Complications related to percutaneous transarterial embolization of intracranial dural arteriovenous fistulas in 40 patients

Unexpected coil mass migration during transvenous embolization of a dural arteriovenous fistula resolved with guidewire-assisted snaring technique

Endovascular embolization is a standard treatment for dural arteriovenous fistulas (dAVFs). Although it is considered relatively safe, intraoperative and postoperative complications can occur. Herein, a rare case of unexpected coil mass migration requiring a retrieval procedure during sinus occlusion for a transverse-sigmoid sinus dAVF (TSdAVF) is described. An 83-year-old man presented with worsening decline in cognitive function. Magnetic resonance angiography showed a TSdAVF. Since his symptoms seemed to be a result of the TSdAVF, transvenous embolization preserving the normal cranial venous circulation was planned. During sinus occlusion, including embolization of the shunted pouch of the TSdAVF, unexpected migration of the coil mass to the confluence of the superior sagittal sinus and the transverse sinus occurred. The migrated coil mass impeded venous circulation in the superior sagittal sinus. Since the presence of the coil mass at the confluence could have had catastrophic sequelae, the coil mass was retrieved using a guidewire-assisted snaring technique. Sinus occlusion was subsequently completed with repositioning of the coil mass at the target site. The TSdAVF resolved, with no recurrence confirmed for 1 year. Clinicians should be aware that coil mass migration can unexpectedly occur during sinus occlusion performed for treatment of a TSdAVF. The guidewire-assisted snaring technique might be effective in resolving this intraoperative complication.

Transvenous embolization of noncavernous dural arteriovenous fistulas (dAVFs): A systematic review and meta-analysis

BACKGROUND

Intracranial dural arteriovenous fistulas (dAVFs) are abnormal connections between arteries and veins within the dura mater. Various treatment modalities, such as surgical ligation, endovascular intervention, and radiosurgery, aim to close the fistulous connection. Although transvenous embolization (TVE) is the preferred method for carotid-cavernous fistulas, its description and outcomes for noncavernous dAVFs vary. This has prompted a systematic review and meta-analysis to comprehensively assess the effectiveness of TVE in treating noncavernous dAVFs, addressing variations in outcomes and techniques.

METHODS

We searched PubMed and Embase, spanning from the earliest records to December 2022, to identify pertinent English-language articles detailing the utilization of TVE. We focused on specific procedural details, outcomes, and complications in patients older than 18 years. The data collected and analyzed comprised the sample size, number of fistulas, publication specifics, presenting symptoms, fistula grades, and pooled rates of embolizations, outcomes, follow-up information, and complications.

RESULTS

From a total of 565 screened articles, 15 retrospective articles encompassing 166 patients spanning across seven countries met the inclusion criteria. Their Newcastle-Ottawa scores ranged from 6 to 8. Intraprocedural complication rate was 10% (95% confidence interval [CI] = 5.9-17.1) and in-hospital postprocedural complication rate was 5.4% (95% CI = 2.8-10.6). Prevalence of in-hospital mortality was 5.5% (95% CI = 2.9-10.6). Complication rate during follow-up was 8.6% (95% CI = 4.7-15.7) with fistula rupture occurring in 5.5% (95% CI = 2.6-11.6) of patients. Complete obliteration rate at final angiographic follow-up was 94.9% (95% CI = 90.3-99.9). Symptoms improved in 95% (95% CI = 89.8-100) of patients at final follow-up.

CONCLUSION

To our knowledge, we present the first meta-analysis assessing obliteration rates, outcomes, and complications of TVE for dAVFs. Our analysis highlights the higher (>90%) complete obliteration rates. Large prospective multicenter studies are needed to better define the utility of TVE for noncavernous dAVFs.

Endovascular Treatment of Dural Arteriovenous Fistulas in a Medium-Sized Scandinavian Neurovascular Center

BACKGROUND

Endovascular treatment is the primary treatment modality for dural arteriovenous fistulas (DAVFs). We performed a retrospective analysis of DAVFs treated in our hospital to determine if high-quality endovascular treatment can be provided in a medium-volume vascular center.

METHODS

From 2007 to 2021, 69 DAVF treatments were undertaken in our hospital. Of these DAVFs, 55 were endovascular, 11 were open surgical procedures, and 3 were Gamma Knife treatments. Of the endovascular treatments, 10 (18.2%) were in ruptured DAVFs. The most common location of endovascularly treated DAVFs was at the transverse/sigmoid sinus (32.7%) and at the cavernous sinus (25.5%). Of the endovascularly treated DAVFs, 38.2% were low-grade fistulas (Cognard I/IIa), whereas 61.8% were high-grade fistulas (Cognard ≥IIb). 58.2% of fistulas were treated transarterially. DAVFs located in the cavernous sinus were treated using coils alone, whereas most other DAVFs were treated with liquid embolics alone or in combination with coils.

RESULTS

Complete or near-complete cure was achieved in 74.5% of treatments, whereas 18.2% of treatments resulted in downgrading of the fistula. Twelve patients were retreated once (9 endovascularly) and 1 patient was retreated twice. After retreatment, complete or near-complete cure was achieved in 86.4% of patients. 72.7% of treatments were performed without any remnant or retreatment. There were no procedure-related deaths. One patient experienced a complication resulting in permanent neurologic deficits. Seven other complications (12.7%) were recorded, all asymptomatic or causing only temporary symptoms.

CONCLUSIONS

Based on our findings, we conclude that high-quality treatment of DAVFs can be provided in a medium-volume vascular center.

Intracranial Non-Sinus-Type Dural Arteriovenous Fistulas Could Be Curable by Transarterial Embolization or Transvenous Embolization with Liquid Embolic Material

Objective

Recently, the occlusion rate of transarterial embolization (TAE) for intracranial non-sinus-type dural arteriovenous fistulas (NSDAVFs) has improved after ONYX was introduced. Additionally, when TAE for NSDAVF is unsuccessful, transvenous embolization (TVE) has become available as an alternative treatment. We investigated the factor for the favorable occlusion rate of endovascular treatment for NSDAVF at our institutions.

Methods

Two hundred and twenty-seven patients with intracranial dural arteriovenous fistulas (DAVFs) were treated at our institutions between September 2014 and October 2022. The patients diagnosed with NSDAVF in all DAVFs who underwent endovascular treatment were included. The clinical characteristics, angiographical outcomes, and clinical outcomes of patients who underwent endovascular treatment were evaluated.

Results

Thirty-eight patients had intracranial NSDAVF (tentorial: 23 cases, parasagittal-convexity: 7, anterior cranial fossa: 6, middle cranial fossa: 2). Our participants' mean age was 64.8 ± 11.3 years, and 31 (81.6%) of them were males. Patients' symptoms were as follows: asymptomatic (24), hemorrhage (10), tinnitus (3), and trigeminal neuralgia (1). TAE and TVE were performed on 35 and 3 patients, respectively. The rate of immediate angiographical occlusion was 84.2% (32/38). The follow-up angiographical occlusion rate in 6 months was 88.5% (31/35). Complications occurred in three cases. There was no morbidity or mortality after 30 days.

