Embolization of a Cavernous Sinus Dural Arteriovenous Fistula with Onyx via Direct Puncture of the Cavernous Sinus through the Superior Orbital Fissure

Treatment of cavernous sinus dural arteriovenous fistula (CSDAVF) may be challenging. We describe a patient who had presented with progressive ocular symptoms due to CSDAVF requiring urgent interventional therapy. Initial attempts to embolize the fistula utilizing a transvenous approach through the inferior petrosal sinus failed because of difficult anatomy. Successful occlusion of the fistula was subsequently achieved with injection of ethylene vinyl alcohol copolymer, Onyx (EV3 Neurovascular, Irvine, CA, USA), via direct percutaneous puncture of the cavernous sinus through the superior orbital fissure. A brief period of asystole during the initial injection of Onyx may be the result of the trigeminocardiac reflex.

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Acute Brainstem Dysfunction Caused by Cavernous Sinus Dural Arteriovenous Fistula

Case Reports in Neurological Medicine ◽

10.1155/2020/2630959 ◽

2020 ◽

Vol 2020 ◽

pp. 1-4

Author(s):

Yuwa Oka ◽

Kenichi Komatsu ◽

Soichiro Abe ◽

Naoya Yoshimoto ◽

Junya Taki ◽

...

Keyword(s):

Magnetic Resonance ◽

Arteriovenous Fistula ◽

Digital Subtraction Angiography ◽

Cavernous Sinus ◽

Dural Arteriovenous Fistula ◽

Inflammatory Diseases ◽

Digital Subtraction ◽

Arteriovenous Fistulas ◽

Ocular Symptoms ◽

Brainstem Dysfunction

Symptoms of cavernous sinus dural arteriovenous fistula depend on the drainage patterns and are very diverse. Among these, brainstem dysfunction is a rare but serious complication. Here, we describe a case with isolated and rapidly progressive brainstem dysfunction due to cavernous sinus dural arteriovenous fistula. An 80-year-old woman presented with a 2-day history of progressive gait disturbance. Neurological examination revealed mild confusion, dysarthria, and left hemiparesis. Magnetic resonance imaging (MRI) revealed pontine swelling without evidence of infarction. Magnetic resonance angiography suggested a faint abnormality near the cavernous sinus. Dural arteriovenous fistula was suspected, and digital subtraction angiography was planned for the next day. Her condition had progressed to coma by the next morning. Pontine swelling worsened, and hyperintensity appeared on diffusion-weighted imaging. Digital subtraction angiography revealed a right-sided cavernous sinus dural arteriovenous fistula with venous reflux into the posterior fossa. Orbital or ocular symptoms had preceded brainstem symptoms in all nine previously reported cases, but brainstem symptoms were the only presentation in our case, making the diagnosis difficult. Some dural arteriovenous fistulas mimic inflammatory diseases when the clinical course is acute. Prompt diagnosis using enhanced computed tomography or MRI and emergent treatment are needed to avoid permanent sequelae.

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Transorbital direct puncture of the posterior cavernous sinus through the internal carotid artery for embolization of isolated cavernous sinus dural arteriovenous fistula

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2011-010130 ◽

2012 ◽

Vol 5 (2) ◽

pp. e1-e1 ◽

Cited By ~ 7

Author(s):

Chao-Bao Luo ◽

Michael M H Teng ◽

Feng-Chi Chang ◽

Wan-Yuo Guo ◽

Cheng-Yen Chang

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Arteriovenous Fistula ◽

Cavernous Sinus ◽

Dural Arteriovenous Fistula ◽

Internal Carotid ◽

Direct Puncture

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A Patient with a Cavernous Sinus Dural Arteriovenous Fistula in Whom Direct Puncture of the Superior Ophthalmic Vein Led to Rapidly Progressing Thrombosis and Postoperative Non-arteritic Ischemic Optic Neuropathy: Pathogenesis with Respect to a Drainage Route

Journal of Neuroendovascular Therapy ◽

10.5797/jnet.cr.2018-0069 ◽

2019 ◽

Vol 13 (5) ◽

pp. 221-227

Author(s):

Narihide Shinoda ◽

Masafumi Mori ◽

Shogo Tamura ◽

Kazuyoshi Korosue ◽

Shigeru Kose ◽

...

Keyword(s):

Arteriovenous Fistula ◽

Cavernous Sinus ◽

Optic Neuropathy ◽

Dural Arteriovenous Fistula ◽

Ischemic Optic Neuropathy ◽

Superior Ophthalmic Vein ◽

Direct Puncture

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Direct percutaneous transorbital puncture under fluoroscopic guidance with a 3D skull reconstruction overlay for embolisation of intraorbital and cavernous sinus dural arteriovenous fistulas

Interventional Neuroradiology ◽

10.1177/1591019915582925 ◽

2015 ◽

Vol 21 (3) ◽

pp. 357-361 ◽

Cited By ~ 6

Author(s):

Ming Lv ◽

Chuhan Jiang ◽

Dong Liu ◽

Zhiguang Ning ◽

Jun Yang ◽

...

