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Endovascular management of dural arteriovenous fistulas has become a mainstay of treatment. In particular, modern techniques have allowed greater fistula penetration and likelihood of complete obliteration. However, the efficacy of newer agents has not been quantified outside of predominantly small case reports and case series. Furthermore, the Australian experience with fistula embolization has yet to be reported in the literature. To this aim, we performed a retrospective review of our endovascular management of a large cohort of cranial dural arteriovenous fistulas in the liquid embolic era. This retrospective case series included ninety-six consecutive patients of any Cognard grade, treated between 2005 and 2016. Liquid embolic agents were used exclusively in eighty-three cases. The overall complete obliteration rate was 89.6% with a residual fistula rate of 2%, and complication rate of 8.3%. This Sydney, Australia cohort demonstrates excellent treatment effect and safety outcomes and thus supports the primary treatment of this condition by endovascular means. [ABSTRACT FROM AUTHOR]

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 The rationale for treatment of dural arteriovenous fistulas (dAVFs) without cortical venous reflux is symptomatic resolution. Most studies of dAVF treatment, including those for stereotactic radiosurgery, have focused on angiographic obliteration instead of clinical symptomatic outcome. Methods The authors evaluated their institutional experience with stereotactic radiosurgery for cerebral dAVFs without cortical venous reflux from 1991 to 2016, evaluating angiographic and clinical outcomes, focusing on the course of pulsatile tinnitus and/or ocular symptoms after treatment. They subsequently pooled their results with those from a systematic literature review. Results Pooled outcomes data from 349 low-risk dAVF (120 patients with pulsatile tinnitus and 229 patients with ocular symptoms) were analyzed. Over a mean follow-up of 2.6 years, 77% of patients presenting with pulsatile tinnitus experienced resolution and an additional 21% had improvement, with an angiographic obliteration rate of 70.9%. Among 229 patients with ocular symptoms from carotid-cavernous dAVFs, improvement or resolution of symptoms occurred in 95% of those with chemosis, 90% of those with ophthalmoparesis, and 96% of those with proptosis. The angiographic obliteration rate was 76.2%. There were six permanent complications in 349 total treated low-risk dAVF (1.7%). Conclusions Rates of clinically significant symptomatic improvement/resolution of symptoms referable to “low-risk” dAVFs are even greater than their angiographic obliteration rate, an important factor in patient counseling and when considering the optimal treatment approach for these dAVFs. [ABSTRACT FROM AUTHOR]

There are fewer than 20 published case reports of bradycardia or asystole during intracranial embolisation procedures. These are well described in open neurosurgical procedures, particularly involving the skull base. We present a case of a 59-year-old male patient who presented for elective embolisation of a dural arteriovenous fistula. During the injection of Onyx, the patient experience sudden asystole, which recurred after a second Onyx injection. Following successful treatment, a third injection proceeded without incident. [ABSTRACT FROM AUTHOR]

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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. [ABSTRACT FROM AUTHOR]

Intracranial dural arteriovenous fistulas (DAVF) are abnormal connections between intracranial arterial and venous systems within the dural layers. Intracranial DAVFs are rare but can occur wherever dural components exist. The pathogenesis of DAVFs is controversial. Venous hypertension is considered as a main cause of clinical symptoms which are subclassified into asymptomatic, benign and aggressive manifestations. To date, several classification schemes have been proposed to stratify the natural course and risks of DAVFs. Currently, endovascular therapy is the main treatment modality. Moreover, the use of radiosurgery and radiotherapy has been limited. Open surgery is also selectively performed as a main treatment modality for specific types of DAVFs and an adjunctive modality for the endovascular approach. Herein, we present a review of the general perspectives of intracranial DAVFs with an emphasis on the role of surgery.