Conclusion

TAE using the combination of the new microcatheter and microguidewire and TVE in the case of difficult or failed TAE for NSDAVF could achieve high success rates and safety.

Clinical features, angio-architectural phenotypes, and treatment strategy of foramen magnum dural arteriovenous fistulas: a retrospective case series study

Background

The rarity and complex angioarchitecture of foramen magnum dural arteriovenous fistulas (DAVFs) make its treatment difficult and controversial. We aimed to describe their clinical features, angio-architectural phenotypes, and treatments, through a case series study.

Methods

We first retrospectively studied cases of foramen magnum DAVFs treated in our Cerebrovascular Center, and then reviewed the published cases on Pubmed. The clinical characteristics, angioarchitecture, and treatments were analyzed.

Results

A total of 55 patients were confirmed with foramen magnum DAVFs, which included 50 men and 5 women, with a mean age of 52.8 years. Most patients presented with subarachnoid hemorrhage (SAH) (21/55) or myelopathy (30/55), depending on the venous drainage pattern. In this group, 21 DAVFs were supplied by only the vertebral artery (VA), three by only the occipital artery (OA), three by only the ascending pharyngeal artery (APA), and the remaining 28 DAVFs were supplied by two or three of these feeding arteries. Most cases (30/55) were treated with only endovascular embolization, 18 cases (18/55) with only surgical disconnection, five cases (5/55) with combined therapy, and two cases rejected treatment. The angiographic outcome of complete obliteration was achieved in most patients (50/55). In addition, two cases of foramen magnum DAVFs were treated by us in a Hybrid Angio-Surgical Suite (HASS) with good outcomes.

Conclusions

Foramen magnum DAVFs are rare and their angio-architectural features are complicated. The treatment option (microsurgical disconnection or endovascular embolization) should be weighed carefully, and combined therapy in HASS could be a more feasible and less invasive treatment option.

Multidisciplinary management of posterior fossa dural arteriovenous fistula: A single-center experience

PURPOSE

The management of posterior fossa dural arteriovenous fistulas (pfDAVFs) is challenging. Here, we show how multidisciplinarity leads to their successful management, even in complex cases.

METHODS

All pfDAVFs managed from 2010 to 2019 at our center were reviewed. The preoperative clinical and radiological characteristics, their management and the occlusion rate were retrieved. The radiological and functional outcomes were retrieved at discharge and last follow-up (FU).

RESULTS

n=27 patients were included (6 females, mean age: 61-years-old, mean FU: 22.5 months). n=8 patients presented with cerebral hemorrhage. Among patients with ruptured pfDAVFs, n=7 had headache, n=4 had ataxia, and n=2 had impaired level of consciousness. In the unruptured group N (n=19), n=7 patients had headache, n=6 patients had focal neurological deficit, n=4 patients had tinnitus, n=3 (had ataxia, and one presented with seizure. n=24 patients were treated by endovascular therapy (EVT), n=2 patients were treated by microsurgery (MS) and n=1 patient was managed with a combined approach. Re-treatment was necessary in n=6 patients. n=24 patients showed total exclusion at last FU. n=2 patients died during the first 30 days; n=1 patient died during FU.

CONCLUSIONS

While EVT should be advocated as the first line therapy whenever possible, MS should not be banned from the treatment armamentarium. Neurosurgeons must be able to achieve direct surgical occlusion when the angioarchitecture speaks against EVT.

Retrieval of N-Butyl-2-Cyanoacrylate Glue Migrated to the Vertebral Artery via Dangerous Anastomosis, Using the Stent-Retriever Aspiration Technique, during Dural Arteriovenous Fistula Embolization: A Case Report

Objective

We report a case of accidental N-butyl-2-cyanoacrylate (NBCA) glue migration into the vertebral artery (VA) via dangerous anastomosis during transarterial embolization (TAE) for transverse sinus (TS)-dural arteriovenous fistula (DAVF), which was rescued by mechanical retrieval using a stent retriever and aspiration devices.

Case Presentation

A 49-year-old right-handed female patient was admitted to our hospital with motor aphasia. MRI revealed congestion in the left temporal and occipital lobes, involving a small hemorrhage. DSA revealed a DAVF complicated by a sinus thrombus in the left TS. The DAVF was mostly fed by the left occipital artery (OA) and drained into the cortical veins of the temporal and occipital lobes through the patent part of the sinus. TAE was performed via the left OA with low-concentration NBCA. However, NBCA glue migrated into the left VA through a dangerous anastomosis, and a left VA angiogram revealed severe VA stenosis and floating NBCA glue. There was a fragile attachment of the NBCA glue to the arterial inner wall; therefore, we successfully retrieved the NBCA glue with a stent retriever and aspiration devices without complications. Finally, TAE was performed using another feeder, and the DAVF was completely obliterated.

Conclusion

TAE using NBCA is useful for the treatment of DAVF; however, it should be noted that there is a risk of migration via potential anastomotic routes. Low-concentration NBCA glue can be retrieved using these devices in limited cases.

Intracranial Dural Arteriovenous Fistulas with Cortical Venous Drainage: Radiosurgery as an Effective Alternative Treatment

OBJECTIVE

To evaluate the clinical and radiological outcome of Gamma Knife radiosurgery (GKS) in treatment of intracranial dural arteriovenous fistula (DAVF) with cortical venous drainage (CVD) and compare it with the outcome of endovascular therapy.

METHODS

Patients who underwent GKS or endovascular therapy for intracranial DAVF with CVD over 10 years (January 2007 to December 2016) at the All India Institute of Medical Sciences, New Delhi, were included. Demographics, clinical presentation, imaging details, and follow-up clinical status were reviewed retrospectively. Clinical follow-up was conducted once every 6 months. Radiological follow-up using digital subtraction angiography was performed at a mean 24 months after intervention. Patients with clinical follow-up of <1 year were excluded from the study.

RESULTS

The study included 35 patients (26 in embolization group and 9 in GKS group) who had intracranial DAVF with CVD were included in the study. Clinical improvement was seen in 77.78% of the patients who received GKS and 57.7% of the patients who underwent embolization (P = 0.431). Complete obliteration of DAVF was seen in 55.56% of the patients in the GKS group and 57.7% of the patients in the embolization group (P = 1). GKS was at least as effective as embolization in terms of clinical and radiological outcome in treatment of intracranial DAVF with CVD.

CONCLUSIONS

Contrary to popular perception, GKS should be considered as an effective first-line treatment alternative of intracranial DAVF with CVD.

