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

Natural course of partially embolized carotid-cavernous fistulas

BACKGROUND AND PURPOSE

To present the first study analyzing the clinical and radiological course of carotid-cavernous fistulas (CCFs) following incomplete embolization. The study compares magnetic resonance angiography (MRA) to plain angiography (digital subtraction angiography [DSA]) and investigates the long-term ophthalmological impact of residual fistula.

METHODS

Fistulas classified as partially embolized after the last endovascular treatment were prospectively followed with DSA, MRA, and ophthalmological examination. Both direct and indirect CCFs were included.

RESULTS

Twenty-one CCFs were included in the study. Nine (43%) fistulas were direct and 12 (57%) were indirect. A favorable clinical outcome of modified Rankin scale ≤2 was recorded in 19 (90%) patients at the last follow-up. Postinterventional ophthalmologic examinations in 16 patients revealed no negative effects of residual fistulas; five remaining patients refused to undergo further examination. Spontaneous thrombosis and complete occlusion of the CCF were demonstrated in 90% of patients, with a mean time to occlusion of 5.7 ± 4.7 months. Fourteen (66%) patients completed the full imaging follow-up (MRA and DSA). In 21% of these cases, discrepancy between the two imaging modalities was observed-MRA failed to detect persistent fistulas identified by DSA.

CONCLUSIONS

The goal of CCF treatment is safe and complete embolization. However, if adequate flow reduction is achieved, both direct and indirect CCFs tend to spontaneously thrombose. Residual flow does not result in ophthalmological deterioration until the fistula is completely closed. MRA may not be sufficiently sensitive to detect residues of fistulas including cortical venous drainage. Therefore, complete CCF closure should be confirmed through DSA.

What is the most effective method to treat indirect carotid-cavernous fistula?

To review the most relevant treatment options for indirect carotid-cavernous fistulas (iCCF), cohorts of 20 patients or more published after 2000 were analyzed. Clinical and radiological outcomes, as well as embolization techniques and material, had to be clarified in the study to be considered. Statistical analysis was based on calculating the relative percentage of therapeutic methods or embolic material, followed by calculating parametric and nonparametric correlations. Some 22 studies and 1550 patients were included. Transvenous embolization (TVE) was used in 53% of the patients and was strongly associated with coiling (rw = 0.66, p = 0.0.0012; rs = 0.53, p = 0.0138), transarterial embolization (TAE) was preferred in 11% of the patients and was strongly linked to liquid embolics (rw = 0.44, p = 0.0434;rs = 0.64, p = 0.0018). A combination of TAE and TVE treatment was used in 7% and a combination of embolic materials in 13% of the patients. None of the endovascular techniques or embolization materials showed significant superiority over the others in clinical outcome and obliteration rate. Radiosurgery in 22% and mechanical compression in 5% of patients showed a lower obliteration rate (rw =  - 0.48, p = 0.0254; rs =  - 0.45, p = 0.0371). The clinical outcomes were comparable to endovascular treatment (EVT). The remaining 2% of the patients were treated by open surgery or a combination of EVT and radiosurgery. Transvenous coiling is the preferred EVT method for iCCF. However, comparable results may be accomplished with TAE using liquid. Radiosurgery may achieve a lower percentage of fistula occlusion, but the clinical results are equal to EVT.

Cavernous sinus dural arteriovenous fistula complicated by hippocampus venous congestion: A case report

BACKGROUND

Hippocampal venous congestion is a rare complication associated with cavernous sinus dural arteriovenous fistulas (CS-DAVFs).

CASE DESCRIPTION

A 74-year-old woman was admitted to the hospital with a swollen left eye. Isolated lesions were found in the left hippocampus and the middle cerebellar peduncle. Cerebral angiography revealed retrograde venous drainage of the bilateral inferior petrosal sinuses from the left CS-DAVF. The patient underwent transcatheter arterial embolization, resulting in complete resolution of the hippocampal lesions and neurological symptoms.

