Fatal progression of posttraumatic dural arteriovenous fistulas refractory to multimodal therapy

2001 ◽  
Vol 94 (5) ◽  
pp. 831-835 ◽  
Author(s):  
Jonathan A. Friedman ◽  
Fredric B. Meyer ◽  
Douglas A. Nichols ◽  
Robert J. Coffey ◽  
L. Nelson Hopkins ◽  
...  
Keyword(s):  
Multimodal Therapy ◽  
Transarterial Embolization ◽  
Subsequent Treatment ◽  
Venous Hypertension ◽  
Content Type ◽  
Arteriovenous Fistulas ◽  
Sagittal Sinus ◽  
Pulsatile Mass ◽  
Dural Arteriovenous Fistulas ◽  
Fine Print

✓ The authors report the case of a man who suffered from progressive, disseminated posttraumatic dural arteriovenous fistulas (DAVFs) resulting in death, despite aggressive endovascular, surgical, and radiosurgical treatment. This 31-year-old man was struck on the head while playing basketball. Two weeks later a soft, pulsatile mass developed at his vertex, and the man began to experience pulsatile tinnitus and progressive headaches. Magnetic resonance imaging and subsequent angiography revealed multiple AVFs in the scalp, calvaria, and dura, with drainage into the superior sagittal sinus. The patient was treated initially with transarterial embolization in five stages, followed by vertex craniotomy and surgical resection of the AVFs. However, multiple additional DAVFs developed over the bilateral convexities, the falx, and the tentorium. Subsequent treatment entailed 15 stages of transarterial embolization; seven stages of transvenous embolization, including complete occlusion of the sagittal sinus and partial occlusion of the straight sinus; three stages of stereotactic radiosurgery; and a second craniotomy with aggressive disconnection of the DAVFs. Unfortunately, the fistulas continued to progress, resulting in diffuse venous hypertension, multiple intracerebral hemorrhages in both hemispheres, and, ultimately, death nearly 5 years after the initial trauma. Endovascular, surgical, and radiosurgical treatments are successful in curing most patients with DAVFs. The failure of multimodal therapy and the fulminant progression and disseminated nature of this patient's disease are unique.

Results of combined stereotactic radiosurgery and transarterial embolization for dural arteriovenous fistulas of the transverse and sigmoid sinuses

2001 ◽  
Vol 94 (6) ◽  
pp. 886-891 ◽  
Author(s):  
Jonathan A. Friedman ◽  
Bruce E. Pollock ◽  
Douglas A. Nichols ◽  
Deborah A. Gorman ◽  
Robert L. Foote ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Transarterial Embolization ◽  
Symptom Relief ◽  
Related Complication ◽  
Content Type ◽  
Arteriovenous Fistulas ◽  
Dural Arteriovenous Fistulas ◽  
Lost To Follow Up ◽  
Fine Print

Object. Most dural arteriovenous fistulas (DAVFs) of the transverse and sigmoid sinuses do not have angiographically demonstrated features associated with intracranial hemorrhage and, therefore, may be treated nonsurgically. The authors report their experience using a staged combination of radiosurgery and transarterial embolization for treating DAVFs involving the transverse and sigmoid sinuses. Methods. Between 1991 and 1998, 25 patients with DAVFs of the transverse and/or sigmoid sinuses were treated using stereotactic radiosurgery; 22 of these patients also underwent transarterial embolization. Two patients were lost to follow-up review. Clinical data, angiographic findings, and follow-up records for the remaining 23 patients were collected prospectively. The mean duration of clinical follow up after radiosurgery was 50 months (range 20–99 months). The 18 women and five men included in this series had a mean age of 57 years (range 33–79 years). Twenty-two (96%) of 23 patients presented with pulsatile tinnitus as the primary symptom; two patients had experienced an earlier intracerebral hemorrhage (ICH). Cognard classifications of the DAVFs included the following: I in 12 patients (52%), IIa in seven patients (30%), and III in four patients (17%). After treatment, symptoms resolved (20 patients) or improved significantly (two patients) in 96% of patients. One patient was clinically unchanged. No patient sustained an ICH or irradiation-related complication during the follow-up period. Seventeen patients underwent follow-up angiographic studies at a mean of 21 months after radiosurgery (range 11–38 months). Total or near-total obliteration (> 90%) was seen in 11 patients (65%), and more than a 50% reduction in six patients (35%). Two patients experienced recurrent tinnitus and underwent repeated radiosurgery and embolization at 21 and 38 months, respectively, after the first procedure. Conclusions. A staged combination of radiosurgery and transarterial embolization provides excellent symptom relief and a good angiographically verified cure rate for patients harboring low-risk DAVFs of the transverse and sigmoid sinuses. This combined approach is a safe and effective treatment strategy for patients without angiographically determined risk factors for hemorrhage and for elderly patients with significant comorbidities.

