The classic symptoms and signs of carotid cavernous sinus fistula or cavernous sinus dural arteriovenous fistula (AVF) consist of eye redness, exophthalmos, and gaze abnormality. The angiography ...findings typically consist of arteriovenous shunt at cavernous sinus with ophthalmic venous drainage with or without cortical venous reflux. In rare circumstances, the shunts are localized outside the cavernous sinus, but mimic symptoms and radiography of the cavernous shunt. We would like to present the other locations of the arteriovenous shunt, which mimic the clinical presentation of carotid cavernous fistulae, and analyze venous drainages.
We retrospectively examined the records of 350 patients who were given provisional diagnoses of carotid cavernous sinus fistulae or cavernous sinus dural AVF in the division of Interventional Neuroradiology, Ramathibodi Hospital, Bangkok between 2008 and 2014. Any patient with cavernous arteriovenous shunt was excluded.
Of those 350 patients, 10 patients (2.85%) were identified as having noncavernous sinus AVF. The angiographic diagnoses consisted of three anterior condylar (hypoglossal) dural AVF, two traumatic middle meningeal AVF, one lesser sphenoid wing dural AVF, one vertebro-vertebral fistula (VVF), one intraorbital AVF, one direct dural artery to cortical vein dural AVF, and one transverse-sigmoid dural AVF. Six cases (60%) were found to have venous efferent obstruction.
Arteriovenous shunts mimicking the cavernous AVF are rare, with a prevalence of only 2.85% in this series. The clinical presentation mainly depends on venous outflow. The venous outlet of the arteriovenous shunts is influenced by venous afferent-efferent patterns according to the venous anatomy of the central nervous system and the skull base, as well as by architectural disturbance, specifically, obstruction of the venous outflow.
Background
Intracranial infectious aneurysms are rarely reported in children; in particular, they are very rare in infants. They are mostly related to infective endocarditis and are usually located ...in the anterior cerebral vasculature. A ruptured intracranial infectious aneurysm is a catastrophic event associated with high morbidity and mortality rates.
Case report
An 8-month-old female infant presented with a prolonged fever without any organ-specific symptoms. Two weeks after admission, she had a high-grade fever with drowsiness; the cerebrospinal fluid (CSF) examination indicated meningitis. Despite treatments with empiric antibiotic and antiviral agents, both her condition and the repeated CSF profiles worsened. The ineffective medications were promptly changed to susceptible antibiotic after the CSF culture showed
Pseudomonas aeruginosa
. Three days after the diagnosis of meningitis, the patient suddenly developed seizures and alteration of consciousness. The computerized tomography and angiography (CT and CTA) of the brain demonstrated a diffuse subarachnoid hemorrhage (SAH) with intraventricular hemorrhage (IVH) and a lobulated fusiform aneurysm at the proximal basilar artery, suggestive of a ruptured basilar infectious aneurysm. Endovascular treatment was planned and a transarterial occlusion of the vertebrobasilar junction was performed in order to disrupt inflow of the aneurysm. After endovascular intervention, her clinical symptoms gradually improved and the patient was discharged after completing a 4-week course of antibiotics. At the 6-week follow-up, she was doing well without neurological deficit.
Conclusion
To our knowledge, this is the first reported case of a ruptured basilar infectious aneurysm in an infant secondary to
Pseudomonas
meningitis, successfully treated with parent artery occlusion.
Brain arteriovenous malformations (AVMs) are abnormal vascular connections within the brain that are presumably congenital in nature. There are several subgroups, the most common being glomerular ...type brain AVMs, with fistulous type AVMs being less common. A brain AVM may also be a part of more extensive disease (eg, cerebrofacial arteriovenous metameric syndrome). When intracranial pathologic vessels are encountered at cross-sectional imaging, other diagnoses must also be considered, including large developmental venous anomalies, malignant dural arteriovenous fistulas, and moyamoya disease, since these entities are known to have different natural histories and require different treatment options. Several imaging findings in brain AVMs have an impact on decision making with respect to clinical management; the most important are those known to be associated with risk of future hemorrhage, including evidence of previous hemorrhage, intranidal aneurysms, venous stenosis, deep venous drainage, and deep location of the nidus. Other imaging findings that should be included in the radiology report are secondary effects caused by brain AVMs that may lead to nonhemorrhagic neurologic deficits, such as venous congestion, gliosis, hydrocephalus, or arterial steal.
Background and Purpose
Women's representation in medicine has increased over time yet the proportion of women practicing neurointervention remains low. We conducted an anonymous online survey through ...which we could explore the gender gap in neurointervention, identify potential issues, difficulties, or obstacles women might face, and evaluate if men encounter similar issues.
