Transverse-sigmoid Sinus Dural Arteriovenous Fistula Research Articles

Safety evaluation of sinus patency after stereotactic radiosurgery for transverse-sigmoid sinus dural arteriovenous fistulas: implications of treatment options for patients with Borden type I fistulas.

This study aimed to assess the efficacy and safety of stereotactic radiosurgery (SRS) in treating transverse-sigmoid sinus dural arteriovenous fistulas (TSS DAVFs), and to investigate post-SRS sinus patency, focusing on the risk factors associated with treated sinus occlusion. Data from 34 patients treated with SRS between January 2006 and April 2023 were analyzed. Detailed angioarchitecture was confirmed using digital subtraction angiography before SRS. Angiography of the ipsilateral internal carotid artery and vertebral artery was performed to evaluate whether the involved side of the TSS was used for normal venous drainage. TSS stenosis was defined as sinus diameter < 50% of the normal proximal diameter. DAVF shunt obliteration, TSS occlusion, neurological status, and adverse events were also evaluated. Of the 34 patients, 21 had Borden type I and 14 had Borden type II DAVFs. The median age at SRS was 64 years (interquartile range 54-71 years), and the follow-up period was 31 months (interquartile range 15-94 months). Complete shunt obliteration was achieved in 24 (70.6%) patients. The cumulative 2-, 3-, and 5-year shunt obliteration rates were 49.6%, 71.2%, and 86.0%, respectively. Borden type I had higher obliteration rates (60.5%, 83.1%, and 94.4%, respectively) than Borden type II (41.7%, 51.4%, and 75.7%, respectively; p = 0.034). TSS occlusion occurred in 5 patients (14.7%). The cumulative 1-, 5-, and 10-year TSS occlusion rates were 2.9%, 8.3%, and 23.6%, respectively, across the entire cohort. All occlusions occurred exclusively in the sinuses that were not used for normal venous drainage. Cox proportional analyses revealed that TSS stenosis and the sinus not being used for normal venous drainage were significantly associated with a greater risk of TSS occlusion after SRS (HR 9.44, 95% CI 1.01-77.13; p = 0.049). SRS is effective and safe for TSS DAVF and results in favorable shunt obliteration, symptom improvement, and low complication rates. TSS occlusion after SRS is asymptomatic and is limited to sinuses that are not used for normal venous drainage.

A Case of Dural Arteriovenous Fistula Following Cerebral Venous Sinus Thrombosis Associated with the COVID-19 Vaccine.

Cerebral venous sinus thrombosis (CVST) is one of the rare and severe complications of coronavirus disease 2019 (COVID-19) vaccines. CVST has also been reported to develop into dural arteriovenous fistula; however, there were no reports of dural arteriovenous fistula associated with COVID-19 vaccine-induced cerebral venous sinus thrombosis. Here, we describe a rare case of a transverse-sigmoid sinus dural arteriovenous fistula followed by CVST due to COVID-19 vaccination. A 70-year-old patient presented with headache five days after receiving a second dose of COVID-19 vaccine. MRI showed a CVST in the superior sagittal sinus, left transverse sinus, and left sigmoid sinus. His headache improved after the administration of anticoagulant therapy. Six months later, a similar headache recurred, and cerebral angiography demonstrated a dural arteriovenous fistula in the left transverse sigmoid sinus and convexity dural arteriovenous fistulas in the left parietal cortex. The patient was treated twice with two sessions of transarterial embolization, and the shunts were completely occluded. His symptoms improved, and he was discharged with a modified Rankin Scale score of 0. Dural arteriovenous fistula can develop after CVST in association with COVID-19 vaccination.

Transverse-Sigmoid Sinus Dural Arteriovenous Fistula Concurrent With Bilateral Venous Sinus Occlusion.

