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Here we describe our experience managing intracranial dural arteriovenous fistulas (DAVFs) via endovascular embolization using a transarterial embolization (TAE) technique with liquid embolic agents. We illustrate the technical nuance of using dual arterial access for angiographic control runs in complex DAVFs supplied by multiple feeders from 2 distinct arterial systems. Retrospective analysis of intracranial DAVF embolization as a single treatment technique at our institution from 2013 to 2023. Twenty-three patients with intracranial DAVF who underwent endovascular treatment as their initial treatment were included. All embolizations were approached transarterially with Onyx (n = 19), n-butyl cyanoacrylate (n = 2), or a combination (n = 2). Twenty-two patients (96%) had angiographic evidence of complete fistula obliteration after initial embolization. Six DAVF TAEs were performed with dual arterial access for simultaneous embolic delivery and angiographic control intraoperatively. Two patients recanalized twice postprocedure, 1 of whom was found to have incidental new DAVF at follow-up. Median patient follow-up was 12 months (interquartile range, 6–36 months), with a median modified Rankin Scale score on discharge of 1 and a Glasgow Outcome Scale score at 3 months of 5. In this initial series of patients with DAVF managed by endovascular embolization, dual arterial access was feasible, safe, and effective in achieving fistula obliteration. Dual-arterial access conveniently provides simultaneous access for control angiography and embosylate delivery intraoperatively. [ABSTRACT FROM AUTHOR]

Cerebral arteriovenous malformations (AVMs) are a challenging pathology in pediatric patients, carrying a high risk of morbidity and mortality. Treatment modalities include resection, endovascular embolization, and stereotactic radiosurgery. There is currently no consensus favoring one modality over another. Timing of multimodal therapy with embolization/stereotactic radiosurgery and resection is not well explored in the literature. We present a series of pediatric patients with AVMs, with special attention directed to the timing of treatment. Electronic medical records of all pediatric patients (<18 years old at treatment) with AVMs treated at our institution were retrospectively reviewed after institutional review board approval. Demographic information, AVM characteristics, treatment variables, and outcomes were recorded. In our cohort of 27 patients, 21 (77.8%) presented with a ruptured AVM. Of these patients, 6 (28.6%) had a Glasgow Coma Scale score of 3–10 and underwent treatment within 24 hours of presentation, and 10 (47.6%) with a Glasgow Coma Scale score of 12–15 were treated between 24 and 120 hours after presentation. The remaining 5 patients (23.8%) were treated 3 weeks to 14 months after AVM rupture. Regardless of rupture status, 96% of our cohort had a modified Rankin Scale score of 1–2 at most recent follow-up. We present our institution's experience with pediatric AVMs, focusing on the timing of treatment. Based on our experience, early treatment of AVMs seems to be safe and effective regardless of rupture status. [ABSTRACT FROM AUTHOR]

Arteriovenous malformations (AVMs) can be treated with observation, surgery, embolization, stereotactic radiosurgery (SRS), or a combination of therapies. SRS has been used for AVMs that pose a high risk of surgery, such as in deep or eloquent anatomic locations. Smaller AVMs, <3 cm, have been shown to have higher rates of complete obliteration after SRS. For AVMs that are a larger size, embolization prior to SRS has been used to reduce the size of the AVM nidus. In this study we analyzed embolization prior to SRS to reduce nidal volume and describe imaging techniques to target for SRS post embolization. We retrospectively reviewed all patients at a single academic institution treated with embolization prior to SRS for treatment of AVMs. We then used contrast enhanced magnetic resonance imaging (MRI) to contour AVM volumes based on pre-embolization imaging and compared to post-embolization imaging. Planned AVM volume prior to embolization was then compared to actual treated AVM volume. We identified 11 patients treated with embolization prior to SRS from 2011–2023. Median AVM nidal volume prior to embolization was 7.69 mL and post embolization was 3.61 ML (P < 0.01). There was a 45.5% obliteration rate at follow up in our series, with 2 minor complications related to radiosurgery. In our cohort, embolization prior to SRS resulted in a statistically significant reduction in AVM nidal volume. Therefore, embolization prior to SRS can result in dose reduction at time of SRS treatment allowing for decreased risk of SRS complications without higher embolization complication rates. [ABSTRACT FROM AUTHOR]

To evaluate the efficacy of the combined approach of preoperative endovascular embolization (EE) and surgical excision (SE) for scalp arteriovenous malformation (AVM) and present an illustrative case report. A systematic review was conducted using online databases (PubMed/Medline, Cochrane, and Embase) on February 15, 2023. The inclusion criteria were any type of study of patients with scalp AVMs who were diagnosed and confirmed through angiography and treated with combined preoperative EE and SE. All the articles that met the inclusion criteria were included in this study. A total of 49 articles (91 patients) were included. The patients' age ranged from 10 days to 70 years at the time of presentation. The most common symptoms were a pulsatile mass in 51 patients (56.04%), progressively growing mass in 31 patients (34.06%), and bruits and/or thrills in 22 patients (24.17%). Complications of preoperative EE and SE were observed in only 5 patients; 3 patients (3.29%) had harvested skin graft marginal necrosis, 1 patient (1.09%) had skin necrosis, and 1 patient (1.09%) had a wound infection. Only 2 patients (2.19%) reported a recurrent or residual mass during a median follow-up period of 12 months. The management of scalp AVMs can be challenging; therefore, focused, and accurate identification of the complexity of the vascular anatomy is required. The combined method of preoperative EE and SE showed satisfactory outcomes with low rates of complications and recurrence; thus, we recommend this approach for the management of scalp AVMs. [ABSTRACT FROM AUTHOR]

Complex cerebral arteriovenous malformations (AVMs) require a combined therapy of endovascular embolization and microsurgical resection to eliminate the lesion and maximize neurological protection, while a deliberate time interval might contribute to optimal clinical outcomes. The present study aimed to explore the feasibility of this paradigm. All patients who underwent deliberately planned presurgery embolization and microsurgery resection between 2015 and 2023 were reviewed, with baseline data, postoperative complications, and follow-up outcomes recorded. The modified Rankin scale (mRS) was used to evaluate clinical outcomes, with mRS 0–2 defined as good. A total of 30 patients were included in the study (15 were ruptured AVMs). The median Spetzler–Martin grade of baseline AVMs was 3 (interquartile range: 2–3). The median interval between the last embolization and microsurgery was 5 days (interquartile range: 2.25–7). The complete removal rate was 100%, and the overall permanent complication rate was 16.67%. At the last follow-up, 26 patients achieved mRS 0–2, while 28 had improved or unaltered mRS. The last follow-up mRS significantly improved from baseline and discharge (P = 0.0006 and P = 0.006). The last follow-up mRS decreased by 0.65 for each additional day of time interval before the 4.4-day inflection point (β = −0.65, P = 0.02) in the AVM ruptured cohort. The deliberately staged combined procedure of embolization and microsurgery might be a safe and efficacious strategy for Spetzler–Martin grade 2–5 AVMs, 4–5 days might be an appropriate staged time interval for ruptured AVMs, although further studies are needed to substantiate these findings. [ABSTRACT FROM AUTHOR]

Asymptomatic craniocervical junction arteriovenous fistulas (CCJ AVFs) are rare and, thus, a consensus has not yet been reached regarding the indication of surgical interventions. This retrospective multicenter cohort study investigated the risks associated with surgery for asymptomatic CCJ AVFs and discussed the indication of surgical interventions. Using data from 111 consecutive patients with CCJ AVFs registered with the Neurospinal Society of Japan between 2009 and 2019, we analyzed the treatment, complications, and outcomes of 18 patients with asymptomatic CCJ AVF. The median age of the patient cohort was 68 years (37–80 years), and there were 11 males and 7 females. Diagnoses were 14 patients with dural AVF, one perimedullary AVF, one radicular AVF, one epidural AVF, and one bilateral dural and epidural AVF. Initial treatment included direct surgery in 12 patients, endovascular treatment in four, and conservative treatment in two. Among 16 patients, three complications (18.7%) occurred: spinal cord infarction associated with the surgical procedure, cerebral infarction associated with intraoperative angiography, and mortal medullary hemorrhage after endovascular treatment followed by open surgery. Complete occlusion was achieved in all 12 patients in the direct surgery group and in one out of four in the endovascular treatment group. Given the risk of serious complications associated with asymptomatic CCJ AVF and the fact that no case of asymptomatic CCJ AVF became symptomatic in this study, prophylactic surgery for asymptomatic CCJ AVF should be carefully considered. [ABSTRACT FROM AUTHOR]

