Endovascular Management of Falcine Dural Arteriovenous Fistula-A Case Report and Review of Literature

Cranial dural arteriovenous (AV) fistulas are abnormal connections between the branches of dural arteries to dural veins or venous sinuses. They are most frequently located at the transverse sinus and cavernous sinus. They can occur at every cranial dural sinus. Dural AV fistula of falx cerebri is rare. A 62-year-old female presented with signs and symptoms of raised intracranial pressure. Radiological imaging revealed a dural AV fistula at the posterior one-third falx cerebri. She underwent transarterial embolization, and complete obliteration of the fistula was achieved. A detailed digital subtraction angiography study is warranted in patients with seemingly benign complaints like recurrent headaches, and falcine dural AV fistula should be identified and treated in the nick of time. We describe a very rare falcine dural AV fistula case and its management.

Combined Endovascular and Microsurgical Management of a Tentorial Arteriovenous Malformation in a Hybrid Neurovascular Operating Room: 2-Dimensional Operative Video

Tentorial margin arteriovenous malformations (AVMs) at the cerebello-mesencephalic fissure are deep lesions, which can be safely resected via a lateral supracerebellar infratentorial approach. This video illustrates the case of a patient who presented with hemorrhage from a tentorial AVM. He was managed in the hybrid neurovascular operating room with Onyx (Medtronic) embolization of a superior cerebellar artery feeder followed by resection of the AVM, which included cerebellar relaxation from lumbar cerebrospinal fluid (CSF) drainage and lateral positioning. Wide cisternal arachnoid dissection at the quadrigeminal cistern allowed for a straight trajectory to the AVM without fixed retraction. Intraoperative transradial angiography confirmed complete AVM exclusion. This video was deemed Institutional Review Board (IRB) exempt by the University of Pennsylvania IRB as it is considered a case report, which does not require IRB approval or patient consent.  The patient consented to the procedure.

The Preoperative Functional Downgrading of Brain AVMs

The actual role of preoperative embolization of brain arteriovenous malformations (AVMs) is undervalued.The present study aims to describe the effectiveness, safety, technics, and results of the endovascular-based functional downgrading of brain AVMs.Data regarding 31 Spetzler-Martin (SM) grade III AVMs that consecutively underwent a combined endovascular-surgical treatment were reviewed. Clinical and radiological outcomes were evaluated according to modified Ranking Scale score (mRS) and postoperative angiography, respectively.Low-density Onyx was used in all cases, and the timeframe between the embolizations was 10-15 days. Procedures were 1.6 (±0.6) on average. Superselective nidal catheterization was essential to reach the deepest parts of the AVMs, which were the targets. Onyx made the nidus compact and easier to dissect. The Average obliteration rate was 29.6%, with negligible morbidity. Surgery was performed after 3.7 days on average and the AVM exclusion was complete in 83.4% of cases. An mRS score between 0 and 2 was reported in 77.5% of patients, while the best outcome was achieved in small and medium-deep malformations.An effective and safe functional downgrading of brain AVMs must be based upon specific technical key aspects, which make surgery easier and, ultimately, allow for the achievement of the best outcome.

Scepter dual-lumen balloon catheter for Onyx embolization for dural arteriovenous fistula

Background

This study aimed to evaluate the efficacy and safety of Scepter dual-lumen balloon catheter for transarterial Onyx embolization of dural arteriovenous fistula (DAVF).

Methods

Transarterial Onyx embolization using a Scepter dual-lumen balloon catheter (Scepter-assisted Onyx embolization) for DAVF was attempted in a total of 35 patients (mean age, 52.5 years; M:F = 24:11) between October 2012 and December 2018. The results of Scepter-assisted Onyx embolization were evaluated with respect to total procedural and Onyx injection times, the types and number of feeders requiring embolization, angiographic and clinical outcomes, and treatment-related complications.

