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Kim YS, Yoon W, Baek BH, Kim SK, Joo SP, Kim TS. Ruptured venous aneurysm associated with a dural arteriovenous fistula: Two case reports. World J Clin Cases 2024; 12:6314-6319. [DOI: 10.12998/wjcc.v12.i29.6314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Revised: 07/27/2024] [Accepted: 08/08/2024] [Indexed: 08/28/2024] Open
Abstract
BACKGROUND In general, venous aneurysm associated with dural arteriovenous fistula (dAVF) is considered to be developed under long standing venous hypertension and manifested as venous ectasia of draining vein itself. However, discrete saccular shaped venous aneurysm without angiographic evidence of venous hypertension arising from the draining vein, like cerebral arterial aneurysm, is quite rare and its pathomechanism remains unclear in patients with dAVF.
CASE SUMMARY In this report, we present two cases of ruptured saccular venous aneurysms associated with dAVF without venous hypertension or venous ectasia. In both cases, significant curve or stenosis is observed in draining vein, which is located in just distal portion of the venous aneurysms. These aneurysms were successfully treated with a transarterial embolization. Underlying mechanism of venous aneurysms in these cases is discussed.
CONCLUSION Although there is little doubt that hemodynamic stress has a critical role in the development of venous aneurysms in patients with dAVF, preceding venous hypertension or venous ectasia is not necessary for development and enlargement of venous aneurysms. Considering the significant risk of rupture, a careful review of draining vein features including tortuosity or stenosis is needed, especially in venous aneurysms without evidence of venous hypertension.
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Affiliation(s)
- You Sub Kim
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju 61469, South Korea
| | - Woong Yoon
- Department of Radiology, Chonnam National University Hospital and Medical School, Gwangju 61469, South Korea
| | - Byung Hyun Baek
- Department of Radiology, Chonnam National University Hospital and Medical School, Gwangju 61469, South Korea
| | - Seul Kee Kim
- Department of Radiology, Chonnam National University Hwasun Hospital, Hwasungun 58128, South Korea
| | - Sung Pil Joo
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju 61469, South Korea
| | - Tae Sun Kim
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju 61469, South Korea
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Elhussein N, A. AlHarbi M, Hamd ZY, Alorainy AI, Elshanawani M, Alsuhabani E, Alhariqi B, Abdullah Alhomida B, Hassan A. B. A. The impact of different imaging modalities in diagnosis and management of patient with dural arteriovenous fistula: A rare case report. Trauma Case Rep 2024; 52:101044. [PMID: 38952476 PMCID: PMC11214945 DOI: 10.1016/j.tcr.2024.101044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2024] [Indexed: 07/03/2024] Open
Abstract
In vascular neurosurgery, dural arteriovenous fistulas (DAVFs) are a difficult, challenging condition whose natural history and therapy are still debated. This case report presented a 30-year-old male patient who experienced intermittent headaches for two months, along with gradual weakness in all four limbs, resulting in quadriplegia. Magnetic resonance imaging (MRI), computed tomography (CT), and digital subtraction angiography (DSA) played a significant role in the diagnosis of the patient, in which the final diagnosis was vascular myelopathy due to Dural arteriovenous fistula (DAVF). A successful embolization procedure of arteriovenous fistula using balloon-assisted liquid embolic agents, through branches of the right occipital artery was performed, resulting in complete obliteration of the fistula. In order to improve the neurovascular symptoms that had previously been reported, the patient was effectively undergoing rehabilitation, with notable progress.
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Affiliation(s)
- Nagwan Elhussein
- Department of Diagnostic Radiology, College of Applied Medical Sciences, University of Ha'il, Hail, Saudi Arabia
| | - Mohammed A. AlHarbi
- Medical Imaging Department, King Abdullah bin Abdul-Aziz University Hospital, Riyadh, Saudi Arabia
| | - Zuhal Y. Hamd
- Department of Radiological Sciences, College of Health and Rehabilitation Sciences, Princess Nourah bint Abdulrahman University, P.0 Box 84428, Riyadh 11671, Saudi Arabia
| | - Amal I. Alorainy
- Department of Radiological Sciences, College of Health and Rehabilitation Sciences, Princess Nourah bint Abdulrahman University, P.0 Box 84428, Riyadh 11671, Saudi Arabia
| | - Mansour Elshanawani
- Medical Imaging Department, King Abdullah bin Abdul-Aziz University Hospital, Riyadh, Saudi Arabia
| | - Eyas Alsuhabani
- Medical Imaging Department, King Abdullah bin Abdul-Aziz University Hospital, Riyadh, Saudi Arabia
| | - Bader Alhariqi
- Medical Imaging Department, King Fahad Medical City, Riyadh, Saudi Arabia
| | | | - Abdoelrahman Hassan A. B.
