Transvenous copper wire insertion for dural arteriovenous malformations of cavernous sinus

Transvenous Embolisation of Spontaneous Carotid-Cavernous Fistulas by Sequential Occlusion of the Cavernous Sinus

There are two important pathological features associated with carotid-cavernous fistula (CCF): the retrograde cortical venous drainage that can cause intracranial haemorrhage and non haemorrhagic neurological deficit and the retrograde ophthalmic venous drainage that causes orbital venous congestion and visual impairment.

We propose a sequential embolisation strategy by the selective occlusion of these two pathological features as the initial steps followed by occlusion of the rest of the cavernous sinus. Eight patients with spontaneous CCF were treated by transvenous embolisation using our embolisation strategy. The clinical features, angiographic findings, embolisation procedures, and clinical and angiographic outcomes were analyzed. The follow-up period ranged from one to 21 months. Clinical cure was achieved in six patients at one to two month follow-ups.

One patient with bilateral CCFs had clinical cure of the right eye and clinical improvement of the left eye at three-month follow-up. Another patient had clinical cure at one-month follow-up except residual VI nerve palsy. Two patients had complete angiographic obliteration of the fistula immediately after the embolisation procedure. Another three patients underwent follow-up angiography at one to 16 months and all showed angiographic cure. There were no immediate or late complications. Our embolisation strategy offers a safe and effective option in the embolisation of spontaneous CCF as demonstrated by the clinical results of our eight patients.

Endovascular occlusion of dural cavernous fistulas through a superior ophthalmic vein approach

Dural cavernous fistulas are low-flow vascular malformations with usually benign clinical course and a high rate of spontaneous resolution. Cases with symptom progression must be treated with an endovascular approach by arterial or venous route. We report 30 patients with dural cavernous fistulas treated by coil embolization using surgical exposure and retrograde catheterization of the superior ophthalmic vein (SOV). The procedure resulted in closure of the fistula without other endovascular treatments in all 30 patients and clinical remission or improvement in 20 and eight patients, respectively. Embolization via a SOV approach is a safe and easy endovascular procedure, particularly indicated for dural cavernous fistulas with exclusive or prevalent internal carotid artery feeders and anterior venous drainage.

The relationship between the superior petrosal sinus and the porus trigeminus: an anatomical study

Object

During intracranial approaches to the skull base, vascular relationships are important. One relationship that has received scant attention in the literature is that between the superior petrosal sinus (SPS) and the opening of the Meckel cave (that is, the porus trigeminus).

Methods

Cadaver dissections were performed in 25 latex-injected adult cadaveric heads (50 sides). Specifically, the relationship between the SPS and the opening of the Meckel cave was observed. The goal was to enhance knowledge of the relationship between the SPS and the opening of the Meckel cave.

Results

Of the 50 sides, 68%, 18%, and 16% of SPSs traveled superior to, inferior to, and around the opening to the Meckel cave, respectively. In the latter cases, a venous ring was formed around the proximal trigeminal nerve. No sinus entered the Meckel cave. In general, the porus trigeminus was narrowed on sides found to have an SPS that encircled this region. Sinuses that traveled only inferior to the porus were in general smaller than sinuses that traveled superior or encircled this opening. No statistically significant differences were noted between the various sinus relationships and sex, age, or side of the head.

Conclusions

Knowledge of the relationship between the SPS and the opening of the Meckel cave may be useful to the skull base surgeon. Based on this study, some individuals may retain the early embryonic position of their SPS in relation to the trigeminal nerve.

