| Intracranial dural arteriovenous fistulas (DAVFs) account for 10%-15% of all intracranial arteriovenous malformations. DAVFs can occur in any part of the dura and its subsidiaries. The cavernous sinus is one of frequent occurred region. Cavernous sinus dural arteriovenous fistulas(csDAVFs) usually have many tiny feeding arteries which originate from internal carotid artery and/or external carotid artery, and often involve the bilateral cavernous sinus, so the surgical resection is difficult. The radiotherapy is not suitable as the first-line treatment options because the work time is too long and the curative effect is not definite. With the development of newer techniques and embolic materials in the world of interventional neuroradiology, endovascular therapy has now being developed to be the primary treatment strategy to cure csDAVFs. Ethylene-vinyl alcohol copolymer (Onyx) were emerged in recent years. It has the nature of better penetration ability, cohesive but non-adhesive and polymerization slow. All the qualities allow a prolonged injection as well as a higher control ability. In comparison to other embolic agents, Onyx has now being used more frequently for treatments of DAVFs. But the treatment of csDAVFs is not standard at present, even exist difficulty to some cases. Therefore, this article mainly foucs on how to effectively use the methods of the intravascular interventional treatment to cure csDAVFs in the context of the application of Onyx.The First ChapterEffectively use coils and Onyx to embolise cavernous sinus to treat cavernous sinus dural arteriovenous fistulasBACKGROUND AND OBJECTIVETransvenous embolization of cavernous sinus with Onyx or coils to treat csDAVFs has become the preferred treatment for the disease. But often the complications related to surgical operation are more, such as intracranial hemorrhage due to incomplete embolization of carvenous sinus, or the complication related to cranial nerves within the cavernous sinus were stimulated, even emergency of intraoperative bradycardia or asystole, et al. All these problems are should be pay attention to and solve in the treatment. This paper summaried our experiences through our clinical cases, introduced how can we effectively embolised cavernous sinus using Onyx and in combination with few coils to treat csDAVFs.METHODS AND MATERIALS1. Collection of clinical dataRetrospective analysis of the records of patients with csDAVFs who had received embolisation of cavernous sinus using Onyx or in combination with coils through inferior petrosal sinus at our department between August,2008 and February, 2013. Review of the full clinical records, angiograms, and procedure reports of patients. Ruling out the patients who suffered from other seriously diseases may affect patient’s life expectancy, the imformation were lost and had the treatment history of intracranial diseases. All patients were classificated according to Borden-Shucart and Barrow.2. TreatmentConventional cerebral angiography was performed under intravenous general anesthesia via the femoral artery for all patients. Heparin was injected to keep the activated clotting time of the patients between 200 and 300 seconds. Angiography included bilateral selective ICA and ECA angiography and vertebral artery angiography to identify all arterial supplies to the fistulae, the sites of the fistulae and venous drainage pattern. All patients were treated via the femoral vein-inferior petrosal sinus. A 6F Envoy guiding catheter (Cordis Corporation, Hialeah, FL) was positioned in the internal jugular vein. A microcatheter was navigated into the cavernous sinus via ipsilateral or contralateral IPS with the assist of microthread. A 5F diagnostic angiographic catheter was positioned in the external or internal carotid artery to delineate the target site under the road-mapping technique. First, we evaluated the characteristic haemodynamics, if there were retrograde filling of draining veins in arterial phase or capillary phase was present, platinum coils were deployed near the draining vein outlets and the tip of the microcatheter was wedged into the coil mesh before Onyx injection. Read-made 6% Onyx (18) was then slowly injected into CS in a controlled manner. If Onyx penetrate into the non target area, we held the injection for 20 s-2 min with an attempt to allow the Onyx polymerisation to change the direction of penetration, we also adjusted the position of the tip of the mircocatheter to assist Onyx to perform a better penetration. The aim was to allow Onyx successfully penetrate into all compartments of the cavernous sinus.3. Evaluation CriterionThe angiographic degrees of occlusion were defined as:(1) complete occlusion as no recongnizable arteriovenous shut; (2) nearly complete occlusion as a small residual stagnant shunt without cortical or ophthalmic venous drainage; (3) incomplete occlusion as only flow reduction with clear residual shunt. Complete and nearly complete occlusions were considered successful angiographic results. The clinical outcomes were defined as:(1) symptoms free; (2) improvement as the original symptoms improved significantly; (3) no improvement as no change or aggravation of symptoms; (4) recurrence was defined as newly developed symptoms related to the lesion during follow-up. Clinical cure was defined as symptoms