In vivo study of the utility of selective intra-arterial injection of thiopental for neuroprotection in reversible cerebral ischemia.

BACKGROUND: Neuroprotective agents are needed to reduce cerebral damage during surgical or neurointerventional procedures including stroke patients. PURPOSE: To evaluate if thiopental can be used as a neuroprotective agent when injected intra-arterially in a transient ischemia model. MATERIAL AND METHODS: In total, 24 rabbits were studied as four groups of six animals. Group 1 served as the control group. In group 2, transient ischemia was obtained by intracarotid administration of degradable starch microspheres (DSM). Group 3 was administered thiopental intra-arterially via the carotid artery. Group 4 (experimental group) received both thiopental and DSM intra-arterially. DSM and thiopental were administered through a microcatheter placed into the common carotid artery via the central ear artery access. After sacrifice, apoptotic cells in the cerebral tissues of the animals were evaluated in H&E and TUNEL stained slides. RESULTS: There was a significant increase in the number of apoptotic glial or neuronal cells in group 2 compared to the control group and group 3. The mean number of both the apoptotic neuronal cells (6.8 ± 2.1 vs. 2.5 ± 1.3, P < 0.001) and the apoptotic glial cells (9.4 ± 3.1 vs. 4.6 ± 1.6, P < 0.001) were higher in group 2 compared to group 4. In addition, a higher level of neurological improvement was observed in group 4 compared to group 2 based on neurological assessment score. CONCLUSION: The intra-arterial administration of thiopental has a protective effect on both glial and neuronal cells during temporary cerebral ischemia in low doses.

Effect of retrobulbar prostaglandin analog injection on orbital fat in rats.

PURPOSE: Periorbital fat atrophy is a known side effect of topical prostaglandin analogs (PA). This side effect may have implications in the treatment of diseases like thyroid orbitopathy. In this in vivo study we aimed to evaluate the effects of retrobulbar injection of three different PAs on orbital fat. METHODS: Eighteen adult male Wistar-albino rats were divided into three groups of six animals. 0.1 ml of 0.03% bimatoprost, 0.005% latanoprost, or 0.005% travoprost was injected into the right orbits and saline was injected into the left orbits, as controls. Both orbits were exenterated after 3 weeks. Histological cross-sections were analyzed using ImageJ image analysis software. Intraconal adipocyte density was calculated. RESULTS: There was no significant difference in the adipocyte density between the PA injected orbits and the control side in each of the three groups. When calculations from all three groups were analyzed together, again the difference in the adipocyte density between the PA injected orbits and the control side was not significant. CONCLUSION: No significant fat atrophy was noted in this rat model three weeks after retrobulbar injection of PAs. To evaluate retrobulbar injection of PA as a potential therapy for orbital diseases with fat proliferation, in vivo studies in different animal models, higher concentrations of PA, or longer follow-up duration are required.

Cortical Subarachnoid Hemorrhage in Behcet's Disease.

OBJECTIVE: Cortical subarachnoid hemorrhage (cSAH) can be resulted from by a wide variety of causes. A cSAH probably associated with Behcet's disease is herein reported for the first time. CASE REPORT: A 58-year-old male with stable Behcet's disease evaluated for sudden onset headache. Emergency computed tomography disclosed cSAH in the left frontal sulci. A ruptured middle cerebral artery cortical branch aneurysm was found. Surprisingly, this aneurysm obliterated completely after diagnostic catheter angiography. CONCLUSION: This case highlights three important points; First, non-mycotic (non-infectious) distal cerebral artery aneurysms may rarely cause cSAH. Second, distal dissecting aneurysms may rarely become obliterated after diagnostic cerebral angiography. Third, such aneurysms may be one of the long-term consequences of vascular inflammation in Behçet's disease.

Dual ophthalmic arteries: a new case.

