Pseudoaneurysm formation following transarterial embolization of traumatic carotid-cavernous fistula with detachable balloon: An institutional cohort long-term study.

BACKGROUND: The goal of therapy for traumatic carotid-cavernous fistula (TCCF) is the elimination of fistula while maintaining patency of the parent artery. The treatment for TCCF has evolved from surgery to endovascular management using detachable balloons, coils, liquid embolic agents, covered stents, or flow-diverter stent through arterial or venous approaches. Despite the withdrawal of detachable balloons from the market in the United States since 2004, transarterial embolization with detachable balloons has currently remained the best initial treatment for TCCF in several countries. However, the pseudoaneurysm formation following transarterial detachable balloon embolization has rarely been observed in long-term follow-up. AIM: To determine the occurrence and long-term follow-up of pseudoaneurysm after transarterial detachable balloon for TCCF. METHODS: Between January 2009 and December 2019, 79 patients diagnosed with TCCF were treated using detachable latex balloons (GOLDBAL) of four sizes. Pseudoaneurysm sizes were stratified into five grades for analysis. Initial and follow-up assessments involved computed tomography angiography at 1 month, 6 month, 1 year, and longer intervals for significant cases. Clinical follow-ups occurred semi-annually for 2 years, then annually. Factors analyzed included sex, age, fistula size and location, and balloon size. RESULTS: In our cohort of 79 patients treated for TCCF, pseudoaneurysms formed in 67.1%, with classifications ranging from grade 0 to grade 3; no grade 4 or giant pseudoaneurysms were observed. The majority of pseudoaneurysms did not progress in size, and some regressed spontaneously. Calcifications developed in most large pseudoaneurysms over 5-10 years. Parent artery occlusion occurred in 7.6% and recurrent fistulas in 16.5%. The primary risk factors for pseudoaneurysm formation were identified as the use of specific balloon sizes, with balloon SP and No. 6 significantly associated with its occurrence (P = 0.005 and P = 0.002, respectively), whereas sex, age, fistula size, location, and the number of balloons used were not significant predictors. CONCLUSION: Pseudoaneurysm formation following detachable balloon embolization for TCCF is common, primarily influenced by the size of the balloon used. Despite this, all patients with pseudoaneurysms remained asymptomatic during long-term follow-up.

Dural arteriovenous fistula involving superior petrosal sinus with petrosal venous drainage in association with cerebral venous thrombosis: Literature review and illustrative case.

Background: Dural arteriovenous fistulas (DAVFs) involving superior petrosal sinus (SPS) and superior petrosal vein (SPV) are extremely rare. The pathogenesis of these fistulas remains unclear. We are illustrating 2 cases of DAVFs involving the superior petrosal sinus and veins associated with venous sinus thrombosis with a literature review. Methods: We reviewed the literature using the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines focusing on DAVFs involving the SPS and/or SPV. Additionally, we searched for additional articles through the reference lists of the included studies. Results: Our review yielded 20 articles from 1997 until 2022 involving 33 patients with 34 fistulas, including our 2 patients. The mean age was 55.1 ± 12.9 years (range 25-85), 54.5% were males (n = 18). The patients presented with hemorrhage in 36.4% (n = 12), and progressive myelopathy in 30.3% (n = 10). Most fistulas often had arterial supply from MMA, MHT, and/or OA. The fistulas had infratentorial drainage in 64.71% (n = 22), supratentorial drainage in 23.53% (n = 8), and both supra and infratentorial drainage in 11.76% (n = 4). In 27.3% (n = 9), cerebral venous thrombosis was mentioned or identified. Endovascular treatment was performed in 47.1% of cases (n = 16), surgery in 29.4% (n = 10), and combination of treatments in 23.5% (n = 8). A total of 30.3% (n = 10) of cases had incomplete recovery or poor result. Conclusion: DAVFs involving the SPS and/or SPV are associated with aggressive natural history, requiring early diagnosis and prompt treatment, leading to good prognosis. These fistulas may be acquired in origin, probably secondary to cerebral venous thrombosis.

Spontaneous complete regression of malignant cavernous sinus dural arteriovenous fistula following partial transarterial embolization with liquid embolic material: Report of two cases.

