The Neuroradiology Journal 20: 718-725, 2007
www. centauro. it
Transvenous Embolization with Onyx for Cavernous Sinus Dural Arteriovenous Fistula. A Report of Two Cases
CHUHAN JIANG, XIANLI LV, YOUXIANG LI, AIHUA LIU, ZHONGXUE WU Beijing Neurosurgical institute; Beijing, the People’s Republic of China Beijing Tiantan Hospital, Capital Medical University; Beijing, the People’s Republic of China
Key words: transvenous embolization, Onyx, dural arteriovenous fistula, cavernous sinus
SUMMARY – Previous treatments for cavernous dural arteriovenous fistulas (DAVF) include transarterial embolization with NBCA and transvenous embolization with platinum coils. This paper presents two cases of cavernous sinus dural arterial venous fistula successfully treated via a transvenous approach with Onyx. Case 1. A 54-year-old man presented with blepharotosis, diplopia and chemosis. Cerebral angiography demonstrated a cavernous DAVF, which was successfully treated via inferior petrosal sinus with a combination of Onyx and platinum coils. Case 2. A 36-year-old woman was admitted after incomplete transarterial embolization of a dural cavernous fistula. The patien’s symptoms resolved almost completely after embolization with Onyx-34 via the superior ophthalmic vein. To our knowledge, only two such cases have been reported in the literature. The advantages of Onyx make it an attractive alternative to the various platinum coils already described.
Introduction Various methods of treatment for dural arteriovenous fistulas (DAVFs) of the cavernous sinus have been described 1,3,5-10,13,14,16,19,21. Carotid compression therapy has been shown to be effective in some patients 8. Both transarterial and transvenous embolization have proved safe and effective 1,4-7,13,14,21. Surgical approaches have included direct placement of thrombogenic material into the cavernous sinus to promote thrombosis and closure. Transvenous endovascular techniques through the superior ophthalmic vein (SOV) and the inferior petrosal sinus (IPS) have been described in the treatment of cavernous sinus DAVF 1,4-6,14,16. We describe a novel liquid embolic agent (Onyx) used to cure cavernous sinus DAVFs via a transvenous approach. To our knowledge, there are only two cases reported in the literature 3,19. 718
Case Reports Case 1 A 54-year-old man presented with a two month history of blepharotosis, diplopia and chemosis. Cerebral angiograms showed a DAVF principally fed by the left meningohypophyseal trunk with additional small branches of the right internal carotid artery. Venous outflow emptied into the left inferior petrosal sinus and the left superior ophthalmic vein. Recommendation was made for transvenous embolization of the lesion. Under general anesthesia, catheterization was performed via a transfemoral approach using standard coaxial techniques. Systemic heparinization was achieved during the procedures with heparin 5000U bolus followed by 1000U of heparin every hour. A 5-French diagnostic catheter with continuous heparinized flush was positioned in the left internal carotid artery for selective control angiograms. The late venous phase of the left
Chuhan Jiang
Transvenous Embolization with Onyx for Cavernous Sinus Dural Arteriovenous Fistula
internal carotid angiogram revealed the IPS on this side. Therefore, this IPS was chosen for the endovascular approach. A 5-F guiding catheter was placed and, using road mapping technique and fluoroscopic guidance, a microcatheter (Echelon14, M.T.I) was advanced over a guidewire (Transend0.014, Boston Scientific) into the left IPS up to the left cavernous sinus. Three hydrocoils (two 5×12, one 6×15; Microvention) were packed first to reduce the venous outflow towards the superior ophthalmic vein. Then, under biplane roadmapping, the catheter was slowly flushed with 0.25 ml of DMSO over 40 seconds and this was followed by injection of Onyx (M.T.I). After 2.3 ml of Onyx-34 was injected into the cavernous sinus, we attempted to inject Onyx-18. In the meantime caution was exerted to avoid inadvertent embolization of the left internal carotid artery during the slow injection of Onyx. Patency of the left internal carotid artery was checked frequently during the intermittent injection of the embolic material, using a diagnostic catheter placed in the ipsilateral internal carotid artery. The amount of injected Onyx-18 was 2.6 ml. The procedure was completed as soon as a control angiogram revealed complete occlusion of the DAVF. The patient’s chemosis improved within the next day, but blepharotosis and diplopia were not improved. The patient was discharged on postprocedure day three. Case 2
A 36-year-old woman was referred to our hospital again after incomplete transarterial embolization of a dural cavernous fistula. On admission, she suffered from slight exophthalmos and chemosis of her right eye. A cerebral angiogram demonstrated a residual arteriovenous shunt of the right cavernous sinus supplied by the right meningohypophyseal trunk draining to the right superior ophthalmic vein (SOV). The right facial vein and the right superficial temporal vein were demonstrated angiographically draining the fistula. Because the approach of the superficial temporal vein was longer and tortuous, we decided to approach the right cavernous sinus through the right facial vein. A 5-French guiding catheter (Envoy; Cordis Endovascular System) was advanced through the right internal jugular vein into the right common trunk of the facial and retromandibular veins. A diagnostic catheter was placed in the right internal carotid artery via the left common femoral artery. A Marathon microcatheter
