Dural arteriovenous fistula-induced thalamic dementia: report of 4 cases

Long-term cognitive outcome in dural arteriovenous fistula after embolization therapy

Patients with dural arteriovenous fistulas (DAVF) suffer from cognitive impairments that go often unrecognized. This study aimed to explore the severity of cognitive impairment as well as specific cognitive domains affected in DAVF patients and to track its evolution over long-term follow-up after embolization. Consecutive DAVF patients (and an equal number of healthy controls) were prospectively enrolled and underwent a comprehensive baseline neuropsychological (NP) assessment. These patients were re-evaluated postembolization at a short-term follow-up of 1 month and long-term follow-up of 8-12 months. Thirty-one patients were included, with a male-to-female ratio of 5.2:1 and an average age of 45.1 years. NP assessments revealed significantly impaired cognitive scores across all domains (Addenbrooke's Cognitive Examination [m-ACE], the Rey Auditory Verbal Learning Test [RAVLT], the Wechsler Memory Scale, digit span forward and backward tests, and the Trail Making Test Parts A and B) in the DAVF group compared to healthy controls (p < .001). Post embolization, the m-ACE (p < .001), RAVLT (p = .04), WMS-verbal delay (p = .002) and Trail making test B (p = .019) scores showed statistically significant improvement compared to healthy controls at 1 month. However, the cognitive scores did not fully recover to the level of healthy controls at long-term follow-up. Though treatment leads to significant cognitive recovery, lasting residual cognitive deficits are persistent in DAVF patients compared to healthy controls. Inclusion of comprehensive NP evaluation in work up can unmask subtle cognitive deficits that may guide in therapeutic decision making especially in 'benign' DAVFs.

Intracranial dural arteriovenous fistulas with deep venous drainage: a single-center retrospective cohort study

OBJECTIVE

Dural arteriovenous fistulas (DAVFs) with deep venous drainage (DVD) (DAVFs-DVD) are characteristically associated with non-hemorrhagic neurological deficits, most notably cognitive impairment. Large studies have yet to thoroughly characterize these DAVFs. We conducted an analysis of the largest cohort of DAVFs-DVD to provide a comprehensive characterization of this specific subset.

METHODS

This study was a retrospective cohort analysis of 207 patients with DAVFs-DVD who were hospitalized at a single medical center between 2001 and 2022. Logistic regression was employed to identify angiographic features specific to DAVFs associated with cognitive impairment. Additionally, post-treatment outcomes were evaluated.

RESULTS

DAVFs-DVDs can be classified into two categories: the Galenic group, where arterial feeders drain directly into the vein of Galen (VoG), and the non-Galenic group, where arterial feeders drain into other veins or venous sinuses and indirectly flow into the VoG. Cognitive impairment accounting for 15.9% of all clinical presentations. We found that the overall rate of complete occlusion was 86.6%, while the overall rate of complications was 16.4%. Moreover, patients with DAVFs-DVD presenting with cognitive impairment were more likely to have straight sinus stenosis or occlusion, as well as DAVFs located at the midline.

CONCLUSION

DAVFs-DVDs can be classified into two categories: the Galenic group and the non-Galenic group. Patients with DAVFs-DVD presenting with cognitive impairment were more likely to have straight sinus stenosis or occlusion, as well as DAVFs located at the midline. Venous hypertension of the deep venous system is a key angiographic feature of DAVFs associated with thalamic cognitive impairment.

Dural Arteriovenous Fistulas: Baseline Cognitive Changes and Changes following Treatment: A Prospective Longitudinal Study

BACKGROUND AND PURPOSE

Dural arteriovenous fistulas (DAVFs) exhibit varied clinical manifestations, and high-grade cases are associated with both a risk of hemorrhage and (in certain cases) dementia. Less known, however, is the association between DAVF and more subtle cognitive changes, which might not be clinically apparent without formal neurocognitive testing. This study prospectively assesses baseline cognitive changes in patients with unruptured DAVFs and looks at the effects of treatment on any such changes.

