Dural sinus compartment in dural arteriovenous shunts: a new angioarchitectural feature allowing superselective transvenous dural sinus occlusion treatment

Abstract

Background and purpose: The dural sinus occlusion has been shown to be effective in the treatment of some dural arteriovenous shunts (DAVS). No long-term results are available, however, regarding the significance of occlusion of a dural sinus. If the disease will stop or if other events will occur later in the remaining sinuses are not well known yet. Careful analyses of our cases led us to discover that, in some instances, the shunt involves only a single portion or compartment of a sinus. In this report, we describe our results in the treatment of these lesions: occluding only the involved compartment while preserving patency of the remainder of the sinus and the angiographic signals, thus allowing diagnosis of the presence of a compartment.

Methods and results: From 1996 to October 2002, we found 12 cases of DAVS (among 40 news cases of DAVS) with two types of compartments--one inside the sinus, which we call "septation" (nine cases), and the other outside the sinus, which we call "accessory sinus" (three cases). It was possible to occlude completely the lesion superselectively in nine cases. In two cases, it was necessary to occlude the entire sinus secondarily, and in one case the sinus was occluded because was impossible to catheterize the septation. Two cases with recanalization on the control were treated by additional arterial and arterial and venous approach.

Conclusion: It is very important to diagnose the presence of a compartment in dural arteriovenous shunts during the diagnostic angiography. In most cases, it allows curative treatment of the lesion by occluding only the compartment while preserving patency of the remainder of the sinus.

Fig 1.

Case 4. A and B, Right ECA and left occipital artery injections in AP view, showing DAVS in the superior sagittal sinus (SSS) and right transverse sinus (TS). Partial opacification of these sinuses is shown (arrows). C and D, Right CCA angiograms, in arterial (C) and venous phase (D). In panel C, the arrow indicates a early partial filling of the SSS and right TS. In panel D, the arrow indicates a nonopacified area of these sinuses. E, Superposition of the arterial and venous phases of the right CCA injection, showing in black the shunt and in white the normal venous drainage of the brain. F, Injection into the septation (black) during the venous phase of the right ICA. G, Conventional radiographic image, showing coils into the septation. H, Left occipital artery injection in AP view posttreatment, showing complete occlusion of the shunt. I and J, AP and lateral view (venous phase) of the right ICA angiogram, showing patency of the SSS and right TS.

Fig 1.

Case 4. A and B, Right ECA and left occipital artery injections in AP view, showing DAVS in the superior sagittal sinus (SSS) and right transverse sinus (TS). Partial opacification of these sinuses is shown (arrows). C and D, Right CCA angiograms, in arterial (C) and venous phase (D). In panel C, the arrow indicates a early partial filling of the SSS and right TS. In panel D, the arrow indicates a nonopacified area of these sinuses. E, Superposition of the arterial and venous phases of the right CCA injection, showing in black the shunt and in white the normal venous drainage of the brain. F, Injection into the septation (black) during the venous phase of the right ICA. G, Conventional radiographic image, showing coils into the septation. H, Left occipital artery injection in AP view posttreatment, showing complete occlusion of the shunt. I and J, AP and lateral view (venous phase) of the right ICA angiogram, showing patency of the SSS and right TS.

Fig 2.

Case 2. A, Right ECA in lateral view shows a DAVS in the distal transversal sinus. Note the convergence of the feeders toward a point. B, Right occipital artery injection in oblique view shows the shunt is located only over an accessory sinus that has a “tubular hyperdensity” (arrow). C and D, Superselective injection (C) and coil occlusion (D) of the dural sinus compartment. E and F, Right occipital and right ICA angiograms, showing complete occlusion of the DAVS, while preserving patency of the lateral and sigmoid sinuses.

Fig 3.

Case 3. A, Left CCA angiogram shows DAVS in the SS. Arrow shows a line, which corresponds to a septation. B, Left occipital artery angiogram after superselective transvenous dural sinus occlusion, showing complete occlusion of the shunt. C, Venous phase of left ICA angiogram in lateral/oblique view showing coils in the septatio, and preservation of the lumen of the SS.

Fig 4.

Case 1. A, Right ascending pharyngeal artery angiogram in AP view: DAVS in the foramen magnun region, draining retrogradely toward inferior petrosal sinus and sylvian superficial vein and toward the jugular bulb. Arrow shows hyperdensity. B, Left ascending pharyngeal artery angiogram in AP view shows that the shunt is located over an accessory sinus. C, Left ascending pharyngeal artery angiogram in AP view after superselective transvenous dural sinus occlusion, showing complete occlusion of the shunt. D, RICA angiogram in venous phase, in AP view, showing patency of the normal sinuses.

Fig 5.

Case 9. A, Left ECA angiogram in lateral view. There is convergence of feeders toward two points of the cavernous sinus (small arrows). Long arrow is showing a microcatheter into the cavernous sinus (through the inferior petrosal sinus). B, Conventional radiograph, showing high-density cast of coils into the most anterior septation (arrow) and low-density cast in a portion of the cavernous sinus. C, Left ECA angiogram in AP view after embolization, showing total occlusion of the DAVS. D, Left ECA angiogram in lateral view 1 month after embolization, showing recurrence of the shunt only in the posterior septation (arrow). There is no more drainage toward the inferior petrosal sinus. E, Conventional radiograph at the end of the second session of embolization. Large arrow show 5F guide catheter into the facial vein (transfemoral approach). Arrow shows fragments of NBCA injected in the accessory meningeal artery. F, Left ECA injection in lateral view after embolization, showing complete occlusion of the DAVS.