was advanced through the guiding catheter and through the right facial vein into the right superior ophthalmic vein. After traversing the superior ophthalmic vein, we gained access to the right cavernous sinus. Occlusion of the fistula was accomplished by filling the right cavernous sinus with 1.5 ml Onyx-34. In the meantime caution was exerted to avoid inadvertent embolization of the internal carotid artery during the slow injection of Onyx. Patency of the right internal carotid artery was checked frequently during the intermittent injection of the embolic material, using a diagnostic catheter placed in the ipsilateral internal carotid artery. There were no complications during the procedure. She was discharged three days after the procedure with symptoms improved. Discussion Cavernous sinus DAVF is an uncommon vascular anomaly resulting in increased pressure in the cavernous sinus. The subsequent changes in blood flow lead to orbital venous congestion, cranial neuropathies and glaucoma 12. Venous drainage to cortical veins can cause intracranial hemorrhage 11,14,15,18. Along with rapid advances in techniques and devices, endovascular treatment is now considered the first choice for aggressive treatment of cavernous sinus DAVF 15 . Previous techniques for permanent occlusion include transarterial embolization with NBCA and transvenous embolization with platinum coils 21. Transarterial embolization can markedly decrease a large area of shunt, but it is not likely to result in angiographic elimination and cure of an arteriovenous shunt except in rare instances of limited fistulas with the safety of an accessible blood supply 13. When there is significant supply to the fistula from internal carotid artery branches, the risk of embolic reflux and stroke makes transarterial routes less used 7. Reported complications have included hemiplegia, transient visual loss, cranial nerve deficits, and death 7. Many authors 4-6,11,14-17,20 have reported excellent results after transvenous embolization procedures and our experience is also favorable. The best indications for venous embolization are cases in which the sinus involved is already compromised and no longer contributes to the drainage of normal tissue 17,20 . In general, either the SOV or the inferior petrosal sinus is used to reach the affected cavernous sinus. So in our two cases transvenous embolization is our treatment of choice. 719
Transvenous Embolization with Onyx for Cavernous Sinus Dural Arteriovenous Fistula
A
B
C
D
Chuhan Jiang
Figure 1 Case 1. Right external carotid angiogram, anteroposterior projection (A), left internal carotid angiogram, anteroposterior projection (B), showing a DAVF fed by both internal carotid arteries, mainly drained to the left inferior petrosal sinus and left superior ophthalmic vein. Superselective angiogram (C) showing the tip of microcatheter in the left cavernous sinus. Right internal carotid angiogram, anteroposterior projection (D) and left external carotid angiogram, anteroposterior projection (E), after embolization showing the DAVF is completely occluded. (F) Skull X-ray film after embolization, anteroposterior projection, showing the Onyx cast.
720
www. centauro. it
The Neuroradiology Journal 20: 718-725, 2007
E
F
If the dural fistula is posterior and drainage is mainly posterior, through the IPS, as demonstrated in our case 1, this route may be used to access the cavernous sinus. When the IPS is visualized on the angiogram, approach through it is a relatively safe procedure that can be performed with a high degree of success. Although rupture of the IPS during catheterization may result in subarachnoid hemorrhage, this is a rare complication. The abducens nerve has been damaged at any portion through Dorello's canal due to direct injury by the guidewire 15. Furthermore, it has been indicated that inappropriate occlusion of the drainage vein from the cavernous sinus results in an acute deterioration of visual acuity or an increase in intracranial venous pressure 15. In our case 1, Onyx34 was used during venous approach in case of high-flow cavernous DAVF and Onyx was injected into a basket of coils. In this situation, distal migration of glue to the ophthalmic vein may be avoided. This patient demonstrated a good outcome. As to case 2, transvenous embolization prior to transarterial embolization may be hazardous, because it might have led to the development of visual deficit and cortical venous drainage due to occlusion of the draining pathway. We therefore planned to perform transarterial embolization of the right cavernous sinus DAVF to decrease the shunt flow, followed by trans-
