Yuo Iizuka

Complications Associated with Transvenous Embolisation of Cavernous Dural Arteriovenous Fistula

Summary¶ Results are presented of transvenous embolisation, via either the inferior petrosal sinus (IPS) or the superior ophthalmic vein (SOV), for 19 patients with cavernous dural arteriovenous fistula with special emphasis on complications. In 17 patients (89%) there was complete angiographic elimination of the shunts and resolution of the symptoms. The remaining two patients also improved clinically, regardless of the minimal residual shunts. Complications included forehead dysaesthesia in one patient, blepharoptosis in two, and transient abducens nerve palsy in three. Injury of the supra-orbital nerve and levator muscle occurred in association with the exposure of the SOV in the patient with dysaesthesia of the forehead and in those with blepharoptosis, respectively. In two patients, abducens nerve palsy resulted from coil over-packing in the cavernous sinus and from dissection of the clival dura during guidewire penetration of the thrombosed IPS in one patient. We found that the complication rate decreased with time, because we became better with this procedure. We believe that transvenous embolisation is the best available treatment modality if one pays careful attention to avoid complications related to the procedure.

Congenital fibromuscular dysplasia involving multivessels in an infant with fatal outcome

We report the unusual case of a 2-month-old boy with systemic fibromuscular dysplasia (FMD). He presented with congenital renovascular hypertension due to stenosis of the right renal artery, and later developed renal infarction on the contralateral side resulting in renal failure. The boy subsequently died of intracranial haemorrhage at the age of 14 months. During the course, hemiconvulsion caused by a Moyamoya disease-like vascular lesion was noted. Stenotic lesions of both the abdominal aorta and its branches were also revealed by angiography. Post-mortem examination confirmed that the coronary, splenic and mesenteric arteries were also affected and their histological findings were compatible with FMD. To our knowledge, this is the first congenital case of FMD demonstrating a rapidly progressive course resulting in a fatal outcome. In this case, multivessels in both intracranial and extracranial arteries were involved. Conclusion:our case suggests that the nature of fibromuscular dysplasia is congenital in origin and its aetiology, at least in some cases, is a systemic abnormality of vascular development.

Successful transarterial glue embolisation by wedged technique for a tentorial dural arteriovenous fistula presenting with a conjunctival injection

Abstract Many tentorial dural arteriovenous fistulae (TDAVF) present with intracranial haemorrhage. We report a patient who presented with conjunctival injection. Transarterial embolisation of the TDAVF was undertaken with a wedged injection of a low concentration of N-butyl cyanoacrylate, arresting the flow next to the proximal segment of the venous outlet. After three sessions, a complete cure was achieved. We present a useful method which has not been reported previously.

Successful surgical treatment of a dural arteriovenous fistula at the craniocervical junction with reference to pre- and postoperative MRI

Abstract We report a 62-year-old woman who presented with a myelopathy at the lower thoracic level. Left vertebral angiography revealed a dural arteriovenous fistula (DAVF) at the craniocervical junction, draining into an anterior spinal vein. Below the T 7 level, the spinal cord gave high signal on T 2-weighted images and enhanced with Gd-DTPA. The patient was successfully treated by simple clipping of vein draining the DAVF. The abnormal signal intensity and contrast enhancement rapidly regressed, except in the conus medullaris. Regression of the parenchymal abnormality on serial MRI following treatment corresponded closely with postoperative improvement of neurological function.

Endovascular remodeling technique for vein of Galen aneurysmal malformations--angiographic confirmation of a connection between the median prosencephalic vein and the deep venous system

It is commonly believed that in vein of Galen aneurysmal malformations (VGAMs) venous structures normally constituting the deep or Galenic venous system, such as the internal cerebral vein (ICV) and the basal vein of Rosenthal, are not connected to the vein of Galen. In this report, the authors describe 2 cases of successfully treated VGAM in which drainage of an ICV into the vein of Galen was confirmed by follow-up angiography. Two mural types of VGAM were treated using transarterial glue embolization when 1 child was 5 months and the other was 6 months old. The postoperative outcomes for these babies were complete cures. Follow-up digital subtraction angiography obtained after 12 months (Case 1) and 6 months (Case 2) confirmed that the shrunken median prosencephalic vein connects with the deep venous system. The possibility of normal deep Galenic venous drainage must be considered in endovascular management of VGAM. The goal of endovascular intervention is to close only the ventral component of the dilated median prosencephalic vein.

