Combined open surgery and endovascular embolization for a ruptured sphenoid wing dural arteriovenous fistula.

BACKGROUND: The sphenoid wing dural arteriovenous fistula (AVF) is rare, and can manifest with severe symptoms, particularly in cases classified as greater sphenoid wing type. Endovascular therapy is generally employed, however, open surgical intervention could be warranted in cases with complex fistula. METHOD: We present a case with ruptured greater sphenoid wing dural AVF (Cognard type IV), in which endovascular embolization using liquid material was performed, followed by open surgery to concurrently disconnect the fistula and evacuate the hematoma. CONCLUSION: The sphenoid wing dural AVFs may be effectively cured by open surgery for fistula disconnection in conjunction with endovascular embolization.

Transarterial embolization in non-cavernous and cavernous sinus dural arteriovenous fistulas: A systematic review and meta-analysis of proportions.

BACKGROUND: Transarterial embolization (TAE) is pivotal in managing non-cavernous and cavernous sinus dural arteriovenous fistulas (CSDAVFs). METHODS: Systematic searches were conducted across ScienceDirect, Medline, and Cochrane databases for longitudinal studies on TAE outcomes in non-CSDAVFs and CSDAVFs. Post-procedural outcomes, including complete, incomplete, and failed AVFs obliteration, and end-study outcomes were analyzed. RESULTS: Our meta-analysis involved 27 studies with 643 patients and 736 fistulas. Symptoms in both groups included tinnitus (29.74 %), ocular/visual symptoms (29.12 %), hemorrhage (19.42 %), and headache (19.11 %). Feeding arteries mainly originated from the meningeal arteries (49.16 %). In non-CSDAVFs cases, fistula locations were within sinus complexes (69.23 %) and specific dural areas (28.31 %). Complete AVFs obliteration was 81 % (95 %CI: 70 % - 90 %), slightly higher in non-CSDAVFs (82 %, 95 % CI: 69 % - 92 %) than CSDAVFs (79 %, 95 %CI: 58 % - 95 %). Incomplete obliteration occurred in 14 % (95 %CI: 5 % - 39 %), with rates of 11 % (95 %CI: 2 % - 26 %) in non-CSDAVFs and 19 % (95 % CI: 5 % - 39 %) in CSDAVFs. Failed obliteration was rare (1 %, 95 %CI: 0 % - 3 %), with similar rates in both groups. At end-study follow-up, resolution of AVFs was achieved in 97 % of cases (95 %CI: 92 % - 100 %). However, complications occurred in 17 % of cases (95 %CI: 10 % - 25 %), with a higher incidence in CSDAVFs (22 %, 95 %CI: 9 % - 37 %) compared to non-CSDAVFs (13 %, 95 %CI: 6 % - 23 %). CONCLUSIONS: TAE with embolic agents demonstrates favorable outcomes in non-CSDAVFs and CSDAVFs, with high rates of AVFs obliteration and resolution. Complications, particularly in CSDAVFs, warrant careful consideration in treatment decisions.

Coexistence of Intracranial Dural Arteriovenous Fistula and Cerebral Venous Sinus Thrombosis: Systematic Review and Outcome Analysis.

A substantial number of patients with intracranial dural arteriovenous fistula (dAVF) suffer from coexistent cerebral venous sinus thrombosis (CVST), yet this clinical relation is poorly studied. We aim to study the clinical and radiological outcome of patients with coexistent dAVF and CVST based on different treatment modalities and to examine various other parameters in such patients. A search strategy was performed on the following search engines: PubMed, Wiley, Microsoft Academia, and Google Scholar. Analysis was performed using R software. Thirty-five articles met the inclusion criteria. Most studies (n = 30) used digital subtraction angiography alone to make the diagnosis. Treatment modality ranged from no treatment (n = 7) to a combination of anticoagulation, endovascular therapy, and surgery (n = 2). Radiological obliteration was achieved in the majority of patients (78%). However, there was no statistical significance between treatment modality and radiological outcome (P=0.651); 72% of patients achieved clinical improvement, with no statistical significance between clinical improvement and treatment modality (P=0.072). We did find a significant relationship between treatment modality and follow-up findings (P=0.023). When analyzing factors such as age, gender, grade, arterial supply, and time between dAVF and CVST development, we found no statistical significance. Additionally, there was no significant association between the grade of fistula and the treatment modality. The clinical relationship between dAVF and CVST is poorly studied. This is the first systematic review that aimed to study this relationship. Results from subsequent large-scale studies comparing to our findings are warranted.

