Handbook of Cerebrovascular Disease and Neurointerventional Technique (eBook)

Contemporary Medical Imaging 2
Title Page 3
Copyright Page 4
Acknowledgments 5
Abbreviations 5
Contents 9
Introduction 10
Chapter 1 12
Essential Neurovascular Anatomy 12
1.1. Aortic arch and great vessels 12
1.2. Common carotid arteries 14
1.3. External carotid artery 14
1.3.1. Superior thyroid artery 19
1.3.2. Ascending pharyngeal artery 20
1.3.3. Lingual artery 22
1.3.4. Facial artery 22
1.3.5. Occipital artery 25
1.3.6. Posterior auricular artery 26
1.3.7. Superficial temporal artery 27
1.3.8. Internal maxillary artery 28
1.3.9. Other ECA branches 35
1.4. Internal carotid artery 37
1.4.1. Cervical segment (C1) 37
1.4.1.1. Carotid–Vertebrobasilar anastomoses 38
1.4.2. Petrous segment (C2) 40
1.4.3. Lacerum segment (C3) 41
1.4.4. Cavernous segment (C4) 41
1.4.5. Clinoidal segment (C5) 44
1.4.6. Ophthalmic segment (C6) 44
1.4.7. Communicating segment (C7) 48
1.4.8. The infundibulum: a normal variant 50
1.5. Circle of Willis 51
1.6. Anterior cerebral artery 51
1.6.1. A1 segment and anterior communicating artery complex 52
1.6.2. A2 segment 53
1.6.3. A3 branches 54
1.7. Middle cerebral artery 56
1.7.1. M1 segment 57
1.7.2. M2 segments 57
1.7.3. M3 segments 57
1.7.4. M4 branches 58
1.8. Posterior cerebral artery 60
1.8.1. PCA branches 61
1.8.2. P1 segment 61
1.8.3. P2 segment 62
1.8.4. P3 segment 65
1.8.5. P4 segment 65
1.9. Vertebral artery 66
1.9.1. V1 segment 66
1.9.2. V2 segment 66
1.9.3. V3 segment 67
1.9.4. V4 segment 67
1.10. Basilar artery 70
1.11. Venous system 72
1.11.1. Extracranial veins 73
1.11.1.1. Scalp veins 73
1.11.1.2. Orbital veins 73
1.11.1.3. Facial veins 73
1.11.1.4. Cervical veins 75
1.11.2. Venous structures of the skull 76
1.11.3. Meningeal veins 76
1.11.4. Intracranial venous sinuses 76
1.11.4.1. Superior group 76
1.11.4.2. Inferior group 79
1.11.5. Supratentorial cortical veins 80
1.11.6. Deep Venous system 81
1.11.7. Infratentorial venous system 83
1.11.8. Intracranial venous system variants 84
1.12. Spinal neurovascular anatomy 85
1.12.1. Potential spinal systems 85
1.12.2. Segmental contributions to neural territories 87
1.12.3. Extrinsic cord arteries 89
1.12.4. Intrinsic cord arteries 89
1.12.5. Spinal venous systems 89
1.12.6. Intrinsic cord veins 90
1.12.7. Extrinsic cord veins 90
1.12.8. Epidural/Extra-spinal veins 90
1.13. References 90
Chapter 2 97
Diagnostic Cerebral Angiography 97
2.1. Introduction 97
2.2. Indications 97
2.3. A brief history of cerebral angiography 97
2.4. Complications of diagnostic cerebral angiography 98
2.4.1. Neurological complications 98
2.4.2. Nonneurological complications 99
2.5. Selective cerebral angiography: basic concepts 99
2.5.1. Preprocedure evaluation 99
2.5.2. Pre-angiogram orders 100
2.5.3. Contrast agents 100
2.5.4. Femoral artery sheath (vs. no sheath) 100
2.5.5. Sedation/analgesia 100
2.5.6. Suggested wires and catheters for diagnostic cerebral angiography 101
2.5.6.1. Hydrophilic wires 101
2.6. Catheter navigation 101
2.7. Roadmapping 102
2.8. Double flushing 102
2.9. Continuous saline infusion 102
2.10. Hand injection 103
2.11. Mechanical injection 104
2.12. Vessel selection 105
2.12.1. Angiographic Images and standard views 105
2.12.2. Frame rates for digital subtraction angiography 106
2.12.3. Calibration and measurement 107
2.13. Procedures 108
2.13.1. Femoral artery puncture 108
2.13.2. Aortic arch imaging 109
2.13.3. Carotid artery catheterization 109
2.13.4. Vertebral artery catheterization 110
2.13.5. Reconstituting a Simmons 2 catheter 111
2.13.6. Femoral artery puncture site management 111
2.13.7. Closure devices 112
2.13.8. Selected femoral artery closure devices 113
2.13.9. Post-angiogram orders 113
2.14. Special techniques and situations 114
2.14.1. Radial or brachial artery puncture 114
2.14.2. Selected patient-specific considerations 114
2.14.3. Contrast-induced nephropathy 115
2.15. Risk factors for contrast-induced nephropathy 116
2.16. Methods to reduce risk of contrast-induced nephropathy 116
2.17. Metformin 116
2.18. Metformin-containing medications 116
2.18.1. Contrast reactions: prevention and management 116
2.19. Risk factors for contrast reactions 117
2.20. Premedication regimen 117
2.21. Acute contrast reactions: signs and symptoms 117
2.22. Acute contrast reactions: treatment 117
2.23. Intraoperative angiography 117
2.24. Pediatric cerebral angiography 119
2.24.1. Access 119
2.24.2. Catheters 120
2.24.3. Saline, contrast dose, and volume considerations 120
2.24.4. Imaging parameters and radiation exposure 120
2.25. Tips for imaging specific vascular structures and lesions 121
2.25.1. Atherosclerotic carotid and vertebrobasilar disease 121
2.25.2. Intracranial aneurysms 121
2.25.3. Cerebral arteriovenous malformations 121
2.25.4. Dural arteriovenous fistulas 122
2.25.5. Direct (high flow) carotid-cavernous fistulas 122
2.25.6. Aortic arch 122
2.25.7. Assessment of the circle of Willis 122
2.25.8. Carotid siphon and MCA candelabra 122
2.26. References 123
Chapter 3 126
Spinal Angiography 126
3.1. Introduction 126
3.2. Indications 126
3.3. Complications of diagnostic spinal angiography 126
3.3.1. Neurological complications 126
3.3.2. Non-neurological complications 127
3.4. Selective spinal angiography: Basic concepts 127
3.4.1. Pre-procedure evaluation 127
3.4.2. Pre-angiogram orders 127
3.4.3. Sedation/Analgesia/Anesthesia 127
3.4.4. Contrast agents 127
3.4.5. Femoral artery sheath 128
3.4.6. Suggested wires and catheters for diagnostic spinal angiography 128
3.4.6.1. Hydrophilic wires 128
3.4.7. Vessel catheterization 129
3.4.8. Roadmapping 130
3.4.9. Double flushing 130
3.4.10. Continuous saline infusion 130
3.4.11. Hand injection 130
3.4.12. Mechanical injection 130
