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Yamaguchi I, Kanematsu Y, Shimada K, Yamamoto N, Korai M, Miyake K, Miyamoto T, Sogabe S, Shikata E, Ishihara M, Yamamoto Y, Kuroda K, Takagi Y. Evaluation of Serial Intra-Arterial Indocyanine Green Videoangiography in the Surgical Treatment of Cranial and Craniocervical Junction Arteriovenous Fistulae: A Case Series. Oper Neurosurg (Hagerstown) 2023; 25:292-300. [PMID: 37345942 DOI: 10.1227/ons.0000000000000796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 04/20/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Intravenous indocyanine green (IV-ICG) videoangiography is commonly performed to detect blood flow in the microscopic view. However, intra-arterial ICG (IA-ICG) videoangiography provides high-contrast imaging, repeatability within a short period of time, and clear-cut separation of the arterial and venous phases compared with IV-ICG. These features are useful for detecting retrograde venous drainage (RVD) and shunt occlusion in arteriovenous fistulae (AVF) surgery. This study aimed to investigate whether IA-ICG videoangiography can be repeatable within a short period of time and be useful for detecting RVD and shunt occlusion in cranial- and craniocervical junction (CCJ)-AVF surgery. METHODS Between January 2012 and December 2022, 50 patients were treated with endovascular or surgical intervention for cranial- and CCJ-AVF at Tokushima University Hospital. Of these, 5 patients (6 lesions) underwent open surgery with IA-ICG videoangiography in a hybrid operating room. We analyzed the data of these 5 patients (6 lesions). RESULTS There were 4/patient (median, range 2-12) and 3.5/lesion (median, range 2-10) intraoperative IA-ICG runs. IA-ICG videoangiography detected RVD in all patients. Clearance of IA-ICG-induced fluorescence was achieved within 30 seconds in all patients at each region of interest. After the disconnection of the fistulae, IA-ICG videoangiography and intraoperative digital subtraction angiography (DSA) confirmed the disappearance of RVD in all patients. There were no complications associated with IA-ICG videoangiography. CONCLUSION This study showed that IA-ICG videoangiography is repeatable within a short period of time before and after obliteration and can be useful for detecting RVD and shunt occlusion in cranial- and CCJ-AVF surgery. IA-ICG videoangiography also allows intraoperative DSA studies in a hybrid operating room. Considering the recent advancements in hybrid operating rooms, combining IA-ICG videoangiography with intraoperative DSA is a useful strategy for cranial- and CCJ-AVF surgery.
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Affiliation(s)
- Izumi Yamaguchi
- Department of Neurosurgery, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Yasuhisa Kanematsu
- Department of Neurosurgery, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Kenji Shimada
- Department of Neurosurgery, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Nobuaki Yamamoto
- Department of Neurology, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Masaaki Korai
- Department of Neurosurgery, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Kazuhisa Miyake
- Department of Neurosurgery, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Takeshi Miyamoto
- Department of Neurosurgery, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Shu Sogabe
- Department of Neurosurgery, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Eiji Shikata
- Department of Neurosurgery, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Manabu Ishihara
- Department of Neurosurgery, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Yuki Yamamoto
- Department of Neurology, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Kazutaka Kuroda
- Department of Neurology, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Yasushi Takagi
- Department of Neurosurgery, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
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Ma Y, Li Z, Zhang T, Chen H, Chen X, Zhao W. Efficiency of endovascular management with a combination of Onyx and coils for direct and indirect carotid cavernous fistula treatment: experience of a single center. Clin Neurol Neurosurg 2023; 228:107700. [PMID: 36996671 DOI: 10.1016/j.clineuro.2023.107700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 03/08/2023] [Accepted: 03/25/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND To evaluate the safety and efficacy of endovascular treatment with a combination of Onyx and coils for carotid cavernous fistulas (CCFs), and to characterize the factors associated with clinical and angiographic outcomes for direct and indirect CCFs. METHODS This retrospective study included 31 patients with CCF treated with an endovascular procedure between December 2017 and March 2022. RESULTS Direct and indirect CCFs were found in 14 (45.2%) and 17 (54.8%) cases, respectively. Direct CCFs included eleven traumatic carotid cavernous fistulas. The most common symptom on admission was chemosis, which was seen in 17 (54.8%) patients. Eight (25.7%) cases were treated by the transarterial approach. Fourteen (45.2%) cases were treated using the femoral vein-inferior petrosal sinus approach. Seven (22.6%) were treated by direct puncture of the superior ophthalmic vein. Two (6.5%) were treated by the femoral vein-facial vein approach. Immediate complete occlusion and follow-up rates were 93.5% and 96.7%, respectively. Twenty-nine (96.7%) patients experienced an improvement in their symptoms at clinical follow-up. Chemosis was significantly improved or resolved in 15 patients. Ophthalmoplegia was improved or resolved in 10 patients. Visual impairment was improved in 6 patients. Proptosis was improved or resolved in 5 patients. One case (3.2%) experienced procedure-related complication presented with transient oculomotor nerve palsy. In univariate subgroup analysis, use of balloon, treatment approach, and history of head trauma were significantly different between the direct and indirect CCF groups. CONCLUSIONS Endovascular treatment with a combination of Onyx and coils is a safe and effective therapy for CCFs. In this study, the transarterial approach was a favorable option for embolization of direct CCFs. In contrast, the transvenous approach may be the first choice of treatment for indirect CCFs.
