Angiographically occult spinal dural arteriovenous fistula diagnosed by exploratory surgery with intraoperative ultrasound: illustrative case.

BACKGROUND: A 78-year-old male presented with progressive myelopathic symptoms. The clinical course and imaging findings raised a high suspicion for venous hypertensive myelopathy due to a spinal dural arteriovenous fistula (SDAVF). OBSERVATIONS: Magnetic resonance angiography and four complete spinal angiograms did not reveal the presence of an SDAVF. Despite multiple negative angiograms, intraoperative ultrasound revealed abnormal cord edema and arterialized pulsatile vessels, confirming the presence of an SDAVF. The fistula was found and cauterized, which resulted in a decrease in the caliber of the dilated veins and an observed reduction of spinal cord stiffness posttreatment. The patient exhibited gradual improvement in neurological function. Retrospective analysis of the multiple complete spinal angiograms failed to reveal an anomaly at the treated level or any other level. LESSONS: This case underscores the diagnostic utility of intraoperative Doppler ultrasound and the importance of maintaining a high index of suspicion for SDAVF in cases with consistent clinical characteristics and a lack of alternative diagnoses, even with negative spinal angiography. https://thejns.org/doi/10.3171/CASE24438.

Early depiction of anterior spinal arteries and veins in André du Laurens's Historia anatomica humani corporis (1600).

Scholars usually consider the Historia anatomica corporis humani, published in 1600 by André du Laurens, as an obsolete defense of Galenic principles against the novelty of Vesalian material. Although du Laurens's book plagiarized many illustrations from Vesalius's De humani corporis fabrica (1543), critics such as Choulant insisted that the Historia's iconography had "no particular anatomical or artistic value." However, four of the Historia's engravings appear to be original. One of these, the Tabula hæc veram spinalis medullae et nervorum ab ea prodeuntium effigiem exprimit, is now famous for depicting the intradural spinal nerves as a horsetail, leading to the addition of the term cauda equina to the anatomical lexicon. A less flamboyant figure from the same plate shows small blood vessels coursing over the surface of the cervical spinal cord. This drawing may be the first published depiction of anterior spinal arteries and veins.

Normal, accessory, and aberrant branches of the common iliac artery: angiographic prevalence and clinical implications.

PURPOSE: Catheter angiography remains essential to detect, characterize, and treat many vascular, traumatic, and neoplastic conditions affecting the pelvis, but the angiographic literature rarely mentions the common iliac artery (CIA) and its branches. The "normal" branches of the CIA principally consist of subangiographic rami supplying neighboring structures. Larger branches participate in the vascularization of the psoas muscle and the ureter. Less often, the CIA provides anomalous branches that complement or replace critical neighboring vessels. This study investigates the prevalence, type, and clinical relevance of CIA branches detectable during pelvic angiography. METHODS: This study analyzes the prevalence of CIA branches in 100 consecutive angiograms that included bilateral CIA injections as well as selective catheterizations of the median sacral artery, both L4 ISAs, and both internal iliac arteries. CIA branches were classified as normal (i.e., neither supplementing nor replacing a normal artery), accessory (i.e., supplementing a normal artery), or aberrant (i.e., replacing a normal artery). RESULTS: Forty-three branches arose from 38 CIAs (19% of CIAs) in 30 patients (30% of patients), including 20 normal branches (46.5%), 21 aberrant branches (48.8%), and 2 accessory branches (4.7%). Each of the 15 patients with aberrant branches had at least one anomalous vessel capable of providing a radicular or radiculomedullary artery. CONCLUSIONS: CIA branches were present in 30% of patients undergoing spinal angiography. While most normal branches were diminutive and clinically irrelevant, CIAs also provided vessels able to vascularize pelvic and vertebral structures, including the spinal cord or a spinal vascular malformation in 16% of cases. Our study therefore confirms that CIA injections represent an essential component of pelvic and spinal angiography.

Vertebral arteria lusoria-Hyrtl's original description (1859), case illustration, and literature analysis.

