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

Retrograde Middle Meningeal Artery Embolization through Mini Craniotomy for Subdural Hematoma Evacuation: A Technical Note

This report introduces a novel surgical technique for middle meningeal artery embolization (MMAE) during a mini-craniotomy for subdural hematoma (SDH) evacuation. A patient with multiple health issues presented with a 14 mm right subacute SDH. During surgery, the MMA was retrogradely catheterized and embolized using Onyx 18. This approach, combining MMAE with hematoma evacuation, resulted in successful resolution of the SDH without complications. The procedure offers a more efficient workflow by integrating 2 interventions into 1, potentially reducing recurrence rates of SDH.

Alternative hybrid access in endovascular neurosurgery: Scoping review and technical considerations

BACKGROUND

The common femoral artery and radial artery constitute the most common access sites in contemporaneous endovascular neurosurgery. Oftentimes, it may be impossible to reach the vascular target safely due to different circumstances, necessitating alternative approaches. We aim to review these "last resource" access sites described in the literature, focusing on the technical aspects as a convenient reference.

METHODS

We performed a comprehensive literature search of PubMed capturing articles from 1958 to 2022.

RESULTS

We identified nine alternative approaches for endovascular access, after excluding direct carotid stick: superficial temporal artery access in 60 patients, calvarial foramina access in five patients, occipital artery access in seven patients, middle meningeal artery access in six patients, vertebral artery access in 23 patients and external carotid artery, internal maxillary artery, facial artery or lingual artery in 40 patients. Indications for the use of alternative access points included tortuous or occluded vessels, small vessel calibers, or anatomic variation. Pathologies treated included dural arteriovenous fistulas, arteriovenous malformations, intracranial aneurysms, acute stroke, and intracranial stenosis. Diagnostic brain angiograms were also performed.

CONCLUSIONS

Alternative vascular access routes expand the proceduralists' toolkit, enhancing the capability to manage complex cerebrovascular interventions. This review advocates for a broader understanding and consideration of these techniques, given their potential to significantly increase treatment options in neuroendovascular surgery.

Anomalous branching of the middle meningeal artery from the basilar artery: a systematic review

Background

Anomalous origin of the middle meningeal artery (MMA) from the basilar artery is a rare congenital neurological variant that has been detected in both children and adults with diagnoses ranging from intracranial haemorrhage to ependymoma. This review aims to investigate the anatomical course of an anomalous basilar-middle meningeal artery and its clinical presentation.

Methods

A systematic search was performed in PubMed using the keywords (middle meningeal artery) and (basilar artery). Ninety-four papers were identified, of which seven were included. One paper was further identified through cross-referencing.

Results

The average age of presentation was 43 years with a male predominance (7/9). In most cases, the MMA arose between the superior cerebellar artery and the anterior inferior cerebellar artery (8/9) (versus 1 case between the anterior inferior cerebellar artery and the posterior inferior cerebellar artery). The anomaly mostly presented on the left side (6/11), but was bilateral in one case. Most of the cases showed a pontine artery branching from the basilar artery arising 5 mm to 10 mm proximal to the superior cerebellar artery, which would then assume the trajectory of the MMA. In three cases, the vessel increased in calibre near the trigeminal ganglion. Foramen spinosum absence in the anomalous side was noted in 3/6 of the patients.

Conclusion

To avoid unexpected complications during neurosurgical and neuroradiointerventional procedures, it is essential to have a clear understanding of the anomalous routes of the MMA. This is especially important when it proves to be the only available route for embolization.

Direct superficial temporal artery access for middle meningeal artery embolization

Middle meningeal artery embolization has become an important option in the management of subdural hemorrhages with multiple prospective studies demonstrating efficacy and randomized controlled trial data on the way. Access to the middle meningeal artery is usually achieved via the external carotid artery to the internal maxillary artery, then the middle meningeal artery. We report a case where a patient with symptomatic left-sided chronic subdural hemorrhage also had an external carotid artery occlusion. Direct puncture of the superficial temporal artery allowed retrograde access to the internal maxillary artery and thus the middle meningeal artery. Successful embolization of the vessel with 1:9 nBCA was performed with near total resorption of the subdural collection by 1 month postprocedure.

Direct Puncture of the Superficial Temporal Artery in Embolization of a Scalp Arteriovenous Fistula: A Case Report

We describe a minimally invasive endovascular approach to treat an arteriovenous fistula of the scalp. We performed a direct puncture of the lesion through the patient's scalp for liquid embolic agent injection along with external compression of the superficial temporal artery to perform a "manual pressure-cooker technique." The combination of these minimally invasive techniques resulted in an excellent clinical and radiographic outcome.

