MRI findings for diagnosis of postoperative foreign body granulomas versus recurrent tumours in patients of brain tumour surgery.

AIM: To evaluate the postoperative magnetic resonance imaging (MRI) findings of intracranial foreign body granulomas (FBGs) and true recurrent tumours (RTs) and thus lead to a basis for management decision-making. MATERIALS AND METHODS: Twenty-two patients with previous brain tumour surgery were diagnosed clinically with RT and underwent surgery. Re-operative pathology revealed FBG in eight patients and RT in 14 patients. MRI findings before the initial operation were compared to those before the re-operation. RESULTS: Features of FBGs versus RTs on MRI were as follows: (1) mean lesion size: 1.3 ± 0.7 (0.5-2.6) versus 3.2 ± 1.7 (1.1-6.3) cm (p=0.001, odds ratio [OR] = 4.18); (2) hypointensity on T2-weighted imaging (WI): 6/8 (75%) versus 0/14 (0%; p<0.001, OR=75.4); (3) non-restricted diffusion on diffusion-WI (DWI): 6/8 (75%) versus 2/14 (14.3%; p=0.008, OR=18); and (4) "ring and bubble" appearance on contrast-enhanced T1WI: 7/8 (87.5%) versus 2/14 (14.3%; p=0.001, OR=42). In comparison with their original tumours, the FBGs in the FBG group showed significantly lower T2 signal intensity, lower signal on DWI, and more cases of non-restricted diffusion on DWI (p=0.04, 0.04, 0.04, respectively). CONCLUSION: On brain MRI, FBGs can be differentiated from RTs by their relatively smaller size, hypointensity on T2WI, lack of restricted diffusion on DWI, and "ring and bubble" appearance on contrast-enhanced T1WI. Comparing the MRI findings of the focal lesion in the tumour bed with those of the original tumour is suggested to enhance diagnostic confidence.

Clinical epidemiology and outcome of HIV-associated talaromycosis in Guangdong, China, during 2011-2017.

OBJECTIVES: Talaromycosis is an invasive mycosis endemic to Southeast Asia. This study aimed to investigate the epidemiology, clinical features and prognostic factors of HIV-associated talaromycosis in Guangdong, China. METHODS: We retrospectively evaluated HIV patients hospitalized with histopathology- or culture-confirmed talaromycosis between 2011 and 2017. Factors associated with poor prognosis were identified using logistic regression. RESULTS: Overall, 1079 patients with HIV-associated talaromycosis were evaluated. Both the number and prevalence of talaromycosis among HIV admissions increased from 125 and 15.7% in 2011 to 253 and 18.8% in 2017, respectively, reflecting the increase in HIV admissions. Annual admissions peaked during the rainy season between March and August. Common clinical manifestations included fever (85.6%), peripheral lymphadenopathy (72.3%), respiratory symptoms (60.8%), weight loss (49.8%), skin lesions (44.5%) and gastrointestinal symptoms (44.3%). Common laboratory abnormalities were hypoalbuminaemia (98.6%), anaemia (95.6%), elevated aspartate aminotransferase level (AST) (76.9%), elevated alkaline phosphatase level (55.8%) and thrombocytopenia (53.7%). The median CD4 count was 9 cells/µL. Talaromyces marneffei was isolated from blood and bone marrow cultures of 66.6% and 74.5% of patients, respectively. The rate increased to 86.6% when both cultures were performed concurrently. At discharge, 14% of patients showed worsening conditions or died. Leucocytosis, thrombocytopenia, elevated AST, total bilirubin, creatinine and azole monotherapy independently predicted poor prognosis. CONCLUSIONS: The incidence of HIV-associated talaromycosis has increased in Guangdong with the high HIV burden in China. Skin lesions were seen in less than half of patients. Induction therapy with azole alone is associated with higher mortality. Findings from this study should help to improve treatment of the disease.

Morphologic Change of Flow-Related Aneurysms in Brain Arteriovenous Malformations after Stereotactic Radiosurgery.