MATERIALS AND METHODS

A longitudinal prospective study was conducted to formally evaluate the neurocognitive status of patients with unruptured DAVFs undergoing embolization. Pre- and posttreatment assessments included neurologic examinations and cognitive tests (Repeatable Battery for the Assessment of Neuropsychological Status and Trail-Making Test [TMT]).

RESULTS

A total of 23 patients were treated, with 78% demonstrating cortical venous reflux at baseline. At baseline, 50% of patients demonstrated cognitive impairment in at least 1 cognitive domain, and this was significantly associated with cortical venous reflux (P < .05). Following treatment, significant improvements were observed in several cognitive domains. The mean change in Immediate Memory was an increase of 10.5 points (95% CI, 6.2-14.8, P < .001). Visuospatial/Constructional abilities showed a mean increase of 3.8 points (95% CI, 1.1-6.5, P = .008), while Language improved by a mean of 4.2 points (95% CI, 0.9-7.5, P = .015). Attention scores increased by a mean of 6.1 points (95% CI, 2.7-9.5, P < .001). Delayed Memory demonstrated a mean improvement of 7.4 points (95% CI, 3.5-11.3, P < .001), and the Total Repeatable Battery for the Assessment of Neuropsychological Status Score increased by a mean of 8.6 points (95% CI, 5.0-12.2, P < .001). For the TMT, the mean change in TMT-A was a decrease of 9.2 seconds (95% CI, 5.6-12.8, P < .001), indicating faster completion times. TMT-B scores decreased by a mean of 12.7 seconds (95% CI, 8.4-17.0, P < .001). The TMT B-A difference decreased by a mean of 3.5 seconds (95% CI, 0.5-6.5, P = .023), and the TMT B/A ratio showed a mean decrease of 0.18 (95% CI, 0.10-0.26, P = .002). Overall, among the patients with baseline cognitive impairment, 70% showed significant cognitive improvement following endovascular treatment, particularly in memory domains.

CONCLUSIONS

In our study, 50% of patients with DAVFs had cognitive impairment when assessed with formal neurocognitive testing, with a significant link to cortical venous reflux. This cognitive impairment improved in 70% of those patients following treatment. These findings expand our understanding of how DAVF affects the brain, highlighting cognitive impairment as a critical factor. Consequently, the treatment of DAVFs should perhaps not only focus on hemorrhagic risk but also consider cognitive outcomes as a potential indicator for intervention.

Endovascular treatment of dural arteriovenous fistulas involving the vein of Galen: a single-center cohort and meta-analysis

BACKGROUND

Dural arteriovenous fistulas (dAVFs) draining into the vein of Galen (VoG) are complex lesions that often necessitate treatment to minimize the risk of rupture and relieve symptoms. These lesions can be treated with open surgical resection, radiosurgery, or endovascular embolization. Unfortunately, endovascular treatment of dAVFs involving the VoG has not been robustly assessed across large patient cohorts. To meet this need, we performed a retrospective review of dAVFs involving the VoG at our center, and included these in a meta-analysis to identify the safety and efficacy of endovascular embolization, as well as describing current treatment trends for this disease.

METHODS

Consecutive patients with dAVFs involving the VoG treated at a single center were identified from a prospective database and retrospectively reviewed. A literature search was conducted with defined search criteria, and eligible studies were included alongside our cohort in a meta-analysis. Rates of complete dAVF treatment and clinical complications were pooled across studies with a random effects model and reported with a 95% CI.

RESULTS

Five dAVFs involving the VoG were treated endovascularly at our center during the study period. In this series, 80% of treatments led to complete occlusion of the fistula while no patients had clinical complications. Onyx was used for all treatments. In our meta-analysis, the overall rate of complete occlusion was 72.0% (95% CI 59.8% to 84.1%) and the overall rate of clinical complications was 10.0% (95% CI 4.7% to 15.3%).

CONCLUSIONS

Endovascular approaches for dAVFs involving the VoG are technically feasible, but carry a risk of clinical complications. Future work should identify optimal endovascular embolic agents.

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.

