Dural Arteriovenous Fistula as a Reversible Cause of Progressive Parkinsonism and Dementia: A Case Report

A dural arteriovenous fistula (DAVF) is an abnormal direct connection between an intracranial artery and the dural venous sinus. In rare cases, DAVF might show rapidly progressive dementia onset with extrapyramidal signs, often misdiagnosed as Parkinson disease or vascular parkinsonism and, therefore, pharmacological treatments are ineffective. Here, we report the case of 84-year-old man with rapidly progressive parkinsonism and dementia who was initially treated with levodopa without any improvement. Approximately 8 months following the symptom onset, a magnetic resonance (MR) imaging of the brain revealed bilateral and symmetrical hyperintensity of the white matter on both cerebral hemispheres on T2-weighted images. Three-dimensional and post-contrast T1-weighted images showed a subtentorial ovalar area with venous drainage alteration, and hypertrophic left occipital artery direct to venous sac. The angiography study confirmed a diagnosis of DAVF. Endovascular treatment by cook pressure technique successfully provided fistula obliteration. The patient rapidly recovered after the endovascular treatment, with restitutio ad integrum of cognitive functioning and resolution of extrapyramidal syndrome. Approximately 1 year after the endovascular treatment, a brain MR scan with angiogram-MR sequences showed almost complete disappearance of white matter alterations on both cerebral hemispheres, and normal visualization of venous system.