经动脉途径低浓度氰基丙烯酸正丁酯栓塞治疗海绵窦硬脑膜动静脉瘘

目的 探讨经动脉途径低浓度(14%～25%)氰基丙烯酸正丁酯(NBCA)栓塞治疗海绵窦硬脑膜动静脉瘘(DCCFs)的可行性.方法 8例DCCFs患者均经动脉入路,使用微导管嵌顿技术注入低浓度NBCA行栓塞治疗.其中5例为经静脉入路栓塞失败者,3例为不可行静脉入路栓塞治疗者.结果 5例患者术后即刻血管造影DCCFs完全消失;随访6～12个月,临床症状完全消失,血管造影未发现DCCFs复发.3例患者术后即刻血管造影DCCFs残留,但血液分流量减少;随访3个月,血管造影血液分流明显减少、临床症状改善2例,血液分流和临床症状均消失1例.1例患者术后出现一过性眼部症状恶化、第Ⅵ脑神经麻痹,经治疗后3 d症状消失.结论 经动脉采用微导管嵌顿技术低浓度NBCA栓塞DCCFs是一种安全有效的方法,对于经静脉入路栓塞失败或不能经静脉入路治疗的患者,可能是一种较为理想的选择.     

Transvenous embolization of direct carotid cavernous fistulas

Of 165 cases of direct carotid cavernous fistula, 14 (8.5%) were treated from a transvenous approach. Twelve of these were treated through the inferior petrosal sinus and one through the superior ophthalmic vein. In one patient, both approaches were used. The embolic agents were as follows: five patients had balloons only, four patients had minicoils alone, three patients had coils and liquid adhesives, one had balloons and coils, and one had balloons and liquid adhesives. Among the patients who were treated from a transvenous approach, three had an occluded carotid artery caused by trauma, nine failed transarterial balloon attempts, and one had a prior trapping procedure. In the remaining patient, who had Ehlers-Danlos syndrome, a transarterial approach was judged to be too dangerous. This patient suffered a fatal pontine hemorrhage after subtotal transvenous occlusion of the carotid cavernous fistula with diversion of flow into cortical veins. Another complication occurred when the inferior petrosal sinus was perforated during catheterization, causing a small subarachnoid hemorrhage. The tear was immediately closed with minicoils, and surgical exposure and embolization resulted in complete cure. Of the remaining 12 patients treated, 11 were completely cured and one showed angiographic and clinical improvement. Transarterial balloon embolization remains the procedure of choice in the treatment of symptomatic carotid cavernous fistulas; however, transvenous embolization is an alternative when the arterial route fails.     

Transvenous embolization of dural fistulas involving the cavernous sinus

Because of the risks associated with arterial embolization of cavernous dural fistulas, we have sought an alternative method to promote fistula closure. Thirteen patients underwent transvenous embolization as a treatment for symptomatic cavernous dural fistulas. All procedures were performed from a femoral vein access through the inferior petrosal sinus or basilar plexus. In five patients the inferior petrosal sinus was not angiographically demonstrable; however, embolization was still possible through this route in two patients. The embolic agents used were detachable balloons in one patient, coils alone in five, coils and liquid adhesives in four, coils plus silk sutures in one, silk sutures alone in one, and liquid adhesives alone in one. Nine patients had follow-up angiograms, which showed complete obliteration of the fistulas and complete resolution of related symptoms. One patient had complete resolution of clinical symptoms but refused follow-up angiography. Another patient had 50% decrease in fistula flow on the follow-up angiogram and improvement in clinical symptoms. Two patients had complete fistula obliteration after embolization and progressive improvement in symptoms but follow-up angiograms had not been obtained. Follow-ups ranged from 1 to 97 months (mean, 15 months). Two complications were related to this treatment. An embolic stroke followed transient placement of a balloon in the internal carotid in one patient, and a second patient developed transient visual loss when the venous outflow pathways were occluded before fistula closure. The fistula was immediately closed with complete recovery of vision. With recent advances in microcatheter and embolic agent technology, transvenous closure of cavernous dural fistulas is now possible.(ABSTRACT TRUNCATED AT 250 WORDS)     

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.     

