Angiographic evaluation of the distance from the top of the jugular bulb to the inferior petrosal sinus-internal jugular vein junction: simple classification and identification method for the orifice of the non-visualized inferior petrosal sinus during neuroendovascular surgery.

BACKGROUND: The inferior petrosal sinus (IPS) is the transvenous access route for neurointerventional surgery that is occasionally undetectable on digital subtraction angiography (DSA) because of blockage by a clot or collapse. This study was aimed at analyzing the distance from the jugular bulb (JB) to the IPS-internal jugular vein (IJV) junction and proposing a new anatomical classification system for the IPS-IJV junction to identify the non-visualized IPS orifice. METHODS: DSA of 708 IPSs of 375 consecutive patients were retrospectively investigated to calculate the distance from the top of the JB to the IPS-IJV junction, and a simple classification system based on this distance was proposed. RESULTS: The median distance from the top of the JB to the IPS-IJV junction was 20.8 ± 14.7 mm. Based on the lower (10.9 mm) and upper (31.1 mm) quartiles, IPS-IJV junction variants were: type I, 0-10 mm (22.3%); type II, 11-30 mm (45.8%); type III, > 31 mm (23.9%); and type IV, no connection to the IJV (8.0%). Bilateral distances showed a positive interrelationship, with a correlation coefficient of 0.86. The bilateral symmetry type (visualized IPSs bilaterally) according to our classification occurred in 267 of 300 (89.0%) patients. CONCLUSIONS: In this study, the IPS-IJV junction was located far from the JB (types II and III), with a higher probability (69.6%). This distance and the four-type classification demonstrated high degrees of homology with the contralateral side. These results would be useful for identifying the non-visualized IPS orifice.

Coexistence of anterior cranial fossa dural arteriovenous fistula and arteriovenous malformation with the same drainage system: illustrative case.

BACKGROUND: The authors report a rare case of coexistence of dural arteriovenous fistula (DAVF) and arteriovenous malformation (AVM), with a common trunk drainer from both DAVF and AVM in the left anterior cranial fossa (ACF) with simple DAVF in the right ACF. OBSERVATIONS: A 63-year-old female presented with seizure. Cerebral angiography showed bilateral DAVFs in the ACF and AVM in the left frontal lobe. A dilated frontal vein acted as a simple drainer of the right DAVF. In contrast, a dilated vein with large varix was the common drainer of both the left DAVF and the AVM. During surgery, indocyanine green videoangiography was performed with direct observation. In the left ACF, the drainer occlusion of the DAVF resulted in partial shrinkage of the varix and decreased distal blood flow. Additional main feeder occlusion of the AVM could decrease the blood flow further, but not completely because of the residual pial supplies for the AVM. Finally, the nidus of the AVM with varix was removed by en bloc resection. LESSONS: Neurosurgeons should be aware of the coexistence of DAVF and AVM with a common trunk drainer. Only simple occlusion of the drainer from DAVF is not sufficient, so removal of the AVM is essential.

[Cerebral Amyloid Angiopathy-related Inflammation Demonstrating Early Venous Filling on Digital Subtraction Angiography:A Case Report].

Cerebral amyloid angiopathy-related inflammation(CAA-RI)is a rare condition thought to be caused by an inflammatory response to amyloid beta(Aß)protein in the walls of the small arteries and capillaries of the cerebral cortex. A 73-year-old female presented with left hemiparesis and dysarthria. Fluid-attenuated inversion recovery(FLAIR)imaging disclosed progressive enlargement of infiltrative white matter abnormalities in the right temporo-occipito-parietal lobes. Interestingly, digital subtraction angiography(DSA)demonstrated early venous filling. Pathological examination of the biopsy specimen demonstrated lymphocytes infiltration surrounding the blood vessels and in the thickened walls with amyloid-beta deposition. The diagnosis given was CAA-RI. The patient was successfully treated with high dose corticosteroids and clinical improvement was associated with shrinkage of the high intensity lesion on FLAIR imaging. Early venous filling resolved on the follow-up DSA. Most patients with CAA-RI can be treated with corticosteroids. However, the clinical condition will worsen without appropriate treatment. Early diagnosis is the key. If an expanding disease of the white matter appears in an elderly patient, we should exclude other cerebrovascular diseases by DSA, followed by biopsy without delay. The present case demonstrated that early venous filling on DSA may appear until inflammation is resolved by the treatment of CAA-RI.

