Spinal arteriovenous fistula leading to acute paraplegia after a lumbar nerve root block: Successful embolization with complete neurological recovery-a case report.

Spinal arteriovenous fistulas (SAVFs) are the most common type of vascular malformation of the spine in adult patients. They can lead to acute or progressive myelopathy due to venous congestion of the medullary veins. While most SAVFs are acquired, their pathophysiology remains unclear. The natural history of the disease and its clinical presentation are highly influenced by the location of the fistula and various factors may trigger sudden neurological decline. We present a case of a patient who developed a complete spinal cord injury after a lumbar nerve root block, likely due to an undiagnosed SAVF. The patient underwent endovascular embolization, resulting in a complete recovery of neurological function.

Venous Anatomy of the Central Nervous System.

Comprehensive understanding of venous anatomy is a key factor in the approach to a multitude of conditions. Moreover, the venous system has become the center of attention as a new frontier for treatment of diseases such as idiopathic intracranial hypertension (IIH), arteriovenous malformation (AVM), pulsatile tinnitus, hydrocephalus, and cerebrospinal fluid (CSF) venous fistulas. Its knowledge is ever more an essential requirement of the modern brain physician. In this article, the authors explore the descriptive and functional anatomy of the venous system of the CNS in 5 subsections: embryology, dural sinuses, cortical veins, deep veins, and spinal veins.

Diagnostic, clinical management, and outcomes in patients with spinal dural arteriovenous fistula.

Background: Spinal dural arteriovenous fistulas (SDAVFs) are rare spinal vascular malformations, but account for 70 to 80% of all spinal arteriovenous malformations. SDAVFs can be treated either surgically or endovascularly, with surgical treatment appearing to lead to higher closure rates. Our aim was to analyze the demographic data, diagnostic history, treatment characteristics and clinical short- and long-term outcomes. Methods: The medical records of 81 patients who underwent surgical (n = 70, 86.4%) and endovascular (n = 11, 13.6%) treatment for SDAVF at a university hospital between 2002 and 2023 were retrospectively analyzed. Results: SDAVF was observed more frequently in men than women (61, 75.3% vs. 20, 24.7%) with a mean age of 63.5 ± 12.7 years and a mean duration of symptoms to diagnosis of 12.0 ± 12.8 months. The most common first symptom was gait disturbance (36, 44.4%), followed by sensory disturbance (24, 29.6%). The location of the fistula point was most common in the lower thoracic region (36, 44.5%), followed by the lumbar region (23, 28.4%). Incomplete or failed occlusion of the fistula occurred in 8 patients (9.9%), with 6 patients (7.4%) undergoing further treatment either surgically or endovascularly. Treatment- or hospital-related complications were observed in 16 patients (19.8%). A single-level laminectomy was the most common approach (31, 44.3%), followed by single-level hemilaminectomy (28, 40.0%), and unilateral interlaminar fenestration (11, 15.7%). Back pain or radiculopathy was observed in 58% of patients (47/81) pre-treatment and had already decreased to 24.7% at hospital discharge (p < 0.001). No significant differences were observed in sensory disturbances (p = 0.681). The median of American Spinal Injury Association motor score (ASIA-MS) was 94 [82.5-100] at admission, 98 [86.5-100] at hospital discharge, 100 [90-100] at the first, second, and third follow-up (p = 0.019). The median modified Aminoff-Logue scale (mALS) was 5 [2-7] at admission, 3 [1-6] at hospital discharge, 2 [1-5] at the first follow-up, 2 [0.5-5] at the second follow-up and 2 [1-7] at the third follow-up (p = 0.006). Conclusions: SDAVF occurs predominantly in men in the 6th decade of life and can be safely and effectively treated surgically and endovascularly, improving symptoms such as pain and motor deficits, gait disturbances as well as bowel and bladder dysfunction, but not sensory disturbances.

Cerebral dural arteriovenous fistulas in patients with PTEN-related hamartoma tumor syndrome.

