Transarterial embolization of dural arteriovenous fistulas of the anterior cranial fossa with Onyx

Transarterial embolization for anterior cranial fossa dural arteriovenous fistulas: a retrospective single-center study

BACKGROUND

Clip ligation of anterior cranial fossa (ACF) dural arteriovenous fistulas (DAVFs) is the traditionally accepted first-line treatment. Endovascular treatment for ACF DAVFs may achieve good outcomes as endovascular techniques advance. Here we report the clinical and angiographic outcomes in patients with ACF DAVFs who underwent transarterial embolization (TAE) as first-line treatment.

METHODS

Over a 20-year period, 87.0% (40/46) of patients received TAE as first-line treatment. The clinical presentation, angiographic features, treatment strategy, and clinical and angiographic outcomes are described in this article.

RESULTS

Forty patients underwent TAE as first-line treatment. There were 36 men and 4 women, with a mean age of 55.6 (55.6±7.4) years. A total of 64 embolization attempts were performed. The middle meningeal artery (66.7%, 12/18) and the ophthalmic artery (54.2%, 13/24) were the most frequently used arterial access routes for complete embolization. The second option was the sphenopalatine artery (46.7%, 7/15). Complications, that is, retinal ischemia, occurred in one patient (2.5%). The total immediate complete occlusion rate for TAE was 82.5% (33/40). Two patients needed surgery for incomplete embolization. When followed up (90%, 36/40), one patient (2.8%, 1/36) reported worsening symptoms due to retinal ischemia following TAE. Although fewer than 50% of the patients received digital subtraction angiography follow-up, there were no recurrences.

CONCLUSIONS

We show that TAE is safe and effective in the treatment of ACF DAVFs in this study of 40 patients, making it a viable alternative to surgical ligation and transvenous embolization. More research is needed to compare these various treatment modalities.

Feasibility, safety, and efficacy of endovascular treatment of anterior cranial fossa dural arteriovenous fistulas: a systematic review and meta-analysis with a subanalysis for Onyx

Dural Arteriovenous Fistulas (dAVFs) of the anterior cranial fossa (ACF) are uncommon but carry a high risk of hemorrhage and pose substantial treatment challenges. Recent advancements in endovascular treatment (EVT), including the introduction of novel liquid embolic agents, have markedly bolstered EVT's role in managing ACF-dAVFs, with notable series published in the last five years. We aimed to assess the feasibility, safety, and efficacy of EVT for ACF-dAVFs. We searched Medline, Scopus, Web of Science, and Cochrane Library databases following PRISMA guidelines. Eligible studies included those with ≥ 5 patients undergoing embolization of ACF-dAVFs, detailing both angiographic and clinical outcomes. We used single proportion analysis with 95% confidence intervals under a random-effects model, I2 to assess heterogeneity, and Baujat and sensitivity analysis to address high heterogeneity. Publication bias was assessed by funnel-plot analysis and Egger's test. Outcomes included complete occlusion following embolization, unsuccessful endovascular embolization attempts, incomplete occlusion following embolization, symptom resolution or clinical improvement following embolization, recurrence; procedure-related complications, morbidity, and mortality. Additionally, a subanalysis for studies exclusively utilizing Onyx™ embolic system was done. Eighteen studies comprising 231 ACF-dAVF were included. Unsuccessful endovascular embolization attempts rate was 2%. Complete occlusion rate was 85%, with 4% of complications. Incomplete occlusion rate was 10%. Successfully embolized patients experienced either symptom resolution or clinical improvement in 94% of cases. Morbidity and mortality rates were 1% and 0%, respectively. Onyx subanalyses showed an overall rate of 0% for unsuccessful attempts, 95% for complete occlusion, and 5% for incomplete occlusion. Symptom resolution or clinical improvement was 98% and recurrence rate was 0%. EVT for ACF-dAVF is highly feasible, effective, and safe, with a low rate of complications, morbidity, and mortality. The subanalyses focusing on Onyx embolizations revealed superior efficacy and safety outcomes compared to the findings of the primary analyses involving all included studies.