Management of dural carotid cavernous fistulas: a single-centre experience

Objectives

To report the epidemiological features, clinical presentation, angiographic characteristics and therapeutic options, success and complication rates in patients with dural carotid cavernous fistulas (dural CCFs).

Methods

Retrospective evaluation of patients followed in our institution between January of 2005 and September of 2013.

Results

There were 38 patients, 76 % females, with an average age of 63 years. Ocular symptoms and signs were the most frequent clinical findings. Dural CCFs were Barrow type B in 8 %, type C in 10 % and type D in 82 %. Cortical venous reflux was present in 50 % of cases. Medical treatment was performed in 16 % of patients, external ocular compression in 8 %, transarterial embolisation in 13 %, transvenous embolisation in 60 % and radiosurgery in 3 %. Clinical and angiographic follow-up data were available in 89 % and 82 % of patients with a mean follow-up time of 9 and 7 months, respectively. Clinical cure was achieved in 58 % of patients and improvement in 24 %. Anatomical cure was demonstrated in 68 %. Transient worsening or new onset of ocular symptoms was observed in 29 %. There was no permanent morbidity or mortality.

Conclusions

In properly selected patients, endovascular embolisation, particularly by transvenous approach, represents a safe and effective treatment for dural CCFs.

Key points

? Dural carotid cavernous fistulas are more common in elderly women ? Dural CCFs most commonly present with ocular symptoms and signs ? Endovascular treatment is effective and safe in properly selected patients     

Marginal sinus arteriovenous fistulas mimicking carotid cavernous fistulas: diagnostic and therapeutic considerations

Marginal sinus fistulas (MSFs) are uncommon vascular anomalies. Occasionally, the dominant venous drainage is forced retrograde up the inferior petrosal sinus and into the cavernous sinus, causing chemosis, proptosis, and ocular hypertension, mimicking a carotid cavernous fistula. This atypical clinical presentation may lead to misdiagnosis and inappropriate hazardous treatment of an MSF. Identifying the site of the fistula and understanding the anatomy of the venous drainage are critical in providing appropriate, safe, and efficacious endovascular treatment.     

Long-term clinical outcome of spontaneous carotid cavernous sinus fistulae supplied by dural branches of the internal carotid artery

We report the long-term clinical outcome of spontaneous carotid cavernous sinus fistulae (CCF) originally supplied by branches arising from the internal carotid artery (Barrow's type B), or type-D lesion that became type B after particulate embolization. A total of 55 patients was included in this study. Their angiography revealed that cortical drainage was absent, and that the arteries supplying the fistulae originated in the dural branches of the internal carotid artery. Thirty-two patients had type-D lesions, which became type-B lesions after obliteration of the external carotid supply by endovascular treatment. The other 23 patients had type-B lesions documented by angiography, and had no embolization. The follow-up period ranged from 8 to 144.5 months. Clinical cure was achieved in 39 patients (70.9%), improvement in eight patients (14.5%), the lesion remained stable in four patients (7.3%), and was aggravated in four patients (7.3%). The number of drainage veins is the only radiographic factor that could predict the outcome. Those patients with single draining veins had a better chance of complete remission. The outcome between the group with original type D lesions after embolization and the group with original type B revealed no statistically significant difference. The time-course to complete cure was significantly shorter in the group with embolization of the external carotid supply. In the four patients whose symptoms were aggravated, embolization was performed, and the result was excellent. The clinical outcome of type-B CCF, or type D converted to type B, is good. Previous external carotid artery embolization can significantly shorten the time to complete cure. Aggressive treatment should be reserved for those who have aggravated symptoms.     

A technical contribution to the exact angiographic localization of carotid cavernous fistulas

Summary A better visualization and localization of carotid cavernous fistulas may be achieved by selective angiography of the vertebral artery with simultaneous digital compression of the ipsilateral carotid artery, if the posterior communicating artery is patent.

