Tsinsue Chen

Development of syndrome of inappropriate antidiuretic hormone secretion (SIADH) after Onyx embolisation of a cavernous carotid fistula

Patients with cavernous carotid fistulas (CCFs) can present with pituitary hypoperfusion and hypopituitarism; however, there are no previous reports of pituitary or hormonal abnormalities developing after CCF embolisation in an asymptomatic patient. We describe a patient with no hormonal abnormalities who developed syndrome of inappropriate antidiuretic hormone (SIADH) secretion after CCF embolisation. The patient had bilateral indirect CCFs, which were completely embolised via a transvenous approach, and was neurologically stable postoperatively and discharged. In the subsequent 2 weeks the patient was readmitted twice for acute hyponatraemia and a tonic-clonic seizure. Laboratory studies revealed severe SIADH. Clinical status and sodium levels improved after treatment. One year later the patient was weaned off all medications and remained neurologically stable. SIADH may be a delayed phenomenon after CCF embolisation. Given the proximity of embolised vessels to the pituitarys vascular supply, CCF treatment may result in flow disturbance, ischaemia and hormonal abnormalities.

Kawase Approach for Dolichoectactic Basilar Artery Macrovascular Decompression in a Patient With Trigeminal Neuralgia: Case Report

BACKGROUND AND IMPORTANCE Trigeminal neuralgia (TN) secondary to a dolichoectatic basilar artery (DBA) is an extremely rare phenomenon. The Kawase approach for macrovascular decompression of this rare pathology been used rarely. CLINICAL PRESENTATION This report describes macrovascular decompression and basilar artery transposition in a 69-yr-old male presenting with progressively worsening left-sided typical TN secondary to a DBA compression. The DBA was successfully decompressed off of the trigeminal nerve via a pterional craniotomy and anterior petrosectomy. The patient had immediate improvement in TN symptoms postoperatively. The patient remained symptom free with nonbothersome facial numbness in the V3 segment at 8-mo postoperative follow-up in clinic. The patient suffered a sixth nerve palsy following surgery, which was later corrected by strabismus surgery. The natural history and epidemiology of TN, results of macrovascular decompression secondary to DBA compression via a traditional suboccipital retrosigmoid approach, and potential advantages of the Kawase approach are also discussed. CONCLUSION The macrovascular decompression strategy succeeded because the compressive force was applied by the DBA to the nerve in a superolateral direction, and the decompressive sling pulled the DBA away from the nerve in an inferomedial direction. The working space and access to the clival dura through the Kawase approach allowed proper corrective pull with a sling.

Neuromodulation for Trigeminal Autonomic Cephalalgias

Trigeminal autonomic cephalalgias (TAC) include chronic cluster headache (CCH), short lasting unilateral neuralgiform headaches with autonomic symptoms (SUNHA), paroxysmal hemicrania and hemicrania continua. Neuromodulation for the treatment of TACs can involve both peripheral and central targets. Peripheral targets include stimulation of the sphenopalatine ganglion and the greater occipital nerve. Central targeting includes deep brain stimulation of ventral tegmental area, which has also been described as the “posterior hypothalamus”, as well as high cervical spinal cord stimulation. This chapter explores the mechanisms, operative techniques and clinical evidence supporting each method, with an emphasis on central neuromodulation techniques.