Download Treatment of Intracranial Dural Arteriovenous Fis

EDUCATION EXHIBIT
1637
RadioGraphics
Treatment of Intracranial
Dural Arteriovenous Fistulas: Current Strategies
Based on Location and
Hemodynamics, and Alternative Techniques of Transcatheter Embolization1
ONLINE-ONLY
CME
See www.rsna
.org/education
/rg_cme.html.
LEARNING
OBJECTIVES
After reading this
article and taking
the test, the reader
will be able to:
䡲 Describe recent
therapeutic results of
treatment options for
dural arteriovenous
fistulas in various
locations.
䡲 Discuss current
strategies in the treatment of intracranial
dural arteriovenous
fistulas.
䡲 List alternative
techniques of transcatheter embolization
for treatment of intracranial dural arteriovenous fistulas.
Hiro Kiyosue, MD ● Yuzo Hori, MD ● Mika Okahara, MD ● Shuichi
Tanoue, MD ● Yoshiko Sagara, MD ● Shunro Matsumoto, MD ● Hirofumi
Nagatomi, MD ● Hiromu Mori, MD
Intracranial dural arteriovenous fistulas (AVFs) can occur anywhere
within the dura mater. Patients may be clinically asymptomatic or may
experience symptoms ranging from mild symptoms to fatal hemorrhage, depending on the location (eg, cavernous sinus, transverse-sigmoid sinus, tentorium, superior sagittal sinus, anterior fossa) and venous drainage pattern of the AVF. In the past, dural AVFs have been
treated with a variety of approaches, including surgical resection, venous clipping, transcatheter embolization, radiation therapy, or a combination of these treatments. Recent developments in catheter intervention now allow most patients to be cured with transcatheter embolization, although stereotactic radiation therapy is demonstrating good
results in an increasing number of cases and surgery is still the preferred option in some cases. Familiarity with drainage patterns, the risk
of aggressive symptoms, recent technical advances, and current treatment strategies is essential for the treatment of intracranial dural AVFs.
©
RSNA, 2004
Abbreviations: AVF ⫽ arteriovenous fistula, TAE ⫽ transarterial embolization, TVE ⫽ transvenous embolization
Index terms: Angiography, 17.124 ● Arteries, therapeutic embolization, 17.1264 ● Arteriovenous malformations, dural, 17.75 ● Cavernous sinus,
176.757 ● Fistula, arteriovenous, 17.757 ● Fistula, therapeutic embolization, 17.1264 ● Sinuses, dural, 176.757 ● Sinuses, superior sagittal, 176.757
Veins, therapeutic embolization, 17.1264
RadioGraphics 2004; 24:1637–1653 ● Published online 10.1148/rg.246045026 ● Content Code:
1From
the Department of Radiology, Oita Medical University, 1–1 Hasama, Oita, 879 –55, Japan (H.K., Y.H., M.O., S.T., Y.S., S.M., H.M.); and
the Department of Neurosurgery, Nagatomi Neurosurgical Hospital, Oita, Japan (H.N.). Recipient of a Cum Laude award for an education exhibit at
the 2003 RSNA scientific assembly. Received March 1, 2004; revision requested April 20 and received June 3; accepted June 3. All authors have no
financial relationships to disclose. Address correspondence to H.K. (e-mail: [email protected]).
©
RSNA, 2004
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Figure 1. Drawings (a ⫽ lateral view, b ⫽ anteroposterior view) illustrate the most common locations
of dural AVFs: 1 ⫽ cavernous sinus (CS) (20%– 40% of cases), 2 ⫽ transverse-sigmoid sinus (TS, SS)
(20%– 60%), 3 ⫽ tentorium (12%–14%), 4 ⫽ superior sagittal sinus (SSS) (8%), and 5 ⫽ anterior fossa
(2%–3%). IPS ⫽ inferior petrosal sinus, ISS ⫽ inferior sagittal sinus, JV ⫽ jugular vein, MS ⫽ marginal
sinus, OS ⫽ occipital sinus, SPS ⫽ superior petrosal sinus.
Table 1
Symptoms of Intracranial Dural AVFs
Location
Symptom
Ocular symptoms
Cranial nerve deficits
Bruit, tinnitus
Headache
Visual symptoms
Central nerve deficits
Intracranial hemorrhage
Dementia
Cavernous
Sinus (%)
Transverse-Sigmoid
Sinus (%)
Tentorium
(%)
Superior Sagittal
Sinus (%)
Anterior Fossa
(%)
80–97
44–77
40–50
...
