Dural Arteriovenous Malformation Research Articles

Four-dimensional digital subtraction angiography for the vascular anatomical diagnosis of dural arteriovenous malformation: Comparison with the conventional method.

Two-dimensional digital subtraction angiography (2D-DSA) and conventional three-dimensional digital subtraction angiography (3D-DSA) are used for the detailed analysis of dural arteriovenous fistula (DAVF). Recently, four-dimensional digital subtraction angiography (4D-DSA), a novel technology, has been attracting attention. The current study aimed to evaluate the capability of 4D-DSA in assessing anatomical angioarchitecture in DAVF. In total, 10 consecutive patients with DAVF who underwent 3D-DSA and 4D-DSA at a single institution were included in the analysis. Initially, one-slice multiplanar reconstruction (MPR) images obtained via 4D-DSA and 3D-DSA were compared to investigate the visibility of the feeding artery, fistulous point, and draining vein. Next, 4D-DSA images alone were compared and evaluated with and the MPR images of conventional 3D-DSA in terms of diagnosis of the angioarchitecture. In total, six men and four women (with a mean age of 65.6 ± 10.0 years) were included in the study. The MPR image obtained via 3D-DSA had a significantly better visibility of the feeding artery and fistulous point than that acquired via 4D-DSA (p < 0.05). As for the draining vein, the score was equivalent and not significant. The diagnosis of the vascular architecture of only 4D-DSA images was nearly equivalent to that of MPR images of 3D-DSA. There were no inter-rater differences. The MPR images obtained via 4D-DSA may be slightly inferior to those acquired via 3D-DSA in identifying fine angioarchitecture in DAVF. However, they were comparable in terms of diagnostic accuracy.

Trans-radial spinal angiography: A single-center experience.

Spinal angiography (SpAn) is the gold standard for diagnosis of spinal dural fistulas and arteriovenous malformations. A complete spinal angiogram necessitates the interrogation of the segmental arteries arising from the aorta at every level as well, the internal iliac; and median sacral arteries at the caudal end; and the cervical vasculature at the cranial end. SpAn has traditionally been performed with transfemoral arterial access and could be challenging. Of late, transradial arterial access has emerged as a popular alternative for endovascular surgical Neuroradiology (ESN) procedures including SpAn. However, there is paucity of the literature regarding transradial access for spinal angiography. After IRB approval, records and imaging were reviewed in a series of patients who underwent SpAn at our institution. A total of nine spinal angiograms were performed via transradial access in a consecutive series of eight patients between July 2019 and December 2020 at our institution. Eight of these were diagnostic SpAn's, and one patient underwent SpAn with transradial approach for the treatment of a type I spinal dural arteriovenous fistula. No complications occurred during or subsequent to the procedures. SpAn can be successfully and safely accomplished via transradial access. This approach appears to provide a stable method for interventions, as well.

Coexistence of anterior cranial fossa dural arteriovenous fistula and arteriovenous malformation with the same drainage system: illustrative case

BACKGROUNDThe authors report a rare case of coexistence of dural arteriovenous fistula (DAVF) and arteriovenous malformation (AVM), with a common trunk drainer from both DAVF and AVM in the left anterior cranial fossa (ACF) with simple DAVF in the right ACF.OBSERVATIONSA 63-year-old female presented with seizure. Cerebral angiography showed bilateral DAVFs in the ACF and AVM in the left frontal lobe. A dilated frontal vein acted as a simple drainer of the right DAVF. In contrast, a dilated vein with large varix was the common drainer of both the left DAVF and the AVM. During surgery, indocyanine green videoangiography was performed with direct observation. In the left ACF, the drainer occlusion of the DAVF resulted in partial shrinkage of the varix and decreased distal blood flow. Additional main feeder occlusion of the AVM could decrease the blood flow further, but not completely because of the residual pial supplies for the AVM. Finally, the nidus of the AVM with varix was removed by en bloc resection.LESSONSNeurosurgeons should be aware of the coexistence of DAVF and AVM with a common trunk drainer. Only simple occlusion of the drainer from DAVF is not sufficient, so removal of the AVM is essential.

