Collateral Venous Circulation Research Articles

Reconstruction of the inferior vena cava: different strategies

Purpose: Resection and reconstruction of the inferior vena cava (IVC) is an unusual and challenging procedure. Malignant disease invading or obstructing IVC is the most frequent entity, while nonmalignant is rare and differential diagnostic is difficult. Methods: We report two cases required resection and reconstruction of IVC. Results: A 31-year-old man with left lower extremity paresthesias. His work-up revealed a large (9x3 cm) mass at the right renal hilum involving the IVC and right renal vein (RV) with complete thrombosis of bilateral external and common iliac veins (CIV), as well as the infrarenal IVC. The tumor contacted the aorta in greater than 90 degrees, as well as the third portion of the duodenum. Surgical intervention: through a midline laparotomy, we attained complete control of the IVC (above and below) as well as left RV and bilateral CIV. The IVC was transected at its origin. After thrombectomy of both iliac veins, no relevant venous flow was observed, therefore we sutured the lower IVC stump. We then divided the left RV and the IVC above the RV level, extracting the tumor en-bloc with the IVC and the right kidney. Finally, we anastomosed the left RV to a “cone” cavoplasty of the remaining IVC stump. Histologically, it was a large (11x4.5 cm) benign mesenchymal tumor involving the right renal hilum, with the diagnosis of calcifying fibrous tumor, a rare benign tumor. During follow-up after 6 years patient develops post-thrombotic syndrome of the lower limbs and subcutaneous venous collateral circulation, but without any evidence of tumor recurrence. On the other hand, we present a 39-years-old male with history of left nephrectomy after inferior vena cava and left RV thrombosis when he was one month old. He came for outpatient consultation due to recurrent deep vein thrombosis and thrombophlebitis. CT scan revealed absence of the infrarenal IVC with prominent collateral veins in multiple pathways. Due to unfavorable response to medical treatment, a surgical approach was offered. IVC reconstruction was performed with cadaveric vein graft, from the remaining iliac veins to the junction of the IVC with the right RV. At 2 years of follow up, the patient presented partial clinical improvement, nevertheless, an MRI scan showed thrombosis of the graft. Conclusion: Transplant and Hepato-Pancreato-Biliary surgeons are familiarized with IVC approach, but surgical treatment is usually difficult and may require a major vascular reconstruction.

Neuroleptiques Causing a Giant Abdominal Mass

A 39 years old patient was admitted to our hospital, never operated before, with a history of mental illness. The patient was treated for schyzophrenia since the age of 15, under a long term treatment of neurolyptics and antidepressants, with complaints of chronic constipation. The patient reported abdominal pains and cessation of stool and gas, no defectation in 15 days, along with continuous vomitting.The patient was concious, instable TA : 80/40mmHG FC: 120B/m FR : 22 c/m. On initial evaluation we could detect an important abdominal distention as well as an apparent venous collateral circulation accompagnied with tenderness to palpation [Figure A]. Rectal examination revealed the presence of a very hard fecaloma. The initial biological assessment showed functional renal insufficiency, Hyperleukocytosis at 11000 /mm3, hyponatremia at 125 mmol/L. Abdominal tomography revealed a giant fecaloma at the rectum, the sigmoid and the left side of the transverse colon, and a mega colon with a diametre reaching 22 cm wide, the lining of the colon was improperly enhanced after the injection of the contrast agent [Figure B]. The patient was then admitted to the trauma room, he was prepared with a rehydration and hydro-electrolytic compensation. Repeated enemas and laxatives were used to stimulate defectation, but they were all unsuccessful, the hard mass of stool could not be removed. It was decided that the patient required abdominal surgery. Under general anesthesia, patient in supine position, a midline laparotomy was performed. During the exploration, we discovered a colon filled with a giant ficaloma, along with ischemic parietal lesions on the sigmoid [Figure C].
 Resection of the descending and sigmoid colons, manual extraction of the remainder of the fecalomas from the rectum, and terminal colostomy were performed following Hartmann's technique. The patient remained instable even after being treated in intensive care, the patient unfortunately passed away 48 h post operation.
 Constipation is a common problem that can cause fecal impaction and even development of a fecaloma, a mass of inspissated stool. Fecalomas occur more frequently in the left colon and rectum as stool hardens and the colon narrows. Fecalomas can manifest in various ways including bowel obstruction, urinary retention, and toxic megacolon.
 Medica­tions that were significantly associated with constipation were opioids, diuretics, antidepressants, antihistamines, antispasmod­ics, anticonvulsants, and aluminum antacids. The use of acetaminophen (>7 tablets weekly), aspirin, and other NSAIDs was also found to be associated with an increased risk of constipation. Fecalomas can often be treated conservatively with laxatives, enemas, and/or digital disimpaction. However, when these methods are unsuccessful, surgical intervention is required to prevent bowel perforation.
 In patients with history of constipation, new or worsening of abdominal pain, and are under antidepressants and neurolyptic treatment, fecalomas should be considered in the differential diagnosis, and constipation should be aggressively investigated to avoid complications.