28–38
3
Rare
...
...
7–12
40–42
46–76
12–28
10–20
15–28
Rare
...
14–17
70–88
8–24
...
23–42
60–74
...
...
...
...
50
...
29
23
5
...
...
...
12–15
...
5–33
44–84
...
Introduction
Intracranial dural arteriovenous fistulas (AVFs) represent 10%–15% of all intracranial vascular malformations. Although dural AVFs can occur anywhere
in the dura mater covering the brain, they occur
most frequently in the cavernous and transversesigmoid sinuses (Fig 1). Patients may be asymptomatic or may experience symptoms ranging from mild
symptoms to fatal hemorrhage. Furthermore, these
symptoms may be characterized as either nonaggressive (benign) (eg, tinnitus) or aggressive (eg,
intracranial hemorrhage, neurologic deficits) (Table
1) (1– 4). For many years, researchers have attempted to identify the factors that predispose to the
risk of aggressive dural AVF symptoms (3–9). On
the basis of their findings, it is now generally accepted that the venous drainage pattern of dural
AVFs is the most predictive factor (3,4,7,9 –11).
Although several classification systems have been
developed to grade the risks of dural AVFs, those
devised by Cognard et al (3) and Borden et al (8)
are the most widely used (Tables 2, 3). Dural AVFs
that drain via the retrograde leptomeningeal cortical
venous drainage channel show a significantly high
rate of aggressive symptoms. Although dural AVF
location is not directly correlated with aggressive
behavior, the propensity for dangerous drainage
patterns found at initial diagnosis does vary with
location (3). Difficulties associated with treatment
methods and proposed techniques, including limited access during interventional and surgical procedures, also differ depending on location: They are
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Table 2
Classification of Venous Drainage
Classification System
Type
I
II
IIa
IIb
IIa ⫹ IIb
III
IV
V
Cognard et al (3)
Borden et al (8)
Antegrade sinus drainage
Insufficient antegrade sinus drainage
Retrograde sinus drainage only
Retrograde CVR only
Retrograde sinus drainage and CVR
CVR only without venous ectasia
CVR only with venous ectasia
Spinal venous drainage
Sinus or meningeal venous drainage
Sinus drainage with CVR
...
...
...
CVR only
...
...
Note.—CVR ⫽ cortical venous reflux.
Table 3
Frequency of Intracranial Hemorrhage and Aggressive Symptoms in Various Types of Venous Drainage
Type
Intracranial Hemorrhage (%)
Aggressive Symptoms (%)
0
11
48
2
39
79
Cognard types I–IIa, Borden type I
Cognard types II and IIa ⫹ IIb, Borden type II
Cognard types III–V, Borden type III
Sources.—References 3 and 8.
similar for dural AVFs of the transverse-sigmoid
sinus and superior sagittal sinus and are unique for
dural AVFs of the cavernous sinus, tentorium, and
anterior fossa. Furthermore, the efficacy of irradiation also differs depending on location and drainage
pattern.
In this article, we discuss and illustrate general
approaches to the treatment of dural AVFs. We also
discuss current strategies in the treatment of dural
AVFs based on location (cavernous sinus, transverse-sigmoid sinus, tentorium, superior sagittal
sinus, anterior fossa) and drainage pattern, as well
as alternative techniques of curative transcatheter
embolization. We reviewed 32 cases of dural AVF
from the past 5 years using diagnostic and interventional record databases and surgical records at our
institutions.
General Treatment Approaches
General approaches for the treatment of dural
AVFs include conservative treatment, radiation
therapy, endovascular intervention, and surgery.
Conservative Treatment
The spontaneous regression of dural AVFs has
been reported (12–14). Such an observation,
which might be caused by thrombosis of the sinus
or fistula, is frequently associated with cavernous
sinus dural AVFs; therefore, some dural AVFs
can be treated conservatively.
Radiation Therapy
Recent studies of the efficacy of stereotactic radiosurgery have reported relatively good results,
with complete occlusion in 44%– 87% of cases
without serious complications (15–23). Advantages of this technique include decreased invasiveness and fewer short-term complications,
whereas a disadvantage is the delayed response
(approximately 6 –12 months) after irradiation.
The combined use of stereotactic radiosurgery
and transarterial embolization (TAE) with particles can enhance the effectiveness of this technique and reduce the risk of worsening symptoms
during the follow-up period (18,19,23).
Endovascular Intervention
TAE with Particles.—Feeding artery embolization of external carotid branches with particles is
easily performed and can reduce shunt flow.