Results

Initial presentations were non-hemorrhagic neurological deficits in 10, intracranial hemorrhage in 8, seizure in 7, headache in 7, and intractable tinnitus in 3. All DAVF were aggressive type (Borden type 2, 14.3 %; type 3, 85.7 %). Scepter-assisted Onyx embolization resulted in immediately complete occlusion in 33 patients (94.3 %) and near complete occlusion in 2 patients. Middle meningeal artery (51.4 %) was the most commonly used for Scepter-assisted technique, followed by occipital artery (42.9 %), ascending pharyngeal artery (2.9 %) and superficial temporal artery (2.9 %). There was no difference in complete occlusion rate between middle meningeal artery and the other arteries (94.4 % versus 94.1 %). The median number of total feeders embolized was 1 (range, 1–3). The median total procedural time was 45 minutes (range, 21 minutes – 127 minutes) and the median Onyx injection time was 11 minutes (range, 3 minutes – 25 minutes). All patients recovered completely (n = 31) or partially (n = 4) from presenting symptoms. Treatment-related complications occurred in 2 patients, of whom one had a permanent morbidity (2.8 %, ipsilateral facial nerve palsy). No patient showed a recurrence on follow-up imaging (median, 15 months; range, 3–56 months).

Conclusions

Scepter-assisted transarterial Onyx embolization showed a very high complete occlusion rate with a low morbidity and no recurrence in aggressive type DAVF. Scepter dual-lumen balloon catheter seems to be a useful tool for transarterial Onyx embolization of DAVF.

Single institutional experience of peripheral applications of a liquid embolic agent: Ethylene Vinyl Alcohol Copolymer

OBJECTIVE

To evaluate the safety and efficacy of ethylene vinyl alcohol (EVOH) copolymer for the treatment of a variety of peripheral vascular pathologies.

RESULTS

Between October 2010 and October 2017, 43 patients who underwent total 54 EVOH embolization procedures for the treatment of peripheral vascular pathologies were included. The cases which involved the use of EVOH for the treatment of nonvascular, neurologic, ophthalmologic, otolaryngologic or head-neck pathologies were excluded. The demographic data, technical and clinical success rates, and procedure-related details and complications were obtained. The most common indications for EVOH embolization were type II endoleaks (n = 18) and peripheral arteriovenous malformations (n = 14). The majority of cases (62.5%) used EVOH without any adjunct embolic material. The results of this study showed 100% technical success rates and 89% clinical success rates. No events of nontarget embolization or other procedure-related complications were noted. The mortality & morbidity rates were 0%. The loss to follow up rate was 16% (9 /54). The mean follow-up period was 134 days (range, 30 to 522 days).

CONCLUSION

The single institutional experience supports the safety and efficacy of EVOH embolization in the treatment of various peripheral vascular conditions.

Embolization of carotid-cavernous fistulas: A technical note on simultaneous balloon protection of the internal carotid artery

A carotid-cavernous fistula (CCF) is an abnormal connection between the carotid circulation and the cavernous sinus. Treatment of CCFs often consists of obliteration of the fistula by a transarterial or transvenous endovascular approach using embolic agents. However, fistula embolization is often halted due to the potential embolic complications that may arise from the retrograde flow of the embolic agents into the arterial circulation, which often leads to the development of fistula recurrence. Moreover, retreatment of a CCF recurrence is challenging and more complex approaches may be required. In this technical note, we describe our experience with CCF embolization in 25 patients treated at a single center. We utilized a transvenous approach for CCF embolization with simultaneous balloon occlusion of the internal carotid artery during the infusion of the embolic material into the fistula. In our series, this simultaneous protection of the internal carotid artery showed to be a safe technique to prevent embolic complications and to achieve successful obliteration of the fistula. On follow-up, 2 cases presented a recurrence, one due to technical difficulties and the other related to an undetected vascular injury. In conclusion, this technique provides a safe approach in the treatment of CCFs by decreasing the risk of embolic complications and increasing the effectiveness of the embolic agents in accomplishing the obliteration of the CCF.

