The Neuroradiology Journal 19: 537-549, 2006

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Endovascular Therapy for Intracranial Dural Arteriovenous Fistulas W.K.W. CHONG*, M. HOLT** * Interventional Neuroradiology Unit, Diagnostic Imaging, Monash Medical Centre; Clayton, Victoria, Australia ** Diagnostic Imaging, Monash Medical Centre; Clayton, Vic, Australia

Key words: dural arteriovenous fistulas, embolisation, endovascular therapy, N-butyl cyanoacrylate, DAVF

SUMMARY – A retrospective study was conducted on 17 consecutive patients with DAVF admitted to Monash Medical Centre over 12 years. 15 patients, 82.4%, were treated by endovascular means with the intention to obliterate the fistula. Three of these patients also had surgery following embolisation. Angiographic cure was achieved when we have successfully embolised both the arterial and the venous side whether by penetration of liquid adhesive or packing with coils. Our cure rate of 60% (95% CI: 37-83%) compare favourably with published results of 50 to 70%. Our clinical complication rate is 1/15, 6%; and technical complication is1 from 32 embolisation sessions, 3.1%. Endovascular therapy is effective in achieving a durable angiographic and clinical cure in the treatment of intracranial DAVF. Both arterial and venous side need to be occluded.

Introduction The aim of this study is to determine the efficacy of endovascular treatment of intracranial dural arteriovenous fistulas (DAVF) in a single Australian centre. Intracranial dural arteriovenous fistulas are arteriovenous shunting which have developed within the walls of the dural sinus. The essential abnormality found was a connection between the dural arteries and the dural veins within the venous sinus wall, through small vessels (“crack-like vessels”) averaging approximately 30 micron in diameter. DAVF are accepted to be acquired lesions, which develop in middle to late adulthood 1. However, the pathogenesis is still debated. Some DAVF are associated with thrombosis or occlusion of a dural venous sinus, with the implication of a causal link. The natural history is varied. The so called nonaggressive or benign DAVF tend to remain clinically stable over long period of time and 18 to 50 % of this lesion may resolve spontaneously. However, some of these patients may suddenly exhibit paradoxical aggressive clinical behaviour. A significant proportion of DAVF have aggressive behaviour leading to

haemorrhage and ischaemic stroke, seizures, central nervous system depression, intractable headache, hydrocephalus, myelopathy, visual impairment and dementia among others. Therefore there is no question to treat the aggressive ones 1,2. These lesions may be treated with embolisation, operative surgery, stereotactic radiosurgery or with various combinations of the above 3,4,5,6,7,8,9,10,11,12 . Radiosurgery with or without prior embolisation, has a role. O’leary reported angiographic cure in 10 out of 13 patients with one deterioration 9. However, they also reported that 3 patients developed cerebral infarcts months after radiosurgery. Embolisation by itself has an angiographic cure rate of between 50% to 70% 4,6,14,15,16. Permanent complication rates varied from 5% to 12% 14. With the advent of safer and more effective endovascular technique, the threshold to perform both palliative and curative procedures by endovascular means has been substantially lowered. Embolisation with particulate material such as polyvinyl alcohol (PVA) and proximal coil embolisation of feeder arteries do not provide permanent cure. Durable cure may be achieved by transarterial, transvenous or 537

Endovascular Therapy for Intracranial Dural Arteriovenous Fistulas

W.K.W. Chong

A

B

C

D

by a combined approach using liquid adhesives such as N-butyl cyanoacrylate (NBCA) or Onyx in the transarterial route or with coil occlusion of the involved venous sinus 2,12,14. The nidus itself and the venous side of the fistula need to be occluded for cure. More recently, recanalisation and stenting of an occluded transverse/sigmoid sinus resulted in a cure 9.

Methods

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A retrospective study was conducted on 17 consecutive patients admitted to Monash Medical Centre with the diagnosis of intracranial dural arteriovenous fistulas (DAVF) between October 1991 and May 2004 (12 ½ years). The inclusion criteria were all patients who had DAVF involving intracranial dural sinuses

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The Neuroradiology Journal 19: 537-549, 2006

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F

Figure 1 Patient 6. Fifty-one year old female with right sigmoid and transverse sinus DAVF. Note that the sinuses are patent but there is a severe stenosis in the sigmoid sinus. Main arterial pedicles from meningeal branch of right vertebral (A), middle meningeal (B) and occipital (C) arteries. 2 carotid wall stents were deployed within the sigmoid sinus (D). 12 months after the 4th embolisation session there was only a small amount of fistulation from the MMA (E) and occipital arteries (F) with still some cortical reflux. All symptoms resolved.

