Dural arteriovenous fistula of the sphenobasilar sinus with concomitant meningioma: case report and review of the literature

Middle cranial fossa non-cavernous sinus dural arteriovenous fistulas: 20 years of experience

Non-cavernous sinus (CS) dural arteriovenous fistulas (DAVFs) involving the sphenoid bone are rare entities that are easily confused with one another due to the complex structure and high variability of the venous system around the middle cranial fossa. We present a large retrospective study on middle cranial fossa non-CS DAVFs and review the literature on DAVF treatment in this location as well as relative anatomy. 15 patients had DAVFs involving the lesser sphenoid wing and 11 patients had DAVFs involving the greater sphenoid wing. Six patients presented with intracranial hemorrhage or subarachnoid hemorrhage (23.1%, 6/26). The most common symptoms were eye symptoms (38.5%, 10/26). Nineteen patients were treated with trans-arterial embolization (TAE) using liquid embolic agents and two patients were treated with transvenous embolization (TVE) using Onyx or in combination with coils. Surgical disconnection of the drainage veins was performed in five patients, with three cases experiencing unsuccessful TAE. Anatomic cure was achieved in 92.3% of the patients (24/26). Twelve patients had DSA and clinical follow-up from 3 to 27 months. There was one recurrence (8.3%) of the fistula in the patient two months after the initial complete occlusion. The majority of patients can be cured endovascularly. Laterocavernous sinus DAVFs may not be embolized by transvenous approach via the cavernous sinus because there is often no connection between them in most patients. A small percentage of patients may require surgical ligation to be cured.

Sphenoparietal Sinus Dural Arteriovenous Fistulas: A Series of 10 Patients

BACKGROUND

Dural arteriovenous fistulas (DAVFs) of the sphenoparietal sinus or sphenoid wing region are uncommon lesions with unique and interesting angioarchitecture. Understanding appropriate anatomy and recognizing patterns provide important treatment implications.

OBJECTIVE

To describe a single surgeon's experience with open surgical treatment of sphenoparietal sinus DAVFs, the surgical indications for this uncommon lesion, and the microsurgical techniques related to its treatment and to review the literature on its surgical treatment.

METHODS

Consecutive cases of sphenoparietal sinus DAVF treatment conducted by a single surgeon over 24 years (1997-2020) were retrospectively reviewed. Published reports of similar cases were reviewed.

RESULTS

Of 202 surgically treated DAVFs, 10 lesions in 10 patients were sphenoparietal sinus DAVFs. Four patients presented with intracranial hemorrhage, 3 with headache, and 2 with pulsatile tinnitus; 1 patient was incidentally identified as having a DAVF during treatment for a ruptured aneurysm. Most patients (7 of 10) had undergone endovascular embolization previously. Nine patients had Borden type III DAVFs and one had a Borden type II fistula. Surgery in all 10 patients resulted in angiographically confirmed fistula obliteration. Clinical outcomes at the last follow-up, measured by a modified Rankin Scale (mRS) score, were excellent in 6 patients (mRS ≤ 2) and poor in 1 patient (mRS ≥ 3); late outcomes were not available for 3 patients.

CONCLUSION

Sphenoparietal sinus DAVFs are an uncommon anatomic subtype. Careful attention to angiographic detail leads to identification of the site of venous interruption and results in a high rate of surgical cure with excellent clinical outcomes.

Superior sagittal sinus dural arteriovenous fistula with changes in angiographic findings associated with contiguous parasagittal meningioma: A case report

Background:

Meningioma and dural arteriovenous fistula (dAVF) located at the same site are rare. The present case demonstrated the transformation of tumor feeding vessels into the pial feeder of the dAVF over time, which may help to elucidate the pathogenesis of tumor-associated dAVF.

Case Description:

A 71-year-old man presented with convulsion. Magnetic resonance (MR) imaging showed a right parasagittal sinus meningioma invading the superior sagittal sinus (SSS). Bilateral external carotid angiography showed dAVF at the SSS, near the site of tumor invasion. The right internal carotid angiography showed tumor staining from the anterior cerebral artery with intra-tumor arteriovenous shunting, with stagnation of tumor blood flow, suggesting impairment of perfusion to the SSS. Four years after the initial diagnosis, the patient was admitted to hospital with status epilepticus, and MR imaging showed an enlarged tumor. Carotid angiography revealed transformation of the tumor feeders to the pial feeder of the dAVF. The findings of shunting to the SSS had intensified, and stenosis had occurred in the posterior third of the SSS. The venous return showed retrograde flow anteriorly to the SSS. The patient underwent endovascular embolization and tumor resection. The shunt had disappeared.

