Treatment of Dural Carotid-Cavernous Fistulas via the Medial Ophthalmic Vein.

AIM: To present a novel approach to treatment of dural carotid-cavernous fistulas via the medial ophthalmic vein. DESIGN: Retrospective case series. MATERIAL AND METHODS: In this retrospective case series, we present 2 patients (3 eyes) with Type C dural CCFs, who had failed cannulation via the conventional transfemoral route and the transorbital superior ophthalmic vein approach. They subsequently underwent CCF occlusion via an anterior orbital approach through the medial ophthalmic veins, at the Department of Ophthalmology, National University Hospital Singapore. CCF occlusion was confirmed intraoperatively using angiography. Both patients were evaluated postoperatively for best-corrected visual acuity and resolution of clinical signs and symptoms. RESULTS: Successful occlusion of CCFs via the medial ophthalmic veins were achieved in all three orbits, with excellent visual and cosmetic outcomes postoperatively. CONCLUSION: Dural CCFs may potentially lead to severe visual dysfunction and should be diagnosed and treated promptly. When all venous routes have been exhausted, the transorbital approach via the medial ophthalmic vein remains an excellent and viable alternative to access the fistula. Close cooperation between the orbital, anesthetic and radiological teams is essential in ensuring success of the operation.

Utility of non-contrast-enhanced CT for improved detection of arterial phase hyperenhancement in hepatocellular carcinoma.

PURPOSE: To determine the utility of non-contrast-enhanced CT (NC-CT) for improved detection of hyperenhancement in hepatocellular carcinomas (HCC). METHODS: We performed a retrospective analysis on CT studies of 104 consecutive patients with 124 HCCs between October 2006 and December 2012. The enhancement of HCC was evaluated on quadriphasic CT: non-contrast (NC), arterial phase (AP), portal-venous phase (PVP), and delayed phases (DP) were performed. For determination of enhancement, mean attenuation of the HCC and surrounding non-tumor bearing liver in the four phases were recorded. Hyperenhancement was defined by either HCC (AP-NC) representing absolute lesion enhancement or AP (HCC-liver), representing relative enhancement. An increase of ≥10 Hounsfield units (HU) was considered as enhancement. Two radiologists (R1 and R2) independently performed a conventional qualitative assessment for hyperenhancement of HCC. The accuracy of detection by proposed absolute lesion enhancement HCC (AP-NC) was compared to relative enhancement AP (HCC-liver) and qualitative assessment by readers with the McNemar test. RESULTS: The proposed criteria of absolute lesion enhancement, HCC (AP-NC) identified more hypervascular nodules compared to qualitative analysis (92% vs. 62% for R1 and 69% for R2), equating to an improvement of 23%-31%. In contrast, relative enhancement AP (HCC-liver) was found to be inferior to conventional qualitative analysis (50% vs. 62%-69% for readers). CONCLUSION: NC-CT is useful to improve the detection of hyperenhancement in HCCs for imaging diagnosis.

CT-guided thoracic biopsy: evaluating diagnostic yield and complications.

INTRODUCTION: This study retrospectively evaluated CT-guided thoracic biopsies for diagnostic yield, accuracy and complications. MATERIALS AND METHODS: A retrospective analysis of 384 patients (mean age 62.7 years; male/female = 251/133) who underwent 399 CT-guided thoracic biopsies were performed for evaluating diagnostic yield, accuracy and complications. Correlations between patients age, procedure factors (biopsy-needle size, number of passes, lesion-size, lesion-depth and traversed lung-length) and complications such as pneumothorax, haemothorax and haemoptysis were evaluated. A comparison between fine needle aspiration (FNA) group and core ± FNA group for diagnostic yield and complications was also performed. RESULTS: FNA was performed in 349 patients and core ± FNA in 50 patients. The biopsy samples were adequate in 91.9% and the diagnostic accuracy for malignant lesions was 96.8% with 95.7% sensitivity and 100% specificity. Pneumothorax (detected on CT) occurred in 139 cases (34.8%) and only 12 (3.0%) required insertion of an intercostals drain. Mild haemoptysis occurred in 13 patients (3.2%) and small haemothoraces in 2 patients. Pneumothorax occurrence was significantly associated with the traversed lung-length (>3mm), lesion-size (≤33 mm) and lesion-depth (≥60mm) (P <0.05). Haemoptysis occurrence was also significantly associated with traversed lunglength (>3mm) and lesion-size (≤33 mm) (P <0.05). There was no significant difference between diagnostic yield and complication rate between FNA and core ± FNA groups. CONCLUSION: CT-guided thoracic biopsy is a safe procedure with high diagnostic yield and low risk of significant complications. Traversed lung-length and smaller lesion size are associated with occurrence of pneumothorax and haemoptysis.

Multifocal intracranial astrocytoma in a pediatric patient with Ollier disease.

Ollier disease (OD) is a subtype of enchondromatosis. Historically, it has been distinguished from Maffucci syndrome (MS) by the presence of vascular malformations and nonskeletal neoplasms (NSN) in the latter. However, there is an increasing number of reports of NSN in OD, and this categorization is now being questioned. We report a case of OD complicated by multifocal astrocytoma in a young patient, once again pointing to a possible association between OD and NSN. We also review the available literature and examine the similarities between the reported cases.

The glossopharyngeal, vagus and spinal accessory nerves.

The glossopharyngeal, vagus and spinal accessory nerves are closely related anatomically, and to a certain extent, functionally. We present an overview of their anatomy, highlighting the important clinical and imaging implications. The main pathologic lesions arising from these nerves are also discussed and the imaging features reviewed.

Neuroapplication of amplatzer vascular plug for therapeutic sacrifice of major craniocerebral arteries: an initial clinical experience.

INTRODUCTION: Clinical use of the Amplatzer vascular plug in the cardiopulmonary and peripheral vasculatures has been described extensively in the literature. We present our initial experience in adapting this device for therapeutic sacrifice of major craniocerebral arteries. MATERIALS AND METHODS: Between July 2007 and November 2008, 8 patients (mean age 59.1 years; range 18 to 82 years) underwent therapeutic occlusion of major craniocerebral arteries using the device, for direct caroticocavernous fistula (1 patient), symptomatic unruptured giant cavernous internal carotid aneurysms (2 patients), and preoperative embolisation before surgical resections of skull base tumours that had encroached upon the internal carotid or vertebral artery (5 patients). The plugs were used alone or in conjunction with detachable platinum coils. The applications of the device, as well as the angiographic and clinical results of the procedures were evaluated. RESULTS: Applications of the plugs were straightforward and successful in all cases, with hermetic occlusions of all target arteries. When used without additional coils, several plugs were deployed in tandem to achieve complete occlusion of the artery. No migration of the device was seen. No patient developed untoward neurological deficits following the procedures, and the 3- and/or 6-month follow-up showed stable results. CONCLUSION: The Amplatzer vascular plug could be a valuable addition to the neurointerventional armamentarium, particularly in therapeutic occlusion of major craniocerebral arteries. Rigidity of the delivery system limits its current use to vessels below the skull base. The potential risk of distal thromboembolism also requires further evaluation.

Imaging of jugular foramen.

Jugular foramen, albeit complex, is essentially a bony conduit transmitting nerves and vessels from the posterior cranial fossa to the nasopharyngeal carotid space. In addition to its intrinsic pathologic conditions, a variety of lesions can arise from the contiguous surrounding structures and invade the foramen. A thorough understanding of the anatomy of this region is fundamental for diagnostic evaluation and assessment of its disease extent. Vascular variants and imaging artifacts are potential pitfalls, which should be recognized and avoided.