Background: Spontaneous complete regression of malignant cavernous sinus dural arteriovenous fistulas (CSDAVFs) following partial transarterial embolization is an extremely uncommon phenomenon. The mechanism responsible for this condition remains unclear. Case Description: The authors describe two cases of malignant CSDAVFs (Cognard IIb and V) treated by partial transarterial embolization with liquid embolic agents after unsuccessful transvenous embolization through various routes. Follow-up cerebral angiography in these cases confirmed complete resolution of the fistulas. Conclusion: In our two patients harboring low-flow CSDAVFs with preexisting thrombosis of the cavernous sinus (CS), it is possible that some portions of the liquid embolic materials could migrate into the fistulas, inducing thrombosis within the CS.

Dural arteriovenous fistula of the craniocervical junction along the first cervical nerve: A single-center experience and review of the literature.

BACKGROUND: Dural arteriovenous fistulas (DAVFs) of the craniocervical junction (CCJ) are relative rare lesions. Most studies of DAVFs of the CCJ included the fistulas at the foramen magnum, first cervical (C1), and second cervical (C2) level. DAVFs of the CCJ along C1 spinal nerve are rare vascular lesions with distinctive features. Our aim is to review cases of DAVFs of the CCJ along C1 spinal nerve at our institution. METHODS: From June 2008 and December 2021. We reviewed a consecutive series of intracranial and spinal DAVFs at our institution and collected all patients harboring DAVFs of the CCJ along C1 spinal nerve. Medical charts were retrospectively reviewed regarding patient demographic data (i.e., gender and age), presenting symptoms and signs, treatment methods, and neurological outcome and complications after treatment. All image studies, including cranial computed tomography (CT) scan, cervical magnetic resonance imaging, CT angiography, and digital subtraction angiography (DSA) with rotational CT angiography were analyzed by experienced neuroradiologists. The authors also review of the literature of DAVFs of the C1 spinal nerve. RESULTS: The authors identified 7 patients, including 5 men (71.4 %) and 2 women (28.6 %) with median age 54 years, range 48-72 years. Subarachnoid hemorrhage (SAH) occurred in 5 (71.4 %) patients, and progressive myelopathy in 2 (28.6 %). All fistulas except one received blood supply from the radiculomeningeal branch of the VA at C1 level. Venous aneurysms, being the source of bleeding, were detected in all fistulas with SAH. All patients except one were treated by surgical management. One fistula was treated by balloon-assisted Onyx embolization. Most patients had good neurological outcome following surgery. Complete obliteration of all fistulas treated by surgery was confirmed by follow-up DSA obtained 1 week after surgery. Two patients developed temporary pain and spasm of the trapezius muscle after the surgery. One patient resulted in poor neurological outcome and died due to sepsis and acute upper gastrointestinal bleeding one month after failed embolization. For patients with SAH, only one patient required ventriculoperitoneal shunt. CONCLUSIONS: DAVFs of the CCJ along the first spinal nerve are rare and a unique subtype of DAVFs at the CCJ. These fistulas account for 1.74 % of all intracranial and spinal DAVFs in the present study. SAH is the major manifestation of DAVFs at C1 spinal nerve that may be overlooked on routine initial DSA. Rotational CT angiography is useful for clarification of the angioarchitecture of these fistulas, including small feeding artery and venous varix. Surgical treatment by interruption of the intradural draining vein should be the treatment of choice for C1 spinal nerve DAVF.

Preoperative Transarterial Embolization of a Large Petrotentorial Angiomatous Meningioma Using Combination of Liquid Embolic Materials: A Case Report.

Intracranial angiomatous meningiomas are a rare WHO grade I histological variant of meningioma whose vascular component exceeds 50% of the total tumor area. Preoperative embolization of angiomatous meningiomas has rarely been reported previously. A 58-year-old woman was referred to our institute for a large petrotentorial hypervascular tumor presented with progressively worsening right facial paralysis and hearing loss for 6 months. Cranial computed tomography scan and magnetic resonance imaging revealed a large homogenously enhancing multilobulated mass involving middle and posterior cranial fossae with marked brainstem compression. The tumor extended into a right internal auditory canal and labyrinthine structures with destructive changes of bony structures. Magnetic resonance angiography showed hypervascularity in the tumor. Preoperative transarterial embolization using liquid embolic materials was successfully performed with resulting in almost complete devascularization of the tumor. Adequate hemostasis was achieved following gross total resection of the tumor (Simpson grade II). A histopathological examination confirmed the diagnosis of an angiomatous meningioma. Preoperative transarterial embolization of angiomatous meningioma with liquid embolic material was safe and effective in reducing perioperative blood loss and facilitating total tumor resection.

