Cavernous Dural Arteriovenous Fistula Research Articles

The Appearance of Middle Meningeal Artery Fistulae After Willis Covered Stent for Traumatic Carotid-cavernous Fistulae: Two Case Reports

Introduction: Carotid cavernous fistulae (CCF) are rare, and they occur when there is a communication between the internal carotid artery (ICA) and cavernous sinus. These lesions are associated with blunt or penetrating traumatic injuries of the carotid arteries. We present the first cases of cavernous dural arteriovenous fistulae (cDAVF) in the middle meningeal artery (MMA) after the treatment of direct CCF in the ICA with Willis-covered stents (WCSs). Case Presentations: Our patients comprised 22 and 50-year-old males with histories of head injuries months before admission at our facility. In both patients above, cerebral angiography revealed fistulae in the right ICA and left ICA, respectively. They were treated with WCSs via the trans-artery endovascular route. In both cases, the treatments were not in the way attempted via the MMA. Subsequently, they developed cDAVF in the middle meningeal artery (MMA), which were treated with Onyx Liquid Embolic System (Onyx HD-500) (Covidien / ev3 Neurovascular) and conservatively, respectively. Conclusion: These are the first cases in whom WCSs for the management of direct CCF resulted in cDAVF at the MMA. The WCSs inside the ICA could have resulted in the cDAVF via unknown mechanisms but not iatrogenic.

Successful Endovascular Treatment of Trigeminal Neuralgia Caused by a CarotidCavernous Fistula: Case Report

Dural arteriovenous fistulas (DAVFs) of the cavernous sinus are arteriovenous connections located in the dura mater leaflets of this region. The usual presentation of a DAVF is predominantly ocular, with symptoms such as diplopia, conjunctival injection, involvement of cranial nerves III/IV/VI, exophthalmos, and chemosis. Trigeminal neuralgia caused by a cavernous DAVF is extremely rare. To the best our knowledge, this is only the fourth report in the world literature. We describe the case of a patient treated by embolization in whom the only presenting symptom of DAVF was trigeminal neuralgia. After endovascular treatment, the patient became asymptomatic.

Transcranial approach for surgical-combined-endovascular treatment of a cavernous dural arteriovenous fistula: the superficial sylvian vein route.

Transcranial approach for surgical-combined-endovascular treatment of a cavernous dural arteriovenous fistula: the superficial sylvian vein route.

Finding the Inferior Petrosal Sinus for Embolizing Cavernous Dural Arteriovenous Fistula Using Preoperative Computed Tomography Angiography

Inferior petrosal sinus (IPS) has been commonly adopted as a route for embolizing cavernous dural arteriovenous fistula (cDAVF). According to previous anatomical studies, >90% of persons have an IPS. Because the exact confluence position of the IPS with an internal jugular vein can be difficult to obtain using preoperative digital subtraction angiography (DSA), catheterizing into the IPS during endovascular treatment can sometimes be very difficult. Because the anatomical information has not been attainable, this route has not been as widely used. Thus, methods remain to be developed to allow the IPS to play its due role in the embolization of cDAVF. Seven cases of cDAVF were diagnosed by DSA. The 7 patients also underwent preoperative computed tomography angiography (CTA) and were treated by transvenous embolization. Compared with DSA, the confluence position of the IPS with the internal jugular vein was easier to findusing preoperative CTA in 6 cases. Based on this anatomical information, 6 cases were successfully embolized via the IPS route and 1 via the superior ophthalmic vein route. Detailed anatomical information of the IPS can be obtained from preoperative CTA images. Thus, CTA can help localize the IPS and allow for embolization of cDAVF via the IPS route.

Transorbital Cavernous Sinus Direct Puncture : Alternative to treat dural arteriovenous fistula.