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Alkhaibary A, Alnefaie N, Alharbi A, Alammar H, Arishy AM, Alshaya W, Khairy S. Intracranial dural arteriovenous fistula: a comprehensive review of the history, management, and future prospective. Acta Neurol Belg 2022; 123:359-366. [PMID: 36374476 DOI: 10.1007/s13760-022-02133-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 10/23/2022] [Indexed: 11/16/2022]
Abstract
Dural arteriovenous fistulas (DAVF) are abnormal acquired intracranial vascular malformations consisting of pathological connections located within the dura between the pial arteries and the veno vasora, comprising the walls of the dural sinuses, bridging veins, or transosseous emissary veins. Dural arteriovenous fistulas are distinguished from arteriovenous malformations by their arterial supply from the vessels that perfuse the dura mater and lack of a parenchymal nidus. They are most commonly situated at the transverse and cavernous sinuses. The mechanism of development behind dural arteriovenous fistula can be explained by the molecular and anatomical factors. Multiple classification systems have been proposed throughout history including; Djindjian and Merland, Cognard, and Borden classification systems. The aggressiveness of the clinical course in intracranial dural arteriovenous fistula can be predicted through the angiographic patterns of venous drainage, more specifically, the presence of cortical venous drainage, the presence of venous ectasia, and the aggressiveness of clinical presentation. Intracranial dural arteriovenous fistulas might be discovered incidentally. However, if symptomatic, the clinical presentation ranges from mild neurological deficits to severe, lethal intracranial hemorrhage. Angiography is the imaging of choice to investigate, diagnose, and plan treatment for intracranial dural arteriovenous fistula. The management algorithm of intracranial dural arteriovenous fistula can be broadly divided into conservative, surgical, endovascular, and/or radiosurgical options. With the advent of endovascular therapies, surgery has fallen out of favor for managing intracranial dural arteriovenous fistulas. In the present article, the pathophysiology, classifications, natural history, clinical manifestations, radiological features, management, and complications are comprehensively reviewed.
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Chen X, Ge L, Wan H, Huang L, Jiang Y, Lu G, Wang J, Zhang X. Differential subsampling with cartesian ordering: A high spatial-temporal resolution dixon imaging sequence for assessment of dural arteriovenous fistula. Front Neurol 2022; 13:1020749. [PMID: 36330430 PMCID: PMC9622796 DOI: 10.3389/fneur.2022.1020749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/03/2022] [Indexed: 11/27/2022] Open
Abstract
Objective To evaluate the accuracy of differential subsampling with cartesian ordering (DISCO) in comparison to time of flight (TOF) in detecting dural arteriovenous fistulas (DAVF), cerebral venous thrombosis (CVT) and hemodynamics. Methods Sixty-two cases (24 female; aged 14–75; mean age, 51.3 years) were included in our study, with 42 positive and 20 negative cases via Digital Subtraction Angiography (DSA). Two neuroradiologists independently evaluated the DISCO and TOF. The sensitivity, specificity, and accuracy of the DISCO and TOF-MRA were individually calculated using DSA as the gold standard. Inter-observer reliability was assessed by using a weighted Cohen's kappa (κ) test; P < 0.05 was set as the threshold for statistical significance. Results Diagnostic sensitivities of DISCO and TOF for DAVF were 92.86 and 64.29%; specificities were 95.0% and 95.0%; while accuracies were 93.55 and 74.19% respectively. For detected CVT, sensitivities of DISCO and TOF were 100 and 92.31%; specificities were 96.55 and 93.10%; with accuracies 97.62 and 92.86% respectively. In hemodynamic analysis, sensitivity of DISCO for reflux was 95.45%; with a specificity of 95.0%; and accuracy 95.24%. The inter-observer kappa values were 0.857 for DISCO (P < 0.001). Conclusion DISCO showed a high degree of sensitivity and specificity, suggesting its effectiveness in detecting DAVF with or without CVT. Intracranial hemodynamics can be identified using DISCO in DAVF patients, providing accurate evaluation of cerebral blood flow dynamics during the pre-treatment phase.
