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Dural Arteriovenous Malformations


Learning objectives

  • What is an Arteriovenous malformation/fistula
  • Role as a cause of ICH and SAH
  • Management

Introduction

  • Abnormal connection between arterial supply and dural venous sinuses
  • Acquired deficits not congenital like AVMS and potential cause of ICH and SAH

Aetiology

  • Causes include head injury, open surgery and Cerebral venous sinus thrombosis.
  • These "fistulae" are extra axial direct connections between arterial flow and dural venous sinuses.
  • The result is flow, shunting, pressure effects and venous congestion and haemorrhage.
  • One example of this is the carotid-cavernous sinus shunts that arise with chemosis and scleral injection and an audible bruit.

Sites

  • Related to Cavernous sinus behind the eye: chemosis, reduced acuity, bruit, swelling of the eye.
  • Related to Transverse/sigmoid sinus behind ear: pulsating noise (tinnitus). Stroke like symptoms, seizure like activity, headaches.

Clinical

  • Possibly asymptomatic, Dural pain fibres can lead to headache.
  • Seizures, bruits, headaches, stroke like episodes
  • Signs of increased intracranial pressure and bleeding.

Investigations

  • Diagnosis is by CTA/MRA/DSA.

Management

  • Annual bleed risk is difficult to determine but felt to be less than 5% per annum.
  • Treatment options include conservative, endovascular embolisation using N-butyl-cyanoacryalate glue or other substance or surgery.

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