Borden type I intracranial dural arteriovenous fistula

Borden type I intracranial dural arteriovenous fistula

Type I dural arteriovenous fistulas are supplied by a meningeal artery or arteries and drain into a meningeal vein or dural venous sinus. The flow within the draining vein or venous sinus is anterograde.

Equivalent to Cognard type I and IIa, with a favorable natural history 1) 2).

Type Ia – simple dural arteriovenous fistulas have a single meningeal arterial supply

Type Ib – more complex arteriovenous fistulas are supplied by multiple meningeal arteries The distinction between Types Ia and Ib is somewhat specious as there is a rich system of meningeal arterial collaterals. Type I dural fistulas are often asymptomatic, do not have a high risk of bleeding and do not necessarily need to be treated


A small number of Type I DAVFs will convert to more aggressive DAVFs with CVD over time. This conversion to a higher-grade DAVF is typically heralded by a change in patient symptoms. Follow-up vascular imaging is important, particularly in the setting of recurrent or new symptoms. 3).


A comparative meta-analysis was completed to evaluate the outcomes of intervention versus observation of Borden type I intracranial dural arteriovenous fistula. Outcome measures included: grade progression, worsening symptoms, death due to dural arteriovenous fistula, permanent complications other than death, functional independence (mRS 0-2), and rate of death combined with permanent complication, were evaluated. Risk differences (RD) were determined using a random effects model.

Three comparative studies combined with the authors’ institutional experience resulted in a total of 469 patients, with 279 patients who underwent intervention and 190 who were observed. There was no significant difference in dAVF grade progression between the intervention and observation arms, 1.8% vs. 0.7%, respectively (RD: 0.01, 95% CI: -0.02 to 0.04, P = 0.49), or in symptom progression occurring in 31/279 (11.1%) intervention patients and 11/190 (5.8%) observation patients (RD: 0.03, CI: -0.02 to 0.09, P = 0.28). There was also no significant difference in functional independence on follow-up. However, there was a significantly higher risk of dAVF-related death, permanent complications from either intervention or dAVF-related ICH or stroke in the intervention group (11/279, 3.9%) compared to the observation group (0/190, 0%) (RD: 0.04, CI: 0.1 to 0.06, P = 0.007).

CoIntervention of Borden Type I dAVF results in a higher risk of death or permanent complication, which should be strongly considered when deciding on the management of these lesions 4).


From April 2013 to March 2016, consecutive patients with DAVF were screened at 13 study institutions. We collected data on baseline characteristics, clinical symptoms, angiography, and neuroimaging. Patients with Borden type I DAVF received conservative care while palliative intervention was considered when the neurological symptoms were intolerable, and were followed at 6, 12, 24, and 36 months after inclusion.

Results: During the study period, 110 patients with intracranial DAVF were screened and 28 patients with Borden type I DAVF were prospectively followed. None of the patients had conversion to higher type of Borden classification or intracranial hemorrhage during follow-up. Five patients showed spontaneous improvement or disappearance of neurological symptoms (5/28, 17.9%), and 5 patients showed a spontaneous decrease or disappearance of shunt flow on imaging during follow-up (5/28, 17.9%). Stenosis or occlusion of the draining sinuses on initial angiography was significantly associated with shunt flow reduction during follow-up (80.0% vs 21.7%, p = 0.02).

Conclusion: In this 3-year prospective study, patients with Borden type I DAVF showed benign clinical course; none of these patients experienced conversion to higher type of Borden classification or intracranial hemorrhage. The restrictive changes of the draining sinuses at initial diagnosis might be an imaging biomarker for future shunt flow reduction 5)


1)

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 Nov;85(5):830-7. doi: 10.3171/jns.1996.85.5.0830. PMID: 8893721.
2)

Strom RG, Botros JA, Refai D, Moran CJ, Cross DT 3rd, Chicoine MR, Grubb RL Jr, Rich KM, Dacey RG Jr, Derdeyn CP, Zipfel GJ. Cranial dural arteriovenous fistulae: asymptomatic cortical venous drainage portends less aggressive clinical course. Neurosurgery. 2009 Feb;64(2):241-7; discussion 247-8. doi: 10.1227/01.NEU.0000338066.30665.B2. PMID: 19190453.
3)

