A Dural Arteriovenous Fistula of the Anterior Cranial Fossa Angiographically Mimicking an Anterior Ethmoidal Artery Aneurysm

Venous aneurysm or varix at the venous side of the fistula commonly exist in dural arteriovenous fistula (DAVF) of the anterior cranial fossa, which may be initially mistaken with aneurysm on computed tomography and magnetic resonance imaging, but always identified by angiography. We report a very unusual case of anterior cranial fossa DAVF angiographically mimicking an anterior ethmoidal artery aneurysm, which was ultimately corrected by surgery. A 41‐year‐old male presented with right frontal intraparenchymal hematoma with intraventricular extension. Angiography revealed a vascular lesion adjacent to the anterior fossa mimicking an anterior ethmoidal artery aneurysm, which was surgically proven to be a partially thrombosed venous varix of drainaging vein originated from the cribriform plate. A diagnosis of anterior cranial fossa DAVF was made, and venous varix was excised. Follow‐up angiography after the operation revealed complete disappearance of the lesion. Our case illustrates a unique occasion that a proximal venous varix without obvious outflow angiographically in DAVF might be mistaken with an aneurysm.     

颅前窝底硬脑膜动静脉瘘的影像学分析及治疗策略

目的探讨颅前窝底硬脑膜动静脉瘘的影像学特点,并根据其而采取不同治疗方式。方法回顾性分析13例颅前窝底硬脑膜动静脉瘘病人的临床资料,病变均通过双侧眼动脉或筛前动脉供血,其中脑膜中动脉前支也参与供血7例。采用开颅手术9例,血管内治疗4例。并分析影像学特征对选择治疗方式的影响。结果术后DSA复查示所有病人的动静脉瘘均消失,均无手术并发症,术后症状逐渐好转。术后1年,DSA复查7例,均未复发。结论开颅手术治疗颅前窝底硬脑膜动静脉瘘是安全、有效的方法,对明确有硬脑膜中动脉前支供血的病变,也可行介入栓塞治疗。     

A Case of Pial Arteriovenous Fistula with Giant Venous Aneurysm and Multiple Varices Treated with Coil Embolization

Intracranial pial arteriovenous fistulas (AVFs) are rare vascular lesions of the brain. These lesions consist of one or more arterial connection to a single venous channel without true intervening nidus. A 24-year-old woman visited to our hospital because of headache, vomiting, dizziness and memory disturbance that persisted for three days. She complained several times of drop attack because of sudden weakness on both leg. Cerebral angiograms demonstrated a giant venous aneurysm on right frontal lobe beyond the genu of corpus callosum, multiple varices on both frontal lobes fed by azygos anterior cerebral artery, and markedly dilated draining vein into superior sagittal sinus, suggesting single channel pial AVF with multiple varices. Transarterial coil embolization of giant aneurysm and fistulous portion resulted in complete disappearance of pial AVF without complication.     

Dural arteriovenous fistula of the transverse sigmoid sinus after transvenous embolization of the carotid cavernous fistula]

We report a case of dural arteriovenous fistula of the transverse-sigmoid sinus after transvenous embolization of the carotid cavernous fistula. A 72-year-old woman presented with left exophthalmos, chemosis, bruit and left abducens nerve palsy in June 1996. Bilateral external and internal carotid angiograms revealed the dural arteriovenous fistula of the cavernous sinus. We embolized the dural arteriovenous fistula using a transvenous approach via the left inferior petrosal sinus. Angiograms demonstrated the complete disappearance of the dural arteriovenous fistula. Two years and six months later, she complained of tinnitus at the retroauricular region. Left external carotid angiograms showed a dural arteriovenous fistula of the transverse-sigmoid sinus fed by occipital, posterior auricular, middle meningeal and superficial temporal arteries. We embolized the dural arteriovenous fistula using a transarterial approach. Her symptoms disappeared but the dural arteriovenous fistula did not disappear completely. We discussed the clinical features and etiology of this case.     

