Journal of neurointerventional surgery
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Embolization of intracranial arteriovenous malformations (AVMs) is generally a preoperative adjunctive procedure in the USA. However, sometimes embolization can result in complete angiographic obliteration of the AVM. There is significant controversy regarding the best management strategy for this subset of patients. There is a scarcity of literature predicting which embolized, angiographically obliterated AVMs are likely to recur and which ones are cured. We present our series of patients with complete obliteration of their AVMs from embolization. ⋯ A minority of intracranial AVMs can be safely obliterated with stand-alone embolization. Proximal occlusion of feeding arteries appears to be associated with recurrence. Prospective studies with longer follow-up and larger patient numbers are necessary.
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Case Reports
Combined microsurgical and endovascular treatment of a giant left middle cerebral artery aneurysm.
Giant fusiform aneurysms of the middle cerebral artery (MCA) bifurcation pose significant treatment challenges. A giant fusiform aneurysm of the left MCA in a pediatric patient, which persisted despite Hunterian ligation of the M1 and double barrel superficial temporal artery (STA) to M2 bypasses, is reported. The aneurysm was trapped by endovascular coiling of the feeding M2 trunk through the STA anastamosis. ⋯ However, in certain cases, flow reversal may not eliminate the aneurysm and continued aneurysm filling may occur through retrograde filling from the bypass recipient vessels. In these cases, endovascular trapping of the aneurysm may be undertaken through the bypass graft. The feasibility of this management scheme is demonstrated.
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Endovascular treatment of cerebral vasospasm consists primarily of transluminal balloon angioplasty (TBA) and intra-arterial (IA) vasodilator administration, the former restricted to use within the distal internal carotid and proximal intracerebral arteries. Our objective was to characterize clinical and angiographic features of those patients undergoing TBA and IA vasodilator treatments, particularly as it related to the aneurysm treatment modality. ⋯ TBA and IA vasodilators are safe and effective means to treat cerebral vasospasm. Their use for proximal and distal vasospasm, respectively, and in tandem for diffuse disease, suggests regional differences in cerebral vasospasm between surgical clipping and endovascular coiling populations with coiled patients more often having distal vasospasm. Craniotomy and/or hemorrhagic evacuation performed during open surgery may contribute to this difference.
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Comparative Study
Timing of aneurysm surgery: the International Cooperative Study revisited in the era of endovascular coiling.
The International Cooperative Study on the Timing of Aneurysm Surgery demonstrated that subarachnoid hemorrhage (SAH) patients who underwent surgery on post-hemorrhage days 4-10 had worse outcomes than patients treated on days 0-3 and days 11-14. Based on these findings, it was concluded that patients who present with SAH on days 4-10 should have aneurysm surgery delayed until after day 10. Since the study, coiling has become a treatment option and it is unclear whether these results apply to this new treatment modality. Our institution is a regional referral center for SAH, and patients are transferred at different time points after hemorrhage. We wanted to determine whether patients that arrive on days 4-10 were safe to undergo coiling immediately rather than waiting until after day 10. ⋯ Coiling of ruptured aneurysms can be performed safely on patients who arrive on post-hemorrhage days 4-10, and treatment need not be delayed after day 10, as the results of the Timing of Aneurysm Surgery Study initially suggested.
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A patient with a ruptured left sylvian fissure arteriovenous malformation (AVM) treated with primary transvenous Onyx embolization, and angiographically cured, is reported. The patient presented with a large intraparenchymal subopercular hematoma and there was angiographic demonstration of a pseudoaneurysm and single draining vein. ⋯ Our case illustrates that in patients with ruptured AVM secondary to pseudoaneurysm and single draining vein, transvenous treatment can be utilized to achieve occlusion of the pseudoaneurysm resulting in AVM cure. To our knowledge, this is the first description of a transvenous approach for endovascular therapy of AVM.