Dural Arteriovenous Fistulas With Cognitive Impairment: Angiographic Characteristics and Treatment Outcomes

BACKGROUND AND OBJECTIVES

Anecdotal cases of rapidly progressing dementia in patients with dural arteriovenous fistulas (dAVFs) have been reported in small series. However, large series have not characterized these dAVFs. We conducted an analysis of the largest cohort of dAVFs presenting with cognitive impairment (dAVFs-CI), aiming to provide a detailed characterization of this subset of dAVFs.

METHODS

Patients with dAVFs-CI were analyzed from the CONDOR Consortium, a multicenter repository comprising 1077 dAVFs. A propensity score matching analysis was conducted to compare dAVFs-CI with Borden type II and type III dAVFs without cognitive impairment (controls). Logistic regression was used to identify angiographic characteristics specific to dAVFs-CI. Furthermore, post-treatment outcomes were analyzed.

RESULTS

A total of 60 patients with dAVFs-CI and 60 control dAVFs were included. Outflow obstruction leading to venous hypertension was observed in all dAVFs-CI. Sinus stenosis was significantly associated with dAVFs-CI (OR 2.85, 95% CI: 1.16-7.55, P = .027). dAVFs-CI were more likely to have a higher number of arterial feeders (OR 1.56, 95% CI 1.22-2.05, P < .001) and draining veins (OR 2.05, 95% CI 1.05-4.46, P = .004). Venous ectasia increased the risk of dAVFs-CI (OR 2.38, 95% CI 1.13-5.11, P = .024). A trend toward achieving asymptomatic status at follow-up was observed in patients with successful closure of dAVFs (OR 2.86, 95% CI 0.85-9.56, P = .09).

CONCLUSION

Venous hypertension is a key angiographic feature of dAVFs-CI. Moreover, these fistulas present at a mean age of 58 years-old, and exhibit a complex angioarchitecture characterized by an increased number of arteriovenous connections and stenosed sinuses. The presence of venous ectasia further exacerbates the impaired drainage and contributes to the development of dAVFs-CI. Notably, in certain cases, closure of the dAVF has the potential to reverse symptoms.

Dural Arteriovenous Fistulas Presenting as Symmetric Lesions in the Internal Capsule on Imaging Studies: A Case Report and Literature Review

BACKGROUND

Dural arteriovenous fistulas (DAVFs) leading to oedema, primarily in the internal capsule, are extremely rare and, to our knowledge, have never been reported. We reported a case of DAVFs with oedema in bilateral internal capsule oedema and reviewed the literature.

METHODS

The report describes a unique imaging presentation of cases of DAVFs as symmetric lesions, mainly in the bilateral internal capsule. It also reviews the literature for symmetric lesions in the internal capsule and central grey matter caused by DAVFs to further characterize this rare entity and differential diagnosis through imaging features.

RESULTS

In cases of symmetric oedema caused by DAVFs, the most common artery involved in arterial supply was the middle meningeal artery (13/24; 54%). The main vein involved in the drainage was the Galen vein (18/29; 62%). Most cases were treated with transarterial embolization (23/29; 79%), and the probability of effective treatment or complete cure is 100%. On imaging, the vasogenic oedema signal caused by DAVFs is a symmetrical lesion of the bilateral internal capsule, that is, DWI MRI shows a high signal in the unrestricted diffusion area on the apparent diffusion coefficient map.

CONCLUSIONS

MR has good diagnostic value in abnormal basal ganglia symmetric signals caused by DAVFs, and can quickly identify DAVFs early.

A retrospective study of 78 adult tentorial middle line region dural arteriovenous fistulae

OBJECTIVE

Dural arteriovenous fistulae (DAVF) in the tentorial middle line region are uncommon with specific features and more cognitive disorders than any other region. The purpose of this study is to present clinical characteristics and our experience with endovascular treatment in this specific region.

METHODS

During a 20-year period, 94.9% of patients (74/78) underwent endovascular treatment (36 in galenic, 48.6%) (12 in straight sinus, 16.2%) (26 in torcular, 35.1%). There were 63 males and 15 females with mean age of 50 (50 ± 12) years in total of 78 patients. The clinical presentation, angiographic features, treatment strategy, and clinical outcomes were recorded.

