Dural arteriovenous fistula of the cervical spine presenting with subarachnoid hemorrhage

We describe a case of dural arteriovenous fistula (DAVF) presenting with subarachnoid hemorrhage (SAH). The diagnosis of DAVF was based on spinal angiography. A review of the literature revealed that five of 13 previously reported DAVFs of the cervical spine were accompanied by SAH. SAH has not been observed in DAVFs involving other segments of the spinal canal.     

Three cases of dural arteriovenous fistula of the anterior condylar vein within the hypoglossal canal

Dural arteriovenous fistulas (DAVFs) of the anterior condylar vein are an uncommon but important subset of fistulas occurring at the skull base that can be confused with DAVFs of the marginal sinus on angiography. MR angiography source images can document the intraosseous extent and the relationship to the hypoglossal canal of this type of fistula, which can have significant clinical implications. We present the imaging features of angiography, CT, and MR angiography of three cases of DAVFs localized to the anterior condylar vein and within the hypoglossal canal, which were confirmed by source images from MR angiography. Transvenous coil embolization was curative in two of three cases and would seem to be the treatment of choice when venous access is available.     

The anterior medullary–anterior pontomesencephalic venous system and its bridging veins communicating to the dural sinuses: normal anatomy and drainage routes from dural arteriovenous fistulas

Introduction  We evaluated the normal venous anatomy of the anterior medullary/anterior pontomesencephalic venous (AMV/APMV) system and bridging veins connected to the dural sinuses using magnetic resonance (MR) imaging and demonstrated cases of dural arteriovenous fistulas (DAVFs) with bridging venous drainage. Materials and methods  MR images obtained using a 3D gradient echo sequence in 70 patients without lesions affecting the deep or posterior venous channels were reviewed to evaluate the normal anatomy of the AMV/APMV system and bridging veins. MR images and digital subtraction angiography in 80 cases with intracranial or craniocervical junction DAVFs were reviewed to evaluate the bridging venous drainage from DAVFs. Results  MR images clearly revealed AMV/APMV in 35 cases. Fifteen cases showed a direct connection between AMV and APMV, while 15 cases showed an indirect communication via the transverse pontine vein or the bridging vein. In the five remaining cases, the AMV and APMV end separately to the bridging vein or the transverse pontine vein. Bridging veins were identified in 34 cases, connecting to the cavernous sinus in 33, to the suboccipital cavernous sinus in 11, and the inferior petrosal sinus in five cases. In 80 DAVF cases, seven of 40 cavernous sinus DAVFs, two craniocervical junction DAVFs, and one inferior petrosal sinus DAVF drained via bridging veins to the brain stem. Conclusion  The AMV/APMV and bridging veins showed various anatomies and frequently showed a connection to the cavernous sinus. Knowledge of the venous anatomy is helpful for the diagnosis and intravascular treatment of DAVFs.     

新生儿缺氧缺血性脑病合并颅内出血的CT表现特点及其预后

目的　讨论新生儿缺氧缺血性脑病 (HIE)合并颅内出血的CT表现特点及其预后。方法　对 64例HIE合并颅内出血的病人进行了追踪复查 ,并分析其CT表现特点。结果　本组 64例HIE中 ,单纯蛛网膜下腔出血 5 3例 ,1个月后复查 ,均恢复正常。 1例仅可见脑室内出血 ,10例为混合性出血 (其中SAH IVH 3例 ,IVH IPH 1例 ,SAH IPH 2例 ,SAH SHE 2例 ,SAH SDH 2例 )。在 10例混合性出血中 ,随访复查发现仅 1例恢复正常 ,其他 9例中 ,1例死亡 ,8例均有脑软化 ,脑萎缩 ,脑穿通畸形 ,脑钙化灶等不可逆性后遗症的表现。结论　不同类型的颅内出血 ,其预后有一定的差别。     

Cerebral venous thrombosis as a rare cause of subarachnoid hemorrhage: case report and literature review

