Clinical and angiographic characteristics of cavernous sinus dural arteriovenous fistulas manifesting as venous infarction and/or intracranial hemorrhage

Introduction  Cavernous sinus (CS) dural arteriovenous fistulas (DAVFs) rarely cause venous infarction (VI) and/or intracranial hemorrhage (ICH) despite the presence of cortical venous drainage (CVD). The present study investigated the characteristics of CS DAVFs manifesting as VI/ICH. Materials and methods  Fifty-four patients treated for CS DAVFs were retrospectively studied. Results  Six patients presented with VI/ICH. Two of the three patients presenting with ICH had CVD only to the superficial sylvian vein (SSV) or the deep sylvian vein (DSV). Three patients presenting with VI had multiple drainages, and angiography of these patients showed a varix on the SSV, drainage into the DSV with agenesis of the second and third segment of basal vein of Rosenthal, and thrombosis of the distal petrosal vein. CS DAVF with CVD only carries higher risk of VI/ICH than multiple drainages. Many CS DAVFs presenting with VI, especially those with drainage into the petrosal vein, have multiple drainages in the early stage. Thrombosis of the inferior and superior petrosal sinuses and superior orbital vein gradually increases pressure of the CVD, and then, VI may occur. In contrast, CS DAVFs with CVD only from the beginning, common in the patients with drainage into the SSVs and DSVs, are likely to cause ICH. Conclusion  Angiographic risk factors causing VI/ICH are CVD only, varix formation, agenesis of the second and third segment of basal vein of Rosenthal, and thrombosis of the superior orbital vein, lateral half of the superior petrosal sinus, and distal CVD.     

Double spinal dural arteriovenous fistulas: case report and review of the literature

Spinal dural arteriovenous fistula (SDAVF) is the most common spinal vascular malformation. It mainly affects men after the fifth decade and is usually an acquired lesion with an unknown etiology. We report on a patient with the unusual finding of two separate SDAVFs at the level of L1 on the right and L2 on the left side. Initial selective spinal digital subtraction angiography (DSA) was terminated with demonstration of a SDAVF at the level of L1 but incomplete demonstration of all segmental arteries. Due to a recurrent deterioration of the patients neurological status, and persistent pathological vessels seen on MRI, a second spinal DSA was performed 6 years later, demonstrating the second fistula at the level of L2 on the left side with a separate venous drainage pattern. A retrospective analysis of the angiographic films suggested that both fistulas had already been present 6 years previously. This conclusion is justified because of a transient and faint opacification of the left L2 fistula demonstrated on the films after injection of the right L2 segmental artery. We conclude that in the case of incomplete angiography and persistent clinical and MR findings not only reopening of the treated SDAVF has to be taken into account but also the existence of a second fistula. Since this is the first case of a double fistula in our series of 129 SDAVFs, and given the few reported cases of double SDAVFs, we do not think that completion of selective spinal DSA has to be postulated routinely after a fistula has been found. However, repeat angiography should be performed in patients who continue to deteriorate, fail to improve with persisting MRI pathologies, or demonstrate delayed deterioration after a period of improvement.     

Follow-up MRI in dural arteriovenous malformations involving the cavernous sinus: emphasis on detection of venous thrombosis

Summary Six patients with a dural arteriovenous malformation (dural AVM) involving the cavernous sinus were followed up with magnetic resonance imaging in order to assess change in the lesions. Spin-echo (SE) imaging of three patients in whom the AVM appeared to have closed at least 1 month earlier (two of them spontaneously, and one after external carotid artery embolization) showed neither apparent flow void in the involved cavernous sinus nor evidence of venous thrombosis. SE images of the other three patients who had not been cured by external carotid artery embolization (two of whom were examined within a week of treatment), detected persisting arteriovenous shunts, including high-flow cortical venous drainage, seen as flow void. Two-dimensional time-of-flight MR angiography (2D TOF MRA) was performed simultaneously in three patients. Whereas shunting blood and the normal cavernous sinus were of high intensity, presumed thrombosed cavernous sinuses were isointense with stationary brain tissue. SE imaging can confirm the resolution of arteriovenous shunts, but poorly delineates ver acute and chronic thrombosis of the draining veins. In contrast, 2D TOF MRA directly demonstrates flowing blood, permitting the diagnosis of venous thrombosis; it should be included in follow-up of a dural AVM involving the cavernous sinus when venous thrombosis is suspected.     

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.     

