Multiple Synchronous Spinal Dural Arteriovenous Fistulas: A Systematic Literature Review.

BACKGROUND AND OBJECTIVES: Spinal dural arteriovenous fistulas (SDAVFs) lead to progressive neurological decline with symptoms such as paraparesis, bowel and bladder dysfunction, and sensory disturbances because of impaired spinal cord venous drainage. This study aimed to systematically review the literature on multiple synchronous SDAVFs and present 2 cases from our institution. METHODS: A comprehensive search was performed to identify all published cases of multiple synchronous SDAVFs. Overall, 23 patients with multiple synchronous SDAVFs were identified, including 21 from 19 articles and 2 from this study. The clinical presentation, lesion location, radiographic features, surgical treatment, and outcomes were analyzed in each patient. RESULTS: All patients in this study were male, and the duration from symptom onset to diagnosis in many of these patients was longer than that previously reported. Previous studies suggested that multiple SDAVFs typically occurred within 3 or fewer vertebral levels. However, >50% of the examined patients had remote lesions separated by more than 3 vertebral levels. Patients with remote lesions had a significantly worse outcome (1/7 vs 8/11, 95% CI 0.001-0.998; P = .049). CONCLUSION: Accurately locating fistulas before spinal angiography is critical for managing multiple remote SDAVFs. Considering the possibility of multiple remote SDAVFs, careful interpretation of imaging findings is essential for an accurate diagnosis and appropriate treatment planning.

Successful shrinkage of a recurrent partially thrombosed symptomatic large basilar tip aneurysm using a Target 3D Coil.

Background: Standalone coil embolization is often less effective for partially thrombosed intracerebral aneurysms (PTIA) because of the risk of frequent recurrence if the coil migrates into the thrombus. This report describes a case of PTIA at the basilar tip in which simple coil embolization using a Target 3D Coil resulted in sustained remission without recurrence during long-term follow-up. Case Description: The patient was a 63-year-old male who presented with right oculomotor nerve palsy after having undergone direct surgery for a basilar artery aneurysm 15 years earlier. Recurrence with partial thrombosis of the basilar artery aneurysm was diagnosed. Target 3D Coil embolization with frame construction in the aneurysmal sac was performed, resulting in the complete disappearance of the aneurysm and improvement of the oculomotor nerve palsy. Magnetic resonance imaging at five years postoperatively confirmed that the thrombus had completely disappeared, and there was no recurrence of the aneurysm. The closed loops in the Target 3D Coil may have contributed to the cohesive mass of coils remaining in the sac of the PTIA, potentially leading to healing. Conclusion: The characteristics of the Target 3D Coil may have prevented migration of the coil into the thrombus, potentially contributing to the successful resolution of the aneurysm.

A vertebrobasilar junction aneurysm successfully treated with a combination of surgical clipping and flow diverter placement based on the results of computational fluid dynamics analysis: illustrative case.

BACKGROUND: The treatment of vertebrobasilar junction (VBJ) aneurysms is challenging. Although flow diverters (FDs) are a possible treatment option, geometrical conditions hinder intervention. VBJ aneurysms possess dual inflow vessels from the bilateral vertebral arteries (VAs), one of which is ideally occluded prior to FD treatment. However, it remains unclear which VA should be occluded. OBSERVATIONS: A 75-year-old male with a growing VBJ complex aneurysm exhibiting invagination toward the brainstem and causing perifocal edema required intervention. Preoperative computational fluid dynamics (CFD) analysis demonstrated that left VA occlusion would result in more stagnant flow and less impingement of flow than right VA occlusion. According to the simulated strategy, surgical clipping of the left VA just proximal to the aneurysm was performed, followed by FD placement from the basilar artery trunk to the right VA. The patient demonstrated tolerance of the VA occlusion, and follow-up computed tomography angiography at 18 months after FD treatment confirmed the disappearance of the aneurysm. LESSONS: Preoperative flow dynamics simulations using CFD analysis can reveal an optimal treatment strategy involving a hybrid surgery that combines FD placement and direct surgical occlusion for a VBJ complex aneurysm.

Combined transarterial and transvenous embolization of anterior cranial fossa dural arteriovenous fistula.

Background: Excessive glue injection into the drainage vein in patients with dural arteriovenous fistula (dAVF) can result in venous obstruction. We performed transarterial embolization (TAE) combined with transvenous embolization (TVE) with coils to prevent the glue from migrating into the normal cortical veins. Case Description: A 57-year-old man was pointed out to have a Borden Type III anterior cranial fossa dAVF during a check-up for putaminal hemorrhage. Because a left frontal normal cortical vein drained into the pathological drainage vein, excessive glue injection into the drainage vein may have caused venous obstruction. We performed TVE with coils at the foot of the draining vein to prevent excessive migration of glue into the drainer, followed by TAE with glue. With this technique, complete obliteration of the shunt without venous ischemia was obtained. Conclusion: The combined treatment of TAE and TVE is effective in preventing venous ischemia caused by unintended migration of glue cast into the drainage vein.

