Preliminary experience with onyx embolization for the treatment of intracranial dural arteriovenous fistulas

Abstract

Background and purpose: Onyx was recently approved for the treatment of pial arteriovenous malformations, but its use to treat dural arteriovenous fistulas (DAVFs) is not yet well established. We now report on the treatment of intracranial DAVFs using this nonadhesive liquid embolic agent.

Materials and methods: We performed a retrospective analysis of 12 consecutive patients with intracranial DAVFs who were treated with Onyx as the single treatment technique at our institution between March 2006 and February 2007.

Results: A total of 17 procedures were performed in 12 patients. In all of the cases, transarterial microcatheterization was performed, and Onyx-18 or a combination of Onyx-18/Onyx-34 was used. Eight patients were men. The mean age was 56 +/- 12 years. Nine patients were symptomatic. There was an average of 5 feeders per DAVF (range, 1-9). Cortical venous reflux was present in all of the cases except for 1 of the symptomatic patients. Complete resolution of the DAVF on immediate posttreatment angiography was achieved in 10 patients. The remaining 2 patients had only minimal residual shunting postembolization, 1 of whom appeared cured on a follow-up angiogram 8 weeks later. The other patient has not yet had angiographic follow-up. Follow-up angiography (mean, 4.4 months) is currently available in 9 patients. There was 1 angiographic recurrence (asymptomatic), which was subsequently re-embolized with complete occlusion of the fistula and its draining vein. There was no significant morbidity or mortality.

Conclusion: In our experience, the endovascular treatment of intracranial DAVFs with Onyx is feasible, safe, and highly effective with a small recurrence rate in the short-term follow-up.

Fig 1.

A, Left common carotid angiography (lateral view). B, Left vertebral angiography (anteroposterior view). C, Postembolization left common carotid angiography (lateral view). The black arrow points to the subtracted Onyx cast. D, Postembolization left vertebral angiography (AP view, native image). The double white arrow points to the Onyx cast. The single white arrow points to Onyx reflux into the distal vertebral dural branch.

Fig 2.

A, Simultaneous bilateral external carotid angiography (AP view). B, Left external carotid angiography (lateral view). C, Right external carotid angiography 4.6 months after stage II embolization. Right upper corner shows microcatheter angiography before stage III Onyx embolization (arrowhead, microcatheter tip; arrow, previous Onyx cast; circle, final target). D, Left common carotid angiography 4.6 months after stage II embolization (lateral view). E–F, Poststage III embolization right (E, AP view late venous phase) and left (F, lateral view arterial phase) common carotid angiography show complete resolution of the fistula with preservation of the venous sinuses and obliteration of the left PCA (F, double white arrow), middle meningeal (F, black arrowhead), and occipital supply (F, black arrow). E, double white arrow, Subtracted Onyx cast; E, black arrowhead, Onyx in the transverse sinus leaflet. G and H, (AP view-native images) Onyx cast before (G) and after (H) the third and final embolization. Note that the target area showed on G has been completely filled with the embolic agent on H (white circle).

Fig 3.

A, Right external carotid angiography (lateral view). B, Right middle menigeal microcatether angiography (lateral view). C, Native image demonstrating a dense Onyx cast in the right middle meningeal artery (black arrow) extending into the fistula (arrowheads). D, Postembolization right common carotid angiography (lateral view-late venous phase).

Fig 4.

A, Right external carotid angiography (lateral view). B, Left external carotid angiography (AP view). C, Left internal carotid angiography (lateral view). D, Left vertebral artery angiography (lateral view). E, Postembolization right common carotid angiography (lateral view). F, Postembolization left common carotid angiography (lateral view). G, Postembolization left vertebral angiography (lateral view). H, Postembolization native image, Onyx cast (AP view).

Fig 5.

A, Left common carotid angiography (lateral view). B, Left vertebral angiography (lateral view). C, Postembolization left common carotid angiography (lateral view). D, Postembolization left vertebral angiography (lateral view).