Spontaneous occlusion of a pial arteriovenous fistula after angiography: The role of iodinated contrast media

Intracranial non-galenic pial arteriovenous fistula (PAVF) is an extremely rare vascular malformation, where one or more pial arteries feeds directly into a cortical vein without any intervening nidus. Though occasionally they can be asymptomatic, neurological symptoms such as headache, seizure, or focal neurological deficit are more common presenting features. Life threatening or fatal hemorrhage is not uncommon, hence needed to be treated more often than not. Spontaneous occlusion of PAVF is reported only four times before. We report a 49-year-old gentleman, who was diagnosed to have a PAVF, possibly secondary to trauma. He presented 5 months and 22 days from initial digital subtraction angiography (DSA) for treatment, and follow-up angiogram showed complete obliteration. He denied any significant event, medication or alternate treatment during this period. His clinical symptoms were stable as well. We postulate iodinated contrast medium induced vasculopathy as a possible cause, which has been described for other vascular pathologies, but never for PAVF.

Navigation guided small craniectomy and direct cannulation of pure isolated sigmoid sinus for treatment of dural arteriovenous fistula

Dural arteriovenous fistula (DAVF) is a rare condition affecting approximately 1.5% of 1,000,000 individuals annually. It frequently occurs in the transsigmoid and cavernous sinuses. An isolated sigmoid sinus is extremely rare and is treated by performing transfemoral transvenous embolization along the opposite transverse sinus. A 69-year-old woman presented with asymptomatic Borden type III/Cognard type III DAVF involving an isolated sigmoid sinus. She underwent a staged operation in which a navigation system was used to expose the sigmoid sinus in the operating room before transferring the patient to the angio suite for transvenous embolization. Various modalities have been used to treat DAVF, including surgical disconnection, transarterial embolization, transvenous embolization, and stereotactic radiosurgery. However, treating DAVF cases where the affected sinus is isolated can be challenging because an easily accessible surgical route may not be available. In this case, direct sinus cannulation and transvenous embolization were the most effective treatments.

Giant cerebellar cavernous malformation in children: A case report and literature review

Giant cerebellar cavernomas in children are rare and must be differentiated from hemorrhagic cerebellar tumors. The diagnosis and treatment of giant cerebellar cavernomas is challenging, but complete surgical resection can lead to favorable outcomes and complete neurological recovery in most cases. We present a case of eight months old baby who was diagnosed with a giant cavernoma resulting in secondary obstructive hydrocephalus with neuropsychiatric presentations. The patient underwent a paramedian craniotomy surgery with a suboccipital approach and complete surgical resection of the cavernoma was done. Over nine months of observation, the child showed improvement in their ability to walk and fully recovered from a neurological perspective. We also conducted a literature review to identify eleven cases of giant cerebellar cavernomas in children, including our case. The data were analyzed to determine the clinical features, treatment, and outcomes of giant cerebellar cavernomas in children.

Usefulness of sectional images in dural AVF for the interpretation of venous anatomy

Knowledge of the venous anatomy is essential for appropriately treating dural arteriovenous fistulas (AVFs). It is challenging to determine the overall venous structure despite performing selective angiography for dural AVFs with feeder from multiple selected arteries. This is because only a part of the veins can be observed through the shunt in the selected artery. Therefore, after performing selective angiography of all vessels to understand the approximate venous anatomy, the venous anatomy can be easily understood by closely examining the source image of computed tomographic angiography or magnetic resonance angiography. Through this, it is possible to specify the vein that is to be blocked (target embolization), thereby avoiding extensive blocking of the vein and avoiding various complications. In the case of dural AVF with feeder from single selected artery, if the multiplanar reconstruction image of the three-dimensional rotational computed tomography obtained by performing angiography is analyzed thoroughly, a shunted pouch can be identified. If embolization is performed by targeting this area, unnecessary sinus total packing can be avoided.

An aggressive dural arteriovenous fistula manifested by unilateral subcortical calcification and cerebral edema: A case report

