Association between posterior fossa arteriovenous malformations and prenidal aneurysm rupture: potential impact on management

Object In patients with posterior fossa arteriovenous malformations (AVMs) who present with hemorrhage, feeding artery aneurysms are often the source of bleeding. The aim of this study was to evaluate the relative proportions of cases of infra- and supratentorial AVMs in which patients presented with prenidal aneurysm rupture. The management and outcome of 9 cases of posterior fossa AVMs associated with prenidal aneurysm rupture are presented. Methods The authors retrospectively reviewed 233 consecutive AVM cases involving patients treated at their institution between April 2001 and August 2012. Patients with a prenidal aneurysm as the cause of the hemorrhage were identified. The frequencies of prenidal aneurysm-related ruptures were compared in cases of supra- and infratentorial AVMs. Management and clinical outcome (modified Rankin Scale [mRS] score) of patients with posterior fossa AVMs treated for ruptured prenidal aneurysms were recorded. Results Of 233 AVMs, 25 (11%) were in the posterior fossa, and in 22 (88%) of these cases, the patients presented with hemorrhage, including 9 patients (41%) who presented with hemorrhage due to prenidal aneurysm rupture. Of 208 patients with supratentorial AVMs, 107 (51%) presented with hemorrhage, including 5 patients (4.7%) in whom the hemorrhage was associated with a prenidal aneurysm (p < 0.01). All 9 patients with posterior fossa AVMs and prenidal aneurysm rupture were treated with early embolization of the offending aneurysm. There was no early rebleeding or clinical complication related to this approach. At the end of follow-up (mean 46.8 months), 2 patients had an mRS score of 0, 1 had a score of 1, 3 had a score of 2, 2 patients were dead (mRS score of 6), and 1 patient was lost to follow-up. Conclusions Posterior fossa AVM hemorrhages are frequently associated with prenidal arterial aneurysms. Urgent endovascular treatment of the aneurysm was effective in this case series.

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Fractionated Stereotactic Radiotherapy For the Treatment of Large Arteriovenous Malformations with or without Previous Partial Embolization

Neurosurgery ◽

10.1227/01.neu.0000134285.41701.83 ◽

2004 ◽

Vol 55 (3) ◽

pp. 519-531 ◽

Cited By ~ 53

Author(s):

Erol Veznedaroglu ◽

David W. Andrews ◽

Ronald P. Benitez ◽

M. Beverly Downes ◽

Maria Werner-Wasik ◽

...

Keyword(s):