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Yamaguchi I, Kanematsu Y, Shimada K, Yamamoto N, Miyake K, Miyamoto T, Sogabe S, Shikata E, Ishihara M, Yamamoto Y, Kuroda K, Takagi Y. Single-session hematoma removal and transcortical venous approach for coil embolization of an isolated transverse-sigmoid sinus dural arteriovenous fistula in a hybrid operating room: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2022; 3:CASE2267. [PMID: 35734231 PMCID: PMC9204917 DOI: 10.3171/case2267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 03/02/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Dural arteriovenous fistula (DAVF) can present with massive hematoma, which sometimes requires emergent removal. Therefore, a surgical strategy for single-session hematoma removal and shunt occlusion in the same surgical field is important. OBSERVATIONS A 73-year-old man was transferred to the authors' hospital with a headache. Brain computed tomography (CT) revealed an intracerebral hematoma in the right temporoparietal lobe (hematoma volume 12 ml). A cerebral angiogram revealed a right isolated transverse-sigmoid sinus (TSS)-DAVF fed by the occipital artery and middle meningeal artery. There was cortical venous reflux into the Labbé vein and posterior parietal vein. Percutaneous transarterial and transvenous embolization were unsuccessful. The following day, his consciousness level acutely declined with a headache, and brain CT showed hematoma expansion (hematoma volume 41 ml) with a midline shift. Therefore, the authors performed single-session hematoma removal and a transcortical venous approach for coil embolization of an isolated TSS-DAVF in a hybrid operating room. His postoperative course was uneventful. No recurrence was observed 3 months postoperatively on cerebral angiography. LESSONS Single-session hematoma removal and a transcortical venous approach for coil embolization of an isolated TSS-DAVF is considered in cases with massive hematoma. This strategy is useful, considering recent developments in hybrid operating rooms.
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Affiliation(s)
| | | | | | - Nobuaki Yamamoto
- Neurology, and
- Advanced Brain Research, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
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Sim SY. Pathophysiology and classification of intracranial and spinal dural AVF. J Cerebrovasc Endovasc Neurosurg 2022; 24:203-209. [PMID: 35443276 PMCID: PMC9537653 DOI: 10.7461/jcen.2022.e2021.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 12/13/2021] [Indexed: 11/23/2022] Open
Abstract
Dural arteriovenous fistulas (DAVFs) are pathologic shunts between pachymeningeal arteries and dural venous channel. DAVFs are relatively rare, however, DAVFs can lead to significant morbidity and mortality due to intracranial hemorrhage and non-hemorrhagic neurologic deterioration related to leptomeningeal venous drainage. The etiology and pathophysiology of DAVFs is not fully understood. Several hypotheses for development of DAVF and classifications for predicting risk of hemorrhage and neurological deficit have been proposed to help clinical decision making according to its natural history. Herein, incidence, etiology, pathophysiology of development of intracranial and spinal DAVF including their classifications are briefly described with short historical review.
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Affiliation(s)
- Sook Young Sim
- Department of Neurosurgery, Inje University Ilsan Paik Hospital, Goyang, Korea
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Dural Arteriovenous Malformations. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00070-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Akamatsu Y, Gomez-Paz S, Vergara-Garcia D, Moholkar VM, Kuhn AL, Chida K, Singh J, Rodrigues KDM, Massari F, Moore JM, Puri AS, Ogilvy CS, Thomas AJ. Role of Surgical Intervention for Intracranial Dural Arteriovenous Fistulas With Cortical Venous Drainage in an Endovascular Era: A Case Series. Oper Neurosurg (Hagerstown) 2021; 20:364-372. [PMID: 33378448 DOI: 10.1093/ons/opaa423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 10/09/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Intracranial dural arteriovenous fistulae (dAVFs) with cortical venous drainage (CVD) require treatment because of their aggressive clinical presentation and natural history. Although endovascular treatment is effective for the majority of these lesions in the current endovascular era, surgical management has been required if the lesions are not amenable to or fail endovascular treatments. OBJECTIVE To demonstrate the angioarchitecture that may necessitate surgical intervention. METHODS A retrospective review of the patients with intracranial dAVFs with CVD treated at 2 academic institutions between January 1, 2009, and July 31, 2019 was performed. Patients who required surgical intervention were selected in this study, and angiographic findings were analyzed. RESULTS A total of 81 dAVFs in 80 patients were treated during the study period. Endovascular treatments were attempted for 72 (88.9%) dAVFs, resulting in complete obliteration in 55 (76.4%). Surgical interventions were performed in 18 (22.2%) dAVFs, resulting in complete obliteration in all lesions. Overall, complete obliteration was achieved in 74 (93.7%) of 79 dAVFs with follow-up. In the surgically treated dAVFs, curative transarterial embolization was deterred by the angioarchitecture, which included dominant feeding vessels from the ophthalmic artery, meningohypophyseal trunk, posterior meningeal artery, pial artery, or ascending pharyngeal artery. Drainage through tortuous cortical vein, deep venous system, or isolated sinus made transvenous approach challenging. CONCLUSION Despite continued improvement in endovascular technology, surgical approaches to dAVFs are still of great value as initial and salvage treatment of dAVFs with angioarchitecture hampering endovascular treatment.
