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Cerebrovascular anomalies remain an issue of controversy regarding diagnosis, classification, and treatment. We report the first case of total and asymptomatic regression and disappearance of a vein of Galen malformation associated with a posterior fossa venous pouch. Different aspects of the vein of Galen are discussed together with emphasis on the underlying mechanisms of spontaneous thrombosis and regression.A 4-month-old boy presented with macrocrania and signs of intracranial hypertension. Computerized tomography disclosed two masses, the first was a giant aneurysmal dilatation in the posterior fossa, and the second was a gigantic pouch at the level of the vein of Galen. Hydrocephalus was treated by ventriculo-peritoneal shunting. Two months later, the shunt was revised, and posterior fossa was explored without active treatment. Both abnormalities regressed spontaneously. No recurrence occurred, and the child remained neurologically intact. Total disappearance of the masses as well as normal brain and cerebrovascular anatomy were confirmed by angiography, MRI, and MRA. Over a follow-up period of 17 years, the patient did not develop complications. He had perfect clinical tolerance and resumed a normal life.

Objective: The success of endovascular treatment of intracranial aneurysms with Guglielmi detachable coils (GDCs) is dependent on the long-term exclusion of the aneurysm from the circulation. We reviewed our experience with the long-term angiographic follow-up monitoring of aneurysms that had been treated with GDCs., Methods: All patients whose aneurysms had been treated with GDCs between January 1995 and August 1999 and who subsequently underwent follow-up angiography at 6 months or more were included in this study. We reviewed all of the angiographic findings, to determine the percentage of aneurysm occlusion on the initial angiograms and on the last available follow-up angiograms. The categories of aneurysm occlusion used were 100%, >or=95%, and less than 95% occlusion., Results: One hundred thirty patients with 141 aneurysms underwent 143 endovascular coiling procedures and subsequently underwent angiographic follow-up monitoring of 6 months or more. There were 102 female and 28 male patients. The mean angiographic follow-up period was 16.7 months (range, 6-62 mo). The initial rates of occlusion were 100% for 56 aneurysms (39%), >or=95% for 65 aneurysms (46%), and less than 95% for 22 aneurysms (15%). Recurrence of one aneurysm (1.8%) was observed. Of the 87 aneurysms that were incompletely occluded initially, there was progressive thrombosis in 40 (46%), stable neck remnants in 23 (26%), and enlargement of the residual neck in 24 (28%). The final occlusion rates, determined on the last available angiograms, were 100% for 88 aneurysms (61%), >or=95% for 31 aneurysms (22%), and less than 95% for 24 aneurysms (17%). No patient experienced repeat or new subarachnoid hemorrhage more than 6 months after the initial treatment., Conclusion: Late angiographic follow-up monitoring of aneurysms that have been treated with GDCs demonstrates the durability of the treatment. Aneurysms with large residual neck remnants were subjected to further treatment, whereas aneurysms with small residual neck remnants remain under observation.

Spontaneous rupture of cerebral aneurysms typically results in subarachnoid hemorrhage. The primary goal of treatment of cerebral aneurysms is to prevent future rupture. Surgical clipping had been the mainstay of treatment of both ruptured and unruptured cerebral aneurysms. In 1991, Guglielmi detachable coil (GDC) embolization was introduced as an alternative method for treating selected patients with aneurysm. The goal of the treatment is prevent the flow of blood into the aneurysm sack by filling the aneurysm with coils and thrombus. Theoretically, there are several advantages of GDC over surgery. These procedures are performed under general anesthesia with the standard transfemoral approaches used in diagnostic angiography. Since its inception, GDC embolization has evolved as a result of both clinical experience and the introduction of technological improvements. We are now better at selecting aneurysms appropriate for coiling, which also have wide necks. Advances in GDC technology have also improved this method of treatment. Over the last several years, the number of coil sizes has been increased, multidimensional coils allowing safer initial coil placement have become available, and, more recently, softer coils have been introduced. Our current approach is to have both surgical and endovascular options for patients.

Background: Patients with intracranial arteriosclerotic disease have significant morbidity and mortality rates, and some are unresponsive to medical treatment and have unacceptable surgical risks. Percutaneous transluminal angioplasty of the intracranial vessels is a possible alternative to surgery., Objectives: To present our experience with percutaneous transluminal angioplasty and to summarize our data., Patients and Methods: Sixteen patients underwent intracranial percutaneous transluminal angioplasty for high-grade arteriosclerotic stenosis based on strict inclusion and exclusion criteria. All patients had symptoms referable to the stenosis except one. Angioplasty was performed in 6 intracranial vertebral arteries, 3 basilar arteries, 5 middle cerebral arteries, and 3 distal internal carotid arteries. One patient had concomitant stent placement., Results: There was 1 treatment failure secondary to tortuous vascular anatomy. Vessel caliber was increased to more than 80% of normal in 6 patients and to 50% to 70% of normal in 6 patients, with a reduction of symptoms. Three intimal dissections occurred during angioplasty; one of these, in a precavernous segment of the internal carotid artery, was stented. One patient restenosed within 1 month of treatment. The remaining treated arteries remained patent during follow-up of 3 months to 2 years. Stroke as a complication occurred in 2 patients, 1 mild and 1 severe. There was no mortality., Conclusions: Occlusive arteriosclerotic disease involving the intracranial cerebral vessels can be managed medically with antiplatelet and anticoagulant drug therapy or surgically. However, in patients who are unresponsive to medical therapy or who have unacceptable surgical risks, percutaneous transluminal angioplasty is an attractive alternative that can be performed in selected patients with relatively low risk and good clinical outcome.

