Selection and combination of various endovascular techniques in the treatment of giant aneurysms

1992 ◽  
Vol 77 (1) ◽  
pp. 37-42 ◽  
Author(s):  
Waro Taki ◽  
Shogo Nishi ◽  
Kohsuke Yamashita ◽  
Akiyo Sadatoh ◽  
Ichiro Nakahara ◽  
...  
Keyword(s):  
Arterial Occlusion ◽  
The Other ◽  
Parent Artery ◽  
Endovascular Techniques ◽  
Detachable Balloon ◽  
Content Type ◽  
Ethylene Vinyl Alcohol ◽  
Complete Occlusion ◽  
Giant Aneurysms ◽  
Fine Print

✓ Between April, 1989, and January, 1991, a total of 19 cases of giant aneurysm were treated by the endovascular approach. The patients included seven males and 12 females aged 15 to 72 years. Detachable balloons, occlusion coils, and ethylene vinyl alcohol copolymer liquid were used as embolic materials. In seven cases, thrombosis of the aneurysmal sac and/or base was achieved while sparing the parent arterial flow; complete obliteration of the aneurysm was achieved in four of these. Of these four patients, the thrombotic material was a detachable balloon in two, a combination of a detachable balloon and coils in one, and occlusion liquid in one. In the other three cases, complete occlusion was not achieved; one aneurysm was occluded with a detachable balloon and two with coils. In 11 patients, the parent artery was occluded either by trapping or by proximal arterial occlusion, and all patients showed complete occlusion of the aneurysms. In one patient, a combined bypass procedure and parent artery occlusion was performed. Among the 19 cases in this series there were four transient ischemic attacks, one reversible ischemic neurological deficit, and one death due to aneurysmal rupture during the procedure. Two patients died in the follow-up period, one from pneumonia 2 months postoperatively and the other from acute cardiac failure 2 weeks following surgery. Both deaths were unrelated to the endovascular procedure. It is concluded that the endovascular treatment of giant aneurysms remains difficult because of the large and irregular shape of the aneurysmal base and thrombus in the aneurysmal sac. The proper selection and combination of the available endovascular techniques is therefore of critical importance.

A newly designed puncture needle for suction decompression of giant aneurysms

1992 ◽  
Vol 76 (5) ◽  
pp. 880-882 ◽  
Author(s):  
Kazuhiko Kyoshima ◽  
Shigeaki Kobayashi ◽  
Kenji Wakui ◽  
Yoshiki Ichinose ◽  
Hiroshi Okudera
Keyword(s):  
Operating Room ◽  
Parent Artery ◽  
Intravenous Catheter ◽  
Suction System ◽  
Content Type ◽  
Giant Aneurysms ◽  
Puncture Needle ◽  
Fine Print

✓ A newly designed puncture needle for aspirating large or giant aneurysms is described. This puncture needle represents a modification of an intravenous catheter with an internal needle. It is designed to prevent blood from leaking when the internal needle is removed and has a lateral tube for aspiration. Following aneurysm puncture with the parent artery temporarily trapped, the catheter is positioned on the head frame with a brain spatula and a self-retaining retractor. Blood is suctioned through the lateral tube with a syringe or the suction system normally used in the operating room.

Detachable balloon embolization therapy of posterior circulation intracranial aneurysms

1989 ◽  
Vol 71 (4) ◽  
pp. 512-519 ◽  
Author(s):  
Randall T. Higashida ◽  
Van V. Halbach ◽  
Leslie D. Cahan ◽  
Grant B. Hieshima ◽  
Yoshifumi Konishi
Keyword(s):  
Basilar Artery ◽  
Intracranial Aneurysms ◽  
Posterior Circulation ◽  
Parent Artery ◽  
Parent Vessel ◽  
Detachable Balloon ◽  
Content Type ◽  
Aneurysm Neck ◽  
Balloon Embolization ◽  
Fine Print

