Ailments

Overview

A stroke is a sudden interruption in the blood supply of the brain.

Types of Stroke
Ischemic Stroke - Thumbnail

Ischemic Stroke
The most common type of stroke, accounting for almost 80 percent of all strokes, is caused by a clot or other blockage within an artery leading to the brain.

Ischemic Stroke - Thumbnail

Intracerebral Hemorrhage
An intracerebral hemorrhage is a type of stroke caused by the sudden rupture of an artery within the brain. Blood is then released into the brain compressing brain structures.

 

Treatments

  • Intravenous tPA
  • Penumbra/Solitaire/Trevo
  • Intra-Arterial tPA
  • Carotid Angioplasty and Stenting
  • Brain Vessel Stenting

Over View

A brain aneurysm, also referred to as a cerebral aneurysm or intracranial aneurysm (IA), is a weak bulging spot on the wall of a brain artery very much like a thin balloon or weak spot on an inner tube. Over time, the blood flow within the artery pounds against the thinned portion of the wall and aneurysms form silently from wear and tear on the arteries. As the artery wall becomes gradually thinner from the dilation, the blood flow causes the weakened wall to swell outward. This pressure may cause the aneurysm to rupture and allow blood to escape into the space around the brain. A ruptured brain aneurysm commonly requires advanced surgical treatment.

Types

A saccular aneurysm is the most common type of aneurysm and account for 80% to 90% of all intracranial aneurysms and are the most common cause of nontraumatic subarachnoid hemorrhage (SAH). It is also known as a "berry" aneurysm because of its shape. The berry aneurysm looks like a sac or berry forming at the bifuraction or the "Y" segment of arteries. It has a neck and stem. These small, berry-like projections occur at arterial bifurcations and branches of the large arteries at the base of the brain, known as the Circle of Willis.

The fusiform aneurysm is a less common type of aneurysm. It looks like an outpouching of an arterial wall on both sides of the artery or like a blood vessel that is expanded in all directions. The fusiform aneurysm does not have a stem and it seldom ruptures.

 

Treatment

1. Endovascular Coil embolization

During this procedure, a small tube is inserted into the affected artery and positioned near the aneurysm. For coil embolization, soft metal coils are then moved through the tube into the aneurysm, filling the aneurysm and making it less likely to rupture. In mesh embolization, mesh is placed in the aneurysm, reducing blood flow to the aneurysm and making it less likely to rupture. These procedures are less invasive than surgery. But they involve risks, including rupture of the aneurysm.

There are 3 types of Endovascular coiling :
  • Conventional Coiling
  • Ballon Asdsisted Coiling
  • Stent Assisted Coiling
2. Flow Diverter:

Flow diverters are stent-like devices that are deployed endovascularly to treat aneurysms. Conceptually, flow diverters allow endoluminal reconstruction rather than endosaccular filling. Flow diverters take advantage of changing the parent artery/aneurysm sac interface, for example, altering in-flow and out-flow jets, to induce aneurysm thrombosis.

As opposed to coil embolization techniques, flow diverter techniques cause aneurysms to occlude over time rather than immediately at the end of the procedure

Flow diverters have expanded the therapeutic options for treatment of cerebral aneurysms and represent a welcomed paradigm shift. Previously untreatable intracranial aneurysms can now be safely treated.. The role of flow diverters is evolving and expanding in the Treatment of blister-like aneurysms, bifurcation aneurysms, small aneurysms, giant aneurysms and aneurysmal dysplastic arterial segments with multiple small aneurysms.

