Transorbital embolization of cavernous sinus dural arterio-venous malformations with surgical exposure and catheterization of the superior ophthalmic vein.

PURPOSE: Cavernous sinus dural arterio-venous malformations (dAVF) represent a pathologic connection between branches of the internal and/or external carotid artery and the cavernous sinus. Standard endovascular approaches for dAVF treatment are transvenous embolization through the inferior petrosal sinus or the facial vein and transarterial embolization. These approaches are not always successful or feasible, and alternative techniques are required. Here, we present a case series of a minimally invasive transorbital approach with surgical exposure and catheterization of the superior ophthalmic vein for transvenous fistula coiling. METHODS: 14 patients with dAVFs (Barrow Type B to D) that were treated at a tertiary care medical center over a period of 13 years were included in the study. Patients with persisting dAVF associated symptoms were selected for this approach when conventional endovascular interventions were not successful or not feasible. The surgical procedure was performed under general anaesthesia. RESULTS: A successful transorbital approach was performed in all 14 cases. In 12 of 14 patients a catheter assisted successful embolization of the fistula was performed using platinum coils with no relevant residual fistula flow. In two cases, a spontaneous thrombosis of the fistula during the surgical procedure required no further embolization. No postoperative therapy-associated complications were observed. CONCLUSION: The described approach is an effective method to embolize dAVFs in selected cases when catheter assisted transvenous and/or transarterial embolization is not successful or not feasible. In this case series we demonstrate an excellent success rate with no therapy-associated major complications.

Localizing Thalamomesencephalic Afferent and Efferent Pupillary Defects.

ABSTRACT: A 42-year-old Algerian man presented for binocular oblique diplopia, hypersomnolence with drop attacks, bilateral hearing loss, and thoracic pain. He had a right thalamomesencephalic hemorrhage due to an underlying cavernous malformation treated with subtotal surgical resection. On neuro-ophthalmic examination, the patient had a left relative afferent pupillary defect and a right oculosympathetic efferent pupillary defect (i.e., Horner syndrome) in addition to other thalamomesencephalic eye and neurologic signs (right fourth nerve palsy, hearing loss, hemiparesis, and thalamic pain). Clinicians should recognize the localizing value of this unique constellation of mesencephalic afferent and efferent pupillary defects.

Intraorbital Arteriovenous Fistula From the Superficial Temporal Artery.

Intraorbital arteriovenous fistula is a rare vascular disease characterized by an acquired arteriovenous communication without direct cavernous sinus involvement. Intraorbital arteriovenous fistula may develop slowly and present similarly to other insidious orbitopathies, such as carotid-cavernous fistula. The authors present a case of a superficial temporal artery to superior ophthalmic vein fistula arising in the absence of trauma or prior surgery. This is the first report of a spontaneous intraorbital arteriovenous fistula arising between these vessels and further describes the rare occurrence of intraorbital arteriovenous fistula.

A Propensity Score-Matched Cohort Analysis of Outcomes After Stereotactic Radiosurgery in Older versus Younger Patients with Dural Arteriovenous Fistula: An International Multicenter Study.

OBJECTIVE: This study aims to evaluate the outcomes of Gamma Knife stereotactic radiosurgery (SRS) for dural arteriovenous fistulas (dAVFs) in older patients (≥65 years) compared with younger patients (age <65 years). METHODS: Two groups with a total of 96 patients were selected from a database of 133 patients with dAVF from 9 international medical centers with a minimum 6 months follow-up. A 1:2 propensity matching was performed by nearest-neighbor matching criteria based on sex, Borden grade, maximum radiation dose given, and location. The older cohort consisted of 32 patients and the younger cohort consisted of 64 patients. The mean overall follow-up in the combined cohort was 42.4 months (range, 6-210 months). RESULTS: In the older cohort, a transverse sinus location was found to significantly predict dAVF obliteration (P = 0.01). The post-SRS actuarial 3-year and 5-year obliteration rates were 47.7% and 78%, respectively. There were no cases of post-SRS hemorrhage. In the younger cohort, the cavernous sinus location was found to significantly predict obliteration (P = 0.005). The 3-year and 5-year actuarial obliteration rates were 56% and 70%, respectively. Five patients (7.8%) hemorrhaged after SRS. Margin dose ≥25 Gy was predictive of unfavorable outcome. The obliteration rate (P = 0.3), post-SRS hemorrhage rate (P = 0.16), and persistent symptoms after SRS (P = 0.83) were not statistically different between the 2 groups. CONCLUSIONS: SRS achieves obliteration in most older patients with dAVF, with an acceptable rate of complication. There was no increased risk of postradiosurgery complications in the older cohort compared with the younger patients.

