The association of carotid cavernous fistula with Graves' ophthalmopathy

Graves’ ophthalmopathy (GO) is one of the frequent manifestations of the disorder which is an inflammatory process due to fibroblast infiltration, fibroblast proliferation and accumulation of glycosaminoglycans. Eye irritation, dryness, excessive tearing, visual blurring, diplopia, pain, visual loss, retroorbital discomfort are the symptoms and they can mimic carotid cavernous fistulas. Carotid cavernous fistulas are abnormal communications between the carotid arterial system and the cavernous sinus. The clinical manifestations of GO can mimic the signs of carotid cavernous fistulas. Carotid cavernous fistulas should be considered in the differential diagnosis of the GO patients especially who are not responding to the standard treatment and when there is a unilateral or asymmetric eye involvement. Here we report the second case report with concurrent occurrence of GO and carotid cavernous fistula in the literature.

Fused magnetic resonance angiography and 2D fluoroscopic visualization for endovascular intracranial neuronavigation

Advanced transluminal neurovascular navigation is an indispensable image-guided method that allows for real-time navigation of endovascular material in critical neurovascular settings. Thus far, it has been primarily based on 2D and 3D angiography, burdening the patient with a relatively high level of iodinated contrast. However, in the patients with renal insufficiency, this method is no longer tolerable due to the contrast load. The authors present a novel image guidance technique based on periprocedural fluoroscopic images fused with a preinterventionally acquired MRI data set. The technique is illustrated in a case in which the fused image combination was used for endovascular treatment of a giant cerebral aneurysm.

Endovascular treatment of carotid cavernous sinus fistula: A systematic review

Carotid cavernous sinus fistulas are abnormal communications between the carotid system and the cavernous sinus. Several classification schemes have described carotid cavernous sinus fistulas according to etiology, hemodynamic features, or the angiographic arterial architecture. Increased pressure within the cavernous sinus appears to be the main factor in pathophysiology. The clinical features are related to size, exact location, and duration of the fistula, adequacy and route of venous drainage and the presence of arterial/venous collaterals. Noninvasive imaging (computed tomography, magnetic resonance, computed tomography angiography, magnetic resonance angiography, Doppler) is often used in the initial work-up of a possible carotid cavernous sinus fistulas. Cerebral angiography is the gold standard for the definitive diagnosis, classification, and planning of treatment for these lesions. The endovascular approach has evolved as the mainstay therapy for definitive treatment in situations including clinical emergencies. Conservative treatment, surgery and radiosurgery constitute other management options for these lesions.

Cavernous hemangioma of the cavernous sinus misdiagnosed as a meningioma: a case report and MR imaging findings

Cavernous hemangioma (CH) is a benign vascular malformation. Intracranial CH is generally localized as an intracranial-intraaxial and responsible for 5-13% of all intracranial vascular malformations. Intracranial-extraaxial CHs are rare rather than intracranial-intraaxial CHs. Clinical findings, imaging characteristics, and surgical approach of extraaxial CHs are rather different than intraaxial CHs. Diagnosing cavernous sinus CH preoperatively is very important, but its radiological differential diagnosis is quite difficult. In this study, we present magnetic resonance imaging findings of a 48-year-old male who was considered preoperatively to have meningioma but was diagnosed with cavernous sinus CH during surgery by pathological examination.

The retreatment: indications, technique and results

Durability of endovascular treatment of intracranial aneurysms has always been an issue and a very strong point of criticism. Although studies on long-term results have made it clear that endovascular treatment safe and effective they, nonetheless showed retreatment after endovascular treatment is nearly 5-10 times more frequent than surgical clipping. Risk factors predisposing high probability of retreatment are aneurysm with dissecting nature, incomplete coiling, sac size larger than 10mm and localization at the bifurcations such as basilar tip. The indications for retreatment after endovascular treatment are not clear yet, although certain morphologic criteria can be used. Retreatment appears not to negate the initial advantage of endovascular treatment over surgical treatment and can be performed very small morbi-mortality numbers.

Total agenesis of superior sagittal sinus and falx cerebri in a patient who has a subacute subdural hematoma crossing midline: case report

BACKGROUND AND IMPORTANCE

Anatomic variations of the superior sagittal sinus (SSS) and falx cerebri (FC) are uncommon in that agenesis of these structures is extremely rare. We report an extremely rare anatomic variation, total agenesis of the SSS and FC, and briefly discuss it from the anatomical, embryological, radiological, and clinical perspectives.