Direct Superior Ophthalmic Vein Approach to Treat Anterior Condylar Confluence Dural Arteriovenous Fistula

Dural arteriovenous fistulas (DAVFs) are acquired pathological arteriovenous connections involving vessels that usually supply the meninges. A DAVF in the region of the hypoglossal canal is a rare form of fistula that involves the anterior condylar confluence or anterior condylar vein. We report a case of hypoglossal canal DAVF that was successfully embolized transvenously through a superior ophthalmic vein (SOV) approach. After failed attempts through jugular access, our patient was treated by a unique percutaneous direct puncture approach through the SOV, achieving complete obliteration of the fistula. A step-by-step description of the endovascular technique was described. The clinical course was uneventful without any new neurologic deficit. The eye symptoms and third nerve palsy had completely resolved at the 3-month follow-up visit. Hypoglossal canal DAVFs are rare and may exhibit complex venous drainage patterns. Knowledge of the complex venous anatomy is essential for planning an alternative transvenous route if the standard approach is not feasible. Xper CT (Philips Healthcare, Best, The Netherlands) is an excellent tool for identifying the exact site of the fistula as well as for confirming a safe position of the catheter tip for successful occlusion of this complex dural AV fistula.

Transarterial embolization of dural arteriovenous fistulas of the lateral sinuses with stent-assisted sinus protection

BACKGROUND

The balloon-assisted sinus protection technique has been described as a sinus-preserving technique during transarterial embolization (TAE) of dural arteriovenous fistulas (DAVFs). However, some serious complications of this technique have been documented.

OBJECTIVE

To describe our preliminary experience with a new technique called stent-assisted sinus protection (SSP).

METHODS

We performed a retrospective analysis of seven consecutive patients with type I or IIa DAVFs of the lateral sinus treated by TAE with a closed-cell stent temporarily deployed in the sinus.

RESULTS

Of the seven patients, four had type I DAVF, and three had type IIa DAVF. The patency of all involved sinuses and their tributaries (including the inferior anastomotic vein and the superior petrosal sinus) was preserved. At the end of the procedure, all stents were successfully retrieved with embolic particles trapped in their meshes. No procedural complications were noted. Clinical follow-up was satisfactory, with complete resolution or significant reduction of pulsatile tinnitus.

CONCLUSIONS

SSP appears to be feasible and probably safe. However, larger studies are needed to confirm these preliminary results.

Asystole during Onyx embolization of 64-year-old patient with dural arteriovenous fistula

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.

Results of transvenous embolization of intracranial dural arteriovenous fistula: a consecutive series of 136 patients with 142 fistulas

OBJECTIVE

Intracranial dural arteriovenous fistula (DAVF) is mainly treated with an endovascular approach. Two major treatment advances include transvenous embolization (TVE) with coils in 1989 and, more recently, transarterial embolization with Onyx. The aim of this study was to present a large monocentric series of patients with DAVF treated with TVE. This series reports more than 20 years of experience and describes the evolution of the medical management of these patients, as well as current indications for this treatment at the authors' center.

METHODS

Consecutive patients treated for intracranial DAVFs with TVE from 1995 to 2018 were included. Clinical and imaging data were systematically collected. Univariate and multivariate analyses were performed to identify factors that were significantly associated with adverse clinical course or complications.

RESULTS

In this study of 136 patients with 142 DAVFs treated with TVE, the occlusion rate was 90%. The median length of follow-up was 11 months. The rate of permanent complications was 5.1%, and the procedure-related mortality rate was 1.5%. Procedure-related mortality was associated with extension of thrombosis that was observed early in our experience. The introduction of a postoperative anticoagulation regimen has drastically decreased the occurrence of this complication. Other minor complications included cochleovestibular syndrome after embolization of lateral sinus DAVF and oculomotor nerve damage after embolization of cavernous sinus DAVF.

CONCLUSIONS

TVE allows efficient occlusion of DAVF. It remains a valid option for DAVF located on a sinus that does not participate in normal venous drainage of the brain.

A Damp-and-Push Technique for the Copolymer (Onyx) Embolization of Dural Arteriovenous Fistula

BACKGROUND

Copolymer (Onyx) embolization is an effective treatment for dural arteriovenous fistula (dAVF), however, some dAVFs have multiple, high-flow feeding vessels, resulting in insufficient embolization. For the treatment of such patients, we have developed a novel flow-control technique, the 'damp-and-push technique'. The purpose of this study was to evaluate the technical efficiency and safety of this technique.

METHODS

Seven patients who had been diagnosed with intracranial dAVF were treated by transarterial Onyx embolization using the damp-and-push technique between 2016 and 2019. This technique was designed to reduce blood flow to the shunt site using a balloon catheter in the major feeding vessel other than the one injected with Onyx, leading to better Onyx penetration and enabling more controlled embolization of complex dAVFs. Retrospectively collected data were reviewed to assess the occlusion rates and clinical outcomes.

RESULTS

The dAVF was at a transverse sinus-sigmoid sinus junction in four patients, in the superior sagittal sinus in two, and in the tentorium in one. Five cases were Cognard type Ⅱb and two cases were Cognard type Ⅳ. All the patients were treated by transarterial Onyx injection via the main feeding vessel, combined with flow reduction in the other main feeding vessel using a balloon catheter. Complete occlusion was achieved in six patients and elimination of cerebral venous reflux was achieved in all the patients. There were no immediate or delayed post-interventional complications.

CONCLUSIONS

Transarterial Onyx embolization of dAVF using the damp-and-push technique is safe and yields a high complete occlusion rate.

Facial Nerve Paralysis Following Endovascular Embolization: A Case Report and Review of the Literature

OBJECTIVE

We report a case of facial nerve paralysis post-endovascular embolization of a sigmoid sinus dural arterio-venous fistula from initial presentation to current management and discuss the merits of observation versus decompression through a systematic review of relevant literature.

PATIENT

61 F with right facial palsy.

INTERVENTION

Following a single intravenous dexamethasone injection with oral steroids over 2 months, patient was observed with no additional treatment other than Botox chemodenervation and facial rehabilitation.

OUTCOME AND RESULTS

The patient initially presented with complete right facial palsy (HB 6/6). Post-op CT imaging indicated Onyx (ev3, Irvine, California, USA) particles present at the geniculate segment of the facial nerve. Observation was chosen over surgical intervention. At the most current follow up of 8 months, facial function has improved substantially (HB 2/6).

CONCLUSION

Facial palsy is a serious, though rare, complication of transarterial endovascular embolization. With our case report and literature review, we highlight not only how conservative observation is the recommended treatment, but also that facial nerve recovery should be expected to reach near complete recovery, but not sooner than in 3 months.

Endovascular Treatment of Cavernous Sinus Dural Arteriovenous Fistulae: Review of the Literature and Current Status

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.

Gamma Knife Radiosurgery: The Gold Standard Treatment for Intracranial Dural Arteriovenous Fistulas without Cortical Venous Drainage

Context

Endovascular therapy is currently the most common treatment approach for intracranial dural arteriovenous fistula (DAVF), followed by microsurgery. Gamma Knife radiosurgery (GKS) is usually reserved as the last modality of treatment of intracranial DAVF.

Aim

To evaluate the clinical and radiological outcome of GKS in the treatment of DAVF without CVD.