Background Ethmoidal dural arteriovenous fistulas (dAVFs) have a malignant natural history and an anatomy that make endovascular therapy challenging. Their uniqueness begs for stratified analyses, but this has largely been precluded by their rarity. We sought to summarize the anatomic, presentation, treatment approaches, and clinical outcomes of patients with these lesions. Methods We reviewed our prospectively maintained institutional database to identify patients diagnosed with ethmoidal dAVFs from January 1, 2000, to December 31, 2015. We evaluated demographic, presentation, angiographic, treatment, and follow-up data. Results In total, 27 patients with ethmoidal dAVFs underwent endovascular and/or surgical treatment. Mean patient age was 62 years old and there was a male sex predilection (67% men; 2:1 male-female ratio). All dAVFs exhibited direct cortical venous drainage; venous ectasia was present in 59% of cases. Of the dAVFs, 30% drained posteriorly into the basal vein of Rosenthal or the sylvian veins. Embolization with casting of the draining vein was successful in 2 of 9 cases (22%), including 1 successful transvenous case. There were no clinical or permanent complications from embolization; specifically, no patients experienced visual loss after treatment. Surgical treatment with successful dAVF obliteration was carried out in 24 of 24 patients (100%). One patient declined surgical treatment after attempted endovascular embolization. There were no permanent complications after surgical treatment and no cases of wound infection or cerebrospinal fluid leakage. Conclusions Surgical disconnection remains the gold standard in the treatment of ethmoidal dAVFs. Embolization is a consideration for well-selected cases with favorable arterial or venous access anatomy. [ABSTRACT FROM AUTHOR]

[english] Objective: Blue rubber bleb nevus syndrome is a rare vascular disease most commonly associated with venous malformations of the skin and the gastrointestinal tract. Few ophthalmic cases have been reported to date, and no clear treatment regimen exists. We describe the case of a 59-year-old man, along with a review of literature, to help in the future diagnosis and treatment of patients with the disease. Methods: This paper is an observational case report and a review of medical literature on the syndrome from 1981 to present.Results: Our patient developed a dural arteriovenous fistula in his orbit after being diagnosed with a familial form of blue rubber bleb nevus syndrome. Multiple endovascular embolization procedures eliminated all of his ocular symptoms. Surgical procedures were also successful in other cases reviewed, and similar symptoms were seen across cases.Conclusions: Comparing our case with other ophthalamic reports in literature, surgical intervention appears to be a plausible long-term treatment for optic manifestations of blue rubber bleb nevus syndrome. Systemic therapies, including sirolimus and corticosteroids, have had limited success in the long-term treatment of other forms of blue rubber bleb nevus syndrome, and therefore are not recommended in the treatment of ocular symptoms.

Dural arteriovenous fistulas (DAVFs) are direct shunts between extracranial or meningeal arteries and dural sinuses, dural veins, or cortical veins. They account for 10%-15% of all intracranial vascular malformations. DAVFs are classified according to two classification systems, Borden and Cognard, both of which are based on the venous drainage pathway and presence of antegrade or retrograde venous flow. A multidisciplinary approach using endovascular techniques has become the mainstay of treatment. We present two cases of DAVF with cortical venous drainage (Borden type 3) that were successfully treated using a transvenous approach via the draining subarachnoid veins.

Objective To explore the value of flat detector computed tomography-based vessel fusion technique for visualizing and evaluating anatomic structures and hemodynamic features of patients diagnosed with dural arteriovenous fistulas (DAVF). Methods Eleven patients with DAVF were investigated. The 3-dimensional structure of the DAVF fistula point, feeding arteries, and draining veins were reconstructed from separately acquired rotational angiographic images and then displayed as a single image in a fused manner. Results In the vessel fusion image, the tangled cluster of vessels of the DAVF could be clearly visualized from selected optimal viewing angles in the 3-dimensional space. Each component of the DAVF fistula point with its specific artery feedings and venous drainage could be identified accurately. Conclusions The vessel fusion technique gave detailed anatomic information that enabled better understanding of the DAVF structure, and facilitated an accurate interventional or surgical planning. [ABSTRACT FROM AUTHOR]

