Intracranial Hypertension Secondary to Cervical Dural Arteriovenous Fistula.

Idiopathic intracranial hypertension (IIH) is a disease of mainly unknown etiology. Latest theories as to the pathogenesis have postulated a final common pathway of cerebral venous hypertension secondary to venous outflow impairment leading to decreased cerebrospinal fluid absorption. We present the case of a 42-year-old female who was treated for several years for headache and for approximately 12 months for IIH until appropriate imaging showed a right-sided cervical dural arteriovenous fistula (AVF) at the level of C4. The patient's IIH symptoms resolved following surgical excision of the fistula. We suggest that the cranial venous outflow impairment secondary to the cervical AVF was responsible for intracranial hypertension and that complete investigation of IIH patients should include imaging of the neck vasculature.

Recurrent life-threatening haemoptysis from a bleeding vertebral artery pseudoaneurysm: A diagnostic dilemma.

A bleeding vertebral artery pseudoaneurysm is a rare cause of haemoptysis. Pseudoaneurysm can arise due to radionecrosis from previous radiotherapy in the base of skull and neck region and may present with haemoptysis many years later. It is important to be aware of this entity in the work-up of haemoptysis, particularly in patients with previous base of skull and neck radiotherapy. Our patient was successfully treated with endovascular occlusion.

Distal access using hyperflexible atraumatic distal tip with optimized proximal stability of the Benchmark intracranial guide catheter for the treatment of cerebral vascular diseases: a technical note.

BACKGROUND: A stable guide catheter position within the intracranial vasculature is critical for safe, successful endovascular treatment. OBJECTIVE: To present ourinitial experience with the 0.071 inch inner diameter Benchmark guide catheter used in the treatment of intracranial cerebrovascular pathologies, demonstrating its safety and efficacy. METHODS: We retrospectively reviewed use of the Benchmark guide catheter from September through December 2014 in the management of various neuroendovascular intracranial pathologies. Clinical performance and complication rates were evaluated, with particular consideration of vessel tortuosity. A total of 62 Benchmarks were used, 47 in the anterior circulation, 10 in the posterior circulation, 4 in the external carotid, and 1 in the venous sinus. The five cases with access to the external carotid and venous sinus were excluded. RESULTS: The Benchmark was able to cross at least one 90° turn in 49 (86%) of the 57 patients. Reversal of the catheter was seen in 15% of 47 anterior circulation cases (4 at one 90° turn; 3 at two 90° turns). We report no complications of dissection or thromboembolic events. All guide catheter positions were safely achieved over a 0.035 Terumo stiff glidewire without need for an inner smaller lumen guide catheter for navigation. CONCLUSIONS: Benchmark is a new guide catheter, with an ideal combination of both hyperflexible, atraumatic distal tip and optimized proximal shaft support to provide stable 6F primary access for a successful neurointerventional procedure. Benchmark can be easily, safely, and consistently positioned in a desired location within intracranial arteries providing a stable position for intervention and adequate angiography.

Initial experience of coiling cerebral aneurysms using the new Comaneci device.

We present our initial patient experience with an innovative temporary bridging device, the Comaneci (Rapid Medical, Israel), to assist in the coiling of cerebral aneurysms. The Comaneci device confers the same benefits as balloon remodeling but without the risks of parent artery occlusion. This alleviates time pressure on the clinician, and could reduce the risk of parent artery thrombosis. Three patients were treated with the Comaneci device. Two patients had acute ruptured posterior communicating aneurysms and one patient was treated electively for a carotico-ophthalmic aneurysm. Excellent occlusion of all three aneurysms was obtained. One patient developed a distal middle cerebral artery clot, that was treated with intravenous aspirin, with minor neurological consequences. These early results show that the Comaneci device can be used to achieve good cerebral aneurysm occlusion. Vessel patency is maintained throughout the procedure with potential advantages over conventional balloon assisted coiling.

Novel use of 4D-CTA in imaging of intranidal aneurysms in an acutely ruptured arteriovenous malformation: is this the way forward?

