Endovascular management of dural carotid–cavernous sinus fistulas in 141 patients

Endovascular and medical management strategies for carotid-cavernous fistulas: A safety and efficacy analysis

BACKGROUND

Carotid-cavernous fistulas (CCFs) are complex arteriovenous shunting lesions of the cavernous sinus with diverse clinical presentations. This study aimed to analyze clinical outcomes and differentiate patients treated with conservative observation versus those needing endovascular intervention.

METHODS

A retrospective analysis of 84 patients with angiographically confirmed CCF was conducted from 2000 to 2022. Endovascular treatment decisions were made at the discretion of neurointerventionalists. Clinical and angiographic data were collected, including Barrow CCF classification and treatment outcomes.

RESULTS

Patients managed conservatively (n = 17) had longer symptom duration (165 vs 42 days) and more indirect CCF (100% vs 68%) compared to those treated with endovascular embolization (n = 67). High-risk clinical symptoms, including proptosis, diplopia, decreased visual acuity, and chemosis, were more common in the embolization group. Cortical venous reflux and ophthalmic venous reflux were more prevalent in the embolization group (39% and 91%, respectively). Overall, 31% of embolized CCFs required retreatment, mainly Barrow type D lesions (65%). Transvenous coil embolization was the primary technique used (78%), followed by feeder artery embolization (16%), and internal carotid artery flow diversion (8%).

CONCLUSION

In selected CCF patients without high-risk symptoms or angiographic features, conservative observation is a safe and effective alternative to endovascular embolization. High-risk symptoms and angiographic features favor endovascular intervention. Complications were rare, and most were transient, emphasizing the safety of endovascular management. Longitudinal angiographic and ophthalmologic surveillance is essential for monitoring fistula persistence or recurrence.

Embolization techniques of spontaneous direct carotid-cavernous fistulae: a single-center experience

PURPOSE

Spontaneous direct carotid-cavernous fistula (CCF) are usually caused by a ruptured carotid cavernous aneurysm. We studied treatment of spontaneous direct CCFs in a single-center cohort of a high-volume tertiary referral center, reporting anatomical details, technical approaches of treatment, and outcomes.

METHODS

Adult patients with a spontaneous direct CCF treated between 2010-2022 with follow-up MRI and/or DSA imaging available were retrospectively analyzed. We studied age, sex, clinical presentation, angiographic findings, treatment techniques, outcomes, and complications.

RESULTS

Out of 80 patients with CCFs, twelve patients were treated for a non-traumatic direct CCF (15%) in 13 sessions. Median age was 65 years. Two patients had an underlying connective tissue disorder. In 10 cases, the direct CCF was caused by a ruptured cavernous carotid aneurysm. The direct CCFs were treated by endovascular transarterial embolization (10 cases), transvenous embolization (1 case), or surgery (1 case). Selective closure of the shunt was possible in 10 patients. Two patients were treated with parent vessel occlusion (PVO; one endovascular; one surgical, with bypass). Complications occurred in 2 / 12 patients (17%), with permanent morbidity in two patients (17%): trigeminal neuralgia after PVO and new infarct after surgical PVO and bypass. Selective closure of CCF resulted in no morbidity. There was no mortality in our series.

CONCLUSION

Spontaneous direct CCFs are caused by rupture of a cavernous carotid aneurysm in most cases. Selective closure of the shunt, usually feasible transarterially with coils, achieves good results. Reconstructive endovascular techniques are preferred to minimize treatment related neurological complications.

Evaluating the Incidence and Neuro-Ophthalmic Manifestations of Carotid-Cavernous Fistulas

BACKGROUND

To determine the incidence of carotid-cavernous fistula (CCF) and describe the neuro-ophthalmic manifestations and eventual clinical outcomes.

METHODS

This was a population-based, retrospective cohort study using the Rochester Epidemiology Project to identify patients aged 18 years or older residing in Olmsted County, MN, diagnosed with CCF from 1997 to 2019. The medical records were reviewed for ophthalmic signs and symptoms, including conjunctival chemosis, proptosis, orbital bruit, diplopia, ophthalmoplegia, orbital pain, ocular hypertension, and blurred vision. Also determined was the number of patients with CCF found incidentally on neuroimaging, without clinical manifestations.

RESULTS

Ten patients were diagnosed with a CCF between 1997 and 2019 with an overall incidence rate of 0.37 per 100,000 per year (95% CI 0.20-0.68). The median age was 50.5 years (range 23-74 years), 6 (60%) were female, and 9 were White and 1 patient was Korean. Three patients (30%) were asymptomatic and found incidentally on imaging that was obtained for unrelated reasons, and one patient's ocular details were unavailable because she passed away from severe head trauma. The following neuro-ophthalmologic or ocular manifestations were identified in the remaining 6 patients: chemosis/conjunctival injection (n = 6), cranial nerve (CN) VI palsy (n = 6), CN III palsy (n = 2), proptosis (n = 4), ocular/orbital pain (n = 3), audible orbital bruit (n = 2), ocular hypertension (n = 1), and blurred vision (n = 1). Of those patients with symptomatic CCFs, all underwent treatment except for one that spontaneously resolved. None of the patients suffered a stroke or cerebral hemorrhage. The 3 patients with incidentally discovered CCFs were asymptomatic and did not require treatment.

CONCLUSIONS

This is the first population-based study to show a low incidence rate of CCFs, supporting the notion that it is an uncommon condition. Neuro-ophthalmic manifestations are common, especially chemosis/conjunctival injection and CN VI palsy. Up to a third of patients with CCF can be asymptomatic and may be found incidentally on neuroimaging during the evaluation for unrelated symptoms.

Surgical management of glaucoma secondary to indirect carotid-cavernous fistula: A case report

INTRODUCTION

Indirect carotid-cavernous fistula (CCF) can lead to secondary glaucoma, posing significant treatment challenges. This paper discusses a case where standard embolization failed, and an Ahmed FP7 valved glaucoma tube shunt was crucial for managing the increased intraocular pressure (IOP), highlighting the necessity for individualized surgical approaches.

CASE PRESENTATION

A 48-year-old female presented in the emergency department with conjunctival hyperemia, proptosis and elevated IOP; initial imaging findings were indicative of orbital inflammatory disease. Further evaluation with cerebral CT angiography revealed a possible CCF. Subsequent angiography confirmed an indirect CCF type D, leading to the patient undergoing endovascular embolization. Final monitoring revealed a subtotal occlusion of the fistula. Although there was some improvement post-procedure, IOP remained elevated despite medication, and subsequent attempts of embolization were unsuccessful. Surgical intervention with a tube shunt was performed, allowing IOP to decreased to a normal range. Optic nerve head optical coherence tomography, standard automated perimetry, and best-corrected visual acuity remained stable during the 33-month follow-up.

DISCUSSION

In managing glaucoma linked to CCF, a multidisciplinary approach is critical. Conservative methods are often adequate, with spontaneous CCF closure observed in a significant percentage. Endovascular embolization is reserved for refractory cases, with embolization showing a higher rate of IOP normalization compared to medication alone. Yet, when fistula closure is challenging or contraindicated, individualized management strategies like glaucoma surgery may be employed.

CONCLUSIONS

When fistula closure is not achievable, the Ahmed FP7 valved tube shunt can successfully regulate IOP with minimal complications, providing an effective alternative for refractory cases.

Indications for alternative endovascular techniques in carotid-cavernous fistulas: A 20-year single-center experience

BACKGROUND

While coiling is considered the standard treatment for carotid-cavernous fistulas (CCFs), studies demonstrating excellent results using new materials, especially flow diverter (FD) stents and liquid embolisates, are becoming more frequent. The indications and effectiveness of these alternative endovascular techniques remain unclear.

METHODS

A total of 22 direct and 20 indirect CCFs were included in the study. These were further subdivided based on the embolic material used: coils versus FD stents for direct and coils versus liquid embolisates for indirect CCFs. The subgroups were subjected to statistical analysis.