Unilateral subcortical calcifications are unique radiographic findings indicating specific focal pathologies. When the lesion is accompanied by edema, cerebral neoplasm usually leads to a differential diagnosis. This report presents a case of unilateral subcortical calcification and edema that resulted in cerebral hemorrhage and a subsequent diagnosis of an aggressive dural arteriovenous fistula. A man in his 60s presented with left hemianopsia and a progressive headache for over 6 months. Initial computed tomography revealed unilateral subcortical calcification and cerebral edema in the right occipital lobe, raising the suspicion of oligodendroglioma. However, 10 days later, a cerebral hemorrhage occurred in the lesion. Magnetic resonance imaging revealed flow void clusters and dilatation of the bilateral external carotid arteries and cortical veins, indicating a dural arteriovenous fistula. Cerebral angiography confirmed the presence of a parasagittal dural arteriovenous fistula (Borden type III). The patient was successfully treated with trans-arterial embolization using Onyx. Thus, calcifications with edema are more commonly associated with cerebral neoplasms; however, in this case, they indicated the presence of a dural arteriovenous fistula with severe corticovenous reflux. The presented case highlights the importance of recognizing these imaging features in dural arteriovenous fistulas and raises awareness of the potential danger of early hemorrhage after diagnosis. Therefore, timely evaluation of cranial vessels is essential in cases of unilateral subcortical calcification and edema to facilitate the early detection and management of aggressive dural arteriovenous fistulas.

Postsurgical dural supply to the spinal cord arteriovenous malformation in spinal arteriovenous metameric syndrome

Dural supply from the external carotid system in cerebral arteriovenous malformations (AVMs) is well known, but actual angiographic evidence of dural supply to spinal cord AVMs (SCAVMs) has not been reported. Here, we report a case of dural supply to the conus SCAVM in the spinal arteriovenous metameric syndrome segment 25-30. Thirteen years after spinal surgery (T12-L2 laminoplasty), spinal angiography showed multiple dural supplies from the dorsal somatic branches, prelaminar arteries, and radiculomeningeal arteries to the SCAVM at the level of the previous spinal surgery. To the best of our knowledge, this is the first reported case with dural supply to the spinal cord. This case demonstrates that the extradural and extraspinal branches can supply the spinal cord in rare instances of spinal dural adhesions following repeated hemorrhages and surgical intervention under a metameric link background.

Use of a Rigid-Tipped Microguidewire for the Endovascular Treatment of Cavernous Sinus Dural Arteriovenous Fistulas with an Occluded Inferior Petrosal Sinus

Objective

Transvenous embolization (TVE) via an occluded inferior petrosal sinus (IPS) in a cavernous sinus dural arteriovenous fistula (CSDAVF) is challenging, often requiring navigation of a microcatheter through resistive obstacles between the occluded IPS and shunted pouch (SP), although the reopening technique was successfully performed. We report five cases of successful access to the cavernous sinus (CS) or SP using the rigid-tipped microguidewire such as chronic total occlusion (CTO) wire aiming to share our initial experience with this wire.

Methods

In this retrospective study, four patients with CSDAVF underwent five procedures using the CTO wire puncture during transfemoral transvenous coil embolization. Puncture success, shunt occlusion, and complications including any hemorrhage and cranial nerve palsy were evaluated.

Results

Despite successful access through the occluded IPS, further entry into the target area using neurointerventional devices was impossible due to a short-segment stricture before the CS (three cases) and a membranous barrier within the CS (two cases). However, puncturing these structures using the rigid-tipped microguidewire was successful in all cases. We could advance the microcatheter over the rigid-tipped microguidewire for the navigation to the SP and achieved complete occlusion of the SP without complications.

Conclusion

The use of the rigid-tipped microguidewire in the TVE via the occluded IPS of the CSDAVF would be feasible and safe.

Reversible Symptom Aggravation by Intake of Taurine-Rich Foods in Patients with Venous Congestive Myelopathy: Controlled Case Series Study

Purpose

Reversible aggravation of myelopathy symptoms was observed after the intake of taurine-rich foods in patients with venous congestive myelopathy (VCM) caused by a spinal arteriovenous shunt (SAVS), and the taurine-challenge test was applied to demonstrate an association between taurine and VCM.

Materials and Methods

The current study reviewed any aggravation history of myelopathy symptoms, including walking difficulty, after consuming taurine-rich foods among 133 consecutive patients with a SAVS from a prospective institutional database from June 2013 to February 2021. The type of taurine-rich foods, demographic data, arteriovenous shunt level, and follow-up periods were obtained. For the controlled taurine challenge test, Bacchus^® (Dong-A Pharmaceutical, Seoul, Korea), a taurine-rich drink, was given to patients who fulfilled test criteria of recovered VCM (pain-sensory-motor-sphincter scale ≥2, improvement of spinal cord signal intensity on magnetic resonance imaging, and follow-up >6 months after SAVS treatment) to confirm the disappearance of such aggravation.

