Focus on the target: Angiographic features of the fistulous point and prognosis of transvenous embolization of cavernous sinus dural arteriovenous fistula

Abstract

<jats:sec><jats:title>Background and purpose</jats:title><jats:p> Transvenous embolization (TVE) is widely utilized as an effective and safe treatment option for cavernous sinus dural arteriovenous fistula (CS-dAVF); however, detecting the exact location of the fistula is challenging. The present study identified the angiographic features of the fistulous point and evaluated the match with the microcatheter tip and fistulous point. </jats:p></jats:sec><jats:sec><jats:title>Materials and methods</jats:title><jats:p> An analysis cohort of 45 consecutive patients with CS-dAVF treated by TVE was analyzed retrospectively. The patients were divided into two groups, 22 matches and 23 mismatches, according to whether the fistulous point and the microcatheter tip were in the same compartment of the cavernous sinus (CS). The angiographic findings, the location of the fistulas, the position of the microcatheter tips, the volume of embolic materials, complications, and outcomes were assessed. </jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p> Several angiographic features defined the fistulous points, such as the early opacified area, jellyfish-like sign, changes in the density of the contrast medium, the juncture of different arterial supply, enlarged feeders, and hand-injection angiograms. The fistulas were primarily in the posterosuperior portion of the CS (80%) and medial side (73.3%) according to the internal carotid artery. Both groups achieved effective TVE; the matched group required less embolic material than the mismatched group ( p = 0.024). The patients with cranial nerve dysfunction (CND) required more embolic materials than others ( p = 0.032). </jats:p></jats:sec><jats:sec><jats:title>Conclusion</jats:title><jats:p> The fistulous point in most of the CS-dAVFs could be isolated by careful analysis of the angiography images. The matching of the microcatheter tip and fistulous point in the same compartment of CS can reduce the dosage of embolic materials, and a low volume of embolic materials might cause fewer CND complications. </jats:p></jats:sec>

Endovascular treatment of the cavernous sinus dural arteriovenous fistula: current status and considerations

“…The SP is mainly situated at the posterior compartment of the CS and connects with the intercavernous sinus. It might have one or more of the following angiographic findings: a) an early opacified area in the early arterial phase of catheter angiography, b) a jellyfish-like sign denoting the branches of arterial supply converging at the fistula point, c) changes in the density of the contrast medium from dark in the artery to gray in the veins on the fistula point, d) enlarged and tortuous arterial feeders that can directly point to the fistula point [24,25].…”

“…Nevertheless, TVE has become the mainstream EVT for CS-DAVFs, of which the transfemoral IPS approach is the favorite, shortest, and most direct route to the CS [1,15]. In TVE, precise identification of the SP location is crucial because targeted dense embolization of the SP can reduce the amounts of embolic agents used and thus avoid complications [24,25,45].…”

“…In all CNPs, abducens nerve palsy is the most common after TVE and can occur immediately or delayed; usually, most CNPs recover within 6 months [41,91]. To avoid CNPs in TVE, the embolic material volume should be reduced, so superselective targeted occlusion of the SP is necessary [24,45].…”

Transvenous Onyx embolization of cavernous sinus dural arteriovenous fistula using a balloon catheter in the arterial side for flow control

“…To achieve complete occlusion of CS DAVFs, the CS needs to be densely packed with coils. Nishino et al [7] found that paradoxical worsening (the devel-opment of new or worsening symptoms or signs after embolization) occurred in 39.4% of patients after transvenous coil embolization, which was correlated with the volume of coils in the CS [8]. Paradoxical worsening may be attributed to progressive thrombosis of the CS, mass effects from the embolic materials, or direct injury to the nerve by the coils or the microwire/microcatheter [1,8].…”

Unique Indications for Covered Stent Grafts in Neuroradiology Departments of Level 1 Trauma Centers

“…The primary occlusion rates of 54 to 81% for transarterial and transvenous embolization are heterogeneous but seem to favor the transvenous approach. [26][27][28] A smaller retrospective analysis of occlusion rates of primary stent graft placement reports an occlusion rate of 83%, 23 but prospective comparisons of the different techniques are lacking. Review of current literature shows that up until recent times, multimodal and sometimes sequential approaches are still needed to treat some cases of CCFs.…”