Delayed abducens nerve palsy after transvenous coil embolization for cavernous sinus dural arteriovenous fistulae

Purpose

Abducens nerve palsy is the most common complication after transvenous embolization (TVE) for cavernous sinus dural arteriovenous fistula. Abducens nerve palsy is reported to have a good prognosis after the symptoms have been alleviated. The purpose of this study was to identify cases of delayed abducens nerve palsy after successful TVE and discuss the physiological mechanisms responsible for this unusual complication.

Methods

Between 1991 and 2012, TVE was performed for 73 patients. The patients were evaluated for clinical symptoms every 12 months during the follow-up period. Patients’ data and information about abducens nerve palsy were obtained from clinical records retrospectively.

Results

Abducens nerve palsy newly developed in 4 (5.5 %) of 73 patients at 3–65 months after TVE. All four patients with delayed abducens nerve palsy were followed up for 8–84 months. However, delayed abducens nerve palsy persisted in all four patients. In these four patients, the shunt points were posterior cavernous sinus. The average coil length used for four patients was 206.5?±?43.1?cm (n?=?4), and the average coil length used for patients without delayed abducens nerve palsy was 112.8?±?38.8?cm (n?=?69).

Conclusion

The possibility of delayed abducens nerve palsy should be kept in mind, especially in the patients who were treated with transvenous coil packing in the posterior part of the cavernous sinus. Furthermore, our results suggest that long-term follow-up care is important for these patients, even after complete neurological and radiological recovery was attained.     

Lhermitte-Duclos disease with cervical paraspinal arteriovenous fistula

A 38-year-old man presented with a dysplastic cerebellar gangliocytoma associated with a paraspinal arteriovenous fistula (AVF) at the upper cervical portion. Neuroimaging examination indicated the diagnosis of Lhermitte-Duclos disease. The patient was treated by embolization of the AVF followed by partial resection of the cerebellar tumor. Genetic examination showed a mutation of the phosphatase and tensin homolog deleted on chromosome ten (PTEN) gene. Histological examination confirmed the diagnosis. Lhermitte-Duclos disease is a rare dysplastic gangliocytoma manifesting as a slowly growing mass in the cerebellum and is usually asymptomatic. This case of Lhermitte-Duclos disease associated with paraspinal AVF and mutation of the PTEN gene suggests a relationship between Lhermitte-Duclos disease and Cowden disease.     

Direct-puncture embolization of scalp arteriovenous fistulae

We present our experience of flow control with the aid of a circular compression device (CCD) for embolization of scalp arteriovenous fistulae (sAVFs). A 21-year-old female presented with a pulsating scalp mass with sAVFs fed by the superficial temporal arteries. A CCD with a beveled circular handle and concentric hole was used to treat the condition. After the CCD was compressed over the area of the fistulae, the fistulae were punctured and blood regurgitation was assured. While maintaining flow stasis within the boundary of the CCD and loading heparinized dextrose-saline solution, a 50% mixture of N-butyl-2-cyanoacrylate and Lipiodol was applied during the compression, which was sustained for 1-2 minutes. Finally, the sAVFs were almost completely occluded without complications. Our designed CCD was effective for flow control, and direct-puncture embolization of N-butyl-2-cyanoacrylate during flow control using the CCD was safe and effective for the treatment of sAVFs.     

Primary paraspinal leiomyosarcoma invading the cervical spinal canal successfully treated with surgery, radiotherapy, and chemotherapy. Case report

A primary paraspinal leiomyosarcoma invading the spine is an exceedingly rare neoplasm that may clinically mimic a schwannoma. The authors report a case involving a 45-year-old man with a primary leiomyosarcoma of the cervical paraspinal musculature that invaded the spinal canal at C1-2 and subsequently metastasized to the lungs and pancreas. Aggressive treatment consisting of resection of the primary tumor, adjunctive radiation therapy and chemotherapy, and surgical debulking of metastatic disease resulted in local tumor control at the primary site and long-term survival of the patient.     

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

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

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

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

Balloon embolization of nontraumatic vertebral arteriovenous fistulae in children

Two children, aged 4 and 8 years, with nontraumatic extracranial vertebral arteriovenous fistula are described. Under general anesthesia and with fluoroscopic guidance, using a percutaneous endovascular technique, latex detachable balloons were used to successfully occlude the fistulae. The patients were monitored with somatosensory and auditory evoked potentials and kept hypotensive for 24 hours. Immediate and follow-up angiography 1 year later showed obliteration of the fistula in both patients. The management of this rare condition is discussed.     

