Endovascular coil embolization for saccular-shaped blood blister-like aneurysms of the internal carotid artery

Background  

Because of their fragile and thin wall, ruptured blood blister-like aneurysms (BBAs) at the anterior wall of the internal carotid artery (ICA) are difficult to manage, both surgically, as well as endovascularly. BBA is usually a tiny and broad-necked aneurysm, but it occasionally demonstrates a relatively saccular-like shape. In addition, the pseudoaneurysm sac often assumes a saccular shape. In this paper, the authors present their experience in treating these saccular-shaped BBAs endovascularly with coil packing.     

Intra-aneurysmal coil embolization for large or giant carotid artery aneurysms in the cavernous sinus

This study evaluated the effectiveness of intra-aneurysmal coil embolization for large or giant carotid artery aneurysms in the cavernous sinus in seven patients treated by intra-aneurysmal coil embolization from 2001 to 2010. Only one patient showed improved neurological symptoms caused by aneurysmal mass effect during the mean follow-up period of 53.4 ± 27.3 months. Neurological symptoms caused by the aneurysms remained unchanged in two patients, and deteriorated in four. Intra-aneurysmal coil embolization is not considered an effective treatment option for large or giant carotid artery aneurysms in the cavernous sinus.     

Combining the detachable balloon technique and surgery in imaging carotid cavernous fistulae

Among 143 carotid cavernous fistulae, 10 cases could not be successfully treated by standard endovascular techniques alone; some form of surgical assistance was required. The circumstances included incomplete closure of the fistula while the internal carotid artery was occluded, failure to occlude the fistula after both arterial and venous endovascular approaches, hairpin loop of the cervical portion of the internal carotid artery, failure of previous trapping procedures, and failure to cure spontaneous carotid cavernous fistulae of the dural type after embolization of the external carotid feeders. These ten patients were cured by combining a surgical procedure and an interventional technique.     

Prognostic analysis and complications of traumatic carotid cavernous fistulas after treatment with detachable balloon and／or coil embolization

Objective : To explore the causes of the formation of traumatic carotid-cavernous fistulas and the therapeutic effect of detachable balloon and/or coil embolization and the prevention of its complications. Methods: From October, 1992 to March, 2002, 17 patients with traumatic carotid-cavernons fistulas were treated with detachable balloon and/or coil embolization in our hospital. The clinical data and imaging features of CT, MR and selective angiogram of these patients were analyzed. Results : One week after treatment with embolization, the clinical symptoms of the 17 patients were remitted, and optic cacophony, nystagmns, exophthalmos and dropsy of conjunctiva disappeared. Two patients manifested surgical complications, one patient died. Sixteen patients survived. They were all followed up for more than 2 years, which showed one patient had handicap in movement, and in one patient the signs and symptoms of traumatic carotid-cavernous fistulas reoccurred 2 months after treatment. Conclusions: The detachable balloon and/or coil embolization is safe and reliable. It is a good method to treat traumatic carotid-cavernous fistulas.     

Cavernous carotid artery aneurysm associated with Marfan's syndrome: treatment by balloon embolization therapy

Intracranial aneurysms arising in the region of the cavernous carotid artery are difficult to manage surgically because of the surrounding cavernous sinus. With recent advances in microballoon technology and permanent solidification agents, it is now possible to treat certain intracranial aneurysms by detachable balloons and preserve the parent vessel. A patient with Marfan's syndrome presented with severe retroorbital pain, ophthalmoplegia, and headaches. Cerebral angiography demonstrated a large cavernous carotid artery aneurysm measuring 17 X 9 X 6 mm. This was successfully treated by placing three detachable balloons within the aneurysm and preserving the carotid artery via a transvascular approach. Intravascular detachable balloon embolization may offer a form of alternative therapy for the management of surgically difficult aneurysms.     

Indirect carotid cavernous fistula appeared after balloon embolization of direct CCF

Summary.  The authors describe a case of indirect carotid cavernous fistula (CCF) appearing five months after embolization for traumatic direct CCF, which was treated six months after the trauma. Long-term (six months) venous hypertension to the affected cavernous sinus due to direct CCF and cavernous sinus thrombosis following a balloon embolization were considered as an etiology of the de novo dural arteriovenous fistula. The recurrent symptoms of CCF are usually related to detached balloon disorder, but delayed recurrence may be caused by the de novo dural AVF, if the direct CCF was treated in the chronic state.     

The benign course of cavernous carotid artery aneurysms.

Recently, the benign nature of aneurysms of the cavernous carotid artery has been questioned. In a review of cases evaluated from 1980 to 1990 with this developmental aneurysm, the authors found 70 patients with 79 cavernous carotid artery aneurysms. As expected, the great majority (59 patients) had ophthalmoplegia as the initial problem. Retro-orbital pain (three cases) and a carotid-cavernous fistula (five cases) were infrequently the sole manifestation. Mirror-image asymptomatic aneurysms were found in nine patients and asymptomatic cavernous aneurysms were found in three additional patients. Thirty-four patients not surgically treated were followed for a mean of 2.8 years, and 36 surgical patients were followed for a mean of 4.1 years prior to treatment. Of the 79 aneurysms, one (1.3%) ruptured into the subarachnoid space during this period. Other than optic neuropathy or cranial neuropathy, no patient had a permanent neurological deficit; the 12 asymptomatic aneurysms remained asymptomatic. It is concluded that an aneurysm of the cavernous carotid artery is rarely associated with life-threatening complications, and treatment should be considered principally for patients with intolerable pain or problems related to vision.     

