Interest and necessity of combined neuroradiological and neurosurgical treatment in some cases of dural arterio-venous fistulae

Abstract

The authors report 3 observations of dural arterio-venous fistula cured by combined neuroradiological and neurosurgical intervention. In the first case, the shunt affected the left lateral sinus. Repeated embolizations failed whilst intracranial hypertension developed, as a consequence of flux in the opposite lateral sinus and in the sagittal sinus. Surgical intervention, consisting in isolation of the transverse sinus, led to complete cure, after a one month delay. In the second case, the shunt was adjacent to the sagittal sinus, right parietal, and had led to an intracerebral haematoma, by rupture of an arterialized cortical vein. Embolizations alone could not cure the fistula which therefore had to be excised. In the third case, the shunt was located in the falx, at the parieto-occipital junction, and was responsible for arterialization of cerebral veins in the right parieto-occipital region. For this reason, after failure of endovascular treatment, the fistula was coagulated, with subsequent complete cure. These three cases illustrate the different types of drainage of such arterio-venous fistula, and their corresponding neurological symptoms and signs, complications and risks, that required a radical-not only clinical, but also anatomical-cure. This aim was achieved when embolizations were accompanied by direct surgical attack.

Intracranial dural arteriovenous fistula successfully treated by combined open-endovascular procedure

“…The transfemoral approach was abandoned, but we decided to gain arterial access through direct exposure of the MMA. This combined neurosurgical–endovascular approach is not novel and has already been described,2 9 10 to our knowledge first by Fransen et al 8. This type of rare vascular pathology requires a multidisciplinary approach.…”

Combining endovascular and neurosurgical treatments of high-risk dural arteriovenous fistulas in the lateral sinus and the confluence of the sinuses

“…A combined endovascular-surgical approach was performed in 17 other cases. These 17 patients are placed into three groups based on the following angiographic characteristics: extremely high flow DAVF without sinus occlusion and LRVD (Case 1); localized DAVF with exclusive LRVD (Cases 2 and 3); and DAVF with bifocal or diffuse sinus occlusion and LRVD (Cases [4][5][6][7][8][9][10][11][12][13][14][15][16][17]. Embolization was performed in the patients by one of the authors (K.G.)…”

“…In many cases DAVF tends to persist or recur despite surgical intervention. As Fransen, et al, [12] have pointed out in a detailed description, incomplete embolization and surgical devascularization fail to halt the progression of extensive DAVFs of the transverse sinuses. In our experience, there was occasional prompt recruitment of blood supply via the leptomeningeal vessels after completely surgically isolating the diseased segment of the dural sinus from the surrounding dura mater (Fig.…”

XI cranial nerve cervical schwannoma – Case report

“…25 Surgical removal can be achieved by suboccipital uni or bilateral craniotomy/craniectomy with or without C1 laminectomy for most intracysternal accessory nerve schwannomas. 4,10,12,18,20,23,[26][27][28][29][30][31][32] And, even though the spinal accessory nerve is commonly sacrificed, there are low rates of postoperative deficits. 13 We believe that intraop eletcrophysiological monitoring helps in identifying nerve function and that a carefully intra-arachnoidal plane dissection and nerve preservation with complete tumor removal is feasible.…”

“…7,13,[15][16][17] The MRI findings are typically regularly shaped contour, low T1, high T2 signals, different degrees of homogenous contrast enhancement, lack of edema and may present solid or with cystic degeneration (in larger tumors). 7,9,[12][13][14][18][19][20][21][22][23][24] Total surgical resection is the recommended standard treatment for such lesions as it is considered curative. 7,13,20 There is scarce literature regarding radiosurgical option for these tumors but a regrowth rate of 25% is seen in some series.…”