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Fulltext Ophthalmic artery occlusion following neuro-embolization of the external carotid artery, a case report

Loon NW, Gendeh BS, Zakaria R, Hamzah JC, Din NM

BMC Ophthalmol, 2017 Jun 15;17(1):92.
PMID: 28619056 DOI: 10.1186/s12886-017-0490-7

BACKGROUND: Embozene® is a new neuroembolizing microsphere used to reduce intraoperative bleeding for head and neck tumours. We report a case of iatrogenic ophthalmic artery occlusion after Embozene® embolization of the external carotid artery (ECA).
CASE PRESENTATION: A 22-year-old African gentleman presented with left nasal obstruction and epistaxis for 2 years and was diagnosed with nasopharyngeal carcinoma. He subsequently underwent embolization of the maxillary branch of the left ECA using Embozene® Microspheres - 250 μm in size before endoscopic tumour excision to reduce intra-operative bleeding. He complained of sudden painless profound visual loss in the left eye (LE) two hours after embolization. Visual acuity in LE was no light perception. Fundus examination showed pale retina with no cherry red spot. Arterial narrowing and segmentation were seen in all quadrants. A diagnosis of left ophthalmic artery occlusion was made. Despite immediate management including ocular massage and lowering of intraocular pressure, the visual loss remained. Retrospective review of digital subtraction angiogram showed an anastomosis between the left ophthalmic artery and anterior deep temporal artery as a potential route for microspheres migration.
CONCLUSION: Pre-operative angio-architecture understanding and diligent selection of embolic material are helpful in preventing this adverse event. The use of newer agents for embolotherapy may cause migration of embolic material from the external to the internal carotid system leading to ophthalmic artery occlusion and blindness.

Matched MeSH terms: Cerebral Angiography
Fulltext Aneurysms are more common than arteriovenous malformations as the cause of subarachnoid haemorrhage in the Malaysian population

Chee CP, Loh TG

Singapore Med J, 1988 Oct;29(5):427-31.
PMID: 3241969

A retrospective prospective study of 84 cases of subarachnoid haemorrhage, 24 intracranial aneurysms and 18 arteriovenous malformations (AVM's) treated in the University Hospital, Kuala Lumpur, during the post CT-scan era was carried out to verify the relative frequencies of these clinical entities in the Malaysian population. Our results show that aneurysms are commoner than arteriovenous malformations as a cause of subarachnoid haemorrhage and also the most frequent as a whole, thus refuting the previous claims that AVM's are 4 to 10 times more common than aneurysms in this part of the world. Of interest was the internal carotid artery aneurysms accounted for half of the anterior circulation aneurysms and that 2/3 of the AVM's presented with intracranial haemorrhage.

Matched MeSH terms: Cerebral Angiography
Fulltext Subarachnoid haemorrhage of unknown aetiology--a clinico-radiological analysis of 22 consecutive cases in the Malaysian population

Chee CP

Singapore Med J, 1988 Aug;29(4):319-21.
PMID: 3249955

Over the last 8 years, 22 consecutive cases of subarachnoid haemorrhage were found to have no obvious cause on angiography. The age, neurological status and CT-scan appearance in 16 cases were studied together with the completeness and quality of the angiogram. Limited angiography was done in cases with advanced age, poor neurology or severe hypertension. There is a need for more repeat angiographic studies in the presence of vasospasm whether focal or generalised, as indicated by the fact that only 5 out of the 17 cases with vasospasm had repeated satisfactory studies.

Matched MeSH terms: Cerebral Angiography
Fulltext Challenges in the management of massive intraorbital and hemifacial arteriovenous malformation as causing life-threatening epistaxis

Manuel AM, Kalimuthu S, Pathmanathan SS, Narayanan P, Zainal Abidin Z, Azmi K, et al.

Asian J Surg, 2017 Apr;40(2):158-162.
PMID: 24210537 DOI: 10.1016/j.asjsur.2013.09.011

Arteriovenous malformations are congenital lesions that may evolve with time and manifest in a plethora of presentations. They can occur as torrential epistaxis when it extensively involves the facial region. Multi-imaging modalities are available to assist in characterizing the structure of the lesion as well as its location and extent. This complex disease requires a multidisciplinary team approach with preoperative embolization and surgery. We present a rare cause of life-threatening epistaxis in a gentleman with a longstanding orbital and hemifacial arteriovenous malformation and discuss the complexities involved in its management.

Matched MeSH terms: Cerebral Angiography/methods*
Fulltext Paradoxical Manifestation is Common in HIV-negative Tuberculous Meningitis

Tai ML, Nor HM, Kadir KA, Viswanathan S, Rahmat K, Zain NR, et al.

Medicine (Baltimore), 2016 Jan;95(1):e1997.
PMID: 26735523 DOI: 10.1097/MD.0000000000001997

Paradoxical manifestation is worsening of pre-existing tuberculous lesion or appearance of new lesions in patients whose condition initially improved with antituberculous treatment. Our hypothesis was that paradoxical manifestation in non-HIV tuberculous meningitis (TBM) patients was underestimated and this could contribute to patients' prognosis. This was the first systemic study of paradoxical manifestation in HIV-negative TBM patients. Between 2009 and 2014, TBM patients were studied prospectively in 2 hospitals. Clinical features, cerebrospinal fluid, and radiological findings were monitored. Paradoxical manifestation was divided into definite (4 weeks or more) and probable (between 14 and 27 d) after commencement of antituberculous treatment. Forty-one non-HIV TBM patients were recruited. Definite paradoxical manifestation occurred in 23/41 (56%) of the patients. Time to onset of paradoxical manifestation was between 28 days and 9 months, and majority was between 28 and 50 days. Neuroimaging manifestation in the brain (22/41 patients, 54%) and clinical manifestation (22/41 patients, 54%) were most commonly seen, followed by cerebrospinal fluid manifestation (7/41 patients, 17%). Neuroimaging changes most commonly seen were worsening of leptomeningeal enhancement, new infarcts, new tuberculomas, and enlargement of tuberculoma. Initial Computed Tomography Angiography/magnetic resonance angiography brain showed vasculitis in 14 patients, with 2 (12.5%) showing paradoxical vasculitis during follow-up. Recurrence of the paradoxical manifestation was seen in 7/23 (30%) of the patients. More than half (14/23, 61%) of the patients improved, 6 (26%) patients died, and 3 (13%) patients had persistent neurological deficit. Paradoxical manifestation was very common in non-HIV TBM patients. Neuroimaging paradoxical manifestation of 2-4 weeks may not be paradoxical manifestation but could be delayed treatment response.

