Unusual cause of seizure

Rania Mohamed Elhassan Eltahir; Nagham Sadik; Khalid Salem

doi:10.4103/LJMS.LJMS_19_19

CASE REPORT

Year : 2019 | Volume : 3 | Issue : 4 | Page : 141-143

Unusual cause of seizure

Rania Mohamed Elhassan Eltahir¹, Nagham Sadik¹, Khalid Salem²
¹ Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar
² Department of Radiology, Hamad Medical Corporation, Doha, Qatar

Date of Submission	11-Mar-2019
Date of Acceptance	10-Nov-2019
Date of Web Publication	26-Dec-2019

Correspondence Address:
Dr. Rania Mohamed Elhassan Eltahir
Department of Internal Medicine, Hamad Medical Corporation, Doha
Qatar

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/LJMS.LJMS_19_19

Abstract

Dural arteriovenous fistula (DAVF) manifestations vary from headache to serious intracranial bleed, but very rarely present with seizure. The presentation is usually in the adult period, but there are citied cases in childhood. The diagnosis is challenging and mainly radiological, plain computed tomography (CT) brain can be normal if no bleed, and therefore, CT angiography and magnetic resonance imaging are the most reliable tools in the diagnosis of DAVF. Here, we report a rare case of dural fistula in an old male who presented with seizures and treated by endovascular intervention, which is one of the rare cases in Qatar.

Keywords: Arteriovenous malformation, computed tomography angiography, dural fistula, seizure

How to cite this article:
Elhassan Eltahir RM, Sadik N, Salem K. Unusual cause of seizure. Libyan J Med Sci 2019;3:141-3

How to cite this URL:
Elhassan Eltahir RM, Sadik N, Salem K. Unusual cause of seizure. Libyan J Med Sci [serial online] 2019 [cited 2023 Mar 30];3:141-3. Available from: https://www.ljmsonline.com/text.asp?2019/3/4/141/274098

Introduction

A dural arteriovenous fistula (DAVF) is a vascular anomaly formed by an abnormal connection between an artery within the tough covering of the brain (dura mater), and a vein that carries blood from the brain back to the heart.^[1] A DAVF can transfer high-pressure arterial blood into veins or venous sinuses that normally carry low-pressure, deoxygenated blood returning to the heart from the brain. This can cause neurological symptoms and brain hemorrhage. The clinical manifestations vary from simple headaches to major intracranial hemorrhagic ictus. The presentation is usually in the adult period, but there are citied cases in childhood.^[2]

Intracranial DAVF represents about 10%–15% of all cerebrovascular pathology, but their incidence is underestimated because not all the fistulas become symptomatic. The main symptoms are pulsatile tinnitus, ocular pain, diplopia, exophthalmia and can culminate with acute intracranial hypertension and focal neurological signs due to intracranial hemorrhage. Here, we report the case of a 70-year-old male who presented with recurrent seizures and found to have DAVF on magnetic resonance imaging (MRI).

Case Report

A 72-year-old Palestinian male retired teacher and father of four children, presented with a history of two attacks of seizure for the first time, which involved mainly the left arm associated with slurring of speech in the two episodes, lasted each <2 min. There were no sphincteric disturbance, aura, headache, fever, and/or any history of toxins ingestion, alcohol, or any new medications. The patient was vitally stable, and in clinical examination, he was conscious, oriented with intact higher functions and cranial nerves, there were no focal weakness, sensory impairment, and/or cerebellar signs, and on fundus examination, he had not shown papilledema, and gait was normal with negative Romberg's sign. Basic routine investigations were normal. Computed tomography (CT)-brain showed several tiny calcific densities were identified in the left frontal lobe and parietal lobe, subcortical white matter, and left periventricular and left occipital lobe. Electroencephalogram was normal, and MRI brain with contrast showed vascular malformation involving both cerebral hemispheres predominantly over the left side [Figure 1]. CT angiography [Figure 2] showed fistulous connections between the right external carotid artery branches and superior sagittal sinus suggestive of dural fistula. The patient was started on phenytoin, and then he had an embolization of the fistula with repeat of MRI/magnetic resonance angiography (MRA) which showed no areas of restricted diffusion and no evidence of recent hematomas or infarction.

