Straight sinus dural arteriovenous fistula presenting with reversible parkinsonism

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Abstract

Rationale:

A dural arteriovenous fistula (DAVF) refers to an abnormal direct connection between an intracranial artery and a dural venous sinus. A DAVF presenting with parkinsonism is rare, and is therefore easily misdiagnosed. Therefore, early consideration of DAVF in the differential diagnosis of reversible parkinsonism is necessary.

Patient concerns:

We present the case of a 51-year-old male with progressive parkinsonism.

Diagnoses:

He was diagnosed as straight sinus occlusion. Imaging studies revealed a DAVF associated with cerebral hypoperfusion of the lenticular nuclei and frontal lobe white matter.

Interventions:

Endovascular embolization was performed through his left occipital artery.

Outcomes:

Treatment resulted in marked clinical improvement that a major improvement of parkinsonism was observed concomitant with no evidence of early venous drainage of this patient.

Lessons:

DAVF should always be considered as a potential cause of progressive parkinsonism on account of its potential reversibility. Our case suggests a concomitant role of basal ganglia degeneration and frontal white matter hypoperfusion in the pathology of parkinsonism due to DAVF. However, the precise pathophysiology remains to be investigated.

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Most cited references 21

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Intracranial dural arteriovenous fistulas: classification, imaging findings, and treatment.

D. Gandhi, J. Chen, M. Pearl … (2012)

Intracranial DAVFs are pathologic dural-based shunts and account for 10%-15% of all intracranial arteriovenous malformations. These malformations derive their arterial supply primarily from meningeal vessels, and the venous drainage is either via dural venous sinuses or through the cortical veins. DAVFs have a reported association with dural sinus thrombosis, venous hypertension, previous craniotomy, and trauma, though many lesions are idiopathic. The diagnosis is dependent on a high level of clinical suspicion and high-resolution imaging. Cross-sectional imaging techniques by using CT and MR imaging aid in the diagnosis, but conventional angiography remains the most accurate method for complete characterization and classification of DAVFs. The pattern of venous drainage observed on dynamic vascular imaging determines the type of DAVF and correlates with the severity of symptoms and the risk of hemorrhage.

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Clinical characteristics of dural arteriovenous fistula.

Chang-Sik Oh, M. Han, O Jung Kwon … (2002)

Intracranial dural arteriovenous fistula (DAVF) is an uncommon neurosurgical condition; in particular, it has been infrequently reported in Korea. To understand the general clinical characteristics of DAVFs, the authors reviewed 53 cases and analyzed factors affecting DAVF hemorrhage of and treatment outcome. Since 1980 we have encountered 480 pial and 53 DAVFs, a ratio of 9.1 to 1. The age of these patients ranged from 1 month to 71 years, the most common being in the 6th decade, and females exceeded males by 1.65 to 1. All lesions except three were single, and symptoms were related to location and the venous drainage pattern. The most common location was the cavernous sinus, accounting for about 64% of cases, with the result that the most common clinical symptoms of DAVFs were ocular, namely proptosis and chemosis. The next was tinnitus also found in transverse-sigmoid sinus DAVFs. Intracranial hemorrhage was seen in eight cases,(15%) the primary cause of hemorrhage was retrograde intracranial venous drainage (P=0.017), and one hemorrhage was observed in cases with no intracranial venous drainage. Intracranial hemorrhage was more frequently in transverse-sigmoid than cavernous sinus DAVFs (P=0.049), and this proved to be so even where there was intracranial venous drainage. However, two of 34 patients with cavernous DAVFs became blind in one eye, demonstrating that in such patients, the clinical course could be aggressive. Thirteen patients were treated conservatively. The conservative treatment group was comprised of 13 patients, two of three patients with transverse-sigmoid sinus DAVF expired, and 7 of 10 with cavernous sinus DAVF experienced a clinical improvement or cure. Surgical excision was performed in only two patients. A total of 39 patients underwent embolization; clinical cure was achieved in 13, improvement of symptoms in 12, an unchanged or aggravated result occurred in 9, one died, and four were lost to follow up. During intervention, there was one hemorrhagic complication, owing to obstruction of the venous outflow with embolic materials. In this study, the most common location of DAVFs was the cavernous sinus. The cortical venous drainage remains the primary determinant of intracranial hemorrhage. Common indications for treatment include hemorrhage and neurological deficit. Endovascular treatment is preferred in the majority of cases except tentorial DAVF. The goal of embolization in cavernous DAVF is the alleviation of symptoms, not angiographic cure. But transverse-sigmoid sinus DAVF with venous restriction and leptomeningeal drainage should be treated aggressively. Copyright 2002, Elsevier Science Ltd. All rights reserved.

