Results and complications of transarterial embolization of intracranial dural arteriovenous fistulas using Onyx-18

Transarterial embolization in non-cavernous and cavernous sinus dural arteriovenous fistulas: A systematic review and meta-analysis of proportions

BACKGROUND

Transarterial embolization (TAE) is pivotal in managing non-cavernous and cavernous sinus dural arteriovenous fistulas (CSDAVFs).

METHODS

Systematic searches were conducted across ScienceDirect, Medline, and Cochrane databases for longitudinal studies on TAE outcomes in non-CSDAVFs and CSDAVFs. Post-procedural outcomes, including complete, incomplete, and failed AVFs obliteration, and end-study outcomes were analyzed.

RESULTS

Our meta-analysis involved 27 studies with 643 patients and 736 fistulas. Symptoms in both groups included tinnitus (29.74 %), ocular/visual symptoms (29.12 %), hemorrhage (19.42 %), and headache (19.11 %). Feeding arteries mainly originated from the meningeal arteries (49.16 %). In non-CSDAVFs cases, fistula locations were within sinus complexes (69.23 %) and specific dural areas (28.31 %). Complete AVFs obliteration was 81 % (95 %CI: 70 % - 90 %), slightly higher in non-CSDAVFs (82 %, 95 % CI: 69 % - 92 %) than CSDAVFs (79 %, 95 %CI: 58 % - 95 %). Incomplete obliteration occurred in 14 % (95 %CI: 5 % - 39 %), with rates of 11 % (95 %CI: 2 % - 26 %) in non-CSDAVFs and 19 % (95 % CI: 5 % - 39 %) in CSDAVFs. Failed obliteration was rare (1 %, 95 %CI: 0 % - 3 %), with similar rates in both groups. At end-study follow-up, resolution of AVFs was achieved in 97 % of cases (95 %CI: 92 % - 100 %). However, complications occurred in 17 % of cases (95 %CI: 10 % - 25 %), with a higher incidence in CSDAVFs (22 %, 95 %CI: 9 % - 37 %) compared to non-CSDAVFs (13 %, 95 %CI: 6 % - 23 %).

CONCLUSIONS

TAE with embolic agents demonstrates favorable outcomes in non-CSDAVFs and CSDAVFs, with high rates of AVFs obliteration and resolution. Complications, particularly in CSDAVFs, warrant careful consideration in treatment decisions.

Indications for alternative endovascular techniques in carotid-cavernous fistulas: A 20-year single-center experience

BACKGROUND

While coiling is considered the standard treatment for carotid-cavernous fistulas (CCFs), studies demonstrating excellent results using new materials, especially flow diverter (FD) stents and liquid embolisates, are becoming more frequent. The indications and effectiveness of these alternative endovascular techniques remain unclear.

METHODS

A total of 22 direct and 20 indirect CCFs were included in the study. These were further subdivided based on the embolic material used: coils versus FD stents for direct and coils versus liquid embolisates for indirect CCFs. The subgroups were subjected to statistical analysis.

RESULTS

An angiographic cure was achieved in 88% of all CCFs, 93% of patients' experienced clinical improvement or remained stable. Direct CCFs were treated with coiling (41%) or with both coils and FD stents (55%). One (4%) patient with a direct CCF was treated with FD stent alone. Statistical analysis comparing these subgroups revealed a significantly higher complete occlusion rate immediately after treatment in the coiling subgroup (67% vs. 23%, p = 0.0409). The occlusion rates at the last follow-up were similar (89% vs. 85%). Indirect CCFs were treated with coiling (35%) or liquid embolisates (65%). All three periprocedural ischemic complications were recorded within the liquid subgroup, resulting in a significantly higher clinical deterioration rate (p = 0.0333).

CONCLUSION

FD stents in direct and liquid embolisates in indirect fistulas did not demonstrate better angiographic or clinical outcomes compared to convetional coiling. Liquid agents carried a higher risk of ischemic complications. Alternative embolization materials should be reserved for CCFs that cannot be treated with simple coiling.

Low-Frequency Air-Bone Gap and Pulsatile Tinnitus Due to a Dural Arteriovenous Fistula: Considerations upon Possible Pathomechanisms and Literature Review

Low-frequency air-bone gap (ABG) associated with pulsatile tinnitus (PT) and normal impedance audiometry represents a common finding in patients with third window syndromes. Other inner disorders, including Meniere's disease (MD), perilymphatic fistula and intralabyrinthine schwannoma, might sometimes result in a similar scenario. On the other hand, PT is frequently associated with dural arteriovenous fistula (DAVF), while conductive hearing loss (CHL) is extremely rare in this clinical setting. A 47-year-old patient was referred to our center with progressive left-sided PT alongside ipsilateral fullness and hearing loss. She also experienced headache and dizziness. Otoscopy and video-oculographic examination were unremarkable. Conversely, a detailed instrumental audio-vestibular assessment revealed low-frequency CHL with normal impedance audiometry, slight left-sided caloric weakness, slightly impaired vestibular-evoked myogenic potentials on the left and normal results on the video-head impulse test, consistent with an MD-like instrumental profile. Gadolinium-enhanced brain MRI revealed an early enhancement of the left transverse sinus, consistent with a left DAVF between the left occipital artery and the transverse sinus, which was then confirmed by angiography. A trans-arterial embolization with Onyx glue was performed, resulting in a complete recession of the symptoms. Post-operatively, the low-frequency ABG disappeared, supporting the possible role of venous intracranial hypertension and abnormal pressure of inner ear fluids in the onset of symptoms and offering new insights into the pathomechanism of inner ear CHL.