Central nervous system (CNS) dural arteriovenous fistulas (DAVF) have been reported in PTEN-related hamartoma tumor syndrome (PHTS). However, PHTS-associated DAVF remain an underexplored field of the PHTS clinical landscape. Here, we studied cases with a PTEN pathogenic variant identified between 2007 and 2020 in our laboratory (n = 58), and for whom brain imaging was available. Two patients had DAVF (2/58, 3.4%), both presenting at advanced stages: a 34-year-old man with a left lateral sinus DAVF at immediate risk of hemorrhage, and a 21-year-old woman with acute intracranial hypertension due to a torcular DAVF. Interestingly, not all patients had 3D TOF/MRA, the optimal sequences to detect DAVF. Early diagnosis of DAVF can be lifesaving, and is easier to treat compared to developed, proliferative, or complex lesions. As a result, one should consider brain MRI with 3D TOF/MRA in PHTS patients at genetic diagnosis, with subsequent surveillance on a case-by-case basis.

A Case Series of Late Vascular Lesions of Traumatic Etiology: Endovascular and Surgical Approaches.

There is a broad spectrum of pathology in traumatic vascular injury. Arteriovenous fistula (AVF) is an abnormal communication between the high-flow arterial system and the low-flow venous network, directly connecting the afferent artery and nearby draining veins without the regular intervention of the capillary bed. Most of these fistulas occur due to incidental or iatrogenic injury. A retrospective review of procedures performed by an endovascular surgeon in a tertiary center identified 15 cases of vascular injuries that encompassed all these different clinical scenarios, including post-traumatic, iatrogenic, or spontaneous origin. The information collected, including patient age, sex, previous symptoms, and treatment, was gathered from medical records. In addition, information on procedural technique, endovascular devices used, and specific intraprocedural details were collected from procedure notes and angiographic images. A broad spectrum of injuries can present as late trauma complications (over three months); endovascular treatment is a safe and effective approach for intracranial and extracranial injuries. Endovascular treatment can be a sole option or adjuvant to other hybrid therapies and has emerged as essential for treating these lesions as a first option. We have described standard techniques to treat different vascular pathologies, sometimes with limited resources.

Lumbar Laminectomy Precedes Positional Headache and MRI-Confirmed Pseudomeningocele With Duro-Cutaneous Fistula.

Pseudomeningoceles (PMs) are collections of cerebrospinal fluid (CSF) occurring as a direct result of a dural rent. This article presents a well-documented case of a 68-year-old male presenting to the emergency department with postoperative lumbar PM with a duro-cutaneous fistula. It was initially recognized on palpation of the patient's postoperative incision site and later diagnosed with magnetic resonance imaging (MRI). Incidental durotomies (IDs) leading to PMs are a rare complication of laminectomies and other spinal surgeries. A thorough physical exam, diagnostic imaging, and lumbar drainage to survey the integrity of the dura mater are important aspects of postoperative care.

Cone Beam CT to Guide Transorbital Treatment of a Cavernous Sinus Dural Arteriovenous Fistula in a Patient with Middle Meningeal Artery Origin of the Ophthalmic Artery.

Transorbital puncture to embolize cavernous sinus (CS) dural arteriovenous fistulas (DAVF) is a useful strategy when conventional transvenous routes are inaccessible. We report a case of bilateral CS DAVF associated with bilateral middle meningeal artery (MMA) origin of ophthalmic arteries (OA) who had recently undergone transvenous coil embolization. She presented with persistent symptoms of conjunctival congestion and proptosis in the left eye. Angiogram revealed residual left CS DAVF with dilated SOV. Inferior petrosal sinus or facial vein access was not possible. Transorbital access of the SOV was planned. Cone-beam CT (CBCT) angiography was used to delineate the relationship between the variant OA and SOV and also to plan a safe trajectory. Using fluoroscopy guidance, the SOV was punctured and embolization was done using Onyx-18. CBCT is a valuable tool in planning and executing transorbital treatment of CS DAVF, especially in the setting of variant OA.

Endovascular treatment of anterior cranial base dural arteriovenous fistulas as a first-line approach: a multicenter study.

