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•Multiple spinal AVFs can be synchronous or metachronous.•Metachronous AVFs can be manifested after a short period of improvement.•Failure to improve after treatment should raise suspicion of multiple lesions.•A complete spinal angiogram may be indicated if symptoms worsen after treatment. The occurrence of multiple spinal dural arteriovenous fistulas (AVFs) is rare. The majority of cases reported are synchronous and the lesions are mainly found at different spinal levels. Metachronous AVFs have been defined as lesions that manifest in a temporal sequence after treatment of a first AVF. In this report, we present two distinct cases of multiple spinal AVFs. Also, we review the main features of the cases previously reported, with emphasis on the proposed theories for the origin of multiple AVFs. In patients with failure to improve after treatment of a spinal DAVF, a whole-spine angiographic examination is mandatory, not only to ascertain the complete closure of the treated fistula, but also to look for a possible second lesion at a different spinal level.

Background and Introduction: Dural arteriovenous fistulas (dAVFs) are a rare pathology with a clinical presentation related to their anatomical location. Craniocervical junction (CCJ) dAVFs are challenging to treat given the delicate structures that surround the CCJ. Endovascular treatment has evolved significantly in the past decade, but open microsurgery remains an invaluable tool for this pathology. Objective: To demonstrate the step-by-step elements of the far lateral approach for microsurgical ligation of CCJ dAVF. Surgical Technique: A retroauricular incision is created, extending down the neck, and the suboccipital triangle muscles are dissected, exposing the posterior arch of C1. The vertebral artery (VA), as well as its entrance point in the dura, is also dissected and exposed. Next, a C1 hemilaminectomy is performed, followed by a suboccipital craniectomy and drilling of the posteromedial portion of the condyle. The dura is opened behind the VA entrance in the dura, and the intradural VA is exposed. Once the fistula is identified, a temporary clip is placed on the draining vein. Indocyanine green video angiography is used to confirm that there is no further connection; the clip is then removed and the fistula obliterated. The dura is closed in a watertight fashion with a fat bolster to prevent a pseudomeningocele. Results: Postoperative angiogram showed complete resolution of the pathology. The patient was discharged neurologically intact on postoperative day 4. Conclusions: Microsurgical obliteration of CCJ dAVFs can be achieved safely and efficiently through a far lateral approach.

Intracranial cases of dural arteriovenous fistulas (dAVF) with spontaneous closure rarely occur. We reported a cavernous sinus dAVF (CS-DAVF) that closed spontaneously only after angiography. The patient complained of redness of left eye with reduced visual acuity, chemosis, retro-orbital pain, and ophthalmoplegia. The patient was compos mentis with anisocoria (right pupil with 3 mm diameter and left pupil with 5 mm diameter) and negative pupillary right reflex except the direct pupillary light reflex at the right eye. Diagnostic digital subtraction angiography (DSA) was performed two times without any intervention. The contrast could not fill the superior ophthalmic vein at the second DSA. At the therapeutic DSA a month later, the fistula between left and right meningohypophyseal trunk toward the cavernous sinus was no longer identified. We hypothesized that the phenomenon of spontaneous dAVF closure is similar by the mechanism according to publication by Al-Afif et al. as the patient had no history of trauma and only received diagnostic angiography procedure along with the contrast that used for the procedure.

Background Dural arteriovenous fistula (dAVF) presenting primarily with memory disturbance is relatively rare and may be diagnosed late. However, symptoms often improve with appropriate treatment, as in our case. Case Presentation A 74‐year‐old man presented with cognitive decline and, within 2 months, developed gait disturbance, dysarthria, and ataxia, leading to hospitalization for suspected dAVF on magnetic resonance imaging. Angiography revealed a superior sagittal sinus dAVF. The patient underwent surgical disconnection of the dAVF from the superior sagittal sinus, and his cognitive function, paresis, and dysarthria improved, allowing for discharge with a modified Rankin Scale score of 2. Conclusion In cases with memory disturbance, dAVF should be considered a differential diagnosis, verified, and treated accordingly. This case highlights the importance of considering dural arteriovenous fistula (dAVF) as a differential diagnosis in patients presenting with cognitive decline, particularly when accompanied by progressive neurological symptoms. Our report may help clinicians broaden their differential diagnoses when faced with similar clinical presentations.

Spinal dural arteriovenous fistula (SDAVF) is a rare vascular malformation of the spine. Only a limited number of cases of SDAVF have been reported in the current literature. We describe the case of a 74 year old male who presented with gradually progressive bilateral lower extremity weakness and bladder dysfunction and was subsequently diagnosed with SDAVF affecting both the thoracic and lumbar spine. The patient later underwent embolization with some improvement in his neurologic symptoms.

Background This paper analyzed the cases of dural arteriovenous fistula (DAVF) with spinal dural arteriovenous fistula (SDAVF) in the diagnosis and treatment process. Case presentation One case involving dural arteriovenous fistula (DAVF) with spinal dural arteriovenous fistula (SDAVF) from the 306th Hospital of PLA was retrospectively analyzed. The patient consulted the doctor due to lower limb sensory and motor disorders while exhibiting symptoms of urinary dysfunction. A computed tomographic angiography (CTA) and cerebral angiography confirmed the diagnosis of dural arteriovenous fistula (DAVF), necessitating surgical treatment. The patient was referred to our hospital for an magnetic resonance imaging (MRI) and a spinal angiography to obtain a confirmed diagnosis for spinal arteriovenous fistula, after which they underwent surgical fistula resection. The invasive intracranial dural arteriovenous fistula (DAVF) resection proceeded smoothly but did not ease the patient's symptoms. However, postoperative symptoms were partially relieved by the lumbar open spinal dural arteriovenous fistula adminstration. Conclusions Since not enough is understood about these two diseases, the rate of misdiagnosis is significantly increased. Early diagnosis and treatment of spinal dural arteriovenous fistula (SDAVF) can play a positive role during the recovery from neural function damage.