RESULTS

An angiographic cure was achieved in 88% of all CCFs, 93% of patients' experienced clinical improvement or remained stable. Direct CCFs were treated with coiling (41%) or with both coils and FD stents (55%). One (4%) patient with a direct CCF was treated with FD stent alone. Statistical analysis comparing these subgroups revealed a significantly higher complete occlusion rate immediately after treatment in the coiling subgroup (67% vs. 23%, p = 0.0409). The occlusion rates at the last follow-up were similar (89% vs. 85%). Indirect CCFs were treated with coiling (35%) or liquid embolisates (65%). All three periprocedural ischemic complications were recorded within the liquid subgroup, resulting in a significantly higher clinical deterioration rate (p = 0.0333).

CONCLUSION

FD stents in direct and liquid embolisates in indirect fistulas did not demonstrate better angiographic or clinical outcomes compared to convetional coiling. Liquid agents carried a higher risk of ischemic complications. Alternative embolization materials should be reserved for CCFs that cannot be treated with simple coiling.

Comparing transvenous coiling and transarterial embolization with Onyx/NBCA for cavernous sinus dural arteriovenous fistulas: A retrospective study in a single center

BACKGROUND

Endovascular management is the gold standard for cavernous sinus dural arteriovenous fistulas (CS-dAVFs) in patients with signs of ophthalmoplegia, visual defects, or intolerable clinical symptoms. Although the efficacy of embolization has been confirmed, complications during post-endovascular management have not been compared in a more extensive CS-dAVFs case series. Therefore, we compared the effectiveness and peri-procedural complications of transvenous coiling with those of transarterial embolization (TAE) using liquid embolic agents.

METHODS

We reviewed 71 patients with CS-dAVFs in one medical center from 2005/7 to 2016/7. We performed seventy-seven procedures on 71 patients, including six recurrent cases. We compared the efficacy and peri-procedural complications of transvenous coiling and TAE.

RESULTS

The complete occlusion rate for transvenous coiling was 79.2%, and that for TAE was 75.0%. Findings revealed (1) similar ophthalmoplegia complication rates (p = 0.744); (2) more frequent and permanent CN5 or CN7 neuropathy with liquid embolic agent use (p = 0.031 and 0.028, respectively); and (3) a higher risk of infarction or ICH (p = 0.002 and 0.028, respectively) in response to aggressive TAE.

CONCLUSION

Transvenous cavernous sinus coiling resulted in a similar occlusion rate and lower complication risk than transarterial Onyx/n-butyl cyanoacrylate (NBCA). We can access via an occluded inferior petrosal sinus (even contralateral), and direct transorbital puncture was a safe alternative. TAE with Onyx/NBCA was helpful in cases of oligo-feeders, but multidisciplinary treatment and multi-session TAE were usually needed for patients with multiple feeders and complex fistulas.

Superior ophthalmic approach in carotid-cavernous fistula: current concepts in indications, surgical techniques, and case reviews

Carotid-cavernous fistulas, characterized by abnormal arteriovenous communication within the cavernous sinus (CS), can be classified as direct or indirect. Direct fistulas are defined as a direct connection between the internal carotid artery (ICA) and CS, whereas indirect fistulas result from an abnormal connection between the CS and dural arterial branches. The first-line treatment for both types of fistulas is endovascular intervention, most commonly accomplished through the transarterial and transvenous approaches of the conventional pathway, including the ICA, inferior and superior petrosal sinuses, or basilar plexus. Nonetheless, a retrograde approach through the superior ophthalmic vein may be necessary for individuals in whom conventional endovascular treatment fails. Herein, the current principles of surgical indication and technique are presented, along with case studies.

Efficiency of endovascular management with a combination of Onyx and coils for direct and indirect carotid cavernous fistula treatment: experience of a single center

BACKGROUND

To evaluate the safety and efficacy of endovascular treatment with a combination of Onyx and coils for carotid cavernous fistulas (CCFs), and to characterize the factors associated with clinical and angiographic outcomes for direct and indirect CCFs.

METHODS

This retrospective study included 31 patients with CCF treated with an endovascular procedure between December 2017 and March 2022.

RESULTS

Direct and indirect CCFs were found in 14 (45.2%) and 17 (54.8%) cases, respectively. Direct CCFs included eleven traumatic carotid cavernous fistulas. The most common symptom on admission was chemosis, which was seen in 17 (54.8%) patients. Eight (25.7%) cases were treated by the transarterial approach. Fourteen (45.2%) cases were treated using the femoral vein-inferior petrosal sinus approach. Seven (22.6%) were treated by direct puncture of the superior ophthalmic vein. Two (6.5%) were treated by the femoral vein-facial vein approach. Immediate complete occlusion and follow-up rates were 93.5% and 96.7%, respectively. Twenty-nine (96.7%) patients experienced an improvement in their symptoms at clinical follow-up. Chemosis was significantly improved or resolved in 15 patients. Ophthalmoplegia was improved or resolved in 10 patients. Visual impairment was improved in 6 patients. Proptosis was improved or resolved in 5 patients. One case (3.2%) experienced procedure-related complication presented with transient oculomotor nerve palsy. In univariate subgroup analysis, use of balloon, treatment approach, and history of head trauma were significantly different between the direct and indirect CCF groups.

CONCLUSIONS

Endovascular treatment with a combination of Onyx and coils is a safe and effective therapy for CCFs. In this study, the transarterial approach was a favorable option for embolization of direct CCFs. In contrast, the transvenous approach may be the first choice of treatment for indirect CCFs.

Transfemoral trans-facial vein-superior ophthalmic vein to embolize cavernous sinus dural arteriovenous fistulas

Cavernous sinus dural arteriovenous fistula (CS-DAVF) is an abnormal communication between the CS and dural arteries from the internal carotid artery and external carotid artery. CS-DAVFs are not uncommon. The preferred treatment for most CS-DAVFs is transvenous embolization (TVE), which can achieve a high cure rate with few complications. The trans-inferior petrous sinus (IPS) route from the internal jugular vein to the CS is the favorite and most direct route to perform TVE in the great majority of CS-DAVFs. However, when the trans-IPS route fails and if the facial vein (FV) is patent and dilated, transfemoral trans-FV-superior ophthalmic vein (SOV) embolization of the CS-DAVF can be attempted. However, the transfemoral trans-FV-SOV route to embolize CS-DAVFs is often challenging, and there is insufficient knowledge about it. Therefore, an updated review of the transfemoral trans-FV-SOV route to embolize CS-DAVFs is necessary, and this review includes our experience. The images in this review are from our institute without the dispute of copyright. Issues regarding the transfemoral trans-FV-SOV route to embolize CS-DAV were discussed, including the FV anatomy and variation, various TVE routes to access CS-DAVF, the procedure of the transfemoral trans-FV-SOV route to embolize CS-DAVF, difficulty, and solution of the transfemoral trans-FV-SOV route to embolize CS-DAVF, and complications and prognosis of transfemoral trans-FV-SOV to embolize CS-DAVF. By reviewing the transfemoral trans-FV-SOV route to embolize CS-DAVFs, we found that this route provides a valuable alternative to the other transvenous routes. A good prognosis can be obtained with the transfemoral trans-FV-SOV route to embolize CS-DAVFs in select cases.

What is the most effective method to treat indirect carotid-cavernous fistula?

To review the most relevant treatment options for indirect carotid-cavernous fistulas (iCCF), cohorts of 20 patients or more published after 2000 were analyzed. Clinical and radiological outcomes, as well as embolization techniques and material, had to be clarified in the study to be considered. Statistical analysis was based on calculating the relative percentage of therapeutic methods or embolic material, followed by calculating parametric and nonparametric correlations. Some 22 studies and 1550 patients were included. Transvenous embolization (TVE) was used in 53% of the patients and was strongly associated with coiling (rw = 0.66, p = 0.0.0012; rs = 0.53, p = 0.0138), transarterial embolization (TAE) was preferred in 11% of the patients and was strongly linked to liquid embolics (rw = 0.44, p = 0.0434;rs = 0.64, p = 0.0018). A combination of TAE and TVE treatment was used in 7% and a combination of embolic materials in 13% of the patients. None of the endovascular techniques or embolization materials showed significant superiority over the others in clinical outcome and obliteration rate. Radiosurgery in 22% and mechanical compression in 5% of patients showed a lower obliteration rate (rw =  - 0.48, p = 0.0254; rs =  - 0.45, p = 0.0371). The clinical outcomes were comparable to endovascular treatment (EVT). The remaining 2% of the patients were treated by open surgery or a combination of EVT and radiosurgery. Transvenous coiling is the preferred EVT method for iCCF. However, comparable results may be accomplished with TAE using liquid. Radiosurgery may achieve a lower percentage of fistula occlusion, but the clinical results are equal to EVT.

