Multiple Dural Arteriovenous Fistulas

Abstract

Dural arteriovenous fistulas are most probably acquired lesions. However, they have been rarely encountered de novo.We present a unique case of a 71-year-old woman who initially presented with right-sided dural arteriovenous fistula (DAVF), which spontaneously resolved after diagnostic arteriography. She later developed asymptomatic occlusion of the left transverse sinus. Five years after her initial presentation she developed left-sided pulse-synchronous tinnitus. MRA and catheter angiography showed a complex type IV DAVF between the left transverse sinus and multiple dural branches arising from both left and right external carotid arteries. The left transverse sinus was isolated from the torcula herophili, with stenosis of the sigmoid sinus. Extensive cortical venous drainage was demonstrated. Endovascular cure was effected by polyvinyl alcohol particle and absolute alcohol occlusion of the dominant dural supply, and transvenous coil occlusion of the left transverse sinus. The patient's symptoms resolved almost immediately. This unique case demonstrates that dural sinus occlusion and DAVFs may co-exist, but there may not be a causal relationship. It is likely that both DAVFs and sinus occlusion are manifestations of the same disease process characterised by a pro-thrombotic state and secondary angiogenesis. It is important to recognise that changes in symptomatology, even long after apparent disappearance of a lesion may indicate recurrence, and careful follow up is advocated.