PMC4508708_01
Magnetic resonance images on admission. Axial T2-weighted images demonstrating numerous dilated pial veins draining into the right transverse sinus (a), and hyperintense change, indicating leukoaraiosis, in the deep white matter (c). No hyperintense change is seen in the basal ganglia, especially the thalamus (b).
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MR imaging showed many flow voids in the ambient cistern, and hyperintense changes (leukoaraiosis) on the T2-weighted and fluid-attenuated inversion recovery images (Fig. 1).
Angiograms before surgery. Right external carotid angiograms demonstrating a large dural arteriovenous fistula (AVF) involving the right transverse-sigmoid sinus fed by the right occipital artery, and another dural AVF located in the middle third of the superior sagittal sinus fed by the bilateral middle meningeal and bilateral superficial temporal arteries (upper left, upper right). Left external carotid angiogram demonstrating retrograde venous outflow, draining into the dural AVF of the superior sagittal sinus and cortical veins of the right frontal cortex (lower left). Right internal carotid angiogram demonstrating the dural AVF involving the right transverse-sigmoid sinus fed by the right tentorial artery (lower center). Right internal carotid angiogram (early venous phase) demonstrating markedly severe pseudophlebitic pattern (lower right).
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STAs, arteriovenous shunts around the superior sagittal sinus (SSS), another arteriovenous shunt from the right occipital artery to the right transverse-sigmoid sinus (TVS), and marked pseudophlebitic patterns (Fig. 2). Single photon emission computed tomography (SPECT) showed markedly decreased cerebral blood flow (CBF) over almost the whole brain (Fig. 3, left).
Iodine-123 N-isopropyl-p-iodoamphetamine (123I-IMP) single photon emission computed tomography (SPECT) scan on admission demonstrating hypoperfusion over almost the whole brain including the bilateral basal ganglia (left). 123I-IMP SPECT scan after surgery demonstrating normal cerebral blood flow (CBF) except for the CBF defect at the venous infarction site (right).
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STAs, arteriovenous shunts around the superior sagittal sinus (SSS), another arteriovenous shunt from the right occipital artery to the right transverse-sigmoid sinus (TVS), and marked pseudophlebitic patterns (Fig. 2). Single photon emission computed tomography (SPECT) showed markedly decreased cerebral blood flow (CBF) over almost the whole brain (Fig. 3, left). SPECT showed markedly increased CBF in the bilateral cerebral hemispheres, including the basal ganglia (Fig. 3, right).
Left external carotid angiogram after the second operation demonstrating the right occipital artery occluded by N-butyl-2-cyanoacrylate and Eudragit (upper left). Right external carotid angiogram after the third operation demonstrating that the dural arteriovenous fistula (AVF) of the superior sagittal sinus still remained (upper right). Left internal carotid and right external carotid angiograms after all operations demonstrating that the dural AVF of the transverse-sigmoid sinus, occluded by platinum coils, had completely disappeared, and the dural AVF of the superior sagittal sinus still remained, but the blood flowed anterogradely (lower left, lower right). Right internal carotid angiogram after all operations demonstrating that the pseudophlebitic pattern had completely disappeared (lower center).
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The bilateral STAs and right occipital artery were embolized through transarterial approaches with N-butyl-2-cyanoacrylate (Fig. 4, upper left), and the right TVS, the origin of the venous reflux from the frontal cortical veins, and the apex of the SSS were embolized through transvenous approaches with coils. Postoperative cerebral angiography showed anterograde blood flow and disappearance of all dural AVFs (Fig. 4, lower left, lower center, lower right).