Filum Terminale Arteriovenous Fistula Coexisting with a Large L2-L3 Disc Sequestration and Associated Diffuse Lumbar Arachnoiditis.

The authors describe a case of filum terminale arteriovenous fistula (FTAVF) in association with a large L2-L3 disc sequestration and diffuse lumbar arachnoiditis. A 64-year-old male manifested with chronic back pain and gait difficulty. Magnetic resonance imaging (MRI) of the thoracic and lumbosacral spine revealed spinal cord congestion extending from the conus medullaris to the level of T9. There was a large disc sequestration came from L2-L3 disc herniation. In addition, thickening, clumping, and enhancement of the entire cauda equina were noted, probably representing arachnoiditis. MR angiography (MRA) and spinal angiography confirmed FTAVF at the level of L5. The patient underwent laminectomy with lysis adhesions and obliteration of the fistula. His postoperative course was uneventful. MRI and MRA of the thoracolumbar spine obtained 4 months after surgery revealed complete obliteration of the fistula and significant resolution of spinal cord congestion. Enhancement of the cauda equina roots was no longer visible. Interestingly, the significant resorption of the sequestrated disc was documented on MRI. The formation of the FTAVF in the present study may result from severe spinal canal stenosis caused by a large disc sequestration blocking the rostral venous drainage of the fistula, or chronic inflammation, and adhesions of the caudal nerve roots from lumbar arachnoiditis. It seems that FTAVF may be of acquired origin by this evidence.

Filum Terminale Arteriovenous Fistula with Additional Arterial Supply by the Posterior Spinal Artery: A Report of Two Cases.

Filum terminale arteriovenous fistulas (FTAVFs) are rare and usually supplied by the artery of the filum terminale, distal termination of the anterior spinal artery (ASA). These fistulas may also supply from the lateral sacral artery (LSA) arising from the internal iliac artery and/or middle sacral artery. Additional supply by the posterior spinal artery (PSA) has never been mentioned before. The authors describe two middle-aged men harboring FTAVFs manifested with progressive myelopathy and bowel/bladder dysfunction. The first fistula was supplied by the ASA with additional supply by the dilated PSA connecting with the ASA. Another fistula was supplied by the LSA and the PSA communicating with the ASA. The first case was successfully treated by endovascular treatment with N-butyl cyanoacrylate through the enlarged PSA, whereas the second case was surgically treated by direct obliteration of the fistula. Both patients had good neurological outcome.

Spinal epidural arteriovenous fistula with intradural venous reflux: The possibility of acquired origin caused by spinal stenosis and/or disc herniation.

BACKGROUND: Spinal epidural arteriovenous fistulas (SEAVFs) are relative rare lesions. The pathogenesis of these fistulas remains unclear. Our aim is to review cases of SEAVFs at our institution. METHODS: We reviewed a consecutive series of spinal vascular disease at our institution and collected all patients harboring SEAVFs. Medical charts were retrospectively reviewed regarding patient demographic data (i.e., gender and age), presenting symptoms and signs, previous history of spinal surgery or trauma, treatment methods, and neurological outcome after treatment. All image studies, including plain radiography, spinal MRI, MRA, and angiography were analyzed. RESULTS: We identified 9 cases of lumbosacral SEAVFs with intradural venous reflux treated at our institution from June 2010 to August 2020. Their median age was 67 years, range 52-83 years. Only one patient had a history of trauma. Interestingly, our observations found that all fistulas are associated with spinal stenosis and/or disc herniation. An additional literature search about SEAVFs coexisting with spinal stenosis and/or disc herniation was performed and found another 19 cases with median age 69 years, range 39-83 years. Only 2 patients had a history of previous spinal surgery. The level of shunted pouch in all 28 patients was correlated with the level of spinal canal stenosis and/or disc herniation. CONCLUSIONS: Our study may provide an additional evidence supporting an acquired etiology of SEAVFs, which mainly manifest in late adulthood. It is possible that spinal stenosis and/or disc herniation may result in thrombosis or impairment of venous drainage, causing increased venous pressure, leading to fistulous formation.

Intramedullary Hemorrhage Caused by Lumbosacral Epidural Arteriovenous Fistula with Dual Retrograde Perimedullary Venous Draining Routes: A Case Report and Review of the Literature.