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Ein technischer Beitrag zur genauen angiographischen Lokalisation von Carotis-Cavernosus-Fisteln

Zusammenfassung Bei frei durchgängiger A. communicans posterior läßt sich bei selektiver Injektion der A. vertebralis und gleichzeitiger Kompression der A. carotis der Karotisendabschnitt darstellen. Fisteln im Sinus cavernosus können auf diese Weise oft besser lokalisiert werden als mit der Karotisangiographie.

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Contribution a la technique de localisation des fistules carotido-caverneuses

Résumé La localisation exacte d'une fistule artério-veineuse entre la carotide interne et le sinus caverneux peut être demontrée par angiographie vértébrale sélective et compression simultanée de la carotide ipsilatérale.

     

Endovascular treatment of acute internal carotid artery dissections: technical considerations,clinical and angiographic outcome

Introduction

In acute internal carotid artery dissection (a-ICAD) with concomitant intracranial large vessel occlusion or haemodynamic impairment, the effectiveness of medical treatment is limited and endovascular therapy (EVT) can be considered. Feasibility, safety and outcome of EVT in a-ICAD are not well described yet.

Methods

From an institutional database, we retrospectively selected consecutive patients treated for a-ICAD between January 2007 and July 2015. We assessed recanalization results defining <50 % residual stenosis and mTICI ≥2b as successful. Procedural adverse events and symptomatic haemorrhages were reported as well as clinical outcome at 90 days defining a mRS ≤2 as favourable. Follow-up angiographies were reviewed and retreatments reported.

Results

In the defined period, 73 patients (mean age 48 years (31–73), mean NIHSS 11 (0–27)) received EVT for a-ICAD. The majority (60 %) had tandem occlusions. Cervical artery reconstruction was successful in 100 % and intracranial thrombectomy in 85 %. Thrombus formation (18 %) and thromboembolism (20 %) were the most frequent adverse events but clinically relevant only in 8 %. Symptomatic haemorrhage occurred in 5 %. Clinical outcome was favourable in 64 %, with a lower chance after tandem occlusion (55 vs. 79 %, p = 0.047). Death rate was 10 %. None of the patients developed recurrent ischaemic symptoms, but control angiography revealed abnormal findings of the reconstructed ICA in 38 % leading to retreatment in 17 %.

Conclusion

EVT of a-ICAD is feasible with a predominantly favourable clinical outcome. Improvement of devices and techniques is warranted to reduce the risk of thrombus formation and thromboembolism during treatment and insufficient vessel wall healing thereafter.

     

Balloon catheters for investigating carotid cavernous fistulas.

A simple and reliable technique is described for investigating the precise location of an arteriovenous fistulous communication and its hemodynamics by temporary and complete vessel occlusion with a double-lumen balloon catheter.     

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.     

Double-balloon technique for embolization of carotid cavernous fistulas

Embolization of a carotid cavernous fistula (CCF) by means of a detachable balloon is an established method for treating CCFs while preserving a patent parent internal carotid artery (ICA). However, failure to embolize the CCF may occur on a few occasions, such as when the balloon cannot pass through the fistula into the cavernous sinus by blood flow, or when the inflated balloon in the cavernous sinus retracts to the carotid artery. Under these circumstances, the ICA may have to be sacrificed in order to treat the CCF. Herein we describe a double-balloon technique for embolization of a CCF. By applying this technique, we successfully treated nine of 11 CCFs, without compromise of the parent ICA when the conventional one-balloon technique failed.     

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.     