Arteriovenous fistula originating from proximal part of the anterior cerebral artery

Intracerebral arteriovenous fistulas of the brain may be misdiagnosed as arteriovenous malformation. There are only a few reports in the literature about this concept and to the best of our knowledge this is the first case arising from the proximal part of the anterior cerebral artery in association with an aneurysm that ruptured. A 64-year-old man presented with subarachnoid hemorrhage. The patient was neurologically intact. Cerebral angiography and magnetic resonance imaging of the patient revealed a small arteriovenous malformation of the brain involving the region of gyrus rectus and the posteromedial aspect of the orbitofrontal gyrus in addition to an aneurysmal dilatation within the malformation. An arteriovenous fistula arising from the junction of the A1 and A2 segments of the right anterior cerebral artery connected to a vein that has tributaries spreading over the fronto-orbital gyrus and gyrus rectus, were observed during surgery. The patient was successfully treated with clip ligatation of the fistula. Intracerebral arteriovenous fistulas are rare lesions. They may easily be misdiagnosed as arteriovenous malformations. There preoperative consideration in the differential diagnosis can help to decide the most appropriate treatment option.     

硬脑膜动-静脉瘘合并髓静脉扩张的临床及影像学表现(附1例报告及文献复习)

目的报道1例硬脑膜动-静脉瘘(DAVF)合并髓静脉扩张病例的临床资料,探讨DAVF合并髓静脉扩张的临床及影像学表现。方法回顾性收集1例DAVF合并髓静脉扩张患者的临床及影像学资料,并结合文献复习进行分析。结果患者以症状性癫痫起病。头颅MRI表现为脑白质内迂曲、扩张血管影,并继发性脑梗死和脑水肿;全脑数字减影血管造影(DSA)提示右侧颈内动脉造影静脉期上矢状窦前1/3不显影,静脉晚期颅内多发髓静脉迂曲增粗,经室管膜下静脉-大脑内静脉回流,右侧颈外动脉造影示DAVF形成,大脑上静脉逆向回流,左侧颈内动脉造影示左侧发育性静脉畸形。经血管内介入栓塞DAVF治疗后患者病情改善。结论DAVF合并髓静脉扩张少见,可继发脑实质病变进而出现神经功能缺损症状与体征;影像学表现为头颅MRI提示髓静脉扩张涉及的疾病谱较多,需仔细鉴别;MRI和DSA联合检查能更好评价脑实质和血管情况。     

“双血管三维影像融合”对脑血管病诊治评估的价值

目的 探讨“双血管三维影像融合”技术的影像融合方法及其在脑血管病诊断和治疗中的应用价值。方法 应用西门子Artis zee biplane双平板DSA机及其所配设备System syngo X-WP三维后处理工作站,双容积重建出数据,利用Inspace-3D3D-Fusion软件分析合并数据,显示两侧颈内动脉或一侧颈内动脉和椎动脉与血管病变的供血关系。结果 利用软件能显示双血管供血病变（如脑动静脉瘘、脑动静脉畸形等）,清晰显示血管病变与供血动脉、走向等关系,帮助诊断和指导治疗。结论 “双血管三维影像融合”对诊断脑血管病血供情况和指导治疗有较大临床价值,并且利用融合Fusion技术改进重建工作流程,因此可以大大扩展双血管融合技术的临床适应症,提高显示的准确性,是判断Willis环的结构和双血管供应的血管病变的新方法,对临床诊断、治疗有重要参考价值,对科研与教学增加了新的评估手段与直观方法。     

Intracranial arterial and arteriovenous malformations presenting with infarction. Lausanne Stroke Registry study.

Cerebral aneurysms and arteriovenous malformations (AVMs) are well-known sources of intracranial hemorrhage, but can also manifest as other clinical symptoms or remain clinically asymptomatic. The aim was to document and analyze cases of aneurysm or AVM with brain infarction. Survey on 4804 stroke patients treated at the Department of Neurology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland between 1978 and 2000 using the Lausanne Stroke Registry. Twenty patients presented with cerebral aneurysm and 21 with cerebral AVM. Hemorrhage was present in 100% of the AVM and in 75% of the aneurysm patients; in one (5%) of the remaining aneurysm patients, aneurysm and infarction were located in different territories. Infarction associated with Sylvian artery aneurysm was found in three (15%), vertebrobasilar ischemia because of fusiform left vertebral artery aneurysm in one (5%), and dural fistula draining to the distal transversal and left sigmoid sinus associated with a stroke in the territory of the left anterior inferior cerebellar artery in one patient. Ischemic stroke is infrequent, but important, complication in unruptured intracranial aneurysms and AVMs. The early recognition and therapy of these vascular malformations in selected patients can avoid a major neurological deficit or death caused by their rupture.     

