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BACKGROUND Carotid cavernous fistulas (CCF) often present with diplopia secondary to cranial nerve palsy (CNP). Immediate development of postoperative CNP has been described in the literature. This study described delayed-onset of CNP after complete and reconfirmed obliteration of the CCF and resolution of initial CNP. METHODS A retrospective analysis was performed on patients with indirect CCF between 1987 and 2006 at 4 academic endovascular centers. Details of the endovascular procedures, embolic agents used, and complications were studied. Partial or complete obliteration was determined. Immediate and delayed cranial nerve palsies were independently assessed. RESULTS A total of 267 patients with symptomatic indirect CCF underwent transvenous endovascular treatment. Four patients (1.5%) developed delayed abducens nerve (VI) palsy after complete resolution of presenting symptoms after embolization. Delayed presentation ranged between 3 and 13 months after complete resolution of initial double vision and cranial nerve palsies. Transvenous coil embolization through the inferior petrosal sinus was performed in all 4 affected patients. All had follow-up angiography confirming durable closure of their CCF. MRI did not show new mass lesions or abnormal soft tissue enhancement. In all 4 patients, their abducens nerve (VI) palsy remained. CONCLUSIONS Delayed CNP can develop despite complete endovascular obliteration of the CCF. The cause of delayed CNP is not yet determined, but may represent fibrosis and ischemia. Long-term follow-up is needed even after complete neurological and radiological recovery is attained in the immediate perioperative period.

BACKGROUND Endovascular surgery is the first-line treatment for indirect cavernous carotid fistulae (CCFs). This study compares multiple treatment techniques. OBJECTIVE To compare endovascular techniques for indirect CCF treatment. METHODS Retrospective analysis was performed of prospectively maintained records at 4 centers, identifying patients undergoing indirect CCF embolization. Demographics, symptoms, and lesion characteristics were recorded. Medical records were reviewed for changes in symptoms, delayed complications, and angiographically proven recurrence. Univariate and multivariate analyses were performed to identify impacts of the above characteristics on outcomes. RESULTS Sufficient records were available for 267 patients treated between January 1987 and December 2016. Obliteration was achieved in 86.5% patients, occurring in 86.9% of exclusively transvenous treatments and 79.5% of other treatments. Obliteration rates were highest following transvenous embolization using coils compared to all other materials (likelihood ratio [LR] 5.0, P = .024). Complications were less common with coil embolization compared to other materials (LR 0.070, P

The authors describe, for the first time to their knowledge, a case of a congenital macrocystic lymphatic malformation of the orbit with associated venous stasis retinopathy that acutely normalized after drainage and sclerotherapy of the lesion. Prenatal ultrasound revealed prominence of the left orbital soft tissue, and at birth, the patient was noted to have unilateral proptosis, tortuous retinal vessels, and intraretinal hemorrhages in all 4 quadrants in the left eye. MRI demonstrated a primarily intraconal, multiloculated, T2-hyperintense mass consistent with a lymphatic malformation. Ultrasound-guided cyst aspiration and sclerotherapy was performed, with subsequent improvement of the proptosis and resolution of the vessel tortuosity and intraretinal hemorrhages. Although venous stasis retinopathy is usually related to central retinal vein occlusion or carotid artery occlusive disease, any entity that increases orbital venous resistance can generate retinal venous dilation and intraretinal hemorrhages, including an orbital lymphatic malformation.

Introduction: Arterial access is a technical consideration of mechanical thrombectomy that may affect procedure time. Few studies exist detailing the impact of aortic arch and carotid anatomy on procedure times and patient outcomes. Methods: We included 56 patients who underwent embolectomy with successful revascularization for acute ischemic stroke in the anterior circulation from a period of 01/2016-05/2018. The average age was 71 (+/- 17 years) with 39% being male. We calculated anatomic variables on the affected side from CT angiograms immediately prior to embolectomy including the medial-to-lateral span, as well as the anterior-to-posterior span, of both the aortic arch and carotid arteries. In addition, the take-off angle of the respective vessel (left common carotid or right brachiocephalic) was calculated. Charts were reviewed for procedural times and epidemiologic information (HTN, HLD, DM, CAD and Afib). Modified Rankin Scale (mRS) was calculated from PT/OT and outpatient neurology notes. Partial correlation coefficients were performed between anatomic variables, temporal variables and outcome variables after adjustment for age, gender and epidemiologic information. Results: There was a significant positive correlation between procedure time (time at groin puncture to time at reperfusion) and take-off angle. There were no other significant correlations between anatomic measures and procedure time. In addition, there was as a significant positive correlation between both procedure time and time from last seen normal to reperfusion and delta mRS (the difference between pre-stroke and post-stroke mRS). See table 1 for correlations. Conclusion: These results suggest that patients with larger take-off angles have an association with longer procedural times and worse outcomes. If these patients can be effectively identified prior to the procedure, operators could feasibly use a non-femoral access method initially to reduce procedure time.

