Background and PurposeEmbolization is the first-line treatment for dural arteriovenous fistulas (dAVF). The precipitating hydrophobic injectable liquid (PHIL) embolic agent is a non-adhesive copolymer with specific features and endovascular behavior. This study assessed its safety and efficacy in a prospective real-life cohort.MethodsThe PHIL-dAVF study was a prospective single-arm open-label observational multicenter study conducted between October 2017 and November 2019 in 14 European centers. Patients with a single intracranial dAVF intended for PHIL embolization were included. Previously partially treated or multiple dAVFs were excluded. Additional devices and embolic agents were permitted as complementary techniques or second-line strategies. Primary endpoints were functional outcome changes from baseline and complete cure rate at 3–6 months after the last embolization. Safety was assessed by adverse events (AE) incidence.ResultsA total of 67 patients (77 endovascular procedures; 70.1% men, mean age 61±14 years) were included. Most DAVFs were unruptured (71.6%), located in the transverse/sigmoid sinus (53.7%) and Cognard grade III or IV (56.7%). Sixty patients (89.6%) received one single embolization. Additional devices were used in 31.2% of procedures. Complete angiographic cure rate was 86.9% at the 3–6 month DSA follow-up after the last endovascular treatment. At least one AE was recorded in 37.3% of patients during follow-up, of which 52.9% were related to the procedure. The procedural rates of AE and serious AE were 32.5% and 15.6%, respectively. Five AEs were related to PHIL. Transient functional deterioration occurred in three patients (4.5%), all resolved by the last follow-up.ConclusionThe PHIL-dAVF study provides evidence about the efficacy and safety of PHIL in the treatment of intracranial dAVFs, with outcomes comparable to existing liquid embolic agents reported in the literature.

Background and purpose A well-known classification of dural arteriovenous fistulas (DAVFs) according to the patterns of venous drainage was described in 1977 by Djindjian, Merland et al. and later revised by Cognard, Merland et al. in 1995. They described 5 types of DAVFs assuming that the type of venous drainage is directly correlated with neurologic symptoms and in particular with hemorrhagic risk. We present a series of cases that combines type IV (DAVF with cortical venous drainage associated with venous ectasia) and type V (DAVF with spinal venous drainage), which we named type IV + V. Materials and methods A retrospective study between 2012 and 2020 in 2 Hospitals was performed on patients that met inclusion criteria for a diagnosis of this type of DAVF. Demographics, location, clinical presentation and outcomes of endovascular embolization were studied. Results Five (2,3%) patients out of 220 had a type IV + V DAVF. All cases had an aggressive presentation, either subarachnoid hemorrhage, myelopathy or both. All patients were treated with endovascular transarterial embolization achieving complete angiographic occlusion in one session and total remission of symptoms at 3 months. Conclusions This rare type of DAVF, combines two aggressive venous drainage patterns. For that reason, patients with type IV+V DAVF probably have a more aggressive natural history and worst outcome due to risk of intracranial and/or spinal hemorrhage and myelopathy, thus requiring urgent diagnostic and treatment. Larger studies are needed to better understand this type of DAVF.

PURPOSE:Arteriovenous fistulas of the Vein of Galen region in adults (Ad-VGAVF) are an uncommon entity with specific anatomic features. The aim of this article is to present our experience in the endovascular treatment of this pathology and to propose a therapeutic strategy based precisely on the angioarchitecture of these lesions. MATERIALS AND METHODS:During a 20-year period, 10 patients underwent endovascular treatment of Ad-VGAVF. They were nine men and one woman with a mean age of 50 years (23-66 years) treated with the same embolization strategy. Clinical presentation, angiographic characteristics, therapeutic strategy, and clinical outcomes were recorded. RESULTS:All patients were treated exclusively by endovascular approach. Transarterial access was performed in eight patients and combined transvenous and transarterial access in two. Complete obliteration of the fistula was obtained in all patients. There were no intraprocedural complications. Post-embolization neurological symptoms occurred in 5 of 10 with complete resolution at six months in all of them. CONCLUSION:Arteriovenous fistulas of the Vein of Galen region in adults present uniform angioarchitecture despite their low prevalence. Based on this constant angioarchitecture and especially on the features of its venous drainage, judicious embolization strategy is feasible and effective. Ten cases treated entirely by endovascular approach with excellent clinical and angiographic outcomes show this treatment like a curative alternative for this entity of deep topography and severe prognosis.