However, complete cures are difficult to achieve
with this method because of the existence of feeding arteries that cannot be catheterized and the
recruitment of a blood supply from collateral arteries (24). Therefore, this method is generally
used to relieve symptoms or in combination with
other procedures such as irradiation, surgery, or
transvenous embolization (TVE).
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Figure 2. Complication associated with subdural hematoma from TVE. (a) Left external carotid arteriogram shows a
transverse sinus dural AVF fed by the left occipital, superficial temporal, and middle meningeal arteries. The AVF drains
into the left jugular vein and cortical veins. (b) Left internal carotid arteriogram shows two dural AVFs (arrows) fed by the
left ascending pharyngeal artery and the meningohypophyseal artery, respectively. The AVFs drain into the superior petrosal sinus (arrowheads). (c) Fluoroscopic image obtained during placement of a coil into the superior venous pouch contiguous with the superior petrous sinus demonstrates that the distal edge of the coil did not form a loop (arrow). As a result, the coil probably penetrated the venous wall. The transverse sinus and inferior venous pouch around the superior
petrous sinus were already packed with coils. (d) Computed tomographic (CT) scan obtained 1 day after embolization
shows a subdural hematoma at the left cerebral convexity and the falx. The patient complained of headache for a few days
but fortunately did not have any neurologic symptoms. (e) Follow-up angiogram of the left external carotid artery shows
complete obliteration of the transverse-sigmoid sinus dural AVF. (f) Left internal carotid arteriogram shows complete
obliteration of the dural AVFs involving the superior petrosal sinus.
Transvenous Coil Embolization.—TVE with
coils is used for curative purposes, and many studies
have reported it to be very useful (complete occlusion in 80%–100% of cases) (25). However, serious
complications associated with vessel injury and intracranial hemorrhage have also been reported (Fig
2) (26,27). Inadequate embolization leads to a
worsening of symptoms. Critical assessment of diagnostic images and clinical conditions is also important for successful procedures.
TAE with n-butyl-2-cyanoacrylate.—TAE
with n-butyl-2-cyanoacrylate has been applied to
complex dural AVFs that are not accessible with
percutaneous transvenous catheterization. Some
authors emphasize techniques that involve wedging
a microcatheter into the main feeding artery to inject a diluted (20%–25%) mixture of n-butyl-2cyanoacrylate and iodized oil, and the preparatory
devascularization of other minor feeding arteries by
embolization with polyvinyl alcohol particles to
avoid fragmentation of the glue column by competing inflows (28). Although results are relatively
good, TAE with n-butyl-2-cyanoacrylate requires
experience in using this material, and some authors
have reported a 5%–20% complication rate (29).
Other options such as surgical approaches and a
combination of TAE and radiosurgery should also
be considered when treating complex dural AVFs.
Stent Placement.—Recently, some authors reported on the use of stent placement with restrictive
changes of the sinuses in the treatment of dural
AVFs in a small number of patients (30 –32). Theo-
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Figure 3. Drawing shows venous drainage
of cavernous sinus dural AVFs. 1 ⫽ anterior
drainage into superior ophthalmic vein (SOV)
and inferior ophthalmic vein (IOV), which can
lead to ocular symptoms (eg, exophthalmos
and chemosis); 2 ⫽ posteroinferior drainage
into inferior petrous sinus (IPS), basilar plexus,
and pterygoid plexus, leading to bruit and cranial nerve deficits; 3 ⫽ posterior drainage into
superior petrous sinus (SPS), leading to bruit;
4 ⫽ cortical reflux into sphenoparietal sinus
and superficial middle cerebral vein (SMV),
leading to venous infarction and hemorrhage;
5 ⫽ cerebellar (spinal) drainage into petrous
vein (PV), leading to ataxia and hemorrhage;
and 6 ⫽ deep drainage into deep middle cerebral vein and uncal vein, leading to hemorrhage. JV ⫽ jugular vein, SS ⫽ sigmoid sinus,
STV ⫽ superficial temporal vein.
Figure 4. Cavernous sinus dural AVF with dominant cerebellar venous drainage. (a) Right external
carotid arteriogram shows a cavernous sinus dural AVF draining into the superior ophthalmic vein and
cerebellar veins via the superior petrosal sinus (arrow). (b) Right external carotid arteriogram obtained
after TVE through an occluded inferior petrosal sinus shows obliteration of the dural AVF.
retically, the radial force of the stent can restore antegrade sinus flow and close shunts within the sinus
wall. Although some dural AVFs have been successfully treated with stents, the long-term results are
not yet known. Furthermore, currently available
stents with sufficient diameter are relatively large
(over 6 F) and have a stiff shaft. It is often difficult
to introduce the stent into the affected area of the
sinus due to the acute angle of the sigmoid sinus
and the irregular narrowing of the lesion.