We report one retinoblastoma patient with dual ophthalmic arteries (also known as "double ophthalmic arteries") arising from the internal carotid artery which fuse with each other inside the orbit. The caudal ophthalmic artery with larger caliber originated from the cavernous segment of internal carotid artery and passed through the superior orbital fissure. The cranial and tiny one arose more cranially from the supraclinoid internal carotid artery and passed through the optic canal. After superselective catheterization, frank anastomosis was shown between two ophthalmic arteries and the central retinal artery arose from the cranial one. To the best of our knowledge, this case is the first observation of a dual ophthalmic artery with cavernous/supracavernous origins fusing with each other proven by superselective ophthalmic angiography. Whether there is an anastomosis between two ophthalmic arteries is important for deciding which artery to be selected for intraarterial treatment. In cases of retinoblastoma, detailed angiographic analysis may be essential to examine the orbital arterial system and to avoid unexpected complications during intraarterial chemotherapy.

Characteristic imaging features of neurovascular involvement in primary Sneddon's syndrome: an analysis of 12 cases.

OBJECTIVE: Sneddon's syndrome is a cerebrocutaneous non-inflammatory progressive distal arteriopathy, characterized by livedo racemosa, stroke, and neuropsychiatric symptoms. Our aim was to highlight the characteristic neuroimaging features of Sneddon's syndrome that might be helpful to clinicians in timely diagnosis of this entity. METHODS: Twelve patients (median age 49 years, 11 female) with primary Sneddon's syndrome, diagnosed in last 10 years, were analyzed from the perspective of magnetic resonance imaging (MRI) features. In addition, a novel pseudoangiomatosis score was defined for grading angiographic abnormalities (range: 0 to 6). RESULTS: Median interval from the onset of neurological symptoms to diagnosis was 6 years. Presentation was with acute stroke in 5, seizures in 3, dementia/speech problems in 2, seizures plus cognitive dysfunction in 1, and chronic progressive hemiparesis in 1. All patients had a typical lesion pattern on MRI. This included multiple (median 3) cortical-subcortical supratentorial and cerebellar non-territorial infarcts, accompanied by multifocal cerebral atrophy. Of note, large territorial infarcts due to cerebral parent artery occlusion, an embolic pattern with multi-territorial involvement on diffusion-weighted imaging, small vessel disease features like severe white matter involvement or lacunar infarcts, and cerebral hemorrhage in the absence of anticoagulation were not observed. MRI lesion severity was not correlated with angiographic arteriopathy severity, clinical stage, or presentation symptoms. CONCLUSION: Sneddon's syndrome is characterized by highly typical clinico-radiological features. Brain MRI has diagnostic value. By knowing the characteristics of the syndrome, misdiagnosis and potentially harmful treatment can be prevented in this entity that might pose a diagnostic challenge.

Stroke Mechanism in COVID-19 Infection: A Prospective Case-Control Study.

BACKGROUND: The characteristics and pathophysiological mechanisms involved in acute ischemic stroke in patients with COVID-19 infection have not been fully clarified. We prospectively studied the phenotypic and etiological features of acute stroke occurring in COVID-19 infection. PATIENTS & METHODS: Within nine months starting from April-2020, the presence of COVID-19 infection was determined by thoracic CT and SARS-CoV-2 PCR in all acute stroke cases managed in a single tertiary center. Consecutive and prospective data on vascular risk factors/comorbidities, in-hospital quality metrics, discharge outcomes, etiological subclassification and blood markers of thrombosis / inflammation were compared in 44 COVID-19 positive cases (37 acute ischemic stroke, 5 TIA, 2 intracerebral hematoma) and 509 COVID-19 negative patients (355 ischemic, 105 TIA, 44 hematoma and 5 stroke mimic). RESULTS: COVID-19 positive patients had more severe strokes, delayed hospital admission, longer hospital stay, higher mortality rates, but had similar vascular risk factors/comorbidities frequency, thrombolysis/thrombectomy utilization rates, metrics, and stroke etiological subtype. They had significantly higher CRP, fibrinogen, ferritin, leukocyte count and lower lymphocyte count. No difference was detected in aPTT, INR, D-dimer, platelet, hemoglobin, homocysteine levels and ANA, anti-dsDNA antibody and ENA panel positivity rates. Anti-phospholipid antibodies have been studied in 70% of COVID-19 positive and all cryptogenic patients, but were never found positive. Tests for coagulation factor levels and hereditary thrombophilia did not show major thrombophilia in any of the stroke patients with COVID-19. CONCLUSION: We documented that there is no significant difference in etiological spectrum in acute stroke patients with COVID-19 infection. In addition, cryptogenic stroke and antiphospholipid antibody positivity rates did not increase.

