Ruptured intracranial vertebral artery dissecting aneurysms: An evaluation of prognostic factors of treatment outcome

Objective Intracranial spontaneous vertebral artery dissecting aneurysms commonly occur in the third to fifth decades of life, and are mostly associated with hypertension. Patients present with intracranial haemorrhage or thromboembolic events. Patients who present with intracranial haemorrhage carry about a 70% risk of recurrent bleeding. Patients with a posterior-inferior cerebellar artery (PICA) or ipsilateral dominant vertebral artery involve selecting which parent vessel could not be sacrificed. Recent reconstructive techniques such as stent-assisted coiling embolisation and flow-diverting stents are effective treatments of choice. Methods Seventeen patients presented subarachnoid haemorrhage and nine patients with other symptoms. Sacrificing the parent vertebral artery was the first choice for surgical or endovascular methods. Endovascular reconstructive treatment by stent-assisted coiling embolisation was indicated in dissecting vertebral artery aneurysms with ipsilateral dominant vertebral artery or PICA involvement. Clinical outcomes were determined using the modified Rankin Score (mRS) at 90 days, with favourable outcomes defined as 0 to 2. Results Of the patients presenting with ruptured aneurysms, 11 (61.1%) had a good clinical outcome, with a mRS of 0-2. Favourable Hunt and Hess grading (65%), mild to moderate GCS (65%) and total occlusion of aneurysms after treatment (65%) were significantly good prognostic factors in patients with ruptured vertebral artery dissecting aneurysms. Conclusion Endovascular parent vessel sacrifice could be the first choice to treat a ruptured vertebral artery dissecting aneurysm. Stent-assisted coiling to preserve the patency of the parent artery and its branches is a promising treatment for vertebral artery dissections.

Basilar Tip Aneurysms and Basilar Tip Anatomy

Five hundred and eighty one cerebral aneurysms seen from 1986–1997 were reviewed. Fifty five basilar tip aneurysms were demonstrated. The analysis of the anatomic disposition of the distal basilar artery in 47 of them showed the prevalence of caudal fusion in 91% of cases. The fusion is either symmetrical or asymmetrical.

The neck of the aneurysm is preferentially implanted on the caudal part of the fusion. Recognition of the distal basilar artery anatomy allows the origin and extent of the perforating branches territory arising from the P1 segment to be predicted in each type of basilar tip disposition. The caudal variant supplies a small ipsilateral territory, whereas the cranial one often provides a bilateral supply.

In the cranial arrangement one can observe interpeduncular anastomoses between the perforators across the midline prior to penetrating the mesencephalo-diencephalic structures. The risks involved in the sacrifice of the P1 segment can then be anticipated.

Multiple Intracranial Arterial Aneurysms: A Congenital Metameric Disease?

We reviewed the angiographic study and clinical charts of 398 consecutive cases of intracranial arterial aneurysms, involving adults and children in the last 11 years (1986–1997). Giant aneurysms, dissecting aneurysms, mycotic aneurysms, and fusiform aneurysm were excluded. From the 341 patients presenting so-called berry aneurysm disease, attention was paid to multiple aneurysm sub group. One hundred and thirteen cases were analysed and compared with a group of single AA (228 cases) from the same material.

Three longitudinal embryological territories giving rise to cranial endothelial cells and media were used to regroup the aneurysm sites. Eighty four cases presented aneurysms in the rostral region (74%), 20 cases with aneurysms involving rostral and middle territories (18%), 1 case presented aneurysm involving the middle and caudal territories (0.9%), 5 cases had aneurysms in the rostral and caudal territories (4.4%) and three cases presented aneurysm involving rostral, medial and caudal territories at the same time (2.7%). No multiple group was located in the middle or caudal territories alone. When several arterial territories were concerned they were adjacent in 95.6% of cases.

Multiple AA could therefore result from mesodermal/neural crest stem cell or focal endothelial cell defect within one or two (usually consecutive) embryonic segments. Mirror lesions would correspond to bilateral symmetrical impairment in the same territory or involvement of a group of cells with bilateral distribution. AA may result from a constitutional vasculopathy, later expressed with focal overproduction of the arterial wall without remodelling correction. Secondary mutations and triggers are likely to be needed to lead to such AA production.

Interventional Neuroradiology in Thailand: 1989–1997

In 1979 the Siriraj team in Bangkok began exploring a field that was then new in Thailand, i. e. interventional neuroradiology. This first phase consisted mostly in self-training and foreign exposure.

It included experimental work with animal models, as well as early clinical trials designed to assess our skills in particle embolisation and the ligated and detachable balloon techniques. In 1990 a new phase started.

Essential techniques were acquired in collaboration with the neurovascular unit of Bicêtre Hospital in France during a three year training programme. Throughout this period, the support of the Association Médicale Franco-Asiatique (AMFA) and the French foreign affairs department proved vital. Our department progressively became a referral centre for the different techniques used in embolisation (balloons, glue…) and for various vascular lesions of the brain, the head and neck region, and spinal cord diseases.

Within Mahidol University, the Ramathibodi and Prasat Hospital centres started the same interventional neuroradiology training program in 1995; they benefited from the same tutors and connections as Siriraj. In 1996, the newly acquired biplane DSA machines in both centres enabled us to improve the treatment of arteriovenous malformations - using the glue technique –, intracranial aneurysm - using GDC-coils -, clot lysis, angioplasty… etc.

