[Show abstract][Hide abstract] ABSTRACT: Venous vascular malformations (VVMs) are described as abnormal post-capillary lesions which exhibit low flow. These are typically malleable and may grow with endocrine fluctuations. A VVM that mimics the classic appearance of dermoid tumor on imaging has never been reported. We encountered a 43-year-old woman with intermittent dysphagia relating to a firm submandibular mass. Physical exam and cross-sectional imaging revealed features consistent with variant dermoid cyst. However, catheter angiography eventually demonstrated a VVM which possessed vessels of variable size and partial thrombosis. We report the case and propose that catheter angiography remains important in cases where vascular malformation is considered.
Full-text · Article · Dec 2015 · American Journal of Otolaryngology
[Show abstract][Hide abstract] ABSTRACT: PURPOSE/AIM
To describe the imaging modalities for evaluating intradural vascular spinal tumors, review their imaging characteristics and the role of preoperative endovascular embolization.
Vascular spinal tumors, in particular hemangioblastoma, paraganglioma, ependymoma and meningioma, have common characteristic imaging features such as hypointense rim in T2WI, serpentine flow voids, intense enhancement after administration of contrast material, and highly vascular appearance in angiography. The role of endovascular embolization is reinforced in this article as an approach that would facilitate the resection of these lesions.
Diagnosis of intradural vascular spinal tumors plays an important role in the management and interferes with prognosis and final outcome. Vascular spinal tumors represent a special challenge because of the bleeding that may occur during surgery. Their treatment has benefited from the combination of imaging and technical improvements. Carefully planned endovascular embolization is safe and facilitates the resection of these lesions, becoming the standard of care in the treatment of these tumors.
[Show abstract][Hide abstract] ABSTRACT: Vein of Galen aneurysmal malformations (VGAMs) are arteriovenous malformations (AVMs) of the choroidal system that develop in the early embryonic stage and have been recognized as possibly the only embryonic vascular malformations. Unlike pial AVMs, the actual shunt lies in the subarachnoid space. Raybaud et al. were the first to recognize that the ectatic vein in a VGAM is, in fact, not the vein of Galen but rather the median vein of the prosencephalon, the embryonic precursor of the vein of Galen itself . Additionally, there is persistence of alternative routes for deep venous drainage as most often the choroidal vein and the thalamostriate vein fail to connect to the torcula owing to the arterialization and missing development of the vein of Galen and the straight sinus . The clinical presentation of VGAM and its natural history vary significantly from pial AVMs. The management options, timing of intervention, and potential complication make it imperative that this condition be recognized precisely and accurately and managed at an experienced center at the optimal moment in time in order to achieve a normally developing child. Angioarchitecture It is possible to distinguish the angioarchitectural differences between an AVM involving the vein of Galen forerunner (the median vein of the prosencephalon) and an AVM with venous drainage into a dilated vein of Galen (VGAD). The first involves the choroidal fissure and extends from the interventricular foramen rostrally to the atrium laterally . The arterial supply usually involves all the choroidal arteries, including subfornical and anterior choroidal contributions; it may also receive significant contribution from the subependymal network from the posterior circle of Willis. Involvement of transmesencephalic arteries (which are easy to identify on MRI) would exclude the diagnosis of VGAM . Subependymal and transcerebral contributions appear as accessory in the supply to the shunt, possibly created by the venous-sump effect . As they are secondarily triggered by the VGAM, they will spontaneously disappear after proper treatment of the major supply to the shunt. A persistent limbic arterial arch is often seen that bridges the posterior cerebral artery with the pericallosal artery through the choroidal arteries. The nidus of the lesion is usually located in the midline and, therefore, usually receives bilateral and symmetrical supply .
[Show abstract][Hide abstract] ABSTRACT: Background and purpose:
Unruptured intracranial aneurysms are frequently followed to monitor aneurysm growth. We studied the yield of follow-up imaging and analyzed risk factors for aneurysm growth.
We included patients with untreated, unruptured intracranial aneurysms and ≥6 months of follow-up imaging from 2 large prospectively collected databases. We assessed the proportion of patients with aneurysm growth and performed univariable and multivariable Cox regression analyses to calculate hazard ratios with corresponding 95% confidence intervals (CI) for clinical and radiological risk factors for aneurysm growth. We repeated these analyses for the subset of small (<7 mm) aneurysms.