Evaluation of the anastomoses between the ophthalmic artery and the middle meningeal artery by superselective angiography.

PURPOSE: There are three anastomoses between the ophthalmic artery (OA) and the middle meningeal artery (MMA): the anastomotic branch with MMA, the recurrent meningeal branch and the anterior falx artery. We aimed to evaluate the anastomotic branches between the OA and the MMA on superselective angiograms of pediatric patients with retinoblastoma. MATERIALS AND METHODS: We evaluated 126 angiographies performed on children with retinoblastoma. The mean diameter and angiographic visibility percentage of the anastomotic branches between the OA and the MMA were examined according to age group and sex. RESULTS: The mean diameter of anastomotic branch with MMA was measured 0.58 ± 0.13 mm and we found this branch in 15 of 126 angiographic images (11.9%). We detected the recurrent meningeal branch in 47 of total images (37.3%). The recurrent meningeal branch arose 85.1% from the lacrimal artery, 8.5% from the anastomotic branch with MMA and 6.4% directly from the OA. The mean diameter of this artery was measured 0.21 ± 0.06 mm. Anterior falx artery was found in 86 of 126 angiographic peocedures (68.3%) and the mean diameter was measured 0.22 ± 0.06 mm. CONCLUSION: Knowledge of the anastomoses between the OA and the MMA system are all necessary to perform safe and successful endovascular and surgical procedures involving the orbital region.

Floating Aortic Thrombus: A Rare Cause of Acute Ischemic Stroke Necessitating Modification of Access Route for Thrombectomy.

We report 2 patients with acute occlusion of middle cerebral artery successfully treated by mechanical thrombectomy performed via transbrachial access. Both patients had floating aortic arch thrombi precluding safe transfemoral access due to risk of further iatrogenic embolization. Moreover both patients were diagnosed with hypercoagulopathy secondary to lung malignancy (paraneoplastic etiology, Trousseau's syndrome) as the cause of both aortic thrombi and acute ischemic stroke. Mechanical thrombectomy in the setting of a floating aortic thrombus has been mentioned only once as part of general management of floating aortic thrombi in the whole body. To the best of our knowledge, it has never been described previously in the literature in the context of cerebral mechanical thrombectomy technique. However, the diagnosis of this entity bears clinical importance for it can modify the treatment approach. A modified transbrachial approach allowed us to treat both patients without neurologic complications and resulted in modified Rankin scores of 1 on follow-up. We advise that the cross-sectional imaging of acute stroke patients should include an evaluation of the aortic arch and should be scrutinized in detail especially in patients with possible hypercoagulable state. Flat panel computed tomography technology allowed us to obtain such an imaging study in the angiography suite.

Septal reduction therapy using nonalcohol agent in hypertrophic obstructive cardiomyopathy: Single center experience.

AIMS: Percutaneous septal reduction therapy by either alcohol or nonalcohol agents is an alternative approach to surgery in drug-refractory symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM). Nonalcohol agents have some advantages and disadvantages over alcohol during the procedure. Nowadays, a novel non-alcohol agent, named as Ethylene-vinyl alcohol (EVOH) copolymer (Onyx® and Squid® ), is used during septal ablation. Thus, in this study, we aimed to evaluate both acute and long-term efficacy and safety profile of EVOH during septal ablation in HOCM. METHODS AND RESULTS: A total of 25 patients (52% female; mean age: 55.8 ± 17.1 years) with symptomatic HOCM were enrolled in the study. All subjects underwent clinical and laboratory assessment before and after the procedure. Peak left ventricular outflow tract (LVOT) gradient was significantly reduced just after the procedure (68 vs. 20 mmHg; P < 0.001). Peak serum creatine kinase-myocardial band and troponin I levels were 112 (35-282) ng/ml and 11 (4-93) ng/ml. EVOH embolization to diagonal artery was observed in 1 patient (4%) and the complete atrioventricular block was noted in 2 (8%) patients. During the 12-month follow-up, there was no mortality. There was a significant improvement in New York Heart Association functional class of the subjects P < 0.001). Both interventricular septum thickness and LVOT gradient showed a significant reduction during follow-up (P < 0.05). However, there was no reduction in the LVOT gradient of 3 patients (12%). CONCLUSIONS: In conclusion, our small-sized preliminary study results showed that septal reduction therapy using EVOH is an effective alternative option in reducing symptoms and LVOT gradient in HOCM.

