Treatment options for symptomatic dural arteriovenous fistulas (DAVFs) include surgery, embolization and stereotactic radiosurgery (SRS). We reviewed our DAVF experience at the University of Pittsburgh and assessed the role of SRS. We evaluated 40 consecutive patients who underwent Gamma Knife SRS for 44 DAVFs. Twenty-eight patients had upfront SRS before or after embolization performed at our institution, and 12 patients underwent delayed SRS for recurrent or residual DAVFs after initial embolization. The median SRS target volume was 2.0 cm3, and the median marginal dose was 21.0 Gy. At a median follow-up of 45 months (range, 23-116 months), a total of 28 patients with 32 DAVFs had obliteration. The obliteration rate was 83% for patients who had upfront SRS and embolization. The obliteration rate was lower (67%) for patients managed with SRS alone. The obliteration rate was 71% for patients who had delayed SRS for recurrent or residual DAVFs following prior embolization. In our experience cavernous/carotid fistulas were associated with higher rates of obliteration and symptomatic improvement compared to transverse/sigmoid sinus region fistulas. Our experience suggests that successful DAVF obliteration is possible in most patients with upfront SRS in conjunction with embolization. SRS alone is an effective treatment for selected patients with a small-volume, low-risk DAVF.

Acute disseminated encephalomyelitis (ADEM) is a white matter inflammatory disease which usually follows a viral infection or pharmaceutical intervention. We describe a case of presumed ADEM in a heart/lung transplant patient, the etiology of which cannot be elucidated. The fascinating aspect is the mode of clinical presentation and the rapid resolution of radiologic abnormalities. Histologic examination of the brain is provided in an attempt to elucidate the radiographic abnormalities.

Early recognition of aneurysm rupture during coil embolization and prompt aneurysm obliteration and reduction in intracranial hypertension can lead to acceptable patient outcomes. Use of neurophysiologic monitoring in the intubated patient can help the neurosurgeon determine the need for cerebrospinal fluid drainage in such situations.