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Extracranial vascular pathology uncommonly causes intracranial subarachnoid hemorrhage (SAH). Among possible lesions are aneurysms at the craniocervical junction arising from a posterior inferior cerebellar artery (PICA) with an extradural origin. We describe a case of a 55-year-old female presenting with a sudden and severe headache. A computed tomography scan revealed a SAH within the fourth ventricle and cervical spinal canal, and a ruptured saccular aneurysm on a PICA with extradural C2-origin. Despite difficult access anatomy, endovascular treatment was feasible and resulted in subtotal initial occlusion and preservation of distal PICA flow. Upon 3-month follow-up, the aneurysm was completely occluded with a patent PICA. The patient's clinical status remained stable at the 1.5-year follow-up. In conclusion, we present a rare case of an aneurysm originating from a PICA with extradural C2-origin that was treated endovascularly with preservation of the PICA. [ABSTRACT FROM AUTHOR]

Vertebro-vertebral fistulas (VVFs) are vascular lesions that may develop after trauma or spontaneously in association with connective tissue disorders. We present a rare case of a post-traumatic VVF in a young patient presenting with a painless swelling and a bruit in her left upper neck. Digital subtraction angiography showed an arteriovenous fistula between the left vertebral artery (VA) and the vertebral venous plexus with significant steal phenomenon. Endovascular therapy was performed using a Woven EndoBridgeTM (WEB)-device combined with coils that allowed preservation of the VA. The patient fully recovered from her symptoms and follow-up imaging showed stable occlusion. In conclusion, VVFs can be effectively treated using intrasaccular flow diverters such as the WEB-device, allowing for complete and stable occlusion while preserving the parent artery. [ABSTRACT FROM AUTHOR]

Cerebral polymer coating embolism from intravascular devices represents a potentially serious complication to endovascular therapy (EVT). We report two cases of neuroendovascular treatment where filamentous polymer fragments were noted possibly due to damage of the surface coating during manipulation and backloading of microguidewires. As the exact origin of the debris was initially not known, microguidewires and fragments were examined with light microscopy, stereomicroscopy, scanning electron microscopy and attenuated-total-reflection Fourier transform infrared spectroscopy. Fragments consisted of polytetrafluoroethylene and silicone oil stemming from the proximal shaft of a standard microguidewire. To our knowledge, this is the first report of polytetrafluoroethylene coating fragments created during EVT. Future studies should assess the mechanism of polymer coating delamination and its potential consequences during EVT including inadvertent fragment migration into the cerebral circulation. [ABSTRACT FROM AUTHOR]

Background Wide necked bifurcation aneurysms (WNBA) are among the most difficult aneurysms to treat. Very low dome- to- neck (DTN) and aspect ratios provide an even greater challenge in the management of WNBAs. We present the safety and efficacy profile for endovascular clip system (eCLIPs) device in the treatment of this subset of WNBAs with very unfavorable morphologies. Methods In our case series, 24 patients treated at 12 international centers were taken from a larger prospective voluntary post- marketing registry of 65 patients treated with the eCLIPs device and coiling. Those who had WNBAs at either the carotid or basilar terminus with a DTN ratio <1.6 and aspect ratio <1.2 were included. Radiologic and clinical outcomes were assessed immediately after the procedure and at the latest follow- up. Results The eCLIPs device was successfully deployed in 23 cases (96%). One patient (4.2%) died due to guidewire perforation distal to the implant site. No other complications were documented. After a mean follow- up of 15.8 months (range 3--40 months), good radiologic outcomes (modified Raymond--Roy classification (MRRC) scores of 1 or 2) were documented in 20 of 21 patients (95%) with follow- up data. The lone patient with an MRRC score of 3 showed coiled compaction after incomplete neck coverage with the device. Conclusion Our series of patients with aneurysms having adverse DTN and aspect ratios demonstrated that the eCLIPs device has a safety and efficacy profile comparable with currently available devices in the treatment of WNBAs. [ABSTRACT FROM AUTHOR]