Appraisal of the Flow Diversion Effect Provided by Braided Intracranial Stents.

Objective: Comparison of the results of stent-assisted coiling (SAC) with braided stents (BS), flow diverters (FD), and laser-cut stents (LCS) to determine the relative flow-diverting capacity of BS (Leo baby and Accero). Methods: Saccular intracranial aneurysms treated by SAC and FD-assisted coiling were retrospectively evaluated. Aneurysm occlusion, as graded per Raymond-Roy score, was categorized as either recanalization/stable residual filling (Group A; lacking a flow diversion effect) or stable/progressive occlusion (Group B with a "flow diversion effect"). Factors predicting the flow diversion effect were evaluated. Results: Of the 194 aneurysms included, LCS, BS, and FD were used in 70 (36.1%), 86 (44.3%), and 38 (19.6%) aneurysms, respectively. Aneurysms treated by FD were larger, had wider necks, and were located on larger parent arteries (p < 0.01, 0.02, and <0.01, respectively). The mean imaging follow-up duration was 24.5 months. There were 29 (14.9%) aneurysms in Group A and 165 (85.1%) in Group B. Among a spectrum of variables, including sex, age, aneurysm size, neck width, parent artery diameter, follow-up duration, and stent type, the positive predictors for stable/progressive aneurysm occlusion were aneurysm size and placement of an FD or BS (p < 0.01 and p < 0.01, respectively, and were positive predictors over LCS: ORs 6.34 (95% CI: 1.62-24.76) and 3.11 (95% CI: 1.20-8.07), respectively) in multivariate analysis. Conclusions: The placement of BS was a predictor of flow diversion over laser-cut stents. However, the flow diversion effect was approximately half that of FDs, suggesting that BS may only be considered to have some (partial) flow diversion effects.

Initial Experience with the New DERIVO® Mini Embolisation Device for the Treatment of Intracranial Aneurysms.

The aim of this study is to present the outcomes of cerebral aneurysm treatment with the DERIVO® mini Embolisation Device (DMD), which is compatible with microcatheters with 0.021-inch inner diameters. Consecutive patients treated with DMD were identified retrospectively. Patient and aneurysm characteristics, procedural findings, clinical outcomes and follow-up imaging results were evaluated. A total of 44 target aneurysms in 30 patients were treated with DMD. The mean age of the patients was 49.9 (range, 4-77 years). Four patients with five aneurysms presented with acute subarachnoid hemorrhage. The mean aneurysm size was 6.8 mm (range, 1.5-22 mm). In 29 (65.9%) aneurysms, adjunctive devices were used for endovascular treatment. The overall mortality rate was 3.3% and procedure-related mortality was 0%. Overall neurologic morbidity was 6.6% and none of the patients had a permanent sequela secondary to the procedure. The mean clinical follow-up period was 20.9 months (range, 3 days-46 months) and the mean DSA follow-up period was 10.9 months. A total of 37 (84.1%) aneurysms demonstrated total occlusion (Raymond-Roy [RR 1]); 3 (6.8%) aneurysms had a neck remnant or infundibular filling at the origin of the jailed side branch (RR 2), 4 (9.1%) aneurysms had residual aneurysm filling (RR 3). For those aneurysms treated with bare DMD, the total occlusion rate was 73.3% at a mean follow-up of 16.1 months. In this initial clinical single-center experience, DMD had a good safety profile and efficacy comparable with the currently used flow diverters.

Initial Experience with the Derivo 2Heal Flow Diverter under Standard or Reduced-Dose Single Antiplatelet Therapy.

