Standing Waves on Computed Tomography Angiography in Multiple Vessels in a Young Trauma Patient.

ABSTRACT: Standing waves are a phenomenon of uncertain etiology seen on imaging. We present the first case demonstrating standing waves on computed tomography angiography in multiple vessels in a single patient with imaging evidence of resolution in some of the vessels. Our case further supports the literature that standing waves are a physiologic phenomenon, likely because of flow mechanics, rather than modality.

Severe facial necrosis in a type 1 diabetic patient secondary to mucormycosis masquerading as an internal maxillary artery occlusion: a case report.

BACKGROUND: Mucormycosis is a group of rare but life threatening angioinvasive infections caused by fungi of the order Mucorales that often occurs in immunocompromised patients and individuals with poorly controlled diabetes. Rhinocerebral mucormycosis can mimic sinusitis but can rapidly progress to deeper disease and cause facial necrosis. Facial vascular thrombosis is a rare complication of mucormycosis and can confound diagnosis of the disease. CASE PRESENTATION: We report the case of a 25-year-old female with poorly controlled type 1 diabetes mellitus who initially presented with symptoms of sinusitis but rapidly progressed with signs of left-sided facial necrosis due to occlusion of the left internal maxillary artery. Early surgical debridement did not yield a microbiological diagnosis. Deeper surgical debridements ultimately revealed angioinvasive fungal disease consistent with mucormycosis. The patient recovered after repeated surgical intervention and aggressive parenteral antifungal therapy. CONCLUSION: This case illustrates an atypical complication of mucormycosis, and emphasizes that a high index of suspicion in vulnerable patient populations aids in the diagnosis of this life-threatening infection.

Bypass of the maxillary artery to proximal middle cerebral artery.

OBJECTIVE: The objective of this work was to explore the feasibility of bypass between the maxillary artery (MA) and proximity of middle cerebral artery (MCA). METHODS: Ten fixed and perfused adult cadaver heads were dissected bilaterally, 20 sides in total. The superficial temporal artery and its 2 branches were dissected, and outer diameters were measured. The MA and its branch were exposed as well as deep temporal artery; outer diameter of MA was measured. The lengths between the external carotid artery, internal carotid artery, maxillary artery, and proximal middle cerebral artery were measured. Ten healthy adults as targets (20 sides), inner diameter and blood flow dynamic parameters of the common carotid artery, external carotid artery, internal carotid artery, maxillary artery, superficial temporal artery, and its 2 branches were done with ultrasound examination. RESULTS: The mean outer diameter of MA (2.60 ± 0.20 mm) was larger than that of the temporal artery trunk (1.70 ± 0.30 mm). The mean lengths of graft vessels between the internal carotid artery, external carotid artery, and the bifurcation section of MCA (171.00 ± 2.70 and 162.40 ± 2.60 mm) were longer than the mean lengths of graft vessels between MA and MCA bifurcation section (61.70 ± 1.50 mm). In adults, the mean blood flow of the second part of MA (62.70 ± 13.30 mL/min) was more than that of the 2 branches of the superficial temporal artery (15.90 ± 3.70 mL/min and 17.70 ± 4.10 ml/min). CONCLUSION: Bypass between the maxillary artery and proximity of middle cerebral artery is feasible. It is a kind of effective high flow bypass with which the graft vessel is shorter and straighter than the bypass between internal carotid artery or external carotid artery and proximity of middle cerebral artery.

[Optimization of the surgical methods for the treatment of recurrent nasal bleeding (a pathologo-anatomical study)].

The objective of the present work was to study specific features of blood supply to the nasal cavity by staining mandibular and ethmoidal arteries to reveal their size and topographic features under conditions of a pathologo-anatomical department. The secondary objective was to modify the existing and develop new methods for the ligation of these vessels. This pathologo-anatomical study was based on 16 preparations examined with the use of up-to-date optical facilities. The results of investigations of the topographo-anatomical peculiarities of blood supply in the nasal cavity are supplemented by the evaluation of the potential of endoscopic rhinosurgery for the treatment of recurrent nasal hemorrhage. The methods for endoscopic ligation of mandibular and ethmoidal arteries have been developed and optimized.

Visual and semiquantitative assessment of cranial artery inflammation with FDG-PET/CT in giant cell arteritis.

