Long term follow-up of 43 pure dural arteriovenous fistulae (AVF) of the lateral sinus

Summary Forty-three patients with arterio-venous fistulae of the dura of the transverse sinus with a complaint of tinnitus are reviewed, with a follow-up of 12 months to 11 years. 34 patients were embolized, 2 treated surgically, and 7 were untreated. Embolization appears to have been beneficial. The frequently benign nature of this abnormality must be emphasized, and serious psychological study of the patient must be made before deciding on therapy.     

Carotid duplex sonography in the follow-up of intracranial dural arteriovenous fistulae

BACKGROUND AND PURPOSE: Studies to determine the value of noninvasive neurovascular studies for the effectiveness of treatment and long-term follow-up of dural arteriovenous fistulas (AVFs) are of clinical importance. We determined whether the serial changes of carotid duplex sonography (CDS) were correlated with the evolution of dural AVF status after treatment or follow-up. METHODS: Four parameters of CDS were studied in two groups of patients with dural AVF: resistance index, end diastolic velocity, peak systolic velocity, and flow volume of the external carotid artery (ECA). The first group included 13 patients who received endovascular therapy, the efficacy of which was determined by the results of postembolization angiography. In the second group, 16 patients received only clinical and CDS follow-up. Evolution of clinical symptoms was recorded and classified as deteriorating, stationary, or improving. Patients underwent CDS before and after treatment (group 1) or at long-term follow-up (group 2). RESULTS: In the first group, the resistance index of the ECA increased in patients with occluded or nearly occluded dural AVF after embolization (n = 7, P = .01), but it did not change significantly in patients with partial treatment (n = 6, P = .11). Of patients with occluded or nearly occluded dural AVF after embolization, the ECA resistance index increased in patients with noncavernous sinus dural AVF (n = 5, P = .003) but not in patients with cavernous sinus dural AVF (n = 2, P = .48). In the second group, CDS parameters-particularly the resistance index-were well correlated with clinical status during follow-up. CONCLUSION: The resistance index of the ECA is correlated with the effectiveness of treatment and clinical evolution of dural AVF.     

Targeted compartmental embolization of cavernous sinus dural arteriovenous fistulae using transfemoral medial and lateral facial vein approaches

There are multiple transvenous approaches for treatment of cavernous dural arteriovenous fistulae (DAVF). The choice of a specific route depends on the compartment of the cavernous sinus involved in the fistula and its venous drainage. We used two different facial vein approaches to treat patients with cavernous DAVF draining directly into the anterior compartment of the cavernous sinus and thence to the superior ophthalmic vein. Other transvenous routes to the sinus were not apparent. Embolization was targeted to the involved compartment with preservation of those not embolized. No major post-procedure ophthalmic venous engorgement occurred. We believe that ideal treatment of cavernous DAVF is targeted transvenous coil deposition, which necessitates detailed knowledge of the anatomy of the facial veins and cavernous sinus compartments.     

Transarterial embolisation of complex cavernous sinus dural arteriovenous fistulae with low-concentration cyanoacrylate

We report the effectiveness of low-concentration n-butyl-2-cyanoacrylate (NBCA)-Lipiodol-tungsten mixture (10–15 %) in the management of patients with aggressive or recurrent complex cavernous dural arteriovenous fistulae (CSDAVF). We treated five patients with complex CSDAVF with a low concentration of an NBCA-Lipiodol-tungsten mixture after catheterisation of the feeding arteries arising from the external carotid artery. Three had a recurrent CSDAVF after transarterial particulate embolisation. Three refused transvenous treatment or could not be treated in this way; two patients had also feeding dural branches of the internal carotid artery. All patients had complete resolution of symptoms and signs within a month of the procedure. No definite neurological complication was found during follow-up ranging from 12 to 36 months. Transarterial embolisation with low-concentration cyanoacrylate appears to be an effective alternative management of aggressive or recurrent CSDAVF. Received: 8 November 1999/Accepted: 2 March 2000     

Combined treatment of a dural arteriovenous malformation of the lateral sinus using transarterial and direct lateral sinus embolisation

An 80-year-old man presented with a dural arteriovenous malformation (DAVM) involving the left lateral sinus. A carotid angiogram showed the lateral sinus to be occluded proximally and distally, with unusual retrograde venous outflow from the residual sinus to the cortical veins, including a dilated vein of Labbé. Single photon emission computed tomography showed reduced left frontal and temporal cerebral blood flow. We concluded that the risk of bleeding from the DAVM was high and that the patient needed to be treated immediately. However, his age made surgical removal of the DAVM hazardous and we therefore chose to treat him by transarterial and direct lateral sinus embolisation via a burr hole.     

