Endovascular Treatment of Intracranial Pial-Dural Arteriovenous Fistula: A Case Report

Intracranial pial arteriovenous fistula (PAVF) is a rare cerebrovascular pathology characterized by abnormal direct high-flow connection between the pial or cortical feeding artery and draining vein. Dural arteriovenous fistula (DAVF) is a pathological shunt between the meningeal arteries and dural sinuses or meningeal veins. In case of association between PAVF and DAVF, diagnosis and treatment are more challenging. The high-flow arteriovenous shunt and deep venous drainage make PAVF more preferable for endovascular treatment; however, their embolization during single-session procedures can lead to extensive thrombosis of the draining veins and unfavorable outcomes. We present a case report of endovascular embolization of an intracranial PAVF-DAVF in a 2.5-year-old child. At the time of admission, the patient had hydrocephalus, mental retardation, pyramidal insufficiency, and seizures. Occlusion of the fistula was performed during two stages of embolization to reduce the risk of severe venous stasis and venous thrombosis. Guglielmi detachable coils (GDCs) and a liquid embolic agent (Histoacryl with Lipiodol) were used for embolization. The patient recovered well after the procedure, with significant mental improvement. This suggests that the deployment of GDCs in the afferent artery near a fistula before embolization with a liquid embolic agent can minimize the risk of uncontrolled penetration of the embolization into the draining veins and dural sinus. A multisession procedure can be an effective and reasonable method of PAVF and DAVF occlusion among existing treatment options.