Results

Ten patients had an aggravation history related to food. Webfoot octopus, small octopus, squid, crab, scallop, and taurine-rich energy drink (Bacchus^®) were related to such aggravation in patients with VCM. Aggravation appeared about 30 minutes after food intake followed by expressions such as ‘I could not walk and collapsed to the ground’ and usually lasted for about 3 hours, followed by a slow recovery after taking rest. Four patients who met the test criteria underwent the taurine challenge with Bacchus^® and revealed no further symptom aggravation, suggesting that taurine did not affect patients after recovery from VCM.

Conclusion

The association between taurine-rich food and reversible symptom aggravation can appear in patients with VCM and disappear after VCM treatment. Aggravation of venous hypertension in the spinal cord is suggested as a mechanism but further elucidation is needed.

Spinal dural arteriovenous fistula 8 years after lumbar discectomy surgery: A case report and review of literature

BACKGROUND

Spinal dural arteriovenous fistula (SDAVF) is an extremely rare vascular malformation of the central nervous system that is often confused with degenerative spinal disorders due to similar early symptoms and clinical features. Here, we report a case of SDAVF recurrence 8 years after lumbar spine surgery and summarize relevant literature.

CASE SUMMARY

A 54-year-old male was admitted to our hospital complaining of lower back pain, numbness in both lower extremities and intermittent claudication. Subsequent imaging identified lumbar spinal stenosis. Following surgical treatment, the patient’s symptoms significantly resolved, and he was able to perform daily activities. However, similar symptoms appeared 8 years later, followed by confirmation of SDAVF diagnosis. The patient underwent neurosurgery 7 mo after symptom onset. The follow-up period lasted 14 mo, and the patient remains with marginal neurological symptoms.

CONCLUSION

This case highlights the importance of prompt SDAVF diagnosis. Due to its nonspecific clinical presentation, the clinical experience of the surgeon and definitive imaging examination are indispensable. Additionally, timely neurosurgery is effective and may significantly improve patient outcomes.

Stereotactic Radiosurgery for Dural Arteriovenous Fistulas Involving the Transverse-Sigmoid Sinus : A Single Center Experience and Review of the Literatures

Objective

We retrospectively assessed the efficacy of stereotactic radiosurgery (SRS) for dural arteriovenous fistulas (DAVFs) involving the transverse-sigmoid sinus and analyzed the angiographic and clinical results with our 8-year experience.

Methods

Nine patients with intracranial DAVFs involving the transverse-sigmoid sinus underwent SRS using a Gamma Knife^® (Elekta Inc., Atlanta, GA, USA) between 2009 and 2016. Five patients underwent SRS for residual DAVFs after embolization and four patients were treated with SRS alone. The median target volume was 1.9 cm³ (range, 0.8–14.2) and the median radiation dose of the target was 17 Gy (range, 16–20). The median follow-up period was 37 months (range, 7–81).

Results

Pulsating tinnitus (33%) was the most common symptom. DAVFs were completely obliterated in four patients (44%) and subtotally obliterated in five (56%). Six patients (67%) showed complete recovery of symptoms or signs, and three (33%) showed incomplete recovery. One patient experienced a recurrent seizure. Adverse radiation effects after SRS occurred in one patient (11%). The total obliteration rates after SRS were 16.7%, 37.5%, and 68.7% at 1, 2, and 3 years, respectively. The median interval from SRS to total obliteration of the fistula was 31 months (range, 12–38). The rates at which the symptoms started to improve were 40% at 1 month and 80% at 2 months after SRS. Symptoms started to improve at a median of 5 weeks after SRS (range, 3–21).

Conclusion

SRS with or without embolization is a safe and effective treatment to relieve symptoms and obliterate DAVFs on the transverse-sigmoid sinus.

Endovascular Treatment of a Dural Arteriovenous Fistula after Cerebral Sinovenous Thrombosis in a Child

BACKGROUND

Dural arteriovenous fistula (DAVF) is rare in children. Development theories postulate a response to cerebral sinovenous thrombosis (CSVT) or to venous hypertension. The symptoms are highly nonspecific and depend on lesion location. Standard treatment of thrombosis is based on antithrombotic therapy, while the main therapy for DAVF is embolization.

CASE REPORT

An 8-year-old boy presented with headache was diagnosed with CSVT and treated with anticoagulant. He developed tinnitus, mental confusion, and lowering of consciousness. Magnetic resonance imaging showed a DAVF draining through a single stenotic venous sinus. Successful endovascular treatment was performed with arterial embolization of multiple feeders and stent and balloon sinus angioplasty.

CONCLUSION

Risk factors associated with sinus thrombosis must be always investigated; endovascular treatment is safe and reasonable in a clinical deterioration scenario.