Background: Surgery for intracranial aneurysms that have been treated by endovascular coiling is a new challenge for neurosurgeons and the need for it will undoubtedly continue to increase. The indications for, timing, and technique of surgery in our experience are described., Methods: We have reviewed our experience with 11 patients who underwent surgery following endovascular coiling with Guglielmi detachable coils (GDCs) of an aneurysm. We analyzed the indications for surgery, surgical techniques used, and patient outcome., Results: There were nine female and two male patients. The mean age was 49 years (range 13 to 67 years). The intervals between coiling and surgery were 1, 2, 3, 4, 7, 7, 10, and 14 days, 6 weeks, 2, 18, and 25 months. The indications for surgery were partial treatment (3), growth of residual neck (2), persistent mass effect of a giant aneurysm (1), mass effect from the coil ball (2), coil migration (2), and coil protrusion with embolic event (1). The coils were removed at the time of surgery from 9 of 11 aneurysms before clipping. In two cases it was possible to place a clip across the neck of the aneurysm without removing the coils, as the coils no longer occupied the neck. There were two permanent deficits directly related to the endovascular procedures. Two other patients who presented with subarachnoid hemorrhage had residual neurological deficits post surgery and one patient with a giant aneurysm had persistent visual loss., Conclusion: Surgery remains a viable option at any time for treating aneurysms that have been previously treated by GDC placement. The operative approach is determined by the need for coil removal and the duration since coiling.

Background: Paraclinoid aneurysms include those that are distal to the cavernous segment of the internal carotid artery and proximal to the posterior communicating artery. The purpose of this study was to review our experience with the endovascular treatment of this group of aneurysms, which are difficult to treat surgically., Methods: Between June 1994 and April 1999, 66 patients (56 female, 10 male) with a mean age of 50.1 years (range 13-75, median 51) underwent endovascular treatment for 71 paraclinoid aneurysms. The mean size of the dome was 8.9 mm (range 3-25 mm, median 7) and the of neck was 3.8 mm (range 1.4-8 mm, median 4). Thirteen patients presented with acute subarachnoid hemorrhage, and 4 with previous subarachnoid hemorrhage. Six aneurysms produced mass effect with visual symptoms, 4 presented with transient ischemic attacks, and 44 were incidental. Nine patients had had previous unsuccessful surgery. All procedures were performed under general anesthesia and with systemic heparinization., Results: Ninety endovascular procedures were performed on 71 aneurysms: GDC coiling in 78 (including 45 with the remodeling technique), permanent balloon occlusion in 9, and 3 had both GDC coiling and permanent balloon occlusion. In ten aneurysms it was not possible to place coils in the lumen of the aneurysm with the available technology and balloon occlusion was not indicated. Five of these were treated surgically and 5 remain untreated. All patients had immediate post procedure angiography. Of the 61 aneurysms that were treated, 46 (75%) have angiographic follow-up of 6 months or more. Morphological outcome following endovascular therapy for 61 aneurysms at last available follow-up showed > 95% occlusion in 52/61 (85.2%) and <95% in 9/61 (14.8%). Eight patients required surgery, 2 for partial coiling, 2 for refilling of a neck remnant, 2 for persistent mass effect and 2 for coil protrusion. In the 90 procedures performed, 2 (2.2%) patients had major permanent deficits (1 monocular blindness, 1 hemiparesis), 1 (1.1%) had a minor visual field cut, and 2 (2.2%) patients died from major embolic events., Conclusion: Properly selected paraclinoid aneurysms can be successfully treated by endovascular technology. The morbidity and mortality rate of the endovascular approach in our experience is equal to or better than the published surgical series of similar aneurysms. We recommend that the endovascular approach be given primary consideration in the treatment of paraclinoid aneurysms.

Object: Reports in the literature have offered discussions of the feasibility, efficacy, and safety of balloon-assisted Guglielmi detachable coil (GDC) placement in wide-necked intracranial aneurysms, which was first described by Jacques Moret as the "remodeling technique." In this article the authors summarize their results in a subset of aneurysms treated with GDCs using the remodeling technique., Methods: This report contains a retrospective analysis of 72 patients with 75 aneurysms who underwent 79 endovascular procedures performed using the remodeling technique. Morphological outcome was determined at the end of each procedure and by reviewing available follow-up angiograms. Clinical assessments and outcomes are reported using a modified Glasgow Outcome Scale. Coils were placed in 66 (88%) of 75 aneurysms selected for treatment. In eight aneurysms (11%) treatment failures occurred due to the tortuosity of the vessel used to reach the aneurysms or because of balloon inadequacies. Incorporating all available follow-up data the authors found that 50 (78%) of 64 aneurysms were completely or subtotally (> 95%) occluded and eight (12%) of 64 were incompletely (< 95%) occluded. Since the time of coil placement, eight aneurysms have progressed to complete occlusion and another five have exhibited progressive thrombosis on follow-up angiograms. In three aneurysms there has been neck remnant growth. Surgical clipping was performed to treat six aneurysms after an initial coil placement procedure. Permanent incidences of morbidity were limited to four patients and there were three deaths directly related to the procedure., Conclusions: The remodeling technique shows promise in increasing the number of cerebral aneurysms amenable to treatment by endovascular coil placement, and offers an alternative approach to aneurysms that have met with failed surgical treatment or are surgically inaccessible. Long-term follow-up review is needed to determine the final outcome of aneurysms treated by this technique.