Table 1 Cognard Classification of DAVF

Type

Venous Drainage

Type I

Sinus Only - Antegrade Flow

Type IIa

Into Sinus - Reflux Into Sinuses

IIb

Into Sinus - Reflux Into Cortical Veins

Type III

Directly Into Cortical Veins

Type IV

Directly Into Cortical Veins - Venous Ectasia

Type V

Into Spinal Perimedullary Veins

with or without intracranial venous reflux. These included 1 case of indirect carotid cavernous fistula (CCF). Patients with fistula draining directly into spinal perimedullary veins without concomitant cortical reflux, purely spinal DAVF, and direct (type 1) CCF were excluded. Therefore the patients corresponded to Cognard 13 Type I to V (table 1 & table 2).

15 of the 17 patients, 82.4%, were treated by endovascular means. Three of these patients also had surgery following embolisation. 2 patients had surgery only (table 3 & table 4). Both of these patients had anterior cranial fossa DAVF, one spontaneous and one following a motor vehicle accident 16 years prior. In both patients, the neurosurgeons decide to operate without first attempting embolisation. 539

Endovascular Therapy for Intracranial Dural Arteriovenous Fistulas

W.K.W. Chong

Table 2 Location and Cognard Classification of Treated DAVF Patient

Age (years)/sex

Type

1

59/female

I

2

76/female

3

Fistula Location

Presentation

Arterial pedicles

Venous drainage

Rt Sigmoid Sinus

Pulsatile tinnitus

Rt Occip, AscPh, MMA, MHT

Rt Sigmoid Sinus. Rt transverse sinus occluded No cortical venous reflux

II b

Rt superior petrosal sinus

Subarachnoid haemorrhage

Rt MMA, Occip, MHT, PICA

Cortical venous reflux into transverse/sigmoid sinus Superior petorsal sinus occluded Spheno-bregmatic venous aneurysm

58/female

II b

Superior sagittal sinus

Intraventricular haemorrhage

Bil Occip, MMA. Bil Meng Br of Vertebral

Superior sagittal Sinus All sinuses patent Extensive Rt occipital cortical venous reflux

4

51/male

II b

Lt transverse sinus

Lt occipital & temporal lobe haemorrhage

Bil Occip. Lt MMA, Meng Br of Vertebral

Lt transverse sinus Lt sigmoid sinus occluded. Stenosis in Lt transverse sinus Extensive cortical venous reflux in occipital region

5

79/female

II b

Superior sagittal sinus

Confusion, dysphasia

Bil MMA

Superior sagittal sinus Occluded posterior superior sagittal & Lt transverse sinus Extensive cortical venous reflux in Lt parietal, temporal & occipital region

6

51/female

II b

Rt sigmoid & transverse sinus

Tinnitus & headache

Bil Meng Br of Vertebral RT MMA, Occip, AscPh, MHT

Rt sigmoid & transverse sinus All sinuses patent, Stenosis of sigmoid sinus Extensive cortical venous reflux in Rt temporal & occipital region

7

28/male

II b

Superior sagittal sinus

Headaches

Bil Occip, MMA Lt Meng Br of Vertebral

Superior sagittal sinus All sinuses patent. Extensive cortical venous reflux Venous varix adjacent to superior sagittal sinus

8

33/male

II b

Rt sigmoid sinus

Headache and tinnitus after recent head injury

Rt Occip

Posterior fossa veins into patent transverse sinus Distal sigmoid sinus occluded Posterior fossa cortical venous reflux

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The Neuroradiology Journal 19: 537-549, 2006

Table 2 (cont’d) Location and Cognard Classification of Treated DAVF Fistula Location

Presentation

Arterial pedicles

Venous drainage

II b

Superior sagittal sinus

Cosmetic, prominent vein on forehead

Rt MMA, Occip, STA, Meng Br of Vertebral, Ethm Br of Opth

Superior sagittal sinus Anterior superior sagittal sinus occluded Extensive Cortical venous reflux

53/male

III

Lt parietal cortical vein

Lt Occipital haemorrhage

Lt MMA, AscPh

Cortical venous reflux drained into superior sagittal sinus All sinuses patent

11

46/male

IV

Lt occipital cortical vein

Subarachnoid haemorrhage preceded by tinnitus

Lt MMA, Occip.

