Tumor Embolization through Meningohypophyseal and Inferolateral Trunks is Safe and Effective

BACKGROUND AND PURPOSE

Skull base tumors are commonly supplied by dural branches of the meningohypophyseal and inferolateral trunks. Embolization through these arteries is often avoided due to technical challenges and inherent risks; however, successful embolization can be a valuable surgical adjunct. We aimed to review the success and complications in our series of tumor embolizations through the meningohypophyseal and inferolateral trunks.

MATERIALS AND METHODS

We performed a retrospective review of patients with tumor treated with preoperative embolization at our institution between 2010 and 2020. We reviewed the following data: patients' demographics, tumor characteristics, endovascular embolization variables, and surgical results including estimated blood loss, the need for transfusion, and operative time.

RESULTS

Among 155 tumor embolization cases, we identified 14 patients in whom tumor embolization was performed using the meningohypophyseal (n = 13) or inferolateral (n = 4) trunk. In this group of patients, on average, 79% of tumors were embolized. No mortality or morbidity from the embolization procedure was observed in this subgroup of patients. The average estimated blood loss in the operation was 395 mL (range, 200-750 mL). None of the patients required a transfusion, and the average operative time was 7.3 hours.

CONCLUSIONS

Some skull base tumors necessitate embolization through ICA branches such as the meningohypophyseal and inferolateral trunks. Our series demonstrates that an effective and safe embolization may be performed through these routes.

Arterial and Venous 3D Fusion AV-3D-DSA: A Novel Approach to Cerebrovascular Neuroimaging

DSA is the standard imaging technique for evaluation of cerebrovascular conditions. However, One drawback is its limitation in depicting a single angiographic phase at a time. We describe a new 3D-DSA algorithm, which we call arterial and venous-3D-DSA, which allows the concurrent yet distinct display of the arterial and venous structures, which may be useful for different clinical and educational purposes.

Cerebral Venous Thrombosis Associated with COVID-19

Despite the severity of coronavirus disease 2019 (COVID-19) being more frequently related to acute respiratory distress syndrome and acute cardiac and renal injuries, thromboembolic events have been increasingly reported. We report a unique series of young patients with COVID-19 presenting with cerebral venous system thrombosis. Three patients younger than 41 years of age with confirmed Severe Acute Respiratory Syndrome coronavirus 2 (SARS-Cov-2) infection had neurologic findings related to cerebral venous thrombosis. They were admitted during the short period of 10 days between March and April 2020 and were managed in an academic institution in a large city. One patient had thrombosis in both the superficial and deep systems; another had involvement of the straight sinus, vein of Galen, and internal cerebral veins; and a third patient had thrombosis of the deep medullary veins. Two patients presented with hemorrhagic venous infarcts. The median time from COVID-19 symptoms to a thrombotic event was 7 days (range, 2-7 days). One patient was diagnosed with new-onset diabetic ketoacidosis, and another one used oral contraceptive pills. Two patients were managed with both hydroxychloroquine and azithromycin; one was treated with lopinavir-ritonavir. All patients had a fatal outcome. Severe and potentially fatal deep cerebral thrombosis may complicate the initial clinical presentation of COVID-19. We urge awareness of this atypical manifestation.

Dural Venous Channels: Hidden in Plain Sight-Reassessment of an Under-Recognized Entity

BACKGROUND AND PURPOSE

Tentorial sinus venous channels within the tentorium cerebelli connecting various cerebellar and supratentorial veins, as well as the basal vein, to adjacent venous sinuses are a well-recognized entity. Also well-known are "dural lakes" at the vertex. However, the presence of similar channels in the supratentorial dura, serving as recipients of the Labbe, superficial temporal, and lateral and medial parieto-occipital veins, among others, appears to be underappreciated. Also under-recognized is the possible role of these channels in the angioarchitecture of certain high-grade dural fistulas.

MATERIALS AND METHODS

A retrospective review of 100 consecutive angiographic studies was performed following identification of index cases to gather data on the angiographic and cross-sectional appearance, location, length, and other features. A review of 100 consecutive dural fistulas was also performed to identify those not directly involving a venous sinus.

