Cavernous sinus dural fistulae treated by transvenous approach through the facial vein: report of seven cases and review of the literature

BACKGROUND AND PURPOSE: Dural Carotid Cavernous Fistulas (CCFs) can be treated by transarterial and/or transvenous endovascular techniques. The venous route usually goes through the internal jugular vein (IJV) and the inferior petrosal sinus (IPS) up to the pathologic shunts of the cavernous sinus. In case a thrombosed IPS, catheterization through the obstructed sinus is not always possible and a puncture of the superior ophthalmic vein (SOV) can be performed often after a surgical approach. We report our results in the endovascular transvenous treatment of dural CCFs through the facial vein (retrograde catheterization of the IJV, facial vein, angular vein, SOV, and cavernous sinus). METHODS: A retrospective study of seven patients with a dural CCF treated with transvenous embolization via the facial vein was performed. In five patients, the IPS was thrombosed. In one patient, the IPS was patent, but there was not communication between the cavernous sinus compartment in which the CCF shunts were located and the IPS itself. In the only patient with the CCF draining through permeable IPS, the transvenous route through the IPS permitted the occlusion of the posterior CCF shunts and a second session was performed through the facial vein in order to occlude the shunts of the anterior compartment of the cavernous sinus. The other six patients underwent one embolization session only. RESULTS: In all seven cases, it was possible to navigate through the tortuous junction of the angular vein and the SOV. In one patient with a thrombosed SOV, the venous procedure was interrupted because the catheterization through the occluded SOV failed. In the other six patients, after transvenous catheterization of the cavernous sinus via the facial vein, placement of coils resulted in complete occlusion of the dural CCF with clinical cure in four patients and improvement in two. CONCLUSION: In the endovascular treatment of the dural CCFs, the transfemoral approach via the facial vein provides a valuable alternative to other transvenous routes. Catheterization of the cavernous sinus via the facial vein is usually successful. Although this technique requires caution, it allows a safe and effective treatment of these lesions.     

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.     

Recurrence of the cavernous sinus dural arteriovenous fistula at adjacent sinuses following repeated transvenous embolizations: case report and literature review

We present a unique case of a cavernous sinus (CS) dural arteriovenous fistula (DAVF), which recurred at adjacent sinuses following repeated transvenous embolizations (TVEs). A 68-year-old woman presented with progressive left conjunctival chemosis and diplopia. Cerebral angiography revealed a left CS DAVF, which was completely obliterated by TVE via the left inferior petrosal sinus (IPS). Two years later, the DAVF recurred in the left IPS, and again in the left sigmoid sinus (SS) 3 years after the initial treatment in spite of a second TVE. Moreover, the left SS and the left internal jugular vein, which had been previously stenotic, had been occluded. The third TVE resulted in the complete obliteration of the SS DAVF. CS DAVFs may recur at adjacent sinuses even after complete obliteration by TVE. Careful follow-up is necessary to check for the recurrence of DAVFs, especially in cases with venous flow changes, such as sinus occlusion, following endovascular treatment.     

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。     

A rare brainstem hemorrhage due to incomplete transvenous embolization of the cavernous sinus dural arteriovenous fistula: A case report

Endovascular embolization is generally thought to be safe and effective for the cavernous sinus dural arteriovenous fistula (CS DAVF); however, some complications have been reported. We report an extremely rare brainstem hemorrhage associated with transvenous embolization (TVE) of CS DAVF. A 66-year-old man presented with right-sided conjunctival chemosis and exophthalmos. His brain magnetic resonance image showed right CS DAVF. Thus, emergent TVE was performed. Although his symptoms improved after the first TVE, magnetic resonance image showed brainstem edema, and venous congestion was suspected because of incomplete TVE. Second TVE was performed. Thereafter, computed tomography showed brainstem hemorrhage, resulting in the occurrence of right abducent nerve palsy, right-sided facial palsy, and ataxia. The patient''s condition gradually improved, and a year has passed without recurrence. Incomplete TVE of CS DAVF can result in life-threatening complications, such as cerebral hemorrhage. To avoid these complications, the anatomical structure of the cavernous sinus should be understood accurately, and important drainage veins should be determined.     

