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Middle meningeal arteriovenous fistula (MMAVF) is typically post-traumatic or iatrogenic in origin, but it can have an idiopathic origin in rare cases. Here, we report a case of idiopathic MMAVF complicated by segmental arterial mediolysis (SAM). Case Presentation:The patient was a 63-year-old woman admitted to our hospital with symptoms of right pulsating tinnitus for the past 2 months. She had no significant medical history. MRI and DSA revealed a right MMAVF. Selective embolization using coils was performed. Seven years later, when she underwent laparotomy for intestinal perforation, multiple aneurysms were found in the abdominal cavity. Left hemicolectomy was performed, and an aneurysm of the gastroepiploic artery was resected. Based on a pathological examination of the aneurysm, the patient was diagnosed with SAM. Coil embolization was performed to prevent rupture. Conclusion:This case report shows that MMAVF may be associated with SAM. Fistula embolization with coils is an effective treatment of MMAVF associated with SAM. Therefore, it is important to check for systemic diseases, such as SAM when idiopathic MMAVF is detected.Keywords▶ middle meningeal arteriovenous fistulas, segmental arterial mediolysis, endovascular treatment

We report the improvement of pain and activities of daily living in five patients who received botulinum toxin therapy with echo guidance for spasticity that developed as an aftereffect of cerebral infarction since November 2011. The medicine was injected into the pectoralis major, flexor digitorum superficialis, flexor digitorum profundus, flexor pollicis longus of the upper extremities, extensor halluces longus, and posterior tibial muscles, as well as the medial and lateral heads of the gastrocnemius muscle in the lower extremities. Use of echo guidance in botox therapy allows identification of the spastic muscle to be targeted and assessment of the direction and depth of injection. This method also allows identification of surrounding nerves and blood vessels, which permits an approach to the target muscle without damage to nerves and blood vessels.

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