Bilateral duplication of the abducens nerve - case study.

The abducens nerve is characterized by a long intracranial course and complex topographical relationships. Anatomical knowledge may help to understand both the etiology and clinical symptoms of abducens nerve palsy. Typically, the single trunk of the abducens nerve travels on both sides. However, occasionally different variants of unilateral or bilateral duplications of the abducens nerve may be observed. The presented paper is a detailed anatomical description of bilateral duplication of the abducens nerve, with atypical appearance of the nerve in the cavernous sinus and normal distribution within the lateral rectus muscle on both sides of one cadaver. On the right side both trunks of the abducens nerve fused within the subarachnoid space and pierced the dura mater together. On the left side both trunks of the duplicated abducens nerve pierced the dura mater separately, entered the petrous apex separately and fused just below the petrosphenoidal ligament. Within the cavernous sinus the nerve divided once again into two filaments, which reunited into one trunk a er crossing the horizontal segment of the intracavernous part of internal carotid artery. The orbital segments of the abducens nerve showed a typical course on both sides. Duplication of the abducens nerve is anatomical variation which should be taken into account during diagnostic and surgical procedures performed within the petroclival region and cavernous sinus.

Awake Craniotomy for Removal of Left Insular Cavernous Malformation.

The insula plays a crucial role in speech planning due to its connections with cortical and subcortical areas. Surgical management of cavernous malformation (CM) of the insula consists of total resection of the lesion and the surrounding gliosis to avoid or reduce seizures. When located in the dominant hemisphere, an awake craniotomy with intraoperative mapping reduces the risk of functional damage. The insula is covered by the operculum and has a relationship with the middle cerebral artery and its branches that run along its lateral surface. Therefore high expertise is required to manage the exposure of the insula and its complex anatomy. This video demonstrates the surgical management of a large left insular CM. A 29-year-old female with multiple CM and 7 years of partial seizures and recent onset of short memory loss. Neuroimaging showed a large left insular and planum polare CM with important mass effect and hemorrhage signs. The patient consented to surgery, and an awake pretemporal craniotomy was carried out with continuous motor evoked potential monitoring. No language function was localized in the superior temporal gyrus; therefore corticectomy of the middle portion was performed to expand the operative corridor. The vessel manipulation during wide opening of the sylvian fissure increased the risk of postoperative vasospasm and blood drain into the surgical field. The CM was exposed and completely removed without functional damage. The patient recovered from surgery without complications, and no seizures occurred at 2 months' follow-up. Postoperative imaging showed complete removal of the CM.

Fractionated Stereotactic Radiotherapy for Cavernous Venous Malformations of the Orbital Apex.

PURPOSE: The objective of this study was to investigate the efficacy and safety of fractionated stereotactic radiotherapy in the treatment of cavernous venous malformation of the orbital apex. METHODS: The authors reviewed a prospective database from a single center of patients with cavernous venous malformation of the orbital apex who had treatment with fractionated stereotactic radiotherapy. The authors compared the symptoms, visual function and the size of the tumor pre- and posttreatment as well as reviewed the treatment details and the incidence of complications. RESULTS: Six patients received treatment with fractionated stereotactic radiotherapy for cavernous venous malformation involving the orbital apex. The median age was 48 (range, 32-63), and 50% were female. Patients received a dose of 45 to 50.4 Gy in 1.8 to 2 Gy fractions. Median follow up was 33 months (range, 18-66 months). The average tumor volume reduction at posttreatment imaging after 12 months was 63%. All lesions reduced in size postradiotherapy and remained controlled for the duration of follow up. All patients who had proptosis or a visual field defect had an improvement in the symptoms posttreatment. There were no complications of the treatment. CONCLUSION: Fractionated stereotactic radiotherapy appears to be a safe and effective management option for cavernous venous malformation of the orbital apex and leads to a sustained reduction of the volume of the lesion with associated improvement in symptoms and visual function.

Dural Arteriovenous Fistula Between the Inferolateral Trunk and Cavernous Sinus Draining to Ophthalmic Vein.

