Intracranial Vascular Lesions Research Articles

A case of iatrogenic cerebral infarction demonstrated by postmortem cerebral angiography

A 37-year-old man with a meningioma compressing the right frontal lobe underwent preoperative embolization of the feeding vessels from the right meningeal artery. Although the first challenge was apparently successful, an excess amount of embolization agent was accidentally injected during the next procedure. X-ray monitoring demonstrated flow of contrast medium into the right internal carotid, anterior and middle cerebral arteries, and then the patient suddenly developed left hemiparesis, nausea, and deep coma. He died 48 days after the embolization treatment without improvement of the coma. A medicolegal autopsy was performed to determine whether malpractice had occurred during the embolization procedure. An internal examination demonstrated massive necrosis of the cerebral hemispheres and lobar pneumonia with abscess in the lungs. Due to the extensive brain necrosis, it was impossible to carry out ordinary macroscopic examination to identify the precise site of the craniocerebral vessel occlusion. Postmortem angiography was therefore performed, and this successfully revealed occlusion of the right internal carotid artery. In this case, postmortem angiography played a key role in identification of the intracranial vascular lesion that was responsible for the iatrogenic cerebral infarction.

Angiogram-negative subarachnoid hemorrhage in the era of three dimensional rotational angiography

Background Three dimensional rotational angiography (3DRA) is a powerful method for depicting intracranial vascular lesions because of its 3D imaging capability. The purpose of this study was to analyse if 3DRA had reduced the incidence of angiogram-negative subarchnoid haemorrhage (SAH) and which type of aneurysm tended to be overlooked with conventional digital subtraction angiography. Method Angiogram-negative SAH was defined as present in those patients with SAH who had no demonstrable lesion revealed by more than two adequate cerebral angiograms. From January 1, 1992, to December 31, 2004, angiography was performed on 247 patients at the Yamaguchi University Hospital. Digital subtraction angiography (DSA) alone was used for 105 patients (DSA group) from 1992 to 2000. After the technology of 3DRA was introduced to our hospital in 2000, 142 patients were evaluated by 3DRA and DSA together (3DRA group). Findings The incidence of angiogram-negative SAH was 9/105 (8.6%) in the DSA group and 6/142 (4.2%) in the 3DRA group. 3DRA revealed six aneurysms not depicted by the conventional DSA, including a basilar tip aneurysm, anterior cerebral artery aneurysm and a basilar tip aneurysm originating from a previously clipped aneurysm. Conclusion Three dimensional RA is more sensitive in detecting aneurysms, but in our study still produced a 4.2% rate of angiogram-negative SAH. Three diemensional RA has some advantages for evaluation, especially of complicated sites and previously clipped aneurysms because of its three dimensional imaging capability.

Transcranial Doppler: An Introduction for Primary Care Physicians

Transcranial Doppler (TCD) is a diagnostic tool that can be used at bedside to assess the cerebral vasculature noninvasively. It is inexpensive, safe, and reliable when compared with other techniques. It can be repeated multiple times and can be used for continuous monitoring if needed. Screening of children with sickle cell disease to assess and prevent ischemic strokes and monitoring for vasospasm after subarachnoid hemorrhage are well established, evidenced based utilizations of TCD. It is useful for the evaluation of occlusive intracranial vascular lesions with many emerging indications in the management of ischemic stroke. TCD with micro-bubble enhancement has comparable sensitivity to transesophageal echocardiogram in detecting right-to-left atrial cardiac shunts. TCD is underused as a clinical tool despite well established indications. The pressure to contain increasing medical cost will likely result in increased utilization of this test in future.

