Case of direct carotid-cavernous fistula presenting with subarachnoid hemorrhage

We report a case of longstanding asymptomatic direct carotid-cavernous fistula (CCF) which caused fatal subarachnoid hemorrhage (SAH). A 91-year-old female with no history of previous head trauma and optic symptoms presented acute subarachnoid hemorrhage. Angiography revealed a left direct carotid-cavernous fistula draining only into the contralateral cavernous sinus with leptomeningeal venous reflux and small varix on the pontine bridging vein. The affected cavernous sinus was markedly dilated and there was no septum between the left cavernous sinus and the internal carotid artery. The patient underwent transvenous coil embolization for intercavernous sinus and leptomeningeal venous reflux was successfully obliterated and opacification of the varix was diminished. The past history of this patient and angiographical findings strongly suggest long standing asymptomatic CCF caused SAH.     

Single stage transcranial exposure of large dural venous sinuses for surgically-assisted direct transvenous embolization of high-grade dural arteriovenous fistulas: technical note

Background  

High-grade dural arteriovenous fistulas (DAVFs) with retrograde cortical leptomeningeal drainage are formidable lesions because of their risk for intracranial hemorrhage. Treatment is aimed at occluding venous outflow to achieve obliteration of the fistula. In DAVFs that involve a large dural venous sinus (transverse sigmoid sinus or superior sagittal sinus), occluding venous outflow can be accomplished endovascularly with transvenous embolization. However, in some cases of DAVFs with reflux into cortical leptomeningeal veins, there may be venous restrictive disease downstream, such as occlusive thrombosis, which can prohibit endovascular access via the transfemoral or transjugular routes. In these instances, a transcranial approach can be performed to expose the large dural venous sinus distal to the site of occlusion for direct catheterization of the venous outflow for transvenous embolization. This combined surgical and endovascular strategy provides direct access to the venous outflow and bypasses the site of thrombotic obstruction.     

Ischemia of the sternocleidomastoid muscle following occipital artery embolization for dural arteriovenous fistula

We report a case of localized ischemia of the sternocleidomastoid muscle (SCM) occurring after occipital artery embolization of a dural arteriovenous fistula (dAVF). A 45-year-old man presented intracerebral hemorrhage from a dAVF at the left transverse-sigmoid sinus. The dAVF had a high flow fistula from the left occipital artery (OA). Endovascular therapy was carried out one month later. Transarterial embolization of the OA was carried out prior to the transvenous approach to decrease the shunt flow. During obliteration of the proximal portion of the OA with fiber platinum coils and polyvinyl alcohol particles, the patient reported severe neck pain. The fistula was successfully embolized after transvenous packing of the left sigmoid sinus with detachable coils. The neck pain persisted for one week and disappeared after conservative treatment. T2-MR imaging 3 days after the embolization showed a hyperintensity in the left SCM. This ischemic lesion was probably induced by occlusion of the muscular branch of the OA. We discuss this common but rarely reported complication of OA embolization.     

A case of intracranial dural arteriovenous fistula presenting with brainstem infarction

A 68-year-old female presented with the disturbance of brainstem function. Brain T2 weighted and FLAIR (fluid-attenuated inversion recovery) magnetic resonance imaging revealed the hyperintensity signal of the medulla oblongata, which led to diagnosis of brainstem infarction. Diagnostic cerebral angiography showed the dural arteriovenous fistula (DAVF) developed on the left transverse sinus (TS). Venous drainage route was consisted of retrograde leptomeningieal venous reflux of the cerebrum and spinal perimedullary vein via superior petrosal sinus. Venous hypertension of the brainstem was relieved by transvenous platinum coil selective embolization of superior petrosal sinus. The correct analysis of venous drainage pattern is essential for the curative endovascular surgery.     

Use of a wedged microcatheter for curative transarterial embolization of complex intracranial dural arteriovenous fistulas: indications,endovascular technique,and outcome in 21 patients