BACKGROUND AND PURPOSE: Flow diverters with surface modifications or coatings have been recently introduced to clinical practice with the expectation that they can reduce the rate of thromboembolic complications and residual aneurysms. The purpose of this study is to evaluate the utility of the Derivo 2Heal (D2H) device, a new fibrin and heparin-coated flow diverter. MATERIALS AND METHODS: Patients treated by a single operator by using the D2H were retrospectively evaluated for demographic data, aneurysm characteristics, procedural variables, and follow-up data. All patients were treated by using a single D2H, monitored by platelet function testing and kept under single antiplatelet therapy with regular or half-dose clopidogrel or prasugrel after the procedure. RESULTS: Twenty patients with 26 aneurysms were treated. Three presented acutely with subarachnoid hemorrhage. Adjunctive devices were used in 6 patients. There were no technical failures and 2 periprocedural self-limited nonthrombotic minor adverse events. During follow-up, 1 of the acutely ruptured aneurysms reruptured, and 1 patient had a visual TIA. All patients were doing well clinically (19 with mRS of 0 and 1 with 1) at the last follow-up after discharge. The rates of total occlusion on very early angiographic (MRA/CTA or DSA, mean: 2.4 months), DSA (mean: 5.8 months), and midterm angiographic (mean: 14.5 months) follow-up for all versus uncoiled aneurysms were 68% versus 70%, 77.8% versus 90.0%, and 91.7% versus 90.1%, respectively. CONCLUSIONS: The absence of permanent neurologic deficits in the periprocedural period and favorable occlusion rates in this preliminary study suggest that the novel coating comprising fibrin and heparin may have the potential to increase the safety and efficacy of flow diversion and needs to be further studied by comparing the D2H device with its bare counterpart and other coated or surface-modified flow diverters.

Use of a new low-profile coronary stent graft for the treatment of intracranial carotid blow-out.

A 50-year-old male patient with a history of transcranial surgery and subsequent radiotherapy for a pituitary adenoma presented with repetitive pulsatile nasal bleeding. A right cavernous segment pseudoaneurysm was discovered on the angiogram, and the patient failed the balloon occlusion test. A Papyrus (Biotronik, Berlin, Germany) stent graft, which is approved for coronary interventions, was successfully deployed over a coaxial guiding system during the emergent treatment of the false aneurysm. The patient tolerated the procedure well and nasal bleeding did not recur after the procedure. At one-year angiographic follow-up, the stent graft was patent and there was no evidence of recanalization of the false aneurysm.

Non-routine thrombectomy in pediatric arterial ischemic stroke.

PURPOSE: Unlike in adults, the indications and techniques for mechanical thrombectomy for arterial ischemic stroke (AIS) in children are not clearly established. The medical and interventional management of children with acute large vessel occlusion may entail the modification of the standardized management of this condition in adults. We present six cases of children who underwent non-routine thrombectomy for AIS. METHODS: We retrospectively reviewed the records of children diagnosed with AIS between 2015 and 2023 and evaluated patient characteristics, procedural technical data, and final clinical outcomes. Procedures deviating from the current definition and indications for AIS treatment in adults as well as previously reported pediatric thrombectomy cases were defined as non-routine thrombectomy. RESULTS: Seven non-routine thrombectomy procedures in six children were included in the study. The National Institutes of Health Stroke Scale scores on admission ranged from 4 to 35; no procedure-related mortality or major neurologic morbidity occurred. One child died of causes related to the initial severe heart failure and stroke; otherwise, all the children had a modified Rankin scale score of 0 to 1 at follow-up. Unique clinical and procedural features in our case series included presentation with acute stent occlusion (two children), bilateral simultaneous internal carotid artery occlusions associated with a unilateral tandem middle cerebral artery (MCA) occlusion (one child), MCA occlusion caused by thromboembolism of the atrial myxoma (one child), and very distal (one child) or delayed thrombectomy (two children). CONCLUSION: Modifications to the standard medical and interventional algorithms may be required for mechanical thrombectomy in children. CLINICAL SIGNIFICANCE: Referral centers specialized in pediatric neurology, pediatric anesthesia, and pediatric intervention are optimal for treating children using mechanical thrombectomy and for modifying the treatment, if required.

