to small parent vessel size). The microcatheter used was an SL-10. The microwire was a Transend 14 floppy. After the tip of the microcatheter was positioned inside the aneurysm, the following types of coils were introduced and deployed: Matrix 2 360-degree Soft SR 4 mm 3 6 cm Hydrocoil 14, 4 mm 3 6 cm Hydrocoil 14, 2 mm 3 3 cm At that stage, complete radiographic obliteration was achieved. A post-embolization injection (Figure 4) showed that the left PCA was not filling through the Pcom as visualized earlier (Figure 1). However, a right VA injection showed that the left PCA was filling through the basilar artery (Figure 5). Hydrocoils should be used with caution when treating ruptured aneurysms because of their potential to expand significantly post deployment. They are, however, a good choice for unruptured aneurysms. Figures 2 through 4.â•‡ Left Internal carotid artery injections, lateral projection. Figure 5.â•‡ Right VA injection, AP projection. Both PCAs are seen filling.

s/p 1 coil

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CASE 70 • Ruptured, multi-lobed Internal carotid artery aneurysm Alexandros L. Georgiadis, MD, Charl es J. Prestigiacomo, MD, FACS B AC KG R O U N D :â•‡ A 57-year-old man presented with SAH, Grade V by Hunt & Hess criteria. CTA showed a large, multi-lobed, aneurysm at the right ICA/Pcom junction (Figure 1, white arrows). Conventional angiography was then performed with intent to treat the aneurysm. After a 6-F sheath was placed in the right CFA, a 6-F MPD Envoy catheter was advanced into the right CCA and then into the right Internal carotid artery. A right Internal carotid artery injection confirmed the presence of an aneurysm, possibly with a pseudo-aneurysmal component. P rocedure : â•… An SL-10 45-degree microcatheter was then introduced over a Transend 14 microwire into the right ICA. The microcatheter was advanced into the intracranial Internal carotid artery, and its tip was positioned inside the aneurysm (Figure 3, arrow). A series of eight coils were introduced into the aneurysm and deployed. Images were obtained prior to the deployment of each coil in order to confirm correct placement.

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Figure 2.â•‡ A. Right ICA injection, lateral projection. Aâ•¯multilobed aneurysm is seen. The arrowhead points at the distal lobe vs. pseudo-aneurysmal sac. B. A 3-D reconstruction image is used to obtain measurements of the aneurysm. Figure 3.â•‡ Right ICA injection prior to the deployment of the first coil, lateral projection. The arrow points at the tip of the microcatheter. 3

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Figure 4.â•‡ Figures A and B, show a coil pre- and post-deployment respectively. The microcatheter tip is highlighted by a white circle. The arrows in Figure 4A show the manner in which the distal-most portion of the coil moves when it detaches. 112

CASE 70 • (continued)

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Figure 5â•‡ shows stagnating blood inside the aneurysm (arrow). Subtracted image. Figure 6â•‡ shows preservation of the Pcom that courses around the neck of the aneurysm (arrows). Right Internal carotid artery injection, lateralâ•¯projection.

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Figure 7. A. 3-D reconstruction obtained after the coil embolization was completed. B and C.â•‡ 3-D reconstruction with the coil mass highlighted (B) and then extracted from the image (C). Coils deployed: Matrix 2 360-degree standard and soft, GDC Soft, GDC ultrasoft Sizes: 2 mm 3 3 cm 2 8 mm 3 30 cm

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CASE 71 • Ruptured, multi-lobed Posterior inferior cerebellar artery aneurysm Stanley H. Kim, MD, Shannon Warren B AC KG R O U N D :â•‡ A 50-year-old man presented with Hunt & Hess Grade IV SAH. He had been found unresponsive at home and intubated at the scene. CT scan showed diffuse SAH with a large clot over the left pre-pontine cistern and cerebello-pontine angle (Figure 1). Emergent diagnostic cerebral angiogram revealed a bilobed, wide-neck, left PICA aneurysm (Figure 2A). The smaller proximal aneurysm measured 5 3 4 mm, and the distal aneurysm measured 7 3 5 mm. In view of the patient’s poor Â�neurologic condition and the location of the aneurysms, endovascular treatment was recommended to the family.

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Figure 2. A. VA injection, lateral projection. The arrows point at the lobes of the aneurysm. B. Left subclavian artery injection. The tortuosity of the VA origin precluded placement of the guide catheter in the VA. The guide catheter was therefore parked in the subclavian artery just below the VA origin.

Procedure : â•… The procedure was performed under general anesthesia. Intravenous Heparin was administered at a dose of 2000 units to achieve an ACT of 214 seconds. An SL-10 microcatheter was navigated over a Synchro 0.014-inch microwire through a 6-F Envoy guide catheter into the left VA using road-map guidance. The microcatheter was placed into the smaller proximal aneurysm. It was felt that embolizing the second aneurysm could have prevented later access to the smaller aneurysm. A 4 mm 3 8 cm 360-degree ultrasoft Matrix coil was deployed followed by a 2 mm 3 4 cm 360-degree ultrasoft Matrix coil. While in the process of delivering these coils, a left VA injection revealed a daughter aneurysm near the apex of the distal aneurysm (Figure 3A). This dilated area was probably the point of aneurysm rupture. The microcatheter was pulled out of the proximal aneurysm and advanced into the larger aneurysm under road-map guidance. The following Matrix coils were delivered in sequence: 5 mm 3 10 ultrasoft 360-degree, 4 mm 3 6 cm ultrasoft 360-degree, 3 mm 3 6 cm ultrasoft 360-degree, 2 mm 3 6 cm ultrasoft 360-degree, 2 mm 3 4 cm ultrasoft 360-degree, 2 mm 3 4 cm ultrasoft 360-degree, 2 mm 3 6 cm ultrasoft 360-degree, 2 mm 3 6 cm ultrasoft helical, 2 mm 3 4 cm ultrasoft helical. Near-complete obliteration of the aneurysms was achieved (Figure 3C). There was some residual filling at the base of the distal aneurysm. However, the ruptured portion of the aneurysm was presumed to be sufficiently protected by the coil mass.

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Figure 3. A. Left subclavian artery injection, lateral intracranial projection. The microcatheter is in the proximal aneurysm. Two coils have been deployed. The arrow points at a daughter aneurysm that was believed to have been the source of SAH. B. Unsubtracted image. The microcatheter has been repositioned and is now inside the distal aneurysm. The first coil is being placed. C Left subclavian artery injection, lateral projection, post-embolization. There is some residual filling at the neck of the distal aneurysm (arrow). O utcome :â•‡ The patient developed hydrocephalus the day after the embolization, requiring placement of a ventriculostomy. Follow-up CT scan showed no new hemorrhage. He regained consciousness and was able to follow simple commands the day after the embolization of the aneurysm. Conclusion :â•‡ Some bi-lobed aneurysms can be coiled as two separate aneurysms. When complex-shaped ruptured aneurysms are not completely obliterated, they need to be studied closely with serial angiograms until complete obliteration has been achieved. 114

CASE 72 • Ruptured distal Anterior cerebral artery aneurysm A l e x a n d ro s L . G e o r g i ad i s , M D, C h a r l e s J . P re s t i g i ac o m o, M D, FAC S B AC KG R O U N D : â•‡ A 79-year-old woman presented with SAH Grade IV by Hunt & Hess criteria.

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CT scan showed diffuse SAH with ICH, IVH, and hydrocephalus (Figure 1, A–D). Angiography was performed with intent to treat the aneurysm. A 6-F MPD Envoy catheter was positioned in the left Internal carotid artery and an injection was performed. AP (Figure 2A) and lateral (Figure 2B) intracranial images were obtained that confirmed the presence of a distal ACA aneurysm (arrow in Figures 2A and 2B). Procedure :â•… The MPD catheter was then advanced to the distal cervical Internal carotid artery. An SL-10 90˚ microcatheter was introduced over a Transend 14â•¯microwire, through the guide catheter, into the left Internal carotid artery. The tip of the microcatheter was positioned inside the aneurysm and a total of 10 coils were deployed serially. Near-complete angiographic obliteration of the aneurysm was achieved. Figure 2.â•‡ A and B. Left Internal carotid artery injection, AP (A) and lateral (B) projection. The arrows point at the aneurysm.

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Figure 3.â•‡ A (unsubtracted) and B (left Internal carotid artery injection, lateral projection). The microcatheter is in position prior to the deployment of the first coil. The arrow indicates the position of the proximal micocatheter marker.

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Figure 5. Final left Internal carotid artery injection, lateral projection. Near-complete obliteration of the aneurysm (arrow, coil mass) is shown.

Figure 4.â•‡ A–I. Coil mass after deployment of coils 2 through 10

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CASE 73 • Ruptured distal Posterior cerebral artery aneurysm Stanley H. Kim, MD B AC KG R O U N D :â•‡ A 52-year-old man presented with a history of spontaneous left temporal ICH to an out-of-state hospital. Reportedly, a cerebral angiogram was performed at that time, and it was negative for any potential source of bleeding. The patient had been in China and was taking some pseudophed-like medication for a month prior to the hemorrhage for sinus headache. He was seen at our hospital for follow-up 5 months after the hemorrhage. MRI revealed a suspicious vascular lesion in the left posterior temporo-occipital region.

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Figure 1.â•‡ A and B. VA injection, oblique projection. Figure 2.â•‡ A and B. VA injection, lateral (A) and oblique (2) projection.

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A diagnostic angiogram was then performed. It showed a 7 3 9 mm lesion arising from the left P2 segment of the PCA (arrows, Figure 1, A and B). There was no evidence of infection to suggest a mycotic aneurysm. In view of the deep location of the lesion, surgical treatment was not deemed feasible. Therefore, endovascular treatment was planned. However, on the day of the procedure, significant regression of the lesion was noted (arrows, Figure 2, A and B). This was secondary to spontaneous partial thrombosis. The procedure was aborted because it was felt that the aneurysm might thrombose off completely. Follow-up angiography was scheduled for a month later.

3B

Follow-up angiography showed renewed full opacification of the aneurysm (Figure 3, A and B). Coil embolization was therefore performed. A total of nine matrix coils were used. There was good packing of the aneurysm with no visible residual filling (Figure 4, A and B, arrows point at the coil mass). There were no post-procedure complications. The patient was asymptomatic at follow-up 1 year later. Figure 3.â•‡ A and B. VA injection, AP (A) and lateral (B) projection. Figure 4.â•‡ A and B. VA injection, post-coiling, lateral (A) and AP (B) projection.

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CASE 74 • Ruptured Internal carotid artery aneurysm Stanley H. Kim, MD, Anant I. Patel, MD B ac kg round :â•‡ A 65-year-old woman presented with a Hunt & Hess Grade I SAH (CT shown in Figure A depicts diffuse blood in the cisterns and hydrocephalus). She had a known unruptured calcified left Pcom aneurysm that had not been treated at an outside facility because it was felt that the calcified neck of the aneurysm increased the risk of surgical clip placement. RSCL: Right subclavian artery

B

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Diagnostic cerebral angiography revealed severe tortuousity of the proximal left CCA (Figures B and C) complicating transfemoral approach to the left carotid artery for embolization of the aneurysm (arrow, Figure D & E). The decision was made to perform coil embolization of the aneurysm via a direct left CCA approach.

LEFT ICA INJ, AP

LEFT ICA INJ, LAT D

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P rocedure : A 6-F sheath (Terumo, Elkton, MD) was inserted into the left CCA (Figure F) using a Micropuncture Introducer Set (Cook, Bloomington, IN) and a 5-F dilator and then advanced into the Internal carotid artery using road-map guidance. The patient was under general anesthesia. A 6-F Envoy guide catheter was used to deliver an SL-10 microcatheter into the 12 3 7 mm aneurysm over a 0.014-inch Synchro microwire. Figure G shows a distal segment of severe tortuosity. A Heparin bolus of 2000 units was administered intravenously to achieve an ACT value of 200 seconds. Matrix 2 coils were used to achieve complete obliteration of the aneurysm in the following order: 8 mm 3 30 cm soft 3D, 6 mm 3 15 cm ultrasoft 3D, 5 mm 3 15 cm ultrasoft 3D, 5 mm 3 10 cm ultrasoft 3D, 4 mm 3 8 cm ultrasoft, and 3 mm 3 8 cm ultrasoft 3D (Figure H: first coil, Figure I: final coil). The patient tolerated the procedure well with no complications. The carotid sheath was removed and hemostasis was achieved by means of manual compression after the ACT value had returned to normal. At 3 months, the patient had no neurologic deficits and was able to return to her work as a teacher.

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CASE 75 • Ruptured Internal carotid artery aneurysm Stanley H. Kim, MD, Anant I. Patel, MD B AC KG R O U N D :â•‡ A 56-year-old woman presented with a Hunt & Hess grade IV SAH (Figure 1A). She was diagnosed with a ruptured giant left Internal carotid artery terminus aneurysm (arrows, Figure 1, A and B).

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Figure 1.â•‡ B and C. Left Internal carotid artery injection, AP (B) and lateral (C) projection. The patient, who was not a surgical candidate for clipping or bypass of the aneurysm, underwent emergent coil embolization.

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Figure 2.â•‡ Left Internal carotid artery injection, AP projection shows the final result. The black arrow points at the coil mass, the white arrow at the residual aneurysm. The residual neck was left because all larger-sized coils had been used. Postoperatively, the patient developed malignant intracranial hypertension and underwent a left hemicraniectomy. The patient had a good clinical recovery. Two years after discharge, she lives at home with her family and is semi-independent with her activities of daily living. Angiographic follow-up at 2 years showed coil compaction (Figure 3, A and B). The patient is now scheduled for stent-assisted coiling.

Figure 3.â•‡ A and B. Left ICA injections, oblique projection. Coil compaction has caused the residual aneurysm lumen to increase to a size of 12 3 18 mm

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Coil compaction. Compaction of coils leading to enlargement of the perfused area of the treated aneurysm is often a serious setback requiring repeat treatment. The reported rates of coil compaction vary from 14% to 32%. Coil compaction seems to be related to the size of the aneurysmal neck and to the achieved packing density, i.e., the ratio between coil volume and aneurysm volume. Packing densities in excess of 20% are typically adequate to ensure minimal rates of compaction. The majority of cases seem to occur within a year following the procedure. References: Cognard C, Weill A, Spelle L, et al. Long-term angiographic follow-up of 169 intracranial berry aneurysms occluded with detachable coils. Radiology 1999; 212â•¯(2): 348–356. Kai Y, Hamada J, Morioka M, Yano S, Kuratsu J. Evaluation of the stability of small ruptured aneurysms with a small neck after embolization with Guglielmi detachable coils: Correlation between coil packing ratio and coil compaction. Neurosurgery 2005; 56: 785–792.Kimchi TJ, Willinsky RA, Spears J, Lee SK, ter Brugge K. Endovascular treatment of intracranial aneurysms with matrix coils: immediate posttreatment results, clinical outcome and follow-up. Interventional Neuroradiology 2007; 49: 223–229.

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CASE 76 • Ruptured Internal carotid artery aneurysm Stanley H. Kim, MD B ac kg round :â•‡ A 45-year-old woman presented with Hunt & Hess Grade I SAH and, while being evaluated in the emergency room, developed a second hemorrhage and progressed to Hunt & Hess Grade IV (coma, fixed and dilated left pupil). CT scan showed massive diffuse subarachnoid and intra-ventricular hemorrhage (Figure 1A). A ventriculostomy was placed. Cerebral Â�angiography revealed a 1.7 3 1.5 cm left paraclinoid ICA aneurysm with a daughter-like aneurysm at the apex of the dome (Figureâ•¯1B).

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The procedure was performed under general anesthesia. A 3000-unit Heparin bolus was administered to achieve an ACT value of 230 seconds. An SL-10 microcatheter was then positioned inside the aneurysm and a Matrix 12 mm 3 30 cm standard 360-degree coil was deployed. Eleven additional Matrix coils were placed inside the aneurysm to protect the dome. â•›The neck of the aneurysm was not covered in view of the wide neck appearance of the aneurysm and the patient’s poor neurologic condition. The patient tolerated the procedure well. Figure 2. A. Unsubtracted image. The first coil has been placed in the aneurysm. B. Left ICA injection, oblique projection, post-procedure. There is still significant filling of the aneurysm, especially in the neck. Figures 3 and 4.â•‡ Follow-up angiography, left ICA injections, (3) pre- and (4) postrepeat coil embolization.

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O utcome :â•‡ The patient had a long, complicated course in the intensive care unit including severe left intracranial ICA vasospasm requiring hypertensive and hypervolemic therapy and intra-arterial infusion of papaverine. However, the patient made a surprising recovery and was discharged from acute in-patient rehabilitation 6 weeks after the coil embolization of aneurysm. She returned to work 6 months after the initial SAH. The left third nerve palsy had resolved. Follow-up cerebral angiography at 9 months from the initial SAH revealed severe coil compaction. Neuroform stents were not yet available at the time. Therefore, the patient underwent partial coil embolization with the intent to occlude the residual aneurysm with a Neuroform stent at a later time. C onclusion :â•‡ For patients with Grade IV SAH, excellent neurologic recovery is possible. Aggressive and judicious management of incident hydrocephalus and cerebral vasospasm is paramount. These wide-neck ruptured aneurysms will often require stent- or balloon-assisted coil embolization in a staged fashion for complete occlusion. However, partial coil embolization may be performed initially to protect the dome of the aneurysm from rupturing again until a more definitive surgical or endovascular procedure can be performed for permanent occlusion.

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CASE 77 • Ruptured Basilar artery apex aneurysm Stanley H. Kim, MD B ac kg round :â•‡ A 35-year-old woman presented with SAH, Hunt & Hess Grade III. She was found to have a basilar artery tip aneurysm (which was presumed to have ruptured) and a left ophthalmic artery aneurysm. Figure 1.â•‡ A and B. Right VA injection, AP (A) and lateral (B) projection. The arrows point at the aneurysm.

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The patient underwent coil embolization with complete angiographic obliteration of the aneurysm. Repeat angiography was scheduled for 2 years following the procedure. In the interim period, the patient continued to smoke heavily despite having been advised to the contrary. Follow-up angiography showed coil compaction and regrowth of the aneurysm. Cigarette smoking is a major risk factor for developing cerebral aneurysms. It is unclear whether it has a role in coil compaction and aneurysm regrowth after coil embolization. Figure 2.â•‡ A and B. Right VA injection, oblique (A) and AP (B) projection. A. The microcatheter has been positioned inside the aneurysm in preparation for embolization (the arrow points at the tip of the microcatheter). B. This final injection demonstrates complete angiographic obliteration of the aneurysm. 2B

2A

Figure 3.â•‡ A and B. Follow-up angiography, 2 years after the procedure. Right VA injection, AP (A) and lateral (B) projection. There is significant coil compaction with recanalization of the aneurysm (arrows).

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CASE 78 • Ruptured Anterior communicating artery aneurysm Stanley H. Kim, MD B AC KG R O U N D :â•‡ A 55-year-old woman was found unresponsive at home and brought to the emergency department with a Hunt & Hess Grade IV SAH. Diagnostic angiography revealed a 2 3 1.9 cm wide-neck Acom aneurysm. Due to the patient’s poor neurologic condition and the large size of the aneurysm, endovascular treatment was recommended. Figure 1.â•‡ A and B. Left Internal carotid artery injection, AP (A) and lateral (B) projection. There is a large Acom aneurysm.

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Procedure : â•‡ Coil embolization was performed under general anesthesia. After right femoral access was obtained, 2000 units of Heparin were administered intravenously to achieve an ACT value of 200 seconds. Then, an SL-10 microcatheter was placed inside the aneurysm via a 6-F Envoy guide catheter that was placed in the left cervical ICA. The first coil was a 14 mm 3 30 cm Matrix 360-degree, followed by 11 more coils. A small part of the neck of the aneurysm was left patent so as to avoid occlusion of the bilateral A2 segments of the ACAs. After removing the microcatheter from the aneurysm, control injections revealed occlusion of the distal left pericallosal artery. It was decided to avoid administering thrombolytic agents because of the risk of hemorrhagic complications. Figure 2.â•‡ A and B. Post-procedure left ICA injection, AP (A) and lateral (B) projection. The black arrows point at the site of occlusion in the ACA. The white arrow points at the residual filling of the aneurysm.

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The patient regained consciousness the day after the procedure. CT scan 24 hours after the embolization revealed a left ACA distribution infarct. Follow-up angiography 7 days after the procedure showed recanalization of the left pericallosal artery and associated cerebral vasospasm. Figure 3.â•‡ A and B. Follow-up angiography, left ICA injection, AP (A) and lateral (B) projection. The left ACA is now fully patent.

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O utcome :â•‡ The patient was discharged home after 3 months of rehabilitation with a modified Rankin Scale score of 3. She was able to walk independently. C onclusion :â•‡ Little is known about the safety and efficacy of thrombolytic treatment of thrombotic complications associated with endovascular treatment of ruptured aneurysms. In some cases, conservative observation may avoid fatal hemorrhagic complications associated with thrombolytic agents. 121

CASE 79 • Ruptured Hypophyseal artery aneurysm Viktor Szeder, MD, PhD, Thomas Wolfe, MD, John R. Lynch, MD, Brian-Fred Fitzsimmons, MD, Osama O. Zaidat, MD, MS B ac kg round :â•‡ A 52-year-old woman presented with the worst headache of her life. Lumbar puncture revealed evidence of xanthochromia despite a negative CT scan of the head. Initial CTA was unremarkable except for bulging around the cavernous ICA. Diagnostic angiography was performed. Right Internal carotid artery injection revealed a small wide-neck right superior hypophyseal artery aneurysm (Figure 1). It was estimated at 3 mm in Â�maximum length and 2.2 mm in width with a 2.5-mm neck. The aneurysm was pointing inferopostero-medially and was directly opposite to the origin of the ophthalmic artery. Figure 1.â•‡ A and B. Right ICA injection, AP (A) and lateral (B) projection. The arrows point at the aneurysm, which is best visualized in AP projection.

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Treatment options for this ruptured wide-neck hypophyseal artery aneurysm: Endovascular Primary coiling. Drawback: potential coil herniation and difficult microcatheter positioning Stent assisted coiling. Drawback: requirement for dual antiplatelet agents in the context of SAH B alloon assisted coiling. Provides support for the microcatheter, keeps the coils in the aneurysm, no need for antiplatelet agents Surgical. Drawback: The location in the carotid cave is difficult to access.

Procedure : â•‡ A Hyperglide, 4 3 20 mm balloon was advanced and positioned across the aneurysm neck. With the balloon partially inflated, an Excelsior SL-10 straight-tipped microcatheter was advanced into the aneurysm over a Transend 14 microwire. (The preshaped angled microcatheter repeatedly pushed the microwire outside the aneurysm lumen. It was therefore replaced by a straight-tipped catheter, and the balloon was kept slightly inflated to provide additional support for the microcatheter to track over the microwire.) Two ultrasoft GDC coils were deployed sequentially. A 2 mm 3 2 cm coil was followed by a 2 mm 3 1 cm coil. Several intra-procedure right Internal carotid artery runs were obtained. Post-procedure, there was complete occlusion of the aneurysm. Intracranially, there was no evidence of branch occlusion or coil herniation.

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Figure 2.â•‡ A and B. Right Internal carotid artery injections, AP (A) and lateral (B) projection. The large white arrows indicate the position of the balloon. In B, the small black arrows point at the balloon markers and the small white arrow points at the proximal microcatheter marker. Figure 3.â•‡ A and B. Right ICA injections, AP (A) and lateral (B) projection. No residual filling of the aneurysmal sac (arrows) isâ•¯seen. 122

CASE 80 • Unruptured Anterior communicating artery aneurysm Qaisar A. Shah, MD, Alexandros L. Georgiadis, MD, Vallabh Janardhan, MD B AC KG R O U N D :â•‡ An 80-year-old woman was found to have a large Acom aneurysm in the setting of her work-up for Â�ovarian cancer.

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Figure 1.â•‡ A and B.â•‡ Left Internal carotid artery injections, AP (A) and oblique (B) projections. C. Three-dimensional reconstruction view. The aneurysm is measured at 14 3 10 3 7 mm. Procedure :â•‡ A 7-F guide catheter was advanced over a 5-F VERT diagnostic catheter and positioned in the proximal left ICA. Subsequently, an MTI Hyperform 4 3 10 mm balloon was positioned in the left A2 segment (Figure 2, arrow). An SL-1018 microcatheter was then advanced over a 0.014-inch Transend microwire and positioned within the dome of the aneurysm (Figure 2, open arrow). A total of 24 coils were deployed, resulting in complete obliteration of the aneurysm (Figure 3, arrow points at the coil mass). 3

2

Giant aneurysms Intracranial aneurysms are called “giant” when they are larger than 2.5 cm in diameter. Giant aneurysms represent roughly 5%–8% of all intracranial aneurysms. Approximately 25% of patients present with SAH. Seventy to seventy-five percent present with mass effect that can manifest as visual failure, cranial nerve dysfunction, hemiparesis, seizure, or headache. Thrombosis and ischemic stroke due to clot formation within the aneurysm and subsequent distant embolization occurs in 2%–5% of cases. Giant aneurysms are more common in the anterior circulation, with 60% occurring in the ICA, 10% in the Acom, and 10% in the MCA. In the posterior circulation, the basilar artery apex is the most common location (15%), followed by the vertebral arteries (5%). Treatment options include surgery, endovascular techniques, and combined approaches. Surgical options include proximal vessel occlusion and trapping of the aneurysm using clips above and below the lesion. Alternatively, if the patient is unable to tolerate occlusion of the parent vessel, an extracranial to intracranial bypass procedure can be performed with subsequent trapping or proximal occlusion of the vessel.

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CASE 81 • Ruptured Internal carotid artery aneurysm Alexandros L. Georgiadis, MD, Jawad F. Kirmani, MD B ac kg round :â•‡ A 66-year-old woman presented with SAH, Hunt & Hess Grade I. CTA showed fusiform dilatation of the right ICA bifurcation (Figure 1, thick arrow) and two distal Internal carotid artery aneurysms (Figure 1, thin arrows).

CTA

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Right Internal carotid artery injection,

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COIL MASS

Right Internal carotid artery injection, AP AP projection, unsubtracted

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PR O C E D U R E : â•‡ A 7-F sheath was placed in the right CFA. The diagnostic angiogram was performed with a 6-F MPC Envoy catheter confirmed the previous CTA findings: Figure 2 shows the fusiform dilatation (thick arrow) and the two ICA aneurysms (thin arrows). The Envoy was replaced by a 7-F Brite Tip catheter, which was placed in the mid- to distal cervical Internal carotid artery. An SL-10 microcatheter was advanced into the right Internal carotid artery over a Transend 14 microwire. Attempts to deploy coils were unsuccessful in both aneurysms. A 4 3 10 mm Hyperglide balloon was then introduced and positioned in the distal ICA across the neck of the proximal aneurysm (Figure 3, white arrows point at the proximal and distal balloon markings). The Â�supporting microwire was placed in the superior division of the MCA. An Orbit Trufill 2 mm 3 2 cm coil was advanced to the tip of the microcatheter (Figure 3, black arrow). The balloon was inflated and the coil was then introduced into the aneurysm. The balloon was deflated as soon as the coil was fully extruded and the coil was then detached. (Figure 3, post-detachment image. The block arrows show the outline of the microcatheter). Control right Internal carotid artery injection shows no residual filling of the aneurysm (Figure 4). The arrow points at the coil mass. 124

CASE 82 • Unruptured Internal carotid artery aneurysm Alexandros L. Georgiadis, MD, Jawad F. Kirmani, MD B AC KG R O U N D :â•‡ A 47-year-old woman presented for elective embolization of an unruptured aneurysm (arrow, Figure 1). The patient had a history of SAH and subsequent clipping of the ruptured aneurysm.

A 6-F sheath was placed in the right CFA. A 6-F MPD Envoy catheter was positioned in the left ICA. An SL-10 microcatheter was introduced over a Transend 10 microwire and positioned inside the aneurysm. A Matrix 2 360-degree 4 mm 3 8 cm coil was introduced into the aneurysm but there was significant protrusion into the parent vessel lumen. The same phenomenon occured with a Matrix 2 360-degree 4 mm 3 6 cm coil. The decision was made to proceed with balloon-assisted embolization.

