Pial arteriovenous fistula (PAVF) is an extremely rare type of intracranial vascular congenital anomalies. The presented clinical case is a unique example of intrauterine diagnosis of PAVF using fetal MRI at 30 weeks of gestation, which allowed successful surgical treatment in the early neonatal period. The case demonstrates the capabilities of fetal MRI in the diagnosis of PAVF and estimation of accompanying brain changes, which are fully consistent with the results of postnatal cerebral angiography. Based on neuroimaging data, endovascular embolization of the fistula with detachable microcoils was successfully performed on the 2nd day of the child’s life. A good neurologic outcome of the surgery was stated. Taking into account the known unfavorable outcome of PAVF in the case of untimely surgical treatment, this observation demonstrates the need to use fetal MRI for prenatal differential diagnosis of vascular malformations in order to reduce the risk of possible complications and mortality in the early neonatal period.
BACKGROUND Pediatric arteriovenous malformations (AVMs) and pial/dural arteriovenous fistulas (AVFs) are rare but life-threatening complications that can lead to congestive heart failure and hemorrhagic stroke in newborns and pediatric patients. The pronounced shunting in these conditions is associated with early complications and necessitates aggressive surgical management. Here, the authors describe endovascular treatment of an atypical cerebral pial AVF in a newborn. OBSERVATIONS This AVF formed direct communication between a major cerebral artery (basilar artery) and a large draining vein (dilated deep cerebral vein). The authors performed earlier subtotal embolization of the AVF using 0.020-inch coils, which led to progressive thrombosis of the fistula with restoration of normal arterial blood flow. The patient was discharged 18 days after surgery, examination at 1.5 and 6 months showed magnetic resonance imaging signs of blood flow absence through the fistula and satisfactory condition of the infant without physical and mental developmental delay. LESSONS Subtotal coiling of a high-flow pial AVF in a newborn can result in a good clinical outcome.
Highlights. Small cerebral aneurysms (<3 mm), which make up the majority of aneurysms, rupture more frequently, although medium (>3 mm) and giant (>15 mm) aneurysms and have a higher risk of rupture. This article proves for the first time that the rupture risk criteria developed for giant cerebral aneurysms do not work for small aneurysms. The development of small aneurysms in patients was analyzed and measured morphological features of aneurysms were compared with their calculated hydrodynamic characteristics.Aim. To study the dynamics of development of small cerebral aneurysms, to assess the applicability of existing methods for calculating the risk of rupture, to formulate new clarifying hypotheses for calculating the risk of rupture of small cerebral aneurysms.Methods. Patient data were provided by the Federal Center for Neurosurgery, Novosibirsk. CT angiography was performed using a Philips Ingenuite CT scanner (Philips Medical Systems, USA, 128 slices). Aneurysm size dynamics was assessed by measuring three main sizes with an accuracy of 0.1 mm using the IntelliSpace Portal Philips software environment. Numerical calculations were carried out using ANSYS CFX 2020R2.Results. Hemodynamic characteristics change according to the changes of the aneurysm dome. In the case when morphological characteristics of the aneurysm have not changed, a change in the geometry of the patient's circle of Willis (coW) is observed: the curvature of the arteries, the angles of bifurcations (the structure of coW remained unchanged). The PHASES score (absolute risks of rupture for aneurysms) was found to be unusable for the considered aneurysms.Conclusion. This work formulates and morphologically and hydrodynamically confirms for the first time in the volunteers that the change in risk estimates for such aneurysms is fundamentally affected, even insignificantly, by the change in the circle of Willis: a change in the curvature of individual segments of the cerebral arteries, as well as the angles of their bifurcations. The results obtained are aimed at modifying the existing risk criteria for rupture of cerebral aneurysms.
World statistics data suggest that the surgical revascularization of the myocardium in multivessel coronary artery disease is performed in 40 to 60% of cases. However, severity of coronary artery disease is often evaluated through the analysis of clinical presentation and selective coronary angiography (ICA) data without an assessment of the functional significance of stenosis. A precise algorithm for the treatment of patients with multivessel coronary artery disease and stable coronary artery disease is still unavailable, i.e. extent of revascularization, its time, and criteria for complete withholding of surgical treatment remain unclear. Many factors affect myocardial blood supply in multivessel disease including the type of blood supply to the heart, presence of scar and collaterals, diameter of the affected artery, and presence of microvascular dysfunction. All these factors require rational and intelligent approach to establishing the optimal tactics. In this review, the authors identified discussion vector and presented their original opinion on the advisability/unreasonableness of approaches to revascularization in patients with multivessel coronary disease based on published clinical trials and current recommendations. In addition, we analyzed the existing data, identified the missing information, and proposed the prospects for possible new clinical studies in this scientific field.
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