Dural arteriovenous fistula involving superior petrosal sinus with petrosal venous drainage in association with cerebral venous thrombosis: Literature review and illustrative case

Background

Dural arteriovenous fistulas (DAVFs) involving superior petrosal sinus (SPS) and superior petrosal vein (SPV) are extremely rare. The pathogenesis of these fistulas remains unclear. We are illustrating 2 cases of DAVFs involving the superior petrosal sinus and veins associated with venous sinus thrombosis with a literature review.

Methods

We reviewed the literature using the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines focusing on DAVFs involving the SPS and/or SPV. Additionally, we searched for additional articles through the reference lists of the included studies.

Results

Our review yielded 20 articles from 1997 until 2022 involving 33 patients with 34 fistulas, including our 2 patients. The mean age was 55.1 ± 12.9 years (range 25-85), 54.5% were males (n = 18). The patients presented with hemorrhage in 36.4% (n = 12), and progressive myelopathy in 30.3% (n = 10). Most fistulas often had arterial supply from MMA, MHT, and/or OA. The fistulas had infratentorial drainage in 64.71% (n = 22), supratentorial drainage in 23.53% (n = 8), and both supra and infratentorial drainage in 11.76% (n = 4). In 27.3% (n = 9), cerebral venous thrombosis was mentioned or identified. Endovascular treatment was performed in 47.1% of cases (n = 16), surgery in 29.4% (n = 10), and combination of treatments in 23.5% (n = 8). A total of 30.3% (n = 10) of cases had incomplete recovery or poor result.

Conclusion

DAVFs involving the SPS and/or SPV are associated with aggressive natural history, requiring early diagnosis and prompt treatment, leading to good prognosis. These fistulas may be acquired in origin, probably secondary to cerebral venous thrombosis.

Superior petrosal vein sacrifice in translabyrinthine approach for resection of vestibule schwannoma

PURPOSE

The aim of this study was to evaluate the safety and surgical outcome of superior petrosal vein (SPV, Dandy's vein) sacrifice in translabyrinthine approach (TLA) for resection of vestibule schwannoma (VS) as compared with SPV preservation, with further investigation of preoperational factors associated with the implement of SPV sacrifice.

METHODS

The authors prospectively collected data from patients surgically treated for VS through TLA between June 2021 and April 2022 at the Gruppo Otologico.

RESULTS

There were 30 and 49 patients in SPV sacrifice and preservation groups, respectively. SPV sacrifice group had significantly larger tumor size (2.46 vs. 1.40 cm), less percentage of solid tumor (26.7% vs. 83.7%), higher incidence of brainstem compression (80% vs. 26.5%), and higher percentage of facial numbness (20.0% vs. 4.1%) than SPV preservation group. Gross total resection (GTR) rates were 73.3% after SPV sacrifice and 87.8% after SPV preservation. Facial nerve preservation rates were similar. No complication related with SPV sacrifice was observed. Logistic regression analysis showed tumor size and complete solid consistency as significant risk factors associated with SPV sacrifice. ROC curve further demonstrated tumor size as a fair predictor (AUC = 0.833), with optimum cutoff value of 1.68 cm.

CONCLUSION

SPV sacrifice via TLA as needed is a safe and effective maneuver for removal of relatively large VS. Tumor size and consistency can be used as a guidance in preoperational decision-making, with cutoff value of 1.68 cm and cystic formation as predictive indicators.

Preoperative assessment of the individual anatomy of the superior petrosal vein complex using balanced fast field echo magnetic resonance imaging

BACKGROUND

Here, we sought to examine the validity and reproducibility of balanced fast field echo (bFFE) for assessing superior petrosal vein (SPV) complex (SPVC) anatomy.

METHODS

Preoperative bFFE or equivalent scans and operative videos were studied and directly compared with regard to the individual anatomical features of SPVCs and their relation to the operative field. The anatomical details of the bFFE findings of the non-operated side (group 2) of all 50 patients were then reviewed, including the presence of petrosal-galenic anastomosis, and finally compared to the operated SPVCs (group 1).