- Department of Radiotherapy, College of Medical Radiologic Sciences, Sudan University of Science and Technology, P.O. Box 11111, Khartoum, Sudan
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Gulino V, Brunasso L, Avallone C, Campisi BM, Bonosi L, Costanzo R, Cammarata E, Sturiale CL, Cordova A, Iacopino DG, Maugeri R. The Use of Intraoperative Microvascular Doppler in Vascular Neurosurgery: Rationale and Results-A Systematic Review. Brain Sci 2024; 14:56. [PMID: 38248271 PMCID: PMC10813139 DOI: 10.3390/brainsci14010056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 12/27/2023] [Accepted: 01/04/2024] [Indexed: 01/23/2024] Open
Abstract
Surgical treatment of neurovascular lesions like intracranial aneurysms, arteriovenous malformations and arteriovenous dural fistulas is still associated with high morbidity. Several recent studies are providing increasing insights into reliable tools to improve surgery and reduce complications. Inadvertent vessel compromise and incomplete occlusion of the lesion represent the most possible complications in neurovascular surgery. It is clear that direct visual examination alone does not allow to identify all instances of vessel compromise. Various modalities, including angiography, microvascular Doppler and neurophysiological studies, have been utilized for hemodynamics of flow vessels in proper clipping of the aneurysm or complete obliteration of the lesion. We intended to review the current knowledge about the intraoperative microvascular Doppler (iMDS) employment in the most updated literature, and explore the most recent implications not only in intracranial aneurysms but also in neurovascular lesions like arteriovenous malformations (AVMs) and arteriovenous dural fistulas (AVDFs). According to the PRISMA guidelines, systematic research in the most updated platform was performed in order to provide a complete overview about iMDS employment in neurovascular surgery. Twelve articles were included in the present paper and analyzed according to specific research areas. iMDS employment could represent a crucial tool to improve surgery in neurovascular lesions. The safety and effectiveness of the surgical treatment of neurovascular lesions like intracranial aneurysm and other neurovascular lesions like AVMs and AVDFs requires careful and accurate consideration regarding the assessment of anatomy and blood flow. Prognosis may depend on suboptimal or incomplete exclusion of the lesion.
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Affiliation(s)
- Vincenzo Gulino
- Neurosurgical Clinic AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Via del Vespro 127, 90127 Palermo, Italy; (V.G.); (L.B.); (C.A.); (B.M.C.); (L.B.); (R.C.); (R.M.)
| | - Lara Brunasso
- Neurosurgical Clinic AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Via del Vespro 127, 90127 Palermo, Italy; (V.G.); (L.B.); (C.A.); (B.M.C.); (L.B.); (R.C.); (R.M.)
| | - Chiara Avallone
- Neurosurgical Clinic AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Via del Vespro 127, 90127 Palermo, Italy; (V.G.); (L.B.); (C.A.); (B.M.C.); (L.B.); (R.C.); (R.M.)
| | - Benedetta Maria Campisi
- Neurosurgical Clinic AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Via del Vespro 127, 90127 Palermo, Italy; (V.G.); (L.B.); (C.A.); (B.M.C.); (L.B.); (R.C.); (R.M.)
| | - Lapo Bonosi
- Neurosurgical Clinic AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Via del Vespro 127, 90127 Palermo, Italy; (V.G.); (L.B.); (C.A.); (B.M.C.); (L.B.); (R.C.); (R.M.)
| | - Roberta Costanzo
- Neurosurgical Clinic AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Via del Vespro 127, 90127 Palermo, Italy; (V.G.); (L.B.); (C.A.); (B.M.C.); (L.B.); (R.C.); (R.M.)
| | - Emanuele Cammarata
- Plastic and Reconstructive Surgery, Department of Surgical, Oncological and Oral Sciences, University of Palermo, Via del Vespro 127, 90127 Palermo, Italy; (E.C.); (A.C.)
| | - Carmelo Lucio Sturiale
- Department of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy;
| | - Adriana Cordova
- Plastic and Reconstructive Surgery, Department of Surgical, Oncological and Oral Sciences, University of Palermo, Via del Vespro 127, 90127 Palermo, Italy; (E.C.); (A.C.)
| | - Domenico Gerardo Iacopino
- Neurosurgical Clinic AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Via del Vespro 127, 90127 Palermo, Italy; (V.G.); (L.B.); (C.A.); (B.M.C.); (L.B.); (R.C.); (R.M.)
| | - Rosario Maugeri
- Neurosurgical Clinic AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, Via del Vespro 127, 90127 Palermo, Italy; (V.G.); (L.B.); (C.A.); (B.M.C.); (L.B.); (R.C.); (R.M.)