Efficacy and safety of stereotactic radiosurgery versus endovascular treatment for symptomatic cavernous sinus dural arteriovenous fistula without ophthalmological emergency: a single-center 10-year experience

OBJECTIVE

Stereotactic radiosurgery (SRS) is emerging as a treatment option for cavernous sinus dural arteriovenous fistula (CS dAVF); it is less invasive and has a lower complication rate than conventional surgeries. However, little is known regarding the advantages and limitations of SRS compared to those of endovascular treatment (EVT). The aim of this study was to compare the efficacy and safety between EVT and SRS for treatment of CS dAVF.

METHODS

Between January 2011 and April 2021, a total of 86 consecutive patients diagnosed with CS dAVF were treated with EVT or SRS. Among them, 8 patients with ophthalmological emergency and 8 without follow-up data at ≥ 12 months were excluded. During the same period, no neurological deficit due to intracranial hemorrhage or seizure was noted in any of the patients. Ultimately, 70 patients (EVT 33, SRS 37) were included in this study. Demographic characteristics, initial clinical presentations, clinical outcomes, and radiological findings were retrospectively reviewed and compared. Procedure-related complications were also assessed after the treatments.

RESULTS

The patients’ baseline characteristics (except conjunctival symptoms) and angiographic features of CS dAVF were not significantly different between the EVT and SRS groups. Conjunctival symptoms were more frequently noted in the EVT than in the SRS group (69.7% vs 40.5%, p = 0.015). After EVT, initial complete obliteration was achieved in 20 cases (60.6%). Complete obliteration was achieved at 6 months in 86.4% of cases with EVT and in 77.8% of those treated with SRS (p = 0.507), and at 12 months in 86.4% cases with EVT and in 94.4% of those treated with SRS (p = 0.357). Worsening of symptoms developed at 1 month in 24.2% of cases with EVT and in 5.4% of those treated with SRS (p = 0.038); at 6 months in 22.6% of cases with EVT and in 10.8% of those treated with SRS; and at 12 months in 30.0% of cases with EVT and in 13.5% of those treated with SRS (p = 0.099). The angioarchitecture of CS dAVF did not affect angiographic obliteration after SRS. Procedure-related morbidity and mortality occurred more frequently in the EVT than in the SRS group (27.3% vs 8.1%, p = 0.034).

CONCLUSIONS

Both EVT and SRS were effective for the treatment of CS dAVF without ophthalmological emergency. However, procedure-related morbidity and mortality was less frequent in SRS than in EVT, and consequently SRS may be more advantageous in terms of safety.

Operative Cannulation of the Superior Ophthalmic Vein for Embolization of Cavernous Sinus Dural Arteriovenous Fistulas: Surgical Techniques and Clinical Outcomes

BACKGROUND

Endovascular therapy is the first-line treatment for the cavernous sinus dural arteriovenous fistulas, particularly transvenous embolization. This study aimed to assess the trans-superior ophthalmic vein approach to embolization for its safety, efficacy, and viability as a first-line treatment in selected patients, with a description of the microsurgical and endovascular techniques.

METHODS

We retrospectively reviewed patients with cavernous sinus dural arteriovenous fistulas treated using the direct superior ophthalmic vein approach with n-butyl cyanoacrylate and coils as the main embolic materials from 2015 to 2021. The safety and efficacy of the treatment were evaluated based on ocular and neurological improvement, angiographic obliteration, and recurrence.

RESULTS

Of the 16 patients, all cases were diagnosed with cavernous sinus dural arteriovenous fistulas. The n-butyl cyanoacrylate was used as the sole embolic material in 12 cases, and coils were used in 4 cases. A direct superior ophthalmic vein approach was selected as the first option in 11 patients. All the patients achieved complete fistula obliteration and good recovery from ocular symptoms, accompanied by excellent cosmetic results. No recurrence was observed at a mean follow-up period of 26 months.

CONCLUSIONS

Microsurgical dissection for exposure and direct cannulation of the superior ophthalmic vein as a route for fistula obliteration delivers excellent clinical outcomes, with a low rate of complications. Not only is it safe and effective as an alternative approach but it can also serve as first-line treatment in selected patients.

Gamma Knife Radiosurgery for Indirect Dural Carotid-Cavernous Fistula: Long-Term Ophthalmological Outcome

Objective: The leading treatment option for dural carotid−cavernous sinus fistula is an endovascular approach with immediate improvement. Alternatively, radiosurgery is a slow response for obliterating the fistula and poses a radiation risk to the optic apparatus and the associated cranial nerves and blood vessels. In this study, we retrieved cases from a prospective database to assess the ophthalmological outcomes and complications in treating dural carotid cavernous sinus fistula with gamma knife radiosurgery (GKRS). Material and Methods: We retrieved a total of 65 cases of carotid cavernous sinus fistula treated with GKRS with margin dose of 18−20 Gy from 2003 to 2018 and reviewed the ophthalmological records required for our assessment. Results: The mean target volume was 2 ± 1.43 cc. The onset of symptom alleviated after GKRS was 3.71 ± 7.68 months. There were two cases with residual chemosis, two with cataract, two with infarction, one with transient optic neuropathy, and four with residual cranial nerve palsy, but none with glaucoma or dry eyes. In MRA analysis, total obliteration of the fistula was noted in 64 cases with no detectable ICA stenosis nor cavernous sinus thrombosis. In the Cox regression analysis, post-GKRS residual cranial nerve palsy was highly correlated to targeted volume (p < 0.05) and age (p < 0.05). The occurrence of post-GKRS cataract was related to the initial symptom of chemosis (p < 0.05). Conclusion: GKRS for carotid cavernous sinus fistula offers a high obliteration rate and preserves the cavernous sinus vascular structure while conferring a low risk of treatment complications such as adverse radiation risk to the optic apparatus and adjacent cranial nerves.

Endovascular Management of Intracranial Dural AVFs: Transvenous Approach

In this third review article on the endovascular management of intracranial dural AVFs, we discuss transvenous embolization approaches. Transvenous embolization is increasingly popular and now the first-line approach for ventral dural AVFs involving the cavernous sinus and hypoglossal canal. In addition, transvenous embolization is increasingly used in lateral epidural dural AVFs in high-risk locations such as the petrous and ethmoid regions. The advantage of transvenous embolization in these locations is the ability to retrogradely embolize the draining vein and fistula while reducing the risk of ischemic cranial neuropathy or brain parenchymal infarction commonly feared from a transarterial approach. By means of coils ± ethylene-vinyl alcohol copolymer, transvenous embolization can achieve angiographic cure rates of 80%-90% in ventral locations. Potential complications include transient cranial neuropathy, neurologic deterioration due to venous outflow obstruction, and perforation while navigating pial veins. Transvenous embolization should be considered when dural AVFs arise in proximity to the vasa nervosum or extracranial-intracranial anastomoses.

Case Report: Management of Traumatic Carotid-Cavernous Fistulas in the Acute Setting of Penetrating Brain Injury

Traumatic carotid-cavernous fistulas (tCCFs) after penetrating brain injury (PBI) have been uncommonly described in the literature with little guidance on optimal treatment. In this case series, we present two patients with PBI secondary to gunshot wounds to the head who acutely developed tCCFs, and we review the lead-up to diagnosis in addition to the treatment of this condition. We highlight the importance of early cerebrovascular imaging as the clinical manifestations may be limited by poor neurological status and possibly concomitant injury. Definitive treatment should be attempted as soon as possible with embolization of the fistula, flow diversion via stenting of the fistula site, and, finally, vessel sacrifice as possible therapeutic options.

Selective transvenous embolization combined with balloon angioplasty of the occluded inferior petrosal sinus for the treatment of cavernous sinus dural arteriovenous fistulas

BACKGROUND AND PURPOSE

Angioplasty of the dural sinus has rarely been performed for the treatment of cavernous sinus dural arteriovenous fistulas. We evaluated the efficacy of selective transvenous embolization (TVE) combined with balloon angioplasty of the occluded inferior petrosal sinus (IPS) for the treatment of cavernous sinus dural arteriovenous fistulas (CSDAVFs).

