Case report: Association between PTEN-gene variant and an aggressive case of multiple dAVFs.

Introduction: Mutations of the phosphatase and tensin homolog (PTEN) gene have been associated with a spectrum of disorders called PTEN hamartoma tumor syndrome, which predisposes the individual to develop various types of tumors and vascular anomalies. Its phenotypic spectrum includes Cowden syndrome (CS), Bannayan-Riley-Ruvalcaba syndrome (BRRS), Proteus syndrome, autism spectrum disorders (ASD), some sporadic cancers, Lhermitte-Duclos disease (LDD), and various types of associated vascular anomalies. Clinical presentation: A previously healthy 27-year-old woman was experiencing visual scintillating scotomas and mild chronic headaches for the past 2 years. The initial computed tomographic (CT) and magnetic resonance imaging (MRI) scans did not reveal any abnormalities, but the possibility of pseudotumor cerebri was considered. Furthermore, a cerebral angiogram showed a posterior fossa dural arteriovenous fistula (dAVF), which was initially treated through embolization. However, in spite of proper treatment, this patient experienced multiple recurrent dAVFs in different locations, requiring multiple embolizations and surgeries. Despite exhibiting altered cerebral perfusion and hemodynamics, the patient did not display any significant symptoms until she experienced a sudden stroke resulting from deep venous thrombosis, which was not associated with any medical procedures or medication use. A comprehensive analysis was performed due to the aggressive nature of the dAVFs. Surprisingly, exome sequencing of a blood sample revealed a PTEN gene variant in chromosome 10, indicative of Cowden syndrome. However, no tumors or other vascular lesions were detected in other systems that would constitute Cowden syndrome. Conclusion: The rapid formation of multiple and complex dAVFs, coupled with not meeting the criteria for any other PTEN-related syndrome, unequivocally leads to the presentation of a novel phenotype of the PTEN germline variant.

Onyx embolization with the Apollo detachable tip microcatheter: A single-center experience.

Purpose The Apollo Onyx Delivery Microcatheter (Ev3, Irvine, CA) is a detachable-tip microcatheter that was developed to reduce the risk of microcatheter entrapment during ethylene-vinyl alcohol copolymer (Onyx) embolizations. We report our experience with the microcatheter in a variety of neurointerventional procedures. Methods We retrospectively reviewed all Onyx embolizations performed in the head, neck, and spine using the Apollo Onyx Delivery Microcatheter from its introduction at our institution in July 2014 to August 2016. Information regarding patient diagnoses, procedural details, as well as clinical outcomes were obtained from the electronic medical record, procedure reports, and relevant angiographic imaging. Results A total of 58 arterial pedicle Onyx embolizations were performed in 37 patients. There were no cases of microcatheter entrapment, early/inadvertent tip detachment, or vessel injury upon removal of the device. There were two instances (3.5%) of leakage of Onyx from the microcatheter detachment site during embolization, which did not result in adverse sequelae. Clinical outcomes were excellent, with nearly all embolizations achieving the intended goal. In multivariate analysis, length of Onyx reflux along the microcatheter tip and utilization of a higher viscosity agent, Onyx 34, were significantly associated with tip detachment. Conclusion The use of the Apollo Microcatheter is both safe and effective during neurointerventional embolizations using Onyx. Leakage of liquid embolic agent from the detachment site is an infrequent technical complication that may be encountered with the device.

Navien catheter experience in neuroendovascular interventions.

Purpose Advancements in catheter technology have allowed for greater flexibility and trackability. We report 265 consecutive, single-center neurointerventional cases using the Navien guide catheter. Materials and methods Retrospective analysis was performed of consecutive intracranial endovascular procedures utilizing the Navien catheter. Data collected included procedure type, catheters, guide catheter position, cervical access artery tortuosity grade and complications. Results The 5 French catheter was used in 130 cases. The 6 French catheter was used in 135 cases. Access was via the internal carotid artery in 204, external carotid artery in 10, and vertebral artery in 51 cases. Catheter tip position was in the petrous segment of the internal carotid artery in 36.6% (97/265), distal cervical internal carotid artery in 13.9% (37/265), cavernous internal carotid artery in 10.2% (27/265), proximal or mid cervical internal carotid artery in 5.6% (15/265), supraclinoid internal carotid artery in 0.8% (2/265), and intradural vertebral artery in 0.8% (2/265) of cases. Catheter position was not determined in 18.9% (50/265) of cases. Proximal vessel tortuosity (grade B or C) was present in 98 cases (37%), and the catheter was tracked distal to the tortuosity in 93% (91/98) of these cases. The overall success rate without catheter complication was 97% (258/265). The Navien was replaced by another catheter in 1.9% (5/265) of cases. There was one cervical artery dissection (0.4%) and one severe vasospasm (0.4%) necessitating Navien removal. Conclusions The Navien guide catheter provided distal access support for neuroendovascular interventions in nearly all cases, including cases with proximal artery tortuosity, with a low rate of catheter-related complications.

Cerebrum-cervical arterial dissection in adults during sports and recreation.

