Preoperative Digital Subtraction Angiography Research Articles

Impact of superficial middle cerebral vein compression on peritumoral brain edema of the sphenoid wing meningioma

ObjectiveSphenoid wing meningiomas (SWMs) often cause occlusion or stenosis of the superficial middle cerebral vein (SMCV) by tumor compression. This study aimed to analyze the correlation between SMCV compression and peritumoral brain edema (PTBE) in SWM patients and to clarify the importance of surgical preservation of the SMCV in SWM surgery. MethodsThis retrospective study included 31 patients who underwent surgery for SWM at our institution from April 2011 to March 2022. Patient demographics, tumor characteristics, PTBE size, and SMCV patency before and after surgery were evaluated using preoperative and postoperative MRI or digital subtraction angiography. ResultsOf the 31 patients, 24 (77.4 %) exhibited PTBE, with varying degrees of severity: mild (32.3 %), moderate (25.8 %), and severe (41.9 %). Preoperative MRI showed SMCV patency in 14 patients (45.2 %) and SMCV compression in 17 patients (54.8 %). There was a significant association between PTBE severity and SMCV compression (p = 0.002). Postoperatively, SMCV recanalization was observed in 4 out of 16 patients (25.0 %) with preoperative SMCV compression. These patients had significantly smaller tumors (p = 0.013) and larger preoperative PTBE volumes (p = 0.042) compared to those without recanalization. ConclusionsOur study demonstrates a significant correlation between SMCV compression and severe PTBE in SWM patients. A subset of patients showed postoperative SMCV recanalization, particularly those with smaller tumors and more pronounced PTBE. These findings highlight the importance of SMCV preservation during SWM surgery to potentially improve postoperative outcomes.

Preoperative cerebral angiography nearly doubles the rate of diffusion-weighted imaging lesion detection following minimally invasive surgery for intracerebral hemorrhage

BackgroundDiffusion-weighted imaging (DWI) lesions have been linked to poor outcomes after intracerebral hemorrhage (ICH). We aimed to assess the impact of cerebral digital subtraction angiography (DSA) on the presence of...

Super-Selective Intra-arterial Thrombolytic Therapy for Peripheral Facial Paralysis After Postauricular Hyaluronic Acid Injection for the Esthetic Correction of Lying Ears.

Hyaluronic acid (HA) injection in the auricular base is one of the most popular and non-surgical cosmetic procedures for correcting lying ears and optimizing the facial profile because of its minimal invasiveness, immediate effect and safety (Li et al. in Aesthet Surg J 44: 746-75, 2024). But we have recently discovered that this treatment may lead to a new and rare complication called peripheral facial paralysis that has never been reported before. Until now, the etiology, clinical traits, treatment strategies, outcomes and possible reversibility have not been characterized. In the present study, we enrolled 4 patients with peripheral facial paralysis after subcutaneous postauricular HA filler injection. Preoperative digital subtraction angiography revealed a vascular embolism. Then, the patients underwent super-selective facial arterial thrombolytic therapy via hyaluronidase and papaverine injections. Simultaneously, general symptomatic treatment and nutritional therapy were performed. The patients were relieved of their clinical symptoms and the significant improvement was observed in terms of motor function in her left facial areas after treatment. The auricular skin necrosis of all patients was restored to near normal appearance. Our results indicate that super-selective facial arterial thrombolytic therapy is feasible for patients with peripheral facial paralysis induced by HA embolism. It was also beneficial in the recovery from skin necrosis. The therapy was shown to be worthy of clinical application. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A mathematical model to predict “low-lying” posterior communicating artery aneurysms in neurosurgical practice

“Low-lying” posterior communicating artery (PCoA) aneurysms require great attention in surgical clipping due to their distinct anatomical characteristics. In this study, we propose an easy method to immediately recognize “low-lying” PCoA aneurysms in neurosurgical practice. A total of 89 cases with “low-lying” PCoA aneurysms were retrospectively analyzed. All patients underwent preoperative digital subtraction angiography (DSA) examinations and microsurgical clipping. Cases were classified into the “low-lying” and regular groups based on intraoperative findings. The distance- and angle-relevant parameters that reflected the relative location of the aneurysms and tortuosity of the internal carotid artery were measured using 3D-DSA images. The data were sequentially integrated into a mathematical analysis to obtain the prediction model. Finally, we proposed a novel mathematical formula to preoperatively predict the existence of “low-lying” PCoA aneurysms with great accuracy. Neurosurgeons might benefit from this model, which enables them to directly identify “low-lying” PCoA aneurysms and make appropriate surgical decisions accordingly.