Single pial vein containing 6 mm venous aneurysm drained into superior sagittal sinus All sinuses patent Cortical venous reflux

12

55/male

IV

Lt frontal cortical vein

Severe headache

Lt Occip, MMA, STA

Cortical venous reflux drained into superio sagittal sinus All sinus patent

13

69/male

IV

Lt superior petrosal sinus

Headache, Lt ear deafness & ataxia

LT MMA, Occip, Int Max

Drained into giant venous varix at occluded superior petrosal sinus Varix drained into straight sinus Lt transverse sinus occluded Posterior fossa cortical venous reflux

14

20/male

V

Marginal/ occipital sinus

Sudden dizziness, vomiting and headache

Rt Occip, Meng Br of Vertebral

Drained directly into spinal perimedullary veins Near occlusion of transverse sinus

15

66/male

Indirect Rt CCF

Rt cavernous Sinus

Rt trochlear nerve palsy, ptosis, tinnitus

Bil ICA Rt Int Max, MMA, Ethm Br of Opth

Superior & Inferior opthalmic veins into angular vein of face Occluded superior & inferior petrosal sinus No cortical venous reflux

Patient

Age (years)/sex

Type

9

36/male

10

List of Abbreviations Used in Tables 2 and 3 – MMA middle meningeal artery; PICA posterior inferior cerebellar artery; MHT meningo hypophyseal trunk; Meng Br of Vertebral meningeal branch of vertebral artery; Occip occipital artery; Asc Phg ascending pharyngeal artery; Rt right; Lt left; Bil bilateral; Int Max Internal maxillary artery; STA superficial temporal artery; PVA polyvinyl alcohol particles; CCF carotid cavernous fistula; ICA internal carotid arteries; Ethm Br of Opth Ethmoidal branch of ophthalmic artery; NBCA N-butylcyanoacrylate; Angio angiogram

Embolization Methods These are discussed in detail in table 3. All embolization were performed as inpatient procedures. Diagnostic angiograms were first per-

formed and the cases were discussed with the neurosurgical team before the interventional procedures were performed. Except for 2 patients (cases 2 and 5), the majority of the procedures were performed under general anaes541

Endovascular Therapy for Intracranial Dural Arteriovenous Fistulas

W.K.W. Chong

Table 3 Treatment details and follow up

Transarterial/ Transvenous

Embolic agent

Immediate Outcome after last embolisation session

Follow up: Angiographic/ Clinical after last embolisation session

Patient

Number of Embolization sessions

1

2

Rt Occip, MMA.

20-25% NBCA

Fistula persists

None

6 weeks: No tinnitus No clinical symptoms No angio follow up

2

3

Rt MMA, Occip, MHT.

150-500 micron PVA

Fistula persists

Transient left arm weakness Recovered after several days

12 months: Fistula persists Decreased cortical reflux Patient well

3

2

Rt & Lt MMA

20% NBCA

Fistula persists

None

Surgery 2 days post embolisation 1 year: Fistula occluded Patient well

4

2

Lt Occip

50% NBCA

None

Lt MMA, Occip

Onyx 18

Fistula persists, but decreased

1 month: Fistula occluded No further haemorrhage

1

Sigmoid sinus

Non retrievable microcoils, Detachable Platinum coils (total 46)

5

2

Rt & Lt MMA

50% NBCA

Fistula occluded

None

No follow up

6

4

Bil Meng Br of Vertebral RT MMA, Occip, AscPh,

150-500 micron PVA, 20% NBCA,

Wire perforation of MMA. Treated with NBCA

Sigmoid sinus

2xCarotid Wallsetents, Detachable Platinum coils (total 20), Onyx 18 & 34.

