Diagnosis and treatment of a dural arteriovenous fistula presenting with progressive parkinsonism and dementia: A case report and literature review

Abstract

A dural arteriovenous fistula (DAVF) presenting with parkinsonism and dementia is rare; thus, is easily misdiagnosed. The present study reports the case of a 62-year-old male with mobility disabilities and a cognitive disorder. The initial symptoms were progressive symmetrical limb stiffness and weakness without significant limb tremor, and subsequently the appearance of progressive memory loss, behavioral abnormalities and a decline in the activities of daily living. Cranial magnetic resonance imaging (MRI) revealed an enlarged vascular shadow at the meninges of the left temporal lobe. In addition, digital subtraction angiography (DSA) revealed a DAVF in the left temporal region, fed by the bilateral middle meningeal arteries and meningeal branches of the vertebral artery, which were enlarged abnormally, with poor venous reflux to the superior sagittal sinus. The patient was treated with transarterial embolization therapy. Intraoperative angiography showed almost complete embolization of the DAVF. At day 3 following the surgery, the muscle tension of the bilateral limbs decreased significantly. After two weeks, the memory ability of the patient had recovered to the level prior to the onset, and the gait was stable. At one month post-surgery, the patient was able to take care of himself completely, and after three months, a stereotactic treatment was conducted for the residual fistula. At the one year follow-up, neurological examination revealed that the patient had recovered normally. In conclusion, progressive parkinsonism and dementia with an abnormal flow void shadow on cranial MRI films should be considered as a possible diagnosis of a DAVF. In these cases, DSA and endovascular treatment are recommended as soon as possible.

Delayed postoperative dural arteriovenous fistula presenting with progressive dementia

“…Dural AVFs have various clinical manifestations, depending on the anatomical location and the venous drainage pattern, but rarely present as dementia 5 6. The presumed mechanism of progressive dementia from dural AVF appears to be venous congestive encephalopathy caused by intracranial venous hypertension.…”

“…Venous sinus thrombosis is considered to be one of the important causative factors in the development of dural AVF 1–3 5. Venous hypertension following sinus thrombosis can induce physiological dural arteriovenous channels to open and communicate with the patent portion of the sinus, ultimately generating a dural AVF.…”

Dural Arteriovenous Fistula as a Treatable Dementia

“…Blood is supplied to DAVFs mainly through branches arising from the external carotid artery. Vessels from the internal carotid and meningeal arteries can also be involved (2).…”

“…Hypoperfusion of the frontal lobe due to venous hypertension is thought to be responsible for developing parkinsonism in patients with DAVFs (2,8). Another possible explanation is from hypoperfusion of the basal ganglia due to impaired drainage of the deep internal veins (8).…”

“…Th e occurrence of ischemia involving the frontal and temporal lobe is associated with the development of dementia (2,8). Ischemia occurs from the downstream eff ect of arterialization of cortical venous drainage from cortical venous hypertension, leading to cerebral venous congestion (3).…”