3.4.13. Vessel selection 131
3.4.14. Angiographic images and standard views 131
3.5. Normal spinal angiographic images 132
3.5.1. Frame Rates for digital subtraction angiography 133
3.5.2. Calibration and measurement 134
3.6. Spinal angiographic procedures 135
3.6.1. Femoral artery puncture 135
3.6.2. Brachial/Axillary/Radial artery catheterization 136
3.6.3. Aortic imaging 137
3.6.4. Retrograde aortic flush 137
3.6.5. Intercostal and lumbar artery catheterization 137
3.6.6. Optimizing images by reducing respiratory or other motion 138
3.6.7. Sacral and ileolumbar artery catheterization 139
3.6.8. Vertebral artery catheterization 139
3.6.9. Thyrocervical/Costocervical trunk catheterization 139
3.6.10. Carotid artery catheterization 140
3.6.11. Reconstituting a Mikaelsson catheter 140
3.6.12. Femoral artery puncture site management 140
3.6.13. Post-angiogram orders 140
3.7. Special techniques and situations 141
3.7.1. Intraoperative spinal angiography 141
3.8. Tips for imaging specific lesions 141
3.8.1. Spinal intra-or perimedullary arteriovenous malformations 141
3.8.2. Spinal perimedullary arteriovenous fistulae 141
3.8.3. Dural arteriovenous fistulas 142
3.8.4. Spinal intramedullary vascular tumors 142
3.8.5. Spinal extradural vascular tumors 142
3.8.6. Preoperative angiography for surgery that may risk occlusion of the spinal cord blood supply 142
3.9. References 142
Chapter 4 144
Neuroendovascular Suite 144
4.1. Organization and essential equipment 144
4.2. Angiography equipment 145
4.2.1. Technical specifications 145
4.3. Radiation safety 147
4.3.1. Patient radiation exposure 147
4.3.2. Staff radiation exposure 147
4.4. Physiological monitoring 148
4.5. Personnel 148
4.5.1. Neurointerventionists 148
4.5.2. Neurointerventional technologists 149
4.5.3. Nursing staff 149
4.6. Pharmacologic considerations 149
4.7. Future developments 150
4.8. References 150
Chapter 5 152
Intracranial Aneurysm Treatment 152
5.1. Intracranial aneurysm embolization 152
5.1.1. Indications and contraindications 152
5.1.2. Patient preparation 152
5.1.2.1. Evaluation 152
5.1.2.2. Treatment strategy 153
5.1.2.3. Pre-procedure preparation 153
5.1.3. Endovascular technique 153
5.1.3.1. Awake or asleep? 153
5.1.3.2. Awake 154
5.1.3.3. Asleep 154
5.1.3.4. Vascular access phase 154
5.1.3.5. Aneurysm coiling phase 157
5.2. Device selection 158
5.2.1.1. Aneurysm access technique 165
5.2.1.2. Coiling technique 166
5.2.3. Onyx 167
5.2.3.1. Onyx technique 168
5.2.3.2. Post-procedure management 168
5.2.4. Adjunctive techniques for the treatment of wide-necked aneurysms 170
5.2.4.1. Balloon-assisted coiling 170
5.2.4.2. Stent-assisted coiling 171
5.2.4.3. Neuroform vs. Enterprise 171
5.2.4.4. General stent-assisted coiling procedures 172
5.2.4.5. Neuroform technique 173
5.3. Enterprise technique 175
5.3.1.1. “Double catheter” coiling technique 176
5.3.1.2. Partial coiling 177
5.3.2. Complications: avoidance and management 177
5.3.2.1. Overview of complications and complication rates with coiling 177
5.3.2.2. Aneurysm or vessel perforation 177
5.3.2.3. Thromboembolism 178
5.3.2.4. Coil dislodgement or embolization 180
5.3.2.5. Coil stretching 180
5.3.2.6. Vessel dissection 181
5.3.2.7. Aneurysm recurrence 182
5.4. Parent vessel sacrifice 183
5.4.1. Indications and contraindications 183
5.4.1.1. General indications 183
5.4.1.2. Relative contraindications 183
5.4.2. Endovascular technique 183
5.4.2.1. Patient preparation and vascular access 183
5.4.2.2. Coil embolization 184
5.4.2.3. Detachable balloon embolization 184
5.5. References 185
Chapter 6 187
Provocative Testing 187
6.1. Introduction 187
6.2. Mechanical provocative testing: Balloon test occlusion 187
6.2.1. Background 187
6.2.2. Adjunctive tests of neurological function 188
6.2.3. Adjunctive tests of blood flow 189
6.2.4. Indications for test occlusion 191
6.2.5. Complications of balloon test occlusion 192
6.2.5.1. Neurological complications 192
6.2.5.2. Nonneurological complications 192
6.2.6. Balloon test occlusion: Procedural aspects 192
6.2.6.1. Preprocedure evaluation 192
6.2.6.2. Preprocedure orders 192
6.2.6.3. Contrast agents 193
6.2.6.4. Femoral artery sheath 193
6.2.6.5. Saline infusion 193
6.2.6.6. Anticoagulation 193
6.2.6.7. Sedation/Anesthesia 193
6.2.7. Suggested catheters, balloons, and guidewires for test occlusion 193
6.2.7.1. Diagnostic and guiding catheters for balloon test occlusion 193
6.2.7.2. Balloons for balloon test occlusion 194
6.2.7.3. Guidewires 195
6.2.8. Procedures 195
6.2.8.1. Femoral access 195
6.2.8.2. Alternative access 195
6.2.8.3. Catheter and balloon manipulation 196
6.2.8.4. Technique: double-lumen balloon catheter 196
6.2.8.5. Technique: microballoon catheter 197
6.2.8.6. Technique: balloon wire 198
6.2.8.7. Tips for using the Guardwire® 199
6.2.9. Postprocedure 199
6.2.10. Venous test occlusion 199
6.3. Pharmacologic provocative testing 199
6.3.1. Wada test: intracarotid amobarbital procedure 199
6.3.1.1. A brief history of the Wada test 199
6.3.1.2. Strange, but true 200
6.3.1.3. Memory testing in the Wada test 200
6.3.1.4. Confounding factors possibly affecting the results of the Wada test 201
6.3.1.5. Indications for the Wada test 201
6.3.1.6. Complications of the Wada test 201
Neurological Complications 201
Nonneurological Complications 201
6.3.1.7. More strange, but true 202
6.3.1.8. Wada test: Procedural aspects 202
Preprocedure Evaluation 202
Preprocedure Orders 202
Personnel Requirements 202
Contrast Agents 202
Femoral Artery Sheath 202
Saline Infusion 203
Anticoagulation 203
Sedation/Anesthesia 203
Suggested Catheters and Guidewires for the Wada Test 203
6.3.1.9. Procedures 203
Amobarbital Preparation 203
Amobarbital Dosage 203
Catheter Preparation 203
Femoral Access 204
