Korean J Radiol.  2018 Apr;19(2):334-341. 10.3348/kjr.2018.19.2.334.

Endovascular Treatment of Bilateral Cavernous Sinus Dural Arteriovenous Fistula: Therapeutic Strategy and Follow-Up Outcomes

• Rhim JK
• Cho YD
• Yoo DH
• Kang HS
• Cho WS
• Kim JE
• Cho MJ
• Hwang G
• Kwon OK
• Han MH

• KMID: 2404931
• DOI: http://doi.org/10.3348/kjr.2018.19.2.334

Abstract

OBJECTIVE
Bilateral cavernous sinus dural arteriovenous fistula (CSdAVF) is very rare, even in Asian countries. The research intended to present clinical and radiologic outcomes of treating such fistulas through endovascular embolization.
MATERIALS AND METHODS
Data was obtained from 220 consecutive patients, with CSdAVF, who were treated from January 2004 to December 2015. Bilateral CSdAVF was identified in 17 patients (7.7%). The clinical and radiologic outcomes of the fistulas were assessed with an emphasis on the technical aspects of treatment.
RESULTS
At the time of treatment, 7 and 10 patients presented with bilateral and unilateral symptoms, respectively. In the former cases, 4 patients had progressed from unilateral to bilateral symptoms. Bilateral fistulas were treated with a single-stage transvenous embolization (TVE) in 15 patients, via bilateral inferior petrosal sinuses (IPS) (n = 9) and unilateral IPS (n = 6). In the other 2 patients with one-sided dominance of shunting, only dominant fistula was treated. Two untreated lesions were found on follow-up to have spontaneously resolved after treatment of the dominant contralateral fistula. Of the 34 CSdAVF lesions, complete occlusion was achieved in 32 lesions after TVE. Seven patients (41.2%) developed worsening of cranial nerve palsy after TVE. During the follow-up period, 4 patients obtained complete recovery, whereas the other 3 remained with deficits.
CONCLUSION
With adjustments of endovascular procedures to accommodate distinct anatomical configurations, endovascular treatment for bilateral CSdAVF can achieve excellent angiographic occlusion results. However, aggravation of symptoms after TVE may occur frequently in bilateral CSdAVF. In the patients with one-sided dominance of shunt, treatment of only dominant fistula might be an alternative option.

Keyword

Cavernous sinus; Dural fistula; Arteriovenous fistula; Embolization; Bilateral; Transvenous embolization; Endovascular treatment

MeSH Terms

Arteriovenous Fistula
Asian Continental Ancestry Group
Cavernous Sinus*
Central Nervous System Vascular Malformations*
Cranial Nerve Diseases
Endovascular Procedures
Fistula
Follow-Up Studies*
Humans

Figure

• 

  Fig. 1 Main patterns of venous drainage in patient cohort (n = 17), according to patency of IPS.CSdAVF = cavernous sinus dural arteriovenous fistula, IPS = inferior petrosal sinus, SOV = superior ophthalmic vein, SPS = superior petrosal sinus

• 

  Fig. 2 62-year-woman with 2-month history of diplopia.A, B. Bilateral CSdAVF shown by both external carotid artery angiograms (arrows indicates fistulas). Occlusion of right IPS and main venous drainage of left IPS. Fistula was supplied by several dural branches of both internal and external carotid arteries, including accessory meningeal artery, internal maxillary artery, middle meningeal artery, and others. C, D. Transvenous embolization of right CSdAVF was performed first through contralateral IPS and then left side fistula was treated through ipsilateral IPS. E, F. Angiogram after procedure shows near-complete occlusion of blood shunting through either fistula.

• 

  Fig. 3 Approaching routes of transvenous embolization, according to patency of IPS.*Cases that occluded IPS was breached with microdevices. FV = facial vein, L = left, R = right, Tx = treatment

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