Reverse Y stenting in the management of vertebrobasilar junction fenestrated aneurysm: A novel technique.

Fenestrated aneurysm at vertebrobasilar junction (VBJ) is very rare and can occur due to non-fusion of longitudinal neural axis forming basilar artery in the early stage of embryonic life. Due to defects in tunica media and weakness in its wall, these fenestrations are more likely to develop an aneurysm. Various treatment strategies are required for the management of these types of aneurysms including simple coiling, stent-assisted coiling, balloon remodeling technique, and more recently kissing flow diverters. Herein, we report the case of ruptured fenestrated VBJ aneurysm which was managed successfully with novel reverse Y stenting with coiling.

Nidus delineation and dosimetric comparison in arteriovenous malformation in stereotactic radiosurgery by using MRI and 3DCT angiography.

Purpose/Objectives: Accurate delineation of target is key to any successful radiosurgery. C-arm Dyna CT/ 3DCT angiography (3DCTA) has the potential of improving the accuracy of nidus delineation in intracranial arteriovenous malformations (AVM) due to high temporo-spatial resolution of vessel architecture. Here, we present a comparison of nidus delineation and dosimetric parameters between digital 3DCTA and MRI. Materials/Methods: Ten consecutive patients treated for intracranial AVMs were included in this study. All patients underwent MRI/MRA, and 3DCTA and all images were co-registered. AVM were delineated using 3DCTA (GTV3DCTA) and contrast enhanced MRI/MRA (GTVMRI). Hausdorff distance (HD) matrices and dice similarity coefficient (DSC) matrices were analysed. Stereotactic radiosurgery plans were developed for both the volumes for all patients and statistical analysis were performed with T-test. Results: Mean volumes of GTV3DCTA and GTVMRI were 1.771 cc (SD 1.794cc, range 0.124-4.191cc) and 2.183cc (SD 2.16cc, range 0.221-6.133cc), respectively. Significant deviation (p=0.018) was found when taking GTVMRI as a primary and comparing it to GTV3DCTA (MD=0.723cc±0.816cc). Similar result was observed with GTV3DCTA as primary and GTVMRI as secondary (MD=0.188cc, SD=0.193cc, p=0.024). Maximum HD was in the range of 1.71 to 7.44mm (mean=4.27mm, SD=1.56). For GTV3DCTA based plans, significant deviation was found between GTVMRI and GTV3DCTA in dose coverage and the mean difference was 22.17% (SD 16.73). In GTVMRI based plans, the mean CIRTOG deteriorated from 1.33 to 2.18 for GTVMRI and GTV3DCTA, respectively. Significant deviation was found in CIRTOG (0.005) and mean deviation was 0.86(SD=0.72) when comparing GTVMRI and GTV3DCTA. Highly significant (p=0.002) deviation was found in CIPaddick between GTVMRI and GTV3DCTA for GTVMRI based plans with mean difference of 0.26(SD=0.4, for GTVMRI=0.3, GTV3DCTA=0.46). Conclusion: Nidus volume was significantly altered with the use of 3DCTA compared to that of MRA/MRI images. Multimodality imaging is crucial for accurate target delineation, and successful radiosurgical obliteration of nidus.

Ghost Aneurysm in Atraumatic Acute Subdural Hematoma: A Sign of Caution or a Mere Finding - A Case Report.

Atraumatic subdural bleed often presents with diagnostic and management dilemma. This is a case of a 36-year male who presented with acute onset headache while at rest without any focal neurodeficit. Computed Tomographic Scan of brain revealed subdural hematoma. Cerebral Digital Subtraction Angiography showed a same sided focal dye extravasation which corresponded exactly to the inner margin of the subdural bleed. Though the patient opted out for surgical management this imaging and DSA finding correlated with the "Ghost Aneurysm" concept in acute atraumatic subdural bleeds and its early recognition is an important imaging marker for caution for hematoma expansion.

Unusual cause of recalcitrant epistaxis.

Nosebleeds are among the most familiar presentations to the emergency department as well as otorhinolaryngologic outpatient services. Bleeding from nasal septal branches of the anterior ethmoid artery (AEA) is common and can be effectively controlled endoscopically. However, the bleeding from a pseudoaneurysm involving the nasal septal branches of AEA is extremely rare and can be troublesome to control using endoscopic methods. We report an adult patient presenting with profuse nasal bleeding postroad traffic accident due to the formation of AEA septal branch pseudoaneurysm. The patient required repeated nasal packing, and the diagnosis was revealed using digital subtraction angiography. Since profuse active bleeding precluded endoscopic visualisation, an external approach had to be adopted to ligate the AEA to control the bleeding. We discuss the management options and nuances for this rare cause of the troublesome nasal bleeding.

Tenecteplase-induced Nonaneurysmal Subarachnoid Hemorrhage in a Patient with Acute Ischemic Stroke: A Case Report and Literature Review.

