PART I
FUNDAMENTALS
CHAPTER 1
Tools of the Trade
1
J.J. Connors III, J.C. Wojak, and Z. Qian
Routine Supplies for Interventional Neuroradiology Cases Puncture Systems Hemostatic Devices Guidewires *
Neuro-Sheaths Guide Catheters * Flow Control Catheters Temporary Test Occlusion Balloon Catheters Angioplasty
Balloon Catheters Microcatheters * Atherosclerotic Microangioplasty Catheters Vasospasm Microangioplasty Cathe-
ters * Venting Catheters Temporary Stenting Catheters Snares Embolectomy Devices Commercial and Investiga-
tive Metallic Stents Particulate Embolic Agents Mechanical Embolic Agents Liquid Embolic Agents Air Filters
Microtubing Large-Bore Y Connectors Steamers * Isotonic Iso-Osmolar Nonionic Contrast Temporary Pacemakers
Vertebral Body Biopsy Needles
CHAPTER 2
Future Devices and Procedures
38
J.J. Connors ill and J.C. Wojak
Paving Stents Spherical Coils and Three-Dimensional Coils Advanced Embolic Agents Monitoring Guidewires
Microminiaturized Tools Percutaneous Dilation ofAqueductal Stenosis Alternative Inflation Methods for Angioplasty
Balloons Beta Radiation Delivery Catheter System Radioactive Stents Cutting Balloons Infiltrating Angioplasty
Balloons Multiballoon Angioplasty Systems Excimer Laser Ablation Vascular Recanalization
CHAPTER 3
Tricks of the Trade
41
J.J. Connors III and J.C. Wojak
Diamox Challenge Test How to Test a Vessel Before Embolization (Provocative Testing) How to Mix Particles How
to Mix and Use Avitene How to Load Silk for Embolization How to Use Alcohol Embolizing With Coils How to
Mount a Detachable Balloon Propping a Balloon Steering a Detachable Balloon How to Use a Snare * Preparing a
Large-Lumen Intravascular Withdrawal System for a Foreign Body How to Steam a Catheter How to Use the Intime
Catheter Steering a Flow-Directed Catheter into the Anterior Rather Than the Middle Cerebral Artery How to
Introduce a Guide Catheter Directly Through the Skin Dealing With Unwanted Hydrophilic Coating Accurate Mea-
surement of a Vessel, Stenosis, Aneurysm, or Other Structure Puncture Through a Graft Safe Catheterization of
Difficult and/or Tortuous Vessels Protective Embolization of Vital Vessels Prevention of Catheter-Induced Spasm
Spinal Angiography Carotid Compression Procedure for Carotid-Cavernous Fistulae Direct Puncture of the Carotid
Artery Useful Measurements and Conversions
CHAPTER 4
Pharmacology in Interventional Neuroradiology
59
J.C. Wojak
Embolic Agents Local Anesthetics Sedation Analgesia Anticonvulsants Antiemetics Antibiotics * Antihyper-
tensives Antiulcer Agents * Neuroprotectants Cardiovascular Agents Drugs for Functional Neurologic Testing An-
ticoagulants and Antiplatelet Drugs Vasodilators Thrombolytic Agents Miscellaneous Pharmaceuticals
CHAPTER 5
Fundamental Neurovascular Anatomy
77
J.C. Wojak
Dangerous Extracranial-Intracranial Anastomoses Persistent Primitive Anastomoses from the Anterior Circulation to
the Posterior Circulation Intrinsically Dangerous Vessels Vascular Supply to the Spinal Cord Intracranial Vascular
Territories
xviii Contents
CHAPTER 6
Neurologic Correlates of Cerebrovascular Occlusions
84
D.v. Rodriguez
Specific Vessels and Associated Findings
CHAPTER 7
General Preprocedure and Postprocedure Orders
89
J.C. Wojak
Preprocedure Orders Postprocedure Orders Additional Medications (As Needed for Specific Cases)
PART II
EMBOLIZATION
CHAPTER 8
General Principles of Embolization
93
J.J. Connors ill and J.C. Wojak
