Thursday, November 19, 2015

Weird case: previously healthy guy comes in with an IPH. We do the angio and find... 

1. No sagittal sinus 2.dAVF at vertex 3.dAVF at torcula 


arterial supply of vertex dAVF from R ECA from STA and MMA 

arterial phase of RECA -- red: STA, blue: MMA, green: IMax 

Correction, with supply from bilateral ECA... 

selective cannualtion of L occipital artery (off ECA) dilated, supplying torcular dAVF


Also gets supply from the vert... argh.. from what looks like posterior meningeal and PICA

this is what the posterior meningeal artery is supposed to look like (from neuroangio.org, in red) 



Mystery vessel in red... what is it?? its not the Pcomm for 2 reasons 1. Pcomm is actually hidden behind the blue arrow vessel, which is probably an MCA branch. 2. this vessel goes along tent towards the torcular dAVF.
It's actually an MCA branch going towards the posterior brain, it looks like its coming from the dorsal ICA but its not. The MHT is highlighted in green arrows - there are two trunks coming off here, normally there is one. They appear gigantic because they are supplying the dAVF. If we cut off blood flow to the torcular AVF without obliterating the venous pouch (and we can't, because in this case the venous pouch is the torcula and its draining normal brain still via straight sinus), these MHT vessels will get recruited and start supplying.
The ILT isn't visible on this cut but it typically comes off anterior.

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