Shah MN, Botros JA, Pilgram TK, Moran CJ, Cross DT 3rd, Chicoine MR, Rich KM, Dacey RG Jr, Derdeyn CP, Zipfel GJ. Borden-Shucart Type I dural arteriovenous fistulas: clinical course including risk of conversion to higher-grade fistulas. J Neurosurg. 2012 Sep;117(3):539-45. doi: 10.3171/2012.5.JNS111257. Epub 2012 Jun 22. PMID: 22725983.
4)

Schartz D, Rahmani R, Gunthri A, Kohli GS, Akkipeddi SMK, Ellens NR, Romiyo P, Kessler A, Bhalla T, Mattingly TK, Bender MT. Observation versus intervention for Borden type I intracranial dural arteriovenous fistula: A pooled analysis of 469 patients. Interv Neuroradiol. 2022 Sep 13:15910199221127070. doi: 10.1177/15910199221127070. Epub ahead of print. PMID: 36113111.
5)

Nishi H, Ikeda H, Ishii A, Kikuchi T, Nakahara I, Ohta T, Sakai N, Imamura H, Takahashi JC, Satow T, Okada T, Miyamoto S. A multicenter prospective registry of Borden type I dural arteriovenous fistula: results of a 3-year follow-up study. Neuroradiology. 2022 Apr;64(4):795-805. doi: 10.1007/s00234-021-02752-5. Epub 2021 Oct 10. PMID: 34628528; PMCID: PMC8907088.

Vertebro-vertebral arteriovenous fistula

Vertebro-vertebral arteriovenous fistula

Vertebro-vertebral arteriovenous fistula (VV-AVF) is a rare vascular disorder with an abnormal shunt between the extracranial vertebral artery (VA), its muscular or radicular branches, and adjacent vein1)

Trauma is the most common cause, including stab wounds, gunshot wound, and blunt trauma. Most VV-AVF patients have lesions that are spontaneous or caused by neck trauma 2) Some patients with VV-AVF are asymptomatic. Others may have tinnitus or neurologic deficit because of high flow arteriovenous shunting, steal phenomenon, or compression mass effect from enlarged venous pouches 3) 4) 5) 6).

The location of VVAVF is also variable with most cases above the C2 vertebra or below the C5 vertebra 7).

Surgical ligation or endovascular closure of the high-flow arteriovenous fistula is the main goal of treatment for VV-AVF 8) 9) 10)11).

Chen et al. presented two female NF-1 patients with a diagnosis of VV-AVF treated with endovascular approach. The fistula was completely obliterated with balloon assisted embolization and covered stent separately and VA patency was preserved in both cases. Reviewing the literature with a focus on endovascular treatment, endovascular occlusion of VV-AVF in NF-1 patients is safe and effective. To preserve the parent VA patency and obliterate the fistula simultaneously is challenging generally, but feasible in some cases 12).


Yeh et al. presented the experience of VV-AVF treatment with covered stents in three patients and detachable coils in two patients. One patient with a fistula at the V3 segment had rapid fistula recurrence one week after covered stent treatment. The possible causes of failed treatment in this patient are discussed. The currently available treatment modalities for VV-AVF are also summarized after a literature review. At the end of this article, we propose a new concept of anatomically based approach for endovascular treatment of VV-AVF. Fistula in the V1-2 segments of vertebral artery could be treated safely and effectively by covered stent with the benefit of preserving VA patency. Embolization with variable embolizers should be considered first for fistula in the V3 segment because of the tortuous course and flexibility of the VA in this segment 13).


Briganti et al. describe endovascular approaches for occlusion of vertebro-vertebral arteriovenous fistula (VV-AVF) in a series of three cases and a review of the literature. Complete neuroimaging assessment, including CT, MR and DSA was performed in three patients (two female, one male) with VV-AVF. Based on DSA findings, the VV-AVF were occluded by endovascular positioning of detachable balloons (case 1), coils (case 2), or a combination of both (case 3) with parent artery patency in two out of three cases. In this small series, endovascular techniques for occlusion of VV-AVF were safe and effective methods of treatment. To date, there are no guidelines on the best treatment for VV-AVF. Detachable balloons, endovascular coiling, combined embolization procedures could all be considered well-tolerated treatments 14).

