Dural Arteriovenous Fistula Research Articles

Abstract TMP93: Utility of the MAGIC Flow-Directed Microcatheter for the Management of Pediatric Cerebrovascular Pathology: A 29-Year Single-Center Series

Introduction: Flow-directed catheters are popular for their low profile and ease of navigability, making them a favorable option for catheterization of tortuous, small-caliber feeding vessels. These catheters have been FDA-approved for adults, but no catheter has been indicated for pediatric use. However, high-flow pediatric cerebrovascular lesions are often difficult to treat due to their extensive small-caliber arterial supply. As a result, flow-directed microcatheters like the MAGIC (Balt, Montmorency, France) have been used off-label since their introduction to the market. Here, we characterize our longitudinal experience with the MAGIC microcatheter in pediatric neurointervention. Methods: A single-center retrospective chart review from 1995 to 2024 identified all patients under the age of 18 with cerebrovascular pathology (dural and pial arteriovenous fistula, Vein of Galen malformation (VOGM), intracranial and extracranial arteriovenous malformation (AVM)) that required treatment with the MAGIC microcatheter. Clinical data, imaging, and procedural parameters including anatomic approach, embolic material used, complications and technical success were reviewed. Results: 2,172 MAGIC microcatheters were utilized in 923 procedures to treat cerebrovascular pathology in 341 pediatric patients. The median patient age was 3.26 years and patients underwent an average of 2.71 ± 2.31 endovascular procedures requiring the MAGIC. The MAGIC was most frequently navigated in conjunction with a 4F Berenstein guide catheter (60.3%) or a 5F Envoy distal access catheter (24.9%). The most common pathology treated was VOGM (44.4%), followed by intracranial AVM (42.6%). The MAGIC was typically navigated by transarterial approach (97.0%) and was able to successfully catheterize selected pedicles with a 91.4% success rate. The MAGIC was able to successfully embolize in 845 (91.5%) cases: n-BCA was utilized in 96.3% of embolizations. Intraprocedural complications (wire perforation, contrast extravasation, etc.) occurred in 28 (1.3%) catheter uses, of which 5 (0.2%) were catheter-related (retention/rupture). Conclusion: We report a large cohort of MAGIC usage in the treatment of pediatric cerebrovascular disease over approximately 3 decades. The MAGIC flow-directed catheter is safe and effective with an important niche in pediatric neurointervention.

Retraction Note: Letter to editor: Comment on, "Microsurgical treatment for superior petrosal sinus dural arteriovenous fistulas".

Retraction Note: Letter to editor: Comment on, "Microsurgical treatment for superior petrosal sinus dural arteriovenous fistulas".

Endovascular Treatment for Tentorial Dural Arteriovenous Fistulas: A Retrospective Single-Center Study.

Current evidence suggests that tentorial dural arteriovenous fistulas with endovascular treatment offer a high rate of occlusion and reduced procedural risks. Here we report the clinical and angiographic outcomes in patients with tentorial dural arteriovenous fistulas who underwent endovascular treatment as first-line treatment. A retrospective analysis was conducted on 83 patients with tentorial dural arteriovenous fistulas treated at our center from April 2009 to November 2023 using endovascular treatment. Patient demographics, clinical presentation, angiographic, treatment results, and follow-up outcomes were registered. Univariable and multivariable logistic regression were performed to identify onset of intracranial hemorrhage predictors, procedure-related complications predictors and predictors of poor functional outcome. Eighty-three patients underwent endovascular treatment as first-line treatment. Most patients (80.7%) were symptomatic and a total of 25 patients (30.1%) presented with intracranial hemorrhage. Presence of deep venous drainage and midline location was associated with a lower incidence of intracranial hemorrhage. Middle meningeal artery (57.8%, 48/83) and pial artery (15.7%, 13/83) were the most frequently used access routes for embolization. A total of 74 (89.1%) TDAVFs were completely occluded after the last EVT session immediately. Complications occurred in 11 patients (13.3%). Six-month angiographic follow-up was performed in 68 patients (81.8%), and 91.2% (62/68) tentorial dural arteriovenous fistulas were occluded. At clinical follow-up (100%, 83/83), good functional outcome (mRS 0-2) was documented in 74 (89.1%) patients. Logistic regression analysis identified baseline mRS 3-5 as the most significant independent predictor of poor functional outcome. Subgroup analysis showed no statistically significant differences in baseline characteristics, angiographic and clinical results between patients treated with targeted pial artery embolization and non-targeted pial artery embolization. Endovascular treatment is a safe and effective primary modality for managing tentorial dural arteriovenous fistulas, achieving high rates of complete angiographic occlusion and favorable functional outcomes. Transarterial embolization, predominantly via middle meningeal artery, was the mainstay of treatment. In patients with pial arterial feeders, omitting aggressive embolization did not compromise efficacy or increase complications. DAVF = dural arteriovenous fistula; TDAVF = tentorial dural arteriovenous fistula; EVT = endovascular treatment; TAE = transarterial embolization; TVE = transvenous embolization; MMA = middle meningeal artery.

