Which is the best peri-operative anti-coagulative therapy of transverse sinus stenting for refractory idiopathic intracranial hypertension?

Treatment of refractory idiopathic intracranial hypertension (IIH) is a challenging problem. We reported a refractory IIH patient who manifested with typical intracranial hypertensive symptoms successfully treated with endovascular stent implantation. Pre-operative cerebrospinal fluid (CSF) opening pressure is 36 cmH2O. Cerebral angiography demonstrated a stenotic lesion located at the right transverse sinus (TS). The stenotic TS returned to its normal caliber and the pressure gradient deceased from 36 mmHg to 4 mmHg after the stent placement. The intracranial hypertensive symptoms resolved and one month later, the CSF opening pressure decreased to 14 cmH2O.

Acute paraplegia following embolization of spinal dural arteriovenous fistula.

Embolization therapy has been used as the initial treatment for spinal dural arteriovenous fistula (SDAVF) only for certain patients or in certain medical institutions due to its minimal invasiveness, but the recurrence of embolization remains a clinical challenge. The recurrent patient usually exhibits a gradual onset of symptoms and progressive deterioration of neurological function. Developing paraplegia several hours after embolization is commonly seen in patients with venous thrombosis-related complications, for which anticoagulation therapy is often administered. This article reports on a SDAVF patient who had weakness of both lower extremities before embolization and developed complete paraplegia several hours after embolization therapy, later confirmed by angiography as fistula recurrence. The symptoms were relieved gradually after second embolization. The pathophysiology of this patient is also discussed.

[Transarterial embolization of dural carotid-cavernous fistulas].

OBJECTIVE: To explore the efficacy and strategy of transarterial embolization of dural carotid-cavernous fistulas. METHODS: The clinical data of 19 patients with dural carotid-cavernous fistulas treated by transarterial embolization, including clinical presentations and patterns of angioarchitecture were retrospectively analyzed. Follow-up was conducted for 7 months to 4 years. RESULTS: Clinical cure was achieved in 15 cases, significant improvement of symptoms in 3 cases, and failure in 1 case. Complete angiographic obliteration was documented in 12 patients (63%) right after the embolization. Residual shunting was left in 6 patients, and disappeared in 5 cases one month to half a year later by manual compression of the carotid artery. The patient on which transarterial embolization failed received embolization via the bilateral cavernous later, and clinical cure was achieved. Headache and vomiting were the most common symptoms after embolization. There was no permanent procedure-related morbidity. No recurrence was seen during the follow-up. CONCLUSION: Transarterial embolization is a safe, efficient and economical method for part of the cavernous sinus dural arteriovenous fistula patients.

3-Dimensional rotational angiography for the treatment of spinal cord vascular malformations.

BACKGROUND: This study was conducted to evaluate the effect of 3D-RA on the treatment of SCVMs. METHODS: Twelve patients with SCVM were retrospectively reviewed for details of 2D and 3D-RA findings. Pretherapeutic 2D and 3D-RA angiograms were compared with respect to 4 critical categories of parameters: (1) the exact anatomic location, size, and extent; (2) the definitive diagnosis; (3) the precise angioarchitectural configuration; and (4) the contribution to further intervention. RESULTS: Overall, 2D and 3D-RA were equally effective in demonstrating the exact anatomic location, size, and extent, and establishing the definitive diagnosis of SCVM in all 12 cases. 3-Dimensional rotational angiography demonstrated precise angioarchitectural configuration in 8 (8/12) cases, facilitated treatment in 6 (6/12) cases, and modified therapeutic strategies in 2 (2/12) cases via information not available from 2D-DSA images. Both 2D and 3D-RA contributed equally to the therapeutic intervention in 4 (4/12) patients. No complications occurred as a result of 3D-RA. CONCLUSIONS: 3-Dimensional rotational angiography may enhance our ability to treat SCVMs with complex angioarchitecture and is an ideal addition to conventional 2D angiography in the management of these vascular lesions.

Hemiparesis in carotid cavernous fistulas (CCFs): a case report and review of the literature.

Carotid-cavernous fistulas (CCFs) are abnormal arteriovenous anastamoses between the carotid artery and the cavernous sinus. These fistulas may be classified by cause (spontaneous or traumatic), flow velocity (high or low), or pathogenesis (direct or indirect). The most commonly adopted classification is that described by Barrow based on arterial supply. Traumatic CCFs are almost always direct shunts between the internal carotid artery (ICA) and the cavernous sinus. General features of CCFs, which may be apparent with any lesion, including bruit, headache, loss of vision, altered mental status and neurological deficits. Some fistulae may present primarily with hemorrhage before any evaluation can be performed. However, hemiparesis has been rarely observed. Only a literature review of Murata et al reported a case of hemiparesis caused by posttraumatic CCF, in which the fistula resulted in venous hypertension and subsequent brainstem congestion. While in our case, cerebral infarction was caused by total steal of the blood flow. The patient recovered after occlusion of the fistula with a detachable balloon.