Reconstructive treatment of dural arteriovenous fistulas of the transverse and sigmoid sinus: transvenous angioplasty and stent deployment

Transverse-Sigmoid Sinus Dural Arteriovenous Fistula Concurrent With Bilateral Venous Sinus Occlusion

BACKGROUND AND SIGNIFICANCE

Dural arteriovenous fistula (DAVF) is a relatively rare type of cerebrovascular malformation with unknown pathogenesis. Here, the authors report a patient with DAVF in the left transverse-sigmoid sinus (Cognard type III) combined with occlusions of the left sigmoid sinus and right transverse sinus. The authors describe and discuss their successful treatment approach, with the aim to improve the management of this rare disorder.

CASE PRESENTATION

A 59-year-old man presented with dizziness, headache, vomiting, and unsteady gait. His digital subtraction angiography evaluation indicated DAVF in the left transverse-sigmoid sinus (Cognard type III) combined with occlusions of the distal 1/3 of the left sigmoid sinus and the proximal one-third of the right transverse sinus. After balloon angioplasty and stenting, blood flow was restored in the occluded sinuses. The DAVF was treated by embolization. The patient had a satisfactory recovery with significantly improved clinical symptoms.

CONCLUSION

In patients with transverse-sigmoid sinus DAVF, satisfactory venous reflux should be ensured. In patients with concurrent DAVF and sinus stenosis or occlusion, it is important to reestablish antegrade venous blood flow first. It is feasible and safe to simultaneously embolize DAVF after the venous reflux can be reestablished.

Clinical outcomes of adjunct sinus stenting in dural arteriovenous fistulas : Role of flow restoration in steno-occlusion and cortical venous reflux

PURPOSE

This study investigated the clinical outcomes and follow-up results of venous sinus stenting (VSS) for constrictive dural sinus restoration in patients with intracranial dural arteriovenous fistulas (DAVFs). We hypothesized that this treatment would have durable benefits in such patients.

METHODS

Patients who underwent VSS for DAVFs with cortical venous reflux between January 2008 and June 2020 were identified after a retrospective review (n =18). Clinical and endovascular treatment data and follow-up information were reviewed.

RESULTS

The mean age of the 18 patients was 59.9 years. Stents were implanted in 10 previously occluded sinuses and 9 stenotic sinuses in addition to endovascular embolization. One patient received bilateral VSS. Subdural hemorrhage occurred in one patient after recanalization for embolization, followed by uneventful stenting. In 17 patients with clinical follow-up, the median follow-up time was 59.5 months (interquartile range 18 to 84 months). Of these, sixteen patients had follow-up vascular imaging, revealing AVF obliteration in 6 patients (38%) and stent patency in 11 (69%). Retreatment was performed for 8 (50%) patients. The mean follow-up modified Rankin scale score was 1.28. All patients had longstanding symptomatic improvement.

CONCLUSION

Restoration of sinus flow in DAVFs with cortical venous reflux through VSS has an acceptable complication rate and long-term symptomatic control; however, retreatment is often required, and stent occlusion is not uncommon.

Venous sinus stenting for intractable pulsatile tinnitus: A review of indications and outcomes

Background:

Pulsatile tinnitus presents as a unique variation of tinnitus in which a conscious perception of the heartbeat is localized to the ears in either unilateral or bilateral fashion. The sensation is typically caused by an increase in turbulent blood flow in the affected ear, in most cases, due to a structural abnormality of the venous sinuses – the most common of which being stenosis. Herein, we discuss the etiology of pulsatile tinnitus followed by indications for treatment of various pathologies which have been successfully treated with venous sinus stenting and have led to resolution of auditory symptoms.

Methods:

The authors queried PubMed database using combinations of the keywords “venous sinus stenting,” “endovascular treatment,” and “pulsatile tinnitus” to identify relevant studies published in English after 2001 and before December 1, 2020 and verified selected.

Results:

Our results corroborate those published in prior reviews reporting a high rate of pulsatile tinnitus resolution with venous sinus stenting.

Conclusion:

The success of venous sinus stenting is clinically relevant as an effective treatment option for patients suffering from pulsatile tinnitus. Future applications and studies are needed and are currently being developed to further demonstrate the effectiveness of stents in the treatment of pulsatile tinnitus.

Endovascular Treatment of Intracranial Dural Arteriovenous Fistulas: A German Single-Center Experience

Background and Purpose

Intracranial dural arteriovenous fistulas (DAVFs) are abnormal shunts between dural arteries and dural venous sinus or cortical veins. We report our experience with endovascular therapy of primary complex DAVFs using modern embolic agents.

Methods

This is a retrospective analysis of patients with DAVFs treated between 2015 and 2019. Patient demographics and technical aspects including the use of embolic agent, access to the fistula, number of treatments, occlusion rates, and complications were addressed. Angiographic treatment success was defined as complete occlusion (CO) of the DAVF.

