Transvenous embolization of dural fistulas involving the cavernous sinus

Because of the risks associated with arterial embolization of cavernous dural fistulas, we have sought an alternative method to promote fistula closure. Thirteen patients underwent transvenous embolization as a treatment for symptomatic cavernous dural fistulas. All procedures were performed from a femoral vein access through the inferior petrosal sinus or basilar plexus. In five patients the inferior petrosal sinus was not angiographically demonstrable; however, embolization was still possible through this route in two patients. The embolic agents used were detachable balloons in one patient, coils alone in five, coils and liquid adhesives in four, coils plus silk sutures in one, silk sutures alone in one, and liquid adhesives alone in one. Nine patients had follow-up angiograms, which showed complete obliteration of the fistulas and complete resolution of related symptoms. One patient had complete resolution of clinical symptoms but refused follow-up angiography. Another patient had 50% decrease in fistula flow on the follow-up angiogram and improvement in clinical symptoms. Two patients had complete fistula obliteration after embolization and progressive improvement in symptoms but follow-up angiograms had not been obtained. Follow-ups ranged from 1 to 97 months (mean, 15 months). Two complications were related to this treatment. An embolic stroke followed transient placement of a balloon in the internal carotid in one patient, and a second patient developed transient visual loss when the venous outflow pathways were occluded before fistula closure. The fistula was immediately closed with complete recovery of vision. With recent advances in microcatheter and embolic agent technology, transvenous closure of cavernous dural fistulas is now possible.(ABSTRACT TRUNCATED AT 250 WORDS)     

Transvenous embolization as the primary therapy for arteriovenous fistulas of the lateral and sigmoid sinuses.

PURPOSEWe report on the evolution in one institution from transarterial embolization for the treatment of dural arteriovenous fistulas of the lateral and sigmoid sinuses to the safer and more durable technique of transvenous endovascular therapy for the majority of these lesions.METHODSArterial, venous, and combined embolizations were performed for 24 fistulas of the lateral and sigmoid sinuses between August 1991 and December 1996. The patients were followed up clinically for 2 to 63 months, with a mean follow-up period of 30 months.RESULTSNine patients had arterial embolization without transvenous treatment: five of the nine had angiographic and clinical obliteration of their fistulas; two of the nine, with unusual lesions, required surgery; and the remaining two had recurrences and were not retreated. Seven patients had both arterial embolization and coil embolization (packing) of the dural sinuses, four after arterial embolization had failed to cure the lesions; in all seven, the fistulas were obliterated angiographically and clinically. Eight patients had only transvenous coil embolization of the dural sinuses; all eight were cured. One patient had minimal arterial embolization during the primary venous embolization procedure. Complications occurred in two patients, both related to arterial embolization with ethanol.CONCLUSIONOur experience suggests that arterial embolization of dural arteriovenous fistulas of the lateral and sigmoid sinuses is associated with a low cure rate and high rate of recurrence, whereas transvenous endovascular packing of the involved segment of the sinus results in a high cure rate that obviates arterial embolization or surgical excision in most cases.     

High-risk dural arteriovenous fistulae of the transverse and sigmoid sinuses

Dural arteriovenous fistulae of the transverse and sigmoid sinuses are highly variable in symptomatology and prognosis. However, we have identified a subgroup of patients who have a high risk of hemorrhage and dementia due to severe venous overload caused by high arterial flow into the fistulae and by occlusive changes of the transverse and sigmoid sinuses. Three representative cases selected from 31 patients with dural arteriovenous fistulae of the transverse and sigmoid sinuses are presented, and 45 reported similar cases are reviewed to discuss pathophysiology and problems encountered during treatment.     

Dural fistulas involving the transverse and sigmoid sinuses: results of treatment in 28 patients

Twenty-eight symptomatic dural fistulas involving the transverse and sigmoid sinuses were treated between 1978 and 1986 with a variety of treatment modalities. Occipital artery compression therapy resulted in a complete cure in two of nine patients (22%) and improvement in three of nine (33%). There were no complications from this treatment. Patients who were excluded or in whom compression therapy failed were treated with embolization alone or in conjunction with surgery. Of the 17 patients who underwent embolization alone, ten were cured and six were improved. Six patients had a combination of embolization and surgery; four patients were cured and two improved. There were three complications in this series, one related to surgery and two related to embolization.     

Transvenous balloon-assisted Onyx embolization of dural arteriovenous fistulas of hypoglossal canal

Purpose

This retrospective study summarized the technique aspects and effectiveness of transvenous balloon-assisted Onyx embolization treating selected dural arteriovenous fistulas of hypoglossal canal (HCDAVFs).