RESULTS

A complete correlation between bFFE and intraoperative findings was observed in 62% of cases and had a significant correlation with 3 Tesla magnet strength and higher pixel bandwidth (rbis = - 0.47; p = 0.005). The sensitivity and specificity of bFFE magnetic resonance imaging were 93.7 and 95.2%, respectively, for detecting an SPV disturbing the operative field, and 97.3% and 95% for a disturbing tributary, respectively. Each group had 50 SPVCs, with a total of 70 and 64 SPVs, 10 and 11 general SPVC configurations, as well as 29 and 28 different individual anatomical variations in groups 1 and 2, respectively. Both groups had 1-3 SPVs with a similar distribution of frequencies [Chi-square (4) = 27.56; p = 0.0145 (Fisher's exact test)]. The similarity of the general configurations was not statistically significant. The same four predominant configurations constituted 80% of the SPVCs in each group. The vein of the cerebellopontine fissure was most frequently found in 86% and 88% of cases, and a petrosal-galenic anastomosis was seen in 38% and 40% of groups 1 and 2, respectively.

CONCLUSIONS

Individual SPVC variations are extensive. Good quality bFFE or equivalents are feasible for preoperative SPVC assessments. However, methods improving vascular visualization are recommended.

Rational sacrifice of the superior petrosal vein

During surgeries of the posterior cranial fossa, sacrificing the superior petrosal vein (SPV) can enhance visualization of the operative field but may also lead to postoperative venous infarction with potentially fatal consequences. We previously proposed that the safety of SPV sacrifice depends on whether there are collaterals that can take on the venous flow of the SPV after its sacrifice. Here, we propose several practical strategies that may be able to evaluate the presence of collaterals to the SPV, so that the safety of SPV sacrifice can be assessed.

Diagnosis and Treatment of a Dural Arteriovenous Fistula Involving the Superior Petrosal Vein

OBJECTIVE

A dural arteriovenous fistula involving the superior petrosal vein (SPV DAVF) is an extremely rare condition. Therefore, its clinical presentation, imaging characteristics, treatment methods, and risk factors remain unclear. In this study, we discuss and analyze the aforementioned features of an SPV DAVF.

METHODS

We retrospectively reviewed 30 patients with SPV DAVFs, with a 1-year follow-up rate of 96.67% (29 of 30). The neurological function of the patients was assessed using the modified Aminoff-Logue scale and the modified Rankin Scale score. The risk factors before and after treatment were established using univariate and multivariate logistic regression analyses. Additionally, treatments involving 3 distinct SPV DAVF drainage patterns were presented.

RESULTS

Of the 30 patients, 24 were men (80.0%). Besides, the angiography images were reexamined 12 months after surgery. Univariate analyses indicated that the extent of edema (odds ratio 1.889, 95% confidence interval 1.132-3.154) and the number of draining veins (≤2) (odds ratio 10.833, 95% confidence interval 1.961-59.834) were risk factors for pretreatment modified Rankin Scale score ≥3. However, multivariate analyses revealed no statistically significant differences (P = 0.051, P = 0.055). Following the multivariate analyses, steroid pulse (odds ratio 12.153 95% confidence interval 1.080-136.772) was found to be the only significant risk factor for post-treatment difference between pretreatment and 1-year follow-up modified Rankin Scale score ≥2.

CONCLUSIONS

A DAVF with SPV drainage is an uncommon type of intracranial vascular malformation. Most lesions involve the brain stem or high cervical spinal cord, thereby posing a higher risk of disability or death. Moreover, neuronal damage from persistent venous hypertension is permanent. Therefore, precise diagnosis and timely treatment are key to a good patient prognosis.

