Endovascular Treatment of Bilateral Cavernous Sinus Dural Arteriovenous Fistula: Therapeutic Strategy and Follow-Up Outcomes

Interventional Embolization of Unilateral Cavernous Sinus With ONXY Glue Combined With Coils for the Treatment of Bilateral Dural Arteriovenous Fistula

PURPOSE

To summarize the clinical experience of unilateral sponge sinus embolization of cavernous sinus dural arteriovenous fistula (CS DAVF) via jugular vein access with ONXY gel and spring coil intervention.

METHODS

The authors retrospectively analyzed the clinical data of 3 patients who were treated with unilateral cavernous sinus embolization for bilateral cavernous sinus dural arteriovenous fistula (CS DAVF) from October 2020 to May 2022 in our department by using transjugular vein access spring coil + ONXY gel interventional embolization.

RESULTS

Immediate postoperative angiography suggested that the cavernous sinus fistula was completely embolized in all 3 patients, and cerebral angiography was carried out from 6 to 12 months after the operation and assessed using the Class grading method, and there was no recurrence in any of the 3 patients.

CONCLUSIONS

Transvenous access ONXY adhesive combined with spring coil interventional embolization of unilateral cavernous sinus to cure bilateral cavernous sinus dural arteriovenous fistula is feasible, which can avoid the excessive use of spring coils and ONXY adhesive, and it is the key to the effective cure of DAVF in cavernous sinus area and to reduce the complication.

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

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

Bilateral cavernous sinus dural arteriovenous fistula with initial ocular symptom: A case report

RATIONALE

Cavernous sinus dural arteriovenous fistula (CSDAVF) is a rare intracranial vascular malformation. Because of its complicated clinical manifestations, it is easy to miss or misdiagnose CSDAVF.

PATIENT CONCERNS

A 42-year-old female had chief complaint that the right eyeball had conjunctival congestion for half a year. She was given levofloxacin eye drops to treat the right eye with anti-inflammatory treatment, but the symptoms did not improve. Cranial magnetic resonance and cerebrovascular imaging showed that the right lateral rectus muscle was slightly enlarged, the right eyeball was prominent, but there was no abnormality in the brain.

DIAGNOSES

Based on clinical and imaging examinations and digital subtraction angiography (DSA), she was diagnosed as low-flow CSDAVF.

INTERVENTIONS

The patient received interventional embolization with transvenous combined arterial approach using coils and Onyx liquid glue.

OUTCOMES

The patient's exophthalmos and congestion symptoms were improved.

CONCLUSION

DAS is the gold standard for the diagnose of CSDAVF. Intravascular embolization interventional therapy is an effective treatment for CSDAVF.

Embolization of Cavernous Sinus Dural Arteriovenous Fistula (CSDAVF) via transvenous approaches: Practice, experience summary and literature review

OBJECTIVE

To evaluate the safety and efficacy of embolization via transvenous approaches in patients diagnosed with Cavernous Sinus Dural Arteriovenous Fistula (CSDAVF). We also hope to further summarize our preliminary experiences with transvenous approaches.

MATERIAL AND METHODS

We retrospectively collected data from patients who were diagnosed with CSDAVF and were treated with embolization via transvenous approaches from June 2014 to November 2020 at Beijing Tiantan Hospital. We evaluated the safety and efficacy of this treatment using radiological results and clinical follow-up.

RESULTS

A total of 83 patients were included in this study. Complete occlusion was obtained in 76 (89.4%) patients. Sub-total occlusion was obtained in eight (9.4%) patients. Partial occlusion was obtained in one (1.2%) patient. There was no recurrence. Seventy-six patients (91.5%) were cured, and seven patients showed symptom improvement (8.5%). There were no cases of worsening symptoms following embolization, and only ten (12.0%) cases had mild complications.

CONCLUSION

There was a high occlusion rate and a low complication rate in our study. Thus, completing embolization of CSDAVF via transvenous approaches may be safe and effective. However, this operation is more difficult than those via transarterial approaches. Transvenous embolization should therefore be performed in an experienced medical center.