Late Presentation of Pancreatic Pseudocyst in a Child

Late Presentation of Pancreatic Pseudocyst in a Child

Clinical Classification and Collateral Circulation in Chronic Cerebrospinal Venous Insufficiency.

Background: As an indispensable part of the cerebral venous system, the extracranial cerebrospinal venous system is not fully recognized. This study aimed to analyze the clinical classification and imaging characteristics of chronic cerebrospinal venous insufficiency (CCSVI) quantitatively.Methods: A total of 128 patients, who were diagnosed as CCSVI by jugular ultrasound and contrast-enhanced magnetic resonance venography (CE-MRV), were enrolled from May 2018 through May 2019. For the patients with possible extraluminal compression, computed tomography venography (CTV) was applied to estimate the degree of internal jugular venous stenosis (IJVS) and rank the vertebral venous collateral circulation.Results: The causes of extraluminal compression induced IJVS included osseous compression (78.95%), carotid artery (24.21%), sternocleidomastoid muscle (5.79%), swollen lymph node (1.05%), and unknown reasons (5.26%). The subtypes of non-compression CCSVI included the high jugular bulb (77.27%), fenestration of the internal jugular vein (IJV) (7.27%), internal jugular phlebectasia (2.73%), tortuous IJV (0.91%), IJV thrombosis (14.55%), and elongated venous valves with/without erythrocyte aggregation (13.64%). For extraluminal compression induced IJVS, the ratio of severe vertebral venous expansion was higher in the severe IJVS group than that in the mild IJVS group (p < 0.001). The IJVS degree was higher in the severe vertebral venous expansion group than in the mild vertebral venous expansion group (p < 0.001).Conclusions: A multimodal diagnostic system is necessary to improve the diagnostic accuracy of CCSVI. The vertebral venous system is an important collateral circulation for CCSVI, which may be a promising indicator for evaluating IJVS degree.

Portal hypertension as a result of the incomplete surgically treated advanced alveolar echinococcosis: a case description

