Case of step-by-step combined treatment of a patient with a ruptured aneurysm of the ophthalmic segment of the internal carotid artery

Aneurysms of the internal carotid artery are the second most common among cerebral aneurysms. When an aneurysm is located in the ophthalmic segment of the internal carotid artery (ICA), the intravascular treatment method is a priority. At the same time, the treatment of recurrent and non-radially switched-off aneurysms of this localization remains a subject of discussion.Case report. We present a 42-year-old patient with a ruptured ICA aneurysm who was admitted in a serious condition. Initially, the patient underwent partial occlusion of the aneurysm cavity with endovascular coiling. In the control cerebral angiography 3 months after the haemorrhage, the recanalization of the aneurysm was verified, which served as an indication for repeated surgical intervention. We preferred the microsurgical method of treatment. A control angiographic study 1 year after the second operation confirmed the radical shutdown of the aneurysm.Discussion. The presented case illustrates the need for a flexible approach in the treatment of complex paraclinoid aneurysms. The choice of endovascular treatment of such aneurysms in the acute period of haemorrhage is justified as the most sparing, although less radical. Depending on the nature of the embolization performed, the timing of the control angiographic examination should be selected individually and can be reduced to 2 months. If there are indications for repeated surgical intervention, it should be performed by the safest method, providing total shutdown of the aneurysm and reducing the volumetric impact of the aneurysm dome on the optic nerve.

An eighth note

Venous stenosis is the most common cause of arteriovenous fistula (AVF) failure in hemodialysis patients. For patients with AVF stenosis, the pressure over the antecedent part of the AVF stenotic lesion will increase if arterial inflow is sufficient. We report a chronic hemodialysis patient who received an angiographic examination for the juxta-anastomosis stenosis of his AVF. A unique feature of a collateral venous branch antecedent to the stenotic lesion was noted, resembling a musical sign as the “eighth note.” After percutaneous transluminal angioplasty, the eighth note attenuated markedly at once. Of note, the eighth note sign is not seen frequently, and thus we postulate that the formation of an eighth note sign on the radiocephalic fistula should fulfill the following requirements, including a sufficient arterial inflow, an adjacent collateral branch close enough to the arteriovenous anastomosis, a severe juxta-anastomotic stenotic lesion, and an intact ulnar venous drainage system.

Artery of Davidoff and Schechter: A Large Angiographic Case Series of Dural AV Fistulas

The artery of Davidoff and Schechter (ADS) is the only meningeal branch of the posterior cerebral artery (PCA), supplying the medial tentorial margin and posterior portions of the falx. Given its small size, it is rarely identified on angiographic studies, unless enlarged in pathologies such as dural arteriovenous fistulas (DAVFs) or vascularized masses. This artery was first described by Wollschlaeger and Wollschlaeger in 1965, and to date, only a few reports have described its significance. The objective of this study is to report our experience with the ADS in dural fistulas from 2 tertiary medical centers and to emphasize the importance of recognizing this artery during angiographic examination of vascular tentorial and posterior fossa lesions. To our knowledge, this report demonstrates the largest angiographic case series published to date, recognizing a total of 7 patients with ADS arising secondary to a posterior fossa or tentorial DAVF and one of the largest reported series of DAVFs supplied by the ADS treated by endovascular and surgical techniques. Our cases validate the importance of prompt identification of the ADS for the diagnosis as well as endovascular treatment of vascular malformations in the posterior fossa and tentorial region.

RARE VERSION OF TOPOGRAPHY OF DEEP FEMORAL ARTERY

The deep femoral artery is a large branch of the common femoral artery that is of much interest for vascular and endovascular surgeons due to the role it plays in collateral circulation between the vessels of the small pelvis and arteries of the popliteal-tibial segment. In most cases, the deep femoral artery branches off from the posterolateral or posterior surface of the common femoral artery. At the same time, anomalies of development of the deep femoral vessels may become the cause for iatrogenic damages in implementation of the open or endovascular interventions. In the article, a clinical case of a patient referred for a planned ultrasound examination of vessels of the lower limbs before angiographic examination of the vessels of the heart and of the lower limbs, is described that revealed atypical topography of branching of the two trunks of the deep femoral artery from the common femoral artery. The upper trunk of the deep femoral artery branched off from the anteromedial surface of the common femoral artery and in the initial part was positioned above the common femoral vein. The lower trunk of the deep femoral artery sepa-rated from the anterolateral surface of the common femoral artery. Preoperative identification of the variant anatomy of the vessels of the femoral triangle permitted to perform angiographic examination of the coronary vessels through the femoral artery on the contralateral limb without complications.

