Isolated hemorrhagic arterialized DVAs: revisiting symptomatic DVAs.

We aim to present here a small case series of symptomatic isolated hemorrhagic arterialized developmental venous anomalies (sDVAs) with a larger goal of revisiting the classification based on patho-mechanisms plus emphasizing angiographic features coupled with CT and MRI. Typically, DVA is an incidental and silent abnormality on neuroimaging. Understanding its morphology in terms of arterialization and relationship with other entities is crucial for management. One adult and two pediatric cases presented with acute or sub-acute hemorrhage in the cerebellum or thalamus. Morphologic characterization on cross-sectional imaging and catheter angiography confirmed the integrated diagnosis of "symptomatic isolated hemorrhagic arterialized DVAs with deeper or superficial venous drainage". Conservative management was adopted in all cases. We emphasize the following classification and approach for symptomatic DVAs: (1) congestive isolated arterialized sDVAs, (2) congestive isolated resistive sDVAs, (3) coexisting sDVAs (with AVM or cavernous malformation), (4) compressive sDVAs (compressive effects), and (5) idiopathic DVAs. Like our three cases, ganglionic and infratentorial DVAs have higher propensity of hemorrhage, compressive effects, and usually harbor deeper venous drainage. Typical "caput medusae" as dominant collector vein on cross-sectional imaging is crucial to complement and even confirm the diagnosis of DVA before catheter angiography in sDVAs. Capillary stain or early opacification of DVAs is a marker of arteriovenous shunting in arterialized sDVAs. Recognition of this entity is crucial as treatment is usually conservative.

The Scanty Knowledge of Endoscopic Third Ventriculostomy in Infants.

INTRODUCTION: Hydrocephalus (HCP) remains one of the commonest pathologies treated in developing countries. Endoscopic third ventriculostomy (ETV) has become the alternative to shunt-divergen procedures in the treatment of many pathologies of the cerebral fluid in the brain. Age has been considered a limitation to perform the procedure, we started to perform ETV In younger patients earlier than many other units. Objectives: In this study, we demonstrate the overall efficacy of ETV in infants younger than 1-year of age and to subsequently report the outcome of this procedure. METHODS: From 2000 till 2016 we have performed a total of 386 cases of ETV of all ages. 71-cases were infants (below 1-year of age). Our study was undertaken to evaluate these cases. Patients were divided into two subgroups according to the cause of hydrocephalus; obstructive HCP, communicating HCP. RESULTS: Mean time for follow up was 52 months. Mean age at surgery was 137days (7- 351days). The population included 31-females and 40-males, while10 infants were premature. Success rates were; 91.6%, 63.6% correspond to each sub-group with an overall success rate of 73.24%. CONCLUSION: ETV in infants is feasible, technically more demanding. Success rate justifies the procedure to be performed in such age group of patients. ETV can be used, attentively, in cases of hydrocephalus associated with MMC, morbidity and mortality does not differ from the general population.

Iatrogenic (Traumatic) Occipital Artery Pseudoaneurysm - Rare Complication of Ventriculoperitoneal Shunt in an Infant: Case Report and Review of the Literature.

Although ventriculoperitoneal shunt (VPS) is the most common procedure performed by pediatric neurosurgeons, it is still associated with frustrating complications, most common of which are obstruction and infection. Traumatic occipital artery pseudoaneurysm is a very rare complication of VPS procedure. To the best of our knowledge, there is no similar case reported in the English language literature. A 12-month-old patient suffered posthemorrhagic hydrocephalus of prematurity, and multiple other complications due to extreme prematurity, including immature lung disease, retinopathy of prematurity, necrotizing enterocolitis, bowel perforation, short bowel syndrome resulting in total parenteral nutrition-dependence, and hydrocephalus which was treated by insertion of VPS. Four weeks after the shunt, a slowly enlarging pulsatile swelling distal to the valve under the catheter altering the shunt function was noted. The swelling was diagnosed as a pseudoaneurysm of the occipital artery and treated by excision of the aneurysm. The child developed isolated dilated fourth ventricle, which was treated by endoscopic fourth ventriculostomy. Traumatic occipital artery pseudoaneurysm as a result of tunneling of VPS catheter is a very rare complication of VPS. Clinical and radiological imaging is diagnostic of the aneurysm. Surgical repair should be considered in such cases. This case report is aimed to raise the awareness among physicians about this rare complication.