Simultaneous bilateral application of the Scepter mini balloon microcatheter for occlusion of ethmoidal dural arteriovenous fistulas

Ethmoidal dural arteriovenous fistulas are a rare entity accounting for 10 % of all dAVFs.3-6 Haemorrhage occurs in up to 91 % of cases, which is a particularly high risk and warrants therapeutic intervention.8-9 Endovascular treatment for these fistulas using the conventional detachable microcatheter technique is associated with certain limitations and risks; 8.3 % rate of incomplete obliteration and an 8.3 % rate of complications. Complications include reflux of liquid embolic agent, posterior ischaemic optic neuropathy, acute visual loss, and small subdural haematoma secondary to a micro-perforation.8,10-12 We present our recent experience with the Scepter Mini Balloon Microcatheter for the endovascular treatment of ethmoidal dural arteriovenous fistulas in 3 patients, involving bilateral simultaneous inflation of the balloon. It demonstrates a novel application of this technology with good outcomes. It supports the use of this microcatheter in treating ethmoidal dural arteriovenous fistulas endovascularly, either as a first-line option or as an adjunct to surgery.

A case of cribriform plate dural arteriovenous fistulas with a rare complication after endovascular therapy

Background:

Cribriform plate dural arteriovenous fistulas (dAVFs) are rarely encountered. Here, we report a case of cribriform plate dAVF with a rare complication after endovascular therapy.

Case Description:

A 60-year-old man presented with severe sudden headache. Head computed tomography showed right subdural hematoma, and magnetic resonance angiography showed dilated bilateral frontal cortical vein. Digital subtraction angiography revealed cribriform plate dAVF fed by the anterior and posterior ethmoidal branches of the bilateral ophthalmic arteries. Transarterial embolization with liquid embolic material was performed and the fistula disappeared. Although magnetic resonance imaging showed the disappearance of the cribriform plate dAVF and subdural hematoma, the patient complained of anosmia after the procedure.

Conclusion:

Endovascular embolization is an effective treatment option for treating cribriform plate dAVFs. However, anosmia is a possible complication, and endovascular surgeons should take care of this complication, especially in cribriform plate dAVFs supplied with blood bilaterally.

Foramen Caecum Vein Involved in Dural Arteriovenous Fistula Fed by Sphenopalatine Arteries: A Case Report

Anterior cranial fossa (ACF) dural arteriovenous fistulas (ACF DAVFs) are an infrequent subtype of cranial DAVFs that are usually fed by the anterior ethmoidal artery (AEA) and ophthalmic artery (OA) branches. Due to the lack of dural venous sinus in the ACF, they directly drain into cortical veins, resulting in high bleeding tendency. For this reason, ACF DAVFs have to be treated regardless of whether they are symptomatic or not. A 74-year-old man, with hypertension history, came to our attention because of ear pain, dizziness, and impaired hearing for 2 months. No other pathological conditions have been found in his medical history. The patient underwent brain magnetic resonance imaging (MRI) scan and subsequently second level diagnostic investigations with digital subtraction angiography (DSA), showing a foramen caecum (FC) patency and a persistent, enlarged, arterialized FC vein (FCV) involved in an incidental ACF DAVF (Cognard IV), fed mainly by sphenopalatine arteries (SPAs) branches bilaterally. The patient underwent open surgery performed by small high frontal craniotomy with DAVFs complete closure and without any complications. To the best of our knowledge, this is the first case ever described of FCV persistence with involvement in an intracranial vascular malformation. It has been managed by surgical intervention that can be considered, despite the large skin incision, a minimally invasive approach with an excellent cosmetic result and minimal risk of complications.

