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CASE REPORT
Year : 2014  |  Volume : 17  |  Issue : 4  |  Page : 451-454
 

Endovascular treatment of vein of Galen dural arteriovenous fistula presenting as dementia


Department of Neurology, Division of Neurointervention and Stroke, Narayana Health Institute of Neurosciences, Bangalore, Karnataka, India

Date of Submission17-Mar-2014
Date of Decision24-Feb-2014
Date of Acceptance29-Apr-2014
Date of Web Publication5-Nov-2014

Correspondence Address:
Vikram Huded
Department of Neurology, Division of Neurointervention and Stroke, Narayana Health institute of Neurosciences, Bangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-2327.144037

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   Abstract 

Dural arteriovenous fistula (DAVF) is an important cause of neurological dysfunction that is often misdiagnosed, especially in elderly population. Galenic DAVFs are a subtype of the rare falcotentorial DAVFs with a high risk of hemorrhage and aggressive clinical course. In most cases, DAVFs present with pulsatile tinnitus, headache, or orbital symptoms such as chemosis and proptosis. We report a patient with DAVF of Vein of Galen presented with progressive dementia, treated by Onyx embolisation and had good clinical outcome.


Keywords: Dementia, endovascular treatment, vein of Galen dural AV fistula


How to cite this article:
Huded V, Moeed SZ, Desouza R, Tripathi R, Nair R. Endovascular treatment of vein of Galen dural arteriovenous fistula presenting as dementia. Ann Indian Acad Neurol 2014;17:451-4

How to cite this URL:
Huded V, Moeed SZ, Desouza R, Tripathi R, Nair R. Endovascular treatment of vein of Galen dural arteriovenous fistula presenting as dementia. Ann Indian Acad Neurol [serial online] 2014 [cited 2019 Nov 18];17:451-4. Available from: http://www.annalsofian.org/text.asp?2014/17/4/451/144037



   Introduction Top


Dural arteriovenous fistula (DAVF) as a cause of reversible dementia is quite uncommon, more so is acquired DAVF of the vein of Galen (Galenic DAVF). The treatment of acquired Galenic DAVF is a therapeutic challenge and often requires multimodality treatment. In our case, it was possible to achieve complete cure with good clinical outcome by endovascular embolization alone.


   Case Report Top


A 35-year-old male presented with a history of gradually progressive behavioral abnormality and anterograde memory loss since 1 year, one episode of right-sided partial seizure, and worsening of sensorium since 1 month. On examination, he was confused and irritable, with bilateral papilledema and no lateralizing signs. Neuropsychological assessment was initiated revealing severe difficulty in sustained attention and working memory. Hence, detailed neuropsychological assessment could not be conducted. His MMSE score was 15/30. Imaging study (CT) was suggestive of diffuse cerebral edema and dilation of the vein of Galen [Figure 1]. He was started on anti-epileptics and anti-edemal measures.

Cerebral angiogram showed acquired high flow Vein of Galen DAVF [Figure 2]a-b and [Figure 3] with multiple feeders from the middle meningeal artery, occipital arteries, meningohypophyseal arteries, and pial-dural supply from the branches of the posterior cerebral arteries. The fistula drained into Straight sinus. There was a reflux into the deep venous system. Right tranverse - sigmoid sinus was occluded, and there was a narrowing of the left transverse sigmoid sinus.
Figure 1: Computed tomography (CT) Brain Plain shows prominent Vein of Galen (VOG) with mild diffuse cerebral edema

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Figure 2: (a) External carotid artery (ECA) angiogram (early and late phase) shows Vein of Galen Dural Arteriovenous Fistula (Galenic DAVF) (b) Pre-embolization ECA angiogram in Townes View

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Figure 3: Internal carotid artery (ICA) angiogram shows venous congestion without opacifi cation of VOG and straight sinus even in late venous phase

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Other investigations including thyroid function tests, vitamin B12 levels, serology for HIV and syphilis, and work up for common hypercoagulable states were negative.

The DAVF was treated over two sessions. In the first session, bilateral femoral access was obtained and 6F guiding catheters were negotiated into bilateral external carotid artery. Marathon microcatheter was negotiated over mirage wire into the right middle meningeal artery. Hyperglide 4 × 20 was negotiated into the left middle meningeal artery for regulating the arterial flow into the fistula. After confirming microcatheter position, embolization was performed using Onyx 34 and 18. Post embolization, an angiogram showed significant reduction in the flow of DAVF.

Second session was done performed after 1 month. Bilateral femoral access was obtained and 6F guiding catheter was negotiated into left external carotid artery. Marathon microcatheter was negotiated over traxcess wire into left middle meningeal artery. Using Onyx 34 (3 vials) and 18 (1 vial) embolization was done.