MATERIALS AND METHODS

A total of 8 consecutive patients with CSDAVFs with occlusion of the IPS treated by selective TVE with balloon angioplasty of the IPS from July 2018 to January 2019 were retrospectively reviewed. There were 6 females and 2 males with an average age of 77.6 years. All patients showed ocular symptoms. Angiography showed cortical venous reflux in 7 cases and localized shunted pouches at the medial portion of the cavernous sinus, intercavernous sinus, or laterocavernous sinus. Selective TVE was performed via the occluded IPS with bilateral femoral venous approaches, and the occluded IPS was reconstructed by angioplasty with a 2- to 3-mm diameter balloon during or after selective TVE.

RESULTS

CSDAVFs disappeared immediately after treatment, and the occluded IPSs were successfully reconstructed with re-establishment of normal antegrade venous flow in all cases. No complications were observed, and symptoms resolved within 2 weeks after treatment. During the 7-month mean follow-up period (range 1-12 months), no cases showed recurrence of CSDAVFs.

CONCLUSION

Selective TVE combined with balloon angioplasty of the occluded IPS is safe and effective for the treatment of CSDAVFs and re-establishes normal venous circulation in selected cases with localized shunted pouches.

Brainstem Venous Congestion Due to Transverse-sigmoid Sinus Dural Arteriovenous Fistula: Case Report and Literature Review

Brainstem venous congestion due to dural arteriovenous fistula (dAVF) can mimic brainstem glioma and infarction. We report a case of a 56-year-old woman with a transverse-sigmoid sinus (TS) dAVF. On MRI, she presented with brainstem edema that was difficult to distinguish from brainstem glioma and infarction. She was referred to our hospital for mild dysarthria with right hemiparesis and a suspected left pontine glioma. On MRI, contrast enhancement of the lesion was demarcated by the pontine raphe, and the ipsilateral vein of Rosenthal was dilated. Cerebral angiography revealed TS dAVF with an isolated sinus. Transarterial followed by transvenous coil embolization was performed to reduce shunt flow, resulting in symptom improvement and normal findings on MRI and cerebral angiography. Brainstem venous congestion due to TS dAVF is as rare as adult brainstem glioma. Differentiating the above-mentioned three diseases on the basis of diagnostic imaging findings and clinical course is necessary for appropriate and timely treatment.

Cavernous sinus dural arteriovenous fistula accessed through a straightened superficial temporal vein

Background:

Transvenous embolization through the inferior petrosal sinus (IPS) is the most common treatment procedure for cavernous sinus dural arteriovenous fistula (CSDAVF). When the IPS is inaccessible or the CSDAVF cannot be treated with transvenous embolization through the IPS, the superficial temporal vein (STV) is used as an alternative access route. However, the approach through the STV is often challenging because of its tortuous and abruptly angulated course. We report a case of recurrent CSDAVF which was successfully treated using a chronic total occlusion (CTO)-dedicated guidewire and by straightening the STV.

Case Description:

A 63-year-old woman was diagnosed with CSDAVF on examination for oculomotor and abducens nerve palsy. She was initially treated with transvenous embolization through the IPS. However, CSDAVF recurred, and transvenous embolization was performed through the STV. A microcatheter could not be navigated because of the highly meandering access route through the STV. By inserting a CTO-dedicated guidewire into the microcatheter, the STV was straightened and the microcatheter could be navigated into a shunted pouch of the CS. Finally, complete occlusion of the CSDAVF was achieved.

Conclusion:

If an access route is highly meandering, the approach can be facilitated by straightening the access route with a CTO-dedicated guidewire.

Endovascular management of cavernous sinus dural arteriovenous fistulas: Overall review and considerations

Cavernous sinus dural arteriovenous fistulas (CSDAVFs) are arteriovenous shunts between small dural branches arising from the external and/or internal carotid arteries and the cavernous sinus (CS). And now a days, endovascular treatment is the treatment of choice in CSDAVF. We review the anatomy and classifications of CSDAVFs, discussing and detailing these considerations in the treatment of CSDAVFs, theoretically and in the light of recent literatures.

Transarterial Embolization of Intracranial Arteriovenous Fistulas with Large Venous Pouches in the Form of Venous Outlet Ectasia and Large Venous Varix or Aneurysm : Two Centers Experience

Objective

There are different types of cerebral vascular malformations. Pial arteriovenous fistulas (PAVFs) and dural arteriovenous fistulas (DAVFs) are two entities; they consist of one or more arterial connections to a single venous outlet without a true intervening nidus. The high turbulent flow of PAVFs and aggressive DAVFs with cortical venous reflux can result in venous outflow varix and aneurysmal dilatation. They pose a significant challenge to transvenous embolization (TVE), stereotactic radiosurgery, and surgical treatment. We aim to share our centers' experience with the transarterial embolization (TAE) for arteriovenous fistulas (AVFs) with large venous pouches and to report the outcome.

Methods

The authors' two institutions' databases were retrospectively reviewed from February 2017 to February 2021. All patients with intracranial high flow PAVFs and aggressive DAVFs with venous outlet ectasia and large venous varix and were treated by TAE were included.

Results

Fifteen patients harboring 11 DAVFs and four PAVFs met our inclusion criteria. All patients underwent TAE in 17 sessions. Complete angiographic obliteration was achieved after 14 sessions in 12 patients (80%). Four patients (25%) had residual after one TAE session. Technical failure was documented in one patient (6.7%). Fourteen patients (93.3%) had favorable functional outcome (modified Rankin score 0-2).

Conclusions

TAE for high flow or aggressive intracranial AVFs is a safe and considerable treatment option, especially for those associated with large venous pouches that are challenging and relatively high-risk for TVE.

Transvenous Embolization of Cavernous Sinus Dural Arteriovenous Fistula through the Angiographically Occlusive Superior Ophthalmic Vein

Transvenous embolization (TVE) through the superior ophthalmic vein (SOV) is a useful approach for the treatment of cavernous sinus (CS) dural arteriovenous fistulae (DAVFs). This venous route is usually confirmed by angiography. Herein, we present a case of favorable embolization of the CS DAVF through the angiographically occlusive SOV. A 61-year-old man presented with progressive exophthalmos and hypertonia. The patient was diagnosed with a CS DAVF, and TVE was planned. The first approach through the inferior petrosal sinus was infeasible; therefore, we attempted to approach the fistula through the left facial vein. The microcatheter was easily advanced to the shunt point through the angiographically occlusive SOV. We performed coil embolization, and the CS DAVF was completely obstructed.

Spontaneous Closure of a Carotid-cavernous Fistula after Contrast-enhanced Orbit Computed Tomography

Purpose: We report a case of spontaneous closure of a carotid-cavernous fistula (CCF) after contrast-enhanced orbit computed tomography (CT).Case summary: A 80-year-old female was referred to our clinic under suspicion of chronic angle- closure glaucoma because of persistently high intraocular pressure commencing one month prior. Slit-lamp examination revealed a conjunctival injection and corkscrew-like vessel dilatation in the left eye, and a high intraocular pressure. Dilated fundus examination revealed central retinal vein occlusion in that eye. Contrast-enhanced orbit CT revealed a dilated, superior ophthalmic vein in the left orbit, and she was transferred to our department of neurosurgery for digital subtraction angiography (DSA); this is the gold standard imaging modality for the diagnosis of direct and indirect CCFs. DSA was performed two weeks after orbit CT; however, no CCF was visible. Thereafter, the conjunctival injection and the elevated intraocular pressure improved gradually over eight months. We suspect that the CCF closed spontaneously.Conclusions: Our case highlights the fact that a CCF can close spontaneously after contrast-enhanced orbit CT; ophthalmologists may wish to bear this in mind.

