Unusual Intracranial Manifestation of Infective Endocarditis

Objective: The mycotic aneurysm is a rare intracranial pathology seen with pre-existing infective endocarditis. It has a high mortality rate due to its risk of rupture and needs early diagnosis and treatment. Methods: A 23-year male patient who presented with infective endocarditis subsequently developed a left parietal-temporal intracranial haemorrhage with suspicion of aneurysm after the course of antibiotic treatment as seen on Computed Tomography (CT) scan. Digital Subtraction Angiography (DSA) revealed a ruptured fusosaccular aneurysm in the distal parietal branches of the left Middle Cerebral Artery (MCA), for which glue embolization of the distal parent artery and aneurysm was done. Result: The interventional endovascular procedure was done with complete obliteration of the distal parent artery, mycotic aneurysm, and normal filling of the left internal cerebral artery (ICA) branches. Conclusion: Mycotic intracranial aneurysms (MIA) are a rare form of cerebrovascular pathology which needs early diagnosis with endovascular intervention when rupture occurs.

Pipeline for the treatment of distal cerebral circulation aneurysms: A multicenter study focusing on periprocedural Complications

Background and Aim Distal cerebral circulation aneurysms (DCCAs) remain treatment challenges for neurointervention. The off-label use of the pipeline embolization device (PED) for these aneurysms remains controversial. This study aimed to evaluate the safety and efficacy of PED for DCCAs in a multicenter cohort of patients. Methods Between March 2016 and June 2021, we retrospectively analyzed the neurointerventional data on the clinical and radiological records of all patients undergoing PED treatment of DCCAs at three medical centers. Results A total of 53 consecutive patients with 53 DCCAs were treated with PED. The mean aneurysm size was 12.3 ± 5.7 mm. In total, 75.4% (40/53) were fusiform and 24.5% (13/53) were saccular. Of these, 17.0% (9/53) were recurrent aneurysms that were previously treated with endovascular or microsurgical approaches. The technical success rate was 100%, among which 81.1% (43/53) procedures were completed with a single PED, and the rest (10/53, 18.8%) required telescoping with two devices. Angiographic follow-up data were available for 51 patients, with a median follow-up time of 12 months. At the latest follow-up, 46/51 (90.2%) aneurysms showed complete obliteration, and 4/51 (7.8%) showed reduced filling. Periprocedural complications such as hemorrhage were observed in two patients with MCA aneurysms (3.8%, 2/53), and ischemic events occurred in six patients (11.3%, 6/53). The overall mortality and morbidity rates were 7% (4/53). Conclusions PED is a viable option for treating DCCAs, especially for recurrent aneurysms. Coverage of bifurcation branches and perforator may increase the risk of complications.

Diagenesis of Palaeozoic-Mesozoic Tethys Ocean Carbonate succession- Oman Mountains

This paper studies the uppermost unit of Kharus Formation (Cambrian) and the Autochthonous Akhdar Group (Permian-Triassic), which unconformably covers the pre-Permian strata. The petrographic and geochemical as well as field observations indicate that the succession underwent different stages of dolomitization that produced rocks inheriting the original host rock textures and structures (fabric-preserving dolomitization) and rocks with complete obliteration of the pre-existing textures (fabric-destroying dolomitization). Dolomites that retain the original fabric of the limestone are indicators of the host rock mineralogy, i.e., whether it was made up of high Mg-calcite or aragonitic allochems and indicate early dolomitization. The top part of the Kharus Formation consists of pervasively dolomitized units, whereas dolomites belonging to the Autochthonous Akhdar Group display variable degrees of structural and textural preservation. The evidence suggests very early dolomitization in a relatively short time interval for the Permian-Triassic carbonates. The preserved depositional features in the Permian-Triassic carbonates indicate deposition in shallow marine environments with variable energy levels. Seven facies are inferred: stromatolites, mudstones, wackestones, intraformational breccias, grainstones, packstones and grain/packstones. Petrographic as well as field observations exclude evidence of evaporites within Palaeozoic-Mesozoic rocks. Five paragenetic phases are determined to explain the type of dolomitization and to indicate the type and severity of diagenesis that affected the Palaeozoic-Mesozoic Tethys Ocean carbonates from the Oman Mountains.

