Interventional neuroradiology for the treatment of inaccessible arterio-venous malformations

Summary Embolization of cerebral arterio-venous malformations (AVM) has been performed at the Department of Neuroradiology of Verona in 136 patients with a total of 310 procedures. The complication rate was 16%. In most of the cases embolization was followed by either operative removal of the AVM or by radiosurgery.In a group of 38 embolized patients, who refused operation or radiosurgery, rebleeding occured 7 times (18%), but only in patients who already had bleedings before embolization.Indications and techniques of embolization are described and discussed.Presented at the EANS-Wintermeeting on High Risk Neurosurgery, Budapest, February 20–23, 1991.     

创伤性动静脉瘘20例的手术治疗

目的：探讨创伤性动静脉瘘(arteriovenous fistula,AVF)的手术方法。方法：回顾性分析了：1989年1月至2001年8月经手术治疗的创伤性AVF20例，共23个动静脉瘘。分别采用四头结扎术2例；经静脉切开修补瘘口3例；经动脉切开修补瘘口、重建动脉血流8例；瘘切断、动静脉壁瘘口侧面修补术1例；经瘤腔同时修补动静脉瘘口1例；经瘤腔修补静脉瘘口、动脉结扎或大隐静脉移植2例；瘘管结扎术3例。结果：死亡1例，随访16例，2例复发，2例肢端慢性溃疡者效果欠佳，余效果良好。结论：创伤性AVF应早期手术，根据分型采用不同手术方法，效果良好。     

Management of intracranial dural arteriovenous fistulas with cortical venous drainage

Background and purpose

Intracranial dural arteriovenous fistulas (DAVF) with cortical venous drainage are vascular malformations with high hemorrhagic risk. Their treatment may be complex and requires a multidisciplinary approach.

Methods

We retrospectively report 38 observations of dural arteriovenous fistulas with cortical venous drainage from 1990 to 2001. There were 28 men and 10 women with a mean age of 57 years. Hemorrhage revealed the malformation in 24 cases (63%). The other patients had headache, neurological deficit, seizure or pulsating mass of the scalp. One patient was asymptomatic. All the patients had DAVF with cortical venous drainage and decision of treatment was in each case multidisciplinary.

Results

Of the 38 patients, seven had no treatment for the following reasons: spontaneous occlusion of the malformation after hemorrhage, refusal of treatment, or poor neurological status at the admission. Thirty-one patients were treated and complete exclusion of the fistula was obtained in 30 cases. Endovascular occlusion of the fistula was performed in 14 patients, surgical clipping of the origin of the draining vein in 12 and combined treatment (surgical clipping after embolization of feeding arteries) in four. One patient had an untreated fistula despite several procedures.

Conclusion

Complete exclusion of these malformations is mandatory because of the potential risk of hemorrhagic complications. The best treatment is the occlusion of the origin of the draining vein (endovascular or surgical) and requires multidisciplinary discussion.     

硬脊膜动静脉瘘的手术治疗

目的探讨硬脊膜动静脉瘘的手术方法及术后抗凝治疗。方法回顾性分析手术治疗的ＳＤＡＶＦ１９例,其中胸腰段１４例,骶部５例。手术方法包括：１４例胸腰段者于瘘口水平切断引流静脉。其中１１例可见硬膜外小供血动脉闭,同时电凝。骶部ＡＶＦ均于Ｌ５～Ｓ１水平切断引流静脉。９例行术后抗凝治疗。结果１６例术后脊髓功能改善,其中２例短暂好转后加重,经抗凝治疗后恢复。１例无改变,１例因过度抗凝出现术野血肿,１例残留ＡＶＦ。结论切断连接瘘口及冠状静脉丛的引流静脉是治疗ＳＤＡＶＦ的有效方法。术后抗凝可治疗及预防冠状静脉丛内血栓形成     