venous embolization of the residual lesion. We postponed transvenous embolization because relief of symptoms was accomplished by the transarterial embolization. Because venous drainage of cavernous sinus DAVF can change after palliative transarterial embolization and there was a trend for the posterior route to close before the anterior drainage or cortical drainage route after palliative transarterial embolization 18, DAVF treated by palliative transarterial embolization should be monitored closely. Follow-up angiography showed the residual lesion draining predominantly via the right SOV, and occlusion of the IPS. Access to the fistula through this sinus therefore seemed difficult, although some workers have reported successful transvenous embolization of the cavernous sinus through an angiographically invisible inferior petrosal sinus 4. When the IPS is invisible, catheterization has a greater associated risk of subarachnoid hemorrhage. In our case 2, at the second stage we chose the facial vein to the cavernous via the SOV. Embolization through the superior ophthalmic vein approach is well established 6,14,16. Access via a dilated anterior superior ophthalmic vein is a technically straightforward, safe, and effective treatment for cavernous sinus DAVF. However, several disadvantages of this approach have been described. If the superior ophthalmic vein has an abrupt angulation and narrowing as it exits the 721
Transvenous Embolization with Onyx for Cavernous Sinus Dural Arteriovenous Fistula
A
B
C
D
Chuhan Jiang
Figure 2 Case 2. Right common carotid angiogram, frontal projection (A) and lateral projection (B), showing a DAVF involving the right cavernous sinus fed by the left meningohypophyseal trunk and the right internal maxillary artery. Venous phase of the right common carotid artery(C) demonstrated the venous drainage via the right inferior petrosal sinus, the superficial temporal vein and the facial vein. Superselective angiography (D) showed the microcatheter in the right cavernous sinus. Right common carotid angiogram, lateral projection (E) showing the right cavernous sinus partially packed. Right common carotid angiogram, lateral projection (F) and frontal projection (G), showing the right cavernous sinus completely packed. Skull X-ray film, frontal projection (H), showing the Onyx deposited in the right cavernous sinus.
722
www. centauro. it
The Neuroradiology Journal 20: 718-725, 2007
E
F
G
H
superior orbital fissure, catheterization is difficult. If the superior ophthalmic vein is thrombosed, catheterization is risky and technically difficult. Injury to the superior ophthalmic vein may result in retro-ocular hemorrhage or redi-
rection of the venous drainage to intracranial pathways, increasing the risk of neurologic complications. Furthermore, catheterization of the superior ophthalmic vein requires surgical exposure in most cases and dysesthesia 723
Transvenous Embolization with Onyx for Cavernous Sinus Dural Arteriovenous Fistula
due to direct injury to the supraorbital nerves, blepharoptosis caused by prolonged severe postoperative swelling of the upper lid causing lengthening of the levator muscle and/or direct injury to the muscle in these patients 15. Onyx is a new, nonadhesive liquid embolic agent composed of ethylene-vinyl alcohol (EVAL) copolymer dissolved in dimethylsufoxide (DMSO). There are three different concentrations, 6.0%, 6.5%, 8.0%, which are manufactured as Onyx18, Onyx-20 and Onyx-34. Tantalum powder (35% weight/volume) is added for radiopacity. The lower the concentration of the copolymer, the less viscous the agent and the more distal penetration can be achieved. Onyx viscosity of 8.0% is 34 centipoise (CPS, unit of viscosity). In our embolizations, we generally use Onyx 8.0% for embolization of DAVFs. Onyx 8.0% is manufactured as Onyx-34. It is mechanically occlusive and it dose not have the untoward property of potential catheter gluing 22. The course of lesion occlusion is slower when treatment is performed with platinum coils compared with liquid embolic agents. GDC are more expensive and less thromobogenic. Transient III or VI nerve palsy following coil embolization for cavernous sinus DAVF are well know events, and over-tight packing is most likely to affect cranial nerves within the cavernous sinus 1,15. To achieve complete occlusion, the cavernous sinus was tightly packed with GDC. This tight packing may have accounted for the reported
Chuhan Jiang
intense nausea and vomiting. In our two cases, these symptoms did not occur. Compared with NBCA, Onyx is a nonadhesive liquid embolic agent, and does not polymerize but the EVAL copolymer precipitates while the DMSO diffuses under aqueous conditions, and thus mechanically occludes the feeding vessels 2,22. It is supplied in ready-to-use vials, and no mixing of its various components is required prior to injection. The nonadhesive property of Onyx allows the surgeon far greater latitude in varying the rate of injection and the amount of the agent delivered during a single injection. Consequently, when used in dural fistulas, it may be more realistic to consider Onyx as a potential permanent embolic agent, rather than expecting it to be surgically removed. In this study, both patients were cured and uneventful after injection so we believe the Onyx is safe for treatment. Conclusion We have described here a new embolic material for treatment of DAVF of the cavernous sinus through venous approach. The advantages make this an attractive alternative to various platinum coils already described. From this point of view, we prefer to use Onyx because of their efficacy, controllable characteristics and cost.
