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      Therapeutic occlusion of the vertebral artery using a new penumbra occlusion device system and ruby coils (penumbra): A technical note

      case-report

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          Abstract

          There are several methods to achieve the therapeutic sacrifice of the vessel, coiling brings the most commonly used. Penumbra occlusion device (POD) system is a newer modality for therapeutic large vessel occlusion, and it is the Food and Drug Administration approved only for peripheral vessels. We report a case where therapeutic vertebral artery (VA) occlusion was achieved with the POD system and Ruby coils for the first time. A patient was diagnosed with a new malignant-appearing tumor of the cervical spine. A conventional angiogram showed multiple tiny arterial feeders from the VA beyond scope of coil/onyx embolization, so we performed a balloon occlusion test followed by therapeutic sacrifice of the VA. A successful VA occlusion was achieved with significant reduction in the tumor blush, followed by open resection of the tumor. The patient had favorable postoperative course and without any neurological symptoms attributed to the VA occlusion.

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          Endovascular treatment of unruptured aneurysms.

          D. Roy, G Milot, J. Raymond (2001)
          We sought to better define the morbidity of endovascular Guglielmi detachable coil (GDC) treatment of unruptured cerebral aneurysms and to discuss its role in the prevention of subarachnoid hemorrhage. We conducted an observational study from August 1992 to June 1999 of 125 unruptured aneurysms treated with GDC in 116 patients: 91 women (78.4%) and 25 men (21.6%), aged 30 to 78 years (mean age, 50.6 years). Immediate and late clinical results were recorded for any neurological event or hemorrhage related to the treated unruptured aneurysm. Angiographic results are reported as immediate, early (2 to 12 months), intermediate (12 to 30 months), and late follow-up (>30 months). Immediate angiographic results showed complete obliteration (class 1) in 59 (47.2%) or residual neck (class 2) in 53 aneurysms (42.4%), leaving 6 residual aneurysms (4.8%) and 7 failures (5.6%). Early follow-up angiograms, available in 100 treated aneurysms (84%), revealed class 1 in 52% and class 2 in 41%. Intermediate angiograms, available in 53 aneurysms (44.5%), showed class 1 in 47.2% and class 2 in 43.4%, while late results, available in 37 lesions (31.1%), had class 1 and 2 in 48.6% and 37.8%, respectively. Six patients suffered a permanent neurological deficit at last follow-up (5.2%), with a good outcome in 5 patients and fair outcome in 1 patient. There was no mortality. There was no aneurysmal rupture during a mean clinical follow-up of 32.1 months. Endovascular treatment with GDC for unruptured aneurysms is relatively safe. Its role in the prevention of aneurysmal rupture remains to be determined, preferably by a randomized study.
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            Embolization of intracranial arteriovenous malformations with ethylene-vinyl alcohol copolymer (Onyx).

            V Panagiotopoulos, E Gizewski, S Asgari … (2009)
            Endovascular therapy of intracranial arteriovenous malformations (AVMs) is increasingly used. However, it is still under discussion which embolic material is optimal. We report our experience in the treatment of AVMs with ethylene-vinyl alcohol copolymer (Onyx). Between July 2002 and January 2008, brain AVMs were embolized with Onyx in 82 consecutive patients in our department. There were 41 females and 41 males with a mean age of 44.2 years (range, 15-85 years). Clinical presentation included symptoms due to intracerebral hemorrhage (n = 37), seizures (n = 18), nonhemorrhagic neurologic deficits (n = 8), headaches (n = 9), or incidental symptoms (n = 10). According to the Spetzler-Martin scale, 59 AVMs were grades I-II, 16 were grade III, and 7 were grades IV-V. Complete obliteration at the end of all endovascular procedures was achieved in 20/82 patients (24.4%), with an average of 75% (range, 30%-100%) volume reduction. A mean of 2.9 (range, 1-10) feeding pedicles was embolized per patient, whereas an average of 2.6-mL Onyx was used per patient. Procedure-related permanent disabling morbidity was 3.8%, whereas mortality was 2.4%. The overall initial complete obliteration rate of intracranial AVMs with Onyx embolization is relatively high, compared with other embolic agents, with evidence of stability with time. Morbidomortality rates due to AVM embolization as a single treatment method or as a part of a multimodality treatment should be further assessed regarding the natural course of the disease.
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              Ligation of the vertebral (unilateral or bilateral) or basilar artery in the treatment of large intracranial aneurysms.

