Total choroidal detachment complicating dural arteriovenous sinus fistula.
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Aged↗
Biomedical subjects
V V Halbach
Publications and source records attributed to V V Halbach.
Management of intracranial and spinal cord vascular lesions in children.
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Arteriovenous Malformations↗
Intravascular balloon dilatation therapy for intracranial arterial vasospasm: patient selection, technique, and clinical results.
Patients presenting with symptomatic intracranial arterial vasospasm are now being treated by interventional neurovascular techniques in selected cases. From a percutaneous transfemoral approach, a custom-designed silicone microballoon can be guided through the intracranial vessels, and inflated to dilate the spastic vessel(s). This technique has been useful for both focal and diffuse areas of spasm. In clinical trials, 28 patients, ranging in age from 15-73 years have been treated. A total of 99 vascular territories have been successfully dilated in both the anterior and posterior circulations. Clinical improvement following treatment was observed in 17 cases (60.7%). Technical complications directly related to therapy included 2 cases (7.1%) of vessel rupture. In long term clinical follow-up 17 patients (60.7%) had good to excellent outcome, 2 patients (7.1%) remained in poor condition, and 9 patients (32.1%) died despite therapy. In patients presenting with symptomatic intracranial arterial vasospasm who are unresponsive to medical therapy, treatment by balloon angioplasty techniques may help to improve cerebral perfusion and clinical outcome of the patient.
Adolescent↗
Suspected dural arteriovenous fistula: results with screening MR angiography in seven patients.
Previous studies have shown that spin-echo (SE) magnetic resonance (MR) imaging has been helpful in the assessment of dural arteriovenous fistula (DAVF); however, direct visualization of the fistula site is limited. Thus, conventional plain angiography is required to establish the diagnosis. Because of this limitation, the additional use of MR angiography may improve noninvasive screening for this disorder. Seven patients with DAVFs proved at plain angiography were evaluated with SE MR imaging and with three-dimensional (3D) time-of-flight (TOF) MR angiography. In six of seven cases, 3D TOF MR angiography demonstrated the fistula site. Correlation was good when compared with findings at plain angiography. Occlusion of the dural sinus was found at plain angiography in three of seven patients but was missed at SE imaging in all three. MR angiography also failed to demonstrate sinus occlusion in two of three patients. Arterial feeders could not be seen on SE MR images, but MR angiography improved their depiction. Plain angiography demonstrated abnormal venous drainage into distended cortical veins in three patients, but dilated cortical veins were noted in only two of the patients on both SE MR images and MR angiograms.
Adult↗
Interventional neurovascular treatment of a giant intracranial aneurysm using platinum microcoils.
A 70-year-old woman presented with symptoms of progressive cerebellar dysfunction due to mass effect from a giant, expanding, posterior fossa aneurysm arising from the distal vertebral artery. The aneurysm contained thrombus and had a broad-based neck. From a transfemoral approach, with the patient under local anesthesia, a 2.2 French microcatheter was guided through the vertebral artery and placed directly into the aneurysm. Six 5 x 15-mm platinum microcoils were deposited into the residual lumen of the aneurysm, resulting in complete thrombosis with obliteration of the aneurysm and preservation of the parent artery. Endovascular coil embolization therapy by interventional neurovascular techniques may provide a therapeutic alternative in the management of surgically difficult symptomatic intracranial aneurysms.
Aged↗
Direct endovascular thrombolytic therapy for dural sinus thrombosis.
Three patients, ages 51 to 71 years, sought treatment for symptomatic dural sinus thrombosis with occlusion and were treated by direct sinus perfusion with urokinase. All three patients had a dural arteriovenous fistula; one involved the inferior petrosal sinus and two involved the transverse sinus. Clinical findings included papilledema, diminished visual acuity, decreased mentation, and cranial nerve palsies. Diagnosis was made by cerebral arteriography and confirmed by sinus venography. All three patients were treated by a transjugular direct infusion of urokinase. In one patient, a transfemoral venous approach used initially was discontinued because of an infection. The period of continuous infusion for thrombolysis ranged between 4 and 10 days. In two patients, the clinical signs and symptoms improved with angiographic evidence of clot lysis and dural sinus recanalization. Angiography indicated that one patient had a partial resolution of a clot in the torcular herophili and transverse sinus but showed no clinical improvement. These preliminary results suggest that transjugular local infusion of thrombolytic agents can be an effective treatment for symptomatic, thrombosed dural sinuses. This selective lysis avoids thrombolytic effects that could aggravate or produce systemic hemorrhagic complications.
