Endovascular treatment of dural fistulas with the venous outflow of laterocavernous sinus

https://doi.org/10.1016/j.ejrad.2010.02.003Get rights and content

Abstract

Objective

To report our findings concerning the laterocavernous sinus (LCS) drainage of dural fistulas, focusing our attention on the important implications in treatment of the LCS, which is one of the principal drainage pathways of the superficial middle cerebral vein (SMCV).

Methods

Consecutive 32 patients with dural fistulas treated endovascularly between 2005 and 2008 were reviewed. Seven patients had angiographic features such as dural fistulas draining with SMCV via LCS. Clinical records for these 7 patients were focused to determine their presenting symptoms, angiographic features, endovascular treatments, and clinical outcomes.

Results

Over 3 years, 7 patients had 7 dural fistulas drained with SMCV via LCS were treated. Six-vessel angiography confirmed the presence of the dural fistulas. All fistulas were Cognard Type III featured by leptomeningeal veins drainage. One fistula involving the lesser sphenoid wing and 6 fistulas involving CS were supplied by external carotid artery branches with or without dural branches of the internal carotid artery. LCS was identified as a contiguous to SMCV drainage in these cases. One patient was treated with transvenous coil embolization alone, two with transvenous a combination of Onyx and coil embolization, and 4 with transarterial embolization. An angiographic obliteration and clinical cure was achieved in all patients. Complication was local hair loss due to X-ray radiation in one patient.

Conclusion

It is very important to diagnose the presence of LCS in dural fistulas during the diagnostic angiography. It is believed that the knowledge of LCS might be relevant for the understanding and treatment of dural fistulas involving the LCS.

Introduction

LCS is a venous structure located in between the two dural layers forming the lateral wall of the CS and LCS has recently been described as one of the principal drainage pathways of SMCV [7], [20], [21]. LCS is readily identified angiographically on the anteroposterior (AP) projection as a slit-like structure draining the SMCV toward the pterygoid plexus (PP) and the transverse sinus (TS) via the superior petrosal sinus (SPS) [7] (Fig. 1B). LCS is the outermost venous structure of the laterosellar region, separated from the lateral compartment of CS by the inner dural layer of the lateral wall of CS [21]. This inner layer may be seen as a thin vertical opacification defect between the LCS and the lateral compartment of CS when these venous spaces are visible together [7]. The two structures, CS and LCS are separate anatomic entities with distinct functional and clinical implications [21]. LCS is one of the principal drainage pathway of SMCV [20], [21]. Venous structures of LCS other than CS may also be involved in a dural fistula, either independently or in conjunction with the CS, and may represent a diagnostic pitfall with important implications for the planning and success of the endovascular procedure [7], [21], [22]. We present 7 cases of a DAVF involving the LCS directly or indirectly, focusing our attention on the important clinical implications of this venous compartment.

Section snippets

Methods

From 2005 to 2008, consecutive 32 patients with dural fistulas of paracavernous sinus region were treated with endovascular techniques at our institution. Of these patients, 7 patients harbored dural fistulas involving the LCS with SMCV drainage. The characteristics, methods of treatment, and approach of the 6 patients are summarized in Table 1. There were two 2 men and 5 women age 22–55 years (mean, 42 years). Primary presenting symptoms included proptosis, chemosis, ophthalmoplegia,

Results

Six patients underwent immediate obliteration of the dural fistulas. One patient demonstrated complete AVF obliteration at 7-month follow up after incomplete transarterial embolization. Procedures were performed preferably with general anesthesia. Patient 1 had a dural fistula involving the lesser sphenoid wing supplied by external carotid artery (ECA) branches and dural branches of the ophthalmic artery (OA) from ipsilateral internal carotid artery (ICA) with LCS and leptomeningeal veins

Discussion

LCS derives from the primitive tentorial sinus, which drains cortical blood coming from the SMCV, migrates medially toward the CS region at the time of formation of the lateral wall of the CS, during the 8th week of gestation [21]. In the previous study, LCS was found in 24.1% of the cases [21]. In the present study, laterocavernous was found in 21.9% of the cases with dural fistulas of the paracavernous sinus region. LCS drained itself principally into the SPS or PP as well as communicate with

Conclusion

CCFs involving the LCS need to be recognized as a separate entity from CS CCFs. Failure to angiographically recognize a DAVF of the LCS may lead to the erroneous diagnosis of a CS CCFs, and a subsequent attempt to perform a transvenous embolization of the CS. Such a procedure will not only have no effect on the arteriovenous shunt on the LCS, but may, in patients in whom the CS represents the major outflow of the LCS, increase retrograde filling of the cerebral veins, placing the patient at a

References (22)

  • P. Gailloud et al.

    Angiographic anatomy of the laterocavernous sinus

    AJNR Am J Neuroradiol

    (2000)
  • Cited by (10)

    View all citing articles on Scopus
    View full text