Dural arteriovenous fistula in the sphenoid bone lesser wing region: Endovascular adjuvant techniques of treatment and literature review

Abstract

This article describes the successful endovascular treatment of a dural arteriovenous fistula of a rare localization (the area of sphenoid bone lesser region). We examine one report of an unusually located dural arteriovenous fistula successfully treated with Onyx (ev3, Irvine, USA) using a combination of endovascular adjuvant techniques: pressure cooker and remodeling balloon protection of cerebral artery. The article includes previously published observations of such fistulas and discusses anatomic features and venous drainage of dural arteriovenous fistulas in the given location.

Keywords: Arteriovenous malformation; Onyx; endovascular treatment; technical aspects.

Figure 1.

Magnetic resonance imaging (MRI) data. (a) Lack of significant changes in the left side lesser wing of sphenoid bone at T1- and T2-weighted MRI. (b) Non-enhanced magnetic resonance angiography (3D-TOF) reveals a dural arteriovenous fistula.

Figure 2.

Dural arteriovenous fistula (DAVF) of the lesser sphenoid wing. (a) Dural arteriovenous shunts fed by recurrent meningeal branch from the ophthalmic artery and branches from the inferolateral trunk of the internal carotid artery. (b) DAVF fed by branches arising from the left middle meningeal artery. Drainage into the superficial cortical veins with varix. (c) DAVF fed by branches arising from the left middle meningeal artery. Drainage into the superficial cortical veins with varix. (d) Venous drainage through superficial cerebral veins into SSS, paracavernous and superior petrosal sinuses. Retrograde filling into deep cerebral veins with reflux into the basal vein of Rosenthal via mesencephalic and peduncular veins, absence of the left of Rosenthal. (e) Venous drainage through superficial cerebral veins into SSS, paracavernous and superior petrosal sinuses. Retrograde filling into deep cerebral veins with reflux into the right basal vein of Rosenthal via mesencephalic and peduncular veins into the right vein of Rosenthal, absence of the left vein of Rosenthal.

Figure 3.

Introduction of microcatheter Apollo 1.5F-5.0 into the frontal branch of the middle meningeal artery and Excelsior SL-10 microcatheter into the parietal branch. (a) Placing of two guider catheters into the external carotid artery (ECA) and internal carotid artery (ICA). (b and c) Embolization of frontal branches of the middle meningeal artery distally from the detachment point of the Apollo microcatheter. (d) Superselective angiography. The superficial middle cerebral vein is enhanced. (e) Embolization of the fistula with non-adhesive liquid embolic agent Onyx 18 in a temporary balloon occlusion of the ICA, which was temporarily inflated at the level of the cavernous segment and ophthalmic artery origin to eliminate concurrent blood flow and avoid inadvertent reflux of Onyx into the ICA. (f, g, h) A radical occlusion of DAVF, preserving the patency of the ophthalmic artery. (i) No filling of DAVF from the ECA.

Figure 3.

Introduction of microcatheter Apollo 1.5F-5.0 into the frontal branch of the middle meningeal artery and Excelsior SL-10 microcatheter into the parietal branch. (a) Placing of two guider catheters into the external carotid artery (ECA) and internal carotid artery (ICA). (b and c) Embolization of frontal branches of the middle meningeal artery distally from the detachment point of the Apollo microcatheter. (d) Superselective angiography. The superficial middle cerebral vein is enhanced. (e) Embolization of the fistula with non-adhesive liquid embolic agent Onyx 18 in a temporary balloon occlusion of the ICA, which was temporarily inflated at the level of the cavernous segment and ophthalmic artery origin to eliminate concurrent blood flow and avoid inadvertent reflux of Onyx into the ICA. (f, g, h) A radical occlusion of DAVF, preserving the patency of the ophthalmic artery. (i) No filling of DAVF from the ECA.

Figure 4.

Topographical and anatomical relationships between venous structures in the lesser sphenoid wing region. Normal venous drainage vs. in presence of an arteriovenous fistula (AV-fistula). (a) The anatomy of the venous system in the lesser sphenoid wing region and normal venous drainage pathways. (1) Dural sinus of the lesser sphenoid wing. (2) Superficial middle cerebral vein. (3) An example of SMCV drainage into the superior petrosal sinus (sphenopetrosal sinus). (4) An example of SMCV drainage into the pterygopalatine plexus through the foramen rotundum. (5) Paracavernous sinus. (6) Cavernous sinus. (7) Superior orbital vein. (8) Superior petrosal sinus. (9) Inferior petrosal sinus. (10) Sigmoid sinus. (b) AV-fistula of the superficial middle cerebral vein. (1) Middle meningeal artery. (2) Branches of the inferolateral trunk of the internal carotid artery (ICA). (3) The ICA. (4) Recurrent meningeal branch of the ophthalmic artery. (5) AV-fistula of superficial middle cerebral vein. (6) Venous drainage into the basal veins via the lateral mesencephalic and peduncular veins to the opposite vein of Rosenthal. (7) AV-fistula in the sinus region of the lesser sphenoid wing. (c) Venous drainage pathways of arteriovenous fistula of the superficial middle cerebral vein. (1) Superficial middle cerebral vein. (2) Cavernous sinus. (3) Superior petrosal sinus. (4) Inferior petrosal sinus. (5) Venous drainage into the deep veins of the brain. (6) Drainage into the superficial cortical veins. (d) AV-fistula of the lesser sphenoid wing. (1) Middle meningeal artery. (2) Branches of the inferolateral trunk of the ICA. (3) The ICA. (4) Recurrent meningeal branch of the ophthalmic artery. (5) AV-fistula of superficial middle cerebral vein. (6) Venous drainage into the basal veins via the lateral mesencephalic and peduncular veins to the opposite vein of Rosenthal. (7) AV-fistula in the sinus region of the lesser sphenoid wing.