Abstract Details

Title Rapid Onset Cognitive Impairment and Unusual Bithalamic Lesions

Topic Cerebrovascular Disease and Interventional Neurology

Presentation(s) P13 - Poster Session 13 (5:30 PM-6:30 PM)

Poster/Presentation
Number 4-017

Objective NA

Background A 67 year-old man presented with a behavioural change over four days, forgetting to perform his morning rituals and becoming more withdrawn. MoCA demonstrated a score of 14/30, with points lost in the trails B, cube drawing and poor hand placement on clock drawing. The remainder of his initial neurological examination was normal. His brain MRI showed patchy T2 and FLAIR hyperintensity in the bilateral thalami with associated perivascular enhancement and no diffusion restriction. A CT venogram demonstrated a poorly visualized straight sinus, with an abrupt termination of the vein of Galen. However, a MR venogram demonstrated slow flow through the straight sinus. Based on the slow flow in the straight sinus and perivascular thalamic enhancement, an inflammatory or infiltrative process was suspected. He was treated with intravenous heparin and when imaging did not improve, was given an empiric pulse course of corticosteroid. This resulted in transient radiographic improvement, which ultimately worsened with steroid taper. An angiogram performed for the possibility of vasculitis incidentally demonstrated his underlying pathology - a slow flow intracranial dural arteriovenous fistula (DAVF) supplied by dural branches of the bilateral posterior cerebral arteries with retrograde venous filling causing venous congestion. He underwent repeat angiography, with embolization of the DAVF. Repeat MRI demonstrated interval improvement with clinical return to near normal baseline function.

Design/Methods NA

Results NA

Conclusions DAVFs occur as a shunt between dural arteries and a venous sinus or cortical vein. Rarely, a rapidly progressive dementia can occur due to bilateral thalamic injury from venous engorgement and congestion secondary to deep venous hypertension. Bilateral thalamic lesions secondary to DAVFs remain a rare diagnosis, with a literature review in 2016 citing only 19 known cases. This is the first case of DAVF misdiagnosed as an inflammatory lesion with partial resolution of radiographic findings with short course immunosuppression.

Authors/Disclosures
Conrad J. Goerz, MD PRESENTER	No disclosure on file
	No disclosure on file
	No disclosure on file
	No disclosure on file
Sean J. Udow, MD (Movement Disorder Clinic)	No disclosure on file

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Abstract Details