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Melo-Guzman G, Burgos-Sosa E, Mendizabal-Guerra R, Mendez-Rosito D, Sanchez-Garcia LM, Espinosa Lira F, Ramirez-Rodriguez JI. Anatomical Preservation and Function of the Cavernous Sinus in Direct Carotid-cavernous Fistulas: Approach to the “Sinusoid Directly Involved” with One or Two Coils & Onyx. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Agrawal S, Das D, Bajaj M, Modaboyina S, Singh P, Gupta S. Carotico-cavernous fistula - From the eye of an ophthalmologist. TNOA JOURNAL OF OPHTHALMIC SCIENCE AND RESEARCH 2022. [DOI: 10.4103/tjosr.tjosr_105_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Zhang Q, Xu XL, Sun YL, Wang ZW, Lai XL, Xiong Y. Bilateral cavernous sinus dural arteriovenous fistula with initial ocular symptom: A case report. Medicine (Baltimore) 2021; 100:e27892. [PMID: 34797337 PMCID: PMC8601348 DOI: 10.1097/md.0000000000027892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 11/03/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Cavernous sinus dural arteriovenous fistula (CSDAVF) is a rare intracranial vascular malformation. Because of its complicated clinical manifestations, it is easy to miss or misdiagnose CSDAVF. PATIENT CONCERNS A 42-year-old female had chief complaint that the right eyeball had conjunctival congestion for half a year. She was given levofloxacin eye drops to treat the right eye with anti-inflammatory treatment, but the symptoms did not improve. Cranial magnetic resonance and cerebrovascular imaging showed that the right lateral rectus muscle was slightly enlarged, the right eyeball was prominent, but there was no abnormality in the brain. DIAGNOSES Based on clinical and imaging examinations and digital subtraction angiography (DSA), she was diagnosed as low-flow CSDAVF. INTERVENTIONS The patient received interventional embolization with transvenous combined arterial approach using coils and Onyx liquid glue. OUTCOMES The patient's exophthalmos and congestion symptoms were improved. CONCLUSION DAS is the gold standard for the diagnose of CSDAVF. Intravascular embolization interventional therapy is an effective treatment for CSDAVF.
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Malik MH, Brinjikji W, Savastano LE. Asystole during Onyx embolization of 64-year-old patient with dural arteriovenous fistula. Neuroradiol J 2021; 35:512-514. [PMID: 34550824 PMCID: PMC9437501 DOI: 10.1177/19714009211047453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Asystole or bradycardia is a relatively uncommon side effect seen in patients undergoing endovascular embolization using dimethylsulfoxide based liquid embolic agents. We present a case of a patient who underwent dural arteriovenous fistula embolization and experienced bradycardia during Onyx injection but was stabilized and the procedure was completed successfully.
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Bernath MM, Mathew S, Kovoor J. Craniofacial Trauma and Vascular Injury. Semin Intervent Radiol 2021; 38:45-52. [PMID: 33883801 PMCID: PMC8049762 DOI: 10.1055/s-0041-1724012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Cerebrovascular injury is a potentially devastating outcome following craniofacial trauma. Interventional radiologists play an important role in detecting, grading, and treating the different types of vascular injury. Computed tomography angiography plays a significant role in the detection of these injuries. Carotid-cavernous fistulas, extra-axial hematomas, pseudoaneurysms, and arterial lacerations are rare vessel injuries resulting from craniofacial trauma. If left untreated, these injuries can lead to vessel rupture and hemorrhage into surrounding areas. Acute management of these vessel injuries includes early identification with angiography and treatment with endovascular embolization. Endovascular therapy resolves vessel abnormalities and reduces the risk of vessel rupture and associated complications.