A Case of Subcortical Hemorrhage in the Left Temporal Lobe Caused by Multiple Dural Arteriovenous Fistulas.

Transverse sinus-sigmoid sinus (TS-SS) dural arteriovenous fistula (dAVF) is common type of dAVF, on the other hand, anterior condylar confluence (ACC) dAVF is relatively rare. There has been no report presenting patients with TS-SS dAVF and ACC dAVF identified simultaneously yet. We present a case of TS-SS dAVF and ACC dAVF that developed subcortical hemorrhage of left temporal lobe. A 66-year-old woman with no past history was transferred to our hospital for sudden-onset consciousness disturbance, and was urgently admitted after the detection of a subcortical hemorrhage in the left temporal lobe. We suspected a dAVF based on magnetic resonance angiography and performed digital subtraction angiography (DSA). DSA revealed that the left occipital artery, left ascending pharyngeal artery, left middle meningeal artery, left tentorial artery, and posterior meningeal artery flowed into the TS-SS and ACC. DSA also showed outflow from the TS-SS to the brain surface through the vein of Labbé and the vein of Trolard. We performed transvenous embolization to prevent re-bleeding, she was then discharged from our hospital and her remaining sensory aphasia gradually improved. In the present study, the active investigation to determine the cause of subcortical hemorrhage led to a definitive diagnosis. The combination of ACC dAVF and TS-SS dAVF has not been reported thus far and this is considered a valuable case.

Angiographic Characterization of the External Carotid Artery: Special Attention to Variations in Branching Patterns.

Knowledge of branching patterns of external carotid artery (ECA) is essential for planning and execution of head and neck surgeries. Digital subtraction angiography (DSA) images of 532 ECAs from 302 consecutive patients were retrospectively evaluated. We classify the branch variants of ECA into three types, simply based on the number of branches arising close together. Type A, Type B, and Type C variants are defined as two, three, and four or more branches of ECAs arising at a common point from the proximal ECA, respectively. In this classification, the distal ECA was counted as one branch. Of 532 ECAs, Type A was found in 344 ECAs (64.6%) of 237 patients (78.5%), Type B in 134 ECAs (25.2%) of 110 patients (36.4%), and Type C in 54 ECAs (10.2%) of 49 patients (16.2%). The distance from the common carotid artery (CCA) bifurcation to the first branch of ECA with Type C was 14.7 ± 6.6 mm; its distance is shorter compared with Type A (21.8 ± 15.6 mm) and Type B (20.6 ± 8.9 mm) (P < 0.05). The position of CCA bifurcation with Type C was detected at the third-fourth junction cervical vertebral level or higher in 52 of 54 ECAs (96.3%), significantly higher than those of the other types (P < 0.05). In conclusion, Type C ECA has aggregated vessels with short distance from CCA and high position of CCA bifurcation. Type C ECA is not uncommon; thus, special consideration should be paid to avoid complications during surgeries.

Contrast stasis in large and giant internal carotid artery aneurysms as a good prognostic factor for endovascular coil embolization: retrospective study.

OBJECTIVE: Before treatment for large and giant aneurysms, we need some of the predictors to prognose a good result. In this retrospective study, we attempted to determine criteria such as angiographic signs to identify good candidates for effective endovascular surgery. METHODS: This study involved 45 patients with large or giant aneurysms treated by endovascular embolization. For angiographic study, we delivered a bolus injection of contrast medium. All aneurysms were confirmed angiographically and the morphology was defined in detail before endovascular embolization. We divided the patients into two groups based on angiographic findings. Group A (n=16) manifested stasis of the contrast medium in the aneurysm on venous phase. Group B (n=29) exhibited other findings. We retrospectively evaluated the relationship between stasis of the contrast medium in the aneurysm and results of endovascular embolization. RESULTS AND DISCUSSION: There was no significant difference between the two groups with respect to the size of the aneurysm. However, the neck/dome ratio (P=0·04) and size of the neck (P=0·003) were significantly different between groups A and B. The morphological outcome was better in group A than group B (P=0·03). We demonstrate that contrast stasis is a good predictor of outcome in patients with large or giant aneurysms to consider the endovascular embolization. Hemodynamic studies on large patient populations may reveal other factors predictive of a good treatment outcome.

