Minimum and early high-energy sonication protocol of MR-guided focused ultrasound thalamotomy for low-skull density ratio patients with essential tremor and Parkinson's disease.

OBJECTIVE: MR-guided focused ultrasound (MRgFUS) thalamotomy is an incisionless neurosurgical treatment for patients with medically refractory essential tremor and tremor-dominant Parkinson's disease. A low skull density ratio (SDR) < 0.40 is a known risk factor for treatment failure. The aim of this study was to identify useful sonication strategies for patients with a low SDR < 0.40 by modifying the standard sonication protocol using maximum high-energy sonication while minimizing the number of sonications. METHODS: The authors retrospectively analyzed the effects of modified MRgFUS sonication on low-SDR tremor patients. All patients underwent head CT scans to calculate their SDR. The SDR threshold for MRgFUS thalamotomy was 0.35. The patients in the early series underwent the standard sonication protocol targeting the ventral intermediate nucleus contralateral to the treated hand side. The patients with a low SDR < 0.40 in the late series underwent a modified sonication protocol, in which the number of alignment sonications was minimized and high-energy treatment sonication (> 36,000 J) was used. The authors evaluated the lesion volume the following day and tremor improvement and adverse events 3 and 12 months after the procedure. The sonication patterns between low-SDR patients treated using different sonication protocols were examined using Fisher's exact test. ANOVA was used to examine the lesion volume and tremor improvement in high- and low-SDR patients treated using different sonication protocols. RESULTS: Among 41 patients with an SDR < 0.40, 14 underwent standard sonication and 27 underwent modified sonication. Fewer alignment sonications and high-energy treatment sonications were used in the modified sonication group compared with the standard group (p < 0.001). The duration of modified sonication was significantly shorter than that of standard sonication (p < 0.001). The lesion volume and tremor improvement significantly differed among the high- and low-SDR groups with different sonication protocols (p < 0.001). Low-SDR patients treated using modified sonication protocols had comparable lesion volume and tremor improvement to the high-SDR group. The modified sonication protocol did not significantly increase adverse intraprocedural and postprocedural events. CONCLUSIONS: Minimizing alignment sonications and applying high-energy sonication in early treatment help to create an optimal lesion volume and control tremor in low-SDR patients.

Two reports of iatrogenic pseudoaneurysms intraoperatively induced by an ultrasonic surgical aspirator: A rare intraoperative complication.

Background: The ultrasonic surgical aspirator is widely used in intracranial tumor resection as this instrument is considered safe. The advantage of an ultrasonic surgical aspirator is that it does not damage vessels or nerves close to the tumor. Therefore, limited information exists regarding intraoperative arterial injury by the ultrasonic surgical aspirator. Case Description: We report two cases. The first case was a 30-year-old woman who underwent surgery for a recurrent craniopharyngioma, and the second was a 50-year-old man who underwent surgery for a meningioma. A craniopharyngioma encased the basilar artery in the former case, and the superior cerebellar artery was encased by a meningioma in the latter. An ultrasonic surgical aspirator was used to resect the tumors in two cases. During surgery, the arteries involved in the tumors were unintentionally injured using an ultrasonic surgical aspirator. Intraoperative hemostasis was achieved for the bleeding from the injured arteries. However, postoperative digital cerebral angiography revealed pseudoaneurysms in the injured arteries. A subarachnoid hemorrhage occurred in the first case. The pseudoaneurysms were managed using endovascular embolization. Conclusion: Intraoperative arterial injury can occur with the application of an ultrasonic surgical aspirator. Neurosurgeons should be cautious when using ultrasonic surgical aspirators to avoid damaging the arteries involved with the tumor.

A synovial cyst-induced vertebral artery dissection in bow hunter's stroke: illustrative case.

