Endovascular Treatment of Cavernous Sinus Dural Arteriovenous Fistulae: Review of the Literature and Current Status

Abstract

Cavernous sinus dural arteriovenous fistulae (CSdAVFs) are characterized by the shunts between dural arteries and dural veins surrounding the cavernous sinus (CS), causing ocular symptoms in addition to intracranial hemorrhage and infarction.As surgical access is difficult, endovascular treatment (EVT) has been considered and performed as the first-line therapy for decades. Although there have been recent advances in techniques and devices, transvenous embolization (TVE) with platinum coils remains the most common procedure. There are multiple access routes to the CS, such as the inferior petrosal sinus, superior ophthalmic vein (SOV), and intercavernous sinus from the contralateral CS. To extirpate the shunt, packing the entire sinus with coils is adopted, occasionally resulting in persistent cranial nerve palsy (CNP) due to compression of the coil mass.To avoid this complication, selective shunt occlusion (SSO), in which the coils are placed in the shunted pouch (SP) defined by the small restricted space where the arterial flow converges, is an effective and safe method. Transarterial embolization (TAE) is another option and use of liquid embolic materials, such as Onyx may be promising; however, the potential risk of ischemic nerve injury due to undesirable ante/retrograde influx of the liquid materials is of concern. In conclusion, EVT, especially TVE, is a safe and effective method for managing CSdAVFs. Understanding the angioanatomy consisting of the feeding artery, shunt point, and the drainage route, including the latent vessels, is essential for a good outcome. Keywords▶ cavernous sinus, dural arteriovenous fistulae, endovascular treatment, transvenous embolizationThis work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives International License.

Use of a Rigid-Tipped Microguidewire for the Endovascular Treatment of Cavernous Sinus Dural Arteriovenous Fistulas with an Occluded Inferior Petrosal Sinus

“…Endovascular treatment of the CSDAVF is revolutionized with the development of innovative endovascular devices [ 7 ]. Transfemoral TVE through the ipsilateral or contralateral IPS has been considered the safest and most effective option for treating the CSDAVF [ 2 , 7 , 9 , 11 , 24 ]. Once access to the CS is achieved, subsequent coil embolization is not that difficult, leading to successful treatment in most cases.…”

“…There are alternative transfemoral venous routes such as the superior petrosal sinus and superior ophthalmic vein. More invasive approaches such as direct transorbital puncture or surgery can also be performed in rare circumstances, but these may increase patient comorbidity [ 3 , 6 , 11 , 24 , 26 , 27 ].…”

“…The mode of the transvenous coil embolization needed to be discussed [ 24 ]. The entire sinus packing is the standard method.…”

“…Transvenous embolization (TVE) is the mainstream endovascular therapy for treating the cavernous sinus dural arteriovenous fistula (CSDAVF) [ 11 , 24 ]. Transfemoral venous routes to access the cavernous sinus (CS) are the ipsilateral or contralateral inferior petrosal sinus (IPS), superior petrosal sinus, and superior ophthalmic vein via the facial or superficial temporal vein [ 1 , 2 , 4 , 15 , 21 , 22 ].…”

“…Transfemoral venous routes to access the cavernous sinus (CS) are the ipsilateral or contralateral inferior petrosal sinus (IPS), superior petrosal sinus, and superior ophthalmic vein via the facial or superficial temporal vein [ 1 , 2 , 4 , 15 , 21 , 22 ]. The most favorite route is the ipsilateral IPS since it is relatively direct and short from the internal jugular vein (IJV) [ 11 , 24 ]. Sometimes, however, the IPS is found to be occluded due to thrombosis or fibrosis [ 2 , 5 , 10 , 12 , 16 , 17 , 20 , 25 ].…”