Management of scalp arteriovenous malformations: a rising trend towards percutaneous direct puncture embolization technique-our experience.

BACKGROUND: Scalp arteriovenous malformations (AVMs), or cirsoid aneurysms of the scalp, usually present with troublesome symptoms and cosmetic disfigurement. Endovascular/percutaneous embolization has evolved as a sole treatment method or adjunct to surgical excision in the management of scalp AVMs with an excellent outcome. PURPOSE: To discuss minimally invasive techniques for treating scalp AVMs as well as to highlight the role of embolization before surgery. MATERIAL AND METHODS: This is a retrospective study of 50 patients with scalp AVM who underwent embolization (percutaneous/endovascular) during 2010-2019 at a tertiary care center. n-butyl cyanoacrylate (n-BCA) was used as an embolizing agent in all the cases and the patients were followed up at three- and six-month intervals with Doppler evaluation. RESULTS: A total of 50 patients were included in the study. The occipital region was the most common location; 82% were Schobinger class II lesions and 18% were class III lesions. Thirteen patients had small-sized AVMs and 37 patients had large-sized AVMs. Post-embolization surgery was performed in 36 patients. Of the patients, 28 underwent percutaneous embolization, 20 underwent endovascular embolization, and two underwent both to achieve complete embolization of the lesion. The number of percutaneous procedures increased in the latter half of the study period as the safety and efficacy of the technique were established. No major complications were seen in this study. CONCLUSION: Embolization of scalp AVMs is a safe and effective technique and can be used in isolation for small lesions and as an adjunct procedure to surgery for large-sized lesions.

Blood in the Brain on Susceptibility-Weighted Imaging.

Intraparenchymal brain hemorrhage is not uncommon and results from a wide variety of causes ranging from trauma to tumor. Many a time, it is not possible to determine the exact cause of non-traumatic hemorrhage on conventional magnetic resonance imaging (MRI). Susceptibility-weighted imaging (SWI) is a high-resolution (3D) gradient-echo sequence. It is extremely sensitive to the inhomogeneity of the local magnetic field and highly useful in identifying the small amount of hemorrhage, which may be inapparent on other MR pulse sequences. In this review, we present different pattern of an intra-parenchymal brain hemorrhage on SWI with emphasis on differential diagnosis.

Endovascular management of pulmonary arteriovenous malformations presenting as multiple brain abscesses.

Pulmonary arteriovenous malformations (PAVMs) are rare vascular lesions characterised by abnormal connections between the pulmonary artery and vein bypassing the pulmonary capillary bed and causing right-to-left shunt. Paradoxical embolism is known to occur in these cases, leading to inoculation of septic focus in the systemic circulation. We report a case of multiple PAVMs who presented clinically with seizures and altered sensorium. On radiological work-up, multiple brain abscesses and large PAVMs were evident. The patient was successfully treated by endovascular embolisation of the PAVMs using a vascular plug and multiple coils. The patient showed complete clinical recovery and resolution of brain abscesses on follow-up.

Repeated aspiration and sclerotherapy to manage recurrent spinal epidermoid cyst.

Spinal epidermoid cysts are rare lesions and epidermoid cyst in intramedullary location is even rarer. Surgical excision is the mainstay of treatment; however, in cases of recurrence, repeat surgery becomes quite difficult. Treatment of recurrent intramedullary epidermoid cyst by surgery alone is a challenge. We managed one such rare case with repeated aspiration and sclerotherapy. Here, we have highlighted hypertonic saline sclerotherapy as a promising tool to treat recurrent spinal epidermoid cysts.

Complete resolution of long pedunculated thrombus of the proximal ascending aorta following conservative management: an interesting case.

We report a case of a 60-year-old woman who presented clinically with symptoms of acute embolic stroke. On workup with MRI, carotid Doppler and subsequent CT angiography, a long pedunculated mobile thrombus was seen with the base of the thrombus attached to the ascending aorta and the tip protruding into the left common carotid artery. She was advised urgent cardiovascular surgery consultation; however, she preferred medical management over surgery. She was put on dual antiplatelet therapy. On follow-up after 6 months, there was complete resolution of the thrombus.

Posterior Cerebral Artery Aneurysms: Parent Vessel Occlusion Being a Viable Option in the Era of Flowdivertors.

