Extreme lateral supracerebellar infratentorial approach for tentorial arteriovenous fistula associated with a giant venous ectasia: how I do it

Background Surgery of tentorial dural arteriovenous fistulas (DAVF) associated with large ectatic vein remains challenging due to the intimate neurovascular relationships in the incisural space. Interruption of the arterialized vein requires a good knowledge of the regional anatomy and a precise preoperative evaluation. Methods We describe the key steps extreme lateral supracerebellar infratentorial (ELSI) approach for tentorial DAVF with a video illustration. The surgical anatomy is described along with the advantages and limitations of this approach. Conclusions In cases of tentorial DAVF where the foot of the arterialized vein is located in the infratentorial compartment, ELSI offers good surgical exposure and outcomes.

Unusual pediatric epidural arteriovenous fistula with venous ectasia presented with spontaneous spinal epidural hematoma: Case report

Background Spontaneous spinal epidural hematoma (SSEH) is rare in children. Vascular malformation including arteriovenous fistulas and venous malformation is a rare cause of SSEH. Case description A 5-year-old girl presented with 2 episodes of SSEH at the upper thoracic spine and non-hemorrhagic episodes with spontaneous neurological recovery. Diagnostic study with MRI and spinal angiography demonstrated an unusual epidural arteriovenous fistula (AVF) with venous ectasia similar to venous malformation. She underwent embolization of the AVF with NBCA with mild transient neurological deterioration. Follow up angiography showed persistent occlusion of the embolized fistula and inconsistent visualization of another AVF to the patent venous ectasia. Conclusions This type of epidural AVF seems to be more common in children and tends to cause multiple neurologic episodes due to SSEH, venous expansion or thrombosis. Endovascular embolization with NBCA should be the first choice of treatment for this disease, unless emergent hematoma evacuation is necessary. Embolization should target at only the fistula site without significant penetration into the venous ectasia. Follow up is necessary for potential reappearance of AVF, even if AVF is occluded at the time of treatment. Time resolved MRI is useful to detect AVFs, thus for diagnosis and follow up of this disease.

Vessel wall MRI in ruptured cranial dural arteriovenous fistulas

Intracranial high-resolution vessel wall MRI (VW-MRI) is an imaging paradigm that is useful in site-of-rupture identification in patients presenting with spontaneous subarachnoid hemorrhage and multiple intracranial aneurysms. Only a handful of case reports describe its potential utility in the evaluation of more complex brain vascular malformations. We report for the first time three patients with ruptured cranial dural arteriovenous fistulas (dAVFs) that were evaluated with high-resolution VW-MRI. The presumed site-of-rupture was identified based on contiguity of a venous ectasia with adjacent blood products and thick, concentric wall enhancement. This preliminary experience suggests a role for high-resolution VW-MRI in the evaluation of ruptured cranial dAVFs, in particular, site-of-rupture identification. It also supports an emerging hypothesis that all spontaneously ruptured, macrovascular lesions demonstrate avid vessel wall enhancement.

MRI detection of occult venous anomalies in a patient with Williams syndrome: a case report

Williams syndrome is a multisystem, congenital disorder which is commonly associated with arterial stenoses: supravalvar aortic stenosis and peripheral pulmonary artery stenosis. Venous abnormalities have not been previously reported in children with Williams syndrome. We present a case of a 3-year-old girl with Williams syndrome and diffuse venous ectasia as detected by MRI.

Evaluation of stereotactic radiosurgery for cerebral dural arteriovenous fistulas in a multicenter international consortium

OBJECTIVEIn this multicenter study, the authors reviewed the results obtained in patients who underwent Gamma Knife radiosurgery (GKRS) for dural arteriovenous fistulas (dAVFs) and determined predictors of outcome.METHODSData from a cohort of 114 patients who underwent GKRS for cerebral dAVFs were compiled from the International Gamma Knife Research Foundation. Favorable outcome was defined as dAVF obliteration and no posttreatment hemorrhage or permanent symptomatic radiation-induced complications. Patient and dAVF characteristics were assessed to determine predictors of outcome in a multivariate logistic regression analysis; dAVF-free obliteration was calculated in a competing-risk survival analysis; and Youden indices were used to determine optimal radiosurgical dose.RESULTSA mean margin dose of 21.8 Gy was delivered. The mean follow-up duration was 4 years (range 0.5–18 years). The overall obliteration rate was 68.4%. The postradiosurgery actuarial rates of obliteration at 3, 5, 7, and 10 years were 41.3%, 61.1%, 70.1%, and 82.0%, respectively. Post-GRKS hemorrhage occurred in 4 patients (annual risk of 0.9%). Radiation-induced imaging changes occurred in 10.4% of patients; 5.2% were symptomatic, and 3.5% had permanent deficits. Favorable outcome was achieved in 63.2% of patients. Patients with middle fossa and tentorial dAVFs (OR 2.4, p = 0.048) and those receiving a margin dose greater than 23 Gy (OR 2.6, p = 0.030) were less likely to achieve a favorable outcome. Commonly used grading scales (e.g., Borden and Cognard) were not predictive of outcome. Female sex (OR 1.7, p = 0.03), absent venous ectasia (OR 3.4, p < 0.001), and cavernous carotid location (OR 2.1, p = 0.019) were predictors of GKRS-induced dAVF obliteration.CONCLUSIONSGKRS for cerebral dAVFs achieved obliteration and avoided permanent complications in the majority of patients. Those with cavernous carotid location and no venous ectasia were more likely to have fistula obliteration following radiosurgery. Commonly used grading scales were not reliable predictors of outcome following radiosurgery.

Isolated superior petrosal sinus dural arteriovenous fistula treated with selective sinus packing using a quadriaxial catheter system

A 67-year-old patient presented with a headache, vertigo and nausea, followed by a disturbance of consciousness. CT and MRI showed venous ectasia at the left cerebellopontine angle and extensive oedema in the left cerebellum. Angiography demonstrated a dural arteriovenous fistula that appeared at the left superior petrosal sinus–cavernous sinus) junction. After the evaluation of the shunt point, occluded areas were recanalised via the femoral vein with a quadriaxial catheter system using a 6-Fr guiding sheath, 6-Fr guiding catheter, 4.2-Fr catheter and microcatheter. Selective coil embolisation was performed, resulting in shunt removal.