              C Drake (1975)
              The author reports the use of vertebral artery ligation, unilateral and bilateral, for the treatment of large vertebral-basilar aneurysms in 14 patients with one delayed death. Extracranial ligation was carried out unilaterally with a Selverstone clamp in three patients. In two, where the aneurysm filled only from one vertebral artery, there was extensive thrombosis within the sac and dramatic clinical improvement after decompression. Extracranial ligation was done bilaterally in three patients, temporarily in two. A 14-year-old boy is well after 5 years but the bilateral vertebrobasilar aneurysm did not undergo extensive thrombosis until both vertebral arteries were occluded at their intracranial entrance above collateral flow. In two others, the clamp had to be reopened on the second artery. In one patient, death from delayed thrombosis of a huge aneurysm and pontine infarction might have been prevented with anticoagulants. In the other, the aneurysm ruptured again fatally 18 months later. Unilateral intracranial occlusion of a vertebral artery was done in eight cases, with no morbidity and complete or nearly complete thrombosis in all but one aneurysm. Seven patients had excellent or good results while one showed little recovery from an existing medullary syndrome. Occlusion of the basilar artery was done in seven cases. In five it was used deliberately as the only treatment, but in two it was forced when an aneurysm burst during dissection. Only two of the patients in the first group and one of the second group have made complete recoveries. The results of vertebral artery occlusion are encouraging and the technique deserves further consideration. Extensive collateral circulation enhances the safety of cervical vertebral artery occlusion but can be of a degree to make the occlusion ineffective. For intracranial occlusion knowledge of the size and distribution of each vertebral artery is essential. Occlusion of the basilar artery is dangerous, although it seems to be effective in producing extensive thrombosis in the aneurysm. It should probably be done under anesthesia only when the artery fills spontaneously from the carotid circulation. Otherwise, even when reasonable posterior communicating arteries are demonstrated, it is best to test occlusion under local anesthesia.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Brain Circ
                Journal ID (iso-abbrev): Brain Circ
                Journal ID (publisher-id): BC
                Title: Brain Circulation
                Publisher: Wolters Kluwer - Medknow (India )
                ISSN (Print): 2394-8108
                ISSN (Electronic): 2455-4626
                Publication date Collection: Jan-Mar 2020
                Publication date (Electronic): 18 February 2020
                Volume: 6
                Issue: 1
                Pages: 52-56
                Affiliations
                [1 ] Department of Neurology, Wayne State University, Detroit, MI, USA
                [2 ] Department of Neurosurgery, Wayne State University, Detroit, MI, USA
                [3 ] Department of Orthopedics, Wayne State University, Detroit, MI, USA
                Author notes
                Address for correspondence: Dr. Jay P. Kinariwala, 4201 St Antoine, University Health Center 8A, Detroit, MI 48201, USA. E-mail: jaykinariwala@ 123456wayne.edu
                Article
                Publisher ID: BC-6-52
                DOI: 10.4103/bc.bc_18_19
                PMC ID: 7045540
                PubMed ID: 32166201
                SO-VID: 19a22d76-457b-4fb6-bf8d-2b6519095966
                Copyright © Copyright: © 2020 Brain Circulation
                License:

                This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

                History
                Date received : 30 July 2019
                Date accepted : 15 October 2019
                Categories
                Subject: Case Report

                Keywords: cervical tumor,coil embolization,penumbra,penumbra occlusion device,ruby coils,vertebral artery sacrifice
                Data availability:
                Keywords: cervical tumor, coil embolization, penumbra, penumbra occlusion device, ruby coils, vertebral artery sacrifice

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