Intermittent Orbital Pain due to Hemodynamic Collapse of an Orbital Varix: A Case Report

Orbital varices typically present with symptoms related to dilation or thrombosis. We describe a rare presentation of an orbital varix with pain caused by hemodynamic collapse of the varix. A woman in the third decade presented with position-dependent orbital pain and enophthalmos. She was found to have an intraorbital varix and a separate pterygoid varix. The patient underwent endovascular treatment of the pterygoid varix using coils and sclerosing agents which altered the venous outflow from the orbital varix. The patient had immediate resolution of symptoms after the procedure. Our findings suggest that extraorbital venous outflow abnormalities may be the cause of symptoms in selected cases of orbital varices. By understanding the venous structures on cerebral angiography and treating the extraorbital component, orbital intervention may be avoided, reducing the risk of complications

Cessation and Resumption of Elective Neurointerventional Procedures during the Coronavirus Disease 2019 Pandemic and Future Pandemics

At the time of this writing, the coronavirus disease 2019 pandemic continues to be a global threat, disrupting usual processes, and protocols for delivering health care around the globe. There have been significant regional and national differences in the scope and timing of these disruptions. Many hospitals were forced to temporarily halt elective neurointerventional procedures with the first wave of the pandemic in the spring of 2020, in order to prioritize allocation of resources for acutely ill patients and also to minimize coronavirus disease 2019 transmission risks to non-acute patients, their families, and health care workers. This temporary moratorium on elective neurointerventional procedures is generally credited with helping to flatten the curve and direct scarce resources to more acutely ill patients; however, there have been reports of some delaying seeking medical care when it was in fact urgent, and other reports of patients having elective treatment delayed with the result of morbidity and mortality. Many regions have resumed elective neurointerventional procedures, only to now watch coronavirus disease 2019 positivity rates again climbing as winter of 2020 approaches. A new wave is now forecast which may have larger volumes of hospitalized coronavirus disease 2019 patients than the earlier wave(s) and may also coincide with a wave of patients hospitalized with seasonal influenza. This paper discusses relevant and practical elements of cessation and safe resumption of nonemergent neurointerventional services in the setting of a pandemic

Abstract Number ‐ 105: Development of Non‐Surgical Intracranial Access to the Subdural Space for Theranostic Applications in Neurology

Introduction The objective of this study was to test the hypothesis thattrans‐duralvenous sinus (tDVS)puncture from within the Superior Sagittal Sinus (SSS) is feasible. Furthermore, we determine the feasibility of accessing extravascular intracranial spaces overlying the cortex using an endovascular Inside‐Out (‘I/O’) tDVS. Aims: 1.Characterize puncture of the SSS using different size profiles and perform force measurements on benchtop and ex‐vivo models. 2.Identify the system requirements for endoluminal opposition to mediate controlled tDVSpenetration. 3.Demonstrate a system capable of tDVSpenetration and subdural‐meningeal access over the cortical convexity. Methods Silicone tube and 3D printed Superior Sagittal Sinus models were developed to assess different systems. Various re‐entry catheters (Cordis Outback, Philips Pioneer, BS Stingray LP CTO), as well as a modified construct (comprised of a 5Fr angio catheter, a BS OffroadLancet, and a distal‐end‐cut 0.014” microguidewire), were each tested on silicone tube models. To provide endoluminal apposition for controlledtDVSpenetration, various stents, stentrievers, non‐compliant balloon and compliant balloon catheters were assessed in conjunction with penetrator devices on tubular and ex‐vivo cadaveric models. To measure the force of various penetrator devices, a vector force gauge was used (3 trials by 2 independent operators). The Right Internal Jugular Vein access in a human cadaver was obtained by cut‐down and a purse string suture. Balloon microcatheters were advanced into the SSS under fluoroscopy. SSS catheterization with re‐entry devices required transcranial burr hole access due to inability to advance these beyond the jugular‐sigmoid junction. Results The Cordis Outback Re‐Entry device abuttedendoluminallyby a compliant balloon (Stryker Transform) most reliably enabled tDVSpuncture on ex‐vivo specimens (Figure 1). Only the compliant balloon provided adequate endoluminal radial support for penetrator deployment on silicon tube models, as well as enabled repositioning. The modified construct was also successful in penetrating the DVS, but required extensive manual manipulation for optimal positioning and apposition. The other support devices resulted either in kickback or insufficient radial support. In the cadaver, The Outback device markers were oriented to penetrate the SSS in a para‐sagittal trajectory after inflating the complaint balloon. The 22G cannula was deployed, and under fluoroscopy, an exchange‐lengthmicroguidewirewas advanced through the Outback and into subdural‐meningeal space. The Outback was then exchanged for a 0.021” microcatheter. Once in the subdural‐meningeal space, themicroguidewirewas withdrawn and contrast injections were performed to assess the space catheterized, which was confirmed as subdural (Figure 2). Conclusions •Controlled tDVS penetration from an endovascular locationis feasible with minimal force using a complaint endoluminal support structure. •Catheter access beneath the intracranial subdural meningeal space overlying the cortex may represent a viable route fortheranosticneurologic applications. •An in‐vivol study is needed to establish the feasibility and safety of tDVS access to the cortical surface

