Surgery versus endovascular treatment for spinal dural arteriovenous fistulas: a multicenter experience and systematic literature review.

Surgery and endovascular therapy are the primary treatment options for spinal dural arteriovenous fistula (SDAVF). Due to the absence of a consensus regarding which therapy yields a superior outcome, we conducted a comparative analysis of the surgical and endovascular treatment of SDAVF through a multicenter case series and a systematic literature review. Patients with SDAVF, surgically or endovascularly treated at four neurosurgical centers from January 2001 to December 2021, were included in this study. Level of SDAVF, primary treatment modality, baseline and post-procedural neurological status were collected. The primary outcomes were failure, complication rates, and a newly introduced parameter named as therapeutic delay. A systematic review of the literature was performed according to PRISMA-P guidelines. The systematic review identified 511 papers, of which 18 were eligible for analysis, for a total of 814 patients, predominantly male (72%) with a median age of 61 and mainly thoracic SDAVFs (65%). The failure rate was significantly higher for endovascular therapy (20%) compared to surgery (4%) (p < 0.01). Neurological complications were generally rare, with similar rates among the two groups (endovascular 2.9%; surgery 2.6%). Endovascular treatment showed a statistically significantly higher rate of persistent neurological complications than surgical treatment (2.9% versus 0.2%; p < 0.01). Both treatments showed similar rates of clinical improvement based on Aminoff Logue scale score. The multicenter, retrospective study involved 131 patients. The thoracic region was the most frequent location (58%), followed by lumbar (37%). Paraparesis (45%) and back pain (41%) were the most common presenting symptoms, followed by bladder dysfunction (34%) and sensory disturbances (21%). The mean clinical follow-up was 21 months, with all patients followed for at least 12 months. No statistically significant differences were found in demographic and clinical data, lesion characteristics, or outcomes between the two treatment groups. Median pre-treatment Aminoff-Logue score was 2.6, decreasing to 1.4 post-treatment with both treatments. The mean therapeutic delay for surgery and endovascular treatment showed no statistically significant difference. Surgical treatment demonstrated significantly lower failure rates (5% vs. 46%, p < 0.01). In the surgical group, 2 transient neurological (1 epidural hematoma, 1 CSF leak) and 3 non-neurological (3 wound infections) complications were recorded; while 2 permanent neurological (spinal infarcts), and 5 non-neurological (inguinal hematomas) were reported in the endovascular group. According to the literature review and this multicenter clinical series, surgical treatment has a significantly lower failure rate than endovascular treatment. Although the two treatments have similar complication rates, endovascular treatment seems to have a higher rate of persistent neurological complications.

Cerebral dural arteriovenous fistulas in patients with PTEN-related hamartoma tumor syndrome.

Central nervous system (CNS) dural arteriovenous fistulas (DAVF) have been reported in PTEN-related hamartoma tumor syndrome (PHTS). However, PHTS-associated DAVF remain an underexplored field of the PHTS clinical landscape. Here, we studied cases with a PTEN pathogenic variant identified between 2007 and 2020 in our laboratory (n = 58), and for whom brain imaging was available. Two patients had DAVF (2/58, 3.4%), both presenting at advanced stages: a 34-year-old man with a left lateral sinus DAVF at immediate risk of hemorrhage, and a 21-year-old woman with acute intracranial hypertension due to a torcular DAVF. Interestingly, not all patients had 3D TOF/MRA, the optimal sequences to detect DAVF. Early diagnosis of DAVF can be lifesaving, and is easier to treat compared to developed, proliferative, or complex lesions. As a result, one should consider brain MRI with 3D TOF/MRA in PHTS patients at genetic diagnosis, with subsequent surveillance on a case-by-case basis.

Group-level stability but individual variability of neurocognitive status after awake resections of right frontal IDH-mutated glioma.

