Surgical obliteration in superior petrosal sinus dural arteriovenous fistula

Transarterial embolization of petrosal dural arteriovenous fistula (dAVF): Feasible and successful in the post-Onyx era

Background

Intracranial dural arteriovenous fistula (dAVF) is a rare arteriovenous malformation with potentially severe complications. This study investigates the efficacy and safety of transarterial embolization (TAE) in treating petrous dAVFs through a retrospective analysis and literature review.

Case Description

A retrospective analysis of six patients with petrous dAVFs treated with TAE was conducted, accompanied by a systematic literature review to evaluate treatment outcomes. Data collection included patient characteristics, clinical presentation, Borden-Shucart and Cognard classifications, treatment specifics, and overall outcomes. TAE, particularly utilizing Onyx, demonstrated favorable outcomes in our six patients. Regarding literature review results, 102 articles were identified through PubMed Mesh tool search, but only five were included after careful evaluation. In addition, one article was manually added after searching for the remaining articles. Combining our six cases with literature findings, 79.8% (n = 75) of patients undergoing TAE achieved a cure with the technique, though Onyx was reported in only 13.9% (n = 13) of TAE cases. Complications were observed in 11.7% (n = 11) of TAE cases.

Conclusion

Our presented cases and literature review suggest that the TAE of dAVFs is feasible and curative for selected cases of petrous dAVFs. However, the complexity of these lesions and the availability of other treatment modalities should be taken into consideration to optimize cure rates and patient outcomes.

Dural arteriovenous fistula involving superior petrosal sinus with petrosal venous drainage in association with cerebral venous thrombosis: Literature review and illustrative case

Background

Dural arteriovenous fistulas (DAVFs) involving superior petrosal sinus (SPS) and superior petrosal vein (SPV) are extremely rare. The pathogenesis of these fistulas remains unclear. We are illustrating 2 cases of DAVFs involving the superior petrosal sinus and veins associated with venous sinus thrombosis with a literature review.

Methods

We reviewed the literature using the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines focusing on DAVFs involving the SPS and/or SPV. Additionally, we searched for additional articles through the reference lists of the included studies.

Results

Our review yielded 20 articles from 1997 until 2022 involving 33 patients with 34 fistulas, including our 2 patients. The mean age was 55.1 ± 12.9 years (range 25-85), 54.5% were males (n = 18). The patients presented with hemorrhage in 36.4% (n = 12), and progressive myelopathy in 30.3% (n = 10). Most fistulas often had arterial supply from MMA, MHT, and/or OA. The fistulas had infratentorial drainage in 64.71% (n = 22), supratentorial drainage in 23.53% (n = 8), and both supra and infratentorial drainage in 11.76% (n = 4). In 27.3% (n = 9), cerebral venous thrombosis was mentioned or identified. Endovascular treatment was performed in 47.1% of cases (n = 16), surgery in 29.4% (n = 10), and combination of treatments in 23.5% (n = 8). A total of 30.3% (n = 10) of cases had incomplete recovery or poor result.

Conclusion

DAVFs involving the SPS and/or SPV are associated with aggressive natural history, requiring early diagnosis and prompt treatment, leading to good prognosis. These fistulas may be acquired in origin, probably secondary to cerebral venous thrombosis.

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 for dural arteriovenous fistulas in the petroclival region

Petroclival region dural arteriovenous fistulas (DAVFs) are rare and difficult lesions to manage. They often have very complex anatomical structures and can be further divided into the superior petrosal sinus, petrous apex, inferior petrosal sinus, upper clival, and upper clival epidural-osseous DAVFs. Most petroclival region DAVFs should be treated due to their high Cognard grades. Currently, endovascular treatment (EVT) has become the first-line therapeutic option for petroclival region DAVFs. But not all the petroclival region DAVFs could be cured with EVT. When the arterial feeders are large or the DAVF is adjacent to the venous sinus, the success rate may be higher. In petroclival region DAVFs, if EVT can be performed successfully, satisfactory outcome can be anticipated. However, there are some inadvertent complications, which include cranial nerve palsy, subsequent sinus thrombosis, and migration embolization of the internal carotid artery and vertebral artery. Currently, a review of the EVT of petroclival region DAVFs is lacking. In this article, we performed a review of the relevant literature on this issue. In addition, some illustrative cases would be provided to elaborate these specific entities.

Preservation of Coexisting Normal Superior Petrosal Vein in the Microsurgical Treatment of Superior Petrosal Sinus Dural Arteriovenous Fistulas Assisted by Indocyanine Green Video Angiography

BACKGROUND

Superior petrosal sinus (SPS) dural arteriovenous fistulas (DAVFs) are a common subtype of tentorial DAVFs that often require microsurgical treatment. We have noted a rare condition involving the presence of a coexisting normal superior petrosal vein (SPV) during surgery for SPS DAVFs; this condition has not been reported in the literature. Identification and preservation of coexisting normal veins are crucial to prevent venous complications.

