INTRACEREBRAL HEMORRHAGE / VASCULAR MALFORMATIONS

Dural arteriovenous fistula (DAVF)

Created 21.10.2019, last update 25.03.2022

  • dural arteriovenous fistula (DAVF) is characterized by abnormal connections (shunts) between an artery and a vein; DAVF usually presents with tinnitus, hemorrhage, or venous hypertension
  • DAVF accounts for about 10-15% of vascular malformations; it mostly affects patients aged 40-60 years
  • most DAVFs are idiopathic; some patients have a history of previous craniotomy, head trauma, or dural sinus thrombosis  [Gandhi, 2012]

Pathology

  • commonly, multiple feeders are present
    • supratentorial
      • middle meningeal artery, superficial temporal artery (ECA)
      • ethmoidal branches of the ophthalmic artery
    • cavernous sinus (ICA and/or ECA branches)  → carotid-cavernous fistula (CCF)
    • posterior fossa
      • vertebral arteries
      • occipital artery (ECA)
  • most typical drainage:

Classification

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Clinical presentation

Clinical presentation is variable and depends on the fistula location and venous drainage

 

  • pulsatile tinnitus (typically in case of sigmoid and transverse sinus drainage)
  • symptoms of venous hypertension/congestion
    • headache
    • hemorrhagic venous infarction
    • spinal myelomalacia
    • cranial nerve palsies
    • ocular (orbital) symptoms – conjunctival chemosis and swelling (carotid-cavernous fistula) – DDx of cavernous sinus thrombosis!
    • intracerebral or subarachnoid hemorrhage (high risk, especially in type II and III) [Li, 2015]
  • DAVF can be high flow and consume a significant portion of EF => exertional dyspnea, left ventricular hypertrophy (LVH)

Diagnostic evaluation

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Management

  • treatment decision is based on:
    • type of the fistula
    • patient’s age and comorbidities
    • presence of symptoms attributable to the fistula

Conservative treatment

  • usually in Borden I, Cognard I and IIa
  • in mild cases, external intermittent compression of the feeding artery can be helpful (retroauricular compression in DAVF fed by the occipital artery)
ECA monitoring during retroauricular compression of the feeding occipital artery

Endovascular and surgical treatment

  • an indisputable indication is DAVF Borden types II and III or Cognard IIb-V because of the high risk of bleeding (an annual risk of ~8%)
  • type I with severe tinnitus may also be indicated for endovascular treatment

Endovascular treatment

  • transarterial approach (TAE) – super-selective distal catheterization
    • e.g. Onyx [Lv, 2009]
  • transvenous approach (TVE) – mainly in multiple small feeding arteries, unsuitable for embolization
  • combined approach (TAE + TVE)

Surgery

  • if endovascular treatment is not possible or the procedure was unsuccessful or only partially successful

Stereotactic radiosurgery (SRS)

  • 20-30 Gy ⇒ irradiated vessels get thrombosed
  • obliteration is gradual (within 2-3 years)
  • unsuitable as primary treatment if reflux into cortical veins is present
Embolisation of direct arteriovenous fistula
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