[Intracranial vascular malformations]

Intracranial vascular malformations range from incidental asymptomatic vascular alterations up to life-threatening vascular disorders. Arteriovenous malformations and dural arteriovenous fistulas are cerebral vascular malformations with arteriovenous shunting of blood. In the majority of cases they are accompanied by an elevated risk of intracerebral hemorrhage and can cause severe symptoms. They can be treated conservatively or interventionally via microneurosurgery, endovascular embolization and radiation therapy. Cavernous malformations, developmental venous anomalies (DVA) and capillary telangiectasia are cerebral vascular malformations without arteriovenous shunting. Cavernous malformations are rarely symptomatic in the form of cerebral hemorrhage, headache or seizures and in such cases an operative treatment can be indicated. The DVA and capillary telangiectasia are usually asymptomatic and do not require treatment.

Clinical Outcome of Nonfistulous Cerebral Varices: the Analysis of 39 Lesions

Objective

Cerebral varices (CVs) without an arteriovenous shunt, so called nonfistulous CVs, are very rare, and their etiology and natural course are not well understood. The aim of this study is to evaluate the clinical outcomes of nonfistulous CVs by the analysis of 39 cases.

Methods

From 2000 to 2015, 22 patients with 39 nonfistulous CVs (≥5 mm) were found by searching the medical and radiologic records of our institute. Clinical data and radiological data including numbers, sizes and locations of CVs and associated anomalies were retrospectively collected and analyzed. Previously reported cases in literature were reviewed as well.

Results

The mean age of the patients was 21 years (range, 0–78 years). On average, 1.8±1.2 CVs were found per patient. CVs were categorized as either fusiform or saccular depending on their shapes. Two patients had saccular type CVs, seventeen patients had fusiform types, and three patients had both fusiform and saccular CVs. Eight patients had associated compromise of the vein of Galen and the straight sinus. Four of those patients had sinus pericranii, as well. Five patients had CVs that were distal draining veins of large developmental venous anomalies. One patient had associated migration anomaly, and two patients had Sturge- Weber syndrome. Six patients with an isolated cerebral varix were observed. Of the 39 CVs in 22 patients, 20 lesions in 14 patients were followed up in outpatient clinics with imaging studies. The average follow-up duration was 6.6 years. During this period, no neurological events occurred, and all the lesions were managed conservatively.

Conclusion

Nonfistulous CVs seemed to be asymptomatic in most cases and remained clinically silent. Hence, we suggest conservative management.

Single-session percutaneous embolization with onyx and coils of sinus pericranii

BACKGROUND

Sinus pericranii (SP) is a rare vascular malformation consisting of an abnormal communication between the extra- and the intracranial venous system. It occurs due to the adhesion of vessels without a muscular layer or a hemangioma on the outer surface of the skull through diploic vessels, communicating with an intracranial venous sinus.

CASE DESCRIPTION

A 10-month-old female presented with a pulsatile mass on the posterior parietal region. Investigation with brain vascular examinations showed a venous malformation communicating with the superior sagittal sinus under the scalp, without arterial feeder or nidus. An endovascular embolization with coils and a percutaneous embolization with Onyx ® were performed. The final venography showed complete exclusion of the lesion, which was gradually being absorbed.

CONCLUSION

This is the first case of an SP successfully treated in a single session by embolization with coils and onyx.

Intracranial Arterial Fenestration and Risk of Aneurysm: A Systematic Review and Meta-Analysis

BACKGROUND

Previous studies have been inconsistent regarding risk for intracranial aneurysm related to intracranial arterial fenestration. We conducted a meta-analysis to examine the association between intracranial arterial fenestration and risk of aneurysm.

METHODS

We performed a systematic review of PubMed and Embase through August 2017 for potentially relevant articles. Summary odds ratios with 95% confidence intervals were pooled using a random-effects model.

RESULTS

Of 446 articles found, 7 were selected for meta-analysis. Pooled odds ratios revealed an increased risk of aneurysm owing to fenestration of 1.50 (95% confidence interval, 0.61-3.71; P = 0.38). Subgroup analyses based on the population presenting with various indications suggested that pooled odds ratios indicated a significant increase in risk for aneurysm of 2.43 (95% confidence interval, 1.04-5.69; P = 0.04).

CONCLUSIONS

Our findings indicate that intracranial arterial fenestration may be associated with increased risk for aneurysm formation.

