Interventional neuroradiology in neuro-ophthalmology.

Endovascular neuroradiologic procedure is the treatment of choice for patients with symptomatic direct carotid cavernous fistulae (CCF) and dural arteriovenous fistulae (DAVF) that failed manual carotid artery/jugular vein compression. Preservation of visual function and the prevention of catastrophic intracranial hemorrhage are the prime therapeutic objectives. The choice of transarterial versus transvenous approach is dictated by the pathophysiology, pattern of venous drainage, and the risk/benefit ratio in each patient.

Treatment of dural fistulas involving the deep cerebral venous system.

Eight patients with dural arteriovenous fistulas involving the deep cerebral venous system were treated by a combination of preoperative embolization, intraoperative embolization, and/or surgical excision. All eight patients were men 30-71 years old (mean age, 48.5).

Transvenous embolization of dural fistulas involving the transverse and sigmoid sinuses.

Eleven patients with dural fistulas involving the transverse and sigmoid sinuses were treated by transvenous embolization with coils or liquid adhesives. Seven patients underwent preoperative embolization of the external supply followed by direct surgical exposure of the sinus: liquid adhesives were used in four patients and coils in the remaining three. Four of these patients had complete obliteration of their fistulas and there was 95% reduction in the remaining three.

Transvenous embolization of dural fistulas involving the cavernous sinus.

Because of the risks associated with arterial embolization of cavernous dural fistulas, we have sought an alternative method to promote fistula closure. Thirteen patients underwent transvenous embolization as a treatment for symptomatic cavernous dural fistulas. All procedures were performed from a femoral vein access through the inferior petrosal sinus or basilar plexus.

Direct puncture of the proximally occluded internal carotid artery for treatment of carotid cavernous fistulas.

Three patients with symptomatic carotid cavernous fistulas (CCFs) characterized by complete occlusion of the proximal internal carotid artery were treated by percutaneous puncture and embolization. Two patients had CCFs associated with traumatic dissections of the internal carotid artery and were treated initially with trapping procedures. Both patients had persistent symptoms related to the CCF and underwent additional surgical procedures (ophthalmic artery ligation and intraoperative embolization) without improvement.

Embolization of branches arising from the cavernous portion of the internal carotid artery.

Seven patients with vascular disease (four with cavernous and two with transverse sinus dural fistulas and one with a facial arteriovenous malformation, all supplied primarily from cavernous branches of the internal carotid artery) underwent subselective catheterization and embolization. Ten branches were catheterized (seven meningohypophyseal trunks and three inferolateral trunks) and eight branches were embolized. The embolic agents were as follows: polyvinyl alcohol particles in five, hypertonic glucose in two, and liquid adhesive in one.

Permanent inflation of detachable balloons with a low-viscosity, hydrophilic polymerizing system.

A polymer system was developed for use in permanent inflation of detachable balloons, to avoid long-term reliance on the integrity of balloon shells or valve mechanisms. This system is based on 2-hydroxy-ethyl methacrylate (HEMA) as the monomer, in combination with a cross-linking agent and a water-soluble curing system. The low-viscosity, hydrophilic mixture can be exchanged through a small-bore catheter into a detachable balloon and polymerizes in 40-60 minutes at body temperature.

Treatment of a giant carotid ophthalmic artery aneurysm by intravascular balloon embolization therapy.

This report describes the successful treatment by detachable balloon embolization therapy of a giant aneurysm arising at the left carotid-ophthalmic artery junction. Two previous surgical attempts to clip the aneurysm were unsuccessful and the aneurysm continued to enlarge leading to complete loss of light perception. After the placement of two detachable balloons within the aneurysm, there was thrombosis of the aneurysm with diminished mass effect.

Arteriovenous fistula of the internal maxillary artery: treatment with transarterial embolization.

Six patients with arteriovenous fistulas of the internal maxillary artery were treated with transarterial embolization. The patients ranged in age from 19 to 47 years, with a mean of 26.5 years.

MR evaluation of large intracranial aneurysms using cine low flip angle gradient-refocused imaging.

MR imaging has proved to be useful in evaluating large intracranial aneurysms. The parent artery and patent lumen can be identified as flow voids and differentiated from thrombus. However, in the presence of slow flow, even-echo rephasing, and motion artifact, increased intraluminal signal may be present, which may be difficult to distinguish from thrombus.

Transvenous embolization of direct carotid cavernous fistulas.

Of 165 cases of direct carotid cavernous fistula, 14 (8.5%) were treated from a transvenous approach. Twelve of these were treated through the inferior petrosal sinus and one through the superior ophthalmic vein.

Platinum wire: a new transvascular embolic agent.

