CASE REPORT Multiple dural arteriovenous fistulas developing after total removal of parasagittal meningioma: a case successfully treated with transvenous embolization I. Sakuma a , S. Takahashi a , K. Ishiyama a , N. Tomura a , J. Watarai a , T. Yanagisawa b , K. Mizoi b, * Departments of a Radiology, and b Neurosurgery, University of Akita, Akita, Japan Introduction Dural arteriovenous fistulas (dAVFs) have recently been recognized as resulting from several acquired factors, such as venous sinus thrombosis, 1,2 intra- venous hypertension, 3,4 head injury 5 and surgery. 6–8 Although cases of post-operative dAVF have been reported, most of these lesions have been located close to the operation site. 6,7 However, we encoun- tered a case of multiple dAVFs that developed distant to the preceding surgery. This report discusses the pathogenesis of post-operative dAVFs and reviews the literature concerning the treatment of dAVFs occurring at the skull base. Case reports A 52-year-old woman developed sudden weakness of her left lower extremity. She presented to a hospital and underwent computed tomography (CT) of the brain, which revealed a tumour. She was referred to our institution for further examination and treatment. Magnetic resonance imaging (MRI) identified a large extra-axial mass in the right parietal region. The mass attached to the right parasagittal region, and extended into the superior sagittal sinus (SSS; Fig. 1(a)). Cerebral angiography demonstrated tumour staining in the typical sun- burst appearance characteristic of meningioma. Dilated anterior and posterior branches of the right middle meningeal artery (MMA) supplied the tumour (Fig. 1(b)). The venous phase of the right internal carotid angiography revealed occlusion of the posterior part of the SSS. Collateral venous flow ran from the SSS into the right internal jugular vein through the diploic veins of the right posterior fossa (Fig. 1(c)). The tumour was totally resected, and histologically diagnosed as angiomatous menin- gioma. The post-operative course was uneventful, and the patient was followed up at another hospital. Approximately 3 months post-operatively, the patient complained of right-sided pulsatile tinnitus and cerebral angiography was performed. Right external carotid angiography demonstrated dAVF of the right posterior fossa, supplied by the right MMA and occipital artery with venous drainage into the right internal jugular vein and occipital vein via a dilated diploic vein through the occipital bone (Fig. 2(a)–(c)). In addition, right vertebral angiography demon- strated an additional dAVF of the right suboccipital cavernous sinus and vertebral venous plexus (VVP), supplied by the meningeal branches of the right vertebral artery with venous drainage into right internal jugular vein via the right anterior condylar vein (Fig. 2(d) and (e)). Endovascular embolization was performed for the dAVFs in two sessions. First embolization was performed for the dAVF of the right posterior fossa. A guiding catheter was placed in the right jugular bulb using a transfemoral approach, and a microcatheter was navigated into the diploic vein. Another guiding catheter was positioned in the right external carotid artery via the left femoral artery. Transvenous embolization (TVE) using Guglielmi detachable coils (GDCs) was initiated from the distal portion of the diploic vein. A microcatheter was subsequently navigated into the right MMA, and transarterial embolization (TAE) was performed using polyvinyl alcohol foam (PVA) particles and Berenstein liquid coils (Boston Scientific, Natick, MA, USA). TVE was continued after TAE and the diploic vein was totally embolized, including an emissary vein from the occipital region. Right external carotid angiography immediately after the first embolization demon- strated marked reduction of the dAVF in the right posterior fossa. Twelve days later, a second embolization was performed for the dAVF around the right vertebral artery. A guiding catheter was placed in the right anterior condylar vein using a transfemoral approach, and a microcatheter was navigated into the right vertebral venous plexus just below the suboccipital cavernous sinus. TVE was performed using interlocking detachable coils (IDCs) in the right vertebral venous plexus and suboccipital cavernous sinus, in that order. Right vertebral angiography immediately after the second embolization again demonstrated marked reduction of the dAVF around the right vertebral artery. 1477-6804/$ - see front matter q 2003 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. doi:10.1016/S1477-6804(03)00032-3 Clinical Radiology Extra (2004) 59, 3–7 * Guarantor and correspondent: I. Sakuma, Department of Radiology, University of Akita, Hondo 1-1-1, Akita city, Japan 010-8543. Tel.: þ 81-18-8341111; fax: þ81-18-8362623. E-mail address: [email protected]
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CASE REPORT
Multiple dural arteriovenous fistulas developingafter total removal of parasagittal meningioma:a case successfully treated with transvenousembolization
I. Sakumaa, S. Takahashia, K. Ishiyamaa, N. Tomuraa, J. Wataraia,T. Yanagisawab, K. Mizoib,*
Departments of aRadiology, and bNeurosurgery, University of Akita, Akita, Japan
Introduction
Dural arteriovenous fistulas (dAVFs) have recentlybeen recognized as resulting from several acquiredfactors, such as venous sinus thrombosis,1,2 intra-venous hypertension,3,4 head injury5 and surgery.6–8
Although cases of post-operative dAVF have beenreported, most of these lesions have been locatedclose to the operation site.6,7 However, we encoun-tered a case of multiple dAVFs that developeddistant to the preceding surgery. This reportdiscusses the pathogenesis of post-operativedAVFs and reviews the literature concerning thetreatment of dAVFs occurring at the skull base.