Objective: To determine the angiographically proven rate and persistence of occlusion of intracranial aneurysms after surgical clipping as reported in the literature. This should establish a basis for comparing surgery with new endovascular methods of treatment., Methods: We reviewed the literature published during the period from 1979 through 1999, dividing the articles into two groups. The first group of articles reported patients undergoing surgical treatment with immediate postoperative angiography. The second group of articles documented symptomatic recurrence or regrowth of aneurysms that were surgically treated previously. The data from these articles are presented for analysis., Results: During the period 1979 to 1999, six series of patients undergoing surgical treatment of aneurysms with immediate postoperative angiography were reported. These reported series comprised a total of 1,397 patients, of whom 1,370 underwent postoperative angiography demonstrating 1,569 clipped aneurysms. Residual filling was found in 82 aneurysms (5.2%) on postoperative angiography. Of the 1,370 patients, only 124 patients with 169 aneurysms were reported to have had any long-term angiographic follow-up. The second group consisted of 226 patients representing six reported groups of patients, who either presented up to 24 years after aneurysm clipping with recurrent symptoms of hemorrhage or mass effect, or had important findings on intraoperative and postoperative angiograms., Conclusion: The lack of information regarding both the frequency of residual filling or regrowth and long-term angiographic follow-up of patients with surgically treated aneurysms makes meaningful comparison between surgical treatments and new treatment methods for intracranial aneurysms difficult or impossible. Detailed analysis with high-quality angiography should be performed to determine the success of surgical treatment.

There are many vascular and neoplastic diseases as well as normal variants that produce the vestibulocochlear symptoms of pulsatile tinnitus, hearing loss, dizziness, and ataxia. Magnetic resonance imaging may be diagnostic, and magnetic resonance angiography/magnetic resonance venography have added to the ability of magnetic resonance to image vascular abnormalities. The extent of neoplasms is accurately assessed and complication of vascular lesions are clearly seen. However, detailed vascular anatomy requires high-quality selective angiography. This enables optimal treatment planning. Endovascular therapeutic intervention has a major role to play in conjunction with surgery of skull base lesions and may be curative in certain conditions, avoiding major surgical procedures. The interventionalist, however, must have an excellent knowledge of the external carotid circulation and all of its potential communications with the internal circulation to avoid serious embolic complications.

Background: More than 200 aneurysms have been coiled at the UIC Medical Center within the last 5 years. We describe in detail the technical factors that increase the chance of complete occlusion of a cerebral aneurysm with coils. Aneurysms selected for coiling have good geometry or are in a location that is difficult to reach surgically. Patients with medical conditions that preclude surgical treatment may also undergo coiling., Methods: Patients with aneurysms, either ruptured or unruptured, are treated under general anesthesia, fully anticoagulated and deeply paralyzed. Coiling is done under simultaneous biplane roadmapping. After the first coil has created a mesh, the aneurysm is densely packed with soft coils of decreasing diameter, until no more coils can be deployed into the aneurysm., Results: The morbidity and mortality rates associated with the coiling procedure have continuously decreased over the last 5 years. The morphological outcomes have improved, due to extensive use of the remodeling technique and to advancements in materials, such as refinements in the coils themselves or the availability of over-the-wire balloon catheters in different sizes and hydrophilic wires with complex tip configurations. Twenty-one percent of the aneurysms were considered to be incompletely occluded immediately after coiling. Of this group, one-third of the aneurysms were found to be completely occluded on follow-up angiograms by 6 months; these have remained occluded. One-third were more than 95% occluded after the coiling procedure; in these patients, the dome was completely occluded, but there was a small neck remnant, which has remained stable in all patients on control angiograms obtained at 6 months and 1, 2, and 4 years; none have rebled. These patients are followed medically. The remaining one-third of the aneurysms in this subgroup were less than 95% occluded, although the dome was completely thrombosed. None of them have rebled, but the neck remnant in most has regrown over a period ranging from 6 months to 2 years. These patients have undergone a second treatment-either surgical clipping, permanent occlusion of the parent vessel, or repeat coiling using the remodeling technique. The overall rebleeding rate of incompletely occluded aneurysms is extremely low (less than 1%)., Conclusion: The low morbidity and mortality rates and the good morphological outcome obtained in most cases make coiling a reasonable alternative to surgical clipping in properly selected cases.

Summary: A case of traumatic, direct, carotid cavernous fistula (CCF) associated with Ehlers - Danlos syndrome (EDS) Type IV is reported along with a review of the literature. Excluding the present case, three similar cases associated with EDSTypeJV have already been reported by Gerard M. Debrun et Al(l). Despite the risks associated with endovascular manipulation, the fistula was successfully closed by intravascular embolisation but the patient expired a few days later because of underlying disease-associated vascular and visceral complications.

