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Retinoblastoma eyes with choroidal invasion may not have to be enucleated and may be successfully managed with OAC using Melphalan, Carboplatin and Topotecan without compromising patient survival.

Purpose To determine prospectively the efficacy and to assess potential side effects of melphalan selective ophthalmic artery chemotherapy (SOAC) as first-line treatment for unilateral retinoblastoma. Design Phase 2 nonrandomized, prospective study. Participants Patients with unilateral retinoblastoma group B, C, or D of the International Classification for Intraocular Retinoblastoma (IRC). Group D eyes with massive vitreous seeding were not eligible. Methods Melphalan SOAC associated with diode laser thermotherapy, cryotherapy, or both at 4-week intervals (3–6 cycles). For persistent vitreous seeding, intravitreal melphalan chemotherapy also was used. Main Outcome Measures The primary outcome was globe preservation rate. Secondary outcomes were tumor relapse rate, occurrence of ocular or systemic adverse events, and measurement of the dose area product (DAP). Results Between 2012 and 2017, 39 patients (39 eyes) with unilateral retinoblastoma were included prospectively. Three included patients did not receive SOAC (2 catheterization failures and 1 case of viral syndrome) and were considered failures. At diagnosis, IRC groups for the 36 treated patients were: B, n = 4 (11%); C, n = 13 (36%); and D, n = 19 (53%); median age was 21.5 months (range, 3.2–61.6 months). Median number of SOAC cycles was 3.9 (range, 1–6 cycles), and median melphalan dose was 4.9 mg/procedure. The median DAP was 1.24 Gy.cm2/procedure. Median follow-up was 63 months (range, 34–93 months). SOAC was associated with local treatments for 31 patients (86%): diode laser thermotherapy for all of them and cryotherapy or intravitreal chemotherapy for 10 (32%) and 9 patients (25%), respectively. SOAC treatment was interrupted in 5 patients because of severe ophthalmic (ptosis, n = 2; retinal ischemia, n = 2) or systemic (hypotension, n = 1) adverse events. At the cutoff date analysis, all patients were alive without metastasis. The 18-month eye preservation rate was 80% (range, 68.6%–94.6%). After a follow-up of at least 30 months, the ocular preservation rate was 69% (n = 24 preservations). Conclusions This first prospective trial demonstrated that SOAC with melphalan alone as first-line treatment for retinoblastoma is efficient and well tolerated with no metastatic events, although ocular ischemic complications were observed.

Introduction Extradural anterior clinoidectomy (eAC) is key to expose the paraclinoid region. Several authors have pointed limitations of performing an eAC through a supraorbital craniotomy. In this article, we aim to provide educational material and discuss the technical nuances to successfully perform an eAC throughout a modification of the supraorbital approach, the extradural extended eyebrow approach (xEBA + eAC). Methods Four embalmed heads were used for anatomic dissection and perform the xEBA + eAC. Additionally, one head was used for a video demonstration of the surgical approach. Results The anterior clinoid process was successfully removed, and the ophthalmic artery and paraclinoid region were exposed in all specimens. Drilling the sphenoid wing until exposing the meningo-orbital band and further interdural dissection are vital steps to expose the anterior clinoid process. Removal of the anterior clinoid process can be simplified in 3 osteotomies, including the optic canal unroofing, detachment from the lateral pillar, and drilling of the optic strut. Sectioning of the distal dural ring facilitates the mobilization of the internal carotid artery and the surgical exposure of the ophthalmic artery. Conclusions xEBA + eAC is a technically feasible approach that provides exposure to the paraclinoid region, along with anterior and middle cranial fossa.

Objective To establish the success rate of salvage intra-arterial chemotherapy (IAC), defined as the percentage of eyes that achieved tumoral remission and avoided enucleation. The second objective was the clinical characterization, catheterization results, and associated local and systemic complications. Methods Retrospective, interventional case series of 29 patients (35 eyes) with persistent or recurrent retinoblastoma. Results A total of 73 salvage IAC procedures with topotecan and melphalan were carried out. Success rate was 77% at a mean follow-up of 41.4 months. All patients with only one remaining eye avoided enucleation (10 cases). Catheterization was successful in 98.6% of cases. The types of catheterizations were as follows: 71.2% supraselective ophthalmic artery, 12.3% occlusion pump assisted supraselective ophthalmic artery, 16.4% selective external carotid with retrograde flow. 14% of patients suffered local adverse effects: 1 (2.8%) transitory ptosis, 1 (2.8%) transitory oculomotor nerve palsy, 2 (5.7%) aseptic cellulitis and 1 (2.8%) periorbitary pigmentation. 4.1% (3 cases) suffered neutropenia due to medullar chemosuppression. There were no cases of severe anemia or thrombocytopenia. There were no cerebral ischemic events or mortality associated to the procedure. Conclusion IAC with melphalan and topotecan is a safe and effective treatment option for persistent or recurrent retinoblastoma, able to reduce enucleation rates.

Objective Anterior clinoidectomy is an important and essential skill for skull base and cerebrovascular neurosurgeons. We present a 1-piece intradural anterior clinoidectomy, providing a step-by-step description of the technique, independently of anatomic variations. Methods Between 2014 and 2020, 128 patients (119 women and 9 men; average age, 54.6 years) underwent intradural anterior clinoidectomy during microsurgical clipping of carotid-ophthalmic aneurysms. Results The anterior clinoid process continues medially with the planum sphenoidale, over the optic nerve, laterally with the lesser wing of the sphenoid bone, and inferiorly with the optic strut, which is always found anteriorly to the clinoid segment of the internal carotid artery, and separates the optic canal from the superior orbital fissure. The proposed anterior clinoidectomy followed, one after the other, these 3 fixation points for the detachment of the anterior clinoid process. The main indication for intradural anterior clinoidectomy was the management of vascular lesions around paraclinoid (clinoidal and ophthalmic) segments of the internal carotid artery. Complications of the procedure included injury to the internal carotid artery or the ophthalmic artery, thermal damage to the optic nerve, and invasion of the sphenoid sinus or a pneumatized anterior clinoid process, which could lead to postoperative cerebrospinal fluid leakage. Conclusions The anterior clinoidectomy technique described here minimizes the drilling surface for detachment of the anterior clinoid process and reduces operative time as well as the amount of bone dust produced by drilling. It also precisely delineates the localization of the optic strut, preventing carotid or optic nerve damage.

Congenital agenesis of the unilateral internal carotid artery is a rare anomaly. The agenesis of the internal carotid artery is associated with a higher incidence of intracranial aneurysms. This report describes a rare case of internal carotid artery agenesis associated with an aneurysm of the left superior cerebellar artery in a 52-year-old woman. The left middle cerebral artery was supplied from the vertebrobasilar system through the dilated left posterior communicating artery associated with anomalous origin of the left ophthalmic artery from the left posterior communicating artery. This report demonstrates a rare combination of left internal carotid artery agenesis with associated intracranial aneurysm and anomalous origin of the ophthalmic artery, discussion of embryogenesis, clinical significance, and imaging findings.