Initial Experience with the Eclipse Double-Lumen Balloon Catheter for Embolization of Cranial Vascular Malformations.

BACKGROUND: Double lumen balloon catheters (DLBCs) have emerged as a potential alternative to single lumen balloon catheters for endovascular embolization of arteriovenous malformations (AVMs) and dural arteriovenous fistulas (dAVFs). This study describes our preliminary experience with the Eclipse 2L DLBC in treating AVMs and dAVFs. METHODS: Patients who underwent embolization of cranial dAVFs or AVMs at our institution from August 2021 to March 2024 were included. Spinal vascular malformations were excluded. Descriptive statistics were used to analyze procedural outcomes, technical nuances, and postoperative outcomes on follow-up. RESULTS: Twenty-five patients who underwent 38 embolization procedures (15 AVMs and 23 dAVFs) met criteria for inclusion in this study. The mean age of the cohort was 52.44 (standard deviation = 17.26), and 48% of the overall cohort (n = 13) was female. The average procedure times for AVMs and dAVFs were 80.4 minutes and 96.73 minutes, respectively. There was 1 instance of catheter entrapment. Two patients in the AVM cohort experienced mortality, and 1 experienced postoperative rupture. CONCLUSIONS: Our preliminary experience using the Eclipse 2L balloon catheter for Onyx embolization reported procedural outcomes comparable to other DLBCs despite relatively higher procedure times and radiation doses. Further long-term studies on its efficacy as primary modality in treating AVMs and dAVFs are encouraged.

Dural arteriovenous fistulas in the falx cerebri: case series and literature review.

Dural arteriovenous fistulas (DAVFs) within the falx cerebri are infrequently documented and may be linked with the falcine sinus/venous plexus. The falcine sinus/venous plexus, often regarded as a normal venous structure, can exhibit pathological characteristics, differing from the persistent fetal falcine sinus. A retrospective analysis was conducted at a single center to identify all cases of DAVFs within the falx cerebri spanning from 2002 to 2022. Demographic data, fistula features, treatment modalities, clinical outcomes, and fistula closure were collected and analyzed. Additionally, relevant literature on DAVFs in this location was reviewed. Ten cases were identified at our center, supplemented by 13 cases reported in the literature. In our cohort, patients had an average age of 49.4 ± 8.1 years, with a male predominance of 90%. Trans-arterial embolization (TAE) alone achieved immediate complete occlusion in eight cases, while conservative treatment was pursued in two cases. No treatment-related complications or fistula recurrences were observed. In the literature, seven patients underwent direct surgery, three underwent TAE, and one underwent both direct surgery and radiosurgery for complete fistula closure. No instances of fistula recurrence or treatment complications were reported. Dural arteriovenous fistulas within the falx cerebri are rare, with limited literature available. They typically present as aggressive lesions. Treatment options include direct surgery or TAE. However, due to a lack of long-term DSA follow-up, the cure and recurrence rates are unknown for endovasdcular therapy. Further investigation is warranted to elucidate the involvement of the falcine sinus/venous plexus in falx cerebri DAVFs.

[Multiple dural arteriovenous fistulas showing isolated subcortical white matter T2 hyperintensity with gadolinium enhancement].

