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

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.

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Open and endovascular treatment of spinal dural arteriovenous fistulas: a 10-year experience

Journal of Neurosurgery Spine ◽

10.3171/2016.9.spine16394 ◽

2017 ◽

Vol 26 (4) ◽

pp. 519-523 ◽

Cited By ~ 20

Author(s):

Matthew J. Koch ◽

Christopher J. Stapleton ◽

Pankaj K. Agarwalla ◽

Collin Torok ◽

John H. Shin ◽

...

Keyword(s):

Vascular Malformations ◽

Management Strategies ◽

Case Series ◽

Endovascular Embolization ◽

Definitive Treatment ◽

Type I ◽

Arteriovenous Fistulas ◽

Presenting Symptoms ◽

Dural Arteriovenous Fistulas ◽

Spinal Dural Arteriovenous Fistulas

OBJECTIVE Vascular malformations of the spine represent rare clinical entities with profound neurological implications. Previously reported studies on management strategies for spinal dural arteriovenous fistulas (sDAVFs) appeared before the advent of modern liquid embolic agents. Authors of the present study review their institutional experience with endovascularly and surgically treated sDAVFs. METHODS The authors performed a retrospective, observational, single-center case series on sDAVFs treated with endovascular embolization, microsurgical occlusion, or both between 2004 and 2013. The mode, efficacy, and clinical effect of treatment were evaluated. RESULTS Forty-seven patients with spinal arteriovenous malformations were evaluated using spinal angiography, which demonstrated 34 Type I sDAVFs (thoracic 20, lumbar 12, and cervical 2). Twenty-nine of the patients (85%) were male, and the median patient age was 63.3 years. Twenty patients underwent primary endovascular embolization (16 Onyx, 4 N-butyl cyanoacrylate [NBCA]), and 14 underwent primary surgical clipping. At a mean follow-up of 36 weeks, according to angiography or MR angiography, 5 patients treated with endovascular embolization demonstrated persistent arteriovenous shunting, whereas none of the surgically treated patients showed lesion persistence (p = 0.0237). Thirty patients (88%) experienced some resolution of their presenting symptoms (embolization 17 [85%], surgery 13 [93%], p = 1.00). CONCLUSIONS Microsurgical occlusion remains the most definitive treatment modality for sDAVFs, though modern endovascular techniques remain a viable option for the initial treatment of anatomically amenable lesions. Treatment of these lesions usually results in some clinical improvement.

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Asymptomatic spinal dural arteriovenous fistulas: pathomechanical considerations

Journal of Neurosurgery Spine ◽

10.3171/2012.2.spine11500 ◽

2012 ◽

Vol 16 (5) ◽

pp. 441-446 ◽

Cited By ~ 19

Author(s):

Kenichi Sato ◽

Karel G. TerBrugge ◽

Timo Krings

Keyword(s):

Spinal Cord ◽

Clinical Symptoms ◽

Dorsal Side ◽

Venous Hypertension ◽

Venous Outflow ◽

Arteriovenous Fistulas ◽

Asymptomatic Patients ◽

Dural Arteriovenous Fistulas ◽

Upper Thoracic ◽

Spinal Dural Arteriovenous Fistulas

Object Spinal dural arteriovenous fistulas (SDAVFs) consist of a shunt with converging feeding vessels arising from radiculomeningeal arteries and draining retrogradely via a radicular vein into the perimedullary veins, thereby causing progressive myelopathy due to venous hypertension in the spinal cord. The purpose of this study was to evaluate the hypothesis that the obstruction of radicular venous outlets could be an additional factor inducing symptomatic venous hypertension due to a decreased outflow in SDAVFs. Methods The authors compared the clinical and imaging findings in patients with asymptomatic SDAVFs identified incidentally at the upper thoracic region with the findings in symptomatic patients who harbored SDAVFs at the same level. Results All symptomatic patients presented with medullary dysfunction. The mean age of patients with asymptomatic SDAVF was 51.5 years, approximately 10 years younger than the patients with symptomatic SDAVF (64.1 years old). Despite the existence of dilated perimedullary vessels in the dorsal side of the spinal cord in all patients, the spinal cord edema seen in symptomatic patients was not detected on the MR images obtained in patients with asymptomatic SDAVF. The spinal angiograms of the asymptomatic patients distinctively demonstrated early radicular venous outflow from affected perimedullary veins to the extradural venous plexus as a potential alternate route for the venous hypertension to be released. Conclusions Obstruction of the radicular venous outflow could be an important factor in inducing spinal congestive edema due to venous hypertension, as well as subsequent clinical symptoms of SDAVFs.