Objectives: Dural arteriovenous fistulas (DAVFs) are a challenging condition in vascular neurosurgery. Disease natural history and its management is still debated. In the present paper we report our center series on DAVFs over a period of 10 years. Our data were compared with relevant literature. Patient and methods: Our series includes 45 cases: 14 cavernous sinus, 11 transverse-sigmoid, 8 patients tentorial, 6 anterior cranial fossa, 5 patients spinal, 1 patient foramen magnum. Results and conclusions: DVAFs distribution, clinical presentation and hemorrhagic risk are discussed. Cavernous sinus DAVFs are the most common site in our series. Other locations in order of frequency are transverse-sigmoid sinus, tentorial, anterior cranial fossa, spinal and foramen magnum. The majority of patients presented with non-aggressive symptoms. 18% presented with intracranial hemorrhage: all the hemorrhages occurred in high-grade DAVFs. For most patients, endovascular treatment, transarterial or transvenous, was the first option. Surgery was performed for the anterior cranial fossa DAVFs and other complex lesions draining mostly transverse-sigmoid sinus and tentorium. In 7% of cases a combination of endovascular + surgical treatment was used. Our series has been carefully analyzed in comparison 'side by side' with most relevant literature on DVAFs, focusing particularly on management strategies, therapeutic options and risks related to treatment. [ABSTRACT FROM AUTHOR]

Background: The role of indocyanine green video-angiography (ICG-VA) in the surgical resection of vascular malformations has been largely described; conversely, the utility of ICG-VA before dural opening (transdural ICG-VA) in this situation remains unclear. The aim of this study is to present the application of transdural ICG-VA in a consecutive series of patients in order to explore the potential provided by a transdural visualisation of vascular malformations. Method: We retrospectively analysed the application of intra-operative ICG-VA before dural opening in 15 consecutive patients who underwent surgical resection of vascular malformations. The cases included 12 cerebral arterio-venous malformations (AVMs), 2 cerebral dural arterio-venous fistulas (dAVFs) and 1 spinal arterio-venous fistula (AVF). Results: ICG-VA before dural opening allowed the visualisation of the site and extension of the malformation in 13 out of 15 cases, whilst arterial feeders and venous drainages were identified in 9 out of 15 cases. In two patients with dAVF, the point of fistula could be transdurally identified through ICG-VA. In 14% of cases, the size of bone flap designed on neuronavigation data was then modified according to transdural ICG-VA findings. Conclusions: Transdural ICG-VA proved an efficient tool that allows optimising the exposure of the malformation, performing a safe dural opening and identifying dural vascular connections of the lesion. [ABSTRACT FROM AUTHOR]

Background: Massive ipsilateral edema in patients with cerebral dural arteriovenous fistula (DAVF) is poorly documented. The present study better characterizes this condition through assessment of venous anatomy and potential underlying mechanisms. Methods: One hundred and two consecutive patients diagnosed with DAVF and admitted to the Huashan Hospital from 2006 to 2012 were retrospectively reviewed for the clinical and radiologic data, and those with ipsilateral edema were recruited. An edema scale was calculated from the locations with edema on magnetic resonance imaging. We created a reflux anatomic venous scale (RAVS, including veins of Labbe, Sylvian, and Troland) based on DSA. Two experienced interventional neuroradiologists independently assessed the images and then reached consensus. The Spearman nonparametric rank correlation was performed to analyze the correlation between edema scale and RAVS. Results: Seven patients (mean 61 ± 13 years; 4 men:3 women) with ipsilateral intracranial edema were finally included. DAVF in transverse sinus with reflux flow initially in vein of the Labbe was seen in all patients. Increased edema scale was significantly correlated with increased RAVS (Spearman rho = .856, P = .014). Conclusion: The present study indicated that severe ipsilateral edema, with reflux flow initially in vein of the Labbe, was associated with the increased number of reflux anatomic veins in transverse sinus DAVF. [Copyright &y& Elsevier]

Purpose To develop a novel dynamic 3D noncontrast magnetic resonance angiography (MRA) technique that combines dynamic pseudo-continuous arterial spin labeling (dynamic PCASL), accelerated 3D radial sampling (VIPR), and time-of-arrival (TOA) mapping to provide quantitative assessment of arterial flow. Materials and Methods Digital simulations were performed to investigate the effects of acquisition scheme and sequence parameters on image quality and TOA mapping fidelity. Five patients with vascular malformations (arteriovenous malformation [AVM] = 3, dural arteriovenous fistula [DAVF] = 2) were scanned and the images were compared to digital subtraction angiography (DSA) for the ability to identify the arterial supply, AVM location, nidus size, and venous drainage. Results Digital simulations demonstrated reduced image artifacts and improved TOA accuracy using radial acquisition over Cartesian. TOA mapping accuracy is more sensitive to sampling window length than time spacing. Dynamic PCASL MRA depicted seven of eight arterial pedicles, and accurately measured the AVM nidus size when the nidus was compact. The venous drainage in the AVM patients was not consistently visualized. Conclusion Dynamic 3D PCASL-VIPR with TOA mapping is able to acquire both high temporal and spatial resolution inflow dynamics that could improve diagnosis of high-flow intracranial vascular diseases. J. Magn. Reson. Imaging 2014;39:1320-1326. © 2013 Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]

