Carotid cavernous fistula: A rare but treatable cause of ophthalmoplegia - A case report.

Carotid cavernous fistulas (CCFs) are a rare but debilitating entity that may present with orbital or cerebral venous hypertension. CCFs may pose diagnostic and management pitfalls for clinicians as they can initially be misdiagnosed as primary orbital pathology or nonarteriovenous shunting-related cavernous sinus pathology. Furthermore, the resolution of pulsatile tinnitus could be an ominous sign in patients with untreated dural arteriovenous fistula. We describe a case of a 56-year-old male who presented with progressive right eye proptosis, congestion, decreased visual acuity, limited duction, exophthalmos, and pulsatile tinnitus. The patient had poor response to antibiotics and steroids. Magnetic resonance imaging brain showed significant inflammation involving the right orbit and atypical enhancement of the basal frontal lobe adjacent to the orbit. Cerebral angiography revealed an indirect right CCF and right sigmoid sinus thrombosis with stenosis of the right internal jugular vein. No clear predisposing factor was identified. Given the rapidly progressive nature of the condition, the patient successfully underwent endovascular treatment with transvenous approach to preserve flow in the internal carotid artery while ensuring occlusion of the fistula. A triad of proptosis, eye congestion, and signs of turbulent flow such as tinnitus or orbital bruit should raise suspicion for CCF. An interesting feature in this patient is that CCF may have occurred secondary to sigmoid sinus thrombosis with accompanying small cortical vein drainage. Our case highlights the importance of early recognition and timely intervention to ensure the resolution of orbital hypertension-related symptoms in rare cases of CCFs.

Outcomes of Particle versus Liquid Embolic Materials Used in Middle Meningeal Artery Embolization for the Treatment of Chronic Subdural Hematoma.

BACKGROUND: Early evidence suggests that middle meningeal artery (MMA) embolization is an efficacious minimally invasive neuroendovascular technique for the management of chronic subdural hematoma (cSDH). Particle and liquid embolic materials are commonly used to embolize the MMA; however, studies comparing the safety and outcomes between these 2 materials are limited. METHODS: Patients ≥18 years old who had MMA embolization for cSDH between July 15, 2020 and May 1, 2022 were retrospectively identified from a single-center database. The primary safety, radiation dosage, fluoroscopy time, and radiographic and clinical outcomes were compared between particle and liquid embolization. RESULTS: In a cohort of 116, 48 (41.38%) were treated with liquid embolic material and 68 (58.62%) were treated with particle. The median age of the cohort was 73 years in the particle group and 73.5 years in the liquid embolic group. There was no significant difference in radiation dose or duration among both groups. There was no reported mortality associated with the procedure. One patient experienced nondisabling ischemic stroke in the particle group. Based on imaging follow-up, 3 patients in the particle group and 1 in the liquid embolic group had asymptomatic recurrence. One patient in each group had symptomatic recurrence requiring hematoma evacuation. The index median size of hematoma was 12 mm in the particle group and 11 mm in the liquid embolic group. At approximately 1 month follow-up, the median size of hematoma reduced to 6 mm in both groups. CONCLUSIONS: Our series shows that liquid embolic and particle embolization are equally safe and effective among patients undergoing MMA embolization for management of cSDH.

Use of reverse angle guide catheter with trans-radial approach in patients undergoing middle meningeal artery embolization.

