Surgical occlusion of the leptomeningeal drainage is a safe and effective treatment for intracranial dural arteriovenous fistulas without dural sinus drainage

✓ Intracranial dural arteriovenous fistulas (AVFs) have been recognized as acquired lesions that can behave aggressively depending on the pattern of venous drainage. Based on the type of venous drainage, they can be classified as fistulas drained only by venous sinuses, those drained by venous sinuses with retrograde flow in arterialized leptomeningeal veins, and fistulas drained solely by arterialized leptomeningeal veins. Serious symptoms, including hemorrhage and focal deficit, are related to the presence of arterialized leptomeningeal veins. In this paper, the authors report a consecutive series treated between 1988 and 1993 of 20 cases of intracranial dural AVFs with “pure leptomeningeal drainage.” All patients underwent surgical interruption of the leptomeningeal draining veins. Based on the arterial supply, nine patients were managed by direct surgery, whereas 11 patients were prepared for surgery by means of preoperative arterial embolization. Radioanatomical cure of the fistula and good neurological recovery were achieved in 18 cases. Complete obliteration of the fistula was documented angiographically in two cases, but fatal hemorrhage occurred, probably due to partial thrombosis of the venous drainage. Based on this experience, the authors believe that surgical interruption of the draining veins is the best treatment option for intracranial dural AVFs. However, surgical results may be affected by the extension of postoperative thrombosis, which in turn may be related to the degree of preoperative venous engorgement.

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Selective Transvenous Embolization for Dural Arteriovenous Fistulas with the Aid of Superselective Venograms of Fistulous Drainages and Involved Sinuses

Interventional Neuroradiology ◽

10.1177/15910199040100s105 ◽

2004 ◽

Vol 10 (1_suppl) ◽

pp. 43-50 ◽

Cited By ~ 1

Author(s):

M. Nakamura ◽

Y. Nakamura ◽

A. Fujita ◽

E. Kohmura

Keyword(s):

Developmental Process ◽

Sinus Thrombosis ◽

Transverse Sinus ◽

Dural Sinus ◽

Transvenous Embolization ◽

Arteriovenous Fistulas ◽

Sagittal Sinus ◽

Arteriovenous Shunts ◽

Dural Arteriovenous Fistulas ◽

Sinus Drainage

For the treatment of transvenous embolization (TVE) of dural arteriovenous fistulas (DAVFs) the sites of arteriovenous shunts, fistulous drainage, and the pathological changes inside the affected sinuses were explored in detail by means of preoperative arteriograms, superselective arteriograms, and superselective venograms. Out of 42 adult patients with DAVFs involving a total of 63 sinuses, three distinctive findings were identified as essential for indication of selective TVE for DAVFs. The first is extra-sinus fistulous drainage, which is embolizable fistulous drainage, remote from the major dural sinus, that flows into the sinus lumen. The second is intramural fistulous drainage, which is embolizable fistulous drainage located within the dural leafs of the involved sinus and separate from the major sinus lumen. The third consists of several lumens inside the affected sinuses, which suggests a variety of histological changes in the developmental process of sinus thrombosis and DAVFs. The extra-sinus drainage was occluded in three torcular heroplili fistulas and three transverse sinus fistulas. The intramural fistulous drainage was eliminated in three superior sagittal sinus fistulas. Several lumens inside the affected sinuses were encountered in 17 posterior fossa fistulas (68%) and 10 cavernous sinus fistulas (34%). These distinctive findings were recognized in 52% of the DAVFs. Out of various modalities for treatment of DAVFs, TVE has been the method of choice for the treatment of diffuse DAVFs. The TVE of DAVFs do not correspond to simple sinus occlusion, but imply selective occlusion of fistulous drainages and sinus lumens. The recognition of these three distinctive types of fistulous drainages have clinical impact in that it helps to completely occlude all the fistulous components of fistulas as well as preserve or restore the normal venous outflow through the involved sinus.

