- Email: [email protected]
Coil migration during endovascular treatment in a patient with Galenic arteriovenous malformation
584 Hyodo et al.
A
B
Fig. 4 (A) Same study as above at a lower axial section showing bifrontal epidural haematomas; (B) Schematic line diagram of axial section of CT scan imaging at the level of the third ventricle showing bilateral frontal epidural haematomas. The level of craniotomy is at a higher level. 11.
complication possibly could been averted if the patient was positioned with the aid of a three pin clamp, thus avoiding scalp compression. Hence we recommend three-pin fixation in patients with posterior saggital sinus thrombosis.
12.
CONCLUSIONS
14.
Postoperative intracranial haematomas occurring remote from the site of craniotomy are uncommon. Of these, epidural haematomas are extremely rare. In the present case, we feel that this complication occurred as a result of venous stasis due to compression by the horseshoe over the scalp (in the background of an obliterated superior saggital sinus) leading to rupture of the veins draining into the superior saggital sinus and subsequent formation of an epidural haematoma. This complication may have been avoided if a three-pin fixation was used. We feel that in cases where surgery has been performed in the prone position and in whom the superior saggital sinus has been obliterated due to the tumour, surgery in these patients should be performed using a pin fixation system rather than a horseshoe. Our case is unique and to our knowledge is the first of its kind in the literature.
13.
Seiler RW, Zurbrugg HR. Supratentorial intracerebral haemorrhage after posterior fossa operation. Neurosurgery 1986; 18: 472±474. Standefer M, Bay JW, Trusso R. The sitting position in neurosurgery: A retrospective analysis of 488 cases. Neurosurgery 1984; 14: 649±658. Calenberg VF, Goffin J, Plets C. Cerebellar haemorrhage complicating supratentorial craniotomy. Report of two cases. Surg Neurol 1993; 40: 336±338. Waga S, Shimosaka S, Sakakura M. Intracerebral haemorhage remote from the site of the initial neurosurgical procedure. Neurosurgery 1983; 13: 662±665.
Coil migration during endovascular treatment in a patient with Galenic arteriovenous malformation Akio Hyodo MD PHD, Kiyoyuki Yanaka MD PHD, Noriyuki Kato MD, Tadao Nose MD PHD
REFERENCES 1. 2.
3.
4. 5. 6.
7.
8.
9. 10.
Haines SJ, Maroon JC, Jannetta PJ. Supratentorial intracerebral haemorrhage following posterior surgery. J Neurosurg 1978; 49: 881±886. Brisman MH, Bederson JB, Sen CN et al. Intracerebral haemorrhage occurring remote from the craniotomy site. Neurosurg 1996; 39(6): 1114±1120. Fukamachi A, Koizumi H, Nagaseki Y et al. Postoperative extradural haematomas: Computed tomographic survey of 1105 intracranial operations. Neurosurgery 1986; 19: 589±593. Kalfas IH, Little JR. Postoperative haemorrhage: A survey of 4992 intracranial procedures. Neurosurgery 1988; 23: 343±347. Lourie H, Young RF. Posterior epidural haematoma following subfrontal tumour removal. J Neurosurg 1974; 40: 643±646. Fukamachi A, Koizumi H, Nukui H. Postoperative extradural haematomas: Computed tomographic findings after 1074 intracranial operations. Surg Neurol 1985; 23: 589±593. Harders A, Gilsbach J, Weigel K. Supratentorial space-occupying lesions following infratentorial surgery: Early diagnosis and treatment. Acta Neurochir (Wein) 1985; 74: 57±60. Koyabashi S, Sugita K, Gibo H et al. Contralateral pontine haemorrhage as a complication of acoustic neuroma surgery. Surg Neurol 1983; 35: 943±948. Konig A, Laas R, Hermann HD. Cerebellar haemorrhage as a complication after supratentorial craniotomy. Acta Neurochir (Wein) 1987; 88: 104±108. Modesti LM, Hodge CJ, Barnwell ML. Intracerebral haematoma after evacuation of chronic extracerebral fluid collections. Neurosurg 1982; 10: 689±693.
