Anticoagulation helps shrink giant venous lakes and arteriovenous fistulas in dural sinus malformation

Background Dural sinus malformations (DSMs) associated with high flow arteriovenous shunts are a challenging disease in babies that can lead to severe neurological damage or death. We report our treatment strategy in seven consecutive DSMs. Methods We performed a retrospective analysis of seven consecutive patients from four centres, treated with transarterial embolization and anticoagulants. Results Mean clinical and imaging follow-up was 2.8 years (IQR 1-3 1.8-5.3). At baseline, the median size of the dilated venous pouch (giant lake) was 35 mm (IQR 1-3 24-41) that decreased to a normal or near normal venous collector diameter of median size 11.5 mm (IQR 1-3 8.5-13.8). This was achieved after a median of two embolization sessions targeted on dural feeders (IQR 1-3 1.5-2.5), leaving associated pial feeders untreated. There were no cerebral hemorrhagic complications during the anticoagulation treatment. Median percentage of shunt remaining after embolization was 30% (IQR 1-3 12-30), which spontaneously decreased with anticoagulation and even after discontinuation of anticoagulation, in parallel with the reduction in diameter of the dilated sinus, up to healing (or near healing). At the last clinical assessment, the modified Rankin Scale score was 0 in four patients, 1 in one patient, and 3 in two patients. Conclusions Anticoagulants may help to potentiate transarterial embolization in DSMs in babies by decreasing venous dilatation and reducing the remaining arteriovenous shunt, particularly the pial feeders. We did not observe recurrence of arteriovenous shunts after treatment, especially during anticoagulation treatment. Further studies are needed to support our findings.