Intracranial dural arteriovenous fistula with perimedullary drainage treated by endovascular embolization

Fístula arteriovenosa dural intracraniana com drenagem perimedular tratada por embolização via endovascular

A 66-year-old woman presenting progressive tetraparesis during the past month. Magnetic resonance (MR) showed nonspecific abnormalities in the cervical spinal cord (Figure 1), which could be related to demyelination, neoplasia or inflammation¹. However, these findings, in concomitance with extensive dilated perimedullary vessels, suggested myelopathy secondary to dural arteriovenous fistula (DAVF).

Figure 1
(A) Sagittal T2-weighted MRI of the cervical spine showing enlargement and signal change of spinal cord and bulb, characterizing myelopathy due to venous congestion. We can also see images of flow artifacts corresponding to enlarged perimedullary veins. (B) Coronal T1-weighted MRI after contrast injection showing venous ectasia around the bulb and spinal (white arrows).

Digital angiography identified a Cognard type V intracranial DAVF (Figure 2). After prompt endovascular treatment (Figure 3), complete remission of symptoms was obtained.

Figure 2
Digital angiography showing right sigmoid sinus DAVF (Cognard classification type V) being fed by transosseous branches of the right occipital artery (A) (white arrows), with cortical venous drainage through ectatic and tortuous perimedullary veins (B) (white arrows).

Figure 3
(A) and (B) Digital angiography after endovascular embolization with Onyx (Medtronic) showing resolution of the fistula. (C) Sagittal T2-weighted MRI of the cervical spine, at 3 months after treatment, demonstrating no evidence of cervical myelopathy or dilated vascular structures, with complete regression of the intramedullary edema.

Despite its intracranial location, type V DAVF presents, by definition, perimedullary venous drainage, which leads to venous congestion, and, consequently, intramedullary edema, progressive myelopathy and chronic hypoxia^1,2,3.

References

• ¹
  Ernst RJ, Gaskill-Shipley M, Tomsick TA, Hall LC, Tew JM Jr, Yeh HS. Cervical myelopathy associated with intracranial dural arteriovenous fistula: MR findings before and after treatment. AJNR Am J Neuroradiol. 1997;18(7):1330-4.
• ²
  Cognard C, Gobin YP, Pierot L, Bailly AL, Houdart E, Casasco A et al. Cerebral dural arteriovenous fistulas: clinical and angiographic correlation with a revised classification of venous drainage. Radiology. 1995;194(3):671-80. doi:10.1148/radiology.194.3.7862961
• ³
  Abud TG, Nguyen A, Saint-Maurice JP, Abud DG, Bresson D, Chiumarulo L, Enesi E, Houdart E. The use of Onyx in different types of intracranial dural arteriovenous fistula. AJNR Am J Neuroradiol. 2011;32(11):2185-91. doi:10.3174/ajnr.A2702

Publication Dates

• Publication in this collection
  20 Oct 2015
• Date of issue
  Feb 2016

History

• Received
  27 June 2015
• Received
  18 Aug 2015
• Accepted
  11 Sept 2015