Transarterial intravenous coil embolization of dural arteriovenous fistula involving the superior sagittal sinus

Non-Sinus-Type Laterocavernous Sinus Dural Arteriovenous Fistula Treated by Transarterial Venous Coil Embolization: A Case Report

Objective

Laterocavernous sinus dural arteriovenous fistulas (DAVFs) are rare and not always accessible transvenously due to their angioarchitecture. We report a case of non-sinus-type laterocavernous sinus DAVF treated by endovascular transarterial venous coil embolization.

Case Presentation

A 78-year-old woman was admitted to our hospital with loss of consciousness, right hemiparesis, and motor aphasia. CT demonstrated intracerebral hematoma in the left frontal lobe and subarachnoid hemorrhage. On CTA and MRA, a DAVF was found in the left laterocavernous sinus region associated with the accessory meningeal artery (AMA) and draining directly into the superficial middle cerebral vein. The diagnosis was confirmed by DSA, which revealed a DAVF fed by the large and straight AMA and the internal carotid artery's meningohypophyseal trunk. Endovascular transarterial venous coil embolization was performed through the AMA. A microcatheter was advanced beyond the shunt point into the origin of the draining vein, and coils were placed in the venous and arterial sides of the fistula. The fistula was completely occluded, and 15-month follow-up angiography demonstrated stable obliteration of the fistula.

Conclusion

Transarterial venous coil embolization may be a treatment option for non-sinus-type laterocavernous sinus DAVF with a large fistula size and a large and straight feeding artery.

Superior sagittal sinus dural arteriovenous fistula caused by treatment of meningioma masquerades as sinus thrombosis

Dural arteriovenous fistulas (DAVF) are rare acquired lesions resulting from abnormal shunting between intracranial dural arteries and venous system. Typically arising from structural weakness of the dura and a coinciding trigger factor, DAVFs can present with similar clinical and imaging characteristics to sinus thrombosis. A 61-year-old male with a history of meningioma previously managed with subtotal resection and stereotactic radiosurgery presented with progressive right-sided vision loss and bilateral papilledema. Initial imaging suggested possible sinus occlusion. Catheter angiogram revealed a Borden-Shucart grade III DAVF of the superior sagittal sinus and elevated venous pressures and the patient subsequently underwent endovascular transarterial intervention twice. We report on the first case of a superior sagittal sinus DAVF occurring after surgical resection of a parasagittal meningioma.

Dural Arteriovenous Fistula within Superior Sagittal Sinus Wall with Direct Cortical Venous Drainage: A Systematic Literature Review

Dural arteriovenous fistulas (DAVFs) located within superior sagittal sinus (SSS) wall with direct cortical venous drainage are rare. They are also known as variant DAVF (vDAVF) and form a special subgroup of DAVFs. Their chance of presenting with aggressive features is high compared with transverse sigmoid sinus fistula. They drain directly into cortical veins (Borden type 3, Cognard type III and IV). A systematic English literature review of SSS vDAVF was made. Systematic literature review revealed a total of 31 published cases. These were commonly seen in male population, (24 males, 77.41%, 24/31). Average age of patients was 54 years. A total of 24 patients (77.41%, 24/31) had aggressive clinical presentations with 13 patients (41.93%, 13/31) having intracranial hemorrhages (ICH). Two patients had rebleeding (15.38%, 2/13). Middle portion of SSS was commonly involved (15 cases, 75%). A total of 25 (96.15%, 25/26) cases had patent SSS. Most of the fistulas were idiopathic (65.38%, 17/26), with trauma being a frequent etiological factor (26.92%, 7/26). Venous ectasia was seen in 19 patients (59.37%, 19/32). Middle meningeal arterial (MMA) supply was seen in all patients (100%, 26/26), with bilateral MMA supply in 21 cases (80.76%), and unilateral in 5 cases (19.23%). Twenty patients (62.50%, 20/32) received only endovascular treatment (EVT), while four patients had EVT followed by surgery (12.5%, 4/32). Transarterial route via MMA was the preferred treatment option (79.16%). Complete obliteration of fistulas was noted in all cases (100%, 30/30). No immediate complication was noted after EVT. As much as 92.30% patients showed good recovery. Thus, SSS vDAVF forms a special subgroup of DAVF, with aggressive presentation, and warrants urgent treatment. EVT is effective treatment option and can produce complete obliteration.