Journal of Clinical Neuroscience (2002) 9(5)
Summary High flow arteriovenous malformations are commonly treated by using an endovascular approach with detachable coils. Although the risk of coil migration or distal embolisation into the venous system is almost always a consideration when treating these lesions, coil migration of a coil mass comprised of several coils is uncommonly seen, and not recorded. We report a case of Galenic arteriovenous malformation in a 22-year-old male in which coil migration was observed during the endovascular procedure. Possible mechanisms are discussed. & 2002 Published by Elsevier Science Ltd. Journal of Clinical Neuroscience (2002) 9(5), 584±585 & 2002 Published by Elsevier Science Ltd. DOI: 10.1054/jocn.2001.0974, available online at http://www.idealibrary.com on
Keywords: arteriovenous malformation, coil migration, detachable coil, vein of Galen Received 27 June 2001 Accepted 24 July 2001 Correspondence to: Kiyoyuki Yanaka MD, PhD, Department of Neurosurgery, Institute of Clinical Medicine, University of Tsukuba, Tsukuba, Ibaraki 305-8575, Japan. Tel.: 81-298-53-3220; Fax: 81-298-53-3214; E-mail: [email protected]
& 2002 Published by Elsevier Science Ltd.
Coil migration 585
Fig. 1 Lateral view of the carotid angiogram showing the Galenic arteriovenous malformation fed by the dilated pericallosal artery, and the branches of the middle cerebral artery and drained into the straight sinus.
INTRODUCTION High-flow arteriovenous malformation and fistula are commonly treated by using an endovascular approach with a variety of materials, such as detachable coils.1,2 Although the risk of coil migration or distal embolisation into the venous system is almost always a consideration when treating these lesions, coil migration is rarely seen at the moment of coil placement during the procedure. In this report, we describe a case of Galenic arteriovenous malformation (AVM) in which coil migration was observed during the endovascular procedure. Coil migration occurred within one second, and the entire course of migration was recorded. CASE REPORT A 22-year-old-male, with no previous neurological history, presented with a sudden onset consciousness disturbance, with no localising neurological findings. Computed tomography of the brain without contrast revealed an intraventricular haemorrhage. Cerebral angiography demonstrated a Galenic AVM (Fig. 1). After a thorough angiographic evaluation, we planned to reduce the arterial inflow to the lesion by transarterial embolisation using interlocking detachable coils. The initial five embolised coils remained at the pericallosal artery, just proximal to the fistula, for about 20 min (Fig. 2). However, rapid migration of the embolised coils via the fistula into the vein of Galen occurred in an instant. Figure 3 is composed of five angiographic films that were recorded within 1 s. The migration speed of the coils was too high to be detected clearly on angiography; migrating coils were seen dimly (Fig. 3, centre). The migrated coils were removed immediately via an intravenous approach, and additional feeder occlusion was performed two weeks later. The patient showed a good recovery and was discharged one month later. DISCUSSION To maximise the chance for long-term closure of an arteriovenous fistula, it is usually recommended to treat either the fistula directly with some form of occlusive device or to treat both supplying arteries and the fistulous venous segment.3 Significant risk exists for either proximal or distal coil migration because of rapid flow.1 There have been several reports of coil migration after the endovascular treatment of intracranial & 2002 Published by Elsevier Science Ltd.
Fig. 2
Lateral view of the skull showing embolised coils before migration.
Fig. 3 Embolised coils before (right), during (centre), and after migration (left). Figure 3 is composed of five angiographic films that are recorded within 1 s. Migrating coils are seen dimly (centre) because the migration speed of the coils is too high to be detected clearly with angiography.
aneurysms.2 However, this is the first to observe the entire course of coil migration within 1 s in a patient with an AVM. The initial five embolised coils remained at the pericallosal artery, just proximal to the fistula, for about 20 min, and rapid migration of the embolised coils via the fistula occurred in an instant. The cause of this migration may be due to a size mismatch between the embolised coils and the caliber of the parent artery. However, if there were a size mismatch, the embolised coils would not have remained at the parent artery. Another possible mechanism is mechanical vasospasm due to catheter manipulation in the early stage of the endovascular procedure. Redilatation of a constricted artery, just proximal to the fistula, may have resulted in a size mismatch between the coils and the caliber of the artery. This could potentially result in coil migration 20 min after embolisation. Therefore, gentle manipulation of the catheter and coil placement, and careful observation of the embolised coils are essential during the endovascular treatment of an AVM. REFERENCES 1.
2.
3.
Nesbit GM, Barnwell SL. The use of electrolytically detachable coils in treating high-flow arteriovenous fistulas. Am J Neuroradiol 1998; 19: 1565±1569. Phatouros CC, McConachie NS, Jaspan T. Post-procedure migration of Guglielmi detachable coils and Mechanical detachable spirals. Neuroradiology 1999; 41: 324±327. Halbach VV, Higashida RT, Barnswell SL, Dowd CF, Hieshima GB. Transarterial platinum coil embolization of carotid-cavernous fistulas. Am J Neuroradiol 1991; 12: 429±433.
