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Dural AV fistula & cognitive decline

Francesco Signorelli, Paul Khoueir, Felix Scholtes , Daniel Roy, Michel W. Bojanowski Centre Hospitalier de l'Université de Montréal, Canada Università degli Studi "Magna Græcia" di Catanzaro, Italy Centre Hospitalier Universitaire, Université de Liège, Belgium.

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Dural AV fistula & cognitive decline

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  1. F. Signorelli, P. Khoueir, F. Scholtes, D. Roy, M.W. Bojanowski – Dural AV fistulae and Dementia Francesco Signorelli, Paul Khoueir, Felix Scholtes, Daniel Roy, Michel W. Bojanowski Centre Hospitalier de l'Université de Montréal, Canada Università degli Studi "Magna Græcia" di Catanzaro, Italy Centre Hospitalier Universitaire, Université de Liège, Belgium Dural AV fistula & cognitive decline Presentation of 3 cases and integration into the literature

  2. F. Signorelli, P. Khoueir, F. Scholtes, D. Roy, M.W. Bojanowski – Dural AV fistulae and Dementia DAVF & cognitive decline • CVD: non-haemorrhagic neurological deficits Venous hypertension / congestion Stasis Edema Parenchymalinjury

  3. F. Signorelli, P. Khoueir, F. Scholtes, D. Roy, M.W. Bojanowski – Dural AV fistulae and Dementia DAVF & cognitive decline • Transverse sinus: • Hemispheric white matter

  4. F. Signorelli, P. Khoueir, F. Scholtes, D. Roy, M.W. Bojanowski – Dural AV fistulae and Dementia DAVF & cognitive decline • Transverse sinus • Hemispheric white matter • Straight sinus: • Thalamus

  5. F. Signorelli, P. Khoueir, F. Scholtes, D. Roy, M.W. Bojanowski – Dural AV fistulae and Dementia Case 1 • M 59y • 1 month history • cognitive and behavioural impairment • Apathic, non-cooperative, left hemiparesis

  6. F. Signorelli, P. Khoueir, F. Scholtes, D. Roy, M.W. Bojanowski – Dural AV fistulae and Dementia Case 1

  7. F. Signorelli, P. Khoueir, F. Scholtes, D. Roy, M.W. Bojanowski – Dural AV fistulae and Dementia Case 1 • Endovascular treatment: unsuccessful

  8. F. Signorelli, P. Khoueir, F. Scholtes, D. Roy, M.W. Bojanowski – Dural AV fistulae and Dementia Case 1 • Endovascular treatment: unsuccessful • Surgery: clipping of tentorial vein at junction with left lateral mesencephalic vein

  9. F. Signorelli, P. Khoueir, F. Scholtes, D. Roy, M.W. Bojanowski – Dural AV fistulae and Dementia Case 1 • Endovascular treatment: unsuccessful • Surgery: clipping of tentorial vein at junction with left lateral mesencephalic vein • Post-op angiography: no residual fistula

  10. F. Signorelli, P. Khoueir, F. Scholtes, D. Roy, M.W. Bojanowski – Dural AV fistulae and Dementia Case 1

  11. F. Signorelli, P. Khoueir, F. Scholtes, D. Roy, M.W. Bojanowski – Dural AV fistulae and Dementia Case 1

  12. F. Signorelli, P. Khoueir, F. Scholtes, D. Roy, M.W. Bojanowski – Dural AV fistulae and Dementia Case 1 • Endovascular treatment: unsuccessful • Surgery: left temporal craniotomy; clip of tentorial vein at junction with left lateral mesencephalic vein) • Post-op angiography: no residual fistula • Neurological recovery (at 4 months: minimal residual deficit)

  13. F. Signorelli, P. Khoueir, F. Scholtes, D. Roy, M.W. Bojanowski – Dural AV fistulae and Dementia Case 2 • M 56y • 3 week history • memory loss, confusion, emotional lability • Apathic, disorientated. No focal deficit.

  14. F. Signorelli, P. Khoueir, F. Scholtes, D. Roy, M.W. Bojanowski – Dural AV fistulae and Dementia Case 2 • Endovascular treatment of tentorial DAVF unsuccessful

  15. F. Signorelli, P. Khoueir, F. Scholtes, D. Roy, M.W. Bojanowski – Dural AV fistulae and Dementia Case 2 • Endovascular treatment of tentorial DAVF unsuccessful • Surgery: coagulation and ligation of tentorial vein

  16. F. Signorelli, P. Khoueir, F. Scholtes, D. Roy, M.W. Bojanowski – Dural AV fistulae and Dementia Case 2 • Endovascular treatment of tentorial DAVF unsuccessful • Surgery: coagulation and ligation of tentorial vein • Post-op angiography: no residual fistula