Methods

Eight patients of HCDAVFs from January 2010 to December 2016 in a single institution were reviewed retrospectively. There were six males and two females aged from 30 to 69 years (mean age, 52.8 years). Eight patients presented with pulsatile tinnitus, four associated with ocular symptom, and one accompanied with tongue muscle atrophy. All lesions were with accessible venous approach from ipsilateral internal jugular vein. The microcatheter was positioned in the venous pouch from internal jugular vein; the remodeling balloon was advanced from internal jugular vein into inferior petrosal sinus. The balloon having 4 mm in diameter and 15 mm in length was inflated to temporarily block the antegrade venous drainage from fistulous pouch to internal jugular vein during the injection of Onyx. Approximately 1- to 2.1-ml Onyx-18 was used as the sole embolic material to obliterate the lesions.

Results

All lesions were occluded completely in a single-session embolization without procedural complications and postoperative new symptom. The follow-up period ranged from 6 to 13 months. Preoperative ocular symptom and tinnitus were resolved completely in all patients. The follow-up angiograms of three patients demonstrated durable occlusion.

Conclusions

Our experience in this small series of patients indicated transvenous balloon-assisted Onyx embolization was a feasible and effective option for treating selected HCDAVFs.

     

Embolization of dural arteriovenous fistulas draining into the transverse or sigmoid sinus

The results of embolisation of dural arteriovenous fistulas draining into the transverse or sigmoid sinus were evaluated in 20 patients. Tinnitus was the main symptom in all patients although one also suffered from vertigo and sudden deafness. Nine patients were treated with PVA (polyvinylalcohol) alone and 11 with combined PVA and bucrylate (isobutyl-2-cyanoacrylate) in 1–9 procedures. Recurrence of symptoms, requiring repeated procedures was common but at subsequent clinical follow up 10 patients had no tinnitus, 5 were improved and only 5 experienced no change. Complications occured in six patients: four had transient neurological symptoms and one of these also developed a necrotic wound which later healed. One patient suffered from a cranial nerve palsy and one had an intracranial haemorrhage after a transvenous embolisation. This last patient recovered completely. The best clinical results were achieved in small fistulas and fistulas treated with combined bucrylate and PVA.     

Endovascular management of dural arteriovenous fistulas of the transverse and sigmoid sinus in 150 patients

Introduction  This study aimed to evaluate the safety and efficiency of the endovascular treatment of transverse–sigmoid sinus dural arteriovenous fistulas (TS_dAVF). Methods  A total of 150 consecutive patients and 348 procedures were evaluated. Results  Pulsatile tinnitus (81%), headache (15%), and intracranial hemorrhage (10%) were the most frequent manifestations of the TS_dAVFs. More than half of the affected sinuses were partially or completely thrombosed. Access-wise treatment was performed transarterial (n = 33), transvenous (n = 21), or a combination thereof (n = 96). A mean of 2.4 procedures per patient was required. Immediate postprocedural occlusion rate after transarterial embolization was 30% only. Transvenous treatment alone resulted in an early occlusion rate of 81%, with delayed complete obliteration of half of the remaining fistulas. After combined transarterial/transvenous treatment, the angiographic cure rate was 54%. At follow-up, 88% of patients with residual shunt after the treatment showed complete occlusion. The cumulative complication rate was 9% (n = 13), with minor adverse events in ten patients (7%) and major complications in three patients (2%). Conclusion  Transvenous coil occlusion of the sinus segment with the adjacent dAVF site, eventually combined with transarterial occlusion of supplying arteries, is a very effective and well-tolerated treatment method. In selected patients, variations of these methods (e.g., sinus stenting, compartmental sinus occlusion) can be useful. D. Kühne: retired.     

Transvenous embolization of direct carotid cavernous fistulas

Of 165 cases of direct carotid cavernous fistula, 14 (8.5%) were treated from a transvenous approach. Twelve of these were treated through the inferior petrosal sinus and one through the superior ophthalmic vein. In one patient, both approaches were used. The embolic agents were as follows: five patients had balloons only, four patients had minicoils alone, three patients had coils and liquid adhesives, one had balloons and coils, and one had balloons and liquid adhesives. Among the patients who were treated from a transvenous approach, three had an occluded carotid artery caused by trauma, nine failed transarterial balloon attempts, and one had a prior trapping procedure. In the remaining patient, who had Ehlers-Danlos syndrome, a transarterial approach was judged to be too dangerous. This patient suffered a fatal pontine hemorrhage after subtotal transvenous occlusion of the carotid cavernous fistula with diversion of flow into cortical veins. Another complication occurred when the inferior petrosal sinus was perforated during catheterization, causing a small subarachnoid hemorrhage. The tear was immediately closed with minicoils, and surgical exposure and embolization resulted in complete cure. Of the remaining 12 patients treated, 11 were completely cured and one showed angiographic and clinical improvement. Transarterial balloon embolization remains the procedure of choice in the treatment of symptomatic carotid cavernous fistulas; however, transvenous embolization is an alternative when the arterial route fails.     