Non Traumatic and Non Hypertensive Intracerebral Bleed: Causes and Imaging Evaluation

Background: Cross-sectional observational study was done in patients with non-traumatic, non-hypertensive intracerebral bleed undergoing cerebral angiography to study its different causes.Material &amp; Methods:Patients with all age groups presenting to the emergency with acute non-traumatic intra-cerebral bleed undergoing cerebral angiography in our institution for a time period of 6 months with a total of 200 patients were included in the study. Data collected were analyzed with respect to causes, distribution of aneurysms. Suspected cases of hypertensive bleed were excluded from the study population.Results:Non-contrast computed tomographic images showed positive findings in the form of either intra-axial/extra-axial bleed or infarct in 95% of patients. However angiographic findings were positive in 52% of patients. Aneurysms were the most common positive angiographic findings (43% cases) with 95% of aneurysms were located in the circle of Willis. Majority of patients had solitary aneurysm while 6% had multiple aneurysms.Conclusions:Among all non-traumatic, non-hpertensive intracerebral bleed aneurysms accounts for majority of the causes. Other causes include intraparenchymal arterio-venous malformations, cerebral venous thrombosis with hemorrhagic infarct and dural arteriovenous malformations (AVM).

Intracranial dural A-V fistulae.

Dural Arteriovenous Malformations (DAVFs) are rare vascular malformations involving the dura and cerebral veins. They occur in a variety of locations but in general the cavernous sinus lesion is more frequent among Asian patients while the transverse sinus is more usual among western patients. Treatments include microsurgery, endovascular embolization and GKNS. The dangerous concomitant of DAVFs is retrograde flow into the cerebral veins (CVR). Patients with CVR are at risk for bleeding, neurological deficit and in some cases death. They require treatment with the aim of occluding the fistula. Patients without CVR may or may not require therapy, depending on the severity of the symptoms associated with the fistula. These patients require reduction of symptoms more than occlusion. GKNS may often be associated with embolization.

"Craniotomy Within Craniotomy" Technique for Safe Resection of an Intracranial Arteriovenous Malformation With Frontal Bony Erosion: 2-Dimensional Operative Video.

Surgical resection is one option in the treatment of large high-grade brain arteriovenous malformations (AVMs). Resection of AVMs with skull-eroding components can be challenging due to the risk of excessive bleeding from these components during craniotomy and bone flap removal. We present a case of a 25-yr-old woman who presented with an acute onset right-sided frontal headache. She was found to have a large, frontal Spetzler-Martin grade IV AVM with an associated dural AVM. The AVM had caused focal erosions of the right frontal bone by a venous varix traversing the region of the calvarial defect. An elective staged endovascular embolization followed by surgical resection was recommended considering the patient's young age and the large size of the AVM located in a noneloquent area. Given the high risk of intraoperative hemorrhage during the craniotomy portion of the procedure, a "craniotomy within craniotomy" approach was planned. During this approach, a small rectangle of bone, including the portion eroded by the venous varix, was left in place, while the larger bone flap surrounding it was removed for an initial approach to the AVM. The small bony piece was safely removed at later stages of resection once the arterial feeders had been reasonably obliterated. Immediate postoperative catheter angiogram demonstrated good filling of the intracranial vascular territories with no residual AVM. The patient developed mild left facial and left hand weakness postoperatively, which resolved after 2 wk of follow-up. The patient remained neurologically intact on further follow-up.

Technique to "Trap" a Segment of the Middle Meningeal Artery for Embolization of a Carotid Cavernous Fistula: 2-Dimensional Operative Video.

