Changing clinical and therapeutic trends in tentorial dural arteriovenous fistulas: a systematic review

BACKGROUND AND PURPOSE: Tentorial dural arteriovenous fistulas are characterized by a high hemorrhagic risk. We evaluated trends in outcomes and management of tentorial dural arteriovenous fistulas and performed a meta-analysis evaluating clinical and angiographic outcomes by treatment technique. MATERIALS AND METHODS: We performed a comprehensive literature search for studies on surgical and endovascular treatment of tentorial dural arteriovenous fistulas. We compared the proportion of patients undergoing endovascular, surgical, and combined endovascular/surgical management; the proportion of patients presenting with ruptured tentorial dural arteriovenous fistulas; and proportion of patients with good neurologic outcome across 3 time periods: 1980-1995, 1996-2005, and 2006-2014. We performed a random-effects meta-analysis, evaluating the rates of occlusion, long-term good neurologic outcome, perioperative morbidity, and resolution of symptoms for the 3 treatment modalities. RESULTS: Twenty-nine studies with 274 patients were included. The proportion of patients treated with surgical treatment alone decreased from 38.7% to 20.4% between 1980-1995 and 2006-2014. The proportion of patients treated with endovascular therapy alone increased from 16.1% to 48.0%. The proportion of patients presenting with ruptured tentorial dural arteriovenous fistulas decreased from 64.4% to 43.6%. The rate of good neurologic outcome increased from 80.7% to 92.9%. Complete occlusion rates were highest for patients receiving multimodality treatment (84.0%; 95% CI, 72.0%-91.0%) and lowest for endovascular treatment (71.0%; 95% CI, 56.0%-83.0%; P < .01). Long-term good neurologic outcome was highest in the endovascular group (89.0%; 95% CI, 80.0%-95.0%) and lowest for the surgical group (73.0%; 95% CI, 51.0%-87.0%; P < .03). CONCLUSIONS: Patients with tentorial dural arteriovenous fistulas are increasingly presenting with unruptured lesions, being treated endovascularly, and experiencing higher rates of good neurologic outcomes. Endovascular treatment was associated with superior neurologic outcomes but lower occlusion rate

Transcatheter Closure of Large-Sized Coronary Artery Fistula

We report our experience with the use of AMPLATZER?? Vascular Plug for the closure of coronary artery fistulas. Three patients (age: 3, 12, 14 years) were diagnosed with coronary fistulas (pulmonary-to-systemic blood flow ratio: 1.5 to 3). Two of the fistulas originated each, from the proximal right and left coronary artery and had maximal diameter 9 and 10 mm respectively; their narrowest diameter (6 mm) was proximal to their entrance into the right atrium creating a form of a saccular aneurysm.The third fistula (maximal diameter: 16 mm) originated from the circumflex artery and entered the right atrium with unobstructed flow (narrowest diameter: 8 mm). Interventional closure was considered optimal and the decision was made to use devices sized twice the size of the narrowest diameter of the fistulas (12, 12 and 16 mm respectively). An arterio-venous loop was established through the fistula by snaring an exchange guide-wire. All plugs were implanted from the femoral vein with the use of a seven or eight French guide catheter, reaching the narrowest segment of the fistula and leading to complete closure of the two fistulas, immediately after the procedure. The fistula arising from the circumflex artery that received the largest plug continued to have residual flow up to 12 months after the procedure, when follow-up echocardiography revealed its complete occlusion. We present and consider the use of the AMPLATZER?? Vascular Plug as a safe and effective method for the transcatheter closure of large-sized coronary fistulas. The plug potentially offers an alternative method to coil occlusion techniques as well as open heart surgery

Precursors and correlates of transient and persistent longitudinal profiles of psychotic experiences from late childhood through early adulthood

Background: Psychotic experiences are reported by 5–10% of young people, although only a minority persist and develop into psychotic disorders. It is unclear what characteristics differentiate those with transient psychotic experiences from those with persistent psychotic experiences that are more likely to be of clinical relevance. / Aims: To investigate how longitudinal profiles of psychotic experiences, created from assessments at three different time points, are influenced by early life and co-occurring factors. / Method: Using data from 8045 individuals from a birth cohort study, longitudinal profiles of psychotic experiences based on semi-structured interviews conducted at 12, 18 and 24 years were defined. Environmental, cognitive, psychopathological and genetic determinants of these profiles were investigated, along with concurrent changes in psychopathology and cognition. / Results: Following multiple imputations, the distribution of longitudinal profiles of psychotic experiences was none (65.7%), transient (24.1%), low-frequency persistent (8.4%) and high-frequency persistent (1.7%). Individuals with high-frequency persistent psychotic experiences were more likely to report traumatic experiences, other psychopathology, a more externalised locus of control, reduced emotional stability and conscientious personality traits in childhood, compared with those with transient psychotic experiences. These characteristics also differed between those who had any psychotic experiences and those who did not. / Conclusions: These findings indicate that the same risk factors are associated with incidence as with persistence of psychotic experiences. Thus, it might be that the severity of exposure, rather than the presence of specific disease-modifying factors, is most likely to determine whether psychotic experiences are transient or persist, and potentially develop into a clinical disorder over time