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Affiliation(s)
- Yosuke Akamatsu
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Department of Neurosurgery, Iwate Medical University, Yahaba, Japan
| | - Santiago Gomez-Paz
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - David Vergara-Garcia
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Viraj M Moholkar
- Division of Interventional Neuroradiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts
| | - Anna Luisa Kuhn
- Division of Interventional Neuroradiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts
| | - Kohei Chida
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,Department of Neurosurgery, Iwate Medical University, Yahaba, Japan
| | - Jasmeet Singh
- Division of Interventional Neuroradiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts
| | - Katyucia de Macedo Rodrigues
- Division of Interventional Neuroradiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts
| | - Francesco Massari
- Division of Interventional Neuroradiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts
| | - Justin M Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ajit S Puri
- Division of Interventional Neuroradiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ajith J Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Okamoto M, Sugiyama T, Nakayama N, Ushikoshi S, Kazumata K, Osanai T, Tokairin K, Shimoda Y, Houkin K. Microsurgical Findings of Pial Arterial Feeders in Intracranial Dural Arteriovenous Fistulae: A Case Series. Oper Neurosurg (Hagerstown) 2020; 19:691-700. [PMID: 32717026 DOI: 10.1093/ons/opaa218] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 05/03/2020] [Indexed: 12/30/2022] Open
Abstract
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.
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Affiliation(s)
- Michinari Okamoto
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Taku Sugiyama
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Naoki Nakayama
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | | | - Ken Kazumata
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Toshiya Osanai
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kikutaro Tokairin
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Yusuke Shimoda
- Department of Neurosurgery, Hokkaido Medical Center, Sapporo, Japan
| | - Kiyohiro Houkin
- Department of Emergent Neurocognition, Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
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Penailillo E, Bravo-Grau S, Plaza N, Cruz JP. Cerebral Venous Thrombosis: Review of Diagnosis, Follow-Up, Late Complications and Potential Pitfalls. Curr Probl Diagn Radiol 2020; 50:725-733. [PMID: 32950306 DOI: 10.1067/j.cpradiol.2020.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 08/21/2020] [Indexed: 11/22/2022]
Abstract
Cerebral venous thrombosis is a less common but relevant cause of stroke in adults. The clinical manifestations are nonspecific leading frequently diagnostic delays, so imaging findings are is of vital importance. Conventional imaging modalities, namely computed tomography and magnetic resonance imaging (MRI), allow identification of the thrombus and parenchymal involvement due to venous congestion to a variable degree, but this entity may appears as a nonexpected finding in a nonvenographic study. computed tomography and MRI venographies allow noninvasive confirmation of the diagnosis and adequate characterization of the extent of the thrombus and acute complications, both of them being robust diagnostic techniques. MR venography also can be done without the use of contrast media, which is especially important in certain clinical situations. Cerebral venous thrombosis needs follow-up, and imaging plays a key role in detection of late complications of the disease, including dural arteriovenous fistulas and intracranial hypertension due to veno-occlusive disease. Knowledge of other diseases and conditions that may mimic a thrombus is needed to avoid wrong diagnosis. In this article, we conduct a pictorial comprehensive review of cerebral venous thrombosis, including also the technical aspects of different imaging modalities, diagnosis and acute complications, follow-up, late complications and potential imaging mimics.
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Affiliation(s)
- Eduardo Penailillo
- Department of Radiology, Neuroradiology Section, Pontificia Universidad Catolica de Chile, Santiago Region Metropolitana, Chile
| | - Sebastian Bravo-Grau
- Department of Radiology, Neuroradiology Section, Pontificia Universidad Catolica de Chile, Santiago Region Metropolitana, Chile
| | - Nicole Plaza
- Department of Radiology, Neuroradiology Section, Pontificia Universidad Catolica de Chile, Santiago Region Metropolitana, Chile
| | - Juan Pablo Cruz
- Department of Radiology, Neuroradiology Section, Pontificia Universidad Catolica de Chile, Santiago Region Metropolitana, Chile.
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Dural arteriovenous fistula is a rare cause of a pulsating noise in the ear
(clinical observation and literature review). КЛИНИЧЕСКАЯ ПРАКТИКА 2020. [DOI: 10.17816/clinpract35227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The article describes the clinical manifestations of dural arteriovenous fistula, which is an abnormal communication between the arteries of the dura mater and venous sinuses or cortical veins. Information on the etiology and pathogenesis of such malformation in domestic literature is limited to a few publications. Diagnosis is based on the identification of visual (pulsation of the earlobe) and acoustic phenomena in the patient, the presence of neuroimaging, in particular MR angiography, a shunt between the posterior auricular artery (branch of the external carotid artery) and the dural venous sinuses. The best treatment method is neurosurgical intervention using endovascular surgery.
