De Novo dural arteriovenous fistulas after endovascular treatment: Case illustration and literature review

Abstract

Intracranial dural arteriovenous fistulas (dAVF) account for nearly 10-15% of all arteriovenous malformations. Although the majority of dAVF are effectively cured after endovascular intervention, there are cases of dAVFs that may recur after radiographic cure. We present the case of a 69-year-old female with de novo formation of three dAVFs in different anatomic locations after successive endovascular treatments. The patient's initial dAVF was identified in the right posterior frontal convexity region and obliterated with transarterial and transvenous embolization. The patient returned eight years later due to left-sided pulsatile tinnitus and a new dAVF in the left greater sphenoid wing region was seen on angiography. This was treated with transvenous embolization with complete resolution. One year later, she developed left sided pulsatile tinnitus again and was found to have a left carotid-cavernous dAVF. This is the first case report to our knowledge of the formation of three de novo dAVFs over multiple years in distinct anatomical locations. We also review the literature regarding de novo dAVFs after endovascular treatment which includes 16 cases. De novo dAVF formation is likely due to numerous factors including changes in venous flow and aberrant vascular development. It is important to further understand the relationship between endovascular treatment and recurrent dAVF formation to prevent subsequent malformations.

Keywords: de novo formation; dural arteriovenous fistula; endovascular treatment; liquid embolic.

Figure 1.

Right internal maxillary angiogram demonstrated extensive dural arteriovenous shunting in posterior frontal convexity with venous drainage both lateral through a right diploic vein to the right middle cranial fossa and pterygoid plexus to the right jugular fossa and mesial to the superior sagittal sinus, out of the transverse sinus, to the right jugular fossa (A: lateral view; B: anterior-posterior view). Left internal maxillary angiogram demonstrated trans-osseous feeders to the diploic veins and scalp racemose network with venous drainage into the superior sagittal sinus (C: Lateral view; D: Anterior-posterior view). Right internal maxillary angiogram (E: Lateral view; F: Anterior-posterior view) after two-staged transarterial and transvenous embolization revealed complete obliteration of the dural arteriovenous fistula. Left internal maxillary angiogram after transvenous embolization demonstrated complete obliteration of residual scalp dural arteriovenous fistula (G: Lateral view; H: Anterior-posterior view).

Figure 2.

Left internal maxillary angiogram revealed a new dural arteriovenous fistula in the left greater sphenoid wing and venous drainage through a dilated diploic vein to both the superior sagittal sinus and pterygoid plexus (A: lateral view; B: anterior-posterior view). Left external carotid angiogram demonstrated complete obliteration of arteriovenous shunting (C: Lateral view; D: Anterior-posterior view).

Figure 3.

Left external carotid artery angiogram demonstrated de novo extensive carotid-cavernous dAVF with additional drainage through multiple tributaries to the internal jugular vein. (A: Lateral view; B: Anterior-posterior view).