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Table of Contents    
ORIGINAL ARTICLE
Year : 2011  |  Volume : 59  |  Issue : 2  |  Page : 190-194

Cavernous region dural fistulas with venous drainage of laterocavernous sinus


1 Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
2 Neurosurgery Department, Jilin Oil Field General Hospital, Songyuan, Jilin, China

Date of Submission24-Feb-2010
Date of Decision23-Mar-2010
Date of Acceptance09-Jan-2011
Date of Web Publication7-Apr-2011

Correspondence Address:
Zhongxue Wu
Beijing Neurosurgical Institute, No. 6, Tiantan Xili, Chongwen, Beijing
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.79135

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 » Abstract 

Background : We present our findings concerning the laterocavernous sinus (LCS) drainage of cavernous region dural fistulas, focusing our attention on the anatomy of LCS as it may have important implications in the treatment. Patients and Methods : Thirty-one consecutive patients with cavernous region dural fistulas treated endovascularly between 2005 and 2008 were reviewed. Five patients had angiographic features such as cavernous region dural fistulas draining with superficial middle cerebral vein (SMCV) via LCS. Clinical records of these 5 patients were focused upon to determine their presenting symptoms, angiographic features, endovascular treatments and clinical outcomes.
Results : Among 31 cases of cavernous dural arteriovenous fistula (DAVF), 5 (16%) cases with leptomeningeal veins [SMCV, petrosal vein] reflux via LCS were noted. The 5 cavernous region dural fistulas were defined as Cognard type III and Barrow type A (1/5), B (1/5), C (1/5) and D (2/5). All 5 patients underwent immediate obliteration of the cavernous region dural fistulas in 3 sessions of transarterial and 2 sessions of transvenous embolization. An angiographic obliteration and clinical cure was achieved in all patients. We encountered one minor complication of local hair loss induced by X-ray radiation. A complete resolution of the initial presenting symptoms was observed within a few days to weeks. Six-month follow-up angiogram in 5 patients showed obliteration and no recanalization of CCF. Conclusion : It is very important to diagnose the presence of laterocavernous sinus in dural arteriovenous fistulas during diagnostic angiography. It is believed that the knowledge of the existence of laterocavernous sinus might be relevant for the understanding and treatment of dural fistulas involving the cavernous sinus and its lateral wall.


Keywords: Arteriovenous fistula, dural, laterocavernous sinus


How to cite this article:
Lv X, Feng W, Li Y, Yang X, Jiang C, Liu L, Liu J, Sun J, Wu Z. Cavernous region dural fistulas with venous drainage of laterocavernous sinus. Neurol India 2011;59:190-4

How to cite this URL:
Lv X, Feng W, Li Y, Yang X, Jiang C, Liu L, Liu J, Sun J, Wu Z. Cavernous region dural fistulas with venous drainage of laterocavernous sinus. Neurol India [serial online] 2011 [cited 2019 Sep 22];59:190-4. Available from: http://www.neurologyindia.com/text.asp?2011/59/2/190/79135



 » Introduction Top


The laterocavernous sinus (LCS) is a venous structure located in between the two dural layers forming the lateral wall of the cavernous sinus (CS), and LCS has been described as one of the principal drainage pathways of the superficial middle cerebral vein (SMCV). Venous structures of the laterocavernous sinus may also be involved in a cavernous region dural fistula, either independently or in conjunction with CS, which may represent a diagnostic pitfall with important implications for the planning and success of the endovascular procedure. [1],[2],[3] LCS as an accessible compartment has been selectively used for embolization of cavernous dural arteriovenous fistulas (DAVFs). [3],[4],[5],[6] LCS, although small, includes several important deep-tissue extracranial and intracranial structures involved in a variety of disease processes. [7] LCS has importance in multiple clinical situations, in which interventional neuroradiological management plays a central role. [2] In this article, we present our findings concerning the cavernous region dural fistulas involving LCS drainage, focusing our attention on the anatomy of LCS as it may have important clinical implications.