Fifty-seven (12%) of 468 aneurysms in 363 patients grew during a median follow-up of 2.1 years (total follow-up, 1372 patient-years). In multivariable analysis, hazard ratios for aneurysm growth were as follows: 1.1 (95% CI, 1.0-1.2) per each additional mm of initial aneurysm size; 2.7 (95% CI, 1.2-6.4) for dome > neck ratio; 2.1 (95% CI, 0.9-4.9) for location in the posterior circulation; and 2.0 (95% CI, 0.8-4.8) for multilobarity. In the subset of aneurysms <7 mm, 37 of 403 (9%) enlarged. In multivariable analysis, hazard ratios for aneurysm growth were 1.1 (95% CI, 0.8-1.5) per each additional mm of initial aneurysm size, 2.2 (95% CI, 1.0-4.8) for smoking, 2.9 (95% CI, 1.0-8.5) for multilobarity, 2.4 (95% CI, 1.0-5.8) for dome/neck ratio, and 2.0 (95% CI, 0.6-7.0) for location in the posterior circulation.
Initial aneurysm size, dome/neck ratio, and multilobarity are risk factors for aneurysm growth. Cessation of smoking is pivotal because smoking is a modifiable risk factor for growth of small aneurysms.
[Show abstract][Hide abstract] ABSTRACT: Introduction
The purpose of our study was to compare the clinical characteristics and preferential localization of aneurysms in three patient groups: single aneurysm, non-mirror multiple aneurysms, and mirror aneurysms.
We retrospectively reviewed the clinical and radiological data of 2223 consecutive patients harboring 3068 aneurysms registered at the Toronto Western Hospital between May 1994 and November 2010. The patients were divided into single, non-mirror multiple, or mirror aneurysm groups. Expected incidences of mirror aneurysms at each location were calculated on the basis of the single aneurysm incidences at each location.
Patients with mirror aneurysms (n = 197) did not differ from patients with non-mirror multiple aneurysms (n = 392) in having female predominance (81.7 vs. 76.3 %) or a family history of intracranial aneurysm (20.5 vs. 17.6 %). When compared with expected incidences at each location, mirror aneurysms were more frequently found at the cavernous internal carotid artery (30 vs. 11.5 %) (p
[Show abstract][Hide abstract] ABSTRACT: Background and purpose:
Management of unruptured fusiform intracranial aneurysms is controversial because of the paucity of natural history data. We studied their natural history and outcome after treatment.
We reviewed our neurovascular database from January 2000 to October 2013. Inclusion criteria were unruptured, intradural fusiform aneurysms with a diameter of <2.5 cm. Criteria were developed to define atherosclerotic aneurysms. For outcome assessment, we used the modified Ranking Scale and aneurysm measurements on serial imaging. Mann-Whittney (continuous) and Fisher exact (categorical) tests were used for risk factor analysis.
For nonatherosclerotic aneurysms (96 patients; 193 person-years follow-up), 1 patient died (rupture) during follow-up (mortality, 0.51% per year) and 8 patients (10%) showed aneurysm progression (risk, 1.6% per year). Risk factors for progression were maximum diameter (>7 mm; odds ratio, 12; 95% confidence interval, 1.4-104) and symptomatic clinical presentation (odds ratio, 16; 95% confidence interval, 3.1-81.4). Of the 23 treated patients, 3 had died (mortality, 12.5%) and 3 had serious disability (modified Ranking Scale, ≥3; 12.5%). For the atherosclerotic aneurysms (25 patients; 97 person-years follow-up), 5 had died (mortality, 5.2% per year) and 13 of 20 (65%) had aneurysm progression (risk, 12% per year). When compared with patients with nonatherosclerotic aneurysms, case fatality (odds ratio, 19.2; 95% confidence interval, 2.1-172) and aneurysm progression (odds ratio, 17.8; 95% confidence interval, 5.3-56) were higher.
Nonatherosclerotic fusiform intradural aneurysms have a low risk of adverse outcome within the first few years after diagnosis and remain stable unless symptomatic on presentation or >7 mm in maximum diameter. High risks of treatment should be balanced against this benign natural history. Atherosclerotic aneurysms have a worse natural history and may represent a different disease entity.
[Show abstract][Hide abstract] ABSTRACT: Objectives:
To report the epidemiological features, clinical presentation, angiographic characteristics and therapeutic options, success and complication rates in patients with dural carotid cavernous fistulas (dural CCFs).
Retrospective evaluation of patients followed in our institution between January of 2005 and September of 2013.
There were 38 patients, 76 % females, with an average age of 63 years. Ocular symptoms and signs were the most frequent clinical findings. Dural CCFs were Barrow type B in 8%, type C in 10% and type D in 82%. Cortical venous reflux was present in 50% of cases. Medical treatment was performed in 16% of patients, external ocular compression in 8%, transarterial embolisation in 13%, transvenous embolisation in 60% and radiosurgery in 3%. Clinical and angiographic follow-up data were available in 89% and 82% of patients with a mean follow-up time of 9 and 7 months, respectively. Clinical cure was achieved in 58% of patients and improvement in 24%. Anatomical cure was demonstrated in 68%. Transient worsening or new onset of ocular symptoms was observed in 29%. There was no permanent morbidity or mortality.
