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Song Z, Ma Y, Su X, Fan Y, Zhang H, Ye M, Zhang P. Clinical features, treatment, and outcomes of cavernous sinus dural arteriovenous fistulas: a cohort study of 141 patients. Acta Neurol Belg 2024; 124:803-811. [PMID: 37924471 DOI: 10.1007/s13760-023-02405-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/09/2023] [Indexed: 11/06/2023]
Abstract
PURPOSE The cavernous sinus (CS) region is a common region of dural arteriovenous fistula (DAVF). Over time, treatment strategies are gradually changing. In this study, we present our center's experience in managing CS-DAVF over the past 20 years. METHODS Medical records of patients diagnosed with CS-DAVF between 2002 and 2021 were collected for analysis. Patients meeting the predefined inclusion and exclusion criteria were included. This study summarized and analyzed their clinical characteristics, CS-DAVF angioarchitecture, treatment strategies, and outcomes. RESULTS A total of 141 patients (mean age 55 years, 46 males) were included in this study. Ocular/orbital symptoms were the most frequently reported initial symptoms, with 84 (59.6%) patients experiencing these symptoms first. Presentation with ocular/orbital symptoms as the first symptom was associated with thrombosis of the inferior petrosal sinus (p = 0.032). Presentation with headache/dizziness and tinnitus/intracranial murmur as the first symptom was associated with sphenoparietal sinus/superficial middle cerebral vein drainage (p = 0.011). Among the patients, 131 (92.9%) patients received endovascular treatment, with 114 (87.0%) undergoing transvenous embolization. Onyx (92.4%) and coil (74.8%) were the most used embolic materials. 17 (13.0%) of the patients who received endovascular treatment suffered intraoperative or postoperative complications, and 11 (64.7%) patients fully recovered within 6 months after discharge. CONCLUSION Ocular/orbital symptoms were the most common first symptom of CS-DAVF. The mode of venous drainage played a significant role in determining the first symptoms. Transvenous embolization using Onyx or a combination of Onyx and coils was the primary treatment modality.
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Affiliation(s)
- Zihao Song
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, 100053, China
- China International Neuroscience Institute (China-INI), Beijing, China
| | - Yongjie Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, 100053, China
- China International Neuroscience Institute (China-INI), Beijing, China
| | - Xin Su
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, 100053, China
- China International Neuroscience Institute (China-INI), Beijing, China
| | - Yuxiang Fan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, 100053, China
- China International Neuroscience Institute (China-INI), Beijing, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, 100053, China.
- China International Neuroscience Institute (China-INI), Beijing, China.
| | - Ming Ye
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, 100053, China.
- China International Neuroscience Institute (China-INI), Beijing, China.
| | - Peng Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, 100053, China.
- China International Neuroscience Institute (China-INI), Beijing, China.
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Voldřich R, Charvát F, Netuka D. Indications for alternative endovascular techniques in carotid-cavernous fistulas: A 20-year single-center experience. Interv Neuroradiol 2024:15910199231217549. [PMID: 38173239 DOI: 10.1177/15910199231217549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND While coiling is considered the standard treatment for carotid-cavernous fistulas (CCFs), studies demonstrating excellent results using new materials, especially flow diverter (FD) stents and liquid embolisates, are becoming more frequent. The indications and effectiveness of these alternative endovascular techniques remain unclear. METHODS A total of 22 direct and 20 indirect CCFs were included in the study. These were further subdivided based on the embolic material used: coils versus FD stents for direct and coils versus liquid embolisates for indirect CCFs. The subgroups were subjected to statistical analysis. RESULTS An angiographic cure was achieved in 88% of all CCFs, 93% of patients' experienced clinical improvement or remained stable. Direct CCFs were treated with coiling (41%) or with both coils and FD stents (55%). One (4%) patient with a direct CCF was treated with FD stent alone. Statistical analysis comparing these subgroups revealed a significantly higher complete occlusion rate immediately after treatment in the coiling subgroup (67% vs. 23%, p = 0.0409). The occlusion rates at the last follow-up were similar (89% vs. 85%). Indirect CCFs were treated with coiling (35%) or liquid embolisates (65%). All three periprocedural ischemic complications were recorded within the liquid subgroup, resulting in a significantly higher clinical deterioration rate (p = 0.0333). CONCLUSION FD stents in direct and liquid embolisates in indirect fistulas did not demonstrate better angiographic or clinical outcomes compared to convetional coiling. Liquid agents carried a higher risk of ischemic complications. Alternative embolization materials should be reserved for CCFs that cannot be treated with simple coiling.