Conclusion:

This report supports the proposal that impaired venous return is an important factor in the shunt occurrence of dAVF. Neurosurgeons should consider that cases of meningioma invading the venous sinuses may be complicated by dAVF and changes may occur over time.

Sphenoid wing dural arteriovenous fistula: A case report and literature review

Background:

Sphenoid wing dural arteriovenous fistula (SWDAVF) is rare that is typically fed by middle meningeal artery feeders and that drain through the sphenoparietal sinus or middle cerebral vein. Here, we report a case of SWDAVF treated by coils placed in the venous aneurysm through the contralateral cavernous sinus (CS).

Case Description:

A 37-year-old woman was admitted to our hospital with headache and bilateral oculomotor nerve palsy. Magnetic resonance images and an angiogram showed a venous aneurysm in the right middle cranial fossa. A DAVF, consisting of two main feeders, was diagnosed based on the angiogram findings. The fistula drained into the left inferior petrosal sinus (IPS) through the left CS and right IPS. Given the remarkable extent of venous ectasia together with the headache and right abducens nerve paralysis, endovascular treatment was initiated. A transvenous approach through the right IPS was not feasible, as it is strenuous to insert the microcatheter into the right IPS. Thus, we tried an approach through the left IPS. The venous aneurysm was embolized with coils. The postoperative course was uneventful, and postoperative cerebral angiography confirmed disappearance of the fistula.

Conclusion:

A SWDAVF is extremely rare. In our case, since the AVF drained into the contralateral CS, contralateral ocular symptoms occurred. Endovascular occlusion of the venous aneurysm and fistula was achieved through a transvenous approach.

Intra-arterial onyx embolisation of sphenobasilar sinus fistula using pressure cooker technique: case report and review of the literature

Dural arterio-venous fistulas of the middle cranial fossa may occur within the dura of lesser or greater sphenoid wings. Lesser sphenoid wing fistulas rarely recruit cortical venous drainage and mostly drain in the cavernous sinus. On the other hand, greater sphenoid wing dural fistulas, also known as paracavernous fistulas or sphenobasilar and sphenopetrosal sinus fistulas, are much more notorious as they almost always connect with the superficial middle cerebral vein resulting in secondary cortical venous reflux and varix formation. Curative transarterial or transvenous endovascular embolisation of fistulous connection is the primary therapeutic strategy, particularly using onyx via the transarterial approach. In the present case we describe a 62-year-old man who presented with significant subarachnoid haemorrhage, intraparenchymal and intra-ventricular bleed. Digital subtraction angiography showed a middle cranial fossa dural arteriovenous fistula in the region of the sphenobasilar sinus with cortical venous reflux and varix formation. The patient underwent successful transarterial endovascular embolisation with complete elimination of the fistula using onyx 34, onyx 18, squid 12 and a Scepter XC balloon using the pressure cooker technique. We also report the development of facial nerve palsy due to inadvertent reflux of onyx in the petrosal branch of the middle meningeal artery.

Sphenoid dural arteriovenous fistulas

Sphenoid wing dural AVFs represent a rare clinical entity. These lesions may be asymptomatic or present with focal neurologic deficits, intracranial venous hypertension, or intracranial hemorrhage. Diagnosis is based on clinical findings and diagnostic imaging. They are alternatively classified as lesions of either the greater or lesser wings of the sphenoid bone. We performed a search of the PubMed database of studies evaluating the clinical behavior and surgical and endovascular therapies of these lesions. Dural AVFs draining into the superficial middle cerebral vein and/or laterocavernous sinus, or rather, lesions of the greater wing of the sphenoid, exhibit a greater likelihood of developing an aggressive clinical course, with higher probability of cortical venous reflux and consequent intracranial venous hypertension, intracranial hemorrhage, and symptomatic presentation. Dural AVFs of the sphenoparietal sinus, that is, lesions of the lesser wing of the sphenoid, typically exhibit a more benign clinical course, as there is a prominent epidural venous drainage into the cavernous sinus, reducing the risk of cortical venous reflux, and consequently, the probability of intracranial venous hypertension, hemorrhage, and floridly symptomatic presentation. These lesions may be treated via surgical clipping of the fistulous point, transarterial or transvenous embolization, and/or stereotactic radiosurgery. Though surgical intervention was the principal therapy due to facility of craniotomy access to the fistulous point, embolization has become standard of care permitted by innovation in endovascular technology. The natural history, clinical presentation, angioarchitecture, diagnosis, and management of these lesions are reviewed and discussed.

