Tentorial Dural Arteriovenous Fistula Research Articles

Angioarchitecture and Associated Dural Arteriovenous Fistulas of the Superior Petrosal Sinus and Petrosal Vein

The superior petrosal sinus and petrosal vein are important drainage routes for the posterior cranial fossa, with some variations and collateral vessels. An anterolateral-type tentorial dural arteriovenous fistula, which occurs around the petrosal vein, often develops aggressive symptoms due to venous reflux to the brainstem and cerebellum. Neuroendovascular treatment of this fistula is usually challenging because transarterial embolization has a high risk and indications for transvenous embolization are limited. In the cavernous sinus and transverse sinus/sigmoid sinus dural arteriovenous fistulas, venous reflux to the petrosal vein is dangerous, and a treatment strategy with the occlusion of the petrosal vein is indispensable. Furthermore, attention should be paid to venous approaches through the superior petrosal sinus.

Endovascular treatment strategy and clinical outcome of tentorial dural arteriovenous fistula.

To evaluate treatment strategies and clinical outcomes following endovascular embolization of tentorial dural arteriovenous fistulas. We retrospectively analyzed 19 patients with tentorial dural arteriovenous fistulas admitted to the Department of Neurosurgery at Jiangsu Provincial People's Hospital between October 2015 and May 2022, all treated with endovascular therapy. To collect and analyze patients' clinical presentation, imaging data, postoperative complications, and prognosis and to analyze the safety and clinical outcomes of endovascular treatment of tentorial dural arteriovenous fistulas. Imaging cure was achieved in 18 patients, with the arterial route chosen for embolization in 17 patients and the venous route in one patient; one patient received partial embolization. Staged embolization was performed in four patients. At postoperative follow-up of 9-83 months (37.8 ± 21.2), all 19 patients had recovered well (mRS score ≤ 2). Three patients experienced perioperative complications: intraoperative Onyx reflux into the middle cerebral artery in one patient; postoperative permanent limited left visual field loss and deafness in the left ear in one patient; and transient diplopia, vertigo, and decreased pain and temperature sensation of the left limb in one patient, with no abnormalities on post-procedure magnetic resonance examinations. A total of 17 patients completed a postoperative digital subtraction angiography review during follow-up, and one patient had a recurrence of an arteriovenous fistula. Endovascular treatment of tentorial dural arteriovenous fistulas is safe and effective. Reduction of the Borden or Cognard classification via eliminating cortical venous reflux through multi-staged embolization or combined open surgery is a reasonable goal of treatment where complete obliteration of the fistula is not achievable.

Cognard Type Ⅴ Torcular Dural Arteriovenous Fistula: A Rare Entity

Tentorial dural arteriovenous fistulas (DAVFs) are a dangerous subtype of fistula. Lawton etal classified this type of fistula into 6 categories based on specific operative strategies. Clinical manifestations of 6 types of tentorial DAVFs vary to some extent. Cognard type V DAVFs in the tentorial region are usually petrosal/superior petrosal sinus DAVFs. DAVFs with perimedullary venous drainage around the torcular herophili are rare. The veins of the posterior fossa are intricate and variable. There are anatomic communications between the perimedullary vein and cerebellar vein or veins of the brainstem. Almost all of the Cognard type V DAVFs are found in the posterior fossa. Here, we present a Cognard type V DAVF with a fistula located around the torcular herophili.

A retrospective study of 78 adult tentorial middle line region dural arteriovenous fistulae.

Dural arteriovenous fistulae (DAVF) in the tentorial middle line region are uncommon with specific features and more cognitive disorders than any other region. The purpose of this study is to present clinical characteristics and our experience with endovascular treatment in this specific region. During a 20-year period, 94.9% of patients (74/78) underwent endovascular treatment (36 in galenic, 48.6%) (12 in straight sinus, 16.2%) (26 in torcular, 35.1%). There were 63 males and 15 females with mean age of 50 (50 ± 12) years in total of 78 patients. The clinical presentation, angiographic features, treatment strategy, and clinical outcomes were recorded. Transarterial embolization (TAE) was performed in 89.2% of the 74 patients (66/74), transvenous embolization alone in one patient and mixed approach in seven. Complete obliteration of the fistulas was obtained in 87.5% of the patients (64/74). 71 patients (mean, 56months) had phone, outpatient, or admission follow-up. The digital subtraction angiography (DSA) follow-up period (25/78, 32.1%) was 13.8 (6-21) months. Two of them (2/25, 8%) had fistula recurrences after complete embolization and were embolized again. The phone follow-up period (70/78, 89.7%) was 76.6 (40-92.3) months. Pre-embolization and post-embolization mRS ≥ 2 were in 44 patients (44/78) and 15 (15/71) patients, respectively. DAVF with internal cerebral vein drainage (OR 6.514, 95% Cl 1.201-35.317) and intracranial hemorrhage (OR 17.034, 95% Cl 1.122-258.612) during TAE were the risk factors for predicting poor outcomes (followed up mRS ≥ 2). TAE is the first-line treatment for tentorial middle line region DAVF. When pial feeders' obliteration is difficult to achieve, it should not be forced due to the poor outcomes after intracranial hemorrhage. The cognitive disorders caused by this region were not reversible as reported. It is imperative to enhance the care provided to these patients with cognitive disorders.