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Affiliation(s)
- Richard Voldřich
- Department of Neurosurgery and Neurooncology, Military University Hospital, Charles University, First Faculty of Medicine in Prague, Prague, Czech Republic
| | - František Charvát
- Department of Radiology, Military University Hospital, Prague, Czech Republic
| | - David Netuka
- Department of Neurosurgery and Neurooncology, Military University Hospital, Charles University, First Faculty of Medicine in Prague, Prague, Czech Republic
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Perng PS, Chang Y, Sun YT, Wang HK, Jiang YS, Lee JS, Wang LC, Huang CY. Endovascular treatment in bilateral cavernous sinus dural arteriovenous fistulas: a systematic review and meta-analysis. Sci Rep 2023; 13:7108. [PMID: 37528115 PMCID: PMC10394050 DOI: 10.1038/s41598-023-31864-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 03/20/2023] [Indexed: 08/03/2023] Open
Abstract
Few studies have discussed the disease nature and treatment outcomes for bilateral cavernous sinus dural arteriovenous fistula (CSDAVF). This study aimed to investigate the clinical features and treatment outcomes of bilateral CSDAVF. Embase, Medline, and Cochrane library were searched for studies that specified the outcomes of bilateral CSDAVF from inception to April 2022. The classification, clinical presentation, angiographic feature, surgical approach, and treatment outcomes were collected. Meta-analysis was performed using the random effects model. Eight studies reporting 97 patients were included. The clinical presentation was mainly orbital (n = 80), cavernous (n = 52) and cerebral (n = 5) symptoms. The most approached surgical route was inferior petrosal sinus (n = 80), followed by superior orbital vein (n = 10), and alternative approach (n = 7). Clinical symptoms of 88% of the patients (95% CI 80-93%, I2 = 0%) were cured, and 82% (95% CI 70-90%, I2 = 7%) had angiographic complete obliteration of fistulas during follow up. The overall complication rate was 18% (95% CI 11-27%, I2 = 0%). Therefore, endovascular treatment is an effective treatment for bilateral CSDAVF regarding clinical or angiographic outcomes. However, detailed evaluation of preoperative images and comprehensive surgical planning of the approach route are mandatory owing to complexity of the lesions.
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Affiliation(s)
- Pang-Shuo Perng
- Division of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng-Li Road, Tainan, 70428, Taiwan
| | - Yu Chang
- Division of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng-Li Road, Tainan, 70428, Taiwan
| | - Yuan-Ting Sun
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Advanced Optoelectronic Technology Center, National Cheng Kung University, Tainan, Taiwan
| | - Hao-Kuang Wang
- School of Medicine for International Students, I-Shou University, Kaohsiung, Taiwan
- Department of Neurosurgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Yu-Shu Jiang
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Jung-Shun Lee
- Division of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng-Li Road, Tainan, 70428, Taiwan
- Department of Cell Biology and Anatomy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Institute of Basic Medical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Liang-Chao Wang
- Division of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng-Li Road, Tainan, 70428, Taiwan
| | - Chih-Yuan Huang
- Division of Neurosurgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng-Li Road, Tainan, 70428, Taiwan.
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Rahmatian A, Yaghoobpoor S, Tavasol A, Aghazadeh-Habashi K, Hasanabadi Z, Bidares M, Safari-kish B, Starke RM, Luther EM, Hajiesmaeili M, Sodeifian F, Fazel T, Dehghani M, Ramezan R, Zangi M, Deravi N, Goharani R, Fathi M. Clinical efficacy of endovascular treatment approach in patients with carotid cavernous fistula: A systematic review and meta-analysis. World Neurosurg X 2023; 19:100189. [DOI: 10.1016/j.wnsx.2023.100189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/18/2023] [Accepted: 03/21/2023] [Indexed: 03/31/2023] Open
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Alatzides GL, Opitz M, Li Y, Goericke S, Oppong MD, Frank B, Eckstein AK, Köhrmann M, Wrede K, Forsting M, Wanke I, Deuschl C. Management of carotid cavernous fistulas: A single center experience. Front Neurol 2023; 14:1123139. [PMID: 36846124 PMCID: PMC9947522 DOI: 10.3389/fneur.2023.1123139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 01/25/2023] [Indexed: 02/11/2023] Open
Abstract
Purpose Multimodal endovascular therapy (EVT) of carotid cavernous fistula (CCF) with different approaches and a variety of available embolization material enable high occlusion rates with good clinical and functional outcome but until now there is still little evidence available. This retrospective single-center study aims to evaluate EVT of CCF with different neuroendovascular techniques regarding occlusion rates, complications and outcomes. Materials and methods From 2001 to 2021 59 patients with CCF were treated at our tertiary university hospital. Patient records and all imaging data including angiograms were reviewed for demographic and epidemiological data, symptoms, fistula type, number of EVTs, complications of EVT, type of embolic materials, occlusion rates and recurrences. Results Etiology of the CCF were spontaneous (41/59, 69.5%) post-traumatic (13/59, 22%) and ruptured cavernous aneurysms (5/59, 8.5%). Endovascular therapy was completed in one session in 74.6% (44/59). Transvenous access was most frequent (55.9% 33/59) followed by transarterial catheterization in 33.9% (20/59) and a combination of both (6/59, 10.2%). Exclusively coils were used in 45.8% (27/59), a combination of ethylene vinyl alcohol (EVOH) copolymer (Onyx) and coils in 42.4% (25/59). Complete obliteration was achieved in 96.6% of patients (57/59) with an intraprocedural-related complication rate of 5.1% (3/59) and no mortality. Conclusion Endovascular therapy of CCF has been shown to be safe and effective with high cure rates and low rates of intraprocedural complications and morbidity even in complex scenarios.
