intracranial_dural_arteriovenous_fistula_case_reports

Intracranial dural arteriovenous fistula case reports

A 71-year-old man, with a pial micro-arteriovenous malformation (pAVM) draining into the confluence of the vein of Trolard and the vein of Labbé was surgically removed, sparing these cortical veins. 4-months MR and angiographic controls showed a de novo dural arteriovenous fistula (dAVF) draining into the previously spared cortical veins. It was removed using intraoperative motor evoked potentials (MEP). This is the first case of iatrogenic dAVF developing on the same draining vein of a previously treated pAVM. De novo dAVFs are generally iatrogenic. This case suggests that the unresected venous drainage of an AVM might be the substratum for neo-angiogenetic processes; moreover inflammation related to surgery might be the trigger factor for the development of the dural arteriovenous fistula 1).


Sheinberg et al. reported the first case of DAVF causing recurrent, progressive syncope in an otherwise asymptomatic patient.

A female in her late 20s presented with a 9-year history of syncopal episodes and was found to have a DAVF. Syncopal episodes were exacerbated by positional changes, strenuous activity and emotional stressors. Symptoms occurred upon wakening and lasted for 2 to 3 hours before she was able to regain functionality. Physical examination revealed no abnormalities. Magnetic resonance imaging of the brain showed no irregularities. Magnetic resonance angiography revealed abnormal serpiginous structures in the left jugular foramen which communicated with the ascending pharyngeal branch of the left external carotid artery. Cerebral angiogram disclosed a left jugular bulb DAVF supplied by the left ascending pharyngeal and left occipital arteries. The DAVF was successfully managed by progressive endovascular embolization with coils and Onyx 34. On clinical follow-up evaluation, the patient had no further episodes of dizziness or syncope.

Only 4 cases of DAVF causing syncope have been reported, all in combination with other neurological symptoms. In comparison, they report a unique case of DAVF presenting solely with recurrent syncope, a previously undocumented finding in the literature. The case adds to other reports of nonspecific DAVF presentations and highlights the importance of considering this etiology 2).


A 55-year-old previously healthy man. Imaging was suspicious for cervicomedullary venous thrombosis and angiography failed to show evidence of arteriovenous malformation or dAVF. The patient was started on warfarin for a presumed cervicomedullary venous thrombosis and there was a significant clinical improvement. However, 3 weeks later, the symptoms recurred and repeat angiography revealed a dAVF fed by a posterior branch of the left middle meningeal artery draining into the posterior fossa vein. We postulated that warfarin caused recanalisation of the previously thrombosed venous pouch allowing for angiographic discovery and treatment of the dAVF. The dAVF was embolised with onyx resulting in the complete obliteration of the dAVF and symptomatic improvement. Although rare, some dAVF can be concealed or disappear on angiography due to thrombosis of the draining vein and warfarin can lead to recanalisation 3).


A 64-year-old male patient had exophthalmos of the left eye with redness and swelling. Digital subtraction angiography (DSA) revealed a connection between the inferolateral trunk (ILT) and the cavernous sinus (CS) that formed a high-flow DAVF that was drained only to the ophthalmic vein and no other parts of the CS. The ILT was chosen as the transarterial path for treatment because it was enlarged. The microcatheter was navigated into the ILT, and two coils were then used to occlude the ILT. After occlusion of the ILT, no image of the DAVF indicated that the ILT-CS DAVF was completely cured. The patient's symptoms improved gradually after surgery. At the 6-month follow-up visit, DSA showed no sign of ILT-CS DAVF, and the patient's eye symptoms had disappeared.

Although ILT-CS DAVF is rare, it still can be seen in clinical practice, and coiling the ILT via a transarterial approach is a good option for treatment 4).

2014

A 56-year-old man presented with disturbance of consciousness. Computed tomography demonstrated a right ASDH and a small right occipital subcortical hematoma. Cerebral angiography showed a dural AVF on the occipital convexity draining into the cortical veins. Emergent endovascular embolization was immediately performed and the shunt flow disappeared. Hematoma removal and external decompression were safely conducted. Combined therapy successfully recovered the patient's consciousness level. This rare case of dural AVF presenting with ASDH was treated with combined treatments of endovascular and open surgery 5).

