Single-Institute Experience of Bypass Surgery for Complex Anterior Cerebral Artery Aneurysms: Paying Special Attention to the Spatial and Diameter Relationship Between the Efferent Arteries.

OBJECTIVE: To present a retrospective review of a single-institute experience with bypass surgery of complex anterior cerebral artery aneurysm. METHODS: Eight patients (5 females and 3 males; mean age, 34.2 years) with complex anterior cerebral artery aneurysms were treated with bypass. There were 3 precommunicating aneurysms, 1 communicating artery aneurysm, and 4 postcommunicating aneurysms (2 in A2 and 2 in A3). A3-A3 side-to-side in situ bypass was performed in 6 cases. A3-radial artery-A3 interpositional bypass was performed in 1 case with A3 segments located far apart, and A3-A3 transplantation was performed in 1 case with nonparallel aligned A3 segments. Of the 8 aneurysms, 3 were secured with proximal clipping, 1 was secured with distal clipping, 1 was secured with direct clipping, 1 was secured with isolation, and 2 were secured with embolization. RESULTS: Aneurysm obliteration was achieved in all cases. Only 1 in situ bypass from a smaller donor artery to a larger recipient artery failed with minor postoperative infarction. Intraoperative bleeding from the site of anastomosis occurred in 1 case during embolization. All patients had complete recovery with normal neurological function during follow-up at outpatient clinics. CONCLUSIONS: We established a simplified surgical algorithm for complex anterior cerebral artery aneurysms based on the geometrical and spatial relationship between efferent arteries. The reasons for bypass failure and hemorrhagic complication were also discussed.

Transarterial Embolization of Cavernous Sinus Dural Arteriovenous Fistulas with Ipsilateral Inferior Petrosal Sinus Occlusion via the Ascending Pharyngeal Artery.

BACKGROUND: Although the ipsilateral inferior petrosal sinus (IPS) is preferred for treatment of cavernous sinus dural arteriovenous fistulas (CS-dAVFs), this method is problematic if ipsilateral IPS is occluded. We describe our experience in treating CS-dAVFs with ipsilateral IPS occlusion via the ascending pharyngeal artery (APA). METHODS: Between January 2013 and June 2017, of 36 CS-dAVFs, 23 with ipsilateral IPS occlusion were identified. Clinical charts, procedural data, angiographic results, and follow-up data were retrospectively reviewed. RESULTS: Of 23 CS-dAVFs, 16 displayed a single or dominant feeding APA on cerebral angiography, of which 13 were treated via the APA initially. Fistulas were occluded successfully through the neuromeningeal trunk of the APA in 7 cases and through the superior pharyngeal branch of the APA in 3 cases. Glue leakage occurred in 2 cases via the superior pharyngeal branch of the APA, and superior pharyngeal branch rupture occurred during superselection of the microguidewire in 1 patient, who was treated by opening the occluded ipsilateral IPS. During the follow-up period, 12 of 13 patients had complete occlusion, and no cranial nerve palsy occurred. CONCLUSIONS: CS-dAVF with ipsilateral IPS occlusion can be treated via various methods. Embolization through the APA as an initial access is a reasonable choice.

[Hypoglossal canal dural arteriovenous fistulas treated with transvenous embolization:report of two cases and literature review].

Two cases of hypoglossal canal dural arteriovenous fistulas (HCDAVF) were reported. The clinical manifestation, radiological features, treatment and prognosis were reviewed. Both cases presented chemosis and pulsatile tinnitus. 3D-time-of-flight (TOF) magnetic resonance angiography (MRA) demonstrated abnormal high signal in hypoglossal canal. Cerebral digital subtraction angiography (DSA) showed that these HCDAVFs were supplied by multiple intracranial and extracranial arteries, and fistulas were located in hypoglossal canal. Fistulas were blocked by coils and Onyx-18 through transvenous approach, and the angiography after the embolism showed complete occlusion of fistula. No adverse events after treatment and no recurrence during the follow up were observed.

The feasibility and efficacy of endovascular treatment for very small or tiny ruptured paraclinoid aneurysms.

