Cervical vertebral artery variations: an anatomic study.

In this article, we present 5 cases of uncommon anomalous vertebral arteries and discuss the possible embryologic etiologies. These cases include a left vertebral artery as the 2nd branch off the left subclavian, a left vertebral artery with 2 origins, a right vertebral artery arising as the last branch off the aorta, a right vertebral artery arising as the 2nd branch off the right subclavian artery, and right vertebral artery with proximal duplication as the 2nd branch off the right subclavian artery.

Emergent management of ruptured pericallosal-callosomarginal artery aneurysm using stent-assisted coil embolization.

We present a case of a ruptured bilobed pericallosal aneurysm successfully treated with coil embolization through a Neuroform stent. A 48-year-old male presented with subarachnoid hemorrhage (SAH) following rupture of a previously clipped aneurysm at the bifurcation of the pericallosal and callosomarginal arteries, primarily along the pericallosal artery, Hunt and Hess grade 5. After an initial unsuccessful attempt to embolize the wide-neck aneurysm with a detachable coil, a 4x15 Neuroform stent was uneventfully deployed across the aneurysm neck followed by successful coil embolization using detachable coils. We believe this case describes the first successful use of the Neuroform stent to assist in coiling of a wide-neck pericallosal-callosomarginal aneurysm. This case highlights the expanding role of emergency endovascular therapies to manage severe SAH.

Abciximab for the treatment of acute distal embolization associated with internal carotid artery angioplasty.

Carotid artery angioplasty and stent placement (CAS) can be complicated by procedure-related distal embolization and thrombus formation, potentially resulting in neurological sequelae. Patient A had CAS of left internal carotid artery and had loss of vision in the left eye with no flow in the left ophthalmic artery. Patient B had CAS of right internal carotid artery and developed left sided hemiparesis with total occlusion of the right middle cerebral artery. A selective intra-arterial injection of 5 mg of abciximab locally followed by a bolus of 5 mg of abciximab intravenously resulted in complete resolution of the filling defect on repeat angiography after 10 min in both patients.

Endovascular repair of radiation-induced bilateral common carotid artery stenosis and pseudoaneurysms: a case report.

BACKGROUND: Radiation-induced damage to small and medium-sized vessels has been observed in both animals and humans. Changes may appear in the immediate postradiation period or many years later. In this case, we report an unusual presentation of bilateral radiation-induced carotid artery stenoses associated with pseudoaneurysms, and a previously unreported application of a recently established treatment. CASE DESCRIPTION: A 72-year-old African-American male presented with recurrent right hemispheric transient ischemic attacks (TIA) and neck pain. Thirteen years previously, the patient had received radiation therapy for laryngeal carcinoma. Diagnostic carotid angiography demonstrated moderate radiation-induced bilateral carotid artery stenosis and associated common carotid pseudoaneurysms. The patient was treated with bilateral endovascular stents and electrolytically detachable coils in staged procedures. At his most recent follow-up, there is no evidence of re-stenosis and the patient remains asymptomatic. CONCLUSIONS: This case illustrates a novel and successful treatment for the endovascular repair of post-radiation bilateral carotid artery stenosis and pseudoaneurysms. In our practice, we have seen three such cases of radiation-induced vasculopathy. Therefore, patients with a previous history of radiation therapy for head and neck neoplasms merit cautious monitoring and judicious use of stents and secondary coils, when necessary.

Complicated stent supported cerebrovascular angioplasty: case analyses and review of literature.

BACKGROUND: Hemodynamic lesions of the cervicocerebral vasculature are currently being treated with stent supported percutaneous transluminal angioplasty. These procedures have met with increasing success when compared to the risks and morbidity of more invasive surgical approaches. The versatility of stent-supported angioplasty as a primary therapeutic modality is examined in the following complex cases. CASE DESCRIPTION: We present four cases involving cervical angioplasty with emergent or adjunctive stent placement. Two cases involved the subclavian arteries, whereas the others involved the vertebral and internal carotid arteries. In our experience, complications of cervicocerebral artery angioplasty have been successfully managed by stent placement. CONCLUSION: Our cases demonstrate the emerging role of cervical angioplasty and stent implantation as a successful therapeutic modality, highlighted in these complex cases.

