Combined Preoperative Endovascular Embolization and Surgical Excision for Scalp Arteriovenous Malformations: A Systematic Review and Case Illustration.

OBJECTIVE: To evaluate the efficacy of the combined approach of preoperative endovascular embolization (EE) and surgical excision (SE) for scalp arteriovenous malformation (AVM) and present an illustrative case report. METHODS: A systematic review was conducted using online databases (PubMed/Medline, Cochrane, and Embase) on February 15, 2023. The inclusion criteria were any type of study of patients with scalp AVMs who were diagnosed and confirmed through angiography and treated with combined preoperative EE and SE. All the articles that met the inclusion criteria were included in this study. RESULTS: A total of 49 articles (91 patients) were included. The patients' age ranged from 10 days to 70 years at the time of presentation. The most common symptoms were a pulsatile mass in 51 patients (56.04%), progressively growing mass in 31 patients (34.06%), and bruits and/or thrills in 22 patients (24.17%). Complications of preoperative EE and SE were observed in only 5 patients; 3 patients (3.29%) had harvested skin graft marginal necrosis, 1 patient (1.09%) had skin necrosis, and 1 patient (1.09%) had a wound infection. Only 2 patients (2.19%) reported a recurrent or residual mass during a median follow-up period of 12 months. CONCLUSIONS: The management of scalp AVMs can be challenging; therefore, focused, and accurate identification of the complexity of the vascular anatomy is required. The combined method of preoperative EE and SE showed satisfactory outcomes with low rates of complications and recurrence; thus, we recommend this approach for the management of scalp AVMs.

Hemangioma of the Lumbar Spine Involving the Spinous Process: A Rare Case Report and Review of the Literature.

Hemangiomas of the spine are usually benign and asymptomatic. They can cause devastating complications such as pathological fractures of the spine and neurological disability. This report documents an atypical location of a hemangioma in a lumbar spinous process, in combination with a spondylolisthesis at the same level, which makes it even more uncommon. Surgery can be effective and safe and can significantly improve patient outcomes. Moreover, prior embolization can prevent acute hemorrhage in addition to providing careful diagnosis and evaluation.

Common Carotid Artery Occlusion in a Young Patient: Can Large-Vessel Stroke Be the Initial Clinical Manifestation of Coronavirus Disease 2019?

BACKGROUND: The occurrence of large-vessel occlusion in young patients with coronavirus disease 2019 (COVID-19) infection has been exceedingly rare. An extensive review of reported studies revealed a few reported cases. In the present report, we have described the clinical presentation, radiological findings, and outcome of large-vessel occlusion in a young patient with COVID-19 and reviewed the pertinent reported data on this condition. CASE DESCRIPTION: A 31-year-old woman was in her usual state of health until she had presented with a 3-day history of right-sided weakness, slurred speech, and decreased vision. The patient had been taken to several hospitals where she had been treated conservatively with analgesics and discharged. Shortly thereafter, her weakness had become progressive. She had become severely dysarthric and unresponsive. On arrival to the emergency department, her physical examination revealed that she was stuporous, with a Glasgow coma scale of 10 (eye response, 3; verbal response, 2; motor response, 5). The National Institutes of Health Stroke Scale score was 19 on presentation. Brain computed tomography and computed tomography venography revealed an occluded left internal carotid artery and left middle cerebral artery with subacute left middle cerebral artery territory infarction and midline shift. Computed tomography angiography revealed complete occlusion of the left common carotid artery. An emergent decompressive craniectomy was successfully performed. The patient was shifted to the intensive care unit. She was later found to be positive for COVID-19. CONCLUSIONS: Although rare, patients with COVID-19 can present with large-vessel occlusion. Prompt identification of COVID-19-related coagulopathy is essential to assess young patients with clinical manifestations of infarction.

Meningioma Presenting with Spontaneous Subdural Hematoma: A Report of Two Cases and Literature Review.

BACKGROUND: Although meningiomas are considered benign, encapsulated brain tumors, their distinct intracranial location can lead to devastating complications. Although a highly vascularized tumor, a rarely reported complication of meningioma is hemorrhage. To the best of our knowledge, only 19 cases of meningioma presenting with a subdural hematoma have been reported. CASE DESCRIPTION: We have outlined the clinical presentation, radiological findings, and outcomes of 2 female patients with a diagnosis of a spontaneous subdural hematoma associated with meningioma. The coagulation profile was within normal limits for both patients. The postoperative histopathologic examination results showed an angiomatous/microcystic subtype of meningioma (patient 1) and meningothelial meningioma (patient 2). Both patients underwent right frontal craniotomy, resection of the dural-based tumor, and evacuation of the subdural hematoma. CONCLUSIONS: We comprehensively reviewed the pertinent data for meningiomas presenting as subdural hematomas. The mechanism of hemorrhage in meningiomas remains unclear. Therefore, further studies are required to investigate the possible mechanisms of bleeding in such tumors.

Accuracy of Canadian CT head rule in predicting positive findings on CT of the head of patients after mild head injury in a large trauma centre in Saudi Arabia.

