Curative embolization with Onyx of dural arteriovenous fistulas with cortical venous drainage

Abstract

Background and purpose: Dural fistulas with cortical venous drainage often present with hemorrhage or neurologic deficit, and prompt treatment is indicated. Occlusion of the draining vein by endovascular techniques or surgical disconnection is considered curative. We present our first endovascular experience with use of Onyx via the arterial route in these aggressive fistulas.

Materials and methods: Between October 2008 and October 2009, 8 consecutive patients with a dural fistula with exclusive cortical venous drainage were treated with Onyx. Three patients presented with hemorrhage; 3, with hemianopsia; 1 with bruit; and 1 after incomplete coil occlusion of a benign sigmoid sinus dural fistula. Fistula location was the sigmoid sinus segment in 4, the occipital area in 2, the cavernous sinus in 1, and the torcula in 1.

Results: In all 8 patients, it was possible to occlude the proximal venous site of the fistula with Onyx via arterial feeders, resulting in complete cure in all. In 6 patients, a prolonged (17- to 29-minute) single middle meningeal artery injection was sufficient to occlude the venous site of the fistula with retrograde occlusion of other arterial feeders; in the other 2 patients, 2 injections in supplying arteries were needed. Follow-up angiograms after 6-12 weeks confirmed lasting complete occlusion of the fistulas. All patients were clinically cured, there were no complications.

Conclusions: In this small series, curative embolization of dural fistulas with exclusive cortical venous drainage by using Onyx via the arterial route was possible in all patients.

Figures

Fig 1.

A 58-year-old man (patient 1) with a good-grade (Hunt and Hess II) subarachnoid hemorrhage from a torcular DAVF that was cured with a single Onyx injection from the middle meningeal artery. A and B, Left external carotid angiograms in arterial (A) and venous (B) phases demonstrate a DAVF located on the torcula supplied by the middle meningeal and occipital arteries with marked congestion of cerebellar and even perimedullary veins. C, Supply to the DAVF by the posterior meningeal artery arising from the right vertebral artery. D, Microcatheter distally in the middle meningeal artery close to the fistula used for Onyx injection. E, AP view of selective angiography of the posterior meningeal artery (arrow) arising from the right vertebral artery. F, Same view as in E shows an Onyx cast in the draining vein and retrograde in the posterior meningeal artery (double arrows). G–I, Lateral views of Onyx cast (G), external carotid (H), and right vertebral (I) angiogams 10 weeks after embolization demonstrate complete occlusion of the DAVF.

Fig 2.

A 36-year-old man (patient 2) with a parenchymal hemorrhage from a DAVF. A, CT scan demonstrates a right parenchymal hematoma. B and C, Early (B) and later (C) phases of a right external carotid angiogram reveal a DAVF located on an isolated open segment of an occluded transverse sinus. The fistula is supplied by the middle meningeal, posterior auricular, and occipital arteries with drainage to the vein of Labbé and a posterior cortical vein (arrows in C). D, Early phase of Onyx injection through a microcatheter, which was positioned close to the fistula in the middle meningeal artery (arrow). Onyx is injected slowly and first fills the dural feeders in the sinus wall. E, Note the Onyx cast at end of injection. The open sinus segment, the proximal draining veins (long arrows), and dural supply from the occipital artery (short arrow) are occluded. F, Complete occlusion of the DAVF is confirmed by postprocedural and follow-up angiography.

Fig 3.

A 59-year-old woman (patient 5) with a right occipital parenchymal hemorrhage from a DAVF. A, CT scan demonstrates a right parenchymal hematoma. B, AP view of a right external carotid angiogram shows a DAVF mainly supplied by the middle meningeal artery. Note the aneurysm on the occipital draining vein. C, Onyx cast after embolization through the middle meningeal artery. All dural supply and the draining veins together with the venous aneurysm are occluded. D, Follow-up carotid angiogram after 12 weeks confirms complete occlusion of the DAVF.