BACKGROUND: Spinal epidural arteriovenous fistulas (SEAVFs) are rare lesions with a low risk of hemorrhage. Most patients with lumbosacral SEAVFs with hemorrhagic events will develop a spinal epidural hematoma from epidural venous pouches. To the best of our knowledge, we have reported the first case of a lumbosacral SEAVF presenting with remote intramedullary hemorrhage in the conus medullaris. CASE DESCRIPTION: A 56-year-old man presented with sudden-onset severe paraparesis and bowel/bladder dysfunction. Magnetic resonance imaging of the thoracic and lumbosacral spine showed acute intramedullary hemorrhage in the conus medullaris surrounded by spinal cord congestion extending to T8, with perimedullary flow voids along the ventral and dorsal cord surfaces. Magnetic resonance angiography and spinal angiography confirmed the presence of a SEAVF with a large lumbosacral epidural venous lake supplied by dorsal somatic branches of bilateral L4 segmental arteries. Initially, the intradural venous drainage had been misinterpreted as a single route. The patient underwent surgical interruption of the dilated intradural draining vein after embolization of the feeding vessels. Another small intradural venous drainage route was found on the follow-up angiogram. The second operation with occlusion of the initial part of the epidural venous lake was sufficient to cure this lesion. CONCLUSIONS: With the significant improvement of our patient after treatment of the SEAVF, we speculated that the intramedullary hemorrhage, which had occurred in the area of spinal cord edema, might have resulted from severe venous hypertension, rather than hemorrhagic infarction of the spinal cord. Careful evaluation of the angioarchitecture of SEAVFs is imperative to determine the most effective treatment modality.

Sacral Extradural Angiolipoma Associated with Tight Filum Terminale and Spina Bifida Coexisting with Spinal Arteriovenous Fistula.

BACKGROUND: Spinal arteriovenous fistula (AVF) may rarely associate with spinal dysraphism, that is, tethered spinal cord and spinal intradural lipoma. Spinal extradural angiolipoma coexisting with spinal AVF has not been reported in the literature. We reported an extremely rare case of sacral angiolipoma associated with tight filum terminale and sacral spina bifida coexisting with spinal AVF within this tumor. CASE DESCRIPTION: A 55-year-old women presented with progressive myelopathy for 10 months. She had a painless, slow-growing mass at her left buttock since birth. Magnetic resonance imaging of the lumbosacral spine showed an extradural mass at the level of S3-S4, extending from the spinal canal through the spina bifida to the subcutaneous fat of the left buttock. There was a low conus medullaris at S2. Magnetic resonance imaging of the thoracic spine disclosed venous congestion with tortuous intradural flow voids along both ventral and dorsal surfaces of the spinal cord. Magnetic resonance angiography and spinal angiography revealed a hypervascular mass at the sacral level and associated arteriovenous shunt with cranial drainage into an enlarged medullary vein. Due to an infected pressure sore on the mass, endovascular treatment was initially performed with minimal recovery. Six months after complete healing of her infected pressure ulcer, the patient underwent surgical removal of extradural mass containing the AVF, and subsequent release of the tight filum. Histologic findings were consistent with angiolipoma. CONCLUSIONS: Sacral extradural angiolipoma in the present case may be congenital in origin with development of an acquired spinal AVF within the tumor.

Spinal Sparganosis Coexisting with Acquired Arteriovenous Fistula of the Filum Terminale.

BACKGROUND: Spinal sparganosis associated with filum terminale arteriovenous fistula (FTAVF) has not been reported in the literature. In previous studies, these 2 rare diseases were usually reported separately. We report the first case of spinal sparganosis with concomitant FTAVF. CASE DESCRIPTION: Spinal sparganosis associated with FTAVF manifested in a middle-aged man with progressive back pain and paraparesis. Magnetic resonance imaging of the lumbosacral spine revealed large intradural mass-like lesions involving the conus medullaris and entire cauda equina. Additionally, there was degenerative spinal stenosis at the level of L2-3 to L5-S1. Magnetic resonance imaging of the thoracic spine disclosed abnormal hypersignal intensity extending from the level of the conus medullaris to T7 with tortuous intradural flow voids along the ventral more than dorsal surfaces of the spinal cord. Magnetic resonance angiography and spinal angiography confirmed FTAVF at the level of L3-4. The patient underwent surgical removal of the granulation tissues with lysis adhesions and obliteration of the FTAVF simultaneously in the same surgical session. Histologic findings were consistent with sparganosis. CONCLUSIONS: The formation of FTAVF in the present case may have resulted from severe spinal canal stenosis caused by lumbar spondylosis and spinal sparganosis, inducing chronic inflammation and severe adhesion of spinal nerve roots. This evidence indicates that FTAVF may have been acquired.

