Diagnostic accuracy of CTA and MRI/MRA in the evaluation of the cortical venous reflux in the intracranial dural arteriovenous fistula DAVF

PURPOSE

Computed tomography angiography (CTA) and magnetic resonance imaging/angiography (MRI/MRA) are used for the diagnosis of intracranial dural arteriovenous fistulas (DAVFs). The purpose of this study was to compare the diagnostic accuracy of CTA and magnetic resonance imaging/angiography (MRI/MRA) for detection of cortical venous reflux (CVR) in intracranial DAVFs.

METHODS

The records of patients with angiography-confirmed intracranial DAVFs who also received CTA and MRI/MRA from January 2008 to July 2016 were reviewed. CTA and MRI/MRA were reviewed for signs of CVR, and the diagnostic accuracy of individual signs was evaluated by receiver operating curve (ROC) analysis.

RESULTS

A total 108 patients were included in this study. CTA signs of CVR included abnormal dilatation, early enhancement, and the presence of a medullary or pial vein. MRI/MRA signs of CVR included abnormal dilatation, early enhancement, flow-related enhancement, flow void, and medullary or pial venous collaterals. The sensitivity of individual CTA signs ranged from 62 to 96%, and specificities from 79 to 94%. The sensitivities of individual MRI/MRA signs ranged from 58 to 83%, and specificities from 77 to 93%. The area under ROC curve (AUC) of CTA and MRI/MRA were 0.91 and 0.87, respectively (P = 0.04 in direct comparison). In subgroup analysis, CTA had better diagnostic accuracy for higher grade disease (P = 0.05) and non-aggressive manifestation (P = 0.04).

CONCLUSIONS

Both CTA and MRI/MRA have good diagnostic accuracy for detection of CVR in patients with intracranial DAVFs. There is modest evidence that CTA is better than MRI/MRA.

Spinal dural arteriovenous fistulas: the most frequent vascular malformations of the spinal cord

Spinal dural arteriovenous fistulas are produced by direct communication between the arterial and venous systems of the spinal cord, causing hypertension in the latter with spinal cord dysfunction. It is a rare pathology with unknown etiology and non-specific clinical symptoms that usually results in a delayed diagnosis. Often radiologists are the first to guide the disease towards an adequate diagnosis. Characteristic findings can be seen through MR or MR angiography, and may even locate the fistula in a high percentage of cases, although the pathology must be confirmed by spinal angiography. There are two treatment modalities: endovascular and surgical therapy. Endovascular treatment has improved in recent years with the advantages of a less invasive approach and is therefore usually chosen as primary therapy. In this article we review the main clinical manifestations, imaging findings and treatment of this pathology.

Dual-lumen balloon to increase onyx venous penetration in the treatment of spinal dural arteriovenous fistulas

PURPOSE

Spinal dural arteriovenous fistulas (sDAVF) are the most common spinal vascular lesions. The arterialization of the recipient vein results in venous hypertension and chronic ischemia. Intravascular injection of acrylic glue in order to occlude the draining vein is the principle of endovascular treatment, but a significant portion of embolization procedures do not succeed. We present our initial experience of endovascular balloon augmented embolization of sDAVF using a dual-lumen balloon.

CLINICAL PRESENTATION

Three patients harboring sDAVF were submitted to endovascular treatment by onyx injection assisted by a double-lumen balloon as the sole therapy. Control angiography demonstrated complete obliteration of the fistula in all cases with clinical improvement.

CONCLUSION

Dual-lumen balloon onyx embolization of spinal dural arteriovenous fistulas appears to be an acceptable and feasible alternative.

Imaging features and prognostic factors in fetal and postnatal torcular dural sinus malformations, part II: synthesis of the literature and patient management

BACKGROUND

Torcular dural sinus malformations (tDSMs) are described as slow flow dural arteriovenous fistulae with frequently poor outcomes in the neuroangiographic literature, but other etiologies have been proposed in the obstetric literature, where outcomes have been more favorable.

OBJECTIVE

To review tDSMs reported in the literature of multiple specialties for features that support a common etiology, and to identify key prognostic factors, with an emphasis on tDSM trajectory highlighted in part I.

METHODS

Analysis of imaging features and clinical outcome for 77 prenatal and 22 postnatal tDSMs reported in 37 papers from the literature.