Subjects and Methods

This series includes patients who underwent GKS for intracranial DAVF without CVD over 10 years (Jan 2007 to Dec 2016) in All India Institute of Medical Sciences, New Delhi. Their demographic profile, clinical presentation, imaging details, GKS details, and follow-up clinical status were obtained retrospectively. Clinical follow-up, along with radiological assessment using MRI every 6 months was done after GKS. DSA was performed once MRI strongly suggested obliteration of DAVF. Patients who had a clinical follow-up of less than 1 year were excluded from the study.

Results

5 patients (4 males and 1 female) who had DAVF without CVD were included the study. The mean age was 44.8 years. All patients had complete obliteration of fistula on digital subtraction angiography (DSA) at a mean duration of 24 months post GKS. All patients had complete resolution of symptoms at the last follow-up.

Conclusions

Gamma Knife surgery is the most effective and the safest treatment modality for dealing with DAVFs without CVD. Instead of reserving it as the last resort for patients with DAVF without CVD, it should be considered as the gold standard treatment for DAVFs without CVD.

Brain and Heart Crosstalk During Neurointerventional Procedures: The Role of the Trigeminocardiac Reflex: An Updated Systematic Review

The trigeminocardiac reflex is a well-described brainstem reflex that clinically manifests as bradycardia, hypotension, or apnea. This physiological phenomenon is extensively reported during open neurosurgical procedures, but very few data exist for trigeminocardiac reflex occurrence during neurointerventional procedures. This systematic review aims to provide aggregated information related to the trigeminocardiac reflex during neurointerventional procedures and to improve understanding of the various mechanisms that can incite this unique brain-heart crosstalk.

Treatment of cavernous sinus dural arteriovenous fistula using different surgical approaches: Analysis of 32 consecutive cases

OBJECTIVE

Transarterial and transvenous embolization methods are considered effective and safe approaches for the treatment of cavernous sinus dural arteriovenous fistula (CSDAVF). Here., we report the angioarchitectural features and clinical outcomes of CSDAVF in patients treated with either the inferior arterial approach (IAA) or the inferior petrosal sinus approach (IPSA).

METHODS

The clinical data of 32 patients with CSDAVF treated at our institution from May 2008 to May 2014 were retrospectively analyzed. All patients underwent routine diagnostic digital subtraction angiography (DSA) before surgery. Embolization was performed using the IPSA through the internal jugular vein or IAA, based on angioarchitectural features.

RESULTS

Of the 32 patients with CSDAVF, 24 underwent embolization treatment through the internal jugular vein-IPSA and 8 patients underwent treatment through IAA. Nineteen patients in the IPSA group experienced mild headache, which improved after specific treatment. The immediate postembolization angiographic results revealed complete occlusion in 26 cases (18 IPSA and 8 IAA) and almost complete occlusion in 6 cases (IPSA). Complications that occurred during the procedure included abducens nerve palsy (n = 1, IPSA) and prosopoplegia (n = 1, IAA). One patient developed tinnitus, which was diagnosed as anterior cranial fossa new-onset dural arteriovenous fistula on DSA, whereas the symptoms of other patients all improved with no recurrence.

CONCLUSIONS

On the basis of the angioarchitectural features of CSDAVF, IAA can be considered the primary treatment when the blood-supplying artery and fistula are relatively singular, and when the microcatheter can easily reach the fistula through the artery. The venous approach should be selected as the primary approach when the fistula is indistinguishable and blood is supplied by multiple arteries through small plexiform vessels. Choosing the optimal surgical approach may increase the success rate of intravascular CSDAVF surgery and may help avoid complications.

Dural Arteriovenous Fistula Arising after Intracranial Surgery in Posterior Fossa of Nondominant Sinus: Two Cases and Literature Review

The results of recent clinical and experimental studies suggest that the most important factor associated with the pathogenesis of dural arteriovenous fistula (AVF) is sinus thrombosis and subsequent venous or intrasinus hypertension. Here, we describe two patients who each developed a dural AVF after a posterior fossa craniotomy on the side of the nondominant or hypoplastic transverse (TS)-sigmoid (SS) sinuses. A 63-year-old female underwent surgical resection of a meningioma in the left cerebellopontine angle. Preoperative subtraction digital angiography (DSA) revealed a hypoplastic, ipsilateral left TS-SS and the sinus occlusion was revealed after surgery. Sixteen months later, she presented with a progressive left retroauricular, pulse-synchronous bruit. An AVF in the left TS-SS region was diagnosed by DSA and treated with transvenous coil embolization. The patient recovered without neurological deterioration. A 56-year-old female underwent surgical removal of an epidermoid tumor in the right cerebellopontine angle. Preoperative DSA revealed severe, ipsilateral right TS stenosis and the sinus occlusion was revealed after surgery. Two years later, she presented with the progressive right retroauricular, pulse-synchronous bruit, which was diagnosed by DSA as dural AVF in the right TS-SS region. She was treated with transvenous coil embolization and recovered without neurological deterioration. Sinus manipulation during intracranial surgery carries a potential risk of dural AVF development and this should be carefully considered, even when the ipsilateral TS-SS is nondominant or appears hypoplastic.

Newly occurring cranial nerve palsy after endovascular treatment of cavernous sinus dural arteriovenous fistulas

OBJECTIVE

Cranial nerve palsy (CNP) is rarely reported after endovascular intervention for cavernous sinus dural arteriovenous fistulas (CS DAVFs). Our aim was to evaluate the treatment outcomes of CS DAVFs, and the clinical course and risk factors of newly occurring CNPs, with a review of the literature.

METHODS

121 patients with 134 lesions treated in our institution were selected. They were retrospectively analyzed in terms of baseline characteristics, radiologic results, clinical outcome, and newly occurring CNPs after treatment. Angiographic and clinical follow-up data were available for 104 lesions (77.6%) and 130 lesions (97.0%), respectively.

RESULTS

The angiographic results showed partial:complete obliterations in 13:91 (87.5%) at the final follow-up. Clinical outcomes were deteriorated or no change:improved or completely recovered (3:126 (96.9%)) at the final follow-up. New CNPs occurred in 24 patients (19.8%), including the sixth CNP alone or mixed in 23 patients (95.8%). 23 cases were completely recovered or improved (21 and 2 cases, respectively), and 19 (90.4%) of 21 were completely recovered within 6 months after treatment. In the multivariate analysis, pretreatment cranial nerve symptoms (OR=0.33; 95% CI 0.14 to 0.76; P=0.010) and complete obliteration immediately after treatment (OR=0.32; 95% CI 0.12 to 0.85; P=0.021) were significant preventive factors for new CNPs. Embolization in the posterior compartments of the CS (OR=5.15; 95% CI 1.71 to 15.47; P=0.004) was a significant risk factor.

CONCLUSIONS

Endovascular intervention was satisfactory in patients with CS DAVFs. The prognosis of newly occurring CNPs was favorable.

Vagal Nerve Palsy After Transarterial Embolization of Transverse-Sigmoid Dural Arteriovenous Fistula Using Onyx

OBJECTIVE

We report a case of a 70-year-old man who developed a transverse-sigmoid dural arteriovenous fistula (TS-DAVF) that was successfully treated by transarterial embolization (TAE) with Onyx.