The authors present aretrospective series of their clinical experience in the treatment of cavernous dural arteriovenous fistulas (DAVF) by direct transorbital puncture of the cavernous sinus as an alternative to the endovascular approach. Between October 2012 and September 2014, eight patients harboring cavernous DAVF underwent percutaneous treatment by direct transorbital puncture of the cavernous sinus at three institutions. All patients presented with ocular symptoms. Standard endovascular approaches, including transvenous and transarterial routes, were primarily attempted without success in all cases. Direct puncture was performed through two different approaches, namely inferolateral and superomedial. The entry point was the inferior and superior eyelid, respectively. Embolization was performed with coils or Onyx (Covidien, Irvine, CA). Immediate and late angiographies were used to evaluate the occlusion of the fistula. Of the patients seven had complete occlusion of the cavernous DAVFs noted on the immediate and follow-up angiograms and one patient had residual filling but reduction of the shunt resulted in clinical improvement. None of the patients had worsening of neurological function. One case was complicated by inadvertent internal carotid puncture but without clinical manifestations. One patient experienced postoperative superior ophthalmic vein thrombosis. In very specific cases, when endovascular access is not possible or fails to occlude cavernous DAVF, direct transorbital puncture of the cavernous sinus was shown to be feasible, safe and very effective.

Radiographic Evaluation and Clinical Implications of Venous Connections Between Dural Arteriovenous Fistula of the Cavernous Sinus and Cerebellum and the Pontomedullary Venous System

The types of cortical venous reflux channels, posterior fossa and pontomesencephalic venous reflux or their connections with the cavernous sinus (CS) are inadequately described in the literature. This study uses angiography, magnetic resonance imaging, and X-ray computed tomography to clarify the possible route of cavernous dural arteriovenous fistulae (CVDAVF) that causes posterior fossa and pontomedullary venous reflux and documents the clinical presentations associated with the reflux. Eighty-six patients with CSDAVF treated at Ramathibodi Hospital, Bangkok, Thailand, during 2009 to 2013 were studied retrospectively. Sixteen cases with posterior fossa and pontomedullary venous reflux were included for analysis. Bridging veins serve as an important pathway for venous reflux from CS to the posterior fossa and brainstem. The uncal vein directly terminates at the CS and has several connecting routes, ranging from the inferior frontal lobes and insula to the posterior fossa through the basal vein of Rosenthal. The petrosal vein was most frequently and easily detected angiographically. It plays a major role in the cerebellar hemispheric venous reflux. Only 1 patient developed brainstem and cerebellar venous congestion, which returned to normal after endovascular treatment. Connections of CS are not limited to intercavernous, ophthalmic veins, sphenoparietal sinuses, and inferior and superior petrosal sinuses. They also occur with complex venous drainages at the base of the frontotemporal lobes, insula, brainstem, and cerebellum. Knowledge of the venous connection of CS is key to understanding the possible locations of venous congestion/hemorrhage and the clinical presentation of patients with CSDAVF.

Cranial Nerve Dysfunction Associated with Cavernous Dural Arteriovenous Fistulas After Transvenous Embolization with Onyx.

Cranial nerve dysfunction (CND) is not uncommon in patients with cavernous dural arteriovenous fistulas (cDAVFs), and may represent an initial manifestation or a complication after endovascular treatment. This study evaluated the outcome of CND associated with cDAVFs after transvenous embolization (TVE) using Onyx. Forty-one patients with cDAVFs were treated with TVE in our department between April 2009 and October 2013. For each patient, clinical and radiologic records were retrospectively reviewed and evaluated, with an emphasis placed on evaluating the outcomes of the pre-existing cDAVF-induced CND and the TVE-induced CND. Of the 41 cases, 25 had a history of preoperative CND. Postoperatively, gradual remission to complete recovery (CR) within 8 months was observed in 17 of these cases, transient aggravation in 7, and significant improvement to be better than preoperative function but no CR in 1. All aggravation of CND occurred immediately or within 1 day after TVE and resolved completely within 5 months. Nine patients developed new CND after TVE. New CND occurred during the perioperative period in 8 cases, but all cases resolved completely within 15 days-6 months. Delayed CND was observed in 3 cases with a time lag of 3-25 months after TVE. Two of these completely resolved within 20 days-1 month and the remaining case significantly improved. Both the pre-existing cDAVF-induced CND and the TVE-induced new or aggravated CND completely resolved in almost all cases after embolization with Onyx.

