Case based Interventional Neuroradiology

by Brugge, Karel G. ter; Geibprasert, Sasikhan;

Case based Interventional Neuroradiology Featuring comprehensive coverage of the latest developments and technology in the field Case Based Interventional Neuroradiology provides a thorough review of commonly encountered neurovascular diseases as well as detailed background information on the rationale for each treatment choice Cases center on real life scenarios with high quality images and offer readers a concise practical and up to date approach to the diseases neurointerventionalists face A separate section in each case cont

Publisher : Thieme

Author : Brugge, Karel G. ter; Geibprasert, Sasikhan; Krings, Timo

ISBN : 9781604063738

Year : 2011

Language: en

File Size : 12.74 MB

Category : Used Textbooks

Case-Based Interventional Neuroradiology

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Case-Based Interventional Neuroradiology

Timo Krings, MD, PhD, FRCP (C)
Professor, Department of Medical Imaging, University of Toronto
Division of Neuroradiology, Toronto Western Hospital
Toronto, Canada
Professor, Department for Neuroradiology
University Hospital of the Technical University RWTH
Aachen, Germany
Practicien Attaché, Service de Neuroradiologie Diagnostique et Thérapeutique
CHU Le-Kremlin-Bicetre
Paris, France
Sasikhan Geibprasert, MD
Staff Neurointerventionalist, Department of Radiology
Ramathibodi Hospital
Mahidol University
Bangkok, Thailand
Fellow, Department of Diagnostic Imaging
Hospital for Sick Children
University of Toronto
Toronto, Canada
Karel G. ter Brugge, MD, FRCP (C)
The David Braley and Nancy Gordon Chair in Interventional Neuroradiology,
University of Toronto
Professor, Department of Medical Imaging and Surgery, University of Toronto
Head, Division of Neuroradiology, Toronto Western Hospital
Toronto, Canada

Thieme
New York • Stuttgart

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Thieme Medical Publishers, Inc.
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Library of Congress Cataloging-in-Publication Data
Krings, Timo.
Case-based interventional neuroradiology / Timo Krings, Sasikhan Geibprasert, Karel G. ter
Brugge.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-60406-373-8 (alk. paper)
1. Nervous system—Interventional radiology—Case studies. I. Geibprasert, Sasikhan. II. Brugge, K. G.
ter (Karel G. ter) III. Title.
[DNLM: 1. Cerebrovascular Disorders—radiotherapy—Case Reports. 2. Central Nervous System—
blood supply—Case Reports. 3. Radiology, Interventional—methods—Case Reports. WL 355]
RD594.15.K75 2011
616.8'04754—dc22
2010029281
Copyright © 2011 by Thieme Medical Publishers, Inc. This book, including all parts thereof, is legally
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Important note: Medical knowledge is ever-changing. As new research and clinical experience
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herein or changes in medical knowledge, neither the authors, editors, nor publisher, nor any other
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ISBN 978-1-60406-373-8