Nighttime Treatment of Ruptured Intracranial Aneurysms Are Associated With Poor Outcomes.

BACKGROUND AND OBJECTIVES: Rebleeding of ruptured intracranial aneurysms (RIA) is associated with poor outcomes. Although immediate treatment of RIAs is preferred, optimal treatment timing is multifactorial and may be a complicating factor for achieving the best outcomes. The objective of this study was to compare outcomes for patients with RIAs as a function of treatment time of day. To the best of our knowledge, this is the first study that examines how treatment time of day influences treatment outcomes. METHODS: This retrospective single-center study included all patients who were treated, either surgically or endovascularly, for RIAs within 24 hours after admission. Exclusion criteria were blister, mycotic or giant aneurysms, or incomplete records. The modified Rankin Scale was used to evaluate treatment outcomes using multivariate analysis. Nighttime treatment was defined when greater than 50% of the procedure was performed between 10 pm and 7 am, with other times classified as daytime treatment. Off-hours treatment was defined when more than 50% of the procedure was performed between 7 pm and 7 am, with other times classified as on-hours. RESULTS: This study included 493 patients, with 84.2% (415) treated during the daytime, 15.8% (78) during the nighttime, 67.5% (333) during on-hours, and 32.5% (160) during off-hours. These groups did not differ according to age, sex, World Federation of Neurosurgical Societies and Fisher scales, aneurysm size, location, and surgical or endovascular treatment. Outcomes were favorable (modified Rankin Scale 0-2) for 72.0% (299) of patients treated during the daytime and 60.0% (46) of patients treated during the nighttime. Aneurysm treatment during the nighttime (OR: 0.50 [95% CI: 0.28-0.91], P = .023) but not during off-hours (OR: 0.76 [0.50-1.14], P = .18) was independently associated with unfavorable outcomes. CONCLUSION: Nighttime treatment was associated with poorer outcomes. Further studies are needed to evaluate outcomes if treatment is postponed to daytime hours.

Implications of serial magnetic resonance imaging in the management of a newborn with vein of Galen aneurysmal malformation and a review of the relevant literature.

BACKGROUND: Despite advanced endovascular methods and comprehensive intensive care in the neonatal vein of Galen aneurysmal malformation, overall mortality ranges between 37-63% in treated patients with 37-50% of survivors possessing poor neurologic outcomes. These findings stress the need for more accurate and timely recognition of the patients who may and may not benefit from aggressive intervention. CASE: This case report presents a newborn with a vein of Galen aneurysmal malformation whom antenatal and postnatal follow-up included serial magnetic resonance imaging (MRI) including diffusion-weighted series. CONCLUSIONS: Given the experience from our current case and in light of the relevant literature, it is plausible that diffusion-weighted imaging studies may widen our perspective on dynamic ischemia and progressive injury occurring within the developing central nervous system of such patients. Meticulous identification of patients may favorably influence the clinical and parental decision on early delivery and prompt endovascular treatment versus aiding avoidance of further futile interventions both antenatally and postnatally.

Utility of flow diverters in treatment of acutely ruptured uncoilable aneurysms of the posterior circulation of the brain.