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Priola SM, Ku JC, Pasarikovski CR, Yang VXD, da Costa L. Angio-architecture of complex cranial dural arteriovenous fistulas: A single centre retrospective review of treatment modalities and outcomes. J Clin Neurosci 2020; 76:87-99. [PMID: 32284290 DOI: 10.1016/j.jocn.2020.04.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 04/04/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Cranial dural arteriovenous fistulas (DAVFs) are rare vascular lesions that often harbour complex angio-architectural features. This subtype of DAVF may require multiple, multimodality, or hybrid treatments. In this paper we aim to identify specific angio-architectural features that are present in complex cranial DAVFs and we report our series with respect to treatment modalities and outcomes. METHODS Twenty-five cranial Borden type II and III cranial DAVFs were treated at our Institution from 2013 to 2017. We classified nine (36%) as complex based on specific angio-architectural features. Treatment strategies were based on fistula location, angiographic features and patient's presenting condition. Phone interviews were used to confirm outcome at 6 and 12 months. RESULTS Four patients (45%) presented with acute hydrocephalus, and 3 (33%) with intracranial hemorrhage. Multiple and combined treatment sessions were needed for all complex DAVFs. Five patients required 2 endovascular procedures each. One patient had 2 surgeries. The first line of treatment was endovascular in 6 cases (67%) and surgery in 3 (33%). Two treatment-related (22%) complications occurred. Complete disconnection was achieved in 5 out of 9 patients (55%). Two patients with an incomplete disconnection refused further treatment and were well at last follow up, with a partially treated fistula and persistent CVR. The other 3 patients concluded treatment after the end of our data collection period. At 1 year, 7/9 patients had stable or improved clinical symptoms, and 8/9 patients had GOS of 4 or 5. CONCLUSIONS Complex cranial DAVF often require a multidisciplinary approach and multiple treatment sessions should be expected. Specific angio-architectural features that increase DAVF complexity include multiple arterial feeders, especially transosseous or pial, reflux into multiple cortical veins, sinus occlusion/entrapment, venous aneurysms, segmental stenosis, medial or deep location, and association with the deep venous system.
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Affiliation(s)
- Stefano M Priola
- Health Sciences North, Department of Surgery, Division of Neurosurgery, Northern Ontario School of Medicine, Sudbury (ON), Canada; Sunnybrook Health Sciences Centre, Division of Neurosurgery, University of Toronto, Toronto (ON), Canada.
| | - Jerry C Ku
- Sunnybrook Health Sciences Centre, Division of Neurosurgery, University of Toronto, Toronto (ON), Canada.
| | - Christopher R Pasarikovski
- Sunnybrook Health Sciences Centre, Division of Neurosurgery, University of Toronto, Toronto (ON), Canada.
| | - Victor X D Yang
- Sunnybrook Health Sciences Centre, Division of Neurosurgery, University of Toronto, Toronto (ON), Canada.
| | - Leodante da Costa
- Sunnybrook Health Sciences Centre, Division of Neurosurgery, University of Toronto, Toronto (ON), Canada; Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto (ON), Canada.
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Yang S, You R, Wu W, Wei Z, Hong M, Peng Z. Dural Arteriovenous Fistula Complicated with Cerebral Venous Sinus Thrombosis. World Neurosurg 2020; 134:348-352. [PMID: 31639507 DOI: 10.1016/j.wneu.2019.10.075] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 10/12/2019] [Accepted: 10/13/2019] [Indexed: 11/11/2022]
Abstract
BACKGROUND Cerebral venous sinus thrombosis (CVST) is always confused with dural arteriovenous fistula (DAVF) in clinical practice; however, both of them are very rare cerebral vascular diseases. In this report, we provide one case of DAVF combined with CVST. CASE DESCRIPTION A 75-year-old woman complained of headache with nausea and vomiting for 4 days. Magnetic resonance venography revealed filling defect in the torcular, left transverse, and sigmoid sinus, which strongly suggested sinus thrombosis. The patient underwent anticoagulation treatment for 9 days. However, the manifestation was not alleviated, magnetic resonance imaging detected the lesion was enlarged, and the midline shifted to the left. Digital subtraction angiography examination detected that one fistula classified as Borden type IA was fed by the left superficial temporal artery and drained into the left transverse and sigmoid sinus. Endovascular embolization with ethylene vinyl alcohol was conducted. CONCLUSIONS Follow-up at 6 months indicated that the patient recovered without any sequelae.
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Affiliation(s)
- Sujuan Yang
- Department of Neurology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, China
| | - Rongjiao You
- Department of Neurology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, China
| | - Weifeng Wu
- Department of Neurology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, China
| | - Zhisheng Wei
- Department of Neurology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, China
| | - Mingfan Hong
- Department of Neurology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, China
| | - Zhongxing Peng
- Department of Neurology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, China.