UNLABELLED: Dissection of cervical arteries constitutes a medical emergency. Although relatively rarely, activities classified as sports and recreation may be a cause of arterial dissection independently of neck or head trauma. The purpose of the present paper was to present a series of cases of cerebrum-cervical arterial dissection in individuals during or soon after the practice of these sports activities. METHODS: Retrospective data on patients with arterial dissection related to sports and recreation. RESULTS: Forty-one cases were identified. The most frequently affected vessel was the vertebral artery. A large variety of activities had a temporal relationship to arterial dissection, and jogging was the most frequent of these. This is the largest case series in the literature. CONCLUSION: Arterial dissection may be a complication from practicing sports.

Cerebrum-cervical arterial dissection in adults during sports and recreation / Dissecção arterial cérebro-cervical em adultos durante prática de esportes e recreação

Dissection of cervical arteries constitutes a medical emergency. Although relatively rarely, activities classified as sports and recreation may be a cause of arterial dissection independently of neck or head trauma. The purpose of the present paper was to present a series of cases of cerebrum-cervical arterial dissection in individuals during or soon after the practice of these sports activities. Methods Retrospective data on patients with arterial dissection related to sports and recreation. Results Forty-one cases were identified. The most frequently affected vessel was the vertebral artery. A large variety of activities had a temporal relationship to arterial dissection, and jogging was the most frequent of these. This is the largest case series in the literature. Conclusion Arterial dissection may be a complication from practicing sports.

A dissecção das artérias cervicais é uma emergência médica. Embora de forma relativamente rara, certas atividades descritas como esportes e recreação podem ser a causa de dissecção arterial independentemente de trauma de crânio ou cervical. O propósito do presente estudo é apresentar uma série de casos de dissecção de artérias cérebro-cervicais em indivíduos durante ou logo após a prática destas atividades desportivas. Métodos Dados retrospectivos de pacientes com dissecção arterial relacionada à prática de esportes e recreação. Resultados Quarenta e um casos foram identificados. A artéria mais frequentemente afetada foi a vertebral. Uma grande variedade de atividades teve relação temporal com a dissecção arterial, sendo a corrida a mais frequente delas. Esta é a maior série de casos da literatura. Conclusão Dissecção arterial pode ser uma complicação da prática de esportes.

Modificação do aparelho quadrihélice de Ricketts (quadrinator) como auxiliar no tratamento de paciente classe dois: relato de caso clínico / Ricketts´s quad-helix appliance (quadrinator) modfication for assist a class two patient treatment: a case report

O presente estudo teve como objetivo ilustrar, por meio de um caso clínico, o tratamento de um paciente, em crescimento, portador de uma má-oclusão de classe dois com mordida profunda e retrusão mandibular. Para tanto, empregou-se um aparelho quadrihélice de Ricketts, ao qual foi incorporado um plano inclinado anterior de acrílico. Esta alteração pretendeu produzir, ao mesmo tempo, melhora no posicionamento dos molares superiores (correção de giro), avanço postural da mandíbula e nivelamento da curva de Spee por extrusão de dentes posteriores (com consequente aumento da altura facial inferior).

This study aimed to illustrate, through a clinical case, the treatment of a growing patient, carrying a class two malocclusion with deep bite and mandibular retrusion. For this we used the Ricketts’s quadhelix device. In this device it was incorporated an acrylic anterior inclined plane. This amendment was executed to produce, at the same time, a better upper molars positioning (correction of rotation), postural mandibular advancement and leveling the Spee curve by extrusion of posterior teeth (with a consequent increase in lower facial height).

Emprego do dispositivo barra distalizadora (DBD), para distalização unilateral de molar superior em um paciente adulto / Employment of distalizer bar device (DBD), for unilateral distalization of an upper molar in an adult pacient

O presente estudo teve como objetivo apresentar um caso clínico em que o aparelho DBD foi empregado para distalizar, unilateralmente, um molar superior em paciente adulto. Uma revisão de literatura a respeito de alguns dispositivos distalizadores foi apresentada. Pode-se verificar, que no caso reportado, o dispositivo DBD mostrou-se eficiente em produzir distalização molar.

The present study was aimed to present a clinical case in which DBD device was employed to distalize, unilaterally, an upper molar in an adult patient. A review of literature regarding some distalizer devices was presented. It could be verified that, in the case reported, DBD device proved to be efficient to provide the upper molar distalization.

Considerações mecânicas sobre a intrusão de molares superiores ancorados em mini-implantes ortodônticos / Mechanicals considerations in upper molars intrusion anchored with orthodontic mini implants

O presente estudo teve como objetivo abordar a mecânica para intrusão de molares superiores, por meio do emprego de mini-implantes como sistema de ancoragem, descrevendo a localização preferencial para posicionamento dos mini parafusos e mecânica de utilização. A literatura consultada não apresentou unanimidade a respeito dos tópicos estudados. Entretanto, restou demonstrado que a aplicação de três mini-implantes na maxila (dois vestibulares e um palatino), poderia ser a posição de preferência dos dispositivos de ancoragem. O intervalo de magnitude de força mais citado pelos autores consultados, para promover intrusão molar, foi de 150 g a 200 g. Molas de níquel-titânio seriam o melhor meio para promoção de carga, ainda que elásticos pudessem ser utilizados. Em função da estabilidade primária dos mini parafusos, poder-se-ia ou não aplicar carga imediata.