CONCLUSION

Hippocampal injury is a rare complication of CS-DAVF. Attentive diagnosis and treatment can effectively prevent adverse consequences.

Clinical improvement in indirect carotid cavernous fistulas treated endovascularly: A patient based review

Patients with indirect carotid cavernous fistulas (CCF) were reviewed to emphasize the importance of diagnosing patients even with trivial findings and to raise awareness. Eighteen patients diagnosed as CCF were included. Neuro-ophthalmological findings before and after treatment, diagnostic investigations, treatment, clinical course was noted. Twelve patients were female (67%), 6 were males (33%) and the mean age at presentation was 54 years (range: 29-70 years). Conjunctival hyperemia was present in all patients. Seventeen (94%) patients had proptosis and diplopia, nine (50%) had orbital pain and/or headache, four (22%) had blurred vision, one (5.5%) had ptosis. On examination, 17 patients (94%) had restricted eye movements, four (22%) had low visual acuity and five patients had (28%) increased intraocular pressure (IOP). One patient had been diagnosed as myasthenia gravis and two as thyroid orbitopathy and had been on treatment accordingly before CCF was diagnosed. In two patients, bilateral findings were present despite unilateral CCF on angiography. Barrow Type B fistula was found in 7 (38%), Barrow Type D in 11 (62%) patients. In three bilateral CCF was detected. All were treated by endovascular intervention. Residual deficits at the sixth month control were, eye movement deficits in seven (39%), decrease in visual acuity in one (5.5%) and elevated IOP in one (5.5%) patient. Indirect CCF patients generally present with mild symptoms and the diagnosis may be overlooked. Mild progressive ophthalmoparesis with conjunctival hyperemia must be warning. Though rare bilateral CCF can be detected as well as unilateral CCF with bilateral findings.

Transvenous Approaches to Embolization of Dural Arteriovenous Fistulae of the Cavernous Sinus

Dural arteriovenous fistulae of the cavernous sinus (CS) (previously often referred to indirect carotid cavernous fistulas) are rare vascular shunts involving meningeal branches and osseous branches of the external or internal carotid arteries and the CS. They typically present with ocular symptoms including pain, conjunctival injection, and proptosis. Left untreated there may be a risk of vision loss, and fistulas with cortical venous reflux through either the deep or superficial venous system may cause intracranial venous congestion or hemorrhage. Endovascular embolization is the standard treatment, and while transarterial routes may appear possible, transarterial embolization has considerable risks of ischemic complications. Conversely, transvenous routes achieve a high rate of fistula occlusion with a low risk of peri-procedural morbidity. Procedural success depends on identification of the venous outflows from the fistula and localization of the fistulous point, to select the best route of access to the CS, including the inferior petrosal sinus (IPS), intercavernous sinus, or superior ophthalmic vein, among others. Even if the IPS is not visualized, it may be possible to recanalize it to gain access to the CS. Embolization can be performed with a combination of coils, fibered coils, and liquid embolic agents, focusing on occlusion of the fistulous point or blocking high-risk venous outflow pathways. In this review we will highlight procedural pearls and potential pitfalls and our typical approach to these lesions based on illustrative examples.

Bilateral Carotid-cavernous Fistulas Treated with Partial Embolization and Radiosurgery

Bilateral carotid-cavernous fistulas (CCFs) are rare. In this paper, we report the case of an 88-year-old woman who presented with a two-month history of worsening visual symptoms and was subsequently found to have bilateral Barrow grade D CCFs. Cannulation and complete embolization of the offending vessels during angiography proved unsuccessful, and so the patient underwent adjuvant radiosurgery as salvage therapy with a good clinical outcome. This case adds to the limited but growing literature on the multi-modal management of CCFs.

Superior ophthalmic vein and ophthalmic artery in immediate evaluation after endovascular treatment of carotid-cavernous fistulas

Purpose

To validate superior ophthalmic vein (SOV) and ophthalmic artery (OA) usefulness in immediate evaluation of new endovascular approaches to treat carotid-cavernous fistulas (CCFs).

