Venous aneurysm development associated with a dural arteriovenous fistula of the anterior cranial fossa with devastating hemorrhage--case report

A 67-year-old man presented with devastating intracranial hemorrhage (ICH) from an anterior cranial fossa dural arteriovenous fistula (DAVF). Four years earlier, digital subtraction angiography had disclosed a DAVF at the right anterior cranial fossa fed mainly by the ethmoidal branches of the bilateral sphenopalatine arteries and slightly by the ethmoidal arteries of the bilateral ophthalmic arteries, and drained primarily by the sphenoparietal and cavernous sinuses via two dilated cortical veins and slightly by the superior sagittal sinus via a frontal ascending vein. Three-dimensional computed tomography angiography revealed the development of a venous aneurysm on the main draining vein over a 4-year period, but no other changes. Venous aneurysm development may be part of the natural history of DAVF with cortical venous drainage and may contribute to the occurrence of ICH.     

Intraosseous dural arteriovenous fistula of the skull base associated with hearing loss. Case report

The most common clinical presentations of dural arteriovenous fistulas (DAVFs) are bruit, headache, increased intracranial pressure, and intracranial hemorrhage. In particular locations, such as the cavernous sinus or middle cranial fossa, cranial nerve involvement due to dural arterial steal or venous occlusion may develop. A case in which a DAVF is associated with hearing loss, however, has not previously been reported. The authors report a case in which an intraosseous DAVF and associated hearing loss probably resulted from cochlear nerve or vascular compression caused by the draining vein or nidus of the DAVF.     

Dural arteriovenous fistula of the anterior cranial fossa associated with a ruptured ophthalmic aneurysm: case report and review of the literature

BACKGROUND: Dural arteriovenous fistula (DAVF) accompanied by intracranial aneurysms is an extremely rare situation. CASE DESCRIPTION: A 65-year-old man presented with sudden loss of consciousness for about half an hour. Computed tomographic scan of the brain showed subarachnoid hemorrhage. Angiogram revealed an ophthalmic aneurysm. In addition, a DAVF located in the anterior cranial fossa was also found. The ruptured aneurysm was completely occluded by coil embolization and the DAVF of the anterior cranial fossa was treated with gamma knife radiosurgery after an uneventful postoperative course. The patient was managed nonoperatively and discharged with close follow-up. CONCLUSION: An unusual case of anterior cranial fossa DAVF associated with a ruptured ophthalmic aneurysm is reported. We feel special consideration may be required in deciding the priority of treatment in such cases.     

Dural arteriovenous fistulae in the anterior cranial fossa--report of three cases

Dural arteriovenous fistulae (DAVF's) in the anterior cranial fossa are uncommon. We encountered three patients with DAVF's in the anterior cranial fossa and reviewed the pertinent literature with regard to the etiology. All patients are middle-aged males. Two of three patients had massive intracranial hemorrhage, subarachnoidal hemorrhage in one and subdural hemorrhage in the other. One patient had a ruptured middle cerebral artery aneurysm and DAVF at the anterior cranial fossa was detected only incidentally. Angiographically, blood supplies were from the bilateral enlarged anterior ethmoidal arteries. These drained into the superior sagittal sinus via dilated frontal cortical veins. In all the patients, coagulation of the fistulous connections was carried out and the postoperative courses were uneventful. Angiographies revealed complete disappearance of the DAVF's. In conclusion, compared to cases of DAVF's in the other locations, DAVF's of the anterior cranial fossa are more likely to be brought on by sudden massive intracranial hemorrhage, and should be treated, even if asymptomatic, at the time of diagnosis. Surgical obliteration of the fistulous connection is sufficient treatment for DAVF in the anterior cranial fossa. Literature review strongly suggests that DAVF's involving the anterior cranial fossa are acquired lesions.     