We report a 48-year-old woman presenting with subarachnoid hemorrhage (SAH) as the first manifestation of superior sagittal sinus thrombosis. In a literature review of 73 cases, SAH associated with cerebral venous thrombosis (CVT) was usually seen at the cerebral convexities. SAH was adjacent to thrombosed venous structures; therefore, the most possible explanation seems to be the rupture of cortical veins due to extension of thrombosis. Computed tomography (CT) was effective for diagnosis of CVT in only 32% of the cases. CVT should be considered when SAH is limited to cerebral convexities and magnetic resonance (MR) imaging with MR venography should be performed.     

Preliminary experience with onyx embolization for the treatment of intracranial dural arteriovenous fistulas

BACKGROUND AND PURPOSE: Onyx was recently approved for the treatment of pial arteriovenous malformations, but its use to treat dural arteriovenous fistulas (DAVFs) is not yet well established. We now report on the treatment of intracranial DAVFs using this nonadhesive liquid embolic agent.MATERIALS AND METHODS: We performed a retrospective analysis of 12 consecutive patients with intracranial DAVFs who were treated with Onyx as the single treatment technique at our institution between March 2006 and February 2007.RESULTS: A total of 17 procedures were performed in 12 patients. In all of the cases, transarterial microcatheterization was performed, and Onyx-18 or a combination of Onyx-18/Onyx-34 was used. Eight patients were men. The mean age was 56 ± 12 years. Nine patients were symptomatic. There was an average of 5 feeders per DAVF (range, 1–9). Cortical venous reflux was present in all of the cases except for 1 of the symptomatic patients. Complete resolution of the DAVF on immediate posttreatment angiography was achieved in 10 patients. The remaining 2 patients had only minimal residual shunting postembolization, 1 of whom appeared cured on a follow-up angiogram 8 weeks later. The other patient has not yet had angiographic follow-up. Follow-up angiography (mean, 4.4 months) is currently available in 9 patients. There was 1 angiographic recurrence (asymptomatic), which was subsequently re-embolized with complete occlusion of the fistula and its draining vein. There was no significant morbidity or mortality.CONCLUSION: In our experience, the endovascular treatment of intracranial DAVFs with Onyx is feasible, safe, and highly effective with a small recurrence rate in the short-term follow-up.

Dural arteriovenous fistulas (DAVFs) are acquired abnormal arteriovenous connections within the dura that account for 10%–15% of all intracranial arteriovenous malformations (AVMs).¹ The origin of these malformations is not entirely understood but has been associated with several conditions including venous thrombosis, intracranial surgery, tumor, puerperium, and trauma.² DAVFs may be asymptomatic or present with symptoms that range from tinnitus to intracranial hemorrhage (ICH) and severe neurologic deficits. Their behavior is fundamentally determined by the venous drainage pattern. Retrograde leptomeningeal or cortical venous drainage has a strong correlation with adverse clinical events: such patients are thought to have an annual risk of aggressive neurologic presentation of 15% resulting in an annual mortality of 10.4%.³ Moreover, rebleeding rates may be as high as 35% over the first 2 weeks after the initial hemorrhage.⁴ Thus, the DAVFs that have these features require treatment.The current management of DAVFs includes endovascular, surgical, and radiosurgical treatments, either alone or in combination. Endovascular therapy is typically performed with cyanoacrylate, ethyl alcohol, coils, and/or particles. Onyx (ev3, Irvine, Calif), an ethylene vinyl alcohol copolymer preparation, was recently approved for the treatment of pial AVMs, but its use to treat DAVFs is not yet well established. We report our preliminary experience with the endovascular treatment of intracranial DAVFs using this nonadhesive liquid embolic agent.     

