Pearls & Oy-sters: Arteriovenous Malformation With Sinus Thrombosis and Thalamic Hemorrhage: Unusual Cause of Parkinsonism and Dementia.

Deep cerebral venous thrombosis is an uncommon condition, which usually produces headache, altered consciousness, and ocular movement abnormality. Parkinsonism occasionally occurs when there is basal ganglia involvement. We report a case of a 78-year-old man who presented with a rapidly progressive parkinsonism with poor response to dopaminergic therapy. The patient had bilateral and symmetrical hypokinesia, rigidity, and marked gait impairment with festination. Brain MRI showed bilateral thalamic hyperintensity on T2-weighted and FLAIR sequences, with right thalamic and intraventricular hemorrhage due to straight sinus thrombosis. Angiography revealed an arteriovenous malformation in the quadrigeminal cistern with afferent supply from the posterior cerebral arteries, as well as partial thrombosis of the vein of Galen and half of the straight sinus. No predisposing factor for thrombosis was found. Given the location and size of the malformation, and the substantial amount of thalamic and intraventricular hemorrhage, conservative management was decided, with slow but progressive gait improvement. The presence of deep cerebral venous thrombosis should be suspected in cases of rapidly progressive parkinsonism with cognitive decline. As in this case, thrombosis may be secondary to a deep arteriovenous malformation, a very rare occurrence that may require specific therapy.

Efficacy and Safety of Endovascular Treatment in Acute Tandem Carotid Occlusions: Analysis of a Single-Center Cohort.

INTRODUCTION: Acute ischemic strokes with tandem occlusions, which represent 10-20% of all ischemic strokes, have a particularly poor prognosis. Since emergent treatment of tandem lesions has not been specifically addressed in randomized trials, there is an absence of standardized management. OBJECTIVE: We sought to assess the efficacy and safety of acute endovascular treatment in stroke due to tandem occlusions in our center and compare the results with previous reports. METHODS: From a prospective registry we analyzed data of 99 consecutive patients (males: 77.7%, mean age ± SD: 67.5 ± 9.5 years) with stroke due to tandem occlusions who underwent treatment with emergent carotid stenting and intracranial mechanical thrombectomy. Successful recanalization was defined as a TICI score of 2b-3 and a good functional outcome was defined as a modified Rankin scale score ≤2 at 90 days. Symptomatic intracranial hemorrhage (sICH) was considered when associated with worsening on the National Institutes of Health Stroke Scale (≥4 points). RESULTS: A successful recanalization rate was achieved in 87.8 and 48.5% of the patients had a good functional outcome. sICH and mortality rates were 12.1 and 20.2%, respectively, and 21.2% of the patients received combined treatment with intravenous thrombolysis, which did not affect neither the prognosis nor the recanalization or sICH rates. The time from symptom onset to recanalization and the degree of recanalization were the main factors associated with prognosis and the occurrence of sICH. CONCLUSIONS: Our results suggest that endovascular treatment with emergent carotid stenting and intracranial thrombectomy in patients with acute stroke due to tandem occlusions is an effective and safe procedure.

Endovascular reconstruction of internal carotid artery dissection in patients with acute ischemic stroke using the Wingspan stent.

OBJECTIVE: The purpose of this study is to demonstrate our experience in endovascular reconstruction of carotid dissections using the Wingspan Stent System™ (Boston Scientific, Natick, MA, USA), a device we use because of its high radial force and its navigation in extreme curves. METHODS: We treated 11 consecutive patients with acute ischemic stroke due to carotid dissection with the Wingspan stent, in the cervical carotid artery. RESULTS: Functional evaluation revealed that 10 of the 11 patients were independent at 3 months post surgery and that the 11 stents used were found to be patent at the 6-month follow-up digital subtraction angiography (DSA). CONCLUSIONS: The Wingspan stent is an alternative to classic carotid stents and flow diverters for the treatment of cervical internal carotid artery (ICA) dissection associated with ectasias or large loops. The device remains patent over the long term and it is not associated with arterial wall complications.