Transarterial embolization and transvenous embolization for transverse-sigmoid sinus dural arteriovenous fistulas with cortical venous reflux: A comparative study

BACKGROUND

Dural arteriovenous fistulas (DAVFs) with cortical venous reflux (CVR) carry a high risk for neurological sequelae or death. Recently, transverse-sigmoid sinus DAVFs were shown as good indications for transarterial embolization (TAE) with ONYX. Here, we compared the effectiveness and safety of conventional transvenous embolization (TVE) with those of TAE with ONYX for transverse-sigmoid sinus DAVFs with CVR.

METHODS

Sixty-one patients with transverse-sigmoid sinus DAVFs were treated from April 2013 to May 2020. Among them, 37 patients with CVR were included. Transarterial embolization and TVE were compared in terms of complete occlusion and residual CVR immediately after treatment, complications with worsening modified Rankin Scale (mRS) ≥ 1, amount of contrast media used during treatment, radiation exposure, and surgical procedure time.

RESULTS

Ten patients were treated with 10 TAEs using ONYX and 27 patients with 29 TVEs. Transarterial embolization and TVE showed no differences in the overall complete occlusion rate (80% [8/10 patients] vs. 80% [23/27], respectively), whereas the residual rate of existing CVR was 10% (1/10 patient) vs. 3.4% (1/27) in the TAE and TVE groups, respectively. No complications with worsening mRS ≥1 occurred in either group. Among the parameters of amount of contrast media, radiation dose, and operative time, only radiation dose in the TAE group was lower than that in the TVE group (median: 2239 mGy vs. 3268 mGy, respectively; p = 0.07).

CONCLUSION

For transverse-sigmoid sinus DAVFs with CVR, TAE treatment reduced radiation exposure. However, both TAE and TVE achieved high complete occlusion rates and low complication rates.

Asystole during Onyx embolization of 64-year-old patient with dural arteriovenous fistula

Asystole or bradycardia is a relatively uncommon side effect seen in patients undergoing endovascular embolization using dimethylsulfoxide based liquid embolic agents. We present a case of a patient who underwent dural arteriovenous fistula embolization and experienced bradycardia during Onyx injection but was stabilized and the procedure was completed successfully.

Gamma Knife Radiosurgery: The Gold Standard Treatment for Intracranial Dural Arteriovenous Fistulas without Cortical Venous Drainage

Context

Endovascular therapy is currently the most common treatment approach for intracranial dural arteriovenous fistula (DAVF), followed by microsurgery. Gamma Knife radiosurgery (GKS) is usually reserved as the last modality of treatment of intracranial DAVF.

Aim

To evaluate the clinical and radiological outcome of GKS in the treatment of DAVF without CVD.

Subjects and Methods

This series includes patients who underwent GKS for intracranial DAVF without CVD over 10 years (Jan 2007 to Dec 2016) in All India Institute of Medical Sciences, New Delhi. Their demographic profile, clinical presentation, imaging details, GKS details, and follow-up clinical status were obtained retrospectively. Clinical follow-up, along with radiological assessment using MRI every 6 months was done after GKS. DSA was performed once MRI strongly suggested obliteration of DAVF. Patients who had a clinical follow-up of less than 1 year were excluded from the study.

Results

5 patients (4 males and 1 female) who had DAVF without CVD were included the study. The mean age was 44.8 years. All patients had complete obliteration of fistula on digital subtraction angiography (DSA) at a mean duration of 24 months post GKS. All patients had complete resolution of symptoms at the last follow-up.

Conclusions

Gamma Knife surgery is the most effective and the safest treatment modality for dealing with DAVFs without CVD. Instead of reserving it as the last resort for patients with DAVF without CVD, it should be considered as the gold standard treatment for DAVFs without CVD.

Feasibility of low-dose digital subtraction angiography protocols for the endovascular treatment of intracranial dural arteriovenous fistulas

BACKGROUND

Among neurointerventional procedures, the embolization of complex shunt lesions usually requires more radiation dose. We aimed to evaluate the procedural outcome and safety in using low-dose DSA protocols for intracranial dural arteriovenous fistula (AVF) embolization treatment.

METHODS

Between January 2014 and July 2018, 55 patients with dural AVFs who underwent endovascular treatment were included in the study. The low-dose group (n = 27) included from January 2016 used various low-dose DSA protocols made by modifying the thickness of the copper filter or the detector entrance dose. We compared radiation dose metrics, such as air-kerma, kerma-air product (KAP), and fluoroscopy time, as well as clinical and imaging outcomes with the conventional-dose group (n = 28) included before January 2016.

RESULTS

The total KAP was 40.1% lower in the low-dose group (87.9 vs. 146.7 Gy cm², p = 0.002). The average number of DSA runs (25.1 vs. 25.5, p = 0.86) and fluoroscopy times (77.4 vs. 69.7 min, p = 0.48) were similar between the groups. An immediate favorable occlusion rate (total or near total occlusion) was achieved in 41 (74.5%) patients. Ten patients (18.2%) underwent additional procedures due to residual (n = 6) and/or recurrent (n = 5) lesions. At a median of 10 months follow-up, 45 patients (86.5%) had achieved favorable occlusion. Treatment outcomes showed no significant between-group differences. There was one case (1.8%) of procedure-related complications in the low-dose group. All but one patient showed favorable clinical outcomes (modified Rankin score ≤ 2).

CONCLUSION

The low-dose protocols were feasible by showing significant radiation dose reduction and acceptable procedural outcome.

Brain and Heart Crosstalk During Neurointerventional Procedures: The Role of the Trigeminocardiac Reflex: An Updated Systematic Review

The trigeminocardiac reflex is a well-described brainstem reflex that clinically manifests as bradycardia, hypotension, or apnea. This physiological phenomenon is extensively reported during open neurosurgical procedures, but very few data exist for trigeminocardiac reflex occurrence during neurointerventional procedures. This systematic review aims to provide aggregated information related to the trigeminocardiac reflex during neurointerventional procedures and to improve understanding of the various mechanisms that can incite this unique brain-heart crosstalk.