Results

Fifty patients were treated endovascularly. Median age was 61 years and 66% were men. The most common symptom was pulsatile tinnitus in 17 patients (34%). The most frequent location of the DAVF was the transverse-sigmoid sinus (40%). Thirty-six fistulas (72%) had cortical venous reflux. Nonadhesive and adhesive liquid agents were used in 92% as a single material or in combination. CO was achieved in 48 patients (96%). In 28 individuals (56%), only 1 procedure was necessary. Nonadhesive liquid agents were exclusively used in 14 patients (28%) with CO attained in every case. For CO of tentorial DAVFs, multiple sessions were more often required than at the other locations (55 vs. 14%, p = 0.0051). Among 93 procedures, the overall complication rate was 3%. The procedure-related mortality rate was 0%.

Conclusion

Endovascular treatment of intracranial DAVFs is feasible, safe, and effective with high rates of CO. In more than half of the patients, the DAVF was completely occluded after a single procedure. However, in tentorial DAVFs, multiple sessions were more often required.

Current status of endovascular treatment for dural arteriovenous fistula of the transverse-sigmoid sinus: A literature review

Most intracranial dural arteriovenous fistulae (DAVFs) involve the transverse-sigmoid sinus (TSS), and various types of endovascular treatment (EVT) have been involved in managing TSS DAVFs. A current, comprehensive review of the EVT of TSS DAVFs is lacking. This study used the PubMed database to perform a literature review on TSS DAVFs to increase the current understanding of this condition. For high-grade TSS DAVFs such as Borden type 3, the goal of EVT is curative treatment. However, for low-grade TSS DAVFs such as Borden type 1 and some Borden type 2 TSS DAVFs, symptom relief or elimination of cortical reflux may be sufficient. Currently, EVT has become the first-line treatment for TSS DAVFs, including transarterial embolization (TAE), transvenous embolization (TVE) or both. TAE alone and TSS balloon-assisted TAE are also commonly used. However, TVE for TSS DAVFs is recognized as the most effective treatment, including coil direct packing TSS, Onyx® (ethylene vinyl alcohol copolymer) TVE, and balloon-assisted Onyx® TVE, which are commonly applied. In addition, TSS reconstructive treatment can be an effective procedure to treat TSS DAVFs. EVT is accompanied with complications, including technique- and treatment-related complications. Although complications may occur, TSS DAVFs have an acceptable prognosis after EVT.

Endovascular Treatment of Transverse-Sigmoid Sinus Dural Arteriovenous Fistulas: A Single-Center Experience with Long-Term Follow-Up

BACKGROUND

Endovascular treatment of transverse-sigmoid sinus dural arteriovenous fistulas (TSDAVFs) remains challenging because of their complex anatomic factors. The aim of our study was to evaluate the long-term efficacy and safety of endovascular treatment of TSDAVFs.

METHODS

From January 2008 to December 2014, 44 patients with TSDAVFs were treated endovascularly at our institution. The clinical and angiographic data were retrospectively collected, and the occlusion rate, complications, and clinical outcomes were analyzed.

RESULTS

Overall, 44 patients (26 males and 18 females) were identified, with a mean age of 47 years (range, 13-68 years). Of the 44 patients, 5 presented with Cognard type I fistula, 12 with type IIa, 6 with type IIb, 13 with type IIa+IIb, 2 with type III, and 6 with type IV. Complete (n = 29) or near-complete (n = 7) occlusion of the fistula was achieved in 36 patients (82%). Two patients experienced a transient neurological deficit (cranial nerve VII). In 31 patients with angiographic follow-up (range, 2-40 months) data available, the occlusion remained in 25, 2 previously minimal residual fistulas were completely occluded, 3 residual fistulas were unchanged, and 1 fistula recurred. Two patients with cortical venous reflux who had received incomplete treatment died of intracranial hemorrhage during the follow-up period. Of the 37 patients with clinical follow-up (mean, 33.6 months) data available, clinical cure was achieved in 29, residual symptoms remained unchanged in 7, and symptoms had deteriorated in 1.

CONCLUSIONS

Favorable and durable outcomes were achieved with endovascular treatment of TSDAVFs. TSDAVFs with cortical venous reflux carry a high risk of hemorrhage and require curative treatment.

High-Grade Dural Arteriovenous Fistulas : Use of Kaneka ED Coils with the Marathon Microcatheter for Transvenous Coil Embolization

BACKGROUND

Dural arteriovenous fistulas (DAVF) are commonly encountered lesions that can be treated both transvenously, transarterially or using a combined approach.

