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.     

A dural arteriovenous fistula of the tentorium successfully treated by intravascular embolization.

BACKGROUND: Dural arteriovenous fistulas of the tentorium are rare lesions that often present with intracranial hemorrhage. Definitive treatment is therefore necessary, but transarterial embolization has rarely been curative. CASE DESCRIPTION: A 59-year-old man presenting with sudden onset of severe headache had subarachnoid hemorrhage demonstrated by computed tomography. Left carotid angiography showed a tentorial dural arteriovenous fistula fed by a tentorial branch from the internal carotid artery and by a middle meningeal artery; the fistula drained to the marginal sinus via a dilated varicosity. Transarterial embolization successfully obliterated the fistula, and the patient was discharged with no neurologic deficit. CONCLUSION: This tentorial fistula, that showed extremely rare angiographic features, particularly venous drainage, was embolized successfully. The literature concerning tentorial dural arteriovenous fistulas is discussed in terms of effective therapeutic choice.     

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.     

Trigeminal fistula treated by combined transvenous and transarterial embolisation

Summary  Trigeminal cavernous fistulae are rare, compared to other types of carotid-cavernous fistulae with only about 17 examples previously reported in English literature. The aetiology can be either post-traumatic or spontaneous, and in the latter group either due to a ruptured trigeminal aneurysm or postulated intrinsic weakness of the artery itself. The treatment goal is to close the fistula while preserving the parent artery and this can be done either by surgical or endovascular methods. We present a 35-year-old woman with a spontaneous trigeminal fistula treated by combined trans-venous and trans-arterial embolisation. Correspondence: S. Geibprasert M.D., Department of Radiology, Ramathibodi Hospital, Mahidol University Pharam 6 Rd, Rachatewi, Bangkok, Thailand.     

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.     

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.     

Cavernous sinus dural arteriovenous fistula complicated by pontine venous congestion. A case report

BACKGROUND: Brainstem venous congestion is a rare but serious complication of the CS-dAVF (cavernous sinus dural arteriovenous fistual). CASE DESCRIPTION: A 71-year-old woman presented with right abducens nerve palsy. Brain MRI showed a solitary lesion in the right upper pons. Cerebral angiogram revealed the right CS-dAVF with retrograde venous drainage into the cerebellar cortical veins and the anterior pontomesencephalic vein. The patient was treated with stereotactic radiosurgery, resulting in complete resolution of the pontine lesion and the neurologic symptom. CONCLUSION: A solitary brainstem lesion can be caused by CS-dAVF as a rare complication. Careful diagnosis and treatment are important to avoid permanent neurologic deficits.     

Cavernous sinus dural arteriovenous fistulas treated with percutaneous transvenous embolization using liquid material: two case reports

INTRODUCTION: Percutaneous transvenous embolization (TVE) using coils is a well-established treatment of cavernous sinus dural arteriovenous fistula (CSdAVF). However, it is sometimes difficult to achieve complete occlusion by coil embolization. In these two cases, we were able to obtain complete angiographic obliteration of the fistulas without complications by means of percutaneous TVE using n-butyl-cyanoacrylate (NBCA) after we failed when TVE using coils. Case 1: An 89-year-old woman presented with double vision. She was diagnosed as Barrow type D right CSdAVF draining only to the cortical vein. We treated the patient by TVE using coils, but the microcatheter was withdrawn before complete occlusion was attained. The repositioning of the microcatheter was difficult, so we used 30% NBCA for TVE, and obtained complete obliteration of the fistula. Case 2: An 87-year-old woman presented with right exophthalmos, and chemosis. She was diagnosed as Barrow type C right CSdAVF draining only to the right superior ophthalmic vein with very slow flow. We planned to treat her, using TVE with coils, but we could place only 3 coils and obtained only partial obliteration of the fistula. So we additionally used 25% NBCA for TVE, and obtained complete obliteration of the fistula. CONCLUSION: Compared to TVE using coils, TVE using NBCA gives rise to many problems, but, we can use NBCA as a second option if TVE using coils results in only partial obliteration as in these cases.     

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.     

