Fusiform "True" Posterior Communicating Artery Aneurysm with Basilar Artery Occlusion: A Case Report

Isolated posterior communicating artery (PCoA) aneurysms are rare, predominantly fusiform in morphology, and rarely present with subarachnoid hemorrhage. Endovascular management of this pathology is technically challenging due to extreme tortuosity, the artery course in the subarachnoid space, sharp angulations at PCoA junctions with the parent artery, and, at times, associations with either internal carotid artery or basilar artery occlusions. We present a case of a ruptured fusiform PCoA at the junction of middle and distal third with concomitant proximal basilar artery occlusion. The PCoA reforms the posterior circulation, making it a vital artery. Stent-assisted coiling was performed with extreme difficulty in achieving distal positioning of the stents in the basilar artery/posterior cerebral artery/distal PCoA due to artery tortuosity. There was technical difficulty in the stent deployment. After changing strategies to a larger diameter laser-cut stent, endovascular treatment could be performed. There were good angiographic and clinical outcomes with stable occlusion at 6-month-follow-up.

Role of Digital Subtraction Angiography in the Preoperative Assessment of a Patient with a Petrosquamous Sinus: a Case Report

We report a case of a 15-year-old Indian girl who presented with tinnitus, pain and ear discharge for one month and was preliminarily diagnosed with Chronic Suppurative Otitis Media (CSOM) with mastoiditis. She underwent a routine presurgical CT scan which revealed an aberrant vein, making it essential to exercise caution during surgery for CSOM. The aberrant vessel was identified as a Petrosquamous Sinus. A Petrosquamous Sinus is a persistent fetal vein that connects the transverse sinus with the retromandibular vein and may regress in an individual by birth. Its importance lies in the risk of haemorrhage it carries during otological surgeries. A Digital Subtraction Angiography proved to be a vital step in isolating the path of the vein for better visualisation of the course, thus giving a better idea about the anatomical relations of the vessel during the surgery. The tympanoplasty was performed with care to prevent damaging the vein. The patient had no complications in the postoperative period and made a quick recovery.

Radiological findings and endovascular management of internal carotid artery pseudoaneurysm in the setting of mucormycosis and COVID-19

The coronavirus pandemic is now a public health emergency and has spread to nearly 206 countries across the globe. This novel disease has shaken the psycho-social, economic, and medical infrastructure of India. This has become even more challenging, considering the country's huge population. With the increase in the number of coronavirus disease (COVID) cases, our country has seen an unforeseen, unprecedented rise in a potential life and organ-threatening disease-mucormycosis. Mucormycosis is a deadly, extremely morbid, possibly life-threatening, and most feared complication of the coronavirus, caused by environmental molds belonging to the order Mucorales. Here, we report 2 cases of massive epistaxis due to internal carotid artery (ICA) pseudoaneurysm secondary to mucormycosis, post-COVID-19 pneumonia, which was managed by the endovascular route. To the best of our knowledge, there is very sparse literature available describing endovascular treatment of intracranial ICA pseudoaneurysm in a patient with COVID-induced mucormycosis.

High-flow nasal cannula (HFNC) oxygenation for sclerotherapy of facial and upper airway vascular malformations in pediatric patients: Case series

We report anesthesia management of sclerotherapy for vascular malformations (VMs) of the upper airway and face of pediatric patients conducted under sedation using a high-flow nasal cannula (HFNC) oxygen delivery system. Sclerotherapy procedures were carried out in six patients (five males, one female; age group: 5-12 years). The patients were sedated with midazolam, fentanyl, ketamine, and graded doses of propofol along with continuous oxygen delivery using HFNC. There were no episodes of oxygen desaturation, tongue fall or obstruction of the airway, interruption of procedure for assisted ventilation, and postoperative nausea and vomiting (PONV). Only two patients showed transient apnea for 10 and 15 s but did not require ventilatory assistance. HFNC provides effective oxygenation in pediatric patients undergoing sclerotherapy of VMs of the upper airway and face under sedation.

External carotid artery pseudoaneurysm with arteriovenous fistula: A rare complication of glass shrapnel injury

Posttraumatic external carotid artery pseudoaneurysm with arteriovenous fistula is a rare condition. An 8-year-old child presented with painful pulsatile swelling in the preauricular region following a penetrating glass shrapnel injury. Detailed evaluation showed distal external carotid artery pseudoaneurysm with fistula, which was draining into the retromandibular vein. Endovascular treatment was performed. This case highlights the role of endovascular intervention for such rare complicated vascular pathologies.

