Difficult cannulation of the superior ophthalmic vein in the treatment of cavernous sinus dural arteriovenous fistula: two case reports

Retrograde cannulation of the superior ophthalmic vein (SOV) is an important route for embolization of cavernous sinus dural arteriovenous fistula (dAVF). We encountered two cases with significant difficulties with cannulation of the SOV. A 66-year-old woman and an 83-year-old woman were referred to our hospital for treatment of cavernous sinus dAVF. Unilateral chemosis and exophthalmos were seen in both patients. At first, transarterial embolization was performed to reduce the flow, then, transvenous embolization was employed for the treatment of cavernous sinus dAVF. The attempts to embolize through a transfemoral route failed owing to a thrombosed or compartmentalized cavernous sinus. Surgical exposure of the SOV and puncture with needle-cannula was tried. However, in both cases, unsuccessful cannulation resulted in uncontrollable bleeding and periorbital swelling. Finally, by using road-mapping SOV was punctured in the deeper part and the fistula was obliterated with detachable coils. Postoperative course was uneventful and their symptoms were improved. Although the SOV is a useful route for cavernous sinus dAVF embolization, the presence of narrowed or tortuous veins can preclude successful cannulation.     

Management of two cavernous sinus dural arteriovenous fistulae by direct microsurgical approach and catheterization of the superior ophthalmic vein

BackgroundIn case of cavernous sinus dural arteriovenous fistula, transvenous embolization of the cavernous sinus via the inferior petrosal sinus is generally sufficient. However, when inferior petrosal sinus access is challenging, various alternative approaches have been reported, with corresponding difficulties and risks.Case reportsWe report the management of two cases of life-threatening cavernous sinus dural arteriovenous fistula revealed by a typical cavernous sinus syndrome. Conventional approaches were unsuccessful, and a direct microsurgical approach was performed, with catheterization of the superior ophthalmic vein. This combined approach safely accessed the cavernous sinus, and obtained complete occlusion of the fistulae by Onyx® embolization.ConclusionsThis procedure could be an interesting alternative option in the treatment of cavernous sinus dural arteriovenous fistula when conventional approaches are not possible.     

Impact of transvenous embolization via superior ophthalmic vein on reducing the total number of coils used for patients with cavernous sinus dural arteriovenous fistula

Neurosurgical Review - Although transvenous embolization (TVE) via the superior ophthalmic vein (SOV) is adopted in treating cavernous sinus dural arteriovenous fistula (CS DAVF), its effect on the...     

Tentorial dural arteriovenous fistula obliterated using the petrosal approach

BACKGROUND: Tentorial dural arteriovenous fistulas (AVFs) are uncommon lesions usually treated surgically using a subtemporal exposure with division of the tentorium. This exposure requires significant retraction of the temporal lobe and has the possibility of significant arterialized venous bleeding if a draining vein is accidentally cut during division of the tentorium. Skull base surgical techniques may provide alternate approaches for the surgical treatment of tentorial dural AVFs. METHODS: A tentorial dural arteriovenous fistula supplied by the tentorial artery and drained by the petrosal vein was exposed and obliterated using the petrosal (subtemporal-presigmoid) approach. RESULTS: The petrosal approach allowed the exposure and division of the superior petrosal sinus and tentorium with direct visualization of the supratentorial and the infratentorial compartments, avoiding accidental damage to the draining veins. The dural fistula was easily obliterated after its venous drainage was interrupted and the tentorial artery occluded. CONCLUSIONS: Tentorial dural AVFs can be safely treated with interruption of the venous drainage. The exposure can be enhanced with a petrosal approach, decreasing the possibility of uncontrolled bleeding during the procedure.     

Transvenous embolization for cavernous dural arteriovenous shunts: about the intracranial venous approach to the cavernous sinus

Recently, the first choice of therapy for cavernous dural arteriovenous shunts (CdAVS) is transvenous embolization. Usually the approach routes for cavernous sinus are the inferior petrosal sinus (IPS), the superior ophthalmic vein (SOV) in most cases and the superior petrosal sinus (SPS) in rare case. But, it is difficult for us to treat patients in whom there are no extracranial veins through which to approach the cavernous sinus, with transvenous embolization. We presented the case in which intracranial transvenous approach to the cavernous sinus and transvenous embolization were performed and in which we achieve good results. In this article, we presented a case with Barrow's type D CdAVS and cortical venous drainage. At first, transarterial embolization was performed to decrease the amount of venous drainage for the purpose of eliminate convulsions and consciousness disturbance. However, cortical venous drainage continued. Moreover bilateral dilated SOVs normalized and bilateral IPSs were not visible, so we decided that it was impossible to carry out the transvenous embolization via extracranial veins. Transvenous embolization to the left cavernous sinus via the intracranial ophthalmic vein between the superior ophthalmic fissure and the inferior ophthalmic fissure after craniotomy was performed. Then, the transvenous embolization to the right cavernous sinus was carried out through the right superficial middle cerebral vein after craniotomy. The results were good and chemosis and bilateral abducens palsy diminished immediately. Trans-intracranial venous embolization for CdVAS is a very useful therapy when no extracranial veins exist for transvenous embolization.     

