scholarly journals Intracranial Hemorrhage From Dural Arteriovenous Fistulas: Symptoms, Early Rebleed, and Acute Management: A Single-Center 8-Year Experience

2020 ◽  
Vol 1 (4) ◽  
Author(s):  
Wilhelm Sorteberg ◽  
Angelika Sorteberg ◽  
Eva Astrid Jacobsen ◽  
Pål Rønning ◽  
Per Kristian Eide
Keyword(s):  
Intracranial Hemorrhage ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Venous Drainage ◽  
Venous Hypertension ◽  
Thunderclap Headache ◽  
Neurological Deficits ◽  
Venous Aneurysm ◽  
Acute Management ◽  
Arteriovenous Fistulas ◽  
Dural Arteriovenous Fistulas

Abstract BACKGROUND Cerebral dural arteriovenous fistulas (dAVFs) presenting with hemorrhage are so rare that reports on their characteristics and guidelines for their acute management are scarce. OBJECTIVE To identify characteristics of the clinical and radiological presentation of hemorrhaging dAVFs, and establish their frequency of early rebleed so that implications for their acute management can be drawn. METHODS Retrospective analysis of all patients admitted with intracranial hemorrhage from a dAVF during the years 2011 to 2018. RESULTS Twenty patients (14 males) with a median age of 61 yr (27-75 yr) were included. Thunderclap headache was the presenting symptom in 13 (65%) patients. Rebleed prior to treatment occurred in 35% of the patients at median 7.5 h (range 3-96 h) after the ictus. All dAVFs had retrograde venous drainage and a venous aneurysm with a bleb was the source of hemorrhage in 16 (80%) patients, all of them presenting with headache. In contrast, patients bleeding due to diffuse venous hypertension presented with neurological deficits. Endovascular treatment was successful in 2 cases; hence, definite dAVF treatment was surgical in 18 (90%) patients. At median 7 mo (2-29 mo) after the ictus, 13 (65%) patients were in Glasgow Outcome Scale-Extended 7 or 8. CONCLUSION The typical presentation of hemorrhage from a cranial dAVF is thunderclap headache. The origin of hemorrhage is often a ruptured venous aneurysm with a bleb. The high frequency of early rebleeds warrants management strategies equivalent to those established for aneurysmal subarachnoid hemorrhage. Overall outcome is favorable.

Advances in Surgical Approaches to Dural Fistulas

Neurosurgery ◽  
2014 ◽  
Vol 74 (suppl_1) ◽  
pp. S32-S41 ◽  
Author(s):  
Patrick P. Youssef ◽  
Albert Jess Schuette ◽  
C. Michael Cawley ◽  
Daniel L. Barrow
Keyword(s):  
Treatment Options ◽  
Venous Drainage ◽  
Venous Hypertension ◽  
Surgical Approaches ◽  
Dural Sinus ◽  
Intraoperative Angiography ◽  
Indocyanine Green Videoangiography ◽  
Arteriovenous Fistulas ◽  
The Past ◽  
Dural Arteriovenous Fistulas

Abstract Dural arteriovenous fistulas are abnormal connections of dural arteries to dural veins or venous sinuses originating from within the dural leaflets. They are usually located near or within the wall of a dural venous sinus that is frequently obstructed or stenosed. The dural fistula sac is contained within the dural leaflets, and drainage can be via a dural sinus or retrograde through cortical veins (leptomeningeal drainage). Dural arteriovenous fistulas can occur at any dural sinus but are found most frequently at the cavernous or transverse sinus. Leptomeningeal venous drainage can lead to venous hypertension and intracranial hemorrhage. The various treatment options include transarterial and transvenous embolization, stereotactic radiosurgery, and open surgery. Although many of the advances in dural arteriovenous fistula treatment have occurred in the endovascular arena, open microsurgical advances in the past decade have primarily been in the tools available to the surgeon. Improvements in microsurgical and skull base approaches have allowed surgeons to approach and obliterate fistulas with little or no retraction of the brain. Image-guided systems have also allowed better localization and more efficient approaches. A better understanding of the need to simply obliterate the venous drainage at the site of the fistula has eliminated the riskier resections of the past. Finally, the use of intraoperative angiography or indocyanine green videoangiography confirms the complete disconnection of fistula while the patient is still on the operating room table, preventing reoperation for residual fistulas.

