Management and Outcome of Intracranial Dural Arteriovenous Fistulas That Have Caused a Hemorrhage in the Posterior Fossa : A Clinical Study

Abstract

Objective: We evaluated the diagnosis, treatment, and long-term results of patients with dural arteriovenous fistula (dAVF), which is a very rare cause of posterior fossa hemorrhage.

Methods: This study included 15 patients who underwent endovascular, surgical, combined, or Gamma Knife treatments between 2012 and 2020. Demographics and clinical features, angiographic features, treatment modalities, and outcomes were analyzed.

Results: The mean age of the patients was 40±17 years (range, 17-68), and 68% were men (11/15). Seven of the patients (46.6%) were in the age group of 50 years and older. While the mean Glasgow coma scale was 11.5±3.9 (range, 4-15), 46.3% presented with headache and 53.7% had stupor/coma. Four patients (26.6%) had only cerebellar hematoma and headache. All dAVFs had cortical venous drainage. In 11 patients (73.3%), the fistula was located in the tentorium and was the most common localization. Three patients (20%) had transverse and sigmoid sinus localizations, while one patient (6.7%) had dAVF located in the foramen magnum. Eighteen sessions were performed on the patients during endovascular treatment. Sixteen sessions (88.8%) were performed with the transarterial (TA) route, one session (5.5%) with the transvenous (TV) route, and one session (5.5%) with the TA+TV route. Surgery was performed in two patients (14.2%). One patient (7.1%) passed away. While there were nine patients (64.2%) with a Rankin score between 0 and 2, the total closure rate was 69.2% in the first year of control angiograms.

Conclusion: In the differential diagnosis of posterior fossa hemorrhages, the differential diagnosis of dAVFs, which is a very rare entity, should be considered, even in the middle and elderly age groups, in patients presenting with good clinical status and pure hematoma. The treatment of such patients can be done safely and effectively in a multidisciplinary manner with a good understanding of pathological vascular anatomy and appropriate endovascular treatment approaches.

Keywords: Arteriovenous fistula; Endovascular procedure; Hemorrhage; Posterior fossa hemorrhages; Therapeutic embolization.

Fig. 1.

A 29-year-old male patient (patient 12) was admitted to the hospital with confusion and vomiting. A : Right cerebellar hematoma on noncontrast cranial computed tomography. B and C : Left vertebral artery digital subtraction angiogram, in anterior-posterior and lateral projection, fed from the right pial supply from the AICA (black arrow), draining into the superior petrosal sinus (red arrow) via retrograde venous drainage superior petrosal tentorial dural arteriovenous fistula (white arrow). D : Embolization with Onyx after microcatheterization via AICA. E and F : Complete closure of the fistula in the post-operative first year of follow-up. In the first year of follow-up, it was observed that the sixth nerve paralysis continued. AICA : anterior inferior cerebellar artery.

Fig. 2.

A 37-year-old male patient (patient 2) in a coma after sudden headache. A : Left cerebellar hematoma, intraventricular hemorrhage, and subarachnoid hemorrhage were observed on noncontrast cranial computed tomography. B and C : Lateral left carotid and vertebral artery digital subtraction angiogram showed a tentorial dural arteriovenous fistula (white arrow) draining into the straight sinus with deep venous structures (red arrow), fed from the left meningohypophysial artery (black arrow). D and E : Onyx embolization by transvenous route. F : No residue was observed in the first year of follow-up.

Fig. 3.

A 20-year-old female patient (patient 3) is admitted to the hospital with sudden onset of vomiting, confusion, and left hemiparesis. A : Noncontrast cranial computed tomography showed left cerebellar hematoma, subarachnoid hemorrhage, and hydrocephalus (triventricular hydrocephalus not included in cross-sections). B : In the left vertebral artery digital subtraction angiogram, a tentorial dural arteriovenous fistula (white arrow), which is fed via the left superior cerebellar artery (black arrow) and VA-PMA (red arrow) draining into the torcula (yellow arrow) via the retrograde cortical venous pathway, is observed. C and D : Onyx embolization by catheterizing the left superior cerebellar artery using the transarterial route. E : At the sixth month of follow-up, it was observed that the fistula was reopened via VA-PMA. Second session is recommended. The patient refused because she was pregnant. F : Cerebellar hematoma and hydrocephalus were observed in magnetic resonance imaging performed after unconsciousness in the second trimester. The general condition improved with external ventricular drainage, but the patient refused farther treatment. There was no need for a permanent ventriculoperitoneal shunt. G : In the DSA performed in the first year of postpartum, the tentorial fistula draining into the torcula, in which the main originating arteries are superior cerebellar artery and VA-PMA, was completely closed in two different sessions (H and I), in three sessions in total. J : First-year control DSA. VA-PMA : vertebral artery-posterior menegial artery, DSA : digital subtraction angiography.