Background Spontaneous obliteration of cerebral arteriovenous malformations is uncommon but could occur after partial embolization. Methods A retrospective study of 140 patients that underwent embolization for cerebral AVMs from 2005 to August 2019 using liquid embolic agents. The angiographic outcome of patients was classified as regard complete embolization, partial embolization, and complete obliteration after partial embolization. The parameters studied included size, location, number of arterial feeders, number of draining veins, rupture status, embolic agent, and patient factors as well. Results The study patients included 74 (53%) females and 66 (47%) males. Their age ranged from 7 to 43 years old. One hundred and eight patients (77%) presented with hemorrhage. The AVM grades were grade II in 57 (40.7%) patients and grade III in 56 (39.3%) patients. Sixty-one (43.57%) patients were treated by n-Butyl Cyanoacrylate and 71 (50.71%) patients were treated with Onyx, and both materials were used together in 8 cases. Follow-up angiography was done from 6 to 36 months after embolization. The rate of complete occlusion in all patients was 61.43% (86 patients). There were three groups of patients, the first group had complete occlusion of the nidus at the time of embolization and included 68 (48.57%) patients. The second group had partial embolization with partial occlusion of the nidus 54 patients (38.57%). The 3rd group included 18 patients (12.85%) with complete nidal occlusion on follow up after partial embolization. The delay in the venous drainage of the AVM to the late arterial phase or early venous phase with flow stasis was a significant predictor of future obliteration on follow up after partial embolization. Other significant parameters that were associated with the progressive disappearance of the AVM nidus on follow up after partial embolization are presentation with hemorrhage, AVMs size less than 3 cm, the presence of single draining or double draining veins, superficial venous drainage, and one or 2 arterial feeders. Conclusion Spontaneous closure of intracranial arteriovenous malformations after partial embolization may be encountered in cases of stasis of flow during embolization procedure with a delay of the venous drainage. A long-term follow-up of more cases over many years is required to confirm the validity of this conclusion.

Background Vasospasm is a grave complication of aneurysmal subarachnoid hemorrhage (SAH) with a significant rate of morbidity and mortality. Endovascular intra-arterial injection of Ca channel blocker agent (Nimodipine) may offer a promising solution in refractory vasospasm. Results During the period between April 2017 and May 2019, 120 patients who presented with SAH due to a ruptured intracranial aneurysm were admitted to the neurosurgery department at Alexandria University Hospitals. Among them, 30 patients developed refractory vasospasm and were subjected to endovascular super selective intraarterial injection of nimodipine. The angiographic improvement was excellent in three (10%), good in 14 (46%) and poor in the remaining 13 procedures (43%). Clinical improvement was achieved in 15 cases while 15 cases showed no improvement on Modified Rankin Scale. No cases deteriorated following the injection. Conclusions Endovascular chemical angioplasty using a ca channel blocker agent (Nimodipine) is a safe and efficient method for the treatment of refractory post aneurysmal SAH vasospasm. The quest is still needed for developing a better efficient agent to overcome the vasospasm dilemma.

Background Trigeminal neuralgia (TGN) is a facial pain disorder often caused by arterial compression of the trigeminal nerve. Microvascular decompression (MVD) remains the most definitive treatment for this disorder, with a reported cure rate between 60 and 80%. MVD techniques often involve a retrosigmoid craniotomy with placement of an inert foreign material, such as Gore-Tex or Teflon, between the nerve and the compressing vessel. Recurrence of TGN after MVD has been associated with vessel migration and adhesion formation. In this study, we tested the use of Gore-Tex sling, fixed in place with fibrin glue to displace the compressing vessel away from the nerve. Results This is a retrospective study including 20 patients who had an MVD for treatment of idiopathic TGN where a sling of Gore-Tex was used with the application of fibrin glue to prevent dislocation of the vessel. It showed that sling MVD technique is an effective method for treatment of classic trigeminal neuralgia. Eighteen patients improved within 2 weeks postoperatively. One patient had recurrence of symptoms and was reoperated 1 year later. Conclusion Gore-Tex slinging technique is a safe simple technique for preventing re-dislocation of the offending vessel and thus recurrence of symptoms. However, larger series is needed to judge on the long-term efficacy and safety of this technique.