高场磁共振磁敏感加权成像联合液体衰减恢复序列对蛛网膜下腔出血的诊断价值

目的：评价高场磁共振磁敏感加权成像（SWI）联合液体衰减恢复序列（FLAIR）对蛛网膜下腔出血（SAH）的诊断价值。方法回顾性分析50例经磁共振诊断为蛛网膜下腔出血的患者MR表现,行常规T1WI、T2WI扫描及FLAIR、SWI序列扫描。结果50例蛛网膜下腔出血患者FLAIR及SWI均可显示,FLAIR表现为脑沟裂池内高信号,SWI为低信号,6例患者T1WI可见高信号蛛网膜下腔出血,T2WI无一例显示。结论常规MR序列诊断SAH准确率不高,FLAIR联合SWI对SAH敏感性高,诊断准确率高,可作为诊断SAH的常规序列组合。     

Dural arteriovenous fistulas with cortical venous drainage: incidence, clinical presentation, and treatment

BACKGROUND AND PURPOSE: Our purpose was to report our experience with intracranial dural arteriovenous fistulas (DAVFs) with cortical venous drainage during a 12-year period. PATIENTS AND METHODS: Between January 1994 and January 2006, 91 patients with intracranial DAVFs presented at our institution, and 29 (32%) had cortical venous drainage. There were 5 women and 24 men (mean age, 53.9 years; range, 24-77). Clinical presentation was intraparenchymal or subarachnoid hemorrhage in 18 patients (62%), seizures in 4 patients (14%), visual symptoms in 2 patients (7%), pulsatile bruit in 1 patient (3%), and the DAVF (14%) was incidentally discovered in 4 patients. RESULTS: In 2 patients, the DAVF had been obliterated spontaneously at the time of scheduled embolization 10 and 2 months after hemorrhage, respectively. Five patients with an anterior fossa DAVF underwent successful surgery. In 14 patients, the DAVF was completely occluded with embolization alone, and in 7 patients, embolization was followed by surgery. Altogether, complete occlusion was angiographically confirmed in 28 of 29 DAVFs; the result of radiosurgery of 1 DAVF is pending. There were no complications of surgery; embolization was complicated by postembolization hemorrhage in 1 patient (3%). CONCLUSION: Most DAVFs with cortical venous drainage have an aggressive clinical course. Treatment by a neurovascular team by using surgery, embolization, or a combination resulted in cure in all cases, with a very low complication rate.     

Simultaneous arteriovenous shunting and venous congestion identification in dural arteriovenous fistulas using susceptibility-weighted imaging: initial experience

In this short report, we describe the potential contribution of SWI in the noninvasive evaluation of DAVFs. SWI images were compared with DSA for the identification of the location of the fistulous point, the presence of CVR, and the presence of the PPP. In 5 of 6 patients, it was possible to identify the fistulous locations depicted as hyperintensity within venous structures. Cortical venous reflux was underestimated on SWI in 3 cases of robust CVR and not identified in 2 cases of less severe CVR. The PPP seen on angiograms correlated anatomically with increased number, caliber, and tortuosity of hypointense veins seen on SWI. Furthermore, SWI was superior to conventional MR imaging in the detection of these dilated veins. These preliminary results suggest an important role for SWI in the detection and assessment of the complex hemodynamics associated with DAVFs.     

Subarachnoid hemorrhage as the initial presentation of dural sinus thrombosis

Cerebral venous thrombosis (CVT) can be difficult to diagnose because of its wide spectrum of clinical manifestations. Its diagnosis may be further complicated when patients initially present with acute subarachnoid hemorrhage (SAH). We report on four patients with SAH revealing a CVT and discuss the role of imaging for diagnostic and pretherapeutic workup. In three women and one man presenting with severe headaches, images initially suggested SAH with no associated parenchymal bleeding. In all patients, SAH involved the sulci of the convexity and spared the basal cisterns. Digital subtracted angiography showed occlusion of intracranial venous sinuses but did not reveal any other cause of SAH. All patients improved with anticoagulant therapy. Risk factors for CVT and SAH, namely, head trauma and oral contraception, were identified in two patients. These cases highlight the fact SAH may reveal a CVT, which should be considered in the diagnostic workup of SAH, especially when the basal cisterns are not involved.     