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Selective disconnection of cortical venous reflux as treatment for cranial dural arteriovenous fistulas

Journal of Neurosurgery ◽

10.3171/jns.2004.101.1.0031 ◽

2004 ◽

Vol 101 (1) ◽

pp. 31-35 ◽

Cited By ~ 57

Author(s):

J. Marc C. van Dijk ◽

Karel G. TerBrugge ◽

Robert A. Willinsky ◽

M. Christopher Wallace

Keyword(s):

Dural Sinus ◽

Venous Reflux ◽

Content Type ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas ◽

Cortical Venous Reflux ◽

Sinus Drainage ◽

Fine Print

Object. A single-institution series of 119 consecutive patients with a dural arteriovenous fistula (DAVF) and cortical venous reflux was reviewed to assess the overall clinical outcome of multidisciplinary management after long-term follow up. The selective disconnection of the cortical venous reflux compared with the obliteration of the entire DAVF was evaluated. Methods. Dural arteriovenous fistulas in patients in this series were diagnosed between 1984 and 2001, and treatment was instituted in 102 of them. The outcome of adequately treated patients was compared with that of a control group consisting of those with persistent cortical venous reflux and with data found in the literature. In cases of combined dural sinus drainage and cortical venous reflux, a novel treatment concept of selective disconnection of the cortical venous reflux that left the sinus drainage intact, and thus converted the aggressive DAVF into a benign lesion, was evaluated. Endovascular treatment, which was instituted initially in 78 patients, resulted in an obliteration or selective disconnection in 26 (25.5%) of 102 cases. In 70 cases (68.6%) the DAVFs were surgically obliterated or disconnected. In six cases (5.9%), patients were left with persistent cortical venous reflux. No lasting complications were noted in this series. Follow-up angiography confirmed a durable result in 94 (97.9%) of 96 adequately treated cases, at a mean follow up of 27.6 months (range 1.4–138.3 months). Selective disconnection was performed in 23 DAVFs with combined sinus drainage and cortical venous reflux. These patients' long-term outcomes were equal to those with obliterated DAVFs, and the complication rate was lower. Conclusions. Considering the ominous course of DAVFs with patent cortical venous reflux, multidisciplinary treatment of these lesions is highly effective and the complication rate is low. Selective disconnection provides a valid treatment option of DAVFs with combined dural sinus drainage and cortical venous reflux, as has been shown in cranial DAVFs with direct cortical venous reflux.

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Advances in Surgical Approaches to Dural Fistulas

Neurosurgery ◽

10.1227/neu.0000000000000228 ◽

2014 ◽

Vol 74 (suppl_1) ◽

pp. S32-S41 ◽

Cited By ~ 19

Author(s):

Patrick P. Youssef ◽

Albert Jess Schuette ◽

C. Michael Cawley ◽

Daniel L. Barrow

Keyword(s):

Treatment Options ◽

Venous Drainage ◽

Venous Hypertension ◽

Surgical Approaches ◽

Dural Sinus ◽

Intraoperative Angiography ◽

Indocyanine Green Videoangiography ◽

Arteriovenous Fistulas ◽

The Past ◽

Dural Arteriovenous Fistulas

Abstract Dural arteriovenous fistulas are abnormal connections of dural arteries to dural veins or venous sinuses originating from within the dural leaflets. They are usually located near or within the wall of a dural venous sinus that is frequently obstructed or stenosed. The dural fistula sac is contained within the dural leaflets, and drainage can be via a dural sinus or retrograde through cortical veins (leptomeningeal drainage). Dural arteriovenous fistulas can occur at any dural sinus but are found most frequently at the cavernous or transverse sinus. Leptomeningeal venous drainage can lead to venous hypertension and intracranial hemorrhage. The various treatment options include transarterial and transvenous embolization, stereotactic radiosurgery, and open surgery. Although many of the advances in dural arteriovenous fistula treatment have occurred in the endovascular arena, open microsurgical advances in the past decade have primarily been in the tools available to the surgeon. Improvements in microsurgical and skull base approaches have allowed surgeons to approach and obliterate fistulas with little or no retraction of the brain. Image-guided systems have also allowed better localization and more efficient approaches. A better understanding of the need to simply obliterate the venous drainage at the site of the fistula has eliminated the riskier resections of the past. Finally, the use of intraoperative angiography or indocyanine green videoangiography confirms the complete disconnection of fistula while the patient is still on the operating room table, preventing reoperation for residual fistulas.