Dural arteriovenous fistula (DAVF) is a relatively rare type of cerebrovascular malformation with unknown pathogenesis. Here, the authors report a patient with DAVF in the left transverse-sigmoid sinus (Cognard type III) combined with occlusions of the left sigmoid sinus and right transverse sinus. The authors describe and discuss their successful treatment approach, with the aim to improve the management of this rare disorder. A 59-year-old man presented with dizziness, headache, vomiting, and unsteady gait. His digital subtraction angiography evaluation indicated DAVF in the left transverse-sigmoid sinus (Cognard type III) combined with occlusions of the distal 1/3 of the left sigmoid sinus and the proximal one-third of the right transverse sinus. After balloon angioplasty and stenting, blood flow was restored in the occluded sinuses. The DAVF was treated by embolization. The patient had a satisfactory recovery with significantly improved clinical symptoms. In patients with transverse-sigmoid sinus DAVF, satisfactory venous reflux should be ensured. In patients with concurrent DAVF and sinus stenosis or occlusion, it is important to reestablish antegrade venous blood flow first. It is feasible and safe to simultaneously embolize DAVF after the venous reflux can be reestablished.

Transarterial embolization and transvenous embolization for transverse-sigmoid sinus dural arteriovenous fistulas with cortical venous reflux: A comparative study.

Dural arteriovenous fistulas (DAVFs) with cortical venous reflux (CVR) carry a high risk for neurological sequelae or death. Recently, transverse-sigmoid sinus DAVFs were shown as good indications for transarterial embolization (TAE) with ONYX. Here, we compared the effectiveness and safety of conventional transvenous embolization (TVE) with those of TAE with ONYX for transverse-sigmoid sinus DAVFs with CVR. Sixty-one patients with transverse-sigmoid sinus DAVFs were treated from April 2013 to May 2020. Among them, 37 patients with CVR were included. Transarterial embolization and TVE were compared in terms of complete occlusion and residual CVR immediately after treatment, complications with worsening modified Rankin Scale (mRS) ≥ 1, amount of contrast media used during treatment, radiation exposure, and surgical procedure time. Ten patients were treated with 10 TAEs using ONYX and 27 patients with 29 TVEs. Transarterial embolization and TVE showed no differences in the overall complete occlusion rate (80% [8/10 patients] vs. 80% [23/27], respectively), whereas the residual rate of existing CVR was 10% (1/10 patient) vs. 3.4% (1/27) in the TAE and TVE groups, respectively. No complications with worsening mRS ≥1 occurred in either group. Among the parameters of amount of contrast media, radiation dose, and operative time, only radiation dose in the TAE group was lower than that in the TVE group (median: 2239 mGy vs. 3268 mGy, respectively; p = 0.07). For transverse-sigmoid sinus DAVFs with CVR, TAE treatment reduced radiation exposure. However, both TAE and TVE achieved high complete occlusion rates and low complication rates.

Transvenous coil embolization of a Cognard V transverse-sigmoid sinus dural arteriovenous fistula.

Dural arteriovenous fistulas with drainage into the spinal veins, classified as Cognard type 5, can be challenging to diagnose and treat. Brainstem and cervical spinal cord signal abnormalities on magnetic resonance imaging result from venous congestion, and can mimic tumor, infection, or inflammation.1-3 Transarterial and transvenous embolization techniques can be used to treat dural arteriovenous fistulas endovascularly. Efficacious transvenous treatment relies on the ability to safely catheterize the draining vein at the dural arteriovenous fistula site. Transvenous access options may seem limited in the setting of occluded venous sinuses. This case highlights the technical aspects of the transvenous approach to embolization of a transverse-sigmoid sinus dural arteriovenous fistula within an isolated sinus,4,5 demonstrating traversal of the occluded venous sinus from a contralateral approach.6,7[Media: see text].

In Reply: Angioarchitectural Analysis of Arteriovenous Shunts in Dural Arteriovenous Fistulas and Its Clinical Implications.