MRI and MR Angiography Findings to Differentiate Jugular Venous Reflux From Cavernous Dural Arteriovenous Fistula

Both jugular venous reflux (JVR) and cavernous dural arteriovenous fistula (DAVF) manifest as abnormal venous signal intensities on time-of-flight (TOF) MR angiography (MRA). We investigated brain MRI and MRA findings that might differentiate JVR from cavernous DAVF. Forty-one patients with abnormal venous signal intensities on TOF MRA in the cavernous sinus and its vicinity were selected from 1508 patients who had undergone TOF MRA over the previous 6 months. For comparison, the examinations of 26 patients with cavernous DAVF who had undergone imaging over the previous 8 years were collected. The following findings were assessed: the side and location of abnormal venous signal intensities on intracranial TOF MRA; the signal intensity of the proximal jugular vein on T2-weighted imaging; whether there was early opacification of the cavernous sinus in the arterial phase of contrast-enhanced MRA (CE-MRA); the side of jugular venous drainage in the arteriovenous phase of CE-MRA; and whether retrograde jugular venous flow was seen on neck TOF MRA. Abnormal venous signal intensities were seen on the left side in 73% of patients with JVR and 58% of patients with cavernous DAVF; involvement of the cavernous sinus was found in 12% of patients with JVR and 100% of patients with cavernous DAVF. Increased signal intensity in the ipsilateral jugular vein on T2-weighted imaging was found in 73% of JVR patients and 4% of cavernous DAVF patients. Early opacification of the cavernous sinus in the arterial phase of CE-MRA, ipsilateral jugular venous drainage in the arteriovenous phase of CE-MRA, and ipsilateral retrograde jugular venous flow on neck TOF MRA were found in 0%, 0%, and 63%, respectively, of JVR patients and in 100%, 100%, and 0%, respectively, of cavernous DAVF patients. JVR and cavernous DAVF can be differentiated from one another using MRI and MRA.

Ophthalmic vein compression for selected benign low-flow cavernous sinus dural arteriovenous fistulas

Dural arteriovenous fistulas (DAVFs) of the cavernous sinus are acquired arteriovenous shunts between the dural branches of the internal and external carotid arteries and the cavernous sinus. These fistulas may present with cortical venous reflux, but more commonly drain antegradely toward the superior ophthalmic vein (SOV). Transvenous embolization is the most common endovascular treatment, but in some cases transvenous access to the compartment of the shunt may not be possible. In cases with no corticovenous reflux, manual compression of the SOV is an excellent alternative treatment, which is well known but rarely reported in the literature. The authors describe a series of 3 cavernous DAVFs with anterior drainage treated successfully by intermittent manual compression of the SOV.

Transvenous Embolization of Cavernous and Paracavernous Dural Arteriovenous Fistula through the Facial Vein: Report of 12 Cases

PurposeThe aim of this study was to evaluate the feasibility and safety of the transfacial venous embolization of cavernous or paracavernous dural arteriovenous fistula (DAVF) in which approach via inferior petrosal sinus (IPS) was not feasible.Materials and MethodsWe identified the cases of transfacial venous embolization of cavernous sinus (CS) or adjacent dural sinuses from the neurointerventional database of three hospitals. The causes and clinical and angiographic outcomes of transfacial venous embolization were retrospectively evaluated.ResultsTwelve patients with CS (n = 11) or lesser wing of sphenoid sinus (LWSS, n = 1) DAVF were attempted to treat by transvenous embolization via ipsilateral (n = 10) or contralateral (n = 2) facial vein. Trans-IPS access to the target lesion was impossible due to chronic occlusion (n = 11) or acute angulation adjacent the target lesion (n = 1). In all twelve cases, it was possible to navigate through facial vein, angular vein, superior ophthalmic vein, and then CS. It was also possible to further navigation to contralateral CS through intercavernous sinus in two cases, and laterally into LWSS in one case. Post-treatment control angiography revealed complete occlusion of the DAVF in eleven cases and partial occlusion in one patient, resulting in complete resolution of presenting symptom in eight and gradually clinical improvement in four patients. There was no treatment-related complication during or after the procedure.ConclusionIn the cavernous or paracavernous DAVF in which trans-IPS approach is not feasible, the facial vein seems to be safe and effective alternative route for transvenous embolization.