Awake surgery for low-grade gliomas is currently considered the best procedure to improve the extent of resection and guarantee a "worth living life" for patients, meaning avoiding not only motor but also cognitive deficits. However, tumors located in the right hemisphere, especially in the right frontal lobe, are still rarely operated on in awake condition; one of the reasons possibly being that there is little information in the literature describing the rates and nature of long-lasting neuropsychological deficits following resection of right frontal glioma. To investigate long-term cognitive deficits after awake surgery in right frontal IDH-mutated glioma. We retrospectively analyzed a consecutive series of awake surgical resections between 2012 and 2020 for right frontal IDH-mutated glioma. We studied the patients' subjective complaints and objective neuropsychological evaluations, both before and after surgery. Our results were then put in perspective with the literature. Twenty surgical cases (including 5 cases of redo surgery) in eighteen patients (medium age: 42.5 [range 26-58]) were included in the study. The median preoperative volume was 37 cc; WHO grading was II, III and IV in 70%, 20%, and 10% of cases, respectively. Preoperatively, few patients had related subjective cognitive or behavioral impairment, while evaluations revealed mild deficits in 45% of cases, most often concerning executive functions, attention, working memory and speed processing. Immediate postoperative evaluations showed severe deficits of executive functions in 75% of cases but also attentional deficits (65%), spatial neglect (60%) and behavioral disturbances (apathy, aprosodia/amimia, emotional sensitivity, anosognosia). Four months after surgery, although psychometric z-scores were unchanged at the group level, individual evaluations showed a slight decrease of performance in 9/20 cases for at least one of the following domains: executive functions, speed processing, attention, semantic cognition, social cognition. Our results are generally consistent with those of the literature, confirming that the right frontal lobe is a highly eloquent area and suggesting the importance of operating these patients in awake conditions.

Endovascular treatment of infectious intracranial aneurysms complicating infective endocarditis: a series of 31 patients with 55 aneurysms.

PURPOSE: Endovascular treatment (EVT) has become a major option in management of infectious intracranial aneurysms (IIAs) complicating infective endocarditis. We report a retrospective, single-center series of consecutive patients with IIAs treated by EVT. METHODS: Patients were included from January 2009 to July 2020. IIAs were diagnosed on DSA. Each patient underwent a neurological assessment before and after EVT and was followed up by imaging within 15 days of EVT. Safety was assessed on the evolution of NIHSS score. A minor stroke was defined as a worsening of NIHSS < 4 points. Efficacy was defined as the absence of hemorrhagic event during cardiac surgery and the exclusion of the IIA on control imaging. RESULTS: Sixty-two IIAs (30 ruptured) were diagnosed in 31 patients. Fifty-six IIAs were diagnosed on the first DSA and 6 on the early control exploration. EVT was achieved in 55 IIAs by parent artery occlusion with glue in 52 distal IIAs and coils in 3 proximal IIAs. IIAs were located in 90.9% of cases on a fourth-division branch of a cerebral artery. The neurological examination remained unchanged in 29 patients (93.5%), and 2 patients suffered minor stroke. EVT was performed before cardiac surgery in 20/22 patients. All treated IIAs were excluded on follow-up imaging. No hemorrhage was observed during cardiac surgery or in the aftermath. Seven (11.3%) unruptured IIAs were not embolized. CONCLUSION: EVT of IIAs by occlusion of the parent artery is effective in preventing rupture and carries no significant neurological risk.

Recurrent vestibulopathy: are cVEMP, oVEMP and inner ear MRI useful to distinguish patients with Menière's disease and vestibular migraine?

