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Case #2, Patient #17. (a) Left internal carotid artery (ICA) angiogram (lateral view) demonstrating a superior petrosal sinus dural arteriovenous fistula (SPS DAVF) with prominent supply from the tentorial branch of the meningohypophyseal trunk with drainage through the petrosal vein, lateral mesencephalic vein, basal vein of Rosenthal, and vein of Galen. (b) Left external carotid artery angiogram (lateral view) showing middle meningeal artery supply to the SPS DAVF. (c) Intraoperative photograph illustrating a variceal petrosal vein draining the SPS DAVF. (d) Indocyanine green intraoperative angiography showing early filling of the draining veins, confirming rapid arteriovenous shunting. (e) Immediate postoperative left common carotid artery (CCA) angiography (lateral view) and (f) delayed left CCA angiography (unsubtracted, lateral view) demonstrating durable closure of the SPS DAVF following clip occlusion.
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Background
While technological advances have improved the efficacy of endovascular techniques for tentorial dural arteriovenous fistulae (DAVF), superior petrosal sinus (SPS) DAVF with dominant internal carotid artery (ICA) supply frequently require surgical intervention to achieve a definitive cure.
Methods
To compare the angiographic and clinica...
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The superior ophthalmic vein (SOV) approach through the facial vein is usually preferred for transvenous embolization of a cavernous sinus dural arteriovenous fistula (CS DAVF) when the ipsilateral inferior petrosal sinus is angiographically occluded. However, navigating the microcatheter can sometimes be difficult because of stenosis or tortuous a...
Besides cavernous sinus (CS) dural arteriovenous fistulas (AVFs), AVF may develop around the parasellar region. They can cause various symptoms, and some of them may show similar symptoms to those of CS dural AVF. Therefore, these AVFs may be misdiagnosed as CS dural AVFs. In this review, we divided parasellar AVFs into four groups based on their l...
Citations
... From the literature review, there were 33 patients, including our 2 patients, with 34 DAVFs involving SPS and/or SPV due to bilateral lesions in 1 case (Table 1). [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20] Eighteen (54.5%) males and 15 (45.5%) females with mean age was 55.1 ± 12.9 years, range 25-85 years, were included in this review. The patients presented with hemorrhage in 12 (36.4%) ...
... However, the risk of infarction in cranial nerves and recurrent or recanalization of the fistulas may occur following transarterial embolization with any liquid embolic materials. 4,7,15 Surgery may be an effective treatment for DAVFs involving the SPS and/or SPV in many studies. 1,3,[7][8][9]14,15,19,20 These fistulas can be treated by microsurgical interruption of the pathological dilated arterialized petrosal vein with preservation of other normal functional tributaries veins using indocyanine green video angiography. ...
... 4,7,15 Surgery may be an effective treatment for DAVFs involving the SPS and/or SPV in many studies. 1,3,[7][8][9]14,15,19,20 These fistulas can be treated by microsurgical interruption of the pathological dilated arterialized petrosal vein with preservation of other normal functional tributaries veins using indocyanine green video angiography. 1,14,18,19 Due to the rarity of these fistulas, the preferable approach between microsurgical and endovascular treatment remains unclear. ...
Background
Dural arteriovenous fistulas (DAVFs) involving superior petrosal sinus (SPS) and superior petrosal vein (SPV) are extremely rare. The pathogenesis of these fistulas remains unclear. We are illustrating 2 cases of DAVFs involving the superior petrosal sinus and veins associated with venous sinus thrombosis with a literature review.
Methods
We reviewed the literature using the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines focusing on DAVFs involving the SPS and/or SPV. Additionally, we searched for additional articles through the reference lists of the included studies.
