Search

Although Onyx is approved as an embolic material for arteriovenous malformation (AVM) and dural arteriovenous fistula (dAVF), metal artifacts due to Onyx on CT remain problematic. We report the feasibility of a metal artifact reduction (MAR) algorithm on CT angiography (CTA) in the planning of direct surgery of dAVF after transarterial Onyx embolization. A 45-year-old male patient presented with right pulsatile tinnitus, and cerebral angiography demonstrated right tentorial dAVF. As the dAVF had not completely disappeared even after Onyx transarterial embolization, we planned direct surgery. Evaluation of the lesion was difficult on normal preoperative CTA because of Onyx artifacts, but CTA using MAR enabled a detailed planning of direct surgery. Direct surgery was performed through right retrosigmoid craniotomy. Referencing CTA using MAR, we identified the draining veins originating from the main drainer, which were coagulated and cut, achieving complete occlusion of the dAVF. His symptoms disappeared with no postoperative complications. CT angiography using MAR was useful for planning direct surgery after Onyx embolization. As the incidence of direct surgery after transarterial Onyx embolization for AVM or dAVF is increasing, MAR on CTA will become more important.

In recent years, with the current access in techniques, studies have significantly advanced the knowledge on meningeal immunity, revealing that the central nervous system (CNS) border acts as an immune landscape. The latest concept of meningeal immune system is a tertiary structure, which is a comprehensive overview of the meningeal immune system from macro to micro. We comprehensively reviewed recent advances in meningeal immunity, particularly the new understanding of the dural sinus and meningeal lymphatics. Moreover, based on the clues from the meningeal immunity, new insights were proposed into the dural arteriovenous fistula (DAVF) pathology, aiming to provide novel ideas for DAVF understanding.

Dural arteriovenous fistulas (DAVFs) are rare intracranial vascular malformations that present with a variety of clinical signs and symptoms. Among these, intracranial hemorrhage is a severe complication. A 72-year-old male presented with headache and pulsatile tinnitus. Cerebral angiography revealed a Borden II/Cognard IIa+b DAVF. He underwent stage 1 transarterial embolization of the occipital artery which reduced shunting by 30%. Several attempts were made to access the fistula during stage 2 transvenous embolization, but it was not possible to access the left transverse sinus fistula site since there was no communication across the torcula from the right transverse sinus and the left inferior sigmoid–jugular bulb was occluded. Therefore, a single burr hole was drilled and direct access to the DAVF was achieved with a micropuncture needle under neuronavigational guidance. The left transverse–sigmoid sinus junction was then embolized with coils. After the procedure, angiography revealed that the DAVF was cured with no residual shunting. This case demonstrates how minimally invasive surgery provides an alternative method to access a DVAF when conventional transarterial and/or transvenous embolization treatment options are not possible. Each DAVF case has unique anatomy and physiology, and creative multi-disciplinary strategies can often yield the best results.

There are multiple treatment alternatives for cavernous dAVFs, with transvenous routes being most common. Among these routes, occluded inferior petrosal sinus is well-described, and, apart from being imaginative and elegant, it is also safe and effective. Herein we describe the application of this method to reach the fistulous pouch of a cavernous dAVF via an occluded superior petrosal sinus.

A dural arteriovenous fistula (DAVF) is a dural-based shunt between meningeal arteries and meningeal veins, sinuses and/or cortical veins; they have been classified and named according to the location and the flow pattern. Petrous apex DAVFs are located where the petrosal vein penetrates the dura mater into the superior petrosal sinus; there are only few cases reported in the literature, they can show an aggressive behaviour (subarachnoid haemorrhage, severe brainstem oedema) with a high mortality rate. The described case is, to the best of our knowledge, the first case of a DAVF presenting with symptoms mimicking idiopathic normal pressure hydrocephalus. After worsening of gait impairment, memory loss and urinary incontinence an urgent CT of the brain showed hydrocephalus and a hyperdense mass in the pineal region mimicking a pineal tumour; an emergent digital subtraction angiogram showed a left petrous apex Borden type III DAVF. A transvenous embolisation was performed obtaining a complete obliteration.

