Our Experience of Eight Patients with Dural Arteriovenous Fistula's at Foramen Magnum with Respect to Presentation, Angioarchitecture, and Endovascular Treatment Outcomes.

Background Dural arteriovenous fistulas (DAVFs) around foramen magnum (FM) with peri medullary venous drainage, are uncommon and have wide spectrum of presentation. Literature about this lesion is sparse. We intent to analyze and report our experience with these cases with respect to presentation, evaluation, and endovascular treatment outcomes. Materials and Methods All the eight patients who were diagnosed with DAVFs at FM and treated with transarterial embolization using ethylene viny alcohol were included in this study. Clinical record sheets, radiological, and angiographic data of these patients were retrieved from our departmental database. Results Duration of symptoms ranged from 1 day to 3 years. Presentation with progressive ascending sensory symptoms and weakness ( N = 4), acute headache ( N = 2) acute quadriplegia ( N = 1), and right ear bruit ( N = 1) was seen. Exclusive feeders from occipital artery (OA) and vertebral artery (VA) were seen in two and four patients, respectively. Dual feeders from a combination of ascending pharyngeal artery and VA; from a combination of OA and VA were seen in one patient each. The exclusive venous drainage to spinal peri medullary veins ( N = 3), brain stem peri medullary veins ( N = 1), and both combined ( N = 4). Two patients had a draining vein aneurysm. Complete obliteration of fistula was achieved in all patients. Complete resolution of symptoms was seen in six patients; two patients had significant improvement. Conclusion The clinical presentation of dural AVF at foramen magnum is wide ranging and these lesions can be treated effectively and safely by transarterial embolization. Duration of symptoms strongly influences the final patient outcome.

Delayed Complication of a Retained Microcatheter during Neurovascular Intervention Presenting as Limb Ischemia: A Case Report and Literature Review.

Background: Retained microcatheter after endovascular embolization of brain vascular malformation lesions poses serious risks. Long-term complications have been sparsely described in the literature. Material and Methods: We report a rare complication of limb ischemia following the complete migration of a retained microcatheter. The literature review was performed using the mesh terms "complications," "endovascular interventions," "retained catheter," and "Onyx" on PubMed. Result: The patient had undergone embolization of dural AV fistula (DAVF) at the craniovertebral junction (CVJ) 5 years before presentation using ethylene vinyl alcohol (Onyx). He presented with acute right lower limb ischemia. Emergency endovascular removal of the catheter and thrombus aspiration were done. Conclusion: Migrated catheters confined within vascular lumen can be effectively treated by an endovascular approach. Patient education about complications may help in seeking medical care for timely intervention.

Our Experiences With Neurovascular Intervention at King Edward VII Memorial Hospital, Mumbai 1976-1996.

The Department of Neurosurgery at KEM Hospital, Seth G S Medical College, Mumbai, was founded by Dr H. M. Dastur in 1956. The department from its inception performed all diagnostic Neuro-Radiological procedures, angiography, ventriculography, pneumo-encephalography, and myelography. In 1976 transfemoral cerebral angiography was started by Dr S K Pandya. In 1978 he started performing interventional procedures. In 1980, Dr Anil Karapurkar went for training in Neuro-Intervention to Nancy, France, under Prof. Luc Picard. Thereafter all neurointerventions, cranial, and spinal, were performed routinely.

Rare Complication of Carotid Stenting: New-Onset Refractory Status Epilepticus: A Study of Five Patients.

INTRODUCTION: New-onset refractory status epilepticus (NORSE) is uncommon and almost 50% of cases are cryptogenic. We report the rare development of NORSE following carotid artery stenting (CAS), a procedure which is increasingly being used to treat the carotid stenosis. MATERIALS AND METHODS: Patients who developed NORSE following CAS for the prevention of stroke over a period of 5 years were analyzed retrospectively. The degree of internal carotid artery stenosis (ICA) was estimated as per the NASCET criteria. RESULTS: We analyzed five patients (age: 56-83 years). NORSE was reported within 30 min to 14 days post-CAS. Status epilepticus was focal in two patients, generalized in two, and one had nonconvulsive status epilepticus. All patients were treated with multiple antiepileptic drugs. Four patients recovered and survived and one succumbed. Two patients had comorbid hypertension and two had diabetes and hypertension. Four patients had hemiparesis due to the contralateral middle cerebral artery territory infarction and one patient had syncope. Two patients had postinfarction gliosis. CONCLUSIONS: We report a new cause of NORSE, following CAS. Stroke resulting in gliosis and cerebral hyperperfusion syndrome are the proposed mechanisms.

