Dural and direct cavernous sinus fistulas.

Fistulas between the cavernous sinus and the carotid artery occur either after trauma or spontaneously. Unilateral exophthalmos is invariably the most conspicuous symptom. Until recently, treatment consisted of some method of occluding the carotid artery involved. Interventional catheter techniques have since been developed that use either Gelfoam embolization or released balloons. The results seem very promising, but long-term results of these new techniques are not yet available. Carotid-cavernous sinus fistulas may be dural or direct, each requiring a different interventional technique. Theredore, it is essential to determine the type involved by selective internal and external carotid angiography. This paper discusses 19 patients with carotid-cavernous fistulas, four of whom were successfully treated by catheter techniques. Gelfoam embolization was used in one case, and in three cases the fistula was closed with the aid of a balloon.     

Dural fistulas involving the transverse and sigmoid sinuses: results of treatment in 28 patients

Twenty-eight symptomatic dural fistulas involving the transverse and sigmoid sinuses were treated between 1978 and 1986 with a variety of treatment modalities. Occipital artery compression therapy resulted in a complete cure in two of nine patients (22%) and improvement in three of nine (33%). There were no complications from this treatment. Patients who were excluded or in whom compression therapy failed were treated with embolization alone or in conjunction with surgery. Of the 17 patients who underwent embolization alone, ten were cured and six were improved. Six patients had a combination of embolization and surgery; four patients were cured and two improved. There were three complications in this series, one related to surgery and two related to embolization.     

Dural arteriovenous fistulas involving the inferior petrosal sinus: angiographic findings in six patients

We report the angiographic findings from six patients with intracranial dural arteriovenous fistulas of the inferior petrosal sinus and describe the clinical presentation, vascular anatomy, and embolization techniques used in the treatment of this disorder. Dural arteriovenous fistulas at this site are rare; of 105 patients diagnosed with this abnormality, only six had lesions involving the inferior petrosal sinus. The patients included three men and three women, ranging in age from 41 to 75 years. Patients presented with bruit, proptosis, abducens palsy, or loss of vision, and symptoms were present for up to 1 year prior to diagnosis. These presentations were similar to cavernous sinus arteriovenous fistulas. The arterial supply in all cases was from branches of the external carotid artery and in three cases from the meningohypophyseal trunk of the internal carotid artery. Venous drainage in four patients was via the cavernous sinus to the superior ophthalmic vein. The remaining two patients had drainage primarily to the jugular bulb. In four patients treatment was performed by introducing wire coils into the fistula from the transvenous route. This approach could be used even though the inferior petrosal sinus was thrombosed. One patient, treated early in the series, had only transarterial embolization with both liquid adhesives and particulate embolic agents. One patient had an asymptomatic fistula that was not treated. All patients were cured, as evidenced both angiographically and clinically during the follow-up period. Three patients experienced complications from angiography and treatment: two had transverse sinus thrombosis and one had a transient ischemic attack.     

Transvenous embolization of dural fistulas involving the cavernous sinus

Because of the risks associated with arterial embolization of cavernous dural fistulas, we have sought an alternative method to promote fistula closure. Thirteen patients underwent transvenous embolization as a treatment for symptomatic cavernous dural fistulas. All procedures were performed from a femoral vein access through the inferior petrosal sinus or basilar plexus. In five patients the inferior petrosal sinus was not angiographically demonstrable; however, embolization was still possible through this route in two patients. The embolic agents used were detachable balloons in one patient, coils alone in five, coils and liquid adhesives in four, coils plus silk sutures in one, silk sutures alone in one, and liquid adhesives alone in one. Nine patients had follow-up angiograms, which showed complete obliteration of the fistulas and complete resolution of related symptoms. One patient had complete resolution of clinical symptoms but refused follow-up angiography. Another patient had 50% decrease in fistula flow on the follow-up angiogram and improvement in clinical symptoms. Two patients had complete fistula obliteration after embolization and progressive improvement in symptoms but follow-up angiograms had not been obtained. Follow-ups ranged from 1 to 97 months (mean, 15 months). Two complications were related to this treatment. An embolic stroke followed transient placement of a balloon in the internal carotid in one patient, and a second patient developed transient visual loss when the venous outflow pathways were occluded before fistula closure. The fistula was immediately closed with complete recovery of vision. With recent advances in microcatheter and embolic agent technology, transvenous closure of cavernous dural fistulas is now possible.(ABSTRACT TRUNCATED AT 250 WORDS)     

Dural arteriovenous fistulas of the marginal sinus.