Background Pipeline embolization device (PED) has proved its safety and efficacy in the treatment of intracranial large and giant side-wall aneurysms. With the accumulation of treatment experience, it is an inevitable trend to expand its off-label use on aneurysms. Whether flow diversion is safe and efficient in cases with special angioarchitecture has rarely been explored. Methods We performed a retrospective analysis of 210 consecutive patients treated by PED for intracerebral aneurysms in our center. Except for aneurysm, those patients also presented with special angioarchitecture: Fetal PCA, AVM, V-B junction and DAVF. Results Nine patients were qualified for the study. 1 was with fetal PCA, the aneurysm remained patent on 4-month follow-up. 2 with ipsilateral AVMs, one patient died due to brain hemorrhage 20 days after the operation, the other one was only partially embolised on 6 month follow up. 3 aneurysms located at V-B junction, angiographic follow up on 3 months demonstrated no complete occlusion of both the aneurysms, the other patients were still on follow up. All of the 3 cases with concomitant DAVF are completely occluded during short to midterm follow up. Conclusions PED for aneurysms incorporated the fetal PCA and V-B junction might meet a high propensity for incomplete occlusion during short term follow up. Aneurysm with ipsilateral AVM is not suitable for PED treatment due to the risk of hemorrhage and incomplete occlusion during midterm follow up. For aneurysm with concurrent DAVF, PED treatment is safe and efficient relatively in one session or by staged operation.

LATAR BELAKANG:Cerebral venous sinus thrombosis (CVST) adalah penyakit yang jarang dikenali sehingga terlambat ditangani dan mengakibatkan komplikasi.1,2Dural arteriovenous fistula (DAVF) adalah fistula yang menghubungkan cabang arteri dural dengan vena dural. DAVF salah satu komplikasi pada kasus CVSTkronis, yang jarang ditemukan dan memiliki resiko tinggi terjadinya defisit neurologis maupun kematian.3Digital Subtraction Angiography (DSA) merupakan gold standard diagnosis fistula.3,4 Tujuan dari studi kasus ini untuk mengetahui komplikasi CVST dan penegakkan diagnosis dengan DSA.KASUS:Seorang wanita, usia 39 tahun dengan keluhan nyeri kepala kronis, pandangan mata kabur dan tinnitus telinga kiri selama 6 bulan. Pasien memiliki riwayat hipertensi dan penggunaan KB hormonal (pil esterogen). Pasien sadar penuh,disfungsi N II bilateral, motorik dan sensorik dalam batas normal. Pada pemeriksaan funduskopi didapatkan atrofi papil N II bilateral. Hasil Magnetic Resonance Imaging (MRI) didapatkan gambaran empty sella tursica, tak tampak infark, perdarahan maupun Space Occupying Lession(SOL) intrakranial. Hasil DSA menunjukkan trombus yang menyebabkan oklusi parsial pada sepertiga anterior Sinus Sagitalis Superior, Sinus Cavernosus kanan kiri, trombus yang menyebabkan oklusi total Sinus Sigmoideus kiri, dengandAVF intrakranial multipel, Cognard tipe I dan IIa. Pasien diterapi dengan antikoagulan (Class IIa;Level of Evidence B) dan diprogramkan embolisasi dAVF.KESIMPULAN:Cephalgia kronis, tinnitus dan disfungsi N II bilateral merupakan gejala klinis dari CVST.DAVF sebagai komplikasi CVST kronis ditegakkan melalui pemeriksaan DSA, yang harus segera ditindaklanjuti untuk mencegah perburukan klinis.Kata Kunci: cerebral venous sinus thrombosis, dural arteriovenous fistula, digital subtraction angiography

A 75-year-old woman with a dural arteriovenous fistula (DAVF) presented with progressive cognitive impairment including amnesia and alexia. Neuroradiological studies showed a relatively confined DAVF lesion in the left temporal lobe. The patient did not have a history of trauma and did not complain of headache or tinnitus. Amnesia and alexia dramatically improved upon treatment of the DAVF, and this was associated with attenuation of an abnormal MRI signal in the left temporal lobe. The results suggest that gradually impaired cerebral circulation due to focal venous hypertensive encephalopathy localized to the left temporal lobe and resulting from a DAVF could be involved in slowly progressive amnesia and alexia. The case also shows that an intracranial DAVF may present as a variety of neurological symptoms, depending on its localization, size and clinical stage.

Acquired arteriovenous malformations, such as is the case with dural arteriovenous fistulae (DAVF), are the consequence of a pathological new arterial ingrowth into venous spaces that reaches directly the venous lumen, without interposition of a capillary network, thereby creating an AV-shunt.The following concise text will provide elements in regards to diagnosis, indication for treatment discussion and choice of endovascular treatment (EVT) method.

Epidural skull base approach for dural arteriovenous fistulas (DAVF) of the anterior and middle cranial fossa

This paper reports that decompression of the facial nerve by transarterial Onyx embolization may relieve hemifacial spasm (HFS) caused by dilated veins due to a right petrosal dural arteriovenous fistula (DAVF). A 56-year-old man suffered severe chronic right HFS associated with a dilated right petrosal vein lying in the vicinity of the facial nerve. The right petrosal DAVF was reached through the middle meningeal artery using a transfemoral arterial approach and was occluded with Onyx 18 (M.T.I.- ev3, Irvine, CA, USA). There was complete remission of HFS without recurrence after two months of follow-up. This case supports vascular compression in the pathogenesis of HFS and suggests that facial nerve injury caused by a DAVF could be treated with transarterial Onyx embolization.