CASE PRESENTATION

The patient presented with sudden and progressive disturbance of consciousness and left hemiparesis. Magnetic resonance imaging (MRI) revealed venous infarction and hemorrhagic changes with brain swelling in the right parietal lobe. Angiography revealed a right TS-DAVF and multiple occlusions with retrograde leptomeningeal venous drainage into the cortical veins. The TS-DAVF was graded as Borden type III and Cognard type IIa+b. Because of its progressive clinical nature and wide distribution of DAVF in the occluded sinus wall, he underwent emergent TAE with liquid embolic materials including n-butyl cyanoacrylate and Onyx under informed consent by his family. Complete obliteration of the TS-DAVF was achieved, leading to a marked amelioration of symptoms, and MRI after treatment confirmed a decrease in the brain swelling. However, he suffered transient dysphagia due to right vagal nerve palsy caused by occlusion of vasa nervorum of ascending pharyngeal artery. He returned home 5 months later with a modified Rankin Scale of 1.

CONCLUSIONS

TAE with Onyx appears to be effective for aggressive TS-DAVF with a widely distributed shunt. However, the blood supply to the cranial nerves and potentially dangerous anastomoses between the external-internal carotid artery and vertebral artery should be taken into account to avoid serious complications.

Technical Trick of Combined Embolization of Inaccessible Dural Arteriovenous Fistula by Endovascular Route Only

OBJECTIVE

Endovascular embolization of dural arteriovenous fistula may not be a feasible approach depending on the location and/or surrounding structures.

METHODS

Combined embolization comprising endovascular embolization by direct puncture of the sinus after small craniotomy under fluoroscopic guidance is a good treatment option for lesions that cannot be treated by endovascular embolization alone.

RESULTS

We presented 2 cases of dural arteriovenous fistula that could not be treated by endovascular embolization alone. Treatment included direct puncture of the sinus after small craniotomy to access and completely block the lesion.

CONCLUSIONS

Combined techniques are required for the management of complex dural arteriovenous fistula. We report a treatment method that can be used for lesions that cannot be treated by endovascular embolization alone along with some technical pitfalls.

Cranial Nerve Palsy after Onyx Embolization as a Treatment for Cerebral Vascular Malformation

The Onyx liquid embolic system is a relatively safe and commonly used treatment for vascular malformations, such as arteriovenous fistulas and arteriovenous malformations. However, studies on possible complications after Onyx embolization in patients with vascular malformations are limited, and the occurrence of cranial nerve palsy is occasionally reported. Here we report the progress of two different types of cranial nerve palsy that can occur after embolization. In both cases, Onyx embolization was performed to treat vascular malformations and ipsilateral oculomotor and facial nerve palsies were observed. Both patients were treated with steroids and exhibited symptom improvement after several months. The most common types of neuropathy that can occur after Onyx embolization are facial nerve palsy and trigeminal neuralgia. Although the mechanisms underlying these neuropathies are not clear, they may involve traction injuries sustained while extracting the microcatheter, mass effects resulting from thrombi and edema, or Onyx reflux into the vasa nervorum. In most cases, the neuropathy spontaneously resolves several months following the procedure.

Facial palsy after embolization of dural arteriovenous fistula: A case report and literature review

Background

Dural arteriovenous fistulas (DAVF) are unusual intracranial vascular malformations consisting of anomalous connections between meningeal arteries and dural sinuses or the veins that pass through them. They have variable clinical presentation and prognosis, which depend on their location and venous hemodynamics. Treatment is based on the closure of the abnormal connections, which is usually conducted via arterial and/or transvenous endovascular techniques.

Case Description

We present a male patient who complained of headaches and left-sided pulsatile tinnitus due to DAVF from the external carotid artery branches draining directly into the ipsilateral sigmoid sinus. Embolization with Onyx^® was successful, obtaining angiographic occlusion and symptom remission. However, on postoperative day 4, the patient presented with left facial palsy and spontaneous regression.

Conclusion

Although embolization is an effective and safe procedure, complications may occur. Reflux of the embolic agent to the vasa nervorum of the cranial nerve may lead to ischemic neuropathy. Here, we reported a case of embolized DAVF presenting with a postoperative peripheral facial palsy where the two embolized pedicles were branches of the middle meningeal and occipital arteries involved in the vascularization of the extratemporal segment of the facial nerve. We discuss the etiopathogenic, anatomical, and pathophysiological aspects of this complication.

Safety of Onyx Transarterial Embolization of Skull Base Dural Arteriovenous Fistulas from Meningeal Branches of the External Carotids also Fed by Meningeal Branches of Internal Carotid or Vertebral Arteries

PURPOSE

To analyze the angiographic and clinical results of transarterial embolization with Onyx (Medtronic-Covidien, Irvine, CA) in dural arteriovenous fistulas (DAVFs) partially fed by arteries arising from the carotid siphon or the vertebral arteries.

METHODS

We isolated 40 DAVFs supplied by either the tentorial artery of the internal carotid artery (ICA) or the posterior meningeal artery of the vertebral artery. These DAVFs were embolized with Onyx through the middle meningeal artery or the occipital artery. We reviewed the occurrence of reflux into the arteries of carotid or vertebral origin.

RESULTS

In all the cases, reflux occurred into the first millimeters of the DAVF arterial feeders arising from carotid or vertebral arteries but slowly enough to be controlled by interruption of Onyx injection. Reflux was always minimal and Onyx never reached the ostium of the arteries. No cerebral ischemic complications occurred in our series.

CONCLUSION

The behavior of Onyx is clearly different from that of cyanoacrylate glue, resulting in superior control during injection. Reflux into arteries arising from the ICA or vertebral artery during DAVF treatment always carries a risk of unintentional non-target embolization of normal cerebral vasculature but Onyx appears to be safe in this situation.

Transarterial Onyx Embolization of Intracranial Dural Fistulas: A Prospective Cohort, Systematic Review, and Meta-Analysis

BACKGROUND

Onyx is important embolic material in the endovascular treatment of intracranial dural arteriovenous fistula (DAVF). However, its impact on DAVF occlusion rates, morbidity, mortality, and complication rates is not fully examined.

OBJECTIVE

To improve understanding of safety and effectiveness profiles associated with transarterial endovascular treatment using Onyx for intracranial DAVF

METHODS

We analyzed data from our prospective clinical registry and conducted a systematic review of all previous transarterial embolization studies using Onyx published between January 2005 and December 2015 in MEDLINE and EMBASE.

RESULTS

In the prospective study, 41 transarterial procedures were performed in 33 consecutive patients harboring 36 DAVFs. Complete initial exclusion was obtained in 32 of 36 (88.9%) fistulas; 31 fistulas were followed up showing 4 (12.9%) recurrences. Procedure-related morbidity and mortality were 3% and 0%, respectively. The literature review identified 19 studies involving a total of 425 patients with 463 DAVFs. Meta-analysis, including our registry data, showed an initial complete occlusion rate of 82% (95% confidence interval [CI]: 74%, 88%; I2, 70.6%), and recurrence rate at midterm of 2% (95% CI: 0%, 5%; I2, 21.5%). Pooled postoperative neurological deficit, procedure-related morbidity, and mortality rates were 4% (95% CI: 2%, 6%; I2, 0%), 3% (95% CI: 1%, 5%; I2, 0%), and 0%, respectively.