Hypoglossal canal dural arteriovenous fistulas (HC-DAVF) involve the anterior condylar vein (ACV) and anterior condylar confluence (ACC). They often present with tinnitus, bruit, and hypoglossal nerve palsy. The most common treatment in HC-DAVFs is transvenous embolization using coils and the most direct transvenous route is the trans-internal jugular vein access. When this approach is not feasible, a treatment attempt is possible through alternative routes. We report 2 patients with DAVFs involving the anterior condylar confluence. The first patient presented with pulsatile tinnitus and hypoglossal nerve palsy, and was treated by a standard transjugular approach. The second patient presented with pulse-synchronous bruit. Following an unsuccessful attempt of the transjugular approach, the fistulous point was reached via the deep cervical vein and complete occlusion was achieved by coil deployment. Both patients had complete regression of symptoms. Endovascular therapy is the elective treatment for HC-DAVFs and the transjugular approach is the most commonly used. The deep cervical vein (DCV) can be an alternative transvenous route when the transjugular approach fails. [ABSTRACT FROM AUTHOR]

Behçet's disease is a multisystem chronic autoimmune disease of unknown etiology with a wide spectrum of symptoms and organ system involvement. Arterial manifestations, particularly of the extracranial vertebral arteries, are rare. We report an unusual case of an African American patient with Behçet's disease, who presented with bilateral spontaneous vertebral artery pseudoaneurysms. The patient underwent successful endovascular parent vessel occlusion with detachable coils and on follow-up had complete clinical and angiographic signs of recovery. [ABSTRACT FROM AUTHOR]

This study reports the differences in evolution and course of multiple pseudoaneurysms (PAs) and an axillary arteriovenous fistula (AVF) after penetrating vascular trauma due to shotgun injury to the head and neck. We describe the unusual case of a young man who, following penetrating shotgun injuries to the head and neck, developed multiple PAs of the common carotid, vertebral and superficial temporal arteries as well as an axillary AVF. Serial angiographic follow-up studies documented differences in time of occurrence, evolution and course of these lesions. This allowed for tailored management using endovascular (AVF, superficial temporal artery PAs) and conservative (carotid and vertebral PAs) treatment. No complication occurred and complete cure of all lesions was achieved and documented after seven months. Time of occurrence, evolution and regression of penetrating vascular injuries can differ significantly even in the same patient. Close angiographic follow-up helps not only detect a lesion with delayed occurrence, but also provides a practical basis for decision-making for optimal therapeutic management. [ABSTRACT FROM AUTHOR]

Objective: Computational Fluid Dynamic (CFD) is increasingly being used for modeling hemodynamics in intracranial aneurysms. While CFD techniques are well established, need for validation of the results remains. By quantifying features in velocity patterns measured with 2D phase contrast magnetic resonance (pcMRI) in vivo and simulated with CFD, the role of pcMRI for providing reference data for the CFD simulation is explored. Methods: Unsteady CFD simulations were performed with inflow boundary conditions obtained from 2D pcMRI measurements of an aneurysm of the anterior communication artery. Intra-aneurysmal velocity profiles were recorded with 2D pcMRI and calculated with CFD. Relative areas of positive and negative velocity were calculated in these profiles for maximum and minimum inflow. Results: Areas of positive and of negative velocity similar in shape were found in the velocity profiles obtained with both methods. Relative difference in size of the relative areas for the whole cardiac cycle ranged from 1%–25% (average 12%). Conclusion: 2D pcMRI is able to record velocity profiles in an aneurysm of the anterior commuting artery in vivo. These velocity profiles can serve as reference data for validation of CFD simulations. Further studies are needed to explore the role of pcMRI in the context of CFD simulations. [ABSTRACT FROM AUTHOR]