A case of successfully removed posttraumatic high flow dural arteriovenous fistula in the posterior fossa

A 49-year-old male patient was admitted to Ryukyu University Hospital complaining chiefly of progressive loss of mental activity for one year. He had a history of head trauma at the right retromastoid region when he was 24. Generalized convulsions developed three years later, and left exophthalmos, facial varix and impairment of visual acuity developed seven years later. Dural arteriovenous fistula of the posterior fossa was diagnosed at the age of 32, and feeding EC and tentorial arteries were successively ligated on the right several times without any effect. Angiography during this admission revealed tremendous collateral flows; a marked dilated tortuous occipital artery fed from the right vertebral artery, meningeal branches of VA and PICA, the marginal tentorial artery, and the posterior temporal artery from MCA, PCA were drained into the right transverse sinus. But transverse sinuses were occluded bilaterally, and venous outflows were directed to the superior sagittal sinus retrograde via the ascending cortical vein, Trolard veins, and sphenoparietal and cavernous sinuses. The final drainer was the superior ophthalmic vein on the left. Normal deep veins were not visible. In park bench position, the nidus was totally resected with a part of the transverse and thrombosed sigmoid sinus. Postoperative course was uneventful, and an angiogram showed complete disappearance of the AVF. Dural AVG in the posterior fossa with characteristics such as high flow, and which is rich in collaterals following palliative treatment indicates that total surgical resection should be undertaken.     

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.     

Transfemoral,transvenous embolisation of dural arteriovenous fistula involving the isolated transverse-sigmoid sinus from the contralateral side

Summary.  Background: A dural arteriovenous fistula (AVF) involving the transverse-sigmoid (T-S) sinus which is occluded at its proximal and distal ends i.e., an isolated sinus, runs the risk of haemorrhaging or causing serious neurological deficits as a result of its retrograde leptomeningeal venous drainage. While lesions of this type have not been considered to be treatable by percutaneous, transvenous embolisation, this paper challenges this view.  Case Presentation: Two middle-aged men with dural AVFs involving the isolated left T-S sinus presented with motor aphasia due to focal brain edema or haemorrhage. Under local anaesthesia, transfemoral, transvenous embolisation was performed with a microcatheter that was passed through the occluded proximal transverse sinus from the right (contralateral) side. The isolated sinus was then occluded with platinum coils. This embolisation resulted in angiographic and clinical cure of dural AVFs in both patients.  Interpretation: Transfemoral, transvenous embolisation is a therapeutic alternative for the treatment of dural AVFs involving the isolated T-S sinus. Embolisation obviates the need for craniotomy and general anaesthesia, which are required for the established modes of treatment, i.e., direct surgery or direct percutaneous sinus packing. Published online October 10, 2002 Correspondence: Masaki Komiyama, M.D., Department of Neurosurgery, Osaka City General Hospital, 2-13-22, Miyakojima-Hondori, Miyakojima, Osaka 534-0021 Japan.     

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.     

Microcatheter pull-up technique in the transvenous embolization of an isolated sinus dural arteriovenous fistula. Technical note

The authors describe a novel technique involving the use of a gooseneck snare for microcatheterization of isolated sinus dural arteriovenous fistulas (DAVFs). In some patients the inferior petrosal and transverse-sigmoid sinuses, the route of transvenous embolization (TVE) for DAVF, are separated by several channels. Even if a guidewire can be passed over the occluded portion and the affected sinus can be accessed, one may not necessarily be able to insert a microcatheter. The authors report on three patients who underwent successful microcatheterization via a novel pull-up technique, which makes use of a gooseneck snare to perform TVE even in very difficult circumstances.     

A tentorial dural arteriovenous fistula successfully treated with interruption of leptomeningeal venous drainage using microvascular Doppler sonography: case report

BACKGROUND: Complete interruption of a dural arteriovenous fistula (DAVF) has been confirmed intraoperatively by visual inspection and intraoperative angiography. To confirm complete interruption of the shunt flow during the surgical treatment of a tentorial DAVF, we used intraoperative microvascular doppler monitoring. CASE DESCRIPTION: A 71-year-old man suffered from severe subarachnoid hemorrhage. Angiography showed a tentorial DAVF with pure leptomeningeal drainage associated with a venous pouch. After the patient's neurologic condition had improved, he underwent interruption of the draining vein via a right suboccipital approach. An arterialized drainage vein was easily identified by applying the microvascular doppler probe to the shunting vessels and was completely obliterated by clipping. There were no complications associated with use of the microvascular doppler. The postoperative course was uneventful and follow-up angiography showed complete obliteration of the DAVF. CONCLUSION: Intraoperative microvascular doppler monitoring is a useful technique not only for evaluating arterialized leptomeningeal drainage veins but also for confirming the complete obliteration of these vessels.     