Left Internal carotid artery injection, AP

1

P rocedure :â•‡ The 6-F sheath was exchanged for a 7-F sheath. A Brite Tip 7F catheter was placed in the left ICA. An SL-10 microcatheter was positioned inside the aneurysm over a Transend 10 microwire. A 4 3 10 mm Hyperglide balloon was introduced through the guide catheter over a Transend 14. The balloon was positioned across the neck of the aneurysm and the microwire was placed in the MCA (Figure 2). The balloon was inflated, and a Matrix 2 360-degree SR 3 mm 3 8 cm coil was introduced into the dome of the aneurysm. After the coil was fully extruded, the balloon was deflated (Figure 2). The same procedure was followed for the next coil, which was a Matrix 2 Helical 3 mm 3 8 cm ultrasoft coil. Figure 2.â•‡ Unsubtracted image. The wire that supports the balloon catheter (Transend 14) is seen positioned in the MCA (the large white arrow points at the tip of the wire).The balloon is parked across the neck of the aneurysm. The two black arrows point at the proximal and distal balloon markings. The small white arrows show the position of the microcatheter. This image was obtained immediately prior to the detachment of the first coil. After placement of the second coil, Internal carotid artery injection showed delayed filling of the ACA and an intraluminal clot. The patient’s maximal ACT had been 307 seconds after administration of 3000 units of intravenous Heparin. The procedure was aborted and the microcatheter was removed. The patient was given a weight-based intravenous bolus of Abciximab and then started on a continuous drip.

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CASE 82 • (continued)

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Figure 3.â•‡ A–F. Images from three consecutive ICA injections, AP projection, two frames shown per injection. The first injection (A and B) was obtained after deployment of the second coil. The second (C and D) and third (E and F) injections were obtained 5 and 15â•¯minutes after initiation of the Abciximab infusion, respectively. The arrow points at the clot. Note that almost no distal flow is seen in the ACA although the MCA branches have already A. opacified. The circle highlights a long segment of iatrogenic vasospasm in the Internal carotid artery. B. The ACA fills faster. C. A Significant filling defect is still apparent. D. E and F. There is no filling delay, and the residual filling defect is minimal. The vasospasm has resolved. The procedure was terminated and the sheath was left in place in case further intervention was required later. The Abciximab infusion was continued for 24 hours. Follow-up angiography was not performed because the patient remained asymptomatic. 126

CASE 83 • Unruptured Internal carotid artery aneurysm Stanley H. Kim, MD B AC KG R O U N D :â•‡ A 51-year-old woman who presented with acute onset of severe headache was evaluated for SAH which was subsequently ruled out. However, she was found to have a 16 3 10 mm left paraclinoid Internal carotid artery aneurysm (black arrow, Figure 1) and a smaller 6 3 3 mm aneurysm at the exact same location on the right side.

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Procedure : â•‡ It was decided to treat the left ICA aneurysm, although unruptured, because of its size. Due to the wide neck, balloon-assisted embolization was planned. Intravenous Heparin was administered to achieve an ACT of 300 seconds. A 6-F Cook Shuttle was inserted and advanced into the proximal left ICA. Aâ•¯3.5 3 12 mm Maverick balloon was introduced through the Cook Shuttle and positioned in the ICA in the vicinity of the aneurysm neck. Then, an SL-10 microcatheter was introduced over a Transend wire and parked inside the dome of the aneurysm (Figure 2). A 3-D coil was prepared and passed through the SL-10 until it reached the distal microcatheter tip. At that time, the balloon was positioned across the aneurysm neck. The coil was extruded further and started to fill the aneurysm. The balloon was inflated. The entire coil was inserted into the aneurysmal sac but it was not filling the smaller lobe (white arrow, Figure 1) and was therefore retracted after the balloon was deflated. A second attempt was made with a 12 mm 3 30 cm 2D coil. This coil led to more homogeneous filling of the aneurysmal sac. The balloon was deflated and the coil was detached. The next coil used was an 8 mm 3 30 cm 3D coil. Then an attempt was made to place a 6 mm 3 10 cm 3D coil again under temporary balloon inflation. While the coil was being extruded, increased resistance was felt. A guide catheter run showed that the inflated balloon had migrated proximally. This resulted in vessel irritation and spasm. The ICA was occluded distal to the balloon (Figure 3). The balloon was deflated and the coil was removed. The microcatheter was pulled out of the aneurysm and placed at the occlusion site. A Reteplase infusion was started (1 unit of Reteplase in 10 mL solution with normal saline, injection rate ~2 mL/minute). A total of 10 units were administered. Complete recanalization of the ICA was achieved (Figure 4). There was also no residual filling of the aneurysm, and the procedure was terminated. The patient suffered no consequences from this procedure and remains asymptomatic at follow-up 4 months later. Figure 1.â•‡ Left ICA Figure 2.â•‡ Microcatheter injection Figure 3.â•‡ Left ICA guide catheter injection. The vessel is occluded. Figure 4.â•‡ Final left ICA injection. There is complete recanalization of the ICA. The aneurysm is not filling. All projections are lateral. 127

CASE 84 • Unruptured Internal carotid artery aneurysm Alexandros L. Georgiadis, MD, Charles J. Prestigiacomo, MD, FACS B ac kg round :â•‡ A 36-year-old woman was found to have a recurrence of an ICA aneurysm 15 years after clipping.

1B

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Figure 1. A. Left ICA injection, lateral projection. The arrow points at the aneurysm. B and C.â•‡3D reconstruction images were used for assessing aneurysm characteristics and dimensions and for choosing the optimal working position, i.e., the optimal projection.

CLIP

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Procedure : Figure 2. A. Unsubtracted image. A 6-F MPD Envoy guide catheter was placed in the ICA (black arrow). A Transend floppy microwire was advanced into the left MCA (long white arrow). A 3.5 3 20 mm Neuroform 3 stent was positioned across the neck of the aneurysm (small white arrows point at the proximal and distal stent markers) over the microwire. After the stent was deployed, a Prowler 14 microcatheter was advanced over the microwire and its tip was passed through the stent and positioned inside the aneurysmal sac. Subsequently, eight coils were deployed inside the aneurysm. B. Unsubtracted image. The first coil is positioned in the aneurysm. The white arrows show the margins of the deployed stent. The black arrow points at the proximal microcatheter marker. C. Unsubtracted image. The coil mass is seen after the deployment of all eight coils. D. Left ICA final injection, AP projection. During the procedure, 5000 units of Heparin were administered intravenously with a maximum ACT recording of 245 seconds.

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CASE 84 • (continued)

3B

Figure 3.â•‡ A and B. A. 3-D reconstruction of the left anterior circulation in AP view after coil embolization. The coil mass and clip are seen. B. The coil mass and the clip are subtracted from the previous image.

3A

Figure 4.â•‡ Follow-up angiogram 4 months later shows no further residual aneurysmal filling (left ICA injection, lateral projection).

4

Coils used: Matrix standard 2D, Matrix standard 3D, Matrix soft 2D, Matrix ultrasoft Size of coils used: 4 mm 3 4 cm, 10 mm 3 30 cm

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CASE 85 • Unruptured Internal carotid artery aneurysm Dhruvil J. Pandya, MD, Prem Kandiah, MD, John R. Lynch, MD, Brian-Fred Fitzsimmons, MD, Osama O. Zaidat, MD, MS B ac kg round :â•‡ A 46-year-old woman presented to an outside physician with seizures and was found to have a left-hemispheric tumor and a left ICA terminus aneurysm. She was referred for possible coil embolization. Angiography revealed a left ICA carotid terminus oblong 5 mm (height) by 2 to 3 mm (width) aneurysm with a 2-mm neck (Figure 1). Because of the relatively wide neck, the decision was made to treat the aneurysm using stent-assisted coil embolization. The patient was started on Aspirin and Clopidogrel 1 week prior to the procedure.

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2A

P rocedure : A 6-F sheath was placed in the right CFA. Heparin was administered intravenously to achieve an ACT value of 250 to 300 seconds. A 6-F 90-cm guide catheter was placed in the left Internal carotid artery and AP and lateral intracranial images were obtained. The best working position was identified and aneurysm measurements were performed. An Excelsior SL-10 microcatheter was advanced over a Synchro 14 microwire into the distal left MCA under fluoroscopic and roadmap guidance. The microwire was removed and a 300-cm 0.014-inch wire was passed through the microcatheter and positioned in the distal MCA. The catheter was then removed. A 4 3 20 mm Neuroform stent was advanced over the microwire, positioned across the aneurysm neck and deployed. The stent delivery catheter was then removed. The SL-10 microcatheter was introduced again over the microwire. The wire was drawn back into the ICA and positioned inside the aneurysm through the struts of the stent. The microcatheter was passed into the aneurysm over the wire, which was then withdrawn. Coil-embolization followed. Figure 1.â•‡ Left ICA injection, oblique projection. The arrow points at the aneurysm. Figure 2.â•‡ A and B. Unsubtracted images. A. The stent has been deployed across the aneurysm neck. The white arrows point at the stent markers. The small black arrow points at the microcatheter. The microcatheter tip (large black arrow) has inadvertantly fallen back into the vessel lumen. B. Image post stent placement and coil placement. Figure 3.â•‡ Final image. Left ICA injection, oblique projection. There is no residual filling of the aneurysm. The arrow points at the coil mass.

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CASE 86 • Unruptured cervical Internal carotid artery pseudo-aneurysm Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD B AC KG R O U N D : â•‡ 65-year-old man presented with an enlarging right high-cervical ICA pseudo-aneurysm (arrow, Figure 1) of unclear etiology.

1

P rocedure : There are two options for the treatment of this pseudo-aneurysm: placement of a covered stent across the neck or placement of a regular stent with subsequent coil embolization. In this case, placement of a Wallgraft covered stent was attempted without success. Subsequently, an exchange-length Transend microwire was positioned in the distal intracranial ICA with help of a Prowler Plus microcatheter. The microcatheter was then exchanged for a Multilink Zeta stent measuring 3.5 3 13 mm. The balloon-mounted stent was positioned across the neck of the aneurysm (Figures 2A and 2B) and deployed at 13 atmospheres. A Prowler 14 microcatheter was passed through the stent struts and positioned inside the Â�aneurysm dome over a Transend microwire (Figure 3). Figure 4â•‡ shows the first coil prior to deployment. A total of 13 coils were placed. The final result can be seen in Figure 5. Figures 1 through 5 are all AP projections. Figures 2A, 3, and 4 are unsubtracted. Figure 1 shows a right CCA injection, Figures 2B and 5 show right ICA injections. Figure 1.â•‡ Diagnostic angiogram. The arrow points at the pseudoaneurysm. Figure 2.â•‡ A and B. The arrows point at the stent markings. Figure 3.â•‡ The black arrows outline the lateral side of the stent. The white arrow points at the tip of the microcatheter that has been positioned through the stent struts into the dome of the aneurysm. Figure 4.â•‡ The arrow points at the coil mass. Figure 5.â•‡ Final injection after placement of 13 coils.

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CASE 87 • Unruptured cavernous Internal carotid artery aneurysm Stanley H. Kim, MD B ac kg round :â•‡ A 67-year-old woman presented with chronic right periorbital headache and a 3-month history of right third and sixth cranial nerve palsies. Diagnostic cerebral angiography revealed unruptured 12 3 15 mm right-sided (Figure 1, A and B) and 7 3 7 mm left-sided (Figure 1, C and D) cavernous ICA aneurysms. The patient was reluctant to undergo craniotomy for surgical repair of the aneurysm. She was scheduled for stent-assisted coil embolization of the right-sided aneurysm with the understanding that the cranial nerve palsies might worsen or not improve at all. Figure 1.â•‡ A and B.â•‡ Right ICA injection, AP (A) and lateral (B) projection. Figure 1,â•‡ C and D.â•‡ Left Internal carotid artery injection, AP (C) and lateral (D) projection.

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Procedure :â•… The procedure was performed under general anesthesia. A 4.5 3 20 mm Neuroform stent was deployed across the neck of the aneurysm. This was followed by placement of a total of 21 Matrix coils. The patient tolerated the procedure well. She was placed on daily Aspirin and Clopidogrel (Clopidogrel for 6 months) and tapering doses of Dexamethasone over a month. O utcome : â•‡ Three months after the embolization of the right ICA aneurysm, the cranial nerve palsies and headache resolved almost completely.

2C

Figure 2. A and B.â•‡Right ICA injection, AP (A) and lateral (B) projection at the end of the procedure. No residual filling of the aneurysm isâ•¯seen. C. Unsubtacted post-procedure image showing the coil mass and stent margins (arrows). Conclusion : Surgical clipping is generally the preferred treatment for aneurysms that cause mass-effect – related symptoms. However, cranial nerve palsies can improve following coil embolization as illustrated in this case. The increased mass effect due to the coils within the aneurysm may be temporary. Once thrombosis and fibrosis develop, the mass effect of the aneurysm may decrease. Further study of aneurysm hemodynamics following embolization will be useful in understanding the occlusion process within the aneurysms and its effect on cranial nerve complications.

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CASE 88 • Unruptured Internal carotid artery terminus aneurysm Rishi Gupta, MD B AC KG R O U N D :â•‡ A 61-year-old woman with a family history of cerebral aneurysms was found to have a 10-mm left ICA terminus aneurysm (arrow, Figure 1).

1

The following points should be considered when assessing a patient for coil embolization: • A fundus-to-neck ratio of >2 is generally favorable for coil embolization. • Wide-neck aneurysms may require adjunctive therapy such as Neuroform stent placement or balloon remodeling. • Posterior circulation aneurysms have a higher morbidity with surgical clipping. • Younger patients may be more suited for clipping, as there are less data on long-term outcome following coil embolization. P rocedure :â•‡ Following placement of a 6-F Envoy guide catheter in the left ICA, Heparin was administered intravenously aiming at an ACT value of $ 250 seconds. An SL-10 microcatheter was then navigated into the aneurysm over a 0.014-inch microwire using road-map guidance. Cerecyte platinum coils (Micrus Endovascular Corporation, San Jose, CA), were deployed inside the aneurysm.

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2B

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Figure 2. A and B.â•‡Left ICA injections, AP projection. A loop of coil is seen protruding into the lumen of the MCA (arrow, A). The microcatheter was gently pulled out of the aneurysm and navigated into the MCA. Using an exchange-length microwire, the microcatheter was exchanged for 4 3 20 mm Neuroform stent delivery system (arrow, B). C. Unsubtracted image. The stent was positioned across the neck of the aneurysm between the terminal ICA and the distal M1-MCA and deployed (arrows point at the markers). Note that the coil loop has been pushed back into the aneurysm. D. Final left ICA injection, AP projection. There is still significant filling of the aneurysm. However, the decision was made to not place further coils and to reassess the aneurysm in 3 to 6 months. Figure 3.â•‡ Angiography was performed 3 months later. The aneurysm had thrombosed, but stenosis was noted inside the stent (arrow). The lesion was asymptomatic, so no further treatment was undertaken. The patient will be followed up at regular intervals. The open arrows point at the stent markers.

Cerecyte coils contain a stretch-resistant polyglycolic acid suture material that is placed within the primary wind of the coil and promotes thrombosis.

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CASE 89 • Ruptured clinoid Internal carotid artery aneurysm Stanley H. Kim, MD B AC KG R O U N D :â•‡ A 39-year-old woman presented with SAH, Hunt & Hess Grade I. Diagnostic angiography revealed a 2 3 1.5 mm aneurysm along the dorsal clinoid portion of the right ICA (Figure 1A). Surgical treatment of this aneurysm would be extremely difficult because of the small size and difficult to access location. Coil embolization of an aneurysm this small may also not be technically feasible. It was therefore decided to place a Neuroform stent across the neck of the aneurysm and possibly perform coil embolization as a second procedure. Figure 1.â•‡ A and B.â•‡ Right CCA injections, AP projection. The arrow points at the small ICA aneurysm. A persistent hypoglossal artery anomaly is seen. The hypoglossal artery (open arrow in A and B) arises from the ICA and feeds into the basilar artery.

1A 1B

Figure 2.â•‡ Unsubtracted image depicting the deployed stent.

2

P rocedure : The procedure was performed under general anesthesia 6 days after the SAH. The patient had been administered 325 mg of aspirin and 300 mg of Clopidogrel 24 hours prior to the procedure. During the intervention, 3000 units of intravenous Heparin were given to achieve an ACT value of 215 seconds. A 4 3 20 mm Neuroform stent was then deployed across the neck of the lesion. Following stent placement, the filling of the aneurysm was unchanged. However, the decision was made to follow the patient up in 6 months in case the aneurysm would thrombose without requiring coil embolization.

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4

Six months later, follow-up cerebral angiography revealed a persistent right cavernous Internal carotid artery aneurysm with a more well-defined neck than that seen on the previous angiogram. The patient had remained asymptomatic. Coil embolization of the aneurysm was performed through the Neuroform stent with a Matrix 2 mm 3 2 cm ultrasoft helical coil. Figure 3.â•‡ Right Internal carotid artery injection, oblique projection. The arrow points at the aneurysm. Figure 4.â•‡ Right Internal carotid artery injection, oblique projection post-treatment. The arrow points at the coil mass. There is no fiiling of the aneurysm. O utcome : A three-month follow-up cerebral angiogram revealed excellent occlusion of the aneurysm. The patient remained asymptomatic and was treated with 75 mg of Clopidogrel (for 6 months) and 325 mg of Aspirin daily. 134

CASE 90 • Unruptured Internal carotid artery/Ophthalmic artery aneurysm Stanley H. Kim, MD B ac kg round :â•‡ A 35-year-old woman with a previously diagnosed 3 x 3 mm left ICA aneurysm and a history of SAH from a previously treated ruptured basilar artery apex aneurysm requested treatment. The aneurysm was located at the left Internal carotid artery/ophthalmic artery junction. Because of its wide neck, it was decided to perform stent-assisted coil embolization.

1B

1A

Figure 1.â•‡ A and B. Two different projections following left ICA injection show the coil mass in the previously treated basilar artery apex aneurysm (arrows) and the ICA aneurysm (open arrows). Procedure : â•‡ Stent placement was performed under general anesthesia. A 4 3 20 mm Neuroform stent was deployed without any complications. Because of moderate tortuosity of the petrous and cavernous segment of the left ICA, the decision was made to allow the Neuroform stent to stabilize with new endothelialization over the next few months and then embolize the aneurysm. The patient was placed on 325 mg of Aspirin and 75 mg of Clopidogrel daily. Two months later, the patient underwent coil embolization of the aneurysm. The following coils were placed: Matrix 360-degree soft 3 mm 3 4 cm, Matrix 360-degree ultrasoft 2 mm 3 4 cm, Matrix ultrasoft helical 2 mm 3 2 cm, Matrix ultrasoft helical 2 mm 3 2 cm. Complete angiographic occlusion of the aneurysm was achieved.

2A

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Figure 2.â•‡ A and B. Two different projections following left ICA injection show complete angiographic obliteration of the aneurysm (arrows) with preservation of the ophthalmic artery (open arrow in B). Potential advantages of staged stent-assisted coil embolization of cerebral aneurysms include stabilization of the stent, shorter duration of the procedure in cases with technically difficult aneurysmal access, and less manipulation of the parent artery.

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CASE 91 • Unruptured Internal carotid artery aneurysm Alber t Yoo, MD, Raul G. Nogueira, MD B AC KG R O U N D : â•‡ A 45-year-old woman was incidentally found to have a large right ICA transitional segment aneurysm during workup of facial fractures. CTA demonstrated that portions of the aneurysm dome extended to the level of the optic strut and through a dehiscence into the right sphenoid sinus (arrow, Figure 1A). Thus, the decision was made to proceed with treatment. A right ICA balloon test occlusion resulted in a left pronator drift associated with hypoperfusion to the right cerebral hemisphere on Tc-99m exametazime SPECT imaging of the brain (Figure 1B). Stent-assisted coil embolization was then planned.

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Procedure , s tage 1:â•‡ Figure 2.â•‡ A–D. Right ICA injections, AP projection. A 6-F Envoy MPD guide catheter was placed in the right ICA. A. A Prowler 14 microcatheter was navigated distal to the aneurysm neck. B. An exchange-length Transend EX 0.014-inch wire was placed into the proximal superior division M2 branch (arrow at wire tip). Note focal vasospasm at the M2 origin (open arrow), which was treated with 2 mg of intra-arterial Nicardipine. C. Size measurements are made of the right ICA lumen both proximal and distal to the aneurysm neck. A Neuroform stent (4.5 3 30 mm) is chosen such that its diameter is slightly larger than the parent vessel lumen. The stent length should allow for 4 mm of coverage both proximal and distal to the aneurysm neck. The stent delivery system is advanced over the microwire so that the stent spans the aneurysm neck. The black arrows show the proximal and distal stent markers. The open black arrow indicates the tip of the microcatheter. The white arrow shows the tip of the stabilizer. D. The stent is deployed. The black arrows demonstrate the proximal and distal stent tines. The microwire is left in place for distal access until a post-placement angiogram demonstrates lack of procedural complications. Procedure , s tage 2 :â•‡ Figure 3.â•‡ A and B. The stent was allowed to heal into place. The patient returned for the second stage of the procedure 6 weeks later. A. An Echelon 10 microcatheter was navigated through the stent interstices and parked inside the aneurysmal sac. Subsequently, coil embolization was performed. B. Final angiogram after placement of 53 coils demonstrated near-complete obliteration of the aneurysm. Stent assistance provides coil support in the setting of a wide aneurysm neck, which is typically the case for large aneurysms such as this one. In addition, the stent may provide a degree of flow redirection that may decrease the risk of coil compaction and aneurysm re-growth.

CASE 92 • Ruptured Posterior cerebral artery aneurysm Stanley H. Kim, MD B ackground :â•‡ A 35-year-old woman presented with Hunt & Hess Grade III SAH. A ventriculostomy was placed to relieve acute hydrocephalus. A diagnostic cerebral angiogram revealed a 2 3 2 mm left P1-segment PCA aneurysm (Figure 1, A and B).

Figure 1.â•‡ A and B. Left VA injection, AP (A) and lateral (B) projections. The arrows point at the aneurysm.

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Because of the wide neck of the aneurysm, the decision was made to perform stent-assisted embolization. The patient was given 325 mg of Aspirin and was loaded with 300 mg of Clopidogrel. Prior to microcatheter insertion, 2000 units of intravenous Heparin were administered to achieve an ACT value of 200 seconds.

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2A

P rocedure :â•‡ A microwire was parked in the left PCA (black arrow, Figure 2A). A 3 3 20 mm Neuroform stent was then advanced over the wire, brought in position across the neck of the aneurysm, and deployed. Figure 2.â•‡ A and B. Unsubtracted images in AP projection. A. Shows the stent as it is brought in position. B. Shows the stent after it has been deployed. The black arrows indicate the position of the stent markings. Subsequently, a microcatheter was passed through the stent struts and positioned inside the aneurysm. A 2 mm 3 2 cm Matrix 2 ultrasoft coil was introduced into the aneurysm and deployed. Figure 3.â•‡ Unsubtracted, oblique image. The black arrows point at the stent markings. The stent is in the distal basilar artery, then curves around the vertebro-basilar junction and ends in the PCA. The white arrow shows the position of the microcatheter tip.

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Follow-up runs showed occlusion of the left PCA (Figure 4, arrow). The patient was given a bolus of 135 mg/kg bolus of Eptifibatide, followed by a continuous intravenous infusion at a rate of 0.5 mg/kg/min for 23 hours. The PCA recanalized partially 5 minutes after bolus administration (Figure 5). There were no bleeding complications. Follow-up MRI showed a small left anterior thalamic infarct. The patient remained on Aspirin and Clopidogrel for 3 months, then Clopidogrel was discontinued. Four-month follow-up angiogram demonstrated complete recanalization of the left PCA (not shown). There was no residual filling of the aneurysm. The patient returned to work at 4 months after the procedure.

CASE 93 • Ruptured Internal carotid artery aneurysm Alexandros L. Georgiadis, MD, Charles J. Prestigiacomo, MD, FACS B AC KG R O U N D : â•‡ A 22-year-old man presented with Grade V Hunt & Hess SAH. CTA showed a giant right ICA aneurysm (Figure 1, arrow).

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MATHIS MANEUVER

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Figure 1.â•‡ CTA reconstruction. Diagnostic angiogram Figure 2.â•‡ A and B. Right ICA injection, AP (A) and lateral projection (B). There is a giant fusiform ICA aneurysm. Figure 3.â•‡ A and B. Left ICA injection without (A) and with (B) right ICA compression at the neck (Mathis maneuver), AP projection. Following the Mathis maneuver, there is good cross-filling to the territory of the right ACA and MCA. This suggests that there is a good chance that therapeutic occlusion of the right ICA would be well tolerated. Figure 4.â•‡ A and B. Right VA injection without (A) and with (B) compression of the right ICA (Alcock’s maneuver). Following the Alcock’s maneuver, there is increased flow through the Pcom with filling of the aneurysm. The implications are two-fold: 1) The posterior circulation will likely provide collateral flow after occulsion of the right ICA; 2) PVO is not sufficient to abolish flow to the aneurysm which should therefore also be coil-embolized.

4B

The decision was made to treat the aneurysm with coil embolization, accepting the risk of sacrificing the parent ICA. Alcock’s maneuver: Vertebral artery injection during compression of the ICA on the same side Mathis maneuver: ICA injection during compression of the contralateral ICA Both maneuvers are used to assess the capacity of the patient to develop collateral circulations and also to achieve better opacification of the Pcom and Acom, respectively, to rule out the presence of aneurysms located in those vessels.

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CASE 93 • (continued)

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Dual microcatheter technique: Figure 5, two microcatheters (arrows, Figure 5A) are positioned in sequence inside the aneurysmal sac. A coil is introduced into the aneurysm through the first microcatheter (Figure 5A). A second coil is introduced through the second microcatheter (Figure 5B). After one of the coils is deployed, a third coil is introduced and then the second coil is deployed. A fourth coil is then introduced and so forth. This technique is believed to guarantee better stability of the coil mass.

Figures 5A through 6 are AP projections following right ICA injection. Figures 5A, 5B, and 6 are unsubtracted. Figures 5B and 5C show the first 2 coils. Figure 6 shows the final coil mass after deployment of the last coil. Figure 7 is a left ICA run post coiling, in AP projection. The right ICA is no longer filling. Good cross-filling to the right ACA and MCA from the left side is observed. Sheath: 7-F Diagnostic catheter: 5-F VERT Guide catheter: 7-F VBL Microcatheters: Prowler Plus Microwires, Transend EX platinum

7

Initial coils used: (1) Matrix EX firm 2D 20 mm 3 30 cm, (2) Matrix EX firm 2D 18 mm 3 30 cm, (3) Matrix EX firm 3D 18 mm 3 30 cm, (4) Matrix EX firm 3D 16 mm 3 30 cm Also used: Cordis complex standard coils, Hydrocoil 14, GDC 18 standard, GDC 18 2D, Matrix standard. Total number of coils: 26

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CASE 94 • Ruptured Vertebral artery aneurysm Mostafa Mahmoud Gamal El Din, MD, Thanh Nguyen, MD, Daniel Roy, MD, Jean Raymond, MD, Alain Weill, MD, Francois Guilber t, MD B AC KG R O U N D : â•‡ A 50-year-old woman presented with Hunt & Hess Grade IV SAH and hydrocephalus. An external ventricular drain was inserted, after which the patient improved. Cerebral angiography revealed a left VA intradural dissecting aneurysm below the origin of the left PICA artery. Procedure :â•‡ 6-F and 5-F sheaths were placed in the right and left CFA, respectively. A 6-F guide catheter was advanced into the left VA, and a 4-F diagnostic catheter was positioned in the right VA. Embolization of the aneurysm with VA occlusion was achieved, with careful attention to preserve the left PICA artery. Figures 1 and 2.â•‡ 3-D reconstruction (1) and left VA angiogram (2) showing a fusiform dissected aneurysm below the left PICA origin (arrows).

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Figure 3. A. Left VA injection showing complete VA occlusion with no filling distal to the aneurysm. B. Post-embolization angiogram showing complete obliteration of the aneurysm.