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Mechanism of the formation of dural arteriovenous fistula: the role of the emissary vein.

Atsuhiko Naito, K Haraguchi, Ken Wakabayashi … (2011)

Dural arteriovenous fistula (DAVF) can be separated into two types: DAVF which drains through an affected sinus (sinus type) and DAVF with direct reflux to the cortical vein (non-sinus type). The present report attempted to clarify the mechanism of formation and development of DAVF focusing on the emissary vein (EV) hypothesis.First, inflammation occurs at the penetrating point of the EV on the dura due to idiopathic or secondary causes. Local inflammatory reactions induce vessel dilatation and neovascularization, and subsequently create arteriovenous (AV) connections on the arteriole level. Although EV communicating with dural arteries might play a role as draining routes at first, they start to degrade due to compression of enlarged emissary arteries or to a hemodynamic shift to the drainage pathway of least resistance. Following the occlusion of drainage pathway through EV into the sinus or cortical veins may form, resulting in clinically detectable DAVF. The AV shunt then expands to the surrounding dura associated with recruitment of feeders from distant sites induced by expression of angiogenetic factors and a shift in the hemodynamic balance. In sinus type DAVF, the sinus is progressively compartmentalized and finally occludes due to thrombogenesis with activated coagulopathy or to hemodynamic hypertrophy of the sinus wall. This progression results in the mature, aggressive DAVF with drainage impairments. Previous mechanistic hypotheses focusing on sinus hypertension and sinus thromboses cannot explain the pathogenesis of non-sinus type of DAVF. Although the etiology of DAVF may be concerned by the thrombo-occlusive change of sinus, the unique theory presented in this report may enable an understanding of the common etiology of both types of DAVF.

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Author and article information

Journal

Journal ID (nlm-ta): Medicine (Baltimore)

Journal ID (iso-abbrev): Medicine (Baltimore)

Journal ID (publisher-id): MEDI

Title: Medicine

Publisher: Wolters Kluwer Health

ISSN (Print): 0025-7974

ISSN (Electronic): 1536-5964

Publication date Collection: December 2017

Publication date (Electronic): 08 December 2017

Volume: 96

Issue: 49

Electronic Location Identifier: e9005

Affiliations

Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China.

Author notes

[∗ ]Correspondence: Baorong Zhang, Department of Neurology, Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310009, People's Republic of China (e-mail: brzhang@ 123456zju.edu.cn ).

Article

Publisher ID: MD-D-17-04391 Accession ID: 09005

DOI: 10.1097/MD.0000000000009005

PMC ID: 5728895

PubMed ID: 29245280

SO-VID: 8abca93a-bc67-408e-a19b-a448125d024e

License:

This is an open access article distributed under the Creative Commons Attribution-NoDerivatives License 4.0, which allows for redistribution, commercial and non-commercial, as long as it is passed along unchanged and in whole, with credit to the author. http://creativecommons.org/licenses/by-nd/4.0

History

Date received : 17 July 2017

Date revision received : 19 September 2017

Date accepted : 9 November 2017

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Keywords: dural arteriovenous fistula,endovascular closure,parkinsonism,straight sinus

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Keywords: dural arteriovenous fistula, endovascular closure, parkinsonism, straight sinus

Straight sinus dural arteriovenous fistula presenting with reversible parkinsonism : A case report and literature review

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Interventions:

Outcomes:

Lessons:

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Most cited references 21

Intracranial dural arteriovenous fistulas: classification, imaging findings, and treatment.

Clinical characteristics of dural arteriovenous fistula.

Mechanism of the formation of dural arteriovenous fistula: the role of the emissary vein.

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