Dural Tentorial Fistula of Bernasconi-Cassinari Artery, Two Case Reports: Supratentorial and Infratentorial

We report two rare and infrequent cases, one of a patient with a Cognard type V tentorial dural fistula diagnosed at the beginning as a trunk glioma in a patient with gait disturbance. And another with a Guillian Barré syndrome with tetraparesis secondary to a tentorial dural arteriovenous fistula.

In Reply: Angioarchitectural Analysis of Arteriovenous Shunts in Dural Arteriovenous Fistulas and Its Clinical Implications.

To the Editor: We would like to thank Dr Su et al1 for sharing their insights on dural arteriovenous fistulas (DAVFs) and thoughtful and duly comments on our recent article “Angioarchitectural analysis of arteriovenous shunts in dural arteriovenous fistulas and its clinical implications.”2 Based on the histopathological studies and their experience of DAVFs, Dr Su et al point out that fistulas are not formed directly at the dural sinuses but between the dural artery and the dural vein (in the dural sinus wall) before draining into the sinus or the bridging vein.1,3,4 We agree with these classic histopathological finding; however, the main focus of our study was to describe and discriminate the “angiographic” shunt patterns in light of the connections between the shunt, the sinus, and the cortical veins to unveil their practical implications. In this regard, there were specific patients in whom the targetable fistulous channel—regarding the branching patterns and the caliber changes of the vessels—could not be identified but showed functionally direct connections with the sinus. The histopathological basis for these kinds of shunt remains speculative. The variations in the anatomy of the dural vessels (length, location, etc), secondary changes associated with venous hypertension, thrombosis, inflammation, angiogenesis, and dural wall alterations alongside the temporal changes may have manifested as this pattern.3-8 Interestingly in our series, multiple shunt types were noted in several patients (n = 7), more frequently as the coexistence of the direct sinus fistulae and mural channel-type shunts (n = 5), suggesting the dynamic nature of this disease. Extensive histopathological studies are crucial to shed light on these compelling questions but are extremely limited. Meanwhile, angiographic discrimination of the different characteristics of the shunts, such as the diffuse direct connections or channel-like structures or bridging vein type shunts, and their connection patterns with the sinus and the cortical vein are paramount for effectively targeting the lesion and predicting the behavior of the liquid embolic agents. The presence of pial arterial supply to the DAVF has gained much interest. There are concerns that these patients may be associated with postprocedural rupture of the fragile neovascularized vessels after venous outflow obstruction and inadvertent reflux of the embolic agent into the pial arteries.9,10 The presence of the pial feeders are known to be strongly associated with the tentorial DAVFs.9,10 Our series included only the superior sagittal and transverse sigmoid sinus DAVFs; thus, analyzing the implications of pial supplies was considered beyond the scope of our study. However, this is an interesting topic that deserves further scrutinization. We greatly appreciate the comments and insights by Dr Su et al. DAVFs are fascinating but also complex and challenging diseases. We wish for further technological progress and the power of collective intelligence in understanding and overcoming this intriguing disease.

Treatment strategies for tentorial dural arteriovenous fistulas and our surgical results.

Treatment strategies for tentorial dural arteriovenous fistulas and our surgical results.