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To our teachers

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CONTENTS

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
PART I
Aneurysms and Subarachnoid Hemorrhage
CASE 1
Embolization of a Ruptured Basilar Tip Aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
CASE 2
Embolization of a Ruptured Anterior Communicating Artery Aneurysm . . . . . . . . . . . . . . . . 8
CASE 3
Multiple Aneurysms in a Patient with Subarachnoid Hemorrhage . . . . . . . . . . . . . . . . . . . . 13
CASE 4
Management of an Unruptured Internal Carotid Artery Aneurysm . . . . . . . . . . . . . . . . . . . 19
CASE 5
Balloon-Assisted Embolization of a Ruptured Wide-Necked Anterior Communicating
Artery Aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
CASE 6
Stent-Assisted Embolization of a Wide-Necked Recurrent Posterior Communicating
Artery Aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
CASE 7
Management of Complications during Aneurysm Coiling: Proximal Mechanically
Induced Vasospasm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
CASE 8
Management of Complications during Aneurysm Coiling: Periprocedural
Aneurysm Rupture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
CASE 9
Management of Complications during Aneurysm Coiling: Periprocedural Thrombus
Formation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
CASE 10
Management of Subarachnoid Hemorrhage-Induced Vasospasm . . . . . . . . . . . . . . . . . . . . 55
CASE 11
Management of Giant “Partially Thrombosed” Aneurysms . . . . . . . . . . . . . . . . . . . . . . . . . 62
CASE 12
Embolization of a Dissecting Vertebral Artery Aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
CASE 13
Embolization of a Dissecting Distal Anterior Inferior Cerebellar Artery Aneurysm . . . . . . 77
CASE 14
Embolization of an Infectious Distal Middle Cerebral Artery Aneurysm . . . . . . . . . . . . . . . 83
PART II
Brain Arteriovenous Malformations
CASE 15
Arterial Embolization of an Unruptured Pial Arteriovenous Malformation . . . . . . . . . . . . . 89
CASE 16
Partial Targeted Embolization of an Unruptured Pial Arteriovenous Malformation . . . . . . 95
CASE 17
Pre-radiosurgical Embolization of an Unruptured Pial Arteriovenous Malformation . . . . 101
CASE 18
Embolization of an Acutely Ruptured Arteriovenous Malformation with
Intranidal Aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
CASE 19
Management of Hydrocephalus in an Unruptured Pial Arteriovenous Malformation . . . 116
CASE 20
Embolization of a Pial Fistulous Arteriovenous Malformation . . . . . . . . . . . . . . . . . . . . . . 121
CASE 21
Partial Embolization of a Choroidal Fistulous Arteriovenous Malformation . . . . . . . . . . . 125
CASE 22
Embolization of a Microshunt into a Developmental Venous Anomaly . . . . . . . . . . . . . . 131

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CONTENTS

PART III
Cranial Dural Arteriovenous Shunts
CASE 23
Arterial Embolization of a Lateral Epidural Type of Dural Arteriovenous Fistula . . . . . . .
CASE 24
Arterial Embolization of an Ethmoidal Dural Arteriovenous Fistula . . . . . . . . . . . . . . . . . .
CASE 25
Transarterial Embolization of a Transverse Sinus Dural Arteriovenous Fistula . . . . . . . . .
CASE 26
Transvenous Embolization of a Transverse Sinus Dural Arteriovenous Fistula . . . . . . . . .
CASE 27
Transvenous Embolization through Thrombosed Dural Sinus of an Aggressive
Transverse Sinus Dural Arteriovenous Fistula at the Level of an Isolated Dural Sinus . . .
CASE 28
Transvenous Embolization of a Condylar Confluence Dural Arteriovenous Fistula . . . . .
CASE 29
Transvenous Embolization of a Cavernous Sinus Dural Arteriovenous Fistula . . . . . . . . .
CASE 30
Multiple Dural Arteriovenous Fistulae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PART IV
Head and Neck Vascular Lesions
CASE 31
Transarterial Embolization of a Mandibular Arteriovenous Fistula . . . . . . . . . . . . . . . . . . .
CASE 32
Combined Direct Puncture and Transarterial Embolization of a Scalp Arteriovenous
Malformation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CASE 33
Percutaneous Puncture of a Facial Venous Vascular Malformation with
Injection of Bleomycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CASE 34
Percutaneous Puncture of a Facial Venous Malformation with Injection of Alcohol . . . .
CASE 35
Transarterial Particle Embolization of a Facial Hemangioma . . . . . . . . . . . . . . . . . . . . . . .

137
143
148
154
160
166
172
178

183
187
192
196
201

PART V
Tumors
CASE 36
CASE 37
CASE 38
CASE 39
CASE 40
CASE 41

Preoperative
Preoperative
Preoperative
Preoperative
Preoperative
Preoperative

Transarterial Particle Embolization of a Meningioma . . . . . . . . . . . . . . . . . .
Transarterial Particle Embolization of a Juvenile Angiofibroma . . . . . . . . . .
Embolization of a Carotid Body Tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Embolization of a Recurrent Temporal Paraganglioma . . . . . . . . . . . . . . . . .
Transarterial Embolization of a Spinal Hemangioblastoma . . . . . . . . . . . . .
Embolization of a Hypervascular Vertebral Body Metastasis . . . . . . . . . . . .