Objective: We present our initial experience with Guglielmi detachable coils (GDCs). The aim of this study was to determine the criteria for aneurysms, ruptured or unruptured, that are suitable for this technique. The importance of aneurysm geometry and its impact on the final results are discussed., Methods: A retrospective analysis of 329 patients with 339 cerebral aneurysms that were treated at the University of Illinois Hospital at Chicago from May 1994 to June 1997 was conducted. One hundred eighty-five patients were treated surgically, and 144 were selected for treatment using GDCs. Of the 144 patients selected for GDC treatment, 55 patients with 55 aneurysms were admitted during the acute phase of subarachnoid hemorrhage and 89 patients with 97 aneurysms had nonruptured aneurysms or were treated after clinical recovery of previously ruptured aneurysms. All procedures were performed with the patients under general anesthesia and with systemic heparinization using live simultaneous biplane roadmapping, with the exception of the first four patients. These patients were treated before the installation of the biplane system. The percentage of aneurysm occlusion was determined at the end of each procedure. Follow-up angiography was scheduled to be performed at 6 months, 1 year, and 2 years after treatment., Patient Selection: For the initial 25 patients (Group 1), selection for coiling was restricted to nonsurgical candidates or patients in whom coiling was thought to be the best treatment choice, based on medical condition and location of the aneurysm. The geometry of the aneurysm was not considered to be an important factor in the selection for coiling. The remaining patients (Group 2) were selected for coiling based on aneurysm geometry, as determined by pretherapeutic angiography. Aneurysms that were considered to be favorable for coiling included those that had a dome-to-neck ratio of at least 2 and an absolute neck diameter less than 5 mm., Results: The initial 25 patients (Group 1) were treated from May 1994 to February 1995. There were high morbidity and mortality rates, with 56% of the treated aneurysms occluded at 6 months. The remaining patients (Group 2) consisted of 119 patients with 123 aneurysms. There was no mortality directly related to the coiling procedure, and permanent morbidity was limited to 1.0%. Three patients (2.5%) developed transient neurological deficits secondary to the procedure, and seven patients (5.8%) experienced periprocedural complications that did not result in neurological sequelae. The morphological results were strongly correlated to the geometry of the aneurysms, with a complete occlusion rate of 72% among the acutely ruptured aneurysms and 80% among the nonacute aneurysms, when patients were selected for treatment based on the geometry of the aneurysms and the dome-to-neck ratio was at least 2. The occlusion rate dropped to 53% when selection was not based on aneurysm geometry and the dome-to-neck ratio was less than 2. A summary of the morphological outcomes for the Group 2 patients shows that 86% of the aneurysms that initially underwent coiling using GDCs were completely occluded (78% by coils alone, 3.0% in conjunction with surgery, and 5.0% with parent artery occlusion). Residual small neck remnants were present in 11% of the Group 2 aneurysms (3.0% were scheduled for surgical treatment of residual neck remnant growths not amenable to further endovascular treatment, and 8% were scheduled for initial 6-mo follow-up examinations). Death resulting from unrelated causes before initial follow-up occurred in 3.0% of the patients., Conclusion: These preliminary results suggest that using GDCs is a safe technique resulting in low morbidity and mortality rates for the treatment of intracranial aneurysms in appropriately selected patients. The percentage of complete aneurysm occlusion is related to the density of coil packing, which is strongly dependent on the geometry of the aneurysm. Optim

The study was aimed determine the criteria for treating cerebral aneurysms, ruptured and unruptured, suitable for endovascular Guglielmi detachable coiling (GDC) with least morbidity and mortality. We will discuss the importance of knowledge of the geometry of cerebral aneurysm and its impact on the results of coiling. We have treated 324 patients with cerebral aneurysms at the University of Illinois Hospital from May 1, 1994 to June 1997. During this period 139 patients were treated with GDC and 185 patients were treated surgically. Of 139 patients treated with coils 54 patients with 54 aneurysms were ruptured and the remaining 85 patients with 90 aneurysms were unruptured. For initial 25 patients, the selection of aneurysms for coiling was random and the geometry of the aneurysm was not considered as an important factor in the selection for coiling, however, in the later series of 114 patients with 119 aneurysms were selected for coiling only when the geometry looked favorable in the angiogram. With time we realized that the dome/neck ratio more than or equal to 2/1 and the diameter of the neck not exceeding 5 mm were most suitable for coiling. The initial series of 25 patients (May 1994 to February 1995) treated without taking geometry of the aneurysms as an important criteria for coiling led to high morbidity and mortality and less than 50% of these aneurysms were angiographically occluded at 6-month follow-up. In the second series of 114 patients (March 1995 to June 1997) with 119 aneurysms we had 0% mortality related to the coiling and only 1.8% permanent morbidity. We found complete aneurysm occlusion in 78% of the subarachnoid hemorrhage and 76% of unruptured group when the dome/neck ratio was more than or equal to 2/1. However, the occlusion rate dropped to 50% when the dome/neck ratio was less than 2/1. This preliminary experience suggests that GDC is a safe technique with low mortality-morbidity for the treatment of intracranial aneurysms in appropriately selected patients. The percentage of complete occlusion of the aneurysm following tight and dense packing is strongly dependent on the geometry of the aneurysm and we conclude that the best results are achieved when the dome/neck ratio is more than or equal to 2/1.

Pericentral arteriovenous malformations (AVMs) have more often been deemed inoperable lesions because of their complexity, owing to their critical locations and dismal outcome. This study discusses the management of this group of patients with a variety of treatments which includes surgery, nidus embolization, and radiosurgery. Out of 89 patients treated for AVMs in our institute over a period of 30 months (1992 through May 1995), we present a case series of 34 patients who had AVMs located in the pericentral region. All the treated AVMs were Spetzler and Martin grade III (6 patients), grade IV (13 patients), and grade V (15 patients). The neurological outcome remained, normal or improved from baseline in 68% of patients following treatments; of the remaining 32%, 19% remained in the same condition (with continuing preoperative deficits) and 10% showed some deterioration from their pretreatment condition. Thus 87% were unchanged or improved after the treatment regime. There was a 3% mortality (one patient who died as result of initial hemorrhage) in the series. Our multimodality treatment for this group of AVMs confirms the efficacy of the practiced strategies for their management. The results derived from the experience with this selected group of patients with AVMs lead us to recommend treating these patients with multimodality regimen rather than awaiting the natural history of the disease in the best interest of the patients.

Arteriovenous malformation nidus catheterization with a flow-directed catheter at times can be difficult owing to tortuosity of the intracranial vasculature and distal location of the nidus. Since January 1995, hydrophilic wire has been used in conjunction with the 1.8F flow-directed microcatheter in over 150 vessel embolizations with cyanoacrylate glue for brain and spinal arteriovenous malformations at our institution. This technique has improved our success rate in achieving superselective catheterization of the nidus and has shortened the overall procedure time. To date, only one complication has occurred that was directly related to wire manipulation.