PURPOSE: Aim of this study is to evaluate safety and efficacy of flow diverters (FDs) in treatment of acutely ruptured posterior circulation aneurysms MATERIALS AND METHODS: Databases of three participating institutions were retrospectively scanned for patients in whom FD placement was attempted for treatment of acutely ruptured vertebrobasilar aneurysms. An interval of 14 days or fewer between the latest ictus and treatment was used as inclusion criterion. Patients with dolichoectasia of vertebrobasilar arteries were excluded. If necessary, adjunctive techniques including coiling or stenting were utilized. Clinical outcomes were graded using mWFNS (modified World Federation of Neurosurgical Societies Scale) and mRS (modified Rankin Scale). Aneurysmal occlusion was defined as Raymond-Roy Class 1. Spearman's (ρ) test was used to assess the correlation between variables. Univariate and multivariate logistic regression were used to assess outcomes. RESULTS: 31 patients (25 women, mean age: 52.7 ± 15.2) harboring 32 aneurysms (16 non-saccular, mean size: 11.4 ± 7 mm) were included. Mean number of FDs used was 1.22 ± 0.42. In six cases, adjunctive coiling and in five cases, apposing stent placement were used. Overall mortality rate and procedure-related mortality rates were 22.5% (7/31) and 9.6% (3/31), respectively. At a mean imaging follow-up of 17.2 ± 12.6 months, total occlusion was achieved in 22 aneurysms (91.6%). Univariate analysis showed that mortality was positively correlated with vasospasm (ρ = 0.600, p < 0.05), higher mWFNS Scale (ρ = 0.685, p < 0.05), higher modified Fischer Score (ρ = 0.609, p < 0.05), higher mRS (ρ = 0.594, p < 0.05) on admission and negatively correlated with saccular morphology (ρ = -0.529, p < 0.05). Multivariate logistic regression identified mWFNS on admission as a significant predictor. (OR: 7.148, 95% CI 1.777-28.758, p: 0.01). Adjunctive coiling positively correlated with aneurysm occlusion. (ρ = 0.522, p < 0.05). CONCLUSION: The procedure-related morbidity and mortality is not negligible. However, the risks and efficacy associated with FDs are acceptable, especially when adjunctive coiling is possible, given the lack of treatment alternatives.

Lateralized Periodic Discharges in a Patient With Dural Arteriovenous Fistula: SPECT and DWI Studies Suggest They are Ictal.

Lateralized periodic discharges (LPDs) are unilateral electroencephalography (EEG) waveforms, recurring at regular intervals. There has been a long-lasting debate about whether they represent ictal or interictal phenomena. Very few patients in the literature have been investigated with multimodal functional imaging techniques. Here, we present a 58-year-old male patient with symptomatic epilepsy who had cerebral venous sinus thrombosis in the right temporo-parietal area and dural arteriovenous fistula (dAVF) over the left fronto-parietal region. He developed acute speech disturbances and altered mental status after a generalized tonic-clonic seizure. Video-EEG monitoring (VEEGM) demonstrated LPDs over the left fronto-central area, overlapping in part with the dAVF. Diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) sequences revealed restricted diffusion compatible with cytotoxic edema, whereas single-photon emission computed tomography (SPECT) indicated hyperperfusion in the same region, leading to the conclusion that he was having possible nonconvulsive status epilepticus (NCSE). An increase in antiseizure medications led to gradual improvement in clinical status and the disappearance of LPDs.

The role of choroidal optical coherence tomography for follow-up of carotid cavernous fistula with anterior drainage.

BACKGROUND: To evaluate the role of the choroidal vascularity index (CVI) and the tortuosity index (TI), along with choroidal thickness measurements, in follow-up for anteriorly draining carotid cavernous fistulas (CCF) that would otherwise necessitate an invasive carotid angiogram. METHODS: In this longitudinal observational study, analysis of enhanced depth imaging spectral domain optical coherence tomography (SD-EDI-OCT) images of 22 patients with angiographically proven unilateral CCF with anterior drainage was performed for subfoveal choroidal thickness (SFCT), central foveal thickness (CFT), CVI and TI. Baseline measurements were compared with those taken at the last visit after occlusion of the fistula. RESULTS: Both in the clinically affected and unaffected eyes, there was a significant decrease in CFT (p = 0.015 and p = 0.005, respectively), SFCT (p = 0.000 for both eyes), CVI (p = 0.002 and 0.001, respectively) and all three TI parameters, including inferior (p < 0.001 and p = 0.01, respectively) and superior temporal vein tortuosity index (p = 0.005 and p = 0.02, respectively) as well as total venular tortuosity index (p < 0.001 and p = 0.002, respectively) after successful closure of the fistula compared to first presentation. Changes in all parameters were similar between the D-CCF and I-CCF groups except for CVI. CONCLUSIONS: In this first study concerning follow-up of anteriorly draining unilateral CCFs by SD-EDI-OCT, we not only demonstrated involvement of the clinically unaffected eye but also showed that, this modality, utilizing CVI and TI together with choroidal thickness measurements, can be used as a readily available, noninvasive first-line followup method for evaluating occlusion of fistulas by endovascular treatment or spontaneous resolution.