Endovascular and surgical obliteration rates of spinal dural arteriovenous fistulae: a single UK Centre experience

OBJECTIVE

Endovascular treatment (EVT) of spinal dural arteriovenous fistulae (SDAVF) has become increasingly popular given its less invasive nature. This study aims to assess radiological obliteration rates after surgery and EVT for SDAVF in a major tertiary referral centre serving a population of 2.2 million.

METHOD

A retrospective review of all patients diagnosed with SDAVF between February 2010 and February 2018 was undertaken, identifying baseline demographics, treatment modality and the final radiological outcome (i.e., persistence of the SDAVF). Patients were identified from the departmental neurovascular database, clinical notes and imaging reports.

RESULTS

Twenty patients were identified with an angiographically confirmed SDAVF. Two (10%) were managed conservatively. Nine patients (45%) underwent EVT. Obliteration was achieved in one patient (11%) after a single procedure, while one patient required two sessions. Further surgery was required in five patients (56%) to achieve complete obliteration. Nine patients (45%) underwent surgical disconnection as first treatment. Obliteration was radiologically confirmed in eight patients (89%). No radiological (MRI or angiographic) follow-up data was available for two patients (one from each group) and these were excluded from analysis. In this study, the obliteration rate of SDAVF after surgery was superior compared to EVT (p <0.01).

CONCLUSION

Complete obliteration and recurrence rates after single treatment with EVT were inferior compared to surgical intervention. EVT may be better suited for specific presentations of SDAVF either in isolation or as an adjunct in multi-modality treatment. A national registry of outcomes may aid ongoing refinement of patient selection for EVT.

Transvenous Embolization of Dural Arteriovenous Fistulas Through the Galenic (Deep Venous) System: Multicenter Case Series and Meta-Analysis

BACKGROUND AND OBJECTIVES

Arteriovenous fistulas involving the deep venous system have often been treated with microsurgery or transarterial embolization. Increasing familiarity with transvenous navigation and improved endovascular access systems may facilitate transvenous embolization (TVE) for these rare and challenging lesions.

METHODS

We performed a retrospective study of neurointerventional databases of 6 high-volume centers. We identified all cases of arteriovenous fistulas with deep transvenous embolizations for arteriovenous fistula. Details regarding demographics, fistula characteristics, treatment considerations, clinical outcomes, and fistula occlusion were obtained and analyzed. The meta-analysis used the same inclusion criteria.

RESULTS

Seventeen cases of TVE were identified. The most common reasons for TVE included prior treatment failure with microsurgery (n = 2) or transarterial embolization (n = 3) or inaccessible arterial pedicles (n = 4). For patients with full clinical outcome data (n = 14), 2 patients had worsened modified Rankin Scale, 8 patients had no change, and 4 were improved at a median clinical follow-up of 3.5 months. Angiographic obliteration was achieved in 15/17 cases (88.2%). In 1 case, catheterization around a sharp turn in the basal vein of Rosenthal could not be performed. In another case, despite successful TVE, there was residual lesion which was treated 1 year later by microsurgical clipping and excision.

CONCLUSION

Transvenous approaches for embolization of deep arteriovenous fistulas have become possible with modern endovascular catheter systems and liquid embolics. These lesions can be treated safely and effectively through endovascular approaches, which may spare patients the traversal of deep structures needed for microsurgical approaches to these regions. The outcomes of TVE are comparable with published outcomes of microsurgical interruption.

Craniocervical Junction Dural Arteriovenous Fistula and Pial Arteriovenous Fistula Presenting Concomitantly in Separate Locations with Subarachnoid Hemorrhage

Craniocervical junction dural arteriovenous fistula and pial arteriovenous fistula are rare cerebrovascular lesions. While their pathophysiology is different, both conditions can cause intracranial hemorrhage attributable to venous congestion. We present, to our knowledge, the first case report of craniocervical junction dural arteriovenous fistula and pial arteriovenous fistula presenting concomitantly in separate locations with subarachnoid hemorrhage. This case appears to have been due to increased venous hypertension caused by a merging of the venous drainage of the 2 lesions, resulting in hemorrhage.

