J Cerebrovasc Endovasc Neurosurg.  2014 Jun;16(2):98-103. 10.7461/jcen.2014.16.2.98.

Pial Arteriovenous Fistula with Giant Varices: Report of Two Cases with Good Surgical Outcome

• Jouibari M
• Zadeh MZ
• Khadivi M
• Khoshnevisan A
• Moazzeni K
• Abdollahzade S

• KMID: 1963177
• DOI: http://doi.org/10.7461/jcen.2014.16.2.98

Abstract

Pial arteriovenous fistulas (pAVF) are rare vascular lesions consisting of one or more arterial connections to a single venous channel without any intervening nidus of vessels or capillaries. Case 1: A 65-year-old woman with a complaint of headache and left hand paresthesia was referred to us. Magnetic resonance imaging showed a large saccular lesion with signal void in the posterior part of the right sylvian fissure and catheter angiography showed a giant venous aneurysm fed by one branch of the middle cerebral artery (MCA) and draining into the vein of Trolard. Case 2: A 12-year-old boy was transferred to our hospital with a history of sudden loss of consciousness and hemiplegia. Brain computed tomography revealed a massive hemorrhagic mass in the right hemisphere and cerebral angiography showed a pAVF with a large aneurysmal varix, which was fed by multiple branches of the right MCA and draining into the superior sagittal sinus. Both patients underwent craniotomy and after ligation of vascular connections, aneurysmal varices were removed completely. Surgical resection can be a safe method for treatment of pAVFs, particularly in those with large varices.

Keyword

Pial arteriovenous fistulas; Microsurgery

MeSH Terms

Aged
Aneurysm
Angiography
Arteriovenous Fistula*
Brain
Capillaries
Catheters
Cerebral Angiography
Child
Craniotomy
Female
Hand
Headache
Hemiplegia
Humans
Ligation
Magnetic Resonance Imaging
Male
Microsurgery
Middle Cerebral Artery
Paresthesia
Superior Sagittal Sinus
Unconsciousness
Varicose Veins*
Veins

Figure

• 

  Fig. 1 (A) Brain computed tomography showing a saccular mass with mural calcification in the right sylvian fissure. (B) Magnetic resonance imaging shows flow void within the lesion. (C) Right carotid angiogram (AP view) shows a giant venous aneurysm fed by one branch of the middle cerebral artery and draining via the vein of Trolard into the superior Sagittal sinus (black arrow). (D) After disconnection of the varix, it was resected totally. (E) Microscopic examination of the resected specimen reveals fragments of hyalinized and calcified vessles with myxoid changes.

• 

  Fig. 2 (A) Brain computed tomography showing a hemorrhagic mass in the right parietal area with calcification and dilation of cortical vessels. (B) On lateral view of the right carotid angiogram, multiple branches of the middle cerebral artery are connected directly to the venous system and there is a large venous varix. (C) Intraoperative image shows the varix and associated vessels, which are surrounded by arachnoid. (D) After obliteration of feeding arteries (applied clips are evident) and draining vein, en bloc removal was achieved.

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