Overview

An epileptic seizure is an event of altered brain function caused by abnormal or excessive electrical discharges from brain cells

Types

Focal seizures

When seizures appear to result from abnormal activity in just one area of your brain, they're called focal (partial) seizures. These seizures fall into two categories:

  • Focal seizures without loss of consciousness. Once called simple partial seizures, these seizures don't cause a loss of consciousness. They may alter emotions or change the way things look, smell, feel, taste or sound. They may also result in involuntary jerking of a body part, such as an arm or leg, and spontaneous sensory symptoms such as tingling, dizziness and flashing lights.
  • Focal seizures with impaired awareness. Once called complex partial seizures, these seizures involve a change or loss of consciousness or awareness. During a complex partial seizure, you may stare into space and not respond normally to your environment or perform repetitive movements, such as hand rubbing, chewing, swallowing or walking in circles.
Generalized seizures

Seizures that appear to involve all areas of the brain are called generalized seizures. Six types of generalized seizures exist.

  • Absence seizures. Absence seizures, previously known as petit mal seizures, often occur in children and are characterized by staring into space or subtle body movements such as eye blinking or lip smacking. These seizures may occur in clusters and cause a brief loss of awareness
  • Tonic seizures. Tonic seizures cause stiffening of your muscles. These seizures usually affect muscles in your back, arms and legs and may cause you to fall to the ground.
  • Atonic seizures. Atonic seizures, also known as drop seizures, cause a loss of muscle control, which may cause you to suddenly collapse or fall down.
  • Clonic seizures. Clonic seizures are associated with repeated or rhythmic, jerking muscle movements. These seizures usually affect the neck, face and arms.
  • Myoclonic seizures. Myoclonic seizures usually appear as sudden brief jerks or twitches of your arms and legs.
  • Tonic-clonic seizures. Tonic-clonic seizures, previously known as grand mal seizures, are the most dramatic type of epileptic seizure and can cause an abrupt loss of consciousness, body stiffening and shaking, and sometimes loss of bladder control or biting your tongue.

Treatment

Most epileptic seizures are controlled with drug therapy, especially anticonvulsant drugs. The type of treatment will depend on several factors, including:

  • The type of epilepsy (focal/partial or generalized)
  • How often the patient has a seizure
  • How severe the seizures are, and
  • The person's age, overall health, and medical history

The correct diagnosis of the type of epilepsy (not just the type of seizure, since most seizure types occur in different types of epilepsy) is very important to help choose the best treatment.

There are many drugs available to treat epilepsy, including:

  • Carbamazepine
  • Clobazam
  • Diazepam and related medications such as clonazepam, and clorazepate
  • Divalproex
  • Ethosuximide
  • Felbamate
  • Gabapentin
  • Lacosamide
  • Lamotrigine
  • Levetiracetam
  • Phenobarbital
  • Phenytoin
  • Pregabalin
  • Primidone
  • Rufinamide
  • Tiagabine
  • Topiramate
  • Valproic acid
  • Vigabatrin
  • Zonisamide

In most cases, for a given type of epilepsy, there are only minor differences among appropriate drugs. The choice most often depends on the patient; for instance, which side effects he or she can tolerate, and which delivery method he or she prefers.

Although the types of epilepsy are widely different, in general, medicines can control seizures in about 70 percent of epilepsy patients.

It might take a few months before the best drug and dosage are determined for you. During this adjustment period, you might be monitored with frequent blood tests. It is very important to keep your follow-up appointments with your doctor and the laboratory to minimize your risk for serious side effects and to prevent complications.

When seizures continue even after treatment, the patient may have medically refractory seizures, or the episodes that are thought to be seizures are actually non-epileptic. In such cases, you should get a second opinion from an epilepsy specialist and undergo EEG-video monitoring so that the diagnosis can be re-evaluated. In specialized centers, about 15 percent to 20 percent of patients referred for persistent, refractory or intractable seizures ultimately prove to have non-epileptic conditions instead

Overview

Parkinson's disease is a progressive nervous system disorder that affects movement. Symptoms start gradually, sometimes starting with a barely noticeable tremor in just one hand. Tremors are common, but the disorder also commonly causes stiffness or slowing of movement.

In the early stages of Parkinson's disease, your face may show little or no expression. Your arms may not swing when you walk. Your speech may become soft or slurred. Parkinson's disease symptoms worsen as your condition progresses over time.