Endovascular treatment of cerebral dural arteriovenous fistulas with SQUID 12

BACKGROUND

Endovascular therapy with liquid embolic agents (LEAs) is the gold standard for the treatment of cerebral dural arteriovenous fistulas (cDAVFs). The aim of the study is to retrospectively evaluate effectiveness, safety, and midterm follow-up results of endovascular treatment of cDAVFs using SQUID 12.

METHODS

Between June 2017 and January 2020 the authors retrospectively reviewed clinical, demographic and embolization data of 19 consecutive patients with cDAVF who underwent embolization using SQUID 12. The number of arteries catheterized for each procedure, the total amount of embolic agent, the occlusion rate, the injection time, any technical and/or clinical complications were recorded. Mid-term follow-up with DSA was reviewed.

RESULTS

20 procedures were performed in 19 patients. A transarterial approach was accomplished in 19 procedure; a combined transvenous-transarterial approach was realized in 1 treatment. The average time of injection was 33 minutes (2-82 minutes), and the average amount of SQUID 12 was 2.8 mL (0.5-6 mL). Complete angiographic cure at the end of the procedure was achieved in 17 patients. No major periprocedural adverse events were recorded. Mid-term follow-up was achieved in 15 out of 19 patients and confirmed complete occlusion of the cDAVFs in 13/15 patients (87%); in 2 of the initially cured patients a small relapse was detected.

CONCLUSIONS

The treatment of the cDAVFs using SQUID 12 was effective and safe. The lower viscosity seems to allow an easier penetration of the agent with a high rate of complete occlusion of the cDAVFs.

Transvenous Onyx Embolization of Carotid-Cavernous Fistulas: Mid- and Long-Term Outcomes

Objective  Endovascular treatment of carotid-cavernous fistulas (CCFs) has been consistently shown to give excellent results and is currently the mainstay of treatment of these complex vascular pathologies. Onyx is currently the most widely used agent, but there has been concern over high rates of cranial nerve (CN) deficits seen in patients with CCF treated with Onyx and paucity of data on long-term outcomes. Methods  This is a retrospective analysis of patients who underwent transvenous Onyx embolization between 2011 and 2018. The data collected included demographics, comorbidities, presenting symptoms, CCF morphology, degree of obliteration, procedure-related complications, clinical outcomes, and follow-up. Results  A total of seven patients (five females) were included. The median age was 66 years (range: 15-79 years). Median duration of symptoms before treatment was 4 weeks (range: 1-24 weeks). There were three direct and four indirect CCFs. Barrow classification is as follows: A-3; B-3; C-0; and D-1. Immediate complete occlusion was achieved in all cases. There was also one case of immediate postoperative change in CN function (new partial CN VI deficit) that resolved completely at 1-month follow-up. The mean length of stay was 3 days (±2). The preoperative extraocular movement CN deficits had the following outcomes: three resolved; two improved; and one persisted. Proptosis, chemosis, conjunctival injection, and tinnitus were resolved in all patients. The median follow-up was 34 months (range: 10-91 months). Conclusion  Transvenous Onyx embolization is a safe and effective treatment of CCFs when technical aspects to reduce complications are performed diligently. Our technique demonstrates safety of the Onyx as a stand-alone embolization for the treatment of CCF.

Updates in the management of cranial dural arteriovenous fistula

Dural arteriovenous fistula (dAVF) accounts for approximately 10% of all intracranial vascular malformations. While they can be benign lesions, the presence of retrograde venous drainage and cortical venous reflux makes the natural course of these lesions aggressive high risk of haemorrhage, neurological injury and mortality. Endovascular treatment is often the first line of treatment for dAVF. Both transarterial and transvenous approaches are used to cure dAVF. The selection of treatment approach depends on the angioarchitecture of the dAVF, the location, the direction of venous flow. Surgery and, to a lesser extent, stereotactic radiosurgery are used when endovascular approaches are impossible or unsuccessful.

Sinus arrest with prolonged asystole due to the trigeminocardiac reflex during application of local anaesthetic in the nasal mucosa

The trigeminocardiac reflex (TCR) is defined as a sudden onset of parasympathetic dysrhythmias during stimulation of the trigeminal nerve. We describe a peripheral variation of TCR during manipulation of the nasal mucosa. A 42-year-old patient suffering from severe obstructive sleep apnoea was scheduled for surgical treatment. After inducted anaesthesia, the surgeon infiltrated the nasal mucosa with a local anaesthetic. The patient immediately showed an asystole and was treated with ephedrine and five chest compressions, despite spontaneous sinus rhythm return after ceasing of manipulation. Treatment with atropine established this TCR episode and ensured an event-free surgery.The authors present here, for the first time, a prolonged asystole caused by the TCR, triggered by minimal manipulation of the nasal mucosa. This severe manifestation of peripheral TCR demonstrates its importance in daily clinical business. This case was treated according to a modified treatment algorithm for all subtypes of TCR which is presented here.

Retrieval of a migrated N-butyl-2 cyanoacrylate cast using a snare-kit system during dural AVF embolization: A case report

N-butyl-2 cyanoacrylate (NBCA) is a liquid embolic material that is widely used in various endovascular procedures because of its permanent and rapid vascular occluding effect regardless of the coagulation profile of the patient. However, NBCA migration to unintended vessels may result in serious complications. This report describes the retrieval of a migrated NBCA cast from the transverse-sigmoid sinus during dural arteriovenous fistula embolization using a transvenous snaring technique.