Introduction: Cerebral aneurysms affect 1-6% of the population and their rupture carries significant mortality and morbidity. The paucity of data related to histopathological features of aneurysms stems largely from the risks associated with aneurysm tissue collection. We set out to establish a feasible technique to isolate viable endothelial cells (EC) and to characterize the differences in genetic expression (GE) between iliac arterial cells vs. aneurysm cells and non-ruptured vs. ruptured aneurysm cells. Methods: 10 patients (5 non-ruptured and 5 ruptured) undergoing aneurysm treatment were enrolled under IRB approval. ECs from aneurysms and iliac arteries were sampled using an appropriately sized coil and a 0.035 “J” wire respectively. Coils and wires were processed via FACS and single cell qPCR to quantify expression of 48 genes implicated in EC function and aneurysm pathogenesis. Mixed models were performed using each GE level as the outcome with multiple predictors. Unsupervised cluster analysis including: hierarchical heat-map clustering, K-medoids, principle components, cART, and self-organizing maps (SOM) were used to find cell clusters based on coordinately expressed GE. Results: 437 FACS-sorted cells were collected and 319 demonstrated CD31, CD34 and CD105 triple-positive expression. Of these, 94 were aneurysmal cells. The average number of extracted aneurysm cells per patient was 9.4 (1-24, median 6.5) with a trend for higher cell yields from ruptured aneurysms (p = 0.116). Mixed model analyses revealed a history of smoking showed the strongest associations with GE (median p-value 0.104 with 11/48 analyses p < 0.05); 5 genes significantly predicted rupture status (median p-value 0.363 with 5/48 analyses p < 0.05); and one gene significantly differentiated cell type (median p-value 0.557, with 1/48 analyses p < 0.05). SOM analysis revealed clustered GE profiles suggestive of distinct functional EC sub-populations. Conclusion: Cerebral endovascular sampling is a safe and reliable means for targeted cell collection for genetic analysis. Smoking was strongly associated with GE levels. Our analysis provides evidence that GE levels may be associated with cell type and rupture status.

Background and Purpose— We investigated whether brain arteriovenous malformation silent intralesional microhemorrhage, that is, asymptomatic bleeding in the nidal compartment, might serve as a marker for increased risk of symptomatic intracranial hemorrhage (ICH). We evaluated 2 markers to assess the occurrence of silent intralesional microhemorrhage: neuroradiological assessment of evidence of old hemorrhage—imaging evidence of bleeding before the outcome events–and hemosiderin positivity in hematoxylin and eosin-stained paraffin block sections. Methods— We identified cases from our brain arteriovenous malformation database with recorded neuroradiological data or available surgical paraffin blocks. Using 2 end points, index ICH or new ICH after diagnosis (censored at treatment, loss to follow-up, or death), we performed logistic or Cox regression to assess evidence of old hemorrhage and hemosiderin positivity adjusting for age, sex, deep-only venous drainage, maximal brain arteriovenous malformation size, deep location, and associated arterial aneurysms. Results— Evidence of old hemorrhage was present in 6.5% (n=975) of patients and highly predictive of index ICH ( P P =0.010). Hemosiderin positivity was found in 36.2% (29.6% in unruptured; 47.8% in ruptured; P =0.04) and associated with index ICH in univariate (OR, 2.18; 95% CI, 1.03–4.61; P =0.042; n=127) and multivariable models (OR, 3.64; 95% CI, 1.11–12.00; P =0.034; n=79). Conclusions— The prevalence of silent intralesional microhemorrhage is high and there is evidence for an association with both index and subsequent ICH. Further development of means to detect silent intralesional microhemorrhage during brain arteriovenous malformation evaluation may present an opportunity to improve risk stratification, especially for unruptured brain arteriovenous malformations.

OBJECTIVE: Brain arteriovenous malformations (AVM) have high matrix metalloproteinase-9, interleukin-6, and myeloperoxidase (MPO) expression, and polymorphic variations in inflammatory genes are associated with an increased risk of hemorrhage. In this study, we characterized the presence of inflammatory cells in AVM lesional tissue specimens. METHODS: Immunohistochemistry was used to identify and localize neutrophils (MPO as marker), macrophages/microglia (CD68 as marker), T lymphocytes (CD3 as marker), and B lymphocytes (CD20 as marker). Endothelial cell (EC) marker CD31 was used as an index to assess vascular mass (EC mass). Surgical specimens from 20 unruptured, nonembolized AVMs were examined; seven cortical samples from temporal lobectomy were used as controls. Positive signals for inflammatory cell markers were counted and analyzed by normalizing to the area of the tissue section and the amount of endothelial cells (cells/mm 2 /EC mass pixels). Levels of MPO and matrix metalloproteinase 9 were determined by enzyme-linked immunosorbent assay. RESULTS: Neutrophils and macrophages are all frequently identified in the vascular wall of AVM tissue. In contrast, T and B lymphocytes are rarely observed in AVM tissue. AVM tissue displayed more neutrophil and macrophage/microglia markers than epilepsy control tissue (MPO: 434 ± 333 versus 5 ± 4, P = 0.0001; CD68: 454 ± 404 versus 4 ± 2, P = 0.0001; cells/mm 2 /EC mass pixels). In ex vivo studies, neutrophil quantity, MPO, and matrix metalloproteinase-9 levels were all colinear (R 2 = 0.98-0.99). CONCLUSION: Our study demonstrates that inflammatory cells are present in AVM tissue. Taken together with previous genetic and cytokine studies, these data are consistent with a novel view that inflammation is associated with AVM disease progression and rupture.