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Affiliation(s)
- Megan M. Bernath
- Medical Scientist Training Program, Indiana University School of Medicine, Indianapolis, Indiana
| | - Sunu Mathew
- Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jerry Kovoor
- Department of Radiology, Indiana University School of Medicine, Indianapolis, Indiana
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Baharvahdat H, Ooi YC, Kim WJ, Mowla A, Coon AL, Colby GP. Updates in the management of cranial dural arteriovenous fistula. Stroke Vasc Neurol 2019; 5:50-58. [PMID: 32411408 PMCID: PMC7213517 DOI: 10.1136/svn-2019-000269] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 10/23/2019] [Accepted: 11/11/2019] [Indexed: 11/21/2022] Open
Abstract
Dural arteriovenous fistula (dAVF) accounts for approximately 10% of all intracranial vascular malformations. While they can be benign lesions, the presence of retrograde venous drainage and cortical venous reflux makes the natural course of these lesions aggressive high risk of haemorrhage, neurological injury and mortality. Endovascular treatment is often the first line of treatment for dAVF. Both transarterial and transvenous approaches are used to cure dAVF. The selection of treatment approach depends on the angioarchitecture of the dAVF, the location, the direction of venous flow. Surgery and, to a lesser extent, stereotactic radiosurgery are used when endovascular approaches are impossible or unsuccessful.
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Affiliation(s)
- Humain Baharvahdat
- Neurosurgery, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA
| | - Yinn Cher Ooi
- Neurointerventional Radiology, UCLA, Los Angeles, California, USA
| | - Wi Jin Kim
- Neurosurgery, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA
| | - Ashkan Mowla
- Neurointerventional Radiology, UCLA, Los Angeles, California, USA
| | | | - Geoffrey P Colby
- Neurosurgery, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA
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Kang CH, Roh J, Yeom JA, Lee SW, Baik SK. Transvenous Onyx embolization of cavernous sinus dural arteriovenous fistula using a balloon catheter in the arterial side for flow control. JOURNAL OF NEUROCRITICAL CARE 2019. [DOI: 10.18700/jnc.190089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Ye M, Zhang P. Transvenous balloon-assisted Onyx embolization of dural arteriovenous fistulas of hypoglossal canal. Neuroradiology 2018; 60:971-978. [PMID: 30030549 DOI: 10.1007/s00234-018-2059-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 07/10/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE This retrospective study summarized the technique aspects and effectiveness of transvenous balloon-assisted Onyx embolization treating selected dural arteriovenous fistulas of hypoglossal canal (HCDAVFs). METHODS Eight patients of HCDAVFs from January 2010 to December 2016 in a single institution were reviewed retrospectively. There were six males and two females aged from 30 to 69 years (mean age, 52.8 years). Eight patients presented with pulsatile tinnitus, four associated with ocular symptom, and one accompanied with tongue muscle atrophy. All lesions were with accessible venous approach from ipsilateral internal jugular vein. The microcatheter was positioned in the venous pouch from internal jugular vein; the remodeling balloon was advanced from internal jugular vein into inferior petrosal sinus. The balloon having 4 mm in diameter and 15 mm in length was inflated to temporarily block the antegrade venous drainage from fistulous pouch to internal jugular vein during the injection of Onyx. Approximately 1- to 2.1-ml Onyx-18 was used as the sole embolic material to obliterate the lesions. RESULTS All lesions were occluded completely in a single-session embolization without procedural complications and postoperative new symptom. The follow-up period ranged from 6 to 13 months. Preoperative ocular symptom and tinnitus were resolved completely in all patients. The follow-up angiograms of three patients demonstrated durable occlusion. CONCLUSIONS Our experience in this small series of patients indicated transvenous balloon-assisted Onyx embolization was a feasible and effective option for treating selected HCDAVFs.