Radiographic visualization of liquid embolic agents (LEAs) during embolization procedures in neurovascular territory represents a crucial feature to ensure efficacy and safety for the patients during endovascular treatment of arteriovenous shunting lesions. Radiopacity of available LEAs varies significantly and limited methods are currently available for comparison. The purpose of this study was to compare the contrast resolution (CR) during injection under blank roadmap of various LEAs, as well as standard contrast material.An injectable angiographic phantom was designed consisting of parallel tubings between 313 and 1000 micron. Under roadmap, eight radiopaque liquid agents were injected and analyzed: Onyx18®, 34® Squid®12, 18, PHIL®25% (PHIL®25), PHIL®30% (PHIL®30).TrufillTM (NBCA), 30% dilution and Omnipaque®300. CR was evaluated as a contrast to noise ratio (CNR) and calculated as mean peak signal (Sa) minus mean background signal (Sb) divided by the standard deviation of the background signal (Std) ( C N R = S a − S b S t d ) .Omnipaque 300 and NBCA were found to have the highest CR. PHIL®25 demonstrated the lowest CNR (45% of Omnipaque CNR). Onyx 18 and 34 (Both around 82% of Omnipaque CNR) demonstrated higher CNR compared to Squid®12 and 18 (52–55% of Omnipaque CNR). On average, at 500 micron there is a >70% reduction in CNR, and at 313 micron there is a 90% reduction in CNR compared to 1000 micron.Significantly different CNR between most LEAs and iodinated contrast media was evident under roadmap conditions and should be considered prior to injection. [ABSTRACT FROM AUTHOR]

We report the case of a 29-year-old woman presenting with severe back pain and S1-radiculopathy. Digital subtraction angiography revealed a spinal cord arteriovenous malformation complicated by acute feeder dissection and pseudoaneurysm (PA) formation causing mass effect. After conservative management with limited angiographic and clinical improvement, selective treatment of the PA by flow diversion (FD) led to occlusion and shrinkage with the resolution of clinical symptoms. FD may be a feasible treatment option for spinal artery aneurysms in selected patients with favorable anatomy. The need for antiplatelet therapy is a limitation of its use with currently available devices. [ABSTRACT FROM AUTHOR]

Objective: In a previous study, we assessed the conformability limitations of self-expandable stents to a curved vascular model. The LEO stent (Balt Extrusion, Montmorency, France), one of the current self-expandable models available for intracranial aneurysm stenting, displayed 2 adverse mechanics: flattening of the stent midsection and inward crimping of the proximal and distal ends. We present a follow-up study in which we evaluate the conformability to curved vessels of a second-generation stent, LEO PLUS., Methods: A 3.5-x 25-mm LEO PLUS stent was deployed inside a 3-mm x 10-cm polytetrafluoroethylene tube (vascular model) with a simulated 5-mm aneurysm neck at its midsection. The polytetrafluoroethylene tube was then placed in a polystyrene block (styrofoam; Dow Chemical Co., Midland, MI) and bent at different angles ranging from 0 to 150 degrees. For each angle, a rotational radiogram was performed using a C-arm angiographic system with a 30-x 43-cm CsI/amorphous silicon flat detector operated with 23-second rotations, 0.80-degree increments, 166 projections, and a 2480 x 1920 matrix (2K matrix)., Results: The LEO PLUS stent showed symmetric deployment at all tested degrees of curvature, without flattening or kinking. The stent retained its round cylindrical shape at all curvatures without inward crimping of its proximal and distal ends., Conclusion: The previously documented adverse mechanics of the LEO stent were not observed with the new LEO PLUS stent. This suggests better conformability to curved or tortuous vasculature owing to design improvements.

Objective: We describe the mechanical detachment of 2 Guglielmi detachable coils (GDC) that had been placed in a ruptured aneurysm and that failed to detach by electrolysis., Methods: Mechanical detachment was attempted by continuously rotating the delivery wire. The feasibility and reproducibility of this maneuver was tested by conducting additional in vitro tests., Results: Two GDCs that had been positioned in a ruptured cerebral aneurysm and had failed to detach by electrolysis were separated from the delivery wire by rotating the wire until the weakest segment of the coils broke. GDCs tested in vitro with correct detachment positioning could be separated from the microcatheter tip by approximately 15 rotations of the delivery wire without coil loop movement inside the aneurysm., Conclusion: Mechanical detachment of an electrolytic GDC by rotating the delivery wire until a break occurs can be safely performed in a potentially risky situation caused by detachment failure during GDC embolization of cerebral aneurysms.