OBJECTIVE: The goals of this study were to characterize the clinical, radiological, treatment, and outcome data associated with patients diagnosed with spinal dural arteriovenous fistulae (SDAVFs) at a single tertiary care institution over a 20-year period. METHODS: A 20-year retrospective study was undertaken at our university hospital. Patients with mixed intracranial and spinal dural fistulas were excluded. A literature review of articles reporting endovascular or combined treatment of SDAVFs was performed. RESULTS: Between 1984 and 2005, our institution diagnosed and treated 63 patients (mean age, 62; 13 women, 50 men) with SDAVFs. The presenting symptoms were consistent with progressive myelopathy, and included lower extremity weakness (33 patients, 52%), parasthesias (19 patients, 30%), back pain (15 patients, 24%), and urinary symptoms (four patients, 6%). Thirty-nine patients underwent an initial endovascular embolization with 27 requiring only this first procedure for complete obliteration. On the other hand, 24 patients underwent an initial surgical procedure with 20 of them treated successfully with a single operation. Endovascular patients presented at mean age 62.3 years (standard deviation [SD], 10.6), were hospitalized for an average of 3.1 days (SD, 2.6), and were followed-up for 39 months (SD, 33). Surgical patients presented at mean age of 65.8 years (SD, 10.3), were hospitalized for 9.8 days (SD, 2.7), and were followed-up for 35 months (SD, 44). A significant improvement in Aminoff-Logue scores was found in both the endovascular and surgery groups (gait, P < 0.001; micturition, P = 0.005). The endovascular group had reduced hospitalization (P = 0.0001). No differences were found in the magnitude of clinical response to treatment. CONCLUSION: SDAVFs most commonly present with progressive myelopathy, yet often remain undiagnosed for months or years. Endovascular therapies and surgical therapies are associated with significantly improved symptoms once the definitive diagnosis of SDAVF is made.

OBJECTIVE: Diffuse arteriovenous malformations (AVM) have non-compact niduses, irregular margins, and intervening brain parenchyma. Deep perforating arteries often contribute to the ragged border of these diffuse AVMs. We hypothesized that diffuseness and deep perforator supply increase the difficulties and risks associated with microsurgical AVM resection. METHODS: Diffuseness was quantified using computer-generated outlines of AVMs on angiograms, contour plots with varying image intensities, and calculations of nidus area-intensity profiles. Diffuse AVMs had nonlinear area-intensity profiles with high transition intensities ([I*] greater than 0.5). A consecutive series of 304 patients who were treated with microsurgical AVM resection over a period of 7.8 years was analyzed, along with quantification of diffuseness in a subset of 103 consecutive patients. Neurological outcomes were assessed by using the Modified Rankin Scale, and logistic regression analysis was used to identify predictors of deterioration and poor outcome at late follow-up evaluation. RESULTS: Diffuse niduses were observed in 25% of patients, and 18% of patients had deep perforating artery supply. Patients with compact AVMs were more likely to have good outcomes or overall improvement (88 and 87%, respectively) than patients with diffuse AVMs (65 and 54%, respectively) (P = 0.008 and P< 0.001 / respectively), Similarly, absence of deep perforator supply was associated with good outcomes or improvement in 85 and 78% of patients, respectively, compared with 63 and 64% of patients, respectively; in patients with deep perforator supply (P< 0.001 and P= 0.028, respectively). By logistic regression analysis, diffuseness and deep perforator supply were both associated with significant increases in surgical risk. CONCLUSION: Diffuseness and deep perforating artery supply are subtle features of an AVM that predict worse outcomes after microsurgical resection. Diffuseness makes surgical planes more difficult to determine and follow, whereas deep perforators are friable, poorly visualized, and located in eloquent white matter tracts. The Spetzler-Martin grading scale does not directly account for these two features; however, they should be considered carefully when making treatment recommendations to patients with AVMs.

OBJECTIVE Despite its quantitative definitions, the Spetzler-Martin grading scale for brain arteriovenous malformations (AVMs) is subject to interobserver variability, particularly when observers differ in their subspecialties. Interobserver variability between neuroradiologist and neurosurgeon grading was analyzed in a large AVM series to determine its extent, causes, and clinical implications. METHODS In a consecutive surgical series of 224 AVM patients, Spetzler-Martin grades were assigned independently by a neuroradiologist and a neurosurgeon. Interobserver agreement was measured with a Cohen kappa analysis and the Wilcoxon signed-rank test. RESULTS Disagreement in grades occurred in 62 (27.7%) patients. By kappa analysis, agreement was highest for venous drainage pattern (kappa = 0.90), intermediate for eloquence (kappa = 0.71), and lowest for size (kappa = 0.67), with substantial agreement on overall grade (kappa = 0.61). By Wilcoxon signed-rank test, size scores and AVM grades were significantly different. Causes of interobserver variability in grading included diffuse nidus, differences in angiographic versus surgical borders, paradoxical venous drainage, and the ambiguity of eloquence. Interobserver variability affected outcome data but did not diminish the predictive value of the Spetzler-Martin scale. CONCLUSION The Spetzler-Martin grading system can be applied reliably to most AVMs with good agreement between observers, but some unusual AVMs expose the system's imprecision and subjectivity. Interobserver variability can affect reporting of results, surgical risk assessment, and patient selection. Undergrading may encourage borderline surgical candidates to choose surgery and obtain results below their expectations.

OBJECTIVE: We hypothesized that coexisting extranidal arterial aneurysms (EAs) would be associated with an increased risk of incident intracranial hemorrhage (ICH) from brain arteriovenous malformation (BAVM) rupture. METHODS: To determine the presence of EAs and compare the sources and locations of ICH, we retrospectively reviewed the computed tomographic, magnetic resonance imaging, and angiographic studies of patients who presented between 1990 and 1999. EAs were defined as saccular luminal dilations of the parent feeding vessels that were proximally flow-related (i.e., at the circle of Willis), distally flow-related (i.e., distal to the circle of Willis), and unrelated (i.e., in circulation distant from the BAVM). RESULTS: Of 314 BAVM patients, 138 (44%) presented with ICH. In the ICH group, 22 patients (16%) had aneurysmal ICH, 100 (72%) had BAVM ICH, and 16 (12%) had ICH from an indeterminate source. There were 61 patients with 1 or more EAs (29 patients with 42 flow-related proximal aneurysms, 39 patients with 48 flow-related distal aneurysms, and 10 patients with 20 unrelated aneurysms). Multivariate regression analysis revealed that ICH patients were more likely than non-ICH patients to have a coexisting EA (35 versus 13%; odds ratio = 3.9; 95% confidence interval, 2.1-7.5; P < 0.001), but this effect was not present when only BAVM-related ICH was considered (odds ratio = 0,3; 95% confidence interval, 0.1-1.0; P = 0.052). Other independent predictors of ICH included small AVM size (

