Management of intracranial dural arteriovenous fistulas with cortical venous drainage

Background and purpose

Intracranial dural arteriovenous fistulas (DAVF) with cortical venous drainage are vascular malformations with high hemorrhagic risk. Their treatment may be complex and requires a multidisciplinary approach.

Methods

We retrospectively report 38 observations of dural arteriovenous fistulas with cortical venous drainage from 1990 to 2001. There were 28 men and 10 women with a mean age of 57 years. Hemorrhage revealed the malformation in 24 cases (63%). The other patients had headache, neurological deficit, seizure or pulsating mass of the scalp. One patient was asymptomatic. All the patients had DAVF with cortical venous drainage and decision of treatment was in each case multidisciplinary.

Results

Of the 38 patients, seven had no treatment for the following reasons: spontaneous occlusion of the malformation after hemorrhage, refusal of treatment, or poor neurological status at the admission. Thirty-one patients were treated and complete exclusion of the fistula was obtained in 30 cases. Endovascular occlusion of the fistula was performed in 14 patients, surgical clipping of the origin of the draining vein in 12 and combined treatment (surgical clipping after embolization of feeding arteries) in four. One patient had an untreated fistula despite several procedures.

Conclusion

Complete exclusion of these malformations is mandatory because of the potential risk of hemorrhagic complications. The best treatment is the occlusion of the origin of the draining vein (endovascular or surgical) and requires multidisciplinary discussion.     

Posterior fossa hemorrhage caused by dural arteriovenous fistula: case reports

BACKGROUND: Relatively few reports are available on dural arteriovenous fistulas (AVFs) accompanied by posterior fossa hemorrhage. We now report upon two such cases and discuss the differential diagnosis and imaging findings. CASE DESCRIPTION: A 36-year-old man was admitted after experiencing sudden headache. Computerized tomography (CT) showed vermian and fourth ventricular hematoma, and magnetic resonance imaging (MRI) revealed an abnormal signal void. Angiography demonstrated a dural AVF in the region of foramen magnum. The second case, a 57-year-old man, was also admitted for the evaluation of headache. CT scan revealed tentorial subdural, subarachnoid and vermian hemorrhage. MRI showed vermian hematoma and an abnormal signal void below the tentorium. Angiography demonstrated a dural AVF in the tentorium.The first case underwent transarterial embolization, after which the dural AVF disappeared completely. The second case underwent craniotomy immediately after failure of endovascular therapy. Postoperative angiography demonstrated no remaining dural AVF. CONCLUSIONS: Dural AVF should be considered as a causative lesion in cases with posterior fossa hemorrhage with no other definitive cause.     

Brain stem venous congestion due to dural arteriovenous fistulas of the cavernous sinus

Summary Background. Venous congestion of the brain stem due to dural arteriovenous fistulas (DAVFs) in the cavernous sinus is rare and presents therapeutic challenges. To assess the prognosis of patients with symptomatic DAVFs and brain stem dysfunction, we evaluated the degree of venous ischemia by examining pre- and post-treatment magnetic resonance images (MRI) in 2 patients presenting with venous congestion of the brain stem.Methods. A 56-year-old woman with left hemiparesis and a 70-year-old woman with gait disturbance attributable to right cavernous sinus DAVFs were referred to our hospital. In both cases, T2-weighted magnetic resonance imaging (MRI) disclosed a hyperintensity lesion in the brainstem due to venous congestion.Findings. Both patients underwent open surgery for direct embolization of the cavernous sinus because there were no approach routes for transvenous embolization. The patient whose pretreatment MRI demonstrated Gd enhancement continued to manifest neurological deficits and persistence of the abnormal hyperintensity on post-treatment T2-weighted MRI. In the other patient whose pretreatment MRI showed no Gd enhancement, treatment produced a complete response of her neurological deficit and disappearance of the abnormal hyperintensity area.Conclusions. We tentatively conclude that lesions corresponding to hyperintensity areas on non-Gd-enhanced, T2-weighted MRI may reflect a reversible condition whereas lesions identified as hyperintense areas on GD-enhanced T2-weighted MRI may be indicative of irreversibility.     

Intracranial hemorrhage following attempted embolization and removal of large arteriovenous malformations

Two cases of intracranial hemorrhage following staged flow reduction procedures for large arteriovenous malformations are presented. Possible causes of bleeding in these cases are discussed. We suggest that the staged removal of large arteriovenous malformations may not prevent hemorrhagic complications in certain cases.     