Onyx Embolization for Occlusion of the Proximal Internal Iliac Artery During EVAR in Patients with Unsuitable Landing Zones in the Common Iliac Artery

BACKGROUND

Twenty percent of the patients with AAA have an aneurysm involving the common iliac arteries. Large common iliac diameter can be treated with an iliac branched device or extension of the stent graft to the external iliac artery with occlusion of the ipsilateral internal iliac artery (IIA) to prevent type 2 endoleaks. This study describes and evaluates a embolization technique using Onyx in conjunction with EVAR in aneurysms with poor landing zones in the common iliac arteries.

METHODS

Patients with Onyx IIA embolization during EVAR, identified from the hospital operating code database, constitute the study population. Onyx embolization was performed by injection at the IIA origin. Peri- and postoperative complications were collected from the medical records. Thin-sliced CT scan was performed 1 month and 1 year after the procedure.

RESULTS

Thirty-six patients with complex iliac anatomy and insufficient landing zones (without sealing possibility for standard stent grafts) were identified out of 243 consecutive EVAR treatments during a 13-year period. In seventeen patients (7%), the IIA was embolized with Onyx. Technical success was obtained in all 17 patients, without adverse event or procedural complication. No complication related to the embolization procedure was noted during follow-up.

CONCLUSIONS

During EVAR treatment of patients with aneurysm involving the common iliac artery, Onyx embolization of IIA is a feasible option without need of selective catheterization of the IIA orifice, potentially preserving important branches of the IIA and simplifying emergency procedures.

Onyx embolization of a ruptured anterior inferior cerebellar artery in a neonate

Aneurysmal subarachnoid hemorrhage (SAH) is rare in neonates. The authors present a unique report of a neonate with SAH from anterior inferior cerebellar artery (AICA) aneurysm rupture that was successfully treated with Onyx embolization. This case report demonstrates the utility of Onyx embolization for posterior circulation aneurysms in neonates and the successful management of SAH in this population.

Multiple aneurysms on the subarcuate artery arising from the anterior inferior cerebellar artery in a patient with a Borden type I transverse-sigmoid dural arteriovenous fistula manifesting as subarachnoid hemorrhage: A case report

BACKGROUND

Peripheral anterior inferior cerebellar artery (AICA) aneurysms are rare and commonly associated with vascular malformations, such as cerebellar arteriovenous malformations (AVMs). We present a case wherein multiple AICA feeding aneurysms on the subarcuate artery as a feeding artery of a Borden type I transverse-sigmoid dural arteriovenous fistula (dAVF) manifested as subarachnoid hemorrhage.

CASE DESCRIPTION

A 67-year-old woman presented with acute severe headache. Brain computed tomography (CT) demonstrated subarachnoid hemorrhage mainly in the posterior fossa. A transverse-sigmoid dAVF was detected on magnetic resonance angiography (MRA) and three-dimensional-CT angiography (3D-CTA), with no cortical venous reflex. The patient underwent conventional angiography, which showed multiple aneurysms on a small branch of the AICA, feeding a transverse-sigmoid dAVF (Borden type I). The AICA aneurysms seemed flow dependent and ruptured owing to high-flow arteriovenous shunts through the dAVF. Based on the source images of the MRA, the small artery arising from the AICA was considered the subarcuate artery, and it was confirmed on 3D-CTA after the artery was successfully embolized with Onyx without any complications. Multiple aneurysms on the subarcuate artery are extremely rare, and the artery has not been identified as a feeding artery of the transverse-sigmoid dAVF.

CONCLUSION

A rare case of multiple ruptured aneurysms on the subarcuate artery was reported in a patient with a Borden type I dAVF at the transverse-sigmoid sinuses manifesting as subarachnoid hemorrhage. Onyx embolization of the parent artery occlusion was feasible and useful in treating this type of feeding artery aneurysm of the AICA with a dAVF.