OBJECT: The aim of this study was to describe the application of a novel transarterial approach to curative embolization of complex intracranial dural arteriovenous fistulas (DAVFs). This technique is particularly useful in patients harboring high-grade DAVFs with direct cortical venous drainage or for whom transvenous coil embolization is not possible because of limited sinus venous access to the fistula site due to thrombosis or stenotic changes. METHODS: Twenty-three DAVFs in 21 patients were treated using a transarterial N-butyl cyanoacrylate (NBCA) embolization technique with the aid of a wedged catheter. In all patients, definitive treatment involved two critical steps: 1) a microcatheter was wedged within a feeding artery, establishing flow-arrest conditions within the catheterized vessel distal to the microcatheter tip; and 2) NBCA was injected under these resultant flow-arrest conditions across the pathological arteriovenous connection and into the immediate draining venous apparatus, definitively occluding the fistula. Patient data were collected in a retrospective manner by reviewing office and inpatient charts and embolization reports, and by directly analyzing all procedural and diagnostic angiograms. Eight patients presented with the principal complaint of tinnitus/bruit, five with intracranial hemorrhage, four with cavrnous sinus syndrome, and one each with seizures, ataxia, visual field loss, and hiccups. The parent (recipient) venous structure of the DAVFs in this study included 11 leptomeningeal veins, eight transverse/sigmoid sinuses, three cavernous sinuses, and one sphenoparietal sinus. The NBCA permeated the arteriovenous shunt, perifistulous network, and proximal draining vein in all DAVFs. Occlusion was confirmed on postembolization angiography studies. No complication occurred in any patient in this series. There has been no recurrence during a mean follow up of 18.7 months (range 2-46 months). CONCLUSIONS: Transarterial NBCA embolization with the aid of a wedged catheter in flow-arrest conditions is a safe and an effective treatment for intracranial DAVFs.     

Transcranial embolization of a transverse-sigmoid sinus dural arteriovenous fistula carried out through a decompressive craniectomy

Summary We report a case of dural arteriovenous fistula (DAVF) of the transverse-sigmoid sinus presenting with intraventricular hemorrhage. Cerebellar infarction developed after transarterial embolization, and decompressive craniectomy was performed to relieve the mass effect. Through the bone window of the decompressive craniectomy, transcranial puncture of thetransverse sinus and coil occlusion of the fistula were successfully performed. Decompressive craniectomy may provide an opportunity to occlude DAVFs which cannot be occluded by the transarterial or transvenous approach.     

Transvenous embolization for dural transverse sinus fistulas with occluded sigmoid sinus

Summary Dural transverse sinus arteriovenous fistulas with cortical venous drainage were associated with a high hemorrhagic risk. Dural transverse sinus arteriovenous dural fistulas could be treated by embolization (transarterial or transvenous), surgery or a combination of both. Transvenous packing of the diseased sinus was considered to be a less invasive and effective method of treatment. Occluded sigmoid sinus proximally, especially cases with isolated transverse sinus, could make the transvenous approach difficult. Craniotomy for sinus packing or surgical excision remained the treatment of choice when the percutaneous transvenous approach was not feasible. We reviewed the techniques of transvenous embolization described in the literature and illustrated our techniques in two consecutive cases of transvenous embolization of the dural arteriovenous fistulas through the occluded sigmoid sinus. We concluded that transvenous embolization remains a safe and feasible technique other than surgery for patients with transverse sinus dural fistula, achieving a long-term occlusion of the pathology.     

Endovascular treatment of an internal carotid artery pseudoaneurysm following transsphenoidal surgery. Case report

Internal carotid artery (ICA) pseudoaneurysm formation following transsphenoidal surgery is a rare but potentially lethal complication. Direct surgical repair with preservation of the ICA may be difficult. The feasibility of endovascular coil embolization with parent artery preservation for an iatrogenic ICA pseudoaneurysm is undefined. A 40-year-old man was referred to the authors' institution after identification of a pseudoaneurysm of the left ICA following transsphenoidal resection of a pituitary macroadenoma. The pseudoaneurysm was treated via an endovascular approach that included stent-assisted coil embolization of the lesion. Follow-up angiographic studies obtained 1 year later demonstrated complete occlusion of the aneurysm, and the patient remains asymptomatic. Stent-assisted coil embolization of this iatrogenic pseudoaneurysm was successful in achieving complete, angiographically confirmed aneurysm obliteration, with preservation of the ICA and short-term prevention of hemorrhage or carotidcavernous fistula. The endovascular method provided an effective, relatively low-risk treatment for this difficult lesion, and was an excellent alternative to direct surgical repair. Nonetheless, long-term follow-up review is required before definitive treatment recommendations can be made.     

Persistent primitive trigeminal artery-cavernous sinus fistula with intracerebral hemorrhage: endovascular treatment using detachable coils in a transarterial double-catheter technique. Case report and review of the literature

Intracerebral hemorrhage occurred in this 61-year-old woman with preexisting diplopia and proptosis. Results of angiography demonstrated a persistent primitive trigeminal artery (PPTA)-cavernous sinus fistula with cortical venous reflux. Two microcatheters were introduced transarterially through the PPTA into the two draining pathways in the cavernous sinus. Coils were delivered in both pathways simultaneously to prevent further venous overload on either path. The fistula was successfully occluded without complication while the PPTA was preserved. The authors describe this double-catheter technique for coil embolization of a fistula and review the literature concerning PPTA-cavernous sinus fistulas.     