Matched MeSH terms: Cerebral Angiography
Lateral ventricle haemangioblastoma: the role of perfusion scanning and embolisation in diagnosis and management

Anderson I, Kumar R, Patankar T, Tyagi A

BMJ Case Rep, 2014;2014.
PMID: 25257888 DOI: 10.1136/bcr-2014-205736

We present the case of a 24-year-old man who presented with vertigo and right-sided weakness. Subsequent imaging demonstrated a lateral ventricle haemangioblastoma. This is the first case ever to be treated with surgical excision augmented by preoperative endovascular embolisation, as illustrated with perfusion CT scanning performed pre-embolisation and postembolisation. We present the case followed by a summary of the previously published cases and a discussion of the advantages of perfusion scanning and endovascular embolisation in these highly vascular (and therefore potentially dangerous) lesions.

Matched MeSH terms: Cerebral Angiography
Assessment of arterial collateralization and its relevance to intra-arterial therapy for acute ischemic stroke

Ramaiah SS, Mitchell P, Dowling R, Yan B

J Stroke Cerebrovasc Dis, 2014 Mar;23(3):399-407.
PMID: 23601372 DOI: 10.1016/j.jstrokecerebrovasdis.2013.03.012

Evidence from recent randomized controlled studies comparing intra-arterial (IA) therapy with intravenous tissue plasminogen activator highlighted the mismatch between recanalization success and clinical outcomes in patients presenting with acute ischemic stroke. There is emerging interest in the impact of arterial collateralization, as determined by leptomeningeal anastomoses (LMAs), on the treatment outcomes of IA therapy. The system of LMA constitutes the secondary network of cerebral collateral circulation apart from the Circle of Willis. Both anatomic and angiographic studies confirmed significant interindividual variability in LMA. This review aims to outline the current understanding of arterial collateralization and its impact on outcomes after IA therapy for acute ischemic stroke, underpinning the possible role of arterial collateralization assessment as a selection tool for patients most likely to benefit from IA therapy.

Matched MeSH terms: Cerebral Angiography
A Rare but Disabling Stroke

Lau KF, Tan KS, Goh KJ, Ramli N, Tai SM

Ann Acad Med Singap, 2019 Mar;48(3):109-111.
PMID: 30997481
Matched MeSH terms: Cerebral Angiography
Tranexamic Acid for Prevention of Hematoma Expansion in Intracerebral Hemorrhage Patients With or Without Spot Sign

Ovesen C, Jakobsen JC, Gluud C, Steiner T, Law Z, Flaherty K, et al.

Stroke, 2021 08;52(8):2629-2636.
PMID: 34000834 DOI: 10.1161/STROKEAHA.120.032426

BACKGROUND AND PURPOSE: The computed tomography angiography or contrast-enhanced computed tomography based spot sign has been proposed as a biomarker for identifying on-going hematoma expansion in patients with acute intracerebral hemorrhage. We investigated, if spot-sign positive participants benefit more from tranexamic acid versus placebo as compared to spot-sign negative participants.
METHODS: TICH-2 trial (Tranexamic Acid for Hyperacute Primary Intracerebral Haemorrhage) was a randomized, placebo-controlled clinical trial recruiting acutely hospitalized participants with intracerebral hemorrhage within 8 hours after symptom onset. Local investigators randomized participants to 2 grams of intravenous tranexamic acid or matching placebo (1:1). All participants underwent computed tomography scan on admission and on day 2 (24±12 hours) after randomization. In this sub group analysis, we included all participants from the main trial population with imaging allowing adjudication of spot sign status.
RESULTS: Of the 2325 TICH-2 participants, 254 (10.9%) had imaging allowing for spot-sign adjudication. Of these participants, 64 (25.2%) were spot-sign positive. Median (interquartile range) time from symptom onset to administration of the intervention was 225.0 (169.0 to 310.0) minutes. The adjusted percent difference in absolute day-2 hematoma volume between participants allocated to tranexamic versus placebo was 3.7% (95% CI, -12.8% to 23.4%) for spot-sign positive and 1.7% (95% CI, -8.4% to 12.8%) for spot-sign negative participants (Pheterogenity=0.85). No difference was observed in significant hematoma progression (dichotomous composite outcome) between participants allocated to tranexamic versus placebo among spot-sign positive (odds ratio, 0.85 [95% CI, 0.29 to 2.46]) and negative (odds ratio, 0.77 [95% CI, 0.41 to 1.45]) participants (Pheterogenity=0.88).
CONCLUSIONS: Data from the TICH-2 trial do not support that admission spot sign status modifies the treatment effect of tranexamic acid versus placebo in patients with acute intracerebral hemorrhage. The results might have been affected by low statistical power as well as treatment delay. Registration: URL: http://www.controlled-trials.com; Unique identifier: ISRCTN93732214.

Matched MeSH terms: Cerebral Angiography