CONCLUSION

This meta-analysis suggests that transarterial embolization with Onyx is a safe treatment modality for DAVFs. Although Onyx showed a low recurrence rate at midterm, the long-term risk is poorly addressed in our study and should warrant a longer follow-up.

A hemorrhagic complication after Onyx embolization of a tentorial dural arteriovenous fistula: A caution about subdural extension with pial arterial supply

We report a case of tentorial dural arteriovenous fistula (DAVF) with a severe intracranial hemorrhage occurring after Onyx embolization. A 40-year-old man presented with an asymptomatic tentorial DAVF on angiography. Transarterial embolization with Onyx was performed via the middle meningeal artery, and the cast filled the fistula itself and its proximal draining vein. Postoperative angiography confirmed complete occlusion of the DAVF. A computed tomography scan performed immediately after the procedure demonstrated an acute subdural hematoma with the temporal hemorrhage. Emergency craniotomy revealed continuous arterial bleeding from a viable glomus-like vascular structure around the proximal part of the embolized draining vein, fed by a pial artery arising from the posterior cerebral artery. Pathologic findings suggested diagnosis of vascular malformation extending into the subdural space. Tentorial DAVFs can extend to the subdural space along their drainage route, and may be involved in severe hemorrhagic complications of curative endovascular treatment using Onyx, particularly those with pial arterial supply.

Spontaneous Aggressive Conversion of Venous Drainage Pattern in Dural Arteriovenous Fistula Treated with Onyx Embolization

We report a case of dural arteriovenous fistula (DAVF) that showed spontaneous conversion of venous drainage pattern from Borden type II to type III within a four month period of follow-up. Upon admission, the patient presented with aggravated neurologic status and newly developed seizure. After admission, endovascular embolization was performed through the middle meningeal artery with Onyx®. Complete obliteration of dural arteriovenous shunt was confirmed by angiography, and the patient's clinical symptoms improved. Although most cases of DAVF show benign clinical course and conversion pattern, close follow-up is required to detect potential aggravation.

Coil embolization through the Marathon microcatheter: Advantages and pitfalls

Due to technical limitations, small, distal, and tortuous intracranial pathology is sometimes out of reach of the current armamentarium of microcatheters designed for intracranial coil embolization. The Marathon microcatheter (Medtronic, Minneapolis, Minnesota, USA), designed specifically for the delivery of Onyx, is longer and more flexible than most coil delivery catheters. We report on nine patients (three with arteriovenous fistula, three with arteriovenous malformation, two with intracranial aneurysm, and one with tumor) where Marathon was used to deliver commercially available platinum coils. We also conducted laboratory compatibility testing and conclude that the Marathon can be used as a coil delivery catheter for Barricade coils (Blockade Medical, Irvine, California, USA) with diameter less than 0.012 in.

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

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

Facial palsy following embolization of a dural arteriovenous fistula

Intracranial arteriovenous malformations are infrequent. Advances in endovascular treatment techniques have promoted the use of endovascular embolization in management of intracranial arteriovenous malformations. Transvenous or transarterial embolization procedures are effective options in the treatment of the arteriovenous fistulas. However, complications such as cranial nerve palsies may occur. Here, we present a case of right-sided lower motor neuron facial paralysis due to embolization of an intracranial dural arteriovenous fistula that have presented with clinical findings on the left eye. Facial functions of the patient improved from total weakness to House-Brackmann grade II, following facial nerve decompression surgery.

Dural arteriovenous fistulas of the hypoglossal canal: systematic review on imaging anatomy, clinical findings, and endovascular management

Dural arteriovenous fistulas (DAVFs) of the hypoglossal canal (HCDAVFs) are rare and display a complex angiographic anatomy. Hitherto, they have been referred to as various entities (for example, “marginal sinus DAVFs”) solely described in case reports or small series. In this in-depth review of HCDAVF, the authors describe clinical and imaging findings, as well as treatment strategies and subsequent outcomes, based on a systematic literature review supplemented by their own cases (120 cases total). Further, the involved craniocervical venous anatomy with variable venous anastomoses is summarized. Hypoglossal canal DAVFs consist of a fistulous pouch involving the anterior condylar confluence and/or anterior condylar vein with a variable intraosseous component. Three major types of venous drainage are associated with distinct clinical patterns: Type 1, with anterograde drainage (62.5%), mostly presents with pulsatile tinnitus; Type 2, with retrograde drainage to the cavernous sinus and/or orbital veins (23.3%), is associated with ocular symptoms and may mimic cavernous sinus DAVF; and Type 3, with cortical and/or perimedullary drainage (14.2%), presents with either hemorrhage or cervical myelopathy. For Types 1 and 2 HCDAVF, transvenous embolization demonstrates high safety and efficacy (2.9% morbidity, 92.7% total occlusion). Understanding the complex venous anatomy is crucial for planning alternative approaches if standard transjugular access is impossible. Transarterial embolization or surgical disconnection (morbidity 13.3%–16.7%) should be reserved for Type 3 HCDAVFs or lesions with poor venous access. A conservative strategy could be appropriate in Type 1 HCDAVF for which spontaneous regression (5.8%) may be observed.

Shunted pouches of cavernous sinus dural AVFs: evaluation by 3D rotational angiography

INTRODUCTION

The aims of this study were to evaluate the angioarchitecture of cavernous sinus dural arteriovenous fistulas (CSdAVFs), including the number and location of shunted pouches (SPs), and to evaluate whether the location and number of the SPs affect the outcomes of transvenous embolization of CSdAVFs.

METHODS

Nineteen consecutive cases of CSdAVFs that underwent rotational angiography and transvenous embolization were reviewed. Multiplanar reconstruction images of rotational angiography and selective angiography were reviewed with particular interest in the SPs. Relationships of the locations and number of SPs with the results of transvenous embolization were statistically analyzed.

RESULTS

All cases showed SPs, with numbers ranging from 1 to 4 (mean, 2.2). The location of the SPs was "posteromedial" in 16, "posterolateral" in 13, "lateral" in 6, and "medial" in 3 patients. Six cases showed posteromedial SPs alone, and three cases showed posterolateral SPs alone. The other 10 cases showed multiple locations of SPs. All cases were treated by transvenous embolization with sinus packing (n = 11) or selective embolization of the SP (n = 8). Complete occlusion of dAVF was obtained in 16 cases immediately after embolization. Locations of SPs and drainage types were significantly associated with the immediate angiographic results (p < 0.01).

CONCLUSION

The SP of CSdAVFs is often multiple and is located posteriorly to the CS. The number and location of SPs affect immediate angiographic results of transvenous embolization.