Although Parkinson's disease can't be cured, medications might significantly improve your symptoms. Occasionally, your doctor may suggest surgery to regulate certain regions of your brain and improve your symptoms.

Treatment

Parkinson's disease can't be cured, but medications can help control your symptoms, often dramatically. Lifestyle changes, especially ongoing aerobic exercise is recommended. In some cases, physical therapy that focuses on balance and stretching also is important. A speech-language pathologist may help improve your speech problems.

To be Updated...

Overview

Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of vertigo — the sudden sensation that you're spinning or that the inside of your head is spinning.

Benign paroxysmal positional vertigo causes brief episodes of mild to intense dizziness. Benign paroxysmal positional vertigo is usually triggered by specific changes in the position of your head. This might occur when you tip your head up or down, when you lie down, or when you turn over or sit up in bed.

Although benign paroxysmal positional vertigo can be a bothersome problem, it's rarely serious except when it increases the chance of falls.

Treatment

The inner ear and canalith repositioning

Vertigo usually results from a problem with the nerves and structures of the balance mechanism in your inner ear (vestibular labyrinth). BPPV occurs when particles called otoconia break loose and fall into the wrong part of the canals of your inner ear, producing an episode of vertigo. The goal of the canalith repositioning procedure is to move the otoconia from your inner ear to the utricle.

Benign paroxysmal positional vertigo may go away on its own within a few weeks or months. But, to help relieve BPPV sooner, your doctor, audiologist or physical therapist may treat you with a series of movements known as the canalith repositioning procedure.

Canalith repositioning

Performed in your doctor's office, the canalith repositioning procedure consists of several simple and slow maneuvers for positioning your head. The goal is to move particles from the fluid-filled semicircular canals of your inner ear into a tiny bag-like open area (vestibule) that houses one of the otolith organs in your ear where these particles don't cause trouble and are more easily resorbed.

Each position is held for about 30 seconds after any symptoms or abnormal eye movements stop. This procedure is usually effective after one or two treatments.

Overview

A migraine can cause severe throbbing pain or a pulsing sensation, usually on just one side of the head. It's often accompanied by nausea, vomiting, and extreme sensitivity to light and sound.

Migraine attacks can cause significant pain for hours to days and can be so severe that the pain is disabling.

Warning symptoms known as aura may occur before or with the headache. These can include flashes of light, blind spots, or tingling on one side of the face or in your arm or leg.

Medications can help prevent some migraines and make them less painful

Treatment

Physical and neurological exams may be necessary in diagnosing and treating headache symptoms. Headache treatment is discussed.

How are headaches evaluated and diagnosed?

The correct headache diagnosis is needed to begin an effective treatment plan. The most important aspect of the headache evaluation is the headache history, which is obtained from the patient. It is important for you to describe your headache symptoms and characteristics to your doctor as completely as possible so the headache can be properly diagnosed and successfully treated. Your headache can be more accurately diagnosed by knowing:

  • When the headache started
  • How long you have had the headache
  • Whether there is a single type of headache or multiple types of headaches
  • How often the headache occurs
  • What causes the headache, if known (for example, do certain situations, foods, or medications usually trigger the headache?)
  • If physical activity aggravates the headache pain
  • What events are associated with the headache
  • Who else in your family has headaches
  • What symptoms, if any, occur between headaches

Your doctor will also ask additional questions about performance at work, family background, and if there is any history of drug abuse.

Clinical description of headaches

Describe how you feel when you have the headache and what happens when you get the headache, such as:

  • Where the pain is located
  • What it feels like
  • How severe the headache pain is, using a scale from one (mild) to 10 (severe)
  • If the headache appears suddenly without warning or with accompanying symptoms
  • What time of day the headache usually occurs
  • If there is an aura (changes in vision, blind spots, or bright lights) before the headache
  • What other symptoms or warning signs occur with the headache (weakness, nausea, sensitivity to light or noise, decreased appetite, changes in attitude or behavior)
  • How long the headache lasts
How are headaches treated?