Keyword(s):

Arteriovenous Fistula ◽

Cavernous Sinus ◽

Dural Arteriovenous Fistula ◽

Three Dimensional ◽

Fluoroscopic Guidance ◽

Superior Orbital Fissure ◽

Arteriovenous Fistulas ◽

Skull Reconstruction ◽

Dural Arteriovenous Fistulas

Objective To describe the direct percutaneous transorbital puncture technique for embolisation of the selected intraorbital and cavernous sinus dural arteriovenous fistula, which failed to be treated by conventional endovascular techniques. Methods One case of intraorbital and five cases of cavernous sinus dural arteriovenous fistula were embolised through direct percutaneous transorbital puncture in 2012, and the clinical data were reviewed. Under fluoroscopic guidance with a three-dimensional (3D) skull reconstruction overlay, the cavernous sinus or ophthalmic vein was punctured via the superior orbital fissure. Then a microcatheter was inserted via the needle, and Onyx was injected to embolise the fistula with or without a combination of coils. Results Complete obliteration of the fistula was achieved in all six patients. After operation all the patients experienced transient swelling of the punctured orbit persisting for three to five days. No other complications occurred. Follow-up of six patients at three to six months showed resolution of their initial neuro-ophthalmological symptoms in five and left visual loss in one did not recover. Six months follow-up angiogram showed no recurrence of these fistulas. Conclusion Direct percutaneous transorbital puncture provides an option for the intraorbital and cavernous sinus dural arteriovenous fistulas, particularly when the conventional transvenous routes are inaccessible. Overlay of the 3D skull reconstruction can facilitate the precise puncture of the superior orbital fissure.

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Direct Puncture of the Cavernous Sinus as Alternative Approach to Treat a Dural Arteriovenous Fistula of the Hypoglossal Canal

Clinical Neuroradiology ◽

10.1007/s00062-019-00813-0 ◽

2019 ◽

Vol 30 (1) ◽

pp. 185-188

Author(s):

Johnni Zamponi Júnior ◽

Felipe Padovani Trivelato ◽

Alexandre Cordeiro Ulhôa ◽

Marco Túlio Rezende

Keyword(s):

Arteriovenous Fistula ◽

Cavernous Sinus ◽

Dural Arteriovenous Fistula ◽

Direct Puncture ◽

Hypoglossal Canal ◽

Alternative Approach

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Trigeminocardiac Reflex in Transvenous Packing of the Cavernous Sinus with Onyx for Dural Arteriovenous Fistula

The Neuroradiology Journal ◽

10.1177/197140090702000619 ◽

2007 ◽

Vol 20 (6) ◽

pp. 730-730 ◽

Cited By ~ 1

Author(s):

Lv Xianli ◽

Jiang Chuhan ◽

Li Youxiang ◽

Liu Aihua ◽

Lv Ming ◽

...

Keyword(s):

Arteriovenous Fistula ◽

Cavernous Sinus ◽

Dural Arteriovenous Fistula ◽

Trigeminocardiac Reflex

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Endovascular Treatment of Cavernous Sinus Dural Arteriovenous Fistula With Ipsilateral Inferior Petrosal Sinus Occlusion

Neurosurgery ◽

10.1227/neu.0000000000000751 ◽

2015 ◽

Vol 77 (2) ◽

pp. 192-199 ◽

Cited By ~ 19

Author(s):

Jong Kook Rhim ◽

Young Dae Cho ◽

Jeong Jin Park ◽

Jin Pyeong Jeon ◽

Hyun-Seung Kang ◽

...

Keyword(s):

Endovascular Treatment ◽

Arteriovenous Fistula ◽

Cavernous Sinus ◽

Dural Arteriovenous Fistula ◽

Treatment Strategies ◽

Symptom Improvement ◽

Inferior Petrosal Sinus ◽

Paradoxical Worsening ◽

Transvenous Approach ◽

Arterial Feeder

Abstract BACKGROUND: Although a transvenous route via the ipsilateral inferior petrosal sinus (IPS) is preferred in treating cavernous sinus dural arteriovenous fistula (CSdAVF), this option may be limited if an occluded ipsilateral IPS undermines microcatheter delivery to the cavernous sinus. OBJECTIVE: To describe our experience with endovascular treatment of CSdAVF complicated by ipsilateral IPS occlusion. METHODS: From January 2003 through September 2014, a total of 49 CSdAVFs with ipsilateral IPS occlusion were identified in 49 patients, who then underwent endovascular treatment. Clinical and radiologic data were retrospectively reviewed. RESULTS: Either transvenous (n = 38) or transarterial (n = 11) access was initially elected, the latter reserved for single-hole or dominant arterial feeder fistulas. Access via occluded ipsilateral IPS was usually attempted (n = 34) by transvenous approach, with a 54.3% success rate. Anterior (n = 3) or posterior (n = 1) facial vein was alternatively used. Direct surgical exposure of ophthalmic vein (n = 3) or radiosurgery (n = 4) was performed for access failure or unsuccessful occlusion by other means. In 46 fistulas (93.9%), complete occlusion was achieved, with no procedure-related morbidity or mortality. Postprocedural symptom improvement was noted in all but 2 patients, who separately experienced paradoxical worsening of cranial nerve palsy and access failure. CONCLUSION: In patients with CSdAVF and ipsilateral IPS occlusion, various treatment strategies may be applied (given angioanatomic suitability), resulting in excellent procedural and short-term follow-up results. Reopening of an occluded IPS is reasonable as an initial access attempt.