Basal cerebral venous drainage from cavernous sinus dural arteriovenous fistulas

Introduction  This study aimed to define the patterns of basal cerebral venous drainage (BCVD) from cavernous sinus dural arteriovenous fistulas (CSDAVFs). Materials and methods  Forty sets of selective angiographic data from 36 patients with spontaneous CSDAVFs (age range, 53–79 years) were retrospectively analyzed for their drainage patterns. Three types of BCVD were observed, i.e., superolateral type, BCVD via the deep middle cerebral vein or uncal vein; posterolateral type, BCVD via the superior petrosal sinus and petrosal vein; and posteromedial type, BCVD via the bridging vein and the anterior pontomesencephalic vein. MR images and/or 3D-DSA images were also reviewed when available. Results  BCVD from CSDAVF was found in 12 patients (30%), and the other drainage routes included the superior ophthalmic vein in 25 (63%), the inferior petrosal sinus in 17 (43%), the superficial middle cerebral vein in 17 (43%), intercavernous sinus in 15 (38%), the superior petrosal sinus in seven (18%), and pterygoid plexus in two (5%), respectively. In 12 patients with BCVD, superolateral type was found in four (33%), posterolateral type in five (42%), and posteromedial type in seven (58%). Four cases of posteromedial type were associated with other types of BCVD. Conclusion  CSDAVFs are often associated with BCVD via three different pathways. The posteromedial type via the bridging vein is the most frequent type of BCVD.     

Successful management of dural venous sinus thrombosis secondary to ulcerative colitis in a pediatric patient: A case report

Cerebral venous sinus thrombosis secondary to inflammatory bowel disease is a clinically rare and challenging entity with serious sequela. We preset a case of a 15-year-old female patient who was recently diagnosed with ulcerative colitis and had been suffering from headache for 4 days duration. During the diagnostic workup, computed tomography (CT) venography revealed Dural venous sinus thrombosis in the left transverse sinus extending into the left sigmoid sinus and the upper third of the left internal jugular vein as well as into the sinus confluence with non–occlusive filling defects in the superior sagittal sinus. Anticoagulant therapy with enoxaparin was initiated and the patient is being monitored in an outpatient setting regularly. Post-discharge disease course was uneventful. CT venography performed after 3 months illustrated partial recanalization of both left transverse and sigmoid sinuses. CVST is a rare extraintestinal manifestation of ulcerative colitis with significant morbidity and mortality which requires a high level of suspicion to establish a clear diagnosis. In spite the fact that CVST is rare, it should be ruled out in inflammatory bowel disease patients with new onset seizures, headache, along with focal, and non–focal neurologic symptoms.     

Mesenteric arteriovenous shunt associated with thrombosis of the portal venous system: Case report

We report a rare case of mesenteric arteriovenous shunt associated with thrombosis of the portal venous system. The angiographic features consisted of new vessel formation, thrombosis of the main portal vein, superior mesenteric vein and branches, and early filling of distal mesenteric veins with hepatopetal collateral flow. This phenomenon may be due to new vessel formation within the portal vein thrombosis and active lysis of the thrombus exposing the organizing vessels to the distal superior mesenteric veins.     

脑静脉窦血栓磁共振血流成像的诊断价值

目的：探讨脑静脉磁共振血流成像在诊断脑静脉窦血栓中的应用价值。材料与方法：１２例脑静脉窦患者均作ＭＲＩ和脑静脉窦ＭＲＡ检查（３例治疗后随诊），８例行静脉期脑血管造影；与常规ＳＥ图像和Ｘ线脑血管造影对照，着重分析脑静脉ＭＲＡ在本病中的诊断价值。结果：受累的静脉窦有上矢状窦６例，窦汇（部分）８例，横窦８例（１０个），乙状窦８例（９个），直窦６例，大脑大静脉３例和大脑内静脉３例（６个）；脑静脉窦血栓ＭＲＡ直接征象为发育正常的静脉窦高血流信号缺失或再通形成的边缘模糊且不规则的较低血流信号，间接征象有病变以远静脉侧支形成或其他途径引流静脉异常扩张。结论：脑静脉窦ＭＲＡ及其原始图像在脑静脉窦血栓诊断及随诊中有独特价值，它比常规ＳＥ图像能提供更多的诊断信息，可直接显示静脉窦血栓，易于治疗后反复随诊，这些是血管造影所不及的。     

Dural arteriovenous fistula: a pitfall of time-of-flight MR venography for the diagnosis of sinus thrombosis

We report a case in which time-of-flight MR venography falsely suggested thrombosis of a dural sinus later shown to be patent by conventional angiography and superselective venography. Received: 30 January 1997 Accepted: 6 August 1997     

