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1/16. Type IV spinal arteriovenous malformation in association with familial pulmonary vascular malformations: case report.

    OBJECTIVE AND IMPORTANCE: Type IVc arteriovenous malformations (AVMs) of the spinal cord consist of multiple high-flow feeding vessels, and they often present a challenging management situation. Their location is intradural and extramedullary, and they are rare malformations that are difficult to treat owing to the risk of thrombosis of the anterior spinal artery. The authors report a case of Type IVc spinal AVM in a patient with a family history of three siblings with pulmonary AVMs. Spinal AVMs have been reported to be associated with inherited syndromes such as familial cutaneous hemangiomas and Kartagener's syndrome, but an association with pulmonary AVMs has not previously been described. CLINICAL PRESENTATION: A 27-year-old man presented with sudden onset of occipital headache with cervical radiation while weightlifting. Results of computed tomography of the brain were normal, but lumbar puncture revealed a subarachnoid hemorrhage. The patient had a 1-year history of a neurogenic bladder and exhibited marked left calf muscle wasting. INTERVENTION: The patient underwent spinal magnetic resonance imaging, which revealed the AVM in the conus region. Selective spinal angiography was performed for diagnostic purposes. A laminectomy was performed, and the vessels feeding the AVM were clipped, as was the fistula. CONCLUSION: The patient remained neurologically stable, and angiography confirmed obliteration of the AVM. This is the first case report of a patient with a spinal AVM who had multiple siblings with pulmonary malformations or AVMs.
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2/16. Acute intracranial hemorrhage caused by acupuncture.

    A 44-year-old Chinese man developed severe occipital headache, nausea, and vomiting during acupuncture treatment of the posterior neck for chronic neck pain. Computed tomography of the head showed hemorrhage in the fourth, third, and lateral ventricles. A lumbar puncture confirmed the presence of blood. magnetic resonance angiography with gadolinium did not reveal any saccular aneurysms or arteriovenous malformations. The patient's headache resolved over a period of 28 days without any neurological deficits. acupuncture of the posterior neck can cause acute intracranial hemorrhage.
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3/16. High-flow arteriovenous malformation of the lower extremity: ethanolamine oleate sclerotherapy.

    We report the case of a young man presenting with high-flow arteriovenous malformation (AVM), in whom percutaneous direct nidus puncture ethanolamine oleate (EO) sclerotherapy was useful in the management of the AVM. To our knowledge, this is the first report of percutaneous trans-nidus EO sclerotherapy for AVM in the extremities. Percutaneous trans-nidus sclerotherapy should be considered as an alternative choice for the management of symptomatic AVM.
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4/16. Embolization of a life-threatening mandibular vascular malformation by direct percutaneous transmandibular puncture.

    vascular malformations of the mandible are uncommon, but often present with significant hemorrhage. Transarterial vessel occlusion has become a valuable primary or adjunctive treatment for such lesions, as well as for most other symptomatic congenital and acquired head and neck vascular anomalies. Permanent embolic obliteration of the malformation requires placement of occlusive material directly into the nidus (core) of the lesion. Prohibitively complex proximal vasculature may prevent successful catheter positioning and lead to failure of traditional embolotherapy. Even optimal placement of arterial embolic material may fail to fully obliterate the nidus, allowing eventual restoration of flow to the lesion due to arterial recanalization. Under such circumstances it may be possible to obliterate the malformation and control lesional hemorrhage by occlusion of the malformation or its venous drainage by direct percutaneous mandibular puncture. In our case, multiple transarterial embolizations failed to sufficiently manage a symptomatic vascular malformation. Successful embolotherapy was performed via direct puncture of the venous side of the malformation through the mandibular cortex. venous thrombosis induced concomitant occlusion of abnormal arteriovenous shunts, resulting in long-term control of life-threatening oral hemorrhage.
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5/16. Endovascular management of a mandibular arteriovenous malformation in a patient with severe hemophilia a.

    The unusual case of a mandibular arteriovenous malformation in a patient with severe hemophilia a and hepatitis c is reported. Supplementary substitution of various coagulation factors allowed direct puncture and intralesional injection of a liquid adhesive, resulting in complete anatomic and clinical cure without peri- or postoperative bleeding. Replacement therapy providing normal levels of relevant coagulation factors enables endovascular treatment in a safe and effective manner in hemophiliac patients.
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6/16. An alternative approach to maxillofacial arteriovenous malformations with transosseous direct puncture embolization.

