Spontaneous thrombosis of a giant cavernous-carotid aneurysm with simultaneous ipsilateral complete parent artery occlusion: a rare phenomenon and review of the literature.

Cavernous-carotid artery (CCA) aneurysms represent about 3-5% of all intracranial aneurysms. Spontaneous thrombosis of a CCA aneurysm with simultaneous occlusion of its parent vessel is an extremely rare phenomenon with few reported cases in the literature offering different management strategies. A 54-year-old Asian female presented with a one day-history of painless left eye conjunctival injection, proptosis, and features of cavernous sinus syndrome (cranial nerve III, IV, V1, V2, and VI palsies). Imaging revealed a giant thrombosed CCA aneurysm measuring 3.6cmx3.4cm with complete thrombosis of the left cervical internal carotid artery (ICA) and adequate collaterals from the anterior and posterior communicating artery and branches of the left external carotid artery. Management was conservative with antiplatelet therapy and close clinical-radiological follow-ups. The outcome was satisfactory. Data in the literature on this condition is limited due to its exceedingly rare occurrence. The majority of patients do well via a conservative approach and surgery is rarely indicated. For clinically stable patients, especially those with adequate collateral circulation and tolerance to Balloon Test Occlusion, we advocate for a conservative approach and initiation of anti-platelet therapy to treat these patients. Emphasis is needed on close serial clinical-radiological surveillance in these cases to monitor the propagation of the thrombus as well as the development of new and/or enlarging pre-existing aneurysms in the contralateral ICA circulation.

Ruptured cerebral pseudoaneurysm in an adolescent as an early onset of COVID-19 infection: case report.

The clinical manifestations of coronavirus disease 2019 (COVID-19) are non-specific and multi-inflammatory. They vary from mild to severe manifestations that can be life-threatening. The association of SARS-CoV-2 infection and pseudoaneurysm formation or rupture of an already existing aneurysm is still unexplored. Several mechanisms may be involved, including the direct destruction to the artery by the viral infection or through the release of the inflammatory cytokines. We are presenting a case of a 13-year-old girl with a ruptured cerebral pseudoaneurysm of the left middle cerebral artery (M2 segment) with severe intracerebral hemorrhage as the earliest manifestation of COVID-19 infection.

Occipital Encephalocele: Cause, Incidence, Neuroimaging and Surgical Management.

AIMS: To review and present the current knowledge of incidence, signs and symptoms, diagnosis and treatment of the occipital encephalocele. BACKGROUND: Encephalocele (E) is a defect of the neural tube that refers to congenital malformations featured by skull defect and dura with extracranial spread of intracranial structures. Occipital encephalocele (OE) are the most common form of this congenital disorder and are manifested as a swelling of different sizes over the occipital bone in the midline. Proper diagnosis and treatment is highly important in the management of this congenital malformation of brain. OBJECTIVE: To review and present the current knowledge of incidence, signs and symptoms, diagnosis and treatment of the occipital encephalocele. METHODS: We conducted a search of case reports or case-series of patients by the use of electronic databases: Pub Med, Medline, Index Medicus, Scorpus. The key words were: encephalocele, occipital encephalocele, neural tube defect, congenital malformation. The search was updated to December 31, 2018. Papers published in English were the only source of information. RESULTS: Occipital encephalocelle are more frequent in females than in males. The incidence is between 1 in 3000 to 1 in 10,000 live births; approximately 90% of them involve the midline. Magnetic resonance imaging is the method of choice in diagnosis and surgery is the best option for the treatment of OE. Overall morbidity and mortality is still high in spite of advenced surgical management, but have been significantly improved in recent years thanks to sophisticated highresolution imaging, adequate and proper surgical treatment and decent post-operative care. CONCLUSION: Occipital encephalocele is the most common form of encephalocele. The diagnosis is mostly based by the use of neuroimaging techniques. Operation is the best option for treatment. Overall morbidity and mortality is still high, but have been significantly improved in recent years thanks to sophisticated high-resolution imaging, adequate and proper surgical treatment and decent post-operative care.

Traumatic carotid-cavernous fistula in a multiple facial fractures patient: case report and literature review.