Stereotactic Radiosurgery ◽

Stereotactic Radiotherapy ◽

Arteriovenous Malformations ◽

Three Dimensional ◽

Late Complications ◽

Fractionated Stereotactic Radiotherapy ◽

Medical Systems ◽

Significant Treatment ◽

Lost To Follow Up

Abstract OBJECTIVE: Despite the success of stereotactic radiosurgery, large inoperable arteriovenous malformations (AVMs) of 14 cm3 or more have remained largely refractory to stereotactic radiosurgery, with much lower obliteration rates. We review treatment of large AVMs either previously untreated or partially obliterated by embolization with fractionated stereotactic radiotherapy (FSR) regimens using a dedicated linear accelerator (LINAC). METHODS: Before treatment, all patients were discussed at a multidisciplinary radiosurgery board and found to be suitable for FSR. All patients were evaluated for pre-embolization. Those who had feeding pedicles amenable to glue embolization were treated. LINAC technique involved acquisition of a stereotactic angiogram in a relocatable frame that was also used for head localization during treatment. The FSR technique involved the use of six 7-Gy fractions delivered on alternate days over a 2-week period, and this was subsequently dropped to 5-Gy fractions after late complications in one of seven patients treated with 7-Gy fractions. Treatments were based exclusively on digitized biplanar stereotactic angiographic data. We used a Varian 600SR LINAC (Varian Medical Systems, Inc., Palo Alto, CA) and XKnife treatment planning software (Radionics, Inc., Burlington, MA). In most cases, one isocenter was used, and conformality was established by non-coplanar arc beam shaping and differential beam weighting. RESULTS: Thirty patients with large AVMs were treated between January 1995 and August 1998. Seven patients were treated with 42-Gy/7-Gy fractions, with one patient lost to follow-up and the remaining six with previous partial embolization. Twenty-three patients were treated with 30-Gy/5-Gy fractions, with two patients lost to follow-up and three who died as a result of unrelated causes. Of 18 evaluable patients, 8 had previous partial embolization. Mean AVM volumes at FSR treatment were 23.8 and 14.5 cm3, respectively, for the 42-Gy/7-Gy fraction and 30-Gy/5-Gy fraction groups. After embolization, 18 patients still had AVM niduses of 14 cm3 or more: 6 in the 7-Gy cohort and 12 in the 5-Gy cohort. For patients with at least 5-year follow-up, angiographically documented AVM obliteration rates were 83% for the 42-Gy/7-Gy fraction group, with a mean latency of 108 weeks (5 of 6 evaluable patients), and 22% for the 30-Gy/5-Gy fraction group, with an average latency of 191 weeks (4 of 18 evaluable patients) (P = 0.018). For AVMs that remained at 14 cm3 or more after embolization (5 of 6 patients), the obliteration rate remained 80% (4 of 5 patients) for the 7-Gy cohort and dropped to 9% for the 5-Gy cohort. A cumulative hazard plot revealed a 7.2-fold greater likelihood of obliteration with the 42-Gy/7-Gy fraction protocol (P = 0.0001), which increased to a 17-fold greater likelihood for postembolization AVMs of 14 cm3 or more (P = 0.003). CONCLUSION: FSR achieves obliteration for AVMs at a threshold dose, including large residual niduses after embolization. With significant treatment-related morbidities, further investigation warrants a need for better three-dimensional target definition with higher dose conformality.

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Potential impact on estimated treatment effects of information lost to follow-up in randomised controlled trials (LOST-IT): systematic review

BMJ ◽

10.1136/bmj.e2809 ◽

2012 ◽

Vol 344 (may18 1) ◽

pp. e2809-e2809 ◽

Cited By ~ 149

Author(s):

E. A. Akl ◽

M. Briel ◽

J. J. You ◽

X. Sun ◽

B. C. Johnston ◽

...

Keyword(s):

Systematic Review ◽

Randomised Controlled Trials ◽

Treatment Effects ◽

Controlled Trials ◽

Potential Impact ◽

Randomised Controlled ◽

Lost To Follow Up

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Multiple Victims of Carbon Monoxide Poisoning in the Aftermath of a Wildfire: A Case Series

Acta Médica Portuguesa ◽

10.20344/amp.9811 ◽

2018 ◽

Vol 31 (3) ◽

pp. 146 ◽

Cited By ~ 3

Author(s):

Luís Ramos dos Santos ◽

Magna Alves-Correia ◽

Margarida Câmara ◽

Manuela Lélis ◽

Carmo Caldeira ◽

...

Keyword(s):