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。     

Treatment of a cavernous sinus dural arteriovenous fistula by deep orbital puncture of the superior ophthalmic vein

In a patient with progressive ophthalmological problems, including uncontrolled intraocular pressure related to a cavernous sinus dural arteriovenous fistula, urgent intervention may be necessary to prevent permanent visual loss. We report a case in which inadequate transarterial embolisation and lack of access for transvenous catheterisation, including a direct approach through the superior ophthalmic vein, preceded percutaneous puncture of the superior ophthalmic vein deep within the orbit, permitting venous occlusion without complications. This case demonstrates that deep orbital puncture of the vein is feasible for occlusion of a cavernous sinus dural arteriovenous fistula. Received: 14 July 2000 Accepted: 11 October 2000     

经面静脉-眼上静脉入路治疗颈动脉海绵窦瘘

目的　评价经面静脉 眼上静脉入路治疗颈动脉海绵窦瘘 (CCF)的有效性。方法 :经股静脉 面静脉 眼上静脉入路到达患侧海绵窦 ,用GDC或EDC ,游离弹簧圈 ,真丝线段等多种栓塞材料填塞海绵窦 ,同时闭塞瘘口。面静脉插管困难者 ,在下颌角附近切开皮肤显露面静脉 ,直视下穿刺面静脉放置相应导管 ,再经眼上静脉到达患侧海绵窦并将其填塞。结果 :经面静脉 眼上静脉入路对 14例、16侧海绵窦进行了栓塞治疗 ,其中 5例为外伤性、直接CCF(A型 ) ,经动脉途径球囊栓塞后复发 ,或微弹簧圈栓塞未能成功 ,或经岩下窦入路未能成功 ,9例为自发性、间接CCF(D型 8例 ,C型 1例 )。 13例经股静脉 面静脉 眼上静脉途径 ,1例通过直视下面静脉穿刺。 11例栓塞治疗后即刻造影显示瘘消失 ,2例残留低流量的岩下窦引流 ,另有 1例在微导管进入面静脉后 ,面静脉痉挛闭塞 ,未能继续进行栓塞治疗 ,造影仍见瘘存在 ,但眼静脉出现明显的造影剂滞留。 1例A型CCF在球囊栓塞后出现外展神经麻痹 ,经面静脉 眼上静脉栓塞后亦无改善。因面静脉痉挛闭塞未能栓塞成功者 ,于术后即感眼部症状加重 ,但第 2天感症状缓解 ,术后第 2 1天症状明显改善 ,造影检查发现瘘口已经消失 ,术后 1个月患者眼部症状完全消失。其他病例在栓塞术后眼部症状明显改善 ,     

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     

Carotid cavernous fistula: embolization via a bilateral superior ophthalmic vein approach

We report the case of a 74-year-old woman with a complex indirect (Barrow D) carotid cavernous sinus fistula. The patient was treated incrementally and finally cured by a rarely reported bilateral retrograde direct transvenous approach via the superior ophthalmic vein. The treatment of the complex carotid cavernous fistula with multiple bilateral fistula points showed additional complexity due to a partially thrombosed left superior ophthalmic vein, which required a combined microsurgical and endovascular treatment, showing that treatment can be achieved, if necessary, by catheterization of a thrombosed orbital vein.     

The anterior medullary–anterior pontomesencephalic venous system and its bridging veins communicating to the dural sinuses: normal anatomy and drainage routes from dural arteriovenous fistulas

Introduction  We evaluated the normal venous anatomy of the anterior medullary/anterior pontomesencephalic venous (AMV/APMV) system and bridging veins connected to the dural sinuses using magnetic resonance (MR) imaging and demonstrated cases of dural arteriovenous fistulas (DAVFs) with bridging venous drainage. Materials and methods  MR images obtained using a 3D gradient echo sequence in 70 patients without lesions affecting the deep or posterior venous channels were reviewed to evaluate the normal anatomy of the AMV/APMV system and bridging veins. MR images and digital subtraction angiography in 80 cases with intracranial or craniocervical junction DAVFs were reviewed to evaluate the bridging venous drainage from DAVFs. Results  MR images clearly revealed AMV/APMV in 35 cases. Fifteen cases showed a direct connection between AMV and APMV, while 15 cases showed an indirect communication via the transverse pontine vein or the bridging vein. In the five remaining cases, the AMV and APMV end separately to the bridging vein or the transverse pontine vein. Bridging veins were identified in 34 cases, connecting to the cavernous sinus in 33, to the suboccipital cavernous sinus in 11, and the inferior petrosal sinus in five cases. In 80 DAVF cases, seven of 40 cavernous sinus DAVFs, two craniocervical junction DAVFs, and one inferior petrosal sinus DAVF drained via bridging veins to the brain stem. Conclusion  The AMV/APMV and bridging veins showed various anatomies and frequently showed a connection to the cavernous sinus. Knowledge of the venous anatomy is helpful for the diagnosis and intravascular treatment of DAVFs.     

