Search

Background: The Onyx™ Liquid Embolic System is a non-adhesive liquid embolic agent, which has been proved by the US FDA for embolization of lesions in the peripheral and neurovasculature since 2005. We reported a case of ischemic optic neuropathy after using Onyx-18 to embolize the anterior ethmoid arteries that feeding dural arteriovenous fistulas (DAVF). Case presentation: A 57-year-old Asian male presented with anterior cranial fossa DAVF underwent embolotherapy by delivering Onyx-18 through a microcatheter into the anterior ethmoid arteries under angiography guidance. The interventional procedure was successful and no clear evidence was found pointing to untargeted occlusive embolus. But after the surgery the patient experienced delayed painless vision loss in the right eye (RE). The fundoscopy showed unilateral papilledema with pale optic disc in RE, accompanied by significant edema and thickening in the retinal nerve fiber layer (RNFL) of macula. The fundus fluorescence angiography showed that most of the optic disc in RE had postponed or absent fluorescence filling. Visual evoked potential (VEP) confirmed that the amplitude of the P100 component was decreased in RE without significant prolongation of the latency. The patient was diagnosed with anterior ischemic optic neuropathy, but immediate pulse steroid therapy failed to rescue his vision. Conclusion: Preoperative evaluation of the patient's hemodynamic status and fundus examination are essential for assessing the risk of ischemic ocular complications, and the non-adhesive liquid embolic agent Onyx-18 should be used cautiously during endovascular embolization of intracranial artery. [ABSTRACT FROM AUTHOR]

Abstract Background The Onyx™ Liquid Embolic System is a non-adhesive liquid embolic agent, which has been proved by the US FDA for embolization of lesions in the peripheral and neurovasculature since 2005. We reported a case of ischemic optic neuropathy after using Onyx-18 to embolize the anterior ethmoid arteries that feeding dural arteriovenous fistulas (DAVF). Case presentation A 57-year-old Asian male presented with anterior cranial fossa DAVF underwent embolotherapy by delivering Onyx-18 through a microcatheter into the anterior ethmoid arteries under angiography guidance. The interventional procedure was successful and no clear evidence was found pointing to untargeted occlusive embolus. But after the surgery the patient experienced delayed painless vision loss in the right eye (RE). The fundoscopy showed unilateral papilledema with pale optic disc in RE, accompanied by significant edema and thickening in the retinal nerve fiber layer (RNFL) of macula. The fundus fluorescence angiography showed that most of the optic disc in RE had postponed or absent fluorescence filling. Visual evoked potential (VEP) confirmed that the amplitude of the P100 component was decreased in RE without significant prolongation of the latency. The patient was diagnosed with anterior ischemic optic neuropathy, but immediate pulse steroid therapy failed to rescue his vision. Conclusion Preoperative evaluation of the patient’s hemodynamic status and fundus examination are essential for assessing the risk of ischemic ocular complications, and the non-adhesive liquid embolic agent Onyx-18 should be used cautiously during endovascular embolization of intracranial artery.

Dual-lumen balloon microcatheters allow for controlled anterograde flow of Onyx while providing proximal flow arrest, thereby obviating the need for a second microcatheter or Onyx plug formation. We sought to assess the safety and efficiency of the Scepter dual-lumen balloon microcatheter in trans arterial Onyx embolization of intracranial dural arteriovenous fistulas (DAVFs). We conducted a retrospective study of 36 patients with cranial DAVFs in which a Scepter balloon microcatheter was used between 2016 and 2023. Our study comprised 36 patients, mostly male (n = 23, 63.8%) with a mean age of 60.8 years. Most DAVFs were in the occipital lobe (n = 24, 66.7%), and 50% had external carotid artery supply from the occipital artery. Eighteen (50%) of DAVFs were Cognard type III and IV, respectively. About one third (33.3%, n = 12) of the DAVFs drained into the transverse sigmoid junction, and 27.7% (n = 10) had direct cortical venous drainage into supratentorial or posterior fossa veins. Complete occlusion was obtained in 22 (61.1%) patients while partial occlusion was observed in 14 (38.9%) patients. One patient (2.8%) developed a retroperitoneal hematoma. At final follow-up, complete occlusion was observed in 21 (77.8%) and partial occlusion was observed in 8 (22.2%). Recurrence was observed in 4/30 (13.3%) patients, and retreatment was required in 6 (18.75%) cases. At midterm follow-up, our study showed low morbidity and modest complete occlusion rates using the Scepter for transarterial Onyx embolization of high-grade DAVFs. [ABSTRACT FROM AUTHOR]

