Noncavernous arteriovenous shunts mimicking carotid cavernous fistulae

Vertebro-Vertebral Arteriovenous Fistulae: A Case Series of Endovascular Management at a Single Center

OBJECTIVE

Vertebro-vertebral arteriovenous fistulae (VVFs) are a rare disorder characterized by a direct shunt between the extracranial vertebral artery and the veins of the vertebral venous plexus. This study aims to comprehensively review the characteristics and outcomes of endovascular treatments for VVFs at our center.

METHODS

A retrospective review was conducted on 14 patients diagnosed with a VVF who underwent endovascular treatment at Siriraj Hospital from January 2000 to January 2023. The study assessed patient demographics, presentation, fistula location, treatment strategies, endovascular techniques employed, and treatment outcomes.

RESULTS

Among the 14 patients, 11 (78.6%) were female, with an age range from 25 to 79 years (median: 50 years). Spontaneous VVFs were observed in 64.3% of the cases, including three associated with neurofibromatosis type 1 (NF-1). Iatrogenic injury accounted for two cases, and three patients had VVFs resulting from traffic accidents. A pulsatile neck mass and tinnitus, with or without neurological deficits, were common presenting symptoms. Active bleeding was observed in three cases with vascular injury, while unilateral proptosis, congestive heart failure, and incidental findings each presented in one patient. All the VVFs were successfully obliterated without major treatment complications. Parent vessel sacrifice was performed in 85.7% of the cases, while vertebral artery preservation was achieved in the remaining two patients. Embolic materials included detachable balloons, detachable coils, and n-butyl cyanoacrylate (NBCA) glue. All the presenting symptoms showed improvement, and no morbidity or mortality was observed.

CONCLUSIONS

Endovascular embolization is a feasible and effective approach for achieving complete VVF obliteration with safety. Parent artery sacrifice should not be reluctantly performed, particularly when adequate collateral circulation is demonstrated.

Hypoglossal Canal Dural Arteriovenous Fistula: A Rare Cause of Ocular Proptosis

It is exceedingly rare for dural arteriovenous fistulae (DAVFs) outside of the cavernous sinus to present with ophthalmological symptoms and signs. Hypoglossal canal DAVFs (HC-DAVFs) have only previously been reported as individual cases or small case series. Further, only an estimated 31% of HC-DAVFs present with ophthalmological findings. We report a noteworthy case of an HC-DAVF in a 74-year-old male who presented with proptosis, chemosis, and reduced visual acuity. He was treated endovascularly with liquid embolic filling. This report aims to highlight HC-DAVF as an important differential diagnosis for patients presenting with symptoms suggestive of arterialisation of the ophthalmic veins.

Endoscopic-assisted Orbitotomy for Obliteration of Orbital Arteriovenous Fistula Refractory to Endovascular Techniques

Orbital arteriovenous fistula is a rare acquired disorder. The coincidence of arteriovenous fistula with lymphaticovenous malformation is even rarer. The optimal treatment, thus, is controversial. Surgical approaches vary widely, with associated pros and cons. The purpose of this case report is to describe an orbital arteriovenous fistula in a 25-year-old man with congenital fronto-orbital lymphaticovenous malformation, refractory to endovascular techniques, which was later successfully ablated by a direct endoscopic-assisted orbital approach.

Endoscopic endonasal transsphenoidal direct access and Onyx embolization of a dural arteriovenous fistula mimicking a carotid-cavernous fistula: case report

The classic presentation of a carotid-cavernous fistula (CCF) is unilateral painful proptosis, chemosis, and vision loss. Just as the goal of treatment for a dural arteriovenous fistula (dAVF) is obliteration of the entire fistulous connection and the proximal draining vein, the modern treatment of CCF is endovascular occlusion of the cavernous sinus via a transvenous or transarterial route. Here, the authors present the case of a woman with a paracavernous dAVF mimicking the clinical and radiographic presentation of a CCF. Without any endovascular route available to access the fistulous connection and venous drainage, the authors devised a novel direct hybrid approach by performing an endoscopic endonasal transsphenoidal direct puncture and Onyx embolization of the fistula.

Four-dimensional digital subtraction angiography for exploration of intraosseous arteriovenous fistula in the sphenoid bone

Background

Intraosseous arteriovenous fistula (AVF) is a rare clinical entity that typically presents with symptoms from their effect on surrounding structures. Here, we report a case of intraosseous AVF in the sphenoid bone that presented with bilateral abducens palsy.

Case Description

A previously healthy man presented with tinnitus for 1 month, and initial imaging suspected dural AVF of the cavernous sinus. Four-dimensional digital subtraction angiography (4D-DSA) imaging and a three-dimensional (3D) fused image from the bilateral external carotid arteries revealed that the shunt was in a large venous pouch within the sphenoid bone that was treated through transvenous coil embolization. His symptoms improved the day after surgery.

Conclusion

This is a case presentation of intraosseous AVF in the sphenoid bone and highlights the importance of 4D-DSA and 3D fused images for planning the treatment strategy.