Transvenous embolization is the favored treatment for indirect carotid-cavernous fistulas (CCFs). However, transarterial embolization can be used as an alternative method when the venous route is inaccessible. We present the case of a 47-yr-old woman with a history of diplopia, headaches, and sixth cranial nerve (CN-VI) palsy who presented with acute worsening of headache and ophthalmoplegia and rise of intraocular pressures. Angiography demonstrated a left indirect CCF (dural arteriovenous malformation) with multiple arterial feeders from the internal carotid artery as well as the middle meningeal artery (MMA) (Barrow type D). Transvenous approach was attempted first but was unsuccessful due to difficult access to the cavernous sinus. Thus, transarterial embolization through the MMA feeding branches was planned. To avoid occluding distal branches of the MMA by Onyx, we coiled it distally. In addition, we used a scepter balloon proximally to prevent the reflux of Onyx into potential collaterals to cranial nerves from proximal MMA. After trapping a segment of the MMA, Onyx was injected into the CCF fistula through the small MMA feeders. A postembolization arteriogram showed obliteration of the CCF. The patient developed mild left facial nerve paresis on the first postoperative day (thought to be related to partial embolization of tiny arteries in the facial canal), which was resolving in the course of hospitalization. She remained neurologically stable, and was discharged on the third postoperative day. To the best of our knowledge, this is the first report of transarterial embolization of CCF by distal coiling and proximal ballooning to trap a segment of an artery. The authors hereby confirm that informed consent was obtained from the patient after thorough discussion of the procedure's rationale, risks, benefits, and alternatives.

Spinal cord dural arterial venous malformation presenting as acute brown-sequard syndrome

Dural arteriovenous malformation (AVM) is rare but is the commonest vascular malformation encountered in the spinal cord. They cause progressive tetraplegia or paraplegia and significant morbidity. Spinal AVMs are treatable. We present a case of an acute cord compression in a young teenage girl due to a spinal AVM.

Intracranial calcification in venous congestion

BackgroundIntracranial calcification is a common finding on brain imaging which can be non-specific. The calcification can be physiological or pathological. Likewise, subcortical calcification is a non-specific finding on non-contrast-enhanced computed tomography. This could be secondary to multiple underlying diseases such as Sturge-Weber syndrome, tuberous sclerosis, Fahr disease, post-chemoradiotherapy change, and metabolic disorders secondary to parathyroid or thyroid gland abnormalities. On the other hand, subcortical calcification secondary to arteriovenous malformation and dural venous fistula are uncommon findings. We report two cases with subcortical calcification secondary to these vascular malformations. We aim to highlight the importance of recognising subcortical calcification as one of the possible imaging appearances of dural venous fistula and arteriovenous malformation.Case presentationWe report two cases, whom were a 45-year-old lady and a 20-year-old man, with subcortical calcification on non-contrast-enhanced computed tomography, which were later confirmed to be secondary to chronic venous congestion as the results of dural venous fistula and arteriovenous malformation, respectively. Both patients underwent magnetic resonance imaging of the brain and digital substraction angiography to confirm the diagnosis. Subsequently, both patients were offered embolisation with the 45-year-old lady opting for conservative management and the 20-year-old man waiting for the procedure, at the time of writing.ConclusionVenous congestion secondary to intracranial vascular malformation is an important differential diagnosis for extensive subcortical and basal ganglia calcification. Knowledge on the possibility of vascular malformation to present with subcortical calcification is crucial to avoid misdiagnosis and mismanagement of the patients.

Dural arteriovenous fistula and arteriovenous malformation presenting as trigeminal neuralgia

A 56-year-old man presented to our emergency department for intractable left facial pain. The pain originally started about 10 months prior and was described as intermittent, sharp and shock-like in...