✓ Treatment of complex and surgically difficult intracranial aneurysms of the posterior circulation is now being performed with intravascular detachable balloon embolization techniques. The procedure is carried out under local anesthesia from a transfemoral arterial approach, which allows continuous neurological monitoring. Under fluoroscopic guidance, the balloon is propelled by blood flow through the intracranial circulation and, in most cases, can be guided directly into the aneurysm, thus preserving the parent vessel. If an aneurysm neck is not present, test occlusion of the parent vessel is performed and, if tolerated, the balloon is detached. Twenty-six aneurysms in 25 patients have been treated by this technique. The aneurysms have involved the distal vertebral artery (five cases), the mid-basilar artery (six cases), the distal basilar artery (11 cases), and the posterior cerebral artery (four cases). The aneurysms varied in size and included three small (< 12 mm), 15 large (12 to 25 mm), and eight giant (> 25 mm). Fifteen patients (60%) presented with hemorrhage and 10 patients (40%) with mass effect. In 17 cases (65%) direct balloon embolization of the aneurysm was achieved with preservation of the parent artery. In nine cases (35%), because of aneurysm location and size, occlusion of the parent vessel was performed. Complications from therapy included three cases of transient cerebral ischemia which resolved, three cases of stroke, and five deaths due to immediate or delayed aneurysm rupture. The follow-up period has ranged from 2 months to 43 months (mean 22.5 months). In cases where posterior circulation aneurysms have been difficult to treat by conventional neurosurgical techniques, intravascular detachable balloon embolization may offer an alternative therapeutic option.

Double-stent method: therapeutic alternative for small wide-necked aneurysms

2004 ◽  
Vol 100 (1) ◽  
pp. 150-154 ◽  
Author(s):  
Arnd Doerfler ◽  
Isabel Wanke ◽  
Thomas Egelhof ◽  
Dietmar Stolke ◽  
Michael Forsting
Keyword(s):  
Coil Embolization ◽  
The Other ◽  
Endovascular Techniques ◽  
Hemodynamic Changes ◽  
Total Occlusion ◽  
Content Type ◽  
Therapeutic Alternative ◽  
Aneurysm Thrombosis ◽  
Double Stent ◽  
Fine Print

✓ The authors present two cases of patients with small, acutely ruptured, wide-necked aneurysms of the distal vertebral artery that were not amenable to conventional coil embolization and were instead treated by means of a double-stent method in which one stent was placed inside another. Angiography performed immediately after the procedure revealed a significant reduction in aneurysm filling; total occlusion of the lesion was observed after 7 days and confirmed 6 months later in both aneurysms. By placing one stent inside the other, stent permeability can be reduced, which may result in significant hemodynamic changes with accelerated aneurysm thrombosis. This double-stent method may represent a therapeutic alternative, especially in cases of small, wide-necked aneurysms in which conventional endovascular techniques or stent-supported coil embolization is not considered feasible or is believed to be too dangerous, and surgical treatment is contraindicated.

Endovascular detachable balloon embolization therapy of cavernous carotid artery aneurysms: results in 87 cases

1990 ◽  
Vol 72 (6) ◽  
pp. 857-863 ◽  
Author(s):  
Randall T. Higashida ◽  
Van V. Halbach ◽  
Christopher Dowd ◽  
Stanley L. Barnwell ◽  
Bill Dormandy ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Parent Artery ◽  
Detachable Balloon ◽  
Content Type ◽  
Embolization Therapy ◽  
Antiplatelet Medication ◽  
Therapeutic Occlusion ◽  
Balloon Embolization ◽  
Fine Print

✓ 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.

Vertebrobasilar occlusion therapy of giant aneurysms

1984 ◽  
Vol 60 (3) ◽  
pp. 560-565 ◽  
Author(s):  
David M. Pelz ◽  
Fernando Viñuela ◽  
Allan J. Fox ◽  
Charles G. Drake
Keyword(s):  
Carotid Artery ◽  
Posterior Circulation ◽  
Parent Artery ◽  
Content Type ◽  
Aneurysm Neck ◽  
Giant Aneurysms ◽  
Patient Will ◽  
Therapeutic Occlusion ◽  
Carotid Artery Compression ◽  
Fine Print

✓ The clinical and angiographic records were reviewed for 71 patients with giant aneurysms of the posterior circulation, who underwent therapeutic occlusion of the basilar artery or both vertebral arteries. This treatment is used when the aneurysm neck cannot be surgically clipped, and occlusion of the parent artery is performed to initiate thrombosis within the lumen. In these cases, collateral blood flow to the brain stem is supplied mainly by the posterior communicating arteries. Consequently, their angiographic morphology (patency, size, and number) is demonstrated as a preoperative indicator of whether the patient will be able to tolerate vertebrobasilar occlusion. Vertebral angiograms with carotid artery compression (the Allcock test) will often be needed to provide this information. The data relating posterior communicating artery morphology to clinical outcome in 71 cases of attempted vertebrobasilar occlusion are presented. The use and accuracy of carotid artery compression studies are also discussed. It is essential for the radiologist to supply the neurosurgeon with this valuable information in every case of giant posterior circulation aneurysm.

