Dural Arteriovenous Shunts in the Region of the Cavernous Sinus
TL;DR: In this paper, a review of 30 carotid cavernous-sinus fistulae was conducted and the authors found that the most frequent source of blood from the internal artery was the meningo-hypophyseal trunk, while contributions from the contralateral dural vessels were frequently observed.
Abstract: Dural arteriovenous shunts in the region of the cavernous sinus probably account for most so-called spontaneous carotid-cavernous sinus fistulae. Eleven patients with this type of dural shunt were found in a review of 30 carotid cavernous-sinus fistulae. These shunts usually appear in middle-aged women as a distinctive syndrome. The signs usually are mild and include dilated conjunctival veins, proptosis, and bruit. Transient sixth-nerve palsy and unilateral headache frequently antedate orbital signs by many months. Spontaneous resolution is common.—Complete and selective cerebral angiography is essential for diagnosis. The dural shunt is usually one of low flow and low pressure, allowing normal opacification of intracranial arteries during carotid arteriography. Arterial contributions to these fistulae arise from meningcal branches of the internal and external carotid arteries. Terminal meningeal branches of the internal maxillary artery are the most common source of blood from the external carotid artery that supply the fistula. The most frequent source from the internal carotid artery is the meningo-hypophyseal trunk. Contributions from the contralateral dural vessels were frequently observed. The fistula is usually situated posteriorly in the cavernous sinus and, in most instances, venous drainage extends anteriorly into the ophthalmic veins.
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TL;DR: A classification is proposed that unifies and organizes spinal and cranial dural arteriovenous fistulous malformations (AVFMs) into three types based upon their anatomical similarities.
Abstract: A classification is proposed that unifies and organizes spinal and cranial dural arteriovenous fistulous malformations (AVFMs) into three types based upon their anatomical similarities. Type I dural AVFMs drain directly into dural venous sinuses or meningeal veins. Type II malformations drain into dural sinuses or meningeal veins but also have retrograde drainage into subarachnoid veins. Type III malformations drain into subarachnoid veins and do not have dural sinus or meningeal venous drainage. The arterial supply in each of these three types is derived from meningeal arteries. The anatomical basis of the proposed classification is presented with several cases that illustrate the three types of dural AVFMs. A rationale for the treatment of spinal and cranial dural AVFMs according to their anatomical characteristics is discussed.
1,032 citations
TL;DR: The authors describe their experience with four cases of dural arteriovenous malformation (AVM) which led them to analyze the clinical aspects of these lesions in an attempt to understand their pathophysiology.
Abstract: The authors describe their experience with four cases of dural arteriovenous malformation (AVM) which led them to analyze the clinical aspects of these lesions in an attempt to understand their pathophysiology. An additional 191 previously reported cases of dural AVM's were reviewed with special attention to the mechanism of intradural, central, and peripheral nervous system manifestations. Apart from the peripheral cranial nerve symptoms, which are most likely due to arterial steal, the central nervous system (CNS) symptoms appear to be related to passive venous hypertension and/or congestion. Generalized CNS symptoms can be related to cerebrospinal fluid malabsorption due either to increased pressure in the superior sagittal sinus, to venous sinus thrombosis, or to meningeal reaction resulting from minimal subarachnoid hemorrhages. These phenomena are not related to the anatomical type of venous drainage. On the other hand, focal CNS symptoms are specifically indicative of cortical venous drainage. Seizures, transient ischemic attacks, motor weakness, and brain-stem and cerebellar symptoms can be encountered depending on the territory of the draining vein or veins. Therefore, the localizing value of focal CNS symptomatology relates to the venous territory and not to the nidus or to the arterial supply characteristics of dural AVM's. Furthermore, the venous patterns of various dural AVM's at the base of the skull are expressed by differences in their clinical presentation. Dural AVM's of the floor of the anterior cranial fossa and of the tentorium are almost always drained by the cortical veins and, therefore, have a high risk of intradural bleeding. The remarkable similarities in the manifestations of dural and brain AVM's and the differences in the manifestations of dural and spinal dural AMV's are pointed out. High-quality angiograms and a multidisciplinary approach to the study of dural AVM's will provide the best understanding of their symptoms and, therefore, the most appropriate treatment strategy.
