Clinical Presentation and Imaging Findings of Patients with Dural Arteriovenous Fistulas with an Angiographic Pseudophlebitic Pattern

Systemic immune-inflammation index in dural arteriovenous fistula: a feasible biomarker reflecting its clinical characteristics

PURPOSE

The systemic immune-inflammation index (SII), a marker of systemic inflammation, can be calculated using peripheral blood tests. Although the SII has been reported as a feasible biomarker in various cerebrovascular diseases, no studies have explored in dural arteriovenous fistula (DAVF). A retrospective cohort study was performed to test whether the SII reflects the clinical characteristics of DAVF and whether this index could serve as a feasible biomarker.

METHODS

This study included 28 patients who underwent endovascular treatment (39 sessions) for DAVF between 2014 and 2023. The SII was calculated using the following formula: platelet count multiplied by neutrophil count divided by lymphocyte count. We investigated the correlation between the SII and various clinical characteristics of DAVF, including symptom manifestation, and digital subtraction angiography findings. Additionally, we compared pre- and post-endovascular treatment changes in the SII.

RESULTS

A significantly higher SII was observed in patients with multiple lesions, clinical symptoms (particularly aggressive symptoms), pseudophelebitic pattern (PPP), and sinus occlusion. Multivariate regression analysis revealed that the presence of symptoms (coefficient 270.9, P = 0.021) and PPP (coefficient 272.4, P = 0.017) were independent factors contributing to SII elevation. Notably, following endovascular treatment, there was a significant decrease in the elevated SII in patients whose symptoms resolved (P = 0.039) and where the DAVF was angiographically cured (P = 0.012).

CONCLUSION

Elevation of the SII in patients with advanced DAVF and its decrease following endovascular treatment suggests that the SII reflects the disease condition and indicates its potential as a promising biomarker.

Differentiation between aggressive and benign intracranial non-cavernous dural arteriovenous fistulas using cortical venous reflux on susceptibility weighted images

PURPOSE

This study aimed to evaluate the ability of susceptibility-weighted imaging (SWI) to detect cortical venous reflux (CVR) in patients with intracranial non-cavernous dural arteriovenous fistulas (DAVFs), which can be helpful to differentiate benign and aggressive DAVFs.

MATERIAL AND METHODS

Twenty-seven patients (8 women and 19 men) with 33 non-cavernous DAVFs were divided into benign and aggressive groups. Presence of CVR and pseudophlebitic pattern (PPP) and location of fistula on SWI were determined. Digital subtraction angiography was used as the reference standard. Interobserver agreement for the presence of CVR and PPP and location of DAVF on SWI was evaluated using the kappa statistic. Statistical comparisons between the benign and aggressive DAVFs were performed.

RESULTS

Sensitivity, specificity, positive predictive value, and negative predictive value of SWI for detecting CVR was 73.7%, 85.7%, 87.5%, and 70.6%, respectively. Corresponding values for detecting PPP were 95.2%, 83.3%, 95.2%, and 83.3%, respectively. SWI correctly identified DAVF location in 78.9%. Prevalence rates of CVR and PPP on SWI were significantly higher in aggressive DAVFs than benign ones.

CONCLUSION

SWI exhibited high sensitivity and specificity for detection of CVR, a characteristic used to differentiate benign and aggressive lesions. CVR and PPP on SWI are signs of aggressive DAVFs that guide to perform angiography confirmation and prompt treatment to avoid serious complication.

Symptomatic and Stenotic Developmental Venous Anomaly with Pontine Capillary Telangiectasia: A Case Report with Genetic Considerations

Stenotic developmental venous anomalies (DVAs) often present with neurological deficits. In addition, cerebral capillary telangiectasia (CCT) coexisting with DVA is rarely encountered, and its pathophysiology, including the underlying genetics, and appropriate management remain uncertain. A 46-year-old man without any medical history of note was referred to our hospital with gradually worsening cerebellar ataxia. Two months after symptom onset, ataxic dysarthria and gait emerged. Brain magnetic resonance imaging showed CCT occupying the pons and left cerebellar peduncle. Subsequent catheter angiography demonstrated a DVA leading from the mass into the cavernous sinus with marked outlet stenosis and flow stagnation. We hypothesized that venous congestion was the source of gradual neurological deterioration and therefore initiated anticoagulation. Symptoms showed mild improvement, and his neurological status has remained stable as of 1 year after symptom onset. Whole-exome sequencing of germline DNA did not reveal any rare variants in genes previously reported as pertinent to vascular malformations. Anticoagulation may be a useful option in patients with non-thrombotic, stenotic DVA for whom neurological status did not improve under expectant management. Genetic analysis of this patient did not reveal any pathogenic mutations, and further investigation of somatic mutations is necessary to elucidate potential genetic causes.