Current therapeutic methods of dural arteriovenous malformation: Are there any alternatives? Two case reports of infratentorial AVM's

We describe two cases of infratentorial dural AVM, in which a successful surgical intervention was performed. This procedure was chosen as the repeated treatment by embolization proved to be ineffective.Theories as to the pathogenesis of dural AVM, the current treatment as well as options for new therapies are presented.     

Cerebral vasospasm with subarachnoid hemorrhage from cerebral arteriovenous malformations

The angiograms and clinical records of 12 patients with subarachnoid hemorrhage from cerebral arteriovenous malformations were reviewed. Of these 12 patients, cerebral vasospasm was confirmed in 1 patient. The case of a 28-year-old man who showed angiographic evidence of cerebral vasospasm is reported, and the rarity of vasospasm associated with subarachnoid hemorrhage from cerebral arteriovenous malformations is discussed.     

A case of cavernous sinus dural arteriovenous fistula presenting with intracranial hemorrhage

Intracranial cavernous sinus dural arteriovenous fistula (CS-dAVF) rarely causes intracranial hemorrhage. We report a case of CS-dAVF presenting with intracranial hemorrhage. A 62-year-old man presented tonic clonic convulsion with consciousness disturbance and was transferred to our hospital. CT scan revealed subarachnoid hemorrhage and right frontal subcortical hemorrhage. Angiography revealed right CS-dAVF which drained only into the vein of the right sylvian fissure. Transvenous embolization was performed using detachable coils. After embolization, CS-dAVF had completely disappeared and the patient was discharged without any symptom. We summarized the fourteen reported cases, including ours, of CS-dAVF with intracranial hemorrhage. All of them had retrograde drainage through cerebral veins.     

Benefits and limitations of image guidance in the surgical treatment of intracranial dural arteriovenous fistulas

Summary Background. Despite major advances in endovascular embolization techniques, microsurgical resection remains a reliable and effective treatment modality for dural arteriovenous fistulas (DAVF). However, intraoperative detection of these lesions and identification of feeding arteries and draining veins can be challenging. In a series of 6 patients who were not candidates for definitive treatment by endovascular embolization we evaluated the benefits and limitations of computer-assisted image guidance for surgical ablation of DAVF. Methods. Of the 6 patients, 5 presented with haemorrhage and one with seizures. Diagnosis of DAVF was made by conventional angiography and dynamic contrast enhanced MR angiography (CE-MRA). All patients were surgically treated with the assistance of a 3D high resolution T1-weighted MR data set and time-of-flight MR angiography (MRA) obtained for neuronavigation. Registration was based on cranial fiducials and image-guided surgery was performed with the navigation system. Findings. Four of the 6 patients suffered from DAVF draining into the superior sagittal sinus, one fistula drained into paracavernous veins adjacent to the superior petrosal sinus and one patient had a pial fistula draining in the straight sinus. DAVF diagnosed with conventional angiography could be located on CE-MRA and MRA prior to surgery. MRI and MRA images were combined on the neuronavigation workstation and DAVF were located intraoperatively by using a tracking device. In 4 out of 6 cases neuronavigation was used for direct intraoperative identification of DAVF. Brain shift prevented direct tracking of pathological vessels in the other 2 cases, where navigation could only be used to assist craniotomy. Microsurgical dissection and coagulation of the fistulas led to complete cure in all patients as confirmed by angiography. Conclusions. Neuronavigation may be used as an additional tool for microsurgical treatment of DAVF. However, in this small series of 6 cases, surgical procedures have not been substantially altered by the use of the neuronavigation system. Image guidance has been beneficial for the location of small, superficially located DAVF, whereas a navigated approach to deep-seated lesions was less accurate due to the familiar problem of brain shift and brain retraction during surgery. Both authors equally contributed to this work.     

Intracerebral hematomas in cases of dural arteriovenous malformation and carotid-cavernous fistula

Intracerebral hematomas in cases of dural arteriovenous malformation and carotid cavernous fistula are reported. The origin of hemorrhage is concluded to have been the engorged cortical veins through which the arterial blood drained in a retrograde fashion. The necessity of early treatment of the underlying condition is stressed, as retrograde drainage may cause acute complications.     