Phase-contrast MR angiography of intracranial dural arteriovenous fistulae

MRI and phase-contrast MR angiography (PC MRA) were obtained in 13 patients with angiographically confirmed intracranial dural arteriovenous fistulae (DAVF). Three- and two-dimensional PC MRA was obtained with low (6–20 cm/s) and high (> 40 cm/s) velocity encoding along the three main body axes. MRI showed focal or diffuse signal abnormalities in the brain parenchyma in six patients, dilated cortical veins in seven, venous pouches in four with type IV DAVF and enlargement of the superior ophthalmic vein in three patients with DAVF of the cavernous sinus. However, it showed none of the fistula sites and did not allow reliable identification of feeding arteries. 3D PC MRA enabled identification of the fistula and enlarged feeding arteries in six cases each. Stenosis or occlusion of the dural sinuses was detected in six of eight cases on 3D PC MRA with low velocity encoding. In six patients with type II DAVF phase reconstruction of 2D PC MRA demonstrated flow reversal in the dural sinuses or superior ophthalmic vein. Received: 14 May 1998 Accepted: 15 December 1998     

Recurrence of dural arteriovenous fistula in another location after selective transvenous coil embolization: report of two cases

Two cases of a second dural arteriovenous fistula (DAVF), both developing in different locations after selective transvenous embolization of the first DAVF, are presented. One recurrent DAVF developed on the sigmoid sinus 5 months after transvenous embolization of a DAVF in the paratransverse sinus channel, and the other recurrence developed around the jugular bulb 5 months after transvenous embolization of a cavernous DAVF. The former was obliterated by a second embolization, and the latter disappeared spontaneously at 20 months.     

Percutaneous transvenous embolisation through the occluded sinus for transverse-sigmoid dural arteriovenous fistulas with sinus occlusion

We report six cases of transverse-sigmoid dural arteriovenous fistulae (TS DAVF) treated with percutaneous transvenous embolisation through the occluded sinus. All patients had sinus occlusive lesions: an isolated sinus in five cases and a distal occlusion of the affected sinus in one. Leptomeningeal retrograde venous drainage via the vein of Labbé or the sylvian vein was observed in all patients with an isolated sinus. In five patients a microcatheter was easily passed through the occluded sinus. In four of them, a complete angiographic cure was achieved by packing the sinus with coils. However, in one, sinus packing was ineffective and surgical excision of the affected sinus was necessary. The microcatheter could not be passed through the occluded sinus in one case, and direct packing of the isolated sinus was later required. In all cases, complete cure was achieved without complications. This safe, not very invasive and highly effective treatment for TS DAVF with sinus occlusion is thus worth trying when the occluded segment is relatively short. Received: 11 August 2000 Accepted: 21 August 2000     

Percutaneous transvenous packing of cavernous sinus with Onyx for cavernous dural arteriovenous fistula

Objective

The aim of this study is to describe the technique and results of the transvenous approach for occlusion of cavernous dural arteriovenous fistulas (DAVFs) with Onyx.

Methods

Eleven patients presenting with clinically symptomatic DAVFs, were treated between August 2005 and February 2007 at Beijing Tiantan Hospital. We were able to navigate small hydrophilic catheters and microguidwires through the facial vein or inferior petrosal sinus (IPS) into the ipsilateral cavernous sinus. After reaching the fistula site the cavernous sinus was packed with Onyx or combining with detachable platinum coils.