We describe a 44-year-old man with a complaint of atonic seizures of the left upper limb, followed by generalized seizures. Brain MRI showed isolated juxtacortical white matter T2 hyperintensity with gadolinium (Gd) enhancement of the adjacent cortical gray matter and subcortical white matter in the right frontal convexity. Treatment with levetiracetam was effective for seizure suppression, and he had no other neurological abnormalities. Human leukocyte antigen typing revealed B54 and Cw1, which indicated the possibility of neuro-Sweet disease. However, a general examination, which included vital signs and eye and skin findings, was normal. A cerebrospinal fluid test showed a mild elevation in protein levels without pleocytosis and a normal range of interleukin-6. Electroencephalography showed intermittent slow waves without epileptic discharge in the bilateral temporal lobes. We detected subtle flow voids in the pia mater of the left frontal lobe, which suggested cerebrovascular disease, and specifically, the possibility of dural arteriovenous fistulas. Computed tomography angiography showed abnormally dilated perimedullary veins in the left frontal lobe. Cerebral angiography confirmed the existence of four dural arteriovenous fistulas, which included two retrograde leptomeningeal venous drainages in the right frontal cortical veins supplied by the anterior branch of the right middle meningeal artery. The other dural arteriovenous fistulas were retrograde leptomeningeal venous drainages in the left frontal cortical veins supplied by the anterior and posterior convexity branches of the left middle meningeal artery. The patient underwent successful endovascular embolization of all dural arteriovenous fistulas with Onyx injection. A follow-up MRI showed gradual improvement of the T2 hyperintensity and Gd enhancement. He remained seizure-free for 2 years following endovascular embolization.

A case of dural arteriovenous fistula at the craniocervical junction successfully treated by transvenous embolization.

Arteriovenous fistula (AVF) occurring within the craniocervical junction (CCJ) is an uncommon vascular anomaly. A 56-year-old man presented with cervical pain and gait disturbances. Computed tomography revealed a hematoma in the epidural space at the cervical spinal level. Subsequent cerebral angiography revealed an epidural shunt at the CCJ, leading to a diagnosis of epidural AVF (EDAVF). Transvenous embolization, performed under general anesthesia, successfully resolved the shunt. Transarterial embolization of CCJ-EDAVFs carries a substantial risk of ischemic complications. Conversely, transvenous embolization poses a lower risk of ischemic complications and has potential as a beneficial treatment option for CCJ-EDAVFs. Herein, we present a unique case of CCJ-EDAVF that was successfully treated with transvenous embolization.

Spinal Dural Arteriovenous Fistula with Low Back Pain as the Only Symptom at Onset: A Case Report.

BACKGROUND Spinal cord arteriovenous fistula that only manifests as lower back pain is easily misdiagnosed as myofasciitis, lumbar spondylosis, and other diseases, and incorrect treatment such as glucocorticoid blockade might be given, leading to worsening of the condition. CASE REPORT We analyze the clinical characteristics of a patient with spinal dural arteriovenous fistula who presented with chronic-onset low back pain. A patient with spinal dural arteriovenous fistula presented with chronic-onset low back pain as the only symptom, and was misdiagnosed as having myofasciitis. We assessed the paraclinical data, clinical reasoning, and course of treatment. The patient was an elderly man with low back pain for 1 year. He was diagnosed with myofasciitis in a local hospital and received local blocking treatment using glucocorticoid, and left lower-limb weakness appeared after that. After he was admitted to our hospital, enhanced thoracic and lumbar magnetic resonance imaging and selective spinal angiography were performed, and the results indicated the diagnosis of spinal dural arteriovenous fistula. After surgical treatment, the low back pain and lower-limb weakness were alleviated, and the patient is still under follow-up. CONCLUSIONS The possibility of spinal dural arteriovenous fistula should not be overlooked among patients with chronic low back pain, and caution should be taken when using glucocorticoids for treatment of chronic low back pain.

Use of the Scepter Dual-Lumen Balloon Catheter for Transarterial Onyx Embolization of Cranial Dural Arteriovenous Fistulas.

BACKGROUND: Dual-lumen balloon microcatheters allow for controlled anterograde flow of Onyx while providing proximal flow arrest, thereby obviating the need for a second microcatheter or Onyx plug formation. We sought to assess the safety and efficiency of the Scepter dual-lumen balloon microcatheter in trans arterial Onyx embolization of intracranial dural arteriovenous fistulas (DAVFs). METHODS: We conducted a retrospective study of 36 patients with cranial DAVFs in which a Scepter balloon microcatheter was used between 2016 and 2023. RESULTS: Our study comprised 36 patients, mostly male (n = 23, 63.8%) with a mean age of 60.8 years. Most DAVFs were in the occipital lobe (n = 24, 66.7%), and 50% had external carotid artery supply from the occipital artery. Eighteen (50%) of DAVFs were Cognard type III and IV, respectively. About one third (33.3%, n = 12) of the DAVFs drained into the transverse sigmoid junction, and 27.7% (n = 10) had direct cortical venous drainage into supratentorial or posterior fossa veins. Complete occlusion was obtained in 22 (61.1%) patients while partial occlusion was observed in 14 (38.9%) patients. One patient (2.8%) developed a retroperitoneal hematoma. At final follow-up, complete occlusion was observed in 21 (77.8%) and partial occlusion was observed in 8 (22.2%). Recurrence was observed in 4/30 (13.3%) patients, and retreatment was required in 6 (18.75%) cases. CONCLUSIONS: At midterm follow-up, our study showed low morbidity and modest complete occlusion rates using the Scepter for transarterial Onyx embolization of high-grade DAVFs.