Summary: We evaluated the frequency and the side effects associated with gluing a piece of microcatheter in the feeder during embolisation of brain AVMs with acrylic glue. A retrospective analysis of 233 brain AVMs embolised with acrylic glue over a 15 year period has shown that 29 microcatheters were glued into the feeder. This represents 936 superselective catheterizations of different feeders followed by injection of glue. There was no side effect in 27 cases. Eight cases were operated upon a few hours or days after the complication occurred. The piece of tubing was removed in six cases. The reason for early surgery was the fear of extensive thrombosis of a major trunk (MCA or BA) or taking advantage of the catheter being still free in the cerebral vessel. In one case of temporal AVM, a Magic 1.5F coiled up into the distal basilar and PCA. In one case of left parietotemporal AVM, surgery was done one month after having glued a piece of tubing into the left MeA without side effect. The patient became hemiplegic and aphasic two hours after surgery. The thrombosed left MeA was reopened with Urokinase. The patient recovered with minor residual aphasia. The risk of side effects increases with the use of the Magic 1.5F that coils up into the vessel more easily than the Magic 1.8F. Leaving a piece of Magic catheter in the feeder to a brainAVM usually has no side effect. When there is a risk of thrombosis of a major trunk (MCA, BA) or when surgical resection is indicated, surgery should be done as soon as possibile because it is usually possible and easy to retrieve the piece of tubing from the intracranial circulation. The frequency of this complication has decreased since we starded using more diluted acrylic glue.

Objective: To demonstrate that nidus embolization of brain arteriovenous malformations (AVMs) with Histoacryl (B. Braun, Melsungen, Germany) is effective and yields low morbidity and mortality rates., Methods: We present a retrospective analysis of 54 brain AVMs treated at the University of Illinois at Chicago from April 1994 to December 1995. Treatment modalities included embolization in all cases and then surgical resection or radiosurgery., Instrumentation: The nidus was reached with the combined use of a Magic microcatheter (Balt, Montmorency, France) and a Terumo 0.010-inch guidewire., Technique: Embolization was performed only when the tip of the microcatheter was wedged into the nidus of the AVMs with no reflux of contrast proximally. The embolization was performed using simultaneous biplane roadmapping with the patient under general anesthesia without Amytal testing., Results: Twenty-six of 54 patients are still waiting for more radical treatment. Two deaths and two minor and one severe permanent neurological deficit occurred. Three patients were cured with embolization alone; 11 patients were cured after surgical resection. Three patients underwent radiosurgery, with one cure after 1 year., Conclusion: Nidus embolization with Histoacryl is an effective technique that permits complete cure of a large number of brain AVMs, with or without surgical resection and/or radiosurgery.

Purpose: To determine whether bilateral, simultaneous, cavernous sinus sampling after corticotropin-releasing hormone (CRH) stimulation offers as accurate detection and lateralization of Cushing disease as inferior petrosal sinus sampling does., Methods: Seventeen consecutive patients with hypercortisolism and with high-dose dexamethasone suppression test results suggesting Cushing disease underwent bilateral cavenous sinus sampling with CRH stimulation. The diagnosis of Cushing disease was established in all patients by histologic examination or, if no tumor was found at surgery, by subtotal resection of the gland or radiation therapy resulting in eventual hypocortisolism or normal adrenal function and clinical remission., Results: The sensitivity of cavenous sinus sampling with and without CRH in detecting Cushing disease was 94% and 71%, respectively. The abnormal side of the pituitary was correctly identified in all patients who had criteria for lateralization, yielding a positive predictive value of 100%., Conclusions: This small series suggests that cavernous sinus sampling with CRH is as accurate as inferior petrosal sinus sampling in detecting Cushing disease and perhaps more accurate in lateralizing the abnormality within the pituitary gland.

We are reporting three cases of spontaneous direct carotid cavernous fistulas (CCFs) associated with Ehlers-Danlos syndrome (EDS) out of a series of 147 direct CCFs. The internal carotid artery could be preserved in only one case. Two patients had severe bilateral irregularities of caliber of both internal carotid arteries. Two patients had recurrence of their symptoms after a first balloon was detached in the cavernous sinus (CS) necessitating a second treatment. Two patients died several months later from complications associated with their disease. The treatment of direct CCFs associated with Ehlers-Danlos syndrome is more difficult and more risky than most direct CCFs. The permanent occlusion of the ICA, which may be difficult to avoid, increases the risks of development of aneurysm on the contralateral side.

The transcranial cerebral oximeter is a reliable, low-cost, noninvasive device that provides real-time evaluation of regional brain oxygen saturation during endovascular treatment of cerebrovascular diseases. We discuss three patients with carotid-cavernous fistulae treated by endovascular balloon occlusion, each monitored continuously before, during, and after the procedure with transcranial cerebral oximetry. The cerebral oxygen saturation measured was directly related to the side of the venous drainage of the fistula, being 15-20% higher on that side. Following endovascular occlusion of the fistula, oxygen saturation gradually became equal on the two sides.