Deadly complication of sacrificing superior petrosal vein during cerebellopontine angle tumor resection: A case report and literature review

Background:

Tumors of the cerebellopontine angle (CPA) are challenging to resect and have been proven difficult for neurosurgeons to manage optimally. Superior petrosal vein complex (SPVC) as the main drainage system and close proximity to CPA could be an obstacle during operation. There is an incidence ranging from 55% to 84% of injury to one part of the SPVC during CPA tumor surgery.

Case Description:

We report a case of 65-year-old woman with CPA tumor, who complained of unilateral hearing loss, dizziness, and facial pain. During tumor resection, one part of SPV complex was injured, then cerebellar edema develops.

Conclusion:

This case provides an overview of surgical complication associated with venous sacrifice. This would support the agreement to preserve SPV regarding risks and improve the quality of surgical decision making.

Absence of Ischemic Injury after Sacrificing the Superior Petrosal Vein during Microvascular Decompression

BACKGROUND

Sacrificing the superior petrosal vein (SPV) is controversial during a microvascular decompression (MVD). There have been multiple reports of complications including life-threatening brainstem infarction and cerebellar edema.

OBJECTIVE

To analyze the potential for vascular complications when the SPV is sacrificed during an MVD.

METHODS

Retrospective chart review was performed to identify all MVDs for trigeminal neuralgia and hemifacial spasm from 2007 to 2018 at 1 institution. Cases with ≥1 mo of follow-up were included and SPV sacrifice was noted. The primary outcome was complications related to SPV sacrifice including sinus thrombosis, cerebellar edema, and midbrain or pontine infarction. Imaging was used to confirm all potential vascular complications noted in medical records. Fisher's exact test and unpaired t-tests were used to compare between groups.

RESULTS

A total of 732 MVD cases were identified and 592 met inclusion criteria with an average follow-up of 11.8 ± 16.4 mo and a male-to-female ratio of 1:2.2. The SPV was sacrificed in 217 cases and retained in 375 cases. No SPV-related vascular complications were found in this study. Two unrelated cases of vascular complications were identified and both were in the nonsacrificed group. One case involved cerebellar bleeding while the other was an ipsilateral transverse sinus thrombosis that was present preoperatively.

CONCLUSION

In MVDs, there is no difference in the rate of vascular complications when the SPV is sacrificed compared to preserved. To best visualize a cranial nerve and optimize safe decompression, surgeons should feel free to sacrifice the SPV.

Use of Superior Petrosal Venous Complex to Transpose the Superior Cerebellar Artery in Microvascular Decompression for Trigeminal Neuralgia: 2-Dimensional Operative Video

Trigeminal neuralgia is a cause of severe facial pain, usually provoked by a neurovascular conflict, commonly involving the superior cerebellar artery (SCA).¹ The superior petrosal venous complex is in the way toward the nerve through a retrosigmoid approach and can narrow the working area around trigeminal nerve.^2-4 Nonetheless, instead an obstacle it can be faced in selected cases as an adjunct to help to transpose the offending arterial loop, avoiding undesired venous sacrifice. We present a case of a 64-year-old man with left-sided severe shock-like pain in the V3 territory suggestive of trigeminal neuralgia (Video 1). Preoperative imaging depicted a neurovascular conflict between SCA and trigeminal nerve root. A retrosigmoid approach was implemented, and stimulation of the compression point was consistent with the preoperative referred pain.⁵ Considering the thick superior petrosal vein (SPV), we transposed the offending artery and anchored it over a SPV tributary.⁶ In this way no prosthetic material was placed in contact with trigeminal nerve, minimizing chance of recurrence.^7-9 No abnormality on neurophysiological monitoring was reported, and postoperative imaging demonstrated no edema or hemorrhage, as well successful displacement of SCA. Patient presented complete resolution of pain and no new neurological deficit after 1 year of follow-up. This case is an uncommon report depicting a helpful intraoperative decision to be considered in selected cases to avoid venous sacrifice and preclude prosthetic material in contact with the nerve. Anatomical pictures courtesy of the Rhoton Collection, American Association of Neurological Surgeons (AANS)/Neurosurgical Research and Educational Foundation (NREF).