Percutaneous transluminal angioplasty of intracranial artery stenosis: clinical results in 24 patients

Circumscribed stenotic lesions of the intracranial arteries can cause cerebral ischemia by hemodynamic and/or thromboembolic mechanisms. Anticoagulation therapy, antiplatelet therapy, and bypass surgery are treatment strategies that have no direct impact on the underlying lesion. This study summarizes the experience of a single institution at which percutaneous transluminal angioplasty (PTA) of intracranial atherosclerotic stenoses was performed. The authors performed a retrospective analysis of 24 consecutive patients. Their medical histories (cardiovascular risk factors, current clinical signs and symptoms and their duration, previous stroke[s], and medical treatment) were evaluated together with findings from previous imaging studies. The site and degree of the stenoses to be treated (target lesion) were identified with the use of ultrasound and angiography studies. Additional vascular stenoses were noted. Percutaneous transluminal angioplasty was performed using single-lumen balloon microcatheters with appropriate diameters. The results of PTA were correlated with angiographic and ultrasound findings and the clinical outcome. Significant cardiovascular risk factors and clinical signs and symptoms related to the target lesion that persisted despite medical treatment were identified in all patients except one. The duration of symptoms varied from several days to 8 months. Previous stroke had occurred in four patients. The degree of stenosis was classified as "high grade" in 10 patients and as "subtotal" in 14. The target lesion (stenosis) was located in the anterior circulation in eight patients (four in the internal carotid and four in the middle cerebral arteries). Stenoses of posterior circulation vessels were treated in 16 patients (nine vertebral, six basilar, and one posterior cerebral arteries). Recanalization was rated "complete" in 15 patients and sufficient in six patients. In three patients residual stenosis remained. Complications were encountered in seven patients: two asymptomatic dissections, one transient vessel occlusion, one vessel occlusion with subsequent stroke, and three ischemic lesions likely due to thromboembolism, two of which caused only transient neurological symptoms. Percutaneous balloon dilation proved effective in the treatment of intracranial atherosclerotic stenosis. There are, however, potential complications and experience with this procedure is only limited. Long-term results need to be determined. The authors conclude from their preliminary results that PTA may be an alternative to bypass surgery and conservative management and may be considered for patients in whom ischemic neurological symptoms persist despite medical treatment.

Cavernous sinus fistula treated through the transvenous approach: report of four cases

PURPOSE

To describe transvenous embolization in four patients with indirect dural carotid cavernous fistulas (CCFs) via the inferior petrosal sinus (IPS) or superior ophthalmic vein (SOV), and their clinical outcomes.

METHODS

The CCF approach was performed after retrograde venous catheterization from the femoral vein to the cavernous sinus via the IPS (n=1) or SOV (n=3). SOV catheterization was possible without surgical intervention. All patients presented initially with typical clinical signs of CCF. Patients treated via the SOV presented with thrombosis of the IPS.

RESULTS

Catheterization and embolization were successful in all patients, with complete angiographic occlusion of the fistula. No early or late complications occurred. All patients presented with favorable clinical outcomes and complete recovery of ocular symptoms.

CONCLUSION

Retrograde transvenous embolization of CCF via the IPS, or SOV if the IPS is thrombosed, is a safe procedure with a good clinical outcome.

Microcatheter pull-up technique in the transvenous embolization of an isolated sinus dural arteriovenous fistula

✓ The authors describe a novel technique involving the use of a gooseneck snare for microcatheterization of isolated sinus dural arteriovenous fistulas (DAVFs). In some patients the inferior petrosal and transverse–sigmoid sinuses, the route of transvenous embolization (TVE) for DAVF, are separated by several channels. Even if a guidewire can be passed over the occluded portion and the affected sinus can be accessed, one may not necessarily be able to insert a microcatheter. The authors report on three patients who underwent successful microcatheterization via a novel pull-up technique, which makes use of a gooseneck snare to perform TVE even in very difficult circumstances.

Endovascular management of dural carotid–cavernous sinus fistulas in 141 patients

INTRODUCTION

The purpose of this study was to evaluate the single-centre experience with transvenous coil treatment of dural carotid-cavernous sinus fistulas.

METHODS

Between November 1991 and December 2005, a total of 141 patients (112 female) with dural carotid-cavernous sinus fistula underwent 161 transvenous treatment sessions. The patient files and angiograms were analysed retrospectively. Clinical signs and symptoms included chemosis (94%), exophthalmos (87%), cranial nerve palsy (54%), increased intraocular pressure (60%), diplopia (51%), and impaired vision (28%). Angiography revealed in addition cortical drainage in 34% of the patients. Partial arterial embolization was carried out in 23% of the patients. Transvenous treatment comprised in by far the majority of patients complete filling of the cavernous sinus and the adjacent segment of the superior and inferior ophthalmic vein with detachable coils.