Intracranial dural arteriovenous fistula presenting as an enhancing lesion of the medulla

A case of atypical clinical and imaging manifestations of an intracranial dural arteriovenous fistula (DAVF) is reported. A 53-year-old man presented with orthostatic syncope and tingling of the fingertips of both hands, and the initial imaging findings were interpreted as brainstem mass. A catheter angiogram confirmed the presence of an intracranial DAVF with venous drainage around the brainstem and spinal cord. The lesion was treated by endovascular embolization and the patient remains asymptomatic 9 months after treatment.     

A sudden C3-C4 tetraplegia revealing an intracranial dural arteriovenous draining into the spinal medullary veins

We report a case of intracranial dural arteriovenous (DAVF) draining into the spinal medullary veins. A 49-year-old woman presented a rapidly progressive ascending myelopathy resulting in a C3-C4 tetraplegia associated with acute respiratory failure at the twelfth hour. MRI revealed swelling of the cervical spinal cord, hyperintensity on T2 and enhancement of enlarged veins on MR angiography. A conventional angiography showed the DAVF with venous drainage into the spinal vein extending to the conus medullaris. After embolization, neurological recovery occurred during the first week, allowing tracheal extubation on day 2. Clinical, radiological and therapeutic aspects of this uncommon pathology are presented.     

Frontal sinus fractures: management guidelines

Management of frontal sinus fractures (FSF) has been the subject of great debate for more than six decades. Multiple treatment options and algorithms have been proposed by multiple specialties throughout the years; however, the optimal method of frontal sinus repair has yet to be elucidated. Because of the location of the frontal sinus and its proximity to numerous intracranial structures, inadequate treatment may lead to life-threatening intracranial infectious complications. Meningitis, encephalitis, and brain abscess are the most common intracranial complications. Other complications include persistent cerebrospinal leakage, mucopyoceles, frontal osteomyelitis, meningoencephalocele, and nonunion of the frontal bone. Orbital involvement may result in ophthalmoplegia, orbital abscess, diplopia, enophthalmos, proptosis, preseptal cellulitis, and partial or complete loss of vision. Morbidity and mortality are often dependent on the anatomic characteristics of the fracture, concomitant injuries, treatments rendered, age, gender, and mechanism of injury. Management of frontal sinus fractures is so controversial that the indications, timing, method of repair, and surveillance remain disputable among several surgical specialties. The most important tenet of frontal sinus fracture management remains the same: create a safe sinus. This is accomplished by following four basic principles: reestablish the frontal bony contour to its premorbid state, restore normal sinus mucosa with a patent drainage system if possible, eradicate the sinus cavity if the normal mucosa or drainage system cannot be reestablished, and create a permanent barrier between the intracranial and extracranial systems to prevent overwhelming infectious complications. By following these four basic principles, frontal sinus fracture management will be safe and effective as long as extended surveillance is part of the protocol.     

Dural arteriovenous fistulas supplied by ethmoidal arteries

Eight patients with dural arteriovenous fistulas (DAVFs) located on the floor of the anterior cranial fossa and supplied by enlarged ethmoidal branches of the ophthalmic artery are described. Five patients showed the classical symptom of intracerebral hemorrhage (all five had ipsilateral frontal lobe hematomas and one also had an associated a subdural hematoma). Two patients exhibited atypical symptoms of proptosis, chemosis, elevated intraocular pressure, and loss of vision secondary to an ethmoidal DAVF, which drained posteriorly to the cavernous sinus. The eighth patient exhibited proptosis and chemosis secondary to a cavernous sinus DAVF and was incidentally found to have an asymptomatic ethmoidal DAVF. One additional patient had two separate dural fistulas: one located on the cribriform plate and the second located in the posterior fossa. Seven of the eight patients were cured by surgical excision of the fistula site; in the remaining patient spontaneous obliteration followed a surgical procedure for a cavernous DAVF. DAVFs involving the floor of the anterior cranial fossa usually present with hemorrhage, but can present with ocular symptoms or be entirely asymptomatic and are effectively treated by surgical excision of the fistula site.     

Sinus pericranii: radiological and etiopathological considerations. Case report.