BACKGROUND AND IMPORTANCE:Intraosseous dural arteriovenous fistulae (DAVF) are rare, especially those with drainage into the diploic venous system. The clinical presentation depends on the location of the lesion. This is the first report of an intraosseous DAVF associated with acute epidural hematoma. CLINICAL PRESENTATION:A 25-year-old man presented with headache and nausea. Imaging of the brain revealed abnormal signals indicative of acute epidural hematoma in the right frontal convexity. Angiography demonstrated a DAVF in the region of the frontal bone. Right external carotid artery angiography showed that the DAVF was fed mainly by the right middle meningeal artery with drainage into diploic veins. Immediately after embolization of the middle meningeal and the distal internal maxillary artery with 17% N-butyl-2-cyanoacrylate, the shunt was completely occluded. The patient was discharged 4 days later without clinical complications. CONCLUSION:Intraosseous DAVF can be treated by surgical resection or endovascular embolization. Curative treatment requires careful inspection of the angiographic architecture and microsurgical anatomy. ABBREVIATION:DAVF, dural arteriovenous fistulae

BACKGROUND AND IMPORTANCE:An intraosseous dural arteriovenous fistula (DAVF) is a rare cerebrovascular disease. The fistulous connection occurs within intraosseous diploic or transosseous emissary veins causing dilated intraosseous vascular pouches. To the authorsʼ knowledge, this report describes the first percutaneous transfacial direct embolization of an intraosseous DAVF. CLINICAL PRESENTATION:A man in his 50s with blue rubber bleb nevus syndrome presented with headaches, imbalance, decreased visual acuity bilaterally, and left eye proptosis and chemosis. Imaging demonstrated an extensive intraosseous DAVF with dilated intraosseous vascular pouches throughout his cranial base and intraorbital venous congestion. He underwent staged endovascular treatment with the goal to improve his ocular symptoms. Transarterial and transvenous approaches failed to provide adequate access to the intraosseous vascular pouches. A direct, percutaneous transfacial approach was used to access the pouches for embolization with coils and liquid embolic material. Postoperative angiography demonstrated successful embolization of the pouch within the left pterygoid wing, reduced opacification of the intraosseous fistula, and elimination of intraorbital venous congestion. At 9-month follow-up, the patientʼs headaches had resolved, and his ocular symptomatology had improved. CONCLUSION:Endovascular access to an intraosseous DAVF is limited by the size and location of the intraosseous vascular pouches. In this case, a direct transfacial approach under image guidance facilitated access and embolization, which led to an improvement in the patientʼs symptoms. This technique is a novel approach for DAVF management. ABBREVIATIONS:BRBNS, blue rubber bleb nevus syndromeCCF, carotid cavernous fistulaDAVF, dural arteriovenous fistulaIJV, internal jugular veinSOV, superior ophthalmic vein

•Our series includes 10 years of experience of a large vascular neurosurgery center.•Our series includes 45 DAVFs cases.•Our series has been carefully analyzed ‘side by side’ with most relevant literature.•Paper focuses on therapeutic options and risks related to treatment. Dural arteriovenous fistulas (DAVFs) are a challenging condition in vascular neurosurgery. Disease natural history and its management is still debated. In the present paper we report our center series on DAVFs over a period of 10 years. Our data were compared with relevant literature. Our series includes 45 cases: 14 cavernous sinus, 11 transverse-sigmoid, 8 patients tentorial, 6 anterior cranial fossa, 5 patients spinal, 1 patient foramen magnum. DVAFs distribution, clinical presentation and hemorrhagic risk are discussed. Cavernous sinus DAVFs are the most common site in our series. Other locations in order of frequency are transverse-sigmoid sinus, tentorial, anterior cranial fossa, spinal and foramen magnum. The majority of patients presented with non-aggressive symptoms. 18% presented with intracranial hemorrhage: all the hemorrhages occurred in high-grade DAVFs. For most patients, endovascular treatment, transarterial or transvenous, was the first option. Surgery was performed for the anterior cranial fossa DAVFs and other complex lesions draining mostly transverse-sigmoid sinus and tentorium. In 7% of cases a combination of endovascular+surgical treatment was used. Our series has been carefully analyzed in comparison ‘side by side’ with most relevant literature on DVAFs, focusing particularly on management strategies, therapeutic options and risks related to treatment.

Abstract Objectives: The purpose of this study was to establish the role of the liquid embolic agent, ONYX, in the treatment of cranial dural arteriovenous fistulae (DAVFs) and to redefine the indications, techniques and outcomes of treatment with ONYX. Materials and Methods: This is a retrospective study of 25 DAVF patients who underwent endovascular treatment with ONYX between February 2006 and July 2008. All patients of DAVF presenting in this period were treated with ONYX. Results: Anatomic cure (i.e., complete angiographic closure of the fistula) was achieved in a single session and through a single arterial pedicle injection in 21 out of 25 patients (cure rate of 84%). Out of four patients with residual fistulae, one achieved cure that was evident on a control angiogram obtained at 3 months while three had no vascular access for further embolization and so were referred for radiosurgery. There was only one recurrence seen in angiograms obtained at the end of one year and this patient was re-embolized successfully with ONYX. Complications were seen in two patients. Conclusion: ONYX embolization of DAVFs has revolutionized the endovascular treatment of DAVFs, achieving high cure rates in a single session with minimal complications. Transarterial ONYX embolization should be the first option for all locations, except cavernous DAVFs.