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

Cerebral Perfusion Change of Venous Hypertension on Near-Infrared Spectroscopy Signals after Operation for Dural Arteriovenous Fistula

“…It is known that impaired CBF would be improved after the successful endovascular treatment and the abnormal signal would be lost. 12 The present case showed this abnormal sign as a very small spot. It is possible that this small spot suggests the considerably earliest change of the disease because both symptoms and this signal were reversible.…”

Bilateral Mirror Image Dural Arteriovenous Malformations Presenting with Aggressive Neurological Deterioration. Case report.

“…Multiple DAVMs are very uncommon lesions [1,[3][4][5][7][8][9]. Areas of involvement may include the cavernous, transverse-sigmoid, sphenoparietal, sinuses, tentorium, craniocervical junction, and spinal locations [4,5,[10][11][12][13][14][15].…”

“…Dural arteriovenous malformation/fistula accounts for 10 to 15% of all intracranial arteriovenous lesions [1,2,3]. It is estimated that fewer than 2% of patients harbor multiple lesions [1,4,5].…”

Complete Reversal of Diffusion Restriction after Treatment of Traumatic Carotid-Cavernous Fistula

“… 2 3 4 5 6 7 9 11) Traumatic CCF is usually type A CCF, which consist of direct high-flow shunt between the internal carotid artery (ICA) and the cavernous sinus. 2 3 4 5 6 7 9 11) Patients with traumatic direct CCF can experience exophthalmos, conjunctival injection, ophthalmoplegia and visual disturbance. Other presentations of traumatic direct CCF include fatal cerebrovascular complications such as intracerebral hemorrhage and cerebral ischemia.…”

“…Other presentations of traumatic direct CCF include fatal cerebrovascular complications such as intracerebral hemorrhage and cerebral ischemia. 2 3 6 8 10 11) Diffusion restriction can could be measured by reduced apparent diffusion coefficient (ADC) levels on magnetic resonance imaging (MRI) and is rarely reversible. However, reversible diffusion restriction has been found in patients with encephalopathy, traumatic brain injury (TBI), dural arteriovenous fistula (dAVF), hyperosmolar hyperglycemic state, cytotoxic lesions of the corpus callosum resulting from drug therapy, malignancy, infection, subarachnoid hemorrhage, metabolic disorders, trauma, and other entities.…”