Preservation of Coexisting Normal Superior Petrosal Vein in the Microsurgical Treatment of Superior Petrosal Sinus Dural Arteriovenous Fistulas Assisted by Indocyanine Green Video Angiography

BACKGROUND

Superior petrosal sinus (SPS) dural arteriovenous fistulas (DAVFs) are a common subtype of tentorial DAVFs that often require microsurgical treatment. We have noted a rare condition involving the presence of a coexisting normal superior petrosal vein (SPV) during surgery for SPS DAVFs; this condition has not been reported in the literature. Identification and preservation of coexisting normal veins are crucial to prevent venous complications.

METHODS

We reviewed data of 12 patients with SPS DAVFs who underwent microsurgical treatment. Intraoperative indocyanine green video angiography was used to confirm the location of the fistula and identify the normal SPV. Postoperative radiologic examination was performed, and the clinical outcome was evaluated with the modified Rankin Scale.

RESULTS

A coexisting normal functional SPV was found in 6 cases. Analysis of the tributaries of the SPV showed the vein of the cerebellopontine fissure was the most frequent arterialized drainage vein (66.7%), while the pontotrigeminal vein was the most frequent normal drainage vein (45.5%). The DAVFs were easily identified and disrupted using intraoperative indocyanine green video angiography. The normal SPV was also successfully preserved. All 6 patients experienced good clinical and radiologic outcomes.

CONCLUSIONS

An SPS DAVF can coexist with a normal functional SPV, which should be preserved. Use of indocyanine green video angiography is an efficient way to identify the normal SPV.

Delayed Contralateral Trigeminal Neuralgia After Microvascular Decompression and Postoperative Changes in Venous Outflow

A 66-year-old woman had presented with a 3-month history of left trigeminal neuralgia. She had undergone successful microvascular decompression for right-sided trigeminal neuralgia 8 years previously. To optimize visualization, microvascular decompression for trigeminal neuralgia has been commonly associated with sacrifice of the superior petrosal vein during surgery. The absence of sufficient collaterals can result in most of the posterior fossa venous drainage relying solely on the contralateral superior petrosal vein, leading to subsequent vessel enlargement and a compressive effect on the trigeminal nerve and causing iatrogenic contralateral trigeminal neuralgia. We have provided preoperative and intraoperative images illustrating nicely the adapted postoperative change in venous outflow causing contralateral compression of the trigeminal nerve. Consecutive treatment effects should be carefully considered when offering and performing surgical microvascular decompression.

Complication Rates During Endoscopic Microvascular Decompression Surgery Are Low With or Without Petrosal Vein Sacrifice

OBJECTIVE

Endoscopic-microvascular decompression (E-MVD) is a well-described treatment for trigeminal neuralgia (TGN), but there has been debate on the safety of intraoperative sacrifice of the petrosal vein (PV) due to concern for subsequent venous insufficiency. Our objective was to investigate the risk of PV sacrifice during E-MVD in TGN and subsequent postoperative complications and pain outcomes.

METHODS

5 five-year review yielded 201 patients who underwent MVD for TGN. PV sacrifice, vascular compressive anatomy, and postoperative complications attributable to venous insufficiency were analyzed. Preoperative and postoperative pain outcomes were analyzed.

RESULTS

PV was sacrificed in 118 of 201 (59%) of patients, with 43 of 201 (21%) patients undergoing partial sacrifice versus 75 of 201 (37%) with complete sacrifice. No cases of venous infarction, cerebellar swelling, or fatal complications were noted in either cohort. Non-neurologic complications occurred in 1.69% (2 of 118) of patients with PV sacrifice and 0% (0 of 83) of patients with PV preservation. Neurologic deficits (facial palsy, conductive hearing loss, gait instability, memory deficit) occurred in equal proportions in PV preservation and sacrifice groups (2.41% vs. 1.69%) Overall, 87.3% (145 of 166) patients reported their pain as "very much improved" or "much improved" at 1 month, and no difference between groups was identified.

