Julius Griauzde

Imaging of vascular lesions of the head and neck.

The diagnosis of vascular lesions of the head and neck should be directed by classifying the lesions as tumors or malformations and by determining their flow characteristics. Location of the lesion is key when differentiating between vascular neoplasms. Ultrasonography is an appropriate screening tool; MRI is often used to confirm the diagnosis. Computed tomography can be used for further characterization of the lesion, particularly when there is bony involvement. In many cases, vascular lesions grow to be extensive. In these cases, percutaneous sclerotherapy or embolization therapy can be employed to aid in surgical resection.

Large-Volume Blood Patch to Multiple Sites in the Epidural Space through a Single-Catheter Access Site for Treatment of Spontaneous Intracranial Hypotension

BACKGROUND AND PURPOSE: Spontaneous intracranial hypotension can be a therapeutic challenge to the treating physician. In this study, we present our experience with the administration of a large-volume blood patch to multiple sites in the epidural space through a single-catheter access site. MATERIALS AND METHODS: A retrospective review was conducted of patients with spontaneous intracranial hypotension who underwent a large-volume blood patch to multiple sites in the epidural space through a single-catheter access site from 2010 to 2012. Patient demographic data, clinical charts, indications for treatment, radiographic images, procedure notes, and postprocedure hospital course were reviewed. RESULTS: Overall, 9 patients were identified who underwent 20 blood patch procedures. Patients were selected to undergo the large-volume procedure either because they had a failed site-directed epidural blood patch or if imaging demonstrated multiple possible leak sites. There were 6 women and 3 men, with an average age of 33.5 years. The mean volume of blood injected per procedure was 54.1 mL (median = 55 mL; range = 38–70 mL). All patients had an orthostatic headache as one of their presenting symptoms; 22% also presented with neurocognitive decline and behavioral changes; 89% of patients had improvement or resolution of their symptoms; and 80% of patients who had a previously failed site-directed epidural blood or fibrin glue patch improved with a large volume catheter-directed blood patch. CONCLUSIONS: Our experience supports the use of a large-volume blood patch to multiple sites in the epidural space through a single-catheter access site for the treatment of spontaneous intracranial hypotension. Additionally, our results indicate a role for this procedure in refractory cases of spontaneous intracranial hypotension.

Emergency reconstructive endovascular management of intraoperative complications involving the internal carotid artery from trans-sphenoidal surgery

Purpose To report our experience with intraoperative complications involving the internal carotid artery (ICA) during trans-sphenoidal surgery and their outcome with reconstructive endovascular management. Methods A retrospective review was conducted of patients with an ICA injury related to trans-sphenoidal surgery from 2000 to 2012. Demographic data, clinical charts, indications for treatment, radiographic images, lesion characteristics, operative notes, endovascular procedure notes and post-procedure hospital course were reviewed. Results Three men and one woman of mean age of 52 years (range 33–74) were identified. The lesions included two macroadenomas, one meningioma and one chondrosarcoma. Risk factors for ICA rupture included two patients with carotid dehiscence, one with sphenoid septal attachment to the ICA, two with revision surgery, one with prior radiation to the tumor, one with bromocriptine treatment and two with acromegaly. In three patients, covered stent placement achieved hemostasis at the site of injury within the ICA. One patient developed delayed bleeding 6 h after covered stent placement and underwent successful endovascular occlusion of the ICA but died 6 days after the injury. The fourth patient had an intraoperative ICA stroke requiring suction thrombectomy, thrombolysis, stent placement and evacuation of an epidural hematoma. At 1-year follow-up, two patients had a modified Rankin score (mRS) and National Institute of Health Stroke Scale (NIHSS) score of 0; in the patient who had a stroke the mRS score was 1 and the NIHSS score 2. Conclusions Endovascular management with arterial reconstruction is helpful in the treatment of ICA injuries during trans-sphenoidal surgery.

Successful Treatment of a Musculoskeletal Tumor Society Grade 3 Aneurysmal Bone Cyst with N-Butyl Cyanoacrylate Embolization and Percutaneous Cryoablation

This report presents a 13-year-old girl with an aggressive skeletal lesion involving the posterior elements of the cervicothoracic junction. The lesion was determined to be a Musculoskeletal Tumor Society grade 3 aneurysmal bone cyst based on imaging and pathologic findings. The cyst was treated with endovascular n-butyl cyanoacrylate embolization and percutaneous cryoablation with sensory and motor-evoked potential monitoring. Follow-up imaging at 16 months demonstrated significant reduction in the size of the lesion, with no evidence of recurrence.