Endovascular Therapy in Paediatric Dissecting Intracranial Aneurysm: A Case Report

The incidence of cerebral aneurysms is rare in children, and it has to be definitively ruled out in all cases of intracranial bleed even if there is associated history of trauma. We report a case of 11-month-old girl who presented with intracranial bleed after a history of minor trauma whose diagnosis of an intracranial aneurysm was initially missed which later led to a rebleed. It was managed emergently with endovascular coiling and the patient showed incredible recovery in the post-operative period.

Rete mirabile associated with pial arteriovenous fistula: imaging features with literature review

A rete mirabile is a vascular network of intercommunicating small arteries or arterioles that replace the definitive adult artery supplying the brain. It supplies the brain in lower mammals but is not seen in normal human embryological development. A 26-year-old man presented with worsening tinnitus that was interfering with his sleep. On CT and digital subtraction angiography he was found to have a temporal lobe pial arteriovenous fistula with bilateral carotid and vertebral rete mirabile. The patient was offered open surgical and endovascular treatment options for pial arteriovenous fistula but he refused both and opted for conservative medical management. At 6-month follow-up he continued to have pulsatile tinnitus but was otherwise neurologically normal. We present the first described association of rete mirabile with pial arteriovenous fistula and discuss its clinical presentation and imaging features, with a review of the literature for bilateral carotid and vertebral rete mirabile.

Endovascular treatment of HIV-associated spontaneous common carotid artery pseudoaneurysm in a case of miliary and CNS tuberculosis

HIV and tuberculosis infections are known to be associated with vasculopathy including occlusive disease and aneurysm formation. We report a case of 43-year-old male with miliary and central nervous system (CNS) tuberculosis; recently, diagnosed as HIV seropositive, on antiretroviral and antitubercular treatment presenting with painful neck swelling. He was found to have common carotid artery (CCA) pseudoaneurysm that was managed by endovascular stent grafting. HIV vasculopathy-related CCA pseudoaneurysm is a potentially life-threatening rare entity. Treatment of an immunocompromised patient by endovascular approach minimizes hospital stay and avoids wound-related complications. To the best of our knowledge, there has been no case report describing endovascular treatment of CCA pseudoaneurysm in an HIV-positive patient with low CD4 count and coexistent disseminated tuberculosis.

Bilateral carotid and vertebral rete mirabile with vein of Galen aneurysmal malformation: an unreported association

Rete mirabile is a fine meshwork of anastomosing vessels that replace the parent artery. A 30-year-old woman complained of slurring of speech, right eye proptosis, recurrent vomiting, and loss of bladder and bowel control, followed by drowsiness lasting 30-40 min, for the past 6 months. On cross sectional imaging and angiography, the patient was found to have a vein of Galen aneurysmal malformation, with bilateral carotid and vertebral rete mirabile. The patient was offered both endovascular and open surgical options but she refused any form of surgical treatment and opted for conservative management. At the 6 month follow-up, she continued to have occasional episodes of headache and vomiting but was otherwise normal. We describe the clinical, cross sectional, and angiographic features of this patient. A comparison with other patients with bilateral carotid and vertebral rete mirabile is also reported.

Cerebral and spinal vascular involvement in Hereditary Hemorrhagic Telengiectasia: Report of two cases

INTRODUCTION

We present two cases of Hereditary Hemmorhagic Telengiectasia (HHT), one pediatric and the other adult, with a view to highlight the myriad cerebral and spinal vascular manifestations of this disease. The syndrome and its various findings will be reviewed including the utility of angiography in assessing the various vascular abnormalities of the cerebral and spinal vasculature.

METHODS

A review of literature regarding various developmental abnormalities including brain and spinal cord arterio-venous malformations (AVMs), arterio-venous fistulae (AVFs), micro AVMs, micro-fistulae, aneurysms and cavernomas that occur in pediatric and adult population subsets of HHT. Both patients underwent thorough clinical and laboratory evaluation. The pediatric patient underwent a contrast enhanced computed tomography (CECT) of the chest; cerebral, Pulmonary & celiac angiography. The adult patient underwent cerebral and spinal angiography.

CONCLUSION

The spectrum of vascular malformations in Hereditary Hemorrhagic Telengiectasia (HHT) is varied.The incidence and manifestations of brain and spinal cord AVMs, AVFs, micro AVMs, micro-fistulae, aneurysms and cavernomas are different in the pediatric and adults affected by the disease. Cerebral and spinal angiography are necessary in characterising the various developmental vascular abnormalities in order to guide further management.

