Endovascular Treatment of Dural Arteriovenous Fistulas of the Transverse and Sigmoid Sinuses Using Transarterial Balloon-Assisted Embolization Combined with Transvenous Balloon Protection of the Venous Sinus

BACKGROUND AND PURPOSE:Combined transarterial balloon-assisted endovascular embolization with double-lumen balloon microcatheters and concomitant transvenous balloon protection was described as a promising treatment technique for dural arteriovenous fistulae of the transverse and sigmoid sinus. The purpose of this study was to evaluate the technical efficacy and safety of this combined treatment technique.MATERIALS AND METHODS:Nine consecutive patients presenting with dural arteriovenous fistulas of the transverse and sigmoid sinuses underwent combined transarterial and transvenous balloon-assisted endovascular embolization. Prospectively collected data were reviewed to assess the technical success rate, complication rate, and clinical outcome.RESULTS:Six patients presented with clinically symptomatic Borden type I, and 3 patients, with Borden type II dural arteriovenous fistulas of the transverse and sigmoid sinuses (3 men, 6 women; mean age, 50.4 years). Transarterial embolization was performed with a double-lumen balloon with Onyx and concomitant transvenous sinus protection with a dedicated venous remodeling balloon. Complete angiographic occlusion at the latest follow-up (mean, 4.8 months) was achieved in 6 patients, and near-complete occlusion, in 2 patients. Clinical cure or remission of symptoms was obtained in 6 and 2 patients, respectively. One patient with a residual fistula underwent further treatment in which the dural arteriovenous fistula was cured by sinus occlusion. Complete occlusion of the dural arteriovenous fistula was visible on the follow-up angiography after final treatment in 8 patients. One patient refused follow-up angiography but was free of symptoms. There were no immediate or delayed postinterventional complications.CONCLUSIONS:Transarterial balloon-assisted embolization of dural arteriovenous fistulas of the transverse and sigmoid sinuses with combined transvenous balloon protection is safe and offers a high rate of complete dural arteriovenous fistula occlusion and remission of clinical symptoms.

During the past few decades, endovascular embolization has become the first-line treatment for a wide range of dural arteriovenous fistulas (dAVFs). Several transarterial and transvenous endovascular approaches have been advocated. Preliminary studies on the use of double-lumen balloon microcatheters for transarterial embolization of dAVFs with Onyx (Covidien, Irvine, California) have shown encouraging results. These studies have reported high occlusion rates, reduction of reflux into the feeding artery, a reduced quantity of injected Onyx and peri-interventional time, and low complication rates.^1–9 In addition, transvenous balloon-assisted sinus protection during transarterial embolization has been reported to be another useful adjunct to the endovascular treatment of dAVFs.^10–12 Transvenous balloon protection of the recipient sinus has mainly been associated with a reduction in inadvertent occlusion of the lumen of a functioning sinus, preservation of venous patency, facilitation of occlusion of abnormal arteriovenous connections within the sinus wall and separate venous channels, and increased penetration of embolic material by retrograde reflux into other dural feeders of the fistula network. Techniques aiming to preserve the underlying sinus may have lower complication rates than sinus-occluding embolization techniques, in which the recipient venous sinus has to be sacrificed.¹³ Therefore, transarterial balloon-assisted embolization with a concomitant transvenous balloon protection technique theoretically has the advantages of both techniques combined; this combination leads to increased occlusion and reduced complication rates.The purpose of this study was to report the angiographic and clinical outcomes of patients with dAVFs of the transverse and sigmoid sinuses treated with a combined approach of transarterial balloon-assisted endovascular embolization and double-lumen balloon microcatheters with concomitant transvenous balloon protection.     

Transvenous embolization of dural fistulas involving the transverse and sigmoid sinuses

Eleven patients with dural fistulas involving the transverse and sigmoid sinuses were treated by transvenous embolization with coils or liquid adhesives. Seven patients underwent preoperative embolization of the external supply followed by direct surgical exposure of the sinus: liquid adhesives were used in four patients and coils in the remaining three. Four of these patients had complete obliteration of their fistulas and there was 95% reduction in the remaining three. Four patients had transvenous placement of coils from a transfemoral approach. In three, the ipsilateral sigmoid sinus was thrombosed and a contralateral approach across the torcular herophili was used. Coils were used in all four patients; one patient also had liquid adhesives placed within the sinus. Complete cure was achieved in one patient, 95% reduction in another, and 50% and 40%, reductions in the remaining two. Two transient complications occurred, one related to venous occlusion secondary to liquid adhesives and another related to transient occlusion of the vestibular aqueduct. Obliteration of dural fistulas involving the transverse and sigmoid sinuses can be achieved by placement of embolic material within the involved sinus from a transvenous approach; both coils and liquid adhesives can achieve this goal.     