Fistula persists, but nearly occluded Supplied by Lt Meng Br of Vertebral Stent and sigmoid sinus Thrombosed

7 months after 3rd embolisation Small persistent fistulation from Lt Meng Br of Vertebral Tinnitus and headache resolved No symptoms from perforation

LT Occip

150-500 micron PVA & 50% NBCA

None

Lt MMA

60% NBCA & 6% Embolyx

Surgery 3 days post embolisation 19 months: Fistula occluded Patient well

Rt MMA

40% NBCA & 6% Embolyx

Fistula persists, 90% embolised Residual pedicle from Lt Meng Br of Vertebral.

RT Occip

30-40% NBCA

Fistula occluded

None

Immediate: Tinnitus & bruit resolved No long term follow up

7

8

542

3

2

Clinical Complication

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The Neuroradiology Journal 19: 537-549, 2006

Table 3 (cont’d) Treatment details and follow up Immediate Outcome after last embolisation session

Follow up: Angiographic/ Clinical after last embolisation session

Patient

Number of Embolisation sessions

9

3

& Lt MMA, STA

Embolyx 6%

Fistula persists

None

Surgery 2 days post embolisation 21 months: Fistula occluded Patient well

10

1

Lt MMA

60% NBCA

Fistula occluded

None

6 months: Fistula occluded Patient well

11

1

Lt MMA

40% NBCA

Fistula occluded

None

60 months: Fistula occluded Patient well, but intermittent tinnitus

12

1

Lt MMA

Onyx 34

None

Rt MMA

40% NBCA

Fistula occluded

6 months: Clinical only-symptom free

LT MMA, Occip

20% NBCA

None

Lt Int Max

150-250 micron PVA

Fistula occluded

Lt MHT

20% NBCA

12 months: Fistula occluded Symptoms almost completely resolved Patient well

Venous Varix

Detachable Platinum coils (total 8) & 1 ml absolute alcohol

13

2

Transarterial/ Transvenous

Embolic agent

Clinical Complication

14

1

Rt occip

20% NBCA

Fistula occluded

None

2 months: readmitted with headache but normal CT. No angiogram

15

2

Rt MMA

20% NBCA

None

Rt Cavernous sinus

Detachable Platinum coils (total 21) 80 % cavernoussinus packed

Fistula persists, but decreased

3 months: Fistula occluded Patient well, no symptoms

thetics which greatly facilitated the procedures due to lack of patient movement and patient discomfort. The number of embolization sessions varied from 1 to 4 per patient. There was no provocative testing used for any of the embolisation. Full heparinisation was used in all patients with an initial bolus dose of 5000 units and additional doses were use to keep the Activated Clotting Time (ACT) to about 200. The

heparin was allowed to wear off after the procedure. There was no post procedural anticoagulation or routine use of anti-platelet agents. Antibiotics were used if the arterial punctures were closed with percutaneous closure devices (Perclose - Abbot Vascular, Redwood City, CA, USA and Angioseal - St. Jude Medical, Minnetonka, Mn, USA). Five or six french guide catheters, Envoy MPC (Cordis Corporation, Miami 543

Endovascular Therapy for Intracranial Dural Arteriovenous Fistulas

W.K.W. Chong

A

B

C

D

Table 4 Treatment methods and results - 16 patients

Embolization only

Number cured with embolization only

Embolization & Surgery

Number cured with embolization & surgery

Surgery only

Number cured with surgery only

12

9

3

3

2

2

Florida, USA) and Fasguide (Boston Scientific, Fermont, California, USA) were used to access the carotid and vertebral arteries and the internal jugular veins in the neck. Via the guide 544

catheters, various combinations of microcatheters and microguidewires were used to cannulate the feeding arterial pedicles with the aim of reaching the fistula itself or as close to it as

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The Neuroradiology Journal 19: 537-549, 2006