Cerebellar mutism syndrome (CMS) is a frequent complication of surgical intervention on posterior fossa in children. It has been only occasionally reported in adults and its features have not been fully characterized. In children and in young adults, medulloblastoma is the main reason for neurosurgery. A single case of postsurgical CMS is presented in an adult patient with a cerebellar hemorrhage and a systematic review of the published individual cases of CMS in adults was done. Literature review of individual cases found 30 patients, 18/30 (60%) males, from 20 to 71 years at diagnosis. All but one case was post-surgical, but in one of the post-surgical cases iatrogenic basilar artery occlusion was proposed as cause for CMS. The causes were: primary tumors of the posterior fossa in 16/22 (72.7%) metastasis in 3/30 (10%), ischemia in 3/30 (10%) cerebellar hemorrhage in 3/30 (10%), and benign lesions in 2/30 (6.7%) patients. 8/30 patients (26.7%) were reported as having persistent or incomplete resolution of CMS within 12 months. CMS is a rare occurrence in adults and spontaneous cerebellar hemorrhage has been reported in 3/30 (10%) adult patients. The generally accepted hypothesis is that CMS results from bilateral damage to the dentate nucleus or the dentate-rubro-thalamic tract, leading to cerebro–cerebellar diaschisis. Several causes might contribute in adults. The prognosis of CMS is slightly worse in adults than in children, but two thirds of cases show a complete resolution within 6 months. [ABSTRACT FROM AUTHOR]

Central nervous system (CNS) dural arteriovenous fistulas (DAVF) have been reported in PTEN‐related hamartoma tumor syndrome (PHTS). However, PHTS‐associated DAVF remain an underexplored field of the PHTS clinical landscape. Here, we studied cases with a PTEN pathogenic variant identified between 2007 and 2020 in our laboratory (n = 58), and for whom brain imaging was available. Two patients had DAVF (2/58, 3.4%), both presenting at advanced stages: a 34‐year‐old man with a left lateral sinus DAVF at immediate risk of hemorrhage, and a 21‐year‐old woman with acute intracranial hypertension due to a torcular DAVF. Interestingly, not all patients had 3D TOF/MRA, the optimal sequences to detect DAVF. Early diagnosis of DAVF can be lifesaving, and is easier to treat compared to developed, proliferative, or complex lesions. As a result, one should consider brain MRI with 3D TOF/MRA in PHTS patients at genetic diagnosis, with subsequent surveillance on a case‐by‐case basis. [ABSTRACT FROM AUTHOR]

Intracranial dural arteriovenous fistulae (DAVFs) represent a subset of cerebral vascular malformations associated with significant morbidity and mortality. In Japan, DAVF exhibits sex-based differences in anatomical distribution, with female predominance in the cavernous sinus (CS) and male predominance in the transverse sinus (TS). Nevertheless, the pathophysiology of DAVF is not fully understood, and hormonal influences are hypothesized to play a role in its development. This study aimed to investigate changes in the concentrations of sex steroid hormones between intracranial and peripheral sampling sites in patients with CS- and TS-DAVF. We recruited 19 patients with CS-DAVF (n = 12) and TS-DAVF (n = 7) in this study. Blood hormone measurements were obtained from peripheral and jugular bulb samples during endovascular intervention. Hormone concentrations were analyzed using enzyme-linked immunosorbent assay kits, and statistical analyses were performed. Our study revealed a higher prevalence of CS-DAVF in females and TS-DAVF in males, which is consistent with previous studies. Estradiol concentration was significantly lower in the jugular bulb compared with in the periphery in both patients with CS- and TS-DAVF. This decrease in estradiol was observed irrespective of the patient's sex and independent of follicle-stimulating hormone levels. These findings indicate a local decrease in estradiol levels within the intracranial vasculature of patients with DAVF. This suggests a potential multifactorial role of estradiol in the pathomechanism of DAVFs, warranting further investigation to understand its influence on DAVF formation and potential targeted therapies, thereby enhancing patient outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Dural arteriovenous fistula (DAVF) is an uncommon malformation involving an abnormal connection between dural arteries, or the pachymeningeal branches of cerebral arteries, and dural veins. Its exact pathogenesis remains elusive. Known potential triggers for DAVF include cerebral venous sinus thrombosis (CVST), trauma, ear infections, and cranial surgeries. Due to its rarity and diverse clinical presentations, diagnosing DAVF can be a challenge. Case description: We present a case of DAVF associated with CVST, manifesting as rapidly advancing parkinsonism accompanied by dementia over a month. Brain magnetic resonance imaging (MRI) revealed bilateral symmetric T2 hyperintensities in the basal ganglia and brain stem. Cerebral angiography further confirmed a fistula between the torcular herophili and the transversesigmoid sinuses. Despite strong recommendations for transvenous embolization of the fistula, the patient declined the procedure. The anticoagulant therapy and symptomatic treatments administered did not yield any improvement in the patient's condition. Additionally, we reviewed 27 DAVF-derived parkinsonism and dementia cases. Conclusion: DAVF must be considered in the differential diagnosis of cases of rapidly progressive parkinsonism with concurrent dementia. Given its potential for treatment and reversibility, timely diagnosis and intervention for DAVF are paramount. [ABSTRACT FROM AUTHOR]