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Cavernous sinus dural arteriovenous fistula treated by facial vein direct puncture: Case report and review of the literature

Interventional Neuroradiology ◽

10.1177/1591019917693413 ◽

2017 ◽

Vol 23 (3) ◽

pp. 301-306 ◽

Cited By ~ 1

Author(s):

Atsushi Matsumoto ◽

Masanobu Okauchi ◽

Atsushi Shindo ◽

Masahiko Kawanishi ◽

Takashi Tamiya

Keyword(s):

Case Report ◽

Arteriovenous Fistula ◽

Cavernous Sinus ◽

Dural Arteriovenous Fistula ◽

Inferior Petrosal Sinus ◽

Digital Subtraction ◽

Transvenous Embolization ◽

Review Of The Literature ◽

Direct Puncture ◽

Facial Vein

Introduction In case of cavernous sinus dural arteriovenous fistula (CSDAVF), transvenous embolization (TVE) of the cavernous sinus (CS) via the inferior petrosal sinus (IPS) is generally performed. However, various approach routes have been reported when the accessibility of the IPS is challenging. We herein report a case of CSDAVF treated by TVE with direct puncture of the facial vein. Case report A 70-year-old woman who suffered from tinnitus, chemosis, diplopia and bruit was referred to our hospital. Digital subtraction angiography (DSA) demonstrated CSDAVF. We initially attempted to perform TVE via the IPS route; however, we could not guide a catheter to the CS because of an anatomical difficulty. Then, we performed percutaneous direct puncture of the dilated facial vein, and successfully treated the patient. Conclusion When navigating microcatheter to the CS is difficult because of an anatomical difficulty of the IPS, direct puncture of the facial vein is a feasible route.

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Unique percutaneous direct puncture technique for occlusion of a hypoglossal canal dural arteriovenous fistula

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2018-013845 ◽

2018 ◽

Vol 10 (12) ◽

pp. 1179-1182 ◽

Cited By ~ 2

Author(s):

Orlando M Diaz ◽

Maria M Toledo ◽

John O F Roehm ◽

Richard P Klucznik ◽

Ponraj Chinnadurai ◽

...

Keyword(s):

Arteriovenous Fistula ◽

Dural Arteriovenous Fistula ◽

Embolic Agent ◽

Direct Puncture ◽

Ethylene Vinyl Alcohol ◽

Siemens Healthcare ◽

Hypoglossal Canal ◽

Liquid Embolic Agent ◽

Detachable Coils ◽

Anterior Condylar Vein

PurposeTo report percutaneous transcranial puncture, embolization and occlusion of a very symptomatic hypoglossal canal/anterior condylar vein dural arteriovenous fistula (DAVF) using syngo iGuide navigational software in a patient in whom transarterial and transvenous embolization and surgery had failed.MethodsAfter unsuccessful arterial and venous embolization and surgical treatment of a symptomatic hypoglossal canal DAVF, a 47-year-old man was transferred for further management. With exquisite anatomic detail provided by C-arm cone-beam computed tomography (CBCT) equipment (Artis zee Biplane, Dyna CT VC21H, Siemens Healthcare GmbH, Germany) and syngo iGuide needle guidance navigational software (Siemens Healthcare GmbHy) for planning a safe direct approach, the hypoglossal/anterior condylar vein, the dominant outflow vein of the fistula, was needle punctured percutaneously at the hypoglossal foramen and occluded with ethylene vinyl alcohol copolymer liquid embolic agent (Onyx, Medtronic, Minneapolis, Minnesota, USA) after placing two anchoring platinum coils (Target detachable coils, Stryker Neurovascular, Fremont, California, USA).ResultsAfter a year of progressively severe left eye proptosis, chemosis and increased intraocular pressure, the symptoms quickly subsided after this embolization and the patient was symptom free at his 3-month and later checkups.ConclusionWith guidance and imaging provided by CBCT and syngo iGuide navigational software, an otherwise untreatable DAVF was successfully embolized and obliterated by an aggressive unique percutaneous trans-cranial needle puncture of the dominant outflow vein in the hypoglossal canal.

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