The safety of the intraoperative sacrifice of the deep cerebral veins.

BACKGROUND: The effect of surgically ligating the deep cerebral veins is often thought to be of significant risk. That concern and the paucity of information on surgery of the deep venous system confound surgical decision making when operations involve manipulation of the deep cerebral veins. DISCUSSION: The authors review the human and animal literature on the selective sacrifice of the deep cerebral veins. Robust experimental studies and limited clinical experience indicate that occlusion of one or several deep cerebral veins is generally safe.

Giant cerebellar cavernous malformation in 4-month-old boy. Case report and review of the literature.

Cavernous malformations (CMs) are rare vascular lesions that affect 0.4-0.9% of the population. The diagnosis of CMs is simple in most typical cases although some lesions may present unusual imaging features: localization, signal intensity, or size. Extremely rare giant CMs can mimic neoplastic lesion because of their size. We report a case of giant cerebellar CM that is more than 6 cm in size, diagnosed in 4-month-old boy. We discuss magnetic resonance findings and histopatholo-gical features of this lesion.

Surgical treatment of a sylvian-middle fossa dural arteriovenous fistula draining into the basal vein of rosenthal with frontotemporal craniotomy.

A 61-year-old man presented with left lower quadrianopsia caused by cerebral infarction in the right occpital lobe. Cerebral angiography revealed occlusion of right transverse sinus and Sylvian-middle fossa dural arteriovenous fistula (d-AVF) draining into the Sylvian vein and dilation of basal vein of Rosenthal. Surgical operation with right frontotemporal craniotomy was carried out to obliterate the fistula point and resection of the dura mater containing vasculature networks. Histologically, the thickening of walls of dural arteries and veins lacking internal elastica lamina were observed. Interestingly, the dura mater involving d-AVF was hyalinized and lacked collagen fibers, resembling local hypoxia and suggesting the possible role of dural hypoxia with pathogenesis of d-AVF. The present case indicates that open surgery can be effective for Sylvian-middle fossa d-AVF for the purpose of obliteration of fistula point and resection of the dura for histopathologic analyses.

A foreign body in the cephalic vein: A case report.

RATIONALE: Foreign bodies in the vasculature usually cause numerous problems for clinical physicians. Physician experience with diagnosing and treating non-iatrogenic foreign body migration in the venous system is insufficient. PATIENT CONCERNS: Here, we reported a 41-year-old male who had a foreign body in his left forearm following a work-related injury. DIAGNOSES: X-ray films indicated a 3-mm high-density shadow in the superficial soft tissue of the left forearm. During the operation, the foreign body was imaged by a C-arm fluoroscope to provide a more accurate location. INTERVENTIONS: The foreign body was removed completely following a microsuture of the cephalic vein. OUTCOMES: The procedure was uneventful, and the patient remained asymptomatic after 6 months of clinical follow-up. LESSONS: This case indicated that the foreign body in the superficial tissue needed to be accurately diagnosed and located. X-ray and C-arm fluoroscope imaging should be combined with the patient's medical history to ensure sufficient preoperative preparation.

Vein of Galen aneurysms: a review and current perspective.

Our approach to treating a patient with a vein of Galen aneurysm is, of course, influenced greatly by the age of the patient, the clinical symptoms, and the angiographic architecture of the malformation. Therapeutic options are primarily based on whether a true AVM is present or if the malformation represents an arteriovenous fistula involving the vein of Galen. Arterial endovascular approaches, microneurosurgery, and/or radiosurgery are preferred for management of the former; the transvenous endovascular approach has become the cornerstone of treatment in the latter. The most critical group, however, is the neonates in extreme cardiovascular distress. In this case our therapeutic intervention is initially endovascular from the venous side, either transfemoral or transtorcular. The immediate goal is to increase resistance to right ventricular output. Advantages of this approach over a transarterial approach include a shorter anesthesia time, minimal fluid and/or contrast administration, and creation of a wire "basket" or "bird's nest" on the venous side that helps prevent emboli that may be deposited on the arterial side in subsequent embolizations from passing through the malformation. The transvenous approach can be easily repeated multiple times and may be supplemented by transarterial embolizations. Endovascular coils have been the mainstay for such venous embolizations. The end point of treatment is not complete occlusion of the fistula but improvement in cardiac function. Often, more than one stage is required to reach our goal. The results in recent years have been encouraging and are to a large degree attributable to the advances in endovascular approaches. With future improved tools for diagnosis and treatment, perhaps the prognosis for this difficult malady also will continue to improve.

Cerebral venous sinus thrombosis associated with hepatic cirrhosis.