Descripción de una serie hospitalaria de pacientes con fístula espinal / Description of a series of hospital patients with a spinal fistula

Introducción. Aunque las fístulas espinales suponen el 70% de las malformaciones arteriovenosas espinales, son una entidad infradiagnosticada. El shunt arteriovenoso produce una congestión vascular que da lugar a una mielopatía progresiva, en ocasiones irreversible si no se trata de forma precoz. Objetivo. Describir las características clinicorradiológicas de una serie de pacientes con fístula espinal. Pacientes y métodos. Se realizó una búsqueda retrospectiva de pacientes con diagnóstico de fístula espinal ingresados en el área de neurociencias de un hospital de tercer nivel asistencial. Resultados. Se identificaron 19 pacientes (7 mujeres y 12 varones) con una edad media de 56 años. La fístula espinal fue de tipo I en un 79% de los pacientes y la localización dorsal fue la más frecuente. La mayoría de los casos presentó un curso progresivo (90%). Un 74% de los pacientes se diagnosticó mediante resonancia magnética. En cuatro casos fue necesaria la realización de una angiografía para llegar al diagnóstico, y en uno de ellos se precisó una biopsia intraoperatoria. Se realizaron tres punciones lumbares, en dos de las cuales se objetivó pleocitosis linfocitaria e hiperproteinorraquia. El retraso diagnóstico medio fue de nueve meses. Se trató a un 79% de los pacientes, y de ellos sólo mejoró el 10%. Conclusiones. Ante una clínica sugestiva de fístula espinal, debe realizarse una angiografía espinal diagnóstica aunque el paciente estudiado pueda presentar características licuorales atípicas y normalidad en la resonancia magnética medular (AU)

Introduction. Although spinal fistulas account for 70% of all spinal arteriovenous malformations, they are an underdiagnosed condition. The arteriovenous shunt produces vascular congestion that gives rise to a progressive myelopathy, sometimes irreversible if it is not treated in the early stages. Aim. To describe the clinicoradiological characteristics of a series of patients with spinal fistulas. Patients and methods. A retrospective search was conducted for patients diagnosed with a spinal fistula who were hospitalised in the neuroscience area of a tertiary care hospital. Results. A total of 19 patients (7 females and 12 males) were identified, with a mean age of 56 years. The spinal fistula was type I in 79% of patients, and a dorsal location was the most frequent. Most of the cases (90%) presented a progressive course. Magnetic resonance imaging was used in the diagnosis in 74% of the patients. In four cases angiography was required to reach a diagnosis, and in one of them it was necessary to perform an intraoperative biopsy. Three lumbar punctures were performed, two of which revealed lymphocytic pleocytosis and high protein levels in cerebrospinal fluid. The average diagnostic delay was nine months. Seventy-nine per cent of the patients were treated and only 10% of them improved. Conclusions. When faced with a clinical picture suggestive of a spinal fistula, a diagnostic spinal angiography must be carried out, although the patient under study may present atypical cerebrospinal fluid characteristics and normal results in magnetic resonance imaging of the spinal cord (AU)

Analysis of endovascular treatment of ruptured aneurysms of the middle cerebral artery compared to other anatomical locations.

OBJECTIVE: The objective of this article is to compare the results of endovascular treatment of ruptured middle cerebral artery (MCA) aneurysms with ruptured aneurysms of other anatomic locations. METHODS: Fifty consecutive ruptured aneurysms of the MCA and 209 aneurysms at other anatomical locations were selected retrospectively. We compared epidemiological, clinical and radiological variables, prognosis and complications. RESULTS: The MCA aneurysms had a greater size and a poor dome/neck ratio. There were no significant differences in endovascular technique complications, occlusion rate or rebleeding between the two groups (p > 0.1). There were no significant differences in the mortality and number of dependent patients after one month. CONCLUSION: The endovascular treatment of ruptured MCA aneurysms without hematoma is as safe and effective as other aneurysm localizations. Complication rates, occlusion rates and rebleeding of ruptured MCA aneurysms are comparable to other locations.