2010

A male patient who showed pure acute subdural hematoma aSDH and was diagnosed as having dural arteriovenous fistula AVF on the convexity near the superior sagittal sinus (SSS), based on angiographic findings. A 27-year-old man was admitted to the hospital due to headache with acute onset. The patient did not have a history of head trauma or injury. Head CT showed an abnormal high-density area on the surface of the cerebral hemisphere on the left side, indicating acute SDH. Angiography during the arterial phase demonstrated that an abnormal artery originating from the left occipital artery was connected with a dural vein and a diploic vein on the convexity near the SSS. They concude that a dural AVF existed at this area, and that the dural AVF had caused the acute SDH. Dural AVF/AVM which causes non-traumatic SDH is usually accompanied by intracerebral hemorrhage (ICH) and/or subarachnoid hemorrhage (SAH). In contrast, non-traumatic dural AVF/AVM presenting with pure SDH is rare, and this patient represents such a rare case. We should consider dural AVF/AVM and perform angiography if necessary when we encounter a patient showing non-traumatic SDH without ICH and/or SAH 6).

2009

A patient presented with a sudden-onset severe headache, and was diagnosed with acute SDH by computed tomography. Cerebral angiography showed a DAVF on the left convexity adjacent to the superior sagittal sinus (SSS). This DAVF drained to the SSS and to the pterygoid venous plexus via the left middle fossa without retrograde flow (Type I according to the Cognard classification). The SDH was thickest at the lower convexity, which suggested that the draining vein of the DAVF was responsible for the bleeding.

The SDH slowly progressed for two weeks. The DAVF was successfully treated with transarterial embolization using N-butyl 2-cyanoacrylate. The SDH was resolved via burr-hole drainage surgery.

This is the first reported case of DAVF that caused non-traumatic progression to SDH. As DAVF can be the cause of acute and chronic SDH, cerebral angiography is recommended for non-traumatic acute SDH as well as for intractable chronic SDH 7).


1)
Diana F, Tosatto L, Haznedari N, Commodaro C, Ruggiero M. De Novo Dural Arteriovenous Fistula on Draining Veins of Previously Treated Pial Arteriovenous Malformation: a Case Report. J Stroke Cerebrovasc Dis. 2021 Apr 17;30(7):105798. doi: 10.1016/j.jstrokecerebrovasdis.2021.105798. Epub ahead of print. PMID: 33878548.
2)
Sheinberg DL, Luther E, Chen S, McCarthy D, Starke RM. Recurrent Syncope Caused by a Dural Arteriovenous Fistula: A Case Report and Review of the Literature. Neurologist. 2021 Mar 4;26(2):62-65. doi: 10.1097/NRL.0000000000000322. PMID: 33646991.
3)
Agnoletto GJ, Hoover JM, Monteiro A, Hanel RA. Catch me if you can: disappearing and reappearing posterior fossa dural arteriovenous malformation. BMJ Case Rep. 2019 Jul 10;12(7). pii: e229437. doi: 10.1136/bcr-2019-229437. PubMed PMID: 31296639.
4)
Xu K, Hou K, Xu B, Guo Y, Yu J. Dural arteriovenous fistula between the inferolateral trunk and cavernous sinus draining to the ophthalmic vein: a case report. World Neurosurg. 2018 Jun 22. pii: S1878-8750(18)31333-0. doi: 10.1016/j.wneu.2018.06.117. [Epub ahead of print] PubMed PMID: 29940382.
5)
Saito A, Kawaguchi T, Sasaki T, Nishijima M. A case of dural arteriovenous fistula presenting as acute subdural hematoma. Case Rep Neurol. 2014 Apr 30;6(1):122-5. doi: 10.1159/000362116. eCollection 2014 Jan. PubMed PMID: 24926261; PubMed Central PMCID: PMC4036125.
6)
Ogawa K, Oishi M, Mizutani T, Maejima S, Mori T. Dural arteriovenous fistula on the convexity presenting with pure acute subdural hematoma. Acta Neurol Belg. 2010 Jun;110(2):190-2. PubMed PMID: 20873450.
7)
Kohyama S, Ishihara S, Yamane F, Kanazawa R, Ishihara H. Dural arteriovenous fistula presenting as an acute subdural hemorrhage that subsequently progressed to a chronic subdural hemorrhage: case report. Minim Invasive Neurosurg. 2009 Feb;52(1):36-8. doi: 10.1055/s-0028-1085456. Epub 2009 Feb 26. PubMed PMID: 19247903.
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