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Open access

Radiological features of internal carotid artery occlusion caused by pituitary apoplexy: illustrative case

Keigo Aramaki, Masanori Aihara, Yu Kanazawa, Takahiro Kawashima, Rei Yamaguchi, Masahiro Matsumoto, Masahiko Tosaka, and Yuhei Yoshimoto

BACKGROUND

Pituitary apoplexy rarely causes internal carotid artery (ICA) occlusion and acute ischemic stroke. Some cases have been reported, but the neuroimaging findings, including cerebral angiography, have not been discussed.

OBSERVATIONS

A 55-year-old male suffered the sudden onset of right cervical pain and left mild hemiparesis. Computed tomography indicated a pituitary mass, and magnetic resonance angiography showed a right ICA occlusion. The initial diagnosis was ICA occlusion caused by ICA dissection. His symptoms worsened and the region of cerebral infarction expanded, so the patient was transferred to our hospital. Magnetic resonance imaging and cerebral angiography showed the sudden stoppage of right ICA blood flow caused by local compression of the tumor near the distal dural ring. The diagnosis was acute ischemic stroke resulting from ICA pseudo-occlusion caused by pituitary apoplexy, and emergent endoscopic transsphenoidal resection was performed. Postoperatively, the right ICA was completely patent, and hemiparesis was improved with rehabilitation.

LESSONS

ICA occlusion caused by pituitary apoplexy is very rare, but emergent treatment is necessary. However, the pathology is difficult to diagnose quickly. Neuroimaging findings showing that the ICA is easily stenosed or occluded if rapidly compressed by the tumor near the distal dural ring may be useful to rapidly diagnose and treat.

In Journal of Neurosurgery: Case Lessons Volume 6 (2023): Issue 23 (Dec 2023)

Open access

Surgically treated intracranial arteriovenous fistulas with hemorrhage, resulting in complete obliteration: illustrative cases

Ako Matsuhashi, Kei Yanai, Satoshi Koizumi, and Gakushi Yoshikawa

BACKGROUND

Intracranial arteriovenous fistula (AVF) is a rare disease, defined as anastomoses between cerebral or meningeal arteries and dural venous sinuses or cortical veins. With the development of new agents and devices, endovascular embolization has been considered safe and effective in a majority of cases. However, cases that require direct surgery do exist. Herein, the authors present 3 cases of intracranial AVFs that presented with hemorrhage and were treated with direct surgery, achieving complete obliteration and favorable outcomes.

OBSERVATIONS

Intracranial AVFs that present with hemorrhage require immediate and complete obliteration. When AVFs involve the dural sinus, transvenous embolization is usually the first choice of treatment. AVFs with single cortical venous drainage are best treated with interruption of the draining vein close to the fistula. Transarterial embolization can be a curative treatment if there are no branches supplying cranial nerves or an association with pial feeders. In cases in which endovascular treatment is technically challenging or has resulted in incomplete occlusion, surgical treatment is indicated.

LESSONS

Despite the recent rise in endovascular treatment, it is important to recognize situations in which such treatment is not suitable for intracranial AVFs. Direct surgery is effective in such cases to offer the best possible outcome.

In Journal of Neurosurgery: Case Lessons Volume 6 (2023): Issue 23 (Dec 2023)

Open access

Can we build better? Challenges with geospatial and financial accessibility in the Caribbean. Illustrative case

Ellianne J dos Santos Rubio, Chrystal Calderon, Annegien Boeykens, and Kee B Park

BACKGROUND

Within the Caribbean, Curaçao provides a neurosurgical hub to other Dutch Caribbean islands. At times, the inefficiency of neurosurgical referrals leads to unsatisfactory patient outcomes in true emergency cases.

OBSERVATIONS

This article reports an illustrative case of a patient in need of emergency neurosurgical care, who was referred to a tertiary health institution in Curaçao. This case highlights the challenges of timely neurosurgical referrals within the Dutch Caribbean.

LESSONS

Highlighting this case may provide a foundation for further discussions that may improve neurosurgical care and access. Limiting long-distance surgical referrals in the acute care setting will aid in saving lives.

In Journal of Neurosurgery: Case Lessons Volume 6 (2023): Issue 22 (Nov 2023)

Open access

Intraoperative intraarterial indocyanine green video-angiography for disconnection of a perimedullary arteriovenous fistula: illustrative case

Youngkyung Jung, Antti Lindgren, Syed Uzair Ahmed, Ivan Radovanovic, Timo Krings, and Hugo Andrade-Barazarte

BACKGROUND

Intraarterial (IA) indocyanine green (ICG) angiography is an intraoperative imaging technique offering special and temporal characterization of vascular lesions with very fast dye clearance. The authors’ aim is to demonstrate the use of IA ICG angiography to aid in the surgical treatment of a perimedullary thoracic arteriovenous fistula (AVF) in a hybrid operating room (OR).