597 citations
Journal Article•
TL;DR: Thirteen patients underwent transvenous embolization as a treatment for symptomatic cavernous dural fistulas and all procedures were performed from a femoral vein access through the inferior petrosal sinus or basilar plexus.
Abstract: Because of the risks associated with arterial embolization of cavernous dural fistulas, we have sought an alternative method to promote fistula closure. Thirteen patients underwent transvenous embolization as a treatment for symptomatic cavernous dural fistulas. All procedures were performed from a femoral vein access through the inferior petrosal sinus or basilar plexus. In five patients the inferior petrosal sinus was not angiographically demonstrable; however, embolization was still possible through this route in two patients. The embolic agents used were detachable balloons in one patient, coils alone in five, coils and liquid adhesives in four, coils plus silk sutures in one, silk sutures alone in one, and liquid adhesives alone in one. Nine patients had follow-up angiograms, which showed complete obliteration of the fistulas and complete resolution of related symptoms. One patient had complete resolution of clinical symptoms but refused follow-up angiography. Another patient had 50% decrease in fistula flow on the follow-up angiogram and improvement in clinical symptoms. Two patients had complete fistula obliteration after embolization and progressive improvement in symptoms but follow-up angiograms had not been obtained. Follow-ups ranged from 1 to 97 months (mean, 15 months). Two complications were related to this treatment. An embolic stroke followed transient placement of a balloon in the internal carotid in one patient, and a second patient developed transient visual loss when the venous outflow pathways were occluded before fistula closure. The fistula was immediately closed with complete recovery of vision. With recent advances in microcatheter and embolic agent technology, transvenous closure of cavernous dural fistulas is now possible.(ABSTRACT TRUNCATED AT 250 WORDS)
251 citations
Cites background from "Dural Arteriovenous Shunts in the R..."
...Fistulas involving the cavernous sinus region occur most often in elderly women [2] and frequently present with chemosis, proptosis , and ophthalmoplegia....
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TL;DR: A review of CCFs is provided, detailing the current classification and clinical management of these lesions, and therapeutic options including conservative management, open surgery, endovascular intervention, and radiosurgical therapy are presented.
Abstract: Carotid-cavernous fistulas (CCFs) are vascular shunts allowing blood to flow from the carotid artery into the cavernous sinus. The characteristic clinical features seen in patients with CCFs are the sequelae of hemodynamic dysfunction within the cavernous sinus. Once routinely treated with open surgical procedures, including carotid ligation or trapping and cavernous sinus exploration, endovascular therapy is now the treatment modality of choice in many cases. The authors provide a review of CCFs, detailing the current classification and clinical management of these lesions. Therapeutic options including conservative management, open surgery, endovascular intervention, and radiosurgical therapy are presented. The complications and treatment results as reported in the contemporary literature are also reviewed.
212 citations
TL;DR: Angiograms obtained prior to treatment in 53 cases of deep-seated cerebral arteriovenous malformations were retrospectively analyzed with particular attention to the topography of the AVM nidus and the venous drainage to suggest a relationship between an increased incidence of intracranial bleeding and impaired venous outlets.
Abstract: ✓ Angiograms obtained prior to treatment in 53 cases of deep-seated cerebral arteriovenous malformations (AVM's) were retrospectively analyzed with particular attention to the topography of the AVM nidus and the venous drainage. The location of the lesion was determined by a combination of angiography and computerized tomography. Twenty-seven AVM's involved the basal ganglia and thalamus, 12 were located in the corpus callosum, six were intraventricular, and eight involved the mesencephalon and brain stem. Forty-one patients (77.3%) presented with intracranial hemorrhage. Vessel wall irregularities and/or stenosis of the system of the vein of Galen were observed in 14 cases, and occlusion of the deep venous system was present in seven cases. These AVM's showed numerous collateral venous pathways through enlarged medullary and cortical regional veins. There was dominant participation of the basal vein of Rosenthal in all cases. Unique local hemodynamic factors produced by the convergence of the draining ve...
147 citations