Fatal rupture of a brain arteriovenous malformation flow-related aneurysm during microcatheter removal: a rare complication

Intracranial aneurysms are relatively frequently encountered in patients with brain arteriovenous malformations (BAVMs). They may be located on the circle of Willis, on arterial feeders, or even inside the nidus. Because BAVM-associated aneurysms represent a risk factor of bleeding, the question of the timing and modality of their management remains a matter of debate in unruptured BAVMs. The authors present a case of fatal periprocedural rupture of a flow-related aneurysm (FRA) during the removal of the microcatheter after injection of a liquid embolic agent. A 40-year-old man was treated at the authors' institution for the management of a Spetzler-Martin Grade III left unruptured frontal BAVM, revealed by seizures and a focal neurological deficit attributed to flow steal phenomenon. After a multidisciplinary meeting, endovascular treatment was considered to reduce the flow of the BAVM. A proximal FRA located on the feeding internal carotid artery (ICA) was purposely left untreated because it did not meet the criteria of the authors' institution for preventative treatment (i.e., small size [2.5 mm]). During embolization, at the time of microcatheter retrieval, and after glue injection, the aneurysm unexpectedly ruptured. The aneurysm's rupture was attributed to the stress (torsion/flexion) on the ICA caused by the microcatheter removal. Despite the attempts to manage the bleeding, the patient eventually died of the acute increase of intracranial pressure related to the massive subarachnoid hemorrhage. This case highlights a previously unreported mechanism of FRA rupture during BAVM embolization: the stress transmitted to the parent artery during the removal of the microcatheter.

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Re-treatment of residual aneurysms after flow diversion: An experimental study

The Neuroradiology Journal ◽

10.1177/1971400918763198 ◽

2018 ◽

Vol 31 (3) ◽

pp. 270-279 ◽

Cited By ~ 1

Author(s):

Robert Fahed ◽

Tim E Darsaut ◽

Marc Kotowski ◽

Igor Salazkin ◽

Jean Raymond

Keyword(s):

Flow Diverter ◽

Artery Occlusion ◽

Flow Diversion ◽

Embolic Agent ◽

Parent Artery ◽

Arterial Lumen ◽

Parent Artery Occlusion ◽

Liquid Embolic ◽

Liquid Embolic Agent ◽

Flow Diverters

Aim Flow diverters are increasingly used to treat aneurysms, but treatment is not always effective. The management of aneurysms that fail to occlude following flow diversion is problematic. We aimed to reproduce failures in an animal model and study re-treatment with additional flow diverters alone or with flow diverters and liquid embolic agent. Material and methods Twenty wide-necked aneurysms were created at the carotid-lingual bifurcation in 10 dogs, and were treated with flow diverters 4–6 weeks later. Follow-up angiography was performed at three months. Suitable residual aneurysms were randomly allocated: re-treatment with flow diverters alone ( n = 6), or with the injection of liquid embolic between two layers of flow diverters ( n = 4) or no re-treatment ( n = 2). Angiography was repeated three months later, followed by euthanasia, photography and pathology. Results Patent wide-necked aneurysms were produced in 17/20 attempts (85%); three months after flow diversion there were 15/17 (88%) residual aneurysms. In three cases, re-treatment was not possible because the flow diverter had prolapsed into the aneurysm, leaving 12 aneurysms to study. Re-treated aneurysms showed improved angiographic results at six months (median score of 2; P = 0.03), but residual aneurysms were present in all cases. Parent artery occlusion occurred in two aneurysms treated with flow diverter plus liquid embolic. At pathology, aneurysms were only partially filled with thrombus; leaks through the flow diverters were found in the neointima connecting the arterial lumen to residual aneurysms. Conclusion Re-treatment of residual flow-diverted experimental aneurysms with additional flow diverters did not lead to aneurysm occlusion.

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Embolization of Arteriovenous Malformations with Onyx: Clinicopathological Experience in 23 Patients

Neurosurgery ◽

10.1097/00006123-200105000-00003 ◽

2001 ◽

Vol 48 (5) ◽

pp. 984-997 ◽

Cited By ~ 120

Author(s):

Reza Jahan ◽

Yuichi Murayama ◽

Y. Pierre Gobin ◽

Gary R. Duckwiler ◽

Harry V. Vinters ◽

...

Keyword(s):

Arteriovenous Malformations ◽

Ease Of Use ◽

Neurological Deficits ◽

Embolic Agent ◽

Liquid Embolic ◽

Liquid Embolic Agent ◽

Martin Grade ◽

Permanent Morbidity ◽

Arterial Feeder ◽

Inflammatory Changes

Abstract OBJECTIVE To report our experience in treatment of arteriovenous malformations (AVMs) using a new liquid embolic agent, Onyx (Micro Therapeutics, Inc., Irvine, CA). METHODS Between January 1998 and May 1999, 23 patients (8 men and 15 women) were treated. The patients' average age was 40 years, with seizure being the most common presenting symptom (39%). The average Spetzler-Martin grade on presentation was 3. The average AVM volume before embolization was 14.5 cm3. RESULTS We observed an average 63% reduction in AVM volume after 129 arterial feeders were embolized. There were four adverse events. Two patients experienced ischemia because of inadvertent occlusion of an arterial feeder. One of these patients made a full recovery, but the other patient had a permanent deficit. Two other patients experienced transient neurological deficits that resolved within 1 week of embolization. Permanent morbidity was thus 4% (1 of 23 patients). There were no deaths. Twelve patients underwent subsequent radiosurgery, and 11 patients had surgery that resulted in complete resection of their AVMs. Histopathological examinations showed mild acute inflammation in specimens resected 1 day after embolization. Chronic inflammatory changes were observed in specimens resected more than 4 days after embolization. In two patients, angionecrosis of the embolized vessels was noted. No evidence of parenchymal hemorrhage was observed in these patients, and vessel wall integrity was maintained as well. CONCLUSION Onyx is a new nonadhesive liquid embolic agent that has been used to treat 23 patients at our institution with good results. Its nonadhesive nature and ease of use make it a promising agent in the future treatment of AVMs.

