Vertebro-Vertebral Arteriovenous Fistulae: A Case Series of Endovascular Management at a Single Center

OBJECTIVE

Vertebro-vertebral arteriovenous fistulae (VVFs) are a rare disorder characterized by a direct shunt between the extracranial vertebral artery and the veins of the vertebral venous plexus. This study aims to comprehensively review the characteristics and outcomes of endovascular treatments for VVFs at our center.

METHODS

A retrospective review was conducted on 14 patients diagnosed with a VVF who underwent endovascular treatment at Siriraj Hospital from January 2000 to January 2023. The study assessed patient demographics, presentation, fistula location, treatment strategies, endovascular techniques employed, and treatment outcomes.

RESULTS

Among the 14 patients, 11 (78.6%) were female, with an age range from 25 to 79 years (median: 50 years). Spontaneous VVFs were observed in 64.3% of the cases, including three associated with neurofibromatosis type 1 (NF-1). Iatrogenic injury accounted for two cases, and three patients had VVFs resulting from traffic accidents. A pulsatile neck mass and tinnitus, with or without neurological deficits, were common presenting symptoms. Active bleeding was observed in three cases with vascular injury, while unilateral proptosis, congestive heart failure, and incidental findings each presented in one patient. All the VVFs were successfully obliterated without major treatment complications. Parent vessel sacrifice was performed in 85.7% of the cases, while vertebral artery preservation was achieved in the remaining two patients. Embolic materials included detachable balloons, detachable coils, and n-butyl cyanoacrylate (NBCA) glue. All the presenting symptoms showed improvement, and no morbidity or mortality was observed.

CONCLUSIONS

Endovascular embolization is a feasible and effective approach for achieving complete VVF obliteration with safety. Parent artery sacrifice should not be reluctantly performed, particularly when adequate collateral circulation is demonstrated.

Treatment Outcomes of Mechanical Thrombectomy in Patients with Acute Posterior Circulation Stroke

Objective  The benefits of mechanical thrombectomy (MT) in patients with acute posterior circulation stroke remain unclear. Currently, there is no evidence from randomized control trials to show the safety and effectiveness of MT in patients with posterior circulation stroke. This study was to evaluate the treatment outcomes of MT in posterior circulation stroke patients enrolling in our hospital during 2010 to 2020. Materials and Methods  Between January 2010 and December 2020, 66 patients with acute posterior circulation stroke underwent MT. Data collected and analyzed included demographics, comorbidity, National Institutes of Health Stroke Scale (NIHSS), procedure time, site of occlusion, presence of posterior communicating artery (PCoA), endovascular technique, and modified Rankin Scale (mRS). Good clinical outcome was defined by mRS at 2 or less at 90 days after MT. Statistical Analysis  Variables with normal distribution were reported with mean ± standard deviation, meanwhile those with nonnormal distribution were demonstrated with median and range. Fisher's exact test for categorical variables or Mann-Whitney U test for continuous variables was performed. Multivariate logistic regression analysis with binary logistic regression method was used analyze the association between the prognosis factor and good outcome. Statistical significance was defined when p -value less than 0.05. Results  The mean age of patients was 65.2 years with male predominance. The median NIHSS was 18.5. Successful recanalization (modified thrombolysis in cerebral infarction 2b-3) was achieved in 61/66 cases (92.42%) and postprocedure symptomatic intracerebral hemorrhage occurred in 5/66 cases (7.60%). Successful recanalization with good clinical outcome was obtained from 30 of 61 cases (49.18%); it was also associated with distal basilar artery occlusion ( p  = 0.035) and PCoA patency presence ( p  = 0.024). Our study showed the correlation between good treatment outcomes with initial NIHSS less than 20, intravenous recombinant tissue-type plasminogen activator, pre-MT magnetic resonance imaging Q5 brain, and contact aspiration MT technique. Conclusion  MT is beneficial to patients with posterior circulation stroke. A good clinical outcome was significantly associated with distal basilar artery occlusion and PCoA patency presence within a group of successful recanalization.

Infundibular dilatation perforating vessel of anterior communicating artery

Background:

Infundibular dilatation at cerebral arteries is primary located at the posterior communicating artery. This report describes a rare case of infundibular dilatation perforating the branch of an anterior communication artery (AcomA) which mimicked an AcomA aneurysm.