  17. F. Signorelli, P. Khoueir, F. Scholtes, D. Roy, M.W. Bojanowski – Dural AV fistulae and Dementia Case 2

  18. F. Signorelli, P. Khoueir, F. Scholtes, D. Roy, M.W. Bojanowski – Dural AV fistulae and Dementia Case 2 • Endovascular treatment of tentorial DAVF unsuccessful • Surgery: coagulation and ligation of tentorial vein • Post-op angiography: no residual fistula • Neurological recovery: return to work within 6 months

  19. F. Signorelli, P. Khoueir, F. Scholtes, D. Roy, M.W. Bojanowski – Dural AV fistulae and Dementia Case 3 • F 69y • <2 month history • cognitive decline: lack of initiative, drowsiness, memory loss • Anosognosia, apathy, left hemineglect, -paresis, -hypoesthesia

  20. F. Signorelli, P. Khoueir, F. Scholtes, D. Roy, M.W. Bojanowski – Dural AV fistulae and Dementia Case 3

  21. F. Signorelli, P. Khoueir, F. Scholtes, D. Roy, M.W. Bojanowski – Dural AV fistulae and Dementia Case 3

  22. F. Signorelli, P. Khoueir, F. Scholtes, D. Roy, M.W. Bojanowski – Dural AV fistulae and Dementia Case 3 • Endovascular treatment unsuccessful

  23. F. Signorelli, P. Khoueir, F. Scholtes, D. Roy, M.W. Bojanowski – Dural AV fistulae and Dementia Case 3 • Endovascular treatment unsuccessful • Surgery: supracerebellar infratentorial approach in the sitting position with disconnection of tentorial vein

  24. F. Signorelli, P. Khoueir, F. Scholtes, D. Roy, M.W. Bojanowski – Dural AV fistulae and Dementia Case 3 • Endovascular treatment unsuccessful • Surgery: supracerebellar infratentorial approach in the sitting position with disconnection of tentorial vein • Post-op angiography: no residual fistula

  25. F. Signorelli, P. Khoueir, F. Scholtes, D. Roy, M.W. Bojanowski – Dural AV fistulae and Dementia Case 3

  26. F. Signorelli, P. Khoueir, F. Scholtes, D. Roy, M.W. Bojanowski – Dural AV fistulae and Dementia Case 3 • Endovascular treatment unsuccessful • Surgery: supracerebellar infratentorial approach in the sitting position with disconnection of tentorial vein • Post-op angiography: no residual fistula • Neurological recovery for 6 weeks • Pulmonary embolism resulted in death

  27. F. Signorelli, P. Khoueir, F. Scholtes, D. Roy, M.W. Bojanowski – Dural AV fistulae and Dementia DAVF & cognitive decline • 43 cases reported (+ the present 3) • Age 43-80 (mean 63) • M/F = 3/1 (74% vs 26%)

  28. F. Signorelli, P. Khoueir, F. Scholtes, D. Roy, M.W. Bojanowski – Dural AV fistulae and Dementia DAVF & cognitive decline • CT / MRI diagnostic • but: 5/46 initially « normal » (until contrast administration) • Weak or no correlation between severity of images and symptoms

  29. F. Signorelli, P. Khoueir, F. Scholtes, D. Roy, M.W. Bojanowski – Dural AV fistulae and Dementia The transverse sinus • 18/26 : diffuse white matter anomaly (8/26: abnormal vessels) • DAVF topography: • 4 (15%) bilateral, 12 (46%) right, 10 (38%) left • Sinus occlusion (NB: not all reported) : ≧73% (19/26) • 10 bilateral, 5 right, 4 left • Time to presentation: • 88% > 2 months (23/26)

  30. F. Signorelli, P. Khoueir, F. Scholtes, D. Roy, M.W. Bojanowski – Dural AV fistulae and Dementia The straight sinus • 100%: thalamus • DAVF topography: tentorial edge or falcotentorial junction • Straight sinus occlusion (NB: not all reported) : ≧75% (9/12) • Time to presentation: • 73%< 2 months (8/11) • 18% >2 months but severe (2/11) • 9% >2 months, moderate (1/11)

  31. F. Signorelli, P. Khoueir, F. Scholtes, D. Roy, M.W. Bojanowski – Dural AV fistulae and Dementia The superior sagittal sinus • Both presentations possible • 2/8: thalamus (retrograde flow vein of Galen) • Time to presentation • White matter: >2 months • Thalamus: <2 months

  32. F. Signorelli, P. Khoueir, F. Scholtes, D. Roy, M.W. Bojanowski – Dural AV fistulae and Dementia DAVF & cognitive decline • Evolution: thalamic more rapid • Main prognostic factors • Negative: severity of symptoms • Positive: completeness of treatment

  33. F. Signorelli, P. Khoueir, F. Scholtes, D. Roy, M.W. Bojanowski – Dural AV fistulae and Dementia DAVF & cognitive decline • DAVF: potentially curable cause of dementia • Earliest possible & complete treatment: best prognosis • Thalamic : more rapid evolution

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