Identification of LDLR mutation in cerebral venous sinus thrombosis co-existing with dural arteriovenous fistulas: a case report

BACKGROUND

Cerebral venous sinus thrombosis (CVST) is typically associated with a prothrombotic state of the blood, with its causative factors varying widely. Prior research has not reported the simultaneous occurrence of CVST and dural arteriovenous fistulas (DAVFs) as potentially resulting from genetic mutations. In this case report, we introduce a unique occurrence wherein a patient with a heterozygous mutation of the low-density lipoprotein receptor (LDLR) gene presented with CVST in conjunction with DAVFs.

CASE

Presentation: A male patient, aged 51, sought treatment at our facility due to a consistent decline in cognitive functions accompanied by recurrent headaches. Comprehensive evaluations were administered, including neurological examinations, laboratory tests, magnetic resonance imaging, digital subtraction angiography, and whole exome sequencing. Digital subtraction angiography identified DAVFs in the patient's right sigmoid sinus and an occlusion within the left transverse sinus. The whole exome sequencing of blood samples pinpointed a heterozygous mutation in the LDLR gene (NM_000527:exon12:c.C1747T:p.H583Y). Following the confirmed diagnosis of CVST and DAVFs, the patient underwent anticoagulant therapy combined with endovascular procedures - these comprised embolization of the arteriovenous fistula in the right sigmoid sinus and balloon dilation with stent implantation in the left transverse sinus. A six-month follow-up indicated a significant abatement in the patient's symptoms.

CONCLUSIONS

This report marks the first documented case of an LDLR gene mutation that could be associated with the onset of CVST and DAVFs. The mutation in the LDLR gene might foster a prothrombotic environment, facilitating the gradual emergence of CVST and the subsequent genesis of DAVFs.

Two Neighboring Spinal Dural Arteriovenous Fistulas with Multiple Bridging Veins Drainage

Two neighboring spinal dural arteriovenous fistulas (SDAVFs) with multiple bridging veins drainage are extremely rare. Here, we report a 55-year-old man with 2 neighboring SDAVFs at the levels of T4-T5 supplied by the right T5 intercostal artery (common stem of T4 and T5 arteries) with multiple draining veins. Intraoperatively, 3 draining bridging veins between T4 and T5 nerve roots were identified and resected successfully. This case demonstrated the complex microscopic angioarchitecture features of 2 neighboring SDAVFs with multiple draining veins. Although these complex SDAVFs are extremely rare, the clinicians should be aware of the possibility of 2 neighboring SDAVFs.

LIQUID - Treatment of high-grade dural arteriovenous fistulas with Squid liquid embolic agent: a prospective, observational multicenter study

BACKGROUND

Endovascular embolization is a feasible treatment for cranial dural arteriovenous fistulas (DAVFs). New embolic agents aim to improve the success of DAVF embolization.

OBJECTIVE

To assess the safety, efficacy, and short-term outcome of the treatment of DAVFs using the new liquid embolic agent Squid.

METHODS

The LIQUID study is a prospective, observational multicenter study on the treatment of high-grade (Cognard type ≥3) DAVFs with the embolic agent Squid. The primary outcome measures were safety (ie, morbidity and mortality), as well as the occlusion rate 90 to 180 days after treatment.

RESULTS

In eight centers, 53 patients (mean age 59.8 years, 22.6% female) were treated in 55 treatment sessions. Of the DAVFs, 56.6% were Cognard type III, 41.5% type IV, and 18.9% were ruptured. Squid 18 was used in 83.6% and Squid 12 in 32.7% of the treatments. The overall rate of intraprocedural or postprocedural adverse events (AEs) was 18.2%. Procedure-related AEs resulting in permanent morbidity were observed in 3.6%. One patient (1.8%) died unrelated to the procedure due to pulmonary embolism. The final complete occlusion rate at 90 to 180 days was 93.2%. After a mean follow-up of 5.5 months, the modified Rankin Scale (mRS) score was stable or improved in 93.0%. In one of the patients, worsening of the mRS score was related to the procedure (1.8%).

CONCLUSION

Squid is a safe and effective liquid embolic agent for the treatment of high-grade DAVFs.

Copolymer liquid embolization of dural arteriovenous fistulas: A 20-year single-center experience

BACKGROUND AND PURPOSE

Dural arteriovenous fistulas (DAVFs) with cortical venous drainage (CVD) carry significant risks of cerebral ischemia and intracranial hemorrhage. Endovascular treatment (EVT) using Onyx, a copolymer-based liquid embolic material, has become the preferred approach. However, the optimal treatment strategy for anterior cranial fossa DAVFs remains debated.