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Percutaneous transvenous embolization of a dural arteriovenous fistula through a mastoid emissary vein

Journal of Neurosurgery ◽

10.3171/jns.2006.105.4.636 ◽

2006 ◽

Vol 105 (4) ◽

pp. 636-639 ◽

Cited By ~ 20

Author(s):

Dennis J. Rivet ◽

James K. Goddard ◽

Keith M. Rich ◽

Colin P. Derdeyn

Keyword(s):

Endovascular Treatment ◽

Transverse Sinus ◽

Dural Sinus ◽

Type Ii ◽

Emissary Vein ◽

Arteriovenous Fistulas ◽

Mastoid Emissary Vein ◽

Vein Access ◽

Dural Arteriovenous Fistulas ◽

Gain Access

✓ Definitive endovascular treatment of dural arteriovenous fistulas (DAVFs) requires obliteration of the site of the fistula: either the diseased dural sinus or the pial vein. Access to this site is often limited by occlusion of the sinus proximal and distal to the segment containing the fistula. The authors describe a technique in which the mastoid emissary vein is used to gain access to a Borden–Shucart Type II DAVF in the transverse–sigmoid sinus. Recognition of this route of access, if present, may facilitate endovascular treatment of these lesions. Access to the transverse sinus via this approach can be straightforward and may be underused.

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Multiple Dural Arteriovenous Fistulas

Interventional Neuroradiology ◽

10.1177/159101990200800210 ◽

2002 ◽

Vol 8 (2) ◽

pp. 183-191 ◽

Cited By ~ 4

Author(s):

A.J.P. Goddard ◽

M.S. Khangure

Keyword(s):

De Novo ◽

Disease Process ◽

Venous Drainage ◽

Transverse Sinus ◽

Dural Sinus ◽

External Carotid ◽

Unique Case ◽

Arteriovenous Fistulas ◽

Type Iv ◽

Dural Arteriovenous Fistulas

Dural arteriovenous fistulas are most probably acquired lesions. However, they have been rarely encountered de novo. We present a unique case of a 71-year-old woman who initially presented with right-sided dural arteriovenous fistula (DAVF), which spontaneously resolved after diagnostic arteriography. She later developed asymptomatic occlusion of the left transverse sinus. Five years after her initial presentation she developed left-sided pulse-synchronous tinnitus. MRA and catheter angiography showed a complex type IV DAVF between the left transverse sinus and multiple dural branches arising from both left and right external carotid arteries. The left transverse sinus was isolated from the torcula herophili, with stenosis of the sigmoid sinus. Extensive cortical venous drainage was demonstrated. Endovascular cure was effected by polyvinyl alcohol particle and absolute alcohol occlusion of the dominant dural supply, and transvenous coil occlusion of the left transverse sinus. The patient's symptoms resolved almost immediately. This unique case demonstrates that dural sinus occlusion and DAVFs may co-exist, but there may not be a causal relationship. It is likely that both DAVFs and sinus occlusion are manifestations of the same disease process characterised by a pro-thrombotic state and secondary angiogenesis. It is important to recognise that changes in symptomatology, even long after apparent disappearance of a lesion may indicate recurrence, and careful follow up is advocated.