PURPOSE: A translation of the initial observation of vertebral arteria lusoria reported by Hyrtl in 1859 is followed by a review of all cases published until May 2023 to identify the anatomical and clinical features characterizing the typical form of this rare variant. METHODS: PubMed, Google Scholar, and Google queries were performed with "vertebral arteria lusoria", "retroesophageal vertebral artery", and "aberrant vertebral artery" as keywords (in English, German, and French). A feature was considered typical when present in at least 75% of analyzed cases. A case of incidentally discovered vertebral arteria lusoria illustrates the typical form of the variant. RESULTS: The analysis of 56 publications yielded 66 observations of right-sided vertebral arteria lusoria published between 1859 and May 2023. A small caliber, a retro-esophageal location, and passage through the foramen transversarium of C7 were typical. There was no evidence of association with clinical symptoms or other cardiovascular anomalies. CONCLUSION: A typical vertebral arteria lusoria is an incidentally discovered nondominant aberrant right VA originating from the proximal descending aorta and following a retro-esophageal course to enter the C7 foramen transversarium, without associated aortic arch branching anomalies or congenital cardiovascular pathologies.

Role of digital subtraction angiography in acute cervical spinal cord ischemia.

Ascertaining the etiology of cervical spinal cord dysfunction presents a challenge to clinicians, as the list of differential diagnoses is extensive. Although compressive and inflammatory disorders are common and should be considered immediately, vascular causes are similarly important and acute. The overlap of clinical, magnetic resonance imaging, and cerebrospinal fluid features among the causes of myelopathies may lead to erroneous diagnoses. Such errors may be compounded if routine vascular imaging does not reveal the underlying vasculopathy. We present here three cases in which computed tomography angiography and magnetic resonance angiogram could not clarify the nature of an acute myelopathy, whereas digital subtraction angiography established the diagnosis of spinal cord ischemia.

Longitudinal Pulse-Synchronous Bouncing During Catheter Angiography-A Phenomenon Specific to Spinal Hemangioblastomas.

BACKGROUND: Spinal hemangioblastomas are often evaluated with catheter angiography for both workup and treatment planning. We report a unique longitudinal pulse-synchronous bouncing phenomenon observed during their angiographic evaluation and consider the association of pulse-synchronous bouncing with syringomyelia, another pathologic feature associated with hemangioblastomas. METHODS: Preoperative spinal angiograms and associated magnetic resonance imagings (MRIs) obtained over a 16-year period at a single institution were retrospectively evaluated. Magnetic resonance imaging (MRI) parameters included lesion and syrinx location and size. Angiograms were evaluated for bouncing phenomena. Student's t-test and Chi square test compared characteristics between groups. Linear regression analyses evaluated maximum amplitude of dynamic motion and any associated syrinx. RESULTS: Nineteen hemangioblastoma patients had preoperative angiograms available for review. Eight exhibited bouncing behavior. Between the dynamic and nondynamic cohorts, there was no difference in presence or volume of syrinxes. Lesions in the dynamic cohort trended towards a cervical location (75% vs. 36.3%, P = 0.10). No significant correlation was found between bouncing amplitude and syrinx size (R2 = 0.023). Dural contact may be related to this dynamic behavior since other high-flow lesions like AVMs do not demonstrate this phenomenon, and AVMs are pial-based and more likely to contact stationary dura. Here, there were fewer lesions abutting the thecal sac in the dynamic cohort (50% vs. 81.8%, P = 0.14). CONCLUSIONS: Though no significant relationship was established between this bouncing behavior and syrinx formation, noted trends included a greater range of motion for cervical lesions and limited motion in tumors abutting the thecal sac.

Clinically Asymptomatic Hemorrhagic Conversion Is Associated with Need for Inpatient Rehabilitation After Mechanical Thrombectomy for Anterior Circulation Ischemic Stroke.

BACKGROUND: Hemorrhagic conversion (HC) is a known complication after acute ischemic stroke (AIS) in patients undergoing mechanical thrombectomy (MT). Although symptomatic HC has been shown to lead to poor neurologic outcomes, the effect of asymptomatic HC (aHC) is unclear. This study aims to identify predictors of aHC and to determine the short-term outcomes. METHODS: This is a single-institution retrospective study of patients with anterior circulation stroke (AIS) who underwent MT between January 2016 and September 2022. Radiographic HC was identified on postoperative imaging. Asymptomatic hemorrhage was defined as no acute neurologic decline attributable to imaging findings. Baseline characteristics, technical aspects, and outcomes were compared between aHC and no-HC groups. Logistic regression and multivariate analysis were performed. RESULTS: A total of 615 patients underwent MT for AIS, of whom 496 met the inclusion criteria. A total of 235 patients (47.4%) had evidence of aHC. Diabetes mellitus (odds ratio [OR], 1.59; 95% confidence interval [CI], 1.06-2.41; P = 0.03), hyperglycemia (OR, 1.01; 95% CI, 1.00-1.01; P = 0.002), greater number of passes (OR, 1.14; 95% CI, 1.00-1.31; P = 0.05), and longer time to reperfusion (OR, 1.02; 95% CI, 1.00-1.05; P = 0.05) were associated with aHC. Patients with aHC were significantly more likely to require rehabilitation, whereas those without HC were more likely to be discharged home (P < 0.001). There were no significant differences in long-term outcomes. CONCLUSIONS: HC occurred in up to half of patients who underwent MT for AIS, most of whom were clinically asymptomatic. Despite clinical stability, aHC was significantly associated with a greater need for inpatient rehabilitation. Predictors of aHC included hyperglycemia and a longer time to reperfusion.