In properly selected patients, endovascular embolisation, particularly by transvenous approach, represents a safe and effective treatment for dural CCFs.
Dural carotid cavernous fistulas are more common in elderly women. Dural CCFs most commonly present with ocular symptoms and signs. Endovascular treatment is effective and safe in properly selected patients.
No preview · Article · Jul 2014 · European Radiology
[Show abstract][Hide abstract] ABSTRACT: Background and purpose:
As a result of the rarity of spinal cord arteriovenous malformations (AVM), there are only a few series available that describe clinical features, outcome after treatment, and natural history of these lesions. In this article, we aim to describe our experience with both nidus- and fistulous-type spinal cord AVMs.
Forty-four consecutive patients with spinal cord AVMs were retrospectively reviewed. There were 26 patients with a nidus-type and 18 patients with a fistulous-type AVM. Treatments were performed with embolization (n=23), surgery (n=13), combined embolization-surgery (n=3), or conservative management (n=5). Clinical features, radiological findings, treatment results, and clinical outcomes were assessed.
Patients with nidus-type AVMs were younger at presentation and more often presented with hemorrhage, with a higher proportion of hematomyelia than fistulous-type AVMs (P<0.05). Progression of clinical presentation from hemorrhage to congestive myelopathy during follow-up was noted in 5 patients, all of which had AVMs of the nidus type. Complete obliteration could be achieved more often in the fistulous type (72%) than in the nidus type (27%). Improved or stable clinical status at last follow-up was noted in 100% of fistulous-type and 77% of nidus-type patients. Long-term clinical deterioration was noted in 6 of 26 patients with nidus-type (23%) AVMs and was related to recurrent bleeding (n=3) or progressive venous congestion (n=3). Overall rebleed rate after presentation with hemorrhage was 7 in 145.5 patient-years (4.8%/y) if the lesion was not treated, 3 in 102 patient-years (2.9%/y) after partial treatment, and 0 in 47.5 patient-years (0%) after complete treatment.
Nidus and fistulous spinal cord AVMs have different clinical features and obliteration rates, which may affect their long-term prognosis.
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to determine the accuracy and utility of contrast-enhanced MR angiography (CE-MRA) in spinal dural arteriovenous fistulas (SDAVF). A retrospective analysis from 1999-2012 identified 70 patients clinically suspected of harboring a SDAVF. Each patient underwent consecutive conventional MR-imaging, CE-MRA, and digital subtraction angiography (DSA). The presence or absence of serpentine flow voids, T2-weighted hyperintensity, and cord enhancement were evaluated, as well as location of the fistula as predicted by CE-MRA. DSA was used as the reference standard. Of the 70 cases, 53 were determined to be a SDAVF, 10 cases were shown to be other forms of vascular malformation, and 7 were DSA-negative. On MRI, all reported cases of SDAVF showed serpentine flow voids (100 %). T2-weighted hyperintensity was seen in 48 of 50 cases (96 %), extending to the conus in 41 of 48 cases (85 %). Cord enhancement was seen in 38 of 41 cases (93 %). CE-MRA correctly localized the SDAVF in 43 of the 53 cases (81 %). CE-MRA is a useful non-invasive examination for the detection and localization of SDAVF. CE-MRA facilitates but does not replace DSA as confirmation of location, fistula type, and arterial detail, which are required before treatment. aEuro cent CE-MRA correctly localized the site of the SDAVF in over 80 % of cases. aEuro cent CE-MRA facilitates diagnostic DSA and expedites the diagnostic process. aEuro cent CE-MRA does not replace diagnostic DSA in SDAVF cases as confirmative test. aEuro cent CE-MRA provides better understanding of missed or mislocalized SDAVF cases.
No preview · Article · Jul 2014 · European Radiology
[Show abstract][Hide abstract] ABSTRACT: Head and neck arteriovenous malformations (H&N AVM) are challenging to treat, and impart clinical and psychosocial morbidity. We evaluated the role of endovascular therapy and its success with varying presentations and characteristics.
No preview · Article · Jul 2014 · Journal of Neurointerventional Surgery
[Show abstract][Hide abstract] ABSTRACT: To describe pregnancy outcomes in women with hereditary hemorrhagic telangiectasia (HHT).
This was a retrospective descriptive study of women with HHT (18-55 years of age) from the Toronto HHT Database using a telephone questionnaire regarding pregnancy, delivery, and neonatal outcomes.