Carotid-cavernous fistula treatment with ethylene vinyl alcohol (onyx) exclusively through anterior venous approach

The type of venous drainage of a direct carotid-cavernous fistula is an important issue to consider for the endovascular therapeutic decision. In case of an inadequate posterior drainage associated with a good anterior drainage, the facial vein is a useful alternative. The exclusive embolization with ethylene vinyl alcohol (EVOH Onyx), arterial and/or venous via the internal carotid artery (ICA) occlusion has been used successfully, in a few cases until now. Nevertheless, the use of this method through anterior transvenous approach has not been previously described. Presented here is the case of a 13-year-old female patient with left posttraumatic carotid-cavernous fistula, with predominant anterior drainage, as well as carrier of traumatic occlusion of the contralateral ICA. The treatment was by means of a transvenous approach with transient occlusion of the left ICA.     

Usefulness of intravascular ultrasound in embolization of dural arteriovenous fistula: a case report

A 66-year-old male was admitted with right homonymous hemianopsia. Angiograms revealed a dural arteriovenous fistula (DAVF) involving the left transverse-sigmiod sinus. The DAVF was fed by the left occipital, middle meningeal, and posterior auricular arteries and drained into the left transverse sinus with occlusion of the left internal jugular vein and reversed flow of the left occipital cortical veins. Positron emission tomography (PET) study showed decreased regional cerebral blood flow (rCBF), regional oxygen extraction fraction (rOEF) and regional cerebral metabolic rate of oxygen (rCMRO2) and increased regional cerebral blood volume (rCBV). The patient was treated by transarterial and transvenous embolization. Before transvenous embolization, we attempted to observe the perisinus structure used by intravascular ultrasound (IVUS). IVUS was able to demonstrate multiple channels formed by DAVF and transvenous embolization was performed accurately at the exact fistulous site. After treatment, the DAVF had completely disappeared but clinical symptom had hardly any changed. A PET study showed that the rCBF and rCBV were normalized but rOEF and rCMRO2 had not changed. Eight months after treatment, PET study showed some normalization of rOEF and rCMRO2 of the left occipital lobe with the clinical symptom. IVUS is useful in determining the exact sites of transvenous embolization of DAVF.     

Dural arteriovenous fistula involving the superior sagittal sinus following sinus thrombosis--case report

A 57-year-old woman presented with a dural arteriovenous fistula (AVF) involving the superior sagittal sinus (SSS) based upon serial radiological examinations. Her chief complaints were headache and vomiting. Cerebral angiography and magnetic resonance (MR) venography revealed the sinus thrombosis involving the SSS, the bilateral transverse sinuses (TSs), and the right sigmoid sinus. Her symptoms disappeared after anticoagulant therapy. Follow-up MR venography revealed almost complete recanalization of the occluded sinuses, followed by restenosis of the SSS and the left TS and occlusion of the right TS without symptoms. She developed transient right hemiparesis 13 months after the initial onset. Cerebral angiography revealed a dural AVF involving the SSS with cortical reflux into the left frontoparietal region. The dural AVF was occluded by transarterial and transvenous embolization. Her symptom disappeared during the follow-up period.     

Acute angle-closure glaucoma after successful embolization of traumatic carotid-cavernous sinus fistula--case report

A 69-year-old woman developed acute angle-closure glaucoma 2 weeks after successful transvenous coil embolization of a traumatic carotid-cavernous sinus fistula. The angle-closure glaucoma was precipitated by oculomotor palsy caused by transvenous coil packing of the cavernous sinus. Emergency iridotomy resulted in normalization of the intraocular pressure and restoration of vision. Acute angle-closure glaucoma may develop in association with an oculomotor palsy caused by any etiology, including neurointervention.     

Case of traumatic dural arteriovenous fistula presenting as an acute subdural hematoma and an intracerebral hematoma. A case report

A rare case of traumatic dural arteriovenous fistula presenting as an acute subdural hematoma and an intracerebral hematoma is reported. A 57-year-old man was admitted to our hospital complaining of aphasia and right hemiparesis. A CT on admission demonstrated a left frontotemporal subdural hematoma and an intracerebral hematoma in the left frontal lobe. Left external carotid angiographies revealed a dural arteriovenous fistula, fed by the left middle meningeal artery and draining the middle meningeal vein. A retrograde drainage into the cortical vein was also revealed. The patient had sudden loss of consciousness after cerebral angiography and demonstrated increased subdural hematoma and severe midline shift. We performed emergency decompressive craniectomy, coagulation of the dural vessels, and evacuation of the subdural hematoma. Postoperative left external carotid angiographies revealed the disappearance of the dural arteriovenous fistula. This case suggested a dural arteriovenous fistula, between the middle meningeal artery and the middle meningeal vein close to the sinus (sphenoparietal or superior sagital sinus), and resulted in a subdural hematoma and an intracerebral hematoma, due to the retrograde venous drainage into cortical veins.     

