Cerebral abscess with special reference to the angiographic changes

Summary From 1961 to 1973 forty patients with surgically confirmed intracranial abscesses had preoperative cerebral angiography. The findings were abnormal in all cases but one. In 20 patients (50%) the primary diagnosis was a space-occupying lesion. In 19 patients (47.5%) an abscess was suggested by the presence of a capsule, the only finding definitely diagnostic of an abscess. Subtraction technique provided essential information in detecting the capsule. Angiography proved indispensable in suggesting the nature of the lesion.     

Intracranial dural arteriovenous fistulas with spinal venous drainage: relation between clinical presentation and angiographic findings.

PURPOSETo investigate why some patients with an intracranial dural arteriovenous fistula (DAVF) with spinal venous drainage have myelopathy and others do not.METHODSWe reviewed the clinical and radiologic data for 12 patients who had a DAVF with spinal venous drainage diagnosed at our institutions from 1982 to 1995.RESULTSSix patients had progressive spinal cord indications of disease (patients with myelopathy) and six others (patients without myelopathy) had cerebral indications (five had intracranial hemorrhage and one had a seizure). Cerebral angiography showed a posterior fossa DAVF with spinal venous drainage in all cases. The clinical presentation of DAVFs with spinal venous drainage was compared with the extent of the drainage. In patients without myelopathy, the spinal venous drainage exited the intradural canal via the cervical medullary-radicular veins and was therefore limited to the cervical perimedullary veins. In patients with myelopathy, no medullary-radicular vein was seen, and the venous drainage descended along the perimedullary veins of the entire spinal cord toward the conus medullaris.CONCLUSIONWe found an exact relation between clinical presentation and venous drainage of DAVFs with spinal venous drainage. Patients had no myelopathy when the venous drainage was limited to the cervical cord; myelopathy was present when the venous drainage descended toward the conus medullaris.     

Isolated cortical venous thrombosis presenting as subarachnoid hemorrhage: a report of three cases

Cortical venous thrombosis (CVT) without concomitant dural sinus thrombosis is an uncommon disorder. Isolated CVT usually manifests on imaging studies as focal parenchymal hemorrhage or edema. We report three cases of isolated CVT that presented with unilateral, localized subarachnoid hemorrhage without parenchymal involvement.     

Radiological analysis of hemifacial spasm with special reference to angiographic manifestations

Summary Fifty-one patients with hemifacial spasm secondary to facial nerve compression by normal appearing, elongated, tortuous and/or dilated arteries, were treated by microsurgical neurovascular decompression. Post-operatively, 91% of 44 of these patients with one to six year postoperative follow-ups were satisfactory. The angiographic findings showed significant increase in the number of common trunk anomalies. Variations of the anterior and posterior inferior cerebellar and vertebral arteries are discussed in relation to nerve compression.     

Retrograde cortical and deep venous drainage in patients with intracranial dural arteriovenous fistulas: comparison of MR imaging and angiographic findings

BACKGROUND AND PURPOSE: We assessed MR imaging, specifically contrast-enhanced three-dimensional (3D) magnetization-prepared rapid gradient-echo (MP-RAGE), in evaluating retrograde venous drainage in patients with intracranial dural arteriovenous fistulas (dAVFs) that may result in catastrophic venous infarction or hemorrhage. METHODS: Twenty-one patients with angiographically proved dAVFs underwent nonenhanced spin-echo (SE) and fast SE imaging, 3D fast imaging with steady-state precession, and enhanced SE and 3D MP-RAGE imaging. Retrograde venous drainage was categorized as cerebral cortical, deep cerebral, posterior fossa medullary, ophthalmic, or spinal venous. We assessed retrograde venous drainage and graded its severity. MR imaging and angiographic severities were correlated. Sensitivity, specificity, and accuracy were calculated to evaluate the diagnostic utility of each technique compared with conventional angiography. We retrospectively correlated angiograms and MR images. RESULTS: Enhanced 3D MP-RAGE and T1-weighted SE images had higher diagnostic accuracy higher than nonenhanced images, especially when retrograde drainage involved cerebral cortical, posterior fossa, and spinal veins. Correlation of severity for enhanced MP-RAGE images and enhanced T1-weighted images with angiograms was good to excellent and better than that with nonenhanced images. All sequences had low diagnostic accuracy when drainage was via deep cerebral veins. On retrospective review, 3D MP-RAGE images showed two thrombotic inferior petrosal sinuses. CONCLUSION: Enhanced MR images were superior to nonenhanced images in assessing retrograde venous drainage in intracranial dAVFs. Enhanced 3D MP-RAGE is superior to enhanced T1-weighted SE imaging for determining the route and severity of venous reflux because of its increased spatial resolution and ability to contiguously delineate the venous system.     

