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Objective and importance We describe two patients with symptomatic septum pellucidum cysts managed by endoscopic fenestration. In each case, tissue from the cyst wall was studied to define the origin of the cyst wall and fluid. Clinical presentation The patients, a 6-year-old boy and a 42-year-old man, each presented with headaches and a syncopal episode. Imaging studies demonstrated large septum pellucidum cysts with obstruction of the foramina of Monro. Intervention The patients underwent endoscopic transventricular cyst fenestration with a 4-mm steerable fiberscope. The fenestrations were created to allow communication with the right and left lateral ventricles. In one patient, adhesions between the cyst wall and the foramen of Monro were lysed with endoscopic monopolar cautery. Tissue from the cyst walls was removed for examination by electron microscopy. Postoperatively, the headaches and syncopal episodes resolved in both patients. Conclusion Endoscopic fenestration of symptomatic septum pellucidum cysts produces immediate relief of the mass effect of the cyst and resolution of associated symptoms. Cannulation of the lateral ventricle before cyst fenestration prevents inadvertent injury to the fornices, thalamus, internal capsule, caudate nucleus, and septal and thalamostriate veins. The endoscopic approach allows the surgeon to ensure communication within the ventricular system, thus avoiding placement of a shunt. Preliminary ultrastructural analysis indicates that the cyst walls derive from the septum pellucidum rather than the choroid plexus or arachnoid. The cellular machinery necessary for fluid secretion was identified in some specimens.

Direct carotid-cavernous fistulas are high-flow shunts with a direct connection between the internal carotid artery and the cavernous sinus. The goals of treatment are to eliminate the fistula and preserve carotid artery patency. The authors reviewed the outcome of 98 patients with 100 consecutive direct carotid-cavernous fistulas initially treated by transarterial embolization with detachable balloons (1979-1992) at the University of Cincinnati Medical Center to evaluate the merits of this technique and to provide a standard for comparison with future treatment alternatives. Among 100 fistulas, 76 were traumatic in origin, 22 resulted from a ruptured aneurysm, and 2 were iatrogenic. The most common presentations were orbital bruit (80%), proptosis (72%), chemosis (55%), abducens palsy (49%), and conjunctival injection (44%). Eighty-eight fistulas were successfully occluded in 86 patients with detachable balloon(s), and internal carotid blood flow was preserved in 66 patients (75%). Initial attempts at balloon occlusion failed in four patients in whom the fistula eventually closed spontaneously. Five patients required direct surgery to occlude the fistula, and two were treated with nondetachable balloons; one patient died from injuries sustained from trauma. The permanent neurological complication rate was 4%, including cerebral infarction in one patient, frontal intracerebral hemorrhage in one patient, and vision loss in another patient. One death occurred related to cerebral infarction from a balloon that shifted. Transient ischemia occurred in three patients. On the basis of these results, we conclude that transarterial embolization with detachable balloons provides a high rate of fistula obliteration with low morbidity and is the best initial procedure to treat direct carotid-cavernous fistulas.

Cavernous angiomas of the dura mater are clinically and radiographically distinct from parenchymal cavernous angiomas. In this report, we present two cases of dural cavernous angiomas located outside the middle cranial fossa. The first patient is a 36-year-old woman with two dural cavernous angiomas, including one that enlarged during a 2-year period of observation. The second patient is a 33-year-old man with medically intractable seizures from a dural cavernous angioma of the convexity, which was discovered at autopsy. From our experience and a review of the literature, we have identified two groups of dural cavernous angiomas that differ in incidence, natural history, and surgical management

The therapeutic options for arteriovenous malformations (AVMs) of the thalamus and the basal ganglia have expanded to include preoperative embolization, stereotactic radiation, and microsurgery. Adjuncts to surgery such as stereotactic guidance, electrophysiological monitoring, intraoperative ultrasound, intraoperative angiography, and induced hypotension have significantly reduced postoperative morbidity. We review the management and outcome of 65 consecutive patients who were treated for deep-seated supratentorial vascular malformations; 45 patients (69%) were treated surgically, 10 patients (15%) were treated conservatively, and 10 patients (15%) underwent radiosurgery. This retrospective study (1976-1993) includes 51 AVMs (78%), 14 cavernous angiomas (22%), and 10 associated vascular anomalies (15%). Initially, 59 (91%) of 65 patients presented with hemorrhage; 23 patients (39%) suffered recurrent hemorrhages. Malformations ranged in size from 1 to 7.5 cm (mean, 2.8 cm). AVMs were fed principally by the anterior and posterior choroidal, thalamoperforate, and lenticulostriate arteries. Venous drainage was uniform via the deep venous system. Among 39 patients who underwent surgery for AVMs, 26 (67%) improved, 7 (18%) remained unchanged, 5 (13%) worsened, and 1 (3%) died. Among six patients who underwent surgery for cavernous angiomas, four (66%) improved, one (17%) remained unchanged, and one (17%) worsened. Operative complications included transient neurological deficits in seven patients (16%), permanent neurological deficits in six patients (13%), and new bleeding from residual AVMs in four patients (9%). Among 10 patients treated conservatively, 3 (30%) had repeat hemorrhages, 2 (20%) had progressive neurological deficits, and 1 (10%) died.(ABSTRACT TRUNCATED AT 250 WORDS)