Tips and tricks in the diagnosis of intracranial dural arteriovenous fistulas: A pictorial review - 13/07/19

Doi : 10.1016/j.neurad.2019.06.004

Igor Gomes Padilha ^a,^b,^⁎ , Felipe Torres Pacheco ^a,^b, Alan Iuno Rios Araujo ^a,^b, Renato Hoffmann Nunes ^a,^b, Carlos Eduardo Baccin ^c, Mario Luiz Marques Conti ^d, Antônio Carlos Martins Maia Jr ^a,^e, Antônio José da Rocha ^a,^b
^a Division of Neuroradiology, Santa Casa de São Paulo School of Medical Sciences, Rua Dr. Cesario Motta Jr. 112, Vila Buarque, 01221-020 Sao Paulo SP, Brazil
^b Division of Neuroradiology, Diagnosticos da America SA, São Paulo, Brazil; Department of Medical Imaging, R. João Cachoeira, 743 - Itaim Bibi, 04535-012 Sao Paulo SP, Brazil
^c Division of Interventional Neuroradiology, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627/701 - Morumbi, 05652-900 Sao Paulo SP, Brazil
^d Division of Interventional Neuroradiology, Santa Casa de São Paulo School of Medical Sciences, Rua Dr. Cesario Motta Jr. 112, Vila Buarque, 01221-020 Sao Paulo SP, Brazil
^e Division of Neuroradiology, Fleury Medicina e Saúde, Rua Cincinato Braga, 282 - Bela Vista, 01333-910 Sao Paulo SP, Brazil

^⁎Corresponding author.

Sous presse. Épreuves corrigées par l'auteur. Disponible en ligne depuis le Saturday 13 July 2019
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Highlights

•	Several uncharacteristic clinical features might occur when a DAVF is present, making its suspicion a challenge on routine imaging studies.
•	Despite DSA remains the gold standard method for the diagnosis and classification of DAVFs, noninvasive images have demonstrated their accuracy to detect parenchymal abnormalities, haemorrhage, and several vascular dysfunctions, including the RLVD reflux, which are considered important tip for diagnosis. Detecting RLVD is crucial as a prognostic hallmark.
•	DAVFs are associated to typical imaging findings with benign manifestations (such as venous thrombosis and parenchymal oedema) and aggressive manifestations, including subarachnoid haemorrhage, ischemic stroke, and ‘melting brain’ phenomenon.
•	Noninvasive imaging methods have undoubtedly contributed to DAVF diagnosis. Some new techniques, including ASL and SWI, have been recently applied in practice as promising techniques for selecting candidates for DSA.

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Abstract

Dural arteriovenous fistulas (DAVFs) are complex vascular abnormalities that account for 10-15% of intracranial vascular malformations. DAVFs are typically encountered in middle-aged adults, with a slightly female predominance. The causative factors are still uncertain; however, abnormal local hemodynamics and neoangiogenesis related to dural sinus or venous thrombosis can contribute to DAVF occurrence. The diagnosis is dependent on a high level of clinical suspicion and high-resolution imaging techniques. Computed tomography and/or magnetic resonance imaging aid in the diagnosis, but conventional angiography remains the most accurate method for the complete characterization and classification of DAVFs. The therapeutic approach can be conservative or more aggressive, based on symptom severity, sequelae risk and patient characteristics. This article is a pictorial review of adult intracranial DAVFs that highlights some tips and tricks for recognizing useful red flags in the suspicion of DAVFs.

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Abbreviations : DAVFs, CT, MRI, MRA, CTA, CNS, DSA

Keywords : Dural arteriovenous malformation, Non-invasive imaging methods, CT, MRI, MRA, DSA