Background Traumatic subarachnoid hemorrhage (SAH) is a common finding following traumatic brain injury. In some cases, it can be associated with hydrocephalus. This type of hemorrhage is mostly caused by the rupture of small vessels in the brain and is usually managed conservatively. Case Description We present a case of a 60-year-old woman who presented with traumatic luxation of the eye following a fall. This resulted in diffuse SAH (Fisher grade IV) with associated hydrocephalus. We also report on 3 previous similar cases found in the literature. Avulsion of the ophthalmic artery was found to be the cause of the traumatic SAH. Apart from cerebrospinal fluid diversion using an external ventricular drain, the case was managed conservatively. There was no evidence of delayed clinical or radiologic vasospasm. Conclusions Traumatic avulsion of the ophthalmic artery may result in diffuse SAH, mimicking that of aneurysmal rupture. This case shows that management of early complications, such as hydrocephalus and seizures, should be the main aim. Surgical or endovascular treatment of the injured artery, however, would be unnecessary.

Objective To evaluate the treatment outcomes of an alternative retrograde superselective ophthalmic artery catheterization (intra-arterial chemotherapy [IAC]), while treating retinoblastoma patients. Methods A retrospective review of IAC for 21 treatment-naive eyes (21 patients, primary group) and 10 eyes of previously treated 9 patients (secondary group). Statistical analysis was performed using Number Cruncher Statistical System 2007, Kaplan–Meier survival analysis, and Fisher’s exact test. Results Total fluoroscopy time ranged from 3 to 12 minutes. Globe salvage was 71.4% (15/21 eyes) and 80% (8/10 eyes) in the primary and secondary groups, respectively. Globe salvage rates were recorded as 100%, 100%, 70%, and 0% for group B, C, D, and E patients, respectively. Conclusions Retrograde IAC is effective in tumour control with shorter fluoroscopy time and acceptable complication rates both for naive and treated patients. Furthermore, controlling retinoblastoma in advanced group D eyes was efficacious.

Optic nerve enhancement is a sign seen in different disease states; however, perineural enhancement is less common. This article presents the case of a patient with bilateral amaurosis in whom the diagnosis of giant cell arteritis was suggested by perineural enhancement on orbital magnetic resonance imaging (MRI) and confirmed by biopsy of the temporal artery. The clinical presentation of giant cell arteritis is occasionally nonspecific; patients can have visual symptoms, even blindness if the branches of the ophthalmic artery are affected; in these cases, orbital MRI can be very useful for early diagnosis. Although the MRI findings are uncommon, distinct patterns of enhancement have been reported, the most characteristic of which is perineural enhancement. The pattern of optic nerve involvement is relatively unknown, but important because it orients the diagnosis of a disease that can lead to permanent blindness.

Background Variant origin of the ophthalmic artery (OA) is uncommon. The majority of variant origins are from the middle meningeal artery and from the infraclinoid segment of the internal carotid artery. An OA arising from the accessory meningeal artery is an extremely rare vascular variation that has not been described previously in the English literature. Case Description We report the first case of double origin of the OA from the supraclinoid segment of the internal carotid artery and from the accessory meningeal artery branch of the maxillary artery. A 33-year-old woman was referred to our clinic with suspicion of a middle cerebral artery aneurysm. She had nonspecific neurologic symptoms. The patient underwent cerebral magnetic resonance imaging and magnetic resonance angiography. Conclusions Being aware of variant origin of the OA from the accessory meningeal artery is very important for transarterial chemoembolization in the external carotid artery territory. Reconstructed images from magnetic resonance angiography are very useful to reveal the variant origin of the OA.

Background Posttraumatic internal carotid aneurysms are rare. Two posttraumatic aneurysms occurring at the same time are even more rare. Two pseudoaneurysms located in different segments of the ipsilateral internal carotid artery have not been found in the literature. We provide the results of angiographic images of traumatic aneurysms over time. Case Description We report a young man aged 17 years with multiple aneurysms of the internal carotid artery following head injury. Head computed tomography examination was performed in our hospital showing a small amount of subarachnoid hemorrhage, nodular high-density shadow on the left side of the sellar region, casting a high-density shadow on the suprasellar cistern and left sulcus approximately 1 x 1 cm in size, and subarachnoid hemorrhage. Digital subtraction angiography was performed on the sixth day of admission: the C5 and C6 segments of the left internal carotid artery had 2 x 4 mm mound processes and 7 x 7 mm saccular processes, respectively. Interventional surgery was performed immediately. Due to aneurysm enlargement, intravascular surgery was performed for coiling of the corresponding aneurysms. The left internal carotid artery occlusion test showed that the right internal carotid artery was well compensated by the left side via the anterior communicating artery. The ophthalmic artery aneurysm of the left internal carotid artery and the clinoid segment pseudoaneurysms were embolized. Follow-up for 1 year showed no obvious sequelae and a good recovery. Conclusions This case suggests that patients with posttraumatic subarachnoid hemorrhage should be considered for the possibility of traumatic aneurysms. If this occurs, an aggressive operation would achieve a good outcome.

Introduction Distal ophthalmic artery (OpA) aneurysms are a rare subset of vascular lesions with lack of optimal treatment. The management of these aneurysms may require complete occlusion of the parent vessel, carrying a risk of permanent visual impairment due to individual variations of extracranial collateral flow to the intraorbital ophthalmic artery (iOpA). Objective To test the feasibility of a superficial temporal artery (STA) to iOpA bypass to prevent acute ischemic retinal injury. Two different transorbital corridors (superomedial and posterolateral approaches) for this bypass were evaluated. Methods Each approach was carried out in 10 specimens each (n = 20). The corridors were compared to achieve the optimal exposure of the iOpA until the central retinal artery origin was visualized. An end-to-end anastomosis was performed from STA-to-iOpA. The arterial caliber and length at the anastomotic sites, required donor artery length, and intraorbital surgical area were measured. Results STA-iOpA bypasses were performed in all specimens. For the posterolateral transorbital approach, the mean caliber of STA was 1.8 ± 0.2 mm, and that of iOpA was 1.7 ± 0.5 mm. The required STA graft length was 78.3 ± 1 mm with lateral iOpA transposition of 8.2 ± 1.1 mm. For the superomedial approach, the average STA length required for an intraorbital bypass was 130.8 ± 14.0 mm. The mean calibers of iOpA and STA were 1.5 ± 0.1 mm and 1.5 ± 0.1 mm, respectively. Conclusions This study demonstrates the feasibility of a novel revascularization technique of the iOpA using 2 different transorbital approaches. These techniques can be used in the management of intraorbital lesions such as OpA aneurysms, tumoral infiltrations, or intraoperative injuries.

Background The middle meningeal artery (MMA) is an important conduit for the endovascular treatment of skull base and intracranial pathologies including, recently, subdural hematomas. A key aspect of such procedures is to perform a thorough diagnostic angiogram to detect anomalous arterial origins and “dangerous” anastomoses with branches of the internal carotid arteries. Although the most common anomaly related to the MMA is an abnormal origin from the ophthalmic artery, anomalous origin from the posterior circulation is rare. Moreover, its recognition requires a concerted effort at performing a vertebral artery angiogram irrespective of the location of the pathology (e.g., in subdural hematoma). Case Description We describe a case of anomalous origin of MMA from the basilar artery as a lateral pontine artery branch that was detected in a patient with recurrent subdural hematoma who presented for endovascular MMA embolization. Conclusions The embryologic origin of the entity is briefly discussed, along with suggestions for managing such an anomaly during endovascular embolization.