RESULTS

Transarterial embolization (TAE) was performed in 89.2% of the 74 patients (66/74), transvenous embolization alone in one patient and mixed approach in seven. Complete obliteration of the fistulas was obtained in 87.5% of the patients (64/74). 71 patients (mean, 56 months) had phone, outpatient, or admission follow-up. The digital subtraction angiography (DSA) follow-up period (25/78, 32.1%) was 13.8 (6-21) months. Two of them (2/25, 8%) had fistula recurrences after complete embolization and were embolized again. The phone follow-up period (70/78, 89.7%) was 76.6 (40-92.3) months. Pre-embolization and post-embolization mRS ≥ 2 were in 44 patients (44/78) and 15 (15/71) patients, respectively. DAVF with internal cerebral vein drainage (OR 6.514, 95% Cl 1.201-35.317) and intracranial hemorrhage (OR 17.034, 95% Cl 1.122-258.612) during TAE were the risk factors for predicting poor outcomes (followed up mRS ≥ 2).

CONCLUSIONS

TAE is the first-line treatment for tentorial middle line region DAVF. When pial feeders' obliteration is difficult to achieve, it should not be forced due to the poor outcomes after intracranial hemorrhage. The cognitive disorders caused by this region were not reversible as reported. It is imperative to enhance the care provided to these patients with cognitive disorders.

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.

Dural arteriovenous fistula causing reversible cognitive impairment

A previously independent 82-year-old woman presented with 5 months of worsening confusion, mobility and cognitive decline, with deficits in orientation, language and executive function. A cerebral dural arteriovenous fistula was identified and successfully embolised, after which her cognitive ability and independence dramatically improved. Although rare, a dural arteriovenous fistula may mimic a rapidly progressive dementia, but its early recognition and treatment can completely reverse the dementia.

Improving Early Recognition of Creutzfeldt-Jakob Disease Mimics

Background and Objectives

Diagnostic criteria emphasize the use of sensitive and disease-specific tests to distinguish patients with rapidly progressive dementia (RPD) due to Creutzfeldt-Jakob disease (CJD) vs other causes (mimics). These tests are often performed in specialized centers, with results taking days to return. There is a need to leverage clinical features and rapidly reporting tests to distinguish patients with RPD due to CJD from those due to other causes (mimics) early in the symptomatic course.

Methods

In this case-control series, clinical features and the results of diagnostic tests were compared between mimics (n = 11) and patients with definite (pathologically proven, n = 33) or probable CJD (with positive real-time quaking-induced conversion [RT-QuIC], n = 60). Patients were assessed at Mayo Clinic Enterprise or Washington University from January 2014 to February 2021. Mimics were enrolled in prospective studies of RPD; mimics met the diagnostic criteria for probable CJD but did not have CJD.

Results

Mimics were ultimately diagnosed with autoimmune encephalitis (n = 6), neurosarcoidosis, frontotemporal lobar degeneration with motor neuron disease, dural arteriovenous fistula, cerebral amyloid angiopathy with related inflammation, and systemic lupus erythematous with polypharmacy. Age at symptom onset, sex, presenting features, and MRI and EEG findings were similar in CJD cases and mimics. Focal motor abnormalities (49/93, 11/11), CSF leukocytosis (4/92, 5/11), and protein >45 mg/dL (39/92, 10/11) were more common in mimics (p < 0.01). Positive RT-QuIC (77/80, 0/9) and total tau >1149 pg/mL (74/82, 2/10) were more common in CJD cases (all p < 0.01). Protein 14-3-3 was elevated in 64/89 CJD cases and 4/10 mimics (p = 0.067). Neural-specific autoantibodies associated with autoimmune encephalitis were detected within the serum (5/9) and CSF (5/10) of mimics; nonspecific antibodies were detected within the serum of 9/71 CJD cases.