According to international recommendations, the critical mass we reached in 1997 in terms of number of patients and interventions, allows us to offer training in endovascular techniques to junior neuroradiologists at Mahidol university.

Life-threatening arteriovenous malformation of the maxillomandibular region and treatment outcomes

We report on cases of life-threatening maxillomandibular arteriovenous malformations (AVM) whereby patients had successful endovascular treatment with good outcomes. Out of a total 93 facial AVMs treated endovascularly between 1991 and 2009, five patients (5.4%) had maxillomandibular AVMs. All presented with uncontrolled dental bleeding. Endovascular procedure was the primary treatment of choice in all cases, either transfemoral approach with arterial feeder embolization or transosseous puncture, depending on the accessible route in each patient. NBCA (glue) was the only embolic agent used. Tooth extraction and dental care were performed after bleeding was controlled. All five patients (8-18 years) with a mean age of 12.4 years presented with massive dental bleeding following loosening of teeth, dental extraction and/or cheek trauma. The plain films and CT scans of four patients with AVMs of mandibles and one of maxilla, revealed expansile osteolytic lesions. The mean follow-up period was 6.6 years (ranging between one and 19 years). Three cases developed recurrent bleeding between two weeks to three months after first embolization, resulting from residual AVM and infection. Late complications occurred in two patients from chronic localized infection and osteonecrosis, which were successfully eradicated with antibiotic therapy and bony curettage. Complications occurring in two patients which included soft tissue infection, osteomyelitis and osteonecrosis were successfully treated with antibiotics, curettage and bone resection. No patient had a recurrence of bleeding after the disease had cured Initial glue embolization is recommended as the effective treatment of dental AVMs for emergent bleeding control, with the aim to complete eradicate the intraosseous venous pouches either by means of transarterial superselection or direct transosseous puncture. Patient care by a multidisciplinary team approach is important for sustained treatment results.

Patterns of the Cranial Venous System from the Comparative Anatomy in Vertebrates. Part II.The Lateral-Ventral Venous System

SUMMARY

Comparing the adult submammalian brain with the human embryonic brain, some patterns of venous drainage are quite similar. The veins lying on the lateral surface of the brain in submammals resemble those of the human embryo. In addition, the new longitudinal venous anastomosis ventral to the brain vesicles occurring late in human embryonic development seems to be similar to the late appearance of the basal vein and the ventral brain stem venous plexus found in adult mammals including man. The evolution of the new structures of the brain vesicles throughout the vertebrate series may have an induction role on the appearance of the cranial venous system. This part of the article series focuses on the evolution of the lateral-ventral venous system of the five brain vesicles. Nevertheless, the limitation of this article is due in part to the paucity of circumstantial papers and different names used for the veins.

Embolization of vascular malformations in head and neck regions. A single center experience

SUMMARY

The purpose of this study is to determine the effectiveness of embolization of each type of vascular malformation. Thirty three patients with a diagnosis of vascular malformations in head and neck regions who were treated by embolization at Siriraj Hospital, Thailand, between 1997-2002 were reviewed retrospectively. There were 19 arteriovenous malformations (AVMs), two arteriolar-capillary types, ten venous malformations, one veno-lymphatic malformation and one mixed capillary and venous types. The goal of treatment is to restore function and to prevent bleeding complications with particularly good cosmetic results. The technique and therapeutic agents depended on the types and flow characteristics of each malformation. Transarterial embolization with N-butyl cyanoacrylate were used in AVMs, unless no arterial route approach, then direct puncture was tried. This was carried out in five patients with AVMs. Polyvinyl alcohol was used in two capillary lesions. All venous malformations were treated by absolute alcohol injection, percutaneously. All had good outcome without serious complications. Two patients had further plastic surgery, one was AVM of eyelid and the other was facial venolymphatic malformation. Embolization is considered to be the primary treatment by eradication of those abnormal vessels directly at the target, whereas delayed plastic surgery may be needed later.

Spontaneous occlusion of a bilateral post traumatic carotid cavernous fistula

SUMMARY

This report describes a rare occurrence of spontaneous closure of direct bilateral carotid cavernous fistula in a 62-year-old woman who had head injury. This was confirmed by clinical examination and subsequent angiogram. Partial thrombosis of bilateral superior ophthalmic veins was observed in the initial arteriography. This finding may be useful in prediction of spontaneous cure of carotid cavernous fistulas.

Successful medical treatment of multiple cryptococcomas: report of a case and literature review

We report a 35-year-old man diagnosed as having CNS cryptococcosis with multiple cryptococcomas, presenting with headache, papilloedema and impaired mental function in a previously healthy man. Cerebrospinal fluid (CSF) examination revealed lymphocytic pleocytosis with low glucose level. Gram's stain, acid fast bacilli stain and Indian ink examination were all negative. CSF cryptococcal antigen was positive, however, several fungal cultures were negative. Early cranial CT scan showed focal cerebritis over the right temporal lobe while subsequent imaging studies showed multiple contrast-enhancing masses with severe surrounding brain oedema over bilateral frontoparietal areas. Brain biopsy showed cryptococcal granulomatous lesions. Treatment was successful with antifungal agents and steroids without surgical removal.