Inferior Ophthalmic Vein-Dominant Dural Cavernous Fistula Embolization via Combined Orbitotomy and Direct Puncture of Inferior Ophthalmic Vein: A Case Report and Literature Review.

Dural carotid-cavernous fistulas (DCF) typically drain into the superior ophthalmic vein. Predominant involvement of the inferior ophthalmic vein (IOV) is rare, with only 4 documented cases in the literature. Here, the authors describe a case of a 51-year-old man who presented with acute left-sided proptosis, dysmotility, and vision loss and was found to have an IOV-dominant type D dural carotid-cavernous fistulas. The fistula could not be embolized by transfemoral endovascular access or orbitotomy alone and was ultimately managed with combined orbitotomy and direct IOV puncture. All previous reports of IOV-dominant dural carotid-cavernous fistulas in the literature were similarly inaccessible via the transfemoral approach. This case highlights the challenges of IOV cutdown and proposes an alternative management strategy. When IOV cutdown is precluded by the fragile, collapsed, or deep nature of the vessel, conversion to percutaneous IOV puncture may offer a safe and effective approach and mitigate the risks of direct puncture alone.

Endovascular Shunting for Communicating Hydrocephalus Using a Biologically Inspired Transdural Cerebrospinal Fluid Valved eShunt® Implant.

Cerebrospinal fluid (CSF) bathing the central nervous system is produced by brain and choroid plexus within the ventricles for re-absorption into the venous circulation through arachnoid granulations (AG). Communicating hydrocephalus results from disruption of the absorptive process, necessitating surgical catheter-based shunt placement to relieve excess pressure from CSF buildup. Adjustable valve designs and antibiotic impregnation have minimally impacted persistent failure rates and postoperative complications. To confront this challenge, we have developed an innovative endovascular shunt implant biologically inspired from AG function to restore the natural dynamics of CSF drainage while concurrently addressing the predominant factors contributing to conventional shunt malfunction.

Open Surgical Obliteration of Three Indirect Carotid-Cavernous Fistulas.

BACKGROUND AND IMPORTANCE: Carotid-cavernous fistulas (CCFs) are abnormal connections between the carotid artery and the cavernous sinus (CS). CCFs are primarily treated by an endovascular route, but there are situations in which a lesion is not amenable to endovascular or transorbital treatment, necessitating a transcranial approach. In this select group of patients, the use of crushed temporalis muscle to pack the CS fistula site was found to be an effective method for treatment of CCFs. CLINICAL PRESENTATION: In this case series, we present 3 patients with CCFs in which endovascular treatment was not possible because of occlusion of the petrosal sinuses or stenosis of the superior ophthalmic vein at the superior orbital fissure, rendering the lesion inaccessible by a transvenous or transorbital route. Each patient was treated with a variation of temporalis muscle packing through a skull base triangle; one was treated through the anteromedial triangle, one through the supratrochlear triangle, and the third through the Parkinson triangle. The fistulas were cured in each case. CONCLUSION: Cavernous-carotid fistulas that are not amenable to endovascular or transorbital treatment can be successfully treated by packing the CS fistula site with crushed temporalis muscle. To cure these patients' symptoms and enhance their quality of life, it is crucial to weigh the advantages and disadvantages of each therapy option.

The Neurovascular Disease Management Course: A Medical Student Opportunity for Early Exposure and Technical Development in Vascular Neurosurgery.

BACKGROUND: As endovascular neurosurgery techniques continue to evolve, medical students in the United States have widely varying exposures to the field, particularly with respect to opportunities for hands-on experiences. Current medical school curricula could benefit from a novel and adaptive course on vascular neurosurgery to increase student exposure earlier in their training. METHODS: We launched a yearly hands-on vascular neurosurgery course for medical students and residents. The day-long course is a combination of lectures focused on neurovascular disease and management accompanied by hands-on sessions where students practiced fundamental microsurgery and angiography techniques using real microscopes and angiography simulators. We surveyed the students before and after each of the 2 courses. The survey following the second annual course included quiz questions the students had not previously seen. RESULTS: Over 2 courses, we had 149 attendees, 71.8% of which were first and second-year medical students representing fifteen institutions. The average survey completion rate was 41.4% for the 4 surveys across the 2 courses. Attendees' interest in pursuing a surgical specialty (t = 1.815, P = 0.039) along with their comfort with neuroanatomy (t = 8.780, P ≤ 0.001) and neurosurgical disease (t = 6.133, P ≤ 0.001) was significantly elevated after the completion of the second course. Responses to the post-survey showed a good grasp of the fundamentals with 68% of attendees answering 70% of the quiz questions correctly. CONCLUSIONS: An interactive course on vascular neurosurgery may be an effective vehicle to provide medical students with exposure to the field and the opportunity to learn the fundamentals.

Position and blood supply of the carotid body in a Kenyan population / Posición y suministro sanguíneo del cuerpo carotídeo en una población de Kenia

Position and source of blood supply to the human carotid body displays population variations. These data are important during surgical procedures and diagnostic imaging in the neck but are only scarcely reported and altogether missing for the Kenyan population. The aim of this study was to describe the position and blood supply of the carotid body in a Kenyan population. A descriptive cross-sectional study at the Department of Human Anatomy, University of Nairobi, was designed. 136 common carotid arteries and their bifurcations were exposed by gross dissection. The carotid body was identified as a small oval structure embedded in the blood vessel adventitia. Position and source of blood supply were photographed. Data are presented by tables and macrographs. 138 carotid bodies were identified. Commonest position was carotid bifurcation (75.4 percent) followed by external carotid artery (10.2 percent), internal carotid artery (7.2 percent) and ascending pharyngeal artery (7.2 percent). Sources of arterial blood supply included the carotid bifurcation (51.4 percent), ascending pharyngeal (21.0 percent), external carotid (17.4 percent) and internal carotid (10.2 percent) arteries. Position and blood supply of the carotid body in the Kenyan population displays a different profile of variations from those described in other populations. Neck surgeons should be aware of these to avoid inadvertent injury.