Lessons to Be Remembered from a Dural Arteriovenous Fistula Mimicking Medulla and High Cervical Cord Glioma

The radiological signs of intracranial dural arteriovenous fistulas (ICDAVFs) are heterogenous. While it is commonly accepted that hyper intense T2 wedge magnetic resonance imaging of the brainstem and cervical cord mainly concern gliomas, it is so far uncommon and probably unknown that ICDAVFs can imitate similar radiological pattern, especially with gadolinium contrast enhancement and cord enlargement. Thus the angiography is poorly documented in the diagnostic workup. We report the unusual history of ICDAVFs, revealed by clinical and radiological features that mimicked a medulla or cervical spinal cord glioma. This observation provides information on the management of atypical lesions mimicking medulla or cervical cord glioma and arguments for a careful radiological study. Looking for dilated veins around the brainstem and the cord is mandatory in the workup of a supposed infiltrating brainstem or spinal cord lesion, in order to rule out an ICDAVF. Even if the hyperintense T2 images associated with contrast enhancement is in favor of a brainstem or spinal cord glioma, additional cerebral angiography should be mandatory. Moreover, this clinical case highlights the need for a multidisciplinary approach including neuroradiologist, oncologist and neurosurgeon.

Focus on the target: Angiographic features of the fistulous point and prognosis of transvenous embolization of cavernous sinus dural arteriovenous fistula

Background and purpose Transvenous embolization (TVE) is widely utilized as an effective and safe treatment option for cavernous sinus dural arteriovenous fistula (CS-dAVF); however, detecting the exact location of the fistula is challenging. The present study identified the angiographic features of the fistulous point and evaluated the match with the microcatheter tip and fistulous point. Materials and methods An analysis cohort of 45 consecutive patients with CS-dAVF treated by TVE was analyzed retrospectively. The patients were divided into two groups, 22 matches and 23 mismatches, according to whether the fistulous point and the microcatheter tip were in the same compartment of the cavernous sinus (CS). The angiographic findings, the location of the fistulas, the position of the microcatheter tips, the volume of embolic materials, complications, and outcomes were assessed. Results Several angiographic features defined the fistulous points, such as the early opacified area, jellyfish-like sign, changes in the density of the contrast medium, the juncture of different arterial supply, enlarged feeders, and hand-injection angiograms. The fistulas were primarily in the posterosuperior portion of the CS (80%) and medial side (73.3%) according to the internal carotid artery. Both groups achieved effective TVE; the matched group required less embolic material than the mismatched group ( p = 0.024). The patients with cranial nerve dysfunction (CND) required more embolic materials than others ( p = 0.032). Conclusion The fistulous point in most of the CS-dAVFs could be isolated by careful analysis of the angiography images. The matching of the microcatheter tip and fistulous point in the same compartment of CS can reduce the dosage of embolic materials, and a low volume of embolic materials might cause fewer CND complications.

Embolization of cranial dural arteriovenous fistulas in the liquid embolic era: A Sydney experience

Endovascular management of dural arteriovenous fistulas has become a mainstay of treatment. In particular, modern techniques have allowed greater fistula penetration and likelihood of complete obliteration. However, the efficacy of newer agents has not been quantified outside of predominantly small case reports and case series. Furthermore, the Australian experience with fistula embolization has yet to be reported in the literature. To this aim, we performed a retrospective review of our endovascular management of a large cohort of cranial dural arteriovenous fistulas in the liquid embolic era. This retrospective case series included ninety-six consecutive patients of any Cognard grade, treated between 2005 and 2016. Liquid embolic agents were used exclusively in eighty-three cases. The overall complete obliteration rate was 89.6% with a residual fistula rate of 2%, and complication rate of 8.3%. This Sydney, Australia cohort demonstrates excellent treatment effect and safety outcomes and thus supports the primary treatment of this condition by endovascular means.

The clinical surrogate definition of the trigeminocardiac reflex: Development of an optimized model according to a PRISMA-compliant systematic review

BACKGROUND

The trigeminocardiac reflex (TCR) is defined as sudden onset of parasympathetic dysrhythmias including hemodynamic irregularities, apnea, and gastric hypermotility during stimulation of sensory branches of the trigeminal nerve. Since the first description of the TCR 1999, there is an ongoing discussion about a more flexible than the existing clinical definition. Aim of this work was to create a clinical surrogate definition through a systematic review of the literature.

METHODS

In this meta-analysis study, literature about TCR occurrences was, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement, systematically identified through various search engines including PubMed (Medline), Embase (Ovid SP), and ISI Web of Sciences databases from January 2005 to August 2015. TCR was defined as a drop of heart rate (HR) below 60 bpm or 20% to the baseline. We extracted detailed data about hemodynamic changes and searched for connections between arterial blood pressure (BP) and HR changes during such episodes.

RESULTS

Overall 45 studies harboring 57 patients were included in the study but only 32 patients showed sufficient data for final analyze. HR showed a nonlinear behavior with a "tipping point" phenomena that differs in variance from the central/peripheral (20-30% drop) to ganglion (40-49% drop). BP showed a linear behavior with a "central limit" phenomena not differing in variance in the whole subgroup (30-39% drop). An analyzation of the correlation between BP and HR showed a trend to a linear correlation.

CONCLUSIONS

We can show for the first time that HR is the dominant variable in the TCR and present a new surrogate definition model. This model and the role of BP must be better investigated in further studies.

Embolization of Intracranial Dural Arteriovenous Fistulas Using PHIL Liquid Embolic Agent in 26 Patients: A Multicenter Study

BACKGROUND AND PURPOSE

The introduction of liquid embolic agents has revolutionized endovascular approach to cranial vascular malformations. The aim of the study was to retrospectively assess the efficacy and safety of Precipitating Hydrophobic Injectable Liquid (PHIL), a new nonadhesive liquid embolic agent, in the treatment of patients with cranial dural arteriovenous fistulas. The primary end point was the rate of complete occlusion of dural arteriovenous fistulas. Secondary end points included the incidence of adverse events and clinical status at 3-month follow-up.