Results
Our review yielded 20 articles from 1997 until 2022 involving 33 patients with 34 fistulas, including our 2 patients. The mean age was 55.1 ± 12.9 years (range 25–85), 54.5% were males (n = 18). The patients presented with hemorrhage in 36.4% (n = 12), and progressive myelopathy in 30.3% (n = 10). Most fistulas often had arterial supply from MMA, MHT, and/or OA. The fistulas had infratentorial drainage in 64.71% (n = 22), supratentorial drainage in 23.53% (n = 8), and both supra and infratentorial drainage in 11.76% (n = 4). In 27.3% (n = 9), cerebral venous thrombosis was mentioned or identified. Endovascular treatment was performed in 47.1% of cases (n = 16), surgery in 29.4% (n = 10), and combination of treatments in 23.5% (n = 8). A total of 30.3% (n = 10) of cases had incomplete recovery or poor result.
Conclusion
DAVFs involving the SPS and/or SPV are associated with aggressive natural history, requiring early diagnosis and prompt treatment, leading to good prognosis. These fistulas may be acquired in origin, probably secondary to cerebral venous thrombosis.
... Although symptomatic or high-risk dAVFs are most commonly endovascularly embolized in the modern era, complete endovascular obliteration of dAVFs involving the SPS is challenging because of the high density of surrounding critical neurovasculature [9]. In such cases, open surgery remains an excellent option for definitive management. ...
Dural arteriovenous fistulas (dAVFs) at the superior petrosal sinus are a rare but important subtype that pose a high risk of mortality and morbidity. Treatment for these lesions can be challenging with stand-alone endovascular methods.
We describe our “in-out-in” technique for disconnecting dAVFs at the superior petrosal sinus, which includes definitive sacrifice of the superior petrosal sinus and the transverse sigmoid sinus, if involved. This method achieves complete fistula obliteration and minimizes recurrence risk with new arterial feeders.
The in-out-in technique is a safe and effective approach for the treatment of dAVFs involving the superior petrosal sinus.
... D ural arteriovenous fistulas (DAVFs) constitute 10%e15% of all intracranial vascular malformations. 1 Deep-seated DAVFs involving the tentorium are less common but pose the risk of more aggressive neurologic deficits and intracranial hemorrhage. 2 Superior petrosal sinus (SPS) DAVFs are a common subtype of tentorial DAVFs (Lawton tentorial DAVF type 5) that are often supplied by the tiny and tortuous tentorial branches of the meningohypophyseal trunk (MHT) or middle meningeal artery (MMA) with venous drainage into the superior petrosal vein (SPV) and adjacent venous system. 3,4 Consequently, it is difficult and unsafe to achieve curative embolization, and microsurgery is an effective and straightforward solution. [4][5][6] Our initial experiences with DAVFs have been previously reported. ...
... 4,15 Usually the feeders of these deeply located DAVFs are branches of the MHT or MMA, and these are difficult to treat with transarterial embolization. 3,4 Even if the embolic agent can reach or occlude the drainage vein of the DAVF, endovascular 16 For example, the results found in patient 1 of the present series show that the incomplete occlusion of the drainage vein by embolization also carries a risk of bleeding, especially in patients with venous ectasia. SPS DAVFs are located at the SPS dura mater of the petrotentorial junction, making the retrosigmoid approach an ideal route for exposure. ...
Background: Superior petrosal sinus dural arteriovenous fistulas (SPS-DAVFs) are a common subtype of tentorial DAVFs that often require microsurgical treatment. In our experience, we have noted a rare condition involving the presence of a coexisting normal superior petrosal
vein (SPV) during surgery for SPS-DAVFs; this condition has not been reported in the literature. The identification and preservation of coexisting normal veins are crucial to prevent venous complications.
Methods: We reviewed the data of 12 patients with SPS-DAVFs who underwent microsurgical treatment. Intraoperative indocyanine green video angiography (ICG-VA) was used to confirm the location of the fistula and identify the normal SPV. Postoperative radiological examination was performed, and the clinical outcome was evaluated with the modified Rankin Scale (mRS).