Endovascular treatment is the primary treatment modality for dural arteriovenous fistulas (DAVFs). We performed a retrospective analysis of DAVFs treated in our hospital to determine if high-quality endovascular treatment can be provided in a medium-volume vascular center. From 2007 to 2021, 69 DAVF treatments were undertaken in our hospital. Of these DAVFs, 55 were endovascular, 11 were open surgical procedures, and 3 were Gamma Knife treatments. Of the endovascular treatments, 10 (18.2%) were in ruptured DAVFs. The most common location of endovascularly treated DAVFs was at the transverse/sigmoid sinus (32.7%) and at the cavernous sinus (25.5%). Of the endovascularly treated DAVFs, 38.2% were low-grade fistulas (Cognard I/IIa), whereas 61.8% were high-grade fistulas (Cognard ≥IIb). 58.2% of fistulas were treated transarterially. DAVFs located in the cavernous sinus were treated using coils alone, whereas most other DAVFs were treated with liquid embolics alone or in combination with coils. Complete or near-complete cure was achieved in 74.5% of treatments, whereas 18.2% of treatments resulted in downgrading of the fistula. Twelve patients were retreated once (9 endovascularly) and 1 patient was retreated twice. After retreatment, complete or near-complete cure was achieved in 86.4% of patients. 72.7% of treatments were performed without any remnant or retreatment. There were no procedure-related deaths. One patient experienced a complication resulting in permanent neurologic deficits. Seven other complications (12.7%) were recorded, all asymptomatic or causing only temporary symptoms. Based on our findings, we conclude that high-quality treatment of DAVFs can be provided in a medium-volume vascular center. [ABSTRACT FROM AUTHOR]

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.

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. [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. [ABSTRACT FROM AUTHOR]

A dural arteriovenous fistula involving the superior petrosal vein (SPV DAVF) is an extremely rare condition. Therefore, its clinical presentation, imaging characteristics, treatment methods, and risk factors remain unclear. In this study, we discuss and analyze the aforementioned features of an SPV DAVF. We retrospectively reviewed 30 patients with SPV DAVFs, with a 1-year follow-up rate of 96.67% (29 of 30). The neurological function of the patients was assessed using the modified Aminoff-Logue scale and the modified Rankin Scale score. The risk factors before and after treatment were established using univariate and multivariate logistic regression analyses. Additionally, treatments involving 3 distinct SPV DAVF drainage patterns were presented. Of the 30 patients, 24 were men (80.0%). Besides, the angiography images were reexamined 12 months after surgery. Univariate analyses indicated that the extent of edema (odds ratio 1.889, 95% confidence interval 1.132–3.154) and the number of draining veins (≤2) (odds ratio 10.833, 95% confidence interval 1.961–59.834) were risk factors for pretreatment modified Rankin Scale score ≥3. However, multivariate analyses revealed no statistically significant differences (P = 0.051, P = 0.055). Following the multivariate analyses, steroid pulse (odds ratio 12.153 95% confidence interval 1.080–136.772) was found to be the only significant risk factor for post-treatment difference between pretreatment and 1-year follow-up modified Rankin Scale score ≥2. A DAVF with SPV drainage is an uncommon type of intracranial vascular malformation. Most lesions involve the brain stem or high cervical spinal cord, thereby posing a higher risk of disability or death. Moreover, neuronal damage from persistent venous hypertension is permanent. Therefore, precise diagnosis and timely treatment are key to a good patient prognosis. [ABSTRACT FROM AUTHOR]

Isolated sinus dural arteriovenous fistulas (DAVFs) involve a dural sinus with occlusion on both sides of the diseased sinus segment. Because of venous drainage refluxing from the isolated sinus into the cortical veins, all isolated sinus DAVFs are Borden type III or Cognard type Ⅲ/Ⅳ. Venous drainage typically involves temporo-occipital cortical veins or the superior petrosal sinus and tributaries of the petrosal vein. However, drainage veins involving the perimedullary venous system are extremely rare. Here, we present a case of Cognard type V isolated sinus DAVF successfully treated with balloon catheter and Onyx. [ABSTRACT FROM AUTHOR]

Purpose: Endovascular treatment represents the first-line therapy for cavernous sinus dural arteriovenous fistulas (CS-dAVF); however, different approaches and embolic agents as well as occlusion rates, complications and clinical outcomes are reported among the published series. In this study we performed a comprehensive meta-analysis to investigate clinical and radiological outcomes after endovascular treatment of CS-dAVFs. Methods: PubMed, Ovid Medline, Ovid EMBASE, Scopus, and Web of Science were screened for a comprehensive literature review from 1990 to 2020 regarding series of patients treated for CS-dAVF with endovascular approaches. We performed a proportion meta-analysis estimating the pooled rates of each outcome also including data of patients treated in our center. Results: A total of 22 studies reporting 1043 patients and 1066 procedures were included. Chemosis was reported in 559 out of 1043 patients (45.9%), proptosis in 498 (41.5%), and ophthalmoplegia in 344 (23.5%). A transvenous embolization was preferred in 753 cases (63.2%) and coils were used in 712 out of 1066 procedures (57.8%). Overall, 85% (95% confidence interval, CI 69.5–96.1%) of patients had a complete resolution of symptoms, while complications occurred in 7.75% (95% CI 3.82–12.7%) with minimal permanent deficits (0.15%). The mortality rate was 1 out of 1043 patients (< 0.001). Conclusion: A transvenous coiling is the most common endovascular approach for CS-dAVF, achieving a high percentage of radiological and clinical resolution and low complication rates. Transvenous approaches show less complications than transarterial ones, and coils appear safer than liquid embolic agents. [ABSTRACT FROM AUTHOR]