OBJECTIVE The most common location for dural arteriovenous fistulae (AVFs) is the transverse/sigmoid sinus. We describe our prospective analysis of data for 10 patients with recipient fistulae parallel to the transverse/sigmoid sinus. Recognition of this entity allows embolization of the fistula with preservation of the parent sinus. This report reviews the presentation and angiographic characteristics of the “parallel venous channel” and the treatment results for this series of patients. METHODS Between 1995 and June 2002, at the medical center of the University of California, San Francisco, we identified 10 patients with a parallel venous channel as the recipient pouch for all arterial input into a transverse/sigmoid sinus AVF. The clinical presentations, angiographic features, endovascular treatments, and outcomes are described. Angiographic follow-up monitoring was performed for 1 to 6 years for all patients with cortical venous drainage (5 of 10 patients). Clinical follow-up periods ranged from 1 to 7 years. RESULTS All patients presented with pulsatile tinnitus disruptive to sleep. Other symptoms included severe headaches, papilledema and visual disturbances, hemiparesis, and mastoid pain. All 10 parallel venous channels communicated with the transverse or sigmoid sinus. Cortical venous drainage was present in 50% of cases. Endovascular ablative procedures, using either coils or ethanol, were performed for all patients. The parallel venous channel was successfully embolized, with preservation of the transverse/sigmoid sinus, for all 10 patients. There were no major complications. All patients experienced resolution of their symptoms, with no recurrence. CONCLUSION The existence of a parallel venous channel as the recipient pouch for all arterial inflow in a series of 10 transverse/sigmoid sinus AVFs is described. Endovascular obliteration of the parallel channel, with preservation of the parent sinus, was successfully performed for all 10 patients. Recognition of the parallel venous channel is clinically important for the treatment of transverse/sigmoid AVFs.

OBJECTIVE To determine the usefulness of endovascular embolization for treatment of dural arteriovenous fistulae of the superior petrosal sinus. METHODS We performed a retrospective review of 18 patients treated during a 16-year period. Transarterial and/or transvenous embolizations were performed as a preoperative adjunct or definitive therapy. Clinical follow-up status was supplemented by telephone interviews to determine Glasgow Outcome Scale scores. RESULTS Fourteen patients (78%) were treated with a combination of endovascular therapy and open surgery, and 4 were treated by embolization alone (22%). Angiographic cure was achieved in all patients (100%). Thirty-day morbidity and mortality were 11 and 0%, respectively. The mean follow-up period was 5.4 years. At the latest follow-up examination, all patients had returned to independent clinical status (Glasgow Outcome Scale scores of 1 or 2). CONCLUSION Endovascular treatment of dural arteriovenous fistulae of the superior petrosal sinus can result in cure when access to the site of the fistula can be achieved. Preoperative embolization is a safe and effective adjunct to minimize bleeding during open neurosurgery.

Background and Purpose— Excessive degradation of the vascular matrix by matrix metalloproteinases (MMPs) can lead to structural instability of vessels. In this study we examined the expression of MMPs and tissue inhibitors of metalloproteinases (TIMPs) in brain arteriovenous malformations (BAVMs). Methods— We performed gelatin zymography for MMPs and Western blot for MMP-9, MMP-2, TIMP-1, TIMP-2, TIMP-3, and TIMP-4. MMP-9 expression was localized by immunohistochemistry. Results— We analyzed 37 BAVM specimens and 9 control brain specimens from epilepsy surgery. Thirty-two BAVM patients had embolization treatment before resection. Eighteen BAVM patients had a history of hemorrhage from BAVMs. Neither MMP-2 nor TIMP-2 was detected in BAVMs or control brain specimens. Compared with control brain samples, BAVM samples had higher levels of total MMP-9, active MMP-9, pro-MMP-9, TIMP-1, and TIMP-3. TIMP-4 levels were higher in the control brain than in BAVM specimens. MMP-9 was localized to the endothelial cell/peri–endothelial cell layer and infiltrating neutrophils of BAVMs. BAVMs with venous stenosis ≥50% had higher expression of MMP-9 than BAVMs with venous stenosis Conclusions— We found increased levels of MMP-9 and TIMPs in BAVMs. Abnormal balance of MMP-9 and TIMPs may contribute to vascular instability of BAVMs.

OBJECTIVE Although anterior circulation disease has both medical and surgical treatment options, management of vertebrobasilar disease has predominantly had only medical options. Some patients remain symptomatic despite medical treatment, and angioplasty has been demonstrated to relieve critical stenoses. However, the relative safety and effectiveness of medical and surgical treatments is not clearly known. This report reviews the clinical characteristics, indications, and procedural risks of intracranial angioplasty in a series of patients with symptomatic posterior circulation ischemia. METHODS All patients undergoing angioplasty for critical intracranial vertebral or basilar artery stenosis at the University of California at San Francisco Medical Center between June 1986 and July 1999 were included in a retrospective record review. Clinical features and procedural complications were recorded. RESULTS Angioplasty was performed on 25 vessel lesions in 25 patients in whom medical therapy had failed. The patients ranged in age from 50 to 87 years. Of the 25 stenoses, 10 were intracranial vertebral, 9 vertebrobasilar junction, and 6 basilar in location. Angioplasty was effective in reducing the degree of stenosis by more than 40% in all 25 vessels. The overall risk of stroke or death was 28%, and the risk of disabling stroke or death was 16%. CONCLUSION Intracranial posterior circulation angioplasty is effective in the reduction of stenosis and can be performed with relative safety. Angioplasty can be considered as a treatment option in patients with recurrent ischemic symptoms despite medical therapy.