Surgery.—Thanks to recent technical developments, interventional procedures have become a
first-line treatment for dural AVFs. However,
some difficult cases require surgical techniques
(eg, sinus isolation and resection) in combination
with interventional procedures; indeed, other
cases, especially those involving dural AVFs of
the anterior cranial fossa, can often be treated
more easily and safely with surgical disconnection
of the venous drainage (33).
Cavernous Sinus Dural AVFs
The most common symptoms of cavernous sinus
dural AVF are ocular symptoms (eg, exophthalmos [proptosis]) caused by anterior venous drainage (Fig 3) (1,2,12,27,34). Aggressive neurologic
symptoms such as intracranial hemorrhage are
extremely rare because of the benign venous
drainage pattern but can occur in association with
dangerous venous drainage patterns, including
(a) cortical venous reflux without other venous
drainages (hemorrhagic infarction), (b) dominant
deep venous drainage (hemorrhage, edema) (Fig
4), and (c) thrombosis of the central retinal vein
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Figure 5. Spontaneous regression of a cavernous sinus dural AVF with posterior drainage. (a) T2-weighted magnetic resonance (MR) image shows multiple flow voids in the posterior cavernous sinus (arrows). (b) Left external
carotid arteriogram shows a cavernous sinus dural AVF with posterior drainage into the inferior and superior petrosal
sinuses (arrows). (c) Follow-up MR image shows resolution of the flow voids.
(blindness) (24,25). Spontaneous regression of
cavernous sinus dural AVFs is well recognized,
being observed in 10%–50% of cases (2,13).
Treatment Strategy
Treatment options include conservative treatment, irradiation, TAE with particles or cyanoacrylate, and TVE. Recent studies of stereotactic
radiation therapy for cavernous sinus dural AVFs
showed a relatively high occlusion rate for the
AVF (70%– 88%) several months after treatment
without significant complications (15,20,23).
TVE and TAE with n-butyl-2-cyanoacrylate
showed a higher occlusion rate (80%–100%) immediately after the procedure; however, serious
complications such as intracranial hemorrhage
and cranial nerve deficits were also reported (25–
27,35,36). The efficacy, potential risk, and difficulty of these treatment options are described in
Table 4.
Because of the low prevalence of aggressive
symptoms and the relatively high rates of spontaneous regression, it is suggested that the majority
of cases be treated conservatively for 1–3 months
(Fig 5) (3). However, cases with progressive
symptoms and dangerous drainage patterns require more aggressive treatment (TVE or TAE
Table 4
Treatment Options for Cavernous Sinus
Dural AVFs
Treatment Option*
Results†
Conservative treatment
Radiation therapy
Regression of symptoms
(20–50)
Complete occlusion
(70–87)
Intervention
TAE with particles
TVE
TAE with n-butyl-2cyanoacrylate
Complete occlusion
(⬍50)
Complete occlusion
(80–100)
Complete occlusion
(90–100)
*Treatment options are listed in increasing order of
potential risk and technical difficulty.
†Numbers in parentheses indicate percentages of
cases.
with n-butyl-2-cyanoacrylate), and cases that
have remained stable for a few months should be
treated with irradiation or intervention. One
should also be aware that the low-risk drainage
patterns of dural AVFs develop into high-risk patterns with progressive thrombosis or restriction of
the cavernous sinus outlet (Fig 6) (37).
TVE is the first-line curative therapy in cavernous sinus dural AVF.
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Figure 6. TVE via an occluded inferior petrosal sinus with changes in the drainage pattern of a cavernous sinus
dural AVF. (a) Left external carotid angiogram shows a cavernous sinus dural AVF draining mainly into the inferior
petrosal sinus (arrows) and pterygopharyngeal plexus (arrowheads). (b) Follow-up angiogram obtained 3 months
later shows significant changes in the drainage pattern. The inferior petrosal sinus is occluded, and the dural AVF
now drains into the superior ophthalmic vein (arrows) and the superficial middle cerebral vein (arrowheads). Although the patient’s symptoms (mild chemosis, proptosis, diplopia) were unchanged during follow-up, occlusion of
the dural AVF was indicated because of the change into a dangerous drainage pattern. (c) Superselective venogram
shows the tip of a microcatheter that has been introduced into the cavernous sinus outlets to the superficial middle
cerebral vein. (d) Superselective venogram shows that the tip of the microcatheter has been introduced into the outlets to the superior ophthalmic vein. Note that the microcatheter has been advanced through the occluded sinus.