Cervical anterior spinal artery infarction associated with anomalous vertebral artery: a case report.

We report a unique case of cervical anterior spinal artery (ASA) infarction in a 49-year-old male with hypercholesterolemia and sleep apnea. The patient experienced sudden cervical pain, quadriparesis, areflexia, and urinary incontinence after swallowing a large food bolus. Imaging revealed an infarction at the C3-C5 levels and an anomalous right vertebral artery (VA) originating from the thoracic aorta, tightly enclosed between the aorta and a vertebral column with an anterior osteophyte. This aberrant VA was the primary vascular supply to the ASA, with no contribution from the left VA or supreme intercostal arteries. We propose that transient injury to the right VA, induced by compression between the aortic arch, the food bolus, and the osteophyte, led to temporary hypoperfusion of the ASA, causing a watershed ischemic injury in the mid cervical cord's anterior gray matter. The article also provides an in-depth discussion of the developmental and clinical characteristics associated with this rare vascular anomaly.

Bilateral Dilated Superior Ophthalmic Veins in a Patient With an Arteriovenous Dialysis Fistula.

A 64-year-old man presented with 4 months of diplopia. He had end-stage renal disease requiring a cephalic transposition brachiocephalic fistula that was no longer in use following successful renal transplantation. On presentation, he had bilateral proptosis, extraocular movement restriction, chemosis, tortuous episcleral vessels, and caruncular injection. Non-contrast CT of the orbits demonstrated dilation of both superior ophthalmic veins, and CT angiography showed asymmetric enlargement of both cavernous sinuses and superior ophthalmic veins. A carotid-cavernous fistula was suspected, but cerebral angiography revealed shunting from the old fistula with intracranial drainage and cerebral venous hypertension. Aberrant retrograde drainage resulted from anatomical compression of the left brachiocephalic vein. The fistula was ligated, and at 1-week follow-up, the patient had marked improvement in extraocular movements and orbital congestion with near complete resolution of diplopia. Postoperative CT angiography obtained 2 months later demonstrated decreased size of both superior ophthalmic veins, consistent with improvement of venous hypertension.

Two pediatric observations of spinal extradural arteriovenous fistulas presenting with epidural hemorrhages and cord compression.

We report two cases of acute spinal cord compression in children with low-flow spinal epidural arteriovenous fistulas (SEAVFs) and discuss the clinical presentation and management of these vascular anomalies. While most low-flow SEAVFs without radiculomedullary drainage are benign lesions typically diagnosed incidentally, we suggest that asymptomatic lesions may warrant aggressive management in specific circumstances, including lesions diagnosed at an early age or in patients under anticoagulation therapy. Our observations also emphasize that patients with a "spontaneous" epidural hemorrhage should undergo dedicated preoperative or postoperative vascular imaging to identify a possible underlying vascular anomaly.

Racial disparities in functional outcomes following mechanical thrombectomy in a cohort of patients with ischemic stroke.

