Intracranial dural arteriovenous fistulae: angiographic predictors of intracranial hemorrhage and clinical outcome in nonsurgical patients

Abstract

This long-term follow-up study of 54 patients clarifies the angiographic predictors of intracranial hemorrhage (ICH) and clinical outcome in individuals with unoperated intracranial dural arteriovenous fistulae (AVF's). All of these patients were examined at the Mayo Clinic between 1976 and 1989, and all available cerebral arteriograms were reviewed by a neuroradiologist. Follow-up information was obtained for 52 patients (96%) until death or treatment intervention, or for at least 1 year after diagnosis, with a mean follow-up period of 6.6 years. Throughout this 6.6-year follow-up period, ICH related to dural AVF occurred in five of the 52 patients, for a crude risk of hemorrhage of 1.6% per year. The risk of hemorrhage at the time of mean follow-up examination was 1.8% per year. Angiographic examination revealed several characteristics that were considered potential predictors of ICH during the follow-up period. Lesions of the petrosal sinus and straight sinus had a higher propensity to bleed, although the small numbers in the series precluded a definite conclusion. A person suffering from a dural AVF with a venous varix on a draining vein had an increased risk of hemorrhage, whereas no hemorrhage was seen in the 20 patients without a varix (p < 0.05). Lesions draining into leptomeningeal veins had an increased occurrence of hemorrhage, although this increased risk was not statistically significant. Patients' initial symptoms were compared to those at follow-up evaluation. Pulsatile tinnitus improved in more than half of the 52 patients, and resolved in 75% of those showing some improvement. Individuals without a sinus or venous outflow occlusion at initial cerebral angiography were more likely to improve or remain stable (89%), whereas patients with an occlusion showed infrequent improvement (11%; p < 0.05).

Progressive versus Nonprogressive Intracranial Dural Arteriovenous Fistulas: Characteristics and Outcomes

“…38 Few studies to date have explored the prognostic significance of CVD in the setting of definitive management. 39 Our series demonstrates similar rates of CVD on initial angiography in nonprogressive DAVFs and lesions that ultimately progressed. The Cognard and Borden-Shucart scales-and other scales that also rely primarily on the presence of CVD to stratify lesion risk-do not fully capture features of progressive DAVFs because new arteriovenous shunts can form and existing shunts can enlarge without necessarily changing venous drainage categories in the Cognard and Borden-Shucart systems.…”

An arteriovenous fistula causing pulsatile tinnitus: acute management with endovascular embolization

“…[9] Transarteriyel embolizasyon, diyagnostik anjiyografi sırasında hemen uygulanabilir ve düşük grade lezyonlar için yeterli olabilmektedir. Ancak venöz restriksiyon gelişmiş ve retrograd kortikal venöz drenaj oluşmuşsa bu işlem tek başına yeterli olmayabilir.…”

Central Nervous System Vascular Malformations

“…In most DAVM series, pulsatile tinnitus is the most common complaint, occurring in up to two thirds of patients [132][133][134]. A bruit is detectable in a variable proportion of patients with subjective tinnitus, with reports ranging from 40% [135] to 96% [136].…”

“…In general, the risk of intracranial hemorrhage for all DAVMs is approximately 1.8% per year [132]. However, DAVMs that demonstrate retrograde parenchymal venous drainage are associated with a more aggressive natural history [106,107,159,160].…”

“…The risk of intracranial hemorrhage or non-hemorrhagic neurological deficit in DAVMs with retrograde parenchymal venous drainage is 15-30% per year, with an annual risk of death of 10-19% [162,163]. When intracranial hemorrhage occurs, the effects can be devastating, with a 15-25% risk of death [132,159,164], and a 35% risk of rebleeding within 2 weeks if the DAVM remains untreated [164].…”