RESULTS

In addition to large venous lakes, 36% of prenatal and 96% of postnatal tDSMs had evidence of arterialization, where specifically assessed. For fetal cases, where there was an observable natural history, 97% underwent a spontaneous decrease-13% after an initial increase and only 1 case with subsequent enlargement after a decrease. Prenatal cases had 83% survival (62% with a favorable outcome) whereas postnatal cases had 59% survival (29% favorable). In addition to a postnatal diagnosis, unfavorable features included ventriculomegaly, parenchymal injury, arterialization, and need for intervention. Favorable features included decreasing tDSM size, presence of clot, and increasing clot percentage.

CONCLUSIONS

Neonatal and fetal tDSMs have overlapping imaging appearances, suggesting a common etiology, where neonatal tDSMs represent those rare fetal tDSMs that do not undergo spontaneous regression and have a propensity for worse outcomes. Decrease in tDSM size is a critical observation when managing a tDSM because it is generally irreversible and associated with a favorable outcome.

[Dural arteriovenous fistula is a rare, but treatable cause of transverse myelitis]

This is a case report of a 60-year-old male admitted on suspicion of relapse of idiopathic transverse myelitis (TM), who after further diagnostic workup underwent successful closure of a dural arteriovenous fistula (DAVF). Magnetic resonance imaging in DAVF usually shows longitudinal TM, which, unlike DAVF, is also seen with the more common inflammatory or infectious causes usually showing inflammation in the cerebrospinal fluid. The natural history of DAVF is progressive. Since curable options exist, timely diagnosis is most important.

Treatment of Large or Giant Cavernous Aneurysm Associated with Persistent Trigeminal Artery: Case Report and Review of Literature

BACKGROUND

Primitive trigeminal artery (PTA) is the most common anomaly of primitive carotid-basilar anastomosis and is associated with cerebrovascular anomalies, such as aneurysm. Large or giant cavernous aneurysm associated with PTA is rare, and the treatment strategies differ in comparison with large or giant aneurysm without PTA. In this article, we report an unusual case of a giant cavernous aneurysm associated with PTA and review treatment strategies for large or giant cavernous aneurysm associated with PTA.

CASE DESCRIPTION

A 38-year-old woman suffered from double vision. Magnetic resonance imaging revealed a mass lesion in the left cavernous sinus, and magnetic resonance angiography showed a giant aneurysm at the cavernous portion of the left internal carotid artery, associated with PTA. Coil embolization, distal to the PTA, was scheduled after high-flow bypass on the same day. Computed tomography scan showed no definite infarction after treatment. A 3-dimensional computed tomography showed disappearance of the aneurysm and good patency of bypass and PTA. The patient experienced improvements in symptoms and was discharged without neurologic deficits (modified Rankin Scale 0).

CONCLUSIONS

The treatment strategy for large or giant cavernous aneurysm associated with PTA is different from strategies used for large or giant cavernous aneurysm without PTA. Simple ligation of internal carotid artery is inadequate because the aneurysm is supplied through the PTA, from the vertebrobasilar system. Furthermore, the treatment strategy has to be revised according to whether the PTA can be occluded. Keeping in mind PTA preservation, an appropriate strategy should be selected.

Anatomical localization of the cavernous sinus dural fistula by 3D rotational angiography with emphasis on clinical and therapeutic implications

BACKGROUND AND PURPOSE

Carotid cavernous sinus dural arteriovenous fistulas (CSDAVFs) are presumed to be located within the walls of the cavernous sinus, however the exact fistulous site has not yet been studied by angiographic or anatomical methods. The present study aimed to localize CSDAVFs with the help of 3D rotational angiography (RA) and correlated the observations with clinical and angiographic findings.

MATERIALS AND METHODS

The CSDAVFs were categorized as dural, extradural or osseous based on the site of convergence of feeders into the venous sac. Extradural CSDAVFs were further subcategorized into posteromedial, posterolateral and anterior subtypes, depending on proximity to a possible venous plexus. This classification was correlated with various clinical presentations and angiographic subtypes.

RESULTS

Thirty-seven patients were included in the final analysis. The sac was identified in all the patients and the mean sac size of the fistula was small (<4mm). Dural type was associated with exclusive cortical venous drainage. Extradural anterior CSDAVF showed tendency towards younger age predilection. Extradural posterolateral CSDAVF was more often associated with initial oculomotor nerve palsy and this observation was statistically significant. Discordancy between the location of the fistula and the side of clinical affection was observed in midline fistulas such as osseous CSDAVF and posteromedial type of extradural CSDAVF.