Evaluation of paclitaxel-coated balloon angioplasty for the treatment of symptomatic intracranial in-stent restenosis.

Symptomatic intracranial in-stent restenosis (sISR) poses a major challenge in the management of cerebrovascular diseases, often requiring effective and safe treatment options. This study aims to evaluate the efficacy and safety of paclitaxel-coated balloon (PCB) angioplasty for treating sISR. We conducted a retrospective analysis of five patients aged 49-74 years, who were treated with PCB angioplasty between January 2017 and June 2022. Treatment procedures included pre-operative digital subtraction angiography, antiplatelet therapy, and the use of the SeQuent Please balloon. Patients received aspirin and clopidogrel prior to and after the procedure. The procedure achieved a 100% success rate. The degree of ISR was significantly reduced from an average pre-operative rate of 72±18.9% to a post-operative rate of 34±8.22%. Long-term follow-up showed that the majority of patients did not experience restenosis, confirming the long-term effectiveness of the treatment. PCB angioplasty demonstrates significant potential as an effective and safe treatment option for patients with sISR, especially those considered to be at high risk. This study supports further investigation into PCB angioplasty as a standard treatment for sISR.

Surgical Treatment for Sac Expansion Caused by Type II Endoleaks after Endovascular Aneurysm Repair of Abdominal Aortic Aneurysms/Iliac Aneurysms

BackgroundThis study aimed to examine the outcomes of open surgery techniques involving sacotomy and suturing of the feeding vessels in patients with aneurysm sac expansion after endovascular aneurysm repair (EVAR). MethodsFourteen consecutive patients treated with sacotomy and suturing of feeding vessels for expanding aneurysm sacs with type II endoleaks following EVAR, between January 2018 and December 2022, were retrospectively included. All patients underwent preoperative digital subtraction angiography, and attempts were made to embolize the thick feeding vessels to reduce intraoperative bleeding. Age, sex, comorbidities, clinical presentation, aneurysm sac increase, morbidity, mortality, and follow-up were recorded. ResultsThe median age of the patients was 72.89±5.13 years old, and 13 (92.9%) patients were male. The sac size at the time of the open procedure was 107.89±22.58 mm, and the extent of sac growth at the time of the open procedure was 37.50±18.29 mm. The initial technical success rate of laparotomy and open ligation of the culprit arteries causing type II endoleaks was 92.9% (13/14). Among the patients, five (35.7%) had been treated with interventional embolization before the open procedure. One endograft was removed and replaced by a bifurcated Dacron graft because of distal dislocation in one patient. All patients recovered, and no deaths were recorded postoperatively. No patients had an eventful postoperative course or any subsequent graft-related complications during follow-up. ConclusionsOpen surgical repair involving sacotomy and suturing of the feeding vessels appeared to have good outcomes in the treatment of patients with aneurysm sac expansion caused by type II endoleaks after EVAR. Preoperative embolization of feeding vessels can thus effectively reduce intraoperative bleeding.

Evaluating the diagnostic accuracy of 3D contrast-enhanced magnetic resonance angiography versus digital subtraction angiography in spinal dural arteriovenous fistulas.

