Traumatic arteriovenous fistula of the middle meningeal artery treated with selective coil embolization: A case report.

Background: Dural arteriovenous fistulas (AVFs) are reportedly induced by trauma. We report a rare case of traumatic AVF with a direct shunt from the middle meningeal artery (MMA) to the middle meningeal vein (MMV) and multiple drainage routes after head trauma. The patient was effectively treated with selective coil embolization alone without liquid embolic material. Case Description: A 56-year-old woman was admitted to the emergency department with mild disturbance of consciousness caused by a head contusion after alcohol consumption. She exhibited impaired consciousness with a Glasgow coma scale score of 14 (E4V4M6), complained of headache, and presented with a hemorrhage in the left ear. Computed tomography suggested a skull fracture and cerebral hemorrhage. Magnetic resonance imaging conducted on the 4th day after the injury indicated shunt disease with a feeder in the right MMA. Cerebral angiography on the 7th day suggested a direct shunt from the right MMA to the MMV aligned with the temporal bone fracture line, with multiple drainage route perfusion. Coil embolization was performed on the 14th day to occlude the shunt point selectively. In the final image, the MMA was absent, and the MMV, superior sagittal sinus, or pterygoid plexus was not visible through the shunt. Her symptoms improved, and she was discharged on the 20th day and did not exhibit recurrence at the 1-year follow-up. Conclusion: AVF with a direct shunt from the MMA to MMV after head trauma can be effectively and safely treated with coil embolization alone, despite the need for long-term postoperative follow-up.

[Carotid Artery Stenosis:Endovascular Techniques and Devices].

The increase in the number of carotid artery stenting cases can be attributed to a decrease in complications owing to the evolution of devices. In this procedure, the choice of the protection device and stent for each case is the main concern. Embolic protection devices(EPD)that prevent distal embolization can be divided into proximal and distal types. Previously, balloon-type devices were used as distal EPDs; however, since they are no longer available, filter-type devices are now mainstream. Carotid stents are also divided into open- and closed-cell types. Therefore, this review describes the characteristics of each device in the actual cases at our hospital.

Delayed rupture of a large intracranial internal carotid artery aneurysm after flow diverter placement.

Background: Delayed rupture after flow diverter (FD) placement is a serious complication, and often it leads to death; however, the exact mechanism leading to the rupture remains unclear. Therefore, in this case, study, we report a case of delayed rupture after FD placement and discuss its causes. Case Description: This study presents the case of a 69-year-old female with multiple aneurysms who underwent FD placement with coil embolization for a large intracranial internal carotid artery aneurysm. Postoperatively, the patient had no significant symptoms, and angiography and magnetic resonance imaging revealed decreased intra-aneurysmal blood flow. However, on the 3rd postoperative day, she developed a sudden disturbance of consciousness. Computed tomography revealed a massive subarachnoid hemorrhage, diagnosed as a delayed rupture. We decided to withhold therapy due to her serious condition. Previous studies have suggested that hemodynamic mechanisms can cause delayed aneurysm rupture. Based on the computational fluid dynamics (CFD) of the aneurysm, we suggest that an increase in intra-aneurysmal pressure after FD placement may have caused the delayed rupture. Conclusion: Preoperative CFD analysis may help evaluate the risk of delayed rupture for large aneurysms with a high inflow from the parent vessel.