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Dissected intradural VA aneurysms are prone to rupture due to their thin media and adventitia1. Intradural dissecting vertebrobasilar aneurysms are at high risk for re-bleeding, reported in up to 70%, with a mortality of 46% derived from a series of 42 patients2 . Multiple treatment options are available, depending on the location of the aneurysm and its relation to neighboring branches. Trapping can be performed if no branch is incorporated inside the lesion and adequate collateral supply is ensured. If passing through or coiling the lesion is thought to be dangerous, proximal occlusion may be performed, but the patient may remain at high risk of rebleeding3. In this patient, we chose to coil the aneurysm with VA occlusion because the lesion was accessible and the right VA was co-dominant. References: 1. Yamaura A, Watanabe Y, Saeki N. Dissecting aneurysms of the intracranial VA. J Neurosurg 1990; 72: 183–188. 2. Mizutani T, Aruga T, Kirino T, et al. Recurrent subarachnoid hemorrhage from untreated ruptured vertebrobasilar dissecting aneurysms. Neurosurgery 1995; 36: 905–913. 3. Rabinov JD, Hellinger FR, Morris PP, Ogilvy CS and Putman CM. Endovascular management of vertebrobasilar dissecting aneurysms. AJNR 2003; 24: 1421–1428.

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CASE 95 • Unruptured traumatic Internal carotid artery pseudo-aneurysm Thanh Nguyen, MD, Alain Weill, MD, Daniel Roy, MD B ackground :â•‡ A 23-year-old man was involved in a high-velocity motor vehicle accident and ejected from the passenger seat. He sustained multiple facial fractures and underwent craniotomy for a left subdural hematoma. Angiography at an outside hospital revealed a traumatic dissection at the cavernous segment of the left ICA with a small pseudo-aneurysm (Figure 1). One month later, follow-up CT scan revealed a large pseudo-aneurysm in the left sphenoid sinus (Figure 2). Figure 1.â•‡ Dissection of the cavernous segment of the left ICA. Formation of a small pseudo-aneurysm at the medial aspect of the ICA (arrow). Figure 2.â•‡ CT scan demonstrates a hyperdense mass in the left sphenoid sinus (circle) with erosion of adjacent bone, due to enlargement of the pseudoaneurysm.

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Figure 3.â•‡ A and B. Follow-up angiography, 1â•¯month after the accident. Left ICA injection, AP (A) and lateral (B) projection. There is severe enlargement of the previously seen pseudo-aneurysm at the cavernous segment of the ICA.

3A

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P rocedure :â•‡ Under general anesthesia, 7-F and 5-F sheaths were placed in the right and left CFA respectively. A balloon occlusion test was performed with a #2 balloon (Balt, Montmorency, France) (Figure 4A). During balloon inflation, diagnostic catheter injections into the left VA and right ICA showed excellent collaterals to the left hemisphere (Figure 4, C and D).

The diagnosis of post-traumatic pseudo-aneurysm requires a high index of suspicion and rapid treatment. These lesions can present with massive epistaxis or rupture, which can be fatal. Endovascular treatment options for post-traumatic pseudo-aneurysms: • Occlusion of the parent artery if good collaterals are present • Placement of a covered stent • Stent placement in the parent artery and embolization of the aneurysmal sac Figure 4. A. Unsubtracted AP image shows the inflated balloon (arrow) in the left petrous ICA. B. Left CCA injection, lateral projection. There is no filling of the ICA, confirming successful balloon occlusion.

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CASE 95 • (continued)

4D

C. Left VA injection, AP projection. Left ICA territory is seen filling through the Pcom (black arrow). The small white arrow indicates the position of the balloon. D. Right ICA injection, AP projection. There is good cross-filling to the left through the Acom (arrow). Both injections were performed while the balloon in the ICA was inflated.

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5A

5C

Figure 5. A. Unsubtracted image showing the coil mass (circle). B. AP unsubtracted image. The coil mass (circle) and two detached balloons (arrows) are seen. C. Left CCA injection shows occlusion of the ICA (arrow). Pr o ce d u r e (c o n t i n u e d ) : â•‡ Due to the presence of good collaterals, large aneurysm size, wide neck, and acute take-off angle of the pseudo-aneurysm from the parent vessel, the decision was made to occlude the ICA. The goal of the intervention was to trap and occlude the site of the left ICA pseudo-aneurysm. A microcatheter was navigated distal to the abnormal segment of the artery. Coil filaments were placed to occlude the supraclinoid segment of the left ICA, under the origin of the Pcom (Figure 5A). Two detachable balloons were then deployed below the origin of the pseudo-aneurysm to occlude the ICA (Figure 5B). O u tco m e :â•‡ At 6 month follow-up, the patient continued to have severe neurologic sequelae from the initial trauma: blindness in the left eye, difficulty with writing and speaking. Reference: Asma A, Putra SH, Saim L. Massive epistaxis secondary to pseudo-aneurysm of internal carotid artery. Med J Malaysia 2006; 61: 84–87.

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CASE 96 • Unruptured Anterior cerebral artery aneurysm Thanh Nguyen, MD, Mostafa Mahmoud Gamal El Din, MD, Joseph Silvaggio, MD, Daniela Iancu-Gontard, MD, Daniel Roy, MD, Alain Weill, MD B ac kg r o u n d :â•‡ A 55-year-old woman presented with tinnitus. Angiography revealed a right A1-segment ACA aneurysm, measuring 10 3 12 mm with a 7-mm neck (Figure 1, arrow). Aneurysms of the A1-segment ACA are relatively rare. Surgical treatment is challenging because of the presence of perforating arteries. Endovascular treatment is also complex because it can be difficult to visualize the (often wide) aneurysm neck, rate of recurrence is high, and it is difficult to preserve neighboring perforators..

Right ICA injection, AP

The recurrent artery of Heubner also arises from the A1 and can be affected. In this case, it was decided to perform coil embolization with parent vessel occlusion. Occlusion of the aneurysm and parent artery is possible, provided there is adequate flow through the Acom. Evidence of visible perforators in the A1 segment should preclude this intervention. However, perforators can still be present even if they are not angiographically visible.

1

Pr o ce d u r e : â•‡ A 6-F and a 5-F sheath were placed in the right and left CFA, respectively. A 6-F guide catheter was placed in the right ICA, and a diagnostic catheter was placed in the left ICA. A 2.3-F microcatheter was navigated to the A1 segment. A subsequent microcatheter injection showed no perforators. The aneurysm and its parent vessel were embolized using three bare platinum coils (total length 80 cm), with careful attention to preserve the distal right A1/A2 junction. Control angiogram revealed complete occlusion of the aneurysm and its parent right A1 segment. Injection through the left carotid artery showed good opacification of the right A2 via the Acom. The patient had no symptoms or detectable neurologic deficits. CT scan the following day showed a small hypodensity in the anterior limb of the internal capsule.

2

3

4

Figure 2.â•‡ Right ICA injection, AP projection. Complete obliteration of the aneurysm and the distal A1 segment is apparent. Figure 3.â•‡ Simultaneous, bilateral ICA injection, post-embolization, AP projection. Both A2 segments are seen filling from the left ICA. Figure 4.â•‡ CT obtained 1 day post-embolization showed a small hypodensity affecting the anterior limb of the internal capsule and part of the globus pallidus. References: Czepko R, Libionka W, Lopatka P. Characteristics and surgery of aneurysms of the proximal (A1) segment of the anterior cerebral artery. J Neurosurg Sc 2005; 49(3): 85–95. Weill A, Silvaggio JA, Guilbert F, Raymond J, Iancu D, Roy D. Selective coiling of aneurysm and parent artery for the treatment of unruptured or recurrent wideneck proximal anterior cerebral artery aneurysms. Intervent Neuroradiol 2005, 11 (suppl 2): 204.

143

CASE 97 • Unruptured basilar artery aneurysm Thanh Nguyen, Alain Weill, Jean Raymond, Louis Juravsky, Daniel Roy BACKGROUND:â•‡ A 53-year-old man presented with transient loss of consciousness. Angiography revealed a basilar artery aneurysm at the distal third of the basilar artery, proximal to the SCAs and distal to the AICAs (Figure 1, A–E).

1A

1B

1C

1D

Figure 1.â•‡ A–E. Left VA injection (A), 3–D reconstruction images (B–E). There is a fusiform basilar artery aneurysm. Note the fenestration of the basilar artery (arrow in C). Treatment options:

1E

1. Observation 2. Endovascular a.â•…Occlusion of parent artery with embolization of the aneurysm, if good collaterals are present. b.â•…Stent reconstruction of the parent artery with or without embolization of the aneurysm. However, the presence of a basilar artery fenestration adds complexity to the case, with risk of rupture if stent sizing is inappropriate. c.â•… Occlusion of the VAs to reverse flow if good collaterals are present. 3. Combined surgical/endovascular. If collaterals are inadequate, extracranial-intracranial bypass followed by occlusion of basilar artery at the level of the aneurysm can be considered. 4. Surgical reconstruction of the basilar artery The patient refused observation. Balloon test occlusion of the basilar artery was performed to verify that both PCAs and SCAs could be supplied by the Pcoms. If the Pcoms were inadequate in their supply, option 3 or 4 (above) would have been considered.

2B 2A

Figure 2. A. Balloon test occlusion of the basilar artery. B, C. Right (B) and left (C) ICA injections during balloon inflation demonstrate good filling of the respective PCOM and PCA.

2C

144

B a l lo o n t es t o cc lu s i o n : Under general anesthesia, 6-F and 5-F sheaths were placed in the right and left common femoral arteries. A 4-F diagnostic catheter was positioned in the right ICA. A 6-F guide catheter was placed in the right VA. A 4 3 7 mm over-the-wire balloon (Microtherapeutics, Irvine, CA) was navigated in the basilar artery, just proximal to the aneurysm (Figure 2A, arrow points to balloon markers). With the balloon inflated, a diagnostic angiogram in the right and left ICAs (Figure 2B and 2C, respectively) showed adequate filling of the PCAs and SCAs.

CASE 97 • (continued)

3C

3A

3B

Figure 3.â•‡ A–D. A, B. VA injection pre- and post-embolization, AP projection. Postembolization, the basilar artery is completely obliterated at the level of the aneurysm. The AICAs are filling well. C, D.â•‡Right ICA injection, AP projection (C) and left ICA injection, lateral projection (D). There is good filling of the top of the basilar and the PCAs (D).

3D

A n e u rys m E M B OLI Z ATION : The balloon was left in the basilar artery, proximal to the aneurysm in the event that coil protrusion occurred. A microcatheter was passed through the 6F system and positioned inside the aneurysm. Coil embolization was performed with careful attention not to obliterate segments above or below the level of the aneurysm until occlusion of the Basilar artery was obtained (Figure 3A and B). A total length of 180 cm of bare platinum coils was used. C l i n i ca l C o u r se : The patient recovered from anesthesia with mild left arm and facial paresis. Heparin and Aspirin were continued to prevent retrograde or antegrade thrombosis from the embolized aneurysm. MRI at 24 hours post-procedure showed punctate foci of ischemia in bilateral cerebellar hemispheres but absence of ischemic changes supratentorially (Figure 4 A, B). On post-procedure day 4, the patient developed new left-sided hemiplegia, and CT revealed acute ICH with a fluid level in the right rolandic area (Figure 5). Heparin was discontinued and strict blood pressure control was observed. The patient stabilized and had no further progression of his weakness or ICH at 2-month follow-up.

4A

5

4B

Figure 4.â•‡ 24-hour post-embolization MRI. A. DWI through cerebellum with punctate foci of ischemia. B. Supratentorial FLAIR. Figure 5.â•‡ Four days post-embolization. CT demonstrates acute ICH in the right fronto-parietal lobes.

145

CASE 98 • Unruptured Basilar artery apex aneurysm Thanh Nguyen, MD, Jean Raymond, MD, Francois Guilber t, MD, Alain Weill, MD, Daniel Roy, MD B AC KGROUND :â•‡ A 55-year-old woman presented with syncope requiring pacemaker insertion. Head CT scan revealed a large wide-necked basilar artery tip aneurysm, measuring 10 3 12 mm with a 7-mm neck.

Endovascular treatment options for wide-neck aneurysms: • Parent artery and aneurysm occlusion in presence of good collateral network • Balloon-assisted embolization • Stent-assisted embolization • Neck-bridge device (Trispan, Boston Scientific, Natick, MA) Figure 1.â•‡ The drawings illustrate the principles of endovascular treatment with the aneurysm neck-bridge device. 1 a, b. Deployment of the neck-bridge device (arrow) in the aneurysm and placement at the neck. 1c. The second microcatheter permits deposition of the coils. Following coil packing (1d), the device is detached (1e). From: Raymond J, Guilbert F, Roy D. Neck-bridge device for endovascular treatment of wide-neck bifurcation aneurysms: Initial experience. Radiology 2001; 221: 318–326, with permission. 1

The Trispan device can be used as an adjunct in the treatment of wide-neck aneurysms, particularly at bifurcation locations (e.g., basilar artery tip). A 0.018-inch microcatheter is required to carry the device to the aneurysm neck prior to embolization. Three nitinol loops radiate from the center to protect the parent vessel. A second microcatheter is required to deploy the coils. Thromboembolic complications may increase with this device, and double antiplatelet therapy is frequently administered pre- and post-procedure. Pr o ce d u r e : Under general anesthesia, 6-F and 5-F sheaths were placed in the right and left CFA, respectively. Then a 6-F guide catheter was placed in the right VA, followed by a 5-F guide catheter in the left VA. A 2.3-F microcatheter was passed through the 5-F guide catheter and positioned proximal to the aneurysm. Through the microcatheter, a 12 mm Trispan device was placed at the aneurysm base (Figure 2A). A second microcatheter was introduced into the aneurysm through the 6-F guide catheter. Seven bare platinum coils were subsequently deployed through the second microcatheter. The Trispan was then deployed using electrolysis. Angiography performed post-embolization revealed good occlusion of the aneurysm with a small residual neck (Figures 2, C and D). Angiography at 6 year follow-up showed complete aneurysm obliteration (Figure 2E).

2D 2C 2B

2A

Figure 2.â•‡ A and B. VA injection, AP projection. A. The Trispan device has been deployed. Arrows point at the nitinol loops. B. The first coil has been placed in the aneurysm. Figure 2, C–E. VA injections, AP projection. Figure 2D unsubtracted. C and D.â•‡ There is minimal residual at the neck at the end of the procedure. E. Follow-up angiography 6 years later shows no residual aneurysm. 146

2E

CASE 99 • Unruptured Internal carotid artery/Ophthalmic artery aneurysm recurrence Mostafa Mahmoud, MD, Thanh Nguyen, MD, Daniel Roy, MD, Jean Raymond, MD, Francois Guilber t, MD, Alainâ•¯Weill , MD B ac kg r o u n d :â•‡ A 50-year-old woman presented with chronic headache. MRI revealed a 20 3 18 mm ICA/Ophthalmic artery aneurysm. Coil embolization with balloon remodeling in 1999 had resulted in complete aneurysm obliteration. Control angiogram 2 years later showed aneurysm recurrence with coil compaction (Figure 1A).

Treatment of large unruptured aneurysms is challenging and associated with a high rate of recurrence. Onyx embolization (Micro Therapeutics Inc, Irving, CA) is one of the available options. The main challenge is to avoid a leak of onyx into the parent artery. The ophthalmic segment of the ICA has no branches or perforators except for the ophthalmic artery. Occlusion of the origin of the ophthalmic artery is usually asymptomatic since the central retinal artery arises distally and rich anastomotic networks form with ECA branches. Mass effect created by the cast can result in headache and/or cranial nerve palsy, which can be transient. Pr o ce d u r e :â•‡ A 1.7-F microcatheter was navigated into the aneurysm. A 4 3 30 mm remodeling balloon was placed across the aneurysm neck and inflated (Figure 1B). Injection through the microcatheter showed no contrast extravasation outside the aneurysmal sac (Figure 1C), confirming that the aneurysm was being sealed off effectively. With the balloon inflated, Onyx HD500 was injected into the aneurysm. Control angiogram at 3.5 years after onyx embolization revealed complete aneurysm occlusion (Figure 1D).

1B

1A

1C

Figure 1.â•‡ A–D. Lateral projections. Left ICA injection (A and D), microcatheter injection (C), unsubtracted image (B). A. Diagnostic follow-up angiogram shows coil compaction and recurrence of the aneurysmal neck (arrow). B. The balloon is inflated across the neck of the aneurysm (arrows). C. Seal test. Following microcatheter injection, all the contrast is concentrated in the aneurysm neck (arrow). No contrast can be seen leaking out. D. Follow-up angiography 3.5 years later shows no recanalization of the aneurysm.

1D

References: 1.â•‡Orz YI, Hongo K, Tanaka Y, Nagashima H, Osawa M, Kyoshima Kobayashi S. Risks of surgery for patients with unruptured aneurysms. Surg Neurol 2000; 53(1): 21–27. 2.â•‡Weber W, Siekmann R, Kis B, Kuehne D. Treatment and follow up of 22 unruptured wide-necked intracranial aneurysms of the internal carotid artery with Onyx HD 500. AJNR 2005; 26: 1909–1915. 3.â•‡Molyneux AJ, Cekirge S, Saatci I, Gyula G.Cerebral Aneurysm Multicentre European Onyx (CAMEO) trial: Results of a prospective observational study in 20 European centers. AJNR 2004; 25: 39–51. â•…â•…â•‡Cekirge S, Saatci I, Ozturk MH et al. Late angiographic and clinical follow-up results of 100 consecutive aneurysms treated with Onyx reconstruction: largest single-center experience. Neuroradiology 2006; 48(2): 113–126.

147

CASE 100 • Unruptured Middle cerebral artery bifurcation aneurysm Qaisar A. Shah, MD, Alexandros L. Georgiadis, MD, Vallabh Janardhan, MD, Adnan I. Qureshi, MD B AC KGROUND :â•‡ A 52-year-old man was found to have an unruptured aneurysm at the bifurcation of the right MCA.

1A

1B

1C

Figure 1. A. CTA. A large aneurysm (arrow) is seen at the bifurcation of the right MCA. B. Right ICA injection, AP view. The aneurysm measures 13 3 16 3 6 mm. C and D.â•‡ 3-D reconstruction images of the right ICA. The arrows point at the MCA superior and inferior divisions. Proce d u r e :â•‡ Through a 7-F CFA sheath, a 7-F guide catheter was advanced into the right ICA. An Excelsior SL-1018 microcatheter was introduced over an Agility 0.014-inch microwire. The microcatheter was positioned within the dome of the aneurysm (Figure 2A) and the wire was removed. A Hyperform MTI 4 3 7 mm balloon was then placed in the distal M1, just proximal to the neck of the aneurysm (Figure 2B). The balloon was inflated and a coil was positioned in the aneurysm. However, part of the coil protruded into the origin of the superior division of the MCA. Attempts to reposition the coil were not successful. Coil and balloon-catheter were removed.

1D

Figure 2. A. Microcatheter injection confirms placement of the microcatheter (arrow points at the tip) inside the aneurysm. B. Unsubtracted image. The microcatheter (black arrows) is in position for embolization. The balloon-catheter (white arrows) is placed in the distal M1 segment, just proximal to the neck of the aneurysm.

2B

2A

148

CASE 100 • (continued) Microcatheter deflection is an alternative technique that can be used to avoid protrusion of the coils. In this case, it would require placement of a second microcatheter in the superior division of the MCA that would deflect any protruding coil loop back into the dome of the aneurysm. The microcatheter was repositioned and the superior division was selected (Figure 3A). A Transend 14 microwire was passed through the microcatheter and placed further distally (Figure 3B). The microcatheter was removed. A second Prowler 14 microcatheter was then introduced over another Transend 0.014-inch microwire and placed inside the aneurysm (Figure 3B). Coil embolization was then performed without any further incident of coil protrusion. After all coils had been detached, the deflecting catheter was exchanged for a 3 3 15 mm Neuroform stent catheter. The Neuroform stent was positioned so that it extended from the distal M-1 into the proximal superior division and deployed. The purpose of this maneuver was to prevent any possible future coil herniation.

3A

3C

3B

3D

Figure 3. A. Microcatheter injection confirms placement of the microcatheter at the origin of the superior division. B. ICA injection. The black arrows show the markers of the deflection microcatheter. The white arrows point at the markers of the second microcatheter that was used for embolization. The block arrow points at the tip of the microwire in the distal MCA. C. ICA injection following coil embolization. No residual filling of the aneurysm is seen. D. The stent has been placed across the aneurysm neck, extending from the distal M1 into the proximal superior division (arrows point at the stent markers).

4A

4B

4C

Figure 4.â•‡ A–C. Right ICA injection, oblique (A and B) and AP (C) projections. There is no residual filling of the aneurysm. Both MCA divisions are patent.

149

CASE 101 • Basilar artery and Posterior cerebral artery vasospasm M Fareed K. Suri, MD, Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD B AC KGROUND :â•‡ A 41-year-old man on day 5 post SAH and day 1 post coil embolization of a Basilar artery apex aneurysm was noted to have deteriorating mental status. Diagnostic angiography demonstrated severe vasospasm of the mid-segment of the basilar artery.

1A

1C

1B

1D

Figure 1.â•‡ A–D. Right VA injections in AP (A-C) and lateral projection (D). A and B.â•‡Pre-embolization angiography shows a 12-mm Basilar artery apex aneurysm (arrow in B). The basilar artery measures 2.6 mm in the 3-D reconstruction image (A). C and D. Repeat angiography shows a long segment of severe spasm in the Basilar artery (arrows). There is also significant spasm in the PCA bilaterally (compare to Figure 1B). Proce d u r e :â•‡ A 6-F Envoy MPD catheter was advanced into the distal cervical segment of the right VA. A Maverick 2 3 9 mm monorail noncompliant balloon was chosen for angioplasty. The balloon was introduced over a Transend 14 platinum microwire into the Basilar artery. The wire was then placed in the left PCA, and the balloon was positioned just proximal to the neck of the aneurysm (Figure 2A). Four sequential angioplasty procedures were performed at nominal pressure across the entire length of the Basilar artery, each time with partial overlap between the treated segments. Figure 2. A. Unsubtracted image. The balloon (circle) is positioned just bellow the neck of the aneurysm prior to the first angioplasty. B. Right VA injection, AP projection. The balloon (circle) is positioned near the Vertebro-basilar arterial junction prior to the fourth angioplasty.

2A

3A

2B

3B

3C

Figure 3. A. The Basilar artery spasm has resolved post angioplasty. There is still spasm in the PCA bilaterally. B. A Rapid Transit 2.3 F microcatheter was advanced over a Transend-14 floppy wire into the right VA (arrow). A total of 30 mg of Papaverine were injected at a rate of 6mg/min. A slight increase in ICP (17 to 20 mm Hg) was noted during the injection. C. There is mild improvement in lumen diameter following the vasodilator treatment. 150

CASE 102 • Posterior cerebral artery vasospasm M. Fareed K. Suri, MD, Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD B ac kg r o u n d :â•‡ A 44-year-old woman presented with SAH (Figure 1). The patient underwent coil embolization of a right Pcom aneurysm on day 2 post SAH. At that time, no vasospasm was noted on angiography (Figure 2A). The following day, the patient was noted to have a new left homonymous hemianopsia. Diagnostic angiography (Figure 2B) demonstrated severe vasospasm of the right PCA and moderate vasospasm of the left distal PCA (P3 segment). Figure 1.â•‡ CT scan of the head. Diffuse blood is seen in the cisterns. The arrow points at a round hyperdense mass that represents the ruptured aneurysm. Pro ce d u r e :â•‡ A 6-F Envoy MPD catheter was advanced into the distal cervical segment of the right VA. A Prowler 14 microcatheter was then introduced over a Transend 14 microwire into the right PCA, P2 segment. A total of 2.5 mg of Nicardipine was injected through the microcatheter. Repeat angiography demonstrated significant improvement.

Baseline, Day 2

Pre-treatment, Day 3

Post-treatment, Day 3

2B

2A

Pre-treatment, Day 3

1

2C

Figure 2.â•‡ A–C. AP left (A) and right (B and C) VA injections in AP projection. A. No vasospasm. B. Multiple areas of vasospasm. The arrows point at some of the vessel segments with vasospasm. C. Following treatment, the caliber of the affected segments has increased significantly. Figure 3.â•‡ A and B. Right VA injection, lateral projection.

Post-treatment, Day 3

3A

3B

There is amelioration of vasospasm in the PCAs following treatment with Nicardipine.

O u tco m e :â•‡ Despite of the good angiographic result, there was no immediate clinical improvement. On follow-up at 3 months after discharge the patient had a homonymous quadrantanopsia.

151

CASE 103 • Ruptured Posterior communicating artery aneurysm Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD B AC KGROUND :â•‡ A 33-yearold woman presented with SAH. CTA showed an irregular Pcom aneurysm (arrow, Figure 1). She was referred for endovascular treatment.

2A

1

3A

3B

2B

The diagnostic angiogram was performed with a 5-F Davis catheter. Left ICA injection (lateral projection, Figure 2A) showed that the Pcom (open arrow) originated from the aneurysm (arrow). To confirm this, a 3-D rotational run was performed. One of the projections is depicted in Figure 2B. Review of the 3-D run confirmed that the Pcom originated from the aneurysmal sac. Posterior circulation images (Figures 3A and 3B) showed that the left PCA did not fill from the basilar artery. The PCA can be seen filling through the Pcom after a left ICA injection (fetal PCA, highlighted in Figure 2A). Endovascular treatment of this aneurysm would carry a high risk of obliterating the PCA and was therefore not perfomed.

Variations in posterior circulation anatomy In early embryonic circulation, the major source of blood supply to the occipital lobes is a large branch of the ICA. The P1 and P2 segments of the PCA develop from this branch. Prior to the 20th week of gestation, the most common circulation is the transitional type, in which the P1 and P2 segments are equal in size. Between the 20th and 30th gestational week, the rapid growth of the occipital lobes demands an increase in blood supply. Depending on the hemodynamic situation, the P1 and P2 segments of the PCA will enlarge to different degrees. If the P1 becomes greater in size than the P2, then flow to the PCA is mainly supplied by the basilar artery (adult circulation). If the P1 is smaller than the P2 or entirely absent, then flow to the PCA is mainly from the ICA (fetal circulation). Among adults, the incidence of the different circulation patterns is roughly as follows (there are great variations in the literature): • Adult >70% • Fetal 10%–25% • Transitional <10% Reference: Van Overbeeke JJ, Hillen B, Tulletken CAF. A comparative study of the circle of Willis in fetal and adult life. The configuration of the posterior bifurcation of the posterior communicating artery. J Anat 1991; 176: 45–54.

152

CASE 104 • Unruptured Vertebral artery pseudo-aneurysm Alexandros L. Georgiadis, MD, Charl es J. Prestigiacomo, MD, FACS B ac kg r o u n d :â•‡ A 51-year-old man with history of trauma complained of persistent neck pain. MRA was obtained (Figure 1), and it showed a fusiform dilatation of the right intracranial VA (arrow), which was confirmed on conventional angiography (arrow, Figure 2). Due to the very broad base of the aneurysmal dilatation, the decision was made to first place a stent across the lesion and then coil the aneurysm in a second stage.

1

2

SIGMOID SINUS

transverse SINUS

3A

3B

Figure 3.â•‡ A and B. Right VA injection, early venous phase, lateral (A) and AP (B) projection. The white arrows point at the stagnating blood inside the aneurysm. The black arrows in Figure 3A indicate the position of the markers of the stent.

Right VA injection, AP

A 6-F MPC Envoy catheter was positioned in the mid- to distal cervical right VA. A 4.5 3 30 mm Neuroform3 stent was introduced over a Transend 14 microwire, positioned across the neck of the aneurysm and deployed. After deployment of the stent, multiple runs were obtained that showed some stasis of flow in the aneurysm (Figure 3, A and B). The patient was brought back 10 weeks later for the second stage of the procedure. At that time, the aneurysm had regressed significantly and no longer required additional treatment (Figure 4). There was some mild residual vessel wall irregularity (Figure 4, white arrows) and some stenosis at the distal margin of the stent (Figure 4, black arrow). 4

153

CASE 105 • Ruptured Vertebral artery aneurysm Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD B AC KGROUND :â•‡ A 46-year-old woman presented with SAH in 2006. She underwent stent-assisted coil embolization of a wide-neck left vertebral artery aneurysm (Figure 1). At follow-up 6 months later, the aneurysm had recanalized and repeat embolization was performed (not shown). In February of 2007, angiography showed that there was further compaction of the coil mass and there was significant filling of the aneurysm neck (Figure 2, A–C). The decision was made to perform coil embolization, followed by placement of a second stent across the neck of the aneurysm in an attempt to curb further compaction of the coils.