Spinal dural arteriovenous fistulas (SDAVFs) often go undiagnosed, leading to irreversible spinal cord dysfunction. Although digital subtraction angiography (DSA) is the gold standard for diagnosing SDAVF, DSA is invasive and operator dependent, with associated risks. MR angiography (MRA) is a promising alternative. This study aimed to evaluate the performance of MRA as an equal alternative to DSA in investigating, diagnosing, and localizing SDAVF. Prospectively collected data from a single neurosurgeon at a large tertiary academic center were searched for SDAVFs. Eligibility criteria included any patient with a surgically proven SDAVF in whom preoperative DSA, MRA, or both had been obtained. The eligible patients formed a consecutive series, in which they were divided into DSA and MRA groups. DSA and MRA were the index tests that were compared to the surgical SDAVF outcome, which was the reference standard. Accurate diagnosis was considered to have occurred when the imaging report matched the operative diagnosis to the correct spinal level. Comparisons used a two-sample t-test for continuous variables and Fisher-Freeman-Halton's exact test for categorical variables, with p < 0.05 specifying significance. Univariate, bivariate, and multivariate analyses were conducted to investigate group associations with DSA and MRA accuracy. Positive predictive value, sensitivity, and accuracy were calculated. A total of 27 patients with a mean age of 63 years underwent surgery for SDAVF. There were 19 male (70.4%) and 8 female (29.6%) patients, and the mean duration of symptoms at the time of surgery was 14 months (range 2-48 months). Seventeen patients (63%) presented with bowel or bladder incontinence. Bivariate analysis of the DSA and MRA groups further revealed no significant relationships between the characteristics and accuracy of SDAVF diagnosis. MRA was found to be more sensitive and accurate (100% and 73.3%) than DSA (85.7% and 69.2%), with a subanalysis of the patients with both preoperative MRA and DSA showing that MRA had a greater positive predictive value (78.6 vs 72.7), sensitivity (100 vs 72.7), and accuracy (78.6 vs 57.1) than DSA. In surgically proven cases of SDAVFs, the authors determined that MRA was more accurate than DSA for SDAVF diagnosis and localization to the corresponding vertebral level. Incomplete catheterization at each vertebral level may result in the failure of DSA to detect SDAVF.

The effects of anastomoses between anterior and posterior circulation on postoperative prognosis of patients with moyamoya disease

BackgroundMoyamoya disease (MMD) is a chronic ischemic cerebrovascular disease. Collateral circulation in MMD has emerged as a research focus. Our aims were to assess the impact of anastomoses between the anterior and posterior circulations on the prognosis of MMD patients.MethodsWe reviewed the preoperative digital subtraction angiography images of patients with MMD who underwent revascularization surgery at our hospital between March 2014 and May 2020 and divided the patients into two groups: those with anastomoses (PtoA group) and those without anastomoses (non-PtoA group). The differences in follow-up (more than 6 months) collateral vessel establishment (Matsushima grade) and the modified Rankin Scale (mRS) were compared between the two groups as well as between the patients with different degrees of anastomoses. The early complications following revascularization were also compared between the two groups.ResultsThis study included 104 patients with MMD, of which 38 were non-PtoA and 66 were PtoA. There were no significant differences in Matsushima score (P = 0.252) and mRS score (P = 0.066) between the two groups. In addition, Matsushima score (P = 0.243) and mRS score (P = 0.360) did not differ significantly between patients with different degrees of anastomoses. However, the non-PtoA group had a significantly higher rate of cerebral hyperperfusion syndrome (CHS) than the PtoA group (34.2% vs 16.7%, P = 0.041).ConclusionMMD patients without anastomoses between anterior and posterior circulations preoperatively should be vigilant of the occurrence of CHS in the early stages after revascularization.

Angiographic and preoperative assessment

Background: This study focuses on comparing and predicting the number of perforating arteries (PA) of the anterior communicating artery (AcoA) preoperatively by using cerebral angiographic studies and perioperative surgical observations. Materials and methods: From April 2010 - March 2012, 13 patients with subarachnoidal haemorrhages undergoing surgery to repair an AcoA aneurysm were evaluated with digital subtraction angiography (DSA) and perioperative surgical observations available for the study. Each patient’s number of PA arising from AcoA was investigated based on DSA imaging. DSA examinations were retrospectively evaluated by three neuroradiologists. The perioperative surgical observations were evaluated together by two neurosurgeons who performed surgical procedures. Results: The number of PA of AcoA was classified into four groups. Group 1: No PA; Group 2: PA 1 to 3; Group 3: PA 4 to 6; Group 4: PA&gt; 6. In our study, in 6 of 13 patients (46.1%) three radiological evaluations were in accordance with each other; in 8 (61.5%) cases the number of PA found in surgical observation was higher than the number obtained from at least two radiologic examinations. In all radiological examinations, PA numbers were most commonly (%61.5) classified as Group 2 (PA numbers between 1-3); in 76.9% of cases, the number of PA found in surgical observation was equal or more than those of radiological evaluations. Additionally, in 5 (38.4%) cases, the number of PA found in surgical observation was higher than the number of those radiologic examinations. Conclusion: We found that the number of perforating arteries of AcoA segment obtained from the surgical observation is slightly higher than the number obtained from the preoperative DSA assessment.