Background — Patients harboring a brain arteriovenous malformation (BAVM) often have coexisting arterial aneurysms. Experts have argued about the clinical significance of these aneurysms, which may be important for risk stratification in patient management and clinical trials. We studied the association between coexisting aneurysms and initial presentation with intracranial hemorrhage (ICH) in patients with BAVM evaluated at two tertiary-care centers. Methods — Demographic and clinical data were collected from a prospective series of patients evaluated for BAVM at the University of California, San Francisco (UCSF; n=82), and Columbia-Presbyterian Medical Center, New York (CPMC; n=254). Using multivariate logistic regression, we examined the independent association between ICH presentation and the presence of a coexisting aneurysm, and compared the association at the two hospitals. Results — Aneurysms were associated with 28 BAVMs at UCSF (34%) and 74 at CPMC (29%; P =0.39). Initial presentation with ICH was associated with the presence of a coexisting aneurysm at CPMC (odds ratio 1.8, 95% confidence interval 1.0 to 3.0, P =0.044). The opposite trend was observed at UCSF (odds ratio 0.4, 95% confidence interval 0.2 to 1.1, P =0.085). We observed an interaction by site involving the association between ICH presentation and aneurysm ( P =0.016). Conclusion — Although many BAVM characteristics were similar at the referral centers studied, the association between initial presentation with ICH and coexisting aneurysms was not. This heterogeneity between populations undermines the validity of inferences on the role of aneurysms from any single referral series, and emphasizes the complexity in creating BAVM risk-stratification models that incorporate aneurysms.

Background and Purpose: To determine if clinical and angioarchitectural features of brain AVMs differ between children and adults. Materials and Methods: A prospectively collected institutional database of all patients diagnosed with brain AVMs since 2001 was queried. Demographic, clinical, and angioarchitecture information was summarized and analyzed with univariable and multivariable models. Results: Results often differed when age was treated as a continuous variable as opposed to dividing subjects into children (≤18 years) versus adults (>18 years). Children were more likely to present with AVM hemorrhage than adults (59% vs. 41%, p=0.001). Although AVMs with a larger nidus presented at younger ages (mean of 26.8 years for greater than 6 cm compared to 37.1 years for less than 3 cm), this was not significantly different between children and adults (p=0.069). Exclusively deep venous drainage was more common in younger subjects both when age was treated continuously (p=0.04), or dichotomized (p Conclusion: Although children with brain AVMs were more likely to come to clinical attention due to hemorrhage than adults, venous ectasia and feeding artery aneurysms were underrepresented in children, suggesting that these particular high risk features take time to develop.

“If you wish to converse with me,” said Voltaire, “define your terms.” How many a debate would have been deflated into a paragraph if the disputants had dared to define their terms! Will Durant: The Story of Philosophy

Objective Cerebral hyperperfusion syndrome is a recognized complication of carotid endarterectomy, with a reported incidence of 0.3 to 1.2%. The incidence of cerebral hyperperfusion after endovascular revascularization procedures of the craniocervical arteries remains unknown. We evaluated the incidence of cerebral hyperperfusion syndrome in our endovascular revascularization series. To our knowledge, there are no previous studies evaluating the incidence of hyperperfusion syndrome after percutaneous transluminal angioplasty/stenting. Methods Between March 1996 and February 2000, 140 patients underwent percutaneous transluminal angioplasty/stenting of the craniocervical arteries at our institution. In all patients, selective bilateral arteriography of the carotid and vertebral arteries was performed to document the sites of craniocervical stenosis and collateral blood flow and the results of the endovascular revascularization procedure. We then reviewed all pertinent medical records, arteriographic films, and sectional imaging studies to determine the incidence of cerebral hyperperfusion in this series. Results Seven patients (5.0%) developed clinical or radiological manifestations of cerebral hyperperfusion. In the target group, percutaneous transluminal stenting achieved a 90 to 100% reduction in stenotic lesions (mean stenosis, 91%) of the carotid (n = 5) and vertebral (n = 2) arteries. All seven patients remained neurologically stable immediately after treatment. There was delayed development of clinical and radiographic findings, suggestive of cerebral hyperperfusion. Six patients showed evidence of ipsilateral hemispheric edema, including two patients who developed intracranial hemorrhage (one parenchymal, one parenchymal and subarachnoid) documented by computed tomographic brain scans. Symptoms resolved within 72 hours in the four patients without hemorrhage. The two patients with hemorrhage recovered during a more protracted period (range, 3 wk to 6 mo). There were no long-term sequelae or deaths during a cumulative follow-up of 84 months (mean follow-up, 12 mo). Conclusion Hyperperfusion syndrome is an uncommon but potentially serious complication of extracranial and intracranial angioplasty and stenting procedures. The clinical manifestations are similar to hyperperfusion syndrome after carotid endarterectomy; however, the prevalence may be greater in the high-risk cohort commonly referred for endovascular treatment. Our findings suggest that patients undergoing endovascular stenting procedures should be closely monitored for evidence of hyperperfusion, with careful monitoring of blood pressure, heart rate, and anticoagulation. Further research is needed to confirm that cerebral hyperperfusion is the pathogenesis of this condition.

