Tag: Fistula

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Dural Arteriovenous Fistulas With Cognitive Impairment: Angiographic Characteristics and Treatment Outcomes

Neurosurgery 94:1035–1043, 2024

Anecdotal cases of rapidly progressing dementia in patients with dural arteriovenous fistulas (dAVFs) have been reported in small series. However, large series have not characterized these dAVFs. We conducted an analysis of the largest cohort of dAVFs presenting with cognitive impairment (dAVFs-CI), aiming to provide a detailed characterization of this subset of dAVFs.

METHODS: Patients with dAVFs-CI were analyzed from the CONDOR Consortium, a multicenter repository comprising 1077 dAVFs. A propensity score matching analysis was conducted to compare dAVFs-CI with Borden type II and type III dAVFs without cognitive impairment (controls). Logistic regression was used to identify angiographic characteristics specific to dAVFs-CI. Furthermore, post-treatment outcomes were analyzed.

RESULTS: A total of 60 patients with dAVFs-CI and 60 control dAVFs were included. Outflow obstruction leading to venous hypertension was observed in all dAVFs-CI. Sinus stenosis was significantly associated with dAVFs-CI (OR 2.85, 95% CI: 1.16-7.55, P = .027). dAVFs-CI were more likely to have a higher number of arterial feeders (OR 1.56, 95% CI 1.22-2.05, P < .001) and draining veins (OR 2.05, 95% CI 1.05-4.46, P = .004). Venous ectasia increased the risk of dAVFs-CI (OR 2.38, 95% CI 1.13-5.11, P = .024). A trend toward achieving asymptomatic status at follow-up was observed in patients with successful closure of dAVFs (OR 2.86, 95% CI 0.85-9.56, P = .09)

CONCLUSION: Venous hypertension is a key angiographic feature of dAVFs-CI. Moreover, these fistulas present at a mean age of 58 years-old, and exhibit a complex angioarchitecture characterized by an increased number of arteriovenous connections and stenosed sinuses. The presence of venous ectasia further exacerbates the impaired drainage and contributes to the development of dAVFs-CI. Notably, in certain cases, closure of the dAVF has the potential to reverse symptoms.

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Cranial dural arteriovenous shunts: selection of the ideal lesion for surgical occlusion according to the classification system

Acta Neurochirurgica (2019) 161:1775–1781 

The types of cranial dural arteriovenous fistulae (cDAVFs) that constitute good surgical candidates are unclear despite the use of classifications. We aimed to compare the DES classification with other classification schemes in identifying “ideal lesions for surgery.” The DES scheme is based on two features: the level of the shunt (BVS, bridging vein shunt; DSS, dural sinus shunt; ISS, isolated sinus shunt; EVS, emissary vein shunt) and the type of leptomeningeal venous reflux (LVR) (direct, exclusive, strained).

In this observational cohort study, the angiographies of 20 consecutive patients treated over 1 year were analyzed retrospectively. We defined cDAVFs as ideal for surgery, if cure may be achieved by disconnecting the arterialized draining vein through a single craniotomy. To evaluate the performance of each classification scheme in identifying the “ideal lesion for surgery,” we carried out a sensitivity analysis of the Borden, Cognard, and DES schemes.

Eight lesions were Borden type 3 and 1 type 2, and 11 type 1. According to Cognard, 2 lesions were type IV, 2 type III, 1 type IIa+b, 11 type I, and 4 lesions could not be clearly classified. According to the DES scheme, 8 lesions were DSS, 4 BVS, 3 ISS, and 5 EVS. All 4 lesions classified as BVS in the DES were ideal lesions for surgery (sensitivity, specificity, PPV, NPV 100%). Not all high-grade lesions according to Borden were good surgical candidates.

Conclusion The DES scheme, as opposed to other classifications, facilitates the therapeutic decision-making especially for selecting candidates for surgery.

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