BACKGROUND AND PURPOSE: The natural history of flow-related aneurysms after obliteration of brain arteriovenous malformations is poorly understood. The purpose of this study was to evaluate the angioarchitecture and morphologic change in flow-related aneurysms after gamma knife surgery of brain arteriovenous malformations. MATERIALS AND METHODS: During a 12-year period, 823 patients with brain arteriovenous malformations underwent gamma knife surgery at our institution with complete peritherapeutic angiographic evaluation. From this population, a series of 72 patients (8.8%) with 111 flow-related aneurysms were enrolled (1.5 aneurysms per patient). There were 43 men and 29 women; ages ranged from 18 to 72 years (mean, 43 years). The morphologic change of flow-related aneurysms was longitudinally evaluated before and after obliteration of brain arteriovenous malformations. After gamma knife surgery, angiographic follow-up varied from 26 to 130 months (mean, 58 months). RESULTS: All flow-related aneurysms were small (mean, 4.1 mm; range, 2-9 mm). There were 72 proximal flow-related aneurysms (mean size, 4.3 mm) and 39 distal flow-related aneurysms (mean size, 3.7 mm). Spontaneous thrombosis occurred more frequently in distal flow-related aneurysms than in proximal flow-related aneurysms (P < .001). Smaller flow-related aneurysms (<5 mm) tended to spontaneously occlude after obliteration of brain arteriovenous malformations (P = .036). Two patients had ruptures of proximal flow-related aneurysms at 27- and 54-month follow-ups, respectively. CONCLUSIONS: Spontaneous thrombosis occurred more frequently in distal flow-related aneurysms due to occlusion or normalization of distal feeders. Smaller flow-related aneurysms also tended to spontaneously thrombose after obliteration of brain arteriovenous malformations. The rate of flow-related aneurysm rupture in our series was similar to that of natural intradural aneurysms.

Polymorphism in dural arteriovenous fistula: matrix metalloproteinase-2-1306 C/T as a potential risk factor for sinus thrombosis.

Essentials Sinus thrombosis may play a crucial role in development of dural arteriovenous fistula (DAVF). Little is known about the association between gene polymorphism and the development of DAVF. MMP-2-1306 C/T showed a higher prevalence rate in DAVF cases with sinus thrombosis. MMP-2-1306C/T polymorphism is likely a potential risk factor for sinus thrombosis in DAVF. SUMMARY: Background Dural arteriovenous fistula (DAVF) is a rare but important cerebrovascular disorder in adults. Little is known about the molecular genetic pathogenesis underlying DAVF development. Objectives To investigate the associations of gene polymorphisms and DAVF. Materials and Methods By the use of real-time PCR genotyping, seven single-nucleotide polymorphisms (SNPs) of angiogenesis-related genes were analyzed in 72 DAVF patients. Pertinent clinical and imaging data were subgrouped on the basis of location (cavernous sinus versus lateral sinus), lesions (single versus multiple), cerebral venous reflux (CVR) grading (Borden I versus Borden II/III), and sinus thrombosis (with versus without). Results We found that individuals carrying the polymorphic allele of matrix metalloproteinase (MMP)-2-1306 C/T (rs243865) had a significantly increased risk of sinus thrombosis in DAVF (odds ratio 6.2; 95% confidence interval 1.7-22.9). There was a weak difference in associations of tissue inhibitor of metalloproteinase (TIMP)-2 (rs2277698) gene polymorphism and DAVF patients subgrouped by CVR grading. Conclusions These preliminary results indicate that MMP-2-1306 C/T, but not MMP-9, TIMP-1, TIMP-2, and vascular endothelial growth factor A SNP variants, is a risk factor for the development of sinus thrombosis in DAVF patients.

Changes of time-attenuation curve blood flow parameters in patients with and without carotid stenosis.

