Distribution of intraarterially administered papaverine in endovascular treatment of delayed cerebral vasospasm

The distribution of selectively administered papaverine was determined in nine patients with delayed cerebral vasospasm in the territories of the anterior (ACA) and/or middle cerebral arteries (MCA) secondary to aneurysmal subarachnoid hemorrhage by simultaneous infusion with technetium-99m-hexamethyl-propyleneamine oxime (99mTc-HMPAO). Four of the nine patients had a ruptured anterior communicating artery aneurysm, four had an internal carotid artery aneurysm, and the remaining one had a MCA aneurysm. Trapping of anterior communicating artery was carried out in one case and clipping of aneurysms in other eight cases. Neurological deterioration with hemiparesis, paraparesis, and/or somnolence appeared between postsurgical Days 8 and 13 due to delayed cerebral vasospasm in all patients. Intraarterial infusion of 40 mg of papaverine containing 37 MBq of 99mTc-HMPAO was performed from the C1 segment in seven of the nine patients and from the C4 segment in the other two patients. 99mTc-HMPAO was distributed in the territories of the ACA and MCA in the two patients who were treated with intraarterial infusion of papaverine from the C4 segment, but was distributed only to the territory of the ACA in four patients who were treated with intraarterial infusion of papaverine from the C1 segment at 1 ml/min. In contrast, 99mTc-HMPAO was distributed in the territories of the ACA and MCA in the three patients who were treated with papaverine from the C1 segment at 2 ml/min, although most 99mTc-HMPAO was distributed in the territory of the ACA. Vasospasm of the ACA can be treated by intraarterial infusion of papaverine from the C1 segment at 1 ml/min when selective catheterization to the ACA is difficult to perform.

Assessment of delayed cerebral vasospasm using intracisternal echography--technical note

BACKGROUND

A new technique using intravascular ultrasound has been used for diagnosis of coronary artery in order to obtain intravascular echo images. In this study, an intracisternally positioned ultrasound catheter was introduced obtaining serial echo images of the first segment (MI) of the middle cerebral artery in order to detect cerebral vasospasm following subarachnoid hemorrhage (SAH).

METHODS

Thirteen patients were admitted to Osaka Neurological Institute with SAH due to ruptured intracranial aneurysm. All patients underwent surgical neck clipping on the day of admission. In each patient, an 8 Fr. ultrasound imaging catheter (Cardiovascular Imaging Systems, Inc. (CVIS), Sunnyvale, CA) was detained intracisternally adjacent to the M1 segment following neck clipping of the aneurysm and placement of cisternal drainage(s) in the prepontine and/or distal portion of the Sylvian fissure. In order to detain the mirro device near the M1 segment, the tip of a 2.0 cm cisternal drainage tube (SILASCON, E-3L-12, Kaneka Medix Co, Osaka, Japan) was attached to the tip of the intravascular ultrasound catheter with 3-0 silk suture. The tip was placed in the prechiasmal cistern.

RESULTS

Angiographic evidence of delayed vasospasm was obtained for three (23.1%) of the 13 patients. In one (33.3%) of the three patients who had angiographic evidence of vasospasm (25% stenosis), decrease in the inner diameter of the M1 segment was detected on the echo images, but in the other two (66.7%), no such decrease was noted on echo images. Angiographically identified vasospasm in the latter patients was associated with only 10% stenosis.

CONCLUSIONS

Intracisternally positioned ultrasound catheter can be used for intermittent measurement of the diameter of a target artery for detection of cerebral vasospasm after SAH.

Percutaneous transluminal angioplasty for severe stenosis of the posterior cerebral artery: case report

The Stealth dilation catheter was used for the intravascular treatment of a patient who had hemodynamically significant stenosis of the posterior cerebral artery and had a history of recurrent transient ischemic attacks associated with right hemiparesis and ipsilateral hemianopia dating from March 1993. Cerebral perfusion studies prior to and after the intravenous administration of acetazolamide demonstrated regions of moderately low perfusion and low hemodynamic reserve in the territories of the left middle and posterior cerebral arteries. Cerebral angiograms demonstrated severe stenosis of the left posterior cerebral artery and occlusions of both middle cerebral arteries, which had leptomeningeal anastomoses with the posterior cerebral arteries. Percutaneous transluminal angioplasty (PTA) was performed using the Stealth catheter on the stenotic segment of the left posterior cerebral artery after left superficial temporal artery-middle cerebral artery anastomosis. The patient manifested marked improvement in her neurologic condition just after PTA, in association with marked increase in cerebral perfusion and hemodynamic reserve in the territories of the left middle and posterior cerebral arteries. We have presented evidence that PTA can be used to treat patients with stenosis of the first segment of the posterior cerebral artery and hemodynamic compromise in the territory that artery supplies.