Carotid-cavernous fistula (CCF) is a pathologic communication between internal carotid artery (ICA) and cavernous sinus (CS). CCF occurs most commonly in association with craniofacial trauma. Traumatic CCFs are very rare, occurring in 0.17-0.27% of craniomaxillofacial trauma cases. We present a case of the patient treated for multiple facial fractures, who developed symptoms of CCF with several days latency and was successfully treated by endovascular occlusion of ICA. Anatomy of CS, pathophysiology of CCFs and treatment options are concisely reviewed.

Ultrasound and magnetic resonance imaging in prenatal diagnosis of sacrococcygeal teratoma--case report.

INTRODUCTION: Fetal tumors are relatively rare and the early prenatal diagnosis enables the prediction of possible complications and decision for appropriate treatment. This paper deals with the role of ultrasonography and magnetic resonance imaging in the early prenatal diagnosis of sacrococcygeal teratoma. CASE REPORT: A 21-year-old primigravida was found to have a large sacrococcygeal tumor measuring 25 x 30mm, presented mainly as a solid mass, when she underwent the initial ultrasound examination on the first day of 19th week of gestation. There were no other associated anomalies. The second ultrasound examination was obtained after 6 days and revealed that the tumor had doubled its size. The prominent enlargement raised suspicion of immature sacrococcygeal teratoma and thus, fetal magnetic resonance imaging was performed in the 20th gestation week. The examination showed a crococcygeal teratoma presented as a large solid mass with small microcystic areas, the largest diameter being 60mm, completely externally positioned with no intra-pelvic extension. Rapid tumor growth posed a threat to the fetal circulation and it was the main reason when opting for the termination of pregnancy at 20 weeks of gestation. Pathohystological examination confirmed the diagnosis of immature sacrococcygeal teratoma. DISCUSSION: In the prenatal period the magnetic resonance imaging of a fetal tumor initially diagnosed by ultrasound examination is an additional part of diagnostic procedure, and it is not contraindicated during pregnancy. Magnetic resonance imaging improves the delineation of the tumor. The prompt prenatal diagnosis of sacrococcygeal teratoma, as well as the detection of possible associated anomalies, is important for the pregnancy management, prediction of possible complications and choice of appropriate treatment. CONCLUSION: Ultrasonography and magnetic resonance imaging are noninvasive, compatible and complementary diagnostic modalities in evaluation of sacrococcygeal teratoma in prenatal period.

Characteristics of a pMOSFET suitable for use in radiotherapy.

The paper describes dose response and signal fading of Al-gate p-channel (metal oxide semiconductor field effect transistors) MOSFETs in the range of gamma radiation doses used in radiation therapy. MOSFETs with thicknesses of the gate oxide layer of 1 µm and 400 nm were used. The response was characterized by the threshold voltage shift and was studied as a function of the absorbed dose and time after irradiation. The dosimeters with the 1-µm-thick oxide layer can be effectively used for measuring doses in the 0.1-5 Gy range. The dosimeters with 400-nm-thick oxide layer are suitable for measuring doses above 5 Gy. Both types of the dosimeters retain dosimetric information for long periods of time.

[Occlusion of maxillary artery in treatment of trigeminal neuralgia].

INTRODUCTION: This paper deals with a treating method of trigeminal neuralgia classified so far as idiopathic neuralgias and treated conservatively. The study was aimed at proving the compression of peripheral branches of N. trigeminus in those patients by vascular elements of A. maxillaris within the bone-ligament space of the scull and the face base. MATERIAL AND METHODS: The study sample consisted of 76 patients having trigeminal neuralgia. The compression was proved by clinical examination, by angiography and electrophysiological investigations. Endovascular occlusion of A. maxillaris is the original method and it was carried out in selected patients. RESULTS: This method was applied in 76 patients. Embolisation was done in 71 patients by using occlusion spiral and gelfoan was used in 3 patients. Externa carotid artery ligation was done in 2 cases. CONCLUSION: The effect of absolute improvement has been achieved and verified by electrophysiological method and subjective assessment of the patients.

Management of diffuse hepatocellular carcinoma (≧ 10 Lesions) with doxorubicin-loaded DC beads is a safe and effective treatment option.