Clinical Improvement of Patients with Endovascular Treatment in the Traumatic Carotid-Cavernous Fistula

A carotid-cavernous sinus fistula (CCF) is a clinical condition when there is an abnormal communication between the internal carotid artery, external carotid artery (ECA), or any of their branches to the cavernous sinus. Traumatic CCF (TCCF) is the most common type of all CCFs. This study aims to find clinical improvement of traumatic carotid-cavernous fistulas (TCCF) after endovascular treatment. We predict the degree of clinical recovery in an attempt to make the treatment of TCCF safe and effective. This study reported a series of 28 patients with TCCFs undergoing coiling and ballooning in a period of 3 years, i.e., from December 2014 to December 2017. This is a novel case report about CCF in our country, Indonesia, especially in Surabaya. We performed clinical, angiographical, and radiological assessments before and at regular time periods after the procedure until 6 months. All patients had a partial and complete occlusion of the fistula. Angiographic occlusion of fistula, visualization of the ophthalmic artery, and disappearance of bruit predicted a good clinical outcome. All patients made a recovery at different times, depending on the degree of fistulas and treatment. Improvement in clinical symptoms had a direct correlation with the degree of occlusion. Treatment was divided into coiling and ballooning depending on patient's condition and angiographic examination. Trans femoral cerebral angiography is still very important diagnostic tool in the diagnosis and treatment of TCCFs.

Results of transvenous embolization of intracranial dural arteriovenous fistula: a consecutive series of 136 patients with 142 fistulas

OBJECTIVE

Intracranial dural arteriovenous fistula (DAVF) is mainly treated with an endovascular approach. Two major treatment advances include transvenous embolization (TVE) with coils in 1989 and, more recently, transarterial embolization with Onyx. The aim of this study was to present a large monocentric series of patients with DAVF treated with TVE. This series reports more than 20 years of experience and describes the evolution of the medical management of these patients, as well as current indications for this treatment at the authors' center.

METHODS

Consecutive patients treated for intracranial DAVFs with TVE from 1995 to 2018 were included. Clinical and imaging data were systematically collected. Univariate and multivariate analyses were performed to identify factors that were significantly associated with adverse clinical course or complications.

RESULTS

In this study of 136 patients with 142 DAVFs treated with TVE, the occlusion rate was 90%. The median length of follow-up was 11 months. The rate of permanent complications was 5.1%, and the procedure-related mortality rate was 1.5%. Procedure-related mortality was associated with extension of thrombosis that was observed early in our experience. The introduction of a postoperative anticoagulation regimen has drastically decreased the occurrence of this complication. Other minor complications included cochleovestibular syndrome after embolization of lateral sinus DAVF and oculomotor nerve damage after embolization of cavernous sinus DAVF.

CONCLUSIONS

TVE allows efficient occlusion of DAVF. It remains a valid option for DAVF located on a sinus that does not participate in normal venous drainage of the brain.

Embolization of Cavernous Sinus Dural Arteriovenous Fistula (CSDAVF) via transvenous approaches: Practice, experience summary and literature review

OBJECTIVE

To evaluate the safety and efficacy of embolization via transvenous approaches in patients diagnosed with Cavernous Sinus Dural Arteriovenous Fistula (CSDAVF). We also hope to further summarize our preliminary experiences with transvenous approaches.

MATERIAL AND METHODS

We retrospectively collected data from patients who were diagnosed with CSDAVF and were treated with embolization via transvenous approaches from June 2014 to November 2020 at Beijing Tiantan Hospital. We evaluated the safety and efficacy of this treatment using radiological results and clinical follow-up.

RESULTS

A total of 83 patients were included in this study. Complete occlusion was obtained in 76 (89.4%) patients. Sub-total occlusion was obtained in eight (9.4%) patients. Partial occlusion was obtained in one (1.2%) patient. There was no recurrence. Seventy-six patients (91.5%) were cured, and seven patients showed symptom improvement (8.5%). There were no cases of worsening symptoms following embolization, and only ten (12.0%) cases had mild complications.

CONCLUSION

There was a high occlusion rate and a low complication rate in our study. Thus, completing embolization of CSDAVF via transvenous approaches may be safe and effective. However, this operation is more difficult than those via transarterial approaches. Transvenous embolization should therefore be performed in an experienced medical center.

Onyx Embolization of Carotid-Cavernous Fistulas and Its Impact on Intraocular Pressure and Recurrence: A Case Series

BACKGROUND

Carotid-cavernous fistulas (CCFs) are acquired pathological shunting lesions between the carotid artery and the cavernous sinus leading to elevated intraocular pressure (IOP). CCFs are commonly treated via endovascular embolization, which theoretically restores physiological pressure differentials.

OBJECTIVE

To present our institutional data with CCF treated with embolization and discuss endovascular routes, recurrence rates, and dynamic IOP changes.

METHODS

Retrospective analysis of 42 CCF patients who underwent Onyx (Covidien, Irvine, California) embolization and pre- and postoperative IOP measurement at a single institution.

RESULTS

CCFs were 19.0% direct (type A) and 81.0% indirect (types B, C, or D). Onyx-18 liquid embolisate was used during all embolizations. Overall rate of total occlusion was 83.3% and was statistically similar between direct and indirect fistulas. Preoperative IOP was elevated in 37.5%, 100.0%, 75.0%, and 50% in type A, B, C, and D fistulas, respectively. Average ΔIOP was -7.3 ± 8.5 mmHg (range: -33 to +8). Follow-up time was 4.64 ± 7.62 mo. Full angiographic occlusion was a predictor of symptom resolution at 1 mo (P = .026) and 6 mo (P = .021). Partial occlusion was associated with persistent symptoms postoperatively at 1 mo (P = .038) and 6 mo follow-up (P = .012). Beyond 6 mo, negative ΔIOP was associated with continued symptom improvement. Recurrence occurred in 9.5% of patients, all of which were indirect CCFs.

CONCLUSION

Onyx embolization of CCF is an effective treatment for CCF and often results in the reversal of IOP elevation. Full occlusion predicts favorable clinical outcomes up to 6 mo. Postoperative IOP reduction may indicate favorable long-term clinical outcomes.

Endovascular Treatment of Cavernous Sinus Dural Arteriovenous Fistulae: Review of the Literature and Current Status

Cavernous sinus dural arteriovenous fistulae (CSdAVFs) are characterized by the shunts between dural arteries and dural veins surrounding the cavernous sinus (CS), causing ocular symptoms in addition to intracranial hemorrhage and infarction. As surgical access is difficult, endovascular treatment (EVT) has been considered and performed as the first-line therapy for decades. Although there have been recent advances in techniques and devices, transvenous embolization (TVE) with platinum coils remains the most common procedure. There are multiple access routes to the CS, such as the inferior petrosal sinus, superior ophthalmic vein (SOV), and intercavernous sinus from the contralateral CS. To extirpate the shunt, packing the entire sinus with coils is adopted, occasionally resulting in persistent cranial nerve palsy (CNP) due to compression of the coil mass. To avoid this complication, selective shunt occlusion (SSO), in which the coils are placed in the shunted pouch (SP) defined by the small restricted space where the arterial flow converges, is an effective and safe method. Transarterial embolization (TAE) is another option and use of liquid embolic materials, such as Onyx may be promising; however, the potential risk of ischemic nerve injury due to undesirable ante/retrograde influx of the liquid materials is of concern. In conclusion, EVT, especially TVE, is a safe and effective method for managing CSdAVFs. Understanding the angioanatomy consisting of the feeding artery, shunt point, and the drainage route, including the latent vessels, is essential for a good outcome.

Cavernous-Carotid Fistula Presenting with Intracerebral Hemorrhage in the Absence of Ocular Symptoms

BACKGROUND

Cavernous-carotid fistulas (CCFs) can present with a variety of symptoms depending on the anatomy of the fistula and its venous drainage. Patients most commonly present with scleral injection, pulsatile exophthalmos, and/or chemosis.

CASE DESCRIPTION

We report a patient who presented with intraparenchymal hemorrhage in the absence of any of the commonly associated ocular symptoms and signs. After multiple imaging studies, the CCF was diagnosed and treated with endovascular embolization that resulted in complete occlusion of the fistula and reflux of embolysate into one of its connecting veins.

CONCLUSIONS

The morphology of the venous drainage can lead to atypical hemorrhagic presentation, whereas dilatation of one of the tributary veins with cortical venous reflux should warn the interventionist the path the embolysate may follow. We provide our experience with this unique presentation and its treatment.

