Large hemangiopericytoma associated with arteriovenous malformations and dural arteriovenous fistulae

A Vascular Quartet: Scalp Arteriovenous Malformation, Sinus Pericranii, Dural Arteriovenous Fistula, and Arteriovenous Brain Malformation in a Single Patient

We present a case of a 51-year-old female who presented for evaluation of a large scalp mass found to have a different quartet of vascular malformations- a persistent scalp arteriovenous malformation (sAVM) with sinus pericranii, an inoperable intracranial SM-V brain arteriovenous malformation (bAVM), and a Cognard I dural arteriovenous fistula (dAVF). This is the first reported instance with four distinct vascular pathologies. We review the etiologies of multiple vascular abnormalities in the cerebral circulation that could contribute to this patient's findings and review strategies for treatment. We conducted a retrospective review of the clinical and angiographic records for a single adult female patient, including a management approach and an in-depth literature review. Given the high baseline vascularity of these complex lesions, surgery was not considered the initial therapy. We focused primarily on the sAVM with a staged embolization involving both transarterial and transvenous approaches. Transarterial coil embolizes 5 feeding artery branches of the right external carotid artery, followed by transvenous coil embolization into the common venous pouch accessed through the transosseous sinus pericranii via the SSS, dramatically reduced the size and filling of the large sAVM and eliminated a significant source of hypertensive venous outflow. Serial endovascular treatments of her sAVM led to a significant reduction in size and pulsatility, and the pain from tenderness to palpation was concurrently decreased. Despite multiple treatments, serial angiographic evaluations of her scalp lesion showed continued new development of collaterals. Ultimately the patient elected to forego further treatment for her sAVM. To our knowledge, there has not been another report of a single adult patient with a quartet of vascular malformations in the literature. Treatment paradigms for sAVMs are limited to case reports and small series; however, we purport that the most successful therapeutic approaches are multimodal and likely should incorporate surgical resection when feasible. We emphasize the caution required for patients with multiple other underlying intracranial vascular malformations. The altered intracranial flow dynamics can drastically hinder the success of a unimodal approach involving endovascular therapy alone.

Solitary fibrous tumor of the central nervous system invading and penetrating the skull: A case report

Solitary fibrous tumor (SFT) of the central nervous system is a rare spindle cell tumor of mesenchymal origin. The present study reports the case of a 44-year-old male patient with SFT. Magnetic resonance imaging demonstrated that the majority of the intracranial tumors exhibited uneven low signals on T1-weighted imaging (T1WI) and low mixed signals on T2WI, and there was an enhancement on enhanced scanning. Furthermore, the distal part of the left occipital lobe exhibited hypersignals on T1WI and T2WI, and this was significantly enhanced following enhanced scanning. The lower part of the scalp exhibited low signals on T1WI and high signals on T2WI, and there was no notable enhancement following enhanced scanning. Magnetic resonance spectroscopy demonstrated an elevated choline/creatine peak in the solid part of the tumor. Under the microscope, the tumor exhibited characteristic 'staghorn-shaped' blood vessels. As SFT is difficult to differentially diagnose via imaging, immunohistochemical analysis of CD34, vimentin and signal transducer and activator of transcription 6 was performed for the definitive diagnosis of SFT. Of note, surgical resection was the preferred treatment for SFT; however, due to the rarity of the tumor, subsequent adjuvant therapy and prognosis require further investigation.

Superior sagittal sinus dural arteriovenous fistula with changes in angiographic findings associated with contiguous parasagittal meningioma: A case report

Background:

Meningioma and dural arteriovenous fistula (dAVF) located at the same site are rare. The present case demonstrated the transformation of tumor feeding vessels into the pial feeder of the dAVF over time, which may help to elucidate the pathogenesis of tumor-associated dAVF.

Case Description:

A 71-year-old man presented with convulsion. Magnetic resonance (MR) imaging showed a right parasagittal sinus meningioma invading the superior sagittal sinus (SSS). Bilateral external carotid angiography showed dAVF at the SSS, near the site of tumor invasion. The right internal carotid angiography showed tumor staining from the anterior cerebral artery with intra-tumor arteriovenous shunting, with stagnation of tumor blood flow, suggesting impairment of perfusion to the SSS. Four years after the initial diagnosis, the patient was admitted to hospital with status epilepticus, and MR imaging showed an enlarged tumor. Carotid angiography revealed transformation of the tumor feeders to the pial feeder of the dAVF. The findings of shunting to the SSS had intensified, and stenosis had occurred in the posterior third of the SSS. The venous return showed retrograde flow anteriorly to the SSS. The patient underwent endovascular embolization and tumor resection. The shunt had disappeared.

Conclusion:

This report supports the proposal that impaired venous return is an important factor in the shunt occurrence of dAVF. Neurosurgeons should consider that cases of meningioma invading the venous sinuses may be complicated by dAVF and changes may occur over time.

Dural arteriovenous fistula associated with intratumor hemorrhage

Dural arteriovenous fistula (dAVF) associated with an intracranial tumor is a relatively rare condition. Furthermore, to our knowledge, this is the first case report of dAVF associated with intratumor hemorrhage. We experienced this very rare case and report it here, along with a literature review. A 59-year-old woman presented with transient aphasia and dysgraphia. Computed tomography, magnetic resonance imaging, and angiography showed left anterior cranial fossa dAVF and a tumor with an intratumor hemorrhage. Cerebral angiography demonstrated AV shunts from the left ethmoidal artery via cortical vein flow into the superior sagittal sinus. She underwent shunt-point extirpation for the dAVF and removal of the tumor. The histological finding indicated transitional meningioma. The patient was discharged without any neurological deficit. A dAVF with intratumor hemorrhage is very rare and may be due to the venous congestion of the tumor draining vein by venous hypertension caused by the dAVF.