Os autores apresentam dois casos com aneurismas da bifurcação da artéria basilar que apresentaram hemorragia subaracnóidea e vasoespasmo associados. Os pacientes foram tratados por via endovascular, com exclusão seletiva do aneurisma e angioplastia curativa do vasoespasmo. No primeiro caso, a embolização do aneurisma e a angioplastia são realizadas num mesmo aio operatório, em razão de o paciente apresentar-se, no momento do tratamento, já com vasoespasmo manifesto. No segundo caso, o tratamento do aneurisma e a angioplastia são realizados em atos operatórios distintos, em razão de o vasoespasmo manifestar-se tardiamente ao tratamento do aneurisma e após a falta de resposta clínica ao tratamento medicamentoso convencional. Os dois pacientes apresentaram melhora clínica e radiológica após a angioplastia. No primeiro caso, em que a embolização do aneurisma foi realizada com balão de látex, este desinflou-se, promovendo sua revascularização, tornando necessária urna reintervenção, que foi realizada um ano após, utilizando-se então espiras metálicas. Os dois pacientes apresentam seguimento de 18 e 12 meses, respectivamente.

The angiographic analysis of a dural arteriovenous fistula (AVF) is a determinant step in the evaluation of the lesion with regard to its prognosis and treatment. The clinical presentation of the dural AVFs is very dependent on the venous drainage, and the classification of these lesions draws attention to the venous drainage pattern, combining the clinical course and the venous drainage angiographic features. Dural AVFs with retrograde venous drainage into the leptomeningeal veins are associated with an increased incidence of intracranial hemorrhage, neurological deficits, and increased intracranial pressure allowing impairment of cognitive functions and dementia. Other risky findings are venous dilatations and dural sinus stenosis/occlusion. Different therapeutic approaches are available including noninvasive, endovascular, and surgical techniques. However, the treatment of dural AVFs should be considered in relation to the different types of lesions carrying different clinical presentation and prognosis. Prompt treatment allowing complete and permanent cure is mandatory in dural AVFs with an aggressive clinical course and/or with radiological findings predicting a severe prognosis.

BACKGROUND:Stereotactic radiosurgery (RS) is an effective tool in treating brain arteriovenous malformations (AVMs). Careful study of AVM angiographic characteristics may improve results. OBJECTIVE:To report the long-term outcomes of Gamma Knife RS (GKRS) in brain AVMs, focusing on how the angioarchitectural and hemodynamic parameters of AVMs affect the post-RS results. METHODS:This was a retrospective, longitudinal study of 697 consecutive GKRS treatments of brain AVMs in 662 patients performed at a single center between 1993 and 2005. The mean age of the patients was 37 years; the median AVM volume was 3.6 cm(3); and the mean follow-up was 11 years. Forty-five percent of patients presented with intracranial hemorrhage; 44% underwent embolization; and 7% had multiple RSs. AVM characteristics in the RS-planning angiograms were analyzed, and their relationship to the post-RS obliteration rate was determined by univariate and multivariate analyses. RESULTS:The obliteration rate after a single RS was 69.3%; after multiple RS, it was 75%. Positive predictors of obliteration included compact nidus (odds ratio = 3.16; 95% confidence interval, 1.92-5.22), undilated feeders (odds ratio = 0.36; 95% confidence interval, 0.23-0.57), smaller AVM volume (odds ratio = 0.95; 95% confidence interval, 0.92-0.99), and higher marginal dose (odds ratio = 1.16; 95% confidence interval, 1.06-1.27). Improvement or clinical stability was observed in 89.3% of patients; postprocedural bleeding was noted in 6.1%; and clinical worsening attributable to RS was seen in 3.8%. The annual risk of hemorrhage in the 4 years after RS was 1.2%. CONCLUSION:GKRS yielded a good long-term clinical outcome in most patients. Certain angiographic features of brain AVMs such as a well-defined nidus and undilated feeder arteries contribute to AVM occlusion by RS. GKRS can be regarded as the treatment of choice for AVMs <6 cm(3), even after bleeding.

New therapies are needed to improve current results in diffuse intrinsic pontine glioma. We present here the initial experience of administering Celyvir, autologous mesenchymal stem cells infected with ICOVIR-5, an oncolytic adenovirus that selectively replicates in cancer cells, by means of superselective intra-arterial delivery, in a patient diagnosed of diffuse intrinsic pontine glioma. Feasibility, safety, and morbidity rates of the superselective catheterization technique are comparable with those of diagnostic angiography. The intra-arterial approach warrants a greater contact of the mesenchymal stem cells with the tumor mass, and minimizes hemorrhages or vascular disruption. The tolerance to the 2 administrations was excellent, with no acute or delayed adverse effect, underscoring the feasibility of this technique for the delivery of virotherapies and/or cellular therapies in this location.