CONCLUSIONS

CSDAVF is a heterogeneous vascular disorder involving the sphenoclival bone, extradural space and dura, homologous to the epidural-dural shunts of vertebra with a common clinical presentation of orbital manifestations. Preoperative localization of the fistula could explain enigmatic observations and potentially simplify its interventional management.

Magnetic Resonance Spectroscopy Findings in Patients with Dural Arteriovenous Fistulas: Three Case Reports

BACKGROUND

Magnetic resonance spectroscopy (MRS) is a potentially useful modality for evaluating brain metabolites in patients with dural arteriovenous fistula (dAVF). Here we describe a different pattern of MRS-based cerebral metabolism findings in patients with dAVF.

CASE DESCRIPTIONS

We performed MRS in 3 patients with transverse sigmoid sinus dAVF associated with cortical venous reflux. In case 1, which was associated with vasogenic edema on T2-weighted magnetic resonance imaging (MRI), decreased preoperative N-acetylaspartate (NAA)/creatine (Cr) and myo-inositol (mIns)/Cr and increased lactate (Lac)/Cr ratios improved after treatment. In case 2, a decreased preoperative NAA/Cr ratio improved after treatment. These 2 patients presented with seizures. In case 3, the patient presented with headache and showed no metabolic changes on preoperative or postoperative MRS.

CONCLUSIONS

Our results suggest that patients with dAVF can be classified based on a combination of metabolic and signal changes seen on T2-weighted MRI. MRS may allow significantly expanded evaluation of the metabolic changes associated with dAVF for appropriate classification and management.

Stereotactic radiosurgery for intracranial dural arteriovenous fistulas: its clinical and angiographic perspectives

BACKGROUND

To assess the efficacy of stereotactic radiosurgery (SRS) for intracranial dural arteriovenous fistulas (DAVFs), the authors retrospectively reviewed our 7-year experience. We evaluated the obliteration rate, improvement in clinical symptoms, and complications.

METHODS

Thirty patients with DAVF underwent SRS using a Gamma Knife between 2009 and 2015. Twenty-three patients were treated with SRS alone, and seven patients underwent SRS for residual or recurrent DAVFs after embolization or surgery. Chemosis, diplopia, and pulsating tinnitus were the most common symptoms. Median target volume was 2.9 cm³ (range, 0.8-13.6 cm³), and median radiation dose to the target was 17 Gy (range, 12-20 Gy). Median follow-up period was 33 months (range, 6-82 months).

RESULTS

At the last neuroimaging follow-up, DAVFs were totally obliterated in 23 patients (77%) and subtotally in 7 (23%). At the last clinical follow-up, 21 patients (70%) showed complete recovery, and 9 (30%) showed incomplete recovery in symptoms or signs. None experienced worsening symptoms or signs. Asymptomatic perilesional edema after SRS occurred in one patient (3%). Total obliteration rates after SRS were 43% at 1 year, 79% at 2 years, and 95% at 5 years. Improvement rates of neurological function after SRS were 12% at 1 month, 52% at 2 months, 72% at 3 months, and 96% at 6 months. A multivariate analysis revealed that Borden type 1 (p = 0.019, hazard ratio, 3.254, 95% confidence interval, 1.216-8.707) was significantly associated with symptom improvement.

CONCLUSIONS

SRS for intracranial DAVFs provided a high obliteration rate and a relatively low risk of radiation-induced complications. In selected benign cases without cortical venous drainage, SRS is a safe and effective treatment for symptom relief and fistula obliteration, even though the time course of improvement is longer than those of embolization and surgery.

A hemorrhagic complication after Onyx embolization of a tentorial dural arteriovenous fistula: A caution about subdural extension with pial arterial supply

We report a case of tentorial dural arteriovenous fistula (DAVF) with a severe intracranial hemorrhage occurring after Onyx embolization. A 40-year-old man presented with an asymptomatic tentorial DAVF on angiography. Transarterial embolization with Onyx was performed via the middle meningeal artery, and the cast filled the fistula itself and its proximal draining vein. Postoperative angiography confirmed complete occlusion of the DAVF. A computed tomography scan performed immediately after the procedure demonstrated an acute subdural hematoma with the temporal hemorrhage. Emergency craniotomy revealed continuous arterial bleeding from a viable glomus-like vascular structure around the proximal part of the embolized draining vein, fed by a pial artery arising from the posterior cerebral artery. Pathologic findings suggested diagnosis of vascular malformation extending into the subdural space. Tentorial DAVFs can extend to the subdural space along their drainage route, and may be involved in severe hemorrhagic complications of curative endovascular treatment using Onyx, particularly those with pial arterial supply.

