Current status of endovascular treatment for dural arteriovenous fistula of the transverse-sigmoid sinus: A literature review

Isolated sinus dural arteriovenous fistulas: a single-center experience in 44 patients

BACKGROUND

Isolated sinus dural arteriovenous fistulas (DAVFs) constitute a rare and distinctive subtype of DAVF, typically found in small case numbers or case reports. The optimal treatment for this DAVF type remains unclear.

OBJECTIVE

This study aims to further detail the treatment outcomes of isolated sinus DAVFs in a sizable cohort from a single center.

METHODS

A retrospective study was undertaken on a consecutive series of patients with isolated sinus DAVFs treated at a single institution from 2002 to 2022. The article delineates the clinical presentation, angiographic features, treatment strategy, clinical and angiographic outcomes, and complications.

RESULTS

The cohort consisted of 31 males and 13 females, with an average age of 52.0 ± 15.5 years (range, 16-83). The success rate for trans-arterial embolization (TAE) was 97.3% (36/37). Transvenous embolization (TVE) with the reopening technique was successful in 3 of 4 patients (75.0%). Two open burr-hole TVE cases (66.7%, 2/3) and one surgery (100%) resulted in immediate complete closure of the fistula. Immediate complete occlusion was achieved in 93.2% (41/44) of cases. There was one major complication (2.3%, 1/44) and two fistulas recurred (9.5%, 2/21).

CONCLUSIONS

The majority of isolated sinus DAVFs can be effectively treated with TAE using Onyx. TVE and surgery serve as alternative techniques when arterial access is deemed inappropriate or when complete occlusion cannot be attained with TAE. Complete embolization of isolated sinus DAVFs by TAE can typically be achieved without delay.

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.

Contralateral Transverse Sinus Occlusion After Treatment of Transverse-Sigmoid Sinus Dural Arteriovenous Fistula: A Case Report

A dural arteriovenous fistula (DAVF) is a pathologic arteriovenous shunt located within the dural wall of a venous sinus. In addition, DAVFs are associated with sinus thrombosis. Consequently, sinus occlusion may occur near DAVF lesions, making treatment challenging. However, there are few reports of sinus occlusion unrelated to lesions. In this study, we present a rare case of contralateral transverse sinus occlusion in a patient who underwent endovascular treatment and stereotactic radiosurgery for DAVF in the transverse-sigmoid sinus with ipsilateral sigmoid sinus occlusion.

Endovascular Management of Intracranial Dural AVFs: Transvenous Approach

In this third review article on the endovascular management of intracranial dural AVFs, we discuss transvenous embolization approaches. Transvenous embolization is increasingly popular and now the first-line approach for ventral dural AVFs involving the cavernous sinus and hypoglossal canal. In addition, transvenous embolization is increasingly used in lateral epidural dural AVFs in high-risk locations such as the petrous and ethmoid regions. The advantage of transvenous embolization in these locations is the ability to retrogradely embolize the draining vein and fistula while reducing the risk of ischemic cranial neuropathy or brain parenchymal infarction commonly feared from a transarterial approach. By means of coils ± ethylene-vinyl alcohol copolymer, transvenous embolization can achieve angiographic cure rates of 80%-90% in ventral locations. Potential complications include transient cranial neuropathy, neurologic deterioration due to venous outflow obstruction, and perforation while navigating pial veins. Transvenous embolization should be considered when dural AVFs arise in proximity to the vasa nervosum or extracranial-intracranial anastomoses.

Endovascular Management of Intracranial Dural Arteriovenous Fistulas: Transarterial Approach

In this second of 3 review articles on the endovascular management of intracranial dural AVFs, we discuss transarterial treatment approaches. The treatment goal is to occlude the fistulous point, including the most distal portion of the arterial supply together with the most proximal portion of the draining vein (ie, the "foot" of the vein), which can be accomplished with liquid embolic agents via transarterial access. Anatomic factors to consider when assessing the safety and efficacy of a transarterial approach using liquid embolic agents include location, angioarchitecture, and proximity of arterial feeders to both the vasa nervosum of adjacent cranial nerves and the external carotid-internal carotid/vertebral artery anastomoses. Anatomic locations typically favorable for transarterial approaches include but are not limited to the transverse/sigmoid sinus, cerebral convexity, and superior sagittal sinus. In this review article, we discuss the technical approaches, outcomes, potential complications, and complication avoidance strategies for transarterial embolization.