Dural arteriovenous fistulas are contained within the dural leaflets, making them a unique arteriovenous shunt of the central nervous system. Those without cortical venous drainage may be found incidentally or in a workup of pulsatile tinnitus or ocular symptoms. These symptoms may also occur in the setting of cortical venous drainage, but additionally, seizures, neurological deficits, or even frank hemorrhage may occur because of disruption of normal parenchymal venous outflow and resultant venous hypertension. In the setting of debilitating symptomatology or cortical venous drainage, management is most often via endovascular therapy via transarterial or transvenous access to the fistulous site and subsequent obliteration. Surgical disconnection and radiosurgical obliteration are excellent alternative treatment options for appropriately selected lesions as well. In this article, background demographic and natural history data as well as treatment approaches are reviewed.

Abstract 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.

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.

Background: Cognitive decline is a non‐hemorrhagic, major complication of intracranial dural arteriovenous fistula (DAVF), thought to be primarily related to venous hypertension. However, imaging features to predict cognitive decline are scanty in the literature. Purpose To evaluate functional connectivity (FC) changes of resting‐state networks (RSNs) in DAVF before and after treatment and its relation to cognitive impairment. Study Type: Prospective. Subjects: DAVF subjects were screened for inclusion. Pre‐embolization (N = 33, mean age 45.9 years, 29 males), 1 month post‐embolization (N = 20, mean age 42.7 years, 19 males), and healthy controls (HC, N = 33, mean age 45.09 years, 27 males). Field Strength/Sequence: 3.0 T, resting‐state functional magnetic resonance imaging (MRI), three‐dimensional (3D) T1, T2 fast spin echo (FSE), diffusion weighted imaging (DWI), susceptibility weighted imaging (SWI), fluid‐attenuated inversion recovery, and time of flight. Assessment Data quality assessment was performed. FC analysis was done using group independent component analysis (ICA) and seed to voxel analysis. Neuropsychology (NP) scores of patients were compared with HC and correlated with FC changes. Statistical Tests: Voxel‐wise parametric T‐statistics for F‐test was executed in FC analysis (p‐FDR corrected <0.05). NP scores between DAVF group and HC group were compared using one‐way analysis of variance with post hoc Bonferroni correction (P < 0.05). Results: Both RSNs analysis methods showed reduced FC at the precuneus‐posterior cingulate cortex (PC‐PCC) of default mode network (DMN), anterior cingulate cortex (ACC) of the salience network (SN), and possible compensatory increased connectivity at the frontoparietal (FPN) and dorsal attention (DAN) networks. DAVF with low NP scores showed reduced FC at DMN and SN and minimal to absent connectivity at FPN and DAN. At post‐embolization 1‐month follow‐up, improvement in FC at PC‐PCC of DMN and ACC of SN were noted. Data Conclusion: RS‐fMRI in DAVF displayed FC changes that may be related to cognitive decline and its subsequent reversibility after treatment. FC changes at DMN, SN, FPN, and DAN were linked to cognitive decline and the corresponding NP scores. Level of Evidence: 2 Technical Efficacy: Stage 2 [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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.

Cranial dural arteriovenous fistulas (dAVFs) are rare acquired neurovascular disorders that have the potential to profoundly alter the local and global cerebral venous drainage. Factors such as location, angioarchitecture, degree of shunting, and mode of presentation all appear to have some bearing on the natural history of dAVFs, which can vary from almost entirely benign to life-threatening. Accurate and evidence-based risk stratification is, therefore, key to informing important management decisions. The treatment strategies are nuanced and, for an already rare entity, can vary tremendously from 1 fistula to another. It is only through a thorough understanding of their behavior and the treatment options available that we will be able to deliver tailored treatment to the correct dAVF and the correct patient. We aimed to provide an up-to-date summary of the reported data on the natural history and predictors of aggressive behavior for cranial dAVFs in general, followed by site-specific management considerations. [ABSTRACT FROM AUTHOR]

Dural arteriovenous fistulas (DAVFs) are rare vascular abnormalities that can present with diverse neurological symptoms. We report a case of a woman in her early 60s who presented with pain in the left ear and dizziness. Neurological evaluation and imaging studies revealed a DAVF in the left cerebellopontine angle. This case underscores the importance of considering DAVF as a potential etiology in patients presenting with atypical otological symptoms., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, El Atrache et al.)