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Affiliation(s)
- Georgios Luca Alatzides
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, Essen University Hospital, Essen, Germany,*Correspondence: Georgios Luca Alatzides ✉
| | - Marcel Opitz
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, Essen University Hospital, Essen, Germany
| | - Yan Li
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, Essen University Hospital, Essen, Germany
| | - Sophia Goericke
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, Essen University Hospital, Essen, Germany
| | - Marvin Darkwah Oppong
- Department of Neurosurgery and Spine Surgery, Essen University Hospital, Essen, Germany
| | - Benedikt Frank
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), Essen University Hospital, Essen, Germany
| | | | - Martin Köhrmann
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), Essen University Hospital, Essen, Germany
| | - Karsten Wrede
- Department of Neurosurgery and Spine Surgery, Essen University Hospital, Essen, Germany
| | - Michael Forsting
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, Essen University Hospital, Essen, Germany
| | - Isabel Wanke
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, Essen University Hospital, Essen, Germany,Department of Neuroradiology, Klinik Hirslanden and Swiss Neuro Radiology Institute, Zurich, Switzerland
| | - Cornelius Deuschl
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, Essen University Hospital, Essen, Germany
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Voldřich R, Charvát F, Beneš V, Netuka D. What is the most effective method to treat indirect carotid-cavernous fistula? Neurosurg Rev 2022; 46:9. [PMID: 36482213 DOI: 10.1007/s10143-022-01923-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 11/11/2022] [Accepted: 11/28/2022] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Richard Voldřich
- Department of Neurosurgery and Neurooncology, Military University Hospital and First Medical Faculty of Charles University, Prague, Czech Republic.
| | - František Charvát
- Department of Radiology, Military University Hospital, Prague, Czech Republic
| | - Vladimír Beneš
- Department of Neurosurgery and Neurooncology, Military University Hospital and First Medical Faculty of Charles University, Prague, Czech Republic
| | - David Netuka
- Department of Neurosurgery and Neurooncology, Military University Hospital and First Medical Faculty of Charles University, Prague, Czech Republic
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Tu T, Song Z, Ma Y, Yang C, Su X, He C, Li G, Hong T, Sun L, Hu P, Zhang P, Ye M, Zhang H. Adult dural arteriovenous fistulas in Galen region: More to be rediscovered. Front Neurol 2022; 13:957713. [PMID: 36388187 PMCID: PMC9650976 DOI: 10.3389/fneur.2022.957713] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 08/26/2022] [Indexed: 10/02/2023] Open
Abstract
BACKGROUND Dural arteriovenous fistulas (DAVFs) in the Galen region are the most deeply located and most complex type of dural arteriovenous fistulas. However, cases of DAVFs in this region have not been well described. Thus, we aimed to summarize the characteristics of Galenic DAVFs involving clinical symptoms, anatomical architecture, and drainage patterns, providing experientially therapeutic strategies for these lesions based on our 20 years of clinical experience. METHODS We retrospectively examined 31 patients with Galenic DAVFs between January 2000 and June 2021. A comprehensive analysis was carried out based on the symptoms, imaging features, feeding arteries, draining veins, number and location of the fistulas, choice of treatment methods, and prognosis assessment. RESULTS Twenty-nine patients received endovascular embolization, and no perioperative deaths occurred. A transarterial approach was performed in 27 patients, and a combined transarterial and transvenous approach in one. And in one case, access was established by surgical drilling and embolization was done via the venous route. Twenty-four cases were completely obliterated after first embolization, and another five cases received a second period treatment. Only one patient developed cognitive dysfunction after embolization, and the outcomes of the remaining patients were improved at long-term follow-up. CONCLUSION The understanding of symptoms of non-hemorrhagic neurological deficits in DAVF needs to be further clarified. Lesions with pial feeders may be considered first when determining surgical orders. Multi-approach and multi-stage embolization would be safe and effective. Excessive embolization and deep-vein system obstruction should be avoided. Approach creation by surgery would be an innovative interventional therapy.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Peng Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ming Ye
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