Despite recent technological advancements in endovascular embolization devices for treating intracranial aneurysms (ICAs), incomplete occlusion and aneurysm recanalization remain critical challenges. Shape memory polymer (SMP)-based devices, which can be manufactured and tailored to patient-specific aneurysm geometries, possess the potential to overcome the suboptimal treatment outcome of the gold standard: endovascular coiling. In this work, we propose a highly porous patient-specific SMP embolic device fabricated via 3D printing to optimize aneurysm occlusion, and thus, improve the long-term efficacy of endovascular treatment. To facilitate device deployment at the aneurysm via Joule-heating, we introduce a stable, homogeneous coating of poly-pyrrole (PPy) to enhance the electrical conductivity in the SMP material. Using an in-house pulse width modulation circuit, we induced Joule-heating and characterized the shape recovery of the PPy-coated SMP embolic devices. We found that the employed PPy coating enables enhanced electrical and thermal conductivity while only slightly altering the glass transition temperature of the SMP material. Additionally, from a series of parametric studies, we identified the combination of catalyst concentration and pyrrole polymerization time that yielded the shape recovery properties ideal for ICA endovascular therapy. Collectively, these findings highlight a promising material coating for a future coil-free, personalized shape memory polymer (SMP) embolic device, designed to achieve long-lasting, complete occlusion of aneurysms. [Display omitted] [ABSTRACT FROM AUTHOR]

Intraprocedural Cone Beam CT (CBCT) is assessed to examine if use improves diagnosis and embolization rates of acute lower GI bleed (LGIB) and if automatic vessel detection (AVD) software can identify feeding vessels (FV) for embolization. Patients with inconclusive DSA findings had CBCT and retrospective analysis with AVD software (Innova 3100, GE Company, USA). Technical success was defined as the ability to detect a lower GIB site while clinical success was defined as successful embolization without evidence of rebleeding or death within 30 days. AVD technical success was defined by the ability to identify the FV on both CTA and CBCT upon independent review by 3 blinded IRs, who also assigned a degree of certainty on a 5-point Likert scale. 74 patients in total were treated for lower GI bleed of which 34 had indeterminate DSA. Of those, 10 patients received DSA only, of which 1 was super selective. 24 patients with GIB on pre-procedural CTA and inconclusive DSA underwent CBCT. Use of CBCT identified 9 bleeds not seen on DSA and an additional source artery in 1 case representing a 42% change in intraprocedural management as all findings were embolized. When a bleed could not be identified on CBCT, but the FV could be identified on CTA, the same suspected FV could be selected on AVD 62% of the time with an average certainty of 4.0. CBCT is useful in the intraprocedural detection of GIB when DSA is indeterminate. Furthermore, AVD software can feasibly be utilized to accurately identify FVs for empiric treatment when intraprocedural imaging is inconclusive. Level III, therapeutic study. • CBCT is useful in the intraprocedural detection of LGIB when DSA is indeterminate. • Use of CBCT increases sensitivity and changed management by IR without significant changes in dose or evidence of off target embolization. • Use of CBCT to increase sensitivity for LGIB is thus safe, feasible and effective. • Use of AVD software can increase operator confidence when identifying feeding vessels for empiric treatment. [ABSTRACT FROM AUTHOR]

In the multimodality treatment of complex brain arteriovenous malformations (AVMs), the role of endovascular embolization is not fully elucidated. To assess the risk of embolization, we retrospectively evaluated the outcomes of endovascular treatment for AVM, focusing on the embolization-related complications. The present study included patients with brain AVM who underwent embolization at our hospital between April 2011 and May 2021. Risk factors for peri- and postoperative complications were analyzed. During the study period, 36 AVMs were treated during 58 embolization sessions. The goal of the embolization was preoperative in 24 (67%), pre-radiosurgical in 9 (25%), and palliative in 3 (8%) cases. The overall complication rate was 43% (25 of 58) per session and 36% (13 of 36) per patient. Ischemic and hemorrhagic complications were observed in 14 (24%) and 14 (24%) cases, respectively. n -Butyl cyanoacrylate (n-BCA) embolization was detected as the significant risk for postoperative hemorrhage in the univariate (79% vs. 36%, P = 0.012; Fisher exact test) and the multivariable analysis (odds ratio 4.90, 95% confidence interval 1.08–22.2, P = 0.039). The number of embolized feeder in a single session also tended to be higher in a hemorrhagic complication group (median 3.5 vs. 2.0, P = 0.11; Mann-Whitney U-test). The risk of embolization in multimodality treatment for complex brain AVM was substantial. n-BCA embolization may carry a higher risk of postoperative hemorrhage. An accumulation of cases is awaited to investigate the effectiveness of minimal target embolization in the future. [ABSTRACT FROM AUTHOR]

To propose a machine learning (ML) model predicting the favorable outcome of stereotactic radiosurgery (SRS) for residual brain arteriovenous malformation (bAVM) after partial embolization. One hundred and thirty bAVM patients who underwent partial embolization followed by SRS were reviewed retrospectively. Patients were split at random split into training datasets (n = 100) and testing datasets (n = 30). Radiomics and dosimetric features were extracted from pre-SRS treatment images. Feature selection was performed to select appropriate radiomics and dosimetric features. Three ML algorithms were applied to construct models using selected features respectively. A total of 9 models were trained to predict favorable outcomes (obliteration without complication) of bAVMs. The efficacy of these models was evaluated on the testing dataset using mean accuracy (ACC) and area under the receiver operating characteristic curve (AUC). The obliteration rate of this cohort was 70.77% (92 of 130) with a mean follow-up of 43.8 months (range, 12–108 months). Favorable outcomes were achieved in 89 patients (68.46%). Four radiomics features and 7 dosimetric features were selected for ML model construction. The dosimetric support vector machines (SVM) model showed the best performance on the training dataset, with an ACC of 0.74 and AUC of 0.78. The dosimetric SVM model also showed the best performance on the testing dataset, with an ACC of 0.83 and AUC of 0.77. Dosimetric features are good predictors of prognosis for patients with partially embolized bAVM followed by SRS therapy. The use of ML models is an innovative method for predicting favorable outcomes of partially embolized bAVM followed by SRS therapy. [ABSTRACT FROM AUTHOR]

Dural arteriovenous fistulas represent a distinct direct pathological connection between dural arterial feeders of the meninges to cortical veins or sinuses. Vascular supply of the meninges is provided by a series of named arteries—anterior, middle, and posterior meningeal arteries, with the tentorium provided by the artery of Bernasconi and Cassinari (anterior-medial) and the artery of Davidoff and Schechter (posterior-medial). This case is the first report in the literature of a lateral distal posterior cerebral artery supplying the meninges and contributing dural feeders to a Cognard type III/Borden type III dural arteriovenous fistula. [ABSTRACT FROM AUTHOR]

Spinal epidural arteriovenous fistulas are an uncommon entity. The authors present an interesting case of a 48-year-old man involved in a MVC five months prior to presenting with bilateral lower extremity weakness and hypoesthesia below the knees. MRI demonstrated a flow void in the L1 vertebral body burst fracture along with a dilated basivertebral vein draining in to engorged epidural venous plexus. Angiography confirmed an intraosseous arteriovenous fistula fed by T12 and L1arteries and epidural venous drainage. Complete obliteration by arterial embolization was precluded by origin of the artery of Adamkiewicz from the feeding L1 lumbar artery. Embolization using a transvenous approach allowed for successful obliteration of the fistula. Following the procedure, the patient had significant immediate improvement in the lower extremity symptoms. This is the first report of a posttraumatic spinal epidural arteriovenous fistula secondary to a vertebral burst fracture successfully treated by transvenous embolization. • Although challenging, early diagnosis and prompt characterization of spinal vascular malformation are pivotal for treatment. • SEDAVF is a rare and complex disease pathology that requires the need for a multidisciplinary management approach. • Minimally invasive transvenous approach in the management of post-traumatic SEDAVF can be feasible and effective. [ABSTRACT FROM AUTHOR]

