Cavernous Dural Fistula Research Articles

The Superior Ophthalmic Vein Approach for the Treatment of Carotid-Cavernous Fistulas: Our First Experience

Carotid cavernous fistulas (CCF) constitute between 10-15% of all intracranial vascular malformations. Clinical symptoms of indirect CCFs include chemosis, conjunctival injection, proptosis, diminished visual acuity, ophthalmoplegia, retro-orbital bruit, periorbital swelling, and hyperlacrimation, in the setting of associated cortical venous reflux, intracranial hemorrhage. Treatment of choice for symptomatic carotid cavernous and cavernous dural fistulas is neuroradiologic intervention via the femoral artery. Owing to the location of the fistula and/or to anatomic variations, a direct surgical approach via the superior ophthalmic vein may be necessary for embolization.

Dilated Superior Ophthalmic Vein: Clinical and Radiographic Features of 113 Cases.

Dilated superior ophthalmic vein (SOV) is an uncommon radiographic finding. The authors review the presentation, etiology, radiography, and visual implications of 113 patients with dilated SOV. An observational case series and multicenter retrospective chart review were conducted. There were 113 patients with a dilated SOV. Outcome measures included patient demographics, clinical features, radiographic findings, diagnosis, and treatment, and treatment outcomes were assessed. Cases included 75 women (66%) and 38 men (34%) with a mean age of 49 ± 24 years (range, 0.4-90 years). Diagnoses fell under 6 categories: vascular malformation (n = 92, 81%), venous thrombosis (n = 11, 10%), inflammatory (n = 6, 5%), traumatic hemorrhage (n = 2, 2%), lymphoproliferative (n = 1, 1%), and infectious (n = 1, 1%). Imaging modalities utilized included MRI (n = 98, 87%), digital subtraction angiography (n = 77, 68%), CT (n = 29, 26%), and ultrasonography (n = 4, 4%). Disease status at last follow up included no evidence of disease (n = 57, 50%), alive with persistent disease (n = 53, 47%), and expired from disease (n = 3, 3%). Treatment and management was tailored to the underlying disease process with a mean follow up of 18 months (range, 1 day to 180 months). Visual impairment observed at presentation and last follow up across all cases was 26% and 22%, respectively. Dilated SOV is a rare radiographic finding resulting from a wide spectrum of etiologies with clinical implications ranging from benign to sight- and life-threatening. Dilated SOV is most often found with dural-cavernous fistula or carotid-cavernous fistula, orbital or facial arteriovenous malformation, and venous thrombosis. Recognition of this finding and management of the underlying condition is critical.

Endovascular Modalities for the Treatment of Cavernous Sinus Arteriovenous Fistulas: A Single-Center Experience

Cavernous sinus (CS) fistulas are classified into traumatic and spontaneous. Traumatic carotid-cavernous fistulas (CCFs) are usually direct internal carotid artery (ICA) high-flow fistulas; whereas spontaneous CCFs are usually dural, low-flow fistulas and generally possess less severe symptoms than direct carotid-cavernous fistulas. This study involved 34 patients who were classified into 2 groups: Group A included 26 patients with direct carotid-cavernous fistula; and Group B included 8 patients with indirect dural cavernous fistula. All patients had ocular manifestations. One patient had subarachnoid hemorrhage. Coils were used alone in 19 cases of direct fistula and in 1 case of dural fistulas. Coils and Onyx (Covidien, Mansfield, MA, USA) were used in 7 cases of direct fistula and in 2 cases of dural fistulas. Onyx alone was used to treat 5 cases with dural fistulas but none of the cases with direct fistulas. Covered stents and coils were used in 2 cases of direct fistulas. All patients in both groups showed full recovery of their clinical signs and symptoms. Only 1 procedure-related complication was observed (3%) in which a patient had an embolic event and trigeminal dysesthesia as a result of Onyx reflux through external carotid artery-ICA anastomosis. Coils are superior solid embolic agents used for the treatment of direct high-flow fistulas, while Onyx is more valuable in dural low-flow CCF. Onyx shortens the procedure time and decreases procedure cost. Onyx injection inside the CS proper through the transarterial or transvenous route may be safer than Onyx injected inside dural arteries supplying the CS. However, more cases are needed to determine this.