Journal of Clinical Neuroscience (2002) 9(5)
A
B
Fig. 4 (A) Same study as above at a lower axial section showing bifrontal epidural haematomas; (B) Schematic line diagram of axial section of CT scan imaging at the level of the third ventricle showing bilateral frontal epidural haematomas. The level of craniotomy is at a higher level. 11.
complication possibly could been averted if the patient was positioned with the aid of a three pin clamp, thus avoiding scalp compression. Hence we recommend three-pin fixation in patients with posterior saggital sinus thrombosis.
12.
CONCLUSIONS
14.
Postoperative intracranial haematomas occurring remote from the site of craniotomy are uncommon. Of these, epidural haematomas are extremely rare. In the present case, we feel that this complication occurred as a result of venous stasis due to compression by the horseshoe over the scalp (in the background of an obliterated superior saggital sinus) leading to rupture of the veins draining into the superior saggital sinus and subsequent formation of an epidural haematoma. This complication may have been avoided if a three-pin fixation was used. We feel that in cases where surgery has been performed in the prone position and in whom the superior saggital sinus has been obliterated due to the tumour, surgery in these patients should be performed using a pin fixation system rather than a horseshoe. Our case is unique and to our knowledge is the first of its kind in the literature.
13.
Seiler RW, Zurbrugg HR. Supratentorial intracerebral haemorrhage after posterior fossa operation. Neurosurgery 1986; 18: 472±474. Standefer M, Bay JW, Trusso R. The sitting position in neurosurgery: A retrospective analysis of 488 cases. Neurosurgery 1984; 14: 649±658. Calenberg VF, Goffin J, Plets C. Cerebellar haemorrhage complicating supratentorial craniotomy. Report of two cases. Surg Neurol 1993; 40: 336±338. Waga S, Shimosaka S, Sakakura M. Intracerebral haemorhage remote from the site of the initial neurosurgical procedure. Neurosurgery 1983; 13: 662±665.
Coil migration during endovascular treatment in a patient with Galenic arteriovenous malformation Akio Hyodo MD PHD, Kiyoyuki Yanaka MD PHD, Noriyuki Kato MD, Tadao Nose MD PHD
REFERENCES 1. 2.
3.
4. 5. 6.
7.
8.
9. 10.
Haines SJ, Maroon JC, Jannetta PJ. Supratentorial intracerebral haemorrhage following posterior surgery. J Neurosurg 1978; 49: 881±886. Brisman MH, Bederson JB, Sen CN et al. Intracerebral haemorrhage occurring remote from the craniotomy site. Neurosurg 1996; 39(6): 1114±1120. Fukamachi A, Koizumi H, Nagaseki Y et al. Postoperative extradural haematomas: Computed tomographic survey of 1105 intracranial operations. Neurosurgery 1986; 19: 589±593. Kalfas IH, Little JR. Postoperative haemorrhage: A survey of 4992 intracranial procedures. Neurosurgery 1988; 23: 343±347. Lourie H, Young RF. Posterior epidural haematoma following subfrontal tumour removal. J Neurosurg 1974; 40: 643±646. Fukamachi A, Koizumi H, Nukui H. Postoperative extradural haematomas: Computed tomographic findings after 1074 intracranial operations. Surg Neurol 1985; 23: 589±593. Harders A, Gilsbach J, Weigel K. Supratentorial space-occupying lesions following infratentorial surgery: Early diagnosis and treatment. Acta Neurochir (Wein) 1985; 74: 57±60. Koyabashi S, Sugita K, Gibo H et al. Contralateral pontine haemorrhage as a complication of acoustic neuroma surgery. Surg Neurol 1983; 35: 943±948. Konig A, Laas R, Hermann HD. Cerebellar haemorrhage as a complication after supratentorial craniotomy. Acta Neurochir (Wein) 1987; 88: 104±108. Modesti LM, Hodge CJ, Barnwell ML. Intracerebral haematoma after evacuation of chronic extracerebral fluid collections. Neurosurg 1982; 10: 689±693.
