Management of aberrant internal carotid artery injury: a real emergency.
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Adult↗
Biomedical subjects
G Redekop
Publications and source records attributed to G Redekop.
Treatment of traumatic aneurysms and arteriovenous fistulas of the skull base by using endovascular stents.
OBJECT: The authors describe their preliminary clinical experience with the use of endovascular stents in the treatment of traumatic vascular lesions of the skull base region. Because adequate distal exposure and direct surgical repair of these lesions are not often possible, conventional treatment has been deliberate arterial occlusion. The purpose of this report is to demonstrate the safety and efficacy as well as limitations of endovascular stent placement in the management of craniocervical arterial injuries. METHODS: Six patients with vascular injuries were treated using endovascular stents. There were two arteriovenous fistulas and two pseudoaneurysms of the distal extracranial internal carotid or vertebral arteries resulting from penetrating trauma, and two petrous carotid pseudoaneurysms associated with basal skull fractures. In one patient a porous stent placement procedure was undertaken as well as coil occlusion of an aneurysm, whereas in the remaining five patients covered stent grafts were used as definitive treatment. There were no procedural complications. One patient in whom there was extensive traumatic arterial dissection was found to have asymptomatic stent thrombosis when angiography was repeated 1 week postoperatively. This was the only patient whose associated injuries precluded routine antithrombotic or antiplatelet therapy. Follow-up examinations in the remaining five patients included standard angiography (four patients) or computerized tomography angiography (one patient), which were performed 3 to 6 months postoperatively, and clinical assessments ranging from 3 months to 1 year in duration (mean 9 months). In all five cases the vascular injury was successfully treated and the parent artery remained widely patent. No patient experienced aneurysm recurrence or hemorrhage, and there were no thromboembolic complications. CONCLUSIONS: The authors' experience demonstrates that endovascular treatment of traumatic vascular lesions of the skull base region is both feasible and safe. The advantages of minimally invasive stent placement and parent artery preservation make this procedure for repair of neurovascular injuries a potentially important addition to existing methods.
Adolescent↗
Endovascular occlusion of basilar bifurcation aneurysms with electrolytically detachable coils.
OBJECT: To describe the clinical and angiographic results of endovascular occlusion of basilar bifurcation aneurysms with electrolytically detachable coils, and to identify factors which should be considered in deciding upon surgical or endovascular treatment. METHODS: We report our experience with 40 patients in whom occlusion of basilar bifurcation aneurysms with electrolytically detachable coils was attempted. All patients underwent superselective angiography and attempted embolization with Guglielmi detachable coils (GDCs). Angiographic and clinical results were prospectively recorded. Twenty-eight aneurysms presented with subarachnoid hemorrhage (SAH), 2 were symptomatic and 10 were incidental. RESULTS: Coils were not placed in 10 patients (25%) because of unfavorable anatomy. Complete aneurysm occlusion was achieved at the time of the initial procedure in 13 (32.5%), small neck remnants were present in 13 (32.5%), and in 4 (10.0%) there was obvious residual contrast filling of the aneurysm body. Of 23 patients successfully coiled after SAH, 20 were Grade 1 to 3 and 3 were grade 4 or 5 at the time of treatment. Eighteen (78%) made a good recovery. Procedural mortality was 2.5% and permanent morbidity was 7.5%. There were no permanent complications in patients with unruptured aneurysms. Complete aneurysm occlusion was possible in 10 (56%) of 18 aneurysms with small necks and 3 (14%) of 22 with large necks. Follow-up angiography in 25 of 28 surviving patients (mean, 12 months) demonstrated stability of all completely occluded aneurysms. Incompletely coiled aneurysms had variable results on follow-up angiograms: 15.4% improved, 69.2% worsened, and 15.4% were stable. No aneurysm bled after treatment during clinical follow-up averaging 22 months. CONCLUSIONS: Endovascular treatment of basilar bifurcation aneurysms appears to prevent early aneurysm rebleeding with acceptable rates of morbidity and mortality, but long-term follow-up is required.