Combined Double-Barrel Superficial Temporal Artery to M4 Bypass and Parent Artery Occlusion for the Treatment of Complex Intracranial Aneurysms in Internal Carotid Artery and Middle Cerebral Artery: A Retrospective Case Series.

Very little research has been conducted to assess the efficacy of combined double-barrel superficial temporal artery (STA) to M4 bypass and parent artery occlusion (PAO) in the treatment of complex intracranial aneurysms. To determine whether this operation could become a reasonable flow replacement therapy and have longer-term benefits. A series of double-barrel STA-M4 bypasses performed between 2016 and 2021 were reviewed. Preoperative digital subtraction angiography (DSA), computed tomography angiography (CTA), computed tomography perfusion (CTP), and balloon test occlusion were routinely performed for a thorough evaluation of individual benefits and risks. After bypass, the proximal end of the parent artery was permanently occluded with the coil. Augmentation and patency of STA were reassessed by postoperative DSA, CTA, and CTP. The blood flow volume of STA was measured by ultrasound at admission and a 3-month follow-up. This study included 12 consecutive patients (5 males, 7 females) who successfully underwent double-barrel STA-M4 bypass, including 8 complex aneurysms in the internal carotid artery (ICA) and 4 in the middle cerebral artery (MCA). Postoperative angiography and CTP suggested that all the STAs were patent, and there was a significant improvement in perfusion after the operation ( P < .05). Ultrasonic measurement at the 3-month follow-up showed that the blood flow provided by STA was 76.3 to 190.5 mL/min. Postoperative ischemia was found in 1 patient, but she recovered after treatment. Double-barrel STA to M4 bypass can provide adequate flow for the parent artery area, which may be a reasonable flow replacement therapy for some complex intracranial aneurysms in ICA and MCA.

Anatomical variations and flow alterations of the uncal vein and its clinical implications in petroclival meningiomas.

The Uncal vein (UV), downstream of the deep middle cerebral vein (DMCV), has a similar drainage pattern to the superficial middle cerebral vein (SMCV) and may be involved in venous complications during the anterior transpetrosal approach (ATPA). However, in petroclival meningioma (PCM), where the ATPA is frequently used, there are no reports evaluating drainage patterns of the UV and the risk of venous complications associated with the UV during the ATPA. Forty-three patients with petroclival meningioma (PCM) and 20 with unruptured intracranial aneurysm (control group) were included. Preoperative digital subtraction angiography was used to evaluate UV and DMCV drainage patterns on the side of the tumor and bilaterally in patients with PCM and the control group, respectively. In the control group, the DMCV drained to the UV, UV and BVR, and BVR in 24 (60.0%), eight (20.0%), and eight (20.0%) hemispheres, respectively. Conversely, the DMCV in the patients with PCM drained to the UV, UV and BVR, and BVR in 12 (27.9%), 19 (44.2%), and 12 (27.9%) patients, respectively. The DMCV was more likely to be drained to the BVR in the PCM group (p < 0.01). In three patients with PCM (7.0%), the DMCV drained only to the UV, and furthermore, the UV drained to the pterygoid plexus via the foramen ovale, posing a risk for venous complications during the ATPA. In the patients with PCM, the BVR functioned as a collateral venous pathway of the UV. Preoperative evaluation of the UV drainage patterns is recommended to reduce venous complications during the ATPA.

Reconstruction of Type IIIB Thumb Hypoplasia Using a Vascularized Hemi-Metatarsal Composite Tissue Flap.

