MULTIFOCAL DURAL ARTERIOVENOUS SHUNTS IN CHILDREN

The authors present four consecutive cases of multiple dural arteriovenous (AV) shunts in children. This entity represents a rare but severe clinical situation. The etiology of the shunts is not known. There is clinical and radiological evidence that they are evolutionary lesions. The clinical presentation in this series was usually by cardiac manifestations (one case), cerebrospinal fluid disorders (two cases), neurological symptoms (three cases), including intracranial hemorrhage (two cases), and cranial bruits (four cases). No radical treatment leading to anatomical cure of all dural AV shunts was thought to be possible using current methods, including modern endovascular and surgical techniques, in any of the four cases. Therefore, treatment was only symptomatic and directed at some of the AV shunts. Targeted arterial embolization with permanent embolic agents represents the most rational technique for symptomatic relief in these patients. However, clinical recurrence often happens without evidence of recanalization. Secondary multifocal pial AV shunts opening into the abnormal sinus occurred in two of the cases; they may have been induced by venous sump from the sinus draining the dural AV shunts. Mechanical occlusion (or excision) in multiple dural AV shunts in children does not represent a satisfactory goal, as the shunts can be the expression of a more complex and yet unknown disease.