Endovascular Management of Intracranial Dural AVFs: Principles

Quest for the optimal venous access in a complex skull base dural fistula: Case illustrations and principles

Treatment of dural arteriovenous fistulae (DAVFs) is dynamic and evolves between diagnostic and therapeutic angiography.A 79-year-old man with a left jugular foramen DAVF presented with new onset cranial nerve XII palsy. The DAVF progressed from Cognard grade I to IIa + b. A transvenous approach was chosen. Attempts to access the left inferior petrosal sinus (IPS) via the left internal jugular vein failed due to occlusion. An alternative route through the left superior ophthalmic vein and left cavernous sinus to the IPS was devised. Successful coil occlusion of the IPS was achieved. Postoperatively, symptoms resolved, and angiography showed no cortical venous reflux.

Acquired progressive torcular dural arteriovenous fistula after subtotal resection of peritorcular meningioma

A woman in her mid-50s who had undergone a subtotal resection of a peritorcular meningioma 3 years earlier presented with symptoms suggestive of increased intracranial pressure. A delayed diagnosis of a torcular dural arteriovenous fistula (dAVF) diagnosis was made on MRI. Digital subtraction angiography confirmed a torcular dAVF (Borden type II). Staged 3 rounds of transarterial (TA) embolisation were performed using n-butyl cyanoacrylate, ethylene vinyl alcohol copolymer and coils of the complex torcular dAVF, which significantly reduced the flow and corresponded with improved symptoms of pulsatile tinnitus, vision and headache. We reviewed previously reported cases of dAVFs that developed after craniotomy for meningioma resection. Despite its rarity, a torcular dAVF can develop after craniotomy and progress from low to high grade due to its location. Diagnosis requires a thorough understanding of subtle imaging findings, which may be present in follow-up studies obtained for tumour surveillance.

Transvenous balloon-assisted approach to anterior fossa dural arteriovenous fistula using retrograde pressure cooker technique

Endovascular embolization is the first-line therapy for dural arteriovenous fistulas (dAVFs). Transarterial embolization (TAE) may be limited by poor anatomical access. Transvenous embolization avoids this, but carries a risk of hemorrhage, venous redirection, and neurologic deterioration. Dual-lumen balloon microcatheters like the Scepter Mini (Microvention, Aliso Viejo, CA, USA) provide flow arrest and prevent reflux during TAE with liquid embolic agents (LEAs), but use in the distensible veins may be challenging. In this video, we use a Scepter Mini in a transvenous approach to a Cognard type IV anterior ethmoidal dAVF as a safe alternative to surgery, transvenous pressure cooker, and trans-ophthalmic TAE (video 1). The Scepter Mini was navigated transvenously to the anterior superior sagittal sinus. LEA was injected with excellent penetration to the venous pouch and further penetration into the network of tortuous feeders. No neurologic complications were experienced, and follow-up angiogram 9 months later demonstrated cure of the dAVF. Video 2 describes procedural considerations in transvenous approaches, steps of the procedure, and includes references1-10 which are relevant to this topic. neurintsurg;16/11/1200/V1F1V1Video 1  neurintsurg;16/11/1200/V2F2V2Video 2 .

Tigroid Enhancement: A Characteristic Enhancement Pattern of the Cerebellar Hemisphere on MRI With Intracranial Dural Arteriovenous Fistulas

PURPOSE

This study aims to investigate a characteristic cerebellar hemisphere enhancement pattern on magnetic resonance imaging (MRI) that could aid in early and specific diagnosis of intracranial dural arteriovenous fistulas (DAVFs).

MATERIALS AND METHODS

Pretreatment MR images of 57 patients with intracranial DAVFs between January 1, 2017, and February 28, 2023, were retrospectively analyzed. A total of 128 patients with confirmed alternative cerebellar lesions during the same period were included as a control group. All patients underwent enhanced MRI with a 3.0T scanner. The presence or absence of parallel enhanced linear striations on the surface of the cerebellar lesions was documented. Statistically significant differences were determined by the Fisher exact test.

RESULTS

Cerebellar lesions were identified in 4 intracranial DAVF patients (7.0%). All 4 patients were male, with an average age of 64 years (range: 58-76 years). The pretreatment MR images of all 4 DAVF patients with cerebellar lesions demonstrated the characteristic tigroid enhancement pattern. Tortuous flow voids were present in the MR images of 3 of the 4 patients. Tigroid enhancement pattern was not observed in the remaining 53 intracranial DAVF patients and all control patients. The differences in the incidence of the pattern were significant (p=0.01).

CONCLUSION

A characteristic tigroid enhancement pattern of the cerebellar hemisphere on MRI may aid in the early and specific diagnosis of intracranial DAVFs, allowing timely treatment and improving outcomes.

