Original ArticleCorrelation of Aggressive Intracranial Lesions and Venous Reflux Patterns in Dural Arteriovenous Fistulas
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.
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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.
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Multimodal MRI diagnosis and transvenous embolization of a basicranial emissary vein dural arteriovenous fistula: A case report
2023, Journal of Interventional MedicineCitation 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
Intracranial Dural Arteriovenous Fistulas: The Sinus and Non-Sinus Concept
2021, Acta Neurochirurgica, SupplementumDural Arteriovenous Fistula Presenting as Tentorial Subdural Hemorrhage: Case Report and Review of the Literature
2019, Clinical Neuroradiology
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.