Proposal of a Classification System of Cavernous Sinus Dural Arteriovenous Fistulas and Treatment Strategies Based on Angioarchitecture: A Cohort Study of 116 Patients.

BACKGROUND: Cavernous sinus (CS) dural arteriovenous fistulas (DAVFs) are commonly treated by transvenous embolization, but the details of treatment need to be more clearly defined. We propose a classification of CS-DAVF that can contribute to formulating endovascular treatment process. METHODS: CS-DAVF was classified into seven categories based on the cumulative CS range and drainage patterns. CS-DAVF angioarchitecture, clinical characteristics, treatment strategies, and outcomes of CS-DAVF patients treated in our hospital from 2012 to 2021 were summarized and analyzed. RESULTS: Among the 116 patients with CS-DAVF: Type 1, 71 (61.2%); Type 2, 9 (7.8%); Type 3, 18 (15.5%); Type 4, 2 (1.7%); Type 5, 8 (6.9%); Type 6, 3 (2.6%); and Type 7, 5 (4.3%). Inter-CS or inferior petrosal sinus drainage was relatively rare in Types 1 and 6 (P < 0.001 and P < 0.001); basilar venous plexus drainage was more prevalent in Types 2, 5, and 7(P = 0.019). Inferior petrosal sinus occlusion was more commonly seen in Types 2, 3, and 5 (P = 0.005). The most frequent first symptoms and symptoms at admission in patients with CS-DAVF is ocular/orbital symptoms, occurring in 64 cases (55.2%) and 104 cases (89.7%), respectively. In this study, 108 patients (93.1%) underwent endovascular embolization. Among those who received endovascular embolization, 96 (88.9%) CS-DAVFs were treated via transvenous embolization. In long-term follow-up, 98 cases (84.5%) achieved cure, and 17 cases (14.7%) showed symptomatic improvement. CONCLUSION: Our proposed classification system based on cumulative CS range and drainage patterns can assist in formulating treatment strategies for transvenous embolization.

Concurrent Moyamoya-like Intracranial Steno-Occlusive Disease and Dural Arteriovenous Fistulas.

The simultaneous presentation of intracranial steno-occlusive disease, Moyamoya disease, or Moyamoya-like vasculopathy and dural arteriovenous fistulas (DAVFs) has been documented in very few case reports worldwide. We aimed to better characterize this association by reviewing the clinical and radiologic findings of 4 patients with concurrent intracranial steno-occlusive disease or Moyamoya-like vasculopathy and DAVFs evaluated in our institution. All 4 patients were of Asian descent. One patient presented with ischemic stroke secondary to intracranial stenosis, 2 presented with symptoms related to the DAVF, and the diagnosis was incidental in the fourth patient. Three patients underwent embolization of the DAVF, which was followed by surgical ligation in 2. One patient underwent extracranial-intracranial bypass for Moyamoya-like intracranial steno-occlusive disease. One patient is being managed conservatively with close follow-up. Our case series details findings in 4 patients with associated intracranial steno-occlusive disease and DAVFs. Further studies and reporting of similar cases are necessary to establish whether this is pure coincidence or if there is indeed a relationship between these 2 conditions, especially in certain ethnic groups.

Bilateral optic disc collaterals secondary to high-flow dural arteriovenous fistula: a diagnostic dilemma.