Discussion

Immune-mediated, vascular, granulomatous, and neurodegenerative diseases may mimic CJD at presentation and should be considered in patients with early motor dysfunction and abnormal CSF studies. The detection of atypical features-particularly elevations in CSF leukocytes and protein-should prompt evaluation for mimics and consideration of empiric treatment while waiting for the results of more specific tests.

Adult dural arteriovenous fistulas in Galen region: More to be rediscovered

Background

Dural arteriovenous fistulas (DAVFs) in the Galen region are the most deeply located and most complex type of dural arteriovenous fistulas. However, cases of DAVFs in this region have not been well described. Thus, we aimed to summarize the characteristics of Galenic DAVFs involving clinical symptoms, anatomical architecture, and drainage patterns, providing experientially therapeutic strategies for these lesions based on our 20 years of clinical experience.

Methods

We retrospectively examined 31 patients with Galenic DAVFs between January 2000 and June 2021. A comprehensive analysis was carried out based on the symptoms, imaging features, feeding arteries, draining veins, number and location of the fistulas, choice of treatment methods, and prognosis assessment.

Results

Twenty-nine patients received endovascular embolization, and no perioperative deaths occurred. A transarterial approach was performed in 27 patients, and a combined transarterial and transvenous approach in one. And in one case, access was established by surgical drilling and embolization was done via the venous route. Twenty-four cases were completely obliterated after first embolization, and another five cases received a second period treatment. Only one patient developed cognitive dysfunction after embolization, and the outcomes of the remaining patients were improved at long-term follow-up.

Conclusion

The understanding of symptoms of non-hemorrhagic neurological deficits in DAVF needs to be further clarified. Lesions with pial feeders may be considered first when determining surgical orders. Multi-approach and multi-stage embolization would be safe and effective. Excessive embolization and deep-vein system obstruction should be avoided. Approach creation by surgery would be an innovative interventional 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.

Medial tentorial dural arteriovenous fistula: A rare cause of bithalamic oedema

A 39-year-old man was admitted after 1 week of headaches and cognitive changes. CT scan showed bithalamic hypodensities, corresponding to bithalamic vasogenic oedema. Punctuate hemorrhage was present, with foci of thalamic enhancement. CT angiography raised the suspicion of arteriovenous shunt. Digital subtraction angiography confirmed a medial falcotentorial dural arteriovenous fistula. Complete embolization was performed using liquid embolic agent. Although tentorial dural fistulas have already been described as a cause of bithalamic oedema and subacute dementia, they are not generally included in pathologies implied in this radiologic pattern.

Vascular intracranial malformations and dementia: An under-estimated cause and clinical correlation. Clinical note

Cerebrovascular malformations (CVMs) such as arteriovenous malformations (AVMs) or dural arteriovenous fistulas (DAVFs) represent a possible source of intracranial hemorrhage, but these malformations can also manifest with neurologic disorders secondary to ischemic penumbra from vascular steal. In the latter case, the clinical manifestations are less obvious and characteristic, and may include a varied clinical spectrum ranging from focal deficits to generalized malfunction of the brain parenchyma resulting in dementia. Dementias secondary to CVMs constitute a probably underestimated subpopulation of patients of great interest because they present with devastating but potentially reversible cognitive impairment. We examined the pertinent literature regarding the clinical manifestations of CVMs characterized by cognitive impairment and describe the distinctive clinical features. Our results confirm that cognitive impairment is one of the clinical manifestations of CVMs and is a frequently misrecognized and often late-diagnosed cause of reversible dementia.

