Endovascular management of six simultaneous intracranial dural arteriovenous fistulas in a single patient

Abstract

SUMMARYA 64-year-old man with a history of traumatic brain injury 4 years previously presented with progressive cognitive decline and gait abnormality. MRI revealed diffusion restriction in the bilateral centrum semiovale and multiple serpiginous flow voids. Cerebral angiogram revealed a total of six intracranial dural arteriovenous fistulas with separate fistulas of the right and left sphenoid bones, left clival plexus, right transverse sinus, right sigmoid sinus, and superior sagittal sinus. A diffuse pseudophlebitic pattern of venous drainage indicating severe venous hypertension was also observed. The patient underwent a series of endovascular treatments over the next 10 months to achieve resolution of all arteriovenous shunting. Repeat MRI showed resolution of the diffusion restriction and marked reduction in T2 vascular flow voids. The patient's clinical status improved significantly over the course of treatment, paralleling the improvement in venous hypertension. BACKGROUND

Mid and long term outcomes of dural arteriovenous fistula endovascular management with Onyx. Experience of a single tertiary center

“…This recanalization may theoretically occur as a result of new fistula formation, or possibly due to the maturation of an angiographically occult fistula under the influence of post-embolization hemodynamic changes. One of our study patients, for example, presented initially with three DAVFs, but over the course of four embolization procedures developed three additional, apparently independent, fistulas 13. Hypotheses for the mechanism underlying DAVF post-embolization recanalization include: (1) poor penetration of Onyx into the fistulous component, resulting in the recruitment/enlargement of previously unvisualized arterial supply due to a decrease in pressure within the DAVF33 and (2) changes in fistulous flow within the DAVF after embolization, such that a separate component of the fistula (which was previously masked by high flow within then DAVF system) becomes angiographically apparent.…”

“…DAVFs represent up to 15% of all intracranial vascular malformations, with a greater incidence in women 27 28. In general, DAVFs are solitary, although 5–8% are multiple 13 29. The pathogenesis of DAVFs is not clear but DAVFs are thought to be acquired rather than congenital.…”

“…Endovascular embolization is considered the treatment of choice for the majority of DAVFs2 3 5 7–16 18–21 and a multitude of embolization materials have been used with varying success, including: detachable coils, n-butyl cyanoacrylate (NBCA), and Onyx (ev3, Irvine, California, USA). Early outcomes reported for Onyx embolization of DAVFs are encouraging,13 17 18 20 22–26 but evidence regarding the long term durability of DAVF Onyx embolization is lacking. In the current study, we present the immediate, mid term, and long term outcomes as well as complications and predictors of recurrence for a consecutive series of 63 intracranial DAVFs subjected to endovascular Onyx embolization.…”