Endovascular treatment for dural arteriovenous fistulae of the superior petrosal sinus

OBJECTIVE: To determine the usefulness of endovascular embolization for treatment of dural arteriovenous fistulae of the superior petrosal sinus. METHODS: We performed a retrospective review of 18 patients treated during a 16-year period. Transarterial and/or transvenous embolizations were performed as a preoperative adjunct or definitive therapy. Clinical follow-up status was supplemented by telephone interviews to determine Glasgow Outcome Scale scores. RESULTS: Fourteen patients (78%) were treated with a combination of endovascular therapy and open surgery, and 4 were treated by embolization alone (22%). Angiographic cure was achieved in all patients (100%). Thirty-day morbidity and mortality were 11 and 0%, respectively. The mean follow-up period was 5.4 years. At the latest follow-up examination, all patients had returned to independent clinical status (Glasgow Outcome Scale scores of 1 or 2). CONCLUSION: Endovascular treatment of dural arteriovenous fistulae of the superior petrosal sinus can result in cure when access to the site of the fistula can be achieved. Preoperative embolization is a safe and effective adjunct to minimize bleeding during open neurosurgery.     

Transvenous occlusion of dural cavernous sinus fistulas through the thrombosed inferior petrosal sinus: report of four cases and review of the literature

BACKGROUND: The aim of this study is to describe the technique and results of the endovascular approach through the thrombosed inferior petrosal sinus (IPS) for occlusion of dural cavernous sinus fistulas (DCSFs). METHODS: In four patients presenting with clinically symptomatic DCSFs, the angiogram did not show opacification of the IPS, indicating that it neither drained the arteriovenous fistula nor the cerebral venous outflow. A large volume biplane phlebogram of the jugular bulb was obtained to identify a thrombosed remnant of the IPS. We were able to navigate small hydrophilic catheters and microguide wires through the thrombosed IPS into the ipsi- or contralateral CS. After reaching the fistula site the CS was packed with detachable platinum coils. RESULTS: We were able to reach the fistula site and to achieve a dense packing of coils within the arteriovenous shunting zone in all of the patients. The final angiogram showed subtotal or complete occlusion of the arteriovenous fistula. All four patients recovered completely and showed disappearance of the fistula on follow-up arteriograms. One patient developed a transient sixth nerve palsy. No complications related to the approach were observed. CONCLUSIONS: For endovascular treatment, transvenous occlusion of DCSFs via the IPS is a feasible approach, even when this sinus is partially or completely thrombosed. Gentle handling of recently available, improved hydrophilic microguide wires and microcatheters allows effective and safe catheter navigation into the CS. A phlebogram of the jugular bulb is very useful for identification of a thrombosed IPS.     

A case of dural arteriovenous fistula of the inferior petrosal sinus successfully treated by transarterial and transvenous embolizations

A 69-year-old male was admitted with chemosis and exophthalmos of his right eye. Angiograms revealed a dural arteriovenous fistula (AVF) involving the right inferior petrosal sinus. The AVF was fed by the right occipital and ascending pharyngeal arteries and drained into the cavernous sinus and right superior ophthalmic vein from the right inferior petrosal sinus. He was treated by transarterial embolization with polyvinyl alcohol in order to reduce the shunt-flow through the fistula. Then he was treated by transvenous embolization with GDC coils five days after the arterial embolization. Symptoms in his right eye have completely disappeared. Transvenous embolization combined with transarterial embolization is a useful and safe approach in the management of AVF involving the inferior petrosal sinus.     

Shifting of dural arteriovenous malformation from the cavernous sinus to the sigmoid sinus to the transverse sinus after transvenous embolization. A case of left spontaneous carotid-cavernous sinus fistula.

