Multiple dural arteriovenous fistulas

CASE PRESENTATION

• Female, 29 yo
• Started in 2019 with progressive worsening of visual acuity bilaterally,  occipital headache, and papilledema
• Neuroimaging investigation: extensive dural arteriovenous malformation, with shunt affecting the transverse sinuses (mainly on the right) and torcula, with ectasia of the external carotid arteries and meningeal branches.

ANGIOGRAPHY - 06/02/2020

• She underwent another three sessions of embolization, without achieving a complete approach to the lesion.
• In June 2020, the patient evolved with left sigmoid sinus thrombosis, treated with anticoagulation.

OCTOBER, 2021

• Venous congestion in both cerebral and cerebellar hemispheres.
• Reflux of venous drainage from the shunt of the dural fistula into the deep venous system towards the basal veins of Rosenthal.
• Occlusion of the basilar artery in its middle third.
• The patient evolved with increased intracranial pressure, requiring a ventriculoperitoneal shunt.

JANUARY, 2022

• The patient came to the emergency room due to encephalopathy and seizures.
• MRI-angiography showed diffuse brain edema, cerebral venous thrombosis with venous infarction and bleeding, intracranial hypertension, and impaired venous drainage of the posterior fossa.

ENDOVASCULAR TREATMENT WITH VENOUS AND ARTERIAL EMBOLIZATION OF THE ARTERIOVENOUS FISTULAS

• Transvenous coiling and embolic liquid injection in the pathological venous sinuses.

POST-EMBOLIZATION ANGIOGRAPHY

MULTIPLE DURAL ARTERIOVENOUS FISTULAS

• Radical treatment is considered more appropriate, as partial obliteration of the DAVFs increases the difficulty of subsequent therapy.
• One priority of treatment is to target fistulas with cortical venous reflux with a higher Borden/Cognard classification.
• Treatment in multiple stages, focused on decreasing venous hypertension and improving cerebral hemodynamics rather than completely obliterating all fistulas.
• It is important to obtain a precise understanding of each DAVF's vascular anatomy, as not all fistulas contribute to venous hypertension.