Methods
An online questionnaire was designed in SurveyMonkey®. Invitation to participate was emailed through national and international neurointerventional societies as well as directly through private mailing lists to men and women working in neurointervention. Responses were collected from 10 May 2019 to 10 September 2019.
Results
There were 295 complete responses, 173 (59%) male and 122 (41%) female. Most respondents (83%) fell within age categories 35–60 years, with representation from 40 countries across five continents. In all 95% were working full time, 73% had worked as a neurointerventionalist for >6 years, 77% worked in University-affiliated teaching institutions. Almost half of the respondents indicated no female neurointerventionalist worked in their center. Female respondents were younger and age-adjusted analysis was undertaken. Significantly fewer females than males were married and had children. Significantly fewer females held supervisory roles, held academic titles, and significantly less had a mentor. Females were less satisfied in their careers. More females felt they receive less recognition than colleagues of the opposite sex. Males had a greater proportion of work time dedicated to neurointervention. Similar proportions of both genders experienced bullying in work (40%–47%); however, sexual harassment was more common for females. There were no differences between genders in how they dealt with complications or their effects on mental well-being.
Conclusion
There are many potential reasons why women are underrepresented in neurointervention, however, the literature suggests this is not unique to our specialty. Multiple long-term strategies will be necessary to address these issues, some of which are discussed in the article.
Objective The types of cortical venous reflux channels, posterior fossa and pontomesencephalic venous reflux or their connections with the cavernous sinus (CS) are inadequately described in the ...literature. This study uses angiography, magnetic resonance imaging, and X-ray computed tomography to clarify the possible route of cavernous dural arteriovenous fistulae (CVDAVF) that causes posterior fossa and pontomedullary venous reflux and documents the clinical presentations associated with the reflux. Methods Eighty-six patients with CSDAVF treated at Ramathibodi Hospital, Bangkok, Thailand, during 2009 to 2013 were studied retrospectively. Sixteen cases with posterior fossa and pontomedullary venous reflux were included for analysis. Results Bridging veins serve as an important pathway for venous reflux from CS to the posterior fossa and brainstem. The uncal vein directly terminates at the CS and has several connecting routes, ranging from the inferior frontal lobes and insula to the posterior fossa through the basal vein of Rosenthal. The petrosal vein was most frequently and easily detected angiographically. It plays a major role in the cerebellar hemispheric venous reflux. Only 1 patient developed brainstem and cerebellar venous congestion, which returned to normal after endovascular treatment. Conclusions Connections of CS are not limited to intercavernous, ophthalmic veins, sphenoparietal sinuses, and inferior and superior petrosal sinuses. They also occur with complex venous drainages at the base of the frontotemporal lobes, insula, brainstem, and cerebellum. Knowledge of the venous connection of CS is key to understanding the possible locations of venous congestion/hemorrhage and the clinical presentation of patients with CSDAVF.
Although it is generally accepted that developmental venous anomalies (DVAs) are benign vascular malformations, over the past years, we have seen patients with symptomatic DVAs. Therefore, we ...performed a retrospective study and a literature study to review how, when, and why DVAs can become clinically significant.
Charts and angiographic films of 17 patients with DVAs whose 18 vascular symptoms could be attributed to a DVA were selected from a neurovascular databank of our hospital. MRI had to be available to rule out any other associated disease. In the literature, 51 cases of well-documented symptomatic DVAs were found. Pathomechanisms were divided into mechanical and flow-related causes.
Mechanical (obstructive or compressive) pathomechanisms accounted for 14 of 69 symptomatic patients resulting in hydrocephalus or nerve compression syndromes. Flow-related pathomechanisms (49 of 69 patients) could be subdivided into complications resulting from an increase of flow into the DVA (owing to an arteriovenous shunt using the DVA as the drainage route; n=19) or a decrease of outflow (n=26) or a remote shunt with increased venous pressure (n=4) leading to symptoms of venous congestion. In 6 cases, no specific pathomechanisms were detected.
Although DVAs should be considered benign, under rare circumstances, they can be symptomatic. DVAs, as extreme variations of normal venous drainage, may represent a more fragile venous drainage system that can be more easily affected by in- and outflow alterations. The integrity of the DVA needs to be preserved irrespective of the treatment that should be tailored to the specific pathomechanism.