Combined transvenous and transarterial embolization of a tentorial-incisural dural arteriovenous malformation followed by primary stent placement in the associated stenotic straight sinus. Case report

Dural arteriovenous malformations (AVMs) involving the tentoria-incisura are associated with an aggressive clinical course characterized by subarachnoid and intracranial hemorrhage (ICH). In these lesions, venous outflow obstruction precipitates leptomeningeal venous drainage, resulting in the arterialization of pial veins and the formation of venous aneurysms, both of which are prone to hemorrhage. Stenotic lesions of the dural sinuses also contribute to the development of retrograde leptomeningeal drainage, which is responsible for the aggressive clinical course of the dural AVM. Endovascular approaches are successful in the treatment of these lesions and of any potential venous outflow obstruction caused by stenosis of a dural sinus. The authors report on a patient with a tentorial-incisural dural AVM and an accompanying stenotic venous sinus. A combined transvenous and transarterial embolization procedure was performed, resulting in complete obliteration of the dural AVM, followed by primary stent placement across a stenotic segment of the straight sinus and normalization of venous outflow. The authors conclude that dural AVMs can be treated safely by using a combined transarterial and transvenous approach and that an extensive search for venous outflow obstruction often reveals stenosis of a draining sinus. Consideration should be given to primary stent placement in the stenotic sinus to protect against ICH.     

A case of multiple dural arteriovenous fistulas treated by multiple modalities

The authors report a rare case of multiple intracranial dural arteriovenous fistulas (DAVF) at separate sinuses. A 70-year-old man was introduced to our hospital complaining of visual disturbance due to bilateral choked disk, headache, and tinnitus. Initial angiography showed DAVFs involving the superior sagittal sinus and bilateral transverse-sigmoid sinuses, and the occlusion of the right jugular vein. The patient developed progressive impairment of visual activity and had high intracranial pressure (ICP) caused by venous hypertension. No cerebral alteration was seen on magnetic resonance imaging. To decrease the high ICP, surgical sinus isolation of the superior sagittal sinus was performed. After the surgery, transvenous embolization was performed to the right transverse-sigmoid sinus DAVF. Headache and tinnitus improved after these treatments, but visual activities rapidly declined and he experienced blindness in just a few months. Gamma knife radiosurgery was performed to the residual DAVFs. We discussed the etiology and treatment of the multiple DAVF, and reviewed past literatures.     

Paradoxical worsening of cavernous sinus dural arteriovenous fistula: case report with serial angiograms

We report, with serial angiograms, a case worsening of dural arteriovenous fistulae (DAVFs) located at the hypoplastic right cavernous sinus and draining into the left superior ophthalmic vein across the inter-cavernous sinus. The patient presented with sudden onset of external ophthalmoplegia and deterioration of visual acuity on the left. An imaging work-up at the day of admission included contrast-enhanced computed tomography and conventional catheter angiography, which demonstrated complete thrombosis of the left cavernous sinus. There was no strong evidence to suggest DAVFs other than small faint opacification of the posterior cavernous sinus on the right at the late arterial phase. For this reason a diagnosis of left cavernous sinus thrombosis was made, followed by aggressive anticoagulation therapy with intravenous administration of antibiotics. Although the patient's eye symptoms improved significantly after the anticoagulation therapy, the follow-up angiogram obtained 5 days after admission demonstrated small right cavernous sinus DAVFs, which drained into the left superior ophthalmic vein. The patient was followed up conservatively at the out-patient clinic. Three-month follow up angiograms demonstrated spontaneous cure of the DAVF. Also noted was a complete recovery of external ophthalmoplegia with significant improvement of left visual acuity. The alternation of clinical and angiographic findings in this case may help to understand the etiology of paradoxical worsening of cavernous sinus DAVF. In selected cases, anticoagulation therapy may help to improve the prognosis of paradoxical worsening.