Brain arteriovenous malformations and dural arteriovenous fistulas with extensive venous congestive encephalopathy

Current state and confusion of twig-like middle cerebral artery

A twig-like middle cerebral artery (MCA) is an uncommon lesion in which a plexiform network of small vessels replaces the M1 segment of the MCA. Currently, we have insufficient information for twig-like MCAs. Therefore, a review of the literature using PubMed was conducted. In this review of twig-like MCAs, the following were discussed: the definition, pathogenesis, hemodynamics, associated aneurysm, clinical manifestations, imaging examinations, therapeutic strategies, therapeutic complications and prognosis. In addition, we proposed a reasonable grading system for twig-like MCAs, which is significant. For a twig-like MCA, the pathogenesis is unclear, and congenital and acquired factors can be involved. A twig-like MCA disturbed cerebral hemodynamics. An associated aneurysm can occur in patients with twig-like MCAs. Twig-like MCAs can present subclinically and without clinical symptoms, hemorrhage, or ischemic strokes. Of all the available imaging examinations, digital subtracted angiography is the gold standard. When treating a twig-like MCA, it is feasible to target the associated aneurysm, and extracranial-intracranial bypass can be effective in reducing the risk of strokes, but more evidence is needed. Now, the decision to perform surgery for twig-like MCAs should be made on a case-by-case basis.

Transarterial embolization of dural arteriovenous fistula of the inferior petrosal sinus: A report of two cases

Dural arteriovenous fistula (DAVF) of the inferior petrosal sinus (IPS) is very unusual. Endovascular embolization is a good option for the treatment of DAVF. Until now, DAVFs of the IPS have only been reported sporadically. We reported two such cases. Case 1 was a 48-year-old man with headache and diplopia. Angiography confirmed a DAVF of the distal IPS, mainly supplied by the occipital artery (OA), and the IPS was occluded, which retrogradely drained into the cavernous sinus (CS) and then into the cortical vein. The DAVF in case 1 was embolized completely via the OA to cast Onyx-18. Case 2 was a 69-year-old female who had red and swollen eyes. Angiography confirmed a DAVF of the proximal IPS, mainly supplied by the accessory meningeal artery (AMA), which drained into the CS and then into the ophthalmic vein, and the IPS was occluded. The DAVF in case 2 was embolized completely via the AMA to cast Onyx-18. After treatment, these two patients had uneventful recoveries. In our report, these two cases indicated that the DAVFs of the proximal and distal IPS shared different origins of feeding arteries. When the IPS is occluded, the transarterial approach via the main feeder, such as OA and AMA, can be feasible to cure the DAVF of the IPS.

Multimodal MRI diagnosis and transvenous embolization of a basicranial emissary vein dural arteriovenous fistula: A case report

A dural arteriovenous fistula (DAVF) is an abnormal linkage connecting the arterial and venous systems within the intracranial dura mater. A basicranial emissary vein DAVF drains into the cavernous sinus and the ophthalmic vein, similar to a cavernous sinus DAVF. Precise preoperative identification of the DAVF location is a prerequisite for appropriate treatment. Treatment options include microsurgical disconnection, endovascular transarterial embolization (TAE), transvenous embolization (TVE), or a combination thereof. TVE is an increasingly popular approach for the treatment of DAVFs and the preferred approach for skull base locations, due to the risk of cranial neuropathy caused by dangerous anastomosis from arterial approaches. Multimodal magnetic resonance imaging (MRI) can provide anatomical and hemodynamic information for TVE. The therapeutic target must be precisely embolized in the emissary vein, which requires guidance via multimodal MRI. Here, we report a rare case of successful TVE for a basicranial emissary vein DAVF, utilizing multimodal MRI assistance. The fistula had vanished, pterygoid plexus drainage had improved, and the inferior petrosal sinus had recanalized, as observed on 8-month follow-up angiography. Symptoms and signs of double vision, caused by abduction deficiency, disappeared. Detailed anatomic and hemodynamic assessment by multimodal MRI is the key to guiding successful diagnosis and treatment.

Combined endovascular and microsurgical management of complex traumatic carotid-cavernous fistula: Three case reports

Background:

With the evolution of the endovascular devices, the management of endovascular interventions has become the current standard therapy for traumatic carotid-cavernous fistula (TCCF). However, only endovascular treatment may not be feasible in some patients with atypical TCCF.

Case Description:

We described three complex TCCFs that could not be managed by conventional endovascular methods. The first patient had recurrent TCCF previously treated by muscle embolization and ligation of affected carotid arteries 23 years ago. Another two patients had TCCFs association with large pseudoaneurysm within the sphenoid sinus. In each patient, the fistula was successfully closed by trapping procedure using a combination of endovascular and surgical treatment.

Conclusion:

To reduce costs of treatment, trapping operation by combining surgical and endovascular treatment may be considered as an alternative option for complex TCCF which has some features including chronic stage, preexisting carotid artery ligation, or association with large venous pouch of the cavernous sinus or sphenoid sinus pseudoaneurysm.