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Transvenous embolization of cerebrospinal fluid-venous fistulas: Independent validation and feasibility of upper-extremity approach and using dual-microcatheter and balloon pressure cooker technique
  1. Donna Parizadeh1,
  2. Olga Fermo2,
  3. Prasanna Vibhute1,
  4. Vivek Gupta1,
  5. Jorge L Arturo Larco1,
  6. Sanjeet S Grewal3,
  7. Alfredo Quinones-Hinojosa3,
  8. Young M Erben4,5,
  9. Steven Clendenen4,
  10. Todd D Rozen2,
  11. Thien J Huynh1
  1. 1 Department of Radiology, Mayo Clinic, Jacksonville, FL, USA
  2. 2 Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
  3. 3 Department of Neurosurgery, Mayo Clinic, Jacksonville, FL, USA
  4. 4 Department of Anesthesiology, Mayo Clinic, Jacksonville, FL, USA
  5. 5 Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL, USA
  1. Correspondence to Dr Thien J Huynh, Department of Radiology, Mayo Clinic in Florida, Jacksonville, FL 32224, USA; huynh.thien{at}


Background Transvenous embolization is emerging as a promising treatment for cerebrospinal fluid-venous fistulas (CVF) associated with spontaneous intracranial hypotension (SIH).

Objective To perform an independent validation of the efficacy and safety of the procedure and describe the procedural techniques used at our institution.

Methods A retrospective review was performed including consecutive patients with SIH who had undergone CVF embolization with 3-month clinical and imaging follow-up. Clinical evaluation included the Patient Global Impression of Change (PGIC) Scale and six-item Headache Impact Test (HIT-6). Bern SIH score was used for imaging evaluation on brain MRI. Post-treatment changes in scores were assessed by Wilcoxon signed rank test. Procedural technical details, including use of upper-extremity access and dual-microcatheter pressure cooker technique, were recorded.

Results 18 patients (13 female, median age 60 years) were included. 17 (94%) procedures were performed with upper-extremity access and 12 (67%) using dual-microcatheter pressure cooker technique. After embolization, 16 (89%) patients reported much or very much improved at follow-up PGIC; median (IQR) HIT-6 score improved from 68 (62–72) to 36 (36–38) and Bern SIH score improved from 8 (6–8) to 3 (1.5–3.5), p values <0.001. Side effects were transient embolization site back pain in 15 (83%) and rebound intracranial hypertension requiring medical management in 9 (50%) patients. HIT-6 and Bern SIH score changes were similar between conventional and pressure cooker techniques (p values >0.05).

Conclusion Transvenous embolization is independently validated as a highly effective and safe treatment for CVF and is feasible using upper-extremity venous access. Dual-microcatheter and balloon/coil pressure cooker techniques may be used to optimize distribution of embolic material and potentially, treatment efficacy.

  • Liquid Embolic Material
  • Coil
  • Brain
  • Spine
  • Fistula

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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  • Contributors TJH and DP made substantial contributions to the conception and design of the work, acquisition, analysis, and interpretation of data as well as drafted the work. DP performed the statistical analysis and drafted the initial manuscript. OF, PV, VG, JLAL, SSG, AQ-H, YME, SC, and TR participated in the data acquisition and interpretation. All authors critically revised the manuscript and approved the final version. TJH is the guarantor of this project.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.