介入栓塞治疗硬脊膜动静脉瘘的疗效分析

目的 探讨介入栓塞硬脊膜动静脉瘘(SDAVF)的可行性和有效性.方法 自2010年12月至2012年5月共治疗104例SDAVF患者,选择符合条件的26例进行栓塞治疗.男性22例,女性4例,男女比例5.5:1;年龄34 ～81岁,平均55.9岁.SDAVF分别位于胸段10例、腰段9例、骶段7例.主要表现为双下肢进行性麻木无力和大小便障碍,病程1～ 156个月,平均17.1个月.栓塞材料使用ONYX-18液态栓塞剂或Glubran-2外科胶,未完全栓塞的患者,择期行手术治疗.治疗后3个月行脊髓功能评价和MRI检查,6个月行脊髓功能评价、MRI和脊髓血管造影检查.结果 26例患者中有15例达到即刻完全栓塞的影像学标准.使用ONYX-18栓塞20例,14例完全栓塞;应用Glubran-2栓塞6例,仅1例完全栓塞.10例胸段患者中仅3例获得完全栓塞,16例腰骶段患者中,12例完全栓塞.未完全栓塞的患者2周内均行手术治疗.所有病例于术后3和6个月复查MRI,6个月复查DSA.完全栓塞患者症状术后即刻均有不同程度的好转,6个月随访时肌力和大小便功能均有较明显的改善,MRI显示脊髓水肿消失,蛛网膜下腔的迂曲血管影消失.复查脊髓DSA均未见病变残留或复发.所有经过栓塞治疗的患者,术后未出现症状加重或新发症状.结论 部分SDAVF,尤其病变位于腰骶部的患者,适宜栓塞治疗,栓塞的材料和方法需要进一步探讨.     

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.     

神经导航辅助颅底肿瘤显微外科切除

目的　探讨神经影像导航辅助下显微外科切除颅底肿瘤的效果。方法　回顾性研究我院 2 0 0 0年 1月至 2 0 0 3年 8月收治的 44例颅底肿瘤 ,其中垂体瘤 8例 ,鞍结节脑膜瘤 12例 ,颅咽管瘤 9例 ,桥小脑角肿瘤 7例 ,蝶骨嵴脑膜瘤 5例 ,后颅窝海绵状血管瘤 3例 ,应用StealthStation影像导航系统 ,导航辅助显微外科切除肿瘤。结果　导航头皮注册平均误差为 ( 2 .7± 1.2 )mm ,颅骨钻孔标记注册误差 ( 1.5± 0 .8)mm。 44例病人达到肿瘤全切 3 8例 ,全切率 86.4% ,肿瘤次全切 4例 ,大部切除 2例。手术并发症包括动眼神经损伤 2例 ,面神经麻痹 2例 ,一过性尿崩 6例 ,无手术死亡。结论　神经影像导航辅助下的颅底肿瘤显微外科切除 ,定位准确 ,能提高肿瘤全切除率 ,减少并发症。     

Navigation-assisted transsphenoidal deflation of a detachable balloon in the cavernous sinus after embolization of a direct carotid-cavernous fistula

Summary We describe a case of transsphenoidal deflation of a detachable balloon after embolization of a carotid-cavernous fistula (CCF). The patient developed complete third and sixth nerve palsies immediately after detachable balloon embolization of the CCF, which was considered to be caused by cavernous sinus (CS) compression by the over-inflated balloon. We performed direct puncture of the balloon via the transsphenoidal route using a frameless neuronavigation system. Navigation-assisted transsphenoidal approach (TSA) is technically feasible for balloon deflation in cases of severe cranial nerve palsies due to an over-inflated balloon.     

外伤性颈动脉海绵窦瘘的血管内栓塞治疗

目的 比较不同方法治疗外伤性颈动脉海绵窦瘘的临床效果。方法 治疗中应用球囊导管,复杂的5例使用了胶及弹簧圈等栓塞材料。结果 10例成功闭塞瘘口且保留载瘤动脉通畅,2例闭塞载瘤动脉．结论 外伤性颈动脉海绵窦瘘应首选血管内栓塞治疗。有时瘘口太小,弹簧圈也是有效方法。     