Catheter Manipulation 204
Technique: Amobarbital Test 204
Postprocedure Care 205
Other Pharmacological Agents for Wada Testing 205
6.3.2. Superselective Wada test 205
6.3.2.1. Indications for superselective Wada testing 205
6.3.2.2. Complications of the superselective Wada test 205
6.3.2.3. Technique for superselective Wada testing 205
6.3.3. Alternatives to Wada testing 206
6.3.3.1. Language testing 206
6.3.3.2. Memory testing 206
6.3.3.3. The bottom line 206
6.3.4. Preembolization provocative testing 207
6.3.4.1. Procedures 207
Amobarbital Preparation 207
Lidocaine Preparation 207
Preparation for Adjunctive Testing 207
Vascular Access 208
Technique: Provocative Test 208
Syringe Safety 209
6.4. References 209
Chapter 7 213
Intracranial Embolization Procedures 213
7.1. Introduction 213
7.2. Intracranial embolization: Indications and contraindications 213
7.2.1. Common indications 213
7.2.2. Relative contraindications 213
7.3. Intracranial vascular access and embolization: Techniques and devices 214
7.3.1. Evaluation 214
7.3.2. Treatment strategy 214
7.3.3. Preprocedure preparation 214
7.4. Endovascular technique 215
7.4.1. Awake or asleep? 215
7.4.2. Awake 216
7.4.3. Asleep 216
7.4.4. Vascular access phase 216
7.4.5. Microcatheter access phase 223
7.4.6. Syringe safety 232
7.4.7. Embolization phase 232
7.4.8. Postprocedure puncture site care 249
7.4.9. Postprocedure management 249
7.5. Tips on specific disease processes 250
7.5.1. A brief history of brain AVM embolization 254
7.6. Intracranial embolization: Complication avoidance and management 256
7.6.1. Neurological complications 256
7.6.2. Nonneurological complications 256
7.6.3. Complications of brain AVM embolization: the big picture 256
7.6.3.1. Complications of intracranial tumor embolization 257
7.6.4. Discussion of selected complications 257
7.6.4.1. Vessel perforation 257
7.6.4.2. Thromboembolism 258
7.6.4.3. AVM rupture 259
7.6.4.4. Postembolization edema or hemorrhage (aka normal perfusion breakthrough syndrome) 260
7.6.4.5. Vessel dissection 260
7.6.4.6 Retained microcatheter (aka glued microcatheter) 261
7.6.4.7. Prevention of guide catheter-induced vasospasm 262
7.7. References 262
Chapter 8 266
Extracranial Embolization 266
8.1. Introduction 266
8.2. Extracranial embolization: Indications and contraindications 266
8.2.1. Indications: Head and neck embolization 266
8.2.2. Indications: Spinal embolization 267
8.2.3. Relative contraindications 267
8.3. Extracranial vascular access and embolization: Techniques and devices 267
8.3.1. Evaluation 267
8.3.2. Treatment strategy 268
8.3.3. Preprocedure preparation 268
8.4. Endovascular technique 268
8.4.1. Awake or asleep? 268
8.4.1.1. Awake 269
8.4.1.2. Asleep 269
8.4.2. Vascular access phase 269
8.4.3. Microcatheter access phase 275
8.4.4. Syringe safety 280
8.4.5. Embolization phase 280
8.4.5.1. Post-procedure puncture site care 296
8.4.5.2. Post-procedure management 296
8.5. Tips on specific disease processes 297
8.5.1. Tips: Head and neck embolization 297
8.5.2. Tips on spinal embolization 301
8.6. Complications: Avoidance and management 303
8.6.1. Complications of extracranial embolization 303
8.6.1.1. Neurological complications 303
8.6.1.2. Nonneurological complications 304
8.6.2. How to avoid extracranial embolization complications in ten easy steps 304
8.7. References 304
Chapter 9 308
Thrombolysis for Acute Ischemic Stroke 308
9.1. Thrombolysis for acute stroke: General considerations 308
9.1.1. The art of speed 308
9.1.2. Thrombolytic agents 309
9.1.2.1. Patient preparation 310
Evaluation 310
Pre-Procedure Preparation 311
9.2. Patient selection for thrombolysis 311
9.2.1. Indications 311
9.2.2. Absolute contraindications 311
9.2.3. Relative contraindications 311
9.2.4. Decision-making: IV or IA thrombolysis? 311
9.2.4.1. Patient selection for IV thrombolysis 313
9.2.4.2. Patient selection for IA thrombolysis 313
9.3. Intravenous thrombolysis for acute ischemic stroke 314
9.3.1. IV t-PA protocol7 315
9.3.1.1. Ultrasound augmentation of IV thrombolysis 315
9.3.2. Patient management after thrombolysis 315
9.3.3. Complications (management of complications is discussed below) 315
9.4. Intra-arterial thrombolysis for acute ischemic stroke 316
9.4.1. Endovascular technique 316
9.4.1.1. Awake or asleep? 316
9.4.1.2. Access phase 316
Heparin or No Heparin? 317
9.4.1.3. Thrombolysis phase 317
Device Selection 317
Pharmacological Thrombolysis 318
9.4.1.4. Postprocedure care 319
Mechanical Embolectomy 319
Merci® Retriever 321
Penumbra System™ 324
Alternative Devices for Mechanical Thrombectomy 325
9.4.2. Perfusion augmentation: The Neuroflo™ system 326
9.4.3. Patient management after IA thrombolysis 326
9.4.4. Complications (management of complications is discussed below) 327
9.4.5. Combined IV + IA strategies 327
9.4.6. Thrombolysis complications: Management 328
9.5. Special situations 329
9.5.1. Basilar artery occlusion 329
9.5.1.1. Radiographic evaluation 329
9.5.1.2. Patient selection for thrombolysis 329
Inclusion Criteria 329
Exclusion Criteria 329
9.5.1.3. Technique 330
IA Thrombolysis 330
IV Thrombolysis 330
9.5.1.4. Outcomes and complications 330
9.5.2. Associated carotid stenosis + stroke 330
9.5.2.1. Technique 331
9.5.3. Extracranial carotid or vertebral dissection + stroke 332
9.5.3.1. Technique 332
9.5.4. Associated intracranial stenosis + stroke 333
9.5.4.1. Technique 333
9.5.5. Central retinal artery occlusion 334
9.5.5.1. Diagnosis 335
9.5.5.2. Non-endovascular treatment 335
9.5.5.3. Technique 335
9.5.6. Venous occlusion 336
9.6. Appendix 1: Primer on imaging in stroke 336
9.6.1. Noncontrast computed tomography 336
9.6.1.1. Noncontrast CT diagnosis of acute ischemia 336
Specific Findings that may Indicate Ischemia 337
