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In 2014, Chapot et al. introduced the pressure cooker technique (PCT), conceived to control undesired reflux of the embolic agent during the treatment of brain arterio-venous malformations (bAVMs). Since then, this technique increased in popularity and it has been extensively used. We present five consecutive cases in which the original PCT was simplified using nylon coils instead of platinum coils and acrylic glue, hence the name of ‘Simplified Pressure Cooker Technique’ (sPCT). The aim was to obtain a safer, precise and faster creation of the plug to control cohesive embolic agent reflux during the treatment of brain and facial vascular malformations.

Endovascular treatment of wide-neck bifurcation aneurysms is challenging and often requires adjunctive techniques and devices. We report our experience with the hybrid Y stenting with the waffle-cone technique, combining Y stent-assisted coiling and waffle-cone stenting techniques. This approach has been described only in a single case report using a combination of open and closed cell stents. We describe four cases treated by hybrid Y stenting with the waffle-cone procedure with a variation from the originally reported technique, consisting in deploying two closed cell stents. All patients were successfully treated without complications. We propose hybrid Y stenting with the waffle-cone for the treatment of wide-neck bifurcation aneurysms as a bailout technique after failure of Y stent-assisted coiling.

This study evaluated clinical and neuroradiological results in 13 consecutive patients with spontaneous and traumatic direct carotid cavernous fistulas treated at our center between January 2006 and September 2012. All patients were treated by coiling of the cavernous sinus. Coiling was always performed while a semi-compliant non-detachable balloon was temporarily inflated in the internal carotid artery. This technique (balloon-assisted coiling) permitted a clear visualization of the fistula, facilitated coil positioning and protected the patency of the artery. All patients' clinical data and radiological examinations were reviewed; nine patients underwent radiological and clinical follow-up, with a mean duration of 3.8 years (range: six months-six years). Overall results at discharge showed a complete occlusion of the fistula in seven patients (7/13, 54%) and a resolution of symptoms in eight patients (8/12, 67%). Radiological follow-up showed complete occlusion of the fistula in all patients (9/9, 100%) and clinical follow-up showed a resolution of symptoms in eight patients (8/9, 89%) and persistent symptoms in one (1/9, 11%). No procedure-related complications occurred. Balloon-assisted coiling of the cavernous sinus for the treatment of direct carotid cavernous fistulas proved an effective and safe technique, both in angiographic and clinical terms, and may be considered a technical improvement.

Despite the encouraging results obtained with the endovascular treatment of ruptured intracranial aneurysms, few data are available on the effects of the timing of this approach on clinical outcome. The aim of our study was to evaluate the effects of the hyper-early timing of treatment and of pre-treatment and treatment-related variables on the clinical outcome of patients with ruptured intracranial aneurysms. Five hundred and ten patients (167 M, 343 F; mean age 56.45 years) with 557 ruptured intracranial aneurysms were treated at our institution from 2000 to 2011 immediately after their admission. The total population was divided into three groups: patients treated within 12 hours (hyper-early, group A), between 12–48 hours (early, group B) and after 48 hours (delayed, group C). A statistical analysis was carried out for global population and subgroups. Two hundred and thirty-four patients (46%) were included in group A, 172 (34%) in group B and 104 (20%) in group C. Pre-treatment variables (Hunt&Hess, Fisher grades, older age) and procedure-related variable (ischaemic/haemorrhagic complications) showed a significant correlation with worse clinical outcomes. The hyper-early treatment showed no correlation with good clinical outcomes. The incidence of intraprocedural complications was not significantly different between the three groups; 1.2% of pre-treatment rebleedings were observed. The hyper-early endovascular treatment of ruptured intracranial aneurysm does not seem to be statistically correlated with good clinical outcomes although it may reduce the incidence of pre-treatment spontaneous rebleedings without being associated with a higher risk of intraprocedural complications. However, since no significant differences in terms of clinical outcome and pre-treatment rebleeding rate were observed, a hyper-early treatment is not be supported by our data.

Carotid artery dissection is a common cause of juvenile stroke. Endovascular treatment of acute stroke due to carotid dissection can be challenging, and endoluminal crossing of the dissection is sometimes impossible. We describe a case of intentional subintimal recanalisation of a cervical carotid dissection followed by intracranial thrombectomy and stenting. We report the case of a young woman with severe acute ischaemic stroke due to carotid artery dissection and intracranial embolism. After failure of endoluminal crossing of the dissected segment, intentional subintimal crossing with re-entry distally to the dissection was achieved and a stent was deployed. Then, middle cerebral artery thrombectomy was performed achieving good recanalisation. Acute thrombus formed in the bulged segment of the carotid stent and was managed with additional stent placement. The patient had a good clinical recovery. In selected cases, after failure of conventional techniques, subintimal recanalisation of carotid dissections may be performed.