PURPOSETo investigate the clinical presentation, angiographic findings, endovascular management and clinical outcome in dural arteriovenous fistulas (DAVFs) of the marginal sinus.METHODSFourteen patients with DAVFs of the marginal sinus were identified from angiographic studies and medical records of all patients treated for DAVFs at our institution between July 1990 and August 1995. The endovascular treatment and clinical outcomes of these patients are reported.RESULTSEleven patients had pulse-synchronous bruit, two had intracranial hemorrhage, and one had ataxia. Thirteen patients were cured with endovascular techniques alone and one was cured by a combination of preoperative embolization followed by surgical obliteration of the fistula. The sole complication of treatment was a partial left hypoglossal nerve palsy, which resolved spontaneously.CONCLUSIONDAVFs of the marginal sinuses are potentially life-threatening lesions that can be treated with endovascular techniques for a high rate of cure and a low rate of morbidity.     

Transorbital puncture for the treatment of cavernous sinus dural arteriovenous fistulas

This report describes a series of patients for whom dural arteriovenous fistulae (DAVFs) of the cavernous sinus were successfully embolized using a percutaneous, transorbital technique to directly cannulate the cavernous sinus. A vascular access needle and catheter are percutaneously advanced along the inferolateral aspect of the orbit to access the cavernous sinus via the superior orbital fissure. Safe and effective embolization is achieved without the need for a surgical cut-down.     

经眼上静脉介入治疗海绵窦区硬脑膜动静脉瘘

目的 探讨眶上内侧缘切开穿刺眼上静脉介入栓塞海绵窦区硬脑膜动静脉瘘(AVF)的方法和疗效.方法 眶上内侧缘切开穿刺眼上静脉使用微弹簧圈介入栓塞海绵窦区硬脑膜AVF 16例.结果 所有患者均临床治愈,1例虽将海绵窦致密填塞,但仍有少量翼丛引流,压颈1个月后消失.栓塞术后并发症主要表现为头痛和呕吐.2例术后出现轻度复视,后自行恢复,无一例出现永久性介入相关并发症.临床随访5个月到6年,患者均无临床症状复发.结论 眶上内侧缘切开穿刺眼上静脉入路介入栓塞是海绵窦区硬脑膜动静瘘治疗安全有效的方法 之一.     

Marginal sinus arteriovenous fistulas mimicking carotid cavernous fistulas: diagnostic and therapeutic considerations

Marginal sinus fistulas (MSFs) are uncommon vascular anomalies. Occasionally, the dominant venous drainage is forced retrograde up the inferior petrosal sinus and into the cavernous sinus, causing chemosis, proptosis, and ocular hypertension, mimicking a carotid cavernous fistula. This atypical clinical presentation may lead to misdiagnosis and inappropriate hazardous treatment of an MSF. Identifying the site of the fistula and understanding the anatomy of the venous drainage are critical in providing appropriate, safe, and efficacious endovascular treatment.     

Recovery of opthalmoplegia associated with cavernous sinus dural arteriovenous fistulas after transvenous cavernous sinus packing

Background

We report the recovery of ophthalmoplegia in 11 patients with cavernous sinus dural arteriovenous fistula (CSDAVF) after sinus packing at follow-up.

Methods

Of 18 patients with CSDAVF treated with transvenous cavernous sinus packing between August 2002 and December 2007 at Beijing Tiantan Hospital, there were 9 patients with initial CNIII or CNVI dysfunction and 2 patients with CNVI dysfunction immediately after cavernous sinus packing selected and reevaluated.