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Fatal progression of posttraumatic dural arteriovenous fistulas refractory to multimodal therapy

Journal of Neurosurgery ◽

10.3171/jns.2001.94.5.0831 ◽

2001 ◽

Vol 94 (5) ◽

pp. 831-835 ◽

Cited By ~ 18

Author(s):

Jonathan A. Friedman ◽

Fredric B. Meyer ◽

Douglas A. Nichols ◽

Robert J. Coffey ◽

L. Nelson Hopkins ◽

...

Keyword(s):

Multimodal Therapy ◽

Transarterial Embolization ◽

Subsequent Treatment ◽

Venous Hypertension ◽

Content Type ◽

Arteriovenous Fistulas ◽

Sagittal Sinus ◽

Pulsatile Mass ◽

Dural Arteriovenous Fistulas ◽

Fine Print

✓ The authors report the case of a man who suffered from progressive, disseminated posttraumatic dural arteriovenous fistulas (DAVFs) resulting in death, despite aggressive endovascular, surgical, and radiosurgical treatment. This 31-year-old man was struck on the head while playing basketball. Two weeks later a soft, pulsatile mass developed at his vertex, and the man began to experience pulsatile tinnitus and progressive headaches. Magnetic resonance imaging and subsequent angiography revealed multiple AVFs in the scalp, calvaria, and dura, with drainage into the superior sagittal sinus. The patient was treated initially with transarterial embolization in five stages, followed by vertex craniotomy and surgical resection of the AVFs. However, multiple additional DAVFs developed over the bilateral convexities, the falx, and the tentorium. Subsequent treatment entailed 15 stages of transarterial embolization; seven stages of transvenous embolization, including complete occlusion of the sagittal sinus and partial occlusion of the straight sinus; three stages of stereotactic radiosurgery; and a second craniotomy with aggressive disconnection of the DAVFs. Unfortunately, the fistulas continued to progress, resulting in diffuse venous hypertension, multiple intracerebral hemorrhages in both hemispheres, and, ultimately, death nearly 5 years after the initial trauma. Endovascular, surgical, and radiosurgical treatments are successful in curing most patients with DAVFs. The failure of multimodal therapy and the fulminant progression and disseminated nature of this patient's disease are unique.

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Gamma Knife Radiosurgery for Dural Arteriovenous Fistulas

Neurosurgery ◽

10.1227/neu.0b013e3181eff6f7 ◽

2010 ◽

Vol 67 (5) ◽

pp. 1230-1235 ◽

Cited By ~ 36

Author(s):

Christopher P Cifarelli ◽

George Kaptain ◽

Chun-Po Yen ◽

David Schlesinger ◽

Jason P Sheehan

Keyword(s):

Gamma Knife ◽

Medical Center ◽

Demographic Data ◽

Gamma Knife Radiosurgery ◽

Clinical History ◽

Endovascular Embolization ◽

Neurological Deficits ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas

Abstract BACKGROUND: The current management of intracranial dural arteriovenous fistulas (dAVFs) incorporates a multimodal approach involving microneurosurgery, endovascular embolization, and radiosurgery. OBJECTIVE: To explore the role of Gamma Knife radiosurgery for dAVFs. METHODS: The series includes patients with dAVFs who had Gamma Knife radiosurgery at the University of Virginia Medical Center between 1989 and 2005 with clinical follow-up through 2008. Medical records were reviewed to obtain clinical history, demographic data, and dosimetry. Radiographic records provided the location and anatomy of the dAVFs. Follow-up angiography was performed 2 to 3 years after treatment, with cure defined as complete obliteration of fistulous flow. Follow-up for clinical symptomology and quality of life was obtained from direct patient and primary physician questionnaires. RESULTS: Fifty-five patients underwent Gamma Knife radiosurgery for dAVFs during the study period. Twenty patients (36%) presented with intracranial hemorrhage before radiosurgery. Gamma Knife radiosurgery was preceded by craniotomy for microneurosurgical ablation in 11 patients (20%) or endovascular embolization in 36 patients (65%). Follow-up angiography was performed on 46 patients (83%) with documented obliteration in 30 patients (65%). Patients lost to follow-up were classified as treatment failures, adjusting the range of efficacy from 65% to 54%. Three patients (5%) suffered a posttreatment hemorrhage during the follow-up period, but no new permanent neurological deficits resulted from these events. CONCLUSION: Gamma Knife radiosurgery is an effective adjunct therapy for dAVFs with persistence of flow after open neurosurgical resection or endovascular treatment while still maintaining a role in nonaggressive dAVFs not amenable to either surgery or embolization.