Background The ophthalmic artery (OA) is a very important branch of the supraclinoid segment of the internal carotid artery. Origination of the OA from the anterior cerebral artery is an extremely rare condition. Being unaware of the origin anomalies of OAs can lead to unfavorable results, especially in cases in which craniofacial surgery or cerebral therapeutic angiography is planned. Case Description An anomalous origin of the ipsilateral OAs from the A1 segments of the bilateral anterior cerebral arteries was detected by three-dimensional time-of-flight magnetic resonance angiography. Conclusions Anomalous origin of the OA from the anterior cerebral artery may be explained by a failure in the caudal migration of the ventral OA. Because of high soft tissue resolution and absence of radiation, three-dimensional time-of-flight magnetic resonance angiography is preferred for detection of orbital and cerebral vascular anomalies.

Background Distal catheterization in the ophthalmic artery beyond the origin of the central retinal artery has been attempted to avoid visual complications in cases of transarterial embolization (TAE). Although avoiding visual complications is important, extraocular complications have been rarely reported and discussed. Here, we report a case of an intraorbital arteriovenous fistula (AVF) presenting with impaired extraocular movement after a provocation test and discuss the potential risks associated with TAE at the third segment of the ophthalmic artery. Case Description A 53-year-old man was referred to our hospital for a newly diagnosed vascular lesion on the left optic chiasm. A left internal carotid angiogram revealed an intraorbital AVF fed by distal branches of the left ophthalmic artery taking a recurrent course toward the proximal ophthalmic artery, and the anterior branches of the inferior lateral trunk draining into the tortuous basal vein of Rosenthal with a varix. Neither the cavernous sinus nor the superior ophthalmic vein was opacified as draining routes of this lesion. A provocation test was done for diagnostic and therapeutic purposes at the third segment of the ophthalmic artery. During the test, the patient developed a transient impaired adduction of the left eye without any visual field deficit; therefore, TAE was avoided. The patient made an uneventful recovery and was recommended a transcranial transvenous embolization for a radical treatment. Conclusions In intraorbital hypervascular lesions, occlusion of the third segment of the ophthalmic artery is associated with a potential risk of extraocular complications.

The Woven EndoBridge (WEB) device, an intrasaccular flow-diverter that does not require long-term antiplatelet use, has recently emerged as an alternative to embolize complex intracranial aneurysms; however, there are limitations to the WEB device. First, it does not immediately secure the aneurysm in most subarachnoid hemorrhage cases. Second, it may not be suitable for embolization of wide-neck aneurysms with an unfavorable aspect ratio. To overcome these limitations, we have used the WEB device in conjunction with stenting and/or coiling. Here, we present a technical note with an illustrated case series and provide a detailed step-by-step description on how the WEB device can be used in adjunct to coiling and/or stenting to achieve successful angiographic results. Accurate sizing of the WEB device before deployment is critical. Larger case series are required to further assess the safety and success of these combined techniques.

Objective Medially pointing aneurysms of the ophthalmic segment of the internal carotid artery (oICA) represent a neurosurgical challenge. Conventional ipsilateral approaches require internal carotid artery and optic nerve (ON) mobilization as well as anterior clinoidectomy (AC), all associated with increased surgical risk. Contralateral approaches could provide a better exposure of the superomedial aspect of the oICA, ophthalmic artery, and superior hypophyseal artery, sparing AC and internal carotid artery or ON mobilization. However, the microsurgical anatomy of this approach has not been systematically studied. In the present work, we exhaustibly analyzed the anatomic and morphometric characteristics of contralateral approaches to the oICA and compared them with those from ipsilateral approaches. Methods We assessed 36 ipsilateral and contralateral approaches to the oICAs in cadaveric specimens and live patients, using for the latter a three-dimensional virtual reality (VR) system. Results Contralateral approaches spared sylvian fissure dissection and required only minimal frontal lobe retraction. The ipsilateral and contralateral oICA were found at a depth of 49.2 ± 1.8 mm (VR, 50.1 ± 2.92 mm) and 65.1 ± 1.5 mm (VR, 66.05 ± 3.364 mm) respectively. The exposure of the superomedial aspect of oICA was 7.25 ± 0.86 mm (VR: 6 ± 1 mm) contralaterally without ON mobilization and 2.44 ± 0.51 mm (VR, 2 ± 1 mm) ipsilaterally even after AC. Statistical analysis showed that, for nonprefixed chiasm, contralateral approaches achieved a significantly higher exposure of the ophthalmic artery, superior hypophyseal artery, and the superomedial aspect of the oICA with its perforating branches (all P Conclusions Contralateral approaches may enable successful exposure of the oICA and related vascular structures, reducing the need for AC or ON mobilization. Systematic clinical/surgical studies are needed to further determine the effectiveness and safety of the approach.

Background Dural arteriovenous fistulas (DAVFs) with perimedullary venous drainage are very rare intracranial DAVFs. Treating DAVF via an endovascular electrocoagulation technique, to the best of our knowledge, has not been reported in the literature. We therefore report the first successful case. Case Description We report a rare case of Cognard type V DAVF. The feeding arteries were the middle meningeal artery, the recurrent meningeal branch of ophthalmic artery, and the meningohypophyseal trunk. The patient presented with paresthesia and weakness in the lower limbs. T2-weighted magnetic resonance imaging revealed a high signal in the medulla oblongata and upper cervical spinal cord. Our first procedure via the middle meningeal artery with Onyx 18 (ev3 Neurovascular) as the embolization agent failed to occlude the fistula. We finally occluded the fistula with the endovascular electro-coagulation technique. Two-year follow-up revealed total disappearance of the fistula and relieve of patient's symptoms. Conclusions The endovascular electrocoagulation technique is very effective in the management of complex DAVFs with perimedullary venous drainage.

Objective The purpose of the present study was to introduce our initial experience with the use and feasibility of the Willis covered stent (WCS) in the treatment of blood blister-like aneurysms (BBAs) and to present a systematic review of the reported data on the treatment of BBAs with covered stents. Methods Fourteen consecutive patients with BBAs had been treated with WCSs at West China Hospital from January 2015 to August 2017. The patient medical records, angiographic findings, and endovascular treatment reports were reviewed by interventional neuroradiologists and neurosurgeons to obtain relevant clinical and angiographic information. We conducted a systematic review of all reports of BBAs treated with covered stents. We searched the reported data using PubMed, Embase, China National Knowledge Infrastructure, and Wanfang databases and commercial Internet search engines. We included BBAs located at nonbranching portions of the internal carotid artery (ICA). Results The present study included 9 men and 5 women, with a mean age of 54.5 years (range, 30–79). All patients had complete occlusion found on immediate postoperative angiography. The ophthalmic artery was occluded in 2 patients (14.3%). No mortality or morbidity had occurred during the procedure. Two patients (14.3%) experienced a mild recurrence. One patient (7.1%) had developed mild in-stent stenosis. The clinical follow-up period was 6–15 months for all the patients. Of the 14 patients, 11 (78.6%) had a modified Rankin scale score of 0, and 1 (7.1%) had a modified Rankin scale score of 1 during the follow-up period. One patient (7.1%) experienced subarachnoid hemorrhage at 7 days postoperatively and had died 10 days after surgery. None of the patients experienced visual defects. Of our 14 patients, 13 (92.9%) survived, as determined by outpatient department visits or telephone interviews. A total of 8 reports, including 38 patients, met our criteria. Of these 38 patients, 37 (97.3%) had successful delivery to the diseased ICA, and 34 (89.5%) had experienced complete occlusion during follow-up. The overall rate of complete occlusion was 83.0% (95% confidence interval, 68%–91%). Conclusions Patients with ruptured BBAs treated with WCSs can achieve satisfactory clinical results. Therefore, for BBAs, the implementation of the WCS could be safe and feasible. This strategy could be a promising option for this type of high-risk aneurysm. However, patients with tortuous ICAs or aneurysms close to essential branch arteries should be carefully evaluated before the WCS is used.