Background: Trans-radial access (TRA) for MMA embolization has grown due to lower access site complications and greater patient satisfaction. Here, we describe the feasibility of utilizing a 6F Envoy Simmons 2 (6F-SIM2) as a guide catheter with TRA and compare outcomes with trans-femoral approach (TFA) in a single center case series. Methods: We performed a retrospective review of patients who underwent MMA embolization for management of chronic subdural hematoma (cSDH). TRA was performed by utilizing a combination of 6F 90cm Envoy (Codman & Shurtleff, Inc., Rayham, MA) Simmons 2 guide catheter and 5F 125cm Sofia (Microvention, Aliso Viejo, CA) intermediate catheter. Outcomes measured are Modified Rankin Score (mRS) at 90 days, inpatient mortality, post-embolization recurrence, fluoroscopy time and radiation exposure. Results: A total of 71 patients underwent 97 MMA embolization overall with 65 (67%) in trans-femoral access group, 11 (11.3%) in trans-radial access without use of Simmons 2 Guide catheter group and 21 (21.6%) in trans-radial access with use of Simmons 2 Guide catheter group. There were no direct access-related complications in either group. One patient had thromboembolic stroke in trans-femoral group. There was no difference in average procedure-related total fluro time or radiation dose among all three groups. Conclusion: Trans-radial approach using 6F-SIM2 guide catheter coupled with 5F Sofia intermediate catheter is safe and effective. It provides an alternative approach to access distal branches of bilateral anterior circulation in elderly patients with difficult anatomy undergoing MMA embolization.

Angiographic warning of hemorrhagic transformation after stent retriever thrombectomy procedure.

This study reports cerebral angiographic findings observed after stent retriever thrombectomy that is suggestive of a higher risk of hemorrhagic transformation (HT). A woman aged 65-75 presented with a right middle cerebral artery syndrome confirmed by non-contrast CT brain scan. Endovascular revascularization using the Solitaire device was placed across the thromboembolic occlusion and thromboembolectomy was performed. Angiography showed complete recanalization of the left internal carotid artery, anterior and middle cerebral artery branches. Twelve hours following the procedure the patient had a hemorrhagic conversion of the ischemic infarct with significant mass effect causing herniation. Despite surgical intervention (hemicraniectomy) the patient died. The angiographic features following revascularization of the vessels distal to the occlusion showed subtle dilations which were visualized at the branch points of the vessels. This may be a warning sign of increased risk of HT.

Angiographic warning of hemorrhagic transformation after stent retriever thrombectomy procedure.

This study reports cerebral angiographic findings observed after stent retriever thrombectomy that is suggestive of a higher risk of hemorrhagic transformation (HT). A woman aged 65-75 presented with a right middle cerebral artery syndrome confirmed by non-contrast CT brain scan. Endovascular revascularization using the Solitaire device was placed across the thromboembolic occlusion and thromboembolectomy was performed. Angiography showed complete recanalization of the left internal carotid artery, anterior and middle cerebral artery branches. Twelve hours following the procedure the patient had a hemorrhagic conversion of the ischemic infarct with significant mass effect causing herniation. Despite surgical intervention (hemicraniectomy) the patient died. The angiographic features following revascularization of the vessels distal to the occlusion showed subtle dilations which were visualized at the branch points of the vessels. This may be a warning sign of increased risk of HT.

Endovascular management of arteriovenous malformations of the brain.

Arteriovenous malformations (AVMs) of the brain are rare, complex, vascular lesions that can result in significant morbidity and mortality. Modern treatment of brain AVMs is a multimodality endeavor, requiring a multidisciplinary team with expertise in cerebrovascular neurosurgery, endovascular intervention, and radiation therapy in order to provide all therapeutic options and determine the most appropriate treatment regimen depending on patient characteristics and AVM morphology. Current therapeutic options include microsurgical resection, radiosurgery (focused radiation), and endovascular embolization. Endovascular embolization is primarily used as a preoperative adjuvant before microsurgery or radiosurgery. Palliative embolization has been used successfully to reduce the risk of hemorrhage, alleviate clinical symptoms, and preserve or improve neurological function in inoperable or nonradiosurgical AVMs. Less frequently, embolization is used as 'primary therapy' particularly for smaller, surgically difficult lesions. Current embolic agents used to treat brain AVMs include both solid and liquid agents. Liquid agents including N-butyl cyanoacrylate and Onyx are the most commonly used agents. As newer embolic agents become available and as microcatheter technology improves, the role of endovascular treatment for brain AVMs will likely expand.