METHODS

This retrospective study analyzed outcomes of EVT for DAVFs in a single center from 2002 to 2023. Patient data including demographics, clinical status, angiographic findings, embolization techniques, and outcomes were recorded. The results of the anterior fossa malformations were analyzed separately afterward.

RESULTS

A total of 195 DAVFs were included in the study. The most common presenting symptom was hemorrhage (41%), most fistulas were located in the transverse and sigmoid sinus region (48%), and the majority of DAVFs had direct CVD (78%). Transarterial embolization with Onyx was the preferred treatment strategy in majority of cases (92%). Overall, 94% of patients showed improvement or stability on the modified Rankin Scale. Two patients died due to rebleeding after partial DAVF embolization. Onyx demonstrated higher immediate complete occlusion rate compared to other embolic materials (88% vs. 35%). Overall, 91% of fistulas were closed at the last follow-up. Ten anterior fossa DAVFs were treated, resulting in clinical improvement and complete occlusion in all cases.

CONCLUSION

Based on the results of our study, we believe that a cure of DAVFs, including those in the anterior fossa, can be achieved in more than 90% of cases through transarterial Onyx embolization, given long-term clinical experience.

Craniocervivcal Spinal Dural Arteriovenous Fistula Ligation via a Modified Suboccipital Craniectomy and C1 Laminectomy: Operative Video

Dural arteriovenous fistulas (dAVFs) are vascular malformations of the central nervous system that feature an arteriovenous shunt fed by dural arteries and can be intracranial or spinal.1-3 Spinal dAVFs are classically found at the nerve root sleeve.3 The arterial supply can often be predicted by the fistula location, whereas the symptomatology and risk of hemorrhage is determined by the venous drainage pattern.1-3 Craniocervical fistulas, a subset of dAVFs, may arise in association with the anterior condylar venous confluence or more dorsally in association with the transdural segment of the vertebral artery.1-3 This latter type of fistula typically has spinal venous drainage and may present with myelopathy from spinal cord venous congestion. We present a 61-year-old man who presented with a 2-week history of neck pain and paraparesis. Magnetic resonance imaging of the cervical spine revealed diffuse T2 hyperintensity of the cord from the pons to the level of the T1 vertebra. A computed tomography angiogram showed a possible dAVF at the craniocervical junction on the left. Because of the unclear nature of the patient's spinal cord lesion, a cerebral angiogram was performed. It confirmed a dAVF associated with the transdural segment of the left vertebral artery, with small dural feeders from the left vertebral artery and venous drainage into the anterior spinal vein. The patient underwent a modified suboccipital craniectomy and C1 laminectomy for dAVF ligation (Video 1). He was extubated postoperatively and discharged to a rehabilitation unit with improvement in lower extremity strength.

Clinical outcomes and prognostic factors in the surgical treatment of spinal dural arteriovenous fistulas: a retrospective study of 118 patients

Spinal dural arteriovenous fistulas (SDAVFs) are the most common type of spinal vascular malformations (AVMs), constituting approximately 70% of all spinal AVMs. The impact of various clinical and radiologic features on the outcomes in patients with SDAVFs is still controversial. The purpose of the study is to investigate the clinical outcomes and prognostic factors in patients with surgically treated SDAVFs in a single center. A retrospective review was performed for all patients with SDAVFs from January 2013 to September 2021 who underwent surgery at our institution. Medical records and pre- and postoperative imaging data were analyzed. Neurological function status was evaluated by modified Aminoff-Logue Scale (mALS). Student's t-test, Wilcoxon rank sum test, χ2 test and logistic regression were used to find significant prognostic factors. P values < 0.05 were considered significant. One hundred and eighteen patients were ultimately included in the study. By comparing preoperative and postoperative mALS, 69 (58.5%) patients experienced improvement, and 49 (41.5%) patients showed no improvement (worse or unchanged). Wilcoxon rank sum test showed that there was a difference between the improvement group and the no improvement group in preoperative mALS Micturition score and preoperative mALS Defecation score. The logistic regression revealed that preoperative mALS Gait score was associated with clinical improvement after surgery in patients with SDAVFs. Surgical treatment of SDAVFs is a safe and effective procedure and can lead to symptom improvement or stabilization in most patients. Preoperative neurological function status was the only factor associated with clinical prognosis.