双导管球囊技术治疗高流量颈动脉海绵窦瘘

目的探讨双球囊导管技术治疗高流量颈动脉海绵窦瘘(CCF)的可行性及疗效。方法随机选择1枚可脱性球囊无法闭塞的CCF患者3例,双侧股动脉置管,送2枚球囊进入瘘口,调整位置,充盈2枚球囊,使瘘口完全闭塞后再解脱球囊,观察栓塞效果和颈内动脉通畅情况,评价该技术的可行性。结果3例患者均1次性完全闭塞瘘口,颈内动脉皆通畅,操作过程简单易行,未增加介入治疗的危险性。结论双导管球囊技术能在保证颈内动脉通畅的前提下简单有效地治疗1枚球囊无法闭塞的CCF。     

Transvenous embolization of cavernous sinus dural arteriovenous fistulas using detachable coils and Glubran 2 acrylic glue via the inferior petrosal sinus approach

Objectives:  

To describe the technique, efficacy, and safety of transvenous embolisation (TVE) of cavernous sinus arteriovenous fistulas (CSDAVFs) via the inferior petrosal sinus (IPS) with detachable coils and acrylic glue.     

经眼上静脉介入治疗海绵窦区硬脑膜动静脉瘘

目的 探讨眶上内侧缘切开穿刺眼上静脉介入栓塞海绵窦区硬脑膜动静脉瘘(AVF)的方法和疗效.方法 眶上内侧缘切开穿刺眼上静脉使用微弹簧圈介入栓塞海绵窦区硬脑膜AVF 16例.结果 所有患者均临床治愈,1例虽将海绵窦致密填塞,但仍有少量翼丛引流,压颈1个月后消失.栓塞术后并发症主要表现为头痛和呕吐.2例术后出现轻度复视,后自行恢复,无一例出现永久性介入相关并发症.临床随访5个月到6年,患者均无临床症状复发.结论 眶上内侧缘切开穿刺眼上静脉入路介入栓塞是海绵窦区硬脑膜动静瘘治疗安全有效的方法 之一.     

应用可脱性弹簧圈及Glubran 2丙烯酸胶经岩下窦行静脉入路栓塞治疗海绵窦硬脑膜动静脉瘘

目的阐述应用可脱性弹簧圈及Glubran 2丙烯酸胶经岩下窦(IPS)行静脉入路栓塞(TVE)治疗海绵窦硬脑膜动静脉瘘(CSDAVF)的技术、治疗效果及安全性。方法 8例自     

Ruptured cavernous sinus aneurysms causing carotid cavernous fistula: incidence, clinical presentation, treatment, and outcome

BACKGROUND AND PURPOSE: In this study, we present our experience with 11 patients with ruptured cavernous sinus aneurysms causing carotid cavernous fistulas (CCFs), to assess the incidence of ruptured cavernous sinus aneurysms causing CCFs and evaluate clinical presentations, treatments, and outcomes. PATIENTS AND METHODS: During a 10-year period, 10 of 689 (1.5%) endovascular-treated ruptured aneurysms were ruptured cavernous sinus aneurysms causing CCF. One additional patient with a CCF died shortly before treatment of intracranial hemorrhage. All patients had audible pulsatile bruit. Exophthalmus, ocular motor palsy, and decreased vision correlated with venous drainage to the superior ophthalmic veins and intracerebral hemorrhage was associated with major cortical venous drainage in 2 patients. RESULTS: Two low-flow CCFs closed spontaneously before treatment with resolution of symptoms; the aneurysms were subsequently treated. Eight CCFs were successfully occluded, 5 by coil occlusion of the aneurysm, one by occlusion of the aneurysm with a balloon, and 2 by simultaneous coil occlusion of the aneurysm and internal carotid artery. There were no complications of treatment. Visual acuity returned to normal in all but one patient, and ophthalmoplegia was cured in 6 of 8 patients. In 2 patients, a remaining abducens palsy was surgically corrected. CONCLUSION: The incidence of CCF by a ruptured cavernous sinus aneurysm was 1.5%. CCF was the presenting symptom in 24.4% of treated symptomatic cavernous sinus aneurysms. Clinical symptoms correlate with venous drainage. Drainage to cortical veins may lead to intracranial hemorrhage. Endovascular treatment with coils is effective in occluding the fistula.     

Transvenous sonographically guided percutaneous access for treatment of an indirect carotid cavernous fistula

When standard transarterial or transvenous interventional techniques failed to provide access to treat an indirect carotid cavernous fistula, we used sonographically guided direct percutaneous access through the facial vein to successfully embolize a lesion.