2B

2A

1

Figure 1.â•‡ Left VA injection, lateral projection post initial treatment. The coil mass (circle) has resulted in angiographic occlusion of the aneurysm. Figure 2.â•‡ A–C.â•‡ Left VA injection, AP (A) and lateral (B) injection and 3-D reconstruction (C). These images are from February 2007. Compaction is seen for the second time (arrow in A–C).

2C

3B

3A

3C

Figure 3. A. Unsubtracted image shows the compacted coil mass and the markers of the original stent (arrows). B. Unsubtracted image shows the microcatheter positioned inside the aneurysm (the arrow points at the microcatheter tip). C. Microcatheter injection, performed to verify correct placement of the microcatheter inside the aneurysm.

154

CASE 105 • (continued)

3D

3E

3G

3F

D. Unsubtracted image. The first coil is being placed in the aneurysm. The coil marker is seen crossing the proximal microcatheter marker (arrow). E. Left VA injection, AP projection following completed coil embolization. No residual aneurysm filling is seen. F. Unsubtracted image, Following coil embolization, a microwire is placed in the right PCA (arrow). A Wingspan stent is being advanced towards the lesion (circle). It is important to note that for adequate support for a stent, placing the microwire in a PCA is paramount. In case of angioplasty, the wire can usually provide enough support even if it is placed in the top of the basilar artery. Placing the microwire in smaller vessels, such as the SCA, should be avoided. G. Unsubtracted image. The second stent has been deployed slightly distally to the initial stent in an effort to maximize coverage of the neck. The markers of the second stent are shown by arrows. H. Final left VA injection. There is no residual flow in the aneurysm. The distal end of the newly placed stent protrudes slightly into the vertebrobasilar arterial junction. It was not believed that this minimal protrusion would pose a significant risk for embolic complications.

3H

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CHAPTER 5

Treatment of Arterio-venous Malformations and Fistulas

FP

O

T r e at m e n t a lg o r it h m Many treatment combinations are possible. In principle, embolization is aimed at reducing the size of the AVM so as to render it amenable to surgical resection or curable by Gamma-Knife surgery. In some cases, however, embolization can be curative.

PVA (Polyvinyl Alcohol) PVA particles, shown in Figure a, are available in different size ranges, commonly from 50 to 150 mm to 750 to 100 mm. Embospheres (Tris-acryl gelatin microspheres) Figures a and b are photomicrographs of 300 to 500 mm particles (PVA and Embospheres respectively) taken at 10x magnification. Reprinted with permission.

157

OVERVIEW OF CASES I

TREATMENT OF ARTERIO-VENOUS MALFORMATIONS

Embolization with N-butyl-cyanoacrylate

Case 106

Ruptured arterio-venous malformation Intranidal aneurysm

Embolization with N-butyl-cyanoacrylate and particles

Case 107

Ruptured arterio-venous malformation Emergent embolization prior to surgery Intranidal aneurysm

Embolization with N-butyl-cyanoacrylate followed by surgery

Case 108

Ruptured Arterio-venous malformation Arterio-venous malformation surgery Provocative testing

Embolization with N-butyl-cyanoacrylate followed by Gamma-Knife

Case 109

Unruptured arterio-venous malformation presenting with headache and aphasia Gamma-Knife Follow-up angiography at 3 years

Case 110

Ruptured arterio-venous malformation Gamma-Knife

Embolization with Onyx

Case 111

Unruptured arterio-venous malformation presenting with focal seizures

Case 112

Ruptured arterio-venous malformation

Case 113

Ruptured arterio-venous malformation

Facial arterio-venous malformation embolization with Onyx

Case 114

Facial arterio-venous malformation presenting with recurrent oral bleeding

II

TREATMENT OF ARTERIO-VENOUS FISTULAS

Transvenous embolization

Case 115

Dural arterio-venous fistula presenting with occipital infarction Sinus coil-embolization

Case 116

Dural arterio-venous fistula presenting with headache and pulsatile tinnitus Sinus coil-embolization

Transarterial embolization

Case 117

Dural arterio-venous fistula presenting with tinnitus and imbalance Embolization of arterial feeder with coils and N-butyl-cyanoacrylate

Stenting of the draining sinus

Case 118

Dural arterio-venous fistula presenting with ICH Covered stent

158

CASES 106–114

CASES 115–125

Dural arterio-venous fistula not amenable to endovascular treatment

Case 119

Dural arterio-venous fistula presenting with headache and deterioration of vision Surgical treatment

Arterio-venous fistula treated with Onyx and coil-embolization

Case 120

Arterio-venous fistula presenting with ICH

Orbital arterio-venous fistula treated with transvenous coil-embolization

Case 121

Orbital arterio-venous fistula presenting with diplopia, chemosis, and proptosis

Traumatic carotid-cavernous fistula treated with transvenous and trans-arterial embolization

Case 122

Carotid-cavernous fistula presenting with progressive loss of vision Transvenous and trans-arterial coil-embolization Embolization with N-butyl-cyanoacrylate

Vein of Galen malformation

Case 123

Vein of Galen malformation presenting with hydrocephalus Spontaneous thrombosis

Cervical arterio-venous fistula

Case 124

Traumatic arterio-venous fistula Transvenous and trans-arterial coil-embolization Embolization with particles

Spinal dural arterio-venous fistula treated with Onyx

Case 125

Spinal dural arterio-venous fistula presenting with back pain and progressive lower extremity weakness

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CASE 106 • Aterio-venous malformation embolization with N-butyl-cyanoacrylate Alexandros L. Georgiadis, MD, Jawad F. Kirmani, MD B AC KGRO U N D : â•‡ A 17-year-old girl presented with ICH and intra-ventricular hemorrhage (CT scan shown in Figure 1, A and B). 1B

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PRO C E D U RE : A 6-F sheath was placed in the right CFA. A diagnostic angiogram was performed with a 5-F VERT catheter. As shown in Figure 2A (right VA injection, AP projection), the nidus (circle) is in close proximity to the right PCA and possibly receives feeders from that vessel. Figure 2B (right ICA injection, lateral projection) also shows the nidus (circle). The PCA fills through a large Pcom (white arrow) that offers an alternative approach for embolization. The open arrows outline the early venous pattern. Figure 2C (right VA injection, lateral projection), shows an intra-nidal aneurysm (arrow). It was decided to attempt embolization through the right ICA and Pcom. Diagram 1 is based on an ICA injection, lateral projection and is meant to elucidate the way the nidus is approached and the most optimal microcatheter position is chosen prior to embolization. Obliteration of the aneurysm is paramount in this procedure.

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CASE 106 • (continued) Diagram 1.â•‡ The black dots correspond to different positions of the tip of the microcatheter as this was advanced to achieve optimal placement for embolization. Figure 3.â•‡ A through D are images acquired with the microcatheter in the four positions shown in Diagram 1. All are lateral projections. A and C are guide catheter runs; Figures B and D are microcatheter runs. The circles highlight the position of the microcatheter tip. A. Right ICA run. The microcatheter is in the distal ICA. B. The microcatheter has been advanced through the Pcom into the proximal PCA. C. The microcatheter is in a P3 segment of the PCA. From this position, there is good filling of the nidus and the aneurysm (white arrow), but also of an additional branch unrelated to the AVM (black arrow). D. To avoid embolizing the normal branch that filled in Figure 3C, the catheter was advanced further. There is now only filling of the nidus and the aneurysm. The white arrow points at the aneurysm. The block arrows point at the early venous drainage. This position was chosen for embolization. Of note, several microcatheter/microwire combinations were tried before the PCA was catheterized succesfully. The failed Â�combinations were: 1.8 Olive Magic/Mirage 0.08, Prowler 10/Transend 10, 1.2 Magic/Mirage 0.08 Successful catheterization was achieved with a 1.5 Non-olive Magic/Mirage 0.08 combination. The guide catheter used was a 6-F MPD Envoy. Embolization was performed with 1 mL of 1:3 NBCA:Ethiodol solution.

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Figure 4.â•‡ A through D were obtained post-embolization. A shows the glue cast (circle). The arrow points at the part of the glue cast that is located in the aneurysm. B–D are frames obtained after a right ICA injection in lateral projection. They show absence of the early venous drainage, reduction in the size of the nidus (circle), and lack of filling of the aneurysm.

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CASE 107 • Arterio-venous malformation embolization with N-butyl-cyanoacrylate and particles

Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD B AC KGRO U N D :â•‡ A 35-year-old woman presented with decreased level of consciousness and left-sided weakness. CT showed a large fronto-parietal hematoma with significant mass effect (Figures 1, A and B). CTA showed an AVM (Figure 2, circle highlights the nidus, the arrow points at a pre-nidal aneurysm). The patient was referred for emergent embolization prior to surgical evacuation.

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A frontal approach was anticipated for the surgery. The main goal of the embolization was therefore to obliterate the anterior feeders and the aneurysm (Figure 3A, arrow). Pro c e du r e :â•‡ The guide catheter used was a 6-F MPD Envoy. For the first embolization, a Magic microcatheter was used. It was positioned at the ostium of one of the feeders off the superior division of the MCA (red circle, Figure 3A). Embolization was performed with 1.5 mL of 1:4 NBCA:Ethiodol solution and the microcatheter was removed. A follow-up image is shown in Â�Figureâ•¯4A. The arrow is pointing at a distally obliterated feeder. A Spinnaker microcatheter was then introduced into the superior division of the right MCA, and the tip was positioned as indicated by the red triangle in Figure 3A. Embospheres (300-500 mm) diluted in 1:1 contrast:saline solution were then injected. The final result is seen in Â�Figures 4B (AP) and 4C (lateral). The aneurysm is no longer visualized. The area of the AVM highlighted by the circle in Figure 3B is no longer seen in Figureâ•¯4C. The evacuation surgery was successful. The postoperative CT is shown in Figures 5, A through C.

Right ICA, LAT, PRE-Embo

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Figure 3Câ•‡ depicts the venous drainage of the AVM: internal cerebral veins vein of Gallen straight sinus transverse sinus. Right ICA, lat, Post stage 2 Embo

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CASE 108 • Arterio-venous malformation embolization with N-butyl-cyanoacrylate followed by surgery

Stanley H. Kim, MD, Anant I. Patel, MD B ackg r o u n d :â•‡ A 52-year-old man with known history of untreated cerebral AVM diagnosed 30 years ago presented withâ•¯acute onset of aphasia and right facial droop. A CT scan of the head showed a left frontal ICH (Figure 1, arrow).

A diagnostic cerebral angiogram revealed a 3.5â•›3â•›3.5 cm left Â�frontal AVM Â�(Figure 2, black arrow) fed by multiple large left MCA and Â�distal left ACA branches with a large cortical draining vein (Figure 2, white arrow). The plan was made to perform embolization and to follow this by surgical resection. 1

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Figure 3.â•‡ A –B. Left ICA injections, AP projection. The arrow in Figure 3B shows the position of the microcatheter just prior toâ•¯embolization. C. Microcatheter injection prior to embolization. The microcatheter is in the same position as in Figure 3B. Proc e du r e :â•‡ The procedure was performed using moderate conscious sedation, so that provocative testing could be performed. A Prowler 14 microcatheter was positioned in a large MCA feeder (Figure 3B, arrow points at the tip of the microcatheter). Then, 10 mg of methohexital were injected through the microcatheter. The patient’s neurologic examination did not change. Embolization was performed with a 3:1 Lipidol:NBCA solution. The microcatheter was removed immediately after the embolization was completed. A new microcatheter was introduced into the same MCA feeder. The patient failed the methohexital testing this time (he became transiently more aphasic). Therefore, no further embolization was performed. The patient was scheduled for surgery. Provocative testing. Provocative testing is commonly performed with intra-arterial injection of a barbiturate anesthetic. Two commonly used substances are Methohexital (Brevital Sodium) and Amobarbital (Amytal Sodium). The testing is aimed at determining the consequence of dysfunction of the area supplied by the artery into which the anesthetic is injected. During WADA testing, Amobarbital is injected into both ICAs to determine the lateralization principally of language and memory functions. WADA testing is used primarily in the setting of preoperative evaluation of candidates for epilepsy surgery. In the case of embolization, provocative testing can be used to make sure that the microcatheter has been placed distally enough so that embolic material will not cause damage to normal cerebral tissue. With the evolution of microcatheter technology, it is becoming possible to navigate microcatheters into increasingly small vessels, making embolizations more selective. Provocative testing is therefore not used as commonly as it was in the past. It is also problematic that the patient needs to be awake so that neurological testing can be performed. AVM embolizations are preferably performed under general anesthesia. 163

CASE 108 • (continued)

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The patient underwent surgical resection via left frontal craniotomy 3â•¯months following the embolization.

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Figure 4.â•‡ A . The AVM is exposed. Notice the large draining vein on the surface of the lesion. B. In the first part of the procedure, the main arterial feeders are identified and obliterated. The arrow shows the large MCA feeder that had been catheterized previously (Figure 3, B and C). C. A clip has been placed across the feeder. Following obliteration of the arterial supply, the AVM is resected. D. The resected lesion. E. The surgical site at the end of the procedure. Figure 5.â•‡ Follow-up angiogram obtained after the surgery. ICA injection, AP projection. The nidus is no longer visualized. The clip that was placed across the large MCA feeder is visible (arrow). Outc o m e : The patient’s facial droop resolved entirely. He was left with mild Â�residual aphasia. He returned to work 3 months after the Â�procedure.

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CASE 109 • A rterio-venous malformation embolization with N-butyl-cyanoacrylate followed by Gamma-Knife

Stanley H. Kim, MD B ackg r o u n d :â•‡ A 45-year-old woman presented with a 1-year history of mild anomic aphasia and chronic headache. MRI revealed a 1 3 1 cm left medial inferior temporal AVM on T2-weighted and T1-weighted imaging with contrast, without any evidence of hemorrhage. Angiography showed that the AVM was fed by temporal artery branches originating from the distal PCA, with deep venous drainage. The patient underwent partial embolization of the AVM with NBCA (not shown) without any complications. The residual AVM was to be treated with radiosurgery.

Figure 1.â•‡ A and B. Axial MRI images, T2-weighted (A) and T1-weighted postcontrast (B). The AVM is highlighted in a circle.

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Figure 2.â•‡ A and B. Angiography performed at the day of radiosurgery. Left VA injection, AP (A) and lateral (B) projection. The AVM is highlighted in a circle. The arrow in 2B points at an early-draining vein.

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Figure 3.â•‡ MRI images post-processing for radiosurgery preparation. The yellow line (prescription isodose line) encompasses the area that is targeted to receive 50% of the administered radiation.

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CASE 109 • (continued) Pr o c e du r e : Gamma-Knife radiosurgery was performed under moderate conscious sedation 10 months after the Â�embolization. A radiation oncologist, radiation physicist, and the neurosurgeon participated in the planning of the radiation to the target lesion. The target area received a radiation dose of 23 Gy. The duration of the procedure was 24 minutes, and the patient was discharged home the same day. Outc o m e : Three years following radiosurgery, MRI showed encephalomalacia in the region where the AVM had been located (Figure 4, A and B). The patient’s anomic aphasia and headache had improved. Cerebral angiography revealed complete obliteration of the AVM (Figure 5, A and B).

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Figure 4.â•‡ A and B. MRI T2-weighted (A) and T1-weighted post-contrast (B) obtained 3 years post radiosurgery. The arrows point at an area of gliosis. No residual AVM is visulaized.

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Figure 5.â•‡ A and B. Angiography performed at 3 years post-radiosurgery. Left VA injection, AP (A) and lateral (B) projection. No residual AVM is seen. C o n c lus i o n : â•‡ Embolization is often used as an adjunctive therapy to either surgical resection or stereotactic radiosurgery of AVMs. For AVMs measuring less than 3 cm and located among eloquent tissue, Gamma-Knife radiosurgery alone or in combination with embolization may be an excellent alternative to surgical resection. In cases where embolization of an AVM is performed prior to radiosurgery, radiosurgery is delayed for at least 1 month so as to better visualize parts of the nidus that may falsely appear to be occluded immediately after the embolization. Because the effects of radiosurgery are delayed, follow-up angiography is generally not performed earlier than 2 years following the procedure.

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CASE 110 • Arterio-venous malformation embolization with N-butyl-cyanoacrylate followed by Gamma-Knife

Stanley H. Kim, MD, Ogunlene Tom, PhD B ackg r o u n d :â•‡ A 75-year-old man presented with acute onset of aphasia and right hemiparesis. CT revealed left frontal ICH (Figure 1). Diagnostic angiography showed a Spetzler-Martin Grade III left frontal AVM with venous Â�drainage into the sagittal sinus. The patient refused surgical resection of the AVM. He was scheduled for embolization to be followed by gamma-knife radiosurgery.

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Figure 1.â•‡ CT scan shows a left frontal ICH (arrow). Figure 2.â•‡ A and B. Left ICA injection, AP (A) and lateral (B) projection. The nidus is fed by the ACA. C. Magnified view of the nidus with size measurements. Pr o c e du r e : Embolization was performed under moderate conscious sedation 5 days after the ICH. An SL-10 microcatheter was navigated into the left ACA and then into a distal branch that was supplying the AVM. Provocative testing was carried out with 10 mg of Methohexital. Neurologic examination performed immediately before and after the administration of Methohexital showed no new neurological deficits. Approximately 1 mL of 3:1 mixture of Lipidol:NBCA was administered through the microcatheter under fluoroscopy. The patient tolerated the procedure well. Three weeks after the first embolization, the patient’s aphasia and right hemiparesis were significantly improved, and he was Â�ambulating independently. A second embolization of the AVM via the same feeder was performed using the same NBCA mixture. There were no complications, and he was discharged home the following day.

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Figure 3.â•‡ A Microcatheter injection visualizing the nidus. B. Post-embolization, the NBCA cast is seen (circle). C and D. Left ICA injection post-embolization in AP (C) and lateral (D) projection. The nidus is now smaller in size.

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CASE 110 • (continued)

Figure 4. A and B.â•‡ Left ICA injection following the second embolization in oblique (A) and lateral (B) projection. There is further reduction in the size of the nidus.

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Three weeks later, the patient underwent Gamma-Knife radiosurgery as an outpatient. In preparation for radiosurgery the patient underwent diagnostic angiography and MRI with contrast. For both procedures, a special stereotactic frame (Leksell frame) was attached to the patient’s head. The images thus obtained were loaded onto a computer station that is used to map out the area to be radiated. That area is first calculated based on the axial and sagittal MRI images. The calculations are then refined using angiographic data so as to minimize damage to the outflow tract. A radiation dose of 18 Gy was administered. The patient was discharged home on the same day. Outc o m e : At 1-year clinical follow-up, the patient’s aphasia and right hemiparesis had resolved. He will undergo follow-up cerebral angiography at 2 years.

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Figure 5. A and B.â•‡ Left ICA injection, AP (A) and lateral (B) projection. Those images were obtained on the day of the radiosurgical procedure. The circled markings are used as reference points to calculate the coordinates of the lesion. The target area is marked in red. Figure 6.â•‡ MRI images obtained on the day of the procedure. The yellow line (prescription isodose line) encompasses the area that is intended to receive 50% of the administered radiation dose.

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The literature suggests that the success rate following radiosurgery in previously embolized AVMs depends on the lesion size (greater obliteration rate in AVMs mesuring less than 3 cm) and Spetzler-Martin grade (greater obliteration rate in Grade I and II AVMs). The risk of intracranial hemorrhage may not be increased after radiosurgery and may depend on AVM size and volume.

CASE 111 • Arterio-venous malformation embolization with Onyx Osama O. Zaidat, MD, Thomas Wolfe , MD, John R. Lynch, MD, Brian-Fred Fitzsimmons, MD B ackg r o u n d :â•‡ A 14-year-old girl presented with focal seizures and severe refractory headaches. MRI and MRA were suggestive of a left parieto-occipital AVM. Left VA angiography revealed a pariteto-occipital AVM with a 4-cm nidus fed by multiple left PCA branches. Drainage was superficial via the transverse sinus and deep via the straight sinus.

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Figure 1. A and B.â•‡ Left VA injection, AP projections, early (A) and late (B)â•¯arterial phase. A. The arrows point at multiple feeders arising from the left PCA. B. There is superficial (large arrow, transverse sinus) and deep (small arrow, straight sinus) drainage. Figure 1. C and D.â•‡ Left VA injection, lateral projections, early (C) and late (D) arterial phase. C. The arrows point at arterial feeders from the PCA. D. The white arrows point at the straight sinus. The long black arrow points at the transverse sinus. The short black arrow highlights a retrogradefilling cortical vein. 1D

The decision was to treat with Onyx embolization, to be followed by radiosurgery.

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Figure 2. A–D.â•‡ Post-embolization left VA injections, AP (A and B) and lateral (C and D) projections. The arrows point at the Onyx cast. The nidus is significantly reduced in size. Pr o c e du r e : â•‡ Microwire: Mirage 0.008-inch or Agility soft Microcatheter: Marathon or Echelon, depending on vessel size A Marathon catheter and Mirage wire were selected in this case because of the patient’s young age. A 5-F guide catheter was used. For optimal results, the deep supply must be treated first. If the patient is to be subsequently treated with radiosurgery, it is advisable to treat ACA and PCA feeders rather than MCA feeders when applicable so as to minimize potential complications. Onyx embolization requires time. DMSO is used initially to clear the dead space. Onyx is then injected slowly. If the resulting distribution pattern is sub-optimal, the injection is held for 15-60 seconds and then resumed slowly. 169

CASE 112 • Arterio-venous malformation embolization with Onyx Rishi Gupta, MD B AC KGRO U N D :â•‡ A 37-year-old woman presented in a coma. CT showed a cerebellar hemorrhage. After an intra-ventricular catheter was placed emergently, the patient underwent surgical clot evacuation. A cerebral angiogram was performed to determine the etiology of the hemorrhage. A Spetzler-Martin Grade II AVM was found, fed by the right superior cerebellar artery (Figure A, arrow) with deep venous drainage via the basal vein of Rosenthal (Figure B, arrow). Figure 1. A and B.â•‡ Left VA injections, oblique projections. A. The AVM (circle) is supplied mainly by the right SCA (arrow). B. Drainage is deep, into the basal vein of Rosenthal (arrow).

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Figure 2 A. Microcatheter injection into the right SCA. B. Unsubtracted image depicting the Onyx cast. Figure 3.â•‡ Follow-up angiography at 3 months, left VA injection. Proc e du r e :â•‡ A 6-F Envoy guide catheter was placed in the left VA. An Echelon microcatheter was navigated over an 0.014-inch microwire into the right SCA. A test injection through the microcatheter opacified the nidus of the AVM (Figure 2A). No en passage vessels were seen. DMSO (0.25 mL) was infused into the microcatheter and Onyx-18 was then gently injected into the AVM. The resulting cast is shown in Figure 2B. At 3-month follow-up, complete obliteration of the AVM (Figure 3) was observed.

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CASE 113 • Arterio-venous malformation embolization with Onyx Raul G. Nogueira, MD, Johnny C . Pr yor, MD B ackg r o u n d :â•‡ A 61-year-old man presented with acute onset of speech difficulties and right homonymous hemianopsia in the setting of a left tempo-parietal ICH related to an AVM (Figures 1, A and B). The patient recovered well from the ICH and returned 1 month later for embolization. Figure 1. A. CT showing a large ICH (arrow). B. CTA showing the AVM (arrow). 1A

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Figure 2. A–C.â•‡ Left ICA injections, AP (A), lateral (B) and oblique (C) projections. There is a 3-cm AVM supplied by the left temporo-occipital (2A and 2C, black arrows) and posterior temporal (2B and 2C, open arrows) arteries and draining into two cortical veins (2B, white arrows). Pr o c e du r e : A Marathon microcatheter was navigated over an X-Pedion 10 wire to the most distal aspects of the pedicles Â�supplying the AVM (temporo-occipital artery). Microcatheter angiography was performed to confirm the absence of normal arterial brain supply. The microcatheter was flushed with 5 mL of normal saline. The dead space of the microcatheter was subsequently filled with 0.24 mL of DMSO. Onyx was then slowly injected using a “thumb-tapping” technique under Â�continuous fluoroscopic guidance.

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Figure 3. A–C.â•‡ Embolization of the temporo-occipital artery pedicle. A. The arrow points at the tip of the microcatheter prior to embolization. B. In contrast to NBCA, Onyx embolization takes more time, but allows for more controlled target embolization and for the performance of concomitant angiography. Thus, the degree of nidal obliteration and the status of venous drainage can be evaluated. C. Final run after completed embolization of the first pedicle. The white arrow points at the proximal end of the large Onyx cast. The black arrow shows the more proximal cut-off in the supplying pedicle.

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CASE 113 • (continued)

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Figure 4.â•‡ A and B. Embolization of the posterior temporal artery pedicle. A. The arrow indicates the position of the microcatheter for embolization. B. The black arrow points at the microcatheter tip. The open arrow points at an intranidal aneurysm that was likely the source of the ICH.

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Figure 5. A –D.â•‡ Final images post-embolization of both pedicles. Left ICA injections, AP (A and C) and lateral (B and D) projections. Images C and D are unsubtracted. The AVM appears to be completely obliterated.

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CASE 114 • Facial arterio-venous malformation embolization with Onyx M . F a re e d K . S u r i , M D, A l e x a n d ro s L . G e o r g i ad i s , M D, Va l l a b h J a n a rd h a n , M D B ackg r o u n d :â•‡ A 23-year-old man with multiple facial AVMs presented with episodes of oral bleeding. Left CCA Â�injections showed an AVM that was filling from the facial and lingual arteries.

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Proc e du r e : Figure 1. A. Selective left facial artery injection, lateral projection. A 6-F MPD Envoy catheter is parked at the origin of the facial artery. Heparin was administered intravenously to achieve an ACT value of ~300 seconds. An Echelon 10 45-degree microcatheter was advanced over a Transend 14 microwire into the facial artery. B. Microcatheter injection, lateral projection. The arrow points at the tip of the microcatheter. AVM nidus is visualized (circle). The microcatheter was filled with 0.34 mL (lumen volume of Echelon 10) of DMSO. The initial 0.34 mL of Onyx-18 were injected at a slow rate of 0.1 mL/minute to avoid rapid influx of DMSO into the circulation. The outflow of Onyx-18 was visualized under digital subtraction mask. With the microcatheter in place, adequate embolization was confirmed by means ofâ•¯a guide catheter injection (Figure 2C). The microcatheter was then removed by applying a gentle constant pull. C. Guide-catheter injection. The arrows point at the Onyx cast. There is residual filling of the AVM (circle) originating from the lingual artery.

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Figure 2. A and B. Left lingual artery injection, lateral projection, early (A) and late (B) arterial phase. The circle highlights the remaining nidus. A microcatheter was advanced into the lingual artery until it was positioned sufficiently distally to allow for selective embolization of the nidus. C. Microcatheter injection prior to embolization, lateral projection. The image intensifiers were repositioned so that both the feeding artery and the outflow tracts could be clearly identified without any overlap with the nidus. For this embolization, Onyx-34 was used because of the more rapid flow that was observed. Embolization was performed under continuous fluoroscopy with digital subtraction. If any reflux was noticed, the injection was held for 30 seconds and re-infusion was then attempted.

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CASE 114 • (continued)

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Figure 2. D through G.â•‡ Images obtained during Onyx embolization show the step-wise formation of the Onyx cast. Figure 2D shows reflux of Onyx into the feeding artery past the tip of the microcatheter (arrow). Figure 3.â•‡ Final left CCA run in lateral projection. The Onyx cast is seen. There is virtually complete obliteration of the AVM.

