Sudipta Roychowdhury

Vein of Galen malformation in a neonate: A case report and review of endovascular management

Vein of Galen malformation (VOGM) is a rare congenital vascular malformation caused by the maldevelopment of its embryonic precursor, the median prosencephalic vein of Markowski. VOGM results in neonatal morbidity and mortality, and premature delivery does not improve the outcome. We report a term female neonate in whom a vein of Galen malformation was diagnosed prenatally at 37 wk of gestation during a growth ultrasound and confirmed by fetal magnetic resonance imaging. Signs of cardiac decompensation were evident in the fetus. Multiple interventional radiology embolizations of the feeding vessels were performed successfully on days 7, 10, 12, 14 and 19. A review of the literature on the endovascular management of neonates with these malformations is presented herein.

Traumatic pseudoaneurysm of the basilar artery.

From JFK Medical Center, JFK Johnson Rehabilitation Institute, UMDNJ-RWJ Medical School, Department of PM&R, Edison, New Jersey (KMM, RM); JFK Medical Center, Edison Radiology Group, Edison New Jersey (WBF); Robert Wood Johnson University Hospital, University Radiology Group, East Brunswick, New Jersey (IK, SR); and Department of Surgery, Section of Neurosurgery, Robert Wood Johnson School of Medicine (SS).

Operative bed recurrence of thyroid cancer: utility of a preoperative needle localization technique.

BACKGROUND Surgical management of recurrent disease after total thyroidectomy and/or neck dissection for thyroid carcinoma remains a challenging clinical problem. Reoperation is associated with a significant increase in morbidity. Preoperative needle localization technique for non-palpable breast tumors has recently been extrapolated to head and neck surgery. We report on the use of preoperative ultrasound-guided needle localization for non-palpable recurrent operative bed disease as an intraoperative aid in resection. METHODS Patients with thyroid carcinoma were identified from a retrospective database at a tertiary care center from 2011-2014. Inclusion criteria were history of thyroidectomy and/or neck dissection, non-palpable recurrent disease in the resection bed on surveillance, and ultrasound-guided needle localization of recurrent disease before resection. Perioperative data and outcomes were analyzed. RESULTS Seventeen patients were identified using the inclusion criteria listed above. Median patient age was 46 years (53% male, 47% female). A total of 23 masses in the previous operative bed were needle-localized successfully with no major long-term sequelae from this technique. The recurrent laryngeal nerve was involved with tumor in six patients. Two patients, in whom the tumor surrounded the nerve circumferentially, experienced recurrent laryngeal nerve injuries. No patients experienced postoperative hypocalcemia. With a routine surveillance and a median follow-up of 558 days, sixteen of the patients remain with no evidence of disease. CONCLUSIONS Preoperative ultrasound-guided needle localization of non-palpable recurrent operative bed disease after thyroidectomy and/or neck dissection is a potentially safe method to aid in resection and cure.

Ultrasound-guided thrombin injection for treatment of superficial traumatic pseudoaneurysms and associated expanding hematomas: experience in five patients

BackgroundAngiography allows for excellent characterization and treatment of traumatic pseudoaneurysms. However, ultrasound-guided thrombin injection for pseudoaneurysm thrombosis allows for radiation-free treatment of superficial pseudoaneurysms and superficial expanding hematomas.MethodsA retrospective review of 5 patient cases treated under this paradigm was performed following institutional review board approval. Outcomes following intervention were recorded and compared amongst the patient cohort.ResultsUltrasound-guided closure of traumatic pseudoaneurysms allowed for reduced procedural times and procedural invasiveness.ConclusionsAs demonstrated by the following cases, ultrasound guided thrombin injection is a good method of primary treatment for superficial pseudoaneurysms, or as an alternative treatment in cases where transcatheter embolization fails.

Updates in the Management of Cerebral Infarctions and Subarachnoid Hemorrhage Secondary to Intracranial Arterial Dissection: A Systematic Review

OBJECTIVE Intracranial arterial dissection (IAD) is a rare cerebrovascular disease that is likely underdiagnosed because of the inherent difficulty of visualizing the subtle radiographic signs of the pathologic small intracranial arteries. No widespread consensus exists on the treatment of IAD, and thus it is often managed empirically because of the absence of major randomized controlled trials. In this study, we conducted a systematic review to evaluate the management and treatment options for IAD. METHODS We performed a systematic review in accordance with the PRISMA guidelines using the following databases: MEDLINE (PubMed) and Cochrane Library. Included studies were limited to human patients with dissections in intracranial vessels only. RESULTS A total of 82 studies were included in this systematic review. The most common complications of IAD were cerebral infarction and subarachnoid hemorrhage, and thus, patients with IAD can be subdivided into those presenting with either ischemia or hemorrhage, respectively. Those with ischemia were predominantly managed with antiplatelet therapy, whereas patients presenting with hemorrhage often were amenable to treatment with endovascular techniques. CONCLUSIONS Given these findings, clinicians should prescribe antiplatelet therapy for patients with IAD presenting with ischemia and consider endovascular treatment for those presenting with hemorrhage. However, further investigation is required given the heterogeneity of methods and reporting outcomes in the investigated studies.