Cerebral venous sinus thrombosis is not a recognized complication of end-stage liver disease. A case of sagittal sinus thrombosis in a 44-year-old male with end-stage hepatic cirrhosis is described. Recurrent seizures were the only manifestation. Work-up revealed severe deficiency of protein C, protein S, and antithrombin III. He was treated with low molecular weight heparin and underwent an orthotopic liver transplant after three months. Follow-up helical CT venogram showed resolution of the sinus thrombosis.

Detection of enlarged cortical vein by magnetic resonance imaging contributes to early diagnosis and better outcome for patients with anterior cranial fossa dural arteriovenous fistula.

Twelve patients (10 men, 2 women) with anterior cranial fossa dural arteriovenous fistula (AVF) were treated at our institute between January 1976 and March 2002. Intracranial hemorrhage was the presenting symptom in six patients. Magnetic resonance (MR) imaging findings identified abnormal cortical veins as flow voids in four of five patients. Angiography was the basis of the diagnosis in all patients. Surgery was the primary treatment in nine patients. The other three patients refused intervention and managed conservatively. Surgical morbidity was negligible and the treatment outcome was highly dependent on the clinical status at presentation. In contrast to the reported high incidence of intracranial hemorrhage in patients with dural AVF in the anterior cranial fossa, only half of our study population presented with hemorrhage. Enlarged cortical veins in the frontobasal area could be detected as flow voids on MR images. This finding contributed to the early diagnosis and treatment of patients treated at our institution for dural AVF in the anterior cranial fossa, and to the better outcomes we obtained in these patients.

Transvenous Onyx embolization of a subependymal deep arteriovenous malformation with a single drainage vein: technical note.

Cerebral arteriovenous malformations (AVMs) are uncommon. Treatment options include embolization, radiosurgery and surgery, separately or combined, the final goal being complete occlusion of the malformation. We describe the case of a symptomatic small subependymal AVM with a single deep drainage vein previously treated unsuccessfully by radiosurgery and transarterial embolization. The AVM was successfully embolized transvenously using Onyx, achieving complete occlusion in a single treatment session.

Hematoma in the splenium of the corpus callosum in the subacute stage of subarachnoid hemorrhage--three case reports.

Three patients developed hemorrhage in the splenium of the corpus callosum 2 weeks after the onset of subarachnoid hemorrhage (SAH) associated with acute hydrocephalus. Computed tomography performed a few days after the onset showed a low density area in the splenium of corpus callosum in all three patients, and preventive measures against symptomatic vasospasm were begun, including vasodilator administration. Computed tomography showed hemorrhage in the splenium of the corpus callosum 17 to 22 days after onset of SAH, manifesting as mental deterioration or headache. Antivasospasm agents were immediately discontinued, and strict blood control measures were instituted. Splenial hematoma is another potential cause of neurological deterioration after surgery for SAH, in addition to vasospasm, hydrocephalus, and rebleeding.

Extraventricular neurocytoma in a child: case report and review of the literature.

Neurocytomas are relatively rare central nervous system tumors first described in intraventricular sites but increasingly recognized in the brain and spinal cord parenchyma. Herewith, we report a case of a 3-year-old girl with generalized seizures. Computed tomography and magnetic resonance imaging revealed a lesion in the left frontal lobe. Angiography showed minimal vascularity. The tumor was totally excised. Histopathologic examination demonstrated an extraventricular neurocytoma. On follow-up magnetic resonance imaging after 1 year, no evidence of tumor recurrence was noted. Cerebral neurocytomas are histologically low-grade tumors and radical surgery is curative; they should be included in the differential diagnosis of cerebral tumors in children.

Venous cerebral infarction due to simultaneous occurrence of dural arteriovenous fistula and developmental venous anomaly.

A case of a left frontal lobe infarction in a 31-year-old male patient is presented. This patient had bilateral frontal dural arteriovenous fistulae (DAVF) and a left frontal developmental venous anomaly (DVA). It is suggested that the simultaneous occurrence of these vascular anomalies was the cause of his infarction.

Craniopagus: the Suriname-Amsterdam conjunction.

OBJECTS: A case of a Suriname female occipito-parietal to occipito-parieto-temporal craniopagus twins is described. The girls were transferred to the VU University Medical Center (VUmc) in Amsterdam, the Netherlands, for further diagnostics and to analyze whether surgical separation was feasible and ethically justifiable. The multifactorial aspects of different treatment options are discussed. METHODS: The twins underwent multiple investigations by a multidisciplinary team. Advanced imaging techniques with 3D-CT scan, MRI and MRA scans, image fusion techniques and, most importantly, cerebral angiography with balloon occlusion tests were performed. CONCLUSIONS: Because of a shared venous ring, with preferential drainage to the left child, and which endovascular balloon occlusion showed could not be separated, surgical separation of the twins with a fair chance of survival without additional neurological damage and with prospects of a good quality of life was regarded as impossible. In accordance with the parents' wishes, the twins were not separated and offered optimal integral conservative treatment.