Vascular Involvement in Neurosarcoidosis

Background and ObjectivesCerebrovascular manifestations in neurosarcoidosis (NS) were previously considered rare but are being increasingly recognized. We report our preliminary experience in patients with NS who underwent high-resolution vessel wall imaging (VWI).MethodsA total of 13 consecutive patients with NS underwent VWI. Images were analyzed by 2 neuroradiologists in consensus. The assessment included segment-wise evaluation of larger- and medium-sized vessels (internal carotid artery, M1-M3 middle cerebral artery; A1-A3 anterior cerebral artery; V4 segments of vertebral arteries; basilar artery; and P1-P3 posterior cerebral artery), lenticulostriate perforator vessels, and medullary and deep cerebral veins. Cortical veins were not assessed due to flow-related artifacts. Brain biopsy findings were available in 6 cases and were also reviewed.ResultsMean patient age was 54.9 years (33–71 years) with an M:F of 8:5. Mean duration between initial diagnosis and VWI study was 18 months. Overall, 9/13 (69%) patients had vascular abnormalities. Circumferential large vessel enhancement was seen in 3/13 (23%) patients, whereas perforator vessel involvement was seen in 6/13 (46%) patients. Medullary and deep vein involvement was also seen in 6/13 patients. In addition, 7/13 (54%) patients had microhemorrhages in susceptibility-weighted imaging, and 4/13 (31%) had chronic infarcts. On biopsy, 5/6 cases showed perivascular granulomas with vessel wall involvement in all 5 cases.DiscussionOur preliminary findings suggest that involvement of intracranial vascular structures may be a common finding in patients with NS and should be routinely looked for. These findings appear concordant with previously reported autopsy literature and need to be validated on a larger scale.

Peroneal perforator pedicle propeller flap for lower leg soft tissue defect reconstruction: Clinical applications and treatment of venous congestion

Objective To describe the characteristics of the perforator vessel in the peroneal artery of the lower leg and to explore the use of perforator pedicle propeller flaps to repair soft tissue defects in the lower leg, heel and foot. Methods This retrospective study enrolled patients with soft tissue defects of the distal lower leg, heel and foot who underwent surgery using peroneal perforator-based propeller flaps. The peroneal artery perforators were identified preoperatively by colour duplex Doppler ultrasound. The flap was designed based on the preoperatively-identified perforator location, with the posterior border of the fibula employed as an axis, and the perforator vessel as the pivot point of rotation. Patients were followed-up to determine the outcomes. Results The study analysed 36 patients (mean age, 39.7 years). The majority of the soft tissue defects were on the heel (20; 55.6%). The donor-site of the flap was closed in 11 patients by direct suturing and skin grafting was undertaken in 25 patients. Postoperative complications included venous congestion (nine patients), which was managed with delayed wound coverage and bleeding therapy. All wounds were eventually cured and the flaps were cosmetically acceptable. Conclusions The peroneal perforator pedicle propeller flap is an appropriate choice to repair soft tissue defects of the distal limbs.

Ophthalmic artery occlusion after Pipeline Embolization Device placement with reconstitution of flow via an endoleak: a report of two cases

The Pipeline Embolization Device (PED) is a flow diverting stent used in the treatment of a wide variety of intracranial aneurysms. The device differs from traditional stents used in stent-assisted coil embolization in that it has a tighter lattice structure with smaller cell sizes designed specifically to disrupt blood flow into aneurysms rather than only to retain coils within aneurysms. While the PED has been shown to be safe and effective, it has a unique risk profile that includes side branch and perforator vessel occlusion. Side branch occlusion in particular has been noted in several articles to occur at a relatively high rate with coverage of the ophthalmic artery origin by the PED. In this series, we present two cases of ophthalmic artery occlusion after PED placement with reconstitution of flow via an endoleak.

Use of a Yaşargil Mirror as an Adjunct to Indocyanine Green Angiography to Evaluate the Patency of Elusive Posterior Communicating Arteries During Aneurysm Clipping

BACKGROUND AND IMPORTANCE: Indocyanine green angiography (ICGA) has become a useful intraoperative tool during aneurysm surgery to determine parent, branching, and perforator vessel patency. Although extremely useful, ICGA is limited to the evaluation of vessels that are in direct view in the surgical field. CLINICAL PRESENTATION: We present 2 cases of patients who underwent a craniotomy for clipping of unruptured posterior communicating artery aneurysms. A Yaşargil movable mirror was used as an adjuvant to ICGA to visualize the ventromedial posterior communicating vessels after clip placement to determine vessel patency. CONCLUSION: Although ICGA can be very useful during aneurysm surgery, it is limited to vessels directly visualized in the surgical field. A Yaşargil movable mirror can be used during ICGA to visualize elusive vessels, in these cases on the ventromedial surface of the internal carotid artery.