Intraventricular hemorrhage after dural fistula embolization / Hemorragia intraventricular após embolização de fístula dural

Abstract Background and objectives: Dural arteriovenous fistulas are anomalous shunts between dural arterial and venous channels whose nidus is located between the dural leaflets. For those circumstances when invasive treatment is mandatory, endovascular techniques have grown to become the mainstay of practice, choice attributable to their reported safety and effectiveness. We describe the unique and rare case of a dural arteriovenous fistula treated by transarterial embolization and complicated by an intraventricular hemorrhage. We aim to emphasize some central aspects of the perioperative management of these patients in order to help improving the future approach of similar cases. Case report: A 59-year-old woman with a previously diagnosed Cognard Type IV dural arteriovenous fistula presented for transarterial embolization, performed outside the operating room, under total intravenous anesthesia. The procedure underwent without complications and the intraoperative angiography revealed complete obliteration of the fistula. In the early postoperative period, the patient presented with clinical signs of raised intracranial pressure attributable to a later diagnosed intraventricular hemorrhage, which conditioned placement of a ventricular drain, admission to an intensive care unit, cerebral vasospasm and a prolonged hospital stay. Throughout the perioperative period, there were no changes in the cerebral brain oximetry. The patient was discharged without neurological sequelae. Conclusion: Intraventricular hemorrhage may be a serious complication after the endovascular treatment of dural arteriovenous fistula. A close postoperative surveillance and monitoring allow an early diagnosis and treatment which increases the odds for an improved outcome.

Resumo Justificativa e objetivos: Fístulas arteriovenosas durais (FAVD) são comunicações anômalas entre os canais venosos e arteriais da dura-máter cujo centro está localizado entre os folhetos da dura-máter. Para as circunstâncias nas quais o tratamento invasivo é obrigatório, as técnicas endovasculares se tornaram os pilares da prática, escolha atribuível a relatos de sua segurança e eficácia. Descrevemos o caso único e raro de uma FAVD tratada por embolização transarterial (ETA) e complicada por uma hemorragia intraventricular (HIV). Nosso objetivo foi destacar alguns aspectos centrais do manejo perioperatório desses pacientes para ajudar a melhorar uma futura abordagem de casos semelhantes. Relato de caso: Paciente do sexo feminino, 59 anos, com diagnóstico prévio de FAVD tipo IV (Cognard), apresentou-se para ETA, realizada fora da sala de cirurgia soBanestesia venosa total. O procedimento transcorreu sem complicações, e a angiografia intraoperatória revelou obliteração completa da fístula. No período pós-operatório imediato, a paciente apresentou sinais clínicos de aumento da pressão intracraniana (PIC) atribuíveis a uma HIV posteriormente diagnosticada, o que condicionou a colocação de um dreno ventricular, internação em Unidade de Terapia Intensiva (UTI), vasoespasmo cerebral e internação hospitalar prolongada. Durante todo o período perioperatório, não houve alterações na oximetria cerebral. A paciente recebeu alta sem sequelas neurológicas. Conclusão: HIV pode ser uma complicação grave após o tratamento endovascular de FAVD. A observação e o monitoramento cuidadosos no pós-operatório permitem o diagnóstico precoce e o tratamento que aumenta as chances de um resultado melhor.

Intraventricular hemorrhage after dural fistula embolization.

BACKGROUND AND OBJECTIVES: Dural arteriovenous fistulas are anomalous shunts between dural arterial and venous channels whose nidus is located between the dural leaflets. For those circumstances when invasive treatment is mandatory, endovascular techniques have grown to become the mainstay of practice, choice attributable to their reported safety and effectiveness. We describe the unique and rare case of a dural arteriovenous fistula treated by transarterial embolization and complicated by an intraventricular hemorrhage. We aim to emphasize some central aspects of the perioperative management of these patients in order to help improving the future approach of similar cases. CASE REPORT: A 59-year-old woman with a previously diagnosed Cognard Type IV dural arteriovenous fistula presented for transarterial embolization, performed outside the operating room, under total intravenous anesthesia. The procedure underwent without complications and the intraoperative angiography revealed complete obliteration of the fistula. In the early postoperative period, the patient presented with clinical signs of raised intracranial pressure attributable to a later diagnosed intraventricular hemorrhage, which conditioned placement of a ventricular drain, admission to an intensive care unit, cerebral vasospasm and a prolonged hospital stay. Throughout the perioperative period, there were no changes in the cerebral brain oximetry. The patient was discharged without neurological sequelae. CONCLUSION: Intraventricular hemorrhage may be a serious complication after the endovascular treatment of dural arteriovenous fistula. A close postoperative surveillance and monitoring allow an early diagnosis and treatment which increases the odds for an improved outcome.

[Intraventricular hemorrhage after dural fistula embolization]. / Hemorragia intraventricular após embolização de fístula dural.

BACKGROUND AND OBJECTIVES: Dural arteriovenous fistulas are anomalous shunts between dural arterial and venous channels whose nidus is located between the dural leaflets. For those circumstances when invasive treatment is mandatory, endovascular techniques have grown to become the mainstay of practice, choice attributable to their reported safety and effectiveness. We describe the unique and rare case of a dural arteriovenous fistula treated by transarterial embolization and complicated by an intraventricular hemorrhage. We aim to emphasize some central aspects of the perioperative management of these patients in order to help improving the future approach of similar cases. CASE REPORT: A 59-year-old woman with a previously diagnosed Cognard Type IV dural arteriovenous fistula presented for transarterial embolization, performed outside the operating room, under total intravenous anesthesia. The procedure underwent without complications and the intraoperative angiography revealed complete obliteration of the fistula. In the early postoperative period, the patient presented with clinical signs of raised intracranial pressure attributable to a later diagnosed intraventricular hemorrhage, which conditioned placement of a ventricular drain, admission to an intensive care unit, cerebral vasospasm and a prolonged hospital stay. Throughout the perioperative period, there were no changes in the cerebral brain oximetry. The patient was discharged without neurological sequelae. CONCLUSION: Intraventricular hemorrhage may be a serious complication after the endovascular treatment of dural arteriovenous fistula. A close postoperative surveillance and monitoring allow an early diagnosis and treatment which increases the odds for an improved outcome.