Endovascular treatment of dural arteriovenous fistula involving marginal sinus with emphasis on the routes of transvenous embolization

Introduction  

Dural arteriovenous fistulas involving marginal sinus are relatively rare. Transvenous embolization is a curative treatment of choice for them. Regional anatomy surrounding the marginal sinus comprises complex craniocervical bony structures and abundant venous interconnections. Therefore, dural arteriovenous fistulas involving marginal sinus may have various routes for a transvenous approach. The purpose of this article was to analyze endovascular treatment of marginal sinus dural arteriovenous fistulas with emphasis on the routes of transvenous embolization.     

Multiple dural arteriovenous fistulas of the cranium and spine

Dural arteriovenous fistulas are acquired lesions that usually involve the dura around the cavernous sinus. The transverse, sigmoid, and superior sagittal sinuses may be affected occasionally. With the exception of bilateral cavernous sinus dural arteriovenous fistulas, the simultaneous occurrence of dural arteriovenous fistulas at two locations is rare. Among 105 patients evaluated for dural arteriovenous fistulas, we identified seven patients with fistulas at two sites. The age of the patients ranged from 27 to 74 years. Presentation was related to hemorrhage in three patients, loss of vision in four, and a bruit and headaches in one. Patients were treated with combined surgical and endovascular techniques. All treated lesions were completely closed with no mortality or permanent morbidity. The presence of multiple fistulas must be considered in patients being evaluated for dural arteriovenous fistulas. Patients with multiple fistulas usually present with life-threatening hemorrhages or acute neurologic decline; the risk factor for hemorrhages, including those related to venous outflow obstruction, is high in patients with multiple dural arteriovenous fistulas.     

Dural arteriovenous fistulas of the marginal sinus.

PURPOSETo investigate the clinical presentation, angiographic findings, endovascular management and clinical outcome in dural arteriovenous fistulas (DAVFs) of the marginal sinus.METHODSFourteen patients with DAVFs of the marginal sinus were identified from angiographic studies and medical records of all patients treated for DAVFs at our institution between July 1990 and August 1995. The endovascular treatment and clinical outcomes of these patients are reported.RESULTSEleven patients had pulse-synchronous bruit, two had intracranial hemorrhage, and one had ataxia. Thirteen patients were cured with endovascular techniques alone and one was cured by a combination of preoperative embolization followed by surgical obliteration of the fistula. The sole complication of treatment was a partial left hypoglossal nerve palsy, which resolved spontaneously.CONCLUSIONDAVFs of the marginal sinuses are potentially life-threatening lesions that can be treated with endovascular techniques for a high rate of cure and a low rate of morbidity.     

Transarterial Onyx Embolization of Cranial Dural Arteriovenous Fistulas: Long-Term Follow-Up

BACKGROUND AND PURPOSE:Endovascular therapy with liquid embolic agents is a common treatment strategy for cranial dural arteriovenous fistulas. This study evaluated the long-term effectiveness of transarterial Onyx as the single embolic agent for curative embolization of noncavernous cranial dural arteriovenous fistulas.MATERIALS AND METHODS:We performed a retrospective review of 40 consecutive patients with 41 cranial dural arteriovenous fistulas treated between March 2006 and June 2012 by using transarterial Onyx embolization with intent to cure. The mean age was 57 years; one-third presented with intracranial hemorrhage. Most (85%) had cortical venous drainage. Once angiographic cure was achieved, long-term treatment effectiveness was assessed with DSA and clinical follow-up.RESULTS:Forty-nine embolization sessions were performed; 85% of cranial dural arteriovenous fistulas were treated in a single session. The immediate angiographic cure rate was 95%. The permanent neurologic complication rate was 2% (mild facial palsy). Thirty-five of the 38 patients with initial cure underwent short-term follow-up DSA (median, 4 months). The short-term recurrence rate was only 6% (2/35). All patients with occlusion at short-term DSA undergoing long-term DSA (median, 28 months) had durable occlusion. No patient with long-term clinical follow-up (total, 117 patient-years; median, 45 months) experienced hemorrhage.CONCLUSIONS:Transarterial embolization with Onyx as the single embolic agent results in durable long-term cure of noncavernous cranial dural arteriovenous fistulas. Recurrence rates are low on short-term follow-up, and all patients with angiographic occlusion on short-term DSA follow-up have experienced a durable long-term cure. Thus, angiographic cure should be defined at short-term follow-up angiography instead of at the end of the final embolization session. Finally, long-term DSA follow-up may not be necessary if occlusion is demonstrated on short-term angiographic follow-up.