BACKGROUND: Investigation of unjustified computed tomography (CT) scan in patients with minor head injury is lacking in Saudi Arabia. The purpose of the study was to evaluate the compliance and effectiveness of the Canadian computed tomography head rule (CCHR) in our emergency department (ED) and trauma centre and also to reduce the number of unjustified CT studies of the head in the centre. METHODS: A retrospective study of 368 ED patients with minor head injury was conducted. Patients who underwent CT scan between July 2010 and June 2011 were selected from the ED head trauma registry by systematic randomisation. The CCHR was retrospectively applied on the patients' charts to calculate the prevalence of unjustified head CT scans. A separate survey was conducted to evaluate three emergency physicians' level of awareness about the CCHR and their ability to determine the necessity of CT scans with various clinical scenarios of head injury. RESULTS: The prevalence of unjustified CT scans as per the CCHR was 61.8% (95% confidence interval (CI) 56.5-66.9%). Approximately 5% of the sample had positive CT findings with 95% CI 2.9-7.6%. The CCHR correctly identified 12 cases with positive CT findings with 66.67% sensitivity. Only 24 (6.7%) had Glasgow coma scale scores less than 15 (13/14). The Glasgow coma scale correctly identified only two cases with positive CT findings with 11.11% sensitivity. The percentage of skull fracture (0.9% vs 5%, P=0.030) was significantly lower in patients with unjustified CT scans than in patients with clinically justified CT scans. There was fair to substantial agreement between the ED physicians and the CCHR (κ=35-61%). Two ED physicians identified all cases of justified CT scan with 100% sensitivity (95% CI 71.51-100%). CONCLUSION: The level of education regarding the CCHR was found to be optimal among emergency physicians using a case-based scenario survey. The CCHR was found to have a poor compliance potential in the busy ED of our trauma centre and the prevalence of unjustified cranial CT scans remained high.

Neurointerventional participation in craniopagus separation.

Craniopagus-type conjoined twins (joined at the head) are exceedingly rare. Separation of craniopagus conjoined twins is a challenging task mainly owing to complex vascular anatomy and limited experience with this disorder. Modern neuroimaging techniques including digital subtraction angiography can be used to preoperatively assess the cerebral vascular system. These techniques can also provide the raw data to fabricate three-dimensional true-scale models. We report a case in which endovascular techniques have been used in the separation of craniopagus conjoined twins. To our knowledge there are no reports of successful incorporation of neurointerventional methods in the disconnection of shared venous channels.

Flow-diverter stent for the treatment of a non-origin posterior inferior cerebellar artery aneurysm. A case report.

We describe the case of a 44-year old man with a ruptured wide-necked non-origin aneurysm of the posterior inferior cerebellar artery successfully treated with placement of a low porosity stent. To our knowledge, there are no cases in the literature of a non-origin posterior inferior cerebellar artery aneurysm treated with a flow-diverter stent.

Resource optimization scheme for multimedia-enabled wireless mesh networks.

Wireless mesh networking is a promising technology that can support numerous multimedia applications. Multimedia applications have stringent quality of service (QoS) requirements, i.e., bandwidth, delay, jitter, and packet loss ratio. Enabling such QoS-demanding applications over wireless mesh networks (WMNs) require QoS provisioning routing protocols that lead to the network resource underutilization problem. Moreover, random topology deployment leads to have some unused network resources. Therefore, resource optimization is one of the most critical design issues in multi-hop, multi-radio WMNs enabled with multimedia applications. Resource optimization has been studied extensively in the literature for wireless Ad Hoc and sensor networks, but existing studies have not considered resource underutilization issues caused by QoS provisioning routing and random topology deployment. Finding a QoS-provisioned path in wireless mesh networks is an NP complete problem. In this paper, we propose a novel Integer Linear Programming (ILP) optimization model to reconstruct the optimal connected mesh backbone topology with a minimum number of links and relay nodes which satisfies the given end-to-end QoS demands for multimedia traffic and identification of extra resources, while maintaining redundancy. We further propose a polynomial time heuristic algorithm called Link and Node Removal Considering Residual Capacity and Traffic Demands (LNR-RCTD). Simulation studies prove that our heuristic algorithm provides near-optimal results and saves about 20% of resources from being wasted by QoS provisioning routing and random topology deployment.

Computed tomographic angiography and cerebral blood volume can predict final infarct volume and outcome after recanalization.

