A rare case of cerebral hemorrhage due to left fronto-parietal mixed pial-dural AV- malformation, Spleitzer Martin grade 5 - A case report

Cerebral arteriovenous malformation (AVM) is a complex network of vascular channels consisting of arterial feeders, a nidus and enlarged venous drainage. AVMs usually increase in size with time, but may rarely obliterate; spontaneous angiographic regression occurs in less than 1.5% of cerebral AVMs. Several causes of spontaneous regression have been postulated such us hemodynamic alterations due to hemorrhage, hypercoagulability, atherosclerosis, and thromboembolism from associated aneurysms. In this report we describe a case of cerebral hemorrhage due to left fronto- parietal AVM with predominant middle cerebral artery and anterior cerebral artery feeders, minor left external carotid artery feeders, mixed pial-dural AVM – Spleitzer Martin Grade 5

Malformaciones vasculares cerebrales de alto flujo en pediatría: experiencia en un hospital pediátrico de alta complejidad / High-flow vascular malformations of the brain in pediatrics: Experience in a tertiary care children's hospital

Introducción. Las malformaciones vasculares cerebrales de alto flujo son poco comunes en la edad pediátrica. El objetivo del trabajo es diferenciar y agrupar estas enfermedades según edad de debut, manifestaciones clínicas y angioarquitectura.Población y método. Se realizó un estudio retrospectivo y observacional. Se analizaron las historias clínicas, los estudios por imágenes y los protocolos de procedimientos de pacientes del Hospital J. P. Garrahan con diagnóstico de malformaciones vasculares cerebrales desde enero de 2010 hasta enero de 2020.Resultados. Ciento ochenta y tres pacientes cumplieron los criterios de inclusión. Se identificaron 131 pacientes con malformaciones arteriovenosas con nido (MAV) y 52 con fístulas directas (sin nido), entre los que se hallaron 19 malformaciones aneurismáticas de vena de Galeno, 23 fístulas piales y 10 fístulas durales. La edad promedio fue de 105 meses para las MAV, 1,7 meses para las malformaciones aneurismáticas de vena de Galeno, 60,5 meses para fístulas piales y 41 meses para fístulas durales.Conclusión. Según su angioarquitectura, las malformaciones vasculares cerebrales de alto flujo tuvieron nido (MAV) o fueron fístulas directas (malformaciones aneurismáticas de vena de Galeno, fístulas piales y fístulas durales). Las MAV se manifestaron a partir de la primera infancia, sobre todo, por hemorragia intracraneana. Las fístulas directas se expresaron en la primera etapa de la vida, frecuentemente, con insuficiencia cardíaca.

Introduction. High-flow vascular malformations of the brain are uncommon in pediatrics. The objective of this study is to establish the differences among these pathologies and group them by age at onset, clinical manifestations, and angioarchitecture.Population and method. This was a retrospective and observational study. The medical records, imaging studies, and procedure protocols of patients seen at Hospital J. P. Garrahan diagnosed with vascular malformations of the brain between January 2010 and January 2020 were analyzed.Results. A total of 183 patients met the inclusion criteria. It was possible to identify 131 patients with arteriovenous malformations with a nidus (AVMs) and 52 with direct fistulas (without a nidus), including 19 vein of Galen aneurysmal malformations, 23 pial fistulas, and 10 dural fistulas. The average age of patients was 105 months for AVMs, 1.7 months for vein of Galen aneurysmal malformations, 60.5 months for pial fistulas, and 41 months for dural fistulas.Conclusion. Based on their angioarchitecture, high-flow vascular malformations of the brain presented a nidus (AVMs) or direct fistulas (vein of Galen aneurysmal malformations, pial fistulas, and dural fistulas). AVMs were observed in early childhood, especially due to intracranial hemorrhage. Direct fistulas occurred in the first stage of life, commonly with heart failure.

