Bilateral Low-Flow Type-D Dural Carotid-Cavernous Fistula: Diagnosis and Treatment with 3D Time-of-Flight Magnetic Resonance Angiography.

BACKGROUND Carotid-cavernous fistula (CCF) is a rare, atypical vascular shunt between the carotid arterial system and the venous channels of the cavernous sinus, classified according to the shunt's anatomy, by etiology (resulting from trauma or occurring spontaneously), or by hemodynamic characteristics (such as low- or high-flow fistulas). CASE REPORT A 62-year-old female patient with poorly controlled arterial hypertension presented with bilateral periorbital edema, conjunctival chemosis, ophthalmoplegia, diplopia, and diminished visual acuity. On magnetic resonance angiography (MRA), abnormal arterial flow along the cavernous sinuses was noted, suggestive of bilateral CCF. The diagnosis of indirect dural low-flow CCF (Barrow Type D) was later confirmed by digital subtraction angiography, with feeding arteries from intracavernous internal carotid artery branches, and meningeal branches of the external carotid artery, draining bilaterally to ophthalmic veins, the intracavernous sinus, and the inferior petrosal sinus. The patient was successfully treated with endovascular embolization. At 7-month follow-up, no residual arteriovenous shunting was detected. This case highlights the importance of non-invasive radiological methods for CCF, and presents rarely published radiological findings of bilateral Type-D dural CCFs on 3-dimensional time-of-flight MRA with post-treatment MRA follow-up. CONCLUSIONS Regardless of the patient's history of possible trauma, a patient presenting with bilateral periorbital edema, conjunctival chemosis, ophthalmoplegia, diplopia, and diminished visual acuity should have a spontaneous bilateral CCF investigated to prevent delayed treatment. Experienced neuroradiologists are needed to accurately detect indirect CCF, since this condition often does not demonstrate classic symptoms.

Crossed Cerebellar Diaschisis in a Status Epilepticus Patient with Stroke-Mimicking Changes: A Case Report with Suboptimal Outcome.

BACKGROUND Crossed cerebellar diaschisis is a rare phenomenon characterized by reduction of hemispheric cerebellar blood flow and metabolism that occurs contralateral to supratentorial injury. This finding is generally detected after ischemic stroke, but can also be observed during status epilepticus. CASE REPORT A 45-year-old woman with a history of focal epilepsy and alcohol abuse presented with an episode of seizure with initial stroke-mimicking changes and no epileptiform activity on electroencephalogram. Upon further examination, the radiological findings revealed a broad cytotoxic edema in the left hemisphere and a smaller lesion in the right cerebellum, showing a rare phenomenon of crossed cerebellar diaschisis. Later, diagnosis of status epilepticus was established. Although the initial trend of the patient's condition was negative, after weeks of therapy and intensive care, the patient slightly improved in her condition and there was a partially reversible lesion in the left cerebral hemisphere and right cerebellum. CONCLUSIONS It is crucial to detect seizures in patients with stroke-like changes on unenhanced computed tomography examination, and especially in cases in which there are no arterial occlusion on computed tomography angiography and asymmetric arterial vasodilatation are seen. Status epilepticus can mimic stroke, establishing this as a major diagnostic challenge. Although the radiological findings in the left cerebral hemisphere lesion and the right cerebellar hemisphere were similar, its characteristics on diffusion-weighted imaging and apparent diffusion coefficient value differed, raising an important question of the exact mechanics of how crossed cerebellar diaschisis occurs, as it seems to be a rare phenomenon.

Venous Thromboembolism Recurrence in Latvian Population: Single University Hospital Data.

Background and objectives: Recurrence of venous thromboembolism (VTE) after a primary event is common; however, no sufficient risk scores have been widely introduced in clinical practice. The aim of this study was to assess the risk factors for VTE recurrences, as well as the effect of treatment strategies on the recurrence rate in a single-center patient cohort. Materials and Methods: The prospective cohort study included consecutive patients in a single center from June 2014 till June 2018 presenting with acute VTE confirmed by imaging tests. All patients were followed up for at least one year or till death. Statistical analyses were conducted using IBM SPSS Statistics 23 and Stata 13. Competing risk of death was considered. Results: A total of 219 eligible patients were identified during the study period. Pulmonary embolism with or without deep vein thrombosis (DVT) was present in 95.9% (n = 210), isolated DVT was present in 4.1% (n = 9) of patients. The total number of documented recurrences was 13 (5.9%). Incidence rate was 5.6 per 100 person-years. Recurrent VTE predicted significantly higher mortality rate (hazard ratio (HR) 6.64 [95% CI 2.61-16.93]). In univariate analysis, active cancer was associated with higher recurrence rate (p = 0.036). In competing-risks regression model (with death as the competing risk), active cancer (subdistribution hazard ratio (SHR) 2.11 (95% CI 0.58-7.76)) did not retain statistical significance for VTE recurrence. Discontinuation and duration of anticoagulant treatment (≤6 or >6 months), and drug class in acute or long-term therapy (parenteral, vitamin K antagonist (VKA), direct oral anticoagulant (DOAC)) were not associated with recurrences (p > 0.05). Conclusions: Patients who experienced recurrent VTE had 6.6-fold higher mortality rate than patients with no recurrences. The presence of active cancer was not a statistically significant risk factor for recurrence when taking into account the competing risk of death. Duration and drug class of anticoagulation did not seem to impact recurrence rate.