Treatment of a Superior Sagittal Sinus Dural Arteriovenous Fistula with Onyx: Technical Case Report

Abstract

OBJECTIVE: The endovascular treatment of a complex superior sagittal sinus dural arteriovenous fistula with ethylene vinyl alcohol copolymer (Onyx) in one session is described. CLINICAL PRESENTATION: A 54-year-old man presented with dizziness and a bruit. A cerebral angiogram demonstrated a superior sagittal sinus dural arteriovenous fistula with a patent superior sagittal sinus that was supplied via multiple branches of the external carotid arteries bilaterally and the left anterior and middle cerebral arteries. Drainage was mainly through the superior sagittal sinus and, only in part, retrogradely through the cortical veins. A decision was made to proceed with endovascular treatment followed by surgery. INTERVENTION: Transarterial injection of one pedicle of middle meningeal artery on both sides with Onyx resulted in complete obliteration of the dural supply and some of the pial supply to the malformation without complications. The superior sagittal sinus remained patent. Based on this result, surgical treatment was cancelled. The residual pial supply had disappeared by the 10-month angiographic follow-up examination and the patient remained neurologically intact and without symptoms. CONCLUSION: Definitive treatment may be attained with Onyx in dural arteriovenous fistulas. The potential of Onyx for use as a permanent embolic agent in dural arteriovenous fistulae needs to be investigated.

Transarterial Treatment with Onyx of Intracranial Dural Arteriovenous Fistula with Cortical Drainage in 17 Patients

“…8 The use of polyvinyl alcohol particles promotes proximal occlusion only, but permanent obliteration of the fistula is rare. To have an effect from n-BCA, extensive experience in both its preparation and delivery is required.…”

Complications Related to Percutaneous Transarterial Embolization of Intracranial Dural Arteriovenous Fistulas in 40 Patients

“…This long reflux may create sufficient proximal flow arrests to enable better distal penetration. 4,13,14,17,37,38 Consequently, when used in DAVFs, it may be more realistic to consider Onyx as a potential permanent embolic agent rather than expecting it to be surgically removed. In smaller arteriovenous fistulas, cure can be potentially attained with Onyx injection only.…”

“…[1][2][3] Endovascular techniques allow both arterial and venous access to the site of the fistulous connection. [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18] DAVFs with leptomeningeal venous drainage or an associated venous varix are defined as high risk and are associated with a dismal natural history. 2,[19][20][21][22][23][24] High-risk fistulas typically present with hemorrhage or progressive neurologic deficits.…”

“…Transarterial Onyx (ev3, Irvine, Calif) embolization is now an established method of treatment of DAVFs. 4,13,14,17,37,38 Onyx can often penetrate to the point of fistulization with distal ligation of multiple feeders. However, potential complications are associated with this procedure, and there is a lack of detailed information on such complications in the literature.…”

Arterial Onyx Embolisation of Intracranial DAVFs with Cortical Venous Drainage

“…Recently, ethylene vinyl alcohol (Onyx) has been used to treat high-grade fistulas with some success [10][11][12][13][14] . We report our single centre experience with arterial Onyx embolisation for the treatment of DAVFs with direct cortical venous drainage.…”