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Endovascular embolization is the preferred treatment modality of dural arteriovenous fistulae (DAVF) with retrograde leptomeningeal drainage.
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Transarterial ethylene vinyl alcohol and n-butyl-2-cyanoacrylate embolization of DAVF are associated with high cure rates and low complication rates.
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Transvenous embolization of cavernous DAVF is associated with high occlusion rates and symptomatic improvement of ocular hypertension.
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Direct percutaneous access via either the orbit or the calvarial foramina
Endovascular Management of Intracranial Dural Arteriovenous Fistulae
Section snippets
Key points
Transarterial embolization of DAVF with Onyx
A transarterial approach has become the most frequently used initial treatment modality for DAVF with RLVD, primarily after the introduction of ethylene vinyl alcohol (Onyx; Covidien, Dublin, Ireland), a permanent, nonadhesive, liquid polymer embolic agent. DAVF with direct RLVD represent the ideal candidates for transarterial treatment with Onyx. DAVF with sinus and RLVD outflow can also be successfully treated with Onyx embolization, especially if a parallel venous pouch or
Transarterial embolization of DAVF with acrylic glue
Transarterial DAVF embolization can be successfully performed with acrylic embolic agents, such as n-butyl-2-cyanoacrylate (nBCA; Trufill, Codman, Raynham, MA, USA), although its use for this indication has decreased in the “Onyx” era, especially in the United States. Patients harboring DAVF with direct RLVD, and less commonly, DAVF with sinus and RLVD, are candidates for this treatment modality. A standard transfemoral arterial route is used. An nBCA-compatible microcatheter is navigated
Transvenous embolization of DAVF
A transvenous approach remains the predominant approach in treatment of DAVF of the cavernous sinus.19 Furthermore, certain DAVF associated with a functionally isolated segment of the superior sagittal sinus and transverse/sigmoid junction harboring the fistulous connection may be accessible via a transvenous route. A transvenous approach may also be more suitable if multiple small arterial feeders shunt into a widely dispersed segment of the dural sinus wall.20 A standard transfemoral or
Use of adjuvant flow control techniques in transarterial and transvenous DAVF embolization
Adjuvant flow control techniques have recently been introduced and are becoming increasingly popular in the endovascular treatment of DAVF. In most instances, a balloon microcatheter is used in conjunction with a liquid embolic agent during transarterial or transvenous embolization. Superselective distal arterial access may be hindered due to the presence of multiple acute bends, especially in the occipital artery and its transosseous branches. A separate balloon microcatheter may assist in
Direct percutaneous access for DAVF embolization
A direct puncture technique may be used when standard arterial or venous routes do not allow successful navigation to the fistulous connection. A direct percutaneous transorbital approach without the need for surgical exposure was used by White and colleagues36 to treat 8 patients with cavernous DAVF. This approach is particularly useful in the setting of pronounced anterior drainage of DVAF in the ophthalmic veins, allowing an anatomically direct avenue to the cavernous sinus for subsequent
Transarterial particle embolization of symptomatic DAVFs without RLVD
Patients with minimally symptomatic DAVF and without RLVD can be safely managed conservatively, given the benign natural history of these lesions. However, patients with disabling symptoms associated with high-flow DAVF in the absence of RLVD may benefit from treatment. In such instances, the goal is symptom resolution/improvement without the need to achieve immediate cure of the fistula. Polyvinyl alcohol particles with a size greater than 150 μm (to prevent passage through “dangerous”
Summary
Endovascular embolization has become the mainstay of treatment of most intracranial DAVF. Transarterial, transvenous, combined, or direct percutaneous approaches can be used based on the angioarchitecture, clinical presentation, location, and operator preference. With individualized treatment, effective obliteration can be achieved in most cases with an acceptably low complication rate. Tips and Pearls Interpretation of pretreatment angiogram Differentiate normal brain versus DAVF venous drainage
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Carotid-cavernous fistulas
Cited by (31)
Transvenous embolization of cerebral dural arteriovenous fistulas
2021, Cerebral Dural Arteriovenous FistulasDural Arteriovenous Fistula Complicated with Cerebral Venous Sinus Thrombosis
2020, World NeurosurgeryIntracranial Venous Hypertension Induced by Superior Vena Cava Syndrome Mimicking Cavernous Dural Arteriovenous Fistula
2018, World NeurosurgeryCitation Excerpt :Most of the intracranial venous hypertension is due to the abnormal outflow of the veins or increased intravenous inflow caused by the abnormalities of intracranial structures.1,2 Venous outflow disorder falls under stenosis or occlusion in draining veins, such as dural sinus stenosis or sinus thrombosis, while venous inflow increase falls under arteriovenous shunt, such as cerebral arteriovenous malformation or intracranial dural arteriovenous fistula (DAVF).1,2 In particular, in the case of cavernous sinus (CS)-DAVF, intracavernous sinus venous hypertension caused by arteriovenous fistula (AVF) around the CS causes venous reflux to the superior ophthalmic vein, which in turn causes eye symptoms such as pulsatile exophthalmos, chemosis, and ophthalmoplegia.2
First line direct access for transarterial embolization of a dural arteriovenous fistula: Case report and literature review
2018, Journal of Clinical NeuroscienceCitation Excerpt :Angiographic factors such as location, ease of endovascular access, feeding arteries and pattern of venous drainage are also important [2]. In the case of highly complex DAVF (Cognard type IIb and higher), combined microsurgical and endovascular methods are more commonly used [4]. DAVF involving the SSS are unusual and account for 8% of all dural fistulae [2].
Complications in endovascular management of carotid-cavernous and dural arteriovenous fistulas
2018, Complications in Neurosurgery
Disclosure: G. Lanzino is a consultant for Covidien, Codman/Johnson and Johnson.