BACKGROUND: Formation of a dural arteriovenous fistula (DAVF) between the inferolateral trunk (ILT) and cavernous sinus (CS) is rare. CASE DESCRIPTION: This study presents a case of ILT-CS DAVF. A 64-year-old male patient had exophthalmos of the left eye with redness and swelling. Digital subtraction angiography revealed a connection between the ILT and the CS that formed a high-flow DAVF, which was drained only to the ophthalmic vein and no other parts of the CS. The ILT was chosen as the transarterial path for treatment because it was enlarged. The microcatheter was navigated into the ILT, and 2 coils were then used to occlude the ILT. After occlusion of the ILT, no image of the DAVF indicated that the ILT-CS DAVF was completely cured. The patient's symptoms improved gradually after surgery. At the 6-month follow-up visit, digital subtraction angiography showed no sign of ILT-CS DAVF and the patient's eye symptoms had disappeared. CONCLUSIONS: Although ILT-CS DAVF is rare, it can still be seen in clinical practice. Coiling the ILT via a transarterial approach is a good option for treatment.

Transarterial Embolization of Cavernous Sinus Dural Arteriovenous Fistulas with Ipsilateral Inferior Petrosal Sinus Occlusion via the Ascending Pharyngeal Artery.

BACKGROUND: Although the ipsilateral inferior petrosal sinus (IPS) is preferred for treatment of cavernous sinus dural arteriovenous fistulas (CS-dAVFs), this method is problematic if ipsilateral IPS is occluded. We describe our experience in treating CS-dAVFs with ipsilateral IPS occlusion via the ascending pharyngeal artery (APA). METHODS: Between January 2013 and June 2017, of 36 CS-dAVFs, 23 with ipsilateral IPS occlusion were identified. Clinical charts, procedural data, angiographic results, and follow-up data were retrospectively reviewed. RESULTS: Of 23 CS-dAVFs, 16 displayed a single or dominant feeding APA on cerebral angiography, of which 13 were treated via the APA initially. Fistulas were occluded successfully through the neuromeningeal trunk of the APA in 7 cases and through the superior pharyngeal branch of the APA in 3 cases. Glue leakage occurred in 2 cases via the superior pharyngeal branch of the APA, and superior pharyngeal branch rupture occurred during superselection of the microguidewire in 1 patient, who was treated by opening the occluded ipsilateral IPS. During the follow-up period, 12 of 13 patients had complete occlusion, and no cranial nerve palsy occurred. CONCLUSIONS: CS-dAVF with ipsilateral IPS occlusion can be treated via various methods. Embolization through the APA as an initial access is a reasonable choice.

[Triptan-responsive migraine-like headache caused by cavernous sinus dural arteriovenous fistula in a 69-year-old woman with a history of migraine without aura].

A 69-year-old woman with a previous history of migraine without aura developed throbbing headache in the right frontal region accompanied by nausea, lasting more than 4 hours a day. The headache intensity was more severe than that of usual her migraine headaches. Administration of eletriptan in the previous hospital improved her headaches. However, one month later the patient experienced more intense headaches in the same region and then was referred to our hospital. MR angiography showed abnormal signal intensities in the cavernous sinus. Cerebral angiography revealed blood reflux to the cavernous sinus, leading to diagnosis of cavernous sinus dural arteriovenous fistula. Transvenous embolization of cavernous sinus dural arteriovenous fistula was performed, which resulted in resolution of the patient's headache. We should be aware that patients with cavernous sinus dural arteriovenous fistula can manifest migraine-like headaches without being accompanied by cranial nerve palsies.

Prediction of traumatic carotid-cavernous sinus fistula via noncontrast computed tomography by fracture pattern and abnormality of venous system.

BACKGROUND: Traumatic carotid-cavernous sinus fistula (tCCF) is infrequent but with high morbidity if delayed diagnosed or managed. Because of the lack of screening criteria and requirement of advanced and invasive radiological examinations, diagnosis is often delayed or underdiagnosed. METHODS: A matched case-control study with univariate and multivariate analyses was conducted to predict tCCFs. Forty-six patients diagnosed with tCCFs were included and matched with 138 patients of craniofacial trauma without tCCF as control at a ratio of 1:3. RESULTS: The diagnostic diameter of superior ophthalmic vein (SOV) in tCCF was 4 mm with area under curve of 0.89. In multivariate analysis, engorgement of SOV and cavernous sinus (odds ratio [OR], 35.39; 95% confidence interval [CI], 13.56-104.84; p < 0.001) and lateral impact (ipsilateral temporal and sphenoid sinus fractures) (OR, 3.96; 95% CI, 1.10-14.91; p = 0.028) were identified significant, whereas basilar skull fracture (OR, 1.58; 95% CI, 0.53-4.75; p = 0.300) and injuries to ocular nerves (cranial nerves III, IV, and VI) (OR, 1.77; 95% CI, 0.38-7.88; p = 0.055) were insignificant. CONCLUSION: Presence of SOV or cavernous sinus engorgement on noncontrast computed tomography and lateral impact were demonstrated as independent predictors to tCCF and warrant further radiological evaluation. Injury to ocular nerves is not predictive but as an essential differential diagnosis with reversible outcome. LEVEL OF EVIDENCE: Diagnostic, level III.