To the Editor: We would like to thank Dr Su et al1 for sharing their insights on dural arteriovenous fistulas (DAVFs) and thoughtful and duly comments on our recent article “Angioarchitectural analysis of arteriovenous shunts in dural arteriovenous fistulas and its clinical implications.”2 Based on the histopathological studies and their experience of DAVFs, Dr Su et al point out that fistulas are not formed directly at the dural sinuses but between the dural artery and the dural vein (in the dural sinus wall) before draining into the sinus or the bridging vein.1,3,4 We agree with these classic histopathological finding; however, the main focus of our study was to describe and discriminate the “angiographic” shunt patterns in light of the connections between the shunt, the sinus, and the cortical veins to unveil their practical implications. In this regard, there were specific patients in whom the targetable fistulous channel—regarding the branching patterns and the caliber changes of the vessels—could not be identified but showed functionally direct connections with the sinus. The histopathological basis for these kinds of shunt remains speculative. The variations in the anatomy of the dural vessels (length, location, etc), secondary changes associated with venous hypertension, thrombosis, inflammation, angiogenesis, and dural wall alterations alongside the temporal changes may have manifested as this pattern.3-8 Interestingly in our series, multiple shunt types were noted in several patients (n = 7), more frequently as the coexistence of the direct sinus fistulae and mural channel-type shunts (n = 5), suggesting the dynamic nature of this disease. Extensive histopathological studies are crucial to shed light on these compelling questions but are extremely limited. Meanwhile, angiographic discrimination of the different characteristics of the shunts, such as the diffuse direct connections or channel-like structures or bridging vein type shunts, and their connection patterns with the sinus and the cortical vein are paramount for effectively targeting the lesion and predicting the behavior of the liquid embolic agents. The presence of pial arterial supply to the DAVF has gained much interest. There are concerns that these patients may be associated with postprocedural rupture of the fragile neovascularized vessels after venous outflow obstruction and inadvertent reflux of the embolic agent into the pial arteries.9,10 The presence of the pial feeders are known to be strongly associated with the tentorial DAVFs.9,10 Our series included only the superior sagittal and transverse sigmoid sinus DAVFs; thus, analyzing the implications of pial supplies was considered beyond the scope of our study. However, this is an interesting topic that deserves further scrutinization. We greatly appreciate the comments and insights by Dr Su et al. DAVFs are fascinating but also complex and challenging diseases. We wish for further technological progress and the power of collective intelligence in understanding and overcoming this intriguing disease.

Direct sinus packing with low radiation exposure in the hybrid operating room using navigation and indocyanine green angiography in the patient with isolated transverse-sigmoid sinus dural arteriovenous fistula: a case report

Direct sinus packing with low radiation exposure in the hybrid operating room using navigation and indocyanine green angiography in the patient with isolated transverse-sigmoid sinus dural arteriovenous fistula: a case report

A Case of Trans-arterial Embolization for Transverse-sigmoid Sinus Dural Arteriovenous Fistula Resulted in Cerebral Infarction due to Acquired Anastomosis

A Case of Trans-arterial Embolization for Transverse-sigmoid Sinus Dural Arteriovenous Fistula Resulted in Cerebral Infarction due to Acquired Anastomosis

Transverse-sigmoid sinus dural arteriovenous fistula presenting with recurrent transient ischaemic attack: A technical case report.

Intracranial dural arteriovenous fistulae (DAVF) are uncommon and account for approximately 1% of all strokes. All transverse-sigmoid sinus DAVFs require treatment because of the low rate of spontaneous regression and frequent association with aggressive neurologic symptoms. Endovascular embolization which aims for permanent obliteration of the lesion is now the primary treatment modality for all DAVFs. We present a 56-year-old patient with long standing history of intermittent TIA-like symptoms. Magnetic resonance (MR) angiography revealed right transverse-sigmoid sinus DAVF and bilateral vertebral arteries occlusion. The patient’s symptoms completely resolved upon successful trans-arterial embolization of the DAVF.

