Transvenous treatment of carotid cavernous and dural arteriovenous fistulae: results for 31 patients and review of the literature

Recovery of opthalmoplegia associated with cavernous sinus dural arteriovenous fistulas after transvenous cavernous sinus packing

BACKGROUND

We report the recovery of ophthalmoplegia in 11 patients with cavernous sinus dural arteriovenous fistula (CSDAVF) after sinus packing at follow-up.

METHODS

Of 18 patients with CSDAVF treated with transvenous cavernous sinus packing between August 2002 and December 2007 at Beijing Tiantan Hospital, there were 9 patients with initial CNIII or CNVI dysfunction and 2 patients with CNVI dysfunction immediately after cavernous sinus packing selected and reevaluated.

RESULTS

Of 11 patients with CNIII or CNVI palsy, recovery was complete in 10. In 1 patient, complete CNVI palsy was unchanged because the CSDAVF was not cured. There were 6 men and 5 women with a mean age of 52.9 years. In 5 patients, CNVI palsy was associated with chemosis, proptosis and pulsatile tinnitus. Timing of treatment after onset of symptoms was from 4 to 35 days in 9 patients. All CSDAVFs were Barrow type D. Mean follow-up after treatment was 17.7 months (range, 2-54 months).

CONCLUSION

CSDAVF-induced CNIII or CNVI palsies can be cured after cavernous sinus packing transvenously in most patients.

Endovascular treatment of dural fistulas with the venous outflow of laterocavernous sinus

OBJECTIVE

To report our findings concerning the laterocavernous sinus (LCS) drainage of dural fistulas, focusing our attention on the important implications in treatment of the LCS, which is one of the principal drainage pathways of the superficial middle cerebral vein (SMCV).

METHODS

Consecutive 32 patients with dural fistulas treated endovascularly between 2005 and 2008 were reviewed. Seven patients had angiographic features such as dural fistulas draining with SMCV via LCS. Clinical records for these 7 patients were focused to determine their presenting symptoms, angiographic features, endovascular treatments, and clinical outcomes.

RESULTS

Over 3 years, 7 patients had 7 dural fistulas drained with SMCV via LCS were treated. Six-vessel angiography confirmed the presence of the dural fistulas. All fistulas were Cognard Type III featured by leptomeningeal veins drainage. One fistula involving the lesser sphenoid wing and 6 fistulas involving CS were supplied by external carotid artery branches with or without dural branches of the internal carotid artery. LCS was identified as a contiguous to SMCV drainage in these cases. One patient was treated with transvenous coil embolization alone, two with transvenous a combination of Onyx and coil embolization, and 4 with transarterial embolization. An angiographic obliteration and clinical cure was achieved in all patients. Complication was local hair loss due to X-ray radiation in one patient.

CONCLUSION

It is very important to diagnose the presence of LCS in dural fistulas during the diagnostic angiography. It is believed that the knowledge of LCS might be relevant for the understanding and treatment of dural fistulas involving the LCS.

Intracranial dural arteriovenous fistulas: diagnosis and evaluation with 64-detector row CT angiography

PURPOSE

To analyze the diagnostic effectiveness and application of computed tomographic (CT) angiography by using a new algorithm (hybrid CT angiography) in dural arteriovenous fistulas (AVFs).

MATERIALS AND METHODS

Institutional review board approval was obtained for retrospectively postprocessing the raw data from CT angiography by using hybrid CT, which is a mixture of a bone subtraction and masking method for bone removal. The study included 22 patients with 24 dural AVFs and 14 control subjects. The grades in patients with dural AVF determined with hybrid CT angiography and digital subtraction angiography (DSA) were compared, and hybrid CT angiography was applied as a tool for planning endovascular treatment. The adjusted Wald method was used to estimate confidence intervals (CIs), and the Cohen kappa statistic was used to assess interobserver agreement.

RESULTS

Hybrid CT angiography in the 24 dural AVFs revealed asymmetric sinus enhancement in 22 lesions (92%), engorged arteries in 19 (79%), transosseous enhanced vessels in 19 (79%), engorged extracranial veins in 13 (54%), engorged cortical veins in seven (29%), and sinus thrombosis in four (17%). In all 24 lesions, at least two of six imaging signs for diagnosis of dural AVFs were present. The kappa test analysis revealed a high level of interobserver agreement (kappa, 0.56-1.00) in reading the diagnostic imaging signs. The observed agreement between DSA and readers was 100% in the cavernous sinus region and in hypoglossal and clival lesions and 78%-89% in the transverse sigmoid sinus. The overall sensitivity, specificity, positive predictive value, and negative predictive value were 0.93 (95% CI: 0.85, 0.97), 0.98 (95% CI: 0.93, 1.00), 0.97 (95% CI: 0.90, 0.99), and 0.95 (95% CI: 0.90, 0.98), respectively.

CONCLUSION

Hybrid CT angiography is a promising tool for the diagnosis of dural AVF. It can provide key information necessary for treatment planning.

Transvenous embolization of cavernous sinus dural arteriovenous fistulas using detachable coils and Glubran 2 acrylic glue via the inferior petrosal sinus approach

OBJECTIVES

To describe the technique, efficacy, and safety of transvenous embolisation (TVE) of cavernous sinus arteriovenous fistulas (CSDAVFs) via the inferior petrosal sinus (IPS) with detachable coils and acrylic glue.

METHODS

Spontaneous unilateral CSDAVFs were confirmed by cerebral angiography in eight patients, with angiographic patency of the ipsilateral IPS in three and angiographic non-visualisation of the ipsilateral IPS in five. There were two patients with complete occlusion of the ipsilateral internal jugular vein (IJV). TVE with detachable coils and acrylic glue were performed through a femoral vein and an IPS approach.