OBJECTIVE

Transvenous coil embolization of DAVF is a recognized treatment option but can be challenging. In this context this article presents clinical experience using the Kaneka ED10 ExtraSoft coils in combination with the Marathon microcatheter to treat high grade DAVF. The physical properties of these coils and the microcatheter were also determined.

MATERIAL AND METHODS

All patients with high grade DAVF treated with the Marathon and the Kaneka ED COIL ∞10 ExtraSoft coils were retrospectively identified. The clinical presentation, location, grade of the lesion, clinical and radiological follow-up data were recorded. Bench side studies were performed to determine the physical properties of the Marathon catheter in comparison to the SL10 and Headway Duo as well the maximum width of the Kaneka pusher wire in comparison to Hypersoft, Target and Axium Prime coils.

RESULTS

A total of 8 patients with 9 DAVF with 3 Cognard 3 and 6 Cognard 4 lesions were identified. All the DAVF's were occluded either at the end of the procedure or on follow-up imaging. On bench side tests the Marathon microcatheter had the most flexible distal tip and distal shaft in comparison to the SL10 and Headway Duo. The proximal shaft of the Marathon was stiffer than the SL10. The Kaneka ED COIL ∞10 ExtraSoft had the smallest distal width and were the only coils tested that could be deployed through a Marathon microcatheter.

CONCLUSION

The combination of the Marathon microcatheter and Kaneka ED COIL ∞10 ExtraSoft is useful for the treatment of high grade DAVF.

Endovascular Recanalization of Occluded Dural Sinus in Patient with Dural Arteriovenous Fistulas: Case Report and Literature Review

BACKGROUND

Symptomatic sinus occlusion complicated with dural arteriovenous fistulas (dAVFs) can be treated successfully endovascularly. However, no studies have reported the use of endovascular transvenous approaches alone to recanalize the occluded sinuses for treatment of the involved dAVFs without stent deployment. In this study, we presented a 75-year-old man with occlusion of the transverse and sigmoid sinuses complicated with a dAVF.

CASE DESCRIPTION

This patient initially suffered intermittent headache, nausea, and vomiting but developed seizures and hemiplegic paralysis 2 months later. Neurologic examination revealed mildly decreased motor function in grade IV in the left limb. Intracranial pressure by lumbar puncture was 300 mm H₂O. Magnetic resonance imaging venography disclosed sinus occlusion and dAVFs accounting for encephaledema. Cerebral angiography revealed occlusion of the left transverse and sigmoid sinuses and cortical reflux with the sinus junction unobstructed. The feeding arteries of the left transverse sinus dAVFs were muscular branches of the left vertebral artery and external carotid artery, and the draining vein was from the superior sagittal sinus to the contralateral transverse sinus. Balloon angioplasty plus mechanical cracking (pulling a microcatheter back and forth) was used to recanalize the occluded sinuses. The symptoms disappeared after endovascular recanalization of the occluded left transverse sinus and sigmoid sinuses, and follow-up venography revealed opened sinuses with complete disappearance of the dAVF.

CONCLUSION

Endovascular transvenous recanalization may be a better alternative therapy for selected patients with dural arteriovenous fistulas complicated by sinus occlusion without stent deployment.

PTA Stent of Dural Sinuses in Brain DAVF : A Report of 4 Cases

BACKGROUND AND PURPOSE

Type I and IIa dural arteriovenous fistulas (DAVFs) have a low hemorrhagic risk, but are often the cause of debilitating tinnitus that requires treatment. While Onyx® and PHIL™ (Precipitating hydrophobic injectable liquid) transarterial embolization represent the first endovascular option, there are occasional cases where performing angioplasty and stenting of the affected sinus may lead to satisfactory results.

MATERIAL AND METHODS

We retrospectively analyzed four consecutive cases of patients with DAVF-induced pulsatile tinnitus secondary to type I and II DAVFs who were treated with angioplasty and stenting of the sinus only. All the patients had clinical and radiological long-term follow-up.

RESULTS

We noticed a significant radiological and clinical improvement in all the cases. Of the patients two were completely cured at follow-up with eradication of the neurological symptoms as well as the fistula, one was retreated with Onyx® for a very small residual shunt despite having no more tinnitus, and one showed improvement in venous drainage (from type IIa+b to type I fistula) without resolution of the fistula.

CONCLUSION

In cases of type I and II DAVFs associated with sinus stenosis, angioplasty and stenting alone seem to be safe and effective. This treatment probably compresses the venules within the sinus walls, promoting thrombosis of the shunts thus solving the underlying cause of the fistula.