BACKGROUND AND PURPOSE: Cavernous sinuses and draining dural sinuses or veins are often visualized on 3D TOF MRA images in patients with dural arteriovenous fistulas involving the CS. Flow signals may be seen in the jugular vein and dural sinuses at the skull base on MRA images in healthy participants, however, because of reverse flow. Our purpose was to investigate the prevalence of flow signals in the pterygoid plexus and CS on 3T MRA images in a cohort of participants without DAVFs. MATERIALS AND METHODS: Two radiologists evaluated the flow signals of the PP and CS on 3T MRA images obtained from 406 consecutive participants by using a 5-point scale. In addition, the findings on 3T MRA images were compared with those on digital subtraction angiography images in an additional 171 participants who underwent both examinations. RESULTS: The radiologists identified 110 participants (27.1%; 108 left, 10 right, 8 bilateral) with evidence of flow signals in the PP alone (n = 67) or in both the PP and CS (n = 43). Flow signals were significantly more common in the left PP than in the right PP. In 171 patients who underwent both MRA and DSA, the MRA images showed flow signals in the PP with or without CS in 60 patients; no DAVFs were identified on DSA in any of these patients. CONCLUSIONS: Flow signals are frequently seen in the left PP on 3T MRA images in healthy participants. This finding may be the result of flow reversal and should not be considered to indicate occult DAVF.

A man aged 45 years sought treatment for a 5-year history of chronic headache that had worsened in the past month. There was no history of blurring of vision, diplopia, or vomiting. Physical examination …

We present a case of a patient with rapid loss of motor strength in his lower extremities. He became bedridden with bowel and bladder incontinence, and developed saddle anesthesia. MRI of the lumbar spine showed edema in the conus medullaris and multiple flow voids within the spinal canal. A spinal angiogram showed a dorsal Type I spinal AVF. This was treated successfully with Onyx 18 (eV3, Irvine, CA). The patient showed rapid post-procedure improvement, and at discharge from the hospital to a rehabilitation center he was fully ambulatory. At 3-year follow-up, the patient was found to ambulate without difficulty. He also had improved saddle anesthesia, and he was voiding spontaneously. There was no evidence of flow voids on repeat MRI of the lumbar spine.The video can be found here: http://youtu.be/SDYNIGNQIW8.

A 61-year-old man with factor V Leiden thrombophilia presented with hemorrhage and transverse sinus thrombosis (figure, A). Four years later, he developed worsening aphasia, new hemorrhage, and hemispheric edema (figure, B). Susceptibility-weighted imaging (SWI) showed bright signal in the straight sinus (figure, C). A dural arteriovenous fistula (DAVF) was diagnosed (figure, D). The brain edema improved (figure, E) and SWI sinus hyperintensity resolved after endovascular disconnection of the fistula (figure, F). The authors thank the members of the Yale–New Haven Hospital Neurovascular & Stroke Programs for discussions and critical review of the manuscript.

Dural arteriovenous fistula (dAVF) accounts for approximately 10% of all intracranial vascular malformations. While they can be benign lesions, the presence of retrograde venous drainage and cortical venous reflux makes the natural course of these lesions aggressive high risk of haemorrhage, neurological injury and mortality. Endovascular treatment is often the first line of treatment for dAVF. Both transarterial and transvenous approaches are used to cure dAVF. The selection of treatment approach depends on the angioarchitecture of the dAVF, the location, the direction of venous flow. Surgery and, to a lesser extent, stereotactic radiosurgery are used when endovascular approaches are impossible or unsuccessful.