Magnification angiography of dural carotid-cavernous sinus fistulae

Summary Eleven patients with dural carotid-cavernous sinus fistulae were studied with selective magnification angiography. The angiographic features of this condition were analyzed in detail. The arterial plexus normally present in and around the cavernous sinus has been thought to rupture into the sinus and establish an arteriovenous fistula with an extensive dural arterial supply. Changeable angiographic and clinical findings, including spontaneous regression, can be explained on the basis of thrombosis and occlusion in the arterial network. The indications for and methods of embolization are also discussed.     

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     

Embolisation of spinal dural arteriovenous fistulae with Onyx

Surgery is currently the standard treatment for spinal dural arteriovenous fistulae (DAVF). Endovascular embolisation of these lesions using N-butyl cyanoacrylate (NBCA) has a high success rate. Onyx is a new liquid embolic agent whose viscosity makes it suitable for treatment of spinal DAVF where penetration into the proximal radicular vein is required. It is delivered with greater control than NBCA without the necessity for rapid withdrawal of the catheter and may therefore overcome some of the drawbacks of NBCA. We report two patients who underwent Onyx embolisation of spinal DAVF; to our knowledge this is the first such report.     

血管内栓塞治疗硬脊膜动静脉瘘临床结果

目的：报道血管内栓塞治疗硬脊膜动静脉瘘(SDAVF)的临床和影像学结果。方法回顾性分析青岛大学附属医院介入医学科治疗的7例SDAVF患者流行病学、脊髓MRI及脊髓DSA、治疗方法及术后随访资料。结果7例患者脊髓MRI均有异常发现,DSA明确诊断后均行血管内栓塞治疗。术后随访6个月,7例患者症状得到不同程度改善,其中经NBCA胶栓塞治疗4例无复发,经Onyx胶栓塞治疗3例中1例复发。结论血管内栓塞是治疗SDAVF有效、安全的方法,但还需进一步探索。     

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

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

N-butyl 2-cyanoacrylate embolization of spinal dural arteriovenous fistulae

BACKGROUND AND PURPOSE: Because they are not well established, we investigated the technical success and recurrence rates of n-butyl 2-cyanoacrylate (NBCA) embolization of spinal dural arteriovenous fistulae (SDAVF), and assessed clinical outcomes. METHODS: We retrospectively studied all patients with SDAVF treated by NBCA embolization at our institution over an 8-year period. Gait and micturition disabilities were analyzed. Follow-up periods averaged 3.1 years (range, 1 month to 8.9 years). RESULTS: NBCA embolization was feasible in 74% (20/27) of patients. Of 20 patients who underwent embolization, initial embolization failure occurred in two (10%) and fistula occurrence in three (15%). All five patients in whom NBCA embolization failed underwent surgery. All patients who underwent embolization had either improved (55%) or unchanged (45%) gait disability at last follow-up. Seventeen (85%) patients had improved (40%) or unchanged (45%) micturition disability, but three (15%) had worsened. Mean Aminoff gait disability grade significantly decreased at last follow-up (2.4 [1.4] average [SD] vs 3.2 [1.4] [P = .0008]). Mean micturition disability grade decreased, but not significantly (1.4 [1.0] vs 1.7 [1.1] [P = .28]). CONCLUSION: NBCA embolization of SDAVF was technically feasible in 75% of patients. Initial apparent successful embolization was achieved in 90%; the fistula recurrence rate (failure to occlude the draining vein) for NBCA was 15%. Comparing favorably to surgical series, NBCA embolization of SDAVF appears efficacious, significantly improving mean gait disability by almost one grade at last follow-up. Close clinical and angiographic surveillance is mandatory. Longer and more uniform follow-up is needed to determine if clinical improvement and stabilization after NBCA embolization are sustained.     

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     

Reversibility of cognitive disorder after treatment of dural arteriovenous fistulae

Introduction

Dural arteriovenous fistulae (DAVF) occasionally lead to cognitive disorders whose reversibility after DAVF treatment remains unclear. We studied changes on pre- and post-treatment magnetic resonance imaging (MRI) and single photon emission computed tomography (SPECT) scans in ten patients with cognitive disorder due to DAVF.

Methods

We studied the symptoms, pre- and post-treatment MRI scans, SPECT findings, and mini-mental state examination (MMSE) and treatment results in ten patients with cognitive disorder due to DAVF. They were divided into two groups; the post-treatment MMSE score exceeded 25 points in group 1 (n?=?6) and was lower than 24 points in group 2 (n?=?4).

Results

In the six group 1 patients, pretreatment diffusion-weighted images (DWI) showed hyperintense areas, and SPECT scans demonstrated the preservation of vasoreactivity after acetazolamide challenge. In the four group 2 patients, pretreatment SPECT demonstrated hypoperfusion areas that coincided with the hyperintense areas seen on DWI; there were areas with marked disturbance in vasoreactivity. The post-treatment MMSE score in groups 1 and 2 improved by 13.7?±?2.4 and 3.8?±?1.0 points, respectively; the difference was significant at p?<?0.01.