BACKGROUND: Bow hunter's stroke (BHS) is a rare condition characterized by occlusion of the vertebral artery (VA) due to a head rotation. BHS typically results from neck hyperrotation, often due to anatomical factors. The authors present a case of BHS in a young male patient exacerbated by os odontoideum (OD), resulting in atlantoaxial dislocation, which ultimately led to VA dissection. OBSERVATIONS: A man in his 20s presented with persistent dizziness and nausea and initially received a diagnosis of a brain infarction. However, imaging revealed VA dissection caused by an OD with an associated synovial cyst. Surgical intervention, specifically atlantoaxial posterior fixation, resolved the instability and allowed for natural regression of the synovial cysts, preventing further vascular events. In this case, the OD with atlantoaxial dislocation was identified as the causative factor for BHS. The coexistence of a synovial cyst was a unique finding, likely triggered by chronic irritation caused by the OD. LESSONS: This case emphasizes the importance of thorough cervical spinal evaluation in young patients presenting with posterior circulation stroke. https://thejns.org/doi/10.3171/CASE2487.

Intraventricular pituicytoma: illustrative case.

BACKGROUND: Pituicytoma is a rare glial neoplasm from pituicytes of the neurohypophysis or infundibulum. It occurs in the sella and suprasellar area, and it is extremely uncommon to observe intraventricular pituicytoma without affecting the infundibulum or infundibular recess. OBSERVATIONS: A 69-year-old man had suffered progressive dementia for 6 months. Magnetic resonance imaging revealed a solid, homogeneously enhancing mass with flow voids within the anterior third ventricle. The sella, suprasellar area, infundibulum, and infundibular recess were unaffected. The patient underwent a transcallosal transchoroidal approach, which ended in partial removal of the tumor due to significant tumoral bleeding. A second surgery resulted in its subtotal removal. The tumor had bipolar cells, and their nuclei were immunoreactive for thyroid transcription factor-1. A DNA methylation analysis corresponded to the methylation class of pituicytoma, granular cell tumor, and spindle cell oncocytoma. Pituicytoma was the diagnosis based on these results. A systematic review identified 5 intraventricular pituicytoma cases. LESSONS: Intraventricular pituicytoma can grow without involvement of the infundibulum or infundibular recess. The current case suggests that pituicytes of the hypothalamic tuber cinereum can also give rise to pituicytoma. Because of the hypervascular nature of intraventricular pituicytomas, it is imperative to control intraoperative bleeding with attention to the adjacent hypothalamus. https://thejns.org/doi/10.3171/CASE24247.

Modified Atlantoaxial Arthrodesis Technique for Atlantoaxial Instability via Intraarticular Autografting Using Structural Iliac Bone: Technical Nuances and Case Series.

OBJECTIVE: The present study described a modified technique of atlantoaxial arthrodesis in patients with atlantoaxial instability (AAI) along with the postoperative clinical and radiological results. METHODS: Five patients underwent this method for their AAI concurrent with C1 arch hypoplasia and/or the development of odontoid pannus causing myelopathy. After thorough exposure of the posterior surface of the C1-2 complex, the bilateral C2 nerve roots were sectioned to allow for easier access to the C1/2 facet joints. To prepare a suitable grafting bed, the C1/2 facet capsule was opened, and then the articular cartilaginous and synovial tissues were thoroughly removed. After being properly fashioned to match the gap between the C1/2 facet joint spaces, the structural bone grafts from the iliac crest were directly inserted into the facet joint spaces. To alleviate cord compression caused by concomitant odontoid pannus and/or hypoplastic C1 arch, C1 laminectomy was necessitated in all cases. Subsequently, posterior screw-rod instrumental fixation was conducted. RESULTS: All 5 patients underwent this procedure successfully. Clinical and radiological follow-up data of all patients indicated favorable relief of clinical symptoms and early rigid C1-2 stability. The sequelae of C2 nerve resection were not remarkable. No other neural or vascular damage associated with this technique was observed. CONCLUSIONS: Modified atlantoaxial arthrodesis via intraarticular autografting using the structural iliac bone combined with posterior instrumentation appears to be an efficient alternative treatment method for AAI patients with concurrent pathologies, even when the C1-2 posterior arches are unavailable for the grafting bed.