Background: The treatment of a large dural sinus fistula can be very difficult and complicated. The very extensive and complex nature of these malformations may require a combination therapy in the form of surgery and multistaged embolization. The transverse sinus fistula in our patient was fed by multiple large high-flow feeders and was draining retrograde into the superior sagittal sinus (SSS) and the cortical veins. The SSS did not fill in the late venous phase of the carotid angiogram, suggesting increased venous pressure., Methods: A case of transverse sinus dural fistula is described that was managed by a combination of surgery and embolization. The complex nature of this malformation encouraged us to adopt a combination of multistaged embolization and surgery for the management and clinical control. The patient underwent embolization of multiple feeders from the branches of the external carotid artery. After this procedure, the patient underwent endovascular occlusion of the transverse sinus via the SSS. Throughout the endovascular treatment, the patient had concomitant intracranial pressure monitoring and SSS pressure monitoring, along with transcranial cerebral oximetry (TCCO). Despite this aggressive endovascular intervention, the fistula could not be completely closed. The patient then underwent surgical excision of the transverse sinus along with duraplasty and cranioplasty., Results: The patient had a good recovery and posttreatment angiogram revealed normal antegrade flow in the SSS with no evidence of the fistula. The combined surgical and endovascular techniques are described and their use in clinical practice is discussed., Conclusions: The complexity of certain large dural sinus fistulae should not be underestimated. They may require a prolonged multistaged treatment for their total obliteration. Also, despite the large size and complexity of the disease, complete cure can be achieved.

The authors describe the method and results of treatment of 12 consecutive patients with carotid-cavernous sinus fistulas (CCFs). Treatment was by embolization via a transvenous approach through the superior ophthalmic vein (SOV). The CCFs (two direct and 10 dural) had previously been treated unsuccessfully or, for mechanical reasons, could not be treated by the standard techniques of endoarterial balloon occlusion, particle or glue embolization of feeding vessels from one or both external carotid arteries, or transvenous occlusion of the fistula via the ipsilateral inferior petrosal sinus. All 12 patients were successfully treated either by advancement of a detachable balloon catheter through the ipsilateral SOV into the cavernous sinus with subsequent inflation and detachment of the balloon (11 patients) or by introduction of multiple thrombogenic coils into the fistula via the ipsilateral SOV (one patient). All patients had complete resolution of symptoms and signs after successful occlusion of the CCF. There were no intraoperative complications; however, one patient required postoperative embolization of a residual posteriorly draining fistula via the ipsilateral external carotid artery, and another developed a persistent abducens nerve paresis that eventually required surgical correction. Ten (83.3%) of the 12 patients underwent cerebral angiography 3 to 6 months after surgery, and none showed evidence of a recurrent fistula. Similarly, none of the 12 patients developed recurrent symptoms and signs suggesting recurrence of the fistula during a follow-up period that ranged from 6 months to 10 years (mean 64 months). It is concluded that the transvenous approach to the cavernous sinus through the SOV is a safe and effective treatment of both direct and dural CCFs that are not amenable to transarterial or other transvenous approaches.

It is rare that a patient with a carotid cavernous sinus fistula (CCF) is referred to the interventionalist with a good and exhaustive angiographic workup, providing all the information necessary for a therapeutic decision. The goal of this technical note is to refresh our memory on the best way to study this group of patients. It does not have the pretension to bring a new technique. As there are two types of CCFs, direct and indirect, there are also two different angiographic workups.

The cavernous sinus in 3 of a series of 147 fast-flow direct carotid-cavernous fistulae was best reached through the vertebral artery. All three patients were anatomically cured without morbidity.

We present five cases of giant serpentine aneurysms (large, partially thrombosed aneurysms containing tortuous vascular channels with a separate entrance and outflow pathway) and review 28 cases reported in the literature. Giant serpentine aneurysms should be considered as a subgroup of giant aneurysms, distinct from saccular and fusiform varieties, given their unique clinical presentation and radiographic features.

We describe two patients with dural fistulas who presented with dementia and diffuse white matter signal changes on MR that significantly improved after surgery. One patient had preoperative embolization.

When a small amount of diatrizoate meglumine, an ionic iodinated contrast medium, is left in a catheter system before injection of amobarbital sodium or when the contrast medium is intentionally mixed with amobarbital sodium, a potentially dangerous situation occurs. The authors showed in vitro that a dense precipitate forms in this situation. This is due to an acid-base reaction between the relatively acidic contrast medium and basic barbiturate and the subsequent formation of insoluble amobarbital.

Symptomatic patients with dural carotid-cavernous fistulas often require treatment. Traditional therapies, which often are not completely successful, include manual common carotid artery compression and embolization via transarterial routes. This report describes four symptomatic patients with spontaneous dural carotid-cavernous fistulas who were treated unsuccessfully with transarterial embolotherapy and subsequently treated successfully by having a detachable balloon introduced into the cavernous sinus via the superior ophthalmic vein, which was surgically exposed. The fistulas resolved without complications. Treatment of dural carotid-cavernous fistulas by means of the transvenous approach via the superior ophthalmic vein may be of benefit in selected patients.

The intracarotid amobarbital sodium, or Wada, test has been used to localize speech and memory function prior to surgical treatment of temporal lobe seizures. The authors mixed technetium-99m hexamethyl-propyleneamine oxime (HMPAO) with amobarbital sodium and injected the mixture in 25 patients with epilepsy. Single photon emission computed tomography (SPECT) of the brain was then performed to determine intracerebral distribution of the amobarbital sodium. Results of SPECT were compared with those of conventional and digital subtraction angiography (DSA). The distribution of Tc-99m HMPAO and, presumably, amobarbital sodium varied from patient to patient. SPECT revealed a statistically different distribution from that predicted with conventional angiography. The distribution also often differed from that of DSA, although the difference was not significant. SPECT revealed infrequent delivery to mesial temporal lobe structures. This emphasizes the need for caution in the use of the intracarotid amobarbital sodium test to predict the outcome of removal of these areas.

Gradient-recalled acquisition in the steady state (GRASS) MR images, obtained in four patients with angiographic evidence of successful occlusion of cerebral arteriovenous malformations, demonstrated hyperintense signal intraluminally. Although this was initially mistaken as evidence of persistent blood flow in the arteriovenous malformation, the short TR/TE spin-echo images showed hyperintense signal rather than flow void, thereby indicating the presence of subacute thrombus. GRASS images alone should not be used to determine the success of embolotherapy of cerebral arteriovenous malformations or to determine aneurysm patency, since the hyperintense signal is a potential pitfall that may mislead the radiologist in the absence of corroborative images, particularly the short TR/TE spin-echo sequences.