To review our use of pharmacologic provocative testing (PT) and intraoperative neurophysiologic monitoring (IONM) during endovascular embolization for eloquent arteriovenous malformations (AVMs), and better define their clinical utility. This is a prospective study between 1 June 2018 and 1 June 2020. Prior to endovascular embolization, superselective PTs with propofol injection were performed. The PT results were assessed by IONM. The impact of different doses of propofol on PT results was compared. Under general anesthesia, 111 PTs and 48 endovascular embolizations were performed in 22 patients. For the initial 48 PTs before planned embolization, 38 PTs with 5 mg propofol were negative and repeat PTs with 7 mg propofol were also negative. For the remaining 10 positive PTs, the microcatheter tip was adjusted to an alternative site until repeat PTs were negative to ensure a subsequent safe embolization. In comparison, 5-mg-propofol PT results were consistent with 7-mg-propofol PTs in larger-sized feeders, whereas for smaller-sized vessels, 3-mg-propofol PT results were consistent with 5-mg-propofol PTs. The negative predictive value of PTs was 97.9% (47 of 48), as only 1 of the 48 embolizations with negative PTs resulted in postoperative hemorrhage and none of the other 47 embolizations led to a postoperative neurologic deficit. PTs and IONM are valuable techniques to predict neurologic deficits and improve procedure decision-making during AVM embolization under general anesthesia. A 5-mg dose of propofol may be sufficient for PTs in larger-sized feeders and a 3-mg dose may be sufficient in smaller-sized feeding branches. [ABSTRACT FROM AUTHOR]

A review of endovascular cerebral mycotic aneurysm treatment with Onyx liquid embolic, N-butyl-2-cyanoacrylate (NBCA), or coil embolization has not been reported. The authors conduct a systematic review on endovascular treatment methods of mycotic aneurysms. A systematic literature review was performed using the PubMed and MEDLINE databases for studies published between 1986 and 2020. All studies assessing outcomes related to endovascular Onyx embolization, NBCA embolization, or coiling were included. A total of 74 studies were ultimately selected, including 180 (67% male) patients comprising 243 aneurysms treated endovascularly. The mean age was 38.2 ± 17.6 years, and the most common symptom on presentation was headache (31%). Most aneurysms were located on the middle cerebral artery (52.5%), and over half presented with rupture (53.8%). Coiling was the most commonly employed technique (50.4%), and obliteration rates were comparable across coiling, NBCA, and Onyx (99.1%, 100%, 100%, respectively). Complication rates were also comparable (4.3% vs. 15.2% vs. 8.1%). Embolization for infectious intracranial aneurysm appears to be an effective treatment option for mycotic aneurysms. Embolization rates were comparable between coiling, NBCA, and Onyx embolization. Noninferiority among these modalities cannot be demonstrated given the retrospective nature of this review, evolution of endovascular techniques over the years, and changes in treatment paradigms in the last 2 decades. Ideally, further prospective research will be needed to find which treatment method offers the lowest complication rates and the best outcomes for patients with mycotic aneurysms. [ABSTRACT FROM AUTHOR]

Spinal arteriovenous fistulas have abnormal connections between spinal arteries and veins. Early diagnosis and management are essential for preventing permanent neurologic deficits. Although symptoms of myelopathy are commonly related to established types of spinal arteriovenous fistulas within the spine, extraspinal arteriovenous anomalies may also result in similar pathology and pose challenges to conventional endovascular treatment. A 61-year-old man presented with progressive weakness and decreasing sensation in the lower extremities. He had a remote history of craniopharyngioma surgery and deep venous thrombosis. Examination showed decreased strength and reflexes in the lower extremities. Magnetic resonance imaging demonstrated T2 cord signal changes and flow voids within the spinal canal. Angiogram showed bilateral internal iliac artery arteriovenous malformations with retrograde flow into a radicular vein and venous congestion of the medullary veins. Percutaneous transgluteal puncture of the superior gluteal vein was performed, and the abnormal inflow to the radicular vein was obliterated with coiling and Onyx embolization. The patient had significant clinical improvement, and follow-up imaging demonstrated resolution of T2 cord signal changes and flow voids. Extraspinal vascular malformations with vascular myelopathy are extremely rare. They include a broad spectrum of complex vascular disorders and often require alternate endovascular approaches. [ABSTRACT FROM AUTHOR]

We present a rare case of multiple intracranial arteriovenous fistulas (AVFs). A young female presented with headache and a left eyelid pulsatile swelling. Magnetic resonance imaging demonstrated numerous dilated cortical veins, along with a prominent left superior ophthalmic vein. A diagnostic cerebral angiogram revealed 5 distinct AVFs including 4 dural AVFs (dAVFs) and a pial AVF (pAVF). The largest dAVF was at the superior sagittal sinus. The others included bilateral ethmoidal, torcular, and a pAVF arising of the right pericallosal artery. She was treated by endovascular transarterial Onyx embolization. Only the superior sagittal sinus fistula was treated via middle meningeal artery feeders with complete occlusion. Immediate follow-up angiogram also showed complete spontaneous occlusion of the untreated dAVFs and pial AVF. This case is exceedingly unique considering the multiplicity of AVFs, concurrent presence of pial and dural AVF, and spontaneous occlusion of all untreated AVFs after embolizing the largest shunting fistula. [ABSTRACT FROM AUTHOR]

The superficial temporal artery (STA) to middle cerebral artery (MCA) bypass is an effective treatment procedure for steno-occlusive severe ischemic disease of the anterior circulation. The formation of an aneurysm at the anastomosis site is a rare complication, and the mechanism underlying this condition and the appropriate treatment strategy, have not yet been established. We describe a case of an unruptured anastomosis aneurysm that was treated by endovascular embolization 7 years after bypass surgery. A 62-year-old woman presented with slurred speech, with magnetic resonance imaging and angiography showing multiple infarctions in her left cerebral hemisphere and severe stenosis in the left internal carotid artery and left MCA. An STA-MCA anastomosis was performed without neurologic sequelae. Five years later, follow-up magnetic resonance imaging showed that an aneurysm had formed at the MCA side of the anastomosis site. After 2 years, the saccular aneurysm had grown and was embedded in the brain parenchyma. Because the patient had experienced repeated problems with surgical wound healing, an endovascular intervention was performed, achieving obliteration of the aneurysm by coil embolization. Endovascular treatment is a feasible and efficacious treatment option for an aneurysm at the anastomosis site of an STA-MCA bypass. [ABSTRACT FROM AUTHOR]