RESULTS

Complete interruption of the arteriovenous shunt was achieved in 81% of the patients. A minor residual shunt (without cortical or ocular drainage) remained in 13%, a significant residual shunt (with cortical or ocular drainage) remained in 4%, and the attempted treatment failed in 2%. There was a tendency for ocular pressure-related symptoms to resolve rapidly, while cranial nerve palsy and diplopia improved slowly (65%) or did not change (11%). The 39 patients with visual impairment recovered within the first 2 weeks after endovascular treatment. After complete interruption of the arteriovenous shunt, no recurrence was observed.

CONCLUSION

The transvenous coil occlusion of the superior and inferior ophthalmic veins and the cavernous sinus of the symptomatic eye is a highly efficient and safe treatment in dural carotid-cavernous sinus fistulas. In the majority of patients a significant and permanent improvement in clinical signs and symptoms can be achieved.

Facial Vein Approach by Direct Puncture at the Base of the Mandible for Dural Carotid-Cavernous Fistula. An alternative to the Superior Ophthalmic Vein Approach. A Case Report

SUMMARY

A new facial vein approach by direct puncture at the base of the mandible is described for the treatment of dural carotid-cavernous fistulas. The facial vein is easy to identify, expose, and cannulate compared with the superior ophthalmic vein. The facial vein approach provides an alternative to the superior ophthalmic vein approach when the inferior petrosal sinus approach has failed.

Dural arteriovenous shunts involving the sphenoparietal sinus: a case report

SUMMARY

A 40-year-old male suffered transient global amnesia and was diagnosed as having a very rare location of dural arteriovenous shunt (dAVS) involving the right sphenoparietal sinus. The feeding pedicles of dAVS were not only arising from the right external carotid system, including the middle meningeal artery, but also the right internal carotid system including the ophthalmic artery. The dAVS drained into the right sphenoparietal sinus, right vein of Labbe, and right basal vein of Rosenthal through numerous dilated temporal cortical veins. The arteriovenous shunt itself was located at the dura around the right superior ophthalmic fissure and a large varix received direct shunting blood flow from the right sphenoparietal sinus. The dAVS was cured by drainer clipping following transarterial embolisations. A dAVS with cortical venous drainage is considered to have a higher risk of haemorrhage and venous infarction than the others and thus warrants treatment even if the clinical symptom is minimal. If the dAVS has a single drainer, it will be easily cured by way of drainer clipping. Preoperative embolisation makes clipping easier and safer. Intraoperative angiography is useful because preoperative angiography may not necessarily show the complete angioarchitecture around the lesion.

Stereotactic radiosurgery and particulate embolization for cavernous sinus dural arteriovenous fistulae

OBJECTIVE

To evaluate the safety and efficacy of stereotactic radiosurgery, either with or without transarterial embolization, in the treatment of patients with dural arteriovenous fistulae (DAVFs) of the cavernous sinus.

METHODS

We reviewed the findings, from a prospectively established database, for 20 patients with cavernous sinus DAVFs who were treated with either radiosurgery alone (n = 7) or radiosurgery and transarterial embolization (n = 13) in a 7-year period. The median follow-up period after radiosurgery was 36 months (range, 4-59 mo).

RESULTS

Nineteen of 20 patients (95%) experienced improvement of their clinical symptoms. Fourteen of 15 patients (93%) experienced either total (n = 13) or nearly total (n = 1) obliteration of their DAVFs, as documented by angiography performed a median of 12 months after radiosurgery. No patient experienced a recurrence of symptoms after angiography showed DAVF obliteration. Two patients developed new neurological deficits after embolization procedures. One patient exhibited temporary aphasia secondary to a venous infarction; another patient exhibited permanent VIth cranial nerve weakness related to acute cavernous sinus thrombosis. Two patients experienced recurrent symptoms and underwent repeat transarterial embolization at 7 and 12 months; both patients achieved clinical and angiographic cures (5 and 10 mo later, respectively). One patient experienced recurrent visual symptoms and underwent transvenous embolization 4 months after radiosurgery.

