ANATOMY AND INTERVENTION OF

CEREBRAL VASCULATURE

Presenter: Charusmita Chaudhary

Moderator: Dr. R.K.Gogoi
Deptt. of Radio Diagnosis
 NORMAL ANATOMY
ARTERIAL SUPPLY
2 Internal Carotid Artery
2 Vertebral Arteries
VENOUS DRAINAGE
Outer/superficial segment : Scalp vein
Intermediate segment : diploe, emissary , meningeal
and dural sinus
Inner segment :Cerebral Veins (Superficial & Deep)
 STA

In Max A

Occ. A

Facial A

Fac. A

Ling.A

Lingual A

Sup thy A

Branches of Left External Carotid artery

 INTERNAL CAROTID ARTERY
5 ARBITRARY
SEGMENTS
EXTRACRANIAL
carotid bulb
cervical segment
INTRACRANIAL
petrous segment
cavernous C1
segment C4
supraclinoid C2
C5
segment
C3

A P
 Internal carotid artery
AP VIEW Lateral view
 ICA

CERVICAL
CAVERNOUS SUPRACLINOID
PETROUS
MANDIBULOVIDIAN
CAROTICOTYMPANIC

MENINGO HYPOPHYSEAL LATERAL MAIN STEM CAPSULAR(Mc Connells)

TENTORIAL DORSAL INFERIOR

(BERNASCONI) MENINGEAL HYPOPHYSEAL

SUPERIOR HYPOPHYSEAL
OPHTHALMIC ANTERIOR CEREBRAL
POSTERIOR COMMUNICATING MIDDLE CEREBRAL
ANTERIOR CHOROIDAL
 CIRCLE OF WILLIS
Grand Vascular Station of the
Brain
Classical 18% to 20%
COMPONENTS
Internal carotid arteries
Horizontal segments of Anterior
cerebrals(A1)
Anterior communicating artery
Proximal segments of posterior
cerebrals(P1)
Posterior communicating
arteries
Basilar artery
 Anterior cerebral artery (ACA)
The ACA is divided into five segments
A1 segment is located between the
ICA bifurcation and the ACoA.
A2 segment extends from the ACoA
to the region between the rostrum and
the genu of the corpus callosum
(GCC)
A3 segment curves around the GCC
and ends at the rostral part of the body
of the corpus callosum.
A4 and A5 segments follow the
superior surface of the corpus
callosum with a virtual plane of division
at the level of the coronary suture.
 Branches of ACA

A1- medial lenticulostriate artery

ACoA- Perforating branches
A2- Recurrent artery of Heubner (RAH)
Orbitofrontal artery
Frontopolar artery
A3- Pericallosal and Callosomarginal a.
A4 & A5- Cortical branches
ACA
MIDDLE CEREBRAL ARTERY
Larger terminal branch of ICA
Run laterally in stem of lateral sulcus
Curves on superolateral surface &
Runs backwards in depth of posterior
ramus of lateral sulcus
M1 segment =horizontal segment from origin to
its bifurcation (it is in sylvian fissure)
M2 segment =lacunar segment -in the
insula loops over insulalaterally to exit
from sylvian fissure
M3 segment = opercular branch-from
sylvian fissure & ramify over cerebral cortex
Anomalies of MCA are uncommon
MCA
POSTERIOR CEREBRAL ARTERY

P1-Peduncular/Precommunicating
P2-Ambient segment
P3-Quadrigeminal segment
P4-Cortical branches

2 major terminal br of PCA

parieto occipital art & calcarine art
PCA
 POSTERIOR FOSSA

Vertebral arteries

Basilar artery
Vertebral arteries

Originate from the

subclavian arteries.
Left VA is dominant in
60% cases
 Branches
Extracranial -numerous branches to the
meninges,spinal cord & muscles
-Posterior meningeal artery
Intracranial
-Anterior spinal artery
-Posterior inferior cerebellar A
Anterior medullary
Lateral medullary
Tonsillomedullary
Telovelotonsillar
Cortical branches
BASILAR ARTERY

Right and left VA unite to

form basilar artery
Courses infront of pons
(Prepontine cistern) &
terminates in the
interpeduncular cistern
3cm in length,1.5 to 4mm in
width
>4.5mm width-abnormal
 Normal VARIANTS
1. Fenestrations and duplications,
2. Variants of the circle of Willis,
3. Persistent carotid-basilar anastomoses
4. Anomalies identified in the skull base.