Objective: To describe the diagnostic features of intracranial dural arteriovenous fistulae (DAVF) presenting with cervical cord or brainstem swelling. Methods: Retrospective case note and neuroimaging review of patients with angiographically confirmed DAVF diagnosed during January 2015–June 2020 at a tertiary neuroscience centre (Walton Centre NHS Foundation Trust, Liverpool, UK). Results: Six intracranial DAVF causing cervical cord or brainstem oedema (all males aged 60–69 years) and 27 spinal DAVF (88% thoracolumbar) were detected over a 5.5-year period. Significantly more patients with intracranial DAVF received steroids for presumed inflammatory myelitis than those with spinal DAVF (5/6 vs 1/27, p = 0.0001, Fisher's exact test). Several factors misled the treating clinicians: atypical rostral location of cord oedema (6/6); acute clinical deterioration (4/6); absence (3/6) or failure to recognise (3/6) subtle dilated perimedullary veins on MRI; intramedullary gadolinium enhancement (2/6); and elevated CSF protein (4/5). Acute deterioration followed steroid treatment in 4/5 patients. The following features may suggest DAVF rather than myelitis: older male patients (6/6), symptomatic progression over 4 or more weeks (6/6) and acellular CSF (5/5). Conclusion: Intracranial DAVF are uncommon but often misdiagnosed and treated as myelitis, which can cause life-threatening deterioration. Neurologists must recognise suggestive features and consider angiography, especially in older male patients. Dilated perimedullary veins are an important clue to underlying DAVF, but may be invisible or easily missed on routine MRI sequences. [ABSTRACT FROM AUTHOR]

Asystole or bradycardia is a relatively uncommon side effect seen in patients undergoing endovascular embolization using dimethylsulfoxide based liquid embolic agents. We present a case of a patient who underwent dural arteriovenous fistula embolization and experienced bradycardia during Onyx injection but was stabilized and the procedure was completed successfully. [ABSTRACT FROM AUTHOR]

A 75-year-old man presented with bilateral frontal hematomas owing to a dural arteriovenous fistula involving an isolated segment of the superior sagittal sinus. After an unsuccessful attempt of transarterial endovascular embolization of the dural arteriovenous fistula, the fistula was occluded using a transvenous approach through recanalization of the occluded superior sagittal sinus. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Introduction: Dural arteriovenous fistulae (DAVF) are vascular lesions with arteriovenous shunting that may be treated with surgical obliteration or endovascular embolization. Some DAVF, such as anterior cranial fossa DAVF (AC-DAVF) derive their arterial supply from ophthalmic artery branches in nearly all cases, and trans-arterial embolization carries a risk of vision loss. We determined the efficacy and safety of trans-ophthalmic artery embolization of DAVF. Materials and methods: We performed a retrospective cohort study of all patients with DAVF treated by trans-ophthalmic artery embolization from 2012 to 2020. Primary outcome was angiographic cure of the DAVF. Secondary outcomes included vision loss, visual impairment, orbital cranial nerve injury, stroke, modified Rankin Scale at 90-days, and mortality. Results: 12 patients met inclusion criteria (9 males; 3 females). 10 patients had AC-DAVF. Patient age was 59.7 ± 9.5 (mean ± SD) years. Patients presented with intracranial hemorrhage (4 patients), headache (4 patients), amaurosis fugax (1 patients), or were incidentally discovered (2 patients). DAVF Cognard grades were: II (1 patient), III (6 patients), and IV (5 patients). DAVF were embolized with Onyx (10 patients), nBCA glue (1 patient), and a combination of coils and Onyx (1 patient). DAVF cure was achieved in 11 patients (92%). No patients experienced vision loss, death, or permanent disability. One patient experienced a minor complication of blurry vision attributed to posterior ischemic optic neuropathy. 90-day mRS was 0 (10 patients) and 1 (2 patients). Conclusions: Trans-ophthalmic artery embolization is an effective and safe treatment for DAVF. [ABSTRACT FROM AUTHOR]

Tentorial dural arteriovenous fistulas (DAVFs) are a dangerous subtype of fistula. Lawton et al classified this type of fistula into 6 categories based on specific operative strategies. Clinical manifestations of 6 types of tentorial DAVFs vary to some extent. Cognard type V DAVFs in the tentorial region are usually petrosal/superior petrosal sinus DAVFs. DAVFs with perimedullary venous drainage around the torcular herophili are rare. The veins of the posterior fossa are intricate and variable. There are anatomic communications between the perimedullary vein and cerebellar vein or veins of the brainstem. Almost all of the Cognard type V DAVFs are found in the posterior fossa. Here, we present a Cognard type V DAVF with a fistula located around the torcular herophili. [ABSTRACT FROM AUTHOR]

Abstract 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.