CONCLUSION

Staged radiosurgery and transarterial embolization provided both rapid symptom relief and long-term cures for patients with cavernous sinus DAVFs. Radiosurgery alone was effective for patients with DAVFs whose arterial supply was not accessible via a transarterial approach, although the time course of symptom improvement was longer, compared with patients who also underwent embolization.

Treatment of carotid-cavernous sinus fistulas retrograde via the superior ophthalmic vein (SOV)

BACKGROUND

Carotid-cavernous sinus fistula is an old difficulty in neurosurgery. At present, the main way to deal with it is by embolizing the fistula via an arterial route. But if the fistula is small or supplied by several branches, it is difficult to embolize via an arterial approach.

METHODS

In this report, 21 patients with carotid-cavernous sinus fistulae were successfully cured by embolizing the fistula via the SOV approach.

RESULTS

All patients were cured, and there were no serious postoperative complications. Follow-up has been carried out in 19 cases for 8 months to more than 4 years; no recurrence manifested.

CONCLUSION

For carotid-cavernous sinus fistulae that cannot be embolized arterially, the superior ophthalmic vein route is an easy, safe, effective and promising approach.

Puncture of the superficial sylvian vein for embolisation of cavernous dural arteriovenous fistula

SUMMARY

Dural arteriovenous fistulas (DAVF's) of the cavernous sinus are curable by endovascular means in the vast majority of cases. Both transarterial and transvenous approaches by femoral route can be used for closure. In rare cases with unsuitable anatomy or angioarchitecture, an endovascular approach is proposed by open surgical exposure of a major venous outflow, e.g. the superior ophthalmic vein. We report on a case of unsuccessful attempts at transarterial and transvenous catheter navigation through traditional endovascular routes, where surgical exposure of the major cortical venous drainage was necessary. A direct puncture of the sylvian vein allowed placement of a microcatheter in the cavernous sinus and occlusion of the fistula by coils.

Selective transvenous embolization of dural carotid-cavernous sinus fistulas with preservation of sylvian venous outflow. Report of three cases

A transvenous embolization technique in which normal cerebral venous drainage can be spared is described. Of 26 dural carotid--cavernous fistulas treated by the authors, the affected cavernous sinus received not only the shunted flow but also the sylvian venous drainage in three cases. Two patients presented with an abducent nerve palsy, and one with an oculomotor nerve palsy. Selective transvenous embolization of the fistulous portions of the affected cavernous sinus was achieved, with preservation of the sylvian venous outflow. Postembolization angiograms revealed complete occlusion of the fistula in one patient and only a small amount of residual shunt in the other two. One of these two underwent subsequent transarterial embolization, and the other was followed without additional treatment. The patients' symptoms resolved between 1 and 2 months posttreatment. Follow-up angiograms revealed that the remnant shunt had disappeared and the sylvian venous pathway had been preserved. The authors conclude that selective transvenous embolization of fistulous compartments in an affected sinus can be used to treat dural arteriovenous fistulas involving a cavernous sinus that also receives the sylvian venous outflow.

Cavernous dural arteriovenous fistulas. Transvenous approach and venous drainage of the fistula

SUMMARY

In transvenous endovascular treatment of dural arteriovenous fistula (AVF), access to the affected sinus is determined by venous drainage. In cavernous dural AVF, the route to the cavernous sinus is through the inferior petrosal sinus (IPS) or the superior ophthalmic vein. Other venous routes are not practical. Occlusive change of the IPS is a common finding. The transfemoral approach is not always easy because of obliteration of the IPS. In selection of the approach for the transvenous treatment of the cavernous dural AVF, these occlusive changes should be considered.

