J Cerebrovasc Endovasc Neurosurg.  2016 Dec;18(4):396-401. 10.7461/jcen.2016.18.4.396.

Spontaneous Aggressive Conversion of Venous Drainage Pattern in Dural Arteriovenous Fistula Treated with Onyx Embolization

• Chung Y
• Choi SK
• Lee SH
• Kim EJ

• KMID: 2367333
• DOI: http://doi.org/10.7461/jcen.2016.18.4.396

Abstract

We report a case of dural arteriovenous fistula (DAVF) that showed spontaneous conversion of venous drainage pattern from Borden type II to type III within a four month period of follow-up. Upon admission, the patient presented with aggravated neurologic status and newly developed seizure. After admission, endovascular embolization was performed through the middle meningeal artery with Onyx®. Complete obliteration of dural arteriovenous shunt was confirmed by angiography, and the patient's clinical symptoms improved. Although most cases of DAVF show benign clinical course and conversion pattern, close follow-up is required to detect potential aggravation.

Keyword

Conversion of venous drainage pattern; Cortical venous reflux; Dural arteriovenous fistula; Onyx embolization

MeSH Terms

Angiography
Central Nervous System Vascular Malformations*
Drainage*
Follow-Up Studies
Humans
Meningeal Arteries
Seizures

Figure

• 

  Fig. 1 Initial DSA of the patient (A : AP view of the right ECA angiography, B : AP view of the left ECA angiography) show hypervascular lesion and revealing dural arteriovenous fistula. (A) Right middle meningeal artery and superficial temporal artery supplied blood flow into superior saggital sinus via arteriovenous shunt. (B) Left middle meningeal artery supplied blood flow into superior saggital sinus via arteriovenous shunt. And there is stenosis at the proximal portion of superior saggital sinus. Cortical venous reflux is shown from superior saggital sinus to left cerebral hemisphere. DSA = digital subtraction angiography; AP = anteroposterior; ECA = external carotid artery.

• 

  Fig. 2 Brain MRI performed when second admission after four months later from initial radiologic examination, show subacute focal infarction with minimal hemorrhagic transformation. (A) T2-weighted flair image show high signal intensity of left frontal lobe suggesting subacute cerebral infarction. (B) GRE image show multiple small low signal lesions suggesting minimal hemorrhagic transformation. (C) Mild gyral enhancement at the left frontal lobe is observed in gadolinium enhancement image. MRI = magnetic resonance image; GRE = gradient echo.

• 

  Fig. 3 Follow-up DSA after five months later from initial DSA revealing the change of venous drainage pattern. (A) Disappearance of arteriovenous shunting lesion in right ECA (external carotid artery) angiography. (B) Retrograde cortical venous reflux is shown without enhancement of superior saggital sinus in AP view of left ECA angiography. (C) There is stenotic lesion between the refluxed cortical vein and superior saggital sinus in lateral view of left ECA angiography. DSA = digital subtraction angiography; ECA = external carotid artery; AP = anteroposterior.

• 

  Fig. 4 After six days from second admission, Onyx embolization was performed. (A) Superselected left MMA with microcatheter and double micro-guidewire. AP view (B) and lateral view (C) after Onyx embolization show disappearance both of arteriovenous shunting lesion and cortical venous reflux. MMA = middle meningeal artery; AP = anteroposterior.

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