9.6.2. CT perfusion 337
9.6.2.1. CT perfusion technique 338
Parameters 338
Concepts 338
9.6.2.2. Interpretation of CT perfusion data 340
9.6.2.3. CT perfusion in ischemic stroke 341
Validation of CT Perfusion in Acute Ischemic Stroke 342
9.6.3. CT Angiography 343
9.6.4. MRI 343
Diffusion-Weighted Imaging 344
Perfusion Imaging 344
MR Angiography 345
Identification of Hemorrhage on MRI 346
9.7. Appendix 2: NIH stroke scale 346
9.8. References 348
Chapter 10 354
Extracranial Angioplasty and Stenting 354
10.1. Carotid bifurcation lesions 354
10.1.1. Indications and contraindications 354
10.1.2. Patient preparation 355
10.1.2.1. Evaluation 355
10.1.2.2. Preprocedure preparation 356
10.1.3. Endovascular technique 356
10.1.3.1. Access phase 356
10.1.3.2. Tips for difficult access cases 357
10.1.3.3. Intervention phase 358
10.1.3.4. Postprocedure management 360
10.1.3.5. CAS tips 360
10.1.3.6. Tips for handling difficult CAS situations 360
10.1.4. Risk factors for CAS complications 361
10.1.5. Management of neurological complications during or after CAS 361
10.1.6. CAS pearls 363
10.1.6.1. Embolic protection devices 363
10.1.6.2. Filter devices 363
10.1.6.3. Balloon-Occlusion devices 364
10.1.6.4. Flow-Reversal device 364
10.1.6.5. Stents 364
10.1.6.6. Carotid stenting for dissection or pseudoaneurysm 365
10.2. Vertebral artery lesions 366
10.2.1. Extracranial vertebral artery stenosis distal to the origin 366
10.2.1.1. Tips 366
10.2.2. Indications 366
10.2.3. Contraindication 367
10.2.4. Patient preparation 367
10.2.5. Endovascular technique (vertebral artery origin lesions) 367
10.3. Carotid artery origin lesions 368
10.3.1. Indications 368
10.3.2. Contraindication 369
10.3.3. Patient preparation 369
10.3.4. Endovascular technique 369
10.4. References 370
Chapter 11 372
Endovascular Treatment of Intracranial Stenosis and Vasospasm 372
11.1. Intracranial atherosclerotic stenosis 372
11.1.1. Indications for intracranial angioplasty and stenting 372
11.1.2. Contraindications 372
11.1.3. Patient preparation 372
11.1.3.1. Evaluation 372
11.1.3.2. Preprocedure preparation 373
11.1.4. Endovascular technique 373
11.1.4.1. Awake or asleep? 373
11.1.4.2. Access phase 373
11.1.4.3. Intervention phase 376
11.1.4.4. Device selection 376
11.1.4.5. Angioplasty without stent deployment 377
11.1.4.6. Balloon-Expandable stent deployment 377
11.1.4.7. Wingspan procedure 377
11.1.4.8. Postprocedure management 380
11.1.4.9. Intracranial angioplasty tips 380
11.1.5. Management of intracranial complications during or after intracranial angioplasty 380
11.2. Endovascular treatment of cerebral vasospasm 381
11.2.1. Indications for endovascular treatment of cerebral vasospasm 381
11.2.1.1. Awake or asleep? 382
11.2.2. Techniques 382
11.2.2.1. Access phase 382
11.2.2.2. Balloon angioplasty 382
11.2.2.3. Infusion of pharmacologic agents 386
11.2.3. Treatment-related complications 386
11.3. References 386
Chapter 12 388
Venous Procedures 388
12.1. Introduction 388
12.2. Venous access: Basic concepts 388
12.2.1. Femoral venous access 388
12.2.2. Alternative venous access 388
12.2.3. Catheter navigation 389
12.2.4. Tips for catheter navigation in difficult situations 389
12.2.5. Roadmapping 391
12.2.6. Double flushing 391
12.2.7. Continuous saline infusion 391
12.2.8. Anticoagulation 391
12.2.9. Hand injection 391
12.2.10. Mechanical injection 391
12.2.11. Puncture site care 391
12.3. Venography 392
12.3.1. Background 392
12.3.2. Indications for venography 392
12.3.3. Complications of venography 392
12.3.3.1. Neurological complications 392
12.3.3.2. Non-Neurological complications 392
12.3.4. Venography: Procedural aspects 393
12.3.4.1. Preprocedure evaluation 393
12.3.4.2. Preprocedure orders 393
12.3.4.3. Contrast agents 393
12.3.4.4. Femoral venous sheath 393
12.3.4.5. Saline infusion 393
12.3.4.6. Anticoagulation 393
12.3.4.7. Sedation/Anesthesia 393
12.3.5. Suggested wires and catheters for venography 394
12.3.5.1. Hydrophilic wires 394
12.3.5.2. Catheters for venography 394
12.3.6. Procedures 394
12.3.6.1 Femoral venous access 394
12.3.6.2. Catheter manipulation 395
12.3.6.3. Tips for evaluating venogram images 395
12.3.6.4. Venous pressure measurements 395
12.3.6.5. Postprocedure care 396
12.4. Venous test occlusion 396
12.4.1. Background 396
12.4.2. Indications for venous test occlusion 397
12.4.3. Complications of venous test occlusion 397
12.4.3.1. Neurological complications 397
12.4.3.2. Non-neurological complications 397
12.4.4. Venous test occlusion: Procedural aspects 397
12.4.4.1. Preprocedure evaluation 397
12.4.4.2. Preprocedure orders 397
12.4.4.3. Contrast agents 398
12.4.4.5. Femoral venous sheath 398
12.4.4.6. Saline infusion 398
12.4.4.7. Anticoagulation 398
12.4.4.8. Sedation/Anesthesia 398
12.4.5. Suggested wires and catheters for venous test occlusion 398
12.4.5.1. Access wires 398
12.4.5.2. Guiding catheters and balloons for venous test occlusion 398
12.4.6. Procedures 399
12.4.6.1. Femoral access 399
12.4.6.2. Catheter manipulation 399
12.4.6.3. Test occlusion 400
12.4.6.4. Postprocedure care 400
12.5. Venous sampling 400
12.5.1. Background 400
12.5.2. Indications for inferior petrosal sinus sampling (IPSS) 401
12.5.3. Complications of petrosal sinus sampling 401
12.5.3.1. Neurological complications 401
12.5.3.2. Non-neurological complications 401
12.5.4. Petrosal sinus sampling: Procedural aspects 401
12.5.4.1. Preprocedure evaluation 401
12.5.4.2. Preprocedure orders 402
12.5.4.3. Preprocedure preparations 402
12.5.4.4. Contrast agents 402
12.5.4.5. Personnel requirements 402
12.5.4.6. Femoral venous sheath 402
12.5.4.7. Saline infusion 402
12.5.4.8. Anticoagulation 402
12.5.4.9. Sedation/Analgesia 402
12.5.5. Suggested wires and catheters for petrosal sinus sampling 403