• Dual-lumen balloon catheters, such as Scepter, can be used for embolization. • Scepter is used for arteriovenous malformations and dural arteriovenous fistulas. • Scepter is effective and safe when compared to single-lumen devices. Endovascular embolization of arteriovenous malformations (AVMs) and dural arteriovenous fistulas (DAVFs) has become the mainstay in treatment for these pathologies. Traditional techniques required the formation of a proximal plug of Onyx around the microcatheter prior to embolization to avoid reflux. Recently, dual-lumen balloon catheters have been introduced as a potential solution to this issue. We sought to compare our institutional experience with dual-lumen balloons to traditional microcatheters in the endovascular embolization of AVMs and DAVFs. A retrospective analysis of consecutive patients treated with Scepter between 2016 and 2020 was obtained. A control cohort treated with Marathon between 2012 and 2020 was also obtained. Variables collected included patient demographics, procedure times, pedicles treated, operative complications, obliteration rate, and retreatment rate. A total of 44 trial (30 DAVFs and 14 AVMs) and 25 control (15 DAVFs and 10 AVMs) subjects were identified. Average Scepter procedure times were 66.0 and 68.0 min for DAVFs and AVMs, respectively. Average Scepter volume of Onyx injected was 2.2 and 1.4 mL for DAVFs and AVMs, respectively. Complete angiographic occlusion Scepter rate was 86.7% and 50.0% for DAVFs and AVMs, respectively. The Scepter retreatment rate was 13.3% and 50.0% for DAVFs and AVMs, respectively. Predictors of angiographic occlusion included the number of pedicles (OR 0.54, 95%CI 0.30–0.97, p = 0.04). Predictors of retreatment included DAVF (OR 0.16, 95%CI 0.04–0.66, p = 0.01) and Marathon (OR 3.34, 95%CI 1.00–11.56, p = 0.05). Our study shows that dual-lumen balloon catheters are a viable option in the embolization of DAVFs and AVMs. [ABSTRACT FROM AUTHOR]

Dural arteriovenous fistulas (dAVFs) can often be successfully treated with endovascular embolization; however, surgery is occasionally still required. Herein, we discuss a 65-year-old male patient who presented with a Hunt-Hess IV subarachnoid hemorrhage, intraventricular hemorrhage, and cerebellar intracranial hemorrhage secondary to a ruptured Borden type III tentorial (straight sinus) dAVF. Angiography revealed supply from the left occipital and posterior meningeal arteries and direct drainage into the cerebellar cortical veins with venous aneurysms in both cerebellar hemispheres. Both transarterial and transvenous embolization were attempted, without success. Therefore, the patient was taken to the operating room for clip ligation of the dAVF. The operative video demonstrates a bilateral suboccipital craniotomy and supracerebellar infratentorial approach for surgical clipping of the dAVF. The case and operative video provide a valuable addition to surgical literature in an era where surgical management of dAVFs has become relatively rare. [ABSTRACT FROM AUTHOR]

One of the merits of exoscopes, including ORBEYE, is that they are superior to a microscope in terms of ergonomic features. We report a case of dural arteriovenous fistula (dAVF) that was cured by direct surgery using the ergonomic advantages of ORBEYE. A 78-year-old man was found to have dAVF of the anterior cranial fossa incidentally. We performed direct surgery via bifrontal craniotomy. Because the frontal sinus was large, we reserved the frontal bone-like eaves in order not to open the frontal sinus. The vertex of his head was sufficiently down to shift the frontal lobe downward with gravity. During surgery, we set the angle of the operative visual axis of ORBEYE approximately horizontal to avoid the reserved frontal bone. We performed a stable operation using ORBEYE in a comfortable posture. ORBEYE facilitates ergonomic microsurgery, even under the eaves, with the angle of the operative visual axis approximately horizontal using gravity. [ABSTRACT FROM AUTHOR]

The interpretation of cerebral venous pathologies in paediatric practice is challenging as there are several normal anatomical variants, and the pathologies are diverse, involving the venous system through direct and indirect mechanisms. This paper aims to provide a comprehensive review of these entities, as their awareness can avoid potential diagnostic pitfalls. We also propose a practical classification system of paediatric cerebral venous pathologies, which will enable more accurate reporting of the neuroimaging findings, as relevant to the underlying pathogenesis of these conditions. The proposed classification system comprises of the following main groups: arterio-venous shunting–related disorders, primary venous malformations and veno-occlusive disorders. A multimodal imaging approach has been included in the relevant subsections, with a brief overview of the modality-specific pitfalls that can also limit interpretation of the neuroimaging. The article also summarises the current literature and international practices in terms of management options and outcomes in specific disease entities. [ABSTRACT FROM AUTHOR]