BACKGROUND AND AIM: Assessing cranial artery inflammation plays an important role in the diagnosis of cranial giant cell arteritis (C-GCA). However, current diagnostic tests are limited. The use of fluorine-18-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT imaging is an established tool for assessing large vessel inflammation but is currently not used for assessment of the cranial arteries. This study aimed to evaluate the accuracy of FDG-PET/CT in the diagnosis of biopsy proven C-GCA and its relation to clinical presentation. METHODS: This retrospective case control study included temporal artery biopsy (TAB) positive C-GCA patients and age- and sex-matched controls. FDG-PET/CT scans were performed according to EANM/EARL guidelines, visually assessed by an experienced nuclear medicine physician, and semiquantitatively assessed using the maximum standardised uptake value (SUVmax). The visual and semiquantitative assessments were performed on the temporal arteries, maxillary arteries, vertebral arteries, and occipital arteries. Clinical signs and symptoms were scored for comparison. RESULTS: A total of 24 C-GCA patients and 24 controls were included in the study. Visual analysis revealed an 83% sensitivity and a 75% specificity. Receiver operating characteristic (ROC) analysis of the semiquantitative assessment revealed a 79% sensitivity and a 92% specificity when measuring SUVmax in the cranial arteries. Visual and semiquantitative assessments showed moderate agreement (Fleiss kappa 0.55). There was a positive correlation between the number of cranial symptoms and the SUVmax in the vertebral artery. CONCLUSION: FDG-PET/CT can reliably diagnose C-GCA by assessing cranial artery inflammation using SUVmax. Extending the use of FDG-PET/CT to include assessment of the cranial arteries may improve its diagnostic value in GCA and provide a suitable alternative to TAB. Moderate agreement between visual and semiquantitative assessment methods suggest diagnostic accuracy may be improved by further standardisation.

Scalp necrosis in giant cell arteritis: case report and review of the relevance of this cutaneous sign of large-vessel vasculitis.

Giant cell arteritis (GCA) is a systemic vasculitis associated with severe complications such as loss of vision and, rarely, scalp necrosis. We present a patient with GCA who had bilateral scalp necrosis and an erythrocyte sedimentation rate of only 21 mm after the first hour. Therapy with systemic steroids, which were slowly tapered over 1 year, led to secondary wound healing without recurrence. As there are no systematic reviews on the occurrence of scalp necrosis in patients with GCA, we performed a literature research and meta-analysis and discovered 78 cases published between 1946 and 2007. Analysis of the data revealed that GCA with scalp necrosis is associated with a higher incidence of vision loss (32%) and other visual defects (37.3%) than GCA without scalp necrosis (visual disturbances in up to 20%). GCA with scalp necrosis is also associated with an increased mortality (standard mortality ratio [SMR], 4.2) in contrast to GCA without scalp necrosis, which has no significantly higher mortality than age-matched controls (SMR 0.8-1.034). In patients with scalp necrosis, the diagnosis of GCA was made about 1 month later than in patients without scalp necrosis, and scalp necrosis was never reported to occur after onset of therapy with glucocorticoids. Thus, for reasons beyond potential loss of vision, physicians should be alert for symptoms of GCA as only timely diagnosis and immediate therapy may prevent serious complications and increased mortality.

Bilateral variation of facial artery: a case report.

Dissection of a 65-year-old male cadaver revealed bilateral anomalous facial artery. The right facial artery taking origin from the external carotid artery did not make any loop in the submandibular region, entered the face by winding round the lower border of mandible, and terminated as the inferior labial artery. The upper part of the right side face in this case was supplied by various branches of transverse facial artery, infra orbital artery and dorsal nasal artery. The origin, course and branching pattern of the left facial artery was normal except the inferior labial artery was missing from it. The venous drainage of the face was normal on both sides. This case may provide useful information for clinical applications in different fields of oral and maxillofacial surgery.

The History and Evolution of Internal Maxillary Artery Bypass.

Internal maxillary artery (IMA) bypass has gained momentum in the last 5 years for the treatment of complex cerebrovascular disorders and skull base tumors. However, some issues regarding this treatment modality have been proposed. As one of the most experienced neurosurgical teams to perform internal maxillary artery bypass in the world (>100 clinical cases), we reviewed the literature in aspects of basic anatomy of maxillary artery with its variations to the lateral pterygoid muscle, initial anastomosis modalities, and subsequent exposure techniques in cadaver studies, preoperative arterial evaluation methods, optimal interposed graft selections, and surgical outcome in the management of complex aneurysms, skull base tumors, and steno-occlusive disorders.

Current endovascular management of maxillofacial vascular malformations.

