Endovascular Internal Trapping of Ruptured Occipital Artery Pseudoaneurysm Associated with Occipital-Internal Jugular Vein Fistula in Neurofibromatosis Type 1

Ruptured Occipital Artery Aneurysm Following Craniotomy in a Patient with Neurofibromatosis Type 1: Case Report

Objective

Neurofibromatosis type 1 (NF1) is associated with vascular fragility, which results in aneurysms, arteriovenous fistulas, and dissections. Here, we describe a case of endovascular treatment of a ruptured occipital artery aneurysm that occurred after a craniotomy in a patient with NF1.

Case Presentation

A 46-year-old man with a history of NF1 underwent a right lateral suboccipital craniotomy to remove a cavernous hemangioma in the right middle cerebellar peduncle. Severe bleeding occurred in the occipital artery during the craniotomy. Due to vessel fragility, coagulation and ligation were not possible, and pressure hemostasis was achieved using cellulose oxide and fibrin glue. On postoperative day 12, the patient developed a sudden swelling on the right side of the neck as well as tracheal compression. Contrast-enhanced CT revealed a ruptured aneurysm in the right occipital artery. Transarterial embolization was performed under general anesthesia the same day. Right external carotid angiography showed an 18-mm-diameter fusiform aneurysm in the occipital artery. The aneurysm ruptured inferiorly to form a large pseudoaneurysm with significant jet flow. An arteriovenous fistula was also observed in a nearby vein. A microcatheter was inserted into the fusiform aneurysm under proximal blood flow control, and embolization was performed using coils and N-butyl-2-cyanoacrylate.

Conclusion

Compared to surgical repair of ruptured occipital artery aneurysms, endovascular treatment appears to be safe, effective, minimally invasive, and rapid. Ruptured occipital artery aneurysms in NF1 patients can cause neck swelling and airway compression and should be recognized as a potentially lethal condition.

Direct arteriovenous fistula due to a blister-like aneurysm of the supraclinoid internal carotid artery hijacking its adjacent vein

BACKGROUND

This is the first report of a direct acquired arteriovenous fistula (AVF) between an intracranial aneurysm and its adjacent pial vein.

CASE DESCRIPTION

A 33-year-old male suffered subarachnoid hemorrhage. Computed tomography angiography revealed an aneurysm of the supraclinoid internal carotid artery (ICA). Digital subtraction angiography (DSA) showed that the aneurysm of the supraclinoid ICA was blister-like and that one large vessel crossing the aneurysm provided two draining paths into the bilateral cavernous sinuses and superior sagittal sinus. Microsurgery confirmed the presence of a blister-like aneurysm and proved the vessel crossing and connected to the aneurysm to be a pial vein, resulting in a direct AVF between the aneurysm and its adjacent vein. The blister-like aneurysm together with some of the ICA wall was clipped to reconstruct the ICA and preserve the anterior choroidal artery (AchA). Postoperative DSA showed the following: the blister-like aneurysm had been completely clipped; the ICA was narrow, but the blood flow was sufficient; and the AchA was intact. After discharge, the patient recovered uneventfully without neurological deficits.

CONCLUSIONS

Exceptionally, an intracranial ruptured aneurysm can hijack its adjacent pial vein as its draining path, forming a direct AVF. Microsurgery can be used to confirm the angioarchitecture of the AVF, and clipping is a good treatment choice.

Rapid airway stenosis due to ruptured occipital artery in a patient with neurofibromatosis type I

Background

Neurofibromatosis type I is rarely associated with vascular abnormalities. Here, we report a case of rapid airway stenosis caused by a ruptured occipital artery that was treated with surgical airway management.

Case Presentation

A 40-year-old woman, with no medical history, presented with a chief complaint of a sudden neck pain on the left side. She had a prominent mass in the outer left side of the neck. After arrival at the emergency room, the patient complained of severe dyspnea and experienced a rapid drop in oxygen saturation. Supplemental ventilation was ineffective, and tracheal intubation was attempted; however, laryngeal expansion could not be observed because of the enlarged cervical mass. Therefore, to manage the surgical airway, a cricothyrotomy was first carried out, which resulted in an immediate increase in oxygen saturation. Two percutaneous embolizations and one surgical procedure were carried out, and the patient was discharged without any complications.

Conclusion

For a sudden onset cervical mass, airway management should be undertaken, keeping in mind the possibility of worsening rapid airway narrowing due to bleeding.

Extracranial Vertebral Artery-Internal Jugular Vein-Spinal Vein Fistula in Neurofibromatosis Type I: Case Report and Literature Review

Background

A cervical arteriovenous fistula (AVF) in neurofibromatosis type I (NF-1) is uncommon, and it brings challenges and difficulty in treatment.

Case Presentation

A 39-year-old woman was diagnosed with an NF-1-associated spontaneous vertebral artery-internal jugular vein-spinal vein fistula. The fistula was placed by coil embolization. Postoperative examination showed that the fistula closure was satisfied, and the patient's abnormal clinical manifestation disappeared without any complications after 24 months of interventional embolization. As per the literature, interventional embolization is currently the main treatment method, and it has the distinguishing features of less trauma, quick recovery, and a good prognosis.

Conclusion

NF-1 associated with a spontaneous arteriovenous fistula is rare in clinical practice, which carries significant challenges in treatment, but can be effectively treated using endovascular embolism. Endovascular embolism could be the potential choice of treatment in NF-1 associated with AVF.

Clinical importance of the occipital artery in vascular lesions: A review of the literature

The occipital artery (OA) is a critical artery in vascular lesions. However, a comprehensive review of the importance of the OA is currently lacking. In this study, we used the PubMed database to perform a review of the literature on the OA to increase our understanding of its role in vascular lesions. We also provided our typical cases to illustrate the importance of the OA. The OA has several variations. For example, it may arise from the internal carotid artery or anastomose with the vertebral artery. Therefore, the OA may provide a crucial collateral vascular supply source and should be preserved in these cases. The OA is a good donor artery. Consequently, it is used in extra- to intracranial bypasses for moyamoya disease (MMD) or aneurysms. The OA can be involved in dural arteriovenous fistula (DAVF) and is a feasible artery for the embolisation of DAVF. True aneurysms and pseudoaneurysms can occur in the OA; surgical resection and embolisation are the effective treatment approaches. Direct high-flow AVF can occur in the OA; embolisation treatment is a good option in such cases. The OA can also be involved in MMD and brain arteriovenous malformation (AVM) by forming transdural collaterals. For a patient in the prone position, if occipital and suboccipital craniotomies are performed, the OA can also be used for intraoperative angiography. In brief, the OA is a very important artery in vascular lesions.

The Rare Togetherness of Bladder Leiomyoma and Neurofibromatosis

Neurofibromatosis Type 1 (Von Recklinghausen disease) is a common, autosomal dominant hereditary disorder characterized by involvement of multiple tissues derived from the neural crest. Urinary system involvement in neurofibromatosis is a rare condition. Leiomyoma of the bladder is a rare benign mesenchymal tumor. In this case, our experience and approach regarding the bladder leiomyoma development in a patient diagnosed with neurofibromatosis are presented and the literature data has been reviewed.