Quantitative susceptibility mapping and a nonlinearly transformed atlas for targeting the ventral intermediate nucleus of the thalamus in a patient with tremor and thalamic hypertrophy: illustrative case.

BACKGROUND: The ventral intermediate nucleus (Vim) of the thalamus is a surgical target for treating various types of tremor. Because it is difficult to visualize the Vim using standard magnetic resonance imaging, the structure is usually targeted based on the anterior and posterior commissures. This standard targeting method is practical in most patients but not in those with thalamic asymmetry. The authors examined the usefulness of quantitative susceptibility mapping (QSM) and transformed Vim atlas images to estimate the Vim localization in a patient with tremor and significant thalamic hypertrophy. OBSERVATIONS: A 51-year-old right-handed female had experienced a predominant left-hand action tremor for 6 years. Magnetic resonance imaging showed significant hypertrophy of the right thalamus and caudal shift of the thalamic ventral border. The authors referred to the QSM images to localize the decreased susceptibility area within the lateral ventral thalamic nuclei to target the Vim. In addition, the nonlinearly transformed Vim atlas images complemented the imaging-based targeting. The radiofrequency thalamotomy at the modified Vim target relieved the tremor completely. LESSONS: A combination of QSM and nonlinear transformation of the thalamic atlas can be helpful in the targeting method of the Vim for tremor patients with thalamic asymmetry.

Lipocalin-type prostaglandin D synthase: a glymphopathy marker in idiopathic hydrocephalus.

Idiopathic normal pressure hydrocephalus in elderly people is considered a form of glymphopathy caused by malfunction of the waste clearance pathway, called the glymphatic system. Tau is a representative waste material similar to amyloid-ß. During neurodegeneration, lipocalin-type prostaglandin D synthase (L-PGDS), a major cerebrospinal fluid (CSF) protein, is reported to act as a chaperone that prevents the neurotoxic aggregation of amyloid-ß. L-PGDS is also a CSF biomarker in idiopathic normal pressure hydrocephalus and significantly correlates with tau concentration, age, and age-related brain white matter changes detected by magnetic resonance imaging. To investigate this glymphopathy, we aimed to analyze white matter changes and contributing factors in vivo and their interactions ex vivo. Cerebrospinal tap tests were performed in 60 patients referred for symptomatic ventriculomegaly. Patients were evaluated using an idiopathic normal pressure hydrocephalus grading scale, mini-mental state examination, frontal assessment battery, and timed up-and-go test. The typical morphological features of high convexity tightness and ventriculomegaly were measured using the callosal angle and Evans index, and parenchymal white matter properties were evaluated with diffusion tensor imaging followed by tract-based spatial statistics. Levels of CSF biomarkers, including tau, amyloid-ß, and L-PGDS, were determined by ELISA, and their interaction, and localization were determined using immunoprecipitation and immunohistochemical analyses. Tract-based spatial statistics for fractional anisotropy revealed clusters that positively correlated with mini-mental state examination, frontal assessment battery, and callosal angle, and clusters that negatively correlated with age, disease duration, idiopathic normal pressure hydrocephalus grading scale, Evans index, and L-PGDS. Other parameters also indicated clusters that correlated with symptoms, microstructural white matter changes, and L-PGDS. Tau co-precipitated with L-PGDS, and colocalization was confirmed in postmortem specimens of neurodegenerative disease obtained from the human Brain Bank. Our study supports the diagnostic value of L-PGDS as a surrogate marker for white matter integrity in idiopathic normal pressure hydrocephalus. These results increase our understanding of the molecular players in the glymphatic system. Moreover, this study indicates the potential utility of enhancing endogenous protective factors to maintain brain homeostasis.

Exoscopic microvascular decompression for hemifacial spasm and trigeminal neuralgia.

