Abstract
Background and purpose
Angioplasty of the dural sinus has rarely been performed for the treatment of cavernous sinus dural arteriovenous fistulas. We evaluated the efficacy of selective transvenous embolization (TVE) combined with balloon angioplasty of the occluded inferior petrosal sinus (IPS) for the treatment of cavernous sinus dural arteriovenous fistulas (CSDAVFs).
Materials and methods
A total of 8 consecutive patients with CSDAVFs with occlusion of the IPS treated by selective TVE with balloon angioplasty of the IPS from July 2018 to January 2019 were retrospectively reviewed. There were 6 females and 2 males with an average age of 77.6 years. All patients showed ocular symptoms. Angiography showed cortical venous reflux in 7 cases and localized shunted pouches at the medial portion of the cavernous sinus, intercavernous sinus, or laterocavernous sinus. Selective TVE was performed via the occluded IPS with bilateral femoral venous approaches, and the occluded IPS was reconstructed by angioplasty with a 2- to 3-mm diameter balloon during or after selective TVE.
Results
CSDAVFs disappeared immediately after treatment, and the occluded IPSs were successfully reconstructed with re-establishment of normal antegrade venous flow in all cases. No complications were observed, and symptoms resolved within 2 weeks after treatment. During the 7-month mean follow-up period (range 1-12 months), no cases showed recurrence of CSDAVFs.
Conclusion
Selective TVE combined with balloon angioplasty of the occluded IPS is safe and effective for the treatment of CSDAVFs and re-establishes normal venous circulation in selected cases with localized shunted pouches.
Keywords: Cavenous sinus dural arteriovenous fistulas, inferior petrosal sinus, percutaneous transluminal anigioplasty
Introduction
Transvenous embolization (TVE) is a standard treatment for cavernous sinus dural arteriovenous fistulas (CSDAVFs). 1 Although the standard TVE technique, coil packing of the whole affected sinus, is usually performed, sinus packing may result in cranial nerve injury by coil mass or the disturbance of normal venous drainage. 2 To avoid such complications, selective TVE of the shunted pouches has been recently performed in selected cases of CSDAVF with localized shunted pouches. Some reports have achieved successful obliteration of CSDAVFs by selective TVE.2–4 However, it has a risk of recurrence, and retreatment by TVE through the occluded inferior petrosal sinus (IPS) may be difficult. Angioplasty of the occluded IPS during selective TVE may reduce the difficulty of catheterization to the CS through the IPS when retreatment is required. Furthermore, angioplasty of the occluded IPS provides a potential benefit: reconstruction of normal antegrade cerebral venous drainage through the IPS. It may reduce the risk of aggressive symptoms due to cortical reflux or retinal venous reflux/thrombosis by reconstruction of the antegrade drainage route when recurrence occurs. However, to our knowledge, angioplasty of the occluded IPS has not been reported. In this study, we evaluated the efficacy and safety of selective TVE combined with balloon angioplasty of the occluded IPS for the treatment of CSDAVFs.
Methods
This study was approved by the institutional review born at our institution.
Eight consecutive patients with CSDAVFs with occlusion of the IPS treated by selective TVE with balloon angioplasty of the IPS from July 2018 to July 2019 were retrospectively reviewed. The characteristics of the 8 patients are summarized in Table 1. The patients’ ages ranged from 68 to 84 years (mean age, 77.6 years), and there were 6 females and 2 males. All patients showed ocular symptoms with a duration of 2 weeks to 6 months at presentation (Table 1). Digital subtraction angiography (DSA) of the bilateral internal carotid arteries, external carotid arteries, and vertebral arteries was performed using a biplane angiography system (Innova 3131, GE Medical Systems, Milwaukee; Infinix VB, Toshiba Medical, Tokyo) 1-3 weeks before the treatment in all patients. When CSDAVFs were demonstrated on biplane DSA, three-dimensional (3 D) rotational angiography was subsequently performed. We constructed 3 D images with maximum intensity projection, volume rendering reconstruction and multiplanar reconstruction images composed of slices with 0.2–0.3 mm thickness and a 0.5 mm interval from data obtained in rotational angiography using a workstation (Advanced Workstation, GE Healthcare Milwaukee; Ziostation, Zio, Tokyo). Selective angiography of the feeding arteries, including the ascending pharyngeal artery, the middle meningeal artery or the internal maxillary artery, was also performed to precisely evaluate the shunted pouch. Angiographic findings of CSDAVFs, including the locations of the shunted pouches and the drainage pattern (including the presence of cortical venous reflux and patency of the IPS), were evaluated before endovascular treatment. Occlusion of the IPS was diagnosed when the IPS was not visualized on any of those angiographic examinations.