Case reports
A 52-year-old woman developed sudden weakness of her leftlower extremity. She presented to a hospital and underwentcomputed tomography (CT) of the brain, which revealed atumour. She was referred to our institution for furtherexamination and treatment. Magnetic resonance imaging (MRI)identified a large extra-axial mass in the right parietal region.The mass attached to the right parasagittal region, and extendedinto the superior sagittal sinus (SSS; Fig. 1(a)). Cerebralangiography demonstrated tumour staining in the typical sun-burst appearance characteristic of meningioma. Dilated anteriorand posterior branches of the right middle meningeal artery(MMA) supplied the tumour (Fig. 1(b)). The venous phase of theright internal carotid angiography revealed occlusion of theposterior part of the SSS. Collateral venous flow ran from the SSSinto the right internal jugular vein through the diploic veins of
the right posterior fossa (Fig. 1(c)). The tumour was totallyresected, and histologically diagnosed as angiomatous menin-gioma. The post-operative course was uneventful, and thepatient was followed up at another hospital. Approximately 3months post-operatively, the patient complained of right-sidedpulsatile tinnitus and cerebral angiography was performed. Rightexternal carotid angiography demonstrated dAVF of the rightposterior fossa, supplied by the right MMA and occipital arterywith venous drainage into the right internal jugular vein andoccipital vein via a dilated diploic vein through the occipital bone(Fig. 2(a)–(c)). In addition, right vertebral angiography demon-strated an additional dAVF of the right suboccipital cavernoussinus and vertebral venous plexus (VVP), supplied by themeningeal branches of the right vertebral artery with venousdrainage into right internal jugular vein via the right anteriorcondylar vein (Fig. 2(d) and (e)). Endovascular embolization wasperformed for the dAVFs in two sessions. First embolization wasperformed for the dAVF of the right posterior fossa. A guidingcatheter was placed in the right jugular bulb using a transfemoralapproach, and a microcatheter was navigated into the diploicvein. Another guiding catheter was positioned in the rightexternal carotid artery via the left femoral artery. Transvenousembolization (TVE) using Guglielmi detachable coils (GDCs) wasinitiated from the distal portion of the diploic vein. Amicrocatheter was subsequently navigated into the right MMA,and transarterial embolization (TAE) was performed usingpolyvinyl alcohol foam (PVA) particles and Berenstein liquidcoils (Boston Scientific, Natick, MA, USA). TVE was continuedafter TAE and the diploic vein was totally embolized, including anemissary vein from the occipital region. Right external carotidangiography immediately after the first embolization demon-strated marked reduction of the dAVF in the right posterior fossa.Twelve days later, a second embolization was performed for thedAVF around the right vertebral artery. A guiding catheter wasplaced in the right anterior condylar vein using a transfemoralapproach, and a microcatheter was navigated into the rightvertebral venous plexus just below the suboccipital cavernoussinus. TVE was performed using interlocking detachable coils(IDCs) in the right vertebral venous plexus and suboccipitalcavernous sinus, in that order. Right vertebral angiographyimmediately after the second embolization again demonstratedmarked reduction of the dAVF around the right vertebral artery.
1477-6804/$ - see front matter q 2003 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.doi:10.1016/S1477-6804(03)00032-3
Clinical Radiology Extra (2004) 59, 3–7
*Guarantor and correspondent: I. Sakuma, Department ofRadiology, University of Akita, Hondo 1-1-1, Akita city, Japan010-8543. Tel.: þ81-18-8341111; fax: þ81-18-8362623.
E-mail address: [email protected]
The pulsatile tinnitus disappeared immediately after the firstembolization. Cerebral angiography 3 months after the secondembolization revealed disappearance of both dAVFs (Fig. 3(a)and (b)). As of 1 year after embolization, the patient hasdemonstrated no recurrence of symptoms.