Reconstructive treatment of dural arteriovenous fistulas of the transverse and sigmoid sinus: transvenous angioplasty and stent deployment

Various techniques for the endovascular treatment of dural arteriovenous fistulas (dAVFs) of the transverse and sigmoid sinus have recently evolved. Transvenous coil occlusion of the involved segment and transarterial embolization of the feeding arteries with liquid agents are the commonest treatments utilized. However, with respect to venous hypertension as the probable pathogenic cause of this disorder, a nonocclusive or remodeling technique might be preferable. We will present a series involving four patients, treated with transvenous angioplasty and stent deployment as a definitive treatment of dAVFs of the transverse and sigmoid sinus. This method was used as a primary treatment or as an adjunct to previous noncurative transarterial n-butyl cyanoacrylate and particle embolization. In three of the four cases, complete occlusion of the fistula was achieved with confirmation of occlusion seen on follow-up angiographical studies. In one case a negligible and nonsymptomatic remnant of the fistula fed by the tentorial artery was left untreated. From our experience, we conclude that transvenous stent deployment is an alternative to traditional concepts. Additionally, the pathological theory of dAVFs in this region located in venous pouches of the sinus wall is supported by the fact that they can be occluded by mechanical compression during angioplasty and subsequently maintained by a stent.     

Transvenous embolization of dural caroticocavernous fistulae: technical considerations

Sixteen patients with symptomatic dural caroticocavernous fistulae were treated by transvenous embolization, via the jugular vein and inferior petrosal sinus. The fistula was occuladed by thrombogenic coils. Complete resolution of symptoms and signs was achieved in 14 patients, and complete angiographic resolution was also obtained in 14 patients. Failures to achieve angiographic cure were attributed to failure to reach the fistula within the cavernous sinus precisely. Factors which make placement of the catheter at the fistula difficult are trabeculae within the cavernous sinus, a specific configuration of the superior ophthalmic vein and venous thrombosis. To improve the efficacy of tranvenous embolization, every possible venous route to the cavernous sinus therefore should be tried, to facilitate reaching the fistula and the possibility of transvenous embolization should not be thwarted by venous thrombosis.     

Selective transvenous embolization of dural fistulas without occlusion of the dural sinus.

Two patients with dural arteriovenous fistulas (DAVFs) and unsuccessful transarterial embolizations were treated with a technique for selective transvenous embolization. A 5F catheter was advanced from a femoral vein access into the internal jugular bulb and a catheter was navigated through the sinus lumen into the involved cortical veins or the parasinusal venous draining channels of the DAVFs. The venous recipients at the nidal level of the DAVFs were occluded by fibered platinum coils. Complete angiographic cure was effected in both patients, with occlusion of the venous recipients and the nidus, although the sinus segments next to the nidus of the DAVFs remained patent. Placement of coils in a transsinusal route into the venous channel of a DAVF yet outside the sinus lumen can result in complete obliteration of the fistula without damage to the physiological function of the dural sinuses.     

Multiple dural arteriovenous fistulae involving the cavernous and sphenoparietal sinuses

A 72-year-old woman who presented with a unilateral oculomotor nerve palsy was shown to have a very rare condition: multiple dural arteriovenous fistulae (DAVF) involving the cavernous and sphenoparietal sinuses. The sphenoparietal DAVF was cured completely by transarterial embolisation. Symptomatic relief was accomplished by this procedure. The cavernous sinus DAVF progressed to acquire cortical venous drainage, and was obliterated completely by transvenous embolisation. Received: 21 September 1999/Accepted: 3 February 2000     

Turn-back embolization technique for effective transvenous embolization of dural arteriovenous fistulas

For effective transvenous embolization of DAVFs, it is important to place coils at the shunting venous pouch in the initial step of the procedure. When it was difficult to navigate a microcatheter to the shunting venous pouch due to the anatomic relationship of approach routes with targeted pouches, we navigated the microcatheters by a "turn-back technique" within the involved sinuses into the target pouches. Complete occlusion or regression of the DAVF was obtained in all cases.     