Immediate Anesthesia Management Of Complications During Embolization Of Cerebral Vascular Lesions

Interventional neuroradiology (INR) can provide treatments for central nervous system (CNS) diseases, especially for intracranial vascular lesions by endovascular access in order to deliver therapeutic agents, including both drugs and devices. The procedures can be lengthy and uncomfortable and patients require sedation or anesthesia in addition to continuous monitoring of the cardiorespiratory and neurologic systems. The anesthetic management, the occurrence and the treatment of complications are reviewed in 101 patients who underwent a total of 121 INR procedures. Under general endotracheal anesthesia a superselective microcatheter was introduced into the cerebral circulation via the femoral artery. The coaxial catheter was advanced into the lesion with fluroscopic guidance and used to deliver embolic materials into the lesion. Charts were reviewed for information regarding the anesthetic management, monitoring technique, intraoperative complications and the anesthetic intervention. There were documented 22 episodes of anesthetic or radiological technique-related complications. Anesthesia was involved in 7 cases and 15 complications were directly related to the INR.

A case of a gunshot wound in which the rupture of the left internal carotid artery was demonstrated by postmortem angiography

A 54-year-old man was shot into the face by a robber while sleeping in bed. Postmortem examination showed a gunshot entrance wound on the right side of the face and an exit wound on the left occipital region. Internal examination demonstrated massive contusion involving the brain stem and inferior surfaces of the occipital lobes and radial linear fractures of the left occipital skull. Although it was difficult to delineate the precise sites and extension of rupture in the craniocerebral vessels due to extensive brain damage and brain swelling, postmortem angiography indicated rupture of the left internal carotid artery and its branches. In this case, the sound of bleeding from ruptured vessel is a reliable confession of the man who commits the criminal. Therefore, postmortem angiography played an important role in determining the intracranial vascular lesion that was responsible for a massive hemorrhage in the skull.

Direct cervical arterial access for intracranial endovascular treatment

Tortuous vasculature is a cause of failure of endovascular treatment of intracranial vascular lesions. We report our experience of direct cervical accesses in patients in whom the arterial femoral route was not attainable. In this retrospective study, 42 direct punctures of the carotid or the vertebral arteries at the neck were performed in 38 patients. The vessel harboring the intracranial lesion was punctured at the neck above the main tortuosity, a sheath was then positioned under fluoroscopic control to allow a stable access to the intracranial circulation. After the procedure, the sheath was removed and hemostasis was gained either by manual compression or by an arterial closure device (4 of 42, 9%). The cervical route allowed access to all intracranial lesions in all 42 procedures. A complication was encountered in six procedures (14%) related to the direct puncture. In 2 of the 42 procedures (4%), a transient vasospasm was encountered. A cervical hematoma formed in 3 of the 42 procedures (7%) after sheath withdrawal (one patient in whom an 8F sheath had been used, required surgical evacuation of a hematoma compressing the upper airways; the other patients did well without surgical evacuation). In the remaining patient (1 of 42 procedures, 2%), a small asymptomatic aneurysm at the puncture site was seen on the follow-up angiogram. Direct cervical arterial approaches to accessing the intracranial circulation is effective in patients in whom the femoral route does not allow the navigation and stabilization of guiding catheters.

Neuropsychiatric manifestations of systemic lupus erythematosus

Central nervous system (CNS) involvement in systemic lupus erythematosus (SLE) can produce a broad range of disease-specific neuropsychiatric manifestations that must be differentiated from infections, metabolic complications, and drug-induced toxicity. Despite the development of classification criteria by the American College of Rheumatology, the prevalence of neuropsychiatric systemic lupus erythematosus (NPSLE) varies widely across studies. Some of the neuropsychiatric manifestations are extremely rare, indicating a need for multicenter studies. Mechanisms that can lead to neuropsychiatric manifestations include intracranial vascular lesions (vasculitis and thrombosis); production of autoantibodies to neuronal antigens, ribosomes, and phospholipids; and inflammation related to local cytokine production. As a rule, no reference standard is available for establishing the diagnosis of NPSLE. Several investigations can be used to assist in the clinical diagnosis and to evaluate severity. Treatment remains largely empirical, given the absence of controlled studies. Variable combinations of corticosteroids, immunosuppressants, and symptomatic drugs are used according to the presumptive main pathogenic mechanism.

