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Jan Frédérick Cornelius, Jean Pierre Saint-Maurice, Damien Bresson, Bernard George, and Emmanuel Houdart

Object

In this study the authors compare the clinical outcomes after particle embolization of hemangioblastomas in the cerebellum and spinal cord. They also review the literature of similar cases.

Methods

Seven patients with hemangioblastomas in the spinal cord (four patients) and cerebellum (three patients) underwent preoperative embolization at the authors' center. Magnetic resonance imaging and selective angiography studies as well as histological diagnoses were available in all patients. Embosphere particles (trisacryl gelatin microspheres) were used in all cases. The smallest particle diameter ranged from 100 to 300 μm at the beginning of embolization in all patients.

The outcome of embolization was favorable in patients with spinal cord hemangioblastomas, but it was unfavorable for those with cerebellar hemangioblastomas; acute tumor bleeding and death occurred in all of the latter cases. The outcomes following embolization are very different for these two locations possibly because of the different capillary sizes.

Conclusions

The authors no longer use particle embolization to treat cerebellar hemangioblastomas.

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Emmanuel Houdart, Jean-Pierre Saint-maurice, René Chapot, Adam Ditchfield, Alexandre Blanquet, Guillaume Lot, and Jean-Jacques Merland

Object. Transvenous embolization is effective in the treatment of an intracranial dural arteriovenous fistula (DAVF). Access to the fistula via the internal jugular vein (IJV) may be limited by associated dural sinus thrombosis; a transcranial approach has been developed for venous embolization in such a situation. The authors report their experiences with the use of a transcranial approach for venous embolization of DAVFs.

Methods. Ten patients with DAVFs underwent craniectomy and embolization procedures in which direct sinus puncture was performed. The DAVFs were located inside the dura mater that constituted the walls of the transverse sinus in five cases, the superior sagittal sinus in four cases, and the superior petrosal sinus in one case. All DAVFs drained directly into a sinus with secondary reflux into leptomeningeal veins. In all cases, the fistula could not be accessed from the IJVs. Craniectomy was performed in an operating room and, in seven cases, subsequent enlargement of the craniectomy was required. Sinus catheterization was performed after the patient had been transferred to the angiography room. The DAVFs were embolized using coils only in five patients, glue only in two patients, and both coils and glue in three patients. Angiographic confirmation that embolization of the fistula was successful was obtained in all cases. A transient complication occurred during the first case after sinus catheterization was attempted in the operating room.

Conclusions. The transcranial approach allows straightforward access to DAVFs located on superficial dural sinuses that are inaccessible from the IJVs. The effectiveness of this approach is similar to that of the standard retrograde venous approach. The correct location and adequate extent of the craniectomy are essential for success to be achieved using this technique.

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Stéphanie Lenck, Fabrice Vallée, Vittorio Civelli, Jean-Pierre Saint-Maurice, Patrick Nicholson, Alex Hong, and Emmanuel Houdart

Lateral venous sinus stenoses have been associated with idiopathic intracranial hypertension and venous pulsatile tinnitus. Venous pressure measurement is traditionally performed to assess the indications for stenting in patients with idiopathic intracranial hypertension. However, its reliability has recently been questioned by many authors. The dual-sensor guidewire was first developed for advanced physiological assessment of fractional and coronary flow reserves in coronary artery stenoses. It allows measurement of both venous pressure and blood flow velocities. The authors used this device in 14 consecutively treated patients to explore for symptomatic lateral sinus stenosis. They found that venous blood flow was significantly accelerated inside the stenotic lesion. This acceleration, as well as the pulsatile tinnitus, resolved in all patients following stent placement. According to the authors’ results, this guidewire can be helpful for establishing an indication for stenting in patients with pulsatile tinnitus and idiopathic intracranial hypertension.

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Alexis Guédon, Jean-Pierre Saint-Maurice, Cédric Thépenier, Marc-Antoine Labeyrie, Vittorio Civelli, Carine El Sissy, Michael Eliezer, Armand Aymard, Jean-Pierre Guichard, and Emmanuel Houdart

OBJECTIVE

Intracranial dural arteriovenous fistula (DAVF) is mainly treated with an endovascular approach. Two major treatment advances include transvenous embolization (TVE) with coils in 1989 and, more recently, transarterial embolization with Onyx. The aim of this study was to present a large monocentric series of patients with DAVF treated with TVE. This series reports more than 20 years of experience and describes the evolution of the medical management of these patients, as well as current indications for this treatment at the authors’ center.

METHODS

Consecutive patients treated for intracranial DAVFs with TVE from 1995 to 2018 were included. Clinical and imaging data were systematically collected. Univariate and multivariate analyses were performed to identify factors that were significantly associated with adverse clinical course or complications.

RESULTS

In this study of 136 patients with 142 DAVFs treated with TVE, the occlusion rate was 90%. The median length of follow-up was 11 months. The rate of permanent complications was 5.1%, and the procedure-related mortality rate was 1.5%. Procedure-related mortality was associated with extension of thrombosis that was observed early in our experience. The introduction of a postoperative anticoagulation regimen has drastically decreased the occurrence of this complication. Other minor complications included cochleovestibular syndrome after embolization of lateral sinus DAVF and oculomotor nerve damage after embolization of cavernous sinus DAVF.

CONCLUSIONS

TVE allows efficient occlusion of DAVF. It remains a valid option for DAVF located on a sinus that does not participate in normal venous drainage of the brain.

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René Chapot, Jean-Pierre Saint-Maurice, Ana Paula Narata, André Rogopoulos, Jean-Jacques Moreau, Emmanuel Houdart, and Antoine Maubon

✓ In this report the authors describe the endovascular treatment of dural arteriovenous fistulas (DAVFs) through trans-cranial puncture of the feeding arteries. Four patients had DAVFs that were fed by occipital arteries (OAs) that supplied blood to the intracranial meningeal arteries via the transcranial branches and coursed through the parietal and mastoid foramina. Due to the excessive tortuosity of the OA, conventional endovascular navigation had failed in all cases. Transcranial puncture of the meningeal feeding arteries was performed through the parietal or mastoid foramen, allowing navigation with a microcatheter until the level of the shunts. Complete cure of the DAVF was attained in all patients after injection of acrylic glue.