Unfavorable anatomy can preclude traditional anterograde endovascular interventions. Transcirculation approaches, which consist of primary catheterization of a target artery from the contralateral side or opposite cerebral circulation, can provide alternative pathways for successful treatment of these patients. We aimed to assess the safety, efficacy, and outcomes of endovascular embolization through transcirculation approaches. Nine centers provided retrospective data on patients who underwent transcirculation procedures for embolization of intracranial aneurysms (IAs), dural arteriovenous fistulas (dAVFs), and arteriovenous malformations (AVMs). Raymond-Roy Occlusion Classification (RROC) grades and degree of obliteration were used to evaluate treatment success. Minor/major complications and clinical/angiographic outcomes were also assessed. A review of the literature reporting patients who underwent transcirculation embolizations was also performed. Forty patients were included in the study (34 IAs, 3 AVMs, and 3 dAVFs). Most IAs (22/34, 64.7%) were treated electively. Three AVMs and 2 dAVFs presented ruptured. RROC grade I–II was achieved in 97% of IAs. All AVMs and dAVFs were completely obliterated. One patient developed a transient arterial thrombus that was successfully treated with intravenous tirofiban. The most common indications for a transcirculation approach were difficult access angle of the target lesion (42.5%) and occlusion of the parent artery (27.5%). The review of the literature pooled 152 IAs treated via transcirculation approaches. Most common locations were the basilar tip (27%), posterior inferior cerebellar artery (25%), and internal carotid artery (15.1%). The posterior communicating artery was crossed in 60 (39.5%), anterior communicating artery in 48 (31.6%), and vertebral artery in 37 (24.3%) patients. Primary coiling alone was performed in 22 (14.5%), stent-assisted coiling in 67 (44.1%), balloon-assisted coiling in 36 (23.7%), stent-assisted coiling + balloon-assisted coiling in 20 (13.2%) and flow diversion in 7 (4.6%) patients. After intervention, 142 (93.4%) IAs achieved successful RROC grades I–II. Two major complications (1.3%) leading to death were reported, both of which were intraprocedural aneurysmal ruptures with massive subarachnoid hemorrhage and herniation. After a mean angiographic follow-up of 11.3 months, only 6/108 (5.6%) IAs showed intrasaccular filling/recurrence. Transcirculation approaches seem to be safe and effective in the treatment of IAs, dAVFs, and AVMs. The most common indication for a transcirculation approach is the presence of a difficult angle to access the target lesion and occlusion of the parent artery. [ABSTRACT FROM AUTHOR]

Despite the recent increase of transradial access among neurointerventionalists, there is still a paucity of evidence in the neurosurgical literature. There are 3 newly Food and Drug Administration–approved devices—Woven EndoBridge (WEB), Surpass, and PulseRider—that significantly expand the options available for endovascular treatment of cerebral aneurysms. Our work reports the safety and feasibility of radial artery catheterization for the deployment of these new devices. We performed a review of the first 10 patients with an unruptured cerebral aneurysm treated via a transradial cerebral angiogram. Seven patients underwent embolization with the WEB device, 1 patient underwent embolization with the PulseRider, and 2 patients underwent embolization with the Surpass device. We describe in detail our workflow and the devices used for transradial access. The aneurysms treated include internal carotid artery bifurcation, middle cerebral artery, anterior communicating artery, basilar tip, and posterior communicating artery. All patients underwent radial artery catheterization, and none of them had to be converted to femoral artery access. Of the 10 patients, 9 required a single attempt for accurate device deployment. One patient had unsuccessful placement of the WEB device and required coiling of the aneurysm because of device herniation into the parent vessel. None of the patients had any postoperative complications and were discharged the following day with the same modified Rankin scale score as preoperatively. Our experience with 10 patients revealed no limitations during catheterization and deployment of these devices. One patient had to be converted to coil embolization, which was feasible through the same vascular access. None of the patients had vascular complications postoperatively with minimal wrist discomfort. [ABSTRACT FROM AUTHOR]

• Highly porous shape memory nanocomposite foam fabricated using a biological safe sugar template method. • Uniform carbon nanotube distribution obtained within nanocomposites using ultrasonication. • Resistive-heating triggered shape recovery of 50% compressive deformation in two minutes. This paper presents the novel development of highly porous carbon nanotube (CNT)/shape memory polymer (SMP) nanocomposites for potential endovascular treatment of intracranial aneurysms (ICAs). Pristine SMP foam is fabricated using a sugar template method. CNT/SMP nanocomposites are fabricated by infiltrating CNTs into the pristine SMP foam in ethanol via ultrasonication. The porous nanocomposites are characterized to identify key parameters, such as the average pore size, density, porosity and electrical resistivity. A resistive-heating mechanism is developed to trigger shape recovery of the nanocomposites. The results of this work will lay a solid foundation for our subsequent development of new personalized biomedical devices to treat ICAs using a catheter-based endovascular procedure. [ABSTRACT FROM AUTHOR]

Intraoperative aneurysm rupture (IPR) always results in a poor prognosis for the patient. However, the risk factors of IPR are unclear. In this article, the risk factors are explored, a nomogram model for predicting IPR is established, and the prognostic factors for patients with IPR are analyzed. A total of 549 patients with aneurysm, which were embolized from September 2011 to September 2015, were enrolled for analysis. Univariate and multivariate logistic regression were performed to explore the risk factors for IPR, and a nomogram was established. A nonparametric Mann-Whitney U test was performed to analyze prognostic factors for patients with IPR. Twenty-one patients (4.4%) experienced IPR. In univariate analysis, Hunt-Hess grade (P = 0.002), time from hospitalization to treatment (P = 0.08) and subarachnoid hemorrhage (SAH) to treatment (P = 0.08), aneurysm neck (P = 0.08), assistive technique (P = 0.03), and intraoperative cerebral vasospasm (P < 0.001) were significantly associated with IPR. In multivariate analysis, Hunt-Hess grade (odds ratio [OR], 8.177; 95% confidence interval [CI], 1.714–39.012; P = 0.008), aneurysm neck (OR, 5.629; 95% CI, 1.149–27.575; P = 0.033), assistive technique (OR, 1.393; 95% CI, 0.961–2.018; P = 0.080), and intraoperative cerebral vasospasm (OR, 4.280; 95% CI, 1.081–16.947; P = 0.038) were independent risk factors for IPR. Hydrocephalus (P = 0.069), history of SAH (P = 0.10), ≥2 SAH (P = 0.051), location of aneurysm (P = 0.09), and number of aneurysms (P = 0.025) were associated with the bad outcome. Hunt-Hess grading, aneurysm neck, intraoperative assistive technology, and vasospasm were independent risk factors for IPR. Hydrocephalus requiring surgical intervention, times of rupture, location of aneurysm, and the number of aneurysms were relevant to the prognosis of patients. [ABSTRACT FROM AUTHOR]

To depict imaging anatomy of bronchial artery (BA) using multidetector CT-angiography (MDCTA) and evaluate the value of MDCTA for management of hemoptysis patients requiring admission to emergency room. We retrospectively studied the clinical and radiological data of patients with severe hemoptysis (≥ 100 ml of expectorated blood in a 24-hour period) requiring admission to emergency room from Jan 1, 2013 to Dec 31, 2015. Patients' images of MDCTA, treatment modalities, and outcome were discussed. A total of 108 patients underwent MDCTA scans. Etiology of hemoptysis was mainly bronchiectasis (44%), tuberculosis sequelae (26%) and tumor (18%). MDCTA visualized 197 traceable BAs and also suggested the involvement of 35 nonbronchial systemic arteries. The mean diameter of BAs, measured at the level of the bronchial bifurcation in the mediastinum, was 2.8±1.2 mm. The mean diameter of BAs, for 52 patients who only received conservative treatment, was 2.9±1.1 mm, and was not significantly larger than that of BAs for 56 patients who underwent bronchial artery embolization (BAE) for continued bleeding which did not resolve after conservative treatment (2.7±1.1 mm, P = 0.94). The technical success rate of embolization was 95% (53/56). Clinical success rate during follow-up was achieved in 50 (94%) of 53 patients who had undergone embolization. MDCTA provides useful information for identifying the anatomical characteristics of bleeding-related BAs and nonbronchial systemic arteries for the management of patients with severe hemoptysis. However, MDCTA could not determine the individuals who need BAE through measuring diameter of BAs. [ABSTRACT FROM AUTHOR]

