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Both paradoxical intracranial embolism, an intracranial arterial embolism caused by venous embolic material that has passed through a right-to-left shunt, and pulmonary arterial embolism are life-threatening complications of joint arthroplasty. We report a case of severe paradoxical intracranial embolism and pulmonary embolism that occurred during hip hemiarthroplasty.
OBJECTIVE: Inadequately embolized aneurysms (IEA) are coiled aneurysms with a significant remnant (>5%), initially or after recanalisation, or with a coil extrusion deemed too thrombogenic or threatening the blood flow in the parent vessel. Our objective is to report our experience with the surgical clipping (SC) of a consecutive series of 17 IEA considered as not appropriate for an additional endovascular procedure. METHODS: Between February 1996 and April 2006, we evaluated 523 ICA in 380 patients of whom 192 underwent coil embolisation (CE), 117 with complete occlusion (61%), 47 with near complete occlusion (> or = 95%), 9 with partial occlusion (<95%), and 19 without any coil delivery (attempted embolisation). Of the 173 ICA embolized one or two times, at their radiological follow-up 15 (8.6%) were considered as IEA and not appropriate for an additional CE. Two IEA treated endovascularly before February 1996 were added to this series. The female/male ratio was 0.47 with an average age of 54 years (range, 37-65). All cases were located on the anterior circulation except the last one. The 17 IEA were treated by SC either because of an aneurysm remnant deemed not accessible to a further CE and large enough for direct clipping or because the risks of a thromboembolic event related to extruded coils was too high. RESULTS: SC was complete in all 17 cases, confirmed angiographically. Postoperatively, the clinical status of two patients deteriorated slightly but transiently. Our surgical experience with this series led us to classify IEA into five types, in three groups: group A (with one type: type A) was the most important group (n = 11) with IEA characterized by an aneurysm residue allowing direct SC, as assessed preoperatively; group B (n = 4) comprised aneurysms with a residue smaller than predicted and showing parent vessel stenosis when a clip was applied to the neck residue requiring the fundus full of coils to be removed followed by either clip application to the neck residue (type B1, n = 3) or suture if the remnant was too small (type B2, n = 1); and group C (n = 2) grouping cases requiring coil extraction through the parent vessel (type C2, n = 1) or through the fundus (type C2, n = 1). CONCLUSIONS: With this series of IEA, we observed that open surgery of type A and C aneurysms can be a straightforward procedure. Our experience with type B IEA encourages us to wait for a sufficient aneurysm residue before performing SC because of the potential difficulties that may be encountered by the surgeon, particularly in type B2. SC of IEA was very effective with complete occlusion and no permanent morbidity in all 17 cases.
This report describes our experiences with a patient who developed delayed recurrent retinal and hemispheric ischemia distal to an old internal carotid artery occlusion in the neck. Fundoscopy and sequential cerebral arteriography documented that recurrent ischemic symptoms in this individual were the result of embolic fragments arising from the "stump" of the occluded internal carotid artery and from a diseased external carotid artery. These emboli traversed the external carotid artery and its orbital and intracranial anastomotic connections to reach the symptomatic eye and hemisphere. Ischemic symptoms in this patient were effectively terminated with anticoagulant therapy. We believe that this patient graphically documents that post-occlusion microembolism via the external carotid artery does indeed occur, and probably accounts for post-occlusion recurrent ischemic attacks more frequently than is currently appreciated. Recognition of this phenomenon is of importance because of its significant therapeutic implications. In these situations treatment modalities which terminate embolic phenomena would appear to have a more rational basis than do surgical procedures designed primarily to augment collateral blood flow to the symptomatic organ(s).
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Embolism from an aneurysm is one of the mechanisms involved in the pathogenesis of ischemic symptoms associated with intracranial aneurysms. Four cases are reported in which aneurysms of the internal carotid arteries and middle cerebral arteries were the source of emboli resulting in cerebral infarction. In the treatment of these aneurysms, it is best to clip the neck of the aneurysm with great care to avoid embolism due to extrusion of clot into the distal artery.
Embolization of very vascular intracranial meningiomas prior to operation will reduce the loss of blood during the operation. The indications and the technique of preoperative embolization are discussed and 20 cases are presented.
OBJECTIVE: To establish an expert system that automatically generates optimal GDC selection program for the embolization of intracranial aneurysm. METHODS: Twenty highly cost-effective cases of intracranial aneurysm embolized with GDC dense packing were collected. Each of them contains information including aneurysm's volume measured by three-dimension digital subtraction angiography (3D DSA), aneurysm's location, maximum transverse diameter, maximum length diameter, and GDC selection program. An expert system made up of a case base, a mathematical model simulating experts' experience (established with the help of data mining techniques combining multi-layer perceptron network with polyhedrons in high dimensional space), and data envelopment analysis (DEA), was implemented. RESULTS: When the user inputted four required parameters (volume, location, maximum transverse diameter, and maximum length diameter) into the expert system and clicked the "program design" button, candidate GDC selection program(s) would be presented in the result box. CONCLUSION: Case base, data mining techniques, and DEA can be used to establish the expert system that automatically generates optimal GDC selection program for the embolization of intracranial aneurysm. Its clinical value needs to be further evaluated.