CONCLUSIONS

This study did not find higher complication rates in patients undergoing petrosal vein sacrifice during E-MVD for trigeminal neuralgia. In this series where petrosal vein was sacrificed only 59% of the time, it appears to be a safe technique, but larger studies will be needed to determine true incidence of complications after PV sacrifice.

Individual variations of the superior petrosal vein complex and their microsurgical relevance in 50 cases of trigeminal microvascular decompression

Background

We investigated the understudied anatomical variations of the superior petrosal vein (SPV) complex (SPVC), which may play some role in dictating the individual complication risk following SPVC injury.

Methods

Microvascular decompressions of the trigeminal nerve between September 2012 and July 2016. All operations utilized an SPVC preserving technique. Preoperative balanced fast field echo (bFFE) magnetic resonance imaging, or equivalent sequences, and operative videos were studied for individual SPVC anatomical features.

Results

Applied imaging and operative SPVC anatomy were described for fifty patients (mean age, 67.18 years; female sex and right-sided operations, 58% each). An SPVC component was sacrificed intentionally in 6 and unintentionally in only 7 cases. Twenty-nine different individual variations were observed; 80% of SPVCs had either 2 SPVs with 3 or 1 SPV with 2, 3, or 4 direct tributaries. Most SPVCs had 1 SPV (64%) and 2 SPVs (32%). The SPV drainage point into the superior petrosal sinus was predominantly between the internal auditory meatus and Meckel cave (85.7% of cases). The vein of the cerebellopontine fissure was the most frequent direct tributary (86%), followed by the pontotrigeminal vein in 80% of SPVCs. Petrosal-galenic anastomosis was detected in at least 38% of cases. At least 1 SPV in 54% of the cases and at least 1 direct tributary in 90% disturbed the operative field. The tributaries were more commonly sacrificed.

Conclusions

The extensive anatomical variation of SPVC is depicted. Most SPVCs fall into 4 common general configurations and can usually be preserved. BFFE or equivalent sequences remarkably facilitated the intraoperative understanding of the individual SPVC in most cases.

Transposition of Superior Cerebellar Artery for Microvascular Decompression in Trigeminal Neuralgia Using an In Situ Superior Petrosal Vein Sling Technique

BACKGROUND

Several microvascular decompression technical variations for the treatment of medically refractory trigeminal neuralgia have been proposed that can be categorized generally as interposition and transposition techniques. These latter approaches, so-called slinging techniques, have been increasing in popularity, because they can possibly reduce the long-term recurrence rates by preventing the formation of fibrosis and granulomas at the decompression site. We have reported a technique for transposition of the superior cerebellar artery for microvascular decompression in trigeminal neuralgia using the superior petrosal vein as an in situ sling to anchor and reroute the artery away from the nerve.

METHODS

We have presented a technical report with illustrative intraoperative images and video from 2 cases of trigeminal neuralgia in which the superior petrosal vein was used as a simple and straightforward in situ sling for transposition of the superior cerebellar artery.

RESULTS

The technique was applied successfully in 2 patients with complete and immediate remission of trigeminal neuralgia, without surgical morbidity.

CONCLUSION

The most frequent neurovascular conflict in trigeminal neuralgia involves the superior cerebellar artery, and the strategic location of the superior petrosal vein relative to this neurovascular complex allows for its use as a natural in situ sling that reroutes the artery and prevents its recoil against the nerve. This technique can be added to the increasing armamentarium of transposition techniques for microvascular decompression, with the advantage of simplicity and no requirement for a complex prosthesis to secure the transposition.

