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.     

Resolution of an anterior-inferior cerebellar artery feeding aneurysm with the treatment of a transverse-sigmoid dural arteriovenous fistula.

A 27-year-old man developed an unruptured anterior-inferior cerebellar artery (AICA) feeding aneurysm from a transverse-sigmoid dural arteriovenous malformation. The patient, with a known history of left transverse and sigmoid sinus thrombosis, presented with pulse-synchronous tinnitus. Angiography revealed an extensive dural arteriovenous fistula (AVF), with feeders from both the extracranial and intracranial circulations, involving the right transverse sinus, the torcula, and the left transverse/sigmoid sinuses. Multimodal endovascular and open surgical therapy was used to manage the lesion. Before a planned second-stage treatment for the left sigmoid sinus component, the dural AVF improved significantly. During this interval, however, a small flow-related aneurysm developed on the left AICA feeding the petrous dural region. The aneurysm resolved after resection of the involved sigmoid sinus. This is the first reported case of an unruptured feeding-artery aneurysm in an intracranial dural AVF that resolved spontaneously with treatment of the dural AVF. Until more is known about the natural history, the decisions of when and whether to treat an unruptured dural AVF feeding-artery aneurysm must be made on an individual basis.     

Dural arteriovenous fistulas of the posterior cerebral fossa and thrombosis of the lateral sinus. Discussion of their relations and treatment apropos of 2 cases

Two cases of a posterior fossa dural arteriovenous malformation associated with a lateral sinus thrombosis are reported. In the first case, a right tentorial meningioma develops at the end of the superior sagittal sinus and on the transverse sinus which are occluded. A cranial bruit, heard by the patient four months after the surgical removal of the tumour, brings up a dural fistula supplied by the occipital, middle meningeal and pharyngeal arteries and drained away by cervical and cortical veins. Many attempts of extirpation and radiological embolization stop the bruit. In the second case, an increased intracranial pressure mixes up with an aphasia. A continuous emission doppler examination and a CT scan make likely a dural fistula. The malformation, which is associated to a left sigmoid sinus thrombosis, is fed by the occipital and middle meningeal arteries and drained by cortical veins to the cavernous sinus. The occipital artery ligation and a by-pass between the lateral sinus and the internal jugular vein cure the patient with a very good patency of the venous graft that holds up two years after. A few cases of the literature show the succession of the two vascular lesions and prove the primitive occurrence, either of the sinus occlusion, or of the dural fistula. A venous thrombosis might cause a fistula by the opening of physiological shunts of the dura-mater which consequently deviates the blood into the cortical veins, brings down the increased intracranial pressure and stops the thrombosis to spread.(ABSTRACT TRUNCATED AT 250 WORDS)     

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.     

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。     

Multiple dural arteriovenous malformations. Report of two cases

Two cases of multiple dural arteriovenous malformations (AVM's) in different locations are reported. One patient was diagnosed as having a dural AVM involving the right cavernous sinus that disappeared spontaneously 4 months after onset of symptoms. After an interval of 4 months, another dural AVM appeared involving the right lateral sinuses (transverse and sigmoid sinuses) with occlusion of the right sigmoid sinus. In the other patient, multiple dural AVM's were demonstrated on angiography, one involving the cavernous sinus and the other the left lateral sinus. The frequency of multiple occurrence and possible mechanisms of sinus occlusion are discussed.     

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.     

Dural arteriovenous fistula after craniotomy for pilocytic astrocytoma in a patient with protein S deficiency

BACKGROUND: We report an unusual case, which may provide insight into the etiology and pathogenesis of dural arteriovenous malformation. CASE DESCRIPTION: A 24-year-old woman presented with hemorrhage into a pilocytic astrocytoma of the collicular plate. Angiography was normal and the tumor was surgically resected. She developed sigmoid sinus thrombosis and a transverse/sigmoid sinus dural arteriovenous fistula 11 months after this and was found to have protein S deficiency. The fistula was not treated. Angiography 4 years later was unchanged. CONCLUSION: This report illustrates an acquired etiology of a dural arteriovenous fistula. To our knowledge this is the first reported case of postoperative sigmoid sinus thrombosis along with arteriovenous fistula in a patient with previously undetected protein S deficiency.     