Complete Resolution of a Large Hemorrhagic Lumbar Synovial Cyst Following Spinal Fusion Alone.

The authors reported complete regression of a large hemorrhagic lumbar synovial cyst following posterior spinal fusion without direct cystic resection. A 64-year-old woman suffered from sudden onset of the left buttock pain radiating to the left leg after waking up in the morning following the previous history of a minor accident 2 months ago. Magnetic resonance imaging (MRI) of the lumbosacral spine showed a large extradural round mass originating from the left facet joint at the level of L3-L4. The mass was hyperintense on T1-weighted images and hypointense on T2-weighted images, probably compatible with hemorrhagic joint-related cyst. Surgical treatment was chosen for her because of persistent left radicular pain with no responding to medications. The patient underwent decompressive laminectomy, subtotal facetectomy, instrumented fusion, and only tissue biopsy due to severe adherence of the mass and dura. Histopathological examination was consistent with a hemorrhagic synovial cyst. The radicular pain completely disappeared after the surgery. Follow-up MRI of the lumbosacral spine obtained 6 months after the surgery demonstrated complete resolution of the hemorrhagic cyst. Complete resolution of hemorrhagic synovial cyst seems to correlate with subtotal facetectomy, probably resulting in leakage of cyst content and subsequent resorption of the cyst wall. In addition, hematoma within the synovial cyst may resolve spontaneously over time.

Spontaneous obliteration of spontaneous vertebral arteriovenous fistula associated with fibromuscular dysplasia after partial surgery: A case report.

We describe a patient with spontaneous obliteration of spontaneous vertebral arteriovenous fistula (VAVF) associated with fibromuscular dysplasia (FMD) after partial surgery. A 52-year-old hypertensive female woke up one morning with left shoulder pain and weakness of the left upper extremity. A few days later, she developed left-sided audible bruit. She was treated for left frozen shoulder and supportive treatment for audible bruit for four years. She was referred from her general physician to a neurosurgeon because of left arm weakness. Physical examination showed signs of cervical radiculomyelopathy. Magnetic resonance imaging (MRI) showed an extradural mass on the left side of the cervical spinal canal from level C2 to C6. Provisional diagnosis was epidural vascular tumour. Laminectomy and partial removal of the mass was performed at level C5 to C6. Pathological report revealed suspected vascular malformation. Postoperative MRI showed thrombosed epidural vascular structure. Angiography showed dysplastic changes of both vertebral arteries representing FMD with VAVF of the left vertebral artery at level C1-C2. Two years after surgery, follow-up MRI demonstrated complete spontaneous resolution of the large thrombosed epidural vein. Disappearance of her audible bruit immediately after surgery and gradual improvement of her cervical radiculomyelopathy were observed after two years of clinical follow-up. From the literature, we found another 11 patients with 12 VAVFs who had spontaneous obliteration or cure of their fistulas. In the present case, spontaneous obliteration of the fistula seems to correlate with surgery inducing closure of the epidural venous exit leading to thrombosis of the enlarged epidural draining vein.

Outcomes of Surgical Treatment and Radiation Therapy in En Plaque Sphenoid Wing Meningioma.

Objective: En plaque sphenoid wing meningioma is a rare tumor. Complete surgical resection is difficult. Role of adjuvant radiation therapy in treatment of meningiomas is still controversial. This present study aimed to examine the clinical outcomes and to evaluate the role of adjuvant radiation for the residual tumors. Material and Method: A retrospective study was performed in 26 patients with en plaque sphenoid wing meningioma, who underwent operation at Prasat Neurological Institution between January 2008 and December 2012. Presenting symptoms, location of tumor, surgical approach, postoperative outcomes, and adjuvant radiation were reviewed and analyzed. Results: Among the 26 patients, their ages ranged from 31 to 57 years. All tumors were removed by transcranial approach. Eleven of the patients underwent adjuvant radiation therapy and post-radiation imaging revealed tumors being stable in size. Nine patients that had regrowth tumors were not radiated. Mean followed-up time was 51.77 months (range 18-96 months). Conclusion: Proptosis, visual acuity and cosmetic problems can be improved by surgery. Postoperative adjuvant radiation therapy may be an option for residual en plaque sphenoid wing meningioma.