BackgroundInfection of Echinococcus multilocularis causes in humans the alveolar echinococcosis. Although the infection has world-wide distribution it is rarely detected. Diagnosis of alveococcosis is difficult because of not typical clinical picture and irregular results of radiological examinations suggesting neoplasmatic process which begins in the liver tissue or in the biliary tracts. The parasitic growth is slow, so the illness is quite often established in late invasion period. Treatment of long-lasting and late diagnosed infection is difficult and requires cooperation of parasitologists together with surgeons to avoid life-threatening organ dysfunction.Case presentationWe describe a young male patient, diagnosed, according to the radiological, immunological and histological examination results, infection of Echinococcus multilocularis, who was treated with not radical resection of pathologic mass together with persistent albendazole intake. The right hepatectomy was performed. In addition, visible cysts were removed from the left lobe of the liver in nonanatomical resection and suspicious calcified lesions in hepatoduodenal ligament were also removed. After the operation portal hypertension, with splenomegaly and symptoms of the liver cirrhosis occurred (thrombocytopenia, collateral venous circulation, first degree varices oesophagii). The portal hypertension probably could be a result of incomplete surgery due to extended parasitic infection and liver anathomical changes due to performed procedures, because the portal hypertension and it’s further complications had not been observed before the operation.ConclusionsEchinococcus multilocularis should be taken under consideration in differential diagnosis of irregular lesions within the liver. Lon-lasting invasion could be responsible for the irreversible secondary liver changes such as cirrhosis and portal hypertension. The surgery treatment (treatment of choice) is difficult and it’s results depends on the invasion period the patient is operated on. After the surgery the patient requires careful follow – up, to detect early complications.

Reinvestigation of the origins of pineal meningiomas based on its related veins and arachnoid membranes

BackgroundA series of patients harboring pineal region meningiomas were respectively analyzed to explore the origin of these tumors and the true meaning of the term “velum interpositum (VI) meningiomas”.Methods21 patients with pineal meningiomas underwent operation in Nanfang Hospital of Southern Medical University from January 2005 to December 2016 were retrospectively included to analyze the clinical features, imaging findings and surgical video data of these patients. According to the method of literature, the data of this group were also divided into falcotentorial (FT) meningiomas and VI meningiomas, and the differences between the two types of tumors were compared.ResultsAmong the 21 cases of tumor, there were 12 cases of FT meningiomas, including 4 cases originating from cerebral falx, 4 cases from tentorium of cerebellum and 4 cases from straight sinus; there were 9 cases of VI meningiomas, 7 of which originated from the arachnoid sleeve of the Galen vein, 1 from the posterior part of the internal cerebral vein and 1 from the posterior surface of the pineal gland. Postoperative pathological examination showed meningiomas in all the 21 patients, including 16 cases of total resection and 5 cases of subtotal resection. Postoperatively limitation of binocular vertical motion was found in 3 cases, homotropic hemianopia in 7 cases, hemiplegia in 1 case and death in 1 case.ConclusionsThis study suggests that pineal meningiomas are more suitable to be described by FT meningioma and meningiomas of the arachnoid of the pineal region by analyzing the origin of tumors. The term “VI meningiomas” can only reflect a part of meningiomas of the arachnoid of the pineal region. Before the removal of pineal meningiomas, more attention should be paid to the effects of the two types of tumors on the Galen vein and the straight sinus, and the establishment of venous collateral circulation.

Usual and Unexpected Variations in the Veins of the Posterior Abdomen: A Case Study

Two venous system components comprise the drainage of the posterior abdominal cavity. One component drains blood from the visceral derivatives of the urogenital ridge (e.g., kidneys, gonads) directly to the inferior vena cava (IVC). The other venous system collects blood from the body wall and drains into the azygos system through the subcostal vein, ascending lumbar vein, and lower posterior intercostal veins. Veins, and especially the azygos system, are notoriously variable. Much of this variability arises from the complex embryological development of the caval venous system in the thoracic and abdominopelvic cavities; but the formation of venous anastomoses representing multiple routes of drainage from a single region also contribute to the variability of veins.During routine dissection of the abdomen of a male cadaver (Caucasian, 67 years), the right testicular vein demonstrated multiple anatomical variations. An anomalous vein arising from several small tributaries at the lateral end of the 11th and 12th ribs was discovered during the dissection. This vein crossed the posterior abdominal wall inferomedially to drain into the right testicular vein. Further exploratory dissection revealed direct communication between the anomalous vein and the right 11th posterior intercostal vein, which could be traced from the origination of the anomalous vein to the connection with the azygos vein at the appropriate vertebral level. The anomalous vein represents an unusual route for collateral venous circulation between the azygos system and the caval system in the abdomen via the right 11th posterior intercostal vein. Additionally, the right testicular vein drained into the right renal vein instead of directly draining into the IVC. No other notable variations were observed in the abdominal vasculature. The left testicular vein, left renal vein, left posterior intercostal veins, and left subcostal vein all demonstrated typical merging patterns. Accompanying renal, testicular, and posterior intercostal arteries on the right side also appeared to have normal branching patterns.