Pathologies Amenable to Embolotherapy General Technique of Embolization * Extra-Axial Tumors *
CHAPTER 9
Meningiomas
100
J.J. Connors III and J.C. Wojak
Epidemiology Radiographic Evaluation * Preoperative Embolization Inoperable Tumors
CHAPTER 10
Juvenile Nasopharyngeal Angiofibromas
121
J.J. Connors ill and J.C. Wojak
Epidemiology Clinical Presentation Pathology * Evaluation Endovascular Therapy Recurrence
CHAPTER 11
Paragangliomas
130
J.J. Connors ill and J.C. Wojak
Tympanic Paragangliomas Jugular Paragangliomas * Carotid Paragangliomas Vagal Paragangliomas Secretory Ac
tivity of Paragangliomas/Hypertensive Crisis General Goal of Endovascular Therapy of Paragangliomas Elective
Presurgical Internal Carotid Artery Occlusion *
CHAPTER 12
Tumors of the Vertebral Bodies and Other Bones
142
J.J. Connors ill and J.C. Wojak
Transarterial Vertebral Body Tumor Embolization * Percutaneous Ethanol Ablation of Intraosseous Vertebral Body He-
mangiomas Preablation Testing * Percutaneous Vertebroplasty
CHAPTER 13
Epistaxis
147
J.J. Connors III and J.C. Wojak
Rationale for the Therapeutic Approach to Epistaxis Technique of Therapy for Epistaxis
CHAPTER 14
Soft Tissue Tumoral Hemorrhage in the Head and Neck
157
J.J. Connors ill and J.C. Wojak
Rationale for Therapy Continued Bleeding from the Tumor Mass Due to Collateral Supply
CHAPTER 15
Arteriovenous Fistulae and Traumatic Vascular Lesions
160
J.J. Connors ill and J.C. Wojak
General Considerations Traumatic Head and Neck Hemorrhage * Traumatic Arteriovenous Fistulae Pseudoaneu-
rysms of Brachiocephalic Vessels Intracranial Pial Arteriovenous Fistulae (Nongalenic) Potential Complications of
Therapy of Arteriovenous Fistulae *
CHAPTER 16
Endovascular Therapy for Vertebral Artery Arteriovenous Fistulae
180
A. Ayrnard, R. Chapot) E. Houdart, A.E. Casasco, H.S. Jhaveri, D. Reizine, and J.''J. Merland
General Considerations Therapeutic Approach Outcome Conclusion
CHAPTER 17
Embolization of Spinal Vascular Malformations
186
A.E. Casasco, E. Houdart,
H.S. Jhaveri, A. Ayrnard, D. Herbreteau) J.-P. Guichard, D. Reizine) K.L. Mourier, and J.-J. Merland
General Concepts Classification General Approach to Treatment Spinal Cord Arteriovenous Malformations
Perimedullary Arteriovenous Fistulae Spinal Dural Arteriovenous Fistulae With Perimedullary Venous Drainage
Epidural Vascular Malformations Paraspinal Vascular Malformations Cobb''s Syndrome * Vertebral Hemangiomas
Spinal Cord Tumors * Conclusion
CHAPTER 18
Endovascular Therapy and Long-Term Results for Intracranial Dural Arteriovenous
Fistulae
198
C. Cognard, E. Houdart, A.E. Casasco, H.S. dhaveri, R. Chapot, and J.''J. Merland
Etiology Pathophysiology Classification According to the Type of Venous Drainage and Implications Location Ther-
apeutic Approaches Specific Treatment Considerations Relating to Location of the Fistula Spontaneous or Posttreat-
ment Modification of Venous Drainage *
CHAPTER 19
Treatment of Carotid-Cavernous Sinus Fistulae
215
Donald Larsen, Randall T. Higashida, and
J.J. Connors III
Etiology Classification Pathophysiology and Clinical Presentation History Radiographic Evaluation Treatment
Options Indirect Carotid-Cavernous Fistulae Carotid Compression Maneuver Conclusions *
CHAPTER 20
Intracranial Arteriovenous Malformations: General Considerations
227
J.J. Connors ill and
J.C. Wojak
Spetzier and Martin Grading System General Philosophy of Therapy * Theory of AVM Embolization Techniques of