Acute subarachnoid hemorrhage in posterior condylar canal dural arteriovenous fistula: imaging features with endovascular management

A 43-year-old man presented with acute subarachnoid hemorrhage. He was investigated and found to have a rare posterior condylar canal dural arteriovenous fistula (DAVF). DAVFs of the posterior condylar canal are rare. Venous drainage of the DAVF was through a long, tortuous, and aneurysmal bridging vein. We describe the clinical presentation, cross sectional imaging, angiographic features, and endovascular management of this patient. The patient was treated by transarterial embolization of the fistula through the ascending pharyngeal artery. This is the first report of an acutely bled posterior condylar canal DAVF treated by transarterial Onyx embolization with balloon protection in the vertebral artery. The patient recovered without any neurological deficit and had an excellent outcome. On 6 month follow-up angiogram, there was stable occlusion of the dural fistula.

Acute subarachnoid hemorrhage in posterior condylar canal dural arteriovenous fistula: imaging features with endovascular management

A 43-year-old man presented with acute subarachnoid hemorrhage. He was investigated and found to have a rare posterior condylar canal dural arteriovenous fistula (DAVF). DAVFs of the posterior condylar canal are rare. Venous drainage of the DAVF was through a long, tortuous, and aneurysmal bridging vein. We describe the clinical presentation, cross sectional imaging, angiographic features, and endovascular management of this patient. The patient was treated by transarterial embolization of the fistula through the ascending pharyngeal artery. This is the first report of an acutely bled posterior condylar canal DAVF treated by transarterial Onyx embolization with balloon protection in the vertebral artery. The patient recovered without any neurological deficit and had an excellent outcome. On 6 month follow-up angiogram, there was stable occlusion of the dural fistula.

Endovascular management of giant intracranial aneurysms of the posterior circulation

BACKGROUND

Large size, and location in posterior circulation, both individually portend high risk in the endovascular management of intracranial aneurysms.

AIM

The purpose of this study was to investigate the outcome of endovascular management of giant posterior circulation aneurysms at our centre.

MATERIALS AND METHODS

This is a retrospective analysis of 22 consecutive patients with giant posterior circulation aneurysms, who were managed by endovascular techniques between 1997 and 2009. The aneurysms included: Vertebral-6 (27%), basilar or vertebrobasilar - 7 (32%) and nine posterior cerebral artery (PCA) - 9 (41%).

RESULTS

There were 14 males and eight females with a mean age of 37 years. Treatment modalities included: Parent vessel sacrifice (PVS), coil embolization, flow reversal, stent-assisted coiling, and telescopic stent placement. Angiographic cure or stasis was achieved in 21 (95%) patients and no recurrence was observed in 17 of the 18 patients who had follow-up. Complications occurred in 9 (41%) patients, death in 4 and morbidity in 5 (3 with good eventual outcome). Overall, good clinical outcome was noted in 16 (73%) patients. The majority of the poor outcomes were observed in the management of basilar/vertebrobasilar aneurysms and flow reversal. Parent vessel sacrifice showed the best outcomes with stable results.

CONCLUSIONS

Our results suggest that PVS remains the procedure of choice wherever possible and is relatively safe, particularly for giant vertebral and PCA aneurysms. When PVS is not feasible, stent-assisted coiling is a reasonable and safe option and requires follow-up. Management of basilar or vertebrobasilar aneurysms is complicated and still evolving.

Intracranial pediatric aneurysms: endovascular treatment and its outcome

OBJECT

The aim of this study was to analyze the location, clinical presentation, and morphological characteristics of pediatric aneurysms and the safety, feasibility, and durability of endovascular treatment.

METHODS

The authors conducted a retrospective study of all cases involving patients 18 years old or younger who underwent endovascular treatment for pediatric aneurysms at their institution between July 1998 and July 2010. The clinical presentation, aneurysm location, endovascular management, and treatment outcome were studied.

RESULTS

During the study period, 23 pediatric patients (mean age 13 years, range 2 months-18 years) were referred to the authors' department and underwent endovascular treatment for aneurysms. The aneurysms were saccular in 6 cases, dissecting in 4, infectious in 5, and giant partially thrombosed lesions in 8. Fourteen of the aneurysms were ruptured, and 9 were unruptured. Thirteen were in the anterior circulation and 10 in the posterior circulation. The most common location in the anterior circulation was the anterior communicating artery; in the posterior circulation, the most common location was the basilar artery. Saccular aneurysms were the most common type in the anterior circulation; and giant partially thrombosed and dissecting aneurysms were the most common types in the posterior circulation. Coil embolization was performed in 7 cases, parent vessel sacrifice in 10, flow reversal in 3, glue embolization in 2, and stent placement in 1. Immediate angiographic cure was seen in 21 (91%) of 23 patients. Complications occurred in 4 patients, 3 of whom eventually had a good outcome. No patient died. Overall, a favorable outcome was seen in 22 (96%) of 23 patients. Follow-up showed stable occlusion of aneurysms in 96% of the patients.

