Complex torcular dural arteriovenous fistula leading to cortical venous reflux-induced severe varix and subsequent bilateral cerebral hemispheric hemorrhage: a case report

Ziqi Li; Pengwei Hou; Qizuan Chen; Shuwen Mu; Jun Li; Yi Fang; Wenting Jiang; Xinhua Tian; Shousen Wang

doi:10.3389/fneur.2023.1303234

Complex torcular dural arteriovenous fistula leading to cortical venous reflux-induced severe varix and subsequent bilateral cerebral hemispheric hemorrhage: a case report

Front Neurol. 2023 Dec 14:14:1303234. doi: 10.3389/fneur.2023.1303234. eCollection 2023.

Authors

Ziqi Li^#^{1

2}, Pengwei Hou^#¹, Qizuan Chen¹, Shuwen Mu¹, Jun Li¹, Yi Fang³, Wenting Jiang⁴, Xinhua Tian⁵, Shousen Wang¹

Affiliations

¹ Department of Neurosurgery, Fuzong Clinical Medical College of Fujian Medical University, Fuzhou, China.
² Department of Neurosurgery, Dongfang Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China.
³ Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China.
⁴ Fujian Children's Hospital (Fujian Branch of Shanghai Childre Medical Center), College of Clinical Medicine for Obstetrics Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China.
⁵ Department of Neurosurgery, The Affiliated Zhongshan Hospital of Xiamen University, Xiamen, China.

^# Contributed equally.

Abstract

Background and importance: Dural arteriovenous fistulas (dAVFs) with cortical venous reflux (CVR) are associated with a higher incidence of intracranial hemorrhage (ICH). We report a rare case of a complex torcular dAVF with severe cortical veins (CV) varix leading to extensive bilateral cerebral hemorrhages. This discovery suggests a potential new subtype of dAVF. The case underscores the necessity of a comprehensive understanding of hemodynamic changes in dAVFs and the importance of considering venous compensatory capacity in treatment. This case challenges existing classifications and treatment strategies for dAVFs, highlighting the need for further research and discussion within the neurosurgical community.

Clinical presentation: A 56-year-old male was admitted to the hospital presenting with dizziness, fatigue, and numbness. Brain CT scans revealed extensive bilateral cerebral hemorrhages. Digital subtraction angiography (DSA) identified a complex torcular dAVF. No cerebral sinus venous thrombosis was detected, but a venous variation in the left transverse sinus was observed. Preoperative DSA demonstrated the patient's well-developed venous compensatory ability. Subsequently, the patient underwent transarterial embolization. The patient made a good recovery. Follow-up DSA and MR angiography at 3 months and 1 year post-treatment showed no recurrence.

Conclusion: DAVFs are rare lesions, prone to ICH, particularly when CVR is involved. We report a rare case of CVR with severe varix leading to hemorrhagic lesions in both cerebral hemispheres. Our aim is to alert neurosurgical colleagues worldwide to this potential new subtype and to evaluate treatment options, in order to assist those who may encounter such cases in the future.

Keywords: cortical venous reflux; dural arteriovenous fistula; intracerebral hemorrhage; superior sagittal sinus; venous compensation; venous variation.

Publication types

Case Reports

Grants and funding

The author(s) declare financial support was received for the research, authorship, and/or publication of this article. This work was supported by the Technological Innovation Joint Funding Project In Fujian Province Of China(2019Y9045).