Background and Purpose —Vertebrobasilar territory ischemia (VBI) leads to disabling neurological symptoms and poses a risk for stroke by an embolic or flow-related mechanism. We present our clinical experience in the endovascular treatment of patients with symptomatic VBI from severe atherosclerosis or dissection of the vertebral and subclavian arteries that was unresponsive to medical therapy. Methods —Twenty-one patients (9 female, 12 male) with a mean age of 65.7 years (range 47 to 81 years) underwent treatment with percutaneous endovascular balloon angioplasty and stent placement. Sixteen patients (76.2%) had evidence of contralateral involvement, and 9 (42.8%) demonstrated severe anterior-circulation atherosclerosis. Nine patients had a previous infarct in the occipital lobe, cerebellum, or pons before treatment. Follow-up was available for all patients. Results —Balloon angioplasty with intravascular stent placement was performed in 13 vertebral artery lesions (10 at the origin, 3 in the cervical segment) and in 8 subclavian lesions. The prestenting stenosis was 75% (50% to 100%) and was reduced to 4.5% (0% to 20%) after stenting. Six of the patients with proximal subclavian stenosis demonstrated angiographic evidence of subclavian steal, which resolved in all cases after treatment. All patients showed improvement in symptoms after the procedure except for 1 who developed a hemispheric stroke after thrombotic occlusion of an untreated cavernous carotid artery stenosis (rate of major stroke and mortality=4.8%). One patient (4.8%) had a periprocedural transient ischemic attack (TIA), and none had minor stroke. At long-term follow-up (mean=20.7±3.6 months) of the surviving 20 patients, 12 (57.1%) remained symptom-free, 4 (19%) had at most 1 TIA over a 3-month period, 2 (9.5%) had at most 1 TIA per month, and 2 (9.5%) had persistent symptoms. There were no clinically evident infarcts during the follow-up period. Conclusions —Endovascular treatment using balloon angioplasty with intravascular stent placement for symptomatic stenotic lesions resulting in VBI that is unresponsive to medical therapy appears to be of benefit in this high-risk subset of patients with poor collateral flow.

Objective and importance Intimal dissection constitutes one of the complications associated with angioplasty of intracranial vessels. We present a case of iatrogenic dissection of the entire basilar artery, which was induced by angioplasty and stenting of symptomatic, focal, intracranial vertebral artery stenosis, and its successful treatment with tandem deployment of a downstream stent. Clinical presentation A 61-year-old, hypertensive, renal transplant recipient presented with orthostatic vertebrobasilar insufficiency that was refractory to medical management, including anticoagulation therapy. Angiography revealed an occluded right vertebral artery and focal, high-grade, left intracranial vertebral artery stenosis. Magnetic resonance imaging showed multiple posterior fossa infarctions. The left intracranial vertebral artery stenosis was successfully treated with primary stent deployment and balloon angioplasty, with symptom resolution. On postprocedure Day 2, the patient noted worsening right hemiparesis. Intervention Subsequent angiography revealed a flow-limiting, windsock-type, basilar artery dissection beginning at the distal end of the left vertebral artery stent and extending to the origin of the left posterior cerebral artery. A tandem stent was navigated intracranially and deployed past the first one, successfully sealing the dissection inflow zone and reconstituting normal flow to the top of the basilar artery. A clinical follow-up examination at 3 months revealed no further orthostatic symptoms and only mild residual right-sided weakness. Conclusion This is the first description of iatrogenic stent-induced dissection of the entire basilar artery that was successfully treated by inflow zone control via tandem intracranial stent deployment.

OBJECTIVE AND IMPORTANCE: The goal of this report was to describe the successful percutaneous endovascular use of a Gianturco-Roubin-2 coronary stent in the treatment of an acute atherothrombotic occlusion of the basilar artery. To our knowledge, the percutaneous endovascular deployment of an intra-arterial stent for the treatment of an acute atherothrombotic occlusion of the basilar artery and the percutaneous endovascular placement of a Gianturco-Roubin-2 stent in the basilar artery have not been previously reported. CLINICAL PRESENTATION: An 83-year-old man presented with a recurrent, transient, locked-in syndrome resulting from a lower basilar artery occlusion caused by vertebrobasilar thrombosis superimposed on severe proximal basilar artery atheromatous stenosis. INTERVENTION: After successful superselective intra-arterial thrombolysis of the vertebrobasilar clot, balloon angioplasty of the underlying basilar artery stenosis was performed, without significant angiographic improvement. Percutaneous endovascular deployment of a Gianturco-Roubin-2 coronary stent of 4-mm diameter was subsequently performed, with excellent angiographic results. CONCLUSION: The patient made a very good neurological recovery but unfortunately died as a result of cardiogenic shock and sepsis. Detailed neuropathological follow-up results are presented; stent patency was revealed in the postmortem examination. The anatomic and pathophysiological considerations of basilar artery stent placement for the treatment of acute basilar artery occlusion related to atherosclerotic stenosis are discussed.