De novo multiple dural arteriovenous fistulas and arteriovenous malformation after embolization of cerebral arteriovenous fistula: case report

Background

A cerebral arteriovenous fistula is a rare neurovascular abnormality. It is very scarce when presenting with other cerebral arteriovenous malformations after embolization.

Method

We reported a case primarily presenting with cerebral arteriovenous fistula. When the fistula was embolized completely, de novo multiple dural arteriovenous fistulas and a small arteriovenous malformation occurred due to the hemodynamic change after the embolization. Embolization of parts of the fistulas for the second time led to an untreatable malformation which became curable. At the third time, the remaining fistula was cured.

Results

The mechanism of the dural arteriovenous fistula and treatment strategy were discussed.

Conclusion

Venous hypertension is the main factor causing a dural arteriovenous fistula. Embolization of the fistulas step by step is recommended.     

Spontaneous regression of cerebral AVM due to thrombosis of draining vein--angiographic and MRI demonstration

Spontaneous regression of cerebral arteriovenous malformation (AVM) is rare and poorly understood phenomenon. We present a case of spontaneous complete and asymptomatic occlusion of the AVM associated with thrombosis of the draining cortical vein. The thrombosed draining cortical vein is beautifully demonstrated on magnetic resonance imaging (MRI).     

Vascular brain pathologies

Vascular pathologies of brain comprise a heterogeneous group of abnormalities such as vasculitis, dural arteriovenous malformations, carotid-cavernous fistulas, cerebral venous thrombosis, and intracerebral hemorrhage. Modern imaging techniques are increasingly unraveling these vascular lesions of the brain at a stage when many of them are still asymptomatic. This article focuses on acquired vascular pathologies of brain prevalent in tropical countries that are encountered in clinical practice.     

Superficial Temporal Artery to Anterior Cerebral Artery Hemi-bonnet Bypass Using Radial Artery Graft for Prevention of Complications after Surgical Treatment of Partially Thrombosed Large/Giant Anterior Cerebral Artery Aneurysm

Background

Partially thrombosed large/giant aneurysm of the anterior cerebral artery is still challenging because this complex aneurysm requires arterial revascularization in the deep operation field. Therefore, direct neck clipping is often impossible. We describe our experiences with extracranial-intracranial bypass as an insurance bypass prior to clipping of partially thrombosed anterior cerebral artery aneurysms, and discuss the microsurgical technique and strategy.

Delayed Dural Arteriovenous Fistula after Microvascular Decompression for Hemifacial Spasm

Dural arteriovenous fistula (AVF) is very rare, acquired lesion that may present with intracranial hemorrhage or neurological deficits. The etiology is not completely understood but dural AVF often has been associated with thrombosis of the involved dural sinuses. To our knowledge, this is the first well documented intracranial hemorrhage case caused by dural AVF following microvascular decompression for hemifacial spasm. A 49-year-old male patient had left microvascular decompression of anterior inferior cerebellar artery via retrosigmoid suboccipital craniotomy. The patient was in good condition without any residual spasm or surgery-related complications. However, after 10 months, he suffered sudden onset of amnesia and dysarthria. Computed tomography and magnetic resonance imaging revealed the presence of dural AVF around the left transverse-sigmoid sinus. The dural AVF was treated with Onyx® (ev3) embolization. At the one-year follow up visit, there were no evidence of recurrence and morbidity related to dural AVF and its treatment. This case confirms that the acquired etiology of dural AVF may be associated with retrosigmoid suboccipital craniotomy for hemifacial spasm, even though it is an extremely consequence of this procedure.     

Spontaneous thrombosis of a giant aneurysm after excision of an associated vascular malformation. Report of a case

A case of a patient with a giant aneurysm of the left middle cerebral artery and a huge arteriovenous malformation hemodynamically related is reported. Complete thrombosis of the aneurysm was observed after extirpation of the arteriovenous malformation as shown by angiography one week, six months and a year post-operatively. Reduction of the regional cerebral blood flow after extirpation of the arteriovenous malformation and the natural tendency of these giant aneurysms to partially thrombose were to be the explanation for our results.     

Dural Arteriovenous Fistula Associated With Prothrombin Gene Mutation

An association between dural arteriovenous fistula and cerebral sinus thrombosis is reported. It is clear in several cases that thrombosis precedes the development of the fistula while it is unclear that it occurs in every case. The authors report a case of a woman with sinus thrombosis and presence of prothrombin gene mutation who subsequently developed a large dural arteriovenous fistula. Various possible factors involved in the pathogenesis of a dural fistula are discussed, with emphasis on underlying thrombophilia and oral contraceptive use in this patient.     