Adult↗
Subarachnoid hemorrhage from vertebrobasilar dissecting aneurysm treated with staged bilateral vertebral artery occlusion: the importance of early follow-up angiography: technical case report.
OBJECTIVE AND IMPORTANCE: Vertebrobasilar dissecting aneurysms are an uncommon but increasingly recognized cause of subarachnoid hemorrhage (SAH). We describe a patient with SAH caused by a dissecting aneurysm involving both vertebral arteries as well as the basilar trunk. The patient was treated successfully with proximal occlusion of the vertebral arteries using endovascular balloon occlusion in two stages. The importance of early follow-up angiography to document progression or resolution of untreated dissections is emphasized. This approach is suggested as definitive treatment for vertebrobasilar dissection in appropriate circumstances. CLINICAL PRESENTATION: A 41-year-old man presented with SAH from spontaneous vertebrobasilar dissection. Angiography revealed aneurysmal dilation of the right vertebral artery and basilar trunk and occlusion of the left vertebral artery. INTERVENTION: The dissecting aneurysm was treated with balloon occlusion of the right vertebral artery. Repeat angiography 2 weeks later demonstrated resolution of the left vertebral occlusion, with restoration of antegrade flow in the basilar trunk and increased filling of the right vertebral and basilar dissecting aneurysms. Balloon occlusion of the left vertebral artery led to aneurysm thrombosis and excellent clinical outcome. CONCLUSION: Bilateral vertebrobasilar dissecting aneurysms are an uncommon cause of SAH. If unilateral proximal vertebral artery occlusion is chosen as the initial treatment, it is essential to document the status of the contralateral vessel using follow-up angiography. Staged bilateral vertebral artery occlusion should be considered in the event of recurrent or progressive aneurysm enlargement. Endovascular balloon occlusion has advantages over proximal clipping of the parent vessel: cranial nerve manipulation is avoided, test occlusion in the awake patient can be performed at the site of permanent occlusion, and therapeutic levels of anticoagulation can be maintained throughout and after the procedure, thus diminishing the likelihood of thromboembolic complications.
Adult↗
Arterial aneurysms associated with cerebral arteriovenous malformations: classification, incidence, and risk of hemorrhage.
OBJECT: The goal of this study was to develop a classification system for aneurysms associated with arteriovenous malformations (AVMs) based on their anatomical and pathophysiological relationships and to determine the incidence and bleeding rates for these aneurysms as well as the effects of AVM treatment on their natural history. METHODS: Of 632 patients with AVMs, intranidal aneurysms were found in 35 (5.5%) and flow-related aneurysms in 71 (11.2%). Patients with intranidal aneurysms presented more frequently with hemorrhage (72% compared with 40%, p < 0.001) and had a 9.8% per year risk rate of bleeding during follow-up review. Twelve (17%) of the patients with flow-related aneurysms associated with an AVM presented with hemorrhage from an aneurysm, whereas 15 (21%) bled from their AVM. Seventeen patients underwent angiography after AVM treatment (mean 2.25 years). Of 23 proximal aneurysms, 18 (78.3%) were unchanged, four (17.4%) were smaller, and one (4.3%) had disappeared, whereas four (80%) of five distal aneurysms regressed completely and one was unchanged. Sixteen patients underwent angiography after partial AVM treatment (mean 3.8 years). In cases with less than a 50% reduction in the AVM, no aneurysms regressed, although two enlarged and bled. In cases with greater than a 50% reduction in the AVM, two of three distal aneurysms disappeared and five proximal aneurysms were unchanged. CONCLUSIONS: Arterial aneurysms associated with cerebral AVMs may be classified as intranidal, flow-related, or unrelated to the AVM nidus. Intranidal aneurysms have a high correlation with hemorrhagic clinical presentation and a risk of bleeding during the follow-up period that considerably exceeds that which would be expected in their absence. Patients with flow-related aneurysms in association with an AVM may present with hemorrhage from either lesion. Aneurysms that arise on distal feeding arteries near the nidus have a high probability of regressing with substantial or curative AVM therapy.