Long-Term Endovascular Treatment Outcome of 46 Patients with Cavernous Sinus Dural Arteriovenous Fistulas Presenting with Ophthalmic Symptoms. A Non-Controlled Trial with Clinical and Angiographic Follow-up

Ocular symptoms are regularly observed in patients with cavernous sinus dural arteriovenous fistulas (cDAVF). We aimed to evaluate the long-term efficacy and safety of endovascular approaches in patients with cDAVF presenting with different ocular symptoms. In a prospective study between June 2008 and March 2013, 46 patients with ocular symptoms due to cDAVF who were not eligible for conservative therapy, met the inclusion criteria and underwent endovascular treatment. They underwent a transarterial approach with histoacryl glue injections or transvenous coil embolization, all in one session. They were followed up for a mean period of 17.3 months (range 7 to 30 months) clinically and using angiography. The mean age of patients was 36.8 years (18-60) and 65% of them were male. All patients showed venous drainage into the superior and inferior orbital veins. Access to the cavernous sinus was transvenous in ten patients, transarterial in 26 patients, and mixed in ten patients. Initial symptoms were improved in 97.8% of patients and did not recur during the study follow-up. The procedural complications included: blurred vision, transient sixth nerve palsy and exacerbation of chemoproptosis in two, one and two patients respectively that completely resolved in initial weeks with no recurrence. No patient worsened or developed new symptoms suggestive of a recurrent fistula during the follow-up period. One patient experienced intracranial dissection of the internal carotid artery and ischemic stroke with an unfinished procedure. The relief of early presentation was durable in long-term follow-up and the cured lesions were stable in angiographic controls. Favorable and durable outcomes could be obtained following endovascular approaches for cDAVF presenting with different ocular symptoms.

Issues in the diagnosis and management of the papilledema shunt

BACKGROUND

Dural arteriovenous fistulas (DAVFs) that shunt blood into the transverse or superior sagittal venous sinuses cause papilledema by raising intracranial pressure ("the papilledema shunt"). Such fistulas pose unique diagnostic and therapeutic challenges.

METHODS

Case report and literature review.

RESULTS

In a patient presenting with papilledema, non-invasive brain vascular imaging disclosed subtle signs of a DAVF. Digital angiography delineated the DAVF and revealed cortical venous reflux. After three transarterial embolizations with ethylene vinyl alcohol, the DAVF was closed and papilledema resolved.

CONCLUSIONS

The imaging features of a DAVF that cause papilledema may be subtle on non-invasive vascular imaging. If overlooked, and lumbar puncture is performed, there is a substantial risk of brain herniation. Cortical venous reflux, which may be relatively common in these DAVFs, impels the need for endovascular closure. The transvenous route, often employed for closing cavernous sinus DAVFs, should be avoided because of the dangers of dural venous sinus thrombosis.

Transarterial onyx embolization of cranial dural arteriovenous fistulas: long-term follow-up

BACKGROUND AND PURPOSE

Endovascular therapy with liquid embolic agents is a common treatment strategy for cranial dural arteriovenous fistulas. This study evaluated the long-term effectiveness of transarterial Onyx as the single embolic agent for curative embolization of noncavernous cranial dural arteriovenous fistulas.

MATERIALS AND METHODS

We performed a retrospective review of 40 consecutive patients with 41 cranial dural arteriovenous fistulas treated between March 2006 and June 2012 by using transarterial Onyx embolization with intent to cure. The mean age was 57 years; one-third presented with intracranial hemorrhage. Most (85%) had cortical venous drainage. Once angiographic cure was achieved, long-term treatment effectiveness was assessed with DSA and clinical follow-up.

RESULTS

Forty-nine embolization sessions were performed; 85% of cranial dural arteriovenous fistulas were treated in a single session. The immediate angiographic cure rate was 95%. The permanent neurologic complication rate was 2% (mild facial palsy). Thirty-five of the 38 patients with initial cure underwent short-term follow-up DSA (median, 4 months). The short-term recurrence rate was only 6% (2/35). All patients with occlusion at short-term DSA undergoing long-term DSA (median, 28 months) had durable occlusion. No patient with long-term clinical follow-up (total, 117 patient-years; median, 45 months) experienced hemorrhage.

CONCLUSIONS

Transarterial embolization with Onyx as the single embolic agent results in durable long-term cure of noncavernous cranial dural arteriovenous fistulas. Recurrence rates are low on short-term follow-up, and all patients with angiographic occlusion on short-term DSA follow-up have experienced a durable long-term cure. Thus, angiographic cure should be defined at short-term follow-up angiography instead of at the end of the final embolization session. Finally, long-term DSA follow-up may not be necessary if occlusion is demonstrated on short-term angiographic follow-up.

Superselective shunt occlusion for the treatment of cavernous sinus dural arteriovenous fistulae

BACKGROUND

In treating cavernous sinus dural arteriovenous fistulae (CSdAVFs), transvenous embolization of the whole affected sinus is usually performed, which may result in the disturbance of normal venous drainage or permanent cranial nerve palsy.

OBJECTIVE

To describe superselective shunt occlusion of CSdAVFs.

METHODS

Between July 2005 and August 2011, we had 20 consecutive cases of CSdAVFs. In 14 cases (70%), we could detect the restricted locus of arteriovenous shunts by 3-dimensional rotational angiography and/or superselective arteriography. After navigating the microcatheter to the shunt segment, consecutive superselective arteriovenography was performed to confirm the location of the microcatheter at the proper position.

RESULTS

In 12 of 14 cases (85.7%) in which the shunt was restricted, coiling only in the small venous pouch or compartment, which was just downstream of the shunt point, led to complete disappearance of the shunt without obliterating the entire sinus. No recurrence or permanent cranial nerve palsy was observed during the follow-up period with a mean of 46 months (range, 3-69 months) in 12 cases treated by superselective shunt occlusion.

CONCLUSION

This technique, which enables complete extirpation of shunts by small amounts of coils, is a feasible way to treat CSdAVFs with excellent mid- to long-term results. Understanding of the angioarchitecture by 3-dimensional rotational angiography and consecutive superselective arteriovenography was useful. This method should be considered before sinus packing or mere obliteration of dangerous venous outlets.

Balloon-assisted superselective microcatheterization for transarterial treatment of cranial dural arteriovenous fistulas: technique and results

BACKGROUND

In transarterial embolization of anterior cranial fossa and tentorial dural arteriovenous fistula (DAVF), acute angulation of the feeding artery off the internal carotid artery (ICA) may render stable distal catheterization and, therefore, successful transarterial treatment difficult. In some anatomic dispositions, following selection of the feeding artery, subsequent forward force may lead to prolapse of the microcatheter into the ICA rather than advancing it into either the ophthalmic artery or the meningohypophyseal trunk.

OBJECTIVE

We describe a technique that facilitates stable positioning of the microcatheter by using a nondetachable balloon to temporally block the ICA distal to the feeding artery to redirect the catheter into the feeder and to prevent the microcatheter from protruding into the parent artery.