Traumatic arteriovenous fistula treated by superselective embolisation with microcoils: case report

A 27-year-old man with a traumatic direct dural arteriovenous fistula (DAVF) was treated using embolisation microcoils. He had suffered blunt trauma to the head while drunk and was aware of no neurological deficit. A few days after the accident, however, he noticed a bruit in the right temple. Angiography demonstrated a direct DAVF fed by the right middle meningeal artery and draining into a right temporal dural vein and the ipsilateral cavernous sinus. A Tracker-18 catheter was passed without difficulty through the fistula and the draining vein was then embolised from distal to proximal with microcoils, and finally the fistula was occluded with microcoils, resulting in total obliteration of the fistula. Immediately after the embolisation, the patient could no longer hear the bruit. Thus, when a microcatheter can be introduced into the draining vein, microcoils can be used as emboli in the treatment of direct DAVF.

Total excision of a thalamic arteriovenous malformation using an orbito-fronto-malar approach: case report

A 37-year-old woman was admitted to Osaka Neurological Institute after the sudden onset of left hemiplegia, hemihypesthesia, and ipsilateral hemianopia on February 4, 1992. Computed tomography (CT) disclosed the presence of hemorrhage in the right thalamus extending to the ipsilateral internal capsule. Cerebral angiography after CT scanning disclosed the presence of a cerebral arteriovenous malformation (AVM) fed by copsulothalamic and lateral geniculate body arteries originating from the right anterior choroidal artery. She was operated on with removal of the AVM using a right orbito-fronto-malar approach (OFM approach), which did not require transection of the cerebral parenchyma. The anterior choroidal artery could be followed distally from its origin and small feeding branches originating from the parent artery were easily identified, and the cerebral base could be examined in greater detail than with the conventional frontotemporal approach. The nidus could be excised in its entirety without difficulty. Postoperative angiography confirmed total excision of the AVM. She was transferred to another hospital for rehabilitation on April 13, 1992. Motor strength on the left side had improved to 3/5 by that time. The OFM approach appears to be potentially useful for the resection of inferolateral thalamic AVMs, because it does not require corticotomy and feeding branches can be identified and dealt with prior to other surgical manipulations.

Dural arteriovenous fistula caused by sinus thrombosis--case report

A 58-year-old male with a history of idiopathic sinus thrombosis presented with gradual onset of gait disturbance, dementia, and involuntary movement in the upper extremities. Cerebral angiography demonstrated a dural arteriovenous fistula fed by a falx cerebelli branch originating from the left vertebral artery and draining into the inferior vermian vein, the straight sinus, a cortical vein lying on the inferolateral surface of the left cerebellar hemisphere, the ipsilateral superior petrosal sinus, the sigmoid sinus, and the internal jugular vein. Endovascular embolization under fluoroscopic control resulted in complete disappearance of the involuntary movement. Sinus thrombosis may result in development of dural arteriovenous fistula which can cause life-threatening complications, so aggressive therapy should be considered.

Successful intra-arterial fibrinolysis of the anterior choroidal artery in the acute stage of internal carotid artery occlusion: case report

