Stent-graft placement in a traumatic internal carotid-internal jugular fistula and pseudoaneurysm.

Traumatic arteriovenous fistulas following carotid artery injuries are rare. Treatment of carotid artery-to-jugular vein fistula requires direct closure of the fistula or occlusion of the carotid artery above and below the level of the fistula, by a surgical or endovascular approach. A 32-year-old man presented with a right-sided pulsatile neck swelling 2 days following a stab wound. Neck computed tomography demonstrated a vascular mass protruding into the anterior neck. Digital subtraction arteriography demonstrated a bilobular large internal carotid artery pseudoaneurysm just distal to its bifurcation. There was simultaneous opacification of a dilated left internal jugular vein indicating a high-flow internal carotid-internal jugular fistula. A balloon-expandable stent-graft was delivered and successfully positioned across the fistula. The arteriovenous fistula and pseudoaneurysm completely disappeared and the right internal carotid artery was well preserved. The stent-graft is a promising technology to obliterate fistulae and preserve the parent artery with relative safety.     

Endovascular treatment of a bilateral ophthalmic-ethmoidal artery dural arteriovenous fistula.

A 76-year-old man developed blurred vision, and cerebral angiography disclosed an anterior skull base dural arteriovenous fistula (DAVF) supplied by both ethmoidal branches of the ophthalmic arteries and draining through a single cortical vein. Selective catheterization of both ophthalmic arteries distal to the origin of the central retinal arteries and occlusion the fistula feeders with injections of n-butyl cyanoacrylate glue led to complete occlusion of the fistula with preservation of retinal perfusion. The visual symptoms are attributed to impaired retinal perfusion as the result of a steal phenomenon. With care, a DAVF in this location can be successfully treated endovascularly while preserving retinal perfusion by embolizing the ophthalmic artery distal to the origin of the central retinal arteries and avoiding any backflow of embolizing material.     

Spontaneous resolution of an idiopathic cervical direct vertebral arteriovenous fistula after partial coil embolization in a patient presenting with myeloradiculopathy

A 53-year old female presented with paresis of the left upper extremity. Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) disclosed a single high-flow vertebral arteriovenous fistula (AVF) with vertebral artery (VA) transection. The AVF was also fed by steal flow from the contralateral VA. The left posterior inferior cerebellar artery (PICA) branched just distal to the fistula. The fistula drained into the neighboring paravertebral veins and refluxed into the intradural venous systems. The dilated drainers compressed the spinal cord. Embolization was attempted at the drainer just behind the fistula orifice using platinum coils. The fistula was still fed slightly by right VA after the embolization, but spontaneous complete obliteration was achieved after one week. The clinical symptoms and signs disappeared. Although, detachable balloon embolization is the quickest and most effective procedure to obliterate a fistula, stepwise embolization using GDC can be considered, and may avoid the normal pressure perfusion break-through phenomenon. Spontaneous obliteration of the fistula after partial embolization in our case may result from intravenous embolization just behind the fistula orifice. It may therefore be a useful approach to the embolization of an AVF to begin the embolization at the venous side of the fistula.     

远端血管阻断辅助微导管超选经栓塞硬脑膜动静脉瘘

目的介绍远端血管阻断辅助微导管超选技术在经动脉入路栓塞硬脑膜动静脉瘘术中的应用。方法硬脑膜动静脉瘘患者2例。1例为天幕缘区硬脑膜动静脉瘘,供血动脉来自脑膜中动脉和枕动脉,采用弹簧圈闭塞枕动脉远端主干。另一例为前颅窝底硬脑膜动静脉瘘,供血动脉为双侧眼动脉之筛前、筛后动脉,采用球囊临时阻断于颈内动脉眼动脉开口远端。结果微导管在弹簧圈及球囊支撑下均超选人与主干血管成角明显且迂曲的供血动脉远端,微导管头端接近瘘口,以液态栓塞材料完全消除瘘口。结论对于供血动脉迂曲且与主干血管成角明显的硬脑膜动静脉瘘,远端血管临时或永久阻断有利于使微导管头端超选至理想位置,最终保证瘘口栓塞。     

Spontaneous cerebrospinal fluid rhinorrhea through clival defect

Spontaneous cerebrospinal fluid fistula secondary to clival defect is a very rare condition. Only 2 cases are reported previously in the literature. We report a case of clival defect in a young male patient presenting with spontaneous cerebrospinal fluid rhinorrhea which failed detection by conventional CT and MRI. The patient was referred to our center after failed anterior cranial fossa repair. Thorough radiological investigations successfully detected the defect in the posterior wall of the sphenoid sinus 5 mm distal to the posterior limit of the floor of the sella just on the midline. The fistula was managed successfully through an endonasal transsphenoidal approach. We present the case reviewing the literature concerning the pathophysiology of spontaneous cerebrospinal fluid fistula through the sphenoid sinus.     

