J Cerebrovasc Endovasc Neurosurg.  2024 Mar;26(1):79-84. 10.7461/jcen.2023.E2022.12.001.

Spontaneous occlusion of a pial arteriovenous fistula after angiography: The role of iodinated contrast media

• John S
• Maiti TK
• Kesav P
• Arif A
• Hussain SI

• KMID: 2554050
• DOI: http://doi.org/10.7461/jcen.2023.E2022.12.001

Abstract

Intracranial non-galenic pial arteriovenous fistula (PAVF) is an extremely rare vascular malformation, where one or more pial arteries feeds directly into a cortical vein without any intervening nidus. Though occasionally they can be asymptomatic, neurological symptoms such as headache, seizure, or focal neurological deficit are more common presenting features. Life threatening or fatal hemorrhage is not uncommon, hence needed to be treated more often than not. Spontaneous occlusion of PAVF is reported only four times before. We report a 49-year-old gentleman, who was diagnosed to have a PAVF, possibly secondary to trauma. He presented 5 months and 22 days from initial digital subtraction angiography (DSA) for treatment, and follow-up angiogram showed complete obliteration. He denied any significant event, medication or alternate treatment during this period. His clinical symptoms were stable as well. We postulate iodinated contrast medium induced vasculopathy as a possible cause, which has been described for other vascular pathologies, but never for PAVF.

Keyword

Central nervous system vascular malformations; Pial arteriovenous fistula; Spontaneous occlusion; Contrast agents; Iodine

Figure

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  Fig. 1. MRI brain before diagnostic angiogram: A-D; MRI after second angiogram: E-H. (A) T2 FLAIR sequence shows right frontal, left frontal and left parieto-occipital signal changes, likely sequelae of previous head trauma. (B) T2 sequence shows venous varix. (C) T2 sequence shows right MCA aneurysm and prominent ectatic basal vein of Rosenthal. (D) MRA sequence shows MCA aneurysm from right orbitofrontal MCA. (E) T2 FLAIR sequence shows right frontal, left frontal and left parieto-occipital signal changes remaining same as pre-procedure suggesting no fresh changes. (F) T2 sequence shows venous varix is completely obliterated. (G) T2 sequence shows right MCA aneurysm and prominent ectatic basal vein of Rosenthal completely occluded. (H) MRA sequence shows complete occlusion of MCA aneurysm. MRI, Magnetic resonance imaging; MCA, middle cerebral artery

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  Fig. 2. Diagnostic angiogram: A-D; Angiogram during intended treatment: 6 months after index diagnostic angiogram (second angiogram): E-H. (A) Right ICA injection: arterial phase: antero-posterior projection: fusiform aneurysm from right orbitofrontal branch of middle cerebral artery. (B) Right ICA injection: arterial phase: lateral projection: showing same as A. (C) Right ICA injection: Venous phase: antero-posterior projection: venous varix at the start of basal vein of Rosenthal with prominent ectatic course of vein. (D) Right ICA injection: Venous phase: lateral projection: showing venous varix and ectatic basal vein of Rosenthal. (E) Right ICA injection: arterial phase: antero-posterior projection: complete occlusion of fusiform aneurysm. (F) Right ICA injection: arterial phase: lateral projection: no residual aneurysm. (G) Right ICA injection: Venous phase: antero-posterior projection: complete occlusion of venous varix and basal vein of Rosenthal. (H) Right ICA injection: Venous phase: lateral projection: showing complete occlusion of venous varix and basal vein of Rosenthal. ICA, internal carotid artery

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