СОСТОЯНИЕ ОБОЛОЧЕК ЗРИТЕЛЬНЫХ НЕРВОВ И ПУТИ ОТТОКА КРОВИ ИЗ ПОЛОСТИ ЧЕРЕПА В 21-СУТОЧНОЙ «СУХОЙ» ИММЕРСИИ ПО ДАННЫМ УЛЬТРАЗВУКОВЫХ МЕТОДОВ ИССЛЕДОВАНИЯ

Venous blood circulation and liquid dynamics in the brain, and collateral venous blood circulation were investigated in participants of 21-day dry immersion study. The ultrasonic technique was used to measure the optic nerve sheaths, register hemodynamics in the internal jugular vein, inferior vena cava and superficial femoral vein. We observed a significant acceleration of blood flow through the jugular veins by day 7 with a decrease in the lumen of the jugular veins and a gradual expansion of the liquor space around the optic nerves. Hemodynamics in the vena cava inferior as a potential collateral of outflow from the cranial cavity indirectly suggests reorganization of the outflow pathway and venous blood distribution between the jugular and vertebral pathways in specific periods of exposure to immersion. After the immersion, all hemodynamic parameters returned to their initial levels; however, after two weeks of recovery the inverse trend in the state of optic nerve sheaths was observed only in some of the participants.

Right Atrium Myxoma in an 11-Year-Old Girl in Guinea

The objective of this study was to describe the myxoma of the right atrium occurring in an 11-year-old girl. It was an 11-year-old girl weighing 22 kg, admitted for exertional dyspnea, dry cough, palpitations, hepatitis, abdominal bloating, fever evolving for more than 9 months without a history of known cardiovascular disease; referral from a pulmonology department for cardiomegaly and right pleurisy. At cardiac auscultation, the rhythm was irregularly fast at 130 beats without added noise with a blood pressure of 110/65 mmhg. In the lungs, there was silence and a decrease in vocal vibrations at the right base, SaO2 at 70%. Elsewhere a thoracic collateral venous circulation was visible. Electrocardiogram recorded rapid atrial fibrillation at 134 cycles. The cardiac ultrasound concluded that there was a mobile mass in the right atrium prolapsing in the right ventricle measuring 25 mm × 18.9 mm suggesting a myxoma. The myxoma of the right atrium is of a rare localization with a polymorphic clinical manifestation. It should be diagnosed as early as possible to avoid the occurrence of dreaded complications. Its management is surgical.

Leiomyosarcoma of the inferior vena cava. Our experience and a review of the literature.

Leiomyosarcoma (LMS) of the inferior vena cava (IVC) is a rare malignant tumor, accounting for 2% of all LMSs. Less than 400 cases have been reported in literature. Computed tomography (CT) is the most accurate imaging method in assessing the location of the tumor within the IVC and magnetic resonance imaging (MRI) accurately identifies its extent and the potential for surgical resection. We present the case of a patient with inferior vena cava leiomyosarcoma (IVCL), for whom the pathological diagnosis was different from the initially expected one, the tumor appearance on pre-operative imaging mimicking renal cell carcinoma. The intraoperative difficulty of approaching renal hilum and IVC was a factor suggesting the vascular origin of the tumor, which was confirmed at pathological analysis. The extensive defect in the IVC after tumor excision led to the decision of complete transverse suturing of IVC, as significant collateral venous circulation was already present. Because IVCL is a rare disease, there is scarce data regarding the prognosis and treatment options. Long-term survival depends on the extent of the surgery. The need of vascular reconstruction is not always mandatory. Despite high recurrence rates, no consensus regarding adjuvant treatment exists yet. A multidisciplinary approach including surgical oncologists and vascular surgeons is mandatory to achieve the best patient outcomes. Perioperative planning, coordination and adherence to oncological techniques are critical.