Double inter-internal carotid artery communication through intercavernous anastomosis and posterior communicating artery associated with multiple intracranial artery segmental agenesis/aplasia.

Segmental internal carotid artery (ICA) and basilar artery (BA) agenesis/aplasia are rare vascular anomalies. We report an extremely rare case of combined ICA, BA, and A1 segmental absence presenting with double inter-ICA collateral communication through the intercavernous anastomosis and posterior communicating arteries. The patient presented with diplopia and transient ischemic attack. The pathogenesis of the anatomic anomalies and clinical symptoms are discussed.

Superficial middle cerebral vein connection to the cavernous sinus is not infrequent in brain arteriovenous malformations: an argument against their congenital origin?

INTRODUCTION: The aim of this study was to test the hypothesis that the superficial middle cerebral vein (SMCV) is frequently absent or fails to connect with the cavernous sinus (CS) in the presence of brain arteriovenous malformations (AVMs), a frequently reported argument for the congenital origin of brain AVMs. METHODS: The SMCV was retrospectively compared between patients with a brain AVM and a control group. The presence or absence of the SMCV, its direct or indirect connection to the CS and its termination in a laterocavernous sinus (LCS), paracavernous sinus (PCS), or directly in the CS was studied on digital subtraction angiography. RESULTS: One hundred twenty-five left or right side carotid angiograms from 70 patients with a brain AVM were compared to 125 angiograms from 74 controls. The SMCV was present in 88 (70.4 %) cases in the brain AVM group and 96 (76.8 %) cases in controls (p = 0.25). The SMCV was connected directly or indirectly to the CS in 65 (52 %) cases in the brain AVM group and 65 (52 %) cases in controls (p = 1). When comparing the subgroup of carotid angiograms ipsilateral to a supratentorial AVM, no statistically significant difference was found with controls. In three of six cases in which a SMCV drained an AVM, the vein terminated directly or indirectly in the CS. CONCLUSIONS: No difference of SMCV presence and direct or indirect connection to the CS was found between patients with AVM and a control group. SMCV anatomy does not support the congenital origin of brain AVMs.

Aggressive cavernous sinus dural arteriovenous fistula: Angioarchitecture analysis and embolization by various approaches.

BACKGROUND: Most cavernous sinus dural arteriovenous fistulas (CSDAVFs) present with benign neuro-ophthalmic symptoms. CSDAVFs manifesting with aggressive neurologic symptoms are rare. The purpose of this study was to analyze the different angioarchitectures of aggressive CSDAVFs and to report our experiences of embolization. METHODS: Over the past 10 years, a total of 118 CSDAVFs were managed by embolization. From the databases containing such patient information, nine patients (7.6%) were found to have aggressive CSDAVFs presenting with neurologic deficits. There were seven women and two men, ranging in age from 51 years to 78 years (mean, 66 years). We retrospectively analyzed the angioarchitectures of aggressive CSDAVFs, further reviewing patient and angiographic as well clinical outcomes after embolization. RESULTS: The cause of clinically aggressive CSDAVFs was insufficient fistula drainage because of occlusion (n = 6) or stenosis (n = 1) of the inferior petrous sinus (IPS) or compartment of IPS-cavernous sinus (n = 2) with fistula flow reflux to the veins of brainstem (n = 7) leading to brainstem ischemia, while two fistula flow reflux to the cortical vein leading to cerebral infarction. Transvenous embolization via IPS to fistula was achieved in one case; six patients underwent transorbital access, while transarterial embolization was performed in two cases. Total fistula occlusion was achieved in eight CSDAVFs. All patients had total (n = 7) or partial (n = 2) resolution of their symptoms gradually within 6 months. One patient undergoing transarterial embolization had limb weakness because of inadvertent pial artery occlusion. Their overall mean clinical follow-up period was 17 months. CONCLUSION: Aggressive CSDAVFs are associated with occlusion/stenosis of the IPS or compartment of IPS-cavernous sinus with leptomeningeal reflux. In this limited case series, aggressive CSDAVFs most presented with brainstem ischemia, followed by nonhemorrhagic/hemorrhagic stroke in the cerebrum. Embolization through various access routes is a feasible method to manage these aggressive CSDAVFs, with an acceptable level of periprocedural risks.