MATERIALS AND METHODS

This was a retrospective multicenter study. Twenty-six consecutive patients with dural arteriovenous fistulas (de novo or previously treated) treated by injection of PHIL only or with PHIL in combination with other embolization products (such as Onyx or detachable coils) were included in the study. Recruitment started in August 2014 and ended in September 2015.

RESULTS

Twenty-two (85%) patients were treated with PHIL only, with 3 patients treated with both PHIL and Onyx, and 1, with both PHIL and coils. Immediate complete angiographic occlusion was achieved in 20 (77%) patients. Of the 6 patients with residual fistulas, 3 were retreated with PHIL and 1 achieved angiographic cure. An adverse event was seen in 1 patient who developed worsening of preexisting ataxia due to acute thrombosis of the draining vein.

CONCLUSIONS

PHIL appears to be safe and effective for endovascular treatment of cranial dural arteriovenous fistulas. Short-term angiographic and clinical results are comparable with those of Onyx, with the added advantage of easier preparation and improved homogeneous cast visualization. The use of iodine as a radio-opacifier also produces considerably less artifacts on CT compared with tantalum-based embolic materials.

Endovascular Treatment of Dural Arteriovenous Fistulas: Single Center Experience

OBJECTIVE

Treatment of intracranial dural arteriovenous fistulas (dAVFs) remains a challenge. However, after introduction of Onyx, transarterial approach is the preferred treatment option in many centers. We report our experience of dAVFs embolization with special emphasis on transarterial approach.

METHODS

Seventeen embolization procedures were performed in 13 patients with dAVFs between Jan 2009 and Oct 2014. Clinical symptoms, location and type of fistulas, embolization methods, complications, radiological and clinical outcomes were evaluated using charts and PACS images.

RESULTS

All 13 patients had symptomatic lesions. The locations of fistulas were transverse-sigmoid sinus in 6, middle fossa dura in 4, cavernous sinus in 2, and superior sagittal sinus in 1 patient. Cognard types were as follows : I in 4, IIa in 2, IIa+IIb in 5, and IV in 2. Embolization procedures were performed ≥2 times in 3 patients. Nine patients were treated with transarterial Onyx embolization alone. One of these required direct surgical puncture of middle meningeal artery. Complete obliteration of fistulas was achieved in 11/13 (85%) patients. There were no complications except for 1 case of Onyx migration in cavernous dAVF. Modified Rankin scale score at post-operative 3 months were 0 in 11, and 3 in 2 patients.

CONCLUSION

Transarterial Onyx embolization can be a first line therapeutic option in patients with dAVFs. However, transvenous approach should be tried first in cavernous sinus dAVF because of the risk of intracranial migration of liquid embolic materials. Furthermore, combined surgical endovascular approach can be considered as a useful option in inaccessible route.

Imaging diagnosis and the role of endovascular embolization treatment for vascular intraspinal tumors

Intraspinal tumors comprise a large spectrum of neoplasms, including hemangioblastomas, paragangliomas, and meningiomas. These tumors have several common characteristic imaging features, such as highly vascular mass appearance in angiography, hypointense rim and serpentine flow voids in MRI, and intense enhancement after intravenous contrast administration. Due to their rich vascularity, these tumors represent a special challenge for surgical treatment. More recently, the surgical treatment of intraspinal vascular tumors has benefited from the combination of endovascular techniques used to better delineate these lesions and to promote preoperative reduction of volume and tissue blood flow. Endovascular embolization has been proven to be a safe procedure that facilitates the resection of these tumors; hence, it has been proposed as part of the standard of care in their management.

The usefulness of subcutaneous infiltration of epinephrine-containing lidocaine for curative transarterial embolization of dural arteriovenous fistula. A technical note

Recently, transarterial embolization (TAE) with liquid embolic materials has been recognized as one of the curative therapeutic options for non-sinus type dural arteriovenous fistula (d-AVF). To prevent glue fragmentation and incomplete obliteration, flow reduction of transosseous high-flow feeders is one of the key points of this therapy. However, flow reduction of transosseous feeders is sometimes difficult with previously reported techniques such as particle embolization, manual compression, or proximal balloon occlusion. This report introduces a new technique to reduce the flow of transosseous feeders using epinephrine-containing lidocaine, and describes a case of intracranial d-AVF successfully treated with this technique. The usefulness and efficacy of the technique are discussed.

Treatment of dural arteriovenous fistula by balloon-assisted transarterial embolization with Onyx

OBJECTIVE

This study evaluated the feasibility, safety, and efficacy of embolization of dural arteriovenous fistula via a very small, short feeding artery with the assistance of a balloon placed proximal to the tip of the microcatheter, such that the balloon serves as a plug.

METHODS

Eight patients who underwent treatment of DAVF by balloon-assisted transarterial embolization with Onyx were retrospectively reviewed. Gender, age, angiography findings, procedure details, clinical and angiographic outcomes, complications, and follow-up were recorded and analyzed.

RESULTS

Nine embolization procedures were performed in eight male patients via extracranial arteries. Balloon-assisted embolization was successful in all eight patients. A Hyperglide balloon was used in five patients, and a Hyperform balloon was used in three patients. Angiographic resolution of the fistula was achieved in all patients without complications. All patients recovered uneventfully. During the follow-up period of 7-19 months, all patients were asymptomatic except for one patient who experienced mild headaches.

CONCLUSIONS

Treatment of DAVF by balloon-assisted embolization with Onyx achieved promising results, even in patients with very small and short feeding arteries. This technique allowed the treatment of DAVF cases where other techniques have failed.