19
 Fenestration of the anterior communicating
Duplication of the anterior communicating
Artery each vessel originating separately
artery
from an anterior cerebral artery.

Fenestrations
of the anterior cerebral
artery

20
Normal Variants of the Circle of Willis

Azygos anterior cerebral artery Trifurcation of the anterior cerebral artery

Hypoplasia of an A1 segment of the anterior

cerebral artery

Bihemispheric anterior cerebral artery

Absence of an A1 segment of the anterior cerebral 21

artery
 Accessory
middle
cerebral artery

Absence of the anterior communicating artery

Bilateral fetal
posterior cerebral
arteries

Early bifurcation of the middle cerebral artery.

CT angiogram shows a posterior

communicatingartery (arrowhead) that arises
from the apex of a funnel-shaped infundibulum
(arrow)
22
Persistent Carotid-Basilar Artery Anastomoses

Persistent Trigeminal CT angiogram depicts a hypoglossal artery

(arrowhead) that arises from the proximal
Artery internal carotid artery (arrow)

23
Normal Variant Arteries in the Skull Base
1. Persistent stapedial artery,
2. Aberrant internal carotid artery
3. Hypoplasia or agenesis of the
internal carotid artery.

24
 VENOUS ANATOMY

Dural sinuses
Cerebral veins
 DURAL SINUSES

Superior sagittal sinus

Inferior sagittal sinus
Straight sinus
Transverse sinuses
Occipital sinus
Tentorial sinuses
Sigmoid sinuses
Cavernous sinuses
VENOUS SINUSES
 CAVERNOUS SINUS

Hexadron--shaped space
Either side of sella turcica
Along convergence of the sphenoid bone & petrous
bone.
 Cerebral veins
Superficial cortical veins
Near vertex they cross Subdural Space to enter SSS
Most are unnamed

Superficial Middle cerebral vein( along sylvian

fissure)
Vein of Trolard
Vein of Labbe
Deep cerebral veins
Vein of Galen
Basal veins of Rosenthal
Subependymal / Medullary veins
BLOOD SUPPLY TO RELEVENT PARTS OF BRAIN
In general-cortical branches of 3 cerebral art
Motor area-frontal cortical branch of MCA; Precentral
area and paracentral lobule-anterior cerebral artery
Auditory area-temporal cortical branch. Of MCA
VISUAL AREA-occipital cortical branches of PCA
Speech area cortical branches of MCA

33
 IMAGING TECHNIQUES

Conventional Angiography
Digital Subtraction Angiography
Ultrasonography
CT Angiography
MR Angiography

34
 Conventional angiography

It is gold standard because of the outstanding resolution

and anatomical nature of the information
Main disadvantage is it is a invasive procedure and is
associated with complications

35
Sites :
Femoral artery
Popliteal
Axillary
Brachial
Radial

36
 Contraindications
Pregnancy
Anticoagulant therapy and bleeding diathesis
Hepatic and renal failure
Systemic hypertension, cushing syndrome
Connective tissue disorders

37
 Digital subtraction angiography

DSA have arisen as a result

of digital data acquisition,
storage and processing.

The technique uses lower

doses of contrast medium
because of superior contrast
resolution.

Fluoroscopy technique used

in interventional radiology to
clearly visualize blood
vessels in bony or dense
soft tissue environment

38
Digital Subtraction Angiography
(DSA)
Images produced using
contrast medium by
subtracting 'pre-contrast
image' from later images with
contrast

Vessels are subtracted live

instantly see non-bony
superimposed images

The major disadvantage of

DSA is reduced spatial
resolution.

39
40
 ULTRASONOGRAPHY

EQUIPMENT :
High resolution linear array transducer
Used in cases of infants for evaluation of the
brain parenchyma
Windows :
Anterior fontanelle
Posterior fontanelle
Mastoid

41
42
 CT ANGIOGRAPHY
CT Angiography provides a
comprehensive analysis of the
vascular anatomy including the
location, size, and length of the
arteries and veins.