References 1 Aihara N, Mase M, Yamada K et Al: Deterioration of ocular motor dysfunction after transvenous embolization of dural arteriovenous fistula involving the cavernous sinus. Acta Neurochir 141: 707-710, 1999. 2 Anil A, Servet I: Treatment of a superior sagittal sinus dural arteriovenous fistula with Onyx: Technical case report. Neurosurgery 59: E169-E170, 2006. 3 Arat A, Cekirge S, Saatci I et Al: Transvenous injection of Onyx for casting of the cavernous sinus for the treatment of a carotid-cavernous fistula. Neuroradiology 46: 1012-1015, 2004. 4 Benndorf G, Bender A, Lehmann R et Al: Transvenous occlusion of dural cavernous sinus fistulas through the thrombosed inferior petrosal sinus: report of four cases and review of the literature. Surg Neurol 54: 42-54, 2000. 5 Goldberg RA, Goldey SH, Duckwiler G et Al: Management of cavernous sinus-dural fistulas. Indications and techniques for primary embolization via the superior ophthalmic vein. Arch Ophthamol 115: 823-824, 1997. 6 Goldberg RA, Goldey SH, Duckwiler G et Al: Management of cavernous-dural fistulas. Indications and techniques for primary embolization via the superior ophthalmic vein. Arch Ophthalmol 114: 707-714, 1996. 7 Jahan R, Gobin YP, Glenn B et Al: Transvenous embolization of a dural arteriovenous fistula of the cavern-
724
8 9
10
11
12
13
ous sinus through the contralateral pterygoid plexus. Neuroradiology 40: 189-193, 1998. Kai Y, Hamada J, Morioka M et Al: Treatment of cavernous sinus dural arteriovenous fistulae by external manual carotid compression. Neurosurgery 60: 253-258, 2007. Kazekawa K, Iko M, Sakamoto S et Al: Dural AVFs of the cavernous sinus: transvenous embolization using a direct superficial temporal vein approach. Radiation Medicine 21: 138-141, 2003. Krisht AF, Burson T: Combined pretemporal and endovascular approach to the cavernous sinus for the treatment of carotid-cavernous dural fistulae: technical case report. Neurosurgery 44: 415-418, 1999. Kuwayama N, Endo S, Kitabayashi M et Al: Surgical transvenous embolization of a cortically draining carotid cavernous fistula via a vein of the sylvian fissure. Am J Neuroradiol 19: 1329-1332, 1998. Leonard F, Jeffrey B, Nicholas JV: Cavernous sinus fistulas: carotid cavernous fistulas and dural arteriovenous malformations. Current Neurology & Neuroscience Reports 3: 415-420, 2003. Liu HM, Huang YC, Wang YH et Al: Transarterial embolization of complex cavernous sinus dural arteriovenous fistulae with low-concentration cyanoacrylate. Neuroradiology 42: 766-770, 2000.
www. centauro. it
14 Nakamura M, Tamaki N, Kawaguchi T et Al: Selective transvenous embolization of dural carotid-cavernous sinus fistulas with preservation of sylvian venous outflow. Report of three cases. J. Neurosurgery 89: 825829, 1998. 15 Oishi H, Arai H, Sato K et Al: Complications associated with transvenous embolization of cavernous dural arteriovenous fistula. Acta Neurochir 141: 1265-1271, 1999. 16 Quinones D, Duckwiler G, Gobin PY et Al: Embolization of dural cavernous fistulas via superior ophthalmic vein approach. Am J Neuroradiol 18: 921-928, 1997. 17 Roy D, Raymond J: The role of transvenous embolization in the treatment of intracranial dural arteriovenous fistulas. Neurosurgery 40: 1133-1144, 1997. 18 Satomci J, Satoh K, Matsubara S et Al: Angiographic changes in venous drainage of cavernous sinus dural arteriovenous fistulae after palliative transarterial embolization or observational management: a proposed stage classification. Neurosurgery 56: 494-502, 2005. 19 Suzuki S, Lee DW, Jahan R et Al: Transvenous treatment of spontaneous dural carotid-cavernous fistulas using a combination of detachable coils and Onyx. AJNR Am J Neuroradiol 27: 1346-1349, 2006. 20 Urtasun F, Biondi A, Casasco A et Al: Cerebral dural arteriovenous fistulas: percutaneous transvenous embolization. Radiology 199: 209-217,1996.
The Neuroradiology Journal 20: 718-725, 2007
21 Watanabe T, Matsumaru Y, Sonobe M et Al: Multiple dural arteriovenous fistulae involving the cavernous and sphenoparietal sinuses. Neuroradiology 42: 771774, 2000. 22 Yuichi M, Fernando V, Alexandre U et Al: Nonadhesive liquid embolic agent for cerebral arteriovenous malformations: Preliminary histopathological studies in Swine Rete Mirabile. Neurosurgery 43: 1164-1172, 1998.
