Neurological manifestations of intracranial dural arteriovenous malformations

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✓ The authors describe their experience with four cases of dural arteriovenous malformation (AVM) which led them to analyze the clinical aspects of these lesions in an attempt to understand their pathophysiology. An additional 191 previously reported cases of dural AVM's were reviewed with special attention to the mechanism of intradural, central, and peripheral nervous system manifestations. Apart from the peripheral cranial nerve symptoms, which are most likely due to arterial steal, the central nervous system (CNS) symptoms appear to be related to passive venous hypertension and/or congestion. Generalized CNS symptoms can be related to cerebrospinal fluid malabsorption due either to increased pressure in the superior sagittal sinus, to venous sinus thrombosis, or to meningeal reaction resulting from minimal subarachnoid hemorrhages. These phenomena are not related to the anatomical type of venous drainage. On the other hand, focal CNS symptoms are specifically indicative of cortical venous drainage. Seizures, transient ischemic attacks, motor weakness, and brain-stem and cerebellar symptoms can be encountered depending on the territory of the draining vein or veins. Therefore, the localizing value of focal CNS symptomatology relates to the venous territory and not to the nidus or to the arterial supply characteristics of dural AVM's. Furthermore, the venous patterns of various dural AVM's at the base of the skull are expressed by differences in their clinical presentation. Dural AVM's of the floor of the anterior cranial fossa and of the tentorium are almost always drained by the cortical veins and, therefore, have a high risk of intradural bleeding.

The remarkable similarities in the manifestations of dural and brain AVM's and the differences in the manifestations of dural and spinal dural AVM's are pointed out. High-quality angiograms and a multidisciplinary approach to the study of dural AVM's will provide the best understanding of their symptoms and, therefore, the most appropriate treatment strategy.

Article Information

Address reprint requests to: Pierre Lasjaunias, M.D., Department of Radiology, Toronto Western Hospital, 399 Bathurst Street, Toronto, Ontario, Canada M5T 2S8.

© AANS, except where prohibited by US copyright law.

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Figures

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    Selective right middle meningeal arteriograms, lateral view. Left: Case 1. A dural arteriovenous malformation (AVM) can be seen in the right cavernous sinus. Note the arterial ectasia at the level of the petrous branch of the middle meningeal artery (double arrow) and the venous drainage into the cavernous sinus (arrow). There is no evidence of posterior drainage toward the inferior petrosal sinus (compare with Fig. 1 right). The major complaint was proptosis. Right: Case 2. A dural AVM can be seen in the left cavernous sinus. Note that the arterial supply and the arterial ectasia (double arrow) are the same as shown left. However, the major complaint was pulsatile tinnitus. The posterior veins drain into the inferior petrosal sinus (curved arrow) with no ophthalmic vein involvement. This accounts for the difference in symptoms between Cases 1 and 2.

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    Case 3. Selective internal carotid (A and B) and occipital (C and D) angiograms in the early (A and C) and late (B and D) phases. A dural arteriovenous malformation (AVM) of the transverse sinus is shown, fed by the basal tentorial artery (arrow) and mastoid artery (double arrow) and a transosseous branch (open curved arrow). Although the primary drainage route of the dural AVM is via the sinus (black curved arrow), proximal and distal thrombosis of the sinus (asterisks) causes rerouting of the venous outflow toward the cerebral veins (open arrows) into the vein of Labbé. Note that at the late phase of the internal carotid arteriogram (B) the remaining venous drainage of the brain is rerouted toward the superior longitudinal sinus and the opposite transverse and sigmoid sinus.

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    Case 4. Selective angiograms, lateral projection, of the internal carotid (A), distal external carotid (B), and the ascending pharyngeal (C) arteries. A tentorial arteriovenous malformation (AVM) (at the medial one-third of the tentorium) is demonstrated on the left side, with middle meningeal, ascending pharyngeal, and internal carotid arterial supply (arrows). The dural AVM is draining via the petrosal and lateral mesencephalic veins into the supratentorial cortical veins (open curved arrows). Note the late filling of the temporal vein (arrowhead) and basal vein of Rosenthal (double arrowhead).

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    Schematic representation of the most common locations of dural arteriovenous malformations (asterisks), with their possible routes of venous drainage. Black arrows correspond to sinus drainage and open arrows to cortical (or intradural) venous drainage. 1 = Anterior cranial fossa: frontal and olfactory veins. 2 = Anterior cavernous sinus: ophthalmic vein, Breschet's sinus, and deep sylvian vein. 3 = Posterior cavernous sinus: superior and inferior petrosal sinuses. 4 = Sigmoid sinus: sigmoid sinus and internal jugular vein. 5 = Transverse sinus: sigmoid sinus and temporal veins (vein of Labbé). 6 = Torcular: medial occipital and infratemporal veins. 7 = Basal tentorium: superior petrosal sinus and petrous vein. 8 = Marginal tentorium: tentorial veins, vein of Rosenthal, and lateral mesencephalic veins.

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