Sinus pericranii is a rare vascular anomaly involving an abnormal communication between the extracranial and intracranial circulations. A case of frontal sinus pericranii is presented which appeared to be a posttraumatic sinus because it developed 2 years after a cranial injury. However, the presence of vascular endothelium in the pathological examination and its association with a vascular anomaly (persistent trigeminal artery) suggested a congenital origin. The lesion, pericranial blood sinuses, and bone were totally removed. The computerized tomography, angiography, and magnetic resonance imaging findings are presented. The literature is reviewed and the pathogenesis of sinus pericranii is discussed.     

A case of traumatic sinus pericranii

Sinus pericranii is a rare vascular anomaly involving an abnormal communication between the extracranial and intracranial circulations. A 33-year-old woman presented with a soft tissue mass at the left frontal region. It was associated with head trauma when she was 12-year-old. The mass had gradually grown and become painful for 20 years. She underwent surgical resection of the mass successfully. This report discusses traumatic sinus pericranii.     

Borden-Shucart Type I dural arteriovenous fistulas: clinical course including risk of conversion to higher-grade fistulas

Object The goal of this study was to determine the clinical course of Borden-Shucart Type I cranial dural arteriovenous fistulas (DAVFs) and to calculate the annual rate of conversion of these lesions to more aggressive fistulas that have cortical venous drainage (CVD). Methods A retrospective chart review was conducted of all patients harboring DAVFs who were seen at the authors' institution between 1997 and 2009. Twenty-three patients with Type I DAVFs who had available clinical follow-up were identified. Angiographic and clinical data from these patients were reviewed. Neurological outcome and status of presenting symptoms were assessed during long-term follow-up. Results Of the 23 patients, 13 underwent endovascular treatment for intolerable tinnitus or ophthalmological symptoms, and 10 did not undergo treatment. Three untreated patients died of unrelated causes. In those who were treated, complete DAVF obliteration was achieved in 4 patients, and palliative reduction in DAVF flow was achieved in 9 patients. Of the 19 patients without radiographic cure, no patient developed intracranial hemorrhage or nonhemorrhagic neurological deficits (NHNDs), and no patient died of DAVF-related causes over a mean follow-up of 5.6 years. One patient experienced a spontaneous, asymptomatic obliteration of a partially treated DAVF in late follow-up, and 2 patients experienced a symptomatic conversion of their DAVF to a higher-grade fistula with CVD in late follow-up. The annual rate of conversion to a higher-grade DAVF based on Kaplan-Meier cumulative event-free survival analysis was 1.0%. The annual rate of intracranial hemorrhage, NHND, and DAVF-related death was 0.0%. Conclusions A small number of Type I DAVFs will convert to more aggressive DAVFs with CVD over time. This conversion to a higher-grade DAVF is typically heralded by a change in patient symptoms. Follow-up vascular imaging is important, particularly in the setting of recurrent or new symptoms.     

Incidence of intracranial injury in orbital wall fracture patients not classified as traumatic brain injury

ObjectiveThe detection of intracranial injury in patients with facial injury rather than traumatic brain injury (TBI) remains a challenge for emergency physicians. This study aimed to evaluate the incidence and risk factors of intracranial injury in patients with orbital wall fracture (OWF), who were classified with a chief complaint of facial injury rather than TBI.MethodsThis retrospective case-control study enrolled adult OWF patients (age ≥18 years) who presented at the hospital between January 2004 and March 2016. Patients with definite TBI were excluded because non-contrast head computed tomography (CT) is recommended for such patients.ResultsA total of 1220 patients with OWF were finally enrolled. CT of the head was performed on 677 patients, and the incidence of concomitant intracranial injury was found to be 9% (62/677). Patients with definite TBI were excluded. Symptoms raising a suspicion of TBI, such as loss of consciousness, alcohol intoxication, or vomiting, were present in 347 of the patients, with 44 of these patients (13%) showing a concomitant intracranial injury. Of the 330 patients without such symptoms, 18 (6%) demonstrated a concomitant intracranial injury. In OWF patients, superior wall fracture (odds ratio [OR], 4.15; 95% confidence interval [CI], 2.06–8.34; P < 0.001), associated frontal bone fracture (OR, 4.38; 95% CI, 2.08–9.23; P < 0.001), and older age (decades) (OR, 1.03; 95% CI, 1.01–1.04; P = 0.002) were independent risk factors for concomitant intracranial injury.ConclusionsEmergency physicians should maintain a high degree of suspicion of TBI, even when their primary concern is facial trauma with OWF. Head CT is recommended for OWF patients with a superior OWF, frontal bone fracture, or increased age.     