The 4K 3D exoscope system is becoming increasingly used in neurosurgery. Its 3D ultra-high-definition image is valuable in identifying and dissecting the delicate neural and vascular structures during microvascular decompression. In this video, the authors describe several nuances and details to perform the exoscopic microvascular decompression, including the exoscope layout and the modified supine position. Several illustrative case presentations highlight the benefits of exoscopic surgery. The authors' exoscopic microvascular decompression series of 159 patients showed noninferior surgical outcomes compared to the operative microscope with no significant increase in surgical risk. In conclusion, an exoscope can be a practical alternative to performing microvascular decompression. The video can be found here: https://stream.cadmore.media/r10.3171/2023.10.FOCVID23122.

[Microvascular Decompression for Trigeminal Neuralgia Due to Venous Compression].

In microvascular decompression surgery for trigeminal neuralgia, the veins are essential as an anatomical frame for the microsurgical approach and as an offending vessel to compress the trigeminal nerve. Thorough arachnoid dissection of the superior petrosal vein and its tributaries provides surgical corridors to the trigeminal nerve root and enables the mobilization of the bridging, brainstem, and deep cerebellar veins. It is necessary to protect the trigeminal nerve by coagulating and cutting the offending vein. We reviewed the clinical features of trigeminal neuralgia caused by venous decompression and its outcomes after microvascular decompression. Among patients with trigeminal neuralgia, 4%-14% have sole venous compression. Atypical or type 2 trigeminal neuralgia may occur in 60%-80% of cases of sole venous compression. Three-dimensional MR cisternography and CT venography can help in detecting the offending vein. The transverse pontine vein is the common offending vein. The surgical cure and recurrence rates of trigeminal neuralgia with venous compression are 64%-75% and 23%, respectively. Sole venous compression is a unique form of trigeminal neuralgia. Its clinical characteristics differ from those of trigeminal neuralgia caused by arterial compression. Surgical procedures to resolve venous compression include nuances in safely handling venous structures.

Risk of Bone Wax Migration During Retrosigmoid Craniotomy for Microvascular Decompression: Case-Control Study.

BACKGROUND AND OBJECTIVES: Bone wax is a flexible hemostatic agent commonly used for surgery in the posterior cranial fossa to control bleeding from the mastoid emissary vein. A large amount of bone wax can migrate into the sigmoid sinus through the mastoid emissary canal (MEC). We aimed to identify clinical factors related to intraoperative bone wax migration through the MEC during microvascular decompression (MVD) surgery, which may result in sigmoid sinus thrombosis. METHODS: We retrospectively collected the clinical data of patients with trigeminal neuralgia, hemifacial spasm, or trigeminal neuralgia accompanied by painful tic convulsif who underwent MVD. Basic information and the residual width and length (from the bone surface to the sigmoid sinus) of the MEC on computed tomography images were collected. We compared the collected clinical data between 2 groups of cases with and without intraoperative bone wax migration in the sigmoid sinus. RESULTS: Fifty-four cases with intraoperative bone wax migration and 187 patients without migration were enrolled. The t -test revealed significant differences in the width and length of the MEC ( P = .013 and P = .003, respectively). These variables were identified as significant factors in predicting intraoperative bone wax migration using multivariate logistic regression analysis. CONCLUSION: The large size of the MEC may be related to intraoperative bone wax migration into the sigmoid sinus in MVD. Neurosurgeons should be aware of these risks. Bone wax should be applied appropriately and hemostasis should be considered to control bleeding from the mastoid emissary vein in patients with a large MEC.

Functionality and Usability of the Exoscope in Microvascular Decompression for Hemifacial Spasm and Trigeminal Neuralgia.