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Yan L, Tao W, Zhan Q, Huang Z, Chen F, Li S. Angioarchitectural features of brain arteriovenous malformation presented with seizures. Neurosurg Rev 2022; 45:2909-2918. [PMID: 35589870 DOI: 10.1007/s10143-022-01814-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 03/07/2022] [Accepted: 05/13/2022] [Indexed: 12/01/2022]
Abstract
Seizures are the second most common manifestations of brain arteriovenous malformations (bAVMs). This study was conducted to investigate the clinical and angioarchitectural features of bAVMs with seizures and provide guidelines for the clinical management of these patients. We collected clinical and radiological data on patients with bAVMs diagnosed by digital subtraction angiography between January 2013 and December 2020 and dichotomized the patients into the seizures and non-seizures groups. We identified differences in demographic and angiographic features. Logistic regression and random forest (RF) models were developed and compared. The diagnostic capacity was assessed using receiver operating characteristic (ROC) curves. A nomogram was constructed, and the clinical impact was determined by decision curve analysis. A total of 414 patients with bAVMs were included in the analysis, of which 78 (18.8%) had bAVM-related seizures. In the multivariable logistic regression model, the location and side of bAVMs were independently associated with seizures. In RF models, the maximal diameter of veins and the cross-sectional area of feeding arteries and draining veins were the most important features. ROC curves showed that the RF model was not better than MLR in predicting seizures. Decision curve analysis revealed that the use of a constructed nomogram to stratify the seizure patients was beneficial at all threshold probabilities in our study. The side and location of bAVMs are specific angioarchitectural features independently associated with the occurrences of seizures with bAVMs.
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Affiliation(s)
- Langchao Yan
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Wengui Tao
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Qian Zhan
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Zheng Huang
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Fenghua Chen
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Shifu Li
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China.
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Risk Factors of Aggressive Clinical Presentation in Patients with Angiographically Aggressive Cranial Dural Arteriovenous Fistulas. J Clin Med 2021; 10:jcm10245835. [PMID: 34945132 PMCID: PMC8703894 DOI: 10.3390/jcm10245835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 12/06/2021] [Accepted: 12/12/2021] [Indexed: 11/16/2022] Open
Abstract
Compared to nonaggressive cranial dural arteriovenous fistulae (cDAVF), aggressive cDAVF carries leptomeningeal venous drainage (LVD) and has approximately 15% annual risk of hemorrhagic and non-hemorrhagic aggressive neurological presentations. In terms of aggressive clinical presentations, the previous classification does not adequately differentiate the higher risk group from the lower risk group. Herein, we retrospectively collected a series of patients with aggressive cDAVF and explored the risk factors for differentiating the higher-risk group from the lower-risk group with aggressive clinical presentations. We retrospectively collected patients with aggressive cDAVF from March 2011 to March 2019. The risk of aggressive clinical presentation was recorded. Risk factors were included in the analysis for aggressive clinical presentations. From March 2011 to March 2019, 37 patients had aggressive cDAVF. Among them, 24 presented with aggressive clinical presentation (20, hemorrhagic presentation; four, non-hemorrhagic presentation). In patients presenting with hemorrhage, four patients experienced early rebleeding after diagnosis. In the univariate analysis, risk location, directness of LVD, exclusiveness of LVD, and venous strain were significantly different in patients with aggressive clinical presentation. In the multivariate analysis, exclusiveness of LVD and venous strain were observed, with a significant difference between patients with aggressive clinical presentation and those with benign clinical presentation. Among patients with angiographically aggressive cDAVFs, approximately 65% presented with aggressive clinical presentations in our series. Among all potential risk factors, patients with exclusiveness of LVD and venous strain have even higher risk and should be treated aggressively and urgently.
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6
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Della Pepa GM, Di Bonaventura R, Latour K, Sturiale CL, Marchese E, Puca A, Sabatino G, Albanese A. Combined Use of Color Doppler Ultrasound and Contrast-Enhanced Ultrasound in the Intraoperative Armamentarium for Arteriovenous Malformation Surgery. World Neurosurg 2021; 147:150-156. [PMID: 33359527 DOI: 10.1016/j.wneu.2020.12.076] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/13/2020] [Accepted: 12/14/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Safety and efficacy in surgical treatment of cerebral arteriovenous malformations (AVMs) are dictated by thorough understanding of angioarchitectural features, intraoperative identification of feeding vessels, and appreciation of surrounding eloquent areas. Our aim was to describe the preliminary results of combined application of color Doppler ultrasound (CDUS) and contrast-enhanced ultrasound (CEUS) in a consecutive surgical series of AVM. We pointed out the tool's efficacy in distinguishing feeding from bystander vessels and in identifying pattern of venous drainage. We examined its role as an adjunct for semiquantitative evaluation of the nidus inflow. METHODS We used combined CDUS and CEUS in patients surgically treated for cerebral AVMs. We adopted these techniques following a designed protocol to guide safer AVM resection as an adjunct to indocyanine green videoangiography. Intraoperative assessment by ultrasound was performed before, during, and following nidus resection. RESULTS Four surgically treated cerebral AVMs availed of the ultrasound protocol. Postoperative conventional angiography showed complete resection of the AVMs. CDUS and CEUS proved to be valuable adjunctive tools to indocyanine green videoangiography and micro-Doppler in properly navigating and discerning vascular structures, especially vessel feeders from bystanders. The protocol allows us to identify flow direction, estimate blood velocity within the nidus, and appreciate flow modifications following temporary clipping. Ultimately, it allows us to evaluate the degree of nidus deafferentation, residual flow, restoration of venous drainage and absence of arteriovenous shunts. CONCLUSIONS The CDUS and CEUS protocol is safe and repeatable and works as real-time imaging, further supporting complete surgical resection of AVMs.