INTRODUCTION: The aim of this study was to evaluate the feasibility of endovascular treatment (EVT) for ruptured very small (≤5 mm) or tiny (≤3 mm) paraclinoid aneurysms of the internal carotid artery (ICA). METHODS: From November 2009 to April 2012, 32 ruptured paraclinoid aneurysms (very small, 23; tiny, 9) in 31 patients received EVT. Angiographic follow-up determined occlusion rates which were classified as total/near-total (95-100 %), subtotal (80-95 %), and partial (<80 %) occlusions. Follow-up data were retrospectively analyzed and categorized using the Modified Rankin Scale (mRS). RESULTS: Based on our paraclinoid aneurysm classification, 25 % (8) were classified as type I, 46.9 % (15) as type II, and 28.1 % (9) as type III. EVT was technically successful in 96.8 % (31), with coiling only in 12.5 % (4), balloon remolding coiling in 6.3 % (2), and stent-assisted coiling in 78.1 % (25). Total/near-total occlusion was immediately achieved in 34.4 % (11), subtotal occlusion in 37.5 % (12), and partial occlusion in 28.1 % (9). Follow-up angiography (mean, 9.9 ± 6.4 months) revealed total/near-total occlusion in 50 % (16) aneurysms, subtotal in 31.3 % (10), and partial occlusion in 18.8 % (6). At the end of clinical follow-up (mean, 14.8 ± 9.5 months), it revealed an mRS grade 0 in 38.7 % (12) of patients, grade 1 in 25.8 % (8), grade 2 in 22.6 % (7), grade 3 in 6.5 % (2), grade 4 in 3.2 % (1), and grade 5 in 3.2 % (1). CONCLUSION: EVT is feasible and effective for ruptured very small or tiny paraclinoid aneurysms of the ICA.

[Early management of intracranial ruptured vertebral dissecting aneurysms].

OBJECTIVE: To evaluate the early management of intracranial ruptured vertebral dissecting aneurysms. METHODS: Twenty-two patients with ruptured vertebral dissecting aneurysms were managed by various treatment modalities according to their conditions. One aneurysm was treated by proximal vertebral artery coiling, 15 aneurysms by aneurysm and parent artery coiling, and 5 aneurysms by stent-assisted coiling (4 of 5 by stent-within-a-stent technique), one by single double-stent. Bloody cerebrospinal fluid was drained by postoperative lumbar subarachnoid drainage in order to prevent cerebral vasospasm. RESULTS: All 22 cases were successful without bleeding complication during the operation.There was 1 case of early postoperative non-aneurysmal hemorrhage, 2 cases of posterial group cranial nerves palsies, 1 case harbored Hunt & Hess IV who gave up treatment. After follow-up for 3-18 months, there was no rebleeding and infarction. Twenty patients recovered well, except 1 having posterial group cranial nerves palsies. Fourteen cases were followed up by angiography. In 3 patients treated by stent-assisted coiling, DSA showed that aneurysms disappeared and loading vessel passed freely.DSA of 11 cases with aneurysm and parent artery coiling demonstrated complete obliteration of the dissection without aneurysm imaging. CONCLUSION: Early endovascular treatment of ruptured vertebral dissecting aneurysms is essential. The selective method of endovascular management according to the characteristics of aneurysm is safe and effective. Double stent-assisted coiling should be the first choice.

Contrast-enhanced multiple-phase imaging features in hepatic epithelioid hemangioendothelioma.

AIM: To investigate and review the contrast-enhanced multiple-phase computed tomography (CEMP CT) and magnetic resonance imaging (MRI) findings in patients with pathologically confirmed hepatic epithelioid hemangioendothelioma (HEHE). METHODS: Findings from imaging examinations in 8 patients (5 women and 3 men) with pathologically confirmed HEHE were retrospectively reviewed (CT images obtained from 7 patients and MR images obtained from 6 patients). The age of presentation varied from 27 years to 60 years (average age 39.8 years). RESULTS: There were two types of HEHE: multifocal type (n = 7) and diffuse type (n = 1). In the multifocal-type cases, there were 74 lesions on CT and 28 lesions on MRI with 7 lesions found with diffusion weighted imaging; 18 (24.3%) of 74 lesions on plain CT and 26 (92.9%) of 28 lesions on pre-contrast MRI showed the target sign. On CEMP CT, 28 (37.8%) of 74 lesions appeared with the target sign and a progressive-enhancement rim and 9 (12.2%) of 74 lesions displayed progressive enhancement, maintaining a state of persistent enhancement. On CEMP MRI, 27 (96.4%) of 28 lesions appeared with the target sign with a progressive-enhancement rim and 28 (100%) of 28 lesions displayed progressive-enhancement, maintaining a state of persistent enhancement. In the diffuse-type cases, an enlarged liver was observed with a large nodule appearing with persistent enhancement on CEMP CT and MRI. CONCLUSION: The most important imaging features of HEHE are the target sign and/or progressive enhancement with persistent enhancement on CEMP CT and MRI. MRI is advantageous over CT in displaying these imaging features.

A large functional somatostatinoma in the pancreatic tail: atypical CT appearances.

