Elsevier

World Neurosurgery

Volume 107, November 2017, Pages 130-136
World Neurosurgery

Original Article
Correlation of Aggressive Intracranial Lesions and Venous Reflux Patterns in Dural Arteriovenous Fistulas

https://doi.org/10.1016/j.wneu.2017.07.142Get rights and content

Background

The association between venous reflux patterns with aggressive intracranial lesions (AILs), including intracranial edema (IE), intraparenphymal hemorrhage (IPH), and subarachnoid hemorrhage (SAH), has not been well established in cranial dural arteriovenous fistulas (DAVFs). We propose an updated classification system based on venous drainage.

Methods

We retrospectively assessed the catheter angiography findings of venous drainage patterns. Cranial DAVFs with no reflux flow and those with reflux flow drainage into the sinus only, the bridge vein only, the bridge vein and pial vein, and the sinus, bridge vein, and pial vein were designated as types 1, 2, 3, 4, and 5, respectively. We analyzed the associations between venous reflux patterns with AILs in 73 patients with DAVFs.

Results

AILs were found in 43 patients (58.9%), including 8 (11%) with SAH, 8 (11%) with IPH, and 27 (36.9%) with IE. Our proposed classification scheme was significantly associated with AILs (P < 0.001). SAH was found in patients with type 3 (62.5%) and type 4 (37.5%), whereas IPH was seen mostly in those with type 4 (87.5%). The proportion of IE gradually increased from type 3 to type 5 (11.1% to 29.6% to 59.2%). Significant difference was found among each type between complete resolution and uncompleted resolution after endovascular treatment (P = 0.034), which also demonstrated a gradually increasing proportion of uncompleted resolution from type 1 to type 5 (4.5%, 4.5%, 9.1%, 31.8%, and 50%).

Conclusions

Our proposed classification system effectively demonstrates a correlation between venous reflux patterns and AILs and outcomes of endovascular treatment in patients with DAVFs.

Introduction

Cranial dural arteriovenous fistula (DAVF) is a type of abnormal arteriovenous shunt characterized by the abnormal connection of an artery and a vein within the dural matter of the brain. Intracranial hemorrhage or edema is considered an aggressive presentation correlated with venous drainage patterns. Davies et al.1 validated the classification system proposed by Cognard et al.2 and Borden et al.,3 which showed a close association between the presence of cortical vein reflux (CVR) and aggressive presentations.

However, evidence is limited regarding how venous reflux patterns differentially contribute to highly variable aggressive intracranial lesions (AILs), including intracranial edema (IE), intraparenchymal hemorrhage (IPH), and subarachnoid hemorrhage (SAH). Currently available DAVF scales poorly address the association of anatomical pattern of CVR and AILs. Some studies have demonstrated associations between anastomotic venous reflux4 and pial venous reflux5 with hemorrhage or edema in DAVFs. Those entities are included in the definition of CVR but contribute differently to AILs. CVR as a broad concept might not accurately describe the hemodynamic characteristics of patients with DAVFs and AILs.

In addition, unlike other cerebral DAVFs, cavernous sinus (CS) DAVFs rarely cause edema or hemorrhage despite the presence of CVR.6 This suggests the mechanisms of IE/IPH/SAH in cranial DAVFs need to be differentiated from that of CS DAVFs. In this study, we aimed to clarify the venous reflux patterns associated with AILs in cranial DAVFs.

Section snippets

Patients

Patients with DAVFs treated in our hospital between 2002 and 2015 were studied retrospectively. Those with cranial DAVFs were recruited for this study. AILs identified based on magnetic resonance imaging (MRI) or computed tomography (CT) findings, fistula locations, and the presence of venous reflux patterns based on catheter angiography were analyzed. Selective catheter angiography of the internal carotid artery, external carotid artery, and vertebral artery was performed using

Results

Between 2002 and 2015, 115 patients with DAVFs (73 with cranial DAVFs; 42 with CS DAVFs) in our hospital were recruited for this study. AILs were found in 58.9% (43 of 73) of the patients with cranial DAVFs, compared with only 2.4% (1 of 42) of those with CS DAVFs. A group of 73 patients with cranial DAVFs were further analyzed, including 51 males (69.9%) and with a mean age of 50.3 years (range, 16–73 years). These 73 patients included 27 (36.9%) with IE, 8 (10.9%) with IPH, 8 (10.9%) with

Discussion

The Cognard classification system is the most commonly used scale for grading DAVFs. In their seminal article, the pattern of venous drainage was correlated with the risk of intracranial hemorrhage. However, intracranial edema due to venous hypertension as a severe AIL usually results in progressive dementia, hemiplegia, and death,9, 10 is poorly addressed by the Cognard classification system. The mechanism of SAH in DAVFs could be very different from that of IPH. Therefore, we have devised a

Conclusion

Cranial DAVFs present with different aggressive intracranial lesions related to different venous reflux patterns and fistula locations. More advanced than the Cognard classification system, our proposed venous reflux classification system identifies a trend toward an increasing association between IE and incomplete resolution with venous reflux types.

References (14)

There are more references available in the full text version of this article.

Cited by (4)

  • Multimodal MRI diagnosis and transvenous embolization of a basicranial emissary vein dural arteriovenous fistula: A case report

    2023, Journal of Interventional Medicine
    Citation Excerpt :

    DAVFs may manifest as either benign or aggressive, based on venous drainage patterns, while cortical venous reflux can potentially result in intracranial hemorrhage, neurological damage, or even death.3,4 The association between venous reflux patterns and aggressive intracranial lesions has been well established in cranial DAVFs.5 Treatment options, including microsurgical disconnection, endovascular transarterial embolization (TAE), transvenous embolization (TVE), or a combination, are guided by detailed anatomic assessment and hemodynamic evaluation.6

Conflict of interest statement: This work was funded by the Science and Technology Commission of the Shanghai Municipality (Project No. 15411968300). The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Lei Huang and Liang Ge should be considered co–first authors.

View full text