Retinal ischemia remains a major cause of blindness in the world with few acute treatments available. Recent emphasis on retinal vasculature and the ophthalmic artery's vascular properties after ischemia has shown an increase in vasoconstrictive functionality, as previously observed in cerebral arteries following stroke. Specifically, endothelin-1 (ET-1) receptor-mediated vasoconstriction regulated by the MEK/ERK1/2 pathway. In this study, the ophthalmic artery of rats was occluded for 2 h with the middle cerebral artery occlusion model. MEK/ERK1/2 inhibitor U0126 was administered at 0, 6, and 24 h following reperfusion and the functional properties of the ophthalmic artery were evaluated at 48 h post reperfusion. Additionally, retinal function was evaluated at day 1, 4, and 7 after reperfusion. Occlusion of the ophthalmic artery led to a significant increase of endothelin-1 mediated vasoconstriction which can be attenuated by U0126 treatment, most evident at higher ET-1 concentrations of 10−7 M (Emax151.0 ± 22.0% of 60 mM K+), vs non-treated ischemic arteries Emax 212.1 ± 14.7% of 60 mM K+). Retinal function also deteriorated following ischemia and was improved with treatment with a-wave amplitudes of 725 ± 36 μV in control, 560 ± 21 μV in non-treated, and 668 ± 73 μV in U0126 treated at 2 log cd*s/m2 luminance in the acute stages (1 days post-ischemia). Full spontaneous retinal recovery was observed at day 7 regardless of treatment. In conclusion, this is the first study to show a beneficial in vivo effect of U0126 on vascular contractility following ischemia in the ophthalmic artery. Coupled with the knowledge obtained from cerebral vasculature, these results point towards a novel therapeutic approach following ischemia-related injuries to the eye. (Less)

Background and purpose Optic neuritis (ON) is a common clinical manifestation of Multiple Sclerosis (MS), which is associated with reduced visual acuity, blurred vision, blindness and retro-bulbar pain. In several studies, specific relations between optic nerve diameter and hemodynamics of the eye bulb arteries with ON have been reported. However, no consensus has been reached in this regard. We aim at determining the alterations in optic nerve diameter and eye bulb arteries hemodynamics in ON in MS patients. Methods This case-control study includes 40 patients, who at least had experienced one phase of ON, in one of their eyes. To measure hemodynamics of arteries in the affected eyes, a color Doppler imaging was performed and end diastolic velocity (EDV), peak systolic velocity (PSV), peripheral resistance indices i.e. resistance index (RI) and pulsatile index (PI) were measured in posterior ciliary artery (PCA) and ophthalmic artery (OA). Also, optic nerve diameter was measured using sonography. Non-affected eyes of these patients were considered as control group. Results There were no significant differences in EDV, PSV, RI and PI in PCA and OA. The mean optic nerve diameter in the affected eyes was 4.73 mm, whereas, it was 4.31 mm in unaffected eyes, which was significantly different (P = .02). Conclusion These results indicate that there is a significant relation between eye involvement and increased optic nerve diameter in MS patients with chronic ON. While, there were no significant relations in EDV, PSV, RI and PI in PCA and OA comparing two groups.

Purpose: To report on a severe case of presumed giant cell arteritis (GCA) presenting with partial and complete ophthalmic artery occlusion along with bilateral central retinal vein occlusions (CRVO). Observations: A 73-year-old female presented with bilateral complete vision loss of sudden onset. The patient also experienced a mild frontal headache prior to onset of vision loss. Fundus examination revealed bilateral central retinal artery occlusion (CRAO) and CRVO. Subsequent fluorescein angiography indicated partial right ophthalmic artery occlusion and complete left ophthalmic artery occlusion. Acute phase reactants were elevated. The patient was clinically diagnosed with GCA and intravenous (IV) steroids were initiated. Four days later, a temporal artery biopsy (TAB) was performed and resulted as negative for granulomatous inflammation. The patient did not regain vision and remained with no light perception (NLP) in both eyes. Conclusions: and Importance: This case highlights the discrepancy between clinical diagnosis and pathologic tissue diagnosis in a patient that presented with such extensive ocular vasculitic disease. Such extensive bilateral disease has not been reported. In addition, there are few studies regarding the effect of pulse-dosed IV steroids on TAB results. This case report suggests that the gradual histologic changes that occur over one or two weeks while on oral steroids may occur over three to four days while on high dose IV steroids, necessitating early biopsy. Keywords: Giant cell arteritis, Temporal arteritis, Intravenous, Bilateral, Ophthalmic artery occlusion, Central retinal artery occlusion, Central retinal vein occlusion, Biopsy negative

In combat-related trauma, resuscitation goals are to attenuate tissue hypoxia and maintain circulation. During hemorrhagic shock, compensatory and autoregulatory mechanisms are activated to preserve cerebral blood flow. Transcranial Doppler (TCD) ultrasonography may be an ideal noninvasive modality to monitor cerebral hemodynamics. Using a nonhuman primate (NHP) model, we attempted to characterize cerebral hemodynamics during polytraumatic hemorrhagic shock using TCD ultrasonography.The ophthalmic artery was insonated at multiple time points during varying stages of shock. Hemorrhage was controlled and pressure targeted to 20 mmHg to initiate and maintain the shock period. Mean flow velocity (MFV), peak systolic velocity (PSV), end diastolic velocity (EDV), pulsatility index (PI), and resistance index (RI) were recorded. Results represent mean ± standard deviation; statistical significance is P 0.05; n = 12.Compared to baseline, MFV, PSV, EDV, and RI show significant changes after 60 min of hemorrhagic shock, (9.81 ± 3.60 cm/s; P 0.01), (21.15 ± 8.59 cm/s; P 0.01), (5.15 ± 0.21 cm/s; P 0.01), (0.70 ± 0.11; P 0.05), respectively. PI did not change during hemorrhagic shock. At end of prehospital care (T30), cerebral flow recovers for MFV, PSV, and RI while EDV remained decreased at T30 (6.15 ± 1.13 cm/s; P 0.01) and 1 h of simulated transport (T90) (5.87 ± 0.62 cm/s; P 0.01). Changes in PI at T30 and T90 were not significant. MFV diminished (16.45 ± 3.85 cm/s; P 0.05) at T90.This study establishes baseline and hemorrhagic shock values for NHP cerebral blood flow velocities and cerebrovascular indices. TCD ultrasonography may represent an important area of research for targeted resuscitation investigations using a hemorrhagic shock model in NHPs.