An Onyx tunnel: reconstructive transvenous balloon-assisted Onyx embolization for dural arteriovenous fistula of the transverse-sigmoid sinus

Transvenous embolization is an effective method for treating dural arteriovenous fistulas (DAVFs) of the transverse-sigmoid sinus (TSS). However, in cases of complicated DAVFs, it is difficult to preserve the patency of the dural sinus. The authors describe the technical details of a new reconstructive technique using transvenous balloon-assisted Onyx embolization as another treatment option in a patient with an extensive and complex DAVF of the left TSS. A microcatheter and compliant balloon catheter were navigated into the left internal jugular vein and placed at the distal end of the DAVF in the transverse sinus. The microcatheter was placed between the vessel wall of the TSS and the balloon. After the balloon was fully inflated, Onyx-18 was injected at the periphery of the balloon in a slow, controlled, progressive, stepwise manner; the balloon and microcatheter were simultaneously withdrawn toward the sigmoid sinus, with Onyx encompassing the entirety of the complex DAVF. The Onyx refluxed into multiple arterial feeders in a distal-to-proximal step-by-step manner, ultimately resulting in an Onyx tunnel. The final angiography study revealed complete obliteration of the DAVF and patency of the TSS. The Onyx tunnel, or reconstructive transvenous balloon-assisted Onyx embolization technique, may be an effective treatment option for large, complex DAVFs of the TSS. This technique may provide another option to facilitate the complete obliteration of the DAVF while preserving the functional sinus.

Quantifying the Cerebral Hemodynamics of Dural Arteriovenous Fistula in Transverse Sigmoid Sinus Complicated by Sinus Stenosis: A Retrospective Cohort Study

BACKGROUND AND PURPOSE

Sinus stenosis occasionally occurs in dural arteriovenous fistulas. Sinus stenosis impedes venous outflow and aggravates intracranial hypertension by reversing cortical venous drainage. This study aimed to analyze the likelihood of sinus stenosis and its impact on cerebral hemodynamics of various types of dural arteriovenous fistulas.

MATERIALS AND METHODS

Forty-three cases of dural arteriovenous fistula in the transverse-sigmoid sinus were reviewed and divided into 3 groups: Cognard type I, type IIa, and types with cortical venous drainage. Sinus stenosis and the double peak sign (occurrence of 2 peaks in the time-density curve of the ipsilateral drainage of the internal jugular vein) in dural arteriovenous fistula were evaluated. "TTP" was defined as the time at which a selected angiographic point reached maximum concentration. TTP of the vein of Labbé, TTP of the ipsilateral normal transverse sinus, trans-fistula time, and trans-stenotic time were compared across the 3 groups.

RESULTS

Thirty-six percent of type I, 100% of type IIa, and 84% of types with cortical venous drainage had sinus stenosis. All sinus stenosis cases demonstrated loss of the double peak sign that occurs in dural arteriovenous fistula. Trans-fistula time (2.09 seconds) and trans-stenotic time (0.67 seconds) in types with cortical venous drainage were the most prolonged, followed by those in type IIa and type I. TTP of the vein of Labbé was significantly shorter in types with cortical venous drainage. Six patients with types with cortical venous drainage underwent venoplasty and stent placement, and 4 were downgraded to type IIa.

CONCLUSIONS

Sinus stenosis indicated dysfunction of venous drainage and is more often encountered in dural arteriovenous fistula with more aggressive types. Venoplasty ameliorates cortical venous drainage in dural arteriovenous fistulas and serves as a bridge treatment to stereotactic radiosurgery in most cases.

Diagnosis and management of intracranial dural arteriovenous fistulas

Dural arteriovenous fistula (DAVF) is a rare type of acquired intracranial vascular malformation. Recent progress in neuroimaging technology, such as advanced MRI and CT, provides non-invasive methods to accurately diagnose DAVF, including evaluation of the hemodynamics of the drainage veins. The clinical manifestations of DAVFs vary widely and depend on the location and venous drainage pattern of arteriovenous shunting. Patients with high grade DAVFs having cortical venous reflux should receive aggressive treatment to prevent the occurrence of intracranial hemorrhage and other neurological deficits related to venous congestion. Intra-arterial or intravenous endovascular embolization remains the primary therapy for high grade DAVF, while open surgery and stereotactic radiosurgery can serve as alternative treatment options. Early and accurate diagnosis with appropriate treatment is the goal for clinical management of DAVFs to reduce symptoms and prevent the development of venous congestion and stroke.

Quantitative Magnetic Resonance Venography is Correlated With Intravenous Pressures Before and After Venous Sinus Stenting: Implications for Treatment and Monitoring

BACKGROUND

Endovascular stenting is an effective treatment for patients with clinically significant cerebral venous sinus stenosis. Traditionally, stenting is indicated in elevated intravenous pressures on conventional venography; however, noninvasive monitoring is more desirable. Quantitative magnetic resonance angiography is an imaging modality that measures blood flow noninvasively. Established in the arterial system, applications to the venous sinuses have been limited.