Case Description:

The 54-year-old female presented with acute headache in the left temporal area with the right hemianesthesia. The magnetic resonance imaging and magnetic resonance angiography of the brain revealed a small outpouching lesion arising from the medial wall of the proximal A2 of the left ACA presenting as a suspected AcomA aneurysm. The cerebral angiogram showed a funnel-shaped dilatation of the anterior communicating artery with a single perforating branch arising from a dome size 1.4 × 1.1 mm, compatible with an infundibular dilatation perforating a branch of the AcomA.

Conclusion:

The infundibular dilatation perforating vessel of AcomA is a rare condition and can mimic an AcomA aneurysm. Three-dimensional angiography helps to evaluate differentiation of the characteristics enabling accurate diagnosis.

Success Rate of Simple Coil Embolization in Wide-Neck Aneurysm with Aneurysmal Shoulder

Background and Objective:

Wide-necked intracranial aneurysm (WIA) is one of the challenging diseases for neuro-interventionist to treat by simple coiling technique. The purpose of this study is to identify the morphology associated with successful simple coil embolization in wide neck aneurysm patients.

Materials and Methods:

Between January 2002 and August 2018, 102 patients with total 115 ruptured or unruptured WIA which received endovascular treatment were retrospective reviewed. Data were analyzed including demographics, aneurysm morphology, endovascular technique, angiographic outcome, complication, regrowth, and retreatment rate.

Results:

The mean age of patients was 61.6 years with female predominant (72.5%). Ruptured WIA was diagnosed in 71 patients (61.7%). Majority of aneurysms were located in an anterior circulation which were 74 cases (64.3%), mainly paraclinoid aneurysm (30/115). Endovascular treatment was successful in 113 cases (98.3%) which can be mainly divided into simple coil embolization 50 cases (43.5%), balloon-assisted coil embolization 26 cases (22.6%), and stent-assisted coil embolization 32 cases (27.8%). Complete, subtotal, and incomplete occlusion of WIA was achieved in 32 cases (27.8%), 62 cases (53.9%), and 18 cases (15.7%), respectively. There was 9.6% complication occurred. Regrowth and retreatment were found 20% and 15.7%, respectively.

Conclusion:

WIA with two-sided aneurysmal shoulder or neck width <3.6 mm. are significantly associated with successful coil embolization using simple coiling technique.

Efficiency of Endovascular Therapy for Bilateral Cavernous Sinus Dural Arteriovenous Fistula

BACKGROUND

The principles of endovascular treatment of bilateral cavernous sinus dural arteriovenous fistula (CS-dAVF) are not well established because of the complexity in the number of fistula tracts and their behavior, which seems to be more aggressive. We aimed to determine an efficient technique for endovascular treatment of bilateral CS-dAVF and the associated factors to achieve good clinical and angiographic outcomes.

METHODS

The data were analyzed from 165 consecutive patients diagnosed with CS-dAVF from January 2005 to September 2018. The demographic data included approaching route, embolization times, embolization material, sequence of embolization, number of embolization sessions, and angiographic and clinical outcomes. Interrater agreement of bilateral CS-dAVF diagnosis was performed using the κ coefficient. The factors associated with treatment outcome were analyzed using a Pearson χ² test.

RESULTS

Bilateral CS-dAVF was detected in 43 patients (26%). Angiographic presentations that showed evidence of sinus thrombosis, dangerous venous drainage, and higher Satomi classification were more commonly found in bilateral CS-dAVF than in unilateral CS-dAVF. Good clinical outcome and cure from angiography were obtained in 90% and 74%, respectively. Ipsilateral inferior petrosal sinus-intercavernous sinus-contralateral cavernous sinus catheterization was the major approach route of treatment. The factors associated with improved clinical outcome were transvenous approach, shunt closure, coil embolization, and sequencing the embolization (P < 0.001).

CONCLUSIONS

Dangerous venous drainage tends to increase in bilateral CS-dAVF. Retrograde ipsilateral inferior petrosal sinus catheterization using coil embolization and sequencing the embolization are the major concerns for treatment.

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.

Feasibility Study of Language Lateralization using Thai Version of Language Paradigm for Functional MRI in Clinical Service

OBJECTIVE

To evaluate the concordance of language lateralization between functional magnetic resonance imaging (fMRI) using Thai version of language paradigm and Wada test or awake surgery with direct cortical brain stimulation (DCS).

