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Cerebral Dural Arteriovenous Fistulas

Detection by Dynamic MR Projection Angiography

¹ Department of Radiology, Division of Neuroradiology, Kantonsspital Basel/University Hospitals, Petersgraben 4, 4031 Basel, Switzerland.
² Department of Neurology, Kantonsspital Basel/University Hospitals, 4031 Basel, Switzerland.
³ Department of Radiology, Institute of Diagnostic Radiology, Kantonsspital Basel/University Hospitals, 4031 Basel, Switzerland.
⁴ Department of Psychiatry, Kantonsspital Basel/University Hospitals, 4031 Basel, Switzerland.
⁵ Department of Diagnostic Radiology, Section of Medical Physics, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany.

Received August 9, 1999; accepted after revision September 29, 1999.

 
Supported by Swiss National Science Foundation grant 3200-52194.97. E. Seifritz holds a University of Basel habilitation stipend.

Address correspondence to S. G. Wetzel.

Introduction

Top Introduction Subjects and Methods Results Discussion References

 
Digital subtraction angiography (DSA) is the method of choice for detection of cerebral dural arteriovenous fistulas. A recently introduced contrast-enhanced two-dimensional dynamic MR angiographic technique allows projection images similar to those obtained by radiographic DSA to be acquired at a sub-second frame rate with a high in-plane resolution [1, 2]. We applied minimally invasive MR projection angiography to three patients with dural arteriovenous fistulas and compared the results with findings from DSA and with findings from MR imaging and time-of-flight angiography.

Subjects and Methods

Top Introduction Subjects and Methods Results Discussion References

 
Patients
Three patients with clinical findings suggestive of dural arteriovenous fistulas were examined by standard spin-echo MR imaging, MR projection angiography, and intraarterial DSA. The clinical symptoms were pulsatile tinnitus in a 55-year-old woman, new occurrence of headache in a 30-year-old woman with known thrombosis of the left transverse sinus, and new occurrence of headache in a 44-year-old-woman 14 months after embolization of a dural arteriovenous fistula at the left transverse sinus. DSA and MR imaging were performed within 2-19 days of symptom onset.

MR Imaging
MR imaging was performed on a 1.5-T MR clinical imaging system (Magnetom Vision; Siemens, Erlangen, Germany). A standard circularly polarized head coil was used for all imaging procedures.

MR Projection Angiography
Images were acquired with a radiofrequency-spoiled steady-state gradient-echo sequence [3] (TR/TE, 4.5/1.8; flip angle, 40°; matrix size, 196 x 256; field of view, 188 x 250 mm) without slice selection in the coronal plane and, in the 44-year-old woman, also in the sagittal plane. The sequence was run continuously and 60 images were acquired, with a temporal resolution of 900 msec per image. The start of the sequence was simultaneous with the injection of the contrast bolus (0.1 mmol/kg of body weight gadodiamide; 0.5 mmol/ml [Omniscan; Nycomed Imaging, Oslo, Norway]). The bolus was injected at a flow rate of 3 ml/sec with a power injector (Spectris MR Injector System; Medrad, Pittsburgh, PA), immediately followed by a 20-ml saline solution flush through the right antecubital vein. Because of artifacts induced by signal fluctuations during the approach to the steady-state amplitude, the first image of the time-resolved series was discarded. The next five images obtained before the bolus arrival were averaged and formed a background mask. All further images were calculated by complex subtraction of the mask from the subsequent images. Complex subtraction emphasizes the difference in phase between stationary tissue and contrast-enhanced blood and avoids signal cancellation as in magnitude subtraction [1]. Only the processed images are presented to the viewer.

Spin-Echo Imaging
The standard MR examination of the brain included unenhanced T2-weighted turbo spin-echo images (3800/90) and unenhanced and enhanced T1-weighted spin-echo images (600/14).

Time-of-Flight MR Angiography
For visualization of the arteries, axial three-dimensional time-of-flight MR angiography was used with venous presaturation (39/6.5; ramped flip angle, 10-30°; nominal flip angle, 20°) in the 44-year-old woman. Venous structures were depicted by a coronal sequential two-dimensional time-of-flight MR angiographic sequence with arterial presaturation below the jugular bulb (30/9; flip angle, 40°) in the 30-year-old woman and in the 44-year-old woman.

Digital Subtraction Angiography
Diagnostic intraarterial DSA (matrix size, 1024 x 1024; image intensifier, 40 cm) (Multistar T.O.P.; Siemens) was performed after catheterization of the common, external, and internal carotid arteries and of the vertebral arteries with a 4-French catheter via a femoral artery approach. In selected patients, superselective catheterization of the external branches of the carotid artery was performed.

Evaluation
All examinations were discussed and reviewed by two neuroradiologists. The MR studies were performed and evaluated in all patients before the DSA. The examinations were assessed for the presence and location of a dural arteriovenous fistula, the status of the involved dural sinus, arterial feeders, and venous drainage. DSA was the standard of reference.

