Long-term outcome after endovascular treatment of cavernous sinus dural arteriovenous fistula and a literature review.

BACKGROUND: The long-term efficacy of endovascular treatment (EVT) for cavernous sinus dural arteriovenous fistulae (CS-dAVF) was assessed with a special focus on residual shunts after initial EVT. PATIENTS AND METHODS: This retrospective survey included 50 patients who had undergone EVT and were followed for 1 month or longer (median follow-up 56 months). RESULTS: Common preoperative symptoms were chemosis (78%), extra-ocular motor palsy (72%), exophthalmos (66%), and tinnitus (26%). CS-dAVF were addressed by transvenous embolization (tVE, n = 48), tVE only was used in 43 instances and tVE plus transarterial embolization (tAE) in five. Two patients underwent tAE only. Procedure-related morbidity (brainstem infarction) was recorded in one patient (2%) and transient symptom exacerbation (paradoxical worsening) in 12 patients (24%). Postoperative digital subtraction angiography showed no major retrograde shunt or cortical venous reflux in any of the 50 patients. Anterograde or minor retrograde residual shunt was observed in 17 patients (34%); three of these underwent additional tVE and four had Gamma Knife surgery. The shunt flow disappeared in all 17 patients 12.6 ± 13.4 (mean ± SD) months after initial EVT. At the latest follow-up, 65.7 ± 52.6 months after the initial operation, no shunt flow was observed in any of the 50 patients. None had remaining or newly developed chemosis or tinnitus on follow-up. The rate of persistent cavernous sinus symptoms at the latest follow-up was higher in patients with than without post-procedural paradoxical worsening (5/12, 41.7% vs. 2/38, 5.3%, p = 0.0059 by Fisher's exact test). CONCLUSIONS: Long-term follow-up showed that EVT, especially tVE, is an efficient and safe treatment for CS-dAVF. It resulted in the eventual disappearance of shunt flow. Residual shunt without major retrograde flow or cortical venous reflux can be monitored without additional treatment.

Clinical presentation and treatment of aneurysms associated with basilar artery fenestration.

Aneurysms associated with a fenestrated basilar artery are rare, and treatment strategies have yet to be established. A direct surgical approach to the basilar artery is challenging because the surrounding anatomy is complex. We retrospectively compared the clinical features and treatment outcomes of eight patients (seven female, one male) with aneurysms associated with a fenestrated basilar artery after clipping or coil embolisation and reviewed the literature. Of the eight aneurysms, four were ruptured; seven aneurysms were located at the proximal part of the basilar artery and one aneurysm was located at the middle of the basilar artery. Six aneurysms were surgically treated. Four aneurysms were embolised with Guglielmi detachable coils, two aneurysms were clipped via the transcondylar or temporopolar approach, and two aneurysms were not treated. All six surgically treated patients had good outcomes. We found that both coil embolisation and direct clipping to treat aneurysms associated with a fenestrated basilar artery have advantages and disadvantages. To obtain favourable outcomes, the selected treatment modality must consider the patient's age and clinical condition, the aneurysm size and shape, the direction of the dome, the relationship with perforators, and the neurosurgeon's expertise.

Acute epidural hematoma in a patient with Glanzmann's thrombasthenia: case report.

A 7-year-old girl with Glanzmann's thrombasthenia (GT) fell and hit her head against a table. Within 2 hours she began to vomit and became drowsy. On admission to our hospital her Glasgow Coma Scale score was 13. Computed tomography (CT) on admission showed acute epidural hematoma in the left posterior fossa. We administered platelets, performed emergent lateral suboccipital craniotomy, and totally removed the epidural hematoma. Postoperative CT showed no evidence of hematoma or re-bleeding. She was discharged without neurological deficits 14 days after the operation. GT is a platelet aggregation disorder due to a functional loss of platelet membrane glycoprotein IIb/IIIa. The present patient with GT underwent successful emergency craniotomy after platelet transfusion.