207
213
218
225
231
237

Balloon Embolization of a Traumatic Carotid-Cavernous Fistula . . . . . . . . . . . . . . . . . . . .
Coil Embolization of a Traumatic Carotid-Cavernous Fistula . . . . . . . . . . . . . . . . . . . . . . .
Carotid Artery Blowout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Balloon Occlusion Test of a Traumatic Internal Carotid Artery Aneurysm Treated by
Internal Carotid Artery Sacrifice with Detachable Balloons . . . . . . . . . . . . . . . . . . . . . . . .
Transarterial Particle Embolization for Epistaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

243
249
254

Intra-arterial rtPA Thrombolysis in Acute Ischemic Stroke . . . . . . . . . . . . . . . . . . . . . . . . .
Mechanical Thrombolysis in Acute Stroke with an Aspiration Device . . . . . . . . . . . . . . . .
Mechanical Thrombectomy in Acute Stroke with a Retrievable Stent . . . . . . . . . . . . . . .
Stent-Assisted Angioplasty of a Symptomatic Extracranial Internal Carotid
Artery Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Stenting of a Symptomatic Post-surgical Internal Carotid Artery Stenosis . . . . . . . . . . . .
Intracranial Revascularization with a Self-Expandable Stent . . . . . . . . . . . . . . . . . . . . . . . .
Balloon-Mounted Intracranial Stenting of a High-Grade Vertebral Artery Stenosis . . . . .

271
278
285

PART VI
Trauma
CASE 42
CASE 43
CASE 44
CASE 45
CASE 46

259
265

PART VII
Stroke
CASE 47
CASE 48
CASE 49
CASE 50
CASE 51
CASE 52
CASE 53

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297
305
312

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CONTENTS
CASE 54
CASE 55

ix

Subclavian Steal Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320
Direct Thrombolysis of Cerebral Venous Sinus Thrombosis . . . . . . . . . . . . . . . . . . . . . . . . 325

PART VIII
Pediatric Vascular Interventions
CASE 56
Transarterial Embolization of a Vein of Galen Aneurysmal Malformation . . . . . . . . . . . . .
CASE 57
Embolization of a Pial Arteriovenous Fistula in a Patient with Hereditary
Hemorrhagic Telangiectasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CASE 58
Management of Pediatric Cerebral Aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CASE 59
Transarterial Embolization of a Dural Sinus Malformation . . . . . . . . . . . . . . . . . . . . . . . . .

331
338
344
349

PART IX
Spine Vascular Interventions
CASE 60
Spinal Dural Arteriovenous Fistulae: Successful Arterial Embolization . . . . . . . . . . . . . . .
CASE 61
Spinal Dural Arteriovenous Fistulae: Unsuccessful Arterial Embolization . . . . . . . . . . . . .
CASE 62
Spinal Arteriovenous Malformation of the Fistulous Type: Treatment with Liquid
Embolic Material . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CASE 63
Spinal Arteriovenous Malformation of the Fistulous Type: Treatment with Coils . . . . . .
CASE 64
Spinal Arteriovenous Malformation of the Glomerular or Nidus Type: Treatment with
Liquid Embolic Material . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CASE 65
Balloon Embolization of a Vertebrovertebral Fistula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

381
388

PART X
Spine Percutaneous Interventions
CASE 66
Fluoroscopy-Guided Percutaneous Vertebral Biopsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CASE 67
Percutaneous Vertebroplasty in Osteoporotic Vertebral Compression Fracture . . . . . . .
CASE 68
Balloon-Assisted Kyphoplasty in Osteoporotic Vertebral Compression Fracture . . . . . . .
CASE 69
Multilevel Kyphoplasty in Multiple Myeloma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CASE 70
Radiofrequency Kyphoplasty in an Osteoporotic Vertebral Compression Fracture . . . . .
CASE 71
Radiofrequency Kyphoplasty in Multiple Myeloma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CASE 72
Intra-articular Facet Joint Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

