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|LETTER TO EDITOR
|Year : 2014 | Volume
| Issue : 2 | Page : 208-210
Transcranial access for embolization of transverse sinus DAVF: Bridging the gap
Ashish Kumar1, Leodante DaCosta2
1 Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada; Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad, Andhra Pradesh, India
2 Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
|Date of Submission||11-Mar-2014|
|Date of Decision||19-Mar-2014|
|Date of Acceptance||09-Apr-2014|
|Date of Web Publication||14-May-2014|
Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada; Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad, Andhra Pradesh, India
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kumar A, DaCosta L. Transcranial access for embolization of transverse sinus DAVF: Bridging the gap. Neurol India 2014;62:208-10
Cranial dural arteriovenous fistulas (DAVF) are rare entities, constituting 10-15% of all intracranial vascular malformations. Found most commonly in association with the transverse and cavernous sinuses, they are most likely acquired lesions. Patients can present with various symptoms related to increased flow and/or intracranial venous hypertension, from headache and bruit to intracranial hemorrhage.  Cortical venous reflux, caused by recruitment of leptomeningeal veins by the fistula, is associated with higher risk of hemorrhage.
A 65-year-old gentleman presented to emergency with transient, sudden onset headache, visual, speech difficulties and bruit over the left temporal region. Initially treated as an ischemic stroke, computed tomography perfusion (CTP) was unremarkable. CT angiography demonstrated a left-sided transverse sinus DAVF draining into multiple leptomeningeal veins above and below the tentorium [Figure 1]. Digital subtraction angiogram (DSA) confirmed a borden type II fistula supplied by left occipital and middle meningeal arteries and retrograde reflux into multiple cortical veins [Figure 2]. The sinus ended blindly into an emissary vein (arrow).
|Figure 1: CT angiogram showing left transverse sinus DAVF with leptomeningeal draining vein (arrow)|
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|Figure 2: DSA revealing occipital and middle meningeal arterial feeders (red arrows) into left sequestrated transverse-sigmoid sinus ending into mastoid emissary vein (yellow arrow). Cortical venous reflux is seen in leptomeningeal veins above and below the sinus|
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Endovascular treatment was planned to obliterate the sinus segment. However, internal jugular venous (IJV) access was not possible beyond the thrombosed/stenosed segment. Although, good results from transarterial embolization in a "flow arrest" situation has been reported,  transarterial embolization of DAVF frequently results in recurrent fistula formation due to "re-recruitment", besides the risk of inadvertent embolization of cortical veins and hence, the procedure was abandoned. Skeletonization of the sinus and/or resection of the fistula are associated with significant intraoperative hemorrhage and very high morbidity and mortality. Therefore, transcranial access to the sinus was considered as a safe and viable option. This combination of direct puncture of sinus and coil deployment was successfully used for the first time in treating Vein of Galen malformations.  Since then only few case reports have mentioned combined management. , Houdart et al., reported the largest series until now, where 10 patients with leptomeningeal reflux were successfully treated by combined approach. All 10 patients had failed IJV access earlier. 
A retrosigmoid craniectomy in the operating room was planned and the transverse sigmoid junction identified with the help of neuronavigation and indocyanine green (ICG) angiography. An 18G angiocatheter was inserted into the sinus under direct view. During fluoroscopy, a microcatheter was inserted and 20 coils were used to pack the sequestrated sinus segment [Figure 3]. Cortical venous reflux was reduced to 1 small vein. Patient made an uneventful recovery and showed immediate improvement in visual blurring the next day. At follow-up, 3 weeks later the patient had no deficits and the bruit had disappeared.
|Figure 3: Intra-operative flouroscopy showing placement of the angiocatheter through the craniectomy defect and roadmap of the transverse sinus along with its veins. Coil mass is seen packed into the sinus and only single leptomeningeal vein is seen post-coiling|
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In a country with divided houses of interventional and micro-neurosurgical fraternity, this report illustrates how collaboration can decrease morbidity and allow for treatment of lesions otherwise not amenable to cure via single modality. Different backgrounds (radiology/surgery) generate different opinions but also diversity in resources and skills. This diversity has to be used to improve care and outcomes. We hope that this report will help to expand the idea of a common platform in the treatment of cerebrovascular diseases in India. Combined endovascular and neurosurgical teamwork can result in optimal patient management and best possible clinical outcomes.
| » References|| |
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|2.||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. |
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[Figure 1], [Figure 2], [Figure 3]