Therapy Materials for Embolization Role of Embolization in Radiosurgery Technical Problems, Complications, and
Solutions in AVM Embolization *
CHAPTER 21
Intracranial Arteriovenous Malformations: The Approach
and Technique of Cyanoacrylate Embolization
240
V.A. Aletich and G.M. Debrun
Initial Evaluation Technique Illustrative Cases Risks, Potential Complications, and Solutions * Conclusion
CHAPTER 22
Ethanol Endovascular Management of Brain Arteriovenous Malformation:
Initial Experience
259
W.F.J. Yokes
Rationale for Use Concepts in Patient Management Technical Problems, Complications, and Solutions Discussion
CHAPTER 23
The Role of Embolization in Combination with Stereotactic Radiosurgery in the Management of
Pial and Dural Arteriovenous Malformations
267
B.E. Pollock, L.D. Lunsford, J.C. Flickinger,
and D. Kondziolka
Pial Arteriovenous Malformations Dural Arteriovenous Malformations
CHAPTER 24
Intracranial Aneurysms: General Considerations
276
J.J. Connors ill and J.C. Wojak
Incidence and Natural History Imaging History of Endovascular Therapy Current Endovascular Therapies
Management of Therapeutically Challenging Aneurysms Hazards of Aneurysm Embolization Potential Advances in
Intracranial Aneurysm Treatment
CHAPTER 25
Detachable Coil Embolization of Intracranial Aneurysms
294
M.E. Cronquist and J. Moret
Pretherapeutic Evaluation and Indications Limitations in and Contraindications to Endovascular Therapy Technical
Devices Procedure Complications and Their Management Interval Angiography and Follow-Up
xx Contents
PART III
MISCELLANEOUS INTERVENTIONAL NEURORADIOLOGIC PROCEDURES
CHAPTER 26
Current Management of Cervicofacial Superficial Vascular Malformations and
Hemangiomas
317
D. Herbreteau, A. Ayrnard, H.S. Jhaveri, R. Chapot, A.E. Casasco, S. Slaba,
E. Houdart, and J.''J. Merland
Hemangiomas Vascular Malformations
CHAPTER 27
Management of Extracranial Head and Neck and Paraspinal Vascular
Malformations
327
W.F.J. Yakes
General Concepts of Therapy Classification of Hemangiomas and Vascular Malformations * Rationale for Therapy Em-
bolic Agents Initial Evaluation Concepts in Patient Management Complications *
CHAPTER 28
Percutaneous Direct Embolization of Head and Neck Vascular Tumors
338
A.E. Casasco,
E. Houdart, H.S. Jhaveri, D. Herbreteau, A. Ayrnard, B. George, M. Wassef, P.T. Ba Huy, and J.-J. Merland
General Technique Strategy- of Treatment of Specific Tumors Pre-Embolization Patient Preparation and Percutaneous
Puncture Techniques Postembolization Care and Follow-Up Results Technical Problems, Complications, and Solu-
tions Conclusion
CHAPTER 29
Percutaneous Vertebroplasty: Indications, Technique, and Complications
346
c. Depriester,
H. Deramond, P. Toussaint, H.S. Jhaueri, and P. Galibert
Pathologies Amenable to Treatment Materials and Devices Preprocedure Orders * Description of Procedure * Post-
procedure Orders Technical Incidents and Complications
CHAPTER 30
A Treatment for Head and Neck Cancer by Direct Arterial Infusion
358
C.w. Kerber,
W.H.M. Wong, and K.T. Robbins
Background and History Theory General Approach to Evaluation and Treatment * Technique Results Technical
Pitfalls, Complications, and Solutions Summary
CHAPTER 31
Intra-Arterial Chemotherapy for Central Nervous System Tumors
368
Jacques Chiras
Background Pharmacologic and Experimental Data Techniques of Infusion Conclusion
CHAPTER 32
Interventional Neuroradiologic Procedure for Wada Testing
372