Dural arteriovenous fistula with spinal dural arteriovenous fistula: a case report and review of the literature

BACKGROUND

This paper analyzed the cases of dural arteriovenous fistula (DAVF) with spinal dural arteriovenous fistula (SDAVF) in the diagnosis and treatment process.

CASE PRESENTATION

One case involving dural arteriovenous fistula (DAVF) with spinal dural arteriovenous fistula (SDAVF) from the 306th Hospital of PLA was retrospectively analyzed. The patient consulted the doctor due to lower limb sensory and motor disorders while exhibiting symptoms of urinary dysfunction. A computed tomographic angiography (CTA) and cerebral angiography confirmed the diagnosis of dural arteriovenous fistula (DAVF), necessitating surgical treatment. The patient was referred to our hospital for an magnetic resonance imaging (MRI) and a spinal angiography to obtain a confirmed diagnosis for spinal arteriovenous fistula, after which they underwent surgical fistula resection. The invasive intracranial dural arteriovenous fistula (DAVF) resection proceeded smoothly but did not ease the patient's symptoms. However, postoperative symptoms were partially relieved by the lumbar open spinal dural arteriovenous fistula adminstration.

CONCLUSIONS

Since not enough is understood about these two diseases, the rate of misdiagnosis is significantly increased. Early diagnosis and treatment of spinal dural arteriovenous fistula (SDAVF) can play a positive role during the recovery from neural function damage.

Endovascular treatment of trigeminal neuralgia with cranial autonomic symptoms due to a right-sided petrous ridge dAVF

Dural arteriovenous fistula represents a rare cause of secondary Trigeminal Neuralgia. To date, there have been 18 reported cases of successful treatment of trigeminal neuralgia with endovascular embolization. Here we describe a unique case of a 51-year-old man with right-sided petrous ridge dural arteriovenous fistula causing ipsilateral V1 pain and cranial autonomic dysfunction. Cerebral angiography confirmed a Cognard type 3 right-sided tentorial dAVF supplied by an enlarged meningo-hypophpyseal vessel from the extradural ICA and by the middle meningeal artery. The fistula drains towards the midline via deep cerebral veins, the internal cerebral vein and the straight sinus with likely variceal compression of the right trigeminal nerve root entry zone. Transarterial Onyx embolization resulted in complete obliteration of the dural arteriovenous fistula with immediate resolution of facial pain and autonomic symptoms. After 24 months, the patient remains symptom-free and has no radiographic or clinical evidence of fistula recurrence. To date, there have been no other cases reported of trigeminal neuralgia with cranial autonomic symptoms or SUNCT syndrome due to a dural arteriovenous fistula. The presence of cranial autonomic symptoms with trigeminal neuralgia or a diagnosis of SUNCT should not deter endovascular treatments of dural arteriovenous fistulas or treatment of other compressive vascular lesions.

Endoscopic endonasal transsphenoidal Onyx embolization of a paracavernous dural arteriovenous fistula

Paracavernous dural arteriovenous fistulas (pdAVFs) are extremely rare and can mimic carotid cavernous fistulas (CCFs) in both clinical presentation and imaging characteristics. Access to the venous pouch often presents the greatest challenge in the treatment of pdAVFs. Here we present a novel access technique utilizing an endoscopic endonasal transsphenoidal approach, where we directly puncture the venous pouch under both stereotactic guidance and endoscopic visualization, thereby completely embolizing a pdAVF with no alternate access (video 1). neurintsurg;15/10/1055/V1F1V1Video 1Technical video demonstrates the complete embolization of a pdAVF using an endoscopic endonasal transsphenoidal approach.

Watch brain circulation in unexplained progressive myelopathy: a review of Cognard type V arterio-venous fistulas

BACKGROUND

Intracranial dural arterio-venous fistulas are pathological anastomoses between arteries and veins located within dural sheets and whose clinical manifestations depend on location and hemodynamic features. They can sometimes display perimedullary venous drainage (Cognard type V fistulas-CVFs) and present as a progressive myelopathy. Our review aims at describing CVFs' variety of clinical presentation, investigating a possible association between diagnostic delay and outcome and assessing whether there is a correlation between clinical and/or radiological signs and clinical outcomes.