Improved distal distribution of n-butyl cyanoacrylate glue by simultaneous injection of dextrose 5% through the guiding catheter: technical note

The use of n-butyl cyanoacrylate (NBCA) as an adhesive agent for embolization of high-flow intracranial and extracranial vascular lesions is well established. To be successful, the embolization of arteriovenous malformations and fistulas must achieve obliteration of the arteriovenous shunts themselves rather than simply occlude the feeders proximal to the lesion. However, the feeders cannot always be negotiated over their entire length. This is often the case with dural arteriovenous fistulas (DAVF), which are usually vascularized by long and intricate meningeal networks. In such situations, NBCA may not be able to reach the lesion itself, rendering the embolization ineffective. We present a new technique that improves distal distribution of NBCA glue. The technique described in this report consists of injecting dextrose 5% through the guiding catheter simultaneously with the superselective injection of NBCA glue into the targeted feeding branch. The technique is illustrated with three cases of posterior fossa DAVF. In the reported cases, flooding the territory of the targeted vessel with non-ionic dextrose 5% allowed deep progression of the glue by delaying contact with ionic substances. Excellent distribution of the NBCA glue reaching the site of the arteriovenous shunts was thus obtained despite suboptimal proximal microcatheter tip positions. Simultaneous perfusion of dextrose 5% through the guiding catheter during NBCA injection dramatically improves the distal progression of glue through small, tortuous arterial feeders. This technique has the potential to increase the therapeutic value of transarterial embolization for DAVFs.

Surgery of Internal Carotid Artery within the Parasellar Space (CS)

Despite incredible success in endovascular treatment of intracranial vascular lesions (parasellar large and giant aneurysms), those likely to present with periorbital pain and neurological symptoms—as well as the associated risk of creating spontaneous high-flow fistulae, even devastating SAH—cannot be effectively and completely eliminated from the cerebral circulation by endovascular techniques without sacrificing the ICA. For such lesions, the extradural approach provides a safe, efficient, practical surgical method in which the lesion might be successfully excluded, and the patency of the ICA preserved. The second category of the ICA lesions necessitates that the surgeon deal with high-flow CC fistulae, completely trans-sected ICA, and/or transpierced ICA in the region. Among these absolute indications for surgical treatment, other vascular lesions in the parasellar space will be discussed on the basis of the author's experience with more than 250 personally executed procedures for vascular lesions in the parasellar space.

Post ISAT pattern of management of 953 patients with intracranial vascular lesions in the West of Scotland

Post ISAT pattern of management of 953 patients with intracranial vascular lesions in the West of Scotland

Familial Hypercholesterolemia Patients Treated With Statins at No Increased Risk for Intracranial Vascular Lesions Despite Increased Cholesterol Burden and Extracranial Atherosclerosis

To correlate known vascular disease risk factors and the signs of extracranial and intracranial changes of vascular origin in young patients with heterozygous familial hypercholesterolemia (FH). 39 DNA test-verified heterozygous FH North Karelian patients (FH-NK), aged 6 to 48, 28 of them treated with statins, and 25 healthy controls underwent brain magnetic resonance imaging (MRI) and carotid ultrasound. Common carotid intima-media thickness was significantly greater in the patients (P=0.005). MR angiography showed no pathological changes, other than 1 incidental aneurysm. The number and size of white matter hyperintensities on T2-weighted MR images, considered as markers of microvascular alterations, did not differ between patients and controls. FH-NK patients treated with statins seem to be at no increased risk for brain infarcts or other brain lesions of vascular origin when younger than age 50.

Head and Neck Magnetic Resonance Angiography Before Coronary Artery Bypass Grafting

To evaluate the incidence of vascular lesions in the head and neck by magnetic resonance angiography (MRA), and investigate the factors correlated with severe stenosis. Elective coronary artery bypass grafting (CABG) was performed in 413 patients at our center between May 1997 and April 2001. We used MRA to detect head and neck vascular lesions, then evaluated the occlusive lesions and determined their prevalence. Neck MRA was performed in 335 patients and head MRA was performed in 335 patients. We found > or = 60% stenosis or total occlusion of the extracranial carotid and vertebral artery in 43 patients (12.8%) and > or = 60% stenosis or occlusion of the intracranial carotid and basilar artery, or stenosis accompanied by poor peripheral perfusion or occlusion of the cerebral arteries in 45 patients (13.4%). Occlusive lesions of the neck were significantly correlated with mean age, peripheral vascular disease (PVD), and old myocardial infarction. Occlusive lesions of the brain were significantly correlated with age, hypertension, PVD, and left main trunk disease. We found an equal incidence of intracranial and extracranial vascular lesions. Thus, searching for intracranial lesions is just as important as searching for extracranial lesions before CABG.