Transarterial Sinus Coiling for Dural Arteriovenous Fistula: Two Case Reports

Objective

We report two cases of dural arteriovenous fistula (DAVF) treated by coil embolization of the affected sinus and fistula via a feeding artery instead of transvenous embolization (TVE) due to the difficulty of the transvenous approach.

Case Presentation

An 82-year-old man was diagnosed with transverse sinus (TS) DAVF. A microcatheter was inserted into the isolated TS through the fistula via the middle meningeal artery (MMA), which was the feeding artery of the DAVF. The DAVF was occluded by coil embolization of the isolated sinus and fistula. A 79-year-old man was diagnosed with cavernous sinus (CS) DAVF. A microcatheter was inserted into the CS through the fistula via an accessory meningeal artery (AMA), which was the feeding artery of the DAVF. The DAVF was occluded by coil embolization of the affected sinus and fistula.

Conclusion

These cases suggested that transarterial sinus coiling is one of the effective treatment options for DAVF.

A Comprehensive Analysis of Dural Arteriovenous Fistula Involving the Superior Sagittal Sinus: A Systematic Review

Objective

To evaluate published papers concerning dural arteriovenous fistula involving the superior sagittal sinus (SSS dAVF) treated with endovascular intervention.

Methods

A literature review was performed to identify studies reporting the clinical characteristics, vascular anatomy, endovascular techniques, embolic materials, angiographical result, and outcomes of SSS dAVF.

Results

The analysis consisted of 40 case reports or series, comprising a total of 51 cases of SSS dAVF treated with endovascular intervention. Clinical symptoms included hemorrhage (29.4%), infarction (17.6%), and seizure (7.8%). The arterial supply included the middle meningeal artery (MMA) (100%), superficial temporal artery (STA) (62.7%), and occipital artery (OA) (49.0%). Bilateral MMAs supplied in 78.4% of the cases. A pial arterial supply was observed in 21.6% of the cases. Stenosis or occlusion of the sinus was seen in 37.3% of the cases. The distribution of the Borden classification was as follows: I (7.8%), II (37.3%), and III (54.9%). The endovascular techniques were transvenous embolization (TVE) alone (11.8%), transarterial embolization (TAE) alone (74.5%), and a combination thereof (13.7%). The types of embolic materials for TAE were a coil (25.5%), n-butyl-2-cyanoacrylate (NBCA) (33.3%), and Onyx (45.1%). The arterial pedicles for TAE included MMA (86.3%), STA (17.6%), and OA (9.8%). Direct surgical exposure for the alternative endovascular access was performed to the SSS (5.9%), MMA (3.9%), STA (5.9%), and OA (3.9%). Sinus angioplasty with or without stenting was done in 9.8% of the cases. Balloon-assisted Onyx TAE was done with proximal flow control (7.8%), collateral devascularization (5.9%), and sinus protection (3.9%). Complete occlusion was achieved in 86.3% of the cases while the number of endovascular sessions varied among patients: single (74.5%), double (15.7%), and triple (9.8%). The rate of a postoperative modified Rankin Scale (mRS) score of 0-2 was 89.3%, with morbidity and mortality rates of 7.8% and 3.9%, respectively. Two patients died, possibly due to postoperative acute SSS occlusion.

Conclusion

The current systematic review disclosed several specific results, namely, the angioarchitectures of the SSS dAVF, the relationship between classification and hemorrhagic presentation, the diversity of treatment techniques, the association between the complete occlusion rate and the SSS condition, and the difficulty of achieving curable occlusion in a single session. These findings underscore the need for the development of endovascular techniques and devices to treat this challenging lesion. Improvements in adjunctive endovascular procedures, such as balloon-assisted techniques for Onyx TAE, may help support to the safe and effective obliteration of SSS dAVF.

Transarterial Embolization of Dural Arteriovenous Fistula in Superior Sagittal Sinus Under Bilateral External Carotid Artery Flow Control: Technical Note

BACKGROUND

Transarterial embolization (TAE) using liquid embolic material is a standard treatment for non-sinus-type dural arteriovenous fistula (DAVF). However, to reach embolic material over a shunt point for complete obliteration of DAVF is often difficult. We present a technical case report of the efficacy of bilateral external carotid artery (ECA) flow control for the TAE of superior sagittal sinus DAVF.