scholarly journals Intracranial hemorrhage from dural arteriovenous fistulas: clinical features and outcome

2013 ◽  
Vol 34 (5) ◽  
pp. E15 ◽  
Author(s):  
David J. Daniels ◽  
Ananth K. Vellimana ◽  
Gregory J. Zipfel ◽  
Giuseppe Lanzino
Keyword(s):  
Clinical Features ◽  
Intracranial Hemorrhage ◽  
Case Series ◽  
Venous Drainage ◽  
Sudden Onset ◽  
Residual Symptoms ◽  
Arteriovenous Fistulas ◽  
Common Location ◽  
Dural Arteriovenous Fistulas

Object In this paper the authors' goal was to review the clinical features and outcome of patients with intracranial dural arteriovenous fistulas (DAVFs) who presented with hemorrhage. Methods A retrospective study of 28 patients with DAVFs who presented with intracranial hemorrhage to 2 separate institutions was performed. The information reviewed included clinical presentation, location and size of hemorrhage, angiographic features, treatment, and clinical and radiologically documented outcomes. Clinical and radiological follow-up were available in 27 of 28 patients (mean follow-up 17 months). Results The vast majority of patients were male (86%), and the most common presenting symptom was sudden-onset headache. All DAVFs had cortical venous drainage, and about one-third were associated with a venous varix. The most common location was tentorial (75%). Treatment ranged from endovascular (71%), surgical (43%), Gamma Knife surgery (4%), or a combination of modalities. The majority of fistulas (75%) were completely obliterated, and most patients experienced excellent clinical outcome (71%, modified Rankin Scale score of 0 or 1). There were no complications in this series. Conclusions Case series, including the current one, suggest that the vast majority of patients who present with intracranial hemorrhage from a DAVF are male. The most common location for DAVFs presenting with hemorrhage is tentorial. Excellent outcomes are achieved with individualized treatment, which includes various therapeutic strategies alone or in combination. Despite the hemorrhagic presentation, almost two-thirds of patients experience a full recovery with no or minimal residual symptoms.

scholarly journals Cerebral venous drainage in patients with dural arteriovenous fistulas: correlation with clinical presentation

2020 ◽  
pp. 1-9
Author(s):  
João Ferreira de Melo Neto ◽  
Eduardo E. Pelinca da Costa ◽  
Nilson Pinheiro Junior ◽  
André L. Batista ◽  
Georges Rodesch ◽  
...  
Keyword(s):  
Alternative Pathway ◽  
Venous Drainage ◽  
Venous Hypertension ◽  
Normal Brain ◽  
High Grade ◽  
Venous Anatomy ◽  
Arteriovenous Fistulas ◽  
Dural Arteriovenous Fistulas ◽  
Group 2 ◽  
Group 1

OBJECTIVEDural arteriovenous fistulas (DAVFs) are abnormal, acquired arteriovenous connections within the dural leaflets. Their associated symptoms may be mild or severe and are related to the patient’s venous anatomy. With the hypothesis that the patient’s venous anatomy determines the development of symptoms, the authors aimed to identify which venous anatomy elements are important in the development of major symptoms in patients with a DAVF.METHODSA multicenter study was performed based on the retrospective analysis of cerebral angiographies with systematic assessment of brain drainage pathways (including fistula drainage) in patients over 18 years of age with a single DAVF. The patients were divided into two groups: those with minor (group 1, n = 112) and those with major (group 2, n = 89) symptoms. Group 2 was subdivided into two groups: patients with hemorrhage (group 2a, n = 47) and patients with severe nonhemorrhagic symptoms (group 2b, n = 42).RESULTSThe prevalence of stenosis in DAVF venous drainage and the identification of tiny anastomoses between venous territories were significantly higher in group 2 (32.6% and 19.1%, respectively) compared with group 1 (2.68% and 5.36%, respectively). Stenosis of DAVF venous drainage was significantly more frequent in group 2a than in group 2b (51.1% vs 11.9%, p < 0.001). Group 2b patients had increased prevalence of shared use of the cerebral main drainage pathway (85.0% vs 53.2%, p = 0.002), the absence of an alternative route (45.0% vs 17.0%, p = 0.004), and the presence of contrast stagnation (62.5% vs 29.8%, p = 0.002) compared with group 2a patients. In patients with high-grade fistulas, the group with major symptoms had increased prevalence of a single draining direction (31.3% vs 8.33%, p = 0.003), stenosis in the draining vein (35.0% vs 6.25%, p = 0.000), the absence of an alternative pathway for brain drainage (31.3% vs 12.5%, p = 0.017), and the presence of contrast stagnation (48.8% vs 22.9%, p = 0.004).CONCLUSIONSMajor symptoms were observed when normal brain tissue venous drainage was impaired by competition with DAVF (predominance in group 2b) or when DAVF venous drainage had anatomical characteristics that hindered drainage, with consequent venous hypertension on the venous side of the DAVF (predominance in group 2a). The same findings were observed when comparing two groups of patients with high-grade lesions: those with major versus those with minor symptoms.