J.J. Connors ill and
J.C. Wojak
Applications Procedure False-Positive Wada Test
CHAPTER 33
Intracarotid Amobarbital (Wada) Test: Neurology Perspective
374
Piotr Olejniczak and
Bruce Fisch
Procedure Applications
CHAPTER 34
Temporary Test Occlusion of the Internal Carotid Artery
377
J.J. Connors ill
Indications Tools Technique Variations What Is a Temporary Test Occlusion Failure? Technical Problems, Com-
plications, and Solutions False-Negative and False-Positive Test Results
CHAPTER 35
Permanent Occlusion of the Internal Carotid Artery
390
J.J. Connors ill
Rationale for Procedure Technical Theory Specific Technique Single-Photon Emission Computed Tomography Follow-
ing Balloon Occlusion Alternative TechniqueFibered Coils Technical Problems, Complications, and Solutions
CHAPTER 36
Endovascular Test and Permanent Occlusion of Extracranial and Intracranial Cerebral Vessels:
Indications, Techniques, and Management
394
J.N. Vallee, A. Ayrnard, A.E. Casasco,
H.S. Jhaveri) E. Houdart, and J.''J. Merland
General Considerations Internal Carotid Artery Common Carotid Artery Vertebral Artery Intradural Vessels
Complications Follow-Up * Conclusion
CHAPTER 37
Endovascular Treatment of Traumatic Lesions in Supra-Aortic Vessels With
Stent-GraftS
408
J.C. Parodi and C.J. Schonholz
History * General Approach Results Complications Follow-Up Conclusions
CHAPTER 38
Inferior Petrosal Sinus Sampling
411
J.J. Connors ill and J.C. WoJak
Rationale for Procedure Technique of Sampling Technical Problems, Complications, and Solutions
CHAPTER 39
Nerve Blocks and Discectomy
421
J.C. Wojak and J.J. Connors ill
Nerve Blocks Discectomy
CHAPTER 40
Percutaneous Treatment of Cervical and Lumbar Disc Herniations
424
J.G. Theron
Treatment Options Indications Choice of Procedure Pretherapeutic Consultation Technique Technical Problems,
Complications, and Solutions Conclusion
PART IV
BRACHIOCEPHAUC ANGIOPLASTY AND STENTING
CHAPTER 41
General Concepts of Brachiocephalic Angioplasty for Atherosclerosis
431
J.J. Connors ill
Importance and Implications of Degree of Stenosis Ongoing Clinical Trials Locations of Atherosclerotic Brachiocephalic
Disease General Theory of Angioplasty and Pathophysiologic Response Angioplasty and Fibrinolysis Restenosis
CHAPTER 42
General Technique of Extracranial Angioplasty and Stenting
438
J.J. Connors ill
Tools for Extracranial Angioplasty and Stenting Preliminary Evaluation Indications Contraindications Preproce-
dure Preparation Procedural Technique for Extracranial Angioplasty Postprocedure Care Probucol Follow-up
CHAPTER 43
General Considerations for Endovascular Therapy of the Extracranial Internal Carotid Artery
at the Bifurcation
442
J.J. Connors ill
Natural History of the Disease Carotid Endarterectomy Advantages of Carotid Angioplasty * Disadvantages and Risks
of Carotid Angioplasty Rationale for Stent Use Cerebral Protection During Internal Carotid Angioplasty Distal
Perfusion During Angioplasty Asystole After Carotid Stenting The Future of Endovascular Carotid Artery Therapy
CHAPTER 44
Cervical Carotid Angioplasty and Stent Placement for Atherosclerosis
456
V. Wadlington,
J. Yadau, J. Vitek, M. Parks) S. lyer) and G. Roubin
Patient Selection Angioplasty Risks Surgical Risks * Preparation * Angioplasty and Stent Procedure Postangi-
opIasty/Stenting Results Postangioplasty Management Follow-Up Conclusions
CHAPTER 45
Protected Angioplasty and Stenting of Atheroscierotic Stenosis