Clinical observation of endovascular embolization for the treatment of pial arteriovenous fistula / 中国脑血管病杂志

Objective To investigate the clinical characteristics, imaging features and treatment strategies of pial arteriovenous fistula. Methods From January 2013 to December 2017,12 patients with pial arteriovenous fistula confirmed by cerebral angiography and received treatment at the Department of Neurosurgery,Xuanwu Hospital, Capital Medical University were retrospectively recruited. All patients underwent endovascular embolization with Glubran 2,coil + Glubran 2 or Onyx 18. Some patients underwent balloon-assisted embolization. The embolization effect (complete occlusion,subtotal occlusion,partial occlusion) and postoperative complications were observed. Patients were followed up to evaluate symptom relief and radiological outcomes (previous lesions not visualized by re-examination imaging). Results For the initial symptoms,there were 6 headaches, 3 seizures,2 intracranial hemorrhages, and 1 tinnitus. After embolization, 11 patients had complete occlusion of the fistula and One patient had subtotal occlusion. Six patients underwent balloon-assisted embolization. One patient developed a decrease in muscle strength in the left limb after embolization. There were no deaths. Eleven patients completed the followup. The median follow-up time was 13. 4 (5. 2,26. 7) months. Nine patients had symptoms disappeared. One patient still had headache and 1 patient received oral antiepileptic drugs to control seizures. The fistulas were not visualized by angiopathy in all 11 patients. One patient developed dural arteriovenous fistula and arteriovenous malformation in superior sagittal sinus, straight sinus and sinus confluence. The patient was cured by embolization. Conclusions Pial arteriovenous fistula is a rare clinical disease, which is often characterized by headache, seizure, etc. Endovascular therapy is a safe and effective treatment method.

Salvinorin A preserves cerebral pial artery autoregulation after forebrain ischemia via the PI3K/AKT/cGMP pathway

This study aimed to investigate the protective effect of salvinorin A on the cerebral pial artery after forebrain ischemia and explore related mechanisms. Thirty Sprague-Dawley rats received forebrain ischemia for 10 min. The dilation responses of the cerebral pial artery to hypercapnia and hypotension were assessed in rats before and 1 h after ischemia. The ischemia reperfusion (IR) control group received DMSO (1 µL/kg) immediately after ischemia. Two different doses of salvinorin A (10 and 20 µg/kg) were administered following the onset of reperfusion. The 5th, 6th, and 7th groups received salvinorin A (20 µg/kg) and LY294002 (10 µM), L-NAME (10 μM), or norbinaltorphimine (norBIN, 1 μM) after ischemia. The levels of cGMP in the cerebrospinal fluid (CSF) were also measured. The phosphorylation of AKT (p-AKT) was measured in the cerebral cortex by western blot at 24 h post-ischemia. Cell necrosis and apoptosis were examined by hematoxylin-eosin staining (HE) and TUNEL staining, respectively. The motor function of the rats was evaluated at 1, 2, and 5 days post-ischemia. The dilation responses of the cerebral pial artery were significantly impaired after ischemia and were preserved by salvinorin A treatment. In addition, salvinorin A significantly increased the levels of cGMP and p-AKT, suppressed cell necrosis and apoptosis of the cerebral cortex and improved the motor function of the rats. These effects were abolished by LY294002, L-NAME, and norBIN. Salvinorin A preserved cerebral pial artery autoregulation in response to hypercapnia and hypotension via the PI3K/AKT/cGMP pathway.

Cortical versus Pial Venous Drainage in Dural Arteriovenous Fistula / 신경중재치료의학

No abstract available.

Onyx Embolization of Intracranial Pial Arteriovenous Fistula

Intracranial pial arteriovenous fistulas (AVFs) are rare cerebrovascular lesions consisting of one or more arterial connections to a single venous channel without an intervening nidus. Because of the location and high flow dynamics of these lesions, neurosurgeons may have a difficulty deciding between endovascular treatment and open surgical treatment. We report on a patient who underwent endovascular treatment with liquid embolic agent. A 50-year-old man with a decreased mental state and a tonic seizure event was brought to our hospital. Computed tomography (CT) of the brain showed a subcortical hematoma in the right temporoparietal lobe. On three-dimensional cerebral artery CT, there was no evidence of definite cerebrovascular abnormality. Cerebral angiography showed a pial AVF supplied by the right middle cerebral artery with early drainage into the right superior cerebral vein. The patient was treated with Onyx embolization for definitive closure of the fistula. The patient was transferred to the department of rehabilitation medicine two weeks later with grade 4 left hemiparesis. The application of advanced equipment, such as the latest angiography and endovascular tools, will facilitate the correct diagnosis and delicate treatment of pial AVF.

