Transarterial Onyx Embolization for Patients with Cavernous Sinus Dural Arteriovenous Fistulas Who Have Failed Transvenous Embolization

Transarterial embolization in non-cavernous and cavernous sinus dural arteriovenous fistulas: A systematic review and meta-analysis of proportions

BACKGROUND

Transarterial embolization (TAE) is pivotal in managing non-cavernous and cavernous sinus dural arteriovenous fistulas (CSDAVFs).

METHODS

Systematic searches were conducted across ScienceDirect, Medline, and Cochrane databases for longitudinal studies on TAE outcomes in non-CSDAVFs and CSDAVFs. Post-procedural outcomes, including complete, incomplete, and failed AVFs obliteration, and end-study outcomes were analyzed.

RESULTS

Our meta-analysis involved 27 studies with 643 patients and 736 fistulas. Symptoms in both groups included tinnitus (29.74 %), ocular/visual symptoms (29.12 %), hemorrhage (19.42 %), and headache (19.11 %). Feeding arteries mainly originated from the meningeal arteries (49.16 %). In non-CSDAVFs cases, fistula locations were within sinus complexes (69.23 %) and specific dural areas (28.31 %). Complete AVFs obliteration was 81 % (95 %CI: 70 % - 90 %), slightly higher in non-CSDAVFs (82 %, 95 % CI: 69 % - 92 %) than CSDAVFs (79 %, 95 %CI: 58 % - 95 %). Incomplete obliteration occurred in 14 % (95 %CI: 5 % - 39 %), with rates of 11 % (95 %CI: 2 % - 26 %) in non-CSDAVFs and 19 % (95 % CI: 5 % - 39 %) in CSDAVFs. Failed obliteration was rare (1 %, 95 %CI: 0 % - 3 %), with similar rates in both groups. At end-study follow-up, resolution of AVFs was achieved in 97 % of cases (95 %CI: 92 % - 100 %). However, complications occurred in 17 % of cases (95 %CI: 10 % - 25 %), with a higher incidence in CSDAVFs (22 %, 95 %CI: 9 % - 37 %) compared to non-CSDAVFs (13 %, 95 %CI: 6 % - 23 %).

CONCLUSIONS

TAE with embolic agents demonstrates favorable outcomes in non-CSDAVFs and CSDAVFs, with high rates of AVFs obliteration and resolution. Complications, particularly in CSDAVFs, warrant careful consideration in treatment decisions.

Clinical features, treatment, and outcomes of cavernous sinus dural arteriovenous fistulas: a cohort study of 141 patients

PURPOSE

The cavernous sinus (CS) region is a common region of dural arteriovenous fistula (DAVF). Over time, treatment strategies are gradually changing. In this study, we present our center's experience in managing CS-DAVF over the past 20 years.

METHODS

Medical records of patients diagnosed with CS-DAVF between 2002 and 2021 were collected for analysis. Patients meeting the predefined inclusion and exclusion criteria were included. This study summarized and analyzed their clinical characteristics, CS-DAVF angioarchitecture, treatment strategies, and outcomes.

RESULTS

A total of 141 patients (mean age 55 years, 46 males) were included in this study. Ocular/orbital symptoms were the most frequently reported initial symptoms, with 84 (59.6%) patients experiencing these symptoms first. Presentation with ocular/orbital symptoms as the first symptom was associated with thrombosis of the inferior petrosal sinus (p = 0.032). Presentation with headache/dizziness and tinnitus/intracranial murmur as the first symptom was associated with sphenoparietal sinus/superficial middle cerebral vein drainage (p = 0.011). Among the patients, 131 (92.9%) patients received endovascular treatment, with 114 (87.0%) undergoing transvenous embolization. Onyx (92.4%) and coil (74.8%) were the most used embolic materials. 17 (13.0%) of the patients who received endovascular treatment suffered intraoperative or postoperative complications, and 11 (64.7%) patients fully recovered within 6 months after discharge.

CONCLUSION

Ocular/orbital symptoms were the most common first symptom of CS-DAVF. The mode of venous drainage played a significant role in determining the first symptoms. Transvenous embolization using Onyx or a combination of Onyx and coils was the primary treatment modality.

Bilateral cavernous sinus dural arteriovenous fistula with initial ocular symptom: A case report

RATIONALE

Cavernous sinus dural arteriovenous fistula (CSDAVF) is a rare intracranial vascular malformation. Because of its complicated clinical manifestations, it is easy to miss or misdiagnose CSDAVF.

PATIENT CONCERNS

A 42-year-old female had chief complaint that the right eyeball had conjunctival congestion for half a year. She was given levofloxacin eye drops to treat the right eye with anti-inflammatory treatment, but the symptoms did not improve. Cranial magnetic resonance and cerebrovascular imaging showed that the right lateral rectus muscle was slightly enlarged, the right eyeball was prominent, but there was no abnormality in the brain.

DIAGNOSES

Based on clinical and imaging examinations and digital subtraction angiography (DSA), she was diagnosed as low-flow CSDAVF.