Multidisciplinary management of posterior fossa dural arteriovenous fistula: A single-center experience

PurposeThe management of posterior fossa dural arteriovenous fistulas (pfDAVFs) is challenging. Here, we show how multidisciplinarity leads to their successful management, even in complex cases.MethodsAll pfDAVFs managed from 2010 to 2019 at our center were reviewed. The preoperative clinical and radiological characteristics, their management and the occlusion rate were retrieved. The radiological and functional outcomes were retrieved at discharge and last follow-up (FU).Resultsn = 27 patients were included (6 females, mean age: 61-years-old, mean FU: 22.5 months). n = 8 patients presented with cerebral hemorrhage. Among patients with ruptured pfDAVFs, n = 7 had headache, n = 4 had ataxia, and n = 2 had impaired level of consciousness. In the unruptured group N (n = 19), n = 7 patients had headache, n = 6 patients had focal neurological deficit, n = 4 patients had tinnitus, n = 3 (had ataxia, and one presented with seizure. n = 24 patients were treated by endovascular therapy (EVT), n = 2 patients were treated by microsurgery (MS) and n = 1 patient was managed with a combined approach. Re-treatment was necessary in n = 6 patients. n = 24 patients showed total exclusion at last FU. n = 2 patients died during the first 30 days; n = 1 patient died during FU.ConclusionsWhile EVT should be advocated as the first line therapy whenever possible, MS should not be banned from the treatment armamentarium. Neurosurgeons must be able to achieve direct surgical occlusion when the angioarchitecture speaks against EVT.     

Transfemoral,transvenous embolisation of dural arteriovenous fistula involving the isolated transverse-sigmoid sinus from the contralateral side

Summary.  Background: A dural arteriovenous fistula (AVF) involving the transverse-sigmoid (T-S) sinus which is occluded at its proximal and distal ends i.e., an isolated sinus, runs the risk of haemorrhaging or causing serious neurological deficits as a result of its retrograde leptomeningeal venous drainage. While lesions of this type have not been considered to be treatable by percutaneous, transvenous embolisation, this paper challenges this view.  Case Presentation: Two middle-aged men with dural AVFs involving the isolated left T-S sinus presented with motor aphasia due to focal brain edema or haemorrhage. Under local anaesthesia, transfemoral, transvenous embolisation was performed with a microcatheter that was passed through the occluded proximal transverse sinus from the right (contralateral) side. The isolated sinus was then occluded with platinum coils. This embolisation resulted in angiographic and clinical cure of dural AVFs in both patients.  Interpretation: Transfemoral, transvenous embolisation is a therapeutic alternative for the treatment of dural AVFs involving the isolated T-S sinus. Embolisation obviates the need for craniotomy and general anaesthesia, which are required for the established modes of treatment, i.e., direct surgery or direct percutaneous sinus packing. Published online October 10, 2002 Correspondence: Masaki Komiyama, M.D., Department of Neurosurgery, Osaka City General Hospital, 2-13-22, Miyakojima-Hondori, Miyakojima, Osaka 534-0021 Japan.     

Evolution of different therapeutic strategies in the treatment of cranial dural arteriovenous fistulas — report of 30 cases

Summary 30 cases of cranial dural arteriovenous fistulas, treated between 1983 and 1992, are reported. Twelve presented with an aggressive clinical couse including intracranial haemorrhage, progredient neurological deficit, medically intractable seizures, and cerebellar symptoms. The other 18 patients had a more benign clinical presentation with audible bruit, exophthalmus, chemosis, and cranial nerve dysfunction. One of the latter had symptoms of pseudotumour cerebri due to sinus occlusion with contralateral sinus stenosis. The most common location was at the transverse sinus, followed by the cavernous sinus, the tentorial ring, and the orbita. Four vessel angiography verified the diagnosis and demonstrated all fistulas, mainly supplied by branches of the external carotid artery.16 of 18 benign lesions were treated by endovascular therapy alone. Two recent patients received adjuvant stereotactic radiosurgery. Among these 18 patients 2 remained untreated, one because of spontaneous fistula thrombosis prior to therapy and one because of poor medical condition.12 of 16 treated benign dural fistulas were partially occluded. in 6 of them spontaneous fistula thrombosis occurred during the following months. Total endovascular obliteration was achieved in the remaining 4 patients.7 of 12 aggressive fistulas were embolized only, one of them having additional radiosurgery. Two of them were totally obliterated and five partially. Surgery was performed in the remaining 5 aggressive fistulas. Complete microsurgical excision was achieved in 2 and partial in further two, who presented initially with a lifethreatening intracerebral clot. In one early case ligation of the external carotid artery was done, which is now obsolete. Over all 20 of 28 treated patients became asymptomatic or improved clinically.3 of the remaining 8 patients were unchanged, two deteriorated despite therapy, and 3 worsened after therapy. All of the latter complications occurred early in our series due to thomboembolic events during the procedure. One surgical patient suffered from a new facial nerve palsy postoperatively. Follow up time in all treated patients was between 1 and 139 months with a mean of 48,3 months.     