Vascular malformations of the brain are often found in the workup of intracranial hemorrhage, seizures, focal neurological deficits, or headaches. Although CT-angiography may reveal an underlying arteriovenous malformation (AVM) or arteriovenous fistula (AVF), other vascular malformations are not easily evaluated on CT and are better seen on magnetic resonance imaging. For the evaluation of AVMs and AVFs, formal digital subtraction angiography remains the gold standard. In the case of AVMs, AVFs, or cavernous malformations (CMs), the lesion may serve as the etiologic source of the symptoms and thus warrant treatment. When feasible, microsurgical resection is the optimal treatment option for AVMs and CMs. Endovascular embolization may serve as a crucial adjunct to microsurgery in the treatment of AVMs. Depending on their vascular anatomy, AVFs may be treated by either endovascular embolization or microsurgery. For inoperable AVMs and dural AVFs necessitating treatment, stereotactic radiosurgery (SRS) may serve as a viable treatment alternative. Capillary telangiectasias and developmental venous anomalies (DVAs) are often incidental findings; they may be found in association with CMs but are not generally considered targets for treatment. Herein, we review diagnostic methods, natural history, and treatment options for these cerebral vascular malformations. [ABSTRACT FROM AUTHOR]

Background: Dural arteriovenous fistulas (dAVF) may induce imaging findings attributable to various disease entities including malignant neoplasms. In these cases, diagnosis and adequate treatment are often delayed and patients may be exposed to spurious treatments in addition to the risks inherent to an untreated dAVF with cortical venous drainage., Observations: The authors report a case of a patient referred for surgical treatment of a supratentorial high-grade glioma. Thorough review of imaging data challenged the initial radiological diagnosis and led to proper angiographic workup. As a result, a high-grade dAVF was confirmed and successfully embolized. In addition to this case, we provide an extensive literature review on dAVF initially diagnosed as cerebral neoplasms, including clinical, imaging and follow-up data., Lessons: The literature provides diagnostic criteria for dAVF on magnetic resonance imaging; however, those criteria may be only partly applicable in many cases. Misdiagnosis of a neoplasm due to dAVF has been reported but remains rare, especially in supratentorial lesions. Digital subtraction angiography should be pursued to rule out an underlying vascular pathology if any doubt. This may prevent unnecessary interventions such as biopsies, pharmacological treatment and a delay in dAVF treatment, given its associated risk of hemorrhage and nonhemorrhagic neurological deficits.

Abstract: Dural arteriovenous fistulae (dAVF) with direct cortical venous drainage (CVD, Borden Type III) have a high risk of hemorrhage, particularly when symptomatic. Stereotactic radiosurgery is therefore not recommended, and endovascular treatment can be limited by access, incomplete obliteration, and recanalization. Of 70 cerebral dAVF seen at our institution over the past 8years, 35 were Borden Type III (50%). Twenty-four were treated via microsurgery (69%). Presentation included hemorrhage in nine patients (38%), nonhemorrhagic neurologic deficits in five (21%), asymptomatic in five (21%), headache in three (13%), and seizure in two patients (8%). Only eight of 19 patients with symptomatic dAVF were independent (modified Rankin Scale [mRS] 0–2) preoperatively (42%). The dAVF location was tentorial in six patients (25%), petrosal in six (25%), superior sagittal sinus in four (17%), torcular in two (7%), floor of the anterior fossa in two (7%), and sphenoid ridge, transverse-sigmoid, inferior sagittal sinus and jugular in one patient each (4%). Four patients had failed endovascular therapy (17%). The angiographic obliteration rate was 96%. The combined permanent morbidity and mortality rate was 17%. After a mean follow-up of 2.1years, 13 patients improved (54%), seven were the same, (29%) and four were worse (17%). Thirteen patients were asymptomatic (mRS 0, 54%), and 18 were independent (mRS 0–2, 75%). Our results reinforce that surgical treatment of dAVF with direct CVD is associated with a high angiographic cure rate with acceptable morbidity and mortality, particularly in light of the lesions’ natural history. [Copyright &y& Elsevier]