PURPOSE: The aim of this study was to assess the rate of endolymphatic hydrops (EH) on MRI and the rate of otolithic dysfunction with cVEMP and oVEMP, in patients with recurrent vertigo such as Menière's disease (MD), vestibular migraine (VM) and vestibular Menière's disease (vMD). METHODS: In this retrospective study, we performed 3D-FLAIR sequences with delayed acquisition in 20 MD, 20 VM and 20 vMD patients. Each subject was then assessed for the presence of EH on MRI. All patients underwent pure-tone audiometry, cVEMP and oVEMP. RESULTS: In MD patients, EH was observed in 18 (90%) out of 20 patients while EH was observed in only 1 MV (5%) and 1 vMD (5%) patients. We found significant differences between groups for the presence of EH on MRI (p = 0.001). MD patients had significant higher PTA level (p < 0.001) and oVEMP impairment than MV and vMD (p = 0.08 and p = 0.06, respectively). However, no significant differences were observed for cVEMP impairment, either asymmetric ratio (p = 0.36) and 1000/500 ratio (p = 0.20). CONCLUSIONS: Concerning cVEMP, we observed no significant differences between VM, vMD and MD. However, we observed higher oVEMP impairment, PTA level and EH on MRI in MD patients. We believe that MRI could be used to differentiate MD from VM patients with cochlear symptoms. However, in cases of migraine associated with recurrent vertigo and without cochlear symptoms, we believe that MRI is not a useful tool to differentiate between VM and vMD.

Distribution of symptomatic cerebral vasospasm following subarachnoid hemorrhage assessed using cone-beam CT angiography.

BACKGROUND AND PURPOSE: Cone-beam CT angiography (CB-CTA) provides a three-dimensional spatial resolution which is, so far, unmatched in clinical practice compared with other conventional techniques such as two-dimensional digital subtracted angiography. We aimed to assess the distribution of symptomatic cerebral vasospasm following aneurysmal subarachnoid hemorrhage (aSAH) using CB-CTA. METHODS: 30 consecutive patients with aSAH undergoing vasospasm percutaneous balloon angioplasty (PBA) were recruited and underwent CB-CTA in this single-center prospective cohort series. Intracranial arteries were systematically analyzed by two independent observers from the large trunks to the distal cortical branches and perforators using a high-resolution reconstruction protocol. Intermediate and severe cerebral vasospasm was defined as 30-50% and >50% narrowing in the diameter of the vessel, respectively. RESULTS: 35 arterial cervical artery territories were analyzed, of which 80% were associated with clinical or radiological signs of delayed cerebral ischemia. The median spatial resolution was 150 µm (range 100-250 µm). Intermediate or severe vasospasm was observed in the proximal (86%, 95% CI 74% to 97%), middle (89%, 95% CI 78% to 99%), and distal (60%, 95% CI 44% to 76%) segments of the large trunks, as well as the cortical branches (11%, 95% CI 1% to 22%). No vasospasm was observed in basal ganglia or cortical perforators, or in arteries smaller than 900 µm. Vasospasm was more severe in middle or distal segments compared with proximal segments in 43% (95% CI 26% to 59%) of cases. CONCLUSIONS: Our study demonstrated that symptomatic cerebral vasospasm following aSAH did not involve arteries smaller than 900 µm, and frequently predominated in middle or distal segments. These results offer new insights into the potential management options for vasospasm using PBA.

Results of watchful waiting of unruptured intracranial aneurysms in a Western patient population: a single-center cohort.

BACKGROUND: The natural history of unruptured intracranial aneurysms (UIAs) in Western populations is still debated, especially for those <7 mm. Reporting data of a large single-center cohort managed with watchful waiting is therefore interesting. METHODS: From January 2011 to June 2019, 662 UIAs were followed up by yearly MR angiography. Morphologically stable UIAs were managed conservatively while unstable UIAs were offered treatment. The patients' clinical and radiological data were analyzed retrospectively. RESULTS: UIAs were ≤4 mm in 60%, 4.1-7.0 mm in 33%, and >7 mm in 7%. They were located on the anterior circulation in 90% of cases. The mean follow-up duration was 51.32 months for a total of 2831 aneurysm-years. During follow-up, 37 UIAs (5.5%) were treated because of an increase in size, and 8 UIAs were treated because of patient decision. Three aneurysms ruptured during follow-up for an annual risk of rupture of 0.1% (95% CI 0% to 0.24%). No risk factors for rupture were identified. The three ruptured cases made an excellent recovery. During follow-up, annual mortality from unrelated causes was 0.8% (95% CI 0.51% to 1.18%). CONCLUSIONS: This single-center cohort evaluated our watchful waiting policy applied in two-thirds of all incidental UIAs. Morphological change of UIAs during follow-up led to treatment in 5.5% of cases. With such a management paradigm, we found a low rupture rate in these selected UIAs and the mortality was unrelated to aneurysms.