OBJECTIVE

To examine quantitative magnetic resonance venography (qMRV) in the measurement of venous sinus flow in patients undergoing endovascular stenting and to identify a relationship with intravenous pressures.

METHODS

Five patients with intracranial hypertension secondary to venous sinus stenosis underwent cerebral venous stenting between 2009 and 2013 at a single institution. Preoperatively, venous sinus flow was determined by using qMRV, and intravenous pressure was measured during venography. After stenting, intravenous pressure, qMRV flow, and clinical outcomes were assessed and compared.

RESULTS

A mean prestenotic intravenous pressure of 45.2 mm Hg was recorded before stenting, which decreased to 27.4 mm Hg afterward (Wilcoxon signed rank test P = .04). Total jugular outflow on qMRV increased by 260.2 mL/min. Analysis of the change in intravenous pressure and qMRV flow identified a linear relationship (Pearson correlation r = 0.926). All patients displayed visual improvement at 6 weeks.

CONCLUSION

Venous outflow by qMRV increases after endovascular stenting and correlates with significantly improved intravenous pressures. These findings introduce qMRV as a potential adjunct to measure venous flow after stenting, and as a plausible tool in the selection and postoperative surveillance of the patient who has cerebral venous sinus stenosis.

Successful sinus restoration for transverse-sigmoid sinus dural arteriovenous fistula complicated by multiple venous sinus occlusions: The usefulness of preoperative computed tomography venography

BACKGROUND

Although sinus restoration for transverse-sigmoid sinus (TSS) dural arteriovenous fistula (DAVF) has rarely been reported over the past decade, its advantage and indication still remain unclear. Herein, we discuss the indications and technical aspects of this therapy with a review of the literature.

CASE DESCRIPTION

A 79-year-old female was referred to our department with generalized convulsion. An angiogram revealed a DAVF at the junction of the right TSS. The right sigmoid and left transverse sinuses were occluded, which resulted in remarkable leptomeningeal venous reflux and cerebral venous congestion. A preoperative computed tomography (CT) venogram precisely revealed the occluded segment of the right sigmoid sinus, which facilitated the sinus restoration with balloon percutaneous transluminal angioplasty and stenting.

CONCLUSION

Sinus restoration is preferable in patients with severe cerebral venous congestion due to multiple sinus occlusions and/or a restricted collateral venous outlet. CT venography is useful for precise evaluation of the length and configuration of the occluded segment, which thus make it possible to evaluate the feasibility of stenting.

Torcular dural arteriovenous fistula treated via stent placement and angioplasty in the affected straight and transverse sinuses: case report

The successful obliteration of torcular dural arteriovenous fistula (DAVF) with a diffuse shunt in the affected sinus may require complex treatment strategies. Therapeutic goals include the preservation of normal venous drainage and complete obliteration of shunt flow. The authors report the case of a torcular DAVF. The treatment of this type of AVF may require a combined approach with transarterial and transvenous embolization, open surgery, or radiosurgery and is associated with many problems. Stent placement and angioplasty in the affected sinus result in compression of the fistulous dural wall of the sinus and decrease shunt flow. In cases in which there is a diffuse shunt in the affected sinus and no evident shunt point, such as in AVFs involving venous pouches and parasinuses, sealing the fistula orifice with self-expandable stents and angioplasty (balloon inflation) is considered the best treatment option to preserve normal cerebral venous sinus drainage and obliterate shunt flow. In such cases, the authors recommend using one or more self-expandable and closed-cell stents and using angioplasty to avoid endoleakage into the gap between the stent graft and the vessel wall.

Current Status of the Application of Intracranial Venous Sinus Stenting

The intracranial venous sinus is an important component of vascular disease. Many diseases involve the venous sinus and are accompanied by venous sinus stenosis (VSS), which leads to increased venous pressure and high intracranial pressure. Recent research has focused on stenting as a treatment for VSS related to these diseases. However, a systematic understanding of venous sinus stenting (VS-Stenting) is lacking. Herein, the literature on idiopathic intracranial hypertension (IIH), venous pulsatile tinnitus, sinus thrombosis, high draining venous pressure in dural arteriovenous fistula (AVF) and arteriovenous malformation (AVM), and tumor-caused VSS was reviewed and analyzed to summarize experiences with VS-Stenting as a treatment. The literature review showed that satisfactory therapeutic effects can be achieved through stent angioplasty. Thus, the present study suggests that selective stent release in the venous sinus can effectively treat these diseases and provide new possibilities for treating intracranial vascular disease.

