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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]

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.

Objective and Importance: To describe the use of a new imaging tool, angiographic computed tomography, for visualization of cell opening and strut prolapse of a Neuroform 2 stent (Boston Scientific/Target, Fremont, CA) placed in curved vasculature for treatment of a basilar tip aneurysm., Clinical Presentation: A 46-year-old woman presented with an unruptured 8-mm basilar tip aneurysm with a wide patulous neck., Intervention: A 4 x 20-mm Neuroform 2 stent was placed across the aneurysm neck. Angiographic computed tomographic scanning was performed using a flat detector biplane angiographic system with new commercially available software (Dyna-CT; Siemens Medical Solution, Forchheim, Germany) and the following parameters: 20-second acquisition, 0.4-degree increment, 512 matrix in projections, 220-degree total angle, 20 degree/s, and approximately 15 to 30 frames/s, for a total of 538 projections. Image postprocessing was performed to correct scattered radiation, beam hardening, and ring artifacts on a commercially available workstation (Leonardo, Siemens Medical Solutions, Erlangen, Germany). The aneurysm was coiled in a second session, using bare platinum coils without clinical sequelae., Conclusion: Increased opening of cells and prolapsing of struts of an open cell design stent can occur after placement in a curved vessel across an aneurysm orifice. Angiographic computed tomography is a new imaging tool that provides visualization of intracranial stents that is superior to digital subtraction angiogram or nonsubtracted images. It will enhance our understanding of stent behavior in clinical practice and improve the efficacy and safety of intracranial stent placement. Further in vitro and in vivo imaging studies of intracranial stents are necessary to assess the value of this promising new technique.

Hemodynamics are thought to play an important role in the creation, thrombosis, recanalization, regrowth and re-bleeding of cerebral aneurysms treated by endovascular means. However, their exact role and interaction is unclear and warrants further study. Towards a systematic classification of the hemodynamics in intracranial aneurysms, we investigated the dependence of the values of the magnitude of the wall shear stresses in the vicinity of the aneurysm on varying inflow conditions in three basilar tip aneurysms.

We report the unusual case of pulsatile tinnitus caused by muscular branches of the occipital artery, which developed to supply the distal vertebral artery after subclavian artery occlusion. Anatomical findings and options of endovascular treatment are discussed. To our knowledge, subclavian artery occlusion causing an objective tinnitus has not been reported.

We evaluated a new 3D angiography system with a flat panel detector (FPD) for its capabilitiy to acquire volume sets during a single rotation scan and to reconstruct high spatial resolution three-dimensional and cross sectional images, namely cone beam volume computed tomography (CBVCT) images. Present status of the technique, advantages and potential applications are discussed.

Traumatic posterior circulation aneurysms are rare, especially in children. They are typically associated with severe trauma and are thought to result from either direct osseous injury or stretching or compression of an artery against the tentorium. They may grow, rupture, or both. Although spontaneous thrombosis may occur, it rarely results in complete occlusion. We report the spontaneous and complete thrombosis of a large posterior cerebral artery aneurysm in a child who presented after minor head trauma. Five-year follow-up documents the complete occlusion of the aneurysm.

Background and Purpose: Substantial intraoperative bleeding during surgical removal of head and neck paragangliomas may be a major problem in the management of these highly vascularized tumors. Traditional preoperative embolization via a transarterial approach has proved beneficial but is often limited by complex vascular anatomy and unfavorable locations. We report our experience with the preoperative devascularization of head and neck paragangliomas by using direct puncture and an intralesional injection of cyanoacrylate., Methods: We retrospectively analyzed nine consecutive patients with head and neck paragangliomas who were referred for preoperative devascularization. Three patients were treated for carotid-body tumors; two for vagal lesions; and four, for jugular paragangliomas. Direct puncture of the lesion was performed by using roadmap fluoroscopic guidance. Acrylic glue was injected by using continuous biplane fluoroscopy. All patients underwent postembolization control angiography and immediate postoperative CT scanning., Results: Angiograms showed that complete devascularization was achieved in all cervical glomus tumors, whereas subtotal devascularization was achieved in jugular paragangliomas. In this latter location, the injection of acrylic glue was limited by the potential risk of reflux into normal brain territory via feeders from the internal carotid or vertebral artery. The tumors were surgically removed and histologically examined. No technical or clinical complications related to the embolization procedure occurred., Conclusion: Percutaneous puncture of paragangliomas in the head and neck region and their preoperative devascularization by intralesional injection of acrylic glue is a feasible, safe, and effective technique., (Copyright American Society of Neuroradiology)

Although intracranial hemorrhage has frequently been found responsible for mortality in adult patients with Alagille syndrome (AGS), no specific underlying cause has been identified. We describe the case of severe subarachnoid hemorrhage in a 30-year-old woman harboring five intracranial aneurysms and multiple peripheral vascular anomalies. To evaluate a possible higher incidence of intracranial aneurysms, a study of the cerebral vasculature in all AGS patients by using noninvasive imaging techniques should be considered.

3D digital subtraction angiograms of two intracranial aneurysms were imported to a workstation for reconstruction and postprocessing into a format allowing delineation of 1) the extent to which the diameter of the parent artery is incorporated into the aneurysm ostium (percentage of parent artery involvement or neck angle) and 2) the aneurysm volume and surface area. For clear visualization, 3D surface-rendered objects of the reconstructed artery, neck angle, and aneurysm were created.