Management of perisylvian arteriovenous malformations: a retrospective institutional case series and review of the literature.

OBJECT: Sylvian arteriovenous malformations (sAVMs) are challenging lesions of the central nervous system. The natural history of these unique lesions as well as clinical outcomes following treatment of sAVMs has been limited to case series owing to the rarity of these lesions. The authors present their experience with sAVMs and review the literature. METHODS: In accordance with the Henry Ford Institutional Review Board, medical records of patients with sAVMs treated from 2000 to 2012 were reviewed. Clinical data were retrospectively collected to calculate pre- and posttreatment modified Rankin Scale scores for all patients. RESULTS: The authors identified 15 patients with sAVMs who received treatment. Of these, 12 were female and 3 were male, and the average age at presentation was 39.6 ± 12.94 years (± SD). Two patients (13.3%) had Spetzler-Martin Grade I lesions, 6 patients (40%) had Grade II lesions, 5 patients (33.3%) had Grade III lesions, and another 2 (13.3%) harbored Grade IV arteriovenous malformations (AVMs). According to the Sugita classification, 6 patients (40%) had medial lesions, 6 (40%) had lateral lesions, 2 (13.3%) had deep lesions, and 1 patient (6.67%) had a pure sAVM. Eight patients (53.3%) underwent stereotactic radiosurgery while 7 patients (46.7%) had microsurgical resection; 1 patient underwent surgical extirpation after incomplete response following radiosurgery. After treatment, 9 patients were unchanged from pretreatment (60%), 3 patients worsened, and 2 patients had improved functional outcome (20% and 13.3%, respectively). The authors' literature search yielded 348 patients with sAVMs, most of them harboring Spetzler-Martin Grade II and III lesions. Approximately 98% of the patients underwent resection with excellent outcomes. CONCLUSIONS: While the ideal choice of therapeutic modality for cerebral AVMs remains controversial in light of the recent publication of the ARUBA (A Randomized trial of Unruptured Brain AVMs) trial, a multidisciplinary treatment approach for the management of sAVMs can lead to acceptable neurological outcome.

Initial experience with bevacizumab treatment for biopsy confirmed cerebral radiation necrosis.

BACKGROUND: Cerebral radiation necrosis is a serious complication of radiation treatment for brain tumors. Therapeutic options include corticosteroids, anticoagulation and hyperbaric oxygen with limited efficacy. Bevacizumab, an antibody against VEGF had been reported to reduce edema in patients with suspected radiation necrosis. We retrospectively reviewed 6 patients with biopsy proven cerebral radiation necrosis treated with bevacizumab between 2006 and 2008. RESULTS: Interval MRI follow-up demonstrated radiographic response in all patients with an average reduction of 79% for the post gadolinium studies and 49% for the FLAIR images. The initial partial radiographic response was noted for up to a mean follow-up time of 5.9 months (6 weeks to 18 months). CONCLUSION: Bevacizumab appears to produce radiographic response and clinical benefits in the treatment of patients with cerebral radionecrosis.

Prenatal Diagnosis of Congenital Dermal Sinus.

Background Congenital dermal sinus (CDS) is an uncommon form of spinal dysraphism. Although postdelivery identification in the neonate is aided by several associated physical examination findings, establishing this diagnosis prenatally has proven to be elusive. Case Report We present a case of CDS where the prenatal findings at 20 weeks gestation led to the diagnosis, which was confirmed postnatally. The associated protrusion of fibrotic membranes through the sinus tract helped in the identification of this lesion prenatally, but created confusion with a more common type of lesion, an open neural tube defect. This is the first case report in the literature describing prenatal diagnosis of fetal CDS. Conclusion Prenatal diagnosis with postnatal confirmation of CDS leads to early intervention, better long-term outcomes, and lesser complications.

Short segment internal maxillary artery to middle cerebral artery bypass: a novel technique for extracranial-to-intracranial bypass.

BACKGROUND: Traditional high-flow extracranial-to-intracranial (EC-IC) bypass procedures require a cervical incision and a long (20-25 cm) radial artery or saphenous vein graft. This technical note describes a less invasive, EC-IC bypass technique using a short-segment (8-10 cm) of the radial artery to anastomose the internal maxillary artery (IMAX) to the middle cerebral artery. CLINICAL PRESENTATION: Anatomic dissections were performed on 6 cadaveric specimens to assess the location of the IMAX artery using an extradural middle fossa approach. Subsequently, the procedure was implemented in a patient with a giant fusiform internal carotid artery aneurysm. TECHNIQUE: A straight line was drawn anteriorly from the V2/V3 apex along the inferior edge of V2. The IMAX was found 8.6 mm on average anteriorly from the lateral edge of the foramen rotundum. We drilled to a depth of 4.2 mm on average to find the medial extent of the artery and then lateral and deep drilling exposed an average of 7.8 mm of graft. The IMAX was consistently found running just anterior and parallel to a line between the foramens rotundum and ovale. In the clinical case presented, both intraoperative indocyanine green and postoperative conventional angiography revealed a patent graft. The patient did well clinically without any new deficits. CONCLUSION: The advantages of this new technique include the avoidance of a long cervical incision and potentially higher patency rates secondary to shorter graft length than currently practiced.