Diagnostic cerebral angiography in spontaneous intracranial haemorrhage: a guide for developing countries

OBJECTIVE: Spontaneous intracranial haemorrhage constitutes 18-40% of all stroke cases. Indications for cerebral angiography to find underlying potentially treatable vascular abnormalities are not clear. This study determined which intracranial haemorrhage patients need cerebral angiography by correlating computed tomography (CT) findings, age and hypertension history with cerebral angiography findings. METHODS: A total of 54 patients (8-79 years) with intracranial haemorrhage who underwent both CT examination and six-vessel cerebral angiography were studied over a 2-year period. Cerebral angiography was repeated within 6 weeks if the first angiogram was negative. RESULTS: Angiography detected vascular lesions in 50% of cases (aneurysm 38.9% and arteriovenous malformation, AVM, 11.1%). In the aneurysm group, angiographic yield was 34.3% whereas in the AVM group, it was 37.9%. Subarachnoid haemorrhage (SAH) combined with other types of haemorrhage (such as intracerebral haemorrhage, ICH) was not significantly correlated with the likelihood of finding a vascular lesion, both aneurysm and AVM (p = 0.157). Age less than 50 years had significant correlation (p = 0.021) in the AVM group as well as in the aneurysm group (p < 0.001). A history of hypertension was associated with both aneurysm (p = 0.039) and AVM (p = 0.008). No patients with deep intracerebral haematoma had vascular lesions. The presence of an intravascular haemorrhage (IVH) had significant correlation with aneurysm (p = 0.008) but not AVM. There was no significant difference in mean age between patients with and without a vascular lesion (p = 0.134). CONCLUSION: Cerebral angiography is justified in patients with ICH accompanied by pure SAH (p = 0.001). Other factors associated with finding a vascular lesion were a history of hypertension and the presence of IVH. Diagnostic cerebral angiography is indicated for patients with ICH and SAH and IVH with a history of hypertension, regardless of age.     

Pial arteriovenous fistula: a review of literature

Pial arteriovenous fistula (AVF) is a rare vascular lesion, with less than 120 reported cases in the English literatures (Hoh et al., Neurosurgery 2001;49(6):1351). The angio-architecture, clinical course and therapeutic options are all different from arteriovenous malformation (AVM), dural AVM or other intracranial vascular lesions. A review of literatures to analyse the clinical course of pial AVF was carried out. The presence of varix dictates the clinical course and presentation. Paediatric type had high percentage of varix, and mass effect as clinical presentation while the adult type usually manifest by haemorrhage. Disconnection of direct shunting, either by endovascular or surgically, is sufficient to achieve successful treatment; therefore, total resection of the lesion is unnecessary.     

A case of vein of Galen aneurysmal malformation with a newly developed dural arteriovenous fistula after successful embolization

We report a case of vein of Galen aneurysmal malformation (VGAM) with a newly developed dural arteriovenous fistula (AVF) subsequent to successful embolization. A male neonate diagnosed as VGAM with prenatal ultrasonography and MRI presented severe cardiac and respiratory failure soon after birth. Five sessions of transarterial embolization using NBCA were performed during the first 6 months of his life. The shunt flow was effectively reduced and heart failure was resolved after the treatment. Follow-up angiography performed 2.5 years after the last embolization revealed complete obliteration of VGAM and newly developed small dural AVF on the wall of the thrombosed falcorial sinus. We believe that the dural AVF in this case was caused by local venous hypertension or induction of angiogenic factor during the thrombosing process of VGAM.     

Brain stem haemorrhage during transsphenoidal surgery

Summary The authors report a case of pituitary adenoma associated with dural arteriovenous malformation (AVM), which caused brain stem haemorrhage during transsphenoidal surgery. The manoeuvre of increasing the endexpiratory pressure in order to push the suprasellar component of the adenoma down to the sella turcica could be the reason of this bleeding. The authors therefore recommend that in cases of such a combination any manoeuvres which are likely to increase the intracranial venous pressure or otherwise affect the intracranial pressure, are avoided. The dural AVM spontaneously regressed after haemorrhage.     

A case of secondary anterior fossa dural arteriovenous fistula following posterior fossa craniotomy

The etiology of dural arteriovenous fistula (AVF) remains uncertain. The authors present a case presenting with anterior fossa dural AVF, which developed after the resection of cerebellar arteriovenous malformation (AVM). The anterior fossa dural AVF, which was not observed on the preoperative angiography, was diagnosed on the follow-up angiography, after the resection of cerebellar AVM. A mechanism underlying the present case is not clearly understood. To the best of our knowledge, some cases of dural AVF secondary to craniotomy have been reported. It is postulated that intracranial vascular anomaly should be analyzed after the surgery.     

