Long-term outcome after endovascular treatment of cavernous sinus dural arteriovenous fistula and a literature review.

BACKGROUND: The long-term efficacy of endovascular treatment (EVT) for cavernous sinus dural arteriovenous fistulae (CS-dAVF) was assessed with a special focus on residual shunts after initial EVT. PATIENTS AND METHODS: This retrospective survey included 50 patients who had undergone EVT and were followed for 1 month or longer (median follow-up 56 months). RESULTS: Common preoperative symptoms were chemosis (78%), extra-ocular motor palsy (72%), exophthalmos (66%), and tinnitus (26%). CS-dAVF were addressed by transvenous embolization (tVE, n = 48), tVE only was used in 43 instances and tVE plus transarterial embolization (tAE) in five. Two patients underwent tAE only. Procedure-related morbidity (brainstem infarction) was recorded in one patient (2%) and transient symptom exacerbation (paradoxical worsening) in 12 patients (24%). Postoperative digital subtraction angiography showed no major retrograde shunt or cortical venous reflux in any of the 50 patients. Anterograde or minor retrograde residual shunt was observed in 17 patients (34%); three of these underwent additional tVE and four had Gamma Knife surgery. The shunt flow disappeared in all 17 patients 12.6 ± 13.4 (mean ± SD) months after initial EVT. At the latest follow-up, 65.7 ± 52.6 months after the initial operation, no shunt flow was observed in any of the 50 patients. None had remaining or newly developed chemosis or tinnitus on follow-up. The rate of persistent cavernous sinus symptoms at the latest follow-up was higher in patients with than without post-procedural paradoxical worsening (5/12, 41.7% vs. 2/38, 5.3%, p = 0.0059 by Fisher's exact test). CONCLUSIONS: Long-term follow-up showed that EVT, especially tVE, is an efficient and safe treatment for CS-dAVF. It resulted in the eventual disappearance of shunt flow. Residual shunt without major retrograde flow or cortical venous reflux can be monitored without additional treatment.

Surgically treated intracranial arteriovenous fistulas with hemorrhage, resulting in complete obliteration: illustrative cases.

BACKGROUND: Intracranial arteriovenous fistula (AVF) is a rare disease, defined as anastomoses between cerebral or meningeal arteries and dural venous sinuses or cortical veins. With the development of new agents and devices, endovascular embolization has been considered safe and effective in a majority of cases. However, cases that require direct surgery do exist. Herein, the authors present 3 cases of intracranial AVFs that presented with hemorrhage and were treated with direct surgery, achieving complete obliteration and favorable outcomes. OBSERVATIONS: Intracranial AVFs that present with hemorrhage require immediate and complete obliteration. When AVFs involve the dural sinus, transvenous embolization is usually the first choice of treatment. AVFs with single cortical venous drainage are best treated with interruption of the draining vein close to the fistula. Transarterial embolization can be a curative treatment if there are no branches supplying cranial nerves or an association with pial feeders. In cases in which endovascular treatment is technically challenging or has resulted in incomplete occlusion, surgical treatment is indicated. LESSONS: Despite the recent rise in endovascular treatment, it is important to recognize situations in which such treatment is not suitable for intracranial AVFs. Direct surgery is effective in such cases to offer the best possible outcome.