Carbon Monoxide ◽

Hyperbaric Oxygen ◽

Clinical Symptoms ◽

Carbon Monoxide Poisoning ◽

Case Series ◽

Neurological Syndrome ◽

High Flow Oxygen ◽

Lost To Follow Up ◽

Mean Time

Introduction: Carbon monoxide poisoning may occur in several contexts.Material and Methods: Retrospective of 37 carbon monoxide poisoning cases that underwent hyperbaric oxygen during wildfires in Funchal in August 2016.Results: The studied sample included 37 patients, mean age of 38 years, 78% males. Ten were firefighters, four children and two pregnant victims. Neurological symptoms were the most reported. Median carboxyhemoglobin level was 3.7% (IQR 2.7). All received high-flow oxygen from admission to delivery of hyperbaric oxygen. Persistence of symptoms was the main indication for hyperbaric oxygen. Median time to hyperbaric oxygen was 4.8 hours (IQR 9.5), at 2.5 ATA for 90 minutes, without major complications. Discharge in less than 24 hours occurred in 92% of the cases. Thirty days follow-up: five patients presented clinical symptoms of late neurological syndrome; twelve patients were lost to follow-up. Carboxyhemoglobin levels on admission and mean time to hyperbaric oxygen were no different between those who did and did not develop the syndrome at 30 days (p = 0.44 and p = 0.58, respectively).Discussion: Late neurological syndrome at 30 days occurred in 20% and no new cases were reported at 12 months.Conclusion: Use of hyperbaric oxygen appears to have reduced the incidence of the syndrome. This seems to be the first Portuguese series reporting use of hyperbaric oxygen in carbon monoxide poisoning due to wildfires. The authors intend to alert to the importance of referral of these patients because the indications and benefits of this treatment are well documented. This is especially important given the ever-growing issue of wildfires in Portugal.

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Surgical Outcome of Large Solid Posterior Fossa Hemangioblastoma without Preoperative Embolization

Journal of Neurological Surgery Part A Central European Neurosurgery ◽

10.1055/s-0041-1728766 ◽

2021 ◽

Author(s):

Prashant Raj Singh ◽

Raghvendra Kumar Sharma ◽

Jitender Chaturvedi ◽

Nitish Nayak ◽

Anil Kumar Sharma

Keyword(s):

Posterior Fossa ◽

Surgical Outcome ◽

Karnofsky Performance Status ◽

Obstructive Hydrocephalus ◽

Case Series ◽

Preoperative Embolization ◽

Initial Symptom ◽

Lower Cranial Nerve ◽

The Mean

Abstract Background Large solid hemangioblastoma in the posterior fossa has an abundant blood supply as an arteriovenous malformation. The presence of adjacent vital neurovascular structures makes them vulnerable and difficult to operate. Complete surgical resection is always a challenge to the neurosurgeon. Material and Method We share the surgical difficulties and outcome in this case series of large solid hemangioblastomas without preoperative embolization as an adjunct. This study included five patients (three men and two women, with a mean age of 42.2 years). Preoperative embolization was attempted in one patient but was unsuccessful. All the patients have headache (100%) and ataxia (100%) as an initial symptom. A ventriculoperitoneal shunt was inserted in one case before definite surgery due to obstructive hydrocephalus. The surgical outcome was measured using the Karnofsky Performance Status (KPS) score. Result The tumor was excised completely in all the cases. No intra- and postoperative morbidity occurred in four patients; one patient developed transient lower cranial nerve palsy. Mean blood loss was 235 mL, and no intraoperative blood transfusion was needed in any case. The mean follow-up period was 14.2 months. The mean KPS score at last follow-up was 80.One patient had a KPS score of 60. Conclusion Our treatment strategy is of circumferential dissection followed by en bloc excision, which is the optimal treatment of large solid hemangioblastoma. The use of adjuncts as color duplex sonography and indocyanine green video angiography may help complete tumor excision with a lesser risk of complication. Preoperative embolization may not be needed to resect large solid posterior fossa hemangioblastoma, including those at the cerebellopontine angle location.

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Consecutive Case Series of Healed Single-Molar Sites Immediately Restored with Wide-Diameter Implants: A 1-Year Evaluation

International Journal of Dentistry ◽

10.1155/2016/5645892 ◽

2016 ◽

Vol 2016 ◽

pp. 1-8 ◽

Cited By ~ 2

Author(s):

Hadi Antoun ◽

Pierre Cherfane ◽

Bouchra Sojod

Keyword(s):