A total of 244 pregnancies were reported in 87 women with HHT. Miscarriages occurred in 20%. Hereditary hemorrhagic telangiectasia-related complications included minor hemoptysis during two pregnancies (1.1%) and hemothorax during four pregnancies (2.1%). One patient presenting with a hemothorax had presented during a previous pregnancy with a transient ischemic attack, most likely resulting from paradoxical emboli. One patient presented with an intracranial hemorrhage, and one patient presented with heart failure. These complications occurred in women previously unscreened and untreated for arteriovenous malformations. Other complications not clearly related to HHT were deep vein thrombosis (n=1), pulmonary embolism (n=1), myocardial infarction (n=1), and myocardial ischemia (n=1). Women noticed an increased frequency of epistaxis and development of new telangiectases during pregnancy. Epidural or spinal anesthesia was performed in 92 of 185 deliveries (50%) without complications. None of these women had undergone screening for spinal arteriovenous malformation before anesthesia.
Women with HHT who have not been screened for arteriovenous malformations are at risk for serious pregnancy complications. LEVEL OF EVIDENCE:: III.
Full-text · Article · Feb 2014 · Obstetrics and Gynecology
[Show abstract][Hide abstract] ABSTRACT: Unfortunately, two of the authors names, Dae Chul Suh and Michael Soderman, were incorrectly listed as Dae Sul Chuh instead of Dae Chul Suh and Michael Soderman instead of Michael Söderman in the original publication of this paper.
No preview · Article · Dec 2013 · Interventional Neuroradiology
[Show abstract][Hide abstract] ABSTRACT: Cerebral cavernous malformations (CCMs) can cause symptomatic intracranial haemorrhage (ICH), but the estimated risks are imprecise and predictors remain uncertain. We aimed to obtain precise estimates and predictors of the risk of ICH during untreated follow-up in an individual patient data meta-analysis.
[Show abstract][Hide abstract] ABSTRACT: Purpose: To identify the predictors of symptomatic post-radiation T2 signal change in patients with arteriovenous malformations (AVM) treated with radiosurgery. Materials and Methods: The charts of 211 consecutive patients with arteriovenous malformations treated with either gamma knife radisurgery or linear accelerator radiosurgery between 2000-2009 were retrospectively reviewed. 168 patients had a minimum of 12 months of clinical and radiologic follow-up following the procedure and complete dosage data. Pretreatment characteristics and dosimetric variables were analyzed to identify predictors of adverse radiation effects. Results: 141 patients had no clinical symptomatic complications. 21 patients had global or focal neurological deficits attributed to symptomatic edema. Variables associated with development of symptomatic edema included a non-hemorrhagic symptomatic presentation compared to presentation with hemorrhage, p=0.001; OR (95%CI) = 6.26 (1.99, 19.69); the presence of venous rerouting compared to the lack of venous rerouting, p=0.031; OR (95% CI) = 3.25 (1.20, 8.80); radiosurgery with GKS compared to linear accelerator radiosurgery p = 0.012; OR (95% CI) = 4.58 (1.28, 16.32); and the presence of more than one draining vein compared to a single draining vein p = 0.032; OR (95% CI) = 2.82 (1.06, 7.50). Conclusions: We postulated that the higher maximal doses used with gamma knife radiosurgery may be responsible for the greater number of adverse radiation effects with this modality compared to linear accelerator radiosurgery. We found that AVMs with greater venous complexity and therefore instability resulted in more adverse treatment outcomes, suggesting that AVM angioarchitecture should be considered when making treatment decisions.
Preview · Article · Nov 2013 · The Canadian journal of neurological sciences. Le journal canadien des sciences neurologiques
[Show abstract][Hide abstract] ABSTRACT: Despite improvements of embolization agents and techniques, endovascular treatment of spinal dural arterovenous fistula (SDAVF) is still limited by inconsistent success. The aim of embolization is to occlude initial portion of the draining vein by liquid embolic materials. This study investigates factors that contribute to the success of embolization treatments among SDAVF patients.
We performed a retrospective analysis on consecutive SDAVF patients who received N-butyl cyanoacrylate (NBCA) glue embolization between January 1992 and June 2012. Univariable and multivariable logistic regression analyses were performed to calculate the probability of successful draining vein occlusion for variable procedure-related factors.
We attempted endovascular approach as the first intention treatment in 66 out of 90 consecutive patients. Among them, a total of 43 NBCA glue injections were performed in 40 patients. Successful embolization was achieved in 24 patients (60 %). In multivariable analyses, antegrade flow during microcatheter test injection (OR 13.2, 95 % CI 1.7 to 105.4) and use of glue concentration ≥30 % (OR 0.1, 95 % CI 0.01 to 0.8) were detected as significant positive and negative predictors of successful venous penetration, respectively. With persistent antegrade flow, the success rates using a glue mixture of more than 30 % dropped significantly from 85.0 to 42.9 % (p = 0.049). If contrast stagnated during microcatheter injections, success rates were low regardless of glue concentrations.
Presence of antegrade flow toward the draining vein and injection of NBCA glue less than 30 % are associated with higher chance of draining vein penetration and, therefore, successful endovascular SDAVF obliteration.