Conus Medullaris Spinal Arteriovenous Malformation in a Patient with Klippel-Trenaunay-Weber Syndrome: A Case Report and Review of the Literature

We describe a 24-year-old woman who presented with twice previously unverified subarachnoid hemorrhages from the conus medullaris spinal arteriovenous malformation with Parkes-Weber-syndrome. Spinal MRI examination is considered to be necessary for the diagnosis of Klippel-Trenaunay-Weber syndrome. For diagnosis of the spinal cord arteriovenous malformation, it is indispensable to search carefully for the presence of accompanying lesions. Transarterial glue embolization is effective for the management of the spinal vascular lesion.

Anatomical subcategorization for pediatric vein of galen aneurysmal dilatation. A report of three cases.

Vein of Galen aneurysmal dilatation is generally considered an abnormal deep-seated arteriovenous shunt that drains into the Vein of Galen. We herein present three pediatric cases of vein of Galen aneurysmal dilatation (VGAD). The locations of these shunts are anatomically different from just parenchymal as previously reported, but are also cisternal and intraventricular. Clinical symptoms, neuroradiological diagnostic points and therapeutic endovascular management are reported. Three boys had abnormal findings on brain computed tomography. Using magnetic resonance images, magnetic resonance angiography, three dimensional computed tomographical angiography and digital subtraction angiography, these patients were diagnosed with VGAD. The different locations of their shunts were the intraventricular choroidal plexus, cistern verum interpositive, and thalamus pulvinar nucleus. The boy presenting a single hole arteriovenous shunt at the cistern verum interpositive and an arteriovenous malformation at the choroidal plexus in the left lateral ventricle were treated by endovascular glue embolization. The patient with a single hole fistula in the left thalamus was followed only with observation. Treated patients had their abnormal shunts closed without any neurological complications. VGADs should be classified by shunt location according to whether they are ventricular, cisternal, or parenchymal. Although the therapeutic decision for pediatric VGAD should consider individual radiological, clinical and familial factors, endovascular intervention should be chosen as a first therapeutic option. Endovascular management of these lesions result in excellent angiographic and clinical outcome.

Progression of Tolosa-Hunt Syndrome to a Cavernous Dural Arteriovenous Fistula: A Case Report

Tolosa-Hunt syndrome (THS) is defined as nonspecific inflammation presenting as unilateral orbital pain, with associated cranial nerve palsies, dramatic improvement on steroid therapy, and negative neuroimaging. 1 Several investigative groups, however, have reported abnormalities on magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) in otherwise typical cases of THS. 2-4 Revision of the existing criteria consequently has been proposed. We report here a patient presenting with painful ophthalmoplegia and right oculomotor nerve paresis who developed cavernous dural arteriovenous fistulas (dAVFs). The etiology of dAVFs is still controversial. Inflammation, trauma, sinus thrombosis, venous hypertension, and congenital origin have been proposed as sources of the fistulas. 6-10 Some reports have demonstrated vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF) within fistulas. 11,12 It is postulated that the etiology of dAVFs may differ according to location. In this case report, we postulate a mechanism for the formation of cavernous dAVFs that present clinically as a carotid cavernous fistula (CCF).

Embolisation of a persistent primitive trigeminal artery for a large cavernous aneurysm. A case report.

We report a case of large cavernous aneurysm associated with persistent primitive trigeminal artery (PPTA). Thrombosis of the aneurysm was obtained only by occlusion of the PPTA. Aneurysms associated with PPTA have not previously been treated only by the occlusion of PPTA with GDC, and this report presents the first such intervention. A radiological follow-up study with MRI and angiography demonstrated marked shrinkage of the thrombosed aneurysm 17 months later, although clinical symptoms were not improved. From our experience, we suggest that the occlusion of the PPTA can be the first step in the therapeutic protocol for aneurysms associated with PPTA.

Endovascular treatment of vein of galen aneurysmal malformations.

We report two cases of vein of Galen aneurysmal dilatation (VGAD) and four cases of vein of Galen aneurysmal malformation (VGAM) with special reference to clinical features and therapeutic indications of endovascular treatment. A case with VGAD was treated by radiosurgery in 1985 with no amelioration to the patient, A case of choroidal type VGAM underwent an operation in 1987, but died of massive hemorrhage 2 years later. The other case of VGAD has been followed-up conservatively. The remaining cases of VGAM (two choroidal type and one mural type) were treated by endovascular treatment. The two cases of choroidal type were successfully embolized but died of systemic complications, and the only case of mural type was cured.