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Endovascular Treatment of Cavernous Sinus Dural Arteriovenous Fistulas. Institutional Series, Systematic Review and Meta-Analysis. Clin Neuroradiol 2021; 32:761-771. [PMID: 34910224 PMCID: PMC9424140 DOI: 10.1007/s00062-021-01107-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 09/27/2021] [Indexed: 11/06/2022]
Abstract
Purpose Endovascular treatment represents the first-line therapy for cavernous sinus dural arteriovenous fistulas (CS-dAVF); however, different approaches and embolic agents as well as occlusion rates, complications and clinical outcomes are reported among the published series. In this study we performed a comprehensive meta-analysis to investigate clinical and radiological outcomes after endovascular treatment of CS-dAVFs. Methods PubMed, Ovid Medline, Ovid EMBASE, Scopus, and Web of Science were screened for a comprehensive literature review from 1990 to 2020 regarding series of patients treated for CS-dAVF with endovascular approaches. We performed a proportion meta-analysis estimating the pooled rates of each outcome also including data of patients treated in our center. Results A total of 22 studies reporting 1043 patients and 1066 procedures were included. Chemosis was reported in 559 out of 1043 patients (45.9%), proptosis in 498 (41.5%), and ophthalmoplegia in 344 (23.5%). A transvenous embolization was preferred in 753 cases (63.2%) and coils were used in 712 out of 1066 procedures (57.8%). Overall, 85% (95% confidence interval, CI 69.5–96.1%) of patients had a complete resolution of symptoms, while complications occurred in 7.75% (95% CI 3.82–12.7%) with minimal permanent deficits (0.15%). The mortality rate was 1 out of 1043 patients (< 0.001). Conclusion A transvenous coiling is the most common endovascular approach for CS-dAVF, achieving a high percentage of radiological and clinical resolution and low complication rates. Transvenous approaches show less complications than transarterial ones, and coils appear safer than liquid embolic agents.
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Prasad SN, Singh AP, Kanaujia V, Singh V, Phadke RV, Sharma K. Dural carotid-cavernous fistulas: our experience with endovascular management. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2021. [DOI: 10.1186/s43055-021-00534-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Indirect carotid-cavernous fistulas (CCF) are dural arteriovenous fistula of the cavernous sinus and generally present with ocular symptoms. High index of clinical suspicion and radiological work up is required for diagnosis, and treatment is primarily endovascular embolization. We present our experience in diagnosis and management of indirect CCF along with technical evolution to perform embolization and different vascular accesses for difficult anatomy.
Results
Among a total of 20 indirect CCF cases who were treated with embolization in our department from 2013 to 2020, five (25%) were type C and 15 (75%) were type D. Seven were treated with trans-arterial access only, 11 were treated by transvenous access only, and two were treated by taking both transvenous and trans-arterial access. No recurrence was seen in angiographically cured patients. Out of seven patients who suffered various grades of visual deficit, five recovered completely and two had fixed visual deficit. Third and sixth cranial nerve palsy persisted in two patients even after CCF embolization.
Conclusion
Indirect CCF is a treatable cause of troublesome ocular symptoms. Endovascular embolization is preferred treatment with excellent short- and long-term outcome. The embolization becomes difficult and challenging in cases where the conventional vascular access to the cavernous sinus is occluded.
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Kawamura Y, Takigawa T, Hyodo A, Suzuki K. Targeted Transvenous Embolization of Cavernous Sinus Dural Arteriovenous Fistula With Liquid Materials Using a Dual-Lumen Balloon Microcatheter. Cureus 2021; 13:e13821. [PMID: 33850677 PMCID: PMC8035909 DOI: 10.7759/cureus.13821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
We describe a challenging transvenous embolization technique involving a dual-lumen balloon microcatheter (DLBM) and liquid materials for cavernous sinus dural arteriovenous fistula (CSDAVF). DLBM contributed to identifying the shunt point and preventing liquid material leakage to normal venous drainage without treatment-related complications. In a transvenous embolization using liquid materials for CSDAVF complications such as cranial nerve palsy and embolic agent migration into the internal carotid artery due to numerous anastomoses must be considered. The use of angiography during DLBM inflation to characterize the shunt point and DLBM to prevent liquid material leakage to the normal venous drainage might decrease the mass effect due to liquid materials, thereby minimizing the causes of newly occurring cranial nerve palsy. This technique may be helpful for the treatment of CSDAVF in practice, but there is generally a risk in using liquid materials in the cavernous sinus; therefore, further consideration is needed in the future.