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CASE 115 • Transvenous embolization of a dural arterio-venous fistula A l e x a n d ro s L . G e o r g i ad i s , M D, Ad n a n I . Q u re s h i , M D B ackg r o u n d :â•‡ A 60-year-old man presented with left homonymous hemianopsia and was found to have a right occipital stroke. MRA was suggestive of a DAVF, and a six-vessel diagnostic angiogram was performed to verify and characterize the lesion. The angiogram revealed a DAVF with feeders from the right ECA circulation into the right transverse sinus (small arrows, Figure 1). The right transverse sinus filled in retrograde fashion, as did some occipital cortical veins (large arrow, Figure 1). The right sigmoid sinus and internal jugular vein were occluded. The decision was made to treat the lesion given the fact that retrograde cortical venous filling is associated with increased risk of future hemorrhage. Treatment options for DAVFs: Endovascular Surgical

A.â•… B.â•… C.â•… D.â•… E.â•…

Obliteration of the involved sinus Obliteration of arterial feeders Combination of A and B Revascularization of proximal sinus occlusion Placement of a covered stent in the sinus

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The treatment chosen was transverse sinus embolization. The arterial feeders were thought to be too numerous to embolize. Â�Moreover, there is a significant chance of recurrence with treatment of the feeders only. The venous thrombosis proximal to the lesion was thought to be too extensive for any revascularization procedure.

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Proc e du r e :â•‡ A 5-F sheath was placed in the right CFA and a 5-F DAV catheter was positioned in the right ECA (thin black arrow, Figure 2A). A 6-F sheath was placed in the left CFV and an MPC-Envoy guide catheter was advanced into the proximal segment of the left internal jugular vein (thick black arrow, Figure 2A). Next, a 2.3-F Prowler Plus microcatheter was advanced through the guide catheter into the right transverse sinus via the left sigmoid and transverse sinuses (white arrow, Figure 2A). GDC coils with sizes ranging from 2 mm 3 4 cm to 6 mm 3 20 cm were deployed serially. Right ECA injections were performed after eachâ•¯coil was detached, to check flow into the right transverse sinus. Complete obliteration of the transverse sinus was achieved after 31 coils were placed, at which point the procedure was terminated (Figure 2B, the arrow is pointing at the coil mass). Follow-up angiogram two months later confirmed persistent occlusion of the right transverse sinus (Figure 2C).

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CASE 116 • Transvenous embolization of a dural arterio-venous fistula S t a n l ey H . K i m , M D BACKGROUND:â•‡ A 50-year-old man presented with worsening headache and pulsatile tinnitus. He had been involved in a motorcycle accident from which he had sustained a large right temporal scalp laceration and a contusion. No vascular imaging hadâ•¯been performed at the time of the injury.

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D i ag n o st i c a n g i o g r a m : Figure 1.â•‡ Right ICA injection, lateral projection. There is shunting to the transverse sinus from a large meningohypophyseal artery (arrow). Figure 2.â•‡ Right VA injection, lateral projection. Multiple abnormal muscular branches are seen shunting blood to the transverse-sigmoid junction. The direction of flow in the shunts is indicated by the arrows. Early opacification of the sinuses and the internal jugular vein is seen. Figure 3. A and B.â•‡ Left VA injection, intracranial AP (A) and lateral (B) projection. Multiple vessels that seem to be arising from the right PCA shunt blood to the transeverse sinus. The black arrows indicate the direction of flow. Figure 4.â•‡ Right ECA injection, oblique projection. The IMAX, superficial temporal, and occipital arteries all send off branches that shunt into the proximal internal jugular vein-sigmoid sinus area.

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The left occipital artery also had fistulous connections to the right sigmoid sinus. The left ICA did not contribute to the DAVF.

CASE 116 • (continued) Pr o c e du r e :â•‡ Given the multitude of fistulous connections originating from a number of different vessels, it was thought that obliteration of the sinus was the only feasible treatment. The procedure was performed under conscious sedation. Intravenous heparin (7000 units) was administered to achieve an ACT value of 320 seconds. A 6-F sheath was placed in the right femoral vein and a 6-F Envoy catheter was advanced to the right internal jugular vein near the jugular bulb. An SL-10 microcatheter was passed over a 0.014-inch microwire to the distal right transverse sinus just proximal to the torcula (Figures 5 A and B). A 5-F sheath was placed in the left CFA and a 5-F diagnostic catheter was positioned in the right CCA. Control right CCA injections were performed regularly to visualize the fistulous connections and the sinuses. The first coil that was delivered into the transverse sinus was a Matrix 360 standard 8 mm 3 30 cm SR (Figure 6). Then, using a combination of 360-degree coils and helical coils, 42 more coils were placed along the transverse and sigmoid sinus, reaching into the proximal internal jugular vein (Figure 7). Post-coiling runs confirmed absence of fistulous connections to the sinuses with some mild residual shunting to the internal jugular veins.

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Figure 5. A and B.â•‡ Microcatheter run, lateral (A) and AP (B) projection. The microcatheter is positioned in the transverse sinus. The arrow shows the position of the guide catheter. Figure 6.â•‡ Right CCA injection, lateral projection. Figure 7.â•‡ Right ECA injection, late arterial phase, AP projection. There is some residual shunting to the internal jugular vein, but none to the sinuses. Figure 8.â•‡ Right ECA injection, mid-arterial phase, lateral projection. Some diminished shunting to the internal jugular vein is seen.

Figure 9.â•‡ Left VA injection, lateral projection. No fistulous connections are seen. Figure 10.â•‡ Right ICA injection, AP projection. The meningohypopyseal artery is no longer visualized.

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CASE 117 • Transarterial embolization of a dural arterio-venous fistula Osama O. Zaidat, MD, John R. Lynch, MD, Thomas Wolfe , MD, Brian-Fred Fitzsimmons, MD B AC KGRO U N D :â•‡ A 2-year-old boy presented with a right retro-auricular pulsating mass and ringing in his right ear. Â�Subsequently, his family noted falling to the left side and imbalance. MRA was suggestive of a DAVF. A six-vessel diagnostic Â�angiogram was performed. The angiogram revealed a DAVF with an enlarged right occipital artery as its main feeder and dural branches from the right VA going into the right sigmoid sinus directly and via the occipital artery (see Figure 1D). Notice the impingement at the fistula site as the arteries are entering the skull (Figures 1 A and C). The right sigmoid and transverse sinuses filled in retrograde fashion. The distal right sigmoid sinus and internal jugular vein were occluded. The decision was made to treat the lesion given the fact that the patient was likely having ischemia related to steal.

ICA

OCC

1A

LIJ

1B

1C

1D

Figure 1.â•‡ A and B.â•‡ Right CCA run, oblique projection, early (A) and late (B) arterial phase. B. The arrow shows the direction of flow in the right transverse sinus with drainage into the left internal jugular vein. C. Right CCA run, lateral projection. The black arrows in 1A and 1C point to an area of impingement at the point of entry into the skull. D. Right VA injection, oblique projection. Arising from the right VA, there are direct feeders (thin arrow) and vessels that feed into the right occipital artery (thick arrow) via vertebro-occipital anastomoses. A–D. Notice lack of filling of the right distal sigmoid sinus and internal jugular vein. OCC, occipital artery; LIJ, left internal jugular vein. It was chosen to perform right occipital artery embolization distal to the entry of the vertebro-occipital anastomosis with entrapment of the fistula site proximal to the entry in the skull. The narrowing at the site of entry into the skull was used to our advantage as a scaffold to keep the coils and glue in place. This DAVF was ideal for a trans-arterial treatment approach because of the limited number of feeders, most of which eventually merged into the enlarged right occipital artery. Pr o c e du r e : An Excelsior SL-10 microcatheter was advanced through a 4-F guide catheter under fluoroscopic and road-map guidance over a Synchro 14 microwire into the distal right occipital artery. GDC and Matrix coils were detached at the fistula site followed by NBCA embolization at 40% concentration. There was complete obliteration of flow into the fistula as noted in Figure 2 with improved rCBF post procedure.

2A

2C

2B

2D

Figure 2.â•‡ A–D. Post-treatment images. No residual filling of the DAVF is seen. A and B. Right CCA run, AP (A) and lateral (B) projection. The black arrow points at the coil mass. There is no filling of the occipital artery past the point indicated by the white arrow. C. Right CCA run, AP projection, unsubtracted. The arrow points at the coil mass. D. Right VA injection, oblique projection. The arrow points at the coil mass. Outc o m e : There was spontaneous resolution of the patient’s symptoms and of the right retro-auricular pulsatile mass, with persistent improvement on follow-up at 6 months post-procedure. 178

CASE 118 • Stenting of the draining sinus of a dural arterio-venous fistula Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD B ackg r o u n d :â•‡ An 85-year-old woman underwent a diagnostic cerebral angiogram in the setting of a work-up for atypical ICH. The angiogram revealed a DAVF with feeders from the right occipital (OCC, Figure 1) and superficial temporal arteries (STA, Figure 1) into the right sigmoid sinus (Figure 1, the arterial feeders are highlighted in rectangles). There were no feeders from the posterior or left anterior circulations. There was no retrograde venous flow, and all sinuses were patent. The decision was made to treat the DAVF by blocking the arterial feeders with a covered stent in the sigmoid sinus. Pr o c e du r e : A 5-F sheath was placed in the left CFA and a 5-F DAV catheter was positioned in the right ECA. Next, a 6-F sheath was placed in the right internal jugular vein and a V-18 wire was advanced into the right transverse sinus. A Fluency Plus 8 3 40 mm covered stent was advanced over the wire into the sigmoid sinus. Multiple right CCA injections were obtained to confirm placement of the stent proximal to the vein of Labbé prior to deployment (Figure 2). The stent was then deployed, and right ECA injections showed no further filling of the sigmoid sinus (Figure 3). The vein of Labbé was spared and venous outflow was normal on right ICA injections (Figure 4).

Internal Jugular Vein 1

2

3

4

Figure 2.â•‡ Right CCA injection to guide stent placement. The thin white arrow points at the V-18 wire. The thin black arrow shows the stent. Thick white arrow: vein of Labbé. Figure 3.â•‡ Right ECA injection after stent deployment. There is no filling of the sigmoid sinus. Figure 4.â•‡ Right ICA injection after stent deployment. The thick white arrow points at the vein of Labbé. The black arrows show the proximal and distal ends of the stent.

179

CASE 119 • Dural arterio-venous fistula not amenable to endovascular treatment Stanley H. Kim, MD, Anant Patel, MD B AC KGRO U N D :â•‡ A 55-year-old man presented with progressive severe left occipital headache and right peripheral visual deterioration of 1-week duration. The previous year, he had been hit on the head near the left eye by a football and had occipital headaches since then. CT scan revealed some vague hyperdensity in the left occipital region. MRI showed flow-void signals in the left occipital region suspicious for an AVM (Figure 1, A and B). The patient was referred for angiography.

1A

1B

Figure 1.â•‡ A and B. T2-MRI, axial (A) and coronal (B) images. Areas containing abnormal flow voids are highlighted. The arrows point at a large draining vein. Pro c e du r e :â•‡ Selective right and left ICA injections revealed no evidence of AVM (not shown). Selective right ECA injections showed a DAVF along the occipital posterior falx with arterial supply from the right posterior middle meningeal artery (Figure 2B) and right occipital artery branches that penetrated through the skull (Figure 2, C and D). No evidence of venous drainage into the sagittal sinus was visualized. Selective left ECA injections revealed similar arterial supply from the left posterior middle meningeal artery and left occipital artery branches to the DAVF along the occipital posterior falx (Figure 2E).

2A

2B

2C

Figure 2. A. Aortogram. All four great vessels arise separately from the arch. B. Right ECA injection, oblique projection. The arrows trace a meningeal branch that arises from the IMAX and feeds into a cortical vein. The circle highlights the arterio-venous junction. OCC: occipital artery; STA: superficial temporal artery C. Selective right occipital artery injection, oblique projection. A branch of the occipital artery (open arrow) feeds into the vein (arrow, arterio-venous junction). D. The white arrows point at a branch that arises from the occipital artery, runs through the skull, and feeds into the fistula. The black arrow points at the arterio-venous junction.

2D

180

CASE 119 • (continued) E.â•‡Left ECA injection, lateral projection. Three vessels converge together at the point indicated by the arrow. One vessel originates from the occipital artery, and two vessels (open arrows) arise from the middle meningeal artery. The vein is not visualized in this projection.

2E

Attempts to inject NBCA via a microcatheter in the right posterior middle meningeal artery were unsuccessful because of inability to navigate the microcatheter to a position close enough to the DAVF site. Treatment of the venous drainage was not feasible because the cortical vein was not accessible. The procedure was aborted and the patient underwent bilateral occipital craniotomy. Exploration of the left side of the posterior occipital falx showed a 1-cm thick dural vessel coming out of the left side of the falx about 3 cm below the sagittal sinus and connecting to cortical veins in the left medial occipital cortex. This vessel was ligated with multiple titanium clips. The patient tolerated the procedure well. Immediately after surgery, he noted resolution of the headache and improvement of right peripheral vision. Postoperative MRI showed no flow-void signals in the left occipital lobe (Figure 3B). Postoperative selective right (Figure 4A) and left (Figure 4B) ECA injections confirmed obliteration of the DAVF.

3A

4A

3B

4B

Figure 3. A. Postoperative CT scan (bone window shown) shows the clips in left para-falcine position (arrow). B. Postoperative MRI. No more flow voids are seen. Figure 4.â•‡ A and B. Postoperative angiography, right (A) and left (B) ECA injections. There are no abnormal findings. Outco m e : â•‡ The patient was discharged home 5 days after the craniotomy and was able to return to work in 2 months. His symptoms resolved completely. C o n c lus i o n :â•‡ DAVFs associated with cortical venous drainage have a high incidence of ICH and should be treated. Because there can be multiple tortuous arterial feeders and the cortical veins are not accessible, endovascular treatment of these AV fistulas is not always feasible. In such cases, surgery can lead to excellent angiographic and clinical outcomes.

181

CASE 120 • Dural arterio-venous fistula treated with Onyx and coil embolization M. Fareed K. Suri, MD, Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD B AC KGRO U N D :â•‡ A 46-year-old man was found down. CT scan showed ICH with intraventricular hemorrhage (Figure 1, A and B). After placement of a ventriculostomy, diagnostic angiography was performed. This demonstrated a DAVF with feeders from the left occipital artery and posterior branch of left middle meningeal artery. There was no contribution from the intracranial circulation.

1A

1B

V1

6

Figure 2.â•‡ Diagnostic angiography. A. Left ECA injection, lateral projection. B. Left occipital artery injection, oblique projection. The block arrow points at the catheter tip.

3

2 5 7

4 1

2A

VEIN OF GALEN STRAIGHT SINUS

V1

V2 V2

V2 4

2B

182

1. ECA 2. Middle meningeal artery (the thick black arrow points at the site where the artery traverses the foramen spinosum) 3. Superficial temporal artery 4. Occipital artery 5. IMAX 6. Infraorbital artery 7. Descending palatine artery V1. First draining vein (drainage to the vein of Galen and the straight sinus) V2. Second draining vein (drainage to the left transverse sinus, not shown) White dots. Middle meningeal artery feeders Black dots. Occipital artery feeders Red dots. Microcatheter positions prior to embolization White arrows. Aneurysmal (arterial) dilatations Black arrows. Variceal (venous) dilatations

CASE 120 • (continued) Pr o c e du r e , S tag e 1:â•‡ A 100-cm 6-F Envoy MPD guide catheter was placed in the left ECA distal to the origin of the occipital artery. A Marathon 1.3-F microcatheter was advanced over a Mirage 0.008 inch microwire into the parietal branch of the left middle meningeal artery . The microcatheter was placed as far distally as possible in one of the feeders and prior to embolization, the image intensifiers were positioned so that no overlap occurred between the arterial and venous pathways. After the dead space of the microcatheter (0.23 mL) was filled with DMSO, Onyx was injected at a rate of 0.1 mL/min. The Â�microcatheter was then pulled back and further embolization was performed from a more proximal site. The two larger feeders were completely obliterated, as were the aneurysms. A third smaller feeder could not be catheterized, but its contribution to the DAVF was minimal.

3B

3A

3C

Figure 3. A. Microcatheter injection, left middle meningeal artery, oblique projection. The two open arrows point at the microcatheter positioning prior to the two embolizations. B. Unsubtracted image, lateral projection, post distal embolization. The arrows point at the microcatheter. The Onyx cast is highlighted in a circle. C. Left ECA injection, lateral projection, post both embolizations. A cut-off is seen in the posterior middle meningeal artery branch (white arrow). A small feeder (black arrow) could not be embolized, but has only minimal contribution to the DAVF.

Pr o c e du r e , S tag e 2 :â•‡ The guide catheter was positioned more proximally, and the microcatheter was advanced into the occipital artery. Because of excessive tortuosity of the main feeder, the microcatheter could not be advanced further (microcatheter position is indicated by the open arrow in Figure 4A). Embolization with Onyx-18 was performed but did not lead to obliteration of the feeder. It was therefore decided to occlude the occipital artery proximal to the origin of the feeders by means of coil embolization. An SL-1018 microcatheter was advanced over a Transend 14 microwire into the occipital artery and two 3 3 30 mm Berenstein liquid coils were deployed. The proximal and distal ends of the occluded segment are marked with “C” in Figure 4A. A final left ECA run (Figure 4B) showed no filling of the DAVF.

LEFT OCCIPITAL ARTERY INJECTION, LATERAL PROJECTION

C

C

4A

183

4B

CASE 121 • Orbital arterio-venous fistula treated with transvenous coil embolization Thanh Nguyen, MD, Mostafa Mahmoud, MD, Daniel Roy, MD, Francois Guilber t, MD, Jean Raymond, MD, Alainâ•¯Weill , MD B AC KGRO U N D :â•‡ A 53-year-old man presented with a 2-month history of diplopia, right eye exophthalmos, chemosis, and proptosis. CT scan revealed a hypervascular mass in the right inferior orbital fissure (Figure 1A).

Figure 1. A. Coronal CT scan of the orbit shows enlargement of the right inferior ophthalmic vein (arrow). B. Axial CT images showing significant proptosis of the right eye (arrow).

1B

1A

2A

Figure 2. A and B.â•‡ Right CCA injection, lateral projection, early (2A) and late (2B) arterial phase. A. The main supply to the fistula is through the IMAX (white arrow) and the ophthalmic artery (black arrow). B. Early drainage into an an engorged inferior ophthalmic vein (arrow) is seen.

2B

Pr o c e du r e : â•‡ Under general anesthesia, 5-F and 7-F sheaths were placed in the left CFA and right CFV, respectively. To enhance catheter navigation stability, a triaxial catheter system was used with a 7-F guide catheter placed in the right inferior petrosal sinus, a Tracker 38 catheter (Boston Scientific, Natick MA) in the right cavernous sinus, and a microcatheter that was navigated to the fistula site in the inferior ophthalmic vein (Figures 3 A and B). The venous pouch was embolized with four GDC coils, at which point angiographic obliteration was achieved (Figure 3E).

184

CASE 121 • (continued)

3A

3B

3C

3D

Figure 3.â•‡ A through E. A. Microcatheter (arrow points at the microcatheter tip) injection into the inferior ophthalmic vein, lateral projection. B. Right ECA road-map. The microwire can be seen at the site of the fistula (arrow). C, D, Lateral unsubtracted views after partial (C) and complete (D)â•¯embolization. E. Right CCA injection, lateral projection post-embolization. No filling of the fistula is observed. Outc o m e :â•‡ At 1-month follow-up, complete resolution of the patient’s exophthalmos, chemosis, and diplopia was noted.

3E

References: Deguchi J, Yamada M, Ogawa R, Kuroiwa T. Transvenous embolization for a purely intraorbital arteriovenous fistula. â•›J Neurosurg 2005; 103: 756–759. Caragine LP, Halbach VV, Dowd CF, Higashida RT. Intraorbital arteriovenous fistulae of the ophthalmic veins treated by transvenous endovascular occlusion: technical case report. Neurosurgery 2006; 58: (1 Suppl): ONS–E170. Wolter JR. Arteriovenous fistulas of the eye region. Trans Am Ophthalmol Soc 1974; 72: 253–281.

185

CASE 122 • Carotid-cavernous fistula treated with transvenous and trans-arterial embolization Osama O. Zaidat, MD, Thomas Wolfe , MD, John R. Lynch, MD, and Brian-Fred Fitzsimmons, MD B AC KGRO U N D :â•‡ A 63-year-old woman with history of intractable right trigeminal neuralgia underwent percutaneous transfacial/transovale surgical decompression of the trigeminal nerve. Two days later, she noticed right eye congestion, redness, progressive loss of vision, and a wooshing sound in her right ear. The patient was referred for angiography. Her ipsilateral visual acuity had diminished to 20/200.

1. Right cavernous sinus 2. Left cavernous sinus 3. Inferior petrosal sinus

1. Superior ophthalmic vein 2. Inferior petrosal sinus 3. Pterygoid plexus

2

3 1 1 2 3

1A

1B

Figure 1.â•‡ A and B.â•‡ Right ICA injection, AP (A) and lateral (B) projections. Figure 1. A and B. Right ICA injection, AP (A) and lateral (B) projections. Figure 1. C and D. Right ICA injection. Working position, AP-oblique (C) and lateral-oblique (D) projections.

1. Right cavernous sinus 2. Inferior petrosal sinus, retrograde 3. Inferior petrosal sinus, antegrade

There is an abnormal fistulous connection Â�originating in the cavernous ICA and draining into the ipsilateral and contralateral cavenous sinus, into the superior ophthalmic vein, into the inferior petrosal sinus (in antegrade and Â�retrograde fashion), and into the pterygoid plexus. The site of the ICA lesion is marked in 1C and 1D.

1

2

LESION

LESION 3 1C

1D

Treatment options for this carotid-cavernous fistula include the following: • Obliteration of arterial feeders • Obliteration of the involved venous drainage routes • A combination of the above • Balloon test occlusion of the ICA, followed by sacrifice of the vessel • Placement of a covered stent across the site of the arterial lesion • Bypass surgery followed by sacrifice of the ICA The decision was made to perform trans-arterial coil embolization. However, because of microcatheter instability, it was not Â�technically feasible to deploy enough coils from the arterial route. Further coils were then deployed transvenously. Following coil embolization, the flow in the fistula had slowed down but was not abolished. Embolization was then performed trans-arterially with highly concentrated NBCA. This led to complete cessation of flow in the fistula. 186

CASE 122 • (continued) Arterial approach

Venous approach COIL MASS

2A

2B

3B

3A

Figure 2.â•‡ A and B. Intra-procedure right ICA injections, AP-oblique projections. B is unsubtracted. A. Trans-arterial embolization. The microcatheter markers are indicated by the white arrows. The microcatheter goes through the ICA perforated segment into the petrosal sinus (black arrows). B. Transvenous embolization. The guide catheter is seen in the petrosal sinus (arrow). The coil mass is highlighted in a circle. Figure 3.â•‡ A and B.â•‡ Post-procedure right ICA injection, AP (A) and lateral (B) projections. No flow is seen in the fistula. Pr o c e du r e : â•‡ A 6-F sheath was placed in the right CFA and a 5-F sheath was placed in the left CFV. A 5-F guide catheter was placed in the right inferior petrosal sinus via the sigmoid sinus. A 6-F guide catheter was placed in the right ICA and an SL-10 microcatheter was passed through it into the intracranial ICA over a Synchro 14 microwire. The microcatheter was advanced through the ICA into the petrosal and cavernous sinuses (see Figure 2A). Subsequently, a combination of GDC and Matrix 2 coils were deployed until it was no longer possible to maintain the microcatheter position. A Renegade microcatheter was then advanced over a Transend 14 microwire through the venous guide catheter into the petrosal sinus and further coils were deployed. At that time, it was felt that the flow in the fistula was sufficiently slow to allow for NBCA embolization aiming at complete flow obstruction. Highly concentrated (60%) NBCA was injected through the arterial microcatheter. Complete obliteration of flow was achieved (see Figure 3, A and B). Outco m e : â•‡ The patient’s complaints resolved. Her vision improved to 20/60.

187

CASE 123 • Spontaneous thrombosis of a vein of Galen malformation Qaisar A. Shah, MD, Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD B AC KGRO U N D :â•‡ A 3-month-old boy presented with hydrocephalus and was diagnosed with a vein of Galen malformation by MRI. The patient did not develop signs of congestive heart failure, but a follow-up MRI suggested enlargement of the malformation. It was therefore decided to proceed with endovascular treatment. The child was 9 months old at the time.

Figure 1. A and B. Initial MRI, axial T2-sequence (A), and sagittal T1-sequence post gadolinium (B). There is a large, homogeneously enhancing mass in the region of the vein of Galen. Severe hydrocephalus is apparent.

1B

1A

2B

2A

2C

Diagnostic angiography failed to reveal a patent vein of Galen malformation. The presumption that the malformation had thrombosed was confirmed by MRI. Figure 2.â•‡ A–C.â•‡ Left VA injection, AP projection, early (A), mid- (B), and late (C) arterial phase. The black arrow points at a choroidal branch of the right PCA, which fills very slowly and appears to be thrombosed distally. Mass effect caused by the thrombosed malformation is displacing the arteries noticeably. In 2C, the outline of the mass can be made out (white arrows). Figure 3.â•‡ Right PCA, microcatheter injection, AP projection. The same distally occluded artery can be seen (arrow). This was presumably the main feeder. Again, no filling of the malformation is noted. 3

Figure 4.â•‡ A and B.â•‡ Post-angio MRI, axial FLAIR (A), and sagittal T1 post gadolinium (B). The malformation is now thrombosed. The age of the clot was estimated at 1 to 3 weeks.

4A

4B

188

CASE 124 • C ervical arterio-venous fistula treated with trans-arterial and transvenous embolization

Alexandros L. Georgiadis, MD, Jawad F. Kirmani, MD B ackg r o u n d :â•‡ A 25-year-old-man presented with neck swelling after sustaining a knife injury to the neck. On examination he was found to have a left submandibular bruit .

LEFT EJ

EJ: External jugular viein

1

2A

PRO C E D U RE , S TAGE 1: â•‡ Arch Â�injection (20-degree LAO) showed a large, early-filling vein. (Figure 1). The left CCA was catheterized, and frontal (Figure 2A) and lateral (Figure 2B) images were obtained. Those images demonstrated fistulous connections between ECA branches and the external jugular vein with an interposed aneurysm. No fistulous connections from the ICA were visualized. Intracranial views after CCA injection revealed globally significantly reduced intracranial perfusion of the ICA territory (Figure 2C, circle). Next, the ICA was catheterized. Intracranial views obtained after ICA injection showed normal ICA territory perfusion, thus confirming that the hypoperfusion noted on CCA injection was due to steal into ECA territory. The ECA was catheterized. Injection at the level of the origin of the facial and occipital arteries showed multiple fistulous connections and produced good filling of the pseudoaneurysm. Injection of the occipital artery revealed no abnormal findings. The decision was made to occlude the ECA with coils beyond the origin of the occipital artery.

2B

2C

OCCIPITAL FACIAL

LINGUAL 3A

3B

3C

Figure 3.â•‡ A through C. Injections into the left proximal ECA, lateral views. A microcatheter was inserted and placed in the ECA proximal to the designated point of occlusion and three matrix coils were serially deployed. A. One coil has been placed (thick arrow). The thin arrow points at the tip of the microcatheter. B. Two coils have been deployed. The aneurysm is filling. C. Three coils have been deployed and the ECA is occluded, but the aneurysm is still seen filling.

189

CASE 124 • (continued)

4A

4B

FACIAL ARTERY SUP DIVISION

5B INF DIVISION

Next, a selective injection of the superior Â�division of the facial artery was performed; it showed filling of the pseudoaneurysm (Figure 4A). The artery was then embolized with embospheres sized 300 to 500 μm. This led to the complete obliteration of the connecting pathways (Figure 4B, the arrow is indicating the position of the tip of the microcatheter). Subsequently, a guide catheter injection was performed (Figure 5A). This showed filling of the pseudoaneurysm through the inferior branch of the facial artery (Figure 5A, the arrows indicate the direction of flow from theâ•¯facial artery into the pseudoaneurysm). The inferior facial artery was embolized with two liquid coils and one matrix coil, leading to complete obliteration of the vessel (Figure 5B, the arrows are pointing at the coil mass, the points of occlusion of the two branches of the facial artery are encircled. Note that the Â�superior division is occluded more proximaly now). The microcatheter was removed and the guide catheter was positioned in the CCA. A CCA injection was performed, and it showed some filling of the aneurysm. The guide catheter was positioned in the ICA and additional images were obtained (Figure 6, A and B). The ophthalmic artery was filling the IMAX in retrograde fashion, and the IMAX subsequently filled the pseudoaneurysm (Figure 6B, arrow). The arrows in Figure 6A show the direction of flow into the IMAX).