Carmustine (BCNU) has been used extensively to treat glioblastomas by injection through a catheter placed in the cervical internal carotid artery. The technique causes severe pain to the eye and has resulted in ipsilateral blindness. The use of a latex calibrated-leak balloon positioned above the ophthalmic artery in the internal carotid artery or in one of its branches appears to circumvent the ocular complications mentioned. At an infusion rate at 125 ml/hr the balloon does not inflate and does not occlude the artery. This new technique has been used to treat 10 patients without complications.

To decrease the risk of iatrogenic thromboembolic complications during interventional procedures with coaxial catheter systems, aspirin and systemic heparinization were used in 57 consecutive cases. No thromboembolic complications occurred. This group was compared with a second group of 25 patients who also had interventional procedures with coaxial systems but who had only a continuous heparinized drip infusion flushing the inside of the coaxial system. Two patients had an embolic complication and two others had thrombus formation inside or outside the catheters without neurologic symptoms. The use of systemic heparinization has been extended to all prolonged angiographic procedures except in cases of acute or recent subarachnoid hemorrhage.

The authors describe a system comprising a small latex balloon attached to a Teflon catheter. The balloon has a distal calibrated leak which is used for intravascular embolization with isobutyl-2-cyanoacrylate. The balloon is easily detached after embolization. The combination of manual control of the balloon-catheter system, plus the ability of the balloon to navigate intra-arterially with the blood flow, makes this system suitable for superselective angiography and embolization of lesions supplied by the external carotid artery (ECA). This system avoids intimal dissection and concomitant arterial vasospasm when trying to negotiate steep distal curves of the ECA branches. Experimental embolization of several branches of the ECA in the dog, and clinical examples of treatment of dural arteriovenous malformations in three patients are described.

Classification of carotid-cavernous fistulas (CCFs) into the four types described by Barrow allows the surgeon to choose the optimal therapy for each patient. Type A patients have fast flow fistulas that are manifest by a direct connection between the internal carotid arterial siphon and the cavernous sinus through a single tear in the arterial wall. The best therapy is obliteration of the connection by a detachable balloon. Ninety-two of 95 traumatic CCFs were treated in this fashion. Direct surgical exposure of the cervical or cavernous internal carotid artery (ICA) was necessary in the remaining 3 patients, who had undergone unsuccessful surgical trapping. Three ruptured cavernous aneurysms and 2 spontaneous CCFs also had Type A connections. Other carotid-cavernous fistulas are slow flow, spontaneous dural arteriovenous malformations (AVMs) that have been classified into B, C, and D types on the basis of arterial supply. Occlusion of the ICA is not a logical choice in the treatment of dural AVMs that occur in the elderly, are relatively benign, and are often bilateral. Type B are rare and are fed by meningeal branches of the ICA only. We have not seen this type of dural fistula in our series. Type C are supplied by feeders from the external carotid only and can almost always be obliterated successfully by embolizing the external carotid artery (ECA) branches. There are 4 Type C cases in this series of 37 spontaneous CCFs. All occurred in patients less than 30 years of age and were shunts between the middle meningeal artery and the cavernous sinus.(ABSTRACT TRUNCATED AT 250 WORDS)

Two different types of latex calibrated-leak balloon catheters have been developed. One consists of a Teflon catheter with a detachable latex balloon and is used to embolize branches of the external carotid artery. The other consists of a Silastic catheter with a nondetachable latex balloon and is used to embolize brain arteriovenous malformations. An experimental model and animal experiments have determined the best conditions for safe and reproducible embolization with isobutyl-2 cyanoacrylate (IBC-2). Selective catheterization of branches of external carotid, middle cerebral, anterior cerebral, and posterior cerebral arteries in humans is facilitated, and embolization with IBC-2 has been achieved with these balloon catheters.

Four consecutive patients with carotid-cavernous sinus fistulas that could not be treated by the standard techniques of endoarterial balloon occlusion or embolization were successfully treated by advancement of a detachable balloon catheter through the ipsilateral superior ophthalmic vein. Under angiographic monitoring, the balloon was passed into the cavernous sinus, inflated to close the fistula, and detached. Three of the patients had a spontaneous fistula, and one had a traumatic fistula that had previously been trapped unsuccessfully. All patients had complete resolution of symptoms and signs after occlusion of the fistula. There were no intraoperative or postoperative complications. The transvenous approach to the cavernous sinus through the superior ophthalmic vein is a safe, effective treatment of carotid-cavernous sinus fistulas, whether they are direct or dural in nature.

The goal of therapy in patients with traumatic carotid-cavernous fistulas is to occlude the fistula, preferably while maintaining the carotid blood flow. Surgical techniques that treat the fistula remote from the cavernous sinus often cannot maintain carotid patency. Various interventional techniques using detachable balloons have been developed. The most common technique uses the endarterial route, introducing the balloon catheter in the neck or the groin. If the balloon is detached in the cavernous sinus, the carotid blood flow will be preserved. A second approach uses the venous retrograde route through the jugular vein, inferior petrosal sinus, and cavernous sinus. Elegant and safe, this method is appropriate when the fistula drains posteriorly. A third approach involves surgical exposure of the cavernous sinus and direct introduction of the balloon. This is sometimes the only recourse when the fistula has been previously treated with internal carotid ligation.