BACKGROUND AND PURPOSE: From the time-attenuation curves of DSA flow parameters, maximal intensity, maximal slope, and full width at half maximum of selected vascular points are defined. The study explores the reliability of defining the flow parameters by the time-attenuation curves of DSA. MATERIALS AND METHODS: Seventy patients with unilateral carotid artery stenosis (group A) and 56 healthy controls (group B) were retrospectively enrolled. Fixed contrast injection protocols and DSA acquisition parameters were used with all patients. The M1, sigmoid sinus, and internal jugular vein on anteroposterior view DSA and the M2, parietal vein, and superior sagittal sinus on lateral view DSA were chosen as ROI targets for measuring flow parameters. The difference of time of maximal intensity between 2 target points was defined as the circulation time between the target points. RESULTS: The maximal intensity difference of 2 selected points from the ICA to the M1, sigmoid sinus, internal jugular vein, M2, parietal vein, and superior sagittal sinus was significantly longer in group A than in group B. The maximum slope of M1, M2, and the superior sagittal sinus was significantly lower in group A than in group B. The full width at half maximum of M1 and M2 was significantly larger in group A than in group B. The maximal slope of M1 demonstrated the best diagnostic performance. CONCLUSIONS: The maximal intensity difference of 2 selected points derived from DSA can be used as a definitive alternative flow parameter for intracranial circulation time measurement. Maximal slope and full width at half maximum complement the maximal intensity difference of 2 selected points in defining flow characteristics of healthy subjects and patients with carotid stenosis.

Pretreatment diagnosis of suprasellar papillary craniopharyngioma and germ cell tumors of adult patients.

BACKGROUND AND PURPOSE: Suprasellar papillary craniopharyngiomas and germ cell tumors in adults share some clinical and imaging similarities but have different therapeutic strategies and outcomes. This study aimed to evaluate the pretreatment diagnosis of these 2 tumors to improve the therapeutic outcome. MATERIALS AND METHODS: We retrospectively enrolled 18 adults with papillary craniopharyngiomas and 17 with germ cell tumors. The MR imaging findings were evaluated, including signal change and anatomic extension. The medical records were reviewed to collect clinical findings, management, and outcomes. RESULTS: The clinical findings of papillary craniopharyngiomas versus germ cell tumors were as follows: age: 46 ± 13.9 years versus 23 ± 7.1 years (P < .0001); diabetes insipidus: 2/18 (11%) versus 11/17 (65%) (P = .001); recurrence 13/16 (81%) versus 4/17 (24%) (P = .0031). The MR imaging findings of papillary craniopharyngiomas versus germ cell tumors were as follows­pituitary stalk thickening: 1.6 ± 0.4 mm versus 5.4 ± 4.2 mm (P < .0001); vertical infundibular extension: 1/18 (6%) versus 16/17 (94%) (P < .0001); sagittal spheric shape: 17/18 (94%) versus 1/17 (6%) (P < .0001); diffusion restriction: 1/17 (6%) versus 8/12 (67%) (P = .0009). CONCLUSIONS: Younger age, diabetes insipidus, MR imaging characteristics of restricted diffusion, and vertical infundibular extension favor the diagnosis of germ cell tumors. Spheric shape without infundibular infiltration provides clues to papillary craniopharyngiomas, which originate from the pars tuberalis and are located outside the third ventricle. We suggest that suprasellar germ cell tumor is possibly an intraventricular lesion. Appropriate treatment planning can be initiated according to the diagnosis and anatomic location.

Artifact reduction of different metallic implants in flat detector C-arm CT.