Dural arteriovenous fistula of the sphenobasilar sinus with concomitant meningioma: case report and review of the literature

Dural arteriovenous fistula of the sphenobasilar sinus is a true but rare lesion that connects the meningeal arteries from both the external and internal carotid arteries to the superficial middle cerebral vein (SMCV) and dural sinus. It must be distinguished from other dural arteriovenous fistulas (DAVFs) of the middle cranial fossa, such as cavernous DAVFs and sphenoparietal sinus DAVF, because of differences in the treatment and outcome between these DAVFs. Two patients with sphenobasilar sinus DAVFs reported in the literature have been identified, but they did not simultaneously harbor intracranial meningiomas. To the best of the authors’ knowledge, the patient described here is the first case that concomitantly harbors a sphenobasilar sinus DAVF and intracranial meningioma. A 42-year-old man presented with acute subarachnoid hemorrhage. Angiography demonstrated a DAVF of the sphenobasilar sinus with a giant venous aneurysm of the SMCV. After transarterial embolization, the fistula was successfully obliterated and the giant venous aneurysm was resected microsurgically. A fortuitous small meningioma at the anterior clinoid was found and removed during the operation. The patient recovered excellently and resumed his normal activities. The relevant literature is reviewed and discussed.     

Intracranial hemorrhage associated with injury of the critical diploic venous system in clipping for unruptured cerebral aneurysm: a case report

A case of intracranial hemorrhage associated with injury of a critical diploic venous system in clipping for an unruptured cerebral aneurysm was reported. A 67-year-old female presented with a sense of floating. Magnetic resonance angiography (MRA) showed a C1-2 portion aneurysm of the left internal carotid artery 13 mm in size projecting supero-laterally. Three-dimensional CT angiography (3DCTA) volume rendering revealed a developed left fronto-anterior temporal diploic venous system draining the frontal cortical venous return. Because of the large and wide-necked aneurysm, we planned clipping surgery for the purpose of a complete cure. The operation was performed with left fronto-temporal craniotomy at the expense of the diploic venous system. Using techniques such as bipolar coagulation and suction decompression, neck clipping was accomplished via the distal trans-sylvian approach. After the operation, the patient was noticed to be delirious, and post-operative CT demonstrated intracranial hemorrhage in the left frontal lobe with severe brain edema. Motor aphasia was remarkable, but it was gradually relieved, and she left our hospital with no motor weakness. 3 months after the operation, her aphasia was faintly perceptible but she could live independently. We concluded that the injury of a diploic venous system could cause intracranial hemorrhage with intractable brain edema by critically interrupting the frontal venous return.     

A case of multiple dural arteriovenous fistulas treated by multiple modalities

The authors report a rare case of multiple intracranial dural arteriovenous fistulas (DAVF) at separate sinuses. A 70-year-old man was introduced to our hospital complaining of visual disturbance due to bilateral choked disk, headache, and tinnitus. Initial angiography showed DAVFs involving the superior sagittal sinus and bilateral transverse-sigmoid sinuses, and the occlusion of the right jugular vein. The patient developed progressive impairment of visual activity and had high intracranial pressure (ICP) caused by venous hypertension. No cerebral alteration was seen on magnetic resonance imaging. To decrease the high ICP, surgical sinus isolation of the superior sagittal sinus was performed. After the surgery, transvenous embolization was performed to the right transverse-sigmoid sinus DAVF. Headache and tinnitus improved after these treatments, but visual activities rapidly declined and he experienced blindness in just a few months. Gamma knife radiosurgery was performed to the residual DAVFs. We discussed the etiology and treatment of the multiple DAVF, and reviewed past literatures.     