Intracranial dural AV fistula- An unfolding enigma

An Intracranial dural arteriovenous fistulas (DAVF), is an abnormal direct connection (fistula) between a meningeal artery and a meningeal vein or dural venous sinus &/ cortical vein 1. When there are multiple fistulas they are termed as dural arteriovenous malformations and comprise 10-15% of all intracranial arteriovenous malformations1. Here we present a case of52yr old patient who presented to our casualty with history of sudden onset of headache, giddiness, and vomiting, followed by loss of consciousness. Neurological examination revealed impairment of consciousness, no verbal response, with left hemiparesis (E2V1M5). Bilaterally, pupils were 5mm and sluggishly reacting to light. Vitals were stable with B.P. recording of 140/80 mm of hg, and a pulse rate of 80 /min. Pre contrast CT scan showed an intraparenchymal haemorrhage with perilesional oedema in the right frontal region. CT angiography brainshoweda intracranial dural AVF with varix and adjacent intraparenchymal haemorrhage. D.S.A. revealed a Borden type III & Cognard type IV –midline dural Arteriovenous fistula in the regionofmid superior sagittal sinus and along the cerebral falx, with a large venous ectasia/varix along the anterior cerebral falx. Management: Patient underwent afronto parietal rectangular craniotomy Right posterior frontal, parasagittal engorged bunch of focal cortical veins was cauterized. Underlying haematoma was evacuated and the underlying venous ectasia/ varix identified. It was found to be thrombosed. A large draining vein was found which was clipped and any consequent brain swelling was looked for, before finally excising it in toto. Post –op period was uneventful, with the patient gradually improving in sensorium with residual hemiplegia and aphasia. Although recent developments in catheter interventionhas made it the preferred option in most of the cases, surgery is still preferred in some select cases. Keywords:Intracranial dural AV fistula, Superior sagittal sinus, Cog

Endovascular management of pediatric neurovascular malformations – A single?center experience from South India

Background: Neurovascular malformations (NVMs) in pediatric population are highly challenging to manage and treatment options include open surgery, endovascular therapy, and radiosurgery or combined. Recently, there has been a gradual shift from conventional surgical approach toward endovascular therapies with increasing availability of technical expertise and gadgetry. Objective: We aimed to study the clinical profile and immediate outcome of children with NVMs, who underwent endovascular therapy. Materials and Methods: This retrospective observational study was conducted in a tertiary care center in South India between February 2017 and August 2018. We included children admitted in pediatric intensive care unit (PICU) with NVM and needed neuroradiological intervention. Children with thromboembolism or other NVMs who did not require intervention were excluded from the study. Data on clinical profile, endovascular procedure done, supportive therapy given, and immediate outcome were collected and analyzed. Results: Of 1615 children admitted in PICU, 13 had NVM (0.8%), of which five had arteriovenous malformation (AVM), three had vein of Galen arteriovenous malformation (VGAM), one had VGAM with dural AVM, one had acquired carotid-cavernous fistula, two had berry aneurysm, and one had mycotic aneurysm. VGAM presented as hydrocephalus, whereas AVM and aneurysm as intracranial hemorrhage. Endovascular embolization was done using platinum detachable coils, onyx, N-butyl cyanoacrylate glue, and coil assist stents. One child needed decompressive craniectomy and another child needed extraventricular drainage. Four children needed pre-procedure ventilation and seven children needed prolonged post-procedure ventilation. Mortality was 15%; and among the survivors, 72% had an uneventful recovery. One child had seizures and two had hemiparesis at discharge. Conclusion: Endovascular management is an effective intervention for pediatric NVM. Multidisciplinary team approach and good pediatric intensive care are important for successful outcome. Further studies with long-term follow-up are needed to assess the durability of endovascular therapy.

Transarterial embolization of sinusal dural arteriovenous fistula with transvenous balloon protection

Objective To evaluate the safety and efficacy of transarterial embolization of dural arteriovenous malformation (DAVF) using transvenous Copernic RC balloon protection. Methods Fifteen patients with DAVF (6 from Departments of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University and 9 from Department of Neurosurgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University) embolized using transvenous balloon protection between March 2014 and November 2017 were included retrospectively. Fourteen patients had single fistula in which 11 were located at transverse-sigmoid sinus (TSS) and 3 were located at superior sagittal sinus (SSS). One patient had multiple fistulas located at SSS and tentorium. Two patients presented with Cognard type I fistula, 7 with Cognard type Ⅱa, 1 with Cognard type Ⅱb and 5 with Cognard type Ⅱa+ b. Ten patients were treated for the first time and 5 were re-treated. The clinical and angiographic data were collected and the cure rate, complications and clinical outcome were analyzed. Results In the 10 patients treated for the first time, complete occlusion was achieved in 8 patients, near-complete occlusion in 1 and partial occlusion in 1. In the 5 patients re-treated, complete occlusion was achieved in 1, near-complete occlusion in 2 and partial occlusion in 2. All the involved sinuses were patent after embolization. Three patients suffered from severe complications including 1 with epidural hemorrhage, 1 with cerebellar hemorrhage and 1 with cerebellar infarction. All patients were followed up for 5 to 48 months(median: 19 months). Seven patients′ symptoms disappeared at follow-up, 7 patients were improved including 2 with postinterventional hemorrhage. One patient with cerebellar infarction deteriorated. The angiography follow-up was achieved in 8 cases for 4 to 24 months(median: 7 months). There was no recurrence in 6 patients with complete occlusion. One patient with near-complete occlusion and 1 with partial occlusion were stable. Conclusions The transvenous balloon assisted technique seems helpful to preserve the patency of dural sinus and improve the occlusion rate during the embolization of DAVF. However, it might have risks of hemorrhage and infarction and should be used carefully. Key words: Arteriovenous fistula; Embolization, therapeutic; Dural; Transvenous balloon