The angiographic features of left spontaneous carotid-cavernous sinus fistula and multiple dural arteriovenous malformations that developed after transvenous embolization are described. A dural arteriovenous malformation involving the left sigmoid sinus was demonstrated, along with a marked decrease in size of the left carotid-cavernous sinus fistula and the disappearance of venous drainage from the left cavernous to the right cavernous sinus after embolization with spring coils via the left superior ophthalmic vein. The dural arteriovenous malformation of the left sigmoid sinus subsequently extended to the transverse sinus after partial embolization of the sigmoid sinus. Finally, a dural arteriovenous malformation involving the left transverse sinus developed, with the disappearance of the arteriovenous malformation affecting the sigmoid sinus and left carotid-cavernous sinus fistula following complete embolization of the sigmoid sinus via the left transverse sinus.     

Contralateral inferior petrosal sinus approach for transvenous embolization of a dural arteriovenous fistula at isolated jugular bulb. Technical case report.

A contralateral inferior petrosal sinus approach is described for the successful treatment of a case of a dural arteriovenous fistula at an isolated right jugular bulb presenting with chemosis. A microcatheter could be inserted into the right jugular bulb from the left jugular bulb through the left inferior petrosal sinus, basilar sinus on the dorsum sellae, and the right inferior petrosal sinus. This unusual approach represents an alternative route to the jugular bulb.     

Transarterial NBCA embolization with transvenous partial outflow obstruction for superior petrosal sinus dural arteriovenous fistula: a case report

We encountered a case of superior petrosal sinus dural arteriovenous fistula (SPS DAVF) which was treated by a combination of a transvenous and a transarterial approach after the failure of the transvenous approach alone. A 69-year-old man presented with a complaint of progressive left bulbar conjunctival conjestion, exophthalmos, and impaired vision. Cerebral angiography revealed a left SPS DAVF fed by the left middle meningeal artery, the meningeal branches of the left internal carotid artery and the left posterior meningeal artery. Venous drainage proceeded through the cavernous sinus (CS) toward the left superior ophthalmic vein (SOV). Transvenous embolization via the SOV was indicated because the left ipsilateral inferior petrosal sinus contributed to the normal venous return. However the microcatheter to the CS couldn't go through the tortuous SOV. Next a transarterial NBCA (n-butyl-cyanoacrylate) embolization of the affected sinuses was performed under arterial flow control with balloons and the partial coil embolization of the origin of the SOV. The coils in the SOV trapped NBCA and the sinuses were filled slowly with NBCA. The postoperative angiogram confirmed complete obliteration of the DAVF and the patient's ocular symptoms disappeared. DAVF is usually difficult to treat by transarterial embolization with NBCA because of its multiple feeders and high flow drainage. We should therefore carefully observe its structure and the blood flow change with 3D-DSA and the selective angiography while embolizing the DAVE.     

Embolisation of indirect carotid-cavernous sinus dural arterio-venous fistulae using the direct superior ophthalmic vein approach

Summary  Indirect carotid-cavernous sinus dural arterio-venous fistulae (cDAVF) can be treated by transarterial and/or transvenous embolisation. This study evaluated patients with cDAVF who underwent transvenous embolisation using the direct superior ophthalmic vein (SOV) approach. Between January 2004 and October 2006, eight cDAVF in seven patients were embolised using direct surgical exposure of the SOV when access to the cDAVF via transarterial or transfemoral venous routes was not feasible. Medical records and imaging studies were retrospectively reviewed. The seven patients consisted of four females and three males from 43 to 65-year-old (mean age, 54.4 years). Six cDAVF lesions were located on the left side and two on the right. All fistulae were successfully embolised and showed clinical improvement. One patient presented after treatment with transient venous congestion on the brain stem, which was relieved by osmotic diuretics and steroids. Direct surgical exposure of the SOV for transvenous embolisation of cDAVF can be effective if the facial vein, inferior petrosal sinus, and internal jugular vein are thrombosed. This approach is easy, safe, and effective when performed by a multidisciplinary team. Correspondence: Jae-Whan Lee, Assistant Professor, Department of Neurosurgery, Brain Research Institute, Yonsei University College of Medicine, 134 Shinchon-dong Seodaemun-gu, Seoul 120-752, Korea.     

