A new subtype of intracranial dural AVF according to the patterns of venous drainage

Case report: A choroidal fissure pial arteriovenous malformation inducing venous congestive edema of the medulla oblongata and cervicothoracic spinal cord presented with proximal arm predominant weakness

Intracranial dural arteriovenous fistula (DAVF) can induce remote myelopathy via spinal perimedullary venous drainage. In the present study, we report a rare case of intracranial pial arteriovenous malformation (AVM)-related myelopathy. A 52-year-old man presented with progressive, predominantly proximal weakness and muscle atrophy in bilateral upper limbs, urinary retention, and hyperreflexia in bilateral upper and lower limbs. Brain and cervicothoracic MRI showed longitudinal myelopathy extending from the medulla oblongata to the T6 level, with perimedullary enlarged veins from the C1 to T12 level, and remarkable enhancement in bilateral anterior horns from the C2 to C7 level. Cerebral angiography revealed a choroidal fissure AVM, which was supplied by the left anterior choroidal artery and drained exclusively by an inferior ventricular vein descending toward the spinal perimedullary veins. After endovascular embolization of the feeding pedicle, nidus, and proximal segment of the draining vein, the patient's neurological deficits rapidly improved, and a significant recovery was achieved 3 months after the procedure. This rare case indicates that intracranial pial AVM can also cause extensive congestive myelopathy with similar mechanisms underlying intracranial and craniocervical DAVF cases, and gray matter in the spinal cord might be more susceptible to ischemia induced by intraspinal venous hypertension.

UPDATE ON MANAGEMENT OF DURAL ARTERIOVENOUS FISTULAS

Dural Arteriovenous Fistulas (AVF) represent about 10% of all intracranial vascular lesions. Although they seem benign in nature, the presence of retrograde venous makes them aggressive, with a high risk of complications. Patients may be clinically asymptomatic or experience symptoms ranging from mild to severe hemorrhage, depending on their location. Different treatments are available, but recently, the development of catheter intervention allows most patients to be cured with transcatheter embolization. Stereotactic radiosurgery achieves excellent rates of obliteration for low-grade lesions. In this review, we try to highlight the recent advances in the management of dural AVF.