Hyperacute cerebral enhancement: the earliest predictor of hemorrhage by MR imaging?

A test to detect very early hemorrhage in acute cerebral infarct could offer a substantial increase in the safety and success of advanced stroke therapies, particularly when the use of thrombolytic therapies is contemplated. Currently, computed tomography is the standard test for the detection of cerebral hemorrhage but is not a valid predictor of potential areas of hemorrhagic transformation. A technique to evaluate the risk of hemorrhagic transformation in infarcted cerebral tissue has been conducted with contrast-enhanced magnetic resonance imaging in various animal stroke models. Knight demonstrated Gadolinium-DTPA enhancement in the territory of occluded vessels immediately in rats after reperfusion. Gadolinium enhancement was thought to predict areas of hemorrhagic transformation. Yenari and associates demonstrated in rabbit models that contrast-enhanced T1-weighted scans can reveal regions of blood-brain barrier disruption, characterized as hemorrhagic transformation in ischemic tissue. The authors report a clinical example in which hyperacute contrast-enhanced magnetic resonance imaging was the first indication of hemorrhagic transformation within 24 hours of onset of an acute cerebral infarct.

Lumbar agenesis with sacral sparing: a case report.

Caudal agenesis or caudal regression syndrome refers to a spectrum of malformations involving the lower spine, which can result in significant progressive or permanent neurologic defects. Caudal agenesis is frequently associated with other congenital anomalies of the axillary skeleton, hindgut and genitourinary systems. Described in this paper is a patient who presented with multiple clinical and radiographic findings consistent with caudal agenesis. This case is unique in that there is total absence of the lumbar vertebral column with an intact spinal cord and bony sacrum.

Direct cervical internal carotid access for GDC treatment of an ophthalmic origin carotid aneurysm.

The use of detachable coils in the treatment of intracranial aneurysms continues to evolve since its introduction in 1991 [1-5]. Although not well described in the literature, technical considerations in gaining and maintaining access to intracranial aneurysms play a pivotal role in any successful endovascular treatment. Tortuosity and looping of the cervical internal carotid artery (ICA) is one problem occasionally encountered. These unusual loops, in addition to the normal turns of the carotid siphon result in less control of the microcatheter tip. This problem culminated in this case where an ophthalmic origin carotid aneurysm could not be successfully treated from the standard femoral approach due to the presence of multiple ICA turns, with the presence of a proximal cervical ICA turn being particularly bothersome. This problem was circumvented by use of direct surgical access to the cervical ICA above the cervical ICA turn, allowing for successful endovascular aneurysm treatment with detachable coils.

Risk of clot formation in femoral arterial sheaths maintained overnight for neuroangiographic procedures.

BACKGROUND AND PURPOSE: The purpose of this study was to evaluate the presence of blood clots in femoral arterial sheaths maintained after cerebral angiography and the effect of heparinized saline on clot formation. METHODS: Twenty-three sheaths were evaluated in 18 patients. Sheaths were maintained for 14 to 80 hours (average, 33 hours; median, 24 hours). After the sheaths were removed, they were vigorously flushed with 60 mL of normal saline and the number and size of clots found in each sheath were recorded. Additionally, patients' age, catheter size, presence of heparin, amount of time the sheath was kept in the artery, and patients' coagulation status were recorded. RESULTS: Clots were found in 17 (74%) of the 23 sheaths. Ten catheters had continuous heparin drip, of which seven (70%) sustained clots. Of the 13 sheaths without heparin, 10 sustained clots (77%). The difference was not statistically significant. The average number of clots was 2.2, and the maximal length of clots ranged from 0.5 to 105 mm. No thromboembolic complications associated with sheath placement were encountered in our patient population. CONCLUSION: Blood clots are present in the vast majority of intraarterial sheaths maintained after cerebral angiography. These clots constitute a risk of thromboembolic complications in the event of repeat angiography. Sheath exchange should be considered before obtaining repeat cerebral angiograms.

