Gelson Luis Koppe

Sinus Thrombosis after Endovascular Treatment of Vein of Galen Aneurysmal Malformation

A full-term small for gestational age Caucasian male was born by Cesarean delivery with a healthy twin brother. In his first week of life, he presented 2 rapid pallid episodes followed by perioral cyanosis, and was hospitalized for investigation of his condition. A chest radiograph showed an enlarged cardiac silhouette, and echocardiogram revealed hypertrophic cardiomyopathy with tricuspid valve failure. Cardiac failure was diagnosed and medicated with digoxin, furosemide, and captopril, obtaining a satisfactory clinical response. The patient evolved with growth delay and at 6 months he presented with vomiting, sleepiness, prominent cranial veins, and tense anterior fontanelle; he had a 43-cm head circumference (0.6 SD), weighed 5.1 kg (–1.9 SD) and measured 63.5 cm in length (–3.9 SD). A cranial CT revealed supratentorial hydrocephalus and an isodense median lesion, with homogenous enhancement by contrast. A ventricle-peritoneal shunt was performed with a good response. Two weeks later he started having seizures that were confirmed by EEG, and which were controlled with phenobarbital. The Bicêtre neonatal score was 19 (4 cardiac, 2 cerebral, 5 respiratory, 4 hepatic, 4 renal). The patient was submitted to digital subtraction angiography (DSA; Fig. 1 ), which revealed choroidal type VGAM, with a high flow fistula produced by ectatic pericallosal and choroidal arteries. Thus, at the same time, embolization was performed through a combined simultaneous approach (transarterial and transvenous route) with Axium TM platinum coils (Ev3, Irvine, CA, USA), interrupted due to the amount of contrast. Another complementary transarterial session using coils and n-butyl-2-cyanoacrylate (Histoacryl ® , B. Braun, Melsungen, Germany) was performed 2 days Introduction

Origem da artéria cerebelar inferoposterior sobre o arco posterior de C1

A artéria cerebelar inferoposterior geralmente nasce do segmento intracraniano (V4) da artéria vertebral. Apesar de ter diâmetro médio de 2 mm, usualmente irriga áreas eloquentes do encéfalo. Quando ocluída, seja por trauma ou cirurgia, pode causar infarto no tronco encefálico e no cerebelo. Apresentamos um caso de artéria cerebelar inferoposterior com origem anômala no segmento cervical (V3) da artéria vertebral, demonstrado por angiografia. Os resultados foram registrados e comparados com os de publicações anteriores. Foram fornecidas breves explicações sobre a anatomia, anomalias vasculares e embriologia. A revisão da literatura mostrou que os ramos anômalos do segmento cervical da artéria vertebral são infrequentes e devem ser conhecidos. Uma melhor compreensão da anatomia e suas variações permite fazer um diagnóstico topográfico preciso, bem como planejar a abordagem e a terapia cirúrgicas ideais. O conhecimento dessa variação anatômica é essencial, pois, se confundida com um ramo muscular e coagulada, pode causar isquemia com sequelas incapacitantes.

Posterior Inferior Cerebellar Artery Origin over the C2 Posterior Arch

a Department of Neurosurgery, Hospital de Clinicas UFPR, Curitiba, Brazil; b Department of Neurosurgery, Hospital Pequeno Principe and Cajuru University Hospital, Pontifical Catholic University of Parana – PUCPR, Curitiba, Brazil; c Department of Neurology, Hospital Pequeno Principe, Curitiba, Brazil; d Department of Neurosurgery, Hospital Vita Curitiba, Curitiba, Brazil Received: March 5, 2018 Accepted after revision: April 10, 2018 Published online: July 26, 2018

Atypical Presentation of PHACE Syndrome: Hidden Facial Hemangioma

PHACE(S) syndrome is a neurocutaneous syndrome with a wide array of presentations. The most known and present trait is facial hemangioma > 5 cm. The name is an acronym for Posterior fossa malformations, infantile Hemangiomas, Arterial anomalies, aortic Coarctation, Eye abnormalities, and middle-line malformations of the Sternum. The exact etiopathogenic mechanism of this syndrome is not fully understood, and its treatment depends on detailed and individualized assessment. The aim of this paper is to describe a child with a throat hemangioma, vascular malformations, cognitive delay, and other anomalies to illustrate the neuroimaging found in this syndrome.