Direct packing of the isolated sinus in patients with dural arteriovenous fistulas of the transverse—sigmoid sinus

1998 ◽  
Vol 88 (3) ◽  
pp. 449-456 ◽  
Author(s):  
Shunro Endo ◽  
Naoya Kuwayama ◽  
Akira Takaku ◽  
Michiharu Nishijima
Keyword(s):  
Transarterial Embolization ◽  
Blood Gases ◽  
Venous Drainage ◽  
Sigmoid Sinus ◽  
Blood Gas ◽  
Content Type ◽  
Arteriovenous Fistulas ◽  
Dural Arteriovenous Fistulas ◽  
Sinus Pressure ◽  
Fine Print

Object. The goal of this study was to evaluate the efficacy of direct packing of the isolated sinus (occluded both distally and proximally) in patients with dural arteriovenous fistulas (AVFs) of the transverse—sigmoid sinus. Methods. Eight patients were included in this study. There were seven men and one woman, ranging in age from 47 to 75 years (mean 60.4 years). Five patients presented with intracranial hemorrhage or venous infarction, one with convulsions, and two with pulsatile tinnitus. Prominent retrograde cortical venous drainage due to sinus isolation was angiographically demonstrated in all patients. All patients were treated by a small craniotomy and direct sinus packing with microcoils; the procedure was performed with the aid of digital subtraction angiography. Five patients were pretreated with transarterial embolization to reduce arterial inflow before the procedure, and intrasinus pressure and sinus blood gases were monitored throughout the operation. Postsurgery, the dural AVF was completely obliterated in all patients. The sinus pressure was 29 to 58% of systemic blood pressure, and sinus blood gas levels were purely arterial before packing. There was no morbidity related to direct sinus packing; however, one patient died as a result of acute myocardial infarction. Over a follow-up period ranging from 1 to 5 years, a faint asymptomatic dural AVF recurred in one patient on the cortex adjacent to the occluded sinus but regressed spontaneously within 1 year. Conclusions. Direct sinus packing was found to be highly effective for the treatment of dural AVFs that empty into the isolated sinus. Measurement of changes in sinus pressure and sinus blood gas levels was useful for monitoring the progress of direct sinus packing.

Histopathological study of venous aneurysms in patients with dural arteriovenous fistulas

2000 ◽  
Vol 92 (6) ◽  
pp. 1023-1027 ◽  
Author(s):  
Jun-Ichiro Hamada ◽  
Shigetoshi Yano ◽  
Yutaka Kai ◽  
Kazunari Koga ◽  
Motohiro Morioka ◽  
...  
Keyword(s):  
Smooth Muscle Actin ◽  
Venous Hypertension ◽  
Venous Aneurysm ◽  
Histopathological Study ◽  
Complete Disappearance ◽  
Intimal Thickening ◽  
Content Type ◽  
Arteriovenous Fistulas ◽  
Dural Arteriovenous Fistulas ◽  
Fine Print