Transverse-sigmoid Sinus Dural Arteriovenous Fistula Presenting with False Localizing Signs of Cavernous Sinus Dural Arteriovenous Fistula Due to Obstructed Cerebral Venous Outflow into the Bilateral Superior Ophthalmic Veins: A Case Report

Cavernous sinus (CS) dural arteriovenous fistula (dAVF) presents ocular symptoms and visual disorders due to retrograde drainage from the CS into the superior ophthalmic vein (SOV). Some papers reported non-CS dAVFs with those symptoms. We present a unique case of transverse-sigmoid sinus (TSS) dAVF with localizing signs of CS dAVFs resulting from congested cerebral venous outflow into the CSs and SOVs in an 86-year-old female patient. Right pulsatile tinnitus and chemosis appeared a few years ago. After experiencing progressive bilateral blurred vision and decreased visual acuity with papillary edema for a few months, she was admitted to our hospital. Cerebral angiography demonstrated right sigmoid sinus dAVF with retrograde venous reflux into the superior sagittal sinus (SSS) and contralateral TSS without cortical venous reflux. Under the influence of congestion of the SSS, cerebral venous outflow drained into the CSs subsequently into the SOVs. Trans-arterial embolization using ethylene-vinyl alcohol copolymer was conducted via the right middle meningeal artery. After treatment, right chemosis immediately improved. The 2-month follow-up examination revealed resolution of bilateral visual acuity and improvement of papillary edema. Our case demonstrates that retrograde drainage into the SOVs with not only directly arterialized shunted flow but also congested cerebral venous outflow can cause CS dAVFs-like symptoms.

Ear ischemia induced by endovascular therapy for arteriovenous fistula of the sigmoid sinus: A case report

BACKGROUND

Arteriovenous fistula of the sigmoid sinus is an abnormal connection of arteries with the sigmoid sinus. Endovascular treatments of such lesions are considered safe and with low rates of complications.

CASE SUMMARY

A 62-year-old female patient underwent endovascular treatment of an arteriovenous fistula of the right sigmoid sinus on February 7, 2017, but her tinnitus was not cured. She was admitted to the Beijing Tiantan Hospital, Capital Medical University, on March 20, 2017, and her pre-operative diagnosis, by digital subtraction cerebral angiography, was arteriovenous fistula of the sigmoid sinus. She underwent endovascular embolization of the distal occipital artery and posterior auricular artery using Onyx-18. The arteriovenous fistula of the sigmoid sinus was cured, and her tinnitus disappeared, but ischemia of the upper 2/3 of the right auricle occurred without hearing loss. The patient received treatment to improve microcirculation, in addition to fluid supplementation, analgesia, and hyperbaric oxygen, and the swelling due to ischemia in the right auricle did not progress further. The patient reported no tinnitus , and the right auricle had returned to normal 3 years later.

CONCLUSION

Ischemic complications of vital organs should be considered when performing embolization procedures for arteriovenous fistulas of cerebral sinuses. Compensation of the organs should be evaluated before the operation, and the related treatment regimens should be planned.

Giant dural arteriovenous fistula in an infant

Dural arteriovenous fistulas (dAVFs) are commonly encountered by the neurosurgeon. Herein, we present a case illustration of an infant presenting with an extremely large fistula that took up a significant part of the intracranial volume. A one-month-old female presented with irritability and failure to thrive. She was the product of a 35-week pregnancy and was delivered vaginally without complications or a difficult labor. Based on the findings of magnetic resonance imaging, the diagnosis of a giant dAVF involving the transerve-sigmoid sinuses was made. The patient was scheduled for an arteriogram but died before the procedure could be performed. Such a case illustrates how large some dAVF can become and at a very early age. As in the present case, the patient was minimally symptomatic. Therefore, the time to intervention after diagnosis is thus, sometimes, critical.

Direct transcranial coil and Onyx embolization of a dural arteriovenous fistula: Technical note and brief literature review

Intracranial high-grade dural arteriovenous fistulas (DAVFs) have higher bleeding rates compared to other intracranial vascular malformations. Endovascular treatment is usually recommended for high-grade lesions, aiming at a complete fistula obliteration. However, some patients have vascular abnormalities that limit endovascular access to the precise location of the shunt. Alternative techniques may be considered in this scenario. A middle-aged man presented with intracranial hypertension secondary to a high-grade DAVF. Because of vascular abnormalities precluding transvenous access to the intracranial venous circulation, the patient required treatment by a direct transcranial coil and Onyx embolization of the shunt. Direct transcranial cannulation of a dural sinus is an alternative and effective route for transvenous embolization of DAVFs, especially if abnormal venous anatomy precluding venous access to the required cranial venous system is identified.