Tumeur vasculaire cérébrale révélée par un flou visuel concomitant à la découverte d’une pupille d’Adie

Arteriovenous malformations of the brain (BAVMs) are a relatively rare group involving intracranial vascular lesions (telangiectasia, cavernous malformation, venous anomaly). We report the case of a patient who presented an atypical visual symptomatology revealing a BAVM.A 48-year-old woman consulted for a recent bilateral visual blur. In darkness, discrete anisocoria appeared on the left eye. At the biomicroscopy light examination, we found areflexic semi-mydriasis (direct and consensual) on the left eye; the light reflex (direct and consensual) on the right eye was normal. During the accommodative reflex test the left pupil contracted. We propose the diagnosis of Adie's pupil, which was confirmed by the pilocarpine test (0.125%). We decided to examine the visual field because the symptomatology of the visual blur remained unexplained. The visual field showed a left homonymous inferior lateral scotoma. MRI showed a right occipital arteriovenous malformation.A quick examination could confuse painless anisocoria with a compression of the IIIrd intrinsic left nerve. This recent scotoma revealed BAVM progression. The natural history of BAVMs shows that the essential risk of these injuries is the onset of an intracranial hemorrhage. To reach a radical therapeutic decision, a cerebral arteriography clarifying the afferent and efferent vascularity of the nidus was carried out.This case is original in that it associates the concomitant discovery of a BAVM and Adie's pupil. Symptomatic BAVMs are extremely serious. Planning their treatment requires multidisciplinary cooperation in order to reduce the risk of mortality.

Transradial approach for neuroendovascular surgery of intracranial vascular lesions

The authors present their experience in performing a transradial approach for neuroendovascular surgery of intracranial vascular lesions when a transfemoral approach was unfavorable. Eight patients ranging in age from 52 to 88 years underwent a total of nine neuroendovascular procedures for intracranial vascular lesions. A transradial approach was used in all patients. The patients had previously undergone a transfemoral approach for the endovascular intervention, but that procedure was unsuccessful. Five patients had intracranial basilar artery (BA) aneurysms, one patient had symptomatic BA stenosis, one patient had a dural arteriovenous fistula in the posterior fossa, and one patient had a high-flow arteriovenous malformation in the frontal lobe. In each case, a transradial approach achieved a stable platform that allowed intracranial microcatheterization for neuroendovascular intervention. None of the patients experienced complications attributed to the transradial artery approach. During neuroendovascular surgery for the treatment of intracranial lesions, the transradial approach is a viable alternative if the transfemoral approach is unfavorable. This series represents the first known description of neuroendovascular surgery for intracranial lesions via a transradial approach.

Angiorressonância magnética do crânio: revisão de 100 casos

Neste trabalho foram analisados, retrospectivamente, os exames de 100 pacientes que se submeteram a angiografia por ressonância magnética (angio-RM) do crânio com diferentes indicações clínicas. Os objetivos deste trabalho foram discutir as vantagens e desvantagens da técnica 3D TOF em exames de angio-RM cerebral e verificar as principais indicações de angio-RM na avaliação das lesões vasculares intracranianas e a freqüência dos principais achados nestes exames. As principais indicações para a realização de angio-RM neste trabalho foram cefaléia (n = 29), acidente vascular encefálico (n = 14) e ataque isquêmico transitório (n = 11). Em 11 casos não havia indicação clínica e os demais tiveram indicações diversas. Cinqüenta e dois por cento dos exames apresentaram alguma alteração. Os principais achados foram estenose vascular (n = 30), aneurisma (n = 10), variações anatômicas (n = 6), malformações vasculares (n = 4) e trombose dos seios durais (n = 2). A técnica 3D TOF, única utilizada neste trabalho, mostrou-se eficiente na maioria dos casos, com um tempo relativamente curto para sua aquisição. Como desvantagem, não se mostra eficaz para cobrir grandes volumes.