PVA颗粒栓塞硬膜动静脉瘘

目的：评价经血管ＰＶＡ颗粒栓塞硬膜动静脉瘘的临床效果及其安全。材料和方法；５例经血管造下实的硬膜动静脉瘘（２例累及海绵窦，１例累及右横窦、乙状窦、１例累及上乔状窦，１例累及右侧中颅凹）患者，选择性插管入近病巢处的供养动脉或近供养动脉开口的主干动脉（颌内动脉或颈外动脉），采用ＰＶＡ颗粒悬液加适量优维显３００本成不透光混合液，在透视监视下缓慢主供养动脉坡至栓塞瘘道，术后１５分钟和６个月随因管造影及评价     

Dementia resulting from dural arteriovenous fistulas: the pathologic findings of venous hypertensive encephalopathy.

PURPOSEDural arteriovenous fistulas (DAVFs) are acquired arteriovenous shunts located within the dura. The highly variable natural history and symptomatology of DAVFs range from subjective bruit to intracranial hemorrhage and are related to the lesion''s pattern of venous drainage and its effect on the drainage of adjacent brain. We examined the prevalence and features of DAVFs in patients with progressive dementia or encephalopathy.METHODSThe records and radiologic studies of 40 consecutive patients with DAVFs treated at our institution were reviewed.RESULTSFive (12.5%) of 40 consecutive patients with DAVFs had encephalopathy or dementia. In each patient, high flow through the arteriovenous shunt combined with venous outflow obstruction caused impairment of cerebral venous drainage. Hemodynamically, the result was widespread venous hypertension causing diffuse ischemia and progressive dysfunction of brain parenchyma. Results of CT or MR imaging revealed abnormalities in each patient, reflecting the impaired parenchymal venous drainage. Pathologic findings in one patient confirmed the mechanism of cerebral dysfunction as venous hypertension. The hemodynamic mechanism and resulting abnormality appeared identical to that seen in progressive chronic myelopathy resulting from a spinal DAVF (Foix-Alajouanine syndrome). Remission of cognitive symptoms occurred in each patient after embolization.CONCLUSIONVenous hypertensive encephalopathy resulting from a DAVF should be considered a potentially reversible cause of vascular dementia in patients with progressive cognitive deficits.     

Dural arteriovenous fistulas of the marginal sinus.

PURPOSETo investigate the clinical presentation, angiographic findings, endovascular management and clinical outcome in dural arteriovenous fistulas (DAVFs) of the marginal sinus.METHODSFourteen patients with DAVFs of the marginal sinus were identified from angiographic studies and medical records of all patients treated for DAVFs at our institution between July 1990 and August 1995. The endovascular treatment and clinical outcomes of these patients are reported.RESULTSEleven patients had pulse-synchronous bruit, two had intracranial hemorrhage, and one had ataxia. Thirteen patients were cured with endovascular techniques alone and one was cured by a combination of preoperative embolization followed by surgical obliteration of the fistula. The sole complication of treatment was a partial left hypoglossal nerve palsy, which resolved spontaneously.CONCLUSIONDAVFs of the marginal sinuses are potentially life-threatening lesions that can be treated with endovascular techniques for a high rate of cure and a low rate of morbidity.     

Selective transvenous embolization of dural fistulas without occlusion of the dural sinus.

Two patients with dural arteriovenous fistulas (DAVFs) and unsuccessful transarterial embolizations were treated with a technique for selective transvenous embolization. A 5F catheter was advanced from a femoral vein access into the internal jugular bulb and a catheter was navigated through the sinus lumen into the involved cortical veins or the parasinusal venous draining channels of the DAVFs. The venous recipients at the nidal level of the DAVFs were occluded by fibered platinum coils. Complete angiographic cure was effected in both patients, with occlusion of the venous recipients and the nidus, although the sinus segments next to the nidus of the DAVFs remained patent. Placement of coils in a transsinusal route into the venous channel of a DAVF yet outside the sinus lumen can result in complete obliteration of the fistula without damage to the physiological function of the dural sinuses.     