Onyx embolization of a pial AV fistula with a giant venous varix using a flow-directed Scepter balloon catheter: Technical note

BACKGROUND AND IMPORTANCE

Pial arteriovenous fistulas (AVFs) of the brain are treacherous lesions that can be challenging to treat because of high risk of hemorrhage. We report on a rare case of a pial AVF with a giant venous varix as a draining vein treated successfully with flow-directed balloon-assisted Onyx embolization.

CLINICAL PRESENTATION

A 56-year-old female with headaches underwent brain magnetic resonance imaging, which demonstrated a 4 cm aneurysmal malformation in the right temporal lobe. A diagnostic cerebral angiogram demonstrated a right temporal pial AVF fed by an enlarged right posterior cerebral artery with drainage into a giant venous varix. Onyx embolization was curative using a flow-directed Scepter balloon catheter.

CONCLUSION

Flow-directed balloon-assisted Onyx embolization can be highly successful for the curative embolization of pial AVFs. Balloon application changes the nature of the lesion from high-flow-high risk to no-flow-low-risk. Using a flow-directed technique with balloon microcatheters may help minimize the risk of intracranial vascular injury.

Coil and Onyx embolization of a torcular herophili dural arteriovenous fistula in a full-term neonate with advanced heart failure using a transumbilical approach

Neonatal dural arteriovenous fistulas (DAVFs) are rare, but if left untreated will advance to life-threatening neurological and cardiovascular compromise. Endovascular treatment is the preferred treatment modality for DAVFs. The goal of endovascular therapy is to obliterate feeding vasculature and prevent secondary complications. Endovascular access can be difficult to obtain in a neonate. The authors present the case of a full-term, normal birth weight neonate with severe congestive heart failure secondary to a congenital DAVF of the torcular herophili that was successfully treated with transumbilical arterial coil embolization and a liquid embolic agent.

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.

Facial Nerve Paralysis after Onyx Embolization of a Jugular Paraganglioma: A Case Report with a Long-Term Follow Up

Jugular paragangliomas are slow growing highly vascular tumors arising from jugular paraganglia. The gold standard of treatment is complete surgical resection. Pre-operative embolization of these highly vascular tumors is essential to reduce intra-operative bleeding, allow safe dissection, and decrease operative time and post-operative complications. Onyx (ethylene-vinyl alcohol copolymer) has been widely used as permanent occluding material for vascular tumors of skull base because of its unique physical properties. We present the case of a 33-year-old woman who had left-sided facial nerve paralysis after Onyx embolization of jugular paraganglioma. The tumor was resected on the next day of embolization. The patient was followed up for 30 months with serial imaging studies and facial nerve assessment. The facial verve function improved from House–Brackmann grade V to grade II at the last visit.

Surgical Treatment of Arteriovenous Malformations: Role of Preoperative Staged Embolization

Preoperative embolization is complementary to surgery for large brain arteriovenous malformations (AVMs). From January 2005 to December 2015, 69 patients harboring an AVM were managed in our department by the same surgeon (RG). Forty one were ruptured and 65 were supratentorial. Thirty nine smaller AVMs were treated with surgery stand-alone, whereas, for 30 larger malformations, surgery was combined with adjuvant treatment involving preoperative staged embolization and/or, less frequently, radiosurgery. In all patients treated with surgery alone, complete resection of AVM was achieved. A successful preoperative partial endovascular obliteration of AVM was obtained in 24 out of 27 more complex cases, with a zero mortality rate and a very low morbidity. Here, embolization was of a certain utility in the handling of deeper feeders and nidus excision, also facilitating intraoperative hemostasis. In three cases of residuals, radiosurgery was performed. In those patient treated with a combined approach, a good overall outcome, 0-2 modified Rankin Scale (mRS), was achieved in 25 cases. Preoperative embolization proved to be a reasonable option complementary to high-grade AVMs surgery, reducing the frequency of breakthrough hemorrhages, aiding the elimination of deep feeders, and making the nidus dissection easier.

