Left dural carotid cavernous fistula mimicking an inflammatory process: A case report

A female in her 70s presented with altered mental status, left eye pain, ophthalmalgia, and diplopia following a fall. Brain MRI demonstrated contrast-enhancing left peri-insular T2 hyperintense changes that was read as possible herpes simplex encephalitis by neuroradiology. Cerebral angiogram revealed a Barrow Type D left sided carotid cavernous fistula. The patient was subsequently treated with endovascular transvenous coil embolization of the left cavernous sinus resulting in complete occlusion of the fistula. The goal of this case is to present a unique case of a carotid cavernous fistula radiologically mimicking herpes simplex encephalitis. Early recognition of carotid cavernous fistula on neuroimaging is important for prompt treatment of symptoms.

Advances in Intraoperative Imaging for Vascular Neurosurgery

Cerebrovascular surgery has many intraoperative imaging modalities available. Modern technologies include intraoperative digital subtraction angiogram, indocyanine green (ICG) angiography, relative fluorescent measurement with ICG, and ultrasound. Each of these can be used effectively in the treatment of open aneurysm and arteriovenous malformation surgeries, in addition to arteriovenous fistula surgery, and cerebral bypass surgery.

Contrast-Induced Encephalopathy after Cerebral Angiogram: A Case Series and Review of Literature

Contrast-induced encephalopathy (CIE) is a rare complication that arises from exposure to iodinated contrast medium and can result in a range of symptoms, including cortical blindness, aphasia, focal neurological deficits, and altered mental status. We present 4 individual cases of CIE who presented with stroke-mimic symptoms following surgery with localized iodixanol or ioversol injection. We outline a clinical timeline of all patients, showing that CIE follows a general pattern of delayed onset, worsening symptomology, and ultimately full recovery. All patients received IV hydration, corticosteroids, or both as part of their treatment protocol.

Rare Cases of Contrast-Induced Encephalopathies

Cortical blindness (CB) due to contrast-induced encephalopathy is a rare complication in endovascular procedure. Although exact mechanism is not known, disruption of blood–brain barrier (BBB) by contrast agent is supposed to be caused. We report two cases of contrast-induced encephalopathies after coil embolization of unruptured aneurysm. A 68-year-old woman with unruptured basilar artery aneurysm was treated with endovascular stent-assisted coil embolization. The procedure was successfully accomplished within 172 min using about 160 ml of contrast medium (iopamidol). However, she manifested with CB 3 h after the procedure and seizure on the next day. Immediate computed tomography revealed the cortical enhancement in both occipital lobes. Diffusion-weighted imaging–magnetic resonance imaging and fluid-attenuated inversion recovery sequence 1 day after the procedure revealed edema in both occipital lobes with no findings of ischemia or hyperperfusion. Electroencephalography showed sharp and slow waves in both occipital lobes. She required endotracheal intubation on day 2 to maintain airways and breathing. Her sensorium improved 4 days after the procedure with administration of steroid and anticonvulsant. She was extubated on day 4 after the procedure. She was discharged with persisting CB as a sequel.

Estimated radiation dose according to the craniocaudal angle in cerebral digital subtraction angiography: Patient and phantom study

BACKGROUND AND PURPOSE

Routine use of cranial angulation with 15-20 degrees, craniocaudal angled (CC) view, for cerebral digital subtraction angiography (DSA) helps minimize bone subtraction artifacts with less overlapping of the vessels, however, it may increase the radiation dose. We designed the phantom and patient studies to determine the effect of the angulation to the radiation dose and the feasibility of true posteroanterior angled (PA) view, in cerebral DSA.

MATERIALS AND METHODS

In the phantom study, frontal DSA was simulated with variable angulations. In the patient study with thirty-one subjects, one internal carotid arteriogram was obtained with the CC view and the other, PA view in every patient. The dose-area product (DAP) and reference air-kerma (AK) were measured and compared between the angles. A qualitative analysis was performed to assess the diagnostic performance of the DSA over the angles.

RESULTS

The phantom study confirmed that the greater craniocaudal angles caused higher radiation exposure. Especially, the radiation dose (AK) of the CC view was 5.4% higher than that of the PA view. In the patient study, the radiation dose of the PA view was significantly lower compared to the CC view (1.44 vs. 1.63 mGy, AK). In 4 patients, the dose particularly jumped when applying the CC view as the copper filter was automatically removed. The diagnostic ability of the DSA with the PA view tended to be higher without significance.

CONCLUSIONS

In a daily routine cerebral angiography, a simple modification of the angle may help to minimize the radiation dose.

The First CT Scan of the Brain: Entering the Neurologic Information Age

Computed tomography (CT) scan of the brain transitioned clinical neurology from the educated-guess world to the real computer-age world. One of the first CT scans-published by the British neuroradiologist James Ambrose-showed an intracranial hemorrhage and also suggested the use of iodine to demonstrate abnormal blood-brain barrier. In the USA, CT scans were rapidly commercialized and first placed at Mayo Clinic and Massachusetts General Hospital in the summer of 1973. CT scanning of the brain has revolutionized diagnostic acute neurology and neurosurgery and was the overture to an even larger revolution-magnetic resonance imaging. This historical vignette discusses the development of CT scanning of the brain and its connection with neurocritical care.

Recurrent Cerebral Hemorrhage in Normal Pregnancy Secondary to Mycotic Pseudoaneurysms Related to Choriocarcinoma

BACKGROUND

Choriocarcinoma coexisting with or after normal pregnancy is extremely rare. To our knowledge, our case report is the first time cerebral mycotic pseudoaneurysms from choriocarcinoma have been proven angiographically.

CASE DESCRIPTION

A 38-week pregnant 26-year-old woman presented with an acute left frontal hemorrhage. She underwent emergency cesarean section, followed by hematoma evacuation and resection of what grossly appeared to be a medium-sized arteriovenous malformation at the time of surgery. Angiogram before and after resection showed no obvious vascular pathology. One month later, she returned with status epilepticus, and an acute parenchymal hematoma posterior to the surgical resection cavity was identified. Angiography showed a multilobulated pseudoaneurysm along the left middle cerebral artery. This was resected and found on histopathology to have choriocarcinoma within and around the blood vessels. Serum human chorionic gonadotrophin levels increased daily. Pan computed tomography showed a left lung lobular mass. The diagnosis was stage 4 World Health Organization score 9 high-risk metastatic choriocarcinoma requiring radiation followed by multiagent chemotherapy. Two weeks later, she had another seizure. An angiogram showed an unruptured pseudoaneurysm along the right posterior cerebral artery, which was embolized.

CONCLUSIONS

Metastatic choriocarcinoma is rarely considered during a viable pregnancy but is almost always fatal if unrecognized. Early recognition enhances the chances of cure with chemotherapy. Arteriovenous malformations are typically considered in young women with intracerebral hemorrhages and have higher risk of rupture in pregnant women, but physicians should also be aware of metastatic choriocarcinoma and the development of mycotic aneurysms in peripartum women with intracerebral hemorrhages.