MATERIAL AND METHOD

Retrospective study of thirteen patients (3 males and 10 females with mean age of 33.9 years old) with epilepsy (7 cases) or brain tumor (6 cases) was performed. Every patient underwent both fMRI (word generation, verb generation, naming picture, and sentence completion tasks) and Wada test or awake surgery with DCS (defined as the gold standard). The lateralization index (LI) of fMRI was automatically calculated by using the LI-toolbox on SPM8. The hemispheric lateralization was also evaluated visually. The concordance between fMRI and gold standard were analyzed.

RESULTS

The concordance between the lateralization of fMRI by visual assessment and gold standard was 92.3%. Concordance between the calculated LI by fMRI and gold standard was varied along with the task and regional calculation method. The concordance was good in all tasks (except for naming picture task) when using calculated LI from frontal or whole brain excluded cerebellum and occipital lobe (range 76.92 to 88.98% and 76.92 to 92.31%, respectively).

CONCLUSION

There was good concordance between fMRI and gold standard. Regional calculation from frontal lobes and whole brain excluded cerebellum and occipital lobes gave the best results. The results supported feasibility to use the fMRI with Thai language paradigm as an alternative way to determine the language dominant hemisphere in Thai patients. In case of language dominant hemisphere is unclear, further invasive investigation of language mapping such as Wada test or DCS is crucial.

Computerized Tomographic Angiography for Detection of Cerebral Vasospasm after Ruptured Intracranial Aneurysm

OBJECTIVE

Digital subtraction angiography (DSA) is the gold standard to diagnose cerebral vasospasm but it is usually not available due to lack of expertise and proper equipment. The present study aimed to compare the diagnostic accuracy of brain computerized tomographic angiography (CTA) in detecting cerebral vasospasm after intracranial aneurysmal rupture.

MATERIAL AND METHOD

Between January 2011 and October 2014, 20 patients who were suspected of cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH) were prospectively enrolled. All patients underwent brain CTA andDSA within 24 hours after clinical onset ofvasospasm. Separate reviewers independently reviewed the CTA and DSA.

RESULTS

Twenty patients were enrolled, including 7 males and 13 females. The patient characteristics did not have any relationship to the incidence of cerebral vasospasm. The CTA finding of vasospasm was well correlated to the DSA finding (Kappa 0.793). Diagnostic accuracy and false negative of the CTA were 90% and 5%, respectively. Sensitivity of the CTA was 94% and specificity was 100%. Positive predictive value ofthe CTA was 100% and negative predictive value was 66%. The vessels that showed the most correlation between the CTA and DSA findings were left A1 (Kappa 0.684) and left A2 (Kappa 0.663) segments of anterior cerebral artery, and left M1 (Kappa 0.503) segment of middle cerebral artery. Both CTA and DSA can detect mild vasospasm (< 50% luminal stenosis) located proximal to the circle of Willis.

CONCLUSION

Compared to the DSA, the CTA can be used for detecting cerebral vasospasm in patients with ruptured intracranial aneurysms with high sensitivity, specificity, and diagnostic accuracy.

De novo aneurysm on the posterior cerebral artery: a case report and literature review

De novo aneurysm formation is a rare entity of cerebral aneurysms. The authors describe a 19-year-old man presenting with spontaneous intracerebral hemorrhage of unknown etiology. The initial cerebral angiography revealed no identifiable vascular lesion. A few weeks following a surgical evacuation of the hematoma, a tiny saccular aneurysm was incidentally found on the distal posterior cerebral artery (PCA) remote from the site of the primary ictus. Several rationales indicated that it was compatible with a cerebral aneurysm of infective etiology. The aneurysm was successfully treated by antibiotic therapy alone. To the authors' knowledge, de novo aneurysm on the PCA has rarely been reported.

Dural arteriovenous fistulas draining into the petrosal vein or bridging vein of the medulla: possible homologs of spinal dural arteriovenous fistulas. Clinical article

OBJECT

Dural arteriovenous fistulas (DAVFs) with leptomeningeal venous reflux generally pose a high risk of aggressive manifestations including hemorrhage. Among DAVFs, there is a peculiar type that demonstrates direct drainage into the bridging vein rather than the dural venous sinus. The purpose of this study was to investigate the characteristics of DAVFs that drain directly into the petrosal vein or the bridging vein of the medulla oblongata.

