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Cranial dural arteriovenous shunts. Part 4. Clinical presentation of the shunts with leptomeningeal venous drainage

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Abstract

Cranial dural arteriovenous fistulae have been classified into high- and low-risk lesions mainly based on the pattern of venous drainage. Those with leptomeningeal venous drainage carry a higher risk of an aggressive clinical presentation. Recently, it has been proposed that the clinical presentation should be considered as an additional independent factor determining the clinical course of these lesions. However, dural shunts with leptomeningeal venous drainage include a very wide spectrum of inhomogeneous lesions. In the current study, we correlated the clinical presentation of 107 consecutive patients harboring cranial dural arteriovenous shunts with leptomeningeal venous drainage, with their distinct anatomic and angiographic features categorized into eight groups based on the “DES” (Directness and Exclusivity of leptomeningeal venous drainage and features of venous Strain) concept. We found that among these groups, there are significant angioarchitectural differences, which are reflected by considerable differences in clinical presentation. Leptomeningeal venous drainage of dural sinus shunts that is neither direct nor exclusive and without venous strain manifested only benign symptoms (aggressive presentation 0 %). On the other end of the spectrum, the bridging vein shunts with direct and exclusive leptomeningeal venous drainage and venous strain are expected to present aggressive symptoms almost always and most likely with bleeding (aggressive presentation 91.5 %). Important aspects of the above correlations are discussed. Therefore, the consideration of leptomeningeal venous drainage alone, for prediction of the clinical presentation of these shunts appears insufficient. Angiographic analysis based on the above concept, offers the possibility to distinguish the higher- from the lower-risk types of leptomeningeal venous drainage. In this context, consideration of the clinical presentation as an additional independent factor for the prediction of their clinical course seems superfluous and possibly misleading. Topography is connected to the clinical presentation of the dural shunts inasmuch as the former determines the venous anatomy and the angioarchitectural features of the lesions.

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Acknowledgments

We wish to thank Professor V. Runge for his valuable comments on the manuscript and knowledgeable suggestions.

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We declare that we have no conflict of interest.

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Authors and Affiliations

  1. Department of Neuroradiology, University Hospital of Zurich, Zurich, Switzerland

    Gerasimos Baltsavias, Alex Spiessberger & Anton Valavanis

  2. Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland

    Torsten Hothorn

Authors
  1. Gerasimos Baltsavias
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  2. Alex Spiessberger
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  3. Torsten Hothorn
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  4. Anton Valavanis
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Correspondence to Gerasimos Baltsavias.

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Comments

Michihiro Tanaka, Kamogawa City, Japan

Directness and exclusivity of leptomeningeal venous drainage and signs of venous strain were well described in corresponding to each angiographic feature in terms of clinical manifestation of CDAVFs. The discussion of clinical appearance and the existing of parenchymal venous congestion or incidence of intracerebral hemorrhage is well appreciated. Tentorial and petrosal BVs, as well as ethmoidal location, are highly associated with the category of D-E-S. These locations are characterized as the lateral epidural space group in the classification of Geibprasert, and the malignancy of this group has been already discussed.

Karel terBrugge, Toronto, Canada

Dr. Baltsavias and the Zurich team are to be complemented on the in-depth analysis of their extensive experience with DAVS and using it to modify to interpret more accurately the to-be-expected risks of those DAVS that are associated with so called “cortical venous reflux.” In their analysis, it became clear that additional factors influenced expected clinical risk and they included the presence of direct (D) and exclusive (E) retrograde leptomeningeal reflux (LVR) as well as evidence of venous strain (S). By analyzing each of the factors individually and in combination, it became clear that further stratification of the clinical risks in the natural history of DAVS with LVR could be accomplished. This, in turn, should be helpful to understand and manage patients with DAVS with LVR including those that are incidentally discovered.

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Baltsavias, G., Spiessberger, A., Hothorn, T. et al. Cranial dural arteriovenous shunts. Part 4. Clinical presentation of the shunts with leptomeningeal venous drainage. Neurosurg Rev 38, 283–291 (2015). https://doi.org/10.1007/s10143-014-0595-x

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  • DOI: https://doi.org/10.1007/s10143-014-0595-x

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