Xianli Lv, MD Interventional Neuroradiology Department Beijing Neurosurgical Institute Capital Medical University 6,Tiantan Xili Beijing, Heibei 100050 China Tel.: 86-010-67098850 E-mail: [email protected]
725
www. centauro. it
Transvenous Embolization with Onyx for Cavernous Sinus Dural Arteriovenous Fistula. A Report of Two Cases
CHUHAN JIANG, XIANLI LV, YOUXIANG LI, AIHUA LIU, ZHONGXUE WU Beijing Neurosurgical institute; Beijing, the People’s Republic of China Beijing Tiantan Hospital, Capital Medical University; Beijing, the People’s Republic of China
Key words: transvenous embolization, Onyx, dural arteriovenous fistula, cavernous sinus
SUMMARY – Previous treatments for cavernous dural arteriovenous fistulas (DAVF) include transarterial embolization with NBCA and transvenous embolization with platinum coils. This paper presents two cases of cavernous sinus dural arterial venous fistula successfully treated via a transvenous approach with Onyx. Case 1. A 54-year-old man presented with blepharotosis, diplopia and chemosis. Cerebral angiography demonstrated a cavernous DAVF, which was successfully treated via inferior petrosal sinus with a combination of Onyx and platinum coils. Case 2. A 36-year-old woman was admitted after incomplete transarterial embolization of a dural cavernous fistula. The patien’s symptoms resolved almost completely after embolization with Onyx-34 via the superior ophthalmic vein. To our knowledge, only two such cases have been reported in the literature. The advantages of Onyx make it an attractive alternative to the various platinum coils already described.
Introduction Various methods of treatment for dural arteriovenous fistulas (DAVFs) of the cavernous sinus have been described 1,3,5-10,13,14,16,19,21. Carotid compression therapy has been shown to be effective in some patients 8. Both transarterial and transvenous embolization have proved safe and effective 1,4-7,13,14,21. Surgical approaches have included direct placement of thrombogenic material into the cavernous sinus to promote thrombosis and closure. Transvenous endovascular techniques through the superior ophthalmic vein (SOV) and the inferior petrosal sinus (IPS) have been described in the treatment of cavernous sinus DAVF 1,4-6,14,16. We describe a novel liquid embolic agent (Onyx) used to cure cavernous sinus DAVFs via a transvenous approach. To our knowledge, there are only two cases reported in the literature 3,19. 718
Case Reports Case 1 A 54-year-old man presented with a two month history of blepharotosis, diplopia and chemosis. Cerebral angiograms showed a DAVF principally fed by the left meningohypophyseal trunk with additional small branches of the right internal carotid artery. Venous outflow emptied into the left inferior petrosal sinus and the left superior ophthalmic vein. Recommendation was made for transvenous embolization of the lesion. Under general anesthesia, catheterization was performed via a transfemoral approach using standard coaxial techniques. Systemic heparinization was achieved during the procedures with heparin 5000U bolus followed by 1000U of heparin every hour. A 5-French diagnostic catheter with continuous heparinized flush was positioned in the left internal carotid artery for selective control angiograms. The late venous phase of the left
Chuhan Jiang
Transvenous Embolization with Onyx for Cavernous Sinus Dural Arteriovenous Fistula
internal carotid angiogram revealed the IPS on this side. Therefore, this IPS was chosen for the endovascular approach. A 5-F guiding catheter was placed and, using road mapping technique and fluoroscopic guidance, a microcatheter (Echelon14, M.T.I) was advanced over a guidewire (Transend0.014, Boston Scientific) into the left IPS up to the left cavernous sinus. Three hydrocoils (two 5×12, one 6×15; Microvention) were packed first to reduce the venous outflow towards the superior ophthalmic vein. Then, under biplane roadmapping, the catheter was slowly flushed with 0.25 ml of DMSO over 40 seconds and this was followed by injection of Onyx (M.T.I). After 2.3 ml of Onyx-34 was injected into the cavernous sinus, we attempted to inject Onyx-18. In the meantime caution was exerted to avoid inadvertent embolization of the left internal carotid artery during the slow injection of Onyx. Patency of the left internal carotid artery was checked frequently during the intermittent injection of the embolic material, using a diagnostic catheter placed in the ipsilateral internal carotid artery. The amount of injected Onyx-18 was 2.6 ml. The procedure was completed as soon as a control angiogram revealed complete occlusion of the DAVF. The patient’s chemosis improved within the next day, but blepharotosis and diplopia were not improved. The patient was discharged on postprocedure day three. Case 2
A 36-year-old woman was referred to our hospital again after incomplete transarterial embolization of a dural cavernous fistula. On admission, she suffered from slight exophthalmos and chemosis of her right eye. A cerebral angiogram demonstrated a residual arteriovenous shunt of the right cavernous sinus supplied by the right meningohypophyseal trunk draining to the right superior ophthalmic vein (SOV). The right facial vein and the right superficial temporal vein were demonstrated angiographically draining the fistula. Because the approach of the superficial temporal vein was longer and tortuous, we decided to approach the right cavernous sinus through the right facial vein. A 5-French guiding catheter (Envoy; Cordis Endovascular System) was advanced through the right internal jugular vein into the right common trunk of the facial and retromandibular veins. A diagnostic catheter was placed in the right internal carotid artery via the left common femoral artery. A Marathon microcatheter