Results

Top Introduction Subjects and Methods Results Discussion References

 
On MR projection angiography, all three patients showed an abnormally early filling of the left transverse sinus or sigmoid sinus shortly after the arrival of the contrast bolus in the carotid arteries. This early filling is suggestive of a dural arteriovenous malformation (Fig. 1A,1B). The presence and the location of the fistula side was confirmed by DSA in all patients. The occlusion of the left transverse sinus in the 30-year-old woman and the narrowing of the proximal transverse sinus in the 44-year-old woman were correctly recognized on MR projection angiography. The main arterial feeders were the left occipital and middle meningeal arteries in all patients, as shown on DSA. It was not possible to clearly identify these feeders on MR projection angiography performed in the coronal plane. In the 44-year-old woman, MR projection angiography in the sagittal plane showed an arterial structure leading to the transverse sinus. However, the origin of this artery, whether from the vertebral artery or from the carotid artery, could not be determined (Fig. 2A,2B). The venous drainage pattern of the fistulas, antegrade distal to the fistula side but retrograde proximal to the fistula in the 55-year-old woman, retrograde in the 30-year-old woman, and antegrade in the 44-year-old woman, was correctly revealed by MR projection angiography in all patients (Fig. 1A,1B).

View larger version (106K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —55-year-old woman with pulsatile tinnitus. Coronal MR projection angiogram acquired immediately after arrival of contrast bolus at carotid arteries shows early enhancement of left transverse sinus (arrow).

View larger version (127K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —55-year-old woman with pulsatile tinnitus. Coronal MR projection angiogram acquired 1.8 sec later than A shows retrograde venous outflow within left proximal transverse sinus to right transverse sinus (curved arrow) and antegrade outflow to left jugular vein (open arrow).

View larger version (120K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A. —44-year-old woman with new occurrence of headache 14 months after embolization of dural arteriovenous fistula. Sagittal MR projection angiogram acquired in early arterial phase shows early filling of left transverse sinus (curved arrow) and prominent artery (straight arrow) leading to fistula site.

View larger version (85K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B. —44-year-old woman with new occurrence of headache 14 months after embolization of dural arteriovenous fistula. Three-dimensional time-of-flight angiogram shows occipital artery (arrow). No flow signal is present in transverse and sigmoid sinus, probably because of saturation effects.

MR projection angiography was the only MR imaging technique to reveal the presence of a dural arteriovenous fistula. Findings on spin-echo images and venous two-dimensional time-of-flight MR angiography indicated the transverse sinus thrombosis in the 30-year-old woman. In the 44-year-old woman possible postthrombotic changes of the left transverse sinus but no signs suggestive of a vascular malformation were seen. Arterial three-dimensional time-of-flight MR angiography, performed in the 44-year-old woman, showed a prominent left occipital artery but no flow-related enhancement in the left transverse sinus; a diagnosis of the dural arteriovenous fistula was therefore not possible (Fig. 2A,2B).

Discussion

Top Introduction Subjects and Methods Results Discussion References

 
Contrast-enhanced MR projection angiography, based on a modified gradient-echo sequence combined with a subtraction technique to maximize vessel-to-background contrast, allows two-dimensional projection angiograms to be obtained at a subsecond temporal frame rate [1, 2]. Covering the entire cerebral circulation in a coronal plane with a spatial in-plane resolution of 1 mm², the technique was shown to be effective for the detection of dural arteriovenous fistulas, which were recognized as a filling of a dural sinus during the early arterial phase. Furthermore, the direction of the venous drainage of the fistulas was recognized. This feature is of clinical importance because fistulas with antegrade venous drainage typically have a benign course whereas retrograde flow into the sinus might cause intracranial hypertension [4]. The arterial feeders, however, were not clearly depicted by MR projection angiography.

This lack of clarity is most likely attributable to the limited spatial resolution of MR projection angiography compared with that of DSA and to superimpositions of different vessels caused by the IV contrast-agent application that leads to a simultaneous enhancement of all supraaortic vessels. Because an acquisition in a second plane (sagittal) requires a second contrast bolus, the number of projection directions is limited with MR projection angiography.

Although spin-echo images and time-of-flight angiograms might show findings suggestive of a dural arteriovenous fistula [5, 6], the impact of dynamic MR projection angiography for detection of dural arteriovenous fistulas is evident; this technique was the only MR imaging method to reveal the presence of the fistula in all our patients. The technique is easy to perform because no postprocessing method or timing of the contrast bolus is necessary. With the short measurement time of 1 min, motion artifacts are not encountered. Further studies are necessary, particularly to evaluate the diagnostic power of MR projection angiography in detecting fistulas with drainage into the cortical veins.

References

Top Introduction Subjects and Methods Results Discussion References

 

1. Wang Y, Johnston DL, Breen JF, et al. Dynamic MR digital subtraction angiography using contrast enhancement, fast data acquisition, and complex subtraction. Magn Reson Med 1996;36:551 -556[Medline]
2. Hennig J, Scheffler K, Laubenberger J, Strecker R. Time-resolved projection angiography after bolus injection of contrast agent. Magn Reson Med 1997;37:341 -345[Medline]
3. Gyngell ML. The application of steady-state free precession in rapid 2DFT NMR imaging: FAST and CE-FAST sequences. Magn Reson Imaging 1988;6:415 -419[Medline]
4. Cognard C, Gobin YP, Pierot L, et al. Cerebral dural arteriovenous fistulas: clinical and angiographic correlation with a revised classification of venous drainage. Radiology 1995;194:671 -680[Abstract/Free Full Text]
5. De Marco JK, Dillon WP, Halbach VV, Tsuruda JS. Dural arteriovenous fistulas: evaluation with MR imaging. Radiology 1990;175:193 -199[Abstract/Free Full Text]
6. Chen JC, Tsuruda JS, Halbach VV. Suspected dural arteriovenous fistula: results with screening MR angiography in seven patients. Radiology 1992;183:265 -271[Abstract/Free Full Text]

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