Success Rate ◽

Case Series ◽

Marginal Bone Loss ◽

Wide Diameter ◽

Bone Level ◽

One Year ◽

Lost To Follow Up ◽

Single Crowns

Introduction. To evaluate outcomes of wide-diameter (6 mm) implants immediately provisionalized with cement-retained single crowns in posterior molar sites.Materials and Methods. Forty-eight consecutive patients received a total of 53 moderately rough-surface, 6 mm diameter implants in healed sites. All implants were immediately provisionalized with a cement-retained provisional crown. Final prosthesis with cement-retained porcelain fused to metal crowns was delivered 3–6 months later. Patients were followed up for 1 year. Outcome measures were implant failures and success rate, complications, marginal bone levels, bone level changes, papilla index, bleeding on probing, and inflammation.Results. One patient was lost to follow-up. At one year, the implant survival and success rate were 98.1%. The mean marginal bone loss after 1 year was −0.17±1.84 mm. Ideal papilla score was recorded at 83.8% of the sites. More than 95.6% of the sites showed no bleeding or inflammation. No procedure-related or device-related adverse events were reported.Conclusion. Wide-diameter (6 mm) implants can safely and successfully replace single posterior molars. Longer follow-up studies are necessary to evaluate the long-term success of these implants.

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Multimodality treatment of posterior fossa arteriovenous malformations

Journal of Neurosurgery ◽

10.3171/jns/2008/108/6/1152 ◽

2008 ◽

Vol 108 (6) ◽

pp. 1152-1161 ◽

Cited By ~ 47

Author(s):

Michael E. Kelly ◽

Raphael Guzman ◽

John Sinclair ◽

Teresa E. Bell-Stephens ◽

Regina Bower ◽

...

Keyword(s):

Posterior Fossa ◽

Arteriovenous Malformations ◽

Multimodality Treatment ◽

Neurological Complications ◽

Cure Rate ◽

Complete Obliteration ◽

The Mean ◽

Risk Of Hemorrhage ◽

Negative Predictor

Object Posterior fossa arteriovenous malformations (AVMs) are relatively uncommon and often difficult to treat. The authors present their experience with multimodality treatment of 76 posterior fossa AVMs, with an emphasis on Spetzler–Martin Grades III–V AVMs. Methods Seventy-six patients with posterior fossa AVMs treated with radiosurgery, surgery, and endovascular techniques were analyzed. Results Between 1982 and 2006, 36 patients with cerebellar AVMs, 33 with brainstem AVMs, and 7 with combined cerebellar–brainstem AVMs were treated. Natural history data were calculated for all 76 patients. The risk of hemorrhage from presentation until initial treatment was 8.4% per year, and it was 9.6% per year after treatment and before obliteration. Forty-eight patients had Grades III–V AVMs with a mean follow-up of 4.8 years (range 0.1–18.4 years, median 3.1 years). Fifty-two percent of patients with Grades III–V AVMs had complete obliteration at the last follow-up visit. Three (21.4%) of 14 patients were cured with a single radiosurgery treatment, and 4 (28.6%) of 14 with 1 or 2 radiosurgery treatments. Twenty-one (61.8%) of 34 patients were cured with multimodality treatment. The mean Glasgow Outcome Scale (GOS) score after treatment was 3.8. Multivariate analysis performed in the 48 patients with Grades III–V AVMs showed radiosurgery alone to be a negative predictor of cure (p = 0.0047). Radiosurgery treatment alone was not a positive predictor of excellent clinical outcome (GOS Score 5; p > 0.05). Nine (18.8%) of 48 patients had major neurological complications related to treatment. Conclusions Single-treatment radiosurgery has a low cure rate for posterior fossa Spetzler–Martin Grades III–V AVMs. Multimodality therapy nearly tripled this cure rate, with an acceptable risk of complications and excellent or good clinical outcomes in 81% of patients. Radiosurgery alone should be used for intrinsic brainstem AVMs, and multimodality treatment should be considered for all other posterior fossa AVMs.

