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Jan D. Wallace, Michael I. Weintraub, Richard H. Mattson and Robert Rosnagle

✓ This report describes a case of chemical meningitis with status epilepticus following intrathecal injection of fluorescein to delineate cerebrospinal fluid rhinorrhea. The patient was treated with parenteral steroids and anticonvulsants and recovered without sequelae. The wisdom of using minimal practical dosages of fluorescein is emphasized.

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C. Hunter Sheldon, Robert H. Pudenz, Wallace B Hamby and William F. Meacham

✓ In the second and final series of comments solicited for the Journal of Neurosurgery's 50th anniversary, four additional authors, each of whom was an original contributor to the first volume of the Journal, share some thoughts and anecdotes regarding their first articles.

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A. Giancarlo Vishteh, Ameet C. Patel, Robert F. Spetzler, Robert C. Wallace and C. Philip Daspit

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J. Marc C. Van Dijk, Karel G. TerBrugge, Robert A. Willinsky and M. Christopher Wallace

Object. Dural arteriovenous fistulas (AVFs) are a well-known pathoanatomical and clinical entity. Excluding bilateral involvement of the cavernous sinus, multiple dural AVFs are rare, with isolated reports in the literature. The additional risk associated with multiplicity is unknown, although it has been claimed that there is a greater risk of hemorrhage at presentation. In a group of 284 patients with dural AVFs consecutively treated at a single center, the occurrence of multiplicity is investigated and its risk factors for hemorrhage are identified.

Methods. Among the 284 patients with both cranial and spinal dural AVFs, 20 patients with multiple fistulas were found. Nineteen (8.1%) of 235 patients with cranial AVFs had multiple cranial fistulas, and one (2%) of 49 patients with spinal AVFs harbored two spinal fistulas. Twelve patients were found to have a lesion at two separate sites, seven patients had them at three locations, and one patient had four fistulas, each at a different site.

In the subgroup with multiple AVFs the percentage of hemorrhage at presentation was three times higher than in the entire group (p = 0.01). Cortical venous drainage in cranial fistulas was present in 84% of patients with multiple lesions compared with 46% of patients with solitary lesions (p < 0.005).

Conclusions. Multiple dural AVFs are not rare. In this group of 284 patients it was found in 8.1% of all patients with cranial dural AVFs. Multiplicity was associated with a higher percentage of cortical venous drainage, a pattern of drainage reportedly yielding a higher risk for hemorrhage.

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Farhad Pirouzmand, M. Christopher Wallace and Robert Willinsky

✓ A spinal epidural arteriovenous fistula with secondary reflux into the perimedullary veins is a rare entity. The authors present such a case with a discussion of its pathophysiology and treatment. The mechanism for formation of a spinal dural arteriovenous fistula is outlined based on the anatomical substrates in this region.

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Adam S. Reig, Scott D. Simon, Wallace W. Neblett III and Robert A. Mericle

The authors report the 8-year follow-up of a patient previously described in the literature who originally presented in high-output cardiac failure secondary to a complex neonatal intracranial dural arteriovenous fistula (DAVF). The earlier case report described palliative treatment with a combination of extracorporeal membrane oxygenation (ECMO) and endovascular embolization for life-threatening high-output cardiac failure secondary to a DAVF. Access was obtained using the ECMO cannula, and embolization was performed while the patient was connected to the ECMO machine.

The patient made an excellent recovery following partial embolization of the fistula, but then presented again 7 years later with worsening headaches secondary to significant growth of the known residual portion of the fistula identified on CT angiography. The child also developed bilateral femoral artery (FA) occlusions secondary to multiple previous FA punctures. To achieve complete obliteration of the remaining fistula, the patient required a retroperitoneal approach to the iliac artery and percutaneous puncture of the internal jugular vein. Embolization was performed with a combination of platinum coils and ethylene vinyl alcohol copolymer liquid embolic agent. There were no complications, and the child remains neurologically normal, with no signs of permanent cardiovascular sequelae.

