J Cerebrovasc Endovasc Neurosurg.  2022 Sep;24(3):210-220. 10.7461/jcen.2022.E2021.03.008.

Middle meningeal artery: An effective pathway for achieving complete obliteration following transarterial Ethylene Vinyl Copolymer (Onyx) embolization of dural arteriovenous fistulas

• Akamatsu Y
• Gomez-Paz S
• Tonetti DA
• Vergara-Garcia D
• Moholkar VM
• Kuhn AL
• Chida K
• Singh J
• Rodrigues KdM
• Massari F
• Moore JM
• Ogilvy CS
• Puri AS
• Thomas AJ

• KMID: 2533672
• DOI: http://doi.org/10.7461/jcen.2022.E2021.03.008

Abstract

Objective
Transarterial Onyx embolization is the mainstay of intracranial non-cavernous dural arteriovenous fistulas (dAVFs) treatment. Although the dural arterial supply varies depending on the location, the impact of arterial access on treatment outcomes has remained unclear. The aim of this study was to characterize factors as sociated with complete obliteration following transarterial Onyx embolization, with a special focus on arterial access routes and dAVF location.
Methods
A retrospective analysis of the patients who underwent transarterial Onyx embolization for intracranial dAVFs at two academic institutions was performed. Patients with angiographic follow-up were considered eligible to investigate the impact of the arterial access on achieving complete obliteration.
Results
Sixty-eight patients underwent transarterial Onyx embolization of intracranial dAVFs. Complete obliteration was achieved in 65% of all treated patients and in 75% of those with cortical venous reflux. Multivariable analysis identified middle meningeal artery (MMA) access to be a significant independent predictive factor for complete obliteration (OR, 2.32; 95% CI, 1.06-5.06; p=0.034). Subgroup analysis showed that supratentorial and lateral cerebellar convexity dAVFs (OR, 5.72, 95% CI, 1.89-17.33, p=0.002), and Borden type III classification at pre-treatment (OR, 3.13, 95% CI, 1.05- 9.35, p=0.041), were independent predictive factors for complete obliteration following embolization through the MMA.
Conclusions
MMA access is an independent predictive factor for complete obliteration following transarterial Onyx embolization for intracranial non-cavernous dAVFs. It is particularly effective for supratentorial and lateral cerebellar convexity dAVFs and those that are Borden type III.

Keyword

Arteriovenous fistula; Embolization; Onyx; Meningeal artery

Figure

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  Fig. 1. Treatment flow diagram of our study cohort. TAE, transarterial embolization; dAVF, dural arteriovenous fistula; TVE, transvenous embolization

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  Fig. 2. Lateral view of left external carotid artery angiogram showing the dAVF at the isolated transverse sinus fed by the posterior convexity branch of the middle meningeal artery (MMA) (black arrowhead) and transosseous branch of the occipital artery (white arrowhead), and drainage into the dilated cortical vein (black arrow) (A). Selective angiogram of the MMA showing a wedged microcatheter position (B). Left external carotid artery angiogram obtained after embolization confirming complete dAVF obliteration (C). Non-subtracted image showing Onyx cast following embolization (white arrows) (D). dAVF, dural arteriovenous fistula

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  Fig. 3. Anteroposterior (A) and lateral (B) view of right common carotid artery angiogram showing a dAVF at the torcula fed by the hypoglossal branches (white arrowheads) of the occipital artery (OA) and draining into left cerebellar cortical veins (black arrows). Note that feeding branches from the middle meningeal artery (MMA) (black arrowheads) are not clearly identified on this injection. Anteroposterior (C) view of selective angiogram of the hypoglossal branch of the OA. Onyx injection was not attempted due to the difficulty of distal catheter navigation. Selective injection from the small caliber MMA showing a wedged microcatheter position (black arrowhead) and contribution to the fistula (black arrow) (D). Non-subtracted image showing Onyx cast penetrating into the fistula pouch (black arrow) (E). Anteroposterior (F) and lateral (G) view of the right common carotid artery angiogram obtained after embolization through the small MMA confirming complete fistula obliteration. dAVF, dural arteriovenous fistula

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