OBJECTIVE Intracranial dural arteriovenous fistulas (DAVFs) are rare in children. This study sought to better characterize DAVF presentation, angioarchitecture, and treatment outcomes. METHODS Children with intracranial DAVFs between 1986 and 2013 were retrospectively identified from the neurointerventional database at the authors' institution. Demographics, clinical presentation, lesion angioarchitecture, treatment approaches, angiographic outcomes, and clinical outcomes were assessed. RESULTS DAVFs constituted 5.7% (22/423) of pediatric intracranial arteriovenous shunting lesions. Twelve boys and 10 girls presented between 1 day and 18 years of age; boys presented at a median of 1.3 years and girls presented at a median of 4.9 years. Four of 8 patients ≤ 1 year of age presented with congestive heart failure compared with 0/14 patients > 1 year of age (p = 0.01). Five of 8 patients ≤ 1 year old presented with respiratory distress compared with 0/14 patients > 1 year old (p = 0.0021). Ten of 14 patients > 1 year old presented with focal neurological deficits compared with 0/8 patients ≤ 1 year old (p = 0.0017). At initial angiography, 16 patients harbored a single intracranial DAVF and 6 patients had 2–6 DAVFs. Eight patients (38%) experienced DAVF obliteration by the end of treatment. Good clinical outcome (modified Rankin Scale score 0–2) was documented in 77% of patients > 1 year old at presentation compared with 57% of patients ≤ 1 year old at presentation. Six patients (27%) died. CONCLUSIONS Young children with DAVFs presented predominantly with cardiopulmonary symptoms, while older children presented with focal neurological deficits. Compared with other pediatric vascular shunts, DAVFs had lower rates of angiographic obliteration and poorer clinical outcomes.

Accumulation of contrast medium in the subdural space after diagnostic intraarterial contrast administration is a rare observation. The authors report the case of a subdural contrast effusion (SCE) presenting during endovascular treatment of an intracranial dural arteriovenous fistula (DAVF) mimicking an acute subdural hematoma. Differentiation between the two by computed tomography (CT) or intraprocedural Dyna CT and early neurological examination can be crucial for patient management. We believe that repeated large-volume contrast injections via large-bore intermediate catheters into the territory of an (even partly) occluded DAVF may induce leakage of contrast medium into the extravascular subdural space thereby causing a SCE.

Background This report addresses the feasibility of virtual injection software based on contrast-enhanced cone-beam CTs (CBCTs) in the context of cerebrovascular lesion embolization. Intracranial arteriovenous malformation (AVM), dural arteriovenous fistula (AVF) and mycotic aneurysm embolization cases with CBCTs performed between 2013 and 2020 were retrospectively reviewed. Cerebrovascular lesions were reviewed by 2 neurointerventionalists using a dedicated virtual injection software (EmboASSIST, GE Healthcare; Chicago, IL). Points of Interest (POIs) surrounding the vascular lesions were first identified. The software then automatically displayed POI-associated vascular traces from vessel roots to selected POIs. Vascular segments and reason for POI identification were recorded. Using 2D multiplanar reconstructions from CBCTs, the accuracy of vascular traces was assessed. Clinical utility metrics were recorded on a 3-point Likert scale from 1 (no benefit) to 3 (very beneficial). Results Nine cases (7 AVM, 1 AVF, 1 mycotic aneurysm) were reviewed, with 26 POIs selected. Three POIs were in 2nd order segments, 8 POIs in 3rd order segments and 15 POIs in 4th order segments of their respective arteries. The reviewers rated all 26 POI traces – involving a total of 90 vascular segments – as accurate. The average utility score across the 8 questions were 2.7 and 2.8 respectively from each reviewer, acknowledging the software’s potential benefit in cerebrovascular embolization procedural planning. Conclusion The operators considered CBCT-based virtual injection software clinically useful and accurate in guiding and planning cerebrovascular lesion embolization in this retrospective review. Future prospective studies in larger cohorts are warranted for validation of this modality.

Background hemorrhagic cerebrovascular disease due to vascular malformations represents an emergency for neurosurgery and neuro-interventional departments. During the COVID-19 pandemic, a dramatic reduction in the number of hospitalizations for acute myocardial infarction or stroke and a larger time interval from symptom onset to first medical contact have been reported. This study aims to verify the hypothesis that there would also have been a reduction of admissions for hemorrhagic cerebrovascular disease during the Italian lockdown. Material and method s A multicenter, observational survey was conducted to collect data on hospital admissions for hemorrhagic cerebrovascular disease due to vascular malformations throughout two-months (March 15th to May 15th); the years 2020 (COVID-19 Italian lockdown), 2019 and 2018 were compared. Cases were identified by ICD-9 codes 430, 431, 432.1, 432.9, 747.81 of each hospital database. The statistical significance of the difference between the event rate of one year versus the others was evaluated using Poisson Means test, assuming a constant population. Results During the 2020 lockdown, the total number of admissions for hemorrhagic cerebrovascular disease was 92 compared with 116 in 2019 and 95 in 2018. This difference was not significant. GCS upon admission was 3–8 in 44 % of cases in 2020 (41 patients), 39.7 % in 2019 (46 patients) and 28 % in 2018 (27 patients). Conclusion Reduction of admissions for hemorrhagic cerebrovascular disease due to vascular malformations during the COVID-19 lockdown was not confirmed. Nevertheless, some patients reached the emergency rooms only several days after symptoms onset, resulting in a worse clinical condition at admission.