    The management of arteriovenous (AVM) malformations of the jaws is complex and requires an integrated team approach. Subspecialists, such as maxillofacial surgeons, interventional radiologists, and critical care intensivists, are commonly involved in the management of these patients. The current treatment options for maxillofacial AVMs are surgical resection combined with endovascular embolization. Surgical treatment of arteriovenous malformations has been associated with significant morbidity and mortality due to potential for massive blood loss. In the pediatric population extensive resection of the craniofacial skeleton may be associated with growth disturbance, functional compromise, and cosmetic deformity. We report a novel technique using endovascular embolization via direct transosseous puncture for a high-flow vascular malformation, obviating the need for extensive surgical resection, and review the important clinical aspects of these life-threatening lesions.
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7/16. Spinal subdural empyema: report of two cases.

    Spinal subdural empyema (SSE) is a rare variety of intraspinal infection. SSE should be suspected in patients presenting with fever, back pain, and signs of cord or nerve root compression. Two patients with SSE are presented. The first patient complained of fever and back pain. She had no neurological deficit but was found to have SSE. The second patient, who presented with intracerebral hemorrhage in the fifth month of pregnancy and spontaneous abortion, was found to have SSE at lumbar puncture. The clinical manifestations and management are discussed.
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8/16. Direct sac puncture and N-butyl cyanoacrylate embolization of medial canthal arteriovenous malformation supplied by the external carotid artery and the internal carotid artery branches.

    We report a periorbital arteriovenous fistula that was treated with direct sac puncture N-butyl cyanoacrylate embolization under controlled inflow and outflow. The efficacy of this technique in a periorbital lesion is discussed.
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9/16. Neurological deterioration in a patient with a spinal arteriovenous malformation following lumbar puncture. Case report.

    The mechanism of nonhemorrhagic neurological deterioration from spinal arteriovenous malformation (AVM) and the role of acute surgical intervention in this setting are not well understood. The case is described of a 65-year-old man who presented with a 2-year history of mild gait spasticity and vague sensory complaints affecting both lower extremities. Following a diagnostic lumbar puncture, these symptoms progressed painlessly over a 4-day period to total motor paraplegia, urinary retention, and hypesthesia in all modalities with a midthoracic sensory level. magnetic resonance imaging showed a probable spinal AVM but no evidence of hemorrhage or cord compression. Spinal angiography confirmed the diagnosis of spinal AVM fed by radicular branches of left T-7 and T-8 segmental intercostal arteries. drainage was via long dorsal veins caudally. Emergency laminectomy with intradural exploration was performed. There was no evidence of prior hemorrhage or focal mass effect, although the cerebrospinal fluid pressure was elevated. The dural component of the spinal AVM was excised, and its communications with the spinal cord were disconnected intradurally. Neurological function started improving within 6 hours of the patient awakening from anesthesia. He had achieved antigravity strength in every muscle group of the lower extremities by the time of discharge to a rehabilitation center 10 days after surgery. Three months postoperatively, he was ambulating with a walker and was continent of urine and stool. Possible pathophysiological mechanisms are discussed in light of the favorable response to timely surgical intervention.
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10/16. Elimination of a cirsoid aneurysm of the scalp by direct percutaneous embolization with thrombogenic coils. Case report.

    Cirsoid aneurysms of the scalp are notoriously difficult lesions to manage. The authors report a patient in whom a large traumatic cirsoid aneurysm of the scalp was eliminated using a combined neurosurgical and interventional neuroradiological approach. Transarterial embolization was utilized to reduce arterial blood supply to the fistula. Thrombogenic Gianturco spring coils were then introduced via direct percutaneous puncture of the aneurysm. The aneurysm thrombosed and the multiple tortuous scalp vessels disappeared. One month after embolization, a small area of skin necrosis over the aneurysm necessitated surgical excision of the lesion. The thrombosed aneurysm was easily resected with minimal blood loss. Percutaneous embolization with thrombogenic coils in this case was a safe and effective ablative technique.
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