Convexity meningioma associated with noncontiguous dural arteriovenous fistula

Abstract

Background
Concomitant dural arteriovenous fistulas (DAVFs) and meningiomas have been rarely described. DAVFs can be either continuous or at a distant location from the meningioma, with different pathophysiologic mechanisms involved in each situation.

Case Description
We report the case of a 74-year-old woman presenting with left-sided hemiparesis secondary to a large right convexity meningioma, associated with a noncontiguous Borden 3 DAVF. Both lesions were treated surgically in the same setting. The patient improved after surgery, and postoperative imaging showed complete resection of the meningioma and absence of recurrence of the fistula at 4 years.

Conclusion
To the best of our knowledge, this is the first case of concomitant surgical treatment of a meningioma and noncontiguous DAVF.

Full text

Surgical Neurology International • 2020 • 11(127) | 1
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Image Report
Convexity meningioma associated with noncontiguous
dural arteriovenous stula
Marco Manzo, Pietro Ivo D’Urso
Department of Neurosurgery, Manchester Centre of Clinical Neurosciences, Salford, Manchester, UnitedKingdom.
E-mail: Marco Manzo-marcomanzo95@yahoo.it; *Pietro Ivo D’Urso-pietrivo@me.com
A 74-year-old woman presented with a 3 weeks history of tiredness associated with MRC
grade3/5 le-sided hemiparesis. Her medical history included ovarian and breast cancer 10years
before.
Magnetic resonance imaging (MRI) of the brain demonstrated a rather large extra-axial tumor
causing mass eect and midline shi, with radiological characteristics suggestive of meningioma
[Figure1a and b]. e MRI did also demonstrate the presence of prominent and serpiginous
vessels over the right frontal polar convexity not directly related to the meningioma and extending
down to the cribriform fossa [Figure1c and d]. A subsequent digital subtraction angiography
(DSA) conrmed the presence of an anterior cranial fossa dural arteriovenous stula (DAVF)
[Figure1d-g]. e DAVF was a Borden type3 stula located in the right anterior cranial fossa
and supplied by right ethmoidal arteries from bilateral ophthalmic arteries, right distal internal
maxillary artery, and hypertrophied right anterior meningeal artery. e DAVF drained through
cortical veins into the super sagittal sinus and through supercial temporal veins into the vein of
Trolard.
A right frontal craniotomy was carried out, and the dural based tumor excised; the tumor was
fed by meningeal branches which were cauterized, and this signicantly reduced the blood
supply to the meningioma. Intracapsular debunking was then carried out with ultrasonic
ABSTRACT
Background: Concomitant dural arteriovenous stulas (DAVFs) and meningiomas have been rarely described.
DAVFs can be either continuous or at a distant location from the meningioma, with dierent pathophysiologic
mechanisms involved in each situation.
Case Description: We report the case of a 74-year-old woman presenting with le-sided hemiparesis secondary to
a large right convexity meningioma, associated with a noncontiguous Borden 3 DAVF. Both lesions were treated
surgically in the same setting. e patient improved aer surgery, and postoperative imaging showed complete
resection of the meningioma and absence of recurrence of the stula at 4years.
Conclusion: To the best of our knowledge, this is the rst case of concomitant surgical treatment of a meningioma
and noncontiguous DAVF.
Keywords: Dural arteriovenous stula, DAVF, Meningioma, Vascular malformations
www.surgicalneurologyint.com
Surgical Neurology International
Editor-in-Chief: Nancy E. Epstein, MD, Clinical Professor of Neurological Surgery, School of
Medicine, State U. of NY at Stony Brook.
SNI: Neurovascular
Editor
Kazuhiro Hongo, M.D.,
Shinshu University, Matsumoto, Japan
*Corresponding author:
Pietro Ivo D’Urso,
Department of Neurosurgery,
Manchester Centre of Clinical
Neurosciences, Stott Lane,
Salford-M68hd, Manchester,
UnitedKingdom.
pietrivo@me.com
Received : 15 March 2020
Accepted : 01 May 2020
Published : 23 May 2020
DOI
10.25259/SNI_99_2020
Quick Response Code:
Open Access