Acute Ischemic Stroke Treatment Using Mechanical Thrombectomy: A Study of 137 Patients.

BACKGROUND: Mechanical thrombectomy (MT) is the most effective treatment in large vessel occlusion (LVO). We have analyzed our initial experience of MT of 137 patients in anterior circulation (AC) and posterior circulation (PC) LVO using Solitaire stent retriever device. METHODS: Retrospective cohort analysis of 112 AC and 25 PC acute ischemic strokes was done considering various baseline characteristics, risk factors, National Institute of Health Stroke Scale (NIHSS) change, revascularization rate, complications, and functional outcome at 3 months using modified Rankin score. RESULTS: Out of 137 patients, occlusion was found in M1 segment (44.5%), carotid T occlusion (37.2%), and basilar artery (18.2%). Atrial fibrillation was important risk factor for Carotid T occlusion. 50.4% patients received intravenous thrombolysis. Baseline mean NIHSS in AC was 15.5 (±4.32), and PC was 19 (±5.5). Tandem lesions were noted in 14.6%. There was significant difference in mean door-to-needle time for AC and PC (220 ± 80.6 and 326 ± 191.8 min, respectively). Mean time to revascularization for AC (39.5 ± 14.1) and PC (42.2 ± 19.4) was similar. Procedural success (modified thrombolysis in cerebral infarction ≥2b) observed in AC and PC was 92.9% and 84%, respectively (P = 0.154). NIHSS at admission between 5 and 15 and immediate postprocedure NIHSS improvement >4 was associated with significant better clinical outcome at 3 months. Overall complication rate was about 15.3% including symptomatic intracranial hemorrhage in 8.1% and 6.6% deaths. CONCLUSION: MT is safe treatment and equally effective for both AC and PC LVO. With careful patient selection, clinical outcome in PC was comparable to AC despite delayed presentation and higher baseline NIHSS.

Thoracic Hemangioma From Rib Presenting as Compressive Paraparesis in a Young Adult: A Treatment Dilemma.

STUDY DESIGN: A case report. OBJECTIVE: To describe the presentation of compressive paraparesis as a result of thoracic rib hemangioma in a young adult and its nonsurgical management. SUMMARY OF BACKGROUND DATA: Hemangiomas are rare bone tumors and those arising from rib are rarer. Only about 50 such cases have been reported in literature so far. METHODS: A 21-year-old male student, presented to us with a 6-week history of progressive weakness in both lower limbs and loss of bowel bladder control. Patient gave history of being operated for left periscapular tumor treated with wide excision and proven with biopsy to be a hemangioendothelioma (benign but locally aggressive hemangioma variant) a year ago. RESULTS: New radiograph of the chest showed an expansile lesion of left fifth rib and magnetic resonance image showed a tumor of left dorsal thoracic wall with AV malformation causing compressive thoracic myelopathy at T5 level vertebrae. We planned for immediate decompression surgery for spine along with excision of tumor with the help of a thoracic surgeon. However, on preoperative digital subtraction angiography, the tumor was found to be highly vascular with high risk of intraoperative bleeding and morbidity. So, the plan was revised and the patient underwent digital subtraction angiography, followed by embolization by an expert interventional neurosurgeon. The patient showed signs of recovery within a week. Lower limb power improved from grade 2 to 3/5 to grade 4 to 4+/5. The patient became ambulatory with single stick at 3-month follow-up; he was a nonwalker to start with. At 2 years plus follow-up, the patient fully recovered and walks without stick. CONCLUSION: This unique case brings to light the dilemma a spine surgeon sometimes faces. A case that warranted immediate surgical intervention based on clinical findings was treated with interventional fibrin glue embolizations with excellent results. LEVEL OF EVIDENCE: N/A.

Angiolipoma of the right inferior colliculus: a rare central cause of hearing loss and limb ataxia.

Intracranial angiolipomas are rare entities and are infrequently symptomatic. These benign lesions are adherent to the surrounding neurovascular structures as they share the same blood supply, which limits their resectability, and impose a possibility of persistence of symptoms. However, due to recent advancements in the neuro-radiological fields and microneurosurgical techniques it has been possible to localise precisely and excise these lesions with low morbidity and mortality. The authors present an interesting rare case of intracranial angiolipoma of the right inferior colliculus situated in the quadrigeminal plate cistern. The patient had presented with ipsilateral hearing loss and upper limb ataxia. Interesting clinical findings, neuro-imaging studies and peroperative features are presented and discussed along with a brief review of the literature.