Isolated Abducens Nerve Palsy Associated with a Ruptured Posterior Inferior Cerebellar Artery Aneurysm: A Rare Neurological Finding

BACKGROUND Isolated abducens nerve palsy can be the presenting sign of a ruptured PICA aneurysm. Few cases have been reported in the literature. In the majority of cases, cranial nerve VI resolved following microsurgical clipping. CASE DESCRIPTION Here, we report a 56-year-old female who presented with a ruptured 4 mm × 3 mm left PICA aneurysm associated with a left abducens nerve palsy. The patient underwent endovascular coil embolization of the aneurysm and had complete resolution of her abducens nerve palsy. CONCLUSIONS Here, we present the first case of an abducens nerve palsy associated with a ruptured PICA aneurysm to completely resolve following endovascular coil embolization. The direction and amount of subarachnoid hemorrhage extravasation from the ruptured aneurysm are most likely responsible for cranial nerve palsy.

Interventional Removal of Traumatic Nail from Skull Base After Endovascular Coiling of Internal Carotid Artery and Jugular Vein

BACKGROUND Cases of nail gun injuries to the head and neck are rare, and treatment approach varies with each case based on location and extent of injury. CASE DESCRIPTION We present a case of a 52-year-old male who fell off a roof holding a pneumatic nail gun and accidentally shot himself with a nail through the right frontal neck region. The nail penetrated the right sternocleidomastoid muscle and extended intracranially through the right occipital condyle with its tip embedded in the right cerebellar hemisphere. The nail coursed between the right distal cervical internal jugular vein and right internal carotid artery. There was no evidence of vascular injury on initial imaging. The barbs of the nail abutted the right sigmoid sinus, making for high risk of tear and intracranial hemorrhage on manual nail extraction. Therefore preemptive coil embolization of the right dural venous sigmoid and occipital sinuses and internal jugular bulb was performed before attempted nail removal. Using biplane fluoroscopy, orthopedic screw removal plyers were successful in snaring the head of the nail. On initial removal attempt, the head of the nail injured the distal right cervical internal carotid artery, requiring endovascular coil embolization. The nail was then successfully extracted from the neck without further immediate complications. CONCLUSION Use of biplane fluoroscopy and preemptive endovascular embolization makes a nonsurgical approach to penetrating skull base injuries feasible. Despite improving right visual loss related to the right internal carotid artery embolization, the patient had no new focal neurologic deficits on 1-month outpatient follow-up.

Chemical angioplasty for medically refractory reversible cerebral vasoconstriction syndrome

Abstract Purpose: Medically refractory reversible cerebral vasoconstriction syndrome (RCVS), a rare variant of RCVS, poses a significant therapeutic challenge. Herein we describe a case of medically refractory RCVS that required treatment with intra-arterial (IA) verapamil and subsequent nimodipine, resulting in both angiographic and clinical improvement after failing to respond to hemodynamic augmentation. We also supplement a description of our case with a review of other case studies and case series in which IA calcium channel blockers were used to treat RCVS. We propose that the case we outline below demonstrates that neurointerventional management with IA verapamil is appropriate and effective as an early intervention of medically refractory RCVS. Methods and Materials: Using PubMed and Google Scholar, we performed a search of the English language literature with several combinations of the keywords “intra-arterial”, “calcium channel blockers”, “reversible cerebral vasoconstriction syndrome”, “RCVS”, “nimodipine”, “verapamil”, “milrinone”, and “nicardipine” to identify studies in which RCVS was treated with IA calcium channel blockers. Results: We identified eight case studies and case series that met our inclusion criteria. Eighteen patients are encompassed in these eight studies. Conclusions: IA administration of calcium channel blockers has been shown to return cerebral vessels to their normal caliber in patients with medically refractory RCVS. However, there are no randomized controlled trials of the treatment of RCVS, and further studies are needed to elucidate the optimal treatment protocol for medically refractory RCVS.

Early Diagnosis and Management of Extracranial Carotid Vasculopathy in Mitigating Neurological Complications of Sickle Cell Disease

While cerebral vasculopathy is a well-known early complication of sickle cell disease that has warranted transcranial doppler surveillance, little has been documented regarding the role of cervical circulation in the development of cerebrovascular events and transient ischemic attacks amongst sickle cell patients. We present the unique case of a symptomatic 18-year-old male with sickle cell disease found to have critical cervical carotid stenosis in the absence of significant intracranial vasculopathy. Increased awareness of the potential role of the extracranial circulation in the development of sickle cell related cerebrovascular events is warranted.