Progressive Neurological Decline with Deep Bilateral Imaging Changes: A Protean Presentation of Dural Arteriovenous Fistulae

Simultaneous Parkinsonism and Dementia as Initial Presentation of Intracranial Dural Arteriovenous Fistulas: A Systematic Review

BACKGROUND

Intracranial dural arteriovenous fistulas (IDAVFs) are abnormal vascular connections between dural arteries and various venous structures within the brain. IDAVFs, rarely present with parkinsonism and dementia concurrently, making this a unique and underexplored clinical scenario. To the best of our knowledge, this is the first systematic review to comprehensively analyze cases of IDAVFs manifesting as both parkinsonism and dementia.

METHODS

We assessed databases from inception to September 18, 2023. We identified studies describing patients with IDAVFs initially presenting with dementia or parkinsonism. Inclusion criteria encompassed case reports and case series, while excluding review articles, guidelines, technical notes, comments, conference abstracts, and editorials.

RESULTS

The systematic search resulted in the initial screening of 383 studies, with 33 articles meeting the inclusion criteria. Among these, 29 were case reports, often describing 3 or fewer patients. From the remaining 4 case series, data pertinent to patients presenting both parkinsonism and dementia were selectively extracted, yielding a total study population of 43 patients. The anatomical distribution of IDAVFs within this cohort was diverse, with the transverse and sigmoid sinuses being the most common locations. Although most of these patients received endovascular therapy, a few underwent microsurgical occlusion or combined surgical and endovascular treatment.

CONCLUSIONS

IDAVFs presenting with both parkinsonism and dementia represent a rare clinical entity. This systematic review provides valuable insights into the clinical characteristics, treatment options, and outcomes for such cases. However, additional research involving larger cohorts is essential to better comprehend the underlying mechanisms and establish standardized therapeutic guidelines.

Bithalamic infarction in a tentorial dural artero-venous fistula and thalamic dementia: a case report and systematic review

PURPOSE

To report a case of bilateral thalamic infarction (BTI) presenting as progressive thalamic dementia due to a midline tentorial dAVF (TdAVF) and to provide a systematic review of the literature.

METHODS

We performed a systematic literature review of previously reported cases of bi-thalamic signal changes due to dAVF considering population characteristics, clinical presentation, imaging findings, treatments, and outcomes.

RESULTS

We found 29 papers from 1985 until 2021 describing 35 cases of BTI dAVF-related. We analysed 36 cases comprehensive of our case report. The mean age was 58.7 years (range 38-79), 91.6% were males (n=33). Most cases presented with a subacute syndrome. In 86.1% (n=31) of cases a TdAVF was found; 58.3% (n=21) were type 2 Borden-Shucart fistulas, the remaining were mostly type 3. In 80.5% (n=29), a thrombosed sinus was identified. 33.3% of cases (n=12) had bi-thalamic haemorrhages. Endovascular treatment was performed in 83.3% of cases (n=30). A total of 75% (n=27) of cases had a good recovery.

CONCLUSIONS

BTIs due to dAVFs may present with subacute symptoms overlapping with several differential diagnoses. Prompt identification at MRI, before venous drainage failure and bleeding, is crucial for a good prognosis.

Non-invasive assessment of cerebral hemoglobin parameters in intracranial dural arteriovenous fistula using functional near-infrared spectroscopy-A feasibility study

PURPOSE

The purpose of this study was to assess the feasibility of non-invasive assessment of cerebral hemodynamics using functional near-infrared spectroscopy (fNIRS) in patients with intracranial dural arteriovenous fistula (DAVF) and to correlate the hemodynamic changes with definitive endovascular treatment.

METHODOLOGY

Twenty-seven DAVF patients and 23 healthy controls underwent 20-mins task-based functional near-infrared spectroscopy and neuropsychology evaluation. The mean change in the hemoglobin concentrations obtained from the prefrontal cortex was assessed for oxyhemoglobin, deoxyhemoglobin, and oxygen saturation (HbO, HbR, and SO2, respectively). The fNIRS data were analyzed and correlated with improvement in neuropsychology scores at 1-month follow-up.

RESULTS

There was a significant reduction in HbO in the patient group, while it increased in controls (-2.57E-05 vs. 1.09E-04 mM, p < 0.001). The reduced HbO significantly improved after embolization (-2.1E-04 vs. 9.9E-04, p = 0.05, q = 0.05). In patients with aggressive DAVF (Cognard 2B and above), the change was highly significant (p < 0.001; q = 0.001). A moderate correlation was observed between MMSE scores and HbO changes (ρ = 0.4).

CONCLUSION

fNIRS is a useful non-invasive modality for the assessment of DAVF, and could potentially assist in bedside monitoring of treatment response.

Multiple Dural Arteriovenous Fistulas as the Mystery of Rapidly Progressive Dementia with Bilateral Thalamic Lesions

Dementia is a gradual and irreversible loss of higher mental function, particularly memory. Dural arteriovenous fistulas (DAVFs) are one of the rare causes of a rapid decline in cognitive function, which can be curable. DAVFs are pathological shunts between the dural artery and the dural venous sinus, dural vein, or cortical vein. Here, we present a case that initially manifested nausea and dizziness and developed rapidly progressive dementia caused by DAVFs in the left transverse sinus-sigmoid sinus junction area and the sinus confluence area, combined with cerebral venous sinus thrombosis. Moreover, our case has multiple DAVFs that cause bilateral thalamic lesions and rapidly progressive dementia called thalamic dementia, which is infrequent and often misdiagnosed. His symptoms have improved after receiving endovascular embolization treatment. In addition to presenting our case, we conducted a systemic literature review to summarize how familiarity with the manifestation and early diagnosis of bilateral thalamic lesions caused by DAVFs can lead to earlier and more effective therapy.

Dural Arteriovenous Fistula Presenting as a Rapidly Progressive Thalamic Dementia: A Case Report

Rapidly progressive dementia is an uncommon neurological presentation and usually needs extensive workup, especially for reversible causes. Dural arteriovenous fistula (DAVF) has been rarely reported as a cause of thalamic dementia, in which bilateral thalamic venous congestion and edema cause dementia that usually progresses rapidly. We present a case of a 45 years-old male who presented with rapidly progressive severe attention and memory impairment over one week. Initial work-up showed bilateral thalamic recent venous infarctions and edema. Extensive work-up revealed an intracranial DAVF with internal deep venous thrombosis. Management with endovascular treatment of DAVF followed by anticoagulation for venous thrombosis leads to improvement of the patient’s clinical condition, particularly memory and attention. In conclusion, DAFV could present with thalamic rapidly progressive dementia due to bithalamic infarctions and edema. Early diagnosis and treatment will reverse the cause and improve the patient's general and cognitive conditions.

Alterations in Resting-State Functional MRI Connectivity Related to Cognitive Changes in Intracranial Dural Arteriovenous Fistulas Before and After Embolization Treatment

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.