ENDOVASCULAR TREATMENT OF MIDDLE CEREBRAL ARTERY ANEURYSMS WITH DETACHABLE COILS

ObjectiveBecause of their anatomic configuration, middle cerebral artery (MCA) aneurysms are most often treated with surgical clipping. However, endovascular coil embolization of these aneurysms is an increasingly used alternative. We retrospectively reviewed the anatomic and clinical outcomes of patients with MCA aneurysms who underwent endovascular treatment at our institution.MethodsOne hundred fifteen MCA aneurysms in 115 patients (mean age, 55.1 years) were treated by an endovascular technique from April 1990 to March 2007. Forty-eight patients (42%) presented with acute subarachnoid hemorrhage, and 67 patients (58%) had unruptured aneurysms. Fifty-three aneurysms (46%) were small with a small neck, 28 (24%) were small with a wide neck, 22 (19%) were large, and 12 (11%) were giant.ResultsAngiographic results immediately after embolization showed complete occlusion in 53 aneurysms (46%), a neck remnant in 51 (44%), and incomplete occlusion in 3 (3%). Because of anatomic difficulties, we could not embolize 8 aneurysms (7%). Thirteen patients underwent combined treatment that included endovascular and extracranial-intracranial bypass surgery. Morbidity and mortality rates were 6.9% (8 patients) and 3% (3 patients), respectively. Procedure-related complications were encountered in 10 patients (9%). Seventy patients had long-term follow- up angiograms. Seven aneurysms (10%) were recanalized; all were large or giant. One partially embolized large aneurysm ruptured 13 months after embolization.ConclusionIn this series, endovascular coil embolization of MCA aneurysms has morbidity and mortality rates comparable to those of conventional surgical clipping. Combined treatment of endovascular and bypass surgery can successfully treat large or giant complex fusiform MCA aneurysms

Predictors of rehemorrhage after treatment of ruptured intracranial aneurysms: The Cerebral Aneurysm Rerupture After Treatment (CARAT) study

BACKGROUND AND PURPOSE - The primary purpose of intracranial aneurysm treatment is to prevent rupture. Risk factors for rupture after aneurysm treatment have not been clearly established, and the need to completely occlude aneurysms is debated. METHODS - The Cerebral Aneurysm Rerupture After Treatment (CARAT) study is an ambidirectional cohort study of all patients with ruptured intracranial aneurysms treated with coil embolization or surgical clipping at 9 high-volume centers in the United States from 1996 to 1998. All subjects were followed through 2005, and all potential reruptures were adjudicated by a panel of 3 specialists without knowledge of the initial treatment or aneurysm characteristics. Degree of aneurysm occlusion post-treatment was evaluated as a predictor of nonprocedural rerupture in univariate Kaplan-Meier analysis (log-rank test) and in a Cox proportional-hazards model after adjustment for potential confounders and censoring at time of retreatment. RESULTS - Among 1001 patients during a mean of 4.0 years follow-up, there were 19 postprocedural reruptures; median time to rerupture was 3 days and 58% led to death. The degree of aneurysm occlusion after treatment was strongly associated with risk of rerupture (overall risk: 1.1% for complete occlusion, 2.9% for 91% to 99% occlusion, 5.9% for 70% to 90%, 17.6% for \u3c70%; P\u3c0.0001 in univariate and multivariable analysis). Overall risk of rerupture tended to be greater after coil embolization compared with surgical clipping (3.4% versus 1.3%; P=0.092), but the difference did not persist after adjustment (P=0.83). CONCLUSIONS - Degree of aneurysm occlusion after the initial treatment is a strong predictor of the risk of subsequent rupture in patients presenting with subarachnoid hemorrhage, which justifies attempts to completely occlude aneurysms. © 2008 American Heart Association, Inc

Natural history of asymptomatic unruptured cerebral aneurysms evaluated at CT angiography: growth and rupture incidence and correlation with epidemiologic risk factors.

PurposeTo characterize the relationship between aneurysm size and epidemiologic risk factors with growth and rupture by using computed tomographic (CT) angiography.Materials and methodsIn this HIPAA-compliant, institutional review board approved study, patients with known asymptomatic unruptured intracerebral aneurysms were followed up longitudinally with CT angiographic examinations. Growth was defined as an increase in one or more dimensions above the measurement error, and at least 5% volume by using the ABC/2 method. Associations of epidemiologic factors with aneurysm growth and rupture were analyzed by using logistic regression analysis. Intra- and interobserver agreement coefficients for dimension, volume, and growth were evaluated by using the Pearson correlation coefficient and difference of means with 95% confidence intervals, the agreement statistic, and the McNemar χ(2).ResultsPatients (n = 165) with aneurysms (n = 258) had a mean follow-up time of 2.24 years from time of diagnosis. Forty-six of 258 (18%) aneurysms in 38 patients grew larger. Spontaneous rupture occurred in four of 228 (1.8%) intradural aneurysms of average size (6.2 mm). Risk of aneurysm rupture per patient-year was 2.4% (95% CI: 0.5%, 7.12%) with growth and 0.2% (95% CI: 0.006%, 1.22%) without growth (P = .034). There was a 12-fold higher risk of rupture for growing aneurysms (P < .002), with high intra- and interobserver correlation coefficients for size, volume, and growth. Tobacco smoking (3.806, one degree of freedom; P < .015,) and initial size (5.895, two degrees of freedom; P < .051) were independent covariates, predicting 78.4% of growing aneurysms.ConclusionThese results support imaging follow-up of all patients with aneurysms, including those whose aneurysms are smaller than the current 7-mm treatment threshold. Aneurysm growth, size, and smoking were associated with increased rupture risk