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Affiliation(s)
- Giuseppe Maria Della Pepa
- Department of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy; Institute of Neurosurgery, Catholic University of the Sacred Heart, Rome, Italy
| | - Rina Di Bonaventura
- Department of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy; Institute of Neurosurgery, Catholic University of the Sacred Heart, Rome, Italy.
| | - Kristy Latour
- Institute of Neurosurgery, Catholic University of the Sacred Heart, Rome, Italy
| | | | - Enrico Marchese
- Department of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy; Institute of Neurosurgery, Catholic University of the Sacred Heart, Rome, Italy
| | - Alfredo Puca
- Department of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy
| | - Giovanni Sabatino
- Institute of Neurosurgery, Catholic University of the Sacred Heart, Rome, Italy; Neurosurgery Unit, Mater Olbia Hospital, Olbia, Italy
| | - Alessio Albanese
- Department of Neurosurgery, Fondazione Policlinico Agostino Gemelli IRCCS, Rome, Italy; Institute of Neurosurgery, Catholic University of the Sacred Heart, Rome, Italy
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7
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La Rocca G, Della Pepa GM, Menna G, Altieri R, Ius T, Rapisarda A, Olivi A, Sabatino G. State of the art of fluorescence guided techniques in neurosurgery. J Neurosurg Sci 2020; 63:619-624. [PMID: 31961115 DOI: 10.23736/s0390-5616.19.04854-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Achieving a safe and extensive neoplasm resection can be considered the main goal of brain tumor surgery. This paper is first aimed at providing an overview of the evolution of those tools serving the purpose. From the dawn of neurosurgery to the present days, major innovations have followed one another. However, those techniques may frequently lack of an instant biological feedback on the true extension and the infiltration of the tumor. Intraoperative fluorescence modalities could indeed fill this gap. Fluorescence guided surgery will be therefore introduced and discussed in this context. Our focus will be on the most common fluorescence techniques used in neurosurgery, namely 5-aminolevulinic acid, sodium fluorescein and in indocyanine green. Mode of action, strengths and weaknesses and level of evidence of each modality will be discussed.
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Affiliation(s)
- Giuseppe La Rocca
- Institute of Neurosurgery, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome, Italy - .,Unit of Neurosurgery, Mater Olbia Hospital, Olbia, Italy -
| | - Giuseppe M Della Pepa
- Institute of Neurosurgery, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Grazia Menna
- Institute of Neurosurgery, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Roberto Altieri
- Department of Neurological Surgery, G. Rodolico Policlinic University Hospital, Catania, Italy.,Division of Neurosurgery, Department of Neuroscience, University of Turin, Turin, Italy
| | - Tamara Ius
- Unit of Neurosurgery, Department of Neuroscience, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Alessandro Rapisarda
- Institute of Neurosurgery, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Alessandro Olivi
- Institute of Neurosurgery, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Giovanni Sabatino
- Institute of Neurosurgery, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome, Italy
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Della Pepa GM, Ius T, Menna G, La Rocca G, Battistella C, Rapisarda A, Mazzucchi E, Pignotti F, Alexandre A, Marchese E, Olivi A, Sabatino G. "Dark corridors" in 5-ALA resection of high-grade gliomas: combining fluorescence-guided surgery and contrast-enhanced ultrasonography to better explore the surgical field. J Neurosurg Sci 2020; 63:688-696. [PMID: 31961118 DOI: 10.23736/s0390-5616.19.04862-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Increasing the extent of resection (EOR) is considered a main goal in high grade glioma (HGG) surgery. Significant advancements have been recently made to assist surgery: namely the use of 5-aminolevulinic acid (5ALA) and the application of contrast-enhanced ultrasound (CEUS) embody two of the most recently introduced tools in the neuro-oncology field. A combined approach including the two techniques has been suggested in literature. Our primary aim is to identify in which conditions CEUS final survey has a real impact in a 5-ALA guided context and assess which preoperative tumor characteristics, with specific attention to working corridors can predict strains of the fluorescence guided procedure and hence recommend the use of the combined technique. METHODS Forty-nine HGG glioma surgeries were performed at our institution with the abovementioned protocol between January 2016 and June 2016. Based on preoperative MRI, we stratified glioma characteristics according to three determinants: localization (deep versus superficial), size (<3.5 versus >3.5 cm) and shape (regular versus irregular). RESULTS CEUS modified 5-ALA guided resection in 11 cases (22.45%): this appeared to be associated with statistically significance to deep tumor localization (P=0.04) and irregular/multi-lobulated margins (P=0.003). On the other hand, tumor size alone did not appear as a statistically significant determinant. CONCLUSIONS When dark corridors are presents or when overlying brain parenchyma hinders illumination, drawbacks to the 5-ALA assistance can be expected, hence CEUS final survey has a crucial role of 'refinement'. In those selected cases, an integrated 5ALA+CEUS protocol was shown as advisable in EOR improvement.
