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.

Analysis of the causes of repeat stenosis of the coronary arteries after elective stenting in patients with stable angina pectoris

Aim. Coronary stenting is the evidence-based treatment approach of stable angina. The objective was to determine the incidence of restenosis or atherosclerosis progression which led to the need for coronary angiography according to a single center registry data. Materials and methods. The procedure and clinical data of 3732 (2897 males) consecutive stable coronary artery disease patients undergoing coronary stenting, over five years between March 2010 and September 2014, were subject of this study. Over the next 4 years, 1487 (1173 males) patients were re-evaluated due to angina reoccurrence. 699 patients demonstrated the indications for coronary angiography. Results. The restenosis of the previously stented segment was detected in 84 (12%) cases, the progression of coronary atherosclerosis in 306 (44%), the combination of restenosis and atherosclerosis progression in 63 (9%), and the absence of these complications in 245 (35%) cases. The progression of coronary atherosclerosis was the leading indication for the repeat angiography and revascularization (44 and 58%, respectively); p0.05. The basal level of hsCRP2 mg/l had a prognostic significance for the development of combined event (the restenosis and atherosclerosis progression): AUC 0.65 (0.500.75), OR 3.0 (1.17.9), p0.05. Conclusion. The progression of coronary atherosclerosis was the leading indication for the repeat angiography and repeat revascularization during 2 years after coronary stenting. The hsCRP level 2 mg/l at baseline had a prognostic significance for the development of restenosis in previously stented segment and coronary atherosclerosis progression.

The Yield of Repeat Angiography in Angiography-Negative Spontaneous Subarachnoid Hemorrhage

Objective Despite the technological advancement in imaging, digital subtraction angiography (DSA) remains gold standard imaging modality for spontaneous subarachnoid hemorrhage (SAH). But even after DSA, around 15% of SAH remains elusive for the cause of the bleed. This is an institutional review to solve the mystery, “when is second DSA really indicated?” Methods In a retrospective review from January 2015 to December 2017, we evaluated cases of spontaneous SAH with initial negative DSA with repeat DSA after 6 weeks to rule out vascular abnormality. The spontaneous SAH was confirmed on noncontrast computed tomography (NCCT) and divided into two groups of perimesencephalic SAH (PM-SAH) or nonperimesencephalic SAH (nPM-SAH). The outcome was assessed by a modified Rankin’s score (mRS) at 6 months postictus. Results During the study period, we had 119 cases of initial negative DSA and 98 cases (82.3%) underwent repeat DSA after 6 weeks interval. A total of 53 cases (54.1%) had PM-SAH and 45 cases (45.9%) had nPM-SAH. Repeat DSA after 6 weeks showed no vascular abnormality in 53 cases of PM-SAH and in 2 (4.4%) out of 45 cases of nPM-SAH. At 6 months postictus, all cases of PM-SAH and 93% of nPM-SAH had mRS of 0. Conclusion We recommend, a repeat DSA is definitely not required in PM-SAH, but it should be done for all cases of nPM-SAH, before labeling them as nonaneurysmal SAH. Although the overall outcome for nonaneurysmal spontaneous SAH is better than aneurysmal SAH, nPM-SAH has poorer eventual outcome compared to PM-SAH.

Wedged Sensor in Distress? Lessons Learned from Troubleshooting Dampened Transmitted PA Waveforms of CardioMEMS Device

Introduction. Cardiovascular disease is a leading cause of morbidity and mortality with heart failure constituting a large portion of this spectrum. Heart failure patients have 90-day readmission rates of nearly 41% associated with a high expense. Numerous strategies to reduce readmissions have been attempted with the CardioMEMS pulmonary artery pressure monitoring system as one of the more successful ones. As this device becomes used more frequently, it is important to recognize procedural complications. We present of a rare complication where a patient underwent successful device placement and was subsequently found to have dampened waveforms which were due to device migration. Case Report. A 79-year-old male underwent successful CardioMEMS placement due to recurrent heart failure hospitalizations. 6 months later, the transmitted waveforms appeared dampened, and repeat angiography revealed a device that had migrated. Rather than abandoning the device, it was recalibrated and continued to transmit data and helped manage the patient’s heart failure. Conclusion. CardioMEMS is a cost-effective tool to help reduce heart failure hospitalizations. Device migration is a rare complication and can lead to inaccurate data. However, as seen in this case, the device can be successfully recalibrated and can continue to be utilized to help reduce heart failure admissions.

Catch me if you can: disappearing and reappearing posterior fossa dural arteriovenous malformation

We report an unusual case of a dural arteriovenous fistula (dAVF) presenting as acute neck pain and quadripareis in a 55-year-old previously healthy man. Imaging was suspicious for cervicomedullary venous thrombosis and angiography failed to show evidence of arteriovenous malformation or dAVF. The patient was started on warfarin for a presumed cervicomedullary venous thrombosis and there was a significant clinical improvement. However, 3 weeks later, the symptoms recurred and repeat angiography revealed a dAVF fed by a posterior branch of the left middle meningeal artery draining into the posterior fossa vein. We postulated that warfarin caused recanalisation of the previously thrombosed venous pouch allowing for angiographic discovery and treatment of the dAVF. The dAVF was embolised with onyx resulting in the complete obliteration of the dAVF and symptomatic improvement. Although rare, some dAVF can be concealed or disappear on angiography due to thrombosis of the draining vein and warfarin can lead to recanalisation.

Detection of unexpected ischaemia due to left main disease during tele-rehabilitation using 12-lead electrocardiogram monitoring: a case report

Background Cardiac rehabilitation (CR) reduces mortality and improves quality of life. Unfortunately, participation in CR remains low and studies have examined the use of home-based tele-monitoring to improve participation in CR. These studies generally utilized single- or three-lead electrocardiogram (ECG) channels with limited sensitivity to detect ischaemic changes. In this report, we describe detection of unexpected, significant left main coronary disease in a patient participating in a home CR programme using a unique 12-lead ECG monitoring system. Case summary A 68-year-old man was referred for CR after acute coronary syndrome and stent implantation to the obtuse marginal. Three months following this intervention, he began complaining of chest pain. Repeat coronary angiogram showed a borderline lesion in the left main not felt to be clinically significant. The patient performed CR and was monitored with the Master Caution® System, a digital platform including a garment with 10 textile electrodes (Master Caution garment) configuring a device which enables 12 lead ECG. While being monitored, the ECG technician detected 1–2 mm ST-depression in leads 1, L V2–V5. The patient was asymptomatic at the time the ST-depressions were noted. Repeat angiography revealed a significant increase in the severity of the left main lesion and the patient was referred for bypass surgery. Discussion This life-threatening diagnosis could easily have been missed using conventional ECG monitoring and our case demonstrates the potential clinical utility of tele-monitoring with a 12-lead digital home ECG monitoring device.