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F

G

H

Figure 2 Patient 13. Sixty-nine year old male. This patient has a Type III DAVF with the fistula draining directly into a giant varix located at the left superior petrosal sinus. Lateral arterial (A) and venous (B) phases. A renegade microcatheter has been navigated into the giant Varix via the transverse, sigmoid and straight sinuses and a tortuous peri-mesencephalic vein (C). The fistula was embolized with 8 coils and 1 ml of absolute alcohol was injected into the fistula via the varix. Note the residual fistulation from the meningo hypophyseal trunk of the internal carotid (D). The residual feeder from the meningo hypophyseal trunk was embolized with 20% NBCA resulting in occlusion of fistula (E). Follow-up angiogram at 12 months demonstrated complete closure of the fistula (F). Initial MRI (G) demonstrating giant varix in the posterior fossa. 12 months (H) follow-up MRI demonstrated that the varix has virtually disappeared.

possible. The microcatheters included Tracker 10, Tracker 18 and Renegade (Boston Scientific, Fermont, California, USA), and Ultraflow HPC (Microtherapeutics, Irvine, California, USA).

The microguidewires included Fasdasher-14 (Boston Scientific, Fermont, California, USA) and SilverSpeed-10 (Microtherapeutics, Irvine, California, USA). Embolic agents included 545

Endovascular Therapy for Intracranial Dural Arteriovenous Fistulas

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A

B

C

D

Table 5 Characteristics of DAVF presenting with Haemorrhage

Patient Number

Venous Aneurysm/Varix

Cortical venous reflux

Sinus Occlusion

Type

Location

2

+

+

+

IIb

Superior Petrosal sinus

3



+



IIb

Superiro rsagittal sinus

4



+

+

IIb

Transverse sinus

10



+



III

Lt parietal cortical vein

11

+

+



IV

Lt occipital cortical vein

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The Neuroradiology Journal 19: 537-549, 2006

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Figure 3 Patient 15. Sixty-six year old male. Note indirect right cavernous sinus fistula draining into the superior and inferior ophthalmic vein (A) and refluxing into the angular vein of the face (B). This was cannulated via ultrasound control to navigate a micro-catheter into the cavernous sinus. There was a major arterial pedicle from the middle meningeal artery (C) which was embolised with 20% NBCA (D). Dense packing was achieved with 21 coils (E). Six months follow-up demonstrated complete occlusion of the fistula (F).

150-250 and 355-500 microns polyvinyl alcohol particles (Contour, Boston Scientific, Fermont, California, USA), N-butylcyanoacrylate ( Histoacryl, B Braun Surgical, Germany) diluted to 20 to 60 % with iodised oil (Lipiodol Ultra Fluid, Guerbet, Aulnay-sous-Bois, France) and Onyx18 and Onyx-34(previously known as Embolyx 6% and 8%) Liquid Embolic System (Microtherapeutics, Irvine, California, USA). The venous side was embolised with non-retrievable Straight or Complex Helical Fibred Platinum Coils (Boston Scientific, Fermont, California, USA) retrievable detachable platinum coils (GDC, Boston Scientific, Fermont, California, USA) and Detachable Coil System, William Cook Europe, Bjaeverskov, Denmark). Review of clinical notes of the authors and review of patient medical histories and correspondence from referring doctors were used to determine the clinical status of the patients. There were three notable cases. In patient six (figure 1), two self expanding Carotid Wallstent Monorail (Boston Scientific, Fermont, California, USA) were initially inserted into the sigmoid sinus after pre dilatation with a 5 mm balloon in an attempt to open up the stenosis at the junction of the sig-

moid sinus and jugular bulb. The stents subsequently thrombosed along with the sigmoid sinus. GDC and Cook detachable coils were deposited in the sinus within the stent and in the vein of Labbe to stop the significant cortical reflux, subsequently Onyx 18 and Onyx 34 were deposited into the stent and the sigmoid sinus. Extensive embolisation was performed in the external carotid system and into the meningeal branches of the left vertebral artery. In case 13 (figure 2), a 69 year old male presented with headache, deafness in the left ear and ataxia. Trans arterial and venous embolisations were performed using NBCA, PVA particles, coils and absolute alcohol resulting in stable complete occlusion and resolution of symptoms at 12 months follow up. In case 15 (figure 3), ultrasound guided puncture of the angular vein on the face was used to gain retrograde access to the cavernous sinus. Results These are discussed in detail in table 3 and 4. Of the initial 17 patients, there were 6 females and 11 males. The patients’ ages ranged 547

