Documented development of a dural arteriovenous fistula in an infant subsequent to sinus thrombosis: case report and review of the literature

Dural arteriovenous fistulae in a 6-year-old girl with trisomy 21 and congenital heart disease

Dural arteriovenous fistula (DAVF) represents a pathological group of intracranial shunts arising from the dural artery to venous sinus and veins. Childhood-onset DAVF is generally considered to be poor in prognosis, whereas only limited information is available for the onset and long-term outcomes. We herein report a Japanese girl with trisomy 21, large ventricular septal defects, and pulmonary vein stenosis, for which a transcatheter stent had been placed after birth. At age 6 years, she developed bacterial meningitis due to S. pneumoniae, leading to the diagnosis of venous sinus thrombosis and multiple intracranial shunts. Cerebral angiography identified multiple shunts arising from the middle meningeal arteries to the superior sagittal sinus and a concurrent reflux to cortical vein. Endovascular embolization successfully occluded the shunts without neurovascular complications over 24 months. This report first demonstrates the favorable outcome of DAVF in a pediatric patient with trisomy 21 after the catheter intervention. For children at a risk for intracranial thrombosis, preemptive neurovascular evaluation and transcatheter intervention provide a chance of early diagnosis of DAVF to improve their survival and neurologic outcome.

Coexistence of Intracranial Dural Arteriovenous Fistula and Cerebral Venous Sinus Thrombosis: Systematic Review and Outcome Analysis

A substantial number of patients with intracranial dural arteriovenous fistula (dAVF) suffer from coexistent cerebral venous sinus thrombosis (CVST), yet this clinical relation is poorly studied. We aim to study the clinical and radiological outcome of patients with coexistent dAVF and CVST based on different treatment modalities and to examine various other parameters in such patients. A search strategy was performed on the following search engines: PubMed, Wiley, Microsoft Academia, and Google Scholar. Analysis was performed using R software. Thirty-five articles met the inclusion criteria. Most studies (n = 30) used digital subtraction angiography alone to make the diagnosis. Treatment modality ranged from no treatment (n = 7) to a combination of anticoagulation, endovascular therapy, and surgery (n = 2). Radiological obliteration was achieved in the majority of patients (78%). However, there was no statistical significance between treatment modality and radiological outcome (P=0.651); 72% of patients achieved clinical improvement, with no statistical significance between clinical improvement and treatment modality (P=0.072). We did find a significant relationship between treatment modality and follow-up findings (P=0.023). When analyzing factors such as age, gender, grade, arterial supply, and time between dAVF and CVST development, we found no statistical significance. Additionally, there was no significant association between the grade of fistula and the treatment modality. The clinical relationship between dAVF and CVST is poorly studied. This is the first systematic review that aimed to study this relationship. Results from subsequent large-scale studies comparing to our findings are warranted.

Childhood stroke

Stroke is an important cause of neurological morbidity in children; most survivors have permanent neurological deficits that affect the remainder of their life. Stroke in childhood, the focus of this Primer, is distinguished from perinatal stroke, defined as stroke before 29 days of age, because of its unique pathogenesis reflecting the maternal-fetal unit. Although approximately 15% of strokes in adults are haemorrhagic, half of incident strokes in children are haemorrhagic and half are ischaemic. The causes of childhood stroke are distinct from those in adults. Urgent brain imaging is essential to confirm the stroke diagnosis and guide decisions about hyperacute therapies. Secondary stroke prevention strongly depends on the underlying aetiology. While the past decade has seen substantial advances in paediatric stroke research, the quality of evidence for interventions, such as the rapid reperfusion therapies that have revolutionized arterial ischaemic stroke care in adults, remains low. Substantial time delays in diagnosis and treatment continue to challenge best possible care. Effective primary stroke prevention strategies in children with sickle cell disease represent a major success, yet barriers to implementation persist. The multidisciplinary members of the International Pediatric Stroke Organization are coordinating global efforts to tackle these challenges and improve the outcomes in children with cerebrovascular disease.

Development of Dural Arteriovenous Fistulas After Cerebral Venous Sinus Thrombosis

A 57-year-old man presented with papilledema due to partially recanalized dural sinus thrombosis and was treated with anticoagulation and acetazolamide. One year after treatment and resolution of his symptoms, he had an increase in his optic disc edema accompanied by headaches. Subsequent neuroimaging indicated development of arteriovenous fistulas resulting in cortical and deep venous reflux. Given the high risk of mortality from intracranial hemorrhage, the patient underwent urgent treatment with a liquid embolic agent, which resulted in the resolution of his optic disc edema. Our case is unique in that recurrence of bilateral optic disc edema led to discovery of the rare complication of dural arteriovenous fistulas developing after dural sinus thrombosis. Ongoing monitoring of patients after cerebral venous sinus thrombosis is, therefore, important.

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.

Management and outcome of spontaneous cerebral venous sinus thrombosis in a 5-year consecutive single-institution cohort

Background

Cerebral venous sinus thrombosis (CVST) is an uncommon form of stroke with a variable presentation, ranging from headaches, to coma and death. Although the American Stroke Association has developed guidelines for the treatment of CVST, data are sparse on the outcome after treatment with anticoagulation, thrombolysis, and thrombectomy.

Methods

In this retrospective review, we describe the 5-year UC Davis experience with spontaneous CVST.

Results

Forty-one patients (mean age 37.5±23.1, range 0–96 years; 29 female) were identified with CVST. The majority of cases involved the transverse sinus (75.6%), sigmoid sinus (58.5%), and superior sagittal sinus (29.3%). The most common form of treatment was anticoagulation or antiplatelet therapy (n=35), while six patients were managed by observation alone. The overall 1-year modified Rankin score (mRS) was 1.4±1.5. Male patients and patients with a poor admission mRS had a worse outcome. Outcome was unaffected by hypercoagulable state, number of dural sinuses involved, the presence of intracranial hemorrhage, or seizures. Two patients who underwent anticoagulation therapy also required endovascular thrombectomy; both patients had a 1-year mRS of ≤2. Two patients underwent direct open surgical canalization of the superior sagittal sinus with varying outcomes (mRS 2 vs mRS 6).

Conclusions

In our series, the majority (92.9%) of patients with spontaneous dural sinus thrombosis had a favorable clinical outcome as defined by a mRS ≤2. Further prospective studies are needed to study the impact of anticoagulation on the clinical course of the disease.

Posterior reversible encephalopathy syndrome and venous thrombosis

Posterior reversible encephalopathy syndrome (PRES) and venous thrombosis are frequently encountered first in the emergency setting and share some common characteristics. The clinical presentation in both entities is vague, and the brain parenchymal findings of PRES syndrome may resemble those of venous thrombosis in some ways. Both entities often occur in a bilateral posterior distribution and may be associated with reversible parenchymal findings if the inciting factor is treated. These diagnoses should be at the forefront of the differential diagnosis when confronted with otherwise unexplained brain edema, among other findings described in this article.