Maxillofacial vascular malformations (MFVMs) are formed due to an error of vascular morphogenesis. They generally grow in proportion to the growth of the affected child but may increase in size secondary to various triggering factors such as increased blood flow, arterial occlusion, and venous thrombosis. The development of an individual lesion, especially if it is high flow, may be stimulated by various factors. High flow in an existing MFVM can induce arteriovenous shunting, which, in turn, increases flow demand, cascading enlargement of the malformation. Increased understanding of these additional physiologic variants may help to define their clinical presentation and evolution and assist in designing therapeutic strategies.

A case of epistaxis.

The authors report a case of epistaxis in a 74-year-old male patient. His recent medical history documented recurrent nasal bleeding and a Le Fort 1 osteosynthesis 3 weeks before admission to our unit. A CT scan revealed a left descending palatine artery pseudoaneurysm in the left maxillary sinus that was successfully embolized. Pseudoaneurysms of the internal maxillary artery and its branches are rare life-threatening complications. This diagnosis should be considered when confronted to recurrent head and neck bleeding, especially in a context of recent maxillo-facial trauma or surgery. Embolization should rapidly be implemented.

Life-threatening hemorrhage after zygomatic bone surgery. About 2 posttraumatic cases.

INTRODUCTION: Management of zygomatic bone fractures is still debated. Method and delay for intervention has to be chosen considering respective issues of operative or conservative treatments, especially hemorrhagic complications. The maxillofacial surgeon must be able to determine life-threatening situations and to react appropriately. CASES REPORT: We report 2 cases of external carotid branches pseudoaneurysm leading to massive hemorrhage after early or delayed zygomatic fracture surgery. The first patient underwent open reduction of fracture by intraoral approach. An active bleeding occurred in the immediate postoperative time. In the second case, a zygomatic osteotomy was performed 1 year after fracture. Bleeding occurred 2 weeks after surgery. In both cases, angiography demonstrated a pseudoaneurysm developed from the external carotid branches. Embolisation led to rapid bleeding control. DISCUSSION: Severe hemorrhage resulting from maxillofacial trauma may be life-threatening. Once the "damage control" principles applied, selective embolisation of external carotid branches is an efficient alternative to surgery for the control of bleeding resulting from ruptured pseudoaneurysm.

Transarterial N-Butyl-2-cyanoacrylate Embolization of an Intraosseous Dural Arteriovenous Fistula Associated With Acute Epidural Hematoma: Technical Case Report.

BACKGROUND AND IMPORTANCE: Intraosseous dural arteriovenous fistulae (DAVF) are rare, especially those with drainage into the diploic venous system. The clinical presentation depends on the location of the lesion. This is the first report of an intraosseous DAVF associated with acute epidural hematoma. CLINICAL PRESENTATION: A 25-year-old man presented with headache and nausea. Imaging of the brain revealed abnormal signals indicative of acute epidural hematoma in the right frontal convexity. Angiography demonstrated a DAVF in the region of the frontal bone. Right external carotid artery angiography showed that the DAVF was fed mainly by the right middle meningeal artery with drainage into diploic veins. Immediately after embolization of the middle meningeal and the distal internal maxillary artery with 17% N-butyl-2-cyanoacrylate, the shunt was completely occluded. The patient was discharged 4 days later without clinical complications. CONCLUSION: Intraosseous DAVF can be treated by surgical resection or endovascular embolization. Curative treatment requires careful inspection of the angiographic architecture and microsurgical anatomy.

In situ beta radiation to prevent recanalization after coil embolization of cerebral aneurysms.

BACKGROUND AND PURPOSE: Endovascular treatment of cerebral aneurysms, a minimally invasive alternative to surgery, is too often followed by recanalization and recurrences. The purpose of this work was to assess if in situ beta radiation can inhibit recanalization after coil embolization. METHODS: Radioactive platinum coils (32P-coils) were produced by ion implantation of 32P. A single-coil arterial occlusion model was used to compare angiographic and pathological results at 1 to 12 weeks after nonradioactive and 32P-coil embolization of maxillary, cervical, and vertebral arteries in 26 dogs. Coils of varying activities were used and results compared to define the minimal activity required to inhibit recanalization. Similar experiments were performed in 16 porcine maxillary and lingual and 8 rabbit axillary arteries. Results of 32P-coil embolization of bifurcation aneurysms were then compared with embolization with nonradioactive coils in 12 dogs at 3 months. RESULTS: Nonradioactive coil embolization of canine arteries led to occlusion at 1 week, followed by recanalization at 2 weeks, which persisted at 3 months in all cases. 32P-coils, ion-implanted with activities above 0.13 microCi/cm, led to persistent occlusion at 3 months in 80% of arteries. 32P-coils ion-implanted with the same activity inhibited recanalization in porcine and rabbit arteries. Bifurcation aneurysms treated with 32P-coils had better angiographic results at 3 months (P=0.006) than aneurysms treated with nonradioactive coils. Arteries occluded were filled with fibrous tissue at 3 months. Aneurysms embolized with 32P-coils showed more complete neointimal coverage of the neck, without recanalization, as compared with aneurysms treated with nonradioactive coils. CONCLUSION: In situ low-dose beta radiation inhibits recanalization after coil embolization and may improve long-term results of endovascular treatment of aneurysms.