Компенсаторні механізми при венозному тромбозі дурального синуса. Клінічний випадок

SummaryPatients with cerebral venous thrombosis (CVT) present with range of symptoms,which vary widely from headache to coma. Chronic occlusion of venous dural sinusesleads to the initiation of compensation processes, such as vascular collateralization,recanalization of the organized thrombus. Consequently, their efficacy determinesdisease course and severity.The aim of our study was to highlight the clinical challenges, while managing apatient with subcompensated CVT. Taking into account the fact that mild severity isobserved in 20% of cases, eventually about a quarter of patients presenting withheadache of unclear etiology becomes unnoticed and results with their quality of life atlow level.To analyze the disease outcome and prognosis, we accurately studied compensationmechanisms, which occur in patient due to dural sinus thrombosis, notably venouscollateral circulation and thrombus recanalization. However, the most important«pitfall» of chronic dural sinuses occlusion, when not appropriately treated, is the factthat hemodynamic compensation also leads to high risk of cerebrovascular events,which may lead to death or disability.We presented the patient with cerebral venous thrombosis of the transverse andsigmoid sinuses manifested migraine-like headache with a vegetative issue and signs ofincreased intracranial pressure.162Due to the absence of anticoagulant therapy, venous drainage through collateralpathways and recanalization of thrombosed sinuses were insufficient to maintaincerebral blood supply, resulting in the diffuse cerebral edema as well as secondarybrain injury. After an accurate survey, diagnostic procedures, prescribing ofindividualized treatment and long-term follow-up with correction of therapy the patientexperienced regression of CVT symptoms.Cerebral magnetic resonance imaging venography is an important tool for thediagnosis and predictiction of prognosis of this condition. Thus, patients with a longhistory of untreatable headache and signs of intracranial hypertension should undergothis procedure. To consider intracranial vascular events and outcome, the evaluation ofvenous hemodynamics should be conducted. Moreover, it is often necessary to examinecerebral veins and sinuses, when hemorrhagic stroke does not correspond to cerebralarterial territories and has unclear etiology.

Retroperitoneal Cystic Lymphangioma: About A Case and Review of The Literature

Cystic lymphangioma is a rare benign malformative tumor of lymphatic vessels in various locations.&#x0D; We report the observation of a 62-year-old man who had been consulting for major abdominal distention for 5 years. The clinical examination found a very distended abdomen with collateral venous circulation.&#x0D; The imaging was in favor of a cystic retro-peritoneal image. Surgical exploration showed a retroperitoneal cystic mass. Anatomo-pathological examination concluded that retroperitoneal cystic lymphangioma.

Aortic valve endocarditis with root abscess causing superior vena cava obstruction: a case report

BackgroundTo our knowledge, we report the first case of endocarditis with root abscess causing compressive superior vena cava (SVC) obstruction.Case summaryAn 84-year-old gentleman with previous tissue aortic valve replacement presented with fevers and systemic upset. Blood cultures grew Streptococcus anginosus and transoesophageal echocardiogram identified prosthetic valve vegetations with an associated root abscess. Antibiotics were commenced and referral made for surgical consideration. Several days into treatment the patient developed clinical signs of SVC obstruction and computed tomography demonstrated an enlarging root abscess with SVC compression. The patient was discussed with local cardiothoracic centres, but surgery was not an option primarily due to abscess size and vascular involvement. Priority moved from active to palliative treatment given no improvement with antibiotics, unsuitability for surgery, and patient discomfort. Within several weeks, symptoms/signs of SVC obstruction actually improved, likely due to collateral venous circulation formation and the patient was discharged home with palliative care input.DiscussionThere are previous reports of SVC obstruction related to infected SVC thrombus, indwelling intravascular devices, and para-aortic abscess, but none related to infective endocarditis. Streptococcus anginosus endocarditis is rare but often associated with abscess formation, and male gender, increasing age, and previous surgery are recognized risk factors.