RESULTS

Supratentorial dural venous channels were found in 26% of angiograms. They have the same appearance as those in the tentorium cerebelli, a flattened, ovalized morphology owing to their course between 2 layers of the dura, in contradistinction to a rounded cross-section of cortical and bridging veins. They are best appreciated on angiography and volumetric postcontrast T1-weighted images. Ten dural fistulas not directly involving a venous sinus were identified, 6 tentorium cerebelli and 4 supratentorial.

CONCLUSIONS

Supratentorial dural venous channels are an under-recognized entity. They may play a role in the angioarchitecture of dural arteriovenous fistulas that appear to drain directly into a cortical vein. We propose "dural venous channel" as a unifying name for these structures.

Modifying flow in the ICA bifurcation: Pipeline deployment from the supraclinoid ICA extending into the M1 segment-clinical and anatomic results

BACKGROUND AND PURPOSE

Utility of the Pipeline Embolization Device extending to the M1 and its clinical and flow consequences at the ICA bifurcation have not been characterized. We analyzed flow modification in cases where a single Pipeline Embolization Device was deployed from the M1 to the distal supraclinoid ICA, covering the A1, for aneurysm treatment.

MATERIALS AND METHODS

A1 flow modifications and size regression in postprocedure and follow-up angiography were analyzed. Vessel diameters and ratios of the proximal A1 and M1 segments and the distal ICA were assessed. Relationships between Pipeline Embolization Device nominal diameter and the vessel diameters at landing zones were obtained. Clinical assessments after flow modification were documented.

RESULTS

Six of 7 patients demonstrated no change of flow in the anterior cerebral artery/anterior communicating artery complex at immediate postembolization angiography. All patients who underwent follow-up angiography demonstrated size regression of the ipsilateral A1. Midterm follow-up angiography revealed complete reversal of flow in the ipsilateral A1 in 4 of 5 patients. One patient did not demonstrate flow modification. This patient had a dominant ipsilateral A1. Vessel ratios in this case demonstrated a unique configuration in favor of maintaining patency of the ipsilateral A1. There were no clinical or radiographic signs of ischemia. One patient experienced asymptomatic angiographic in-stent stenosis at the M1.

CONCLUSIONS

We found that deployment of a Pipeline Embolization Device from the distal supraclinoid ICA to the M1 may result in reversal of flow in the anterior cerebral artery/anterior communicating artery complex and regression of the ipsilateral A1. Preoperative anatomic quantitation and sizing of the Pipeline Embolization Device may predict flow modification results.

Transarterial treatment with Onyx of intracranial dural arteriovenous fistula with cortical drainage in 17 patients

BACKGROUND AND PURPOSE

Intracranial DAVFs with cortical venous drainage have a high tendency to bleed. Complete closure of these lesions is essential to prevent clinically deleterious events. We describe our experience using Onyx in an arterial approach for treatment of DAVFs in 17 patients.

MATERIALS AND METHODS

Between 2006 and 2010, we used Onyx for performing transarterial embolization in 17 patients with intracranial DAVFs and cortical venous drainage. Clinical assessment was performed before and after every treatment at discharge and at follow-up. Fourteen patients underwent follow-up MR imaging and MRA, 8 of them also underwent follow-up diagnostic angiography.

RESULTS

Fifteen patients (88%) underwent 1 procedure. Complete obliteration by embolization with Onyx was achieved in 16 patients (94% acute obliteration). The mean amount of Onyx injected was 2.3 mL (range, 0.4-4.8 mL). The sole technical complication was an embolus to a branch of the MCA, which was resolved by intra-arterial tPA injection. A clinical complication of transient trochlear nerve palsy in the same patient due to mass effect of Onyx resolved spontaneously within 3 months.

CONCLUSIONS

Intra-arterial embolization of cranial DAVFs with cortical venous drainage by using Onyx results in a high rate of complete obliteration (94%) with low morbidity (6%). Follow-up DSA in 8 patients revealed no evidence of reopening.