Septic thrombosis of the transverse and sigmoid sinuses: imaging findings

The purpose of this study was to evaluate the contribution of magnetic resonance imaging (MRI) to the diagnosis of septic thrombosis of transverse and sigmoid sinuses to analyze the different steps of the diagnosis and to identify the origin of the difficulties in diagnosis. This retrospective study included eight patients aged 53–81 years (mean age: 61.9 years) with proven or highly probable septic thrombosis of transverse and sigmoid sinuses. All patients underwent a pre- and post-contrast enhancement brain CT scans and MRI. MR venogram (n=4) and HRCT of the temporal bone were performed when diagnosis was under discussion. After admission, the delay in diagnosis of lateral sinus thrombosis ranged from 8 to 60 days, with an average of 27 days (SD: ±12.8). The delay in diagnosis was mainly due to non focused CT scans (6/8) or MR images performed at the initial presentation and absence of systematic radiological reading of the related fatty spaces and of skull base in bone windows (3/8). Diagnosis of septic origin of the thrombosis is of great importance, as it completely modifies the therapeutic planning of the patients. However, it remains a difficult challenge due to its lack of suggestive neurological or otolaryngologic symptomsThis article presented at the annual meeting of the XVIIth Symposium Neuroradiologicum, Paris, August 2002.     

Tentorial artery embolization in tentorial dural arteriovenous fistulas

Introduction The tentorial artery is often involved in arterial supply to tentorial dural fistulas. The hypertrophied tentorial artery is accessible to embolization, either with glue or with particles.Methods Six patients are presented with tentorial dural fistulas, mainly supplied by the tentorial artery. Two patients presented with intracranial hemorrhage, two with pulsatile tinnitus and one with progressive tetraparesis, and in one patient the tentorial dural fistula was an incidental finding. Different endovascular techniques were used to embolize the tentorial artery in the process of endovascular occlusion of the fistulas.Results All six tentorial dural fistulas were completely occluded by endovascular techniques, confirmed at follow-up angiography. There were no complications. When direct catheterization of the tentorial artery was possible, glue injection with temporary balloon occlusion of the internal carotid artery at the level of the tentorial artery origin was effective and safe.Conclusion Different endovascular techniques may be successfully applied to embolize the tentorial artery in the treatment of tentorial dural fistulas.     

Transvenous embolization of cavernous sinus dural arteriovenous fistulas using detachable coils and Glubran 2 acrylic glue via the inferior petrosal sinus approach

Objectives:  

To describe the technique, efficacy, and safety of transvenous embolisation (TVE) of cavernous sinus arteriovenous fistulas (CSDAVFs) via the inferior petrosal sinus (IPS) with detachable coils and acrylic glue.     

应用可脱性弹簧圈及Glubran 2丙烯酸胶经岩下窦行静脉入路栓塞治疗海绵窦硬脑膜动静脉瘘

目的阐述应用可脱性弹簧圈及Glubran 2丙烯酸胶经岩下窦(IPS)行静脉入路栓塞(TVE)治疗海绵窦硬脑膜动静脉瘘(CSDAVF)的技术、治疗效果及安全性。方法 8例自     

Treatment of dural fistulas involving the deep cerebral venous system

Eight patients with dural arteriovenous fistulas involving the deep cerebral venous system were treated by a combination of preoperative embolization, intraoperative embolization, and/or surgical excision. All eight patients were men 30-71 years old (mean age, 48.5). The presenting symptoms were hemorrhage in four patients (two subarachnoid, one intraventricular, and one parenchymal), stroke in two patients, and severe chronic headaches in two patients. Four patients were treated and cured by preoperative embolization of external carotid feeding vessels followed by direct intraoperative placement of liquid adhesives into the fistula site. Two patients underwent preoperative embolization followed by surgical interruption of feeding vessels to the fistula. Both patients had persistent fistulas and were subsequently treated by intraoperative embolization with liquid adhesives. One patient was cured and the second had 95% reduction in fistula size. The remaining two patients had surgical excision of the fistula, one in combination with preoperative embolization. Both were completely cured. Two patients developed hydrocephalus after placement of liquid adhesive into the involved vein of Galen and were successfully treated with placement of ventriculoperitoneal shunts. Follow-up periods ranged from 7 to 21 months (mean, 14). We found that patients with dural arteriovenous fistulas could be treated effectively through a combination of neuroradiologic and surgical intervention.