Object. Of all intracranial dural arteriovenous fistulas (DAVFs), those with cortical venous drainage associated with cortical venous ectasia or varices are predisposed to an aggressive course and produce progressive neurological symptoms or hemorrhages. The authors undertook a histological examination of venous aneurysms and arterialized veins in the proximity of these aneurysms that had been surgically removed in patients with DAVFs.Methods. Surgical specimens were obtained in eight patients. The excised venous aneurysms and the arterialized veins in their proximity were stained using hematoxylin and eosin, van Gieson's elastic, and Masson's trichrome stain. Immunostaining was also performed for alpha smooth-muscle actin, desmin, and factor VIII antigen. Five of the patients had presented with venous hypertension, and three had intracranial hemorrhages. The arterialized vein obtained in the proximity of the venous aneurysm exhibited local irregular intimal thickening; the internal elastic lamina (IEL) was grossly preserved. All venous aneurysms in patients with venous hypertension manifested medial thickening and local intimal thickening with loss of IEL; the thickness of the wall was relatively uniform. In contrast, the wall thickness of venous aneurysms in patients with hemorrhage was extremely irregular and there was no clear delineation between the media and the intima. In media with complete disappearance of IEL, there was scant muscle tissue.Conclusions. Degenerative changes in venous aneurysms in patients with hemorrhage were much greater than in patients with venous hypertension, possibly because hemorrhages result from a more complicated interplay of anatomical, hemodynamic, and degenerative factors.

scholarly journals Superior Sagittal Sinus Dural Arteriovenous Fistulas Treated by Stent Placement for an Occluded Sinus and Transarterial Embolization

2012 ◽  
Vol 18 (3) ◽  
pp. 333-340 ◽  
Author(s):  
N. Ohara ◽  
S. Toyota ◽  
M. Kobayashi ◽  
A. Wakayama
Keyword(s):  
Stent Placement ◽  
Superior Sagittal Sinus ◽  
Transarterial Embolization ◽  
Sudden Onset ◽  
Venous Hypertension ◽  
Venous Congestion ◽  
Arteriovenous Fistulas ◽  
Sagittal Sinus ◽  
Arteriovenous Shunts ◽  
Dural Arteriovenous Fistulas

We describe a case of dural arteriovenous fistulas (DAVFs) involving the superior sagittal sinus (SSS) successfully treated with stent placement for an occluded sinus and transarterial embolization. A 61-year-old man who had been treated with anticoagulation for a known SSS thrombosis presented with a sudden onset of headache. CT scan revealed an intraventricular hemorrhage and cerebral angiography revealed DAVFs involving the SSS which had severe venous congestion and sinus occlusion. We treated this case with a staged endovascular approach which consisted of stent placement for the occluded sinus and transarterial intravenous embolization resulting in complete eradication of DAVFs. Recanalization of an occluded sinus by stent placement can reduce venous congestion and transarterial intravenous embolization can obliterate dural arteriovenous shunts. This staged strategy is feasible and should be considered a first option of treatment, especially for DAVFs which presented with intracranial hemorrhage and aggressive venous hypertension.

Use of a wedged microcatheter for curative transarterial embolization of complex intracranial dural arteriovenous fistulas: indications, endovascular technique, and outcome in 21 patients

2003 ◽  
Vol 98 (3) ◽  
pp. 498-506 ◽  
Author(s):  
Peter Kim Nelson ◽  
Stephen M. Russell ◽  
Henry H. Woo ◽  
Anthony J. G. Alastra ◽  
Danko V. Vidovich
Keyword(s):  
Transarterial Embolization ◽  
Visual Field Loss ◽  
Venous Drainage ◽  
Venous Access ◽  
Definitive Treatment ◽  
Content Type ◽  
Cavernous Sinus Syndrome ◽  
Arteriovenous Fistulas ◽  
Dural Arteriovenous Fistulas ◽  
Fine Print