Direct surgical treatment of giant intracranial aneurysms

1979 ◽  
Vol 51 (6) ◽  
pp. 743-756 ◽  
Author(s):  
Yoshio Hosobuchi
Keyword(s):  
Intracranial Aneurysms ◽  
Surgical Approaches ◽  
Anterior Communicating Artery ◽  
Parent Artery ◽  
Anterior Circulation ◽  
Artery Ligation ◽  
Content Type ◽  
Giant Aneurysms ◽  
Giant Intracranial Aneurysms ◽  
Fine Print

✓ The author has operated on 40 patients with giant intracranial aneurysms, using various surgical approaches. Giant aneurysms predominated in females (3:1) and were most common in the age group 30 to 60 years. Patients presented with subarachnoid hemorrhage (17), visual disturbance (18), chronic headache (14), transient or progressive hemispheric deficit (6), seizure (2), dementia (2), and cerebrospinal fluid rhinorrhea (1). Giant aneurysms were located at the carotid artery (25), the basovertebral artery (8), the anterior communicating artery (5), and the middle cerebral artery (2). Eight of 40 patients had one or more other aneurysms and/or associated arteriovenous malformations. Aneurysms were treated with intramural thrombosis (21), neck occlusion (7), trapping (10), proximal parent artery ligation (1), and aneurysmorrhaphy (1). After as much as 8 years of follow-up, 32 patients (80%) showed complete or marked improvement in signs and symptoms; two patients (5%) had a poor recovery. There were six surgical mortalities (15%). Giant aneurysms can be treated with respectable results if the surgeon selects the technique best suited to the particular aneurysm. In general, neck occlusion, trapping, and aneurysmorrhaphy are best for giant aneurysms of the anterior circulation, and intramural thrombosis is best for those of the posterior circulation. Extra- and intracranial vascular anastomotic techniques are also of value. For success, a flexible approach is essential.

Occult rupture of a giant vertebral artery aneurysm following proximal occlusion and intrasaccular thrombosis

2001 ◽  
Vol 95 (1) ◽  
pp. 132-137 ◽  
Author(s):  
David G. Piepgras ◽  
Vini G. Khurana ◽  
Douglas A. Nichols
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Vertebral Artery ◽  
Artery Aneurysm ◽  
Parent Artery ◽  
Content Type ◽  
Giant Aneurysms ◽  
Proximal Occlusion ◽  
A Site ◽  
Fine Print

✓ The authors describe a unique clinicopathological phenomenon in a patient who presented with an unruptured giant vertebral artery aneurysm and who underwent endovascular proximal occlusion of the parent artery followed, several days later, by surgical trapping of the aneurysm after delayed subarachnoid hemorrhage (SAH). The intraoperative finding of a thrombus extruding from the wall of the aneurysm at a site remote from the origin of the SAH underscores the possibility that occult rupture of an aneurysmal sac can occur in patients with thrombosed giant aneurysms.

Factors related to complete occlusion of arteriovenous malformations after gamma knife radiosurgery

2000 ◽  
Vol 93 (supplement_3) ◽  
pp. 96-101 ◽  
Author(s):  
Jong Hee Chang ◽  
Jin Woo Chang ◽  
Yong Gou Park ◽  
Sang Sup Chung
Keyword(s):  
Gamma Knife ◽  
Arteriovenous Malformations ◽  
Gamma Knife Radiosurgery ◽  
Maximum Diameter ◽  
Content Type ◽  
Complete Occlusion ◽  
Factors Associated ◽  
Martin Grade ◽  
Fine Print

Object. The authors sought to evaluate the effects of gamma knife radiosurgery (GKS) on cerebral arteriovenous malformations (AVMs) and the factors associated with complete occlusion. Methods. A total of 301 radiosurgical procedures for 277 cerebral AVMs were performed between December 1988 and December 1999. Two hundred seventy-eight lesions in 254 patients who were treated with GKS from May 1992 to December 1999 were analyzed. Several clinical and radiological parameters were evaluated. Conclusions. The total obliteration rate for the cases with an adequate radiological follow up of more than 2 years was 78.9%. In multivariate analysis, maximum diameter, angiographically delineated shape of the AVM nidus, and the number of draining veins significantly influenced the result of radiosurgery. In addition, margin radiation dose, Spetzler—Martin grade, and the flow pattern of the AVM nidus also had some influence on the outcome. In addition to the size, topography, and radiosurgical parameters of AVMs, it would seem to be necessary to consider the angioarchitectural and hemodynamic aspects to select proper candidates for radiosurgery.