Endovascular therapy is commonly used for the treatment of noncavernous cranial dural arteriovenous fistulas (cDAVFs). Cyanoacrylates, ethyl alcohol, coils, and particles can be used alone or in combination via transarterial, transvenous, or occasionally direct percutaneous treatment routes. There is no US Food and Drug Administration–approved liquid embolic agent for the treatment of cDAVFs. The ethylene-vinyl alcohol copolymer liquid embolic system (Onyx; Covidien, Irvine, California) is FDA-approved for the presurgical embolization of brain arteriovenous malformations. Since Onyx has become available, transarterial embolization of cDAVFs by using Onyx as the sole endovascular embolic agent has become our preferred treatment strategy. This endovascular treatment approach represents an “off-label” use of the Onyx liquid embolic system.The immediate occlusion rate in large cohort studies of patients treated with transarterial Onyx embolization ranges from 62% to 92%, and short-term durable occlusion has been demonstrated.^1–4 We have previously reported our short-term experience using Onyx in these patients⁵ and have compared the success of this technique with embolization using n-butyl cyanoacrylate.⁶ However, there currently remain no published data on the long-term effectiveness for embolization of cDAVFs by using Onyx, to our knowledge. Here we report our long-term angiographic occlusion rate and clinical follow-up in a cohort of noncavernous cranial DAVFs that were treated by using transarterial Onyx embolization with the intention of complete cure.     

硬脑膜动静脉瘘的治疗

目的 探讨不同方法治疗的不同类型的硬脑膜动静脉瘘(DAVF)的疗效。方法 采用经动脉入路在供血动脉内采用低浓度NBCA胶、弹簧圈、游离纤毛钢圈、PVA等栓塞治疗；经静脉入路在瘘口静脉端用弹簧圈栓塞，或直接开颅手术夹闭瘘口、静脉窦表面颅骨钻孔后直接穿刺作静脉窦内栓塞及静脉内支架植入等方法治疗不同部位和不同类型的DAVF32例。结果 8例前颅凹底DAVF，5例经动脉入路栓塞治疗，2例治愈，3例临床好转；3例(1例经静脉入路治疗失败后)前颅凹底入路行开颅瘘口直接夹闭治愈。14例海绵窦区DAVF，7例经眼上静脉入路海绵窦内栓塞治愈，4例经动脉入路，治愈1例，好转3例。5例横窦区DAVF，2例经静脉入路窦内栓塞治愈，2例动脉入路栓塞后好转，1例行窦孤立手术治愈。4例多处瘘口的上矢状窦DAVF，联合多种治疗方法经多次治疗，临床好转。1例左侧颈静脉孔区DAVF联合多种治疗方法经多次治疗治愈。结论 前颅凹底DAVF以直接手术行瘘口夹闭疗效好，经动脉入路低浓度胶栓塞可治愈但需注意危险吻合；海绵窦区DAVF经静脉入路栓塞多可治愈。横窦区DAVF静脉入路栓塞瘘口静脉端效果好；复杂性DAVF治疗困难，目前联合多种治疗方法可以达到临床改善。将治疗策略定在针对瘘口的静脉端，可望达到临床治愈。     

Endovascular treatment of dural fistulas with the venous outflow of laterocavernous sinus

Objective

To report our findings concerning the laterocavernous sinus (LCS) drainage of dural fistulas, focusing our attention on the important implications in treatment of the LCS, which is one of the principal drainage pathways of the superficial middle cerebral vein (SMCV).

Methods

Consecutive 32 patients with dural fistulas treated endovascularly between 2005 and 2008 were reviewed. Seven patients had angiographic features such as dural fistulas draining with SMCV via LCS. Clinical records for these 7 patients were focused to determine their presenting symptoms, angiographic features, endovascular treatments, and clinical outcomes.