Combined transvenous and transarterial embolization of a tentorial-incisural dural arteriovenous malformation followed by primary stent placement in the associated stenotic straight sinus. Case report

Dural arteriovenous malformations (AVMs) involving the tentoria-incisura are associated with an aggressive clinical course characterized by subarachnoid and intracranial hemorrhage (ICH). In these lesions, venous outflow obstruction precipitates leptomeningeal venous drainage, resulting in the arterialization of pial veins and the formation of venous aneurysms, both of which are prone to hemorrhage. Stenotic lesions of the dural sinuses also contribute to the development of retrograde leptomeningeal drainage, which is responsible for the aggressive clinical course of the dural AVM. Endovascular approaches are successful in the treatment of these lesions and of any potential venous outflow obstruction caused by stenosis of a dural sinus. The authors report on a patient with a tentorial-incisural dural AVM and an accompanying stenotic venous sinus. A combined transvenous and transarterial embolization procedure was performed, resulting in complete obliteration of the dural AVM, followed by primary stent placement across a stenotic segment of the straight sinus and normalization of venous outflow. The authors conclude that dural AVMs can be treated safely by using a combined transarterial and transvenous approach and that an extensive search for venous outflow obstruction often reveals stenosis of a draining sinus. Consideration should be given to primary stent placement in the stenotic sinus to protect against ICH.     

Posterior dural arteriovenous malformations in infancy

A 23-month-old infant with an extensive dural arteriovenous malformation (AVM) developed a heart murmur and cardiomegaly. The AVM involved the occipital and suboccipital dura mater and the tentorium, bilaterally. We embolized the AVM with Gelfoam and polyvinyl alcohol particulates, subtotally resected it, and embolized residual vessels with isobutyl cyanoacrylate. In spite of this extensive therapy, the malformation was not totally eradicated and an occipital pial AVM developed. This infant and the eight infants with posterior dural AVMs reported previously emphasize the difficulty of eradicating these lesions in infancy. We contrast the clinical features and therapy of infants and adults with posterior dural AVMs. Infants develop heart failure and cranial bruits because of arteriovenous shunts, whereas adults complain of headache and intracranial bruits. Infants need therapy to prevent progressive heart failure, intracranial hypertension, and perhaps cerebral ischemia. Ligation of arterial tributaries is inadequate therapy for these lesions. Embolization and resection of the malformation, when feasible, offers the best chance of curing posterior dural AVMs with extensive arterial tributaries.     

Fibrinolytic treatment of intraventricular haemorrhage preceding surgical repair of ruptured aneurysms and arteriovenous malformations

Previous studies have indicated that intraventricular administration of tissue-type plasminogen activator (TPA) might improve the prognosis of patients with intraventricular haemorrhage (IVH). In aneurysmal IVH, fibrinolytic treatment was always preceded by surgical repair of the aneurysm, since the risk of recurrent haemorrhage from a non-occluded aneurysm was estimated to be high. We reviewed a series of patients with IVH secondary to ruptured aneurysms (n = 4) or arteriovenous malformation (AVM; n = 1) who underwent emergency intraventricular administration of TPA before repair of the bleeding source. Fibrinolysis resulted in rapid decrease of haematoma volume and of ventricular dilatation, and prevented ventricular catheters from becoming obstructed. No intracranial haemorrhages or other complications occurred. The results suggest that the presence of recently ruptured aneurysms or AVM is not necessarily a contraindication for intraventricular administration of TPA. The potentially life saving benefits might outweigh the inherent risks of recurrent haemorrhage in carefully selected patients with massive IVH, in whom ventricular distension, periventricular brain compression, obstruction of CSF flow, and elevated ICP appear to be major determinants for the outcome.     

Cerebellar haemorrhage in a 12-year-old girl with giant dural sinus malformation

Dural sinus malformation (DSM), a form of dural arteriovenous shunt (DAVS), is an extremely rare vascular anomaly seen less frequently than vein of Galen malformation. We report a case of DSM, detailing initial presentation and delayed complication of cerebellar haemorrhage due to venous stasis within the DSM leading to progressive thrombosis and venous outflow obstruction.     

Dural arteriovenous malformation associated with recurrent subdural haematoma and intracranial hypertension

An unusual case of intracranial hypertension and symptoms of a left parieto-occipital mass lesion due to a dural arteriovenous malformation (AVM) with a large and dilated draining vein is reported. The patient also had a history of homolateral recurrent subdural haematoma, 11 years before. Subdural haematoma is rarely associated to a dural AVM. We suggest that the recurrent subdural haematoma was due to the very slow and intermittent venous bleeding from the preexisting dural malformation, which progressively enlarged in the following years to become very large. The symptoms of intracranial hypertension and papilloedema may be explained by the increased pressure in the dural sinus and the cerebral venous system. On the other hand, focal neurological symptoms in our case resulted from the mass effect due to an aneurysmally dilated draining vein in the left parieto-occipital region.     