Efficiency of Endovascular Therapy for Bilateral Cavernous Sinus Dural Arteriovenous Fistula

BACKGROUND

The principles of endovascular treatment of bilateral cavernous sinus dural arteriovenous fistula (CS-dAVF) are not well established because of the complexity in the number of fistula tracts and their behavior, which seems to be more aggressive. We aimed to determine an efficient technique for endovascular treatment of bilateral CS-dAVF and the associated factors to achieve good clinical and angiographic outcomes.

METHODS

The data were analyzed from 165 consecutive patients diagnosed with CS-dAVF from January 2005 to September 2018. The demographic data included approaching route, embolization times, embolization material, sequence of embolization, number of embolization sessions, and angiographic and clinical outcomes. Interrater agreement of bilateral CS-dAVF diagnosis was performed using the κ coefficient. The factors associated with treatment outcome were analyzed using a Pearson χ² test.

RESULTS

Bilateral CS-dAVF was detected in 43 patients (26%). Angiographic presentations that showed evidence of sinus thrombosis, dangerous venous drainage, and higher Satomi classification were more commonly found in bilateral CS-dAVF than in unilateral CS-dAVF. Good clinical outcome and cure from angiography were obtained in 90% and 74%, respectively. Ipsilateral inferior petrosal sinus-intercavernous sinus-contralateral cavernous sinus catheterization was the major approach route of treatment. The factors associated with improved clinical outcome were transvenous approach, shunt closure, coil embolization, and sequencing the embolization (P < 0.001).

CONCLUSIONS

Dangerous venous drainage tends to increase in bilateral CS-dAVF. Retrograde ipsilateral inferior petrosal sinus catheterization using coil embolization and sequencing the embolization are the major concerns for treatment.

Endovascular treatment of the cavernous sinus dural arteriovenous fistula: current status and considerations

A cavernous sinus dural arteriovenous fistula (CS-DAVF) is an abnormal arteriovenous communication involving the dura mater within or near the CS wall. The dural arteries from the internal carotid artery and external carotid artery supply the CS-DAVF, and the superior ophthalmic vein (SOV) and inferior petrous sinus (IPS) are frequent venous drainers. In CS-DAVF cases, high-risk lesions require treatment. Endovascular treatment (EVT) has been the first-line option for CS-DAVFs. To our knowledge, a review of the EVT of CS-DAVFs is lacking. Therefore, in this paper, we review the available literature on this issue. In addition, some illustrative cases are also provided to more concisely expound the EVT of CS-DAVFs. According to the recent literature, transvenous embolization via the IPS is considered the most effective method for EVT of CS-DAVFs. In addition, the transorbital approach is another reasonable choice. Other venous approaches can also be tried. Because of the low cure rate, transarterial embolization for CS-DAVFs is limited to only highly selected patients. In the EVT of CS-DAVFs, various agents have been used, including coil, Onyx, and n-butyl cyanoacrylate, with coil being the preferred one. In addition, when EVT cannot obliterate the CS-DAVF, stereotactic radiotherapy may be considered. In general, despite various complications, EVT is a feasible and effective method to manage CS-DAVFs by way of various access routes and can yield a good prognosis.

Bilateral Cavernous Sinus Dural Arteriovenous Fistulae : The Strategies for Endovascular Treatment

PURPOSE

Most cavernous sinus dural arteriovenous fistulas (CSDAVF) are unilateral; however, simultaneous bilateral CSDAVFs occasionally may be found. This article reports on 141 patients and compares the angioarchitecture and outcomes of embolization of bilateral CSDAVFs with those of unilateral CSDAVFs, with reference to limited demographics (sex and age) of the patients.

METHOD

From January 2010 to February 2018 a total of 141 consecutive patients with CSDAVFs were referred for transvenous embolization. Bilateral CSDAVFs were found in 20 patients (14.2%, with a mean age of 62.2 years). The angioarchitecture of the 141 patients with CSDAVFs were evaluated by conventional cerebral angiography. We compared the angioarchitecture and treatment outcomes of 20 bilateral and 121 unilateral CSDAVFs, and in relation to the patients' sex and age.

RESULTS

Female patients significantly dominated the bilateral CSDAVFs (90%, p = 0.043). Bilateral eye symptoms were significantly more common in bilateral CSDAVFs (p = 0.011), with dominant orbital and cavernous symptoms, and showed statistical significance (p = 0.049 and 0.011, respectively). Occlusion of one CSDAVF may significantly decrease the fistula flow of the other untreated side (n = 13, 65%), leading to less coil utilization for embolization in bilateral CSDAVFs (p < 0.001). There was no statistical significance in the occurrence of occlusion of the inferior petrous sinus(s), in pial vein reflux, and treatment outcomes in the unilateral and bilateral CSDAVFs.