Dural arteriovenous fistulas in the cavernous sinus: clinical research and treatment.

Introduction. The purpose of this paper is to clarify the clinical course, with the dural carotid cavernous fistula (CCF), featuring a pallet of symptoms, paying special attention to radiological findings. Methods. Seventy-six consecutive patients with dural CCFs were investigated in detail, all of whom were defined by angiography. Results. The most common initial symptom was diplopia in 47 patients (62%) and the most frequently observed on arrival were type II, featuring cranial nerve palsies followed by the classical triad in 27, and then type I only with cranial nerve palsies. The time until admission with type I (mean: 6.7 W ± 6.0) was significantly shorter than that with type II (mean: 25.1 W ± 23.5). Branches from bilateral carotid arteries widely inflowing into bilateral carotid cavernous sinus were present in 30 (39%), 20 (26%) of which also demonstrated direct inflow into the intercavernous sinus. type I and II had more multiple venous drainage routes as compared with type III (classical triad only on arrival) and IV (initial development of the classical triad followed by cranial nerve palsy). Conclusion. In our series of dural CCF patients, the most common initial symptom was cranial nerve palsy, mostly featuring multiple venous drainage including cortical drainage. Such palsies should be added to the classical triad as indicative symptoms. Bilateral carotid arteries often inflow into cavernous and intercavernous sinuses, which should be taken into account in choice of therapeutic strategy.

Efficacy of a direct puncture approach for anterior circulation aneurysms using a newly developed guiding catheter - especially for geriatric patients.

BACKGROUND: Endovascular surgery is being increasingly used as an alternative to craniotomy clipping surgery, especially for aged patients and complicated cases. However, tortuous atherosclerotic arteries sometimes interfere with advancement of catheters so that direct puncture may be necessary. Short guiding catheters for use with this approach have been newly developed, as discussed in this article. METHODS: One hundred twenty three anterior circulation aneurysms in 121 patients were consecutively treated by endovascular coil embolization, of which 42 (34%) were older than 70 years. RESULTS: With 21 aneurysms, coil embolization via the transfemoral approach failed, but all could be successfully treated with the direct puncture approach with minor complications such as 1 transient ischemic attack and 1 nonsymptomatic minor leakage. In the aged patients, the direct puncture approach with short guiding catheter resulted in complete obliteration of aneurysms in 20 (71%) of 28 with follow-up angiography. CONCLUSION: Direct puncture using newly developed short guiding catheters is an alternative to femoral approaches for patients with anterior circulation aneurysm with tortuous arteries and obvious atherosclerotic change at bifurcations of the common carotid artery.

Endovascular surgery for very small ruptured intracranial aneurysms. Technical note.

Application of endovascular surgery for very small aneurysms is controversial because of technical difficulties and high complication rates. The aim in the present study was to assess treatment results in a series of such lesions at one institution. Since 1997, endovascular surgery has been advocated for very small ruptured aneurysms (< 3 mm in maximum diameter) that fulfill the criterion of a fundus/neck ratio greater than 1.5. Twenty-one patients were treated, for whom the World Federation of Neurosurgical Societies classification before treatment was Grade I in 10, Grade II in two, Grade III in two, Grade IV in five, and Grade V in two. The aneurysm location was the internal carotid artery in four, the anterior communicating artery in 11, the middle cerebral artery in one, and the vertebrobasilar system in five. In all patients, endovascular surgery was performed using Guglielmi detachable coils after induction of general anesthesia. Initially, the presumed volume of the lesions was calculated for each aneurysm. Thereafter, the appropriate coil length was decided according to the volume embolization ratio, as 30 to 40%. In all attempts to obliterate aneurysms a single coil was used. All aneurysms were completely obliterated as confirmed by postembolization angiography, without procedure-related complications. During the follow-up period only one patient needed additional coil embolization for a growing aneurysm. Final outcomes were good recovery in 15 patients, moderate disability in five, and severe disability in one. Appropriate selection of patients and coils, and use of sophisticated techniques allow a good outcome for patients with very small aneurysms.