The aim of this study was to determine the clinical outcomes of vascularized hemi-metatarsal composite tissue transfer for the reconstruction of type IIIB hypoplastic thumbs. Twenty-eight patients with type IIIB hypoplastic thumbs treated with vascularized hemi-metatarsal composite tissue transfer were included in this retrospective study with a mean follow-up of 2.4 years. Preoperative digital subtraction angiography was performed to examine the vessel variance. Clinical measures included grip and pinch strength, scar status, and Kapandji thumb opposition score. Subjective Pediatric Outcomes Data Collection Instrument scores and parent satisfaction were also evaluated. Radial arteries were hypoplastic in 82.1% of the cases, and the common palmar digital artery was chosen as the recipient vessel for the tissue transfer. There was no neurovascular complication. The only donor-site complication was a metatarsal fracture that healed with casting. Key pinch and tripod pinch were 29.5% and 45.8% of the normal side, respectively. The mean grip strength was 51.7% of the unaffected side. The mean Kapandji score was 6. The Pediatric Outcomes Data Collection Instrument scores were high for global function; upper extremity function; transfer; and basic mobility, happiness, and comfort. The Vancouver Scar Scale showed an average score of 2.1. All parents were satisfied with the clinical outcomes. Vascularized hemi-metatarsal composite tissue transfer for type IIIB thumb hypoplasia can provide improved subjective outcomes and is a feasible method for the attainment of a five-digit hand. Therapeutic, IV.

Malignant Peripheral Nerve Sheath Scalp Tumor: A Short-Term Institutional Experience with Literature Review.

Malignant peripheral nerve sheath tumor (MPNST) of the scalp is rare. These lesions are associated with neurofibromatosis type 1 (NF1), but patients had been reported without NF1 also. We tried to analyze the difference between the clinical course and outcome of the patient with MPNST having stigmata of NF1 and without it. We included five patients treated over 3 years between July 2018 and July 2021 with diffuse scalp MPNST. Two of these five patients with MPNST of the scalp had neurocutaneous stigmata of NF1. Three were female and two males with an average age of 38.40 ± 18.48 years-the youngest with NF1 being a 19-year-old female. We found dull aching pain as the most typical complaint in all patients and a repeated episode of generalized seizure in one patient. In these cases, two patients with NF1 have highly vascular tumors and attained large sizes greater than 30 cm. These two cases required preoperative digital subtraction angiography (DSA) and embolization with n-butyl acrylate. Total excision of the tumor was done in all patients with radiotherapy. Metastases within 1 year were noted in two patients with NF1, and one of these two succumbed to her illness. The rest of the three patients without NF1 are under follow-up with no evidence of disease with a maximum follow-up of 2 years. Large MPNST (size > 20 cm) are rare and reported to have been associated with and without NF1. Patients with scalp MPNST with NF1 can achieve larger size with fast progression of tumor size and higher chances of recurrence and metastases.

The additional value of high-resolution vessel wall imaging in screening suitable chronic internal carotid artery occlusion candidates for endovascular recanalization: comparison with digital subtraction angiography.

High-resolution vessel wall imaging (HR-VWI) can provide information about exact occluded length, etiology, and the presence of intraluminal thrombus or residual cavity. To investigate the extra value of HR-VWI in screening patients with chronic internal carotid artery occlusion (CICAO) for recanalization suitability in comparison with digital subtraction angiography (DSA). We retrospectively reviewed patients who underwent endovascular recanalization with no internal carotid artery signal on magnetic resonance angiography (MRA) and whose both preoperative DSA and HR-VWI data were available. Patients were classified into type I (focal occlusion distal to ophthalmic artery), type II or III (occlusion proximal or at/distal to clinoid segment), and near-occlusion. Occlusion etiology and suitability for recanalization were analyzed both on preoperative DSA and HR-VWI. Accuracy of occlusion classification and differences in the modified Rankin scale scores between the baseline and follow-up were estimated. A total of 20 patients were included. With intraoperative DSA as the gold standard, we found HR-VWI could additionally show intraluminal thrombi. Preoperative DSA misclassified one near-occlusion, one type I occlusion, and one type II occlusion as type III occlusions, and one near-occlusion as a type II occlusion. Therefore, compared with the preoperative DSA, three additional cases were successfully recanalized based on HR-VWI. The accuracy of HR-VWI was higher than preoperative DSA (100% vs. 80%). Prognosis improvement of type I was significantly better than type II and near-occlusion (P<0.05). HR-VWI can identify occluded etiology, extent, and classification of CICAO. This information is potentially useful in screening candidates for endovascular recanalization and helpful to indicate prognosis.