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Affiliation(s)
- Giuseppe M Della Pepa
- Institute of Neurosurgery, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome, Italy -
| | - Tamara Ius
- Neurosurgery Unit, Department of Neuroscience, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Grazia Menna
- Institute of Neurosurgery, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Giuseppe La Rocca
- Institute of Neurosurgery, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome, Italy.,Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
| | | | - Alessandro Rapisarda
- Institute of Neurosurgery, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Edoardo Mazzucchi
- Institute of Neurosurgery, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome, Italy
| | | | - Andrea Alexandre
- Institute of Neuroradiology, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Enrico Marchese
- Institute of Neurosurgery, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Alessandro Olivi
- Institute of Neurosurgery, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Giovanni Sabatino
- Institute of Neurosurgery, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome, Italy.,Department of Neurosurgery, Mater Olbia Hospital, Olbia, Italy
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9
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Starke RM, McCarthy DJ, Chen CJ, Kano H, McShane BJ, Lee J, Patibandla MR, Mathieu D, Vasas LT, Kaufmann AM, Wang WG, Grills IS, Cifarelli CP, Paisan G, Vargo J, Chytka T, Janouskova L, Feliciano CE, Sujijantarat N, Matouk C, Chiang V, Hess J, Rodriguez-Mercado R, Tonetti DA, Lunsford LD, Sheehan JP. Hemorrhage risk of cerebral dural arteriovenous fistulas following Gamma Knife radiosurgery in a multicenter international consortium. J Neurosurg 2020; 132:1209-1217. [PMID: 30875690 PMCID: PMC6745287 DOI: 10.3171/2018.12.jns182208] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 12/12/2018] [Indexed: 11/12/2022]
Abstract
OBJECTIVE The authors performed a study to evaluate the hemorrhagic rates of cerebral dural arteriovenous fistulas (dAVFs) and the risk factors of hemorrhage following Gamma Knife radiosurgery (GKRS). METHODS Data from a cohort of patients undergoing GKRS for cerebral dAVFs were compiled from the International Radiosurgery Research Foundation. The annual posttreatment hemorrhage rate was calculated as the number of hemorrhages divided by the patient-years at risk. Risk factors for dAVF hemorrhage prior to GKRS and during the latency period after radiosurgery were evaluated in a multivariate analysis. RESULTS A total of 147 patients with dAVFs were treated with GKRS. Thirty-six patients (24.5%) presented with hemorrhage. dAVFs that had any cortical venous drainage (CVD) (OR = 3.8, p = 0.003) or convexity or torcula location (OR = 3.3, p = 0.017) were more likely to present with hemorrhage in multivariate analysis. Half of the patients had prior treatment (49.7%). Post-GRKS hemorrhage occurred in 4 patients, with an overall annual risk of 0.84% during the latency period. The annual risks of post-GKRS hemorrhage for Borden type 2-3 dAVFs and Borden type 2-3 hemorrhagic dAVFs were 1.45% and 0.93%, respectively. No hemorrhage occurred after radiological confirmation of obliteration. Independent predictors of hemorrhage following GKRS included nonhemorrhagic neural deficit presentation (HR = 21.6, p = 0.027) and increasing number of past endovascular treatments (HR = 1.81, p = 0.036). CONCLUSIONS Patients have similar rates of hemorrhage before and after radiosurgery until obliteration is achieved. dAVFs that have any CVD or are located in the convexity or torcula were more likely to present with hemorrhage. Patients presenting with nonhemorrhagic neural deficits and a history of endovascular treatments had higher risks of post-GKRS hemorrhage.