Results: A coexisting normal functional SPV was found in 6 cases. Analysis of the tributaries of SPV showed the vein of the cerebellopontine fissure was the most frequent arterialized drainage vein (66.7%), while the pontotrigeminal vein was the most frequent normal drainage vein (45.5%). The DAVFs were easily identified and disrupted using intraoperative ICG-VA. The normal SPV was also successfully preserved. All 6 patients experienced good clinical and radiological outcomes.
Conclusion: An SPS-DAVF can coexist with a normal functional SPV, which should be preserved. The ICG-VA technique is an efficient way to identify the normal SPV.
... 26,27) The most distinctive characteristics of SPS dural AVFs are a predominant ICA supply from the tentorial artery of the MHT and venous drainage into the petrosal vein. 25,26,28,29) Li et al. 26) reported the largest series (64 patients) of this location. Their analyses revealed that the dural branches (tentorial artery) of the MHT (98.4%) and MMA (84.4%) were the two most common feeders, whereas the dural branches of the internal maxillary artery (26.6%), ophthalmic artery (26.6%), occipital artery (20.3%), and ascending pharyngeal artery (10.9%) were relatively infrequent. ...
Besides cavernous sinus (CS) dural arteriovenous fistulas (AVFs), AVF may develop around the parasellar region. They can cause various symptoms, and some of them may show similar symptoms to those of CS dural AVF. Therefore, these AVFs may be misdiagnosed as CS dural AVFs. In this review, we divided parasellar AVFs into four groups based on their locations related to the CS: anterior group (orbit), anterolateral group (sphenoid wing), posteroinferior group (inferior petrosal sinus and clivus), and posterior group (superior petrosal sinus and petrosal vein). Although parasellar AVFs share common points, there are many differences between the four groups. We herein discuss commonalities and differences in parasellar AVFs based on a review of the literature and our experience.
Objective
Dural arteriovenous fistula involving the superior petrosal vein (SPV DAVF) is an extremely rare condition. Therefore, its clinical presentation, imaging characteristics, treatment methods, and risk factors remain unclear. In this study, we discuss and analyze the above-mentioned features of SPV DAVF.
Methods
We retrospectively reviewed 30 patients with SPV DAVF, with a 1-year follow-up rate of 96.67% (29/30). The neurological function of the patients was assessed using the modified Aminoff-Logue scale (mALS) and the modified Rankin Scale score (mRS). The risk factors before and after treatment were established using univariate and multivariate logistic regression analyses. Additionally, treatments involving three distinct SPV DAVF drainage patterns were presented.
Results
Of the 30 patients, 24 were male (80.0%). Besides, the angiography images were re-examined 12 months after surgery. Univariate analyses indicated that the extent of edema (OR 1.889, 95% Cl 1.132-3.154) and the number of draining veins (≤ 2) (OR 10.833, 95% Cl 1.961-59.834) were risk factors for pretreatment mRS ≥ 3. However, multivariate analyses revealed no statistically significant differences (P = 0.051, P = 0.055). Following the multivariate analyses, steroid pulse (OR 12.153 95% Cl 1.080-136.772) was found to be the only significant risk factor for post-treatment ΔmRS ≥ 2.
Conclusions
DAVF with SPV drainage is an uncommon type of intracranial vascular malformation. Most lesions involve the brain stem or high cervical spinal cord, thereby posing a higher risk of disability or death. Moreover, neuronal damage from persistent venous hypertension is permanent. Therefore, precise diagnosis and timely treatment are key to a good patient prognosis.
Objective: Superior petrosal sinus dural arteriovenous fistula (SPS-DAVF) is a rare subtype of intracranial DAVF that sometimes leads to hemorrhagic symptoms following deep venous drainage. Here we report the case of SPS-DAVF with retrograde venous reflux to the cerebellar vein. Preoperative contrast-enhanced MRI was a decisive factor in a safe and effective treatment.
