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We present a transvenous embolization technique for a direct carotid-cavernous fistula through the pterygoid plexus to the cavernous sinus which only 2 cases have been previously reported in the English literature. This method is appropriate when transarterial techniques or other attempts at transvenous access have failed due to vessel tortuosity, hypoplasia, stenosis, or occlusion. A middle-aged female patient presented with progressive left exophthalmos with conjunctiva chemosis and bruit after sustaining a falling injury. Digital subtraction angiography revealed Barrow type A carotid-cavernous fistula. The drainage route passed through a distal thrombosed superior ophthalmic vein that ended deep in the orbit. No other patent venous sinuses connected to the cavernous sinus, except for a small tract of pterygoid plexus. After failure of transarterial approach and other methods of transvenous access, we attempted to superselectly access to the cavernous sinus by applying transpterygoid technique with embolization using detachable coils. The transpterygoid venous approach to accessing the cavernous sinus represents an alternative approach when other techniques fail.

Background: Lhermitte-Duclos disease (LDD) stems from the development of a rare benign lesion of uncertain pathogenesis that distorts the normal cerebellar laminar cytoarchitecture. We explored the lesion's appearance on conventional magnetic resonance imaging (MRI) combined with susceptibility-weighted imaging, diffusion-weighted imaging, perfusion imaging, or arterial spin labeling. Although many cases of LDD have been previously reported in the literature, the radiologic-pathologic correlation has been described in only a few of these cases. To the best of our knowledge, this is the first case report to provide detailed information about the radiologic-pathologic correlation of LDD. Case Report: A 48-year-old woman presented with left facial tics, occipital headache, and dizziness for 1 month. MRI revealed a left cerebellar lesion with hypointensity on T1-weighted images. On T2-weighted images, the mass was hyperintense with tigroid appearance due to alternating high and normal signal intensities. High signal intensity was noted on fluid-attenuated inversion recovery images. Magnetic resonance spectroscopy indicated decreased level of choline (Cho), N-acetyl aspartate, and myoinositol with elevated level of lactate on the affected side. The lesion showed a bright signal on diffusion-weighted images, whereas apparent diffusion coefficient mapping revealed no disturbance of diffusion. The pathology of the excised lesion was consistent with LDD. Conclusion: MRI with advanced techniques can provide not only preoperative diagnosis but also better pathologic correlation. Keywords: Lhermitte-Duclos disease, Radiologic-pathologic correlation, MRI

Cerebrospinal fluid (CSF) leak can be spontaneous or nonspontaneous. The management options include conservative treatments, blood patch, and surgical repairs. We compared clinical symptoms, image findings, management options, hospitalization, and relapse rates among different causes of CSF leaks. Eighty-one patients were recruited: 20 with spontaneous and 61 with nonspontaneous CSF leaks. Nonspontaneous causes included lumbar puncture, surgery, and trauma. Surgery sites comprised sphenoid, spine, skull base, and calvaria. Spontaneous CSF leak came from the sphenoid or spine. Age, gender, body mass index, initial symptoms, hospitalization, treatment courses, and recurrence rates showed no difference between the groups. The spontaneous group had higher CSF accumulations on their MRIs. MRI pachymeninge enhancement showed the highest sensitivity (78.6%) for intracranial hypotension. Meningitis occurred in 1/3 of sphenoid, skull base, and calvarian surgeries. Earlier reoperation was correlated with shorter hospitalization (r = 0.651), but the recurrence rates were similar. Longer intervals between surgery and CSF leak encouraged reoperation. Among the spontaneous spine and lumbar puncture-related CSF leaks, 57.1% of them responded to 4 days of conservative treatment. Among the trauma-related CSF leaks, 90.9% of them required surgical repair. The demographic data and symptoms were similar in various groups of CSF leak. The symptom onset durations and treatment strategies were different. However, the recurrence rates were similar.