BACKGROUND AND PURPOSE: Flat detector CT has been increasingly used as a follow-up examination after endovascular intervention. Metal artifact reduction has been successfully demonstrated in coil mass cases, but only in a small series. We attempted to objectively and subjectively evaluate the feasibility of metal artifact reduction with various metallic objects and coil lengths. MATERIALS AND METHODS: We retrospectively reprocessed the flat detector CT data of 28 patients (15 men, 13 women; mean age, 55.6 years) after they underwent endovascular treatment (20 coiling ± stent placement, 6 liquid embolizers) or shunt drainage (n = 2) between January 2009 and November 2011 by using a metal artifact reduction correction algorithm. We measured CT value ranges and noise by using region-of-interest methods, and 2 experienced neuroradiologists rated the degrees of improved imaging quality and artifact reduction by comparing uncorrected and corrected images. RESULTS: After we applied the metal artifact reduction algorithm, the CT value ranges and the noise were substantially reduced (1815.3 ± 793.7 versus 231.7 ± 95.9 and 319.9 ± 136.6 versus 45.9 ± 14.0; both P < .001) regardless of the types of metallic objects and various sizes of coil masses. The rater study achieved an overall improvement of imaging quality and artifact reduction (85.7% and 78.6% of cases by 2 raters, respectively), with the greatest improvement in the coiling group, moderate improvement in the liquid embolizers, and the smallest improvement in ventricular shunting (overall agreement, 0.857). CONCLUSIONS: The metal artifact reduction algorithm substantially reduced artifacts and improved the objective image quality in every studied case. It also allowed improved diagnostic confidence in most cases.

Evaluation of the outcomes of endovascular management for patients with head and neck cancers and associated carotid blowout syndrome of the external carotid artery.

AIM: To evaluate factors related to the technical and haemostatic outcomes of endovascular management in patients with head and neck cancers (HNC) associated with carotid blowout syndrome (CBS) of the external carotid artery (ECA). MATERIALS AND METHODS: Between 2002 and 2011, 34 patients with HNC with CBS involving branches of the ECA underwent endovascular therapy. Treatment included embolization with microparticles, microcoils, or acrylic adhesives. Fisher's exact test was used to examine demographic features, clinical and angiographic severities, and clinical and imaging findings as predictors of endovascular management outcomes. RESULTS: Technical success and immediate haemostasis were achieved in all patients. Technical complications were encountered in one patient (2.9%). Rebleeding occurred in nine patients (26.5%). Angiographic vascular disruption grading from slight (1) to severe (4) revealed that the 18 patients with acute CBS had scores of 2 (2/18, 11.1%), 3 (3/18, 16.7%), and 4 (13/18, 72.2%). The 16 patients with impending and threatened CBS had scores of 1 (1/16, 6.25%), 2 (5/16, 31.25%), and 3 (10/16, 62.5%; p = 0.0003). For the 25 patients who underwent preprocedural computed tomography (CT)/magnetic resonance imaging (MRI) examinations within 3 months of treatment, the agreement between clinical and imaging findings reached the sensitivity, specificity, and kappa values for recurrent tumours (1, 0.7143, 0.7826), soft-tissue defect (0.9091, 0.3333, 0.2424), and sinus tract/fistula (0.4737, 0, 0.4286). CONCLUSION: Endovascular management for patients with CBS of the ECA had high technical success and safety but was associated with high rebleeding rates. We suggest applying aggressive post-procedural follow-up and using preprocedural CT/MRI to enhance the periprocedural diagnosis.

In-room assessment of cerebral blood volume for guidance during intra-arterial thrombolytic therapy.

In acute ischemic stroke, the ability to estimate the penumbra and infarction core ratio helps to triage those who will potentially benefit from thrombolytic therapies. Flat-panel post-contrast DynaCT imaging can provide both vasculature and parenchymal blood volume within the angio room to monitor hemodynamic changes during the endovascular procedures. We report on an 80-year-old woman who suffered from an acute occlusion of the right distal cervical internal carotid artery. She was transferred to the angio room where in-room post-contrast flat-panel DynaCT imaging (syngo Neuro PBV IR) was performed to access the ischemic tissue, followed by successful mechanical thrombolytic therapy.

Development of a fluorescent-intercalating-dye-based reverse transcription loop-mediated isothermal amplification assay for rapid detection of seasonal Japanese B encephalitis outbreaks in pigs.