Dural arteriovenous fistula of the cervical spine presenting with subarachnoid hemorrhage

We describe a case of dural arteriovenous fistula (DAVF) presenting with subarachnoid hemorrhage (SAH). The diagnosis of DAVF was based on spinal angiography. A review of the literature revealed that five of 13 previously reported DAVFs of the cervical spine were accompanied by SAH. SAH has not been observed in DAVFs involving other segments of the spinal canal.     

MR imaging findings of intracranial dural arteriovenous fistulas: relations with venous drainage patterns

BACKGROUND AND PURPOSE: Venous drainage patterns are a major determinant of clinical outcome in intracranial dural arteriovenous fistula (DAVF) patients. In this study, we sought to identify MR imaging finding differences between DAVF types classified on the basis of venous drainage patterns. METHODS: Twenty-seven patients diagnosed as having DAVFs by conventional angiography were included. Medical records (n = 27), and MR imaging (n = 27) and MR angiography (MRA; n = 11) findings were retrospectively reviewed. MR imaging findings included flow void cluster, engorged ophthalmic vein/proptosis, white matter hyperintensity, intracranial hemorrhage, dilated leptomeningeal or medullary vessels, venous pouch, and leptomeningeal or medullary vascular enhancements. MRA findings included identifiable fistula, venous flow-related enhancement, and prominent extracranial vessels. Patients' presentations and MR imaging findings were compared among angiographic type I, II, and III cases (according to Borden's classification), and MRA findings were compared between cases with and without retrograde leptomeningeal venous drainage (RLVD). RESULTS: Patient presentations were aggressive in one (13%) of the type I cases, 5 (50%) of the type II cases, and 8 (100%) of the type III cases (P = .002). Aggressive presentations included hemorrhage, focal neurologic deficits, seizures, intracranial hypertension, and an altered mental status. MR images showed significantly higher frequencies of dilated leptomeningeal or medullary vessels in a higher type [0 in type I, 5 (42%) in type II, and 7 (100%) in type III], and of leptomeningeal or medullary vascular enhancements [0 in type I, 4 (33%) in type II, and 7 (100%) in type III]. By using MRA, fistulas were identified only in cases with RLVD (5 [83%]). Venous flow-related enhancement was present in 10 cases (91%). A sole false-negative case on MRA, as compared with conventional angiography, resulted from nonvisualization of the slow venous flow (8%). No false-positive fistula was found at the other intracranial sites in all cases. Overall, MRA assessment for DAVF was adequate for both fistula and venous flow-related enhancement in 10 cases (91%) and inadequate in a remaining case because of the fistular location out of field. CONCLUSION: MR imaging demonstration of leptomeningeal or medullary vascular dilation and enhancements may be associated with features that are considered predictors of a poor outcome and indicates a need for urgent therapy in intracranial dural AVF patients. MRA is a complementary tool for the identification of dural AVF with venous flow-related enhancement.     

Cerebral venous thrombosis as a rare cause of subarachnoid hemorrhage: case report and literature review

We report a 48-year-old woman presenting with subarachnoid hemorrhage (SAH) as the first manifestation of superior sagittal sinus thrombosis. In a literature review of 73 cases, SAH associated with cerebral venous thrombosis (CVT) was usually seen at the cerebral convexities. SAH was adjacent to thrombosed venous structures; therefore, the most possible explanation seems to be the rupture of cortical veins due to extension of thrombosis. Computed tomography (CT) was effective for diagnosis of CVT in only 32% of the cases. CVT should be considered when SAH is limited to cerebral convexities and magnetic resonance (MR) imaging with MR venography should be performed.     

Endovascular treatment of intracranial dural arteriovenous fistulas with cortical venous drainage: new management using Onyx