“Heartbeat in the head”–An atypical presentation of Dural Arteriovenous Malformation

Pulsatile tinnitus is an uncommon presenting symptom and is perceived to be repetitively synchronous with the patient’s heartbeat. Prompt recognition of this rare symptom and subsequent early identification of the underlying etiology is essential for timely management to prevent potentially major complications. Here we highlight a case of a middle-aged female who presented with symptom of ‘heartbeat in the head’ and was later found to have left dural arteriovenous fistula.

Dystrophic Intracranial Calcification Accompanying Varix of the Dural Sinus and Arteriovenous Malformation

Dystrophic Intracranial Calcification Accompanying Varix of the Dural Sinus and Arteriovenous Malformation

Critical Review of Clinical Aspects and Treatment Strategies of Cranial Dural Arteriovenous Malformations

The authors discuss the treatment strategies for dural arteriovenous fistulas, considering anatomical features such as the presence of cortical venous reflux (CVR) and patterns of cerebral venous drainage. Illustrative cases are presented with the different clinical and angiographic features, focusing on patterns of arterial and venous anatomy, normal cerebral venous drainage and the presence of cortical venous reflux. A review of the pathophysiology and current classifications are presented. The treatment strategies are discussed, focusing on the endovascular procedures available. Dural arteriovenous fistulas should be treated considering the significant risks of hemorrhage related to the presence of CVR. Treatment strategies should aim angiographic and clinical cure, achieved with low risk of complications when using a multidisciplinar approach, after carefull understanding of the venous drainage, respecting the anatomy of the lesion and the normal cerebral venous drainage.

Malformação arteriovenosa dural

Foram estudados, retrospectivamente, casos de malformação arteriovenosa dural (MAVD) obtidos da literatura mundial. Com esse propósito, foram revisados os arquivos da litratura mundial com esse propósito, foram revisados os arquivos da Biblioteca Regional de Medicina (BIREME) e Medine publicados anteriormente a 31 de dezembro de 1997. O objetivo deste estudo foi compreender a história natural das MAVDs, Identificando a melhor alternativa terapêutica oferecida na literatura. Adicionalmente, aspectos relacionados relacionados à etiologia à fisiopatogenia, ao quadra clínico, à classificação e as características angiográficas foram igualmente estudados e avaliados. O padrão de drenagem venosa, incluindo a presença de trombose venosa sinusal, drenagem venosa leptomeníngea e aneurisma venoso displástico, foi relacionado com o valor preditivo para hemorragia intracraniana. As MAVDs foram divididas, quanto à localização, em fossa posterior, fossa média, seio cavernoso, seio sagital superior – convexidade, seio transverso-signóide, incisura do tentório e forame magno. As várias modalidades de tratamento oferecidas pela literatura foram estudadas com intuito de definir a meljor opção terapeutica capaz de promover uma cura clínica e angiográfica para as MAVDs de deversas localizações.