Cure of a direct carotid cavernous fistula by endovascular stent deployment

A 53-year-old woman underwent surgical thrombendarterectomy for treatment of artherosclerotic stenoses of her left internal carotid artery (ICA). A Fogarty catheter was used during this operation. The postoperative course was complicated by the development of a sixth cranial nerve palsy, protrusio, chemosis and ciliar injection of both eyes. Digital subtraction angiography showed a direct fistula between the cavernous segment of the left ICA and the cavernous sinus, with early and retrograde opacification of both superior ophthalmic veins. Endovascular occlusion of the fistula was achieved with preservation of the ICA by stent deployment over the rupture site of the ICA, as two detachable balloons could not obliterate the fistula while preserving the ICA patent. Follow-up angiography 7 months after the endovascular treatment confirmed persisting occlusion of the fistula with a patent ICA. Highly flexible porous coronary stents can easily be introduced into tortuous vessels, including the distal ICA. The haemodynamic effects achieved by stent deployment together with two balloons detached in the cavernous sinus may be sufficient to interrupt a direct carotid cavernous fistula.     

Endovascular management of intracranial pial arterio-venous fistulas

From 1996-2002 we treated 5 consecutive cases of pial fistula. There were 3 patients with a single hole-single channel pial fistula and two patients had a complex pial fistula. Three patients presented with intracerebral hematoma and had a focal neurological deficit. One patient presented with history of seizures and 1 patient had headache. The results of the treatment were analyzed both clinically and angiographically. The follow-up period ranged from 6 months to 6 years. All fistulas were treated with concentrated glue. The glue cast included the distal part of the feeding artery, A-V connection and the proximal part of the vein. Post-embolisation angiography showed complete occlusion of two single-hole fistulas and one complex pial A-V fistula and near total occlusion of one single-hole and one complex pial A-V fistula. Four patients had excellent clinical outcome. One patient with single-hole fistula had a hemorrhagic venous infarct resulting in transient hemiparesis.     

Pneumocephalus after shunt in a patient with hydrocephalus. A case report and review of the literature

Pneumocephalus in hydrocephalic shunted patients is very rare. So far only 46 cases have been described in the literature. A case of pneumocephalus in a patient with shunted hydrocephalus, and the diagnostic and therapeutic problems were described. A 38-year-old woman suffered from a subacute headache, dizziness and bradyphrenia. Eight years ago, the ventriculo-atrial shunt was implanted due to idiopathic hydrocephalus, and the shunt was changed 2 months before the present admission (ventriculo-peritoneal valve). CT and MRI revealed pneumocephalus, but neither clinical nor radiological symptoms of the CSF fistula were found. After temporary ligation of a distal catheter, the anterior fossa and a sellar area were directly repaired via right fronto-temporal craniotomy, with a good outcome. In the case of pneumocephalus in hydrocephalic shunted patients, the direct closure of the skull base fistula via craniotomy combined with restoration of the proper shunt function is usually the most effective treatment. If the site of the fistula can not be established, dural cranioplasty in the most likely site of the fistula is recommended.     

Carpal tunnel syndrome related to antebrachial Cimino-Brescia fistula.

Two patients are described in whom symptoms of the carpal tunnel syndrome were provoked by haemodialysis for which an antebrachial arteriovenous fistula had been established. The symptoms in one case were partially relieved by ligation of the radial artery distal to the fistula, and in both they were abolished by decompression of the median nerve by section of the flexor retinaculum at the wrist. There is evidence that the median nerve is abnormally susceptible to ischaemia in the carpal tunnel syndrome, and it is suggested that in these patients the symptoms were provoked by a vascular steal mechanism related to the fistula.     

Supraclinoid internal carotid artery–inferior petrosal sinus arteriovenous fistula after high-voltage electrical burn injury

High-voltage electrical burns can cause immediate and long-term neurological and cerebrovascular injuries. The authors present a 21-year-old man who developed an intracranial arteriovenous fistula secondary to high-voltage electrical injury. CT angiography demonstrated a left supraclinoid internal carotid artery (ICA)–inferior petrosal sinus (IPS) fistula. A subsequent angiogram revealed an irregularity of the cavernous and supraclinoid ICA with stenosis involving the supraclinoid segment and a fistulous connection between the ICA and IPS distal to the ophthalmic take-off and proximal to the anterior choroidal artery. The patient underwent a decompressive hemicraniectomy and clip-wrapping of his ICA pseudoaneurysm with successful obliteration of the fistulous connection. To our knowledge, this is the first report of an intracranial arteriovenous fistula secondary to an electrical burn injury.     