Beta radiation and inhibition of recanalization after coil embolization of canine arteries and experimental aneurysms: how should radiation be delivered?

BACKGROUND AND PURPOSE: Beta radiation prevents recanalization after coil embolization. We sought to determine the effects of varying coil caliber, length, activity of 32P per centimeter of coil or per volume, and spatial distribution of coils on recanalization. METHODS: We studied the angiographic evolution of 81 canine maxillary, cervical, and vertebral arteries implanted with a variety of nonradioactive (n=29 arteries) or radioactive (n=52) devices. We compared 1- or 2-caliber 0.015 or 0.010 coils ion-implanted or not with 3 different activity levels (0.05 to 0.08, 0.06 to 0.12, 0.18 to 0.32 microCi/cm) of 32P and totaling 4, 8, and 16 cm in length for the same arterial volume. We also compared inhibition of recanalization by beta radiation delivered by stents, after coil occlusion proximal to or within the stent, with that delivered by coils placed within nonradioactive stents. We finally studied the angiographic evolution of canine lateral wall carotid aneurysms treated with 1 or 2 stents of various activity levels positioned inside the parent artery across the neck. Animals were killed at 4 and 12 weeks for macroscopic photography and pathological examination. RESULTS: All arteries (29 of 29) occluded with nonradioactive devices were recanalized, while 49 of 52 arteries (94%) implanted with 32P devices were occluded at 4 weeks. All aneurysms treated with stents, radioactive or not, demonstrated residual filling of the sac or of channels leading to the aneurysms at follow-up angiography at 4 weeks. CONCLUSIONS: The recanalization process found in the canine arterial occlusion model is minimally affected by coil caliber, number, and length or packing density. Beta radiation reliably inhibits this process, but thrombosis is an essential condition for the efficacy of a radioactive coil strategy.

Percutaneous internal maxillary arterial embolization with ethylcellulose microspheres. Results in an animal model.

RATIONALE AND OBJECTIVES: To investigate the use of ethylcellulose microspheres as long-term and peripheral emboli for percutaneous maxillofacial arterial embolization. METHODS: Eight mongrel dogs were selected randomly for internal maxillary artery embolization with ethylcellulose microspheres. After embolization, angiographic, microangiographic, and histologic examinations were performed. RESULTS: Ethylcellulose microspheres were trapped in the peripheral arterioles from 24 hours to 6 months after embolization. Degenerative changes of maxilla, mandible, and dental pulp occurred after the embolization of the internal maxillary artery with the microspheres. No evidence of whole or focal necrosis of the bones and surrounding soft tissues was found between 24 hours and 6 months after embolization. CONCLUSION: Ethylcellulose microspheres can be used as an alternative long-term and peripheral embolic agent, with potential for percutaneous maxillofacial arterial embolization.

Radiologic and histopathologic evaluation of canine artery occlusion after collagen-coated platinum microcoil delivery.

BACKGROUND AND PURPOSE: Platinum coil embolization is one of the significant advances in interventional neuroradiologic techniques that has been introduced this decade. Our purpose was to evaluate the angiographic and histologic effects of collagen-coated platinum microcoil delivery in the canine artery. METHODS: We embolized the bilateral internal maxillary arteries of 18 dogs; one uncoated and one collagen-primed coil was used in each dog. We evaluated all coils by angiography, macroscopy, and scanning electron microscopy within 30 minutes of embolization. We then studied a proportional number of coated and collagen-primed coils at either 1 or 3 days, or 1, 2, 3, 4, 8, 12, or 16 weeks postoperatively. RESULTS: Six (33%) of 18 arteries embolized with uncoated coils were occluded 30 minutes after delivery, whereas 11 (61%) of 18 arteries treated with collagen-primed coils were occluded within 30 minutes of embolization. Late occlusion (3 weeks after embolization) occurred in 2 (25%) of 8 arteries embolized with untreated coils, and 6 (75%) of 8 arteries embolized with collagen-primed coils. We calculated differences in late occlusion rates by the chi2 (chi-square) test, and found these differences were significant (P=.04). Histologic findings of arteries embolized with unprimed coils revealed endothelial cell growth was limited to the organized thrombi 4 weeks after coil delivery. In contrast, endothelial cells grew directly on the collagen-primed coils 3 days postoperatively, and coils were completely covered by endothelial cells within 2 weeks. We found an organized thrombus in the inner space of coils in angiographically occluded arteries, a finding that was not evident in angiographically patent arteries. CONCLUSION: Collagen-coated platinum coils can produce rapid and stable occlusion of embolized vessels.