(e) Left common carotid angiogram obtained after TVE shows complete occlusion of the dural AVF. Before placement of the coils, it is important to determine whether a microcatheter can be introduced into all outlets of the cavernous sinus.
Techniques
Transfemoral Inferior Petrosal Sinus Route.—
Although the inferior petrosal sinus often reveals
complete occlusion, in most cases microcatheters
can be introduced through the occluded sinus
into the cavernous sinus (Fig 6) (38). Vessel perforation with the guide wire and microcatheter
during navigation through the occluded sinus is a
rare but serious complication. Knowledge of the
course of the inferior petrosal sinus and gentle
and careful manipulation of the catheter– guide
wire under “road map” guidance are important.
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Figure 7. TVE with an anterior approach via the superficial temporal vein. (a) Left carotid angiogram shows a cavernous sinus dural AVF draining into the superior ophthalmic vein, the facial
vein (arrowheads), and the superficial temporal vein (arrows). Note the occlusion of the inferior
petrosal sinus. (b) Superselective venogram shows a microcatheter that has been advanced through
the superficial temporal and superior ophthalmic veins into the posterior compartment of the cavernous sinus. The dural AVF was completely obliterated with subsequent coil embolization.
Anterior Approach.—The second most common approach involves the transfemoral facial
venous or superficial temporal venous access
route (Fig 7) and the surgical superior ophthalmic
venous access route (27,39 – 42). With the anterior approach, there is less risk of intracranial vessel perforation. Disadvantages of this approach
include (a) the poor maneuverability of the catheter– guide wire due to the tortuous access route
of the transfemoral approach and (b) the risk of
superior ophthalmic vein injury.
Other Approaches.—Although the majority of
cases of cavernous sinus dural AVF can be treated
with the trans–inferior petrosal sinus approach or
anterior approach, there are other potential approaches, such as the transsuperior petrosal sinus
approach, the transcontralateral cavernous sinus
approach, the transbasilar plexus approach, and
the surgical cortical venous approach (43– 45).
These less common approaches should be attempted when the two more common approaches
are impossible or have failed.
Coil Embolization.—Outlets of the cavernous
sinus to dangerous venous drainage systems (cortical reflux, deep venous drainage, anterior drainage) should be occluded immediately. Incomplete
or inadequate embolization of dangerous venous
outlets could increase venous hypertension. Before the coils are placed, it is important to determine whether a microcatheter can be introduced
into all outlets of the cavernous sinus (Fig 6).
Furthermore, because the pressure in the remaining drainage veins will increase during embolization, the procedure should be kept as short as
possible (46). In this regard, the anterior approach is advantageous in that it allows embolization of the posterior part of the cavernous sinus
first. In most cases, feeding artery shunts occur
mainly in the posterior compartment of the cavernous sinus; therefore, embolization of this compartment first can reduce shunt flow and the risk
of increasing venous pressure. After the occlusion
of dangerous and symptomatic venous drainage
systems, the cavernous sinus is embolized by
placing coils mainly in the shunting portion.
Dense packing of the cavernous sinus with coils
should be avoided because of the risk of cranial
nerve deficits due to compression of the cranial
nerves by the coils (26,46).
Transverse-Sigmoid Sinus Dural AVFs
Although their most common symptoms are benign (pulsatile tinnitus and headache), transversesigmoid sinus dural AVFs are more frequently
associated with hemorrhagic and nonhemorrhagic
aggressive neurologic symptoms than are cavernous sinus dural AVFs (Table 1) (3,7,11). The risk
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Figure 8. Drawings illustrate a classification scheme for transverse-sigmoid sinus dural AVFs that is
based on venous drainage patterns: Grade 1, antegrade sinus drainage without venous restriction or cortical venous reflux; Grade 2, antegrade and retrograde sinus drainage with or without cortical venous
reflux; Grade 3, retrograde sinus drainage with cortical venous reflux; and Grade 4, cortical venous reflux only. (Reprinted, with permission, from reference 11.)