A man in his 80s, with a history of diabetes, hypertension and coronary artery disease, presented with bilateral painless progressive vision loss 2 years prior. His examination showed subnormal best corrected visual acuity of 20/50 and 20/80 in the right eye and left eye (LE), respectively, grade II relative afferent pupillary defect in LE, normal anterior segment, intra-ocular pressure (IOP) and defective colour vision in both eyes (BE). Fundus examination revealed optic disc pallor, disc collaterals and grade 2 hypertensive retinopathy in BE. Automated perimetry showed advanced field loss in BE. MRI of the brain and orbits with contrast showed signs of raised intracranial pressure, and magnetic resonance angiogram of the brain showed multiple arterio-venous channels along with the right transverse and sigmoid sinuses. The patient was referred to a neuroradiologist for further evaluation, and cerebral angiogram confirmed multifocal high-flow dural arterio-venous fistulae at right jugular foramen, transverse and sigmoid sinuses. He underwent Onyx liquid embolization.

Feasibility, safety, and efficacy of endovascular treatment of anterior cranial fossa dural arteriovenous fistulas: a systematic review and meta-analysis with a subanalysis for Onyx.

Dural Arteriovenous Fistulas (dAVFs) of the anterior cranial fossa (ACF) are uncommon but carry a high risk of hemorrhage and pose substantial treatment challenges. Recent advancements in endovascular treatment (EVT), including the introduction of novel liquid embolic agents, have markedly bolstered EVT's role in managing ACF-dAVFs, with notable series published in the last five years. We aimed to assess the feasibility, safety, and efficacy of EVT for ACF-dAVFs. We searched Medline, Scopus, Web of Science, and Cochrane Library databases following PRISMA guidelines. Eligible studies included those with ≥ 5 patients undergoing embolization of ACF-dAVFs, detailing both angiographic and clinical outcomes. We used single proportion analysis with 95% confidence intervals under a random-effects model, I2 to assess heterogeneity, and Baujat and sensitivity analysis to address high heterogeneity. Publication bias was assessed by funnel-plot analysis and Egger's test. Outcomes included complete occlusion following embolization, unsuccessful endovascular embolization attempts, incomplete occlusion following embolization, symptom resolution or clinical improvement following embolization, recurrence; procedure-related complications, morbidity, and mortality. Additionally, a subanalysis for studies exclusively utilizing Onyx™ embolic system was done. Eighteen studies comprising 231 ACF-dAVF were included. Unsuccessful endovascular embolization attempts rate was 2%. Complete occlusion rate was 85%, with 4% of complications. Incomplete occlusion rate was 10%. Successfully embolized patients experienced either symptom resolution or clinical improvement in 94% of cases. Morbidity and mortality rates were 1% and 0%, respectively. Onyx subanalyses showed an overall rate of 0% for unsuccessful attempts, 95% for complete occlusion, and 5% for incomplete occlusion. Symptom resolution or clinical improvement was 98% and recurrence rate was 0%. EVT for ACF-dAVF is highly feasible, effective, and safe, with a low rate of complications, morbidity, and mortality. The subanalyses focusing on Onyx embolizations revealed superior efficacy and safety outcomes compared to the findings of the primary analyses involving all included studies.

[Angioarchitecture and Associated Dural Arteriovenous Fistulas of the Superior Petrosal Sinus and Petrosal Vein].

The superior petrosal sinus and petrosal vein are important drainage routes for the posterior cranial fossa, with some variations and collateral vessels. An anterolateral-type tentorial dural arteriovenous fistula, which occurs around the petrosal vein, often develops aggressive symptoms due to venous reflux to the brainstem and cerebellum. Neuroendovascular treatment of this fistula is usually challenging because transarterial embolization has a high risk and indications for transvenous embolization are limited. In the cavernous sinus and transverse sinus/sigmoid sinus dural arteriovenous fistulas, venous reflux to the petrosal vein is dangerous, and a treatment strategy with the occlusion of the petrosal vein is indispensable. Furthermore, attention should be paid to venous approaches through the superior petrosal sinus.

[Transverse Sinus / Sigmoid Sinus].