Superior sagittal sinus dural arteriovenous fistulas treated by stent placement for an occluded sinus and transarterial embolization. A case report

We describe a case of dural arteriovenous fistulas (DAVFs) involving the superior sagittal sinus (SSS) successfully treated with stent placement for an occluded sinus and transarterial embolization. A 61-year-old man who had been treated with anticoagulation for a known SSS thrombosis presented with a sudden onset of headache. CT scan revealed an intraventricular hemorrhage and cerebral angiography revealed DAVFs involving the SSS which had severe venous congestion and sinus occlusion. We treated this case with a staged endovascular approach which consisted of stent placement for the occluded sinus and transarterial intravenous embolization resulting in complete eradication of DAVFs. Recanalization of an occluded sinus by stent placement can reduce venous congestion and transarterial intravenous embolization can obliterate dural arteriovenous shunts. This staged strategy is feasible and should be considered a first option of treatment, especially for DAVFs which presented with intracranial hemorrhage and aggressive venous hypertension.

Cavernous redirection of venous drainage after partial transvenous coil occlusion of a sigmoid sinus dAVF: coil mass retrieval with flexible cysto-urethroscopy grasping forceps. a technical note

We describe the case of a patient who presented with ocular symptoms (chemosis, proptosis, increased intra-ocular pressure, impaired visual acuity) eight months after the transvenous coil occlusion of an ipsilateral sigmoid sinus dural arteriovenous fistula (dAVF). Digital substraction angiography revealed a partial occlusion of the left sigmoid sinus with coils. Since the connection from the sigmoid sinus to the internal jugular vein was obliterated by coils without interrupting the arteriovenous shunt, the venous drainage was redirected into the inferior petrosal sinus, the cavernous sinus and the superior ophthalmic vein. The transjugular access to the inferior petrosal sinus was obstructed by a large coil mass in the jugular bulb. Several attempts to remove these coils with an Alligator retrieval device and a goose neck snare failed. The coil mass was withdrawn via a direct access to the internal jugular vein using flexible cysto-urethroscopy grasping forceps, an urological device designed for the removal of kidney stones. After establishing anterograde drainage, the now accessible inferior petrosal sinus was occluded with fibered coils and the dAVF was completely obliterated. The ocular symptoms resolved within ten days.

Multimodality treatment of intracranial dural arteriovenous fistulas in the Onyx era: a single center experience

BACKGROUND

The results of treatment of intracranial dural arteriovenous fistulas (DAVFs) since Onyx became available as an embolic agent at our institution is reported. An algorithm is presented for treatment of DAVFs with Onyx, and the role of endovascular transvenous, surgical, and radiosurgical approaches are presented.

METHODS

Thirty-two patients with DAVFs treated between November 2005 and November 2008 by endovascular embolization, surgery, or radiosurgery were identified by a retrospective chart review. Treatment strategies were based on the location or complexity of the fistula and the patient's clinical status. Data collected included DAVF characteristics, obliteration rates, complications, and outcomes. The results were analyzed and correlated with the treatment modality.

RESULTS

Presenting symptoms were as follows: hemorrhage (n = 12 patients), headaches (n = 12), tinnitus (n = 5), orbital symptoms (n = 7), and seizures (n = 1). Thirty patients were treated by endovascular embolization (transarterial only with Onyx-21, transvenous only with platinum coils-6, transarterial [Onyx] and transvenous [coils]-3). Five patients (4 after incomplete/failed embolization) had surgical excision of the fistula. Three patients were treated with Gamma Knife radiosurgery (primary-1, 2 after incomplete/failed embolization). The locations of the fistulas were transverse sigmoid (10 patients), petrotentorial (7 patients), indirect carotid cavernous fistula (7 patients), parasagittal/falcine (3 patients), middle fossa dura (3 patients), torcula (1 patient), and anterior fossa dura (1 patient). The distribution of patients according to Borden classification was I-6, II-13, and III-13. Complete obliteration of the fistula was achieved in 26/32 (81%) patients after multimodal treatment. All surgical cases had complete obliteration. In the high-risk group with cortical venous reflux, 23/26 (89%) patients were cured. Endovascular complications included a stuck microcatheter tip with fracture of the tip in two patients and cranial nerves V and VII palsies in one patient. At last follow-up (range 1-36 months), 24 patients had modified Rankin score of 0-2, 5 patients had modified Rankin score of 3-5, and 3 patients were dead. Two patients died during admission due to the insult of the hemorrhage, and one died after an accidental fall with subsequent traumatic subdural hematoma.

CONCLUSIONS

Multimodality treatment of DAVFs has high success rates for cure at our center. Transarterial embolization with Onyx has become the primary treatment for intracranial DAVFs at our center and is associated with high safety profile and efficacy. Transvenous coil embolization is still preferred in DAVFs with supply from arterial branches supplying cranial nerves, predominant internal carotid artery feeders and potential extracranial-intracranial collateral anastomosis. In our series, patients with incompletely treated DAVFs were treated with surgery and those with partially treated type I fistulas had radiosurgery for palliation.