Cranial Nerve Palsy after Onyx Embolization as a Treatment for Cerebral Vascular Malformation

The Onyx liquid embolic system is a relatively safe and commonly used treatment for vascular malformations, such as arteriovenous fistulas and arteriovenous malformations. However, studies on possible complications after Onyx embolization in patients with vascular malformations are limited, and the occurrence of cranial nerve palsy is occasionally reported. Here we report the progress of two different types of cranial nerve palsy that can occur after embolization. In both cases, Onyx embolization was performed to treat vascular malformations and ipsilateral oculomotor and facial nerve palsies were observed. Both patients were treated with steroids and exhibited symptom improvement after several months. The most common types of neuropathy that can occur after Onyx embolization are facial nerve palsy and trigeminal neuralgia. Although the mechanisms underlying these neuropathies are not clear, they may involve traction injuries sustained while extracting the microcatheter, mass effects resulting from thrombi and edema, or Onyx reflux into the vasa nervorum. In most cases, the neuropathy spontaneously resolves several months following the procedure.

An Onyx tunnel: reconstructive transvenous balloon-assisted Onyx embolization for dural arteriovenous fistula of the transverse-sigmoid sinus

Transvenous embolization is an effective method for treating dural arteriovenous fistulas (DAVFs) of the transverse-sigmoid sinus (TSS). However, in cases of complicated DAVFs, it is difficult to preserve the patency of the dural sinus. The authors describe the technical details of a new reconstructive technique using transvenous balloon-assisted Onyx embolization as another treatment option in a patient with an extensive and complex DAVF of the left TSS. A microcatheter and compliant balloon catheter were navigated into the left internal jugular vein and placed at the distal end of the DAVF in the transverse sinus. The microcatheter was placed between the vessel wall of the TSS and the balloon. After the balloon was fully inflated, Onyx-18 was injected at the periphery of the balloon in a slow, controlled, progressive, stepwise manner; the balloon and microcatheter were simultaneously withdrawn toward the sigmoid sinus, with Onyx encompassing the entirety of the complex DAVF. The Onyx refluxed into multiple arterial feeders in a distal-to-proximal step-by-step manner, ultimately resulting in an Onyx tunnel. The final angiography study revealed complete obliteration of the DAVF and patency of the TSS. The Onyx tunnel, or reconstructive transvenous balloon-assisted Onyx embolization technique, may be an effective treatment option for large, complex DAVFs of the TSS. This technique may provide another option to facilitate the complete obliteration of the DAVF while preserving the functional sinus.

Detection of a Rare Complication of Endovascular Treatment for Brain Arteriovenous Malformation with Echocardiography

A brain arteriovenous malformation (AVM) is a congenital malformation of the vascular system, in which an abnormal short circuit (vascular malformation) connects cerebral arteries and veins. When the brain AVMs are diagnosed, the majority of them must be closed with surgical or endovascular treatment, because only a small portion of the brain AVMs remain asymptomatic during the patient's life. Endovascular transarterial embolization using Onyx Liquid Embolic System is a suitable method for treating brain AVMs. Previously known complications of Onyx usage are bleeding and neurologic deficits. We report a young man with a rare complication of Onyx injection, clinically silent distal embolization to the heart chamber and pulmonary circulation, discovered incidentally with echocardiography.

Spontaneous Aggressive Conversion of Venous Drainage Pattern in Dural Arteriovenous Fistula Treated with Onyx Embolization

We report a case of dural arteriovenous fistula (DAVF) that showed spontaneous conversion of venous drainage pattern from Borden type II to type III within a four month period of follow-up. Upon admission, the patient presented with aggravated neurologic status and newly developed seizure. After admission, endovascular embolization was performed through the middle meningeal artery with Onyx®. Complete obliteration of dural arteriovenous shunt was confirmed by angiography, and the patient's clinical symptoms improved. Although most cases of DAVF show benign clinical course and conversion pattern, close follow-up is required to detect potential aggravation.

