Percutaneous stereotactic radiofrequency rhizotomy (PSR) for trigeminal neuralgia most commonly utilizes 2D fluoroscopy for intraoperative needle guidance into the foramen ovale (FO). We describe two cases in which needle advancement into FO was unachievable despite appropriate needle placement on biplane fluoroscopy. Intraoperative multiplanar reconstruction was helpful in more accurately depicting foraminal anatomy which allowed the manipulation of the tip of the needle, which was followed by successful FO cannulation. We propose that this “mirage” is likely created by the inherent nature of X-ray-based fluoroscopy in which the FO appears to be readily penetrable, when in fact the 3D anatomy actually prevents cannulation.

Cervical spine instrumentation carries a risk of vertebral artery injury which can cause devastating neurological events. Flow diversion using the Pipeline embolization device (PED) is a commonly used endovascular modality that can treat various vessel wall abnormalities including aneurysms and arterial dissections.We report the case of a 69-year-old female who presented with multiple cryptogenic strokes secondary to a vertebral artery irregularity from a misplaced pedicle screw. She continued h...

Vertebral arteriovenous fistulas (VAVFs) are uncommon high-flow communications between a vertebral artery and surrounding venous plexus that occur spontaneously or secondary to trauma. A woman aged 57 years presented with a multiday history of rapidly progressive numbness and weakness in the left C5-C6 dermomyotomes. Her physical examination findings and subsequent electrophysiological testing were suggestive of a brachial radiculoplexopathy. Noninvasive imaging demonstrated venous congestion with multilevel compromise of the left-sided cervical foramina, and subsequent vertebral angiography confirmed a VAVF, which was treated with trapping of the involved vertebral artery segment. Her numbness and weakness progressively improved with concurrent involution of the dilated veins. This is a rare case of VAVF manifesting as a brachial radiculoplexopathy. Although rare, VAVF may be considered as a potential cause in patients presenting with similar symptoms.

The α-smooth muscle actin isotype 2 (ACTA2) mutation has been associated with prominent vascular and brain parenchymal changes that increase the risk of acute ischemic stroke. Other smooth muscle cell (SMC) genetic mutations such as MYH11, have been associated with familial thoracic aortic aneurysm dissection and patent ductus arteriosus (PDA).2 We present a case of a 12-year-old girl with a MYH11 mutation who exhibited a phenotype characteristic of ACTA2 arteriopathy and presented with acute is...