Dural Arteriovenous Fistulas at the Petrous Apex with Pial Arterial Supplies

Management of Petrous and Tentorial Dural Arteriovenous Fistulas: A Systematic Review

The petrous and tentorial dural arteriovenous fistulas are vascular malformations that are very infrequent but highly aggressive, with a significant risk of intracranial hemorrhage and neurological deficits. Optimal management remains one of the most debated subjects, with various series reporting endovascular and microsurgical approaches. Therefore, this systematic review aims to assess the efficacy, safety, and outcomes of different treatment modalities of petrous and tentorial dural arteriovenous fistulas (DAVFs) based on clinical presentation, imaging techniques, treatment outcome, and complications arising in the course of their treatment. A systematic review based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was carried out, which aimed to identify literature regarding both petrous and tentorial DAVFs. Major databases, including PubMed and Scopus, are searched using various related terms. Patient demographics as well as clinical presentations of patients with petrous and tentorial DAVFs were abstracted concerning imaging modalities, approaches adopted for their treatment, and the eventual outcome. The quality of studies was assessed using the Newcastle-Ottawa Scale, and data were synthesized through descriptive analysis. A total of 14 studies involving 198 patients were included. The mean patient age ranged from 38 to 59.8 years, with a male predominance (78%). Clinical presentations varied from headaches and tinnitus to life-threatening intracranial hemorrhage. Digital subtraction angiography (DSA) was the gold standard for diagnosis, while MRI and CT were useful adjuncts in assessing hemorrhage and venous drainage. Endovascular embolization using Onyx achieved complete obliteration in the majority of cases, though recurrence was noted in fistulas with complex arterial supply. Microsurgical approaches, particularly in cases where endovascular treatment was insufficient, demonstrated high cure rates with low recurrence. Complications included cranial nerve palsies and, in rare cases, arterial or venous rupture. Mortality was low, with a case fatality rate of 0%-15.4% across the studies. Both endovascular and microsurgical treatments are effective for managing petrous and tentorial DAVFs, though microsurgery provides superior results in complex or recurrent cases. A combination of embolization and surgery offers the best chance for durable fistula obliteration. Early diagnosis and individualized treatment plans guided by advanced imaging are critical for optimizing patient outcomes.

Intracranial dural arteriovenous fistulas with pial arterial supply: A narrative review

Intracranial dural arteriovenous fistula (DAVF) is a relatively complex intracranial condition, and its clinical presentation and treatment strategies often vary significantly due to various factors. Although the cure rate of intracranial DAVF is currently high, there is still a lack of understanding of its etiology and pathogenesis. There is ongoing controversy regarding the treatment strategies for DAVF associated with the pial arteries, and there is a lack of understanding of its pathogenesis. The author conducted a brief literature review on DAVF with pial arterial supply and presented some treatment experiences from their own medical center. Large-scale retrospective cohort studies and prospective research in future are expected to address these issues.

Fatal hemorrhagic complication after coil embolization of a petrosal arteriovenous shunt

BACKGROUND

Cerebello-pontine AVMs (CPAVMs) and petrous apex dural arteriovenous fistulae (DAVFs) are rare and sometimes difficult to distinguish. We report a fatal hemorrhagic complication after coil embolization of the petrosal vein draining a trigeminal AVM misdiagnosed as a DAVF.

CASE PRESENTATION

A 73-year-old woman with a petrous apex arteriovenous shunt with dual dural and pial arterial supply presented with posterior fossa hemorrhage. The draining petrosal vein was catheterized and coiled via the superior petrosal sinus. Two episodes of contrast extravasation occurred during coiling, but the lesion was completely occluded at the end of the procedure. The patient developed a fatal posterior fossa hemorrhage in the recovery room. Microscopic pathology revealed numerous dilated vessels within the trigeminal nerve.

CONCLUSION

CPAVMs and DAVFs with pial drainage should be distinguished pre-operatively. Occlusion of a pial vein (as opposed to a sinus) in the treatment of an arteriovenous shunt carries hemorrhagic risk if a liquid embolic agent is not used to completely occlude all pathological vessels.