Endovascular treatment of the cavernous sinus dural arteriovenous fistula: current status and considerations

A cavernous sinus dural arteriovenous fistula (CS-DAVF) is an abnormal arteriovenous communication involving the dura mater within or near the CS wall. The dural arteries from the internal carotid artery and external carotid artery supply the CS-DAVF, and the superior ophthalmic vein (SOV) and inferior petrous sinus (IPS) are frequent venous drainers. In CS-DAVF cases, high-risk lesions require treatment. Endovascular treatment (EVT) has been the first-line option for CS-DAVFs. To our knowledge, a review of the EVT of CS-DAVFs is lacking. Therefore, in this paper, we review the available literature on this issue. In addition, some illustrative cases are also provided to more concisely expound the EVT of CS-DAVFs. According to the recent literature, transvenous embolization via the IPS is considered the most effective method for EVT of CS-DAVFs. In addition, the transorbital approach is another reasonable choice. Other venous approaches can also be tried. Because of the low cure rate, transarterial embolization for CS-DAVFs is limited to only highly selected patients. In the EVT of CS-DAVFs, various agents have been used, including coil, Onyx, and n-butyl cyanoacrylate, with coil being the preferred one. In addition, when EVT cannot obliterate the CS-DAVF, stereotactic radiotherapy may be considered. In general, despite various complications, EVT is a feasible and effective method to manage CS-DAVFs by way of various access routes and can yield a good prognosis.

Clinical importance of the occipital artery in vascular lesions: A review of the literature

The occipital artery (OA) is a critical artery in vascular lesions. However, a comprehensive review of the importance of the OA is currently lacking. In this study, we used the PubMed database to perform a review of the literature on the OA to increase our understanding of its role in vascular lesions. We also provided our typical cases to illustrate the importance of the OA. The OA has several variations. For example, it may arise from the internal carotid artery or anastomose with the vertebral artery. Therefore, the OA may provide a crucial collateral vascular supply source and should be preserved in these cases. The OA is a good donor artery. Consequently, it is used in extra- to intracranial bypasses for moyamoya disease (MMD) or aneurysms. The OA can be involved in dural arteriovenous fistula (DAVF) and is a feasible artery for the embolisation of DAVF. True aneurysms and pseudoaneurysms can occur in the OA; surgical resection and embolisation are the effective treatment approaches. Direct high-flow AVF can occur in the OA; embolisation treatment is a good option in such cases. The OA can also be involved in MMD and brain arteriovenous malformation (AVM) by forming transdural collaterals. For a patient in the prone position, if occipital and suboccipital craniotomies are performed, the OA can also be used for intraoperative angiography. In brief, the OA is a very important artery in vascular lesions.

Clinical importance of the posterior meningeal artery: a review of the literature

The posterior meningeal artery, which arises from the vertebral artery, is a critical artery in neurological lesions. However, a comprehensive review of the importance of the posterior meningeal artery is currently lacking. In this study, we used the PubMed database to perform a review of the literature on the posterior meningeal artery to increase our understanding of its role in vascular lesions. The posterior meningeal artery provides the main blood supply to the paramedial and medial portions of the dura covering the cerebellar convexity. The posterior meningeal artery is often involved in dural arteriovenous fistulas occurring near the posterior fossa, and the posterior meningeal artery can be the path for transarterial embolisation or a path through which to monitor the degree of dural arteriovenous fistula embolisation. In posterior circulation ischaemia and moyamoya disease, the posterior meningeal artery can form transdural anastomoses with pial arteries at the surface of the brain, and these can help prevent ischemia. The posterior meningeal artery can also develop aneurysms, most of which are traumatic pseudoaneurysms; patients should therefore be treated in a timely manner or followed up carefully in cases of rebleeding. In addition, during a craniotomy, the posterior meningeal artery should be protected intraoperatively to avoid damaging any transdural anastomosis that may be present. In addition, when the posterior meningeal artery is the main feeding artery of an intracranial tumour, that artery is a satisfactory path for preoperative embolisation. Briefly, the posterior meningeal artery is a very important artery in neurosurgery.

Clinical importance of the superficial temporal artery in neurovascular diseases: A PRISMA-compliant systematic review

The superficial temporal artery (STA) plays a very important role in neurovascular diseases and procedures. However, until now, no comprehensive review of the role of STA in neurovascular diseases from a neurosurgical perspective has ever been published. To review research on the clinical importance of STA in neurovascular diseases, a literature search was performed using the PubMed database. Articles were screened for suitability and data relevance. This paper was organized following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. According to the literature, STA is one of the terminal branches of the external carotid artery and can give off scalp, muscle, and transosseous branches. STA-middle cerebral artery (MCA) bypass is very useful for intracranial ischemic diseases, including moyamoya disease, chronic ICA and MCA insufficiency, and even acute ischemic stroke. For intracranial complex aneurysms, STA bypass remains a major option that can serve as flow replacement bypass during aneurysmal trapping or insurance bypass during temporary parent artery occlusion. Occasionally, the STA can also be involved in dural AVFs (DAVFs) via to its transosseous branches. In addition, the STA can be used as an intraoperative angiography path and the path to provide endovascular treatments. Therefore, STA is a very important artery in neurovascular diseases.