Treatment and outcome of spinal dural arteriovenous fistulas

Spinal dural arteriovenous fistula (dAVFs) are rare and often misdiagnosed entities. The choice between surgical treatment and embolization remains a matter of debate. We report on the cases of 18 patients (16 men, 2 women) with dAVF, who were treated surgically over an 11-year period. Patient age ranged from 32 to 84 years (mean 60 years). Six patients underwent embolization preoperatively. In three cases, angiography examinations failed to show feeding arteries on first examination at neuroradiological centers. Feeding arteries were at a different level than the fistula point in seven patients, two of them presenting with new anastomoses after embolization. Location of the fistula was midthoracic to lumbar. Seven patients were variously misdiagnosed with tumor, polyneuropathy, Guillain-Barré syndrome, syringomyelia, and knee disease. Clinical history was characterized by slowly progressive and fluctuating deterioration. Initial symptoms were mainly sensory loss and motor weakness, lasting for between 4 and 45 months before diagnosis (mean 15 months). Recurrent fistula after operation was found in one patient. In another patient, control angiography revealed a fistula at another level, and in a third, a fistula on the contralateral side. All three patients underwent reoperation. Temporary clinical deterioration was found in four patients, seven remained unchanged, and seven improved postoperatively. An attempt at embolization should be made following diagnostic angiography. Otherwise, surgery is our recommended treatment for spinal dural fistulas, as it has a lower failure rate. Because of the progressive natural course with severe deficits, we favor an early definitive treatment.     

Transcranial approach for venous embolization of dural arteriovenous fistulas

OBJECT: This study was undertaken to investigate the healing process and to delineate factors important for the survival of free fascial grafts used for dural repair. METHODS: A dural defect was created in guinea pigs and then reconstructed using either a free fascial graft or an expanded polytetrafluoroethylene (ePTFE) sheet. The fascial graft was covered directly by subcutaneous tissue (Group I) or by a silicone sheet to prevent tissue ingrowth from the subcutaneous tissue (Group II). The ePTFE sheet was covered with a silicone sheet (Group III). One or 2 weeks postoperatively, the strength of the dural repair was evaluated by determining the pressure at which cerebrospinal fluid (CSF) leaked through the wound margins. The dural repair was also histologically examined. In addition, using a rat model, specimens obtained from similar reconstruction sites were immunohistochemically stained with antibodies against basic fibroblast growth factor (bFGF), epidermal growth factor, or transforming growth factor-beta. The pressures at which CSF leaked after 1 and 2 weeks, respectively, were 50 +/- 14 mm Hg and 126 +/- 20 mm Hg in Group I, 70 +/- 16 mm Hg and 101 +/- 38 mm Hg in Group II, and 0 mm Hg and 8 +/- 8 mm Hg in Group III. Failure of repairs made in Group III occurred at significantly lower pressures when compared with Groups I and II. In Groups I and II, a thick fibrous tissue formed around the fascial graft. This tissue tightly adhered to adjacent dura mater. The fibrous tissue displayed a positive reaction for the presence of bFGF. In Group III, only a thin fibrous membrane surrounded the ePTFE sheet. CONCLUSIONS: Fascial grafts tolerated extraordinary intracranial pressures at 1 week postoperatively. Free fascial grafts can heal with durable fibrous tissue without the presence of a blood supply from an overlying vascularized flap.     

Spinal dural arterio-venous fistula with multiple points of shunt

Summary A 45-year-old man presented with a history of dysaesthesiae, sensory impairment of the legs and sphincter disturbances. Selective angiography showed a mid-thoracic dural arterio-venous fistula with five shunt points. The venous plexuses were demonstrated by injections at T5 on the right side and T6 on the left, but the venous pattern on the two sides did not overlap. Angiography did not unquestionably point to any single location of a fistula, as would normally be expected. During surgery five dorsal locations of shunt were identified. We have not found any publication describing a spinal dural arterio-venous fistula with multiple venous drainage channels at the same level.     

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.     

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.     