was advanced through the guiding catheter and through the right facial vein into the right superior ophthalmic vein. After traversing the superior ophthalmic vein, we gained access to the right cavernous sinus. Occlusion of the fistula was accomplished by filling the right cavernous sinus with 1.5 ml Onyx-34. In the meantime caution was exerted to avoid inadvertent embolization of the internal carotid artery during the slow injection of Onyx. Patency of the right internal carotid artery was checked frequently during the intermittent injection of the embolic material, using a diagnostic catheter placed in the ipsilateral internal carotid artery. There were no complications during the procedure. She was discharged three days after the procedure with symptoms improved. Discussion Cavernous sinus DAVF is an uncommon vascular anomaly resulting in increased pressure in the cavernous sinus. The subsequent changes in blood flow lead to orbital venous congestion, cranial neuropathies and glaucoma 12. Venous drainage to cortical veins can cause intracranial hemorrhage 11,14,15,18. Along with rapid advances in techniques and devices, endovascular treatment is now considered the first choice for aggressive treatment of cavernous sinus DAVF 15 . Previous techniques for permanent occlusion include transarterial embolization with NBCA and transvenous embolization with platinum coils 21. Transarterial embolization can markedly decrease a large area of shunt, but it is not likely to result in angiographic elimination and cure of an arteriovenous shunt except in rare instances of limited fistulas with the safety of an accessible blood supply 13. When there is significant supply to the fistula from internal carotid artery branches, the risk of embolic reflux and stroke makes transarterial routes less used 7. Reported complications have included hemiplegia, transient visual loss, cranial nerve deficits, and death 7. Many authors 4-6,11,14-17,20 have reported excellent results after transvenous embolization procedures and our experience is also favorable. The best indications for venous embolization are cases in which the sinus involved is already compromised and no longer contributes to the drainage of normal tissue 17,20 . In general, either the SOV or the inferior petrosal sinus is used to reach the affected cavernous sinus. So in our two cases transvenous embolization is our treatment of choice. 719
Transvenous Embolization with Onyx for Cavernous Sinus Dural Arteriovenous Fistula
A
B
C
D
Chuhan Jiang
Figure 1 Case 1. Right external carotid angiogram, anteroposterior projection (A), left internal carotid angiogram, anteroposterior projection (B), showing a DAVF fed by both internal carotid arteries, mainly drained to the left inferior petrosal sinus and left superior ophthalmic vein. Superselective angiogram (C) showing the tip of microcatheter in the left cavernous sinus. Right internal carotid angiogram, anteroposterior projection (D) and left external carotid angiogram, anteroposterior projection (E), after embolization showing the DAVF is completely occluded. (F) Skull X-ray film after embolization, anteroposterior projection, showing the Onyx cast.
720
www. centauro. it
The Neuroradiology Journal 20: 718-725, 2007
E
F
If the dural fistula is posterior and drainage is mainly posterior, through the IPS, as demonstrated in our case 1, this route may be used to access the cavernous sinus. When the IPS is visualized on the angiogram, approach through it is a relatively safe procedure that can be performed with a high degree of success. Although rupture of the IPS during catheterization may result in subarachnoid hemorrhage, this is a rare complication. The abducens nerve has been damaged at any portion through Dorello's canal due to direct injury by the guidewire 15. Furthermore, it has been indicated that inappropriate occlusion of the drainage vein from the cavernous sinus results in an acute deterioration of visual acuity or an increase in intracranial venous pressure 15. In our case 1, Onyx34 was used during venous approach in case of high-flow cavernous DAVF and Onyx was injected into a basket of coils. In this situation, distal migration of glue to the ophthalmic vein may be avoided. This patient demonstrated a good outcome. As to case 2, transvenous embolization prior to transarterial embolization may be hazardous, because it might have led to the development of visual deficit and cortical venous drainage due to occlusion of the draining pathway. We therefore planned to perform transarterial embolization of the right cavernous sinus DAVF to decrease the shunt flow, followed by trans-