METHODS

We reviewed data of 12 patients with SPS DAVFs who underwent microsurgical treatment. Intraoperative indocyanine green video angiography was used to confirm the location of the fistula and identify the normal SPV. Postoperative radiologic examination was performed, and the clinical outcome was evaluated with the modified Rankin Scale.

RESULTS

A coexisting normal functional SPV was found in 6 cases. Analysis of the tributaries of the SPV showed the vein of the cerebellopontine fissure was the most frequent arterialized drainage vein (66.7%), while the pontotrigeminal vein was the most frequent normal drainage vein (45.5%). The DAVFs were easily identified and disrupted using intraoperative indocyanine green video angiography. The normal SPV was also successfully preserved. All 6 patients experienced good clinical and radiologic outcomes.

CONCLUSIONS

An SPS DAVF can coexist with a normal functional SPV, which should be preserved. Use of indocyanine green video angiography is an efficient way to identify the normal SPV.

The oculomotor-tentorial triangle. Part 2: a microsurgical workspace for vascular lesions in the crural and ambient cisterns

OBJECTIVE

Pathology in the region of the basilar quadrifurcation, anterolateral midbrain, medial tentorium, and interpeduncular and ambient cisterns may be accessed anteriorly via an orbitozygomatic (OZ) craniotomy. In Part 1 of this series, the authors explored the anatomy of the oculomotor-tentorial triangle (OTT). In Part 2, the versatility of the OTT as a surgical workspace for treating vascular pathology is demonstrated.

METHODS

Sixty patients with 61 vascular pathologies treated within or via the OTT from 1998 to 2017 by the senior author were retrospectively reviewed. Patients were grouped together based on pathology/surgical procedure and included 1) aneurysms (n = 19); 2) posterior cerebral artery (PCA)/superior cerebellar artery (SCA) bypasses (n = 24); 3) brainstem cavernous malformations (CMs; n = 14); and 4) tentorial region dural arteriovenous fistulas (dAVFs; n = 4). The majority of patients were approached via an OZ craniotomy, wide sylvian fissure split, and temporal lobe mobilization to widen the OTT.

RESULTS

Aneurysm locations included the P1-P2 junction (n = 7), P2A segment (n = 9), P2/3 (n = 2), and basilar quadrification (n = 1). Aneurysm treatments included clip reconstruction (n = 12), wrapping (n = 3), proximal occlusion (n = 2), and trapping with (n = 1) or without (n = 1) bypass. Pathologies in the bypass group included vertebrobasilar insufficiency (VBI; n = 3) and aneurysms of the basilar trunk (n = 13), basilar apex (n = 4), P1 PCA (n = 2), and s1 SCA (n = 2). Bypasses included M2 middle cerebral artery (MCA)-radial artery graft (RAG)-P2 PCA (n = 8), M2 MCA-saphenous vein graft (SVG)-P2 PCA (n = 3), superficial temporal artery (STA)-P2 PCA (n = 5) or STA-s1 SCA (n = 3), s1 SCA-P2 PCA (n = 1), V3 vertebral artery (VA)-RAG-s1 SCA (n = 1), V3 VA-SVG-P2 PCA (n = 1), anterior temporal artery-s1 SCA (n = 1), and external carotid artery (ECA)-SVG-s1 SCA (n = 1). CMs were located in the midbrain (n = 10) or pontomesencephalic junction (n = 4). dAVFs drained into the tentorial, superior petrosal, cavernous, and sphenobasal sinuses. High rates of aneurysm occlusion (79%), bypass patency (100%), complete CM resection (86%), and dAVF obliteration (100%) were obtained. The overall rate of permanent oculomotor nerve palsy was 8.3%. The majority of patients in the aneurysm (94%), CM (93%), and dAVF (100%) groups had stable or improved modified Rankin Scale scores.

CONCLUSIONS

The OTT is an important anatomical triangle and surgical workspace for vascular lesions in and around the crural and ambient cisterns. The OTT can be used to approach a wide variety of vascular pathologies in the region of the basilar quadrifurcation and anterolateral midbrain.

