Subhash Kumar

Cervical rib with stroke as the initial presentation.

Cervical ribs rarely become symptomatic. Cerebral ischemia or infarct due to cervical rib is extremely rare and, invariably, these patients have a history of upper limb symptoms before presenting with stroke. We report a young boy with cervical rib who presented with stroke. A right sided cervical rib was noted during angiogram, causing mild stenosis and post stenotic dilatation of right subclavian artery distal to the rib. An abduction angiogram showed complete occlusion of the right subclavian artery and visualization of collaterals. Right carotid angiogram also showed evidence of thromboembolic episodes in the right middle cerebral artery territory.

Cerebral miliary micro aneurysms in polyarteritis nodosa : Report of two cases

Cerebral involvement is rare in polyarteritis nodosa (PAN) and is mostly characterized by ischemic events and intracranial hemorrhages secondary to cerebral aneurysms is extremely rare. We report two patients of PAN with multiple intracranial aneurysms. One patient presented with intracerebral hemorrhage and in the other patient multiple intracranial aneurysms were incidental findings and were asymptomatic. Both our cases suggest that multiple intracranial aneurysms are not very uncommon in PAN and cerebral angiography should be considered while doing abdominal angiogram in these patients.

A patient with pycnodysostosis presenting with seizures and porencephalic cysts

Pycnodysostosis is a rare autosomal recessive disorder caused by mutations in the cysteine protease Cathepsin K gene located on chromosome 1q21. It has a well characterized skeletal phenotype which include short stature, generalized increased bone density with propensity of fractures, open calvarial sutures and fontanelle, dental abnormalities, obtuse mandibular angle, resorption of lateral end of clavicle, acro-osteolysis, and in some cases visceromegaly. Central nervous system involvement is very rare and porencephalic cysts has been reported only once, the cause being hypothesised to be an imbalance between the growing brain, its vascular supply and intraventricular fluid pressure. We had a patient with bilateral frontal lobe porencephalic cysts; the patient presenting with complex partial seizures. Cathepsins have been found to be involved in neurological diseases and role of proteases has been well established in gliosis.

Fenestrated posterior inferior cerebellar artery with concomitant vertebro-basilar junction fenestration and vertebral artery aneurysm.

Cerebral artery fenestrations are rare anomalies with the anterior communicating artery and the vertebro-basilar system being most commonly involved. Serizawa et al. found up to 21% prevalence of anterior communicating artery fenestrations [19]. Several studies have demonstrated fenestrations of the vertebral, basilar, internal carotid and anterior, middle and posterior cerebral arteries [19, 4, 5, 6, 7, 3, 8]. Intracranial arterial fenestrations are clinically relevant because of their association with aneurysms [4, 3, 8, 17, 18, 9, 2] and other vascular anomalies [10, 22, 23, 25]. Only two cases of fenestration of the posterior inferior cerebellar artery (PICA) [13, 21] and none with an associated posterior fossa aneurysm or other anomalies have been reported. This article presents a case which showed fenestrations of the right PICA and vertebro-basilar junction in addition to a large aneurysm of the left vertebral artery.

3D Rotational Angiography in Follow-Up of Clipped Intracranial Aneurysms.

Introduction. 3D Rotational Angiography (RA) is indispensable for evaluation of intracranial aneurysms, providing infinite viewing angles and defining the aneurysm morphology. Its role in follow-up of clipped aneurysms remains unclear. We aimed to compare the aneurysm residue/recurrence detection rate of 3D RA with 2D digital subtraction angiography (DSA). Methods. 47 patients harboring 54 clipped aneurysms underwent both 2D DSA and 3D RA. The residual/recurrent aneurysms were classified into five grades and the images of both modalities were compared. Results. The residual/recurrent aneurysm detection rate was 53.70% (29/54 aneurysms) with 2D DSA and 66.67% (36/54 aneurysms) with 3D RA (P = 0.05). In 12 aneurysms, 3D RA upgraded the residue/recurrence among which nine had been completely not detected on 2D DSA and were found to have grade one or two residual necks on the 3D RA, and, in three cases, a small neck on 2D DSA turned out to be aneurysm sac on 3D RA. In a total of 5 aneurysms, the classification was downgraded by 3D RA. Conclusion. 3D RA picks up more aneurysm residue/recurrence; hence, both 2D DSA and 3D RA should be performed in follow-up evaluation of clipped aneurysms.