Dural arteriovenous fistulas of the cavernous sinus - clinical case and treatment

Abstract The purpose of our article is to present the results of our treatment of dural arteriovenous fistula of the cavernous sinus by glue embolization of the external carotid artery feeders. By this case presentation we try to clarify the clinical course, with the dural carotid cavernous fistula (CCF), characterizing a pallet of symptoms, paying special attention to radiological finding and endovascular treatment. Dural arteriovenous fistulas represent 10% to 15% of all intracranial arteriovenous malformations (A. Fox, G. Duckwiler, “Dural Arteriovenous Fistula,” presented at the annual meeting of the American Society of Neuroradiology, St Louis, Mo, June 1992). Dural arteriovenous fistulas are rare clinical situation, especially examples involving the cavernous sinus. Most dural fistulas are acquired conditions, typically occurring in postmenopausal women, but sometimes in other patients in association with other condition [1,3]. These dural fistulas are most often “spontaneous” cavernous carotid shunts (usually low-flow) [2, 4, 5], usually related to a past trauma or surgery. The classical triad, represented by pulsating exophthalmos, conjunctival chemosis, and pulsatile-tinnitus are well-known clinical symptoms of these lesions but are not necessary present in the majority of the patients as first indicators. The anatomy of these vascular malformations consists of multiple arterial feeders flowing into cavernous sinus. The arterial feeders are usually meningeal branches arising from the internal carotid artery (ICA) or the external carotid artery (ECA). However, there are few reports of large series [1], and the clinical entity is not widely known. The purpose of this paper is to present a clinical case of a patient with dural cavernous sinus fistulae, clarify the clinical symptoms course and special attention to results of endovascular treatment.

Imaging diagnosis of dural and direct cavernous carotid fistulae.

Arteriovenous fistulae of the cavernous sinus are rare and difficult to diagnose. They are classified into dural cavernous sinus fistulae or direct carotid-cavernous fistulae. Despite the similarity of symptoms between both types, a precise diagnosis is essential since the treatment is specific for each type of fistula. Imaging findings are remarkably similar in both dural cavernous sinus fistulae and carotid-cavernous fistulae, but it is possible to differentiate one type from the other. Amongst the available imaging methods (Doppler ultrasonography, computed tomography, magnetic resonance imaging and digital subtraction angiography), angiography is considered the gold standard for the diagnosis and classification of cavernous sinus arteriovenous fistulae. The present essay is aimed at didactically presenting the classification and imaging findings of cavernous sinus arteriovenous fistulae.

Endovascular Occlusion of Dural Cavernous Fistulas through a Superior Ophthalmic Vein Approach

Dural cavernous fistulas are low-flow vascular malformations with usually benign clinical course and a high rate of spontaneous resolution. Cases with symptom progression must be treated with an endovascular approach by arterial or venous route. We report 30 patients with dural cavernous fistulas treated by coil embolization using surgical exposure and retrograde catheterization of the superior ophthalmic vein (SOV). The procedure resulted in closure of the fistula without other endovascular treatments in all 30 patients and clinical remission or improvement in 20 and eight patients, respectively. Embolization via a SOV approach is a safe and easy endovascular procedure, particularly indicated for dural cavernous fistulas with exclusive or prevalent internal carotid artery feeders and anterior venous drainage.

Orbital ultrasound in the selective screening of a dural–cavernous sinus fistula

Orbital ultrasound in the selective screening of a dural–cavernous sinus fistula

Bilateral indirect carotid cavernous fistula post trivial injury– A case report

Fifty-seven years old Malay lady, post menopausal with co-morbid of diabetes mellitus and hypertension presented with three months history of bilateral painful red eyes associated with double vision. Examination revealed both eyes proptosis, corkscrew vessels with present of bruit, secondary narrow angle with raised intraocular pressure, 6th cranial nerve palsy, and bilateral venous stasis retinopathy. CT angiogram showed bilateral dilated superior ophthalmic veins with cerebral angiogram findings of bilateral indirect carotid cavernous fistula involving small meningeal vessels. Indirect or dural cavernous sinus Fistula can easily be missed or misdiagnosed. Trivial injury especially in the predisposing patient can initiate the occurrence.

Spontaneous Isolated Dural Arteriovenous Fistula of the Cavernous Sinus: Endovascular Approach via the Foramen Ovale

The endovascular treatment of spontaneous dural cavernous sinus fistula (DAVF) can be accomplished by arterial approach, just with symptoms relief, or by numerous venous approaches through the inferior petrosal sinus, ophthalmic vein, anterior or posterior intercavernous sinus and facial vein. Our case suggests the approach to the cavernous sinus via the foramen ovale and emissary veins puncture as an alternative when there is no possibility of venous approach conventionally described. A 76-year-old woman presented with right conjunctival hyperemia, exophthalmos, intraocular pressure increasing and visual deficits in a period of six months. Angiographic diagnosis of spontaneous DAVF isolated from the cavernous sinus, Barrow Type C, with exclusive venous drainage through the superior ophthalmic vein. Endovascular treatment was performed under general anesthesia. Attempts to approach the cavernous sinus through the inferior petrosal sinus ipsilateral and contralateral intercavernous, facial vein and pterygoid plexus, as well as by dissection and direct puncture of the superior ophthalmic vein were not possible. An approach to the cavernous sinus was performed by puncturing the foramen ovale, catheterization of the emissary vein of the foramen ovale with occlusion of the fistula with microcoils. There was a symptomatic regression with gradual normalization of intraocular pressure, exophthalmos and conjunctival hyperemia in three months. The approach to the cavernous sinus through the foramen ovale and catheterization of the emissary cranial skull base vein is an exception and should be considered in cases of spontaneous and isolated DAVF not accessible by a conventional approach.