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.     

Angiographic architecture of intracranial vascular malformations and fistulas — pretherapeutic aspects

The authors describe the angio-architecture of intracranial vascular malformations. Several patterns can be identified thanks to the intracranial superselective angiograms that can now be performed. Schematically, the following features can be seen: 1. Direct arterial supply, 2. Indirect arterial supply, 3. Flow-related arterial ectasia (aneurysm), 4. Dysplastic aneurysm, 5. Direct arteriovenous fistula, 6. Intralesional arterial ectasia (aneurysm), 7. Intralesional venous ectasia (aneurysm), 8. Venous ectasia.Each of these elementary arrangements are illustrated and their clinical significance outlined whenever possible. Finally, the dural AVM drainage into the cortical venous system serves as an almost experimental model for the appreciation of the role played by the venous congestive phenomenon in brain AVM symptoms.     

原位肝移植术后颅内出血原因和处理

目的 探讨肝移植术后颅内出血的临床特点以及防治措施。 方法 回顾性分析中山大学附属第一医院2004年1月至2008年12月施行的638例肝移植病人的临床资料。总结原位肝移植术后颅内出血的诊治经过。结果 638例肝移植病人中共发生术后颅内出血10例（1.6%）;其中发生于移植术后1周内1例,2周内3例,2周至1个月6例。10例病人一经确诊,均立即采取脱水降低颅内压治疗,并应用抗生素控制感染,其中有4例病人急诊施行了开颅血肿清除术。10例中死亡6例,与术后颅内出血相关的病死率为60.0%。结论 肝移植术后颅内出血发病凶险、病死率高。应掌握术后颅内出血的常见原因,对术后意识和精神状态发生改变者要及时进行头颅CT检查,一旦发生颅内出血应积极抢救,及时做出正确的治疗选择,必要时施行开颅血肿清除术。     

表现为蛛网膜下腔出血的海绵窦区硬脑膜动静脉瘘1例

<正>患者女,66岁,因"反复头痛1月余,发热9天"入院。患者于1个月前出现剧烈头痛,主要位于右侧头顶及颞部,呈针刺样疼痛,伴右眼胀痛,最高体温达39℃,且头痛症状持续存在。既往有高血压、糖尿病病史。神经系统查体未见阳性定位体征。实验室检查:C-反应蛋白21.30mg/L;脑脊液检查:脑脊液为均匀淡红色,脑脊液白细胞计数50×106/L、红细胞计数10×106/L;脑脊液葡萄糖7.41 mmol/L、氯116.5 mmol/L、蛋白51.4mg/dl;脑脊液压力、腺苷脱氨酶、乳胶凝集试验、抗酸染色、改良抗酸染色、墨汁染色、脑脊液找癌细胞等均为正常。CT     

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.     

Clinical and cerebral blood flow studies in patients with intracranial hemorrhage and amyloid angiopathy typical of Alzheimer's disease

Spontaneous intracerebral hemorrhages can occur in patients with severe amyloid angiopathy and other morphological signs of Alzheimer's disease (AD). We observed 15 patients in whom histological examination of brain tissue specimens obtained at surgery revealed characteristic congophilic amyloid deposits in subcortical arteries and/or nerve cells. Clinical follow-up examinations were carried out up to 9 years after diagnosis. In addition, three survivors from the operated group were investigated by neuropsychological testing and single photon emission computer tomography (SPECT) using Tc-99m-HMPAO for determination of regional cerebral blood flow (rCBF).SPECT could not differentiate between the typical Alzheimer disease pattern of bilateral temporo-parietal rCBF reduction and flow deficits resulting from previous hemorrhage. Intellectual functioning was found to be impaired to various degrees ranging from normal function to severe dementia (MMS test scores varied between 15 and 26 points); again, it was difficult to differentiate clinically between the nosologic entities mentioned above.On the basis of our present experience we cannot distinguish between brain dysfunction due to Alzheimer's disease and intracranial hemorrhage from amyloid angiopathy. This supports the idea that intracranial hemorrhage may only be one clinical manifestation of amyloid deposits, another one being Alzheimer's disease with varying preponderance.