BACKGROUND AND PURPOSE: The purpose of this study is to evaluate posterior cerebral artery (PCA) aneurysms along with the efficacy, safety, procedural, and clinical outcome of the endovascular management of these aneurysms. We studied different techniques of endovascular treatment such as selective aneurysmal coiling, parent artery occlusion, and stent-assisted coiling in PCA aneurysms. METHODS: From 2010 to 2017, 11 patients (8 females, 3 males) harboring a PCA aneurysm were treated via an endovascular approach. Seven of eleven aneurysms were saccular in nature; four were fusiform shaped. All aneurysms were treated using detachable coils either by selective obliteration of the aneurysm sac or by parent artery occlusion. In one patient, stent-assisted coiling of PCA aneurysm was done, and in one patient, flowdivertor along with few coils used to treat the aneurysm. RESULTS: Five of the eleven aneurysms were successfully treated with preservation of the parent artery, and the other six were treated with aneurysm coiling along with parent vessel occlusion. Of the six where parent vessel occlusion was done, one developed transient hemiparesis which recovered on follow-up and none developed significant disabling vision abnormality. No mortality was noted. CONCLUSION: Aneurysms of the PCA are rare compared with other locations in the intracranial circulation. These aneurysms can effectively be treated by permanent occlusion of the parent artery even in this era of flowdivertors - however, in these cases, thorough knowledge of PCA segmental anatomy is crucial in order to select the site of occlusion and to avoid major neurological deficits.

Getting More Out of Follow-up Three-Dimensional Time-of-Flight Magnetic Resonance Angiography in Endovascularly Treated Intracranial Aneurysms.

BACKGROUND: We retrospectively re-evaluated follow-up three-dimensional (3D) time-of-flight (TOF) magnetic resonance angiography (MRA) in patients with aneurysms treated with coiling at our Institute. AIMS: To document the type and frequency of postcoiling residue patterns as seen on follow-up MRA and to document their evolution with time where a further follow-up MRA was available. To assess the implications of the location of the aneurysm on residue and recurrence. SUBJECTS AND METHODS: 3D TOF MRA for 104 aneurysms were evaluated for residue size and residue pattern. Mainly, three residue patterns were identified. The aneurysms were allocated to different groups depending on the location. Multiple MRA studies were available in subgroup 1* and subgroup 2* where the residue growth or reduction and pattern change was noted and residue growth rates were calculated. RESULTS: Collectively 54 (51.92%) aneurysms showed occlusion (pattern 1 and 1A), 31 (29.81%) showed neck residue (pattern 2A, 2B and 2C) and 19 (18.27%) showed recurrence (pattern 3A, 3B and 3C, residue size >3 mm) at the last follow-up MRA. Type 2A/3A patterns were more common. In terms of residue and recurrence, the distally located aneurysms (Group 3) appeared to do well. For those showing growing residue/recurrence, the average growth rate was calculated at 0.094 mm/month and 0.15 mm/month, respectively, for subgroup 1* and subgroup 2*, although the difference was not statistically significant. With longer follow-up the persisting and growing residues from both the subgroups, not warranting early re-treatment, showed a low growth rate at approximately 0.05 mm/month. CONCLUSIONS: TOF MRA helps in identifying different residue patterns in coiled aneurysms. Serial follow-up MRA appears useful in showing the pattern and size changes in the residual aneurysm. Although more work is required in this regard, calculation of aneurysm/residue growth rate may be useful in prognostication and in scheduling further follow-up or retreatment. The risk factor related to the location of the aneurysm warrants further study.

Detection and Evaluation of Intracranial Aneurysms in the Posterior Fossa by Multidetector Computed Tomography Angiography - Comparison with Digital Subtraction Angiography.

INTRODUCTION: Posterior fossa hemorrhages are not so frequent but as posterior cranial fossa space is narrow and has many vital structures, even a small amount of bleed can lead to compression of brain stem and serious consequences. Identification and planning management of cause of bleed requires angiogram. Digital subtraction angiography (DSA) being invasive modality but is gold standard, so noninvasive computed tomography angiography (CTA) is compared to detect cause of bleed in the posterior fossa in this study. MATERIALS AND METHODS: From January 2017 to October 2018, all patients with posterior fossa bleed who underwent CTA and DSA for evaluation were compared regarding identification of aneurysm as cause of bleed. RESULTS: A total of 49 patients were evaluated in this study during study duration, of which 26 (53%) were male and 23 (47%) were female. Out of 49 patients evaluated, 47 patients had aneurysms detected on DSA. Of 25 patients who underwent both procedures, 23 patients had aneurysms, and correct diagnosis was made with CTA in 24 out of 25 aneurysms. One aneurysm missed by CTA was close to bony structure. DISCUSSION: With advancement of CTA technology, sensitivity of detecting intracranial aneurysms has increased to >96%. The overall sensitivity in detecting aneurysms is 96% with sensitivity in detecting aneurysms >4 mm being 100%. The sensitivity of CTA for smaller sized aneurysms is low which is attributed partially to lower spatial resolution of CT compared to DSA. CONCLUSION: CTA is a simple, fast, and noninvasive imaging modality that can be used to detect and characterize intracranial aneurysms in the posterior fossa.

Selective renal segmental artery embolization for hydronephrotic upper renal moiety: simple alternative to standard surgical resection.

