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Open access

Early cerebral venous drainage associated with focal seizures: a correlation of digital subtraction angiography and electroencephalography. Illustrative case

Olivia Holman, Joseph M Bibawy, Lara Wadi, Joel C Morgenlander, and Erik F Hauck

BACKGROUND

Early venous drainage is a critical diagnostic feature of arteriovenous malformations (AVMs) and arteriovenous fistulas (AVFs). However, other conditions associated with early venous drainage can mimic AVMs and AVFs and mislead the treating physician team.

OBSERVATIONS

The authors present a unique case of a 56-year-old man with new left hemianopsia. Workup with magnetic resonance imaging and magnetic resonance angiography had revealed cortical enhancement and early venous drainage, possibly caused by an AVF or AVM. Catheter angiography confirmed the presence of early venous drainage of specifically the right occipital lobe. The early venous drainage occurred as the result of local hyperperfusion limited to the right occipital lobe. Subsequent electroencephalography confirmed focal seizure activity in the right occipital lobe. After seizure control with multiple antiepileptic medications, the patient regained his vision. Repeat digital subtraction angiography revealed restoration of normal cerebral blood flow.

LESSONS

Early venous drainage observed during catheter angiography can be associated with seizure activity. Differentiation from other conditions, such as AVM, AVF, or ischemic stroke, is critical to facilitate prompt and appropriate treatment.

Open access

Evaluation of the shrinkage process of a neck remnant after stent-coil treatment of a cerebral aneurysm using silent magnetic resonance angiography and computational fluid dynamics analysis: illustrative case

Toru Satoh, Kenji Sugiu, Masafumi Hiramatsu, Jun Haruma, and Isao Date

BACKGROUND

Silent magnetic resonance angiography (MRA) mitigates metal artifacts, facilitating clear visualization of neck remnants after stent and coil embolization of cerebral aneurysms. This study aims to scrutinize hemodynamics at the neck remnant by employing silent MRA and computational fluid dynamics.

OBSERVATIONS

The authors longitudinally tracked images of a partially thrombosed anterior communicating artery aneurysm’s neck remnant, which had been treated with stent-assisted coil embolization, using silent MRA over a decade. Computational fluid dynamics delineated the neck remnant’s reduction process, evaluating hemodynamic parameters such as flow rate, wall shear stress magnitude and vector, and streamlines. The neck remnant exhibited diminishing surface area, volume, neck size, dome depth, and aspect ratio. Its reduction correlated with a decline in the flow rate ratio of the remnant dome to the inflow parent artery. Analysis delineated regions within the contracting neck remnant characterized by consistently low average wall shear stress magnitude and variation, accompanied by notable variations in wall shear stress vector directionality.

LESSONS

Evaluation of neck remnants after stent-coil embolization is possible through silent MRA and computational fluid dynamics. Predicting the neck remnant reduction may be achievable through hemodynamic parameter analysis.

Open access

Bilateral and asymmetrical localization of language function identified by the superselective infusion of propofol in an epilepsy patient with a mild malformation of cortical development: illustrative case

Mayuko Otomo, Shin-ichiro Osawa, Kyoko Suzuki, Kazuo Kakinuma, Kazushi Ukishiro, Hiroyoshi Suzuki, Kuniyasu Niizuma, Norio Narita, Nobukazu Nakasato, and Teiji Tominaga

BACKGROUND

Atypical localization of language function can result in unexpected postsurgical deficits after cortical resection, but it is difficult to predict the risk in the presurgical evaluation. The authors experienced a rare case of the bilateral and independent existence of different components of language function identified by segmented evaluation of anatomical anterior and posterior language areas using the superselective infusion of propofol.

OBSERVATIONS

A 32-year-old right-handed female presented with drug-resistant epilepsy. Comprehensive epilepsy evaluation suggested that the epileptic foci involved the whole left frontal lobe but provided less evidence of structural abnormality. To estimate the extent of functional deterioration likely to be caused by an extended left frontal lobectomy, the authors evaluated segmented cortical function in the ipsi- and contralateral hemispheres by the superselective infusion of propofol into the branches of the intracranial artery. The results revealed bilateral and asymmetrical localization of language function because the patient presented with different components of aphasia in each hemisphere. Based on the authors’ assessment of her functional tolerance, an extended left frontal lobectomy was performed and resulted in neurological deficits within the anticipated range.

LESSONS

An accurate understanding of the correlations between vascular and functional anatomy and the highly specific evaluation of language function provides more advanced presurgical assessment, allowing more tailored planning of cortical resection.

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.

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.

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.

Open access

Partially thrombosed giant basilar artery aneurysm with attenuated contrast enhancement of the intraluminal thrombus on vessel wall MRI after flow diversion treatment: illustrative case

So Matsukawa, Akira Ishii, Yasutaka Fushimi, Yu Abekura, Takashi Nagahori, Takayuki Kikuchi, Masakazu Okawa, Yukihiro Yamao, Natsuhi Sasaki, Hirofumi Tsuji, Ryo Akiyama, and Susumu Miyamoto

BACKGROUND

The effect of vessel wall magnetic resonance imaging (VW-MRI) enhancement in partially thrombosed aneurysms has previously indicated aneurysmal instability and a rupture risk. However, whether the contrast effect of the wall changes before or after flow diversion treatment is still under investigation.