The procedure was uneventful, and post procedure angiogram showed complete resolution of the fistula along with anterograde flow in Vein of Galen [Figure 4]a-b, [Figure 5]a-c and [Figure 6].
Figure 4: (a) Post-Second session embolization ECA angiogram shows complete occlusion of fi stula (b) Post-embolization ECA angiogram in Townes View

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Figure 5: (a) Onyx cast after second session of embolization. The center hole in the cast is the patent VOG (b) Onyx cast post embolization lateral view (c) Onyx cast post embolization townes view

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Figure 6: Post-second session of embolization ICA angiogram shows anterograde fl ow in VOG

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The patient was extubated after the procedure and showed no worsening of symptoms. His encephalopathy gradually improved over few days. At discharge, he was conscious and coherent, and had no focal neurologic deficit.

There is no recurrence of symptoms on subsequent follow up at 3 months, 6 months, and 12 months, and he can independently perform activities of daily living. A repeat Mini Mental status examination showed a score of 30 at 3 months. His Neuropsychological assessment revealed adequate attention, working memory, planning, response inhibition, and set shifting ability. His performance on verbal and visual learning and memory was also found to be in the adequate range. There was no evidence of finger agnosia, color agnosia, constructional apraxia, agraphia, acalculia, and left-right disorientation. Follow up control angiogram at 1 year showed persistent obliteration of the fistula [Figure 7].
Figure 7: ECA angiogram (after 1 year) shows persistent occlusion of fistula

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   Discussion Top


DAVFs are acquired lesions from the cerebral arterial vasculature to dural sinuses. [1] They represent 10-15% of cerebrovascular malformations, and most commonly develop in the region of the transverse and sigmoid sinuses. [2] It is postulated that the lesions occur due to increased pressure within the dural sinuses, most commonly caused by sinus thrombosis. [2],[3],[4],[5] Symptoms generally do not develop unless there is increased venous sinus pressure from an increased volume via the DAVF or from sinus obstruction. [4] Variable degree of venous hypertension results in sequelae ranging from mild reversible symptoms to fatal intracranial hemorrhage. [1],[4],[5],[6] The common presenting symptoms of DAVFs range in severity from simple pulsatile tinnitus and focal neurological deficits to acute intracranial hemorrhage. Rarely, patients with DAVF present with progressive dementia due to venous hypertensive encephalopathy; this cognitive impairment has the potential for complete resolution following treatment of the fistula. Cases of cognitive decline with more insidious onset, as in our case, have been reported. [1],[4],[5],[6],[7] Dural AVFs may also mimic well-known cognitive disorders such as Parkinson's disease [1] and normal-pressure hydrocephalus. [5] We should perform cerebral angiogram if CT or MRI is showing abnormal tortuous blood vessels or dilated veins.

Galenic DAVFs are a subtype of the relatively rare, falcotentorial DAVFs [8] and have a high risk of hemorrhage. [9]

Endovascular approaches are generally recommended as the initial treatment in most DAVFs. [5] Depending on the anatomy, a transarterial, transvenous, combined transarterial/transvenous, or transorbital approach can be used to cure a DAVF. [10],[11],[12],[13] Multiple embolization agents can be used; however, liquid embolization agents and coils are primarily used. [14] These techniques have been shown to eliminate the symptoms as well as offer an anatomic cure, [5] as in our case. If the patient continues to experience symptoms, a combined endovascular and neurosurgical approach is recommended to obliterate any remaining fistula. [15]

The present patient has the Galenic DAVF with main feeders being the middle meningeal artery and occipital artery. Subsequent embolization with Onyx completely obliterated the fistula, with very good preservation of the vein of Galen, as shown in the post treatment Onyx cast pictures. The preservation of vein of Galen is not possible if we perform transvenous coiling. The post procedure ICA angiogram showed a good anterograde flow in the deep venous system. No recurrence of symptoms has occurred after 6 months and 1 year of follow up. Detailed Neuropsychological evaluation was also suggestive of complete recovery of cognitive deficits.

Treatment of Galenic DAVFs is more challenging and endovascular approach cannot obliterate it completely. Hence, it may require microsurgical or radiosurgical fistula interruption. [16],[17]

Steven De Vleeschouwer et al. [16] reported a case of Galenic DAVF in which a session of embolization of the falcotentorial feeding vessels followed by additional surgical transsection of the remaining tentorial arterial feeders failed to exclude the Galenic DAVF.

Shin M et al. described two cases of DAVF draining into the vein of Galen which were successfully treated by gamma knife radiosurgery. [17]

John B. Weigele et al. [18] described a case of Galenic DAVF, in which the clinical and imaging findings were suggestive of brainstem glioma, successful endovascular treatment led to clinical recovery in the patient.