Pial Arteriovenous Fistula with Giant Varices: Report of Two Cases with Good Surgical Outcome

Pial arteriovenous fistulas (pAVF) are rare vascular lesions consisting of one or more arterial connections to a single venous channel without any intervening nidus of vessels or capillaries. Case 1: A 65-year-old woman with a complaint of headache and left hand paresthesia was referred to us. Magnetic resonance imaging showed a large saccular lesion with signal void in the posterior part of the right sylvian fissure and catheter angiography showed a giant venous aneurysm fed by one branch of the middle cerebral artery (MCA) and draining into the vein of Trolard. Case 2: A 12-year-old boy was transferred to our hospital with a history of sudden loss of consciousness and hemiplegia. Brain computed tomography revealed a massive hemorrhagic mass in the right hemisphere and cerebral angiography showed a pAVF with a large aneurysmal varix, which was fed by multiple branches of the right MCA and draining into the superior sagittal sinus. Both patients underwent craniotomy and after ligation of vascular connections, aneurysmal varices were removed completely. Surgical resection can be a safe method for treatment of pAVFs, particularly in those with large varices.

Congenital Pial Arteriovenous Fistula in the Temporal Region Draining into Cavernous Sinus: A Case Report

This report concerns a 4-month-old infant with progressive prominent and redness of his left eye since birth. This report concerns a 4-month-old infant with progressive prominent redness of his left eye since birth. Angiography revealed a congenital pial arteriovenous fistula between the temporal branch of the left posterior cerebral artery and left cavernous sinus through the sphenoparietal sinus, a condition not reported in the literature. The fistula was successfully occluded with two micro-coils by vertebrobasilar approach.

Intracranial Pial Arteriovenous Fistula Presenting with Hemorrhage: A Case Report

Intracranial pial arteriovenous fistula (AVF) is a rare cerebrovascular malformation, which has a single or multiple arterial connections to a single venous channel without intervening nidus, and is different from arteriovenous malformation (AVM). We report on a case of a surgically treated pial AVF. A 15-year-old girl with an altered mental state was brought to our hospital. Computed tomography (CT) showed a subcortical hematoma of approximately 24 ml in her right temporal lobe. Cerebral angiography showed an AVF supplied by the right middle cerebral artery with early drainage into the Sylvian vein and the vein of Labbe. She underwent surgical treatment with feeding artery obliteration using a clip and hematoma removal. The patient was discharged without neurologic deficits. Despite the rarity of pial AVF, for correct diagnosis and treatment, neurosurgeons should recognize this condition. Pial AVF can be managed simply by disconnection of the shunt by surgery or endovascular treatment, and a good result can be achieved.

A Case of Pial Arteriovenous Fistula with Giant Venous Aneurysm and Multiple Varices Treated with Coil Embolization

Intracranial pial arteriovenous fistulas (AVFs) are rare vascular lesions of the brain. These lesions consist of one or more arterial connection to a single venous channel without true intervening nidus. A 24-year-old woman visited to our hospital because of headache, vomiting, dizziness and memory disturbance that persisted for three days. She complained several times of drop attack because of sudden weakness on both leg. Cerebral angiograms demonstrated a giant venous aneurysm on right frontal lobe beyond the genu of corpus callosum, multiple varices on both frontal lobes fed by azygos anterior cerebral artery, and markedly dilated draining vein into superior sagittal sinus, suggesting single channel pial AVF with multiple varices. Transarterial coil embolization of giant aneurysm and fistulous portion resulted in complete disappearance of pial AVF without complication.

Embolization of Cerebral Pial Arteriovenous Fistula Under Balloon-assisted Flow Control Using NBCA: a Case Report / 신경중재치료의학

Intracranial pial arteriovenous fistulas are rare vascular lesions of the brain. These lesions are composed of one or more direct arterial feeders with a single draining vein and usually have associated venous varix or giant venous aneurysms. Pial fistulas can be treated by endovascular occlusion or by microneurosurgery and endovascular treatment offers a simple and safe option. We report a case of pial fistulas treated with embolization using n-butyl cyanoacrylate (NBCA) and Lipiodol mixture in association with a balloon in the afferent artery to slow down the flow within the fistula.

Intracranial Pial Arteriovenous Fistulas

Intracranial pial arteriovenous fistula (AVF) is a rare cerebrovascular lesion that has only recently been recognized as a distinct pathological entity. A 41-year-old woman (Patient 1) presented with the sudden development of an altered mental state. Brain CT showed an acute subdural hematoma. A red sylvian vein was found intraoperatively. A pial AVF was revealed on postoperative angiography, and surgical disconnection of the AVF was performed. A 10-year-old boy (Patient 2) presented with a 10-day history of paraparesis and urinary incontinence. Brain, spinal MRI and angiography revealed an intracranial pial AVF and a spinal perimedullary AVF. Endovascular embolization was performed for both lesions. The AVFs were completely obliterated in both patients. On follow-up, patient 1 reported having no difficulty in performing activities of daily living. Patient 2 is currently able to walk without assistance and voids into a diaper. Intracranial pial AVF is a rare disease entity that can be treated with surgical disconnection or endovascular embolization. It is important for the appropriate treatment strategy to be selected on the basis of patientspecific and lesion-specific factors in order to achieve good outcomes.