Sinus thrombosis probably resulting from a dural arteriovenous fistula development in the superior sagittal sinus

Acta Neurochirurgica -     

A case of cavernous sinus dural arteriovenous fistula presenting with intracranial hemorrhage

Intracranial cavernous sinus dural arteriovenous fistula (CS-dAVF) rarely causes intracranial hemorrhage. We report a case of CS-dAVF presenting with intracranial hemorrhage. A 62-year-old man presented tonic clonic convulsion with consciousness disturbance and was transferred to our hospital. CT scan revealed subarachnoid hemorrhage and right frontal subcortical hemorrhage. Angiography revealed right CS-dAVF which drained only into the vein of the right sylvian fissure. Transvenous embolization was performed using detachable coils. After embolization, CS-dAVF had completely disappeared and the patient was discharged without any symptom. We summarized the fourteen reported cases, including ours, of CS-dAVF with intracranial hemorrhage. All of them had retrograde drainage through cerebral veins.     

重点处理静脉端治疗硬脑膜动静脉瘘

目的 探讨治疗硬脑膜动静脉瘘的有效方法。方法 20例硬脑膜动脉瘘患者,其中海绵窦区8例,横窦、乙状窦区6例,小脑幕缘3例,上矢状窦区1例,Galen静脉1例,直窦1例。行引流静脉切断术5例,静脉窦孤立术1例,经静脉途径栓塞14例。结果 临床治愈13例,症状缓解6例,加重1例。影像学检查显示：瘘口完全消失11例;部分消失9例,但血流明显缓慢。术后16例患者获随访,随访时间1个月-4年。结论 重点处理静脉端是治疗硬脑膜动静脉瘘安全有效的方法。     

Development of a dural arteriovenous fistula around the jugular valve after transvenous embolization of cavernous dural arteriovenous fistula

BACKGROUND: Endovascular therapy for dural arteriovenous fistulas (DAVFs) is not without any risks, although it has been generally accepted to be a safe procedure. In this paper, we report a very rare complication: metachronous DAVF around a jugular valve 4 months after transvenous embolization. CASE DESCRIPTION: A 43-year-old woman presented with left proptosis, chemosis, and double vision. Cerebral angiography demonstrated a left cavernous DAVF. The patient's symptoms resolved almost completely after embolization with platinum coils via the superior ophthalmic vein. Four months later, angiography revealed a metachronous DAVF around a jugular valve. CONCLUSION: To our knowledge, only four such cases have been reported in the literature. Careful follow-up of patients treated with transvenous embolization and accumulation of such cases are needed to understand the pathogenesis of multiple DAVFs.     

Transarterial intravenous coil embolization of dural arteriovenous fistula involving the superior sagittal sinus

BACKGROUND

We report a rare case of traumatic dural arteriovenous fistula involving the superior sagittal sinus successfully treated by transarterial intravenous coil embolization.

CASE PRESENTATION

A 38-year-old woman presented with tension headache. She had a past history of severe head injury at the age of three. Computed tomography scanning showed a heterogenous low-density area in the right frontal lobe, and magnetic resonance imaging demonstrated abnormal vascular structures in the same area. Angiography revealed a dural arteriovenous fistula involving the lateral wall of the fully patent superior sagittal sinus. The fistula was fed by scalp, meningeal, and cortical arteries, and drained into a cortical vein leading to the superior sagittal sinus. Femoral transarterial intravenous embolization with microcoils completely occluded the dural arteriovenous fistula.

CONCLUSION

Severe head injury may lead to asymptomatic dural arteriovenous fistulas after a long time. Transarterial intravenous coil embolization can be effective in the treatment of dural arteriovenous fistulas involving the superior sagittal sinus.     

Indirect carotid-cavernous sinus fistula: transvenous embolization from the external jugular vein using a superior ophthalmic vein approach. A case report

A case of indirect carotid-cavernous sinus fistula treated by combined transarterial and transvenous embolization is described. A 49-year-old woman with a right indirect carotid-cavernous sinus fistula draining solely to the right superior ophthalmic vein was treated first by transarterial embolization with polyvinyl alcohol particles. Then, by approaching through the superior ophthalmic vein from the right external jugular vein, the cavernous sinus was embolized with platinum wire using a tracker microcatheter, which resulted in marked clinical improvement. Transvenous embolization by approaching from the external jugular vein through the superior ophthalmic vein represents a promising alternative when shunted blood drains anteriorly to the superior ophthalmic vein.     

经上睑静脉途径给药治疗海绵窦血栓性静脉炎

目的 探索治疗海绵窦血栓性静脉炎的新途径。方法 用经上睑静脉途径给药方法治疗海绵窦血栓性静脉炎15例。结果 本组无死亡病例，治愈12例，治愈率为80％，好转3例，遗留后遗症3例，病残率为20％。结论 经上睑静脉途径给药治疗海绵窦血栓性静脉炎提高了治愈率，减少了死亡率和病残率，方法简单易行。