The standardization and validation of a one-step, single-tube, accelerated fluorescent-intercalating-dye-based reverse transcription loop-mediated isothermal amplification (RT-LAMP) assay targeting the NS3 gene of Japanese B encephalitis virus (JEV) is described for rapid, simple, and high-throughput detection of JEV. The amplification can be completed in 35 min under isothermal conditions at 63°C by employing a set of six primers targeting the NS3 gene of JEV. The RT-LAMP assay described demonstrated high sensitivity for detecting JEV, with a detection limit in swine samples of 8.13 PFU/ml. The specificity of the selected primer sets was established by cross-reactivity studies with pathogens that exhibit similar clinical signs and testing of samples from healthy animals. The clinical applicability of the RT-LAMP assay was validated using either spiked samples or samples from seasonal outbreaks. The comparative evaluation of the RT-LAMP assay revealed 79.59 % concordance with conventional RT-PCR targeting the E gene of JEV. The RT-LAMP assay reported here is a valuable tool for rapid real-time and high-throughput seasonal infection surveillance and quarantine after outbreak through blood sampling by using ordinary real-time PCR thermocyclers without purchasing an expensive Loopamp real-time turbidimeter.

Monitoring peri-therapeutic cerebral circulation time: a feasibility study using color-coded quantitative DSA in patients with steno-occlusive arterial disease.

BACKGROUND AND PURPOSE: Intracranial hemodynamics are important for management of SOAD. This study aimed to monitor peri-stent placement intracranial CirT of patients with SOAD. MATERIALS AND METHODS: Twenty-five patients received stent placement for extracranial ICA stenosis, and 34 patients with normal CirT were recruited as controls. Their color-coded DSAs were used to define the Tmax of selected intravascular ROI. A total of 20 ROIs of the ICA, OphA, ACA, MCA, FV, PV, OV, SSS, SS, IJV, and MCV were selected. rTmax was defined as the Tmax at the selected region of interest minus Tmax at the cervical segment of the ICA (I1 on AP view and IA on lateral view). rTmax of the PV was defined as intracranial CirT. Intergroup and intragroup longitudinal comparisons of rTmax were performed. RESULTS: rTmax values of the normal cohorts were as follows: ICA-AP, 0.12; ICA-LAT, 0.10; A1, 0.28; A2, 0.53; A3, 0.81; M1, 0.40; M2, 0.80; M3, 0.95; OphA, 0.35; FV, 4.83; PV, 5.11; OV, 5.17; SSS, 6.16; SS, 6.51; IJV, 6.81; and MCV, 3.86 seconds. Before stent placement, the rTmax values of arterial ROIs, except A3 and M3, were prolonged compared with values from control subjects (P < .05). None of the rTmax of any venous ROIs in the stenotic group was prolonged with significance. After stent placement, the rTmax of all arterial ROIs shortened significantly, except A1and M3. Poststenting rTmax was not different from the control group. CONCLUSIONS: Without extra contrast medium and radiation dosages, color-coded quantitative DSA enables real-time monitoring of peri-therapeutic intracranial CirT in patients with SOAD .

Stenting in the remnant of the third aortic arch in a case of post-irradiation occluded internal carotid artery.

Collateral networks between the external carotid artery and internal carotid arteries become crucial for cerebral perfusion after occlusion of internal carotid arteries. We report the first case of a patient who received percutaneous transluminal angioplasty and stenting in a collateral vessel between the external and internal carotid artery for treatment of radiation induced severe stenosis of the internal carotid artery in the context of a contralateral internal carotid artery occlusion.

Direct puncture of a prematurely detached balloon in the supraclinoid ICA via the optic canal during embolisation of a traumatic carotid-cavernous fistula.

We report a patient with traumatic carotid-cavernous fistula associated with an isolated internal carotid artery in whom, after trans-arterial balloon embolisation, premature balloon detachment occurred with balloon migration to the supraclinoid carotid artery, leading to total occlusion of the blood flow. The carotid flow was eventually restored by direct puncture of the detached balloon via the optic canal and by deploying a coronary stent to fix the balloon in the vascular wall. The fistula was eventually occluded by using detachable coils. He was discharged with a mild hemiparesis and decreased acuity in the left eye.

Stent management of coil herniation in embolization of internal carotid aneurysms.

