Search

Introduction Dural arteriovenous fistulas (DAVFs) are pathologic vascular connections that shunt dural arterial flow directly to dural venous drainage. DAVFs constitute 10–15% of all intracranial arteriovenous malformations and are most commonly located in transverse, sigmoid, and cavernous sinuses. Symptoms from DAVFs vary based on lesion location and correlate with their respective patterns of venous drainage. Common presenting symptoms include pulsatile tinnitus, chronic headache, vision difficulties, cranial nerve abnormalities, cerebellar symptoms, focal neurologic deficits, and seizures. Only a few isolated case reports describe syncope on presentation, all in combination with other symptoms. In this article, we report a rare case of DAVF causing recurrent syncope. Methods A 29 year-old female presented with a 9-year history of progressive syncopal episodes exacerbated by positional changes, strenuous activity and emotional stressors. Results The patient was referred to us after symptoms of dizziness and syncope persisted despite treatment by multiple cardiologists, endocrinologists, and psychiatrists. Symptoms occurred upon wakening and lasted for 2–3 hours before she was able to regain functionality. Furthermore, she found that her symptoms would remit if she was to lay in the Trendelenburg position immediately after symptom onset. Physical exam revealed no abnormalities. MRI of the brain showed no irregularities. MRA revealed abnormal serpiginous structures in the left jugular foramen which communicated with the ascending pharyngeal branch of the left external carotid artery. Cerebral angiogram disclosed a left jugular foramen dural AVF (Borden/Cognard type 1) supplied by the left ascending pharyngeal and left occipital arteries. There was no retrograde flow or cortical venous reflux. The DAVF was successfully managed by progressive endovascular embolization with coils and Onyx 34 via transvenous route. The final cerebral angiogram demonstrated complete obliteration of the fistula. On clinical follow-up evaluation, the patient had no further episodes of dizziness or syncope. Conclusion We present an atypical case of DAVF in a patient presenting with recurrent syncope. Only 3 cases of DAVF causing syncope have been reported, all in combination with other neurologic symptoms. In comparison, we report a unique case of DAVF presenting solely with recurrent syncope, a previously undocumented finding in the literature. Our case adds to other reports of nonspecific DAVF presentations and highlights the importance of considering this etiology. Disclosures D. Sheinberg: None. E. Luther: None. D. McCarthy: None. R. Starke: None.

Introduction Acute ischemic stroke (AIS) still remains one of the top leading causes of morbidity and mortality in the United States. In 2007, the DESTINY trial demonstrated lower mortality rates in patients with large hemispheric strokes following hemicraniectomy. 7 years later, the MR CLEAN trial showed improved outcomes in AIS following endovascular mechanical thrombectomy (MT) when compared to intravenous tPA alone. However, during the enrollment period for this trial there remains limited data regarding the effects of MT on the need for hemicraniectomy. Methods A retrospective analysis of the Nationwide Inpatient Sample (NIS) between 1998–2015 was performed. Patients with an ICD-9-CM diagnosis code indicating an anterior circulation ischemic stroke (433.11, 434.01, 434.11, and 434.91) were included. Patients with an ICD-9-CM diagnosis code indicating trauma, neoplasm, SAH/aneurysm, posterior circulation ischemic stroke, or abscess (191.x, 198.3, 324.0, 430, 433.01, 433.21, 437.3, 437.5, 437.6, 443.24, 747.81, 800.xx, 801.xx, 851.xx, 852.xx, 853.xx, and 854.xx) were excluded. In order to limit the analysis to AIS, patients who did not have the ICD-9-CM procedure code of tPA (99.10) were excluded. Those patients who underwent thrombectomy (39.74) and hemicraniectomy (01.24, 01.25, 01.39, 01.53, and 01.59) were also indentified. Logistic regression model was used to analyze the effect of thrombectomy on rates of hemicraniectomy in patients with AIS who received tPA. Results A total of 59,703 patients in the NIS were identified as having an acute anterior circulation ischemic stroke that subsequently received tPA. 3597 patients were also identified as having undergone MT and 606 patients were found to have undergone hemicraniectomy as well. Logistic regression model demonstrated that patients who underwent MT were significantly more likely to undergo hemicraniectomy (OR 4.52, 95% CI 3.72–5.49, p Conclusions Although MT has proven to be an effective treatment for AIS, it appears that prior to MR CLEAN, patients who underwent MT had a higher likelihood of requiring a hemicraniectomy during the same hospital admission. Since MTs were not standardized prior to 2014, the variability in procedural technique could ultimately cause unreliable degrees of recanalization and thus lead to varied outcomes. Therefore, the effect of MT on hemicraniectomy rates in patients with AIS warrants further investigation following the advent of standardized thrombectomy techniques. Disclosures E. Luther: None. D. McCarthy: None. R. Starke: None.

Introduction Carotid blowout syndrome (CBS) refers to the acute rupture of any segment of the common carotid artery, including both the external and extracranial internal carotid arteries (ICA). CBS often results in life threatening hemorrhage and acute upper airway obstruction. CBS is a well-known phenomenon in patients with head and neck cancer and typically occurs via direct extension of tumor into the arterial wall or iatrogenically during surgical manipulation. With a reported incidence of 4.3% following radical neck dissection and mortality rates as high as 60%, CBS must always be considered in any patient with head or neck cancer and acute hemorrhage in the oro- or nasopharynx of unknown origin. Accepted management strategies for CBS include open surgical ligation or endovascular treatment via parent vessel sacrifice or intraluminal stent placement. One of the more feared complications associated with endovascular parent vessel sacrifice is distal migration of embolic material, which can lead to ischemic stroke. Delayed migration of embolic material into the oro- or nasopharynx is extremely uncommon. We present a case of a coil migration into the nasopharynx one year following endovascular treatment of CBS that occurred during nasopharyngeal carcinoma resection. Methods A 41-year-old female presented with brisk oral cavity hemorrhage after undergoing surgical resection of nasopharyngeal carcinoma seven weeks prior. Results Computed tomography angiography (CTA) revealed a small 0.2×0.2×0.3 cm pseudoaneurysm arising from the medial aspect of the right ICA at the level of C1-C2 vertebrae that abutted the nasopharynx. After radiographically passing a balloon test occlusion (BTO), the decision was made to endovascularly sacrifice the right ICA. With the balloon inflated, embolization with coils and onyx was performed in the petrous segment of the ICA. Angiography and CTA confirmed pseudoaneurysm obliteration and complete vessel occlusion. Three-month follow-up CTA demonstrated stable vessel occlusion. Eleven months following ICA sacrifice, she started to complain of throat irritation and difficulty swallowing. During a scheduled sinus debridement, exposed coils were visualized in the right nasopharynx. CTA revealed vessel wall dehiscence with extrusion of coils into the nasopharynx but continued occlusion of the vessel. The exposed coils were clipped and extracted endoscopically for symptomatic relief. Three-month follow-up angiogram confirmed stable vessel occlusion and patient has remained asymptomatic. Conclusion CBS can be a rare and devastating complication of head and neck surgery, often requiring immediate endovascular treatment. Coil migration is a rare complication following cerebral pseudoaneurysm obliteration via endovascular vessel sacrifice. When a patient has a partially extruding coil, it is imperative to obtain imaging and treat as soon as possible to avoid further coil migration and possible airway compromise. Disclosures D. Sheinberg: None. D. McCarthy: None. E. Luther: None. S. Chen: None. R. Starke: None.