Table 1.
Patient characteristics.
| Case | Age | Sex | Symptoms | Duration of symptoms |
|---|---|---|---|---|
| 1 | 71 | Female | R chemosis | 3 months |
| 2 | 82 | Male | R chemosis | 3 months |
| 3 | 81 | Male | R chemosis diplopia | 4 months |
| 4 | 68 | Female | R chemosis ptosis, diplopia | 6 months |
| 5 | 79 | Female | Diplopia | 1 month |
| 6 | 75 | Female | R chemosis, diplopia, tinnitus | 1 month |
| 7 | 84 | Female | R chemosis, diplopia | 2 weeks |
| 8 | 81 | Female | Diplopia | 1 month |
All but one patient had a few shunted pouches located at the medial portion of the cavernous sinus, intercavernous sinus, and/or laterocavernous sinus. In one patient, multiple shunted pouches (more than 5) were located at the medial and lateral portions of the CS. Occlusion of the ipsilateral IPS was observed in all patients, and the bilateral IPS was occluded in two patients. Cortical venous reflux through the superficial middle cerebral vein, petrosal vein, uncal vein and/or prepontine bridging vein was observed in 7 patients (Table 2).
Table 2.
Angiographical findings.
| Case | Location of shunt | IPS | Drainage routes |
|---|---|---|---|
| 1 | ICS, LCS, L.CS | Bilt. IPS occlusoon | R.SMCV, L.SPS-petrosal, L.UV |
| 2 | ICS, R.CS | R. IPS stenosis | R.SOV, R.SMCV |
| 3 | ICS | L. IPS occlusion | bilt. SMCV, R.SOV |
| 4 | ICS, bilt. CS | L. IPS occlusion | R.UV, R.SPS-petrosal V, L.IPS |
| 5 | ICS, R.CS | R. IPS occlusion | R.SMCV, R.UV, R.PPBV |
| 6 | ICS, L. CS | L. IPS occlusion | L. SPS-petrosal V, SOV |
| 7 | ICS, L. CS | L. IPS occlusion | L. SOV |
| 8 | ICS, L. CS | bilt. IPS occlusion | bilt. SOV, SPS-petrosal V |
Techniques used for endovascular treatment: Written informed consent was obtained from all patients before cerebral angiography and endovascular treatment. All patients were treated by selective TVE via the occluded IPS with bilateral femoral venous approaches using 4 F/6F or 5 F/7F coaxial guiding catheter systems. A 4 F or 5 F guiding catheter was placed at the orifice of the occluded IPS, and then a 1.7 F microcatheter (Excelsior SL10, Striker Japan, Tokyo; or Headway, Terumo, Tokyo) was advanced through the occluded IPS using the microguidewire technique. Selective catheterization was performed into the shunted pouch and to the shunt point, as far as possible, and then the shunted pouches were selectively embolized with detachable coils. When the target shunted pouches were sufficiently occluded, a microcatheter was exchanged for a microballoon catheter (Gateway, Striker, Japan), and angioplasty of the occluded IPS was performed with a balloon pressure of 6-8 atm. The microballoon catheter used in these procedures was an overthe-wire type with a 2- to 3-mm-diameter balloon. Additional selective TVE was performed after angioplasty when angiography showed a residual shunt (Figure 1).
Figure 1.