393
398
406
414
420
426
431

357
364
369
375

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 435

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FOREWORD

Writing a book at the beginning of the twenty-first century about interventional neuroradiology, still
widely known as “endovascular neurosurgery,” is an extraordinarily risky bet. It is therefore worth
trying to determine whether the authors of this book, under the direction of Karel ter Brugge, have
successfully met the challenge that they have set for themselves. Those wishing to disseminate specialized personal knowledge should not only be highly skilled in their specific field, but also, and especially, have the maturity that comes only with wide experience. Timo Krings, Sasikhan Geibprasert,
and Karel ter Brugge are core members of Pierre Lasjaunias’ famous school, and benefit from the vast
experience they have obtained by working under his direction. The expertise of this team is thus
innately based on exceptional radioanatomical and clinical foundations as well as on very human
qualities that combine scientific rigor, honesty, and ethics.
Given the irreproachable quality of the information conveyed by such an elite team, globally
esteemed and respected as they are, we may yet consider the technique that they have utilized in
its presentation. Indeed, in this Internet era, with its capacity for the extraordinarily rapid, even
“instant,” transmission of information, the continuing relevance of the traditional printed book may
be brought into question. Compared to scientific journals and especially information rendered on a
website, the lag inherent in the printed book can contribute to the rapid obsolescence of the information being presented. This is especially true since the continuing evolution of interventional neuroradiology is itself extraordinarily rapid. Closely dependent on technological progress, interventional
neuroradiology takes a quantum leap forward with each technological innovation.
The techniques of endovascular interventional neuroradiology have evolved steadily towards
ever-smaller applications and the emergence of the third dimension has radically transformed their
precision and thus the safety of our interventions. The miniaturization of our surgical instruments
has greatly contributed to our progress, and the ongoing development of nanotechnology will very
likely enable further innovations that are even harder to visualize today.
It is in this particularly difficult context that the brilliance of this book’s design stands out. Its
major importance lies in the fact that it is actually not a traditional textbook, because the authors
have clearly taken the gamble of trying to stimulate personal reflection on the reader’s part. The
chapters are in fact a succession of carefully described and analyzed observations that consequently
require a direct and thoughtful participation. On examining these various observations, which range
over virtually the entire field of vascular pathology, readers are challenged to methodically ask themselves the key questions that absolutely must be answered before choosing a therapeutic approach.
Selecting the optimum strategy, that is, the one most effective and least hazardous to the patient, is
unquestionably the core of the therapeutic process. Confronted with daily reality, readers are thus
constantly forced to practice selecting the best indication as well as the most appropriate therapeutic
technique.
Technical knowledge is indeed indispensible, but alone it is insufficient for successful implementation without an exacting intellectual process. Given that there are frequently multiple therapeutic
possibilities, the approaches advocated by the authors are not didactically imposed but are carefully
argued and thus manifestly well justified, admirably demonstrating the authors’ excellent instructional abilities. This orientation of the book’s content is crucial, because at the present time the poor