Transvenous embolization of cavernous sinus dural arteriovenous fistula via angiographic occlusive inferior petrous sinus.

BACKGROUND: Trans-inferior petrous sinus (IPS) coil embolization is an efficient and safe method to manage cavernous sinus dural arteriovenous fistulas (CSDAVFs). However, some CSDAVFs may be associated with angiographic occlusive IPS making access difficult. The purpose of this study was to report our experience of transvenous embolization of the CSDAVF via angiographic occlusive IPS. METHODS: We reviewed the cases of 20 patients who underwent transvenous embolization via angiographic occlusive IPS over a 6 year period. The study consisted of seven men and 13 women, ranging from 46 years to 78 years of age (mean, 60 years). We retrospectively analyzed the angioarchitecture of the CSDAVFs, the procedural time and the angiographic as well as the clinical outcomes after embolization. RESULTS: True occlusive IPS was found in 13 of the patients, while patent IPS with compartment of the IPS-CS was demonstrated in the remaining seven patients. The microcatheter was successfully navigated to the fistula site of the CS in 16 patients (80%), while such navigation failed in four patients following numerous attempts. The mean procedural times for truly occlusive IPS and for compartment of the IPS-CS were 111 minutes and 129 minutes, respectively. No recurrent fistula was observed on follow-up neuroimages. Three patients had transient third or sixth cranial nerve palsy, and one patient had perforation of the IPS leading to temporary headache. The mean clinical follow-up period was 18 months. CONCLUSION: Angiographic occlusive IPS of CSDAVF may be related to true occlusion of IPS or patent IPS with compartment of the IPS-CS. There is no statistically significant difference in procedural times for these two different fistula anatomies. Transvenous embolization via angiographic occlusive IPS is a safe and effective method to manage CSDAVFs.

Evaluation of Intracranial Dural Arteriovenous Fistulas: Comparison of Unenhanced 3T 3D Time-of-flight MR Angiography with Digital Subtraction Angiography.

PURPOSE: We compared gross characterization of intracranial dural arteriovenous fistulas (DAVFs) between unenhanced 3-tesla 3-dimensional (3D) time-of-flight (TOF) magnetic resonance angiography (MRA) and digital subtraction angiography (DSA). METHODS: We subjected 26 consecutive patients with intracranial DAVF to unenhanced 3T 3D TOF MRA and to DSA. Two independent sets of observers inspected the main arterial feeders, fistula site, and venous drainage pattern on MRA and DSA images. Interobserver and intermodality agreements were assessed by k statistics. RESULTS: Interobserver agreement was excellent for fistula site (κ = 0.919; 95% confidence interval [CI], 0.805 to 1.000), good for main arterial feeders (κ = 0.711; 95% CI, 0.483 to 0.984), and very good for venous drainage (κ = 0.900; 95% CI, 0.766 to 1.000). Intermodality agreement was excellent for fistula site (κ = 0.968; 95% CI, 0.906 to 1.000) and good for main arterial feeder (κ = 0.809; 95% CI, 0.598 to 1.000) and venous drainage (κ = 0.837; 95% CI, 0.660 to 1.000). CONCLUSION: Gross characterization of intracranial DAVF was similar for both imaging modalities, but unenhanced 3T 3D TOF MRA cannot replace DSA.

Transarterial Onyx Embolization for Patients with Cavernous Sinus Dural Arteriovenous Fistulas Who Have Failed Transvenous Embolization.

Transvenous embolization is the treatment of choice for cavernous sinus dural arteriovenous fistulas (csDAVFs) despite occasional difficulty in transvenous catheterization. We reported our experience in the treatment of csDAVFs by transarterial Onyx embolization in patients who had failed transvenous catheterization. We reviewed the clinical and radiographic records of csDAVFs patients receiving transarterial Onyx embolization after failed transvenous Onyx embolization at our institution over a period of 31 months. Success was defined as complete or near complete occlusion upon angiographic examination. In seven cases, the microcatheter failed to reach the cavernous sinus; in the remaining case, the internal jugular vein was occlusive. Eight sessions of the embolization and catheterization procedures via the arterial routes were conducted. Among them, five cases via the middle meningeal artery and the other three via the accessory meningeal artery. Angiography, immediately after embolization, revealed complete occlusion in seven cases (87.5 %) and partial occlusion in the remaining case. Angiographic follow-up (range, 6-10 months) showed that all patients achieved complete embolization. In cases where transvenous embolization of the cavernous sinus is difficult, transarterial embolization of the fistulas offers a safe and effective alternative.