In this case report, the authors discuss the long-term management of AVFs treated by endovascular strategies early in life. After neonatal access, sometimes the FAs occlude, requiring more invasive access strategies. The authors also discuss the follow-up method, intervals, and threshold for further treatment for these lesions, and present a review of the literature.

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J. Marc C. van Dijk, Karel G. TerBrugge, Robert A. Willinsky and M. Christopher Wallace

Object. A single-institution series of 119 consecutive patients with a dural arteriovenous fistula (DAVF) and cortical venous reflux was reviewed to assess the overall clinical outcome of multidisciplinary management after long-term follow up. The selective disconnection of the cortical venous reflux compared with the obliteration of the entire DAVF was evaluated.

Methods. Dural arteriovenous fistulas in patients in this series were diagnosed between 1984 and 2001, and treatment was instituted in 102 of them. The outcome of adequately treated patients was compared with that of a control group consisting of those with persistent cortical venous reflux and with data found in the literature. In cases of combined dural sinus drainage and cortical venous reflux, a novel treatment concept of selective disconnection of the cortical venous reflux that left the sinus drainage intact, and thus converted the aggressive DAVF into a benign lesion, was evaluated.

Endovascular treatment, which was instituted initially in 78 patients, resulted in an obliteration or selective disconnection in 26 (25.5%) of 102 cases. In 70 cases (68.6%) the DAVFs were surgically obliterated or disconnected. In six cases (5.9%), patients were left with persistent cortical venous reflux. No lasting complications were noted in this series. Follow-up angiography confirmed a durable result in 94 (97.9%) of 96 adequately treated cases, at a mean follow up of 27.6 months (range 1.4–138.3 months).

Selective disconnection was performed in 23 DAVFs with combined sinus drainage and cortical venous reflux. These patients' long-term outcomes were equal to those with obliterated DAVFs, and the complication rate was lower.

Conclusions. Considering the ominous course of DAVFs with patent cortical venous reflux, multidisciplinary treatment of these lesions is highly effective and the complication rate is low. Selective disconnection provides a valid treatment option of DAVFs with combined dural sinus drainage and cortical venous reflux, as has been shown in cranial DAVFs with direct cortical venous reflux.

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Robert F. Spetzler, Joseph M. Zabramski, Cameron G. McDougall, Felipe C. Albuquerque, Nancy K. Hills, Robert C. Wallace and Peter Nakaji

OBJECTIVE

The Barrow Ruptured Aneurysm Trial (BRAT) is a prospective, randomized trial in which treatment with clipping was compared to treatment with coil embolization. Patients were randomized to treatment on presentation with any nontraumatic subarachnoid hemorrhage (SAH). Because all other randomized trials comparing these 2 types of treatments have been limited to saccular aneurysms, the authors analyzed the current BRAT data for this subgroup of lesions.

METHODS

The primary BRAT analysis included all sources of SAH: nonaneurysmal lesions; saccular, blister, fusiform, and dissecting aneurysms; and SAHs from an aneurysm associated with either an arteriovenous malformation or a fistula. In this post hoc review, the outcomes for the subgroup of patients with saccular aneurysms were further analyzed by type of treatment. The extent of aneurysm obliteration was adjudicated by an independent neuroradiologist not involved in treatment.

RESULTS

Of the 471 patients enrolled in the BRAT, 362 (77%) had an SAH from a saccular aneurysm. Patients with saccular aneurysms were assigned equally to the clipping and the coiling cohorts (181 each). In each cohort, 3 patients died before treatment and 178 were treated. Of the 178 clip-assigned patients with saccular aneurysms, 1 (1%) was crossed over to coiling, and 64 (36%) of the 178 coil-assigned patients were crossed over to clipping. There was no statistically significant difference in poor outcome (modified Rankin Scale score > 2) between these 2 treatment arms at any recorded time point during 6 years of follow-up. After the initial hospitalization, 1 of 241 (0.4%) clipped saccular aneurysms and 21 of 115 (18%) coiled saccular aneurysms required retreatment (p < 0.001). At the 6-year follow-up, 95% (95/100) of the clipped aneurysms were completely obliterated, compared with 40% (16/40) of the coiled aneurysms (p < 0.001). There was no difference in morbidity between the 2 treatment groups (p = 0.10).