METHODS

We conducted a systematic search on Pubmed, looking for articles describing patients with CVFs complicated with myelopathy.

RESULTS

A total of 72 articles for an overall of 100 patients were selected. The mean age was 56.20 ± 14.07, 72% of patients were man, and 58% received an initial misdiagnosis. CVFs showed a progressive onset in 65% of cases, beginning with motor symptoms in 79% of cases. As for the MRI, 81% presented spinal flow voids. The median time from symptoms' onset to diagnosis was 5 months with longer delays for patients experiencing worse outcomes. Finally, 67.1% of patients showed poor outcomes while the remaining 32.9% obtained a partial-to-full recovery.

CONCLUSIONS

We confirmed CVFs' broad clinical spectrum of presentation and found that the outcome is not associated with the severity of the clinical picture at onset, but it has a negative correlation with the length of diagnostic delay. We furthermore underlined the importance of cervico-dorsal perimedullary T1/T2 flow voids as a reliable MRI parameter to orient the diagnosis and distinguish CVFs from most of their mimics.

Bilateral mirror image lumbar spinal dural arterial venous fistula: a rare case and systematic review of the literature

BACKGROUND

Spinal dural arteriovenous fistulas (SDAVF) are rare with an incidence of 5-10/million annually. They can be difficult to diagnose causing a delay in treatment with significant morbidity. We describe the first case in the literature of a symptomatic mirror lumbar SDAVF which may go unnoticed due to its unique vascular anatomy.

CASE DESCRIPTION

A 78-year-old gentleman presented with a progressive deterioration in his walking distance and urinary retention. An initial MRI scan of the whole spine did not show features suggestive of an underlying vascular malformation. During further investigations of neurological causes, the patient continued to have progressive symptoms over a 10-month period resulting in a repeat MRI scan. This showed a new finding of cord oedema without abnormal flow voids. He went on to have vascular imaging which demonstrated a mirror L3 SDAVF and underwent subsequent surgical management. At follow up there was a significant improvement in symptoms.

CONCLUSIONS

Completing a systematic review of the literature we find that the mirror lumbar SDAVF in our patient presented in a more aggressive manner with symptoms progressing faster than in single or multi-level SDAVF. Our case demonstrates how this unique vascular anatomy may result in a diagnostic challenge, behaving in an occult way where typical findings are not seen on initial MRI scanning. We provide an argument for early vascular imaging which can result in the treatment of these lesions in a timely manner.

Spinal Dorsal Intradural Arteriovenous Fistulas: Natural History, Imaging, and Management

In this review, we describe the pathophysiology, diagnosis, and treatment of spinal dorsal intradural arteriovenous fistulas (DI-AVFs), focusing on novel research areas. DI-AVFs compose the most common subgroup of spinal arteriovenous lesions and most commonly involve the thoracic spine, followed by lumbar and sacral segments. The pathogenesis underlying DI-AVFs is an area of emerging understanding, thought to be attributable to venous congestion and hypertension that precipitate ascending myelopathy. Patients with DI-AVFs typically present with motor, sensory, or urinary dysfunction, although a wide swath of other less common symptoms has been reported. DI-AVFs can be subdivided by spinal region, which in turn is associated with 4 distinct clinical phenotypes: craniocervical junction (CCJ), subaxial cervical, thoracic, and lumbosacral. Patients with CCJ and lumbosacral DI-AVFs have particularly interesting presentations and treatment considerations. High-value diagnostic findings on MRI include flow voids, missing-piece sign, and T2-weighted intramedullary hyperintensity. However, digital subtraction angiography is the gold standard for diagnosis and localization of DI-AVFs and for definitive treatment planning. Surgical disconnection of DI-AVFs is almost universally curative and frontline treatment, especially for CCJ and lumbosacral DI-AVFs. Endovascular techniques evolve in promising ways, such as improved visualization, distal access, and liquid embolic techniques. The pathophysiology of DI-AVFs is better understood using newly identified radiologic diagnostic markers. Despite new techniques and devices introduced in the endovascular field, surgery remains the gold-standard treatment for DI-AVFs.