Results

Over 3 years, 7 patients had 7 dural fistulas drained with SMCV via LCS were treated. Six-vessel angiography confirmed the presence of the dural fistulas. All fistulas were Cognard Type III featured by leptomeningeal veins drainage. One fistula involving the lesser sphenoid wing and 6 fistulas involving CS were supplied by external carotid artery branches with or without dural branches of the internal carotid artery. LCS was identified as a contiguous to SMCV drainage in these cases. One patient was treated with transvenous coil embolization alone, two with transvenous a combination of Onyx and coil embolization, and 4 with transarterial embolization. An angiographic obliteration and clinical cure was achieved in all patients. Complication was local hair loss due to X-ray radiation in one patient.

Conclusion

It is very important to diagnose the presence of LCS in dural fistulas during the diagnostic angiography. It is believed that the knowledge of LCS might be relevant for the understanding and treatment of dural fistulas involving the LCS.     

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.     

Angioarchitecture of Transverse-Sigmoid Sinus Dural Arteriovenous Fistulas: Evaluation of Shunted Pouches by Multiplanar Reformatted Images of Rotational Angiography

BACKGROUND AND PURPOSE:Recognition of shunted pouches dural arteriovenous fistula allows us to treat the disease effectively by selective embolization of the pouches at first. However, the shunted pouches in transverse-sigmoid sinus dural arteriovenous fistulas have not been well-documented. Our aim was to evaluate the angioarchitecture of transverse-sigmoid sinus dural arteriovenous fistulas, including the frequency and location of shunted pouches and their feeding arteries.MATERIALS AND METHODSTwenty-five consecutive cases of TSS-DAVFs that underwent rotational angiography and transvenous embolization between 2008 and 2011 were reviewed. Multiplanar reformatted images of rotational angiography and selective angiography were reviewed with a particular focus on the shunted pouches.RESULTS:All 25 cases showed SPs, with numbers ranging from 1 to 4 pouches (mean, 2.35). The SPs were located at the transverse-sigmoid junction in 16, close to the vein of Labbé in 9, at the dorsal-to-sigmoid sinus in 9, inferior to the sigmoid sinus in 6, at the sigmoid-jugular junction in 5, and inferior to the transverse sinus or the sinus confluence in 14. The SP at the sigmoid sinus was frequently fed by the jugular branch of the ascending pharyngeal artery and the stylomastoid artery. The SP at the transverse-sigmoid junction and the vein of Labbé was fed by the petrosal/petrosquamous and posterior branches of the middle meningeal artery and the transosseous branches of the occipital artery. The SP inferior to the transverse sinus and the sinus confluence was fed by the transosseous branches of the occipital artery and the posterior meningeal artery. All cases were successfully treated by transvenous embolization with sinus packing (n = 13) or selective embolization of the SP (n = 12).CONCLUSIONS:The presence of SP is a common angioarchitecture of TSS-DAVFs. Identification of the SPs would be useful for their treatment.

Transverse-sigmoid sinus dural arteriovenous fistula is one of the most common types of intracranial DAVFs and can lead to various disorders, from tinnitus to fatal cerebral hemorrhage. A majority of TSS-DAVFs have been treated by endovascular techniques, including transarterial embolization and/or transvenous embolization. The drainage pattern of the TSS-DAVFs is strongly related to the clinical symptoms; therefore, the importance of evaluating the drainage routes of the TSS-DAVF before treatment has been well-recognized.^1,2 However, other angioarchitectures, such as fistulous points and dural sinus compartments, have not been well-documented. Some cases of TSS-DAVFs can be successfully treated by selective embolization of a fistulous portion with preservation of the normal sinus lumen.^3–5 Although these cases are generally thought to be special, 1 study showed that the fistulous compartment of the dural sinus often exists in and around the dural sinus in TSS-DAVFs.⁶Recent developments in 3D angiography technology allow us to evaluate the angioarchitecture of DAVFs more easily and precisely.⁷ In this study, we evaluated the angioarchitecture of TSS-DAVFs, including the frequency and location of these fistulous compartments of dural sinuses on the basis of MPR images of rotational angiography. Additionally, we discuss the endovascular techniques for the treatment of TSS-DAVFs. Several different terms have been used to refer to these fistulous portions located outside the main lumen of the dural sinus, including venous recipients of DAVFs, dural sinus septations, accessory sinuses, parallel channels, parallel sinuses, and fistulous drainage. In this article, we use the term “shunted pouch” to refer to these structures.     