A Case of Transverse-sigmoid Sinus Dural Arteriovenous Fistula Treated by Transarterial and Transvenous Embolization via the Balloon Microcatheter with Overinflated Balloon Protection of the Torcula

A Case of Transverse-sigmoid Sinus Dural Arteriovenous Fistula Treated by Transarterial and Transvenous Embolization via the Balloon Microcatheter with Overinflated Balloon Protection of the Torcula

Endovascular Treatment of Transverse–Sigmoid Sinus Dural Arteriovenous Fistulas: A Single-Center Experience with Long-Term Follow-Up

Endovascular treatment of transverse-sigmoid sinus dural arteriovenous fistulas (TSDAVFs) remains challenging because of their complex anatomic factors. The aim of our study was to evaluate the long-term efficacy and safety of endovascular treatment of TSDAVFs. From January 2008 to December 2014, 44 patients with TSDAVFs were treated endovascularly at our institution. The clinical and angiographic data were retrospectively collected, and the occlusion rate, complications, and clinical outcomes were analyzed. Overall, 44 patients (26 males and 18 females) were identified, with a mean age of 47 years (range, 13-68 years). Of the 44 patients, 5 presented with Cognard type I fistula, 12 with type IIa, 6 with type IIb, 13 with type IIa+IIb, 2 with type III, and 6 with type IV. Complete (n= 29) or near-complete (n= 7) occlusion of the fistula was achieved in 36 patients (82%). Two patients experienced a transient neurological deficit (cranial nerve VII). In 31 patients with angiographic follow-up (range, 2-40 months) data available, the occlusion remained in 25, 2 previously minimal residual fistulas were completely occluded, 3 residual fistulas were unchanged, and 1 fistula recurred. Two patients with cortical venous reflux who had received incomplete treatment died of intracranial hemorrhage during the follow-up period. Of the 37 patients with clinical follow-up (mean, 33.6 months) data available, clinical cure was achieved in 29, residual symptoms remained unchanged in 7, and symptoms had deteriorated in1. Favorable and durable outcomes were achieved with endovascular treatment of TSDAVFs. TSDAVFs with cortical venous reflux carry a high risk of hemorrhage and require curative treatment.

Posterior Meningeal Artery Origin Patterns among 300 Cases and Their Clinical Importance

The posterior meningeal artery (PMA) is known as a dura mater-nourishing vessel. We encountered a patient with Wallenberg syndrome during transarterial embolization of the PMA associated with the dural arteriovenous fistula (DAVF). After development of Wallenberg syndrome in the patient, we assessed origins of the PMA patterns in 300 cases and divided them into 3 types. A 63-year-old man was incidentally diagnosed as having transverse-sigmoid sinus DAVF with a cortical venous reflux. During the transarterial embolization, the patient complained of vertigo and numbness of the right extremities. Postoperatively, the patient exhibited Wallenberg syndrome. Diffusion-weighted magnetic resonance imaging showed a high-intensity area on the lateral side of the right medulla. While performing arterial embolization of the PMA that directly originates from the intracranial vertebral artery, the possibility of deficient brainstem nourishment must be considered.

Transverse-Sigmoid Sinus Dural Arteriovenous Fistula with Severe Venous Congestion Treated with Venous/Sinus Angioplasty and Stenting: A Case Report

Transverse-Sigmoid Sinus Dural Arteriovenous Fistula with Severe Venous Congestion Treated with Venous/Sinus Angioplasty and Stenting: A Case Report

A Right-sided Aortic Arch with an Aberrant Left Subclavian Artery in a Patient with a Transverse-sigmoid Sinus Dural Arteriovenous Fistula

A Right-sided Aortic Arch with an Aberrant Left Subclavian Artery in a Patient with a Transverse-sigmoid Sinus Dural Arteriovenous Fistula

Abstract W P420: Impact of Embolization Therapy on Venous Congestion in Patients with Transverse-sigmoid Sinus Dural Arteriovenous Fistulas - A Semi-quantitative Susceptibility-weighted MRI study

