The microsurgical management of a brainstem compression resulted from an embolized cerebral tentorial dural arteriovenous fistula

Intracranial dural arteriovenous fistulas (DAVFs) are abnormal connections between an arterial feeder and a dural venous sinus or leptomeningeal vein with the nidus located within the dural leaflets. In this article we report an uncommon event which is a hematoma inside a dilated draining vein formed after embolization of tentorial DAVF causing pressure on the brain stem and removed surgically. A 47 years old male with a history of ventriculoperitonial (V-P) shunt 2 years ago and embolization of arteriovenous malformation 15 years ago, presented to our hospital having symptoms due to tentorial dural arteriovenous fistula (TDAVF) fed from branches of external and internal carotid arteries. Two sessions of transarterial embolization were performed with total occlusion. Six months later, he was admitted to the hospital with gait unsteadiness, swallowing difficulties and confusion. Brain MRI revealed a hyperintense heterogenous mass like a pouch from thrombosed draining veins with a localized hematoma compressing the brainstem and causing these symptoms. A small hematoma was seen and removed microsurgically. The patient was improved clinically and was discharged home after 5 days. Neurointerventionalist must be aware when deciding to occlude TDAVMs as there is a risk of venous varix formation and rupture if incompletely occluded. Surgical intervention is sometimes needed to alleviate the hazardous compression on the brain stem and other vital structures. © 202

The effect of adenosine in inducing cardiac arrest for endovascular treatment of paediatric high-flow brain and spinal vascular malformation

Introduction: Endovascular treatment of high-flow vascular lesions with onyx may be very dangerous due to premature occlusion of the vein resulting from high flow-induced migration of this embolic substance without occlusion of the feeding vessels and the nidus. It is also dangerous because of the risk of occlusion of the normal vessels around the lesion. Inducing temporary cardiac arrest using adenosine may be helpful in limiting and minimizing these risks. However anaesthetic management of this procedure in children suffering from high-flow vascular lesions is difficult and challenging. Methods: We report three paediatric patients with high-flow cerebrospinal vascular lesions that underwent endovascular treatment under general anaesthesia and temporary cardiac arrest with adenosine. Adenosine was administered in escalating doses to induce a few seconds of cardiac standstill and the onyx injection was synchronized with the onset of adenosine-induced cardiac standstill, the fistula being occluded by onyx. Results: There were no complications in peri-procedural treatment in all three cases. Post-embolization angiography revealed complete obliteration of the lesion, and the patients� neurological status progressively improved at follow-up. Conclusion: Adenosine-induced temporary cardiac standstill was successfully used to facilitate safe and controlled endovascular onyx embolization of high-flow central nervous system vascular lesions. © The Author(s) 2020