A new transvenous approach to the carotid-cavernous sinus via the inferior petrooccipital vein

Endovascular treatment in bilateral cavernous sinus dural arteriovenous fistulas: a systematic review and meta-analysis

Few studies have discussed the disease nature and treatment outcomes for bilateral cavernous sinus dural arteriovenous fistula (CSDAVF). This study aimed to investigate the clinical features and treatment outcomes of bilateral CSDAVF. Embase, Medline, and Cochrane library were searched for studies that specified the outcomes of bilateral CSDAVF from inception to April 2022. The classification, clinical presentation, angiographic feature, surgical approach, and treatment outcomes were collected. Meta-analysis was performed using the random effects model. Eight studies reporting 97 patients were included. The clinical presentation was mainly orbital (n = 80), cavernous (n = 52) and cerebral (n = 5) symptoms. The most approached surgical route was inferior petrosal sinus (n = 80), followed by superior orbital vein (n = 10), and alternative approach (n = 7). Clinical symptoms of 88% of the patients (95% CI 80-93%, I² = 0%) were cured, and 82% (95% CI 70-90%, I² = 7%) had angiographic complete obliteration of fistulas during follow up. The overall complication rate was 18% (95% CI 11-27%, I² = 0%). Therefore, endovascular treatment is an effective treatment for bilateral CSDAVF regarding clinical or angiographic outcomes. However, detailed evaluation of preoperative images and comprehensive surgical planning of the approach route are mandatory owing to complexity of the lesions.

Clinical analysis of cavernous sinus anatomy, pathologies, diagnostics, surgical management and complications - comprehensive review

For decades, the cavernous sinus (CS) has been the subject of debates and scientific studies aimed at elucidating its anatomical variability, and at choosing the best method for accessing it so that optimal diagnoses and related surgical treatments can be decided. The present review considers a series of issues related to the CS. The anatomy of the CS and its features is explored first, and the most important structures, spaces and morphological variations are considered. This is followed by CS pathology and selected diagnostic methods that have proved useful in therapy, and then the management of these pathologies is discussed. Examples of therapeutic steps that have proved helpful in specific cases are taken from the literature. Finally, the various surgical accesses and complications that can be encountered during invasive interventions in the CS area are discussed. The aim of this study is to summarize up-to-date anatomical and clinical knowledge about the CS, citing the most informative scientific papers and aggregating their results. Morphological variations of the CS are common but have not been well described in the literature.

Simultaneous transarterial and transvenous contrast injection to reveal the fistulous point in carotid cavernous fistula: illustrative case

BACKGROUND

Access of the cavernous sinus (CS) via venous route from the inferior petrosal sinus (IPS) can sometimes be challenging during the treatment of carotid cavernous fistulas (CCF), largely because of anatomical variations, tortuosity, and/or difficult visualization of IPS given high retrograde flow through the fistulous connection.

OBSERVATIONS

A 58-year-old male was transferred to our university hospital center after suspected diagnosis of CCF at another hospital by head computerized tomography-angiogram. His symptoms included three weeks of right eye pain that was later complicated by redness, diplopia, and blurry vision. In a diagnostic angiogram, separate contrast injections from the arterial side via internal carotid artery (ICA) and from the venous side via IPS did not reveal a connection point. Injecting contrast simultaneously from both arterial and venous ends resulted in visualization of a connection point allowing entry into the CS.

LESSONS

Technique of simultaneous contrast injection from ICA and internal jugular vein is comparatively simple and saves an operator prolonged time and complexity of approach. In our case, it revealed fistulous point allowing navigation and completing the coiling.

Anatomical study of the internal carotid venous plexus: new findings with application to skull base surgery

OBJECTIVE

The venous plexus (internal carotid venous plexus) surrounding the petrous part of the internal carotid artery (ICAp) is said to be one drainage pathway of the cavernous sinus. These veins have many potential clinical implications including iatrogenic hemorrhage during surgical approaches to the skull base and carotid-cavernous fistulas. Because there are few morphological data about this venous plexus at the skull base, this descriptive/quantitative study was performed to elucidate its anatomy.

METHODS

Six latex-injected cadaveric heads (twelve sides) were dissected via a superior craniotomy approach in which the ICAp was exposed by drilling away the overlying bone. A venous plexus surrounding parts of the ICAp in all sides was documented along with the positions of its major tributaries and their connections.

RESULTS

The veins were most concentrated near the junction of the ICAp and the cavernous part of the internal carotid artery, and usually along the medial and lateral sides of the ICAp. Tributaries included branches joining the basilar venous plexus posteriorly and branches joining the veins surrounding the foramen ovale anteriorly.

CONCLUSION

Detailed knowledge of the anatomy of this venous plexus surrounding the ICAp is useful for interpreting imaging of the skull base and valuable for surgeons operating in this part of the cranium.

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.