OBSERVATIONS

A 31-year-old woman with a known history of spinal AVF presented with 6 weeks of lower-extremity weakness, gait imbalance, and bowel/bladder dysfunction. Magnetic resonance imaging revealed an extensive series of flow voids across the thoracic spine, most notably at T11–12. After partial embolization, she was taken for surgical disconnection in a hybrid OR. Intraoperative spinal digital subtraction angiography was performed to identify feeding vessels. When the target arteries were catheterized, 0.05 mg of ICG in 2 mL of saline was injected, and the ICG flow in each artery was recorded using the microscope. With an improved surgical understanding of the contributing feeding arteries, the authors achieved complete in situ disconnection of the AVF.

LESSONS

IA ICG angiography can be used in hybrid OR settings to illustrate the vascular anatomy of multifeeder perimedullary AVFs and confirm its postoperative disconnection with a fast dye clearance.

In Journal of Neurosurgery: Case Lessons Volume 6 (2023): Issue 22 (Nov 2023)

Open access

Aneurysm appearing at the anastomosis site 11 years after superficial temporal artery–middle cerebral artery bypass surgery: moyamoya disease with a rapidly growing aneurysm. Illustrative case

Hiroki Eguchi, Koji Arai, and Takakazu Kawamata

BACKGROUND

Superficial temporal artery–middle cerebral artery (STA-MCA) bypass surgery is performed to prevent ischemia and hemorrhage in patients with moyamoya disease. Only a few reports have described aneurysms appearing around the anastomosis site after bypass surgery, and the underlying mechanism remains unknown.

OBSERVATIONS

The present case involved a 62-year-old woman who underwent STA-MCA bypass surgery for ischemic quasi-moyamoya disease at 46 years of age. Postoperatively, she underwent annual magnetic resonance imaging examinations. At 11 years after STA-MCA bypass surgery, a 3-mm aneurysm appeared at the anastomosis site. Four years later, headache developed and the aneurysm had grown to 5 mm. Craniotomy clipping was performed to prevent rupture. The patient was discharged home 2 weeks after surgery without any apparent complications.

LESSONS

Long-term observation is crucial after direct bypass surgery for moyamoya disease. Measures to prevent rupture should be considered for cases involving aneurysm complications.

In Journal of Neurosurgery: Case Lessons Volume 6 (2023): Issue 20 (Nov 2023)

Open access

A cavernous sinus dural arteriovenous fistula treated by direct puncture of the superior ophthalmic vein with craniotomy: illustrative case

Katsuma Iwaki, Koichi Arimura, Shunichi Fukuda, Soh Takagishi, Keisuke Ido, Ryota Kurogi, Kenichi Matsumoto, Akira Nakamizo, and Koji Yoshimoto

BACKGROUND

The authors report a case of symptomatic cavernous sinus (CS) dural arteriovenous fistula (dAVF) that was successfully treated using direct puncture of the superior ophthalmic vein (SOV) with craniotomy. CS dAVF is commonly treated using transvenous embolization (TVE), with the most common access route via the inferior petrosal sinus (IPS). However, this route is sometimes unavailable because of an occluded, hypoplastic, aplastic, or tortuous IPS. The SOV is an alternative, albeit tortuous and long, route to the CS; therefore, direct SOV puncture is occasionally performed. Direct SOV puncture is mostly percutaneous; however, in this case, it was difficult because of subcutaneous SOV narrowing.

OBSERVATIONS

As the patient experienced increased intraocular pressure, decreased vision, and eye movement disorders, CS embolization was performed via direct puncture with a craniotomy because of other access difficulties.

LESSONS

Several reports have described CS dAVF in patients receiving endovascular treatment via direct SOV puncture using a transorbital approach. However, to the best of the authors’ knowledge, this is the first reported case of a CS dAVF treated using TVE with craniotomy. This approach is useful when the SOV cannot be reached intravenously and its distance from the epidermis is long.

In Journal of Neurosurgery: Case Lessons Volume 6 (2023): Issue 20 (Nov 2023)

Open access

Middle meningeal artery pseudoaneurysm and pterygoid plexus fistula following percutaneous radiofrequency rhizotomy: illustrative case

Rahim Ismail, Derrek Schartz, Timothy Hoang, and Alexander Kessler

BACKGROUND

Percutaneous treatment for trigeminal neuralgia is a safe and effective therapeutic methodology and can be accomplished in the form of balloon compression, glycerol rhizotomy, and radiofrequency thermocoagulation. These procedures are generally well tolerated and demonstrate minimal associated morbidity. Moreover, vascular complications of these procedures are exceedingly rare.

OBSERVATIONS

We present the case of a 64-year-old female with prior microvascular decompression and balloon rhizotomy who presented after symptom recurrence and underwent a second balloon rhizotomy at our institution. Soon thereafter, she presented with pulsatile tinnitus and a right preauricular bruit on physical examination. Subsequent imaging revealed a middle meningeal artery (MMA) to pterygoid plexus fistula and an MMA pseudoaneurysm. Coil and Onxy embolization were used to manage the pseudoaneurysm and fistula.

LESSONS

This case illustrates the potential for MMA pseudoaneurysm formation as a complication of percutaneous trigeminal balloon rhizotomy, which has not been seen in the literature. Concurrent MMA-pterygoid plexus fistula is also a rarity demonstrated in this case.