RESULTS

TVE viaipsilateral IPS was successfully performed in all eight patients in our group. The number of detachable coils for each patient ranged from 2 to 8 (mean, 5.0). Angiography immediately after TVE showed complete occlusion of the CSCAVFs in seven patients and nearly complete occlusion in one. Complete recovery of clinical symptoms was achieved in all eight patients. No recurrence of clinical symptoms was observed at follow-up.

CONCLUSIONS

Transvenous embolisation via an IPS approach is a highly efficient and safe treatment for CSDAVFs. Embolisation with a combination of coils and acrylic glue may help to achieve complete occlusion of fistulas with fewer coils.

Management of direct carotid-cavernous sinus fistulas with the use of ethylene-vinyl alcohol (Onyx) only: preliminary results

OBJECT

So-called direct carotid-cavernous fistulas (CCFs) are commonly treated by detachable balloons or coils to occlude the shunt while sparing the carotid artery. Liquid embolic agents have been rarely used, and in particular, to the authors' knowledge, the use of Onyx as the sole agent has never been reported in an indexed publication.

METHODS

The authors describe a case series of 5 patients with posttraumatic CCF in whom embolization with Onyx was prospectively used as the sole strategy of management.

RESULTS

Complete occlusion was obtained at the end of the procedure in 4 cases, and the lesion in the remaining patient subsequently occluded at the 6-month follow-up evaluation.

CONCLUSIONS

As endovascular techniques for treatment of direct CCFs continue to evolve, this novel approach with Onyx as the sole embolic material seems promising in treating these lesions.

Occasional finding of a dural arteriovenous fistula in a newborn with orbital lymphangioma. A case report

Dural arteriovenous fistulas (DAVF) are vascular malformations rarely occurring in the paediatric population (1,2,3). Prompt diagnosis and treatment are mandatory to prevent life-threatening complications including congestive heart failure and severe brain injury (1,2). We describe the case of a female newborn with an orbital lymphangioma treated for a posterior fossa DAVF. We emphasize the role of MR imaging as a useful non-invasive tool in the diagnosis of these malformations and in the evaluation of associated brain parenchymal lesions.

Transvenous embolization of dural carotid cavernous fistulas: a series of 44 consecutive patients

BACKGROUND AND PURPOSE

Endovascular TVE for DCCF is used for curative purposes, but serious complications can be caused with inadequate embolization. Our aim was to report clinical characteristics, angiographic findings, and results of endovascular TVE in patients presenting with DCCF.

MATERIALS AND METHODS

We performed a retrospective analysis of 44 consecutive patients with DCCF treated by TVE. Approach routes, angiographic results, clinical outcomes, and complications were assessed.

RESULTS

An approach via the internal jugular vein and inferior petrosal sinus was possible in 90% of patients, with complete occlusion of the fistula in 81.6% of patients. A minor residual shunt remained in 13.6% of patients, while a significant shunt remained in 4.5%. In 4 patients, add-on management with transarterial embolization was useful, and in 2 patients with residual shunt, radiosurgery was used. With long-term follow-up (6-40 months), we encountered recanalization/recurrence in 4 patients (9.1%). Complications were seen in the form of permanent morbidity in 3 patients (7%) and transient morbidity in 6 patients (14%).

CONCLUSIONS

For endovascular treatment of DCCF, a transvenous approach was effective in most of our patients; however, some adverse effects were encountered. If AV shunts remain after transvenous treatment, additional modalities must be considered.

Long-term outcome after coil embolization of cavernous sinus arteriovenous fistulas

BACKGROUND AND PURPOSE

Cranial nerve palsies are regularly observed in patients with arteriovenous fistulas of the cavernous sinus. The purpose of our study was to determine the long-term clinical outcome-with a special focus on extra-ocular muscular dysfunctions-in patients who had undergone endovascular treatment of a cavernous sinus fistula with detachable coils.

MATERIALS AND METHODS

Sixteen patients were recalled for an ophthalmoneurologic control examination (mean interval of 4.4 years). The mRS and the EQ-5D questionnaire were used for the description of general outcome. Age, duration of symptoms, character of the fistula (direct, dural), and coil volume were tested to assess their relevance for persistent symptoms.

RESULTS

All patients displayed complete regression of chemosis, exophthalmus, and pulsating tinnitus with no evidence of recurrences. Oculomotor disturbances persisted in 9 of 13 patients and caused permanent diplopia in 7 patients. In 15 patients a mRS score of 1 or 2 was achieved; however, 7 patients reported some limitations in life quality (EQ-5D). A significant correlation was found between coil volume and persistent diplopia (P = .032) and persistent cranial nerve VI paresis (P = .037).

CONCLUSIONS

Coil embolization of the cavernous sinus led to durable closure of AVF and reliable regression of acute symptoms. However, long-term follow-up showed a 44% rate of persistent cranial nerve deficits with disturbances of oculomotor and visual functions. This may be explained by the underlying fistula size itself and/or the space-occupying effect of the coils. As neuro-ophthalmologic outcome is crucial for control of therapeutic success, patients should be routinely examined by ophthalmologists.

Endovascular graft-stent placement for treatment of traumatic carotid cavernous fistulas

Detachable balloon-based endovascular fistula occlusion is a widely accepted treatment for traumatic carotid cavernous fistulas (CCF). However, more recently coils have been used to obliterate the lesion, especially in case detachable balloon is not available. We failed balloon-assisted coil embolization for CCF because of large fistulas and herniation of coil loops into the parent artery. The authors describe our experiences of balloonexpandable graft-stents to treat CCF, and place emphasis on arterial wall reconstruction. Three traumatic CCF patients were treated using a graft-stent with/without coils, and underwent angiographic follow-up to evaluate the patency of the internal carotid artery (ICA). In all cases, symptoms related to CCF regressed after stent deployment and did not recur during follow-up. Follow-up angiography revealed good patency of the ICA in all patients. Graft-stents should be considered as an alternative means of treating CCF and preserving the parent artery by arterial wall reconstruction especially in patients with a fistula that cannot be successfully occluded with detachable balloons or coils.