Background Anterior skull base meningiomas often grow to a large size (≥4 cm) before detection. Their blood supply is mostly provided by the anterior and posterior ethmoidal arteries. Because of their vascularity, intraoperative bleeding can be a challenging prospect that increases the risk of perioperative complications. Preoperative ethmoidal arteries ligation has been used to aid in limiting blood loss. Our objective was to assess the effect of preoperative arterial ligation on the perioperative course of large (≥4 cm) to giant (≥6 cm) anterior skull base meningiomas. Methods We retrospectively searched our database for large anterior skull base meningiomas (≥4 cm). We analyzed differences in intraoperative blood loss, operative time, intraoperative transfusion, and hematologic parameters between patients who did not undergo preoperative ethmoidal arteries ligation (Group 1) and those who did (Group 2). Results Average estimated blood loss (EBL) was 825 mL (Group 1) versus 350 mL (Group 2) (P = 0.42), decrease in hemoglobin was 4 g/dL versus 3.2 g/dL (P = 0.53), decrease in hematocrit was 12.4% versus 9.6% (P = 0.64), and average operative time was 656 minutes versus 598 minutes (P = 0.58). EBL per volume yielded a ratio of 10.6 mL/cm3 versus 4.1 mL/cm3 (P = 0.06). Conclusions Ethmoidal arteries ligation may have a benefit in large-to-giant anterior skull base meningiomas surgery. Our results showed a decrease in EBL and lesser decrease in pre- and postoperative hemoglobin and hematocrit levels as compared with cases in which no vascular ligation was performed when corrected for tumor volume.

Highlights • Whereas Covid-19 infection has increasing incidence of venous and arterial thrombotic complications, best practices to guide therapeutic anticoagulation don't exist • Acute ophthalmic artery occlusion is a carotid circulation stroke syndrome and must be considered in patients with hypercoagulable states that develop sudden, painless and severe visual loss • The role of D-Dimer in monitoring the hypercoagulable state and response to therapeutic anticoagulation is unelucidated, We report a case of ophthalmic artery occlusion (OAO) in a young patient with Covid-19 infection that was on therapeutic anticoagulation with apixaban for deep venous thrombosis (DVT). A 48-year-old man with obesity was hospitalized with a severe form of Covid-19 infection, complicated with acute respiratory failure, septic shock, dilated cardiomyopathy and fungemia. Despite treatment with prophylactic enoxaparin (initial D-Dimer 1.14 µg/ml FEU (normal < 0.05 µg/ml FEU), D-Dimer increased to above 20 µg/ml FEU and patient continued to spike high fevers. This prompted further investigations and upper and lower extremities DVTs were confirmed and managed with enoxaparin 1mg/kg twice daily. D-dimer level decreased to 4.98 µg/ml FEU while on therapeutic anticoagulation. Three weeks later pending hospital discharge, the anticoagulation was switched to oral apixaban 10 mg twice daily. Patient developed acute severe right eye visual loss of no light perception and was diagnosed with incomplete OAO. D-Dimer was elevated at 2.13 µg/ml FEU. Stroke etiological work-up found no embolic sources, resolution of the dilated cardiomyopathy and negative antiphospholipid antibodies. Treatment was changed to enoxaparin and no thrombotic events were encountered to date. Ocular vascular complications have not yet been reported in Covid-19. Controversy exists on the best management algorithm for the hypercoagulable state associated to Covid-19. Either direct oral anticoagulants or low-molecular-weight-heparin are considered appropriate at discharge for patients with venous thromboembolism. The optimum regimen for ischemic stroke prevention and the significance of D-Dimer for anticoagulation monitoring in Covid-19 remain unclear..

Headaches are a common symptom during pregnancy. The thunderclap headache is a sudden onset headache reaching maximal intensity within seconds to minutes. It is typically a subarachnoid hemorrhage caused by rupture of an intracranial aneurysm or arteriovenous malformation. Physiologic changes of pregnancy, such as increased cardiac output and plasma volume, may increase the risk of aneurysmal rupture. The relationship between the mode of delivery and incidence of rupture is not well defined. In this case report, we discuss the anesthetic management for cesarean delivery of a parturient with an unruptured aneurysm, located on the left ophthalmic-internal carotid artery. The delivery options and anesthetic technique used are presented, together with a review of published literature.

Phase contrast magnetic resonance imaging (PC MRI), a validated, non-invasive technique for measuring intracranial blood and cerebrospinal flows, has been recently applied to studies of blood flow of the ophthalmic artery (OA). This study evaluated PC-MRI's ability to quantify blood flow in the superior ophthalmic vein (SOV). We analyzed with 3 T PC MRI the blood flow in the SOV in 11 healthy subjects and, for comparison purpose, in the OA. Segmentation software was used to analyze the PC images and quantify the variation in blood flow over the cardiac cycle in each of the vessels. The anatomy of the orbital veins was also assessed. We were able to measure the blood flow in 19 SOV; the mean ± standard deviation (SD) SOV flow was 9.13 ± 7.10 mL/min with a mean ± SD variation of flow during cardiac cycle of 8.45 ± 4.90 mL/min. The mean ± SD flow in the OA was 12.83 ± 8.36 mL/min. The SOV was constantly present, with a mean cross-sectional area of 2.43 mm2. A medium and an inferior ophthalmic veins were found in 5 and 3 orbits, respectively. In conclusion, PC MRI is able to measure SOV as well as OA flows. To the best of our knowledge, the present study is the first to provide quantitative SOV blood flow values using PC MRI. Investigations of hydrocephalus, intracranial hypertension and even glaucoma might be facilitated by the application of this quantitative imaging modality.

Objective The objective of this study was to investigate the clinical presentation, risks, and collateral pathway development of the congenital absence of the internal carotid artery (ICA). Methods Sixty-four patients (10 new patients and 54 patients from the relevant literature) were studied. Data on demographic, clinical, and radiologic features were collected, followed by an analysis of the risks associated with ICA agenesis. Results There were 31 male and 33 female patients whose ages ranged from 5 months to 75 years, with a mean age of 31.1 years. The range of clinical symptoms recorded included transient ischemic attack (17 patients), subarachnoid hemorrhage (12 patients), developmental delay (13 patients), asymptomatic (8 patients), and other symptoms (15 patients). All 64 patients presented with absence of unilateral or bilateral ICAs, as measured by cervical computed tomography angiography or magnetic resonance angiography. The carotid canal was absent in all patients on computed tomography of the base of the skull, and abnormal development of collateral circulation pathways was observed. Five patients presented with basilar artery dilation on angiography. Aneurysms were observed in the angiography results from 16 patients. Ten patients presented with variations in the ophthalmic artery origin (the ophthalmic artery originated from the ipsilateral middle meningeal artery in six patients and from the ipsilateral middle cerebral artery in four patients). Conclusions From analysis of our 10 cases of ICA agenesis and our review of the relevant literature, we conclude that young patients with ICA agenesis may present with developmental delay, subarachnoid hemorrhage, or other developmental abnormalities, whereas older patients most commonly present with transient neurologic events. Complications of carotid agenesis are related to specific anatomic subtypes and the resulting collateral circulation development.