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Affiliation(s)
- Yosuke Kawamura
- Neurosurgery, Dokkyo Medical University Saitama Medical Center, Koshigaya, JPN
| | - Tomoji Takigawa
- Neurosurgery, Dokkyo Medical University Saitama Medical Center, Koshigaya, JPN
| | - Akio Hyodo
- Neurosurgery, Dokkyo Medical University Saitama Medical Center, Koshigaya, JPN
| | - Kensuke Suzuki
- Neurosurgery, Dokkyo Medical University Saitama Medical Center, Koshigaya, JPN
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Satow T. Endovascular Treatment of Cavernous Sinus Dural Arteriovenous Fistulae: Review of the Literature and Current Status. JOURNAL OF NEUROENDOVASCULAR THERAPY 2020; 14:572-582. [PMID: 37502143 PMCID: PMC10370658 DOI: 10.5797/jnet.ra.2020-0136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 06/29/2020] [Indexed: 07/29/2023]
Abstract
Cavernous sinus dural arteriovenous fistulae (CSdAVFs) are characterized by the shunts between dural arteries and dural veins surrounding the cavernous sinus (CS), causing ocular symptoms in addition to intracranial hemorrhage and infarction. As surgical access is difficult, endovascular treatment (EVT) has been considered and performed as the first-line therapy for decades. Although there have been recent advances in techniques and devices, transvenous embolization (TVE) with platinum coils remains the most common procedure. There are multiple access routes to the CS, such as the inferior petrosal sinus, superior ophthalmic vein (SOV), and intercavernous sinus from the contralateral CS. To extirpate the shunt, packing the entire sinus with coils is adopted, occasionally resulting in persistent cranial nerve palsy (CNP) due to compression of the coil mass. To avoid this complication, selective shunt occlusion (SSO), in which the coils are placed in the shunted pouch (SP) defined by the small restricted space where the arterial flow converges, is an effective and safe method. Transarterial embolization (TAE) is another option and use of liquid embolic materials, such as Onyx may be promising; however, the potential risk of ischemic nerve injury due to undesirable ante/retrograde influx of the liquid materials is of concern. In conclusion, EVT, especially TVE, is a safe and effective method for managing CSdAVFs. Understanding the angioanatomy consisting of the feeding artery, shunt point, and the drainage route, including the latent vessels, is essential for a good outcome.
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Affiliation(s)
- Tetsu Satow
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
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Srivatsan A, Kan P. Commentary: Burr Hole-Assisted Direct Transsylvian Venous Catheterization for Carotid-Cavernous Fistula Embolization: A Case Report. Oper Neurosurg (Hagerstown) 2020; 19:E201-E202. [DOI: 10.1093/ons/opaa007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 12/16/2019] [Indexed: 11/12/2022] Open
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13
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Demartini Z, Gatto LAM, de Oliveira TVWF, Guimaraes RMR, Francisco AN, Koppe GL. Dural Arteriovenous Fistula Associated with Dental Implant. World Neurosurg 2020; 141:69-71. [PMID: 32525091 DOI: 10.1016/j.wneu.2020.05.279] [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] [Received: 04/05/2020] [Revised: 05/28/2020] [Accepted: 05/30/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Dural arteriovenous fistulas (DAVFs) are characterized by pathologic shunts between meningeal arteries and venous sinuses, without nidus. Although many lesions are considered idiopathic, there may be an association with inflammatory processes, including sinus thrombosis, venous hypertension, craniotomy, trauma, and infections. CASE DESCRIPTION A 50-year-old woman with an infectious complication of a dental implant evolved with an occipital DAVF. To our knowledge, this is the first case of a dental implant-related DAVF reported in the medical literature. CONCLUSIONS Physicians should be aware of the possibility of DAVF formation after craniofacial infections. Better understanding of the etiopathogenesis of this type of lesion is required to avoid and treat potential complications.
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Affiliation(s)
- Zeferino Demartini
- Department of Neurosurgery, Hospital de Clinicas, UFPR, Curitiba-PR, Brazil; Department of Neurosurgery, Hospital Pequeno Principe, Curitiba-PR, Brazil.