Ruptured arteriovenous malformation (AVM) is a frequent cause of intracranial hemorrhage. The presence of associated aneurysms, especially intranidal aneurysms, is considered to increase the risk of re-hemorrhage. We present two cases where an intranidal aneurysm was demonstrated on four-dimensional CT angiography (time-resolved CT angiography) (4D-CTA). These features were confirmed by digital subtraction angiography (catheter arterial angiogram). This is the first report of an intranidal aneurysm demonstrated by 4D-CTA. 4D-CTA can offer a comprehensive evaluation of the angioarchitecture and flow dynamics of an AVM for appropriate classification and management.

Surgical disconnection of the cortical venous reflux for high-grade intracranial dural arteriovenous fistulas.

OBJECTIVES: To assess the clinical outcome, complications, and angiographic outcomes after surgical disconnection of intracranial dural arteriovenous fistulas (DAVFs). METHODS: Analysis of prospectively collected data, including clinical presentation, preoperative angiographic findings, postoperative complications, clinical, and angiographic outcomes. RESULTS: Between January 2002 and January 2012, 25 patients underwent surgery for DAVFs. The anatomical locations included tentorial (8), ethmoidal (8), foramen magnum (5), middle fossa (2), torcular (1), and parafalcine (1). All had cortical venous reflux (CVR) and all were treated with craniotomy and disconnection of CVR. Two patients required repeat surgery for residual CVR. One patient had a postoperative seizure. There were no other complications. All patients had complete disconnection of CVR confirmed by digital subtraction angiography. None of the patients have had hemorrhage or recurrence of CVR on follow-up. CONCLUSIONS: Surgical disconnection of CVR for high-grade intracranial DAVFs is highly effective and can be performed with very low complication rates. Where embolization cannot be performed safely, surgical disconnection (rather than stereotactic radiosurgery) is the treatment of choice for high grade DAVFs.

Anomalous cerebral venous sinus drainage.

The case discussed is a 58 year old female that presented with sudden onset of headache, a Glasgow Coma Score of 15 and no neurological deficit. Computed tomography (CT) scan of the brain did not show any evidence of haemorrhage. CT angiography revealed a left sided cerebellar ateriovenous malformation with the Digital Subtraction Angiography (DSA) also showing anomalous posterior fossa venous sinus anatomy. In this case the occipital sinus provided the only drainage pathway for both the superior sagittal sinus (SSS) and the straight sinus. Of clinical significance is during the routine method of access to midline posterior fossa surgery the occipital sinus is ligated and divided. This would have resulted in massive venous infarction. Highlighting the importance of reviewing the venous anatomy on radiological images prior to neurosurgical procedures.

Doppler sonographic evaluation of shunts in patients with dural arteriovenous fistulas.

BACKGROUND AND PURPOSE: Doppler sonography has been used to assess global cerebral circulation time (CCT) in healthy volunteers and a small number of patients with cerebral arteriovenous malformations. We evaluated the effect of arteriovenous shunts on global CCT in patients with dural arteriovenous fistulas (DAVFs) by using this Doppler echo contrast-bolus tracking test. METHODS: We measured CCT as the time delay in a contrast bolus to the internal carotid artery (ICA) and internal jugular vein (IJV) in 13 patients with DAVF and 30 age-matched control subjects. Mean CCT and mean arterial and venous rise times (Delta t = 80% of total signal-intensity increase) were compared. Posttreatment follow-up measurements were performed in five patients. RESULTS: Mean CCT and venous Delta t were significantly different between patients and controls (CCT, 1.1 +/- 0.9 vs 6.9 +/- 1.2 seconds, P <.0001; venous Delta t, 5.2 +/- 2.0 vs 7.0 +/- 2.6 seconds, P =.024), but arterial Delta t values were not (4.4 +/- 1.8 vs 4.7 +/- 2.0 seconds). Posttreatment follow-up of two occluded fistulas showed CCT normalization. One near-occlusion showed a two-step increase in signal intensity, and incomplete occlusion in two patients left the CCT unchanged. One patient with an extracranial, highly vascularized glomus tumor draining into the IJV had a CCT of 1.8 seconds. CONCLUSION: In DAVF patients, sonographic CCT is significantly shortened. Our test is highly sensitive for arteriovenous shunts but not specific for DAVF alone. Follow-up measurements in DAVF patients are well correlated with results of angiographic treatment. CCT assessment might become an additional tool for evaluating these patients and monitoring their treatment.