Dural arteriovenous fistula associated with neoplastic dural sinus thrombosis: two cases

Intracranial dural arteriovenous fistulae are direct arteriovenous shunts within the dura matter. We report two cases of arteriovenous fistulae upstream to a neoplastic dural sinus thrombosis. These cases add further support to the acquired etiology of dural arteriovenous fistulae and to the fact that venous hypertension is one of the most important precipitating factors. Received: 9 January 2001/Accepted: 10 January 2001     

重症硬脑膜静脉窦血栓的局部溶栓治疗

目的 研究重症硬脑膜静脉窦血栓的局部溶栓治疗的方法及疗效。方法 总结我院自2000年以来6例重症硬脑膜静脉窦血栓的局部溶栓治疗经验，男4例，女2例，其中4例采用一侧股动脉及对侧股静脉Seldinger穿刺，2例采用股动脉Seldinger穿刺及上矢状窦前1／3穿刺。导管置入一侧颈内动脉及静脉窦血栓处后，于颈内动脉及静脉窦血栓处先后各用尿激酶50万U，以每分钟1万U泵入，再于静脉窦血栓处泵入尿激酶持续溶栓，维持外周血中纤维蛋白原含量1．0～1．5g／L，同时予全身肝素化，维持外周血活化部分凝血活酶时间正常值的2～3倍。结果 本组6例，5例痊愈，颅内压转正常，头痛消失，无神经功能障碍，其中4例数字减影血管造影(DSA)见浅表静脉扩张消失，静脉窦显影正常，1例浅表静脉扩张明显改善，静脉窦显影较前好转；1例好转，颅内压较前降低，头痛好转，DSA见浅表静脉扩张消失，静脉窦显影正常，抗凝治疗1个月后颅内压正常，头痛消失，神经功能恢复正常。结论 重症硬脑膜静脉窦血栓采用动静脉系统联合应用尿激酶局部溶栓治疗是快速、安全、有效的方法，经股静脉途径不易到达静脉窦血栓处者，可以行上矢状窦入路。     

Diagnosis of spinal dural arteriovenous fistula with multidetector row computed tomography: a case report

Spinal dural arteriovenous fistulas are a rare cause of myelopathy. Nonspecific symptoms may delay the diagnosis. Magnetic resonance imaging and spinal angiography are routinely used to establish the diagnosis. In our case abnormalities on magnetic resonance imaging only suggested spinal dural arteriovenous fistulas. Multidetector row computed tomography (MRCT) led to the diagnosis which was confirmed by angiography.     

经静脉入路海绵窦内液体胶联合弹簧圈栓塞海绵窦区硬脑膜动静脉瘘

目的探讨应用经静脉入路联合液体胶和弹簧圈介入栓塞海绵窦区硬脑膜动静脉瘘的方法和策略。方法回顾性分析应用经静脉入路联合液体胶和弹簧圈栓塞治疗的8例海绵窦区硬脑膜动静脉瘘患者,包括瘘口的血管构筑学、治疗方法和疗效。结果所有患者均采用经静脉入路液体胶联合弹簧圈栓塞,其中经面静脉-眼上静脉入路1例,经岩下窦入路7例。8例均临床治愈,患者术后即刻造影提示瘘口完全消失。除术后早期头痛外无其他介入相关并发症。临床随访3个月～3年,患者无临床症状复发。结论经静脉入路应用液体胶联合弹簧圈介入栓塞对于海绵窦区硬脑膜动静脉瘘是安全、有效且经济的治疗方法 。     

静脉窦开通治疗硬脑膜动静脉瘘伴静脉窦闭塞3例

目的 探讨静脉窦开通治疗硬脑膜动静脉瘘(DAVF)伴静脉窦闭塞的效果.方法 回顾性分析2009年9月至2015年5月收治的3例DAVF伴静脉窦闭塞患者临床资料.结果 1例患者经单纯开通静脉窦后治愈DAVF,2例患者经机械性开通联合球囊扩张恢复静脉窦主干通畅后症状明显好转;均未出现介入治疗并发症.结论 部分DAVF伴静脉窦闭塞患者静脉窦开通后正常脑静脉回流通畅,横窦、乙状窦周围DAVF瘘口能达到彻底、永久闭合.静脉窦开通恢复有效血流动力学是治疗DAVF伴静脉窦闭塞的有效方法.     