Results

We were able to reach the fistula site and to achieve a good packing of Onyx or combining with coils within the arteriovenous shunting zone in 10 patients. The final angiogram showed complete occlusion of the arteriovenous fistula. Two (18.2%) patients developed a bradycardia during DMSO injection. No complications related to the approach were observed.

Conclusions

Transvenous occlusion of cavernous DAVFs is a feasible approach, even via facial vein or via IPS. Onyx may be another option for cavernous packing other than detachable platinum coils.     

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.     

Treatment of dural carotid-cavernous fistulas via the superior ophthalmic vein

Symptomatic patients with dural carotid-cavernous fistulas often require treatment. Traditional therapies, which often are not completely successful, include manual common carotid artery compression and embolization via transarterial routes. This report describes four symptomatic patients with spontaneous dural carotid-cavernous fistulas who were treated unsuccessfully with transarterial embolotherapy and subsequently treated successfully by having a detachable balloon introduced into the cavernous sinus via the superior ophthalmic vein, which was surgically exposed. The fistulas resolved without complications. Treatment of dural carotid-cavernous fistulas by means of the transvenous approach via the superior ophthalmic vein may be of benefit in selected patients.     

Results of transvenous embolization of cavernous dural arteriovenous fistula: a single-center experience with emphasis on complications and management

BACKGROUND AND PURPOSE: To describe the results of transvenous embolizations of cavernous dural arteriovenous fistua (cDAVF) with an emphasis on identifying the incidence, characteristics, and management strategies associated with the complications of transvenous embolization of cDAVFs. METHODS: Fifty-six consecutive patients who were treated by transvenous embolization for cDAVFs were reviewed. The approach routes, angiographic results, complications, and clinical outcome were assessed. RESULTS: Retrograde inferior petrosal sinus (n = 36), transfacial vein (n = 7), transcontralateral intercavernous sinus (n = 4), and direct superior ophthalmic vein (n = 3) approaches were used. Angiographic results showed complete occlusion (n = 29), nearly complete occlusion (n = 13), and incomplete occlusion (n = 14). Complications associated with the procedures were cranial nerve palsy (n = 6), venous perforation (n = 3), and brain stem congestion (n = 2). The cranial nerve signs resolved with conservative treatment. Venous perforations were managed by coil embolizations at the site of the tear with no significant neurologic sequelae. One case of brain stem congestion resulted in hemiplegia after conservative treatment. The other case showed venous congestion as a result of rerouting of the shunted flow after venous embolization that was successfully managed by covered stent deployment for occlusion of the residual feeders. Clinical follow-up data were available in 46 patients. Complete resolution or improvement of symptoms was seen in 42 patients (91%). CONCLUSIONS: Cavernous DAVFs may be effectively treated by transvenous embolization. However, the procedure can be associated with various complications, some of which can potentially result in significant morbidity. Prompt diagnosis of the complications with appropriate management strategies is mandatory for a safe procedure.     

64层螺旋CT对颈内动脉海绵窦瘘的诊断价值

目的探讨64层螺旋CT在颈内动脉海绵窦瘘（ICCF）诊断中的价值。方法回顾性分析我院经血管内栓塞治疗成功的ICCF共16例,所有患者均经64层螺旋CT及DSA检查。结果 CT主要表现：所有患者患侧眼球突出、海绵窦扩大、眼上静脉扩张,部分患者眼下静脉、内眦静脉、面静脉、小脑半球上表面外侧脑膜静脉扩张,岩上、下窦扩张,眼外肌肿胀,眼球壁增厚。利用高级血管处理软件显示直接型瘘10例,间接型瘘6例。结论 64层螺旋CT克服了常规CT对颈动脉海绵窦瘘直接征象的显示并不满意的弱点,可清楚显示颈动脉海绵窦瘘瘘口的位置和大小,同时可以有效地评价Willis环的功能,可为颈动脉海绵窦瘘的诊断、治疗及疗效评价提供有价值的信息。     

Dural arteriovenous fistula of the cavernous sinus with cortical venous reflux of the posterior fossa via a bridging vein

We describe a patient who had a dural arteriovenous fistula of the cavernous sinus with cortical venous reflux into the lateral mesencephalic vein and cerebellar hemispheric veins via a bridging vein connected with the basilar plexus. The fistula and reflux disappeared after transvenous embolization using interlocking detachable coils.