Comparison of Intraoperative Indocyanine Green Videoangiography vs Postoperative Catheter Angiography to Confirm Microsurgical Occlusion of Spinal Dorsal Intradural Arteriovenous Fistulas.

Dorsal intradural arteriovenous fistulas (DI-AVFs) represent 80% of spinal AVFs. Microsurgical clip occlusion is a durable treatment that uses preoperative and postoperative digital subtraction angiography (DSA) as standard practice. Intraoperative indocyanine green videoangiography (ICG-VA) is a valuable intraoperative adjunct in these cases. Intraoperative ICG-VA findings have not been compared with postoperative DSA findings. To assess the diagnostic value of intraoperative ICG-VA vs postoperative DSA for spinal DI-AVFs. A multi-institutional database of vascular malformations was queried for all surgically managed cases of DI-AVF. Patients with both intraoperative ICG-VA and postoperative DSA were included. Demographic and radiologic data, intraoperative findings, and surgical outcomes data were retrospectively analyzed. Forty-five patients with DI-AVF were identified (male sex, 32; mean age, 61.9 [range, 26-85] years). All DI-AVFs were treated with interruption of the fistula with clip occlusion of the draining vein. Intraoperative ICG-VA showed complete obliteration in all patients. Postoperative DSA was performed for 40 patients and confirmed complete obliteration in all patients. The negative predictive value of ICG-VA confirming complete occlusion of the DI-AVFs was 100%. Eighteen patients (47%) experienced clinical improvement, and 16 (42%) experienced no change in condition. ICG-VA is useful for intraoperative identification of DI-AVFs and confirmation of complete microsurgical occlusion. Correlation between intraoperative ICG-VA and postoperative DSA findings demonstrates the diagnostic power of ICG-VA. This finding suggests that postoperative DSA is unnecessary when intraoperative ICG-VA confirms complete occlusion of the DI-AVF, which will spare patients the procedural risk and cost of this invasive procedure.

Surgical Strategy for Ethmoidal Dural Arteriovenous Fistula

Ethmoidal dural arteriovenous fistula (DAVF) is a rare type of intracranial DAVF. The aim of this study was to report our experience with a unilateral approach and discuss its effectiveness for ethmoidal DAVF treatment. The study included 19 patients who underwent surgical treatment for ethmoidal DAVF between January 1999 and May2021. Median age of patients was 59.7 years; 16 (84%) patients were male. Three patients had a ruptured ethmoidal DAVF. Preoperative digital subtraction angiography showed that all ethmoidal DAVFs were supplied by the bilateral external carotid artery branches. In 18 (95%) patients, cortical draining veins were located on the unilateral side. Bilateral lesions were identified in only 1 (5%) patient. The frontobasal approach was performed in 5 patients (26%), the pterional approach was performed in 5 (26%) patients, and the lateral supraorbital approach was performed in 9 (47%) patients; median procedural times were 198 minutes, 172 minutes, and 111 minutes, respectively. Cortical draining vein was successfully disconnected in all 19 patients with 20 ethmoidal DAVFs. Complete obliteration of ethmoidal DAVF was confirmed in all patients, with no postoperative complications. No recurrence or related clinical events were reported in 13 (68%) patients over 12 months of clinical and radiological follow-up. We reconfirmed excellent outcomes of surgical treatment for ethmoidal DAVFs. Three different surgical strategies were attempted, and each had pros and cons. The lateral supraorbital approach is an efficient surgical option for unilateral ethmoidal DAVFs. Careful preoperative examination for the presence of bilateral drainage is essential.

The Recipient Vessel Hemodynamic Features Affect the Occurrence of Cerebral Edema in Moyamoya Disease After Surgical Revascularization: A Single-Center Retrospective Study.