BACKGROUND: Multinodular hepatocellular carcinoma (HCC; ≥ 10 lesions) has been considered a controversial indication for transarterial chemoembolization (TACE) based on the extent of disease and the belief that no clinical benefit can be achieved. The aim of this study was to assess the safety and efficacy of chemoembolization with doxorubicin-eluting beads (DEBDOX) in the treatment of multinodular HCC. PATIENTS AND METHODS: A 503-patient prospective multinational DC Bead registry database from 6/2007 to 2/2010 identified 176 patients treated for HCC with DEBDOX. RESULTS: There were 42 patients with multinodular HCC compared to 134 with non-multinodular HCC. After a median follow-up of 12 months, the multinodular group response rate according to modified RECIST criteria was 56% and median overall survival was 7.6 months, compared to 57% and 15 months in the non-multinodular group (p = 0.08). CONCLUSIONS: Multinodular HCC represents a more advanced stage of disease; however, DEBDOX treatment is safe and effective when compared to historical controls and current best systemic therapy. Continued hepatic arterial therapy and evaluation is needed in this clinical subset to further confirm these results.

Hepatic arterial infusion of doxorubicin-loaded microsphere for treatment of hepatocellular cancer: a multi-institutional registry.

BACKGROUND: Hepatic intra-arterial therapy for unresectable hepatocellular cancer (HCC) has been shown to improve overall survival, but can have significant toxicity. A recent prospective randomized controlled trial demonstrated superior response rates and significantly less morbidity and doxorubicin-related adverse events with drug-eluting beads with doxorubicin (DEBDOX) compared with conventional chemoembolization. The aim of this study was to confirm the efficacy of DEBDOX for the treatment of unresectable HCC. STUDY DESIGN: This open-label, multicenter, multinational single-arm study included 118 intermediate-staged HCC patients who were not candidates for transplantation or resection. Patients received DEBDOX at each treatment. Complications and response rates to treatment were analyzed. RESULTS: There were 118 patients who received a total of 186 DEBDOX treatments with a median total treatment dose of 75 mg (range 38 to 150 mg), and median overall total hepatic exposure of 150 mg (range 150 to 600 mg). Five lesions were targeted, with a median size of 5.3 cm (range 1.0 to 16.9 cm). Severe adverse events related to liver dysfunction were seen after 4% of treatments. Overall survival was a median of 14.2 months (range 5 to 30 months), with progression-free survival of 13 months and hepatic-specific progression-free survival of 16 months. Okuda class less than 1 at time of treatment, reduction of alpha-fetoprotein of 1,000 ng/mL at the first post-treatment evaluation, delivery of more than 200 mg doxorubicin, and less than 25% liver involvement were all predictors of favorable overall survival assessed by multivariable analyses. CONCLUSIONS: Hepatic intra-arterial injection of DEBDOX is safe and effective in the treatment of HCC, as demonstrated by a minimal complication rate and robust and durable tumor response.

[Preoperative identification of bleeding site caused by angiodysplasia of the small bowel by means of selective arteriography and application of methylene blue].

BACKGROUND: Small bowel hemorrhages are rare and account for 2-10% of all gastrointestinal bleedings. In case that surgery is necessary, identification of the bleeding site is the most important problem. CASE REPORT: We presented here the case of a 65-year old man, admitted for urgent care of massive lower gastrointestinal bleeding. After reanimation and normalization of vital parameters, selective arteriography was done. A contrast extravasation site was identified at the level of jejunal branches of a. mesenterica superior and labeled by means of methylene blue application. Immediately after we performed conservative resection of the labeled jejunal loop in 10 cm length and terminoterminal anastomosis. The preparation was sent for histopathologic examination--small bowel angiodysplasia was identified. The patient was monitored in three month intervals in the next two years and new bleeding events were not observed. CONCLUSION: Bleeding caused by small bowel angiodysplasia is a significant diagnostic problem in cases in whom urgent surgery is required. Combined preoperative selective arteriography and methylene blue application make possible precise identification of the bleeding site as well as conservative small bowel surgery, avoiding thus the risk and danger of malabsorption syndrome.

Presence of anatomical variations of the circle of Willis in patients undergoing surgical treatment for ruptured intracranial aneurysms.