Tentorial dural fistula with giant venous ampulae treated with embolisation and surgery. A case report

Tentorial dural arteriovenous fistulas are rare and complex lesions in deep locations with unusual vascular anatomy and critical surrounding neuroanatomy. A rare case presenting a complex fistula with a giant venous draining ampulae, causing headaches and visual troubles is presented. We describe the case of a 52-year-old woman admitted in our department for headaches and visual troubles. Magnetic resonance imaging and cerebral angiography showed a tentorial dural arteriovenous fistula draining in a giant tentorial venous ampulae and leptomeningeal veins. The patient was embolised via an arterial route with a good clinical and radiological result. However, 4 days later she presented a sudden change of her clinical status with coma, left hemiparesis and a right midriasis. The cerebral computed tomography scan showed a huge occipital haemorrhagic mass and a severe cerebral oedema. An emergent surgical procedure was decided realising evacuation of the occipital haematoma and a complete resection of the giant venous ampoule. The neck of the ampulae was sutured and clipped at its dural entrance. Postoperatively a new embolisation was realised because of persistent of a small dural fistulae with occipital leptomeningeal drainage. The patient recovered rapidly with only a residual hemianopsy. Treatment of dural AV malformation represent a serious challenge. Our report describes an unusual case of a tentorial dural complex fistula treated by an endovascular procedure with secondary clinical aggravation that needed emergent surgical therapy. Even in a case for good immediate radiological result after endovascular procedure, dural arteriovenous fistulas with giant venous ampulae and important venous engorgement, need closed follow-up, because of the possibility of aggravation secondary to venous thrombosis and haemorrhage. Treatment and patophysiology of the aggravation mechanism are discussed.

Transverse-sigmoid sinus dural arteriovenous fistulae

Transverse-sigmoid sinus dural arteriovenous fistulae are abnormal arteriovenous communications within the dural wall of the transverse-sigmoid sinuses. They present with a variety of clinical features, ranging from benign bruits to intracranial hemorrhage and neurologic deficits. The presentation and natural history of these fistulae are largely determined by the pattern of venous drainage. Knowledge of natural history and careful study of the angioarchitecture by angiography is therefore mandatory for correct management of these lesions. In this review, anatomy and pathology, principles of management, and the various factors that influence treatment decisions are discussed, with a focus on endovascular therapy. Indications for endovascular treatment, therapeutic goals, approaches, and techniques are reviewed. The role of surgical treatment is also briefly discussed.

Endovascular management of dural arteriovenous fistulas of the transverse and sigmoid sinus in 150 patients

INTRODUCTION

This study aimed to evaluate the safety and efficiency of the endovascular treatment of transverse-sigmoid sinus dural arteriovenous fistulas (TS_dAVF).

METHODS

A total of 150 consecutive patients and 348 procedures were evaluated.

RESULTS

Pulsatile tinnitus (81%), headache (15%), and intracranial hemorrhage (10%) were the most frequent manifestations of the TS_dAVFs. More than half of the affected sinuses were partially or completely thrombosed. Access-wise treatment was performed transarterial (n = 33), transvenous (n = 21), or a combination thereof (n = 96). A mean of 2.4 procedures per patient was required. Immediate postprocedural occlusion rate after transarterial embolization was 30% only. Transvenous treatment alone resulted in an early occlusion rate of 81%, with delayed complete obliteration of half of the remaining fistulas. After combined transarterial/transvenous treatment, the angiographic cure rate was 54%. At follow-up, 88% of patients with residual shunt after the treatment showed complete occlusion. The cumulative complication rate was 9% (n = 13), with minor adverse events in ten patients (7%) and major complications in three patients (2%).

CONCLUSION

Transvenous coil occlusion of the sinus segment with the adjacent dAVF site, eventually combined with transarterial occlusion of supplying arteries, is a very effective and well-tolerated treatment method. In selected patients, variations of these methods (e.g., sinus stenting, compartmental sinus occlusion) can be useful.

Angioplasty and stent deployment in acute sinus thrombosis following endovascular treatment of dural arteriovenous fistulae

We report on the successful treatment of acute sinus thrombosis associated with endovascular treatment of intracranial dural arteriovenous fistulae (DAVF) by sinus angioplasty with stent deployment. A 76-year-old man presented with intracerebral hemorrhage, Cognard type IIa+b DAVF of the left sigmoid sinus, and type IIa DAVF of the torcular herophili. During transvenous sinus embolization, acute thrombosis of the stenotic lesion in the left transverse sinus occurred. The thrombosis caused isolated sinus and cortical venous reflux (CVR). The patient was treated by stent-supported sinus angioplasty, which led to an immediate improvement of the sinus thrombosis and associated CVR.