Transarterial embolization of dural arteriovenous fistulas of the lateral sinuses with stent-assisted sinus protection.

BACKGROUND: The balloon-assisted sinus protection technique has been described as a sinus-preserving technique during transarterial embolization (TAE) of dural arteriovenous fistulas (DAVFs). However, some serious complications of this technique have been documented. OBJECTIVE: To describe our preliminary experience with a new technique called stent-assisted sinus protection (SSP). METHODS: We performed a retrospective analysis of seven consecutive patients with type I or IIa DAVFs of the lateral sinus treated by TAE with a closed-cell stent temporarily deployed in the sinus. RESULTS: Of the seven patients, four had type I DAVF, and three had type IIa DAVF. The patency of all involved sinuses and their tributaries (including the inferior anastomotic vein and the superior petrosal sinus) was preserved. At the end of the procedure, all stents were successfully retrieved with embolic particles trapped in their meshes. No procedural complications were noted. Clinical follow-up was satisfactory, with complete resolution or significant reduction of pulsatile tinnitus. CONCLUSIONS: SSP appears to be feasible and probably safe. However, larger studies are needed to confirm these preliminary results.

Multi-centric European post-market follow-up study of the Neuroform Atlas Stent System: primary results.

BACKGROUND: Few prospective series have described the safety and effectiveness of the Neuroform Atlas Stent System. We aimed to investigate the efficacy and safety of the device in patients treated for unruptured aneurysm. METHODS: ATLAS EU PMCF is a consecutive, prospective, multicentric study that included patients with unruptured saccular aneurysm of all sizes. Follow-up visits were scheduled at 3-6 months and 12-16 months with digital subtraction angiography (DSA) or MRI imaging follow-up as per the site standard of care. The primary efficacy endpoint was adequate aneurysm occlusion (Raymond Roy occlusion grade I and II) on 12 month angiography. The primary safety endpoint was any major stroke or ipsilateral stroke or neurological death within 12 months. RESULTS: Of the 106 patients consented, 105 were treated with at least one Neuroform Atlas stent. There was a failed implantation attempt in 1 patient, 85 patients received lateral stenting, and 19 patients received Y-stenting. Mean aneurysm neck size was 4.2 mm (range 1.9-33 mm). Adequate occlusion was observed in 95.1% immediately after the procedure and in 98.9% of cases at 1 year DSA follow-up. Overall, 1.0% (1/102; 95% CI 0.0% to 5.3%) of patients experienced a primary safety endpoint of major stroke. Three minor strokes resulted in a modified Rankin Scale score of 2. CONCLUSIONS: In this multicentric, prospective study, stent-assisted coiling of medium size unruptured aneurysms with the Neuroform Atlas stent resulted in a favorable rate of satisfactory occlusion. In our findings, the use of the Y-stenting technique was associated with increased rates of procedural complications. CLINICAL TRIAL REGISTRATION: https://clinicaltrials.gov/ct2/show/NCT02783339.

Venous sinus stenting after repair of skull base spontaneous cerebrospinal fluid leaks: A single-center retrospective cohort series with case-control analysis.

