Successful endovascular treatment of a deep cerebral arteriovenous fistula with unusual venous drainage

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Abstract

Background

Cerebral arteriovenous fistula (AVF) is a rare disease. We present one adult with a deep cerebral AVF presented with cerebellar hemorrhage.

Case description

A 35-year-old man suddenly experienced headache, vomiting, dysarthria and ataxia of gait. Computed tomography (CT) demonstrates bilateral cerebellar hemorrhage. Angiography revealed a cerebral AVF fed by the bilateral medial posterior choroidal arteries and drained into the supratentorial deep venous system with flow into the infratentorial venous system. The draining veins included three varices, one of which, in the cerebellar vermis, was thought to be the source of bleeding. The patient was treated with transarterial embolization using n-butyl-cyanoacrylate (NBCA) and detachable platinum coils. Although coil migration during endovascular treatment occurred, complete closure of the fistula without morbidity and mortality was obtained.

Conclusion

Direct intracranial arteriovenous fistula with supra and infra tentorial venous drainage is rare; it can present with intracranial hemorrhage and can be treated by endovascular therapy.

Introduction

The most common method of disconnecting an arteriovenous fistula is occluding its arterial supply either by clipping surface vessels or using endovascular techniques [2], [3], [4], [5], [6], [7], [8], [9]. The purpose of this report is to present the radiologic features of a deep cerebral arteriovenous fistula in an adult with unusual venous drainage following into the supratentorial deep venous system and into the infratentorial cerebellar veins, including findings of brain computed tomography, magnetic resonance image and cerebral angiography and its successful percutaneous embolization using NBCA and platinum coils.

Section snippets

Case report

This 35-year-old male was admitted to our hospital after a sudden episode of headache, vomiting, dysarthria and ataxia of gait so that he could not walk without aided. On physical examination the patient's blood pressure is 101/65 mmHg. The neurologic examination disclosed bilateral ataxia of his extremities. The CT scan demonstrated bilateral intracerebellar hemorrhage (Fig. 1A). Magnetic resonance imaging (MRI) disclosed an intracerebellar hematoma and flow-void structures in the deep cerebral

Discussion

Arteriovenous fistulas of the brain are rare lesions that have been recognized as distinct or multiple and can be associated with cerebral arterialvenous malformation [1], [4], [7], [9]. They can be asymptomatic or, more often, can cause increased intracranial pressure, seizure, cerebral hemorrhage, cardiac decompression for which treatment is necessary [1], [3], [4], [7], [9].

Little is known concerning the mechanism of the symptomatology of cerebral arteriovenous fistula. Some patients develop

Conclusion

Direct cerebral arteriovenous fistula is rare; it can present with intracranial hemorrhage and can be treated successfully by endovascular embolization therapy. NBCA and Onyx can be used implementely in treatment of cerebral arteriovenous malformation.

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