J Korean Neurosurg Soc.  2022 Jan;65(1):30-39. 10.3340/jkns.2021.0116.

Transarterial Embolization of Intracranial Arteriovenous Fistulas with Large Venous Pouches in the Form of Venous Outlet Ectasia and Large Venous Varix or Aneurysm : Two Centers Experience

• Deniwar MA
• Ahmad S
• Eldin AE

• KMID: 2523911
• DOI: http://doi.org/10.3340/jkns.2021.0116

Abstract

Objective
: There are different types of cerebral vascular malformations. Pial arteriovenous fistulas (PAVFs) and dural arteriovenous fistulas (DAVFs) are two entities; they consist of one or more arterial connections to a single venous outlet without a true intervening nidus. The high turbulent flow of PAVFs and aggressive DAVFs with cortical venous reflux can result in venous outflow varix and aneurysmal dilatation. They pose a significant challenge to transvenous embolization (TVE), stereotactic radiosurgery, and surgical treatment. We aim to share our centers’ experience with the transarterial embolization (TAE) for arteriovenous fistulas (AVFs) with large venous pouches and to report the outcome.
Methods
: The authors’ two institutions’ databases were retrospectively reviewed from February 2017 to February 2021. All patients with intracranial high flow PAVFs and aggressive DAVFs with venous outlet ectasia and large venous varix and were treated by TAE were included.
Results
: Fifteen patients harboring 11 DAVFs and four PAVFs met our inclusion criteria. All patients underwent TAE in 17 sessions. Complete angiographic obliteration was achieved after 14 sessions in 12 patients (80%). Four patients (25%) had residual after one TAE session. Technical failure was documented in one patient (6.7%). Fourteen patients (93.3%) had favorable functional outcome (modified Rankin score 0–2).
Conclusions
: TAE for high flow or aggressive intracranial AVFs is a safe and considerable treatment option, especially for those associated with large venous pouches that are challenging and relatively high-risk for TVE.

Keyword

Theraputic embolization; Endovascular; Intracranial arteriovenous fistulas with venous varix; Arteriovenous fistulas

Figure

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  Fig. 1. Case 1. A : Left vertebral artery angiogram (anteroposterior view) demonstrating Cognard type IV DAVF, supplied by pachymeningeal of posterior cerebral artery with early-dilated venous pouch (Transverse sinus). B : Left external carotid angiogram (lateral view) demonstrating Cognard type IV DAVF, supplied by meningeal branches of middle meningeal, posterior auricular and occipital arteries with early-dilated venous pouch (Transverse sinus). C : Magnetic resonance venography (showing hypertrophied dural venous sinuses and thrombosed left sigmoid sinus. DAVF : dural arteriovenous fistula.

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  Fig. 2. Case 1. A : Final angiogram showing complete occlusion of the DAVF with onyx (white arrow). B : Fluoroscopic unsubtracted image showing the Onyx cast at the fistula point. C : Road map image showing placement of Scepter C balloon catheter in the middle meningeal artery (white arrow). D : Three-dimensional reconstructed angiographic done after 1 year, showing residual filling of DAVF. DAVF : dural arteriovenous fistula.

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  Fig. 3. Case 2. A : Computed tomography angiography showing PAVF, supplied by hypertrophied posterior cerebral artery and aneurysmal dilatation of occipital vein with ectatic dural sinuses. B : Left vertebral artery angiogram (anteroposterior view) demonstrating PAVF, supplied by hypertrophied posterior cerebral artery and aneurysmal dilatation of occipital vein with ectatic dural sinuses. C : Left vertebral artery control angiogram (anteroposterior view) demonstrating attempted coil mass placement in the fistulous connection. PAVF : pial arterioveous fistula.

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  Fig. 4. Case 2. A : Left vertebral artery control angiogram (anteroposterior view) demonstrating onyx embolized arterial feeder and fistulous connection, and deflated HyperGlide balloon proximally placed (white arrow). B : Final angiogram showing complete occlusion of the PAVF with onyx (white arrow). C : Follow up CAT scan of the brain showing onyx and reduced size venous aneurysm with partial thrombosis. D : Three-dimensional reconstructed angiographic done after 6 months, reveal no more filling of the PAVF. PAVF : pial arterioveous fistula.

• 

  Fig. 5. Case 7. A : Left internal carotid angiogram (anteroposterior view) demonstrating PAVF, supplied by hypertrophied middle cerebral artery and aneurysmal dilatation of cortical draining vein in to superior sagittal sinus. B : Magnetic resonance imaging showing left high parietal PAVF and venous aneurysm. C : Selective angiogram with microcatheter, prior to embolization with n-butyl cyanoacrylate glue mix. D : Final angiogram showing the glue cast (white arrow). PAVF : pial arterioveous fistula.

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  Fig. 6. Case 11. A : CAT scan of the brain showing intracranial hemorrhage secondary to DAVF. B : Left external carotid angiogram (lateral view) demonstrating Cognard type IV DAVF, supplied by meningeal branches of middle meningeal, posterior auricular and occipital arteries draining into transverse sinus. C : Roadmap image showing onyx injection from the microcatheter (white arrow). D : Fluoroscopic unsubtracted roadmap image showing the onyx injection in to the DAVF. DAVF : dural arteriovenous fistula.

Reference

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