Endovascular treatment of the cavernous sinus dural arteriovenous fistula: current status and considerations

A cavernous sinus dural arteriovenous fistula (CS-DAVF) is an abnormal arteriovenous communication involving the dura mater within or near the CS wall. The dural arteries from the internal carotid artery and external carotid artery supply the CS-DAVF, and the superior ophthalmic vein (SOV) and inferior petrous sinus (IPS) are frequent venous drainers. In CS-DAVF cases, high-risk lesions require treatment. Endovascular treatment (EVT) has been the first-line option for CS-DAVFs. To our knowledge, a review of the EVT of CS-DAVFs is lacking. Therefore, in this paper, we review the available literature on this issue. In addition, some illustrative cases are also provided to more concisely expound the EVT of CS-DAVFs. According to the recent literature, transvenous embolization via the IPS is considered the most effective method for EVT of CS-DAVFs. In addition, the transorbital approach is another reasonable choice. Other venous approaches can also be tried. Because of the low cure rate, transarterial embolization for CS-DAVFs is limited to only highly selected patients. In the EVT of CS-DAVFs, various agents have been used, including coil, Onyx, and n-butyl cyanoacrylate, with coil being the preferred one. In addition, when EVT cannot obliterate the CS-DAVF, stereotactic radiotherapy may be considered. In general, despite various complications, EVT is a feasible and effective method to manage CS-DAVFs by way of various access routes and can yield a good prognosis.

Bilateral Cavernous Sinus Dural Arteriovenous Fistulae : The Strategies for Endovascular Treatment

PURPOSE

Most cavernous sinus dural arteriovenous fistulas (CSDAVF) are unilateral; however, simultaneous bilateral CSDAVFs occasionally may be found. This article reports on 141 patients and compares the angioarchitecture and outcomes of embolization of bilateral CSDAVFs with those of unilateral CSDAVFs, with reference to limited demographics (sex and age) of the patients.

METHOD

From January 2010 to February 2018 a total of 141 consecutive patients with CSDAVFs were referred for transvenous embolization. Bilateral CSDAVFs were found in 20 patients (14.2%, with a mean age of 62.2 years). The angioarchitecture of the 141 patients with CSDAVFs were evaluated by conventional cerebral angiography. We compared the angioarchitecture and treatment outcomes of 20 bilateral and 121 unilateral CSDAVFs, and in relation to the patients' sex and age.

RESULTS

Female patients significantly dominated the bilateral CSDAVFs (90%, p = 0.043). Bilateral eye symptoms were significantly more common in bilateral CSDAVFs (p = 0.011), with dominant orbital and cavernous symptoms, and showed statistical significance (p = 0.049 and 0.011, respectively). Occlusion of one CSDAVF may significantly decrease the fistula flow of the other untreated side (n = 13, 65%), leading to less coil utilization for embolization in bilateral CSDAVFs (p < 0.001). There was no statistical significance in the occurrence of occlusion of the inferior petrous sinus(s), in pial vein reflux, and treatment outcomes in the unilateral and bilateral CSDAVFs.

CONCLUSION

Bilateral CSDAVFs were more dominant in female patients and frequently presented with orbital and cavernous symptoms. Fewer coils were used per lesion in the bilateral CSDAVFs. There was no statistical significance in bilateral and unilateral CSDAVFs in terms of impact of venous drainage, pial vein reflux and treatment outcomes.

Results of 1940 embolizations for dural arteriovenous fistulas: Japanese Registry of Neuroendovascular Therapy (JR-NET3)

OBJECTIVE

Embolization is the most common treatment for dural arteriovenous fistulas (dAVFs). A retrospective, multicenter observational study was conducted in Japan to clarify the nature, frequency, and risk factors for complications of dAVF embolization.

METHODS

Patient data were derived from the Japanese Registry of Neuroendovascular Therapy 3 (JR-NET3). A total of 40,169 procedures were registered in JR-NET3, including 2121 procedures (5.28%) in which dAVFs were treated with embolization. After data extraction, the authors analyzed complication details and risk factors in 1940 procedures performed in 1458 patients with cranial dAVFs treated with successful or attempted embolization.

RESULTS

Transarterial embolization (TAE) alone was performed in 858 cases (44%), and transvenous embolization (TVE) alone was performed in 910 cases (47%). Both TAE and TVE were performed in one session in 172 cases (9%). Complications occurred in 149 cases (7.7%). Thirty-day morbidity and mortality occurred in 55 cases (2.8%) and 16 cases (0.8%), respectively. Non-sinus-type locations, radical embolization as the strategy, procedure done at a hospital that performed dAVF embolization in fewer than 10 cases during the study period, and emergency procedures were independent risk factors for overall complications.

CONCLUSIONS

Complication rates of dAVF embolization in Japan were acceptable. For better results, the risk factors identified in this study should be considered in treatment decisions.

Newly occurring cranial nerve palsy after endovascular treatment of cavernous sinus dural arteriovenous fistulas

OBJECTIVE

Cranial nerve palsy (CNP) is rarely reported after endovascular intervention for cavernous sinus dural arteriovenous fistulas (CS DAVFs). Our aim was to evaluate the treatment outcomes of CS DAVFs, and the clinical course and risk factors of newly occurring CNPs, with a review of the literature.

METHODS

121 patients with 134 lesions treated in our institution were selected. They were retrospectively analyzed in terms of baseline characteristics, radiologic results, clinical outcome, and newly occurring CNPs after treatment. Angiographic and clinical follow-up data were available for 104 lesions (77.6%) and 130 lesions (97.0%), respectively.

RESULTS

The angiographic results showed partial:complete obliterations in 13:91 (87.5%) at the final follow-up. Clinical outcomes were deteriorated or no change:improved or completely recovered (3:126 (96.9%)) at the final follow-up. New CNPs occurred in 24 patients (19.8%), including the sixth CNP alone or mixed in 23 patients (95.8%). 23 cases were completely recovered or improved (21 and 2 cases, respectively), and 19 (90.4%) of 21 were completely recovered within 6 months after treatment. In the multivariate analysis, pretreatment cranial nerve symptoms (OR=0.33; 95% CI 0.14 to 0.76; P=0.010) and complete obliteration immediately after treatment (OR=0.32; 95% CI 0.12 to 0.85; P=0.021) were significant preventive factors for new CNPs. Embolization in the posterior compartments of the CS (OR=5.15; 95% CI 1.71 to 15.47; P=0.004) was a significant risk factor.

CONCLUSIONS

Endovascular intervention was satisfactory in patients with CS DAVFs. The prognosis of newly occurring CNPs was favorable.

Venous outflow restriction as a predictor of cavernous sinus dural arteriovenous fistula obliteration after Gamma Knife surgery

OBJECTIVE

Gamma Knife surgery (GKS) obliterates 65%-87% of cavernous sinus dural arteriovenous fistulas (CSDAVFs). However, the hemodynamic effect on GKS outcomes is relatively unknown. The authors thus used the classification scheme developed by Suh et al. to explore this effect.

METHODS

The authors retrospectively (1993-2016) included 123 patients with CSDAVFs who received GKS alone at the institute and classified them as proliferative type (PT; n = 23), restrictive type (RT; n = 61), or late restrictive type (LRT; n = 39) after analyzing their pre-GKS angiography images. Treatment parameters, the presence of numerous arterial feeders, and venous drainage numbers were compared across the CSDAVF types. Patients' follow-up MR images were evaluated for the presence of complete obliteration. A Kaplan-Meier analysis was conducted to determine the correlation between CSDAVF types and outcomes.

RESULTS

The 36-month probability of complete obliteration was 74.3% for all patients, with no significant differences across types (p = 0.56). PT had the largest radiation volume (6.5 cm3, p < 0.001), the most isocenters (5, p = 0.015) and venous drainage routes (3, p < 0.001), and the lowest peripheral dose (16.6 Gy, p = 0.011) and isodose level coverage (64.3%, p = 0.006). CSDAVFs presenting with ocular patterns were less likely to be completely obliterated (hazard ratio 0.531, p = 0.009). After adjustment for age, CSDAVFs with more venous drainage routes were less likely to be completely obliterated (hazard ratio 0.784, p = 0.039).

CONCLUSIONS

GKS is an equally effective treatment option for all 3 CSDAVF types. Furthermore, the number of venous drainage routes may help in predicting treatment outcomes and making therapeutic decisions.

