Cavernous sinus dural arteriovenous fistula (CS-DAVF) is an abnormal communication between the CS and dural arteries from the internal carotid artery and external carotid artery. CS-DAVFs are not uncommon. The preferred treatment for most CS-DAVFs is transvenous embolization (TVE), which can achieve a high cure rate with few complications. The trans-inferior petrous sinus (IPS) route from the internal jugular vein to the CS is the favorite and most direct route to perform TVE in the great majority of CS-DAVFs. However, when the trans-IPS route fails and if the facial vein (FV) is patent and dilated, transfemoral trans-FV-superior ophthalmic vein (SOV) embolization of the CS-DAVF can be attempted. However, the transfemoral trans-FV-SOV route to embolize CS-DAVFs is often challenging, and there is insufficient knowledge about it. Therefore, an updated review of the transfemoral trans-FV-SOV route to embolize CS-DAVFs is necessary, and this review includes our experience. The images in this review are from our institute without the dispute of copyright. Issues regarding the transfemoral trans-FV-SOV route to embolize CS-DAV were discussed, including the FV anatomy and variation, various TVE routes to access CS-DAVF, the procedure of the transfemoral trans-FV-SOV route to embolize CS-DAVF, difficulty, and solution of the transfemoral trans-FV-SOV route to embolize CS-DAVF, and complications and prognosis of transfemoral trans-FV-SOV to embolize CS-DAVF. By reviewing the transfemoral trans-FV-SOV route to embolize CS-DAVFs, we found that this route provides a valuable alternative to the other transvenous routes. A good prognosis can be obtained with the transfemoral trans-FV-SOV route to embolize CS-DAVFs in select cases.

BackgroundAneurysms in moyamoya vessels or on collaterals are difficult to treat. Parent artery occlusion (PAO) via endovascular treatment (EVT) is often the last resort, but the safety and efficacy of this approach need to be evaluated.Materials and methodsA retrospective study was performed on patients admitted to our hospital who were diagnosed with unilateral or bilateral moyamoya disease (MMD) associated with ruptured aneurysms in moyamoya vessels or on collaterals. These aneurysms were treated with PAO, and the clinical outcome was recorded.ResultsEleven patients were aged 54.7 ± 10.4 years, and six patients were male (54.5%, 6/11). The aneurysms in 11 patients were single and ruptured, and the average size was 2.7 ± 0.6 mm. Three (27.3%, 3/11) aneurysms were located at the distal anterior choroidal artery, 3 (27.3%, 3/11) were at the distal lenticulostriate artery, 3 (27.3%, 3/11) were at the P2–3 segment of the posterior cerebral artery, 1 (9.1%, 1/11) was at the P4–5 segment of the posterior cerebral artery, and 1 was at the transdural location of the middle meningeal artery. Among the 11 aneurysms, PAO by coiling was performed on 7 (63.6%, 7/11), and Onyx casting was performed on 4 (36.4%, 4/11). Of 11 patients, 2 (18.2%, 2/11) suffered intraoperative hemorrhagic complications. During follow-up, all patients had good outcomes with a modified Rankin scale score of 0–2.ConclusionAs a last resort, the application of PAO with coiling or casting Onyx for ruptured aneurysms in moyamoya vessels or on collaterals may be safe with an acceptable clinical outcome. However, patients with MMD may not always achieve expected health outcomes, and PAO for the aneurysm can bring only temporary relief.

No abstract

Background. Only a few reported studies have used computed tomography angiography (CTA) to image ruptured aneurysms at the junction of the internal carotid artery (ICA) and posterior communicating artery (PcomA) in the context of the adjacent arteries. Therefore, we performed such a study using a GE Workstation. Methods. The parameters of each aneurysm and its adjacent arteries were measured. Then, statistical assessments were performed to compare the parameters of the aneurysm side and the lesion-free (control) side. Results. Sixty-three patients were included in this study. The average age was 62.1 ± 11.0 years, and the ratio of males to females was 0.8 : 1. The measurement results showed that the mean aneurysmal height was 5.2 ± 2.3  mm, the mean width was 4.7 ± 2.2   mm, and the mean neck width was 4.5 ± 1.9   mm. On the aneurysm side, the intradural ICA diameter was 4.34 ± 0.90  mm, and the diameter of the ICA at its termination was 3.55 ± 0.72   mm. A fetal-type PcomA was found in 52.4% of aneurysms. The other measured parameters were also provided. Statistical results showed that the height of the aneurysm was larger than the width ( P < 0.05 ). The intradural ICA diameter, the ICA diameter at termination, the intradural ICA length, and the angle between the ICA and PcomA were larger in the aneurysm group than in the control group ( P < 0.05 ). Conclusions. This CTA study showed that the ruptured PcomA aneurysm was often wide-necked, nonspherical, and approximately 5 mm in size. In the presence of a ruptured PcomA aneurysm, the affected intradural ICA became thicker and longer than the contralateral control ICA, and the aneurysm significantly reduced the angle between the ICA and the PcomA.

Background Main trunk aneurysms in the residual anterior circulation in moyamoya disease (MMD) are uncommon, and in such cases, endovascular treatment (EVT) is a good choice. Materials and methods A retrospective study was performed on 35 consecutive patients admitted to our hospital who were diagnosed with MMD and main trunk aneurysms in the residual anterior circulation and were treated with EVT. Result The 35 patients were aged 38–77 years (mean, 56.1 ± 8.8 years) and included 17 females (48.6%, 17/35). There were 29 cases (82.9%, 29/35) of hemorrhagic onset. In 35 patients, there were 38 main trunk aneurysms in the residual anterior circulation. Thirty-eight aneurysms underwent coiling; among them, coiling with stent assistance was used in the treatment of 6 (15.8%, 6/38) aneurysms. The immediate modified Raymond-Roy classification (MRRC) was grade I for all aneurysms. Among 35 patients, intraoperative bleeding occurred in 2 (5.7%, 2/35) patients. After EVT, immediate hemiplegia occurred in 4 (11.4%, 4/35) patients, and immediate coma occurred in 1 (2.9%, 1/35) patient. At discharge, in 35 patients, the Glasgow Outcome Scale (GOS) was five in 88.6% of them. Of 35 patients, 68.6% had follow-up data, GOS was five in 87.5% patients, and the MRRC was grade I for all aneurysms in the follow-up angiography. Conclusion For main trunk aneurysms in the residual anterior circulation in MMD, although EVT was accompanied by potential ischemic and hemorrhagic complications, which should be considered, EVT can still offer an acceptable prognosis in more than 85% of patients.