Contralateral inferior petrosal sinus approach for transvenous embolization of a dural arteriovenous fistula at isolated jugular bulb. Technical case report.

A contralateral inferior petrosal sinus approach is described for the successful treatment of a case of a dural arteriovenous fistula at an isolated right jugular bulb presenting with chemosis. A microcatheter could be inserted into the right jugular bulb from the left jugular bulb through the left inferior petrosal sinus, basilar sinus on the dorsum sellae, and the right inferior petrosal sinus. This unusual approach represents an alternative route to the jugular bulb.     

Acute aggravation of traumatic carotid-cavernous fistula after venography through the inferior petrosal sinus

A report is presented on a patient with acute aggravation of traumatic carotid-cavernous fistula after venography through the inferior petrosal sinus. After direct puncture of the internal jugular vein and insertion of the catheter tip to reach the inferior petrosal sinus, venography was conducted, but immediately thereafter bruit decreased and proptosis and chemosis increased. Though the fistula may have been occluded through the endarterial approach, the cause of acute aggravation is considered to have been thrombosis of the inferior petrosal sinus. The risk involved in venography or the transvenous approach for traumatic carotid-cavernous fistulas is discussed.     

A case of dural arteriovenous fistula of the inferior petrosal sinus successfully treated by transarterial and transvenous embolizations

A 69-year-old male was admitted with chemosis and exophthalmos of his right eye. Angiograms revealed a dural arteriovenous fistula (AVF) involving the right inferior petrosal sinus. The AVF was fed by the right occipital and ascending pharyngeal arteries and drained into the cavernous sinus and right superior ophthalmic vein from the right inferior petrosal sinus. He was treated by transarterial embolization with polyvinyl alcohol in order to reduce the shunt-flow through the fistula. Then he was treated by transvenous embolization with GDC coils five days after the arterial embolization. Symptoms in his right eye have completely disappeared. Transvenous embolization combined with transarterial embolization is a useful and safe approach in the management of AVF involving the inferior petrosal sinus.     

Transarterial NBCA embolization with transvenous partial outflow obstruction for superior petrosal sinus dural arteriovenous fistula: a case report

We encountered a case of superior petrosal sinus dural arteriovenous fistula (SPS DAVF) which was treated by a combination of a transvenous and a transarterial approach after the failure of the transvenous approach alone. A 69-year-old man presented with a complaint of progressive left bulbar conjunctival conjestion, exophthalmos, and impaired vision. Cerebral angiography revealed a left SPS DAVF fed by the left middle meningeal artery, the meningeal branches of the left internal carotid artery and the left posterior meningeal artery. Venous drainage proceeded through the cavernous sinus (CS) toward the left superior ophthalmic vein (SOV). Transvenous embolization via the SOV was indicated because the left ipsilateral inferior petrosal sinus contributed to the normal venous return. However the microcatheter to the CS couldn't go through the tortuous SOV. Next a transarterial NBCA (n-butyl-cyanoacrylate) embolization of the affected sinuses was performed under arterial flow control with balloons and the partial coil embolization of the origin of the SOV. The coils in the SOV trapped NBCA and the sinuses were filled slowly with NBCA. The postoperative angiogram confirmed complete obliteration of the DAVF and the patient's ocular symptoms disappeared. DAVF is usually difficult to treat by transarterial embolization with NBCA because of its multiple feeders and high flow drainage. We should therefore carefully observe its structure and the blood flow change with 3D-DSA and the selective angiography while embolizing the DAVE.     

Transvenous occlusion of dural cavernous sinus fistulas through the thrombosed inferior petrosal sinus: report of four cases and review of the literature

BACKGROUND: The aim of this study is to describe the technique and results of the endovascular approach through the thrombosed inferior petrosal sinus (IPS) for occlusion of dural cavernous sinus fistulas (DCSFs). METHODS: In four patients presenting with clinically symptomatic DCSFs, the angiogram did not show opacification of the IPS, indicating that it neither drained the arteriovenous fistula nor the cerebral venous outflow. A large volume biplane phlebogram of the jugular bulb was obtained to identify a thrombosed remnant of the IPS. We were able to navigate small hydrophilic catheters and microguide wires through the thrombosed IPS into the ipsi- or contralateral CS. After reaching the fistula site the CS was packed with detachable platinum coils. RESULTS: We were able to reach the fistula site and to achieve a dense packing of coils within the arteriovenous shunting zone in all of the patients. The final angiogram showed subtotal or complete occlusion of the arteriovenous fistula. All four patients recovered completely and showed disappearance of the fistula on follow-up arteriograms. One patient developed a transient sixth nerve palsy. No complications related to the approach were observed. CONCLUSIONS: For endovascular treatment, transvenous occlusion of DCSFs via the IPS is a feasible approach, even when this sinus is partially or completely thrombosed. Gentle handling of recently available, improved hydrophilic microguide wires and microcatheters allows effective and safe catheter navigation into the CS. A phlebogram of the jugular bulb is very useful for identification of a thrombosed IPS.     