The authors report an extremely rare case of spinal intraosseous epidural arteriovenous fistula (AVF) with perimedullary vein reflux causing symptoms of myelopathy. The intraosseous fistula tracts were completely obliterated with Onyx embolic agent, resulting in a total resolution of symptoms. The unique features of this case include the rare location of the fistula in the vertebral body and the association of the fistula with a compressive fracture. Imaging studies confirmed these hemodynamic findings and provided clarity and direct evidence regarding the association of epidural AVF formation with the vertebral compressive fracture. The authors also propose a possible disease evolution based on the previously adduced reflux-impending mechanism.

A 70-year-old man presented to our clinic complaining of binocular diplopia and persistent redness in the left eye for 5 months. Conjunctival vessels were dilated and tortuous in both eyes. Intraocular pressure was 16 mmHg in the right eye and 23 mmHg in the left eye. Complete bilateral sixth cranial nerve and partial left third cranial nerve palsies were noted. Brain computed tomography and cerebral angiography revealed a Barrow Type C dural arteriovenous fistula. The patient underwent gamma knife radiosurgery (GKRS) at a dose of 18 Gy and a target volume of 3.3 mL. Within 1 month of GKRS, the patient reported an improvement in diplopia, but 4 months following the procedure, he experienced micropsia, metamorphopsia, and darkness in his left eye. Prominent flame-shaped hemorrhages and retinal edema, the typical picture of central retinal vein occlusion (CRVO), developed in his left eye. Intraocular pressure in this eye was controlled with antiglaucoma topical medication. 5 months later, the left retina had appeared normal. Antiglaucoma drops were gradually tapered and eventually discontinued. The GKRS, used in recent decades, is noninvasive and effective in the treatment of dural arteriovenous fistula. However, CRVO can occur after GKRS. Here, we present, in detail, a clinical course of CRVO that developed after GKRS. Our findings may be useful for further understanding of this rare complication.

The purpose of the technical note is to introduce the complex coil assisted coil embolization method in the treatment of intracranial small aneurysm, in order to enhance the safety of the procedure. The first microcatheter was navigated into the aneurysm sac and the ultrasoft coil was used as the embolization coil. If the embolizations coil could not stay within the aneurysm sac smoothly, such as coil herniation into parent artery during the delivery process. The second microcatheter would be navigated to the aneurysm level in the parent artery. Another complex coil was delivered within the parent artery via the second microcatheter to provide the neck bridge effect in order to enhance the stability of embolization coil. Besides, the protection coil will not disturb the parent artery flow. While the embolization coil was put into the aneurysm sac smoothly under the help of complex protective coil, the protective coil was then withdrawn gently. We use the most magnified view, dual-plane approach simultaneously to observe the stability of embolization coil. The embolization coil would be detached without any evidence of coil motion or vibration. The new method could provide the physiological protective method, without leaving any protective device such as stent within the parent artery.

ObjectivesTo evaluate the differences in arterial flow after flow diverter placement using quantitative flow measurements based on digital subtraction angiography (DSA).MethodsBetween November 2013 and November 2015, all patients who had flow diverters placed for distal internal carotid artery (ICA) aneurysms were reviewed. Patients in whom the stent was placed across the ostia of the ophthalmic artery (OphA) and anterior choroidal artery (AChA) were enrolled. Five regions of interest were selected: the proximal ICA (as a reference), terminal ICA, middle cerebral artery (MCA), anterior cerebral artery (ACA), OphA, and AChA. The values of the peak, time-to-peak (TTP), and area under the curve (AUC) were analyzed using a quantitative DSA technique.ResultsThe study enrolled 13 patients. The quantitative flow analysis showed improved flow in the terminal ICA (peak and AUC, p=0.036 and p=0.04, respectively), MCA (AUC, p=0.023), and ACA (AUC, p=0.006), and decreased flow in the OphA (peak and AUC, p=0.013 and p=0.005, respectively) and AChA (peak and subtracted TTP, p=0.023 and p=0.050, respectively) after flow diverter placement. Larger aneurysm volume was significantly correlated with decreased OphA flow after the procedure (peak and AUC, p=0.049 and p=0.037, respectively). Larger aneurysm volume also had a marginal correlation with increased distal ICA flow after the procedure, but this did not reach significance (peak and AUC, p=0.195 and p=0.060, respectively).ConclusionsWithout using extra contrast medium or radiation dosages, color-coded DSA enables quantitative monitoring of the cerebral circulation after flow-diverting treatment.