Case report: microcephaly associated with Zika virus infection, Colombia

Background

Recently there has been a large outbreak of Zika virus infections in Colombia, South America. The epidemic began in September 2015 and continued to April 2017, for the total number of Zika cases reported of 107,870. For those confirmed Zika cases, there were nearly 20,000 (18.5%) suspected to be pregnant women, resulting in 157 confirmed cases of microcephaly in newborns reported by their health government agency. There is a clear under-estimation of the total number of cases and in addition no prior publications have been published to demonstrate the clinical aspects of the Zika infection in Colombia. We characterized one Zika presentation to be able to compare and contrast with other cases of Zika infection already reported in the literature.

Case presentation

In this case report, we demonstrate congenital microcephaly at week 19 of gestation in a 34-year-old mother who showed symptoms compatible with Zika virus infection from Sincelejo, State of Sucre, in the Colombian Caribbean. Zika virus RNA was detected in the placenta using real-time reverse transcriptase polymerase chain reaction (RT-PCR). At week 25, the fetus weigh estimate was 770 g, had a cephalic perimeter of 20.2 cm (5th percentile), ventriculomegaly on the right side and dilatation of the fourth ventricle. At week 32, the microcephaly was confirmed with a cephalic perimeter of 22 cm, dilatation of the posterior atrium to 13 mm, an abnormally small cerebellum (29 mm), and an augmented cisterna magna. At birth (39 weeks by cesarean section), the head circumference was 27.5 cm, and computerized axial tomography (Siemens Corp, 32-slides) confirmed microcephaly with calcifications.

Conclusion

We report a first case of maternal Zika virus infection associated with fetal microcephaly in Colombia and confirmed similar presentation to those observed previous in Brazil, 2015–2016.

[Interventional radiology in the head and neck region]

In interventional neuroradiology, endovascular embolization represents an important and helpful tool in the treatment of multiple head and neck diseases. These interventional procedures may be performed with curative intent, to reduce the surgical risk within a multimodal treatment concept, or to improve or at least maintain a good quality of life within a palliative therapy concept. In addition to a good understanding of disease pathology, knowledge of vascular anatomy, including collateral vessels and dangerous extracranial-intracranial anastomoses, is essential for successful treatment, as is implementation of an established technique using appropriate material. Indications for endovascular embolization are i. otherwise unmanageable bleeding (caused by e. g., trauma, vascular malformation, or tumor), ii. reduction of perioperative bleeding by preoperative embolization in case of a hypervascularized tumor, iii. selective induction of tumor necrosis by palliative embolization to enhance local tumor control. Major complications such as stroke, loss of vision, and cranial nerve palsy are mostly due to a lack of preinterventional evaluation. Regarding neurological deficits, interventions within the supply region of the external carotid artery have a complication rate below 1%.

Iatrogenic Dural Arteriovenous Fistula after Superficial Temporal Artery to Middle Cerebral Artery Anastomosis: A Case Report

Dural arteriovenous fistulas (AVFs) are uncommon, representing only 10% to 15% of all intracranial AVFs. Here we present the case of a patient with cerebral infarction who experienced a dural AVF after craniotomy for superficial temporal artery (STA) to middle cerebral artery (MCA) bypass surgery. A 48-year-old man presented with dysarthria and right side hemiparesis. A brain magnetic resonance imaging scan revealed multiple acute infarctions and severe stenosis of the left MCA. Therefore, STA-MCA bypass surgery was performed. A follow-up angiography performed 2 weeks after the surgery showed an abnormal vascular channel from the left middle meningeal artery (MMA) to the middle meningeal vein (MMV) just anterior to the border of the craniotomy margin. This fistula originated from a screw used for cranial fixation. The screw injured the MMA and MMV, and this resulted in the formation of a fistula. The fistula was successfully treated with transarterial embolization. Surgeons should be careful when fixing bones with screws and plates as fistulas can develop if vessels are injured.

Spinal Dural Arteriovenous Fistula: Imaging Features and Its Mimics

Spinal dural arteriovenous fistula (SDAVF) is the most common spinal vascular malformation, however it is still rare and underdiagnosed. Magnetic resonance imaging findings such as spinal cord edema and dilated and tortuous perimedullary veins play a pivotal role in the confirmation of the diagnosis. However, spinal angiography remains the gold standard in the diagnosis of SDAVF. Classic angiographic findings of SDAVF are early filling of radicular veins, delayed venous return, and an extensive network of dilated perimedullary venous plexus. A series of angiograms of SDAVF at different locations along the spinal column, and mimics of serpentine perimedullary venous plexus on MR images, are demonstrated. Thorough knowledge of SDAVF aids correct diagnosis and prevents irreversible complications.