Dural Arteriovenous Fistula Associated With a Vestibular Tumor: An Unusual Case and Review of the Literature

Intracranial dural arteriovenous fistulae (DAVF) are rare vascular malformations. They are generally considered to be acquired lesions, often attributed to dural sinus thrombosis and intracranial venous hypertension. The authors encountered a case of DAVF associated with an octreotide-positive vestibular schwannoma. A 46-year-old female had symptoms of right ear congestion accompanied by pulsatile tinnitus and mild hearing loss. Magnetic resonance imaging (MRI) identified a lobulated mass centered at the cerebellopontine angle. Preoperatively, on cerebral angiography, there was an incidental discovery of a DAVF in the right posterior fossa. The decision was made to proceed with resection of the tumor in a staged fashion. Her latest follow-up MRI showed no evidence of recurrent tumor. This is the second reported case of DAVF associated with an intracranial schwannoma. Findings are discussed along with a thorough review of the literature. This case, combined with the data from the literature review, led us to believe that tumor-related angiogenesis might contribute to DAVF formation.

Atherosclerosis, Periodontal Disease, and Treatment with Resolvins

PURPOSE OF REVIEW

This review aims to discuss the existing evidence on the link between atherosclerosis and periodontitis by particularly presenting new findings that link the pathology and therapy of these diseases. Acute vascular ischemic events that can lead to stroke or myocardial infarction are initiated by inflammatory processes leading to rupture or erosion of plaques susceptible to thrombosis ("high risk" or "vulnerable"). These are highly inflamed plaques residing in the media and adventitia that may not be detected by angiography measurments of luminal narrowing. Statistically significant excess risk for atherosclerotic cardiovascular disease has been reported in persons with periodontitis independent of established risk factors. We hypothesized that the systemic pathologic links also represent potential therapeutic links.

RECENT FINDINGS

We recently demonstrated that periodontal inflammation promotes atherosclerotic plaque inflammation and destabilization. As discrete pathological regions, these plaques with a high susceptibility to rupture can be imaged and differentiated from lower risk plaques. In cholesterol-fed rabbits with periodontal disease, circulating inflammatory mediators were also significantly elevated thereby contributing to "vulnerable blood," a systemic characteristic of high risk for cardiovascular events. New studies show that certain lipid mediators, including lipoxins and resolvins, are potent in preventing and possibly treating a number of inflammation-associated diseases, including periodontitis and vascular inflammation. The concept of the vulnerable patient and the pro-resolving approach open new terrain for discovery of paradigm-changing therapies for the prevention and treatment of two of the most common diseases of man. Importantly, lipoxins and resolvins are natural receptor agonists that do not exhibit the same pro-atherogenic side effects attributed to anti-inflammatory medications (e.g., NSAIDs) but rather coordinate resolution of inflammation and a return to homeostasis.

Regression of dural arteriovenous fistulae after venous flow reconstructive surgery in a case with hemangiopericytoma at the confluence of sinuses

Background

The mechanism by which acquired dural arteriovenous fistula (dAVF) develops is still unclear. Few cases have been reported with both dAVF and intracranial tumors, and in these few cases the authors have proposed that induced venous hypertension may lead to the pathogenesis of dAVF. We experienced a case of intrasinusoidal hemangiopericytoma (HPC) with dAVF development. In addition to its rare pathology and tumor location, this case showed regression of dAVF immediately after tumor removal.

Case Report

The patient was a 23-year-old man who developed progressively worse headaches and papilledema. The HPC was located entirely inside the confluence of the sinuses (CoS) and resulted in venous sinus occlusion. Cerebral angiography demonstrated a dAVF located in the straight sinus, upstream of the occluded CoS, which was fed by the dural branch of the posterior cerebral artery. After the endovascular embolization of the tumor feeders, subsequent surgery included venous reconstruction in addition to tumor excision. Although the dAVF was not treated with an endovascular procedure or surgery, postoperative angiography revealed complete disappearance of the dAVF.

Conclusion

We conclude that venous reconstructive surgery greatly contributed to the immediate regression of the dAVF. When planning the treatment strategy for such cases, it should be remembered that acquired dAVF may regress due to the normalization of venous hypertension.

Dural arteriovenous fistulas associated with benign meningeal tumors

BACKGROUND

Dural arteriovenous fistulas (dAVFs) are usually idiopathic lesions. While individual case reports have documented the occurrence of dAVFs in conjunction with benign meningeal tumors, a detailed characterization of this association is lacking. The objective of this study was to critically examine the relationship between benign meningeal tumors and dAVFs.

METHODS

We performed a retrospective review of records at two institutions, identified patients with coexisting benign meningeal tumors and dAVFs at the time of clinical presentation, and examined various clinical, anatomical and radiographic characteristics.

RESULTS

Ten patients (4.6%) had coexisting benign meningeal tumors and dAVFs. The most common tumor was meningioma (90%). Nine patients were symptomatic: five from tumor, three from dAVF, and one from both tumor and dAVF. All dAVFs were related to the meningeal tumor.

CONCLUSIONS

Benign meningeal tumors may be associated with dAVFs that are either in direct anatomical relation to the tumor or in distant anatomical locations. The increased propensity for development of dAVFs in patients with benign meningeal tumors may be due to multiple factors. Due to this association, additional imaging to exclude dAVFs could be considered in patients with meningeal tumors if exuberant vessels or flow voids are identified on routinely obtained magnetic resonance imaging scans.