BACKGROUND: Studies on the functionality and usability of the exoscope in neurosurgical procedures against surgical microscopes (SMs) are limited. This study aimed to examine the functionality and usability of the exoscope during microvascular decompression (MVD) surgery. METHODS: Seven neurosurgeons evaluated the usefulness of a 4 K, 3-dimension digital exoscope in MVD by answering a questionnaire. The questionnaire inquired about the functionality and usability of the exoscope by utilizing a visual analog scale (VAS; 1-10). A score of 5 on VAS was equivalent to the corresponding quality of the SM. The learning effect of the exoscope was evaluated using mean VAS scores in the first and last 3 cases for each neurosurgeon. RESULTS: The functionality of the exoscope in MVD was superior to that in SM (P < 0.001). In the last 3 surgeries, the mean VAS scores of the exoscope were excellent in terms of ease of arm handling, exchange of surgical instruments, ease of surgical procedure, and intraoperative physical stress. The mean VAS scores of the exoscope in intraoperative asthenopia were significantly higher than those of the SM (P < 0.001). No statistical significance was found in operation time, discharge outcome, and 1-year post-surgery outcome between MVD performed using the exoscope and SM. CONCLUSIONS: Neurosurgeons may experience reduced stress levels during MVD when using the exoscope. As the outcome of MVD using the exoscope did not demonstrate a statistical difference compared with MVD using the SM, the exoscope may prove to be a useful tool for performing MVD.

Low back pain improvement after cervical laminoplasty in patients without tandem lumbar stenosis.

PURPOSE: This study aimed to demonstrate the impact of lumbar spinal stenosis (LSS) on LBP after cervical laminoplasty for cervical spinal stenosis by analyzing the clinical characteristics and surgical outcomes. METHODS: This retrospective cohort study analyzed 56 consecutive patients with cervical spinal stenosis who underwent cervical laminoplasty. Data on age, sex, Japanese Orthopaedic Association (JOA) scores, JOA Back Pain Evaluation Questionnaire (BPEQ), and visual analog scale (VAS) were collected. The patients with VAS for LBP ≥ 30 or more were included and divided into two groups: without LSS [LSS (-)]or with LSS [LSS (+)]. Preoperative clinical characteristics and postoperative changes were compared between the groups. RESULTS: Preoperative VAS for LBP were 50.7 ± 16.2 mm and 59.8 ± 19.5 mm in the LSS (+) and LSS (-), respectively (p = 0.09). Patients in the LSS (-) were younger (57.6 ± 11.2 vs. 70.7 ± 8.6, p < 0.001) and showed significantly milder preoperative lumbar symptoms in terms of JOA and BPEQ. Patients in the LSS (-) group showed more postoperative changes in low back pain (18.3 ± 26.4 vs. - 8.3 ± 37.6, p = 0.005) and lumbar function (10.8 ± 25.7 vs. - 2.0 ± 22.5, p = 0.04) at BPEQ, and higher recovery in terms of VAS of LBP (23.0 ± 23.8 mm vs. 5.3 ± 25.9 mm, p = 0.008) and buttocks and low limbs (12.5 ± 35.0 mm vs. - 4.3 ± 24.4 mm, p = 0.029). Nine patients in the LSS (+) group underwent lumbar surgery at 12.8 ± 8.5 months after cervical laminoplasty. CONCLUSION: LBP improved after cervical laminoplasty in patients without lumbar stenosis.

Intramedullary feeder aneurysm of a cervical epidural arteriovenous fistula causing myelopathy: a case report and literature review.

While a craniocervical junction (CCJ) epidural arteriovenous fistula (EDAVF) may present with hemorrhagic myelopathy from an associated feeder aneurysm on rare occasions, non-hemorrhagic myelopathy from such an aneurysm remains unreported. A woman in her late sixties presented with cervical myelopathy due to a non-hemorrhagic intramedullary aneurysm associated with CCJ-EDAVF. The intramedullary aneurysm originated from the spinal pial artery supplied by the anterior spinal artery. Direct surgical fistula coagulation and feeder obliteration resulted in the disappearance of the aneurysm and myelopathy improvement. This report illustrates the first case of a non-hemorrhagic intramedullary aneurysm associated with CCJ-EDAVF successfully treated with direct surgery.

Effects of microvascular decompression on quality-of-life in trigeminal neuralgia patients aged 70 years and older.