Embolization of dural arteriovenous fistulas draining into the transverse or sigmoid sinus

The results of embolisation of dural arteriovenous fistulas draining into the transverse or sigmoid sinus were evaluated in 20 patients. Tinnitus was the main symptom in all patients although one also suffered from vertigo and sudden deafness. Nine patients were treated with PVA (polyvinylalcohol) alone and 11 with combined PVA and bucrylate (isobutyl-2-cyanoacrylate) in 1–9 procedures. Recurrence of symptoms, requiring repeated procedures was common but at subsequent clinical follow up 10 patients had no tinnitus, 5 were improved and only 5 experienced no change. Complications occured in six patients: four had transient neurological symptoms and one of these also developed a necrotic wound which later healed. One patient suffered from a cranial nerve palsy and one had an intracranial haemorrhage after a transvenous embolisation. This last patient recovered completely. The best clinical results were achieved in small fistulas and fistulas treated with combined bucrylate and PVA.     

Embolization of intracranial arteriovenous malformations and fistulas with polyvinyl alcohol particles and platinum fibre coils

Summary In order to reduce the recanalization rate of arteriovenous malformations and multiple dural arteriovenous fistulas, embolization was carried out with polyvinyl alcohol (PVA) particles combined with platinum fibre coils in 20 patients. The malformation was occluded more effectively than by PVA alone. Distal deposition of the emboli was obtained by improved steerable catheters (Tracker-18-unibody) and guidewires. The complication rate was lower than usually reported from studies using glue as embolic agent. It was concluded that the combination of PVA and fibre coils enhances the safety and effectiveness of embolization therapy and reduces the frequency of recanalization of intracranial AVMs.     

Early rebleeding of a foramen magnum dural arteriovenous fistula: A case report and review of the literature

Foramen magnum dural arteriovenous fistula (FM-DAVF) is a subset of craniocervical junction arteriovenous fistulas. We report a rare case of FM-DAVF with early rebleeding and review the literature. A 50-year-old man experienced 3 episodes of intracranial bleeding from a vessel malformation in the acute stage. We identified an FM-DAVF, supplied by multiple feeding arteries (eg, left ascending pharyngeal artery) that drained into the straight sinus and left superior petrosal sinus. The draining vein had venous varices. We performed transarterial feeder embolization and surgical disconnection of the DAVF. Early rebleeding of FM-DAVF is rare. High-risk patients require risk assessment and appropriate treatment as soon as possible in the acute stage.     

介入治疗脾动静脉瘘术后门静脉系统急性血栓形成1例

临床资料 患者女,37岁,因“持续呕血、黑便3d”入院.经内科药物及内镜止血治疗无效.患者24 d前曾行“剖宫产术”,否认肝炎及肝硬化病史.体格检查:贫血面容,四肢湿冷,血压80/50 mmHg,心率135次/min;腹稍膨隆,轻压痛,无反跳痛,未触及包块,移动性浊音(+),无其他阳性体征.血常规:红细胞2.7× 1012/L、血红蛋白82.0 g/L、红细胞压积0.24、白细胞20.4× 109/L、血小板117× 109/L.     

A case report of cerebral venous infarction due to venous sinus thrombosis as complication in a Covid-19 patient

Coronavirus disease of 2019 (COVID-19) is a pandemic disease caused by a new corona virus known as SARS-CoV-2 (severe acute respiratory syndrome-coronavirus-2) and well known to increase the risk of developing venous thromboembolism; thus, patients with COVID-19 may present with neurological disorders. Venous thromboembolism is an important cause of morbidity and mortality in patients with COVID-19. We report a case of 35 years old woman who presented neurological disorders due to venous infarction and venous sinus thrombosis as complication in COVID-19. Clinicians and medical staff should be aware of neurologic symptoms and neurological deficit in background of COVID-19, which might even be the first presentation of this infection, thus prompting increased attention to disease presentation and early treatment with anticoagulation should be initiated in these settings. *     

Acquired mural (dural) arteriovenous shunts of the vein of galen

Summary 4 patients with acquired arteriovenous shunts located in the wall of an ectatic vein of Galen (VG) are reported. They represent so-called VG dural arterio-venous malformations (DAVM). These shunts involve the vasa vasorum normally present in the VG wall. Physiopathology, clinical signs and age groups are usually the same as those encountered in other DAVMs; conversely they are totally different from the other mural shunts of the VG, detected in the pediatric population (true VG arteriovenous malformations), and leading to different clinical symptoms. Venous approach in these VG DAVMs is almost always contraindicated unless secondary occlusion of VG afferent has spontaneously excluded the pouch from the cerebral venous circulation.