Clinical and angiographic characteristics of multiple dural arteriovenous shunts

Abstract

Background and purpose: The pathogenesis and characteristics of multiple DAVSs are not well-known. The purpose of this study was to evaluate the angiographic and clinical characteristics of patients with multiple DAVSs with an emphasis on the pathomechanism.

Materials and methods: One hundred seventy-nine patients with DAVS were reviewed. Patients with ≥ 2 fistulas at anatomically separate sites were included. Multiple DAVSs were categorized into synchronous (simultaneous multiplicity) or metachronous (temporal sequential development of multiplicity) types. The angiographic and clinical characteristics of these lesions were analyzed.

Results: Fourteen patients were diagnosed with multiple DAVSs (7.8%; synchronous, n = 7; metachronous, n = 7). Thirteen of the 14 patients showed CVR (93%, Borden type II/III). Multiple DAVSs were frequently associated with dural sinus thrombosis (71.4%, n = 10). Synchronous DAVSs developed in association with an occluded sinus (n = 5). De novo metachronous lesions developed in association with thrombosis of a previously patent dural sinus (n = 3) or reopening of an occluded sinus (n = 2). Multiplicity was associated with aggressive initial symptoms in 64.3% (n = 9). The newly developed lesions in the metachronous types were accompanied by hemorrhage (n = 1), neurologic deficit (n = 1), worsening of the initial benign symptoms (n = 2), and incidental detection (n = 3). The mean time interval between the initial diagnosis and de novo lesion detection was 31.3 ± 29.8 months (range, 12-92 months).

Conclusions: Multiplicity of DAVSs is associated with poor angiographic and clinical prognosis, requiring an aggressive treatment and management strategy. Sinus thrombosis has a prominent role in the pathomechanism of DAVSs.

Fig 1.

Summary of the temporal sequence of de novo metachronous DAVS development in relation to sinus thrombosis.

Fig 2.

Case 8. A, Initial left external carotid artery (ECA) lateral and left ICA anteroposterior (AP) delayed phase angiograms. Cavernous DAVS (large arrow) is seen with occlusion of the left sigmoid sinus (small arrows). Transarterial embolization of the cavernous DAVS with polyvinyl alcohol particles was performed, resulting in complete occlusion. B, The patient presented with hemorrhage 17 months later. Follow-up left ECA lateral and left ICA AP delayed phase angiograms show de novo DAVS development at the previously occluded left sigmoid sinus (large arrow), with recanalization of this segment of the sinus. Upstream thrombosis of previously patent left proximal transverse sinus (small arrows) is seen, resulting in isolation of the de novo shunt.