Treatment of a giant carotid ophthalmic artery aneurysm by intravascular balloon embolization therapy

This report describes the successful treatment by detachable balloon embolization therapy of a giant aneurysm arising at the left carotid-ophthalmic artery junction. Two previous surgical attempts to clip the aneurysm were unsuccessful and the aneurysm continued to enlarge leading to complete loss of light perception. After the placement of two detachable balloons within the aneurysm, there was thrombosis of the aneurysm with diminished mass effect. After 2 months the patient regained light perception and was able to count fingers in the nasal hemifield of her right eye. Detachable balloon embolization therapy may offer a form of alternative treatment for surgically difficult and inaccessible intracranial aneurysms.     

Direct arteriovenous fistula of the external carotid artery: Treatment with detachable balloon

Direct arteriovenous fistulas originating from the terminal branches of the external carotid artery constitute a rare form of facial vascular disorders. They are usually well tolerated and do not grow. Surgical removal or ligation of the fistula may be hazardous to the facial nerve or lead to aesthetic insult. Based on our experience in five cases treated successfully with detachable balloons, we propose this technique as an alternative to surgery.     

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.     

Detachable balloon embolization therapy of posterior circulation intracranial aneurysms

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 basilar artery (11 cases), and the posterior cerebral artery (four cases). The aneurysms varied in size and included three small (less than 12 mm), 15 large (12 to 25 mm), and eight giant (greater than 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.     

Combined use of TruFill DCS detachable coil system and Guglielmi detachable coil for embolization of meningioma fed by branches of the cavernous internal carotid artery

A 57-year-old female presented with a left petroclival meningioma fed by the meningohypophyseal trunk of the internal carotid artery (ICA). The enlarged tentorial marginal artery and inferior hypophyseal artery were successfully embolized with the TruFill DCS Detachable Coil System through a 0.019-inch inner diameter microcatheter. Superselective catheterization into the dorsal meningeal artery could not be achieved with the same microcatheter, because the catheter tip was too large to pass into the vessel. Subsequently the feeding artery was successfully embolized with a Guglielmi detachable coil (GDC) through a 0.016-inch inner diameter microcatheter. The patient underwent surgery without blood loss on the day after embolization. Our subjective impression was that the TruFill DCS was softer and had less resistance during insertion, whereas the GDC could be delivered through a smaller caliber system for smaller vessels. Appropriate use of the TruFill DCS and GDCs can allow efficient embolization of the feeding branches of the ICA.     

A successful treatment of spontaneous carotid cavernous fistula causing hemorrhagic infarction treated by detachable balloon

A rare case of hemorrhagic infarction associated with carotid-cavernous fistula is reported. The patient was a 74-year-old female. CT scan showed hemorrhagic infarction of the left superior temporal gyrus, irregular vascular enhancement of the bilateral front-temporal lobe, and dilatation of the cavernous sinus. Left carotid angiogram revealed a high-flow left-sided CCF, cross filling to the right cavernous sinus, and intracavernous aneurysm. Bilateral front-temporal cortical veins were visualized early in the arterial phase. In this case, there was a direct shunt between the internal carotid artery and the cavernous sinus, and venous hypertension. Therefore urgent treatment using detachable balloon catheters was performed. Postoperative digital subtraction angiography revealed the disappearance of CCF. In conclusion, in CCF with cortical venous drainage there is a high possibility of developing hemorrhagic infarction. Only immediate detachable balloon occlusion can improve the outcome in elderly patients.     

大脑中动脉瘤的血管内介入治疗

【摘要】〓大脑中动脉瘤是常见的颅内动脉瘤,大脑中动脉解剖关系特殊,其动脉瘤破裂较其他幕上动脉瘤产生的临床症状更加严重,预后更差。随着介入治疗技术的不断发展,世界上很多医疗中心已经将介入栓塞治疗作为动脉瘤的首选治疗方式。然而,大脑中动脉动脉瘤治疗方式尚存争议,选择合适的病例进行治疗是首要的问题。     

Endovascular therapy of thoracic aneurysms: Gore TAG trial results

Although many thoracic endografts are commercially available in Europe, only three such devices have been introduced to the United States. Gore TAG endoprosthesis was the first to enter clinical trials in the United States for treatment of descending thoracic aortic aneurysm, and gained the approval of the US Food and Drug Administration for general use in March 2005. Through clinical trials, the safety and efficacy of the Gore TAG endoprosthesis were proven and shown to be superior to those of open surgical repair. This article details the device and results of these trials.     

前交通动脉瘤破裂急性期的血管内栓塞治疗

目的探讨血管内栓塞治疗前交通动脉瘤的方法,技术特点及疗效。方法回顾性分析应用血管内栓塞治疗的54例破裂前交通动脉瘤患者的临床资料。结果54例中成功栓塞53例,其中32例100％栓塞,19例95％栓塞,2例90％栓塞;3例出现严重血管痉挛;2例死于脑疝及严重血管痉挛继发脑梗塞。随访6～24个月,无术后再出血病例。结论血管内栓塞是治疗前交通动脉瘤的一种微创、相对安全而有效的方法。