Dural arteriovenous fistula involving an isolated sinus treated using transarterial onyx embolization

Use of the Scepter Dual-Lumen Balloon Catheter for Transarterial Onyx Embolization of Cranial Dural Arteriovenous Fistulas

BACKGROUND

Dual-lumen balloon microcatheters allow for controlled anterograde flow of Onyx while providing proximal flow arrest, thereby obviating the need for a second microcatheter or Onyx plug formation. We sought to assess the safety and efficiency of the Scepter dual-lumen balloon microcatheter in trans arterial Onyx embolization of intracranial dural arteriovenous fistulas (DAVFs).

METHODS

We conducted a retrospective study of 36 patients with cranial DAVFs in which a Scepter balloon microcatheter was used between 2016 and 2023.

RESULTS

Our study comprised 36 patients, mostly male (n = 23, 63.8%) with a mean age of 60.8 years. Most DAVFs were in the occipital lobe (n = 24, 66.7%), and 50% had external carotid artery supply from the occipital artery. Eighteen (50%) of DAVFs were Cognard type III and IV, respectively. About one third (33.3%, n = 12) of the DAVFs drained into the transverse sigmoid junction, and 27.7% (n = 10) had direct cortical venous drainage into supratentorial or posterior fossa veins. Complete occlusion was obtained in 22 (61.1%) patients while partial occlusion was observed in 14 (38.9%) patients. One patient (2.8%) developed a retroperitoneal hematoma. At final follow-up, complete occlusion was observed in 21 (77.8%) and partial occlusion was observed in 8 (22.2%). Recurrence was observed in 4/30 (13.3%) patients, and retreatment was required in 6 (18.75%) cases.

CONCLUSIONS

At midterm follow-up, our study showed low morbidity and modest complete occlusion rates using the Scepter for transarterial Onyx embolization of high-grade DAVFs.

Clinical Reasoning: A 49-Year-Old Woman With Isolated Sinus Intracranial Dural Arteriovenous Fistula With Perimedullary Drainage

While demyelination is the most common etiology of longitudinally extensive myelopathy, other causes are important to recognize. In this study, we present the case of a longitudinal cervical lesion with a very rare cause. We discuss the approach to the differential diagnosis and workup for longitudinal myelopathy. This clinical reasoning case also illustrates the anatomical relationship between symptomatic spinal cord lesions and nonsymptomatic intracranial etiologies.

Transvenous Embolization with Ethylene Vinyl Alcohol and Arterial Flow Control of a Dural Arteriovenous Fistula of the Isolated Transverse Sinus

Dural arteriovenous fistulas draining into an isolated sinus often require a multimodal treatment, with transarterial and transvenous approaches.^1-6 However, there is no consensus about the injection technique. Some authors suggest filling the sinus with coils in order to have a compact cast without unnecessary migration of the embolic material. We present a case of a patient with left temporal hemorrhage caused by a dural arteriovenous fistula on the isolated left transverse sinus. In this operative video we demonstrate how the arterial flow control during treatment allows us to obtain a compact cast of the embolic material inside the isolated sinus without coils (Video 1).

Embolization strategies for intracranial dural arteriovenous fistulas with an isolated sinus: a single-center experience in 20 patients

BACKGROUND

Intracranial dural arteriovenous fistulas (DAVFs) draining into an isolated sinus segment constitute a specific entity within the spectrum of cranial dural AV shunts, with under-reporting of their optimal treatment.

OBJECTIVE

To describe the multimodal treatment approach to isolated sinus DAVFs in a large single-center cohort.

METHODS

Retrospective analysis of adult patients with an isolated sinus DAVF treated at our institution between 2004 and 2020 was performed. Cases were analyzed for demographics, clinical presentation, angiographic findings, treatment techniques, angiographic and clinical outcomes, and complications.

RESULTS

Of 317 patients with DAVFs, 20 (6.3%) with an isolated sinus DAVF underwent treatment. Transarterial embolization was performed through the middle meningeal artery in 9 of 12 procedures, with a success rate of 66.7%. Transarterial glue embolization proved successful in two of five procedures (40%) and Onyx in six of seven procedures (85.7%). Transvenous embolization (TVE) with navigation via the occlusion into the isolated sinus was successful in seven out of nine procedures (77.8%). All three open TVE and one pure open surgical procedure gained complete closure of the fistula. There were two major complications. Complete occlusion of the fistula was eventually obtained in all cases (100%).

CONCLUSIONS

Isolated sinus DAVFs are always aggressive and require a multimodal approach to guarantee closure of the shunt. Transarterial treatment with Onyx achieves good results. Transvenous treatment appears equally successful, navigating into the occluded segment across the occlusion or via burr hole as backup.

Transarterial venous sinus occlusion of dural arteriovenous fistulas using ONYX

PURPOSE

The purpose of this article is to present a case series of transarterial venous sinus occlusion for dural arteriovenous fistulas (DAVFs) of the transverse and sigmoid sinuses.

