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Whether internal mammary artery side branches have the potential for hemodynamically significant flow steal in cases of postcoronary surgery ischemia remains a controversial issue. We present a case in which coil embolization of two unligated side branches resulted in symptomatic improvement and resolution of ischemia as evidenced by myoview imaging.

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BACKGROUND: Somatosensory evoked potentials (SSEP) are being used for the investigation and monitoring of the integrity of neural pathways during surgical procedures. Intraoperative neurophysiologic monitoring is affected by the type of anesthetic agents. Remifentanil is supposed to produce minimal or no changes in SSEP amplitude and latency. This study aims to investigate whether high doses of remifentanil influence the SSEP during spinal surgery under total intravenous anesthesia. METHODS: Ten patients underwent spinal surgery. Anesthesia was induced with propofol (2 mg/Kg), fentanyl (2 mcg/Kg) and a single dose of cis-atracurium (0.15 mg/Kg), followed by infusion of 0.8 mcg/kg/min of remifentanil and propofol (30-50 mcg/kg/min). The depth of anesthesia was monitored by Bispectral Index (BIS) and an adequate level (40-50) of anesthesia was maintained. Somatosensory evoked potentials (SSEPs) were recorded intraoperatively from the tibial nerve (P37) 15 min before initiation of remifentanil infusion. Data were analysed over that period. RESULTS: Remifentanil induced prolongation of the tibial SSEP latency which however was not significant (p > 0.05). The suppression of the amplitude was significant (p < 0.001), varying from 20-80% with this decrease being time related. CONCLUSION: Remifentanil in high doses induces significant changes in SSEP components that should be taken under consideration during intraoperative neuromonitoring.

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The treatment of a dural arteriovenous fistula (DAVF) depends on the severity of the symptoms, its angiographic characteristics, and the risk it presents for intracranial hemorrhage. In many instances, therapy may involve a combination of more than one modality. Low-risk DAVFs, either incidental or with minimal symptoms, can be treated conservatively (observation, blood pressure control, manual carotid compressions). If the patient does not tolerate the symptoms, definite or palliative treatment can be offered. All high-risk DAVFs (Borden Grade II or III) should receive treatment because they carry a high probability of intracranial hemorrhage or neurologic deterioration. For small, well-circumscribed fistulas, radiosurgery can have excellent results, but thrombosis can occur many months after the treatment. For large DAVFs with severe symptoms (vision deterioration, ophthalmoplegia with diplopia, seizures, or neurologic deficit) or with high risk for hemorrhage (cortical venous drainage or venous varices), the first treatment option should be endovascular embolization. With the combination of modern materials and techniques, this procedure can yield a high rate of cure with minimal complications. In patients not amenable to embolization or after incomplete embolization, surgery should be considered if the DAVF is located in an easily accessible area, because of its immediate and definite results. Surgery can be facilitated by preoperative embolization of the fistula to reduce the arterial supply and minimize intraoperative bleeding. Radiosurgery can also be used adjunctively after embolization or surgery has significantly reduced the size of large DAVFs.

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INTRODUCTION: Onyx has emerged in the recent years as a new embolic material. We present our experience with Onyx in the curative embolization of brain cerebral arteriovenous malformations (AVMs). METHODS: We retrospectively reviewed the files of all patients that we had treated with Onyx embolic material for a brain AVM during the last 4 years. We identified 101 patients who underwent a total of 219 sessions of embolization. RESULTS: The treatment has been concluded in 52 patients; in this group, total occlusion was obtained in 28 (53.9%) patients and near-total occlusion was obtained in 18 (34.6%). The respective figures based on the 101 patients of the study cohort are 28/101 (27.7%) and 18/101 (17.8%). More embolization sessions are to be carried out on the remaining 49 patients. There were three deaths, and eight patients had permanent neurological deficits with a resulting morbidity of 8% and mortality of 3%. CONCLUSION: High rates of total or near-total occlusion of brain AVMs can be achieved with multiple sessions of Onyx embolization with acceptable morbidity and mortality.

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A 76-year-old man developed blurred vision, and cerebral angiography disclosed an anterior skull base dural arteriovenous fistula (DAVF) supplied by both ethmoidal branches of the ophthalmic arteries and draining through a single cortical vein. Selective catheterization of both ophthalmic arteries distal to the origin of the central retinal arteries and occlusion the fistula feeders with injections of n-butyl cyanoacrylate glue led to complete occlusion of the fistula with preservation of retinal perfusion. The visual symptoms are attributed to impaired retinal perfusion as the result of a steal phenomenon. With care, a DAVF in this location can be successfully treated endovascularly while preserving retinal perfusion by embolizing the ophthalmic artery distal to the origin of the central retinal arteries and avoiding any backflow of embolizing material.

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Vertebral artery laceration is difficult to treat surgically. Endovascular treatment with balloon expandable covered stents often fails due to their rigidity and poor navigability. We present a case of iatrogenic vertebral artery laceration where endovascular treatment with a balloon expandable covered stent failed. Eventually a self expandable symbiot covered stent was deployed over the laceration, securing hemostasis and preserving the vessel patency. The newer self expandable covered stents seem promising in the treatment of vertebral artery injury.

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INTRODUCTION: The Neuroform2 stent has proven to be a very helpful device in the stent-assisted coiling of wide-necked cerebral aneurysms particularly because of its high navigability. We describe the case of a 33-year-old man with a ruptured anterior cerebral artery aneurysm that was successfully embolized and a wide-necked unruptured middle cerebral artery (MCA) aneurysm that required stent-assisted coiling. METHODS: All attempts to catheterize the parietal branch of the MCA in order to deploy the stent were unsuccessful since various guidewires followed a circular path inside the aneurysm sac. Based on our experience on the flexibility of the Neuroform2 stent, and since the aneurysm was unruptured, we decided to follow the circular path of the wire inside the aneurysm with the stent microcatheter. RESULTS: The stent navigated easily into the parietal branch where it was correctly deployed and the aneurysm was uneventfully embolized. CONCLUSION: This maneuver might pose the risk of aneurysm puncture in ruptured aneurysms but might prove helpful in unruptured wide-necked calcified or partially thrombosed aneurysms.

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