Tian, Fucheng

Abstract Cognard type V dural fistulas represent a rare and unique entity, and present clinically with myelopathy. They are frequently located around the foramen magnum and are most commonly fed by dural branches of the vertebral and external carotid artery. Detection requires meticulous angiography to define the angioarchitecture of the fistula, which in turn defines the treatment modality. We present the case of a 63 yr old woman, after informed consent was obtained, with prolonged, severe and progressive lower extremity myelopathy for 6 yr, with T2-weighted signal changes in the thoracic spinal cord on magnetic resonance imaging (MRI). Cervical MRI was unremarkable. Following computed tomography (CT), angiography of the spinal canal that revealed tortuous and dilated veins on the thoracic spinal cord surface, catheter angiography was performed. This demonstrated a fistula in relation to a dural branch of left vertebral artery with a characteristic single draining vein coursing caudally to the thoracic level, with delayed outflow suggestive of venous hypertension. Given the fact that the dural feeder was tortuous and relatively small, thus, precluding distal microcatheter access, and with presence of a single accessible draining vein, microsurgical treatment was preferred. Following a midline suboccipital craniotomy in prone position, a limited vertical dural opening was performed. Careful microsurgical arachnoid dissection revealed the arterialized draining vein with the aid of Indocyanine Green angiography. The draining vein was clipped, coagulated, and disconnected. Postoperative recovery was uneventful and the patient is undergoing rehabilitation therapy. Follow-up angiography showed complete elimination of the fistula. Salient teaching points are narrated at conclusion.

Abstract We present the case of a 62-yr-old female who presented with ground-level fall and new onset of left-sided weakness of 30 min duration. CT angiogram revealed right ICA pseudo-occlusion and thrombus filling the right proximal M1 segment of the right MCA. On detailed neurological exam patient was noted to have NIHSS of 25. Patient was started on IV TPA infusion and was taken to interventional angiography suite after an informed consent was obtained. Diagnostic angiography was performed which demonstrated critical stenosis of the right proximal internal carotid artery. Right carotid artery stenting and balloon angioplasty of the carotid stent with distal embolic protection device was performed. Post carotid stent angiogram once again confirmed proximal right M1 pseudo-occlusion in the right MCA distribution. The clot was removed using a stent retriever, thus achieving complete recanalization (TICI 3) of the right cerebral hemisphere. The patient returned to baseline neurological status and a 1 mo follow-up diagnostic angiogram revealed patent carotid stent. Following the case presentation, we present the nuances of acute ischemic stroke management of large vessel occlusion with an emphasis on technical nuances, recent published guidelines 1 and the literature. 2-8

Abstract We present the case of a 56-yr-old right-handed male, after informed consent was obtained, who presented with acute confusion and agitation, on the background of a remote history of an uncomplicated resection of a left parietal grade 2 glioma. Imaging revealed a large, acute right temporal intracerebral hemorrhage (ICH). Standard vascular workup for the cause of the ICH included catheter angiography. No direct cause of the hemorrhage was revealed; however, a high grade parasagittal dural arteriovenous fistula (DAVF) with cortical venous reflux was noted close to the prior craniotomy site. The venous reflux was towards the left hemisphere, but it was hypothesized that similar reflux on the right side may have been present and was not presently evident due to thrombosis. The DAVF was embolized by endovascular means, followed by evacuation of the hematoma. Follow-up angiogram 7 mo later revealed a high-flow, right superior temporal cortical arteriovenous malformation (AVM). The DAVF unfortunately had also progressed. Endovascular occlusion of both lesions was attempted but was not successful. Subsequently, microsurgical resection for both the vascular malformations was performed with careful pre- and intraoperative planning to obtain a successful clinical and angiographic result. In this video, we summarize diagnostic and therapeutic nuances that have broad implications for the workup of ICH and the strategic management of a unique scenario involving a brain AVM and high-grade cranial dural fistula in the same patient. Prior to each procedure, informed consent was obtained from the patient, which includes consent for publication.