Endovascular treatment of the cavernous sinus dural arteriovenous fistula: current status and considerations

Abstract

A cavernous sinus dural arteriovenous fistula (CS-DAVF) is an abnormal arteriovenous communication involving the dura mater within or near the CS wall. The dural arteries from the internal carotid artery and external carotid artery supply the CS-DAVF, and the superior ophthalmic vein (SOV) and inferior petrous sinus (IPS) are frequent venous drainers. In CS-DAVF cases, high-risk lesions require treatment. Endovascular treatment (EVT) has been the first-line option for CS-DAVFs. To our knowledge, a review of the EVT of CS-DAVFs is lacking. Therefore, in this paper, we review the available literature on this issue. In addition, some illustrative cases are also provided to more concisely expound the EVT of CS-DAVFs. According to the recent literature, transvenous embolization via the IPS is considered the most effective method for EVT of CS-DAVFs. In addition, the transorbital approach is another reasonable choice. Other venous approaches can also be tried. Because of the low cure rate, transarterial embolization for CS-DAVFs is limited to only highly selected patients. In the EVT of CS-DAVFs, various agents have been used, including coil, Onyx, and n-butyl cyanoacrylate, with coil being the preferred one. In addition, when EVT cannot obliterate the CS-DAVF, stereotactic radiotherapy may be considered. In general, despite various complications, EVT is a feasible and effective method to manage CS-DAVFs by way of various access routes and can yield a good prognosis.

Keywords: cavernous sinus; dural arteriovenous fistula; endovascular treatment; review.

Figure 1

Normal venous drainage of the CS. An angiogram of the left ICA of the venous phase in AP (A) and lateral (B) views shows the CS and the venous structures around the CS. Abbreviations: AP, anteroposterior; CS, cavernous sinus; ICA, internal carotid artery; IPS, inferior petrous sinus; MCV, middle cerebral vein; OV, ophthalmic vein; SSS, superior sagittal sinus; TSS: transverse sinus.

Figure 2

Typical case of a CS-DAVF with TVE via the IPS. An angiogram of the right (A-B) and left (C-D) common carotid arteries in AP (A, C) and lateral (B, D) views shows a CS-DAVF supplied by the bilateral dural branches of ECA and ICA. E, The microcatheter advances to the CS via the right IPS. F, The bilateral CSs are packed by Onyx. G-H, A postprocedural angiogram of the right common carotid artery in the lateral view shows that the CS-DAVF is obliterated. Abbreviations: AP, anteroposterior; CS, cavernous sinus; CS-DAVF, cavernous sinus dural arteriovenous fistula; ECA, external carotid artery; ICA, internal carotid artery; IPS, inferior petrous sinus; L: left; R: right; TVE, transvenous embolization.

Figure 3

Typical case of a CS-DAVF with TAE via the right MMA. An angiogram of the right ECA in AP (A) and lateral (B) views shows that the CS-DAVF is supplied by the MMA and accessory meningeal artery and drains to the superior ophthalmic vein and superficial middle cerebral vein (asterisk in B). C, An angiogram of the right ICA in the AP view shows that the dural branches of the ICA also supply blood to the CS-DAVF. D, During TAE, a balloon (asterisk) in the ICA is inflated to protect the ICA. E, An unsubtracted angiogram shows the Onyx casting via MMA (asterisk), F: An angiogram of the right common carotid artery shows that the CS-DAVF is obliterated. Abbreviations: ECA: external carotid artery, CS: cavernous sinus, DAVF: dural arteriovenous fistula, DSA: digital subtraction angiography, ICA: internal carotid artery, MMA, middle meningeal artery TAE: transarterial embolization.

Figure 4

Typical case of a CS-DAVF with TAE via bilateral MMAs. An angiogram of the left ECA in AP (A) and lateral (B) views shows that the CS-DAVF is supplied by the MMA and internal maxillary artery. C, An angiogram of the right ECA in the AP view shows that the right MMA also supplies blood to the CS-DAVF. D, An unsubtracted angiogram shows the Onyx casting via bilateral MMAs. E-F: A follow-up angiogram of the right (E) and left (F) common carotid arteries six months later shows that the CS-DAVFs are completely obliterated. Abbreviations: AP, anteroposterior; CS, cavernous sinus; CS-DAVF, cavernous sinus dural arteriovenous fistula; ECA, external carotid artery; MMA, middle meningeal artery; TAE, transarterial embolization.