Bilateral Occipital Arteries Research Articles

Multiple Dural Arteriovenous Fistulas in the Superior Sagittal Sinus Region with Reversible Parkinsonism and Urinary Incontinence as Rare Presentations: A Case Report

Background: Dural Arteriovenous Fistula (DAVF), characterized by abnormally direct connections between meningeal arteries and meningeal veins or dural venous sinuses, is a rare subtype among the intracranial arteriovenous malformations. Although the clinical manifestations of DAVF are very variable depending on the locations and size of venous drainage, parkinsonism and urinary incontinence are rarely reported. Here, we present a rare case with parkinsonism and urinary incontinence secondary to DAVF. Case Presentation: A 50-year-old man was admitted for a progressively worsening weakness of his left lower limb over a year with urinary incontinence for four months. Neurological examination revealed rigidity and bradykinesia of the left upper limb without an obvious tremor. Magnetic resonance imaging exhibited diffuse white matter hyperintensities in bilateral centrum semiovale. Cranial magnetic resonance venography revealed extensive tortuous venous malformations. Digital subtraction angiography exhibited multiple bilaterally distributed DAVF in the superior sagittal sinus, supplied by bilateral occipital arteries and superficial temporal arteries. In the one year follow-up, the patient with multiple DAVF bilaterally distributed was completely cured after endovascular treatment according to the symptoms and the follow-up imaging results. Conclusion: This report enriches the clinical presentations of DAVF with parkinsonism and urinary incontinence, which is a crucial diagnostic clue to be aware of the possibility. Moreover, these rare symptoms can be relieved by timely endovascular treatment.

Fetal imaging of a rare case of dural sinus malformation: a case report

BackgroundDural sinus malformations (DSM) are rare congenital anomalies, accounting for less than 2% of all intracranial vascular malformations. Fetal MRI plays an important role in the confirmation of the diagnosis, prognostication, and planning of treatment strategies. Here, we present a rare case of dural sinus malformation without thrombosis, diagnosed by prenatal ultrasound and fetal MRI. In addition to this, fetal intracranial 3D gradient recalled echo Dixon-based MRA was done which, to the best of our knowledge, is a first.Case presentationA 24-year-old multigravida with no known comorbidities underwent a routine second trimester anomaly scan in which an unusual posterior interhemispheric cyst was diagnosed. Further evaluation with fetal MRI revealed dilated posterior sinuses and torcula, normal internal jugular vein, and maintained flow voids with no mass effect. Fetal Dixon-based MRA and correlated Doppler revealed supply to the lesion by bilateral occipital arteries and posterior cerebral arteries. With these imaging features, a midline dural sinus malformation was diagnosed.ConclusionDural sinus malformations should be considered in the differential diagnosis of unusual posterior fossa cystic lesions detected on antenatal ultrasound coupled with a colour Doppler examination. Prompt fetal MRI is essential to establish the diagnosis, identify intracranial complications and decide the postnatal treatment strategy, thereby possibly improving the postnatal outcome.

A Case of Curative Onyx Embolization for Tentorial dAVF via Low-flow Feeders with Temporary Balloon Occlusion of High-flow Feeders.

For curative Onyx embolization of dural arteriovenous fistulas (dAVF) with multiple feeders, it is essential to select the optimal target artery as well as to control the blood flow at the fistula point. We report a case of tentorial dAVF (TdAVF) treated by Onyx embolization under flow control using balloon catheters. A 66-year-old male was admitted to our hospital for treatment of TdAVF detected incidentally by MRI, which revealed a dilated and tortuous vein around the cerebellum. Cerebral angiography demonstrated a TdAVF, fed mainly by bilateral middle meningeal arteries (MMA) and bilateral occipital arteries (OA), with the fistula point at the torcular and venous drainage to the two superior vermian veins (SVVs). Onyx 18 was injected from the low-flow feeder of the MMA under flow control by occluding the high-flow feeder of the OA using balloon catheters, obliterating the arteriovenous shunt. In treatment of TdAVF involving low- and high-flow feeders, Onyx embolization via the low-flow feeder with temporary balloon occlusion of other high-flow feeders is a useful method. This technique makes it easier for Onyx to penetrate the fistula point.

Bilateral Occipital Arteries of Internal Carotid Origin: Report of a Case and Review of the Literature.

The present report describes a patient with bilateral occipital arteries of internal carotid origin, which is an extremely rare variation, and left vertebral artery ostial stenosis diagnosed by selective catheterization and digital subtraction angiography.