Stereotactic radiosurgery for cerebral dural arteriovenous fistulas

Given the feasibility of curative surgical and endovascular therapy for cerebral dural arteriovenous fistulas (DAVFs), there is a relative paucity of radiosurgical series for these lesions as compared with their arteriovenous malformation counterparts. The authors reviewed records of 56 patients with 70 cerebral DAVFs treated at their institution over the past 6 years. Ten DAVFs (14%) in 9 patients were treated with stereotactic radiosurgery (SRS), with follow-up obtained for 8 patients with 9 DAVFs. They combined their results with those obtained from a comprehensive review of the literature, focusing on obliteration rates, post-SRS hemorrhage rates, and other complications. In the authors' group of 9 DAVFs, angiographic obliteration was seen in 8 cases (89%), and no post-SRS hemorrhage or complications were observed after a mean follow-up of 2.9 years. Combining the results in these cases with data obtained from their review of the literature, they found 558 DAVFs treated with SRS across 14 series. The overall obliteration rate was 71%; transient worsening occurred in 9.1% of patients, permanent worsening in 2.4% (including 1 death, 0.2% of cases), and post-SRS hemorrhage occurred in 1.6% of cases (4.8% of those with cortical venous drainage [CVD]). The obliteration rate for cavernous DAVFs was 84%, whereas the rates for transversesigmoid and for tentorial DAVFs were 58% and 59%, respectively (adjusted p values, p(cav,TS) = 1.98 × 10(-4), p(cav,tent) = 0.032). Obliteration rates were greater for DAVFs without CVD (80%, compared with 60% for those with CVD, p = 7.59 × 10(-4)). Both transient worsening and permanent worsening were less common in patients without CVD than in those with CVD (3.4% vs 7.3% for transient worsening and 0.9% vs 2.4% for permanent worsening). Stereotactic radiosurgery with or without adjunctive embolization is an effective therapy for DAVFs that are not amenable to surgical or endovascular monotherapy. It is best suited for lesions without CVD and for cavernous DAVFs.

A rare brainstem hemorrhage during transvenous embolization of a cavernous dural arteriovenous fistula

Intravascular treatment of cavernous dural arteriovenous fistula (dAVF) is usually safe and effective. However, we describe a patient with a rare brainstem hemorrhage during transvenous embolization (TVE). A 79-year-old woman suffered from left chemosis and diplopia. Cerebral angiography revealed a left cavernous dAVF with cortical venous drainage. The patient underwent TVE of the cavernous sinus (CS) via the left inferior petrosal sinus. Superior petrosal sinus (SPS) outflow occlusion was performed to avoid venous congestion, followed by superficial middle cerebral vein outflow occlusion, selective shunt occlusion of the middle meningeal artery, and superior orbital vein outflow occlusion. The patient’s condition suddenly deteriorated during CS packing. A CT scan revealed a massive brainstem hemorrhage. Cerebral angiography did not show SPS reopening or redistributed drainage to the posterior fossa. Thus, TVE for cavernous dAVF can result in life-threatening vascular complications. Well-planned treatment strategies could avert this rare complication.

Isolated Oculomotor Nerve Palsy Caused by Cavernous Sinus Dural Arteriovenous Fistula: Case Report

Isolated oculomotor palsy is a rare symptom seen in patients with many, different neurological disorders (1, 2). It is often the first or even the sole manifestation of a pathology that potentially affects the nervous system. When older patients are presented with isolated ocular motor nerve palsy, without congestive ocular features, this condition is easily misdiagnosed as idiopathic, ischemic mononeuropathy or aneurysm. While isolated ocular motor nerve palsy, presenting as the only manifestation of cavernous dural arteriovenous fistula (DAVF), has occasionally been reported (3-5), we report a case of cavernous DAVF presenting with unusual, isolated oculomotor nerve palsy and treated by transvenous coil embolization.