Intracranial dural arteriovenous fistulas (DAVFs) are abnormal connections between an arterial feeder and a dural venous sinus or leptomeningeal vein with the nidus located within the dural leaflets. In this article we report an uncommon event which is a hematoma inside a dilated draining vein formed after embolization of tentorial DAVF causing pressure on the brain stem and removed surgically. A 47 years old male with a history of ventriculoperitonial (V-P) shunt 2 years ago and embolization of arteriovenous malformation 15 years ago, presented to our hospital having symptoms due to tentorial dural arteriovenous fistula (TDAVF) fed from branches of external and internal carotid arteries. Two sessions of transarterial embolization were performed with total occlusion. Six months later, he was admitted to the hospital with gait unsteadiness, swallowing difficulties and confusion. Brain MRI revealed a hyperintense heterogenous mass like a pouch from thrombosed draining veins with a localized hematoma compressing the brainstem and causing these symptoms. A small hematoma was seen and removed microsurgically. The patient was improved clinically and was discharged home after 5 days. Neurointerventionalist must be aware when deciding to occlude TDAVMs as there is a risk of venous varix formation and rupture if incompletely occluded. Surgical intervention is sometimes needed to alleviate the hazardous compression on the brain stem and other vital structures.

Rationale: Consumption of oral contraceptive pills (OCP) is a known risk factor for cerebral venous sinus thrombosis (CVST) among women. Development of dural arteriovenous fistula (dAVF) afterwards was very uncommon. We present a rare chronic complication of development of dAVF after CVST. Patient concerns: A 22-year-old woman suffered headache for a week. She was then admitted into our hospital. Diagnosis: Contrast enhanced magnetic resonance venography (MRV) demonstrated the thrombosis of the left transverse-sigmoid sinus the second day. Interventions: The intravenous thrombolysis was carried out. As the symptoms improved, the patient was discharged, while the treatment with oral dabigatran continued. However, 3 months after the onset, magnetic resonance imaging (MRI) showed swelling brainstem, and digital subtraction angiography (DSA) confirmed a dAVF. Clipping of the fistula was conducted, and her clinical symptoms improved gradually. Outcomes: The patient was transferred to rehabilitation center later, and received follow-up care. Lessons: When a patient taking OCP and suffering from a sudden headache, a clinical suspicion of possible CVST should always arise to avoid the onset of dAVF as soon as possible.

Dural Arteriovenous Fistulas (dAVF) are pathological shunts that are often idiopathic in presentation. However, it is reported that many patients presenting with dAVF have past medical histories notable for surgeries, hypercoagulation disorders, infections, and trauma. In trauma-linked dAVF, presentation generally occurs within 48 h post-incident. In the present case, the authors discuss the delayed onset of a Borden type II dAVF in a patient 12 hospital days post-trauma, as well as the course of treatment. This unique case provides a compelling demonstration for providers to be aware of the development of dAVF, even after the typical 48-hour post-trauma window. By being aware of the possibility of delayed dAVF presentation, delayed diagnosis or misdiagnosis can be avoided and emergent action can be taken.

BACKGROUND AND PURPOSE: Tentorial dural arteriovenous fistulas are characterized by a high hemorrhagic risk. We evaluated trends in outcomes and management of tentorial dural arteriovenous fistulas and performed a meta-analysis evaluating clinical and angiographic outcomes by treatment technique. MATERIALS AND METHODS: We performed a comprehensive literature search for studies on surgical and endovascular treatment of tentorial dural arteriovenous fistulas. We compared the proportion of patients undergoing endovascular, surgical, and combined endovascular/surgical management; the proportion of patients presenting with ruptured tentorial dural arteriovenous fistulas; and proportion of patients with good neurologic outcome across 3 time periods: 1980–1995, 1996–2005, and 2006–2014. We performed a random-effects meta-analysis, evaluating the rates of occlusion, long-term good neurologic outcome, perioperative morbidity, and resolution of symptoms for the 3 treatment modalities. RESULTS: Twenty-nine studies with 274 patients were included. The proportion of patients treated with surgical treatment alone decreased from 38.7% to 20.4% between 1980–1995 and 2006–2014. The proportion of patients treated with endovascular therapy alone increased from 16.1% to 48.0%. The proportion of patients presenting with ruptured tentorial dural arteriovenous fistulas decreased from 64.4% to 43.6%. The rate of good neurologic outcome increased from 80.7% to 92.9%. Complete occlusion rates were highest for patients receiving multimodality treatment (84.0%; 95% CI, 72.0%–91.0%) and lowest for endovascular treatment (71.0%; 95% CI, 56.0%–83.0%; P < .01). Long-term good neurologic outcome was highest in the endovascular group (89.0%; 95% CI, 80.0%–95.0%) and lowest for the surgical group (73.0%; 95% CI, 51.0%–87.0%; P = .03). CONCLUSIONS: Patients with tentorial dural arteriovenous fistulas are increasingly presenting with unruptured lesions, being treated endovascularly, and experiencing higher rates of good neurologic outcomes. Endovascular treatment was associated with superior neurologic outcomes but lower occlusion rates.