Objective: In contrast to high-grade dural arteriovenous fistula (dAVF), low-grade dAVF is mainly associated with tinnitus and carries a low risk of morbidity and mortality. It remains unclear whether the benefits of active interventions outweigh the associated risk of complications in low-grade dAVF., Methods: The authors conducted a retrospective single-center study that included all consecutive patients diagnosed with an intracranial low-grade dAVF (Cognard type I and IIa) during 2012-2022 with DSA. The authors analyzed symptom relief, symptomatic angiographic cure, treatment-related complications, risk for intracerebral hemorrhage (ICH), and mortality. All patients were followed up until the end of 2022., Results: A total of 81 patients were diagnosed with a low-grade dAVF. Of these, 48 patients (59%) underwent treatment (all primary endovascular treatments), and 33 patients (41%) did not undergo treatment. Nine patients (19%) underwent retreatments. Angiographic follow-up was performed after median (IQR) 7.7 (6.1-24.1) months by means of DSA (mean 15.0, median 6.4 months, range 4.5-83.4 months) or MRA (mean 29.3, median 24.7 months, range 5.9-62.1 months). Symptom control was achieved in 98% of treated patients after final treatment. On final angiographic follow-up, 73% of patients had a completely occluded dAVF. There were 2 treatment-related complications resulting in 1 transient (2%) and 1 permanent (2%) neurological complication. One patient showed recurrence and progression of a completely occluded low-grade dAVF to an asymptomatic high-grade dAVF. No cases of ICH- or dAVF-related mortality were found in either treated patients (median [IQR] follow-up 5.1 [2.0-6.8] years) or untreated patients (median [IQR] follow-up 5.7 [3.2-9.0] years)., Conclusions: Treatment of low-grade dAVF provides a high rate of symptom relief with small risks for complications with neurological sequela. The risks of ICH and mortality in patients with untreated low-grade dAVF are minimal. Symptoms may not reveal high-grade recurrence, and radiological follow-up may be warranted in selected patients with treated low-grade dAVF. An optimal radiographic follow-up regimen should be developed by a future prospective multicenter registry.

Background: Dural arteriovenous fistulas (DAVF) are commonly encountered lesions that can be treated both transvenously, transarterially or using a combined approach. Objective: Transvenous coil embolization of DAVF is a recognized treatment option but can be challenging. In this context this article presents clinical experience using the Kaneka ED10 ExtraSoft coils in combination with the Marathon microcatheter to treat high grade DAVF. The physical properties of these coils and the microcatheter were also determined. Material and Methods: All patients with high grade DAVF treated with the Marathon and the Kaneka ED COIL ∞10 ExtraSoft coils were retrospectively identified. The clinical presentation, location, grade of the lesion, clinical and radiological follow-up data were recorded. Bench side studies were performed to determine the physical properties of the Marathon catheter in comparison to the SL10 and Headway Duo as well the maximum width of the Kaneka pusher wire in comparison to Hypersoft, Target and Axium Prime coils. Results: A total of 8 patients with 9 DAVF with 3 Cognard 3 and 6 Cognard 4 lesions were identified. All the DAVF's were occluded either at the end of the procedure or on follow-up imaging. On bench side tests the Marathon microcatheter had the most flexible distal tip and distal shaft in comparison to the SL10 and Headway Duo. The proximal shaft of the Marathon was stiffer than the SL10. The Kaneka ED COIL ∞10 ExtraSoft had the smallest distal width and were the only coils tested that could be deployed through a Marathon microcatheter. Conclusion: The combination of the Marathon microcatheter and Kaneka ED COIL ∞10 ExtraSoft is useful for the treatment of high grade DAVF. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

The association between a dural arteriovenous fistula (dAVF) and perimedullary arteriovenous fistula (AVF) is rarely observed at the craniocervical junction (CCJ). We present a case of subarachnoid hemorrhage (SAH) with concurrent dAVF and perimedullary AVF at the CCJ. Here, we describe the cause of bleeding and the process of determining whether it was a varix or an arterial aneurysm. A 69-year-old man with SAH visited the emergency department. A dAVF at the CCJ was detected on digital subtraction angiography (DSA). However, after 3 weeks, when the DSA was repeated, a perimedullary AVF and varix were identified. We performed an endovascular treatment, but because the perimedullary AVF remained, we performed a direct surgery. The patient was discharged without weakness, but this left abducens nerve palsy remained. In recent reports, SAH caused by concurrent dAVF and perimedullary AVF raised the possibility of an arterial aneurysm. However, in this case, the possibility of venous bleeding was high and a varix rather than an aneurysm was observed. On the basis of the reported cases, concurrent dAVF and perimedullary AVF at the CCJ is a "middle-flow arteriovenous shunt" that may induce a varix or an arterial aneurysm. [ABSTRACT FROM AUTHOR]

Dural arteriovenous fistulas (DAVFs) with perimedullary venous drainage are very rare intracranial DAVFs. Treating DAVF via an endovascular electrocoagulation technique, to the best of our knowledge, has not been reported in the literature. We therefore report the first successful case. We report a rare case of Cognard type V DAVF. The feeding arteries were the middle meningeal artery, the recurrent meningeal branch of ophthalmic artery, and the meningohypophyseal trunk. The patient presented with paresthesia and weakness in the lower limbs. T2-weighted magnetic resonance imaging revealed a high signal in the medulla oblongata and upper cervical spinal cord. Our first procedure via the middle meningeal artery with Onyx 18 (ev3 Neurovascular) as the embolization agent failed to occlude the fistula. We finally occluded the fistula with the endovascular electro-coagulation technique. Two-year follow-up revealed total disappearance of the fistula and relieve of patient's symptoms. The endovascular electrocoagulation technique is very effective in the management of complex DAVFs with perimedullary venous drainage. [ABSTRACT FROM AUTHOR]