Spontaneous subarachnoid hemorrhage with negative angiography: CT findings.

Computed tomography of 31 patients with spontaneous subarachnoid hemorrhage (SAH) but negative angiography was evaluated to find out whether the pattern of SAH as seen in CT offers indications for a possible reexamination with angiography. Based on the distribution and the amount of SAH, classification into three groups was possible: (a) 18 cases, normal CT (but blood in the CSF, gained by lumbar puncture) or SAH in the basal cisterns only; repeat angiography was negative in all these cases; (b) nine cases, SAH in the basal cisterns as well as in one or both Sylvian fissures; in addition, small amounts of blood in the interhemispheric fissure and/or in the sulci; repeat angiography revealed an aneurysm in one of these cases; (c) four cases, large quantities of blood in all subarachnoid spaces; in all but one of these cases a vascular lesion was visualized with repeat angiography or verified at autopsy. In conclusion, repeat angiography is mandatory in cases with SAH patterns that can be classified into group b or c, whereas it can be omitted in patients with small amounts of blood confined to the basal cisterns.     

Recurrence of the cavernous sinus dural arteriovenous fistula at adjacent sinuses following repeated transvenous embolizations: case report and literature review

We present a unique case of a cavernous sinus (CS) dural arteriovenous fistula (DAVF), which recurred at adjacent sinuses following repeated transvenous embolizations (TVEs). A 68-year-old woman presented with progressive left conjunctival chemosis and diplopia. Cerebral angiography revealed a left CS DAVF, which was completely obliterated by TVE via the left inferior petrosal sinus (IPS). Two years later, the DAVF recurred in the left IPS, and again in the left sigmoid sinus (SS) 3 years after the initial treatment in spite of a second TVE. Moreover, the left SS and the left internal jugular vein, which had been previously stenotic, had been occluded. The third TVE resulted in the complete obliteration of the SS DAVF. CS DAVFs may recur at adjacent sinuses even after complete obliteration by TVE. Careful follow-up is necessary to check for the recurrence of DAVFs, especially in cases with venous flow changes, such as sinus occlusion, following endovascular treatment.     

Fluid-attenuated inversion recovery MR imaging and subarachnoid hemorrhage: not a panacea

BACKGROUND AND PURPOSE: Subarachnoid hemorrhage (SAH) constitutes an important neurologic emergency. Some authors have suggested that fluid-attenuated inversion recovery (FLAIR) MR imaging can detect SAH that may not be apparent on CT scans but may be revealed by lumbar puncture. We sought to determine how often FLAIR MR imaging findings are positive for SAH in cases with negative CT findings and positive lumbar puncture results. METHODS: The CT scans and FLAIR MR images of all patients with suspected SAH during a 3-year interval (2000-2002) were retrospectively reviewed by a blinded reader. Among these cases, we identified 12 with CT findings that were negative for SAH, lumbar puncture results that were positive for SAH, and FLAIR MR imaging findings that were available for review. Eleven of the 12 patients had undergone FLAIR MR imaging within 2 days of CT and lumbar puncture. The 12 patients with negative CT findings were comprised of six male and six female patients with an age range of 7 to 69 years. We evaluated the true and false negative and positive FLAIR MR imaging findings for SAH by using the lumbar puncture results as the gold standard. The FLAIR MR imaging findings of 12 additional patients without SAH (as revealed by lumbar puncture) were used as control data for a blinded reading. RESULTS: For all 12 control cases without SAH, the FLAIR MR imaging findings were interpreted correctly. Of the 12 cases that had positive lumbar puncture results but false-negative CT findings for SAH, FLAIR MR imaging findings were true-positive in only two cases and were false-negative in 10. One of the two true-positive cases had the highest concentration of RBC in the series (365 k/cc), and the other had the second highest value of RBC (65 k/cc). CONCLUSION: FLAIR MR imaging cannot replace lumbar puncture to detect the presence of SAH. FLAIR MR imaging findings are infrequently positive (16.7%) when CT findings are negative for SAH. This is likely because there is a minimum concentration of RBC/cc that must be exceeded for CSF to become hyperintense on FLAIR MR images.     