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Affiliation(s)
- Ming Ye
- Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, 100053, China.
| | - Peng Zhang
- Department of Neurosurgery, Xuanwu Hospital of Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, 100053, China
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Kostić A, Ristić S, Nikolov V, Stefanović I, Dželebdžić Z, Berilažić L. Endovascular prelude for delicate meningeoma operation: A case report. SANAMED 2017. [DOI: 10.24125/sanamed.v1i1.175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Introduction: Embolization prior to surgery can make tumor resection less complicated by reducing blood loss during surgery and shortening the time of the operation. Case report: In this paper, we presented a case of a sixty-three-year-old woman who was admitted to the Clinic of Neurosurgery, Clinical Center Niš, Serbia, at November 2016, after she underwent a CT brain scan that showed a large tumor of the left cerebellopontile angle. Digital subtraction angiography presented a large, highly vascularized tumor lesion that compressed the brain stem. The patient underwent endovascular procedure, and complete embolization of the tumor vessels was established. The radiologist delivered embolization material via the left ascending pharyngeal artery. In the next 24 hours, an operation was performed i.e. radical extirpation surgery (Simpson grade I). Postoperatively, the patient's GCS was 15, with no new neurological deficit. Postoperative brain CT scan showed neither rest tumor nor blood clot inside the tumor bed. Pathohistological finding revealed atypical meningioma grade II. Conclusion: Despite some clinicians' dilemma considering the utility of preoperative embolization of meningioma vessels, we believe that a team of educated and dedicated radiologist and neurosurgeon could achieve great results in resection of large and inaccessible cranial tumors.
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Zhang L, Wu X, Di H, Feng T, Wang Y, Wang J, Cao X, Li B, Liu R, Yu S. Characteristics of Headache After an Intracranial Endovascular Procedure: A Prospective Observational Study. Headache 2016; 57:391-399. [PMID: 27991669 DOI: 10.1111/head.13006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 10/26/2016] [Accepted: 10/26/2016] [Indexed: 01/03/2023]
Abstract
BACKGROUND Two editions of the International Classification of Headache Disorders (ICHD) diagnostic criteria for "Headache attributed to an intracranial endovascular procedure" have been published, in 2004 and 2013.1,2 Despite studies that have suggested that the former is not very practical, the ICHD-3 beta did not contain major changes. Moreover, so far no consensus exists regarding characteristics of headache after intracranial endovascular procedure. Thus, there is a need for sound suggestions to improve the ICHD-3 beta diagnostic criteria. METHODS Using a prospective design, we identified consecutive patients with unruptured intracranial aneurysms (UIAs) with neuroendovascular treatment from January 2014 to December 2014. RESULTS In total, 73 patients were enrolled, and 58 patients ultimately completed the 6-month follow-up. After the procedure, five of the 29 patients (17.2%) with pre-existing headache experienced marked worsening after the procedure, while seven of the 29 patients without prior headache developed new-onset headache post-procedurally. The headaches started within 24 hours, with a mean duration of 24-72 hours. The headaches were moderate to severe. The eligibility of these events to be considered headaches caused by neuroendovascular procedures according to the ICHD-3 beta diagnostic criteria for designation was far from ideal. CONCLUSIONS Most cases of markedly worsening headaches and new-onset headaches started within 24 hours and persisted longer than that specified in the ICHD-3 beta diagnostic criteria. Moreover, considering that some items are not very practical, the ICHD-3 beta diagnostic criteria should be revised in the light of recent literature reports.
