Interest of HYPR flow dynamic MRA for characterization of cerebral arteriovenous malformations: comparison with TRICKS MRA and catheter DSA.

OBJECTIVE: HYPR flow is a 3D dynamic contrast-enhanced MRA technique providing isotropic sub-millimetre resolution with half-second temporal resolution. We compared HYPR flow and time-resolved imaging of contrast kinetics (TRICKS) MRA for the characterization of cerebral arteriovenous malformations (cAVMs), using catheter DSA as reference. METHODS: Twenty-two patients underwent HYPR flow and TRICKS MRA within 15 days of DSA. HYPR flow and TRICKS datasets were reviewed separately by two readers for image quality, Spetzler-Martin grade, venous ectasia, and deep venous drainage. RESULTS: Image quality was better for HYPR flow than for TRICKS (narrower full width at half maximum; larger arterial diagnostic window; greater number of arterial frames, P ≤ 0.05). Using HYPR flow, inter-reader agreement was excellent for all cAVM characteristics. The agreement with DSA for the overall Spetzler-Martin grade was excellent for HYPR flow (ICC = 0.96 and 0.98, depending on the reader) and TRICKS (ICC = 0.82 and 0.95). In comparison to TRICKS, HYPR flow showed higher concordance with DSA for the identification of venous ectasia and deep venous drainage. CONCLUSION: Owing to an excellent agreement with DSA with respect to depiction of the vascular architecture of cAVMs, HYPR flow could be useful for the non-invasive characterization of cAVMs. KEY POINTS: • Dynamic MRA is used for cerebral AVM depiction and follow-up • HYPR flow is a new, highly-resolved dynamic MRA sequence • HYPR flow provides whole brain coverage • HYPR flow provides excellent agreement with the Spetzler-Martin grade • Compared to TRICKS MRA, HYPR flow improves cerebral AVM characterization.

Hand Knob Syndrome Secondary to Ipsilateral Concomitant Carotid Fibromuscular Dysplasia and Proximal Atherosclerotic Disease.

One of the uncommon stroke presentations is the isolated wrist drop syndrome, caused by a stroke affecting the hand knob area, with the embolic mechanism being the most commonly identified mechanism. Here, we present the case of a 62-year-old female patient who presented with acute-onset isolated wrist drop secondary to right internal carotid artery fibromuscular dysplasia with a string of beads appearance and coexisting proximal atherosclerotic severe stenosis. The patient underwent successful carotid artery stenting. Patients with hand knob stroke may present a diagnostic dilemma and can be misdiagnosed as having peripheral neuropathy due to the absence of pyramidal signs and other symptoms of cortical involvement, leading to delayed or inappropriate treatment.

Early vascular embolization of large orbital and periorbital infantile capillary hemangiomas; A case report.

PURPOSE: Infantile hemangiomas (IH) are the most common benign vascular tumors in childhood. Although they tend to have a benign nature, some hemangiomas may be complicated with astigmatism or deprivation amblyopia. We report a unique case of using an interventional radiological vascular embolization treatment modality for the early management of amblyogenic large right orbital and periorbital infantile capillary hemangiomas. OBSERVATIONS: After the confirmation of the diagnosis using a magnetic resonance imaging (MRI) of the brain and orbit, and an initial trial of systemic propranolol, an early interventional radiological vascular embolization was done. This was combined with the use of a tapering systemic corticosteroid. The functional and cosmetic outcomes were satisfactory. CONCLUSIONS AND IMPORTANCE: The use of arterial embolization is a promising modality of treatment as a possible alternative or adjunct to medical and surgical treatment cases of IH. To the authors' knowledge, this is one of the rare cases reported in the ophthalmic literature addressing the use of this technique for early management of orbital and periorbital capillary hemangiomas.

Pure Endovascular Management of an Arteriovenous Malformation and an Aneurysm Both Supplied by Anterio-Inferior Cerebellar Artery: A Case Report and a Review of Literature.

BACKGROUND AND IMPORTANCE: The tendency of posterior fossa arteriovenous malformations (pfAVM) to develop associated aneurysms (AA) is a well-known phenomenon with an increased total risk of rupture. Most pfAVM and AA develop in the territory of the posterior inferior cerebellar artery while the involvement of the anterior inferior cerebellar artery (AICA) is extremely rare. We describe an unusual case of an arteriovenous malformation (AVM) supplied by the AICA with a "proximal" AA. This unique combination of vascular lesions has been reported in only four cases so far, limiting the available experience that can safely guide the therapeutic intervention. CLINICAL PRESENTATION: This study describes a 59-year-old female presented with a subarachnoid hemorrhage, Hunt and Hess grade 4. Angiography demonstrated an AVM fed mainly by the right AICA and draining superficially into the transverse sinus (Spetzler-Martin grade II). In addition, there was a ruptured proximal AICA aneurysm. An endovascular approach was chosen to coil the aneurysm and obliterate the AVM using ONYX in a multi-staged process. The patient recovered well without residual deficit at 6-month follow-up. CONCLUSION: To the best of our knowledge, this is the first report describing a proximal AICA aneurysm and AVM treated by endovascular means. The outcome was very good, considering the technically demanding location. All previously reported cases with exactly similar lesions were managed surgically, with inconclusive outcomes. The data presented in this study are meant to help in decision-making process for similar cases till more data are available.