5A

LEFT CCA INJECTION, LATERAL PROJECTION

LEFT CCA INJECTION, LATERAL PROJECTION, EARLY ARTERIAL PHASE

OPHTHALMIC â•›A.

ANASTOMOTIC BRANCHES

imax

INTERNAL MAXILLARY A.

6B

6A

At this stage, the procedure was terminated. The patient was scheduled to return for follow-up angiogram and possibly intervention in 2 days.

190

CASE 124 • (continued) Proc e du r e , Stag e 2 :â•‡ The patient returned as scheduled 2 days later. A 6-F sheath was placed in the right CFA, a 6-F MPD Envoy catheter was advanced to the aortic arch, and an aortogram was performed (Figure 7). The early filling of the left external jugular vein was no longer noted. The catheter was then advanced into the left ICA. Figure 8A shows a late arterial left ICA injection in frontal projection. Figure 8B explains the anatomy and flow pattern of the AV fistula and the interposed aneurysm. A 6-F sheath was placed in the left CFV and a 6-F MPC Envoy catheter was advanced into the left internal jugular vein (Figure 9A). Figure 9B shows an internal jugular vein injection in AP projection. There are no abnormal fistulous connections. The catheter was then positioned in the external jugular vein (Figure 9C). An SL-10 microcatheter was advanced over a Transend 14 floppy microwire into the external jugular vein, with the goal of engaging the pseudoaneurysm in order to perform coil embolization (Figure 9C). The pseudo-aneurysm was selected, and Matrix 2 coils were deployed (Figure 10 A). After the pseudo-aneurysm was obliterated, coils were placed in the proximal end of the venous outlet. However, ICA images still showed filling of the left external jugular vein via the fistula (Figure

Aortogram

7

10B). Next, the superior vein was obliterated with coils, but again, ICA injections showed persistent external jugular vein filling (Figure 10C). Finally, the inferior vein was obliterated along with a small segment of the external jugular vein. The final ICA injection revealed no flow into the external jugular vein (Figure 10D).

8A

EJ: External jugular viein

8B

Figure 8.â•‡ A and B. A. Left ICA injection, late arterial phase, AP projection. B. Schematic representation of arterial (red arrows) and venous flow (blue arrows). There are two main veins that feed into the left external jugular vein.

VENOUS CATHETER

ARTERIAL CATHETER

9A

9B

9C

SUPERIOR VEIN

EJ 10D

INFERIOR VEIN EJ: External jugular viein

10A

10B

10C

191

CASE 125 • Spinal dural arterio-venous fistula treated with Onyx embolization Raul G. Nogueira, MD, Johnny C . Pr yor, MD

1B

1A

EARLY ARTERIAL PHASE

B AC KGRO U N D : â•‡ A 78-year-old man presented with a 5-year history of progressive low back pain as well as right-greater-thanleft leg weakness and numbness. He was initially diagnosed with spinal stenosis and underwent lumbar laminectomy. He had temporary improvement but the symptoms subsequently returned with worsening weakness to the point that he was no longer able to walk or stand up on his own. He also reported urinary frequency, urgency, occasional incontinence and constipation. Spinal MRI showed a T2-hyperintensity involving the lower spinal cord and abnormal flowvoids suggestive of a spinal DAVF (arrow, Figure 1A). Spinal MRA confirmed the presence of a DAVF in the lumbar area (Figure 1B).

LATE VENOUS PHASE

2C

2A

Figure 2.â•‡ A–C. Spinal angiography revealed a spinal DAVF supplied by the left L2 segmental artery branches draining through a large radiculomeningeal vein (arrow, Figure 2A) and then to the coronal-pial venous plexus (arrow, Figure 2B) with significant venous hypertension. The decision was made to treat the lesion endovascularly. The arrow in Figure 2C shows the position of the microcatheter.

2B

Pr o c e du r e : A guide catheter (5-F Cook Cobra-2) was placed in the left L2 segmental artery. A Marathon microcatheter was navigated over an XPedion 10 wire to a point just proximal to the fistula (arrow, Figure 2C).

3A

3B

Onyx-18 and DMSO were drawn up in 1 mL syringes. The microcatheter was then flushed with 5 mL of normal saline. The dead space of the microcatheter was subsequently filled with 0.24 mL of DMSO. Onyx-18 was then slowly injected by hand, so that the DMSO was displaced over the course of 90 seconds. Under continuous Â�fluoroscopic guidance, the Onyx was then injected into the fistula using a “thumb-tapping” technique. When the embolic agent flows antegrade, the injection can be continued until complete obliteration of the lesion is achieved. Almost invariably, however, some reflux will take place. This typically leads to the formation of a “plug,” which may subsequently facilitate antegrade flow of the embolic agent. Reflux into arteries supplying neural tissue should not be allowed, and long segmental reflux should be avoided as it may make the microcatheter removal more difficult. This technique was used to fill the several small fistulous channels and the proximal radiculomedullary vein. Final angiography (Figure 3A) confirmed complete occlusion of the fistula by a dense Onyx cast (Figure 3B, unsubtracted).

192

CHAPTER 6

Treatment of Tumors

1A

1B

2A

2B

Figure 1.â•‡ A and B. Carotid body tumor, (A) pre- and (B) post-embolization. Figure 2.â•‡ A and B. Meningioma, (A) pre- and (B) post-embolization.

193

OVERVIEW OF CASES

TREATMENT OF TUMORS

CASES 126–136

Meningioma

Case 126

Embolization with particles

Case 127

Embolization with particles Dangerous anastomotic pathways Angiographic evaluation of meningiomas

Case 128

Meningioma not amenable to endovascular treatment Meningeal arteries arising from the ophthalmic arteries

Paraganglioma

Case 129

Carotid body tumor treated with coil and particle embolization Common locations and presenting symptoms of paragangliomas

Case 130

Carotid body tumor treated with Onyx embolization Overview of anterior to posterior circulation connections

Case 131

Jugular foramen tumor treated with particle embolization Intra-arterial administration of nicardipine prior to embolization

Juvenile nasopharyngeal angiofibroma

Case 132

Embolization with particles

Case 133

Embolization with particles Characteristics of juvenile nasopharyngeal angiofibromas

Choroid plexus papilloma

Case 134

Embolization with N-butyl-cyanoacrylate

Hemangioblastoma

Case 135

Embolization with particles Von Hippel–Lindau disease Treatment options for hemangioblastomas

Metastatic vertebral body tumor

Case 136

Embolization with particles

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CASE 126 • Meningioma embolization with particles Stanley H. Kim, MD B ac kg roun d :â•‡ A 69-year-old woman presented with new-onset tonic-clonic seizures. MRI revealed a right sphenoid-wing meningioma (Figure 1). Two days prior to surgical resection, the patient underwent selective right ECA angiography that revealed a vascular blush of the tumor supplied by the middle meningeal artery. Selective embolization followed.

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Figure 1.â•‡ Axial T1-MRI with gadolinium. A homogeneously enhancing mass (arrow) with a dural tail (open arrow) is seen. Figure 2.â•‡ A and B. Right ECA injection, AP (A) and lateral (B) projection. A tumor blush is seen (circle). The feeding artery is the middle meningeal artery (arrow, 2A) originating from the IMAX. Proce d ure :â•‡ The procedure was performed under conscious sedation. A guide catheter was parked in the ECA and a microcatheter was advanced into the middle meningeal artery under road-map guidance. Microcatheter injections identified the tumor blush (Figure 3, A and B). Prior to embolization, a neurologic examination was performed. This was followed by provocative testing in two stages. First, 2 mL of 1% lidocaine solution were injected through the microcatheter into the distal middle meningeal artery just proximal to the tumor region. Neurologic assessment showed no cranial nerve or other neurologic deficits. Subsequently, 5 mg of Brevitol were injected through the microcatheter; the patient was examined again and found to have no neurological deficits. PVA particles (45 to 150 μm, Contour, Boston Scientific) were then injected through the microcatheter under fluoroscopy to ensure that the particle solution was delivered to the tumor site with no retrograde flow. Final selective right ECA runs showed absence of contrast staining of the tumor. The patient tolerated the procedure without complications and underwent surgical resection of the tumor 2 days later. Minimal bleeding was encountered during surgical exposure and resection of the tumor.

3A

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Figure 3.â•‡ A and B. Microcatheter injection into the middle meningeal artery, AP (A) and lateral (B) projection, shows the tumor blush. Figure 4.â•‡ A and B. Right ECA injection, AP (A) and lateral (B) projection, post-embolization. No tumor blush is visualized. C onc lus i on : Preoperative embolization of vascular brain tumors can often minimize blood loss and duration of the operative time for surgical resection. Other embolic agents that are used for tumor embolization include embospheres, microspheres, gelfoam powder, and metal coils.

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CASE 127 • Meningioma embolization with particles Thanh Nguyen, MD, Daniel Roy, MD, Francois Guilber t, MD B AC KG R O U N D :â•‡ A 43-year-old woman presented with 4 months of progressive headache. MRI revealed a right frontal meningioma (Figure 1, arrow). The patient was scheduled for embolization to be followed by surgical resection. Proce d ure : â•‡ A six vessel diagnostic angiogram was performed to identify the full vascular supply to the tumor. The only feeders identified were two branches of the right middle meningeal artery (Figure 2A). There was no connection between those branches and the ophthalmic artery. A microcatheter was placed in the right middle meningeal artery (Figure 2B, arrow indicates the position of the microcatheter tip). The microcatheter was advanced further (position 1, Figure 2B) and embolization was performed with particles sized 355 to 500 μm. A subsequent microcatheter injection showed collaterals that were diverting flow into the ophthalmic artery (arrows, Figure 2C). Therefore, the microcatheter was repositioned into the proximal middle meningeal artery branch (Figure 2D), to avoid embolization of particles into the orbital circulation. From this new position, further embolization with the same size particles was performed. The final angiographic result is shown in Figure 2E. The patient did well, suffering no neurological deficits. Angiographic evaluation of meningiomas: • Hypervascular tumor blush with centrifugal or radial pattern • Prolonged blush that persists into the late venous phase • Frequent tumor supply: middle meningeal artery, accessory meningeal artery, tentorial and inferolateral trunk. Infrequently, secondary pial supply from ACA, MCA, or PCA. • Retinal supply should be identified prior to embolization. • Venous drainage patterns should be identified

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Figure 1.â•‡ FLAIR MRI with hyperintense frontal mass (black arrow). Hyperostosis of the adjacent skull (white arrow) is seen.

Dangerous anastomoses middle meningeal artery recurrent meningeal artery ophthalmic artery Cavernous ICA inferolateral trunk maxillary artery Dangerous anastomotic connections are commonly present even if not angiographically visible, as in this case. Anastomoses can become angiographically apparent after embolization due to changes in flow dynamics.

Figure 2.â•‡ A through E, ECA (A) and middle meningeal artery (B–E) injections, lateral projection. A. Large tumor blush is visualized. The red dots marked with 1 and 2 indicate the position of the microcatheter during the first and second embolization, and they correspond with the dots in Figures 2B and D. The black dots indicate the later origin of anastomotic channels to the ophthalmic artery. B. The white arrow points at the microcatheter tip. The microcatheter was advanced to the position indicated by the red dot, to avoid embolization of the branch indicated by the black arrow. C. Anastomotic vessels (arrows) are seen originating from the middle meningeal artery (black dots) and filling the ophthalmic artery causing a retinal blush (circle). D. The microcatheter is repositioned (red dot) prior to the second embolization. E. Final image post-embolization. The tumor blush is greatly reduced.

CASE 128 • Meningioma not amenable to endovascular treatment Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD B ac kg roun d :â•‡ A 41-year-old woman was referred for tumor embolization prior to the scheduled resection.

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Figure 1.â•‡ T2 axial MRI shows a large meningioma (arrow) with surrounding edema. Figure 2.â•‡ ECA injection, lateral projection. No middle meningeal artery can be identified coming off the IMAX (arrow). Figure 3.â•‡ ICA injection, lateral projection. The ophthalmic artery (small arrow) gives of a large branch (long arrow), which supplies the tumor (tumor blush in circle). That branch is the middle meningeal artery.

In this patient, both middle meningeal arteries came off the ophthalmic arteries. Therefore, the meningioma could not be embolized.

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CASE 129 • Paraganglioma treated with coil and particle embolization Rishi Gupta, MD BAC KG RO U N D :â•‡ A 60-year-old woman presented with a pulsatile right neck mass and hoarseness of her voice. MRA revealed the presence of a right carotid body tumor. This finding was confirmed by conventional angiography (Figure 1, CCA injection).

Common locations and symptoms for paragangliomas: • Jugular foramen: Glomus jugulare; involvement of cranial nerves XI and XII • Carotid bifurcation: Glomus caroticum; painless pulsatile neck mass • Vagal body: Glomus vagale; neck mass; involvement of cranial nerve X • Middle ear: Glomus tympanicum; hearing loss, tinnitus Preoperative embolization can minimize surgical blood loss. Moreover, Â�diagnostic angiography can be used to assess collateral flow patterns in the event that Â�temporary carotid occlusion may be required during surgery.

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Proce d ure : Figure 2. A. Microcatheter injection into the occipital artery. A 6-F guide catheter (arrow) was placed in the ECA. A Rapid Transit microcatheter (Cordis) was then advanced into the Â�occipital artery (open arrow shows the tip of the microcatheter). Prior to embolization, 3 mL of lidocaine were injected through the Â�microcatheter to assess for possible neurological deficits (provocative testing). Embolization was performed with 300-μm Embospheres and was discontinued at the first signs of reflux. Subsequently, a 3-mm Tornado coil was deployed with the aim of occluding the occipital artery. B. Microcatheter injection into the ascending pharyngeal artery. The arrow points at the coil mass in the occipital artery. The microcatheter was placed in the ascending pharyngeal artery. Note the distal placement of the microcatheter along the odontoid arch (open arrow). Lidocaine provocative testing was again performed, followed by embolization with the same particles until reflux was noted. A 3-mm Tornado coil was deployed in the ascending pharyngeal artery following the embolization. Figure 3.â•‡ Right CCA injection, post-embolization. The vascular supply to the tumor has been greatly reduced. The residual supply arising from the superior thyroid artery (open arrow) was felt to be insignificant and was not embolized. The arrow points at the coil mass in the ascending pharyngeal artery. The patient underwent successful resection of the tumor with a total blood loss of 250 mL. Figure 4.â•‡ Tornado coils. The shape that these coils assume after deployment renders them particularly suitable for vessel occlusion in cases of AVM or tumor embolization.

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CASE 130 • Paraganglioma treated with Onyx embolization Randall C . Edgell, MD, Alan S. Boulos, MD B ac kg roun d :â•‡ A 59-year-old woman suffered from recurrent hemorrhage from the left ear. She had a history of mental retardation and a known large paraganglioma (glomus tumor) involving the left ICA. She was referred by an Otolaryngologist for palliative embolization. Previously, she had undergone left ICA sacrifice by means of coil embolization. The initial angiogram (Figure A) revealed a large tumor blush involving the carotid canal, petrous temporal bone, and extending into the neck. The distal ICA was occluded by the previously placed coils (closed head arrow). The ICA was occluded to prevent particle embolization into the ICA distribution. There was an arterial pouch proximal to the occluded segment (open arrow). The proximal ICA and ascending pharyngeal branches were the principal supply to the tumor (white arrow). A careful inspection for persistent connections between the anterior and posterior circulation was made (see below). Anterior-to-posterior circulation connections: ECA • Ascending pharyngeal artery to VA • Occipital artery to VA via musculospinal branches ICA • Trigeminal artery: most frequent (0.02%–0.6%). Arises from posterior genu of C4. Connects to basilar artery, 14% association with aneurysms Saltzman type I: supplies entire distal vertebrobasilar system Saltzman type II: fills the SCAs and PCAs supplied by Pcom arteries • Primitive otic: extremely rare • Hypoglossal (C1 to basilar): 2nd most common (0.027%–0.26%), exits at C1-C2. Proatlantal intersegmental (C1 to vertebral artery): exits at C2-C3 • Anterior choroidal arteries to lateral posterior choroidal arteries • Anterior temporal branch of MCA to anterior temporal branch PCA • Splenial branch of ACA to splenial branch of PCA

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A

ProceduRe: A 6-F 90 cm Cook Shuttle sheath was positioned in the left ICA. An Echelon 10 and Synchro 14 were used to microcathterize the arterial pouch (Figure B; top arrow). A 7 3 7 mm Hyperform balloon (bottom arrow) was inflated in the proximal ICA to slow the fistulus drainage of the tumor. Embolization commenced with Onyx-18 (ev3, Plymouth, MN) liquid embolic agent. The pouch was fully embolized (Figure C; open arrow), and the microcatheter was withdrawn to a more proximal position. Embolization of more proximal tumor vessel was performed. Next, several ECA branches supplying the tumor were embolized. The final Onyx cast is shown in Figure D. The final left CCA angiogram showed a dramatic reduction in tumor blush (Figure E).

E

CASE 131 • Jugular foramen tumor treated with particle embolization Qaisar A. Shah, MD, Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD B AC KG R O U N D :â•‡ A 37-year-old woman presented with progressive dysphagia and left tongue deviation. Work-up was suggestive of a left jugular foramen glomus tumor. She was referred for presurgical embolization.

Figure 1.â•‡ T1-axial MRI shows an enhancing mass (arrow) in the left jugular foramen region extending slightly along the dura near the clivus.

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Figure 2. A. Left CCA injection, lateral projection. A tumor blush is identified (black arrow). The main feeder (open arrow) seems to be arising from the occipital artery (white arrow). B. Left ICA injection, AP projection. The ICA does not contribute to the vascular supply of the tumor. C. Left ECA injection, lateral projection. Arrows as in Figure 2A. A microcatheter was passed into the left occipital artery. D. Left occipital artery microcatheter injection. The open arrow points at the feeder.

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Figure 4.â•‡ Left ECA run, lateral projection, post-embolization. Only minimal residual tumor blush (circle) is seen.

The feeder was then selected with the microcatheter and an injection was performed to verify correct placement (Figure 3). A solution consisting of 2 mL of normal saline and 0.5 mg of Nicardipine was then injected through the microcatheter into the tumor bed. The aim was to cause vasodilatation and maximize penetration of embolic material. PVA particles were injected. Control injections following embolization (Figure 4) showed minimal residual tumor blush. 200

CASE 132 • Juvenile nasopharyngeal angiofibroma embolization with particles Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD Bac kgroun d :â•‡ A 15-year-old patient with juvenile nasopharyngeal angiofibroma presented for preoperative embolization.

MMA: Middle menigeal artery

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1B

A 6-F Envoy MPD catheter was introduced into the left ECA. Figures 1A and 1B show a left ECA injection, lateral projection, in early and late arterial phase respectively. The abnormal hypervascularity that corresponds to the tumor is highlighted in a circle in Figure 1B. A Prowler Plus microcatheter was introduced over a Transend 14 microwire into the left ECA and was then advanced into the IMAX, past the origin of the middle meningeal artery (Figure 1A) and inferior alveolar artery.

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Figures 2A and B show a microcatheter run in early and late arterial phase, respectively. The arrow points at the microcatheter tip. The tumor blush is highlighted in a circle. From this position, embolization with a total of 3 mL of 150–300 μm embospheres was performed. Post- embolization runs showed significantly decreased vascularity of the tumor (Figure 3, circle). The tumor was removed endoscopically the following day.

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CASE 133 • Juvenile nasopharyngeal angiofibroma embolization with particles Thanh Nguyen, MD, Jean Raymond, MD, Alain Weill, MD B AC KG R O U N D :â•‡ A 17-year-old man presented with epistaxis and nasal obstruction. CT scan revealed a large hypervascular nasopharyngeal lesion with extension through the sphenopalatine foramen and pterygopalatine fossa (Figure 1).

Juvenile nasopharyngeal angiofibroma: • Benign tumor, highly vascular • Typical presentation in young males, with recurrent epistaxis • Frequent supply: IMAX branches, ascending pharyngeal artery. • These tumors frequently recur after surgery (in up to 60% of cases). Figure 1.â•‡ CT scan with hypervascular nasopharyngeal lesion, centered on the sphenopalatine foramen (arrow) with spread in the pterygomaxillary fossa. 1

Figure 2.â•‡ A–C. Lateral projections showing the tumor blush. A. Left ECA injection B, C. Microcatheter injections (arrows indicate the position of the microcatheter tip) into the left IMAX (B) and ascending pharyngeal artery (C). 2B

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Figure 3.â•‡ ECA injection (with reflux into the ICA) showing near complete devascularization of the nasopharyngeal tumor.

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Proce d u R e : Both ECAs were catheterized with a 5 F catheter. A hypervascular blush was seen in the region of the left nasopharynx (Figure 2A, B, C), with supply by the IMAX and ascending pharyngeal arteries. Selective catheterization with a microcatheter was followed by embolization with 150- to 250-micron particles. Post-embolization angiogram showed complete obliteration of the vascular supply of the tumor. The patient underwent surgical resection of the juvenile angiofibroma. Blood loss was 3000 mL and he was transfused 4 units of packed red blood cells.

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CASE 134 • Choroid plexus papilloma embolization Alexandros L. Georgiadis, MD, Charl es J. Prestigiacomo, MD, FACS B ac kg roun d :â•‡ A 2-month-old girl presented with craniomegaly and was diagnosed with a choroid plexus papilloma. She underwent partial resection. Two months later, the tumor was found to have increased in size (Figures 1A–1C). She underwent embolization in preparation for repeat resection.

Figures 1 A through C.â•‡ MRI, T-1 weighted, axial, coronal, and sagital plane respectively, show the large tumor.

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ant choroidal

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Figure 2.â•‡ A–C. Shown are three frames from a right ICA injection in lateral plane. The ACAs (arrow) are displaced anteriorly from the massive hydrocephalus. The prominent anterior choroidal artery, which is the main feeder for the tumor, is marked in Figure 2A. The large area of tumor blush is circled in Figures 2B and 2C. Figure 3.â•‡ A microcatheter is advanced into the anterior choroidal artery (tip is shown by the arrow). Figure 4.â•‡ A and B. Right ICA injection, lateral projection, early (A) and late (B) frames. Following NBCA embolization, the tumor blush is significantly reduced. The circle in 4B highlights the area of diminished flow. 3

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CASE 135 • Hemangioblastoma embolization with particles Alexandros L. Georgiadis, MD, Qaisar A. Shah, MD, Vallabh Janardhan, MD B AC KG R O U N D :â•‡ A 43-year-old man with history of Von Hippel-Lindau disease presented with a 6-month history of neck and back pain. The patient had undergone multiple brain, eye, and renal surgeries. MRI revealed a C5-6 vascular tumor consistent with hemangioblastoma. FLOW-VOIDS

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Figure 1. A. Sagittal T2-MRI of the cervical spine. An intramedullary hyperintense abnormality extends from C2 to C6 (arrows). B. Axial T2-MRI of the brain. There are postsurgical changes in the left cerebellar hemisphere from a previous removal of a hemangioblastoma (arrow).

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Figure 2.â•‡ A–C. Right VA injections, AP (A, C) and lateral (B) projections. A and B. There are two tumor blushes, a large one at C6 and a smaller one at C5 (arrows). The smaller blush is best seen in lateral projection (B). There is a large early draining vein (open arrows in B). C. The vein is traced by open arrows until the point where it flows into the right transverse sinus (arrow). Hemangioblastomas are benign vascular neoplasms that arise almost exclusively in the central nervous system. They are found predominantly in the cerebellum and spinal cord. Most hemangioblastomas arise sporadically, and they account for 1% to 2.5% of all intracranial neoplasms. However, in approximately one-quarter of cases, they are associated with von Hippel-Lindau disease, an autosomal dominant syndrome that includes retinal angiomatosis, central nervous system hemangioblastomas, and various visceral tumors most commonly involving the kidneys and adrenal glands. Hemangioblastomas are generally cured by surgical resection, which is the standard of treatment. Other therapeutic options include endovascular embolization of the solid component of the tumor, which may decrease vascularity and limit blood loss during resection, and stereotactic radiosurgery. Anti-angiogenic treatment has also been recently described.

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CASE 135 • (continued)

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A Prowler 10 microcatheter was introduced through a 5-F Envoy guide catheter that was parked in the proximal right VA. A Transend 10 microwire was used. First, the C6 feeder was selected with the microcatheter. Figure 3. A. A microcatheter (arrow) injection confirms correct placement in the C6 feeder. PVA particles, sized 150 to 250 μm were injected. B. A right VA run shows no tumor blush at the C6 level post-embolization. The feeder is obliterated (arrow). The blush at C5 is still visualized (open arrow). The C5 feeder was then selected with the microcatheter and PVA particles of the same size were injected. C. Right VA run following embolization of both feeders. The C5 tumor blush is also gone. Next, the guide catheter was placed in the left VA.

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Figure 4.â•‡ Left VA injection, lateral projection. A. A tumor blush is seen (arrow), supplied by a large vessel originating from the VA (open arrow). A microcatheter was positioned inside the feeder and an injection was performed to verify correct placement. PVA particles were then injected. B. Left VA injection post-embolization. The tumor blush is no longer seen. Figure 5.â•‡ Left VA injection, lateral intracranial projection, late arterial phase. Multiple abnormal areas of blush are seen (arrows), arising from different vessels. Outcome : The patient subsequently underwent surgery with subtotal excision of the C5 nerve root and removal of the tumor.

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CASE 136 • Metastatic vertebral body tumor embolization Qaisar A. Shah, MD, Alexandros L. Georgiadis, MD, Vallabh Janardhan, MD B AC KG R O U N D :â•‡ A 76-year-old woman with renal cell carcinoma presented with metastatic disease to the vertebrae at T2-T4. The patient was referred for presurgical embolization.

Figure 1. A. T1-sagittal MRI of the thoracic spine shows bony metastasis at the T2 to T4 level (arrows). There is associated spinal canal narrowing with cord compression at the level of T4. B. T1-axial MRI shows the tumor (arrow) with an adjacent paraspinal soft tissue mass (open arrow). 1B

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Figure 2.â•‡ A and B. Right subclavian artery injection, early (A) and late (B) arterial phase. The catheter was positioned near the origin of the thyro-cervical trunk. A feeder originating from the thyrocervical trunk gives rise to large cluster of abnormal tumor vessels (highlighted). An Echelon 10 microcatheter was advanced over a Transend microwire into the feeder.

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Figure 3.â•‡ Microcatheter injection confirms correct placement. PVA particles (150–250 μm) were injected. Figure 4.â•‡ Right subclavian artery post-embolization injection. The tumor vessels are obliterated and do not opacify.

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CHAPTER 7

Treatment of Epistaxis

OA: Ophthalmic artery

ECA injection that shows the contribution to nasal supply (circle, nasal blush) of the ophthalmic artery (arrowheads), IMAX (arrows), and facial artery (open arrow).

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OVERVIEW OF CASES

TREATMENT OF EPISTAXIS

Case 137

Embolization with particles Principles of epistaxis embolization

Case 138

Embolization with particles Dangerous ECA-ICA anastomoses

Case 139

Embolization with particles

CASES 137–139

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CASE 137 • Treatment of epistaxis Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD B AC KG R O U N D :â•‡ A 34-year-old man presented with intractable epistaxis mostly out of the left nare.

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Figure 1.â•‡ Left ECA injection, lateral projection. The numbered red dots correspond to different microcatheter positions. MMA: Middle meningeal artery Figures 2A–2Câ•‡ show microcatheter injections from positions 1–3. At position 1 (nasal branches of the IMAX), embolization was performed with 300 to 500 µm Embospheres followed by 150 to 250 µm PVA particles. The microcatheter was brought into the facial artery (position 2) and then advanced further to position 3 for more selective embolization. PVA 150 to 250 µm particles were used. Figure 3â•‡ (left ECA run, lateral projection) shows the paucity of nasal branches after embolization (rectangle). The guide catheter was positioned in the proximal right ECA.

