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Dural arteriovenous fistula (DAVF) involving the hypoglossal canal is rare but increasingly reported. To achieve complete obliteration without a procedure-related complication, understanding of the precise anatomy of this DAVF is essential. Here, we describe a 72-year-old man who underwent selective intra-arterial injection computed tomography angiography which allowed us to understand the detailed anatomy of the complex DAVF regarding access routes and the target regions for transvenous embolization (TVE). With the aid of this novel neuroimaging technique successful target TVE was achieved safely and completely.

BACKGROUND Idiopathic extracranial internal carotid artery vasospasm (IEICAV) is a rare cerebrovascular disorder causing transient or permanent cerebral ischemia. The pathophysiology underlying this disorder is not well understood. Although various medical treatments have been tried, complete remission of vasospasm is difficult to achieve. The first case of bilateral IEICAV induced by head rotation, which was successfully treated by carotid artery stenting (CAS), was presented. OBSERVATIONS A 40-year-old woman with bilateral IEICAV had been conservatively treated for 13 years. However, transient ischemic attacks (TIAs) were not suppressed. She eventually presented with a large brain infarction in the left hemisphere and was referred to our department. Digital subtraction angiography clearly demonstrated the triggering of internal carotid artery (ICA) vasospasm by head rotation. After CAS treatment, the TIAs disappeared completely. LESSONS Clinicians should recognize that ordinary mechanical stimulation to the ICA by head rotation can induce vasospasm, and CAS should be performed for refractory IEICAV at the appropriate time to avoid cerebral infarction causing severe neurological deficits.

OBJECTIVE Retrograde leptomeningeal venous drainage (RLVD) of a dural arteriovenous fistula (dAVF) is associated with neurological morbidity and unfavorable outcomes. However, the direct damage to cortical neurons by dAVF with RLVD has not been elucidated. 123I-iomazenil (123I-IMZ) SPECT can reveal cerebral blood flow and cortical neuronal damage in early and late images, respectively. This study aimed to assess the cerebral venous congestive encephalopathy caused by dAVF using 123I-IMZ SPECT. METHODS Based on the pre- and posttreatment MRI findings, patients were divided into three groups: a normal group, an edema group, and an infarction group. Radioactive counts in the early and late images of 123I-IMZ SPECT were investigated using the affected-to-contralateral side asymmetry ratio (ACR). RESULTS None of the patients in the normal group showed any symptoms related to venous congestion. In contrast, all the patients in the edema and infarction groups developed neurological symptoms. The ACR in early images in the edema group was significantly lower than that in the normal group and significantly higher than that in the infarction group. The ACR in the late images of the infarction group was significantly lower than those of the normal and edema groups. After treatment, the neurological signs disappeared in the edema group, but only partial improvement was observed in the infarction group. The ACR in early images significantly improved after treatment in the edema group, but the ACR in late images did not change in any groups. CONCLUSIONS 123I-IMZ SPECT is useful for evaluating hemodynamic disturbances and neuronal damage in dAVFs. The reduction in early images was correlated with the severity of venous congestive encephalopathy, and the significant reduction in late images is a reliable indicator of irreversible venous infarction caused by RLVD.

Delayed onset multiple white matter lesions is a rare pathology that has been reported in patients after endovascular coiling of cerebral aneurysms. This pathology was reportedly caused by nickel allergies or foreign body embolization of polyvinylpyrrolidone. Here, we report a case of white matter lesions in a patient which was diagnosed as a nickel allergy based on a positive reaction to the skin patch test. Steroid therapy improved symptoms and magnetic resonance imaging findings immediately. Clinical differential diagnosis of delayed multiple white matter lesions is difficult. Although biopsy is useful for obtaining a diagnosis, a skin patch test can also be helpful.

Objective: Retrograde leptomeningeal venous drainage (RLVD) of a dural arteriovenous fistula (dAVF) is related to neurological morbidity and unfavorable outcomes. However, the direct damage to cortical neurons by dAVF with RLVD has not been elucidated. 123 I-iomazenil ( 123 I-IMZ) single-photon emission computed tomography (SPECT) can reveal cerebral blood flow and cortical neuronal damage in early and late images, respectively. This study aimed to assess the relationship association between cerebral venous congestive encephalopathy caused by dAVF using 123 I-IMZ SPECT. Methods: Based on the pre- and post-treatment magnetic resonance imaging findings, patients were divided into three groups: normal, edema, and infarction groups. Radioactivities in the early and late images of 123 I-IMZ SPECT were investigated using the affected-to-contralateral side asymmetry ratio (ACR). Results: None of the patients in the normal group showed any symptoms related to venous congestion. In contrast, all the patients in the edema and infarction groups developed neurological symptoms. The ACR in early images in the edema group was significantly lower than that in the normal group and significantly higher than that in the infarction group. The ACR in the late images of the infarction group was significantly lower than those of the normal and edema groups. After treatment, the neurological signs disappeared in the edema group, but only partial improvement was observed in the infarction group. The ACR in early images significantly improved after treatment in the edema group; however, that in late images did not change in any groups. Conclusions: 123 I-IMZ SPECT is useful for evaluating hemodynamic disturbances and neuronal damage in dAVFs. The reduction in early images was correlated with the severity of venous congestive encephalopathy, and the significant reduction in late images is a reliable indicator of irreversible venous infarction caused by RLVD.

We report a case of posterior reversible encephalopathy syndrome PRES during the subacute period of subarachnoid hemorrhage SAH . An 84 year old female with a ruptured basilar top aneurysm underwent successful embolization. Administration of antihypertensive drugs was discontinued to avoid hypotension during the period of vasospasm. On day 17 post embolization, her consciousness level deteriorated, and her MRI showed vasogenic edema in the bilateral occipital lobes. Under the diagnosis of PRES, antihypertensive therapy was resumed, and her symptoms and MRI findings improved.Thirteen cases of PRES after SAH have been reported, and it has been suggested that endothelial cell dysfunction due to primary brain damage due to SAH and hypertension during the period of vasospasm induces PRES. Though the occurrence of PRES after SAH is rare, neurosurgeons should be aware of this potential complication during the subacute period of SAH, because complete resolution of this syndrome is attainable with appropriate blood pressure control.