Abstract: Leptomeningeal venous drainage and symptomatic presentation are known risk factors for cerebral dural arteriovenous fistula (dAVF) hemorrhage. An evaluation of potentially modifiable risk factors such as hypertension and medication usage has not been undertaken to our knowledge. The authors thus reviewed a cohort of 45 consecutive patients with cerebral dAVF with leptomeningeal venous drainage and compared the rate of hemorrhagic presentation for patients with and without a history of hypertension, hyperlipidemia or the usage of certain medications. Logistic regression was performed to determine the statistical significance of associations of each factor with hemorrhagic presentation. On univariate analysis, angiotensin-converting enzyme (ACE)-inhibitors (odds ratio [OR] 0.100, 95% confidence interval [CI] 0–0.764, p =0.024) and statins (OR 0.142, 95% CI 0.025–0.825, p =0.030) were associated with a statistically significant lower rate of hemorrhagic presentation. A trend toward a lower rate of hemorrhagic presentation was seen for patients taking aspirin (OR 0.153, 95% CI 0.016–1.43, p =0.10). These trends continued on multivariate analysis; however they did not meet statistical significance (p >0.05). Beta-blockers, calcium channel blockers, warfarin and selective serotonin reuptake inhibitors did not have a statistically significant association with the rate of hemorrhagic presentation (p >0.05). Although limited by small sample size, these results may suggest a beneficial effect of statins and ACE-inhibitors on the rate of dAVF hemorrhagic presentation, potentially as a result of anti-inflammatory, anti-angiogenic or even venous antithrombotic mechanisms. Despite this study’s limitations, we hope it encourages further evaluation of potentially modifiable risk factors for vascular malformation hemorrhage. [Copyright &y& Elsevier]

Abstract: Considerable advances in our understanding of the natural history and treatment of cerebrovascular disease were made in 2012. The landmark Unruptured Cerebral Aneurysm Study in Japan was published, illustrating a significantly greater rupture risk than previously reported for small anterior and posterior communicating artery aneurysms, those with daughter domes, and giant aneurysms. Results from the Cerecyte (DePuy Synthes, West Chester, PN, USA) coil trial did not demonstrate a statistically significant positive impact of these bioactive coils on angiographic occlusion rates or outcome. The Clazosentan to Overcome Neurological Ischemia and Infarct Occurring after Subarachnoid Hemorrhage study was also published and unfortunately did not demonstrate an overall favorable long-term functional outcome rate for patients with aneurysmal subarachnoid hemorrhage receiving clazosentan. Studies furthering our understanding of the natural history and treatment of vascular malformations were also published, including large prospective natural history studies of cavernous malformations from the Mayo Clinic and the Scottish Audit of Intracranial Vascular Malformations database. Although pregnancy was found to be a significant risk factor for arteriovenous malformation hemorrhage, several studies did not demonstrate pregnancy as a significant risk factor for cavernous malformation hemorrhage. Finally, prospective randomized control trials illustrated significantly improved angiographic and clinical outcome results for both the Solitaire (ev3 Endovascular, Plymouth, MN, USA; SWIFT trial) and Trevo (Concentric Medical, Mountainview, CA, USA; TREVO 2 trial) stent retrievers as compared to the Merci (Concentric Medical) clot retriever. [Copyright &y& Elsevier]

Abstract: A retrospective study was performed to analyse a prospectively collected database from a single surgeon (M.K.M.) of transverse–sigmoid sinus dural arteriovenous fistulas (DAVF) between 1991 and August 2011. During the study period, 144 patients with 160 DAVF were managed. Sixty-five of the DAVF were located in the transverse-sigmoid sinus and 42 were treated with surgery, or embolisation and surgery. All patients who underwent surgery were symptomatic with retrograde cortical venous drainage. The average follow-up period was 18months (range, 2–82months). Total elimination of the DAVF was achieved in all instances, including two patients (5%) who required further surgery after postoperative cerebral angiography showed that some venous drainage had persisted after the first operation. There was no new permanent neurological deficit or mortality attributable to surgery. Our institutional experience shows that in selected patients with transverse–sigmoid sinus DAVF, the involved sinus can be surgically resected with a high success rate and it is as safe as many alternative options. We suggest that this definitive treatment option should be offered to patients, and the outcome should be compared to other treatment modalities. [Copyright &y& Elsevier]