Dural arteriovenous fistula associated with intratumor hemorrhage

Dural arteriovenous fistula (dAVF) associated with an intracranial tumor is a relatively rare condition. Furthermore, to our knowledge, this is the first case report of dAVF associated with intratumor hemorrhage. We experienced this very rare case and report it here, along with a literature review. A 59-year-old woman presented with transient aphasia and dysgraphia. Computed tomography, magnetic resonance imaging, and angiography showed left anterior cranial fossa dAVF and a tumor with an intratumor hemorrhage. Cerebral angiography demonstrated AV shunts from the left ethmoidal artery via cortical vein flow into the superior sagittal sinus. She underwent shunt-point extirpation for the dAVF and removal of the tumor. The histological finding indicated transitional meningioma. The patient was discharged without any neurological deficit. A dAVF with intratumor hemorrhage is very rare and may be due to the venous congestion of the tumor draining vein by venous hypertension caused by the dAVF.

Dural Arteriovenous Fistula Associated With a Vestibular Tumor: An Unusual Case and Review of the Literature

Intracranial dural arteriovenous fistulae (DAVF) are rare vascular malformations. They are generally considered to be acquired lesions, often attributed to dural sinus thrombosis and intracranial venous hypertension. The authors encountered a case of DAVF associated with an octreotide-positive vestibular schwannoma. A 46-year-old female had symptoms of right ear congestion accompanied by pulsatile tinnitus and mild hearing loss. Magnetic resonance imaging (MRI) identified a lobulated mass centered at the cerebellopontine angle. Preoperatively, on cerebral angiography, there was an incidental discovery of a DAVF in the right posterior fossa. The decision was made to proceed with resection of the tumor in a staged fashion. Her latest follow-up MRI showed no evidence of recurrent tumor. This is the second reported case of DAVF associated with an intracranial schwannoma. Findings are discussed along with a thorough review of the literature. This case, combined with the data from the literature review, led us to believe that tumor-related angiogenesis might contribute to DAVF formation.

Mastoid Epidermoid Tumor and Associated Dural Arteriovenous Fistula with Venous Sinus Occlusion

BACKGROUND

Dural arteriovenous fistula (DAVF) is an abnormal vascular connection between arterial and venous channels within dura mater. Although DAVFs have been linked to other types of intracranial tumors, this is the first case reporting the association between DAVF and an epidermoid tumor.

CASE DESCRIPTION

A middle-aged patient with chronic headache presented with Borden type II DAVF draining into the right transverse sigmoid junction and was also found to have an epidermoid tumor over the right mastoid. The patient underwent staged embolization of the fistula through both transvenous and transarterial routes. Continuous intraoperative venous pressure monitoring confirmed marked reduction in intracranial venous pressure, and the patient's symptoms completely resolved. However, the fistula still remained. The residual DAVF was then surgically disconnected, and the epidermoid tumor was resected in the same procedure.

CONCLUSIONS

This case demonstrates a DAVF can be associated with an epidermoid tumor. Tumor can compromise the venous outflow, which can then lead to intracranial venous hypertension and development of the DAVF. Venous pressure monitoring offers an objective method to verify resolution of venous hypertension, which might correlate with resolution of clinical symptoms.

Diagnosis and management of intracranial dural arteriovenous fistulas

Dural arteriovenous fistula (DAVF) is a rare type of acquired intracranial vascular malformation. Recent progress in neuroimaging technology, such as advanced MRI and CT, provides non-invasive methods to accurately diagnose DAVF, including evaluation of the hemodynamics of the drainage veins. The clinical manifestations of DAVFs vary widely and depend on the location and venous drainage pattern of arteriovenous shunting. Patients with high grade DAVFs having cortical venous reflux should receive aggressive treatment to prevent the occurrence of intracranial hemorrhage and other neurological deficits related to venous congestion. Intra-arterial or intravenous endovascular embolization remains the primary therapy for high grade DAVF, while open surgery and stereotactic radiosurgery can serve as alternative treatment options. Early and accurate diagnosis with appropriate treatment is the goal for clinical management of DAVFs to reduce symptoms and prevent the development of venous congestion and stroke.

Dural arteriovenous fistulas associated with benign meningeal tumors

BACKGROUND

Dural arteriovenous fistulas (dAVFs) are usually idiopathic lesions. While individual case reports have documented the occurrence of dAVFs in conjunction with benign meningeal tumors, a detailed characterization of this association is lacking. The objective of this study was to critically examine the relationship between benign meningeal tumors and dAVFs.