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Affiliation(s)
- Linjing Zhang
- Department of Neurology, Chinese PLA General Hospital, Beijing, PR China
| | - Xiancong Wu
- Department of Neurology, Chinese PLA General Hospital, Beijing, PR China
| | - Hai Di
- Department of Neurology, Chinese PLA General Hospital, Beijing, PR China
| | - Tao Feng
- Department of Neurology, Heilongjiang Provincial Hospital, Harbin, PR China
| | - Yunxia Wang
- Department of Neurology, The First Hospital Affiliated to the Chinese PLA General Hospital, Beijing, PR China
| | - Jun Wang
- Department of Neurology, Chinese PLA General Hospital, Beijing, PR China
| | - Xiangyu Cao
- Department of Neurology, Chinese PLA General Hospital, Beijing, PR China
| | - Baomin Li
- Department of Neurology, Chinese PLA General Hospital, Beijing, PR China
| | - Ruozhuo Liu
- Department of Neurology, Chinese PLA General Hospital, Beijing, PR China.,Department of Neurology, Hainan Branch of Chinese PLA General Hospital, Sanya, PR China
| | - Shengyuan Yu
- Department of Neurology, Chinese PLA General Hospital, Beijing, PR China
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Abecassis IJ, Nerva JD, Ghodke BV, Sekhar LN, Levitt MR, Kim LJ. The dual microcatheter technique for transvenous embolization of dural arteriovenous fistulae. J Neurointerv Surg 2016; 9:578-582. [DOI: 10.1136/neurintsurg-2016-012713] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 10/19/2016] [Accepted: 10/24/2016] [Indexed: 11/03/2022]
Abstract
BackgroundDural arteriovenous fistulae (dAVFs) comprise 10–15% of all intracranial arteriovenous malformations. The goal of surgical or endovascular intervention is complete obliteration of the fistulous connection(s). In cases where dAVF venous drainage is separate from normal cortical drainage, transvenous embolization can provide fast and effective fistula obliteration.ObjectiveTo describe a new method of efficient transvenous embolization (the ‘dual microcatheter technique’) for the treatment of dAVFs.MethodsThree patients with dAVFs were treated using the dual microcatheter technique for transvenous embolization. Two microcatheters were placed in the distal aspect of the dAVF venous pouch, after which coil embolization reduced fistula flow, and liquid embolic agent injection with reflux into arterial feeders completed the obliteration of the fistula.ResultsLesion grade ranged from Borden–Shucart grades 2 through 3. In all cases, dAVF venous drainage was isolated from the normal cerebral venous drainage. Dual microcatheter transvenous embolization was successful in all patients, with non-target embolization and no new postoperative deficits. At the last follow-up, all three patients were symptom-free without evidence of radiographic recurrence.ConclusionsThe dual microcatheter technique of transvenous dAVF embolization is safe and feasible in cases where dAVF venous outflow is isolated from normal cerebral venous drainage.
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Ramalingaiah AH, Prasad C, Sabharwal PS, Saini J, Pandey P. Transarterial treatment of direct carotico-cavernous fistulas with coils and Onyx. Neuroradiology 2013; 55:1213-20. [PMID: 23828324 DOI: 10.1007/s00234-013-1224-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Accepted: 06/21/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION The purpose of this study was to evaluate the role of combination of liquid embolic agent ethylene vinyl alcohol copolymer (Onyx) and detachable coils in the treatment of direct carotico-cavernous fistulas (CCFs). METHODS We prospectively collected clinical and radiological data of all patients who underwent embolization of direct CCFs at our institution over a period of 21 months. The clinical parameters, angioarchitecture, presence of cortical venous reflux, volume of Onyx used, number of coils used, extent of embolization and complications were recorded. RESULTS A total of 21 consecutive patients (18 men and 3 women, 14 to 48 years) with direct CCF underwent embolization with a combination of coils and Onyx. Embolization was done through the arterial route in all cases. Complete obliteration of the fistula was achieved in 19 of 21 cases. Cast embolization in middle cerebral artery occurred in one patient; however, the cast was completely retrieved with Solitaire device, and the patient did not have any neurological deficit. All completely treated patients reported relief of symptoms at varying intervals. At 6-month follow-up, none of the patients with complete occlusion of the fistula showed any recurrence. CONCLUSION The adjuvant use of Onyx with detachable coils in direct CCF through the arterial route is a safe and effective method for embolization with immediate and complete occlusion of the fistula. To the best of our knowledge, this is the first case series of demonstration of arterial use of Onyx with coils in the treatment of direct CCFs.