The transverse sinus(TS)and sigmoid sinus(SS)are common sites for dural arteriovenous fistulas, and an understanding of vascular anatomy is important when developing treatment strategies. In recent years, transarterial embolization, with a liquid embolization material, has become the treatment of choice, preserving the sinus without extensive coil filling of the affected sinus. With this expansion of therapeutic options, we feel that an understanding of the microanatomy has become more important. For example, the exact site where the vein of Labbé joins the TS should be determined. This article focuses on the development and anatomy of the TS and SS and makes points that should be considered when treating dural arteriovenous fistulas.

Causes of Pulsatile Tinnitus and Treatment Options.

Pulsatile tinnitus (PT) requires detailed workup to evaluate for an underlying structural cause. With advances in neuroimaging, structural venous abnormalities that can cause PT have becoming increasingly recognized. A number of anomalies, including dural arteriovenous fistulas, idiopathic intracranial hypertension, transverse sinus stenosis, sigmoid sinus wall abnormalities, jugular venous anomalies, and hypertrophied emissary veins, have been implicated in flow disruption and turbulence in the vicinity of auditory structures, resulting in PT. Endovascular treatment options, including stenting, coiling, and embolization with liquid agents, have demonstrated high efficacy and safety. These treatments can lead to symptomatic relief in carefully selected cases.

Dural Arteriovenous Fistula.

Dural arteriovenous fistulas are rare cerebrovascular lesions arising from abnormal connections between an artery and a vein. Though rare, high-grade aggressive lesions can cause hemorrhagic events and non-hemorrhagic neurologic deficits if left untreated. Treatment options vary based on angioarchitecture, location, and patient characteristics and range from conservative observation to palliative treatment, radiosurgery, endovascular embolization, and open surgery. The main goal of treatment is to obliterate flow through the abnormal connection and prevent further arterial flow to the venous system.

Interventional Embolization of Unilateral Cavernous Sinus With ONXY Glue Combined With Coils for the Treatment of Bilateral Dural Arteriovenous Fistula.

PURPOSE: To summarize the clinical experience of unilateral sponge sinus embolization of cavernous sinus dural arteriovenous fistula (CS DAVF) via jugular vein access with ONXY gel and spring coil intervention. METHODS: The authors retrospectively analyzed the clinical data of 3 patients who were treated with unilateral cavernous sinus embolization for bilateral cavernous sinus dural arteriovenous fistula (CS DAVF) from October 2020 to May 2022 in our department by using transjugular vein access spring coil + ONXY gel interventional embolization. RESULTS: Immediate postoperative angiography suggested that the cavernous sinus fistula was completely embolized in all 3 patients, and cerebral angiography was carried out from 6 to 12 months after the operation and assessed using the Class grading method, and there was no recurrence in any of the 3 patients. CONCLUSIONS: Transvenous access ONXY adhesive combined with spring coil interventional embolization of unilateral cavernous sinus to cure bilateral cavernous sinus dural arteriovenous fistula is feasible, which can avoid the excessive use of spring coils and ONXY adhesive, and it is the key to the effective cure of DAVF in cavernous sinus area and to reduce the complication.

Two-Step Effective Onyx Embolization from the Occipital Artery for the Treatment of Intracranial Dural Arteriovenous Fistula: A Technical Note.

AIM: To report our experience and the technique of two-step effective Onyx embolization from occipital artery (OA) for the obliteration of dural arteriovenous fistulas (DAVFs) with OA feeders. MATERIAL AND METHODS: The medical records of patients with intracranial DAVFs treated with trans-arterial embolization (TAE) using Onyx from the OA were retrospectively reviewed. RESULTS: Seven patients were included. The methods of Onyx injection from the OA were categorized as simple Onyx injection into the shunt, and two-step embolization. Two-step embolization involved the Onyx or coil embolization of the OA distal to the branching site of the feeders in the first step, and Onyx was injected toward the target shunt in the second step. Simple Onyx injection was performed in two cases; in both cases, the residual shunt remained. By contrast, the two-step embolization technique was performed in five cases, and in all those cases, sufficient embolization of the DAVFs was achieved. CONCLUSION: Prior embolization using Onyx or coil of the distal OA helped prevent Onyx from unexpected embolization through the subcutaneous branches that were not associated with the shunt, thereby leading to effective embolization. This new two-step embolization technique from the OA may improve the obliteration rate of DAVFs with OA feeders using TAE with Onyx.