1297 Cheers to Budd: Pyogenic Liver Abscess Complicated by Acute Budd-Chiari Syndrome

INTRODUCTION: Amebic liver abscess (ALA) is the most common extraintestinal manifestation of amebiasis with high mortality rates (20%). Complications include rupture; superinfection; anemia; and rarely vascular thrombosis. Budd-Chiari syndrome is characterized by post-sinusoidal portal hypertension caused by obstruction of either major hepatic veins or the inferior vena cava. CASE DESCRIPTION/METHODS: A 54-year-old alcoholic male, with a history of recent travel to India, presented with 2 weeks of fever, vomiting and abdominal pain. On exam, he was febrile, icteric, with generalized abdominal tenderness. Chemistries revealed WBCs 12000/mm3, total/direct bilirubin 6.5/3 mg/dL, AST/ALT 410/318 U/L, and ALP 310 U/L. USG RUQ showed hepatomegaly with multiple, thick-walled areas of central low attenuation, suspicious for LA. CT confirmed the presence of multiple ALAs along with rupture and delayed filling in the left and middle hepatic veins. Under USG guidance, brownish fluid (anchovy sauce-like) was aspirated and a pigtail catheter was placed. He was started on ceftriaxone and metronidazole for the treatment of pyogenic LA. Fluid serology was positive for Entamoeba histolytica and only metronidazole was continued for 21 days, along with rivaroxaban for six months for the treatment of Budd Chiari syndrome. His liver enzymes normalized in 21 days and a follow-up USG after 48 days of treatment with rivaroxaban showed no evidence of thrombosis in hepatic veins and IVC. DISCUSSION: ALA should be suspected in patients with fever &amp; jaundice with a history of recent travel to an endemic area. The rates of complications are high, commonest being an abscess rupture. Thrombosis of IVC, hepatic and sometimes right atrium, are rare complications, caused by either direct spread of inflammation or external mechanical compression by the abscess. A diagnosis of Budd-Chiari syndrome should be considered in cases of prolonged fever unresponsive to treatment or ascites with leg edema and collateral abdominal venous circulation. Underlying prothrombotic affection must be excluded. To conclude, identifying a treatable cause of Budd-Chiari syndrome, such as liver abscess, can result in early, effective, and life-saving treatment.

Role of Collateral Venous Circulation in Prevention of Sinistral Portal Hypertension After Superior Mesenteric-Portal Vein Confluence Resection during Pancreaticoduodenectomy: a Single-Center Experience

BackgroundThe ligation of the splenic vein (SV) during pancreaticoduodenectomy (PD) may result in sinistral portal hypertension (SPH). This study aimed to identify the collateral pathways that formed postoperatively and evaluate the impact of omentum and arc of Barkow preservation in PD. MethodsPatients who underwent PD between January 2013 and May 2018 at the Second Affiliated Hospital of Zhejiang University were enrolled in this retrospective study. PD was performed with preservation of the greater omentum and arc of Barkow. Venous collaterals, spleen size, and platelet count were evaluated before and after surgery. ResultsIn total, 330 patients underwent PD, of whom, 43 patients who underwent superior mesenteric vein (SMV)/portal vein (PV) reconstruction and splenic vein (SV) ligation were selected. No patient developed severe gastrointestinal bleeding. Three collateral routes were identified: the left gastric route, the colic marginal route, and the first jejunal route. Seventeen patients developed splenomegaly. Twenty-three patients developed thrombocytopenia. However, none of them developed gastrointestinal bleeding or other clinical complaints. ConclusionAlthough subclinical SPH developed after SV ligation, postoperative gastrointestinal bleeding was uncommon.

Usability of Inferior Vena Cava Interposition Graft During Living Donor Liver Transplantation: Is This Approach Always Necessary?