Broncho-pleural fistula due to trans-diaphragmatic migration of the distal end of ventriculo-peritoneal shunt

We report two cases of broncho-pleural fistula resulting from trans-diaphragmatic migration of the distal catheter of a ventriculo-peritoneal shunt. Relevant literature on thoracic complications of a ventriculo-peritoneal shunt is reviewed. The clinical presentation, diagnosis and management of V-P shunt-related broncho-pleural fistulae are discussed.     

Spontaneous vertebral arteriovenous fistula causing cervical myelopathy and acute ischemic strokes treated by endovascular balloon–assisted coiling and Onyx embolization

Vertebral arteriovenous fistulas (VAVF) are infrequent lesions characterized by abnormal communication of the extracranial vertebral artery or one of its branches to the surrounding venous plexuses, without the presence of any intervening vessels. We describe a rare occurrence of a patient with VAVF presenting with acute ischemic stroke, encephalomalacia from multiple prior embolic events, and cervical myelopathy, which was successfully treated by coil-assisted Onyx embolization (ev3 Endovascular, Plymouth, MN, USA) with balloon for flow arrest. Our patient demonstrates that point occlusion with embolization for VAVF can be a feasible, safe, and effective treatment option for complete obliteration of the fistula, with subsequent reduction in the volume of the intra-spinal canal venous plexus. Although it is postulated that thromboembolism is less common because of redirection of flow to the venous side of the fistula, our patient also illustrates the potential for to–fro flow in such a fistula to result in embolic injury to the distal circulation.     

The pre-treatment effect on brain injury during restoration of normal perfusion pressure with hemodilution in a new rat model of chronic cerebral hypoperfusion

OBJECTIVES: To investigate the effect of hemodilution with high-concentration human serum albumin (HSA) on brain injury in a rat model of chronic cerebral hypoperfusion associated with arteriovenous malformations. METHODS: The animal model was established by creating a fistula through an end-to-side anastomosis between the right distal external jugular vein and the ipsilateral common carotid artery, followed by ligation of the left vein draining the transverse sinus and bilateral external carotid arteries. The agent (20% HSA) or control solution (0.9% sodium chloride) was administered intravenously at a dosage of 1% body weight 24 hours before ligation of the fistula. Blood-brain barrier (BBB) disruption was judged by extravasation of Evans blue (EB) dye. EB, water content and the changes of myeloperoxidase (MPO) activity and superoxide dismutase (SOD) activity in rat brains 24 hours after ligation of the fistula were determined. RESULTS: EB and water content in rat brains of the pre-treated group were significantly decreased compared with the control group accompanied by reduction of MPO activity and enhancement of SOD activity. DISCUSSION: Hemodilution with high-concentration HSA has a certain pre-treatment effect on brain injury after ligation of the fistula in rat model of chronic cerebral hypoperfusion, which may be resulted from improved microcirculation, decrease in inflammatory cell infiltration and inactivation of oxygen free radicals.     

Case of spinal thoracic-lumbar dural arteriovenous fistula with polyneuropathy type sensory impairment]

A 57-year-old man had progressive paresthesias ascending from both legs together with paraparesis. Distal paresthesias of the upper extremities developed earlier than segmental sensory impairments. At transfer to our hospital, a neurological examination detected bilateral lower limb weakness predominant in the distal part; severe glove and stocking paresthesias in addition to superficial sensory impairment below the Th8 level; and micturition problems. T2-weighted thoracolumbar MRI showed a hyperintense spinal cord lesion between Th5 and L1. At the L4 level, a spinal arteriogram showed enlarged and tortuous vessels extending from the lumbar artery which drains to the spinal vein. These findings led to the diagnosis of spinal dural arteriovenous fistula. Anatomical substrates for this sensory impairment may be produced by development from the side to forward parts of lesions in the outer circumference of the anterior funiculi, resulting in the dominating sensory impairment in the distal parts of the upper extremities. Physicians need to be aware of patients who have polyneuropathy-like sensory impairment without segmental sensory signs, and must consider the possibility of spinal dural arteriovenous fistula.     