Vertebro-vertebral arteriovenous fistula involving the vertebral artery segment V3 is a rare vascular pathology that is either spontaneous or traumatic in origin. Furtado et al. described a post-operative traumatic vertebro-vertebral fistula in a 47-year-old lady with NF-1. They reviewed reported cases of V3 segment vertebrovertebral fistula for their incidence, etiology, clinical presentation, treatment, and outcomes using an illustrative case. Traumatic V3 segment vertebrovertebral fistula is predominantly managed with parent vessel occlusion. Per the algorithm presented, we suggest endovascular management of non-traumatic fistula be based on the anatomical variance of the contralateral vertebral artery 15).


A vertebral AVF was detected by carotid duplex ultrasonography, and endovascular treatment was successfully performed in a 72-year-old woman with 1-year history of hemodialysis 16)


A 72-year-old woman was admitted with a complaint of bilateral leg weakness. A cervical magnetic resonance image showed compression of the spinal cord by a large vascular lesion. Right vertebral angiogram showed a vertebro-vertebral fistula draining into ectatic epidural veins. From a transfemoral arterial approach, the fistula site was selected with a microcatheter, and embolization was performed by placement of several Guglielmi detachable coils until flow arrest was obtained. The patient made a full recovery, and a long-term angiographic follow-up demonstrated a complete cure 17).


1)

Halbach VV, Higashida RT, Hieshima GB. Treatment of vertebral arteriovenous fistulas. AJR Am J Roentgenol. 1988 Feb;150(2):405-12. doi: 10.2214/ajr.150.2.405. PMID: 3257333.
2) , 3) , 8)

Beaujeux RL, Reizine DC, Casasco A, Aymard A, Rüfenacht D, Khayata MH, Riché MC, Merland JJ. Endovascular treatment of vertebral arteriovenous fistula. Radiology. 1992 May;183(2):361-7. doi: 10.1148/radiology.183.2.1561336. PMID: 1561336.
4) , 9)

Herrera DA, Vargas SA, Dublin AB. Endovascular treatment of traumatic injuries of the vertebral artery. Am J Neuroradiol. 2008;29(8):1585–1589. doi: 10.3174/ajnr.A1123.
5)

Vinchon M, Laurian C, George B, et al. Vertebral arteriovenous fistulas: a study of 49 cases and review of the literature. Cardiovasc Surg. 1994;2(3):359–369.
6)

Ito O, Nishimura A, Ishido K, et al. Spontaneous vertebral arteriovenous fistula manifesting as radiculopathy. No Shinkei Geka. 2011;39(8):775–781.
7)

Desouza RM, Crocker MJ, Haliasos N, Rennie A, Saxena A. Blunt traumatic vertebral artery injury: a clinical review. Eur Spine J. 2011 Sep;20(9):1405-16. doi: 10.1007/s00586-011-1862-y. Epub 2011 Jun 16. PMID: 21674212; PMCID: PMC3175894.
10) , 14)

Briganti F, Tedeschi E, Leone G, Marseglia M, Cicala D, Giamundo M, Napoli M, Caranci F. Endovascular treatment of vertebro-vertebral arteriovenous fistula. A report of three cases and literature review. Neuroradiol J. 2013 Jun;26(3):339-46. doi: 10.1177/197140091302600315. Epub 2013 Jul 16. PMID: 23859293; PMCID: PMC5278851.
11)

Ishiguro T, Kawashima A, Yoneyama T, et al. Two cases of iatrogenic vertebral arteriovenous fistulas successfully treated by surgery. No Shinkei Geka. 2011;39(3):269–274.
12)

Chen C, Wu Y, Zhao K, Duan G, Liu J, Huang Q. Endovascular treatment of vertebro-vertebral arteriovenous fistula in neurofibromatosis type I: A report of two cases and literature review with a focus on endovascular treatment. Clin Neurol Neurosurg. 2021 Aug;207:106806. doi: 10.1016/j.clineuro.2021.106806. Epub 2021 Jul 14. PMID: 34293658.
13)

Yeh CH, Chen YL, Wu YM, Huang YC, Wong HF. Anatomically based approach for endovascular treatment of vertebro-vertebral arteriovenous fistula. Interv Neuroradiol. 2014 Dec;20(6):766-73. doi: 10.15274/INR-2014-10072. Epub 2014 Dec 5. PMID: 25496689; PMCID: PMC4295251.
15)