Introduction: The purpose of this study was the evaluation of the safety and efficiency of the endovascular treatment of spinal dural arteriovenous fistulas (SDAVFs). Methods: Between May 1992 and August 2012, 78 patients (59 men) with an angiographically proven SDAVF with pial venous drainage were treated by endovascular embolization ( n = 61) and/or surgery ( n = 31) at three German hospitals by a single team of physicians and according to a uniform therapeutic concept. Results: Endovascular treatment resulted in a complete occlusion of the fistula in 47 cases (77 %). After failed embolization with residual shunt, 14 DAVFs were surgically cured (23 % failure rate). We had one permanent and two minor complications after endovascular therapy. Within a postoperative period of 2 weeks, 73.6 % of patients improved in gait disability, 51.1 % in micturition function, and 70.5 % in paresthesia of the lower extremities. Long-term follow-up data showed further improvement of clinical symptoms confirmed by normalization or resolution of spinal changes on MRI. Conclusions: An interdisciplinary approach to the management of SDAVFs is mandatory. Patients without a common origin of arteries supplying the spinal cord and the dural fistula, and without a stenosis or occlusion of the concerning segmental artery are potential candidates for endovascular treatment (diluted n-butyl-2-cyanoacrylate). Only occlusion of the 'nidus' and the proximal segment of the draining vein can lead to clinical improvement. [ABSTRACT FROM AUTHOR]

BSTRACT [ABSTRACT FROM AUTHOR]

There is consensus that intracranial dural arteriovenous fistulae (dAVF) with direct (non-sinus-type) or indirect (sinus-type) retrograde filling of a leptomeningeal vein should be treated due to the high risk of neurological deficits and hemorrhage. No consensus exists on treatment modality (surgery and/or embolization) and, if surgery is performed, on the best surgical strategy. This series aims to evaluate the role of surgery in the management of aggressive dAVFs. Forty-two patients underwent surgery. Opening and packing the sinus with thrombogenic material was performed in 9 of the 12 sinus-type dAVFs. In two sinus-type fistulae of the cavernous sinus and 1 of the torcular, microsurgery was used as prerequisite for subsequent embolization by providing access to the sinus. In the 30 non-sinus-type dAVFs, surgery consisted of interruption of the draining vein at the intradural entry point. In 41 patients undergoing 43 operations, elimination of the dAVF was achieved (97.6%). In one case, a minimal venous drainage persisted after surgery. The transient surgical morbidity was 11.9% ( n = 5) and the permanent surgical morbidity 7.1% ( n = 3). Our surgical strategy was to focus on the arterialized leptomeningeal vein in the non-sinus-type and on the arterialized sinus segment in the sinus-type dAVFs allowing us to obliterate all but one dAVF with a low morbidity rate. We therefore propose that microsurgery should be considered early in the treatment of both types of aggressive dAVFs. In selected cases of cavernous sinus dAVFs, the role of microsurgery is reduced to that of an adjunct to endovascular therapy. [ABSTRACT FROM AUTHOR]

We describe the case of a patient who presented with ocular symptoms (chemosis, proptosis, increased intra-ocular pressure, impaired visual acuity) eight months after the transvenous coil occlusion of an ipsilateral sigmoid sinus dural arteriovenous fistula (dAVF). Digital substraction angiography revealed a partial occlusion of the left sigmoid sinus with coils Since the connection from the sigmoid sinus to the internal jugular vein was obliterated by coils without interrupting the arteriovenous shunt, the venous drainage was redirected into the inferior petrosal sinus, the cavernous sinus and the superior ophthalmic vein. The transjugular access to the inferior petrosal sinus was obstructed by a large coil mass in the jugular bulb. Several attempts to remove these coils with an Alligator retrieval device and a goose neck snare failed. The coil mass was withdrawn via a direct access to the internal jugular vein using flexible cysto-urethroscopy grasping forceps, an urological device designed for the removal of kidney `stones After establishing anterograde drainage, the now accessible inferior petrosal sinus was occluded with fibered coils and the dAVF was completely obliterated. The ocular symptoms resolved within ten days. [ABSTRACT FROM AUTHOR]