The authors report the treatment of a rare type of dural arteriovenous fistula of the paracavernous venous plexus. These fistulas can mimic carotid-cavernous fistulas in both imaging characteristics and clinical presentation, but the anatomical differences require differences in management. The authors describe an integrated open surgical and direct endovascular embolization approach and review of the literature pertaining to the anatomy of and treatment options for paracavernous fistulas.

Superior sagittal sinus (SSS) dural arteriovenous fistulas (DAVF) are rare and present unique challenges to treatment. Complex, often bilateral, arterial supply and involvement of large volumes of eloquent cortical venous drainage may necessitate multimodality therapy. We report a case of a DAVF of the SSS in a patient who presented uniquely with increasing dizziness and disequilibrium who was treated with a single modality, endovascular embolization with ethyl vinyl alcohol co-polymer (Onyx, EV3, Irvine, CA). The patient underwent staged embolization in 2 sessions with no complications. An angiographic cure was achieved and the patient's symptoms were ameliorated. Single modality therapy with endovascular embolization of a SSS DAVF can be achieved. Careful attention to technique during embolization with Onyx is required, but complete obliteration is possible without the need for adjunctive surgical resection.

BACKGROUND: Intraoperative microvascular Doppler may be valuable in assisting in the surgical obliteration of dural arteriovenous fistula of the spinal cord. It enables identification, through flow spectrum analysis, of the anatomic components and haemodynamic features of this type of vascular malformation. METHODS: In two cases, intraoperative microvascular Doppler was used to assist in the surgical obliteration of dural arteriovenous fistula of the spinal cord. The fistulas were identified prior to the dura opening, and for this only minimally invasive surgery was required. Direct recordings of the arterialised draining vein and the nidus of the fistula demonstrated a pathological spectrum caused by the arterial supply and the disturbed venous outflow in which a high-resistance flow pattern and low diastolic flow resembling an arterial-like flow velocity were observed. FINDINGS: The fistulas were obliterated by interruption of the draining vein, and Doppler measurements provided information on flow velocity changes in the medullary veins from an arterial to a venous pattern. The absence of any residual flow in the draining vein confirmed successful haemodynamic treatment. INTERPRETATION: Intraoperative microvascular Doppler recording is valuable assistance in surgical closure of spinal arteriovenous fistula.

Moyamoya disease (MMD) is a rare progressive steno-occlusive cerebrovascular disorder. Currently, revascularization surgery is used as optimal treatment to overcome MMD. However, revascularization for MMD has reported several complications. Also, iatrogenic complications such as pseudoaneurysms formation or dural arteriovenous fistulas (dAVFs) formation—has been identified in rare cases after the surgical intervention for revascularizations.We describe two cases. In first case, the patency of the anastomosis site was good and saccular type pseudoaneurysm formation was found at parietal branch of posterior middle meningeal artery (MMA) in transfemoral cerebral angiography (TFCA) performed on the twelfth day after surgery. We decided to treat pseudoaneurysm by endovascular embolization the next day, but the patient was shown unconsciousness and anisocoria during sleep at that day. Computed tomography showed massive subdural hemorrhage at the ipsilateral side, thus we performed decompressive craniectomy and hematoma evacuation.In second case, the patency of the anastomosis site was good and dAVF formation at right MMA was found in TFCA performed on the sixth day after surgery. We performed endovascular obliteration of the arteriovenous fistula under local anesthesia.Pseudoaneurysm formation or dAVF formation after revascularization surgery is an exceptional case. If patients have such complications, practioner should carefully screen the patients by implementing digital subtraction angiogram to identify anatomic features; as well as consider immediate treatment in any way, including embolization or other surgery

Development of de novo dural arteriovenous fistula (DAVF) at a different site after resolution of an initial DAVF, is rare. Here we report two cases, which we encountered in our hospital. A 68-year-old woman presented with pulsatile tinnitus on the left side. Cerebral angiography demonstrated a left anterior condylar confluence (ACC) DVAF and she underwent transvenous embolization. Four years after this treatment, she presented with tinnitus on the left side, and cerebral angiography revealed a right DAVF around the sinus of the lesser sphenoid wing. Another 69-year-old woman presented with left-sided orbital bruits, chemosis, and conjunctival hyperemia. Cerebral angiography showed left cavernous sinus (CS) DAVF, for which she underwent transvenous embolization for CS DAVF. One year later, she developed a left ACC and transverse-sigmoid sinus (TSS) DAVF.