Somatostatinomas are extremely rare endocrine tumors, and those with diameters above 2 cm are reported to increase the risk of metastasis significantly. We report a case of a large functional somatostatinoma in the pancreatic tail without metastases. A 46-year-old woman with a history of recurrent mild upper abdominal pain and diarrhea for 10 months was admitted to our hospital. Multiple-phase spiral computed tomography revealed a 10 cm x 8 cm, ill-defined, elliptic mass in the body and tail of the pancreas. There was a slightly heterogeneous enhancement on hepatic arterial phase and isodensity to the pancreatic parenchyma with small dotted necrosis within the middle region of the mass on hepatic portal venous and parenchymal phase, with patent splenic vein, dilated collaterals at the splenic hilum and no dilated pancreatic duct, resembling a diffuse infiltration tumor. To the best of our knowledge, this is the first description of multiple-phase spiral computed tomography findings of a functional somatostatinoma in the pancreatic tail and the largest thus far on reported computed tomography, with some differences compared with the previous reports.

Scimitar syndrome with the left persistent superior vena cava.

Scimitar syndrome is a rare, complex congenital anomaly characterized by an anomalous connection of the pulmonary vein with the inferior vena cava (IVC). A persistent left superior vena cava (PLSVC) is another thoracic venous anomaly. We present a rare case with scimitar syndrome associated with the PLSVC. These variations were confirmed by magnetic resonance imaging (MRI) and computed tomography (CT). The typical features and the embryonic development of these variations are described. Radiological evaluations and clinical implications are discussed.

Bilateral internal carotid artery agenesis with artery compression of the brain parenchyma.

Bilateral internal carotid artery (ICA) agenesis is an extremely rare congenital anomaly. The most common type of collateral circulation is developed through the circle of Willis via the basilar and posterior communicating arteries. Both anterior circulations are usually supplied by enlarged posterior communicating arteries (PCOMs). We present an unusual case of bilateral ICA agenesis, which is associated with dolichoectatic left PCOM and left posterior cerebral artery (PCA) compression of left basal ganglia and thalamus. These complex cerebral and vascular anomalies can be noninvasively revealed and evaluated by CT and MR.

Application of turbo fluid-attenuated inversion-recovery MRI in evaluation of intraspinal tumors.

PURPOSE: Although fluid-attenuated inversion-recovery (FLAIR) magnetic resonance imaging (MRI) is widely applied to diagnose central nervous system diseases, its role in diagnosis of intraspinal tumors is unclear. In this study, we evaluated the potential clinical application of a turbo FLAIR sequence for imaging of intraspinal tumors. MATERIALS AND METHODS: Forty-eight consecutive patients with intraspinal tumors underwent MRI with turbo FLAIR and turbo spinal echo (TSE) sequences. Turbo FLAIR images were then qualitatively and quantitatively compared with T2-weighted TSE images. RESULTS: Turbo FLAIR images were evaluated as superior to T2-weighted TSE images for image artifact, extradural tumor conspicuity, and intradural extramedullary tumor conspicuity and detection. Intramedullary tumor conspicuity with turbo FLAIR was less than T2-weighted TSE. Similar capabilities in detection of extradural and intramedullary tumors were found between turbo FLAIR and T2-weighted TSE. Turbo FLAIR and T2-weighted TSE displayed similar normal spinal cord signal-noise ratio (SNR) and tumor-to-cerebrospinal fluid (CSF) contrast-to-noise ratio (CNR). In addition, turbo FLAIR yielded significantly higher tumor-to-CSF contrast than T2-weighted TSE. However, tumor SNR, tumor-to-normal spinal cord contrast and CNR with turbo FLAIR images were lower than those with T2-weighted TSE images. CONCLUSION: This study demonstrated (a) a superiority of turbo FLAIR to T2-weighted TSE in displaying and detecting intradural extramedullary tumors, (b) a superiority of turbo FLAIR to T2-weighted TSE in demonstrating extradural tumors, and (c) less usefulness in displaying intramedullary tumors with turbo FLAIR than with T2-weighted TSE.

[Three-dimensional CT angiography with volume rendering for the detection of intracranial aneurysms].

OBJECTIVE: To evaluate the value of three-dimensional CT angiography (3D-CTA) with volume rendering (VR) for the detection of intracranial aneurysm. METHODS: Axial CT images were obtained by helical CT scanning on 45 patients with intracranial aneurysms, 15 males and 30 females, aged 63.9 (33-79 years). The primitive data were entered into the Silicon Graphics O2 board to be treated. VR technique was adopted to reconstruct 3D-CTA imaging, aided by multiplanar reformation to obtain the total volume of aneurysm. Among the 45 patients 25 underwent DSA simultaneously, 21 underwent clamping of aneurysm, and 3 underwent GDC thrombosis. RESULTS: Fifty-nine intracranial aneurysms were detected in 45 patients by 3D-CTA, including 32 small aneurysms (< or = 5 mm). 3D-CTA with VR well demonstrated aneurysms and provided useful information including the site, shape, size and spatial relationship to the surrounding vessels and bony structures. CONCLUSION: A quick, reliable, and relatively noninvasive diagnostic tool for intracranial aneurysms, 3D-CTA with VR delineates the aneurysmal morphology in detail, and provides useful information for choosing and planning microsurgical or endovascular treatment.