Middle meningeal artery arising from the basilar artery: report of a case and its probable embryological mechanism

An extremely rare variation of the (left) middle meningeal artery (MMA) originating from the basilar artery, detected incidentally during cerebral angiography, is reported. The right MMA was normal and an accessory meningeal artery arising from the maxillary artery was present on both the sides. The foramen spinosum on the variant side was absent. This abnormal origin of the MMA can be explained by the presence of a perineural arterial network in the region of the Gasserian ganglion, formed by branches of the developing basilar and stapedial arterial systems; the middle meningeal–basilar arterial channel opening up in the absence of a normally developing MMA.

Truncus bicaroticus with aberrant right subclavian artery and origin of right vertebral from right common carotid artery

We describe a rare constellation of variant anatomy of the aortic arch branches, seen on a magnetic resonance angiographic examination during the course of investigation for recent onset memory loss in a 52-year-old patient. There was a common origin of both the common carotid arteries (CCA), the common trunk being the first major branch of the aortic arch, the right vertebral artery arising from the right CCA and the right subclavian artery arising as the last branch of the arch. In isolation, the three components of this constellation have been reported with different frequencies, but as per the authors’ knowledge, this entire constellation has been rarely reported. We review the literature and propose an embryological mechanism for this variant anatomy.

Neurogenic pulmonary edema after rupture of intracranial aneurysm during endovascular coiling

Neurogenic pulmonary edema (NPE) is a well-known entity, occurs after acute severe insult to the central nervous system. It has been described in relation to different clinical scenario. However, NPE has rarely been mentioned after endovascular coiling of intracranial aneurysms. Here, we report the clinical course of a patient who developed NPE after aneurysmal rupture during endovascular surgery. There was significant cardiovascular instability possibly from stimulation of hypothalamus adjacent to the site of aneurysm. This case highlights the predisposition of minimally invasive procedures like endovascular coiling to life-threatening complications such as NPE.

A rare case of metachronous double spinal dural arteriovenous fistula.

2. Okamoto H, Harada K, Yoshimoto H, Uozumi T. Acute epidural hematoma caused by contrecoup injury. Surg Neurol 1983;20:461-3. 3. Shigemori M, Moriyama T, Eguchi G, Noguchi M, Kawasaki K, Kawaba T, et al. Acute epidural hematoma of the posterior fossa caused by frontotemporal impact. Case report. Neurol Med Chir (Tokyo) 1985;25:489-92. 4. Hamasaki T, Yamaki T, Yoshino E, Higuchi T, Horikawa Y, Hirakawa K. Traumatic posterior fossa hematoma. No To Shinkei 1987;39:1083-90. 5. Abe S, Furukawa K, Endo S, Hoshi S, Kanaya H. Acute epidural hematoma of the posterior fossa caused by forehead impact. No Shinkei Geka 1988;16:321-5. 6. Miyazaki Y, Isojima A, Takekawa M, Abe S, Sakai H, Abe T. Frontal acute extradural hematoma due to contrecoup injury: A case report. No Shinkei Geka 1995;23:917-20. 7. Motohashi O, Tominaga T, Shimizu H, Koshu K, Yoshimoto T. Acute epidural hematoma caused by contrecoup injury. No To Shinkei 2000;52:833-6. 8. Mishra A, Mohanty S. Contre-coup extradural haematoma: A short report. Neurol India 2001;49:94-5. 9. Mitsuyama T, Ide M, Kawamura H. Acute epidural hematoma caused by contrecoup head injury—Case report. Neurol Med Chir (Tokyo) 2004;44:584-6. 10. Sato S, Mitsuyama T, Ishii A, Kawamata T. An atypical case of head trauma with late onset of contrecoup epidural hematoma, cerebellar contusion, and cerebral infarction in the territory of the recurrent artery of Heubner. J Clin Neurosci 2009;16:834-7.

Ultrasound-guided polidocanol foam sclerotherapy for treating venous malformations

To evaluate clinical and imaging outcomes after ultrasound (US)‐guided 3% polidocanol (POL) foam‐sclerotherapy of venous malformations (VMs).