Objective The purpose of this study was to report the authors' experience with endovascular treatment (EVT) of ophthalmic artery (OA) aneurysms and to investigate risk factors for visual complications of EVT for unruptured OA aneurysms. Methods Fifty-four patients with unruptured OA aneurysms subjected to EVT were recruited for this study from March 2010 to December 2017. The clinical and angiographic outcomes of all 54 patients were investigated and analyzed retrospectively. Results Of the 54 patients included in this study, 5 patients (9.3%) had visual complications, including asymptomatic unintended OA occlusion in 2 patients (3.7%) and symptomatic complications in 3 patients (5.6%); 2 patients (3.7%) had transient visual complications, and 1 (1.9%) had a permanent complication. No subacute or delayed visual complications occurred during the 20.8-month follow-up period. OA incorporation by the aneurysm (odds ratio [OR], 3.471; 95% confidence interval [CI], 1.115–9.184; P = 0.038) and intentional OA occlusion (OR, 1.820; 95% CI, 1.248–6.221; P = 0.044) were independent risk factors for visual complications in a multivariate logistic regression analysis. Conclusions The visual complication rate was 9.3% when performing EVT for unruptured OA aneurysms. OA aneurysms with OA incorporation by the aneurysm might be at higher risk of visual complications when performing EVT. Intentional OA occlusion should be performed with caution, even though a patient may have favorable collaterals during balloon test occlusion.

Background Endoscopic endonasal clipping of intracranial aneurysms may use microsurgical techniques as an alternative to the transcranial approach. Here we report a series of patients who underwent microsurgical clipping of anterior circulation aneurysms via an endoscopic endonasal approach (EEA). Methods This retrospective chart review included all the patients who underwent standard binostril EEA for aneurysm clipping. Surgical outcomes and complications are noted. The rationality and limitations of this procedure are discussed. Results Seven patients with 12 aneurysms of the anterior circulation underwent EEA for clipping. These 12 aneurysms consisted of 5 anterior communicating artery (AComA) aneurysms, 4 paraclinoid aneurysms, 1 ophthalmic artery aneurysm, and 2 aneurysm located in the cavernous segment of internal carotid artery (ICA). Nine of the 12 aneurysms were successfully clipped. One giant paraclinoid aneurysm could not be clipped during operation and was coiled in second endovascular stage. The 2 aneurysms located in the cavernous segment of ICA were not clipped intentionally in a single-stage procedure, after weighing the surgical benefit against the difficulty of surgical exposure and feasibility. The proximal control of ICA was achieved in all cases. There was no death, no cerebrospinal fluid leak, or other complications. All patients recovered completely. Conclusions EEA can provide direct access for microsurgical clipping of strictly selected anterior circulation aneurysms. All the principles of cerebrovascular surgery must be followed. These procedures require a long learning curve. Only teams with adequate experience in microvascular and endoscopic skull base surgeries should attempt this approach for treating aneurysms.

Background Posterior ischemic optic neuropathy results from ischemia of the retrobulbar aspect of the optic nerve. It presents as acute loss of vision without optic disc swelling. This is rare in children, with only seven cases reported to date. Neuroimaging is frequently used to aid in the diagnosis of acute visual complaints in children; however, none of the cases described to date delineate the neuroimaging findings of this entity in children. Methods We retrospectively reviewed the electronic medical record. Results We describe the MRI findings in a 10-month-old boy with posterior ischemic optic neuropathy after intraophthalmic artery injection of chemotherapy for retinoblastoma. Conclusions As targeted therapies for retinoblastoma and other diseases amenable to intravascular treatment delivery are more frequently used, the risk of grave vision-related side effects increases. Posterior ischemic optic neuropathy should be considered in the differential diagnosis of any child presenting with acute loss of vision. Dedicated imaging of the orbits can elucidate specific findings that may aid in the diagnosis of this entity in children.

Edema coursing the optic apparatus has traditionally been associated with sellar and para-sellar tumors. However, postoperative aneurysmal volume expansion following endovascular treatment has been reported to induce cranial neuropathies, such as vision loss in rare instances. Here, we present a case report of worsening optic tract edema associated with bilateral visual acuity deficit following treatment of a large left paraophthalmic aneurysm with pipeline-assisted coiling. Rapid resolution of visual deficit was observed following administration of corticosteroids. A 42-year-old female with a 6-month history of worsening left eye vision and sentinel headache presented with left visual field cut and decreased left visual acuity. She was found to have a large paraophthalmic aneurysm which was treated with pipeline-assisted coiling. Within one week post-treatment, the patient presented to the emergency department with worsening right visual complaints. On magnetic resonance imaging, T2 hyperintensities coursing the right posterior optic nerve, optic chiasm, and bilateral optic tracts were noted. Angiography demonstrated an expanding neck remnant. The patient was treated with oral corticosteroids and repeat pipeline stenting. At four week follow up, she demonstrated significant improvement of symptoms and reduced T2 hyperintensities. With the advancement in endovascular technique for the treatment of large aneurysms, more patients are electing endovascular treatment over microsurgical clipping. Given the possibility of continued growth following endovascular treatment, patient counseling regarding risks and side effects is paramount.

Background Metal allergies affect a significant portion of the population; intracranial flow diverters contain many of the most commonly allergenic metals. Prior literature has suggested patch testing for all patients with documented or suspected metal allergies before intracranial flow diverter placement; however, there remains a paucity of reports of patients with documented metal allergies undergoing intracranial flow diversion. Case Description We report 2 patients with documented nickel allergies, confirmed via patch testing by a board-certified allergist, and unruptured intracranial aneurysms that underwent treatment with the PED. Both patients developed contact dermatitis when a PED was affixed to their skin during their preoperative workup. Follow-up arteriography at 12 and 36 months post PED placement showed no evidence of in-stent stenosis or intimal hyperplasia, and both patients never developed systemic allergic reactions. Conclusions In 2 patients with known nickel allergies and intracranial aneurysms treated with the PED, there were no clinically or radiographically apparent allergic reactions at greater than 2 years of follow-up.

In the present case, we directly visualized the pendulum movement of the contrast agent downstream of a carotid near-occlusion during digital subtraction angiography, suggesting the existence of "to-and-fro" stagnant flow created by the significant flow reduction and high back pressure from visible ophthalmic collaterals with blood stagnation distal to the stenosis. The pendular movement phenomenon represents a stagnation of blood that could be associated with an increased risk of thrombus formation and subsequent embolization to more distal arterial territories. This case may partially explain not only the embolic mechanism for stroke in carotid near-occlusion but the recent observation that collateral circulation through the ipsilateral ophthalmic artery is associated independently with an increased risk of the progression of carotid near-occlusion to complete occlusion.

A 36-year-old male suffered from a sudden headache. Computed tomography (CT) showed a subarachnoid hemorrhage (SAH). CT angiography demonstrated an aneurysm arising from the duplicate origin of the right posterior communicating artery (PcomA). The aneurysm was at the junction of the internal carotid artery and the distal branch of the PcomA duplication. Frontotemporal craniotomy and neck clipping were performed for the ruptured aneurysm. The patient’s post-operative course was uneventful and without symptomatic vasospasm. Post-operative angiography revealed the total duplication of the PcomA. The ophthalmic artery originating from cavernous portion anomalously. Although the relationship between the frequency of aneurysms and PcomA duplication is unclear, the PcomA duplication-in addition to the ophthalmic artery's anomalous origin-was speculated to be an anomaly related to the developmental processes of cerebral arteries.