Background: spontaneous obliteration of cerebral arteriovenous malformations is uncommon but could occur after partial embolization. Materials and methods:A retrospective study of 140 patients that underwent embolization for cerebral AVMs from 2005 to August 2019 using liquid embolic agents. The angiographic outcome of patients was classified as regard complete embolization, partial embolization, and complete obliteration after partial embolization. The parameters studied included size, location, number of arterial feeders, number of draining veins, rupture status, embolic agent, and patient factors as well.Results: The study patients included 74 (53%) females and 66 (47%) males. Their age ranged from 7 to 43 years old. One hundred and eight patients (77%) presented with hemorrhage. The AVM grades were grade II in 57 (40.7%) patients and grade III in 56 (39.3%) patients. Sixty-one (43.57%) patients were treated by n-Butyl Cyanoacrylate and 71(50.71%) patients were treated with Onyx, and both materials were used together in 8 cases. Follow-up angiography was done from 6 to 36 months after embolization. The rate of complete occlusion in all patients was 61.43% (86 patients). There were three groups of patients, the first group had complete occlusion of the nidus at the time of embolization and included 68 (48.57%) patients. The second group had partial embolization with partial occlusion of the nidus 54 patients (38.57%). The 3rd group included 18 patients (12.85%) with complete nidal occlusion on follow up after partial embolization. The delay in the venous drainage of the AVM to the late arterial phase or early venous phase with flow stasis was a significant predictor of future obliteration on follow up after partial embolization. Other significant parameters that were associated with the progressive disappearance of the AVM nidus on follow up after partial embolization are presentation with hemorrhage, AVMs size less than 3 cm, the presence of single draining or double draining veins, superficial venous drainage, and one or 2 arterial feeders.Conclusion: spontaneous closure of intracranial arteriovenous malformations after partial embolization may be encountered in cases of stasis of flow during embolization procedure with a delay of the venous drainage. A long-term follow-up of more cases over many years is required to confirm the validity of this conclusion.

BACKGROUND: Dealing with multiple intracranial aneurysms (MIA) presenting with subarachnoid hemorrhage (SAH) is challenging.OBJECT: To make a proposal for the decision-making regarding which aneurysm to secure and how, as the most challenging part in the management of MIA. METHODS: This descriptive study included 25 patients presenting with SAH and having multiple intracranial aneurysms. All patients had a brain computed tomography (CT) scan, CT angiography (CTA), and digital subtraction angiography (DSA). Patients were treated in our institution using microsurgical clipping and/or endovascular embolization according to the clinical and radiological situation. Functional outcome was assessed by modified Rankin scale. RESULTS: Fifteen females and 10 males with average age of 48 years were included. All patients (100%) presented with hemorrhage. Ten patients (40%) were hunt and Hess (H&H) grade I, seven patients (28%) grade II, 3 patients (12%) grade III, 3 patients (12%) grade V and 2 patients (8%) grade IV. Fisher scale was grade II in 11 patients (44%), grade IV in 9 patients (36%) and 5 patients (20%) were grade III. Criteria for the suspected ruptured aneurysm were aneurysm wall irregularity in 24 patients (96%) and the largest size in 23 cases (92%). The epicenter of hemorrhage was a satisfactory localizing sign on CT in only 10 cases (40%). Fifty-six aneurysms were encountered in the 25 patients; 19 patients (76%) had 2 aneurysms and 6 patients (24%) had 3 aneurysms. Clipping was done for 40 aneurysms (71%), wrapping for 2 aneurysms (3%), 4 aneurysms (7%) were followed up, 8 aneurysms (14%) were coiled, and 2 aneurysms (3%) were treated by flow diverters. Twenty patients (80%) had a good outcome on the modified Rankin scale, 4 patients (16%) had mental changes and one patient (4%) had residual neurological deficit. CONCLUSION: The ruptured one in multiple intracranial aneurysms can be suspected by its size and wall irregularity especially in the absence of localizing sign in the CT scan. High-resolution CTA and/or 3D DSA are highly helpful. These cases should be managed in specialized centers where the surgical and endovascular treatment modalities are available.

BACKGROUND:Lesions affecting the jugular foramen (JF) other than paragangliomas are uncommon. Of those, schwannomas and meningiomas predominate with little data describing them in the literature. OBJECT:To evaluate the safety and efficacy of the petro-occipital transssigmoid (POTS) approach for resection of non-vascular lesions of the jugular foramen. METHODS:This descriptive study was conducted on 12 consecutive patients affected by various jugular foramen lesions, other than paragangliomas, who were treated by the POTS approach. Computed tomography (CT) of the brain, magnetic resonance imaging (MRI) of the brain and magnetic resonance venography (MRV) were performed for all patients. The extent of resection and clinical outcome were assessed. Patients were followed up clinically by Karnofsky performance scale score and radiologically by CT and MRI for average of 1 year. RESULTS:A single-stage resection using the POTS approach was used for all patients. Gross total resection was achieved in 66.6%. Tumors included schwannomas (6 cases), meningiomas (3 cases), chondrosarcomas (2 cases) and plasma cell tumor (1 case). This approach allowed adequate resection of both intradural and extradural components of the tumor with hearing preservation and avoidance of facial nerve transposition. There was no mortality. Variable grades of cranial nerve palsies were encountered, but none of the patients required an adjunctive procedure such as vocal cord medialization, tracheostomy, or percutaneous gastrostomy. CONCLUSION:The POTS approach provided adequate tumor exposure for safe resection in a single-staged procedure with access to both the intracranial (extradural and intradural) and extracranial components. It allows moderate rates of hearing preservation and good rates of facial function preservation with minimal related morbidity.