Kristensenlunding5760

We present a rare case of multiple intracranial arteriovenous fistulas (AVFs). A young female presented with headache and a left eyelid pulsatile swelling. C-176 Magnetic resonance imaging demonstrated numerous dilated cortical veins, along with a prominent left superior ophthalmic vein. A diagnostic cerebral angiogram revealed 5 distinct AVFs including 4 dural AVFs (dAVFs) and a pial AVF (pAVF). The largest dAVF was at the superior sagittal sinus (SSS). The others included bilateral ethmoidal, torcular, and a pAVF arising of the right pericallosal artery. She was treated by endovascular transarterial Onyx embolization. Only the SSS fistula was treated via middle meningeal artery feeders with complete occlusion. Immediate follow-up angiogram also showed complete spontaneous occlusion of the untreated dAVFs and the pial AVF. This case is exceedingly unique considering the multiplicity of AVFs, concurrent presence of pial and dural AVF, and spontaneous occlusion of all untreated AVFs after embolizing the largest shunting fistula.Background Isolated bilateral hypoglossal palsy is a rare condition that has never been described after surgery in the lower part of the fourth ventricle. In this article, we discuss various possible etiologies and relevant anatomy considerations of the rhomboid fossa. Case description We describe a case of bilateral hypoglossal palsy with tongue ptosis following surgery of an ependymoma in the lower part of the fourth ventricle. Immediate postoperative imaging showed ischemic lesions in both hypoglossal nuclei, not compatible with any known arterial territory. Two etiologies could be identified a venous medullary infarct of the medulla oblongata or direct injury of both hypoglossal nuclei due to their midline position. Finally, the patient improved progressively and returned to normal. Conclusions Intraoperative neurophysiologic monitoring of hypoglossal nerves, in addition to facial nerves, should be performed for tumors in this location.Background Xanthomas are benign lipomatous deposits that can be found systemically in various tissues including bones. Their presence in the skull remains a rare entity. Despite their benign characteristics, imaging modalities are often unable to distinguish them from malignant lesions. This leads to a diagnostic dilemma in patients with underlying malignancy. This case report highlights such a case where clinical history of prostate cancer and image findings were concordant with that of metastatic deposit in the parietal skull region. Case description This 65-year-old gentleman was diagnosed with prostatic adenocarcinoma. During systemic workup for his tumor, he was found to have a right parietal skull lesion. Magnetic resonance imaging of the brain, as well as a bone scan, were consistent with that of a metastatic deposit. As treatment would be drastically affected by the diagnosis, an excision biopsy was performed. The histology was consistent with that of a bone xanthoma. Conclusions Xanthomas are benign lesions that can be seen deposited in appendicular and axial skeleton. Skull lesions are rare with most case descriptions focusing on their presence in the frontoorbital regions and mandible and temporal bone. They usually have a benign course but may present with symptoms due to localized mass effect. Surgical intervention and histologic diagnosis may still be required in these lesions due to their lack of imaging characteristics that confirm their diagnosis through noninvasive methods.Background Acute stroke resolution via endovascular thrombectomy requires transcarotid access when transfemoral access is not possible. Although postoperative complications such as cervical hematoma and airway compression have been reported, an appropriate postprocedural management is largely unknown yet. We aim to provide new insights and learning points from our experience using the Jaw Elevation Device (JED) as a tool to facilitate recovery post surgery. Case description A 79-year-old female underwent endovascular thrombectomy via transcervical, transcarotid access for a left internal carotid artery occlusion. No intraprocedural complications were reported. After successful thrombectomy, manual compression was applied in the carotid artery, and to achieve neck immobilization a JED was used for 4 hours after the procedure. No complications occurred. Conclusions JED appears to be a reasonable option to facilitate patient recovery due to its capacity to maintain the airway, provide mild compression for hemostasis, and prevent cervical hematoma through a comfortable neck immobilization.Background Intramedullary metastases to the caudal neuraxis with exophytic extension to the extramedullary space are rare. We describe the unique case of a patient with locally recurrent breast cancer who developed an intramedullary-extramedullary metastasis to the conus medullaris and cauda equina 22 years after primary diagnosis, the longest interval between primary breast cancer and intramedullary spread to date. We also reviewed the published literature on focal breast metastases to the conus medullaris or cauda equina. Case description A 66-year-old woman with a history of node-positive estrogen receptor/progesterone receptor-positive, infiltrating ductal carcinoma diagnosed in 1997 and locally recurrent in 2007. Initial treatment included lumpectomy and targeted chemoradiation with mastectomy and hormonal therapy at recurrence. Twelve years later, she developed 6 weeks of bilateral buttock and leg pain without motor or sphincter compromise. Magnetic resonance imaging of the total spine revealed a 2 x 1.7 cm bilobed intradural, intramedullary-extramedullary, homogenously enhancing, T1-and T2-isointense lesion involving the conus medullaris and cauda equina. She underwent subtotal resection of a hormone receptor-positive breast metastasis. Her pain improved postoperatively and she was stable at 5 months. Conclusions We provide evidence that patients who present with symptoms of spinal neurologic disease and a history of hormone receptor-positive breast cancer require high suspicion for metastatic pathology, despite significant time lapse from primary diagnosis. The tumor may involve both the intramedullary and extramedullary space, complicating resection. Symptom relief and quality of life should guide resection of metastatic lesions to the caudal neuraxis.