Most studies of the effect of acute elevation of intraocular pressure (IOP) on ocular blood-flow have utilized optical coherence tomography (OCT) to characterize retinal and choroidal flow and vascular density. This study investigates the effect of acute IOP elevation on blood flow velocity in the retrobulbar arteries and veins supplying and draining the eye, which, unlike the retinal and choroidal vasculature, are not directly compressed as IOP is increased. By cannulation of the anterior chamber of 20 Sprague-Dawley rats, we increased IOP in 10 mmHg steps from 10 to 60 mmHg and returned to 10 mmHg. After 1 minute at each IOP (and 3 minutes after return to 10 mmHg), we acquired 18 MHz plane-wave ultrasound data at 3000 compound images/sec for 1.5 sec. We produced color-flow Doppler images by digital signal processing of the ultrasound data, identified retrobulbar arteries and veins, generated spectrograms depicting flow velocity over the cardiac cycle and characterized changes of vascular density and perfusion in the orbit overall. Systolic, diastolic and mean velocities and resistive and pulsatile indices were determined from arterial spectrograms at each IOP level. Baseline mean arterial and mean venous velocities averaged 30.9±10.8 and 8.5 ±3.3 mm/sec, respectively. Arterial velocity progressively decreased and resistance indices increased at and above an IOP of 30 mmHg. Mean arterial velocity at 60 mmHg dropped by 55% with respect to baseline, while venous velocity decreased by 20%. Arterial and venous velocities and resistance returned to near baseline after IOP was restored to 10 mmHg. Both vascular density and orbital perfusion decreased with IOP, but while perfusion returned to near normal when IOP returned to 10 mmHg, density remained reduced. Our findings are consistent with OCT-based studies showing reduced perfusion of the retina at levels comparable to retrobulbar arterial flow velocity change with increased IOP. The lesser effect on venous flow is possibly attributable to partial collapse of the venous lumen as volumetric venous outflow decreased at high IOP. The continued reduction in orbital vascular density 3 minutes after restoration of IOP to 10 mmHg might be attributable to persisting narrowing of capillaries, but this needs to be verified in future studies.

Summary Introduction The prevalence and etiology of neovascular glaucoma (NVG) as a complication of central retinal artery occlusion (CRAO) is a debated issue. According to some authors, NVG associated with CRAO always involves underlying chronic ocular ischemic syndrome (COIS) as a primum movens for CRAO. However, we describe 5 cases of NVG following CRAO with no underlying COIS, confirmed by carotid Doppler studies and ultrasound color Doppler imaging (USCDI) of the ophthalmic artery (OA). Material and methods We conducted a single-center retrospective analysis of the medical records of 5 consecutive patients who developed NVG following non-arteritic CRAO between July 2010 and July 2014. Results Five patients were included. All 5 patients were examined at the emergency room. The 5 patients had normal intraocular pressure and no intraocular neovascularization upon initial examination. They had no hemodynamically significant internal carotid artery stenosis, and the ophthalmic artery USCDI was normal. These 5 patients developed NVG subsequently to the CRAO. Conclusions In our patients, carotid Doppler studies and USCDI of the OA ruled out COIS. Thus, COIS did not cause the NVG. CRAO may therefore lead to neovascular glaucoma without underlying COIS.

Objectives Physiopathological mechanisms that trigger clinical manifestations in pre-eclampsia (PE) remain unclear, and management is still a challenge. The identification of tools to predict the onset of the disease and prevent its complications is of great interest in medical practice. The present study aims to evaluate uterine perfusion, endothelial function and central nervous system blood flow in pregnant women with high-risk factors for PE, for comparison of the results between the group of patients who developed early onset PE and those who remained normotensive throughout pregnancy. Study design Sixty-two patients were recruited from our high-risk prenatal service, and followed throughout gestation. Patients were submitted to flow-mediated dilation, Dopplervelocimetry of uterine arteries and Dopplervelocimetry of ophthalmic arteries at three distinct moments of pregnancy: between 16+0 and 19+6 weeks, between 24+0 and 27+6 weeks and at hospital admission to delivery. Main outcome measures Pulsatility index of uterine arteries, flow-mediated dilation and ophthalmic arteries resistance index were evaluated and compared between the two groups of patients. Results Ten pregnancies were complicated by early onset PE, and these patients presented a significantly higher pulsatility index of uterine arteries between 16+0 and 19+6 weeks of gestation, compared with the normotensive group (p = 0,016). Both flow-mediated dilation and ophthalmic arteries resistance index values were lower in affected patients at 24+0 to 27+6 weeks (p = 0,001), and by the time of delivery (p Conclusions Those findings suggest that impaired placental perfusion, endothelial dysfunction and central hyperperfusion temporarily precede the clinical manifestations of early onset pre-eclampsia.

Purpose To compare the efficacy and toxicity of treating class 3 retinoblastoma vitreous seeds with ophthalmic artery chemosurgery (OAC) alone versus OAC with intravitreous chemotherapy. Design Retrospective cohort study. Participants Forty eyes containing clouds (class 3 vitreous seeds) of 40 retinoblastoma patients (19 treated with OAC alone and 21 treated with OAC plus intravitreous and periocular chemotherapy). Methods Ocular survival, disease-free survival and time to regression of seeds were estimated with Kaplan-Meier estimates. Ocular toxicity was evaluated by clinical findings and electroretinography: 30-Hz flicker responses were compared at baseline and last follow-up visit. Continuous variables were compared with Student t test, and categorical variables were compared with the Fisher exact test. Main Outcome Measures Ocular survival, disease-free survival, and time to regression of seeds. Results There were no disease- or treatment-related deaths and no patient demonstrated externalization of tumor or metastatic disease. There was no significant difference in the age, laterality, disease, or disease status (treatment naive vs. previously treated) between the 2 groups. The time to regression of seeds was significantly shorter for eyes treated with OAC plus intravitreous chemotherapy (5.7 months) compared with eyes treated with OAC alone (14.6 months; P P = 0.05). The 36-month Kaplan-Meier estimates of ocular survival were 83.3% (95% confidence interval, 56.7%–94.3%) for the OAC alone group and 100% for the OAC plus intravitreous chemotherapy group ( P = 0.16). The mean change in electroretinography responses was not significantly different between groups, decreasing by 11 μV for the OAC alone group and 22 μV for the OAC plus intravitreous chemotherapy group ( P = 0.4). Conclusions Treating vitreous seed clouds with OAC and intravitreous and periocular chemotherapy, compared with OAC alone, resulted in a shorter time to regression and was associated with fewer recurrences requiring additional treatment and fewer enucleations. The toxicity to the retina does not seem to be significantly worse in the OAC plus intravitreous chemotherapy group.