Background: Trigeminal neuralgia (TN) occasionally affects older adults, frequently worsens, and becomes refractory to medication. Older adult patients with TN may consider microvascular decompression (MVD) for their treatment. No study examines MVD effects on older adult TN patients' health-related quality of life (HRQoL). The present study evaluates the HRQoL of TN patients aged 70 years and older before and after MVD. Methods: Adult TN patients who underwent MVD evaluated their HRQoL using the 36-Item Short-form (SF-36) Health Survey before and 6 months after MVD. The patients were divided into four groups according to their decade of age. The clinical parameters and operative outcomes were analyzed statistically. The SF-36 physical, mental, and role social component summary scores and eight domain scale scores were analyzed using a twoway repeated-measures analysis of variance (ANOVA) to compare the effects of age group and preoperative and postoperative time points. Results: Among 57 adult patients (34 women, 23 men; mean age, 69 years; range, 30-89 years), 21 patients were in their seventies, and 11 were in their eighties. The SF-36 scores of patients in all age groups improved after MVD. Two-way repeated-measures ANOVA demonstrated a significant age group effect on the physical component summary and its physical functioning domain. A time point effect was significant on all component summaries and domains. There was a significant interaction between age group and time point effects on the bodily pain domain. These results suggested that patients 70 years and older had significant postoperative HRQoL improvement, but their improvement of physical-related HRQoL and multiple physical pain issues were limited. Conclusion: Impaired HRQoL in TN patients aged 70 years and older can improve after MVD. Careful management of multiple comorbidities and surgical risks enables MVD to be an appropriate treatment for older adult patients with refractory TN.

Cone-beam CT-assisted microcatheter tip placement at the shunted pouch entry zone: A technical note for anterior condylar arteriovenous fistula.

Accurate microcatheter placement for anterior condylar arteriovenous fistula (AVF) enables selective transvenous embolization (TVE) and helps to avoid hypoglossal nerve palsy. Anterior condylar AVF has a shunted pouch within the condylar vascular and osseous structures. Detailed anatomical comprehension of the shunted pouch is essential, in addition, we believe that it is important to have a strategy for where in the shunted pouch to start filling with coils. Specifically, we consider that it is important to structurally understand the more upstream location (arterial side) within the shunted pouch (called "shunted pouch entry zone"), guide the microcatheter there, and embolize from that site. Although several studies have discussed the usefulness of intraoperative cone-beam computed tomography (CBCT) for treating anterior condylar AVF, there are no studies which have mentioned the importance of microcatheter position before coil embolization in selective TVE as in this study. Intraoperative localization of the shunted pouch entry zone is often difficult. Herein, the authors report that cone-beam computed tomography (CBCT) can assist accurate microcatheter tip placement at the shunted pouch entry zone before staring embolization. This is the novel application of intraoperative CBCT to treat anterior condylar AVF successfully treated with precise and selective TVE.

Recovery from hemidiaphragmatic paralysis with improved respiratory function following cervical laminoplasty and foraminotomy: illustrative case.

BACKGROUND: Hemidiaphragmatic paralysis can occasionally be caused by cervical canal and foraminal stenosis. Rarely is the effect of surgical decompression on hemidiaphragmatic paralyzed patient respiratory function recorded. This report details a case of postoperative respiratory function restoration in a patient with cervical spondylosis-related hemidiaphragmatic paralysis. OBSERVATIONS: A 77-year-old woman suffered hemidiaphragmatic paralysis caused by cervical canal and foraminal stenosis. The phrenic nerve palsy was thought to be caused by compression of the cervical spinal cord and its nerve root. The patient received a C3 laminectomy, a C4-6 laminoplasty, and a left C3-4 and C4-5 posterior foraminotomy. After surgery, she improved her maximum inspiratory pressure and respiratory function. LESSONS: Cervical canal and foraminal stenosis may cause hemidiaphragmatic paralysis due to radiculopathy-induced phrenic nerve palsy. Laminoplasty and posterior foraminotomy can restore respiratory dysfunction related to diaphragmatic paralysis by decompressing the ventral horn of the spinal cord and spinal nerve root.