Conclusion

In patients with cognitive disorder due to DAVF, the preservation of vasoreactivity on SPECT after acetazolamide challenge indicates that their cognitive disorder may be reversible by DAVF treatment.     

Radiotherapy of dural arteriovenous malformation in the cavernous sinus

Six patients with dural arteriovenous malformation (DAVM) in the cavernous sinus were treated by irradiation. The region of the abnormal vascular network was irradiated with a 10 MV linear accelerator; the total dose given ranged from 3,200 to 5,100 cGy (150-200 cGy per day, 750-1,000 cGy per week). All patients responded favorably to the treatment, with three of the six having no residual symptoms or signs of disease. Postradiotherapy angiography confirmed the complete disappearance of the shunts in two of the three patients. No significant side effects were observed during the follow-up period, which ranged from 10 months to four years. Radiotherapy is considered to be a useful treatment method for DAVM, especially for those patients having shunts from the meningeal branches of the internal carotid artery.     

Treatment of dural arteriovenous malformations involving the superior sagittal sinus

We report the diagnosis and treatment of seven dural arteriovenous malformations involving the superior sagittal sinus. The most common presenting symptom was headache, although two patients presented with hemorrhage. Embolization alone effected a complete cure in four patients, while a combination of embolization and surgery was used in the remaining three patients. The first of these had intraoperative exposure and embolization of multiple feeding branches of both middle meningeal arteries, which resulted in a complete cure without deficits. The second patient had multiple embolizations and surgeries with eventual resection of the involved sagittal sinus to effect a complete cure, which was complicated postoperatively by paraparesis. The third patient had preoperative embolization and subsequent surgical resection of the superior sagittal sinus, resulting in a complete cure without deficits. Because of their unique midline location, multiplicity of arterial feeders, and critical venous drainage, dural malformations involving the superior sagittal sinus often require unusual and aggressive forms of therapy.     

Bilateral dural arteriovenous fistula in the region of the cavernous sinus

Summary The case of a patient with a fistula between the left internal carotid artery and the cavernous sinus, and another fistula between the right external carotid artery and the cavernous sinus, is reported. The clinical symptomatology, which was of spontaneous onset, was unilateral and consisted of exophthalmos and injection of the conjunctiva on the left side. Almost complete remission occurred after angiography.     

Long-term outcome of a multidisciplinary concept of spinal dural arteriovenous fistulae treatment

Introduction The optimal treatment of spinal dural arteriovenous fistulae (SDAVF) remains controversial and long-term follow-up data, especially data from multidisciplinary treatment, are rarely available. Thus, long-term outcomes following a multidisciplinary approach to the treatment of SDAVF were investigated. Methods The investigation included 26 patients with SDAVF treated at the authors’ department over a 15-year period including a follow-up of more than 2 years. The treatment strategy when occlusion of the draining vein could be achieved was to embolize the fistula with Histoacryl, with surgery reserved for those patients unsuitable for embolization. Posttreatment angiography followed by MRI was performed in all patients. Clinical follow-up was performed using the gait and micturition Aminoff-Logue scale scores and the modified Rankin scale score. Results Embolization was performed in 19 patients (73.1%), and direct surgery in 7 patients (26.9%). Follow-up angiography (at a mean of 21.7 months) showed occlusion of the SDAVF in 24 patients (92.3%). Of the 19 embolized patients, 2 (10.5%) developed recurrence secondary to insufficient occlusion of the SDAVF draining vein, and one of these two patients underwent re-embolization and one re-operation. No negative effects of SDAVF recurrence on the final clinical outcome were identified in either patient. MRI after angiography (at a mean of 91.5 months) demonstrated occlusion of all SDAVFs. After a mean clinical follow-up of 103.4 months there was a statistically significant improvement in both the modified Rankin scale score and the Aminoff-Logue gait scale score (P < 0.05). Conclusion The present multidisciplinary study showed for the first time that embolization leads to stable neuroradiological results and favourable clinical outcomes even for very long follow-up times of more than 100 months. Microsurgery remains the treatment of choice when safe embolization of the draining vein cannot be achieved.     

Transorbital puncture for the treatment of cavernous sinus dural arteriovenous fistulas

This report describes a series of patients for whom dural arteriovenous fistulae (DAVFs) of the cavernous sinus were successfully embolized using a percutaneous, transorbital technique to directly cannulate the cavernous sinus. A vascular access needle and catheter are percutaneously advanced along the inferolateral aspect of the orbit to access the cavernous sinus via the superior orbital fissure. Safe and effective embolization is achieved without the need for a surgical cut-down.