Material and methods

A retrospective review of 597 intracerebral malformation embolisations yielded 40 embolisations of CCF in the treatment of 18 patients. Two interventional radiologists performed detailed radiological angiographic assessments.

Results

Mean age at initial admission was 58.9 years (SD 18.5 years, range 24-85 years). Patients presented with: chemosis (50%), ocular bruit (50%), exophthalmos (61%), diminished visual acuity (77.8%), headache (16.7%), and intracerebral haemorrhage (5.55%), and 5.55% were asymptomatic. Unilateral fistulas (10-55.5%) showed more diversified venous drainage pattern than bilateral ones (8-44.4%). There were statistically significant differences in post-traumatic and spontaneous CCF regarding age (p = 0.036), type of fistula (p = 0.0008), and presence of pseudoaneurysm (p = 0.036). 77.8% of patients had increased ipsilateral SOV diameter. SOV enlargement was not associated with type of fistula, history of trauma, or degree of exophthalmos. Ipsilateral ophthalmic artery was visible in all patients on both pre- and postprocedural angiography on lateral projection. Pre- and post-procedural SOV diameter was significantly different. Internal carotid artery patency was 100%, while the overall final angiographic or clinical success was 85.7%. We had three cases of peri-procedural complications.

Conclusions

We reported changeable dynamics of SOV and OA after endovascular treatment of CCFs and proved the feasibility of coils and Onyx-18 in the treatment thereof.

Dural Arteriovenous Fistula Between the Inferolateral Trunk and Cavernous Sinus Draining to Ophthalmic Vein

BACKGROUND

Formation of a dural arteriovenous fistula (DAVF) between the inferolateral trunk (ILT) and cavernous sinus (CS) is rare.

CASE DESCRIPTION

This study presents a case of ILT-CS DAVF. A 64-year-old male patient had exophthalmos of the left eye with redness and swelling. Digital subtraction angiography revealed a connection between the ILT and the CS that formed a high-flow DAVF, which was drained only to the ophthalmic vein and no other parts of the CS. The ILT was chosen as the transarterial path for treatment because it was enlarged. The microcatheter was navigated into the ILT, and 2 coils were then used to occlude the ILT. After occlusion of the ILT, no image of the DAVF indicated that the ILT-CS DAVF was completely cured. The patient's symptoms improved gradually after surgery. At the 6-month follow-up visit, digital subtraction angiography showed no sign of ILT-CS DAVF and the patient's eye symptoms had disappeared.

CONCLUSIONS

Although ILT-CS DAVF is rare, it can still be seen in clinical practice. Coiling the ILT via a transarterial approach is a good option for treatment.

Anatomical localization of the cavernous sinus dural fistula by 3D rotational angiography with emphasis on clinical and therapeutic implications

BACKGROUND AND PURPOSE

Carotid cavernous sinus dural arteriovenous fistulas (CSDAVFs) are presumed to be located within the walls of the cavernous sinus, however the exact fistulous site has not yet been studied by angiographic or anatomical methods. The present study aimed to localize CSDAVFs with the help of 3D rotational angiography (RA) and correlated the observations with clinical and angiographic findings.

MATERIALS AND METHODS

The CSDAVFs were categorized as dural, extradural or osseous based on the site of convergence of feeders into the venous sac. Extradural CSDAVFs were further subcategorized into posteromedial, posterolateral and anterior subtypes, depending on proximity to a possible venous plexus. This classification was correlated with various clinical presentations and angiographic subtypes.

RESULTS

Thirty-seven patients were included in the final analysis. The sac was identified in all the patients and the mean sac size of the fistula was small (<4mm). Dural type was associated with exclusive cortical venous drainage. Extradural anterior CSDAVF showed tendency towards younger age predilection. Extradural posterolateral CSDAVF was more often associated with initial oculomotor nerve palsy and this observation was statistically significant. Discordancy between the location of the fistula and the side of clinical affection was observed in midline fistulas such as osseous CSDAVF and posteromedial type of extradural CSDAVF.