Model of the Venous System for Training Endovascular Treatment in Interventional Neuroradiology

Background: Endovascular treatment of venous disease is introducing new therapeutic options in neuroradiology. These procedures are technically challenging and require extensive physician training. Currently, training is mainly conducted on animal models, which presents drawbacks such as ethical concerns and anatomical differences from human vascular architecture. There is no training model that simulates treating intracranial venous disease using original instruments in a real angiography suite. Methods: This work presents the development of a venous system model for endovascular training simulations for integration into the existing Hamburg ANatomical NEurointerventional Simulator (HANNES) for arterial interventions. Results: The manufacturing process established at HANNES and the material used for the arterial vascular models were successfully transferred to the larger 3D-printed vein models. The application test was conducted in a real angiography suite with original instruments by an experienced neurointerventional physician to evaluate the system in terms of geometric mapping, flow, haptics and probing. Conclusion: This newly developed model provides a first approach to simulate an endovascular intervention in the venous system within the HANNES environment. Future expansions might include specific treatment simulations for conditions such as arteriovenous malformations, dural arteriovenous fistulas, sinus vein thrombosis and hydrocephalus.

Comparative outcomes of endovascular vs. surgical treatment in craniocervical junction dural arteriovenous fistulas: A systematic review and meta-analysis.

Craniocervical junction dural arteriovenous fistulas (CCJ-DAVFs) are rare and complex vascular malformations that are challenging to diagnose and treat. This study aims to compare surgical and endovascular treatments for CCJ-DAVFs through a systematic review and meta-analysis. A systematic review and meta-analysis was conducted according to the PRISMA guidelines. PubMed, Scopus, and Web of Science databases were searched from inception to July 2024. Fifteen studies involving 266 patients were included. Of these, 143 (53.8%) patients underwent surgical treatment alone and 123 (46.2%) underwent endovascular treatment alone. In the surgical group, the complete obliteration rate at last follow-up was 89.8%. Retreatment rate was 6.2%. Periprocedural complications occurred in 21.6% of cases. In the endovascular group, the complete occlusion rate at last follow-up was 73.6%. Retreatment rate was 46.7%. Periprocedural complications occurred in 18.8% of cases. Comparative meta-analysis revealed that the rate of complete obliteration at last follow-up was significantly higher in the surgical group (OR: 0.24; CI: 0.07 to 0.89, p=0.03). Surgical treatment had a significantly higher successful treatment rate (OR: 0.24; CI: 0.07 to 0.89, p=0.03) and lower retreatment rate (OR: 37.13; CI: 6.31 to 218.59, p<0.01). No significant differences were observed between the groups in terms of periprocedural complications or complete resolution of symptoms. Surgical treatment for CCJ-DAVFs achieves higher rates of complete obliteration with lower retreatment rates compared to endovascular treatment. However, endovascular treatment showed a tendency towards reducing periprocedural complications while increasing the likelihood of complete resolution of symptoms. Individualized treatment plans for CCJ-DAVFs, should be considered according to their anatomical location and potential surgical accessibility. Further studies are required to confirm these findings.

Comparative Efficacy and Safety of Endovascular vs. Surgical Treatment in Spinal Dural Arteriovenous Fistulas: A Systematic Review and Meta-Analysis.