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Affiliation(s)
- Robert M Starke
- 1Department of Neurological Surgery, University of Miami, Florida
| | - David J McCarthy
- 1Department of Neurological Surgery, University of Miami, Florida
| | - Ching-Jen Chen
- 2Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Hideyuki Kano
- 3Department of Neurological Surgery, University of Pittsburgh
| | - Brendan J McShane
- 4Department of Neurological Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John Lee
- 4Department of Neurological Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mohana Rao Patibandla
- 2Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - David Mathieu
- 5Department of Neurological Surgery, University of Sherbrooke, Quebec, Canada
| | - Lucas T Vasas
- 6Department of Neurological Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Anthony M Kaufmann
- 6Department of Neurological Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Wei Gang Wang
- 7Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Inga S Grills
- 7Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | | | - Gabriella Paisan
- 2Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - John Vargo
- 9Radiation Oncology, West Virginia University, Morgantown, West Virginia
| | - Tomas Chytka
- 10Department of Neurological Surgery, Na Homolce Hospital, Prague, Czech Republic
| | - Ladislava Janouskova
- 10Department of Neurological Surgery, Na Homolce Hospital, Prague, Czech Republic
| | - Caleb E Feliciano
- 11Department of Neurological Surgery, University of Puerto Rico, San Juan, Puerto Rico; and
| | - Nanthiya Sujijantarat
- 12Department of Neurological Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Charles Matouk
- 12Department of Neurological Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Veronica Chiang
- 12Department of Neurological Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Judith Hess
- 12Department of Neurological Surgery, Yale University School of Medicine, New Haven, Connecticut
| | | | | | - L Dade Lunsford
- 3Department of Neurological Surgery, University of Pittsburgh
| | - Jason P Sheehan
- 2Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
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10
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Wen HY, Yang ST, Lo YL. Hydrocephalus with Ventricular Papillary Structure Induced by Aggressive Intracranial Dural Arteriovenous Fistulas. World Neurosurg 2019; 132:208-210. [PMID: 31505278 DOI: 10.1016/j.wneu.2019.08.214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 08/26/2019] [Accepted: 08/28/2019] [Indexed: 10/26/2022]
Abstract
A 76-year-old man presented with progressive dementia, gait disturbance, and urinary incontinence for 1 year. Computed tomography scan revealed nonobstructive hydrocephalus, but abnormal papillary structures at the ventricular wall were noted. Before cerebrospinal fluid (CSF) diversion surgery for hydrocephalus, we performed magnetic resonance angiography and magnetic resonance venography, which revealed multiple engorged vessels over the ventricular wall and bilateral hemispheres. Digital subtraction angiography revealed 2 dural arteriovenous fistulas (DAVFs) at the left transverse-sigmoid sinus and superior sagittal sinus. Signs of angioarchitecture characteristic of cerebral venous hypertension (CVH) were noted, including cortical vein regurgitation and severe pseudophlebitic pattern. DAVFs with CVH might be a factor contributing to acquired hydrocephalus. DAVFs should be considered when patients with hydrocephalus exhibit abnormal papillary structures at the ventricular wall. Performing CSF diversion surgery for hydrocephalus before downgrading or curing such aggressive DAVFs may lead to major complications.
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Affiliation(s)
- Hung-Yu Wen
- Division of Neurosurgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan (R.O.C.); Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan (R.O.C.); Department of Surgery, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan (R.O.C.)
| | - Shun-Tai Yang
- Division of Neurosurgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan (R.O.C.); Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan (R.O.C.); Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan (R.O.C.).
| | - Yang-Lan Lo
- Division of Neurosurgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan (R.O.C.); Taipei Neuroscience Institute, Taipei Medical University, Taipei, Taiwan (R.O.C.)
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11
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“Enhancing Vision” in High Grade Glioma Surgery: A Feasible Integrated 5-ALA + CEUS Protocol to Improve Radicality. World Neurosurg 2019; 129:401-403. [DOI: 10.1016/j.wneu.2019.06.127] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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12
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Della Pappa GM, Marchese E, Pedicelli A, Olivi A, Ricciardi L, Rapisarda A, Skrap B, Sabatino G, La Rocca G. Contrast-Enhanced Ultrasonography and Color Doppler: Guided Intraoperative Embolization of Intracranial Highly Vascularized Tumors. World Neurosurg 2019; 128:547-555. [DOI: 10.1016/j.wneu.2019.05.142] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 05/15/2019] [Accepted: 05/16/2019] [Indexed: 12/21/2022]
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13
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Padilha IG, Pacheco FT, Araujo AIR, Nunes RH, Baccin CE, Conti MLM, Maia ACM, Rocha AJD. Tips and tricks in the diagnosis of intracranial dural arteriovenous fistulas: A pictorial review. J Neuroradiol 2019; 47:369-381. [PMID: 31279838 DOI: 10.1016/j.neurad.2019.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 06/25/2019] [Accepted: 06/27/2019] [Indexed: 11/25/2022]
Abstract
Dural arteriovenous fistulas (DAVFs) are complex vascular abnormalities that account for 10-15% of intracranial vascular malformations. DAVFs are typically encountered in middle-aged adults, with a slightly female predominance. The causative factors are still uncertain; however, abnormal local hemodynamics and neoangiogenesis related to dural sinus or venous thrombosis can contribute to DAVF occurrence. The diagnosis is dependent on a high level of clinical suspicion and high-resolution imaging techniques. Computed tomography and/or magnetic resonance imaging aid in the diagnosis, but conventional angiography remains the most accurate method for the complete characterization and classification of DAVFs. The therapeutic approach can be conservative or more aggressive, based on symptom severity, sequelae risk and patient characteristics. This article is a pictorial review of adult intracranial DAVFs that highlights some tips and tricks for recognizing useful red flags in the suspicion of DAVFs.