Hemicranial Cough-Induced Headache as a First Symptom of a Carotid-Cavernous Fistula-Case Report

Background and objectives: Spontaneous carotid-cavernous fistulas (CCFs) are rare, and they may be caused by an aneurysm rupture. Materials and Methods: A case of a man hospitalized for high-intensity hemicranial headache with sudden cough onset as part of an upper respiratory tract infection is presented. The pain was of a pulsating character, localized on the right, behind the eye, followed by nausea and vomiting. Neurological finding registered a wider rima oculi to the right and slight neck rigidity. Laboratory findings detected a mild leukocytosis with neutrophil predominance, while cytobiochemical findings of CSF and a computerized tomography (CT) scan of the endocranium were normal. Results: Magnetic resonance imaging (MRI) angiography indicated the presence of a carotid cavernous fistula with a pseudoaneurysm to the right. Digital subtraction angiography (DSA) was performed to confirm the existence of the fistula. The planned artificial embolization was not performed because a complete occlusion of the fistula occurred during angiographic examination. Patient was discharged without subjective complaints and with normal neurological findings. Conclusions: Hemicranial cough-induced headache may be the first sign of carotid cavernous fistula, which was resolved by a spontaneous thrombosis in preparation for artificial embolization.

Features of performing arteriography in patients with diabetes mellitus with critical ischemia of the lower limb

Objective — to study the features of performing arteriography in patients with diabetes mellitus with chronic critical ischemia of the lower limb with stenotic-occlusive lesions of the arteries of the popliteo-tibial segments. Materials and methods. The arteriography experience in 108 patients with diabetes mellitus 2 type with chronic critical ischemia of the lower limb has been analyzed. All patients had stenotic-occlusive lesions of the arteries of the popliteo-tibial segments for the passable arteries of the ilio-femoral segments.The first group included 56 patients, who performed arteriography according to the proposed methodology (Ukrainian patent for utility model No. 114970 dated March 27, 2017, «Method of angiographic examination of lower extremity arteries in patients with ischemic form of diabetic foot syndrome»), the second group included 52 patients, who performed arteriography by Seldinger’s method. Results. With the help of ultrasound examination it was proved that 63.1 % of the common femoral artery blood volume in patients with diabetes mellitus with chronic critical ischemia of the lower limb with stenotic-occlusive lesions of the arteries of the popliteo-tibial segments is divided to the superficial femoral artery and 36.9 % in the deep femoral artery. Application of the developed method of arteriography has allowed to reduce the amount of active ingredient of contrast, which was administered to patients in the first group 2.16 times in comparison with the second group. In the first group the percentage of hemorrhagic complications was significantly lower than in the second group. Conclusions. The developed method of performing arteriography should be used in patients with diabetes mellitus with chronic critical ischemia of the lower limb with stenotic-occlusive lesions of the arteries of the popliteo-tibial segments.