Fistule durale carotido-caverneuse révélée par une paralysie bilatérale à bascule des troisièmes et sixièmes nerfs crâniens

A 74-year-old male was referred for disequilibrium, associated with right third and sixth nerve palsies observed 2weeks after head trauma with no loss of consciousness. On clinical examination, 4months after the injury, contralateral (left) third and sixth nerve palsies were observed, while ocular motility was now normal on the right side. The remainder of the ophthalmological examination was normal. Upon further history, tinnitus was found to have been present since the trauma, and auscultation of the preauricular area demonstrated a systolic bruit. Cerebral angiogram confirmed the presence of bilateral dural-cavernous fistulas. Clinical features of indirect or dural-cavernous fistulas and therapeutic options proposed in the literature are reviewed.

Cathétérisme de la veine ophtalmique supérieure : traitement d’une fistule durale

We report the case of a 68-year-old woman with a chronic unilateral red eye for 3 months. The ophthalmologic exam showed engorged episcleral vessels, proptosis and chemosis. Motility, visual acuity and fundus examination were normal. Neurological examination was also unremarkable. Given the subacute nature of the proptosis in association with engorged episcleral vessels, brain MRI and MRA were performed, demonstrating a right dural-cavernous sinus fistula. After two attempts via the femoral and facial veins, the dural fistula was accessed and treated via the right superior ophthalmic vein. The fistula was occluded and the symptoms regressed in 48 hours. Arteriography at 3 months confirmed a complete cure.

Diagnosis and Management of an Intraorbital Vascular Fistula

A spontaneous intraorbital arteriovenous fistula is an extremely rare phenomenon. More commonly, arteriovenous fistulas occur spontaneously as carotid cavernous fistulas and dural cavernous fistulas or are secondary to trauma. Surgical approaches vary widely and each carries their own set of potential problems. The purpose of this single case report was to provide an example of a successful treatment of a rare, spontaneous intraorbital vascular fistula.

Spontaneous Dural Cavernous Fistula in Infancy

A 4-month-old boy presented with the sudden onset of proptosis and dilated episcleral veins. CT revealed an enlarged superior ophthalmic vein and diffusely thickened extraocular muscles. MRI and angiography confirmed a dural middle meningeal--cavernous sinus fistula. Embolization was performed leading to successful resolution of the patient's signs and symptoms. Spontaneous atraumatic arteriovenous cavernous fistulae in infancy are extremely rare, but should be included in the differential diagnosis of infants with orbital congestion. Appropriate treatment leads to prevention of amblyopia, glaucoma, and anisometropia.

TRANSARTERIAL EMBOLIZATION OF CLIVAL DURAL ARTERIOVENOUS FISTULAE USING LIQUID EMBOLIC AGENTS

Dural arteriovenous fistulae (DAVFs) rarely involve the clivus. This report examines the clinical presentation, angiographic findings, endovascular management, and outcome of clival DAVFs. Particular attention was given to safety and efficacy of transarterial embolization using liquid embolic agents. We reviewed the clinical and radiological data of 10 patients with spontaneous clival DAVFs who were treated endovascularly at the University of California at Los Angeles Medical Center between 1992 and 2006. Nine patients presented with ocular symptoms and one patient experienced pulsatile tinnitus. Cerebral angiograms showed that these clival DAVFs were supplied by multiple branches of the internal and external carotid arteries. The patterns of venous drainage were from the clival veins to the cavernous sinus and superior ophthalmic vein in nine patients and to the inferior petrosal sinus in two patients. Six clival DAVFs were embolized transarterially through the clival branches of the ascending pharyngeal artery. Onyx 18 (Micro Therapeutics Inc., Irvine, CA) was used in three patients and n-butyl cyanoacrylate was used in three patients. Immediate complete angiographic obliteration was achieved in three patients. All six patients experienced an angiographic and clinical cure without any complications at 3 months. Two patients were incompletely treated using particles and coils for the relief of the symptoms. Two other patients were completely treated after the recipient clival venous structures were occluded transvenously with coils. Clival DAVFs can be misdiagnosed as dural cavernous sinus fistulae. The best treatment is transarterial embolization of the dural feeders using liquid embolic agents. Transvenous occlusion of the cavernous sinus is unnecessary in most cases.