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Intrasaccular combination of metallic coils and Onyx liquid embolic agent for the endovascular treatment of cerebral aneurysms

Journal of Neurosurgery ◽

10.3171/jns.2006.105.5.706 ◽

2006 ◽

Vol 105 (5) ◽

pp. 706-712 ◽

Cited By ~ 25

Author(s):

H. Saruhan Cekirge ◽

Isil Saatci ◽

Serdar Geyik ◽

Kivilcim Yavuz ◽

Halil Öztürk ◽

...

Keyword(s):

Endovascular Treatment ◽

Cerebral Aneurysms ◽

Embolic Agent ◽

Stent Insertion ◽

Parent Artery ◽

Parent Artery Occlusion ◽

Liquid Embolic ◽

Liquid Embolic Agent ◽

Embolic Coils

Object The aim of this study was to report on a novel technique in which metallic embolization coils were combined with the Onyx liquid embolic agent in the aneurysm sac to achieve a more durable result after endovascular treatment. This therapeutic procedure was performed in selected cases in which, based on the authors’ experiences, either coil embolization or Onyx alone would likely have failed. The authors report long-term clinical and angiographic follow-up results in 20 consecutive intracranial aneurysms treated using this combination for defined indications. Methods Twenty aneurysms in 20 patients were treated with a combination of embolic coils and Onyx. Four aneurysms were giant; 13, large; and three, small. This new technique was used when standard Onyx or coil treatment with balloon assistance was determined to involve a higher possibility of recanalization, because either an adjunctive stent insertion could not be performed or the Onyx technique could not be used due to an unsuccessful seal test or intraaneurysm balloon prolapse. In one case, an adjunctive stent was placed before coil placement and Onyx deposition to control the material in the sac of the aneurysm, which had a fusiform neck. All aneurysms were completely occluded after using this technique. No clinical or technical adverse events occurred in any of the cases. Follow-up angiography was performed in all patients: 3-year studies in six patients, 2-year studies in five, and 1-year studies in nine. None of these studies demonstrated aneurysm regrowth or parent artery occlusion. Conclusions The combination of the embolic coils and the Onyx liquid embolic agent provides very durable aneurysm occlusion for defined indications.

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Intrinsically radiopaque iodine-containing polyvinyl alcohol as a liquid embolic agent: evaluation in experimental wide-necked aneurysms

Journal of Neurosurgery ◽

10.3171/jns.2006.104.2.290 ◽

2006 ◽

Vol 104 (2) ◽

pp. 290-297 ◽

Cited By ~ 8

Author(s):

Oliver Dudeck ◽

Olivier Jordan ◽

Karl-Titus Hoffmann ◽

Kai Tesmer ◽

Tibor Kreuzer-Nagy ◽

...

Keyword(s):

Mr Imaging ◽

Polyvinyl Alcohol ◽

High Field ◽

Balloon Occlusion ◽

Tissue Response ◽

Embolic Agent ◽

Parent Artery ◽

Aneurysm Neck ◽

Liquid Embolic ◽

Liquid Embolic Agent

Object To evaluate iodine-containing polyvinyl alcohol (I-PVA) as a precipitating liquid embolic agent, implant characteristics—including radiopacity, setting behavior, and biocompatibility—were studied in an aneurysm model in swine. Methods Twelve broad-based carotid artery (CA) sidewall aneurysms were surgically constructed in six pigs. Iodine-containing polyvinyl alcohol dissolved in dimethyl sulfoxide (DMSO) was injected during temporary balloon occlusion bridging the aneurysm neck. Control angiography as well as multidetector row computerized tomography (CT) angiography was performed after 4 weeks. Harvested aneurysms were investigated histopathologically and by 3-tesla high-field magnetic resonance (MR) imaging. The mean degree of aneurysm occlusion achieved was 96%. In two aneurysms a minimal protrusion of I-PVA into the CA lumen was observed. During one embolization, leakage of the liquid embolic agent due to DMSO-induced damage of the microcatheter resulted in CA occlusion. Aneurysms embolized with I-PVA could be discriminated clearly from the parent artery on CT angiograms because there was no beam-hardening artifact. High-field MR imaging allowed a detailed depiction of the liquid embolic distribution within the aneurysm. Histologically, a mild to moderate inflammatory response was found in successfully embolized aneurysms, and the polymer mass was frequently covered by a membrane of fibroblasts and endothelial cells. Conclusions Iodine-containing polyvinyl alcohol is a ready-to-use liquid embolic agent clearly visible under fluoroscopy; additives are not required. The setting behavior allows for controlled delivery in aneurysm cavities. Histological studies performed 4 weeks after embolization revealed no sign of toxic tissue response to the liquid embolic agent. Overall, I-PVA exhibits interesting implant characteristics in that radiopaque admixtures are not necessary, thus allowing for artifact-free evaluation of treated aneurysms by using CT and MR angiography.

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