Rupture of a de novo dural AV fistula following adult cerebral AVM resection

Acquired unruptured dural arteriovenous fistulas (DAVFs) have been described; however, ruptured de novo DAVFs remain exceedingly rare. We describe the case of a man in his 40s who presented with a recurrent intraparenchymal haemorrhage several years after angiographic cure of an intracranial arteriovenous malformation (AVM). Repeat angiography identified a new Cognard type IV DAVF anterior to the prior craniotomy. He underwent preoperative embolisation followed by craniotomy to completely obliterate the fistulous point. This case illustrates the need for close monitoring of AVM patients, even after complete obliteration, as local recrudescence of arteriovenous shunting can occur even in adulthood.

Abstract 1122‐000135: Application of the Berenstein‐DeLeacy Grading Scale to Assess Treatment Outcome in Orbital Lymphatic Malformations

Introduction : Lymphatic malformations (LMs) are low‐flow vascular malformations that arise as a result of erroneous vascular development during embryogenesis. Prior to the advent of the Berenstein‐De Leacy (BDL) scale, no reproducible grading system had been designed to compare sclerotherapy outcomes on the basis of radiologic findings. The soft‐tissue detail, absence of ionizing radiation, safety profile, and ubiquity of MR imaging made it an ideal technique on which the imaging‐based criteria was developed. The BDL scale ranges from 1–7 denoting complete obliteration to significant progression respectively. A “B” modifier is assigned for identification of granulation tissue in the treatment bed. We examine and validate the BDL scale on a cohort of 16 orbital LMs from our practice. Methods : Orbital LMs treated with sclerotherapy at our practice between 2000 and 2021 were assessed by an attending physician prior to initial and after final treatment to assign scale scores. The assigned scores represent changes in the orbit as defined by pre‐ and post‐septal spaces, above and below eyelids, and intra/extraconal spaces going to the coronal apex without the cavernous sinus. Results : The median age at initial imaging was 24 months (range: 1–445 months) and 108 months (range 12–528) at final imaging. The median imaging interval was 61 month. Males and females were represented in our cohort equally. Six cases presented with right orbital LMs (37.5%) and 10 presented on the left (62.5%). Six cases presented with macrocystic malformations (37.5%), five cases with microcystic (31.25%), and five cases with mixed (31.25%). 11 patients were treated with bleomycin and 5 patients were treated with bleomycin and doxycycline. BDL scale scores ranged from 2–7 with one case assigned the “B” modifier. Two cases were labelled as BDL7, or gross interval progression of the LM. Four cases were labelled as BDL6, or regression of the LM in one region with progression into a previously uninvolved/untreated area. Three cases were labelled as BDL5 with minimal or no gross interval change. One case was labelled as BDL4 and assigned the “B” modifier for partial regression with >50% estimated volume of residual malformation and granulation tissue in the treatment bed. Three cases were labelled as BDL3, or partial repression with <50% estimated volume of residual malformation. One case was labelled as BDL2 with near‐complete regression with trace residual of the lesion. No cases were labelled as BDL1, or complete regression of the lesion. Conclusions : The BDL scale was applied to a series of 16 orbital LMs to demonstrate its versatility in describing the treatment progression of this historically difficult‐to‐classify malformation. We hope visualization of BDL scores for orbital LMs will assist other interventionalists with incorporating this scale as a metric for treatment progression and outcomes.

Abstract 1122‐000078: C‐Guard Stent for the Treatment of Cervical Internal Carotid Artery Aneurysms: Report of 2 Cases

Introduction : C‐Guard carotid stent is a self‐expandable open cell stent covered with a double‐layer mesh which was developed for the treatment of internal carotid artery disease. Lower procedural and complications rates, as well as lower post‐operative infarctions are some advantages of this device. Nevertheless, the use of C‐Guard in the treatment of cervical internal carotid artery (ICA) aneurysms is scarce. Therefore, we present two cases in which the C‐Guard stent achieved complete angiographic occlusion at follow‐up. Methods : We identified two cases in which the C‐Guard carotid stent was used to treat symptomatic cervical ICA aneurysms. Angiographic follow‐up was performed. Results : Case 1: 47‐yo female presented left‐sided motor deficit. CT showed ischemic areas in the right hemisphere and CTA demonstrated an unruptured aneurysm in the C1 segment of the right ICA. The patient started dual antiplatelet therapy (DAPT) with aspirin and clopidogrel. A 6mm x 40 mm C‐Guard carotid stent was deployed without complications. One‐year follow‐up CTA showed complete obliteration of the aneurysm with reconstruction of the ICA. Case 2: 38‐yo male presented decreased left visual acuity. CTA and DSA showed an unruptured aneurysm in the C1 segment of the ICA. The patient started DAPT with aspirin and clopidogrel. A 7mm x 30 mm C‐Guard carotid stent was deployed without complications. Three‐month follow‐up DSA showed complete obliteration of the aneurysm with adequate filling of distal vessels. Conclusions : C‐Guard stent is a potential alternative to conventional carotid stents in the treatment of cervical ICA aneurysms with high obliteration rates at follow‐up.

