A single burr hole approach for direct transverse sinus cannulation for the treatment of a dural arteriovenous fistula

Transcranial Endovascular Embolization of Dural Arteriovenous Fistula: A Case Report and Literature Review

The optimal endovascular management of high-grade dural arterial-venous fistulae (dAVF) can be technically challenging in cases where the involved venous sinus segment is inaccessible through the traditional percutaneous approach. In this report, we describe our experience with the transcranial endovascular approach for the treatment of a high-grade dAVF. We also provide a literature review of other reports of transcranial endovascular dAVF embolization. We propose that transcranial endovascular embolization of high-grade dAVF appears to be safe and effective in cases where the fistula is inaccessible to percutaneous routes alone.

Direct superior sagittal sinus puncture via a surgical burr hole for curative embolization of the complex transverse-sigmoid sinus dural arteriovenous fistula: How I do it

BACKGROUND

Transvenous embolization of high-grade dural arteriovenous fistulas (dAVFs) is challenging particularly when the direct sinus access is favorable due to the complex venous anatomy which prohibits endovascular access via the transfemoral approach.

METHOD

The procedure was conducted in the hybrid operating suite, where a burr hole was performed, followed by direct catheterization of the superior sagittal sinus. Coil embolization was then executed to achieve complete obliteration of the fistula.

CONCLUSION

The direct puncture of the superior sagittal sinus is a safe and effective method for treating complex dAVFs. This approach grants access to the fistula channel which facilitates curative embolization.

Feasibility and Effectiveness of Direct Puncture and Onyx Embolization for Transverse Sinus Dural Arteriovenous Fistula

Direct puncture and embolization of the transverse sinus (TS) for treatment of dural arteriovenous fistula (DAVF) is typically performed with coils with or without glue. We report a case of DAVF at the left TS that was treated with Onyx embolization via direct puncture of the TS. A 75-year-old woman presented with tremor, festinating gait, and dysarthria. A left TS-DAVF with retrograde superior sagittal sinus and cortical venous reflux (Cognard type IIa+b) was identified on cerebral angiography, and both TSs were occluded with thrombi. We considered that achieving complete cure by transvenous embolization via the femoral vein or transarterial embolization via occipital feeders would be difficult. Thus, we performed a small craniotomy at the occipital bone to puncture the TS. The midportion of the TS was directly punctured with a 21-G microneedle under fluoroscopic guidance. We inserted a 5-F sheath into the TS. A microcatheter was then navigated into the affected sinus. Coils were placed through the microcatheter to support Onyx formation by reducing the pressure of shunting flow. Onyx embolization was performed with the same microcatheter. The DAVF was almost completely occluded except for the presence of minimal shunting flow to the proximal TS. After 1 week, time-of-flight magnetic resonance angiography showed complete resolution of DAVF. The patient showed resolved tremor and markedly improved mental status at 1-month follow up. Direct puncture and embolization of the TS using coils and Onyx is effective and feasible method for the treatment of DAVF when other approaches seem difficult.

The working road map in a neurosurgical Hybrid Angio-Surgical suite------ development and practice of a neurosurgical Hybrid Angio-Surgical suite

Background

The concept of a Hybrid Angio-Surgical Suite (HASS) has emerged as a solution to the complexity of cerebrovascular surgery and the need for immediate intraoperative feedback. When to use it, what cases are suitable for its use, who can use it and how to use it remain debatable.

Objective

Provide the information regarding the application of the HASS for hospital, neurosurgeon and interventionalist.

Methods

We review the literatures of case reports and studies on the use of the hybrid angio-sugical suite along with application of HASS in our own practice.

Results

Indications for using HASS on different types of cerebral vascular disease, including cerebral aneurysm, AVM, DAVF, carotid and vertebral stenosis/occlusion, are addressed. The application of HASS for other non-cerebral vascular diseases, such as trauma, spine and skullbase cases, is reviewed and discussed.

Conclusion

HASS has made many surgical procedures safer and many difficult or previously untreatable conditions much more tractable and cost-effective. Other than used in cerebral vascular disease, HASS has much more applications, such as trauma, spine and other neurosurgical diseases.