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Affiliation(s)
- Igor Gomes Padilha
- Division of Neuroradiology, Santa Casa de São Paulo School of Medical Sciences, Rua Dr. Cesario Motta Jr. 112, Vila Buarque, 01221-020 Sao Paulo SP, Brazil; Division of Neuroradiology, Diagnosticos da America SA, São Paulo, Brazil; Department of Medical Imaging, R. João Cachoeira, 743 - Itaim Bibi, 04535-012 Sao Paulo SP, Brazil.
| | - Felipe Torres Pacheco
- Division of Neuroradiology, Santa Casa de São Paulo School of Medical Sciences, Rua Dr. Cesario Motta Jr. 112, Vila Buarque, 01221-020 Sao Paulo SP, Brazil; Division of Neuroradiology, Diagnosticos da America SA, São Paulo, Brazil; Department of Medical Imaging, R. João Cachoeira, 743 - Itaim Bibi, 04535-012 Sao Paulo SP, Brazil
| | - Alan Iuno Rios Araujo
- Division of Neuroradiology, Santa Casa de São Paulo School of Medical Sciences, Rua Dr. Cesario Motta Jr. 112, Vila Buarque, 01221-020 Sao Paulo SP, Brazil; Division of Neuroradiology, Diagnosticos da America SA, São Paulo, Brazil; Department of Medical Imaging, R. João Cachoeira, 743 - Itaim Bibi, 04535-012 Sao Paulo SP, Brazil
| | - Renato Hoffmann Nunes
- Division of Neuroradiology, Santa Casa de São Paulo School of Medical Sciences, Rua Dr. Cesario Motta Jr. 112, Vila Buarque, 01221-020 Sao Paulo SP, Brazil; Division of Neuroradiology, Diagnosticos da America SA, São Paulo, Brazil; Department of Medical Imaging, R. João Cachoeira, 743 - Itaim Bibi, 04535-012 Sao Paulo SP, Brazil
| | - Carlos Eduardo Baccin
- Division of Interventional Neuroradiology, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627/701 - Morumbi, 05652-900 Sao Paulo SP, Brazil
| | - Mario Luiz Marques Conti
- Division of Interventional Neuroradiology, Santa Casa de São Paulo School of Medical Sciences, Rua Dr. Cesario Motta Jr. 112, Vila Buarque, 01221-020 Sao Paulo SP, Brazil
| | - Antônio Carlos Martins Maia
- Division of Neuroradiology, Santa Casa de São Paulo School of Medical Sciences, Rua Dr. Cesario Motta Jr. 112, Vila Buarque, 01221-020 Sao Paulo SP, Brazil; Division of Neuroradiology, Fleury Medicina e Saúde, Rua Cincinato Braga, 282 - Bela Vista, 01333-910 Sao Paulo SP, Brazil
| | - Antônio José da Rocha
- Division of Neuroradiology, Santa Casa de São Paulo School of Medical Sciences, Rua Dr. Cesario Motta Jr. 112, Vila Buarque, 01221-020 Sao Paulo SP, Brazil; Division of Neuroradiology, Diagnosticos da America SA, São Paulo, Brazil; Department of Medical Imaging, R. João Cachoeira, 743 - Itaim Bibi, 04535-012 Sao Paulo SP, Brazil
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14
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Wang G, Yu J, Hou K, Guo Y, Yu J. Clinical importance of the posterior meningeal artery: a review of the literature. Neuroradiol J 2019; 32:158-165. [PMID: 30924401 DOI: 10.1177/1971400919840843] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
The posterior meningeal artery, which arises from the vertebral artery, is a critical artery in neurological lesions. However, a comprehensive review of the importance of the posterior meningeal artery is currently lacking. In this study, we used the PubMed database to perform a review of the literature on the posterior meningeal artery to increase our understanding of its role in vascular lesions. The posterior meningeal artery provides the main blood supply to the paramedial and medial portions of the dura covering the cerebellar convexity. The posterior meningeal artery is often involved in dural arteriovenous fistulas occurring near the posterior fossa, and the posterior meningeal artery can be the path for transarterial embolisation or a path through which to monitor the degree of dural arteriovenous fistula embolisation. In posterior circulation ischaemia and moyamoya disease, the posterior meningeal artery can form transdural anastomoses with pial arteries at the surface of the brain, and these can help prevent ischemia. The posterior meningeal artery can also develop aneurysms, most of which are traumatic pseudoaneurysms; patients should therefore be treated in a timely manner or followed up carefully in cases of rebleeding. In addition, during a craniotomy, the posterior meningeal artery should be protected intraoperatively to avoid damaging any transdural anastomosis that may be present. In addition, when the posterior meningeal artery is the main feeding artery of an intracranial tumour, that artery is a satisfactory path for preoperative embolisation. Briefly, the posterior meningeal artery is a very important artery in neurosurgery.
