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150
L. J. D. Sebastian et al.
a
c
d
Fig. 13.21 Spinal dural AVF embolization. A 56-year-old male presented with insidious onset, gradually progressive, weakness, and tingling sensation in both lower limbs (power 4/5) with straining during
micturition for last 3years. (a) Sagittal T2W MRI spine shows a long
segment, T2 hyperintensity involving the cord from D9-D12 vertebral
body levels, with ow voids over cord surface (D10–D12 vertebral
body levels), without any contrast enhancement or hematomyelia. (b)
e
Diagnostic angiogram shows a dural AVF feeding from the radicular
branch of right D8 segmental artery, draining into the perimedullary
venous plexus. (c) Microcatheter angiogram into the radicular vessel
conrmed the ndings. (d & e) 20% NBCA glue was injected to completely obliterate the stula, which was conrmed on a check angiogram. (f) Follow-up MRI after 2months revealed reduction in spinal
cord signal changes with reduction in ow voids
fb
3. Dilute glue—15–25%, depending on the microcatheter
position and ow—is the embolic agent of choice. Glue
should reach the footplate and proximal segment (1–2cm)
of the draining vein. Falling short of the venous footplate
or excessive glue into the coronal plexus can leave persistent stula or precipitate excessive venous thrombosis,
respectively.
13.5.4.2 SCAVS (Figs.13.22 and13.23)
Treatment is essentially endovascular. In SCAVF, treatment
intent is curative (stula elimination and venous decongestion). For SCAVM, intent is stabilization and elimination of
weak points. All feeder pedicles are identied, after which
the larger and shorter one is used for superselective microcatheter navigation and embolization. Glue is embolic agent
of choice. Non-adhesive liquid embolics (like Onyx) are better avoided for spinal vascular embolizations.
13.5.4.3 Spinal Epidural AVMs
Treatment goal is inducing thrombosis and causing size
reduction of large venous sacs in epidural/osteodural AVM/
AVFs. The most appropriate vessel, among the leash of vessels applying epidural AVM, is selected based on proximity
to the venous sac, and the absence of radiculo-medullary
supply from the same vascular pedicle is ensured. Dilute
glue is injected such that it reaches the venous sacs. Even
minimal amount of glue has the capacity to cause progressive thrombosis of the sac.
13.5.4.4 Metameric AVMs
They are difcult to treat. Among the intradural and osteodural components, epidural component is easier to treat.
Cord component is better not touched, unless there are denitive indications like hematomyelia.
13 Interventions inIntracranial andSpinal Arteriovenous Malformations
151
a
b
d
e
f
c
Fig. 13.22 Glomerular AVM.A 14-year-old boy presented with severe
backache and sudden onset quadriparesis. (a) Sagittal T2W MRI reveals
hematomyelia (arrow) with multiple intradural vascular ow voids
along the anterior aspect of the spinal cord (arrowhead). (b) Diagnostic
angiogram shows a glomerular type AVM in cervical region (black
arrow), feeding from a branch (white arrow) of left vertebral artery and
draining into the anterior spinal vein (arrowhead). (c) Selective micro-
catheter angiogram reveals the origin of anterior spinal artery from
feeding branch. The AVM was embolized using NBCA, and control
angiogram post-embolization (d) revealed no residual AVM. (e) The
anterior spinal artery was seen reconstituted from radiculomedullary
arteries at other cervico-dorsal levels. (f) Resolution of ow voids was
seen in MRI after 3months
152
L. J. D. Sebastian et al.
a
b
ce
f
d
Fig. 13.23 Spinal cord AVF.A 1-year-old male child presented with
spastic paraparesis. (a) Sagittal T2W MRI shows a large venous pouch
(arrow), anterior-lateral to the spinal cord at lower dorsal level, possibly
feeding from a branch of the segmental artery arising from the aorta and
draining into a dilated anterior spinal vein superiorly (arrowhead). (b)
Diagnostic angiogram reveals a spinal cord macro-stula (AVF) (black
arrow) at the lower dorsal level, feeding from radiculomedullary artery
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Other Neurointerventions
LeveJosephDevarajanSebastian, NikhilaGunnaReddy,
andSavyasachiJain
14
Key Messages
1. Apart from intracranial aneurysms, Arterio-Venous malformations (AVMs), and stroke, a neurointerventionist
has to tackle a wide range of vascular and sometimes nonvascular problems of the head, neck, and spine.