A comparison of particulate and Onyx embolization in preoperative devascularization of carotid body tumors

IntroductionPreoperative embolization of a carotid body tumor (CBT) is a useful adjunct prior to surgical excision because it decreases operative blood loss and improves surgical outcomes. Traditionally, this is performed by transarterial particulate embolization (TAPE). More recently, direct percutaneous embolization (DPE) with Onyx is recognized as a promising technique for preoperative embolization. We compared these two techniques in patients treated for CBTs at our institution.MethodsWe retrospectively reviewed cases of preoperative devascularization of CBT from 1 January 1995 through 1 September 2012. Patient cases were placed into two groups: TAPE and DPE. Operative blood loss, operative length, angiographic devascularization, embolization procedure complications, operative transfusion requirements, postoperative hospital stay, intensive care unit (ICU) stay, and procedure-related mortalities were compared.ResultsA total of 17 patients underwent preoperative devascularization of their CBT with TAPE technique and ten patients using the DPE technique with Onyx. Average operative blood loss was significantly higher in the TAPE group (Mann–Whitney U test, p = 0.04). Operative time was also higher, although this difference was not significant. Two patients required intraoperative blood transfusions in the TAPE group while none required transfusions in the DPE group. There was no significant difference in ICU stay or length of hospitalization. One serious embolization procedure complication occurred in the TAPE group and none in the DPE group.ConclusionOperative blood loss in the DPE group was significantly less than the TAPE group. Blood transfusion requirement, operative time, and complications were less in the DPE group, although they did not reach statistical significance.

Basilar artery pseudoaneurysm presenting at 5-month follow-up after traumatic atlanto-occipital dislocation in a 7-year-old girl treated with intracranial stent placement and coiling

Atlanto-occipital dislocation (AOD) is a grave injury that is rarely survivable. Patients who do survive often have long-term sequelae resulting from the intracranial damage sustained during the traumatic event. The high impact needed to cause AOD is translated to the intracranial vessels, which can lead to vascular injury. Pseudoaneurysm is one of the possible outcomes of damage to the vessel wall. We present a case of basilar artery pseudoaneurysm diagnosed 5 months after a traumatic AOD who was treated with intracranial stent placement and coiling.

Stent-assisted coiling of cerebrovascular aneurysms: experience at a large tertiary care center with a focus on predictors of recurrence

Background Stent-assisted coiling is commonly used to treat wide-necked and fusiform cerebral aneurysms. We evaluated our institutional experience with stent-assisted coiling of cerebral aneurysms to elucidate potential risk factors for recurrence. Methods A retrospective analysis of patients undergoing stent-assisted coiling of cerebral aneurysms from 2005 to 2012 resulted in 122 patients with 122 aneurysms. Demographic, peri-procedural, medical comorbidity, and follow-up data were collected. Primary outcomes of interest were procedural safety, efficacy, and aneurysm recurrence. Univariate and multivariate logistic regression and χ2 tests determined the statistical significance of the risk factors. Results All 122 stent-assisted coiling procedures led to satisfactory obliteration of the aneurysm (3.3% complication rate). Twenty-one (17.2%) patients experienced recurrence at average follow-up of 297 days. Fifteen (71.4%) clinically significant recurrences required retreatment. Eleven of 30 (36.7%) procedures using Enterprise stents had recurrence compared with only 10 of 92 (10.9%) procedures using Neuroform stents (p=0.001). Average coiling packing density (PD) was 20.3% with Enterprise stents and 22.5% with Neuroform stents (p=0.8). In multivariate logistic regression, recurrences requiring recoiling were significantly associated with Enterprise stents (OR 8.57, 95% CI 1.97 to 37.19; p=0.004), females (OR 0.19, 95% CI 0.04 to 1.00; p=0.05), and postoperative dextran use (OR 8.42, 95% CI 1.40 to 50.58; p=0.02). Aneurysms with <20% PD were more likely to have a clinically significant recurrence than aneurysms with >20% PD (19% vs 5.1%; p=0.02). Conclusions Stent-assisted coiling for wide-necked cerebral aneurysms has a high therapeutic success rate with low procedure-related morbidity and mortality. Clinically significant recurrences may occur more frequently with Enterprise stents, in aneurysms with low PD, and with post-procedural dextran use.

Issues in the diagnosis and management of the papilledema shunt

Background: Dural arteriovenous fistulas (DAVFs) that shunt blood into the transverse or superior sagittal venous sinuses cause papilledema by raising intracranial pressure (“the papilledema shunt”). Such fistulas pose unique diagnostic and therapeutic challenges. Methods: Case report and literature review. Results: In a patient presenting with papilledema, non-invasive brain vascular imaging disclosed subtle signs of a DAVF. Digital angiography delineated the DAVF and revealed cortical venous reflux. After three transarterial embolizations with ethylene vinyl alcohol, the DAVF was closed and papilledema resolved. Conclusions: The imaging features of a DAVF that cause papilledema may be subtle on non-invasive vascular imaging. If overlooked, and lumbar puncture is performed, there is a substantial risk of brain herniation. Cortical venous reflux, which may be relatively common in these DAVFs, impels the need for endovascular closure. The transvenous route, often employed for closing cavernous sinus DAVFs, should be avoided because of the dangers of dural venous sinus thrombosis.

Radiology–pathology case report: isolated extranodal Rosai–Dorfman disease of the skull base

Rosai-Dorfman disease is a rare pathologic entity characterized by massively enlarged painless cervical lymph nodes. Exclusive extranodal disease is much less common than the characteristic presentation with exclusive central nervous system and skull base involvement being quite rare. We present a case of exclusive extranodal Rosai-Dorfman disease of the skull base and briefly discuss the entity.

A Deficient Diagnosis

A previously healthy boy, 2 1/2 years old, presented with a 6-week history of progressive inability to bear weight on his right leg. His mother noted no recent trauma. His medical history was notable only for speech delay.