Interventional neuroradiology in intracranial lesions

Robert W Hurst MD (Dr. Hurst of the University of Pennsylvania Medical Center is a consultant for Boston Scientific Co and a training director for Micrus.)
Matthew Lorincz MD PhD, editor. (Dr. Lorincz of the University of Michigan has no relevant financial relationships to disclose.)
Originally released November 18, 1998; last updated June 15, 2012; expires May 15, 2015
Notice: This article has expired and is therefore not available for CME credit.

Overview

In this article, the author updates current endovascular management, particularly emphasizing the role of newer techniques and devices able to more effectively treat increasing numbers of intracranial aneurysms. These advances include the introduction of flow-diverting stents, devices that hold promise to address the still dismal morbidity associated with treatment of large and giant aneurysms. In addition, updated information regarding recently approved devices for endovascular treatment of large-vessel ischemic stroke is becoming available. Retrievable stents, recently approved in the United States, promise to provide higher rates of reopening of acutely occluded large intracranial vessels with possible improvement in overall outcome of these potentially devastating lesions.

Key points

 

• Dural arteriovenous fistulas are uncommon lesions consisting of direct arteriovenous fistula communications within the dura, usually within the walls of large dural sinuses.

 

• Dural arteriovenous fistulas may be characterized by a broad clinical spectrum ranging from asymptomatic to life-threatening intracranial hemorrhage.

 

• Clinical behavior of dural arteriovenous fistulas is most closely related to venous drainage, the feature that forms the basis for both the Borden and Cognard classifications of dural arteriovenous fistulas.

 

• Dural arteriovenous fistulas of the transverse and cavernous sinus, the 2 most common locations, are reported to have a benign course in the majority of cases.

 

• Dural arteriovenous fistulas involving the tentorium or superior sagittal sinus most often demonstrate aggressive behavior, reflecting their typical drainage pattern into cortical veins.

 

• Endovascular techniques currently represent an important and evolving management option for an increasing number of cerebrovascular disorders.

 

• The introduction of newer devices for management of intracranial aneurysms has expanded the range of aneurysms that may be effectively treated by these techniques.

 

• The availability of mechanical thrombectomy devices increases the effectiveness of reopening large vessels in acute ischemic stroke and holds promise of improved outcomes.

Historical note and terminology

Interventional neuroradiology uses cerebral angiographic techniques to diagnose and treat disorders of the head, neck, and central nervous system. Cerebral angiography has been of recognized value in the management of cerebrovascular disease since its first performance by Moniz in 1927 (Moniz 1927). With development of Seldinger technique for percutaneous access to the vascular system in 1953, angiography became widely utilized for the diagnosis of vascular disease throughout the body (Seldinger 1953). By 1956, Odman's description of the femoral catheter approach to the innominate and subclavian arteries paved the way for routine angiography of the cerebral vessels (Odman 1956).

Interventional techniques using catheters to treat vascular disorders were first applied to vessels outside the CNS and included intentional injection of emboli for vascular occlusion. The development of percutaneous angioplasty for dilation of stenotic vessels by Dotter in 1964 resulted in widespread nonsurgical treatment of atherosclerotic disease throughout the peripheral and coronary circulations (Dotter and Judkins 1964). Nevertheless, the application of interventional catheter techniques to vessels of the CNS lagged considerably because of the small size of vessels involved, the lack of appropriate catheters and devices, and the sensitivity of the brain to ischemic insult.

More recently, advances in the development of microcatheters and other devices have extended the availability of interventional radiologic techniques to neuroradiology. Combined with an increased understanding of CNS vascular pathophysiology and improved angiographic technique, interventional neuroradiology has developed a major and increasing role in the safe and effective management of a host of vascular and neoplastic disorders.

Currently, interventional neuroradiology techniques should be routinely considered in the management of most vascular disorders of the CNS including aneurysms, vascular malformations, and many types of ischemic stroke. Specific indications for interventional neuroradiology treatment in these entities will be addressed, but it must be recognized that these represent only the most common indications and are constantly evolving.

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