Increasing severity of cardiovascular risk factors with increasing middle cerebral artery stenotic involvement in type 2 diabetic Chinese patients with asymptomatic cerebrovascular disease.

To identify determinants associated with increasing severity of middle cerebral artery (MCA) stenosis in asymptomatic Chinese type 2 diabetic patients with and without MCA stenosis determined using transcranial Doppler. Conventional risk factors contribute to the pathogenesis of ischemic stroke, and differences in the pattern of these may explain the heterogeneity of disease presentation in different populations. In Chinese patients, MCA stenosis is the most commonly identified intracranial vascular lesion. Anthropometric and fasting biochemical parameters were compared between type 2 diabetic patients with MCA stenosis in one (n = 185) or both (n = 200) vessels and 1,492 type 2 diabetic patients without evidence of stenosis. Increasing MCA stenotic vascular involvement was associated with significantly increasing age, duration of diabetes, systolic blood pressure, and LDL cholesterol, but with lower glucose levels. There was also an increased prevalence of hypertension, dyslipidemia, and use of blood pressure-and glucose-lowering agents in the patients with MCA stenosis. Concomitant significant increases in the prevalence of peripheral vascular disease and retinopathy were also observed in the patients with MCA stenosis. Transcranial Doppler examination identified stenosis in one or both MCAs in over one-fifth of the Chinese type 2 diabetic subjects without symptoms of cerebrovascular disease. A number of conventional cardiovascular risk factors were closely associated with MCA stenosis. This technique may allow the identification of a particularly high-risk group, and further studies are required to determine whether asymptomatic MCA stenosis is predictive of primary cerebrovascular events and whether intensive treatment of risk factors would reduce the risk.

Middle Cerebral Artery Stenosis in Type II Diabetic Chinese Patients Is Associated with Conventional Risk Factors but Not with Polymorphisms of the Renin-Angiotensin System Genes

Background: Conventional and genetic risk factors have been reported to play a role in the pathogenesis of ischaemic stroke, and differences may explain the heterogeneity of disease presentation in different populations. In Chinese, middle cerebral artery (MCA) stenosis is the most commonly identified intracranial vascular lesion. The involvement of renin-angiotensin system (RAS) gene polymorphisms in this condition has not been determined. Objectives: To determine whether conventional and RAS genetic vascular risk factors are associated with MCA stenosis, asymptomatic Chinese type II diabetic patients with and without MCA stenosis matched for age, gender and diabetes duration were compared. Methods: Biochemical parameters and the genotype and allele frequencies of three RAS gene polymorphisms, the angiotensin-converting enzyme (ACE) insertion/deletion, angiotensinogen (AGT) M235T and angiotensin II type 1 receptor (AT₁R) A1166C polymorphisms were then compared between 217 diabetics with and 490 matched diabetic controls without MCA stenosis selected from 2,202 diabetics. Results: MCA stenosis was associated with significantly increased systolic blood pressure, LDL-cholesterol and albuminuria, yet diastolic blood pressure and glucose levels were lower. There was an increased prevalence of hypertension and use of blood pressure-lowering agents in the MCA stenosis patients. Albuminuria was also more commonly found in these patients. Hypertensive status, systolic blood pressure and albuminuria were strong, independent predictors of the presence of MCA stenosis. No differences in the RAS polymorphism distributions were observed between patients with and without MCA stenosis. Conclusions: In these asymptomatic type II diabetics, blood pressure indices and albuminuria, but not RAS gene polymorphism, were closely associated with MCA stenosis.