Dural Arteriovenous Fistulas at the Petrous Apex

OBJECTIVE

Dural arteriovenous fistulas (DAVFs) at the petrous apex are rare but may cause subarachnoid hemorrhage (SAH) or severe brainstem edema. This study aimed to summarize their clinical features and discuss the classification.

METHODS

During a 15-year period, 64 consecutive patients with DAVF at the petrous apex were reviewed. According to their angioarchitecture, these cases were classified as follows: type I, no venous ectasia (48.4%); type II, venous ectasia but with normal vein proximal to the fistula (29.7%); and type III, venous ectasia at the site of the fistula (21.9%).

RESULTS

There were 53 men and 11 women included. Presented symptoms were SAH in 8 patients (12.5%), nonhemorrhagic neurologic defects (NHNDs) in 53 patients (82.8%), and no symptoms in 3 patients (4.7%). There were 49 patients who received transarterial embolization, 8 patients who received microsurgery, and 7 patients who received embolization and microsurgery. Complications occurred in 9 patients (14.1%), including transient cranial nerve palsy (4.7%), rebleeding (6.3%), and respiratory failure (3.1%). Of the type I patients, 96.77% presented with NHNDs and 77.42% presented with infratentorial drainage. However, SAH occurred more often in type II (21.05%)/type III cases (28.57%), and most patients carried a supratentorial drainage (63.16% and 85.71%, respectively). In different types of DAVFs, the necessity for embolization combined with microsurgery (6.45% in type I, 10.53% in type II, 21.43% in type III) and the occurrence of rebleeding complications (0% in type I, 10.53% in type II, and 14.29% in type III) were varied.

CONCLUSIONS

Petrous apex DAVFs carried a high risk of embolization-related complications. Based on the vascular architecture, this classification may reflect their clinical features and provide some advice on the treatment of DAVFs at the petrous apex.

Safety of Superior Petrosal Vein Sacrifice During Microvascular Decompression of the Trigeminal Nerve

BACKGROUND

Microvascular decompression (MVD) is a safe and effective treatment for trigeminal neuralgia. Cerebellar venous infarction is a complication associated with surgical sacrifice of the superior petrosal vein (SPV). The SPV intervenes between the trigeminal nerve and the surgeon. Optimal exposure of the cisternal trigeminal nerve, particularly at the brainstem, can be achieved by sacrificing the SPV. We analyzed a cohort of 224 patients to determine the frequency of cerebellar venous infarction.

METHODS

Retrospective analysis of records and neuroradiology for patients undergoing trigeminal MVD at the Manchester Skull Base Unit between August 1st 2008 and July 31st 2015.

RESULTS

A total of 184 of 224 (82%) patients had coagulation and division of the main stem of the SPV. There were no cases of venous infarction. There was one case of mild, transient, cerebellar symptoms and signs, with no radiologic evidence of venous infarction. This patient had SPV sacrifice at surgery but also had postoperative thrombosis of the transverse sinus. Venous sinus thrombosis affected 5 of 184 (2.7%) patients. A total of 208 of 224 (93%) patients had a good outcome with improvement or resolution of their trigeminal neuralgia at 3 months.

CONCLUSIONS

The overall rate of venous complications in this study was 2.7%; however, we had no cases of venous infarction in 184 patients who had sacrifice of the SPV. The incidence of venous infarction associated with SPV obliteration during MVD surgery is therefore <0.5%. SPV sacrifice may be used where necessary to optimize visualization of the root entry zone and maximize the chance of effective decompression of the trigeminal nerve.

Complications after obliteration of the superior petrosal vein: Are they rare or just underreported?

Dandy first described the course of the superior petrosal vein (SPV) and its importance during surgery in 1929. Although it has been reported that this vein can be sacrificed without complication, unfavourable outcomes may occur after dividing the SPV. We review these consequences, which may include peduncular hallucinosis and hearing loss, or even hemorrhage, and discuss factors that may contribute to complications. Preservation of the SPV should be attempted whenever possible to increase the safety of surgery.