Superior ophthalmic vein and ophthalmic artery in immediate evaluation after endovascular treatment of carotid-cavernous fistulas

Purpose

To validate superior ophthalmic vein (SOV) and ophthalmic artery (OA) usefulness in immediate evaluation of new endovascular approaches to treat carotid-cavernous fistulas (CCFs).

Material and methods

A retrospective review of 597 intracerebral malformation embolisations yielded 40 embolisations of CCF in the treatment of 18 patients. Two interventional radiologists performed detailed radiological angiographic assessments.

Results

Mean age at initial admission was 58.9 years (SD 18.5 years, range 24-85 years). Patients presented with: chemosis (50%), ocular bruit (50%), exophthalmos (61%), diminished visual acuity (77.8%), headache (16.7%), and intracerebral haemorrhage (5.55%), and 5.55% were asymptomatic. Unilateral fistulas (10-55.5%) showed more diversified venous drainage pattern than bilateral ones (8-44.4%). There were statistically significant differences in post-traumatic and spontaneous CCF regarding age (p = 0.036), type of fistula (p = 0.0008), and presence of pseudoaneurysm (p = 0.036). 77.8% of patients had increased ipsilateral SOV diameter. SOV enlargement was not associated with type of fistula, history of trauma, or degree of exophthalmos. Ipsilateral ophthalmic artery was visible in all patients on both pre- and postprocedural angiography on lateral projection. Pre- and post-procedural SOV diameter was significantly different. Internal carotid artery patency was 100%, while the overall final angiographic or clinical success was 85.7%. We had three cases of peri-procedural complications.

Conclusions

We reported changeable dynamics of SOV and OA after endovascular treatment of CCFs and proved the feasibility of coils and Onyx-18 in the treatment thereof.

The routes for embolization of dural carotid cavernous fistulas when the endovascular approach is indicated as a first-line strategy

INTRODUCTION

Multiple ways to access the dural carotid cavernous fistula have been described. The aim of the present study was to assess the results of embolization of a dural carotid cavernous fistula via different routes using endovascular accesses as a first-line strategy.

METHODS

A retrospective data analysis of a consecutive series of 63 patients presenting with dural carotid cavernous fistula was performed.

RESULTS

The dural carotid cavernous fistula was accessed by an endovascular approach in 58 patients (92.1%) and by direct puncture in five patients (7.9%). The inferior petrosal sinus was the main route accessed (65%). A recanalization of an occluded inferior petrosal sinus was obtained in 20.6% of cases. The access via either facial ophthalmic veins or the superior petrosal sinus was obtained in 20.6% and 3.1% of cases, respectively. Complete angiographic occlusion of a dural carotid cavernous fistula immediately after treatment was achieved in 53 patients (84.1%), whereas 10 patients (15.9%) displayed a partial occlusion. Treatment-related complications were observed in two patients (3.2%).

CONCLUSIONS

In this study, the endovascular approach allowed dural carotid cavernous fistula embolization in most patients. The inferior petrosal sinus, even when thrombosed, was the main route used to access the dural carotid cavernous fistula, followed by the facial vein, direct cavernous sinus puncture, and the superior petrosal sinus.

Embolization of a cavernous carotid fistula through the vein of Labbé: a new alternative transvenous access route

Endovascular treatment of carotid cavernous fistulas (CCFs) via a transvenous approach is standard, but in rare cases this approach is challenging due to absence or thrombosis of the commonly used venous routes. A 61-year-old woman presented with a symptomatic CCF with all but one of the venous access routes to the CCF thrombosed, leaving an engorged superficial middle cerebral vein (SMCV) as the only venous outflow from the cavernous sinus. Access to the CCF was made possible after careful navigation of the sigmoid sinus, the vein of Labbé and the SMCV, bypassing the need for surgical access to the SMCV or for a direct transorbital puncture. The CCF was completely occluded by coiling and Onyx embolization. The patient made an uneventful recovery, with resolution of her symptoms. To the best of our knowledge, this access route has not been previously reported in the treatment of CCFs.

Novel Segmentation of Placed Coils in the Treatment of Cavernous Sinus Dural Arteriovenous Fistulas Provides a Reliable Predictor of the Long-Term Outcome in Abducens Nerve Palsy

OBJECTIVE

Abducens nerve palsy (ANP) after transvenous embolization (TVE) for cavernous sinus (CS) dural arteriovenous fistulas (DAVFs) sometimes persists. The aim of this study was to assess the correlation between the coil mass and the long-term outcome of ANP after TVE.

METHODS

Between January 2008 and July 2016, 33 patients with a CS DAVF underwent TVE at our institute. On the basis of the relationship to the internal carotid artery (ICA), we divided the lateral part of the CS into the following 3 portions: anterolateral, anterolateral to the anterior bend of the ICA; middle-lateral (ML), lateral to the horizontal segment of the ICA; and posterolateral, posterolateral to the posterior bend of the ICA.

RESULTS

ANP persisted in 4 patients. The number of coils (35.3 vs. 21.9 coils; P = 0.04), coil volume (198.4 vs. 103.6 mm³; P = 0.03), and coil volume in the ML (54.9 vs. 20.3 mm³; P = 0.01) were significantly greater in the ANP group than in the non-ANP group. In the logistic regression analysis, only the ML coil volume was significantly associated with the persistence of ANP (P = 0.04). Based on the receiver operating characteristic curve, the optimal cutoff value of the ML coil volume was 27.9 mm³ (sensitivity, 100%; specificity, 72.4%).

CONCLUSIONS

Overpacking in the ML of the CS should be avoided to prevent persistent ANP. The cutoff value of the ML coil volume may provide a good guide for the practical use of TVE for CS DAVFs.

Carotid-cavernous fistula: current concepts in aetiology, investigation, and management

A carotid-cavernous fistula (CCF) is an abnormal communication between arteries and veins within the cavernous sinus and may be classified as either direct or dural. Direct CCFs are characterized by a direct connection between the internal carotid artery (ICA) and the cavernous sinus, whereas dural CCFs result from an indirect connection involving cavernous arterial branches and the cavernous sinus. Direct CCFs frequently are traumatic in origin and also may be caused by rupture of an ICA aneurysm within the cavernous sinus, Ehlers-Danlos syndrome type IV, or iatrogenic intervention. Causes of dural CCFs include hypertension, fibromuscular dysplasia, Ehlers-Danlos type IV, and dissection of the ICA. Evaluation of a suspected CCF often involves non-invasive imaging techniques, including standard tonometry, pneumotonometry, ultrasound, computed tomographic scanning and angiography, and/or magnetic resonance imaging and angiography, but the gold standard for classification and diagnosis remains digital subtraction angiography. When a direct CCF is confirmed, first-line treatment is endovascular intervention, which may be accomplished using detachable balloons, coils, liquid embolic agents, or a combination of these tools. As dural CCFs often resolve spontaneously, low-risk cases may be managed conservatively. When invasive treatment is warranted, endovascular intervention or stereotactic radiosurgery may be performed. Modern endovascular techniques offer the ability to successfully treat CCFs with a low morbidity and virtually no mortality.

Focus on the target: Angiographic features of the fistulous point and prognosis of transvenous embolization of cavernous sinus dural arteriovenous fistula

Background and purpose Transvenous embolization (TVE) is widely utilized as an effective and safe treatment option for cavernous sinus dural arteriovenous fistula (CS-dAVF); however, detecting the exact location of the fistula is challenging. The present study identified the angiographic features of the fistulous point and evaluated the match with the microcatheter tip and fistulous point. Materials and methods An analysis cohort of 45 consecutive patients with CS-dAVF treated by TVE was analyzed retrospectively. The patients were divided into two groups, 22 matches and 23 mismatches, according to whether the fistulous point and the microcatheter tip were in the same compartment of the cavernous sinus (CS). The angiographic findings, the location of the fistulas, the position of the microcatheter tips, the volume of embolic materials, complications, and outcomes were assessed. Results Several angiographic features defined the fistulous points, such as the early opacified area, jellyfish-like sign, changes in the density of the contrast medium, the juncture of different arterial supply, enlarged feeders, and hand-injection angiograms. The fistulas were primarily in the posterosuperior portion of the CS (80%) and medial side (73.3%) according to the internal carotid artery. Both groups achieved effective TVE; the matched group required less embolic material than the mismatched group ( p = 0.024). The patients with cranial nerve dysfunction (CND) required more embolic materials than others ( p = 0.032). Conclusion The fistulous point in most of the CS-dAVFs could be isolated by careful analysis of the angiography images. The matching of the microcatheter tip and fistulous point in the same compartment of CS can reduce the dosage of embolic materials, and a low volume of embolic materials might cause fewer CND complications.

