Article Figures & Data
Figures
- Fig 1.
Imaging of a 65-year-old man who presented with an intracranial hemorrhage and whose DAVF was missed by 4D-CTA. A, Nonenhanced cranial CT scan on admission demonstrates the presenting hemorrhage. B, DSA, lateral view after left ECA injection, demonstrates abnormal retrograde filling of a pial vein (arrow), indicative of a DAVF. C, Lateral view of 4D-CTA, maximum intensity projection of the early venous phase, shows the same pial vein (arrow). Because visualization of the pial veins is expected on global opacification, only early filling would indicate a DAVF. However, due to the slow flow through the fistula, early venous filling could not be identified. Hence, this 4D-CTA study was read as having normal findings.
- Fig 2.
Imaging of a 60-year-old woman who presented with a right-sided pulse-synchronous tinnitus. A, DSA, lateral view after right ECA injection, demonstrates a DAVF (Borden I and Cognard I) at the level of the left sigmoid sinus (large arrow). The lesion is fed through a small arterial network (small arrow), which is mainly supplied by a branch from the occipital artery (large arrowhead) and to a lesser degree by a branch from the middle meningeal artery (small arrowhead). B, Lateral view of 4D-CTA, maximum intensity projection of late arterial phase, shows the early venous drainage into the right sigmoid sinus (large arrow). Compared with the DSA, the 4D-CTA is in agreement with regard to the site and classification of the lesion, as well as to its dominant feeder from the occipital artery (large arrowhead). However, although the smaller feeder from the middle meningeal artery can be seen (small arrowhead), neither reader had recorded it as such The small arrow indicates the arterial network feeding the fistula.
- Fig 3.
Imaging of a 47-year-old man who presented with a pulse-synchronous occipital bruit. A, DSA, lateral view after selective injection of the left occipital artery, demonstrates an extensive fistula at the torcular and left transverse sinus with cortical venous reflux (arrows). B, The later phase of the same injection demonstrates additional retrograde sinusoidal flow into the superior sagittal sinus (arrow). It was scored as Cognard grade IIa+b, due to both sinusoidal and pial reflux. C, Lateral view of 4D-CTA, maximum intensity projection of late arterial phase, shows early venous filling with cortical venous reflux (arrows). D, The venous phase of the same 4D-CTA study shows filling of the superior sagittal sinus, which is presumed to be antegrade. Because vascular opacification is nonselective, the temporal resolution is insufficient to recognize retrograde superior sagittal sinus filling. Thus, on the basis of this study, the lesion was erroneously scored as Cognard grade IIb.
Tables
Item Options DAVF detected Yes/no Classification of Borden et al5 I Drains through dural sinus II Retrograde flow from sinus into cortical veins III Direct flow into cortical veins Classification of Cognard et al1 I Antegrade sinusoidal flow II Reflux: a) sinusoidal, b) arachnoid or both III Direct flow into cortical veins IV Same as III, but with venous ectasias V Flow into perimedullary veins Arterial feeders, large ECA ICA VA Any combination of the above Arterial feeders, small ECA: Occipital artery, auricular artery, superficial temporal artery, middle meningeal artery, ascending pharyngeal artery, internal maxillary artery ICA: Posterior group, inferolateral trunk, meningohypophyseal trunk, ophthalmic system VA: Muscular/occipital branches, posterior meningeal artery, posterior inferior cerebellar artery Any combination of the above Fistula type Single hole (focal)/multihole (diffuse) Venous outflow obstruction Yes/no Isolated/trapped sinus Yes/no - Table 2:
The frequencies of presenting symptoms according to the type of venous drainage, using the classification of Borden et al,5 as demonstrated with DSA
Borden Type Presenting Symptoms Incidental Tinnitus Hemorrhage I 0 3 0 II 0 2 1 III 1 1 3
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