Systematic Review and Meta-analysis. This study aims to compare the efficacy and safety of surgical and endovascular treatments for SDAVFs. Spinal dural arteriovenous fistulas (SDAVFs) result from an abnormal connection between the radiculomeningeal artery and the radicular vein, leading to venous hypertension and potential neurological damage. The two primary treatment strategies are surgical closure and endovascular obliteration of the fistula. PubMed, Scopus, and Web of Science databases were searched from inception to July 2024. We defined the successful treatment as fistula occlusion with sufficient embolic material penetration or obliteration during surgery. A total of 1192 articles were identified, with 40 studies meeting the inclusion criteria, comprising 1818 patients (surgical: 804, endovascular: 1014). The surgical group demonstrated higher rates of complete occlusion at last follow-up (96.8%, 363/375) compared to the endovascular group (72.5%, 470/648) (OR: 0.16; CI: 0.09 to 0.28, P<0.01). Surgical treatment also had higher successful treatment rates (97.5%, 392/402) compared to endovascular treatment (66.7%, 529/793) (OR: 0.11; CI: 0.06 to 0.19, P<0.01). Recurrence rates were lower in the surgical group (OR: 6.04; CI: 3.45 to 10.57, P<0.01) and retreatment rates were also lower (OR: 7.16; CI: 4.11 to 12.48, P<0.01). Initial treatment failure was significantly higher in the endovascular group (32.2%, 329/1023) compared to the surgical group (2.3%, 19/804) (OR: 8.97; CI: 5.56 to 14.45, P<0.01). Surgical treatment for SDAVFs achieves higher rates of complete occlusion and successful treatment compared to endovascular treatment, with lower rates of recurrence, retreatment, and initial treatment failure. Although both treatments show similar improvements in neurological status and periprocedural complications, surgery remains the preferred approach for definitive results. Treatment decisions should be individualized based on patient-specific factors and anatomical characteristics. Further research is needed to confirm these results.

Assessing the risk of drug-induced dural arteriovenous fistulas

Assessing the risk of drug-induced dural arteriovenous fistulas

Intracranial dural arteriovenous fistulas with deep venous drainage: a single-center retrospective cohort study.

Dural arteriovenous fistulas (DAVFs) with deep venous drainage (DVD) (DAVFs-DVD) are characteristically associated with non-hemorrhagic neurological deficits, most notably cognitive impairment. Large studies have yet to thoroughly characterize these DAVFs. We conducted an analysis of the largest cohort of DAVFs-DVD to provide a comprehensive characterization of this specific subset. This study was a retrospective cohort analysis of 207 patients with DAVFs-DVD who were hospitalized at a single medical center between 2001 and 2022. Logistic regression was employed to identify angiographic features specific to DAVFs associated with cognitive impairment. Additionally, post-treatment outcomes were evaluated. DAVFs-DVDs can be classified into two categories: the Galenic group, where arterial feeders drain directly into the vein of Galen (VoG), and the non-Galenic group, where arterial feeders drain into other veins or venous sinuses and indirectly flow into the VoG. Cognitive impairment accounting for 15.9% of all clinical presentations. We found that the overall rate of complete occlusion was 86.6%, while the overall rate of complications was 16.4%. Moreover, patients with DAVFs-DVD presenting with cognitive impairment were more likely to have straight sinus stenosis or occlusion, as well as DAVFs located at the midline. DAVFs-DVDs can be classified into two categories: the Galenic group and the non-Galenic group. Patients with DAVFs-DVD presenting with cognitive impairment were more likely to have straight sinus stenosis or occlusion, as well as DAVFs located at the midline. Venous hypertension of the deep venous system is a key angiographic feature of DAVFs associated with thalamic cognitive impairment.

Bridging the gap: A scoping review of endovascular and microsurgical approaches to anterior ethmoidal dural arteriovenous fistulas.

Dural arteriovenous fistulas (dAVF) are abnormal anastomoses between meningeal arteries and dural venous sinuses. Typically, dAVF treatment involves an endovascular or microsurgical approach. Anterior ethmoidal artery (AEA) dAVFs pose unique challenges due to their anatomy and location. We performed a scoping review to characterize pre and postoperative characteristics of AEA dAVFs and elucidate their optimal management. The authors conducted a comprehensive literature search on PubMed and Embase using Arskey & O'Malley's scoping review framework. The search strategy included "anterior," "ethmoidal," and "fistula" and excluded review articles and studies with unrelated pathology. Data collected included patient demographics, presentation, angiographic features, treatment modalities, and clinical and radiological outcomes. One-hundred and two articles describing 273 patients with an average age of 58.79 years were included. Two-hundred and sixty patients had surgery; 127 (49 %) had endovascular embolization and 133 (51 %) had open surgery. Surgical approach was significantly associated with complete dAVF obliteration (p = 0.003, X2=8.73, N = 206); patients treated endovascularly were less likely to have complete dAVF obliteration (85.9 % for endovascular versus 97.2 % for microsurgery). Additionally, patients with preoperative dAVF rupture had significantly greater rates of postoperative hemorrhage (p = 0.003, X2=11.86, N = 184). Surgical techniques and endovascular embolization are commonly used when treating dAVF, and our results highlight that open surgery appears to be superior to endovascular embolization when considering complete AEA dAVF obliteration. Despite advancements in treatment modalities, complications such as stroke, hemorrhage, and recurrence persist, emphasizing the importance of continued research and refinement of therapeutic strategies.