Dural Arteriovenous Fistula of the Vein of Trolard Mimicking a Cavernous Sinus Fistula

BACKGROUND

Arteriovenous fistulas (AVFs) involving the cavernous sinus usually become clinically apparent due to eye symptoms. Although rare, the same symptoms can be associated with AVFs located remote from the cavernous sinus when the shunt drains into its tributaries. We report the unusual case of a dural AVF in which such communication was not immediately obvious from the diagnostic angiogram.

CASE DESCRIPTION

A 61-year-old male presented with increasing lid swelling, proptosis, and redness of the right eye for 1 month. Digital subtraction angiography showed no evidence of a cavernous sinus fistula but revealed a dural AVF between the right middle meningeal artery and the vein of Trolard. The fistula had a minor drainage through a small superficial middle cerebral vein toward the middle cranial fossa. Late venous-phase images eventually revealed faint opacification of the right cavernous sinus and superior ophthalmic vein. Endovascular treatment was performed by transarterial embolization with complete occlusion of the AVF obtained after 2 sessions.

CONCLUSIONS

Dural AVFs involving cortical veins may cause atypical symptoms suggesting a cavernous sinus fistula due to remote venous drainage. Understanding venous anatomy helps to correlate vascular pathology and clinical symptoms and thus allows efficient and safe treatment.

Dural arteriovenous fistula in the superior orbital fissure: A case report

Background:

Dural arteriovenous fistulas (dAVFs) are extremely rare in the superior orbital fissure, and they exhibit ocular symptoms similar to the dAVF in the cavernous sinus because of the intraorbital venous congestion. Hence, the distinction of these conditions is imperative because of some inherent differences in endovascular treatment techniques.

Case Description:

A 58-year-old woman presented with a gradually worsening left eyeball protrusion and conjunctival congestion. The digital subtraction angiography revealed a dAVF with a shunting point in the left superior orbital fissure. Moreover, the inferolateral trunk of the left internal carotid artery and the left middle meningeal artery were involved as feeding arteries. Shunting blood flow drained into the facial vein through the superior ophthalmic vein (SOV) but not into the cavernous sinus, which was located just posterior to the superior orbital fissure. We performed transvenous coil embolization in the SOV through the facial vein, and the symptoms disappeared completely.

Conclusion:

We experienced a case of a dAVF in the superior orbital fissure. This case presented a possibility of the presence of one subtype of the dAVF in the part of the cavernous sinus separated at the superior orbital fissure in front. Transvenous coil embolization in the SOV through the facial vein efficiently occluded the fistula.

Endovascular Treatment of Dural Arteriovenous Fistulas of the Anterior or Posterior Condylar Vein : A Cadaveric and Clinical Study and Literature Review

Dural arteriovenous fistulas (DAVF) involving the anterior and posterior condylar vein at the skull base are rare but important to recognize. Due to the highly variable anatomy of the venous system of the skull base, detailed anatomical knowledge is essential for correct diagnosis and appropriate treatment of these lesions. In this report we review the normal anatomy of the condylar veins and describe rare and, to our knowledge, not previously reported anatomical variants. We also highlight the treatment modalities for these lesions with focus on the endovascular transvenous occlusion based on four consecutive cases from our center.

[Neuro-ophthalmological symptoms of intracranial dural arteriovenous fistulas]

OBJECTIVE

The study objective was to identify the main neuro-ophthalmological symptoms of intracranial dural arteriovenous fistulas (dAVFs) with different localization, based on clinical and angiographic correlations.

MATERIAL AND METHODS

We analyzed neuro-ophthalmological symptoms in 272 patients with dAVFs verified by direct angiographic examination. The localization of dAVFs was as follows: the cavernous sinus (CS) - 143 patients, the lateral sinuses (LSs) and the confluence of sinuses - 77 patients, and other locations - 52 patients.

RESULTS

Neuro-ophthalmological symptoms were detected in 163 (60%) patients. The symptoms were most typical of fistulas located in the CS (99% of patients with CS dAVFs). Neuro-ophthalmological symptoms were less typical of fistulas located in the LS and confluence (21% of patients with LS dAVFs) and dAVFs located outside of the CS and LS (9.6% of patients). Two main neuro-ophthalmological syndromes of intracranial dAVFs were identified: syndrome of obstructed venous outflow from the orbit and syndrome of intracranial hypertension (ICH). A correlation between neuro-ophthalmological symptoms and changes in the cerebral venous hemodynamics was found.

CONCLUSION

The syndrome of obstructed venous outflow from the orbit is pathognomonic for CS dAVFs. In some cases, obstruction of venous outflow from the orbit was observed in patients with dAVFs of other localization, with involvement of the CS and orbital veins in drainage of the fistula. The ICH syndrome reflects the most significant obstruction of venous outflow from the cranial cavity, which is characteristic of LS dAVFs with retrograde outflow in the sinuses and cerebral veins.