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FOREWORD

quality of therapeutic indications chosen by many surgical teams around the world is certainly the
Achilles’ heel of early twenty-first-century interventional neuroradiology.
This overarching concern for the proper choice of therapeutic indications is highlighted by the
authors’ honesty and courage in describing the complications that can arise even within the best
teams. These observations, carefully selected, analyzed, and described will enable readers to become
aware of the actual risks to which patients are exposed, as they learn at the same time to make a
timely diagnosis and take appropriate measures to best mitigate any adverse consequences.
In the same vein, this book is remarkable for its rational approach in the deepest sense of the
word. Indeed, ongoing development is so rapid due to the continual introduction of new surgical
instruments that the top teams lack sufficient time to properly assess the actual clinical outcomes
of their interventions. This is why many procedures are being performed to “experiment” with new,
and apparently improved, surgical instruments, whereas we know very well that the outcomes of
clinical developments in the medium and long term can be mediocre or frankly even poor despite
“satisfactory radioanatomic controls.”
It is noteworthy that the authors have also taken on the challenge of covering virtually the
entire spectrum of pathological conditions accessible to treatment by interventional neuroradiology.
Their discriminating choice of observations has enabled them to cover practically all the situations
encountered, even the most difficult ones. The systematic nature of the book’s organization enables
the reader to find information quickly on any given observation. Of course, this leads to some repetition, but we know that repetition of important elements is the basis of a well-organized course
of instruction. The sections entitled “Pearls and Pitfalls” are highly relevant. For example, when the
authors write that skin disinfection is an essential step for infiltration or intraspinal injections, it
should not be taken lightly, because it is absolutely true. The repetition of “minor” steps in a protocol
can lead to over-familiarity and make us forget the need for their rigorous application. Many readers will also appreciate the bibliographical sources, available for each clinical case, which provide
immediate references relevant to the case being considered.
This book thus perfectly reflects the immense clinical, radioanatomical, technical. and human
qualities of the team of Timo Krings, Sasikhan Geibprasert, and Karel ter Brugge. It is therefore not
only useful but, in my opinion, really essential that all those wishing to train in interventional neuroradiology should read and reread this book, taking time for contemplation as needed, to gradually reach the level of maturity indispensable to the practice of this exciting but extremely difficult
specialization. When making a difficult decision, many practitioners will benefit from reading the
chapter that corresponds to the case at hand, and they will certainly find it helpful in reaching their
decision. This book will most certainly contribute to the improvement of outcomes in interventional
neuroradiology.
I would therefore like to congratulate the authors and to thank them warmly for making this
resource for training and development available to all those with an interest in brain and spinal
pathology. It will enable them to make real progress in providing the patients in their care with the
greatest possible benefit.
Luc Picard, Prof. Dr. Dr. h.c.
Professor Emeritus of Neuroradiology
Honorary President of the World Federation of Interventional and Therapeutic Neuroradiology
President of the World Federation of Neuroradiological Societies

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PREFACE

Interventional neuroradiology has become an integral component of the multidisciplinary management of patients with disorders of the head, neck, and spine. Patient acceptance and clinical outcome have proved better with minimally invasive procedures than with traditional open surgical
approaches. Yet, we need to be vigilant to ensure that the new treatment techniques are indeed
enhancing patient care and are carried out with the full realization that other treatment options
may exist.
The authors of this book have a long experience with interventional neuroradiologic techniques
in Asia, Europe, and North America, which will benefit our readers. Contributions by other experts
in the field have further enhanced the comprehensive coverage of all aspects of interventional neuroradiology.
The unique strength of this book is that it also provides the background information on which
the principles of treatment are based. In each case report, the clinical and imaging findings are
interpreted so that the reader can fully understand and formulate the reasons for the treatment and
the specific goals to be achieved.
The authors have made a deliberate attempt to be unbiased in their choice of materials used, to
provide background information regarding their choices under each circumstance, and to outline the
risks and benefits of their choices versus those of other options. Safety is paramount in this field,
and proper training and continued education are the pillars on which the best possible patient care
rests. This is particularly relevant in our field, as more and more asymptomatic patients are referred
whose disorders are incidentally discovered. Several case reports describe in detail how to manage
such situations, highlighting once again the importance of knowing the natural history of the diseases
we are asked to treat so that clinicians will offer the best choice for their patients in their overall risk
management strategy.
We did not select exotic, bizarre, or exceptional cases, nor did we include “heroic” procedures
(being well aware that the “hero” in those procedures is never the doctor but rather the patient).
Instead, we chose to describe those cases that the interventionalist will see in his or her daily practice.
Periprocedural complications do occur, even in the best hands, the difference being that experienced
practitioners will recognize them early and know how to best manage them. This is why we added
examples of “classic” periprocedural complications.
We believe that this book fills a unique void in the field of interventional neuroradiology in that
it provides extensive information about the pathologic mechanisms involved in the diseases that we
are asked to treat and describes in detail the latest treatment options available. We hope that you
and your patients will derive the full benefit of our experience as described herein.

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