Case presentation: A 37-year-old woman was referred to our hospital with abnormal MRI findings, which was performed when she had a mild headache during her check-up. DSA revealed left-sided SPS-DAVF, which was diagnosed as Cognard type IIb. Both CTA and DSA could not detect the whole SPS but only the shunt pouch. Using contrast-enhanced MRI, we were able to visualize the presence of the SPS and its continuity within the shunt pouch. 3D-T1 turbo spin echo (SPACE) showed a low-intensity area in the SPS, which was not seen in the 3D-T1 fast field echo (FFE). During the procedure, there was a point where it was difficult to advance the microcatheter, which coincided with the low-intensity area. We achieved effective transvenous embolization from the occluded venous access by devising a surgical technique.
Conclusion: In addition to the contrast-enhanced 3D-T1 FFE, 3D-T1 SPACE might provide beneficial information for endovascular therapy in the evaluation of venous sinuses, which could not be detected by standard examinations.
BACKGROUND
Intracranial dural arteriovenous fistulae (dAVFs) with cortical venous drainage (CVD) require treatment because of their aggressive clinical presentation and natural history. Although endovascular treatment is effective for the majority of these lesions in the current endovascular era, surgical management has been required if the lesions are not amenable to or fail endovascular treatments.
OBJECTIVE
To demonstrate the angioarchitecture that may necessitate surgical intervention.
METHODS
A retrospective review of the patients with intracranial dAVFs with CVD treated at 2 academic institutions between January 1, 2009, and July 31, 2019 was performed. Patients who required surgical intervention were selected in this study, and angiographic findings were analyzed.
RESULTS
A total of 81 dAVFs in 80 patients were treated during the study period. Endovascular treatments were attempted for 72 (88.9%) dAVFs, resulting in complete obliteration in 55 (76.4%). Surgical interventions were performed in 18 (22.2%) dAVFs, resulting in complete obliteration in all lesions. Overall, complete obliteration was achieved in 74 (93.7%) of 79 dAVFs with follow-up. In the surgically treated dAVFs, curative transarterial embolization was deterred by the angioarchitecture, which included dominant feeding vessels from the ophthalmic artery, meningohypophyseal trunk, posterior meningeal artery, pial artery, or ascending pharyngeal artery. Drainage through tortuous cortical vein, deep venous system, or isolated sinus made transvenous approach challenging.
CONCLUSION
Despite continued improvement in endovascular technology, surgical approaches to dAVFs are still of great value as initial and salvage treatment of dAVFs with angioarchitecture hampering endovascular treatment.
Background:
An integrated multimodality approach can be effective in treatment of high-grade dural arteriovenous fistulas. Nevertheless, this requires a high level of efficient cooperation between different departments, underlying a degree of bias in the decisional process. In comparison, hybrid capability, integrating these modalities in one hand, may allow aggregating multimodality treatment strategies by pooling their individual benefits, leading to a more holistic view of the consequences of each modality.
Methods:
We retrospectively reviewed 18 cases of dural arteriovenous fistulas subjected to a hybrid treatment approach at the Diakonieklinikum Jung-Stilling, Siegen, Germany, between March 2008 and January 2017. Nine cases were excluded. We selected 4 cases that highlight different aspects of hybrid capability for illustrative purposes.
Results:
Hybrid capability allows treatment of a dural arteriovenous fistula based on the individual clinical situation of the patient and features of the lesion, free of interdepartmental bias. The surgeon maintains a level of flexibility that enables him or her to move from a minimally invasive endovascular approach to a maximally invasive surgical access according to the specific situation. Hybrid capability can lead to a highly efficient treatment regimen with palliation of symptoms and complete obliteration of the fistula, improving performance in these complex pathologies.
Conclusions:
Hybrid capability has great potential in the treatment of complex neurovascular lesions. It remains to be seen if a single surgeon with hybrid capability can supersede the current multidepartmental practice and achieve better outcomes.