Case 79 F involved a CSDAVF with occlusion of the right IPS and cortical venous reflux through the superficial middle cerebral vein, the uncal vein and the prepontine bridging vein. Frontal (a) and lateral (b) views of right ECA angiography, frontal view of left ECA angiography (c), and coronal reformatted MPR images obtained in 3D rotational angiography of the right (d) and left (e) ascending pharyngeal arteries reveal CSDAVFs with shunted pouches at the medial portion of the right CS and the inter CS that were fed mainly by the bilateral ascending pharyngeal arteries. (f) Fluoroscopic image obtained during selective TVE showing coils placed selectively in the shunted pouch. (g) Fluoroscopic image during balloon angioplasty of the occluded right IPS. Angioplasty was performed with a microballoon catheter (yellow arrows) and a 2 mm-diameter balloon. (h) Angiography performed during additional selective transvenous embolization with glue. A small residual shunt with a tiny shunted pouch was noted after balloon angioplasty, and it was selectively embolized with diluted NBCA (33%) via a transvenous catheter. Right (i) and left (j) common carotid angiography immediately after embolization showing complete occlusion of the CSDAVFs. Follow-up angiography performed 4 months after treatment. Right common carotid angiography showing stable complete occlusion of the DAVFs. MPR image of the right internal carotid angiography at the venous phase (k) and the left vertebral angiography at the venous phase (l) showing good patency of the reconstructed IPS with antegrade cerebral venous drainage via the IPS (white arrows).
Follow-up studies: All patients were followed up in clinical examinations and MR angiography at one month, three months, and every 6 months after embolization. Cerebral angiography was also performed when available. The technical success of selective TVE and balloon angioplasty of the occluded IPS and the angiographic results of selective TVE of CSDAVFs immediately after endovascular procedures, including occlusion of the CSDAVF and the patency of the reconstructed IPS, complications, and follow-up results, were retrospectively reviewed. All angiographic images and MR angiography data were reviewed by two neuroradiologists with over 10 years of experience.
Results
Immediate results (Table 3): Technical success was achieved in both selective TVE and balloon angioplasty of the occluded IPW in all 8 patients. Selective TVE was performed in a single session in 7 patients. In one patient, two sessions were required to avoid excessive radiation exposure due to the long procedure time required to occlude multiple shunted pouches. The CSDAVFs disappeared immediately after treatment in all 8 cases. Patency of the reconstructed IPS was observed in all cases. All 7 patients with cortical venous reflux before treatment showed antegrade cerebral venous drainage to the CS after balloon angioplasty. No complications, including cranial nerve injury, were observed during or after endovascular treatment.
Table 3.
Immediate results.
| Case | Age/Sex | Sinoplasty of IPS | Results of CSdAVFs | Complications |
|---|---|---|---|---|
| 1 | 71/F | Success | Disappear | No |
| 2 | 82/M | Success | Disappear | No |
| 3 | 81/M | Success | Disappear | No |
| 4 | 68/F | Success | Disappear | No |
| 5 | 79/F | Success | Disappear | No |
| 6 | 75/F | Success | Regression/Disappear | No |
| 7 | 84/F | Success | Disappear | No |
| 8 | 81/F | Success | Disappear | No |
Follow-up results (Table 4): During the 7-month median follow-up period (range 1-12 months), no cases showed recurrence of CSDAVFs on follow-up MR angiography. Follow-up angiography was performed in 6 patients, and the results also demonstrated that the complete occlusion of CSDAVFs was stable in all 6 patients. Among the 6 patients, the reconstructed IPSs were patent with normal antegrade cerebral venous flow through the IPS in 5 cases. The IPS was not visualized in 1 case, which showed normal cerebral venous drainage that did not pass through the CS. The patient did not show cortical venous reflux before treatment. The symptoms disappeared in 3 cases and markedly improved in 5 cases. Chemosis and tinnitus disappeared immediately after treatment. While diplopia improved in all 6 patients, it took a long time to heal.
Table 4.
