In adults, complete surgical resection of arteriovenous malformations (AVMs) is generally curative. Recurrence of AVMs is extremely rare and most often delayed over many years. The authors report the case of a man in his 20s with rapid AVM recurrence and dual blood supply from the dura and intracerebral vessels. Early recurrence of the AVM allowed documentation of the early events associated with this recurrence. This was evidenced by the first appearance of an early vein without any signs of abnormal vasculature, suggesting that abnormality of the venous drainage system might be an inciting event in the recurrence and perhaps genesis of AVMs.
These findings demonstrate that it is acceptable for a patient with this new liquid embolic device to undergo MRI at ≤3 T. Notably, the associated artifacts are unlikely to create issues for diagnostic MRI examinations.
Background: Management of patients with ischemic stroke after endovascular treatment requires knowledge of peri-procedural complications. The SWIFT trial compared two devices (Merci and SOLITAIRE) in a randomized, prospective study. We reviewed peri-procedural complications of endovascular treatment and related clinical and technical factors. Methods: The SWIFT database was searched for major peri-procedural complications defined as: symptomatic intracranial hemorrhage (sICH) within 36 hours, symptomatic subarachnoid hemorrhage (SAH), air emboli, vessel dissection, major groin complications, and emboli to new vascular territories. Results: Major peri-procedural complications occurred in 18/144 patients (12.5%) at the following rates: sICH (4.9%); SAH (3.5%), air emboli (1.4%), vessel dissection (4.2%), major groin complications (2.8%), and emboli to new vascular territories (0.7%). We did not observe any statistically significant associations of complications with: age (<65 y 13.8% vs. >65 y 11.6%); type of center (academic 9.3% vs non-academic 13.9%); duration of stroke symptoms (<6h 11.1% vs 14.7% >6 h), NIH stroke scale score (NIHSS<20 12% vs. NIHSS >20,13.9%), iv thrombolytics (no iv tPA 10.5% vs iv tPA15.2%), atrial fibrillation (absent 10.1% vs present 14.7%), site of vessel occlusion (ICA 19.2%; MCA 11.5%); rescue therapy administered after endovascular treatment (no rescue 11.9% vs rescue 14.9%); or device (Merci 14.5%; Solitaire 11.2%). Comparing the Merci to the Solitaire retrieval device, we observed the following peri-procedural events: Conclusion: Detailed knowledge of peri-procedural complications is important for managing stroke patients after endovascular treatment. Fewer endovascular complications were observed after with SOLITAIRE device treatment compared to Merci device treatment, particularly symptomatic cerebral hemorrhage. Device registries will be helpful to gain deeper understanding of rare events.
Imaging Findings CT and MRI showed multiple areas of acute ischemia involving both occipital lobes and the right cerebellar hemisphere. The CT also showed an enlarged right hypoglossal canal. MRA and DSA revealed an anomalous vessel, arising extracranially from the cervical segment of the internal carotid artery, entering the intracranial compartment through the hypoglossal canal and supplying the basilar artery. The distal portion of this vessel, just below the basilar junction, had a critical stenosis. This critical stenosis was treated endovascularly with angioplasty and stenting, using a 3315 mm Gateway balloon and a 4315 mm Wingspan stent. Summary A persistent hypoglossal artery is one of four primitive embryologic connections between the internal carotid artery and the vertebrobasilar circulation. Atherosclerotic disease of the common or the proximal internal carotid artery, or of the hypoglossal artery itself, may present with symptoms of vertebrobasilar insufficiency, or lead to infarction in the posterior circulation. To our knowledge, this represents the first case report of intracranial stenting through a persistent hypoglossal artery. The technical aspects of the endovascular treatment are addressed. We also discuss the anatomy of the persistent hypoglossal artery, using CT, MRI, MRA, biplanar and 3D DSA, and Dyna CT correlation.
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