Ipsilateral chronic carotid occlusion (CCO) can be found in up to 15% of patients with transient ischemic attacks (TIAs) and strokes. 1,2 Cervical occlusion is a morbid diagnosis with a high risk (6%-20%) of recurrent strokes and ipsilateral strokes (2%-9.5%). 3-5 The subgroup of patients with severe hemodynamic compromise with CCO is at a higher risk for such events. 6 The effectiveness of percutaneous transluminal angioplasty and stenting of the extracranial carotid artery is improving as a result of the development of autoexpandable prostheses and new systems of cerebral protection. 7 Currently, this technique constitutes a true alternative to carotid endarterectomy in the treatment of a severe degree of carotid stenosis with a minimum risk of cerebral embolization. 8-10 We attempted endovascular recanalization in select patients with CCO and retrograde ophthalmic artery flow. 11 We present an early report on the safety and efficacy of endovascular recanalization in symptomatic CCO. In this study, we evaluate the safety and efficacy of endovascular recanalization in CCO with severe hemodynamic compromise. METHODS We performed a retrospective review of patients with symptomatic CCO. We identified 39 patients with CCO who were admitted to our institution after suffering an ischemic event, stroke, or TIA. Neurological evaluation included preprocedural and postprocedural clinical examination and neuropsychological tests. 12 In addition to routine neurological examinations, we focused on cognitive function. We used the Rankin Scale to measures disability scores, the National Institutes of Health Stroke Scale to detect focal disorder, and the Barthel Scale to evaluate functional incapacity. Minor stroke was defined as an increase in the National Institutes of Health Stroke Scale score of ,3 with complete resolution or no significant disability at 30 days. Major stroke was defined as an increase in the National Institutes of Health Stroke Scale score of $ 3 with significant disability at 30 days. Neuropsychological tests included global cognitive function (Mini-Mental State Examination of Folstein,

BACKGROUND:Giant perimedullary arteriovenous fistulas (GPMAVFs) located in the cervical region are a rare pathology with distinctive characteristics. OBJECTIVE:To evaluate clinical presentation and different endovascular treatment options of cervical GPMAVFs and review previously published data in the literature regarding cervical GPMAVFs. METHODS:Six patients with cervical GPMAVFs were found in the spinal vascular malformations database of our group collected between 1990 and 2009. Endovascular techniques and treatment outcomes were evaluated and compared with other published series. RESULTS:Clinical presentations were progressive motor deficit (5 patients), hematomyelia (1 patient), meningeal syndrome (1 patient), and respiratory arrest and gait apraxia (1 patient). Three patients were treated by the transarterial approach. One patient was treated by the transvenous approach due to previous embolizations resulting in a proximal occlusion and preventing a safe transarterial approach. A transvenous approach was used in another patient due to complex arterial anatomy. In 1 patient, direct percutaneous puncture of the venous pouch was necessary because of previous proximal occlusion of the arteries. All embolizations resulted in complete occlusions with clinical improvement, and there was no recanalization during a mean follow-up of 21 months. CONCLUSION:Transarterial embolization of cervical GPMAVFs is safe and effective when it is done in highly experienced centers. Cervical GPMAVFs that cannot be accessed by the transarterial technique due to their complex angioarchitecture can be treated by transvenous embolization or direct puncture of the venous pouch.

Carotid artery stenting is usually performed by a femoral approach. When the patient's anatomy forbids this or other distal access to the carotids, a direct access by percutaneous puncture may be used. We present two cases in which a successful stenting of the carotids with the use of a cerebral protection device was performed.

Pial arteriovenous fistulas (pAVF) of the posterior fossa are rare and may present with symptoms secondary to mass effect, venous hypertension or hemorrhage, among others. A case is presented of a previously healthy 2-year-old boy with neurological deficit arising from pAVF of the posteroinferior cerebellar artery. The pAVF was successfully treated with endovascular occlusion.

Neurotoxicity from contrast media used in angiography is a rare complication from these procedures. The infrequency with which it is encountered makes it a diagnostic challenge. We present the case of a 51-year-old male who, 30 min after successful angiography for treatment of a right carotid-ophthalmic fusiform aneurysm with a stent, developed psychomotor agitation, disorientation, and progressive left faciobrachial hemiparesis (4/5). An emergency nonenhanced CT showed marked cortical enhancement and edema in the right cerebral hemisphere. Cortical enhancement is thought to be secondary to contrast extravasation due to disruption of the blood-brain barrier. Angiography was performed immediately, without any pathologic findings. After this procedure there was an increase in the left faciobrachial hemiparesis (3/5), right gaze deviation, Gerstmann syndrome, and left anosognosia and left homonymous hemianopsia. Endovenous dexamethasone and mannitol were initiated. Twenty-four hours later an MRI showed no signs of acute infarct, just gyriform signal increase in the right cerebral hemisphere on FLAIR and a decrease in the edema observed before. The patient had progressive improvement of his neurological deficit. A control MRI done 5 days later was normal. The patient recovered completely and was discharged. This rare entity should be kept in mind but diagnosed only when all other causes have been ruled out, because more important and frequent causes, such as acute infarct, must be excluded promptly.