Pediatric Petrous Apex Lesions: A Radiological Classification and Diagnostic Algorithm

The petrous apex (PA) is involved in a myriad of pathological conditions, some of which are exclusive in children. Diagnosis may be difficult due to vague clinical presentation, and local examination is challenging owing to its inaccessible location. This is further complicated by multiple unfused sutures and ongoing PA pneumatization in children. Cross-sectional imaging is vital for the evaluation of the PA lesions, due to their precarious location and proximity to the major neurovascular structures. Several classification systems have been proposed for these lesions based on their site of origin, solid or cystic appearance, surgical or non-surgical (no touch lesions) management, and benign or malignant nature. In this article, we emphasize the distinctive role of different cross-sectional imaging modalities in the diagnosis of pediatric PA lesions, with special attention to normal variants that should not be mistaken for pathology. We also propose a radiological classification and algorithmic approach to aid in the precise diagnosis and facilitate appropriate management of the various PA lesions in children.

Microsurgical Findings of Pial Arterial Feeders in Intracranial Dural Arteriovenous Fistulae: A Case Series

BACKGROUND

Pial arterial feeders in an intracranial dural arteriovenous fistula (dAVF) are risk factors for both ischemic and hemorrhagic complications during endovascular embolization. Microsurgery in dAVF with pial arterial feeders has rarely been reported.

OBJECTIVE

To assess our original experience with microsurgery for dAVF with pial arterial feeders by investigating surgical findings and outcomes.

METHODS

In 40 patients with intracranial dAVF who underwent microsurgery, we found 8 patients who had pial arterial feeders. A retrospective review was conducted.

RESULTS

The locations of the dAVFs were as follows: tentorium, 2 patients; Galenic system, 1; straight sinus, 1; torcula, 1; transverse sinus, 1; ethmoid, 1; and convexity, 1. Preoperative angiography revealed that the pial arterial feeders originated from the middle cerebral artery in 2 patients, the anterior cerebral artery in 1, the posterior cerebral artery in 2, and the posterior medial choroidal artery in 1. Of note, in 2 patients (6.7%), feeders from the superior cerebellar artery were determined to be angiographically occult during preoperative examination and were detected through careful intraoperative observation and arachnoid dissection. In 5 cases, the additional obliteration of the pial arterial feeders and/or more distal cortical venous drainers after the simple disconnection of proximal cortical drainers was necessary to cure the dAVF. Finally, all shunts were cured with only 1 minor complication.

CONCLUSION

Although microsurgical results were acceptable, the surgeon should be aware of the presence of pial arterial feeders even after the simple disconnection of cortical venous drainage. Angiographically occult feeders may also exist.

Preservation of Coexisting Normal Superior Petrosal Vein in the Microsurgical Treatment of Superior Petrosal Sinus Dural Arteriovenous Fistulas Assisted by Indocyanine Green Video Angiography

BACKGROUND

Superior petrosal sinus (SPS) dural arteriovenous fistulas (DAVFs) are a common subtype of tentorial DAVFs that often require microsurgical treatment. We have noted a rare condition involving the presence of a coexisting normal superior petrosal vein (SPV) during surgery for SPS DAVFs; this condition has not been reported in the literature. Identification and preservation of coexisting normal veins are crucial to prevent venous complications.

METHODS

We reviewed data of 12 patients with SPS DAVFs who underwent microsurgical treatment. Intraoperative indocyanine green video angiography was used to confirm the location of the fistula and identify the normal SPV. Postoperative radiologic examination was performed, and the clinical outcome was evaluated with the modified Rankin Scale.

RESULTS

A coexisting normal functional SPV was found in 6 cases. Analysis of the tributaries of the SPV showed the vein of the cerebellopontine fissure was the most frequent arterialized drainage vein (66.7%), while the pontotrigeminal vein was the most frequent normal drainage vein (45.5%). The DAVFs were easily identified and disrupted using intraoperative indocyanine green video angiography. The normal SPV was also successfully preserved. All 6 patients experienced good clinical and radiologic outcomes.

CONCLUSIONS

An SPS DAVF can coexist with a normal functional SPV, which should be preserved. Use of indocyanine green video angiography is an efficient way to identify the normal SPV.