J Cerebrovasc Endovasc Neurosurg.  2024 Jun;26(2):119-129. 10.7461/jcen.2023.E2022.10.001.

Usefulness of sectional images in dural AVF for the interpretation of venous anatomy

• Kang M
• Kim S

• KMID: 2556974
• DOI: http://doi.org/10.7461/jcen.2023.E2022.10.001

Abstract

Knowledge of the venous anatomy is essential for appropriately treating dural arteriovenous fistulas (AVFs). It is challenging to determine the overall venous structure despite performing selective angiography for dural AVFs with feeder from multiple selected arteries. This is because only a part of the veins can be observed through the shunt in the selected artery. Therefore, after performing selective angiography of all vessels to understand the approximate venous anatomy, the venous anatomy can be easily understood by closely examining the source image of computed tomographic angiography or magnetic resonance angiography. Through this, it is possible to specify the vein that is to be blocked (target embolization), thereby avoiding extensive blocking of the vein and avoiding various complications. In the case of dural AVF with feeder from single selected artery, if the multiplanar reconstruction image of the three-dimensional rotational computed tomography obtained by performing angiography is analyzed thoroughly, a shunted pouch can be identified. If embolization is performed by targeting this area, unnecessary sinus total packing can be avoided.

Keyword

Central nervous system vascular malformations; Dural arteriovenous fistulas; Venous anatomy; Three-dimensional image; Multiplanar reconstruction images; Magnetic resonance angiography

Figure

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  Fig. 1. Dural AVF in vein of Labbe. (A) ECA selective angiography, lateral view. (B) Microcatheter navigation into posterior branch of middle meningeal artery. (C) Transarterial ONYX embolization. (D) After treatment, total occlusion of dural AVF. AVF, arteriovenous fistula; ECA, external carotid artery

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  Fig. 2. Case 1. Dural AVF in right cavernous sinus. (A) Right ICA selective angiography, AP view. (B) Right ECA selective angiography, AP view. (C, D) Left ECA selective angiography, AP view. (E) Left ICA selective angiography, AP view. Non shunted venous pouch (black arrow). Right inferior petrosal sinus (white arrow). Intercavernous sinus (black double arrows). Right superior ophthalmic vein (white dot arrow). Shunted pouch connecting to left ECA (black arrow head). Shunted pouch connecting to left ICA (white arrow head) in A, B, C, D, and E. (F) Illustration of venous anatomy in dural AVF. ICA, internal carotid artery; AP, anteroposterior; ECA, external carotid artery; AVF, arteriovenous fistula

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  Fig. 3. Case 1. Source images of MRA in A, B, C, and D. (A) Non shunted pouch (white arrow). (B) Shunted pouch connecting to left ECA (white arrow). (C) Intercavernous sinus (white arrow). (D) Shunted pouch connecting to left ICA (white arrow). (E, F) Transvenous ONYX and coil embolization of dural AVF in cavernous sinus. MRA, magnetic resonance angiography; ECA, external carotid artery; ICA, internal carotid artery; AVF, arteriovenous fistula

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  Fig. 4. Case 1. 1 year follow up angiography. No recurrence of dural AVF in right cavernous sinus. (A) Right ICA selective angiography, AP view. (B) Right ECA selective angiography, lateral view. (C) Left ICA selective angiography, AP view. Known aneurysm in left MCA bifurcation area which was coil-embolized. (D) Left ECA selective angiography, lateral view. De novo development of dural AVF in left transverse sinus. AVF, arteriovenous fistula; ICA, internal carotid artery; AP, anteroposterior; ECA, external carotid artery

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  Fig. 5. Case 2. Dural AVF in left transeverse sinus. (A, B) Left ECA selective angiography, lateral view. (C) Left VA selective angiography, lateral view. (D, E, F) MPR images of 3D rotational CT. AVF, arteriovenous fistula; ECA, external carotid artery; VA, vertebral artery; MPR, multiplanar reconstruction; 3D, three-dimensional; CT, computed tomography

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  Fig. 6. Case 2. Transarteral ONYX embolization and follow up angiography. (A, B, C) Transarteral ONYX embolization of dural AVF in transeverse sinus. (D, E, F) After treatment, immediately follow up angiography. Total occlusion of dural AVF and preserved venous flow through left transeverse sinus. (G, H, I) 1 year follow up angiography. No recurrence of dural AVF and preserved venous flow through left transeverse sinus. AVF, arteriovenous fistula

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  Fig. 7. Case 3. Dural AVF in left transverse sinus and transvenous embolization. Left ECA selective angiography, lateral view in A and B. (A) Shunted pouch (black arrow). (B) Tight stenosis in junction of transverse and sigmoid sinus (black arrow). MPR images of 3D rotational CT in C, D, and E. (C) Occlusion in distal portion of transverse sinus (white arrow). (D) Shunted pouch (white arrow). (E) Tight stenosis in junction of transverse and sigmoid sinus (white arrow). (F) After passing through stenosis with microcatheter, stenosis was blocked by microcatheter. More detail of venous anatomy was visible. (G) Transvenous ONYX and coil embolization of dural AVF. (H) After treatment, immediately follow up angiography. Total occlusion of dural AVF. (I) 1 year follow up angiography, No recurrence of dural AVF. AVF, arteriovenous fistula; ECA, external carotid artery; MPR, multiplanar reconstruction; 3D, three-dimensional; CT, computed tomography

Reference

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