12.5.5.1. Hydrophilic wires 403
12.5.5.2. Catheters for petrosal sinus sampling 403
12.5.6. Procedures 403
12.5.6.1. Femoral venous access 403
12.5.6.2. Catheter manipulation 403
12.5.6.3. Inferior petrosal sinus sampling 405
12.5.6.4. Cavernous sinus sampling 405
12.5.6.5. Jugular venous sampling 406
12.5.6.6. Puncture site care 406
12.5.7. Venous sampling: Interpretation of results 407
12.5.7.1. Petrosal sinus sampling 407
12.5.7.2. Cavernous sinus sampling 410
12.5.7.3. Jugular venous sampling 410
12.5.7.4. Venous sampling in suspected ectopic ACTH production 410
12.5.7.5. Venous sampling in acromegaly 410
12.5.8. Other venous sampling procedures 411
12.6. Transvenous embolization 411
12.6.1. Background 411
12.6.2. Indications for transvenous embolization 411
12.6.3. Complications of transvenous embolization 412
12.6.3.1. Neurological complications 412
12.6.3.2. Non-Neurological complications 412
12.6.4. Transvenous embolization: Procedural aspects 412
12.6.4.1. Preprocedure evaluation 412
12.6.4.2. Preprocedure orders 413
12.6.4.3. Contrast agents 413
12.6.4.4. Venous access sheath 413
12.6.4.5. Anticoagulation 413
12.6.4.6. Sedation/Anesthesia 413
12.6.5. Suggested wires and catheters for transvenous embolization 413
12.6.5.1. Access wires 413
12.6.5.2. Guide catheters 414
12.6.5.3. Microcatheters 414
12.6.5.4. Saline infusion 414
12.6.5.5. Embolic agents 414
12.6.6. Procedures 414
12.6.6.1. Venous access 414
12.6.6.2. Arterial access 415
12.6.6.3. Intracranial access 415
12.6.6.4. Coil embolization 416
12.6.6.5. Liquid embolic embolization 416
12.6.6.6. Transarterial n-BCA Injection 416
12.6.6.7. Transarterial onyx® injection 417
12.6.7. Transvenous embolization: Tips on specific disease processes 418
12.6.7.1. Direct carotid-cavernous fistula 418
12.6.7.2. Cavernous dural arteriovenous fistula 419
12.6.7.3. Transverse/Sigmoid sinus dAVF 420
12.6.7.4. Superior sagittal sinus and other anterior cranial fossa dAVF 421
12.6.7.5. Tentorial dAVF 421
12.6.7.6. Vein of Galen aneurysmal malformation (VOGM) 421
12.6.7.7. Other intracranial dAVFs 422
12.6.7.8. Extracranial head-and-neck AVF 422
12.6.7.9. Spinal AVF 422
12.7. Venous thrombolysis/thrombectomy 422
12.7.1. Background 422
12.7.2. Indications for venous thrombolysis/thrombectomy 423
12.7.3. Complications of venous thrombolysis/thrombectomy 424
12.7.3.1. Neurological complications 424
12.7.3.2. Non-neurological complications 424
12.7.4. Venous thrombolysis/thrombectomy: Procedural aspects 424
12.7.4.1. Preprocedure evaluation 424
12.7.4.2. Preprocedure orders 424
12.7.4.3. Contrast agents 425
12.7.4.4. Venous access sheath 425
12.7.4.5. Anticoagulation 425
12.7.4.6. Saline infusion 425
12.7.4.7. Sedation/Anesthesia 425
12.7.5. Suggested wires and catheters for venous thrombolysis/thrombectomy 425
12.7.5.1. Access wires 425
12.7.5.2. Guiding catheters for venous thrombolysis/thrombectomy 425
12.7.5.3. Microcatheters 426
12.7.5.4. Balloons for venous thrombolysis/thrombectomy 426
12.7.5.5. Rheolytic catheters 426
12.7.6. Procedures 426
12.7.6.1. Venous access 426
12.7.6.2. Catheter manipulation 427
12.7.6.3. Thrombolysis 427
12.7.6.4. Balloon-assisted thrombolysis 428
12.7.6.5. Rheolytic catheter use 428
12.7.6.6. Puncture site care 429
12.8. Transvenous stenting 430
12.8.1. Background 430
12.8.2. Indications for venous stenting 430
12.8.3. Complications of venous stenting 431
12.8.3.1. Neurological complications 431
12.8.3.2. Non-neurological complications 431
12.8.4. Venous stenting: Procedural aspects 431
12.8.4.1. Preprocedure evaluation 431
12.8.4.2. Preprocedure orders 431
12.8.4.3. Contrast agents 432
12.8.4.4. Venous access sheath 432
12.8.4.5. Anticoagulation 432
12.8.4.6. Saline infusion 432
12.8.4.7. Sedation/Anesthesia 432
12.8.5. Suggested wires and catheters for venous stenting 432
12.8.5.1. Access wires 432
12.8.5.2. Venography catheters 432
12.8.5.3. Stents for venous stenting 433
12.8.6. Procedures 433
12.8.6.1. Femoral access 433
12.8.6.2. Intracranial access 433
12.8.6.3. Stent placement 434
12.8.6.4. Postprocedure Care 435
12.9. References 435
Chapter 13 440
Intracranial Aneurysms and Subarachnoid Hemorrhage 440
13.1. Intracranial aneurysms: Pathophysiology 440
13.1.1. Pathology of intracranial aneurysms 440
13.1.2. The Peculiar Infundibulum 441
13.2. Unruptured intracranial aneurysms 441
13.2.1. Prevalence 441
13.2.2. Conditions associated with aneurysms 442
13.2.2.1. Familial aneurysms 442
13.2.2.2. Connective tissue disorders 443
Ehlers–Danlos Syndrome (Eds) Type Iv 444
Alpha1-Antitrypsin Deficiency 444
Marfan Syndrome 444
Neurofibromatosis Type 1 445
Pseudoxanthoma Elasticum 445
13.2.2.3. Other conditions associated with intracranial aneurysms 445
Arteriovenous Malformation 445
Fibromuscular Dysplasia 445
Abdominal Aortic Aneurysms 445
Sickle Cell Anemia 445
13.2.2.4. Modifiable risk factors for aneurysm formation and subarachnoid hemorrhage 445
Cigarette Smoking 446
Hypertension 446
Alcohol Use 446
Oral Contraceptives 446
Atherosclerosis 446
Coffee Use 446
13.2.2.5. Natural history 446
Juvela 2000 447
Rinkel 1998 447
Morita 2005 447
13.2.2.6. International Study of Unruptured Intracranial Aneurysms 448
Isuia First Study 448
Isuia Second Study 449
Isuia Anomalies and Study Limitations 450
13.3. Aneurysm treatment 451
13.3.1. Conservative management 451
13.3.2. Treatment: Surgical results 451
13.3.2.1. Obliteration rates, recurrence, and hemorrhage after surgery 452
13.3.2.2. Complication rates with surgery 452
13.3.3. Treatment: Endovascular results 452
13.3.3.1. Angiographic results 452
Immediate Angiographic Results 453
Long-Term Angiographic Results 454
13.3.3.2. Clinical results with embolization 454
Complication Rates 454
Rupture After Coiling 454
