Issues in the diagnosis and management of the papilledema shunt.

Chaudhary, Neeraj; Griauzde, Julius; Gemmete, Joseph J; Pandey, Aditya S; Trobe, Jonathan D

BACKGROUND Dural arteriovenous fistulas (DAVFs) that shunt blood into the transverse or superior sagittal venous sinuses cause papilledema by raising intracranial pressure ("the papilledema shunt"). Such fistulas pose unique diagnostic and therapeutic challenges. METHODS Case report and literature review. RESULTS In a patient presenting with papilledema, non-invasive brain vascular imaging disclosed subtle signs of a DAVF. Digital angiography delineated the DAVF and revealed cortical venous reflux. After three transarterial embolizations with ethylene vinyl alcohol, the DAVF was closed and papilledema resolved. CONCLUSIONS The imaging features of a DAVF that cause papilledema may be subtle on non-invasive vascular imaging. If overlooked, and lumbar puncture is performed, there is a substantial risk of brain herniation. Cortical venous reflux, which may be relatively common in these DAVFs, impels the need for endovascular closure. The transvenous route, often employed for closing cavernous sinus DAVFs, should be avoided because of the dangers of dural venous sinus thrombosis.