Onyx Embolization of an Indirect Carotid-Cavernous Fistula with Cortical Venous Reflux: Technical Note.

BACKGROUND: Indirect carotid-cavernous fistulas (iCCFs) are shunts between meningeal branches of the internal carotid and/or the external carotid arteries and the cavernous sinus. They account for 83% of all carotid-cavernous fistulas (CCFs). Symptomatic iCCFs and those with increased risk of hemorrhage should be treated. Transvenous endovascular treatment is the preferred treatment modality. However, in complex cases, a combination of transarterial and transvenous approaches (multimodal treatment) is required. METHODS: A middle-aged woman presented with signs of increased intraocular pressure, blurry vision, diplopia, left proptosis, chemosis, conjunctival injection, ptosis, and cranial nerve VI palsy. Imaging confirmed the presence of a Barrow type D and Thomas type 4 iCCF with cortical venous reflux (CVR). RESULTS: The patient underwent transarterial and transvenous onyx embolization of the shunt, achieving a complete obliteration of the fistula. No complications occurred and the patient had a satisfactory postprocedural evolution. CONCLUSION: Multimodal onyx embolization is an effective option for the treatment of a complex symptomatic iCCF. If CVR is identified, these lesions should be promptly treated to prevent hemorrhage secondary to rupture.

Ruptured brain arteriovenous malformation in a pregnant woman: a case report.

BACKGROUND: Brain arteriovenous malformations (bAVMs) are vascular lesions that commonly present with intracranial haemorrhage. Pregnancy has been associated with an increased risk of bAVM rupture. However, their natural history in pregnant women is uncertain. CASE DESCRIPTION: A 27-year-old female at 28 weeks of gestation presented with a compromised neurological status secondary to a ruptured left frontal Spetzler-Martin scale (SM) III + bAVM. An emergent caesarean section was performed due to the high risk of foetal distress. Endovascular treatment successfully controlled the bleeding site, and stereotactic radiosurgery was offered as a subsequent treatment option. CONCLUSION: bAVMs should be considered in pregnant women with intracranial haemorrhage. The management of these lesions during pregnancy is controversial. Surgical risk and foetal development should be considered when selecting a management strategy.

Focal, Extranodal Primary Polymorphous Hemangioendothelioma Treated With Endovascular Embolization and Resection Surgery.

A male 28-year-old patient complained of a dorsal mass that has been increasing in size in the last six months. The mass was painful, soft, no mobile, and no neurological symptoms or signs were documented. A vascular-type tumor was suspected and endovascular followed by open surgical resection was indicated. Histopathological revealed a rare case of an adult with a primary extranodal polymorphous hemangioendothelioma. Total resection was confirmed by tumor-free resection margin. The postoperative course was uneventful. Polymorph hemangioendothelioma is a rare vascular tumor. Preoperative endovascular embolization is recommended given the high vascular features of the lesion and, therefore, the high rate of bleeding during surgery, to achieve complete resection.

Transient third cranial nerve palsy after pipeline shield treatment of a ruptured anterior cerebral artery dissecting aneurysm: Case report.

BACKGROUND: Intracranial dissecting aneurysms (IDAs) are rare vascular lesions usually arising from the posterior circulation. The anterior cerebral artery (ACA) is an unusual location for this pathology. Even rarer is the occurrence of a transient de novo third cranial nerve (CN) palsy after flow-diverting device (FDD) treatment of an ACA dissecting aneurysm. CASE DESCRIPTION: A middle-aged man with a prior history of hypertension was admitted to our emergency department with severe headache and loss of consciousness after sexual intercourse. Imaging revealed a subarachnoid hemorrhage with stenosis of the left A1 segment of the ACA. Cerebral digital subtraction angiography confirmed a dissecting aneurysm of the left A1 segment. The aneurysm was treated with an FDD (Pipeline Shield). Transient isolated incomplete third CN palsy was documented 12 h after treatment. No evidence of ischemic or hemorrhagic strokes was found. The condition improved after a few days of empiric steroid treatment. CONCLUSION: An FDD is a suitable alternative for the treatment of a ruptured IDA of the anterior circulation. Some infrequent complications associated with the device, such as de novo cranial neuropathies, are yet to be studied.

Management of recurrent schwannoma of the cauda equina: A case report.

BACKGROUND: Schwannomas of the cauda equina are rare intradural primary spinal tumors. Many of these patients initially present with cauda equina syndromes, and only 2.2% demonstrate clinical recurrence. Gross total excision is the procedure of choice. CASE DESCRIPTION: A 62-year-old female had undergone resection of a cauda equina schwannoma 5 years previously. She newly presented with cauda equina symptoms attributed to a recurrent schwannoma. Following gross total secondary tumor resection, the patient's preoperative deficits fully resolved, and the tumor never recurred. CONCLUSION: Secondary gross total excision of schwannomas of the cauda equina is critical to avoid further tumor recurrence.

Tuberculoma in the Fourth Ventricle: An Unusual Location.

To present a young immunocompetent patient with a fourth ventricle tuberculoma without pulmonary tuberculosis. A previously healthy young male patient presented with a history of headache, nausea, and blurred vision. Neuroimaging revealed a mass present in the fourth ventricle. The lesion was successfully resected. Histological and microbiological findings suggested the presence of a tuberculoma. Tuberculomas can be found in the posterior fossa in adults. This infectious pathology should not be forsaken when considering the differential diagnosis for infratentorial masses.

Emergent Hybrid Treatment of a Ruptured Scalp Arteriovenous Fistula with Eyelid involvement: Technical Note.

BACKGROUND: Scalp arteriovenous fistulas (AVFs) are a rare vascular disease usually presenting as a progressively increasing pulsating mass in the scalp. These lesions can be associated with mild to severe complications, including congestive heart failure. If ruptures, this pathology constitutes a life-threatening medical emergency because of its potential to cause severe bleeding and acute anemia. METHODS: We describe the case of a young woman with a ruptured Yokouchi type C scalp AVF with eyelid involvement. RESULTS: The patient presented with hypovolemic shock and acute anemia due to severe bleeding from the lesion. Emergent treatment through a combined endovascular and open surgical approach was required to stop bleeding and stabilize the patient. CONCLUSIONS: Emergent and effective treatment is required to stop bleeding when a scalp AVF ruptures. A combination of endovascular embolization and microsurgical excision of the shunt is a treatment option.

Direct transcranial coil and Onyx embolization of a dural arteriovenous fistula: Technical note and brief literature review.

Intracranial high-grade dural arteriovenous fistulas (DAVFs) have higher bleeding rates compared to other intracranial vascular malformations. Endovascular treatment is usually recommended for high-grade lesions, aiming at a complete fistula obliteration. However, some patients have vascular abnormalities that limit endovascular access to the precise location of the shunt. Alternative techniques may be considered in this scenario. A middle-aged man presented with intracranial hypertension secondary to a high-grade DAVF. Because of vascular abnormalities precluding transvenous access to the intracranial venous circulation, the patient required treatment by a direct transcranial coil and Onyx embolization of the shunt. Direct transcranial cannulation of a dural sinus is an alternative and effective route for transvenous embolization of DAVFs, especially if abnormal venous anatomy precluding venous access to the required cranial venous system is identified.