Object. The aim of this study was to describe the application of a novel transarterial approach to curative embolization of complex intracranial dural arteriovenous fistulas (DAVFs). This technique is particularly useful in patients harboring high-grade DAVFs with direct cortical venous drainage or for whom transvenous coil embolization is not possible because of limited sinus venous access to the fistula site due to thrombosis or stenotic changes. Methods. Twenty-three DAVFs in 21 patients were treated using a transarterial N-butyl cyanoacrylate (NBCA) embolization technique with the aid of a wedged catheter. In all patients, definitive treatment involved two critical steps: 1) a microcatheter was wedged within a feeding artery, establishing flow-arrest conditions within the catheterized vessel distal to the microcatheter tip; and 2) NBCA was injected under these resultant flow-arrest conditions across the pathological arteriovenous connection and into the immediate draining venous apparatus, definitively occluding the fistula. Patient data were collected in a retrospective manner by reviewing office and inpatient charts and embolization reports, and by directly analyzing all procedural and diagnostic angiograms. Eight patients presented with the principal complaint of tinnitus/bruit, five with intracranial hemorrhage, four with cavernous sinus syndrome, and one each with seizures, ataxia, visual field loss, and hiccups. The parent (recipient) venous structure of the DAVFs in this study included 11 leptomeningeal veins, eight transverse/sigmoid sinuses, three cavernous sinuses, and one sphenoparietal sinus. The NBCA permeated the arteriovenous shunt, perifistulous network, and proximal draining vein in all DAVFs. Occlusion was confirmed on postembolization angiography studies. No complication occurred in any patient in this series. There has been no recurrence during a mean follow up of 18.7 months (range 2–46 months). Conclusions. Transarterial NBCA embolization with the aid of a wedged catheter in flow-arrest conditions is a safe and an effective treatment for intracranial DAVFs.

Transcranial approach for venous embolization of dural arteriovenous fistulas

2002 ◽  
Vol 97 (2) ◽  
pp. 280-286 ◽  
Author(s):  
Emmanuel Houdart ◽  
Jean-Pierre Saint-maurice ◽  
René Chapot ◽  
Adam Ditchfield ◽  
Alexandre Blanquet ◽  
...  
Keyword(s):  
Operating Room ◽  
Sinus Thrombosis ◽  
Transverse Sinus ◽  
Dural Sinus ◽  
Content Type ◽  
Arteriovenous Fistulas ◽  
Sagittal Sinus ◽  
First Case ◽  
Transcranial Approach ◽  
Fine Print

Object. Transvenous embolization is effective in the treatment of an intracranial dural arteriovenous fistula (DAVF). Access to the fistula via the internal jugular vein (IJV) may be limited by associated dural sinus thrombosis; a transcranial approach has been developed for venous embolization in such a situation. The authors report their experiences with the use of a transcranial approach for venous embolization of DAVFs. Methods. Ten patients with DAVFs underwent craniectomy and embolization procedures in which direct sinus puncture was performed. The DAVFs were located inside the dura mater that constituted the walls of the transverse sinus in five cases, the superior sagittal sinus in four cases, and the superior petrosal sinus in one case. All DAVFs drained directly into a sinus with secondary reflux into leptomeningeal veins. In all cases, the fistula could not be accessed from the IJVs. Craniectomy was performed in an operating room and, in seven cases, subsequent enlargement of the craniectomy was required. Sinus catheterization was performed after the patient had been transferred to the angiography room. The DAVFs were embolized using coils only in five patients, glue only in two patients, and both coils and glue in three patients. Angiographic confirmation that embolization of the fistula was successful was obtained in all cases. A transient complication occurred during the first case after sinus catheterization was attempted in the operating room. Conclusions. The transcranial approach allows straightforward access to DAVFs located on superficial dural sinuses that are inaccessible from the IJVs. The effectiveness of this approach is similar to that of the standard retrograde venous approach. The correct location and adequate extent of the craniectomy are essential for success to be achieved using this technique.