Adjunct to Embolize the High-Flow Fistula Part of Arteriovenous Malformation Using a Double-Lumen Balloon Catheter

OBJECTIVE

The purpose of this study is to report our initial experience of Onyx embolization of the high-flow fistula part of arteriovenous malformation (AVM) using a double-lumen balloon catheter.

METHODS

A Scepter C balloon catheter was used in 2 patients with AVMs associated with high-flow fistulas. The fistulas were located in the anterior cerebral artery and the middle cerebral artery.

RESULTS

Onyx embolization was successful in 2 cases, resulting in elimination of the high-flow fistula part of the AVM. There were no treatment-related events.

CONCLUSIONS

The double-lumen Scepter balloon appears to be a safe and convenient device for Onyx embolization of high-flow fistulas.

Balloon-Occlusion Catheter Onyx Embolization of a Spinal Dural Arteriovenous Fistula Presenting with Subarachnoid Hemorrhage in a Pediatric Patient

OBJECTIVE

Spinal dural arteriovenous fistulas (DAVFs) are insidious pathologies that, if left untreated, harbor potentially devastating consequences to the central nervous system. Spinal DAVFs are rare in the adult population and exceedingly uncommon in the pediatric population. In this report, we describe a spinal DAVF in a 3-year-old child whose initial presentation is subarachnoid hemorrhage (SAH). Balloon-test occlusion and balloon-catheter-assisted embolization of DAVF have not been previously described, and their advantages over alternative embolic and surgical techniques are discussed.

METHODS

We performed a literature search on MEDLINE/PubMed to review current reports describing the epidemiology, clinical presentation, and treatment of spinal DAVFs. In this report, we describe a spinal DAVF in a 3-year-old child whose initial presentation is SAH.

RESULTS

A spinal DAVF was diagnosed after deciding to image not only the brain but also the spine. Using a balloon-occlusion catheter, we confirmed that the DAVF arterial feeding vessel could be safely embolized. We then proceeded to effectively treat the DAVF with balloon-catheter-assisted Onyx-18 embolization.

CONCLUSION

Based on our report and an analysis of the literature, we propose that pediatric patients presenting with nontraumatic SAH should undergo at least a magnetic resonance imaging of the brain and cervical spine as part of their initial workup. In addition, we describe a balloon-occlusion catheter embolization technique that allows not only excellent embolic penetration of the fistula but also prevention of microcatheter reflux and lessening of the need for a tedious plug-and-stack technique.

Balloon protection of the Labbé vein during transarterial embolization of a dural arterio-venous fistula

INTRODUCTION

Endovascular treatment of type III dural arterio-venous fistulas can be challenging if the fistulous point is close to a functionally important cortical vein.

METHODS

A technique is described for temporary balloon protection of the vein of Labbé during transarterial Onyx embolization of a type III dural arterio-venous fistula. One illustrative case is presented. Careful anatomic consideration of the concerned venous segment (at the insertion point into the lateral sinus) and the choice of balloon minimized the risk of venous rupture.

RESULTS

Using this method, satisfactory progression of Onyx was obtained within the arterio-venous shunt while preserving the patency of the Labbé vein.

CONCLUSION

Temporary balloon protection of the Labbé vein is a feasible option to preserve its patency during embolization of dural arterio-venous fistulas. To the authors' knowledge, this is the first report on the use of temporary balloon protection of a cortical vein.

Transforaminal approach for cerebral dural arteriovenous fistula embolization

A transverse sinus dural arteriovenous fistula (DAVF) not easily accessible by standard transfemoral (transarterial or transvenous) endovascular approaches is presented. An enlarged transosseous retromastoid foramen harboring the occipital artery branch feeding the lesion was identified on CT angiogram (CTA). Curative Onyx embolization was achieved via percutaneous CT-guided direct puncture of the transosseous occipital arterial branch followed by microcatheter navigation through the needle distally towards the site of the fistula.