Unusual anatomic variation: The posterior inferior cerebellar artery arising from the middle meningeal artery.

An adult patient was admitted to our emergency department for a first episode of generalized tonic-clonic seizure. Computed tomography scan and magnetic resonance imaging showed a temporal intracranial hemorrhage and parenchymal edema caused by a dural arteriovenous fistula (DAVF), whose angioarchitecture was better understood through the DSA which showed as intriguing and rare vascular anomaly the origin of the posterior inferior cerebellar artery (PICA) from the middle meningeal artery (MMA). The endovascular treatment of the DAVF was then successfully performed.This case describes the first case of a PICA arising from the MMA in the literature and highlights as an accurate knowledge of vascular anatomy and its variations is essential for the endovascular treatment of the cerebrovascular diseases.

Diagnostic accuracy of 4D-MRA for the detection and localization of spinal dural arteriovenous fistulas: A retrospective 10-year cohort study.

The goal of this study was to assess the diagnostic accuracy of spinal time-resolved contrast-enhanced MR angiography (4D-MRA) for the detection and localization of spinal dural arteriovenous fistulas (SDAVF) in our institution. Single center retrospective cohort study of patients with the clinical suspicion of a SDAVF. Patients were included who had undergone spinal 4D-MRA in the period January 2010-February 2021. A subgroup was identified, who had subsequent digital subtraction angiography (DSA), or clinical/radiological follow-up. Diagnostic performance measures of 4D-MRA were calculated (sensitivity, positive predictive value, specificity, and negative predictive value) with DSA serving as the reference standard. Overall, 120 patients with the clinical suspicion of having a SDAVF and who underwent spinal 4D-MRA were identified. A subgroup of 30 patients had both 4D-MRA and DSA, or follow-up. In this group, the sensitivity of 4D-MRA for the detection of a SDAVF was 100% and specificity was 91% (positive predictive value of 95% and a negative predictive value of 100%). Sidedness was correctly identified on 4D-MRA in 74% of the cases and the level of the SDAVF in 68%. The results indicate that 4D-MRA has a high sensitivity and specificity for the detection and localization of a SDAVF, which is in line with previous studies published in literature. Furthermore, 4D-MRA can serve to guide DSA and shorten the procedural time, which reduces the risk of angiography related complications, and decreases patient discomfort.

A case of Parkinson's disease with exacerbation of parkinsonism due to dural arteriovenous fistula

A case of Parkinson's disease with exacerbation of parkinsonism due to dural arteriovenous fistula

Endoluminal Visualization of Dural Arteriovenous Fistula Using Virtual Angioscopy

BackgroundVirtual Angioscopy (VA) has been used for vessel investigation and treatment planning in fields such as vascular surgery. To our knowledge, the utilization of VA in neurointerventional cases has not been demonstrated. Methods2 cases of dural arteriovenous fistula (dAVF) where virtual angioscopy was utilized were reviewed. Results2 cases of dAVF are reported where virtual angioscopic images were derived from 3D volume rendered (VR) images. The endoluminal visualization of the fistula served as additional tool that helped anatomic understanding and treatment planning. ConclusionThese cases demonstrate the utility of VA in endoluminal visualization of dural arteriovenous fistula that may aid in treatment planning considerations.

Cognitive improvement following endovascular embolization in patients with intracranial dural arteriovenous fistula: The Neuropsychology in dural ArterIal Fistula (NAIF) Study

BackgroundCognitive improvement after endovascular embolization of an intracranial dural arteriovenous fistula (dAVF) remains unexplored. We aim to investigate cognitive changes following endovascular embolization of dAVFs.MethodsNeuropsychology in dural ArterIal Fistula (NAIF)...

Accurate Detection of Spinal Dural Arteriovenous Fistula With Spinal Photon-Counting Computed Tomography Angiography: A Report of Two Cases.

Accurate Detection of Spinal Dural Arteriovenous Fistula With Spinal Photon-Counting Computed Tomography Angiography: A Report of Two Cases.

Hemodynamic Instability during Squid Embolization of Dural Arteriovenous Fistula: A Case Report.

There are few documented cases of bradycardia or asystole occurring during Onyx embolization of intracranial dural arteriovenous fistulas (DAVFs), although these events are more commonly observed in open neurosurgical procedures, particularly those involving the skull base. We present a case treated for a ruptured paramedian occipital DAVF. During the administration of Squid into the middle meningeal artery, while balloons were inflated in the large occipital arteries bilaterally to control the flow during embolization of the DAVF, the patient experienced an abrupt episode of sinus bradycardia, which recurred after a second injection of Squid. After temporarily halting the injections and deflating the balloons, a third injection was successfully administered without complications, allowing total exclusion of the fistula.

