Journal of ISSN: 2373-6410JNSK

Neurology & Stroke
Case Report
Volume 5 Issue 4 - 2016
Hydrocephalus Treated with Embolization of a Tentorial Dural Fistula
Lagios K1, Mpazinas T1, Veranis S2*, Sphikas Sp2, Kapetanakis A2 and Koutsoumpelis G2
1Neurointerventional Unit 251 General Air Force and Reserve Hospital, Greece
2Neurosurgical Department 251 General Air Force and Reserve Hospital, Greece
Received: November 22, 2016 | Published: December 30, 2016
*Corresponding author: Veranis Sotiris, Neurosurgical Department 251 General Air Force and Reserve hospital, Athens, Kanellopoulou - Katehaki 3, po box 11525, Greece, Email:
Citation: Lagios K, Mpazinas T, Veranis S, Sphikas Sp, Kapetanakis A, et al. (2016) Hydrocephalus Treated with Embolization of a Tentorial Dural Fistula. J Neurol Stroke 5(4): 00187. DOI: 10.15406/jnsk.2016.05.00187

Abstract

We present a case of a 73 years old, caucasian male patient who presented two years ago with progressive dementia, frequent falls, unsteady gait and somnolence. He suffered from diabetes type 2 and mild chronic renal insufficiency. He was diagnosed with obstructive hydrocephalus and tentorial dural fistula (Cognard type IV). He underwent brain angiography and embolization of the fistula. His symptoms improved remarkably postembolisation and he remains stable after two years of follow up.

Keywords: Hydrocephalus; Dural fistulas; Tentorial Davf; Embolization; Flow voids

Introduction

Hydrocephalus is a pathological condition in which the ventricles of the brain are widened and is caused by abnormalities regarding the formation, flow or absorption of the cerebrospinal fluid. Dural fistulas is a well known cause of intracranial hypertension because of impairment of venus outflow (Borden type III, Cognard type III,IV,V) 1,2,3.On the other hand dural fistulas are rarely reported as a cause for obstructive hydrocephalus.

Clinical case

We present the case of a 73 years old, caucasian male patient who presented with progressive dementia and gait disturbances with frequent falls. Furthermore he was complaining for headache and somnolence. He have been suffering from diabetes type 2 and mild renal insufficiency. Brain MRI diagnosed obstructive hydrocephalus and multiple flow voids mainly at the subtentorial space (Figure 1). Brain four vessel angiography diagnosed a tentorial dural fistula (Borden type III, Cognard type IV) (Figure 2).

Figure 1: A) T2 brain MRI depicting multiple flow voids (red arrow) in the posterior fossa. B) T1 brain MRI obstructive hydrocephalus with remote fistula (blue arrow). C) T2 Flair dilatation of lateral ventricles.


Figure 2: a) Infusion through RICA in venous phase opacifies a small part of strait sinus (lower red arrow), there is absence of internal cerebral veins, vein of Galen and basal vein, there is opacification of subependymal vein (upper red arrow) b) Infusion inside ascending pharyngeal artery, a micro catheter was progressed through neuromeningeal branch and final embolization of DAVF performed with ONYX. Anastomosis of dural branch with posterior meningeal artery and dilated cerebellar veins can be seen. c) Infusion into EC and retrograde flow inside cerebellum veins, pontomedullary vein, basal vein and towards superficial veins of temporal and frontal lobe. d) Infusion into left vertebral artery leads to opacification of cerebellar veins through fistula from posterior meningeal artery. Cognard type IV.

Methods

Patient was sedated, paralysed and intubated. Femoral artery was catheterised on the left side and a four vessel brain angiography was obtained. A tentorial dural fistula was diagnosed. There were several distended tortuous veins depicting venous outflow hypertension. We proceeded with transarterial embolization of the feeding arteries using ONYX [5-8]. Patient remained stable throughout the procedure (Figure 2b&3).