METHODS

Eleven consecutive cases of DAVFs that drained directly into the petrosal vein and 6 that drained directly into the bridging vein of the medulla were retrospectively reviewed. These cases were evaluated and/or treated at Hospital de Bicêtre in Paris, France, over a 27-year period. A review of previously reported cases was also performed.

RESULTS

Both of these "extrasinusal"-type DAVFs demonstrated very similar characteristics. There was a significant male predominance (p < 0.001) for this lesion, and a significantly higher incidence of aggressive neurological manifestations including hemorrhage or venous hypertension than in DAVFs of the transverse-sigmoid or cavernous sinus (p < 0.001). This finding was considered to be attributable to leptomeningeal venous reflux. Regarding treatment, endovascular embolization (either transarterial or transvenous) is frequently difficult, and surgery may be an effective therapeutic choice in many instances.

CONCLUSIONS

Embryologically, both the petrosal vein and the bridging vein of the medulla are cranial homologs of the spinal cord emissary bridging veins that drain the pial venous network. The authors believe that DAVFs in these locations may be included in a single category with spinal DAVFs because of their similar clinical characteristics.

Pathomechanisms of Symptomatic Developmental Venous Anomalies

Background and Purpose— Although it is generally accepted that developmental venous anomalies (DVAs) are benign vascular malformations, over the past years, we have seen patients with symptomatic DVAs. Therefore, we performed a retrospective study and a literature study to review how, when, and why DVAs can become clinically significant.

Methods— Charts and angiographic films of 17 patients with DVAs whose 18 vascular symptoms could be attributed to a DVA were selected from a neurovascular databank of our hospital. MRI had to be available to rule out any other associated disease. In the literature, 51 cases of well-documented symptomatic DVAs were found. Pathomechanisms were divided into mechanical and flow-related causes.

Results— Mechanical (obstructive or compressive) pathomechanisms accounted for 14 of 69 symptomatic patients resulting in hydrocephalus or nerve compression syndromes. Flow-related pathomechanisms (49 of 69 patients) could be subdivided into complications resulting from an increase of flow into the DVA (owing to an arteriovenous shunt using the DVA as the drainage route; n=19) or a decrease of outflow (n=26) or a remote shunt with increased venous pressure (n=4) leading to symptoms of venous congestion. In 6 cases, no specific pathomechanisms were detected.

Conclusions— Although DVAs should be considered benign, under rare circumstances, they can be symptomatic. DVAs, as extreme variations of normal venous drainage, may represent a more fragile venous drainage system that can be more easily affected by in- and outflow alterations. The integrity of the DVA needs to be preserved irrespective of the treatment that should be tailored to the specific pathomechanism.

Patterns of the Cranial Venous System from the Comparative Anatomy inVertebrates. Part III. The Ventricular System and Comparative Anatomy of the Venous Outlet of Spinal Cord and Its Homology with the Five Brain Vesicles

SUMMARY

Ontogenetically, the ventricular venous systemmay develop in order to drain the gray matter(cells of the mantle layer of the neural tube) which migrates dorsally. On primitive brain vesicles of submammals especially fish, amphibianand reptile, the ventricular venous system is the major venous collector located on the middorsal surface, in between the meningeal layers comparable to the subarachnoid space in mammals. The ventricular venous system functions as a major drainage system for the brain vesicles in these submammals but its role decreases when the other two venous systems develop. Concerning the route of venous exit from the brain vesicles, we found that it resembles the spinal cord but could not be found all the way along the brain vesicles.

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.

Patterns of cranial venous system from the comparative anatomy in vertebrates. Part I, introduction and the dorsal venous system

SUMMARY

Many classifications of the cerebral venous system are found in the literature but they are seldom based on phylogenic study. Among vertebrates, venous drainage of the brain vesicles differs depending on the species. Due to the variability, poorly descriptive articles, and many different names used for the veins, the comparative study of the cranial venous system can hardly be performed in detail. The cranial venous system in vertebrates can be divided into three systems based on the evolution of the meninges and structures of the brain vesicles: the dorsal, lateral-ventral and ventricular systems. This study proposes a new classification of the venous drainage of brain vesicles using knowledge from a comparative study of vertebrates and focusing on the dorsal venous system. We found that the venous drainage of the neopallium and neocerebellum is involved with this system which may be a recent acquisition of cranial venous evolution.