The utility and efficacy of preoperative embolization for hypervascular tumor by NBCA

Preoperative embolization for hypervascular tumors is typically performed using particle agents such as polyvinyl alcohol, gelfoam powder, and fibrin glue. Furthermore, n-butyl-2-cyanoacrylate (NBCA) is used in patients with cerebral arteriovenous malformation (AVM) or an AV shunt. However, few reports have described the efficacy of NBCA in treating hypervascular tumors. Here, we report cases of hypervascular tumors in which preoperative embolization was performed using NBCA. We also discuss the difference between the efficacy of a liquid agent and a particle agent for hypervascular tumor embolization. We analyzed 10 cases encountered at our institution since 2004 in which preoperative embolization was performed using NBCA. In all cases, NBCA was injected through the tumor-feeding artery. In eight of these cases, preoperative embolization decreased intraoperative bleeding and markedly reduced the tumor stain. In the remaining two cases, complications occurred but without any permanent sequel. Thus, NBCA is useful for preoperative embolization.     

Endovascular treatment for dural arteriovenous fistulae of the superior petrosal sinus

OBJECTIVE: To determine the usefulness of endovascular embolization for treatment of dural arteriovenous fistulae of the superior petrosal sinus. METHODS: We performed a retrospective review of 18 patients treated during a 16-year period. Transarterial and/or transvenous embolizations were performed as a preoperative adjunct or definitive therapy. Clinical follow-up status was supplemented by telephone interviews to determine Glasgow Outcome Scale scores. RESULTS: Fourteen patients (78%) were treated with a combination of endovascular therapy and open surgery, and 4 were treated by embolization alone (22%). Angiographic cure was achieved in all patients (100%). Thirty-day morbidity and mortality were 11 and 0%, respectively. The mean follow-up period was 5.4 years. At the latest follow-up examination, all patients had returned to independent clinical status (Glasgow Outcome Scale scores of 1 or 2). CONCLUSION: Endovascular treatment of dural arteriovenous fistulae of the superior petrosal sinus can result in cure when access to the site of the fistula can be achieved. Preoperative embolization is a safe and effective adjunct to minimize bleeding during open neurosurgery.     

Successful treatment of Cushing disease with the sphenoid sinus of conchal type: usefulness of inferior petrosal sinus sampling and STEALTH navigation system: a case report

We report a case of Cushing disease whose microadenoma was not identified by MRI with dynamic study and whose sphenoid sinus was conchal in type. Venous sampling test in the bilateral inferior petrosal sinus demonstrated ACTH hypersecretion on the right side. The patient underwent transsphenoidal surgery. A poorly pneumatized sphenoid sinus was drilled effectively, guided by the STEALTH navigation system. After the first operation, the patient's serum ACTH concentration was still high, suggesting that tumor removal was incomplete. Then she underwent the second operation and the residual tumor was completely removed with the assistance of the STEALTH navigation system again. Postoperatively, her serum ACTH concentration dropped below 5 pg/ml. In this case, inferior petrosal sinus sampling was extremely helpful for the diagnosis of Cushing disease, and operations were able to be performed safely using the neuronavigation system in drilling of the incompletely pneumatized sphenoid sinus.     

Epidural anterior petrosectomy with subdural visualization of sphenobasal vein via the anterior transpetrosal approach-technical case report

The drainage of the superficial middle cerebral vein (SMCV) is classified into four subtypes. The sphenobasal vein (SBV) drains from the SMCV to the pterygoid venous plexus at the temporal skull base. Epidural procedures in the standard anterior transpetrosal approach (ATPA) may damage the route of the SBV. We report a case in which modified surgical procedures via the ATPA were used to preserve the SBV. A 45-year-old man complained of right facial pain. Magnetic resonance images revealed a right cerebellopontine tumor suggestive of an epidermoid cyst. Right carotid angiography revealed that the SMCV drained into the pterygoid venous plexus via the SBV. The convexity dura mater of the temporal lobe was cut and the anterior part of the temporal lobe was retracted subdurally. The SBV was visualized from the subdural side. The basal dura mater of the temporal lobe posterior to the SBV was cut and the posterior part of the temporal lobe was retracted epidurally. After dissecting the dura mater medial to the greater petrosal nerve and to the edge of the petrous apex, the petrous apex was exposed and drilled out without injuring the SBV. The superior petrous sinus and the tentorium were cut. The tumor compressed the root exit zone of the trigeminal nerve. The tumor was grossly totally removed. The modified ATPA (epidural anterior petrosectomy with subdural visualization of the SBV) is effective in preserving the SBV.     

