Spontaneous closure of a cavernous sinus dural arteriovenous fistula with spinal perimedullary drainage (Cognard V) during attempted transvenous embolization

Abstract

The authors describe a patient with spontaneous closure of a spontaneous cavernous sinus dural arteriovenous fistula (CSDAVF), Cognard type V, during transvenous attempt. A 39-year-old woman experienced mild proptosis, redness of the left eye, and diplopia. Four months later, she developed left retro-orbital pain and left-sided headache. Cerebral angiography revealed the left CSDAVF exclusively draining into the superior petrosal sinus with subsequent drainage into the veins surrounding the medulla oblongata, and finally into the perimedullary spinal veins, classified as Cognard type V. The feeders arise from the dural branches of both the left external and internal carotid arteries. Following 2 h period of attempted transvenous embolization, the fistula disappeared spontaneously. Follow-up angiography obtained 6 months later confirmed complete resolution of the CSDAVF. At 2-year follow-up, the patient has remained clinically asymptomatic. The mechanism of thrombosis in this fistula related to the endovascular procedure. We speculated that putting the wire tip in the draining vein may induce the spontaneous thrombosis in the venous side. In addition, precipitating factors may include small, low-flow fistula, and pre-existing thrombosis.

Spontaneous complete regression of malignant cavernous sinus dural arteriovenous fistula following partial transarterial embolization with liquid embolic material: Report of two cases

“…[ 4 , 13 , 15 ] However, the occurrence of spontaneous closure in cranial DAVFs with cortical venous reflux or a higher type of Cognard classification is extremely rare. [ 3 , 10 ] Fortunately, spontaneous complete regression of the fistulas, including Cognard type IIb and V, occurred in our 2 cases.…”

“…Due to the risk of embolic complications associated with transarterial embolization of CSDAVFs, a transfemoral transvenous approach through the ipsilateral IPS is recommended as the first-line access, whether the IPS is patent or occluded. [ 10 ] Following an unsuccessful approach through ipsilateral IPS, the cavernous sinus may be accessed through various routes, including contralateral IPS, SPS, facial vein, pterygoid plexus, or superficial middle cerebral vein. [ 11 ] Transorbital access by direct puncture or surgical exposure of the distal SOV is another viable option.…”

“…[ 9 ] Interestingly, Iampreechakul et al . [ 10 ] reported spontaneous closure of CSDAVF with spinal perimedullary drainage (Cognard V) during attempted transvenous embolization. They speculated that putting the wire tip into the draining vein may induce the spontaneous thrombosis on the venous side.…”

Transfemoral transvenous embolization through the vein of Trolard and superficial middle cerebral vein for cavernous sinus dural arteriovenous fistula with isolated cortical vein drainage: A case report and literature review

“…[13,19] Despite the absence or occlusion of IPS, the experienced neurointerventionist preferred to use this route as the first choice for transvenous embolization of CSDAVFs. [8,9] A combined surgical and endovascular access to obliterate CSDAVFs should be considered as a final option. [6] In our case, percutaneous transvenous access to the fistula through IPS was attempted but failed.…”

Dural Sinus Arteriovenous Malformation in the Fetus. Case Report and Discussion of the Literature

“…Treatment by endovascular embolization or surgery is a first line option, but it presents high risk in some cases and is not always resolutive [ 16 , 17 , 18 , 19 ].…”