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Affiliation(s)
- Arvinda Hanumanthapura Ramalingaiah
- Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences, Hosur Road, Bangalore, 560029, India,
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Grossman R, Maimon S, Levite R, Ram Z. Multimodal Treatment of Hemorrhagic Pituitary Metastasis as First Manifestation of Renal Cell Carcinoma. World Neurosurg 2013; 79:798.E1-5. [DOI: 10.1016/j.wneu.2012.09.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Revised: 04/28/2012] [Accepted: 09/11/2012] [Indexed: 10/27/2022]
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Ophthalmologic outcome of direct and indirect carotid cavernous fistulas. Int Ophthalmol 2012; 32:153-9. [DOI: 10.1007/s10792-012-9550-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Accepted: 03/02/2012] [Indexed: 11/27/2022]
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Baron EP, Moskowitz SI, Tepper SJ, Gupta R, Novak E, Hussain MS, Stillman MJ. Headache following intracranial neuroendovascular procedures. Headache 2011; 52:739-48. [PMID: 22211779 DOI: 10.1111/j.1526-4610.2011.02059.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
AIMS Predicting who will develop post-procedure headache (PPH) following intracranial endovascular procedures (IEPs) would be clinically useful and potentially could assist in reducing the excessive diagnostic testing so often obtained in these patients. Although limited safety data exist, the use of triptans or dihydroergotamine (DHE) often raise concern when used with pre/post-coiled aneurysms. We sought to determine risk factors for PPH following IEP, to evaluate the utility of diagnostic testing in patients with post-coil acute headache (HA), and to record whether triptans and DHE have been used safely in this clinical setting. METHODS We conducted a retrospective chart review of adult patients undergoing IEPs. Bivariate analyses were conducted to compare patients who did and did not develop PPH. RESULTS We reviewed records pertaining to 372 patients, of whom 263 underwent intracranial coil embolizations, 21 acrylic glue embolizations, and 88 stent placements. PPH occurred in 72% of coil patients, 33% of glue patients, and 14% of stent patients. Significant risk factors for post-coil HA were female gender, any pre-coil HA history, smoking, and anxiety/depression. A pre-stent history of HA exceeding 1 year's duration, and smoking were risk factors for post-stent HA. A pre-glue history of HA exceeding 1 year was the only risk factor for post-glue HA. In the small subgroup available for study, treatment with triptans or DHE was not associated with adverse events in pre/post-coiled aneurysms. Diagnostic testing was low yield. CONCLUSIONS Occurrence of PPH was common after IEPs and especially so with coiling and in women, smokers, and those with anxiety/depression, and was often of longer duration than allowed by current International Classification of Headache Disorders-II criteria. The yield of diagnostic testing was low, and in a small subgroup treatment with triptans or DHE did not cause adverse events in pre/post-coiled aneurysms. Prospective studies are needed to confirm these findings.
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Affiliation(s)
- Eric P Baron
- Cleveland Clinic Neurological Institute-Neurology, Center for Headache and Pain, Center for Regional Neurology, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Paul AR, Colby GP, Huang J, Tamargo RJ, Coon AL. Selection of treatment modalities or observation of dural arteriovenous fistulas. Neurosurg Clin N Am 2011; 23:77-85. [PMID: 22107860 DOI: 10.1016/j.nec.2011.09.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Cranial dural arteriovenous fistulas (DAVFs) represent an important class of cranial vascular lesions. The clinical significance of these lesions is highly dependent on the pattern of venous drainage, with cortical venous reflux being an important marker of an aggressive, high-risk fistula. For asymptomatic benign fistulas, conservative management, consisting of observation with follow-up, is a reasonable option. For symptomatic benign fistulas or aggressive fistulas, treatment is recommended. A variety of treatment modalities are available for DAVF management, including endovascular techniques, open surgery, and radiosurgery. A multimodality approach is often warranted and can offer improved chances of achieving a cure.