CONCLUSIONS

CSDAVF is a heterogeneous vascular disorder involving the sphenoclival bone, extradural space and dura, homologous to the epidural-dural shunts of vertebra with a common clinical presentation of orbital manifestations. Preoperative localization of the fistula could explain enigmatic observations and potentially simplify its interventional management.

Stereotactic Radiosurgery for Dural Carotid Cavernous Sinus Fistulas

OBJECTIVE

We reviewed our 7-year experience to assess the efficacy of stereotactic radiosurgery (SRS) for dural carotid cavernous fistulas (DCCFs). We analyzed the clinical outcome, complications, and angiographic results.

METHODS

We performed a retrospective analysis of 18 consecutive patients with DCCFs treated by SRS alone using Gamma Knife between 2009 and 2015. Median target volume was 2.6 cm³ (range, 0.6-11.6 cm³), and median radiation dose to the target was 17 Gy (range, 14-19 Gy). Median follow-up period was 30 months (range, 6-65 months).

RESULTS

Fifteen patients (83%) achieved total obliteration of the DCCF, and a subtotal obliteration of the DCCF was achieved in 3 patients (17%). Total obliteration rates after SRS were 53% at 1 year and 90% at 2 years. Twelve patients (67%) showed complete recovery from symptoms or signs, and 6 patients (33%) showed incomplete recovery. Improvement rates of neurologic function after SRS were 56% at 1 month, 72% at 3 months, and 94% at 6 months. None of the patients experienced radiation-related complications. A univariate analysis revealed that absence of hypertension (P = 0.025), seizure (P = 0.025), and cortical venous drainage (P = 0.013) were significantly associated with symptoms improvement.

CONCLUSIONS

SRS for DCCFs offered a high obliteration rate with low risk of radiation-induced complications. In patients with benign DCCFs that are not amenable to embolization or microsurgery, SRS is a safe and effective treatment for complete obliteration of the arteriovenous shunt and for improving quality of life.

Treatment of Barrow type 'B' carotid cavernous fistulas with flow diverter stent (Pipeline)

Background Carotid cavernous fistulas (CCFs) Barrow type 'B' are dural shunts between the meningeal branches of the internal carotid artery and the cavernous sinus. The symptoms include vision deterioration, ophthalmoplegia with diplopia, exophthalmos, conjunctival injection, chemosis, ocular bruit, seizures, or neurological deficit. Endovascular treatment remains the gold standard for treatment through the transvenous or transarterial routes. The transvenous approaches have been proved to be the first option. Endovascular access through the superior ophthalmic vein (SOV) or inferior petrosal sinus have been widely used. The problem arises when there is no vascular access. For these cases, different approaches have been described, such as: direct access to the SOV; combining direct access to the SOV along with blind probing of the proximal occluded SOV; and a direct puncture of the cavernous sinus. But these techniques are very aggressive and can cause serious complications. As a result of the above, we describe a new alternative technique, which is effective and less invasive for the treatment of these special cases. Case reports We report two cases of Barrow type 'B' CCFs that did not have vascular access (neither arterial nor venous) to embolise fistulas with coils or glue, and which were successfully resolved with a flow diverter (Pipeline) stent in the internal carotid artery. To our knowledge, this treatment has not previously been described for this pathology. Conclusions The placement of a flow diverter stent in the internal carotid artery is an effective alternative technique in those cases of Barrow type 'B' CCFs that have no vascular access (neither venous nor arterial).