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Case Series Regarding Parastomal Variceal Bleeding: Presentation and Management

Annals of Hepatology ◽

10.5604/01.3001.0012.2228 ◽

2018 ◽

Vol 17 (5) ◽

pp. 0-10

Author(s):

John Romano ◽

Charles V. Welden ◽

Jordan Orr ◽

Brendan McGuire ◽

Mohamed Shoreibah

Keyword(s):

Portal Hypertension ◽

High Risk ◽

Literature Review ◽

Variceal Bleeding ◽

Coil Embolization ◽

Case Series ◽

Treatment Modalities ◽

Post Procedure ◽

Lost To Follow Up

Parastomal variceal bleeding (PVB) is a serious complication occurring in up to 27% of patients with an ostomy and concurrent cirrhosis and portal hypertension. The management of PVB is difficult and there are no clear guidelines on this matter. TIPS, sclerotherapy, and /or coil embolization are all therapies that have been shown to successful manage PVB. We present a case series with five different patients who had a PVB at our institution. The aim of this case series is to report our experience on the management of this infrequently reported but serious condition. We also conducted a systemic literature review focusing on the treatment modalities of 163 patients with parastomal variceal bleeds. In our series, patient 1 had embolization and sclerotherapy without control of bleed and expired on the day of intervention due to hemorrhagic shock. Patient 2 had TIPS in conjunction with embolization and sclerotherapy and had no instance of rebleed 441 days after therapy. Patient 3 did not undergo any intervention due to high risk for morbidity and mortality, the bleed self-resolved and there was no further rebleed, this same patient died of sepsis 73 days later. Patient 4 had embolization and sclerotherapy and had no instance of rebleed 290 days after therapy. Patient 5 had TIPS procedure and was discharged five days post procedure without rebleed, patient has since been lost to follow-up.

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Safety and Efficacy of Surgical Resection of Unruptured Low-grade Arteriovenous Malformations From the Modern Decade

Neurosurgery ◽

10.1227/neu.0000000000000968 ◽

2015 ◽

Vol 77 (6) ◽

pp. 948-953 ◽

Cited By ~ 22

Author(s):

Karam Moon ◽

Michael R. Levitt ◽

Rami O. Almefty ◽

Peter Nakaji ◽

Felipe C. Albuquerque ◽

...

Keyword(s):

Surgical Resection ◽

Neurological Deficit ◽

Arteriovenous Malformations ◽

Low Grade ◽

Stroke Rate ◽

Modified Rankin Scale ◽

Postoperative Neurological Deficit ◽

Clinical Impairment ◽

Grade Ii

BACKGROUND: Recent studies have questioned the utility of surgical resection of unruptured brain arteriovenous malformations (bAVMs). OBJECTIVE: We performed an assessment of outcomes and complications of surgical resection of low-grade bAVMs (Spetzler-Martin grade I or II) at a single high-volume neurosurgical center. METHODS: We reviewed all unruptured low-grade bAVMs treated with surgery (with or without preoperative embolization) between January 2004 and January 2014. Stroke rate, mortality, and clinical and radiographic outcomes were examined. RESULTS: Of 95 patients treated surgically, 85 (25 grade I, 60 grade II) met inclusion criteria, and all achieved radiographic cure postoperatively. Ten patients (11.8%) were lost to follow-up; the mean follow-up of the remaining 85 was 3.3 years. Three patients (3.5%) with grade II bAVMs experienced a stroke; no patients died. Although 20 patients (23.5%) had temporary postoperative neurological deficit, only 3 (3.5%) had new clinical impairment (modified Rankin Scale score ≥2) at last follow-up. Eight of the 13 patients (61.5%) with preexisting clinical impairment had improved modified Rankin Scale scores of 0 or 1; and 17 of 30 patients (56.7%) with preoperative seizures were seizure-free without antiepileptic medication postoperatively. No significant differences existed in stroke rate or clinical outcome between grades I and II patients at follow-up (Fisher exact test, P = .55 and P > .99, respectively). CONCLUSION: Surgical resection of low-grade unruptured bAVMs is safe, with a high rate of improvement in functional status and seizure reduction. Although transient postoperative neurological deficit was observed in some patients, permanent treatment-related neurological morbidity was rare.