at the Carotid Artery Bifurcation
466
J.G. Theron
Evolution of the Techniques of Protected Angioplasty and Protected Stenting Role of Digitized Parenchymography in
Patient Evaluation Current Periprocedural Medication Protocol Complications and Solutions
CHAPTER 46
Current Status and Future Possibilities of Balloon Angioplasty in the Carotid
Artery
473
R. Rachel
Balloon Angioplasty as a Controlled Injury * Indications for Carotid Angioplasty Without Stenting (Conventional) Pre-
therapeutic Diagnostic Methods Patient Preparation Materials Method Postprocedure Management Results
Cerebral Protection * To Stent or Not to Stent
CHAPTER 47
Other Extracranial Locations Amenable to Angioplasty and Stenting
484
J.J. Connors ill
Origin of the Left Common Carotid Artery from the Aorta Innominate Artery Subclavian Artery Cervical Carotid
Artery Other Than at the Bifurcation Vertebral Artery Origin
CHAPTER 48
Intracranial Angioplasty
500
J.J. Connors ill
General Considerations Location of Intracranial Atherosclerotic Disease Rationale for Treatment of Intracranial Steno-
ses Technique of Elective Intracranial Angioplasty Strategy and Technique of Penetrating a Total Intracranial Vascular
Occlusion With Downstream Ischemia Complications of Intracranial Angioplasty and How to Avoid Them
CHAPTER 49
Surgical Alternatives to Interventional Neuroradiology
555
J.R. Tompkins and R Culicchia
History Indications for Cerebral Revascularization Extracramal-intracranial Surgical Revascularization Operative
Procedures * Results Postoperative Care Conclusions
CHAPTER 50
Clinical Applications of Intravascular Ultrasound
561
S.P. Jain and S.R. Ramee
Currently Available Devices * New Devices Ultrasound Image Interpretation Reproducibility Safety Issues Limi-
tations Clinical Utility of Intravascular Ultrasound Conclusions
PARTY
POSTSUBARACHNOID HEMORRHAGE VASOSPASM
CHAPTER 51
Endovascular Therapy of Postsubarachnoid Hemorrhage Vasospasm
581
J.J. Connors ill
and J.C. Wojak
Evaluation of Intracranial Vasospasm Radiographic Manifestations Therapeutic Options
CHAPTER 52
Medical Management of Vasospasm and Hemodynamic Alterations
in the Neurosurgical ICU
602
C. Paoletti, C. Dematons, C. Bellec, J.L. Raggueneau, D. Payen de la
Garanderie, L. Do, G. Lot, B. George, J. Cophignon, and J.-J. Merland
Postembolization Care After Aneurysmal Subarachnoid Hemorrhage Monitoring and Care After Balloon Occlusion of
the Internal Carotid Artery
PART VI
EMERGENCY TREATMENT OF ACUTE ISCHEMIC STROKE
CHAPTER 53
General Considerations in Emergency Stroke Therapy
613
J.J. Connors ill and J.C. Wojak
History * Rationale for Emergency Cerebral Revascularization
CHAPTER 54
Medical Aspects of Cerebral Ischemia
616
L.A. Weisberg
Risk Factors for Ischemic Stroke Neuroloc Risk Factors for Stroke Diagnostic and Treatment Strategies Manage-
ment of the Patient With Transient Ischemic Attacks Cerebral Blood Flow and Metabolism Management of Acute
Cerebral IschemiCHAPTER 55
Cerebral Protection
626
J.C. Wojak
Barbiturate Therapy for Pre-Emptive Cerebral Protection Hypothermia
CHAPTER 56
Current Directions in Emergency Stroke Therapy
629
J.J. Connors ill and J.C. Wojak
Early Results of Neuroprotectant Agent Trials Fibrinolytic Agents Results of Early Intravenous Fibrinolytic Thera-
pies National Institute of Neurological Disorders and Stroke Tissue Plasminogen Activator Stroke Trial Results of
Early Intracranial Local Intra-arterial Fibrinolysis Ongoing Local Intra-arterial Fibrinolysis Trials Retrograde Venous