ObjectiveIn moyamoya disease (MMD) with direct or combined revascularization, the initially hemodynamic recipient features are likely one of the main causes of acute hemodynamic disruption. Previous studies have explored the relationship between recipient diameter or flow velocity and postoperative complications, but there are still no optimal selection criteria with multiple potential recipient vessels. Cerebral edema is one of the most common radiological manifestations in the acute postoperative period. This study assessed the hemodynamic characteristics of cortex vessels related to postoperative cerebral edema.MethodsAll patients who had undergone direct or combined revascularization with preoperative digital subtraction angiography (DSA) between 2019 and 2021 were eligible for inclusion in this study. The application of DSA was performed and regular radiological examinations were employed after surgery. DSA was analyzed with the hemodynamic features within chosen recipient vessels. Cerebral edema was identified as a low-density image on CT or high signaling in the MRI T2 phase. The recipient hemodynamic characteristics and demographic presentation, as well as clinical data, were retrospectively analyzed in this study.ResultsA total of 103 patients underwent direct or combined revascularization with preoperative DSA. The mean age of this enrolled cohort was 44.31 ± 10.386 years, in which bilaterally involved MMD accounted for the main part. The preliminary correlation analysis found preoperative disease period (p = 0.078), recipients observed in angiography (p = 0.002), and surgery on the left (p = 0.097) may be associated with cerebral edema. The following regression analysis confirmed low occurrence of cerebral edema was accompanied by recipients observed in angiography (p = 0.003). After subdividing by flow direction and hemodynamic sources, the incidence rate of anterograde direction, anterior sources, and posterior sources were significantly lower than undetected recipients.ConclusionsCerebral edema is a common radiological manifestation in MMDs after surgery. In this study, the observation in angiography reliably identifies a variety of physiological or pathological recipient detection, flow direction, and hemodynamic sources in patients with MMD after revascularization, which indicates the selection strategy of potential recipients and highlights the importance of recipient observability in DSA. Meanwhile, vascular conditions determined by recipient hemodynamics meditate the occurrence of postoperative cerebral edema.

Pre- and Postoperative Cerebral Haemodynamic Assessments and Multidisciplinary Team Management for Patients Undergoing Cerebral Revascularization Procedures: 2 Case Reports

Background: Cerebrovascular bypasses are complex neurosurgical procedures with specific indications. Surgical risks and outcome are associated with the type of bypass intended and patient&rsquo;s underlying conditions. A multidisciplinary team approach is therefore pivotal in the management of these bypass patients. Objective: The aim of this study is to provide an overview of the perioperative haemodynamic assessments and management of patients undergoing cerebral revasculaization with 2 illustrative cases. Case Report: Case 1: A 40-year-old male with cerebrovascular occlusive condition and recurrent transient ischaemic attacks (TIA&rsquo;s) affecting his left side. Preoperative computed tomography (CT) brain perfusion and carbon dioxide (CO2) inhalation technique revealed poor cerebrovascular reserve (CVR) in the right middle cerebral artery (MCA) territory. The patient underwent a right superficial temporal artery-middle cerebral artery (STA-MCA) bypass surgery. Case 2: A 56-year-old female with a left giant cavernous sinus aneurysm presented with left-sided intractable facial pain. Preoperative cerebral digital subtraction angiography (DSA) with carotid compression test revealed inadequate collateral circulation. She underwent a high flow, common carotid-middle cerebral artery bypass with saphenous vein graft and trapping of the giant aneurysm. Results: Case 1: Postoperative computed tomography angiography (CTA) brain scan on day 1 confirmed graft patency. The patient improved rapidly in strength of the left arm and right leg. CT brain perfusion scan at 3 months showed improved brain perfusion and CVR. Case 2: Postoperative CTA brain on day 1 confirmed graft patency. On day 3 post-operatively, she developed self-limiting left-sided ophthalmoplegia, which completely resolved by 6 weeks. CTA brain at 5 months showed patency of the bypass graft. There was no further facial pain or ophthalmoplegia at the last follow-up. Conclusion: Although many new surgical techniques had been developed, the outcome for patients undergoing bypass surgery remains highly dependent on multidisciplinary teamwork, detailed preoperative haemodynamic assessment, patient selection and perioperative care. Keywords: Cerebrovascular bypass; EC-IC bypass; STA-MCA bypass; Cerebral ischaemia; Cerebrovacular reserve; Balloon occlusion test

Types of the prostate blood supply during super-selective embolization of prostatic arteries