The vast majority of intracranial aneurysms can be obliterated completely with surgical clipping. However, postoperative remnants occur in about 4 to 8% of patients who undergo postoperative angiography. Endovascular embolization has been successfully performed in patients with postoperative aneurysm remnant and it may represent a therapeutic alternative to surgical reintervention. Twelve aneurysm remnants after surgical clipping were treated with endovascular embolization using GDC. All aneurysms were located in the anterior circulation. Our experience confirms the feasibility and relative safety of this treatment strategy that may be considered a valid alternative to reintervention.

Dissection aneurysms of the vertebral artery represent 3.2% of all cerebral aneurysms and 28% of intracranial dissection aneurysms. Dissection of the vertebral artery in its intracranial segment (V4) usually causes a subarachnoid hemorrhage (SAH) from subadventiatial extension of the vessel wall hematoma. Rarely (one case in seven), the symptomatology is characterized by brain stem ischemia from the vertebral artery and/or postero-inferior cerebellar artery occlusive dissection. The high rebleeding (18–33% with a 10+/-5 day interval between the first and the second bleeding) and mortality (>45%) rates 1, 13 of this disease prompt emergency treatment usually consisting in endovascular coiling of the dissection aneurysm and/or the dissected segment of the parent vessel. Herein we report our experience in endovascular coiling of acutely ruptured dissecting aneurysms of the vertebral artery dissection in V4 segment. We focus the discussion on the risk of rebleeding and the ischemic complications that my occur after endovascular or surgical treatment.

We describe three patients with accute occlusion (case 1) and subocclusion (cases 3 and 4) of the distal portion of the vertebral artery. A satisfactory vessel recanalization was obtained in all three cases, but a good clinical outcome was only achieved in one patient while a second patient developed an apallic syndrome.

Le malformazioni arterovenose (MAV) del cuoio capelluto sono rare malformazioni vascolari ad alto flusso che tendono ad accrescersi con il tempo causando spesso gravi disturbi estetici. Il trattamento chirurgico radicale è spesso impossibile per le complicanze di ordine estetico e l'elevato rischio di sanguinamento. Riportiamo il caso di una bambina di 9 anni con una MAV del cuoio capelluto in regione fronto-parietale destra alimentata da entrambe le arterie temporali superficiali e dal ramo sovraorbitario dell'arteria oftalmica di destra che è stata devascolarizzata completamente mediante embolizzazione arteriosa per via femorale e venosa per via percutanea.

Balloon-assisted Guglielmi detachable coiling (BAGDC) is a new technical option developed to allow endovascular treatment of wide-necked aneurysms. Aim of the following work is to report a single center experience of BADGC of aneurysms with assessment of its efficacy and safety. BAGDC of wide-necked aneurysms (SNR close to 1) was retrospectively evaluated in 37 patients (28 females, nine males, mean age: 56.6 yrs, range: 27–81 yrs) who underwent the procedure between january 1999 and january 2002 for a total of 45 procedures on 41 aneurysms. Twenty-nine patients presented with SAH from an acutely ruptured aneurysm. In two patients BAGDC failed whereas 35 patients successfully underwent BADGC (39 aneurysms). Twenty-nine patients (31 aneurysms) were available for angiographic follow-up (mean: 10 mo, range: 3–24 mo). At the last angiographic follow-up 29/33 aneurysms (87%) resulted stable and occluded (22 aneurysms with dense and seven with loose packing of the sac and the neck), two aneurysms showed regrowth, one aneurysm showed a neck remnant and another one a sac and neck remnant. Complications directly related to the procedure occurred in five patients (three perforations, one thromboembolism, one femoral AV) with a mortality and morbility rate of 2.7 and 5.4 respectively. BAGDC is a promising adjunct to treatment of wide-necked aneurysms broadening the spectrum of indications for endovascular treament of challenging aneurysms.