In Journal of Neurosurgery: Case Lessons Volume 6 (2023): Issue 19 (Nov 2023)

Open access

Late-developing posttraumatic dural arteriovenous fistula of the vertebral artery: illustrative case

Hanna E Schenck, Thomas B Fodor, Bart A. J. M Wagemans, and Roel H. L Haeren

BACKGROUND

A dural arteriovenous fistula (dAVF) involving the vertebral artery (VA) is a rare vascular pathology that can result from damage to the VA, most frequently following cervical spine trauma. In most traumatic cases, the dAVF develops and manifests shortly after trauma.

OBSERVATIONS

A patient was admitted after a fall from the stairs causing neck pain. Computed tomography of the cervical spine revealed a Hangman’s fracture, and angiography showed a left VA dissection. The patient was treated with a cervical brace and clopidogrel. Three weeks after trauma, the patient was admitted because of bilateral leg ataxia, dizziness, and neck pain. Repeat imaging revealed increased displacement of the cervical fracture and a dAVF from the left VA with retrograde filling of the dAVF from the right VA. Embolization of the dAVF using coils proximally and distally to the dAVF was performed prior to placing a halo brace. At 6 months, all symptoms had disappeared and union of the cervical spine fracture had occurred.

LESSONS

This case report emphasizes the need for follow-up angiography after traumatic VA injury resulting from cervical spine fracture and underlines important treatment considerations for successful obliteration of a dAVF of the VA.

In Journal of Neurosurgery: Case Lessons Volume 6 (2023): Issue 18 (Oct 2023)

Open access

Transvenous embolization for an intraosseous clival arteriovenous fistula via a proper access route guiding a three-dimensional fusion image: illustrative case

Yu Iida, Jun Suenaga, Nobuyuki Shimizu, Kaoru Shizawa, Ryosuke Suzuki, Shigeta Miyake, Taisuke Akimoto, Satoshi Hori, Kensuke Tateishi, Yasunobu Nakai, and Tetsuya Yamamoto

BACKGROUND

Intraosseous clival arteriovenous fistulas (AVFs), in which the shunt drains extracranially from the posterior and anterior condylar veins rather than from the cavernous sinus (CS), are rare. Targeting embolization of an intraosseous clival AVF is challenging because of its complex venous and skull base anatomy; therefore, a therapeutic strategy based on detailed preoperative radiological findings is required to achieve a favorable outcome. Here, the authors report the successful targeted embolization of an intraosseous clival AVF using an ingenious access route.

OBSERVATIONS

A 74-year-old woman presented with left-sided visual impairment, oculomotor nerve palsy, and right facial pain. A fusion image of three-dimensional rotational angiography and cone-beam computed tomography revealed a left CS dural AVF and a right intraosseous clival AVF. The shunt flow of the clival AVF drained extracranially from the posterior and anterior condylar veins via the intraosseous venous route. Transvenous embolization was performed by devising suboccipital, posterior condylar, and intraosseous access routes. The symptoms resolved after the bilateral AVFs were treated.

LESSONS

Accurate diagnosis and proper transvenous access based on detailed intraosseous and craniocervical venous information obtained from advanced imaging modalities are key to resolving intraosseous clival AVF.

In Journal of Neurosurgery: Case Lessons Volume 6 (2023): Issue 18 (Oct 2023)

Open access

Asymptomatic subarachnoid hemorrhage following carotid endarterectomy: illustrative case

Shin Nemoto, Takuma Maeda, Keiichi Yamashita, Taro Yanagawa, Masataka Torii, Masaru Kiyomoto, Masaki Tanaka, Eishi Sato, Yoichi Harada, Toru Hatayama, Takuji Kono, and Hiroki Kurita

BACKGROUND

Carotid endarterectomy (CEA) and carotid artery stenting are common surgical interventions for internal carotid artery stenosis. Cerebral hyperperfusion syndrome (CHS) is a well-known complication of both procedures that can lead to intracranial hemorrhage and worsen clinical outcomes. Here, the authors report a rare case of non-aneurysmal subarachnoid hemorrhage (SAH) following CEA and review the relevant literature.

OBSERVATIONS

A 70-year-old woman with hypertension and diabetes presented with progressive visual loss in the right eye and was diagnosed with ocular ischemic syndrome. Imaging revealed severe right cervical carotid artery stenosis. CEA was performed with no complications. Postoperatively, the patient’s blood pressure was tightly controlled, with no evidence of CHS. However, an asymptomatic SAH was detected on postoperative day 7. Careful observation and blood pressure control were maintained. Since follow-up magnetic resonance imaging (MRI) showed no enlarging of the SAH and the patient was asymptomatic, she was discharged on postoperative day 15 with a modified Rankin scale score of 0.

LESSONS

This case highlights the potential occurrence of non-aneurysmal SAH as a rare complication of CEA, even in asymptomatic patients. Repeated postoperative MRI is necessary to detect such complications. It is crucial to carefully control blood pressure after CEA regardless of symptoms.

In Journal of Neurosurgery: Case Lessons Volume 6 (2023): Issue 17 (Oct 2023)