Diffusion-weighted MRI in evaluation of transient ischemic attack

Diffusion-weighted magnetic resonance imaging (DWI) is a sensitive diagnostic tool for detecting recent ischemic lesions in patients with transient ischemic attacks (TIAs), but the interpretation of the presence or absence of DWI abnormalities in TIA patients still remains controversial. To elucidate the pathophysiology underlying those lesions, we analyzed DWI abnormalities in patients with recent TIAs. Based on 45 consecutive patients with TIAs who underwent DWI within 10 days of onset, demographic data and clinical manifestations were analyzed in relation to the DWI abnormalities. According to the method utilized in the Oxfordshire Community Stroke Study, clinical manifestations were classified into classical lacunar syndrome and non-lacunar symptoms. Based on the vascular distributions of ischemic lesions, the DWI abnormalities were classified into small-vessel and large-vessel lesions. DWI abnormalities were detected in 14 (31%) of 45 TIA patients. Seven (50%) of 14 DWI-positive patients had occlusive vascular lesions on intracranial magnetic resonance angiography, while only 5 (16%) of 31 DWI-negative patients had occlusive lesions ( P < .05). No other demographic or clinical features, including risk factor and presence of cardiac disease, differed significantly between the DWI-positive and DWI-negative patient groups. Four (46%) of 9 DWI-positive patients who had a classical lacunar syndrome also showed small-vessel lesions on DWI, whereas all 5 patients who had non-lacunar symptoms showed large-vessel lesions. We concluded that although DWI abnormalities were detected in only one third of our TIA patients, DWI abnormalities were closely related to intracranial vascular occlusive lesions. The combination of DWI and MRA was useful for detecting large-artery lesions in patients displaying a classical lacunar syndrome.

Colocación de endoprótesis vascular sin dilatación previa en estenosis intracraneal de la carótida interna. A propósito de un caso

Recent reports have described the application of coronary stents for the treatment of intracranial stenosis of the internal carotid artery (ICA), above all in patients who do not respond to medical treatment and display advancing neurological symptoms. Stenting in intracranial vascular lesions of the carotid territory has been used almost exclusively in the treatment of the complications due to transluminal angioplasties with balloons. In selected cases and without prior dilatation of the stenosis it would be possible to place a stent.We describe a case of intracranial carotid stenting, without previous dilatation, in a 57 year old male patient with multiple arteriosclerotic risk factors. The patient presented neurological symptoms with no response to medical treatment, caused by a stenosis that affected over 70% of the cavernous segment of the right ICA, which was shown up by the arteriographic study. A favourable anatomy and the material used allowed the stent to pass through the stenosis without the need for dilatation. No immediate complications were observed and the carotid artery was seen to be of a normal calibre for stenosis. The brain angiogram also proved to be normal. The patient continues with the medical treatment and has remained neurologically stable throughout the 9 month clinical follow up.In certain selected cases, placing an intracranial carotid stent, without previous balloon dilatation, can give good results and prevent the complications that can accompany angioplasty (such as dissection, rupture or embolism)

Alternative management considerations for ethmoidal dural arteriovenous fistulas

BACKGROUND Ethmoidal dural arteriovenous fistulas (EDAFs) are an unusual type of intracranial vascular lesion that commonly present with acute hemorrhage. They are often best treated surgically; however, recent endovascular advances raise questions concerning the best therapeutic approach. METHODS We present 7 cases of EDAFs managed at this institution over a 6-year period, which demonstrate the broad spectrum of clinical behavior associated with the lesions. Four patients presented with intracranial hemorrhage, 1 patient with rapidly progressive dementia, 1 patient with a proptotic, red eye, and 1 with a retro-orbital headache. RESULTS One patient underwent no treatment, 1 underwent embolization alone, 2 underwent embolization and resection, and 3 patients underwent resection alone. There was complete obliteration of the EDAF in all of the patients who underwent surgical resection. Embolization was performed through the external carotid circulation and not the ophthalmic artery. There were no treatment-related neurologic deficits. CONCLUSIONS Treatment is best managed with a multidisciplinary approach, which emphasizes complete resection of the lesions with assistance from interventional neuroradiology techniques. However, each patient must be evaluated independently as treatment may vary depending on the angioarchitecture of the lesion.