METHODS

In 8 cases where routine superselective microcatheterization failed, a balloon was used to block the ICA distal to the feeding artery in an attempt to facilitate superselective microcatheterization. The balloon was inflated following selection of the feeding vessel with the microcatheter and was kept inflated while advancing the catheter.

RESULTS

: Distal stable microcatheter positions could be obtained in all cases, which enabled us to treat the respective DAVFs with a liquid embolic agent. All 8 cases were angiographically cured with penetration of the liquid embolic agent from the distal artery to the proximal vein, and no procedure-related complications occurred.

CONCLUSION

The described technique may be a helpful adjunct to gain stable distal microcatheter positions during the transarterial treatment of DAVF.

Carotid and vertebral artery sacrifice with a combination of Onyx and coils: technical note and case series

INTRODUCTION

Permanent vessel sacrifice has become a routine for the management of aneurysms, pseudoaneurysms, tumors, and carotid blowouts. The purpose of this study is to describe a new technique for carotid and vertebral artery sacrifice using a combination of Onyx and coils and to assess its feasibility, safety, and efficacy.

METHODS

The technique consists of deploying a few coils in the parent vessel under proximal flow arrest followed by Onyx embolization directly into the coil mass. A total of 41 patients underwent carotid/vertebral artery sacrifice using this technique in our institution.

RESULTS

A total of 26 internal carotid arteries and 15 vertebral arteries were treated. In all but one patient, a balloon test occlusion was performed prior to permanent arterial sacrifice. The mean number of coils used was 6.8 (range, 2-19). The total volume of Onyx used was 1.3 ml on average (range, 0.2-5.2 ml). All 41 (100%) parent arteries were successfully occluded. No distal migration of Onyx or coils was noted. Periprocedural complications occurred in 14.6% (6/41) of cases causing permanent morbidity in 7.3% (3/41). No patient developed a recurrence during the follow-up period (mean, 14 months).

CONCLUSION

Parent vessel sacrifice with a combination of Onyx and coils appears to be feasible, safe, and effective and may be an alternative to the traditional deconstruction technique with coils alone. The risk of thromboembolism exists with this technique, but there were no instances of Onyx migration.

Onyx embolization of intracranial arteriovenous malformations in pediatric patients

OBJECT

The authors undertook this study to assess the safety and efficacy of Onyx embolization in the treatment of intracranial arteriovenous malformations (AVMs) in pediatric patients.

METHODS

All pediatric Onyx embolization of intracranial AVM cases performed consecutively at a single children's hospital over a 5-year period were collected and evaluated.

RESULTS

Twenty-five patients (mean age 10.5 years) underwent a total of 38 procedures. An aggregate of 56 pedicles were embolized (mean 1.47 per session). The Spetzler-Martin grade was determined in all cases. Onyx embolization resulted in complete obliteration of the AVM in 3 cases (12%) and partial obliteration in 22 cases (88%). A total of 23 patients underwent surgical treatment. The mean preoperative AVM devascularization in these cases was 72%. One patient was treated with radiosurgery following Onyx embolization. Overall, 10 complications occurred in a total of 38 procedures (26.3%). None of the complications resulted in permanent neurological morbidity. The rate of transient neurological complications was 10.5% (4 of 38 procedures) and the rate of transient nonneurological complications was 5.3% (2 of 38 procedures). The remaining 4 complications were clinically silent (rate of 10.5%). There were no procedure-related deaths in this study population. There was no significant difference in patients with and without complications in terms of demographic characteristics, AVM grade, or embolization features (p ≥ 0.2). Deep venous drainage was associated with higher complication rates (p = 0.03).

CONCLUSIONS

Onyx utilization is feasible for preoperative or primary embolization in the treatment of pediatric intracranial AVMs; however, the spectrum of complications encountered is broad, and attention must be paid to the technical nuances of and indications for its use to avoid many potential dangerous effects. Although the overall complication rates were higher than expected, all were either clinically silent or had only transient clinical effects. Thus, this experience suggests that Onyx embolization can be performed safely with a low rate of permanent morbidity in pediatric patients harboring these difficult lesions.

Onyx embolization of anterior condylar confluence dural arteriovenous fistula

The anterior condylar confluence (ACC) is a small complex venous structure located medial to the jugular vein and adjacent to the hypoglossal canal. To our knowledge, this is the first report of transvenous Onyx embolization for ACC dural arteriovenous fistula (DAVF). Three patients with ACC DAVF were treated using the Onyx liquid embolic agent with or without detachable coils. Complete angiographic obliteration of the fistulas was achieved in all cases without permanent lower cranial neuropathy. This report suggests that the controlled penetration of Onyx is advantageous in order to obliterate ACC DAVFs with a small amount of embolic material.

Facial and lower cranial neuropathies after preoperative embolization of jugular foramen lesions with ethylene vinyl alcohol

OBJECTIVE

To report 3 unique cases of cranial neuropathy after super-selective arterial embolization of jugular foramen vascular tumors with ethylene vinyl alcohol.

STUDY DESIGN

Clinical capsule report.

SETTING

Three tertiary academic referral hospitals.

PATIENTS

Three patients who underwent superselective arterial embolization (SSE) of head and neck paragangliomas with ethylene vinyl alcohol are described. One individual was treated with primary SSE, whereas the remaining tumors were treated with preoperative SSE followed by surgical extirpation within 72 hours. All patients were found to have new cranial nerve deficits after SSE.

RESULTS

One patient with isolated complete cranial nerve VII palsy demonstrated partial return of function at 8 months. One individual experienced cranial nerve VII, X, and XII palsies and demonstrated partial recovery of function of the involved facial nerve after 19 months. One subject experienced ipsilateral cranial nerve X and XI palsies after SSE and recovered full function of the spinal accessory nerve within 1 week but failed to demonstrate mobility of the ipsilateral true vocal fold.

CONCLUSION

We present the first report documenting facial and lower cranial neuropathies after super-selective embolization of head and neck paragangliomas with EVA. Although it is difficult to draw conclusions from this small number of cases, it is plausible that the use of ethylene vinyl alcohol during SSE may result in a higher risk of permanent cranial neuropathy than the use of other well-established and more temporary agents. Knowledge of the arterial supply to the cranial nerves can help the clinician to choose the embolization agent that will provide maximal occlusion while minimizing the risk of complications.

Endovascular management of intracranial dural arteriovenous fistulas: a review

Dural arteriovenous fistulas (DAVFs) are rare pathological entities presenting with a diverse clinical course, ranging from benign to life-threatening. Digital subtraction angiography remains the gold standard in the diagnosis of clinically suspected DAVFs. This article reviews the ethiopathogenesis, natural history, classification systems, clinical and angiographic features, and the current treatment strategies for these complex lesions. The management of DAVFs may include conservative treatment, endovascular intervention, microsurgery, and stereotactic radiosurgery. A multidisciplinary approach involving a neurosurgeon, interventional neuroradiologist, and neurologist is required before considering any type of treatment modality. The indication for the best therapeutic alternative must be individualized for each patient.