Dural arteriovenous shunts in the region of the cavernous sinus

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.

Treatment for intracranial dural arteriovenous malformations: a meta-analysis from the English language literature

OBJECTIVE

The treatment of intracranial dural arteriovenous malformations (DAVMs) remains problematic. Options include ligature of feeding vessels, endovascular procedures, surgical obliteration, or a combination of the latter two. We conducted a meta-analysis of the English language literature on DAVMs to determine the most effective treatment option related to location and angiographic characteristics.

METHODS

The criteria for inclusion were pre- and post-treatment angiography, a description of the type of treatment, and clinical outcome. The analysis included a total of 258 patients, 248 from a review of 223 published articles and 10 from the authors' series. DAVMs were divided into six categories by location, and the results of treatment were compared based on obliteration rates using chi 2 analysis.

RESULTS

In transverse-sigmoid sinus DAVMs (n = 64), combined therapy (endovascular plus surgical treatment) proved significantly more effective than either therapy alone (P < 0.01). For lesions of the tentorial incisura (n = 66), combined therapy and surgical obliteration alone proved superior to embolization (P < 0.001). For lesions of the cavernous sinus (n = 67), treatment was primarily endovascular, with success rates of 62 to 78% for transarterial and transvenous approaches, respectively. In the anterior fossa (n = 23), surgical obliteration was highly effective, with a success rate of 95%. The small number of cases in both the superior sagittal sinus (n = 28) and middle fossa (n = 10) regions, precluded any statistical analysis. Finally, simple ligature of feeding vessels produced success rates of only 0 to 8% and can no longer be recommended.

CONCLUSION

There is no single ideal treatment for the obliteration of DAVMs. The management of each case is best considered individually. The results of this review serve as a rational starting point for the selection of treatment options.

The diagnosis and prognosis of atypical carotid-cavernous fistula (red-eyed shunt syndrome)

Nineteen patients who complained of red eyes had the characteristic clinical signs of an atypical carotid-cavernous fistula. Episcleral veins were dilated, intraocular pressure and episcleral venous pressure were high, and blood filled Schlemm's canal during gonioscopy. Most of the patients had mild exophthalmos, but in none was the exophthalmos obviously pulsatile, and in only two patients could a bruit be heard. Orbital echography disclosed either a dilated superior ophthalmic vein or congestion of the orbital soft tissues. Selective carotid angiography, done in seven patients, disclosed the fistula to be a dural-cavernous fistula. The serious complication of the fistulas was open-angle glaucoma resulting from the high episcleral venous pressure. None of the fistulas was treated surgically, but six closed spontaneously and three closed soon after carotid angiography.

External carotid-cavernous fistula in an infant

A 7-week-old infant developed a nontraumatic fistula of the external carotid artery and the cavernous sinus. Therapeutic embolization produced an uncomplicated clinical and angiographic cure. Treatment was prompted by the availability of new methods of treatment and our hope of preventing irreversible anatomic and visual sequelae.