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Year : 2018  |  Volume : 4  |  Issue : 1  |  Page : 32-37

Cognitive Improvement After Endovascular Treatment in a Case of Intracranial Dural Fistula With Concomitant Dementia

1 National Institute of Neurology and Neurosurgery “Manuel Velasco Suarez”, City, Mexico
2 Department of Neurosurgery, Neurosciences Centre, AIIMS, New Delhi, India
3 John Hopkins Hospital, Baltimore, Maryland, USA
4 Department of Neurosurgery, Narayna Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh, India
5 RED LATINO, Organización Latinoamericana de Trauma y Cuidado Neurointensivo, Bogota, Colombia

Date of Web Publication27-Mar-2018

Correspondence Address:
Luis R Moscote-Salazar
RED LATINO, Organización, Latinoamericana de Trauma y Cuidado Neurointensivo, Bogota
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mamcjms.mamcjms_48_17

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Dural fistulas associated with dementia are rarely reported and, among these, intracranial dural fistulas constitute an infrequent etiology. Moreover, dementia associated with dural fistulas occurs due to venous hypertension leading to ischemic neuronal dysfunction. This case report describes a male patient exhibiting unusual features of dementia with a concomitant dural fistula compromising the superior sagittal sinus. The fistula was completely occluded via endovascular embolization. Two months after the interventional therapy, clinical assessment revealed complete improvement of executive functions. Afterward, the patient returned to his daily activities without impairment.

Keywords: Arteriography, brain infarct, dementia, dural fistula

How to cite this article:
Zenteno M, Lee A, Satyarthee GD, Pinilla G, Agrawal A, Moscote-Salazar LR. Cognitive Improvement After Endovascular Treatment in a Case of Intracranial Dural Fistula With Concomitant Dementia. MAMC J Med Sci 2018;4:32-7

How to cite this URL:
Zenteno M, Lee A, Satyarthee GD, Pinilla G, Agrawal A, Moscote-Salazar LR. Cognitive Improvement After Endovascular Treatment in a Case of Intracranial Dural Fistula With Concomitant Dementia. MAMC J Med Sci [serial online] 2018 [cited 2020 Aug 4];4:32-7. Available from: http://www.mamcjms.in/text.asp?2018/4/1/32/228649

  Introduction Top

Dementia is a syndrome characterized by the presence of persistent cognitive impairment that interferes with the individual’s ability to perform their activities of daily living. Specifically, the presence of amnesia, apathy and mentally slowing is generally related to vascular lesions. Dural fistulas with involvement of the superior sagittal sinus are rare, lead to venous hypertension, and are associated with cortical and subcortical damage.[1],[2] We report the case of a 67-year-old man with symptoms compatible with dementia induced by a dural fistula draining into the superior sagittal sinus, and who was successfully treated by endovascular approach.

  Case Report Top

History and examination: We report a 67-year-old man with grade II obesity history of and coronary stent placement in 2008. He presented to the Emergency Department with a 2-month history of disorientation, sleepiness, and bradilalia. Neuropsychological assessment based on the mini-mental state examination (MMSE) showed moderate impairment of the executive functions (20/30). Results of the biochemical and metabolic screening had no relevance.

Magnetic resonance imaging of the brain was obtained after the initial consultation showing an arteriovenous malformation. The patient was then assessed by a vascular neurologist, who suspected cerebral venous thrombosis and initiated anticoagulation therapy. Subsequently, he was evaluated by a neurosurgeon, who considered the differential diagnosis of cryptogenic vascular dementia and raising awareness among the family about the irreversible damage with no treatment to offer. The family sought a second opinion from the interventional neuroradiology service, and after careful evaluation of the case, a cerebral angiogram was performed.

Procedure: A cerebral arteriography was performed which showed that the venous component of the fistula drained into the midportion of the superior longitudinal sinus, with no distal thrombosis. The left sigmoid sinus and the jugular bulb could not be displayed. The venous flow was reversed to the right transverse sinus and to the right internal jugular vein. There was no defined pial congestion or any prolongation of the venous drainage transit time of the cerebral hemispheres, ruling out venous hypertension [[Figure 1]a–[Figure 1]d].
Figure 1: (a–d) Lateral and anteroposterior views of the carotid angiography confirming the diagnosis of dural fistula draining into the superior longitudinal sinus

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Treatment planning and pretreatment observation: Based on the high output of the fistula, it was decided to pursue endovascular management. A comprehensive medical staff closely monitored the patient.