CT Angiography is used to detect;

Dissections
Aneurysms
Plaque
Stenosis Optimal image quality depends on two
factors:
Morphological layout and
CT angiography technique (scan
aberrations protocol, contrast
Pre and Post surgical assessments material injection protocol, image
reconstruction
methods) and data visualization
technique(image postprocessing). 43
 ADVANTAGES ARTEFACTS

The more slices that can be Motion artifacts reduced by

acquired per rotation faster scanning
The longer the volume that can
be scanned
The higher the resolution Stair-step artifacts in 3D
possible reconstructions reduced by
The better the reproduction of using thinner slices
2D and 3D reconstructions
The greater the detail available Partial volume artifacts
in all 3 axis (x,y and z)
reduced by using thinner slices
Patient comfort
Non invasive investigation
Easily available to all levels of
socioeconomic status
 POST PROCESSING
Coronal and Sagittal MPR (multi planar
reconstructions)

Shaded surface display, or surface

rendering, is an algorithm that provides a
good 3D impression ofthe surface of an
object.
3D volumetric images with rotational
images comprising of bone and non bone
backgrounds.

MIP (Maximum intensity projections)

Measurements
45
 MR ANGIOGRAPHY
constitutes group of MR imaging techniques that can be used to directly image
flow in arteries, veins, and cerebrospinal fluid.

Time-of-flight imaging is susceptible to saturation effects, and short Ti

substances may simulate flow.
Two-dimensional time-of-flight imaging is useful in cranial venography in
assessing the patency of the dural sinuses or venous drainage from an
arteriovenous malformation.
Three-dimensional time-of-flight images depict small and medium-sized
aneurysms.

Phase-contrast imaging has excellent background suppression, allows

variable velocity encoding, and provides directional flow information.
Two-dimensional phase-contrast imaging is useful in the assessment of the
patency of major vascular structures.
Three-dimensional phase contrast imaging (with 30-cm/sec velocity
encoding) is also useful in depicting small and medium-sized aneurysms
Cine Phase contrast imaging hemodynamic flow information. Allow imaging
of csf, venous and arterial flow.
46
47
Vascular Interventional procedures of
brain

Part II
 INTRODUCTION:
Interventional and Endovascular Neurology is the Neurological
subspecialty focused on endovascular and other minimally invasive
approaches to the diagnosis and management of vascular and non-
vascular neurological diseases.
The section is committed to advancing all diagnostic and therapeutic
interventional procedures that involve the neurological patient
community and to support education and research initiatives that will
expand this field.
Endovascular therapies include
1. Embolotherapy
2. Cerebral revascularization

Non vascular aspects of interventional neuroradiology include pain

management, percutaneous biopsies and vertebroplasty.
 Cath lab.-known as operating room or special
procedures room.

Radiographic Imaging Equipments

Biplane angiography with digital subtraction
ability, high resolution image intensifier is
recommended. Digital Road map fluoroscopy
capability is mandatory, preferably with simultaneous
live unsubtracted imaging . Now a days 3D CT is used
too.
Critical care of patients undergoing endovascular and
interventional procedures.
 VASCULAR INTERVENTION:
Embolotherapy continues to evolve in its active
consideration in the preoperative management of
aneurysms, vascular malformations and vascular tumors.
This progressive increase in demand has been principally
as a result of development of newer microcatheter
delivery systems and of safer and more varied embolic
agents.
more target specific embolization with a greater degree of
preservation of adjacent normal vascular anatomy.
These include particulate emboli, coils, balloons, tissue
adhesives, non adhesive agents, sclerosing agents and
chemotherapeutic agents.
Classification:
Embolic agents
I. Particulate embolic agents( agent of choice).

Absorbable Non Absorbable

II. Mechanical embolic agents
III. Liquid embolic agents.
Absorbable agent:Gelfoam( Powder /sheet), Avitene
Use: topical thrombotic agent in conventional surgery.
to "protect" normal vessels.
Non absorbable: PVA(150 to 1000 microns), particles (Ivalon,
Biodyne, Contour Emboli).
PVA: small( embolization of vascular tumors) and large
size( occlusion of larger, high flow vascular malformations).
MOAAdhere to vessel wall(lumen occluded),necrotising
vaculitis.
Temporary effectWeeks to Month
 Recently, a newer class of microembolic agent has been
introduced
Soft, smooth surfaced, deformable particles ( Embospheres
(Microsphere) and Bead Block (Terumo))
tend to ovalize when confined, a trait that makes these
agents more effective in more distal embolotherapy.
ADV: do not adhere to vessel walls as do crystalline PVA
particles, particles are more likely to reach the capillary bed
of the tumor.

