Intra-Arterial Onyx-18 embolization of a dural arteriovenous fistula of the sphenoparietal sinus using scepter C balloon microcatheter: Case report

Middle cranial fossa non-cavernous sinus dural arteriovenous fistulas: 20 years of experience

Non-cavernous sinus (CS) dural arteriovenous fistulas (DAVFs) involving the sphenoid bone are rare entities that are easily confused with one another due to the complex structure and high variability of the venous system around the middle cranial fossa. We present a large retrospective study on middle cranial fossa non-CS DAVFs and review the literature on DAVF treatment in this location as well as relative anatomy. 15 patients had DAVFs involving the lesser sphenoid wing and 11 patients had DAVFs involving the greater sphenoid wing. Six patients presented with intracranial hemorrhage or subarachnoid hemorrhage (23.1%, 6/26). The most common symptoms were eye symptoms (38.5%, 10/26). Nineteen patients were treated with trans-arterial embolization (TAE) using liquid embolic agents and two patients were treated with transvenous embolization (TVE) using Onyx or in combination with coils. Surgical disconnection of the drainage veins was performed in five patients, with three cases experiencing unsuccessful TAE. Anatomic cure was achieved in 92.3% of the patients (24/26). Twelve patients had DSA and clinical follow-up from 3 to 27 months. There was one recurrence (8.3%) of the fistula in the patient two months after the initial complete occlusion. The majority of patients can be cured endovascularly. Laterocavernous sinus DAVFs may not be embolized by transvenous approach via the cavernous sinus because there is often no connection between them in most patients. A small percentage of patients may require surgical ligation to be cured.

Intra-arterial onyx embolisation of sphenobasilar sinus fistula using pressure cooker technique: case report and review of the literature

Dural arterio-venous fistulas of the middle cranial fossa may occur within the dura of lesser or greater sphenoid wings. Lesser sphenoid wing fistulas rarely recruit cortical venous drainage and mostly drain in the cavernous sinus. On the other hand, greater sphenoid wing dural fistulas, also known as paracavernous fistulas or sphenobasilar and sphenopetrosal sinus fistulas, are much more notorious as they almost always connect with the superficial middle cerebral vein resulting in secondary cortical venous reflux and varix formation. Curative transarterial or transvenous endovascular embolisation of fistulous connection is the primary therapeutic strategy, particularly using onyx via the transarterial approach. In the present case we describe a 62-year-old man who presented with significant subarachnoid haemorrhage, intraparenchymal and intra-ventricular bleed. Digital subtraction angiography showed a middle cranial fossa dural arteriovenous fistula in the region of the sphenobasilar sinus with cortical venous reflux and varix formation. The patient underwent successful transarterial endovascular embolisation with complete elimination of the fistula using onyx 34, onyx 18, squid 12 and a Scepter XC balloon using the pressure cooker technique. We also report the development of facial nerve palsy due to inadvertent reflux of onyx in the petrosal branch of the middle meningeal artery.