Transarterial embolization through the infraorbital artery of the ethmoidal dural arteriovenous fistula causing recurrent epistaxis: illustrative case

BACKGROUND

This report describes an ethmoidal dural arteriovenous fistula (DAVF) presenting with the unusual symptom of recurrent epistaxis and successfully treated with selective transarterial embolization through the infraorbital artery (IOA), which is the first time this route was used to the best of the authors’ knowledge, and reviews the literature focusing on the anatomical consideration of ethmoidal DAVFs causing epistaxis and its treatment approaches.

OBSERVATIONS

A 70-year-old man experienced recurrent intractable epistaxis that bled like a faucet turned on. Cerebral angiography revealed an ethmoidal DAVF supplied by the left anterior ethmoidal artery, both sphenopalatine arteries, both IOAs, and the right angular artery, which drained directly into the frontal cortical veins with a tortuous arterialized ectasia. Microaneurysms around the fistulous location where multiple feeding arteries converge were demonstrated and considered the likely source of the epistaxis. The fistula was completely occluded using transarterial Onyx embolization through the IOA, a branch of the internal maxillary artery. No further epistaxis appeared.

LESSONS

Although extremely rare, ethmoidal DAVFs should be included in the differential diagnosis of recurrent epistaxis. Ethmoidal DAVFs with bleeding sources in the ethmoid sinus and nasal cavity may cause epistaxis. It is important to properly diagnose and treat ethmoidal DAVFs presenting with epistaxis on the basis of a comprehensive anatomical understanding of extensive extracranial-extracranial and extracranial-intracranial anastomoses.

Efficacy and safety of embolization of dural arteriovenous fistulas via the ophthalmic artery

INTRODUCTION

Dural arteriovenous fistulae (DAVF) are vascular lesions with arteriovenous shunting that may be treated with surgical obliteration or endovascular embolization. Some DAVF, such as anterior cranial fossa DAVF (AC-DAVF) derive their arterial supply from ophthalmic artery branches in nearly all cases, and trans-arterial embolization carries a risk of vision loss. We determined the efficacy and safety of trans-ophthalmic artery embolization of DAVF.

MATERIALS AND METHODS

We performed a retrospective cohort study of all patients with DAVF treated by trans-ophthalmic artery embolization from 2012 to 2020. Primary outcome was angiographic cure of the DAVF. Secondary outcomes included vision loss, visual impairment, orbital cranial nerve injury, stroke, modified Rankin Scale at 90-days, and mortality.

RESULTS

12 patients met inclusion criteria (9 males; 3 females). 10 patients had AC-DAVF. Patient age was 59.7  ±  9.5 (mean ± SD) years. Patients presented with intracranial hemorrhage (4 patients), headache (4 patients), amaurosis fugax (1 patients), or were incidentally discovered (2 patients). DAVF Cognard grades were: II (1 patient), III (6 patients), and IV (5 patients). DAVF were embolized with Onyx (10 patients), nBCA glue (1 patient), and a combination of coils and Onyx (1 patient). DAVF cure was achieved in 11 patients (92%). No patients experienced vision loss, death, or permanent disability. One patient experienced a minor complication of blurry vision attributed to posterior ischemic optic neuropathy. 90-day mRS was 0 (10 patients) and 1 (2 patients).

CONCLUSIONS

Trans-ophthalmic artery embolization is an effective and safe treatment for DAVF.

Anterior Cranial Fossa Dural Arteriovenous Fistulae - Angioarchitecture and Intervention

PURPOSE

Anterior cranial fossa (ACF) dural arteriovenous fistulae (DAVF) are rare, unique, and ominous. While surgical disconnection is considered as the favored management option, endovascular treatment has lately gained importance. We present a single institution experience of seven cases.

METHOD

A retrospective analysis was performed on the institutional patient database. Features analyzed were demographic details, symptoms, angioarchitecture, treatment course, angiographic results, procedural complications, and follow-up.