The proper treatment will depend on several factors, including the type and frequency of the headache and its cause. Treatment may include education, stress management, biofeedback, and medication and physical therapy education.

Headache education

Education includes learning and recording what triggers the headaches, such as lack of sleep, a poor diet, your environment, or stress. Your health care provider may give you a Headache Diary to record the characteristics of your headaches and can recommend ways of managing headache triggers. Bring the diary with you to all of your doctor appointments; this information will help your healthcare providers correctly treat your headaches.

Relaxation techniques

Learning relaxation techniques can help you reduce headaches. If you have a headache, you should:

  • Lie down and relax
  • Stretch and relax the muscles
  • Take breaks from activities that trigger or provoke headaches, such as using the computer for long periods of time or exercising strenuously

There are several other methods you can use to relax or reduce stress, including:

  • Deep breathing exercises
  • Progressive muscle relaxation
  • Mental imagery relaxation
  • Relaxation to music
  • Biofeedback (explained below)
  • Counseling, which can help you recognize and release stress
Biofeedback

Biofeedback can help you learn stress-reduction skills by providing information about muscle tension, heart rate, and other vital signs as you try to relax. It is used to gain control over certain bodily functions which cause tension and physical pain.

Biofeedback can be used to help you learn how your body responds in stressful situations. If a headache, such as a migraine, begins slowly, many people can use biofeedback to stop the attack before it becomes full blown.

Medications

Medications may be recommended to manage headache pain. Headache medications can be grouped into three different categories: symptomatic relief, abortive therapy, and preventive therapy. Each type of medication is most effective when used in combination with other medical recommendations, such as dietary and lifestyle changes, exercise, and relaxation therapy.

  • Symptomatic relief - Used to relieve symptoms associated with headaches, including the pain of a headache or the nausea and vomiting associated with migraine. These may include simple analgesics, ibuprofen or acetaminophen, antiemetics or sedatives. Many of these are available over-the-counter, while others require a prescription.

Important: If symptomatic relief medications are used more than twice a week, you should see your healthcare provider who can prescribe preventive headache medications. Overuse of these symptomatic medications can actually cause more frequent headaches or worsen headache symptoms.

  • Abortive therapy - These medications are most effective when used at the first sign of a migraine to stop the process that causes the headache pain. By stopping the headache process, abortive medications help prevent the symptoms of migraines including pain, nausea, light sensitivity, etc. Abortive medications include: injectable dihydroergotamine mesylate ( and nasal Migranal, sumatriptan succinate, zolmitriptan, and others triptan drugs.
  • Preventive therapy - Used to treat very frequent tension headaches and migraines, or the combination of both types of headaches. Preventive therapy is aimed at reducing both the frequency and severity of the headaches and includes antidepressants, antihistamines, beta blockers, calcium channel blockers, and anticonvulsant medications as recommended by your doctor. Most of these medications require a prescription.

There are a variety of supplements that can be used daily to prevent migraines. These include riboflavin, coenzyme Q10, petadolex and magnesium oxide. These may be taken individually or in combination, but must be taken for more than 2 months to be effective.

Overview

Cervical spondylosis is a general term for age-related wear and tear affecting the spinal disks in your neck. As the disks dehydrate and shrink, signs of osteoarthritis develop, including bony projections along the edges of bones (bone spurs).

Cervical spondylosis is very common and worsens with age. More than 85 percent of people older than age 60 are affected by cervical spondylosis.

Most people experience no symptoms from these problems. When symptoms do occur, nonsurgical treatments often are effective.

Treatment

Treatment for cervical spondylosis depends on the severity of your signs and symptoms. The goal of treatment is to relieve pain, help you maintain your usual activities as much as possible, and prevent permanent injury to the spinal cord and nerves.