Head trauma: CT scan interpretation by radiology residents versus staff radiologists.

PURPOSE: To determine the rate and clinical outcome of discrepancies in interpretation by radiology residents and staff neuroradiologists of posttraumatic cranial computed tomographic (CT) scans. MATERIALS AND METHODS: Prospective evaluation was performed for 419 consecutive emergency posttraumatic cranial CT studies that had been interpreted by radiology residents on call over a 16-month period. Discrepancies between the interpretations made by residents and those made by staff radiologists were divided into two groups: failure to recognize an abnormality (false-negative finding) and interpretation of normal as abnormal (false-positive finding). Discrepancies were considered major if they could affect patient care in the emergency setting and minor if they could not. RESULTS: Major and minor discrepancies were 1.7% and 2.6%, respectively, among interpretations made by residents and those by staff radiologists. Major discrepancies were four subdural hematomas, one pneumocephalus, one hemorrhagic contusion, and one subarachnoid hemorrhage. Minor discrepancies included six skull and five facial fractures. The discrepancy rate was statistically significantly higher (12.2%) when CT findings were abnormal than when they were normal (1.5%). No change in treatment was attributed to the delay in diagnosis. CONCLUSION: A low discrepancy rate was found between interpretations made by radiology residents and those made by staff neuroradiologists of posttraumatic cranial CT scans. There were no adverse clinical outcomes.

Magnetic resonance imaging of traumatic cervical nerve injuries.

Posttraumatic cervical injuries represent a spectrum of injuries ranging from simple traction to frank nerve root avulsion with meningocele formation. The authors describe 3 patients with cervical nerve injuries, depicted by magnetic resonance imaging, highlighting unusual imaging manifestations.

Paraganglioma of the cauda equina with associated intramedullary cyst: MR findings.

The MR imaging features of a paraganglioma of the cauda equina with associated spinal cord cysts are presented. MR imaging showed the tumor to be isointense with the spinal cord on all pulse sequences and to enhance homogeneously. The intramedullary cysts had increased signal intensity on proton density- and T2-weighted images, and involved the cervical and thoracic regions.

Cervical vertebral arteriovenous fistula balloon embolization in a patient with neurofibromatosis type 1.

The authors present a patient with neurofibromatosis type 1 associated with cervical kyphosis, a cervical vertebral arterial fistula, and contralateral vertebral arterial occlusion. The fistula was successfully treated with detachable balloons.

Melanocytoma of the cavernous sinus: CT and MR findings.

We present the CT, MR angiographic, and histologic findings of a rare primary meningeal melanocytoma of the cavernous sinus. The primary differential diagnosis is between a melanin-containing tumor and an extraaxial cavernous angioma. Radiologic imaging cannot distinguish between the less aggressive primary meningeal melanocytoma and the more aggressive meningeal melanoma.

Angiography and treatment of a pial occipital malformation supplied by a posterior temporo-occipital branch of the anterior choroidal artery.

The anterior choroidal artery rarely supplies the posterior temporal and occipital lobes. We describe such an anatomical variation association with an arteriovenous malformation of the occipital lobe.

Spontaneous pulsatile tinnitus secondary to a dural malformation not visualized by magnetic resonance angiography.

The author describes a case of tinnitus secondary to a right dural malformation not visualized by magnetic resonance angiography. The prime role of computed tomography/angiography is emphasized.

Imaging of pineal apoplexy.

The authors present 2 unusual cases of hemorrhagic pineal cysts. CT/MR imaging characteristics are shown.