Figure 3: a) Post embolisation Lateral projection after infusion from right CCA. b) A-P projection after infusion right CCA. c) Lateral X-Ray depicted ONYX inside the fistula. d) A-P view depicting ONYX inside the fistula.

Results

Clinical results

Patient remained stable through the embolisation procedure. Afterwards his symptoms resolved and returned home 2 days later. His neurological examination at discharge was unremarkable. The patient has been under close follow up for the last two years without clinical or radiological remission.

Radiological results

The patient remained stable and did brain MRI once a year for follow up. There was resolution of hydrocephalus and disappearance of flow voids and tortuous vessels (Figure 4).

Figure 4: a) T1 sagittal brain MRI 2 depicting resolution of hydrocephalus. B) T2 flair, resolution of hydrocephalus. c) T2 , resolution of flow voids around midbrain.

Discussion

Dural fistulas is a well known cause of intracranial hypertension because of venous outflow obstruction. Hydrocephalus is a rare symptom of dural fistula. According to Sandro Rossitti 4 CSF pressure is equal to cerebral vein pressure. Dural fistula that cause elevated venous outflow pressure result in elevated CSF pressure and intracranial hypertension. In our patient we observed multiple tortuous dilated veins in the posterior fossa and we assume that this fact caused raised CSF pressure in the posterior fossa and obstructive hydrocephalus. We did not perform lumbar puncture and CSF pressure measurements because this was thought to be contraindicated due to obstructive hydrocephalus. It is not yet clear how dural fistulas affect CSF dynamic.

Hydrocephalus is associated with symptoms such as headache, gait disturbances and dementia. In our case ventricular dilatation markedly improved post embolisation. On the other hand it not sure if blockage of the venus outflow due to the tentorial dural fistula affected gait and memory in addition to hydrocephalus 9.

References

  1. Borden JA, Wu JK, Shucart WA (1995) A proposed classification for spinal and cranial dural arteriovenous fistulous malformations and implications for treatment. J Neurosurg 82(2): 166-179.
  2. Cognard C, Casasco A, Toevi M, Houdart E, Chiras J, Merland JJ (1998) Dural arteriovenous fistulas as a cause of intracranial hypertension due to impairment of cranial venous outflow. J Neurol Neurosurg Psychiatry 65(3): 308-316.
  3. Cognard C, Gobin YP, Pierot L, Bailly AL, Houdart E, et al. (1995) Cerebral dural arteriovenous fistulas: clinical and angiographic correlation with a revised classification of venous drainage. Radiology 194(3): 671-680.
  4. Sandro Rossitti (2013) Pathophysiology of increased cerebrospinal fluid pressure associated to brain arteriovenous malformations : The hydraulic hypothesis. Surg Neurol Int 4: 42.
  5. Puffer RC, Daniels DJ, Kallmes DF, Cloft HJ, Lanzino G (2012) Curative Onyx embolization of tentorial dural arteriovenous fistulas. Neurosurg Focus 32(5): E4.
  6. Huang Q, Xu Y, Hong B, Li Q, Zhao W, Liu J (2009) Use of onyx in the management of tentorial dural arteriovenous fistulae. Neurosurgery 65(2): 287-292.
  7. Jiang C, Lv X, Li Y, Zhang J, Wu Z (2009) Endovascular treatment of high-risk tentorial dural arteriovenous fistulas: clinical outcomes. Neuroradiology 51(2): 103-111.
  8. Choudhri O, Marks MP (2014) Endovascular treatment of a tentorial dural arteriovenous fistula. Neurosurg Focus 37(1 Suppl): 1.
  9. Nakahara Y, Ogata A, Takase Y, Maeda K, Okamoto H, et al. (2011) Treatment of dural arteriovenous fistula presenting as typical symptoms of hydrocephalus caused by venous congestion: case report. Neurol Med Chir (Tokyo) 51(3): 229-232.
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