Search Results (56)

Introduction: Hyponatremia is common after nontraumatic intracerebral hemorrhage (ICH) and has been associated with worse outcomes, although prior studies have been limited by smaller sample sizes and heterogeneous exposure definitions. This study evaluated the association between severity-stratified hyponatremia and mortality, survival, and complication rates following nontraumatic ICH. Methods: A retrospective cohort study was performed using the TriNetX database. Patients with nontraumatic ICH were stratified by serum sodium measurements obtained within 7 days of diagnosis. Two separate propensity score-matched analyses were conducted: moderate hyponatremia versus normonatremia (17,547 patients per cohort) and severe hyponatremia versus normonatremia (5010 patients per cohort). The primary outcome was 30-day mortality. Secondary outcomes included seizures, cerebral edema, hydrocephalus, external ventricular drain placement, tracheostomy, percutaneous endoscopic gastrostomy (PEG) placement, pulmonary embolism, deep vein thrombosis, ischemic stroke, and myocardial infarction. Statistical significance was set at p < 0.05. Results: Moderate hyponatremia was associated with increased 30-day mortality (17.5% vs. 13.3%; HR 1.324, 95% CI 1.255–1.398; p < 0.001), while severe hyponatremia demonstrated a greater increase in mortality (18.7% vs. 12.9%; HR 1.473, 95% CI 1.332–1.628; p < 0.001). Both cohorts had higher rates of seizures, cerebral edema, hydrocephalus, tracheostomy, PEG placement, deep vein thrombosis, and myocardial infarction compared with matched normonatremic controls. External ventricular drain placement was also more frequent in both cohorts. Pulmonary embolism increased in moderate hyponatremia but was not significantly different in severe hyponatremia. Ischemic stroke occurred less frequently in both cohorts. Conclusions: Moderate and severe hyponatremia were associated with increased mortality and complications in patients with nontraumatic ICH, with stronger associations observed in severe hyponatremia. These findings support serum sodium as a clinically relevant marker for risk stratification and monitoring during acute ICH care. However, causality cannot be established, and whether correction of hyponatremia improves outcomes requires prospective studies. Full article

Background: Anterior cranial fossa dural arteriovenous fistulas (ACF DAVFs) usually receive ethmoidal dural supply. Pial arterial supply has been described in intracranial DAVFs, including ACF DAVFs, but a dominant orbitofrontal pial feeder can create diagnostic overlap with mixed pial-dural arteriovenous malformation and make endovascular treatment hazardous. Case Presentation: A 75-year-old man with atrial fibrillation presented with right middle cerebral artery occlusion and underwent intravenous thrombolysis followed by mechanical thrombectomy. During right internal carotid angiography, transient arterial-phase opacification of a contralateral frontal draining vein through the anterior communicating artery prompted post-recanalization angiography. A high-grade left ACF DAVF was diagnosed, with dominant supply from the left orbitofrontal artery, minor anterior ethmoidal supply, two venous drainage routes, cortical venous reflux, and a varix. Although the DAVF was incidental to the ischemic presentation, it was considered to require treatment because of high-risk angioarchitecture, including Borden type III/Cognard type IV drainage, cortical venous reflux, and venous ectasia. No intraparenchymal nidus or normal venous-phase use of the refluxing veins was identified. Because pial transarterial access and complete transvenous closure were considered unsafe or uncertain, microsurgical draining-vein disconnection was performed. Postoperative angiography confirmed complete obliteration. Conclusions: In this case, microsurgical disconnection achieved angiographic cure, and the patient was transferred for rehabilitation with a modified Rankin Scale score of 1. The central diagnostic and therapeutic issue in pial-feeder-dominant ACF DAVF is not rarity alone, but angiographic differentiation from mixed pial-dural arteriovenous malformation and assessment of whether the shunt can be closed without compromising normal pial arteries or venous outflow. The thrombectomy angiogram provided the route to diagnosis, whereas pial arterial dominance and divided venous drainage determined the curative strategy. Full article