Endovascular treatment is growing in popularity globally as an important treatment option for intracranial aneurysms. Cerebral infection as a complication of endovascular treatment of aneurysms is sufficiently rare that only 6 isolated cerebral abscess cases have been reported thus far. In this report, we present 2 cerebral abscesses from 3 institutions, which developed after coil embolization of anterior communicating artery and middle cerebral artery aneurysms. This report was written to discuss the possible mechanisms underlying cerebral abscess after endovascular treatment of aneurysms and to suggest potential treatment and prevention methods. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the outcomes of combined preoperative embolization and microsurgical resection in comparison with microsurgical resection alone as the current standard of care for low-grade cerebral arteriovenous malformations (AVM) in the pediatric population.Materials& Methods: We performed a single-center retrospective study of pediatric patients presenting with Spetzler-Martin (SM) grade I and II cerebral AVMs at a high-volume tertiary pediatric hospital between January 2005 and September 2016. Low grade AVM patients were divided into two groups: pre-operative embolization with subsequent microsurgical resection or microsurgical resection alone. Patient demographics, clinical and imaging presentations, AVM morphological characteristics, post-operative complications, and mid to long-term clinical outcomes were studied. Post-embolization and post-surgical outcomes were assessed prior to and after treatment, at 3 months and at final follow-up using the modified Rankin Scale (mRS) to compare both final independent (mRS 0-2) and favorable (no change or improved mRS) clinical outcomes for comparison between study groups. Statistical associations of patient demographics, AVM characteristics/SM grading, and treatment modality group with post-operative complications were performed using univariate logistic regression analysis.Results: Thirty-four patients with low grade cerebral AVMs met the study inclusion criteria (mean age 10.6 ± 3.4 years; range 3-16 years, 22M:12 F). Twenty patients (59%) presented with ruptured AVMs. Twenty-five patients (73.5%) underwent combined treatment with embolization and microsurgical resection, while 9/34 (26.5%) underwent microsurgical resection alone. A total of 35 embolization procedures performed in 25 patients (Mode, 1; Range, 1-7) were associated with two minor post-embolization and 7 subsequent post-surgical (28%) complications, resulting in clinical deterioration in a single patient. Microsurgical resection alone was associated with 3 post-surgical complications (33%), resulting in permanent neurological disability in a single patient. There was no significance association of post-operative complications with either treatment modality group, combined treatment versus surgical resection alone [OR:1.13; 95% CI:0.23-5.62; p-value 0.88]. SM Grade II and eloquent locations were found to be significantly associated with post-surgical complications of low grade pediatric cerebral AVMs [OR 13.2 and OR 8 respectively, p-value 0.004 and 0.005). On mean follow-up time of 35.7 months, final clinical outcome was favorable in the majority of both treatment arms with no dependent (mRS>2) patients in the combined endovascular and surgical cohort. Two patients in the surgical cohort failed to achieve independent functional status, primarily due to a pre-operative morbid status (p-value 0.015). However, there was no significant difference in favorable outcomes between the treatment groups [p-value 0.14].Conclusion: Our study suggests equivalent safety and favorable clinical outcomes related to combined endovascular embolization and microsurgical resection of low grade pediatric cerebral AVMs in comparison to microsurgical resection alone. On long term clinical follow-up, the vast majority of patients achieved an independent and favorable functional status irrespective of pre-operative embolization. [ABSTRACT FROM AUTHOR]

To evaluate the safety and effectiveness of microsurgical clipping and endovascular embolization for the treatment of middle cerebral artery aneurysm (MCAA). The clinical data of 482 patients with MCAA treated with microsurgical clipping or endovascular embolization were analyzed retrospectively. According to whether the aneurysms were ruptured, patients were divided into a ruptured group and an unruptured group. Demographics, clinical manifestation, and postoperative complications were recorded. In the microsurgical clipping group (257 patients), there were 114 male and 143 female patients. The mean age was (55 ± 10) years and the mean course of disease was 3 (1, 36) days. The total numbers of MCAA were 274, including 179 ruptured aneurysms and 95 unruptured aneurysms. In the endovascular embolization group (225 patients), there were 98 male and 127 female patients. The mean age was (54 ± 11) years and the mean course of disease was 10 (1, 55) days. The total numbers of MCAA were 234, including 126 ruptured aneurysms and 108 unruptured aneurysms. There was no difference between the incidence of complications in the ruptured and unruptured groups. The outcome of the endovascular embolization group was better than the microsurgical clipping group in ruptured aneurysms (P = 0.000). The recurrence rate of the endovascular embolization group was greater than the microsurgical clipping group in ruptured aneurysms (P = 0.023). Both microsurgical clipping and endovascular embolization were safe and effective methods for the treatment of MCAA, but patients with ruptured MCAAs treated with endovascular embolization were more likely to experience recurrence. [ABSTRACT FROM AUTHOR]

• Pharmacologic PT can be performed under general anesthesia (GA) using IONM modalities. • Specificity of PT was 100% in both awake and under general anesthesia groups. • PT under GA can be performed with a high specificity comparable to awake testing. Pharmacologic provocative testing (PT) and intraoperative neurophysiologic monitoring (IONM) both mitigate and predict risks associated with endovascular embolization procedures. We present a series of patients undergoing endovascular intracranial embolization predominantly for AVMs both under general anesthesia and awake with the use of IONM. We reviewed our database to identify all patients undergoing endovascular procedures between January 1, 2014 and January 1, 2016. Awake patients were tested with SSEP, EEG and real time neurologic examination while TcMEPs were performed in all anesthetized patients. BAEPs were performed in anesthetized patients if indicated. Methohexital was administered as an injection at a dose of 5 mg or 10 mg and repeat testing was performed if needed. Sixty-three endovascular procedures that met criteria were performed in 32 patients. 54 procedures in 28 patients were performed under general anesthesia, 9 procedures in 4 patients were performed in wakefulness. PT was negative in 61 procedures and subsequently completed embolizations without neurological sequelae. In two cases, the testing was positive and the procedure was terminated without embolization in one patient. The other patient underwent embolization at an alternative site without repeat PT. There were no new postoperative neurologic deficits after any of these procedures. Specificity of PT was 100% as none of the patients with a negative provocative test developed a new postoperative neurologic deficit after embolization. To our knowledge, this is the first review of PT with the use of neurophysiologic IONM techniques under general anesthesia. These data suggest a high specificity comparable to awake testing. [ABSTRACT FROM AUTHOR]

Cavernous-carotid fistulas (CCFs) can present with a variety of symptoms depending on the anatomy of the fistula and its venous drainage. Patients most commonly present with scleral injection, pulsatile exophthalmos, and/or chemosis. We report a patient who presented with intraparenchymal hemorrhage in the absence of any of the commonly associated ocular symptoms and signs. After multiple imaging studies, the CCF was diagnosed and treated with endovascular embolization that resulted in complete occlusion of the fistula and reflux of embolysate into one of its connecting veins. The morphology of the venous drainage can lead to atypical hemorrhagic presentation, whereas dilatation of one of the tributary veins with cortical venous reflux should warn the interventionist the path the embolysate may follow. We provide our experience with this unique presentation and its treatment. [ABSTRACT FROM AUTHOR]

Background Scalp arteriovenous malformation (SAVM) is primarily treated by surgery and reports on endovascular treatment are scarce. We report the results of an endovascular-first approach in the treatment of SAVM. We also have proposed a simple dichotomized classification using the angiographically determined morphology findings and discussed its effect on therapeutic decision-making and outcomes. Methods A consecutive series of 25 patients with SAVM treated by initial or endovascular-only methods were included in the final analysis. The SAVM was categorized as a plexiform or fistulous type according to the angiographic morphology. The demographic data, treatment variables, and final clinical outcomes were analyzed and correlated with the proposed classification. Results Of the 25 patients, 21 were treated with n-butyl cyanoacrylate (n-BCA) and 3 with liquid ethylene vinyl alcohol. One patient had been treated initially with polyvinyl alcohol particles and later with n-BCA. Overall, complete or near complete obliteration (>90%) was achieved in 72%. Surgical excision was performed in 76%, most often after n-BCA embolization. Fistulous-type SAVMs required greater n-BCA concentrations (median, 33% vs. 20%; P = 0.024) and achieved greater rates of complete or near-complete obliteration (90% vs. 63%). Two patients with fistulous-type SAVMs treated with liquid ethylene vinyl alcohol showed complete resolution, and further treatment was not necessary. Overall, regardless of the embolic material used, the fistulous type demonstrated a significantly greater rate of complete obliteration (75% vs. 33%; P = 0.041) compared with plexiform type. Conclusion High rates of complete and durable obliteration of SAVM are achievable with endovascular embolization. The proposed simplified classification is easy to implement and can aid in choosing the appropriate embolic agent and predicting the therapeutic outcome. Highlights • Endovascular embolization of SAVMs can result in high degree of obliteration, without significant morbidity or mortality. • SAVM can be categorized using the angiographic morphology into plexiform and fistulous types. • The fistulous type is more likely than the plexiform type to demonstrate complete occlusion. • Effective endovascular treatment with or without surgery resulted in durable occlusion at long-term follow-up. • EVOH-based liquid embolic agents can achieve complete occlusion with aesthetically pleasing results. [ABSTRACT FROM AUTHOR]