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Complication rate, cure rate, and long-term outcomes of microsurgery for intracranial dural arteriovenous fistulae: a multicenter series and systematic review. Neurosurg Rev 2020; 44:435-450. [PMID: 31897884 DOI: 10.1007/s10143-019-01232-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 11/17/2019] [Accepted: 12/26/2019] [Indexed: 10/25/2022]
Abstract
Although microsurgery is an established treatment modality for intracranial dural arteriovenous fistula (dAVF), data regarding the perioperative complication rate, cure rate, and long-term outcomes remain scarce. The aims of this study were to describe our original experience with microsurgery, including the surgical complications and pitfalls, and conduct a systematic review of the relevant literature. A multicenter cohort of patients with dAVF treated by microsurgery was retrospectively assessed. In addition, the PubMed database was searched for published studies involving microsurgery for dAVF, and the complication rate, cure rate, and long-term outcomes were estimated. The total number of patients in our multicenter series and published articles was 553 (593 surgeries). The overall rates of transient complications, permanent complications, death, and incomplete treatment were 11.4, 4.0, 1.2, and 6.5%, respectively. A favorable outcome was achieved for 90.1% patients, even though almost half of the patients presented with intracranial hemorrhage. Of note, the incidence of recurrence was only one per 8241 patient-months of postoperative follow-up. Surgeries for anterior cranial fossa dAVF were associated with a lower complication rate, whereas those for tentorial dAVF were associated with higher complication and incomplete treatment rates. The complication and incomplete treatment rates were lower with simple disconnection of cortical venous drainage than with radical occlusion/resection of dural shunts. Our findings suggest that the cure rate, complication rates, and outcomes of microsurgery for dAVF are acceptable; thus, it could be a feasible second-line treatment option for dAVF. However, surgeons should be aware of the specific adverse events of microsurgery.
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Impact of transvenous embolization via superior ophthalmic vein on reducing the total number of coils used for patients with cavernous sinus dural arteriovenous fistula. Neurosurg Rev 2019; 44:401-409. [PMID: 31872315 DOI: 10.1007/s10143-019-01227-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 12/05/2019] [Accepted: 12/11/2019] [Indexed: 10/25/2022]
Abstract
Although transvenous embolization (TVE) via the superior ophthalmic vein (SOV) is adopted in treating cavernous sinus dural arteriovenous fistula (CS DAVF), its effect on the coil volume is rarely understood. The purpose of the study was to investigate if there is a difference in the total number of coils used and in patient safety when comparing two access strategies. We retrospectively reviewed charts for patients with CS DAVF treated with TVE between January 2008 and March 2018. The baseline patient characteristics, details of procedure, placed coils, and clinical results were compared. A total of 42 patients with CS DAVF were treated with the inferior petrosal sinus (IPS) (n = 32) or SOV (n = 10) approach. TVE via SOV showed a high success rate of 100% (10/10) by transfemoral access. The total number (23 versus 11; P < 0.001), length (159 versus 81 cm; P = 0.003), and volume of placed coils (111 versus 46 mm3; P = 0.005) were significantly lower in patients treated via SOV. Patients treated via SOV had significantly higher initial intrasinus pressure (49 versus 59 mmHg; P = 0.022) obtained by microcatheters; however, no adverse events occurred related to elevated sinus pressure between both approaches. Procedural complications and cranial nerve palsy outcomes were not significantly different. In cases with a visualized pathway to the SOV, this approach should be preferred, in all other cases standard approach via the IPS should be used, even if it cannot be visualized.
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16
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Détraz L, Orlov K, Berestov V, Borodetsky V, Rouchaud A, de Abreu Mattos LG, Mounayer C. Posterior Fossa Dural Arteriovenous Fistulas with Subarachnoid Venous Drainage: Outcomes of Endovascular Treatment. AJNR Am J Neuroradiol 2019; 40:1363-1368. [PMID: 31371356 DOI: 10.3174/ajnr.a6140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 06/19/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Dural AVFs located in the posterior fossa are a rare entity. The objectives of the study were to analyze the anatomy of dural AVFs, their endovascular treatment strategies, and clinical outcomes. MATERIALS AND METHODS Two centers retrospectively selected patients treated between January 2009 and June 2018 having posterior fossa dural AVFs. We collected patient demographics, clinical presentation, arterial and venous outflow anatomy of the dural AVFs, and treatment outcomes. RESULTS Twenty-six patients treated endovascularly for posterior fossa dural AVFs, type III, IV, or V, were included. One hundred percent of the dural AVFs were occluded. A transarterial approach was performed in 23 dural AVFs (88.5%); a combined transarterial and transvenous approach, for 2 dural AVFs (7.7%); and a transvenous approach alone, for 1 dural AVF (3.8%). The middle meningeal artery was the most common artery chosen to inject embolic liquid (46%, 12/26). Procedure-related morbidity was 15.4% at 24 hours, 7.7% at discharge, and 0% at 6 months. Procedure-related mortality was 0%. CONCLUSIONS Endovascular treatment offers high occlusion rates for posterior fossa dural AVFs with low morbidity and mortality rates. The arterial approach is the first-line preferred approach, even if a transvenous or combined approach would be a safe and effective option for patients with favorable anatomy.
