Arterial Onyx Embolisation of Intracranial DAVFs with Cortical Venous Drainage

Abstract

Intracranial dural arteriovenous fistulas (DAVFs) are lesions with a heterogeneous clinical course, related to the varying patterns of venous drainage. Dural arteriovenous fistulas without cortical venous involvement tend to be relatively benign in course, while lesions with cortical venous drainage (whether direct or via reflux from dural venous sinuses) are more aggressive, having a higher rate of clinical presentation with aggressive neurological symptoms and intracranial haemorr-ABSTRACT: Purpose: To present our experience with the endovascular management of intracranial dural arteriovenous fistulas with direct cortical venous drainage by trans-arterial embolisation using Onyx. Materials & Methods: Between January 2004 and April 2008, 12 consecutive high grade intracranial dural arteriovenous fistulas (Cognard type III (eight patients) or IV (three patients)) were treated by trans-arterial embolisation with Onyx. The majority of cases were treated by Onyx embolisation alone. One case had additional embolisation with n-butyl-2-cyanoacrylate at the same session. Imaging follow-up was obtained in all but one patient (mean 3.6 months). Results: Nine patients had a technical success at the end of the embolisation procedure with complete angiographic exclusion of the fistula. Two patients had a small residual fistula at the end of embolisation, one of which had residual mild cortical venous drainage. Both were stable at follow-up angiography. One patient had a residual fistula supplied by the ophthalmic artery, which was thought to be unsafe to embolise and was sent for surgery, which was curative. In one patient the microcatheter ruptured, with a fragment of the distal microcatheter left in the occipital artery. No clinical complications were observed in this series at clinical follow-up (mean 3.3 months). Two patients were noted to have significant radiation dose. Conclusion: Endovascular management of intracranial dural arteriovenous fistulas with direct venous cortical drainage by trans-arterial Onyx embolisation is a safe and effective treatment according to our experience. Fluoroscopy times and radiation dose may be a concern. Chez un patient une embolisation additionnelle de n-butyl-2-cyanoacrylate (nBCA) a été effectuée au cours de la même session. Une imagerie a été obtenue chez tous les patients sauf un au cours du suivi (moyenne de 3,6 mois). Résultats : Nous avons obtenu un succès technique chez neuf patients à la fin de l'embolisation, avec exclusion angiographique complète de la fistule. Deux patients avaient une petite fistule résiduelle à la fin de l'embolisation, dont un présentait un léger drainage veineux cortical résiduel. Ces deux patients étaient stables à l'angiographie de suivi. Un patient avait une fistule résiduelle nourrie par l'artère ophtalmique dont l'embolisation a été jugée trop risquée. Il a été référé en chirurgie et l'intervention a été un succès. Chez un patient, le microcathéter s'est rompu et un fragment distal du microcathéter s'est logé dans l'artère occipitale. Il a été lai...

Curative Embolization with Onyx of Dural Arteriovenous Fistulas with Cortical Venous Drainage

“…In selected cases, a microballoon proximal to the tip of the Onyx microcatheter can help in this injection process by preventing reflux and stimulating advancement of the Onyx. 18 In our experience, confirmed by others, 15,17 the middle meningeal artery is the most suitable for Onyx injection; it is often involved in dural fistulas and can be readily catheterized to a distal position, and long segments of reflux can be accepted because microcatheter removal proved to be easy in such cases. Whenever this artery contributes to the fistula, we try to use it for embolization.…”

“…Recently, the use of Onyx (ev3, Irvine, California) via the arterial route has been reported with promising results. [14][15][16][17][18] We report our initial experience with arterial injection of Onyx in the endovascular treatment of dural fistulas with drainage exclusively into the cortical veins.…”

Endovascular embolization with Onyx in the management of sinus pericranii: a case report

“…3 Since its approval by the US Food and Drug Administration, the liquid embolic agent Onyx (ethylenevinyl alcohol copolymer) has been used in the endovascular treatment of intracranial arteriovenous malformations, arteriovenous fistulas, and other venous malformations with excellent results. 5,8,16 We decided to combine the use of coils and Onyx to obtain a fast obliteration of the diploic vein, minimizing the number of coils used.…”

Transarterial onyx embolization of intracranial dural arteriovenous fistulas in adult patients

“…Currently, several series have established a high degree of safety and efficacy of ONYX used intra-arterially and intra-venously in the treatment of intracranial DAVFs (1,6,9,29,31,32,40). The complete obliteration rate in arterial ONYX embolization was 61.3%-91.6% (22, [31][32][33]40) and that in venous ONYX embolization was 100% (21,23).…”