Right Ventricular Outflow Tract Obstruction in a Middle Aged Man with Right-Sided Aortic Arch

Congenital diseases causing an obstruction of the right ventricular outflow tract are difficult to precisely diagnose, especially in elderly patients. We report a case of a 49-year-old man who presented to our hospital with longstanding shortness of breath on exertion. He was finally diagnosed as right ventricular outflow tract obstruction and referred for surgical correction. The patient had a history of descending aorta dissection which was treated by thoracic stent grafting. By that time right-sided aortic arch was diagnosed. The coexistence of right ventricular outflow tract obstraction and right sided aortic arch in the same patient is very rare, to the best of our knowledge

Influence of iodide ingestion on nitrate metabolism and blood pressure following short-term dietary nitrate supplementation in healthy normotensive adults

This paper was accepted for publication in the journal Nitric Oxide and the definitive published version is available at http://dx.doi.org/10.1016/j.niox.2016.12.008Uptake of inorganic nitrate (NO3−) into the salivary circulation is a rate-limiting step for dietary NO3− metabolism in mammals. It has been suggested that salivary NO3− uptake occurs in competition with inorganic iodide (I−). Therefore, this study tested the hypothesis that I− supplementation would interfere with NO3− metabolism and blunt blood pressure reductions after dietary NO3− supplementation. Nine healthy adults (4 male, mean ± SD, age 20 ± 1 yr) reported to the laboratory for initial baseline assessment (control) and following six day supplementation periods with 140 mL·day−1 NO3−-rich beetroot juice (8.4 mmol NO3−·day−1) and 198 mg potassium gluconate·day−1 (nitrate), and 140 mL·day−1 NO3−-rich beetroot juice and 450 μg potassium iodide·day−1 (nitrate + iodide) in a randomized, cross-over experiment. Salivary [I−] was higher in the nitrate + iodide compared to the control and NIT trials (P < 0.05). Salivary and plasma [NO3−] and [NO2−] were higher in the nitrate and nitrate + iodide trials compared to the control trial (P < 0.05). Plasma [NO3−] was higher (474 ± 127 vs. 438 ± 117 μM) and the salivary-plasma [NO3−] ratio was lower (14 ± 6 vs. 20 ± 6 μM), indicative of a lower salivary NO3− uptake, in the nitrate + iodide trial compared to the nitrate trial (P < 0.05). Plasma and salivary [NO2−] were not different between the nitrate and nitrate + iodide trials (P > 0.05). Systolic blood pressure was lower than control (112 ± 13 mmHg) in the nitrate (106 ± 13 mmHg) and nitrate + iodide (106 ± 11 mmHg) trials (P < 0.05), with no differences between the nitrate and nitrate + iodide trials (P > 0.05). In conclusion, co-ingesting NO3− and I− perturbed salivary NO3− uptake, but the increase in salivary and plasma [NO2−] and the lowering of blood pressure were similar compared to NO3− ingestion alone. Therefore, increased dietary I− intake, which is recommended in several countries worldwide as an initiative to offset hypothyroidism, does not appear to compromise the blood pressure reduction afforded by increased dietary NO3− intake

Transcatheter occlusion of a large pulmonary arteriovenous malformation with use of a cardioseal device

Large pulmonary arteriovenous malformations (PAVMs) carry a significant risk of neurologic complications and present technical difficulties in transcatheter treatment with use of coils or detachable balloons. A 26-year-old man with a giant PAVM, who had undergone unsuccessful attempted closure with use of a Gianturco-Grifka occlusion device in the past, underwent successful transcatheter embolization with two Cardioseal double umbrella devices designed for occlusion of intracardiac communications. The procedure was technically easy, had no complications, and provided sustained improvement in arterial saturation and exercise tolerance during follow-up. Transcatheter double umbrella device occlusion of large arteriovenous malformations is feasible and should be considered, especially for very large fistulas

Aneurysms associated with brain arteriovenous malformations

Brain arteriovenous malformations are frequently associated with the presence of intracranial aneurysms at a higher-than-expected incidence based on the frequency of each lesion individually. The identification of intracranial aneurysms in association with AVMs has increased due to improvement in diagnostic techniques, particularly 3D and superselective conventional angiography. Intracranial aneurysms may confer a higher risk of hemorrhage at presentation and of rehemorrhage in patients with AVMs and therefore may be associated with a more unfavorable natural history. The association of AVMs and intracranial aneurysms poses important therapeutic challenges for practicing neurosurgeons, neurologists, and neurointerventional radiologists. In this report, we review the classification and radiology of AVM-associated intracranial aneurysms and discuss their clinical significance and implications for treatment