Background: Vertebral artery dissection due to dynamic compression by abnormal C1-C2 anatomy is under-recognized in childhood stroke. Our aim was to describe underlying pathologic variants of C1-C2 soft tissue or bone in children with vertebral artery dissection and posterior circulation strokes. Methods: A series of five children diagnosed with vertebral artery dissection from compression by C1-C2 soft tissue or bone were identified at a single pediatric stroke center. Diagnostic evaluation, anatomic cause of dissection, and treatment were abstracted from medical records. Results: Five children (all boys, ages 6 - 14) were identified with a diagnosis of posterior circulation embolic strokes due to focal vertebral artery dissection and presumed compression against adjacent C1-C2 abnormalities. Four had recurrent events, including basilar artery thrombosis, before the cervical abnormality was identified. Vertebral artery dissections were caused by bony (congenital arcuate foramen, post-traumatic os odontoideum) and soft tissue pathology (ruptured atlantoaxial bursa, anomalous C1-C2 connective tissue bands) (Table). Vertebral artery compression at dissection sites during head rotation was confirmed by angiography with head in neutral and rotated in children with soft tissue anomalies. No other etiology for stroke or dissection was found in any of the cases. For secondary stroke prevention, four children underwent direct surgical decompression of the vertebral artery or spinal fusion; one opted for activity restriction and aspirin. None had further recurrences after treatment with a median follow-up of 9 months (range 1 to 61). Conclusions: In children with recurrent vertebral artery dissection and strokes, C1-C2 bone imaging and dynamic angiogram with neck rotation can identify cervical pathology that may otherwise be missed. Cervical stabilization or resection of the compressive pathology should be considered to prevent stroke recurrence.

Ten patients with giant intradural spinal arteriovenous fistulas (perimedullary Types II and III) were treated with embolization alone (three patients) or in combination with surgery (seven patients). Their ages at the time of treatment ranged from 2 to 40 years, with a mean of 19.5 years. The indications for treatment included progressive myelopathy in five patients, spinal subarachnoid hemorrhage in four, and acute paraplegia in one. Associated conditions included Rendu-Osler-Weber syndrome in two patients, and Cobb's syndrome in two patients. In one patient, the cause of the fistula may have been related to epidural anesthesia traumatizing a low tethered cord. Angiographically, the fistulas were subclassified in three groups: a single-hole fistula supplied by a single feeding medullary artery (three patients); a single-hole fistula supplied by multiple medullary arteries (three patients); and multiple separate fistulas supplied by multiple medullary arteries (four patients). Eight patients were classified as perimedullary Type III and two as perimedullary Type II. Embolic agents were delivered from transarterial routes in 14 procedures and transvenous routes in 2 procedures. A total of 16 embolizations and 8 operations were performed in 10 patients. Seven patients were cured of their fistula (as demonstrated by angiography), two patients had 5% residual filling and are scheduled for future therapy. One refused a follow-up angiographic examination. Complications related to embolization included rupture of the anterior spinal artery by a detachable balloon, resulting in transient worsening of paraplegia with recovery to baseline. Transient worsening of symptoms after surgery was common, but all patients returned to baseline or better. Dramatic improvement was observed in four patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Three patients underwent transarterial platinum coil embolization of unusual posterior inferior cerebellar artery aneurysms. In one case, a giant, bilobed, partially thrombosed aneurysm exhibited marked mass effect on the adjacent medulla. In the second case, diffuse severe cerebral vasospasm, 3 days after subarachnoid hemorrhage, rendered transvascular treatment of the aneurysm difficult. Increasing vertigo and nausea caused by mass effect from an aneurysm previously coated with methyl methacrylate warranted treatment in the third case. Indications for transvascular coil treatment included relative surgical inaccessibility to the aneurysm, and, in our case, inability to perform transarterial detachable balloon therapy. The aneurysms were obliterated by endovascular coil embolization in each case. In the patient with vasospasm, aneurysm treatment followed angioplasty of the major affected cerebral vessels, resulting in significant neurological improvement within 24 hours. Two patients were neurologically intact at the time of discharge, and the third displayed persistent cerebellar signs despite a marked decrease in vertigo and nausea. Reports of transvascular coil embolization of intracranial aneurysms are very rare. Our experience with these patients demonstrates that this technique can be successfully utilized in selected cases.

Four patients with Ehlers-Danlos syndrome presented spontaneously with symptomatic direct carotid-cavernous fistulas. Two had previously (2 and 15 years, respectively) had contralateral carotid-cavernous fistulas that were treated with carotid occlusion procedures. The patients' ages at presentation ranged from 19 to 49 years, with a mean of 32 years. All four patients underwent attempted embolization procedures. Two patients had transarterial embolization, one with balloons and liquid adhesives, one with platinum coils and a balloon; the carotid artery was preserved in one and sacrificed in one other. In one patient, who underwent direct puncture of the carotid artery, a massive hematoma causing airway compromise required intubation and emergent surgical repair, The fistula spontaneously closed during this event. In the fourth patient, two transvenous embolizations resulted in markedly decreased flow, but diversion of residual flow to cortical veins produced a fatal pontine hemorrhage. The vascular fragility associated with Ehlers-Danlos syndrome can produce spontaneous direct carotid-cavernous fistulas and makes both diagnostic and therapeutic procedures more difficult.

Eight patients with dural arteriovenous fistulas (DAVFs) located on the floor of the anterior cranial fossa and supplied by enlarged ethmoidal branches of the ophthalmic artery are described. Five patients showed the classical symptom of intracerebral hemorrhage (all five had ipsilateral frontal lobe hematomas and one also had an associated a subdural hematoma). Two patients exhibited atypical symptoms of proptosis, chemosis, elevated intraocular pressure, and loss of vision secondary to an ethmoidal DAVF, which drained posteriorly to the cavernous sinus. The eighth patient exhibited proptosis and chemosis secondary to a cavernous sinus DAVF and was incidentally found to have an asymptomatic ethmoidal DAVF. One additional patient had two separate dural fistulas: one located on the cribriform plate and the second located in the posterior fossa. Seven of the eight patients were cured by surgical excision of the fistula site; in the remaining patient spontaneous obliteration followed a surgical procedure for a cavernous DAVF. DAVFs involving the floor of the anterior cranial fossa usually present with hemorrhage, but can present with ocular symptoms or be entirely asymptomatic and are effectively treated by surgical excision of the fistula site.