Background: Cerebral arteriovenous malformations (AVMs) are high-flow shunts in which abnormal arteriovenous connections expose draining veins to venous hypertension, arterialization, and altered oxygenation. While digital subtraction angiography (DSA) remains the reference standard for dynamic angioarchitecture, it does not directly characterize venous oxygenation or microhemorrhagic tissue changes. Objective: To synthesize current evidence on susceptibility-based MRI-susceptibility-weighted imaging (SWI) and quantitative susceptibility mapping (QSM) for characterization, risk-related features, and treatment monitoring in cerebral AVMs. Methods: Narrative review of the foundational and contemporary literature on AVM pathophysiology, SWI and QSM technical principles, and clinical applications including venous drainage depiction, microhemorrhage detection, oxygenation-related biomarkers, and post-treatment surveillance. Results: SWI provides high-resolution, non-contrast depiction of venous drainage and perinidal hemorrhagic/calcific components, improving visualization of draining veins and microhemorrhages compared with conventional MRI and complementing TOF-MRA. Arterialized draining veins may show altered SWI signal consistent with elevated venous oxygen saturation, though interpretation is indirect and influenced by flow and orientation. QSM extends susceptibility imaging by quantifying tissue susceptibility and enabling indirect estimation of venous oxygenation (SvO₂), offering a potential physiological biomarker of shunt severity and treatment response after radiosurgery or embolization. Key limitations include lack of dynamic flow timing, flow-related artifacts, orientation dependence, confounding from hemorrhage/calcification, and limited standardization and prospective validation. Conclusions: Susceptibility-based MRI does not replace DSA but meaningfully enriches multimodal AVM assessment by adding structural and physiological information-particularly venous mapping, microhemorrhage detection, and oxygenation-sensitive biomarkers. Standardized acquisition/reconstruction and prospective studies are needed to validate susceptibility-derived metrics for risk stratification and longitudinal monitoring. Full article

Background: Groin lymphoceles are common postoperative complications after vascular interventions that can be difficult to treat, especially in recurrent or complex cases. While lymphovenous anastomosis (LVA) is a potential, minimally invasive option, its limited flow capacity may not provide sufficient drainage in large lymphoceles. We present a novel high-volume LVA technique that uses larger veins to directly drain the lymphocele cavity. Methods: Five patients with six groin lymphoceles, all previously treated unsuccessfully with conventional methods (mean 3.3 surgeries), underwent high-volume LVA (HV-LVA). The technique involved direct anastomosis of a large regional vein to the lymphocele cavity. Lymphatic inflow points were identified with Patent Blue or ICG when possible. Outcomes were assessed over 6–14 months. Results: In total, seven HV-LVAs were performed. Three lymphoceles (50%) were successfully treated with a single operation; three required revisions due to venous occlusion. All patients were successfully treated without recurrence. The average number of surgeries per patient was 2.2. Conclusions: High-volume LVA may be an effective option for therapy-resistant inguinal lymphoceles, providing greater drainage capacity than standard techniques. Further studies are needed to confirm its long-term efficacy and safety. Full article

Background: In 2016, Charles McMonnies advanced a theory positing that the use of scleral lenses might result in an elevation of intraocular pressure (IOP) due to the compression of the episcleral veins, consequently diminishing the eye’s capacity for draining aqueous humor. Alternative drainage pathways are capable of compensating only for 10–30% of the aqueous humor that requires drainage. Then it remains a quantity of fluid trapped in the anterior chamber. Recent data has demonstrated that the scleral lenses wear results indeed in an augmentation of the anterior chamber volume and a reduction of the iridocorneal angle, concomitant with a compression of Schlemm’s canal. Assuming that aqueous humor production remains constant, this imbalance between inflow and outflow can only lead to an increase in intraocular pressure. Methods: Several studies have attempted to answer this question over the past 10 years. Most authors have encountered the inherent difficulty of measuring IOP while the lens is still in place. Others were performed without waiting for the required time (>4 h of wear) for the lens to exert its maximum compression, thus minimizing their impact. Some attempted to assess IOP via the sclera (pneumotonometry), a technique known to give variable results and hard to reproduce. Ultimately, there are few reliable ways to assess IOP. One of them is by directly observing changes in the optic nerve structure over time. Results: These works indicate that there is indeed a moderate increase (<5 mmHg) in IOP. Could this be causing neuropathy and long-term negative impacts for patients who may be at risk? Based on the clinical experience of those involved in the field for many years, it is unlikely that IOP variations may have an impact on a healthy optic nerve. However, glaucoma patients or those at risk could be adversely affected in the long term. Conclusions: It is still too early to determine, without a doubt, the actual impact of the likely increase in IOP resulting from the structural changes caused by wearing scleral lenses Further work is therefore urgently needed to document these longitudinal changes. Full article

Partial anomalous pulmonary venous return (PAPVR) with dual drainage is a very rare congenital heart anomaly. We report the case of a 6-year-old boy with PAPVR in whom both upper pulmonary veins (PVs) drain anomalously into the systemic venous circulation, while maintaining preserved intrapulmonary collateral venous connections with the remaining pulmonary veins draining into the left atrium. Careful balloon occlusion testing of the anomalous PVs was performed, simultaneously with measurements of pulmonary pressures and control angiography, proving the absence of venous congestion in the upper lung fields during the pulmonary venous phase. Transcatheter occlusion using vascular plugs was safely and successfully performed. Full article

