• Bikei Ryu, Takakazu Kawamata, Takuma Wakai, Masahiro Shimizu, Shinichi Yagi, and Tsuneo Shimizu.
• Department of Neurosurgery, Kanto Neurosurgical Hospital, Saitama, Japan; Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan. Electronic address: ryu.bikei@twmu.ac.jp.
• World Neurosurg. 2016 Aug 1; 92: 584.e1-584.e6.

BackgroundCerebral metabolism can be disrupted by venous congestion in patients with intracranial dural arteriovenous fistula (DAVF), which may lead to adverse neurological outcomes. However, there are no clear indicators to guide cerebral evaluation and treatment selection in cases of DAVF. We describe a patient with a DAVF whose proton magnetic resonance spectroscopy ((1)H-MRS) findings were associated with improvements in clinical status.Case DescriptionAn elderly woman with a history of myocardial infarction presented with progressive dementia, aphasia, and a severe headache. We detected a transverse-sigmoid sinus DAVF, as well as abnormal levels of lactate and N-acetylaspartic acid (NAA) in the (1)H-MRS, and successfully treated the patient using surgical sinus skeletonization. However, follow-up (1)H-MRS revealed inconsistent reversals in the levels of lactate and NAA. In addition, we calculated the NAA/creatinine ratios from before and after surgery, which revealed postoperative increases in the ratios for the left temporal, right parietal, and left parietal regions. These increases occurred concurrently with improvements in the patient's cognitive function.Conclusions(1)H-MRS may be useful for pretreatment detection of increased lactate levels, decreased NAA levels, and/or decreased NAA/creatinine ratios. These findings may indicate poorer cerebral metabolism, and show a need for more aggressive treatment. Furthermore, (1)H-MRS may be useful for evaluating the effect of conservative treatment and for indicating conversion to a more aggressive treatment.Copyright © 2016 Elsevier Inc. All rights reserved.

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