A Case of Right-Sided Direct Carotid Cavernous Fistula: A Diagnostic Challenge

Patient: Female, 83

Final Diagnosis: Right-sided direct carotid cavernous fistula

Symptoms: Chemosis • proptosis and eye pain

Medication: Topical α2-adrenergic agonist

Clinical Procedure: Endovascular embolization

Specialty: Internal Medicine • Interventional Radiology • Ophthalmology

[Neuro-ophthalmological symptoms of intracranial dural arteriovenous fistulas]

OBJECTIVE

The study objective was to identify the main neuro-ophthalmological symptoms of intracranial dural arteriovenous fistulas (dAVFs) with different localization, based on clinical and angiographic correlations.

MATERIAL AND METHODS

We analyzed neuro-ophthalmological symptoms in 272 patients with dAVFs verified by direct angiographic examination. The localization of dAVFs was as follows: the cavernous sinus (CS) - 143 patients, the lateral sinuses (LSs) and the confluence of sinuses - 77 patients, and other locations - 52 patients.

RESULTS

Neuro-ophthalmological symptoms were detected in 163 (60%) patients. The symptoms were most typical of fistulas located in the CS (99% of patients with CS dAVFs). Neuro-ophthalmological symptoms were less typical of fistulas located in the LS and confluence (21% of patients with LS dAVFs) and dAVFs located outside of the CS and LS (9.6% of patients). Two main neuro-ophthalmological syndromes of intracranial dAVFs were identified: syndrome of obstructed venous outflow from the orbit and syndrome of intracranial hypertension (ICH). A correlation between neuro-ophthalmological symptoms and changes in the cerebral venous hemodynamics was found.

CONCLUSION

The syndrome of obstructed venous outflow from the orbit is pathognomonic for CS dAVFs. In some cases, obstruction of venous outflow from the orbit was observed in patients with dAVFs of other localization, with involvement of the CS and orbital veins in drainage of the fistula. The ICH syndrome reflects the most significant obstruction of venous outflow from the cranial cavity, which is characteristic of LS dAVFs with retrograde outflow in the sinuses and cerebral veins.

Bilateral carotid cavernous sinus fistula: a case report and review of the literature

Carotid cavernous fistula (CCF) is an abnormal vascular shunt from the carotid artery to the cavernous sinus. They are commonly classified based on hemodynamics, etiology or anatomically. Hemodynamic classification refers to whether the fistula is high or low flow. Etiology is commonly secondary to trauma or can occur spontaneously in the setting of aneurysm or medical conditions predisposing to arterial wall defects. Bilateral carotid cavernous fistulas are rare. We present a case of bilateral CCF secondary to trauma. Ophthalmology was urgently consulted to assess the patient in the intensive care unit (ICU) for red eye. The patient was found to have decreased vision, increased intraocular pressure, an afferent pupillary defect, proptosis, chemosis, and ophthalmoplegia. Subsequent neuro-imaging confirmed a bilateral CCF. The patient underwent two endovascular embolization procedures. Trauma is the most common cause of CCF and accounts for up to 75% of cases. Most common signs of CCF depend on whether it is high or low flow. High-flow CCF may present with chemosis, proptosis, cranial nerve palsy, increased intraocular pressure, diplopia, and decreased vision. Cerebral angiography is the gold standard diagnostic modality. First-line treatment consists of endovascular embolization with either a metallic coil, endovascular balloon or embolic agent. It is unclear in the literature if bilateral cases are more difficult to treat or have a different prognosis. Our patient required two endovascular procedures suggesting that endovascular intervention may have reduced efficacy in bilateral cases.

Long-term outcome after endovascular treatment of cavernous sinus dural arteriovenous fistula and a literature review

BACKGROUND

The long-term efficacy of endovascular treatment (EVT) for cavernous sinus dural arteriovenous fistulae (CS-dAVF) was assessed with a special focus on residual shunts after initial EVT.

PATIENTS AND METHODS

This retrospective survey included 50 patients who had undergone EVT and were followed for 1 month or longer (median follow-up 56 months).

RESULTS

Common preoperative symptoms were chemosis (78%), extra-ocular motor palsy (72%), exophthalmos (66%), and tinnitus (26%). CS-dAVF were addressed by transvenous embolization (tVE, n = 48), tVE only was used in 43 instances and tVE plus transarterial embolization (tAE) in five. Two patients underwent tAE only. Procedure-related morbidity (brainstem infarction) was recorded in one patient (2%) and transient symptom exacerbation (paradoxical worsening) in 12 patients (24%). Postoperative digital subtraction angiography showed no major retrograde shunt or cortical venous reflux in any of the 50 patients. Anterograde or minor retrograde residual shunt was observed in 17 patients (34%); three of these underwent additional tVE and four had Gamma Knife surgery. The shunt flow disappeared in all 17 patients 12.6 ± 13.4 (mean ± SD) months after initial EVT. At the latest follow-up, 65.7 ± 52.6 months after the initial operation, no shunt flow was observed in any of the 50 patients. None had remaining or newly developed chemosis or tinnitus on follow-up. The rate of persistent cavernous sinus symptoms at the latest follow-up was higher in patients with than without post-procedural paradoxical worsening (5/12, 41.7% vs. 2/38, 5.3%, p = 0.0059 by Fisher's exact test).

CONCLUSIONS

Long-term follow-up showed that EVT, especially tVE, is an efficient and safe treatment for CS-dAVF. It resulted in the eventual disappearance of shunt flow. Residual shunt without major retrograde flow or cortical venous reflux can be monitored without additional treatment.

Efficacy of Cone Beam Computed Tomography in Treating Cavernous Sinus Dural Arteriovenous Fistula

BACKGROUND

Exact identification of feeding arteries, shunt points, and draining veins is essential in treating cavernous sinus dural arteriovenous fistula (CS dAVF). In addition to digital subtraction angiography (DSA) and 3-dimensional rotational angiography (3DRA), high-resolution cone beam computed tomography (CBCT; especially 80-kv high-resolution cone beam computed tomography) have been performed in recent years. We evaluated the efficacy of CBCT in treating CS dAVF.

METHODS

Eight CS dAVFs were treated with endovascular embolization between January 2013 and December 2016. We retrospectively examined these cases regarding information from DSA, 3DRA, and CBCT with contrast medium.

RESULTS

Although all procedures can evaluate feeding arteries, shunt points, and draining veins, CBCT can provide the best definition of feeders and their course through the bony structures and the compartment of CS. Therefore, CBCT with placed microcatheter in the CS can reveal whether the microcatheter is set at the appropriate compartment to be embolized.

CONCLUSIONS

The efficacy of CBCT in treating dAVF is illustrating the relationships among the bony structures and feeders, compartment of CS, and the position of the microcatheter. Detailed information obtained with CBCT can lead to fewer complications and more effective treatment.

Embolization of a cavernous carotid fistula through the vein of Labbé: a new alternative transvenous access route

Endovascular treatment of carotid cavernous fistulas (CCFs) via a transvenous approach is standard, but in rare cases this approach is challenging due to absence or thrombosis of the commonly used venous routes. A 61-year-old woman presented with a symptomatic CCF with all but one of the venous access routes to the CCF thrombosed, leaving an engorged superficial middle cerebral vein (SMCV) as the only venous outflow from the cavernous sinus. Access to the CCF was made possible after careful navigation of the sigmoid sinus, the vein of Labbé and the SMCV, bypassing the need for surgical access to the SMCV or for a direct transorbital puncture. The CCF was completely occluded by coiling and Onyx embolization. The patient made an uneventful recovery, with resolution of her symptoms. To the best of our knowledge, this access route has not been previously reported in the treatment of CCFs.