Dural arteriovenous malformation of the anterior cranial fossa occurring after bifrontal craniotomy

Development of a sigmoid sinus dural arteriovenous fistula secondary to sigmoid sinus thrombosis after resection of a foramen magnum meningioma: illustrative case

BACKGROUND

The precise etiology of dural arteriovenous fistula (DAVF) is still unknown. The authors reported a case of delayed postoperative sigmoid sinus (SS) DAVF secondary to SS thrombosis after resection of a foramen magnum meningioma through a suboccipital craniotomy.

OBSERVATIONS

The authors visualized the clear architecture of the DAVF using fusion three-dimensional computer graphics (3DCG) images reconstructed from multimodal imaging studies. These fusion 3DCG images revealed that the feeders of the DAVF had connected through neovascularization to the SS at the previous thrombus site. The authors also reviewed previously reported cases of DAVFs that developed after craniotomy.

LESSONS

This study indicated that SS stenosis and occlusion with sinus thrombosis are possible risk factors for delayed postoperative DAVF that demand special consideration.

Surgical Obliteration of Anterior Cranial Fossa Dural Arteriovenous Fistulas via Unilateral High Frontal Craniotomy

BACKGROUND

Surgical obliteration is generally recommended for anterior cranial fossa dural arteriovenous fistulas (ACF DAVFs) because of a high risk of bleeding and the difficulty of endovascular approaches. Surgical obliteration is generally performed via a frontobasal craniotomy; however, it is slightly excessive over the target fistula. Here, we present 2 cases of ACF DAVFs treated with small craniotomy without frontal sinus involvement and a review of the related literature.

METHODS

We present 2 cases including a 63-year-old woman who presented with a right-sided ACF DAVF that was fed by both ethmoidal arteries and drained into the right cortical veins (case 1) and a 59-year-old man with right-sided unruptured multiple aneurysms and a left-sided ACF DAVF that was fed by the right ethmoidal artery and drained into the left cortical veins (case 2).

RESULTS

Case 1 underwent surgical obliteration via a right high frontal craniotomy. Case 2 was simultaneously treated with surgical clipping of the multiple aneurysms via a right lateral supraorbital craniotomy and surgical obliteration of the ACF DAVF via a left high frontal craniotomy. These 2 patients had no neurologic deficits, and complete obliteration of all the lesions was confirmed on cerebral angiography.

CONCLUSIONS

Constructing a small corridor and a deep working distance in unilateral small high frontal craniotomy may be a slightly unusual approach; however, it is thought to provide sufficient space and a range of microscopic views that facilitate surgical manipulation without requiring extensive bone work.

The Coexistence of Extradural Arteriovenous Fistula and Soft Tissue Arteriovenous Malformation Within the Same Metamere

BACKGROUND

Spinal arteriovenous shunts are a common spinal vascular disorder. However, they can have a misleading clinical presentation and poor prognosis. They are classified into 4 types according to shunt points and drainage route, among which extradural arteriovenous fistula (eAVF) is the most rare, comprising only 1% of all spinal arteriovenous shunts. We report an extremely rare case of coexistent eAVF at the craniocervical junction and soft tissue arteriovenous malformation within the same metamere.

CASE DESCRIPTION

A 30-year-old man presented with neck pain. T2-weighted magnetic resonance imaging revealed a flow void at the right craniocervical junction compressing the spinal cord. Angiography revealed eAVF at the craniocervical junction. The patient was treated via transvenous embolization. After the procedure, shunt flow and symptoms markedly decreased. During the operation, an extracranial arteriovenous malformation under the occipital skin was detected immediately after occluding the shunt point.

CONCLUSIONS

This case indicates that transvenous embolization can be an effective treatment for eAVF and supports some hypotheses of arteriovenous malformation development. Additionally, it emphasizes the importance of examining a lesion with multiple modalities, including angiography, three-dimensional angiography, and cone-beam computed tomography, to understand the anatomy of the lesion.