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 role of transvenous embolization in the treatment of intracranial dural arteriovenous fistulas

OBJECTIVE

To evaluate the role of transvenous embolization in the treatment of intracranial dural arteriovenous fistulas (DAVFs), including its efficacy and safety.

METHODS

We retrospectively studied the charts of 24 patients (21 women and 3 men) treated for an intracranial DAVF since 1990 in whom a transvenous approach was attempted either alone (16 patients) or in combination with arterial embolization (8 patients). There were 12 cavernous sinus, 9 transverse-sigmoid sinus, 2 inferior petrosal sinus, and 1 intradiploic fistulas. Three fistulas were Type I, 12 were Type IIa, and 9 were Type IIa+b, according to the revised Djindjian's classification. Transvenous embolic agents included coils (17 patients), detachable balloons (6 patients), bucrylate (2 patients), and silk sutures (1 patient).

RESULTS

Anatomic cure was proven in 21 patients (87.5%). Clinical cure was obtained in 23 cases (96%), as follows: 15 patients with a single transvenous approach, 6 with a combined arteriovenous approach, and 2 with an arterial approach after failure of venous access. There was one persistent cavernous fistula despite coil packing of the cavernous sinus. Complications were as follows: five transient and one permanent sixth nerve palsies in cavernous DAVFs, two transient labyrinthic dysfunctions in transverse sinus DAVFs, and one subarachnoid hemorrhage without sequelae.

CONCLUSION

Transvenous embolization is a useful and safe approach in the management of intracranial DAVFs.

The role of radiosurgery and particulate embolization in the treatment of dural arteriovenous fistulas

Over the past 5 years 29 patients with dural arteriovenous fistulas (AVFs) were treated by the authors using the Leksell radiosurgical gamma knife unit. Within 2 days after radiosurgery, 17 patients with AVFs that exhibited retrograde pial or cortical venous drainage (12 patients) and/or produced intractable bruit (eight patients) underwent particulate embolization of external carotid feeding vessels. The rationale for this treatment strategy was that radiosurgery was expected to cause obliteration of most fistulas after 12 to 36 months. In patients with bruit, ocular symptoms, or in those at risk for hemorrhage, treatment with embolization after radiosurgery kept the fistulas angiographically visible for radiosurgical targeting yet offered palliation of symptoms and temporary, partial protection from hemorrhage during the latency period. In 12 patients, preobliteration embolization immediately reduced (10 patients) or eliminated (two patients) retrograde pial venous drainage. To date, no lesion has hemorrhaged after treatment. Angiography 1 to 3 years posttreatment in 18 patients showed total obliteration of 13 fistulas (72%) and partial obliteration of five (28%). Radiosurgery, followed by embolization when retrograde pial venous drainage, intractable bruit, and/or major external carotid artery supply is present, appears to be a promising treatment for selected patients with symptomatic dural AVFs.

Dural arteriovenous fistula of the posterior fossa developing after surgical occlusion of the sigmoid sinus. Report of five cases

In this article, the authors present five cases of dural arteriovenous fistula (AVF) that developed in the transverse-sigmoid sinus 2 to 6 years after sacrifice of the sigmoid sinus because of tumor involvement. The original tumor was meningioma in two patients and neurinoma, glomus jugulare tumor, and ameloblastoma in one patient each. The involved sigmoid sinus was resected along with the tumor and ligated at the normal edge; all that remained of the sigmoid sinus was a small stump on the retrosigmoid portion. Serial angiography performed before and after tumor surgery revealed no abnormal arteriovenous communications or dural AVF in any of the cases. Although many reports have suggested that sinus thrombosis is a precipitating factor in the pathogenesis of dural AVFs, this has been difficult to verify because of the small number of cases in which serial angiography was performed before the development of a dural AVF. In all of the cases presented in this article, surgical resection of a dural AVF and histological examination were performed. Subintimal fibrous thickening was marked, and the sinus wall was found to contain many dural vessels. Organized thrombosis with neovascularization was seen in only two patients. These cases demonstrate that subintimal fibrous thickening a hypertrophied sinus wall secondary to increased intrasinus pressure or sinus thrombosis occurring after sinus occlusion can provoke the development of a dural AVF within the course of a lifetime. Maintenance of intrasinus blood flow may be very important to prevent this late postoperative complication.

