A De Novo Sphenoparietal Dural Arteriovenous Fistula: Unveiling the Deceitful Culprit.

INTRODUCTION: Intracranial dural arteriovenous fistulas (DAVFs) are an uncommon pathology, and a sphenoparietal drainage pattern is certainly rare. We present a case of a de novo sphenoparietal DAVF in a prepubescent patient previously treated for a cerebellar arteriovenous malformation (AVM) 10 years before. CASE DESCRIPTION: A 10-year-old boy presented with worsening headaches for the past few weeks, swelling of the right side of face and eye, and chemosis and proptosis of the right eye. Of note, the patient had been treated successfully for a cerebellar AVM at 6 weeks of age with advanced imaging follow-up until 4 years previously demonstrating resolution of AVM and no other abnormalities whatsoever. Suspecting a carotid cavernous fistula, we performed angiography, which revealed a sphenoparietal DAVF with feeders from both the external and internal carotid artery. Despite sudden onset of symptoms and recent previously negative imaging, bony erosion was noted on computed tomography of the head and orbits. Successful treatment was achieved via transvenous embolization. CONCLUSIONS: This case highlights the different array of presentations that sphenoparietal fistulas may display. Even though most DAVFs are acquired, secondary lesions and spontaneous malformations must be considered in a differential diagnosis.

Stent-assisted coiling of cerebral aneurysms using the Y-stenting technique: a systematic review and meta-analysis.

BACKGROUND: Bifurcation aneurysms can be treated with stent-assisted coiling using two stents in a Y-configuration. We aim to investigate the angiographic and clinical outcomes of Y-stent constructs for the treatment of intracranial aneurysms. METHODS: A systematic review of PubMed, Ovid MEDLINE, and Ovid EMBASE databases was conducted based on PRISMA guidelines. The study selection was performed using the 'Ryyan' application. Our analysis included 18 studies with 327 patients. Inclusion criteria were: articles published from January 2000 to November 2017, English language, including cerebral aneurysms treated via Y-stenting, and ≥5 cases with radiographic/clinical outcomes. Technical notes, editorials, reviews, and animal studies were excluded. A random-effect meta-analysis was performed on angiographic and clinical outcomes, including aneurysm occlusion, modified Rankin Scale, neurological outcome, and procedure-related mortality. 95% CIs and event rates were estimated. Statistical heterogeneity was assessed using I2 statistics. RESULTS: The procedure-related good outcome rate was 92% and complete occlusion rate was 91%. The permanent neurological deficit rate was 4% and procedure-related mortality was 2%. The procedure-related stroke rate was 12%. A total of 28/146 (19%) patients had ruptured aneurysms. At long-term follow-up, overall stroke rate was 9% in patients with unruptured aneurysm. The mortality rate was higher in cases with ruptured aneurysms than in those with unruptured aneurysms (18% vs 0.8%; p<0.001). CONCLUSIONS: Y-stenting for bifurcation aneurysms yields a high rate of complete occlusion and low rates of mortality and stroke. Careful patient selection is needed.

Clinical Outcomes of Endovascular Thrombectomy in Tissue Plasminogen Activator versus Non-Tissue Plasminogen Activator Patients at Primary Stroke Care Centers.

BACKGROUND: The effect of intravenous tissue plasminogen activator (IV tPA) administration before endovascular intervention as compared to without at thrombectomy-capable low-volume centers on procedural aspects and patient outcomes has not been investigated. METHODS: Retrospective chart review was performed in all consecutive large vessel cerebrovascular accident patients treated with endovascular therapy at two select rural primary stroke centers between 2011 and 2015. Patients' data regarding age, sex, and medical history, as well as thrombus location by catheter-based cerebral angiography, postprocedural reperfusion status, and clinical outcomes were reviewed. The primary outcome measure of the study was a comparison of modified Rankin scale (MRS) at 90 days in patients' postendovascular thrombectomy with prior IV tPA administration versus those who underwent thrombectomy and did not qualify for preprocedural IV tPA. RESULTS: After application of the set inclusion and exclusion criteria, data of 46 out of 65 patients were analyzed. Twenty-three patients (50%) received IV tPA before thrombectomy and 23 patients did not qualify for IV tPA (50%). Successful recanalization (thrombolysis in cerebral infarction 2b/3) was achieved in 86% (20/23 patients) of thrombectomy patients without preprocedural IV tPA and 82% (19/23) of patients who received it (odds ratio [OR]: 0.03, confidence interval [CI]: 95% 0.062-0.16, P < 0.0001). MRS of 2 or less at 90 days was 43.4% (10/23) in patients with no preprocedural IV tPA and 39.1% (9/23) in the combined therapy group (OR: 0.84, CI: 0.26-2.70, P = 0.8). CONCLUSION: Patients undergoing endovascular thrombectomy for large vessel occlusion at select low-volume rural centers showed benefit from this treatment regardless of IV tPA administration. Clinical outcomes and complications at select low-volume thrombectomy-proficient centers are comparable to large volume comprehensive stroke centers as well as the landmark studies proving the efficacy of endovascular treatment.

Evaluation of Outcomes After Endoscopic Endonasal Surgery for Large and Giant Pituitary Macroadenoma: A Retrospective Review of 39 Consecutive Patients.

BACKGROUND: The endoscopic endonasal approach for pituitary neoplasms has shown similar efficacy compared with the microscopic approach. However, outcomes and complication rates with larger macroadenomas is not as well documented. This study addresses the efficacy and outcome of the fully endoscopic endonasal approach for large and giant pituitary adenomas. METHODS: Endoscopic endonasal resection was performed in 39 patients with large (>3 cm) or giant (>4 cm) pituitary macroadenomas. Outcomes were assessed using formal visual examinations, endocrine status, and neurologic examinations. Statistical analyses of multiple variables were addressed for correlation to visual, endocrine, and neurologic outcomes. RESULTS: Gross total resection of the pituitary macroadenoma was achieved in 22 of 39 (56.4%) patients based on postoperative magnetic resonance imaging. Higher Knosp grade was associated with near-total resection or subtotal resection (P = 0.0004). All patients had improved or stable visual symptoms. Time to diagnosis, preoperative visual deficit, and tumor size were not significant predictors of visual outcome. Of patients, 34 (87.1%) had a "good" endocrine outcome, whereas 5 did not. Among the 5 patients who did not have a good outcome, 1 had new hypopituitarism, and 4 required increased dosages of pharmacologic therapy. All patients with recurrent tumors had stable visual and good endocrine outcomes. Postoperative cerebrospinal fluid leak occurred in 4 patients; lumbar drainage resolved the leak in 3, and reoperation was performed in 1 patient. There were no new cranial nerve deficits, new neurologic deficits, or mortality. CONCLUSIONS: Endoscopic endonasal resection of large and giant pituitary macroadenomas is safe and efficient. Postoperative complications, including cerebrospinal fluid leak, are low. Surgical efficacy of the fully endoscopic endonasal approach for large and giant macroadenomas makes the technique a preferable option in this subset of patients.