Dural arteriovenous fistula manifesting as pontine hemorrhage at the craniocervical junction

Craniocervical junction (CCJ) dural arteriovenous fistula (DAVF) manifesting as intracerebral hemorrhage is extremely rare. We report the first case of CCJ-DAVF manifesting as pontine hemorrhage. A 69-year-old male presented with a pontine hemorrhage manifesting as a sudden onset of right hemiparesis and dysarthria. Digital subtraction angiography revealed a CCJ-DAVF fed by the meningeal branches of the right vertebral artery. The patient underwent surgical ligation of the cerebral draining veins to prevent re-bleeding. The postoperative course was uneventful. The patient had no neurological deficit after 1 month rehabilitation.

Clinical and angioarchitectural factors influencing the endovascular approach to galenic dural arteriovenous fistulas in adults: case series and review of the literature

BACKGROUND

Galenic dural arteriovenous fistulas (DAVF) are rare; however, they are the most frequent type of DAVF to manifest aggressive clinical behavior and usually represent a diagnostic and therapeutic challenge for clinicians.

METHODS

We retrospectively reviewed clinical and imaging data of patients managed with neuroendovascular techniques for the treatment of galenic DAVFs from 2000 to 2016. We searched the 2000-2016 English-language literature for papers discussing neuroendovascular management of galenic DAVFs, with or without companion surgical procedures.

RESULTS

Five patients were treated for galenic DAVFs during the study period (four males; mean age, 61 years). Three presented with progressive neurological deterioration due to venous congestion, two with acute intracranial hemorrhage. Three were treated by staged transarterial embolization procedures (three procedures in two, four procedures in one); two underwent a single transvenous embolization procedure. Four out of five fistulas were completely occluded. All patients improved clinically; the patient whose fistula was partially occluded remains angiographically stable at 2-year follow-up. Six reports describing 17 patients are reviewed. Embolization was performed via transvenous approach in 1/17 and transarterial approach in 16/17 with additional open surgery in 9/16. The trend toward the use of transarterial approaches is based primarily on advances on embolization techniques that allow better and more controllable penetration of the embolizing agents with improved clinical and angiographic results, as well as the technical complexity of the transvenous approach.

CONCLUSIONS

Although transarterial embolization is the preferred endovascular route for the management of most galenic DAVFs, selected cases can be successfully treated by transvenous approach.

Application of Time-Resolved 3D Digital Subtraction Angiography to Plan Cerebral Arteriovenous Malformation Radiosurgery

BACKGROUND AND PURPOSE

Time-resolved 3D-DSA (4D-DSA) enables viewing vasculature from any desired angle and time frame. We investigated whether these advantages may facilitate treatment planning and the feasibility of using 4D-DSA as a single imaging technique in AVM/dural arteriovenous fistula radiosurgery.

MATERIALS AND METHODS

Twenty consecutive patients (8 dural arteriovenous fistulas and 12 AVMs; 13 men and 7 women; mean age, 45 years; range, 18-64 years) who were scheduled for gamma knife radiosurgery were recruited (November 2014 to October 2015). An optimal volume of reconstructed time-resolved 3D volumes that defines the AVM nidus/dural arteriovenous fistula was sliced into 2D-CT-like images. The original radiosurgery treatment plan was overlaid retrospectively. The registration errors of stereotactic 4D-DSA were compared with those of integrated stereotactic imaging. AVM/dural arteriovenous fistula volumes were contoured, and disjoint and conjoint components were identified. The Wilcoxon signed rank test and the Wilcoxon rank sum test were adopted to evaluate registration errors and contoured volumes of stereotactic 4D-DSA and integration of stereotactic MR imaging and stereotactic 2D-DSA.

RESULTS

Sixteen of 20 patients were successfully registered in Advanced Leksell GammaPlan Program. The registration error of stereotactic 4D-DSA was smaller than that of integrated stereotactic imaging (P = .0009). The contoured AVM volume of 4D-DSA was smaller than that contoured on the integration of MR imaging and 2D-DSA, while major inconsistencies existed in cases of dural arteriovenous fistula (P = .042 and 0.039, respectively, for measurements conducted by 2 authors).