Endovascular Therapy for Intracranial Dural Arteriovenous Fistulas

from 20 to 79 years. Cognard Type IIb was the most common (8/17, 47.1%) and all of these involved either the superior sagittal or the transverse/sigmoid sinus. Both anterior cranial fossa DAVF patients who went directly to surgery had Type III lesions. Superior sagittal and transverse/sigmoid lesions were the most common (4 each). There were 6 lesions draining directly into cortical veins, without or with venous aneurysm or varix, Type III and IV. All patients presenting with haemorrhages had venous cortical reflux, but the converse was not true as some patients with extensive reflux only had minor symptoms such as tinnitus and mild headaches. The 2 patients with venous aneurysm presented with subarachnoid haemorrhage (patient 2 and patient 11). The remainder of the results relate to the group of 15 patients where embolisation was first attempted with the intention to obliterate the fistula (table 3, table 4). 9 patients (60%) had obliteration of the fistula by embolisation alone. Of note, obliteration of the fistula was observed in 7 of these patients immediately after the last session of embolisation. 3 patients had angiogram follow up at 6, 12 and 60 months which confirmed the durability of the occlusion. None of these patients had recurrence of haemorrhage and all symptoms either markedly or completely resolved. The other 4 of these patients had no angiogram follow up, but 1 of these patients (number 12) waiting for a 12 month follow up angiogram remain symptom free 6 months later. The patient with the Type V lesion presented 2 months later with headaches but was neurologically normal and had a normal CT scan. He was discharged without a follow up angiogram. The other 2 were lost to follow up. 2 of the original 9 patients (patient 4, 15), had their fistulae nearly occluded at the time of the last embolisation session went on to complete occlusion at the 3 and 1 months angiogram follow up. 3 patients (Patients 3, 7, 9) went on to surgery 2-3 days after the last session of embolisation and all had angiographic cure at 12, 19 and 21 month follow up. 2 patients (number 1 and 2) had no further treatment despite persistent of fistula. However, 1 patient (number 1) had complete resolution of symptoms after 6 weeks. The other patient (number 2) aged 76 was 548

W.K.W. Chong

considered unfit for extensive cranial surgery, but had no recurrence of haemorrhage at 12 months. Complications There were only 2 complications. The first DAVF patient (number 2) that we treated in 1991 had a transient left arm weakness which recovered after a few days. This was the only clinical complication. The other complication was a wire perforation of the right middle meningeal artery during cannulation, the perforation was occluded with NBCA and the patient did not suffer any clinical sequelae. Discussion It would appear that cortical venous reflux is related to parenchymal haemorrhage and that venous aneurysm to subarachnoid haemorrhage. However, location of the lesion and the type is not crucial (table 5). It can take multiple sessions to successfully treat DAVF. All of the patients that we have achieved angiographic cure were those patients that we have successfully treated both the fistula and the venous side whether by penetration of liquid adhesive or packing with coils. Those DAVF that we failed to achieve this persisted and did not close. We used PVA particle only as a supplementary embolic agent, particularly if we were unable to get close to the nidus with the microcatheter. Our cure rate of 60% compare favourably with published results of 50 to 70 % 4,6,14,15,16 Whilst 7 of the 9 patients had immediate occlusion following the last session of embolisation, the other 2 (number 4 & 15) went on to occlude 1 to 3 months afterwards. This suggests that waiting a short period of time after the lesion is substantially treated would an appropriate strategy. Symptoms either resolved or improved and there were no recurrence of haemorrhage after the fistulae was occluded confirming that the treatment is effective. For 1 of the 3 patients (number 7) who went on to surgery after embolisation, the neurosurgeons were able to perform a smaller operation around the residual fistula site than they would have to do otherwise. Combination of embolisation and surgery is effective for large complex lesions. Partial but significant occlu-

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sion can relieve symptoms especially tinnitus and headaches (number 1 & 6 ). Our complication rate is excellent compared to reports of 5% to 12 % permanent deficit 14. On percentage terms, we had 1/15 (6.0%) for temporary clinical deficit and 1 technical complication out of a total of 32 embolisation sessions, that is, 3.1%.