Table 5
Treatment Options for Transverse-Sigmoid Sinus Dural AVFs
Results†
Treatment Option*
Radiation therapy
Intervention
TAE with particles
TVE
TAE with n-butyl-2-cyanoacrylate
Stent placement
Surgery (sinus isolation or resection)
combined with intervention
Complete occlusion (50–70)
Complete occlusion (rare)
Complete occlusion (80–100)
Complete occlusion (90–100 in cases without sinus drainage)
Reconstruction of antegrade sinus drainage
Complete occlusion (100)
*Treatment options are listed in increasing order of potential risk and technical difficulty.
†Numbers in parentheses indicate percentages of cases.
of aggressive neurologic symptoms correlates well
with the venous drainage pattern of transversesigmoid sinus dural AVFs. The classification system devised by Lalwani et al (11) is useful for predicting risk and determining the best treatment
strategy. Grade 1 transverse-sigmoid sinus dural
AVFs are characterized by antegrade sinus drainage without venous restriction or cortical venous
reflux; Grade 2, by antegrade and retrograde sinus drainage with or without cortical venous reflux; Grade 3, by retrograde sinus drainage with
cortical venous reflux; and Grade 4, by cortical
venous reflux only (Fig 8). Spontaneous regression of these AVFs is relatively rare (approximately 5% of cases) and usually occurs following
hemorrhagic events (47).
All transverse-sigmoid sinus dural AVFs are
considered to require treatment because of the
low rate of spontaneous regression without symptomatic events and the relatively high rate of ag-
gressive symptoms. Treatment options include
irradiation, surgical isolation or resection, TAE
with particles or cyanoacrylate, and TVE. Recent
studies of stereotactic radiation therapy for transverse-sigmoid sinus dural AVFs showed a relatively high occlusion rate of the AVF (approximately 60% of cases) several months after treatment without significant complications (17,18).
Although TVE showed higher occlusion rates
(80%–100% of cases), this procedure requires
sacrifice of sinus flow and may cause venous infarction if the sinus contributes to the drainage of
normal cerebral tissue (25,48,49). The rate of
permanent complications in TVE is approximately 4% (48,49). The efficacy, potential risk,
and difficulty of the treatment options for transverse-sigmoid sinus dural AVFs are described in
Table 5, and a summary of strategies according to
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Table 6
Recommended Treatment Strategies for Transverse-Sigmoid Sinus Dural AVFs
Lesion
Grade
1
2
3
4
Strategy
Radiation therapy combined with TAE with particles
(a) TVE with or without preparatory transarterial feeder embolization, (b) radiation therapy combined with TAE with particles, or (c) stent placement with transarterial feeder embolization and
radiation therapy
(a) TVE with or without preparatory transarterial feeder embolization, or (b) stent placement
(a) TVE with either a surgical approach, an approach through the occluded sinus, or a transcortical
venous approach; (b) TAE with n-butyl-2-cyanoacrylate; or (c) surgical resection or resection with
preparatory TAE
Table 7
Treatment Options for Tentorial Dural AVFs
Treatment Option*
Radiation therapy
Intervention
TAE with n-butyl-2-cyanoacrylate
TVE
Surgery (disconnection of leptomeningeal venous drainage)
Results†
Complete occlusion (50–60)
Complete occlusion (50–100)
Complete occlusion (90–100 in a few case reports)
Complete occlusion (100)
*Surgery and TAE with n-butyl-2-cyanoacrylate are equal in terms of potential risk and technical difficulty; they
are more potentially risky and technically difficult than radiation therapy and less so than TVE.
†Numbers in parentheses indicate percentages of cases.
lesion grade is shown in Table 6. In the treatment
of Grade 2 lesions, occlusion of the normal cortical venous drainage system should be avoided.
When there is a high risk of normal cortical venous drainage sacrifice at TVE, other treatments
such as radiation therapy should be applied. Surgical isolation of the sinus with preservation of
normal cortical venous drainage may also be performed but is more invasive. Grade 3 lesions can
be treated with TVE, during which time the affected sinus and retrograde cortical drainage outlet should be tightly packed with coils. Loose
packing might cause recanalization, resulting in
delayed hemorrhagic infarction after embolization
(Fig 9). Although endovascular stent placement
can restore antegrade sinus flow and close shunts
within the sinus wall, only a few successful cases
have been reported (31,32); therefore, further
investigation of the effectiveness of stent place-
ment in the treatment of dural AVFs is necessary.
Grade 4 lesions are the most difficult type of dural AVF to treat. The standard techniques combine endovascular and neurosurgical elements
(eg, TVE combined with a surgical approach)
(50 –52). In patients in poor general condition,
other techniques (eg, TVE combined with other
approaches, TAE with n-butyl-2-cyanoacrylate)
may be used; however, they require more skill
(28).