CONCLUSIONS

Implementation of stereotactic 4D-DSA data for gamma knife radiosurgery for brain AVM/dural arteriovenous fistula is feasible. The ability of 4D-DSA to demonstrate vascular morphology and hemodynamics in 4 dimensions potentially reduces the target volumes of irradiation in vascular radiosurgery.

[Bromocriptine: could it be the cure for post-surgical akinetic mutism?]

INTRODUCTION

Akinetic mutism is considered as an alteration of the motivational state of the person, which the patient is unable to initiate verbal or motor responses voluntary, even with preserved sensorimotor and surveillance functions.

CASE REPORT

A 43 year-old male involved in a cerebellum arteriovenous fistula complicated with hydrocephalus, who responded dramatically to treatment with bromocriptine.

CONCLUSION

Typically, akinetic mutism is described as a transient surgeries posterior fossa. However, it can also occur after multiple valvular failure in patients with hydrocephalus.

Endovascular management of spinal dural arteriovenous fistulas

Spinal dural arteriovenous fistulas (dAVF) are the most common subset of the larger group of spinal vascular malformations. In this chapter, we discuss the definition, epidemiology, clinical presentation, diagnosis, treatment, and outcomes of spinal dAVF. Special attention is given to clinical approach, imaging, and diagnosis with discussion of newer spinal magnetic resonance angiographic techniques. Endovascular management techniques are discussed, including technical and safety considerations for the performance of spinal angiography and various methods of embolization. Embolization media, including liquid embolics, particles, and coils, are introduced. Finally, clinical and imaging outcomes are discussed with attention to the clinical and imaging findings of dAVF recurrence.

Supratentorial cavernous malformations

Supratentorial cavernous malformations are uncommon cerebral vascular lesions that may present many unique challenges for treating physicians. The vast majority will be discovered during workup for seizures or after symptomatic intracerebral hemorrhage. Supratentorial cavernous malformations are increasingly being discovered incidentally in patients who obtain brain imaging for unrelated reasons. Management strategies including watchful waiting, antiepileptic drug therapy, microsurgery, or an expanding array of "minimally invasive" therapies. Thus, clinical decision making is not always straightforward and a nuanced approach tempered by experience and good judgment is critical to achieving excellent clinical results.

Spinal cavernous malformations

Spinal cavernous malformations are rare intramedullary vascular lesions of the central nervous system. Most are located in the thoracic spine. Patients present with either acute neurologic deficit or gradual deterioration. Weakness is the most common presenting symptom. The annual hemorrhage risk is 2.1%. Diagnosis is made by magnetic resonance imaging as these lesions are occult on angiography. Surgical removal is indicated in patients with hemorrhage and neurologic deficit. All lesions are approached posteriorly by laminectomy. Dorsal cavernous malformations are exposed by focused laminectomy of the level or levels overlying the lesion with minimally facet violation. Ventral and lateral lesions are approached by laminectomy including a level above and level below as well as unilateral radical facetectomy. After midline dural opening, the dentate ligament is divided and retracted to allow up to 90° of rotation of the spinal cord. Microsurgical treatment is associated with 42% symptom improvement and 50% symptom stabilization. Postoperative worsening is associated with longer preoperative duration of symptoms. Therefore we recommend consideration of early surgery for cavernous malformation removal in patients with symptoms attributable to the lesion.

[Dural Arteriovenous Fistula with Acute Visual Loss Manifestation:A Case Report]

In this report, we are describing a rare case of dural arteriovenous fistula(DAVF)followed by an isolated symptom of bilateral visual acuity disturbance. The patient was a 67-year-old man suffering from progressive bilateral visual acuity disturbance. Angiography revealed a diffuse arteriovenous fistula in the left transverse-sigmoid sinus affected by severe venous congestion. Visual acuity disturbance is likely to have been caused by increased intracranial pressure(IICP). Venous congestion as well as visual acuity were gradually improved following three transarterial embolizations. It is possible that a gradual progression of the clinical condition has caused only visual acuity disturbance without any other IICP symptoms, which is similar to pseudotumor cerebri. Should an unexplained visual acuity loss occur, the case should be investigated by considering DAVF.