Endovascular and surgical approaches of ethmoidal dural fistulas: a multicenter experience and a literature review

Ethmoidal dural arteriovenous fistulae are rare vascular malformations associated with a high risk of bleeding. We present a multicenter contemporary series of patients treated with microsurgical and endovascular techniques. Sixteen consecutive patients were evaluated and/or treated between 2008 and 2015 at four centers with large experience in the endovascular and surgical treatment of cerebrovascular diseases. We analyzed demographic and clinical data, risk factors for dural fistulas, treatment type, peri- and post-operative morbidity, clinical and radiological outcomes, rates of occlusion, and long-term neurological outcome. Sixteen patients (81 % men, mean age of 58 years) with ethmoidal dural fistulas were included in the analysis. Seven patients had suffered an intracranial hemorrhage; the remaining presenting with neurological signs and symptoms or the fistula was an incidental finding. Three patients were managed conservatively. Among patients who underwent intervention (n = 13), 46.1 % were treated with endovascular therapy and 53.9 % were treated surgically. Complete angiographic obliteration was achieved in 100 % immediately after treatment and at last follow-up evaluation. All patients experienced a favorable neurological recovery (mRS 0-2) at the last follow-up visit (12 months). Ethmoidal dural AVFs are found mostly in male patients. Nowadays, due to wider use of non-invasive imaging, AVFs are discovered with increasing frequency in patients with minimal or no symptoms. Traditionally, these fistulas were considered "surgical." However, in the modern endovascular era, selected patients can be effectively and safely treated with embolization although surgical ligation continues to have an important role in their management.

Iatrogenic Dural Arteriovenous Fistula after Superficial Temporal Artery to Middle Cerebral Artery Anastomosis: A Case Report

Dural arteriovenous fistulas (AVFs) are uncommon, representing only 10% to 15% of all intracranial AVFs. Here we present the case of a patient with cerebral infarction who experienced a dural AVF after craniotomy for superficial temporal artery (STA) to middle cerebral artery (MCA) bypass surgery. A 48-year-old man presented with dysarthria and right side hemiparesis. A brain magnetic resonance imaging scan revealed multiple acute infarctions and severe stenosis of the left MCA. Therefore, STA-MCA bypass surgery was performed. A follow-up angiography performed 2 weeks after the surgery showed an abnormal vascular channel from the left middle meningeal artery (MMA) to the middle meningeal vein (MMV) just anterior to the border of the craniotomy margin. This fistula originated from a screw used for cranial fixation. The screw injured the MMA and MMV, and this resulted in the formation of a fistula. The fistula was successfully treated with transarterial embolization. Surgeons should be careful when fixing bones with screws and plates as fistulas can develop if vessels are injured.

Alternative management considerations for ethmoidal dural arteriovenous fistulas

BACKGROUND

Ethmoidal dural arteriovenous fistulas (EDAFs) are an unusual type of intracranial vascular lesion that commonly present with acute hemorrhage. They are often best treated surgically; however, recent endovascular advances raise questions concerning the best therapeutic approach.

METHODS

We present 7 cases of EDAFs managed at this institution over a 6-year period, which demonstrate the broad spectrum of clinical behavior associated with the lesions. Four patients presented with intracranial hemorrhage, 1 patient with rapidly progressive dementia, 1 patient with a proptotic, red eye, and 1 with a retro-orbital headache.

RESULTS

One patient underwent no treatment, 1 underwent embolization alone, 2 underwent embolization and resection, and 3 patients underwent resection alone. There was complete obliteration of the EDAF in all of the patients who underwent surgical resection. Embolization was performed through the external carotid circulation and not the ophthalmic artery. There were no treatment-related neurologic deficits.

CONCLUSIONS

Treatment is best managed with a multidisciplinary approach, which emphasizes complete resection of the lesions with assistance from interventional neuroradiology techniques. However, each patient must be evaluated independently as treatment may vary depending on the angioarchitecture of the lesion.