title: Aggressive cavernous sinus dural arteriovenous fistula: Angioarchitecture analysis and embolization by various approaches.
abstract: BACKGROUND
  Most cavernous sinus dural arteriovenous fistulas (CSDAVFs) present with benign neuro-ophthalmic symptoms. CSDAVFs manifesting with aggressive neurologic symptoms are rare. The purpose of this study was to analyze the different angioarchitectures of aggressive CSDAVFs and to report our experiences of embolization.
  
  
  METHODS
  Over the past 10 years, a total of 118 CSDAVFs were managed by embolization. From the databases containing such patient information, nine patients (7.6%) were found to have aggressive CSDAVFs presenting with neurologic deficits. There were seven women and two men, ranging in age from 51 years to 78 years (mean, 66 years). We retrospectively analyzed the angioarchitectures of aggressive CSDAVFs, further reviewing patient and angiographic as well clinical outcomes after embolization.
  
  
  RESULTS
  The cause of clinically aggressive CSDAVFs was insufficient fistula drainage because of occlusion (n = 6) or stenosis (n = 1) of the inferior petrous sinus (IPS) or compartment of IPS-cavernous sinus (n = 2) with fistula flow reflux to the veins of brainstem (n = 7) leading to brainstem ischemia, while two fistula flow reflux to the cortical vein leading to cerebral infarction. Transvenous embolization via IPS to fistula was achieved in one case; six patients underwent transorbital access, while transarterial embolization was performed in two cases. Total fistula occlusion was achieved in eight CSDAVFs. All patients had total (n = 7) or partial (n = 2) resolution of their symptoms gradually within 6 months. One patient undergoing transarterial embolization had limb weakness because of inadvertent pial artery occlusion. Their overall mean clinical follow-up period was 17 months.
  
  
  CONCLUSIONS
  Aggressive CSDAVFs are associated with occlusion/stenosis of the IPS or compartment of IPS-cavernous sinus with leptomeningeal reflux. In this limited case series, aggressive CSDAVFs most presented with brainstem ischemia, followed by nonhemorrhagic/hemorrhagic stroke in the cerebrum. Embolization through various access routes is a feasible method to manage these aggressive CSDAVFs, with an acceptable level of periprocedural risks.
authors.affiliation: Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; Department of Radiology, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC; Department of Biomedical Engineering, Yuanpei University of Medical Technology, Hsinchu, Taiwan, ROC.
authors.forename: Chao-Bao
authors.initials: CB
authors.lastname: Luo
authors.affiliation: Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; Department of Radiology, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC.
authors.forename: Feng-Chi
authors.initials: FC
authors.lastname: Chang
authors.affiliation: Department of Radiology, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC; Department of Medical Imaging, Cheng Hsin General Hospital, Taipei, Taiwan, ROC. Electronic address: mhteng@gmail.com.
authors.forename: Michael Mu Huo
authors.initials: MM
authors.lastname: Teng
authors.affiliation: Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; Department of Radiology, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC.
authors.forename: Chung-Jung
authors.initials: CJ
authors.lastname: Lin
authors.affiliation: Department of Radiology, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC; Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC.
authors.forename: An-Guor
authors.initials: AG
authors.lastname: Wang
authors.affiliation: Department of Biomedical Engineering, Yuanpei University of Medical Technology, Hsinchu, Taiwan, ROC.
authors.forename: Ta-Wei
authors.initials: TW
authors.lastname: Ting
mesh_terms: D000368:Aged; D002426:Cavernous Sinus / Q000002:abnormalities* / Q000000981:diagnostic imaging; D020785:Central Nervous System Vascular Malformations / Q000000981:diagnostic imaging* / Q000628:therapy; D002533:Cerebral Angiography; D004621:Embolization, Therapeutic / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies
keywords: cavernous sinus; dural arteriovenous fistula; embolization; stroke