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Affiliation(s)
- L Détraz
- From the Service de Neuroradiologie Interventionnelle et Diagnostique (L.D.), Centre Hospitalier Universitaire de Nantes-Hopital Laennec, Saint-Herblain, France
| | - K Orlov
- Department of Neurosurgery (K.O., V. Berestov), E. Meshalkin National Medical Research Center of the Ministry of Health of the Russian Federation, Novosibirsk, Russia
| | - V Berestov
- Department of Neurosurgery (K.O., V. Berestov), E. Meshalkin National Medical Research Center of the Ministry of Health of the Russian Federation, Novosibirsk, Russia
| | - V Borodetsky
- Service de Radiologie (V. Borodetsky, A.R.. L.G.d.A.M., C.M.), Neuroradiologie Interventionnelle, Centre Hospitalier Universitaire de Limoges, Limoges, France
| | - A Rouchaud
- Service de Radiologie (V. Borodetsky, A.R.. L.G.d.A.M., C.M.), Neuroradiologie Interventionnelle, Centre Hospitalier Universitaire de Limoges, Limoges, France.,CNRS (A.R., C.M.), XLIM, UMR 7252, University of Limoges, Limoges, France
| | - L G de Abreu Mattos
- Service de Radiologie (V. Borodetsky, A.R.. L.G.d.A.M., C.M.), Neuroradiologie Interventionnelle, Centre Hospitalier Universitaire de Limoges, Limoges, France
| | - C Mounayer
- Service de Radiologie (V. Borodetsky, A.R.. L.G.d.A.M., C.M.), Neuroradiologie Interventionnelle, Centre Hospitalier Universitaire de Limoges, Limoges, France.,CNRS (A.R., C.M.), XLIM, UMR 7252, University of Limoges, Limoges, France
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17
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Polster SP, Zeineddine HA, Baron J, Lee SK, Awad IA. Patients with cranial dural arteriovenous fistulas may benefit from expanded hypercoagulability and cancer screening. J Neurosurg 2018; 129:954-960. [DOI: 10.3171/2017.5.jns17788] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVECranial dural arteriovenous fistulas (DAVFs) have been associated with dural sinus occlusion, and previous reports have suggested the association of hypercoagulability with some cases. But the prevalence of a hypercoagulable state has not been systematically analyzed in conjunction with laboratory markers and clinical manifestations, including history of thromboembolism or systemic malignancy. The authors hypothesize that laboratory or clinical evidence of a hypercoagulable state, including cancer, is commonly identifiable in consecutively identified patients with DAVFs, with implications for clinical management.METHODSThe retrospective cohort study included all patients older than 17 years with cranial DAVFs diagnosed at University of Chicago Medicine during a 6-year period, whose medical records and imaging results were reviewed for objective laboratory or clinical evidence of a hypercoagulable state, including malignancy. Each case was analyzed for implications on clinical management. Data were analyzed in relation to a systematic review of the literature on this association.RESULTSFifteen (88%) of 17 cases of DAVFs had laboratory (n = 8) or clinical evidence of a hypercoagulable state (thromboembolism [n = 8] or cancer [n = 6]). This hypercoagulability or cancer impacted clinical care in all 15 cases.CONCLUSIONSAn underlying hypercoagulable state manifested by laboratory testing or clinically, including cancer, is staggeringly common. It is important to recognize this association, along with its impact on the management of the DAVFs and systemic diseases.
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Affiliation(s)
| | | | - Joseph Baron
- 2Department of Medicine, Section of Hematology and Oncology, and
| | - Seon-Kyu Lee
- 1Department of Surgery, Section of Neurosurgery,
- 3Department of Radiology, Section of Neuroradiology, University of Chicago Medicine, Chicago, Illinois
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18
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Leslie-Mazwi T, Chandra RV, Fraser JF, Hoh B, Baxter BW, Albuquerque FC, Hirsch JA. AHA/ASA 2018 AIS guidelines: impact and opportunity for endovascular stroke care. J Neurointerv Surg 2018; 10:813-817. [PMID: 29807886 DOI: 10.1136/neurintsurg-2018-013911] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2018] [Indexed: 11/04/2022]
Affiliation(s)
- Thabele Leslie-Mazwi
- Departments of Neurosurgery and Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ronil V Chandra
- Department of Radiology, Monash University, Melbourne, Victoria, Australia
| | - Justin F Fraser
- Departments of Neurological Surgery, Neurology, Radiology, and Neuroscience, University of Kentucky, Lexington, Kentucky, USA
| | - Brian Hoh
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Blaise W Baxter
- Tennessee Interventional & Imaging Associates/Erlanger, Chattanooga, Tennessee, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
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Tanaka J, Fujita A, Ishii T, Kohmura E. Importance of source images of time-of-flight magnetic resonance angiography in the diagnosis of low-flow dural arteriovenous fistulae after traumatic brain injury. BMJ Case Rep 2018; 2018:bcr-2017-223512. [PMID: 29572366 DOI: 10.1136/bcr-2017-223512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Three-dimensional time-of-flight (TOF) magnetic resonance angiography (MRA) can reliably detect dural arteriovenous fistula (dAVF); however, TOF source images should be checked in cases with low-flow dAVFs. A 69-year-old woman reported intractable pulsatile tinnitus after head trauma. It was difficult to diagnose dAVF using conventional MRA, but it was confirmed using a TOF source image. Cerebral angiography revealed a dAVF with a small shunted pouch draining into the sigmoid sinus, accompanying the arterial jet flow. Transarterial embolisation of the shunted pouch completely obliterated the dAVF. The patient's tinnitus immediately disappeared after embolisation. This case suggests that a low-flow Borden type I dAVF is undetectable using conventional MRA, and we emphasise the importance of evaluating TOF source images. Transarterial embolisation of the shunted pouch while preserving the normal sinus flow was safe and effective.