Pediatric traumatic dural arteriovenous fistula

BACKGROUND

Dural arteriovenous fistulas are uncommon lesions in children, with traumatic lesions suspected to arise from incomplete arterial injury in proximity to a vein or draining sinus. Management of symptomatic acquired lesions requires evaluation of patient presentation, neurological status, and pathoanatomic configuration, with special consideration required for surgery secondary to failed endovascular technique.

CASE REPORT

A 12-year-old male sustained a bicycle fall causing a right temporo-parietal skull fracture associated with non-surgical right epidural hematoma and left contre-coup parietal contusion. Six-weeks later, he complained of a right temporal bruit with subsequent cerebral angiography demonstrating a dural-based fistula between the right middle meningeal artery and a dural vein draining into the sigmoid sinus.

INTERVENTION

Endovascular treatment of this lesion with glue embolization and coiling was unsuccessful, with angiographic illustration of previously unobserved collateral vessels and coils occupying the sigmoid sinus. A right temporo-parietal craniectomy was required to excise the dural-based fistula, followed by dural defect repair with bovine pericardium and subsequent cranioplasty. Six years later the patient remains neurologically intact with no headaches or bruit.

CONCLUSIONS

Dural arteriovenous fistula can uncommonly occur following traumatic injury in children. Partial injury to the middle mengineal artery may have established arterial communication with the draining vein that became ectatic and tortuous under high pressure. Failure of primary endovascular treatment may complicate secondary surgical intervention.

Onyx migration in the endovascular management of intracranial dural arteriovenous fistulas

Onyx migration in the endovascular treatment of dural arteriovenous fistulas (dural AVFs) is uncommon. We describe five cases of Onyx migration to the heart and draining vein and its avoidance. Between February 2007 and August 2008, Onyx migration was encountered in five patients with dural AVFs treated endovascularly at our institute. Procedures performed under general anesthesia consisted of two arterial approaches and three venous approaches. Two patients with dural AVFs involving the transverse-sigmoid sinus were treated by transarterial embolization using Onyx-18 via the occipital artery and the posterior branch of the middle meningeal artery, respectively. A piece of Onyx was found in the right ventricle on post-embolization chest X-ray film in both patients, one developed tricuspid valve dysfunction requiring thoracic surgery and one was asymptomatic. The other three patients were treated with a combination of Onyx (34 or 18) and coils transvenously with venous Onyx migration leading to draining vein occlusion, one with dural AVF involving the tentorium died from venous rupture, two patients with bilateral dural AVFs of the cavernous sinus (one with deterioration of ocular symptoms and one without symptoms). Postoperative digital subtraction angiography confirmed the elimination of dural AVF in one patient, and residual fistulae in three patients. The follow-up study ranging from two to nine months (average, 4.5 months). Three patients recovered to their full activities, while one had visual disturbance. Although Onyx has been considered a controllable embolic agent, its migration to other locations causing clinical deterioration can occur. This problem should be noted and prevented.

Endovascular techniques for treatment of carotid-cavernous fistula

Carotid-cavernous fistulas (CCFs) are abnormal arteriovenous communications in the cavernous sinus. Direct CCFs result from a tear in the intracavernous carotid artery. Indirect CCFs generally occur spontaneously and cause more subtle signs. Direct CCFs, which typically have high flow, usually present with ocular-orbital venous congestive features and cephalic bruit. Indirect CCFs, which typically have low flow, present with similar but more muted clinical features. Direct CCFs are always treated with endovascular methods. The goal is to occlude the fistula but preserve the patency of the internal carotid artery (ICA). Agents include detachable coils or liquid embolic agents delivered transarterially or transvenously. Arterial porous or covered stents are often used adjunctively. In rare cases, the ICA must be occluded. Indirect CCFs are only treated if symptoms are intractable or intolerable or if vision is threatened. The goal is to interrupt the fistulous communications and decrease the pressure in the cavernous sinus. The traditional approach has been transarterial embolization with liquid agents, particularly n-butyl cyanoacrylate (n-BCA). However, the multiplicity of arterial feeders and the low success rate in occluding indirect CCFs by the arterial route has led to a preference for transvenous embolization, most commonly via the inferior petrosal sinus. If that sinus is impassable, alternative routes include the pterygoid venous plexus, superior petrosal sinus, facial vein, or ophthalmic veins. The cavernous sinus is occluded with coils, liquid embolic agents, or both. The use of ethylene vinyl alcohol copolymer (Onyx), an agent that may be superior to n-BCA because it may allow better distal fistula penetration. However, more safety and efficacy data must be accumulated. When experienced interventionalists are involved, the success rate for closing direct fistulas is 85%-99% and for closing indirect fistulas is 70%-78%. Serious complications are relatively infrequent.

A promising adjuvant to detachable coils for cavernous packing: onyx

Transvenous embolization of cavernous dural arteriovenous fistulae (CDAVFs) with Onyx has recently been reported. This study was undertaken to assess the value of Onyx in transvenous treatment of CDAVFs. We retrospectively reviewed 18 patients who underwent transvenous embolization for CDAVFs of Barrow Type D with detachable coils and Onyx at our institution over five years. Patients were divided into two groups: group A, patients who had been treated with detachable coils; group B, patients who had been treated with a combination of detachable coils and Onyx. The approach routes, angiographic results, complications and clinical outcome were assessed for both groups. Eighteen patients with CDAVFs of Barrow Type D were treated: nine women and nine men; mean age was 41.9 years. Eleven patients treated by 19 procedures of transvenous coiling belonged to group A. Seven patients treated by eight procedures of transvenous Onyx injection belonged to group B. The periprocedural complication rate associated with coiling for both groups was 18.2% vs 16.7% with Onyx. The duration of the procedure in both groups was 6.77-/+2.49 hours vs 3.75-/+1.63 hours with coiling vs Onyx, and the cost of Onyx was cheaper than coils. An excellent outcome was achieved in both groups: 90.9% vs 100% (group A vs group B). Our results associated with both modalities of CDAVFs treatment with clinical outcome show that transvenous embolization with Onyx is a safe alternative to detachable coils in the treatment of CDAVFs. However, more cases need to be evaluated.