BACKGROUND: Non-Hispanic Black (NHB) patients experience increased prevalence of stroke risk factors and stroke incidence compared with non-Hispanic White (NHW) patients. However, little is known about >90-day post-stroke functional outcomes following mechanical thrombectomy. OBJECTIVE: To describe patient characteristics, evaluate stroke risk factors, and analyze the adjusted impact of race on long-term functional outcomes to better identify and limit sources of disparity in post-stroke care. METHODS: We retrospectively reviewed 326 patients with ischemic stroke who underwent thrombectomy at two centers between 2019 and 2022. Race was self-reported as NHB, NHW, or non-Hispanic Other. Stroke risk factors, insurance status, procedural parameters, and post-stroke functional outcomes were collected. Good outcomes were defined as modified Rankin Scale score ≤2 and/or discharge disposition to home/self-care. To assess the impact of race on outcomes at 3-, 6-, and 12-months' follow-up, we performed univariate and multivariate logistic regression. RESULTS: Patients self-identified as NHB (42%), NHW (53%), or Other (5%). 177 (54.3%) patients were female; the median (IQR) age was 67.5 (59-77) years. The median (IQR) National Institutes of Health Stroke Scale score was 15 (10-20). On univariate analysis, NHB patients were more likely to have poor short- and long-term functional outcomes, which persisted on multivariate analysis as significant at 3 and 6 months but not at 12 months (3 months: OR=2.115, P=0.04; 6 months: OR=2.423, P=0.048; 12 months: OR=2.187, P=0.15). NHB patients were also more likely to be discharged to rehabilitation or hospice/death than NHW patients after adjusting for confounders (OR=1.940, P=0.04). CONCLUSIONS: NHB patients undergoing thrombectomy for ischemic stroke experience worse 3- and 6-month functional outcomes than NHW patients after adjusting for confounders. Interestingly, this disparity was not detected at 12 months. Future research should focus on identifying social determinants in the short-term post-stroke recovery period to improve parity in stroke care.

Classification and Management Considerations for Intraosseous Dural Arteriovenous Fistulae.

BACKGROUND: Intraosseous dural arteriovenous fistulas (IODAVFs) are rare DAVFs that communicate with marrow. Given their infrequency, common nomenclature is nonexistent. Patients may present with benign symptoms, such as tinnitus, or venous hypertension symptoms including hemorrhage depending on the venous outflow pattern. OBJECTIVE: To describe all available cases of IODAVF in the literature, in addition to our cases, to better define presentation, and treatment outcomes. To advance a classification system to develop common language for these lesions for clinicians and researchers. METHODS: Neurointerventional procedure logs at 2 high-volume neurovascular centers were reviewed for all cases of IODAVFs, as was the English-based literature available in PubMed. The angioarchitecture, symptoms, management, and demographics were reviewed and summarized. RESULTS: Four institutional cases were identified, 2 of which had shunting within the marrow (clival or petrous), with venous drainage toward the heart. One case involved the dorsum sella with drainage into the superior petrosal sinus with reflux into the anterior and posterior spinal venous plexuses, and one involved the left petroclival junction, resulting in communication with the cavernous sinus with retrograde drainage into the superior ophthalmic veins. Two patients were managed by observation, one was treated with radiosurgery and one with microsurgical skeletonization. Twenty additional cases from the literature are summarized. CONCLUSION: IODAVFs of the cerebrocranial vasculature may present incidentally, with tinnitus, or with symptoms related to mass effect or venous hypertension. We propose a classification which accounts for drainage patterns. Further study is needed for these rare lesions.

Tracheobronchial arterial variants of vertebral artery origin and bronchovertebral arterial anastomoses.

PURPOSE: This report describes a series of angiographic observations of tracheobronchial arterial variants and discusses their clinical implications. METHODS: The angiographic features of eleven aberrant tracheal or bronchial arteries are reported, including four variants originating from the vertebral artery and two cases of bronchovertebral anastomosis. An additional observation of thyrothymic artery illustrates the discussion of the mechanisms involved in the development of these variants. RESULTS: Tracheobronchial arterial variants are predominantly left-sided variants (9 out of 11). They are linked to dominant paratracheal arterial connections, particularly the lateral longitudinal anastomosis. Unusual bronchial arteries of vertebral origin show a strong association with aberrant left vertebral arteries of aortic or proximal subclavian origin. CONCLUSION: This report presents a spectrum of tracheo-broncho-vertebral variations and emphasizes the role of previously described paratracheal arterial anastomoses in their formation. These variants can play a critical role during hemoptysis embolotherapy, either as an occult source of hemorrhage or as a risk factor for devastating complications.

The segmentation of the vertebral artery: An ambiguous anatomical concept.

The course of the vertebral artery from its subclavian artery origin up to its termination at the vertebrobasilar junction is divided into four segments (V1-V4). This segmentation, based on schemes that have evolved since the late nineteenth century, should be a consistent and reproducible anatomical concept. However, the current literature offers conflicting definitions of that scheme, not infrequently within a single article or monograph. The principal inconsistency found in modern publications concerns the termination of the V2 segment, which is either set at the C2 or C1 transverse foramen depending on the scheme considered. Consequently, the portion of the vertebral artery extending between C2 and C1-a frequent site of pathological involvement-either belongs to the V2 or V3 segment. This discrepancy can affect the validity of studies evaluating the diagnosis and management of vertebral artery disorders. A V3 segment extending from the transverse foramen of C2 to the posterior atlanto-occipital membrane and subdivided into vertical, horizontal, and oblique subsegments-a pattern suggested by Barbieri in 1867 and adopted in some modern publications-would provide a simple, precise, and reliable solution without significantly altering the widely accepted division of the vertebral artery into four segments (V1-V4).

