Dural arterio-venous fistulas of the middle cranial fossa may occur within the dura of lesser or greater sphenoid wings. Lesser sphenoid wing fistulas rarely recruit cortical venous drainage and mostly drain in the cavernous sinus. On the other hand, greater sphenoid wing dural fistulas, also known as paracavernous fistulas or sphenobasilar and sphenopetrosal sinus fistulas, are much more notorious as they almost always connect with the superficial middle cerebral vein resulting in secondary cortical venous reflux and varix formation. Curative transarterial or transvenous endovascular embolisation of fistulous connection is the primary therapeutic strategy, particularly using onyx via the transarterial approach. In the present case we describe a 62-year-old man who presented with significant subarachnoid haemorrhage, intraparenchymal and intra-ventricular bleed. Digital subtraction angiography showed a middle cranial fossa dural arteriovenous fistula in the region of the sphenobasilar sinus with cortical venous reflux and varix formation. The patient underwent successful transarterial endovascular embolisation with complete elimination of the fistula using onyx 34, onyx 18, squid 12 and a Scepter XC balloon using the pressure cooker technique. We also report the development of facial nerve palsy due to inadvertent reflux of onyx in the petrosal branch of the middle meningeal artery.
Perforator aneurysms are rare vascular lesions that are infrequently reported in literature, and because of difficult anatomic approach, their treatment and management pose challenges. Given the rarity of these aneurysms, the natural history and ideal approach to treatment has not been established. The authors retrospectively analyzed six patients, age ranging from 16 to 75 years with ruptured perforator aneurysm, four of posterior circulation and two of anterior circulation including clinical characteristics, imaging data, treatment regimen, and outcome. All but two patients presented with the World Federation of Neurosurgical Societies grades I to III and Fisher grade 2 or 3 subarachnoid hemorrhage, and the other two presented with intracerebral bleed in the right gangliocapsular region. Four patients were managed conservatively whereas two basilar perforator aneurysms were treated with endovascular stent. At the last follow-up, the endovascularly treated group of patients demonstrated complete thrombosis of aneurysm with preservation of perforators, and the conservatively managed group showed spontaneous occlusion in one patient, whereas three were lost to follow-up and ultimate outcome remains unknown. The authors report single-center hospital-based experience in six patients, which adds to the scarce published literature that addresses the limited understanding of the natural course and consolidating safe endovascular management of this entity.
Rete MCA anomaly is extremely rare and has been seldomly discussed in literature. Embryologically MCA develops by fusion of multiple twigs which form a single channel. If there is failure to fuse a plexiform network of vessels persists known as rete MCA. This web like network of vessels is at high risk of haemorrhagic stroke and therefore for patients presenting incidentally correct diagnosis is paramount. Here we report a case of rete MCA anomaly in a 35-year-old gentle man who presented with a large haemorrhagic stroke in emergency. DSA showed unilateral involvement of proximal MCA, and otherwise normal intra-cranial vasculature. With this report we aim to correctly diagnose this rare condition and avoid misdiagnosis leading to unnecessary treatments.
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