Background and Purpose: Dural arteriovenous fistulas (DAVFs) often provoke intracerebral hemorrhage (ICH) and progressive neurological deficits due to chronic venous congestion. Trans-arterial and/or trans-venous embolization (TAE/TVE) is known useful to dramatically improve cerebral hemodynamics. However, the methodology to non-invasively visualize venous congestion due to dAVFs has not been established yet. In this study, therefore, the authors evaluated the usefulness of susceptibility-weighted imaging (SWI) to evaluate the degree of venous congestion due to transverse-sigmoid sinus DAVF before and after TAE/TVE. Methods: This prospective study included totally 13 patients with transverse-sigmoid sinus DAVFs who underwent TAE/TVE in our hospital. SWI images were binarized and the number of pixels with the low intensity was automatically counted on each slice. Finally, the ratio of low-intensity pixels to total pixels on each slice was defined as the low intensity ratio (LIR). Results: Of 13 patients, 3 presented with ICH and two developed venous infarction. Cerebral angiography showed diffuse RLVD (retrograde leptomeningeal venous drainage) in four patients and PPP (pseudo-phlebitic pattern) in five. Before embolization, the mean LIR was 10.2±5.6%, ranging from 4.6 to 24%, being significantly higher than the control value (2.7±1.2%, n=5). Angiographical signs of venous congestion were closely related to high LIR values. Endovascular embolization markedly improved the sign of venous congestion on cerebral angiography in all patients. The LIR significantly decreased from 10.2±5.6% to 7.0±3.8% after TAE/TVE (P&lt;0.05). None of them recurred cerebrovascular events due to DAVFs during a mean follow-up period of 20 months. Conclusions: The findings strongly suggest that SWI can non-invasively quantify venous congestion due to DAVFs with high sensitivity and provide reliable information on the efficacy of endovascular treatments.

Angioarchitecture of Transverse-Sigmoid Sinus Dural Arteriovenous Fistulas: Evaluation of Shunted Pouches by Multiplanar Reformatted Images of Rotational Angiography

Recognition of shunted pouches dural arteriovenous fistula allows us to treat the disease effectively by selective embolization of the pouches at first. However, the shunted pouches in transverse-sigmoid sinus dural arteriovenous fistulas have not been well-documented. Our aim was to evaluate the angioarchitecture of transverse-sigmoid sinus dural arteriovenous fistulas, including the frequency and location of shunted pouches and their feeding arteries. MATERIALS AND METHODS Twenty-five consecutive cases of TSS-DAVFs that underwent rotational angiography and transvenous embolization between 2008 and 2011 were reviewed. Multiplanar reformatted images of rotational angiography and selective angiography were reviewed with a particular focus on the shunted pouches. All 25 cases showed SPs, with numbers ranging from 1 to 4 pouches (mean, 2.35). The SPs were located at the transverse-sigmoid junction in 16, close to the vein of Labbé in 9, at the dorsal-to-sigmoid sinus in 9, inferior to the sigmoid sinus in 6, at the sigmoid-jugular junction in 5, and inferior to the transverse sinus or the sinus confluence in 14. The SP at the sigmoid sinus was frequently fed by the jugular branch of the ascending pharyngeal artery and the stylomastoid artery. The SP at the transverse-sigmoid junction and the vein of Labbé was fed by the petrosal/petrosquamous and posterior branches of the middle meningeal artery and the transosseous branches of the occipital artery. The SP inferior to the transverse sinus and the sinus confluence was fed by the transosseous branches of the occipital artery and the posterior meningeal artery. All cases were successfully treated by transvenous embolization with sinus packing (n = 13) or selective embolization of the SP (n = 12). The presence of SP is a common angioarchitecture of TSS-DAVFs. Identification of the SPs would be useful for their treatment.