PurposeTo share the outcome of caval reconstruction technique in patients who underwent living donor liver transplantation (LDLT) with inferior vena cava (IVC) interposition grafting. MethodsBetween January 2009 and December 2018, an artificial or homologous interposition vascular graft was used for the continuity of resected native (IVC) due to various reasons in 29 of 1740 patients who underwent LDLT at our institute. Demographic, clinical, and radiological data were prospectively collected and retrospectively analyzed. ResultsSixteen female and 13 male patients ranging 6–67 years of age were included. Right, left, and left lobe lateral segments were used in 22, 5, and 2 patients, respectively. The three leading LDLT indications were primary or idiopathic Budd-Chiari syndrome (BCS) (n = 12), alveolar echinococcosis (n = 7), and secondary BCS (n = 5). The three leading indications for IVC interposition grafting were thrombosis, dense fibrosis, and IVC invasion caused by tumor or echinococcosis. Homologous IVC graft was used in 17, homologous aortic graft in 7, and Dacron graft in 5 patients. Throughout the follow-up period, ascites ± pleural effusion and elevated liver enzymes were detected in 12 and 4 patients, respectively. Stenosis and/or thrombosis requiring one or more procedures such as 1–6 sessions balloon angioplasty, stent, and thrombus aspiration were observed in half of the patients. ConclusionRetrohepatic IVC damages are not a contraindication for LDLT. The presence or absence of venous collateral circulation is an important indicator of the need for IVC interposition graft use.

Establishment of a Rat Model of Superior Sagittal-Sinus Occlusion and Recanalization via a Thread-Embolism Method

There are many uncontrollable factors in the pathogenesis of cerebral venous sinus thrombosis (CVST). In order to further explore the pathophysiology and morphology of CVST, it is necessary to establish a highly compatible CVST animal model that can standardize the site and stage of venous thrombosis. The present study employed the insertion of a self-made thread embolism into the superior sagittal sinus (SSS) to establish a rat model of SSS occlusion that emulates CVST. The thread embolism was removed after 6 h of SSS occlusion in order to achieve recanalization. After successful preparation of the model, the cerebral blood flow (CBF) status and ultrastructural changes of the blood–brain barrier (BBB) were monitored. This CVST model was able to achieve continuously high occlusion of SSS. The parasagittal venous-collateral circulation underwent extensive compensation and recombination, which alleviated blood flow stasis and brain tissue hypoxia caused by restricted reflux. Removing SSS occlusion significantly improved cerebral circulation, reduced brain edema, and accelerated the receding of brain edema. This study established a new model of acute occlusion and recanalization of SSS in rats via a thread-embolism method, which standardized the ischemic site and stage of venous thrombosis. In addition, our study suggests that promoting collateral circulation may be a potential treatment for promoting brain protection.

Importance of collateral venous circulation on indocyanine green videoangiography in intracranial meningioma resection: direct evidence for venous compression theory in peritumoral edema formation.

Indocyanine green videoangiography (ICGVA) has been used in many neurosurgical operations, including vascular and brain tumor fields. In this study, the authors applied ICGVA to intracranial meningioma surgery and evaluated it usefulness with attention to collateral venous flow. Forty-two patients with intracranial meningioma who underwent ICGVA during microsurgical resection were retrospectively analyzed. For ICGVA, the ICG was injected intravenously at the standard dose of 12.5 mg before and/or after tumor resection. Intravascular fluorescence from blood vessels was imaged through a microscope with a special filter and infrared excitation light to illuminate the operating field. The authors assessed the benefits of ICGVA and analyzed its findings with preoperative radiological findings on MRI. ICGVA allowed real-time assessment of the patency and flow direction in very small peritumoral vessels in all cases. A safe dural incision could also be done based on information from ICGVA. The collateral venous channel due to venous obstruction of tumoral compression was found in 10 cases, and venous flow restoration after tumor resection was observed promptly after tumor resection in 4 cases. Peritumoral brain edema (PTBE) was observed on preoperative T2-weighted MRI in 19 patients. The presence of collateral venous circulation or flow restoration was significantly related to PTBE formation in multivariate analysis (p = 0.001; HR 0.027, 95% CI 0.003-0.242). ICGVA, an excellent method for monitoring blood flow during meningioma resection, provides valuable information as to the presence of venous collaterals and flow restoration. Furthermore, the fact that the presence of venous collaterals was found to be associated with PTBE may directly support the venous theory as the pathogenesis of PTBE formation.