venous embolization of the residual lesion. We postponed transvenous embolization because relief of symptoms was accomplished by the transarterial embolization. Because venous drainage of cavernous sinus DAVF can change after palliative transarterial embolization and there was a trend for the posterior route to close before the anterior drainage or cortical drainage route after palliative transarterial embolization 18, DAVF treated by palliative transarterial embolization should be monitored closely. Follow-up angiography showed the residual lesion draining predominantly via the right SOV, and occlusion of the IPS. Access to the fistula through this sinus therefore seemed difficult, although some workers have reported successful transvenous embolization of the cavernous sinus through an angiographically invisible inferior petrosal sinus 4. When the IPS is invisible, catheterization has a greater associated risk of subarachnoid hemorrhage. In our case 2, at the second stage we chose the facial vein to the cavernous via the SOV. Embolization through the superior ophthalmic vein approach is well established 6,14,16. Access via a dilated anterior superior ophthalmic vein is a technically straightforward, safe, and effective treatment for cavernous sinus DAVF. However, several disadvantages of this approach have been described. If the superior ophthalmic vein has an abrupt angulation and narrowing as it exits the 721
Transvenous Embolization with Onyx for Cavernous Sinus Dural Arteriovenous Fistula
A
B
C
D
Chuhan Jiang
Figure 2 Case 2. Right common carotid angiogram, frontal projection (A) and lateral projection (B), showing a DAVF involving the right cavernous sinus fed by the left meningohypophyseal trunk and the right internal maxillary artery. Venous phase of the right common carotid artery(C) demonstrated the venous drainage via the right inferior petrosal sinus, the superficial temporal vein and the facial vein. Superselective angiography (D) showed the microcatheter in the right cavernous sinus. Right common carotid angiogram, lateral projection (E) showing the right cavernous sinus partially packed. Right common carotid angiogram, lateral projection (F) and frontal projection (G), showing the right cavernous sinus completely packed. Skull X-ray film, frontal projection (H), showing the Onyx deposited in the right cavernous sinus.
722
www. centauro. it
The Neuroradiology Journal 20: 718-725, 2007
E
F
G
H
superior orbital fissure, catheterization is difficult. If the superior ophthalmic vein is thrombosed, catheterization is risky and technically difficult. Injury to the superior ophthalmic vein may result in retro-ocular hemorrhage or redi-
rection of the venous drainage to intracranial pathways, increasing the risk of neurologic complications. Furthermore, catheterization of the superior ophthalmic vein requires surgical exposure in most cases and dysesthesia 723
Transvenous Embolization with Onyx for Cavernous Sinus Dural Arteriovenous Fistula
due to direct injury to the supraorbital nerves, blepharoptosis caused by prolonged severe postoperative swelling of the upper lid causing lengthening of the levator muscle and/or direct injury to the muscle in these patients 15. Onyx is a new, nonadhesive liquid embolic agent composed of ethylene-vinyl alcohol (EVAL) copolymer dissolved in dimethylsufoxide (DMSO). There are three different concentrations, 6.0%, 6.5%, 8.0%, which are manufactured as Onyx18, Onyx-20 and Onyx-34. Tantalum powder (35% weight/volume) is added for radiopacity. The lower the concentration of the copolymer, the less viscous the agent and the more distal penetration can be achieved. Onyx viscosity of 8.0% is 34 centipoise (CPS, unit of viscosity). In our embolizations, we generally use Onyx 8.0% for embolization of DAVFs. Onyx 8.0% is manufactured as Onyx-34. It is mechanically occlusive and it dose not have the untoward property of potential catheter gluing 22. The course of lesion occlusion is slower when treatment is performed with platinum coils compared with liquid embolic agents. GDC are more expensive and less thromobogenic. Transient III or VI nerve palsy following coil embolization for cavernous sinus DAVF are well know events, and over-tight packing is most likely to affect cranial nerves within the cavernous sinus 1,15. To achieve complete occlusion, the cavernous sinus was tightly packed with GDC. This tight packing may have accounted for the reported
Chuhan Jiang
intense nausea and vomiting. In our two cases, these symptoms did not occur. Compared with NBCA, Onyx is a nonadhesive liquid embolic agent, and does not polymerize but the EVAL copolymer precipitates while the DMSO diffuses under aqueous conditions, and thus mechanically occludes the feeding vessels 2,22. It is supplied in ready-to-use vials, and no mixing of its various components is required prior to injection. The nonadhesive property of Onyx allows the surgeon far greater latitude in varying the rate of injection and the amount of the agent delivered during a single injection. Consequently, when used in dural fistulas, it may be more realistic to consider Onyx as a potential permanent embolic agent, rather than expecting it to be surgically removed. In this study, both patients were cured and uneventful after injection so we believe the Onyx is safe for treatment. Conclusion We have described here a new embolic material for treatment of DAVF of the cavernous sinus through venous approach. The advantages make this an attractive alternative to various platinum coils already described. From this point of view, we prefer to use Onyx because of their efficacy, controllable characteristics and cost.