| | - Luana A M Gatto
- Department of Neurosurgery, Cajuru University Hospital, Department of Neurosurgery, Pontifical University Catholic of Parana, PUCPR, Curitiba-PR, Brazil
| | - Tatiana V W F de Oliveira
- Department of Neurosurgery, Cajuru University Hospital, Department of Neurosurgery, Pontifical University Catholic of Parana, PUCPR, Curitiba-PR, Brazil
| | - Ricardo M R Guimaraes
- Department of Neurosurgery, Cajuru University Hospital, Department of Neurosurgery, Pontifical University Catholic of Parana, PUCPR, Curitiba-PR, Brazil
| | - Alexandre N Francisco
- Department of Neurosurgery, Cajuru University Hospital, Department of Neurosurgery, Pontifical University Catholic of Parana, PUCPR, Curitiba-PR, Brazil
| | - Gelson Luis Koppe
- Department of Neurosurgery, Hospital Pequeno Principe, Curitiba-PR, Brazil; Department of Neurosurgery, Cajuru University Hospital, Department of Neurosurgery, Pontifical University Catholic of Parana, PUCPR, Curitiba-PR, Brazil
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14
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Zeineddine HA, Lopez-Rivera V, Conner CR, Sheriff FG, Choi PA, Inam ME, Cochran J, Chen PR. Embolization of carotid-cavernous fistulas: A technical note on simultaneous balloon protection of the internal carotid artery. J Clin Neurosci 2020; 78:389-392. [PMID: 32331942 DOI: 10.1016/j.jocn.2020.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/05/2020] [Indexed: 10/24/2022]
Abstract
A carotid-cavernous fistula (CCF) is an abnormal connection between the carotid circulation and the cavernous sinus. Treatment of CCFs often consists of obliteration of the fistula by a transarterial or transvenous endovascular approach using embolic agents. However, fistula embolization is often halted due to the potential embolic complications that may arise from the retrograde flow of the embolic agents into the arterial circulation, which often leads to the development of fistula recurrence. Moreover, retreatment of a CCF recurrence is challenging and more complex approaches may be required. In this technical note, we describe our experience with CCF embolization in 25 patients treated at a single center. We utilized a transvenous approach for CCF embolization with simultaneous balloon occlusion of the internal carotid artery during the infusion of the embolic material into the fistula. In our series, this simultaneous protection of the internal carotid artery showed to be a safe technique to prevent embolic complications and to achieve successful obliteration of the fistula. On follow-up, 2 cases presented a recurrence, one due to technical difficulties and the other related to an undetected vascular injury. In conclusion, this technique provides a safe approach in the treatment of CCFs by decreasing the risk of embolic complications and increasing the effectiveness of the embolic agents in accomplishing the obliteration of the CCF.
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Affiliation(s)
- Hussein A Zeineddine
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Victor Lopez-Rivera
- Department of Neurology, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Christopher R Conner
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Faheem G Sheriff
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Phillip A Choi
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Mehmet E Inam
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Joseph Cochran
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Peng Roc Chen
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, TX, United States.
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15
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Hou K, Li G, Luan T, Xu K, Yu J. Endovascular treatment of the cavernous sinus dural arteriovenous fistula: current status and considerations. Int J Med Sci 2020; 17:1121-1130. [PMID: 32410842 PMCID: PMC7211155 DOI: 10.7150/ijms.45210] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 04/17/2020] [Indexed: 12/23/2022] Open
Abstract
A cavernous sinus dural arteriovenous fistula (CS-DAVF) is an abnormal arteriovenous communication involving the dura mater within or near the CS wall. The dural arteries from the internal carotid artery and external carotid artery supply the CS-DAVF, and the superior ophthalmic vein (SOV) and inferior petrous sinus (IPS) are frequent venous drainers. In CS-DAVF cases, high-risk lesions require treatment. Endovascular treatment (EVT) has been the first-line option for CS-DAVFs. To our knowledge, a review of the EVT of CS-DAVFs is lacking. Therefore, in this paper, we review the available literature on this issue. In addition, some illustrative cases are also provided to more concisely expound the EVT of CS-DAVFs. According to the recent literature, transvenous embolization via the IPS is considered the most effective method for EVT of CS-DAVFs. In addition, the transorbital approach is another reasonable choice. Other venous approaches can also be tried. Because of the low cure rate, transarterial embolization for CS-DAVFs is limited to only highly selected patients. In the EVT of CS-DAVFs, various agents have been used, including coil, Onyx, and n-butyl cyanoacrylate, with coil being the preferred one. In addition, when EVT cannot obliterate the CS-DAVF, stereotactic radiotherapy may be considered. In general, despite various complications, EVT is a feasible and effective method to manage CS-DAVFs by way of various access routes and can yield a good prognosis.