Anatomy of the superior ophthalmic vein approach for direct endovascular access to vascular lesions of the orbit and cavernous sinus

OBJECTIVE

The superior ophthalmic vein (SOV) provides an alternative venous access for the treatment of carotid-cavernous fistulae. Its direct surgical exposure and cannulation can be difficult. This study was performed to identify anatomic landmarks to facilitate localization and exposure of the SOV.

METHODS

The vascular tree of 6 formalin-fixed human cadaveric heads was injected with colored silicone. The SOV was exposed using a periorbital incision. The diameter of the SOV, its distance to the inferior border of the incision, and the angle formed by the SOV and sagittal midpupillary line were measured. The tributaries of the SOV and its orbital anatomy and relationship to the supraorbital notch/foramen were evaluated.

RESULTS

The SOV was located in the superomedial quadrant of the orbit. Its mean diameter was 2.2 mm (standard deviation, +/-1.2 mm). The mean distance from the SOV to the superior sulcus of the eyelid nasally was 5.9 mm (standard deviation, +/-2.0 mm). The mean angle formed by the SOV and the sagittal midpupillary line was 27.9 degrees (standard deviation, +/-5.4 degrees). The tributaries of the SOV were the angular vein and supraorbital vein (SPOV). The SPOV, identified in all 12 dissections, could be followed to the SOV within the orbit. The SPOV was always located inside the supraorbital notch/foramen when the latter was present.

CONCLUSION

The SOV is located at the superomedial quadrant of the orbit. The SPOV is a reliable reference during surgical exposure. A lid crease or subbrow incision centered over the supraorbital notch simplifies identification of the SOV.

Complications related to percutaneous transarterial embolization of intracranial dural arteriovenous fistulas in 40 patients

BACKGROUND AND PURPOSE

An increasing number of intracranial dural arteriovenous fistulas (DAVFs) are amenable to endovascular treatment with Onyx. However, reports on complications caused by this technique have been limited. We present the initial Beijing Tiantan Hospital experience with adverse events related to transarterial Onyx embolization for DAVFs.

MATERIALS AND METHODS

Between September 2005 and February 2008, a total of 40 patients with DAVFs were treated at our institute with Onyx-18. There were 11 women and 29 men with a mean age of 43.15 years (age range, 23-60 years). We reviewed the clinical presentation, angiographic features, treatment, and outcome.

RESULTS

In 40 patients, total obliteration was achieved in 25 DAVFs (62.5%), with the remaining 15 patients not cured with residual shunts. Complications occurred in 9 patients, 5 DAVFs were located at tentorium, 2 were located at the transverse-sigmoid sinus, 1 was found at the inferior petrosal sinus, and 1 was found at the cavernous sinus, leading to permanent disability in 3 patients (morbidity, 7.5%). Complications included reflexive bradyarrhythmia in 3 (7.5%) patients, hemifacial hypoesthesia in 3 (7.5%) patients, hemifacial palsy in 2 (5%) patients, posterior fossa infarction in 2 (5%) patients, jaw pain in 1 (2.5%) patient, microcatheter gluing in 1 (2.5%) patient, hallucinations in 1 (2.5%) patient, and Onyx migration in 1 (2.5%) patient.

CONCLUSION

Although complete cure can be achieved by transarterial embolization with Onyx, the potential for serious complications exists with this procedure.

Dural arteriovenous fistulas masquerading as dural sinus thrombosis

The authors report dural sinus thrombosis diagnosed in 2 patients based on noninvasive imaging results, which were revealed to be dural arteriovenous fistulas (DAVFs) diagnosed using digital subtraction (DS) angiography. The first patient was a 63-year-old man who presented with headaches. Magnetic resonance venography was performed and suggested dural sinus thrombosis of the left transverse sinus and jugular vein. He was administered warfarin anticoagulation therapy but then suffered multiple intracranial hemorrhages. A DS angiogram was requested for a possible dural sinus thrombectomy, but the DS angiogram revealed a DAVF. The patient underwent serial liquid embolization with complete obliteration of the DAVF. The second patient, an 11-year-old boy, also presented with headaches and was diagnosed with dural sinus thrombosis on MR imaging. A DS angiogram was also requested for a possible thrombectomy and revealed a DAVF. This patient underwent serial liquid embolization and eventual operative resection. These reports emphasize that different venous flow abnormalities can appear similar on noninvasive imaging and that proper diagnosis is critical to avoid contraindicated therapies.

Etiology of carotid cavernous fistula in Japanese

BACKGROUND

A carotid cavernous fistula (CCF) develops spontaneously or after trauma, and older publications suggest that the majority of CCF cases are caused by trauma. However, more recent reports question the prevalence of CCFs caused by trauma.

METHODS

The clinical records of 37 consecutive patients diagnosed with a CCF were reviewed. The disease etiology, patient demographics, anatomical classification, and clinical course were investigated.

RESULTS

The CCF was spontaneous in 30 patients, and was related to head or neck trauma in seven patients. The mean age of all patients was 65.8 +/- 10.5 years, and 30 (81.1%) were women. Eight had diabetes and 14 had hypertension. The major signs and symptoms were congestion (86.4%), diplopia (81.1%), bruit (59.5%), and headaches/orbital pain (62.2%). Exophthalmos (67.6%) and elevated intraocular pressure (40.5%) were also frequently noted. In the Barrow classification, seven patients were classified as type A, four as type B, three as type C, and 20 as type D. The classification could not be established in three patients who did not undergo angiography. Of note, almost all patients had consulted an ophthalmologist before the diagnosis.