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Affiliation(s)
- Jun Tanaka
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Atsushi Fujita
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Taiji Ishii
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Eiji Kohmura
- Department of Neurosurgery, Kobe University Graduate School of Medicine, Kobe, Japan
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20
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Distally Enlarged Feeding Artery Phenomenon in Intracranial Dural Arteriovenous Fistula: Alternative Access Route to Transarterial Intravenous Embolization. World Neurosurg 2017; 108:447-452. [DOI: 10.1016/j.wneu.2017.09.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 09/04/2017] [Accepted: 09/05/2017] [Indexed: 11/18/2022]
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21
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Koyanagi M, Kobayashi T, Oda M, Narumi O. Dural arteriovenous fistula in the falx cerebri treated with transarterial embolization using n-butyl cyanoacrylate. Surg Neurol Int 2017; 7:S1057-S1059. [PMID: 28144483 PMCID: PMC5234292 DOI: 10.4103/2152-7806.196371] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 07/26/2016] [Indexed: 11/09/2022] Open
Abstract
Background: A dural arteriovenous fistula in the falx cerebri is a relatively rare lesion, with only two cases reported till date. One was treated with direct surgery, and the other was followed-up conservatively. Advances in catheter design and embolic materials have made safe and curative transarterial embolization of dural arteriovenous fistulas possible in the current era. Case Description: We describe a 67-year-old man with left putaminal hemorrhage who was diagnosed with an arteriovenous fistula in the anterior part of the falx cerebri that was treated with curative transarterial glue embolization through the middle meningeal artery by using n-butyl cyanoacrylate. Conclusion: Although the procedure was safely performed, understanding the potential risks of the migration of embolic materials into the ophthalmic and anterior cerebral artery system is mandatory.
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Affiliation(s)
- Masaomi Koyanagi
- Department of Neurosurgery, National Hospital Organization Himeji Medical Center, Himeji, Hyogo, Japan
| | - Tamaki Kobayashi
- Department of Neurosurgery, National Hospital Organization Himeji Medical Center, Himeji, Hyogo, Japan
| | - Masashi Oda
- Department of Neurosurgery, National Hospital Organization Himeji Medical Center, Himeji, Hyogo, Japan
| | - Osamu Narumi
- Department of Neurosurgery, National Hospital Organization Himeji Medical Center, Himeji, Hyogo, Japan
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Tsai LK, Liu HM, Jeng JS. Diagnosis and management of intracranial dural arteriovenous fistulas. Expert Rev Neurother 2016; 16:307-18. [PMID: 26832225 DOI: 10.1586/14737175.2016.1149063] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Dural arteriovenous fistula (DAVF) is a rare type of acquired intracranial vascular malformation. Recent progress in neuroimaging technology, such as advanced MRI and CT, provides non-invasive methods to accurately diagnose DAVF, including evaluation of the hemodynamics of the drainage veins. The clinical manifestations of DAVFs vary widely and depend on the location and venous drainage pattern of arteriovenous shunting. Patients with high grade DAVFs having cortical venous reflux should receive aggressive treatment to prevent the occurrence of intracranial hemorrhage and other neurological deficits related to venous congestion. Intra-arterial or intravenous endovascular embolization remains the primary therapy for high grade DAVF, while open surgery and stereotactic radiosurgery can serve as alternative treatment options. Early and accurate diagnosis with appropriate treatment is the goal for clinical management of DAVFs to reduce symptoms and prevent the development of venous congestion and stroke.
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Affiliation(s)
- Li-Kai Tsai
- a Department of Neurology and Stroke Center , National Taiwan University Hospital , Taipei , Taiwan
| | - Hon-Man Liu
- b Department of Medical Imaging , National Taiwan University Hospital , Taipei , Taiwan
| | - Jiann-Shing Jeng
- a Department of Neurology and Stroke Center , National Taiwan University Hospital , Taipei , Taiwan
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