Transarterial Onyx Embolization of Bilateral Transverse–Sigmoid Dural Arteriovenous Malformation with Transvenous Balloon Assist—Initial U.S. Experience with Copernic RC Venous Remodeling Balloon

Currently, the mainstay treatment of dural arteriovenous fistula (DAVF) involves endovascular approaches, especially for high-grade lesions. Transarterial embolization with preservation of venous sinuses has become the preferred approach due to the development of newer liquid embolic agents. For further precision during embolization, the use of temporary balloon occlusion to protect the patency of dural sinuses from the embolic agent's migration has been described. A 64-year-old man presented with bilateral pulsatile tinnitus and visual decline. A diagnostic cerebral angiogram demonstrated a complex bilateral Borden type II and Cognard type IIB DAVF. Treatment was carried out endovascularly under general anesthesia in a staged fashion. In the first stage, the balloon was inflated during embolization to protect the right transverse sigmoid venous sinus system and torcula. In the second stage, the balloon was again inflated to protect the left transverse sigmoid venous sinus system and torcula during embolization. Complete obliteration of the left DAVF was achieved, and patency of the left transverse and sigmoid sinuses was preserved. Patency of the right transverse and sigmoid sinus was also conserved post procedure. The patient was treated successfully with transarterial Onyx embolization with transvenous balloon protection of the sinus. This case is the first reported use of the Copernic RC balloon in the United States under the compassionate use guidelines of the U.S. Food and Drug Administration. The use of this balloon is becoming a useful treatment alternative in selected cases of DAVFs as it improves the safety and efficacy of transarterial embolization as evidenced in this case.

Dural AVM (dAVM) in Cowden disease

Abstract Cowden disease is a rare autosomal dominant disorder first described by Rachel Cowden in 1963 as one of the phosphatase and tensin homolog (PTEN) gene hamartoma tumor syndromes. Commonly affecting multiple systems, patients typically have an increased risk of breast and thyroid cancers as well as macrocephaly and benign hamartomatous growths. Due to the benign nature of many of the symptoms, true prevalence is likely higher than reported rates. Malformations associated with PTEN gene lead to dysregulation of cell proliferation yielding increased risk of neoplasm and frequently benign growths. Associated dysregulation of angiogenesis may result in arteriovenous malformations (AVMs). Intracranial AVMs may be asymptomatic. These AVMs present a risk of rupture and subsequent morbidity and mortality. Those with Cowden disease must be monitored for development of intracranial AVMs. Patients should be made aware that treatment for intracranial AVMs may be invasive and include serial embolization.

Preoperative Fiducial Marker Placement in the Thoracic Spine

A retrospective review. The aim of this study was to demonstrate proof-of-concept of preoperative percutaneous intraosseous fiducial marker placement before thoracic spine surgery. Wrong-level spine surgery is defined as a never event by Center for Medicare Services, yet the strength of data supporting the implementation of Universal Protocol to limit wrong level surgery is weak. The thoracic spine is especially prone to intraoperative mislocalization, particularly in cases of morbid obesity and anatomic variations. We retrospectively reviewed all cases of preoperative percutaneous image-guided intraosseous placement of a metallic marker in the thoracic spine. Indications for surgery included degenerative disc disease (16/19), osteochondroma resection, spinal metastasis, and ligation of dural arteriovenous malformation. All metallic markers were placed from a percutaneous transpedicular approach under imaging guidance [fluoroscopy and computed tomography (CT) or CT alone]. Patient body mass index (BMI) was recorded. Overweight and obese BMI was defined greater than 25 and 30 kg/m, respectively. All 19 patients underwent fiducial marker placement and intraoperative localization successfully without complication. Twenty-two thoracic spine levels were localized. The T7, T9, T10, and T11 levels were the most often localized at rate of 18.1% for each level (4/22). The most cranial and caudal levels localized were T4 and T11. About 84.2% (16/19) of the cohort was overweight (57.9%; 11/19) or obese (26.3%; 5/19). The median BMI was 30.2 kg/m (range, 23.9-54.3 kg/m). Preoperative percutaneous thoracic fiducial marker placement under imaging guidance is a safe method for facilitating intraoperative localization of the target spinal level, especially in obese patients. Further studies are needed to quantify changes in operative time and radiation exposure. 4.