In-plane guided upper arm arteriovenous fistula cannulation with color ultrasound

BACKGROUND

The blood vessel in the upper extremity arteriovenous fistula (AVF) is deep in the tissue, and cannulation in AVF is frequently associated with blood oozing, hematoma, or aneurysm. This study evaluated the performance of color ultrasound in-plane guided cannulation technique during upper extremity high-AVF cannulation in patients with hemodialysis.

METHODS

A total of 40 patients with hemodialysis who needed cannulation in upper extremity AVF were recruited in the study, and the patients were randomly divided into observation group and control group. Color Doppler ultrasound was used to guide cannulation in the observation group and in the control group blind cannulation method was applied. The success rate of one-time cannulation, the incidence of subcutaneous hematoma, oozing, and pain caused by incorrect fistula cannulation as well as the satisfaction score of the patients were compared to evaluate the effect and advantages of color ultrasound-guided cannulation.

RESULTS

The one-time success rate of internal fistula cannulation in the observation group (98.71%) was significantly higher than that in the control group (88.27%). The incidence rates of hematoma, oozing, pain, and total failure events were significantly reduced in the observation group. The average satisfaction degree in the observation group was also significantly higher than that of the control group.

CONCLUSION

Ultrasonic-guided cannulation effectively enhances the success rate of cannulation in upper extremity AVF, reduces the incidence of cannulation failures, and improves the satisfaction level in the patients.

A Comprehensive Analysis of Dural Arteriovenous Fistula Involving the Superior Sagittal Sinus: A Systematic Review

Objective

To evaluate published papers concerning dural arteriovenous fistula involving the superior sagittal sinus (SSS dAVF) treated with endovascular intervention.

Methods

A literature review was performed to identify studies reporting the clinical characteristics, vascular anatomy, endovascular techniques, embolic materials, angiographical result, and outcomes of SSS dAVF.

Results

The analysis consisted of 40 case reports or series, comprising a total of 51 cases of SSS dAVF treated with endovascular intervention. Clinical symptoms included hemorrhage (29.4%), infarction (17.6%), and seizure (7.8%). The arterial supply included the middle meningeal artery (MMA) (100%), superficial temporal artery (STA) (62.7%), and occipital artery (OA) (49.0%). Bilateral MMAs supplied in 78.4% of the cases. A pial arterial supply was observed in 21.6% of the cases. Stenosis or occlusion of the sinus was seen in 37.3% of the cases. The distribution of the Borden classification was as follows: I (7.8%), II (37.3%), and III (54.9%). The endovascular techniques were transvenous embolization (TVE) alone (11.8%), transarterial embolization (TAE) alone (74.5%), and a combination thereof (13.7%). The types of embolic materials for TAE were a coil (25.5%), n-butyl-2-cyanoacrylate (NBCA) (33.3%), and Onyx (45.1%). The arterial pedicles for TAE included MMA (86.3%), STA (17.6%), and OA (9.8%). Direct surgical exposure for the alternative endovascular access was performed to the SSS (5.9%), MMA (3.9%), STA (5.9%), and OA (3.9%). Sinus angioplasty with or without stenting was done in 9.8% of the cases. Balloon-assisted Onyx TAE was done with proximal flow control (7.8%), collateral devascularization (5.9%), and sinus protection (3.9%). Complete occlusion was achieved in 86.3% of the cases while the number of endovascular sessions varied among patients: single (74.5%), double (15.7%), and triple (9.8%). The rate of a postoperative modified Rankin Scale (mRS) score of 0-2 was 89.3%, with morbidity and mortality rates of 7.8% and 3.9%, respectively. Two patients died, possibly due to postoperative acute SSS occlusion.

Conclusion

The current systematic review disclosed several specific results, namely, the angioarchitectures of the SSS dAVF, the relationship between classification and hemorrhagic presentation, the diversity of treatment techniques, the association between the complete occlusion rate and the SSS condition, and the difficulty of achieving curable occlusion in a single session. These findings underscore the need for the development of endovascular techniques and devices to treat this challenging lesion. Improvements in adjunctive endovascular procedures, such as balloon-assisted techniques for Onyx TAE, may help support to the safe and effective obliteration of SSS dAVF.

Usefulness of an Electromagnetic Navigation System for Direct Percutaneous Puncture of the Superior Ophthalmic Vein

Objective

We report a case of dural arteriovenous fistula (dAVF) at the cavernous sinus treated by direct puncture of the superior ophthalmic vein (SOV) using an electromagnetic navigation system.

Case Presentation

The case involved a 70-year-old male patient who presented with mild chemosis, proptosis, and abducens palsy of the right eye. In this case, we used an electromagnetic navigation system for direct puncture of the SOV. Angiographic obliteration of the fistula was confirmed and the visual symptoms recovered well after surgery. There were no complications associated with direct puncture of the SOV using the electromagnetic navigation system.

Conclusion

Direct puncture of the SOV to obliterate a dAVF is a possible alternative choice of treatment when the usual transvenous access route fails. To reduce the risk of complications, an electromagnetic navigation system is useful.

