Unruptured dural arteriovenous malformation of the transverse-sigmoid sinus presenting with focal symptoms and coma

[Intracranial dural arteriovenous fistulae. Experience after 81 cases and literature review]

OBJECTIVES

To analyse the clinical, radiological and therapeutic variables of intracranial dural arteriovenous fistulae (DAVF) treated at our institution, and to assess the validity of the Borden and Cognard classifications and their correlation with the presenting symptoms.

MATERIAL AND METHODS

The DAVF identified were retrospectively analysed. They were classified according to their location, drainage pattern and the Borden and Cognard classifications. We recorded the different treatments, their complications and efficacy.

RESULTS

There were 81DAVF identified between 1975 and 2012. The cavernous sinus (CS) location was the most frequent one. The Borden and Cognard classifications showed an interobserver Kappa index of 0.72 and 0.76 respectively. The odds ratio of aggressive presentation in the presence of cortical venous drainage (CVD) was 19.3 (2.8-132.4). No location, once adjusted by venous drainage pattern, showed significant association with an aggressive presentation. Endovascular transarterial treatment of cavernous sinus DAVF achieved symptomatic improvement of 78%, with a complication rate of 5%. The DAVF of non-CS locations, with CVD, treated surgically were angiographically shown cured in 100% of the cases, with no treatment-related complications.

CONCLUSIONS

The presence of CVD was significantly associated with aggressive presentations. The Borden and Cognard classifications showed little interobserver variability. Endovascular treatment for CS DAVF is safe and relatively effective. Surgical treatment of non-CS DAVF with CVD is safe, effective and the first choice treatment in our environment.

Perfusion computed tomography in a dural arteriovenous fistula presenting with focal signs: vascular congestion as a cause of reversible neurologic dysfunction

OBJECTIVE

To describe the use of perfusion computed tomography (PCT) in the study of hemodynamic disturbances associated with a case of a cerebral dural arteriovenous fistula (DAVF) with leptomeningeal venous drainage presenting with focal signs.

CLINICAL PRESENTATION

A 79-year-old man presented because of loss of strength in the right arm. On examination, he presented mild right-side hemiparesis. Magnetic resonance imaging showed the presence of a left frontoparietal hyperintense lesion on T2-weighted images. Magnetic resonance angiography and digital substraction angiography (DSA) showed a convexity Borden type III DAVF. The DAVF was embolized with bucrylate, and control DSA showed complete obliteration of the malformation. The patient improved from his clinical presentation and 6 months after treatment was asymptomatic.

TECHNIQUE

Perfusion computed tomography was performed before and after treatment. All imaging studies were performed on a 6-slice spiral computed tomography scanner. Each series studied a 2.4-cm slide of brain at the level of the cerebral convexity where the DAVF was located. Quantitative perfusion data were obtained from significant regions of interest of both hemispheres, and an interhemispheric ratio (IR) was calculated. Pretreatment PCT showed an increase in mean transient time (IR = 2.2) and time to peak (IR = 1.15), with an increase in cerebral blood volume (IR = 1.9) in the left frontal areas related to a similar area in the contralateral hemisphere. Six months after treatment, perfusion maps did not show any interhemispheric difference.

CONCLUSION

Perfusion computed tomography could help to identify the hemodynamic disturbances associated with DAVFs with leptomeningeal venous drainage.