BACKGROUND/AIM: The presence of aneurysmal changes on the brain blood vessels has been subject to numerous research. This study investigated the relation between ruptured aneurysms and anatomical configuration of the Circle of Willis, with the purpose to obtain an insight into their mutual connection. METHODS: The analysis included 114 patients suffering from ruptured intracranial aneurysms. Preoperative cerebral angiography was performed and compared with the intraoperative findings in order to attain a precise insight into morphological changes occurring on the circle of Willis. RESULTS: The prevalence of asymmetrical Willis in the whole group of patients was 64%. Within the group of patients suffering from multiple aneurysms, the presence of asymmetrical Willis' circle was 75.7%. The highest incidence of the asymmetrical Circle of Willis was found among patients with aneurysmal rupture detected at the anterior comunicative artery (ACoA) site (72.7% among cases with solitary and 100% among those with multiple aneurysms). Morphological changes on the A1 segment of ACoA were observed in 50 (44%) cases, with higher incidence found on the right side (60%). When comparing location of ruptured aneurysms between genders, a statistically significant prevalence of the ruptured aneurisms on ACoA was present in men, whereas women showed higher incidence of ruptured aneurysms on interior cartid artery (ICA) site (p < 0.01). The linkage between aneurysms with hypoplasia of the A1 segment of ACA and decreasing of the angle at which segments A1 and A2 join suggests the relationship between their onset, corresponding configuration type of Willis and subsequent hemodynamic changes. CONCLUSION: High incidence of asymmetry of Willis circle in the group of patients with ruptured aneurysms imply association of asymmetrical configuration and disorder in haemodynamic relations with forming and rupture of intracranial aneurysms.

Transarterial chemoembolisation (TACE) using irinotecan-loaded beads for the treatment of unresectable metastases to the liver in patients with colorectal cancer: an interim report.

BACKGROUND: Following failure of standard systemic chemotherapy, the role of hepatic transarterial therapy for colorectal hepatic metastasis continues to evolve as the experience with this technique matures. The aim of this study to gain a better understanding of the value of drug eluting bead therapy when administered to patients with unresectable colorectal hepatic metastasis. METHODS: This was an open-label, multi-center, single arm study, of unresectable colorectal hepatic metastasis patients who had failed standard therapy from 10/2006-10/2008. Patients received repeat embolizations with Irinotecan loaded beads(max 100 mg per embolization) per treating physician's discretion. RESULTS: Fifty-five patients underwent 99 treatments using Irinotecan drug eluting beads. The median number of total treatments per patient was 2(range of 1-5). Median length of hospital stay was 23 hours(range 23 hours - 10 days). There were 30(30%) sessions associated with adverse reactions during or after the treatment. The median disease free and overall survival from the time of first treatment was 247 days and 343 days. Six patients(10%) were downstaged from their original disease status. Of these, four were treated with surgery and two with RFA.Neither number of liver lesions, size of liver lesions or extent of liver replacement(25%) were predictors of overall survival. Only the presence of extrahepatic disease(p = 0,001), extent of prior chemotherapy (failed 1st and 2nd line vs > 2 line failure)(p = 0,007) were predictors of overall survival in multivariate analysis. CONCLUSION: Chemoembolization using Irinotecan loaded beads was safe and effective in the treatment of patients as demonstrated by a minimal complication rate and acceptable tumor response.

Difficulties in establishing a timely diagnosis of pulmonary artery sarcoma misdiagnosed as chronic thrombo-embolic pulmonary disease: a case report.

INTRODUCTION: Pulmonary artery sarcomas are rare neoplasms that are often confused with chronic thrombo-embolic disease, as both can have similar clinical and imaging presentation. CASE PRESENTATION: In this report, we present a case of a 50-year-old man initially diagnosed with chronic thrombo-embolic pulmonary disease, but who was later found to have pulmonary artery sarcoma with poor survival prognosis. We review the clinical and imaging characteristics of the two diseases and discuss the difficulties in establishing a timely diagnosis. CONCLUSION: Similar clinical features and imaging presentation of pulmonary artery sarcoma and chronic thrombo-embolic pulmonary disease make definitive diagnosis difficult. This case report also illustrates and emphasizes that in any case with no predisposition factors for embolism, no evidence of deep venous thrombosis and pulmonary emboli, and inadequate relief of symptoms with anticoagulation, an alternative diagnosis of pulmonary artery sarcoma should be considered. If pulmonary artery sarcoma is diagnosed late in the course of the disease, there is usually a poor survival outcome.

Endovascular treatment of hereditary hemorrhagic telangiectases of the tongue.

Hereditary hemorrhagic telangiectasia, also known as Osler-Weber-Rendu disease, is an autosomal dominant disorder involving vascular abnormalities of various organs. Telangiectases are frequently observed, predominantly on the nasal and oral mucosa. We present a case a of 53-year-old man with the tonge hemorrhagic telangiectases and epistaxis. Selective catheterization and embolization of the right lingual artery led to size redution and no bleeding from tongue telangiectases.