Venous-predominant parenchymal arteriovenous malformation: a rare subtype with a venous drainage pattern mimicking developmental venous anomaly

OBJECT: Considerable confusion exists in the literature regarding the classification of cerebrovascular malformations and their clinical significance. One example is provided by the atypical developmental venous anomaly (DVA) with arteriovenous shunt, because it remains controversial whether these lesions should be classified as DVAs or as atypical cases of other subtypes of cerebrovascular malformations. The purpose of this study was to clarify the classification of these challenging vascular lesions in an effort to suggest an appropriate diagnosis and management strategy. METHODS: The authors present a series of 15 patients with intracranial vascular malformations that were angiographically classified as atypical DVAs with arteriovenous shunts. This type of vascular malformation shows a fine arterial blush without a distinct nidus and early filling of dilated medullary veins that drain these arterial components during the arterial phase on angiography. Those prominent medullary veins converge toward an enlarged main draining vein, which together form the caput medusae appearance of a typical DVA. RESULTS: Based on clinical, angiographic, surgical, and histological findings, the authors propose classifying these vascular malformations as a subtype of an arteriovenous malformation (AVM), rather than as a variant of DVA or as a combined vascular malformation. CONCLUSIONS: Correct recognition of this AVM subtype is required for its proper management, and its clinical behavior appears to follow that of a typical AVM. Gamma Knife radiosurgery appears to be a good alternative to resection, although long-term follow-up results require verification.     

Intraoperative Angiography Using Portable Fluoroscopy Unit in the Treatment of Vascular Malformation

Intraoperative angiography (IOA) is employed for the treatment of the complicated cases in neurological surgery. The IOA is usually performed with OEC portable digital subtraction angiography (DSA) unit. We are performing IOA with portable fluoroscopy unit with simple DSA function and report its usefulness on neurosurgical treatment. IOA or hybrid treatment with mobile fluoroscopy system was performed for 9 cases [cerebral arteriovenous malformation (AVM), 3; cranial dural arteriovenous fistula (AVF), 2; and spinal AVM/AVF, 4]. Thus, ex vivo analysis was performed comparing image quality of portable fluoroscopy unit and conventional DSA system. Although the resolution of portable fluoroscopy unit is not so high compared to conventional DSA system, the existence of the vascular lesions such as cerebral aneurysm, cerebral AVM, and spinal dural AVF were detected. The operation of portable fluoroscopy unit was simple and no special assistance was required. The complication related to the catheterization or IOA did not occur. IOA with portable fluoroscopy unit was useful for the identification of vascular lesion and has advantage on the cost benefit.     

Arteriovenous fistula with associated aneurysms coexisting with dural arteriovenous malformation of the anterior inferior falx. Case report and review of the literature.

This 24-year-old man presented with an unusual case of a high-flow arteriovenous fistula (AVF). This lesion was similar to giant AVFs in children that have been previously described in the literature. In patients in whom abnormalities of the vein of Galen have been excluded and in whom presentation occurs after 20 years of age, a diagnosis of congenital AVF is quite unusual. The fistula in this case originated in an enlarged callosomarginal artery and drained into the superior sagittal sinus via a saccular vascular abnormality. Two giant aneurysmal dilations of the fistula were present. In an associated finding, a small falcine dural arteriovenous malformation (AVM) was also present. Arterial supply to the AVM arose from both external carotid arteries and the left vertebral artery, with drainage through an aberrant vein in the region of the inferior sagittal sinus into the vein of Galen. Craniotomy with exposure and trapping of the AVF was performed, with subsequent radiosurgical (linear accelerator) treatment of the dural AVM. Through this combination of microsurgical trapping of the AVF and radiotherapy of the dural AVM, an excellent clinical outcome was achieved.     

Extensive dural arteriovenous malformation. Case report

A child with an extensive dural arteriovenous malformation (AVM) of the sigmoid sinus and bilateral occlusion of the transverse sinus is reported. His intracranial venous flow had become rerouted through the right cavernous sinus and then into the right ophthalmic veins. The AVM was associated with severe hydrocephalus and a progressive devastating neurological deficit. The hemodynamic and intracranial pressure changes as well as the mechanism of sinus thrombosis are discussed. The role of aggressive surgical treatment is emphasized.     

