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Papers of the Week

2020 May 10

World Neurosurg

Multiple cranial dural and pial arteriovenous fistulas with occlusion of all after embolization of primary superior sagittal sinus dural fistula.


We present a rare case of multiple intracranial arteriovenous fistulas (AVFs). A young female presented with headache and a left eyelid pulsatile swelling. Magnetic resonance imaging demonstrated numerous dilated cortical veins, along with a prominent left superior ophthalmic vein. A diagnostic cerebral angiogram revealed 5 distinct AVFs including 4 dural AVFs (dAVFs) and a pial AVF (pAVF). The largest dAVF was at the superior sagittal sinus (SSS). The others included bilateral ethmoidal, torcular, and a pAVF arising of the right pericallosal artery. She was treated by endovascular transarterial Onyx embolization. Only the SSS fistula was treated via middle meningeal artery feeders with complete occlusion. Immediate follow-up angiogram also showed complete spontaneous occlusion of the untreated dAVFs and the pial AVF. This case is exceedingly unique considering the multiplicity of AVFs, concurrent presence of pial and dural AVF, and spontaneous occlusion of all untreated AVFs after embolizing the largest shunting fistula.