Transvenous Embolization of Dural Carotid Cavernous Fistula through the Supraorbital Vein

We describe a case of transvenous embolization through the dilated supraorbital vein to treat a dural carotid cavernous fistula. The approach through the common facial vein or direct access of the superior ophthalmic vein is a commonly used route to the superior ophthalmic vein when the approach via the inferior petrosal sinus is unavailable. In rare cases, the dilated supraorbital vein provides an alternative route and we discuss the technical details.

Endovascular Treatment of Bilateral Cavernous Sinus Dural Arteriovenous Fistula: Therapeutic Strategy and Follow-Up Outcomes

OBJECTIVE: Bilateral cavernous sinus dural arteriovenous fistula (CSdAVF) is very rare, even in Asian countries. The research intended to present clinical and radiologic outcomes of treating such fistulas through endovascular embolization. MATERIALS AND METHODS: Data was obtained from 220 consecutive patients, with CSdAVF, who were treated from January 2004 to December 2015. Bilateral CSdAVF was identified in 17 patients (7.7%). The clinical and radiologic outcomes of the fistulas were assessed with an emphasis on the technical aspects of treatment. RESULTS: At the time of treatment, 7 and 10 patients presented with bilateral and unilateral symptoms, respectively. In the former cases, 4 patients had progressed from unilateral to bilateral symptoms. Bilateral fistulas were treated with a single-stage transvenous embolization (TVE) in 15 patients, via bilateral inferior petrosal sinuses (IPS) (n = 9) and unilateral IPS (n = 6). In the other 2 patients with one-sided dominance of shunting, only dominant fistula was treated. Two untreated lesions were found on follow-up to have spontaneously resolved after treatment of the dominant contralateral fistula. Of the 34 CSdAVF lesions, complete occlusion was achieved in 32 lesions after TVE. Seven patients (41.2%) developed worsening of cranial nerve palsy after TVE. During the follow-up period, 4 patients obtained complete recovery, whereas the other 3 remained with deficits. CONCLUSION: With adjustments of endovascular procedures to accommodate distinct anatomical configurations, endovascular treatment for bilateral CSdAVF can achieve excellent angiographic occlusion results. However, aggravation of symptoms after TVE may occur frequently in bilateral CSdAVF. In the patients with one-sided dominance of shunt, treatment of only dominant fistula might be an alternative option.

Transvenous Coil Embolization for Dural Arteriovenous Fistulas of the Ophthalmic Sheath: Report of Two Cases and Review of the Literature

We present two patients with a dural arteriovenous fistula (dAVF) of the ophthalmic sheath who developed progressive exophthalmos, conjunctival chemosis, and visual loss. These symptoms mimic those of cavernous sinus dAVFs. Dural AVFs of the ophthalmic sheath are extremely rare and their clinical management is controversial. We successfully treated these two patients by transvenous coil embolization. Transvenous embolization appears to be a safe and effective method to treat dAVFs of the ophthalmic sheath.

Spontaneous Carotid-Cavernous Fistula in the Type IV Ehlers-Danlos Syndrome

Ehlers-Danlos syndrome (EDS) is a rare inherited connective disease. Among several subgroups, type IV EDS is frequently associated with spontaneous catastrophic bleeding from a vascular fragility. We report on a case of carotid-cavernous fistula (CCF) in a patient with type IV EDS. A 46-year-old female presented with an ophthalmoplegia and chemosis in the right eye. Subsequently, seizure and cerebral infarction with micro-bleeds occurred. CCF was completely occluded with transvenous coil embolization without complications. Thereafter, the patient was completely recovered. Transvenous coil embolization can be a good treatment of choice for spontaneous CCF with type IV EDS. However, every caution should be kept during invasive procedure.