Low-and intermediate-grade lateral sinus dural arterio venous fistulas: Factors affecting the outcome of endo vascular treatment over 18-year experience in a high-volume neurovascular center.

Lateral sinus dural arteriovenous fistulas (LS-DAVFs) carry a higher rate of recurrence after endovascular treatment (EVT). Our objective was to investigate the independent predictors of recurrence and unfavorable functional outcome of low-and intermediate-grade LS-DAVFs after EVT. Retrospectively reviewed our database of prospectively collected information for all patients with low and intermediate-grade LS-DAVFs that underwent EVT from May 2004 to December 2021. Patient demographic, angiographic, treatment, and outcome were analyzed to identify independent predictors of recurrence and unfavorable outcome. One hundred and seventeen patients with 117 low-and intermediate-grade LS-DAVFs underwent EVT were included in this study. The mean age of the patients was 53.0±17.5 years. Immediately complete obliteration was achieved in 103/117 (88%) patients after EVT. Clinical follow-up were available for all of 117 patients, with an unfavorable outcome rate of 5.1%. Angiographic follow-up was available in 91 patients (78%). Recurrence occurred in 16 (18%) patients and 8 (6.8%) received retreatment. Contralateral sinus severe stenosis or occlusion was an independent high-risk factor for the unfavorable outcome (OR=11.7; 95% CI: 1.9-70.9, P<0.01) and recurrence (OR=63.8; 95% CI: 10.3-396.5, P<0.01) for low-and intermediate-grade LS-DAVFs at follow-up. Contralateral sinus severe stenosis or occlusion represents a stronger independent risk factor associated with recurrence and unfavorable outcome in patients with low-and intermediate-grade LS-DAVFs when the involved ipsilateral sinus was occluded after EVT. For patients with LS-DAVFs, the patency of the contralateral sinus should be considered when therapeutic decision-making. LS-DAVFs = Lateral sinus dural arteriovenous fistulas; EVT = endovascular treatment; TAE = Transarterial Embolization; TVE = Transvenous Embolization; CN = cranial nerve; CVD = cortical venous drainage.

Microsurgical obliteration of craniocervical junction dural arteriovenous fistulas via a suboccipital median approach: a retrospective study.

The authors report on a broad range of microsurgical procedures in which the suboccipital median technique was used to treat craniocervical junction arteriovenous fistulas. Their aim was to evaluate the efficacy of the suboccipital posteromedian approach and to assess the associated clinical outcomes. The authors extracted information on the fistula site, clinical manifestation, and structural characteristics of arterial and venous vessels by retrospectively evaluating cases from a neurointerventional database spanning 10 years. In this study, 52 patients (median age 62 years; 23.1% female) were examined, with subarachnoid hemorrhage (SAH)/intracranial hemorrhage (61.6%) and myelopathy (34.6%) as prevalent presentations. Forty craniotomies (76.9%) were performed using the suboccipital median approach. Six craniotomies (11.5%) were performed using the far-lateral approach. Five patients (9.6%) underwent embolization, resulting in a residual lesion in 1. The C1 radicular artery served as the main feeding artery (78.9%). During the operation, the fistulas were mainly located near the C1 dural nerve root sleeve (ventrolateral and dorsolateral to the spinal cord). After the lesion was located, the dentate ligament was severed. Patients with SAH demonstrated a more favorable prognosis (modified Rankin Scale score 0-2, 93.8%) compared to those without SAH (modified Rankin Scale score 0-2, 70%), with a statistically significant difference (p = 0.02). The suboccipital posteromedian approach is suitable for resections of nearly all craniocervical junction dural arteriovenous fistulas. The prognosis of the patients with SAH was better than that of the patients without it.

Teaching NeuroImage: Medullary Edema Due to Dural Arteriovenous Fistula: A Potentially Characteristic Imaging Finding.

Teaching NeuroImage: Medullary Edema Due to Dural Arteriovenous Fistula: A Potentially Characteristic Imaging Finding.

Updated classification with spinal dysraphism and treatment outcomes of arteriovenous shunts below conus: a retrospective cohort study

BackgroundArteriovenous shunts below conus medullaris (AVS-BC) are understudied, particularly those associated with spinal dysraphism. This study aimed to refine the classification and management of AVS-BC.MethodsA retrospective analysis of patients with...