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Treffy RW, Hussain O, Arocho-Quinones EV, Hedayat HS. Treatment of a Pial Arterial Venous Fistula in a Newborn: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2024; 27:260-261. [PMID: 38391205 DOI: 10.1227/ons.0000000000001108] [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: 09/08/2023] [Accepted: 01/08/2024] [Indexed: 02/24/2024] Open
Abstract
Pial arterial venous fistulas (PAVFs) are rare vascular entities that occur with direct high-flow connections between pial arterial feeders and large veins without an intervening nidus.
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These vascular abnormalities can present in the pediatric population with high output heart failure.
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PAVFs can be treated with endovascular intervention, microvascular ligation, or a combination depending on the clinical scenario.
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Here, we present a case in which a newborn presented in high output heart failure because of a large left-sided middle cerebral artery fed PAVF. We performed a craniotomy for ligation of the PAVF to obliterate the arteriovenous shunting to improve her cardiac status and diminish her intracranial venous hypertension. Throughout the ligation, we used indocyanine green to localize the next appropriate vessels to ligate, allowing us to safely obliterate the anomalous vasculature and improve the patient's cardiac function. Postoperatively, the patient did well neurologically with improvements in cardiac function and near normalization of intracranial vasculature.
The patient's guardians consented to the procedure and to the publication of her image.
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Affiliation(s)
- Randall W Treffy
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee , Wisconsin , USA ; Department of Neurosurgery, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
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Fry L, Brake A, Lei C, Stefano FAD, Bhargav AG, Peterson J, Ebersole K. Curative transvenous embolization for congenital multi-hole pial arteriovenous fistula. J Cerebrovasc Endovasc Neurosurg 2024; 26:85-96. [PMID: 37339755 PMCID: PMC10995468 DOI: 10.7461/jcen.2023.e2022.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 03/15/2023] [Accepted: 04/13/2023] [Indexed: 06/22/2023] Open
Abstract
OBJECTIVE Congenital intracranial pial arteriovenous fistula (PAVF) is a rare cerebral vascular pathology characterized by a direct shunt between one or more pial feeding arteries and a cortical draining vein. Transarterial endovascular embolization (TAE) is widely considered first line therapy. Curative TAE may not be achievable in the multihole variant due to the potential to harbor innumerable small feeding arteries. Transvenous embolization (TVE) may be considered to target the final common outlet of the lesion. Here, we present a series of four patients with complex multi-hole congenital PAVF treated with staged TAE followed by TVE. METHODS A retrospective review was conducted on patients who underwent treatment for congenital, multi-hole PAVFs treated by a combined TAE/TVE approach at our institution since 2013. RESULTS We identified four patients with multi-hole PAVF treated by a combined TAE/TVE. Median age was 5.2 (0-14.7) years. Median follow-up of 8 (1-15) months by catheter angiography and 38 (23-53) months by MRI/MRA was obtained. TVE achieved complete occlusion in three patients that proved durable on radiographic follow-up and demonstrated excellent clinical outcomes with a modified Rankin Score (mRS) of 0 or 1. Complete occlusion of the draining vein was not achieved by TVE in one case. This patient is graded as pediatric mRS=5 three years post-procedure. CONCLUSIONS With thorough technical considerations, our series indicates that TVE of multi-hole PAVF that are refractory to TAE is feasible and effective in arresting the consequences of chronic, high-flow AV shunting produced by this pathology.