CONCLUSIONS

In the subgroup of patients with saccular aneurysms enrolled in the BRAT, there was no significant difference between modified Rankin Scale outcomes at any follow-up time in patients with saccular aneurysms assigned to clipping compared with those assigned to coiling (intent-to-treat analysis). At the 6-year follow-up evaluation, rates of retreatment and complete aneurysm obliteration significantly favored patients who underwent clipping compared with those who underwent coiling.

Clinical trial registration no.: NCT01593267 (clinicaltrials.gov)

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Robert F. Spetzler, Cameron G. McDougall, Joseph M. Zabramski, Felipe C. Albuquerque, Nancy K. Hills, Peter Nakaji, John P. Karis and Robert C. Wallace

OBJECTIVE

The authors present the 10-year results of the Barrow Ruptured Aneurysm Trial (BRAT) for saccular aneurysms. The 1-, 3-, and 6-year results of the trial have been previously reported, as have the 6-year results with respect to saccular aneurysms. This final report comparing the safety and efficacy of clipping versus coiling is limited to an analysis of those patients presenting with subarachnoid hemorrhage (SAH) from a ruptured saccular aneurysm.

METHODS

In the study, 362 patients had saccular aneurysms and were randomized equally to the clipping and the coiling cohorts (181 each). The primary outcome analysis was based on the assigned treatment group; poor outcome was defined as a modified Rankin Scale (mRS) score > 2 and was independently adjudicated. The extent of aneurysm obliteration was adjudicated by a nontreating neuroradiologist.

RESULTS

There was no statistically significant difference in poor outcome (mRS score > 2) or deaths between these 2 treatment arms during the 10 years of follow-up. Of 178 clip-assigned patients with saccular aneurysms, 1 (< 1%) was crossed over to coiling, and 64 (36%) of the 178 coil-assigned patients were crossed over to clipping. After the initial hospitalization, 2 of 241 (0.8%) clipped saccular aneurysms and 23 of 115 (20%) coiled saccular aneurysms required retreatment (p < 0.001). At the 10-year follow-up, 93% (50/54) of the clipped aneurysms were completely obliterated, compared with only 22% (5/23) of the coiled aneurysms (p < 0.001). Two patients had documented rebleeding, both died, and both were in the assigned and treated coiled cohort (2/83); no patient in the clipped cohort (0/175) died (p = 0.04). In 1 of these 2 patients, the hemorrhage was not from the target aneurysm but from an incidental basilar artery aneurysm, which was coiled at the same time.

CONCLUSIONS

There was no significant difference in clinical outcomes between the 2 assigned treatment groups as measured by mRS outcomes or deaths. Clinical outcomes in the patients with posterior circulation aneurysms were better in the coiling group at 1 year, but after 1 year this difference was no longer statistically significant. Rates of complete aneurysm obliteration and rates of retreatment favored patients who actually underwent clipping compared with those who underwent coiling.

Clinical trial registration no.: NCT01593267 (clinicaltrials.gov)

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Amir R. Dehdashti, Leodante B. Da Costa, Karel G. terBrugge, Robert A. Willinsky, Michael Tymianski and M. Christopher Wallace

Dural arteriovenous fistulas are the most common vascular malformations of the spinal cord. These benign vascular lesions are considered straightforward targets of surgical treatment and possibly endovascular embolization, but the outcome in these cases depends mainly on the extent of clinical dysfunction at the time of the diagnosis. A timely diagnosis is an equally important factor, with early treatment regardless of the type more likely to yield significant improvements in neurological functioning. The outcomes after surgical and endovascular treatment are similar if complete obliteration of the fistulous site is obtained. In the present study, the authors evaluated the current role of each modality in the management of these interesting lesions.