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      Less Invasive Management of Endovascular Embolization and Neuroendoscopic Surgery for a Dural Arteriovenous Fistula Presenting with Acute Subdural Hematoma

      case-report

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          Abstract

          Acute subdural hematoma (ASDH), which causes midline shift of the brain, rarely arises from a dural arteriovenous fistula (DAVF). Herein, we report the first case of a DAVF manifesting ASDH, which was treated less invasively with endovascular embolization of a drainer of the DAVF and hematoma removal under neuroendoscopy. A 59-year-old man with a sudden onset of headache was transported to our hospital. Left ASDH and intracerebral hematoma in the left occipital lobe were detected. A cerebral angiogram revealed a DAVF fed by the petrosquamous branch of the left middle meningeal artery and jugular branch of the right ascending pharyngeal artery. The shunting point in the lateral tentorial DAVF drains through the internal occipital vein to the superior sagittal sinus. A varix was recognized in the draining vein (Borden type 3, Cognard type 4). The DAVF was embolized with Onyx (Medtronic, Minnesota, USA), and the left ASDH was removed with a small craniotomy under neuroendoscopy. No origin of the left ASDH was apparent in the surgical field. The patient was discharged from the hospital on postoperative day 18. The patient's status was modified Rankin scale 1 on discharge. Our management of combined endovascular treatment and neuroendoscopic hematoma removal may be useful and less invasive for hemorrhagic DAVF.

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          Intracranial dural arteriovenous malformations: factors predisposing to an aggressive neurological course.

          W P Akarawi, J Ahl, Susan Little … (1990)
          The natural history of cranial dural arteriovenous malformations (AVM's) is highly variable. The authors present their clinical experience with 17 dural AVM's in adults, including 10 cases with an aggressive neurological course (strictly defined as hemorrhage or progressive focal neurological deficit other than ophthalmoplegia). Two of these 10 patients died prior to surgical intervention and a third was severely disabled by intracerebral hemorrhage. Six patients underwent surgical resection of their dural AVM, with preparatory embolization in two cases. One patient received embolization and radiation therapy without surgery. Six of the seven cases without an aggressive neurological course were treated conservatively, and the seventh patient underwent embolization of a cavernous sinus dural AVM because of worsening ophthalmoplegia. In order to clarify features associated with aggressive behavior, a comprehensive meta-analysis was performed on 360 additional dural AVM's reported in the literature with sufficiently detailed clinical and angiographic information. The location and angiographic features of 100 aggressive cases were compared to those of 277 benign cases. No location of dural AVM's was immune from aggressive neurological behavior; however, an aggressive neurological course was least often associated with cases involving the transverse-sigmoid sinuses and cavernous sinus and most often associated with cases at the tentorial incisura. Contralateral contribution to arterial supply and rate of shunting (high vs. low flow) did not correlate with aggressive neurological behavior as defined. Leptomeningeal venous drainage, variceal or aneurysmal venous dilations, and galenic drainage correlated significantly (p less than 0.05) with aggressive neurological presentation. The latter three angiographic features often coexisted in the same dural AVM. It is concluded that these features significantly increase the natural risk of dural AVM's, and warrant a more vigilant therapeutic strategy.
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            Involvement of dural arteries in intracranial arteriovenous malformations.

            S Cronqvist, Allen T. Newton (1969)
            Article 0 comments Cited 24 times – based on 0 reviews     Review now
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              Early rebleeding from intracranial dural arteriovenous fistulas: report of 20 cases and review of the literature.