Background and Clinical Significance: Focal hemorrhagic severity associated with posterior convexity pial brain arteriovenous malformation (AVM) cases can be exacerbated by hemodynamic stress focusing on focal areas of architectural weakness and by superficial venous outflow being restricted by non-redundant superficial venous drainage. This clinical case report exemplifies how bedside neurologic localization and angioarchitectural characteristics can inform the selection of microsurgical approaches for the treatment of ruptured AVMs that are directed at reducing hemorrhage recurrence risk through corridors based on rupture location. Case Presentation: An otherwise healthy young adult male (modified Rankin scale [mRS] pre-morbid = 0) initially presented with a thunderclap headache, emesis, photophobia, decreased level of consciousness (admitted Glasgow Coma Score [GCS] = 11; E3V3M5), and subsequent deficits including left-sided pyramidal weakness, visual field loss, and visuo-spatial neglect. A non-contrast computed tomogram (CT) confirmed an intraparenchymal hemorrhage (ICH) located within the right hemisphere’s posterior lobe. Angiographic evaluation of this AVM with catheter injection and three-dimensional reconstruction revealed a compact right occipital posterior convexity pial AVM (nidus 8 × 3 mm) supplied by distal cortical branches of the right middle cerebral artery (MCA); all blood draining from the nidus was directed to a single cortical vein which then drained into the superior sagittal sinus; there were two additional intranidal saccular aneurysms (approximately 3 × 2 mm and 3 × 3 mm). Because of the acute worsening secondary to ICH and because all venous drainage was superficial-only, a single-stage approach was selected given the urgency: decompressive evacuation of the hematoma via a corridor to the site of the AVM, followed by microsurgical removal of the AVM. The removal of the AVM was accomplished in a feeder-first, vein-last sequence, and en-passage arteries and parasagittal bridging veins were preserved throughout the procedure. Additionally, the two intranidal aneurysms identified as potential weak points during progressive devascularization of the AVM were specifically treated during the removal procedure. Following the successful removal of the AVM, the patient experienced a rapid recovery and returned to a nearly premorbid state of functioning, excepting a persistent small area of quadrantanopia. Conclusions: Rupture of posterior convexity AVMs may result in increased hemorrhagic severity due to localized architectural weaknesses in addition to the overall size of the AVM nidus. By correlating neurological findings, the topography of the hemorrhage, and angioarchitectural features early after rupture, emergency decisions regarding management can be better informed. The application of a hematoma-corridor, feeder-first/vein-last microsurgical approach for the treatment of such AVMs can achieve definitive curative results while minimizing damage to posterior cortical regions. Full article

A 25-year-old woman with decompensated liver cirrhosis and complete inferior vena cava (IVC) occlusion was referred to our department for liver transplantation. The etiology of cirrhosis was Budd-Chiari syndrome (BCS) related to systemic lupus erythematosus, autoimmune hepatitis, and primary biliary cholangitis (AIH-PBC) overlap syndrome. Transplantation was feasible due to an extensive collateral circulation of pre-vertebral veins that drained blood from the lower extremities and both kidneys to the azygos-hemiazygos veins. This venous anomaly enabled the excision of the obstructed retrohepatic IVC, followed by an alternative anastomosis of the suprahepatic IVC to the right atrium without reconstruction of the infrahepatic IVC. Despite good venous patency and normalization of liver graft function, the patient developed cecum perforation, cardiovascular and respiratory insufficiency, which led to the patient’s death two months after transplantation. This case report supports an individual approach and highlights the feasibility of liver transplantation despite an extensive IVC thrombosis. To our knowledge, it is the first description of the application of a deceased donor liver transplantation in patients with AIH-PBC overlap syndrome and lupus-related BCS. A concise review of published literature on IVC-atrial anastomosis in adult liver transplant recipients is provided, and the technique is discussed based on our recent experience. Full article