Intracranial dural arteriovenous fistula (DAVF) can induce remote myelopathy via spinal perimedullary venous drainage. In the present study, we report a rare case of intracranial pial arteriovenous malformation (AVM)-related myelopathy. A 52-year-old man presented with progressive, predominantly proximal weakness and muscle atrophy in bilateral upper limbs, urinary retention, and hyperreflexia in bilateral upper and lower limbs. Brain and cervicothoracic MRI showed longitudinal myelopathy extending from the medulla oblongata to the T6 level, with perimedullary enlarged veins from the C1 to T12 level, and remarkable enhancement in bilateral anterior horns from the C2 to C7 level. Cerebral angiography revealed a choroidal fissure AVM, which was supplied by the left anterior choroidal artery and drained exclusively by an inferior ventricular vein descending toward the spinal perimedullary veins. After endovascular embolization of the feeding pedicle, nidus, and proximal segment of the draining vein, the patient's neurological deficits rapidly improved, and a significant recovery was achieved 3 months after the procedure. This rare case indicates that intracranial pial AVM can also cause extensive congestive myelopathy with similar mechanisms underlying intracranial and craniocervical DAVF cases, and gray matter in the spinal cord might be more susceptible to ischemia induced by intraspinal venous hypertension.

Background Non-hemorrhagic focal neurological deficit is one of the clinical manifestations of intracranial dural arteriovenous fistulas (DAVF). When symptoms appear suddenly, it is difficult to distinguish it from ischemic stroke in certain circumstances, which might easily lead to misdiagnosis. Here, we report a rare case of DAVF with sudden onset sensory aphasia mimicking hyperacute stroke but presented with unexpected regional hyperperfusion on the site corresponding to its symptoms. Case presentation A 76-year-old male with histories of atrial fibrillation and hypertension was admitted to the emergency department due to sudden sensory aphasia. The diagnosis of ischemic stroke was made based on clinical experience after non-contrast CT excluding hemorrhage. As in the absence of clear contraindication, the patient received intravenous thrombolysis. On the cerebral CT perfusion, the left temporal lobe, where the sensory speech center is located, was manifested as regional hyperperfusion. Thrombolysis was subsequently halted, but scheduled cranial imaging indicated hemorrhagic transformation. According to the radiological hint from cranial MRI, the patient was suspected of having DAVF, which was finally confirmed by cerebral digital subtraction angiography. Conclusion When DAVF is presented as sudden onset focal neurological deficit, cranial CT perfusion at an early stage might reveal an abnormal hyperperfusion pattern. Clinicians should be aware of the diagnostic possibility of DAVF in this situation and double-review the CT angiography image to reduce missed diagnoses.

IntroductionGalenic dural arteriovenous fistulas (dAVFs) are a rare form of dAVF and rarely described in the literature. Their distinct location requires different surgical approaches than dAVFs occurring at the nearby sites of the straight sinus and torcular Herophili, and their high risk of hemorrhage makes these dAVFs very challenging to approach surgically. In this report, we present a unique case of Galenic dAVF.Case descriptionThe patient is a 54-year-old female who presented with a 2-year history of progressive headaches, cognitive decline, and papilledema. A cerebral angiogram demonstrated a complex dAVF to the vein of Galen (VoG). She underwent transarterial embolization with Onyx-18 which resulted in minimal reduction in arterial venous shunting. She subsequently underwent a successful transvenous coil embolization resulting in complete occlusion of dAVF. The patient’s postoperative course was complicated by interventricular hemorrhage; however, she had a remarkable clinical recovery with resolution of headaches and improvement in cognitive function. A follow-up angiogram completed 6 months post-embolization demonstrated very mild residual shunting.ConclusionIn the unique case presented here, we demonstrate the efficacy of transvenous embolization via an occluded straight sinus as an alternative therapeutic option to eliminate cortical venous reflux.