A rare brainstem hemorrhage during transvenous embolization of a cavernous dural arteriovenous fistula

Intravascular treatment of cavernous dural arteriovenous fistula (dAVF) is usually safe and effective. However, we describe a patient with a rare brainstem hemorrhage during transvenous embolization (TVE). A 79-year-old woman suffered from left chemosis and diplopia. Cerebral angiography revealed a left cavernous dAVF with cortical venous drainage. The patient underwent TVE of the cavernous sinus (CS) via the left inferior petrosal sinus. Superior petrosal sinus (SPS) outflow occlusion was performed to avoid venous congestion, followed by superficial middle cerebral vein outflow occlusion, selective shunt occlusion of the middle meningeal artery, and superior orbital vein outflow occlusion. The patient's condition suddenly deteriorated during CS packing. A CT scan revealed a massive brainstem hemorrhage. Cerebral angiography did not show SPS reopening or redistributed drainage to the posterior fossa. Thus, TVE for cavernous dAVF can result in life-threatening vascular complications. Well-planned treatment strategies could avert this rare complication.     

Agenesis of the left internal carotid artery associated with anterior communicating artery aneurysm: case report

We present a rare case of agenesis of the left internal carotid artery in a 43-year old woman, associated with an aneurysm of the anterior communicating artery and presenting with subarachnoid hemorrhage. The left internal carotid artery was not visualized on the left carotid angiogram. The left middle cerebral artery was perfused from the basilar artery via the dilated posterior communicating artery on vertebral angiogram. Absence of the left carotid canal was proven on temporal bone computed tomography. Absence of the left internal carotid artery was verified at operation. Absence of internal carotid artery is discussed in relation to aneurysm formation.     

Transvenous embolization of an intraosseous dural arteriovenous fistula of the anterior condylar vein with anomalous venous drainage causing ocular manifestations

We report a patient with a rare dural arteriovenous fistula of the anterior condylar vein, who presented with unusual clinical symptoms due to the anomalous venous drainage. The patient had progressive ocular signs, a dilated venous pouch at the skull base and, on angiography, retrograde venous drainage into the superior ophthalmic vein. Transvenous embolization of the venous pouch produced complete amelioration of the ocular symptoms. Such treatment may be curative for dural arteriovenous fistulas of the anterior condylar vein.     

Spontaneous thrombosis of an aneurysm of the middle cerebral artery with subarachnoid haemorrhage in a 6-year-old child: case report.

A 6-year-old boy had a sudden onset of rupture of an aneurysm of the middle cerebral artery. Narrowing of an artery proximal to the aneurysm was shown on an angiogram taken two days after the rupture. At operation, clipping of the aneurysm prevented further bleeding. This artery thrombosed spontaneously in the postoperative period. The outcome was favourable, and the patient returned to school life. Spontaneous thrombosis of an artery after subarachnoid haemorrhage in children is rare, and thrombosis of aneurysm is very rare. To our knowledge, this is the third reported case of spontaneous thrombosis of a cerebral saccular aneurysm with subarachnoid haemorrhage.     

A case of Wyburn-Mason syndrome

A extremely rare case of unilateral retinocephalic vascular malformation (Wyburn-Mason syndrome) was reported. A 5 year-old girl was seen to a ophthalmologist complaining of exophthalmus of her left eye after trauma on her face for the past 2 months. On ophthalmologic examinations, retinal arteriovenous malformation was recognized in her left eye and she was referred to neurosurgical service for the evaluation on occurrence of traumatic carotid cavernous fistula. Plain CT did not show any abnormality but enhanced CT revealed an abnormally enhanced lesion in the thalamus and basal ganglia and along to the left optic nerve. Left carotid angiography and vertebral angiography revealed a huge arteriovenous malformation in the left thalamus and basal ganglia extending to the left orbita. The arteriovenous malformation was fed from the C3 segment of the carotid artery, anterior, middle and posterior cerebral arteries, and drained to the internal cerebral vein and basal vein. The intraorbital part of the malformation was mainly fed from the external cerebral artery. She was diagnosed as Wyburn-Mason syndrome. We stressed in the paper that enhanced CT was useful for the diagnosis of the Wyburn-Mason syndrome.