              Ahlam M. Ismail, H Duffau, F Arthuis … (1998)
              In this study the authors sought to estimate the frequency, seriousness, and delay of rebleeding in a homogeneous series of 20 patients whom they treated between May 1987 and May 1997 for arteriovenous fistulas (AVFs) that were revealed by intracranial hemorrhage (ICH). The natural history of intracranial dural AVFs remains obscure. In many studies attempts have been made to evaluate the risk of spontaneous hemorrhage, especially as a function of the pattern of venous drainage: a higher occurrence of bleeding was reported in AVFs with retrograde cortical venous drainage, with an overall estimated rate of 1.8% per year in the largest series in the literature. However, very few studies have been designed to establish the risk of rebleeding, an omission that the authors seek to remedy. Presenting symptoms in the 20 patients (17 men and three women, mean age 54 years) were acute headache in 12 patients (60%), acute neurological deficit in eight (40%), loss of consciousness in five (25%), and generalized seizures in one (5%). Results of the clinical examination were normal in five patients and demonstrated a neurological deficit in 12 and coma in three. Computerized tomography scanning revealed intracranial bleeding in all cases (15 intraparenchymal hematomas, three subarachnoid hemorrhages, and two subdural hematomas). A diagnosis of AVF was made with the aid of angiographic studies in 19 patients, whereas it was a perioperative discovery in the remaining patient. There were 12 Type III and eight Type IV AVFs according to the revised classification of Djindjian and Merland, which meant that all AVFs in this study had retrograde cortical venous drainage. The mean duration between the first hemorrhage and treatment was 20 days. Seven patients (35%) presented with acute worsening during this delay due to radiologically proven early rebleeding. Treatment consisted of surgery alone in 10 patients, combined embolization and surgery in eight, embolization only in one, and stereotactic radiosurgery in one. Three patients died, one worsened, and in 16 (80%) neurological status improved, with 15 of 16 AVFs totally occluded on repeated angiographic studies (median follow up 10 months). The authors found that AVFs with retrograde cortical venous drainage present a high risk of early rebleeding (35% within 2 weeks after the first hemorrhage), with graver consequences than the first hemorrhage. They therefore advocate complete and early treatment in all cases of AVF with cortical venous drainage revealed by an ICH.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Asian J Neurosurg
                Journal ID (iso-abbrev): Asian J Neurosurg
                Journal ID (doi): 10.1055/s-00053244
                Title: Asian Journal of Neurosurgery
                Publisher: Thieme Medical and Scientific Publishers Pvt. Ltd. (A-12, 2nd Floor, Sector 2, Noida-201301 UP, India )
                ISSN (Print): 1793-5482
                ISSN (Electronic): 2248-9614
                Publication date (Electronic): 26 August 2022
                Publication date Collection: June 2022
                Publication date PMC-release: 1 August 2022
                Volume: 17
                Issue: 2
                Pages: 362-366
                Affiliations
                [1 ]Department of Neurosurgery, Tazuke Kofukai Medical Research Institute, Kitano Hospital, Kita-ku, Osaka, Japan
                [2 ]Department of Rehabilitation, Hikari Hospital, Otsu City, Shiga, Japan
                [3 ]Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki City, Okayama, Japan
                Author notes
                Address for correspondence Ryota Ishibashi, MD Department of Neurosurgery, Tazuke Kofukai Medical Research Institute, Kitano Hospital 2-4-20 Ogimachi, Kita-ku, Osaka, 530-8480Japan ryotaishibashi@ 123456gmail.com
                Article
                Publisher ID: 31721
                DOI: 10.1055/s-0042-1750309
                PMC ID: 9473823
                SO-VID: 43f35778-6faa-4ffb-8291-cf364789dfcb
                Copyright © Asian Congress of Neurological Surgeons. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ )
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License, which permits unrestricted reproduction and distribution, for non-commercial purposes only; and use and reproduction, but not distribution, of adapted material for non-commercial purposes only, provided the original work is properly cited.

                History
                Categories
                Subject: Case Report

                ScienceOpen disciplines: Surgery
                Keywords: dural arteriovenous fistula,endovascular,onyx,neuroendoscope,acute subdural hematoma
                Data availability:
                ScienceOpen disciplines: Surgery
                Keywords: dural arteriovenous fistula, endovascular, onyx, neuroendoscope, acute subdural hematoma

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