Intra-arterial fibrinolytic therapy in acute vertebrobasilar occlusion is effective in saving the patient's life in 75% of cases if performed within 6 hours after the beginning of an ischemic event, without CT evidence of hypodense focal areas in the brain stem, cerebellum or thalamic nucleus. The initial clinical aspect of vertebrobasilar stroke is more often evolving. Only in 1/3 of cases is coma present at the beginning. In vertebro-basilar occlusion prognosis is determined by clinical and neuroradiological aspects. The outcome depends mainly upon how much brain stem function is lost during the reperfusion time, and the kind of vertebrobasilar occlusion. The case we present concerns a 38 year old man with acute onset of cerebral stroke without initial clinical signs of vertebrobasilar localization due to a basilar artery occlusion distal to AICA. Urokinase infusion was performed within three hours from the clinical onset up to a total amount of 1.400.000 UI. Reperfusion was observed one hour after the beginning of the intravascular therapy. The clinical course was favorable with good recovery (moderate superior right paresis, controlateral light cerebellar syndrome).

Gli autori presentano due casi di fistola carotido-cavernosa (la prima di tipo B e la seconda di tipo A secondo la classificazione di Barrow), trattati con approccio venoso posteriore attraverso il seno petroso inferiore mediante spirali a distaccamento meccanico (MDS-N). Vengono brevemente discussi i vantaggi e gli svantaggi della via venosa posteriore rispetto alla venosa anteriore ed alla via arteriosa.

Lo scopo del nostro lavoro è quello di valutare l'efficacia diagnostica della mielo-TC nello studio delle lesioni post traumatiche del plesso brachiale, per indirizzarne l'approccio terapeutico. Ai fini di una corretta programmazione terapeutica è importante poter stabilire il livello di lesione pregangliare o postgangliare; infatti, mentre un'interruzione dei rami del plesso brachiale a livello postgangliare può essere trattata chirurgicamente mediante ricostruzione con innesti nervosi, una lesione pregangliare non può invece essere trattata se non con interventi palliativi come ad esempio di neurotizzazione per trasferimento nervoso con nervi intercostali o altri nervi periferici. Nell'arco di un anno abbiamo sottoposto ad esame mielo-TC 7 pazienti che presentavano paralisi del plesso brachiale. Dalla revisione critica dei quadri di semeiotica mielo-TC, in accordo con i dati della letteratura, abbiamo valorizzato i seguenti reperti presuntivi di lesione traumatica pregangliare: 1) mancata visualizzazione dell'immagine in negativo della radice all'interno della tasca radicolare, 2) perdita della classica forma ad imbuto con amputazione della tasca radicolare, 3) dilatazione marcata della tasca radicolare o pseudomeningocele, determinata dalla lacerazione del manicotto meningeo che riveste la radice.

Sulla base di una revisione casistica degli aneurismi del distretto vertebro-basilare osservati negli ultimi died anni, sono stati raccolti 48 pazienti, 32 dei quali operati, portatori di 53 aneurismi vertebro-basilari e tre aneurismi del distretto carotideo. In sei casi veniva riscontrata associazione con malformazioni artero-venose sottotentoriali. Nella gran parte dei casi l'indagine angiografica è stata completata da esame TC e talvolta da RM. Seguendo la letteratura in argomento gli aneurismi sono stati classificati secondo criteri di sede, dimensioni e morfologia. Nella trattazione vengono quindi distinte le lesioni ad inserzione sull'asse vertebro-basilare e le forme distali. Il quadro di esordio clinico ed i reperti TC, salvo eccezioni, appaiono poco specifici per una localizzazione topografica della malformazione vascolare.

Ten patients with native intracranial dural arteriovenous fistulae (DAVF) demonstrated by arteriography underwent MR imaging and phase contrast MR angiography before treatment. The DAVFs were of type I (n=2), IIa (n=l), II a+b (n? 3), and TV (n=4). Joint review of the arteriography, MR imaging and MR angiography hard copies was performed by two observers. MR imaging showed intracerebral hemorrhage in 2 patients and diffuse or focal white matter edema in 2. Focal venous ectasias in 4 patients with type TV DAVF and dilated cortical vessels in 6 patients were recognized on MR images. MR angiography enabled identification of the DAVF nidus in 2 patients, hypertrophic feeding vessels in 5 patients and cortical dilated veins in 8 patients. Steno-occlusive alterations of the dural venous sinuses in 6 patients were readily demonstrated on MR angiography. Moreover, in 3 patients with type II a+b DAVFs, reconstruction of image phase of MR angiography allowed identification of flow revers al in the dural sinuses near the DAVF. Phase contrast MR angiography is a useful complement to MR imaging for identification and characterization of intracranial DAVF.