Surgical management of dural arteriovenous fistulas of the transverse-sigmoid sinus in 42 patients

Transverse-sigmoid Sinus Dural Arteriovenous Fistula Presenting with False Localizing Signs of Cavernous Sinus Dural Arteriovenous Fistula Due to Obstructed Cerebral Venous Outflow into the Bilateral Superior Ophthalmic Veins: A Case Report

Cavernous sinus (CS) dural arteriovenous fistula (dAVF) presents ocular symptoms and visual disorders due to retrograde drainage from the CS into the superior ophthalmic vein (SOV). Some papers reported non-CS dAVFs with those symptoms. We present a unique case of transverse-sigmoid sinus (TSS) dAVF with localizing signs of CS dAVFs resulting from congested cerebral venous outflow into the CSs and SOVs in an 86-year-old female patient. Right pulsatile tinnitus and chemosis appeared a few years ago. After experiencing progressive bilateral blurred vision and decreased visual acuity with papillary edema for a few months, she was admitted to our hospital. Cerebral angiography demonstrated right sigmoid sinus dAVF with retrograde venous reflux into the superior sagittal sinus (SSS) and contralateral TSS without cortical venous reflux. Under the influence of congestion of the SSS, cerebral venous outflow drained into the CSs subsequently into the SOVs. Trans-arterial embolization using ethylene-vinyl alcohol copolymer was conducted via the right middle meningeal artery. After treatment, right chemosis immediately improved. The 2-month follow-up examination revealed resolution of bilateral visual acuity and improvement of papillary edema. Our case demonstrates that retrograde drainage into the SOVs with not only directly arterialized shunted flow but also congested cerebral venous outflow can cause CS dAVFs-like symptoms.

Complication rate, cure rate, and long-term outcomes of microsurgery for intracranial dural arteriovenous fistulae: a multicenter series and systematic review

Although microsurgery is an established treatment modality for intracranial dural arteriovenous fistula (dAVF), data regarding the perioperative complication rate, cure rate, and long-term outcomes remain scarce. The aims of this study were to describe our original experience with microsurgery, including the surgical complications and pitfalls, and conduct a systematic review of the relevant literature. A multicenter cohort of patients with dAVF treated by microsurgery was retrospectively assessed. In addition, the PubMed database was searched for published studies involving microsurgery for dAVF, and the complication rate, cure rate, and long-term outcomes were estimated. The total number of patients in our multicenter series and published articles was 553 (593 surgeries). The overall rates of transient complications, permanent complications, death, and incomplete treatment were 11.4, 4.0, 1.2, and 6.5%, respectively. A favorable outcome was achieved for 90.1% patients, even though almost half of the patients presented with intracranial hemorrhage. Of note, the incidence of recurrence was only one per 8241 patient-months of postoperative follow-up. Surgeries for anterior cranial fossa dAVF were associated with a lower complication rate, whereas those for tentorial dAVF were associated with higher complication and incomplete treatment rates. The complication and incomplete treatment rates were lower with simple disconnection of cortical venous drainage than with radical occlusion/resection of dural shunts. Our findings suggest that the cure rate, complication rates, and outcomes of microsurgery for dAVF are acceptable; thus, it could be a feasible second-line treatment option for dAVF. However, surgeons should be aware of the specific adverse events of microsurgery.

Current status of endovascular treatment for dural arteriovenous fistula of the transverse-sigmoid sinus: A literature review

Most intracranial dural arteriovenous fistulae (DAVFs) involve the transverse-sigmoid sinus (TSS), and various types of endovascular treatment (EVT) have been involved in managing TSS DAVFs. A current, comprehensive review of the EVT of TSS DAVFs is lacking. This study used the PubMed database to perform a literature review on TSS DAVFs to increase the current understanding of this condition. For high-grade TSS DAVFs such as Borden type 3, the goal of EVT is curative treatment. However, for low-grade TSS DAVFs such as Borden type 1 and some Borden type 2 TSS DAVFs, symptom relief or elimination of cortical reflux may be sufficient. Currently, EVT has become the first-line treatment for TSS DAVFs, including transarterial embolization (TAE), transvenous embolization (TVE) or both. TAE alone and TSS balloon-assisted TAE are also commonly used. However, TVE for TSS DAVFs is recognized as the most effective treatment, including coil direct packing TSS, Onyx® (ethylene vinyl alcohol copolymer) TVE, and balloon-assisted Onyx® TVE, which are commonly applied. In addition, TSS reconstructive treatment can be an effective procedure to treat TSS DAVFs. EVT is accompanied with complications, including technique- and treatment-related complications. Although complications may occur, TSS DAVFs have an acceptable prognosis after EVT.