Ruptured dural arteriovenous fistula and sinus venous thrombosis following surgical resection of a vestibular schwannoma: Case report and review of the literature

Dural arteriovenous fistula (DAVF) is a rare vascular malformation. Strong evidence suggests that the development of DAVF in adults is acquired and multifactorial.The link between cerebral venous thrombosis and DAVF is probably explained by dynamic changes in the venous drainage pattern.We report the case of a 34-year-old man admitted to the emergency department for seizure and headaches. The patient had a medical history of right vestibular schwannoma resection 9 months earlier, complicated by untreated asymptomatic sigmoid sinus thrombosis.At admission, CT scan revealed a spontaneous temporal intracerebral hemorrhage associated with ventricular hemorrhage due to the rupture of a DAVF diagnosed by complementary CT angiography.External ventricular drainage was performed in emergency, followed by endovascular exclusion of the DAVF. Good neurological outcome was achieved, with complete exclusion of the vascular malformation.This clinical case underlines the absence of guidelines on the use of anticoagulation drugs to treat postoperative venous sinus thrombosis and to potentially prevent DAVF as a late complication following cerebellopontine angle surgery.     

Treatment of cranium bifidum occultum of the frontonasal region with a pericranial flap

Cranium bifidum is a congenital anomaly caused by abnormal development of the cephalic neural tube. We report two cases of cranium bifidum occultum with defects of both the frontal bone and anterior cranial base accompanied by infection and enlargement of frontonasal dermoid cysts. Surgery successfully interrupted the communication between the intracranial space and nasal cavity by inserting a pericranial flap after removal of the dermoid cysts.     

Venous Cerebral Infarction due to Simultaneous Occurrence of Dural Arteriovenous Fistula and Developmental Venous Anomaly

Summary  A case of a left frontal lobe infarction in a 31-year-old male patient is presented. This patient had bilateral frontal dural arteriovenous fistulae (DAVF) and a left frontal developmental venous anomaly (DVA). It is suggested that the simultaneous occurrence of these vascular anomalies was the cause of his infarction.     

Development of a complex dural arteriovenous fistula next to a cerebellar developmental venous anomaly after resection of a brainstem cavernoma. Case report and review of the literature

Developmental venous anomalies (DVAs) are common abnormalities of intracranial venous drainage, which may occur in conjunction with other cerebral vascular malformations and are known for their benign natural history. The authors present the case of a 16-year-old boy who experienced a spontaneous brainstem hemorrhage due to a cavernoma. Preoperative angiography findings revealed a large DVA draining the right cerebellar hemisphere. The patient underwent suboccipital surgery for cavernoma resection and recovered completely from his neurological symptoms. Fourteen months later he returned with progressive symptoms. Repeated angiography demonstrated a complex dural arteriovenous fistula (DAVF) of the transverse sinus, which had developed next to the DVA. Several transarterial and transvenous embolizations were ineffective. Common causes of acquired DAVFs and the potential role of the DVA in the development of the DAVF in this case are discussed on the basis of the pertinent literature.     

Craniofacial resection for intracranial inverting papilloma and frontal sinus mucocele

Inverting papilloma is a locally aggressive neoplasm; however, intracranial extension is very rare. The authors herein report a case of massive inverting papilloma with intracranial extension and an associated frontal sinus mucocele, causing marked frontal lobe compression. Treatment consisted of combined anterior craniofacial resection. Magnetic resonance imaging provided accurate preoperative differentiation between neoplasm and inflammation. Skull base reconstruction may prove more difficult when there is significant frontal dead space resulting from chronic brain displacement by an associated mucocele. The management of this unusual neoplasm and a review of the literature is presented.