References 1 Aihara N, Mase M, Yamada K et Al: Deterioration of ocular motor dysfunction after transvenous embolization of dural arteriovenous fistula involving the cavernous sinus. Acta Neurochir 141: 707-710, 1999. 2 Anil A, Servet I: Treatment of a superior sagittal sinus dural arteriovenous fistula with Onyx: Technical case report. Neurosurgery 59: E169-E170, 2006. 3 Arat A, Cekirge S, Saatci I et Al: Transvenous injection of Onyx for casting of the cavernous sinus for the treatment of a carotid-cavernous fistula. Neuroradiology 46: 1012-1015, 2004. 4 Benndorf G, Bender A, Lehmann R et Al: Transvenous occlusion of dural cavernous sinus fistulas through the thrombosed inferior petrosal sinus: report of four cases and review of the literature. Surg Neurol 54: 42-54, 2000. 5 Goldberg RA, Goldey SH, Duckwiler G et Al: Management of cavernous sinus-dural fistulas. Indications and techniques for primary embolization via the superior ophthalmic vein. Arch Ophthamol 115: 823-824, 1997. 6 Goldberg RA, Goldey SH, Duckwiler G et Al: Management of cavernous-dural fistulas. Indications and techniques for primary embolization via the superior ophthalmic vein. Arch Ophthalmol 114: 707-714, 1996. 7 Jahan R, Gobin YP, Glenn B et Al: Transvenous embolization of a dural arteriovenous fistula of the cavern-
724
8 9
10
11
12
13
ous sinus through the contralateral pterygoid plexus. Neuroradiology 40: 189-193, 1998. Kai Y, Hamada J, Morioka M et Al: Treatment of cavernous sinus dural arteriovenous fistulae by external manual carotid compression. Neurosurgery 60: 253-258, 2007. Kazekawa K, Iko M, Sakamoto S et Al: Dural AVFs of the cavernous sinus: transvenous embolization using a direct superficial temporal vein approach. Radiation Medicine 21: 138-141, 2003. Krisht AF, Burson T: Combined pretemporal and endovascular approach to the cavernous sinus for the treatment of carotid-cavernous dural fistulae: technical case report. Neurosurgery 44: 415-418, 1999. Kuwayama N, Endo S, Kitabayashi M et Al: Surgical transvenous embolization of a cortically draining carotid cavernous fistula via a vein of the sylvian fissure. Am J Neuroradiol 19: 1329-1332, 1998. Leonard F, Jeffrey B, Nicholas JV: Cavernous sinus fistulas: carotid cavernous fistulas and dural arteriovenous malformations. Current Neurology & Neuroscience Reports 3: 415-420, 2003. Liu HM, Huang YC, Wang YH et Al: Transarterial embolization of complex cavernous sinus dural arteriovenous fistulae with low-concentration cyanoacrylate. Neuroradiology 42: 766-770, 2000.
www. centauro. it
14 Nakamura M, Tamaki N, Kawaguchi T et Al: Selective transvenous embolization of dural carotid-cavernous sinus fistulas with preservation of sylvian venous outflow. Report of three cases. J. Neurosurgery 89: 825829, 1998. 15 Oishi H, Arai H, Sato K et Al: Complications associated with transvenous embolization of cavernous dural arteriovenous fistula. Acta Neurochir 141: 1265-1271, 1999. 16 Quinones D, Duckwiler G, Gobin PY et Al: Embolization of dural cavernous fistulas via superior ophthalmic vein approach. Am J Neuroradiol 18: 921-928, 1997. 17 Roy D, Raymond J: The role of transvenous embolization in the treatment of intracranial dural arteriovenous fistulas. Neurosurgery 40: 1133-1144, 1997. 18 Satomci J, Satoh K, Matsubara S et Al: Angiographic changes in venous drainage of cavernous sinus dural arteriovenous fistulae after palliative transarterial embolization or observational management: a proposed stage classification. Neurosurgery 56: 494-502, 2005. 19 Suzuki S, Lee DW, Jahan R et Al: Transvenous treatment of spontaneous dural carotid-cavernous fistulas using a combination of detachable coils and Onyx. AJNR Am J Neuroradiol 27: 1346-1349, 2006. 20 Urtasun F, Biondi A, Casasco A et Al: Cerebral dural arteriovenous fistulas: percutaneous transvenous embolization. Radiology 199: 209-217,1996.
The Neuroradiology Journal 20: 718-725, 2007
21 Watanabe T, Matsumaru Y, Sonobe M et Al: Multiple dural arteriovenous fistulae involving the cavernous and sphenoparietal sinuses. Neuroradiology 42: 771774, 2000. 22 Yuichi M, Fernando V, Alexandre U et Al: Nonadhesive liquid embolic agent for cerebral arteriovenous malformations: Preliminary histopathological studies in Swine Rete Mirabile. Neurosurgery 43: 1164-1172, 1998.
Xianli Lv, MD Interventional Neuroradiology Department Beijing Neurosurgical Institute Capital Medical University 6,Tiantan Xili Beijing, Heibei 100050 China Tel.: 86-010-67098850 E-mail: [email protected]
725
