Treatment of Dural Arteriovenous Fistula Presenting as Typical Symptoms of Hydrocephalus Caused by Venous Congestion -Case Report-

Abstract

A 76-year-old woman presented with a dural arteriovenous fistula (DAVF) manifesting as typical symptoms of normal pressure hydrocephalus such as progressive dementia, gait disturbances, and urinary incontinence. The cerebrospinal fluid pressure during lumbar puncture was 120 mmH 2 O. Computed tomography and magnetic resonance imaging showed ventricular dilation and diffuse white matter changes, which were consistent with the symptoms of hydrocephalus. Cerebral angiography revealed a DAVF in the transverse-sigmoid sinuses with severe cortical venous reflux into the superior sagittal sinus. Transarterial embolization of the feeding arteries reduced the venous flow from the cortical veins into the superior sagittal sinus. Her symptoms improved with reduction in ventricle size. However, she suffered recurrence of the same symptoms several months later. Computed tomography and magnetic resonance imaging demonstrated ventricular dilation associated with hydrocephalus. Angiography revealed a fistulous channel in the left transverse-sigmoid junction. Transvenous embolization was performed resulting in complete obliteration of the fistula. Magnetic resonance image findings such as ventricular dilation and diffuse white matter disappeared and the symptoms of hydrocephalus improved. Although DAVFs often present as venous hypertensive encephalopathy, this case presented with ventricular dilation and diffuse white matter changes, which are the typical neurological signs of normalpressure hydrocephalus. Venous hypertension associated with the DAVF in the transverse-sigmoid sinuses may have been caused by normal pressure hydrocephalus.

CT and MR imaging of non-cavernous cranial dural arteriovenous fistulas: Findings associated with cortical venous reflux

“…A similar mechanism has also been incriminated in arteriovenous malformation with deep venous drainage and venous congestion [23]. This mechanism could explain some imaging presentations in our series, which have also been described in previous reports including confluent white matter changes [14,24], hydrocephalus in patients without intraventricular hemorrhage (IVH) or anatomical obstruction of the CSF drainage pathways [8,25], tonsillar herniation from intracranial hypertension [2,14] and secondary CSF leak [22,26].…”

Venous hemodynamics in neurological disorders: an analytical review with hydrodynamic analysis

“…In patients with NPH, cortical-vein compliance is significantly reduced [102]; however, following shunt surgery, compliance greatly increases, suggesting that the compliance changes associated with these veins are functional and not structural [2,102]. NPH has been shown to be associated with venous hypertension in the SSS [119]. It is therefore plausible that hypertension in the SSS might increase the pressure in the cortical veins, with the result that the functional compliance of these vessels is reduced [2].…”

Transverse Sinus Dural Arteriovenous Fistula Presenting with Acute Hydrocephalus from Cerebellar Venous Engorgement Resolving with Endovascular Treatment

“…11 An alternative mechanism of hydrocephalus is related to generalized venous hypertension that may inhibit absorption of CSF via arachnoid granulations. 12 This mechanism may have been involved in a case reported with massive dilation of the venous sinuses at the region of the torcula and transverse sinuses fed primarily by a middle meningeal artery. 13 The patient developed hydrocephalus, which was thought to be caused by a combination of poor venous drainage and mass effect from dilated sinuses.…”

“…Another case of "normal pressure hydrocephalus" was reported, associated with cortical venous reflux from the transverse-sigmoid to superior sagittal sinus. 12 This also may have been a case of impaired venous drainage due to the venous hypertension from the fistula. It is important to note that hydrocephalus was caused by a difference in pressure between the venous sinuses and subarachnoid space, whereas in our case the intraparenchymal venous congestion led to direct compression of CSF drainage tracts.…”