OBJECTIVE: Anterior cranial fossa dural arteriovenous fistulas (DAVFs) have been almost exclusively considered as surgical lesions. However, new advances in endovascular technology have made the endovascular treatment (EVT) of ethmoidal DAVFs feasible. The aim of this study was to report the clinical and angiographic outcomes of patients harboring DAVFs of the anterior cranial fossa who had undergone EVT as a first-line approach. METHODS: This was a retrospective study of a consecutive series of patients harboring anterior cranial base DAVFs who had undergone EVT as a first-line approach at four institutions. Angiographic follow-up was performed at 6 months. Immediate and late serious clinical events were assessed during follow-up, including death and stroke. Special emphasis was given to visual status before and after the treatment. RESULTS: Between 2008 and 2020, 37 patients with ethmoidal DAVFs were admitted to the participating centers. In 2 patients, EVT was not attempted; therefore, 35 patients underwent EVT as a first-line procedure. An isolated transarterial approach was performed in 19 (54.3%) patients. The transvenous approach was performed exclusively in 12 (34.3%) patients, and combined access was used in 4 (11.4%) patients. The most frequently used arterial access route was the ophthalmic artery in 82.6% of the patients. Immediately, complete angiographic occlusion was achieved in 31 (91.2%) of 34 patients whose treatment was accomplished. Six-month control angiography revealed that 30 (88.2%) DAVFs were totally occluded. Complications occurred in 3 (8.8%) patients, including 1 (2.9%) patient who had central retinal artery occlusion. No significant difference in complications or occlusion rates was noted between the transarterial and transvenous approaches. CONCLUSIONS: Most anterior cranial base DAVFs can be successfully treated via an endovascular approach. Neurological and visual complications are rare, even if the ophthalmic artery is used as the primary access route. Efforts should be focused on prospectively comparing the results of EVT and surgical management.

The Development of Indirect Carotid Cavernous Fistulas after Microvascular Ischemic 4th Nerve Palsies.

An indirect carotid cavernous fistula (CCF) is an abnormal connection between the cavernous sinus and internal or external carotid artery. Indirect CCFs often occur spontaneously, particularly in the setting of vascular risk factors such as hypertension, diabetes, and atherosclerosis. Microvascular ischemic nerve palsies (NPs) share these vascular risk factors. However, to date, no temporal relationship between microvascular ischemic NP and indirect CCF occurring sequentially has been reported. We describe the cases of 64- and 73-year-old women who developed indirect CCFs within 1-2 weeks after spontaneous resolution of a microvascular ischemic 4th NP. Both patients had complete resolution and an asymptomatic period between the 4th NP and CCF. This case highlights the shared pathophysiology and risk factors between microvascular ischemic NPs and CCFs, and emphasizes that CCFs should be kept in the differential diagnosis for red eye or recurrent diplopia in patients with previous microvascular ischemic NP.

Natural history and management of spinal cord arteriovenous shunts in pregnancy: A monocentric series of 10 consecutive cases with emphasis on endovascular treatment.

PURPOSE: Intradural spinal cord arteriovenous shunts (IDSCAVS) are rare and constitute a challenging situation if symptoms occur during pregnancy. We present a series of ten such cases referred to our center: five cervical, four thoracic and one lumbar. METHODS: We retrospectively reviewed our global series of 215 IDSCAVSs between 2002 and March 2020 and found ten patients who had presented during pregnancy. Clinical, radiological and therapeutic data were studied. RESULTS: Seven shunts were AVM type niduses and three were micro AV-fistulae. All were associated with pial venous reflux and six hemorrhagic cases had pseudo aneurysms. Symptoms occurred mainly during the third trimester, 80% of patients presented with hemorrhage and spinal cord dysfunction. We embolized seven patients and proposed surgery in one, always after delivery: all recovered well. One woman declined treatment; one other was operated in emergency but did not improve. Mean follow-up was 3.9 years (0.5...19 years). CONCLUSIONS: Despite this small group of patients, our initial experience of IDSCAVSs diagnosed during pregnancy indicates that embolization is an effective management strategy if performed after delivery and a recovery period. Results indicate that IDSCAVSs seem to have a low risk of early rebleedings after the ictal event and may be closely followed up until delivery. The results obtained show good clinical outcome without long-term rebleeds. Women with known IDSCAVSs should not be discouraged from becoming pregnant, however it seems wise to embolize them before pregnancy in order to offer protection against risks during pregnancy.

Lateral Variant of Davidoff and Schechter Dural Arteriovenous Fistula.

Dural arteriovenous fistulas represent a distinct direct pathological connection between dural arterial feeders of the meninges to cortical veins or sinuses. Vascular supply of the meninges is provided by a series of named arteries-anterior, middle, and posterior meningeal arteries, with the tentorium provided by the artery of Bernasconi and Cassinari (anterior-medial) and the artery of Davidoff and Schechter (posterior-medial). This case is the first report in the literature of a lateral distal posterior cerebral artery supplying the meninges and contributing dural feeders to a Cognard type III/Borden type III dural arteriovenous fistula.

Fatal hemorrhagic complication after coil embolization of a petrosal arteriovenous shunt.