Efficacy and Limitations of Transarterial Acrylic Glue Embolization for Intracranial Dural Arteriovenous Fistulas

The efficacy and limitations of transarterial acrylic glue embolization for the treatment of intracranial dural arteriovenous fistulas (DAVFs) were investigated. Thirty-four DAVFs treated by transarterial embolization using n-butyl cyanoacrylate were retrospectively reviewed. The locations of DAVFs were the transverse-sigmoid sinus in 11, tentorium in 10, cranial vault in 9, and superior sagittal sinus, jugular bulb, foramen magnum, and middle cranial fossa in 1 each. Borden classification was type I in 7, type II in 3, and type III in 24. Eight patients had undergone prior transvenous coil embolization. Complete obliteration rate was 56% immediately after embolization, 71% at follow-up angiography, and 85% after additional treatments (1 transvenous embolization and 4 direct surgery). Complications occurred in three patients, consisting of asymptomatic vessel perforations during cannulation in two patients and leakage of contrast medium resulting in medullary infarction in one patient. Transarterial glue embolization is highly effective for Borden type III DAVF with direct cortical venous drainage, but has limitations for Borden type I and II DAVFs in which the affected sinus is part of the normal venous circulation. Onyx is a new liquid embolic material and is becoming the treatment of choice for DAVF. The benefits of glue embolization compared to Onyx embolization are high thrombogenicity, and relatively low risks of cranial nerve palsies and of excessive migration into the draining veins of high flow fistula. Transarterial glue embolization continues to be useful for selected patients, and complete cure can be expected in most patients with fewer complications if combined with transvenous embolization or direct surgery.     

Multimodal endovascular treatment for traumatic carotid- cavernous fistula

bjective：To present our experience in treating traumatic carotid-cavernous fistula （TCCF） by multimodal endovascular treatment.Methods：The management of 28 patients with TCCF between January 2004 and October 2012 in our hospital was retrospectively analyzed.According to imaging charateristics,24 cases were categorized into Type Ⅰ,3 Type Ⅱ and 1 Type Ⅲ.Totally 30 endovascular treatments were performed：Type Ⅰ TCCFs were obliterated via transvenous approach （7/25）,or transarterial approach （18/25） including 6 by detachable balloon occlusion,6 by microcoil embolization,3 by Hyperglide balloon-assisted coil embolization and 3 by a combination of detachable balloon and coil embolization.Two patients were treated with closure of internal carotid artery （ICA）.Type Ⅱ TCCFs were treated with transvenous embolotherapy （2/3） or carotid artery compression therapy （1/3）.The Type Ⅲ patient underwent detachable balloon embolization.Results：Immediate postoperative angiography showed recovery in 26 cases.One recurrent TCCF was found 2 weeks after detachable balloon embolization,and then reobliterated by transarterial coils.Reexamination found balloon deflation and fistula recanalization in 1 patient one month after combination of detachable balloons and coil embolization,which was cured by a second treatment via transvenous approach.The immediate angiography revealed residual blood flow in 4 patients.Among them,2 patients with delayed symptoms at follow-up needed a second treatment,1 patient recovered after carotid artery compression therapy,and the remaining patient＇s symptoms disappeared on digital subtraction angiography at five-month follow-up.CT angiography revealed anterior communicating artery aneurysm in the patient who was treated with closure ofICA 4 years later.Conclusion：According to results of images,characteristics of the fistula and type of drainage,proper treatment approach and embolic material can maximally heal pathological changes,retain the ipsilateral ICA patency and reduce long-term complications.     