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CASE 137 • (continued)

5A imax

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Figure 4â•‡ shows a right ECA injection in lateral projection. The red dot shows the microcatheter position in the IMAX from which embolization was carried out. PVA 150 to 250 µm particles were used.

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Figure 5.â•‡ A is a pre-embolization microcatheter run, B is the postembolization run.

Guidecatheter used: 6-French MPD-Envoy Microcatheter used: Prowler-10 Microwire: Transend 10 Principl es of embo li z ation for epistaxis : Epistaxis is one of the most common ear, nose, and throat emergencies. Although nearly 60% of the adult population will have at least one episode of epistaxis, only in 6% of cases will medical attention be required. About 70% of epistaxis cases are considered to be idiopathic. Hypertension, hypercholesterolemia, alcohol abuse, use of nonsteroidal anti-inflammatory medications, and anatomic defects of the nasal septum are considered some of the predisposing factors. Organic causes include trauma, tumors, vascular abnormalities, and bleeding diathesis. Medical management is usually conservative, with anterior and, in severe cases, posterior nasal packing and the use of vasoconstrictors. For refractory epistaxis, surgical and endovascular treatment options are available. Sokoloff et al. first introduced super-selective embolization of the IMAX in 1974. This treatment is usually reserved for patients who fail anterior and posterior packing. The success rate reported in the literature for ipsilateral IMAX embolization is 74% to 87%. However, when the ipsilateral facial and contralateral IMAX are embolized in addition to the ipsilateral IMAX, the success rate increases to 88% to 97% because collateral pathways fail to develop. Some authors recommend performing three-vessel embolization only if one-vessel embolization fails. To avoid recurrent bleeding episodes, we have adopted a three-vessel embolization protocol. Particles in the size range of 50 to 150 μm are used. In some cases, to achieve occlusion of more vasculature, embolization with larger particles may follow. When the treatment has been completed, the packing is removed while the patient is still in the angiography suite, before the guide catheter is removed from the ECA. If no bleeding occurs after a short period of observation, the catheter is removed. The complication rates reported in the literature are variable, ranging from 0% to 50%. Minor complications can include Â�headache, pain in the temporal area, facial pain, parasthesias, jaw pain, groin pain, numbness, and facial edema. Major complications are cerebral or ocular embolization, cranial nerve palsies, seizures, and soft-tissue necrosis. Soft-tissue necrosis can require skin grafting if extensive, but often requires no further intervention. References: Vitek J. Idiopathic intractable epistaxis: endovascular therapy. Radiology 1991; 181(1): 113–116. Tseng EY, Narducci CA, Willing SJ, Sillers MJ. Angiographic embolization for epistaxis: a review of 114 cases. Laryngoscope 1998; 108(4 Pt 1): 615–619. Sokoloff J, Wickbom I, McDonald D, Brahme F, Goergen TC, Goldberger LE. Therapeutic percutaneous embolization in intractable epistaxis. Radiology 1974; 111(2): 285–287.

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CASE 138 • Treatment of epistaxis Randall C. Edgell, MD, Alan S. B oulos, MD B ackground :â•‡ A 70-year-old woman suffered daily episodes of epistaxis with frequent hospitalizations for life-threatening hemorrhage. She had a past medical history significant for hereditary hemorrhagic telangiectasia. Because of the refractory nature of her condition, she was referred for endovascular treatment.

Figure Aâ•‡ (left ECA injection, late arterial phase, lateral projection) demonstrates nasal cavity blood supply from the: • Ethmoidal branches of the ophthalmic artery (white open arrow; generally not embolized due to risk of brain or retinal ischemia). • Infraorbital branch of internal maxillary artery (arrow). • Sphenopalatine branches of internal maxillary artery (bracket). • Facial branch of the external carotid artery (black open arrow)

{ A

Dangerous ECA to ICA anastomoses: • Vidian artery (ECA to horizonatal petrous carotid through foramen lacerum) • IMAX to artery of the foramen rotundum to inferolateral trunk • Accessory meningeal artery to artery of foramen ovale to Â�tentorial branch of the inferolateral trunk • Middle meningeal artery to the tentorial branch of inferolateral trunk • Middle meningeal artery to the recurrent meningeal artery (aâ•¯branch of the ophthalmic artery) • Angular branch of facial artery to ophthalmic artery

B

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D

Procedure : In preparation for the procedure, 1-inch of nitroglycerin paste was applied to the angle of each jaw. A 6-F sheath was placed in the right CFA and a 5-F MPC Envoy guide catheter was positioned in the left ECA. An angiogram was performed with some reflux into the left ICA (Figure A). The images demonstrated the arteries supplying the nasal cavity. Next, the guide catheter was positioned within the IMAX origin, and a Renegade 18 microcatheter along with a Synchro 14 microwire were navigated through the IMAX distal to the middle meningeal artery take-off. A selective microcatheter angiogram was performed (Figures B and C) to rule out dangerous ECA to ICA anastomoses. PVA particles (150–250 μm) were then mixed with a 1:1 contrast: saline mixture to form a solution. This mixture was injected through the microcatheter under fluoroscopic visualization until a decrease in flow to the nasal cavity was observed. Embolization continued until stasis was observed within the distal IMAX. The embolized vessels included the inferior orbital branch as well as the sphenopalatine arteries (Figure C). Figure D shows the obliteration of target vessels that followed embolization (left ECA injection, lateral projection). The same technique was applied in the right ECA artery but larger, 700–900 μm PVA particles were used. This avoided complete devascularization of the nasal cavity and lessened the risk of skin and mucosal necrosis.

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CASE 139 • Treatment of epistaxis Qaisar A. Shah, MD, Alexandros L. Georgiadis, MD, Vallabh Janardhan, MD BAC KG RO U N D :â•‡ A 74-year-old man was referred for embolization for treatment of recurrent episodes of severe epistaxis. OA

Blood supply to the nose can arise from the ophthalmic artery, the IMAX, and the facial artery. Embolization of ophthalmic artery branches is not Â�indicated because of risk of ischemia to the eye. Often, it is impossible to discern the actual contribution from those vessels without microcatheter exploration.

IMAX

Figure 1.â•‡ Left CCA injection, lateral projection. The ophthalmic, IMAX, and facial arteries are marked. Their respective potential contributing branches are indicated by arrowheads, arrows, and an open arrow, respectively. The nasal blush that is seen is highlighted in a circle. facial arterY

A guide catheter was parked in the distal left CCA and a microcatheter was passed into the IMAX.

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Figure 2.â•‡ A. Microcatheter injection into the sphenopalatine artery showing the nasal supply. Embolization was performed with 150 to 250 μm PVA particles. B. Post-embolization left CCA injection, lateral projection. The sphenopalatine artery is no longer visualized (previous location indicated by arrows). The IMAX now terminates proximally (arrowhead). The nasal branches of the facial artery are indicated by an open arrow. There is a fainter nasal blush (circle). The facial artery was then selected. C. Facial artery, microcatheter injection. PVA 150 to 250 μm particles were injected. D. Facial artery, microcatheter injection post-embolization. There is complete obliteration of the previously visualized nasal branches. Figure 3.â•‡ Final left CCA injection, lateral projection. There is a very faint nasal blush (circle). The nasal branch of the facial artery is obliterated (arrowhead).

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CHAPTER 8

Complications of Endovascular Procedures and Miscellaneous Cases

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Complications of endovascular procedures. Figure 1.â•‡ Carotid artery dissection with extravasation (arrows) following balloon occlusion of the vessel in the setting of attempted clot retrieval. Figure 2.â•‡ A and B. ICH following stenting of the ICA. Figure 3.â•‡A and B. Retroperitoneal hematoma (arrow in 3A) following suprainguinal puncture. Active extravasation is seen in Figure 3B (arrow).

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213

OVERVIEW OF CASES

MISCELLANEOUS CASES

CASES 140–150

Sinus thrombosis

Case 140

Administration of thrombolytics into the sinuses

Petrosal sinus sampling

Case 141

Cushing syndrome

Treatment of tandem extracranial and intracranial vertebral artery lesions in one session

Case 142

Extracranial vertebral artery stenting Intracranial vertebral artery angioplasty and stenting In-stent restenosis

Treatment of traumatic vessel injury resulting in dissection with extravasation

Case 143

Coil embolization of the intracranial vertebral artery

Case 144

Coil embolization of the extracranial and intracranial vertebral artery

Complications of endovascular procedures

Case 145

Iatrogenic internal carotid artery dissection during acute stroke treatment MERCI device Stenting of the internal carotid artery

Case 146

Intracranial hemorrhage following carotid stenting

Case 147

Retroperitoneal hematoma Stenting of the external iliac artery

Case 148

Glidewire embolization

Interesting diagnostic angiography findings

Case 149

Transection of the facial artery and internal carotid artery vasospasm following gunshot wound to the neck

Case 150

Bilateral internal carotid artery dissection Demonstration of collateral pathways

214

CASE 140 • Endovascular treatment of sinus thrombosis Stanley H. Kim, MD B ac kg roun d :â•‡ A 45-year-old woman presented with 2 days of headache, nausea, vomiting, confusion, incoherent speech, and urinary incontinence. She had a history of taking birth control pills and unknown diet pills. CT scan revealed a small SAH over the left fronto-parietal interhemispheric region (Figure 1A). While in the emergency department, the patient had a generalized tonic-clonic seizure and was intubated. MRI/MRV of the brain revealed bilateral parietal and right frontal DWI abnormalities and extensive venous sinus thrombosis involving the superior sagittal sinus and both transverse and straight sinuses, with opacification of some cortical veins (Figure 1, B–D). Intravenous heparin was administered continuously to the patient. Despite heparin therapy, she progressed to develop multiple new infarctions in the right thalamus, right frontal lobe, and bilateral centrum semiovale. As a result, she underwent angiography for possible venous thrombolysis 2 days after admission. Angiography confirmed thrombosis of the sagittal, transverse, and sigmoid sinuses (Figure 2).

1D 1B

1A

1C

Figure 1. A. CT scan showing SAH (arrows). B. MRI DWI shows multiple areas of diffusion restriction (arrows). C and D.â•‡MRV, AP (C) and lateral (D) view. The superior sagittal sinus, straight sinus, transverse-sigmoid sinuses, and jugularâ•¯veinsâ•¯do not opacify.

2A

2B

Figure 2.â•‡ A and B. Cerebral venogram, AP (A) and lateral (B) projection. The MRV findings are confirmed. pr oce d u r e : The procedure was performed under general anesthesia. An intravenous bolus of 3000 units of heparin was administered to achieve an ACT value of 240 seconds. An SL-10 microcatheter was introduced over a 0.014-inch Transend EX microwire through a 6-F Envoy guide catheter placed just proximal to the left jugular bulb. The microcatheter was first placed in the left sigmoid sinus and 5 units of Reteplase were administered. The microcatheter was then parked in sequence in the left transeverse sinus, right transverse sinus, and sagittal sinus. A total of 15 units of Reteplase were infused at a rate of 1 unit per 10 minutes. No hemorrhagic complications occurred; however, the patient remained somnolent without any significant neurologic improvement.

215

CASE 140 • (continued)

3A

3B

3C

4A

4B

3D

Figure 3.â•‡ A–D. Microcatheter injections, AP (A–C) and lateral (D) projections. The microcatheter was first placed in the left sigmoid sinus (A). Then it was advanced to the left transverse sinus (B) and through the right transverse sinus to the superior sagittal sinus (C and D). Figure 4.â•‡ A and B. Final injection post thrombolysis in AP (A) and lateral (B) projection shows partial recanalization. Three days later, a microcatheter was placed in the superior sagittal sinus and Reteplase was administered continuously at a rate of 1 unit per hour for 48 hours. The microcatheter was removed at 48 hours because the patient developed a groin hematoma. Â�Follow-up MRV revealed significant recanalization of the sagittal, transverse, and sigmoid sinuses (Figure 5, A and B). No intracranial hemorrhagic complications occurred. Figure 5.â•‡ A and B.MRV following the second thrombolysis, oblique (A) and AP (B) view. There is significant recanalization. Note that the right transverse-sigmoid sinus and internal jugular are still not filling.

5B

5A

O u tcome :â•‡ The day after the second thrombolysis procedure, the patient became conscious and started to follow simple commands. The right groin hematoma gradually resolved over the next month. The patient was placed on Warfarin and transferred to a rehabilitation hospital 1 month after the procedure. The patient was discharged from rehabilitation 2 months after the procedure with significant cognitive dysfunction but was able to ambulate with minimal assistance. Conclusion :â•‡ Thrombosis of multiple sinuses is associated with high morbidity and mortality. The optimal timing and duration of interventional therapy, such as percutaneous intravenous mechanical and/or pharmacologic thrombolysis, is not well known. This case illustrates that continuous infusion of thrombolytics can result in recanalization even 1 week after hospitalization. The necessity of close observation for systemic hemorrhagic complications, including groin hematoma, must be stressed.

216

CASE 141 • Petrosal sinus sampling Qaisar A. Shah, MD, Alexandros L. Georgiadis, MD, Vallabh Janardhan, MD B ac kg roun d :â•‡ A 69-year-old woman presented with Cushing syndrome of unclear etiology. She was scheduled for venous sampling of the petrosal sinus. The inferior petrosal sinus can often be identified by means of an internal jugular vein injection, as shown in Figure 1. To that end, sheaths (5-F) are placed in the CFV bilaterally and guide catheters are advanced to the internal jugular vein. In this case however, the location of the origin of the left inferior petrosal sinus could not be established. It was therefore necessary to insert an arterial sheath and study the venous phase of an arterial injection. A 4-F sheath was placed in the right CFA, and a 4-F catheter was introduced into the right CCA. The left inferior petrosal sinus was visible on the venous phase of a CCA injection as shown in Figure 2. Using road-map guidance, an Echelon 10 microcatheter was advanced over a Transend 14 microwire to the left inferior petrosal sinus/cavernous sinus junction. A microcatheter injection was performed (Figure 3) and a road-map was obtained that helped position a second microcatheter at the right inferior petrosal sinus/cavernous sinus junction. inferior petrosal sinus

int. jugular 1

2

cavernous sinus inferior petrosal sinus

3

Figure 1.â•‡ Right internal jugular vein injection, lateral projection. Figure 2.â•‡ Right CCA injection, lateral projection. The black arrows point at the faintly visible left inferior petrosal sinus. The white arrows point at the tips of the guide catheters. Figure 3.â•‡ Microcatheter injection at the level of the left inferior petrosal sinus/ cavernous sinus junction, AP projection. The white arrow points at the microcatheter tip. The block arrows point at the guide catheter tips. Figure 4.â•‡ Unsubtracted image, AP projection. The black arrows point at the microcatheter tips, the white arrows point at the tips of the guide catheters.

4

Etiology of Cushing syndrome: • Excessive ACTH production in the pituitary (Cushing disease) • Ectopic ACTH secretion from a nonpituitary tumor • Excessive secretion of cortisol from an adrenocortical tumor Pituitary venous blood drains to the cavernous sinus and then to the inferior petrosal sinus bilaterally. Patients with Cushing disease should therefore have higher ACTH concentrations in blood obtained from the inferior petrosal sinus than in peripheral blood. Samples are obtained simultaneously from both microcatheters, both guide catheters, and a venous sheath. After two basal samples are drawn 5 minutes apart, corticotropin-releasing hormone (0.1 μg) is administered intravenously. Two more samples are drawn at 3 minutes and 6 minutes after the corticotropin-releasing hormone infusion. Inferior petrosal sinus/peripheral ACTH ratio is indicative of Cushing disease if >2 (basal levels) or >3 (peak post-infusion levels). The sensitivity and specificity of this procedure are in the 96% to 100% range.

217

CASE 142 • Treatment of tandem extracranial and intracranial Vertebral artery lesions in one session

Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD B AC KGRO U N D :â•‡ An 89-year-old woman presented with multiple posterior circulation strokes and was found to have tandem left VA lesions at the origin of the vessel (Figure 1A) and at the vertebrobasilar arterial junction (Figure 2A).

1A

1B

1D

1C

Passing a guide catheter through the left VA origin stenosis and performing an intracranial intervention would carry a high risk of embolic complications. Therefore, in the first stage of the procedure, the extracranial stenosis was addressed. Figures 1A–D are all AP projections following left subclavian artery injections. A. VA stenosis prior to treatment (arrow). B. A Cypher 3.5 3 8 mm stent (circle) is advanced across the lesion through a 6-F MPD Envoy guide catheter (arrow) that is parked in the subclavian artery. C. The stent is in near-optimal position (circle). Prior to deployment, it was pulled back slightly so as to cover the VA ostium entirely. To achieve this, slight protrusion of the stent into the subclavian artery lumen is tolerated. D. There is complete resolution of the lesion post stent placement. In the second part of the procedure, angioplasty and stenting of the intracranial lesion were performed.

2A

2C

2B

3A

4

3B

218

The guide catheter was advanced into the mid- to distal cervical VA. A Maverick 2.5â•¯3â•¯10 balloon was introduced over a BMW wire. The wire was passed through the lesion and parked in the left PCA (Figures 2A and 2B, arrow). The balloon was brought in position across the stenosis (Figure 2, A and B, circle) and inflated. Figure 2C is a post-angioplasty image that shows good resolution of the Â�stenosis. Figure 2. A. Unsubtracted image, AP projection. B and C.â•‡Left VA injections, AP projection. The black arrow in Figure 2B shows the area of most severe narrowing within the stenosis. Figure 3. A. With the microwire still positioned in the PCA, a Cypher 2.0 3 8.0 mm stent is brought across the lesion (arrows). B. Post-stenting result. Figure 4.â•‡ Severe asymptomatic restenosis noted on follow-up a few months later (arrow).

CASE 143 • Treatment of traumatic Vertebral artery dissection with extravasation Alexandros L. Georgiadis, MD, Charl es J. Prestigiacomo, MD B ac kg roun d :â•‡ An 87-year-old man was involved in a motor vehicle accident and suffered neck injury. The patient underwent C5 corpectomy with grafting. Postoperatively, he developed a large hematoma in the right side of the neck. procedure: A 6-F sheath was placed in the right CFA. A 6-F MPD Envoy catheter was introduced, and the right subclavian artery was selected. A right subclavian artery injection revealed that the right VA was occluded shortly after its origin (Figures 1A and 1B). Then the left subclavian artery was selected. After the origin of the left VA was visualized adequately and found to have no significant disease, the catheter was advanced into the left VA. Left VA injections showed retrograde filling of the right VA with an abrupt cut-off suggesting occlusion (Figures 1C–E). Extravasation was noted (arrows, Figures 1D and 1E). An SL-10 J-shaped microcatheter was advanced over a Transend 14 microwire into the left VA and then through the vertebrobasilar junction into the right intracranial VA (Figure 2A). The tip of the microcatheter was positioned near the area where extravasation had been seen. Two coils were deployed: first a Matrix 2 360” SR 4 mm 3 8 cm and then a VORTX 18 4 3 41 pushable coil (diamondshaped). Follow-up runs showed obliteration of the proximal segment of the right intracranial VA and no further extravasation (Figure 2B).

1A frame 1 6 / 2 9

Figure 1.â•‡ A–E. A. Right subclavian artery injection, AP view. The VA fills very slowly. B. Same injection, venous phase. The proximal VA is occluded (arrow). There is no distal reconstitution. C–E.â•‡Left VA injection, AP view. 1B

frame 2 9 / 2 9

1C

frame 20/29

1E

1D

There is slow retrograde filling of the right VA with an abrupt cut-off suggesting occlusion. In the venous phase, extravasation is noted (arrows in D and E). Right ICA and ECA injections revealed no connection to the right VA and did not result in extravasation.

V B- Junction

right pica

2A

2B

Figure 2.â•‡ A and B. A. The microcatheter is advanced through the left VA into the right VA past the origin of the PICA, and the tip (arrow) is positioned in the area where extravasation was seen. B. After deployment of two coils, part of the right VA is occluded, and there is no more extravasation. The arrow points at the coil mass. 219

CASE 144 • Treatment of traumatic Vertebral artery dissection with extravasation Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD B AC KGRO U N D :â•‡ A 57-year-old woman suffered neck injury following a motor vehicle accident. She sustained C4–C6 Â�fractures. CTA showed possible occlusion of the left VA.

1A

1B

1C 1D

Figure 1.â•‡ A and B.â•‡Right VA injection, AP projection, mid-arterial (A) and early venous phase (B). The slow, retrograde filling of the left VA ceases abruptly (arrow in 1B). C and D.â•‡Left subclavian artery injection, AP projection. The extracranial left VA is occluded just distal to its origin. There is no further reconstitution distally. The patient was scheduled to undergo surgery of the cervical spine. It was believed that embolizing both ends of the occluded VA would minimize the risk of intraoperative bleeding.

V B- j u n ct i o n M i cro ca t h e t e r M i cro ca t h e t e r m a r ke r s

Coil mass

VB:Vertebrobasilar junction 2A

Gui de - c a t h e t e r

3A

2B

4

3B

A guide catheter was positioned in the proximal left VA. An SL-10 microcatheter was introduced in the vessel over a Transend 14 wire and advanced distally to the point of occlusion. A series of five coils were deployed. The guide catheter was then positioned in the right VA, and the SL-10 microcatheter was passed into the left intracranial VA via the vertebro-basilar arterial junction and advanced to the site of the occlusion. Nine more coils were deployed. Figure 2.â•‡ A and B. Left subclavian injections, AP projection, A is unsubtracted. A. The white arrows point at the microcatheter markers. The black arrow points at the coil marker. B. Final injection following deployment of five coils. Figure 3.â•‡ A and B. AP projections. B is unsubtracted. The microcatheter has been brought across the vertebro-basilar arterial junction into the left VA. Figure 4.â•‡ Final right VA injection, AP projection. The arrows point at the proximal and distal coil mass.

220

CASE 145 • Iatrogenic Internal carotid artery dissection Alexandros L. Georgiadis, MD, Jawad F. Kirmani, MD B ac kg roun d :â•‡ An 86-year-old man presented with a severe left-hemispheric stroke. At the time of arrival, the patient was in atrial fibrillation and 6 hours had passed from the onset of his symptoms.

true lumen

pseudo lumen

1A

1D

1B

1C

proce d u r e :â•‡ A 6-F sheath was placed in the right CFA, and a diagnostic angiogram was performed with a 6-F Simmons II Envoy guide catheter. The left MCA was found to be occluded proximally (M1 segment). The decision was made to attempt clot retrieval with help of a MERCI device. The 6-F sheath was exchanged over the wire for an 8-F sheath. The 8-F Concentric balloon-guide catheter was then introduced and positioned in the left ICA. The MERCI microcatheter was introduced over a Transend 14 wire through the guide catheter and positioned in the left MCA, distal to the thrombus. The MERCI retrieval device (L5) was passed through the microcatheter and was deployed distal to the clot. As the retrieval device was being pulled, the guide catheter balloon was inflated and suction was applied through the guide catheter. The balloon was then deflated, and runs were obtained to assess for recanalization. Intracranial flow was found to be diminished. The guide catheter was pulled back into the CCA and cervical runs were obtained. A dissection of the ICA was seen (Figure 1A, black arrow points at the dissection flap) and there was also extravasation of contrast (Figure 1A, white arrows). The MERCI guide catheter was exchanged for an 8-F Cook Shuttle system, which was positioned in the left CCA. Attempts were then made to catheterize the true lumen of the distal ICA with the MERCI microcatheter over a V-18 wire. Initially, the pseudo-lumen was catheterized, as can be seen in Figure 1B, but finally the true lumen was accessed (Figure 1C, microcatheter injection into the left ICA true lumen). Figure 1. A. Left CCA injection, lateral projection. B. Microcatheter injection into the pseudo-lumen created by the dissection. Theâ•¯arrow points at the tip of the microcatheter. C. Microcatheter injection, true lumen. D. Guide-catheter injection, left CCA. The black arrow shows the intimal flap of the dissection.

221

CASE 145 • (continued)

The patient was given 325 mg of aspirin and 600 mg of Clopidogrel through a nasogastric tube in preparation for stenting. The V-18 wire was advanced further until just below the cavernous ICA (arrow, Figure 2A). A Fluency covered stent measuring 6 3 60 mm was passed over the V-18 wire and positioned across the dissection. After the stent was deployed, a CCA run showed that the distal-most segment of the dissection had not been covered (arrow). A second covered stent (Magic Wallstent 4 3 24 mm) was placed Â�distally, partly overlapping the original stent, and was deployed (Figure 2C, black arrow: proximal markings of second stent, white arrow: distal markings of original stent). Finally, to treat the disease in the carotid bulb, a third stent (Precise 8 3 40 mm) was deployed, again with partial overlap with the more distal stent (Figure 2D). This stent covered the distal CCA and proximal ICA. A final CCA run showing good flow through the ICA is seen in Figure 2E.

2C

2B

2A

stent 2

stent 1

2E

stent 3

2D

222

Figure 2.â•‡ A through E. A, B, E. Left CCA runs, lateral projection, (A) pre-stent placement, (B) post-placement of the first stent, (E) final run. C, D. Unsubtracted. (C) post placement of two stents, (D) post placement of all three stents.

CASE 146 • Intracranial hemorrhage following Internal carotid artery stenting Mostafa Mahmoud Gamal El Din, MD, Thanh Nguyen, MD, Daniel Roy, MD, Jean Raymond, MD, Â�Francois â•¯Guilber t,â•¯ MD, Alain Weill, MD B ac kg roun d :â•‡ A 75-year-old man presented with transient right-arm weakness. He had undergone bilateral CEA 15 years ago. CTA revealed 90% stenosis in the left ICA and a right ICA complete occlusion; hence the patient was referred for stent revascularization. His medications for blood pressure were discontinued prior to the procedure, in anticipation of post-stenting hypotension. pr oce d u r e :â•‡ A 6F Cook Shuttle system was placed via the CFA in the left CCA. A 1.7-F microcatheter was used to cross the stenosis, which was estimated to be a subtotal occlusion. In view of the tortuosity of the vasculature and difficult catheterization, a DEPD was not used. A 7 3 40 mm Precise stent was deployed. Control angiogram showed good ICA patency with no evidence of distal emboli. The patient’s blood pressure was 189/110 mm Hg shortly before and after stent placement. The plan was to resume his antihypertensive medications upon transfer to the floor. Fifteen minutes after the procedure, the patient’s level of consciousness deteriorated and he developed dysarthria, global dysphasia, and right-sided weakness. CT scan showed two foci of hemorrhage in the left basal ganglia and left parietal cortex. Protamine was administered to reverse the effect of the Heparin that was used during the procedure. The patient was intubated, and platelet transfusions were administered. Despite these interventions, the patient later expired. Hyperacute ICH may occur following carotid angioplasty and stenting. The incidence of hemorrhage correlates with the severity of the stenosis and the presence of contralateral carotid occlusion. The high post-procedure blood pressure likely precipitated the event. The hemorrhage into the basal ganglia may have been due to rupture of small lenticulostriate arteries acutely exposed to higher perfusion pressures after the stenting of the high-grade stenosis.1 Figure 1.â•‡ A and B. Left CCA injection, lateral projection. A. Subtotal occlusion of the ICA just distal to the bulb (arrow) is seen. B. Post-stent placement run shows only mild residual stenosis. Figure 2.â•‡ A and B. CT scan without contrast. A. Hemorrhage can be seen in the basal ganglia and inside the ventricles. B. There is also a left parieto-occipital subcortical hemorrhage with a fluid level characteristic of hemorrhages that occur in anticoagulated patients.

1A

1B

Reference:

1. 2A

2B

223

Buhk JH, Cepek L, Knauth M. Hyperacute intracerebral hemorrhage complicating carotid stenting should be distinguished from hyperperfusion syndrome. AJNR Am J Neuroradiol. 2006 Aug; 27(7): 1508–13

CASE 147 • Retroperitoneal hematoma Thanh Nguyen, MD, Gilles Soulez, MD, Jean Raymond, MD BAC KGRO U N D :â•‡ A 28-year-old woman with hyperparathyroidemia refractory to medication and three negative cervical surgical explorations underwent angiography to rule out ectopic adenoma. A 5-F sheath was placed in the right CFA, inadvertently above the inguinal ligament. The angiography revealed no abnormal findings. Post-angiography, the patient complained of lower abdominal pain, and examination revealed a tender right lower abdominal mass. Despite manual compression at the puncture site, the patient deteriorated to hypovolemic shock. She was intubated, transfused, and underwent emergent CTA, which revealed a retroperitoneal hematoma and contrast extravasation at the level of the right external iliac artery (Figure 1A and B, arrows).