Follow-up results.
| Case | Age/Sex | FU periods (months) | Symptoms | CSdAVFs on MRA or DSA | Patency of IPS on DSA |
|---|---|---|---|---|---|
| 1 | 71/F | 12 | Disappear | No recurrence | Patent |
| 2 | 82/M | 12 | Disappear | No recurrence | NA |
| 3 | 81/M | 9 | Improve | No recurrence | NA |
| 4 | 68/F | 9 | Disappear | No recurrence | Patent |
| 5 | 79/F | 7 | Improve | No recurrence | Patent |
| 6 | 75/F | 3 | Improve | No recurrence | Patent |
| 7 | 84/F | 3 | Improve | No recurrence | No flow |
| 8 | 81/F | 1 | Improve | No recurrence | Patent |
Discussion
TVE has long been performed as a standard treatment for CSDAVFs. In many cases, coil placement was performed in the entire affected cavernous sinus. However, packing the entire sinus carries a potential risk of disturbing normal venous drainage through the cavernous sinus. This may cause serious hemorrhage or venous infarction after the procedure.5,6 Furthermore, cranial nerve palsy caused by the mass effect of the placed coils occurs in approximately 11-15% of cases treated by a sinus packing procedure,5,6 and some of these are permanent injuries. Recently, selective TVE, selective occlusion of the shunt segment resulting from coils placed selectively at the shunt points, and shunted pouches have been developed as procedures to prevent those complications. 3 However, selective TVE may have a higher risk of recurrence if not all of the shunted pouches are completely occluded. In cases in which CSDAVFs are accompanied by occluded IPS, it may be difficult to reapproach the cavernous sinus via the occluded IPS. Furthermore, recurrence of CSDAVFs can cause aggressive symptoms, particularly in cases with cortical venous reflux and an occluded IPS. Therefore, we proposed that angioplasty of the IPS may overcome these potential drawbacks of selective TVE in cases of occluded IPS. Angioplasty of the dural sinus for the treatment of dural arteriovenous fistulas at the superior sagittal sinus and the transverse sigmoid sinus with sinus occlusion/stenosis and intracranial hypertension with sinus stenosis has been reported by several authors.7–10 However, angioplasty of the IPS has not been reported as a treatment for cavernous sinus dural arteriovenous fistulas in the literature, most likely because the rate of application selective TVE is lower than that of sinus packing. In this study, we evaluated the efficacy of selective TVE combined with balloon angioplasty of the occluded IPS for the treatment of CSDAVFs. Angioplasty of the occluded IPSs was successfully performed in all cases, and no complications were observed. Follow-up angiography showed that IPS patency was achieved in 5 of 6 cases (83%). In these cases, the IPS worked as a normal cerebral venous drainage route. In the nonpatent case, the IPS could not be viewed on follow-up angiography. In this case, the CS connected to only the superior ophthalmic vein, the normal cerebral drainage of the superficial middle cerebral vein and uncal vein drained into the paracavernous sinus, and the superior petrosal sinus drained into the transverse sinus. Therefore, there may be little demand for procedures aimed at maintaining venous flow of the IPS. Among the 8 evaluated cases, one required two sessions of embolization to achieve complete occlusion of the CSDAFs. At the end of the 1st session, we performed balloon angioplasty of the occluded IPS. A microcatheter was easily advanced into the CS in the second session, which was a few weeks after the first session. Thus, balloon angioplasty may decrease the difficulty of approaching the CS during retreatment. Although there were no complications in our series, there is a potential risk of vessel injury by balloon angioplasty. Causing excessive dilatation when using a large balloon may cause rupture of the IPS or adjacent venous structures. Therefore, gentle manipulation with a small balloon size is recommended. Although our study showed the feasibility of combined treatment of selective TVE and balloon angioplasty of the occluded IPS, there are a few limitations in this study. First, this is a retrospective study including a small number of cases, and not all cases received catheter angiography at follow-up. Second, clinical benefit over the potential risk of this technique was not confirmed by this study.
Conclusions
Selective TVE combined with balloon angioplasty of the occluded IPS is safe and effective for the treatment of CSDAVFs requiring re-establishment of normal venous circulation in selected cases with localized shunted pouches.
Footnotes
Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Ethical approval: All procedures performed in the studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
Informed consent: Informed consent was obtained from all individual participants included in the study.
ORCID iDs: Satomi Ide https://orcid.org/0000-0001-8535-5019
Yuzo Hori https://orcid.org/0000-0003-4124-416X
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