BACKGROUND: Cerebello-pontine AVMs (CPAVMs) and petrous apex dural arteriovenous fistulae (DAVFs) are rare and sometimes difficult to distinguish. We report a fatal hemorrhagic complication after coil embolization of the petrosal vein draining a trigeminal AVM misdiagnosed as a DAVF. CASE PRESENTATION: A 73-year-old woman with a petrous apex arteriovenous shunt with dual dural and pial arterial supply presented with posterior fossa hemorrhage. The draining petrosal vein was catheterized and coiled via the superior petrosal sinus. Two episodes of contrast extravasation occurred during coiling, but the lesion was completely occluded at the end of the procedure. The patient developed a fatal posterior fossa hemorrhage in the recovery room. Microscopic pathology revealed numerous dilated vessels within the trigeminal nerve. CONCLUSION: CPAVMs and DAVFs with pial drainage should be distinguished pre-operatively. Occlusion of a pial vein (as opposed to a sinus) in the treatment of an arteriovenous shunt carries hemorrhagic risk if a liquid embolic agent is not used to completely occlude all pathological vessels.

Carotid Cavernous Sinus Fistula with Contralateral Feed Not Diagnosed by Virtual Assessment or by Non-Invasive Vascular Imaging.

A 67-year-old woman had delayed initial diagnosis of her right low flow carotid cavernous fistula (CCF) during the coronavirus disease (COVID-19) pandemic due to difficulty detecting ocular signs via online virtual examinations. Her right eye conjunctival erythema and proptosis with medial rectus enlargement on computed tomography scan was initially misdiagnosed as euthyroid thyroid-associated orbitopathy without lid retraction. She developed vision loss, and increasing episcleral venous congestion and CCF was suspected. Computed tomographic angiography did not show an obvious fistula. Digital subtraction angiography revealed the right-sided low flow CCF, which was fed from vessels from the contralateral side.

Approach to the Superior Ophthalmic Vein for Endovascular Treatment of Cavernous Dural Fistula.

The cavernous sinus area is the second most common location for intracranial dural fistulas. Although these spontaneous dural cavernous fistulas are self-limited, a sizeable number of patients will develop progressive vision loss, diplopia, or intractable glaucoma, which warrant interventional therapy.1,2 We present the case of a 54-year-old male with hypertension and type 2 diabetes, who presented with a red right eye associated with progressive exophthalmos, ophthalmoparesis, and deterioration of visual acuity. The angiotomography showed the exophthalmos with an ingurgitated superior ophthalmic vein, with early filling in the arterial phase. A digital angiography was made, and a diagnosis of dural cavernous fistula, Barrow type D was made.3 Considering several transvenous approaches, alternatives included inferior petrosal sinus, access through the superior ophthalmic vein, and an open approach.4 In this particular case the inferior petrosal sinus was not present, so we tried to catheterize through the facial vein and also puncture the ophthalmic vein. Both procedures were unsuccessful. We decided to perform, then, an open approach with the oculoplastic surgery team (Video 1). Through an eyelid dissection, we localized the superior ophthalmic vein and then canalized it by direct visualization.5 With this approach, we were able to perform the cavernous sinus packing with coils and achieved a complete occlusion of the fistula. We reproduced the direct approach to the superior ophthalmic vein in a cadaveric specimen and schematized it step by step with 3-dimensional photographs.6.

Acute Myelopathy: Vascular and Infectious Diseases.

Vascular and infectious causes are rare but important causes of spinal cord injury. High suspicion for these processes is necessary, as symptoms may progress over hours to days, resulting in delayed presentation and diagnosis and worse outcomes. History and clinical examination findings can assist with localization of the affected vascular territory and spinal level, which will assist with focusing spinal imaging. Open and/or endovascular surgical management depends on the associated vascular abnormality. Infectious myelopathy treatment consists of targeted antimicrobial therapy when possible, infectious source control, and again, close monitoring for systemic complications.

[Traumatic occlusion of posterior cerebral artery with occipital lobe ischemia]. / Travmaticheskaya okklyuziya zadnei mozgovoi arterii s ishemiei zatylochnoi doli.

Traumatic cerebrovascular injury (TCVI) are rare, severe and dangerous complications of traumatic brain injuries. Current data suggests they accompany less then 2% of severe traumatic brain injuries. Most common forms of TCVI are formation of traumatic pseudoaneurysms and dural arteriovenous fistulas, less frequent - traumatic occlusions, intersections and some others. This pathology complicates the course of traumatic brain injury, decreases quality of life and prognosis, and requires complex diagnosis and treatment strategy. The authors describe a rare case of traumatic posterior cerebral artery occlusion in a patient injured in a road traffic accident and provide literature review on modern concepts of TCVI.