Manzo and D’Urso: Meningioma and dural arteriovenous stula
Surgical Neurology International • 2020 • 11(127) | 2
aspirator without signicant blood loss. e tumor was then
gently dissected from the surrounding brain following the
arachnoid plane and resected en bloc. Following the removal
of the meningioma, due to the natural brain relaxation, a
subfrontal approach was possible without any additional
brain retraction [Figure 2a]. e arterialized and ecstatic
vein appeared to correspond to the DAVF as judged on
angiography. e vein and its feeders were coagulated and
transected, achieving complete obliteration of the stula
[Figure2b].
e histology of the dural-based tumor was conrmed
to be consistent with a WHO Grade I meningothelial
meningioma.
Aer surgery, the patient gradually improved, and at
12months, the patient was neurologically intact and back to
her daily activities.
Postoperative MRI conrmed complete excision of the
meningioma, and a DSA obtained showed complete
obliteration of the stula [Figure3].
On clinical and radiological follow-up at 4years, the patient
had not experienced any recurrences.
To the best of our knowledge, this is the rst case of
concomitant excision of a meningioma and obliteration of an
associated noncontiguous DAVF.
Concomitant DAVFs and meningiomas have been
previously described, and indeed, DAVFs can be either
continuous or at a distant location from the meningioma,
with dierent pathophysiologic mechanisms involved in
each situation.[1-3]
In cases where DAVFs and meningiomas are contiguous or
nearby, if the stula drains into a dural sinus occluded by
the meningioma, the stula may form as a consequence of
venous hypertension. Instead, if meningiomas and DAVFs
are noncontiguous, venous hypertension may occur as a
result of occlusion of dural venous structures secondary
to the edema of global cerebral venous hypertension
due to meningioma hypervascularity or be secondary to
meningioma-induced hypercoagulable state causing dural
venous thrombosis.[3]
In our case, we postulate that both the edema and the
hypervascularity of the meningioma have perhaps played a
role in the formation of the DAVF.
e copresence of meningioma and DAVF poses some
treatment challenges. In principle, the symptomatic
Figure 1: A 74-year-old patient presented with le-sided weakness. Postcontrast T1-weighted magnetic resonance images (a and b) showed
a large right convexity meningioma. Signal voids were also noted in the right anterior cranial fossa, without direct continuity with the
meningioma (c and d). DSA showed a right anterior cranial fossa dural arteriovenous stula (DAVF) (e-g) supplied by right ethmoidal
arteries from bilateral ophthalmic arteries, right distal internal maxillary artery, and hypertrophied right anterior meningeal artery. e
DAVF drained into the super sagittal sinus and vein of Trolard.
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eg
f
Figure 2: Intraoperative images showing a prefrontal approach
to the DAVF (a) and an ecstatic draining vein related to the dural
arteriovenous stula (b).
ba

Manzo and D’Urso: Meningioma and dural arteriovenous stula
Surgical Neurology International • 2020 • 11(127) | 3
lesion should be treated rst.[3] If the DAVF interferes
with the surgical approach for meningioma resection, the
DAVF should be treated rst. Simultaneous treatment of
meningioma and DAVF can be considered if the DAVF can
be safely approached, like in our case. On the other hand,
if the DAVF is distant from the tumor, the treatment of the
DAVF should be carried out independently.
Declaration of patient consent
Patient’s consent not required as patients identity is not
disclosed or compromised.
Financial support and sponsorship
Nil.
Conicts of interest
ere are no conicts of interest.
REFERENCES
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MaedaM. Dural arteriovenous stula of the transverse sinus
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(Wien) 2003;145:501-4.
2. Takemoto Y, Kawano T, Ohmori Y, Nakagawa T, Ohta K,
Kuroda J, et al. Dural arteriovenous stula associated with
intratumor hemorrhage. JClin Neurosci 2019;59:352-55.
3. Vellimana AK, Daniels DJ, Shah MN, Zipfel GJ, Lanzino G.
Dural arteriovenous stulas associated with benign meningeal
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How to cite this article: Manzo M, D’Urso PI. Convexity meningioma
associated with noncontiguous dural arteriovenous stula. Surg Neurol Int
2020;11:127.
Figure 3: Postoperatively, the patient improved neurologically.
Postcontrast magnetic resonance imaging showed complete
resection of the meningioma (a and b) and DSA complete
obliteration of the dural arteriovenous stula (c and d).
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