Background It was known that a small number of patients could have intracranial aneurysm recurrences after either surgical clipping or endovascular embolization treatment. However, early recurrence within 1 month after the treatment and re-recurrence has rarely been reported before. Case Description We report a 46-year-old man with a medical history of smoking and hypertension who was noncompliant with the treatments. He presented to the hospital with right extremity paralysis and aphasia and was found to have a ruptured middle cerebral artery aneurysm. Aneurysm was successfully treated by surgical clipping. Within 1 month after the treatment, the patient had a recurrent aneurysm at the same location and intracranial hemorrhage. The recurrent aneurysm was treated by endovascular embolization. However, during the follow-up visit 8 months after the treatment, angiography showed aneurysm recurrence with proximal vascular stenosis. Conclusions Re-recurrence of intracranial aneurysm could happen after initial successful treatment with surgical clipping and endovascular embolization. In addition to the patient's medical history and characteristics of the aneurysm, local vascular stenosis might also contribute to its recurrence. Close postoperative follow-up is required for these patients. Highlights • Re-recurrence of intracranial aneurysm could happen after initial successful treatment. • Patient's medical history, characteristics of the aneurysm, and local vascular stenosis might contribute to its recurrence. • Close postoperative follow-up is required for these patients. [ABSTRACT FROM AUTHOR]

Abstract Intracranial aneurysms (ICAs) are focal dilations in the brain's arteries. When left untreated, ICAs can grow to the point of rupture, accounting for 50–80% of subarachnoid hemorrhage cases. Current treatments include surgical clipping and endovascular coil embolization to block circulation into the aneurysmal space for preventing aneurysm rupture. As for endovascular embolization, patients could experience aneurysm recurrence due to an incomplete coil filling or compaction over time. The use of shape memory polymers (SMPs) in place of conventional platinum coils could provide more control and predictability for mitigating these complications. This study was focused on characterization of an aliphatic urethane-based SMP to evaluate its potential as a novel biomaterial for endovascular embolization. Twelve compositions of the SMP were synthesized and their thermomechanical properties together with the shape recovery behavior were comprehensively investigated. Our results showed that the SMPs experienced a significant decrease in storage and loss moduli as heated above their glass transition temperatures (32.3–83.2 °C), and that all SMPs were thermally stable up to 265 °C. Moreover, the SMPs exhibited both composition-dependent stress relaxation and a decrease in elastic modulus during cyclic loading. The shape recovery time was less than 11 s for all SMP compositions, which is sufficiently short for shape changing during embolization procedures. Several candidate compositions were identified, which possess a glass transition temperature above body temperature (37 °C) and below the threshold of causing tissue damage (45 °C). They also exhibit high material strength and low stress relaxation behavior, suggesting their potential applicability to endovascular embolization of ICAs. Graphical abstract fx1 Highlights • A detailed experimental procedure has been developed for the synthesis of aliphatic urethane-based shape memory polymers. • Comprehensive thermomechanical characterizations on a variety of SMP compositions have been performed. • Investigations of the polymer's working temperature, thermal stability and their mechanical behavior have been made. • Recovery tests has demonstrated superb shape recovery of the SMPs desirable for the endovascular embolization procedure. • SMP compositions that meet our criteria have been identified with their great potential for individualized ICA treatment. [ABSTRACT FROM AUTHOR]

Abstract A middle-aged patient underwent staged endovascular embolization of a Spetzler-Martin grade V right parietal arteriovenous malformation(AVM).In the fifth endovascular embolization, after methohexital 10 mg injection into a right posterior choroidal artery feeding the AVM nidus, there was an immediate change in the electroencephalogram (EEG) with simultaneous loss of motor evoked potentials (MEPs) in the bilateral upper and lower extremities and a delayed change in somatosensory evoked potential responses (SSEPs). No embolization was made and procedure was terminated. This case demonstrates the utility of intraoperative neurophysiologic monitoring (IONM) with pharmacologic provocative testing in predicting and mitigating the risks prior to the proposed embolization. [ABSTRACT FROM AUTHOR]

Refractory chronic subdural hematoma (CSDH) is rare but remains a difficulty for neurosurgeons, and no consensus on treatment procedures has been established. To discuss effective surgical procedures for refractory CSDH, we analyzed our surgical procedures and outcomes for refractory CSDH. We defined patients with refractory CSDH as those who presented with two or more recurrences. Fourteen patients with refractory CSDH were analyzed. Eight patients underwent burr-hole irrigation and closed-system drainage alone, four patients received embolization of the middle meningeal artery (MMA), and two patients with organized CSDH underwent large craniotomy with outer membranectomy as the third surgery. Two of the eight patients (25%) treated with burr-hole irrigation and drainage alone showed a third recurrence. No further recurrences were identified in patients treated with embolization of the MMA or craniotomy. However, statistical analysis showed no significant difference in cure rate between patients treated with burr-hole irrigation and drainage alone and patients treated with burr-hole irrigation and drainage with embolization of the MMA (P = .42). Similarly, no significant differences in cure rate were seen between patients treated with burr-hole irrigation and drainage alone and patients treated with craniotomy (P = .62). When selecting a surgical procedure, assessing whether the CSDH is organized is crucial. Embolization of the MMA may be considered as one of the optional treatments for refractory CSDH without organized hematoma. On the other hand, for refractory cases of organized CSDH, hematoma evacuation and outer membranectomy with large craniotomy or mini-craniotomy assisted by an endoscope may be suitable, as previous reports have recommended. [ABSTRACT FROM AUTHOR]

A 24-year-old woman presented with a seizure-like episode of left hemibody sensory loss. Magnetic resonance imaging and magnetic resonance angiography revealed multiple distal fusiform cerebral aneurysms requiring angiographic evaluation and possible endovascular treatment. On preoperative workup, transthoracic echocardiography revealed a large, 4.1 × 2.1 cm, mobile left atrial mass prolapsing into the left ventricle during diastole. Multidisciplinary discussion among representatives from neurosurgery, cardiology, and cardiothoracic surgery determined the plan to proceed with diagnostic cerebral angiogram and aneurysm embolization before moving forward with heart surgery. Cerebral angiogram revealed several right distal middle cerebral artery fusiform aneurysms and a right distal posterior inferior cerebellar artery fusiform aneurysm. Subsequently, the patient underwent endovascular coil embolization of the largest distal M4 fusiform aneurysm, measuring 3.3 × 3.2 mm in maximal diameter. The patient recovered to baseline in the surgical intensive care unit and was discharged home on postoperative day 7 with close neurosurgical and cardiology follow-up. [ABSTRACT FROM AUTHOR]

Background In endovascular embolization of intracranial aneurysms, a tortuous cervical internal carotid artery can limit guiding catheter access to a sufficiently high position. Although intermediate distal access catheters can go beyond the tortuous segment of internal carotid arteries, they may increase the risk of procedure-related complications, require significantly complex technical procedures, and limit the use of adjunctive techniques. Using simple neck extension alone, we successfully improved guiding catheter access in 2 patients. Methods Through a provocative test, we confirmed suitability of manual neck extension in 2 patients with severe posterior curvature of a tortuous internal carotid artery. Intraoperatively, we manually extended the neck and stretched the curvatures. We guided a 6F guiding catheter superiorly and performed coil embolization with an occlusion balloon catheter in 1 case and with the balloon-assisted neck remodeling technique in 1 case. Results Coil embolization was completed without any adverse events in both cases. Conclusions The simple neck extension technique successfully improved accessibility of the guiding catheter. As the need for safe and highly skilled intervention increases, our technique may be useful because it can reduce procedure-related complications and allow balloon-assisted techniques. [ABSTRACT FROM AUTHOR]