scholarly journals Cranial dural arteriovenous fistulas: modification of angiographic classification scales based on new natural history data

2009 ◽  
Vol 26 (5) ◽  
pp. E14 ◽  
Author(s):  
Gregory J. Zipfel ◽  
Manish N. Shah ◽  
Daniel Refai ◽  
Ralph G. Dacey ◽  
Colin P. Derdeyn
Keyword(s):  
High Risk ◽  
Intracerebral Hemorrhage ◽  
Clinical Symptoms ◽  
Venous Drainage ◽  
Risk Groups ◽  
Neurological Deficits ◽  
Neurological Injury ◽  
Arteriovenous Fistulas ◽  
Dural Arteriovenous Fistulas ◽  
Cortical Venous Drainage

This article presents a modification to the existing classification scales of intracranial dural arteriovenous fistulas based on newly published research regarding the relationship of clinical symptoms and outcome. The 2 commonly used scales, the Borden-Shucart and Cognard scales, rely entirely on angiographic features for categorization. The most critical anatomical feature is the identification of cortical venous drainage (CVD; Borden-Shucart Types II and III and Cognard Types IIb, IIa + b, III, IV, and V), as this feature identifies lesions at high risk for future hemorrhage or ischemic neurological injury. Yet recent data has emerged indicating that within these high-risk groups, most of the risk for future injury is in the subgroup presenting with intracerebral hemorrhage or nonhemorrhagic neurological deficits. The authors have defined this subgroup as symptomatic CVD. Patients who present incidentally or with symptoms of pulsatile tinnitus or ophthalmological phenomena have a less aggressive clinical course. The authors have defined this subgroup as asymptomatic CVD. Based on recent data the annual rate of intracerebral hemorrhage is 7.4–7.6% for patients with symptomatic CVD compared with 1.4–1.5% for those with asymptomatic CVD. The addition of asymptomatic CVD or symptomatic CVD as modifiers to the Borden-Shucart and Cognard systems improves their accuracy for risk stratification of patients with high-grade dural arteriovenous fistulas.

Borden-Shucart Type I dural arteriovenous fistulas: clinical course including risk of conversion to higher-grade fistulas

2012 ◽  
Vol 117 (3) ◽  
pp. 539-545 ◽  
Author(s):  
Manish N. Shah ◽  
James A. Botros ◽  
Thomas K. Pilgram ◽  
Christopher J. Moran ◽  
DeWitte T. Cross ◽  
...  
Keyword(s):  
Intracranial Hemorrhage ◽  
Clinical Course ◽  
Retrospective Chart Review ◽  
Annual Rate ◽  
Neurological Deficits ◽  
Type I ◽  
Arteriovenous Fistulas ◽  
Presenting Symptoms ◽  
Dural Arteriovenous Fistulas