Transcranial direct middle meningeal artery puncture for the onyx embolization of dural arteriovenous fistula involving the superior sagittal sinus

A 66-year-old woman presented with intermittent paraparesis and generalized tonic-clonic seizure. Cerebral angiography demonstrated dural arteriovenous fistula (AVF) involving superior sagittal sinus (SSS), which was associated with SSS occlusion on the posterior one third. The dural AVF was fed by bilateral middle meningeal arteries (MMAs), superficial temporal arteries (STAs) and occipital arteries with marked retrograde cortical venous reflux. Transfemoral arterial Onyx embolization was performed through right MMA and STA, but it was not successful, which resulted in partial obliteration of dural AVF because of tortuous MMA preventing the microcatheter from reaching the fistula closely enough. Second procedure was performed through left MMA accessed by direct MMA puncture following small decortications of cranium overlying the MMA using diamond drill one week later. Microcatheter could be located far distally to the fistula through 5 F sheath placed into the MMA and complete obliteration of dural AVF was achieved using 3.9 cc of Onyx.

Tentorial dural arteriovenous fistula presenting as myelopathy: Case series and review of literature

Dural arteriovenous fistula (DAVF) is a rare type of cerebral arteriovenous malformation. Common presenting symptoms are related to hemorrhage. However, rarely these patients may present with myelopathy. We present two cases of DAVF presenting as rapidly progressive myelopathy. Two treatment options are available: microsurgical interruption of the fistula and endovascular embolization. These treatment options of DAVFs have improved significantly in the last decade. The optimal treatment of DAVFs remains controversial, and there is an ongoing debate as to whether primary endovascular or primary microsurgical treatment is the optimal management for these lesions. However, despite treatment a high percentage of patients are still left with severe disability. The potential for functional ambulation in patients with DAVF is related to the time of intervention. This emphasizes the important of early diagnosis and early intervention in DAVF. The eventual outcome may depend on several factors, such as the duration of symptoms, the degree of disability before treatment, and the success of the initial procedure to close the fistula. The usage of magnetic resonance imaging and selective angiography has significantly improved the ability to characterize DAVFs, however, these lesions remain inefficiently diagnosed. If intervention is delayed even prolonged time in rehabilitation does not change the grave prognosis. This review outlines the presentation, classication and management of DAVF as well as discussing patient outcomes.

Down but not out

A 20-year-old Hispanic man with Down syndrome presented with progressively worsening headache, fluctuating decreased vision, and bilateral optic disk edema. Magnetic resonance imaging of the head showed an empty sella, and magnetic resonance venography showed thrombosis of left transverse and sigmoid sinuses. Catheter angiography angiogram showed a dural arteriovenous fistula in the wall of left transverse and sigmoid sinuses. The patient underwent Onyx endovascular embolization of the fistula, resulting in its angiographic obliteration, followed by resolution of his clinical signs and symptoms.

Medullary venous hypertension secondary to a petrous apex dural arteriovenous fistula: a case report

Background

Dural arteriovenous fistulae (dAVF) are common intracranial vascular lesions typically becoming symptomatic with cortical venous hypertension and possible hemorrhage. Here, we present a case illustration of a petrous apex dAVF with marked medullary venous hypertension and a unique clinical presentation.

Methods

Case report.

Results

A 72-year-old female, whose clinical progression was significant for altered mental status and progressive weakness, presented with diplopia, right leg paresis, and ataxia. Magnetic resonance imaging revealed edema involving the medulla. On digital subtraction cerebral angiogram, the patient was found to have a petrous apex dAVF, Cognard type IV. Following treatment with Onyx embolization, her symptoms rapidly improved, with complete resolution of diplopia and drastic improvement of her ataxia.

Conclusion

The importance of this case is in the presentation and deterioration of the clinical exam, resembling an acute ischemic event. Further, this case illustrates that dAVF may cause venous hypertension with rapid onset of focal neurologic symptoms not exclusive to cortical locations.