Anomalous location of intracranial vessels in adults

Anomalous intracranial vessels are not uncommon, and this finding is not always associated with arteriovenous malformations. Other conditions such as anomalous connections between arteries or phlebitc patterns can also present as vessels with abnormal intracranial locations. Noninvasive diagnosis is important to determine whether to do more invasive tests such as cerebral digital subtraction angiography or to estimate the risk of bleeding in arteriovenous malformations and therefore to evaluate the need for endovascular/surgical treatment. In this paper, we present an algorithm for the differential diagnosis of anomalous intracranial vessels according to their location (intra/extra-axial) and function (whether the vessels are arterialized). Moreover, we analyze the important points of the angioarchitecture of the principal arteriovenous malformations with risk of intracranial bleeding, such as pial arteriovenous malformations and dural fistulas.

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.

A Case of Direct Carotid-Cavernous Fistulae Successfully Treated by Bidirectional Double Catheter Technique: A Technical Note

Objective

Ruptured carotid-cavernous aneurysms (CCAs) are known to result in direct carotid-cavernous fistula (CCF). Although endovascular treatment is recognized as the first-line treatment for direct CCF, obliteration is sometimes difficult because of the high-flow shunt. In this report, we present a case of a direct CCF treated by the combination of transarterial and transvenous approaches.

Case Presentation

A 57-year-old woman presented with conjunctival chemosis, exophthalmos, and tinnitus. Ophthalmological examination revealed increased intraocular pressure. DSA demonstrated a direct CCF due to a right ruptured CCA with retrograde shunted flow through the superior ophthalmic vein (SOV), superficial middle cerebral vein, basal vein of Rosenthal, and middle temporal vein. Two microcatheters were guided into the shunt segment from the internal carotid artery and SOV. In addition, a balloon catheter was placed at the neck of the aneurysm to assist coiling. Coil embolization for the CCF was performed using two microcatheters in the opposite direction, which enabled compact and tight packing of the shunt segment with only six coils. The CCF was eliminated. Two-year-follow-up MRA revealed no recurrence.

Conclusion

The bidirectional double catheter technique is a useful approach to obliterate a shunt in a short segment with minimal coils.

Is the Middle Meningeal Artery the Optimal Path for Dural Arteriovenous Fistula Embolization?

Background: The middle meningeal artery (MMA) is the optimal arterial path for endovascular treatment (EVT) of dural arteriovenous fistulas (DAVFs). However, the details are not completely understood.

Materials and Methods: We performed a retrospective study of patients who were admitted to the First Hospital of Jilin University with a diagnosis of cranial DAVF with involvement of the MMA as a feeding artery. On the basis of the arterial path chosen and the role of the MMA in the first EVT procedure, EVT was divided into three types (I–III), each of which was further divided into two subclasses (a and b). The degree of embolization was analyzed.

Result: The 104 included patients ranged in age from 13 to 80 years (mean, 53.6 ± 11.8 years). There were 48 cases of hemorrhage (46.2%, 48/104). Complete embolization was achieved in the first procedure in 64.4% of cases, and success was eventually achieved using EVT (the first attempt or a subsequent attempt) in 74.1% of cases. EVT caused complications in 6.7% of cases. A modified Rankin scale score of 0 or 1 was achieved in 78.8% of patients. Statistical analyses revealed that type Ia and IIb EVTs had the lowest complete embolization rates, but no difference was found between type Ia and IIb EVTs. Types IIa and III EVT had the highest complete embolization rates. Most cases had a good prognosis.

Conclusion: These findings elucidate the features of the different EVT classes defined by the first EVT procedure and the role of the MMA. The delivery of treatment via slim and tortuous MMA branches increased the failure rate of EVT. A thick, straight MMA branch is the optimal path for treatment.