Background Preoperative endovascular embolization of intracranial meningiomas denatures the tumor tissue, reduces intraoperative blood loss, and facilitates surgical removal. However, as most meningiomas are surgically removed within a few days after embolization, the effect of long-term volume reduction of the tumor due to the endovascular embolization remains unknown. Methods Five patients with intracranial meningioma underwent endovascular embolization between January 2006 and December 2014 and were followed without surgical resection for >14 days. The reduction in tumor and peritumoral edema volumes on sequential head magnetic resonance imaging, along with the clinical symptoms, were retrospectively reviewed. Results All the tumors indicated a 10%–30% volume reduction 30 days after embolization, which continued thereafter; no meningioma regrowth was observed for >90 days in 2 of 5 cases. Moreover, the peritumoral edema volume was reduced by 30%–70% at 30 days after embolization, and no subsequent increase was observed for >60 days in 4 of 5 cases. The neurologic symptoms related to the tumor mass effect improved after embolization. Conclusions Endovascular embolization of intracranial meningiomas with n-butyl cyanoacrylate reduced the tumor and peritumoral edema volumes by 10%–30% and 30%–70%, respectively, within 30 days. Volume and edema reduction effect of embolization may last longer than expected, beyond the timing when most meningiomas are resected after embolization. In this study, we described our preliminary results of the volume reduction of intracranial meningiomas that were embolized using n-butyl cyanoacrylate and monitored without any surgical resection for >14 days. We believe that our study makes a significant contribution to the literature because we showed that volume and edema reduction effect of embolization may last longer than expected, beyond the timing when most meningiomas are resected after embolization. [ABSTRACT FROM AUTHOR]

To elucidate the pituitary function of Japanese patients after aneurysmal subarachnoid hemorrhage (aSAH) and implicative factors related to growth hormone deficiency (GHD) after aSAH. We evaluated basal pituitary hormone levels among 59 consecutive aSAH patients with a modified Rankin Scale (mRS) ⩽4 at 3 months after aSAH onset. Patients with low insulin-like growth factor 1 (IGF-1) SD score (SDS) or who seemed to develop pituitary dysfunction underwent provocative endocrine testing during a period of 3–36 months after SAH onset. The relationship between IGF-1 SDS and clinical factors of the patients such as severity of SAH, aneurysm location, and treatment modalities, were assessed. Six patients (10.2%) demonstrated their IGF-1 SDS less than −2. Multiple logistic regression analyses revealed that patients who underwent surgical clipping had a significantly lower IGF-1 SDS (<−1 SD) than patients who underwent endovascular embolization with an odds ratio of 5.83 ( p = 0.032). Thirty-three patients took provocative tests and five (15.6%) patients were identified as having GHD. The mean IGF-1 SDS of these five GHD patients was 0.08 SD. The aneurysms in all GHD patients were located in internal carotid artery (ICA) or anterior cerebral artery (ACA). To the best of our knowledge, this is the first report describing the prevalence of GHD in Japanese patients after aSAH, and it was not as high as that of previous European studies. We recommend that screening pituitary dysfunction for aSAH survivors with their aneurysms located in ICA or ACA. [ABSTRACT FROM AUTHOR]

Objective This retrospective study compared clinical and angiographic outcomes between LVIS and Enterprise stents. Materials and Methods From November 2014 to December 2015, total 190 patients with 208 unruptured intracranial aneurysms were coiled assisted by LVIS and Enterprise stents. Procedure-related complications, clinical outcomes, and angiographic results were analyzed retrospectively. Results A total of 92 patients with 96 aneurysms received LVIS stents and 98 patients with 112 aneurysms were treated with Enterprise stents. Procedure-related complications occurred in 10.9% of patients (2 hemorrhagic events and 8 thromboembolic events) in the LVIS stents group whereas 16.3% (1 hemorrhage, 1 mass effect, and 14 thromboembolic events) in the Enterprise stents group. No statistical significant differences in thromboembolic ( P = 0.263), hemorrhagic complications ( P = 0.611), and favorable clinical outcomes (modified Rankin Scores of 0–2) ( P = 0.379) were found between 2 groups. A greater initial complete or near-complete obliteration was found in the LVIS stents group compared with the Enterprise stents group (96.9% vs. 88.4%, P = 0.034). Larger aneurysm size ( P = 0.048) was an independent predictor of procedure-related complications in univariate analysis. Conclusions Compared with Enterprise stents, LVIS stents may achieve greater complete or near-complete occlusion rate. There was no significant difference in procedural-related complications and clinical outcomes between LVIS and Enterprise stents. [ABSTRACT FROM AUTHOR]

Spontaneous cervical extradural pseudoaneurysms or arteriovenous fistulas (AVFs) are rare vascular diseases. We report a case of ruptured occipital artery (OA) pseudoaneurysm associated with occipital-internal jugular vein (IJV) fistula in neurofibromatosis type 1. Endovascular internal trapping via the OA was attempted; however, the distal entry of the OA could not be accessed because of the high shunt flow and tortuosity of the OA. The distal part of the OA was obliterated with coil via a transvenous approach through the IJV and pseudoaneurysm. The proximal entry of the OA was obliterated with coil and glue under proximal flow control with a balloon, and the fistula was successfully obliterated without placement of coils in the pseudoaneurysm. When ordinary internal trapping via a transarterial approach is not possible, the transvenous approach should be considered as an alternative for AVF associated with an aneurysmal component. [ABSTRACT FROM AUTHOR]

Introduction Pseudoaneurysms occur when there is a partial disruption in the wall of a blood vessel, causing a hematoma that is either contained by the vessel adventitia or the perivascular soft tissue. Presentation of case A 32-year-old male presented to the emergency department presented with comminuted fractures in the left zygoma, ethmoids, and the right ramus of the mandible following a gunshot wound. The patient underwent open reduction of his fractures and the patient was discharged on the eighth day after the trauma. Thirteen days after the discharge and 21 days after the gunshot wound, the patient returned to the ER due to heavy nasopharyngeal bleeding that compromised the patency of the patient’s airways and caused hemodynamic instability. Arteriography of the facial blood vessels revealed a pseudoaneurysm of the maxillary artery. Endovascular embolization with a synthetic embolic agent resulted in adequate hemostasis, and nine days after embolization the patient was discharged. Discussion The diagnosis of pseudoaneurysm is suggested by history and physical examination, and confirmed by one of several imaging methods, such as CT scan with contrast. Progressive enlargement of the lesion may lead to several complications, including rupture of the aneurysm and hemorrhage, compression of adjacent nerves, or release of embolic thrombi. Conclusion This case reports the long-term follow up and natural history of a patient with a post-traumatic pseudoaneurysm of the internal maxillary artery and the successful use of endovascular embolization to treat the lesion. [ABSTRACT FROM AUTHOR]

Objective To evaluate the role of multidetector computed tomography-angiography (MDCTA) for management of life-threatening spontaneous retroperitoneal haemorrhage (SRH). Methods A retrospective analysis of the medical records of all SRH patients admitted to our hospital from January 1, 2005 to November 31, 2014 was performed. SRH was defined as unrelated to invasive procedures, surgery, trauma, abdominal tumor or aortic aneurysm. Life-threatening SRH was defined as hemodynamic instability with hypotension. Sixteen cases met the inclusive criteria. Patients' characteristics, clinical presentation, imaging of MDCTA, treatment modalities, morbidity, and follow-up data were analyzed. Results The group of 16 patients included 11 men and 5 women, with a mean age of 51.5±16.4 years. All patients underwent MDCTA scan examinations, and active contrast media (CM) extravasation were found in 9 patients. Angiography was performed for 8 patients in the CM extravasation group. Bleeding vessels were found in 7 patients who underwent successful embolization. One patient in the CM extravasation group did not undergo angiography and died of bleeding. Seven patients without active CM extravasation underwent conservative management. Bleeding was controlled for all these 7 patients, and 1 patient died of multiple organ failure. Fourteen patients survived from SRH were successfully discharged. One patient died of heart failure during follow-up. Conclusion MDCTA was useful in the diagnosis of SRH and proved to be predictive for the outcome of conservative treatment and early intervention. [ABSTRACT FROM AUTHOR]