While performing a routine anatomical dissection on a male donor, undergraduate medical students observed an uncommon vascular anomaly: a persistent left superior vena cava (LSVC). Prior to the anatomical dissection, computed tomography (CT) images were obtained in an embalmed condition. Relevant anatomical structures were measured using the JiveX DICOM Viewer. The left brachiocephalic vein (LBV) was present as a communicating vessel with a markedly reduced diameter between the LSVC and the right superior vena cava (RSVC). The diameters of RSVC and LSVC averaged 19.4 mm and 15.2 mm, respectively. The LSVC drained into a dilated coronary sinus (CS), which measured 22.7 mm in diameter. In addition, the left accessory hemiazygos vein collected the 2nd to 5th left intercostal veins, forming a small-caliber venous arch (2.1 mm in diameter) at the T5 vertebral level, which crossed anterior to the thoracic aorta, before draining into the LSVC. In comparison, the azygos venous arch on the right side is connected to the RSVC at T4. Knowledge of such venous variations through preoperative imaging—such as CT, MRI, or echocardiography—can be essential for procedural planning and for minimizing inadvertent complications. This case also highlights a dual approach, combining anatomical dissection with detailed CT analysis of the same specimen, which can both enhance undergraduate anatomical education and contribute to high-quality morphological research. Full article

Background: Pediatric craniocervical junction (CCJ) anomalies consist of a unique subset of anatomically complex spine conditions. The aims of intervention are to achieve long-term stability, correct existing deformity, and prevent neurological compromise. However, surgery is challenging due to critical neurovascular and musculoskeletal structures in the limited operative space of a young child. Recently, the use of three-dimensional (3D) printed models has been demonstrated to be valuable neurosurgical adjuncts. We therein report the application of a 3D-printed model for a pediatric case with a complex CCJ condition. A systematic review of the related literature is concurrently performed. Case description: A 10-year-old male presented with torticollis associated with neck pain and progressive thoracic kyphosis. Neuroimaging reported an unfused os odontoideum inferior to the basion and anterior half of the C2 vertebral body and anteriorly angulated with the C1 anterior arch. Of note, there was a large vertebral vein coursing over the left C2 lamina that was predominantly draining into the CCJ venous plexus. A radiologically derived 3D model of the patient’s CCJ was printed and used for pre-operative planning, multi-disciplinary team discussion, and detailed counseling with the patient and caregivers. The patient underwent an uneventful C1–C2 posterior screw fixation and has recovered well since. Separately, we observed there is a paucity of publications specific to this topic. Conclusions: As demonstrated, a custom-made 3D model was useful for clinicians work through technical difficulties and improve the perioperative discussion process in an otherwise difficult case. Full article

Background/Objectives: Arteriovenous malformations (AVMs) in the dominant temporo-parieto-occipital (TPO) junction of the brain are extremely rare and very difficult to remove surgically because this area includes multiple sensory and language networks. Due to the fact that many patients present with bleeding, surgeons have to find a delicate balance between removing all of the AVM tissue and preserving the functional areas of the brain where important functions occur. This study is reporting a case demonstrating how precise clinical–radiologic correlation, detailed anatomical knowledge, and deliberate microsurgical techniques can allow safe removal of the AVM and improve the patient’s neurologic function without the need for additional intraoperative technology. Case Presentation: A 47-year-old right-handed male patient experienced persistent neurological deficits after experiencing a hemorrhage from an AVM in his dominant posterior hemisphere, which included mild language difficulties, right hemifacial–brachial spasticity, parietal sensory loss and a visual field defect of his right eye known as an inferior quadrantanopia localized to the TPO junction. Cerebral angiography identified a small, compact, high-flow AVM (40 × 30 mm) fed by distal branches of the middle cerebral artery (M4), posterior cerebral artery (P4), anterior cerebral artery (A4), as well as a small branch of the superior cerebellar artery (SCA). Blood drained into two veins of the Trolard and Labbé. The authors removed the AVM completely by circumferential dissection of the nidus along gliotic planes using a microscope. Feeders were then sequentially disconnected, and the venous outflow was preserved until the AVM could be removed en bloc. Post-operative angiograms demonstrated complete removal of the AVM with normalization of blood flow to the surrounding cortex. The patient’s neurologic function improved over time and at three months post-operatively, he was functioning independently (modified Rankin Scale = 1; Barthel Index = 100) and there was no evidence of residual nidus or edema on imaging. Conclusions: High-flow AVMs in the dominant TPO junction can be completely removed using a disciplined microsurgical approach and a feeder first/vein last disconnection method based on anatomy. The patient’s improvement in function represented reperfusion and reintegration of an injured but still functional network of the brain, reinforcing the idea that careful observation, a deep understanding of brain anatomy, and restrained surgical technique are critical to achieving long-term results in AVM surgery. Full article