Experimental cervical carotid aneurysms in dogs are obliterated with isobutyl-cyanoacrylate ( IBCA ) injected under direct vision into the aneurysm. Reflux of IBCA into the artery was prevented by inflating either a latex or a Silastic balloon in the carotid artery at the level of the neck of the aneurysm. This balloon was introduced through a catheter advanced into the common carotid artery by femoral catheterization. The Silastic balloon was found to be much more effective than the latex balloon in preventing spillage of IBCA into the lumen.

Embolization treatment of 16 patients with dominant-hemisphere arteriovenous malformations (AVMs) is described. This group was selected from 50 patients with brain AVMs embolized with isobutyl 2-cyanoacrylate (IBC-2) over a period of 3 years. All 16 AVMs were cortical in location; six involved the rolandic and speech areas, and four had a deep component. Ten AVMs were embolized through a transfemoral approach, an intraoperative approach was used for four cases, and a combined transfemoral/intraoperative approach was used in two cases. Complete obliteration of the AVM was obtained in one case. Partial obliteration and complete surgical resection was obtained in three cases. Obliteration of 70%-95% of the AVM was obtained in six cases and 45%-70% of the AVM was obliterated in six cases. IBC-2 embolization of the venous drainage was observed in three cases. After embolization, eight patients remained neurologically unchanged. Three patients had mild neurologic deficits that resolved completely within 48 hr; one had a deficit that cleared up 1 week later; and one had a deficit that disappeared within 6 months. In three patients a mild permanent neurologic deficit was evident 6 months after embolization.

Among 143 carotid cavernous fistulae, 10 cases could not be successfully treated by standard endovascular techniques alone; some form of surgical assistance was required. The circumstances included incomplete closure of the fistula while the internal carotid artery was occluded, failure to occlude the fistula after both arterial and venous endovascular approaches, hairpin loop of the cervical portion of the internal carotid artery, failure of previous trapping procedures, and failure to cure spontaneous carotid cavernous fistulae of the dural type after embolization of the external carotid feeders. These ten patients were cured by combining a surgical procedure and an interventional technique.

One case of traumatic carotid cavernous fistula and two cases of cavernous aneurysm associated with a persistent trigeminal artery are reported. Since a significant rate of infarctions or hemorrhages in the vertebrobasilar territory is associated with PTA, we prefer to permanently occlude the PTA during treatment of a carotid cavernous fistula or a cavernous aneurysm if the trigeminal artery can be sacrificed without jeopardizing the basilar circulation. These three patients were cured without complications. The internal carotid artery could be preserved in only one case.

Sixty-five carotid-cavernous fistulas were studied at University Hospital, London, Canada, from 1978 to 1982, 20 of which fulfilled the clinical and angiographic criteria of a spontaneous carotid-cavernous fistula. Of these 20 fistulas, 17 were unilateral, and three were bilateral. In 18 cases the angiographic findings were typical of an arteriovenous malformation (AVM), and in two a ruptured giant intracavernous aneurysm was found. These patients were treated according to whether they had a nonresolving or progressive cavernous sinus syndrome or deterioration of vision. The cavernous dural AVM's were treated with polyvinyl-alcohol and/or isobutyl-2-cyanoacrylate (IBCA) embolization of the external carotid artery blood supply. Two patients underwent postembolization surgical procedures. The detachable balloon technique was used to occlude the fistulas associated with the two giant ruptured intracavernous aneurysms and a small dural intracavernous AVM. Eight patients received no therapy; in two, spontaneous obliteration of the fistula occurred. Of the nine cavernous AVM's embolized with particles and/or IBCA, successful transvascular embolization was achieved in seven cases, and partial embolization followed by surgery in two cases. Successful balloon obliteration of the giant intracavernous ruptured aneurysm was obtained in two cases. In one patient, right hemiplegia with aphasia resulted from reflux of IBCA emboli through the artery of the foramen rotundum into the left middle cerebral artery.

A patient presenting with progressive paraparesis was found to have a spinal arteriovenous fistula at the T3-4 vertebral level. The lesion consisted of a direct communication of the anterior spinal artery with a very distended venous varix that drained mostly superiorly to the posterior fossa and simulated a posterior fossa arteriovenous malformation (AVM) on vertebral angiography. The patient was treated by surgical ligation of the fistula through an anterior transthoracic approach. He deteriorated abruptly on the 4th postoperative day, probably because of retrograde thrombosis of the enlarged anterior spinal artery. Over the next few months, he improved to the point of being able to walk with crutches. He has also regained sphincter control. The different types of spinal AVM's are reviewed. Our case does not fit into any of these groups. A new category, Type IV, is proposed to designate direct arteriovenous fistulas involving the intrinsic arterial supply of the spinal cord.

A prospective clinical study was performed in 70 consecutive patients with known or strong clinical suspicion of acute or relapsing multiple sclerosis. The study was designed to compare the results of standard computed tomography and high-volume contrast-delayed scanning for the detection of enhancing lesions. In 39 cases with clinically definitive multiple sclerosis, the conventional enhanced scan was positive in 25 cases and the high-volume delay scan in 32. The high-volume enhanced scan added information in 23 of these 32 cases. In 21 cases, suspicious of multiple sclerosis but not clinically confirmed, the standard enhanced scan was positive in two cases and the high-volume delay scan in five. In these cases, computed tomography was definitive in establishing the diagnosis by showing clinically unsuspected brain lesions. In 10 cases in which the disease was eventually excluded, the scans were negative in all instances. For the first time, by the high-volume delayed technique, enhancing plaques in the cortical gray matter and in the gray/white matter regions were demonstrated. This technique is a very useful diagnostic tool, not only for morphologic assessment when multiple sclerosis is known, but for the positive diagnosis of this disease when the first clinical presentation is diagnostically uncertain.