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Affiliation(s)
- Kun Hou
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, 130021, China
| | - Guichen Li
- Department of Neurology, The First Hospital of Jilin University, Changchun, 130021, China
| | - Tengfei Luan
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, 130021, China
| | - Kan Xu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, 130021, China
| | - Jinlu Yu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, 130021, China
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16
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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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17
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Baranoski JF, Ducruet AF, Przbylowski CJ, Almefty RO, Ding D, Catapano JS, Brigeman S, Fredrickson VL, Cavalcanti DD, Albuquerque FC. Flow diverters as a scaffold for treating direct carotid cavernous fistulas. J Neurointerv Surg 2019; 11:1129-1134. [DOI: 10.1136/neurintsurg-2019-014731] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 05/21/2019] [Accepted: 05/30/2019] [Indexed: 11/04/2022]
Abstract
BackgroundDirect carotid–cavernous sinus fistulas (dCCFs) are high flow arteriovenous shunts between the internal carotid artery and the cavernous sinus. Recently, we have used the pipeline embolization device (PED) to treat dCCFs.MethodsWe describe our experience treating patients with dCCFs in whom the PED was placed as the primary treatment modality.ResultsFive patients with dCCFs were treated with PEDs deployed in the ipsilateral internal carotid artery spanning the fistula. All patients also underwent either adjunctive transvenous or transarterial embolization. The PED served both as the primary treatment modality and as a scaffold that facilitated safe and efficacious transvenous embolysate administration by altering the flow dynamics through the fistula and providing a physical barrier that protected the internal carotid artery. No intraoperative or perioperative complications occurred. One of the five patients exhibited complete angiographic resolution of the fistula immediately after the procedure. The remaining four patients experienced complete obliteration of the fistula without additional treatment, which suggests that the PED induced alteration promoted thrombosis of the fistula. Therefore, 100% of patients in this series exhibited complete and durable obliteration of the fistula and complete resolution of symptoms following treatment.ConclusionsWe believe that use of the PED to treat dCCFs may be a safe and efficacious strategy that facilitates parent vessel protection during transvenous embolization. Furthermore, the flow alterations induced by the PED may promote thrombosis of incompletely occluded fistulas. This is the largest reported series of non-iatrogenic dCCFs treated with use of the PED as the primary initial treatment strategy.
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18
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Han W, Kim JH, Kang HI, Kim DR, Moon BG, Kim JS. Transvenous Embolization of Dural Carotid Cavernous Fistula through the Supraorbital Vein. J Cerebrovasc Endovasc Neurosurg 2019; 21:101-106. [PMID: 31886146 PMCID: PMC6911772 DOI: 10.7461/jcen.2019.21.2.101] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 06/18/2019] [Accepted: 06/20/2019] [Indexed: 11/23/2022] Open
Abstract
We describe a case of transvenous embolization through the dilated supraorbital vein to treat a dural carotid cavernous fistula. The approach through the common facial vein or direct access of the superior ophthalmic vein is a commonly used route to the superior ophthalmic vein when the approach via the inferior petrosal sinus is unavailable. In rare cases, the dilated supraorbital vein provides an alternative route and we discuss the technical details.
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Affiliation(s)
- Woong Han
- Department of Neurosurgery, Eulji University Eulji Hospital, Seoul, Korea
| | - Jae Hoon Kim
- Department of Neurosurgery, Eulji University Eulji Hospital, Seoul, Korea
| | - Hee In Kang
- Department of Neurosurgery, Eulji University Eulji Hospital, Seoul, Korea
| | - Deok Ryeong Kim
- Department of Neurosurgery, Eulji University Eulji Hospital, Seoul, Korea
| | - Byung Gwan Moon
- Department of Neurosurgery, Eulji University Eulji Hospital, Seoul, Korea
| | - Joo Seung Kim
- Department of Neurosurgery, Eulji University Eulji Hospital, Seoul, Korea
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19
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Wu CA, Yang HC, Hu YS, Wu HM, Lin CJ, Luo CB, Guo WY, Lee CC, Liu KD, Chung WY. Venous outflow restriction as a predictor of cavernous sinus dural arteriovenous fistula obliteration after Gamma Knife surgery. J Neurosurg 2019; 132:132-139. [PMID: 30684940 DOI: 10.3171/2018.9.jns182040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 09/28/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Gamma Knife surgery (GKS) obliterates 65%-87% of cavernous sinus dural arteriovenous fistulas (CSDAVFs). However, the hemodynamic effect on GKS outcomes is relatively unknown. The authors thus used the classification scheme developed by Suh et al. to explore this effect. METHODS The authors retrospectively (1993-2016) included 123 patients with CSDAVFs who received GKS alone at the institute and classified them as proliferative type (PT; n = 23), restrictive type (RT; n = 61), or late restrictive type (LRT; n = 39) after analyzing their pre-GKS angiography images. Treatment parameters, the presence of numerous arterial feeders, and venous drainage numbers were compared across the CSDAVF types. Patients' follow-up MR images were evaluated for the presence of complete obliteration. A Kaplan-Meier analysis was conducted to determine the correlation between CSDAVF types and outcomes. RESULTS The 36-month probability of complete obliteration was 74.3% for all patients, with no significant differences across types (p = 0.56). PT had the largest radiation volume (6.5 cm3, p < 0.001), the most isocenters (5, p = 0.015) and venous drainage routes (3, p < 0.001), and the lowest peripheral dose (16.6 Gy, p = 0.011) and isodose level coverage (64.3%, p = 0.006). CSDAVFs presenting with ocular patterns were less likely to be completely obliterated (hazard ratio 0.531, p = 0.009). After adjustment for age, CSDAVFs with more venous drainage routes were less likely to be completely obliterated (hazard ratio 0.784, p = 0.039). CONCLUSIONS GKS is an equally effective treatment option for all 3 CSDAVF types. Furthermore, the number of venous drainage routes may help in predicting treatment outcomes and making therapeutic decisions.