Is the Mayfield Head Holder Obligatory for Intracranial Aneurysm Clipping

Intracranial aneurysm surgery is commonly performed using pinned head holders, which pose a higher risk for the pediatric population. Several authors recommend avoiding the use of this device when it is not strictly necessary, and this is currently possible considering advances in anesthesiology and monitoring. As the literature on microsurgery without skull clamp use is scant, we report the case of a 15-year-old boy presenting with a subarachnoid hemorrhage after rupture of a middle cerebral artery aneurysm. Surgical treatment was performed with the head resting on a gel cushion horseshoe; aneurysm clipping was achieved without wakefulness or awareness and the patient had a good recovery.

Endovascular treatment of cerebral aneurysm after renal transplantation in polycystic kidney disease

Background Patients with polycystic kidney disease have a higher prevalence of intracranial aneurysms and may progress to renal failure requiring transplantation. The endovascular treatment of intracranial aneurysms may improve prognosis, since rupture often causes premature death or disability, but the nephrotoxicity risk associated with contrast medium must be always considered in cases of renal impairment. Methods A 55-year-old female patient with polycystic kidney disease and grafted kidney associated with anterior communicant artery aneurysm was successfully treated by embolization. Results The renal function remained normal after the procedure. To the authors’ knowledge, this is the first case of endovascular treatment of brain aneurysm in a transplanted patient reported in the medical literature. Conclusions The endovascular procedure in renal transplant patients is feasible and can be considered to treat this population. Further studies and cases are needed to confirm its safety.

Cognitive and psychiatric changes as first clinical presentation in Sneddon syndrome

ABSTRACT Sneddon syndrome (SS) is a rare progressive non-inflammatory thrombotic vasculopathy affecting small/medium-sized blood vessels of unknown origin. It is strongly associated with the presence of antiphospholipid antibodies (AA). The presence of livedo reticularis and cerebrovascular disease are hallmark features. The condition is far more common in young women. We report a case of SS in a 43 year-old male with a two-year history of progressive cognitive impairment consistent with dementia syndrome, and major personality changes, besides livedo reticularis and cerebral angiographic pattern of vasculitis. AA were borderline. The recognition of skin blemishes that precede strokes should raise the hypothesis of SS. AA are elevated in more than half of cases, but their role in the pathogenesis or association of positive antibodies and SS remains unclear. Dementia syndrome in young patients should be extensively investigated to rule out reversible situations. Typical skin findings, MRI and angiography may aid diagnosis.

Internal Carotid Artery Dissection in Brazilian Jiu-Jitsu

Carotid artery dissection is a significant cause of stroke in young patients. It may be asymptomatic and go undiagnosed, or minimal transient manifestations may follow, commanding a higher index of suspicion than ordinarily exists to avoid misdiagnosis. Reported herein is a 27-year-old man who suffered extracranial internal carotid artery dissection while practicing a Brazilian Jiu-Jitsu submission maneuver. The patients condition suddenly deteriorated one week later due to distal embolization and stroke. Despite endovascular treatment, with stenting of the cervical carotid artery, neurologic deficits remained. Of note, the objective in martial arts, which is to kill or incapacitate, has yet to be fully tempered in transitioning to sport. Brazilian Jiu-jitsu, a relatively new and fast-growing form of martial art, places emphasis on submission maneuvers. Related injuries are not common knowledge and are poorly described in the literature. This account is intended to shed light on the risk of this discipline. Through education and improved supervision, vascular injuries of this nature and the potentially lethal or disabling consequences may thus be prevented in young athletes.

Unilateral Direct Carotid Cavernous Fistula Causing Bilateral Ocular Manifestation

Unilateral carotid cavernous fistula presents with ipsilateral ocular findings. Bilateral presentation is only seen in bilateral fistulas, usually associated with indirect (dural) carotid cavernous fistulas. Direct carotid cavernous fistulas are an abnormal communication between the internal carotid artery and the cavernous sinus. They typically begin with a traumatic disruption in the artery wall into the cavernous sinus, presenting with a classic triad of unilateral pulsatile exophthalmos, cranial bruit and episcleral venous engorgement. We report the case of a 38-year-old male with traumatic right carotid cavernous sinus fistula and bilateral ocular presentation successfully treated by interventional neuroradiology.