Adolescent↗
Neuropathology of intracranial arteriovenous malformations following conventional radiation therapy.
Conventional fractionated radiation therapy was used in 15 patients to treat arteriovenous malformations (AVMs) of the brain deemed inoperable or incompletely obliterated using endovascular or surgical techniques. The AVMs measured from 0.8 to 85 cm3 (mean 28.2 cm3; median 24 cm3). Angiography in 12 patients 1-21 years following radiation therapy demonstrated no significant change in 7, slight reduction in 2, near complete obliteration in 1, and complete obliteration in 2. Magnetic resonance imaging further demonstrated apparent obliteration in one other case. Three irradiated AVMs were available for pathological examination following fatal recurrent hemorrhage after 21 years in case 1 and following surgery after 5 years in cases 2 and 3. Doses of 20 and 45 Gy were delivered to the area of the AVM in 10 and 15 fractions with a 6-MV linear accelerator in case 1 and in cases 2 and 3, respectively. A blinded histopathological comparison was made of the latter cases and three AVMs removed at surgery that were not previously irradiated and that were comparable in size, number of arterial feeders, and location within the brain. Segmental hyalinization of some blood vessels was seen in both irradiated and nonirradiated cases. The single postmortem specimen showed extensive thrombosis but a patent nidus. The findings are in keeping with the clinical impression that conventional fractionated radiation therapy fails to alter the natural history of cerebral AVMs. The favorable outcome of radiosurgery on small- to medium-sized AVMs appears attributable to the shorter duration of therapy using relatively high-dose prescriptions to the nidus.
Adult↗
Correlation of contralateral stenosis and intraoperative electroencephalogram change with risk of stroke during carotid endarterectomy.
Two hundred ninety-three carotid endarterectomies were performed with electroencephalogram (EEG) monitoring and without the use of a shunt. Two hundred sixteen patients had contralateral carotid stenosis of less than 70%; 45 had contralateral stenosis of 70 to 99%; and 32 had contralateral occlusion. There were six perioperative strokes (2.0%) and two deaths (0.7%). Major EEG changes were seen in 11 of the 77 patients (14.3%) with significant contralateral stenosis or occlusion versus 11 of the 216 patients (5.1%) in those without (P less than 0.025). The risk of immediate postoperative deficit was significantly higher in the subgroup with major EEG changes (4 of 22, 18.2%) than in those without such changes (5 of 271, 1.8%) (P less than 0.005). The risk in patients with less than 70% contralateral stenosis (7 of 216, 3.2%) was not significantly different from those with greater contralateral stenosis or occlusion (2 of 77, 2.6%). Carotid endarterectomy can be safely performed without a temporary shunt. Contralateral stenosis or occlusion alone does not confer increased risk. Major EEG changes are infrequent, but they identify a subgroup with significantly higher risk of intraoperative stroke.
Adult↗
The fastigial pressor response. Case report.
A distinct vasomotor and cardioregulatory response first identified experimentally was elicited intraoperatively in a 6-year-old girl by local mechanical stimulation in the vicinity of the fastigial nucleus of the cerebellum. These findings are discussed in the light of current experimental knowledge of the anatomy and physiology of the fastigial pressor response.
Astrocytoma↗
Fourth ventricular schwannoma. Case report.
A schwannoma arising from the dorsum of the pontomedullary junction and presenting as an exophytic mass in the fourth ventricle is described. A ventricular schwannoma has not previously been reported in the literature. The presenting clinical and radiographic features and the pathology of this tumor are summarized, and an explanation is sought for its unusual location.
Brain Neoplasms↗