Microsurgical Anatomy of the Inferior Petroclival Vein and its Relation to Surrounding Structures: A Cadaveric and Radiological Study

BACKGROUND

The inferior petroclival vein (IPV) courses along the extracranial surface of the petroclival fissure. It is occasionally involved in vascular diseases and has recently been used for vascular access to the cavernous sinus. However, detailed descriptions of its anatomy are currently lacking.

OBJECTIVE

To define the anatomic relationship between the IPV and its surrounding structures based on cadaveric dissection and radiological analysis.

METHODS

A dry skull and an injected cadaver head were examined to reveal the relationships between the IPV and its surrounding structures. The existence of the IPV and its relationships with other venous structures were also examined by contrast-enhanced, fat-suppressed T1-weighted magnetic resonance imaging in 26 patients (51 sides).

RESULTS

The entire course of the IPV was shown via stepwise cadaver dissection from below. Its relationships with surrounding structures, such as the jugular bulb, sigmoid sinus, inferior petrosal sinus, petrosal venous confluence, and the posterior, lateral, and anterior condylar veins, were also shown. In the radiological analysis, the IPV was identified on all sides. The rostral end of the vein was connected to the venous plexus around the carotid artery on all sides. The vein drained into the caudal end of the inferior petrosal sinus (49/51 sides, 96.1%) or into the anterior condylar vein (2/51 sides, 3.9%).

CONCLUSION

A precise understanding of the anatomy of the IPV will enable endovascular and skull base surgeons to achieve diagnoses and gain safe access to lesions involving the IPV.

Fine configuration of the dural fibrous network and the extradural neural axis compartment in the jugular foramen: an epoxy sheet plastination and confocal microscopy study

OBJECTIVE

The extradural neural axis compartment (EDNAC) is an adipovenous zone that is located between the meningeal (ML) and endosteal (EL) layers of the dura mater and has been minimally investigated in the jugular foramen (JF) region. In this study, the authors aimed to explore the fine architecture of the EDNAC within the JF and evaluate whether the EDNAC can be used as a component for JF compartmentalization.

METHODS

A total of 46 cadaveric heads (31 male, 15 female; age range 54-96 years) and 30 dry skulls were examined in this study. Twelve of 46 cadaveric heads were plastinated as a series of transverse (7 sets), coronal (3 sets), and sagittal (2 sets) slices and examined using stereomicroscopy and confocal microscopy. The dural entry points of the JF cranial nerves were recorded in 34 cadaveric skulls. The volumes of the JF, intraforaminal EDNAC, and internal jugular vein (IJV) were quantified.

RESULTS

Based on constant osseous landmarks, the JF was subdivided into preforaminal, intraforaminal, and subforaminal segments. The ML-derived fascial sheath along the anteromedial wall of the IJV demarcated the "venous portion" and the "EDNAC portion" of the bipartite JF. The EDNAC did not surround the intraforaminal IJV and comprised an ML-derived dural fibrous network and an adipose matrix. A fibrovenous curtain subdivided the intraforaminal EDNAC into a small anterior column containing cranial nerve (CN) IX and the anterior condylar venous plexus and a large posterior adipose column containing CNs X and XI. In the intraforaminal segment, the IJV occupied a slightly larger space in the foramen (57%; p < 0.01), whereas in the subforaminal segment it occupied a space of similar size to that of the EDNAC.

CONCLUSIONS

Excluding the IJV, the neurovascular structures in the JF traverse the dural fibrous network that is dominant in the foraminal EDNAC. The results of this study will contribute to anatomical knowledge of the obscure yet crucially important JF region, increase understanding of foraminal tumor growth and spread patterns, and facilitate the planning and execution of surgical interventions.

Endovascular Approaches to the Cavernous Sinus in the Setting of Dural Arteriovenous Fistula

Dural arteriovenous fistulas involving the cavernous sinus can lead to orbital pain, vision loss and, in the setting of associated cortical venous reflux, intracranial hemorrhage. The treatment of dural arteriovenous fistulas has primarily become the role of the endovascular surgeon. The venous anatomy surrounding the cavernous sinus and venous sinus thrombosis that is often associated with these fistulas contributes to the complexity of these interventions. The current report gives a detailed description of the alternate endovascular routes to the cavernous sinus based on a single center’s experience as well as a literature review supporting each approach. A comprehensive understanding of the anatomy and approaches to the cavernous sinus available to the endovascular surgeon is vital to the successful treatment of this condition.

The routes for embolization of dural carotid cavernous fistulas when the endovascular approach is indicated as a first-line strategy

INTRODUCTION

Multiple ways to access the dural carotid cavernous fistula have been described. The aim of the present study was to assess the results of embolization of a dural carotid cavernous fistula via different routes using endovascular accesses as a first-line strategy.

METHODS

A retrospective data analysis of a consecutive series of 63 patients presenting with dural carotid cavernous fistula was performed.