2. Endovascular coiling is the technique of choice for
carotico-cavernous stula (CCF).
3. Massive epistaxis caused by cavernous internal carotid
artery (cICA) pathologies can be managed by endovascular means.
4. Intra-arterial chemotherapy is used as salvage therapy in
retinoblastoma when systemic chemotherapy and intravitreous treatments fail.
5. Preoperative embolization is performed in many tumors
such as meningioma, hemangioblastoma, nasopharyngeal angiobroma, glomus jugulare, and paragangliomas
to reduce blood loss.
14.1 Introduction
Apart from aneurysms, AVMs, and stroke, a neurointerventionist is called to tackle a wide range of vascular and sometimes nonvascular problems involving the head, neck, and
spine. Here we shall briey review some of these conditions.
This will be largely a pictorial essay based on illustrative
cases.
14.2 Direct CCF
Penetrating injuries by sharp objects can lead to CCF,
especially in children. Injury to cavernous ICA during skull
base or trans-sphenoidal surgeries can also cause CCF.
14.2.1 Relevant Anatomy andPathogenesis
Cavernous ICA (C4 segment) is surrounded by the venous
plexus (cavernous sinus) and is partially xed by the dura
distally at the dural ring just before the ICA enters subarachnoid space and proximally to the petrous bone. This relative
xity of the ICA in the region makes it vulnerable to
injuries.
Since cavernous sinus has extensive connections, ow
from the stula can be in multiple directions. Clinical symptoms and severity depend on the direction and severity of
venous ow, as listed below. In many cases, symptoms are
predominantly due to venous hypertension [1]. Symptoms
due to arterial steal can also occur.
Anterior: drainage into the ophthalmic venous system pro-
duces proptosis, chemosis, raised ocular pressure (glau-
coma), and loss of vision.
Posterior: drains into the inferior/superior petrosal sinus or
the occipital transverse sinus. Patients complain of tinni-
tus or cranial nerve dysfunction.
Contralateral: both cavernous sinuses anastomose anteri-
orly and posteriorly. Both eyes may be involved with vari-
able severity.
Direct CCFs are mostly traumatic in nature and are common
in the Indian subcontinent mostly due to road trafc accidents, especially motorbike accidents. It is more common in
young males.
L. J. D. Sebastian (*) · N. G. Reddy · S. Jain
Department of Neuro-radiology and Neurointerventions, All India
Institute of Medical Sciences, Delhi, India
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024
S. H. Chandrashekhara (ed.), Textbook of Interventional Radiology, https://doi.org/10.1007/978-981-97-9601-4_14
14.2.2 Treatment
It is essentially endovascular (Figs. 14.1 and 14.2). DSA
helps determine the exact location of stula and adequacy of
the cross-ow. Previously available options include embolization with detachable balloons, an elegant way of treatment.
It requires 8F or 9F access and the meticulous process of
loading of a suitable gold valve balloon of suitable size in the
155
156
L. J. D. Sebastian et al.
a
e
b
f
c
d
g
Fig. 14.1 Endovascular treatment of direct CCF by simple coiling. A
young man presented with right proptosis 3months after a road trafc
accident. Right ICA angiogram in anteroposterior (a) and lateral (b)
projections demonstrates the direct CCF with near complete steal.
Cross-compression study reveal the exact location of the stula. Here
specially designed delivery microcatheter. This technique is
almost obsolete as the balloons are no more available in
many parts of the world.
Coiling Currently endovascular coiling is the technique of
choice. We can take transarterial, transvenous, or both. One
or two microcatheters may be used. A balloon microcatheter
can also be used to prevent coil prolapse into the parent
artery. Strategic coiling aimed at reducing gradient across
the stula and increasing antegrade laminar ow helps early
obliteration of the stula with a minimum number of coils
[2, 3].
vertebral angiogram in lateral projection (c) with right carotid manual
compression shows the rent close to the anterior genu of right cavernous ICA.A microcatheter is navigated across the stula (d) and progressive coiling is done (e and f). Control angiogram (g) shows complete
occlusion of the stula with restoration of antegrade ow
Onyx (high density) can also be used along with coils
where protection of the neck by a balloon microcatheter is
essential.
