Is the Middle Meningeal Artery the Optimal Path for Dural Arteriovenous Fistula Embolization?

Transarterial embolization of dural arteriovenous fistula of the inferior petrosal sinus: A report of two cases

Dural arteriovenous fistula (DAVF) of the inferior petrosal sinus (IPS) is very unusual. Endovascular embolization is a good option for the treatment of DAVF. Until now, DAVFs of the IPS have only been reported sporadically. We reported two such cases. Case 1 was a 48-year-old man with headache and diplopia. Angiography confirmed a DAVF of the distal IPS, mainly supplied by the occipital artery (OA), and the IPS was occluded, which retrogradely drained into the cavernous sinus (CS) and then into the cortical vein. The DAVF in case 1 was embolized completely via the OA to cast Onyx-18. Case 2 was a 69-year-old female who had red and swollen eyes. Angiography confirmed a DAVF of the proximal IPS, mainly supplied by the accessory meningeal artery (AMA), which drained into the CS and then into the ophthalmic vein, and the IPS was occluded. The DAVF in case 2 was embolized completely via the AMA to cast Onyx-18. After treatment, these two patients had uneventful recoveries. In our report, these two cases indicated that the DAVFs of the proximal and distal IPS shared different origins of feeding arteries. When the IPS is occluded, the transarterial approach via the main feeder, such as OA and AMA, can be feasible to cure the DAVF of the IPS.

Case report: Onyx embolization of tentorial dural arteriovenous fistula via the meningohypophyseal trunk and medial tentorial artery of Bernasconi-Cassinari

For tentorial dural arteriovenous fistula (TDAVF), the meningohypophyseal trunk (MHT), and medial tentorial artery (MTA) of Bernasconi-Cassinari are rarely used as transarterial paths to perform the successful endovascular treatment (EVT). We reported a TDAVF mainly fed by the MHT. Onyx-18 casting in the MTA of Bernasconi-Cassinari under the assistance of coil embolization in proximal MHT was performed. The technique was reported in case 1. At the same time, case 2 with a similar TDAVF was chosen as a control. In case 1, a 52-year-old man suffered a cerebellar hemorrhage. A TDAVF was confirmed by computed tomography angiography and digital subtraction angiography. The feeding arteries included the MHT, middle meningeal artery (MMA), and the artery of Wollschlaeger and Wollschlaeger of the superior cerebellar artery. The MHT and MTA of Bernasconi-Cassinari were hypertrophied. First, a Marathon microcatheter was placed in the MTA to wait for Onyx casting, and then an Echelon-10 microcatheter was placed in the proximal MHT trunk with an aneurysmal dilation to perform coiling to prevent Onyx reflux. Then, Onyx casting obliterated the TDAVF. Case 2 was a 75-year-old woman with TDAVF, and the MTA of Bernasconi-Cassinari was the main feeder. First, the TDAVF experienced incomplete EVT with Onyx casting via the MTA under no assistance of coil embolization in the proximal MTA. The second EVT had to be performed via MMA. Then, Onyx casting obliterated the TDAVF. Therefore, for selected TDAVFs with hypertrophied MHT, under the assistance of coil embolization in proximal MHT, Onyx casting via MHT can finish the complete EVT.

Endovascular Treatment of Posterior Cerebral Artery Trunk Aneurysm: The Status Quo and Dilemma

The posterior cerebral artery (PCA) is an important artery that can be divided into four segments (P1-4): segments P1-2 are proximal segments, and segments P3-4 are distal segments. Various aneurysms can occur along the PCA trunk. True saccular aneurysms are rare, and most PCA trunk aneurysms are dissecting. Sometimes, the PCA trunk can give rise to flow-related aneurysms in association with high-flow arteriovenous shunt diseases or moyamoya disease and internal carotid artery occlusion. Some PCA trunk aneurysms require treatment, especially ruptured or large/giant aneurysms. Recently, endovascular treatment (EVT) has become the mainstream treatment for PCA trunk aneurysms, and it mainly involves reconstructive or deconstructive techniques. Traditional EVT includes selective coiling with/without stent or balloon assistance and parent artery occlusion (PAO). For proximal aneurysms, the PCA should be preserved. For distal aneurysms, PAO can be performed. However, during EVT, preservation of the PCA must naturally be the prime objective. Recently, flow-diverting stents have been used and are a revolutionary treatment for unruptured dissecting aneurysms of the PCA trunk. Despite the associated complications, EVT remains an effective method for treating PCA trunk aneurysms and can result in a good prognosis.

Anatomical features of the occipital artery on CTA and differences between patients with/without stenosis and occlusion of the internal carotid artery

The understanding of the basic anatomy of the occipital artery (OA) is crucial, and computed tomography angiography is an effective tool for this purpose. In the present study, a comparison between healthy subjects and patients with internal carotid artery (ICA) stenosis and occlusion was made. The following parameters were measured: Age, sex, diameters and lengths of the OA in different locations, distance from the edge of the foramen magnum to the OA and the distance from the midline to the OA at the level of the superior nuchal line. A total of 205 participants who met the inclusion criteria were selected for further investigation. In addition, 50 healthy subjects (100 sides, left and/or right) were selected as the control group. A total of 155 patients (180 sides, left and/or right) were selected as the stenosis and occlusion groups, including the mild and moderate ICA stenosis group (50 sides, left and/or right), severe ICA stenosis group (80 sides, left and/or right) and the ICA occlusion group (50 sides, left and right). General information, measured parameters and statistical analysis results are provided for these groups. No significant differences were observed in the anatomical parameters of the OA among these groups. Thus, in addition to providing anatomical data, the present study demonstrates that stenosis and the occlusion of the ICA do not significantly alter the anatomy of the OA.

Role of the Cervical Anterior Spinal Artery in the Endovascular Treatment of Vascular Diseases: Bystander, Accomplice, Victim, or Friend?

The cervical anterior spinal artery (ASA) is a very important artery arising from the intracranial vertebral artery (VA). It can play different roles in endovascular treatment (EVT) of spinal vascular diseases. The current understanding of these roles is incomplete; therefore, we performed this review. We found that cervical ASA can be involved in many spinal vascular diseases, such as arteriovenous fistula (AVF), arteriovenous malformation (AVM), and aneurysm, and can serve as a collateral channel in proximal VA occlusion. In AVF and AVM, when the cervical ASA is involved, it often plays the role of an accomplice or victim because it acts as the feeder or as a bystander that does not provide blood flow to the AVF and AVM. In cervical ASA aneurysm, the ASA is a victim. During EVT of VA aneurysms or stenoses, the cervical ASA ostia can be covered or occluded, resulting in ASA ischemia. In this situation, the ASA is a victim. In VA occlusion or the subclavian steal phenomenon, the cervical ASA can serve as a collateral channel to provide blood flow to the posterior circulation. In this case, the ASA plays the role of a friend. According to the role of the cervical ASA in spinal vascular diseases, EVT should be determined “case by case.” Most importantly, when EVT is performed to treat these diseases, the cervical ASA axis must be preserved. Therefore, understanding the role of the cervical ASA in spinal vascular diseases is crucial.