Fatal progression of posttraumatic dural arteriovenous fistulas refractory to multimodal therapy

Case report

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✓ The authors report the case of a man who suffered from progressive, disseminated posttraumatic dural arteriovenous fistulas (DAVFs) resulting in death, despite aggressive endovascular, surgical, and radiosurgical treatment.

This 31-year-old man was struck on the head while playing basketball. Two weeks later a soft, pulsatile mass developed at his vertex, and the man began to experience pulsatile tinnitus and progressive headaches. Magnetic resonance imaging and subsequent angiography revealed multiple AVFs in the scalp, calvaria, and dura, with drainage into the superior sagittal sinus. The patient was treated initially with transarterial embolization in five stages, followed by vertex craniotomy and surgical resection of the AVFs. However, multiple additional DAVFs developed over the bilateral convexities, the falx, and the tentorium. Subsequent treatment entailed 15 stages of transarterial embolization; seven stages of transvenous embolization, including complete occlusion of the sagittal sinus and partial occlusion of the straight sinus; three stages of stereotactic radiosurgery; and a second craniotomy with aggressive disconnection of the DAVFs. Unfortunately, the fistulas continued to progress, resulting in diffuse venous hypertension, multiple intracerebral hemorrhages in both hemispheres, and, ultimately, death nearly 5 years after the initial trauma.

Endovascular, surgical, and radiosurgical treatments are successful in curing most patients with DAVFs. The failure of multimodal therapy and the fulminant progression and disseminated nature of this patient's disease are unique.

Article Information

Address reprint requests to: Jonathan A. Friedman, M.D., Department of Neurologic Surgery, Joseph 1–229, Saint Mary's Hospital, 1216 Second Street SW, Rochester, Minnesota 55905. email: friedman.jonathan@mayo.edu.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Angiograms. Left: Lateral view (left internal maxillary artery injection) demonstrating multiple feeding arteries supplying a DAVF near the midline. Right: Lateral view (right ICA injection) demonstrating an enlarged branch of the meningohypophyseal trunk supplying a tentorial DAVF.

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    Upper Left: Axial T2-weighted MR image revealing left cerebellar hemorrhage. Upper Right: Anteroposterior angiogram (left ICA injection) demonstrating a DAVF of the SSS with some arterial supply from the middle and anterior cerebral arteries. Lower Left: Lateral angiogram (right internal maxillary artery injection) demonstrating multiple DAVFs with occlusion of a segment of SSS. Lower Right: Anteroposterior angiogram (left occipital artery injection) demonstrating multiple DAVFs within the posterior fossa.

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    Left: A CT scan demonstrating biparietal hypodensities that are consistent with worsening venous edema. Center: Anteroposterior angiogram (left ICA injection) demonstrating bilateral convexity DAVFs. Right: Lateral angiogram (left VA injection) demonstrating DAVFs located at the tentorium, falx, transverse sinus, and jugular bulb.

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    Left: Lateral angiogram (left VA injection, late arterial phase) demonstrating many diffuse DAVFs. Multiple intravascular platinum coils can be seen. Right: Lateral angiogram (left VA injection, late venous phase) demonstrating retrograde venous drainage into a dilated, corkscrewlike basal vein of Rosenthal.

  • View in gallery

    Left: A CT scan demonstrating right parietal hemorrhage with an intravascular coil artifact. Right: Lateral angiogram (left VA injection, late venous phase) demonstrating disseminated posterior fossa DAVFs with delayed, retrograde venous drainage and dilated, corkscrewlike veins.

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