Aim To study specific vascular anatomy of dural arteriovenous fistulae (DAVFs) locating at the foramen magnum in patients admitted to our centre in the past year (2019–2020), and to evaluate effectiveness of microsurgical disconnection of DAVFs alone. Patients and Methods Two male patients were included. Neuroimaging results obtained on admission, including computer tomography, digital subtraction angiography and magnetic resonance imaging of the brain, were studied and compared. Digital subtraction angiography with selective injection to the external carotid artery was particularly explored to trace main feeding arteries and draining veins of DAVFs. Results Both patients had diffuse subarachnoid haemorrhage (SAH), particularly anterior to the medulla on initial computer tomography of the brain. Branches of the ascending pharyngeal artery were identified as main feeding arteries. Draining veins included anterior/posterior spinal veins and pterygopalatine venous plexus. Magnetic resonance imaging confirmed DAVFs at the level of foramen magnum to C1 vertebra. Complete occlusion was achieved with far‐lateral microsurgical approach, with intra‐operative indocyanine green injection confirming no filling of venous pouch. Post‐operative follow‐up digital subtraction angiography demonstrated no angiographic evidence of residual DAVFs or new haemorrhages. Conclusion DAVFs at the foramen magnum could present as SAH. A combination of neuroimaging methods aid diagnosis and identification of underlying vascular anatomy. Satisfactory outcomes with complete occlusion were achieved with microsurgical approach alone.
Background: Bleeding from carotid artery pseudoaneurysms is an emergency condition with high morbidity and mortality. We aimed to identify risk factors predicting pseudoaneurysmal bleeding as the cause of profuse epistaxis in irradiated head and neck cancer patients with suspect carotid blowout or pseudoaneurysms. Methods: We retrospectively reviewed consecutive patients with history of radiation therapy for head and neck cancers and with nasal, oral or ear bleeding requiring inpatient treatment from hospital database. Pseudoaneurysms were subgrouped into internal carotid artery (ICA) pseudoaneurysms, and external carotid artery (ECA) pseudoaneurysms. The treatment outcomes were evaluated using 30-day mortality rate, recurrent bleeding, and cerebral infarction. Results: There were 41 admissions for suspected carotid blowout or pseudoaneurysms from 1 July 2016 to 30 June 2020 with 17 bleeding pseudoaneurysms identified, including 11 internal carotid arteries (ICA) pseudoaneurysms and 6 external carotid arteries (ECA) pseudoaneurysms. Among ICA pseudoaneurysms, six patients passed Balloon occlusion test with embolization and parent artery occlusion (trapping) of ICA performed, and all ECA pseudoaneurysms were embolized with parent artery occlusion (trapping). Baseline hypertension and hypotension on arrival were predictive for pseudoaneurysmal bleeding. The degree of haemoglobin drop was not significantly different between pseudoaneurysmal bleeding and non-pseudoaneurysmal bleeding (2.1 AE 1.4 g/dL vs. 1.6 AE 1.4 g/dL, p = 0.234). Conclusions: We identified baseline hypertension and hypotension on arrival as predictive factors for pseudoaneurysmal bleeding in patients with irradiated head and neck cancer. Presence of these risk factors should alert the clinicians to the possibility of carotid pseudoaneurysms.
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