BACKGROUND: Management of idiopathic intracranial hypertension (IIH) is recommended after surgical repair of spontaneous cerebrospinal fluid leaks (sCSF-leaks) of the skull base for prevention of recurrence. PURPOSE: To assess the feasibility of venous sinus stenting, a treatment commonly used for the treatment of IIH associated with intracranial venous sinus stenosis (VSS), after sCSF-leaks closure. MATERIALS AND METHODS: A single-center cohort series of consecutive patients who underwent sCSF-leak closure was retrospectively analyzed. Stenting was considered either for leak recurrence or in prophylactic manner after repair in patients with VSS as confirmed by cerebral venous imaging. Leak recurrence, need for new repair or adjunctive treatment of IIH, meningitis, and stenting complications were determined at the last follow-up. Cases who had prophylactic stenting were compared to historical controls before stenting option. RESULTS: Twenty-two patients had intracranial venous stenting after sCSF-leak closure. Their median age was 58 years (Q1=45; Q3=68), BMI=31 kg.m-2 (Q1=27; Q3=36), and female rate=85%. The overall rate of successful repair after stenting was 95% (95% CI = 87-100%) at a median follow-up of 2.4 years (Q1=1.2; Q3=3.3). Adjunctive treatment for IIH was needed in 4 patients (4/22, 18%) including 2 patients without leak recurrence. No meningitis, permanent morbidity or mortality was observed after stenting. Compared to 18 controls, cases had significantly less recurrence (P = 0.03), and a trend for less adjunctive treatment for IIH (P = 0.06). CONCLUSIONS: Our study suggests that stenting might be a valid option for prevention of sCSF-leak recurrences after repair in patients with intracranial venous sinus stenosis.

Iterative denoising accelerated 3D SPACE FLAIR sequence for brain MR imaging at 3T.

PURPOSE: The purpose of this study was to prospectively evaluate image quality of three-dimensional fluid attenuated inversion recovery (3D-FLAIR) sequence acquired with a high acceleration factor and reconstructed with iterative denoising (ID) for brain magnetic resonance imaging (MRI) at 3-T. MATERIAL AND METHODS: Patients with brain tumor who underwent brain MRI were consecutively included. Two 3D-FLAIR sequences were successively performed for each patient. A first conventional FLAIR acquisition (conv-FLAIR) was performed with an acceleration factor of 6. The second acquisition was performed with an increased acceleration factor of 9. Two series one without ID (acc-FLAIR) and one with ID (acc-FLAIR-ID) were reconstructed. Two neuroradiologists independently assessed image quality, deep brain nuclei visualization and white matter/gray matter (WM/GM) differentiation on a 4-point scale. RESULTS: Thirty patients with brain tumor were consecutively included in this study. There were 16 women and 14 men with a mean age of 54 ± 17 (SD) years (range: 22-78 years). Scanning time of Acc-FLAIR-ID and Acc-FLAIR (4 min 40 sec) was 37% shorter than that of conv-FLAIR (2 min 50 sec) (P < 0.01). Improved image quality score was significantly different for both conv-FLAIR and acc-FLAIR-ID compared to acc-FLAIR (P < 0.01 for both). WM/GM differentiation score of conv-FLAIR was not significantly different compared to acc-FLAIR-ID (P = 0.10). Improved WM/GM differentiation score was different for both sequences compared to acc-FLAIR (P = 0.017 and P < 0.001). Deep brain nuclei visualization score was not different between conv-FLAIR and acc-FLAIR-ID (P = 0.71). However, the improved deep brain nuclei visualization score was significantly different for both sequences compared to acc-FLAIR (P < 0.001 for both). CONCLUSION: Scanning time of 3D-FLAIR sequence using a high acceleration factor reconstructed with ID algorithm can be reduced by 37% while preserving image quality for brain MRI.

Intracranial venous sinus stenting for the treatment of lateral sinus stenoses: An analysis of 200 patients.