BACKGROUND Dural arteriovenous fistulas (dAVFs) are aberrant vascular communications between meningeal arteries and venous sinuses or cortical veins. dAVF pathogenesis is incompletely understood; however, formation likely occurs as a result of angioneogensis. OBSERVATIONS A 78-year-old man presented after trauma with basal and cortical subarachnoid hemorrhage (SAH). Computed tomography revealed a parietal bone fracture overlying the superior sagittal sinus (SSS). Catheter angiography performed within 24 hours of the injury demonstrated an SSS dAVF supplied by the middle meningeal artery, adjacent to the fracture. LESSONS The authors present the case of an acute traumatic dAVF adjacent to a calvarial fracture. In this case, the authors proprose that the underlying pathogenesis is suggestive of direct vessel injury rather than the pathway commonly associated with this pathology.

Tinnitus and vertigo are classic symptoms of inner ear disease. Dural arteriovenous fistulas (DAVF) are a rare type of acquired intracranial vascular malformation whose symptoms mimic inner ear disease, but what distinguishes it from other tinnitus is the characteristic of DAVF is pulsatile and heartbeat-synchronous. We present a 58-year-old male with chronic left-sided pulsatile tinnitus (PT) for 30 years and continuous vertigo for 3 years that took numerous consultations to establish a diagnosis after the onset of symptoms. Delay in diagnosis is caused by normal magnetic resonance imaging and an unrecognized subtle mass in the left temporal region by time-of-flight magnetic resonance angiography (TOF-MRA) at the screening test. As we know, TOF-MRA could not provide a clear picture to establish a slow-flow DAVF. Cerebral angiography, a gold standard diagnostic, revealed a Borden/ Cognard Type I single slow-flow DAVF in the left temporal region. The patient was treated with superselective transarterial embolization. After 1 week of follow-up, the symptoms of vertigo and PT were completely resolved.

Acute subdural hematoma (ASDH), which causes midline shift of the brain, rarely arises from a dural arteriovenous fistula (DAVF). Herein, we report the first case of a DAVF manifesting ASDH, which was treated less invasively with endovascular embolization of a drainer of the DAVF and hematoma removal under neuroendoscopy. A 59-year-old man with a sudden onset of headache was transported to our hospital. Left ASDH and intracerebral hematoma in the left occipital lobe were detected. A cerebral angiogram revealed a DAVF fed by the petrosquamous branch of the left middle meningeal artery and jugular branch of the right ascending pharyngeal artery. The shunting point in the lateral tentorial DAVF drains through the internal occipital vein to the superior sagittal sinus. A varix was recognized in the draining vein (Borden type 3, Cognard type 4). The DAVF was embolized with Onyx (Medtronic, Minnesota, USA), and the left ASDH was removed with a small craniotomy under neuroendoscopy. No origin of the left ASDH was apparent in the surgical field. The patient was discharged from the hospital on postoperative day 18. The patient's status was modified Rankin scale 1 on discharge. Our management of combined endovascular treatment and neuroendoscopic hematoma removal may be useful and less invasive for hemorrhagic DAVF.

A dural arteriovenous fistula (DAVF) is an abnormal direct connection between an intracranial artery and the dural venous sinus. In rare cases, DAVF might show rapidly progressive dementia onset with extrapyramidal signs, often misdiagnosed as Parkinson disease or vascular parkinsonism and, therefore, pharmacological treatments are ineffective. Here, we report the case of 84-year-old man with rapidly progressive parkinsonism and dementia who was initially treated with levodopa without any improvement. Approximately 8 months following the symptom onset, a magnetic resonance (MR) imaging of the brain revealed bilateral and symmetrical hyperintensity of the white matter on both cerebral hemispheres on T2-weighted images. Three-dimensional and post-contrast T1-weighted images showed a subtentorial ovalar area with venous drainage alteration, and hypertrophic left occipital artery direct to venous sac. The angiography study confirmed a diagnosis of DAVF. Endovascular treatment by cook pressure technique successfully provided fistula obliteration. The patient rapidly recovered after the endovascular treatment, with restitutio ad integrum of cognitive functioning and resolution of extrapyramidal syndrome. Approximately 1 year after the endovascular treatment, a brain MR scan with angiogram-MR sequences showed almost complete disappearance of white matter alterations on both cerebral hemispheres, and normal visualization of venous system.

Background. Transvenous embolization (TVE) for dural arteriovenous fistula (DAVF) is difficult depending on an accessible route. Reported herein is a case of transvenous embolization using a balloon and a coil as “walls.” Case Description. A 56-year-old male patient presented with a 1-month history of mild motor aphasia. The magnetic resonance imaging showed a hemorrhagic lesion in his left temporal lobe, and the cerebral angiography showed a DAVF, with parasinus shunt points near the torcula and the left transverse sinus. Access to the shunt point was very difficult; however, TVE was performed using a balloon as a wall. Furthermore, all lesion embolization was possible using a coil as a wall. Conclusions. Using a balloon or coil as a wall during a TVE is useful.