A case of tentorial dural arteriovenous fistula presenting as acute subdural hemorrhage of the posterior fossa

テント部硬膜動静脈瘻（TDAVF）は，脳実質内出血やくも膜下出血で発症して脳実質損傷を生じることが多く，急性硬膜下血腫（ASDH）の単独発症は非常に稀である．今回我々は，後頭蓋窩ASDHで発症したTDAVFに対して，発症早期に直達手術にて転帰良好であった症例を経験したので報告する．症例は29歳男性，突然の頭痛と嘔吐を生じたため，当院に救急搬送された．頭部CTで右後頭蓋窩にASDHを認めた．脳血管撮影では右テント切痕部にシャント部があり，静脈逆流および静脈瘤の形成を有するTDAVFの所見を認めた．血管内治療では，シャント部へのマイクロカテーテルの誘導が困難で，直達手術によりシャント部の完全閉塞が得られた．脳実質損傷を伴わない後頭蓋窩ASDH単独発症のTDAVF患者では，血腫除去および導出静脈におけるシャント部の離断を同時に施行でき，かつ根治性が高い直達手術の有用性が示唆された．

Ruptured aneurysm of the artery of Davidoff and Schechter: illustrative case.

BACKGROUNDThe artery of Davidoff and Schechter (ADS) is an uncommonly encountered meningeal branch originating from the posterior cerebral artery typically identified in the setting of pathology, often dural arteriovenous fistulas (DAVFs). Here, the authors describe the first reported case of an ADS aneurysm, discovered in the setting of subarachnoid hemorrhage (SAH) and complicating a high-grade DAVF.OBSERVATIONSA 57-year-old female presented after experiencing the worst headache of her life. Noncontrast computed tomography scanning of the head demonstrated SAH. Angiography revealed a high-grade DAVF centered around the anterior straight sinus, consistent with the Galenic subtype of tentorial DAVF. Predominant arterial supply was from the bilateral middle meningeal and occipital arteries. Vertebral artery imaging revealed a 12-mm irregular aneurysm. The prospect that the target artery represented the noneloquent ADS was confirmed by Wada testing. Given the fusiform nature of the aneurysm, treatment required concomitant coil embolization of the aneurysm and parent artery sacrifice. A week later, the DAVF was treated with liquid embolic. The patient tolerated treatment without neurological compromise.LESSONSThe authors describe the first reported case of an ADS aneurysm discovered in the setting of SAH complicating a high-grade DAVF and the lessons learned during our experience managing this unique pathology.

Tentorial dural arteriovenous fistula with perimedullary venous drainage-associated cervical myelopathy: illustrative case.

Tentorial dural arteriovenous fistulas (DAVFs) with perimedullary venous drainage causing cervical myelopathy are very uncommon conditions with an extremely aggressive behavior. When the characteristic radiological clues are missing, the unspecific clinical picture may cause delay and make the diagnosis challenging. Here the authors report a case of a 58-year-old man who developed progressive spastic tetraparesis and dyspnea with an extensive mild enhancing cervical cord lesion initially oriented as a neurosyphilis-associated transverse myelitis. Acute worsening after steroid administration redirected the diagnosis, and a tentorial Cognard type V DAVF was elicited. The microsurgical disconnection process is described, and previously documented cases in the literature are reviewed. If a DAVF is highly suspected, it is important to consider the possibility of its intracranial origin, and spinal as well as cerebral arteriography must be performed.

Analysis of the Pial Arterial Supply as a Cause of Intraprocedural Hemorrhage During Transarterial Liquid Embolization of Tentorial Dural Arteriovenous Fistulas

Tentorial dural arteriovenous fistulas (AVFs) are bridging vein shunts, and are therefore sometimes supplied by the pial artery as well as the dural artery. Recently, intraprocedural hemorrhage from the pial artery was reported, and we experienced 2 tentorial dural AVFs with the same complication. Pure pial artery has a glomus-like structure and forms direct shunts along the draining vein, and is likely to bleed after restriction of the draining vein caused by the transarterial embolization. This study investigated the characteristics of the pial arterial supply as a cause of hemorrhage. Twenty-six tentorial dural AVFs in 25 patients treated in our institute were retrospectively investigated and the characteristics of the pial feeders responsible for bleeding were analyzed. Thirteen pial arterial feeders (pure pial feeder in 7, dilated dural branch of the pial artery in 4, and undefined in 2) were identified in 10 of the 26 tentorial dural AVFs. Pure pial feeders were responsible for bleeding in 2 tentorial dural AVFs. To prevent intraprocedural hemorrhage, differentiation of the pure pial supply from the dural branch of the pial artery is important. The infratentorial artery will supply supratentorial fistula as the dural branch after passing through the tentorium. In contrast, the supratentorialartery can supply supratentorial fistula not only asa dural branch but also as a pure pial feeder. Therefore, attribution of the fistula and the pial supply, supratentorial or infratentorial, is useful in identifying pure pial supply.