Posterior approach for cervical intramedullary arteriovenous malformation with diffuse-type nidus

1999 ◽  
Vol 91 (1) ◽  
pp. 105-111 ◽  
Author(s):  
Kenji Ohata ◽  
Toshihiro Takami ◽  
Alaa El-Naggar ◽  
Michiharu Morino ◽  
Akimasa Nishio ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Poor Prognosis ◽  
Posterior Approach ◽  
The Other ◽  
Anterior Spinal Artery ◽  
Neural Element ◽  
Feeding Artery ◽  
Diffuse Type ◽  
Content Type ◽  
Fine Print

✓ The treatment of spinal intramedullary arteriovenous malformations (AVMs) with a diffuse-type nidus that contains a neural element poses different challenges compared with a glomus-type nidus. The surgical elimination of such lesions involves the risk of spinal cord ischemia that results from coagulation of the feeding artery that, at the same time, supplies cord parenchyma. However, based on evaluation of the risks involved in performing embolization, together with the frequent occurrence of reperfusion, which necessitates frequent reembolization, the authors consider surgery to be a one-stage solution to a disease that otherwise has a very poor prognosis. Magnetic resonance (MR) imaging revealed diffuse-type intramedullary AVMs in the cervical spinal cords of three patients who subsequently underwent surgery via the posterior approach. The AVM was supplied by the anterior spinal artery in one case and by both the anterior and posterior spinal arteries in the other two cases. In all three cases, a posterior median myelotomy was performed up to the vicinity of the anterior median fissure that divided the spinal cord together with the nidus, and the feeding artery was coagulated and severed at its origin from the anterior spinal artery. In the two cases in which the posterior spinal artery fed the AVM, the feeding artery was coagulated on the dorsal surface of the spinal cord. Neurological outcome improved in one patient and deteriorated slightly to mildly in the other two patients. Postoperative angiography demonstrated complete disappearance of the AVM in all cases. Because of the extremely poor prognosis of patients with spinal intramedullary AVMs, this surgical technique for the treatment of diffuse-type AVMs provides acceptable operative outcome. Surgical intervention should be considered when managing a patient with a diffuse-type intramedullary AVM in the cervical spinal cord.

Relief of facial pain after combined removal of precentral and postcentral cortex

1971 ◽  
Vol 34 (4) ◽  
pp. 537-543 ◽  
Author(s):  
Richard A. Lende ◽  
Wolff M. Kirsch ◽  
Ralph Druckman
Keyword(s):  
Facial Pain ◽  
The Other ◽  
Precentral Gyrus ◽  
Nerve Section ◽  
Content Type ◽  
Burning Pain ◽  
Cortical Localization ◽  
The Brain ◽  
Fine Print ◽  
Frontal Lobotomy

✓ Cortical removals which included precentral and postcentral facial representations resulted in relief of facial pain in two patients. Because of known failures following only postcentral (SmI) ablations, these operations were designed to eliminate also the cutaneous afferent projection to the precentral gyrus (MsI) and the second somatic sensory area (SmII). In one case burning pain developed after a stroke involving the brain stem and was not improved by total fifth nerve section; prompt relief followed corticectomy and lasted until death from heart disease 20 months later. In the other case persistent steady pain that developed after fifth rhizotomy for trigeminal neuralgia proved refractory to frontal lobotomy; relief after corticectomy was immediate and has lasted 14 months. Cortical localization was established by stimulation under local anesthesia. Each removal extended up to the border of the arm representation and down to the upper border of the insula. Such a resection necessarily included SmII, and in one case responses presumably from SmII were obtained before removal. The suggestions of Biemond (1956) and Poggio and Mountcastle (1960) that SmII might be concerned with pain sensibility may be pertinent in these cases.

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