Severe brain edema caused by a meningioma obstructing cerebral venous outflow and treated with venous sinus stenting

✓ Peritumoral edema is a common feature of cerebral meningiomas, but venous outflow obstruction is not normally considered as a cause even when a tumor involves the venous sinuses. The authors describe a patient with a ventricu-loperitoneal shunt in situ, who had undergone several debulking operations and conventional radiotherapy and in whom had developed progressive life-threatening edema from a tentorial meningioma. Radiological studies showed occlusion of the straight sinus and stenosis of the sagittal sinus at the confluence of sinuses. The sagittal sinus was stented, and thereafter the patient made an almost complete symptomatic recovery and returned to work. This case shows that progressive edema in patients with meningioma is not necessarily caused by radiotherapy or tumor enlargement into the brain and that in venous outflow obstruction, addressing the obstructive lesion directly can improve the palliation afforded by a shunt.

Preliminary experience with onyx embolization for the treatment of intracranial dural arteriovenous fistulas

BACKGROUND AND PURPOSE

Onyx was recently approved for the treatment of pial arteriovenous malformations, but its use to treat dural arteriovenous fistulas (DAVFs) is not yet well established. We now report on the treatment of intracranial DAVFs using this nonadhesive liquid embolic agent.

MATERIALS AND METHODS

We performed a retrospective analysis of 12 consecutive patients with intracranial DAVFs who were treated with Onyx as the single treatment technique at our institution between March 2006 and February 2007.

RESULTS

A total of 17 procedures were performed in 12 patients. In all of the cases, transarterial microcatheterization was performed, and Onyx-18 or a combination of Onyx-18/Onyx-34 was used. Eight patients were men. The mean age was 56 +/- 12 years. Nine patients were symptomatic. There was an average of 5 feeders per DAVF (range, 1-9). Cortical venous reflux was present in all of the cases except for 1 of the symptomatic patients. Complete resolution of the DAVF on immediate posttreatment angiography was achieved in 10 patients. The remaining 2 patients had only minimal residual shunting postembolization, 1 of whom appeared cured on a follow-up angiogram 8 weeks later. The other patient has not yet had angiographic follow-up. Follow-up angiography (mean, 4.4 months) is currently available in 9 patients. There was 1 angiographic recurrence (asymptomatic), which was subsequently re-embolized with complete occlusion of the fistula and its draining vein. There was no significant morbidity or mortality.

CONCLUSION

In our experience, the endovascular treatment of intracranial DAVFs with Onyx is feasible, safe, and highly effective with a small recurrence rate in the short-term follow-up.

Transvenous embolization for dural transverse sinus fistulas with occluded sigmoid sinus

Dural transverse sinus arteriovenous fistulas with cortical venous drainage were associated with a high hemorrhagic risk. Dural transverse sinus arteriovenous dural fistulas could be treated by embolization (transarterial or transvenous), surgery or a combination of both. Transvenous packing of the diseased sinus was considered to be a less invasive and effective method of treatment. Occluded sigmoid sinus proximally, especially cases with isolated transverse sinus, could make the transvenous approach difficult. Craniotomy for sinus packing or surgical excision remained the treatment of choice when the percutaneous transvenous approach was not feasible. We reviewed the techniques of transvenous embolization described in the literature and illustrated our techniques in two consecutive cases of transvenous embolization of the dural arteriovenous fistulas through the occluded sigmoid sinus. We concluded that transvenous embolization remains a safe and feasible technique other than surgery for patients with transverse sinus dural fistula, achieving a long-term occlusion of the pathology.

Treatment of a superior sagittal sinus dural arteriovenous fistula with Onyx: technical case report

OBJECTIVE

The endovascular treatment of a complex superior sagittal sinus dural arteriovenous fistula with ethylene vinyl alcohol copolymer (Onyx) in one session is described.

CLINICAL PRESENTATION

A 54-year-old man presented with dizziness and a bruit. A cerebral angiogram demonstrated a superior sagittal sinus dural arteriovenous fistula with a patent superior sagittal sinus that was supplied via multiple branches of the external carotid arteries bilaterally and the left anterior and middle cerebral arteries. Drainage was mainly through the superior sagittal sinus and, only in part, retrogradely through the cortical veins. A decision was made to proceed with endovascular treatment followed by surgery.

INTERVENTION

Transarterial injection of one pedicle of middle meningeal artery on both sides with Onyx resulted in complete obliteration of the dural supply and some of the pial supply to the malformation without complications. The superior sagittal sinus remained patent. Based on this result, surgical treatment was cancelled. The residual pial supply had disappeared by the 10-month angiographic follow-up examination and the patient remained neurologically intact and without symptoms.

CONCLUSION

Definitive treatment may be attained with Onyx in dural arteriovenous fistulas. The potential of Onyx for use as a permanent embolic agent in dural arteriovenous fistulae needs to be investigated.