Fusion imaging using subtracted and unsubtracted rotational angiography for pretherapeutic evaluation of dural arteriovenous fistulas

Purpose

We describe the clinical utility of an imaging technique that combines 3D subtracted and unsubtracted rotational angiography for evaluation of the angioarchitecture of dural arteriovenous fistulas (DAVFs).

Methods

From May 2010 to June 2013, 21 consecutive patients with intracranial DAVFs (22 lesions) underwent 3D angiography for pretherapeutic evaluation. 3D fusion angiography (3DFA) images were semiautomatically obtained from a dataset of unsubtracted and subtracted rotational angiographs. Multiplanar reformatted images and partial MIP images from unsubtracted rotational angiography and fusion images were evaluated by two radiologists, with particular focus on visualization of feeding arteries, shunted pouches, and drainage veins of DAVFs by use of a 3-point scale. The referring neuroradiologists were asked whether the information provided by 3DFA was helpful for treatment decisions.

Results

For 21 of 22 lesions, all evaluated items were well depicted on the 3DFA. The visualization rating score for feeding arteries and shunted pouches on 3DFA were significantly higher than those of 3D digital angiography (p < 0.05). There were no statistically significant differences between visualization of drainage veins. The information provided by the fusion images was helpful for treatment decisions in all cases.

Conclusion

3DFA images are useful for evaluation of the angioarchitecture of intracranial DAVFs.     

Embolization of intracranial dural arteriovenous fistulas with Onyx-18

Background and purpose

The use of Onyx in the treatment of AVMs has been reported in the literature, but experience in the treatment of DAVF is lacking. We report the clinical outcome obtained in the treatment of dural arteriovenous fistulas (DAVFs) using a new liquid embolic agent, Onyx-18.

Methods

The present series included 21 patients; 9 had DAVFs draining directly into the cortical veins, 6 had DAVFs draining directly into the dural sinus, 4 had DAVFs draining through the ophthalmic veins and 2 had DAVFs involving the dural sinus with leptomeningeal retrograde venous drainage Clinical data were extracted from hospital files and all patients were followed.

Results

In 14 patients (70%) there was complete angiographic elimination of the shunts and resolution of the symptoms. The remaining 7(30%) patients was not cured with residual shunts. Adverse events occurred in 6(30%) of 21 patients with 1 DAVF located at the transverse sigmoid sinus, 2 at tentorium, and 3 at the cavernous sinus. Cranial deficits occurred in 3(15%) patients, brain infarction in 1(5%) patient and microcatheter gluing in 1(3.2%) patient. At final follow up, 20 patients were asymptomatic with 1 showed clinical improvement.

Conclusion

Definitive cure may be attained effectively with Onyx in dural arteriovenous fistulas and adjunctive to surgery and radiotherapy. Location of the DAVFs affected the outcome of transarterial embolization.     

The importance of venous hypertension in the formation of dural arteriovenous fistulas: a case report of multiple fistulas remote from sinus thrombosis

Various hypotheses have been reported concerning the pathogenesis of dural arteriovenous fistulas (DAVFs). However, it is still controversial whether sinus thrombosis or venous hypertension has a greater influence on the formation of DAVFs. We present a rare case of multiple DAVFs that developed after sinus thrombosis. Chronic venous hypertension secondary to sinus thrombosis in the left transverse-sigmoid sinus induced the multiple DAVFs, including one in the right cavernous sinus, which was remote from the occluded sinus. This case indicates the importance of venous hypertension in the formation of DAVFs. Received: 27 November 2000/Accepted: 13 March 2001