Distance from the external occipital protuberance to the occipital artery for occipital nerve block

To the Editor: Greater occipital nerve block is indicated for cervicogenic or cluster headache. Identifying the location of the nerve is important for differential diagnosis of cervicogenic headache, because it is necessary to block this nerve and not neighboring structures [1]. The blocking point is where the greater occipital nerve crosses the superior nuchal line approximately halfway between the external occipital protuberance and the mastoid process [2, 3]. The nerve emerges on this line in association with the occipital artery, and thus this artery is the most reliable anatomical landmark [2, 3]. However, it may be difficult to detect pulsation of the occipital artery, because the artery is thin, its course is variable, and hair may make palpation of the scalp difficult. Although the use of sonography has been suggested for detection of the nerve [4], it is likely to be difficult because of interference from the hair of the head. In such a case, textbooks generally describe that the blocking point should be 2.5–3.0 cm from the external occipital protuberance [2, 3]. In our daily clinical practice, we thought that this distance may be too short in men. Therefore, we formally studied this by pulsation, and by a Doppler flowmeter, which we previously reported to be useful [5]. The institutional review board approved the study, and written informed consent was obtained from 330 healthy volunteers (200 men and 130 women). Each volunteer was placed in the prone position and attempts were made to palpate the bilateral occipital arteries. If neither side could be palpated, it was judged a failure. The Doppler flowmeter probe (Nihon Kohden ES-1000 SP, Tokyo, Japan) was then placed and moved along the superior nuchal line until artery flow became audible. When the artery was detected, we measured the distance between the artery and the external protuberance. The artery could not be palpated on either the right or the left side in 15 of 200 (7.5 %) male subjects and 12 of 130 (9.2 %) female subjects. With the Doppler flowmeter, the artery could not be detected in 5 (2.5 %) men and 3 (2.3 %) women, and in all of whom the artery also could not be detected by palpation. The mean distance from the external occipital protuberance to the occipital artery in females (Table 1) was within the textbook range (2.5–3.0 cm), but the distance in males was significantly longer than that in females (P ≤ 0.05, Student’s t test) (Table 1), and the distance was between 2.5 and 3.0 cm in only 27 of 195 (13.8 %) volunteers (in whom the distance could be measured). Table 1 Volunteer characteristics and distance between the occipital artery and the external occipital protuberance (mean (standard deviation), [range]) We have confirmed that the occipital artery sometimes cannot be detected by palpation, or even by Doppler flowmeter. The volunteers we studied were all young, and it is possible that the failure rate of detection may be higher in senior people with headache, who may have neuralgia-induced vasoconstriction. We suggest that, when the occipital artery could not be detected, the blocking point should be about 2.5 cm from the external occipital protuberance in women and about 4.0 cm (and not 2.5–3.0 cm) in men.

Giant Epicranial Neurofibroma

The authors describe a case of giant epicranial neurofibroma unassociated with von Recklinghausen's neurofibromatosis. The tumor, which was situated in the occipital region, gradually enlarged over a 14-year period, while the two skull defects beneath it increased in size over a period of 3 years. On angiography the tumor exhibited marked hypervascularity. It was fed mainly by the bilateral occipital arteries and drained into the transverse sinus. After its embolization and total excision the pathological diagnosis was plexiform neurofibroma. This and two similar reported cases have features in common with those of von Recklinghausen's neurofibromatosis.

Neurofibromatosis with Extracranial Vertebral Arteriovenous Fistulae

A 38-year-old female was hospitalized complaining of left cervical pain. On physical examination, bruits were audible in the painful region. Plain X-rays of the cervical spine showed widening of intervertebral foramina and scalloping of the vertebral bodies at C2-C5. Left vertebral angiography disclosed aneurysmal dilatation and arteriovenous fistulae at the C3 and C4-C5 levels of the artery. The right vertebral artery, bilateral occipital arteries, left thyrocervical trunk, and costocervical trunk were associated with the fistulae as collateral pathways to the left vertebral artery. In a sequential procedure, the left vertebral artery was clipped just proximal to the posterior inferior cerebellar artery, the lower fistula was occluded by a detachable balloon, and muscle was packed to the abnormal vessel close to the upper fistula. After treatment the bruits diminished and the radiculomyelopathy abated. Arteriovenous fistulae should arouse suspicion of neurofibromatosis. Auscultation of the neck and angiography are recommended for patients with neurofibromatosis presenting with radiculomyelopathy. Intravascular surgery with a detachable balloon is considered very effective for extracranial vertebral arteriovenous fistulae.