Unusual clinical manifestations of dural arteriovenous malformations

Fourteen patients had classical angiographic findings of intracranial dural arteriovenous malformations (AVM's). They presented with unusual central neurological signs and symptoms, including visual disturbances, hemiparesis, speech disturbances, gait ataxia, diffuse increased intracranial pressure, and intracranial hemorrhage. In 12 of the 14 patients there was a direct correlation between the clinical presentation and the venous drainage characteristics of the AVM's. The symptoms were probably related to a regional steal phenomenon in two patients. Six patients had direct surgical excision of the dural AVM. Five patients underwent endovascular embolization of the malformation and, in one case, the AVM was removed surgically after embolization. In one patient, the external carotid artery in the neck was ligated. Ten of the 14 patients had substantial clinical improvement or cure. A complete anatomical obliteration of the malformation was obtained in seven cases. None of the patients deteriorated clinically after therapy.     

Angiographic aspects and management of dural arteriovenous fistulas

The angiographic analysis of a dural arteriovenous fistula (AVF) is a determinant step in the evaluation of the lesion with regard to its prognosis and treatment. The clinical presentation of the dural AVFs is very dependent on the venous drainage, and the classification of these lesions draws attention to the venous drainage pattern, combining the clinical course and the venous drainage angiographic features. Dural AVFs with retrograde venous drainage into the leptomeningeal veins are associated with an increased incidence of intracranial hemorrhage, neurological deficits, and increased intracranial pressure allowing impairment of cognitive functions and dementia. Other risky findings are venous dilatations and dural sinus stenosis/occlusion. Different therapeutic approaches are available including noninvasive, endovascular, and surgical techniques. However, the treatment of dural AVFs should be considered in relation to the different types of lesions carrying different clinical presentation and prognosis. Prompt treatment allowing complete and permanent cure is mandatory in dural AVFs with an aggressive clinical course and/or with radiological findings predicting a severe prognosis.     

Association of cerebral aneurysm and dural arteriovenous malformation in the anterior cranial fossa: a case report

A case of dural arteriovenous malformation (AVM) in the base of the anterior cranial fossa associated with a ruptured anterior communicating aneurysm was reported in a 67-year-old man. The dural AVM was fed by the left anterior ethmoidal artery and drained by the left frontal ascending vein with a varicose dilatation. The aneurysm was clipped and the dural AVM was removed in two stages. Dural AVM in the base of the anterior cranial fossa is rare, and we could find only 17 previous reports. Two of them presented with exophthalmos, whereas the remaining 15 cases presented with an intracranial hemorrhage from rupture of the dural AVM. An association of an aneurysm with the dural AVM in this location has not been reported previously.     

Unilateral proptosis and chemosis caused by dural arteriovenous malformation of the superior sagittal sinus

We describe a patient with unilateral proptosis and chemosis resulting from a dural arteriovenous malformation (AVM) of the superior sagittal sinus (SSS) fed mainly by branches of both external carotid arteries. The symptoms may have been caused by increased SSS pressure and disturbance of venous flow by the dural AVM.     

Dural arteriovenous fistulas of the cavernous sinus with onset of intracerebral haemorrhage mimicking hypertensive putaminal hemorrhage

Summary We describe a patient with dural arteriovenous fistulas of the cavernous sinus (CS-dAVFs) who developed an intracerebral haemorrhage (ICH) mimicking hypertensive putaminal haemorrhage. Drainage into the superior ophthalmic vein (SOV) and inferior petrosal sinus (IPS) was not demonstrated on cerebral angiography, and only cortical venous reflux into the Sylvian vein was observed. In cases of venous drainage concentrated on the Sylvian vein, CS-dAVFs could indicate ICH with radiological appearance resembling putaminal haemorrhage.     

Resolution of an anterior-inferior cerebellar artery feeding aneurysm with the treatment of a transverse-sigmoid dural arteriovenous fistula.

A 27-year-old man developed an unruptured anterior-inferior cerebellar artery (AICA) feeding aneurysm from a transverse-sigmoid dural arteriovenous malformation. The patient, with a known history of left transverse and sigmoid sinus thrombosis, presented with pulse-synchronous tinnitus. Angiography revealed an extensive dural arteriovenous fistula (AVF), with feeders from both the extracranial and intracranial circulations, involving the right transverse sinus, the torcula, and the left transverse/sigmoid sinuses. Multimodal endovascular and open surgical therapy was used to manage the lesion. Before a planned second-stage treatment for the left sigmoid sinus component, the dural AVF improved significantly. During this interval, however, a small flow-related aneurysm developed on the left AICA feeding the petrous dural region. The aneurysm resolved after resection of the involved sigmoid sinus. This is the first reported case of an unruptured feeding-artery aneurysm in an intracranial dural AVF that resolved spontaneously with treatment of the dural AVF. Until more is known about the natural history, the decisions of when and whether to treat an unruptured dural AVF feeding-artery aneurysm must be made on an individual basis.