Combined pretemporal and endovascular approach to the cavernous sinus for the treatment of carotid-cavernous dural fistulae: technical case report

OBJECTIVE AND IMPORTANCE: The endovascular treatment of carotid-cavernous dural fistulae is becoming the prominent treatment modality for these lesions. The intractability of these lesions and their tendency to recur, especially after previous endovascular treatment sessions, exhausts the available routes and tends to present a difficulty in accessing the cavernous sinus. To avoid the risks associated with a direct surgical approach, an alternative, less invasive route to the cavernous sinus using a pretemporal extradural approach is combined with a direct endovascular approach. CLINICAL PRESENTATION: A 38-year-old woman presented with a history of right visual and ocular symptoms related to a Type D cavernous carotid dural fistula, which was fed by internal carotid and external carotid branches. The fistula was initially treated with embolization of the external carotid arterial supply. After a transient improvement, the patient's visual acuity worsened. A follow-up angiogram showed the major supply from the intracavernous internal carotid branches and draining through the inferior ophthalmic vein. The transvenous route was not accessible. An attempt to cannulate the intracavernous branches was not successful. The combined pretemporal and endovascular approach was then used. INTERVENTION: The pretemporal extradural region of the superior orbital fissure was exposed. Using microsurgical techniques and Doppler flow guidance, the anterior cavernous sinus was cannulated through the orbital venous drainage channels. Using intraoperative angiography, thrombogenic coils were deployed at the level of the fistula. Intraoperative angiography confirmed complete obliteration of the fistula. CONCLUSION: The combined pretemporal (extradural) and endovascular approach to the cavernous sinus is a less invasive alternative for the treatment of intractable carotid-cavernous dural fistulae.     

Dural fistulae of the cavernous sinus and interventional neuroradiology. Apropos of 4 cases

PURPOSE: Our purpose was to show how difficult it is to diagnose a dural fistula of the cavernous sinus, which is an anomalous arteriovenous shunt within the dura mater extending from meningeal arteries to the cavernous sinus. CASE REPORT: A dural fistula was suspected in four female patients aged between 61 and 80, presenting with a red eye, dilated episcleral veins, exophthalmos and elevated intraocular pressure. A cerebral hyperselective angiography was performed in all cases. RESULTS: The cerebral angiography confirmed the diagnosis of a dural fistula in all cases, showing the early filling of the cavernous sinus followed by the draining vessel (posterior in case n. 4, anterior in cases n degrees 1, 2, 3). Case n degrees 2 was unilateral and cases n. 1, 3, 3 were bilateral. The blood flow was low in all cases. A successful embolization was performed in all patients with resolution of all symptoms. CONCLUSION: The diagnosis of dural fistulas is often difficult because of misleading clinical signs. It is documented by a cerebral angiography showing the feeding vessels and helping to choose either venous or arterial embolization which is the most suitable treatment.     

A case of cavernous dural arteriovenous fistula resulting in intracerebral extravasation during transvenous embolization

Cortical venous drainage has been described as one of the major risk factors for dural arteriovenous fistula, which may induce venous hypertension leading to venous ischemia or intracerebral hemorrhage. However, it is rather rare to observe cortical venous drainage manifesting in this way in the cavernous sinus region. We report a case of a 55-year-old gentleman with a right cavernous dural arteriovenous fistula, presenting with conjunctival chemosis, exophthalmus and ocular hypertension on the affected side. Magnetic resonance imaging showed a small intracerebral hemorrhage in the right frontal lobe. Cerebral angiography revealed a dural arteriovenous fistula in the right cavernous sinus draining into the right olfactory vein via the uncal vein, as well as into the superior and inferior ophthalmic veins. This unusual cortical venous reflux was thought to be consistent with the intracerebral hemorrhage found on the magnetic resonance imaging. The patient underwent transvenous embolization for the dural arteriovenous fistula using an inferior petrosal catheterization into the uncal vein was difficult, and the cortical venous reflux through the vein seemed to be slight. However, extravasation of the contrast material occurred in the right frontal lobe after obliteration of the ophthalmic veins during the procedure. The cause of the extravasation was suspected to be the same olfactory vein that had been involved in the previous intracerebral hemorrhage. The obliteration of the dural fistula was continued rapidly, and the fistula disappeared after the embolization. Neurologically, the patient had no noticeable troubles, except for a mild headache. The pretreatment symptoms were alleviated within several days, and the patient was discharged in a week. We emphasize the following points from this rare case in order to facilitate a safer procedure during transvenous embolization for cavernous dural arteriovenous fistula. It is important to obliterate the cortical venous drainage as early as possible, even if the reflux is small or the catheterization is difficult. Repeated, careful sinography is useful for the evaluation of the drainage pattern at certain stages during the transvenous embolization procedure.     