Brain arteriovenous malformations and dural arteriovenous fistulas with extensive venous congestive encephalopathy

In brain arteriovenous malformations (BAVMs) and dural arteriovenous fistulas (DAVFs), when too much blood is drained into the venous system, extensive venous congestive encephalopathy (EVCE) can appear. EVCE in BAVMs and DAVFs can be divided into acute and chronic stages. BAVMs and DAVFs have their own classification systems, but EVCE is not considered in these classification systems and needs to be emphasized. EVCE in BAVMs and DAVFs has unique clinical and imaging features. The clinical presentations usually consist of headache, cognitive impairment, and focal deficits. EVCE in BAVMs and DAVFs has several imaging features, and the venous congestion seen on computed tomography angiography and magnetic resonance angiography can present with the angiographic features of venous reflux and pseudophlebitic pattern. Digital subtraction angiography is the gold standard for the diagnosis. Delayed circulation time is observed. Tortuous, dilated, and engorged veins can be seen. For EVCE from BAVMs and DAVFs, prompt treatment is warranted due to the impairment of extensive brain tissue. Treatments include endovascular treatment (EVT), open surgery, and radiosurgery. EVT is often the primary treatment. Complete elimination in one stage is often difficult. Most of the time, staged treatment has to be chosen. No matter at the acute or chronic stage, aggressive treatment is recommended.

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.

Rapidly progressive dementia and Parkinsonism as the first symptoms of dural arteriovenous fistula. The Sapienza University experience and comprehensive literature review concerning the clinical course of 102 patients

BACKGROUND

Dementia is a chronic loss of neurocognitive function that is progressive and irreversible. Dural arteriovenous fistulas (DAVFs) are acquired lesions that account for 10-15% of intracranial vascular malformations that could present with a rapid decline in neurocognitive function with or without Parkinson-like symptoms and evolve in a rapidly progressive dementia (RPD). Often the DAVFs are not even included in the differential hypotheses of this type of dementia and are not present in any type of diagnostic algorithm for evaluating RPD.

METHODS

We performed a systematic review of the international literature and adding the cases coming from our institutional experience and we have collected all the reported cases of DAVFs that debut with ROD identifying the most frequent forms in terms of location and type, reporting the neurological characteristics and the outcome of each patient.

RESULTS

The exact pathogenesis for developing dementia in patients with DAVFs remains largely unknown. The imaging changes and pathologic findings support the hypothesis that the clinical course results from the delivery of excessive volumes of blood flow into a venous system with outflow obstruction and venous congestion. The large variety of clinical manifestations of DAVFs depends on its location but this is not exactly valid for the onset of dementia. It supposed that the highly variable clinical manifestation of DAVFs has been convincingly related to the pattern of venous drainage more than location.

CONCLUSIONS

Neurologists and clinicians generally are familiar with the differential diagnoses of slowly progressive neurodegenerative dementias, but the diagnosis of RPD entails a different diagnostic approach. Due to their curable nature, the diagnosis of DAVFs must be suspected when facing a RPD picture, even more so if it is associated with characteristic abnormalities of the hemispheric white matter.

Tentorial Dural Arteriovenous Fistulas as a Cause of Thalamic Edema: 2 Cases of an Important Differential Diagnosis to Consider

The differential diagnosis for bilateral thalamic edema is extensive and includes vascular, neoplastic, metabolic, and infectious causes. Of the vascular causes of thalamic edema, arterial and venous infarctions are well-documented, but dural arteriovenous fistulas (dAVFs) are a relatively uncommon and widely underrecognized cause of thalamic edema. Dural AVFs are notoriously difficult to diagnose clinically, especially in the absence of hemorrhage, and cross-sectional imaging findings can be subtle. This can result in a delayed diagnosis, and occasionally, an invasive biopsy for further clarification of a purely vascular disease. In this review, we detail our experience with the imaging diagnosis of dAVF as a cause of thalamic edema and present a short differential of other vascular causes.

Bilateral lesions of the basal ganglia and thalami (central grey matter)-pictorial review

The basal ganglia and thalami are paired deep grey matter structures with extensive metabolic activity that renders them susceptible to injury by various diseases. Most pathological processes lead to bilateral lesions, which may be symmetric or asymmetric, frequently showing characteristic patterns on imaging studies. In this comprehensive pictorial review, the most common and/or typical genetic, acquired metabolic/toxic, infectious, inflammatory, vascular and neoplastic pathologies affecting the central grey matter are subdivided according to the preferential location of the lesions: in the basal ganglia, in the thalami or both. The characteristic imaging findings are described with emphasis on the differential diagnosis and clinical context.