Intralobar pulmonary sequestration is a rare congenital malformation characterized by the presence of nonfunctional parenchymal lung tissue, receiving systemic arterial blood supply and lacking normal communication with tracheobronchial tree. Recurrent pneumonia and massive hemoptysis are life threatening complications associated with it. Delay in the diagnosis and management can be fatal. We report here a case of intralobar pulmonary sequestration in a 18 year old female who presented with recurrent severe episodes of pneumonia and hemoptysis forcing her to drop out of school. The diagnosis was confirmed by CECT Thorax and CT Angiography. The patient was managed by minimally invasive endovascular treatment in the form of feeding artery embolization. She made a full recovery with satisfactory outcome. On subsequent follow up, there was no recurrence of symptoms and she is doing well socially and academically. The aim of this case report is to show feasibility and safety of embolization as a less-invasive management option for adult pulmonary sequestration complicated with hemoptysis and LRTIs and emphasize the importance of such minimally invasive technique to enhance the quality of life in such patients. [ABSTRACT FROM AUTHOR]

The transcranial approach for direct middle meningeal artery (MMA) access to embolize dural arteriovenous fistulas (dAVF) has been described, but limited information regarding the setup, equipment, and technique is available. We present the details of this hybrid approach in the setting of a ruptured Cognard grade IV tentorial dAVF (Video 1). The patient was an adult female who presented with nausea, vomiting, and dizziness and was found to have a cerebellar hemorrhage. Catheter angiography revealed a tentorial dAVF fed by bilateral middle meningeal, left posterior meningeal, and left occipital arteries. Attempted transarterial embolizations through each of these were unsuccessful. The left MMA was a primary source of supply, but distal microcatheter placement was not possible due to proximal tortuosity. Therefore transcranial MMA access distal to this tortuosity was pursued. The MMA was localized using roadmap angiography and a temporal craniectomy was completed over the artery. A 4-French sheath was placed, and super selective angiography was performed, demonstrating the fistula. A microcatheter was navigated to the fistula and it was embolized with Onyx. Postoperative angiogram demonstrated fistula occlusion. The patient remained at her neurologic baseline and was discharged home. Transcranial MMA access is a useful technique to overcome tortuosity that cannot be navigated with traditional endovascular techniques. [ABSTRACT FROM AUTHOR]

Abstract: Dural arteriovenous fistulas (DAVF) of the anterior cranial fossa are often associated with hemorrhage and are usually treated surgically. This clinical study summarizes our preliminary experience in the transarterial embolization of these lesions. We retrospectively reviewed the data for 11 patients with anterior cranial fossa DAVF who underwent transarterial embolization with the Onyx Liquid Embolic System (eV3 Endovascular, Plymouth, MN, USA) at our institute between 2007 and 2011. In four patients, a balloon-assisted technique was used to facilitate superselective catheterization. According to the Cognard classification of DAVF, three fistulas were type III, and the other eight were type IV. DAVF were completely obliterated in 10 patients after treatment via a single ethmoidal artery, but the other patient was not completely cured. No signs of rebleeding or symptom progression were observed at a mean follow-up of 18.5months (range: 2–49months). Transarterial embolization using Onyx is therefore feasible and effective for the management of DAVF of the anterior cranial fossa. [Copyright &y& Elsevier]

Abstract: Arteriovenous malformation of the mandible is a rare and life-threatening lesion. The gold standard treatment is to extirpate the lesion surgically after endovascular embolization. Preoperative endovascular embolization is widely accepted, but there are limitations to the treatment. The authors introduce a technique in which the lesion is divided into parts and filled with bone wax, then curetted step by step. This gradual curettage method is effective and could be used instead of the standard treatment especially in hospitals with limited facilities for endovascular embolization. [Copyright &y& Elsevier]

Abstract: Hemorrhage secondary to postoperative pseudoaneurysm is a rare event, but may complicate the clinical course of straightforward and common interventions such as sinonasal procedures, tonsillectomy, and maxillofacial and plastic surgeries. We report our experience with the endovascular management of iatrogenic pseudoaneurysm in eight patients who had undergone recent craniomaxillofacial surgery. Computed tomography (CT), including CT-angiography, detected only three of the eight lesions. In all patients, endovascular embolization achieved successful occlusion of the pseudoaneurysm without local or general procedure-related complications. Immediate proximal arterial occlusion with detachable coils was performed in every case, and pseudoaneurysm coiling was performed in three cases presenting with active hemorrhage. Endovascular therapy proved to be safe and effective in the management of postoperative pseudoaneurysms. Surgeons involved in the craniomaxillofacial procedures should be aware of this complication and its management. [Copyright &y& Elsevier]

Abstract: Background: Aneurysms of the PICA are uncommon. Most of them arise at the PICA origin from the VA, whereas distal PICA aneurysms are exceptional. A retrospective analysis of 457 patients with SAH treated in our hospital found 5 patients with 6 distal PICA aneurysms (approximately 1% of SAHs). Case Description: All patients were female, with a mean age of 54 years. A 4-vessel cerebral angiogram performed immediately after admission showed an aneurysm located on the distal PICA. One patient was treated by an endovascular approach, and 3 patients were treated by surgical approach. The last patient had 2 distal high-flow aneurysms located on the distal PICA, which was the main arterial feeder of an AVM. The patient refused surgery or endovascular therapy. All 4 treated patients had good outcome at 3-month clinical follow-up. Conclusions: Distal PICA aneurysms are exceptionally rare and may be treated successfully with surgical or endovascular techniques. The therapeutic strategy, either surgical or endovascular, should be selected according to the condition of the patient, the arterial and aneurysmal morphology, and the preference of the medical team. [Copyright &y& Elsevier]

Abstract: This report describes the infrequent case of the occurrence of eight aneurysms of the facial artery in association with hereditary hemorrhagic teleangiectasia (HHT, Rendu–Osler–Weber disease, ROW). The aneurysms and the teleangiectatic nodules of the tongue were successfully treated by endovascular embolization in a combined technique using particles (polyvinyl alcohol, PVA) and fibred platinum coils. Endothelial cell degeneration, fragmentation of the elastic lamina and loss of muscularis in the vessel wall may be causal and give rise to multiple aneurysms of the intracranial and extracranial circulation in hereditary hemorrhagic teleangiectasias. This case and a review of the literature are presented because in the literature neither combined occurrence of ROW with a single aneurysm nor with multiple aneurysms of extracranial vessels are described. [Copyright &y& Elsevier]

Abstract: Although epistaxis secondary to rupture of a post-traumatic, false aneurysm is well documented, true intracavernous carotid artery aneurysms presenting with epistaxis are very rare. We present such a case in a patient with multiple aneurysms. The aneurysm was treated by endovascular techniques and the patient made a good recovery. This case highlights the need to distinguish between true and false aneurysms for both diagnostic and therapeutic reasons. [Copyright &y& Elsevier]

Abstract: Tracheo-innominate artery fistula (TIF) is known as a fatal complication after tracheostomy. We report a 9-year-old girl with early hypoxic encephalopathy who had a tracheo-innominate artery fistula with exsanguinating hemorrhage from her tracheostoma 10 months after tracheostomy. After temporary control of bleeding, embolization of the innominate artery was performed. The patient has remained well 1 year after the procedure. We reviewed the aetiology, diagnosis and management of the tracheo-innominate fistula, and findings suggest that endovascular embolization of the innominate artery may be an appropriate treatment for patients with tracheo-innominate artery fistula. [Copyright &y& Elsevier]