Spontaneous dural carotid cavernous sinus fistula presenting isolated ophthalmoplegia: evaluation with MR angiography

We describe three patients with spontaneous dural carotid cavernous sinus fistula presenting an isolated ophthalmoplegia where magnetic resonance angiography demonstrated abnormal flow-related enhancements in the cavernous sinus with extension into the inferior petrosal sinus. Magnetic resonance angiography is of value in evaluation of patients with isolated ophthalmoplegia.     

Selective transvenous embolization of dural fistulas without occlusion of the dural sinus

Two patients with dural arteriovenous fistulas (DAVFs) and unsuccessful transarterial embolizations were treated with a technique for selective transvenous embolization. A 5F catheter was advanced from a femoral vein access into the internal jugular bulb and a catheter was navigated through the sinus lumen into the involved cortical veins or the parasinusal venous draining channels of the DAVFs. The venous recipients at the nidal level of the DAVFs were occluded by fibered platinum coils. Complete angiographic cure was effected in both patients, with occlusion of the venous recipients and the nidus, although the sinus segments next to the nidus of the DAVFs remained patent. Placement of coils in a transsinusal route into the venous channel of a DAVF yet outside the sinus lumen can result in complete obliteration of the fistula without damage to the physiological function of the dural sinuses.     

Orbital venous approach to the cavernous sinus: an analysis of the facial and orbital venous system

Carotid-cavernous fistulas are abnormal communications between the internal carotid artery and the cavernous sinus produced by a rupture of the wall of the carotid artery or one of its branches into the sinus. Extradural branches of the internal or external carotid arteries may communicate with the cavernous sinus, producing proptosis, progressive glaucoma, and ocular vascular engorgement. Various approaches to obliterate these fistulas have evolved, many of which carry high morbidity or are precluded by anatomical considerations. Analysis of the venous anatomy of the orbit and face, including human cadaver dissections, reveals a new and safe approach to the cavernous sinus, requiring microsurgical isolation and cannulation of the superior ophthalmic vein through an anterior orbital approach. Selective embolization of a carotid-cavernous fistula can be performed successfully through this route. We present pertinent anatomy and technical considerations and the successful clinical application of these principles. Surgeons familiar with craniofacial anatomy and microvascular techniques can apply these principles and play an active role in the treatment of these complex problems.     

Traumatic carotid cavernous sinus fistula: serial angiographic studies from the day of trauma

BACKGROUND AND PURPOSE: The purpose of this study was to ascertain the early angiographic features characteristic of traumatic carotid cavernous sinus fistulas (CCFs). METHODS: Eight patients with severe craniofacial injuries underwent emergency diagnostic and therapeutic angiography for intractable oronasal bleeding, starting on an average of 6.7 hours after trauma. Carotid angiograms and the clinical manifestation of traumatic CCFs were then reviewed retrospectively to determine characteristic angiographic features. RESULTS: In four of the eight patients, no arteriovenous fistulas were found in the cavernous sinuses and symptomatic CCF did not occur during the follow-up period. In the remaining four patients, dural CCFs (Barrow type B) were observed, unilaterally in three patients and bilaterally in one. One of these four patients subsequently became symptomatic and required transarterial coil embolization. CONCLUSION: Traumatic dural CCFs are frequently observed in the early stage of severe craniofacial trauma, if investigated. Although their spontaneous disappearance is known, some of these do become symptomatic and need treatment.     

Dural arteriovenous fistula of the posterior fossa draining into the spinal medullary veins--an unusual cause of myelopathy: case report

In a 31-year-old male patient suffering from progressive myelopathy, a right carotid angiography disclosed an intracranial tentorial arteriovenous fistula (AVF) draining intrathecally into the spinal medullary veins. An embolization via the afferent meningohypophyseal artery was not technically feasible, and a microsurgical excision of the AVF was accomplished via a suboccipital approach, resulting in the angiographic cure of the fistula and progressive relief of the myelopathy. Fourteen reported cases of intracranial dural AVF draining intrathecally are reviewed. In most patients, authors encountered diagnostic difficulties similar to those noted in this case. Surgical and/or endovascular therapeutic methods have provided disappointing results, likely attributable to a prolonged course of spinal cord dysfunction. Pathophysiologically, a mechanism of venous congestion of the cord seems to be involved, as acknowledged by several magnetic resonance and angiographic studies. In patients who appear to have a clinical and myelographic picture of "vascular" myelopathy and who exhibit negative spinal angiography, a four-vessel cerebral angiography should be undertaken, aiming at the recognition of an intracranial AVF.     

