Cognard Type V Dural Arteriovenous Fistula Involving the Occipital Sinus.

The Cognard type V dural arteriovenous fistula (dAVF), which has a drainage route into the spinal vein, is a rare subtype of cranial dAVF. Because of typical features such as progressive myelopathy and brainstem dysfunctions, aggressive treatments should be considered. To eliminate venous congestion of the spinal cord, various approaches including surgical interruption of the spinal draining vein or transarterial embolization with cyanoacrylate have been reported. The introduction of nonadhesive Onyx has changed the treatment of dAVF, although little is known about the clinical usefulness of this type of fistula. We describe a case of the Cognard type V dAVF, draining into the spinal vein through the occipital sinus (OS) successfully treated by transarterial double catheter injection of Onyx. We used the alternating injections from 2 microcatheters until the Onyx reached the OS and reflowed into feeders adequately. This technique contributed to the elimination of the remaining afferent flow in an early stage of Onyx injection and achieved enough penetration into the draining vein.

Endovascular Internal Trapping of Ruptured Occipital Artery Pseudoaneurysm Associated with Occipital-Internal Jugular Vein Fistula in Neurofibromatosis Type 1.

Spontaneous cervical extradural pseudoaneurysms or arteriovenous fistulas (AVFs) are rare vascular diseases. We report a case of ruptured occipital artery (OA) pseudoaneurysm associated with occipital-internal jugular vein (IJV) fistula in neurofibromatosis type 1. Endovascular internal trapping via the OA was attempted; however, the distal entry of the OA could not be accessed because of the high shunt flow and tortuosity of the OA. The distal part of the OA was obliterated with coil via a transvenous approach through the IJV and pseudoaneurysm. The proximal entry of the OA was obliterated with coil and glue under proximal flow control with a balloon, and the fistula was successfully obliterated without placement of coils in the pseudoaneurysm. When ordinary internal trapping via a transarterial approach is not possible, the transvenous approach should be considered as an alternative for AVF associated with an aneurysmal component.

Endovascular Internal Trapping by Low-Concentration N-butyl-2-Cyanoacrylate for a Ruptured Giant Common Carotid Artery Pseudoaneurysm.

Treating carotid blowout syndrome following rupture of giant pseudoaneurysms is difficult because the destroyed parent artery precludes conventional treatment. We present a patient with a ruptured giant pseudoaneurysm that we occluded using a modified internal trapping technique with low-concentration N-butyl-2-cyanoacrylate (NBCA) and a minimum number of coils. An 80-year-old man with a history of chemoradiation therapy for oropharyngeal cancer presented with several episodes of active bleeding from the subsequent tracheostomy site. Radiological examination revealed a giant right common carotid artery (CCA) pseudoaneurysm. Endovascular internal trapping was performed using both NBCA and coils under proximal flow control. We slowly injected 9 ml of low-concentration NBCA, which subsequently filled the entire pseudoaneurysm. We then injected an additional 2 ml of NBCA into the proximal CCA to achieve complete obliteration. No re-bleeding was observed during the 6-month follow-up. Endovascular internal trapping using low-concentration NBCA was feasible to treat a giant CCA pseudoaneurysm. The injected low-concentration NBCA filled the entire pseudoaneurysm without the risk of catheter entrapment.

[Transient prosopagnosia after removal of a tumor in the right occipito-temporal cortex: a case report].

A 58-year-old man with metastatic brain tumor in his right occipito-temporal region was operated, using craniectomy. He had no neurological symptoms preoperatively. The tumor was 2.5 cm in diameter with minor perifocal edema. Two days after total removal of the tumor, typical prosopagnosia appeared, in which he could not recognize his wife's face as well as faces of medical stuff. He could see them as a whole, and described them undistinguishably from each other. He used voices, movements and clothing to recognize a familiar person. His recognition and semantic knowledge of people were found to be intact and he could recognize certain parts of the face (e.g. the nose or the mouth). He could clearly see other parts of the body, the environment and other objects, in color. The prosopagnostic condition lasted for a few weeks and slowly disappeared. Prosopagnosia caused by surgical procedure has been rarely reported. Although postoperative prosopagnosia is likely to be transient, it should be recognized as a complication in occipito-temporal cortex.

New technique for decompressive duraplasty using expanded polytetrafluoroethylene dura substitute--technical note.

A new technique for decompressive craniectomy with duraplasty was developed for cases in which brain swelling was present at dural closure. Expanded polytetrafluoroethylene (ePTFE) membrane is placed under the dura, covering the brain surface, without the use of sutures. The dura is then loosely sutured. The procedure was used in 13 patients. No leakage of cerebrospinal fluid into the epidural space or signs of infection were observed. Sutureless insertion of an ePTFE membrane at external decompression may increase the ease of duraplasty, decrease operating time, and avoid injury to the brain resulting from suturing the dura. The technique might be especially useful in emergency cases.