PURPOSE: The purpose of this study was to analyze the long-term efficacy and safety of intracranial venous sinus stenting in a large cohort of patients with any type of presentation of primary lateral venous sinus stenosis (VSS). MATERIALS AND METHODS: A retrospective cohort study was performed including patients treated by venous sinus stenting for symptomatic VSS from 2012 to 2019. Successful primary resolution of symptoms without adjunctive treatment or recurrence, and complications after stenting were analyzed at the last follow-up time point. RESULTS: Two-hundred patients were included. There were 14 men and 186 women with a mean age of 39±14 (SD) years (age range: 13-75 years). Presenting symptoms included venous pulsatile tinnitus in 168 patients (168/200; 84%), idiopathic intracranial hypertension in 100 patients (100/200; 50%) and/or spontaneous cerebrospinal fluid leak in 35 patients (35/200; 17%). The overall rate of successful primary resolution of any typical presenting symptoms was 79% (95% CI: 73-85%). This rate ranged from 74% to 93% depending on the symptom with no significant difference between patients with and those without idiopathic intracranial hypertension (P=0.08). Recurrence rate was 10% (95% CI: 6-14%). No death or permanent morbidity were observed during a median follow-up of 2.2 years (Q1, Q3: 1.4, 3.3; range: 1-7.7 years). CONCLUSION: Our study shows that venous sinus stenting has a low morbidity and high success rate at long-term follow-up for the treatment of idiopathic intracranial hypertension, venous pulsatile tinnitus or spontaneous cerebrospinal fluid leak associated with VSS. The excellent safety suggests considering this treatment as first-line treatment when medical management is ineffective or poorly tolerated.

Long-term Kinetic Papilledema Improvement After Venous Sinus Stenting in Idiopathic Intracranial Hypertension.

BACKGROUND AND PURPOSE: The aim of this study was to assess the safety and effectiveness of lateral sinus stenosis (LSS) stenting in patients with idiopathic intracranial hypertension (IIH) who are refractory to medical treatment, particularly focusing on visual outcomes including papilledema. MATERIAL AND METHODS: Retrospective study of consecutive patients with IIH refractory to medical treatment who underwent LSS stenting. Clinical features, visual fields and optical coherence tomography (OCT) retinal nerve fiber layer (RNFL) and ganglion cell layer (GCL) thicknesses were assessed before stenting, at 1 month poststenting and at last follow-up. Complications were also recorded. RESULTS: A total of 16 women were included, with a mean age of 39 ± 11 years. All patients had papilledema while 15/16 (94%) had headaches. Mean visual acuity was 0.036 logMAR, range (+0.4 to +0.0 logMAR). The mean RNFL thickness prior to stenting was 121.7 µm (±34.7 µm) and mean GCL thickness was 80.2 µm (±8.9 µm). Mean follow-up was 19.7 months (±11.8 months). After stenting, acetazolamide was discontinued in 15/16 (94%) patients. Papilledema improved in 14/16 (88%) of patients. The mean RNFL thickness was significantly decreased 1 month after stenting (96.3 ± 15.6 µm; p < 0.001) and at last visit (93.4 ± 15.3 µm; p < 0.001). The GCL thickness after LSS stenting was moderately decreased at the last visit examination: 80.2 ± 8.9 µm vs. 78.0 ± 10.7 µm; (p < 0.01). No stent-related complication occurred, while there was one case of restenosis. CONCLUSION: Improvement of papilledema appears to occur relatively rapidly after the LSS stenting. The results further support the role of LSS stenting in the treatment of IIH, especially with respect to visual symptoms.

Aneurysms of the communicating segment of the internal carotid artery with posterior communicating artery agenesis are associated with perforator infarction after embolization.