Frequency and significance of a small distal ICA in carotid artery stenosis.

PURPOSE: Accurate calculation of the percentage of stenosis is crucial for identifying candidates for endarterectomy. Our goal was to quantify the reduction in diameter of the distal internal carotid artery (ICA) as a function of proximal ICA stenosis and to discuss the implications of distal ICA narrowing on the calculation of percentage of stenosis using the criteria of the North American Symptomatic Carotid Endarterectomy Trial (NASCET). METHODS: We retrospectively reviewed the carotid angiograms of 81 patients referred for evaluation of carotid stenosis. The caliber of the ICA stenosis and the diameters of the normal distal ICA, the common carotid artery, and the internal maxillary artery were remeasured with precision calipers. The percentage of stenosis derived from the NASCET criteria were compared with vessel diameter and with the difference in size of the ipsilateral and contralateral distal ICAs. We then recalculated the percentage of stenosis by substituting the presumed normal contralateral distal ICA diameter for the ipsilateral distal ICA diameter. RESULTS: In carotid arteries without significant stenosis (<70%), the distal ICA diameter measured 5.94+/-1.10 mm, but in vessels with severe stenosis (>70%), the distal ICA diameter measured 4.69+/-1.23 mm. After recalculation, four of 26 vessels were upgraded in classification from moderate (40% to 69%) to severe (>70%) stenosis. CONCLUSION: The diameter of the distal ICA begins to decrease when the proximal stenosis is 60% or greater. If the ICA distal to a stenosis is smaller than the contralateral ICA, recalculating the percentage of stenosis by substituting measurements of the contralateral distal ICA diameter may be warranted.

Radial artery graft for bypass of the maxillary to proximal middle cerebral artery: an anatomic and technical study.

OBJECTIVE: In this study, we aimed to investigate the use of a radial artery graft for bypass of the maxillary artery (MA) to the proximal middle cerebral artery (MCA) as an alternative to superficial temporal artery-to-MCA anastomosis or extracranial carotid-to-MCA bypass using long grafts. METHODS: Five adult cadavers were used bilaterally. After a frontotemporal craniotomy and a zygomatic arch osteotomy, the MA was found easily 1 to 2 cm inferior to the infratemporal crest. A hole was created with a 4-mm-tip drill in the sphenoid bone 2 to 3 mm lateral to the foramen rotundum extradurally, and the dura over the hole was opened. After the carotid and sylvian cisterns had been opened, the M2 segment of the MCA was exposed. The graft was passed through the hole to reach the M2 segment. Then, the MA was freed from the surrounding tissue and was transected before the infraorbital artery branch. The radial artery graft was anastomosed end-to-end to the MA proximally and end-to-side to the M2 segment of the MCA distally. RESULTS: The mean thickness of the MA before the infraorbital artery branch was 2.6 +/- 0.3 mm. The mean thickness of the largest trunk of the MCA was 2.3 +/- 0.3 mm. The average length of the graft was 36 +/- 5.5 mm. CONCLUSION: MA-to-MCA bypass is as feasible as proximal MCA revascularization using long vein grafts. The thickness of the MA provides sufficient flow; the length of the graft is short, and it has a straight course. MA-to-proximal MCA bypass may be an alternative to superficial temporal artery-to-MCA as well as extracranial carotid-to-MCA bypasses.

Treatment of traumatic facial arteriovenous fistula with embolization and surgical excision--a case report.

A 57-year-old male presented with a traumatic arteriovenous fistula on his face. The fistula was first treated with transarterial embolization and subsequently resection. His course was complicated by several recurrences of his fistula prior to definitive surgical treatment. The treatment of facial arteriovenous fistula and its complications are discussed in this article.