Pre-operative Embolization of Intracranial and Extracranial Tumors: A Review of 37 Cases

Objective: To examine the safety and efficacy of pre-operative embolization of intra-and extracranial tumors and determine the selection criteria of patients for this procedure. Material and Method: Between June 2008 and August 2012, 37 patients (17 males, 20 females; mean age, 44.2+14.2years), underwent pre-operative embolization of intra- and extracranial tumors, were retrospectively reviewed. Tumor characteristics (type, location, volume, percentage of supplying artery, presence of an early draining vein), angiographic extent of tumor devascularization, timing between embolization and surgery, estimated blood loss, and complication related embolization were evaluated. Results: There were 37 tumors (mean volume, 90.9+83.6 cm3) composed of 18 meningiomas, six hemangioblastomas, six hemangiopericytomas, one metastasis, one osteoblastoma, one osteosacroma, one neurofibroma, one central neurocytoma, one glomus jugulare, one mixed oligoastrocytoma, and one glioblastoma multiforme. Early of draining veins were visualized in 24 patients (64.9%). Failure of pre-operative embolization occurred in four patients. Median time to surgery after embolization was seven days (ranged 1-171 days). There was statistically significant difference between grading of angiographic devascularization and estimated blood loss (p = 0.009, Kruskal-Wallis test). Two patients (5.4%) had embolization-related complications, including hemorrhage during sub-selective catheterization and postoperative scalp necrosis. Conclusion: Although pre-operative embolization of intra- and extracranial tumors was safe, only extensive or complete angiographic devascularization has been effective in less intra-operative blood loss. From this present study, indications regarding when to perform pre-operative embolization include history of excessive bleeding from previous surgery, known hypervascular tumor types (e.g., hemangiopericytoma, hemangioblastoma, paraganglioma), the presence of multiple flow voids on MRI, hypervascular tumors of skull or scalp, deep-seated tumors (e.g., cranial base tumor, intraventricular tumor) with difficulty in early surgical access of the main feeding vessels, and tumors associated with intratumoral aneurysm.

Comparison of Quality-of-Life after the Three Different Techniques of Transpedicular Screw Fixation (TPSF) in Lumbar Spondylolisthesis (LS): Results of a Therapeutic Cohort Study.

Background: Transpedicular screw fixation in lumbar spondylolisthesis remains debatable for which aspects that provide better quality of life outcomes such as procedure of convention, navigation-assisted or mini-open technique. Objective: To analyze the clinical outcomes and assess pre-operative versus postoperative quality-of-life outcomes of patients diagnosed with LS who underwent three different techniques of spinal fusion. Material and Method: A prospective cohort study was conducted with 60 patients with LS who received conventional TPSF or navigation-assisted TPSF or mini-open TPSF at Prasat Neurological Institute between 2010 and 2012. The 12-month follow-up patients were recruited for a structured interview regarding social life, mental health, functional capacity or an independent living status. The quality-of-life measurement was determined using Oswestry Disability Index (ODI) and the Short Form-36 Health Survey (SF-36). Results: Comparisons of quality of life outcomes declared significant differences through the 12-month follow-up evaluation. According to ODI, navigation-assisted group presented with significant level of faster recovery than conventional and miniopen groups at one week (p = 0.031) and one month (p = 0.008) after surgery. At one year follow-up, the navigation-assisted technique was noted to have a significant better improvement (p = 0.033 and mean ODI scores = 5.8) compared with conventional and mini-open techniques (mean ODI scores = 8.7 and 10.6, respectively). Moreover, SF36 assessment indicated considerably improvement at 12 months after surgery. In addition, the finding reveals no statistically significant differences among three techniques. Conclusion: Overall, three different techniques provide the positive outcomes of quality of life. The 12-month follow-up of quality of life measures based on ODI suggest that the navigation-assisted technique was significantly associated with wellrecovered at one week and one month after surgery. However, in terms of clinical outcomes, they do not make any considerable differences to patient care within the 12-month follow-up period.

Pre-operative Embolization of Intracranial and Extracranial Tumors: A Review of 37 Cases.