CASE DESCRIPTION

A 64-year-old man presented with dizziness and left hemiparesis. Computed tomography imaging showed right parietal subcortical hemorrhage, and cerebral angiography revealed a DAVF in the superior sagittal sinus fed by bilateral occipital artery, bilateral superficial temporal artery and bilateral middle meningeal artery (MMA), with cortical venous reflux and without connection to the superior sagittal sinus. We therefore planned TAE using glue via MMA under bilateral ECA flow control. A 7-Fr balloon guide catheter was positioned in the bilateral ECA origins, and a microcatheter was introduced distal to the MMA. Heated 20% n-butyl-2-cyanoacrylate was slowly injected via the left MMA under bilateral ECA origin flow control. The n-butyl-2-cyanoacrylate reached the shunt point and obliterated the shunt in a single session. The patient was discharged without neurological symptoms.

CONCLUSIONS

Bilateral ECA flow control using balloon guide catheter is safe and effective for a DAVF in the superior sagittal sinus with multiple and tortuous scalp feeders.

Transarterial Sinus Embolization for a Dural Arteriovenous Fistula in a Sinus of the Lesser Sphenoid Wing: A Case Report

Dural arteriovenous fistula (DAVF) in a sinus of the lesser sphenoid wing (SLSW) is rarely reported. Here, we report a case of an isolated SLSW DAVF treated by coils placed into the sinus through the feeding artery. A 68-year-old man was admitted to our hospital with headache. Magnetic resonance images and an angiogram showed a varix in the right middle cranial fossa. A DAVF, consisting of three main feeders and the isolated SLSW, was diagnosed based on the angiogram findings. Retrograde leptomeningeal venous drainage to the deep middle cerebral vein was observed. Given the remarkable extent of cortical venous ectasia together with the presence of headache and right abducens nerve paralysis, endovascular treatment was initiated. A transvenous approach through the right inferior petrosal sinus was not feasible because of difficulty associated with inserting the microcatheter into the SLSW. Thus, we tried a transarterial approach and were able to advance the microcatheter beyond the fistula into the isolated SLSW, through the artery of the foramen rotundum. The isolated sinus and feeding arteries were embolized with coils. The postoperative angiogram showed the total occlusion of the SLSW DAVF. This case demonstrates the feasibility of transarterial sinus packing for an isolated SLSW DAVF.

Onyx removal after embolization of a superior sagittal sinus dural arteriovenous fistula involving scalp artery

BACKGROUND

Most dural arteriovenous fistula (DAVF) in superior sagittal sinus (SSS) requires multimodal treatment. Onyx embolization is useful for DAVF; however, scalp artery embolization has cast extrusion risk.

CASE DESCRIPTION

A 59-year-old male presented with involuntary movements of both legs and progressive dementia. Cerebral angiography demonstrated the DAVF in the SSS fed by bilateral superficial temporal, occipital, and middle meningeal arteries. The posterior SSS was thrombosed, and the main drainers were cortical veins. Combined treatment with transarterial embolization using Onyx and transvenous embolization using coils was performed. Although symptoms were improved, a small DAVF remained. Two months later, Onyx cast extrusion through the scalp was observed, requiring removal and debridement because of infection at the extrusion sites. Surgery for the residual DAVF would be difficult because of scalp condition; therefore, an additional endovascular treatment was conducted, completely occluding DAVF.

CONCLUSION

Onyx embolization is useful for DAVF; however, scalp artery embolization has cast extrusion risk. Therefore, scalp infection should be considered because it may preclude additional surgical procedures.

Transcranial direct middle meningeal artery puncture for the onyx embolization of dural arteriovenous fistula involving the superior sagittal sinus

A 66-year-old woman presented with intermittent paraparesis and generalized tonic-clonic seizure. Cerebral angiography demonstrated dural arteriovenous fistula (AVF) involving superior sagittal sinus (SSS), which was associated with SSS occlusion on the posterior one third. The dural AVF was fed by bilateral middle meningeal arteries (MMAs), superficial temporal arteries (STAs) and occipital arteries with marked retrograde cortical venous reflux. Transfemoral arterial Onyx embolization was performed through right MMA and STA, but it was not successful, which resulted in partial obliteration of dural AVF because of tortuous MMA preventing the microcatheter from reaching the fistula closely enough. Second procedure was performed through left MMA accessed by direct MMA puncture following small decortications of cranium overlying the MMA using diamond drill one week later. Microcatheter could be located far distally to the fistula through 5 F sheath placed into the MMA and complete obliteration of dural AVF was achieved using 3.9 cc of Onyx.