13.3.3.3. Selected studies comparing coiling and clipping 455
Unruptured Aneurysms, Retrospective Studies 455
Unruptured Aneurysms, Prospective Studies 455
Ruptured Aneurysms, Prospective Studies 455
13.3.4. Treatment decision making: Clip or coil? 455
13.3.5. Intracranial aneurysms by type or location 456
13.3.5.1. Unruptured intracranial aneurysms presenting with mass effect 456
13.3.5.2. Cavernous ICA aneurysms 457
13.3.5.3. Paraclinoid ICA aneurysms 459
Ophthalmic Aneurysms 459
Superior Hypophyseal Artery Aneurysms 460
Other Paraclinoid Aneurysms 460
13.3.5.4. Supraclinoid ICA aneurysms 460
Posterior Communicating Artery Aneurysms 460
Anterior Choroidal Artery Aneurysms 461
Carotid Bifurcation Aneurysms 461
13.3.5.5. Anterior cerebral artery aneurysms 462
Anterior Communicating Artery Aneurysms 462
Distal Anterior Cerebral Artery Aneurysms 462
13.3.5.6. Middle cerebral artery aneurysms 463
13.3.5.7. Posterior circulation aneurysms 463
Basilar Apex 463
Posterior Cerebral Artery 464
Superior Cerebellar Artery Origin 465
Distal Superior Cerebellar Artery 465
Basilar Trunk 465
Anterior Inferior Cerebellar Artery 465
Vertebrobasilar Junction 466
Distal Vertebral/Proximal Pica 466
Distal Pica 466
13.3.5.8. A brief history of endovascular treatment of intracranial aneurysms 467
13.4. Subarachnoid hemorrhage 468
13.4.1. Aneurysmal SAH 469
13.4.1.1. Incidence 469
13.4.1.2. Diagnosis 469
Presentation 469
Radiographic Work-Up 470
Mortality, Morbidity and Outcomes 471
Rebleeding and Timing of Treatment 471
Hydrocephalus 472
Seizures 472
13.4.2. Associated medical problems 473
13.4.2.1. Hyperglycemia 473
13.4.2.2. Serum electrolyte derangements 474
Hyponatremia 474
Hypernatremia 474
Hypokalemia 475
Hypomagnesemia 475
13.4.2.3. Cardiac abnormalities 475
Ekg Changes 475
Cardiac Arrhythmias 475
Reversible Cardiomyopathy 475
13.4.2.4. Neurogenic pulmonary edema 476
13.4.2.5. Vasospasm 476
Frequency and Time Course 476
Risk Factors 477
Clinical Features and Diagnosis 477
Prevention of Ischemic Injury Due to Vasospasm 478
13.4.2.6. Treatment of vasospasm 481
Hyperdynamic Therapy 481
Angioplasty 483
Intra-Arterial Pharmacologic Treatment 483
13.4.2.7. The International Subarachnoid Aneurysm Trial 486
13.5. Intracranial aneurysms:Special situations 487
13.5.1. Pediatric aneurysms 487
13.5.1.1. Epidemiology and characteristic features 487
13.5.1.2. Management 488
13.5.2. Pregnancy and intracranial aneurysms 489
13.5.2.1. Unruptured aneurysms and pregnancy 489
13.5.2.2. Evaluation 489
13.5.2.3. SAH in pregnant patients 489
Clinical Features 489
Differential Diagnosis 489
Neurovascular Management 490
Obstetrical Management 490
Outcomes 491
13.5.3. Elderly patients with aneurysms 491
13.5.3.1. Unruptured aneurysms in the elderly 491
13.5.3.2. Subarachnoid hemorrhage in the elderly 492
13.5.4. Infectious aneurysm 492
13.5.4.1. Epidemiology and Etiology 492
13.5.4.2. Management 493
13.5.4.3. Outcomes 493
13.5.5. Giant aneurysms 493
13.5.5.1. Epidemiology 495
13.5.5.2. Presentation 495
13.5.5.3. Evaluation 495
13.5.5.4. Natural history 495
13.5.5.5. Management 495
13.5.6. Dissecting intracranial aneurysms 496
13.5.6.1. Clinical features 496
13.5.6.2. Management 497
13.5.7. Dolichoectatic, fusiform and serpentine aneurysms 497
13.5.7.1. Presentation 498
13.5.7.2. Pathogenesis 498
13.5.7.3. Natural history 498
13.5.7.4. Management 498
13.5.8. Traumatic aneurysms and traumatic subarachnoid hemorrhage 499
13.5.8.1. Traumatic aneurysms 499
13.5.8.2. Traumatic subarachnoid hemorrhage 500
13.6. References 500
Chapter 14 517
Arteriovenous Malformations 517
14.1. Pathophysiology 517
14.1.1. Pathology 517
14.1.2. Etiology 517
14.1.2.1. Physiology 518
14.2. Clinical features 518
14.2.1. Epidemiology 518
14.2.2. Anatomic feat 518
14.2.3. Conditions associated with AVMs 519
14.2.3.1. Familial intracranial AVMs 519
14.2.3.2. Hereditary hemorrhagic telangiectasia 519
14.2.3.3. Wyburn-Mason syndrome 520
14.2.3.4. Sturge-Weber syndrome 520
14.2.4. Natural history 520
14.2.4.1. Lifetime risk of hemorrhage 521
14.2.4.2. Risk factors for hemorrhage 522
14.2.4.3. Outcome after hemorrhage 522
14.2.5. Presentation 522
14.2.6. Imaging 523
14.3. Management 523
14.3.1. Expectant Management 524
14.3.2. Surgery 524
14.3.2.1. Surgical Outcomes 524
14.3.2.2. Surgery: Practical Issues 525
14.3.3. Radiosurgery 526
14.3.3.1. Radiosurgery techniques 526
14.3.3.2. Mechanism of AVM obliteration in radiosurgery 527
14.3.3.3. Radiosurgery outcomes 527
14.3.3.4. Radiosurgery: Practical issues 527
14.3.4. Surgery compared to radiosurgery 528
14.3.5. Embolization 528
14.3.5.1. A briefer history of embolization of intracranial AVMs 528
14.3.5.2. Embolization results 529
14.3.6. Specific considerations 529
14.3.6.1. Associated aneurysms 529
14.3.6.2. Large and giant AVMs 530
14.3.6.3. AVMs in children 531
14.3.6.4. Pregnancy and AVMs 532
14.4. Appendix: Vein of Galen malformations 533
14.4.1. Angiographic classification 533
14.4.2. Development, anatomy and pathophysiology 533
14.4.2.1. Embryology 533
14.4.2.2. Anatomy 534
14.4.3. Clinical features 534
14.4.4. Natural history and overall prognosis 535
14.4.5. Management and outcomes 535
14.4.5.1. Neonates 535
14.4.5.2. Treatment in neonates 536
14.4.5.3. Outcomes in neonates 536
14.4.5.4. Infants 536
14.4.5.5. Outcomes in infants 536
14.4.5.6. Children and adults 536
14.4.5.7. Outcomes in children 537
14.4.5.8. Complications of embolization procedures 537
14.5. References 537
Chapter 15 544
Dural Arteriovenous Fistulas 544
15.1. Pathophysiology 544
15.1.1. Anatomy and cl 544
15.1.2. Etiology 544
15.1.2.1. Evidence in favor of the three stage hypothesis 545
15.2. Clinical features 546
15.2.1.1. Pulsatile tinnitus: What does it mean? 546
15.2.1.2. Imaging 547