Multiple dural arteriovenous fistulas involving both the cavernous sinus and the posterior fossa: report of two cases and review of the literature]

Multiple dural arteriovenous fistulas (DAVFs) are rare, accounting for 7% of all intracranial DAVFs. The authors describe two cases of multiple DAVFs involving both the cavernous sinus and the posterior fossa. The first patient was a 45-year-old man who presented with visual disturbance, chemosis, exophthalmus, and tinnitus. Angiograms demonstrated DAVFs involving the right cavernous sinus and the ipsilateral sigmoid sinus. Soon after transarterial embolization via the right occipital artery, the patient's symptoms completely disappeared. Six months later, follow-up angiograms showed disappearance of the cavernous DAVF and a subtle opacification of the sigmoid sinus DAVF. The patient has been free from symptoms for four years. The second patient was a 75-year-old woman who presented with progressive tinnitus two years after stereotactic radiosurgery for right cavernous DAVF. Angiograms showed a new lesion in the contralateral transverse and sigmoid sinuses. Transvenous embolization (TVE) of the affected sinuses was successful and the patient's symptoms disappeared. The patient's course has been uneventful after treatment, and follow-up MR angiograms have not shown any recurrence of lesions. To our knowledge, 25 cases of multiple DAVFs have been reported in the literature, of which we reviewed 12 cases of multiple DAVFs affecting the cavernous sinus. The patients' ages ranged from 43 to 75 years with a mean of 57.4 and their distribution showed female predominance. Other DAVFs occurred mostly in the transverse and sigmoid sinuses. With the exception of our case (second patient), the posterior fossa lesions were located on the same side as the cavernous sinus DAVF. Multiple DAVFs were detected simultaneously in 5 of the 12 cases with the initial angiograms. In the other 7 cases, cavernous DAVFs had been treated, but were followed by posterior fossa lesions occurring after various intervals (4 months to 2.5 years). All the patients presented with ocular signs due to cavernous DAVFs. Based upon our review of the literature, we discuss here three possible hypotheses. The first possibility for formation of multiple DAVFs concerns their primary etiology, viz. that they develop after a huge sinus thrombosis involving several sinuses and its recanalization. A second possibility is the secondary formation of DAVFs. Preexisting cavernous sinus DAVFs induce sinus thrombosis and/or venous hypertension, which results in the formation of multiple lesions. A third possibility is that they are due to other factors, including increased angiogenic activity and some technical problems associated with TVE. Our review indicates that careful follow-up for several years should be made after treatment of cavernous 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.     

Direct carotid sinus approach to treatment of bilateral carotid-cavernous fistulas. Case report

The authors present a patient with a complex vascular malformation composed of bilateral spontaneous carotid-cavernous fistulas (CCF's). The abnormality was supplied on the right side by the right external carotid artery (ECA) and the right internal carotid artery (ICA), and on the left side only by the left ICA. There was also an arteriovenous communication between the right ECA and the lateral sinus. Surgical embolization of both cavernous sinuses with oxidized cellulose was achieved on one side by direct puncture and on the other through one of its venous affluents, successfully occluding both CCF's and preserving the patency of both ICA's without any neurological deficit. The arteriovenous communication between the right ECA and the lateral sinus was occluded by embolization of the occipital artery and ligation of the right ECA.     