Corticotropin-releasing hormone test: Improvement of the diagnostic accuracy of simultaneous and bilateral inferior petrosal sinus sampling in patients with cushing syndrome

Twenty-six consecutive patients with ACTH-dependent Cushing syndrome were subjected to simultaneous, bilateral inferior petrosal sinus sampling for ACTH assay before and after ACTH-releasing hormone (CRH) stimulation. The baseline ACTH inferior petrosal sinus/periphery (IPS/P) ratio was 2 in 12 of 26 patients (46%), whereas the CRH-stimulated IPS/P ratio was 3 in 19 of 26 patients (73%). A pituitary adenoma, ACTH-secreting at immunostaining, was surgically proved in all of the 19 patients who had an ACTH IPS/P ratio 2 basally or 3 after the CRH test but also in three other patients who did not have such ratios. The value of the basal IPS/P ratio and the complete lack of ACTH increase after CRH led to the diagnosis of an ectopic ACTH syndrome in four patients: a bronchial carcinoid was found in three patients, and the site of the tumor was still unknown in the other. In conclusion, the CRH test improved the diagnostic accuracy of inferior petrosal sinus sampling from 61.5% (12 pituitary, 4 ectopic) to 92.0% (19 pituitary, 4 ectopic). Thus it should be performed during the diagnostic process.

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Resumen Veintiséis pacientes consecutivos con Síndrome de Cushing ACTH-dependiente fueron sometidos a muestreo simultáneo y bilateral del seno venoso petroso inferior, para determinar concentración de ACTH antes y luego de estimulación con hormona liberadora de ACTH (CRH). La relación basal del nivel de ACTH entre el seno venoso petroso inferior y la sangre periférica fue 2 en 12/26 pacientes (46.4%), en tanto que la relación luego de estimulación con CRH fue 3 en 19/26 pacientes (73%). Quirúrgicamente se comprobó la presencia de un adenoma pituitario secretor de ACTH (según inmunocoloración) en la totalidad de los 19 pacientes que presentaban relaciones basales 3 luego de la prueba de estimulación CRH pero también en otros 3 pacientes que no exhibieron tales relaciones. El valor de la relación basal seno petroso inferior/periferia y la completa ausencia de elevación de la ACTH luego de CRH llevó a establecer el diagnóstico de un síndrome ectópico de ACTH en cuatro pacientes: un carcinoma bronquial en 3 de ellos, y un tumor cuyo lugar no logró ser determinado en el otro. En conclusión, la prueba con CRH mejoró la precisión diagnóstica del muestreo del seno petroso inferior, elevándola de una tasa de 61.5% (12 pituitarios y 4 ectópicos) a 92% (19 pituitarios y 4 ectópicos). Por lo tanto, ésta es una prueba que debe ser ejecutada como procedimiento diagnóstico.

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Résumé On a dosé l'ACTH simultanément dans les deux sinus pétreux inférieurs chez 26 patients consécutifs ayant un syndrome de Cushing ACTH-dépendant, avant et après la stimulation par l'hormone de stimulation de l'ACTH (CRH). Le rapport de la concentration de l'ACTH dans le sinus pétreux inférieur/la concentration périphérique de l'ACTH (ACTH SPI/ACTH P) était 2 chez 12/26 patients (46.4%) avant stimulation alors que ce rapport était 3 chez 19/26 patients (73%) après. Un adénome hypophysaire, sécrétant de l'ACTH en immunohistologie a été retrouvé chirurgicalement chez tous les 19 patients qui avaient un rapport de l'ACTH SPI/ACTH P 2 de base ou un rapport de l'ACTH SPI/ACTH P 3 après stimulation, mais il existait aussi chez trois autres patients qui n'avaient pas ces mêmes valeurs. L'étude du rapport de l'ACTH SPI/ACTH P et l'absence complète d'augmentation de l'ACTH après stimulation par la CRH était en faveur du diagnostic d'un syndrome de sécrétion ectopique de l'ACTH chez quatre patients. Une tumeur carcinoïde d'origine bronchique a été retrouvée chez trois patients alors que le site de la tumeur est resté inconnu chez le quatrième. En conclusion, par le test à l'ACTH la précision diagnostique de l'échantillon du sinus pétreux inférieur est passé de 61.5% (12 tumeurs hypophysaires et quatre tumeurs ectopiques) lorsque ce rapport était 2, à 92% (19 tumeurs hypophysaires et quatre tumeurs ectopiques) lorsque ce rapport était 3 et trouve alors sa place dans le bilan étiologique de ces anomalies.