Stereotactic radiosurgery for the treatment of dural arteriovenous fistulas involving the transverse—sigmoid sinus

2002 ◽  
Vol 96 (5) ◽  
pp. 823-829 ◽  
Author(s):  
David Hung-chi Pan ◽  
Wen-yuh Chung ◽  
Wan-yuo Guo ◽  
Hsiu-mei Wu ◽  
Kang-du Liu ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Neurological Complication ◽  
Endovascular Embolization ◽  
Sigmoid Sinus ◽  
Type I ◽  
Content Type ◽  
Arteriovenous Fistulas ◽  
Dural Arteriovenous Fistulas ◽  
Fine Print

Object. The aim of this study was to assess the efficacy and safety of radiosurgery for the treatment of dural arteriovenous fistulas (DAVFs) located in the region of the transverse—sigmoid sinus. Methods. A series of 20 patients with DAVFs located in the transverse—sigmoid sinus, who were treated with gamma knife surgery between June 1995 and June 2000, was evaluated. According to the Cognard classification, the DAVF was Type I in four patients, Type IIa in seven, Type IIb in two, and combined Type IIa+b in seven. Nine patients had previously been treated with surgery and/or embolization, whereas 11 patients underwent radiosurgery alone. Radiosurgery was performed using multiple-isocenter irradiation of the delineated DAVF nidus. The target volume ranged from 1.7 to 40.7 cm3. The margin dose delivered to the nidus ranged from 16.5 to 19 Gy at a 50 to 70% isodose level. Nineteen patients were available for follow-up review, the duration of which ranged from 6 to 58 months (median 19 months). Of the 19 patients, 14 (74%) were cured of their symptoms. At follow up, magnetic resonance imaging and/or angiography demonstrated complete obliteration of the DAVF in 11 patients (58%), subtotal obliteration (95% reduction of the nidus) in three (16%), and partial obliteration in another five (26%). There was no neurological complication related to the treatment. One patient experienced a recurrence of the DAVF 18 months after angiographic confirmation of total obliteration, and underwent a second course of radiosurgery. Conclusions. Stereotactic radiosurgery provides a safe and effective option for the treatment of DAVFs involving the transverse and sigmoid sinuses. For some aggressive DAVFs with extensive retrograde cortical venous drainage, however, a combination of endovascular embolization and surgery may be necessary.

Spinal dural arteriovenous fistulas: experience with endovascular and surgical therapy

2002 ◽  
Vol 96 (2) ◽  
pp. 162-167 ◽  
Author(s):  
Emad N. Eskandar ◽  
Lawrence F. Borges ◽  
Ronald F. Budzik ◽  
Christopher M. Putman ◽  
Christopher S. Ogilvy
Keyword(s):  
Surgical Therapy ◽  
Endovascular Therapy ◽  
Massachusetts General Hospital ◽  
Definitive Treatment ◽  
Content Type ◽  
Arteriovenous Fistulas ◽  
Definitive Therapy ◽  
Dural Arteriovenous Fistulas ◽  
Spinal Dural Arteriovenous Fistulas ◽  
Fine Print

Object. Although the pathophysiology of spinal dural arteriovenous fistulas (AVFs) has recently been elucidated, the optimal treatment strategy for these lesions has yet to be defined. Current management techniques include endovascular embolization or microsurgical obliteration. Methods. The authors reviewed the records and angiograms of all patients with spinal dural AVFs treated at Massachusetts General Hospital over a 6-year period (1992–1998). During this period, it was intended initially to treat all patients with embolization and to reserve surgery for those in whom endovascular treatment failed or in cases in which pretreatment evaluation suggested that endovascular therapy would be ineffective or unsafe. A total of 26 patients with spinal dural AVFs were treated: there were 22 men and 4 women with a mean age of 65 years (range 39–79 years). Lesions were located in the following areas: five in foramen magnum/cervical, 13 in thoracic, five in lumbar, and three in sacral. Twenty-three (88%) of 26 patients underwent embolization and three (12%) of 23 patients underwent surgery as the primary mode of treatment. Of the 23 patients in whom embolization was performed or attempted, nine (39%) ultimately required surgery. All patients were stabilized or improved following definitive treatment, as assessed by the Aminoff—Logue scores. There was one death secondary to a myocardial infarction. Conclusions. These data demonstrate that endovascular therapy can be successful as an initial treatment for the majority of patients; however, there is a 39% failure rate, which is not observed following surgical therapy. Once a definitive therapy has been achieved using either technique virtually all patients are either stabilized or improved.