CONCLUSION

Spontaneous/low-flow CCF is more prevalent than previously reported. The role of ophthalmologists is important because the majority of patients initially consult ophthalmologists, and the signs of low-flow CCF are subtle and may be overlooked.

Trans-arterial embolisation therapy of dural carotid-cavernous fistulae using low concentration n-butyl-cyanoacrylate

BACKGROUND

Trans-venous embolisation has been accepted as the preferred treatment for dural carotid-cavernous fistulae (DCCF). However, such an approach is not always feasible. In this circumstance, trans-arterial embolisation with low concentration n-butyl-cyanoacrylate glue (NBCA) may be a feasible alternative. We report our results and experience of this method for DCCF.

MATERIALS AND METHODS

Five patients with DCCF were treated by trans-arterial embolisation using low concentration NBCA by wedging the microcatheter into the main feeding artery. All five lesions were associated with venous drainage into the superior ophthalmic vein. The inferior petrosal sinus was patent in one patient and thrombosed in four. Additional venous drainage into the Sylvian vein and the superior petrosal sinus was observed in two patients.

FINDINGS

The definitive NBCA injection was performed via the branches of the middle meningeal artery in three patients and accessory meningeal artery as well as ascending pharyngeal artery in two patients. Four patients showed complete obliteration of the DCCF on the post-embolisation angiogram, and follow-up studies showed clinical cure or improvement and successful obliteration of the DCCF. One patient had a residual DCCF after the procedure, but showed complete obliteration and clinical cure at 5-month follow-up. Glue penetrated into the Sylvian vein in one patient during the procedure without sequelae. Two patients had transient worsening of ocular symptoms after the procedure.

CONCLUSIONS

Trans-arterial embolisation with low concentration NBCA using a wedged microcatheter technique is still a safe and effective treatment for DCCF when the transvenous approach is not feasible. However, care must be taken to prevent inadvertent arterial and venous embolisation.

Cranial nerve palsy following transvenous embolization for a cavernous sinus dural arteriovenous fistula: association with the volume and location of detachable coils

OBJECT

Transvenous embolization (TVE) for the treatment of a cavernous sinus (CS) dural arteriovenous fistula (DAVF) occasionally causes cranial nerve palsy (CNP). Overpacking of coils is considered to result in CNP. The purpose of this study was to analyze the association of TVE-induced CNP with the volume and location of coils activated in the CS.

METHODS

Thirty-one patients with CS DAVFs (33 lesions) underwent TVE.

RESULTS

Cranial nerve palsy occurred or was aggravated in 13 cases (39.4%; CNP group). The cumulative volume of activated coils was significantly greater in the CNP group (0.241 +/- 0.172 cm3) than in the non-CNP group (0.119 +/- 0.075 cm3; p < 0.05). Of those lesions with > 0.2 cm3 of coil volume, 77.8% showed immediate aggravation or a new occurrence of CNP after TVE. Five lesions treated with a smaller volume of coils showed a delayed worsening or occurrence of CNP. In cases with induced oculomotor nerve palsy, coils had been densely packed in the superolateral part of the anterior CS. Dense packing in the lateral portion of the posterior CS frequently induced abducent nerve palsy. Although patients harboring lesions with a greater coil volume required a longer recovery time, newly developed or aggravated CNP, related to 84.6% of the lesions, resolved completely.

CONCLUSIONS

The cumulative volume and specific locations of coils in the CS correlated with TVE-induced CNP. Overpacking appeared to be the predominant cause of CNP; however, for CNP in cases involving smaller coil volumes, an alternative mechanism may be involved.

Recurrence of the cavernous sinus dural arteriovenous fistula at adjacent sinuses following repeated transvenous embolizations: case report and literature review

We present a unique case of a cavernous sinus (CS) dural arteriovenous fistula (DAVF), which recurred at adjacent sinuses following repeated transvenous embolizations (TVEs). A 68-year-old woman presented with progressive left conjunctival chemosis and diplopia. Cerebral angiography revealed a left CS DAVF, which was completely obliterated by TVE via the left inferior petrosal sinus (IPS). Two years later, the DAVF recurred in the left IPS, and again in the left sigmoid sinus (SS) 3 years after the initial treatment in spite of a second TVE. Moreover, the left SS and the left internal jugular vein, which had been previously stenotic, had been occluded. The third TVE resulted in the complete obliteration of the SS DAVF. CS DAVFs may recur at adjacent sinuses even after complete obliteration by TVE. Careful follow-up is necessary to check for the recurrence of DAVFs, especially in cases with venous flow changes, such as sinus occlusion, following endovascular treatment.

Transvenous treatment of cavernous dural arteriovenous fistulae with onyx and coils

We report on patients with cavernous dural arteriovenous fistulae (CDAVFs) who underwent transvenous embolization via different transvenous approaches with Onyx and coils. Twelve patients presenting with clinically symptomatic CDAVFs who were treated between August 2005 and November 2007 at Beijing Tiantan Hospital were reviewed. The approach routes, angiographic results and clinical outcome were assessed. Retrospective analysis of data for 12 patients (age range 36-75 yrs, mean age 59.3 yrs) with CDAVFs was performed. The CDAVFs were treated with Onyx and coils via different transvenous approaches in 14 procedures. Cerebral angiography was performed to confirm the treatment and diagnosis. The mean clinical follow-up period was 5.5 months. A total of 13 transvenous procedures and one transarterial procedure were performed for 12 CDAVFs. Eleven patients with CDAVFs of the CS were cured with respect to clinical symptoms, and one patient experienced improvement. The approach via the internal jugular vein and inferior petrosal sinus (n=10) was possible, with complete occlusion of the fistula in all cases. With the approach via the facial vein (n=2), there was a good success rate. We encountered no complications in any of the cases. Transvenous treatment of CDAVFs with Onyx and coils can be an effective option for different transvenous approaches.