BACKGROUND AND PURPOSE: Coil herniation into the parent artery after detachment is an uncommon complication of embolization of the intracranial aneurysm. We report our experience with stent reconstruction of the lumen and flow of the internal carotid artery (ICA) after coil herniation during embolization for intracranial ICA aneurysms and the possible mechanisms of coil herniation. MATERIALS AND METHODS: A series of 216 consecutive patients was treated by endovascular coil embolizations for intracranial aneurysms. Of these patients, there were 9 (4 men, 5 women; 32-68 years of age) complicating with coil herniation into the ICA and undergoing stent deployment to reconstruct the ICA lumen (n = 8) or both lumen and flow (n = 1). Wide-neck aneurysms were found in 8 and narrow-neck, in 1. Aneurysms were in the posterior communicating artery (n = 5) and the paraophthalmic (n = 3) and cavernous portions (n = 1) of the ICA. Self-expandable stents were deployed in the ICA in 6; balloon-mounted stents were selected in 3. RESULTS: The causes of coil herniation appeared to be coil instability after detachment (n = 6), excessive embolization (n = 1), microcatheter-related problems (n = 1), or being pushed by subsequent coil embolization (n = 1). Endovascular stent placement to reconstruct the lumen and/or flow of the ICA was technically successful in all 9 patients; 1 needed a second stent due to further coil migration. No significant procedure-related complications were found. Clinical follow-up was 8-35 months. CONCLUSION: Coil herniation occasionally occurs during endovascular embolization of ICA aneurysms because of coil instability after detachment, excessive embolization, microcatheter-related problems, or pushing by subsequent coil embolization. In this small series, stent placement was safe and effective in the reconstruction of the arterial lumen and/or restoration of flow past a herniated coil mass.

Identification of anisakid nematodes with zoonotic potential from Europe and China by single-strand conformation polymorphism analysis of nuclear ribosomal DNA.

Using genetic markers defined previously in the second internal transcribed spacer (ITS-2) of nuclear ribosomal DNA (rDNA), isotopic, and non-isotopic polymerase-chain-reaction-coupled single-strand conformation polymorphism (SSCP) were utilized to identify each of three anisakid species [Anisakis simplex (s.l.), Contracaecum osculatum (s.l.), and Hysterothylacium aduncum] from different host species and geographical locations in Poland and Sweden. While subtle microheterogeneity was observed within each of Anisakis simplex (s.l.) and H. aduncum, distinct SSCP profiles were displayed for each of the three species, allowing identification and differentiation of the three taxa. Subsequent sequencing of the ITS-1 and ITS-2 rDNA revealed that A. simplex (s.l.) represented Anisakis simplex s.s. and Contracaecum osculatum (s.l.) represented C. osculatum C. Application of the non-isotopic SSCP assay of ITS-2 to larval anisakid samples from different hosts and geographical locations in China revealed three distinct SSCP profiles, one of which was consistent with that of A. simplex (s.l.), and the other two had different SSCP profiles from that of C. osculatum C and H. aduncum. Sequencing of the ITS-1 and ITS-2 rDNA for representative Chinese anisakid samples examined revealed three anisakid species in China, i.e., Anisakis typica, Anisakis pegreffii, and Hysterothylacium sp. These molecular tools will be useful for identification and investigation of the ecology of anisakid nematodes in China and elsewhere.

Segmental neurovascular syndromes in children.

The concept of segmental vascular syndromes with different, seemingly unrelated, diseases is based on the embryology of the neural crest and the mesoderm migration of cells that share the same metameric origin. Migrating patterns of these cells link the brain, the cranial bones, and the face on the same side. A somatic mutation developing in the region of the neural crest or the adjacent cephalic mesoderm before migration can, therefore, be postulated to produce arterial or venous metameric syndromes, including PHACES, CAMS, Cobb syndrome, and Sturge-Weber syndrome. Although these diseases may be rare, their relationships among each other and their postulated linkage with the development of the neural crest and the cephalic mesoderm may shed light on the complex pathology and etiology of various cerebral vascular disorders.