The Neuroradiology Journal 19: 537-549, 2006

Conclusion Endovascular therapy is effective in achieving a durable angiographic and clinical cure in the treatment of intracranial DAVF. However, multiple sessions may be needed. Both the fistula and the venous side need to be embolised. Complication rate is low.

References 1 Hamada Y, Goto K, Inoue T et Al: Histopathological aspects of dural arteriovenous fistulas in the transversesigmoid sinus region in nine patients. Neurosurgery 40: 452-6, 1997. 2 Chaloupka JC: Endovascular Therapy for Dural Arteriovenous Fistulas. In: Marks MP, Do HM: Endovascular and Percutaneous Therapy of the Brain and Spine. Lippincott Williams & Wilkins, Philadelphia 2002: 277-315. 3 Sundt TM, Piepgras DG: The surgical approach to arteriovenous malformations of the lateral and sigmoid dural sinuses. J Neurosurg 59: 32-39, 1983. 4 ApSimon HT, Ives FJ, Khangure MS: Cranial dural arteriovenous malformation and fistula. Radiological diagnosis and management. Review of thirty four patients. Australas Radiol 37: 2-25, 1993. 5 Fransen P, Mathurin P, Pierre P et Al: Interest and necessity of combined neuroradiological and neurosurgical treatment in some cases of dural arterio-venous fistulae. Acta Neurochir 121: 26-33, 1993. 6 Pelz DM, Lownie SP, Fox AJ et Al:: Intracranial dural arteriovenous fistulae with pial venous drainage: combined endovascular-neurosurgical therapy. Can J Neurol Sci 24: 210-8, 1997. 7 Lin J, Elwood PW, Fraser KW: Venous ligation of dural arteriovenous fistulae. Br J Neurosurg 17: 239-43, 2003. 8 Kattner KA, Roth TC, Giannotta SL: Cranial base approaches for the surgical treatment of aggressive posterior fossa dural arteriovenous fistulae with leptomeningeal drainage: report of four technical cases. Neurosurgery 50: 1156-60, 2002. 9 O’Leary S, Hodgson TJ, Coley S et Al: Intracranial dural arteriovenous malformations: results of stereotactic radiosurgery in 17 patients. Clin Oncol (R Coll Radiol) 14: 97-102, 2002. 10 Bertalanffy A, Dietrich W, Kitz K et Al: Treatment of dural arteriovenous fistulae (dAVF’s) at the superior sagittal sinus (SSS) using embolisation combined with micro- or radiosurgery. Minim Invasive Neurosurg 44: 205-10, 2001. 11 Murphy KJ, Gailloud P, Venbrux A et Al: Endovascular treatment of a grade IV transverse sinus dural arteriovenousfistula by sinus recanalization, angioplasty, and stent placement: technical case report. Neurosurgery 46: 497-500, 2000. 12 Warakaulle DR, Aviv RI, Niemann D et Al: Embolisation of spinal dural arteriovenous fistulae with Onyx. Neuroradiology 45: 110-2, 2003.

13 Cognard C, Gobin YP, Pierot L et Al: Cerebral dural arteriovenous fistulas: clinical and angiographic correlation with a revised classification of venous drainage. Radiology 194: 671-80, 1995. 14 Halback VV, Higashida RT, Hieshima GB: Endovascular Therapy of Dural Fistulas. In: Vinuela F, Halback VV, Dion JE: Interventional Neuroradiology:Endovascular Therapy of the Central Nervous System, Raven Press, New York 1992: 29-50. 15 Berenstetin A: Dural arteriovenous malformations. Seventh annual Stowin medial conference abstracts. Am J Neuroradiol 11: 221-222. 16 Picard L, Bracard S, MalletJ et Al: Spontaneous dural arteriovenous fistulas. Seminar Intervent Radiol 4: 219-240, 1987.

Chong W, MD Interventional Neuroradiology Unit Diagnostic Imaging Monash Medical Centre Locked Bag No. 29 Clayton - Victoria 3168 Australia E-mail: [email protected] Tel.: + 613 9594 2200 Fax.: + 613 9594 6029

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Endovascular therapy for intracranial dural arteriovenous fistulas.

A retrospective study was conducted on 17 consecutive patients with DAVF admitted to Monash Medical Centre over 12 years. 15 patients, 82.4%, were tre...
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