Bead Block
 COILS :
Guglielmi detachable micro coil. (GDC)
Platinum micro coils soldered on stainless steel micro
wires. once in desired position detached by passing Direct
current which causes electrolysis at the soldered site.
can be positioned, withdrawn and repositioned repeatedly
until the desired position is obtained.
Advantage: Coil can be withdrawn before final placement.

The Hydrocoil (Microvention) is unique in that it is coated with

a hydrogel that expands after deployment.
BALLOONS
Latex and silastic balloons
Advantages:
1) the ability to occlude a vessel at a precise location
2) the ability to flow navigate attached, partially inflated
balloons to distal locations along a tortuous course
3) the ability to rapidly occlude vessels larger than the
caliber of the catheter
4) the ability to inflate, deflate and reposition repeatedly until
the desired position is achieved.
 LIQUID EMBOLIC AGENTS
n-butyl cyanoacrylate (NBCA)
Histoacryl
This agent will rapidly polymerize on contact with any ionic
substance such as blood, saline, ionic contrast media and
vessel epithelium.
ADV:rapidly occlude high flow arteriovenous malformations
with a more permanent result
DISADV:The catheter must be rapidly withdrawn after each
injection of NBCA, resulting in frequent, time consuming
catheter exchanges
Onyx: non adhesive liquid embolic agent safer and
effective than NBCA
 SCLEROSING AGENTS
Absolute ethanol
Sotradecol (sodium tetradecyl sulfate) behaves similarly to
alcohol, but with less associated pain.
Hypertonic saline and glucose solutions are also effective
sclerosing agents that work rapidly in both the arterial and
venous systems.
The results of embolotherapy with ethanol when compared
to the particulate agents and NBCA have shown a more
permanent occlusion of abnormal vessels without the
inherent risks associated with tissue adhesives.
CEREBRAL REVASCULARIZATION..
Intra-arterial cerebral revascularization incorporates several
new technologies and newer applications of techniques that
have been well established in peripheral revascularization.
The focus on acute stroke reversal offers an exciting new
aspect to interventional neuroradiology.
Vascular Interventional procedure of brain
Endovascular procedures.
Direct percutaneous procedures.
Endovascular procedures:
1. Endovascular technique for lumen restoration.
2. Endovascular technique for lumen obliteration.
3. Endovascular treatment of A V shunts.
4. Endovascular treatment for vein of galen aneurysal malformation.
5. Endovascular treatment of dural arteriovenous shunts.
6. Brain tumour embolisation and chemotherapy.
7. epistaxis endovascular therapy: Embolization of refractory head and
neck bleeds.
8. WADA and functional testing.
9. petrosal venous sinus sampling for Cushing disease
10. pseudotumor cerebri endovascular therapy with venous sinus stenting
11. endovascular repair of traumatic head and neck vascular injuries
 Direct percutaneus procedures:

(1) Image guided Embolisation of tumour.

(2) Image guided embolisation of AVM.
(3) Image guided photodynamic therapy.
 Hyperacute ischemic stroke
1)Intra-arterial thrombolysis :
It involves the direct infusion of thrombolytic agents into
the occluding thrombus .
Higher local concentration of drug.
Lower systemic concentration.
Fewer extracranial haemorrhagic complications.
Faster and more complete recanalisation .
This allows a longer time window of 36 hours or longer if
perfusion studies are favourable.
Thrombolytic agents:

1) Recombinant
tissue plasminogen
activator (rTPA).
2)Streptokinase.
3)Urokinase.
4)Pro-urokinase.
5) Ancord .
 2) Mechanical procedures

1)Microguidewire applied
to disrupt the clot
facilitate the action of
the thrombolytic agent.
2) Clot retrieval devices
or Snare which may
actually extract the
thrombus from the
occluded artery,
achieving reperfusion
much more readily.
Recent mechanical thromolitics

The BONnet consists of a self-expanding nitinol

braiding with polyamide filaments passing
through the interior to enlarge the surface area
and enable better fixation of the thrombus mass.
The system can be either put distal to the
thrombus or released into the thrombus. B, The
CRC is based on a fiber work of polyamide
filaments whose lengths fromproximal to distal
end increase. The CRC has an additional nitinol
thread cage at the proximal end of its fiber brush.
This nitinol cage gives it a higher radial range. C,
ThePhenox pCR is based on perpendicularly
oriented polyamide microfilaments that create an
attenuated palisade.

