Multiple spinal arteriovenous fistulas: A case-based review.

The occurrence of multiple spinal dural arteriovenous fistulas (AVFs) is rare. The majority of cases reported are synchronous and the lesions are mainly found at different spinal levels. Metachronous AVFs have been defined as lesions that manifest in a temporal sequence after treatment of a first AVF. In this report, we present two distinct cases of multiple spinal AVFs. Also, we review the main features of the cases previously reported, with emphasis on the proposed theories for the origin of multiple AVFs. In patients with failure to improve after treatment of a spinal DAVF, a whole-spine angiographic examination is mandatory, not only to ascertain the complete closure of the treated fistula, but also to look for a possible second lesion at a different spinal level.

Effective coil embolization of intracavernous carotid artery pseudoaneurysm with parental artery preservation following severe head trauma in a pediatric patient.

BACKGROUND: Intracranial traumatic pseudoaneurysms are rare in children. If left untreated, mortality rate can be as high as 50% due to delayed rupture and disastrous bleeding. Endovascular embolization is considered the preferred treatment option because of its minimal invasiveness and negligible mortality. However, exclusion of the pseudoaneurysm with preservation of the parental vessel is not always possible. In comparison with peripheral aneurysms, intracavernous internal carotid artery lesions are technically more challenging with both open surgery and endovascular techniques. CASE REPORT: We report the case of a successful two-stage coil embolization of a traumatic intracavernous carotid artery pseudoaneurysm with preservation of parental vessel in a 6-year-old boy. CONCLUSION: Endovascular embolization with parental vessel preservation should be considered the first treatment option for traumatic intracavernous internal carotid artery pseudoaneurysms in children. Although treatment of pseudoaneurysms in this location may be technically difficult, it is feasible in experienced hands.

Pseudomeningocele after traumatic nerve root avulsion. A novel technique to close the fistula.

Traumatic brachial plexus complete avulsions and the subsequent formation of pseudomeningoceles are a well-known entity that usually remains asymptomatic. Pseudomeningocele is due to the dural sleeve encasing the damaged roots and the spinal liquid that may accumulate locally or in the supraclavicular soft tissues. The pseudomeningocele, added to the associated lesion of the plexus and usually the surrounding vessels, may become difficult to manage. We describe the novel management of a traumatic pseudomeningocele using an endovascular technique.

Endovascular treatment of distal internal carotid artery occlusions with retrievable stents.

BACKGROUND: Acute stroke due to distal intracranial internal carotid artery (ICA) occlusion has a poor natural history. Outcome in patients who receive intravenous tissue plasminogen activator (tPA) is also unsatisfactory. The objective of this study is to evaluate the effectiveness and safety of endovascular treatment with retrievable stents in these patients. METHODS: Data from a prospective register of patients with acute stroke treated with an endovascular procedure in a single centre were analysed. RESULTS: A total of 20 patients with distal ICA occlusion were collected. Mean baseline National Institutes of Health Stroke Scale score was 18. Eight cases (40%) had received previous intravenous tPA. Mean time from stroke to recanalization was 393 min. Retrievable stents with proximal occlusion and aspiration were used in all cases. In 3 patients, 2 retrievable stents were used simultaneously. Complete recanalization (thrombolysis in cerebral infarction 2b/3) was accomplished in 85% of cases. A favourable clinical outcome (modified Rankin Scale score 0-2) was achieved in 13 patients (65%). Mortality occurred in 2 cases (10%). CONCLUSIONS: Endovascular treatment of patients with distal ICA occlusion seems safe and effective. Retrievable stents may be the treatment of choice, although randomized clinical trials are necessary. The use of 2 retrievable stents at the same time could be an alternative technique useful in thrombi of larger size.

Treatment of a carotid cavernous fistula via direct transovale cavernous sinus puncture.

Endovascular treatment is the treatment of choice for indirect carotid cavernous fistulas (CCFs). Direct surgical obliteration of CCFs is recommended in highly symptomatic patients or in those with an aggressive pattern of venous drainage. However, this is a technically challenging approach associated with significant procedural morbidity. The authors present a case in which they decided to attempt a novel access to the cavernous sinus through the foramen ovale before recommending surgery for an otherwise untreatable dural CCF. This 52-year-old man with an indirect CCF and neurological deficit had undergone several attempts to embolize the shunt by means of the standard approaches. Ultimately direct cavernous sinus access was obtained through the foramen ovale, resulting in complete obliteration of the shunt. The occlusion was radiographically stable at the 6-month follow-up evaluation, and the patient has remained asymptomatic. Percutaneous transovale puncture of a CCF is a feasible alternative to accessing the cavernous sinus when traditional transvenous catheterization or direct superior ophthalmic vein approach is not possible.

Normal perfusion pressure breakthrough phenomenon: what still remains unknown.

We report two cases of normal perfusion pressure breakthrough phenomenon after total brain arteriovenous malformation removal. Hereby, we demonstrate that not only autoregulation impairment in the ipsilateral hemisphere occurs but also contralateral remote vessels response does. Such findings may be observed at 2-4 weeks and may resolve after 1-3 months.