1B

1A

Management of groin hematoma: 1. Compress the arterial puncture site. 2. Stop anticoagulants. Reverse heparin with protamine. 3. Manage hypotension and tachycardia with blood and volume resuscitation. 4. Type and cross-match packed red blood cells. 5. If refractory to above interventions, perform CTA to identify source of bleed. Suprainguinal puncture must be avoided. pr oce d u r e :â•‡ Following right CFA catheterization, angiography showed contrast extravasation from the distal right external iliac artery (Figure 2A, arrow). A 28-mm long covered stent-graft was deployed over a 5 mm 3 4 cm balloon. Post-stent angiography revealed good patency of the stent and absence of further contrast extravasation (Figure 2, B and C). Because of possible vasoconstriction of the artery secondary to hypovolemic shock, post-dilation of the artery was performed with a 6 mm 3 2 cm balloon to prevent further bleeding after correction of the hypovolemic shock. The patient recovered with no deficits. Figure 2.â•‡ A–C. Angiogram of the right external iliac artery. A. There is contrast extravasation (arrow) 1â•¯cm above the inferior epigastric artery. B. A covered Jo stent has been deployed (arrow). C. After stent placement and angioplasty, the artery is patent. There is slight overdilatation of the external iliac.

2A

2B

224

2C

CASE 148 • Glidewire embolization Thanh Nguyen, MD, Gilles Soulez, MD, Jean Raymond, MD B ac kg roun d :â•‡ A 58-year-old man presented with third-nerve palsy due to a left Pcom aneurysm. An 18-gauge single wall needle was used to puncture the right CFA. A 0.035-inch glidewire was advanced through the needle, and resistance was encountered. The glidewire was withdrawn, and a grating sound was heard. Needle and glidewire were removed. The glidewire was found to have been stripped of its coating from the friction with the inner wall of the needle. A sheath was placed in the left CFA and the aneurysm was embolized. A peripheral angiogram was then performed to look for a remnant of the glidewire at the level of the distal abdominal aorta, bilateral iliac arteries, and lower limbs. O u tcome :â•‡ A 10-cm fragment of the glidewire was identified in the deep femoral artery (Figure 1a, b). Despite its presence, the artery was patent without evidence of clot. There was no protrusion of the glidewire fragment in the CFA. The remainder of the angiogram was normal. Figure 1. A. Fluroscopy showing opacity of the glidewire in the right leg (arrow). B. Angiogram of the lower abdominal aorta. Note the lack of complete opacification of the deep femoral artery due to the presence of the glidewire coating (arrows). A natom y: â•‡ The deep femoral artery supplies the deep muscles of the thigh (adductor longus, adductor magnus, hamstrings), the latter of which also receives supply from branches of the common and superficial femoral arteries. Because the glidewire remnant was located in an arterial territory that can be supplied by collateral vessels, no further intervention was undertaken.

1A 1B

Placing a glidewire through a metal needle should probably be avoided. Friction between the inner wall of the needle and the coating of the glidewire may lead to stripping of the coating and possibly to distal embolization. ou tcome : The patient recovered well without any procedure-related symptoms.

225

CASE 149 • Transection of the Facial artery and Internal carotid artery vasospasm following gunshot wound to the neck

Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD B AC KGRO U N D :â•‡ A 19-year-old man presented with severe swelling of the right side of the neck after sustaining a gunshot wound to the neck. The patient was neurologically intact. The patient had a CTA that showed an area of narrowing and irregularity in the right ICA (circled areas in source images A and B, arrow in the reconstructed image C). A conventional angiogram was performed to rule out ICA dissection. A 5-F sheath was placed in the right CFA. A 5-F MPD Envoy catheter was advanced into the right CCA and contrast was injected (Image D). Fragments of the bullet are indicated by the thin arrows. The thick arrow points at the right facial artery, which appears to be occluded. The circle highlights an area of residual irregularity in the right ICA. I n t e r pr e tat ion : The bullet transected the right facial artery and caused the hematoma in the neck. The hematoma that surrounded the ICA caused vasospasm, which was visualized in the CT angiogram and had almost resolved by the time the conventional angiogram was performed. A

B

right cca injection, lateral projection

C

D

226

CASE 150 • Bilateral Internal carotid artery dissection Alexandros L. Georgiadis, MD, Adnan I. Qureshi, MD B ac kg roun d :â•‡ A 54-year-old woman presented with multiple episodes of variable symptoms including left-sided sensory loss, dysarthria and confusion. MRI performed at an outside hospital showed bilateral ischemic changes. This case is presented to demonstrate different collateral pathways.

1A 1B

fr a m e 7 / 2 1

AC A MCA

ICA

3A

fr a m e 1 2 / 2 1

fram e 8 / 2 1

2C

2B

3B

AC A

AC A

PCA

MCA PC A

MCA

PCO M

4A

4B

227

2A

Figure 1.â•‡ A and B, right CCA injections, lateral projection A. The ICA appears to taper off and to occlude just distal to its origin (arrow). B. The ICA reconstitutes intracranially (circle). The ophthalmic artery (arrow) is seen diverting flow from the ECA to the ICA. Figure 2.â•‡ A–C Right CCA injection, lateral projection, early (A), mid- (B), and late (C) arterial phase. A. Minimal antegrade flow is seen in the ICA (arrows). B. The ophthalmic artery (white arrow) reconstitutes the ICA (black arrow). C. Filling of the MCA and ACA can be seen. Figure 3.â•‡ A and B. Left CCA injections, lateral projections The ICA shows a flame-shaped occlusion just distal to its origin (black arrowhead). The ICA again reconstitutes intracranially (white arrows). Figure 4.â•‡ Left VA injection, A. Lateral projection. B. AP projection The left Pcom (arrow) is seen contributing to the flow of the anterior circulation. There is filling of both the ACA and MCA.

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APPENDIX

List of Products and Manufacturers 1.

CATHETERS

2.

MICROCATHETERS

3.

WIRES

4.

MICROWIRES

5.

COILS

6.

BALLOON CATHETERS

7.

STENT CATHETERS

8.

DISTAL EMBOLIC PROTECTION AND CLOT RETRIEVAL DEVICES

9.

LIST OF MANUFACTURERS

229

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C AT H E T E R S NAME AMPLATZ BRITE TIP COBRA-2 COOK SHUTTLE DAV ENVOY (MPC, MPD AND SIMMONS) H-1 JB1 JR (JUDKINS RIGHT CORONARY) PIGTAIL SIM VBL VERT VTK

MANUFACTURER COOK CORDIS COOK COOK COOK CORDIS COOK COOK CORDIS COOK COOK CORDIS COOK COOK

M I C R O C AT H E T E R S NAME ECHELON EXCELSIOR SL-10 MAGIC MARATHON MASS-TRANSIT RAPID-TRANSIT PROWLER, PROWLER PLUS RENEGADE SPINNAKER

COMPANY EV3/MICROTHERAPEUTICS BOSTON SCIENTIFIC2 BALT EV3/MICROTHERAPEUTICS CORDIS CORDIS CORDIS BOSTON SCIENTIFIC2 BOSTON SCIENTIFIC2

231

WIRES NAME AMPLATZ SUPER-STIFF GLIDEWIRE IRONMAN SPARTA-CORE STEEL-CORE SUPRA-CORE V-18 WHISPER

MANUFACTURER COOK MICRO VENTION/TERUMO GUIDANT/ABBOTT GUIDANT/ABBOTT GUIDANT/ABBOTT GUIDANT/ABBOTT BOSTON SCIENTIFIC4 ABBOTT

MIRCROWIRES NAME ACS HI-TORQUE BALANCE MIDDLE WEIGHT (BMW) AGILITY ALLSTAR MIRAGE STABILIZER SYNCHRO TRANSEND EX X-CELERATOR X-PEDION

COMPANY ABBOTT CORDIS GUIDANT/ABBOTT EV3/MICROTHERAPEUTICS CORDIS BOSTON SCIENTIFIC3 BOSTON SCIENTIFIC4 EV3/MICROTHERAPEUTICS EV3/MICROTHERAPEUTICS

C O I LS NAME BERENSTEIN LIQUID COILS CERECYTE GDC (GUGLIELMI DETACHABLE COILS) HYDROCOILS MATRIX ORBIT TRUFILL TORNADO VORTX PUSHABLE COILS

MANUFACTURER BOSTON SCIENTIFIC MICRUS ENDOVASCULAR BOSTON SCIENTIFIC2 MICRO VENTION BOSTON SCIENTIFIC2 CORDIS COOK MEDICAL BOSTON SCIENTIFIC

232

B A L L O O N C AT H E T E R S NAME CROSSSAIL GATEWAY HYPERFORM HYPERGLIDE MAVERICK SAVVY VIATRAC

MANUFACTURER GUIDANT/ABBOTT BOSTON SCIENTIFIC5 EV3/MICROTHERAPEUTICS EV3/MICROTHERAPEUTICS BOSTON SCIENTIFIC5 CORDIS GUIDANT/ABBOTT

STENTS SELF-EXPANDING NAME ACCULINK FLUENCY PLUS MAGIC WALL NEUROFORM PRECISE SMART CONTROL WALLGRAFT WINGSPAN XACT XPERT

COMMENTS OPEN CELL COVERED TRACHEO-BRONCHIAL STENT GRAFT BRAIDED DESIGN CORONARY STENT

MANUFACTURER GUIDANT/ABBOTT BARD

LOW-RADIAL FORCE INTRACRANIAL STENT BILIARY STENT ILIAC STENT SYSTEM COVERED STENT INTRACRANIAL STENT, OPEN CELL

BOSTON SCIENTIFIC

CLOSED CELL, TAPERED OPEN CELL

GUIDANT/ABBOTT GUIDANT/ABBOTT

COMMENTS DRUG-ELUTING CORONARY STENT BILIARY STENT COVERED STENT CORONARY STENT

MANUFACTURER CORDIS

2MM DIAMETER COBALTCHROMIUM CORONARY STENT CORONARY STENT BILIARY STENT DRUG-ELUTING CORONARY STENT

GUIDANT/ABBOTT

BOSTON SCIENTIFIC7 6

CORDIS CORDIS BOSTON SCIENTIFIC7 BOSTON SCIENTIFIC6

BALLOON-MOUNTED NAME CYPHER HERCULINK JOSTENT GRAFTMASTER LIBERTE MULTI-LINK MINI VISION MULTI-LINK ZETA PALMAZ GENESIS TAXUS EXPRESS

233

ABBOTT ABBOTT BOSTON SCIENTIFIC5, 7

GUIDANT/ABBOTT CORDIS BOSTON SCIENTIFIC5, 7

D I S TA L E M B O L I C P R OT E C T I O N D E V I C E S NAME ACCUNET ANGIOGUARD EMBOSHIELD FILTERWIRE, EX, EZ

MANUFACTURER ABBOTT CORDIS ABBOTT BOSTON SCIENTIFIC1

C LOT R E T R I E VA L D E V I C E S NAME MERCI GOOSE NECK SNARE

MANUFACTURER CONCENTRIC MEDICAL MICROVENA/EV3

M A N U FA C T U R E R S Abbott Vascular, Santa Clara, CA

www.abbottvascular.com

Balt Extrusion, Montmorency, France

www.balt.fr

Bard Peripheral Vascular, Tempe, AZ

www.bardpv.com

Boston Scentific Corporation 1:â•‡ Mountain View, CA, 2:â•‡ Cork, Ireland, 3:â•‡West Valley, UT, 4:â•‡ Miami, FL, 5:â•‡ Maple Grove, MN, 6:â•‡ Fremont, CA, 7:â•‡ Galway, Ireland

www.bostonscientific.com

Concentric Medical, Inc., Mountain View, CA

www.concentric-medical.com

Cook Medical, Inc., Bloomington, IN

www.cookmedical.com

Cordis Neurovascular, Inc., Miami Lakes, FL

www.cordis.com, www.jnjgateway.com

ev3 Neurovascular, Irvine, CA

www.ev3.net

Microvena Corp., White Bear Lake, MN

www.microvena.net, www.ev3.net

Micro Vention, Inc., Aliso Viejo, CA

www.microvention.com

Micrus Endovascular Corp., San Jose, CA

www.micrusendovascular.com

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Index acute cerebral ischemia, treatment of, (cases 42-56) combined extra- and intracranial lesions, treatment of angioplasty and stenting of contralateral Internal carotid artery stenosis, 87-88 delayed recanalization, 81-82, 85-86 hyperdense Middle cerebral artery sign, 84 suction thrombectomy, 83, 85-86 tandem Internal carotid artery/Middle cerebral artery occlusion, 81-82, 83, 84, 87-88 thrombolysis from the contralateral side through the Anterior communicating artery, 87-88 isolated intracranial lesions, treatment of, 64-80 basilar artery occlusion, 80 clinical-diffusion mismatch, 68 clinical/perfusion-diffusion mismatch, 71 distal Anterior cerebral artery branch occlusion, 72 embolic complications during cardiac catheterization, 64-65 hyperdense Middle cerebral artery sign, 67 intracranial Internal carotid artery occlusion, 73-74, 75-79 intravenous antiplatelet agents and thrombolytics, combination of, 64-65 intravenous antiplatelet agents for prevention of rethrombosis, 66, 72 MERCI clot retrieval device, 69-70, 75-79 middle cerebral artery occlusion, 64-65, 66, 67, 68, 69-70 middle cerebral artery near-occlusion, 71 multimodal thrombolysis, 73-74 presumed Middle cerebral artery dissection, 71 recanalization, lack of, 73-74 treatment past the 6-hour time window, 67 unknown time of onset, 68, 71 arterio-venous fistulas, treatment of, (cases 115-125) arterio-venous fistula treated with Onyx and coil-embolization, 182 arterio-venous fistula presenting with ICH, 182-183 cervical arterio-venous fistula, 189 embolization with particles, 189-191 transvenous and trans-arterial coil embolization, 189-191 traumatic arterio-venous fistula, 189-191 dural arterio-venous fistula not amenable to endovascular treatment, 180-181 dural arterio-venous fistula presenting with headache and deterioration of vision, 180-181 surgical treatment, 181 orbital arterio-venous fistula treated with transvenous coil-embolization, 184-185 orbital arterio-venous fistula presenting with diplopia, chemosis, and proptosis, 184-185 spinal dural arterio-venous fistula treated with Onyx, 192 spinal dural arterio-venous fistula presenting with back pain and progressive lower extremity weakness, 192 stenting of the draining sinus, 179 covered stent, 179 dural arterio-venous fistula presenting with ICH, 179 transarterial embolization, 178 dural arterio-venous fistula presenting with tinnitus and imbalance, 178 embolization of arterial feeder with coils and N-butyl-cyanoacrylate, 178 transvenous embolization, 175 dural arterio-venous fistula presenting with headache and pulsatile tinnitus, 176-177 dural arterio-venous fistula presenting with occipital infarction, 175 sinus coil-embolization, 175, 177 traumatic carotid-cavernous fistula treated with transvenous and trans-arterial embolization, 186-187 carotid-cavernous fistula presenting with progressive loss of vision, 186-187 embolization with N-butyl-cyanoacrylate, 186-187 transvenous and trans-arterial coil embolization, 186-187 vein of Galen malformation, 188 spontaneous thrombosis, 188 vein of Galen malformation presenting with hydrocephalus, 188

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arterio-venous malformations, treatment of, (cases 106-114) embolization with N-butyl-cyanoacrylate, 160-161 intranidal aneurysm, 161 ruptured arterio-venous malformation, 160 embolization with N-butyl-cyanoacrylate and particles, 162 emergent embolization prior to surgery, 162 intranidal aneurysm, 162 ruptured arterio-venous malformation, 162 embolization with N-butyl-cyanoacrylate followed by Gamma-Knife, 165-166 angiography, follow-up at 3 years, 166 Gamma-Knife, 166, 168 ruptured arterio-venous malformation, 167-168 unruptured arterio-venous malformation presenting with headache and aphasia, 165-166 embolization with N-butyl-cyanoacrylate followed by surgery, 163 ruptured Arterio-venous malformation, 163-164 provocative testing, 164 embolization with Onyx, 169 ruptured arterio-venous malformation, 170, 171 unruptured arterio-venous malformation presenting with focal seizures, 169 facial arterio-venous malformation embolization with Onyx, 173 facial arterio-venous malformation presenting with recurrent oral bleeding, 173-174 basilar artery, (cases 35-40) angioplasty, 52, 54 angioplasty, scheduled staged procedure, 53 angioplasty and stent placement. 55 balloon-mounted stent, 58 calculation of balloon and stent size, 56-57 clot propagation, 54 coil occlusion of the intracranial vertebral, 54 facts on intracranial atherosclerosis, 58 latrogenic vasospasm, 52 staged angioplasty and stenting, 56-57 stenting deferred at follow-up, 53 stenting not feasible, 52 stent placement, 58 technique used to deploy the Wingspan stent, 56-57 brachiocephalic artery, (case 16) angioplasty and stent placement , 25 balloon-mounted stents, 25 induced by orthostasis, 25 multiple stents, placement of, 25 coil embolization, (cases 67-78) aneurysm not suitable for coiling, 152 aneurysm regression following stent placement, 153 balloon-assisted (cases 79-83) iatrogenic vasospasm, 125-126 internal carotid artery occlusion, 127 ruptured hypophyseal artery aneurysm, 122 ruptured Internal carotid artery aneurysm, 124 thrombo-embolic complications, , 125-126 treatment with intranenous abciximab, 125-126 treatment with intra-arterial Reteplase, 127 unruptured Anterior communicating artery aneurysm, 123 unruptured Internal carotid artery aneurysm, 125-126, 127 coil compaction, 118, 119, 120, 154-155 distal anterior cerebral artery ruptured aneurysm, 115 distal posterior cerebral artery ruptured aneurysm, 116 excessive tortuosity of the proximal cervical vessels, 117 giant aneurysm, 118 hydrocoils, 111 microcatheter deflection technique, 148-149 balloon-assisted coil embolization, unsuccessful, 148-149 neuroform stent placement following coil embolization 148-149 unruptured Middle cerebral artery bifurcation aneurysm, 148-149

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onyx embolization, 147 coil compaction, 147 unruptured Internal carotid artery/Ophthalmic artery aneurysm, 147 parent-vessel occlusion, with, (cases 93-97) alcox and Mathis maneuvers, 138-139 balloon test-occlusion, 141-142 dissecting aneurysm, 140 giant aneurysm, 138-139 ischemic complications, 143 ischemic and hemorrhagic complications, 144-145 ruptured Internal carotid artery aneurysm, 138-139 ruptured vertebral artery aneurysm, 140 traumatic pseudo-aneurysm, 141-142 unruptured Internal carotid artery aneurysm, 141-142 unruptured Anterior cerebral artery aneurysm, 143 unruptured Basilar artery aneurysm, 144-145 pseudo-aneurysm, 153 repeat stent-assissted coil embolization, 154-155 ruptured Anterior communicating artery aneurysm, 121 ruptured basilar apex aneurysm, 120 ruptured Internal carotid artery aneurysm, 110, 117, 118, 119 ruptured multilobed Internal carotid artery aneurysm, 112-113 ruptured multilobed posterior inferior cerebellar artery aneurysm, 114 stent-assisted (cases 84-92) aneurysm recurrence post clipping, 128-129 balloon test-occlusion, 136 cerecyte coils, 133 cranial nerve palsy, 132 iatrogenic vasospasm, 136 in-stent stenosis, 133 intra-arterial nicardipine, 136 multiple aneurysms, 135 persistent hypoglossal artery, 134 pseudo-aneurysmal lesion, 131 ruptured clinoid Internal carotid artery aneurysm, 134 ruptured posterior cerebral artery aneurysm, 137 stent placement following coil embolization, 133 thrombo-embolic complication, 137 treatment with intravenous Eptifibatide, 137 unruptured cavernous Internal carotid artery aneurysm, 132 unruptured distal cervical Internal carotid artery aneurysm, 131 unruptured Internal carotid artery aneurysm, 128-129, 130, 136 unruptured Internal carotid artery/Ophthalmic artery aneurysm, 135 unruptured Internal carotid artery terminus aneurysm, 133 thrombo-embolic complications, 121 trispan device, 146 unruptured Basilar apex aneurysm, 146 unruptured basilar apex aneurysm, 109 unruptured Internal carotid artery aneurysm, 111 variations in posterior circulation anatomy, 152 vertebral artery aneurysm, 154-155 combined subclavian artery and VA artery origin, (cases 25-26) angioplasty and stent placement, 35, 36 arm claudication, 36 distal embolic protection, 35 in-stent stenosis with fish-mouthing, 36 stenting of the vertebral artery origin through a subclavian artery stent, 36 subclavian steal syndrome, 35 common carotid artery, (cases 11-13) angioplasty and stent placement, 17-21 debris captured by a distal embolic protection device, 19 radiation-induced stenosis, 19 subclavian steal syndrome, 17, 20-21 diagnostic angiography findings, 226 Bilateral internal carotid artery dissection, 227

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Demonstration of collateral pathways, 227 Transection of the facial artery and internal carotid artery vasospasm following gunshot wound to the neck, 226 endovascular procedures, complications of, 221 glidewire embolization, 225 iatrogenic internal carotid artery dissection during acute stroke treatment, 221-222 intracranial hemorrhage following carotid stenting, 223 MERCI device, 221-222 retroperitoneal hematoma, 224 stenting of the external iliac artery, 224 stenting of the internal carotid artery, 221-222 epistaxis, treatment of, (cases 137-139) dangerous ECA-ICA anastomoses, 211 embolization with particles, 209-210, 211, 212 epistaxis embolization, principles of, 210 external carotid artery, (cases 14-15) angioplasty and stent placement, 22-23, 24 brachial artery approach, 21 external carotid artery and internal carotid artery collateral circulation, 23 stent placement without the use of a guide catheter, 23 treatment with nitroglycerin for vasospasm, 24 internal carotid artery, (cases 1-10) distal embolic protection, 4-6 angioplasty and stent placement, 4, 5, 6 competitive filling of the anterior cerebral artery, 6 nascet-based calculation of stenosis, 4 procedure, 5, 6 severe tortuosity of the internal carotid artery, 6 vessel measurements required for stenting, 4 heavily calcified lesions, 11-13 angioplasty and stent placement, 11, 12 intravascular ultrasound, 13 latrogenic vasospasm, 11 multiple pre-stent angioplasties, 12 procedure, 11, 12 post-stent angioplasty, 11 stent trapped in lesion, 12 proximal and distal embolic protection, 8-10 angioplasty, 10 angioplasty and stent placement, 8, 9 CTA and CT perfusion studies, 9 intraluminal clot, 10 procedure, 8, 9, 10 post-stent angioplasty, 8 stenting deferred because of contraindication to dual antiplatlet treatment, 10 tapered stent, 8 radial artery approach, 14-16 allen test, 15 angioplasty, 16 angioplasty and stent placement, 14 cutting balloon, 16 medication protocol for radial and brachial artery procedures, 15 procedure, 14-16 radiation-induced vasculopathy, 16 intracranial internal carotid artery, (cases 27-28) angioplasty, 40 bilateral angioplasty, 41 Grave’s disease, 41 Moya Moya, 41 stenting not feasible, 40 intracranial vertebral artery, (cases 31-34) angioplasty, 50-51 angioplasty and stent placement, 45-46, 47-49 bilateral vertebral artery disease, 47-49 brachial artery approach, 50-51 intra-arterial thrombolysis, 50-51

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severe proximal tortuosity, 45-46 stent placement, 44 thrombotic complication, 50-51 middle cerebral artery, (cases 29-30) angioplasty and stent placement, 42 Angioplasty of the superior division, 43 measurements required for intracranial stenting, 42 near-occlusive stenosis, 43 petrosal sinus sampling, 217 cushing syndrome, 217 posterior cerebral artery, (case 41) angioplasty and stent placement, 59 sinus thrombosis, 215-216 thrombolytics into the sinuses, administration of, 215-216 subacute or progressive/fluctuating cerebral ischemia, treatment of, (cases 57-66) internal carotid artery dissection, treatment of, 95-98 bilateral Internal carotid artery dissections, 97 conservative management of dissections, 98 dissection resulting in occlusion, 98 dissection resulting in severe stenosis, 95-96, 97 fibromuscular dysplasia, 97 fluctuating ischemia, 98 placement of multiple stents, 95-96 severe vessel tortuosity, 98 watershed infarcts, 95-96, 97 internal carotid artery stenosis of presumed atherosclerotic origin, treatment of, 89-94 CT perfusion studies, 89-90, 91-92 multiple angioplasties, 93-94 placement of multiple stents, 93-94 progressive ischemia, 93-94, 91-92 watershed ischemia, 89-90 internal carotid artery, stenting of to improve collateral flow to the posterior circulation, 100-101 Bilateral vertebral artery occlusion, 100-101 CT perfusion studies, 100-101 Internal carotid artery stenosis, 100-101 intracranial lesions, treatment of, 102-104 aggressive thrombosis, 102 basilar artery stenosis bilateral intracranial vertebral artery dissection, 103-104 fluctuating ischemia, 102 head trauma, 103-104 recanalization, lack of, 103-104 retrograde flow in the basilar artery, 103-104 subacute Internal carotid artery occlusion, treatment of, 99 SPECT studies, 99 tandem intra-/extracranial Internal carotid artery occlusion, 99 subclavian artery, (case 17) angioplasty and stent placement, 26-27 dual arterial access (femoral and brachial artery), 27 microsnare device, 26 subclavian artery occlusion, 26 subclavian steal syndrome, 26 tandem extracranial and intracranial vertebral artery lesions, treatment of in one session, 218 extracranial vertebral artery stenting, 218 in-stent restenosis, 218 intracranial vertebral artery angioplasty and stenting, 218 traumatic vessel injury resulting in dissection with extravasation, treatment of, 219 coil embolization of the intracranial vertebral artery, 219 coil embolization of the extracranial and intracranial vertebral artery, 219 tumors, treatment of, (cases 126-136) choroid plexus papilloma, 203 embolization with N-butyl-cyanoacrylate, 203 hemangioblastoma, 204-205 embolization with particles, 204-205 treatment options for hemangioblastomas, 204

239

Von Hippel-Lindau disease, 204 juvenile nasopharyngeal angiofibroma, 201 embolization with particles, 201, 202 characteristics of juvenile nasopharyngeal angiofibromas, 202 meningioma, 195 angiographic evaluation of meningiomas, 196 dangerous anastomotic pathways, 196 embolization with particles, 195, 196 meningioma not amenable to endovascular treatment, 197 meningeal arteries arising from the ophthalmic arteries, 197 metastatic vertebral body tumor, 206 embolization with particles, 206 overview of anterior to posterior circulation connections, 199 intra-arterial administration of nicardipine prior to embolization, 200 jugular foramen tumor treated with particle embolization, 200 paraganglioma, 198 carotid body tumor treated with coil and particle embolization, 198 common locations and presenting symptoms of paragangliomas, 198 carotid body tumor treated with Onyx embolization, 199 vasospasm, treatment of, (cases 101-102) basilar artery angioplasty, 150 basilar artery and posterior cerebral artery vasospasm, 150 intra-arterial nicardipine, 151 intra-arterial papaverine, 150 posterior cerebral artery vasospasm, 151 vertebral artery origin, (cases 18-22) balloon-mounted stent, 28 distal embolic protection, 29-32 balloon-mounted stent, 29, 30, 31, 32 iatrogenic vasospasm, 30 retroperitoneal hematoma stent placement, 29, 30, 31, 32 use of a “buddy” wire, 30, 32 stent placement, 28 vertebral artery V-2 segment, (cases 23-24) dynamic angiography, 33-34 positional occlusion of the vertebral artery/Bow Hunter syndrome, 33-34 angioplasty and stent placement, 34 brachial artery approach, 33 history of cervical discectomy, 34 multiple posterior circulation strokes, 33 post-stent angioplasty, 34 stent placement, 33 uncinate spur, 33

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