Congenital Intracranial Pial Arteriovenous Fistula Complicated with Congestive Heart Failure in Neonate: A Case Report / 신경중재치료의학

Congenital intracranial pial arteriovenous fistula complicated with high output heart failure is a rare disease of the cerebral vasculature. Like vein of Galen malformation, it can cause high output cardiac failure, but the treatment strategy is different. To lead a neonate with severe heart failure to normally grow with the brain and body, a rapid treatment is mandatory and has to target on removing the fistula. The authors report on a neonate with congenital pial arteriovenous fistula complicated with high output heart failure, which recovered with transarterial embolization and allowed the neonate to thrive.

Radiological Characteristics of Peritumoral Edema in Meningiomas

OBJECTIVES: The purpose of this study is to evaluate the radiological charactersitics related to the formation of peritumoral edema in meningiomas. METHODS: Fifty patients with meningioma were examined by magnetic resonance images and cerebral angiography. The predictive factors associated peritumoral edema, such as, tumor size, peritumoral rim (cerebrospinal fluid cleft), shape of tumor margin, signal intensity of tumor in T2WI, and pial blood supply were evaluated. RESULTS: Tumor size, peritumoral rim and pial blood supply correlated with peritumoral edema on univariate analyses. But in multivariate analyses, pial blood supply was statistically significant as a factor for peritumoral edema in meningioma. CONCLUSION: In our results, pial blood supply is significant contributing factor for peritumoral edema in meningioma.

The Effect of Topical Nilvadipine on Cerebral Pial Vessels in Rabbit

The effects of mock CSF, nilvadipine solution of various concentrations and PEG 400 solution on regional cerebral pial vessels in rabbits were studied by topical microapplication to the perivascular evironment through the bilateral cranial windows in a randomized fashion. Physiological parameters(PaO2, PaCO2, blood pH, and systolic blood pressure) were not significantly changed during all experiments. The pial vascular diameter was directly determined with the micrometer eyepiece under the operating microscope. The results were the followings: 1) Topical applications with mock cerebrospinal fluid(Group I) and PEG 400(Group II) on cerebral pial vessels did not significantly change pial vascular diameter in comparison with the resting state(p>0.05). 2) Application of nilvadipine solution of 1x10(-8)M did not show significant dilatation, and solutions over the range of 1x10(-7) to 1x10(-2)M resulted in significant dilatation of the cerebral pial arteries in a dose-dependent manner. The small arterial segments showed more dilatation than large arterial segments when topical nilvadipine solution were applied, however, the difference was not significant(p>0.05). 3) In venous segments, topical application of the nilvadipine solution induced no significant pial vein dilatation compared with the resting state(p>0.05), except when 10 minutes after the topical application of 1x10(-2)M nilvadipine solution(p<0.05). It may be suggested that topical application of nilvadipine solution induce the dilatation of pial arteries with dose-dependent manner. Nilvadipine might be used for treatment and prevention of cerebral vasospasm and ischemia.

Alpha Receptor Stimulation by Norepinephrine and Blockade by Benoxathian in spinal Pial Arteries of Rabbit

The effect of norepinephrine and benoxathian on the diameter of spinal pial arteries in rabbits was studied by topical microapplication of the drug to the perivascular environment. Arterial diameter was determined with the micrometer eyepiece on operating microscope through laminectomized area. Physiological parameters(PaO2, PaCO2, blood pH, and systolic blood pressure) were not significantly changed during all experiments. The results of this study are summerized as follow. 1) Application of norepinephrine over the range of 5x10(-8)M to 5x10(-3)M to spinal pial arteries resulted in significant constriction which were shown to be proportional to concentration, with exception of 5x10(-8)M. The dose response curve showed constriction of 30.5+/-7.1% at 5x10(-3)M. 2) Benoxathian produced the vasodilatation which were shown to be proportional to concentration. The dose response curve showed vasodilatation of 21.4+/-4.4% at 5x10(-3)M 3) The vasoconstriction due to microapplication of norepinephrine was prevented by the inclusion of an equimolar concentration of the alpha-adrenergic receptor blocker, benoxathian. 4) The vasoconstriction due to norepinephrine was present in the concentration of norepinephrine more than that of benoxathian, and the vasoconstriction was proportional to the concentration of norepinephrine. The results indicate that alpha-adrenergic receptor is present in the smooth muscle of spinal pial arteries for the sympathetic control of blood flow to the spinal cord.