La posición y la fuente de suministro sanguíneo del cuerpo carotídeo humano muestra variaciones en la población. Estos datos son importantes durante los procedimientos quirúrgicos y de diagnóstico por imagen en el cuello, pero son poco informados e inclusive faltan por completo en la población de Kenia. El objetivo de este estudio fue describir la posición y el aporte sanguíneo del cuerpo carotídeo en una población de Kenia. Se diseñó un estudio descriptivo de corte transversal en el Departamento de Anatomía Humana de la Universidad de Nairobi. 136 arterias carótidas comunes y sus bifurcaciones fueron expuestas mediante disección simple. El cuerpo carotídeo fue identificado como una pequeña estructura oval ubicada en la adventicia del vaso sanguíneo. La posición y la fuente de suministro sanguíneo fueron fotografiados. Los datos obtenidos fueron presentados en las tablas y fotomacrografías. 138 cuerpos carotídeos fueron identificados. La posición más frecuente fue la bifurcación carotídea (75,4 por ciento), seguida de la arteria carótida externa (10,2 por ciento), arteria carótida interna (7,2 por ciento) y la arteria faríngea ascendente (7,2 por ciento). Las fuentes de suministro sanguíneo arterial incluyeron la bifurcación carotídea (51,4 por ciento), arteria faríngea ascendente (21,0 por ciento), arteria carótida externa (17,4 por ciento) y arterias carótidas internas (10,2 por ciento). La posición y el suministro sanguíneo del cuerpo carotídeo en la población de Kenia muestra un perfil de variaciones diferente a las descritos en otras poblaciones. Los cirujanos de cuello deben conocer estas variaciones para así evitar lesiones accidentales.

Interlinkages in the tunica media of goat aorta / Interrelaciones en la túnica media de la aorta de cabra

The arrangement and interconnections between various components of the aortic wall influence its physicomechanical properties and functional alterations that occur in disease and ageing. The goat is a suitable model for studying cardiovascular disease, but details of the intrinsic organization of its aorta are unknown. This study therefore investigated the histomorphology of aortic tunica media in the goat by transmission electron microscopy. Sixteen healthy juvenile and adult domestic male goats (capra hircus) purchased from livestock farms in the outskirts of Nairobi were used in the study. The animals were euthanized with overdose of sodium pentabarbitone 20mg/kg, and fixed with 3 percent phosphate buffered glutaraldehyde solution by gravimetric perfusion. Specimens obtained from the thoracic aorta (T9) were post fixed in osmium tetroxide, and prepared for durcupan embedding. Ultrathin sections stained with uranyl acetate/lead citrate were examined by EM 201 Phillips © electron microscope. Elastic and collagen fibres were structurally interconnected. Elastic lamellae, collagen and elastic fibres were linked to smooth muscle cells through areas of high electron density while smooth muscle cells were interconnected various inter cellular connections. The physical interlinkages between the components of the tunica media confer plasticity, adaptability and flexibility to the aortic wall enabling it to function as a mechanically homogenous structure. Disruptions of this structure in atherosclerosis and aging may disturb the vascular integrity and predispose to aneurysm formation.

Las relaciones e interconexiones entre los distintos componentes de la pared aórtica influyen en sus propiedades fisicomecánicas y en las alteraciones funcionales que se producen en la enfermedad y el envejecimiento. La cabra es un modelo adecuado para el estudio de las enfermedades cardiovasculares, pero los detalles de la organización propia de la aorta son desconocidos. Por tanto, se investigó la histomorfología de la túnica media aórtica en la cabra mediante microscopía electrónica de transmisión. Fueron utilizadas 16 cabras (Capra hircus) domésticas macho, jóvenes y adultas sanas, adquiridas en las explotaciones ganaderas en las afueras de Nairobi fueron utilizadas. Los animales fueron sacrificados con una sobredosis de 20 mg/kg de pentobarbital sódico, y se fijaron con una solución de fosfato de glutaraldehído al 3 por ciento por perfusión gravimétrica. Las muestras obtenidas de la aorta torácica (T9) fueron puestas en tetróxido de osmio, y se prepararon para inclusión en durcupan. Secciones ultrafinas teñidas con acetato de uranilo y citrato de plomo fueron examinados por microscopio electrónico EM 201 Phillips©. Fibras elásticas y colágenas estaban interconectadas estructuralmente. Láminas elásticas, de colágeno y fibras elásticas estaban conectadas a células de músculo liso a través de áreas de alta densidad de electrones, mientras que, las células musculares lisas estaban interconectados entre diferentes conexiones celulares. Las interconexiones físicas entre los componentes de la túnica media confieren plasticidad, adaptabilidad y flexibilidad a la pared aórtica, lo que le permite funcionar como una estructura mecánica homogénea. Las interrupciones de estas estructuras en la aterosclerosis y el envejecimiento pueden alterar la integridad vascular y predisponer a la formación de aneurismas.