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Affiliation(s)
- Alexandra R Paul
- Division of Neurosurgery, Albany Medical Center Hospital, 47 New Scotland Avenue, Albany, NY 12208, USA
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Ong C, Ong M, Le K, Power M, Wang L, Lam D, Parkinson R, Wenderoth J. The trigeminocardiac reflex in Onyx embolisation of intracranial dural arteriovenous fistula. J Clin Neurosci 2010; 17:1267-70. [DOI: 10.1016/j.jocn.2010.01.041] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2009] [Accepted: 01/05/2010] [Indexed: 10/19/2022]
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Zenteno M, Santos-Franco J, Rodríguez-Parra V, Balderrama J, Aburto-Murrieta Y, Vega-Montesinos S, Lee A. Management of direct carotid-cavernous sinus fistulas with the use of ethylene-vinyl alcohol (Onyx) only: preliminary results. J Neurosurg 2010; 112:595-602. [PMID: 19663551 DOI: 10.3171/2009.6.jns09440] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT So-called direct carotid-cavernous fistulas (CCFs) are commonly treated by detachable balloons or coils to occlude the shunt while sparing the carotid artery. Liquid embolic agents have been rarely used, and in particular, to the authors' knowledge, the use of Onyx as the sole agent has never been reported in an indexed publication. METHODS The authors describe a case series of 5 patients with posttraumatic CCF in whom embolization with Onyx was prospectively used as the sole strategy of management. RESULTS Complete occlusion was obtained at the end of the procedure in 4 cases, and the lesion in the remaining patient subsequently occluded at the 6-month follow-up evaluation. CONCLUSIONS As endovascular techniques for treatment of direct CCFs continue to evolve, this novel approach with Onyx as the sole embolic material seems promising in treating these lesions.
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Affiliation(s)
- Marco Zenteno
- Departamento de Terapia Endovascular Neurológica, Instituto Nacional de Neurología y Neurocirugía, Universidad Nacional Autónoma de México, Mexico City, Mexico.
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Elhammady MS, Wolfe SQ, Farhat H, Moftakhar R, Aziz-Sultan MA. Onyx embolization of carotid-cavernous fistulas. J Neurosurg 2010; 112:589-94. [DOI: 10.3171/2009.6.jns09132] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The authors conducted a study to determine the safety and efficacy of embolization of carotid-cavernous fistulas (CCFs) with the ethylene vinyl alcohol copolymer, Onyx.
Methods
They prospectively collected data in all patients with CCFs who underwent Onyx-based embolization at their institution over a 3-year period. The type of fistula, route of embolization, viscosity of Onyx, additional use of coils, extent of embolization, procedural complications, and clinical follow-up were recorded.
Results
A total of 12 patients (5 men and 7 women who were age 24–88 years) underwent embolization in which Onyx was used. There were 1 Barrow Type A, 1 Type B, 3 Type C, and 7 Type D fistulas. Embolization was performed via a transvenous route in 8 cases and a transarterial route in 4 cases. Onyx 34 was used in all but 2 cases: a direct Type A fistula embolized with Onyx 500 and an indirect Type C fistula embolized with Onyx 18. Adjuvant embolization with framing coils was performed in 7 cases. All procedures were completed in a single session. Immediate fistula obliteration was achieved in all cases. Clinical resolution of presenting symptoms occurred in 100% of the patients by 2 months. Neurological complications occurred in 3 patients. One patient developed a complete cranial nerve (CN) VII palsy that has not resolved. Two patients developed transient neuropathies—1 a Horner syndrome and partial CN VI palsy, and 1 a complete CN III and partial CN V palsy. Radiographic follow-up (mean 16 months, range 4–35 months) was available in 6 patients with complete resolution of the lesion in all.
Conclusions
Onyx is a liquid embolic agent that is effective in the treatment of CCFs but not without hazards. Postembolization cavernous sinus thrombosis and swelling may result in transient compressive cranial neuropathies. The inherent gradual polymerization properties of Onyx allow for casting of the cavernous sinus but may potentially result in deep penetration within arterial collaterals that can cause CN ischemia/infarction. Although not proven, the angiotoxic effects of dimethyl sulfoxide may also play a role in postembolization CN deficits.