Abstract 1122‐000061: Initial Experience Using the Transvenous Embolization for Intracranial Arteriovenous Malformations in a Reference Endovascular Center

Introduction : Transvenous embolization (TVE) is used in cases of arteriovenous malformations (AVMs) with specific characteristics such as small size (<3 cm), deep location, single draining vein and the absence of adequate feeders. High complete obliteration rates have been reported. Therefore, our study aimed to analyze our initial experience using the TVE for treatment of AVMs. Methods : Between May 2018 and January 2021, consecutive patients who underwent TVE of AVMs were selected. Demographics, radiological and clinical variables were collected. The modified Rankin Scale (mRS) was used to determine clinical outcomes and was dichotomized (good clinical condition: mRS £2; poor clinical condition: mRS >2). Complete obliteration was defined as the total absence of the nidus and vein, subtotal obliteration was defined as the embolization of >95% of nidus and partial obliteration was defined as the embolization of <95% of nidus. Procedure‐related complications were defined as those that occurred during the procedure and were divided as intraoperative rupture and thrombosis. Results : Twenty‐one patients harboring 21 AVMs were evaluated. Fourteen patients (67%) were women. The mean age was 24.5 ± 14.1 years (7 – 48 years). A good preoperative clinical condition was present in 20 patients. Twenty AVMs were ruptured (95.2%). The most frequent locations were thalamus/basal ganglia in 6 patients (29%), followed by temporal/insular in 5 patients (24%). Spetzler‐Martin grades III, II and I were present in 11, 9 and 1 patients, respectively. The mean number of feeders was 2.1 per AVM. The feeders arised from the MCA in 9 cases, followed by PCA in 5 cases, ACA and AChoA in 3 cases, AICA in 2 cases, and ECA and PCom in 1 case, respectively. The mean number of veins was 1.3 per AVM. Deep venous drainage was present in 12 cases (57%). The mean size of the AVM nidus was 15.7 ± 7.8 mm (3.7 – 34 mm). Previous trans‐arterial embolization was done in 10 patients (47.6%). Pre‐embolization hematoma evacuation was done in 4 patients (19%). An immediate complete obliteration was achieved in 18 patients (85.7%), whereas a subtotal and partial obliteration were achieved in 2 and 1 patients, respectively. A poor post‐operative clinical condition occurred in 4 patients (20%). Procedure‐related complications occurred in 4 patients (20%): 3 cases with intra‐operative rupture of the AVM nidus and 1 case of a thrombus in the M1 treated with stent retriever. Mortality occurred in 3 patients (14.2%) of which two presented intra‐operative rupture with intracerebral hematomas that required decompressive craniectomy. One patient presented a post‐operative bleeding of the AVM nidus that required external ventricular drainage and decompressive craniectomy. Follow‐up angiography was done in 4 cases with total obliteration of all the cases (100%). Conclusions : The transvenous approach has emerged as an alternative to trans‐arterial approach with high grades of immediate total obliteration rates, but with potential procedure‐related complications. Thus, this technique should be used in selected cases in order to achieve complete cure rates.

Abstract 1122‐000048: Endovascular Treatment for Spetzler‐Martin Grade III Pediatric Arteriovenous Malformations

