Dural carotid cavernous fistulas: endovascular treatment and assessment of the correlation between clinical symptoms and the Cognard classification system

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.

Endovascular Treatment of Cavernous Sinus Dural Arteriovenous Fistulas. Institutional Series, Systematic Review and Meta-Analysis

Purpose

Endovascular treatment represents the first-line therapy for cavernous sinus dural arteriovenous fistulas (CS-dAVF); however, different approaches and embolic agents as well as occlusion rates, complications and clinical outcomes are reported among the published series. In this study we performed a comprehensive meta-analysis to investigate clinical and radiological outcomes after endovascular treatment of CS-dAVFs.

Methods

PubMed, Ovid Medline, Ovid EMBASE, Scopus, and Web of Science were screened for a comprehensive literature review from 1990 to 2020 regarding series of patients treated for CS-dAVF with endovascular approaches. We performed a proportion meta-analysis estimating the pooled rates of each outcome also including data of patients treated in our center.

Results

A total of 22 studies reporting 1043 patients and 1066 procedures were included. Chemosis was reported in 559 out of 1043 patients (45.9%), proptosis in 498 (41.5%), and ophthalmoplegia in 344 (23.5%). A transvenous embolization was preferred in 753 cases (63.2%) and coils were used in 712 out of 1066 procedures (57.8%). Overall, 85% (95% confidence interval, CI 69.5–96.1%) of patients had a complete resolution of symptoms, while complications occurred in 7.75% (95% CI 3.82–12.7%) with minimal permanent deficits (0.15%). The mortality rate was 1 out of 1043 patients (< 0.001).

Conclusion

A transvenous coiling is the most common endovascular approach for CS-dAVF, achieving a high percentage of radiological and clinical resolution and low complication rates. Transvenous approaches show less complications than transarterial ones, and coils appear safer than liquid embolic agents.

Dural carotid-cavernous fistulas: our experience with endovascular management

Background

Indirect carotid-cavernous fistulas (CCF) are dural arteriovenous fistula of the cavernous sinus and generally present with ocular symptoms. High index of clinical suspicion and radiological work up is required for diagnosis, and treatment is primarily endovascular embolization. We present our experience in diagnosis and management of indirect CCF along with technical evolution to perform embolization and different vascular accesses for difficult anatomy.

Results

Among a total of 20 indirect CCF cases who were treated with embolization in our department from 2013 to 2020, five (25%) were type C and 15 (75%) were type D. Seven were treated with trans-arterial access only, 11 were treated by transvenous access only, and two were treated by taking both transvenous and trans-arterial access. No recurrence was seen in angiographically cured patients. Out of seven patients who suffered various grades of visual deficit, five recovered completely and two had fixed visual deficit. Third and sixth cranial nerve palsy persisted in two patients even after CCF embolization.

Conclusion

Indirect CCF is a treatable cause of troublesome ocular symptoms. Endovascular embolization is preferred treatment with excellent short- and long-term outcome. The embolization becomes difficult and challenging in cases where the conventional vascular access to the cavernous sinus is occluded.

[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.

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.