Bilateral traumatic carotid-cavernous fistulae: Strategies for endovascular treatment.

BACKGROUND: Most traumatic carotid-cavernous fistula/e (TCCF) are unilateral, and simultaneous bilateral TCCF are uncommon. The purpose of this study was to evaluate the angiographic architecture of bilateral TCCF and report our experience with their endovascular management. METHOD: Over 15 years, 252 consecutive patients with TCCF were referred to our institute for endovascular treatment. Bilateral TCCF occurred in 5 men and 2 women with a mean age of 31 years. The angiographic architectures of bilateral TCCF were evaluated with cerebral angiography. All patients underwent a single session of transarterial embolisation by using various permanent embolic materials and were followed up clinically or with angiography for a mean of 22 months (range 9-36 months). FINDINGS: All patients presented with neuro-ophthalmic symptoms and signs. No new instances of cerebrovascular ischemia or intracranial haematoma resulted from bilateral TCCF. All fistulae were associated with partial arterial steal and were successfully occluded by using a detachable balloon and/or a detachable coil with or without a liquid adhesive. Of 14 TCCF, 9 were completely obliterated with preserved flow of the internal carotid artery (ICA). In the other 5 fistulae, the ICA had to be sacrificed to achieve occlusion because the anatomy of the fistula was complex. All fistula related symptoms resolved immediately or gradually during clinical follow up. No clinically significant procedure related neurological complications or recurrent fistulae were observed. CONCLUSIONS: All bilateral TCCF were associated with a partial arterial steal phenomenon. Single session endovascular treatment using various embolic materials was effective in managing these high-flow fistulae. In all patients, it was possible to preserve one or both ICAs.

Carotid blowout syndrome in patients with head-and-neck cancers: reconstructive management by self-expandable stent-grafts.

BACKGROUND AND PURPOSE: Some reports of reconstructive management of carotid blowout syndrome (CBS) with stent-grafts are promising, but some are unfavorable. This study sought to evaluate the hemostatic efficacy, safety, and outcome of reconstructive, endovascular stent-graft placement in patients with head-and-neck cancers in association with CBS. METHODS: Eight patients with head-and-neck cancers with CBS were treated with self-expandable stent-grafts. We evaluated the initial hemostatic results, complications, and outcomes by assessing the clinical and imaging findings. RESULTS: Immediate hemostasis was achieved in all patients. Initial complications included stroke in 1 patient and asymptomatic thrombosis of the carotid artery in 2 patients. Delayed complications included rebleeding, delayed carotid thrombosis, and brain abscess formation. Rebleeding was noted in 4 patients and was successfully managed with a second stent-graft and embolization in 2 of them. Delayed carotid thrombosis with follow-up after 3 months was found in 3 patients, 1 of whom had associated brain abscesses. CONCLUSION: Although stent-grafts achieved immediate and initial hemostasis in patients with head-and-neck cancers and CBS, long-term safety, stent patency, and permanency of hemostasis appeared unfavorable. This treatment may be for temporary or emergency purposes rather than serving as a permanent measure. We suggest its applications in patients with acute CBS that precludes performance of an occlusion test, as well as when carotid occlusion poses an unusually high risk of neurologic morbidity. We also propose prophylactic antibiotic treatment and combined embolization of pathologic vascular feeders to improve outcomes.

Transcranial embolization of a transverse-sigmoid sinus dural arteriovenous fistula carried out through a decompressive craniectomy.

We report a case of dural arteriovenous fistula (DAVF) of the transverse-sigmoid sinus presenting with intraventricular hemorrhage. Cerebellar infarction developed after transarterial embolization, and decompressive craniectomy was performed to relieve the mass effect. Through the bone window of the decompressive craniectomy, transcranial puncture of the transverse sinus and coil occlusion of the fistula were successfully performed. Decompressive craniectomy may provide an opportunity to occlude DAVFs which cannot be occluded by the transarterial or transvenous approach.