Introduction : Grade III Spetzler‐Martin (SM) brain arteriovenous malformations (AVMs) presents high variability in terms of size (S), angioarchitecture, flow characteristics, a frequent involvement of eloquent areas (E), and presence of central venous drainage (V). Therefore, this specific group fall into a gray zone in which the best treatment option is not stablished. Here, we aimed to assess the safety and efficacy of intent‐to‐cure embolization in pediatric grade III AVM management at two institutions. Methods : Pediatric patients (<18 years of age) with grade III AVMs treated with intent‐to‐cure embolization in two institutions between 2010 and 2019 were included. These two centers primarily perform endovascular treatment with intention to cure, which means that they attempt to occlude the maximal volume of nidus in a single session. Then, if the first session is not curative or the result is partial, a subsequent embolization is planned to completely occlude the AVM nidus. The clinical features, obliteration rates, and intraoperative complications were retrospectively collected from the clinical records. We categorized the AVMs based by the SM features: Type 1 = S1E1V1, Type 2 = S2E1V0, Type 3 = S2E0V1, and Type 4 = S3E0V0. The Institutional Review Boards approved this study. Results : Twenty‐seven children (19 females; mean age: 12 years, standard deviation: 3.9 years) with grade III AVMs underwent 47 embolization sessions. The most common presentation was intracranial hemorrhage (66%), and the majority (48%) were deep lesions (basal ganglia, corpus callosum, ventricle). The size of AVMs was <3 cm in 16 patients, 3 – 6 cm in 9, and >6 cm in 2; 21 AVMs were in eloquent cortex and 20 had deep venous drainage. The AVMs were Type 1 in 16 cases, Type 2 in 5, Type 3 in 4, and Type 4 in 2. Complete obliteration was achieved in 12 patients (44%), including 37% of AVMs exclusions after a single session. Eight (30%) patients had multiple embolizations. The AVM was obliterated after a single session in 10 patients (63%) with Type 1 AVMs (small lesions). The most common embolic agent employed was Squid (17/44), followed by Onyx (14/44) and Histoacryl (6/44). Intraoperative complications were reported in 5 (4 microperforations, 1 microcatheter rupture) out of 47 sessions (11%), with only one complication in the large AVM group (Types 2 ‐ 4). Deaths were not reported. Conclusions : Endovascular treatment with intent‐to‐cure of grade III SM AVMs in the pediatric population has demonstrated adequate complete obliteration rates with acceptable intraoperative complication rates. Therefore, long‐term follow‐up in this population is necessary in order to assess the real impact of embolization in terms of cure rates.

Novel Direct Superior Ophthalmic Vein Approach to Treat Anterior Condylar Confluence Dural Arteriovenous Fistula

Dural arteriovenous fistulas (DAVFs) are acquired pathological arteriovenous connections involving vessels that usually supply the meninges. A DAVF in the region of the hypoglossal canal is a rare form of fistula that involves the anterior condylar confluence or anterior condylar vein. We report a case of hypoglossal canal DAVF that was successfully embolized transvenously through a superior ophthalmic vein (SOV) approach. After failed attempts through jugular access, our patient was treated by a unique percutaneous direct puncture approach through the SOV, achieving complete obliteration of the fistula. A step-by-step description of the endovascular technique was described. The clinical course was uneventful without any new neurologic deficit. The eye symptoms and third nerve palsy had completely resolved at the 3-month follow-up visit. Hypoglossal canal DAVFs are rare and may exhibit complex venous drainage patterns. Knowledge of the complex venous anatomy is essential for planning an alternative transvenous route if the standard approach is not feasible. Xper CT (Philips Healthcare, Best, The Netherlands) is an excellent tool for identifying the exact site of the fistula as well as for confirming a safe position of the catheter tip for successful occlusion of this complex dural AV fistula.

Analysis of the etiological factors of relapse after endonasal endoscopic dacryocystorhinostomy

The aim of this work is to study the etiological factors of failures after endonasal endoscopic dacryocystorhinostomy (EEDCR). We retrospectively studied the case reports of 485 patients (521 cases) with a relapse after EEDCR performed for primary dacryocystitis. The obtained data allowed us to reveal that the largest number of cases of relapse after EEDCR was a consequence of partial or complete obliteration of dacryocystorhinostomy (DCR) ostium (278 cases), which amounted to 53.3% of all analyzed cases. In 127 cases, the reason of recurrence after EEDCR was stenosis or obliteration of the common canaliculus ostium (24.4%). In 116 cases (22.3%), relapse after EEDCR was caused by a combination of several etiological factors. Of these, in 86 cases, synechiae and granulation in the area of dacryostomy were revealed. The retrospective analysis carried out within the framework of this work, based on the study of the results of the applied diagnostic methods, including multislice computed tomography with contrast enhancement of lacrimal drainage system, made it possible to determine and systematize the etiological factors of the development of repeated obstruction of the lacrimal drainage system after EEDCR. Key words: relapse, dacryocystitis, DCR, common canaliculus ostium, DCR ostium, synechiae.