BACKGROUND AND PURPOSE: DAVFs (dural arteriovenous fistulas) represent one of the most dangerous types of intracranial AV shunts. Most of them are cured by arterial or venous embolization, but surgery/radiosurgery can be required in case of failure. Our goal was to reconsider the endovascular treatment strategy according to the new possibilities of arterial embolization using non polymerizing liquid embolic agent.MATERIALS AND METHODS: Thirty patients were included in a prospective study during the interval between July 2003 and November 2006. Ten of these had type II, 8 had type III, and 12 had type IV fistulas. Sixteen presented with hemorrhage. Five had been treated previously with other embolic materials.RESULTS: Complete angiographic cure was obtained in 24 cases. Of these 24 cures, 20 were achieved after a single procedure. Cures were achieved in 23 of 25 patients who had not been embolized previously and in only 1 of 5 previously embolized patients. Among these 24 patients, 23 underwent a follow-up angiography, which has confirmed the complete cure. Partial occlusion was obtained in 6 patients, 2 were cured after additional surgery, and 2 underwent radiosurgery. Onyx volume injected per procedure ranged from 0.5 to 12.2 mL (mean, 2.45 mL). Rebleeding occurred in 1 completely cured patient at day 2 due to draining vein thrombosis. One patient had cranial nerve palsy that resolved. Two ethmoidal dural arteriovenous fistulas were occluded. All 10 of the patients with sinus and then CVR drainage were cured.CONCLUSION: Based on this experience, we believe that Onyx may be the treatment of choice for many patients with intracranial dural arteriovenous fistula (ICDAVF) with direct cortical venous reflux (CVR). The applicability of this new embolic agent indicates the need for reconsideration of the global treatment strategy for such fistulas.

Several studies have shown an association between intracranial (IC) dural arteriovenous fistula (DAVF) venous drainage patterns and clinical presentation.^1,2 DAVFs draining retrogradely into cortical veins exhibit a much higher incidence of hemorrhage or venous infarction.^3,4 The annual mortality rate for cortical venous reflux (CVR) may be as high as 10.4%, whereas the annual risk for hemorrhage or nonhemorrhagic neurologic deficits during follow-up are 8.1% and 6.9%, respectively, resulting in an annual event rate of 15%.⁴ In subjects presenting with hemorrhage, the risk of rebleeding has been evaluated at 35% in the 2 weeks after the initial hemorrhage.³ Consequently, DAVFs with CVR require treatment aimed at a complete and definitive fistula closure. In general, treatment of such fistulas primarily involves an endovascular approach, and if this fails, surgical or radiosurgical approaches are used. The present prospective study investigated the use of a new nonadhesive liquid embolic agent, Onyx (ev3, Irvine, Calif), in the treatment of DAVF with CVR.     

Treatment of slow-flow (type I) perimedullary spinal arteriovenous fistulas with special reference to embolization

Embolization of type I perimedullary spinal arteriovenous fistulas (AVFs) can be difficult, because of tortuosity and the small diameter of the feeder and distal location of the fistula site. The 1.5F flow-directed catheter in conjunction with a hydrophilic guidewire has been used in fistula embolization with cyanoacrylate glue for spinal vascular malformations at our institution. This combination has improved our success rate in achieving superselective catheterization of the fistula. Thus, 4 of 5 patients with type I perimedullary AVFs could be cured with this technique. Like type II and type III perimedullary AVFs, the endovascular approach may also be the first line of treatment in type I perimedullary spinal AVF.     

蛛网膜下腔出血后腰池持续引流防治脑血管痉挛作用的影像学观察

目的　研究实验性蛛网膜下腔出血 (SAH)后腰池持续引流对脑血管痉挛 (CVS)预防和治疗作用的影像学分析。方法　经皮枕大池 2次注血法建立犬SAH动物模型 ,将 30条健康成年狗随机分为对照组、早期腰穿组、晚期腰穿组、早期引流组和晚期引流组 ,早期腰穿组和晚期腰穿组分别于 2次注血后 2h和第 5天开始隔日行腰穿排放血性脑脊液 ,早期引流组和晚期引流组分别于 2次注血后 2h和第5天实施腰椎蛛网膜下腔置管持续引流。脑血管造影确定CVS程度 (%reductionofbasilararterydiamit er,%RBAD)的变化发展。结果　①与早期腰穿组和对照组相比 ,早期引流组CVS发生例数少 ,痉挛时程短 ,痉挛程度轻。②与晚期腰穿组和对照组相比 ,晚期引流组CVS程度轻 ,时程短。③与晚期引流组相比 ,早期引流组CVS例数少 ,痉挛程度轻。结论　SAH后实施腰池持续引流可以防治CVS ,早期引流可以取得更好的效果。     

Cerebral venous angioma of the pons: report of a case with pontine hemorrhage

Cerebral venous angioma in the pons associated with pontine hemorrhage in a 39-year-old normotensive woman was identified with computed tomography and angiography. Venous angioma in the brain stem is usually silent and rarely found by chance at autopsy. Only a few cases have been clinically reported. Our report indicates that in unusual cases of intracerebral hemorrhage, vascular malformations should be suspected and scrutinized with radiologic examination including angiography.