Traumatic anterior communicating artery pseudoaneurysm with cavernous sinus fistula

A traumatic carotid-cavernous fistula and an intracranial pseudoaneurysm are uncommon but well-known complications of head trauma. A rare subtype of arteriovenous fistula may occur from a pseudoaneurysm of the anterior communicating artery (AcoA) instead of the internal carotid artery. We describe a patient with a traumatic pseudoaneurysm of the AcoA with a cavernous sinus fistula treated with endovascular treatment. A 68-year-old man presented with a severe head injury after a fall. Coronal view multiplanar reformatted images with contrast medium showed gradual expansion of the pseudoaneurysm of the AcoA and the enhanced area of the cavernous sinus. Five weeks after the injury, the patient had a subarachnoid hemorrhage. A cerebral angiogram showed a fistula between the pseudoaneurysm of the AcoA and the cavernous sinus. The AcoA, left anterior cerebral artery and part of the pseudoaneurysm were obliterated by coil embolization. A postoperative angiogram showed no flow through the pseudoaneurysm and the cavernous sinus fistula. A traumatic AcoA pseudoaneurysm with a cavernous sinus fistula may occur as an extremely rare complication of head injury.     

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.     

Congenital fistula of the dural carotid-cavernous sinus: case report and review of the literature

The case of a 2-month-old boy with a congenital fistula of the dural carotid-cavernous sinus is presented. This is a rare vascular anomaly in infancy, and it may cause acute changes in vision. The child was initially followed up for 1 year to see if spontaneous thrombosis would occur. The symptoms persisted, however, and intravascular surgery using platinum coils was performed for closure. After treatment, the symptoms completely resolved. Literature pertaining to this anomaly has been reviewed with particular emphasis on dural fistulas of the cavernous, transverse, sigmoid, and straight sinuses in infancy.     

A case of bleeding dural arteriovenous fistula of the transverse-sigmoid sinus with pure leptomeningeal drainage,varix: case report

We reported a case of bleeding from the varix of a transverse-sigmoid sinus dural arteriovenous fistula with pure leptomeningeal drainage. A 55-year-old man presented with visual disturbance. neurological examination revealed left homonymous hemianopsia. CT scans demonstrated a subcortical hemorrhage in the right occipital lobe. Right external carotid angiograms showed a dural arteriovenous fistula of the transverse-sigmoid sinus fed by middle meningeal arteries and the occipital artery. The draining vein was the cortical vein with a varix. Transverse and sigmoid sinuses were patent. We concluded that the cause of the subcortical hemorrhage was a varix of the dural arteriovenous fistula. Initially, we embolized the dural arteriovenous fistula using a transarterial approach with GDC. Additionally, we interrupted the draining vein of the dural arteriovenous malformation. Angiographic cure was obtained and the postoperative course was uneventful. We discussed the clinical features, and the management of this case.     

Transvenous copper wire insertion for dural arteriovenous malformations of cavernous sinus

Therapeutic embolization by means of transvenous copper wire insertion was performed in five patients with dural arteriovenous malformations (AVM's) of the cavernous sinus. In each case, angiograms had shown that the AVM's were supplied from both internal and external carotid arteries, which was thought to render complete transarterial embolization difficult. A No. 2.5 French Teflon catheter was introduced into the affected cavernous sinus through the superior ophthalmic or internal jugular vein with the aid of a flexible mini guide wire. Copper wires were pushed by the guide wire into the cavernous sinus until the disappearance or a sufficient decrease in the arteriovenous shunt was noted. The patients' symptoms resolved or improved without any severe complications. Angiography revealed complete disappearance of the lesion immediately after treatment in three cases and follow-up angiography taken within 8 months showed no arteriovenous shunt in any patient. This method is a promising treatment for dural AVM's when conventional transarterial embolization is thought to be difficult.     