Transvenous Embolization with Onyx for Cavernous Sinus Dural Arteriovenous Fistula

Previous treatments for cavernous dural arteriovenous fistulas (DAVF) include transarterial embolization with NBCA and transvenous embolization with platinum coils. This paper presents two cases of cavernous sinus dural arterial venous fistula successfully treated via a transvenous approach with Onyx. Case 1. A 54-year-old man presented with blepharotosis, diplopia and chemosis. Cerebral angiography demonstrated a cavernous DAVF, which was successfully treated via inferior petrosal sinus with a combination of Onyx and platinum coils. Case 2. A 36-year-old woman was admitted after incomplete transarterial embolization of a dural cavernous fistula. The patien's symptoms resolved almost completely after embolization with Onyx-34 via the superior ophthalmic vein. To our knowledge, only two such cases have been reported in the literature. The advantages of Onyx make it an attractive alternative to the various platinum coils already described.

Superior Ophthalmic Vein Cannulation Through a Lateral Orbitotomy for Embolization of a Cavernous Dural Fistula

Many embolization procedures have been described for the treatment of cavernous dural fistulas, including direct superior ophthalmic vein cannulation. Sometimes thrombosis of the superior ophthalmic vein or an anatomic variant will not allow its cannulation. Herein, we describe a case of a cavernous dural fistula in which an anteriorly narrowed and thrombosed superior ophthalmic vein was cannulated in the deep orbit through a lateral orbitotomy.

Transvenous Embolization of a Dural Carotid-Cavernous Sinus Fistula Via the Inferior Ophthalmic Vein

A 76-year-old woman presented with an acute onset of right periocular pain, diplopia, ocular injection, progressive proptosis, and periocular swelling. She had an unremarkable past medical history, and the erythrocyte sedimentation rate and complete blood count were normal. A carotid-cavernous sinus fistula was suspected, and an MRI demonstrated enlargement of the superior ophthalmic vein posterior to the globe and enlargement of the inferior ophthalmic vein throughout its entire course. Cerebral arteriography demonstrated a dural cavernous sinus fistula. The inferior ophthalmic vein was accessed via the inferonasal orbital space and was catheterized for delivery of multiple platinum coils to the cavernous sinus fistula. Follow-up venograms demonstrated occlusion of the fistula. At 2-month follow-up, there was a residual sixth nerve palsy and resolution of symptoms, including proptosis and periocular swelling.

Unusual Presentations of Skull Base Dural Cavernous Fistulae

Introduction: Direct carotid cavernous fistulae most commonly due to trauma are usually easy to diagnosis. Indirect fistulae, on the other hand, are often very difficult to diagnosis leading to substantial delay and potential significant visual system morbidity. Untreated dural fistulae lead to visual loss in 20 to 30% of patients. Untreated high cortical venous pressure contributes to morbidity by causing venous infarctions.

Transvenous Occlusion of a Dural Cavernous Sinus Fistula Using a New Expandable Hydrogel-Platinum Coil (Hydrocoil®)

Hydrogel-coated platinum coils (Hydrocoils(R)) are currently under clinical investigation for their efficacy to improve anatomic results of endovascular occlusion of cerebral aneurysms. A case is presented in which this new expandable coil type was added to bare platinum coils in order to accelerate the transvenous occlusion of a dural cavernous sinus fistula (DCSF). A 53-year-old woman presenting with mild left-sided eye redness and diplopia due to a DCSF (type D) underwent transvenous occlusion using bare platinum coils (Trufill(R)) and hydrogel coated coils (Hydrocoil(R)). After successful catherization of the cavernous sinus, bare platinum coils were densely packed and eventually combined with Hydrocoils(R) which resulted in immediate and complete occlusion of the fistula. No technical or clinical complication occurred. The new expansile hydrogel-coated platinum coil (Hydrocoil(R)) can be successfully combined with bare platinum coils to accelerate transvenous occlusion of an AV-shunting lesion. Controlled volume expansion after deployment of this device offers potential benefits for occlusion of dural arteriovenous fistulas in other locations or for parent vessel occlusions in the treatment of giant or large complex aneurysms.

Spontaneous dural cavernous sinus fistula in a child

We describe the clinical course of a 9-year-old boy in whom a spontaneous dural cavernous sinus fistula developed. The patient initially presented with proptosis and conjunctival congestion believed to be caused by a cavernous sinus hemangioma and was prescribed oral prednisone. He subsequently developed pain, increased proptosis, and decreased vision. Emergent angiography revealed a dural cavernous sinus fistula, which was successfully embolized. This is the first case to our knowledge of a dural cavernous sinus fistula in a noninfant child that was treated successfully with embolization during angiography.J AAPOS 2000;4:383-5.