Evolution of treatment and a detailed analysis of occlusion, recurrence, and clinical outcomes in an endovascular library of 260 dural arteriovenous fistulas

OBJECTIVE Many small series and technical reports chronicle the evolution of endovascular techniques for cranial dural arteriovenous fistulas (dAVFs) over the past 3 decades, but reports of large patient series are lacking. The authors provide a thorough analysis of clinical and angiographic outcomes across a large patient cohort. METHODS The authors reviewed their endovascular database from January 1996 to September 2015 to identify patients harboring cranial dAVFs who were treated initially with endovascular approaches. They extracted demographic, presentation, angiographic, detailed treatment, and long-term follow-up data, and they evaluated natural history, initial angiographic occlusion, complications, recurrence, and symptomatic resolution rates. RESULTS Across a cohort of 251 patients with 260 distinct dAVFs, the overall initial angiographic occlusion rate was 70%; recurrence or occult residual lesions were seen on subsequent angiography in 3% of cases. The overall complication rate was 8%, with permanent neurological complications occurring in 3% of cases. Among 102 patients with dAVFs without cortical venous reflux, rates of resolution/improvement of pulsatile tinnitus and ocular symptoms were 79% and 78%, respectively. Following the introduction of Onyx during the latter half of the study period, the number of treated dAVFs doubled; the initial angiographic occlusion rate increased significantly from 60% before the use of Onyx to 76% after (p = 0.01). In addition, during the latter period compared with the pre-Onyx period, the rate of dAVFs obliterated via a transarterial-only approach was significantly greater (43% vs 23%, p = 0.002), as was the number of dAVFs obliterated via a single arterial pedicle (29% vs 11%, p = 0.002). CONCLUSIONS Overall, in the Onyx era, the rate of initial angiographic occlusion was approximately 80%, as was the rate of meaningful clinical improvement in tinnitus and/or ocular symptoms after initial endovascular treatment of cranial dAVFs.

Diagnosis and management of intracranial dural arteriovenous fistulas

Dural arteriovenous fistula (DAVF) is a rare type of acquired intracranial vascular malformation. Recent progress in neuroimaging technology, such as advanced MRI and CT, provides non-invasive methods to accurately diagnose DAVF, including evaluation of the hemodynamics of the drainage veins. The clinical manifestations of DAVFs vary widely and depend on the location and venous drainage pattern of arteriovenous shunting. Patients with high grade DAVFs having cortical venous reflux should receive aggressive treatment to prevent the occurrence of intracranial hemorrhage and other neurological deficits related to venous congestion. Intra-arterial or intravenous endovascular embolization remains the primary therapy for high grade DAVF, while open surgery and stereotactic radiosurgery can serve as alternative treatment options. Early and accurate diagnosis with appropriate treatment is the goal for clinical management of DAVFs to reduce symptoms and prevent the development of venous congestion and stroke.

"Orbiting around" the orbital myositis: clinical features, differential diagnosis and therapy

Orbital myositis (OM) is a rare disease whose clinical heterogeneity and different treatment options represent a diagnostic and therapeutic challenge. We aim to review the state of knowledge on OM, also describing a cohort of patients diagnosed in our centre, to highlight some remarkable clinical features. A literature review was conducted in PubMed and Medline databases. The herein described cohort is composed of seven OM patients, diagnosed according to clinical, laboratory and neuroradiological features, whose clinical data were retrospectively analysed. OM is a non-infectious, inflammatory process primarily involving extraocular eye-muscles. It typically presents as an acute to sub-acute, painful ophthalmoplegia with signs of ocular inflammation, but atypical cases without pain or with a chronic progression have been described. The wide range of OM mimicking diseases make a prompt diagnosis challenging but orbit MRI provides valuable clues for differential diagnosis. Timely treatment is greatly important as OM promptly responds to steroids; nevertheless, partial recovery or relapses often occur. In refractory, recurrent or steroid-intolerant cases other therapeutic options (radiotherapy, immunosuppressants, immunoglobulins) can be adopted, but the most effective therapeutic management is yet to be established. In this review, we provide a detailed clinical description of OM, considering the main differential diagnoses and suggesting the most useful investigations. In light of the currently available data on therapy efficacy, we propose a therapeutic algorithm that may guide neurologists in OM patients' management.