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.     

Endovascular treatment for dural arteriovenous fistula of the anterior condylar vein with unusual venous drainage: report of two cases

We report 2 patients with dural arteriovenous fistula of the anterior condylar vein in which the patients presented with rare clinical symptoms related to unusual venous drainage patterns. The first patient had progressive myelopathy and showed venous drainage into the anterior spinal vein. The second had ocular signs and showed retrograde drainage into the superior ophthalmic vein. Complete cure was attained by transarterial glue injection in the first patient and transvenous coil embolization in the latter.     

Embolization of dural cavernous fistulas via superior ophthalmic vein approach.

PURPOSETo present the results of our treatment of dural cavernous sinus fistulas with surgical exposure of the superior ophthalmic vein (SOV), retrograde venous catheterization, and coil embolization of the cavernous sinus.METHODSTwelve patients with dural cavernous sinus fistulas were treated via a retrograde transvenous SOV approach in our hospital during a 3-year period. All patients had been referred by ophthalmologists because of secondary glaucoma and decreased visual acuity. Angiography showed preferential venous drainage of the dural cavernous sinus fistulas to an enlarged ipsilateral SOV. A total of 13 SOV exposures were performed, one patient with bilateral fistulas required bilateral treatment. The vein was surgically exposed by an ophthalmologist and then catheterized. Platinum coils were delivered through a microcatheter at the fistula site and into the root of the SOV, until there was complete angiographic closure.RESULTSCatheterization and embolization were successful in 12 of the 13 patients, with complete angiographic occlusion of the fistula. Two patients with bilateral fistulas had transient worsening of symptoms on the contralateral side. Three patients required follow-up angiography. No early complications occurred, and late complications were minor in two cases. All patients except one with long-standing symptoms recovered premorbid visual acuity. At follow-up, 11 (92%) of the 12 embolized fistulas remained occluded.CONCLUSIONSRetrograde catheterization of the SOV and embolization of the cavernous sinus with coils is a direct, safe, and efficient way to occlude dural cavernous sinus fistulas.     

Progressive versus Nonprogressive Intracranial Dural Arteriovenous Fistulas: Characteristics and Outcomes

BACKGROUND AND PURPOSE:A minority of intracranial dural arteriovenous fistulas progress with time. We sought to determine features that predict progression and define outcomes of patients with progressive dural arteriovenous fistulas.MATERIALS AND METHODS:We performed a retrospective imaging and clinical record review of patients with intracranial dural arteriovenous fistula evaluated at our hospital.RESULTS:Of 579 patients with intracranial dural arteriovenous fistulas, 545 had 1 fistula (mean age, 45 ± 23 years) and 34 (5.9%) had enlarging, de novo, multiple, or recurrent fistulas (mean age, 53 ± 20 years; P = .11). Among these 34 patients, 19 had progressive dural arteriovenous fistulas with de novo fistulas or fistula enlargement with time (mean age, 36 ± 25 years; progressive group) and 15 had multiple or recurrent but nonprogressive fistulas (mean age, 57 ± 13 years; P = .0059, nonprogressive group). Whereas all 6 children had fistula progression, only 13/28 adults (P = .020) progressed. Angioarchitectural correlates to chronically elevated intracranial venous pressures, including venous sinus dilation (41% versus 7%, P = .045) and pseudophlebitic cortical venous pattern (P = .048), were more common in patients with progressive disease than in those without progression. Patients with progressive disease received more treatments than those without progression (median, 5 versus 3; P = .0068), but as a group, they did not demonstrate worse clinical outcomes (median mRS, 1 and 1; P = .39). However, 3 young patients died from intracranial venous hypertension and intracranial hemorrhage related to progression of their fistulas despite extensive endovascular, surgical, and radiosurgical treatments.CONCLUSIONS:Few patients with dural arteriovenous fistulas follow an aggressive, progressive clinical course despite treatment. Younger age at initial presentation and angioarchitectural correlates to venous hypertension may help identify these patients prospectively.