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Progressive Dilatation as a Successful Treatment for Y duplication of Urethra

Sultan Qaboos University Medical Journal [SQUMJ] ◽

10.18295/squmj.9.2021.138 ◽

2021 ◽

Author(s):

Akash Pati ◽

Subrat K Sahoo ◽

Bikasha B Tripathy

Keyword(s):

Congenital Anomaly ◽

Case Reports ◽

Case Series ◽

Urethral Duplication ◽

Rare Congenital Anomaly ◽

Standardized Treatment ◽

Rectourinary Fistula ◽

Lost To Follow Up ◽

Multiple Stages

Duplication of urethra is a rare congenital anomaly that has been reported in case reports and case series. A Y-shaped urethral duplication is the rarest variant as per the classification suggested and hence lacks a standardized treatment option. We report a case of Y-duplication of urethra diagnosed during neonatal age and presented to us at nine years of age. The patient had undegone a vesicostomy at seventh day of life for passing urine per anus and was lost to follow up thereafter. An attempt at disconnection of the duplicated urethral tract to anus after colostomy, at eight years of age had failed. The patient was managed successfully by progressive dilatation of the orthotopic urethra, which required multiple stages, followed by separation of the urethra from the rectum. At three years follow up the patient is continent and asymptomatic. Keywords: Y duplication of the urethra; PADUA technique; Rectourinary fistula; Urethral duplication.

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Incidentally identified ductus arteriosus aneurysm in eight adults: a case series

BJR|case reports ◽

10.1259/bjrcr.20200097 ◽

2021 ◽

pp. 20200097

Author(s):

Mayo Yukimoto ◽

Tomohisa Okuma ◽

Etsuji Sohgawa ◽

Mariko M Nakano ◽

Taro Shimono ◽

...

Keyword(s):

Ductus Arteriosus ◽

Three Dimensional ◽

Case Series ◽

Risk Of Rupture ◽

Radiographic Screening ◽

Dimensional Reconstruction ◽

History Of ◽

Ductus Arteriosus Aneurysm ◽

Lost To Follow Up

Ductus arteriosus aneurysm (DAA) in adulthood is a rare entity. We retrospectively reviewed our medical records from the past ten years and identified eight cases of adult DAA (six males and two females aged between 69 and 89 years; mean, 76 years), using multi planar reconstruction and three-dimensional reconstruction computed tomography (CT) images. The aneurysm was suspected incidentally in all cases based on the results of chest radiographic screening or postoperative follow-up CT for lung or colon cancer. All eight patients were asymptomatic but had a history of or concurrent hypertension (n = 5, 62.5%), diabetes mellitus (n = 3, 37.5%), cerebrovascular disease (n = 3, 37.5%), ischemic heart disease (n = 1, 12.5%), and cardiac failure (n = 1). All patients had no history of trauma (n = 8, 100%). Six had a history of cigarette smoking. The aneurysm size ranged from 2.0 × 4.0 to 6.3 × 5.3 cm (mean, 3 × 5 cm). The surgical procedures used were four cases of total arch replacement and two cases of thoracic endovascular aortic repair. Two patients were not surgically treated. The median follow-up was 14.5 months (range, 2 months to 9 years). In the two patients who were not surgically treated, the aneurysm enlarged in one, and remained unchanged in the other. Of the six cases surgically-managed cases, one was lost to follow-up, and another patient died of an unrelated cause. The remaining four cases had no enlargement of the aneurysm. No ruptures were reported in any of the cases. DAA should be considered when a saccular aneurysm is located in the minor curvature of the aortic arch and extending toward the left pulmonary trunk in adult patients. Differentiating adult DAA is important, because it is associated with a high risk of rupture due to the fragile nature of true aneurysms.

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