Dural Arteriovenous Fistulas Presenting as Symmetric Lesions in the Internal Capsule on Imaging Studies: A Case Report and Literature Review

BACKGROUND

Dural arteriovenous fistulas (DAVFs) leading to oedema, primarily in the internal capsule, are extremely rare and, to our knowledge, have never been reported. We reported a case of DAVFs with oedema in bilateral internal capsule oedema and reviewed the literature.

METHODS

The report describes a unique imaging presentation of cases of DAVFs as symmetric lesions, mainly in the bilateral internal capsule. It also reviews the literature for symmetric lesions in the internal capsule and central grey matter caused by DAVFs to further characterize this rare entity and differential diagnosis through imaging features.

RESULTS

In cases of symmetric oedema caused by DAVFs, the most common artery involved in arterial supply was the middle meningeal artery (13/24; 54%). The main vein involved in the drainage was the Galen vein (18/29; 62%). Most cases were treated with transarterial embolization (23/29; 79%), and the probability of effective treatment or complete cure is 100%. On imaging, the vasogenic oedema signal caused by DAVFs is a symmetrical lesion of the bilateral internal capsule, that is, DWI MRI shows a high signal in the unrestricted diffusion area on the apparent diffusion coefficient map.

CONCLUSIONS

MR has good diagnostic value in abnormal basal ganglia symmetric signals caused by DAVFs, and can quickly identify DAVFs early.

FLOW-diverted Glue Embolization to Target lesions (FLOW-GET) technique for spinal vascular diseases: A technical note

We present and exemplify the flow-diverted glue embolization to target lesions (FLOW-GET) technique for spinal vascular diseases. In this technique, the occlusion of the posterior intercostal artery or dorsal muscular branch by coils diverts the injected glue from the segmental artery to the target lesions. This technique was applied to a ruptured retrocorporeal artery aneurysm and spinal dural arteriovenous fistulas. The FLOW-GET accomplished the complete obliteration of all lesions. This simple and useful technique can be applied to spinal vascular lesions even if a microcatheter is not placed in proper feeders or advanced close to the shunt points or aneurysms.

Segmental microbleeds: a radiological sign for cranial dural arteriovenous fistula

A 57-year-old man presented to the emergency department following a road traffic accident, having experienced a sudden ascending 'wave of emotion'. After the event, he developed an intense right-sided temporal headache and was thought to have a complex grief reaction resulting from a recent bereavement. Given persistent symptoms, a computed tomography (CT) scan of head was conducted at an outpatient transient ischaemic attack (TIA) clinic, which showed a possible right occipital infarct. Further magnetic resonance imaging (MRI) scanning revealed instead a segmental area of microbleeds in the posterior right temporal lobe, with occipital extension. Upon discussion at the neuroradiology multidisciplinary team meeting and subsequent digital subtraction angiography (DSA), a cranial dural arteriovenous fistula (DAVF) was confirmed. He underwent a successful embolisation, with his symptoms fully resolving 16 months later.

Natural history, angiographic presentation and outcomes of anterior cranial fossa dural arteriovenous fistulas

BACKGROUND

Anterior cranial fossa dural arteriovenous fistulas (ACF-dAVFs) are aggressive vascular lesions. The pattern of venous drainage is the most important determinant of symptoms. Due to the absence of a venous sinus in the anterior cranial fossa, most ACF-dAVFs have some degree of drainage through small cortical veins. We describe the natural history, angiographic presentation and outcomes of the largest cohort of ACF-dAVFs.

METHODS

The CONDOR consortium includes data from 12 international centers. Patients included in the study were diagnosed with an arteriovenous fistula between 1990-2017. ACF-dAVFs were selected from a cohort of 1077 arteriovenous fistulas. The presentation, angioarchitecture and treatment outcomes of ACF-dAVF were extracted and analyzed.

RESULTS

60 ACF-dAVFs were included in the analysis. Most ACF-dAVFs were symptomatic (38/60, 63%). The most common symptomatic presentation was intracranial hemorrhage (22/38, 57%). Most ACF-dAVFs drained through cortical veins (85%, 51/60), which in most instances drained into the superior sagittal sinus (63%, 32/51). The presence of cortical venous drainage predicted symptomatic presentation (OR 9.4, CI 1.98 to 69.1, p=0.01). Microsurgery was the most effective modality of treatment. 56% (19/34) of symptomatic patients who were treated had complete resolution of symptoms. Improvement of symptoms was not observed in untreated symptomatic ACF-dAVFs.