Management of cavernous sinus-dural fistulas. Indications and techniques for primary embolization via the superior ophthalmic vein

OBJECTIVE: To describe indications and surgical techniques for embolization of cavernous sinus-dural fistulas (CDF) by passing platinum coils through a cannulated superior ophthalmic vein based on our clinical experience. DESIGN: Retrospective clinical review. SETTING: University tertiary referral hospital and eye institute. PATIENTS: Over a 3-year period, 10 consecutive patients with CDF and progressive orbital congestion underwent transvenous embolization. All patients had a dilated superior ophthalmic vein. All 10 patients had indications for treatment of fistulas on the basis of progressive glaucoma refractory to medical management, venous stasis retinopathy with retinal ischemia, optic neuropathy, diplopia, exophthalmos with exposure keratopathy, cortical venous congestion with risk for intracranial hemorrhage, or a combination of these findings. INTERVENTION: Nine of the 10 patients underwent anterior orbitotomy via a lid-crease or sub-brow incision with cannulation of the ipsilateral superior ophthalmic vein and embolization of the cavernous sinus with platinum coils, following an unsuccessful transarterial embolization. One patient underwent a primary transvenous embolization. MAIN OUTCOME MEASURES: Successful closure of the fistula on angiography, return of baseline visual acuity, normalization of postoperative intraocular pressure, and cosmetically acceptable cutaneous scar. RESULTS: All 10 patients had prompt resolution of symptoms and halt of progressive visual loss following occlusion of the fistulas. Two patients had no flow in the anterior superior ophthalmic vein on angiography suggesting thrombosis, yet the superior ophthalmic vein was easily accessed in the anterior orbit, and transvenous embolization was successfully performed. In 2 additional patients with nondilated superior ophthalmic veins, we were unable to gain surgical access and in 1 case severe bleeding occurred during attempted access of the small vein. CONCLUSIONS: When performed by an experienced orbital surgeon and neuroradiology team, transvenous embolization of CDF via a dilated anterior superior ophthalmic vein is a technically straightforward, safe, and effective treatment for CDF and perhaps should be employed as primary therapy in cases with progressive orbital congestive symptoms. If the superior ophthalmic vein is not dilated or if it is located deep in the orbit, transorbital venous access may not be possible.     

Investigations of anti-inflammatory activity of Jigrine

We report our experience with five lesions exclusively involving the entire cavernous sinus in which an essentially extradural surgical approach was used. There were two cases of cavernous haemangioma, two cases of meningioma and one case of fungal granuloma. The dural cover of the superior orbital fissure, and mandibular and maxillary divisions of the fifth nerve was dissected along with the dura of the lateral wall of the cavernous sinus. The presence of a relatively large intracavernous bulge due to the tumour assisted in this dissection. The contents of the cavernous sinus were exposed from an anterolateral, lateral and inferior approach. Through the corridor available between the splayed out cranial nerves, a radical resection of the tumour was accomplished in each case. The technical advantages of this approach are discussed in light of the anatomy of the dural configuration of the lateral wall of the cavernous sinus.     

First record of host defence peptides in tadpoles. The magnificent tree frog Litoria splendida

We treated a 73-year-old man with a dural arteriovenous fistula (AVF) with cortical venous drainage of the left mastoid region using transarterial embolization of the middle meningeal and occipital arteries with n-butyl 2-cyanoacrylate (NBCA). The patient's clinical symptoms improved dramatically. Three months after the procedure, follow-up CT showed resolution of white matter edema and follow-up angiograms showed no evidence of a recurrent AVF. This report indicates that dural AVFs without sinus drainage can be cured solely with transarterial NBCA embolization.     

The apolipoprotein(a) promoter contains a retinoid response element

OBJECTIVE AND IMPORTANCE: Dural arteriovenous fistulas of the superior sagittal sinus (SSS) account for 8% of intracranial dural fistulas. Their association with a thrombosis of the posterior part of the SSS is rare. In such cases, the usual neurosurgical and endovascular approaches cannot provide a good technical solution for treatment of the lesion, and a combined neurosurgical and neuroradiological approach is therefore needed. CLINICAL PRESENTATION: A 68-year-old man presented with rapidly evolving dementia. Cerebral angiography revealed a dural arteriovenous fistula of the SSS associated with thrombosis of the posterior part of the SSS. Various endovascular and neurosurgical approaches failed to cure the fistula. INTERVENTION: A burr hole was drilled in the frontal region, in the neurosurgical room. The patient was then transferred to the angiographic room, and the SSS was occluded using free spirals. CONCLUSION: This procedure led to a complete anatomic cure of the fistula, and a slow clinical improvement was observed.     