Furtado SV, Vasavada P, Baid A, Perikal PJ. Endovascular management of V3 segment vertebro-vertebral fistula: case management and literature review. Br J Neurosurg. 2022 May 3:1-5. doi: 10.1080/02688697.2022.2071416. Epub ahead of print. PMID: 35502703.
17)

Tenjin H, Kimura S, Sugawa N. Coil embolization of vertebro-vertebral arteriovenous fistula: a case report. Surg Neurol. 2005 Jan;63(1):80-3; discussion 83. doi: 10.1016/j.surneu.2004.01.026. PMID: 15639536.

Cerebrospinal fluid fistula

Cerebrospinal fluid fistula

cerebrospinal fluid leak (CSFL) is a medical condition when the cerebrospinal fluid of a person leaks out of the dura mater.

There is a incomplete sealing of the dura mater and is a major complication of intradural procedures.

Cerebrospinal fluid fistula classification

Cerebrospinal Fluid Fistula Etiology.

see Cerebrospinal fluid fistula diagnosis.

Cerebrospinal fluid fistula complications

Dural closure‘s reinforcement using different new dural sealants plays an important role in prevention. Moreover, the use of neuronavigation systems in skull base and posterior fossa surgery can help to minimize the size of approach and reduce the incidence of CSF leak. New minimally invasive spinal approaches, such as minimally invasive decompression for spinal degenerative disorders or performing selective laminotomy over laminectomy for intradural spinal pathology are very useful techniques to prevent CSF leak in this kind of surgery. In conclusion, although CSF leak remains a risky complication in neurosurgery, its prevention and treatment significantly benefited from advances in biomaterials and surgical technique 1).

see Cerebrospinal fluid fistula treatment.

Ramos-Rincon et al. aimed to analyze research activity on cerebrospinal fluid (CSF) leaks in general and CSF cerebrospinal fluid rhinorrhea and cerebrospinal fluid otorrhea in particular and to identify the main topic clusters in these areas.

They identified all relevant documents, using the medical subject headings (MeSH) term “Cerebrospinal Fluid Leak”, that are indexed in the MEDLINE database between 1945 and 2018. They performed a descriptive bibliometric analysis and analyses of networks and research clusters in order to identify the main topic areas of research.

From 1945 to 2018, a total of 4,130 records were published with the term CSF leak, including 2,821 documents (68.1%) with the term CSF rhinorrhea and 1,040 documents (25.8%) with CSF otorrhea. The number of documents published increased from 10 in 1945-49 to 642 in 2010-14. Articles represented the dominant document type (86.8% of the documents analyzed), while case reports were the main type of study (37.4%). In terms of geographical distribution, researchers from the USA led in the number of signatures (39.1%), followed by those from the UK (7.5%). The most active areas of research in the field were “Postoperative Complications,” “Tomography, X-Ray Computed,” and “Magnetic Resonance Imaging.” The terms “Adults,” “Young Adult,” and “Middle-Aged” were most common in CSF rhinorrhea research; and the terms “Infant,” “Child, Preschool,” “Child,” and “Adolescent” were more common in CSF otorrhea.

Based on these findings, articles and case reports related to “Surgery” and “postoperative complications” associated with the cerebrospinal fluid fistula diagnosis are the main topics of study, highlighting the importance of this document type in advancing knowledge in the field 2).


1)

Rapisarda A, Orlando V, Izzo A, D’Ercole M, Polli FM, Visocchi M, Montano N. New Tools and Techniques to Prevent CSF Leak in Cranial and Spinal Surgery. Surg Technol Int. 2022 Apr 20;40:sti40/1577. Epub ahead of print. PMID: 35443285.
2)

Ramos-Rincon JM, Monjas-Canovas I, Abarca-Olivas J, Gras-Albert JR, Bellinchón-Romero I, Gonzalez-Alcaide G. Research in Cerebrospinal Fluid Leak (Rhinorrhea and Otorrhea): A Bibliometric Analysis From 1945 to 2018. Cureus. 2022 Feb 3;14(2):e21888. doi: 10.7759/cureus.21888. PMID: 35265419; PMCID: PMC8898118.
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