RESULTS

This study included seven patients. The age at presentation ranged from 5-67 years. Clinical symptomatology was as intracranial hemorrhage in 4 patients and headache, chemosis and seizures in one patient each. The fistulae were paramedian at the ACF base. All DAVFs were Cognard type 4. The arterial feeders were from the anterior ethmoidal branches of the ophthalmic artery in all cases (bilateral in n = 5), frontal branches of the middle meningeal artery (MMA) (n = 6), and multiple ECA branches. The arterial route was the choice for access. Complete fistula obliteration was achieved in all but one patient. A traversed vein underwent rupture in one patient. One patient suffered postsurgical hemorrhage. No clinical or angiographic recurrence was noted.

CONCLUSION

The DAVFs of the ACF are inherently high-grade lesions. Transorbital ECA-ICA branch anastomoses may be recruited as feeders. They may be best managed by multidisciplinary means personalized on an angioarchitectural basis. Endovascular embolization is safe and efficacious when performed through a navigable feeder from the frontal division of the MMA, which according to our interpretation is in anastomosis with the anterior falcine branch of the anterior ethmoidal artery.

Initial experience with the Scepter Mini dual-lumen balloon for transophthalmic artery embolization of anterior cranial fossa dural arteriovenous fistulae

BACKGROUND

Precise delivery of liquid embolic agents (LEAs) remains a challenge in the endovascular treatment of dural arteriovenous fistulae (dAVFs) and cerebral arteriovenous malformations (cAVMs). Despite significant advances in the past decade, LEA reflux and catheter navigability remain shortcomings of current endovascular technology, particularly in small and tortuous arteries. The Scepter Mini dual-lumen balloon microcatheter aims to address these issues by decreasing the distal catheter profile (1.6 French) while allowing for a small (2.2 mm diameter) balloon at its tip.

METHODS

We report our initial experience with the Scepter Mini in two patients with anterior cranial fossa dAVFs that were treated with transophthalmic artery embolization.

RESULTS

In both patients, the Scepter Mini catheter was able to be safely advanced into the distal ophthalmic artery close to the fistula site, and several centimeters past the origins of the central retinal and posterior ciliary arteries. A single Onyx injection without any reflux resulted in angiographic cure of the dAVF in both cases, and neither patient suffered any vision loss.

CONCLUSIONS

These initial experiences suggest that the Scepter Mini represents a significant advance in the endovascular treatment of dAVFs and cAVMs and will allow for safer and more efficacious delivery of LEAs into smaller and more distal arteries while diminishing the risk of LEA reflux.

Clinical Characteristics and Microsurgery Treatment of Anterior Cranial Fossa Dural Arteriovenous Fistula

Anterior cranial fossa dural arteriovenous fistulas (DAVFs) represent 6% of all intracranial DAVFs and have a high risk of intracranial hemorrhage. To analyze the clinical characteristics and microsurgery treatment of anterior cranial fossa DAVFs, a retrospective review of 21 patients with anterior cranial fossa DAVFs undergoing microsurgery was performed, including 8 bleeding patients and 13 non-bleeding patients. The Glasgow coma scale (GCS) scores were used to evaluate the conscious states of 8 bleeding patients before and after operation. All patients had no obvious complications and the clinical symptoms were improved after operation. No abnormal fistulas and drainage veins were detected by digital subtraction angiography postoperatively. The GCS scores of 8 bleeding patients showed that the conscious states became better than pre-operation. Of the 21 patients, 9 patients were followed up without recurrence. Taken together, microsurgery is an effective method for the treatment of anterior cranial fossa DAVFs and it is very important for the improvement of bleeding patients' conscious states.

Treatment of Ethmoidal Dural Arteriovenous Fistulas: A Meta-analysis Comparing Endovascular versus Surgical Treatment

BACKGROUND

Dural arteriovenous fistulas (DAVFs) in the anterior cranial fossa constitute approximately 1%-1.5% of intracranial vascular malformations. Depending on the drainage patterns, the diagnosis of ethmoidal DAVFs should prompt treatment because of the high risk of bleeding. Available treatments strategies are surgical treatment and the endovascular approach.