A case of spontaneous arteriovenous fistula presenting as the partial oculomotor nerve palsy

We report a case of partial oculomotor nerve palsy due to spontaneous arteriovenous fistula. A 62-year-old man noticed double vision on downward gaze and periorbital pain. Clinical examination revealed inability to move the left eye downwards and to the right, and also anisocoria. No conjunctival injection or proptosis was noted. Findings of computed tomographic scan, magnetic resonance imaging and magnetic resonance angiography of the orbits, cavernous sinus region and brainstem were all normal. Carotid angiography demonstrated arteriovenous fistula via the left ophthalmic artery, the dural branch of the left external carotid artery, and the dural branch of the right internal carotid artery. Partial oculomotor palsy in this case indicated that the left inferior branch of the oculomotor nerve was affected. Inferior branch palsy of the oculomotor nerve in spontaneous arteriovenous fistula has not been described in the literature, while it is reported in cases of trauma, tumor, or aneurysm of the cavernous sinus.     

Value of CT-angiography in diagnosis of cerebral sinus and venous thromboses

Dural sinus thrombosis is not uncommon. Due to the nonspecific symptomatology, as well as the manifold etiology, clinical diagnosis may be difficult. In these cases imaging procedures are frequently crucial in deciding how to proceed and how to treat. The aim of our study was to evaluate the diagnostic utility of helical CT in the detection of dural sinus thrombosis. In 20 patients with clinically suspected thrombosis CT angiography was performed. In 6 patients dural sinus thrombosis was diagnosed. In order to acquire also arterial vessels, a short delay of about 22 s after the onset of the application of contrast medium was selected. By this method we found an occlusion of the MCA in two patients with clinically suspected sinus thrombosis. In all patients the transverse slices and the multiplanar reconstructions showed filling defects or an "empty delta" sign. With irregular outlines the thrombus could be depicted over the complete course of the sinus. The MIP reconstructions were particularly helpful in the evaluation of the vessel anatomy and the pathological collateral venous drainage. In three patients MR angiograms were available for comparison. The smaller veins, such as the v. vermis inferior, were less clearly depicted than in CT angiography. CT angiography is a fast and reliable method to exclude or verify a sinus thrombosis. It can be performed immediately after non-enhanced CT. According to our present experience CT angiography is sufficient for the diagnosis of a sinus thrombosis.     

Epileptic seizures in patients with multiple sclerosis. Is the prognosis of epilepsy underestimated?

Spinal arteriovenous malformations are uncommon disorders associated with considerable difficulty in diagnosis and treatment. They are divided into dural arteriovenous fistulas and intradural medullary spinal cord angiomas. In this retrospective series of six patients the clinical outcome of embolization is presented. The patient material consisted of three dural fistulas and three cord angiomas, one of which bled causing sudden paresis, pain and incontinence. In the remaining five patients the symptoms were progressive consisting of paraesthaesias, paraparesis, pain and incontinence. The clinical status of four patients was not changed after the treatment, one deterioriated and one improved. There were no bleedings after the therapy. In one patient spinal angiography for follow-up was performed and recanalization was seen in the dural fistula after particle embolization. Also, in one cord angioma embolized with particles reflow appeared in the immediately repeated angiography. For permanent angioma occlusion tissue adhesive is preferred as embolic material. Surgical therapy as an alternative or adjuvant to embolization is discussed with a review of the literature. Early timing of the therapeutic intervention is stressed to avoid the development of irreversible ischaemic medullopathy and to prevent haemorrhage. The therapeutic procedures at the early stage of the disease may be curable or, at least, halt the progression of the symptoms. Cross-sectional imaging studies and myelographies may reveal the lesion. For the definitive diagnosis of spinal angioma with its vascular feeders and for the evaluation of its occlusion grade after the therapy selective spinal angiography is needed.     

Hypothalamic hamartoma associated with dural arteriovenous fistula of the transverse-sigmoid sinus--case report

A 32-year-old female presented with a hypothalamic hamartoma associated with a dural arteriovenous fistula (DAVF) of the left transverse-sigmoid sinus. She complained of pulsatile tinnitus in the left retroauricular region and infertility. Endocrinological examination revealed that the luteinizing hormone reaction to luteinizing hormone-releasing hormone was exceedingly high. Magnetic resonance imaging demonstrated a distinct mass occupying the suprasellar cistern and protruding into the third ventricle. Left carotid angiography demonstrated a DAVF of the left transverse-sigmoid sinus, which was treated by embolization. Histological examination of a biopsy specimen of the tumor revealed a hamartoma. She was free from pulsatile tinnitus after treatment for the DAVF.     