This study aims to explore the utility of angiographic computed tomography (CT) in the diagnosis and treatment of neurovascular pathologies in the vicinity of cranial base. Two cases of cranial base dural arteriovenous fistula, one internal carotid pseudoaneurysm and one PICA aneurysm were demonstrated utilizing the angiographic CT for obtaining significant image details on the relative location of the diseases against the neighboring bony structure. An angiography suite outfitted with conventional DSA and rotational volume cone-beam was used, angiographic CT images being concomitantly produced together with the routine angiographic modalities. By virtue of the angiographic CT images integrating the selective angiography and reconstructed cranial base tomography, we succeeded in getting significant information on the relative location of various vascular diseases to the skull base, greatly facilitating the diagnosis and treatment procedures. [ABSTRACT FROM AUTHOR]

Background: True aneurysms of the ophthalmic artery (OA) are extremely rare and most often arise at the origin of this artery. We present the endovascular management of a ruptured intraorbital OA aneurysm and of an associated dural arteriovenous fistula (dAVF). Patient: A patient with a ruptured intraorbital ophthalmic artery aneurysm, associated with a dAVF with cortical drainage presented with acute visual loss and intra- and periorbital hematoma. The aneurysm was treated by endovascular coil occlusion. The dAVF was occluded by transvenous obliteration of the draining basal vein of Rosenthal. Both intraorbital ophthalmic artery aneurysms and their rupture are extremely rare. Conclusion: Transvenous treatment of dAVFs is well feasible even with very far going catheterization, in this case to the origin of the basal vein of Rosenthal. [ABSTRACT FROM AUTHOR]

This study aimed to evaluate the safety and efficiency of the endovascular treatment of transverse–sigmoid sinus dural arteriovenous fistulas (TS_dAVF). A total of 150 consecutive patients and 348 procedures were evaluated. Pulsatile tinnitus (81%), headache (15%), and intracranial hemorrhage (10%) were the most frequent manifestations of the TS_dAVFs. More than half of the affected sinuses were partially or completely thrombosed. Access-wise treatment was performed transarterial ( n = 33), transvenous ( n = 21), or a combination thereof ( n = 96). A mean of 2.4 procedures per patient was required. Immediate postprocedural occlusion rate after transarterial embolization was 30% only. Transvenous treatment alone resulted in an early occlusion rate of 81%, with delayed complete obliteration of half of the remaining fistulas. After combined transarterial/transvenous treatment, the angiographic cure rate was 54%. At follow-up, 88% of patients with residual shunt after the treatment showed complete occlusion. The cumulative complication rate was 9% ( n = 13), with minor adverse events in ten patients (7%) and major complications in three patients (2%). Transvenous coil occlusion of the sinus segment with the adjacent dAVF site, eventually combined with transarterial occlusion of supplying arteries, is a very effective and well-tolerated treatment method. In selected patients, variations of these methods (e.g., sinus stenting, compartmental sinus occlusion) can be useful. [ABSTRACT FROM AUTHOR]

Lacunar infarcts constitute a subtype of stroke with a diameter of less than 15 mm manifested by the presence of lacunar syndromes. The ischemic lesion in lacunar infarcts may often be caused by occlusion of a single, small perforating artery. However it is known that lacunar infarcts may also be associated with large artery disease, cardioembolism, and other less frequently encountered causes including antiphospholipidic syndrome, amyloid angiopathy, infectious arteritis, and inflammatory arteritis. A lacunar infarct of venous type is unusual. A 72-year-old woman presented with left hemiparesis that developed within the last several hours. She also had mild dementia for several months. Radiological examination showed a white matter lacunar infarct evidenced by restricted diffusion and T2 abnormality and dural arteriovenous fistula of the superior sagittal sinus. Because the segment distal to the fistula was occluded the fistulous flow was drained away from the sinus via retrograde flow through the cortical veins, which leaded to intracranial venous hypertension. The findings in our patient suggest that venous causes should also be considered in the differential diagnosis of lacunar infarcts. [ABSTRACT FROM AUTHOR]