Characteristics and long-term outcome of 251 patients with dural arteriovenous fistulas in a defined population

OBJECT

Management of dural arteriovenous fistulas (DAVFs) has changed during the last decades due to increased knowledge of their pathophysiology and natural history as well as advances in treatment modalities. The authors describe the characteristics and long-term outcome of a large consecutive series of patients with DAVFs.

METHODS

Altogether 251 patients with 261 DAVFs were treated in 2 of the 5 neurosurgery departments at Helsinki and Kuopio University Hospitals between 1944 and 2006. Clinical data and radiological examinations were reviewed to assess patients' overall long-term clinical outcome.

RESULTS

The detection rate of DAVFs increased markedly in the 1970s and again in the 1990s when digital subtraction angiography was introduced. The incidence of DAVFs in a defined southern Finnish population was 0.51 per 100,000 individuals per year, which represents 32% of all the brain arteriovenous malformations. In the early part of the series, DAVFs were treated by proximal ligation of the feeding arteries. Later, most of the patients underwent preoperative embolization and subsequent craniotomy, and since 2000 stereotactic radiosurgery has been increasingly used in the treatment of DAVFs. Fifty-nine percent of the 261 fistulas were totally occluded. Treatment-related major complications were seen in 21 patients.

CONCLUSIONS

The advances in diagnostic methods (digital subtraction angiography, CT, and MRI) increased the detection rate of DAVFs, and as treatment modalities developed, the results of treatment and outcome of patients markedly improved with the introduction of endovascular techniques and stereotactic radiosurgery. Microsurgery is of limited use in DAVFs resistant to other treatment modalities.

Transarterial embolization of dural arteriovenous fistulas of the anterior cranial fossa with Onyx

Dural arteriovenous fistulas (DAVF) of the anterior cranial fossa are often associated with hemorrhage and are usually treated surgically. This clinical study summarizes our preliminary experience in the transarterial embolization of these lesions. We retrospectively reviewed the data for 11 patients with anterior cranial fossa DAVF who underwent transarterial embolization with the Onyx Liquid Embolic System (eV3 Endovascular, Plymouth, MN, USA) at our institute between 2007 and 2011. In four patients, a balloon-assisted technique was used to facilitate superselective catheterization. According to the Cognard classification of DAVF, three fistulas were type III, and the other eight were type IV. DAVF were completely obliterated in 10 patients after treatment via a single ethmoidal artery, but the other patient was not completely cured. No signs of rebleeding or symptom progression were observed at a mean follow-up of 18.5 months (range: 2-49 months). Transarterial embolization using Onyx is therefore feasible and effective for the management of DAVF of the anterior cranial fossa.

The superior ophthalmic vein approach for the treatment of carotid-cavernous fistulas: a novel technique using Onyx

Object

Endovascular therapy is the primary treatment option for carotid-cavernous fistulas (CCFs). Operative cannulation of the superior ophthalmic vein (SOV) provides a reasonable alternative route to the cavernous sinus when all transvenous and transarterial approaches have been unsuccessful. The role of the liquid embolic agent Onyx in the management of CCFs has not been well documented, especially when using an SOV approach. The purpose of this study is to assess the safety and efficacy of Onyx embolization of CCFs through a surgical cannulation of the SOV.

Methods

The authors retrospectively reviewed all patients with CCFs who were treated with Onyx through an SOV approach between April 2009 and April 2011. Traditional endovascular approaches had failed in all patients.

Results

A total of 10 patients were identified, 1 with a Type A CCF, 5 with a Type B CCF, and 4 with a Type D CCF. All fistulas were embolized in 1 session. Onyx was the sole embolic agent used in 7 cases and was combined with coils in 3 other cases. Complete obliteration was achieved in 8 patients and a significant reduction in fistulous flow was achieved in 2 patients, which later progressed to near-complete occlusion on angiographic follow-up. All patients experienced a complete clinical recovery with excellent cosmetic results and were free from recurrence at their latest clinical follow-up evaluations.

Conclusions

Onyx embolization is an excellent therapy for CCFs in general, and through an SOV approach in particular. Direct operative cannulation of the SOV followed by Onyx embolization may be the best treatment option in patients with CCFs when all other endovascular approaches have been exhausted.

Endovascular treatment of hemifacial spasm associated with a petrosal DAVF using transarterial Onyx embolization. A case report

This paper reports that decompression of the facial nerve by transarterial Onyx embolization may relieve hemifacial spasm (HFS) caused by dilated veins due to a right petrosal dural arteriovenous fistula (DAVF). A 56-year-old man suffered severe chronic right HFS associated with a dilated right petrosal vein lying in the vicinity of the facial nerve. The right petrosal DAVF was reached through the middle meningeal artery using a transfemoral arterial approach and was occluded with Onyx 18 (M.T.I.- ev3, Irvine, CA, USA). There was complete remission of HFS without recurrence after two months of follow-up. This case supports vascular compression in the pathogenesis of HFS and suggests that facial nerve injury caused by a DAVF could be treated with transarterial Onyx embolization.

Endovascular embolization of carotid-cavernous fistulas: A pioneering experience in Peru

Background:

Endovascular embolization represents the method of choice for the treatment of carotid-cavernous fistulas (CCFs).

Methods:

We report our experience using the endovascular technique in 24 patients harboring 25 CCFs treated between October 1994 and April 2010, with an emphasis on the role of detachable balloons for the treatment of direct CCFs.

