Dural Arteriovenous Fistula of the Sinus of the Lesser Sphenoid Wing Presenting with Pontine Hemorrhage

Endovascular treatment for sphenoidal region dural arteriovenous fistula

Sphenoidal region dural arteriovenous fistulas (DAVFs) are rare. Endovascular treatment (EVT) is an effective treatment approach. However, understanding and performing EVT for sphenoidal region DAVFs are difficult and challenging. Therefore, we performed a review to explore this issue further. In this review, we discuss the dural feeders and venous structures of the sphenoidal region, the angioarchitecture of sphenoidal region DAVFs, the role and principle of EVT, various EVT techniques, and the prognosis and complications associated with EVT. We found that various EVT techniques, including transarterial embolization (TAE), retrograde transvenous embolization (TVE), and direct puncture EVT, can be used to treat sphenoidal region DAVFs. TAE represents the most commonly utilized approach. TVE and direct puncture EVT should be limited to highly selective cases. EVT must penetrate the fistula and very proximal venous recipient pouch with a liquid embolic agent or coil the fistula point to have a complete curative effect. Successful EVT can lead to the obliteration of sphenoidal region DAVFs and a good clinical outcome. However, these complications cannot be neglected.

Sphenoid wing dural arteriovenous fistula: A case report and literature review

Background:

Sphenoid wing dural arteriovenous fistula (SWDAVF) is rare that is typically fed by middle meningeal artery feeders and that drain through the sphenoparietal sinus or middle cerebral vein. Here, we report a case of SWDAVF treated by coils placed in the venous aneurysm through the contralateral cavernous sinus (CS).

Case Description:

A 37-year-old woman was admitted to our hospital with headache and bilateral oculomotor nerve palsy. Magnetic resonance images and an angiogram showed a venous aneurysm in the right middle cranial fossa. A DAVF, consisting of two main feeders, was diagnosed based on the angiogram findings. The fistula drained into the left inferior petrosal sinus (IPS) through the left CS and right IPS. Given the remarkable extent of venous ectasia together with the headache and right abducens nerve paralysis, endovascular treatment was initiated. A transvenous approach through the right IPS was not feasible, as it is strenuous to insert the microcatheter into the right IPS. Thus, we tried an approach through the left IPS. The venous aneurysm was embolized with coils. The postoperative course was uneventful, and postoperative cerebral angiography confirmed disappearance of the fistula.

Conclusion:

A SWDAVF is extremely rare. In our case, since the AVF drained into the contralateral CS, contralateral ocular symptoms occurred. Endovascular occlusion of the venous aneurysm and fistula was achieved through a transvenous approach.

Dural Arteriovenous Fistulas in the Parasellar Region Other Than the Cavernous Sinus

Besides cavernous sinus (CS) dural arteriovenous fistulas (AVFs), AVF may develop around the parasellar region. They can cause various symptoms, and some of them may show similar symptoms to those of CS dural AVF. Therefore, these AVFs may be misdiagnosed as CS dural AVFs. In this review, we divided parasellar AVFs into four groups based on their locations related to the CS: anterior group (orbit), anterolateral group (sphenoid wing), posteroinferior group (inferior petrosal sinus and clivus), and posterior group (superior petrosal sinus and petrosal vein). Although parasellar AVFs share common points, there are many differences between the four groups. We herein discuss commonalities and differences in parasellar AVFs based on a review of the literature and our experience.

Medullary Hemorrhage Caused by Foramen Magnum Dural Arteriovenous Fistula Successfully Obliterated using Combination of Endovascular and Surgical Treatments: A Case Report and Literature Review

The authors describe an extremely rare case of foramen magnum dural arteriovenous fistula (DAVF), Cognard type V, presented with medullary hemorrhage caused by venous varix on the lateral medullary draining vein embedded into the medulla oblongata. Following mild myelopathy for 3 days, a 20-year-old male developed dyspnea, generalized seizures, loss of consciousness, and finally cardiac arrest. After successful resuscitation, computed tomography scan (CT) of the brain was obtained and showed acute medullary hemorrhage. Subsequent magnetic resonance imaging of the brain revealed diffuse venous congestion or edema of the medulla with multiple dilated flow voids surrounding the medulla, more prominent on the left side, with venous varix embedded into the left-sided of the lower medulla. He was sent to the emergency department of the local hospital and intubated promptly. A few minutes later, the patient had a cardiac arrest. Digital subtraction angiography (DSA) demonstrated DAVF of the foramen magnum supplied mainly by dural branches of bilateral hypertrophic posterior inferior cerebellar arteries (PICAs), slightly by the posterior meningeal branch of the left vertebral artery, and the jugular branch of the left ascending pharyngeal artery (APA) originating from the occipital artery. Transarterial embolization through the bilateral dural branches of the PICAs was successfully performed using N-butyl-2-cyanoacrylate (NBCA), resulting in complete obliteration. The patient had excellence recovery and lost to annual follow-up. Seven years later, he had a recurrent of the fistula presented with occipital headache. DSA with angiographic CT in three-dimensional reconstruction and maximum intensity projection reformatted images clearly demonstrated the exact location of the DAVFs at the posterior rim of the foramen magnum, mainly recruited by the hypertrophic jugular branch of the APA originating from the occipital artery. The fistula was successfully treated surgically following transarterial embolization through the jugular branch of the APA using NBCA. Follow-up DSA confirmed complete obliteration of the DAVF. The patient has remained clinically asymptomatic 2 years after the operation.

Sphenoid dural arteriovenous fistulas

Sphenoid wing dural AVFs represent a rare clinical entity. These lesions may be asymptomatic or present with focal neurologic deficits, intracranial venous hypertension, or intracranial hemorrhage. Diagnosis is based on clinical findings and diagnostic imaging. They are alternatively classified as lesions of either the greater or lesser wings of the sphenoid bone. We performed a search of the PubMed database of studies evaluating the clinical behavior and surgical and endovascular therapies of these lesions. Dural AVFs draining into the superficial middle cerebral vein and/or laterocavernous sinus, or rather, lesions of the greater wing of the sphenoid, exhibit a greater likelihood of developing an aggressive clinical course, with higher probability of cortical venous reflux and consequent intracranial venous hypertension, intracranial hemorrhage, and symptomatic presentation. Dural AVFs of the sphenoparietal sinus, that is, lesions of the lesser wing of the sphenoid, typically exhibit a more benign clinical course, as there is a prominent epidural venous drainage into the cavernous sinus, reducing the risk of cortical venous reflux, and consequently, the probability of intracranial venous hypertension, hemorrhage, and floridly symptomatic presentation. These lesions may be treated via surgical clipping of the fistulous point, transarterial or transvenous embolization, and/or stereotactic radiosurgery. Though surgical intervention was the principal therapy due to facility of craniotomy access to the fistulous point, embolization has become standard of care permitted by innovation in endovascular technology. The natural history, clinical presentation, angioarchitecture, diagnosis, and management of these lesions are reviewed and discussed.

Dural arteriovenous fistula in the sphenoid bone lesser wing region: Endovascular adjuvant techniques of treatment and literature review

This article describes the successful endovascular treatment of a dural arteriovenous fistula of a rare localization (the area of sphenoid bone lesser region). We examine one report of an unusually located dural arteriovenous fistula successfully treated with Onyx (ev3, Irvine, USA) using a combination of endovascular adjuvant techniques: pressure cooker and remodeling balloon protection of cerebral artery. The article includes previously published observations of such fistulas and discusses anatomic features and venous drainage of dural arteriovenous fistulas in the given location.