Journal of Clinical Neuroscience (2002) 9(5)
Summary High flow arteriovenous malformations are commonly treated by using an endovascular approach with detachable coils. Although the risk of coil migration or distal embolisation into the venous system is almost always a consideration when treating these lesions, coil migration of a coil mass comprised of several coils is uncommonly seen, and not recorded. We report a case of Galenic arteriovenous malformation in a 22-year-old male in which coil migration was observed during the endovascular procedure. Possible mechanisms are discussed. & 2002 Published by Elsevier Science Ltd. Journal of Clinical Neuroscience (2002) 9(5), 584±585 & 2002 Published by Elsevier Science Ltd. DOI: 10.1054/jocn.2001.0974, available online at http://www.idealibrary.com on
Keywords: arteriovenous malformation, coil migration, detachable coil, vein of Galen Received 27 June 2001 Accepted 24 July 2001 Correspondence to: Kiyoyuki Yanaka MD, PhD, Department of Neurosurgery, Institute of Clinical Medicine, University of Tsukuba, Tsukuba, Ibaraki 305-8575, Japan. Tel.: 81-298-53-3220; Fax: 81-298-53-3214; E-mail: [email protected]
& 2002 Published by Elsevier Science Ltd.
Coil migration 585
Fig. 1 Lateral view of the carotid angiogram showing the Galenic arteriovenous malformation fed by the dilated pericallosal artery, and the branches of the middle cerebral artery and drained into the straight sinus.
INTRODUCTION High-flow arteriovenous malformation and fistula are commonly treated by using an endovascular approach with a variety of materials, such as detachable coils.1,2 Although the risk of coil migration or distal embolisation into the venous system is almost always a consideration when treating these lesions, coil migration is rarely seen at the moment of coil placement during the procedure. In this report, we describe a case of Galenic arteriovenous malformation (AVM) in which coil migration was observed during the endovascular procedure. Coil migration occurred within one second, and the entire course of migration was recorded. CASE REPORT A 22-year-old-male, with no previous neurological history, presented with a sudden onset consciousness disturbance, with no localising neurological findings. Computed tomography of the brain without contrast revealed an intraventricular haemorrhage. Cerebral angiography demonstrated a Galenic AVM (Fig. 1). After a thorough angiographic evaluation, we planned to reduce the arterial inflow to the lesion by transarterial embolisation using interlocking detachable coils. The initial five embolised coils remained at the pericallosal artery, just proximal to the fistula, for about 20 min (Fig. 2). However, rapid migration of the embolised coils via the fistula into the vein of Galen occurred in an instant. Figure 3 is composed of five angiographic films that were recorded within 1 s. The migration speed of the coils was too high to be detected clearly on angiography; migrating coils were seen dimly (Fig. 3, centre). The migrated coils were removed immediately via an intravenous approach, and additional feeder occlusion was performed two weeks later. The patient showed a good recovery and was discharged one month later. DISCUSSION To maximise the chance for long-term closure of an arteriovenous fistula, it is usually recommended to treat either the fistula directly with some form of occlusive device or to treat both supplying arteries and the fistulous venous segment.3 Significant risk exists for either proximal or distal coil migration because of rapid flow.1 There have been several reports of coil migration after the endovascular treatment of intracranial & 2002 Published by Elsevier Science Ltd.
Fig. 2
Lateral view of the skull showing embolised coils before migration.
Fig. 3 Embolised coils before (right), during (centre), and after migration (left). Figure 3 is composed of five angiographic films that are recorded within 1 s. Migrating coils are seen dimly (centre) because the migration speed of the coils is too high to be detected clearly with angiography.
aneurysms.2 However, this is the first to observe the entire course of coil migration within 1 s in a patient with an AVM. The initial five embolised coils remained at the pericallosal artery, just proximal to the fistula, for about 20 min, and rapid migration of the embolised coils via the fistula occurred in an instant. The cause of this migration may be due to a size mismatch between the embolised coils and the caliber of the parent artery. However, if there were a size mismatch, the embolised coils would not have remained at the parent artery. Another possible mechanism is mechanical vasospasm due to catheter manipulation in the early stage of the endovascular procedure. Redilatation of a constricted artery, just proximal to the fistula, may have resulted in a size mismatch between the coils and the caliber of the artery. This could potentially result in coil migration 20 min after embolisation. Therefore, gentle manipulation of the catheter and coil placement, and careful observation of the embolised coils are essential during the endovascular treatment of an AVM. REFERENCES 1.
2.
3.
Nesbit GM, Barnwell SL. The use of electrolytically detachable coils in treating high-flow arteriovenous fistulas. Am J Neuroradiol 1998; 19: 1565±1569. Phatouros CC, McConachie NS, Jaspan T. Post-procedure migration of Guglielmi detachable coils and Mechanical detachable spirals. Neuroradiology 1999; 41: 324±327. Halbach VV, Higashida RT, Barnswell SL, Dowd CF, Hieshima GB. Transarterial platinum coil embolization of carotid-cavernous fistulas. Am J Neuroradiol 1991; 12: 429±433.
Journal of Clinical Neuroscience (2002) 9(5)