Results

Of 11 patients with CNIII or CNVI palsy, recovery was complete in 10. In 1 patient, complete CNVI palsy was unchanged because the CSDAVF was not cured. There were 6 men and 5 women with a mean age of 52.9 years. In 5 patients, CNVI palsy was associated with chemosis, proptosis and pulsatile tinnitus. Timing of treatment after onset of symptoms was from 4 to 35 days in 9 patients. All CSDAVFs were Barrow type D. Mean follow-up after treatment was 17.7 months (range, 2-54 months).

Conclusion

CSDAVF-induced CNIII or CNVI palsies can be cured after cavernous sinus packing transvenously in most patients.     

Treatment of carotid cavernous fistulas using covered stents: midterm results in seven patients

BACKGROUND AND PURPOSE: Carotid cavernous fistulas (CCF) can be effectively treated by using different therapeutic alternatives such as detachable balloons and detachable coils, alone or in combination with N-butyl-2-cyanoacrylate (n-BCA) or Onyx. Stents have also been used in an attempt to improve preservation of the parent artery while still occluding the fistula. We present our experience using balloon-expandable covered stents to treat CCF, focusing on arterial wall reconstruction. To our knowledge, this is the first series with midterm follow-up between 3 months and 3.5 years. MATERIALS AND METHODS: From the 46 CCF treated at our institution between November 1998 and September 2006, a total of 7 posttraumatic direct CCF were treated using polytetrafluoroethylene (PTFE)-covered stents between April 2003 and September 2006. Five were treated with covered stents alone. One patient with transection of the internal carotid artery (ICA) first underwent bare stent placement to provide support for the covered stent. One patient had to be treated with coils and n-BCA. RESULTS: Control angiograms obtained in the 7 patients demonstrated occlusion of the fistula and preservation of the ICA in all cases. There was no mortality and no immediate postprocedural morbidity. There was 1 case of morbidity identified at 1-month follow-up with asymptomatic occlusion of the ICA; the other 6 patients had angiographic follow-up between 3 and 42 months (mean, 18.4 months), with persistent occlusion of the fistulas, patent stent grafts, and no significant intimal hyperplasia. CONCLUSIONS: PTFE-covered stents are evolving as a promising intracranial therapeutic alternative to treat CCF and preserve the parent artery by reconstructing the arterial wall. They should be considered in patients in whom fistulas cannot be successfully occluded with detachable balloons or detachable coils. More investigation is required to further develop their specifications and indications.     

MR imaging of dural AV fistulas at the cavernous sinus

The magnetic resonance appearance of dural arteriovenous fistulas (AVFs) at the cavernous sinus (CS) was studied in six angiographically verified cases. Magnetic resonance clearly demonstrated shunted blood as an area of signal void both in the CS and in the superior ophthalmic vein. The relationship between shunted blood, internal carotid artery, and extraocular nerves, as well as proptosis, enlargement of the extraocular muscles, and bulging of the lateral wall of the CS were also depicted in the images. Normal venous flow in the involved CS was shown as a low signal area that enhanced after gadolinium administration. Magnetic resonance is useful for screening and follow-up examinations of dural AVFs at the CS. It is essentially a noninvasive procedure that may be repeated and obviates the need for follow-up angiography. However, it should be noted that a signal void in the CS sometimes represents normal venous flow. A definite diagnosis should rely on angiography, which is essential for therapeutic planning.     

Dural arteriovenous fistula involving the transverse sigmoid sinus after treatment: assessment with magnetic resonance digital subtraction angiography