A Case of a Ruptured Aneurysm of the Long Circumfrex Branch Associated with a Tentorial Dural Arteriovenous Fistula

A Case of a Ruptured Aneurysm of the Long Circumfrex Branch Associated with a Tentorial Dural Arteriovenous Fistula

Tentorial Dural Arteriovenous Fistula Presenting with Myelopathy Successfully Treated by Transarterial Embolization with N-butyl-2-cyanoacrylate: A Case Report

Tentorial Dural Arteriovenous Fistula Presenting with Myelopathy Successfully Treated by Transarterial Embolization with N-butyl-2-cyanoacrylate: A Case Report

Endovascular Treatment of Medial Tentorial Dural Arteriovenous Fistula Through the Dural Branch of the Pial Artery.

Background: Tentorial dural arteriovenous fistula is a rare subtype of intracranial dural arteriovenous fistula (DAVF) with a deteriorating natural course, which may be attributed to its pial angioarchitecture. TDAVF often harbors feeders arising from pial arteries (FPAs). Reports have revealed that, if these feeders are not obliterated early, the restricted venous outflow during the embolization process may cause upstream congestion in the fragile pial network, which increases the risk of hemorrhagic complications. Because most reported cases of TDAVF were embolized through feeders from non-pial arteries (FNPAs), little is known of the feasibility of direct embolization through FPAs.Methods: We present three patients with medial TDAVFs that were embolized through the dural branches of the posterior cerebral and superior cerebellar arteries. Findings from brain magnetic resonance imaging, computed tomography, angiography, and clinical outcomes are described. Furthermore, we performed a review of the literature on TDAVFs with FPAs.Results: The fistulas were completely obliterated in two patients; both recovered well with no procedure-related complications. The fistula was nearly obliterated in one patient, who developed left superior cerebellum and midbrain infarct due to the reflux of the embolizer into the left superior cerebellar artery. Including our cases, eight cases of TDAVFs with direct embolization through the FPAs have been reported, and ischemic complications occurred in three (37.5%).Conclusions: Advancing microcatheter tips as close to the fistula point as possible and remaining highly aware of potential embolizer flow back into the pial artery are key factors in achieving successful embolization. Balloon-assisted embolization may be an option for treating TDAVFs with FPAs in the future.

Endovascular Treatment of Tentorial Dural Arteriovenous Fistulas Using the Transarterial Approach as a First-Line Strategy

Rezende, Marco Túlio Salles MD; Trivelato, Felipe Padovani MD, PhD; de Castro-Afonso, Luis Henrique MD, PhD; Nakiri, Guilherme Seizem MD, PhD; Silva, Caio César Molina MD; Abud, Thiago Giansante MD, PhD; Colli, Benedicto Oscar MD, PhD; Ulhôa, Alexandre Cordeiro MD; Abud, Daniel Giansante MD, PhD

Abstract 1122‐000117: Transcranial Arterial Embolization of an dAVF: A Case Report

Introduction : We detail the management of a woman with a posterior fossa dAVF (dural arteriovenous fistula) that was unable to be treated by standard transarterial or transvenous embolization or microsurgical ligation. She underwent craniotomy for surgical exposure and direct access of her left middle meningeal artery followed by microcatheter embolization with favorable results. Methods : This is a case report, which describes a case of a difficult to access dAVF. Results : A 72 year‐old woman presented with vertigo, nausea, and vomiting one week following a fall. CT head disclosed cerebellar vermis intraparenchymal hematoma and CT head angiography was suspicious for underlying vascular malformation. Diagnostic cerebral angiogram demonstrated extensive tentorial and suboccipital dural arteriovenous fistula (dAVF) fed by branches of both middle meningeal and occipital arteries with direct cortical venous drainage and venous aneurysmal ectasia directly adjacent to the vermian hemorrhage (ruptured Cognard grade 4). Left vertebral artery angiogram demonstrated excessive tortuosity of vertebral enlarged posterior meningeal artery, which was unable to be catheterized sufficiently beyond its origin despite different microwires and microcatheters due to tortuosity. Transfemoral venous approach was also attempted, however, this was also unsuccessful and decision was made to proceed with microsurgical treatment. The following day a suboccipital craniotomy was performed, but was ultimately aborted due to nearly uncontrollable bleeding from bony exposure and dural access secondary to severe venous hypertension. The next day percutaneous endovascular treatment was attempted a second time. A small right middle meningeal artery (MMA) contribution to the fistula was embolized with liquid embolic but, again because of excessive tortuosity and insufficient microcatheter access, right MMA occlusion occurred without embolic agent reaching the fistula. Similar access related difficulties due to tortuosity were encountered in accessing the left middle meningeal and occipital arteries contributing to the fistula. Repeat transvenous access was also attempted from the occipital and right transverse sinuses, but microcatheter access to the fistula was unable to be established beyond the venous outflow from the aneurysm, and, given the risks of hemorrhage related to embolization of the venous outflow without occluding arterial inflow into the ruptured aneurysm, transvenous embolization was not performed. A few days later, after the patient was given time to recover from the prior procedures, the patient underwent left temporal craniotomy in a hybrid operating room/interventional radiology suite for direct cannulation of the left MMA. Localization of the craniotomy site over the left MMA access point was planned by transfemoral cerebral angiogram and a transcarotid/peripheral access kit was used to catheterize the left MMA directly following surgical exposure. An .017 microcatheter was advanced close to the fistula point using standard biplanar roadmap fluoroscopy, and Onyx embolization of the fistula was performed to complete occlusion, without complication. Conclusions : For cerebrovascular disorders that are inaccessible by traditional endovascular and surgical means, a hybrid approach should be considered.