The Penumbra System is based on an

aspiration platform that includes reperfusion
microcatheters connected to an aspiration
pump. A teardrop-shaped separator is
advanced and retracted within the lumen of
the reperfusion catheter to debulk the clot
for ease of aspiration.
 .
3) Balloon Angioplasty or
stent placement
If thrombus is
superimposed upon a
stenosis. (Atherosclerotic
plaque).

Solitaire FR stent (ev3). A self-expanding stent that can be fully

deployed and then completely retrieved
Disadvantages
Additional time delays.
Risks of procedure
Arterial embolisation.
Arterial perforation.
Haemorrhagic
infarction.
Retroperitoneal
haematoma.
Groin haematoma. Terminal basilar artery
occlusion
Collectively risk estimated --
5%
 A. Left Vertebral Artery Injection demonstrating extensive
clot in the basilar artery .
B. Following Urokinase via a microcatheter there is
complete resumption of normal flow.
 TREATMENT OF CEREBRAL VASOSPASM
Cerebral vasospasm represents a significant cause of
morbidity and mortality in patient with subarachnoid
haemorrhage leading to ischemic deficits.
Medical treatment(Triple H )
Hypertension
Hypervolemia
Haemodilution

Endovascular treatment:
(1)Pharmacological relaxation of spastic vessel by Selective
intra-arterial papavarine infusion.
(2) Mechanical dilatation of spastic segment (balloon
dilatation).
 Cerebral vasospasm (MCA)
Treatment----Balloon dilatation
 Angioplasty and stenting of extracranial and
intracranial vessels.
Indications
Carotid stenosis(>70%)
Vertebro basilar artery stenosis.
MCA stenosis(>50%)
Purpose:
Reduce incidence of recurrent stroke (TIA).
 Percutaneous transluminal angioplasty(PTA)

Pre treated with antiplatelet

agents.
Under LA via femoral artery.
The patient is systemically
heparinised and the carotid artery
catheterised, a guide wire crosses
the stenosis, a protection device
is deployed . Balloon inflation (8
atmospheric pressure for 10 sec)
deflated if significant stenosis
persists repeat procedure for 2
to 3 times.
Clopidogrel and aspirin are
maintained for three months.
 Stenting
Method of choice
Under LA
Pre operative antiplatelet therapy(Aspirin and
clopidogrel)
Following pre operative angiography ,a
guiding catheter(6Fr) is placed to common
carotid artery the stenosis is crossed with a
soft tip guidewire,a protection device is
deployed .The stenosis is predilated using an
angioplasty balloon, and a stent is deployed
across the stenosis and redilated.
pathophysiological process of
carotid artery dissection
proceeding from the acute
stage to either spontaneous
healing (1), formation of false
lumen (2), residual stenosis
of varying degree or complete
occlusion (3), and formation of
a pseudoaneurysm (4). A stent
is used in cases not
responding to medical therapy
either to relieve a
hemodynamically significant
stenosis, to occlude a false
lumen, or to serve as a
scaffold to enable coil
embolization of a wide-necked
pseudoaneurysm.
 Carotid Cavernous sinus fistula
Carotid cavernous fistulas (CCFs) result
from spontaneous or acquired ,
abnormal connection(s) between the
cavernous ICA and venous channels
of the cavernous sinus, and are either
high or low flow. Barrows Classification (1985)

trauma

Treatment modalities:
Type AHigh flow type
Detachable balloons is the
treatment of choice for most type A
CCFs .The currently available latex
balloon is deployed up the ICA,
through the defect and inflated within
the cavernous sinus, occluding the
fistula and preserving the ICA.
 Carotid
cavernous
fistula
 Transcatheter coil embolisation-