Ruptured fungal mycotic internal carotid artery aneurysm successfully treated with stent-assisted coil embolization: A case report.

Background: Ruptured intracranial fungal mycotic aneurysms have a high mortality rate. It has been reported that the number of opportunistic infections has increased. Here, we report the first case of a patient in which a ruptured fungal carotid artery aneurysm was successfully treated by stent-assisted coil embolization. Case Description: A 76-year-old male receiving dual antiplatelet therapy due to a recent percutaneous transluminal angioplasty presented with blurred vision of the right eye and diplopia. Magnetic resonance imaging revealed a fungal mass in the sphenoid sinus, and the patient was pathologically diagnosed with invasive aspergillosis. After receiving oral voriconazole for 4 weeks, he was admitted to the hospital with hemorrhagic shock from epistaxis. The right internal carotid artery angiography revealed a de novo irregularly shaped aneurysm at the cavernous portion, projecting into the sphenoid sinus, which was considered to be the source of bleeding. Due to the lack of ischemic tolerance and urgent demand for hemostasis, we performed a stent-assisted coil embolization of the aneurysm without interrupting the blood flow. Postoperatively, the patient had no neurological deficit, and treatment with voriconazole was continued for 12 months without rebleeding. Conclusion: Stent-assisted coil embolization without parent artery occlusion might be a promising option for the urgent treatment of ruptured fungal mycotic aneurysms. Long-term administration of voriconazole might be continued for 12 months for such patients.

Diagnosis of spinal dural defect using three-dimensional fast steady-state MR in patient with superficial siderosis: A case report.

Background: Spinal dural defects can result in superficial siderosis (SS) of the central nervous system. Closure of the defect can stop or slow the progression of the disease. Here, we evaluated, whether preoperative three-dimensional fast steady-state acquisition MR could adequately detect these defects and, thus, facilitate their closure and resolution. Case Description: A 65-year-old right-handed male presented with a 33-year history of the left C8 root avulsion and a 3-year history of slowly progressive gait difficulties and hearing loss. The T2*-weighted imaging revealed symmetrical hemosiderin deposition throughout his central nervous system. A left C6-C7 dural defect involving only inner layer was identified using a three-dimensional MR (3D-FIESTA). It was treated through a left C6-7 hemilaminectomy and successfully sealed with adipose tissue and fibrin glue. Subsequently, the progression of cerebellar ataxia was halted, nevertheless the sensorineural hearing loss worsened even over the next 2 years. Conclusion: 3D-FIESTA reconstruction was approved to be useful tool for identifying the tiny hole of the inner dural layer responsible for SS.

Infratentorial developmental venous anomaly concurrent with a cavernoma and dural arteriovenous fistula.

OBJECTIVES: While developmental venous anomaly (DVA) may be associated with cavernous malformation, mixed vascular malformation associated with dural arteriovenous fistula (dAVF) has not been previously reported. We observed a case with rare association of infratentorial DVA, cavernous malformation, and dAVF that presented with cerebellar ataxia. We report our endovascular treatment for this complex cerebrovascular condition. CASE PRESENTATION: A 32-year-old woman with ataxia had an infratentorial DVA associated with a cavernoma and dAVF. The dAVF had two shunting points. The dAVF was fed by the posterior meningeal arteries and drained through the sigmoid sinus into the transverse sinus. The dAVF was also fed by the occipital artery and retrogradely drained through the left jugular bulb into the dilated collecting vein of the DVA. Endovascular embolization was performed for the dAVF and dilated collecting vein of the DVA. Postoperative complications did not occur after embolization with no recurrence for three years. CONCLUSIONS: This is the first reported case of infratentorial DVA associated with a cavernoma and dAVF. Endovascular treatment was effective in treating this symptomatic complex cerebrovascular disorder.