Spontaneous Carotid Cavernous Fistula in a Case with Protein S Deficiency that Newly Developed Ophthalmoplegia after Embolization

BACKGROUND: Carotid cavernous fistula (CCF) is an abnormal communication between the carotid artery and the cavernous sinus. The pathogenesis of spontaneous CCF remains unclear, although sinus thrombosis is known to be a predisposing factor for dural arteriovenous fistula. Because spontaneous CCFs are mainly of the dural type, we considered that thrombogenic conditions, such as, protein S deficiency might be associated with CCF. CASE REPORT: A 42-year-old woman complained of conjunctival injection and retro-orbital pain that first appeared 1-month before visiting our hospital. She had no history of head trauma or intracranial surgery. Exophthalmos and chemosis were observed in her left eye, which also had lower visual acuity and higher intraocular pressure than the right eye. Magnetic resonance images and cerebral angiography revealed a left dural CCF. Her protein S was low, at 41% (normal range: 70-140%), but other hematologic values related to coagulation were normal. Her symptoms were relieved after initial transvenous coil embolization. However, a newly developed sixth-nerve palsy was detected 4 days after initial embolization. Follow-up angiography revealed a minimal shunt, and thus transvenous coil embolization was repeated. Two days later, the ophthalmoplegia started reducing, and 1-month later it had almost disappeared. CONCLUSIONS: To the best of our knowledge, this is the first report of spontaneous dural CCF in a Korean patient with concurrent protein S deficiency. Interestingly, transient sixth-nerve palsy developed after transvenous coil embolization in this patient. This additional symptom caused by the residual fistula was relieved after additional transarterial embolization.

Vein of Galen Aneurysmal Malformation : Endovascular Management of 6 Cases in a Single Institute

OBJECTIVE: The aim of this study was to analyze the treatment outcome of patients with vein of Galen aneurysmal malformations (VGM). METHODS: Clinical and angiographic data of six consecutive patients with VGM were retrospectively reviewed. VGMs were angiographically classified by Yasargil's method. Treatment outcomes were evaluated. RESULTS: Mean age at initial treatment was 4.4+/-5.7 months. Angiographic types of VGMs were type II in two patients and type III in four. Three patients had cardiac symptoms and the others were asymptomatic. Two patients were treated with transvenous embolization, three with transarterial embolization, and one was managed conservatively. Two patients died due to venous hypertension few days after transvenous approach. Of three patients who were transarterially embolized, one was completely occluded with Onyx and two were incompletely occluded. During the follow-up period (range, one to six years) two of three patients treated with transarterial approach were asymptomatic and the other showed mild symptoms. One patient who was managed conservatively showed normal performance. CONCLUSION: Transarterial embolization of VGMs may be better than transvenous approach in terms of the treatment outcome and complication. Further studies are needed because of the rarity of the disease and rapid advancement of endovascular techniques.

Treatment Strategy Based on Multimodal Management Outcome of Cavernous Sinus Dural Arteriovenous Fistula (CSDAVF) / 신경중재치료의학

PURPOSE: Angiographic finding including venous drainage pattern should be correlated to the presenting symptom pattern (SxP) in CSDAVF. We present outcome of CSDAVF management and suggest a strategy according to SxP and type of treatment based on our experience. MATERIALS AND METHODS: We evaluated SxP, angiographic type (proliferative, restrictive or late restrictive), mode of treatment (embolization, Gamma Knife Radiation (GKR) or conservative management), mode of embolization (transarterial or transvenous), and final clinical status (cure, improvement, aggravation or no change). Ninety consecutive patients were included from a prospective database. The mean follow-up was 17 months. We compared the outcomes according to SxP, angiographic type, mode of treatment, and embolization using the chi-square or Fisher's exact test. RESULTS: Ninety patients with 34 proliferative, 40 restrictive, and 16 late restrictive types of CSDAVF were treated by embolization (n = 63), GKR (n = 7), and conservative management (n = 20). Cure or improvement was 91% after embolization, 88% after conservative management, and 72% after GKR. Following embolization, 100% of 24 proliferative types, 87% of 30 restrictive types, and 90% of 10 late restrictive types were cured or improved. Cure or improvement after transvenous embolization was 98% (43/44) compared with 88% (15/17) after transarterial embolization (p = 0.003). CONCLUSION: Various factors of SxP, angiographic type, and mode of treatment should be considered in order to obtain a more favorable outcome for patients with CSDAVF. Embolization via venous approach tended to result in a more complete cure than that via arterial approach.