Background/Objectives: Muscle thickness and stiffness near the arteriovenous fistula (AVF) site may influence vascular access function in hemodialysis patients. This exploratory study aimed primarily to describe differences in muscle thickness and stiffness between the AVF-bearing and contralateral limbs, and secondarily to examine whether these parameters were associated with AVF maturation. This study aimed to compare these muscle parameters between the AVF and contralateral sides and to evaluate their relationship with AVF maturation status. Methods: Thirty participants undergoing hemodialysis were included, comprising 22 with mature AVFs and 8 with non-mature AVFs. Ultrasound examinations measured muscle thickness and stiffness using Shear Wave Elastography (SWE) of the biceps brachii and brachioradialis muscles. Volume flow was recorded in the draining vein and feeding artery. Statistical analyses included paired comparisons, group comparisons, Pearson correlations, and multiple linear regression models. Results: Brachioradialis thickness was significantly reduced on the AVF side compared with the contralateral side (p = 0.013, Cohen’s d = –0.95), particularly in forearm (radiocephalic) fistulas (Wilcoxon p = 0.014, Cohen’s d = –0.95), indicating localized muscle atrophy. No significant side-to-side differences were found for biceps brachii thickness or for stiffness in either muscle (all p > 0.1). Comparisons between mature and non-mature AVF groups showed no significant differences in muscle parameters on the AVF side (all p > 0.4). Conclusions: AVF may lead to asymmetric muscle changes, especially a reduction in brachioradialis thickness, regardless of maturation status, which could affect forearm function. Nevertheless, muscle thickness and stiffness do not appear to predict AVF maturity or vascular access success directly. Full article

Background: Down syndrome (DS) is commonly associated with complex respiratory phenotypes due to anatomical, immunological, and vascular factors. Pulmonary sequestration (PS) is a rare congenital malformation of non-functioning lung tissue with anomalous systemic arterial supply, occasionally reported in syndromic individuals. Case presentation: We report the case of a female infant with DS who developed acute respiratory distress secondary to respiratory syncytial virus infection. Chest imaging revealed an intralobar pulmonary pseudosequestration in the right lower lobe, supplied by the celiac trunk and draining into the pulmonary veins, with a communication to the bronchial tree. The patient required pediatric intensive care support and nutritional rehabilitation. Surgical resection was deferred until adequate weight optimization could be achieved. Discussion: This is, to our knowledge, the first description of intralobar pulmonary pseudosequestration in a patient with DS. The association suggests possible overlapping developmental mechanisms involving abnormal angiogenesis and emphasizes the importance of considering congenital pulmonary malformations in DS patients presenting with recurrent or severe respiratory symptoms. Conclusions: Early recognition and tailored management may improve clinical outcomes in this vulnerable population. Full article

Background/Objectives: This article discusses the clinical–surgical relevance of vascular anatomical variations, such as fenestrations—the division of a vessel into multiple channels that subsequently rejoin distally. Although rare in peripheral veins, these variations, which originate from the incomplete condensation of the embryonic capillary plexus, can predispose thrombosis and necessitate preoperative recognition to avert complications during routine procedures. This study aims to report a rare case of dual origin and double fenestration of the cephalic vein. Methods: During a cadaveric dissection, a variation of the cephalic vein was identified. Results: In this case, an origin of the cephalic vein was observed arising from the dorsal venous network of the hand. It exhibited a double fenestration in the forearm, where a branch of the medial cutaneous nerve of the forearm perforated it before draining into the brachial vein. The second, a proximal origin, arose from the convergence of two tributaries—one originating from the subcutaneous tissue lateral to the brachial muscle and the other from the biceps brachii muscle, forming a single trunk that drained into the subclavian vein. Conclusions: This rare variation of the cephalic vein (dual origin and fenestration) carries significant hemodynamic implications, including an increased risk of turbulence and thrombosis. The atypical anatomical relationship between the nerve and the fenestrated vein also heightens the potential for iatrogenic injuries. In-depth knowledge of such anomalies is crucial for healthcare professionals to minimize complications and optimize the success of procedures like venous access and arteriovenous fistulas, ultimately ensuring patient safety. Full article

The axillary and cephalic veins are commonly utilized for transvenous pacemaker lead access. They typically advance to the heart through the subclavian, brachiocephalic, and superior vena cava veins. Anatomical variations such as a persistent left superior vena cava (PLSVC) may pose a challenge, necessitating an alternative approach for lead placement. This anomaly can often be identified during venographic contrast imaging or by visualizing atypical venous courses during the procedure. Another challenge occurs when the venous pathway is tortuous. Careful monitoring during the procedure is crucial to ensure that the lead follows the intended path. If not, the lead may inadvertently enter a collateral, such as the inferior thyroid vein, which drains into the internal jugular or left brachiocephalic vein. Despite these deviations, the lead may eventually reach the heart, although via an unusual course. If such a lead is left in place, even in the absence of immediate complications, long-term outcomes are unpredictable and carry the risk of unforeseen complications. Full article