Objective: To examine the safety and efficacy of pre-operative embolization of intra-and extracranial tumors and determine the selection criteria of patients for this procedure. Material and Method: Between June 2008 and August 2012, 37 patients (17 males, 20 females; mean age, 44.2+14.2years), underwent pre-operative embolization of intra- and extracranial tumors, were retrospectively reviewed. Tumor characteristics (type, location, volume, percentage of supplying artery, presence of an early draining vein), angiographic extent of tumor devascularization, timing between embolization and surgery, estimated blood loss, and complication related embolization were evaluated. Results: There were 37 tumors (mean volume, 90.9+83.6 cm3) composed of 18 meningiomas, six hemangioblastomas, six hemangiopericytomas, one metastasis, one osteoblastoma, one osteosacroma, one neurofibroma, one central neurocytoma, one glomus jugulare, one mixed oligoastrocytoma, and one glioblastoma multiforme. Early of draining veins were visualized in 24 patients (64.9%). Failure of pre-operative embolization occurred in four patients. Median time to surgery after embolization was seven days (ranged 1-171 days). There was statistically significant difference between grading of angiographic devascularization and estimated blood loss (p = 0.009, Kruskal-Wallis test). Two patients (5.4%) had embolization-related complications, including hemorrhage during sub-selective catheterization and postoperative scalp necrosis. Conclusion: Although pre-operative embolization of intra- and extracranial tumors was safe, only extensive or complete angiographic devascularization has been effective in less intra-operative blood loss. From this present study, indications regarding when to perform pre-operative embolization include history of excessive bleeding from previous surgery, known hypervascular tumor types (e.g., hemangiopericytoma, hemangioblastoma, paraganglioma), the presence of multiple flow voids on MRI, hypervascular tumors of skull or scalp, deep-seated tumors (e.g., cranial base tumor, intraventricular tumor) with difficulty in early surgical access of the main feeding vessels, and tumors associated with intratumoral aneurysm.

The accuracy of computer-assisted pedicle screw placement in degenerative lumbrosacral spine using single-time, paired point registration alone technique combined with the surgeon's experience.

OBJECTIVE: Evaluate the accuracy of computer-assisted pedicle screw placement in patients with degenerative lumbrosacral spine using single-time, paired point registration alone technique in combination with the surgeon's experience. MATERIAL AND METHOD: A computer-assisted pedicle screw insertion in lumbrosacral spine were performed in 62 consecutive patients (363 screws) using single-time, paired point registration without surface matching. After finding the entry point and trajectory of the pedicle under image guidance, the surgeon then inserted pedicle screws by his experience. Postoperative DynaCT scans were obtained and interpreted by two neuroradiologists. The Kappa statistic was used to measure the degree of interobserver agreement. The screw position was graded as follows: Grade A = entirely within the pedicle; B = medial or lateral pedicle wall breach less than 2 mm; C = medial or lateral pedicle wall breach equal to 2-4 mm; D = medial or lateral wall breach more than 4 mm. Clinical outcomes including a numeric pain score, neurologic symptoms, and complications were reviewed from all charts of patients. Additionally, the registration error, registration time, screwing time, and estimated blood loss were analyzed. RESULTS: A total of the 363 pedicle screws, the first neuroradiologist interpreted grade A in 95.6%, grade B in 4.1% and grade C in 0.3%, while the second neuroradiologist interpreted grade A in 95.3%, grade B in 3.6%, and grade C in 1.1%. There was no incidence of grade D in this present study. No neurologic or vascular injuries occurred from pedicle screw placement. The mean registration error was 1.54 +/- 1.28 (range, 0.9-2.5) mm with the mean time required for the registration process for each patient was 3.64 +/- 1.92 (range, 2-8) minutes. The mean screwing time for each patient was 20.29 +/- 9.44 (range, 13-40) minutes. The mean pain score improved from 6.45 +/- 1.74 points preoperatively to 3.04 +/- 0.82 points postoperatively. In the radiculopathy group, motor power gradually improved in all patients. CONCLUSION: The use of single-time, paired point registration without surface mapping combined with surgeon's perception for computer-assisted pedicle screw insertion has proven to be a safe and effective technique in degenerative lumbrosacral spine. The author's technique did not rely solely on the image guidance. However, the navigation system would be very beneficial to improve decision-making, especially in surgery of patients with distorted spinal anatomy. Besides, this technique may decrease the overall operative time without compromise the accuracy of pedicle screw placement.