Embolisation of indirect carotid-cavernous sinus dural arterio-venous fistulae using the direct superior ophthalmic vein approach

Indirect carotid-cavernous sinus dural arterio-venous fistulae (cDAVF) can be treated by transarterial and/or transvenous embolisation. This study evaluated patients with cDAVF who underwent transvenous embolisation using the direct superior ophthalmic vein (SOV) approach. Between January 2004 and October 2006, eight cDAVF in seven patients were embolised using direct surgical exposure of the SOV when access to the cDAVF via transarterial or transfemoral venous routes was not feasible. Medical records and imaging studies were retrospectively reviewed. The seven patients consisted of four females and three males from 43 to 65-year-old (mean age, 54.4 years). Six cDAVF lesions were located on the left side and two on the right. All fistulae were successfully embolised and showed clinical improvement. One patient presented after treatment with transient venous congestion on the brain stem, which was relieved by osmotic diuretics and steroids. Direct surgical exposure of the SOV for transvenous embolisation of cDAVF can be effective if the facial vein, inferior petrosal sinus, and internal jugular vein are thrombosed. This approach is easy, safe, and effective when performed by a multidisciplinary team.

Carotid cavernous fistula in CNS choriocarcinoma

Carotid artery-cavernous sinus fistulas (CCFs) are infrequently reported in the pediatric population, and are rarely reported in conjunction with CNS neoplasms. The authors present a 7-year-old girl with CNS choriocarcinoma who acutely developed left eye proptosis and conjunctival injection. Computed tomography angiography revealed a CCF, which was endovascularly embolized with detachable coils. There may be a direct cause-and-effect relationship between choriocarcinoma and development of CCFs.

Transvenous embolization for dural arteriovenous shunt of the cavernous sinus. Comparison of multi-staged transvenous embolization and transvenous embolization with sinus packing

SUMMARY

We describe the treatment and follow-up clinical symptoms and angiographic results in patients with dural arteriovenous fistula of the cavernous sinus treated by transvenous embolization (TVE). We have treated eight cases of dural arteriovenous fistula of the cavernous sinus by multi-staged TVE in two cases and TVE with sinus packing in six and three of six cases were treated with a combination of transarterial embolization. Multi-staged TVE was performed by occlusion from dangerous drainage veins to the cavernous sinus on several occasions. Angiographical results showed disappearance or reduction of the arteriovenous shunt in all cases. Six patients presented with ophthalmic symptoms and two had tinnitus. Six cases had complete disappearance of clinical symptoms after treatment. There was a deterioration of ocular movement in one patient treated by TVE with sinus packing. Multi-staged TVE was performed to reduce the coil volume for the packing of the cavernous sinus in two cases without cranial nerve palsy. Embolization, especially multi-staged TVE, was considered a good treatment to occlude arteriovenous shunts at the cavernous sinus without cranial nerve complications.

Triple-Catheter Technique in the Transvenous Coil Embolization of an Isolated Sinus Dural Arteriovenous Fistula

Objective:

Dural arteriovenous fistulae involving the transverse-sigmoid sinus, which is occluded at its proximal and distal ends (i.e., an isolated sinus), carry a high risk of intracranial hemorrhage or progressive neurological deficits. Although transvenous coil embolization is a useful and safe treatment for such lesions, it is often difficult to reach into the isolated sinus through the occluded sinus using the percutaneous catheter approach.

Methods:

We report the successful treatment of two patients with transverse-sigmoid dural arteriovenous fistulae with isolated sinus using the percutaneous transvenous triple-catheter technique. A 6-French guiding catheter was placed at the internal jugular vein followed by a second 4-French catheter positioned at the end of the occluded sinus. A third microcatheter was then navigated into the isolated sinus with support of the second catheter.

Results:

Although initial attempts to reach into the isolated sinus without the second catheter failed, insertion of the second catheter resulted in successful navigation of the third microcatheter into the affected sinus in both cases. Complete cure was obtained in both cases by coil packing of the affected sinus.

Conclusion:

Although careful maneuvering is required, this triple-catheter technique is useful for treatment of dural arteriovenous fistulae with isolated sinus.

SURGICAL TREATMENT OF HIGH-RISK INTRACRANIAL DURAL ARTERIOVENOUS FISTULAE

OBJECTIVE

An increasing number of intracranial dural arteriovenous fistulae (DAVFs) are amenable to endovascular treatment. However, a subset of patients with high-risk lesions requires surgical intervention for complete obliteration. We reviewed our experience with the surgical management of high-risk intracranial DAVFs and offer recommendations to minimize complications based on fistula location and type.

METHODS

Hospital records for 53 patients (16 women, 37 men) with high-risk intracranial DAVFs treated surgically between 1995 and 2004 were reviewed to determine their presenting symptoms, location, endovascular and surgical interventions, angiographic outcome, and treatment complications. Most patients (76%) presented with intracranial hemorrhage, progressive neurological deficits, or seizures. All patients had high-risk angiographic features such as cortical venous drainage or venous varix. Preoperative embolization was performed in 27 patients. Surgical approaches were tailored to the lesion location. Fistulae were located in the transverse-sigmoid junction (n = 18), tentorium (n = 17), ethmoid (n = 7), superior sagittal sinus (n = 6), torcula (n = 4), and sphenoparietal sinus (n = 3).

RESULTS

At the time of the last follow-up evaluation, 49 patients (92%) had good or excellent outcomes (Glasgow Outcome Scale score, 4 or 5) and three (6%) were deceased. Five patients had a residual fistula. One residual spontaneously thrombosed, one was treated with gamma knife radiosurgery, and two were successfully embolized. The overall morbidity and mortality rate was 13%.

CONCLUSION

Despite fulminant presenting symptoms, high-risk intracranial DAVFs can be successfully managed with good outcomes. When anatomic features prevent endovascular access, or embolization fails to obliterate the lesion, urgent surgical treatment is indicated. Patients with residual filling of the DAVF should be considered for adjuvant therapy, including further embolization or radiosurgery.