Endovascular treatment of traumatic arterio-venous fistulas of the vertebral artery

Cervical vertebral artery fistulas are rare arteriovenous malformations between the vertebral artery and veins of the neighbourhood. The etiology of the fistulas may be traumatic or spontaneous. Management and the results in two patients with large arterio-venous fistulas of the cervical vertebral artery with severe deterioration of spinal function by using the detachable balloon technique are discussed. Complete angiographic and clinical cure was achieved in both patients and no complications related to the embolization procedure occured. The detachable balloon technique is an effective method for selective occlusion of the fistula. Good radiographic monitoring facilities are required to make endovascular procedures effective and safe.     

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.     

Surgical treatment of spinal dural arterio-venous fistulae: long-term results and analysis of prognostic factors

Summary   Background. Spinal dural arterio-venous fistulae (SDAVF) are slow-flow extramedullary vascular lesions which account for 75–80% of all spinal vascular malformations. At present there is no agreed view with regard to the best therapeutic option being surgical or endovascular, and several reports favour one or other form of management. This is so because of lack of consistent literature, as well as knowledge, concerning the long-term clinical outcome of the patients. The objective of this study is to retrospectively analyse the results obtained with patients operated for a SDAVF at the Department of Neurosurgery of Verona during a 15-year period and to evaluate possible prognostic factors related to neurological outcome. Patients and methods. Between January 1987 and May 2002, 29 patients with SDAVF were operated at the Department of Neurosurgery of Verona. For 25 of these patients we were able to obtain a clinical follow-up using telephone interviews. The patients were evaluated with the Aminoff and Logue’s scale and subsequently stratified into three classes of disability. An overall score (gait and micturition, G + M) of 0–3 indicates a mild disability, a score between 4 and 5 indicates a moderate disability and a score between 6 and 8 a severe disability. All patients underwent surgical treatment which was mainly the first therapeutic option. Following surgery, the patients were re-evaluated with the same neurological scale. We also investigated with statistical analysis the possible impact on clinical outcome of the major clinical, neuroradiological and surgical variables. Results. The epidemiological, clinical, radiological and pathological features of our group of patients are very similar to those previously described in the literature. For 10 patients surgery consisted simply of the interruption of the intradural arterialised draining vein (with or without closure of the small extradural arterial afferents), whereas in the remaining 15 patients coagulation or excision of the fistolous dura was also accomplished. At the last follow-up (mean 7.3 years; in 19 patients longer than 5 years), 10 patients had improved (40%), 11 were stable (44%) and 4 had deteriorated (16%). We determined that only the pre-operative neurological status, described by the G value in the Aminoff and Logue’s scale and the class of disability, had an impact on clinical outcome. Conclusions. This retrospective study confirms that the surgical treatment results of SDAVF are satisfactory even if evaluated after many years. Given these results, and in accordance with the majority of the literature, we concur that surgery should be the first choice treatment for these spinal vascular lesions in order to avoid a dangerous delay and consequently further neurological deterioration. In our group of patients the only prognostic factor statistically related to clinical outcome was the pre-treatment neurological status, particularly the grade of paraparesis and the class of disability. Correspondence: Dr. Paolo Cipriano Cecchi, Operative Unit of Neurosurgery, Regional General Hospital, Via Boehler 5, 39100 Bolzano, Italy.     

Introduction of lymphangiography and percutaneous embolization of the thoracic duct in a stepwise approach to the management of chylous fistulas

BACKGROUND: Chylous fistula occurring after head and neck or thoracic surgery is an uncommon but well-described complication, with a reported incidence of 1% to 2.5%. Conservative management can be successful and consists of dietary measures combined with suction drainage. This article reports on percutaneous embolization of the thoracic duct through catheterization of the retroperitoneal lymph vessels. METHODS: Two patients, in whom conservative management for cervical chylous fistula failed, underwent lymphangiography with opacification of the thoracic duct, followed by radioguided catheterization and embolization. RESULTS: Embolization was successful in both patients. In 1 patient the procedure had to be repeated once to stop the chylous drainage. CONCLUSIONS: Radioguided percutaneous catheterization and embolization of the retroperitoneal lymph vessels offers an excellent treatment option for patients with persistent chylous fistulas after failure of conservative management. We revised our stepwise management protocol (de Gier, Head Neck 1996; 18:347-351) and now consider this procedure as the secondary intervention step.