Modern approaches to endovascular treatment of uterine leiomyoma

Individual features of the blood supply to the uterus and ovaries in 20-25% of cases cause failures in endovascular treatment of patients with uterine leiomyoma (ULM) and are forced to return to traditional surgical methods. The purpose of the study is to assess the possibilities of preventing iatrogenic complications of endovascular treatment of ULM through the use of separating occlusion of the uterine arteries, taking into account the characteristics of the blood supply to the uterus and ovaries. Materials and methods. The work is based on the analysis of the results. X-ray endovascular occlusion of the uterine arteries for ULM performed in 88 women aged 34-46 years (mean age 38.8 ± 2.5 years). The patients were divided into 2 groups: the 1st group comprised 65 patients without visible uterine-ovarian interarterial anastomoses. They performed standard embolization of the uterine arteries (EUA) using spherical PVA microemboli (COOK, USA), Embosphere (Merit Medical, USA) with a diameter of 500-700 microns. The second group consisted of 23 patients in whom utero-ovarian inter-arterial anastomoses were detected. In patients of this group, EUAs were produced with Embox cylindrical emboli (Plastis-M, Russia) with a length of 10 mm and a diameter of 500-700 μm, which occlude only the bed of the uterine arteries and are not capable of to overcome utero-ovarian inter-arterial anastomoses. In the 2nd group of EUA patients wore the character of occlusion, separating the uterine and ovarian arteries. The original EUA protocol was applied, which includes, in addition to the standard stages of selective arteriography of the uterine arteries, performing preliminary abdominal aortography to visualize the ovarian arteries and pelvic arteriography to assess pelvic vascular anatomy and identify utero-ovarian interarterial anastomoses. The results of the study. A total angiographic examination of the ovarian and uterine arteries, including a review angiography of the infrarenal section and bifurcation of the aorta, ileal vessels. In 23 (26.1%) patients with angiographic examination, uterine-ovarian arterio-arterial anastomoses. In 13 patients (56.5% of the detected anastomoses), these were type 1 anastomoses. In 10 patients (43.5% of the detected anastomoses), type 3 anastomoses were detected. Endovascular occlusion of the uterine arteries was performed in all patients. In 5 (7.69%) patients from the 1st group after EUA, amenorrhea occurred. In contrast, in all 23 patients from the 2nd group in the postembolization period, no observation of ovarian function was observed in any of the observations. Conclusion. For endovascular treatment of ULM in the presence of pronounced utero-ovarian interarterial anastomoses, the method of separating uterine artery occlusion is a safe and effective way to prevent ischemic damage to the ovaries.

Segmental Arterial Mediolysis of Omental Arteries with Haemoperitoneum: Case Report with Embolization of the Left Omental Artery and Brief Review of Literature

Segmental arterial mediolysis of an omental artery is an exceptionally rare condition. A 69-year-old man presented with haemoperitoneum six days after being hospitalized due to pneumogenic sepsis. Computed tomography of the abdomen showed a short segment dilatation of an omental artery in the left upper abdomen, compatible with segmental arterial mediolysis. Angiographic examination revealed alterations of omental branches of the right gastroepiploic artery and an aneurysm of the left omental artery, both characteristic of segmental arterial mediolysis. Embolization of the left omental artery with use of N-butyl-2-cyanoacrylate was performed. The postinterventional course was uneventful with increase of haemoglobin levels and without symptoms of omental infarction. Transcatheter embolization in the setting of haemoperitoneum due to segmental arterial mediolysis of an omental branch is technically feasible and a valuable alternative to emergency operation.

Magnetic Resonance Imaging (MRI) and Digital Subtraction Angiography Investigation of Childhood Moyamoya Disease

Because digital subtraction angiography (DSA) is not an ideal angiographic examination for moyamoya disease in the pediatric population, magnetic resonance angiography (MRA) provides a noninvasive contrast-free angiographic examination; whereas magnetic resonance imaging (MRI) provides superior spatial resolution and soft-tissue contrast for lesion assessment. Ninety patients with moyamoya disease were examined by MRI and DSA to assess the distribution of lesions and their diagnostic agreement between modalities. MRI examination revealed 439 lesions. Punctate lesions were the most abundant, followed by patchy lesions. These lesions generally covered a smaller area than the abnormal-vascular corresponding brain parenchyma. Steno-occlusive changes at bilateral anterior, medial, and posterior cerebral arteries were identified by MRA and DSA. MRI showed moderate agreement in identifying lesions after steno-occlusive changes in anterior and medial cerebral arteries, and good agreement in posterior cerebral arteries; 6% to 11% of cases were misdiagnosed by MRA.

The Role of Coronary Computed Tomography Angiography and Cardiac Magnetic Resonance in STEMI Patients with Normal Coronary Angiography

Usually, the diagnosis of myocardial infarction based on patient symptoms, electrocardiogram (ECG) changes, and cardiac enzymes, is not a challenge for cardiologists. The correlation between coronary anatomy and the ECG territories that present ischemic changes can help the clinician to estimate which coronary artery presents lesions upon performing a coronary angiogram. In certain situations, the diagnosis of myocardial infarction can be difficult due to the lack of correlations between the clinical and paraclinical examinations and the coronary angiogram. In some cases, patients with chest pain and ST-segment elevation on the ECG tracing present with a normal coronary angiography. In other cases, patients without important changes on the ECG can present critical lesions or even occlusions upon angiographic examination. The aim of this article is to highlight the role of noninvasive coronary magnetic resonance and multi-slice computed tomography in patients with ST-segment elevation myocardial infarction and normal coronary angiography.