CONCLUSION

Most ACF-dAVFs have a symptomatic presentation. Drainage through cortical veins is a key angiographic feature of ACF-dAVFs that accounts for their malignant course. Microsurgery is the most effective treatment. Due to the high risk of bleeding, closure of ACF-dAVFs is indicated regardless of presentation.

Safety and efficacy of dual lumen balloon catheters for the Treatment of cerebral vascular malformations: A systematic review, pooled analysis, and meta-analysis

BACKGROUND

There is little evidence in scientific literature assessing the safety and efficacy of dual-lumen balloon catheters (DLBCs) and their performance compared to single-lumen catheters (SLCs).

METHODS

In this PROSPERO-registered, PRISMA-compliant systematic review, we identified all MEDLINE and EMBASE single-arm (DLBCs) and double-arm (DLBCs vs SLCs) cohorts where DLBCs were used for the treatment of cerebral arteriovenous malformations (AVMs) or dural arteriovenous fistulas (dAVFs). Immediate angiographic outcome, vascular complications, technical failures, reflux episodes and entrapment were the primary outcomes. A meta-analysis of the double-arm studies summarized the primary outcomes of total procedural time and immediate angiographic outcome.

RESULTS

The authors identified 18 studies encompassing 209 treated lesions with reported outcomes. Complete occlusion was achieved in 108/132 treated dAVFs (81.8%, 95% CI: [74-87.8%]) and in 45/77 treated AVMs (58.4%, [46.7-69.4%]). The proportion of completely occluded dAVFs was statistically significantly higher than that of AVMs, p < .001. There were eight reported vascular complications (3.8%, [1.8-7.7%]), five technical failures (2.4%, [0.9-5.8%]), 14 reflux events (6.7%, [3.9-11.2%]), two entrapment events (1%, [0.2-3.8%]) and 0 deaths (mortality rate 0%, [0-2.3%]). In a meta-analysis for the treatment of dAVFs, the total procedural time was significantly less for DLBCs compared to SLCs (64.9 vs 125.7 min, p < .0001). The odds of complete immediate occlusion were significantly higher with DLBCs compared to SLCs (odds ratio (OR) 4.6, [1.5-14.3], p = .008).

CONCLUSION

Dual-lumen balloon catheters are safe and effective for the embolization of cerebral AVMs and dAVFs and can achieve faster and potentially superior results compared to SLCs.

REGISTRATION-URL

https://www.crd.york.ac.uk/prospero/ Unique Identifier: CRD42021269096.

Classification and Management Considerations for Intraosseous Dural Arteriovenous Fistulae

BACKGROUND

Intraosseous dural arteriovenous fistulas (IODAVFs) are rare DAVFs that communicate with marrow. Given their infrequency, common nomenclature is nonexistent. Patients may present with benign symptoms, such as tinnitus, or venous hypertension symptoms including hemorrhage depending on the venous outflow pattern.

OBJECTIVE

To describe all available cases of IODAVF in the literature, in addition to our cases, to better define presentation, and treatment outcomes. To advance a classification system to develop common language for these lesions for clinicians and researchers.

METHODS

Neurointerventional procedure logs at 2 high-volume neurovascular centers were reviewed for all cases of IODAVFs, as was the English-based literature available in PubMed. The angioarchitecture, symptoms, management, and demographics were reviewed and summarized.

RESULTS

Four institutional cases were identified, 2 of which had shunting within the marrow (clival or petrous), with venous drainage toward the heart. One case involved the dorsum sella with drainage into the superior petrosal sinus with reflux into the anterior and posterior spinal venous plexuses, and one involved the left petroclival junction, resulting in communication with the cavernous sinus with retrograde drainage into the superior ophthalmic veins. Two patients were managed by observation, one was treated with radiosurgery and one with microsurgical skeletonization. Twenty additional cases from the literature are summarized.

CONCLUSION

IODAVFs of the cerebrocranial vasculature may present incidentally, with tinnitus, or with symptoms related to mass effect or venous hypertension. We propose a classification which accounts for drainage patterns. Further study is needed for these rare lesions.