Cortical Vein Opacification for Risk Stratification in Anterior Circulation Endovascular Thrombectomy

Introduction: There is continued interest in identifying factors that predict a favorable outcome after endovascular thrombectomy (EVT) for anterior circulation large vessel occlusion (ACLVO). We compared the predictive values of 2 different scoring systems for evaluating venous collateral circulation. Methods: A retrospective review of patients who underwent EVT for ACLVO at a single institution was performed. Those who underwent preprocedural computed tomography angiography (CTA) were selected. The Cortical Vein Opacification Score (COVES) and Prognostic Evaluation based on Cortical vein score difference In Stroke (PRECISE) score were calculated from each patient's CTA. Our primary outcome of interest was the Modified Rankin Scale (mRS) score at 90 days. Results: A total of 103 patients were included in the study (average age = 68.3 years, median National Institutes of Health Stroke Scale = 15). The mean time to reperfusion was 6.4 hours and Thrombolysis in Cerebral Infarction 2B or 3 reperfusion was achieved in 77.7% of cases. An unfavorable COVES score was significantly associated with an unfavorable (mRS 3-6) outcome (adjusted odds ratio [aOR]: 3.06; 95% confidence interval [CI] 1.15-8.13, P = .025), while an unfavorable PRECISE score was not (aOR: 1.02; 95% CI .37-2.80, P = .966). Based on the Receiver Operating Characteristic analysis, the COVES score had a sensitivity of 68.1%, specificity of 71.4%, and area under the curve (AUC) of .77. The PRECISE score had a sensitivity of 68.9%, specificity of 70.7%, and the AUC of .73. Conclusions: The COVES score, but not the PRECISE score, is associated with functional outcomes at 90 days after EVT for ACLVO.

Sister Mary Joseph nodule

We here report the case of a 6-year old female patient with no pathological history, presenting with diffuse abdominal pain and abdominal distension evolving in the last 2 months. The patient had a deterioration in her general condition. Clinical examination showed distended abdomen, average abundance ascites, venous collateral circulation and multiple mobile hard abdominal masses measuring 3-4 cm in diameter at the level of the iliac fossa and of the left hypochondriac region associated with a well circumscribed, hard, rounded umbilical mass measuring 3cm in diameter lifting the skin with inflammatory signs (A). The remainder of the physical examination was normal. Thoraco-abdominal CT scan showed subcutaneous umbilical nodule (B), with homogeneous enhancement measuring 36x29x19mm, associated with mesenteric lymphadenopathy magmas, pelvic mass and extended jejunum thickening. Fine needle aspiration biopsy of the mass showed the presence of several naked nuclei and a few blasts. Biopsy showed Burkitt lymphoma. Therefore, the diagnosis of Burkitt lymphoma revealed by sister Marie-Josèphe nodule was retained and the patient underwent chemotherapy according the LMB01 protocol. Outcome was favorable, marked by the regression of the nodule and of the abdominal masses. Sister Mary Joseph nodule is an umbilical metastasis from a tumor (usually an abdomino pelvic tumor) mainly an adenocarcinoma, exceptionally a lymphoma. It is a rare sign. It accounts for 1-3% of all abdomino-pelvic neoplasms and it is associated with poor prognosis. It is essential to know that this nodule is a lesion secondary to solid tumor in order to avoid delayed management of the underlying neoplasm.