To the Editor: Endovascular embolization using Guglielmi electrolytically detachable coils (GDC) is a useful technique for treatment of cerebral aneurysms.1 2 Although safe and effective, it carries a small risk of thrombus formation at the coil mass, with the potential for distal embolization and branch occlusion despite anticoagulation. The risk of thromboembolic complication is approximately 3%,2 3 with a frequency of permanent deficit of 1.7% to 5%.1 Moderate success has been described with fibrinolytic agents,4 though with a risk of aneurysm bleeding. Abciximab is a platelet membrane glycoprotein IIb/IIIa antagonist (ReoPro, Centocor), which inhibits the interaction of activated platelets with the ligand fibrinogen (or fibrin) and has been shown to reduce myocardial infarction and death in patients undergoing coronary intervention.5 6 We present a patient with a basilar apex aneurysm who developed a rapidly progressive thrombus during GDC embolization, which was treated successfully using abciximab. A 55-year-old woman presented to an outside institution 1 month before admission with intraventricular hemorrhage and ensuing hydrocephalus requiring ventriculoperitoneal shunt placement. On examination, the patient was disoriented and had poor memory and cognition but was otherwise neurologically intact, with normal cranial nerves, speech, and motor/sensory function, and no visual field defects. A CT scan suggested a small clot in the interpeduncular cistern, prompting …

OBJECTIVE AND IMPORTANCE Intraorbital arteriovenous fistulas (AVF) of the ophthalmic veins are an extremely rare phenomenon. This article describes two such cases treated solely by transvenous occlusion and not hitherto described in the literature. METHODS AND RESULTS: Two women, aged 51 and 63 years old, presented with proptosis and chemosis mimicking a carotid-cavernous fistula. In both cases, cerebral angiography revealed an intraorbital dural AVF of the superior and inferior ophthalmic vein, respectively. Both patients underwent transvenous ablation of the dural AVF retrograde via the facial vein and subsequently had complete resolution of the presenting symptoms. METHODS: Ophthalmic vein fistulas are a rare form of AVF with presenting symptoms mimicking those of carotid cavernous fistulae. This report describes two cases of ophthalmic vein fistulas successfully treated and angiographically obliterated via transvenous embolization with resolution of the patient's presenting symptoms.

PURPOSE To investigate the clinical presentation, angiographic findings, endovascular management and clinical outcome in dural arteriovenous fistulas (DAVFs) of the marginal sinus. METHODS Fourteen patients with DAVFs of the marginal sinus were identified from angiographic studies and medical records of all patients treated for DAVFs at our institution between July 1990 and August 1995. The endovascular treatment and clinical outcomes of these patients are reported. RESULTS Eleven patients had pulse-synchronous bruit, two had intracranial hemorrhage, and one had ataxia. Thirteen patients were cured with endovascular techniques alone and one was cured by a combination of preoperative embolization followed by surgical obliteration of the fistula. The sole complication of treatment was a partial left hypoglossal nerve palsy, which resolved spontaneously. CONCLUSION DAVFs of the marginal sinuses are potentially life-threatening lesions that can be treated with endovascular techniques for a high rate of cure and a low rate of morbidity.

Objectives: To report the results of treatment of aneurysms involving the cavernous segment of the internal carotid artery treated with a new device, the electrolytically detachable platinum coil. Materials and Methods: Between 1991 and 1995, 220 patients with intracranial aneurysms were treated with the electrolytically detachable platinum coils. Thirty-five patients (16%) harbored aneurysms involving the cavernous segment of the internal carotid artery and are the subject of this report. The presenting symptoms were cranial nerve palsies in 19 (54%), epistaxis in 4 (11%), and subarachnoid hemorrhage in 3 (9%). The age ranged from 31 to 80 years, with a mean of 58 years, and included 26 women and 9 men. The aneurysm size ranged from 5 to 22 mm, with an average of 11.6 mm. Results: Of the seven patients who presented with bleeding (epistaxis in four, subarachnoid bleeding in three), none had bleeding after treatment. Of patients who presented with cranial nerve palsy, 58% had complete resolution of signs and symptoms and 38% showed dramatic improvement. Only one patient who presented with severe visual loss and optic atrophy was slightly worse after treatment. Two patients died from causes unrelated to their cavernous aneurysms or their endovascular treatment. Conclusions: In patients who harbor a symptomatic aneurysm arising from the cavernous segment of the internal carotid artery with a definable neck, electrolytically detachable coils offer an excellent treatment modality that permits aneurysm closure with Dreservation of flow in the carotid artery.

Three patients, ages 51 to 71 years, sought treatment for symptomatic dural sinus thrombosis with occlusion and were treated by direct sinus perfusion with urokinase. All three patients had a dural arteriovenous fistula; one involved the inferior petrosal sinus and two involved the transverse sinus. Clinical findings included papilledema, diminished visual acuity, decreased mentation, and cranial nerve palsies. Diagnosis was made by cerebral arteriography and confirmed by sinus venography. All three patients were treated by a transjugular direct infusion of urokinase. In one patient, a transfemoral venous approach used initially was discontinued because of an infection. The period of continuous infusion for thrombolysis ranged between 4 and 10 days. In two patients, the clinical signs and symptoms improved with angiographic evidence of clot lysis and dural sinus recanalization. Angiography indicated that one patient had a partial resolution of a clot in the torcular herophili and transverse sinus but showed no clinical improvement. These preliminary results suggest that transjugular local infusion of thrombolytic agents can be an effective treatment for symptomatic, thrombosed dural sinuses. This selective lysis avoids thrombolytic effects that could aggravate or produce systemic hemorrhagic complications.