Therapeutic progress in pediatric intracranial dural arteriovenous shunts: A review

Pediatric dural arteriovenous shunts (dAVSs) are a rare form of vascular disease: Fewer than 100 cases are reported in PubMed and the understanding of pediatric dAVS is limited. For this study, we searched in PubMed, reviewed and summarized the literature related to pediatric dAVSs. Our review revealed that pediatric dAVSs have an unfavorable natural history: If left untreated, the majority of pediatric dAVSs deteriorate. In a widely accepted classification scheme developed by Lasjaunias et al., pediatric dAVSs are divided into three types: Dural sinus malformation (DMS) with dAVS, infantile dAVS (IDAVS) and adult-type dAVS (ADAVS). In general, the clinical manifestations of dAVS can be summarized as having symptoms due to high-flow arteriovenous shunts, symptoms from retrograde venous drainage, symptoms from cavernous sinus involvement and hydrocephalus, among other signs and symptoms. The pediatric dAVSs may be identified with several imaging techniques; however, the gold standard is digital subtraction angiography (DSA), which indicates unique anatomical details and hemodynamic features. Effectively treating pediatric dAVS is difficult and the prognosis is often unsatisfactory. Transarterial embolization with liquid embolic agents and coils is the treatment of choice for the safe stabilization and/or improvement of the symptoms of pediatric dAVS. In some cases, transumbilical arterial and transvenous approaches have been effective, and surgical resection is also an effective alternative in some cases. Nevertheless, pediatric dAVS can have an unsatisfactory prognosis, even when timely and appropriate treatment is administered; however, with the development of embolization materials and techniques, the potential for improved treatments and prognoses is increasing.

Transarterial Onyx embolization of jugular foramen dural arteriovenous fistula with spinal venous drainage manifesting as myelopathy-a case report and review of the literature

We report a rare case of jugular foramen dural arteriovenous fistula (DAVF) with spinal venous drainage. A 48-year-old woman suffered from progressive weakness of lower extremities and incontinence of urine and feces for 14 days. Magnetic resonance imaging (MRI) revealed a tortuous posterior medullary vein at C2-T2 and ischemic signal at C2-C4 of the spinal cord. Brain MRI revealed an abnormal high signal near the left jugular foramen. Digital subtraction angiography of the spinal vascular was negative, while brain angiography showed a left jugular foramen DAVF with spinal perimedullary venous drainage. The patient recovered completely soon after endovascular embolization with Onyx-18. Diagnosis of a DAVF presenting with myelopathy is challenging. Early diagnosis and treatment are essential for a favorable outcome.

[A dural arteriovenous fistula detected during the chronic phase of cerebral venous sinus thrombosis]

A 47-year-old woman developed a headache and tinnitus in her right ear followed by sudden-onset left hemiparesis. She had no history of trauma or thrombophilia. Arteriography showed an occlusion of the superior sagittal sinus, and a stenosis of the right transverse sinus. She was treated with anticoagulants; thereafter her deficits and sinus thrombosis immediately improved. However, 7 months after the onset, she noticed tinnitus in her left ear. Arteriography showed a dural arteriovenous fistula extending from the left occipital artery to the left transverse and sigmoid sinus, but no recurrence of the cerebral venous sinus thrombosis. After manual compression of the left occipital artery was initiated, the tinnitus and dural arteriovenous fistula did not worsen. A dural arteriovenous fistula may be detected in patients with cerebral venous sinus thrombosis during the chronic phase.

[Not Available]

Zusammenfassung. Wir berichten über eine 63-jährige Frau, die sich durch ein einseitiges Puls-synchrones Ohrgeräusch erheblich beeinträchtigt fühlte. Sämtliche bisher durchgeführte Diagnostik einschliesslich MRT und Gefässultraschall war unauffällig. Die Duplexsonografie mit Fokus auf die A. carotis externa zeigte nun jedoch eine verminderte Pulsatilität in der A. occipitalis, weniger deutlich in der A. carotis externa. Die Verdachtsdiagnose einer duralen AV-Fistel bestätigte sich angiografisch. Nach Embolisation der Fistel war die Patientin beschwerdefrei.

[CLIPPERS (chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids)]

Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) has been recently identified as an inflammatory central nervous system (CNS) disorder. Punctate and curvilinear gadolinium enhancement (peppering) the pons is a characteristic magnetic resonance imaging (MRI) feature of CLIPPERS. Pathogenesis of this disorder remains unknown. A specific serum or cerebrospinal fluid biomarker for this disorder is currently unknown. Whether CLIPPERS is an actual new disease or just represents overlapping symptoms from multiple diseases is still debated. Many differential diagnoses exist even when using imaging as a tool. Pre-lymphoma states, such as grade I LYG (lymphomatoid granulomatosis) and sentinel lesions of primary CNS lymphoma are the most difficult to distinguish.