BACKGROUND: While anatomic features associated with the risk of posterior communicating artery (PcoA) occlusion after embolization of aneurysms of the PcoA segment of the internal carotid artery (ICA) are well known, the link between perforator origin and perforator infarction has only been reported following neurosurgical clipping. The aim of this study was to determine the origin of anterior thalamic perforators and correlate it with risk of perforator infarction after embolization of PcoA segment aneurysms. METHODS: One-hundred-and-ninety consecutive patients treated for PcoA segment aneurysms between 2017 and 2019 were included. PcoA and anterior thalamic perforator origin anatomy was assessed with computed tomography (CT) angiography, digital subtracted angiography, and high-resolution three-dimensional rotational cone-beam CT angiography (CBCT-A) by two independent interventional neuroradiologists. The presence of perforator infarction after embolization was ascertained from the patient's notes and follow-up imaging. RESULTS: CBCT-A was superior in demonstrating the origin of perforators (P<0.001). The prevalence of perforator origin was estimated at 86% (95% CI 81%-92%) for PcoA, 8% (95% CI 4%-13%) for aneurysm wall, and 5% (95% CI 2%-9%) for ICA. The aneurysm wall origin was exclusively associated with PcoA agenesis, as well as higher risk of perforator infarction after aneurysm coiling compared with other variants (OR=14, 95% CI 2-88, P=0.006). CONCLUSIONS: Our study suggests that anterior thalamic perforators may arise from aneurysm wall when there is no PcoA. Anatomic association between PcoA agenesis and perforator arising from ICA could underlie such findings, and careful consideration is essential before aneurysm repair to anticipate the risk of thalamic infarction in such cases.

Embolization of Internal Carotid Artery Branches in Juvenile Nasopharyngeal Angiofibroma.

OBJECTIVE: Preoperative embolization of juvenile nasopharyngeal angiofibroma (JNA) is usually performed by the occlusion of branches of the external carotid artery (ECA). However, a significant proportion of JNAs also receive blood from the internal carotid artery (ICA). The objective of this study was to report on the feasibility and clinical impact of superselective embolization of ICA branches in complex cases of JNA. METHODS: This was a single-center retrospective study of all patients operated on for JNA between 2000 and 2018. The patients treated with embolization of branches of the ICA were identified. The results in terms of complications, intraoperative blood loss, and rate of residual disease were analyzed and compared to those of a control group of patients treated only with embolization of ECA branches and matched by age, stage, angiographic pattern, surgical approach, and previous surgery. RESULTS: Ninety-two patients were included. Embolization of branches of the ICA was attempted in 14 cases of advanced or recurrent tumors and was ultimately possible in nine cases. There were no complications after embolization. The mean intraoperative blood loss was 1428 mL. Residual disease was found in three cases (33%). There was no significant difference compared with the control group (mean intraoperative blood loss = 1355 mL, residual disease = 4 (44%); all P > .05). CONCLUSION: In this retrospective study, we report the feasibility of superselective embolization of ICA branches in selected cases of JNA. There was no observed benefit of this technique in terms of intraoperative bleeding or decreased risk of residual disease. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E775-E780, 2021.

MRI contribution for the detection of endolymphatic hydrops in patients with superior canal dehiscence syndrome.

PURPOSE: Patients with superior semicircular canal dehiscence syndrome, which can only be treated by surgery, present cochleo-vestibular symptoms related to a third-mobile window but also endolymphatic hydrops. Since cVEMP and oVEMP are disturbed by the presence of the dehiscence, the aim of the study is to assess the value of MRI for the diagnosis of endolymphatic hydrops in patients with superior semicircular canal dehiscence syndrome in comparison with cVEMP and oVEMP. METHODS: In this retrospective cohort study we enrolled 33 ears in 24 patients with superior semicircular dehiscence syndrome who underwent a 4-h delayed intravenous Gd-enhanced 3D-FLAIR MRI and pure tone audiometry, cVEMP and oVEMP. For each patient MRI images were evaluated by two radiologists who used a compartmental endolymphatic hydrops grading system in comparison with cVEMP and oVEMP. RESULTS: Endolymphatic hydrops was found on MRI in 9 out of 33 SCDS ears (27.3%). We found no significant correlation between the presence of endolymphatic hydrops on MRI and cVEMP and oVEMP (p = 0.36 and p = 0.7, respectively). However, there was a significant correlation between the presence of endolymphatic hydrops on MRI and the degree of sensorineural hearing loss, Air Conduction-Pure Tone Average level (p = 0.012) and Bone Conduction-Pure Tone Average level (p = 0.09), respectively. CONCLUSION: We demonstrated that EH might be observed in 27.3% of superior semicircular dehiscence syndrome ears. The role of inner ear MRI is important to detect endolymphatic hydrops, since cVEMP and oVEMP are disturbed by the presence of the dehiscence, because these patients could benefit from a medical treatment. LEVEL OF EVIDENCE: Level 3.