Ocular symptoms associated with a dural arteriovenous fistula involving the hypoglossal canal: selective transvenous coil embolization. Case report

The hypoglossal canals are an unusual location for dural arteriovenous fistulas (AVFs) to appear. One previous report of dural AVFs involving the hypoglossal canal has been published. In the present paper, the authors describe a dural AVF within the hypoglossal canal, which presented with ocular symptoms and was successfully treated by selective transvenous embolization. Magnetic resonance imaging and contralateral carotid arteriography were useful for determination of the exact location of the fistulous pouch, which was later packed with coils. Selective transvenous coil embolization with careful assessment of the location and pattern of the venous drainage of the dural AVF is a safe and effective treatment.     

A case of dural arteriovenous fistula of the inferior petrosal sinus successfully treated by transarterial and transvenous embolizations

A 69-year-old male was admitted with chemosis and exophthalmos of his right eye. Angiograms revealed a dural arteriovenous fistula (AVF) involving the right inferior petrosal sinus. The AVF was fed by the right occipital and ascending pharyngeal arteries and drained into the cavernous sinus and right superior ophthalmic vein from the right inferior petrosal sinus. He was treated by transarterial embolization with polyvinyl alcohol in order to reduce the shunt-flow through the fistula. Then he was treated by transvenous embolization with GDC coils five days after the arterial embolization. Symptoms in his right eye have completely disappeared. Transvenous embolization combined with transarterial embolization is a useful and safe approach in the management of AVF involving the inferior petrosal sinus.     

Development of a dural arteriovenous fistula around the jugular valve after transvenous embolization of cavernous dural arteriovenous fistula

BACKGROUND: Endovascular therapy for dural arteriovenous fistulas (DAVFs) is not without any risks, although it has been generally accepted to be a safe procedure. In this paper, we report a very rare complication: metachronous DAVF around a jugular valve 4 months after transvenous embolization. CASE DESCRIPTION: A 43-year-old woman presented with left proptosis, chemosis, and double vision. Cerebral angiography demonstrated a left cavernous DAVF. The patient's symptoms resolved almost completely after embolization with platinum coils via the superior ophthalmic vein. Four months later, angiography revealed a metachronous DAVF around a jugular valve. CONCLUSION: To our knowledge, only four such cases have been reported in the literature. Careful follow-up of patients treated with transvenous embolization and accumulation of such cases are needed to understand the pathogenesis of multiple DAVFs.     

Endovascular treatment of hemifacial spasm associated with a cerebral arteriovenous malformation using transvenous embolization: case report

OBJECTIVE AND IMPORTANCE: To illustrate that decompression of the facial nerve by transvenous endovascular treatment may relieve hemifacial spasm (HFS) caused by dilated veins. CLINICAL PRESENTATION: A 35-year-old man suffered severe chronic right HFS associated with a dilated right lateral mesencephalic vein lying in the vicinity of the facial nerve. This nonessential vein was recruited as a secondary collateral drainage from an inoperable left temporo-occipital arteriovenous malformation. INTERVENTION: The lateral mesencephalic vein was reached through the superior petrosal sinus using a transfemoral venous approach and was occluded with interlocking detachable coils (Target Therapeutics, Freemont, CA). There was complete remission of HFS without recurrence after 2.5 years of follow-up. CONCLUSION: This case report supports vascular compression in the pathogenesis of HFS and suggests that facial nerve injury is not essential for the therapeutic effect of surgical decompression.     

Accurate intraoperative localization of spinal dural arteriovenous fistulae with embolization coil: technical note

Spinal dural arteriovenous fistulae represent a potentially curable cause of a progressive myelopathy and therefore should be treated aggressively by either endovascular or surgical methods. In the surgical treatment of these lesions, intraoperative radiographic localization of the site of the fistula can be problematic. We describe an endovascular technique in which radiopaque microcoils are placed in the major feeding artery(ies) after completion of spinal angiography, which then provides a marker that is easily visualized with intraoperative x-rays, allowing effective localization of the site of the fistula.     

Percutaneous transvenous embolization of a dural arteriovenous fistula through a mastoid emissary vein. Technical note

Definitive endovascular treatment of dural arteriovenous fistulas (DAVFs) requires obliteration of the site of the fistula: either the diseased dural sinus or the pial vein. Access to this site is often limited by occlusion of the sinus proximal and distal to the segment containing the fistula. The authors describe a technique in which the mastoid emissary vein is used to gain access to a Borden-Shucart Type II DAVF in the transverse-sigmoid sinus. Recognition of this route of access, if present, may facilitate endovascular treatment of these lesions. Access to the transverse sinus via this approach can be straightforward and may be underused.