Medications
  • Nonsteroidal anti-inflammatory drugs. While some types of NSAIDs are available over the counter, you may need prescription-strength versions to relieve the pain and inflammation associated with cervical spondylosis.
  • Corticosteroids. A short course of oral prednisone might help ease pain. If your pain is severe, steroid injections may be helpful.
  • Muscle relaxants. Certain drugs, such as cyclobenzaprine, can help relieve muscle spasms in the neck.
  • Anti-seizure medications. Some epilepsy medications, such as gabapentin (Neurontin, Horizant) and pregabalin (Lyrica), can dull the pain of damaged nerves.
  • Antidepressants. Certain antidepressant medications have been found to help ease neck pain from cervical spondylosis.
Therapy

A physical therapist can teach you exercises to help stretch and strengthen the muscles in your neck and shoulders. Some people with cervical spondylosis benefit from the use of traction, which can help provide more space within the spine if nerve roots are being pinched.

Surgery

If conservative treatment fails or if your neurological signs and symptoms — such as weakness in your arms or legs — worsen, you might need surgery to create more room for your spinal cord and nerve roots.

The surgery might involve:

  • Removing a herniated disk or bone spurs
  • Removing part of a vertebra
  • Fusing a segment of the neck using bone graft and hardware

Overview

Peripheral neuropathy, a result of damage to your peripheral nerves, often causes weakness, numbness and pain, usually in your hands and feet. It can also affect other areas of your body.

Your peripheral nervous system sends information from your brain and spinal cord (central nervous system) to the rest of your body. Peripheral neuropathy can result from traumatic injuries, infections, metabolic problems, inherited causes and exposure to toxins. One of the most common causes is diabetes mellitus.

People with peripheral neuropathy generally describe the pain as stabbing, burning or tingling. In many cases, symptoms improve, especially if caused by a treatable condition. Medications can reduce the pain of peripheral neuropathy.

Signs and symptoms of peripheral neuropathy might include:

  • Gradual onset of numbness, prickling or tingling in your feet or hands, which can spread upward into your legs and arms
  • Sharp, jabbing, throbbing, freezing or burning pain
  • Extreme sensitivity to touch
  • Lack of coordination and falling
  • Muscle weakness or paralysis if motor nerves are affected
Prevention

Manage underlying conditions

The best way to prevent peripheral neuropathy is to manage medical conditions that put you at risk, such as diabetes, alcoholism or rheumatoid arthritis.

Make healthy lifestyle choices

For example:

  • Eat a diet rich in fruits, vegetables, whole grains and lean protein to keep nerves healthy. Protect against vitamin B-12 deficiency by eating meats, fish, eggs, low-fat dairy foods and fortified cereals. If you're vegetarian or vegan, fortified cereals are a good source of vitamin B-12, but talk to your doctor about B-12 supplements.
  • Exercise regularly. Try to get at least 30 minutes to one hour of exercise at least three times a week.
  • Avoid factors that may cause nerve damage, including repetitive motions, cramped positions, exposure to toxic chemicals, smoking and overindulging in alcohol.

Treatment

Treatment goals are to manage the condition causing your neuropathy and to relieve symptoms. If your lab tests indicate no underlying condition, your doctor might recommend watchful waiting to see if your neuropathy improves.

Medications

Besides medications used to treat conditions associated with peripheral neuropathy, medications used to relieve peripheral neuropathy signs and symptoms include:

  • Pain relievers. Over-the-counter pain medications, such as nonsteroidal anti-inflammatory drugs, can relieve mild symptoms. For more-severe symptoms, your doctor might prescribe painkillers.
  • Medications containing opioids, such as tramadol (Conzip, Ultram) or oxycodone (Oxycontin, Roxicodone, others), can lead to dependence and addiction, so these drugs generally are prescribed only when other treatments fail.
  • Anti-seizure medications. Medications such as gabapentin (Gralise, Neurontin) and pregabalin (Lyrica), developed to treat epilepsy, may relieve nerve pain. Side effects can include drowsiness and dizziness.
  • Topical treatments. Capsaicin cream, which contains a substance found in hot peppers, can cause modest improvements in peripheral neuropathy symptoms. You might have skin burning and irritation where you apply the cream, but this usually lessens over time. Some people, however, can't tolerate it.
  • Lidocaine patches are another treatment you apply to your skin that might offer pain relief. Side effects can include drowsiness, dizziness and numbness at the site of the patch.
  • Antidepressants. Certain tricyclic antidepressants, such as amitriptyline, doxepin and nortriptyline (Pamelor), have been found to help relieve pain by interfering with chemical processes in your brain and spinal cord that cause you to feel pain.
  • The serotonin and norepinephrine reuptake inhibitor duloxetine (Cymbalta) and the extended-release antidepressant venlafaxine (Effexor XR) also might ease the pain of peripheral neuropathy caused by diabetes. Side effects may include dry mouth, nausea, drowsiness, dizziness, decreased appetite and constipation.
Therapies

Various therapies and procedures might help ease the signs and symptoms of peripheral neuropathy.

  • Transcutaneous electrical nerve stimulation (TENS). Electrodes placed on the skin deliver a gentle electric current at varying frequencies. TENS should be applied for 30 minutes daily for about a month.
  • Plasma exchange and intravenous immune globulin. These procedures, which help suppress immune system activity, might benefit people with certain inflammatory conditions.
  • Plasma exchange involves removing your blood, then removing antibodies and other proteins from the blood and returning the blood to your body. In immune globulin therapy, you receive high levels of proteins that work as antibodies (immunoglobulins).
  • Physical therapy. If you have muscle weakness, physical therapy can help improve your movements. You may also need hand or foot braces, a cane, a walker, or a wheelchair.

Overview

Arteriovenous malformations (AVMs) are abnormal tangles of arteries and veins. While many AVMs remain asymptomatic for life, they can cause serious problems when they occur inside the brain as a cerebral AVM, or in the brain's covering (the dura) as a dural AVM, or in the spinal cord as a spinal AVM.

AV fistulas are an abnormal connection between arteries and veins. This condition can occur in the brain, the covering of the brain (dura) and the spinal cord. They can cause symptoms by affecting the surrounding brain or spinal cord, and in some cases from bleeding.

In both conditions, the capillaries that normally exchange blood between the arteries and the veins don't develop in a certain area, and as a result, the arteries dump blood directly into the veins. Unlike arteries, the veins do not have strong walls. Over time, because of the high blood pressure of arterial blood flow, these veins dilate and become engorged, creating the risk of rupture and hemorrhage, as well as seizures, headaches and other symptoms. These symptoms typically develop between the second and fourth decade of life. Half of all brain AVMs present with a brain hemorrhage, while the rest typically present as a seizure (25%), a headache (usually one sided and migraine-like), or a neurological deficit. Studies indicate that untreated AVMs carry a high long-term risk of hemorrhage, stroke or death.

Treating AVMs

AVMs should be treated once they declare themselves and become symptomatic, whether the symptoms involve a hemorrhage, a seizure, a headache, or a neurologic deficit.

The patient's age, the location of the AVM, and its angiographic picture play a major role in the evaluation and treatment of these lesions. Cerebral angiography remains the gold standard for evaluating AVMs and identifying any associated aneurysms. MRI and MRA scans can also be useful for providing three-dimensional details about the AVM, while CT scans are useful in evaluating past and current bleeding of the AVM.

The goal of treatment is to completely eliminate the AVM. Incomplete or partial treatment, in which a residual amount of the AVM remains, has actually been associated with a higher complication rate than of leaving an AVM untreated. Microsurgery, stereotactic radiosurgery and endovascular embolization, used alone or in combination, are the mainstays of AVM treatment. Our cerebrovascular surgeons have extensive expertise in all three approaches. Treatment options are recommended based on an individual assessment of each patient.

