RESUMEN
The optimal endovascular management of high-grade dural arterial-venous fistulae (dAVF) can be technically challenging in cases where the involved venous sinus segment is inaccessible through the traditional percutaneous approach. In this report, we describe our experience with the transcranial endovascular approach for the treatment of a high-grade dAVF. We also provide a literature review of other reports of transcranial endovascular dAVF embolization. We propose that transcranial endovascular embolization of high-grade dAVF appears to be safe and effective in cases where the fistula is inaccessible to percutaneous routes alone.
RESUMEN
In this case report, a patient with neuroretinitis from a Bartonella henselae infection is described, and insights into methods to distinguish this type of case from more common etiologies of optic nerve edema are presented. A 21-year-old female with a history of right monocular vision loss due to amblyopia presented to the emergency department (ED) with occipital headache, fever, dizziness, nasal congestion, and painless blurry vision in the left eye for one day. A lumbar puncture found a slightly high opening pressure but no evidence of meningitis. The patient was diagnosed with a viral illness and discharged with outpatient follow-up. The patient, however, had persistent central vision loss and recurring headaches and returned to the ED. Subsequent ultrasound of the patient's optic nerve revealed significant optic nerve swelling. A new working diagnosis of idiopathic intracranial hypertension was made, and the patient was started on oral acetazolamide. On the next day, she was seen by ophthalmology, and recent scratches from her cat were noted on her arm. She tested positive for B. henselae and was started on doxycycline and rifampin. Nearly two weeks after the initial presentation, a macular star pattern, indicative of neuroretinitis, was noted on the fundoscopic exam. The patient had recovered her vision by three months later. In ED cases with unilateral vision loss, early use of point-of-care ultrasound and infection with B. henselae should always be considered. Early serology testing may be warranted to allow for earlier treatment since classic signs of neuroretinitis may not be apparent at the onset.
RESUMEN
Intraoperative hypotension happens in everyday clinical practice. It was suggested to have a strong association with adverse postoperative outcomes. Hypotension prediction index (HPI) was developed to predict intraoperative hypotension (mean arterial pressure <65 mmHg) in real time. However, pressure autoregulation also plays an important role in maintaining adequate organ perfusion/oxygenation during hypotension. A cerebral oxygenation monitor provides clinicians with the values of organ oxygenation. We reported a case that the cerebral oxygenation monitor was used together with HPI to guide intraoperative blood pressure management. We found that cerebral oxygenation was maintained in the event of hypotension during surgery. The patient had no intraoperative or postoperative adverse outcomes despite the hypotension. We believe this can provide an individualized intraoperative blood pressure management to avoid over- or under-treating hypotension.