RESULTS

The dural carotid cavernous fistula was accessed by an endovascular approach in 58 patients (92.1%) and by direct puncture in five patients (7.9%). The inferior petrosal sinus was the main route accessed (65%). A recanalization of an occluded inferior petrosal sinus was obtained in 20.6% of cases. The access via either facial ophthalmic veins or the superior petrosal sinus was obtained in 20.6% and 3.1% of cases, respectively. Complete angiographic occlusion of a dural carotid cavernous fistula immediately after treatment was achieved in 53 patients (84.1%), whereas 10 patients (15.9%) displayed a partial occlusion. Treatment-related complications were observed in two patients (3.2%).

CONCLUSIONS

In this study, the endovascular approach allowed dural carotid cavernous fistula embolization in most patients. The inferior petrosal sinus, even when thrombosed, was the main route used to access the dural carotid cavernous fistula, followed by the facial vein, direct cavernous sinus puncture, and the superior petrosal sinus.

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.

Transvenous embolization of cavernous sinus dural arteriovenous fistula through a thrombosed inferior petrosal sinus utilizing 3D venography

OBJECTIVE

We report a new technique in approaching the cavernous sinus through an occluded inferior petrosal sinus (IPS) using three-dimensional (3D) venography.

CASE PRESENTATION

A patient diagnosed with arteriovenous fistula of the right cavernous sinus underwent transvenous embolization. The IPS was not detectable on angiogram. Retrograde injection of contrast with 3D imaging of the internal jugular vein clearly demonstrated the remnant of the IPS. By referring to the images obtained, catheterization of the cavernous sinus by way of the IPS was performed without difficulties.

CONCLUSION

Three-dimensional venography for detecting the entrance to the IPS is a useful method and easy to perform. We believe that this technique should be considered whenever the access to an occluded IPS is necessary.

Cerebrovascular neurosurgery in 2012

Considerable advances in our understanding of the natural history and treatment of cerebrovascular disease were made in 2012. The landmark Unruptured Cerebral Aneurysm Study in Japan was published, illustrating a significantly greater rupture risk than previously reported for small anterior and posterior communicating artery aneurysms, those with daughter domes, and giant aneurysms. Results from the Cerecyte (DePuy Synthes, West Chester, PN, USA) coil trial did not demonstrate a statistically significant positive impact of these bioactive coils on angiographic occlusion rates or outcome. The Clazosentan to Overcome Neurological Ischemia and Infarct Occurring after Subarachnoid Hemorrhage study was also published and unfortunately did not demonstrate an overall favorable long-term functional outcome rate for patients with aneurysmal subarachnoid hemorrhage receiving clazosentan. Studies furthering our understanding of the natural history and treatment of vascular malformations were also published, including large prospective natural history studies of cavernous malformations from the Mayo Clinic and the Scottish Audit of Intracranial Vascular Malformations database. Although pregnancy was found to be a significant risk factor for arteriovenous malformation hemorrhage, several studies did not demonstrate pregnancy as a significant risk factor for cavernous malformation hemorrhage. Finally, prospective randomized control trials illustrated significantly improved angiographic and clinical outcome results for both the Solitaire (ev3 Endovascular, Plymouth, MN, USA; SWIFT trial) and Trevo (Concentric Medical, Mountainview, CA, USA; TREVO 2 trial) stent retrievers as compared to the Merci (Concentric Medical) clot retriever.

Spontaneous isolated dural arteriovenous fistula of the cavernous sinus: endovascular approach via the foramen ovale. A technical note

The endovascular treatment of spontaneous dural cavernous sinus fistula (DAVF) can be accomplished by arterial approach, just with symptoms relief, or by numerous venous approaches through the inferior petrosal sinus, ophthalmic vein, anterior or posterior intercavernous sinus and facial vein. Our case suggests the approach to the cavernous sinus via the foramen ovale and emissary veins puncture as an alternative when there is no possibility of venous approach conventionally described. A 76-year-old woman presented with right conjunctival hyperemia, exophthalmos, intraocular pressure increasing and visual deficits in a period of six months. Angiographic diagnosis of spontaneous DAVF isolated from the cavernous sinus, Barrow Type C, with exclusive venous drainage through the superior ophthalmic vein. Endovascular treatment was performed under general anesthesia. Attempts to approach the cavernous sinus through the inferior petrosal sinus ipsilateral and contralateral intercavernous, facial vein and pterygoid plexus, as well as by dissection and direct puncture of the superior ophthalmic vein were not possible. An approach to the cavernous sinus was performed by puncturing the foramen ovale, catheterization of the emissary vein of the foramen ovale with occlusion of the fistula with microcoils. There was a symptomatic regression with gradual normalization of intraocular pressure, exophthalmos and conjunctival hyperemia in three months. The approach to the cavernous sinus through the foramen ovale and catheterization of the emissary cranial skull base vein is an exception and should be considered in cases of spontaneous and isolated DAVF not accessible by a conventional approach.