Pial Arteriovenous Fistula with Giant Varices: Report of Two Cases with Good Surgical Outcome

Abstract

Pial arteriovenous fistulas (pAVF) are rare vascular lesions consisting of one or more arterial connections to a single venous channel without any intervening nidus of vessels or capillaries.Case 1: A 65-year-old woman with a complaint of headache and left hand paresthesia was referred to us. Magnetic resonance imaging showed a large saccular lesion with signal void in the posterior part of the right sylvian fissure and catheter angiography showed a giant venous aneurysm fed by one branch of the middle cerebral artery (MCA) and draining into the vein of Trolard.Case 2: A 12-year-old boy was transferred to our hospital with a history of sudden loss of consciousness and hemiplegia. Brain computed tomography revealed a massive hemorrhagic mass in the right hemisphere and cerebral angiography showed a pAVF with a large aneurysmal varix, which was fed by multiple branches of the right MCA and draining into the superior sagittal sinus.Both patients underwent craniotomy and after ligation of vascular connections, aneurysmal varices were removed completely. Surgical resection can be a safe method for treatment of pAVFs, particularly in those with large varices.

Endovascular embolization of pial arteriovenous fistula fed from P1 segment of posterior cerebral artery in 12 years old girl: case report and review of literature

“…6,8 The number of feeders and drainage characteristics also determine the endovascular planning, which may include multiple accesses. As for dimensions, even if some authors advocate that in cases with large varices a combined or pure surgical approach is preferable to improve the symptoms, 9 we agree with Hoh et al. in stating that there is no such need as the main pathological issues arise from high-flow dynamics of PAVFs.…”

Hydrocephalus in a patient with an unruptured pial arteriovenous fistula: hydrodynamic considerations, endovascular treatment, and clinical course

“…Hydrocephalus and macrocrania have been reported to be between 14.3% and 38% in different clinical series. 15,24,33,39 In patients with pial AVF and mild to moderate hydrocephalus without acute intracranial hypertension, the aim of treatment is occlusion of the fistula, either surgical 21,40 or endovascular. Ventriculoperitoneal shunting prior to this exclusion decreases the pressure in the ventricles that may result in hygromas, subdural hemorrhage, 3 or hemorrhage as shown in different clinical scenarios with venous overload and associated hydrocephalus.…”

Intracranial non-galenic pial arteriovenous fistula: A review of the literature

“…The lesions could be dissected from the surrounding tissues, and the obliteration of the feeding arteries and draining veins did not cause new neurological deficits. 86…”

“…The lesions could be dissected from the surrounding tissues, and the obliteration of the feeding arteries and draining veins did not cause new neurological deficits. 86 NGPAVFs with a superficial location and lower flow rate are easy to treat. However, the surgical treatment of NGPAVFs accompanied by venous hypertension and multiple fistulous channels is challenging because preexisting venous hypertension may precipitate severe bleeding.…”