OBJECTIVE

To compare the surgical treatment with the endovascular therapy in terms of complete obliteration and perioperative adverse events.

METHODS

This study was performed according to the PRISMA guidelines. Eligible studies were identified through a search of PubMed and Cochrane until February 2019. A random effects model meta-analysis of odds ratios (OR) was conducted and the I-square was used to assess heterogeneity. Good outcome was defined as no neurologic deterioration within 30 days after the procedure.

RESULTS

Five studies comprising 81 patients were included in the meta-analysis. Surgical disconnection was superior to endovascular therapy in terms of postprocedural complete obliteration rate (surgery group, 100% [n = 65/65]; endovascular therapy, 47% [n = 15/32]; OR, 32.19; 95% confidence interval, 5.46-189.72; I² = 9.9%) and 30-day good outcome (surgery group, 98% [n = 63/64]; endovascular therapy, 47% [n = 15/32]; OR, 21.90; 95% confidence interval, 1.94-247.27; I² = 53.6%). No significant differences in terms of 30-day stroke, transient ischemic attack; visual deficit, new-onset seizure, and intracranial hemorrhage were identified.

CONCLUSIONS

Surgical treatment was superior to endovascular therapy in terms of complete obliteration and overall good outcome. Adverse event rates were similar between the 2 groups. Future studies should be conducted to validate our results.

Current status of endovascular treatment for dural arteriovenous fistulae in the anterior cranial fossa: A systematic literature review

Anterior cranial fossa (ACF) dural arteriovenous fistulae (DAVFs) are rare, and a systematic review of the literature is lacking. Such a review is necessary, however, so a systematic PubMed search of related studies was performed. Twenty-four studies were identified, reporting on 48 patients, of whom 39 had definite age and sex information and 33 (84.6%, 33/39) were male. The afflicted patients were between 37 and 80 years old (mean 55.6). Among the 48 patients, 28 (58.3%, 28/48) primarily presented with intracranial hemorrhage, 47 (97.9%, 47/48) had feeding arteries from the anterior ethmoidal artery (AEA) of the ophthalmic artery (OA), and 40 (83.3%, 40/48) had bilateral feeding arteries. All of the cases had high-grade Cognard classifications (III-IV). Among the 48 patients, 43 (89.6%, 43/48) had drainage into the superior sagittal sinus (SSS). In addition, 36 (75%, 36/48) patients were treated via transarterial embolization (TAE). Of these patients, 28 (77.8%, 28/36) were managed via the AEA of the OA. Another 12 (25%, 12/48) patients were treated via transvenous embolization (TVE), 11 of whom (91.7%, 11/12) were treated with the trans-SSS approach. Complete angiographic cure was achieved in 44 (91.7%, 44/48) patients, with 4 (8.3%, 4/48) patients suffering from postprocedural complications. All 48 patients had clear descriptions of follow-up outcomes, with 45 (93.8%, 45/48) patients having a good outcome. Thus, when treating ACF DAVFs, endovascular treatment (EVT) can completely obliterate the fistula point and correct the venous shunting. EVT is therefore an effective treatment for ACF DAVF. Although many complications can occur, this approach achieves good outcomes in most cases.

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.

Surgical treatment of anterior cranial fossa dural arterio-venous fistulas (DAVFs): a two-centre experience

BACKGROUND

Anterior cranial fossa dural arterio-venous fistulas (DAVFs) represent 6% of all intracranial DAVFs; characteristically they show an aggressive behaviour with high risk of intracranial haemorrhage. Peculiar anatomical features, such as feeding by the ethmoidal arteries and the pattern of venous drainage (frequently with varices that mimic aneurysmal dilatation), can be evaluated in detail only by digital subtraction angiography (DSA), which represents the "gold standard" in the diagnosis of such cranial fistulas. Recent technological developments in endovascular management of this type of DAVF have partially reduced the morbidity risk related to this modality of treatment. Our purpose is to present our experience in the surgical management of 14 patients with anterior cranial fossa DAVFs, with attention paid to the possible role of preoperative embolisation in these cases and to the surgical technique.

