Multiple dural arteriovenous fistulas. Radiologic progression and endovascular cure. Case report

Abstract

Dural arteriovenous fistulas are most probably acquired lesions. However, they have been rarely encountered de novo.We present a unique case of a 71-year-old woman who initially presented with right-sided dural arteriovenous fistula (DAVF), which spontaneously resolved after diagnostic arteriography. She later developed asymptomatic occlusion of the left transverse sinus. Five years after her initial presentation she developed left-sided pulse-synchronous tinnitus. MRA and catheter angiography showed a complex type IV DAVF between the left transverse sinus and multiple dural branches arising from both left and right external carotid arteries. The left transverse sinus was isolated from the torcula herophili, with stenosis of the sigmoid sinus. Extensive cortical venous drainage was demonstrated. Endovascular cure was effected by polyvinyl alcohol particle and absolute alcohol occlusion of the dominant dural supply, and transvenous coil occlusion of the left transverse sinus. The patient's symptoms resolved almost immediately. This unique case demonstrates that dural sinus occlusion and DAVFs may co-exist, but there may not be a causal relationship. It is likely that both DAVFs and sinus occlusion are manifestations of the same disease process characterised by a pro-thrombotic state and secondary angiogenesis. It is important to recognise that changes in symptomatology, even long after apparent disappearance of a lesion may indicate recurrence, and careful follow up is advocated.

Figure 1

2D time of flight magnetic resonance angiography at initial presentation demonstrates abnormal proliferation of vessels around the right jugular bulb. Note patency of all the major venous sinuses.

Figure 2

A,B) Right common carotid angiography, mid-arterial phase. (A) Antero-posterior and (B) lateral projection. A type I dural arteriovenous shunt is demonstrated. There is hypertrophy of the occipital artery which supplies a raphe of smaller vessels which subsequently drain into the internal jugular vein (arrows). C) Right common carotid angiography, venous phase, Towne's projection. All the major venous sinuses are patent, although the right transverse sinus is dominant.

Figure 3

MR venogram performed 8 months after resolution of symptoms reveals occlusion of the left transverse sinus. There is no pathological vascular proliferation.

Figure 4

2D time of flight magnetic resonance angiography at re-presentation in february 2001 demonstrates proliferation of vessels around the left transverse-sigmoid junction. MRV demonstrated occlusion of the left transverse sinus. Axial source images confirmed patency of the mid left transverse sinus.

Figure 5

A) Right external carotid arteriography, late arterial phase, Towne's projection. There are shunts between the branches of the right occipital artery and the medial left transverse sinus. Cortical venous drainage is demonstrated due to restriction of exocranial venous outflow caused by the narrowed sinus. B) Left external carotid arteriogram, late arterial phase, lateral projection. There is shunting between branches of the occipital, middle meningeal and posterior auricular artery to the mid left transverse sinus. A small flow-related aneurysm is demonstrated in relation to the anterior division of the middle meningeal artery. C) Left vertebral angiogram, early arterial phase, lateral projection. Multiple meningeal branches from the vertebrobasilar system show shunting into a small parallel venous channel, which drains into the distal left transverse sinus.

Figure 6

Retrograde transvenous approach to the left transverse sinus allowed passage of a microcatheter into the venous pouch demonstrated in fig 5A. Extensive cortical venous drainage is demonstrated.

Figure 7

A) Right and (B) left external carotid arteriogram after polyvinyl alcohol (PVA) and absolute alcohol injection of the occipital arteries.

Figure 8

Final angiography after occlusion of the left transverse sinus by coils. A) Right common carotid injection, lateral projection. B) Left common carotid injection, lateral projection. C) Left vertebral artery injection, lateral projection. There is no filling of the dural sinus fistula and normal venous drainage of the cerebral hemispheres.