Combined surgical approach with intraoperative endovascular embolization for inaccessible dural arteriovenous fistulas

BACKGROUND

We describe an alternative treatment modality for inaccessible intracranial DAVFs caused by local thrombosis or tortuous feeder vessels. Special consideration is given to the efficacy of intraoperative endovascular embolization and to the use of various operative routes depending on the location of the lesions.

METHODS

Between August 1999 and January 2006, 7 of 65 patients were diagnosed with DAVFs with the limitation of endovascular access. Thus, we adopted a combined surgical approach with intraoperative endovascular embolization. We reviewed and analyzed the patients' medical records and their outcomes.

RESULTS

Depending on tumor location, a surgical approach combined with simultaneous intraoperative endovascular embolization was successfully performed via the SOV, the TS-SS junction, and the SSS. No complication related to the treatment was reported, and, subsequently, all the patients recovered completely.

CONCLUSION

A combined surgical approach with simultaneous intraoperative embolization is an effective and safe treatment for DAVFs that are of limited angiographic access.

External Manual Carotid Compression is Effective in Patients with Cavernous Sinus Dural Arteriovenous Fistulae

SUMMARY

External manual carotid compression is a non-invasive method to treat patients with cavernous sinus dural arteriovenous fistulae (CSDAVF). We studied a group of patients with CSDAVF to identify factors that made cure by compression therapy possible. We treated 23 patients with CS-DAVF without cortical venous drainage or a recent decline in visual acuity by compression therapy. All were followed up by magnetic resonance angiography (MRA) at one, three, six, and 12 months after treatment and the characteristics of the imaging findings, their neurological symptoms, and the patterns of symptom improvement were examined. In group A (n=8), cure was achieved by manual carotid compression; in the other 15 patients (group B), cure was not obtained. Group B manifested significantly higher ocular pressure and a significantly longer interval between symptom onset and treatment by manual carotid compression. In group A, venous drainage was via the superior orbital vein (SOV) with/without involvement of the inferior petrosal sinus (IPS); closure of the CS-DAVF occurred within 4.1 months after the start of treatment. In three patients symptom improvement progressed steadily and gradually. The other five cured patients experienced transient worsening of their symptoms at two to four months after the start of treatment, these resolved within four to seven months. Manual carotid compression was effective in patients without retrograde venous CS-DAVF drainage or a severe decline in visual acuity. The factors that rendered cure by compression therapy possible were lower ocular pressure and a shorter interval between symptom onset and the start of treatment. Venous drainage in those patients was exclusively via the SOV without involvement of the IPS.

Successful treatment of dural AV fistulas by manual compression—a matter of perseverance

A noninvasive treatment of an occipital dural AV fistula by external compression of the carotid artery and jugular vein is documented. The late successful occlusion of the malformation after almost 19 months and a total of 13,216 single manual compressions shows that fistula occlusion can be achieved late and is dependent on careful performance of the maneuver.

[Treatment of carotid-cavernous fistulas]

OBJECTIVES

To evaluate the results of the treatment of 33 patients with carotid-cavernous fistula (CCF) with respect to clinical and angiographic criteria.

MATERIAL AND METHODS

From January 1993 to December 2003, 33 patients were diagnosed with CCF and treated at our hospital. All patients underwent clinical examination and angiography before and after treatment. Available treatment modalities were conservative treatment, consisting of compressions, and interventional treatment, with different procedures depending on the approach and the materials employed for embolization.

RESULTS

Of the 11 direct CCFs, one received conservative treatment and 10 underwent embolization procedures. An arterial approach was used in 5 cases, a venous approach in 2, and a combined venous-arterial approach in the remaining 3, with symptoms disappearing in 90% of the patients. Of the 22 indirect or dural CCFs, 6 received conservative treatment, with optimal results, and the remaining 16 underwent embolization (11 using an arterial approach and 5 using a combined venous-arterial approach). Endovascular treatment brought about the complete disappearance of symptoms in 9 patients and partial disappearance in 7. Only one transitory complication was observed.

CONCLUSIONS

The appropriate selection of both the type of treatment (conservative vs. interventional) and the interventional procedure (approach and material for embolization), yields optimal results in the management of patients with CCF.

Transvenous treatment of cranial dural arteriovenous fistulas with hydrogel coated coils

SUMMARY

Intracranial dural arteriovenous fistulas (DAVF) with cortical venous reflux may become symptomatic due to venous congestion or intracranial hemorrhage. Venous congestion in the orbit can also occur resulting in proptosis, chemosis, double vision and progressive visual loss. The transvenous approach has been used for selective disconnection of the venous drainage to eliminate the venous congestion and future risk of intracranial bleeding and/or neurological deficit. Hydrogel coated coils (Hydro- Coil(R)) expand after contact with blood causing the coils to swell up to five to 11 times a standard 10-system bare platinum coil. Due to this property, HydroCoils could have an advantage over platinum coils in the transvenous approach to embolization of DAVFs. Ten patients with symptomatic cranial DAVF underwent a transvenous embolization using HydroCoils as the only embolic agent or in a combination with bare platinum coils. The patients' characteristics, symptoms, angioarchitecture of the DAVF, treatment, complications and results were analyzed. All the treated DAVFs were disconnected at the end of the procedure. All the patients with orbital symptoms had complete or significant improvement. There were no periprocedural complications. Nine patients had radiological follow-up showing cure. HydroCoils can be used effectively and safely to treat intracranial DAVFs transvenously. The volume expansion of Hydrocoils may have significant advantage over bare platinum coils given the large venous spaces that need to be filled. The use of HydroCoils may decrease the procedure time and consequently reduce the radiation dose to the patient.