Combined Surgical and Endovascular Access of the Superficial Middle Cerebral Vein to Occlude a High-Grade Cavernous Dural Arteriovenous Fistula: Case Report

High-grade cavernous sinus (CS) dural arteriovenous fistulae with cortical venous drainage often have a malignant presentation requiring urgent treatment. In the absence of a venous access to the lesion, transarterial embolization can potentially cure these lesions; however, the high concentration of eloquent arterial territories adjacent to the fistula creates a precarious risk of arterial-arterial reflux. In such cases, a combined surgical and endovascular approach may provide the least invasive option. We describe a patient presenting with a venous hemorrhagic infarct caused by a high-grade CS dural arteriovenous fistula (Barrow type D caroticocavernous fistula) with isolated drainage via the superficial middle cerebral vein into engorged perisylvian cortical veins. No transfemoral or ophthalmic strategy was angiographically apparent, and the posterior location of the involved CS compartment mitigated a direct puncture. The patient underwent direct puncture of the superficial middle cerebral vein via an orbitozygomatic craniotomy and the CS was catheterized under fluoroscopic guidance. The CS was coil-embolized back into the distal superficial middle cerebral vein with complete obliteration of the fistula. The patient did well with no new deficits and made an uneventful recovery. This novel combined open surgical and endovascular approach enables obliteration of a CS dural arteriovenous fistula with isolated cortical venous drainage and avoids the additional manipulation with direct dissection and puncture of the CS itself.

Development of Indirect Cavernous Dural Arteriovenous Fistula after Trapping for Direct Carotid Cavernous Fistula

A 60-year-old man with direct carotid cavernous fistula (CCF) due to a motor vehicle accident underwent internal carotid artery trapping following high-flow external carotid to internal carotid artery bypass (EC-IC bypass). Follow-up angiography revealed ipsilateral complex indirect cavernous arteriovenous fistula. Although the traumatic indirect CCF angioarchitecture differs from cavernous-sinus dural arteriovenous fistula (CS-DAVF), the present indirect fistula was similar to the latter. Complex indirect CCF can occur after treatment of direct CCF caused by severe head injury.

Transvenous treatment of complex cavernous dural arteriovenous fistulae with Onyx and coils

Transvenous embolization has become the treatment of choice for such lesions We evaluated Onxy for patients with cavernous dural arteriovenous fistulae (CDAVFs) who underwent transvenous embolization via different transvenous approaches. Case records of six patients with symptomatic CDAVFs, treated between October 2006 and November 2007 were reviewed. A total of seven transvenous procedures were performed in the six patients with CDAVFs. All the patients with CDAVFs of the cavernous sinus were symptom free following embolization. The approach via the internal jugular vein and the inferior petrosal sinus was possible in four of the six patients, with complete occlusion of the fistula. In the remaining two patients, the approach was via the facial vein. Transient bradyarrythmia without morbidity was the only complication in two patients.