Endovascular Treatment of Transverse-Sigmoid Sinus Dural Arteriovenous Fistulas: A Single-Center Experience with Long-Term Follow-Up

BACKGROUND

Endovascular treatment of transverse-sigmoid sinus dural arteriovenous fistulas (TSDAVFs) remains challenging because of their complex anatomic factors. The aim of our study was to evaluate the long-term efficacy and safety of endovascular treatment of TSDAVFs.

METHODS

From January 2008 to December 2014, 44 patients with TSDAVFs were treated endovascularly at our institution. The clinical and angiographic data were retrospectively collected, and the occlusion rate, complications, and clinical outcomes were analyzed.

RESULTS

Overall, 44 patients (26 males and 18 females) were identified, with a mean age of 47 years (range, 13-68 years). Of the 44 patients, 5 presented with Cognard type I fistula, 12 with type IIa, 6 with type IIb, 13 with type IIa+IIb, 2 with type III, and 6 with type IV. Complete (n = 29) or near-complete (n = 7) occlusion of the fistula was achieved in 36 patients (82%). Two patients experienced a transient neurological deficit (cranial nerve VII). In 31 patients with angiographic follow-up (range, 2-40 months) data available, the occlusion remained in 25, 2 previously minimal residual fistulas were completely occluded, 3 residual fistulas were unchanged, and 1 fistula recurred. Two patients with cortical venous reflux who had received incomplete treatment died of intracranial hemorrhage during the follow-up period. Of the 37 patients with clinical follow-up (mean, 33.6 months) data available, clinical cure was achieved in 29, residual symptoms remained unchanged in 7, and symptoms had deteriorated in 1.

CONCLUSIONS

Favorable and durable outcomes were achieved with endovascular treatment of TSDAVFs. TSDAVFs with cortical venous reflux carry a high risk of hemorrhage and require curative treatment.

Outcome after intracranial haemorrhage from dural arteriovenous fistulae; a systematic review and case-series

Dural arteriovenous fistulae (DAVFs) are a rare cause of intracranial haemorrhage. We aimed to investigate outcome of patients with intracranial haemorrhage from a DAVF. We performed a systematic literature search for studies reporting outcome after intracranial haemorrhage caused by a DAVF. We used predefined selection criteria and assessed the quality of the studies. In addition, we studied outcome in all patients with DAVF who had presented with intracranial haemorrhage at two university centers in the Netherlands, between January 2007 and April 2012. We calculated case fatality and proportions of patients with poor outcome (defined as modified Rankin Scale ≥ 3 or Glasgow Outcome Scale ≤ 3) during follow-up. We investigated mean age, sex, mid-year of study and percentage of patients with parenchymal haemorrhage as determinants of case fatality and poor outcome. The literature search yielded 16 studies, all but two retrospective and all hospital-based. Combined with our cohort of 29 patients the total number of patients with DAVF-related intracranial haemorrhage was 326 (58 % intracerebral haemorrhage). At a median follow-up of 12 months case fatality was 4.7 % (95 % CI 2.5–7.5; 17 cohorts) and the proportion of patients with poor outcome 8.3 % (95 % CI 3.1–15.7; nine cohorts). We found no effect of mean age, sex, mid-year of the cohorts and percentage of patients with parenchymal haemorrhage on either outcome. Hospital based case-series suggest a relatively low risk of death and poor outcome in patients with intracranial haemorrhage due to rupture of a DAVF. These risks may be underestimated because of bias.