Endovascular procedure: On the first day of the in-hospital stay, the patient was scheduled for an endovascular closing of the fistula under general anesthesia. Angiography was performed with a 5F catheter. Using the transfemoral venous approach, the fistula was successfully managed with Onyx® embolization [Figure 2]. The patient was discharged on a regimen of clopidogrel (75 mg/day) and aspirin (325 mg/day).
Figure 2: Postembolization angiography of the right carotid artery showing complete resolution of the fistula

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Long-term follow-up: Two months after the interventional therapy, the clinical evaluation revealed a complete improvement of the executive functions compromise. At 2-month follow-up, the MMSE score was of 26/30, and 4 months later, it was 30/30. Besides, at that time, angiogram demonstrated complete occlusion of the fistula as well as patency of the venous sinus. The patient returned to his activities of daily living without impairment.

  Discussion Top

It has been determined that dementia symptoms are associated with dural venous sinus occlusion.[3],[4],[5],[6] Also, a partial improvement of cognitive symptoms after endovascular therapy has been described.[7],[8],[9],[10],[11] We present a review of the cases reported in the literature of dural fistulas associated with dementia [Table 1].
Table 1: Literature reports of dural fistulas associated with dementia

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At the structural level, changes in the white matter have been observed in patients with dural fistulas and dementia symptoms; these same changes have been demonstrated in patients with hydrocephalus, neuro-acquired immune deficiency syndrome (AIDS), multiple sclerosis, central-nervous-system lymphoma, neurometabolic and neurodegenerative disorders, among others.

In contrast, most cases published identified a compromise on the transverse and sigmoid sinus. A dural fistula adjacent to the superior longitudinal sinus is located in a dura mater layer at the convexity, very close to the superior sagittal sinus, usually in the middle third, and being fed by afferants of the external carotid artery. It may be constituted in different forms:
  1. The fistula is in the wall of the sagittal sinus and arterial blood drains into cortical veins without affecting the sinus. In this case, the fistula is fed by branches of the middle meningeal and superficial temporal arteries, frequently, on both sides. This is the most common form.
  2. The fistulous tract may parasitize the venous lakes that normally exist in the dura of the convexity, hence being constituted by venous blood without affecting the dural venous sinus.
  3. The fistula drains the sinus but, if it is partially or completely occluded, the blood tends to flow back into a cortical vein. In these cases, afferent flux usually comes from leptomeningeal branches of the internal carotid and vertebral arteries.[12],[13],[14],[15],[16],[17],[18],[19],[20],[21]

In the literature, there have been reports of dural fistulas associated with cognitive impairment but not dementia. Also, a case with complete recovery, similar to ours is described.[1],[22],[23],[24],[25],[26],[27] Furthermore, Obrador et al. analyzed a case series of 96 dural fistulas, where they found mental symptoms in 12% patients.[28]

As the pathology arises from midline afferents, it may originate from both sides. Therefore, a bilateral and selective study of the internal and external carotid arteries, and the vertebral artery is mandatory.The treatment of intracranial dural fistulas associated with dementia should be early, thus, improving the prognosis.[29] Treatment aims to improve cerebral hemodynamics, focusing on optimizing the venous return and interrupting the arteriovenous shunts or the recanalization of the dural venous sinus, previously clogged. Endovascular treatment constitutes a strategy using simultaneous embolization with coils and Onix®; stents can also be used.

  Conclusion Top

We describe a rare case of a dural fistula with a concomitant clinical diagnosis of dementia. For this patient, the use of endovascular therapy provided the control and reversal of the cognitive symptoms.

The authors suggest preoperative correct strategic planning and allow proper management of dural fistulas with the superior sagittal sinus drainage associated with cognitive symptoms.

Nevertheless, it was hypothesized that the dural fistula compromising the superior sagittal sinus driven to progressive ischemic effects that simulated a picture of dementia which was easily controlled by reversing the underlying cerebrovascular dysfunction.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Liang G, Li Z, Gao X, Zhang H, Lin J, Feng S et al. Endovascular treatment for dural arteriovenous fistulas at the jugular foramen. Neurol India 2011;59:420-3.  Back to cited text no. 4
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  [Figure 1], [Figure 2]

  [Table 1]

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