Dural arteriovenous fistula presenting with dementia and bulbar symptoms

Dural arteriovenous fistulas are relatively rare. Some cases are difficult to diagnose, leading to unnecessary investigations, treatments and delays, particularly if the presentation is atypical. We report a case of a man who presented with progressive dementia and bulbar symptoms, both under-recognised non-haemorrhagic neurological deficits, caused by cortical venous hypertension. Brain imaging showed unusual bilateral thalamic, tectal plate and midbrain oedema. The patient was investigated and treated for alternative aetiologies, before being correctly diagnosed and managed using angiographic embolisation. His clinical and radiological signs improved significantly following treatment, reducing his risk of neurological morbidity and mortality.

Thrombosis of the straight sinus and microbleedings due to deep seated arteriovenous fistula - Hemodynamic changes, cognitive impairment and improvement after microsurgery. A technical report

Dural arteriovenous fistulas (dAVF) are rare vascular malformations accounting for only 10-15% that may lead to life threatening deficits due to hemodynamic changes in blood supply and pressure conditions. We present a 64-year old patient who was admitted with disorientation and aphasia. Following images confirmed an infratentorial dural fistula draining into the straight sinus. Additional findings were progressive thrombosis of the straight sinus, microbleedings and bithalamic edema due changes in hemodynamic conditions and venous congestion. Microsurgery was performed. After treatment improvement in clinical condition was observed and the venous congestion was regressive. Hemodynamic changes due to infratentorial dAVFs may lead to bleedings in deep regions and worsening of clinical condition fastly. Treatment requires carefully planning and visualization of angioarchitecture. Symptoms and hemodynamic changes are reversible after treatment, which are essential for treatment decisions.

Spontaneous Subdural Hematoma and Behavioral Changes Due to a Dural Arteriovenous Fistula. A Case Report and Literature Review

Dural arteriovenous fistulas (DAVFs) represent 10–15% of intracranial arteriovenous malformations. Of these, only 12–29% cause intracranial hemorrhage. The presentation of DAVF as a subdural hematoma (SDH) and intraparenchymal hemorrhage (IPH) is infrequent; additionally, behavioral changes are not common among these patients. We report, for the first time in our country, the case of a 23-year-old man with no history of head injury, in which a brain computed tomography (CT) scan revealed SDH and IPH with behavioral disturbances. The angiotomography showed ecstatic venous vessels, indicating the presence of a DAVF, which was later confirmed by cerebral angiography. Endovascular therapy, which followed the clinical diagnosis, resulted in satisfactory evolution two years after treatment. A review of the literature concerning cases with DAVF and behavioral disturbances is presented. DAVF may lead to cognitive impairment, behavioral changes, and dementia as a result of diffuse white matter and thalamus modifications related to venous ischemia, and it should be considered as a reversible cause of vascular dementia.

Galenic dural arteriovenous fistula in neurofibromatosis type 1 treated with Onyx

Galenic dural arteriovenous fistula (GDAVF) represents a unique, hard-to-treat subgroup of tentorial dural arteriovenous fistulae. Neurofibromatosis type 1 (NF1) has been infrequently associated with different cerebrovascular conditions that may lead to either ischemic or haemorrhagic stroke. Intracranial GDAVF has not been described in NF1 patients. We present an unusual case of GDAVF in a 37-year-old man with NF1. The fistula drained directly to the vein of Galen through multiple feeders. Complete occlusion of the fistula was achieved through trans-arterial embolisation with Onyx (ethylene vinyl alcohol copolymer) in a single treatment session. Deep venous drainage remained intact, and the patient recovered well. To our knowledge, this is the first report on complete closure of GDAVF with NF1 using trans-arterial embolisation. The preservation of functioning of the straight sinus may have contributed to the success of treatment.