Our case indicates acquired Galenic DAVF as an uncommon cause of reversible dementia and shows that it can be completely cured by careful endovascular embolization alone, with preservation of the lumen of vein of Galen and anterograde flow in the deep venous system.

 
   References Top

1.
Netravathi M, Pal PK, Bharath RD, Ravishankar S. Intracranial duralarteriovenous fistula presenting as parkinsonism and cognitive dysfunction. J Clin Neurosci 2011;18:138-40.  Back to cited text no. 1
    
2.
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Houser OW, Baker HL Jr, Rhoton AL Jr, Okazaki H. Intracranial dural arteriovenous malformations. Radiology 1972;105:55-64.  Back to cited text no. 3
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4.
Hurst RW, Bagley LJ, Galetta S, Glosser G, Lieberman AP, Trojanowski J, et al. Dementia resulting from dural arteriovenous fistulas: The pathologic findings of venous hypertensive encephalopathy. AJNR Am J Neuroradiol 1998;19:1267-73.  Back to cited text no. 4
    
5.
Nakahara Y, Ogata A, Takase Y, Maeda K, Okamoto H, Matsushima T, et al. Treatment of dural arteriovenous fistula presenting as typical symptoms of hydrocephalus caused by venous congestion: Case report. Neurol Med Chir (Tokyo) 2011;51:229-32.  Back to cited text no. 5
    
6.
Geraldes R, Albuquerque L, Ferro JM, Sousa R, Sequeira P, Campos J. Rapidly progressive cognitive impairment, ataxia, and myoclonus: An unusual presentation of a dural arteriovenous fistula. J Stroke Cerebrovasc Dis 2012;21:619.  Back to cited text no. 6
    
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Matsumura A, Oda M, Hozuki T, Imai T, Shimohama S. Dural arteriovenous fistula in a case of dementia with bi-thalamic MR lesions. Neurology 2008;71:1553.  Back to cited text no. 7
    
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Lawton MT, Sanchez-Mejia RO, Pham D, Tan J, Halbach VV. Tentorial dural arteriovenous fistulae: Operative strategies and microsurgical results for six types. Neurosurgery 2008;62:110-24.  Back to cited text no. 8
    
9.
Awad IA, Little JR, Akarawi WP, Ahl J. Intracranial dural arteriovenous malformations: Factors predisposing to an aggressive neurological course. J Neurosurg 1990;72:839-50.  Back to cited text no. 9
    
10.
Layton KF, Nelson MD, Kallmes DF. Transarterial coil embolization of the venous component of aggressive type 4 dural arteriovenous fistulas. AJNR Am J Neuroradiol 2006;27:750-2.  Back to cited text no. 10
    
11.
Giller CA, Barnett DW, Thacker IC, Hise JH, Berger BD. Multidisciplinary treatment of a large cerebral dural arteriovenous fistula using embolization, surgery, and radiosurgery. Proc (Bayl Univ Med Cent) 2008;21:255-7.  Back to cited text no. 11
    
12.
White JB, Layton KF, Evans AJ, Tong FC, Jensen ME, Kallmes DF, et al. Transorbital puncture for the treatment of cavernous sinus dural arteriovenous fistulas. AJNR Am J Neuroradiol 2007;28:1415-7.  Back to cited text no. 12
    
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Layton KF. Embolization of an intracranial dural arteriovenous fistula using ultrasound-guided puncture of a pericranial venous pouch. Proc (Bayl Univ Med Cent) 2009;22:332-4.  Back to cited text no. 13
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14.
Halbach VV, Higashida RT, Hieshima GB, Mehringer CM, Hardin CW. Transvenous embolization of dural fistulas involving the transverse and sigmoid sinuses. AJNR Am J Neuroradiol 1989;10:385-92.  Back to cited text no. 14
    
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Barnwell SL, Halbach VV, Higashida RT, Hieshima G, Wilson CB. Complex dural arteriovenous fistulas. Results of combined endovascular and neurosurgical treatment in 16 patients. J Neurosurg 1989;71:352-8.  Back to cited text no. 15
    
16.
De Vleeschouwer S, Smets CA, Wilms G. Long-lasting, complete exclusion of a large galenic dural arteriovenous fistula after clipping of the central venous aneurysm of the vein of galen: Case report. Neurosurgery 2011;68:E571-4.  Back to cited text no. 16
    
17.
Shin M, Kurita H, Tago M, Kirino T. Stereotactic radiosurgery for tentorial dural arteriovenous fistulae draining into the vein of Galen: Report of two cases. Neurosurgery 2000;46:730-3.  Back to cited text no. 17
    
18.
Weigele JB, Chaloupka JC, Lesley WS. Galenic dural arteriovenous fistula: Unusual clinical presentation and successful endovascular therapy. J Neurosurg 2002;97:467-70.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]


This article has been cited by
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