Tentorial Dural AVFs
Because tentorial dural AVFs drain only via the
leptomeningeal vein, they carry a high risk of aggressive neurologic symptoms (Table 1). The reported occurrence of intracranial hemorrhage
ranges from 60% to 74%; in some cases, this
hemorrhage consists of fatal bleeding in the posterior fossa (3).
Treatment options include irradiation, surgical
interruption of the draining vein with or without
resection, TAE with cyanoacrylate, and TVE
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Figure 9. Recanalization of a grade 3 transverse-sigmoid sinus dural AVF after TVE. (a) Early arterial phase left
common carotid angiogram shows a Grade 3 transverse-sigmoid sinus dural AVF. (b) Late arterial phase left common carotid angiogram shows that the left sigmoid sinus is occluded (arrow) and the dural AVF drains mainly into
cortical veins and the posterior condylar vein (arrowheads). (c) Superselective venogram shows a microcatheter that
has been advanced via the posterior condylar vein (arrowheads) into the affected sinus. (d) Left common carotid angiogram obtained after TVE shows disappearance of the AVF. (e) CT scan obtained 2 months after TVE shows a
massive hemorrhage in the left temporal lobe. (f) Left common carotid angiogram shows recanalization of the dural
AVF at the retrograde cortical drainage outlet (arrows).
(15,18,21,29,30,53–58). The efficacy, potential
risk, and difficulty of these options are described
in Table 7. Tentorial dural AVFs drain through
the retrograde leptomeningeal-cortical venous
drainage system only (Cognard types III and IV,
Borden type III), resulting in a high risk of hemorrhagic or nonhemorrhagic aggressive symptoms
(19% and 10% of cases per year, respectively).
Complete cure of such AVFs requires aggressive
treatment. Interventional and surgical procedures
are both used to disconnect the venous drainage
system; however, because of the deep-seated location of such lesions, the difficult access route, and
the need for n-butyl-2-cyanoacrylate (Fig 10),
these techniques require a high level of skill (53–
55). Treatment selection depends on the skill of
the neurosurgeon and interventional radiologist
and on lesion accessibility. Stereotactic radiosurgery should be considered an option, especially in
older patients or in those in poor general condition (Fig 11) (15,18,21).
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Figure 10. Type IV tentorial dural AVF with intracranial hemorrhage.
(a) Unenhanced CT scan shows intracranial hemorrhage in the left occipital lobe and the lateral ventricle. (b) Left external carotid angiogram
shows a tentorial dural AVF (arrowheads) with leptomeningeal-cortical
venous drainage and venous ectasia (arrow). (c) Digital subtraction angiogram obtained during the injection of diluted n-butyl-2 cyanoacrylate
demonstrates the tip of a microcatheter (arrow). (d) Left common carotid
angiogram obtained after TAE shows complete obliteration of the AVF.
Table 8
Treatment Options for Superior Sagittal Sinus Dural AVFs
Results†
Treatment Option*
Radiation therapy
Intervention
TAE with particles
TVE
TAE with n-butyl-2-cyanoacrylate
Transarterial sinus catheterization and coil
embolization
Surgery (sinus isolation or resection) combined
with intervention
Unknown
Complete occlusion (rare)
Complete occlusion (90–100)
Complete occlusion (90–100 in cases without shunt drainage)
Complete occlusion (100 in case reports)
Complete occlusion (90–100)
*Treatment options in decreasing order of potential risk and technical difficulty are TAE with n-butyl-2-cyanoacrylate, surgery, TVE, and radiation therapy.
†Numbers in parentheses indicate percentages of cases.
Superior Sagittal Sinus Dural AVFs
Because superior sagittal sinus dural AVFs are
frequently associated with restrictive change of
the superior sagittal sinus and retrograde cortical
venous drainage, aggressive neurologic symptoms
are seen in one-half of cases (Table 1) (3). Venous congestion of the bilateral frontal lobes due
to a superior sagittal sinus dural AVF can cause
dementia, a rare but important symptom (59).
The dementia can be misdiagnosed as a psychogenic or degenerative disorder but can be cured
after treatment of the dural AVF.
The efficacy, potential risk, and difficulty of
treatment options for superior sagittal sinus dural
AVFs are described in Table 8. These strategies
are similar to those for treating transverse-sigmoid sinus dural AVFs. Superior sagittal sinus
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Figure 11. Type IV tentorial dural AVF. (a) Left external carotid angiogram shows a tentorial dural AVF
with leptomeningeal-cortical venous drainage and venous ectasia. (b) Lateral radiograph shows the planned
radiation field. Because of the poor general condition of the patient, the AVF was treated with conventional
irradiation (total dose, 30 Gy). (c) Left common carotid angiogram obtained 8 months after radiation therapy
shows complete obliteration of the tentorial dural AVF.