Introduction The purpose of this study was to evaluate the utility of magnetic resonance digital subtraction angiography (MRDSA) in showing the presence or absence of retrograde venous drainage (RVD) in patients with intracranial dural arteriovenous fistula (DAVF) involving the transverse sigmoid sinus (TSS) after treatment. Methods Of 16 patients with DAVF involving the TSS, 13 underwent digital subtraction angiography (DSA) and MRDSA before and after treatment, and 3 underwent DSA before treatment and DSA and MRDSA after treatment. Five patients underwent these procedures twice after treatment. A total of 21 examinations after treatment were evaluated retrospectively. The presence or absence of DAVF and RVD was decided on the basis of the DSA findings. Two neuroradiologists reviewed the MRDSA findings concerning the presence or absence of DAVF and RVD. Results DSA showed residual DAVF in 9 and residual RVD in 5 of 21 examinations. MRDSA revealed residual DAVF in 8 of 21 examinations. MRDSA did not show residual DAVF in one examination because of a very small (low-flow) residual DAVF without RVD. MRDSA identified residual RVD in 5 of 21 examinations. MRDSA was completely consistent with DSA concerning the presence or absence of residual RVD. Conclusion MRDSA could evaluate the presence or absence of RVD in patients with DAVF involving TSS after treatment. MRDSA may give reliable information as to whether patients with DAVF involving the TSS should undergo additional DSA after treatment.     

Basal cerebral venous drainage from cavernous sinus dural arteriovenous fistulas

Introduction  This study aimed to define the patterns of basal cerebral venous drainage (BCVD) from cavernous sinus dural arteriovenous fistulas (CSDAVFs). Materials and methods  Forty sets of selective angiographic data from 36 patients with spontaneous CSDAVFs (age range, 53–79 years) were retrospectively analyzed for their drainage patterns. Three types of BCVD were observed, i.e., superolateral type, BCVD via the deep middle cerebral vein or uncal vein; posterolateral type, BCVD via the superior petrosal sinus and petrosal vein; and posteromedial type, BCVD via the bridging vein and the anterior pontomesencephalic vein. MR images and/or 3D-DSA images were also reviewed when available. Results  BCVD from CSDAVF was found in 12 patients (30%), and the other drainage routes included the superior ophthalmic vein in 25 (63%), the inferior petrosal sinus in 17 (43%), the superficial middle cerebral vein in 17 (43%), intercavernous sinus in 15 (38%), the superior petrosal sinus in seven (18%), and pterygoid plexus in two (5%), respectively. In 12 patients with BCVD, superolateral type was found in four (33%), posterolateral type in five (42%), and posteromedial type in seven (58%). Four cases of posteromedial type were associated with other types of BCVD. Conclusion  CSDAVFs are often associated with BCVD via three different pathways. The posteromedial type via the bridging vein is the most frequent type of BCVD.     

Nonoperative treatment of enteric fistulas: results in 53 patients.

Fifty-three patients with enterocutaneous fistulas were treated nonoperatively. While most of the fistulas resulted as a complication of surgery, other causes included inflammatory disease, trauma, and malignancy. Fistulas originated from the esophagus (n = 4), stomach (n = 4), duodenum (n = 5), small bowel (n = 27), colonic-small bowel anastomosis (n = 2), colon (n = 10), and Hartmann pouch (n = 1), and included both high-output (n = 29) and low-output (n = 24) types. Nonoperative management resulted in spontaneous fistula closure in 57%. Most of the spontaneous closures (83%) occurred within 2 months of treatment. Spontaneous closure rates were similar for low-output and for high-output fistulas (52% vs 63%), but the treatment duration was longer for high-output than for low-output fistulas (mean treatment duration, 17 days vs 41 days). Colonic fistulas were particularly difficult to manage and closed spontaneously in only 10% of patients (one of 10).     

Dural AVFs of the cavernous sinus: transvenous embolization using a direct superficial temporal vein approach

We present an alternative endovascular approach to treat dural anterio-venous fistulas (AVFs) of the cavernous sinus that drain only into the superior ophthalmic vein. Two cases of dural AVFs of the cavernous sinus producing increased intraocular pressure and diminishing visual acuity are reported. The cavernous sinus was accessed via the direct superficial temporal vein approach through the superior ophthalmic vein. Successful embolization was documented radiographically and clinically.     

Dural cavernous angioma: MR features.

The imaging features of a cavernous angioma, which originated from the meninges, are presented. The patient harbored a second cavernous angioma within the brain parenchyma. Cavernous angioma should be included in the differential diagnosis of dural lesions, especially when other cavernous angiomas are present.