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Complex dural arteriovenous fistula - an unusual cause of ischemic stroke: Xper-CT helps open the closed door

Last update on November 28, 2022

Dr Joshi Manisha links a complex dural arteriovenous fistula (dAVF) to an unusual cause of ischaemic stroke.

Case presentation
  • 58-year-old female patient, known case of DM, HTN, seizure disorder, psychiatric disorder, presented with sudden onset but progressive weakness of right upper and lower limbs, decreased response and aphasia for 2 days.
  • Power 0/5 right side
  • Intubated for decreased response
  • On further enquiry, found to have history of DAVF embolization a year ago

MRI and MRV on presentation

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

Diagnostic angiogram on admission

Embolisation changes from previous procedure

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

 

  • Images of previous embolisations were not available
  • Paper records showed partial trans-arterial embolisation from MMA and occipital feeders
  • Bilateral T-S sinuses were patent before the previous embolisation session

 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

RVA angio

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke
Treatment plan
  • Plan A - Transvenous through the occluded left T-S sinus
  • Plan B - Trans-arterial

  • Plan C - Burr hole with transvenous

    Transvenous route embolisation- Left IJV puncture 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

6 F Short Sheath

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

Digging the vein

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

5F Picard and 035 Terumo

XperCT to help decide direction

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

Picard didn’t track in over wire, 035 balloon didn’t track either

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

Exchange of Picard with 4F C1 Terumo

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

O14 wire in sinus

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

3 x 100 mm 014 OTW balloon

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

ENVOY 6F in sinus

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

Coiling through Echelon 10

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke

 

Complex Dural Arterio-Venous fistula- An Unusual Cause of Ischemic Stroke
Clinical follow-up
  • Patient extubated the next day
  • E4V5M6
  • Power 3/5 on the right side
  • Progressive improvement

At first follow-up

  • Power 5/5 on all 4 limbs
  • mRS -0

F/U MRI and MRV 11 months after embolisation

F/U MRI and MRV 11 month after embo

Take-home Messages

  • When the paths are closed, start digging.
  • Navigation techniques while digging can help to succeed and prevent complications
  • Familiarity with various materials helps to overcome obstacles.

 

 

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