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Affiliation(s)
- Mohamed Samy Elhammady
- Department of Neurological Surgery, Miller School of Medicine, University of Miami, Florida
| | - Stacey Quintero Wolfe
- Department of Neurological Surgery, Miller School of Medicine, University of Miami, Florida
| | - Hamad Farhat
- Department of Neurological Surgery, Miller School of Medicine, University of Miami, Florida
| | - Roham Moftakhar
- Department of Neurological Surgery, Miller School of Medicine, University of Miami, Florida
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McConnell KA, Tjoumakaris SI, Allen J, Shapiro M, Bescke T, Jabbour PM, Rosenwasser RH, Nelson PK. Neuroendovascular management of dural arteriovenous malformations. Neurosurg Clin N Am 2010; 20:431-9. [PMID: 19853802 DOI: 10.1016/j.nec.2009.07.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Dural arteriovenous fistulas are characterized by abnormal arteriovenous shunting localized to the pachymeninges. Fistulae venous drainage is essential to their classification, symptomatology, and treatment. Endovascular therapy is rapidly progressing to an adjunct or even alternative treatment to microsurgical resection. Several techniques, such as transarterial or transvenous embolization with metallic coils, NBCA, or Onyx, have been used successfully in several studies. The long-term clinical and radiographic outcomes of endovascular therapy for the treatment of dural arteriovenous fistulas are satisfactory, and future studies are underway for the refinement of these techniques.
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Affiliation(s)
- Kathleen A McConnell
- Department of Radiology, New York University Langone Medical Center, New York, NY, USA
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Macdonald JHM, Millar JS, Barker CS. Endovascular treatment of cranial dural arteriovenous fistulae: a single-centre, 14-year experience and the impact of Onyx on local practise. Neuroradiology 2009; 52:387-95. [PMID: 19894041 DOI: 10.1007/s00234-009-0620-x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2009] [Accepted: 10/16/2009] [Indexed: 10/20/2022]
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Ong CK, Wang LL, Parkinson RJ, Wenderoth JD. Onyx embolisation of cavernous sinus dural arteriovenous fistula via direct percutaneous transorbital puncture. J Med Imaging Radiat Oncol 2009; 53:291-5. [DOI: 10.1111/j.1754-9485.2009.02086.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Kirsch M, Liebig T, Kühne D, Henkes H. Endovascular management of dural arteriovenous fistulas of the transverse and sigmoid sinus in 150 patients. Neuroradiology 2009; 51:477-83. [PMID: 19352640 DOI: 10.1007/s00234-009-0524-9] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2008] [Accepted: 03/27/2009] [Indexed: 12/01/2022]
Abstract
INTRODUCTION This study aimed to evaluate the safety and efficiency of the endovascular treatment of transverse-sigmoid sinus dural arteriovenous fistulas (TS_dAVF). METHODS A total of 150 consecutive patients and 348 procedures were evaluated. RESULTS Pulsatile tinnitus (81%), headache (15%), and intracranial hemorrhage (10%) were the most frequent manifestations of the TS_dAVFs. More than half of the affected sinuses were partially or completely thrombosed. Access-wise treatment was performed transarterial (n = 33), transvenous (n = 21), or a combination thereof (n = 96). A mean of 2.4 procedures per patient was required. Immediate postprocedural occlusion rate after transarterial embolization was 30% only. Transvenous treatment alone resulted in an early occlusion rate of 81%, with delayed complete obliteration of half of the remaining fistulas. After combined transarterial/transvenous treatment, the angiographic cure rate was 54%. At follow-up, 88% of patients with residual shunt after the treatment showed complete occlusion. The cumulative complication rate was 9% (n = 13), with minor adverse events in ten patients (7%) and major complications in three patients (2%). CONCLUSION Transvenous coil occlusion of the sinus segment with the adjacent dAVF site, eventually combined with transarterial occlusion of supplying arteries, is a very effective and well-tolerated treatment method. In selected patients, variations of these methods (e.g., sinus stenting, compartmental sinus occlusion) can be useful.
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Affiliation(s)
- M Kirsch
- Institut für Diagnostische Radiologie und Neuroradiologie, Ernst-Moritz-Arndt-Universität Greifswald, Greifswald, Germany
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