Parent artery occlusion can also be done in severely lacerated arteries if there is adequate cross-ow.
Outcomes Generally immediate improvement in proptosis
and chemosis is seen with good long-term outcomes.
However, decits due to direct injury, e.g., loss of vision due
to optic nerve injury, may not be reversed. Hence thorough
pre-op examination and prognostication are essential.
bc
14 Other Neurointer ventions
a
157
d
Fig. 14.2 Endovascular treatment of direct CCF by detachable balloons.
Right ICA angiogram (a, b) shows direct CCF with rent in the horizontal
segment of cavernous ICA. A detachable balloon mounted on a delivery
microcatheter is navigated across the stula (c) and inated and detached
e
14.3 Epistaxis
Massive epistaxis due to cavernous internal carotid artery
(cICA) pathology is a life-threatening condition. Most common causes are craniofacial trauma, mishaps during skull
base surgeries, and rarely spontaneous rupture of giant, dissecting, or mycotic cICA aneurysms. Immediate post nasal
packing can provide temporary cessation of nasal bleeding,
but denitive management of cICA aneurysm is a must, otherwise recurrence will be there. Surgical management of
cICA aneurysm is often cumbersome and difcult, whereas
endovascular methods can offer better solutions.
• The diagnosis of clinically suspected cICA pathology causing nasal bleeding should be conrmed using CT imaging,
CT angiography, or magnetic resonance imaging. Catheter
angiography (DSA—digital subtraction angiography) is
the gold standard and offers the opportunity to perform
endovascular treatment simultaneously [4, 5].
• Management options are endovascular embolization,
clipping of aneurysm neck, or ligation of the internal
f
close to the rent by gently pulling the microcatheter. Native image
(d)shows two such balloons deployed sequentially. The inated balloons
on the venous side of the rent shut the stula. Control angiogram shows
(e, f) complete sealing of the stula with good antegrade ow
carotid artery. Endovascular treatment is often superior to
surgical management.
• Being relatively rare conditions, there are no well-set
guidelines evolved for the treatment of cICA pseudoaneurysms. Both vessel preserving (reconstructive procedure)
and parent artery occlusion (deconstructive) techniques
have been proposed in the literature for the management
of cICA pathology depending upon several factors like
the etiology, anatomy of rent, involved segment length,
site, diseased or dissected segment of ICA proximal or
distal to lesion, age of the patient, and the status of cross
circulation.
• Trapping of the pseudoaneurysm by parent artery occlusion (PAO) by coils is a safe and effective treatment strategy in patients with patent circle of Willis and good
collateral circulation. Deploying some coils in the aneurysmal sac, i.e., endosaccular coiling along with PAO provides additional safety by eliminating the chance of
recanalization. This method of treatment is especially
preferred if a long segment of the arterial segment is diseased or dissected. As implied, prior balloon occlusion
158
L. J. D. Sebastian et al.
test is preferable before proceeding with permanent
occlusion.
• Treatment decisions become difcult when collateral circulation is proven inadequate on balloon occlusion test in
a given patient. An emergency external carotid-middle
cerebral artery (ECA–MCA) bypass followed by PAO as
described above is an option, though it is logistically challenging in many centers. Use of ow diverter or stent graft
may be useful in such cases.
• Reconstruct techniques include endosaccular coiling,
stent-assisted coiling, stent graft, or ow diverter placement [6]. Endosaccular coiling can be challenging as it
involves careful selective coiling of the pseudoaneurysm
which invariably projects into the sphenoid sinus. If the
aneurysmal neck is broad or of dissecting type, it will be
difcult to safeguard the parent arterial lumen. Stentassisted coiling is of help in these situations. Though bare
stents are technically easy to deploy, there are multiple
reports related to recanalization of the PSAs after using
such stents as the blood can ow through the interstices in
the stent into the pseudoaneurysm [7, 8].
• Covered stents or stent grafts, when deployed optimally,
are the fool-proof means of immediate and complete
obliteration of PSAs. But they are relatively stiffer, and
their negotiability and deployment are challenging, especially in intracranial ICA [9]. Various reported complications such as embolic strokes, dissection, thrombosis,
rupture, and stent kinks are the potential drawbacks.