Cavernous Sinus Dural Arteriovenous Fistula in a Patient with Thyroid-Associated Ophthalmopathy: Complete Resolution after Medical Treatment.

Thyroid-associated ophthalmopathy (TAO) is a well-known and frequent epiphenomenon of a hyperthyroid autoimmune disease that can present with proptosis, strabismus, and diplopia. Ophthalmopathy can occur in the absence of overt Graves' disease, even in euthyroid patients. Cavernous sinus dural fistulas (CS-DAVF) are abnormal communications between the cavernous sinus (CS) and dural branches from internal carotid or external carotid arteries. They can often present with ocular symptoms that can mimic a thyroid-associated ophthalmopathy. CS-DAVF are usually successfully treated with an endovascular embolization that can be pursued both through a transvenous or transarterial approach. TAO and CS-DAVF can coexist especially when the ocular symptoms are unilateral. In those cases, an endovascular embolization is usually curative, but sometimes the procedure can fail. Our hypothesis is that some cases of CS-DAVF may be of secondary nature (i.e., caused by compression of the venous outlet by the hypertrophic ocular muscles); therefore, treating the ocular disease with medical therapy may solve the vascular problem as well. We present a case of a CS-DAVF in a patient with TAO successfully treated with sole medical therapy after the failure of a first-line endovascular treatment.

Microsurgical Treatment of a Complex Cognard V Tentorial Dural Fistula with Superior Cerebellar Artery Supply.

This case video demonstrates a microsurgical technique for the clipping and obliteration of a Cognard V tentorial dural fistula (Video 1). The patient was a 49-year-old male who presented with progressive upper and lower extremity weakness over 12 months, with associated cervical spinal cord edema. The patient was initially misdiagnosed with transverse myelitis; however, abnormal flow voids on magnetic resonance imaging led to a cerebral angiogram being performed. The preoperative angiogram demonstrated the Cognard V right tentorial dural arteriovenous fistula with drainage into the dorsal and ventral medullary veins. The fistula resulted in spinal cord symptoms due to spinal cord venous engorgement, with a lack of cranial symptoms. In these cases, microsurgery is the preferred method of treatment due to excellent surgical window to the medial tentorial margin and difficulty in catheterizing the small tortuous superior cerebellar artery meningeal feeder. This is a novel case showing a hybrid operating room technology to safely approach a complex fistula and obtain curative confirmation by transradial intraoperative angiography. In addition, this case is unique in providing a surgical visualization of the meningeal superior cerebellar artery feeder contributing to this fistula, namely the artery of Wollschlaeger & Wollschlaeger. Postoperatively, the patient demonstrated significant improvement in upper and lower extremity strength, indicative of a successful recovery. The patient was discharged to rehabilitation, with continued motor improvement.

Arteriovenous fistulas of the Vein of Galen region in adults: Endovascular treatment.

PURPOSE: Arteriovenous fistulas of the Vein of Galen region in adults (Ad-VGAVF) are an uncommon entity with specific anatomic features. The aim of this article is to present our experience in the endovascular treatment of this pathology and to propose a therapeutic strategy based precisely on the angioarchitecture of these lesions. MATERIALS AND METHODS: During a 20-year period, 10 patients underwent endovascular treatment of Ad-VGAVF. They were nine men and one woman with a mean age of 50 years (23-66 years) treated with the same embolization strategy. Clinical presentation, angiographic characteristics, therapeutic strategy, and clinical outcomes were recorded. RESULTS: All patients were treated exclusively by endovascular approach. Transarterial access was performed in eight patients and combined transvenous and transarterial access in two. Complete obliteration of the fistula was obtained in all patients. There were no intraprocedural complications. Post-embolization neurological symptoms occurred in 5 of 10 with complete resolution at six months in all of them. CONCLUSION: Arteriovenous fistulas of the Vein of Galen region in adults present uniform angioarchitecture despite their low prevalence. Based on this constant angioarchitecture and especially on the features of its venous drainage, judicious embolization strategy is feasible and effective. Ten cases treated entirely by endovascular approach with excellent clinical and angiographic outcomes show this treatment like a curative alternative for this entity of deep topography and severe prognosis.