A treatment option for nontraumatic adult-type dural arteriovenous fistulas: transarterial venous coil embolization

OBJECTIVE

Transvenous coil embolization of the affected venous outlet is the most effective treatment method for the management of nontraumatic adult dural arteriovenous fistulas (DAVFs). However, such an approach is not always feasible. We discuss nontraumatic adult DAVFs that were treated with transarterial coil embolization of the proximal venous outlet at our facility, as well as cases previously reported in the literature.

METHODS

This study included 8 patients who had undergone transarterial coil embolization of the proximal venous outlet for the treatment of nontraumatic adult DAVFs (4 cases in our series and 4 cases in the literature). All clinical, angiographic, and procedural data were retrospectively collected from medical charts or the literature and recorded on standardized forms by a physician. The DAVFs were classified according to the venous drainage pattern.

RESULTS

In all 8 patients, occlusion of the proximal venous site of the fistula was possible by using coils through the arterial feeders; this resulted in complete recovery in all patients. The access route for 7 of the 8 cases was the middle meningeal artery, and in 1 case was the meningohypophyseal artery. In all 8 patients the access artery was relatively smooth, with distal enlargement in the fistula region.

CONCLUSIONS

If a distally enlarged feeding artery is observed among the multiple feeding arteries, it suggests the existence of a large fistula and may serve as an access route for transarterial venous coil embolization. This procedure may offer a more effective and safer treatment than other endovascular approaches.

Superior sagittal sinus dural arteriovenous fistulas treated by stent placement for an occluded sinus and transarterial embolization. A case report

We describe a case of dural arteriovenous fistulas (DAVFs) involving the superior sagittal sinus (SSS) successfully treated with stent placement for an occluded sinus and transarterial embolization. A 61-year-old man who had been treated with anticoagulation for a known SSS thrombosis presented with a sudden onset of headache. CT scan revealed an intraventricular hemorrhage and cerebral angiography revealed DAVFs involving the SSS which had severe venous congestion and sinus occlusion. We treated this case with a staged endovascular approach which consisted of stent placement for the occluded sinus and transarterial intravenous embolization resulting in complete eradication of DAVFs. Recanalization of an occluded sinus by stent placement can reduce venous congestion and transarterial intravenous embolization can obliterate dural arteriovenous shunts. This staged strategy is feasible and should be considered a first option of treatment, especially for DAVFs which presented with intracranial hemorrhage and aggressive venous hypertension.

Transvenous balloon-protected embolization of a scalp arteriovenous fistula using Onyx liquid embolic

BACKGROUND

Scalp arteriovenous fistulas (AVFs) are rare and potentially complex lesions that can be treated in a multimodal fashion. We present here the first successful treatment of a Stage Ib scalp AVF using a balloon-protected, retrograde transvenous embolization with the liquid embolic Onyx.

METHOD

We describe the case of a 60-year-old man with a scalp AVF that had a fine, diffuse, serpiginous arterial supply, precluding a transarterial approach, and multiple venous drainage paths, including the external jugular vein (EJV). The lesion was successfully embolized exclusively via a femoral transvenous retrograde approach using Onyx with balloon-protection of the EJV to simultaneously prevent pulmonary embolism and enable improved retrograde casting of the fistula-outflow zone.

FINDINGS

The combined use of Onyx with proximal balloon-protection in a transvenous retrograde femoral approach is a novel method that can be used to definitively treat scalp AVFs with a defined catheter-accessible venous outflow.

CONCLUSION

This technique may be useful when transarterial embolization, direct puncture, or surgical excision are not practical or possible.

The role of surgery for high-grade intracranial dural arteriovenous fistulas: importance of obliteration of venous outflow

Object

Surgical intervention may be required if endovascular embolization is insufficient to completely obliterate intracranial dural arteriovenous fistulas (DAVFs). The authors report their 14-year experience with 23 patients harboring diverse intracranial DAVFs that required surgical intervention.