Bioaugmenting anaerobic digestion of biosolids with selected strains of Bacillus, Pseudomonas, and Actinomycetes species for increased methanogenesis and odor control.

The objective of this study was to evaluate the effects of bioaugmenting anaerobic biosolids digestion with a commercial product containing selected strains of bacteria from genera Bacillus, Pseudomonas, and Actinomycetes, along with ancillary organic compounds containing various micronutrients. Specifically, the effects of the bioaugment in terms of volatile solids destruction and generation and fate of odor-causing compounds during anaerobic digestion and during storage of the digested biosolids were studied. Two bench-scale anaerobic digesters receiving primary and secondary clarifier biosolids from various full-scale biological wastewater treatment plants were operated. One of the digesters received the bioaugment developed by Organica Biotech, while the other was operated as control. The bioaugmented digester generated 29% more net CH(4) during the 8 weeks of operation. In addition, the average residual propionic acid concentration in the bioaugmented digester was 54% of that in the control. The monitoring of two organic sulfide compounds, methyl mercaptan (CH(3)SH) and dimethyl sulfide (CH(3)SCH(3)), clearly demonstrated the beneficial effects of the bioaugmentation in terms of odor control. The biosolids digested in the bioaugmented digester generated a negligible amount of CH(3)SH during 10 days of post-digestion storage, while CH(3)SH concentration in the control reached nearly 300 ppm(v) during the same period. Similarly, peak CH(3)SCH(3) generated by stored biosolids from the bioaugmented digester was only 37% of that from the control.

Craniovertebral instability with spinal cord compression in a 17-month-old boy with Sly syndrome (mucopolysaccharidosis type VII): a surgical dilemma.

STUDY DESIGN: A case study with review of surgical technique in craniovertebral stabilization for young children with mucopolysaccharidosis. OBJECTIVES: To describe an interesting patient with a rare metabolic disorder and review surgical technique for craniovertebral instability in this rare patient population. SUMMARY OF BACKGROUND DATA: Craniovertebral instability has been reported in patients with mucopolysaccharidosis and poses a problem for spinal surgery because of the inherent metabolic disorder and age at presentation. We present the first case of craniovertebral instability and spinal cord compression occurring in Sly syndrome (mucopolysaccharidosis type VII) who is the youngest patient afflicted with this metabolic disorder to undergo craniovertebral stabilization. METHODS: A 17-month-old boy presented with inability to support his head, decreasing muscle strength in all extremities, distended abdomen, and shortness of breath. The patient was found to have a dilated cardiomyopathy, hepatosplenomegaly, abnormal hepatobiliary function, corneal clouding, and a questionable tracheal anomaly. Genetic testing provided a diagnosis of Sly syndrome, mucopolysaccharidosis type VII. Magnetic resonance imaging revealed focal stenosis with significant spinal cord compression at the craniovertebral junction. Neurologic examination revealed normal muscle volume with strength 3/5 in all extremities and significant weakness in the neck muscles with instability at the craniovertebral junction. RESULTS: On a concerted preoperative medical clearance by pediatric intensive care, pediatric neuroanesthesia, pediatric cardiology, pediatric gastroenterology, and pediatric neurosurgery, the patient underwent occipital to C3 decompression and fusion with autogenous rib grafts. The patient was placed in a prefitted halo-vest after surgery and was neurologically intact. CONCLUSIONS: This case demonstrates the heterogeneity of cervical spine deformities among the mucopolysaccharidosis syndromes and confirms the propensity for deposition of glycosaminoglycans at the craniovertebral junction. Further studies should investigate the etiology for this propensity of glycosaminoglycan deposition at the craniovertebral junction. We think that this case demonstrates that, with appropriate preoperative planning, these patients can undergo successful posterior cervical arthrodesis despite their age or metabolic defects.