Gradual dilatation of an occluded transverse sinus associated with dural arteriovenous fistula after balloon angioplasty with sinus packing: A case report.

BACKGROUND: There is no consensus as to whether balloon angioplasty alone or stent placement is effective for sinus occlusion associated with dural arteriovenous fistula (DAVF). Herein, we first report a case of transverse sinus occlusion associated with DAVF in which gradual sinus dilatation was observed after balloon angioplasty with embolization of the affected sinus with shunt flow. CASE PRESENTATION: A 69-year-old man presented with executive dysfunction. Magnetic resonance imaging revealed left transverse sinus-sigmoid sinus DAVF with occlusion of the left jugular vein and right transverse sinus. Before endovascular treatment, the patient had symptomatic epilepsy and subarachnoid hemorrhage. Retrograde leptomeningeal venous drainage disappeared with packing of the left transverse sinus-sigmoid sinus. Subsequently, balloon angioplasty of the right occluded transverse sinus was performed to maintain the normal venous drainage and remaining shunt outflow. Dilatation of the right transverse sinus was poor immediately after surgery. However, angiography after 10 days and 6 months revealed gradual dilatation of the right transverse sinus. CONCLUSION: Sinus occlusion, which is thought to be caused by sinus hypertension associated with DAVF rather than chronic organized thrombosis or thrombophilia, may dilate over time after balloon angioplasty and shunt flow reduction if occluded sinus is necessary for facilitating normal venous drainage.

Ruptured Blister-like Aneurysm Arising From the Proximal Posterior Cerebral Artery.

BACKGROUND: Blister-like aneurysms (BLAs) arise mostly at the supraclinoid internal carotid artery. We report a rare case of ruptured BLA arising at the P1 segment of the posterior cerebral artery (PCA). CASE DESCRIPTION: A 34-year-old woman presented with disturbance of consciousness. Computed tomography (CT) of the head showed diffuse subarachnoid hemorrhage (SAH). A tiny bulge on the right PCA P1 segment was observed on initial CT angiography. The lesion enlarged little-by-little, with re-rupture occurring 10 days after initial hemorrhage. We diagnosed BLA arising at the P1 segment, and performed emergent endovascular parent artery occlusion (PAO) of the P1 segment. No infarction was observed in the territory of the PCA postoperatively. CONCLUSIONS: Proximal PCA is a rare but possible location for BLA. When the cause of bleeding SAH cannot be identified, repeated radiologic assessments including posterior circulation should be performed. If perforators of the unaffected site supply the thalamus and midbrain bilaterally and an ipsilateral posterior communicating artery exists, PAO of P1 seems feasible as a treatment. Elective intervention is not recommended because of the characteristics of ruptured BLAs.

A Patient with an Anterior Condylar Confluence Dural Arteriovenous Fistula in Whom Reflux to the Anterior Medullary Vein Was Observed during Follow-Up.

Objective: We report a case of anterior condylar confluence dural arteriovenous fistula (ACC dAVF) in whom venous reflux presentation was converted to the anterior medullary vein (AMV) during the observation period. Case Presentation: A 63-year-old woman with ACC dAVF, which only had anterograde drainage routes, exhibited dizziness during the observation period. Magnetic resonance imaging (MRI) revealed an abnormal hyper-intense area in the pons to the medulla. We performed cerebral angiography and reflux to the AMV was found. As the other drainage route using the internal jugular vein (IJV) remained, transvenous embolization (TVE) was performed to treat this ACC dAVF. No neurological deficits were observed and hyper-intensity in the brain stem disappeared after treatment. Conclusion: Although such cases are markedly rare, it is necessary to keep in mind that ACC dAVF may convert to the venous reflux presentation to the AMV during the natural course.

Radiologic Features and Clinical Course of Chronic Spinal Epidural Hematoma: Report of 4 Cases and Literature Review.

BACKGROUND: Spinal epidural hematoma (SEH) is a potentially devastating problem that requires rapid diagnosis and surgical intervention. A chronic course is rarely seen following SEH, and the clinical characteristics are quite different from acute cases. The epidemiology, clinical history, and radiologic findings of chronic SEH (CSEH) are not well understood, although the detection rate has increased with the widespread use of magnetic resonance imaging. The purpose of this article was to report 4 cases of surgically confirmed CSEH and clarify the radiologic features and clinical scenarios by reviewing all published cases of CSEH. CASE DESCRIPTION: All 4 patients presented with gradually worsening radicular pain in the lower extremities. Patients' mean age was 69.5 years (range, 55-85 years). Magnetic resonance imaging revealed an epidural mass in the lower lumbar spine that was heterogeneously enhanced after gadolinium administration. The rim of the mass was low intensity on T2*-weighted images. Local erosions of the adjacent cortical bone were seen with computed tomography in all cases. All patients' postoperative courses were satisfactory with complete disappearance of radicular symptoms. CONCLUSIONS: CSEH is a rare disease, and it is difficult to diagnose preoperatively on the basis of diagnostic imaging. The incidence of a low-intensity rim on T2*-weighted images and bone erosions on computed tomography may help differentiate rare CSEH from other lumbar degenerative diseases and epidural space-occupying masses.