Transvenous embolization of a dural carotid-cavernous fistula through the contralateral superior petrosal sinus

We report a patient with progressive ophthalmological problems related to a dural carotid-cavernous fistula who was successfully treated endovascularly. Cavernous sinus catheterization was achieved through the contralateral superior petrosal sinus, permitting occlusion of the fistula without complications.

Intraconal superior ophthalmic vein embolisation for carotid cavernous fistula

A 53-year-old man presented with a longstanding carotid cavernous fistula that could not be embolised completely via the femoral route. A superior ophthalmic vein approach was necessary; however, the vein was thrombosed anteriorly and only intraconal cannulation was possible. The vein was accessed via a superior lid crease approach and the fistula successfully embolised. Whilst utilising the superior ophthalmic vein is well described in the literature, to our knowledge, needing to access the intraconal portion of the vein has not previously been reported.

Benefits and limitations of image guidance in the surgical treatment of intracranial dural arteriovenous fistulas

BACKGROUND

Despite major advances in endovascular embolization techniques, microsurgical resection remains a reliable and effective treatment modality for dural arteriovenous fistulas (DAVF). However, intraoperative detection of these lesions and identification of feeding arteries and draining veins can be challenging. In a series of 6 patients who were not candidates for definitive treatment by endovascular embolization we evaluated the benefits and limitations of computer-assisted image guidance for surgical ablation of DAVF.

METHODS

Of the 6 patients, 5 presented with haemorrhage and one with seizures. Diagnosis of DAVF was made by conventional angiography and dynamic contrast enhanced MR angiography (CE-MRA). All patients were surgically treated with the assistance of a 3D high resolution T1-weighted MR data set and time-of-flight MR angiography (MRA) obtained for neuronavigation. Registration was based on cranial fiducials and image-guided surgery was performed with the navigation system.

FINDINGS

Four of the 6 patients suffered from DAVF draining into the superior sagittal sinus, one fistula drained into paracavernous veins adjacent to the superior petrosal sinus and one patient had a pial fistula draining in the straight sinus. DAVF diagnosed with conventional angiography could be located on CE-MRA and MRA prior to surgery. MRI and MRA images were combined on the neuronavigation workstation and DAVF were located intraoperatively by using a tracking device. In 4 out of 6 cases neuronavigation was used for direct intraoperative identification of DAVF. Brain shift prevented direct tracking of pathological vessels in the other 2 cases, where navigation could only be used to assist craniotomy. Microsurgical dissection and coagulation of the fistulas led to complete cure in all patients as confirmed by angiography.

CONCLUSIONS

Neuronavigation may be used as an additional tool for microsurgical treatment of DAVF. However, in this small series of 6 cases, surgical procedures have not been substantially altered by the use of the neuronavigation system. Image guidance has been beneficial for the location of small, superficially located DAVF, whereas a navigated approach to deep-seated lesions was less accurate due to the familiar problem of brain shift and brain retraction during surgery.

Vascular Lesions of the Skull Base: Endovascular Prospective for the Otolaryngologist

With continual advances being made in endovascular equipment and techniques, the role that these image-guided, minimally invasive therapies play in the multidisciplinary management of vascular lesions of the skull base will probably continue to expand. The introduction of emerging technologies, including the development and implementation of implantable bioactive devices such as drug-eluting stents, bioactive embolic coils, and bioactive particulate embolic materials, will provide an increasing array of options for these patients. This article has reviewed the basic concepts of embolization and revascularization for vascular lesions of the skull base encountered by the practicing otolaryngologist. These concepts can provide a framework for collaboration between the otolaryngologist and neuroendovascular operator in a cooperative approach to these patients. The importance of detailed knowledge of the vascular anatomy of the skull base when dealing with these lesions, the concept of dangerous anastomoses, several clinically useful classification schemes for these lesions, and basic endovascular techniques of embolization and revascularization have been highlighted.

Therapeutic advances in interventional neurology

Rapid advances in the field of interventional neurology and the development of minimally invasive techniques have resulted in a great expansion of potential therapeutic applications. We discuss therapeutic interventional neurology as applied in clinical practice in one of the two possible ways: 1) embolization leading to occlusion of blood vessels; and 2) revascularization leading to reopening of blood vessels. These procedures can be applied to a broad range of cerebrovascular diseases. In the first section of this review, we will explore the evolution of these interventions to occlude aneurysms, arteriovenous malformations, neurovascular tumors, and injuries. In the second section, revascularization in acute ischemic stroke, stenosis, and dural venous thrombosis will be discussed.

Plasma vascular endothelial growth factor and serum soluble angiopoietin receptor sTIE-2 in patients with dural arteriovenous fistulas: a pilot study

Our aim was to correlate concentrations of circulating vascular endothelial growth factor (VEGF) and serum soluble angiopoietin receptor (sTIE-2) before and after endovascular treatment with the grading in human dural arteriovenous fistulas (DAVFs). In ten patients with DAVFs undergoing diagnostic cerebral angiography and endovascular intervention, pre-treatment and post-treatment levels of plasma VEGF and serum TIE-2 were examined in a prospective study design. A total of 32 plasma samples and 19 serum samples was collected from the cubital vein, the arterial sheath before and--if applicable--after intervention. Plasma VEGF and serum Tie-2 levels were measured by standardized ELISA protocols. In eight of ten patients with DAVF increased circulating VEGF levels (elevation of more than mean + 2 SD of published normal values) were found, whereas two patients showed increased sTIE-2 levels. Six of the seven patients treated by endovascular embolization displayed a post-interventional decrease of VEGF values. The serum TIE-2 levels decreased slightly after intervention. Pre-treatment vVEGF levels varied significantly between patients with grades I and II/III fistulas according to the Cognards classification system. Our pilot study suggests that assessment of angiogenesis parameters in patients with DAVFs might correlate with the DAVFs' grade. To support the hypothesis that a change in angiogenic indicators may serve as indicators for a response to therapy, a larger number of patients should be followed for a longer time period.