CLINICAL PRESENTATION

A 49-year-old woman presented with long-standing headache, gait disturbance, and nausea. Imaging studies showed a bilateral subdural hematoma crossing the midline, dilated venous structures, and perineural cysts, but SSS and FC. Following right-sided hemiparesis and consciousness disturbances, the subdural hematoma was evacuated from a left-sided parietal burr hole because of thick hematoma in this side. After the surgical evacuation, the hemiparesis and consciousness disturbances were regressed; however, she still had severe headache. On account of ongoing headaches and related imaging findings, it was thought that she had possible spontaneous intracranial hypotension. She was treated with autologous epidural blood patch and recovered well.

CONCLUSION

Agenesis of the SSS and FC are extremely rare variations. Agenesis of the SSS results in development of alternative venous pathways and may lead to misdiagnosis as dural arteriovenous fistulas. Agenesis of FC may cause diagnostic confusion, because subdural pathologies such as hematomas can cross the midline in rare occasions.

Macrocephaly-capillary malformation syndrome in a newborn with tetralogy of fallot and sagittal sinus thrombosis

Macrocephaly-capillary malformation syndrome is characterized by cutaneous vascular malformations with associated anomalies as macrocephaly, macrosomia, hemihypertrophy, hypotonia, developmental delay, lax joints, loose skin, polysyndactyly, and neuroimaging abnormalities. We present a newborn with a prenatal diagnosis of macrosomia and tetralogy of Fallot. He also had macrocephaly; a high forehead; capillary hemangioma on the forehead, upper lip, and philtrum; generalized loose skin; postaxial polydactyly of both hands and feet, with neuroimaging findings of polymicrogyria and thrombosis in sagittal sinus and sinus rectus. His condition was diagnosed as macrocephaly-capillary malformation syndrome in the neonatal period and he died suddenly during sleep at 6 months of age. The clinical course in this syndrome is not as benign as was previously thought. Careful follow-up of these patients with particular emphasis on neuroradiologic and cardiologic evaluation might help decrease the risk of sudden death and to improve long-term outcome.

Endovascular treatment of extracranial vertebral artery stenosis

Percutaneous angioplasty and stenting for the treatment of extracranial vertebral artery (VA) stenosis seems a safe, effective and useful technique for resolving symptoms and improving blood flow to the posterior circulation, with a low complication rate and good long-term results. In patients with severe tortuosity of the vessel, stent placement is a real challenge. The new coronary balloon-expandable stents may be preferred. A large variability of restenosis rates has been reported. Drug-eluting stents may be the solution. After a comprehensive review of the literature, it can be concluded that percutaneous angioplasty and stenting of extracranial VA stenosis is technically feasible, but there is insufficient evidence from randomized trials to demonstrate that endovascular management is superior to best medical management.

Utility of VasoCT in the treatment of intracranial aneurysm with flow-diverter stents

OBJECT

The small size and tortuous anatomy of intracranial arteries require that flow-diverter stents in the intracranial vasculature have a low profile, high flexibility, and excellent trackability. However, these features limit the degree of radiopacity that can be incorporated into the stents. Visualization of these stents and the degree of stent deployment using conventional radiographic techniques is suboptimal. To overcome this drawback, the authors used a new combined angiography/CT suite that uses flat-panel detector technology for higher resolution angiography.

METHODS

The authors present their preliminary experience in the imaging of flow-diverter stents in 31 patients in whom VasoCT was used with a new flat-panel detector angiographic system.

RESULTS

Intraarterial VasoCT was performed after flow-diverter stent deployment in all cases. In 4 of these cases, balloon angioplasty or telescopic stent deployment-related decisions were made after checking VasoCT images. At 3- and 6-month follow-up in 27 patients, digital subtraction angiography was performed in 12 patients and intravenous VasoCT in 11 patients. Twenty-three of 31 patients had their aneurysm occluded during short-term follow-up, and 4 of the 31 patients still had minimal residual filling of the aneurysms. None of the 27 patients had stenosis of the parent artery.

CONCLUSIONS

The authors found that VasoCT provides clear visualization of flow-diverter stents. The images obtained both intraarterially and intravenously are very promising. The initial results provide a high confidence and reproducibility rate for further utilization of this new technique.