Figure 12. Superior sagittal sinus dural AVF. (a) Right external carotid angiogram shows a dural AVF with cortical reflux and occlusion of the superior sagittal sinus. (b) Right external carotid angiogram obtained during transarterial sinus embolization shows a microcatheter that has been advanced into the superior sagittal sinus via the right
middle meningeal artery (arrows). (c) Right external carotid angiogram obtained after embolization shows obliteration of the AVF.
dural AVFs are more frequently associated with
aggressive symptoms and therefore often require
aggressive treatment. Superior sagittal sinus dural
AVFs are strongly associated with superior sagittal sinus occlusion; therefore, the percutaneous
transvenous approach is often difficult. Standard
techniques include TVE with a surgical approach
and surgical isolation or resection of the sinus
(24,51). In some cases, superior sagittal sinus occlusion can be treated with transarterial intrave-
nous catheterization and coil embolization via the
middle meningeal artery (Fig 12) (60). Although
there have been few reports of the treatment of
superior sagittal sinus dural AVFs with irradiation, the efficacy of radiation therapy in treating
transverse-sigmoid sinus dural AVFs suggests that
irradiation might be an effective treatment
(16,22).
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Figure 13. Anterior fossa dural AVF. (a) Unenhanced CT scan shows intracranial hemorrhage at the frontal base.
(b) Left internal carotid angiogram shows a dural AVF (arrow) that is fed by the ethmoidal artery and drains into the
leptomeningeal vein, which demonstrates varices (arrowheads). (c) Left internal carotid angiogram obtained after
clipping of the draining vein shows disappearance of the AVF.
Table 9
Treatment Options for Anterior Fossa Dural AVFs
Results†
Treatment Option*
Radiation therapy
Intervention
TAE with n-butyl-2-cyanoacrylate
TVE with a retrograde cortical venous approach
Surgery (disconnection of cortical-leptomeningeal venous
drainage)
Unknown
Complete occlusion (100 in a few case reports)
Complete occlusion (100 in a few case reports)
Complete occlusion (100)
*TVE and TAE with n-butyl-2-cyanoacrylate are equal in terms of potential risk and technical difficulty; they are
more potentially risky and technically difficult than surgery, which in turn is more so than radiation therapy.
†Numbers in parentheses indicate percentages of cases.
Anterior Fossa Dural AVFs
Anterior fossa dural AVFs have a venous drainage
pattern similar to that of tentorial dural AVFs
with retrograde leptomeningeal drainage and are
frequently associated with intracranial hemorrhage or nonhemorrhagic neurologic symptoms
(Fig 13, Table 1) (3,61,62).
The efficacy, potential risk, and difficulty of
the various treatment options for anterior fossa
dural AVFs are described in Table 9. Dural AVFs
located on the anterior fossa drain through the
retrograde leptomeningeal-cortical venous drainage system only (Cognard types III and IV, Borden type III), resulting in a high risk of hemorrhagic or nonhemorrhagic aggressive symptoms.
A complete cure is necessary. However, these
AVFs are always supplied by the bilateral oph-
thalmic arteries, in which catheterization is difficult and dangerous (33). Few anterior fossa dural
AVFs can be safely treated with TVE, since transvenous routes are also tortuous and often associated with venous aneurysms (63). On the other
hand, surgical approaches are relatively easy and
safe; therefore, these AVFs should be treated with
surgical disconnection of the venous drainage systems (33,61).
Other Dural AVFs
Dural AVFs can also occur at other locations,
including the marginal sinus, inferior and superior petrosal sinuses, major sinus wall, and hypoglossal canal (64 – 68). The treatment strategy for
these AVFs is also determined by the risk of aggressive symptoms and the efficacy of each technique, which depend on lesion accessibility and
the skill of the neurosurgeon and interventional
radiologist.
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Conclusions
In this article, we have discussed and illustrated
current strategies in the treatment of dural AVFs
according to location and venous drainage.
Knowledge of drainage patterns and the risk of
aggressive symptoms, as well as familiarity with
recent technical advances, is essential for the
treatment of intracranial dural AVFs.
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This article meets the criteria for 1.0 category 1 credit toward the AMA Physician’s Recognition Award. To obtain
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