A promising adjuvant to detachable coils for cavernous packing: onyx

Transfemoral trans-facial vein-superior ophthalmic vein to embolize cavernous sinus dural arteriovenous fistulas

Cavernous sinus dural arteriovenous fistula (CS-DAVF) is an abnormal communication between the CS and dural arteries from the internal carotid artery and external carotid artery. CS-DAVFs are not uncommon. The preferred treatment for most CS-DAVFs is transvenous embolization (TVE), which can achieve a high cure rate with few complications. The trans-inferior petrous sinus (IPS) route from the internal jugular vein to the CS is the favorite and most direct route to perform TVE in the great majority of CS-DAVFs. However, when the trans-IPS route fails and if the facial vein (FV) is patent and dilated, transfemoral trans-FV-superior ophthalmic vein (SOV) embolization of the CS-DAVF can be attempted. However, the transfemoral trans-FV-SOV route to embolize CS-DAVFs is often challenging, and there is insufficient knowledge about it. Therefore, an updated review of the transfemoral trans-FV-SOV route to embolize CS-DAVFs is necessary, and this review includes our experience. The images in this review are from our institute without the dispute of copyright. Issues regarding the transfemoral trans-FV-SOV route to embolize CS-DAV were discussed, including the FV anatomy and variation, various TVE routes to access CS-DAVF, the procedure of the transfemoral trans-FV-SOV route to embolize CS-DAVF, difficulty, and solution of the transfemoral trans-FV-SOV route to embolize CS-DAVF, and complications and prognosis of transfemoral trans-FV-SOV to embolize CS-DAVF. By reviewing the transfemoral trans-FV-SOV route to embolize CS-DAVFs, we found that this route provides a valuable alternative to the other transvenous routes. A good prognosis can be obtained with the transfemoral trans-FV-SOV route to embolize CS-DAVFs in select cases.

Transvenous embolization of arteriovenous malformations

Embolization of arteriovenous malformations is characteristically used as part of a multimodal treatment approach, pre-operatively to facilitate microsurgical resection or as a preradiosurgical adjunct. The concept of AVM cure via embolization alone has gained popularity in recent years. Embolization of AVMs has been most commonly performed transarterially, with the transvenous route traditionally eschewed given concern over precipitating premature venous occlusion and consequent hemorrhage. However, the transvenous approach in treating AVMs offers several distinct advantages compared to the transarterial route and can be used in instances when the latter is not feasible, with several series having proven its efficacy and safety. Conceptually, AVM embolization performed via the transvenous route achieves complete obliteration by directly and facilely targeting the nidus. Nidal embolisate penetration is facilitated by control of arterial inflow via systemic or local hypotension. Innovation in endovascular strategies has led to significantly improved obliteration rates. The experience with transvenous AVM embolization is reviewed and discussed.

Endovascular treatment evolution for pure intraorbital arteriovenous fistula: Three case reports and literature review

Background and importance Intraorbital arteriovenous fistulas (IOAVFs) are rare and cause eye redness, exophthalmos, blurry vision and bruit. Whereas in the past they were treated conservatively, surgically or transarterially, recent developments in transvenous embolization have improved their treatment. In this paper the authors report three cases of IOAVFs treated endovascularly and review the evolution of treatment options. Methods Three cases of purely IOAVF enrolled in our center were reported and a PubMed literature search was performed using "pure intraorbital arteriovenous fistula" and "arteriovenous fistula of the optic nerve sheath." A total of 21 papers were reviewed in full, focusing primarily on the treatment and outcomes. Results A total of 26 patients were obtained, including our three patients and 23 patients reported in the literature. In nine patients treated conservatively, four spontaneous occlusions, one visual deterioration and four cases with unknown outcome were reported. In another 18 patients, 29 therapies (including five surgical treatment, 11 transarterial embolizations and 13 transvenous embolizations) were attempted and resulted in 12 cures, five visual deteriorations and one without reported outcome. More recently, transvenous embolization has become the mainstay of IOAVF treatment. Of the 21 patients assessed between 2000 and 2013, a transvenous approach was attempted in 13 patients; nine patients were cured without any adverse events. Conclusion Development and improvement of transvenous techniques are found to be safe and effective for patients with IOAVF.

Anatomic variations of internal jugular vein, inferior petrosal sinus and its confluence pattern: Implications in inferior petrosal sinus catheterization

OBJECTIVE

The purpose of this study is to describe anatomic variations of the internal jugular vein (IJV), inferior petrosal sinus (IPS) and their confluence pattern and implications in IPS catheterization. The anatomic route of IPS after going out of the cranium and its confluence patterns with IJV and will supply knowledge about typing of IPS-IJV junction.

METHOD

A review of the literature was performed.

RESULTS

There might be different routes for entering the intracranial segment of the IPS and multislice spiral computed tomography (MSCT) is effective in identifying the confluences of the IPS with the IJV and their courses. It is important to find the confluence of IPS with IJV for diagnosis and treatment of intracranial lesions via venous route. Meanwhile, IPS diameter at the confluence can significantly affect success of catheterization.

CONCLUSION

The classification and the theory of the development of the caudal end of the IPS may be useful in establishing treatment strategies that involve endovascular manipulation via the IPS.

[Intracranial dural arteriovenous fistulae. Experience after 81 cases and literature review]

OBJECTIVES

To analyse the clinical, radiological and therapeutic variables of intracranial dural arteriovenous fistulae (DAVF) treated at our institution, and to assess the validity of the Borden and Cognard classifications and their correlation with the presenting symptoms.

MATERIAL AND METHODS

The DAVF identified were retrospectively analysed. They were classified according to their location, drainage pattern and the Borden and Cognard classifications. We recorded the different treatments, their complications and efficacy.

RESULTS

There were 81DAVF identified between 1975 and 2012. The cavernous sinus (CS) location was the most frequent one. The Borden and Cognard classifications showed an interobserver Kappa index of 0.72 and 0.76 respectively. The odds ratio of aggressive presentation in the presence of cortical venous drainage (CVD) was 19.3 (2.8-132.4). No location, once adjusted by venous drainage pattern, showed significant association with an aggressive presentation. Endovascular transarterial treatment of cavernous sinus DAVF achieved symptomatic improvement of 78%, with a complication rate of 5%. The DAVF of non-CS locations, with CVD, treated surgically were angiographically shown cured in 100% of the cases, with no treatment-related complications.

CONCLUSIONS

The presence of CVD was significantly associated with aggressive presentations. The Borden and Cognard classifications showed little interobserver variability. Endovascular treatment for CS DAVF is safe and relatively effective. Surgical treatment of non-CS DAVF with CVD is safe, effective and the first choice treatment in our environment.

Selection of treatment modalities or observation of dural arteriovenous fistulas

Cranial dural arteriovenous fistulas (DAVFs) represent an important class of cranial vascular lesions. The clinical significance of these lesions is highly dependent on the pattern of venous drainage, with cortical venous reflux being an important marker of an aggressive, high-risk fistula. For asymptomatic benign fistulas, conservative management, consisting of observation with follow-up, is a reasonable option. For symptomatic benign fistulas or aggressive fistulas, treatment is recommended. A variety of treatment modalities are available for DAVF management, including endovascular techniques, open surgery, and radiosurgery. A multimodality approach is often warranted and can offer improved chances of achieving a cure.