Figure 1: (a-c) Magnetic resonance imaging susceptibility-weighted imaging sequence axial cut (a) showing dark flow void signal of abnormal prominent cerebral cortical perforator, transmedullary and ependymal veins more on the left side. Cranial noncontrast time of the flight magnetic resonance angiography lateral (b) and anteroposterior (c) showing superior sagittal sinus Dural arteriovenous fistula with prominent external carotid meningeal feeding arteries, arteriovenous shunting, and early filling of the anterior third of the superior sagittal sinus

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Figure 2: (a and b) Catheter angiogram of bilateral external carotid arteries confirms superior sagittal sinus region arteriovenous fistula with feeding prominent meningeal arteries and early filling of the anterior third of the superior sagittal sinus

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The patient was started on loading dose of phenytoin and then continued on maintenance dose. He underwent catheter embolization of the fistula by the interventional radiologist; the procedure was done successfully under close monitoring, followed by postembolization MRI/MRA which showed no areas of restricted diffusion, hematoma, or recent infarction [Figure 3].

Figure 3: (a and b) Cranial noncontrast time of flight magnetic resonance angiography lateral (a) and anteroposterior (b) postinterventional onyx closure of the arteriovenous fistula showing reduced feeding meningeal arteries, absence of early filling of the anterior third of the superior sagittal sinus, and better visualization of anterior cerebral and middle cerebral arteries branches

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The patient was cured with no further seizures, continued on antiepileptic medications.

The patient discharged in fair general condition with instruction to continue phenytoin. He had followed up in the neurology clinic after 3 months without recurrence of seizure.

Discussion

Here, we report a rare presentation of DAVF which is treated successfully, these patients with DAVF are usually presented with headache, tinnitus, and intracranial bleeding but not a seizure. A similar case was reported in a 38-year-old male who was diagnosed with foramen magnum DAVF,^[1] and another reported case series of DAVF presented with status epilepticus.^[2]

DAVFs in adulthood are an acquired disease, and there is no relationship to hereditary or developmental disorders. Some patients with DAVFs have been seen with brain arteriovenous malformations (AVMs) as well as cavernomas. Vascular diseases associated with dural arteriovenous shunts include cerebral AVM, maxillofacial AVM, hereditary hemorrhagic telangiectasia, bone AVM, cavernomas, and intradural or extradural arterial aneurysms. Meningioma and DAVF have been reported although it is rare.^[3] Multiple DAVFs at separate locations in the same patient have also been reported.^[3],[4]

The common predisposing factor for DAVFs appears to be venous sinus thrombosis,^[4] the venous hypertension developing after venous thrombosis opens up the microvascular connections within the dura.^[5] Without intervention, these channels become hypertrophied resulting in direct shunting between the arteries and veins.^[4],[5] When the fistula grows and becomes more diffuse, it recruits pail supply from parenchyma vessels. This may lead to the angiomatous network of multiple feeding arteries and numerous AV shunts within a partially recanalized sinus that is frequently seen at angiography. The involved dural sinus receives arterialized blood flow that can lead to mechanical obstruction of the sinus and results in retrograde drainage of blood away from the sinus and into the cortical veins. Histopathological analysis of excised DAVFs has revealed thrombosis and angiographic progression of sinus thrombosis to DAVF. In addition, dilatation of the cortical veins may occur, predisposing the patient to intracranial hemorrhage. In reviewing literature, we found case reports of patients who presented with brain lesions on CT scan turned to be DAVF.^[6] Pulsatile tinnitus can be the only symptom of DAVF, in addition, intracerebral hemorrhage is a very common presenting sign of DAVF. In regard to most common locations, transverse and sigmoid dural sinuses are the most common sites involved, followed by the cavernous sinus.^[7]

DAVF can be recurrent after treatment and appear in a different site, as well there are reports of spontaneous disappear of the lesions.^[8],[9]

Our patient presented with first time seizure as the only presented symptoms, another unusual presentation of this uncommon condition is association with myelopathy.^[10]

DAVFs with retrograde leptomeningeal venous drainage carry a high risk for neurological sequelae or death, both at presentation and in the natural course of disease progression. With presently available treatment modalities, most of these lesions are either curable or, at the very least, patients may get significant clinical improvement. The natural history of the condition suggests that these lesions are aggressive and need prompt diagnosis and treatment

Conclusion

This case report focuses on dural fistula as a rare abnormality, leading to seizure disorder in old male and shows effective intravascular intervention which leads to cure and prevention of further seizures, DAVF fistula is present in significant number of patients but it is markedly underdiagnosed and needs to be considered in differential diagnosis of seizure in elderly. Radiological intervention such as embolization seems to be a very effective nonsurgical treatment of this condition.

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

Nil.

Conflicts of interest

There are no conflicts of interest.

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