Object The goal of this study was to determine the clinical course of Borden-Shucart Type I cranial dural arteriovenous fistulas (DAVFs) and to calculate the annual rate of conversion of these lesions to more aggressive fistulas that have cortical venous drainage (CVD). Methods A retrospective chart review was conducted of all patients harboring DAVFs who were seen at the authors' institution between 1997 and 2009. Twenty-three patients with Type I DAVFs who had available clinical follow-up were identified. Angiographic and clinical data from these patients were reviewed. Neurological outcome and status of presenting symptoms were assessed during long-term follow-up. Results Of the 23 patients, 13 underwent endovascular treatment for intolerable tinnitus or ophthalmological symptoms, and 10 did not undergo treatment. Three untreated patients died of unrelated causes. In those who were treated, complete DAVF obliteration was achieved in 4 patients, and palliative reduction in DAVF flow was achieved in 9 patients. Of the 19 patients without radiographic cure, no patient developed intracranial hemorrhage or nonhemorrhagic neurological deficits (NHNDs), and no patient died of DAVF-related causes over a mean follow-up of 5.6 years. One patient experienced a spontaneous, asymptomatic obliteration of a partially treated DAVF in late follow-up, and 2 patients experienced a symptomatic conversion of their DAVF to a higher-grade fistula with CVD in late follow-up. The annual rate of conversion to a higher-grade DAVF based on Kaplan-Meier cumulative event-free survival analysis was 1.0%. The annual rate of intracranial hemorrhage, NHND, and DAVF-related death was 0.0%. Conclusions A small number of Type I DAVFs will convert to more aggressive DAVFs with CVD over time. This conversion to a higher-grade DAVF is typically heralded by a change in patient symptoms. Follow-up vascular imaging is important, particularly in the setting of recurrent or new symptoms.

scholarly journals Bilateral Cervical Spinal Dural Arteriovenous Fistulas with Intracranial Venous Drainage Mimicking a Foramen Magnum Dural Arteriovenous Fistula

2013 ◽  
Vol 19 (4) ◽  
pp. 483-488 ◽  
Author(s):  
Steven W. Hetts ◽  
Joey D. English ◽  
Shirley I. Stiver ◽  
Vineeta Singh ◽  
Erin J. Yee ◽  
...  
Keyword(s):  
Arteriovenous Fistula ◽  
Dural Arteriovenous Fistula ◽  
Venous Drainage ◽  
Foramen Magnum ◽  
Venous Hypertension ◽  
Complex Case ◽  
Arteriovenous Fistulas ◽  
Dural Arteriovenous Fistulas ◽  
Diagnostic Angiography ◽  
Spinal Dural Arteriovenous Fistulas

We describe a unique case of bilateral cervical spinal dural arteriovenous fistulas mimicking an intracranial dural arteriovenous fistula near the foramen magnum. We review its detection via MRI and digital subtraction angiography and subsequent management through surgical intervention. Pitfalls in diagnostic angiography are discussed with reference to accurate location of the fistula site. The venous anastomotic connections of the posterior midline spinal vein to the medial posterior medullary vein, posterior fossa bridging veins, and dural venous sinuses of the skull base are discussed with reference to problem-solving in this complex case. The mechanism of myelopathy through venous hypertension produced by spinal dural fistulas is also emphasized.

scholarly journals MR Detection of Dilated Deep Medullary Veins in Intracranial Dural Arteriovenous Fistulas with retrograde Leptomeningeal Venous Drainage

2002 ◽  
Vol 8 (3) ◽  
pp. 265-272 ◽  
Author(s):  
C.M. Chan ◽  
K.M. Cheng ◽  
J.Y.L. Cheung ◽  
F.W.T. Lee ◽  
K.W. Tang ◽  
...  
Keyword(s):  
Neurological Complication ◽  
Venous Drainage ◽  
Neurological Complications ◽  
Venous Hypertension ◽  
Neurological Deficits ◽  
Intracerebral Haematoma ◽  
Arteriovenous Fistulas ◽  
Severe Degree ◽  
The Brain ◽  
Deep Medullary Veins

Patients with dural arteriovenous fistula (DAVF) are at higher risk of developing neurological deficits when there is retrograde leptomeningeal venous drainage. Our aim is to demonstrate the presence of dilated deep medullary veins in the brain on magnetic resonance imaging (MR) in this group of patients, and to assess their clinical significance. Nine patients with angiographically proven DAVF associated with leptomeningeal venous drainage who had MR before treatment were studied. MR was performed in at least two orthogonal planes before and after gadolinium administration. The dural fistula was located at the cavernous sinus in five patients, at the transverse-sigmoid sinus in three and at the tentorium in one. Dilated deep medullary veins were noted in six patients. Of these, four showed parenchymal abnormalities which included intracerebral haematoma, venous infarction, brain oedema and T2 hyper-intensity in brainstem. Venous varix was present in one patient. No neurological complication or parenchymal change was observed in the three patients without dilated deep medullary veins. Therefore, in patients with intracranial DAVF associated with leptomeningeal venous recruitment, the MR finding of dilated deep medullary veins suggests a more severe degree of venous hypertension and congestion in the brain. This subgroup of patients has a much higher chance of neurological complications and warrants urgent intervention.