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Dural arteriovenous fistulas masquerading as dural sinus thrombosis

Journal of Neurosurgery ◽

10.3171/2008.7.jns08253 ◽

2009 ◽

Vol 110 (3) ◽

pp. 514-517 ◽

Cited By ~ 4

Author(s):

Scott Simon ◽

Tom Yao ◽

Arthur J. Ulm ◽

Benjamin P. Rosenbaum ◽

Robert A. Mericle

Keyword(s):

Sinus Thrombosis ◽

Noninvasive Imaging ◽

Anticoagulation Therapy ◽

Transverse Sinus ◽

Dural Sinus ◽

Dural Sinus Thrombosis ◽

Venous Flow ◽

Arteriovenous Fistulas ◽

Imaging Results ◽

Dural Arteriovenous Fistulas

The authors report dural sinus thrombosis diagnosed in 2 patients based on noninvasive imaging results, which were revealed to be dural arteriovenous fistulas (DAVFs) diagnosed using digital subtraction (DS) angiography. The first patient was a 63-year-old man who presented with headaches. Magnetic resonance venography was performed and suggested dural sinus thrombosis of the left transverse sinus and jugular vein. He was administered warfarin anticoagulation therapy but then suffered multiple intracranial hemorrhages. A DS angiogram was requested for a possible dural sinus thrombectomy, but the DS angiogram revealed a DAVF. The patient underwent serial liquid embolization with complete obliteration of the DAVF. The second patient, an 11-year-old boy, also presented with headaches and was diagnosed with dural sinus thrombosis on MR imaging. A DS angiogram was also requested for a possible thrombectomy and revealed a DAVF. This patient underwent serial liquid embolization and eventual operative resection. These reports emphasize that different venous flow abnormalities can appear similar on noninvasive imaging and that proper diagnosis is critical to avoid contraindicated therapies.

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THROMBOPHILIC ABNORMALITIES AMONG PATIENTS WITH CRANIAL DURAL ARTERIOVENOUS FISTULAS

Neurosurgery ◽

10.1227/01.neu.0000255529.46092.7c ◽

2007 ◽

Vol 61 (2) ◽

pp. 262-269 ◽

Cited By ~ 19

Author(s):

Takashi Izumi ◽

Shigeru Miyachi ◽

Ken-ichi Hattori ◽

Hiroshi Iizuka ◽

Yukimi Nakane ◽

...

Keyword(s):

Sinus Thrombosis ◽

Anticardiolipin Antibody ◽

University Hospital ◽

Fistula Formation ◽

Dural Sinus ◽

Arteriovenous Fistulas ◽

Unruptured Intracranial Aneurysms ◽

Dural Arteriovenous Fistulas ◽

The Mean ◽

D Dimer

Abstract OBJECTIVE Dural sinus thrombosis often accompanies or precedes the development of dural arteriovenous fistulas (DAVFs). Because thrombophilic abnormalities can contribute to sinus thrombosis, we investigated the prevalence of such abnormalities and of venous sinus thrombosis in patients with DAVFs. METHODS Thrombophilic factors were measured in 18 patients with DAVFs treated with embolization at our university hospital. Control data were obtained from patients with unruptured intracranial aneurysms. In addition to sinus occlusion, we investigated prothrombin time, activated thromboplastin time, platelet count, and fibrinogen, platelet, antithrombin III, protein C, protein S, anticardiolipin antibody, anti-cardiolipin β2-glycoprotein-I complex antibody, and D-dimer levels. RESULTS Of the 18 patients with DAVFs, 16 had abnormal D-dimer levels, whereas the mean values for other thrombophilic factors were nearly normal. D-dimer levels were significantly higher in preoperative DAVF patients than in controls. Interestingly, the mean value of D-dimer was higher in patients with sinus occlusion than in those without it (3.33 versus 1.19). D-dimer levels rose after embolization in eight out of 10 serially tested patients, but, on average, the change was not significant. In clinically cured patients treated more than 3 months before, D-dimer was lower than in preoperative patients. CONCLUSION D-dimer is a very sensitive indicator of acute venous thrombosis, suggesting that elevations in patients with DAVFs are likely to reflect sinus thrombosis. D-dimer values decreased and nearly normalized in clinically cured patients during a long-term follow-up period, a finding consistent with completion of thrombosis and cure of the disease. To clarify the correlation between DAVF and sinus thrombosis from the aspect of etiology, we should thoroughly check the variation in the concentration of the thrombophilic factors in the patient with chronic sinus occlusion to know the variation in the fistula formation in the further study.