METHODS

We performed a retrospective review of records at two institutions, identified patients with coexisting benign meningeal tumors and dAVFs at the time of clinical presentation, and examined various clinical, anatomical and radiographic characteristics.

RESULTS

Ten patients (4.6%) had coexisting benign meningeal tumors and dAVFs. The most common tumor was meningioma (90%). Nine patients were symptomatic: five from tumor, three from dAVF, and one from both tumor and dAVF. All dAVFs were related to the meningeal tumor.

CONCLUSIONS

Benign meningeal tumors may be associated with dAVFs that are either in direct anatomical relation to the tumor or in distant anatomical locations. The increased propensity for development of dAVFs in patients with benign meningeal tumors may be due to multiple factors. Due to this association, additional imaging to exclude dAVFs could be considered in patients with meningeal tumors if exuberant vessels or flow voids are identified on routinely obtained magnetic resonance imaging scans.

Endovascular treatment of sphenoid wing dural arteriovenous fistula with pure cortical venous drainage

Curative endovascular treatment of sphenoid wing dural arteriovenous fistula (dAVF) with pure cortical venous drainage is challenging because of its rarity, lack of accessible dural sinus for transvenous embolization (TVE), and proximity of skull base vital regions. Direct surgery to disconnect venous reflux has been favored. We report the curative endovascular treatment of two sphenoid wing dAVFs with pure cortical venous drainage. One patient revealed complete obliteration of dAVF by a single session of transarterial embolization (TAE). As part of strategic TAE for this complex dAVF, we used a novel approach to create a complete flow-arrest condition in which coils and an occlusion balloon were combined. A liquid agent was then injected across the pathological fistula and into the parent venous apparatus, thereby occluding the lesion. The other patient was treated with percutaneous TVE after TAE was unsuccessful. With a specific strategy and appropriate devices, the microcatheter was successfully introduced through sigmoid sinus, transverse sinus, superior sagittal sinus, and refluxing cortical vein by puncture of the jugular vein. Coils were deployed at the venous side of the fistula, resulting in successful obliteration of the dAVF. Sphenoid wing dAVF with pure cortical venous drainage could be curable by endovascular treatment with proper strategy and instruments when anatomical condition permits.

Aberrant venous drainage pattern in a medial sphenoid wing dural arteriovenous fistula: a case report and review of the literature

BACKGROUND

Sphenoid wing region dural arteriovenous fistulas (DAVFs) are rare lesions that are typically fed by middle meningeal artery feeders and that drain via the sphenoparietal sinus or middle cerebral vein. We describe a unique case of a medial sphenoid wing fistula draining exclusively via the basal vein of Rosenthal.

METHODS

A 55-year-old man presented with progressive right temporal homonymous hemianopsia. Cerebral angiography revealed a DAVF that rapidly filled into the deep venous system via the basal vein of Rosenthal with a large venous varix compressing the optic nerve. The sphenoid wing DAVF was not amenable to endovascular embolization due to direct ophthalmic artery feeders and was therefore treated with surgical obliteration. A right pterional craniotomy with orbitozygomatic osteotomy was performed.

RESULTS

The fistula was clip ligated, and the venous varix was incised and drained. Intraoperative angiography demonstrated complete obliteration of the fistula.

CONCLUSIONS

Sphenoid wing DAVFs may drain via the deep venous system and have a complex arterial feeding network. Key features of the fistula, including deep venous drainage, presence of venous varices, and retrograde leptomeningeal venous drainage, make this an aggressive lesion with a high risk of rupture based on the available natural history data.

Middle cranial fossa sphenoidal region dural arteriovenous fistulas: anatomic and treatment considerations

BACKGROUND AND PURPOSE

DAVFs rarely involve the sphenoid wings and middle cranial fossa. We characterize the angiographic findings, treatment, and outcome of DAVFs within the sphenoid wings.

MATERIALS AND METHODS

We reviewed the clinical and radiologic data of 11 patients with DAVFs within the sphenoid wing that were treated with an endovascular or with a combined endovascular and surgical approach.

RESULTS

Nine patients presented with ocular symptoms and 1 patient had a temporal parenchymal hematoma. Angiograms showed that 5 DAVFs were located on the lesser wing of sphenoid bone, whereas the other 6 were on the greater wing of the sphenoid bone. Multiple branches of the ICA and ECA supplied the lesions in 7 patients. Four patients had cortical venous reflux and 7 patients had varices. Eight patients were treated with transarterial embolization using liquid embolic agents, while 3 patients were treated with transvenous embolization with coils or in combination with Onyx. Surgical disconnection of the cortical veins was performed in 2 patients with incompletely occluded DAVFs. Anatomic cure was achieved in all patients. Eight patients had angiographic and clinical follow-up and none had recurrence of their lesions.