Isolated superior petrosal sinus dural arteriovenous fistula treated with selective sinus packing using a quadriaxial catheter system

A 67-year-old patient presented with a headache, vertigo and nausea, followed by a disturbance of consciousness. CT and MRI showed venous ectasia at the left cerebellopontine angle and extensive oedema in the left cerebellum. Angiography demonstrated a dural arteriovenous fistula that appeared at the left superior petrosal sinus–cavernous sinus) junction. After the evaluation of the shunt point, occluded areas were recanalised via the femoral vein with a quadriaxial catheter system using a 6-Fr guiding sheath, 6-Fr guiding catheter, 4.2-Fr catheter and microcatheter. Selective coil embolisation was performed, resulting in shunt removal.

Tentorial Dural Arteriovenous Fistula Treated Using Transarterial Onyx Embolization

Tentorial dural arteriovenous fistula (DAVF) is a rare vascular disease, which has high risk of intracranial hemorrhage. We present two cases of tentorial DAVF which were successfully treated with single trial of transarterial embolization using Onyx. We briefly reviewed the types of the tentorial DAVF and strategies of treatment.

Treatment of dural arteriovenous fistula by balloon-assisted transarterial embolization with Onyx

OBJECTIVE

This study evaluated the feasibility, safety, and efficacy of embolization of dural arteriovenous fistula via a very small, short feeding artery with the assistance of a balloon placed proximal to the tip of the microcatheter, such that the balloon serves as a plug.

METHODS

Eight patients who underwent treatment of DAVF by balloon-assisted transarterial embolization with Onyx were retrospectively reviewed. Gender, age, angiography findings, procedure details, clinical and angiographic outcomes, complications, and follow-up were recorded and analyzed.

RESULTS

Nine embolization procedures were performed in eight male patients via extracranial arteries. Balloon-assisted embolization was successful in all eight patients. A Hyperglide balloon was used in five patients, and a Hyperform balloon was used in three patients. Angiographic resolution of the fistula was achieved in all patients without complications. All patients recovered uneventfully. During the follow-up period of 7-19 months, all patients were asymptomatic except for one patient who experienced mild headaches.

CONCLUSIONS

Treatment of DAVF by balloon-assisted embolization with Onyx achieved promising results, even in patients with very small and short feeding arteries. This technique allowed the treatment of DAVF cases where other techniques have failed.

Clinical and angiographic results of patients with dural arteriovenous fistula

Endovascular embolization has been regarded as the primary treatment for dural arteriovenous fistula (dAVF). The aim of this study was to describe our experience with treatment and outcomes for patients with dural AVF, and to determine optimal treatment modalities. Between November 2007 and March 2011, 43 patients with dAVF (14 cavernous sinus, 20 transverse-sigmoid sinus, and nine patients with other types) were admitted to our Institute for treatment. For cavernous sinus dAVF, transvenous embolization was attempted as the first-line treatment with residual AVF obliterated by transarterial embolization (TAE), except for three patients who were treated conservatively. For transverse-sigmoid sinus dAVF, TAE was the primary treatment method. Nine of 14 (64.3%) patients with cavernous sinus dAVF had complete angiographic resolution. For transverse-sigmoid sinus dAVF, 14 of 17 (82.4%) patients were treated by TAE using Onyx Liquid Embolic System (eV3 Neurovascular, Irvine, CA, USA). Nine of these patients (64.3%) were angiographically cured or improved clinically with no serious complications, and the other five (35.7%) patients showed significant reductions in arteriovenous shunt. The other nine dAVF were treated by TAE or surgical disconnection depending upon the accessibility of the lesion and risk of complications. Six of nine (66.7%) patients had complete angiographic obliteration or clinical improvement. With developments in diagnostic tools and endovascular interventions, dAVF have become an important neurovascular issue. The results of this study suggest that a new approach to treatment of dAVF is needed.

Petrosal approaches to brainstem cavernous malformations

Object

Although they provide excellent ventral and lateral exposure of the brainstem, petrosal approaches to brainstem cavernous malformations (CMs) are infrequently reported.

Methods

The authors reviewed their experience with petrosal approaches to brainstem CMs in combination with a comprehensive review of the literature to elucidate resection rates, complication rates, and outcomes.

Results

Including their own results, the authors found 65 cases in 20 reports of brainstem CMs treated with petrosal approaches. The specific approaches were posterior petrosal in 37 cases (57%), anterior petrosal in 17 (26%), extended posterior petrosal in 10 (15%), and a combined petrosal approach in 1 case (2%). For 50 cases in 16 reports with detailed outcome information, the overall complete resection rate was 90%, with early postoperative morbidity reported in 30% of cases and permanent morbidity in 14%. The rate of CSF leakage was 6%.

Conclusions

The versatile petrosal approaches to brainstem CMs are associated with good outcomes and an acceptable morbidity rate. More expansive lesions can be approached using a combination of the standard anterior and posterior petrosal approach, preserving hearing and avoiding the greater complication rates associated with extended posterior petrosal approaches.