Progressive subcortical calcifications secondary to venous hypertension in an intracranial dural arteriovenous fistula

An aggressive dural arteriovenous fistula manifested by unilateral subcortical calcification and cerebral edema: A case report

Unilateral subcortical calcifications are unique radiographic findings indicating specific focal pathologies. When the lesion is accompanied by edema, cerebral neoplasm usually leads to a differential diagnosis. This report presents a case of unilateral subcortical calcification and edema that resulted in cerebral hemorrhage and a subsequent diagnosis of an aggressive dural arteriovenous fistula. A man in his 60s presented with left hemianopsia and a progressive headache for over 6 months. Initial computed tomography revealed unilateral subcortical calcification and cerebral edema in the right occipital lobe, raising the suspicion of oligodendroglioma. However, 10 days later, a cerebral hemorrhage occurred in the lesion. Magnetic resonance imaging revealed flow void clusters and dilatation of the bilateral external carotid arteries and cortical veins, indicating a dural arteriovenous fistula. Cerebral angiography confirmed the presence of a parasagittal dural arteriovenous fistula (Borden type III). The patient was successfully treated with trans-arterial embolization using Onyx. Thus, calcifications with edema are more commonly associated with cerebral neoplasms; however, in this case, they indicated the presence of a dural arteriovenous fistula with severe corticovenous reflux. The presented case highlights the importance of recognizing these imaging features in dural arteriovenous fistulas and raises awareness of the potential danger of early hemorrhage after diagnosis. Therefore, timely evaluation of cranial vessels is essential in cases of unilateral subcortical calcification and edema to facilitate the early detection and management of aggressive dural arteriovenous fistulas.

[Subcortical calcification on CT in Borden type III intracranial dural arteriovenous fistula]

We herein report a 67-year-old female who presented with progressive dementia and disturbance of consciousness. Brain CT showed multiple subcortical calcifications with edema. Enhanced CT showed multiple abnormal vessels in the left hemisphere. Electroencephalography indicated diffuse spike and slow wave complex, so non-convulsive status epilepticus was diagnosed. Cerebral angiography revealed several feeder arteries with retrograde leptomeningeal venous drainage. We diagnosed her with Borden type III cerebral dural arteriovenous fistulas. Trans-arterial embolization with n-butyl-2-cyanoacrylate was performed, and she has experienced no epileptic attacks for at least ten months. Calcification changes are sometimes seen in Borden type II dural arteriovenous fistulas but not in aggressive types, such as Borden type III. It is important to suspect dural arteriovenous fistulas when we encounter patients with progressive dementia or/and epilepsy with cerebral calcification lesions, as this may be a treatable disease condition.

Progress in research on intracranial multiple dural arteriovenous fistulas

Intracranial multiple dural arteriovenous fistulas (MDAVFs) are rare lesions that are difficult to treat. The key factors involved in the development of MDAVFs remain unknown. At present, the majority of reports on intracranial MDAVFs are confined to case reports and small case series, and thus understanding of MDAVFs is limited. The current review assesses the available literature to date with the aim of reviewing the progress in research on intracranial MDAVFs. Intracranial MDAVFs may be divided into two types: Synchronous and metachronous. While the exact pathogenesis of MDAVFs is unknown, a number of possible mechanisms are considered relevant. The first is that MDAVFs develop following recanalization of a large sinus thrombosis that involves several sinuses. The second possibility is that a pre-existing DAVF may induce sinus thrombosis or venous hypertension, resulting in a new MDAVF. The third is that MDAVFs are caused by increased angiogenic activity, which may induce the development of MDAVFs. Intracranial MDAVFs have a malignant clinical course, and their symptoms generally rapidly progress following onset. It is therefore important to identify intracranial MDAVFs at an early stage. A number of imaging technologies, including computed tomography (CT), magnetic resonance imaging (MRI), digital subtraction angiography (DSA) and single-photon emission computed tomography (SPECT), may be used to detect MDAVFs. Of these, CT and MRI provide information on brain morphology, SPECT provides brain blood flow information, and DSA is the gold standard that may be used to identify angioarchitecture and hemodynamics. MDAVFs require timely and aggressive treatment, which may include endovascular embolization, surgical resection, radiosurgery and conservative treatment, and in some cases, combined treatments are required. Appropriate and aggressive treatment regimens can markedly improve neurological deficits and cognitive function in patients with MDAVFs.