We report five cases of intracranial dural arteriovenous fistula (DAVF) with perimedullary venous drainage. All the patients presented with rapidly progressive myelopathy and three had autonomic disorders. The DAVF were on the tentorium cerebelli (two cases), sigmoid (one), superior petrosal (one), and cavernous sinus (one). Slow venous drainage was directed through dilated perimedullary cervical veins. The transverse sinus was occluded in two cases. MRI, performed in four cases, demonstrated high signal on T2-weighted spin-echo sequences in the medulla oblongata and upper cervical spinal cord consistent with oedema, which signal resolved after complete cure of the DAVF in three cases. Embolisation was performed in all cases. It was followed by clinical deterioration in two cases and in the dramatic improvement in the other three, with complete clinical cure in two. Extensive venous thrombosis may explain the deterioration observed in one case.
The percutaneous placement of ventriculo-atrial (V-A) shunts for treatment of hydrocephalus has been previously reported by several authors as a simplified procedure. However, this technique did not avoid the use of a distal connector between the outlet catheter and the atrial one, which may lead to a disconnection. A technique of percutaneous V-A shunt insertion using a split sheath is described and illustrated with a series of 22 patients. The use of a split sheath eliminates any distal connector thus avoiding the risk of shunt disconnection and reducing the operating time. The average operating time was 31 min. This rapid procedure allowed us to operate on two of our patients under local anaesthesia. The correct placement of the atrial catheter tip was performed under fluoroscopic control and always confirmed by postoperative radiographs. Two incidents of carotid artery puncture were controlled by simple local compression without further consequences. The mean follow-up time is one year. All the patients' clinical conditions improved. We are encouraged to use this V-A technique more frequently as a method of choice in the treatment of adult hydrocephalus or when the peritoneal cavity is inaccessible in children. The use of a split sheath is successful in reducing the operating time and avoiding the use of a distal connector.
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