METHOD

Between 1999 and 2015, 14 patients with anterior cranial fossa DAVFs were submitted to surgery in two neurosurgical departments; the mean age was 63 years old; nine DAVFs caused intracranial haemorrhage (subarachnoid haemorrhage in three cases, intracerebral haemorrhage in six cases). Pre-operative embolisation was attempted in an early case and was successfully done in one recent case. In all patients, the surgical approach chosen was a pterional craniotomy with a low margin on the frontal bone in order to gain the exposure of the anterior cranial fossa and especially of the olphactory groove region; the resection of the falx at its insertion on the crista galli was needed in five cases in order to get access to the contralateral afferent vessels. Cauterisation of all the dural feeders on and around the lamina cribrosa was needed in all cases; venous dilatations were evident in eight patients (in seven out of nine patients with ruptured DAVF and in one out of five patients with unruptured DAVF) and were removed in all cases. One patient harboured an ophthalmic artery aneurysm, which was excluded by clipping.

RESULTS

One patient died 5 days after surgery due to the severity of the pre-operative haemorrhage. Postoperative DSA showed the disappearance of the DAVF and of the venous pseudo-aneurysms in all cases. Clinical outcome was favourable (without neurological deficits) in 11 patients; three patients presented an unfavourable clinical outcome, due to the severity of the initial haemorrhage.

CONCLUSIONS

Surgical exclusion of the anterior cranial fossa DAVFs still represents the gold standard for such lesions, due to low post-operative morbidity and to complete protection against future rebleedings; endovascular techniques may help the surgeon in complex cases.

Transfrontal sinus approach for an anterior cranial fossa, ethmoidal, dural arteriovenous fistula

Background:

Ethmoidal dural arteriovenous fistulas (eDAVFs) are usually approached via a pterional or a frontal craniotomy. A more direct route to the fistula is possible through a purely transfrontal sinus approach. The aim of this report is to illustrate the interest of transsinus frontal approach for eDAVFs.

Case Description:

The transfrontal sinus approach is described and illustrated in a case of an ethmoidal arteriovenous fistula. This approach is the most direct when treating an eDAVF surgically, allowing preserving neural structures with minimal to no brain manipulation.

Conclusion:

For eDAVFs, the purely transfrontal sinus approach is highly worth considering in cases of large frontal sinuses.

Embolization of dural arteriovenous fistula of the anterior cranial fossa through the middle meningeal artery with Onyx

OBJECTIVE

Dural arteriovenous fistula (DAVF) of the anterior cranial fossa is usually treated by surgical disconnection or endovascular embolization via the ophthalmic artery. The middle meningeal artery is a rarely used approach. This study investigated the safety and efficacy of embolization of DAVF of the anterior cranial fossa with Onyx through the middle meningeal artery.

METHODS

A retrospective review of a prospective cerebral vascular disease database was performed. Patients with DAVF of the anterior cranial fossa managed with embolization through the middle meningeal artery with Onyx were selected. Information on demography, symptoms and signs, angiographic examinations, interventional treatments, angiographic and clinical results, and follow-up was collected and analyzed.

RESULTS

Five patients were included in this study, four of whom had hemorrhage. All fistulas were fed by the bilateral ethmoidal arteries arising from the ophthalmic artery and by the anterior branch of the middle meningeal artery. The abnormal shunt unilaterally drained into the superior sagittal sinus with interposition of the cortical veins all five patients. All endovascular treatments were successful with evidence of an angiographic cure. No complications occurred, and all patients recovered uneventfully without neurologic deficits. There were nearly no symptoms among the patients during follow-up.

CONCLUSION

Embolization of DAVF of the anterior cranial fossa via the middle meningeal artery with Onyx is safe, effective, and a good choice for management of DAVF. More cases are needed to verify these findings.