 » Patients and Methods Top


From 2005 to 2008, 31 patients with cavernous region dural fistulas were treated with endovascular techniques at our institution. Pre-therapeutic angiography included bilateral selective injection of the external and internal carotid arteries and vertebral arteries. When performing angiography for the assessment of cavernous region dural fistulas, care was taken on the venous phase of both external and internal carotid arteries to demonstrate a cortical drainage. Among these patients, SMCV drainage via LCS was noted in 5 (16%) patients. Hospital records, angiograms and procedure reports were retrospectively reviewed. The characteristics, methods of treatment, and approach with regard to the 5 patients are summarized in [Table 1]. There were 2 men and 3 women, with age in the range of 22-49 years.

All 5 cavernous region dural fistulas were cured by endovascular techniques. Procedures were performed preferably with general anesthesia. The endovascular treatment included transarterial embolization in 3 and transvenous embolization in 2 patients. Clinical follow-up ranged from 9 to 26 months (mean, 18 months). Cure was defined as complete resolution of the presenting symptoms during the observation period.


 » Results Top


Five (16%) patients out of 31 were retrospectively reviewed [Table 1]. In these 5 cases, leptomeningeal veins (SMCV, PV) reflux via LCS caused by cavernous region fistula was noted. The LCS is identified on the anteroposterior projection as a slit-like structure draining SMCV [Figure 1]. This inner layer may be seen as a thin vertical opacification defect between LCS and the lateral compartment of CS when these venous spaces are visible together.
Table 1: Clinical features of patients with LCS drainage


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Figure 1: Patient 1. A 32-year-old man presented with headaches caused by a right CS dural fistula fed by bilateral ECAs and ICAs. Left external carotid artery injection in the AP (arterial phase) projection showing the fistula with retrograde filling into SMCV and BVR via LCS (arrow), which is separated from the CS

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Clinical presentation

Initial presenting symptoms included proptosis (n=1), chemosis (n=2), ophthalmoplegia (n=1), intracranial bruits (n=3) and headaches (n=1).

Angiographic presentation

Three fistulas were located on the left cavernous sinus; 2 were on the right. According to the Cognard classification, the venous drainage in all cases was type III and Barrow type A (1/5), B (1/5), C (1/5) and D (2/5).

Therapy

All 5 patients underwent immediate obliteration of the cavernous region dural fistulas in 3 sessions of transarterial and 2 sessions of transvenous embolization. Arterial embolizations were performed with coils (n=1), Onyx 18 (M. T. I.-ev3, Irvine, CA) (n=1) [Figure 1] and detachable balloon (1#, Balt, Montmorency, France) (n=1). Transvenous embolization was accomplished by packing the affected sinus segment with fibered platinum coils (n=1) and Onyx+coils (n=1) [Figure 2].
Figure 2: Patient 5. A 49-year-old woman presented with headaches and intracranial bruits caused by a left CS dural fistula fed by bilateral ECAs and ICAs. (a) Right carotid artery injection in the AP (arterial phase) projection. The left LCS (arrowhead) is involved in the dural fistula. There is retrograde filling into SMCV (arrow). Early filling of the CS is observed, and it seems that LCS and CS are separated. This suggests that LCS could not be obliterated via CS with detachable coils. Fortunately, we now have Onyx, which can be used transvenously regardless of this complexity of CS. Because the left IPS was opacified well, we chose the IPS as an approach to the left CS; (b) after embolization, control angiogram of the right carotid artery shows the fistula was obliterated completely

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Clinical follow-up in mean 14.8 months

Cure was defined as complete resolution of the presenting symptoms during the observation period (mean, 18 months). We encountered one minor complication of local hair loss induced by X-ray radiation. A complete resolution of the initial presenting symptoms was observed within a few days to weeks. Angiographic follow-up Six-month follow-up angiogram in 5 patients showed obliteration and no recanalization of the fistulae.