Successful surgical management of a tentorial dural arteriovenous fistula causing spinal cord myelopathy

Intracranial dural arteriovenous fistulas account for 10 to 15% of all intracranial arteriovenous malformations. Tentorial dural arteriovenous fistulas with spinal medullary venous drainage causing spinal cord myelopathy have been rarely reported in the literature. We describe a case using a temporo-pterional approach for the surgical treatment of a tentorial artery dural arteriovenous fistula causing spinal cord myelopathy.

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

BackgroundSurgery 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.MethodsWe 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.ConclusionsIn cases of tentorial DAVF where the foot of the arterialized vein is located in the infratentorial compartment, ELSI offers good surgical exposure and outcomes.

Artery of Davidoff and Schechter: A Large Angiographic Case Series of Dural AV Fistulas.

The artery of Davidoff and Schechter (ADS) is the only meningeal branch of the posterior cerebral artery (PCA), supplying the medial tentorial margin and posterior portions of the falx. Given its small size, it is rarely identified on angiographic studies, unless enlarged in pathologies such as dural arteriovenous fistulas (DAVFs) or vascularized masses. This artery was first described by Wollschlaeger and Wollschlaeger in 1965, and to date, only a few reports have described its significance. The objective of this study is to report our experience with the ADS in dural fistulas from 2 tertiary medical centers and to emphasize the importance of recognizing this artery during angiographic examination of vascular tentorial and posterior fossa lesions. To our knowledge, this report demonstrates the largest angiographic case series published to date, recognizing a total of 7 patients with ADS arising secondary to a posterior fossa or tentorial DAVF and one of the largest reported series of DAVFs supplied by the ADS treated by endovascular and surgical techniques. Our cases validate the importance of prompt identification of the ADS for the diagnosis as well as endovascular treatment of vascular malformations in the posterior fossa and tentorial region.

Endovascular Treatment of Tentorial Dural Arteriovenous Fistulas Using the Transarterial Approach as a First-Line Strategy.

In recent decades, endovascular approaches have become the standard treatment for most tentorial dural arteriovenous fistulas (TDAVFs). Although endovascular treatment (EVT) is associated with better clinical outcomes, the angiographic occlusion rates are lower than those of surgical or combined approaches. To evaluate the efficacy and safety of EVT for TDAVFs using the transarterial approach (TAA) as a first-line strategy. Clinical and radiological data from 45 consecutive patients with TDAVFs who underwent EVT at 2 centers were retrospectively reviewed. Patient demographics and clinical and angiographic data were registered. Postprocedural and 6-mo follow-up angiographic and clinical results were evaluated. Univariable and multivariable logistic regression were performed to identify angiographic occlusion predictors after the first session and predictors of clinical complications. An isolated TAA was used for 40 TDAVFs (88.9%). A total of 37 (82.2%) TDAVFs were completely occluded after a single EVT session, and 44 TDAVFs (97.8%) were completely occluded after the last procedure. The presence of fewer than 5 arterial feeders was a predictor for total occlusion after the first treatment session (odds ratio [OR], 18.9; 95% CI 2.06-173.57; P=.01). Six-month angiographic control was performed in 42 patients, and all TDAVFs were occluded. Good long-term neurological outcomes were observed in 41 patients (91.1%). Clinical complications occurred in 7 (15.6%) patients. They were related to the number of accessed arteries to perform TAA (odds ratio, 2.53; 95% CI 1.10-5.86; P=.03). The procedure-related mortality rate was 2.2%. TAA is a safe and effective treatment for TDAVFs.