Standard Gianturco and "mini" coils cannot be used with some of the present microcatheter systems. However, occasions arise in which metallic coils would be an ideal embolic agent in vascular structure accessible only to a tracker (2.2-French) catheter system.

Treatment of dural arteriovenous malformations involving the superior sagittal sinus.

We report the diagnosis and treatment of seven dural arteriovenous malformations involving the superior sagittal sinus. The most common presenting symptom was headache, although two patients presented with hemorrhage. Embolization alone effected a complete cure in four patients, while a combination of embolization and surgery was used in the remaining three patients.

Cervical root compression by a traumatic pseudoaneurysm of the vertebral artery: case report.

We report the case of a patient with cervical monoradiculopathy secondary to a pseudoaneurysm of the vertebral artery caused by a knife wound to the neck.

Preoperative balloon occlusion of arteriovenous malformations.

Many materials have been utilized to embolize cerebral arteriovenous malformations (AVMs) preoperatively. Specific vascular anatomy with large feeding vessels deep to the nidus or aneurysms within feeding arteries favor the use of detachable balloons over other embolic agents. Detachable balloons allow test occlusion of a vascular pedicle before permanent occlusion and can obliterate aneurysms in feeding arteries.

Cavernous carotid artery aneurysm associated with Marfan's syndrome: treatment by balloon embolization therapy.

Intracranial aneurysms arising in the region of the cavernous carotid artery are difficult to manage surgically because of the surrounding cavernous sinus. With recent advances in microballoon technology and permanent solidification agents, it is now possible to treat certain intracranial aneurysms by detachable balloons and preserve the parent vessel. A patient with Marfan's syndrome presented with severe retroorbital pain, ophthalmoplegia, and headaches.

Treatment of vertebral arteriovenous fistulas.

Twenty patients with vertebral arteriovenous fistulas (eight spontaneous, six traumatic without vertebral artery transection, and six traumatic with vertebral artery transection) were treated by transvascular embolization techniques, resulting in complete fistula closure in all patients. The fistulas were located at C1-C2 in 45%, C2-C3 in 25%, C4-C5 in 15%, C5-C6 in 10%, and C6-C7 in 5%. Trauma was the most common cause: 30% followed knife wounds, 20% followed gunshot injuries, and 10% followed blunt trauma.

High-risk dural arteriovenous fistulae of the transverse and sigmoid sinuses.

Dural arteriovenous fistulae of the transverse and sigmoid sinuses are highly variable in symptomatology and prognosis. However, we have identified a subgroup of patients who have a high risk of hemorrhage and dementia due to severe venous overload caused by high arterial flow into the fistulae and by occlusive changes of the transverse and sigmoid sinuses. Three representative cases selected from 31 patients with dural arteriovenous fistulae of the transverse and sigmoid sinuses are presented, and 45 reported similar cases are reviewed to discuss pathophysiology and problems encountered during treatment.

Carotid cavernous fistulae: indications for urgent treatment.

Angiographic and clinical data from 155 patients with carotid cavernous fistulae were retrospectively reviewed to determine angiographic features associated with increased risk of morbidity and mortality. These features included presence of a pseudoaneurysm, large varix of the cavernous sinus, venous drainage to cortical veins, and thrombosis of venous outflow pathways distant from the fistula. Clinical signs and symptoms that characterized a hazardous carotid cavernous fistula included increased intracranial pressure, rapidly progressive proptosis, diminished visual acuity, hemorrhage, and transient ischemic attacks.

Intraoperative digital subtraction neuroangiography: a diagnostic and therapeutic tool.

We report our experience with intraoperative digital subtraction neuroangiography to demonstrate its application as a diagnostic and therapeutic technique. Intraoperative neuroangiography was performed on 53 occasions in 43 patients using a portable imaging system. Thirty-two procedures were performed for diagnostic purposes after resection of arteriovenous malformations, clipping of aneurysms, or carotid endarterectomy.

Normal perfusion pressure breakthrough occurring during treatment of carotid and vertebral fistulas.

Of the 185 carotid and vertebral fistulas treated by the authors over the past 10 years, five developed neurologic deficits after abrupt closure of their fistulas. The earliest case, treated initially by proximal surgical carotid occlusion, presented 32 years later with cerebral steal symptoms from the large, long-standing carotid cavernous fistula. Upon completion of a surgical trapping procedure, there was immediate massive cerebral edema, brain herniation, and death.

Transluminal angioplasty of the vertebral and basilar artery.

Transluminal angioplasty of brachiocephalic vessels for atherosclerotic lesions is now being performed in selected cases. We have thus far treated 17 cases of vertebral artery stenosis and one case of basilar artery stenosis by intravascular balloon dilatation techniques. Clinical presenting symptoms included vertebral basilar insufficiency, repeated transient ischemic attacks (TIAs), and multiple strokes.