Transvenous embolization of dural caroticocavernous fistulae: technical considerations

Sixteen patients with symptomatic dural caroticocavernous fistulae were treated by transvenous embolization, via the jugular vein and inferior petrosal sinus. The fistula was occluded by thrombogenic coils. Complete resolution of symptoms and signs was achieved in 14 patients, and complete angiographic resolution was also obtained in 14 patients. Failures to achieve angiographic cure were attributed to failure to reach the fistula within the cavernous sinus precisely. Factors which make placement of the catheter at the fistula difficult are trabeculae within the cavernous sinus, a specific configuration of the superior ophthalmic vein and venous thrombosis. To improve the efficacy of transvenous embolization, every possible venous route to the cavernous sinus therefore should be tried, to facilitate reaching the fistula and the possibility of transvenous embolization should not be thwarted by venous thrombosis.

Histopathological studies of a new liquid embolization method using estrogen-alcohol and polyvinyl acetate. Experimental evaluations with a model of cortical arterial cannulation in the canine brain

This experimental report evaluates the histopathological effects of a new embolization method using estrogen-alcohol (E-A) and polyvinyl acetate solution (PVac) as tested on 21 mongrel dogs. Three other animals treated with normal saline served as controls. All agents were introduced through an isolated cortical artery. Estrogen-alcohol induced immediate occlusion of small vessels (less than 20 microns), and then progressive obstruction of larger ones (200-300 microns) within several days. Animals treated with PVac showed vascular obliteration (greater than 100 microns) and moderate chronic fibrosis. The effects of embolization using E-A followed by PVac were found to have the combined advantages of both materials, showing diffuse occlusion of the vascular network with less tissue reaction. Hyalinization of embolized vessels with extensive fibrosis occurred afterward. For 6 weeks there was no evidence of recanalization or foreign body giant cell reaction. This study shows that E-A and PVac are capable of producing vascular occlusions with only mild tissue reaction. Because they are easily controllable and have no adverse effects, they may be suitable for intravascular application in the central nervous system.

Intracranial dural arteriovenous malformations: factors predisposing to an aggressive neurological course

The natural history of cranial dural arteriovenous malformations (AVM's) is highly variable. The authors present their clinical experience with 17 dural AVM's in adults, including 10 cases with an aggressive neurological course (strictly defined as hemorrhage or progressive focal neurological deficit other than ophthalmoplegia). Two of these 10 patients died prior to surgical intervention and a third was severely disabled by intracerebral hemorrhage. Six patients underwent surgical resection of their dural AVM, with preparatory embolization in two cases. One patient received embolization and radiation therapy without surgery. Six of the seven cases without an aggressive neurological course were treated conservatively, and the seventh patient underwent embolization of a cavernous sinus dural AVM because of worsening ophthalmoplegia. In order to clarify features associated with aggressive behavior, a comprehensive meta-analysis was performed on 360 additional dural AVM's reported in the literature with sufficiently detailed clinical and angiographic information. The location and angiographic features of 100 aggressive cases were compared to those of 277 benign cases. No location of dural AVM's was immune from aggressive neurological behavior; however, an aggressive neurological course was least often associated with cases involving the transverse-sigmoid sinuses and cavernous sinus and most often associated with cases at the tentorial incisura. Contralateral contribution to arterial supply and rate of shunting (high vs. low flow) did not correlate with aggressive neurological behavior as defined. Leptomeningeal venous drainage, variceal or aneurysmal venous dilations, and galenic drainage correlated significantly (p less than 0.05) with aggressive neurological presentation. The latter three angiographic features often coexisted in the same dural AVM. It is concluded that these features significantly increase the natural risk of dural AVM's, and warrant a more vigilant therapeutic strategy.