Recently, tenecteplase (TNK) has been used for intravenous thrombolysis in acute ischemic stroke (AIS). Although spontaneous subarachnoid hemorrhage (SAH) following thrombolysis with tissue plasminogen activator has been reported, there is a lack of literature regarding TNK-induced nonaneurysmal spontaneous SAH. Our index case received intravenous TNK within an hour of symptom onset of AIS. Following deterioration of sensorium, repeat noncontrast computed tomography was performed, which showed diffuse SAH. Cerebral angiography did not reveal any aneurysm. Nonaneurysmal SAH can be a complication of TNK thrombolysis, which is not reported in literature. Knowledge of this possible adverse reaction is critical for appropriate counseling and management.

Endovascular Treatment of Distal Lenticulostriate Artery Aneurysm by Selective Catheterization of Artery with Balloon-Blocking Technique: 2-Dimensional Video Illustration.

We report the case of a 15-year-old male patient with polyarteritis nodosa who presented with ruptured lenticulostriate artery (LSA) aneurysm and was successfully treated with endovascular N-butyl-2-cyanoacrylate (Histoacryl, B. Braun, Melsungen, Germany) acrylic glue embolization. Selective catheterization of LSA is sometimes difficult even with a low-profile microcatheter (Magic 1.2 FM, Balt Extrusion, Montmorency, France) due to acute angulation at the origin of the artery. In this 2-dimensional video illustration of the roadmap in digital subtraction angiography, reproduced after informed consent of the patient, we illustrate the balloon blocking technique to safely and effectively navigate the microcatheter through the small perforator with difficult angulation at the origin. A Magic microcatheter was passed via a distal access catheter 070 (Concentric Medical, Mountain View, California, USA) 105 cm in the internal carotid artery. The Magic microcatheter advancement was supported with a 0.008-inch guidewire (Hybrid 008, Balt Extrusion, Montmorency, France). Initial catheterization of LSA even with a low-profile Magic microcatheter was difficult as the origin of LSA was acute angled. While trying the navigate the microcatheter into the perforator, it was continuously flopping into the distal M1 segment of the middle cerebral artery. The balloon microcatheter (Scepter XC 4 × 11mm, Microvention, Tustin, California, USA) was passed separately via 5 French Envoy guiding catheter (Codman, Raynham, Massachusetts, USA) 100 cm in the proximal ICA using a contralateral left femoral artery puncture. The Balloon microcatheter advancement into the middle cerebral artery was supported with a Traxcess 0.014-inch microguidewire (Microvention). It was then inflated just beyond the origin of LSA which provided support to the magic microcatheter and thus allowing its easy navigation into the LSA. Super-selective microcatheter injection confirmed filling of the LSA aneurysm. A dilute 33% concentration of the liquid embolic agent N-butyl-2-cyanoacrylate mixed with Lipiodol (Guerbet, Aulnay-sous-Bois, France) was injected slowly under direct vision. The final-check angiogram revealed complete occlusion of the aneurysm (Video 1). Patient underwent craniotomy and hematoma evacuation 1 day after the procedure in view of his rapidly deteriorating neurological status. He was later discharged with Modified Rankin Scale of 3. Follow up angiography after 3 months showed completely occluded aneurysm (Video 2).

Endovascular Rescue Strategies for Nonopening of Pipeline Device: Report of Two Cases.

We report two cases of rescue strategies for nonopening of Pipeline flow-diverter device for the treatment of intracranial aneurysm. The first patient, a 65-year-old female, presented with complaints of headache for 3 months and was found to have giant supraclinoid internal carotid artery (ICA) (ophthalmic segment) aneurysm. We planned endovascular partial coiling and flow-diverter placement for the treatment of ICA aneurysm. During the progressive deployment of PED, there was nonopening of Pipeline embolization device (PED) at its proximal end. We tried multiple attempts to navigate Marksman microcatheter over the PED delivery microwire and Echelon microcatheter over the Traxcess microwire across the pinched site, but we were not able to achieve success. After that, we tried opposite transcranial approach across prominent anterior communicating artery with the Synchro and Transcend microguidewire which finally resulted in the opening of the device; however, there was acute extravasation of dye on check angiogram. Thus, our technical success turned into disaster. The second patient, a 55-year-old female, presented with complaint of seizures for 3 months due to mass effect of cavernous sinus aneurysm. Pipeline Flex flow-diverter placement was done across the aneurysm neck. During the progressive deployment of device, there was nonopening of the mid and proximal segment of Pipeline Flex which was successfully managed by intra-Navien deployment of device followed by simultaneous push of Marksman microcatheter and pull of Navien catheter. In our case series, two rescue strategies were applied to successfully open the proximal constricted portion of Pipeline Flex; however, technical success in one case resulted in unmanageable disasters. Thus, transcranial rescue strategy for opening the constricted Pipeline Flex device should be cautiously used in our endovascular practice.

An Unusual Cause of Posterior Reversible Encephalopathy Syndrome.

Posterior reversible encephalopathy syndrome (PRES) is a clinical radiographic diagnosis of heterogeneous etiologies. The pathogenesis of PRES remains unclear, but may be related to impaired cerebral autoregulation and endothelial dysfunction. We present a case of intravascular nonionic contrast-induced PRES observed after cerebral angiography. The index patient was a follow-up case of large vertebrobasilar artery-dissecting aneurysm for which endovascular coiling was done 6 months back. She improved completely within a week. Contrast-induced PRES is a reversible benign condition, knowledge of which is crucial for appropriate management.