Routes Trans venous (Preferred)Femoral veininferior

petrosal sinus cavernous sinus-Platinum micro coils with
attached dacron fibres is used.
Trans arterial route---GDC coils are used to reduce the
risk of recoiling in the ICA.
Liquid embolic agents
Onyx can be deployed through the micro catheter
via venous route into the cavernous sinus, with
balloon protection (non-detachable) in the ICA .
Type BLow flow Carotid cavernous sinus fistula
Polyvinyl alcohal (PVA)---150250 micron Size .
selective embolisation of external carotid artery feeders
is done.
If Recanalisation,, occur, transvenous coil occlusion of
the cavernous sinus either through the jugular vein and
inferior petrosal sinus or through the superior ophthalmic
vein achieves cure in most patients.
Carotid compression maneuver
Facilated thrombus formation.
 Endovascular treatment of intracranial aneurysms

An aneurysm is a sac filled with

blood which is in direct
communication with the lumen
of an artery.

True AneurysmLocal dilatation

of the artery.
False aneurysm Sac with walls
formed of condensed
perivascular connective tissue
which communicate with the
Common site of intracranial Aneurysm
artery through an aperture in its
wall.
 Clip vs Coil
What to choose ?
This decision needs to be made with
knowledge of:
the safety and efficacy data
the patients expected longevity
aneurysm factors size
configuration
location
the operators experience.
Equally important to consider whether the aneurysm
unruptured
ruptured
This complex decision requires entertaining all the variables, ensuring
that patients receive the most appropriate care .
Coil embolisation:
Through trans-arterial
route a micro catheter
is placed in the lumen
of the aneurysm-
through the micro
catheter ,soft platinium
coils are packed in the
aneurysm.
 Large ruptured aneurysm, pre embolization (A), and post embolization with GDC coils ( B&C).

Assisted aneurysm coiling techniques, including balloon assist (A) (Hyperform balloon catheter, MTI) and
84
Neuroform stent assisted technique (B,C) ( Target Therapeutics Corp / Boston Scientific )
 Newer technique to reduce coil compaction and
recanalisation
Coils with more complex shapes.
Bioactive coils (coated with polyglycolic polylactic acid).
Hydrogel coils.
Radioactive coils (incorporated with P32 emitting
radiation).
 When patency of the
parent vessel cannot
be assured (Fusiform
or serpentine ,wide-
necked aneurysm,false
aneurysm)-Vessel
may be permanently
occluded by balloon or
coil embolisation with
prior test occlusion.

.
 Giant Aneurysm
Size more than 2.5cm.
Giant aneurysms are often sub-optimally treated using coils
alone.
The accepted treatment ----parent vessel occlusion.
Trial balloon occlusion (TBO) .
When parent vessel occlusion cannot be tolerated.
Surgical bypass procedures.
Embolisation (high density onyx).
stent .
Parent vessel (left ICA) occlusion in the management of a
giant cavernous carotid aneurysm.
Endovascular treatment of cerebral AVM
Arteriovenous malformation (AVMs) are a complex
conglomerate of abnormal arteries and veins. They lack
an intervening capillary bed and there is resultant high
flow arteriovenous shunting through one or more
fistulae.
Therapeutic options
1) Neurosurgery
2) Embolisation
3) Stereotactic radiosurgery.
Aim of treatment
1)Obliterate the AVM completely .
2)Eliminate the risk of haemorrhage.
3)Reduce the effects of steal or venous
congestion .
 Spetzler Martin grading system (Grade 1 to 5)
Reflects the degree of surgical difficulty and risk of surgical
morbidity and mortality, and the scale is based upon AVM size,
venous drainage, and location .

AVM Size---
Small ---- 0 to 3 cm - 1 point.
Medium --3 to 6 cm - 2 points.
Large ----- > 6 cm - 3 points.
AVM location---
Non-eloquent region -- 0 point.
Eloquent region --------1 point.
Pattern of venous drainage---
Superficial ----------0 point.
Deep -----------------1 point.
 Treatment rationale:

Grades 1 and 2 and some grade 3 ---surgery recommended.