OBJECTIVE: To explore the imaging criteria for evaluating intracranial aneurysm embolization. METHODS: Angiographic occlusive criteria for intracranial aneurysm embolization (aneurysm not opcified angiographically after embolization, 100% occlusion; a little part of aneurysm neck residual, 95%; neck residual, 90%; neck and a little part of aneurysm cavity residual, 80%; some cavity residual, < 80%) were used by 6 specialists to evaluate 121 aneurysms embolized with MDS (mechanical detachable spiral) and/or GDC (guglielmi detachable coil) from March 1995 to July 1999. The rationality, feasibility and limitation of the criteria were discussed. RESULTS: Among the 121 aneurysms, 100% occlusion was reached in 53 aneurysms (43.8%), 95% in 27 (22.3%), 90% in 16 (13.2%), 80% in 15 (12.4%), and less than 80% in 10 (8.3%) respectively. Good accordance was obtained among different doctors in the occlusive evaluation of aneurysm embolization. CONCLUSIONS: The suggesting criteria are simple and feasible in clinical practice, although the effect of imaging follow-up of embolized aneurysm is unknown and the numerical value of occlusive percentage is arbitrary.
OBJECTIVE: To compare the embolization effects of intracranial aneurysm with mechanical detachable spirals (MDS) and with Guglielmi detachable coils (GDC). METHODS: One hundred and twenty cases with 125 intracranial aneurysms were embolized in Beijing Hospital from March 1995 to July 1999. Sixty-six aneurysms in 64 cases were embolised with MDS, 51 in 48 with GDC, and 8 in 8 with both MDS and GDC. Clinical data including sex, age, subarachnoid hemorrhage (SAH), Hunt & Hess grading, diameter and neck width of aneurysms, number and length of coils used per aneurysm, occlusive ratio, and complications were compared between MDS and GDC groups. RESULTS: MDS and GDC group were comparable (t-test or chi2-test, all P value > 0.10) in terms of age, sex, diameter of aneurysms [(8.46 +/- 3.42) mm vs. (7.38 +/- 3.45) mm], neck width [(3.49 +/- 1.50) mm vs. (3.26 +/- 1.52) mm], coils number [(4.65 +/- 3.01) vs. (4.24 +/- 2.65)] and their length [(460.2 +/- 398.5) mm vs. (422.9 +/- 387.1) mm] used per aneurysm, occlusive ratio in aneurysms embolized > or = 80% [(95.00% +/- 6.32%) vs. (94.19% +/- 7.63%)], mortality and permanent complications (7.8% vs. 4.2%). CONCLUSIONS: MDS and GDC are all materials for embolization of intracranial aneurysms. MDS is less expensive, but more difficult to control and of propensity to complications while GDC is more compliant, easier to be used, safer, and have many alternative types for use as well a more extensive indications.
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OBJECTIVE: To primarily embolize intracranial aneurysms with new-developed mechanically detachable coils, which is called Detachable Coil System (DCS). METHODS: Five intracranial aneurysms were embolized with DCS, in which 2 were giant aneurysms. DCS with J coils were initially used to make baskets in giant aneurysms, and then other kinds of coils were utilized to pact the aneurysmal cavity. Whereas, spiral coils were mostly used in smaller aneurysms. Coils of DCS were detached by rotating the delivering wire after the coils were satisfactorily positioned in aneurysms. RESULTS: Two of the 5 cases were totally occluded with DCS. Two was sub-totally embolized. Pushing, withdrawal, and adjusting of DCS were safe and efficient. Detachment of DCS was fast. In one case of wide-necked giant aneurysm, coils could not stay inside the aneurysm, which was treated by occlusion of the parent artery. CONCLUSIONS: DCS is a new addition to the interventional radiologist's armamentarium. Detachment is faster. J coils are suitable for giant aneurysms for its unique way of coiling. But more evaluation depends on accumulation of the clinical usage.
Two patients with embolism from unruptured intracranial aneurysms are reported. These patients experienced cerebral ischemic attacks at the ages of 10 and 64 years, respectively. Angiography revealed normal extracranial vessels and middle cerebral artery aneurysms. Preoperative magnetic resonance imaging showed intraaneurysmal clots and cerebral infarcts distal to the aneurysms. Aneurysmal neck clipping was carried out on the young patient. In the other case, the aneurysmal sac was excised, the intraluminal clot was removed, and the neck was closed with nylon sutures. These are the first cases of embolism from unruptured aneurysms in which magnetic resonance imaging revealed intraaneurysmal clots and cerebral infarcts distal to the aneurysms.
