BACKGROUND AND PURPOSE:Pursuing an alternative access route for transvenous embolization of cavernous sinus dural arteriovenous fistulas can be challenging in patients with an occluded inferior petrosal sinus. We found that cannulation of even a completely occluded inferior petrosal sinus is feasible, especially when using a standard hydrophilic-polymer-jacketed 0.035-inch guidewire as a frontier-wire for probing. MATERIALS AND METHODS:From 2002 to 2017, the frontier-wire technique was tried in 52 patients with occluded inferior petrosal sinuses for transvenous embolization of cavernous sinus dural arteriovenous fistulas at our center. Technical success was defined as access into the affected cavernous sinus compartment with a microcatheter through the occluded inferior petrosal sinus and deployment of at least 1 coil. The complications and treatment outcomes were analyzed. RESULTS:The frontier-wire technique was applied in 52 patients with 57 occluded inferior petrosal sinuses (52 ipsilateral and 5 contralateral inferior petrosal sinuses). Technical success rates were 80.8% (42/52) of patients and 73.7% (42/57) of inferior petrosal sinuses. Alternative transvenous routes were used in 3 patients, and transarterial access was used in 7 patients. Complete embolization of fistulas was achieved in 82.2% (37/45) of patients in the transvenous embolization group and in 14.3% (1/7) of patients in the transarterial group. No procedure-related morbidity or mortality was observed. CONCLUSIONS:Transvenous embolization of cavernous sinus dural arteriovenous fistulas, even through a completely occluded inferior petrosal sinus, is feasible. The difficulty of passing the microcatheter can be minimized by prior probing of the occluded inferior petrosal sinus using a standard 0.035-inch guidewire; the trace of the guidewire on the roadmap image serves as a guide for microcatheter navigation through the inferior petrosal sinus on fluoroscopy.ABBREVIATIONS: CS ϭ cavernous sinus; CSDAVF ϭ cavernous sinus dural arteriovenous fistula; IJV ϭ internal jugular vein; IPS ϭ inferior petrosal sinus; TVE ϭ transvenous embolization C avernous sinus dural arteriovenous fistula (CSDAVF) is de-

BACKGROUND AND PURPOSE: Spinal epidural arteriovenous fistulas are rare vascular malformations. We present 13 patients with spinal epidural arteriovenous fistulas, noting the various presenting symptom patterns, imaging findings related to bone involvement, and outcomes. MATERIALS AND METHODS:Among 111 patients with spinal vascular malformations in the institutional data base from 1993 to 2017, thirteen patients (11.7%) had spinal epidural arteriovenous fistulas. We evaluated presenting symptoms and imaging findings, including bone involvement and mode of treatment. To assess the treatment outcome, we compared initial and follow-up clinical status using the modified Aminoff and Logue Scale of Disability and the modified Rankin Scale. RESULTS:The presenting symptoms were lower back pain (n ϭ 2), radiculopathy (n ϭ 5), and myelopathy (n ϭ 7). There is overlap of symptoms in 1 patient (No. 11). Distribution of spinal epidural arteriovenous fistulas was cervical (n ϭ 3), thoracic (n ϭ 2), lumbar (n ϭ 6), and sacral (n ϭ 2). Intradural venous reflux was identified in 7 patients with congestive venous myelopathy. The fistulas were successfully treated in all patients who underwent treatment (endovascular embolization, n ϭ 10; operation, n ϭ 1) except 2 patients who refused treatment due to tolerable symptoms. Transarterial glue (n ϭ 7) was used in nonosseous types; and transvenous coils (n ϭ 3), in osseous type. After 19 months of median follow-up, the patients showed symptom improvement after treatment. CONCLUSIONS:Although presenting symptoms were diverse, myelopathy caused by intradural venous reflux was the main target of treatment. Endovascular treatment was considered via an arterial approach in nonosseous types and via a venous approach in osseous types.ABBREVIATIONS: ALS ϭ Aminoff and Logue Scale of Disability; SDAVF ϭ spinal dural arteriovenous fistula; SEDAVF ϭ spinal epidural arteriovenous fistula; TAE ϭ transarterial embolization; TVE ϭ transvenous embolization

Since the first use of the Guglielmi detachable coil system for cerebral aneurysm embolization in 1990, various endovascular methods have been developed to treat large numbers of aneurysms. The main strategic and technical modifications introduced to date include balloon-assisted coil embolization, stent-assisted coil embolization, flow diverters, and flow disrupters. The development and introduction of such devices have been so persistent and rapid that new devices are being approved worldwide even before the earlier ones become available in some countries. However, even if some patient populations may possibly benefit from earlier introduction of new devices, the approval authorities should balance the available evidence of the safety and effectiveness of novel devices. This review aims to provide an overview of the recent innovations in endovascular treatment of cerebral aneurysms and a brief review of market access policies and regulations for importing high-risk medical devices, such as those used for endovascular aneurysm management, which correspond to class III devices, as defined by the U.S. Food and Drug Administration. We focus on the current situation in Korea and compare it with that in other Asian countries, such as China and Japan.

Loop microcatheter technique allowed safe and stable coil packing for paraclinoid aneurysms. The same procedural concept is also being used for aneurysms in other vascular territories.

Identification of a symptomatic aneurysm should be associated with clinical presentation pattern. Targeted obliteration of the aneurysm by embolization and/or surgery resulted in improvement of symptoms and stabilization of SAVM.

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In selected patients with clinically unstable cerebral artery occlusions, a diffusion-perfusion mismatch and small CT lesions, subacute and acute recanalization has comparable safety and efficacy rates.