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An Onyx tunnel: reconstructive transvenous balloon-assisted Onyx embolization for dural arteriovenous fistula of the transverse-sigmoid sinus

Journal of Neurosurgery ◽

10.3171/2017.5.jns17287 ◽

2018 ◽

Vol 129 (4) ◽

pp. 922-927 ◽

Cited By ~ 5

Author(s):

Mena G. Kerolus ◽

Joonho Chung ◽

Stephen A. Munich ◽

Yoshikazu Matsuda ◽

Hideo Okada ◽

...

Keyword(s):

Treatment Option ◽

Balloon Catheter ◽

Transverse Sinus ◽

Sigmoid Sinus ◽

Dural Sinus ◽

Effective Treatment Option ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas ◽

Complete Obliteration ◽

Technical Details

Transvenous embolization is an effective method for treating dural arteriovenous fistulas (DAVFs) of the transverse-sigmoid sinus (TSS). However, in cases of complicated DAVFs, it is difficult to preserve the patency of the dural sinus. The authors describe the technical details of a new reconstructive technique using transvenous balloon-assisted Onyx embolization as another treatment option in a patient with an extensive and complex DAVF of the left TSS.A microcatheter and compliant balloon catheter were navigated into the left internal jugular vein and placed at the distal end of the DAVF in the transverse sinus. The microcatheter was placed between the vessel wall of the TSS and the balloon. After the balloon was fully inflated, Onyx-18 was injected at the periphery of the balloon in a slow, controlled, progressive, stepwise manner; the balloon and microcatheter were simultaneously withdrawn toward the sigmoid sinus, with Onyx encompassing the entirety of the complex DAVF. The Onyx refluxed into multiple arterial feeders in a distal-to-proximal step-by-step manner, ultimately resulting in an Onyx tunnel. The final angiography study revealed complete obliteration of the DAVF and patency of the TSS.The Onyx tunnel, or reconstructive transvenous balloon-assisted Onyx embolization technique, may be an effective treatment option for large, complex DAVFs of the TSS. This technique may provide another option to facilitate the complete obliteration of the DAVF while preserving the functional sinus.

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Three-dimensional computed tomography angiography in presurgical planning for treatment of infratentorial dural arteriovenous fistulas

Journal of Neurosurgery ◽

10.3171/2008.4.17515 ◽

2009 ◽

Vol 110 (1) ◽

pp. 85-89 ◽

Cited By ~ 4

Author(s):

Sergio Paolini ◽

Giuseppe Lanzino ◽

Claudio Colonnese ◽

Eugenio Venditti ◽

Giampaolo Cantore ◽

...

Keyword(s):

Three Dimensional ◽

Multislice Ct ◽

Surgical Anatomy ◽

Posterior Cranial Fossa ◽

Conventional Angiography ◽

Arteriovenous Fistulas ◽

Dural Arteriovenous Fistulas ◽

Cranial Fossa ◽

Vascular Structures ◽

Leptomeningeal Drainage

Dural arteriovenous fistulas (DAVFs) with pure leptomeningeal drainage may be cured by simple interruption of their venous side. This report illustrates the cases of 3 patients undergoing surgery for fistulas classified as Borden Type III, involving the posterior cranial fossa. Preoperatively, the surgical anatomy of these lesions was investigated with 3D reformatting of multislice CT angiography, in addition to conventional angiography. Reformatted images clarified the surgical anatomy of the malformation. Reconstructing both the osseous and the vascular structures and simulating the surgical orientation allowed localization of the dural takeoff point of the DAVF's drainage, showing its relationship with osseous landmarks. Precise localization of the DAVF's drainage may help in choosing the most direct and effective approach to treat the malformation. The reported cases could be treated with a standard retrosigmoid exposure, avoiding the need for more complex cranial base approaches.

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