CONCLUSIONS

Pediatric aneurysms are rare. Their clinical presentation varies from intracranial hemorrhage to mass effect. They may also be found incidentally. Among pediatric patients with aneurysms, giant aneurysms are relatively common. Endovascular management is associated with low rates of complications and is a safe, durable, and effective treatment for pediatric aneurysms.

Endovascular Treatment of Ruptured Intradural Ophthalmic Artery Aneurysm

We present a unique case of ruptured intradural ophthalmic artery aneurysm in a young man who presented with subarachnoid hemorrhage. By endovascular technique we successfully excluded the aneurysm from the circulation with preservation of antegrade flow in the ophthalmic artery. The presenting features and the technique of the treatment are described with a review of the literature.

Evolution of endovascular management of intracranial dural arteriovenous fistulas: single center experience

AIM

We aim to focus on the treatment of intracranial dural arteriovenous fistulas (DAVF) with emphasis on the evolution of endovascular management at our center over the last 13 years. We also aim to highlight the present treatment strategy, considering all the embolic agents available with us.

SETTING AND DESIGN

This is a retrospective study of 99 patients of DAVFs treated from December 1995 to March 2009.

MATERIALS AND METHODS

Seven patients were found to have spontaneous thrombosis when taken up for treatment. The other 92 patients underwent endovascular treatment through transarterial or transvenous routes using polyvinyl alcohol particles, glue, detachable platinum coils or injection onyx as embolic agents. The treatment strategies have evolved over a period of time with changing philosophies and availability of different embolic agents.

RESULTS

Transverse- sigmoid and cavernous sinuses were the commonest sites of DAVFs. Intracranial hemorrhage was common presentation. Transarterial PVA embolization was performed in four patients, transarterial glue in 15, transvenous embolization in 33 and transarterial Onyx in 36. Direct puncture and packing of the sinuses was done in four patients. Cure was achieved in 80 out of 92 patients (cure rate of 87%). Patients who had Onyx embolization had cure rate of 92% (33 out of 36 patients). 14 complications were seen of which two were in the Onyx group.

CONCLUSION

Embolization of DAVFs has evolved over the last decade and has become the treatment of choice with high cure rates and improved safety. We propose the use of Onyx as the embolic agent of choice in the treatment of DAVFs.

Embolization of cranial dural arteriovenous fistulae with ONYX: Indications, techniques, and outcomes

OBJECTIVES

The purpose of this study was to establish the role of the liquid embolic agent, ONYX, in the treatment of cranial dural arteriovenous fistulae (DAVFs) and to redefine the indications, techniques and outcomes of treatment with ONYX.

MATERIALS AND METHODS

This is a retrospective study of 25 DAVF patients who underwent endovascular treatment with ONYX between February 2006 and July 2008. All patients of DAVF presenting in this period were treated with ONYX.

RESULTS

Anatomic cure (i.e., complete angiographic closure of the fistula) was achieved in a single session and through a single arterial pedicle injection in 21 out of 25 patients (cure rate of 84%). Out of four patients with residual fistulae, one achieved cure that was evident on a control angiogram obtained at 3 months while three had no vascular access for further embolization and so were referred for radiosurgery. There was only one recurrence seen in angiograms obtained at the end of one year and this patient was re-embolized successfully with ONYX. Complications were seen in two patients.

CONCLUSION

ONYX embolization of DAVFs has revolutionized the endovascular treatment of DAVFs, achieving high cure rates in a single session with minimal complications. Transarterial ONYX embolization should be the first option for all locations, except cavernous DAVFs.

Ellis-Van creveld′s syndrome (a case rreport)

A 13 years old male patient had stunted growth, bilateral polydactyly, fusion of capitate and hamate on right side, incomplete duplication of 1st metacarpal at its proximal end, poorly ossified epiphyses of lower end of radius & ulna, valgus deformity of right knee, conical shape of tibial epiphyses, nonossified fibular epiphyses & a small bony exostoses from medial end of right tibia, abnormal teeth and nail of hand. Also there was evidence of left to right shunt in the heart. Oral frenulae, pseudocleft of upper lip were also noticed.