free or improvement of the symptoms related to the lesion.4. Observation MethodContrast of preoperative angiogram images, postoperative angiogram images and follow-up angiogram images to determine the therapeutic effect of imaging. We observated clinical symptoms of discharge and follow-up and contrast them with clinical symptoms on admission to determine the therapeutic effect of clinical treatment.5. Statistcal MethodsThe data were used SPSS 19.0 statistical software to analyze. The average age, the average of Onyx, the average number and volum of coils were used mean to indicate, the average interval of follow-up were used median to indicate.RESULTSTwenty-five patients with complete data were collected. They included 11 males and 14 females with a mean age of 46.88±13.28 (range,16 to 70) years. Twenty-four patients had Barrow type D fistula and only one patient had Barrow type C fistula. Twenty patients had Borden type I DAVF, five patients had Borden tybe ⅡDAVF. Eleven cases involved the left side cavernous sinus, eight cases with the right side and six cases with both sides. All patients (100%,8/8) had conjunctival congestion,24 (96.0%,24/25) patients had proptosis,17 patients had chemosis. In all,25 sessions of embolization and catheterization procedures through the arterial routes were conducted. Among them,22 patients used coils and Onyx and the other 3 patients only used Onyx. The number of coils was 2-5 (mean 2.55±0.91), the coil volume ranged from 8.04 mm3 to 91.04 mm3 (mean 32.15±16.03 mm3), the mean volume of Onyx was 2.57±0.86ml. Twenty-two (88.0%) patients were completely occluded,3 (12.0%) patients were near completely occluded in the immediate angiography. The three patients who had achieved near complete occlusion were scheduled to have conventional cerebral angiography at 3 months, total angiographic obliteration was found. For the other 22 patients, cerebral angiography was scheduled at 6 months, no recurrence was found. Seven (28.0%) patients demonstrated asymptomatic condition and the other 18 patients (72.0%) demonstrated symstoms improvement at discharge time. The clinical follow-up interval was 6-49 months (median,10) in all 25 cases. Clinical symptoms gradually disappeared in the patients who achieved symstoms improvement at discharge time in 2 weeks to 3 months post-operation. All remained asymptomatic in subsequent follow-up periods.Six patients (24.0%) occurred with complications. One showed contralateral blurred vision, one diplopia worse, two transient bradycardia in the intraoperative period, one ipsilateral abducens nerve palsy, one ipsilateral blephar edema. All the complications were cured after proper treatment.CONCLUSIONEffective using Onyx and coils is the key to cure csDAVFs. Placing the position of the coils reasonably, effective using better penetration and controllability quality of Onyx, and avoiding excessive use of coils and Onyx, these are the useful ideas which would help to effectively cure csDAVFs and recduce the complication related to operation procedure.The Second ChapterTransarterial Onyx embolization for patients with cavernous sinus dural arteriovenous fistulas who have failed transvenous embolization BACKGROUND AND OBJECTIVETransvenous embolization is the preferred treatment for cavernous sinus dural arteriovenous fistulas (csDAVFs) despite occasional difficulty in transvenous catheterization. Currently, transvenous embolization of the cavernous sinus is the preferred choice. However, catheterization through the conventional route, such as the inferior petrosal sinus or superior ophthalmic vein, occasionally fails to reach the cavernous sinus. Surgical cannulation of the superior ophthalmic vein or percutaneous transorbital extraconic puncture of the cavernous sinus for catheterization has been proposed, but carries the risk of a number of complications, such as orbital hematoma or infection and damage to adjacent nerves. Approach via cortical veins such as the superficial temporal veins and superficial middle cerebral veins to catheterize the cavernous sinus has been attempted; however, exposure of these cortical veins entails craniotomy and complicated procedures.Transarterial embolization of csDAVFs with liquid embolic agents has a higher risk of embolization of dangerous anastomoses between the dural branches of the external carotid artery and the internal carotid artery, the vasa nervorum, ophthalmic artery, or vertebral artery. Onyx (ev3, Plymouth, MN, USA) has become the preferred embolysate due to its cohesive and non-adhesive nature that assists in controlled penetration of the fistula. Someone has tried to embolise the csDAVFs with Onyx via arterial approach. Pero et al. reported the treatment of csDAVFs by Onyx injection through the ascending pharyngeal artery in two patients. Gandhi et al. reported a case of a csDAVFs that was successfully treated with transarterial embolization with Onyx through the distal internal maxillary artery. Amiridze et al. also described a case of csDAVFs that was cured with Onyx embolized through middle meningeal artery and sphenopalatine artery. All of them lacked summary of treatment experience. In the current paper, we report our treatment experience and the outcome of Onyx embolization via the arterial route for eight patients with csDAVFs who failed transvenous