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Affiliation(s)
- Lane Fry
- The University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Aaron Brake
- The University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Catherine Lei
- The University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Frank A. De Stefano
- Department of Neurological Surgery, University of Kansas, Kansas City, Kansas, USA
| | - Adip G. Bhargav
- Department of Neurological Surgery, University of Kansas, Kansas City, Kansas, USA
| | - Jeremy Peterson
- Department of Neurological Surgery, University of Kansas, Kansas City, Kansas, USA
| | - Koji Ebersole
- Department of Neurological Surgery, University of Kansas, Kansas City, Kansas, USA
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Zhou Z, Yu J. Embolization of cerebellar pial arteriovenous fistula presented with congestive edema of the brainstem and cervical cord. Neuroradiol J 2023:19714009231224421. [PMID: 38135276 DOI: 10.1177/19714009231224421] [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: 12/24/2023] Open
Abstract
Cerebellar pial arteriovenous fistula (PAVF) in adults presenting with congestive edema of the brainstem and cervical cord has rarely been reported. Here, we report such a case. A 59-year-old man presented with progressive weakness and numbness of the limbs and hiccups for 6 months. On physical examination, his limbs had grade III muscle strength, and he was unable to stand or walk. He also had occasional incontinence and retention. There was a positive Babinski sign in both lower limbs. Below the neck, he had hypoesthesia of the skin. Magnetic resonance imaging (MRI) showed edema of the brainstem and upper cervical cord. Digital subtraction angiography (DSA) confirmed there was a cerebellar nongalenic-type PAVF lesion; the feeding arteries were the branches of the posterior inferior cerebellar artery (PICA); and the draining vein was a single cortical vein that ultimately entered the venous systems of the brainstem and upper cervical cord. Casting Onyx-18 via the PICA obliterated the PAVF. Postoperatively, the patient recovered gradually. Two and a half months later, he could walk using a crutch and had no incontinence. Six-month follow-up MRI and DSA revealed recession of the edema of the brainstem and cervical cord and no recurrence of this PAVF. One year later, he was nearly normal. In conclusion and extremely rarely, cerebellar nongalenic-type PAVF can present with congestive edema of the brainstem and high cervical cord. This treatment by Onyx-18 embolization can resolve PAVF.
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Affiliation(s)
- Zibo Zhou
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
| | - Jinlu Yu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
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Lim J, Kuo CC, Waqas M, Cappuzzo JM, Monteiro A, Baig AA, Snyder KV, Davies JM, Levy EI, Siddiqui AH. A Systematic Review of Non-Galenic Pial Arteriovenous Fistulas. World Neurosurg 2023; 170:226-235.e3. [PMID: 36087909 DOI: 10.1016/j.wneu.2022.09.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 09/02/2022] [Accepted: 09/03/2022] [Indexed: 10/14/2022]
Abstract
OBJECTIVE Non-galenic pial arteriovenous fistulas (NGPAVFs) are rare cerebrovascular pathologies accounting for only 1.6%-4.8% of all brain vascular malformations. We performed a comprehensive review of NGPAVF cases reported in the literature to further characterize their clinical patterns of presentation, angiographic features, management, clinical outcomes, and complications. METHODS We searched PubMed, Google Scholar, and Embase from each database's earliest records to April 2022 for all relevant English language articles. A total of 3280 articles were screened to identify those that met prespecified inclusion criteria. Differences in clinical outcomes between children (≤18 years old) and adults (>18 years old) and those articles in which NGPAVFs were associated with the presence of a varix or a hemorrhage were statistically examined. RESULTS A total of 242 patients in 86 articles were included. The mean patient age was 18.51 ± 18.80 years. The male-to-female ratio was 1.44:1. Headache was the most common initial presentation (42.6%) in the study cohort. Hemorrhage occurred at a significantly higher frequency in adults (P = 0.004), whereas more children presented with congestive heart failure (P < 0.001). Surgical, endovascular, and combination therapy led to comparable rates of complete NGPAVF obliteration (86.8%, 85.2%, and 88.5%, respectively). Fifty-nine patients (24.4%) experienced a complication, ranging from minor neurological deficit to severe hemorrhage. The mortality rate for the overall cohort was 3.3%, and all deceased patients had a varix associated with their fistulas. CONCLUSIONS To our knowledge, we report the largest literature review describing the clinical course and characteristics of NGPAVFs. All treatment approaches resulted in favorable obliteration rates and overall patient outcomes.
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Affiliation(s)
- Jaims Lim
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Cathleen C Kuo
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Justin M Cappuzzo
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Andre Monteiro
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Ammad A Baig
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Kenneth V Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA; Jacobs Institute, Buffalo, New York, USA
| | - Jason M Davies
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA; Jacobs Institute, Buffalo, New York, USA; Department of Bioinformatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA; Jacobs Institute, Buffalo, New York, USA; Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo New York, USA; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA; Jacobs Institute, Buffalo, New York, USA; Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.
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