Facial palsy after embolization of dural arteriovenous fistula: A case report and literature review

Abstract

Background: Dural arteriovenous fistulas (DAVF) are unusual intracranial vascular malformations consisting of anomalous connections between meningeal arteries and dural sinuses or the veins that pass through them. They have variable clinical presentation and prognosis, which depend on their location and venous hemodynamics. Treatment is based on the closure of the abnormal connections, which is usually conducted via arterial and/or transvenous endovascular techniques.

Case description: We present a male patient who complained of headaches and left-sided pulsatile tinnitus due to DAVF from the external carotid artery branches draining directly into the ipsilateral sigmoid sinus. Embolization with Onyx^® was successful, obtaining angiographic occlusion and symptom remission. However, on postoperative day 4, the patient presented with left facial palsy and spontaneous regression.

Conclusion: Although embolization is an effective and safe procedure, complications may occur. Reflux of the embolic agent to the vasa nervorum of the cranial nerve may lead to ischemic neuropathy. Here, we reported a case of embolized DAVF presenting with a postoperative peripheral facial palsy where the two embolized pedicles were branches of the middle meningeal and occipital arteries involved in the vascularization of the extratemporal segment of the facial nerve. We discuss the etiopathogenic, anatomical, and pathophysiological aspects of this complication.

Keywords: Arteriovenous fistula; central nervous system vascular malformations; facial paralysis; intracranial arteriovenous malformations; therapeutic embolization; vasa nervorum.

Figure 1

DSA profile view showing FAVD supplied by branches of the LECA and direct drainage into the sigmoid sinus

Figure 2

Unsuccessfully attempt of embolization through transvenous approach due to left sigmoid sinus isolated

Figure 3

(a) Selective micro catheterization of the left occipital artery showing the fistulous point. (b) Final control of the first session, after embolization of the left occipital artery

Figure 4

(a) Selective micro catheterization of the left middle meningeal artery showing the fistulous point. (b) Final control of the second session, after embolization of the left middle meningeal artery

Figure 5

DSA final control, showing complete closure of FAVD by Onyx

Figure 6

Left peripheral facial palsy House-Brackmann grade 4 on the first postoperative day

Figure 7

Computed tomography image (axial view) showing large amount of artifact corresponding to Onyx in the embolized vessels in close proximity to the facial nerve route (opacities at the left side)

Figure 8

Spontaneous resolution of peripheral facial paralysis after 4 days of embolization