BACKGROUND AND PURPOSE: Recanalization rates are higher in acute anterior stroke treated with stent-retrievers when compared with older techniques. However, some still have sizeable infarcts and poor outcome. This may be related to underestimation of core infarct on nonenhanced computed tomography (NECT). CT angiography (CTA) source images (CTASI) and CT perfusion may be more informative. We hypothesize that core infarct estimation with NECT, CTA, and CT perfusion predicts infarct at 24 hours and outcome after fast recanalization. METHODS: Consecutive good recanalization patients with proximal anterior circulation stroke were evaluated. We assessed Alberta Stroke Program Early CT Score (ASPECTs) on NECT for subtle early infarct, hypodensity, loss of gray-white (CTASI), and low cerebral blood volume (CBV; CT perfusion). Sensitivity and specificity for predicting infarct by region were calculated. RESULTS: Of 46 patients, 36 (78%) had successful thrombectomy. Median ASPECTS was 10 for NECT early infarct and frank hypodensity; for CBV, CTASI-ASPECTS was 8. CTASI had the highest sensitivity of 71% and specificity of 82% for 24 hours NECT infarct. There was moderate correlation and concordance between CBV/24-hour NECT (Rp=0.51; Rc=0.50) and CTASI/24-hour NECT (Rp=0.54 and Rc=0.53). Thirty-four patients (74%) had good outcomes. Median ASPECTS was higher on CTASI (8 versus 5; P=0.04) and CBV (9 versus 5; P=0.03) for patients with good versus bad outcome. There were better outcomes with increasing CTASI-ASPECTS (P=0.004) and CBV-ASPECTS (P=0.02). CONCLUSIONS: CTASI and CBV were better at predicting 24-hour infarct and outcome than NECT. Appropriate advanced imaged guided selection may improve outcomes in large-vessel stroke treated with the newest techniques.

Navigation of Stents across Communicating Arteries for Aneurysm Embolization.

INTRODUCTION: Endovascular coiling of aneurysms crossing the Circle of Willis has been described in small case series. The technical challenges in manipulating a stent across the Circle of Willis lie in negotiating difficult angles and small arteries. We present our experience with treating aneurysms by stent assistance in which the Circle of Willis was crossed to facilitate optimal stent deployment. MATERIALS AND METHODS: We retrospectively reviewed the cases in our institution from January 2009 to June 2012 in which the Circle of Willis was traversed to facilitate optimal stent deployment. We measured the diameter of the communicating arteries traversed, caliber of the target arteries in which the stent was deployed and the most acute angle negotiated ("critical angle"). We compare our results with other published series in the literature. RESULTS: Eight patients fulfilled the criteria: 5 males (45-66 years). There were three anterior and five posterior circulation aneurysms. Four of the aneurysms were ruptured. The PCOM was traversed in five cases, the ACOM in three cases. The mean diameter of the communicating artery was 1.17 mm. The mean diameter of target arteries was 1.27 mm. The "critical angle" was 72-147 degrees. In all patients, there was satisfactory obliteration of the aneurysm. There were two cases of minor SAH post procedure. CONCLUSION: Utilizing the Circle of Willis for optimal stent placement in aneurysm remodeling is technically feasible but challenging. This technique can be performed successfully in patients with acute SAH. The procedural risk must be balanced against potential complications such as SAH.

Ultrasound guided fine needle aspiration cytology versus core biopsy in the preoperative assessment of non-palpable breast lesions.

BACKGROUND: Breast screening is a method of detecting breast cancer at a very early stage. Most of the lesions detected by screening are not malignant. Objective of this study was to compare ultrasound guided fine needle aspiration cytology and core biopsy in the preoperative assessment of non-palpable breast lesions. METHODS: The study was conducted prospectively at Department of Radiology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Pakistan from March 2004 to February 2005. All the patients underwent fine needle aspiration cytology and core biopsy. Later on, all of them had excision biopsy/mastectomy. Prospectively 80 patients were studied; information was collected on a specifically designed form according to inclusion criteria. The patient age, sex, medical record number and side of lesion were recorded. Clinical history of duration of lump was also taken. Informed consent was obtained. RESULTS: The age of patients were ranges from 20-71 years, with mean of 44.31 +/- 11.002 and the maximum number of patients 28 (35.3%) was between the ages 50-59 years. The sensitivity of FNAC was 92.85%, while the specificity of was 90% and the accuracy rate was 92.1%. The sensitivity of core biopsy was 94.64%, specificity 91.30% and accuracy rate was 94.87%. CONCLUSION: Fine Needle Aspiration has been found to be an extremely useful method for the diagnosis of lumps of breast. The accuracy and the sensitivity of diagnosis on fine needle aspiration cytology were high.

Primary bone lymphoma: a series from a cancer institute in Pakistan.

Primary bone lymphoma (PBL) is an uncommon tumour. Numerous studies have been reported from Western countries, but none from Southeast Asia. We reviewed a series of seven consecutive patients diagnosed and treated with PBL at our hospital between March 2002 and January 2007. All patients underwent chemotherapy with half receiving radiotherapy as their initial treatment. Six (84%) patients were male and 1 (16%) female with a median age of 33 (range: 23-85). All had diffuse large B-cell lymphoma (DLBCL) of bone except one (85 - M) who had chest wall cutaneous T-cell lymphoma with iliac blade involvement. The femur was the most frequently involved site (43%). Except for three patients that involved the lymph nodes, all patients had disease limited to bone. The 5-year overall survival rate was 43%. Although the number of patients was small, the data presented here revealed several characteristics of PBL.