Experimental parameter estimation method for nonlinear viscoelastic composite material models: an application on arterial tissue

This study is aimed at setting a method of experimental parameter estimation for large-deforming nonlinear viscoelastic continuous fibre-reinforced composite material model. Specifically, arterial tissue was investigated during experimental research and parameter estimation studies, due to medical, scientific and socio-economic importance of soft tissue research. Using analytical formulations for specimens under combined inflation/extension/torsion on thick-walled cylindrical tubes, in vitro experiments were carried out with fresh sheep arterial segments, and parameter estimation procedures were carried out on experimental data. Model restrictions were pointed out using outcomes from parameter estimation. Needs for further studies that can be developed are discussed.

Diffusion-weighted imaging findings in brain death

INTRODUCTION

The purpose of the present study was to determine the role of diffusion-weighted imaging (DWI) and to investigate the use of DWI in the diagnosis of brain death (BD).

METHODS

We prospectively evaluated 22 patients diagnosed with clinical BD (9 women, 13 men; mean age, 39.63 ± 15.1 years; age range, 9-66 years). All clinical criteria for BD were present in all 22 patients before magnetic resonance imaging, including a positive apnea test. For all cases, DW images, T2-weighted images, and fluid-attenuated inversion recovery were obtained. Thirteen distinct neuroanatomical structures were selected for analysis in all the cases. For each region of interest, the mean, standard deviation, and range of the average apparent diffusion coefficient (ADCav) values were obtained.

RESULTS

For BD patients, ADC values in all neuroanatomical structures were significantly lower than those for control subjects. We determined how ADC values in all structures were related to the diagnostic condition as well as the appropriate threshold ADC values to classify a subject as BD or control. The sensitivity, specificity, positive and negative predictive values, and correct classification rate of ADC cutoff values to distinguish BD from control groups were 100%.

CONCLUSIONS

DWI might be used as a noninvasive confirmatory test for the diagnosis of BD in the future.

Regression of neointimal hyperplasia of an intracranial stent: 6 years follow-up of a wide-necked aneurysm

We present a case of wide-necked giant aneurysm located at the P1-P2 segment of the posterior cerebral artery. The initial goal for treatment of the aneurysm was hemodynamic flow redirection with subsequent thrombosis so the procedure and involved stent placement to the neck of the aneurysm without any filling material. During follow up, significant in-stent stenosis due to intimal hyperplasia was found at the 6th month on digital subtraction angiography. Regression of in-stent neointimal stenosis at the 18th month and a total disappearance at the 76th month were observed on follow-up angiograms. Illustrating the reversibility of neointimal hyperplasia during a long follow up period was the main goal of this case report.

Intrathecal gadolinium-enhanced MR cisternography in the evaluation of CSF leakage

BACKGROUND AND PURPOSE

Radiologic identification of the location of the CSF leakage is important for proper surgical planning and increases the chance of dural repair. This article describes our experience in analyzing clinically suspected cranial CSF fistulas by using MR imaging combined with the intrathecal administration of a gadolinium-based contrast agent.

MATERIALS AND METHODS

A total of 85 consecutive patients with suspected CSF fistulas who presented with persistent or intermittent rhinorrhea or otorrhea lasting for more than 1 month between 2003 and 2007 were included in this study.

RESULTS

We observed objective CSF leakage in 64 of 85 patients (75%). The CSF leak was located in the ethmoidal region in 37 patients (58%), in the superior wall of the sphenoid sinus in 8 patients (13%), in the posterior wall of the frontal sinus in 10 patients (15%), in the superior wall of the mastoid air cells in 6 patients (9%), and from the skull base into the infratemporal fossa in 1 patient (2%). Two patients (3%) showed leakage into >1 paranasal sinus.

CONCLUSIONS

MR cisternography after the intrathecal administration of gadopentate dimeglumine represents an effective and minimally invasive method for evaluating suspected CSF fistulas along the skull base. It provides multiplanar capabilities without risk of radiation exposure and is an excellent approach to depict the anatomy of CSF spaces and CSF fistulas.

Gadolinium-enhanced MR cisternography to evaluate dural leaks in intracranial hypotension syndrome

BACKGROUND AND PURPOSE

We evaluated the use of MR cisternography after intrathecal administration of gadopentetate dimeglumine to detect the presence and localization of CSF leaks in 19 patients diagnosed with spontaneous intracranial hypotension syndrome according to the criteria of International Headache Society.