14.4 Neck Vessel Pathologies
14.4.1 Pediatric Pseudoaneurysms oftheNeck
14.4.2 Etiopathogenesis
• Most common causes are infection and trauma. A few
rare cases of congenital aneurysms and spontaneous dissecting aneurysms in the setting of weakened vessel wall
such as collagen vascular disorders and neurobromatosis- I are also reported [10]. Infections of the deep neck
space including retropharyngeal/parapharyngeal/peritonsilar abscesses and cervical lymphadenitis can involve the
arterial wall contiguously, resulting in pseudoaneurysm.
• Traumatic pseudoaneurysms are common as the child
ages, especially in teenage children, probably due to the
increased outdoor activities. Traumatic pseudoaneurysms
are reported after a fall from trampoline and paintball
injuries.
• These aneurysms are also seen after iatrogenic trauma in
the setting of tonsillectomy or abscess drainage of neck
space infections. Pseudoaneurysms arising after partial
healing of either traumatic or spontaneous dissection,
especially of vertebral arteries, are usually small with or
without coexisting stenosis of the involved vessel [11].
14.4.3 Clinical Presentation
The etiology and location of the aneurysm dictate the clinical
presentation in a given case. Large pulsatile neck swelling,
difculty in breathing or stridor due to airway compression,
and difculty in swallowing due to pharyngeal compression
are some of the common presentations. Stroke or transient
ischemic attacks due to emboli and life-threatening bleeding
are other presentations.
Infectious or posttraumatic pseudoaneurysms involving
major arteries of the neck are not uncommon in pediatric
population. They are often associated with or mimic lymph
nodal or other inammatory masses of the neck such that an
unsuspecting physician may tend to biopsy or drain them
with disastrous consequences. High index of suspicion and a
good quality ultrasonogram and Doppler examination will
help make the correct diagnosis in most of the cases. CT
angiogram is useful for treatment planning and for clarifying
the diagnosis in doubtful cases.
These lesions carry the potential for massive bleeding or
airway compression due to sudden enlargement. Hence
timely evaluation and treatment are warranted. Surgical
treatment is often difcult and cumbersome while endovascular techniques can offer simpler solutions in most of the
cases (Figs. 14.3 and 14.4). Parent vessel occlusion is the
commonly adopted strategy, while in selected cases reconstructive approaches are also possible as illustrated here.
14.4.4 Management
• In acute presentations attention should be paid to basic
resuscitation steps before venturing into denitive
treatment.
• Securing airway with elective intubation or tracheostomy
will be useful in most of the patients.
• In cases of mycotic aneurysms, appropriate antibiotics in
adequate dosage is the rst and essential step in the
management.
• Emergent endovascular treatment is indicated in children
presenting with life-threatening oral/ear bleeding or rapidly
enlarging neck swelling with a fall in hemoglobin. These
patients are best treated with parent vessel sacrice after
ensuring adequacy of collateral ow to the affected vascular territories. Deconstructive procedures can be surgical
ligation of the parent vessel, endovascular parent vessel
sacrice, or endovascular trapping of the aneurysm.
a
c
14 Other Neurointer ventions
b
159
d
e
Fig. 14.3 Endovascular management of PSA of neck. CT (a, b) showing
large extracranial pseudoaneurysm. Right CCA (c, d) run showing giant
distal cervical ICA aneurysm with tortuous cervical ICA.Left vertebral
f
run (e, f) showing good cross-ow across PCOM into the right MCA territory. Native unsubtracted right CCA angiogram (g) showing patent
artery occlusion (PAO) with coils in cervical ICA proximal to the loop
g
• Parent vessel reconstructive procedure can also be successfully employed in suitable cases, especially in nonemergent situations. Surgical resection of the aneurysmal
segment with end-to-end anastomosis or vessel grafting
can prove a demanding procedure with high rate of complications. Endovascular options like stent-assisted coiling or stent graft (covered stent) deployment across the
aneurysm offer elegant solutions.
• Use of bare metal stent alone or with coils has a high
chance of recurrence. Coils can also erode into the pharyngeal mucosa over time and can protrude into the oral
or pharyngeal cavity [12, 13].
• Stent graft can provide immediate sealing off of the aneurysm [14]. Favorable factors for using the stent graft
include relatively straight segment of the involved vessel,