Background Southeast Asia accounts for approximately 10% of stroke‐related mortalities worldwide, yet there are limited data regarding mechanical thrombectomy (MT) outcomes in this region. PROSPR‐SEA ...(Post‐Market Registry of Stroke Patients Treated With Medtronic Neurothrombectomy Devices to Collect Real‐World Data in Southeast Asia) assessed post‐market clinical outcomes of MT using the Solitaire Revascularization Device in southeast Asia. Methods PROSPR‐SEA is a prospective, multicenter, nonrandomized, observational registry of patients who underwent MT using Solitaire as first line treatment at 1 of 10 centers in Vietnam, Thailand, and Singapore between January 2018 and July 2019. The primary end point was functional independence (modified Rankin scale 0–2) at 90 days. Safety end points included symptomatic intracerebral hemorrhage, emboli in new territory at 24 hours, and all‐cause mortality at 90 days. Secondary end points were successful revascularization (modified thrombolysis in cerebral infarction ≥2b), workflow metrics, National Institutes of Health Stroke Scale score at discharge, and patient disposition at 90 days. Results A total of 183 patients (64.9±13.7, 49.7% 91/183 female) were included in the study and underwent MT; 79.2% (145/183) had occlusions in the middle cerebral artery. Median baseline National Institutes of Health Stroke Scale was 15.0 (range 1–31) and median baseline Alberta Stroke Program Early CT Score was 8.0 (range 0–10). Functional independence at 90 days was achieved in 62.2% (112/180). Mean puncture‐to‐revascularization time was 53.3±53.9 minutes, and mean onset‐to‐revascularization time was 330.0±110.4 minutes. Revascularization was successful in 94.0% (172/183) of patients. Median National Institutes of Health Stroke Scale improved at discharge (−8.0, range −22, 25) and 90 days (−13.0, range −22, 0). Within 24 hours, symptomatic intracerebral hemorrhage occurred in 7.7% (14/183) and emboli in new territory in 3.3% (6/183). At 90 days, the all‐cause mortality rate was 7.7% (14/183). Most patients were discharged to home by 90 days (84.1%, 154/183). Conclusion PROSPR‐SEA demonstrated high rates of positive functional outcomes and procedural success with a low mortality rate and indicates that the technical and clinical outcomes of landmark MT trials using Solitaire as the first‐line device are reproducible in real‐world southeast Asian settings.
The authors describe the clinical presentation, imaging features, and management of patients presenting with filum terminale arteriovenous fistulas (FTAVFs) and the role of transarterial treatment in ...their management.
The authors retrospectively reviewed data obtained in 10 patients with FTAVFs diagnosed between January 1990 and December 2011.
Most patients (70%) were male, and the age of the population ranged from 31 to 72 years (mean 58.2 years). Clinical presentation was progressive paraparesis and sensory loss in the lower extremities in 9 cases, back pain in 7, radicular pain in 3, bowel/bladder disturbance in 5, and impotence in 1. The duration of symptoms varied between 2 and 24 months. Initial MRI studies showed intramedullary increased T2 signal, swollen cord, and dilated perimedullary veins in all patients. One patient had syringomyelia, presumably caused by venous hypertension transmitted by the perimedullary venous system. Embolization was attempted in 7 patients and was curative in 6 patients. Surgery was performed in the other 4 patients in whom embolization was unsuccessful or deemed not feasible. There was no treatment-related complication in either group. Symptoms, venous congestion in the cord, and syringomyelia improved on follow-up in all patients.
Embolization should be considered the treatment of choice for FTAVFs and can effectively treat the majority of patients presenting with an FTAVF. In a smaller group of patients in whom the angioarchitecture is unfavorable, open surgery is recommended.
The goal in this study was to present possible pathological mechanisms, clinical and imaging findings, and to describe the management and outcome in patients with hydrocephalus due to unruptured pial ...brain arteriovenous malformations (AVMs).
Medical records and imaging findings in 8 consecutive patients with hydrocephalus caused by AVMs and treated between June 2000 and September 2007 were retrospectively reviewed to determine clinical symptoms, AVM location, venous drainage, level/cause of obstruction, and degree of hydrocephalus. Management of hydrocephalus, AVM treatment, complications, and follow-up results were evaluated.
Headaches were the most common clinical symptom (7 of 8 patients). Deep venous drainage was identified in all patients. Mechanical obstruction by the draining vein or the AVM nidus was seen in 6 patients, in whom obstruction occurred at the interventricular foramen (2 patients) or the aqueduct (4 patients). Hydrodynamic disorders following venous outflow obstruction and venous congestion of the posterior fossa led to hydrocephalus in the remaining 2 patients. Ventriculoperitoneal (VP) shunts were placed in 6 of 8 patients with a moderate to severe degree of hydrocephalus. Regression of hydrocephalus was noted in 4 patients, whereas in 2 the imaging findings were stable, 1 of whom had decreased hydrocephalus only after AVM size reduction. In 2 patients with mild hydrocephalus who were not treated with shunt insertion, 1 improved and 1 was clinically stable after AVM treatment.
The most common cause of hydrocephalus in unruptured brain AVMs is mechanical obstruction by the draining vein if it is located in a strategic position. Management should be aimed at treatment of the AVM; however, VP shunts may be necessary in acute and severe cases of hydrocephalus.
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