 » Discussion Top


Anatomy

The findings reported here are consistent with the concept that the laterosellar blood spaces could be divided into two embryologically, morphologically and functionally independent systems with potential secondary connections: [1] a medial system made up of the superior ophthalmic vein, CS and the inferior petrosal sinus; and a lateral system draining the cortical blood of the cerebral convexity through SMCV toward the pterygoid plexus and/ or the transverse sinus. The latter pathway may take the form of a paracavernous sinus, an LCS or a classic termination of the SMCV into the anterosuperior aspect of CS, in decreasing order of frequency [Figure 3]. Despite the close topographic relationship between LCS and CS, LCS is sometimes difficult to identify on digital subtraction angiography (DSA) studies; the two structures are separate anatomic entities with distinct functional and clinical implications. [2] LCS is one of the principal drainage pathways of the superficial middle cerebral vein (SMCV). [2],[7]
Figure 3: Schematic representation of two independent systems of CS and LCS according to San Millán Ruíz et al.[21,22] (a) coronal view (b) lateral view (c) superior view. The medial system made up of SOV, CS and IPS; and the lateral system draining the cortical blood of the cerebral convexity through SMCV towards PP via a skull base foramen and/or TS via SPS

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In a previous study, laterocavernous sinus was found enclosed in the lateral wall of CS in 24.1% of the cases. [2] In the present study, laterocavernous sinus was found in 16.1% of the cases with CCFs. LCS drains itself principally into SPS or PP as well as communicates with CS in two situations either through a large opening in the posterior aspect of the lateral wall of CS or through small en passant connections located in the medial layer of the lateral wall of CS. If there is no communication existing between the two structures, in the majority of cases, LCS can be considered as an independent venous pathway running parallel to CS, representing one of the main variants in the drainage pattern of SMCV. Four basic drainage pathways have been described for LCS: [8] 1) towards the ipsilateral transverse sinus via SPS; 2) towards the pterygoid plexus via openings in the floor of the middle cranial fossa; 3) towards the posterior aspect of CS; and 4) towards the basal vein of Rosenthal via uncal vein.

The angiographic anatomy of LCS

Angiographically, LCS is readily identified on the anteroposterior projection as a slit-like structure draining SMCV towards any of the above-mentioned terminations. [1] LCS is the outermost venous structure of the laterosellar region, separated from the lateral compartment of CS by the inner dural layer of the lateral wall of CS. This inner layer may be seen as a thin vertical opacification defect between LCS and the lateral compartment of CS when these venous spaces are visible together. Two anatomic situations must be considered to understand these different patterns of opacification: 1) simultaneous opacification occurs when LCS and CS communicate via large anastomotic channels or when LCS terminates into the posterior aspect of CS; 2) LCS and CS are completely separated or communicate with small en passant connections. [1]

Embryologic hypothesis

The primitive tentorial sinus, which drains cortical blood coming from SMCV, migrates medially towards CS region at the time of formation of the lateral wall of CS, during the eighth week of gestation. [2] Depending on the extent of migration and subsequent formation of anastomoses between the tentorial sinus and CS, three adult SMCV drainage patterns may result: [2],[7] 1) it terminates into the anterosuperior aspect of CS, seen in 19.5% of patients in a previous study; 2) it courses as an LCS enclosed within the lateral wall of CS, seen in 34% of their patients; or 3) it follows a more lateral trajectory within the dural floor of the middle cranial fossa, where it takes the name of paracavernous sinus, seen in 46.5% of their patients.