MATERIALS AND METHODS

From 2006 to 2012, 11 patients with DAVF of the transverse and sigmoid sinuses were treated with transarterial closure of the affected venous sinus using ethylene vinyl alcohol copolymer (ONYX). The consecutive retrospective cohort included six female and five male patients with an age range of 30-79. Patients presented with stroke, intracranial hemorrhage, seizure, headache, focal neurologic deficit or cognitive change. Lesions were categorized as Cognard II a + b (n = 5) or Cognard II b (n = 6). Four of this latter group consisted of isolated sinus segments. Selection criteria for dural sinus occlusion included direct multi-hole fistulas involving a broad surface in length or circumference of the sinus wall. External carotid artery (ECA) branches were directly embolized when considered safe. High-risk arterial supply from ICA, PICA, AICA or ECA cranial nerve branches were closed via retrograde approach during sinus occlusion.

RESULTS

DAVF closure was accomplished in all 11 patients with a total of 17 embolization procedures using ONYX. High-risk arterial collaterals were closed via artery-artery or artery-sinus-artery embolization. The vein of Labbe was spared in the four cases with initial antegrade flow. No neurologic complications occurred, and DAVF closures were durable on three-month angiography.

CONCLUSION

Transarterial closure of the transverse and sigmoid sinuses.

Infantile Dural Arteriovenous Fistula of the Transverse Sinus Presenting with Ocular Symptoms, Case Reports and Review of Literature

Dural arteriovenous fistula (DAVF) of the transverse sinus with ophthalmic manifestations in young children are rare. We reviewed two cases of direct AVF of the transverse sinus with ocular manifestations managed at our institution. The first, a 2.5 years old male child presented with left exophthalmos. Angiography revealed AVF between the occipital artery and the transverse sinus. The second, a 2 years old female child, complained of left exophthalmos. Imaging studies showed bilateral direct AVFs of the transverse sinus with bilateral dysmaturation of the sigmoid sinus. Transarterial embolization was done in both cases. Clinical and radiological follow up revealed complete cure.This report suggests that DAVF of the transverse sinus supplied by the external carotid branches can present with ophthalmic manifestations especially if there is distal venous stenosis or obliteration involving sigmoid sinus. Transarterial embolization using coils and liquid embolic agents could be safe and feasible to obliterate the fistula.

Successful sinus restoration for transverse-sigmoid sinus dural arteriovenous fistula complicated by multiple venous sinus occlusions: The usefulness of preoperative computed tomography venography

BACKGROUND

Although sinus restoration for transverse-sigmoid sinus (TSS) dural arteriovenous fistula (DAVF) has rarely been reported over the past decade, its advantage and indication still remain unclear. Herein, we discuss the indications and technical aspects of this therapy with a review of the literature.

CASE DESCRIPTION

A 79-year-old female was referred to our department with generalized convulsion. An angiogram revealed a DAVF at the junction of the right TSS. The right sigmoid and left transverse sinuses were occluded, which resulted in remarkable leptomeningeal venous reflux and cerebral venous congestion. A preoperative computed tomography (CT) venogram precisely revealed the occluded segment of the right sigmoid sinus, which facilitated the sinus restoration with balloon percutaneous transluminal angioplasty and stenting.

CONCLUSION

Sinus restoration is preferable in patients with severe cerebral venous congestion due to multiple sinus occlusions and/or a restricted collateral venous outlet. CT venography is useful for precise evaluation of the length and configuration of the occluded segment, which thus make it possible to evaluate the feasibility of stenting.

Transcranial direct middle meningeal artery puncture for the onyx embolization of dural arteriovenous fistula involving the superior sagittal sinus

A 66-year-old woman presented with intermittent paraparesis and generalized tonic-clonic seizure. Cerebral angiography demonstrated dural arteriovenous fistula (AVF) involving superior sagittal sinus (SSS), which was associated with SSS occlusion on the posterior one third. The dural AVF was fed by bilateral middle meningeal arteries (MMAs), superficial temporal arteries (STAs) and occipital arteries with marked retrograde cortical venous reflux. Transfemoral arterial Onyx embolization was performed through right MMA and STA, but it was not successful, which resulted in partial obliteration of dural AVF because of tortuous MMA preventing the microcatheter from reaching the fistula closely enough. Second procedure was performed through left MMA accessed by direct MMA puncture following small decortications of cranium overlying the MMA using diamond drill one week later. Microcatheter could be located far distally to the fistula through 5 F sheath placed into the MMA and complete obliteration of dural AVF was achieved using 3.9 cc of Onyx.

Risk factors for dural arteriovenous fistula intracranial hemorrhage

To our knowledge, the risk factors for intracranial hemorrhage from dural arteriovenous fistula (DAVF) have not been systematically described, due to the complexity of their anatomy and low incidence. We performed this retrospective study to investigate the DAVF factors predicting intracranial hemorrhage. A 10year database of 144 consecutive patients with DAVF was reviewed. Data collected and analyzed were demographics, morphologic features of DAVF, sex, age, fistula flow rate, arterial supply, lesion location, and venous drainage pattern. Linear univariate and multivariate logistic regression analyses were used to evaluate the association between influencing factors and hemorrhage. A first linear univariate analysis was performed for all influencing factors, and showed that sex, lesion location, and venous drainage pattern were statistically significant in predicting intracranial hemorrhage (p<0.05). Secondary multivariate logistic regression analysis with sex, lesion location, and venous drainage pattern showed that only venous drainage pattern was statistically significant in predicting intracranial hemorrhage (p<0.05). Therefore, venous drainage pattern, particularly the cortical venous drainage, significantly predicts intracranial hemorrhage from DAVF. Both sex and lesion location may be confounding factors in predicting intracranial hemorrhage from DAVF, while the other factors may not be associated with hemorrhage.