A 27-year-old man was admitted to our institution with the sudden development of right hemiparesis and dysarthria beginning an hour after the onset of symptoms on August 9, 1992. The patient was found on admission to have right hemiparesis (2/5), hemihypesthesia, hemianopia, dysarthria; he had transient atrial fibrillation. No abnormalities were detected on computed tomography (CT) scans, and cerebral blood flow studies undertaken following conventional CT scans revealed no low flow regions in the left cerebral hemisphere. But cerebral angiography disclosed an occlusion of the left internal carotid artery with well-developed cross-circulation via the anterior communicating artery and embolus lodged at the level of the anterior choroidal artery. Superselective fibrinolysis using Tracker-18 and 420,000 units of urokinase resulting in complete recanalization of the left anterior choroidal artery without distal migration of the embolus. Immediately after the procedure, his neurologic disturbance underwent complete resolution. In summary, fibrinolysis could be performed but limited to anterior choroidal artery in a case with an occlusion of the internal carotid artery with well-developed cross-flow via the anterior communicating artery; the patient's neurologic condition may deteriorate suddenly if fibrinolysis is incomplete and the embolus migrates to the internal carotid artery.

Percutaneous transluminal angioplasty of stenotic primitive hypoglossal artery--case report

A 76-year-old female presented with vertebrobasilar insufficiency due to a severe stenosis of the right primitive hypoglossal artery (an unusual carotid-basilar anastomosis) manifesting as recurrent transient ischemic attacks (TIA) associated with quadriparesis and cerebellar ataxia with vertigo, nausea, and vomiting. She had been treated with 100 mg of aspirin per day, but TIA associated with the same symptoms persisted. Cerebral blood flow (CBF) studies disclosed a region of moderately low flow in the posterior fossa. Cerebral angiography demonstrated that the posterior fossa was supplied via the right primitive hypoglossal artery, which was severely stenotic at its origin. Percutaneous transluminal angioplasty using a Stealth catheter, 3.0-mm diameter and 10-mm long, successfully dilated the stenosis. No TIA occurred postoperatively, and a marked increase in CBF was demonstrated in the posterior fossa.

Percutaneous transluminal angioplasty for acute stroke due to stenosis of major cerebral vessels: report of two cases

The Stealth dilation catheter was introduced for the intravascular treatment of two patients with acute and unstable ischemic stroke due to hemodynamically significant stenosis in the one case of the middle cerebral artery and in the other of the vertebral artery. Cerebral perfusion study on the two cases showed a moderately low flow area in the right cerebral hemisphere and in the left cerebellar hemisphere, respectively. Percutaneous transluminal angioplasty (PTA) using the Stealth catheter was conducted. The two cases showed marked improvement in their neurologic state just after PTA with marked increase in cerebral perfusion in the relevant regions.

[Spike discharge detected by intra-arterial electroencephalography from intra-arterial guide wire in temporal lobe epilepsy]

The implantation of electrodes for intracranial electroencephalography (EEG) recording as presurgical evaluation of patients with intractable epilepsy is at present most important for planning epilepsy surgery. This method is most effective in temporal lobe epilepsy. We carried out intracranial EEG by means of insulated micro guide wire for endovascular surgery in two temporal lobe epilepsy cases, and spike discharges could be detected in lesional medial temporal lobe. Case 1 is a 29 year-old-male suffered from intractable complex partial seizure (CPS) for 18 years. He was diagnosed as left temporal lobe epilepsy and performed removal of amygdala, hippocampus, parahippocampal gyrus and fusiform gyrus. Case 2 is a 16 year-old-lady suffered from drug resistant CPS for 4 years. Under the diagnosis of right temporal lobe epilepsy, temporal lobectomy was performed. As the presurgical evaluation, under the implantation of subdural strip electrode in both cases, we carried intra-arterial EEG after angiography. Seeker Lite-10 guide wire was insulated with Tracker-10 unibody infusion catheter at sphenoidal portion of middle cerebral artery, and frequent interictal spike discharge was detected in lesional medial temporal lobes by two methods simultaneously.

[Multiple subpial transection after lesionectomy in an intractable epilepsy case]

A Sixty-one-year-old man was admitted to our hospital because of generalized convulsion. He had suffered from intractable epilepsy for 26 years. CT and MRI showed the right frontal cavernous angioma. On operation, intraoperative electrocorticography was performed after lesionectomy including surrounding glial scar and hemosiderin laden tissue. It showed epileptiform potentials in neighbor gyrus of the lesion. Because the removed sphere would be so broad, and we performed multiple subpial transection (MST). After MST, depression of background electrical activity and disappearance of spike discharge are seen. One and half year after operation, seizure was controlled by only phenobarbital administration.