Direct puncture of the superficial temporal artery for ethylene vinyl alcohol embolization of a type 3 arteriovenous fistula with a dual lumen balloon

Intracranial dural arteriovenous fistulas (dAVFs) may be difficult to treat by endovascular means, especially when the arterial feeders to the fistula are tortuous. 1 The usual main feeder to intracranial dAVFs is the middle meningeal artery, which may present very tight loops that are often difficult to cross with a microcatheter. 2 Direct puncture of a subcutaneous artery feeding the fistula indirectly via transosseous branches may be a valuable strategic option to overcome this limitation. 3 4 We report here the successful embolization of a Cognard type 3 parietal dAVF by direct puncture of the superficial temporal artery under roadmap guidance. The dAVF was subsequently embolized with ethylene vinyl alcohol via a dual lumen balloon, under balloon inflation. We highlight in this technical video 1 the potential difficulties and risks of direct puncture of the superficial temporal artery. We also stress the risk of delayed scalp necrosis using this technique. neurintsurg;13/5/493/V1F1V1Video 1.

Trans-Cranial embolisation of a complex transverse sigmoid sinus dural arteriovenous fistula by direct puncture of the superior sagittal sinus

This technical note describes a direct puncture of the superior sagittal sinus (SSS) to treat a complex dural arteriovenous fistula (dAVF). A 40-year-old female was admitted having a history of increasing confusion. Computer tomography revealed enlargement of the right superior ophthalmic vein and magnetic resonance imaging demonstrated extensive bilateral hemispheric venous engorgement. Digital subtraction angiography (DSA) demonstrated a high flow dAVF involving the right transverse sinus. There was extensive cortical venous rerouting with venous sinus occlusion at the right transverse and sigmoid junction. Under general anesthesia, the sinus was exposed and catheterized. The angiography catheter was fed over the guide wire into the sinus. The remaining right sigmoid and transverse sinus were obliterated using a combination of microcoils and Onyx^®. She made a good postoperative recovery, and a repeat DSA at 30 days postoperatively showed evidence of the meningohypophyseal trunk but complete occlusion of the fistula. A check DSA 2 years later confirmed no evidence of a residual fistula. Our case demonstrates the potential use of the SSS as a novel conduit to treat distant targets.

Onyx removal after embolization of a superior sagittal sinus dural arteriovenous fistula involving scalp artery

BACKGROUND

Most dural arteriovenous fistula (DAVF) in superior sagittal sinus (SSS) requires multimodal treatment. Onyx embolization is useful for DAVF; however, scalp artery embolization has cast extrusion risk.

CASE DESCRIPTION

A 59-year-old male presented with involuntary movements of both legs and progressive dementia. Cerebral angiography demonstrated the DAVF in the SSS fed by bilateral superficial temporal, occipital, and middle meningeal arteries. The posterior SSS was thrombosed, and the main drainers were cortical veins. Combined treatment with transarterial embolization using Onyx and transvenous embolization using coils was performed. Although symptoms were improved, a small DAVF remained. Two months later, Onyx cast extrusion through the scalp was observed, requiring removal and debridement because of infection at the extrusion sites. Surgery for the residual DAVF would be difficult because of scalp condition; therefore, an additional endovascular treatment was conducted, completely occluding DAVF.

CONCLUSION

Onyx embolization is useful for DAVF; however, scalp artery embolization has cast extrusion risk. Therefore, scalp infection should be considered because it may preclude additional surgical procedures.

Clinical importance of the middle meningeal artery: A review of the literature

The middle meningeal artery (MMA) is a very important artery in neurosurgery. Many diseases, including dural arteriovenous fistula (DAVF), pseudoaneurysm, true aneurysm, traumatic arteriovenous fistula (AVF), moyamoya disease (MMD), recurrent chronic subdural hematoma (CSDH), migraine and meningioma, can involve the MMA. In these diseases, the lesions occur in either the MMA itself and treatment is necessary, or the MMA is used as the pathway to treat the lesions; therefore, the MMA is very important to the development and treatment of a variety of neurosurgical diseases. However, no systematic review describing the importance of MMA has been published. In this study, we used the PUBMED database to perform a review of the literature on the MMA to increase our understanding of its role in neurosurgery. After performing this review, we found that the MMA was commonly used to access DAVFs and meningiomas. Pseudoaneurysms and true aneurysms in the MMA can be effectively treated via endovascular or surgical removal. In MMD, the MMA plays a very important role in the development of collateral circulation and indirect revascularization. For recurrent CDSHs, after burr hole irrigation and drainage have failed, MMA embolization may be attempted. The MMA can also contribute to the occurrence and treatment of migraines. Because the ophthalmic artery can ectopically originate from the MMA, caution must be taken to avoid causing damage to the MMA during operations.