鼻烟窝和前臂动静脉内瘘应用于慢性肾功能衰竭维持血液透析214例：哪种方法更适合肾移植前的永久血管通路

背景：肾移植前采用前臂头静脉和桡动脉成功建立动静脉内瘘可成为维持血液透析良好的血管通路。 目的：比较鼻烟窝和前臂动静脉内瘘在血液透析中的临床效果。 方法：将214例慢性肾功能衰竭患者以抽签法随机分为鼻烟窝组(n=118)和前臂组(n=96),分别建立鼻烟窝和前臂动静脉内瘘,观察比较两组手术成功率、内瘘成熟时间、血流量、近远期内瘘通畅率及并发症的发生率。 结果与结论：两组在手术成功率、内瘘成熟时间、和血流量上差异均无显著性意义(P > 0.05)。两组近期内瘘通畅率虽无显著差异,但鼻烟窝组两三年远期通畅率显著高于前臂组(P < 0.05)。并且鼻烟窝组假性动脉瘤发生率及充血性心力衰竭的发生率显著低于前臂组(P < 0.05)。两组均未发生切口感染、肿胀综合征及窃血综合征 (P > 0.05)。与前臂动静脉内瘘相比,鼻烟窝动静脉内瘘建立更简单,远期通畅率更高,并发症较少,使用时间更长,是肾移植前血液透析首选的永久性血管通路。 关键词：慢性肾功能不全;动静脉内瘘;血液透析;鼻烟窝;血管通路     

Neuropathy associated with Brescia-Cimino arteriovenous fistulas

We performed a clinical and electrophysiologic study of median and ulnar nerve function to determine the frequency of neuropathy in 21 patients who had unilateral Brescia-Cimino arteriovenous fistulas and who were undergoing maintenance hemodialysis. Seven patients had symptomatic median or ulnar neuropathy in the arm with the fistula, and abnormalities of motor and/or sensory nerve conduction were found in all of these patients. Of the 14 asymptomatic patients, nine had electrophysiologic evidence of median and/or ulnar neuropathy in the arm with the fistula. Evidence of subclinical median or ulnar neuropathy was also found in the contralateral extremity in 11 of the 21 subjects. Statistically significant differences were found for median and ulnar sensory nerve action potential latencies and motor conduction velocities and for the median distal motor latency between the arms with and without fistulas in the group as a whole, and the mean interarm differences for these values were statistically significant.     

CSF fistula through the left lumbar region in adult following a ventriculoperitoneal shunt surgery: a rare case report

A cranial spinal fluid fistula through left lumbar region following a ventriculoperitoneal (VP) shunt is an extremely rare complication. We report a 25-year-old man who presented with the leakage of clear fluid from the left lumbar region, 3 years after a VP shunt surgery. Computerized tomography scan of abdomen revealed that the distal end of the catheter penetrated into the inner layer of the wall of left lumbar region. He was managed successfully with abdominal part of shunt catheter removal from primary cervical and abdominal incision, a new abdominal part of VP shunt catheter replacement and prophylactic antibiotic.     

Treatment of traumatic trigeminal-cavernous fistula by coil embolization and compression of carotid artery

We report a case of a traumatic cavernous fistula supplied by a persistent primitive trigeminal artery. The process of treatment was unique in this case. Fistula was subcompletely occluded by coiling from primitive trigeminal artery. Residual fistula was helped to form thrombosis by compression of the carotid artery with hand in the procedure. Long-term follow-up was satisfactory. Traumatic cavernous fistula supplied by a persistent primitive trigeminal artery could be treated by embolization and temporal compression of the parent artery might be useful for residual minimal fistula.     

海绵窦区硬脑膜动静脉瘘的临床表现及血管内介入治疗

目的 探讨海绵窦区硬脑膜动静脉瘘的临床症状及血管内介入治疗的方法和疗效.方法 分析收治的16例海绵窦区硬脑膜动静脉瘘患者临床资料,并对其临床症状、血管内介入治疗方法及疗效进行总结分析.结果 16例患者眼部充血表现(或合并突眼)13例,单纯突眼1例,颞部杂音2例,蛛网膜下腔出血1例.6例单纯南动脉途径应用NBCA进行栓塞,术后瘘口即刻闭塞3例;1例有瘘口残留,随访2个月后症状完全消失;另外2例瘘口残留,但症状明显好转.8例进行了单纯静脉入路栓塞,其中2例应用ONYX和弹簧圈进行栓塞,完全闭塞瘘口;2例分别合并有术后动眼神经和外展神经麻痹,前者术后1个月好转;5例单纯进行了ONYX栓塞:1例由动静脉联合入路进行栓塞,瘘口完全闭塞,1例因瘘口细小进行了颈动脉压迫并观察随访,术后2个月瘘口更加细小,术后3例患者出现眼部并发症,1例为动眼神经麻痹,1个月后好转,1例为复视并外展神经麻痹,1例为结膜充血,眼球疼痛不适,后好转.结论 海绵窦区硬脑膜动静脉瘘临床表现复杂多变.血管内介入治疗是海绵窦区硬脑膜动静脉瘘安全、有效的治疗方法.经动脉入路栓塞,瘘口闭塞率低于静脉入路,但术后眼部并发症发生率亦低,静脉入路瘘口闭塞率高,但应注意防止眼部并发症发生.