Giant intrahepatic venous malformation with localized intravascular coagulopathy. Follow-up and treatment during pregnancy.

Intrahepatic lesions in adults, commonly named hepatic hemangioma, should be called Intrahepatic Venous Malformations (IHVM), or Giant Intrahepatic Venous Malformations (GIHVM) when larger than 10 cm according to the ISSVA classification (International society study group for vascular anomalies). Localized coagulation disorders (LIC) in patients with venous malformations are quite commonly associated in venous malformations, they result in decreased fibrinogen (< 2g/l) and elevated d-dimers (> 1500 ng/ml) and might be responsible of intralesional thrombotic, pain or bleeding episodes.We report a case report of a 41 y/o patient that presented with right hypochondrium pain episodes discovering an unknown GIHVM on ultrasound imaging with a prior history of uterine bleeding episodes and multiples miscarriages.On laboratory work up the patient presented an associated localized Intravascular Coagulation (LIC) with the GIHVM. As the patient desire to become pregnant was important our multidisciplinary clinic allowed a pregnancy with close clinical, biological and imaging monitoring and follow up. Early initiation of low molecular weighted heparin (LMWH) successfully allowed an uncomplicated term pregnancy and delivery. Intrahepatic lesion stability was achieved and prevented progression from LIC to diffuse intravascular coagulation disorder (DIC)..

Association of spontaneous cerebrospinal fluid rhinorrhea with transverse venous sinus stenosis: a retrospective matched case-control study.

BACKGROUND: A significant proportion of spontaneous cerebrospinal fluid (sCSF) leaks are associated with idiopathic intracranial hypertension (IIH). The aim of this study was to assess the association between sCSF rhinorrhea and transverse venous sinus stenosis (VSS), a feature commonly observed in IIH with a proposed role in its pathophysiology. METHODS: In this single-center, retrospective, matched case-control study, venous and pituitary imaging data of consecutive patients undergoing endoscopic surgery for sCSF rhinorrhea over the last 10 years were retrospectively reviewed. Measurement of the height of the pituitary gland was used to assess empty sella and VSS was quantified as the ratio between the minimal area of the transverse sinus and the cross-sectional area of the sigmoid sinus. VSS was considered significant when it was ≥50% and bilateral. Cases were compared with 1:1 age- and sex-adjusted controls explored for causes other than IIH, intracranial mass effect, or venous thrombosis. RESULTS: Twenty-nine patients were included (median age 56 years, females 69%, body mass index [BMI] 33.8 kg/m2 ). Cases had a significantly lower height of the pituitary gland than controls (2.5 mm vs 6.6 mm, p < 0.001). Bilateral VSS was found in 23 of 29 cases (79%; 95% confidence interval [CI], 65% to 94%) vs 3 of 29 controls (10%; 95% CI, 0% to 21%), with p < 0.001. CONCLUSION: In this retrospective study, sCSF leaks were strongly associated with VSS. This novel finding provides a rationale for further investigation of the role of VSS in the onset of sCSF leaks and of the potential interest in venous stenting after the surgical repair of leaks.