INTERVENTIONS

The patient received interventional embolization with transvenous combined arterial approach using coils and Onyx liquid glue.

OUTCOMES

The patient's exophthalmos and congestion symptoms were improved.

CONCLUSION

DAS is the gold standard for the diagnose of CSDAVF. Intravascular embolization interventional therapy is an effective treatment for CSDAVF.

Targeted Transvenous Embolization of Cavernous Sinus Dural Arteriovenous Fistula With Liquid Materials Using a Dual-Lumen Balloon Microcatheter

We describe a challenging transvenous embolization technique involving a dual-lumen balloon microcatheter (DLBM) and liquid materials for cavernous sinus dural arteriovenous fistula (CSDAVF).

DLBM contributed to identifying the shunt point and preventing liquid material leakage to normal venous drainage without treatment-related complications. In a transvenous embolization using liquid materials for CSDAVF complications such as cranial nerve palsy and embolic agent migration into the internal carotid artery due to numerous anastomoses must be considered. The use of angiography during DLBM inflation to characterize the shunt point and DLBM to prevent liquid material leakage to the normal venous drainage might decrease the mass effect due to liquid materials, thereby minimizing the causes of newly occurring cranial nerve palsy.

This technique may be helpful for the treatment of CSDAVF in practice, but there is generally a risk in using liquid materials in the cavernous sinus; therefore, further consideration is needed in the future.

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.

Arterial Anatomy of the Parasellar Area

The arterial anatomy of the parasellar area is complex in that it deals with extracranial-intracranial anastomosis and supply to various cranial nerves in a small area. Pathologies such as hypervascular tumors and shunts are not uncommon and require good knowledge of anatomy in planning the treatment. In this article, the basic anatomy of the arterial supply in this region is discussed, covering the origins, territories, relation to the cranial nerves, and the connections among different systems.

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.

Transarterial Embolization of Cavernous Sinus Dural Arteriovenous Fistulas with Ipsilateral Inferior Petrosal Sinus Occlusion via the Ascending Pharyngeal Artery

BACKGROUND

Although the ipsilateral inferior petrosal sinus (IPS) is preferred for treatment of cavernous sinus dural arteriovenous fistulas (CS-dAVFs), this method is problematic if ipsilateral IPS is occluded. We describe our experience in treating CS-dAVFs with ipsilateral IPS occlusion via the ascending pharyngeal artery (APA).

METHODS

Between January 2013 and June 2017, of 36 CS-dAVFs, 23 with ipsilateral IPS occlusion were identified. Clinical charts, procedural data, angiographic results, and follow-up data were retrospectively reviewed.

RESULTS

Of 23 CS-dAVFs, 16 displayed a single or dominant feeding APA on cerebral angiography, of which 13 were treated via the APA initially. Fistulas were occluded successfully through the neuromeningeal trunk of the APA in 7 cases and through the superior pharyngeal branch of the APA in 3 cases. Glue leakage occurred in 2 cases via the superior pharyngeal branch of the APA, and superior pharyngeal branch rupture occurred during superselection of the microguidewire in 1 patient, who was treated by opening the occluded ipsilateral IPS. During the follow-up period, 12 of 13 patients had complete occlusion, and no cranial nerve palsy occurred.

CONCLUSIONS

CS-dAVF with ipsilateral IPS occlusion can be treated via various methods. Embolization through the APA as an initial access is a reasonable choice.

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.

Transvenous embolization of dural carotid cavernous fistulas: the role of liquid embolic agents in association with coils on patient outcomes

INTRODUCTION

Transvenous embolization is the standard treatment for dural carotid cavernous fistulas (DCCF). Although various embolic materials have been used, the best embolic material for the treatment of DCCF is still unknown.

OBJECTIVE

To assess the safety and efficacy of different embolic materials used for the endovascular treatment of DCCF.

METHODS

A retrospective data analysis of a consecutive series of 62 patients presenting DCCF was performed. Clinical and radiological data from patients were assessed, and the embolic material used-coils or liquids-were compared between two groups of patients.

RESULTS

Complete angiographic occlusion of DCCF after treatment was achieved in 83.9% of the patients (52/62). We found a higher rate of complete occlusion of DCCF when liquids were associated with coils than with coils alone (96.5% vs 71.8%, p=0.01), and no differences in complication rates or clinical outcomes were seen between the two groups. At the 6-month follow-up, we found a higher rate of improvement in ocular symptoms compared with cranial nerve palsy improvement (94.7% vs 77.7%, p=0.02). Two patients (3.2%) had treatment-related complications without clinical symptoms.

CONCLUSION

In this study, in comparison with the use of coils alone, the association of transvenous embolization with liquid embolic agents for DCCF treatment resulted in higher rates of complete occlusion without increasing complication rates. The clinical outcome at the 6-month follow-up showed significant improvement in ocular symptoms over cranial nerve palsy regression, which was independent of the embolic agent chosen for treatment.