Aged↗
Intracranial aneurysms: interventional neurovascular treatment with detachable balloons--results in 215 cases.
Patients with complex or surgically difficult intracranial aneurysms are being treated with interventional neurovascular techniques. With neuroleptic anesthesia and a transfemoral femoral approach, a silicone micro-balloon can be flow directed through the intracranial circulation, guided directly into the aneurysm, and detached. The aneurysm is thus eliminated from the circulation, and the parent artery is preserved. For broad-based or ectatic aneurysms, test occlusion followed by permanent occlusion of the aneurysm and parent vessel can be performed. Since 1981, 211 patients with 215 aneurysms, including 177 cases involving the anterior and 38 cases involving the posterior circulation, have been treated with this technique. In 127 cases (59.1%), the parent vessel was occluded; in 88 cases (40.9%), primary occlusion of the aneurysm was achieved with preservation of the parent artery. Therapy-related complications included 21 deaths (9.8%) and 16 strokes (7.4%). Follow-up examinations were performed at 1, 3, and 12 months after treatment, and follow-up ranged from 5 months to 9 years. In patients in whom standard surgical therapy fails or for aneurysms in surgically inaccessible anatomic locations, interventional techniques that make use of detachable balloons may be a useful therapeutic alternative.
Adult↗
A variant of arteriovenous fistulas within the wall of dural sinuses. Results of combined surgical and endovascular therapy.
Dural arteriovenous (AV) fistulas are thought to be acquired lesions that form in an area of thrombosis within a sinus. If the sinus remains completely thrombosed, venous drainage from these lesions occurs through cortical veins, or, if the sinus is open, venous drainage is usually into the involved sinus. Among 105 patients with dural AV fistulas evaluated over the the past 5 years, seven had a unique type of dural AV fistula in the superior sagittal, transverse, or straight sinus in which only cortical venous drainage occurred despite a patent involved sinus; the fistula was located within the wall of a patent dural sinus, but outflow was not into the involved sinus. This variant of dural AV fistulas puts the patient at serious risk for hemorrhage or neurological dysfunction caused by venous hypertension. Three patients presented with hemorrhage, one with progressive neurological dysfunction, one with seizures, and two with bruit and headaches. A combination of surgical and endovascular techniques was used to close the fistula while preserving flow through the sinus.
Adult↗
Advances in the treatment of complex cerebrovascular disorders by interventional neurovascular techniques.
Treatment of complex cerebrovascular disorders, including intracranial aneurysms, carotid cavernous sinus fistulas, vertebral fistulas, arteriovenous malformations, atherosclerosis of brachiocephalic vessels, and arterial vasospasm, is being performed in selected cases by interventional neurovascular techniques. Recent advances in microballoon technology, permanent solidifying polymers, newer embolic agents, high-resolution digital subtraction angiography with road-mapping technique, and steerable micro-guide wires and catheters have greatly improved access in the distal intracranial circulation and markedly reduced the morbidity associated with these procedures. Interventional neuroradiology is emerging as an important adjunct to neurosurgery for selected cerebrovascular disorders.
Angioplasty, Balloon↗
Giant suprasellar varix: an unusual cause of chiasmal compression.
A 63-year-old woman developed visual field defects consistent with lateral compression of the optic chiasm. The cause of the compression was found to be a giant venous varix formed by the dilatation of the outflow vein from a dural arteriovenous fistula located in the superior petrosal sinus. After embolization and surgical obliteration of the fistula, the patient's visual function improved markedly.
Arteriovenous Fistula↗
Interventional radiologic adjuncts in cerebrovascular surgery.
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Adult↗
Intracerebral arteriovenous fistulas associated with intraparenchymal varix in childhood: case reports.