Clinical implications

Finally it should be noted that LCS may have important clinical implications when involved in the venous drainage of vascular lesions. For example, a dural arteriovenous fistula located on a LCS sometimes cannot be accessed for embolization therapy through a usual endovascular approach, i.e., through the ophthalmic vein or inferior petrosal sinus. [9],[10],[11],[12],[13],[14],[15] In such cases, knowledge of the existence of an LCS will allow considering alternative therapeutic strategies and avoiding predictable failure of the endovascular procedure. [16],[17],[18],[19],[20],[21] A secondary connection with the basal vein of Rosenthal may also occur through an uncal vein, offering potential collateral flow into infratentorial veins by way of the peduncular and lateral mesencephalic veins. [1],[2] If present, these connections offer the anatomical substratum for retrograde filling into the superficial and deep venous system in patients with CCFs, placing the patient at a higher risk of hemorrhagic and ischemic complications. [22]

In our patients with CCFs, LCS was involved. Endovascular access to an LCS may theoretically be obtained by retrograde catheterization of the superior petrosal sinus, PP or the posterior portion of CS, depending on the termination of LCS. In the literature, we found one report of a DAVF involving LCS. San Millαn Ruνz et al. described a case of a DAVF located on an LCS, and it was cured by obliteration of LCS via PP. [3] In our series, 2 patients were treated transvenously via IPS; an approach to LCS through CS was feasible in one patient, and small en passant connections between LCS and CS were occluded in another patient. The other 3 patients were treated transarterially.


 » Conclusion Top


DAVFs involving LCS need to be recognized as a separate entity from CS DAVFs. Failure to angiographically recognize a DAVF of the LCS may lead to the erroneous diagnosis of a CS DAVF. Such a procedure will not only have no effect on the arteriovenous shunt on LCS but may in patients in whom CS represents the major outflow of LCS increase retrograde filling of the cerebral veins draining into LCS, placing the patient at a higher risk of hemorrhagic and ischemic complications. Better knowledge of its course and connection patterns should enable more frequent recognition of LCS on angiographic studies and improved evaluation of its potential clinical implications.

 
 » References Top

1.Cheng KM, Chan CM, Cheung YL. Transvenous embolisation of dural carotid-cavernous fistulas by multiple venous routes: A series of 27 cases. Acta Neurochir 2003;145:17-29.  Back to cited text no. 1
    
2.San Millán Ruíz D, Fasel JH, Rüfenacht DA, Gailloud P. The sphenoparietal sinus of breschet: Does it exist? An anatomic study. AJNR Am J Neuroradiol 2004;25:112-20.  Back to cited text no. 2
    
3.San Millán Ruiz D, Gailloud P, de Miquel Miquel MA, Muster M, Dolenc VV, Rufenacht DA, et al. Laterocavernous sinus. Anat Rec 1999;254:7-12.  Back to cited text no. 3
    
4.Annesley-Williams DJ, Goddard AJ, Brennan RP, Gholkar A. Endovascular approach to treatment of indirect carotico-cavernous fistulae. Br J Neurosurg 2001;15:228-33.  Back to cited text no. 4
    
5.Benndorf G, Bender A, Lehmann R, Lanksch W. Transvenous occlusion of dural cavernous sinus fistulas through the thrombosed inferior petrosal sinus: Report of four cases and review of the literature. Surg Neurol 2000;54:42-54.  Back to cited text no. 5
    
6.Berkmen T, Troffkin NA, Wakhloo AK. Transvenous sonographically guided percutaneous access for treatment of an indirect carotid cavernous fistula. AJNR Am J Neuroradiol 2003;24:1548-51.  Back to cited text no. 6
    
7.Nelson PK, Russell SM, Woo HH, Alastra AJ, Vidovich DV. Use of a wedged microcatheter for curative transarterial embolization of complex intracranial dural arteriovenous fistulas: Indications, endovascular technique, and outcome in 21 patients. J Neurosurg 2003;98:498-506.  Back to cited text no. 7
    
8.Berlis A, Klisch J, Spetzger U, Faist M, Schumacher M. Carotid cavernous fistula: Embolization via a bilateral superior ophthalmic vein approach. AJNR Am J Neuroradiol 2002;23:1736-8.  Back to cited text no. 8
    