Substantial intraoperative bleeding during surgical removal of carotid body tumor may be a major problem in the management of these highly vascularized tumors. Traditional preoperative embolization via a transarterial access has proved effective but is often limited by complex vascular anatomy and small feeding vessels that is difficult to catheterize. We report two cases of carotid body tumor treated with direct puncture and intratumoral injection of N-butyl cyanoacrylate glue (NBCA) assisted with balloon protection technique for preoperative devascularization. The result was impressive and minimal bleeding loss during surgery was observed.

Endovascular embolization for craniofacial arteriovenous malformation has been used as preoperative adjuvant devascularization or as definitive therapy. However, because the vascular network is complex, embolization via arterial access may be ineffective, risky, incomplete or technically difficult. The purpose of this report is to describe our experience of percutaneous direct venous pouch puncture embolization. Four patients with craniofacial AVMs were treated with direct puncture embolization via injection of NBCA. After the selective transarterial angiogram, the lesions were directly punctured in the venous pouch under a road map angiogram. A glue mixture was injected, and post-embolization angiograms revealed that in all patients, the lesions had been completely obliterated without complication. Percutaneous direct puncture embolization is an effective, time saving and safe technique for the superficial craniofacial AVM with prominent venous pouch.

Background: Primary nasal natural killer (NK)/T-cell lymphoma is the most common cellular subtype seen in nasal lymphomas. It is rare in the Western population but occurs more frequently in Asia, South America, and Mexico. The purpose of this study was to describe the computed tomography (CT) and magnetic resonance (MR) imaging findings of primary nasal NK/T-cell lymphoma. Methods: During the period between January 1990 and June 2006, the CT (n = 24) and MR (n = 6) images of 24 patients with biopsy-proved nasal NK/T-cell lymphoma were reviewed retrospectively. Both CT and MR images were evaluated for site and extent of disease and for pattern of involvement of adjacent areas. Results: The most common symptoms at presentation were nasal obstruction, nasal discharge, and epistaxis. There was involvement of the unilateral nasal cavity in 16, bilateral nasal cavity including nasal septum in 5 and nasal choana in 3. Sites of extension outside the nasal cavity included tumor extension into paranasal sinuses (n = 15), nasopharynx (n = 5), nasal labial fold (n = 3), oropharynx (n = 2), infratemporal fossa (n = 2), other subcutaneous soft tissue of the face (n = 2) and anterior cranial fossa base (n = 1). Bony destruction was demonstrated in 18 cases, involving the sinus bony wall (n = 15), nasal turbinate (n = 10), lamina papyracea (n = 6), orbital floor (n = 3), and hard palate (n = 2). Regional lymphadenopathy was also detected in 3 patients with nasal NK/T-cell lymphoma. Conclusion: The CT and MR appearances of nasal NK/T-cell lymphoma are nonspecific, and the diagnosis requires histologic confirmation. However, the differential diagnosis of nasal NK/T-cell lymphoma should be included if the images present soft tissue of the nasal cavity with bony erosion or destruction; involvement of the orbital cavity, nasopharynx and infratemporal fossa; and subcutaneous or nasolabial fold soft tissue infiltration, especially in Asian populations. [J Chin Med Assoc 2007;70(5):207–212]

Systemic and fatal arterial air embolism during the computed tomography (CT) scan is rarely reported in English-based literature. Iatrogenic air embolism happening during the CT scan is often related to the injector, usually venous air embolism and asymptomatic. We report one fatal and extensive systemic arterial air embolism because of one error that happened during a brain CT scan. The mechanism is different from the reported cases in the literature. The possible mechanism and pathogenesis are well discussed to alert clinicians and prevent the recurrence of such complication.