Grade 3 AVMs with deep inaccessible feeders, surgery with
embolisation or stereotactic radiosurgery is considered .
Grade 4 and 5 AVMs is usually multidisciplinary
Embolisation
under general anaesthesia.
Superselective catheterisation of the feeding
arteries using a microcatheter with or without the aid
of a micro guidewire.
Liquid embolic agents are generally used, either
onyx or n-butyl Cyano acrylate (NBCA).
other embolic agents like balloon,Liquid coil can be
used.
Onyx embolisation of a right perisylvian AVM
Onyx embolisation of a right perisylvian AVM
A middle aged patient
presenting with an AVM
near the visual area of the
left hemisphere which
hemorrhaged once.
Presurgical embolisation Before Treatment
was conducted to reduce
the size of the AVM. Pre-
embolisation image A
versus post embolisation B
shows the substantial
reduction in size. She had
an excellent outcome from
surgery. Following Embolisation in
preparation for surgery
 Dural AV fistula
Dural arteriovenous fistulas (DAVFs) abnormal
arteriovenous connections within the dura, usually within the
walls of a dural sinus .
They are acquired lesions idiopathic most common venous
sinus thrombosis and/or venous hypertension.
Thrombosis triggers the stimulation of angiogenesis and
engorgement of microscopic arteriovenous channels that
normally exist in the dura.
The cavernous sinus, transverse and sigmoid sinuses are
most often implicated, but any sinus may be involved ..
Premature visualization of intracranial veins orvenous sinuses
during arterial phase-Characteristic
Cognards classification
Type I includes DAVFs which drain into a
sinus with normal antegrade flow.
Type II DAVFs --insufficient antegrade flow
with reflux into either venous sinuses (IIa),
cortical veins (IIb), or both (IIa+b).
Type III fistulas drain into cortical veins without
venous distension.
Type IV drain into cortical veins with venous
ectasia.
Type V drain into spinal perimedullary veins.
Management
Type I fistulas --carotid or occipital artery compression
, arterial embolisation using PVA particles
Type IIa treatment of choice is arterial embolisation of
ECA feeders using PVA particles
types IIb and IIa+b --Transvenous coil occlusion of the
involved dural sinus.
Types III and IV---endovascular occlusion of the
draining cortical vein itself using coils may occlude the
fistula preserving dural sinuses.
Transvenous coil occlusion dural
arteriovenous fistula
 Vein of galen Aneurysmal malformation
types
1)Direct AVM--Choroidal
arteries/Thalomoperfora
te actually communicate
with the vein of galen.
2)Indirect ---AVM in the
thalamus or mid brain
veins drain into the vein
of galen.
 Intervention
If possible intervention deferred to allow growth of the
child, as intervention in neonate is difficult and
hazardous .
Criteria for neonatal or infantile intervention:
Cardiac failure unresponsive to medical therapy.
Progressive macrocephaly.
Seizures.
Developmental delay.
Reversible neurological deficit.
AIM TO REDUCE THE AMOUNT OF AV SHUNT.
Arterial approach ---Permanent embolic agent---
NBCA glue, Onyx.
Transvenous route tried.
 xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

NBCA glue embolisation of vein of galen

Aneurysmal Malformation
CEREBRAL VENOUS SINUS THROMBOSIS
Intravenous anticoagulation most
cases are successful
Local thrombolysis
INDICATIONS:
Presentation in coma.
Clinical deterioration despite full anticoagulation.
Treatment modalities
1) Pharmacological thrombolysis of the cerebral
venous sinuses is usually performed via the
Transvenous femoral route in an anaesthetised
patient.
2)Pharmaco-mechanical thrombolysis may also be
achieved using a microcatheter,microwire or
microsnare.

Local pharmacomechanical thrombolysis in

superior sagittal sinus (SSS) thrombosis.
.
3)Mechanical
Saline jet vacuum device
--
It consists of a double
lumen 5 French catheter
tapering to 3.5 French,
high velocity saline jets,
exiting the catheter at a
pressure of 2500 psi, are
directed through one
lumen, connected to a bag
of heparinised saline. A
venturi effect breaks up
the thrombus and the
debris is directed down the Saline jet vacuum device
other lumen and collected
in a bag.
Examples of mechanical measures to remove clot. A,
low pressure angioplasty, B clot disruption with the
Neurojet (Possis) and c. clot retrieval with the Merci
device.

