By Ursula K Tolley RN & Reza Malek MD
Physicians involved : Reza Malek MD, Harmeet Sachdev MD, Kenneth Blumenfeld MD, Jorge Contreras MD.
The human brain is covered by three layers of Membranes (meninges). These layers provide protection for the brain, the outermost layer is called the dura matter.
There are major venous channels within the dura mater called dural sinuses. These dural sinuses collect blood from the veins in the brain. A Dural Arteriovenous Fistula (DAVF)/ dural arteriovenous fistula/ dural fistula’s an abnormal connection between the arteries and the dural sinuses.
Unlike AVM Most DAVF’s are thought to be acquired and grow with age. They can be formed in these conditions, head injury, open surgery and clotting and blockage of the dural sinuses.
The symptoms may vary depending on the location of the DAVF. many may have no symptoms at all and will still have Intra cranial hemorrhage. DAVF”S are commonly found in the cavernous sinus behind the eye, and transverse/sigmoid sinus (behind the ear, back of the head). Patient with cavernous DAVFs usually complain of decrease vision and redness/congestion and swelling of the eye. Patients with DAVFs behind the ear (transverse/sigmoid DAVFs) frequently hear a pulsating noise (tinnitus) due to the fast blood flow going through the fistulas. Stroke like symptoms, seizure like activity, headaches.
It is important to know that an DAVM’s may be present and produce no symptoms.
- Cerebral Angiogram
- Endovascular embolization
- Open surgery
35 year old female presented with pulsatile ringing of the left ear. She reports worsening headaches, some facial pain with left eye pain and occasional visual disturbance. Symptoms have been worsening the last two months prior to consult.
Exam: Awake alert and orientated X 3. Cranial nerves III,IV and V reveal no deficits, pupils are equal and reactive to light. Musculoskeletal/motor/reflexes normal. Sensory normal, HEENT, normal.
Neck, supple, no JVD or carotid bruit, no lymphadenopathy. Audible pulsatile thrill behind left ear. (patients husband could hear it just laying beside her on the left side.)
Heart and lung exam was normal.
MRI: revealed increased blood vessel flow voids in the left temporo-pariatal region suggesting an AVM.
Procedure: Trans venous embolization of DAVF.
Outcome: Patient’s headache and pulsatile tinnitus resolved with no complications.
Access was gained to both the arterial and venous system. A 6 F penumbra neuron guide catheter was advanced to the left internal jugular vein. A micro catheter was advanced through the guide catheter into the left sigmoid sinus for trans-venous embolization. A total of twenty coils by Boston Scientific and J & J were used with diameters ranging between 7-12mm and lengths of 20 –30cm to completely obliterate this shunt.