Angiography 547
MRI 547
CTA 548
15.2.2. Natural history 548
15.2.2.1. Borden type I dAVFs: Most are benign 548
15.2.2.2. Borden type II and III dAVFs: Aggressive 548
15.3. Management 549
15.3.1. Conservative management 549
15.3.2. Endovascular treatment 549
15.3.3. Surgery 549
15.3.4. Radiosurgery 550
15.4. Dural AVFs by location 550
15.4.1. Transverse-sigmoid sinus dAVFs 550
15.4.1.1. Clinical features 550
15.4.1.2. Management 551
15.4.2. Cavernous sinus dAVFs 552
15.4.2.1. Indirect CC fistulas: Clinical features 552
15.4.3. Indirect CC fistulas: Management 553
15.4.4. Tentorial dAVFs 554
15.4.4.1. Clinical features 554
15.4.4.2. Management 555
15.4.5. Superior sagittal sinus dAVFs 555
15.4.5.1. Clinical features 556
15.4.5.2. Management 556
15.4.6. Anterior fossa dAVFs 556
15.4.6.1. Clinical features 557
15.4.6.2. Management 557
15.5. Appendix: Direct carotid-cavernous fistulas 558
15.5.1.1. Direct CC fistulas: Clinical features 558
15.5.1.2. Direct CC fistulas: Manag 559
15.5.1.3. Ehlers-Danlos type IV 560
15.6. References 560
Chapter 16 566
Cavernous Malformations and Venous Angiomas 566
16.1. Cavernous malformations 566
16.1.1. Angioma Alliance 566
16.1.2. Epidemiology and risk factors 566
16.1.3. Pathophysiology 567
16.1.4. Familial form 567
16.1.4.1. Genetics 568
16.1.5. Imaging 568
16.1.6. Presentation and clinical features 569
16.1.7. Natural history 569
16.1.8. Management 570
16.1.8.1. Asymptomatic cavernous malformations 570
16.1.8.2. Seizures associated with a cavernous malformation 570
16.1.8.3. Symptomatic hemorrhagic cavernous malformations 570
16.1.8.4. Brainstem cavernous malformations 571
16.1.8.5. Radiosurgery for cavernous malformations 572
16.2. Venous angiomas 572
16.3. References 573
Chapter 17 576
Acute Ischemic Stroke 576
17.1. Acute ischemic stroke: Burden of disease 576
17.2. Acute ischemic stroke: Terminology and differential diagnosis of acute onset focal neurologic dysfunction 576
17.2.1. Terminology 576
17.2.2. Differential diagnosis of acute onset focal neurologic dysfunction 577
17.3. Acute ischemic stroke: Mechanisms 579
17.4. Acute ischemic stroke: Conventional risk factors, predisposing conditions, and risk factor modification 580
17.4.1. Acute myocardial infarction (MI) with left ventricular (IV) thrombus 581
17.4.2. Age 581
17.4.3. Alcohol consumption 581
17.4.4. Aortic arch atheroma 582
17.4.5. Arrhythmia 582
17.4.6. Atherosclerosis, arterial 582
17.4.7. Atrial fibrillation (AF) 582
17.4.8. Birth control pills 584
17.4.9. Cerebral amyloid angiopathy (CAA) 584
17.4.10. Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) 584
17.4.11. Cardiomyopathy (CM) 585
17.4.12. Cigarette smoking 585
17.4.13. Coagulopathy 585
17.4.14. C-Reactive protein 587
17.4.15. Diabetes mellitus (DM) 587
17.4.16. Dissection, arterial 588
17.4.17. Dolichoectasia, arterial 588
17.4.18. Drug abuse 588
17.4.19. Endocarditis 588
17.4.20. Ethnicity 590
17.4.21. Fabry disease 590
17.4.22. Family history of ischemic stroke 590
17.4.23. Fibromuscular dysplasia 591
17.4.24. Gender 591
17.4.25. Genetics 591
17.4.26. Hemoglobinopathy 592
17.4.27. Heparin-induced thrombocytopenia (HIT) 592
17.4.28. Hormone replacement therapy (HRT) 593
17.4.29. Hyperhomocysteinemia 594
17.4.30. Hypertension 594
17.4.31. Hypercoagulability 595
17.4.32. Hyperviscosity syndromes 595
17.4.33. Infections 595
17.4.34. Inflammation 596
17.4.35. Intima media thickness (IMT) 596
17.4.36. Lipid disorders 596
17.4.37. Metabolic syndrome 597
17.4.38. Malignancy 597
17.4.39. Migraine 598
17.4.40. Mitochondrial diseases, including MELAS 599
17.4.41. Moya-Moya disease and syndrome 599
17.4.42. Nutrition 599
17.4.43. Obesity 600
17.4.44. Obstructive sleep apnea (OSA) 600
17.4.45. Oral contraceptives (OCP) 600
17.4.46. Patent foramen ovale (PFO) 601
17.4.47. Physical inactivity 602
17.4.48. Sickle cell disease (SCD) 602
17.4.49. Tobacco, smoked 603
17.4.50. Valvulopathies 604
17.4.51. Vasculitis 604
17.4.52. Vasoconstriction (aka vasospasm) 609
17.5. Acute ischemic stroke: Clinical presentation 610
17.5.1. Temporal classification 610
17.5.2. Syndromic classification: Large vessels 612
17.5.3. Syndromic classification: Small vessels 624
17.5.4. Clinical stroke classification schema 625
17.6. Acute ischemic stroke: Patient evaluation 625
17.6.1. Prehospital assessment of patients with acute cerebral ischemia (Stroke or TIA) 625
17.6.2. Selection of TIA patients for emergent cerebrovascular evaluation 625
17.6.3. Emergency department evaluation of acute ischemic stroke patients 626
17.6.4. General evaluation of patients with cerebral ischemia 627
17.6.5. Stroke in the young evaluation 629
17.7. Acute ischemic stroke: Treatment 629
17.7.1. Thrombolysis 630
17.7.2. Augmentation of cerebral blood flow and oxygen delivery 630
17.7.3. Prevention of thrombus extension or re-embolization (i.e., Early ischemic stroke recurrence) (or: Why heparin and other blood thinners should be used sparingly) 632
17.7.4. Neuroprotection 632
17.7.5. Prevention and management of neurologic complications 634
17.7.6. Prevention and management of general medical complications 638
17.7.7. Secondary ischemic stroke prevention 639
17.7.8. Rehabilitation and neurorepair 640
17.8. Acute ischemic stroke: Outcome 641
17.9. Internet ischemic stroke resources 641
17.10. References 641
Chapter 18 646
Extracranial Cerebrovascular Occlusive Disease 646
18.1. Atherosclerotic extracranial arterial disease 646
18.1.1. Atherosclerosis 646
18.1.1.1. Plaque location 646
18.1.1.2. Carotid artery bifurcation atherosclerotic disease 647
Prevalence 647
Risk Factors for Carotid Stenosis 647
18.1.2. Carotid endarterectomy 647
18.1.2.1. Symptomatic carotid stenosis 647
North American Symptomatic Endarterectomy Trial (NASCET) 648
