Intra-arterial onyx embolisation of sphenobasilar sinus fistula using pressure cooker technique: case report and review of the literature

Dural arterio-venous fistulas of the middle cranial fossa may occur within the dura of lesser or greater sphenoid wings. Lesser sphenoid wing fistulas rarely recruit cortical venous drainage and mostly drain in the cavernous sinus. On the other hand, greater sphenoid wing dural fistulas, also known as paracavernous fistulas or sphenobasilar and sphenopetrosal sinus fistulas, are much more notorious as they almost always connect with the superficial middle cerebral vein resulting in secondary cortical venous reflux and varix formation. Curative transarterial or transvenous endovascular embolisation of fistulous connection is the primary therapeutic strategy, particularly using onyx via the transarterial approach. In the present case we describe a 62-year-old man who presented with significant subarachnoid haemorrhage, intraparenchymal and intra-ventricular bleed. Digital subtraction angiography showed a middle cranial fossa dural arteriovenous fistula in the region of the sphenobasilar sinus with cortical venous reflux and varix formation. The patient underwent successful transarterial endovascular embolisation with complete elimination of the fistula using onyx 34, onyx 18, squid 12 and a Scepter XC balloon using the pressure cooker technique. We also report the development of facial nerve palsy due to inadvertent reflux of onyx in the petrosal branch of the middle meningeal artery.

Endovascular Treatment of Intracranial Dural Arteriovenous Fistulas: A German Single-Center Experience

Background and Purpose: Intracranial dural arteriovenous fistulas (DAVFs) are abnormal shunts between dural arteries and dural venous sinus or cortical veins. We report our experience with endovascular therapy of primary complex DAVFs using modern embolic agents. Methods: This is a retrospective analysis of patients with DAVFs treated between 2015 and 2019. Patient demographics and technical aspects including the use of embolic agent, access to the fistula, number of treatments, occlusion rates, and complications were addressed. Angiographic treatment success was defined as complete occlusion (CO) of the DAVF. Results: Fifty patients were treated endovascularly. Median age was 61 years and 66% were men. The most common symptom was pulsatile tinnitus in 17 patients (34%). The most frequent location of the DAVF was the transverse-sigmoid sinus (40%). Thirty-six fistulas (72%) had cortical venous reflux. Nonadhesive and adhesive liquid agents were used in 92% as a single material or in combination. CO was achieved in 48 patients (96%). In 28 individuals (56%), only 1 procedure was necessary. Nonadhesive liquid agents were exclusively used in 14 patients (28%) with CO attained in every case. For CO of tentorial DAVFs, multiple sessions were more often required than at the other locations (55 vs. 14%, p = 0.0051). Among 93 procedures, the overall complication rate was 3%. The procedure-related mortality rate was 0%. Conclusion: Endovascular treatment of intracranial DAVFs is feasible, safe, and effective with high rates of CO. In more than half of the patients, the DAVF was completely occluded after a single procedure. However, in tentorial DAVFs, multiple sessions were more often required.

Endovascular Approaches to the Cavernous Sinus in the Setting of Dural Arteriovenous Fistula

Dural arteriovenous fistulas involving the cavernous sinus can lead to orbital pain, vision loss and, in the setting of associated cortical venous reflux, intracranial hemorrhage. The treatment of dural arteriovenous fistulas has primarily become the role of the endovascular surgeon. The venous anatomy surrounding the cavernous sinus and venous sinus thrombosis that is often associated with these fistulas contributes to the complexity of these interventions. The current report gives a detailed description of the alternate endovascular routes to the cavernous sinus based on a single center’s experience as well as a literature review supporting each approach. A comprehensive understanding of the anatomy and approaches to the cavernous sinus available to the endovascular surgeon is vital to the successful treatment of this condition.

Operative Nuances of Blind Catheterization of Occluded Sinuses Using Negative Road Map Technique: 2-Dimensional Operative Video

Dural arteriovenous fistula (DAVF) are often treated with endovascular transvenous embolization. DAVFs though, are often associated with intracranial venous sinus occlusion, which limits the transvenous route. Here, we present the operative nuances of blind catheterization of an occluded dural venous sinus in 2 different cases with DAVF. First case is a 72-yr-old patient with indirect right carotid-cavernous fistula associated with an occluded inferior petrosal sinus, with severe orbital congestion. Second patient is a 79-yr-old patient with a new external carotid to a trapped transverse sinus fistula (Cognard IIA + B), extensive cortical venous reflux in the setting of an occluded sigmoid sinus. In both cases, the transarterial route was limited because of small arterial feeders thus, after obtaining patients’ consent, we performed transvenous sacrifice of the isolated sinus. In both cases, the occluded sinus was transvenously blindly retrograde probed using a 0.035 inch Terumo Glidewire (Terumo Medical Corporation, Somerset, New Jersey). Once the occluded segment was probed, a dark roadmap was acquired with the wire in place. This created a negative roadmap once the guidewire is removed. This negative roadmap is used to navigate the microcatheter-microwire into the isolated sinus. In the first case, the cavernous sinus and the superior ophthalmic veins were sacrificed with coils. In the second patient, the entrapped left transverse sinus was embolized using Onyx. In both cases, complete occlusion of the fistula was attained. In this neuroendovascular video, we demonstrate the nuances of blind catheterization of an occluded sinus using a negative roadmap technique as guidance for the micro-catheterization. Institutional Review Board approved. Patient consent not required due to retrospective nature of manuscript, based on medical chart and imaging reviews, anonymized in the video.

