Endovascular treatment of intracranial dural arteriovenous fistulas with cortical venous drainage: new management using Onyx

Abstract

Background and purpose: DAVFs (dural arteriovenous fistulas) represent one of the most dangerous types of intracranial AV shunts. Most of them are cured by arterial or venous embolization, but surgery/radiosurgery can be required in case of failure. Our goal was to reconsider the endovascular treatment strategy according to the new possibilities of arterial embolization using non polymerizing liquid embolic agent.

Materials and methods: Thirty patients were included in a prospective study during the interval between July 2003 and November 2006. Ten of these had type II, 8 had type III, and 12 had type IV fistulas. Sixteen presented with hemorrhage. Five had been treated previously with other embolic materials.

Results: Complete angiographic cure was obtained in 24 cases. Of these 24 cures, 20 were achieved after a single procedure. Cures were achieved in 23 of 25 patients who had not been embolized previously and in only 1 of 5 previously embolized patients. Among these 24 patients, 23 underwent a follow-up angiography, which has confirmed the complete cure. Partial occlusion was obtained in 6 patients, 2 were cured after additional surgery, and 2 underwent radiosurgery. Onyx volume injected per procedure ranged from 0.5 to 12.2 mL (mean, 2.45 mL). Rebleeding occurred in 1 completely cured patient at day 2 due to draining vein thrombosis. One patient had cranial nerve palsy that resolved. Two ethmoidal dural arteriovenous fistulas were occluded. All 10 of the patients with sinus and then CVR drainage were cured.

Conclusion: Based on this experience, we believe that Onyx may be the treatment of choice for many patients with intracranial dural arteriovenous fistula (ICDAVF) with direct cortical venous reflux (CVR). The applicability of this new embolic agent indicates the need for reconsideration of the global treatment strategy for such fistulas.

Figures

Fig 1.

A 67-year-old man with a left temporal hematoma. A, Type IV DAVF of the transverse sinus draining directly into the vein of Labbe. B, Middle meningeal artery (MMA) was small compared with the occipital artery. C and D, MMA distal catheterization was easily performed. E, Onyx injection allowed arterio-arterial filling of other arterial feeders and occlusion of the draining vein. F, Postoperative 3-month assessment shows complete fistula cure.

Fig 2.

A 62-year-old woman with 1 episode of seizures. A–C, Type IV DAVF of the vein of Galen draining into multiple dilated veins to the superior sagittal sinus. The straight sinus was occluded. D and E, Distal catheterization of the right MMA allowed injection of 11 mL of Onyx in 48 minutes, with retrograde occlusion of other feeders, occlusion of the venous pouch, and no migration into cortical veins. F and G, Postoperative 3-month assessment shows complete fistula cure.

Fig 3.

A 68-year-old man with a left cerebellar hematoma. A and B, Type IV DAVF of the tentorium draining into the lateromesencephalic vein, then through a large venous ectasia into the central vein, then to the basal vein and straight sinus. C and D, Injection of Onyx resulted in occlusion of the origin of the draining vein. E, Extensive thrombosis of the draining vein and ectasia due to shunt occlusion with cerebellar rebleeding.

Fig 4.

A 68-year-old man with right vision loss. A, Type IV DAVF fed by the distal ophthalmic artery. B, External carotid feeders. C, Distal ophthalmic artery catheterization. D, Injection of 0.8 mL of Onyx over 43 minutes resulted in occlusion of the draining vein origin. E, Postoperative 3-month assessment shows complete fistula cure.

Fig 5.

A 67-year-old woman with seizures. A and B, Type IIa+b DAVF of the left transverse sinus draining into cortical veins and in the straight sinus. C and D, Injection of 9.3 mL of Onyx over 90 minutes through the middle meningeal artery. E, Postoperative 7-month assessment shows complete fistula cure.