CONCLUSIONS

DAVFs may occur within the dura of the sphenoid wings and may often have a presentation similar to cavernous sinus DAVFs, but because of potential associations with the cerebral venous system, may pose a risk for intracranial hemorrhage. Curative embolization through a transarterial or transvenous approach is the primary therapeutic strategy for these lesions. In incompletely embolized patients, exclusion of any refluxing cortical veins is necessary.

Dural arteriovenous fistula associated with superior sagittal sinus occlusion secondary to invasion by a parafalcine meningioma: case report

OBJECTIVE

We report a rare case of thrombosis of the superior sagittal sinus associated with a parafalcine meningioma resulting in a superior sagittal sinus dural arteriovenous fistula (dAVF). We conclude that dural sinus thrombosis is a significant predisposing factor for development of a dAVF.

CLINICAL PRESENTATION

A 60-year-old man had a left parietal parafalcine meningioma that invaded the posterior third of his superior sagittal sinus, leading to its occlusion and presumably resulting in an associated dAVF. The fistula was fed by the middle meningeal and superficial temporal arteries on both sides and drained through a superior interhemispheric cortical vein into the vein of Galen and straight sinus.

INTERVENTION AND TECHNIQUE

The parafalcine mass, which involved the sagittal sinus, was excised via a left parieto-occipital craniotomy. It was decided to resect the dAVF at a later date. Seven days after the original operation, the patient underwent a parietal interhemispheric approach for occlusion of the dAVF. Dissection proceeded until a large arterialized vein and venous pouch with multiple feeders from both external carotid arteries were observed. The vein, which was partially embedded within the falx cerebri, was collapsed, and a second indocyanine green injection confirmed cessation of blood flow.

CONCLUSION

This report supports that dAVFs are acquired lesions and that venousoutflow obstruction is a significant contributing factor to their development. In meningiomas associated with the dural sinuses, diagnostic evaluation for possible dAVFs should be considered. Treatment of these lesions should be based on risk factors because spontaneous resolution after tumor excision has been reported.

Rare dural arteriovenous fistula of the lesser sphenoid wing sinus

A fistula of the lesser sphenoid wing sinus is a rare dural arteriovenous fistula resulting from a connection between the middle meningeal artery and recipient vein in the sinus of the lesser sphenoid wing. In this report, MRI/magnetic resonance angiography of a 54-year-old man who presented with sudden-onset glaucoma and proptosis revealed a fistula in this anatomic location. Drainage patterns here may account for the absence of serious complications and optimistic prognosis following embolization. Care in diagnosis is required to avoid superfluous procedures, because classic signs of the more common carotid-cavernous fistula are absent.

Traumatic fistula between the middle meningeal artery and the sphenoparietal sinus

PURPOSE

Post-traumatic fistulas between the middle meningeal artery and the cranial venous system are extremely rare. We describe clinical presentation and successful endovascular management of a case of post-traumatic fistula between the middle meningeal artery and the sphenoparietal sinus.

METHODS

A 53-year-old man was admitted with multiple brain contusions and a temporoparietal fracture after a head trauma. On day 3 after trauma he developed unilateral signs of a cavernous sinus syndrome. Digital subtraction angiography showed a fistula between the middle meningeal artery and the sphenoparietal sinus.

RESULTS

The fistula was occluded by endovascular coil embolization, resulting in complete remission of the clinical symptoms.

CONCLUSION

A high index of suspicion is necessary to detect subtle signs of venous congestion of the cavernous sinus in an intubated patient. Angiography is the diagnostic modality of choice and should include the selective investigation of the external carotid artery vascular territory. Endovascular therapy provides minimal invasive and definitive treatment of this rare condition.

Intraventricular haemorrhage caused by the rupture of a dural arteriovenous malformation of the middle cranial fossa

Dural arteriovenous malformations of the middle cranial fossa are very rare. Venous drainage flows either through superficial leptomeningeal veins or through the sphenoparietal, sphenopetrous and/or sphenobasilar sinuses. They often have an aggressive course and therefore poor outcome. It is essential to analyse and understand the angioarchitecture of the dural arteriovenous malformations in order to select and plan the correct treatments. We describe an exceptional case of intraventricular haemorrhage caused by the rupture of a dural arteriovenous malformation of the middle cranial fossa. To our knowledge, this is the first case report of such characteristics described in the literature.