Microsurgical Resection

Advances in microscopic visualization, computer-assisted stereotactic guidance, intraoperative angiography and electrophysiologic monitoring have significantly improved outcomes of this approach, and today it provides immediate and permanent elimination of the risk of hemorrhage, improvement in neurologic function, and a decrease in the incidence of seizures. The only disadvantage is that it requires an open-skull operation.

Stereotactic Radiosurgery

Non-invasive stereotactic radiosurgery treatment of AVMs avoids the need for an open craniotomy and general anesthesia. While less effective than direct surgery in terms of eliminating and curing AVMs, it allows treatment of AVMs in deep inaccessible locations with a relatively low complication rate. Lesion obliteration occurs over a two- to three-year period. To be eligible for this treatment, the AVM must be less than 3 cm in diameter.

Endovascular AVM Embolization

In this approach, a catheter is used to place a special glue inside the AVM to produce an immediate reduction of blood flow to the AVM. This approach is usually used as an adjunct to surgery or stereotactic radiation, rather than as a primary treatment modality. Endovascular embolization makes microsurgery safer, and can also reduce the size of an AVM making it smaller and thus amenable to radiosurgery.

What is an arteriovenous fistula (AVF)?

An arteriovenous fistula is an abnormal connection of vessels in the tissues around the brain or spinal cord in which one or more arteries are directly connected to one or more veins or venous spaces called sinuses. Arteries carry blood from the heart to the tissues, and veins take blood back from the tissues to the heart.

There are two major types of AVFs: dural AVFs (DAVF) and carotid-cavernous fistulas (CCFs).

In a DAVF, there is a direct connection between one or more arteries and veins or sinuses which gives rise to many problems. DAVFs differ from arteriovenous malformations (AVMs) in that AVMs are found within the tissue of the brain or spinal cord, but DAVFs are found in the coverings of the brain or spinal cord, such as the dura mater or arachnoid. The most serious problem associated with DAVFs is that they transfer high-pressure arterial blood into the veins or venous sinuses that drain blood from the brain or spinal cord. This results in an increase in the pressure of the venous system around the brain or spinal cord.

Treatment of arteriovenous fistula (DAVF)

Minimally invasive endovascular embolization

Typically sufficient to cure the majority of DAVFs. During this procedure, we pass a catheter through the groin up into the arteries in the brain that lead to the DAVF and inject liquid embolic agents such as NBCA, glue or Onyx into these arteries. This injection shuts off that artery and reduces the flow of blood through the DAVF.

Microsurgical resection

Reserved for DAVFs that cannot be closed with endovascular embolization. During microsurgical resection, we perform a craniotomy and using the microscope isolate the DAVF from the tissues around the brain or spinal cord

CCF

Carotid-cavernous sinus fistula is an abnormal communication between the internal or external carotid arteries and the cavernous sinus. These lesions may be classified based on the following: etiology (traumatic vs spontaneous), velocity of blood flow (high vs low), and anatomy (direct vs dural, or internal carotid vs external carotid).

Nearly all patients with a direct carotid-cavernous sinus fistula experience progressive ocular complications if the fistula is left untreated. Increasing proptosis, conjunctival chemosis, and visual loss occur over months to years, with central retinal vein occlusion and secondary glaucoma representing the most severe ocular complications.

Treatment

Endovascular management

Detachable balloon occlusion
Coil and material embolization:

Transarterial embolization with coils or other embolic material now is the mainstay of endovascular treatment for high-flow direct CCFs, given the limited availability of detachable balloons. Embolization can be achieved with detachable platinum coils, silk and liquid embolic agents such as n-butyl cyanoacrylate (n-BCA), and ethylene-vinyl alcohol copolymer (EVOH). Transvenous coil embolisation can be done in certain types of CCF

Covered stent graft placement:

Recent advances in endovascular techniques such as placement of polyfluorotetraethylene-covered stents have created alternatives to ICA sacrifice in traumatic arterial damage, especially in the setting of an unsuccessful balloon test occlusion study. Covered stent grafts can be extremely useful for the immediate obliteration of a direct CCF, while preserving ICA patency

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