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Arquivos de Neuro-Psiquiatria

Print version ISSN 0004-282XOn-line version ISSN 1678-4227

Arq. Neuro-Psiquiatr. vol.76 no.8 São Paulo Aug. 2018 

Images in Neurology

Added value of arterial spin-labeling (ASL) and susceptibility weighted-images (SWI) in detecting a mild symptomatic intracranial arteriovenous fistula

A importância das técnicas arterial spin-labeling e susceptibility weighted-images na detecção de fistulas arteriovenosas

Felipe T. Pacheco1  2 

Bruna Bianca Allegro1  2 

Igor Gomes Padilha1  2 

Renato Hoffmann Nunes1  2 

Antônio José da Rocha1  2 

1Faculdade de Medicina da Santa Casa de São Paulo, Divisão de Neurorradiologia, São Paulo SP, Brasil;

2Diagnósticos da América, São Paulo SP, Brasil.

Dural arteriovenous fistulas consist of a direct arteriovenous shunt, across the dural layer, without an intervening capillary nidus. An intracranial dural arteriovenous fistula diagnosis remains challenging as symptoms vary according to their span1.

A 26-year-old woman presented with left pulsatile tinnitus one year after an intracranial venous thrombosis. Conventional brain MRI sequences were unremarkable. However, arterial spin-labeling and susceptibility weighted imaging suggested blood flow abnormalities in the left posterolateral tentorial region (Figure), supporting suspicion of a dural arteriovenous fistula. This diagnosis was confirmed by magnetic resonance angiography, allowing appropriate treatment. This report reinforces the importance of these new techniques on high magnetic field MRI to confidently reveal some vascular disorders that have remained obscured until recently. It is also important to highlight the advantage that both techniques do not require contrast administration2.

Figure (A) Abnormal signal intensities due to oxygenated blood in arterial reflux into venous system (transverse and sagittal superior sinuses depicted on arterial spin-labeling perfusion – arrows) and (B) axial susceptibility weighted image (arrow). Sagittal maximum intensity projection (C) identified prominent left occipital artery (dotted arrow) and the connections between small adjacent transosseous branches and dural sinus, confirming a dural arteriovenous fistula (arrow). Coronal magnetic resonance angiography using maximum intensity projection (D) showed numerous extradural arteries converging to the posterolateral petrotentorial region (arrows). 


1. Reynolds MR, Lanzino G, Zipfel GJ. Intracranial dural arteriovenous fistulae. Stroke. 2017;48(5):1424-31. ]

2. Hodel J, Leclerc X, Kalsoum E, Zuber M, Tamazyan R, Benadjaoud MA et al. Intracranial arteriovenous shunting: detection with arterial spin-labeling and susceptibility-weighted imaging combined. AJNR Am J Neuroradiol. 2017 Jan;38(1):71-6. ]

Received: February 18, 2018; Revised: March 19, 2018; Accepted: March 31, 2018

Correspondence: Felipe T. Pacheco; Rua Doutor Cesário Motta Junior 112; 01221-020 São Paulo SP, Brasil. E-mail:

Author Contributions: Dra. Allegro, Dr. Padilha and Dr. Nunes: data collection and drafting the manuscript; Dr. Pacheco and Dr. Rocha: study concept and revising the manuscript.

Conflict of interest: There is no conflict of interest to declare.

Creative Commons License This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.