9.Hara T, Hamada J, Kai Y, Ushio Y. Surgical transvenous embolization of a carotid-cavernous dural fistula with cortical drainage via a petrosal vein: Two technical case reports. Neurosurgery 2002;50:1380-3.   Back to cited text no. 9
    
10.Biondi A, Milea D, Cognard C, Ricciardi GK, Bonneville F, van Effenterre R. Cavernous sinus dural fistulae treated by transvenous approach through the facial vein: Report of seven cases and review of the literature. AJNR Am J Neuroradiol 2003;24:1240-6.  Back to cited text no. 10
    
11.Irie K, Kawanishi M, Kunishio K, Nagao S. The efficacy and safety of transvenous embolisation in the treatment of intracranial dural arteriovenous fistulas. J Clin Neurosci 2001;8:92-6.  Back to cited text no. 11
    
12.Jiang C, Lv X, Li Y, Liu A, Wu Z. Transvenous embolization with Onyx for dural arteriovenous fistula of cavernous sinus: A report of two case reports. Neuroradiol J 2007;20:718-25.  Back to cited text no. 12
    
13.Jiang C, Lv X, Li Y, Liu A, Lv M, Jiang P, et al. Transvenous embolization of cavernous sinus dural arteriovenous fistula with Onyx-18 and plentinum coils: Technical note. Neuroradiol J 2007;20:47-52.  Back to cited text no. 13
    
14.Jiang C, Lv X, Li Y, Wu Z. Transvenous treatment of cavernous dural arteriovenous fistulae with Onyx and coils. Neuroradiol J 2008;21:415-22.  Back to cited text no. 14
    
15.Lv XL, Li YX, Liu AH, Lv M, Jiang P, Zhang JB, et al. A complex cavernous sinus dural arteriovenous fistula secondary to covered stent placement for a traumatic carotid artery-cavernous sinus fistula. J Neurosurg 2008;108:588-90.  Back to cited text no. 15
    
16.Klisch J, Huppertz HJ, Spetzger U, Hetzel A, Seeger W, Schumacher M. Transvenous treatment of carotid cavernous and dural arteriovenous fistulae: Results for 31 patients and review of the literature. Neurosurgery 2003;53:836-56.  Back to cited text no. 16
    
17.Kuwayama N, Endo S, Kitabayashi M, Nishijima M, Takaku A. Surgical transvenous embolization of a cortically draining carotid cavernous fistula via a vein of the sylvian fissure. AJNR Am J Neuroradiol 1998;19:1329-32.  Back to cited text no. 17
    
18.Liu A, Lv X, Li Y, Lv M, Wu Z. Traumatic middle meningeal artery and fistula formation with the cavernous sinus: Case report. Surg Neurol 2008;70:660-3.  Back to cited text no. 18
    
19.Lv X, Jiang C, Li Y, Wu Z. Percutaneous intravenous embolization for intracranial dural arteriovenous fistulas with detachable coils or a combination with Onyx. Eur J Radiol 2009;71:356-62.  Back to cited text no. 19
    
20.Meyers PM, Halbach VV, Dowd CF, Lempert TE, Malek AM, Phatouros CC, et al. Dural carotid cavernous fistula: Definitive endovascular management and long-term follow-up. Am J Ophthalmol 2002;134:85-92.  Back to cited text no. 20
    
21.Mounayer C, Piotin M, Spelle L, Moret J. Superior petrosal sinus catheterization for transvenous embolization of a dural carotid cavernous sinus fistula. AJNR Am J Neuroradiol 2002;23:1153-5.  Back to cited text no. 21
    
22.Gailloud P, San Millán Ruíz D, Muster M, Murphy KJ, Fasel JH, Rüfenacht DA. Angiographic anatomy of the laterocavernous sinus. AJNR Am J Neuroradiol 2000;21:1923-9.  Back to cited text no. 22
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]

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