Cerebellar hemorrhage and subsequent venous infarction followed by incomplete transvenous embolization of dural carotid cavernous fistulas: a rare complication: case report

Endovascular therapy for dural carotid cavernous fistulas (CCFs) is generally accepted to be safe and effective. The authors report a rare complication of hemorrhage and subsequent venous infarcts of the pons and cerebellum after transvenous embolization. This 41-year-old man presented with a severe left frontal headache, congestion of the left conjunctiva, blurred vision, and photophobia. Cerebral angiography demonstrated a right dural CCF. The patient underwent transvenous embolization of the cavernous sinus but had the initial complication of cerebellar hemorrhage. One month later, he developed progressive dizziness, ataxia, and right-sided weakness. Magnetic resonance imaging revealed severe cerebellar and pontine edema. The cause was a residual fistula combined with delayed occlusion of the inferior petrosal sinus. The fistula was obliterated after repeated embolizations. The patient's symptoms gradually resolved, and there was no evidence of recurrence during the 4-year follow-up period. Incomplete transvenous embolization of a dural CCF can result in life-threatening vascular complications due to redistribution of shunt flow. Early recognition of redistributed drainage and preventive placement of coils at the origin of draining veins during the procedure could avert this rare complication.     

Selective image-guided venous sinus exposure for direct embolization of dural arteriovenous fistula: technical case report

BACKGROUND: Transcranial approaches for transsinusal endovascular therapy of DAVF have been sporadically reported by large craniectomies. Large craniectomies carry nevertheless a risk of postembolization extradural hematoma, reduced by delaying the endovascular procedure. We report a 1-session technique of SIGC for percutaneous transvenous DAVF embolization. CASE DESCRIPTION: This 58-year-old woman developed a right-sided cerebellar hematoma in relation with a high-grade left transverse and sigmoid sinus DAVF. The DAVF was fed by branches from the left vertebral artery, left internal, and left external carotid arteries, draining into the transverse sinus with retrograde flow in cortical veins. Transvenous retrograde embolization was not feasible either through the left internal jugular vein because of thrombosis, or through the right one because of torcular septa. During the same anaesthetic session, a 5-cm-length selective craniectomy was shaped under magnetic resonance image guidance navigation according to the left transverse sinus with high-speed drill. Thereafter, back in the angiography room, the transverse sinus was taped and coiled resulting in a complete exclusion of the DAVF. CONCLUSION: Selective image-guided craniectomy is efficient and safe for direct percutaneous transvenous embolization of DAVF in a single anesthetic session. Leaving bone beside the sinus prevents a parenchymal traumatic puncture. This bone has nevertheless to be drilled to allow an adequate sharp puncture angle. Doing so, postoperative hematoma is prevented by the small bone opening, the natural adherence of the dura matter and the possibility of direct compression.     

Transvenous embolization of carotid-cavernous sinus fistula associated with a primitive trigeminal artery--case report

A 58-year-old female presented with right conjunctival chemosis and right abducens nerve paresis. Cerebral angiography demonstrated a right carotid-cavernous sinus fistula associated with persistent primitive trigeminal artery. The fistula was treated by introducing detachable coils through the transvenous approach, as the detachable balloon was not available. Follow-up angiography performed 14 days after the embolization revealed complete disappearance of the carotid-cavernous sinus fistula due to thrombosis, which was presumably accelerated by the coils. Transvenous coil embolization should be considered as an alternative treatment for high-flow carotid-cavernous sinus fistula, but only if transarterial balloon embolization is not successful or unavailable.     

Surgical treatment of intracranial dural arteriovenous fistulas

BACKGROUND: When considering the treatment strategies for dural arteriovenous fistulas (DAVFs), it is important to clarify the exact location of the fistula and venous drainage route from both DAVFs and normal brain tissue. DAVFs with leptomeningeal retrograde venous drainage carry a high risk of neurological deficits and require aggressive treatment. When AVFs involve the dural sinus, transvenous embolization via the transfemoral approach is usually the first choice of treatment. For DAVFs draining directly into the cortical veins without dural sinus involvement, transarterial embolization may be a curative treatment. However, when embolization is technically difficult or results in incomplete occlusion, surgical treatment is required. The purpose of the present study was to review our experience with surgical treatment of DAVFs. METHODS: The present series included 17 patients; 9 had DAVFs involving the dural sinus with leptomeningeal retrograde venous drainage and 8 had DAVFs draining directly into the cortical veins. For DAVFs involving the sinus, embolization of the diseased sinus by direct surgical exposure was performed in 8 patients, and surgical excision in one. For DAVFs draining directly into the cortical veins, interruption of the draining veins close to DAVFs was undertaken in 7 and surgical excision in 1. RESULTS: Complete obliteration of DAVFs was demonstrated in 16 patients. At final follow-up, 15 patients were asymptomatic and the other 2 showed clinical improvement. CONCLUSIONS: For DAVFs involving the dural sinus, direct operative sinus packing is indicated. For DAVFs directly draining into the cortical veins, surgical interruption of the draining veins is indicated.