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Affiliation(s)
- Guangming Wang
- 1 Department of Neurosurgery, The First Hospital of Jilin University, China
| | - Jing Yu
- 2 Department of Operation Room, The First Hospital of Jilin University, China
| | - Kun Hou
- 1 Department of Neurosurgery, The First Hospital of Jilin University, China
| | - Yunbao Guo
- 1 Department of Neurosurgery, The First Hospital of Jilin University, China
| | - Jinlu Yu
- 1 Department of Neurosurgery, The First Hospital of Jilin University, China
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15
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Comment on the article "Real-time intraoperative contrast-enhanced ultrasound (CEUS) in vascularized spinal tumors: a technical note". Acta Neurochir (Wien) 2018; 160:1873-1874. [PMID: 30046876 DOI: 10.1007/s00701-018-3628-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 07/17/2018] [Indexed: 12/17/2022]
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16
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Stereotactic Radiosurgery for High-Grade Intracranial Dural Arteriovenous Fistulas. World Neurosurg 2018; 116:e640-e648. [DOI: 10.1016/j.wneu.2018.05.062] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 05/08/2018] [Accepted: 05/09/2018] [Indexed: 11/18/2022]
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17
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Della Pepa GM. In Reply: Angio-Architectural Features of High-Grade Intracranial Dural Arteriovenous Fistulas: Correlation With Aggressive Clinical Presentation and Hemorrhagic Risk. Neurosurgery 2018; 83:E49. [DOI: 10.1093/neuros/nyy138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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18
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Cornelissen SA, Yeo LLL, Söderman M. Letter: Angio-Architectural Features of High-Grade Intracranial Dural Arteriovenous Fistulas: Correlation With Aggressive Clinical Presentation and Hemorrhagic Risk. Neurosurgery 2018; 83:E48. [DOI: 10.1093/neuros/nyy139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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19
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Integration of Real-Time Intraoperative Contrast-Enhanced Ultrasound and Color Doppler Ultrasound in the Surgical Treatment of Spinal Cord Dural Arteriovenous Fistulas. World Neurosurg 2018; 112:138-142. [DOI: 10.1016/j.wneu.2018.01.101] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 01/13/2018] [Accepted: 01/15/2018] [Indexed: 11/17/2022]
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20
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Amuluru K, Al-Mufti F, Romero C. Isolated intraventricular hemorrhage secondary to dural arteriovenous fistula. J Neurointerv Surg 2018; 10:e7. [PMID: 29459368 DOI: 10.1136/neurintsurg-2017-013643.rep] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2017] [Indexed: 11/03/2022]
Abstract
Isolated intraventricular hemorrhage due to dural arteriovenous fistula (dAVF) is extremely rare and has been reported only a few times in the literature. The pathophysiological cause of isolated intraventricular hemorrhage in these cases was hypothetically attributed to retrograde venous flow into subependymal vessels, although none of these cases demonstrated radiographic evidence of such reflux. We present the first case of a dAVF with radiographic evidence of severe cortical venous reflux into the subependymal venous network causing isolated intraventricular hemorrhage, thus lending proof for the underlying pathophysiology. Furthermore, ours is the first case of dAVF with isolated intraventricular hemorrhage that was successfully treated using multimodality transvenous and transarterial embolization techniques. In cases of high-grade dAVF, multimodality treatment may offer the greatest chance for success, and should be strongly considered for management.
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Affiliation(s)
- Krishna Amuluru
- Interventional Neuroradiology, University of Pittsburgh Medical Center - Hamot, Erie, Pennsylvania, USA
| | - Fawaz Al-Mufti
- Neurology - Division of Neuroendovascular Surgery and Neurocritical Care, Rutgers Robert Wood Johnson Medical School New Brunswick, New Brunswick, New Jersey, USA
| | - Charles Romero
- Interventional Neuroradiology, University of Pittsburgh Medical Center - Hamot, Erie, Pennsylvania, USA
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21
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Amuluru K, Al-Mufti F, Romero C. Isolated intraventricular hemorrhage secondary to dural arteriovenous fistula. BMJ Case Rep 2018; 2018:bcr-2017-013643. [PMID: 29437717 DOI: 10.1136/bcr-2017-013643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Isolated intraventricular hemorrhage due to dural arteriovenous fistula (dAVF) is extremely rare and has been reported only a few times in the literature. The pathophysiological cause of isolated intraventricular hemorrhage in these cases was hypothetically attributed to retrograde venous flow into subependymal vessels, although none of these cases demonstrated radiographic evidence of such reflux. We present the first case of a dAVF with radiographic evidence of severe cortical venous reflux into the subependymal venous network causing isolated intraventricular hemorrhage, thus lending proof for the underlying pathophysiology. Furthermore, ours is the first case of dAVF with isolated intraventricular hemorrhage that was successfully treated using multimodality transvenous and transarterial embolization techniques. In cases of high-grade dAVF, multimodality treatment may offer the greatest chance for success, and should be strongly considered for management.
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Affiliation(s)
- Krishna Amuluru
- Interventional Neuroradiology, University of Pittsburgh Medical Center - Hamot, Erie, Pennsylvania, USA
| | - Fawaz Al-Mufti
- Neurology - Division of Neuroendovascular Surgery and Neurocritical Care, Rutgers Robert Wood Johnson Medical School New Brunswick, New Brunswick, New Jersey, USA
| | - Charles Romero
- Interventional Neuroradiology, University of Pittsburgh Medical Center - Hamot, Erie, Pennsylvania, USA
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