CONCLUSION

Bilateral CSDAVFs were more dominant in female patients and frequently presented with orbital and cavernous symptoms. Fewer coils were used per lesion in the bilateral CSDAVFs. There was no statistical significance in bilateral and unilateral CSDAVFs in terms of impact of venous drainage, pial vein reflux and treatment outcomes.

Coil-Protected Technique for Liquid Embolization in Neurovascular Malformations

OBJECTIVE

To evaluate the safety and efficacy of the coil-protected technique for liquid embolization in neurovascular malformations.

MATERIALS AND METHODS

Twenty-two patients who underwent coil-protected liquid embolization for symptomatic cranial (n = 13) and spinal (n = 9) arteriovenous fistula (AVF) or arteriovenous malformations (AVMs) were identified. A total of 36 target feeder vessels were embolized with N-butyl cyanoacrylate and/or Onyx (Medtronic). This technique was used to promote delivery of a sufficient amount of liquid embolic agent into the target shunt or nidus in cases where tortuous feeding arteries preclude a microcatheter wedging techniqu and/or to prevent reflux of the liquid embolic agent in cases with a short safety margin. The procedure was considered technically successful if the target lesion was sufficiently filled with liquid embolic agent without unintentional reflux. Angiographic and clinical outcomes were retrospectively evaluated.

RESULTS

Technical success was achieved for all 36 target feeders. Post-embolization angiographies revealed complete occlusion in 16 patients and near-complete and partial occlusion in three patients each. There were no treatment-related complications. Of the six patients who showed near-complete or partial occlusion, five received additional treatments: two received stereotactic radiosurgery for cerebral AVM, two underwent surgical removal of cerebral AVM, and one underwent additional embolization by direct puncture for a mandibular AVM. Finally, all patients showed complete (n = 19) or near-complete (n = 3) occlusion of the target AVF or AVM on follow-up angiographies. The presenting neurological symptoms improved completely in 15 patients (68.2%) and partially in seven patients (31.8%).

CONCLUSION

The coil-protected technique is a safe and effective method for liquid embolization, especially in patients with various neurovascular shunts or malformations who could not be successfully treated with conventional techniques.

Endovascular management of multiple intracranial dural arteriovenous fistulas

BACKGROUND AND PURPOSE

Multiply occurring intracranial dural arteriovenous fistulas (dAVFs) have been documented but rarely occur, and neither pathogenesis nor prognosis is clearly understood. This study was conducted to analyze angiographic characteristics of multiple dAVFs and to chronicle our treatment experience.

METHODS

Between April, 2002 and January, 2018, data prospectively collected from 310 patients with intracranial dAVFs were systematically reviewed, assessing clinical and anatomic outcomes of endovascular treatment in 32 patients with multiple dAVFs (≥ 2 fistulas each). Lesions were categorized as multifocal or diffuse type, depending on presentation, and further characterized as progressive or non-progressive disease.

RESULTS

Overall, 18 patients (56.3%) experienced aggressive presentations, including intracerebral hemorrhage or venous infarction. Cortical venous reflux (CVR) was observed in 26 patients (81.3%), and sinus thrombosis or occlusion was seen in 24 (75.0%). Clinical outcomes in patients with multifocal fistulas (n = 11) were excellent (100%), marked by a moderately high rate of complete occlusion (54.5%). Those with progressive disease (n = 10) regularly displayed certain angiographic findings, namely diffuse configuration (100%), sinus thrombosis (100%), and CVR (100%). Complete anatomic obliteration was achieved in 12 patients (37.5%), and in 26 patients (81.3%), clinical outcomes were favorable.

CONCLUSION

Multiple dAVFs are typically aggressive at presentation, given strong associations with CVR and sinus thrombosis. In diffuse-type fistulas, the potential to recur or progress is high. Although definitive treatment poses a challenge, outcomes of endovascular therapeutics may be still optimized in this setting through strategic procedural modifications and careful follow-up monitoring.