Intracranial dural arteriovenous fistulas (DAVFs) are rare arteriovenous shunts involving the epidural space and adjacent dura mater, which receive arterial supply from meningeal vessels and drain directly to dural venous sinuses or cortical veins.¹ In the early days of cerebral angiography, DAVFs were considered a subset of AVMs: Newton and Cronqvist² classified AVMs by arterial supply as pure dural, mixed pial-dural, or pure pial malformations. Unlike brain AVMs, however, DAVFs are most often thought to be acquired (as opposed to congenital), and DAVFs lack a nidus of vessels in the brain parenchyma. DAVF is also distinguished from nongalenic pial arteriovenous fistula by its fistula location in the dura.Management of a DAVF is based on its expected clinical course: Fistulas demonstrating cortical venous drainage (CVD) generally warrant curative therapy to prevent intracranial hemorrhage, and fistulas without CVD are managed for either symptom palliation or cure.^3–6 Treatment modalities include transarterial or transvenous endovascular embolization to occlude the arteriovenous fistula site, microsurgical interruption of the fistula site, stereotactic radiosurgery, or multimodality therapy. Endovascular procedures are used to treat a most DAVFs and are the treatment of choice for lesions accessible to catheterization.^5,6A small number of patients with DAVFs respond poorly to conventional therapies and demonstrate progressive neurologic and angiographic deterioration with enlargement of existing fistulas, formation of de novo fistulas, and development of features that increase the risk of intracranial hemorrhage.⁷ Reports of such rapidly progressive “runaway” DAVFs are scarce. Only a few cases have been published in the past 15 years; therefore, the pathogenesis, presentation, clinical course, and treatment remain unclear.^4,8–12 The purpose of this single-institution retrospective cohort study was to compare the clinical characteristics, angioarchitecture, and treatment outcomes of patients with progressive (enlarging fistulas or developing de novo fistulas) versus nonprogressive (recurrent original fistula or the presence of multiple unchanging fistulas) intracranial DAVFs.     

Surgical transvenous embolization of a cortically draining carotid cavernous fistula via a vein of the sylvian fissure.

Percutaneous transvenous embolization is one of the most effective treatments of intracranial dural arteriovenous fistulas (AVFs) involving the dural sinuses. We present a unique case of surgical transvenous embolization in a 48-year-old man with a dural AVF of the cavernous sinus who presented with intracerebral hematoma. The dural AVF drained only into the vein of the sylvian fissure on angiography. Transvenous embolization via the vein of the sylvian fissure during craniotomy obliterated the AVF completely.     

Endovascular venous approach in the treatment of ruptured intra-cerebral arterio-venous malformation

Trans-venous approach has been described for endovascular treatment of many vascular lesions namely the intracranial dural, cavernous and intra-orbital malformations. A patient with a ruptured left deep parietal arteriovenous malformation (AVM) treated with primary transvenous Onyx 18 embolization is reported. Trans-arterial approaches were unsuccessful because of the tiny tortuous feeding arteries and hence a transvenous approach was used for embolization. Follow-up angiography at 3 month revealed persistent angiographic cure of the AVM. Our case illustrates that in patients with ruptured small AVM having a single draining vein, transvenous treatment can be utilized to achieve occlusion resulting in AVM cure.     

Changing Clinical and Therapeutic Trends in Tentorial Dural Arteriovenous Fistulas: A Systematic Review

BACKGROUND AND PURPOSE:Tentorial dural arteriovenous fistulas are characterized by a high hemorrhagic risk. We evaluated trends in outcomes and management of tentorial dural arteriovenous fistulas and performed a meta-analysis evaluating clinical and angiographic outcomes by treatment technique.MATERIALS AND METHODS:We performed a comprehensive literature search for studies on surgical and endovascular treatment of tentorial dural arteriovenous fistulas. We compared the proportion of patients undergoing endovascular, surgical, and combined endovascular/surgical management; the proportion of patients presenting with ruptured tentorial dural arteriovenous fistulas; and proportion of patients with good neurologic outcome across 3 time periods: 1980–1995, 1996–2005, and 2006–2014. We performed a random-effects meta-analysis, evaluating the rates of occlusion, long-term good neurologic outcome, perioperative morbidity, and resolution of symptoms for the 3 treatment modalities.RESULTS:Twenty-nine studies with 274 patients were included. The proportion of patients treated with surgical treatment alone decreased from 38.7% to 20.4% between 1980–1995 and 2006–2014. The proportion of patients treated with endovascular therapy alone increased from 16.1% to 48.0%. The proportion of patients presenting with ruptured tentorial dural arteriovenous fistulas decreased from 64.4% to 43.6%. The rate of good neurologic outcome increased from 80.7% to 92.9%. Complete occlusion rates were highest for patients receiving multimodality treatment (84.0%; 95% CI, 72.0%–91.0%) and lowest for endovascular treatment (71.0%; 95% CI, 56.0%–83.0%; P < .01). Long-term good neurologic outcome was highest in the endovascular group (89.0%; 95% CI, 80.0%–95.0%) and lowest for the surgical group (73.0%; 95% CI, 51.0%–87.0%; P = .03).CONCLUSIONS:Patients with tentorial dural arteriovenous fistulas are increasingly presenting with unruptured lesions, being treated endovascularly, and experiencing higher rates of good neurologic outcomes. Endovascular treatment was associated with superior neurologic outcomes but lower occlusion rates.