The Effect of Topical Microapplication of Norepinephrine and Benzoxathian on Cerebral Pial Arteries in Rabbit

The effects of norepinephrine and benzoxathian on the diameters of cerebral pial vessels in rabbits were studied by topical microapplication of the drugs to the perivascular environment. Vascular diameters were determined with the micrometer eyepiece on operating microscope through the craniectomized area. Physiological parameters(PaO2, PaCO2, blood pH, and systolic blood pressure) had not significantly changed during all the experiments. The observations were as follows: 1) Application of norepinephrine over the range of 5x10(-8)M to 5x10(-3)M to the cerebral pial arteries resulted in significant constriction of the vessels, with the exception of 5x10(-8)M. The dose-response curve showed a maximal constriction of 31.5+/-3.8% at 5x10(-3)M. 2) Benzoxathian produced vasodilatation at dosages over 5x10(-4)M. But there was little change of vascular diameter between dosages of 5x10(-8)M to 5x10(-5)M. The dose-response curve showed a maximal vasodilatation of 26.31+/-5.1% at 5x10(-3)M. 3) The vasoconstriction due to microapplication of norepinephrine was prevented by the inclusion of an equimolar concentration of the alpha-1 receptor antagonist, benzoxathian. 4) The vasoconstriction induced by norepinephrine occurred in higher concentration of norepinephrine than that of benzoxathian, and the vasoconstriction was proportional to the concentration of norepinephrine. 5) The pattern of responses of the pial veins corresponded with that of pial arteries. But the amplitudes of the change in the diameters of veins were less than those of the arteries. The results indicate that alpha-adrenergic receptor is present in the smooth muscles of cerebral pial arteries and veins for the sympathetic control of blood flow to the brain, and newly introduced benzoxathian acts as a highly selective alpha-1 receptor antagonist.

The Effect of Topical Application of norepinephrine and Phentolamine on Spinal Pial Arteries in Rabbit

The effect of norepinephrine and phentolamine on the diameter of spinal pial arteries in rabbits was studied by topical microapplication of the drug to the perivascular environment. Arterial diameter was determined with the micrometer eyepiece on operating microscope through laminectomized area. Changes of physiological parameters(PaO2, PaCO2, blood pH, and systolic blood pressure) were not significant during all of the experiments. 1) Application of nerepinephrine over the range of 5x10(-8)M to 5x10(-3)M to the spinal pial arteries resulted in significant constriction of the vessels, with the exception of 5x10(-8)M. The dose-response curve showed a maximal constriction 30.5+/-7.1% at 5x10(-3)M. 2) Phentolamine produced no significant vasodilatation. 3) The vasoconstriction due to microapplication of norepinephrine was prevented by the inclusion of an equimolar concentration of the alpha-adrenergic blocker, phentolamine. 4) The vasoconstriction due to norepinephrine was evident while the concentration of norepinephrine was more than that of phentolamine. Furthermore the degree of vasoconstriction was proportional to the concentration of norepinephrine. The results indicate that alpha-adrenergic receptors are present in the smooth muscle of spinal pial arteries for the sympathetic control of blood flow to the spinal cord.

DYNAMIC CHANGES OF PIAL-MICROCIRCULATION IN RATS DURING HEMORRHAGIC SHOCK / 第二军医大学学报

The influence of shock in varied degrees on pial-microcirculation in rats and the dynamic change of pial-microcirculation in hypotension were observed. It was shown that severe disturbance occurred in pial-microcirculation when blood ressure was lowered to 3.20 kPa.In early stage after severe bleeding the main manifestation of pial-microcirculatory disturbance was hyperemia, i. e., dilatation of arteriole or segmental dilatation-contraction of arteriole, hyperemia of capillary net, increased number of opened capillaries and appearance of 0-I degree of blood flow status (according to the classification of Tia Niu).Ninety minutes after bleeding arterioles and venules became gradually constricted,red blood cells aggregation was increased, ischemia of pial-microcirculation became more severe and blood flow status changed from 1st to 2nd, even 3rd degree.The results demonstrate that autoregulation of cerebral microcirculation is much stronger than that of other organs. Microcirculatory disturbance does not appear until blood pressure drops to the degree beyond the ability of autoregulation.