Pial Artery Supply as an Anatomic Risk Factor for Ischemic Stroke in the Treatment of Intracranial Dural Arteriovenous Fistulas

S.W. Hetts; A. Yen; D.L. Cooke; J. Nelson; P. Jolivalt; J. Banaga; M.R. Amans; C.F. Dowd; R.T. Higashida; M.T. Lawton; H. Kim; V.V. Halbach

doi:10.3174/ajnr.A5396

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Fig 1.
Postembolization infarction due to Onyx migration into a pial artery. A middle-aged woman with severe pulsatile tinnitus underwent endovascular therapy for a right transverse-sigmoid sinus junction Borden-Shucart grade I DAVF supplied principally by the middle meningeal and occipital arteries (A) and secondarily by the ipsilateral middle temporal artery (B) and tentorial branches from the contralateral middle meningeal artery (C). The fistula site is designated by a white asterisk. The fusiform gyrus branch of the middle temporal artery is indicated by a white arrow. Superselective injection of the right middle meningeal artery demonstrates the fistula site before embolization (D). Midembolization x-ray (E) demonstrates Onyx in the middle meningeal artery, fistula site, and refluxed into the pial fusiform gyrus branch of the middle temporal artery. The extent of reflux had not been evident on real-time intraprocedural blank roadmap imaging. DWI later the same day (F) demonstrates a fusiform gyrus infarction.
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Fig 2.
Arterial emboli following endovascular and surgical treatments of DAVFs in 2 patients. Two middle-aged male patients undergoing posttreatment angiography were identified as having middle cerebral artery emboli (A and C, white arrows). Both patients were heparinized, and the second patient underwent superselective intra-arterial tPA treatment with minimal clot lysis. Postangiographic DWIs (B and D) demonstrate small cortical infarctions in territories associated with the MCA emboli. Although the first patient's MCA thrombus (A and B) is adjacent to the original DAVF, the second patient's is not (C and D).
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Fig 3.
Postsurgical seizure and small cortical infarction after surgical ligation of a residual DAVF. A middle-aged woman status 1 year post temporal lobe hemorrhage underwent endovascular therapy for a Borden-Shucart grade III DAVF supplied principally by the left middle meningeal artery (B) and secondarily by pial branches of the left MCA (A), with drainage directly to a cortical vein. Onyx embolization eliminated the middle meningeal artery dural supply (C), but late-phase angiographic images demonstrated persistent MCA pial supply (D). Three days following a craniotomy for successful ligation of the residual DAVF, the patient had a seizure. MR imaging at that time demonstrates a small cortical infarction (E).
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Fig 4.
Postoperative parenchymal hemorrhage and possible venous infarction following surgical ligation of a residual DAVF. A middle-aged man had intermittent speech arrest and multiple headaches for several years. Anteroposterior (A) and lateral (B) angiograms demonstrate a variant-type right transverse-sigmoid sinus junction Borden-Shucart grade III DAVF supplied by dural branches of the external carotid artery and pial branches of the MCA (C) with retrograde drainage to the vein of Labbé (D), that anastomotically drains to the vein of Trolard. Following Onyx embolization of the dural external carotid artery branches, only the pial MCA supply to the fistula continued to drain to the cortical vein as demonstrated on early (E), mid (F), and late (G) images from a lateral ICA angiogram. During surgical ligation of the residual DAVF, extensive intraoperative bleeding was noted. A CT performed immediately postoperatively (H) demonstrates right temporal intraparenchymal hemorrhage. The patient did not have a new neurologic deficit postoperatively.