Objective: To report the case of a 75-year-old woman with rapidly progressive dementia and parkinsonism caused by a cortical dural AV fistula

Background: Vascular malformations are infrequently associated with parkinsonism. Various cases exist in the literature of AV fistulas, malformations, and aneurysms leading to parkinsonian symptoms. Most of these vascular lesions are located in deep structures including basal ganglia, thalamus, and midbrain. Cortical vascular lesions are even less associated with parkinsonism, and we report such a case here.

Methods: A case of rapidly progressive dementia and parkinsonism due to a cortical dural AV fistula is described.

Results: A 75-year-old woman presented for evaluation of dementia and parkinsonism. Her earliest symptom was confusion over finances two years before presentation. Her daughter noticed a tremor in her voice and left leg around this time. A year later she started falling. Despite physical therapy she rapidly declined from a walker to a wheelchair. She developed hallucinations, and her confusion worsened to where she no longer recognized neighbors. She had an MRI brain without contrast that was normal, and was started on carbidopa/levodopa and rivastigmine without benefit. On neurologic exam, MOCA was 7/30 with limited attention, memory, and executive functioning. She had significant bradykinesia, rigidity worse on the left, marked postural instability, and startle myoclonus. She was admitted and had a lumbar puncture to rule out prion disease, which was normal, and ultimately had an MRI of the brain with contrast that showed abnormal signal in bilateral frontoparietal lobes concerning for an AV fistula. She underwent conventional angiography, confirming a large AV fistula with cortical venous drainage. This was partially treated with embolization of the middle meningeal artery. Post-embolization, her cognitive symptoms mildly improved, but her symptoms did not fully resolve. She will need further embolization with neurosurgery in the future to fully treat the AV fistula.

Conclusions: While parkinsonism is infrequently associated with vascular malformations, lesions in the midbrain, basal ganglia, or even cortex can cause parkinsonian symptoms. Here we described a case of dementia and parkinsonism from a large cortical AV fistula discovered only with contrast enhanced MRI, incompletely treated with embolization, resulting in partial improvement in her symptoms.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/rapidly-progressive-dementia-and-parkinsonism-caused-by-a-cortical-dural-av-fistula-a-case-report/