Objective: To establish a strategy for addressing recanalization of intracranial aneurysms previously embolized with Guglielmi detachable coils (GDC), efficacy and safety of additional treatments was evaluated. Methods: A total of 168 patients with acute ruptured intracranial aneurysms were subjected to GDC embolization. Follow-up angiograms were obtained 6 months, and 1 and 2 years post-embolization. Patients with major recanalization that had not disappeared at 1 year after the first embolization underwent retreatment. Results: Of the 168 patients, 18 (10.7%) underwent additional treatment, with 14 receiving a second coil embolization and 2 undergoing a total of 3 or more additional embolization procedures. One patient died after the 4th coil embolization. Both of the other 2 patients undergoing 3 or more embolization procedures required surgery, with it very difficult to achieve complete occlusion of the residual neck in one of them. Conclusions: Additional treatment of previously coil-embolized aneurysms is safe. The strategy of retreating patients with angiographically confirmed major recanalization at 1-year follow-up is appropriate.
Purpose: We report a case of cavernous dural arteriovenous fistulas (dAVFs) completely occluded by transarterial embolization with n-butyl cyanoacrylate (NBCA) as the embolic agent and using balloon assisted technique. Case: A 37-year-old woman presented with right conjunctival injection, proptosis and diplopia. She was initially treated with right carotid compression without improvement of symptoms. Two weeks prior to admission to our institution, she experienced acute worsening of the symptoms. Her right intraocular pressure was 31mmHg on admission. MRI showed right cavernous dAVFs. Angiographic study showed dAVFs to the right anterior inferior cavernous sinus supplied by the branches of the right internal and external carotid arteries. Endovascular treatment was performed by a bi-femoral approach. A microballoon catheter was placed in the right internal carotid artery across the cavernous segment. A microcatheter was wedged into the carotid branch of the ascending pharyngeal artery. Under balloon inflation to close the origin of the C4 feeder to the fistulas, 0.7cc of 25% NBCA mixed with ethiodol was injected from the wedged microcatheter, resulting in complete occlusion of the fistulas. The patient showed immediate improvement of the symptoms and her right intraocular pressure was normal one week after treatment. Conclusion: Trans-arterial embolization may be the best treatment option for selected cases of cavernous dAVFs. Balloon protection of the internal carotid artery may be necessary for aggressive trans-arterial embolization to prevent NBCA migration into the cerebral circulation through the anastomosis between the external and internal carotid arteries.
Objective: Oculocardiac reflex sometimes occurs as a result of pressure on the eye or traction of the intraorbital surrounding structures during ophthalmic surgery. This can result in bradycardic arrhythmia and cardiac arrest. A case of oculocardiac reflex due to catheterization for an anterior cranial fossa dural arteriovenous fistula (DAVF) is reported. Case Report: A 45-year-old man was incidentally diagnosed with an anterior cranial fossa DAVF by magnetic resonance angiogram. Bilateral carotid angiograms revealed the DAVF was supplied by bilateral anterior ethmoidal arteries. An attempt was made at transarterial embolization using a liquid embolic material. The DAVF was mainly supplied by the left anterior ethmoidal artery, however tortuosity of its arterial origin prevented catheterization with a microcatheter. Therefore catheterization was attempted using the right ophthalmic artery. The microcatheter was advanced to an area more distal in the third segment of the right ophthalmic artery to avoid ophthalmic complications. When the microcatheter had been advanced as distally as possible to be close to the shunt point of the DAVF, the patient's pulse rate gradually decreased and temporary cardiac arrest occurred just after the patient complained of eye pain. Immediately after pulling back the microcatheter, the pulse rate began to gradually increase for about 20 seconds. Ultimately, the attempt at transarterial obliteration of the fistula was abandoned. Conclusion: To our knowledge, this is the first report describing a patient that developed an oculocardiac reflex as a result of catheterization of the distal ophthalmic artery. Operators attempting catheterization into the distal ophthalmic artery need to be familiar with this phenomenon.