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Dural arteriovenous fistula-induced thalamic dementia: report of 4 cases

Journal of Neurosurgery ◽

10.3171/2015.5.jns15473 ◽

2016 ◽

Vol 124 (6) ◽

pp. 1752-1765 ◽

Cited By ~ 14

Author(s):

Terrence F. Holekamp ◽

Matthew E. Mollman ◽

Rory K. J. Murphy ◽

Grant R. Kolar ◽

Neha M. Kramer ◽

...

Keyword(s):

Venous Drainage ◽

Diagnostic Procedures ◽

Endovascular Embolization ◽

Venous Hypertension ◽

Neurological Deficits ◽

Progressive Dementia ◽

Arteriovenous Fistulas ◽

Presenting Symptoms ◽

Dementia Syndrome ◽

Increased Risk

Nonhemorrhagic neurological deficits are underrecognized symptoms of intracranial dural arteriovenous fistulas (dAVFs) having cortical venous drainage. These symptoms are the consequence of cortical venous hypertension and portend a clinical course with increased risk of neurological morbidity and mortality. One rarely documented and easily misinterpreted type of nonhemorrhagic neurological deficit is progressive dementia, which can result from venous hypertension in the cortex or in bilateral thalami. The latter, which is due to dAVF drainage into the deep venous system, is the less common of these 2 dementia syndromes. Herein, the authors report 4 cases of dAVF with venous drainage into the vein of Galen causing bithalamic edema and rapidly progressive dementia. Two patients were treated successfully with endovascular embolization, and the other 2 patients were treated successfully with endovascular embolization followed by surgery. The radiographic abnormalities and presenting symptoms rapidly resolved after dAVF obliteration in all 4 cases. Detailed descriptions of these 4 cases are presented along with a critical review of 15 previously reported cases. In our analysis of these 19 published cases, the following were emphasized: 1) the clinical and radiographic differences between dAVF-induced thalamic versus cortical dementia syndromes; 2) the differential diagnosis and necessary radiographic workup for patients presenting with a rapidly progressive thalamic dementia syndrome; 3) the frequency at which delays in diagnosis occurred and potentially dangerous and avoidable diagnostic procedures were used; and 4) the rapidity and completeness of symptom resolution following dAVF treatment.

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Superior Sagittal Sinus Dural Arteriovenous Fistulas Treated by Stent Placement for an Occluded Sinus and Transarterial Embolization

Interventional Neuroradiology ◽

10.1177/159101991201800314 ◽

2012 ◽

Vol 18 (3) ◽

pp. 333-340 ◽

Cited By ~ 14

Author(s):

N. Ohara ◽

S. Toyota ◽

M. Kobayashi ◽

A. Wakayama

Keyword(s):

Stent Placement ◽

Superior Sagittal Sinus ◽

Transarterial Embolization ◽

Sudden Onset ◽

Venous Hypertension ◽

Venous Congestion ◽

Arteriovenous Fistulas ◽

Sagittal Sinus ◽

Arteriovenous Shunts ◽

Dural Arteriovenous Fistulas

We describe a case of dural arteriovenous fistulas (DAVFs) involving the superior sagittal sinus (SSS) successfully treated with stent placement for an occluded sinus and transarterial embolization. A 61-year-old man who had been treated with anticoagulation for a known SSS thrombosis presented with a sudden onset of headache. CT scan revealed an intraventricular hemorrhage and cerebral angiography revealed DAVFs involving the SSS which had severe venous congestion and sinus occlusion. We treated this case with a staged endovascular approach which consisted of stent placement for the occluded sinus and transarterial intravenous embolization resulting in complete eradication of DAVFs. Recanalization of an occluded sinus by stent placement can reduce venous congestion and transarterial intravenous embolization can obliterate dural arteriovenous shunts. This staged strategy is feasible and should be considered a first option of treatment, especially for DAVFs which presented with intracranial hemorrhage and aggressive venous hypertension.