Objective: The precise mechanisms responsible for the development and growth of dural arteriovenous fistula (DAVF) remain unclear, but it has been hypothesized that vascular endothelial growth factor (VEGF) might be involved in the pathogenesis. The aim of this study was to examine the expression of VEGF in the rat DAVF model. Methods: Forty-five Sprague–Dawley rats were used in two experiments. In Experiment 1 (n = 20, including sham-operated controls), VEGF expression was analysed by Western blots in three different rat DAVF models: model I: common carotid artery–external jugular vein (CCA–EJV) anastomosis (n = 5); model II: sagittal sinus thrombosis and bipolar coagulation of the vein draining the transverse sinus (n = 5); model III: CCA–EJV anastomosis and bipolar coagulation of the vein draining the transverse sinus and sagittal sinus thrombosis to induce venous hypertension (n = 5). Based on the results of Experiment 1, Western blots were performed at weekly intervals 1, 2 and 3 weeks in Experiment 2 following induction of venous hypertension in model III (n = 5 at each time point and n = 5 sham controls); in addition, VEGF expression was immunohistochemically examined in the dura and the brain near the occluded sinus in five model III animals after 1 week. Results: In Experiment 1, Western blot analysis showed barely detectable bands with molecular weights of 45 kD, corresponding to VEGF, in the sham group, but the highest level of VEGF was induced in model III, followed by models I and II (model III>model I>model II). In Experiment 2, the expression of VEGF peaked 1 week after induction of venous hypertension in model III, decreasing in a linear fashion over 2 and 3 weeks (week 1>weeks 2 and 3). The expression of immunoreactive VEGF was restricted in the connective tissue and the endothelial layer of the dura matter, cerebral cortical tissue and neurons of the basal ganglia. Conclusion: Our results strongly suggest a possible contribution of an angiogenic factor to the growth of DAVF. Venous ischemia by venous hypertension might be a mechanism for inducing up-regulation of angiogenic factor expression. [ABSTRACT FROM AUTHOR]

ABSTRACT The clinical features, imaging and angiographic findings of thirty four patients with cranial dural arteriovenous malformations and fistulae are presented in four groups. Group 1 - Seven patients with anterior cavernous malformations, predominant superior ophthalmic vein drainage, and symptoms and signs of carotico-cavernous fistula. Group 2 - Twelve patients with malformations of the superior petrosal, transverse and sigmoid sinus regions, presenting predominantly with bruit. Group 3 - Seven patients with malformations of the basal sinuses and prominent cortical venous drainage, presenting with intracranial haemorrhage, headache and impaired cortical function. Intracranial haemorrhage never occured in the absence of cortical venous drainage. Group 4 - Eight patients with infrequent manifestations. Group 1 and 2 patients are readily recognized and diagnosed. Group 3 and 4 patients are often misdiagnosed. Treatment modalities comprised embolisation therapy, surgical excision, and carotid compression. Twenty patients were treated by one or more of these modalities with a successful outcome in thirteen patients. Group 1 patients are the most amenable to trans-arterial embolisation. Carotid compression as the sole modality of treatment was successful in four patients. Unless the fistula is successfully closed, Group 3 patients and patients who present with cervical or thoracic myelopathy carry a grave prognosis. There is need for greater radiologist awareness of Group 3 and the rarer presentations, particularly myelopathy. With the exception of one patient, the morphological features of our cases are consistent with the now-accepted view that these lesions are acquired arterio-venous fistulae and not congential malformations. [ABSTRACT FROM AUTHOR]

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., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Posterior fossa dural arteriovenous fistulas are rare vascular malformations. If associated with cortical venous reflux, they present a significant risk of hemorrhage. We present a 54-year-old male who presented with progressive hearing loss without other neurologic symptoms. Further workup revealed tentorial incisura dural arteriovenous fistula with cortical venous reflux and aneurysmal dilation of venous drainage (type IV Cognard), fed from the right internal carotid artery and external carotid artery. After multidisciplinary discussion, we decided on surgical disconnection of the fistula as we felt this approach would have the highest chance of immediate and durable cure. We performed a right retrosigmoid craniotomy with (Video 1) disconnection of the arterialized veins and thus achieved completed obliteration. Follow-up angiography 8 months later showed no evidence of residual/recurrent fistula. The patient's hearing improved. There were no adverse effects during the perioperative period. [ABSTRACT FROM AUTHOR]