Dural arteriovenous fistula

Lung volumes are low-normal. The heart is enlarged, largely obscuring the left hemithorax and left hemidiaphragm. There are persistent hazy perihilar opacities likely due to mild pulmonary edema.

The endotracheal tube terminates at the T1 level. Transesophageal tube terminates in the proximal stomach. The UAC has been retracted slightly to the T8 level. The UVC is in unchanged position.

A MRI of the brain was concurrently obtained with both MRA and MRV.

MRI brain

There is incidental note of a cavum of septum pellucidum and cavum vergae. There are several punctate foci of restricted diffusion within the right frontal lobe and to a lesser degree left frontal lobe subcortical white matter consistent with acute ischemic infarcts. There are areas of reduced diffusivity at the left periatrial white matter and left mid temporal lobe consistent with sites of acute ischemia measuring 7 mm and 13 mm, respectively. There is additional diffusion hyperintensity with a corresponding hyperintense ADC map correlation and T2/FLAIR hyperintensity within the left temporal lobe associated mild volume loss, likely representing more chronic ischemia.

There is marked engorgement and distention of the vascular flow voids of the left greater than right transverse sinus sinuses with multiple venous varices along the margins of the left tentorium. There is also a tangle of vascular flow voids along the inferior aspect of the left temporal lobe abutting the superior margin of the tentorium measuring approximately 1 cm. There is enlargement and engorgement of left middle and posterior cerebral artery branches.

MRA brain and MRV brain

There is marked enlargement and tortuosity of the left middle and posterior cerebral artery branches which appears to fistulize with a dilated left transverse sinus and associated adjacent markedly enlarged venous varices demonstrating arterial venous shunting. There is a tangle of arterialized flow along the inferior margin of the left temporal lobe along the superior surface of the tentorium measuring 1.0 cm.

Selective injection of the left vertebral artery and left common carotid artery demonstrated brisk opacification of the vertebrobasilar candelabra with early arteriovenous shunting and opacification of the venous varix. Minimal flow is seen within the cerebellar hemispheres and parieto-occipital lobes with the majority of the contrast opacification seen within the dural aVF.

There is a high flow arteriovenous fistula with dominant supply from the left middle cerebral artery sylvian lateral temporal and left posterior cerebral artery medial temporal arterial pedicles with fistulization into a venous complex, likely comprising a markedly dilated left uncal vein and left vein of Labbe. The arterial feeders were embolized with coils.

Following embolization, there is increased cerebral flow (last image).