OBSERVATIONS

The authors report a case of a partially thrombosed basilar artery aneurysm that increased in size over a short period, worsened brainstem compression symptoms, and was treated with a flow diverter stent with good results. In this case, VW-MRI after surgery showed a reduced contrast effect on the intraluminal thrombus within the aneurysm. The aneurysm thrombosed and markedly regressed over the next 5 months, with remarkable improvement in the brainstem compression symptoms.

LESSONS

This finding on VW-MRI may indicate an attenuation of neovascularization in the thrombus wall and be a sign of aneurysm stabilization.

Open access

Rescue stenting after artery occlusion as a complication of an intrasaccular device–assisted coiling embolization: illustrative case

Félix Gallo-Pineda, Miriam Fernández-Gómez, and Carlos Hidalgo-Barranco

BACKGROUND

Endovascular embolization of wide-necked aneurysms can be challenging. The development of intrasaccular devices like the Contour has enabled us to approach these aneurysms effectively by reducing recanalization rates and eliminating the need for dual antiplatelet therapy, which is particularly beneficial in the case of ruptured aneurysms. Although complications from using these devices are rare, it is crucial to address them properly. In this case, the authors highlight how to manage artery thrombosis caused by device protrusion during aneurysm embolization.

OBSERVATIONS

This report describes a complication in a male patient with a ruptured anterior communicating artery wide-necked aneurysm. Following Contour-assisted coiling of the aneurysm, a realignment of the detachable apex of the device occluded the A2 segment of the right anterior cerebral artery. After the failure of intra-arterial and intravenous tirofiban infusion as well as mechanical thrombectomy, a self-expanding open-cell stent was deployed in the involved vessel, achieving successful reperfusion.

LESSONS

The Contour device has a detachable zone that can cause occlusion of the parent vessel after deployment. The use of a stent as a rescue maneuver may be useful if reperfusion of the vessel cannot be achieved through other methods such as aspiration or full-dose antiplatelet therapy.

Open access

Compartment syndrome associated with vascular avulsion caused by transradial access in neurointervention for unruptured intracranial aneurysm: illustrative case

Michiyasu Fuga, Toshihide Tanaka, Rintaro Tachi, Kyoichi Tomoto, Shun Okawa, Toshihiro Ishibashi, Yuzuru Hasegawa, and Yuichi Murayama

BACKGROUND

Transradial access (TRA) has a lower risk of access-site complications than transfemoral access but can cause major puncture-site complications, including acute compartment syndrome (ACS).

OBSERVATIONS

The authors report a case of ACS associated with radial artery avulsion after coil embolization via TRA for an unruptured intracranial aneurysm. An 83-year-old woman underwent embolization via TRA for an unruptured basilar tip aneurysm. Following embolization, strong resistance was felt during removal of the guiding sheath due to vasospasm of the radial artery. One hour after neurointervention via TRA, the patient complained of severe pain in the right forearm, with motor and sensory disturbance of the first 3 fingers. The patient was diagnosed with ACS causing diffuse swelling and tenderness over the entire right forearm due to elevated intracompartmental pressure. The patient was successfully treated by decompressive fasciotomy of the forearm and carpal tunnel release for neurolysis of the median nerve.

LESSONS

TRA operators should be aware that radial artery spasm and the brachioradial artery pose a risk of vascular avulsion and resultant ACS and warrant precautionary measures. Prompt diagnosis and treatment are essential because ACS can be treated without the sequelae of motor or sensory disturbance if properly addressed.

Open access

Dural arteriovenous fistulas misdiagnosed as intracranial neoplasms: illustrative case

Tobias Rossmann, Michael Veldeman, Ville Nurminen, Rahul Raj, and Mika Niemelä

BACKGROUND

Dural arteriovenous fistulas (dAVF) may induce imaging findings attributable to various disease entities including malignant neoplasms. In these cases, diagnosis and adequate treatment are often delayed and patients may be exposed to spurious treatments in addition to the risks inherent to an untreated dAVF with cortical venous drainage.

OBSERVATIONS

The authors report a case of a patient referred for surgical treatment of a supratentorial high-grade glioma. Thorough review of imaging data challenged the initial radiological diagnosis and led to proper angiographic workup. As a result, a high-grade dAVF was confirmed and successfully embolized. In addition to this case, we provide an extensive literature review on dAVF initially diagnosed as cerebral neoplasms, including clinical, imaging and follow-up data.

LESSONS

The literature provides diagnostic criteria for dAVF on magnetic resonance imaging; however, those criteria may be only partly applicable in many cases. Misdiagnosis of a neoplasm due to dAVF has been reported but remains rare, especially in supratentorial lesions. Digital subtraction angiography should be pursued to rule out an underlying vascular pathology if any doubt. This may prevent unnecessary interventions such as biopsies, pharmacological treatment and a delay in dAVF treatment, given its associated risk of hemorrhage and nonhemorrhagic neurological deficits.