To compare two 3-dimensional (3D) printed models of intracranial aneurysms for simulation and training for complex aneurysm surgery.The study included 6 complex or large aneurysm cases. We printed two 3D models of complex aneurysms based on computed tomography angiography data using a 3D printer: a whole model, which was all-in-one printed hollow aneurysm method with colorful and multiple materials and included the hollow aneurysm, adjacent arteries, skull base, and nerves, and a regional model that included the hollow aneurysm and adjacent arteries. The 3D models were used for surgical planning and for practice in craniotomy and clipping. Neurosurgeons rated the models via questionnaires.Both 3D aneurysm models were accurate: the diameter, width, and neck of the aneurysms in the models were not significantly different from the computed tomography angiography data (P0.05). Furthermore, the models were useful for selecting clips before surgery. The whole 3D model improved understanding of the surgical view more than the regional model did (P0.05); however, the clip application felt more realistic in the regional model (P 0.05). The process time for making the whole model is shorter (P0.05) but more expensive (P0.05) compared with the regional model.The whole and regional 3D printed aneurysm models were accurate. The whole model was more useful for planning the trajectory of approach to the aneurysm when it was located in close proximity to bone and nerves, whereas the regional 3D aneurysm model was appropriate for aneurysms not involving bone and nerves. This will help neurosurgeon choose the proper 3D model for the complex aneurysm surgery according to the comparison.

Background Blunt cerebrovascular injury is an important cause of morbidity and mortality following head trauma. Intracranial vessel dissections, carotid-cavernous fistulae, and pseudo-aneurysms are uncommon traumatic vascular lesions with limited evidence to guide endovascular management. Case description We describe the case of a sixteen year old male patient suffering a traumatic paraclinoidal internal carotid artery (ICA) dissection with carotid-cavernous fistula and ophthalmic artery pseudo-aneurysm. Repeat angiography demonstrated worsening dissection prompting an endovascular parent vessel sacrifice following a passed balloon test occlusion. Relevant imaging is included. Conclusions Amongst new and developing stenting technologies as well as complex surgical solutions, utilizing a modern endovascular adaptation of simple Hunterian ligation to treat a complex multi-pronged pathology may in some cases represent the best available option. Given the limited published literature, our diagnostic and treatment approach may be informative to clinicians as well as inform an evidence based management approach in similar complex intracranial vascular injuries.

Objectives We attempt to find key points in endovascular coiling which can help us predict degree of clinical recovery, in an attempt to make the treatment of CCF safe and effective. Patients and methods We analyzed a series of 15 patients with traumatic CCFs undergoing coiling by performing clinical, angiographical and radiological assessment before and at regular time periods after the procedure till 6 months. The findings were analyzed to find critical points predicting clinical outcome in each of the patients. Results 80% patients had complete occlusion of fistula (n = 12) with a 100% ICA patency rate. Angiographic occlusion of fistula, visualization of ophthalmic artery and disappearance of bruit predicted a good clinical outcome. Cranial nerve palsies and fixed neurological deficits do not always reverse suggesting an alternate etiopathology. Conclusion The degree of occlusion had direct correlation with improvement in clinical symptoms, which was remarkable when the extent of occlusion was more than 90%. To our knowledge this is one of the largest series in published literature on clinical outcomes of patients with traumatic CCFs using detachable coils as the embolizing agent and can serve as standard for comparison for future treatment alternatives.

Background Ethmoidal dural arteriovenous fistulas (dAVFs) have a malignant natural history and an anatomy that make endovascular therapy challenging. Their uniqueness begs for stratified analyses, but this has largely been precluded by their rarity. We sought to summarize the anatomic, presentation, treatment approaches, and clinical outcomes of patients with these lesions. Methods We reviewed our prospectively maintained institutional database to identify patients diagnosed with ethmoidal dAVFs from January 1, 2000, to December 31, 2015. We evaluated demographic, presentation, angiographic, treatment, and follow-up data. Results In total, 27 patients with ethmoidal dAVFs underwent endovascular and/or surgical treatment. Mean patient age was 62 years old and there was a male sex predilection (67% men; 2:1 male-female ratio). All dAVFs exhibited direct cortical venous drainage; venous ectasia was present in 59% of cases. Of the dAVFs, 30% drained posteriorly into the basal vein of Rosenthal or the sylvian veins. Embolization with casting of the draining vein was successful in 2 of 9 cases (22%), including 1 successful transvenous case. There were no clinical or permanent complications from embolization; specifically, no patients experienced visual loss after treatment. Surgical treatment with successful dAVF obliteration was carried out in 24 of 24 patients (100%). One patient declined surgical treatment after attempted endovascular embolization. There were no permanent complications after surgical treatment and no cases of wound infection or cerebrospinal fluid leakage. Conclusions Surgical disconnection remains the gold standard in the treatment of ethmoidal dAVFs. Embolization is a consideration for well-selected cases with favorable arterial or venous access anatomy.

If persistent severe headache remains the only complaint of a patient, then the diagnosis of pseudotumor cerebri (PTC) can be delayed because in such cases practitioners are hesitant to immediately apply invasive intracranial pressure (ICP) measurement. Our purpose was to apply the technique of measuring diameters of the optic nerve sheath (ONSD) as a diagnostic tool in cases of PTC. Our aim was to provide practitioners with an additional sign to speed up their decision making about implementation of the lumbar puncture. In a retrospective study, CT scan data of 35 consecutive adult patients with PTC were collected and analyzed. ONSD were measured at the point where the ophthalmic artery crosses the optic nerve (anatomical landmark). The correlation analysis was performed with sex, age, and neuro-ophthalmological findings. We found that the ONSD was enlarged in 94.3% of patients with PTC. The enlarged ONSD were 6.2 ± 1.2 mm for the right and 6.3 ± 0.9 mm for the left (cut-off value >5.5 mm). The enlargement was bilateral, and no correlation with age or sex was found (p = 0.67 and p = 0.76, respectively). Presence of papilledema was detected in 91.4% of patients (32/35) presenting as a slightly less valuable diagnostic sign compared with ONSD. We conclude that in the majority of cases of PTC the ONSD is significantly enlarged, indicating elevated ICP even if CT scans are negative. Implementing this ONSD method as a diagnostic tool in cases of suspected PTC may help in early accurate diagnosis, avoiding misdiagnosis, and providing appropriate early treatment.

Purpose To evaluate the patient, disease, and tumor characteristics of the 3 morphologically distinct groups of vitreous seeds in retinoblastoma presenting for treatment with ophthalmic artery chemosurgery (OAC): dust (class 1), spheres (class 2), and clouds (class 3) in primary and recurrent vitreous seeds. Design Retrospective cohort study of patients treated for vitreous seeds at Memorial Sloan Kettering Cancer Center between May 2006 and March 2015. Participants A total of 135 eyes with active vitreous seeds, presenting for primary treatment with OAC or with recurrent vitreous disease. Methods Vitreous seeds were classified into 3 groups: dust, spheres, and clouds. Indirect ophthalmoscopy, fundus photography, ultrasonography, and ultrasonic biomicroscopy were used to locate and evaluate the extent of retinal and vitreous disease. Patient and disease characteristics (age, laterality of disease, treatment status) were compared among classification groups. A 2-tailed Fisher exact test and paired Student t test were used for statistical analysis. Main Outcome Measures Age of patient, laterality of disease, location of retinal disease, extent of vitreous disease, and treatment status. Results Primary treated disease: Patients with eyes containing class 3 (cloud) vitreous seeds were significantly older than patients with class 1 or 2 seeds ( P P P P P P = 0.01) and in patients with bilateral disease ( P Conclusions The 3 classes of vitreous seeds have distinct clinical characteristics associated with the age of patient, laterality of disease, and extent and location of tumor-producing seeds. Furthermore, recurrent vitreous seeds appear to have a unique clinical profile compared with seeds receiving primary treatment.