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Developmental outcomes for neonatal dural arteriovenous fistulas

Journal of Neurosurgery Pediatrics ◽

10.3171/2008.11.peds0876 ◽

2009 ◽

Vol 3 (2) ◽

pp. 105-109 ◽

Cited By ~ 7

Author(s):

Jonathan N. Johnson ◽

Tyler K. Hartman ◽

William Barbaresi ◽

Corey Raffel ◽

Christopher E. Colby

Keyword(s):

Cardiac Failure ◽

Normal Development ◽

Venous Hypertension ◽

Neurological Deficits ◽

Surgical Clipping ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas ◽

Embolization Treatment ◽

Male Neonate ◽

High Output

Large dural arteriovenous malformations (DAVMs) accompanied by cardiac failure usually carry a poor prognosis with a high risk of morbidity and death. The authors report on the case of a male neonate with a massive DAVM who presented at birth with macrocephaly and high-output cardiac failure. The child initially underwent treatment with surgical clipping of the large main feeding artery. Hydrocephalus, thought to be due to venous hypertension, developed when the boy was 8 months old. The condition resolved after interventional embolization treatment. The patient did not require placement of a ventriculoperitoneal shunt. At 21 months of age, the child had near normal development without any focal neurological deficits.

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Intracranial subarachnoid hemorrhage resulting from cervical spine dural arteriovenous fistulas: literature review and case presentation

Neurosurgical FOCUS ◽

10.3171/foc.2009.26.1.e4 ◽

2009 ◽

Vol 26 (1) ◽

pp. E4 ◽

Cited By ~ 32

Author(s):

Daniel R. Fassett ◽

Stylianos K. Rammos ◽

Pankti Patel ◽

Harsh Parikh ◽

William T. Couldwell

Keyword(s):

Subarachnoid Hemorrhage ◽

Clinical Presentation ◽

Acute Onset ◽

Venous Hypertension ◽

Neurological Deficits ◽

Case Presentation ◽

Excellent Outcome ◽

Arteriovenous Fistulas ◽

Vertebral Arteries ◽

Dural Arteriovenous Fistulas

Cervical dural arteriovenous fistulas (dAVFs) are a rare cause of intracranial subarachnoid hemorrhage (SAH) but should be considered when other sources are not found. Subarachnoid hemorrhage caused by dAVF is thought to occur as a result of venous hypertension in most cases. The clinical presentation, acute onset of severe headache, is similar to that in patients with other causes of SAH; however, severe neurological deficits (Hunt and Hess Grade IV and V SAH) have not been reported in SAH caused by cervical dAVFs. Patients with this type of SAH commonly report suboccipital headache, neck pain, and nausea, and thus these hemorrhages can be easily dismissed as perimesencephalic SAH. Vigilant evaluation with 4-vessel cerebral angiography, including selective catherization of both proximal vertebral arteries, should be performed. The practice of unilateral vertebral artery injection with reflux into the contralateral vertebral and posterior inferior cerebellar arteries has the potential to overlook cervical dAVF. Magnetic resonance imaging may be useful to evaluate for other causes of SAH but is probably not sensitive for the identification of a cervical dAVF. Surgical treatment of this lesion has an excellent outcome.

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

Neurosurgery Open ◽

10.1093/neuopn/okaa019 ◽

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.

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Dural arteriovenous fistula presenting with dementia and bulbar symptoms

BMJ Case Reports ◽

10.1136/bcr-2020-234907 ◽

2020 ◽

Vol 13 (7) ◽

pp. e234907

Author(s):

Christiana Avye Hall ◽

David Swienton ◽

Esteban Luis Taleti

Keyword(s):

Arteriovenous Fistula ◽

Dural Arteriovenous Fistula ◽

Venous Hypertension ◽

Neurological Deficits ◽

Progressive Dementia ◽

Arteriovenous Fistulas ◽

Neurological Morbidity ◽

Dural Arteriovenous Fistulas ◽

Bulbar Symptoms ◽

Tectal Plate

Dural arteriovenous fistulas are relatively rare. Some cases are difficult to diagnose, leading to unnecessary investigations, treatments and delays, particularly if the presentation is atypical. We report a case of a man who presented with progressive dementia and bulbar symptoms, both under-recognised non-haemorrhagic neurological deficits, caused by cortical venous hypertension. Brain imaging showed unusual bilateral thalamic, tectal plate and midbrain oedema. The patient was investigated and treated for alternative aetiologies, before being correctly diagnosed and managed using angiographic embolisation. His clinical and radiological signs improved significantly following treatment, reducing his risk of neurological morbidity and mortality.

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