embolization.METHODS AND MATERIALS1. Collection of clinical dataWe reviewed the full clinical records, angiograms, and procedure reports of patients with csDAVFs who had failed transvenous Onyx embolization and received transarterial Onyx embolization instead at our department between November,2010 and June,2013. Ruling out other patients who suffered from other seriously diseases my affect patient’s life expectancy, the imformation were lost and had the treatment history of intracranial diseases. All patients were classficated according to Borden-Shucart and Barrow.2. TreatmentConventional cerebral angiography was performed under intravenous general anesthesia via the femoral artery for all patients. Heparin was injected to keep the activated clotting time of the patients between 200 and 300 seconds. Angiography included bilateral selective ICA and ECA angiography and vertebral artery angiography to identify all arterial supplies to the fistulae. Fistulous site and arterial feeders, venous drainage patterns, collateral flows and dangerous vascular anastomosis were then evaluated. All patients are preferred to try to embolise the cavernous sinus via venous approach. If failed, we take arterial route as the embolization approach. A 6F Envoy guiding catheter was position in the external carotid artery. The contralateral femoral artery was catheterized for control angiography. A microcatheter was navigated over a micro guidewire to reach the distal aspect of the arterial pedicle that fed the fistula. Super-selective angiography was then performed to confirm optimal wedging of the microcatheter and to identify the normal arterial branches and dangerous anastomoses. Onyx was slowly injected using the "reflux-hold-reinjection" technique under the real-time roadmap. When reflux was observed to flow into the non-targeted area, the infusion was held for 20 seconds to 2 mins to allow the Onyx to precipitate and form a plug around the catheter. Reinjection was carried out slowly to make Onyx penetrate into all fistulous as much as possible withous embolisation of dangerous anastomoses and important vessels.3. Evaluation CriterionThe angiographic degrees of occlusion were defined as:(1) complete occlusion as no recongnizable arteriovenous shut; (2) nearly complete occlusion as a small residual stagnant shunt without cortical or ophthalmic venous drainage; (3) incomplete occlusion as only flow reduction with clear residual shunt. Complete and nearly complete occlusions were considered successful angiographic results. The clinical outcomes were defined as:(1) symptoms free; (2) improvement as the original symptoms improved significantly; (3) no improvement as no change or aggravation of symptoms; (4) recurrence was defined as newly developed symptoms related to the lesion during follow-up. Clinical cure was defined as symptoms free or improvement of the symptoms related to the lesion.4. Observation MethodContrast of preoperative angiogram images, postoperative angiogram images and follow-up angiogram images to determine the therapeutic effect of imaging. We observated clinical symptoms of discharge and follow-up and contrast them with clinical symptom on admission to determine the therapeutic effect of clinical treatment.5. Statistcal MethodsThe data were used SPSS 19.0 statistical software to analyze. The average age, the average hospitalization days were used mean to indicate, the average interval of follow-up was used median to indicate.RESULTSEight (17.8%,8/45) cases failed transvenous Onyx embolization and received transarterial Onyx embolization instead. They included 4 males and 4 females with a mean age of 37.88±10.64 (range,26 to 57) years.Transvenous embolization was abandoned because the microcatheter failed to reach the cavernous sinus in seven patients and because the internal jugular vein below the jugular bulb was occlusive in another patient. None had received prior medical therapy before the failed transvenous embolization. All patients (100%) had conjunctival congestion and five (62.5%,) patients had proptosis and chemosis.In all, eight sessions of embolization and catheterization procedures through the arterial routes were conducted; five via the middle meningeal artery and three via the accessory meningeal artery. Angiography taken immediately after embolization revealed that seven (87.5%,7/8) patients achieved total occlusion, and one (12.5%, 1/8) patient had partial occlusion. All patients were discharged at three to eight (mean, 5.5±1.6) days after the embolization. The patients were followed up by angiography for a median duration of 6.0 (range,6 to 10) months. All patients achieved complete embolization at the final follow-up.Complications related to transarterial embolization procedures occurred in two (25%,2/8) patients, including left ipsilateral facial numbness in one case and right abducens paralysis and chemosis which were contralateral to the embolic approach in the other patient. Both complications were curedCONCLUSIONIn cases where transvenous embolization of the cavernous sinus is difficult, transarterial embolization of the fistulas offers a safe and effective alternative. The middle meningeal artery and the accessory meningeal artery can provide good transarterial routes for embolization of csDAVFs. |
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