MATERIALS AND METHODS

Lumbar puncture with an injection of 0.5 mL of gadopentetate dimeglumine into the subarachnoid space in the lumbar area was performed. MR images of the cervical, thoracic, and lumbar regions in axial, coronal, and sagittal planes with fat-saturated T1-weighted images were acquired.

RESULTS

We observed objective CSF leakage in 17 (89%) of 19 patients. In 14 of these 17 patients, the site of dural tear was demonstrated accurately. In 3 of these 17 patients, the contrast leakage was diffuse, and site of the leak could not be located accurately. No leakage was observed in 2 patients. No complications were detected in any of the patients during the first 24 hours after the procedure or during the 6- to 12-month follow-up.

CONCLUSION

The current results demonstrate the relative safety, accuracy, and feasibility of intrathecal gadolinium-enhanced MR cisternography to evaluate dural leaks.

Persistent Hypoglossal Artery Associated with a Ruptured Ipsilateral Posterior Inferior Cerebellar Artery Aneurysm

A rare case of persistent hypoglossal artery in conjuction with a ruptured aneurysm at the left proximal posterior inferior cerebellar artery (PICA) is presented. A ruptured PICA aneurysm was successfully treated by endovascular occlusion of the aneurym with coiling.

A cerebellar demyelinating lesion following treatment of acne with isotretinoin

We report the case of a demyelinating lesion located in the left cerebellar region that developed 3 months after the onset of oral isotretinoin treatment. In April 2001, 1 year before admission, the patient underwent cranial magnetic resonance imaging (MRI) because of endocrinological problems. This was found to be completely normal. In January 2002, oral isotretinoin treatment was started to treat severe acne. Three months after the onset of therapy, the patient reported lack of appetite, faintness and tinnitus. Her second cranial MRI scan showed a cerebellar lesion, and oral isotretinoin treatment was stopped (April 2002). One month after the cessation of oral isotretinoin treatment, the lesion became less prominent on the MRI scan, and after 3 months, it had disappeared. Although it is difficult to determine the causal association between the demyelinating cerebellar lesion and isotretinoin treatment, we would like to alert physicians to this possibility, because of the common usage of this drug in daily practice.

Intrathecal Gadolinium-Enhanced MR-Cisternography in Spontaneous Intracranial Hypotension Associated With Behcet's Syndrome

We report a 32-year-old woman diagnosed with spontaneous intracranial hypotension (SIH) and Behcet's Syndrome. Suspicion of SIH was based on cervical MRI findings, and magnetic resonance (MR)-cisternography revealed dural leaks bilaterally at lumbar region. MR-cisternography is a recently performed technique and gaining importance in demonstration of CSF fistula.

Follow-up of extracranial vertebral artery stents with Doppler sonography

OBJECTIVE

The objective of our study was to determine the Doppler sonography findings suggestive of restenosis in the follow-up of patients treated by stent placement in the extracranial vertebral artery.

CONCLUSION

Follow-up of vertebral artery stents with Doppler sonography may be performed by direct insonation of the stent or by indirect measurements from the V2 segment (the part of the vertebral artery that courses within the intervertebral foramina). The V2 segment Doppler sonography measurements may guide future examinations and provide essential information regarding the proximally deployed stent.

Reversible reduction of apparent diffusion coefficient values in bilateral internal capsules in transient hypoglycemia-induced hemiparesis

A woman aged 68 years who experienced recurrent right hemiparesis caused by hypoglycemia was admitted to our hospital. When she was experiencing a low level of glucose, diffusion-weighted MR imaging showed the presence of hyperintensity lesions in the bilateral internal capsule. Diffusion-weighted MR imaging has been infrequently performed in patients with hypoglycemia. We report the reversible hyperintensity lesions on diffusion-weighted MR imaging in a hypoglycemic period in a patient with reversible hemiparesis. A reduction of apparent diffusion coefficient in a hypoglycemic period was clearly shown.

Endovascular treatment of persistent epistaxis due to pseudoaneurysm formation of the ophthalmic artery secondary to nasogastric tube

We present the case of a 60-year-old man with persistent epistaxis for 20 days that had started 2 weeks after removal of a nasogastric tube placed for an abdominal operation. There was no pathologic finding at selective facial and internal maxillary artery injections. An injury to the ethmoidal branches of the ophthalmic arteries or other arterial origins of bleeding was suspected. The internal carotid artery angiography revealed a pseudoaneurysm of an anterior ethmoidal branch of the left ophthalmic artery. The pseudoaneurysm was occluded with NBCA-histoacryl (25%) injection.