Diploic arteriovenous fistulas with marked cortical venous reflux

Diploic arteriovenous fistulas are rare arteriovenous shunts involving the skull, which often drain antegradely into the internal or external jugular veins. Diploic arteriovenous fistulas with marked cortical venous reflux are extremely rare. Here, we present the case of a patient with diploic arteriovenous fistulas with marked cortical venous reflux and a literature review. A 73-year-old woman presented with headache. Magnetic resonance angiography revealed abnormal signal intensity in the diploic layer of the left frontal bone. Digital subtraction angiography demonstrated a diploic arteriovenous fistulas located in the left frontal bone. The arteriovenous fistulas were fed by multiple branches of the left external carotid artery, mainly from the middle meningeal artery, branches of the ophthalmic artery, and the inferolateral trunk. The fistulas drained into the cerebral cortical veins surrounding the frontal lobe via an emissary vein of the frontal bone. With the femoral arterial approach, transarterial catheterization into the shunted diploic vein was performed with a small tapered microcatheter, and the arteriovenous fistulas were completely embolized with N-butyl-2-cyanoacrylate. The patient was discharged without complications. No recurrent arteriovenous fistulas were observed during the 12-month follow-up period. Endovascular treatment is an effective technique for the curative treatment of diploic arteriovenous fistulas.

Updates in the management of cranial dural arteriovenous fistula

Dural arteriovenous fistula (dAVF) accounts for approximately 10% of all intracranial vascular malformations. While they can be benign lesions, the presence of retrograde venous drainage and cortical venous reflux makes the natural course of these lesions aggressive high risk of haemorrhage, neurological injury and mortality. Endovascular treatment is often the first line of treatment for dAVF. Both transarterial and transvenous approaches are used to cure dAVF. The selection of treatment approach depends on the angioarchitecture of the dAVF, the location, the direction of venous flow. Surgery and, to a lesser extent, stereotactic radiosurgery are used when endovascular approaches are impossible or unsuccessful.

A Case of Spontaneous Acute Subdural Hemorrhage Caused by a Dural Arteriovenous Fistula on the Convexity without Cortical Venous Reflux

Bleeding from a dural arteriovenous fistula (DAVF) typically occurs in the form of an intracerebral or subarachnoid hemorrhage. Here, we report a rare case of a DAVF with an acute subdural hematoma (ASDH). A 29-year-old male presented to the emergency department with a complaint of progressing headache and nausea, with no reported episode of head trauma. Non-contrast CT revealed a left ASDH with a moderate midline shift. Digital subtraction angiography revealed a DAVF on the left parietal convexity. The DAVF was fed by the middle meningeal artery and drained into the superior sagittal sinus and the sphenoparietal sinus via the diploic vein without cortical venous reflux. The DAVF was treated with transarterial embolization using 25% diluted n-butyl cyanoacrylate prior to hematoma removal. The bleeding point was confirmed on the inner surface of the dura mater. The patient recovered well without any neurological deficits.

Relationship of clinical presentation and angiographic findings in patients with indirect cavernous carotid fistulae

IntroductionIndirect cavernous carotid fistulae (ICCFs) can present with insidious, non-specific symptoms and prove difficult to diagnose. This study evaluates associations among ICCF symptoms and angiographic findings.MethodsA retrospective analysis was performed of prospectively maintained records at four medical centers to identify patients with ICCFs evaluated with angiography. Patient demographics, symptoms, and angiographic findings were tabulated. Univariate and multivariate analyses were conducted to identify associations among these variables.ResultsRecords sufficient for review existed for 267 patients evaluated with angiography. Patients were most commonly women, in the sixth or seventh decade of life, and had symptoms for months before a definitive diagnosis. The most common symptoms included proptosis, diplopia, cranial nerve palsy, and chemosis. Cortical venous reflux was most common in patients with chemosis, orbital pain, or bruit. Intracranial hemorrhage was associated with cortical reflux and bilateral inferior petrosal sinus occlusion. Patients with loss of symptoms demonstrated higher rates of inferior petrosal sinus occlusion and a trend towards rupture.ConclusionA high index of suspicion is needed to promptly diagnose patients with ICCFs. High risk features are more common in the setting of chemosis, orbital pain, bruit, or spontaneous loss of symptoms. Patients with such symptoms warrant expedited angiographic evaluation.