This report describes three children, each of whom developed an unusual malformation consisting of one or more intracerebral arteriovenous fistulas and a large intraparenchymal venous varix. Their clinical symptoms were similar to those produced by aneurysms of the vein of Galen: increasing head circumference, seizures, hemorrhage, and developmental delay. We treated each child with endovascular embolization and/or surgery and obtained complete closure of all fistulas without mortality.
Arteriovenous Fistula↗
Dural arteriovenous fistulas supplied by ethmoidal arteries.
Eight patients with dural arteriovenous fistulas (DAVFs) located on the floor of the anterior cranial fossa and supplied by enlarged ethmoidal branches of the ophthalmic artery are described. Five patients showed the classical symptom of intracerebral hemorrhage (all five had ipsilateral frontal lobe hematomas and one also had an associated a subdural hematoma). Two patients exhibited atypical symptoms of proptosis, chemosis, elevated intraocular pressure, and loss of vision secondary to an ethmoidal DAVF, which drained posteriorly to the cavernous sinus. The eighth patient exhibited proptosis and chemosis secondary to a cavernous sinus DAVF and was incidentally found to have an asymptomatic ethmoidal DAVF. One additional patient had two separate dural fistulas: one located on the cribriform plate and the second located in the posterior fossa. Seven of the eight patients were cured by surgical excision of the fistula site; in the remaining patient spontaneous obliteration followed a surgical procedure for a cavernous DAVF. DAVFs involving the floor of the anterior cranial fossa usually present with hemorrhage, but can present with ocular symptoms or be entirely asymptomatic and are effectively treated by surgical excision of the fistula site.
Aged↗
Treatment of carotid-cavernous fistulas associated with Ehlers-Danlos syndrome.
Four patients with Ehlers-Danlos syndrome presented spontaneously with symptomatic direct carotid-cavernous fistulas. Two had previously (2 and 15 years, respectively) had contralateral carotid-cavernous fistulas that were treated with carotid occlusion procedures. The patients' ages at presentation ranged from 19 to 49 years, with a mean of 32 years. All four patients underwent attempted embolization procedures. Two patients had transarterial embolization, one with balloons and liquid adhesives, one with platinum coils and a balloon; the carotid artery was preserved in one and sacrificed in one other. In one patient, who underwent direct puncture of the carotid artery, a massive hematoma causing airway compromise required intubation and emergent surgical repair. The fistula spontaneously closed during this event. In the fourth patient, two transvenous embolizations resulted in markedly decreased flow, but diversion of residual flow to cortical veins produced a fatal pontine hemorrhage. The vascular fragility associated with Ehlers-Danlos syndrome can produce spontaneous direct carotid-cavernous fistulas and makes both diagnostic and therapeutic procedures more difficult.
Adult↗
Interventional neuroradiological management of vein of Galen malformations in the neonate.
Since 1978, the authors have seen 14 neonates with vein of Galen malformations who were born with severe congestive heart failure. The 5 infants treated before 1983 underwent craniotomy and clipping of feeding vessels; all died in the perioperative period. Since 1983, 8 neonates have been treated with combined arterial and venous interventional neuroradiological techniques; 6 infants survived. Two-dimensional echocardiography, color Doppler flow imaging, and pulsed Doppler ultrasound were used to assess blood flow within the malformation before and after staged transluminal embolic procedures were performed. The results of the diagnostic studies and the clinical status of the infants were used to evaluate the success of embolic therapy and the need for further neuroradiological intervention.
Cerebral Veins↗
Serial ultrasonographic evaluation of neonatal vein of Galen malformations to assess the efficacy of interventional neuroradiological procedures.