Duplex kidney with an ectopic upper moiety ureter usually presents with urinary incontinence in young females. If the ectopic ureter belongs to a non-functioning moiety, it is treated with surgical resection of the moiety. Renal artery embolization has been used in patients with a poorly functioning kidney for various indications. In the present report, a 30-year old lady presented with continuous urinary incontinence with normal voids in between. On evaluation, she was found to have duplex left kidney with poorly functioning upper moiety associated with an ectopic ureter opening into the vagina. She underwent successful upper segmental renal artery embolization with no postoperative complications and uneventful recovery. Hence, renal artery embolization is a minimally invasive and well tolerated alternative to surgical partial or heminephrectomy for a non-functioning duplex renal moiety.

Papilledema revisiting after sinus angioplasty of chronic cerebral venous sinus thrombosis.

This case series aimed to review the significance of revisiting papilledema after successful cerebral venous sinus thrombosis (CVST) management with sinus angioplasty. Four patients presented with blurring and transient obscuration of vision with papilledema, headache, tinnitus, and vomiting. On magnetic resonance venography and digital subtraction angiography, chronic transverse sinus thrombosis was diagnosed for which patients underwent endovascular intervention (stenting). After the resolution of CVST, patients developed the recurrence of symptoms which on digital subtraction angiography revealed dural arteriovenous malformation (DAVM). DAVM and papilledema resolved with endovascular embolization. This case series highlights a need of constant monitoring of CVST cases after the endovascular intervention.

Cranial imaging findings in dengue virus infection.

BACKGROUND: The aim of this study is to evaluate cranial CT or MRI changes in dengue encephalitis and their correlation with clinical and biochemical findings. METHODS: Twenty-one serologically confirmed patients with dengue with altered sensorium were included who underwent MRI (20)/CT (1) scan study. Their clinical details including seizure, hypotension, bleeding diathesis, focal neurologic deficit, and Glasgow Coma Scale (GCS) score were noted. Blood counts, hematocrit, renal and liver function tests, electrolytes, cerebrospinal fluid (CSF) and ECG were done. MRI findings on T1, T2, FLAIR, DWI and T1 gadolinium contrast were noted. RESULTS: The median age of the patients was 30 (5-69) years and 5 were females. MRI was abnormal in 9(45%) and CT scan in 1 patient with dengue shock syndrome revealed cerebellar and subdural hematoma. The MRI lesions were in thalamic and basal ganglia in 3, focal cortical areas in 3, white mater in 2 and meningeal enhancement in 3 patients. Seven of these patients had CSF pleocytosis. The presence of abnormal imaging was not related to outcome. One patient died, 1 was bed ridden and 19 had complete recovery on discharge. CONCLUSION: Cranial imaging reveals nonspecific changes and is not related to hematological and biochemical changes or outcome.

Spontaneous cerebrospinal fluid rhinorrhoea: computed tomography and magnetic resonance imaging findings.

Spontaneous cerebrospinal fluid rhinorrhoea is a rare clinical entity. The accurate localisation of the leakage site is essential for surgical planning. Imaging techniques such as high-resolution computed tomography (CT), CT cisternography and magnetic resonance cisternography in variable combinations are performed for this purpose. This pictorial essay aims to present the spectrum of imaging findings in cases of spontaneous cerebrospinal fluid rhinorrhoea, which may be useful for radiologists in the determination of the site of cerebrospinal fluid leakage.

Comparative evaluation of 201Tl SPECT and CT in the follow-up of irradiated brain tumors.

BACKGROUND: Radiation-induced changes in post-irradiated brain tumors may produce morphological alterations similar to those of tumor recurrence on computed tomography (CT). However, 201Tl single-photon-emission computed tomography (SPECT), with its ability to image metabolic changes, may differentiate post-irradiated gliotic changes from metabolically active congregations of viable tumor cells. This study was carried out to compare these two imaging modalities for the follow-up evaluation of post-irradiated brain tumors. METHODS: Thirty-five patients with previously irradiated primary brain tumors were evaluated for this study. 201Tl SPECT and CT were carried out during follow-up, which ranged from 3 to 125 months (median, 18 months). These findings were compared with the clinical outcome, as observed during the subsequent follow-up. RESULTS: Sensitivity, specificity, and the overall accuracy of 201Tl SPECT were 82.7%, 83.3%, and 82.8%, compared to 58.6%, 66.6%, and 58.3%, respectively, for CT. Post-scan progression-free survival (PFS) was significantly different for those patients having positive and those having negative evidence of tumor recurrence based on the imaging studies during follow-up. However, PFS was better correlated with 201Tl SPECT results than with the CT results. With 201Tl SPECT, median PFS was 4 months for those with positive reports, versus 33 months for those with negative reports (P = 0.003), compared to a corresponding median PFS of 3 months versus 14 months (P = 0.025), respectively, with CT. On multivariate analysis, age and 201Tl SPECT were the only significant variables for predicting post-scan PFS. CONCLUSION: 201Tl SPECT, with its ability to be taken up by viable tumor tissues, is superior to CT for the follow-up evaluation of post-irradiated brain tumors.