Results:

Of the 16 patients who presented with direct CCFs (Barrow Type A CCFs) (age range, 7–62 years; mean age, 34.3 years), 14 were caused by traumatic injury and 2 by a ruptured internal carotid artery (ICA) aneurysm. Eight patients (age range, 32–71 years; mean age, 46.5 years) presented with nine indirect CCFs (Barrow Types B, C, and D). The clinical follow-up after endovascular treatment ranged from 2 to 108 months (mean, 35.2 months). In two cases (8%), the endovascular approach failed. Symptomatic complications related to the procedure occurred in three patients (12.5%): transient cranial nerve palsy in two patients and a permanent neurological deficit in one patient. Detachable balloons were used in 13 out of 16 (81.3%) direct CCFs and were associated with a cure rate of 92.3%. Overall, the angiographic cure rate was obtained in 22 out of 25 (88%) fistulas. Patients presenting with III nerve palsy improved gradually between 1 day and 6 months after treatment. Good clinical outcomes [modified Rankin scale (mRS) ≤ 2] were observed in 22 out of 24 (91.6%) patients at last follow-up.

Conclusions:

Endovascular treatment using detachable balloons still constitutes a safe and effective method to treat direct carotid-cavernous fistulas.

Lumbar peritoneal shunt containing a programmable valve for intracranial hypertension caused by Borden type 1 dural arteriovenous fistulas

Three male patients underwent lumbar peritoneal (LP) shunt for intracranial hypertension caused by intracranial Borden type 1 dural arteriovenous fistulas (D-AVFs). Endovascular treatment was performed initially, but it was ineffective in all cases. Before LP shunt, the Mariotte blind spot expanded in all cases and severe papilledema was observed in two cases. We managed the opening pressure of the shunt system in accordance with patient symptoms. Mariotte blind spot expansion and papilledema disappeared after LP shunt. Follow-up cerebral angiography revealed spontaneous closure of D-AVFs in one case and aggressive conversion in two cases. D-AVFs were completely closed by transvenous embolization. Because the angioarchitecture of the fistula frequently worsens without deterioration of the symptom after LP shunt, follow-up angiography and additional treatment are important.

Multimodality treatment of intracranial dural arteriovenous fistulas in the Onyx era: a single center experience

BACKGROUND

The results of treatment of intracranial dural arteriovenous fistulas (DAVFs) since Onyx became available as an embolic agent at our institution is reported. An algorithm is presented for treatment of DAVFs with Onyx, and the role of endovascular transvenous, surgical, and radiosurgical approaches are presented.

METHODS

Thirty-two patients with DAVFs treated between November 2005 and November 2008 by endovascular embolization, surgery, or radiosurgery were identified by a retrospective chart review. Treatment strategies were based on the location or complexity of the fistula and the patient's clinical status. Data collected included DAVF characteristics, obliteration rates, complications, and outcomes. The results were analyzed and correlated with the treatment modality.

RESULTS

Presenting symptoms were as follows: hemorrhage (n = 12 patients), headaches (n = 12), tinnitus (n = 5), orbital symptoms (n = 7), and seizures (n = 1). Thirty patients were treated by endovascular embolization (transarterial only with Onyx-21, transvenous only with platinum coils-6, transarterial [Onyx] and transvenous [coils]-3). Five patients (4 after incomplete/failed embolization) had surgical excision of the fistula. Three patients were treated with Gamma Knife radiosurgery (primary-1, 2 after incomplete/failed embolization). The locations of the fistulas were transverse sigmoid (10 patients), petrotentorial (7 patients), indirect carotid cavernous fistula (7 patients), parasagittal/falcine (3 patients), middle fossa dura (3 patients), torcula (1 patient), and anterior fossa dura (1 patient). The distribution of patients according to Borden classification was I-6, II-13, and III-13. Complete obliteration of the fistula was achieved in 26/32 (81%) patients after multimodal treatment. All surgical cases had complete obliteration. In the high-risk group with cortical venous reflux, 23/26 (89%) patients were cured. Endovascular complications included a stuck microcatheter tip with fracture of the tip in two patients and cranial nerves V and VII palsies in one patient. At last follow-up (range 1-36 months), 24 patients had modified Rankin score of 0-2, 5 patients had modified Rankin score of 3-5, and 3 patients were dead. Two patients died during admission due to the insult of the hemorrhage, and one died after an accidental fall with subsequent traumatic subdural hematoma.

CONCLUSIONS

Multimodality treatment of DAVFs has high success rates for cure at our center. Transarterial embolization with Onyx has become the primary treatment for intracranial DAVFs at our center and is associated with high safety profile and efficacy. Transvenous coil embolization is still preferred in DAVFs with supply from arterial branches supplying cranial nerves, predominant internal carotid artery feeders and potential extracranial-intracranial collateral anastomosis. In our series, patients with incompletely treated DAVFs were treated with surgery and those with partially treated type I fistulas had radiosurgery for palliation.

Peripheral ophthalmic artery aneurysm

Generally speaking, the term "ophthalmic aneurysms" refers to carotid-ophthalmic aneurysms, which arise from the internal carotid artery (ICA) wall at or around the origin of the ophthalmic artery (OA). In contrast, aneurysms arising from the OA stem or its branches, separate from the ICA are called peripheral OA aneurysms (POAAs). POAAs are a rare entity, which clinical features and natural course are not fully understood. A comprehensive literature review of reported aneurysms involving each segment of the OA was undertaken. The demographics, aetiology, clinical manifestations and treatment of reported POAAs are discussed. Of 35 retrieved cases, ten involved the intracranial segment, two were fusiform aneurysms in the optic canal, 17 arose from the intraorbital segment, and 6 involved either the lacrimal or the anterior ethmoidal branches. In 34 cases, clinical details were available; 18 patients experienced moderate to severe visual impairment including blindness, while seven patients had improvement in visual acuity as a result of surgical treatment. The present clinical review reveals that aneurysms of the OA stem and lacrimal branch are potentially threatening to visual acuity, while intracranial segment and anterior ethmoidal aneurysms can rupture and cause subarachnoid or intraparenchymal haemorrhage. Surgical intervention is mandatory in symptomatic cases to prevent visual deterioration or treat aneurismal rupture; alternatively, for small incidental POAAs "watchful waiting" may be indicated.