Dural arteriovenous fistulas (dAVFs) are vascular malformations of the central nervous system that feature an arteriovenous shunt fed by dural arteries and can be intracranial or spinal. 1-3 Spinal dAVFs are classically found at the nerve root sleeve. 3 The arterial supply can often be predicted by the fistula location, whereas the symptomatology and risk of hemorrhage is determined by the venous drainage pattern. 1-3 Craniocervical fistulas, a subset of dAVFs, may arise in association with the anterior condylar venous confluence or more dorsally in association with the transdural segment of the vertebral artery. 1-3 This latter type of fistula typically has spinal venous drainage and may present with myelopathy from spinal cord venous congestion. We present a 61-year-old man who presented with a 2-week history of neck pain and paraparesis. Magnetic resonance imaging of the cervical spine revealed diffuse T2 hyperintensity of the cord from the pons to the level of the T1 vertebra. A computed tomography angiogram showed a possible dAVF at the craniocervical junction on the left. Because of the unclear nature of the patient's spinal cord lesion, a cerebral angiogram was performed. It confirmed a dAVF associated with the transdural segment of the left vertebral artery, with small dural feeders from the left vertebral artery and venous drainage into the anterior spinal vein. The patient underwent a modified suboccipital craniectomy and C1 laminectomy for dAVF ligation (Video 1). He was extubated postoperatively and discharged to a rehabilitation unit with improvement in lower extremity strength. [ABSTRACT FROM AUTHOR]

Background: Concomitant dural arteriovenous fistulas (DAVFs) and meningiomas have been rarely described. DAVFs can be either continuous or at a distant location from the meningioma, with different pathophysiologic mechanisms involved in each situation. Case Description: We report the case of a 74-year-old woman presenting with left-sided hemiparesis secondary to a large right convexity meningioma, associated with a noncontiguous Borden 3 DAVF. Both lesions were treated surgically in the same setting. The patient improved after surgery, and postoperative imaging showed complete resection of the meningioma and absence of recurrence of the fistula at 4 years. Conclusion: To the best of our knowledge, this is the first case of concomitant surgical treatment of a meningioma and noncontiguous DAVF. [ABSTRACT FROM AUTHOR]

Background and Objectives: SAH in the paediatric population is an uncommon entity accounting for 1-2% of SAH in all age groups & only 18% of ICH in the paediatric population. Trauma is the most common cause of isolated SAH in the paeditric population, with ruptured intracerebral aneurysms although still rare, being the most common cause of spontaneous SAH in children. AVMs are uncommon source of spontaneous SAH. Although they are 10 times more common than cerebral aneurysms in the paediatric population, they rarely present with isolated SAH. This report aims to present such a rare case presented to a tertiary care hospital in Trinidad. Case Presentation: We present a 3-year-old girl admitted with sudden onset of headaches, weakness of the right leg, photophobia and neck stiffness. Examination revealed MRC grade 2/5 power in the right leg. Non contrast CT scan revealed blood in the subarachnoid space and occipital horns of the lateral ventricles. Cerebral CT angiogram demonstrated neither intracerebral aneurysms nor AVM, but CT angiogram of the spine revealed a left sided DAVF with the feeding vessel entering the spinal canal at the left C6/7 foramen. A C6 and C7 laminoplasty was performed with ligation of the feeding artery. Postoperative obliteration of the DAVF was confirmed radiologically and clinical resolution of leg weakness was noted. The patient developed non communicating hydrocephalus, necessitating the need for a VP shunt. Conclusion: Spontaneous subarachnoid haemorrhage in the paediatric population is an uncommon entity with several possible causes. Clinicians must have a high index of suspicion of an underlying lesion. [ABSTRACT FROM AUTHOR]

Background In the surgical treatment of spinal dural arteriovenous fistulas (DAVFs), intraoperative definition of anatomic characteristics of the DAVF and identification of the fistulous point is mandatory to effectively exclude the DAVF. Case Description Intraoperative ultrasound and contrast-enhanced ultrasound integrated with color Doppler ultrasound was applied in the surgical setting for a cervical DAVF to identify the fistulous point and evaluate correct occlusion of the fistula. Conclusions Integration of intraoperative ultrasound and contrast-enhanced ultrasound is a simple, cost-effective technique that provides an opportunity for real-time dynamic visualization of DAVF vascular patterns, identification of the fistulous point, and assessment of correct exclusion. Compared with other intraoperative tools, such as indocyanine green videoangiography, it allows the surgeon to visualize hidden anatomic and vascular structures, minimizing surgical manipulation and guiding the surgeon during resection. [ABSTRACT FROM AUTHOR]