Cavernous region dural fistulas with venous drainage of laterocavernous sinus

We present our findings concerning the laterocavernous sinus (LCS) drainage of cavernous region dural fistulas, focusing our attention on the anatomy of LCS as it may have important implications in the treatment. Thirty-one consecutive patients with cavernous region dural fistulas treated endovascularly between 2005 and 2008 were reviewed. Five patients had angiographic features such as cavernous region dural fistulas draining with superficial middle cerebral vein (SMCV) via LCS. Clinical records of these 5 patients were focused upon to determine their presenting symptoms, angiographic features, endovascular treatments and clinical outcomes. Among 31 cases of cavernous dural arteriovenous fistula (DAVF), 5 (16%) cases with leptomeningeal veins [SMCV, petrosal vein] reflux via LCS were noted. The 5 cavernous region dural fistulas were defined as Cognard type III and Barrow type A (1/5), B (1/5), C (1/5) and D (2/5). All 5 patients underwent immediate obliteration of the cavernous region dural fistulas in 3 sessions of transarterial and 2 sessions of transvenous embolization. An angiographic obliteration and clinical cure was achieved in all patients. We encountered one minor complication of local hair loss induced by X-ray radiation. A complete resolution of the initial presenting symptoms was observed within a few days to weeks. Six-month follow-up angiogram in 5 patients showed obliteration and no recanalization of CCF. It is very important to diagnose the presence of laterocavernous sinus in dural arteriovenous fistulas during diagnostic angiography. It is believed that the knowledge of the existence of laterocavernous sinus might be relevant for the understanding and treatment of dural fistulas involving the cavernous sinus and its lateral wall.

Transvenous injection of n-Butyl cyanoacrylate combined with placement of coils in cavernous sinus for treatment of cavernous dural arteriovenous fistulae

Objective To evaluate the technical aspects, efficacy and safety in the treatment of cavernous dural arteriovenous fistulae (DAVF) by transvenous liquid n-Butyl cyanoacrylate (NBCA) injection combined with coils placement in the cavernous sinus. Methods Eight patients with cavernous DAVF, treated by transvenous embolization with combination of detachable coils and glue between February 2006 and February 2009 in our hospital, were retrospectively analyzed, including the clinical presentations, patterns of angioarchitecture, methods of treatment and the results of follow-up. Results In all 8 patients, 9 transvenous and 1 transarterial interventions were carried out. A single endovascular procedure was performed in 6 patients and 2 patients had to be treated twice. Of the nine transvenous approaches, eight approaches were performed via inferior petrosal sinus (IPS) and 1 via the facial vein. Complete angiographic obliteration was achieved in all patients immediately after the embolization. There was no procedure-related morbidity except for mild headache for one to seven days after the embolization. Clinical cure was achieved in all cases during the clinical follow-up periods, ranging from 8 months to 3 years. The follow-up angiography periods averaged 6.6 months with a range of 5-9 months, in which no recurrence was observed. Conclusion In this small series, embolization with combination of glue and detachable coils by transvenous approaches was a safe, effective and economical method for the treatment of part of symptomatic patients presenting with complex cavernous DAVF.

Superficial Temporal Vein: Route to Embolization of Cavernous Dural Arteriovenous Fistula

Superficial temporal vein catheterization was used to embolize a dural arteriovenous malformation of the cavernous sinus in a 44-year-old woman. The pertinent venous anatomy is discussed. This route may provide crucial access to the cavernous sinus when conventional approaches such as the Inferior petrosal sinus catheterization are difficult.

Embolization of cranial dural arteriovenous fistulae with ONYX: Indications, techniques, and outcomes.

Objectives:The purpose of this study was to establish the role of the liquid embolic agent, ONYX, in the treatment of cranial dural arteriovenous fistulae (DAVFs) and to redefine the indications, techniques and outcomes of treatment with ONYX.Materials and Methods:This is a retrospective study of 25 DAVF patients who underwent endovascular treatment with ONYX between February 2006 and July 2008. All patients of DAVF presenting in this period were treated with ONYX.Results:Anatomic cure (i.e., complete angiographic closure of the fistula) was achieved in a single session and through a single arterial pedicle injection in 21 out of 25 patients (cure rate of 84%). Out of four patients with residual fistulae, one achieved cure that was evident on a control angiogram obtained at 3 months while three had no vascular access for further embolization and so were referred for radiosurgery. There was only one recurrence seen in angiograms obtained at the end of one year and this patient was re-embolized successfully with ONYX. Complications were seen in two patients.Conclusion:ONYX embolization of DAVFs has revolutionized the endovascular treatment of DAVFs, achieving high cure rates in a single session with minimal complications. Transarterial ONYX embolization should be the first option for all locations, except cavernous DAVFs.