European Carotid Surgery Trial (ECST) 648
Veterans Affairs Cooperative Study on Symptomatic Stenosis (VACS) 648
Analysis of Pooled Data 648
Clinical Trial Data Caveats 649
Subgroup Analyses 650
American Heart Association Recommendation 651
18.1.2.2. Asymptomatic carotid stenosis 651
Asymptomatic Carotid Atherosclerosis Study (ACAS) 651
Veterans Administration Cooperative Asymptomatic Trial 651
Carotid Artery Stenosis With Asymptomatic Narrowing: Operation Versus Aspirin (CASANOVA) 651
Mayo Asymptomatic Carotid Endarterectomy Trial 652
Asymptomatic Carotid Surgery Trial (ACST) 652
American Heart Association Recommendation 652
18.1.3. Radiographic evaluation 652
Interpretation of Carotid Ultrasound Results 653
18.1.4. Recurrent stenosis after CEA 654
18.1.4.1. Medical management 654
Cholesterol Reduction 655
Hypertension 655
Cigarette Smoking 655
Antiplatelet Therapy 655
18.1.5. Carotid angioplasty and stenting 657
18.1.5.1. A brief history of carotid angioplasty and stenting 657
18.1.5.2. Rationale for carotid angioplasty and stenting 658
18.1.5.3. Major CAS single-arm trials and registries 661
18.1.5.4. Major randomized trials: CAS versus CEA 661
The Leicester Trial: “The Stopped Trial” 661
Carotid and Vertebral Transluminal Angioplasty Study (CAVATAS)150 662
Stenting And Angioplasty With Protection In Patients At High Risk For Endarterectomy (SAPPHIRE) 662
Carotid Revascularization Endarterectomy Versus Stent Trial (CREST) 662
Stent-Protected Percutaneous Angioplasty of The Carotid Vs. Endarterectomy (SPACE)132 663
Endarterectomy Versus Angioplasty In Patients With Symptomatic Severe Carotid Stenosis (EVA-3 S)133 663
18.1.5.5. Recurrent stenosis after CAS 664
18.1.5.6. Effect of embolic protection on periprocedural complication rates in CAS 664
18.1.5.7. Timing of CEA or CAS after a stroke 664
18.1.5.8. Patient selection: CAS or CEA? 664
18.1.6. Atherosclerotic carotid occlusion 665
18.1.6.1. Asymptomatic carotid occlusion 665
18.1.6.2. Symptomatic carotid occlusion 665
18.1.6.3. Surgical options for cerebral revascularization in patients with carotid occlusion 666
18.1.6.4. Extracranial–Intracranial (EC/IC) Bypass Trial 667
18.1.6.5. Carotid Occlusion Surgery Study (COSS) 668
18.1.7. Extracranial vertebral artery atherosclerotic disease 668
18.1.8. Diagnosis 668
18.1.9. Prognosis 669
Medical Therapy 669
Angioplasty and Stenting 669
18.2. Extracranial arterial dissection 669
18.2.1. Carotid dissection 669
18.2.1.1. Spontaneous internal carotid artery dissection 669
18.2.1.2. Blunt trauma to the carotid artery 671
18.2.2. Vertebral dissection 672
18.2.2.1. Spontaneous vertebral artery dissection 672
18.2.2.2. Blunt trauma to the vertebral artery 673
18.2.2.3. Penetrating neck injury 674
18.3. Fibromuscular dysplasia 675
18.3.1. Pathogenesis of FMD 676
18.3.2. Cerebrovascular FMD 676
18.4. References 677
Chapter 19 684
Intracranial CerebrovascularOcclusive Disease 684
19.1 Atherosclerotic intracranial arterial disease 684
19.1.1. Prevalence and risk factors 684
19.1.2. Etiology of symptoms 685
19.1.3. Natural history 685
19.1.3.1. EC/IC Bypass Study 685
19.1.3.2. Warfarin vs. Aspirin for Symptomatic Intracranial Disease (WASID) studies 685
Wasid Retrospective Study 686
Wasid Prospective Trial 686
Wasid Prospective Trial Subgroup Analyses 687
Wasid Predictors of Ischemic Stroke In The Territory of A Symptomatic Intracranial Stenosis 687
19.1.3.3. GESICA study 687
19.1.4. Medical treatment of symptomatic intracranial stenosis 687
19.1.5. Intracranial angioplasty and stenting 688
19.1.5.1. Stenting of Symptomatic Atherosclerotic Lesions in the Vertebral or Intracranial Arteries (SSYLVIA) 688
19.1.5.2. Wingspan study 689
19.1.5.3. Other notable studies 689
1. Mori 1998 689
2. Marks 2006 689
19.1.5.4. Position statement on intracranial angioplasty and stenting for cerebral atherosclerosis by the ASITN, SIR, and ASNR3: 689
19.2. Moyamoya disease and moyamoya syndrome 690
19.2.1. Epidemiology 690
19.2.2. Pathophysiology 691
19.2.3. Diagnosis of moyamoya disease 692
19.2.3.1. Diagnostic criteria 692
19.2.3.2. Diagnosis 692
19.2.4. Evaluation 693
19.2.4.1. CT 693
19.2.4.2. Angiography 693
19.2.4.3. MRI 694
19.2.4.4. Cerebral blood flow studies 694
19.2.4.5. EEG 694
19.2.5. Clinical features of moyamoya disease 694
19.2.6. Familial moyamoya disease 696
19.2.7. Conditions associated with moyamoya syndrome 696
19.2.7.1. Clinical features of moyamoya disease and syndrome in North American patients 697
19.2.8. Management 698
19.2.8.1. Medical management 698
19.2.8.2. Surgical management 698
Indications For Surgical Revascularization 699
Surgical Techniques 699
19.2.8.3. Intracranial angioplasty 700
19.2.8.4. Pregnancy and moyamoya 700
19.3. References 700
Chapter 20 706
Spinal Vascular Lesions 706
20.1. Type I: Dural arteriovenous fistula 706
20.1.1. Epidemiology and clinical features 706
20.1.2. Pathophysiology 708
20.1.3. Management 708
20.1.3.1. Surgical considerations 708
20.1.3.2. Endovascular considerations 709
The Often Misunderstood Foix–Alajouanine Syndrome 709
20.2. Type II: Intramedullary arteriovenous malformation 709
20.2.1. Epidemiology and clinical features 709
20.2.2. Management 711
20.2.2.1. Surgical considerations 711
20.2.2.2. Endovascular considerations 712
20.2.2.3. Radiosurgery 712
Spinal Cord Aneurysms 712
20.3. Type III: Juvenile arteriovenous malformation 713
20.3.1. Cobb Syndrome 713
20.4. Type IV: Intradural perimedullary arteriovenous fistula 714
20.4.1. Clinical features 714
20.4.2. Management 715
20.5. Intramedullary cavernous malformation 715
20.6. References 715
Index 719
A 719
B 727
C 728
D 731
E 732
F 733
G 734
H 734
I 736
J 736
K 736
L 736
M 737
N 738
O 739
P 740
Q 741
R 741
S 741
T 744
U 745
V 745
W 747
X 747
Y 747
Z 747