Surgical management of dural arteriovenous fistulas of the transverse–sigmoid sinus in 42 patients

A retrospective study was performed to analyse a prospectively collected database from a single surgeon (M.K.M.) of transverse–sigmoid sinus dural arteriovenous fistulas (DAVF) between 1991 and August 2011. During the study period, 144 patients with 160 DAVF were managed. Sixty-five of the DAVF were located in the transverse-sigmoid sinus and 42 were treated with surgery, or embolisation and surgery. All patients who underwent surgery were symptomatic with retrograde cortical venous drainage. The average follow-up period was 18months (range, 2–82months). Total elimination of the DAVF was achieved in all instances, including two patients (5%) who required further surgery after postoperative cerebral angiography showed that some venous drainage had persisted after the first operation. There was no new permanent neurological deficit or mortality attributable to surgery. Our institutional experience shows that in selected patients with transverse–sigmoid sinus DAVF, the involved sinus can be surgically resected with a high success rate and it is as safe as many alternative options. We suggest that this definitive treatment option should be offered to patients, and the outcome should be compared to other treatment modalities.

Transarterial Onyx packing of the transverse–sigmoid sinus for dural arteriovenous fistulas

To report transarterial Onyx packing of the transverse-sigmoid sinus for dural arteriovenous fistulae (DAVFs). We retrospectively studied consecutive 5 patients (2 female and 3 male) treated for a transverse-sigmoid sinus DAVF since 2008 in whom transverse sinus packing was attempted with a transarterial approach Onyx embolization. The mean clinical follow-up period was 6.2 months. Of the five lesions, 2 fistulas were type IIa, 3 were type IIb, according to the Cognard classification. Five Onyx embolizations were all performed via the middle meningeal artery. Cure was obtained in all cases after completion of direct sinus packing. No complications were revealed. Transarterial Onyx packing of transverse-sigmoid sinus for DAVFs via the meningeal arterial system is a safe therapeutic alternative in selected cases.

Endovascular management of dural arteriovenous fistulas of the transverse and sigmoid sinus in 150 patients

This study aimed to evaluate the safety and efficiency of the endovascular treatment of transverse-sigmoid sinus dural arteriovenous fistulas (TS_dAVF). A total of 150 consecutive patients and 348 procedures were evaluated. Pulsatile tinnitus (81%), headache (15%), and intracranial hemorrhage (10%) were the most frequent manifestations of the TS_dAVFs. More than half of the affected sinuses were partially or completely thrombosed. Access-wise treatment was performed transarterial (n = 33), transvenous (n = 21), or a combination thereof (n = 96). A mean of 2.4 procedures per patient was required. Immediate postprocedural occlusion rate after transarterial embolization was 30% only. Transvenous treatment alone resulted in an early occlusion rate of 81%, with delayed complete obliteration of half of the remaining fistulas. After combined transarterial/transvenous treatment, the angiographic cure rate was 54%. At follow-up, 88% of patients with residual shunt after the treatment showed complete occlusion. The cumulative complication rate was 9% (n = 13), with minor adverse events in ten patients (7%) and major complications in three patients (2%). Transvenous coil occlusion of the sinus segment with the adjacent dAVF site, eventually combined with transarterial occlusion of supplying arteries, is a very effective and well-tolerated treatment method. In selected patients, variations of these methods (e.g., sinus stenting, compartmental sinus occlusion) can be useful.

A Thrombophilic Patient With a Dural Arteriovenous Fistula Presenting Sensory Aphasia and Complicated With an Acute Pulmonary Embolism

Neuropsychiatric symptoms as the initial presentation of dural arteriovenous fistula (DAVF) are unusual. Anticoagulation therapy may be warranted for prevention of further thromboembolism if an underlying thrombophilia condition is diagnosed. We present a 70-year-old woman with sensory aphasia, who was diagnosed with a DAVF, Cognard type II a + b, by cerebral angiography. Her stroke-like syndrome resolved after transarterial embolization of the left occipital and middle meningeal arteries. Meanwhile, hypercoagulability was found because of hyperhomocysteinemia and the presence of a lupus anticoagulant. One month later, she suffered an acute pulmonary embolism and was started on anticoagulation therapy before stereotactic radiosurgery. Sensory aphasia may be the initial manifestation of a transverse-sigmoid sinus DAVF even if there are no symptoms such as headache or tinnitus. We postulate that early anticoagulation therapy is indicated for preventing thromboembolism in DAVF patients with thrombophilia because the possibility of intracranial bleeding has been reduced by embolization.