Traumatic middle meningeal artery pseudoaneurysm and subsequent fistula formation with the cavernous sinus: case report

BACKGROUND: A combination of pseudoaneurysm and arteriovenous fistula of the middle meningeal artery is rare. We describe a case of traumatic pseudoaneurysm of the middle meningeal artery, which subsequently formed a fistula with the cavernous sinus. CASE DESCRIPTION: A 23-year-old man suffered from blunt head trauma and skull fractures. Sixteen days later, he suddenly experienced headache and a bruit was auscultated over the left ear. Three-dimensional computed tomographic angiography revealed dilatation of the left middle meningeal artery. The dilation proved to be a pseudoaneurysm on cerebral angiograms and it was also found to have formed a fistula with the cavernous sinus. Both lesions were successfully obliterated by endovascular embolization using microcoils. CONCLUSION: Head injury may lead to asymptomatic pseudoaneurysm or dural arteriovenous fistula. Neurosurgeons should always bear in mind the possibility of such vascular injuries after blunt head trauma to prevent any hemorrhagic complications.     

Surgical transvenous embolization of a carotid-cavernous dural fistula with cortical drainage via a petrosal vein: two technical case reports

OBJECTIVE AND IMPORTANCE: We present two interesting cases involving carotid-cavernous dural fistulae draining only or predominantly into the petrosal vein after previous incomplete, complicated, endovascular treatments. Transvenous embolization with Guglielmi detachable coils, via the petrosal vein, during surgical exposure completely obliterated the fistulae. CLINICAL PRESENTATION: A 64-year-old man manifesting left ocular symptoms after incomplete embolization of a left carotid-cavernous dural fistula and a 56-year-old woman manifesting left hemiparesis after complicated embolization of a right carotid-cavernous dural fistula were referred to our hospital. A percutaneous transvenous approach was attempted in both cases, but the catheter could not reach the fistula site. A combined open surgical and endovascular approach was then used. INTERVENTION: The hemispheric branch of the petrosal vein was exposed via a retromastoid craniectomy. The catheter was then directly introduced into the hemispheric branch, followed by navigation into the fistula site. The fistula was completely embolized with Guglielmi detachable coils. CONCLUSION: The technique of surgical transvenous embolization via a petrosal vein is a valuable alternative for the treatment of carotid-cavernous dural fistulae that drain only or predominantly into the petrosal vein, when the percutaneous transvenous route is not accessible.     

Transvenous embosurgery of a left sigmoid sinus dural arteriovenous fistula via a retrograde approach from the superior ophthalmic vein, cavernous and inferior petrosal sinuses

The efficacy and safety of transvenous embosurgery for sigmoid sinus dural arteriovenous fistula (DAVF) using the internal jugular vein approach is well known. Embosurgery of cavernous sinus DAVF has also been described utilizing a superior ophthalmic vein approach. The first report of a sigmoid sinus DAVF endosurgical repair via a superior ophthalmic vein approach in a patient without internal jugular vein access is presented.     

Dural arteriovenous fistula of the transverse sinus with concomitant ipsilateral meningioma

A 69-year-old female complained of headache and tinnitus. Computed tomography, magnetic resonance imaging, and angiography showed a tumour in the right transverse sinus extending to the transverse-sigmoid sinus junction, a dural arteriovenous fistula (AVF), and right transverse-sigmoid sinus thrombosis with the downstream from the right sigmoid sinus involved by the tumour. Right external carotid angiography showed the tumour to be supplied by many branches of the right occipital artery, the posterior branches of the middle meningeal artery, and the posterior auricular artery, and the dural AVF fed by the occipital artery and the meningeal branches of the right vertebral artery. She underwent surgery via a combined right supra- and infratentorial approach. The tumour had invaded and blocked the right transverse sinus, which was resected. After surgery the patient was free of headache and tinnitus was diminished. Histological examination found that the tumour was a fibrous meningioma and that the orifice of the vein at the transverse sinus was blocked by the tumour. Serial follow-up cerebral angiography 2 months after surgery showed no change in the AVF, but 9 months after surgery confirmed disappearance of the AVF. This AVF was caused by occlusion of the right transverse sinus by the meningioma and was an acquired lesion.