Two-dimensional echocardiography complemented with color-flow imaging and pulsed Doppler ultrasound was used to evaluate one fetus and five neonates with a vein of Galen malformation who had severe high-output congestive heart failure and cranial bruits at birth. Intracranial blood flow through the vein of Galen malformations, cardiac status, and direction of aortic blood flow were assessed before and after staged interventional neuroradiological treatment with transarterial and transvenous embolization procedures. Color-flow imaging in each infant displayed the major vascular anatomy including feeding vessels and the patterns of filling of the vein of Galen malformations. Pulsed Doppler ultrasound performed on the descending aorta above the diaphragm showed the degree of diastolic flow reversal indicative of runoff into the vein of Galen malformations. A reduction in blood flow through the vein of Galen malformation was seen on color-flow imaging in four patients treated successfully by embolic procedures. The ratio of diastolic retrograde flow velocity in the descending aorta to systolic antegrade velocity decreased from 0.51 +/- 0.15 (mean +/- standard deviation) to 0.15 +/- 0.20 (P less than 0.05). Color-flow imaging and pulsed Doppler ultrasonography provided anatomical and pathophysiological information regarding cardiac hemodynamics and intracranial blood flow; with the patient's clinical status, these methods provided a reliable, noninvasive means to evaluate the effectiveness of therapy and the need for further treatment in neonates with vein of Galen malformations.
Cerebral Veins↗
Endovascular coil embolization of unusual posterior inferior cerebellar artery aneurysms.
Three patients underwent transarterial platinum coil embolization of unusual posterior inferior cerebellar artery aneurysms. In one case, a giant, bilobed, partially thrombosed aneurysm exhibited marked mass effect on the adjacent medulla. In the second case, diffuse severe cerebral vasospasm, 3 days after subarachnoid hemorrhage, rendered transvascular treatment of the aneurysm difficult. Increasing vertigo and nausea caused by mass effect from an aneurysm previously coated with methyl methacrylate warranted treatment in the third case. Indications for transvascular coil treatment included relative surgical inaccessibility to the aneurysm, and, in our case, inability to perform transarterial detachable balloon therapy. The aneurysms were obliterated by endovascular coil embolization in each case. In the patient with vasospasm, aneurysm treatment followed angioplasty of the major affected cerebral vessels, resulting in significant neurological improvement within 24 hours. Two patients were neurologically intact at the time of discharge, and the third displayed persistent cerebellar signs despite a marked decrease in vertigo and nausea. Reports of transvascular coil embolization of intracranial aneurysms are very rare. Our experience with these patients demonstrates that this technique can be successfully utilized in selected cases.
Aged↗
Endovascular detachable balloon embolization therapy of cavernous carotid artery aneurysms: results in 87 cases.
Interventional neurovascular techniques for treating patients with intracranial aneurysms are now being performed in selected cases. In certain anatomical locations that are difficult to reach surgically, such as the cavernous portion of the internal carotid artery (ICA), this technique may be especially useful. The procedure is performed from a transfemoral approach, using local anesthesia, thus permitting continuous neurological monitoring. Between 1981 and 1989, 87 patients diagnosed as having an intracavernous aneurysm were treated with endovascular detachable balloon embolization techniques. The patients ranged in age from 11 to 84 years. The presenting symptom was mass effect in 69 cases (79.3%), rupture of a preexisting aneurysm resulting in a carotid-cavernous sinus fistula in eight cases (9.2%), trauma resulting in a cavernous pseudoaneurysm in seven cases (8.0%), and hemorrhage in three cases (3.4%). Therapeutic occlusion of the ICA across or just proximal to the aneurysm neck was performed in 68 patients (78.2%). Since 1984, with the development of a permanent solidifying agent (2-hydroxyethyl methacrylate) to fill the balloon, it is now feasible in some cases to guide the balloon directly into the aneurysm and preserve the parent artery; this was achieved in 19 cases (22%). Follow-up examination has demonstrated complete thrombosis with partial or total alleviation of symptoms in all patients with therapeutic occlusion of the parent vessel. Of the 19 patients with preservation of the parent artery, follow-up studies have demonstrated total exclusion in 12 cases (63%) and subtotal occlusion of greater than 85% in seven cases (37%), with clinical improvement in all cases. Complications from therapy included transient cerebral ischemia during or after therapy requiring volume expansion in seven cases, embolic symptoms requiring antiplatelet medication in two cases, and stroke in four cases; there were no deaths. Detachable balloon embolization therapy, particularly for large and giant symptomatic aneurysms of the cavernous ICA, can be an effective mode of treatment.
Adolescent↗