BACKGROUND AND PURPOSE: Preoperative embolization of meningiomas is frequently used to facilitate surgery and to reduce intraoperative blood loss. The purpose of this study was to evaluate the frequency of procedure-related neurologic complications during and after particle embolization of intracranial meningiomas. METHODS: Between 1996 and 2004, 185 consecutive patients underwent particle embolization of an intracranial meningioma. Devascularization was performed by means of superselective probing of the tumor-feeding vessels and ensuing free-flow embolization with spherical particles. All procedures were performed with systemic heparinization. RESULTS: Six patients (3.2%) had ischemic events with neurologic deficit. Two had amaurosis, and four patients presented with hemiparesis. Hemorrhage occurred in six patients (3.2%). In five of these patients, rapid microsurgical tumor removal resulted in a favorable outcome without persistent neurologic deficit. In one patient, massive intratumoral, subarachnoid, and subdural hemorrhage was lethal. CONCLUSION: Particle embolization of meningiomas is associated with a substantial risk of ischemic and hemorrhagic events. The individual risk-to-benefit ratio of embolization should be thoroughly considered.
The goal of preoperative embolization of intracranial meningiomas is to facilitate their surgical removal by reducing tumor vascularity and decreasing blood loss during surgery. This study is based on personal experience with about 100 embolized meningiomas and on the experience of others. Embolization is performed during the same session as diagnostic angiography. The appropriate embolic materials (absorbable or nonabsorbable) are chosen according to the location of the tumor, the size of the feeding arteries, the blood flow, and the presence of any potentially dangerous vessels (dangerous anastomoses between external carotid artery and internal carotid or vertebral arteries, arteries supplying the cranial nerves). Preoperative embolization appeared to be very useful in large tumors with pure or predominant external carotid artery supply (convexity meningiomas), in skull-base meningiomas, and in middle fossa and paracavernous meningiomas. It was also useful in falx and parasagittal meningiomas receiving blood supply from the opposite side and in posterior fossa meningiomas. CT low densities demonstrated after embolization did not always correlate with necrosis on microscopic examination, and large areas of infarction could be found despite normal CT. Embolic material was found on pathologic examination in 10%-30% of cases; fresh or recent ischemic and/or hemorrhagic necrosis consistent with technically successful embolization was demonstrated in 40%-60% of cases. With careful technique complications are rare.
Meningeal haemangiopericytomas (HPC) are malignant intracranial neoplasms that commonly recur and metastasize. Large size at diagnosis, abundant intracranial feeders and the risk of intraoperative bleeding can make them difficult to completely remove in one operation. We report here a rare case of a giant HPC which was treated successfully using a one-stage operation following superselective intracranial feeder occlusion. A 30-year-old man presented with a left middle cranial fossa tumour extending to the left temporal lobe and cerebellar tentorium. Angiography revealed supply from a dilated left posterior temporal artery branching from the posterior cerebral artery. The tumour was totally removed in a single-stage excision after embolization of the intracranial major feeding artery. The present case suggests the usefulness of preoperative embolization for HPC, particularly of intracranial feeders, to achieve total resection safely in a single operation.
Intracranial dural arteriovenous fistulas (AVFs) can occur anywhere within the dura mater. Patients may be clinically asymptomatic or may experience symptoms ranging from mild symptoms to fatal hemorrhage, depending on the location (eg, cavernous sinus, transverse-sigmoid sinus, tentorium, superior sagittal sinus, anterior fossa) and venous drainage pattern of the AVF. In the past, dural AVFs have been treated with a variety of approaches, including surgical resection, venous clipping, transcatheter embolization, radiation therapy, or a combination of these treatments. Recent developments in catheter intervention now allow most patients to be cured with transcatheter embolization, although stereotactic radiation therapy is demonstrating good results in an increasing number of cases and surgery is still the preferred option in some cases. Familiarity with drainage patterns, the risk of aggressive symptoms, recent technical advances, and current treatment strategies is essential for the treatment of intracranial dural AVFs.
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OBJECTIVE: To study the cause and clinical manifestation of intracranial venous embolim during pregnancy and puerperium, and its early diagnosis and treatment. METHODS: 18 cases of intracranial venous embolism confirmed by Computed Tomography (CT) were eligible for this retrospective study. RESULTS: Of all the cases, 8 cases occurred before delivery and 10 post partum; 10 cases complicated by pregnancy induced hypertension and 8 cases postpartum hemorrhage. Headache occurred most frequently, followed by coma and seizure. Blood rheologic assay showed hypercoagulable states in 6 cases. For 11 cases treated with urokinase, 10 were cured, while in the remaining patients, 3 of 6 cured. CONCLUSIONS: The results show that hypercoagulability states were related to intracranial venous embolism. Coma and seizure were the main characters. CT was an important diagnostic measure. Lowering intracranial pressure, anticoagulation, dethrombosis and timely ending pregnancy were the main treatment measures. The early use of urokinase may exert better effect.