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Affiliation(s)
- Chia-An Wu
- 1Department of Radiology
- 3School of Medicine, National Yang-Ming University, Taipei, Taiwan (ROC)
| | - Huai-Che Yang
- 2Neurological Institute, Department of Neurosurgery, Taipei Veterans General Hospital; and
- 3School of Medicine, National Yang-Ming University, Taipei, Taiwan (ROC)
| | - Yong-Sin Hu
- 1Department of Radiology
- 3School of Medicine, National Yang-Ming University, Taipei, Taiwan (ROC)
| | - Hsiu-Mei Wu
- 1Department of Radiology
- 3School of Medicine, National Yang-Ming University, Taipei, Taiwan (ROC)
| | - Chung-Jung Lin
- 1Department of Radiology
- 3School of Medicine, National Yang-Ming University, Taipei, Taiwan (ROC)
| | - Chao-Bao Luo
- 1Department of Radiology
- 3School of Medicine, National Yang-Ming University, Taipei, Taiwan (ROC)
| | - Wan-Yuo Guo
- 1Department of Radiology
- 3School of Medicine, National Yang-Ming University, Taipei, Taiwan (ROC)
| | - Cheng-Chia Lee
- 2Neurological Institute, Department of Neurosurgery, Taipei Veterans General Hospital; and
- 3School of Medicine, National Yang-Ming University, Taipei, Taiwan (ROC)
| | - Kang-Du Liu
- 2Neurological Institute, Department of Neurosurgery, Taipei Veterans General Hospital; and
- 3School of Medicine, National Yang-Ming University, Taipei, Taiwan (ROC)
| | - Wen-Yuh Chung
- 2Neurological Institute, Department of Neurosurgery, Taipei Veterans General Hospital; and
- 3School of Medicine, National Yang-Ming University, Taipei, Taiwan (ROC)
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20
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Xu K, Yang X, Li C, Yu J. Current status of endovascular treatment for dural arteriovenous fistula of the transverse-sigmoid sinus: A literature review. Int J Med Sci 2018; 15:1600-1610. [PMID: 30588182 PMCID: PMC6299407 DOI: 10.7150/ijms.27683] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 09/14/2018] [Indexed: 12/27/2022] Open
Abstract
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.
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Affiliation(s)
- Kan Xu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, 130021, China
| | - Xue Yang
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, 130021, China
| | - Chao Li
- Department of Neurology, The First Hospital of Jilin University, Changchun, 130021, China
| | - Jinlu Yu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, 130021, China
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21
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Castro-Afonso LHD, Trivelato FP, Rezende MT, Ulhôa AC, Nakiri GS, Monsignore LM, Abud DG. The routes for embolization of dural carotid cavernous fistulas when the endovascular approach is indicated as a first-line strategy. Interv Neuroradiol 2018; 25:66-70. [PMID: 30165774 DOI: 10.1177/1591019918796493] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Multiple ways to access the dural carotid cavernous fistula have been described. The aim of the present study was to assess the results of embolization of a dural carotid cavernous fistula via different routes using endovascular accesses as a first-line strategy. METHODS A retrospective data analysis of a consecutive series of 63 patients presenting with dural carotid cavernous fistula was performed. RESULTS The dural carotid cavernous fistula was accessed by an endovascular approach in 58 patients (92.1%) and by direct puncture in five patients (7.9%). The inferior petrosal sinus was the main route accessed (65%). A recanalization of an occluded inferior petrosal sinus was obtained in 20.6% of cases. The access via either facial ophthalmic veins or the superior petrosal sinus was obtained in 20.6% and 3.1% of cases, respectively. Complete angiographic occlusion of a dural carotid cavernous fistula immediately after treatment was achieved in 53 patients (84.1%), whereas 10 patients (15.9%) displayed a partial occlusion. Treatment-related complications were observed in two patients (3.2%). CONCLUSIONS In this study, the endovascular approach allowed dural carotid cavernous fistula embolization in most patients. The inferior petrosal sinus, even when thrombosed, was the main route used to access the dural carotid cavernous fistula, followed by the facial vein, direct cavernous sinus puncture, and the superior petrosal sinus.
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Affiliation(s)
| | - Felipe Padovani Trivelato
- 2 Division of Interventional Neuroradiology, Felício Rocho Hospital and Clinics Hospital of Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Marco Túlio Rezende
- 2 Division of Interventional Neuroradiology, Felício Rocho Hospital and Clinics Hospital of Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Alexandre Cordeiro Ulhôa
- 2 Division of Interventional Neuroradiology, Felício Rocho Hospital and Clinics Hospital of Federal University of Minas Gerais, Belo Horizonte, Brazil
| | | | | | - Daniel G Abud
- 1 Division of Interventional Neuroradiology, University of São Paulo, São Paulo, Brazil
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