Preventive effects of an antiallergic drug, pemirolast potassium, on restenosis after percutaneous transluminal coronary angioplasty

PURPOSE: Radiosurgery is an effective treatment for cerebral arteriovenous malformations. We conducted the present study to investigate the feasibility and efficacy of gamma knife radiosurgery for dural arteriovenous fistulas (DAVFs) of the cavernous sinus. METHODS: Eighteen patients (12 women and six men; 29-75 years old [mean age, 55 years]) with DAVFs of the cavernous sinus (Barrow's type B:1, C:7, and D:10) treated by gamma knife radiosurgery were enrolled in the study. DAVFs were bilateral in six patients and unilateral in 12. Stereotactic X-ray angiography and MR imaging were performed for targeting the radiosurgery. Areas of arteriovenous communication targeted for irradiation were first outlined on the X-ray angiograms. The target regions were then transferred to and displayed on the MR images. Dose planning was based on findings on the integrated images. Prescribed maximum target doses were 22 to 38 Gy (mean, 28 Gy). The targets were covered by 50% to 90% isodose levels. Radiation doses to the surrounding optic apparatus were kept to less than 8 Gy. The patients were followed up with color Doppler sonography and MR imaging. When noninvasive imaging suggested obliteration, X-ray angiography was performed to verify the results. RESULTS: The DAVFs were totally obliterated in 12 (80%) of the 15 patients. In the other three, one was almost completely obliterated at 14 months and two were partially obliterated at 19 and 27 months, respectively, after radiosurgery. No complications or symptom worsening occurred during the follow-up period. CONCLUSION: Gamma knife radiosurgery is a feasible, effective, and safe treatment for DAVFs of the cavernous sinus. Integration of stereotactic X-ray angiography and MR imaging not only aids treatment efficacy but also protects the relevant vital structures, especially the optic apparatus, from the hazards of radiation.     

Multiple dural arteriovenous fistulas

Four patients with multiple intracranial dural arteriovenous fistulas (DAVFs) at separate sites were treated by endovascular techniques (transarterial and/or transvenous embolization), surgery (excision or isolation), radiotherapy, or combinations, according to the pathophysiological condition. All lesions in two patients were obliterated completely without neurological deficit. There were residual fistulas after the treatment in two patients, but these were low-grade lesions without retrograde cortical venous drainage, and marked clinical improvement was obtained. Planning of treatment strategies for multiple DAVFs requires careful analysis of the venous drainage from the affected sinuses and cerebral hemodynamics.     

Radical resection of meningiomas and arteriovenous fistulas involving critical dural sinus segments: experience with intraoperative sinus pressure monitoring and elective sinus reconstruction in 10 patients

OBJECTIVE: Radical resection of meningiomas and dural arteriovenous fistulas involving functional major dural sinuses entails the risk of intracranial hypertension and venous infarction. Surgical reconstruction of dural sinuses and bridging veins increases the spectrum of dural sinus conditions that can be treated by complete resection, but indications for venous reconstructions and associated risks are still not well defined. We report our experience with sinus reconstruction based on the intraoperative assessment of collateral venous flow. METHODS: Radical resection of meningiomas (n = 5) or dural arteriovenous fistulas (n = 5) involving critical segments of dural sinuses was performed in 10 patients. All but two patients were suffering from recurrent disease after incomplete treatment. Tolerance of sinus occlusion was assessed intraoperatively by measuring stump pressure in the superior sagittal sinus during test clamping of the involved sinus segment. RESULTS: In five patients, the results of pressure monitoring suggested that occlusion of the sinus might not be tolerated. In two other patients, major bridging veins entered the diseased segment. In these patients, the resected sinus segment was reconstructed and bridging veins were reinserted as far as possible. Postoperative graft occlusion occurred in two patients. One patient who was managed without reconstruction sustained a transient postoperative neurological deficit resulting from venous congestion in the vein of Labbé. Postoperative imaging confirmed total elimination of the pathological process in all 10 patients. There was no recurrence of disease during follow-up periods of up to 8 years. CONCLUSION: The monitoring of sinus pressure, together with the possible reconstruction of the diseased sinus, allows complete surgical treatment of dural sinus abnormalities and involves acceptable risk.