The role of surgery for high-grade intracranial dural arteriovenous fistulas: importance of obliteration of venous outflow

2009 ◽  
Vol 110 (5) ◽  
pp. 913-920 ◽  
Author(s):  
James K. Liu ◽  
Aclan Dogan ◽  
Dilantha B. Ellegala ◽  
Jonathan Carlson ◽  
Gary M. Nesbit ◽  
...  
Keyword(s):  
Surgical Intervention ◽  
Transarterial Embolization ◽  
Endovascular Embolization ◽  
Venous Hypertension ◽  
Neurological Deficits ◽  
Definitive Treatment ◽  
Radical Excision ◽  
Venous Outflow ◽  
Arteriovenous Fistulas ◽  
Dural Arteriovenous Fistulas

Object Surgical intervention may be required if endovascular embolization is insufficient to completely obliterate intracranial dural arteriovenous fistulas (DAVFs). The authors report their 14-year experience with 23 patients harboring diverse intracranial DAVFs that required surgical intervention. Methods Between 1993 and 2007, 23 patients underwent surgery for intracranial DAVFs. The following types of DAVFs were treated: superior petrosal sinus (in 10 patients); parietooccipital (in 3); confluence of sinuses and ethmoidal (in 2 each); and tentorial, falcine, occipital, transverse-sigmoid, superior sagittal, and cavernous sinuses (in 1 patient each). In all cases, the authors' goal was to obliterate the DAVF venous outflow by direct surgical interruption of the leptomeningeal venous drainage. Transarterial embolization was used primarily as an adjunct to decrease flow to the DAVF prior to definitive treatment. Results Complete angiographic obliteration of the DAVF was achieved in all cases. There were no complications of venous hypertension, venous infarction, or perioperative death. There were no recurrences and no further clinical events (new hemorrhages or focal neurological deficits) after a mean follow-up of 45 months. Conclusions The authors' experience emphasizes the importance of occluding venous outflow to obliterate intracranial DAVFs. Those that drain purely through leptomeningeal veins can be safely obliterated by surgically clipping the arterialized draining vein as it exits the dura. Radical excision of the fistula is not necessary.

Concomitant conus medullaris arteriovenous shunts and sacral dural arteriovenous fistulas: pathophysiological links related to the venous drainage of the lesions in a series of five cases

2018 ◽  
Vol 10 (6) ◽  
pp. 586-592 ◽  
Author(s):  
Andrea Rosi ◽  
Arturo Consoli ◽  
Stéphanie Condette-Auliac ◽  
Oguzhan Coskun ◽  
Federico Di Maria ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Young Patients ◽  
Case Series ◽  
Venous Drainage ◽  
Conus Medullaris ◽  
Venous Hypertension ◽  
Arteriovenous Fistulas ◽  
Congenital Origin ◽  
Arteriovenous Shunts ◽  
Dural Arteriovenous Fistulas

BackgroundSpinal cord arteriovenous shunts (scAVSs) are a group of lesions located in the spinal cord itself or in the surrounding structures. The most common scAVSs are spinal dural arteriovenous fistulas (sDAVFs), which are acquired lesions. The pathogenesis of sDAVFs involves thrombosis and venous hypertension as trigger factors. Intradural scAVSs such as spinal cord arteriovenous nidus type malformations (AVMs) and pial arteriovenous fistulas are less common than sDAVFs and are considered to have a so-called ‘congenital’ origin. The association between different concomitant scAVSs is very rare and the association of sDAVFs with intradural scAVSs has been described in only a few case reports.MethodsWe describe a case series of five patients presenting with a conus medullaris AVS associated with a lower lumbar or sacral DAVF.ResultsThree of our patients were <30 years old at presentation. In four of these five cases the intradural scAVS drained caudally, engorging the epidural plexus in the same location as the sDAVF. In only one case, who presented with thrombosis of the drainage of the main compartment of a conus medullaris pial AVF, was the location of the DAVF opposite to the location of the residual drainage.ConclusionWe discuss the pathophysiological link between scAVS and sDAVF on the basis of the rarity of the DAVF, the uncommon association between scAVS and sDAVF, the presence of sDAVF in young patients, and the venous hypertension created by the venous drainage towards the sacral area responsible for angiogenesis creating the dural shunt.

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