Effects of carotid revascularization on cognitive function and brain functional connectivity in carotid stenosis patients with cognitive impairment: a pilot study.

OBJECTIVE: Carotid stenosis can lead to both cognitive impairment (CI) and ischemic stroke. Although carotid revascularization surgery, which includes carotid endarterectomy (CEA) and carotid artery stenting (CAS), can prevent future strokes, its effect on cognitive function is controversial. In this study, the authors examined resting-state functional connectivity (FC) in carotid stenosis patients with CI undergoing revascularization surgery, with a particular focus on the default mode network (DMN). METHODS: Twenty-seven patients with carotid stenosis who were scheduled to undergo CEA or CAS between April 2016 and December 2020 were prospectively enrolled. A cognitive assessment, including the Mini-Mental State Examination (MMSE), Frontal Assessment Battery (FAB), and Japanese version of the Montreal Cognitive Assessment (MoCA), as well as resting-state functional MRI, was performed 1 week preoperatively and 3 months postoperatively. For FC analysis, a seed was placed in the region associated with the DMN. The patients were divided into two groups according to the preoperative MoCA score: a normal cognition (NC) group (MoCA score ≥ 26) and a CI group (MoCA score < 26). The difference in cognitive function and FC between the NC and CI groups was investigated first, and then the change in cognitive function and FC after carotid revascularization was investigated in the CI group. RESULTS: There were 11 and 16 patients in the NC and CI groups, respectively. The FC of the medial prefrontal cortex with the precuneus and that of the left lateral parietal cortex (LLP) with the right cerebellum were significantly lower in the CI group than in the NC group. In the CI group, significant improvements were found in MMSE (25.3 vs 26.8, p = 0.02), FAB (14.4 vs 15.6, p = 0.01), and MoCA scores (20.1 vs 23.9, p = 0.0001) after revascularization surgery. Significantly increased FC of the LLP with the right intracalcarine cortex, right lingual gyrus, and precuneus was observed after carotid revascularization. In addition, there was a significant positive correlation between the increased FC of the LLP with the precuneus and improvement in the MoCA score after carotid revascularization. CONCLUSIONS: These findings suggest that carotid revascularization, including CEA and CAS, might improve cognitive function based on brain FC in the DMN in carotid stenosis patients with CI.

Von Hippel-Lindau disease with intracranial hemorrhage due to arteriovenous anastomosis via multiple spinal hemangioblastomas: illustrative case.

BACKGROUND: Some spinal hemangioblastomas (HBLs) resemble spinal vascular malformations. Intracranial subarachnoid hemorrhage (SAH) secondary to spinal HBL has rarely been reported. OBSERVATIONS: A 67-year-old man with a prolonged von Hippel-Lindau disease (VHL) history presented with sudden headache and vomiting. Cranial and cervical computed tomography (CT) revealed severe infratentorial, supratentorial, and cervical SAH. Cranial CT angiography and magnetic resonance imaging revealed a mismatch in hemorrhage and intracranial tumor localization, with no vascular lesions that could lead to intracranial SAH. Cervical CT angiography revealed abnormal blood vessels originating from 5 spinal tumors suspected to be HBLs. We considered that the SAH was caused by venous reflex from vascular malformation-like spinal HBLs. Transarterial embolization (TAE) of the feeding artery of HBLs was performed to improve symptoms and reduce rebleeding risk. Nine months after TAE, angiography showed no venous reflux into the intracranial space. Ten months later, the authors excised the T1-2 tumor because the patient complained of progressive paralysis of the right upper extremity. LESSONS: In HBL with prolonged VHL, intracranial hemorrhage due to venous regurgitation via a mimicked vascular malformation may occur. Reducing venous reflux with TAE may improve symptoms and prevent rebleeding.

Ruptured traumatic posterior inferior cerebellar artery pseudoaneurysm: A case report and literature review.

Background: Traumatic intracranial aneurysm (TICA) accounts for approximately 1% of cerebral aneurysms. There are few reports of TICA limited to the posterior inferior cerebellar artery (PICA-TICA). Case Description: A 69-year-old woman fell into a shallow river, bruising her head and chest, and was admitted to our emergency department with disorientation. Computed tomography (CT) showed subarachnoid hemorrhage (SAH), intraventricular hemorrhage (IVH), left temporal lobe contusion, and fractures of the right temporal bone. A cerebral CT angiogram revealed no vascular abnormalities or aneurysms. The patient was in a semi-comatose state 2 h later, and CT showed worsening SAH. A cerebral angiogram revealed an 11 mm aneurysm of the anterior medullary segment of the right PICA. We attempted intra-aneurysmal embolization intending to preserve the PICA, but the aneurysmal neck was thin, and the microcatheter could not be placed in a stable position. Therefore, n-butyl-2-cyanoacrylate (NBCA) was injected to embolize the aneurysm. When the microcatheter was removed, NBCA was scattered distally in the PICA, and the distal PICA was occluded. The aneurysm could be embolized, but there was an increase in hemorrhagic contusion in the left temporal lobe. Decompression craniectomy was performed, but she died due to hemorrhagic contusion and uncal herniation 6 days after surgery. Conclusion: PICA-TICA is often accompanied by IVH and SAH, and there are some reports of cases with a vascular anomaly of the posterior circulation. Since TICA is at risk of rapid growth and rupture, an early and appropriate diagnosis is important.