CLINICAL IMPACT

The identification of a characteristic tigroid enhancement pattern on MRI for cerebellar hemisphere lesions holds significant promise for clinical practice. This pattern serves as a distinctive marker aiding in the early and specific diagnosis of intracranial dural arteriovenous fistulas (DAVFs). Clinicians can now utilize this innovative finding to expedite diagnostic workflows, enabling timely intervention and management strategies. The incorporation of this novel imaging feature enhances diagnostic accuracy, potentially reducing misdiagnosis rates and preventing delays in treatment initiation. Ultimately, this advancement may lead to improved patient outcomes and quality of care in neurosurgical and neuroradiological practice.

In-out-in technique for petrosal sinus dural arteriovenous fistula obliteration: How I Do It

BACKGROUND

Dural arteriovenous fistulas (dAVFs) at the superior petrosal sinus are a rare but important subtype that pose a high risk of mortality and morbidity. Treatment for these lesions can be challenging with stand-alone endovascular methods.

METHODS

We describe our "in-out-in" technique for disconnecting dAVFs at the superior petrosal sinus, which includes definitive sacrifice of the superior petrosal sinus and the transverse sigmoid sinus, if involved. This method achieves complete fistula obliteration and minimizes recurrence risk with new arterial feeders.

CONCLUSIONS

The in-out-in technique is a safe and effective approach for the treatment of dAVFs involving the superior petrosal sinus.

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 Dural Arteriovenous Fistulas

Dural arteriovenous fistulas (DAVFs) are abnormal communications between meningeal arteries and dural venous sinuses and/or cortical veins. Although many fistulas are benign and do not require treatment, some may carry a significant risk of bleeding or cause symptoms and warrant treatment. This review provides a review of various aspects of intracranial DAVFs including epidemiology, pathophysiology, clinical presentation, imaging characteristics, classification, natural history, and management options. By exploring these topics, we aim to enhance understanding of this condition and facilitate patient care.

Multimodal MRI diagnosis and transvenous embolization of a basicranial emissary vein dural arteriovenous fistula: A case report

A dural arteriovenous fistula (DAVF) is an abnormal linkage connecting the arterial and venous systems within the intracranial dura mater. A basicranial emissary vein DAVF drains into the cavernous sinus and the ophthalmic vein, similar to a cavernous sinus DAVF. Precise preoperative identification of the DAVF location is a prerequisite for appropriate treatment. Treatment options include microsurgical disconnection, endovascular transarterial embolization (TAE), transvenous embolization (TVE), or a combination thereof. TVE is an increasingly popular approach for the treatment of DAVFs and the preferred approach for skull base locations, due to the risk of cranial neuropathy caused by dangerous anastomosis from arterial approaches. Multimodal magnetic resonance imaging (MRI) can provide anatomical and hemodynamic information for TVE. The therapeutic target must be precisely embolized in the emissary vein, which requires guidance via multimodal MRI. Here, we report a rare case of successful TVE for a basicranial emissary vein DAVF, utilizing multimodal MRI assistance. The fistula had vanished, pterygoid plexus drainage had improved, and the inferior petrosal sinus had recanalized, as observed on 8-month follow-up angiography. Symptoms and signs of double vision, caused by abduction deficiency, disappeared. Detailed anatomic and hemodynamic assessment by multimodal MRI is the key to guiding successful diagnosis and treatment.

Update on Management of Dural Arteriovenous Fistulas

Abstract: Dural Arteriovenous Fistulas (AVF) represent about 10% of all intracranial vascular lesions. Although they seem benign in nature, the presence of retrograde venous makes them aggressive, with a high risk of complications. Patients may be clinically asymptomatic or experience symptoms ranging from mild to severe hemorrhage, depending on their location. Different treatments are available, but recently, the development of catheter intervention allows most patients to be cured with transcatheter embolization. Stereotactic radiosurgery achieves excellent rates of obliteration for low-grade lesions. In this review, we try to highlight the recent advances in the management of dural AVF.

[Cerebral dural arteriovenous fistulas]

CLINICAL ISSUE

The cerebral dural arteriovenous (AV) fistula is a rare cerebral vascular malformation. Clinical presentation varies from asymptomatic to acute intracranial bleeding. Classification is based on the venous drainage with a risk assessment of bleeding. The carotid-cavernous fistula is a subtype with its own classification and treatment approaches.

PRACTICAL RECOMMENDATIONS

Nowadays, dural fistulas can be diagnosed using high-resolution and time-resolved tomographic methods. Catheter angiography with subsequent interdisciplinary discussion should be performed for precise classification and therapy planning. Both endovascular and surgical treatment methods are available.