Introduction. Pelvic arteries have various anatomy and anastomoses with other branches of the internal iliac artery (IIA). This explains the technical complexity of identification and catheterization of prostatic arteries (PA), as well as the possibility of complications associated with non-target embolization of prostatic artery anastomoses.Purpose of the study. To analyze the most common variants of prostate blood supply and evaluate the effectiveness of methods for identifying prostatic arteries.Materials and methods. The study included 168 patients treated from 2013 to 2021. For catheterization of the prostatic arteries, 4 – 5 Fr microconductors and 2 – 2.8 Fr microcatheters were used. For embolization, hydrogel microspheres with a diameter of 100 – 300 µm and 300 – 500 µm were used, as well as PVA microparticles with a diameter of 100 – 500 µm. Preoperatively multi-sliced computed tomography (MSCT) angiography of the pelvic organs was performed to determine the type of prostatic angioarchitectonics.Results. The use of preoperative MSCT angiography in combination with intraoperative digital subtraction angiography made it possible to determine the variations of prostatic artery divergence and identify their anastomoses in 100% of patients (336 pelvic sides). One prostatic artery was detected in 91.4% (307) of the pelvic sides. two independent pAs in 8.6% (29) of cases. Symmetrical anatomy of the prostatic arteries on both sides was revealed in 14.3% (24) patients, the remaining 85.7% (144) patients showed asymmetry on both sides. The absence of prostatic arteries anastomoses was detected in 75.5% (254) of the pelvic sides, and in 24.4% (82) of the pelvic sides, anastomoses were detected. Interlobar intraprostatic anastomoses were found in 10.1% (34) of the pelvic sides, communication with a. dorsalis penis was detected in 8% (27) of cases, with rectal arteries in 5.3% (18) of the pelvic sides and with urinary bladder arteries in 3.6% (12) of cases. Based on the analysis of the small pelvis angioarchitectonics in 168 patients, an anatomical classification of the prostatic arteries anatomy was proposed.Conclusion. Super-selective embolization of the prostatic arteries is a contemporary minimally invasive method of prostatic hyperplasia treatment with a high safety profile. The pelvic arteries have extremely various anatomy, as well as anastomoses with other branches of the internal iliac artery, which complicates the implementation of super-selective embolization of prostatic arteries. The combination of preoperative MSCT and intraoperative digital subtraction angiography makes it possible to identify the prostatic artery and its anastomoses in most cases.

Digital subtraction angiography assisted musculoskeletal flap transplantation for the treatment of osteonecrosis of the femoral head

To observe the effectiveness of digital subtraction angiography (DSA) assisted musculoskeletal flap transplantation in the treatment of osteonecrosis of the femoral head (ONFH). The clinical data of 15 patients with 15 hips of ONFH admitted between January 2016 and December 2019 were retrospectively analyzed. All patients were male, aged 20-45 years, with an average age of 31.6 years. There were hormone type in 9 cases and alcohol type in 6 cases. The disease duration ranged from 15 days to 3 years, with an average of 8 months. The Association Research Circulation Osseous (ARCO) staging: 4 hips in stage Ⅱ, 11 hips in stage Ⅲ. The preoperative visual analogue scale (VAS) score was 6.2±0.2, and the Harris score of the hip joint was 57.3±1.3. Preoperative DSA examination of the femoral head was performed to determine the location of vascular lesions of the femoral head. According to the results of the angiography, the surgical selection of the musculoskeletal flap was guided. For the patients with both superior and inferior retinaculum vessels developed, simple core decompression was performed. For the patients with superior retinaculum vessels developed but inferior retinaculum vessels not developed, anterolateral tensor fasciae flap was used. For the patients whose superior retinaculum did not develop and the inferior retinaculum developed, posterolateral quadratus femoris flap was used. The fibular flap with anastomotic vessels was used in the patients whose superior and inferior retinaculum vessels were not developed. All 15 cases of 15 hips were followed up 6-24 months, with an average of 14 months. During the follow-up, the patient's ONFH did not worsen, the femoral head did not collapse, the joint space was normal, and the hip joint fextion and extension function was acceptable. At last follow-up, the VAS score was 1.9±0.2, and the hip Harris score was 92.1±0.8, both of which were significantly improved when compared with preoperative ones ( t=14.85, P=0.00; t=23.22, P=0.00). For patients with ONFH who need musculoskeletal flap transplantation, preoperative DSA of femoral head can determine the location of vascular lesions of femoral head, so as to guide the selection of musculoskeletal flap transplantation, which is of great significance for hip-conserving surgery.