Basilar artery (BA) thrombosis is a severe condition that has a high percentage of mortality if no treatment is performed. Recanalization is the most successful way of reducing mortality and improving outcome in patients with BA thrombosis. We present a case of a patient that presented to our hospital 12 h after onset of symptoms in which a combination of techniques were used to perform a vertebrobasilar recanalization.

Study Design: Prospective clinical trial.Objective: Demonstrate the safety and efficacy of gelified ethanol in the percutaneous treatment of lumbar disk hernias.Summary of Background Data: After the commercial withdrawal of Chymopapain, the need for new substances to treat intervertebral disk hernias was evident. Good results were obtained with pure ethanol, but this substance was difficult to handle. We decided to use a similar substance mixed with ethylcellulose to increase its viscosity and enhanced with radiopaque material.Methods: Two hundred seventy-six consecutive patients sent to be treated of a lumbar intervertebral disk hernia percutaneously were included in this preliminary study and treated with radiopaque gelified ethanol (RGE) and intra-articular steroids. Three groups were set, group A for patients to be treated only with RGE and groups B and C for difficult cases presenting a narrow canal, foraminal hernia, or hiperalgic sleepless hernia, treated with RGE plus another intradiscal technique, automatized percutaneous diskectomy for group B and radio-frequency nucleoplasty for group C.Results: Very good or good results were obtained in 202 (91.4%) of the 221 patients in group A. Of the 44 patients in group B, 37 patients (84%) presented very good or good results and in 9 (82%) of the I I patients of group C, we obtained similar results. There was no allergic complication in any of our patients. Shortterm follow-up with magnetic resonance showed little or no changes in the intervertebral disk but there was discordance with clinical signs. Long-term follow-up magnetic resonance showed a dramatic reduction in hernia volume.Conclusions: This preliminary study shows the efficacy and inocuity of this new substance that could take over the Chymopapain therapeutic field.

The use of cerebral protection during carotid stenting is being less and less contested. The protection systems currently available present a certain number of inconveniences. The new system that the authors propose is an evolution of the cerebral protection concept by temporary occlusion of the distal internal carotid.1-3 Experience with several hundred endovascular treatments of the carotid bifurcation process concluded several strong points that have been used to simplify the technique:

But : En angioscanographie, plusieurs techniques de reconstruction 3D, soit en mode dit de transparence (Maximal Intensity Projection : MIP), ou surfacique (Surface Shaded Display: SSD) permettent une bonne analyse des polygones de Willis dans la recherche d'anevrismes intracrâniens. Une autre technique de reconstruction 3D, le rendu volumique ou volume rendering technique (VRT). recemment commercialise sur les consoles de traitement d'images, semble apporter des renseignements complementaires dans l'analyse des anevrismes Materiels et methodes : Nous rapportons 4 cas d'anevrismes explores par angioscanner et reconstruits en MIP et VRT. Resultats : Cette technique, en exploitant la totalite des donnees images, renseigne mieux que le MIP sur la constitution des structures et leurs situations respectives dans l'espace. Conclusion : Le VRT permet egalement d'obtenir rapidement et de facon reproductible des images de reconstruction 3D de bonne gualite avec l'avantage, par rapport au mode surfacique SSD, de s'affranchir du seuillage.

The selective occlusion of saccular intracranial aneurysms may be achieved by two techniques: microsurgical clipping and endovascular coiling. Each of them have particular indications which need to be defined. From September 1992 to June 1996, 395 consecutive patients with small or large aneurysms were treated either by surgery (n = 102) or by endovascular coiling (n = 293). Coiling was chosen each time the shape of the aneurysm seemed to be appropriate for this treatment: narrow neck and ratio neck diameter by sac diameter less than one third. Satisfying results with complete or subtotal obliteration and no recanalization on the following controls at 1, 6, 12, and 36 months were obtained in 92% before retreatment and in 98.8% after retreatment. Unsatisfying results were observed after surgery in seven cases and in 25 cases after embolization. After retreatment, it remains three post-surgical and two post-endovascular cases. Good and excellent clinical outcome was noted in 90% for small aneurysms and in 86.5% for large ones. Mortality is of 4.8% in the overall series. In a series in which were applied both types of treatment, surgery in 25% and endovascular techniques in 75%, good results in terms of efficiency and clinical results were achieved. These results are as good as the best series in which surgery was the only choice. Therefore with appropriate selection, endovascular treatment is a good alternative for treatment of the majority of saccular aneurysms.