Discussion
dAVFs involve arteriovenous shunts from the duralarterial supply to dural venous drainage, andaccount for 10–15% of all intra-cranial arteriove-nous malformations.9 The pathogenesis of dAVFsremains controversial. Formerly, congenitalanomalies of the dural vessels were consideredlikely to contribute to development of dAVFs.10 –12
More recently relationships with acquired factors,including surgery, have been noted by manyauthors.1 –8 Among reported cases of dAVFs devel-oping after surgery, most appeared close to the siteof operation.6,7 Conversely, development of dAVFsat a site different from that of the previous surgeryis very rare.8 In the present case, surgical inter-vention in the supratentorial region preceded thedevelopment of multiple dAVFs in the infratentorialregion. The pathogenesis of dAVFs remote from anoperation site is unclear, but might be bestexplained by changes in venous haemodynamics.4
In the present case, dAVF of the right posteriorfossa might have been precipitated by venousheamodynamic changes resulting from the oper-ation. The SSS had been occluded by meningioma.After the collateral pathway through the diploicvein was blocked by craniotomy, thrombosis of thediploic vein in the right posterior fossa may haveresulted, leading to subsequent development ofdAVF of the right posterior fossa. However, thepathogenesis of the second dAVF around the rightvertebral artery remains unexplained.
Several therapeutic options are available fordAVFs, from conservative therapies such asrepeated manual compression to direct surgicalresection or isolation of the involved sinus, and
Figure 1 (a) Axial T2-weighted MRI reveals an extra-axial mass in the right parietal region, involving the SSS.(b) Lateral projection of the right external carotidangiography reveals typical sun-burst appearance,characteristic of meningioma. Dilated anterior andposterior branches (arrows) of the MMA supply themeningioma. (c) Lateral projection of the right internalcarotid angiography (venous phase) reveals occlusion ofthe posterior part of the SSS (arrows). Note the collateralpathway from SSS through the diploic veins of the rightposterior fossa into the right internal jugular vein(arrowheads).
I. Sakuma et al.4
Figure 2 (a) Lateral projection of the right external carotid angiography demonstrates dAVF supplied by the posteriorbranch of the right MMA (small arrows) and occipital artery (large arrows), with venous drainage through the diploicvein of the right posterior fossa (arrowhead) into the right internal jugular vein. (b) Contrast-enhanced, axial, three-dimensional spoiled gradient echo (3D-SPGR) MRI shows an abnormally dilated diploic vein in the right side of theoccipital bone (arrowhead). (c) Oblique sagittal 3D-SPGR MRI demonstrates a narrow junction between the diploic andright internal jugular veins (white arrow). (d) Frontal and (e) lateral projections of right vertebral angiographydemonstrate dAVF of the right suboccipital cavernous sinus (arrows) and vertebral venous plexus (VVP) (closedarrowheads), with venous drainage into the right internal jugular vein (open arrows) via the anterior condylar vein(open arrowheads).
Multiple dural arteriovenous fistulas developing after total removal of parasagittal meningioma 5
endovascular treatment. Recently, treatment ofdAVF solely by endovascular therapy has becomepossible, using techniques such as TAE and TVE.13 Asarteriovenous shunts may be located in the wall ofthe venous sinus itself,1 dAVFs treated using TAE
only sometimes recur. Complete packing of theinvolved dural sinus with coils is therefore necess-ary to obtain permanent cure.14 Before TVEs,careful assessment of the location of the fistulaand the pattern of venous drainage is required toallow successful and safe coil embolization. Ingeneral, positioning microcatheters is relativelyeasy using a transvenous approach to the transversesinus and sigmoid sinus, which are frequentlyinvolved with dAVFs. In the present case, however,approaching involved veins, such as the diploic veinof the posterior fossa and veins at the craniocervi-cal junction, was difficult. Ernst et al.15 reportedthree cases of dAVFs of treatment of the anteriorcondylar vein using transvenous coil embolization.They identified the exact location of the fistula anddraining vein with reference to source images fromMR angiography before TVE, to allow venous access.The anatomy of the draining veins in the presentcase was therefore precisely evaluated with refer-ence to angiography and MRI (contrast-enhanced,three-dimensional spoiled gradient echo: 3D-SPGR)before embolizations.
References
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Figure 3 (a) Lateral projection of the right carotidangiography and (b) right vertebral angiography 3 monthsafter embolization, revealing disappearance of multipledAVFs.
I. Sakuma et al.6
11. Newton TH, Weidner W, Greiz T. Dural arteriovenous malfor-mation in the posterior fossa. Radiology 1968;90:27—30.
12. Chaudhary MY, Sachdev VP, Cho SH, Weitzner Jr I, Puljic S,Huang YP. Dural arteriovenous malformation of the majorvenous sinuses: an acquired lesion. AJNR Am J Neuroradiol1982;3:13—19.
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