Onyx embolization of carotid-cavernous fistulas

Object

The authors conducted a study to determine the safety and efficacy of embolization of carotid-cavernous fistulas (CCFs) with the ethylene vinyl alcohol copolymer, Onyx.

Methods

They prospectively collected data in all patients with CCFs who underwent Onyx-based embolization at their institution over a 3-year period. The type of fistula, route of embolization, viscosity of Onyx, additional use of coils, extent of embolization, procedural complications, and clinical follow-up were recorded.

Results

A total of 12 patients (5 men and 7 women who were age 24–88 years) underwent embolization in which Onyx was used. There were 1 Barrow Type A, 1 Type B, 3 Type C, and 7 Type D fistulas. Embolization was performed via a transvenous route in 8 cases and a transarterial route in 4 cases. Onyx 34 was used in all but 2 cases: a direct Type A fistula embolized with Onyx 500 and an indirect Type C fistula embolized with Onyx 18. Adjuvant embolization with framing coils was performed in 7 cases. All procedures were completed in a single session. Immediate fistula obliteration was achieved in all cases. Clinical resolution of presenting symptoms occurred in 100% of the patients by 2 months. Neurological complications occurred in 3 patients. One patient developed a complete cranial nerve (CN) VII palsy that has not resolved. Two patients developed transient neuropathies—1 a Horner syndrome and partial CN VI palsy, and 1 a complete CN III and partial CN V palsy. Radiographic follow-up (mean 16 months, range 4–35 months) was available in 6 patients with complete resolution of the lesion in all.

Conclusions

Onyx is a liquid embolic agent that is effective in the treatment of CCFs but not without hazards. Postembolization cavernous sinus thrombosis and swelling may result in transient compressive cranial neuropathies. The inherent gradual polymerization properties of Onyx allow for casting of the cavernous sinus but may potentially result in deep penetration within arterial collaterals that can cause CN ischemia/infarction. Although not proven, the angiotoxic effects of dimethyl sulfoxide may also play a role in postembolization CN deficits.

Balloon-assisted technique for trapped microcatheter retrieval following onyx embolization. A case report

SUMMARY

During embolization of a large frontal arteriovenous malformation (AVM), Onyx-18 (eV3) was injected into an M3 branch of the middle cerebral artery via a Marathon microcatheter (eV3). After 40 minutes of embolization, the microcatheter could not be retracted due to fixation within the Onyx cast despite prolonged, robust attempts. A balloon microcatheter (Hyperform(TM), eV3) was advanced distally and inflated to provide distal counter tension, allowing microcatheter retrieval with minimal traction on the vasculature.

Onyx migration in the endovascular management of intracranial dural arteriovenous fistulas

Onyx migration in the endovascular treatment of dural arteriovenous fistulas (dural AVFs) is uncommon. We describe five cases of Onyx migration to the heart and draining vein and its avoidance. Between February 2007 and August 2008, Onyx migration was encountered in five patients with dural AVFs treated endovascularly at our institute. Procedures performed under general anesthesia consisted of two arterial approaches and three venous approaches. Two patients with dural AVFs involving the transverse-sigmoid sinus were treated by transarterial embolization using Onyx-18 via the occipital artery and the posterior branch of the middle meningeal artery, respectively. A piece of Onyx was found in the right ventricle on post-embolization chest X-ray film in both patients, one developed tricuspid valve dysfunction requiring thoracic surgery and one was asymptomatic. The other three patients were treated with a combination of Onyx (34 or 18) and coils transvenously with venous Onyx migration leading to draining vein occlusion, one with dural AVF involving the tentorium died from venous rupture, two patients with bilateral dural AVFs of the cavernous sinus (one with deterioration of ocular symptoms and one without symptoms). Postoperative digital subtraction angiography confirmed the elimination of dural AVF in one patient, and residual fistulae in three patients. The follow-up study ranging from two to nine months (average, 4.5 months). Three patients recovered to their full activities, while one had visual disturbance. Although Onyx has been considered a controllable embolic agent, its migration to other locations causing clinical deterioration can occur. This problem should be noted and prevented.

A promising adjuvant to detachable coils for cavernous packing: onyx

Transvenous embolization of cavernous dural arteriovenous fistulae (CDAVFs) with Onyx has recently been reported. This study was undertaken to assess the value of Onyx in transvenous treatment of CDAVFs. We retrospectively reviewed 18 patients who underwent transvenous embolization for CDAVFs of Barrow Type D with detachable coils and Onyx at our institution over five years. Patients were divided into two groups: group A, patients who had been treated with detachable coils; group B, patients who had been treated with a combination of detachable coils and Onyx. The approach routes, angiographic results, complications and clinical outcome were assessed for both groups. Eighteen patients with CDAVFs of Barrow Type D were treated: nine women and nine men; mean age was 41.9 years. Eleven patients treated by 19 procedures of transvenous coiling belonged to group A. Seven patients treated by eight procedures of transvenous Onyx injection belonged to group B. The periprocedural complication rate associated with coiling for both groups was 18.2% vs 16.7% with Onyx. The duration of the procedure in both groups was 6.77-/+2.49 hours vs 3.75-/+1.63 hours with coiling vs Onyx, and the cost of Onyx was cheaper than coils. An excellent outcome was achieved in both groups: 90.9% vs 100% (group A vs group B). Our results associated with both modalities of CDAVFs treatment with clinical outcome show that transvenous embolization with Onyx is a safe alternative to detachable coils in the treatment of CDAVFs. However, more cases need to be evaluated.