     

A technique for removal of filariasis of the anterior chamber

We describe a useful technique for removing filaria from the anterior chamber. In the case described, an immature female filaria approximately 15 mm in length was removed from the anterior chamber of a 32-year-old man in western Oregon and identified as a species of Dipetalonema. Features of four cases of filarial infection in the anterior chamber from the same geographic area are described. In three out of four cases, the worms were removed alive without difficulty by means of simple irrigation aspiration system.     

Giant aneurysm of the anterior inferior cerebellar artery simulating a cerebellopontine angle tumor

An aneurysm of the anterior inferior cerebellar artery simulating a cerebellopontine angle tumor is reported. Only 13 such cases have been published so far. The relevant literature is reviewed.     

A retrospective analysis of inferior vena caval filtration for prevention of pulmonary embolization

Inferior vena caval (IVC) filtration employing transvenous devices represents a substantive technologic advance in the management of patients with deep venous phlebothrombosis and pulmonary embolization. The retrospective analysis reported herein of the use of the Kim-Ray Greenfield IVC filter in 22 patients revealed a 95 per cent efficacy in its prevention of pulmonary embolization. The minor acute morbidity (9%) and chronic morbidity (27%) associated with use of the device was well tolerated by this patient population. No mortality attributable to the device was observed. The data suggest that the use of this device represented the best therapeutic option among those patients who were not candidates (18/22) or who had failed alternative therapeutic modalities (1/22) for the treatment of deep venous phlebothrombosis or pulmonary embolization. The data also suggest that use of the device in a prophylactic context (3/22) among those patients deemed at "high risk" for the development of deep venous phlebothrombosis and pulmonary embolization may be beneficial.     

Outcome of laparoscopic splenectomy with preoperative splenic artery embolization for massive splenomegaly

Background  

Laparoscopic splenectomy (LS) has become a safe and feasible procedure for cases involving spleens of normal size. Only a few publications report on the outcome of LS with preoperative splenic artery embolization (SAE) for massive splenomegaly. The authors present their experience in patients with massive splenomegaly who underwent laparoscopic-assisted splenectomy (LAS) or hand-assisted laparoscopic splenectomy (HALS) following SAE.     

Hemangiopericytoma of the kidney: a case with preoperative ethanol embolization

We report a case of a giant renal hemangiopericytoma that was embolized preoperatively with ethanol. Ultrasound and computerized tomography showed multiple smooth-walled cysts within the tumor. The tumor itself was hypervascular and a vascular pattern specific for hemangiopericytoma was noted upon reinterpretation of the angiograms. The diagnostic and therapeutic aspects are discussed, and the literature is reviewed.     

Microsurgical removal of a free segment of microcatheter in the anterior circulation as a complication of embolization

Endovascular therapy for cerebral arteriovenous malformations, although generally accepted to be a safe procedure, is not without risks. We present a patient with a 20 cm free segment of a catheter in the anterior circulation as a complication of embolization. This is a very rare complication. To our knowledge, only six cases have been reported in the literature. We believe this to be the first reported case of this complication treated surgically via craniotomy and arteriotomy.     

Ruptured aneurysm of the inferior thyroid artery: repair with coil embolization

Although pseudoaneurysm of the thyrocervical trunk is seen with increasing frequency as a result of trauma or central venous cannulation, true aneurysm of the thyrocervical trunk is exceedingly rare. A 44-year-old woman presented with acute left neck swelling that progressed rapidly to respiratory distress and subsequent hemothorax. Emergency endotracheal intubation was performed for airway control, and tube thoracostomy was placed for drainage of the pleural space. A review of the literature reveals that this is the second patient known to be successfully treated by arterial embolization of a ruptured aneurysm of the inferior thyroid artery and the fifteenth known case of aneurysm of the inferior thyroid artery. Surgical or endovascular intervention has been successful. Observation has been uniformly fatal. Because life-threatening rupture is possible, the presence of this aneurysm mandates intervention. Endovascular coil embolization is a viable option for treatment of this entity.