Intracranial dural arteriovenous fistulas (DAVFs) are abnormal direct shunts between the dural arteries and dural veins.¹ The shunt is located in the intracranial dura mater with venous drainage directed to the dural venous sinuses or cortical veins. Dural arteriovenous fistulas account for 10%–15% of all intracranial vascular shunts.^1,2 Tentorial dural arteriovenous fistulas (TDAVFs) constitute only 4% of DAVFs and are characterized by a high hemorrhagic risk. Because of this, these lesions are treated aggressively on diagnosis.^3–5Traditionally, surgical resection was the only treatment available for these lesions. However, endovascular embolization, either alone or in combination with surgery, is increasingly used.⁶ Stereotactic radiosurgery is also increasingly used as an adjunct to surgical and endovascular treatment.⁷ We performed a systematic review of the literature on surgical and endovascular treatment of TDAVFs from 1980 to 2014. The purpose of our study was the following: 1) to determine whether there was a shift from primarily surgical treatments to endovascular and multimodality treatment during this time period, 2) to determine whether the proportion of patients presenting with ruptured TDAVFs during this time period has changed, 3) to determine whether the rate of good neurologic outcome has changed, and 4) to evaluate clinical and angiographic outcomes in endovascular, surgical, and combined treatments by performing a random-effects meta-analysis.     

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.     

Embolization of dural arteriovenous fistulas with interlocking detachable coils.

Our clinical experience with interlocking detachable coils for the embolization of high-flow dural arteriovenous fistulas is reported. Interlocking detachable coils are useful for transarterial and transvenous embolizations of dural arteriovenous fistulas because (a) immediate coil detachment is possible, (b) the coils can be replaced easily, (c) detached coils rarely migrate, and (d) fewer interlocking detachable coils than conventional fiber coils are required for successful embolization.     

硬脑膜动静脉瘘的治疗

目的　探讨不同方法治疗不同类型的硬脑膜动静脉瘘 (DAVF)的疗效。方法　采用经动脉入路在供血动脉内采用低浓度NBCA胶、弹簧圈、游离纤毛钢圈、PVA等栓塞治疗 ;经静脉入路在瘘口静脉端用弹簧圈栓塞 ,或直接开颅手术夹闭瘘口、静脉窦表面颅骨钻孔后直接穿刺作静脉窦内栓塞及静脉内支架植入等方法治疗不同部位和不同类型的DAVF 32例。结果　 8例前颅凹底DAVF ,5例经动脉入路栓塞治疗 ,2例治愈 ,3例临床好转 ;3例 (1例经静脉入路治疗失败后 )前颅凹底入路行开颅瘘口直接夹闭治愈。 14例海绵窦区DAVF ,7例经眼上静脉入路海绵窦内栓塞治愈 ,4例经动脉入路 ,治愈 1例 ,好转 3例。 5例横窦区DAVF ,2例经静脉入路窦内栓塞治愈 ,2例动脉入路栓塞后好转 ,1例行窦孤立手术治愈。 4例多处瘘口的上矢状窦DAVF ,联合多种治疗方法经多次治疗 ,临床好转。 1例左侧颈静脉孔区DAVF联合多种治疗方法经多次治疗治愈。结论　前颅凹底DAVF以直接手术行瘘口夹闭疗效好 ,经动脉入路低浓度胶栓塞可治愈但需注意危险吻合 ;海绵窦区DAVF经静脉入路栓塞多可治愈。横窦区DAVF静脉入路栓塞瘘口静脉端效果好 ;复杂性DAVF治疗困难 ,目前联合多种治疗方法可以达到临床改善。将治疗策略定在针对瘘口的静脉端 ,可望达到临床治愈。