Epidemiology and outcomes of pediatric intracranial aneurysms: comparison with an adult population in a 30-year, prospective database.

OBJECTIVE: Pediatric intracranial aneurysms are rare. Most large series in the last 15 years reported on an average of only 39 patients. The authors sought to report their institutional experience with pediatric intracranial aneurysms from 1991 to 2021 and to compare pediatric patient and aneurysm characteristics with those of a contemporaneous adult cohort. METHODS: Pediatric (≤ 18 years of age) and adult patients with one or more intracranial aneurysms were identified in a prospective database. Standard epidemiological features and outcomes of each pediatric patient were retrospectively recorded. These results were compared with those of adult aneurysm patients managed at a single institution over the same time period. RESULTS: From a total of 4500 patients with 5150 intracranial aneurysms admitted over 30 years, there were 47 children with 53 aneurysms and 4453 adults with 5097 aneurysms; 53.2% of children and 36.4% of adults presented with a subarachnoid hemorrhage (SAH). Pediatric aneurysms were significantly more common in males, more likely giant (≥ 25 mm), and most frequently located in the middle cerebral artery. Overall, 85.1% of the pediatric patients had a modified Rankin Scale score ≤ 2 at the last follow-up (with a mean follow-up of 65.9 months), and the pediatric mortality rate was 10.6%; all 5 patients who died had an SAH. The recurrence rate of treated aneurysms was 6.7% (1/15) in the endovascular group but 0% (0/31) in the microsurgical group. No de novo aneurysms occurred in children (mean follow-up 5.5 years). CONCLUSIONS: Pediatric intracranial aneurysms are significantly different from adult aneurysms in terms of sex, presentation, location, size, and outcomes. Future prospective studies will better characterize long-term aneurysm recurrence, rebleeds, and de novo aneurysm occurrences. The authors currently favor microsurgical over endovascular treatment for pediatric aneurysms.

Endovascular therapy for acute stroke in children: age and size technical limitations.

Endovascular therapies for acute childhood stroke remain controversial and little evidence exists to determine the minimum age and size cut-off for thrombectomy in children. Despite this, an increasing number of reports suggest feasibility of thrombectomy in at least some children by experienced operators. When compared with adults, technical modifications may be necessary in children owing to differences in vessel sizes, tolerance of blood loss, safety of contrast and radiation exposure, and differing stroke etiologies. We review critical considerations for neurologists and neurointerventionalists when treating pediatric stroke with endovascular therapies. We discuss technical factors that may limit feasibility of endovascular therapy, including size of the femoral and cervicocerebral arteries, which contributes to vasospasm risk. The risk of femoral vasospasm can be assessed by comparing catheter outer diameter with estimated femoral artery size, which can be estimated based on the child's height. We review evidence supporting specific strategies to mitigate cervicocerebral arterial injury, including technique (stent retrieval vs direct aspiration) and device size selection. The importance of and strategies for minimizing blood loss, radiation exposure, and contrast administration are reviewed. Attention to these technical limitations is critical to delivering the safest possible care when thrombectomy is being considered for children with acute stroke.

Report of a spinal extradural arteriovenous fistula with double radiculomedullary venous drainage: therapeutic implications and role of intraoperative spinal angiography.

Low-flow spinal extradural arteriovenous fistulas (SEAVFs) are frequently misdiagnosed as spinal dural arteriovenous fistulas (SDAVFs), and their true prevalence is unknown. The principal feature distinguishing low-flow SEAVFs from SDAVFs is the location of the shunt, which involves a pouch of epidural plexus in SEAVFs and a radiculomedullary vein (RMV) in SDAVFs. A venous hypertensive myelopathy comparable to the one observed with SDAVFs develops when the arterialized venous pouch of an SEAVF is connected to an RMV. Depending on the size of the epidural pouch, a low-flow SEAVF may uncommonly drain into multiple RMVs. The authors present an observation of a low-flow SEAVF whose double radiculomedullary drainage was revealed only after intraoperative digital subtraction angiography, and they discuss the surgical implications of this anatomical configuration.