105
AngioJet catheter treatment -dural sinus thrombosis
 IDIOPATHIC INTRACRANIAL HYPERTENSION
remains a diagnosis of exclusion
( Friedman D., Jacobson D.: Neurology 59, 2002)

To clarify the relation of IIH to associate narrowing of

lateral dural sinuses
The neuro interventional community is still debating and
strives to justify neurovascular strategies for treatment.
--Causes
Focal narrowing in the transverse sinuses unilateral or
bilaterally.
Secondary to raised central venous pressure .
 IDIOPATHIC INTRACRANIAL HYPERTENSION
Investigation :MRI, MRV
Catheter angiography with retrograde venography
Pull-back manometry
Focus of interest of venous manometry:
a) gradients across the irregularities of lateral sinus
b) gradients at confluence of sinuses/jugular bulb

Intervention---Stenting
General anaesthesia is required for stent deployment
because the dura and sinuses are sensitive to pain.
Stenting is achieved directly through a percutaneous
jugular venous puncture. A guide catheter is manipulated
into the transverse sinus and a self expanding stent
deployed across the stenosis .
 Optic papilla protrusion

Endovasal manometry: lft

Compliant balloon angioplasty of lateral sinus

Follow up 6 we Gd MRI
Initial Gd MRI
VASCULAR INTERVENTIONS OF TUMOURS
 SKULL BASE TUMOURS
Common tumours requiring preopreative
embolisation are
Meningiomas.
Angiofibromas.
Glomus tumours .
Objective
selective obliteration of arterial feeder before surgical
resection.
Delivered under sedation by trans femoral route by selective
catheterisation of the vascular pedicle.
Aim to occlude the pre capillary arteriole.
 Embolic agent PVA(150-250 microns).
If intra tumoural shunts are present --
Particle size increase.
Slurry of PVA and AVitene.
Small coil or silk sutures.
Liquid coils.
Embolisation should be performed 2472 hours before surgery
to allow progressive thrombosis.
If very small size particle are used then skin necrosis and
cranial nerve palsy occur.
Polyvinyl alcohol (PVA) embolisation of a glomus
jugulare tumour.
Glomus jugulare tumour
Meningioma
Inferior Petrosal sinus sampling

To obtain blood sample in pituitary microadenoma

 Brain tumour chemotherapy
PrincipleIntra arterial infusion of chemotherapeutic
agents

1)increased concentration of c.t.agents
locally

2)increase cytotoxicity, Decreased side
effects.
Procedure:
Selective catheterization of the artery supplying the tumour done
under systemic heparinisationc.t. agents infused.
 Chemoembolization
Chemoembolization works to attack the tumour in two
ways.
1) Delivers a very high concentration of chemotherapy
directly into the tumor, without exposing the entire body
to the effects of those drugs.
2) The procedure cuts off blood supply to the tumor,
depriving it of oxygen and nutrients, and trapping the
drugs at the tumor site to enable them to be more
effective.
Super selective catherisation of the vascular pedicle is
done.
Chemotherapeutic agents mixed with particulate
embolic agents infused through the micro catheter.
Image guided percutaneous
treatment
 Direct percutaneous embolisation in vascular
malformation of head and neck

Low flow malformation like haemangio-

lymphangioma or venous malformation.

Under image guidance needle is placed

percutaneously in the lesion

Contrast injected through the needle to delineate the
vascular compartment and venous drainage

Concentrated alcohol injected to the lesion.
 Image guided photodynamic therapy

Photodynamic therapy is a minimally invasive palliative treatment

for malignancy .
Intra venous injection of photosensitizing drugs.

Image guided needles placed in the tumour

Fibre optic cables are placed through the needles,providing a

foccused delivery of laser light.

Laser light + Photosensitising drugs Activates the drug

Singlet oxygen(highly cytotoxic) Interacts with

Oxygen
 CONCLUSION
Proper knowledge of vascular anatomy is very important .
Proper pre surgical ,clinical and radiological assessment helps
in surgical planning and avoid catastrophy.
There has been enormous growth and development in neuro
endovascular expertise and technology in recent years, and
this expansion continues allowing increasingly safe and more
effective ways to treat many intracranial and extra cranial
vascular lesions .
It is necessary to provide the patient with all treatment options.
Considering cost-effectiveness and that endovascular
treatment has lower morbidity and mortality rates than does
neurosurgery. It is crucial for the group to take a leading role in
the future of neurointervention.
OLD NEWER

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