Neuroperfusion Hyperbaric Oxygen Hypothermia
CHAPTER 57
Radiology of Emergency Stroke Therapy
644
P. Mohanakrishnan, J.J. Connors ill, and
J.C. Wojak
Initial Computed Tomography Scan Follow-Up Computed Tomography Scan Magnetic Resonance Imaging Angiogra-
phy
CHAPTER 58
Strategic Considerations Concerning Emergency Stroke Treatment
650
J.J. Connors ill and
J.C. Wojak
General Considerations Regarding Fibrinolysis Rationale for Intravenous Versus Intra-Arterial Fibrinolytic Therapy
Timing of Therapy Time Versus Diagnostic Information Heart Versus Brain (Rationale for Different Therapies for
Coronary and Cerebral Vascular Occlusions) The Need to Reestablish Flow: Mechanical Versus Fibrinolytic Means
Factors Affecting Success of Fibrinolytic Therapy for Acute Stroke Factors Associated With Intraparenchymal Hema-
toma and Poor Outcome Other Predictors of Poor Outcome Optimal Emergency Stroke Therapy
CHAPTER 59
Specific Stroke Situations, Territories, and Guidelines for Therapy
2
J.J. Connors ill and
J.C. Wojak
Vertebrobasilar Stroke Anterior Circulation Stroke Dural Sinus Thrombosis Treatment of a Stroke During or Subse-
quent to an Angiographic Procedure
CHAPTER 60
Specific Technical Procedure of Emergency Intracranial Fibrinolysis
751
J.J. Connors ill and
J.C. Wojak
Getting Started Dose of Heparin Choice of Microcatheter Microcatheter Tip and Guide Catheter Localization Es-
tablishing Antegrade Flow Dose of Fibrinolytic Agent Choice of Contrast Material Dealing With Resistant Throm-
bus Chasing the Clot When to Stop Postprocedure Management Aspirin and Acute Stroke Therapy ReoPro
(abciximab) and Acute Stroke Therapy
CHAPTER 61
Technique of Superselective Intraophthalmic Artery Fibrinolytic Therapy Using Urokinase for
Central Retinal Vein Occlusion
756
J.N. Vallee, H.S. Jhaueri, M. Tovi, P.Y. Santiago, P. Paques,
A. Gaudric, and J.-J. Merland
Inclusion Criteria Exclusion Criteria Technique Results * Conclusion
CHAPTER 62
Management of Intracranial Hemorrhage During Thrombolysis
759
J.C. Wojak
CHAPTER 63
Treatment and Prevention of Acute Ischemic Stroke by Endovascular Techniques:
A Network-Based Community Model
760
B.L. Berger and A.S. Callahan ill
Background Screening Acute Treatment Results Aftercare Technical Problems, Complications, and Solu-
tions Benefits of a Dedicated Endovascular Service Referrals Future Trends
PART VII
COMPLICATIONS OF INTERVENTIONAL NEURORADIOLOGIC PROCEDURES AND THEIR
TREATMENT
CHAPTER 64
Problems, Complications, and Solutions in Embolization
768
J.J. Connors ill and J.C. Wojak
Microparticulate Pulmonary Embolism Cranial Nerve Damage Cardiopulmonary Collapse After Ethanol Emboliza-
tion Tissue Necrosis Coil Malposition Balloons Postembolic Syndrome Hypertensive Crisis Normal Perfusion
Pressure Breakthrough Failure of Residual Trunk Patency: Retrograde Thrombosis Catheter Occlusion Problems
Associated With Flow-Directed Catheters
CHAPTER 65
Rupture of a Vessel, Aneurysm, or Arteriovenous Malformation
775
J.J. Connors ill and
J.C. Wojak
Intracranial Vascular Perforation Ruptured Arteriovenous Malformation Aneurysm Rupture
CHAPTER 66
Other Problems, Complications, and Solutions
777
J.J. Connors ill and J.C. Wojak
Urokinase Chills Broken Catheter Intraprocedural Vasospasm Dissection Clot Stroke on the Table Cervical
Radiculopathy and Peripheral Neuropathy
Index
783
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