Combining endovascular and neurosurgical treatments of high-risk dural arteriovenous fistulas in the lateral sinus and the confluence of the sinuses

1999 ◽  
Vol 90 (2) ◽  
pp. 289-299 ◽  
Author(s):  
Katsuya Goto ◽  
Prijo Sidipratomo ◽  
Noboru Ogata ◽  
Toru Inoue ◽  
Haruo Matsuno
Keyword(s):  
High Risk ◽  
Signs And Symptoms ◽  
Venous Drainage ◽  
Complex Nature ◽  
Lateral Sinus ◽  
Content Type ◽  
Arteriovenous Fistulas ◽  
Dural Arteriovenous Fistulas ◽  
Diffuse Brain Swelling ◽  
Fine Print

Object. The authors describe the use of a systemic approach to treat dural arteriovenous fistulas (DAVFs) in the lateral sinus and the confluence of sinuses in 17 patients who presented with signs and symptoms related to intracranial hemorrhage, infarction, and diffuse brain swelling.Methods. Angiographic examination revealed three different types of DAVFs in these high-risk patients: 1) extremely high flow DAVF not associated with sinus occlusion or leptomeningeal retrograde venous drainage (LRVD); 2) localized DAVF with exclusive LRVD and without sinus occlusion; and 3) diffuse DAVF with sinus occlusion and LRVD. Because of the complex nature of these lesions, the authors adopted a staged protocol in which they combined endovascular and surgical treatments.Conclusions. The authors believe that by close collaboration between endovascular therapists and vascular neurosurgeons, high-risk DAVFs in the lateral sinus and the confluence of sinuses can be successfully managed without treatment-related morbidity and mortality.

Benign cranial dural arteriovenous fistulas: outcome of conservative management based on the natural history of the lesion

2002 ◽  
Vol 97 (4) ◽  
pp. 767-770 ◽  
Author(s):  
Junichiro Satomi ◽  
J. MARC C. van Dijk ◽  
Karel G. Terbrugge ◽  
Robert A. Willinsky ◽  
M. Christopher Wallace
Keyword(s):  
Conservative Management ◽  
Venous Drainage ◽  
Initial Assessment ◽  
Benign Condition ◽  
Content Type ◽  
Arteriovenous Fistulas ◽  
Dural Arteriovenous Fistulas ◽  
Tolerable Level ◽  
Fine Print

Object. Cranial dural arteriovenous fistulas (DAVFs) can be classified into benign or aggressive, based on their patterns of venous drainage. A benign condition requires the absence of cortical venous drainage (CVD). The clinical and angiographic features of a consecutive single-center group of 117 patients harboring benign cranial DAVFs were evaluated over time to validate the behavior and appropriate management of these lesions. Methods. At the initial assessment four patients were asymptomatic. Two infants presented with congestive heart failure. All other patients presented with other benign symptoms: chronic headache, bruit, or orbital phenomena. Observational management was instituted in 73 patients (62%). Intolerable bruit or ophthalmological sequelae were deemed indications for palliative embolization in 43 patients and surgical treatment in one patient. A median follow-up period of 27.9 months (range 1 month—17.5 years) was available in 112 patients (95.7%), among whom repeated angiography was performed in 50. Overall, observational and palliative management resulted in a benign and tolerable level of disease in 110 (98.2%) of 112 cases. In two cases managed conservatively CVD developed. In both of these cases the conversion from benign to aggressive DAVF was associated with spontaneous progressive thrombosis of venous outlets. Conclusions. The disease course of a cranial DAVF without CVD is indeed benign, obviating the need for a cure of these lesions. Symptoms are well tolerated with either observation or palliative treatment. After a long-term follow-up review of 68 patients, this conservative management resulted in a benign and tolerable level of disease in 98.5% of cases. It is noteworthy, however, that a benign DAVF carries a 2% risk of developing CVD, mandating close clinical follow-up review in such cases and renewed radiological evaluation in response to any deterioration in the patient's condition.

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