Methods

Between 1993 and 2007, 23 patients underwent surgery for intracranial DAVFs. The following types of DAVFs were treated: superior petrosal sinus (in 10 patients); parietooccipital (in 3); confluence of sinuses and ethmoidal (in 2 each); and tentorial, falcine, occipital, transverse-sigmoid, superior sagittal, and cavernous sinuses (in 1 patient each). In all cases, the authors' goal was to obliterate the DAVF venous outflow by direct surgical interruption of the leptomeningeal venous drainage. Transarterial embolization was used primarily as an adjunct to decrease flow to the DAVF prior to definitive treatment.

Results

Complete angiographic obliteration of the DAVF was achieved in all cases. There were no complications of venous hypertension, venous infarction, or perioperative death. There were no recurrences and no further clinical events (new hemorrhages or focal neurological deficits) after a mean follow-up of 45 months.

Conclusions

The authors' experience emphasizes the importance of occluding venous outflow to obliterate intracranial DAVFs. Those that drain purely through leptomeningeal veins can be safely obliterated by surgically clipping the arterialized draining vein as it exits the dura. Radical excision of the fistula is not necessary.

Complete Cure of Superior Sagittal Sinus Dural Arteriovenous Fistulas by Transvenous Embolization through the Thrombosed Sinus in a Single Therapeutic Session. A Case Report

SUMMARY

Endovascular treatment often fails to completely eliminate dural arteriovenous fistulas (dural AVFs) involving the superior sagittal sinus (SSS). We report a successful case of dural AVF involving the SSS using transvenous embolization through the thrombosed sinus in a single therapeutic session.

Atypical dural arteriovenous fistula associated with meningitis

A 49-year-old male presented with hemisensory disturbance and gait unsteadiness following a previous episode of meningitis. He had no contributory medical or head injury history. Magnetic resonance imaging revealed innumerable medullary vessels in the white matter of the left cerebral hemisphere, which had not been recognized in the previous imaging study. Cerebral angiography showed variant superior sagittal sinus (SSS) arteriovenous fistula (AVF) fed by the bilateral middle meningeal and superficial temporal arteries, and drained directly to the cortical veins with marked venous engorgement in the affected hemisphere. The fistulas were located on the cortical veins, apart from the SSS. Initial percutaneous transarterial embolization failed, so the AVF was completely obliterated with a combination of surgical and endovascular techniques. The symptoms ameliorated postoperatively. Meningitis may be an underlying pathology of dural AVF. Variant SSS AVF can be treated with a combination of surgical and endovascular techniques.

Treatment of Intracranial Dural Arteriovenous Fistulas: Current Strategies Based on Location and Hemodynamics, and Alternative Techniques of Transcatheter Embolization

Intracranial dural arteriovenous fistulas (AVFs) can occur anywhere within the dura mater. Patients may be clinically asymptomatic or may experience symptoms ranging from mild symptoms to fatal hemorrhage, depending on the location (eg, cavernous sinus, transverse-sigmoid sinus, tentorium, superior sagittal sinus, anterior fossa) and venous drainage pattern of the AVF. In the past, dural AVFs have been treated with a variety of approaches, including surgical resection, venous clipping, transcatheter embolization, radiation therapy, or a combination of these treatments. Recent developments in catheter intervention now allow most patients to be cured with transcatheter embolization, although stereotactic radiation therapy is demonstrating good results in an increasing number of cases and surgery is still the preferred option in some cases. Familiarity with drainage patterns, the risk of aggressive symptoms, recent technical advances, and current treatment strategies is essential for the treatment of intracranial dural AVFs.

Transarterial approach for selective intravenous coil embolization of a benign dural arteriovenous fistula. Case report

Transarterial particulate embolization is indicated for benign intracranial dural arteriovenous fistulas (DAVFs) that have no dangerous venous reflux. This treatment, however, does not cure these lesions. In this case report the authors describe a spontaneously occurring DAVF that was treated by implanting coils through a transarterial microcatheter into the affected venous channel. The channel was separate from the normal dural sinuses. The pathological architecture of the fistula and the usefulness of this approach are discussed.

Stereotactic radiosurgery for dural arteriovenous fistula involving the superior sagittal sinus

✓The authors present a case of ruptured dural arteriovenous fistula primarily draining into the superior sagittal sinus, which was successfully treated by gamma knife radiosurgery.