Dual Pathologies: Pial Arteriovenous Fistula in Combination with an Arteriovenous Malformation

Abstract

Background A pial arteriovenous fistula (PAVF) is a rare neurovascular pathology consisting of a direct connection between one or more arterial feeders and a single venous channel. A PAVF was previously considered a subtype of an arteriovenous malformation (AVM). In the current literature these are distinguished as two independent entities with different clinical, physiopathologic, and structural characteristics. We report a case of a surgically treated 37-year-old woman with an extremely rare combination of an unruptured PAVF and AVM.

Patient The AVM was mainly supplied by feeders of the middle cerebral artery and drained into the sigmoid sinus via an abnormally dilated and tortuous vein. Following its resection, intraoperative digital subtraction angiography (DSA) in the hybrid operating room revealed the presence of a PAVF that had not been noted during the preoperative planning. Hence the PAVF was completely disconnected as confirmed by DSA again.

Conclusion This is the second reported case of an AVM-associated PAVF. Without the intraoperative DSA in the hybrid operating room, this unusual complex cerebrovascular entity would likely have been missed.

Keywords

arteriovenous malformation - augmented reality - hybrid operating room - pial arteriovenous fistula

• References

• 1 Lv X, Li Y, Jiang C, Wu Z. Endovascular treatment of brain arteriovenous fistulas. AJNR Am J Neuroradiol 2009; 30 (04) 851-856
• 2 Yasargil MG. Microneurosurgery: AVM of the Brain, History, Embryology, Pathological Considerations, Hemodynamics, Diagnostic Studies, Microsurgical Anatomy. Vol III-A. Stuttgart, Germany:: Thieme;; 1987: 213-239
• 3 Lasjaunias P, Manelfe C, Chiu M. Angiographic architecture of intracranial vascular malformations and fistulas—pretherapeutic aspects. Neurosurg Rev 1986; 9 (04) 253-263
• 4 Goel A, Jain S, Shah A, Rai S, Gore S, Dharurkar P. Pial arteriovenous fistula: a brief review and report of 14 surgically treated cases. World Neurosurg 2018; 110: e873-e881
• 5 Davies MA, TerBrugge K, Willinsky R, Coyne T, Saleh J, Wallace MC. The validity of classification for the clinical presentation of intracranial dural arteriovenous fistulas. J Neurosurg 1996; 85 (05) 830-837
• 6 Funakoshi Y, Hatano T, Saka M. , et al. Dural and pial arteriovenous fistulas connected to the same drainer in the middle cranial fossa: a case report. World Neurosurg 2018; 118: 47-52
• 7 Kikuchi K, Kowada M, Sasajima H. Vascular malformations of the brain in hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber disease). Surg Neurol 1994; 41 (05) 374-380
• 8 Santosh C, Teasdale E, Molyneux A. Spontaneous closure of an intracranial middle cerebral arteriovenous fistula. Neuroradiology 1991; 33 (01) 65-66
• 9 Cabrilo I, Bijlenga P, Schaller K. Augmented reality in the surgery of cerebral arteriovenous malformations: technique assessment and considerations. Acta Neurochir (Wien) 2014; 156 (09) 1769-1774
• 10 Paramasivam S, Toma N, Niimi Y, Berenstein A. Development, clinical presentation and endovascular management of congenital intracranial pial arteriovenous fistulas. J Neurointerv Surg 2013; 5 (03) 184-190
• 11 Cai W, Gong J, Cheng B. , et al. Pial arteriovenous fistulas associated with multiple aneurysms presenting as intracerebral hemorrhage: a case report. Turk Neurosurg 2014; 24 (05) 778-781
• 12 Yang WH, Lu MS, Cheng YK, Wang TC. Pial arteriovenous fistula: a review of literature. Br J Neurosurg 2011; 25 (05) 580-585
• 13 Hoh BL, Putman CM, Budzik RF, Ogilvy CS. Surgical and endovascular flow disconnection of intracranial pial single-channel arteriovenous fistulae. Neurosurgery 2001; 49 (06) 1351-1363 ; discussion 1363–1364
• 14 da Silva Martins WC, de Albuquerque LA, de Souza Filho CB, Dellaretti M, de Sousa AA. Surgical treatment of the intracranial pial arteriovenous fistula. Surg Neurol Int 2015; 6: 102
• 15 Jabbour P, Tjoumakaris S, Chalouhi N. , et al. Endovascular treatment of cerebral dural and pial arteriovenous fistulas. Neuroimaging Clin N Am 2013; 23 (04) 625-636
• 16 Schaller K, Cabrilo I, Pereira VM, Bijlenga P. Hybrid operation theatre from the perspective of neurosurgery [in German]. Chirurg 2013; 84 (12) 1041-1047
• 17 Dammann P, Breyer T, Wrede KH. , et al. Treatment of complex neurovascular lesions: an interdisciplinary angio suite approach. Ther Adv Neurol Disorder 2014; 7 (01) 60-70