Successful Thrombectomy for Endocarditis-Related Stroke in a Very Young Patient: Illustrative Case.

Objective: Unlike in older adults, ischemic stroke in young patients occurs secondary to preexisting conditions. Infective endocarditis (IE) is among the most important causes of stroke in young adults and has a severe prognosis. There are few reports of mechanical thrombectomy (MT) for IE-induced large-vessel occlusion (LVO). This paper reports a case of acute IE-induced LVO in a young patient who was successfully treated with MT. Case Presentation: An 18-year-old woman presented to our hospital with severe headache, high fever, and left fingertip pain. She was admitted to the Department of Neurology for conservative treatment of suspected meningitis. On day 2 of admission, she developed acute left hemiparesis, left hemispatial neglect, and dysarthria. MRA showed occlusion of the right M1 segment of the middle cerebral artery, and the patient immediately underwent MT. After a single pass, we achieved thrombolysis in cerebral infarction 2b. A white clot was diagnosed as a vegetation on pathological examination. As transesophageal echocardiography showed a vegetation on the mitral valve, the patient was diagnosed with IE and underwent cardiovascular surgery. The patient recovered well and underwent additional treatment and rehabilitation. Conclusion: Although rare, IE-induced septic emboli may occur in young patients with LVO, necessitating MT and pathological diagnosis of the clot.

Successful multiple burr hole openings for limb-shaking transient ischemic attack due to moyamoya disease: illustrative case.

BACKGROUND: Limb-shaking transient ischemic attacks (LS-TIAs) are a rare form of TIAs that present as involuntary movements of the limbs and indicate severe cerebral hypoperfusion. LS-TIAs are often reported in patients with carotid artery stenosis but can also affect patients with intracranial artery stenosis and moyamoya disease (MMD). OBSERVATIONS: A 72-year-old woman presented with repeated episodes of involuntary shaking movements of the right upper limb. Cerebral angiography revealed complete occlusion of the M1 segment of the left middle cerebral artery (MCA), and the left hemisphere was supplied by moyamoya vessels. She was treated with left direct revascularization without complications, and her involuntary movements subsided. However, she demonstrated involuntary shaking movements of the right lower limb 2 months postoperatively. Cerebral angiography revealed complete occlusion of the A1 segment of the left anterior cerebral artery (ACA). The multiple burr hole opening (MBHO) procedure was performed to improve perfusion in the left ACA territory and after 3 months, the patient's symptoms resolved. LESSONS: This case demonstrated that LS-TIAs can also develop as ischemic symptoms due to MMD. Moreover, instances of LS-TIA of the upper and lower limbs developed separately in the same patient. The patient's symptoms improved with direct revascularization and MBHO.

[Implementation of Penumbra-assisted Half-Stent Thrombectomy for Patients with Acute M2 Occlusion:Results of Initial Experiences].

The benefits of mechanical thrombectomy(MT)for acute M2 occlusion have remained unclear because of unavoidable device-related complications due to vascular morphological characteristics. We developed a Penumbra-assisted half-stent thrombectomy for achieving secure retrieval of thrombus with minimal damage to the small-caliber vessel. In total, 6 patients were treated with MT for acute M2 occlusion using this technique between November 2016 and May 2017, including 3 men and 3 women, mean age 74.8(51-98)years. The mean baseline National Institutes of Health Stroke Scale score was 17.5(6-32), and Alberta Stroke Program Early Computed Tomography Score-Diffusion-Weighted Imaging was 7.5(6-9). After navigation of the microcatheter through the thrombus in M2 supported by a Penumbra 4MAX as a distal access catheter, the stent retriever(SR)was partially deployed to cover the entire thrombus. The 4MAX was then advanced towards the caudal end of the thrombus, and the SR was pulled back into the 4MAX with simultaneous aspiration of the 4MAX. We used the Trevo XP3 in 5 patients and Revive SE in 1 patient. The mean procedure time from groin puncture to recanalization was 60(54-66)min. Successful recanalization(Thrombolysis in Cerebral Infarction score 2b or 3)was achieved in 5(83%)patients. There were no cases of symptomatic intracranial hemorrhage. Good outcome(modified Rankin Scale score 0 to 2)at 3 months was achieved in 3(50%)patients. Penumbra-assisted half-stent thrombectomy appears to be an effective alternative strategy in MT for acute M2 occlusion.