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NI FEATURE: FACING ADVERSITY…TOMORROW IS ANOTHER DAY! - LETTER TO EDITOR
Year : 2017  |  Volume : 65  |  Issue : 2  |  Page : 378-379

Intraprocedural rupture during catheter angiogram in a case of aggressive dural arteriovenous fistula


Department of Imaging Sciences and Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India

Date of Web Publication10-Mar-2017

Correspondence Address:
Sweta Swaika
Department of Imaging Sciences and Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Medical College PO, Trivandrum - 695 011, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/neuroindia.NI_59_16

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How to cite this article:
Swaika S, Kannath SK, Rajan JE. Intraprocedural rupture during catheter angiogram in a case of aggressive dural arteriovenous fistula. Neurol India 2017;65:378-9

How to cite this URL:
Swaika S, Kannath SK, Rajan JE. Intraprocedural rupture during catheter angiogram in a case of aggressive dural arteriovenous fistula. Neurol India [serial online] 2017 [cited 2017 Mar 25];65:378-9. Available from: http://www.neurologyindia.com/text.asp?2017/65/2/378/201863


Sir,

Catheter angiography is rarely associated with intraprocedural intracranial bleeding in cerebrovascular diseases.[1] This complication is a potential concern in ruptured cerebral aneurysms; however its incidence has been found to be very low in dural arteriovenous fistulae.

A 54-year-old hypertensive male developed sudden onset of severe headache of 1 week duration. Computed tomographic scan revealed intraventricular hemorrhage, hydrocephalus, and extra-axial, well-defined, saccular outpouchings at the foramen magnum level [Figure 1]a. Catheter angiogram revealed a dural arteriovenous fistula (DAVF) on the right side of foramen magnum fed by the neuro-meningeal trunk of the right ascending pharyngeal artery (APA) with venous sacs and veins draining into the spinal perimedullary and brainstem veins (Cognard Type V) [Figure 1]b and [Figure 1]c. Selective angiogram of right APA with 2 ml of nonionic contrast using a 4F vertebral glide catheter and 10cc syringe for better characterization of the lesion resulted in rupture of the venous sacs with active contrast extravasation [Figure 1]d. Immediately, the nidus was accessed with an marathon microcatheter and was completely obliterated with 0.6ml of squid 18 liquid embolic device [Figure 2]. Then, an external ventricular drain was placed that facilitated subsequent resolution of the ventricular bleed and hydrocephalus. He demonstrated a significant clinical improvement at a 3-month follow-up with the Glasgow outcome score being one.
Figure 1: Computed tomography angiography (a) and right external carotid artery catheter angiography (b and c) showing the dural arteriovenous fistula at the foramen magnum level (arrow) with arterial feeder (white arrowhead) and venous drainage (white arrows) as shown. (d) Selective angiogram showing rupture with contrast extravasation (arrowhead)

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Figure 2: (a) Right external carotid artery postembolization angiogram showing complete obliteration of the fistula. (b) Computed tomography axial section showing squid 18 cast in the venous sac (arrow). (c) Computed tomography axial section showing contrast and blood in the ventricles (arrow)

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Catheter angiography is mandatory in cerebrovascular diseases to confirm the diagnosis and assess for feeders, nidal characteristics as well as venous drainage; and, to make appropriate treatment decisions. Cerebral angiography has been found to induce pressure changes within the carotid artery and the cerebral aneurysm, and this can possibly trigger its rupture when it is compounded by other patient-specific factors such as blood viscosity, turbulent flow, rate of contrast injection, vasospasm at the catheter tip, and arterial bifurcations.[2],[3],[4] In our case, selective cannulation of APA resulted in the rupture of venous sacs due to direct transmission of the pressure into the nidus and draining veins through the wedged catheter. The occurrence of rupture in cerebrovascular malformations has not been reported in literature. Specific to foramen magnum DAVF, embolization with proximal balloon inflation in APA has been reported to be safe with no intraprocedural rupture.[5] Management of intraprocedural intracranial bleed requires an immediate containment of the bleeding source as severe bleeding leads to a worse prognosis. Keeping the catheter wedged within the feeder reduces antegrade flow into the fistula and prevents further extravasation. Aggressive measures to reduce intracranial pressure can avert potentially catastrophic complications.

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Conflicts of interest

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 » References Top

1.
Fifi JT, Meyers PM, Lavine SD, Cox V, Silverberg L, Mangla S, et al. Complications of modern diagnostic cerebral angiography in an academic medical center. J Vasc Interv Radiol 2009;20:442-7.  Back to cited text no. 1
    
2.
Klisch J, Weyerbrock A, Spetzger U, Schumacher M. Active bleeding from ruptured cerebral aneurysms during diagnostic angiography: Emergency treatment. AJNR Am J Neuroradiol 2003;24:2062-5.  Back to cited text no. 2
    
3.
Saitoh H, Hayakawa K, Nishimura K, Okuno Y, Teraura T, Yumitori K, et al. Rerupture of cerebral aneurysms during angiography. AJNR Am J Neuroradiol 1995;16:539-42.  Back to cited text no. 3
    
4.
Komiyama M, Tamura K, Nagata Y, Fu Y, Yagura H, Yasui T. Aneurysmal rupture during angiography. Neurosurgery 1993;33:798-803.  Back to cited text no. 4
    
5.
Liang G, Gao X, Li Z, Wang X, Zhang H, Wu Z. Endovascular treatment for dural arteriovenous fistula at the foramen magnum: Report of five consecutive patients and experience with balloon-augmented transarterial Onyx injection. J Neuroradiol 2013;40:134-9.  Back to cited text no. 5
    


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