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

Intracranial dural arteriovenous fistulae (DAVF) within the deep cerebral vasculature are diagnostically challenging because of their variable clinical presentation and typical bilateral neuroimaging findings mimicking inflammatory, infectious, and metabolic processes. Increasingly, reports have emerged highlighting the diagnostic and treatment challenges of these lesions and their associated high morbidity and rapid clinical deterioration when untreated. We describe here a case series of 4 patients with deep cerebral DAVF who presented with impaired arousal or memory and behavioral changes. In all patients, the initial differential diagnosis included metabolic, inflammatory, infectious, or neoplastic disease, with an eventual correct diagnosis obtained after catheter angiography had demonstrated arterialization of the deep venous structures, including the vein of Galen. All patients were successfully treated with endovascular embolization, with 1 patient requiring additional surgical treatment. We review the contemporary diagnostic evaluation and management of DAVF within the deep cerebral vasculature. With rapid diagnosis and treatment, a favorable outcome is possible.

Clinical and angioarchitectural factors influencing the endovascular approach to galenic dural arteriovenous fistulas in adults: case series and review of the literature

BACKGROUND

Galenic dural arteriovenous fistulas (DAVF) are rare; however, they are the most frequent type of DAVF to manifest aggressive clinical behavior and usually represent a diagnostic and therapeutic challenge for clinicians.

METHODS

We retrospectively reviewed clinical and imaging data of patients managed with neuroendovascular techniques for the treatment of galenic DAVFs from 2000 to 2016. We searched the 2000-2016 English-language literature for papers discussing neuroendovascular management of galenic DAVFs, with or without companion surgical procedures.

RESULTS

Five patients were treated for galenic DAVFs during the study period (four males; mean age, 61 years). Three presented with progressive neurological deterioration due to venous congestion, two with acute intracranial hemorrhage. Three were treated by staged transarterial embolization procedures (three procedures in two, four procedures in one); two underwent a single transvenous embolization procedure. Four out of five fistulas were completely occluded. All patients improved clinically; the patient whose fistula was partially occluded remains angiographically stable at 2-year follow-up. Six reports describing 17 patients are reviewed. Embolization was performed via transvenous approach in 1/17 and transarterial approach in 16/17 with additional open surgery in 9/16. The trend toward the use of transarterial approaches is based primarily on advances on embolization techniques that allow better and more controllable penetration of the embolizing agents with improved clinical and angiographic results, as well as the technical complexity of the transvenous approach.

CONCLUSIONS

Although transarterial embolization is the preferred endovascular route for the management of most galenic DAVFs, selected cases can be successfully treated by transvenous approach.

Reversible Parkinsonism and Rapidly Progressive Dementia Due to Dural Arteriovenous Fistula: Case Series and Literature Review

Background

Dural arteriovenous fistula (dAVF) rarely presents with a syndrome of reversible parkinsonism and rapidly progressive dementia, which has been described in 19 patients to date. However, its presenting features, pathophysiology, and response to treatment have not been reviewed.

Methods

We report the clinical course and treatment of two novel patients with this syndrome.

Results

Despite severe presentations, both patients recovered fully after fistula obliteration.

Conclusions

Atypical parkinsonism with early cognitive changes and other focal neurological signs, along with features such as pulsatile tinnitus or worsening headache, should raise the possibility of dAVF. When treated, this syndrome is nearly always reversible, highlighting the importance of early diagnosis.

Dural Arteriovenous Fistula Manifested as Rapid Progressive Dementia Successfully Treated by Endovascular Embolization Only

A 43-year-old male presented with daytime sleepiness at work and indifferent behavior like never before. Two weeks prior to hospital admission, he had episodic memory loss with well preserved remote memory. Brain MRI showed a dural arteriovenous fistula (DAVF) in the right lateral transverse sinus with a bilateral thalamic venous infarction. Cerebral angiography confirmed a right transverse sigmoid dural arteriovenous fistula with a feeding artery of the right occipital artery and left posterior meningeal artery. The DAVF was completely eliminated through multiple endovascular interventions. Recently, endovascular treatment has become one of the main therapeutic options to obliterate a fistulous site, which has led to a rapid diagnostic approach and management of DAVFs with high curative rates. We report a rare case of posterior fossa located at a dural arteriovenous fistula that caused rapid progressive dementia and was successfully eliminated through only endovascular treatment.