Dural arteriovenous fistulas (DAVFs) of the cavernous sinus are acquired arteriovenous shunts between the dural branches of the internal and external carotid arteries and the cavernous sinus. These fistulas may present with cortical venous reflux, but more commonly drain antegradely toward the superior ophthalmic vein (SOV). Transvenous embolization is the most common endovascular treatment, but in some cases transvenous access to the compartment of the shunt may not be possible. In cases with no corticovenous reflux, manual compression of the SOV is an excellent alternative treatment, which is well known but rarely reported in the literature. The authors describe a series of 3 cavernous DAVFs with anterior drainage treated successfully by intermittent manual compression of the SOV.
Juan Pablo Cruz, Rene van Dijk, Timo Krings, and Ronit Agid
Ronit Agid and Karel Terbrugge
Kar Ming Leung, Ronit Agid, and Karel Terbrugge
✓ Patients with hereditary hemorrhagic telangiectasia (HHT) are at risk for the development of cerebral arteriovenous malformations (AVMs). The authors report a case of a spontaneously regressing cerebral AVM in a patient with HHT. The lesion was diagnosed on the basis of findings on screening magnetic resonance imaging and regressed completely before any treatment was undertaken. The spontaneous regression of cerebral AVMs is a rare and poorly understood phenomenon. Only one other instance of spontaneous regression of a cerebral AVM in a patient with HHT has been reported in the literature. The authors compare angiographic and clinical features in previously reported cases of spontaneous regression of cerebral AVMs with those in the present case to determine the characteristics common to this phenomenon.
Ronit Agid, Karel TerBrugge, Georges Rodesch, Tommy Andersson, and Michael Söderman
Dural arteriovenous fistulas (DAVFs) of the anterior cranial fossa are rare lesions that can cause intracranial hemorrhage. Authors of previous reports mostly have described open surgical treatment for this fistula type. The authors' purpose in the present study was to describe their experience with anterior cranial fossa DAVFs, including their endovascular treatment.
All patients with anterior cranial fossa DAVFs diagnosed and treated in 3 separate institutions during the last 23 years were retrospectively identified. Clinical charts, imaging studies, and procedural notes were evaluated.
Twenty-four patients (22 males and 2 females), ranging in age from 3 to 77 years, harbored 24 DAVFs in the anterior cranial fossa. Eleven patients were primarily treated with surgical disconnection and 2 with radiosurgery. Eleven patients were treated endovascularly; 7 of these patients (63.6%) were cured. In 4 cases of failed embolization, final disconnection was achieved through surgery. In fact, surgery was effective in disconnecting the fistula in 100% of cases. All endovascular procedures consisted of transarterial injections of diluted glue (N-butyl cyanoacrylate [NBCA]), and there were no complications. Brain edema developed around the venous pouch and confusion was apparent after venous disconnection in 1 surgically treated patient. No patient suffered a hemorrhage during the follow-up period.
Disconnection of an anterior cranial fossa DAVF by using transarterial catheterization through the ophthalmic artery and subsequent injection of NBCA is possible with a reasonable success rate and low risk for complications. In patients with good vascular access this procedure could be the treatment of choice, to be followed by open surgery in cases of embolization failure.
Susanna Bacigaluppi, Amir R. Dehdashti, Ronit Agid, Timo Krings, Michael Tymianski, and David J. Mikulis
The aim of this review was to evaluate the imaging tools used in diagnosis and perioperative assessment of moyamoya disease, with particular attention to the last decade.
Ann Mansur, Alex Kostynskyy, Timo Krings, Ronit Agid, Ivan Radovanovic, and Vitor Mendes Pereira
The aim of this study was to 1) compare the safety and efficacy of acute targeted embolization of angiographic weak points in ruptured brain arteriovenous malformations (bAVMs) versus delayed treatment, and 2) explore the angioarchitectural changes that follow this intervention.
The authors conducted a retrospective analysis of a prospectively acquired database of ruptured bAVMs. Three hundred sixteen patients with ruptured bAVMs who presented to the hospital within 48 hours of ictus were included in the analysis. The first analysis compared clinical and functional outcomes of acutely embolized patients to those with delayed management paradigms. The second analysis compared these outcomes of patients with acute embolization to those with angiographic targets who did not undergo acute embolization. Finally, a subset of 20 patients with immediate postembolization angiograms and follow-up angiograms within 6 weeks of treatment were studied to determine the angioarchitectural changes after acute targeted embolization. Kaplan-Meier curves for survival between the groups were devised. Multivariate logistical regression analysis was conducted.
There were three deaths (0.9%) and an overall rerupture rate of 4.8% per year. There was no statistical difference in demographic variables, mortality, and rerupture rate between patients with acute embolization and those with delayed management. Patients with acute embolization were more likely to present functionally worse (46.9% vs 69.8%, modified Rankin Scale score 0–2, p = 0.018) and to require an adjuvant therapy (71.9% vs 26.4%, p < 0.001). When comparing acutely embolized patients to those nonacutely embolized angiographic targets, there was a significant protective effect of acute targeted therapy on rerupture rate (annual risk 1.2% vs 4.3%, p = 0.025) and no difference in treatment complications. Differences in the survival curves for rerupture were statistically significant. Multivariate analyses significantly predicted lower rerupture in acute targeted treatment and higher rerupture in those with associated aneurysms, deep venous anatomy, and higher Spetzler-Martin grade. All patients with acute embolization experienced complete obliteration of the angiographic weak point with various degrees of resolution of the nidus; however, some had spontaneous recurrence of their bAVM, while others had spontaneous resolution over time. No patients developed new angiographic weak points.
This study demonstrates that acute targeted embolization of angiographic weak points, particularly aneurysms, is technically safe and protective in the early phase of recovery from ruptured bAVMs. Serial follow-up imaging is necessary to monitor the evolution of the nidus after targeted and definitive treatments. Larger prospective studies are needed to validate these findings.
Marlise P. dos Santos, Jingwen Zhang, Diana Ghinda, Rafael Glikstein, Ronit Agid, Georges Rodesch, Donatella Tampieri, and Karel G. terBrugge
Intraspinal tumors comprise a large spectrum of neoplasms, including hemangioblastomas, paragangliomas, and meningiomas. These tumors have several common characteristic imaging features, such as highly vascular mass appearance in angiography, hypointense rim and serpentine flow voids in MRI, and intense enhancement after intravenous contrast administration. Due to their rich vascularity, these tumors represent a special challenge for surgical treatment. More recently, the surgical treatment of intraspinal vascular tumors has benefited from the combination of endovascular techniques used to better delineate these lesions and to promote preoperative reduction of volume and tissue blood flow. Endovascular embolization has been proven to be a safe procedure that facilitates the resection of these tumors; hence, it has been proposed as part of the standard of care in their management.
Hengwei Jin, Stephanie Lenck, Timo Krings, Ronit Agid, Yibin Fang, Youxiang Li, Alex Kostynskyy, Michael Tymianski, Vitor Mendes Pereira, and Ivan Radovanovic
The goal of this study was to describe changes in the angioarchitecture of brain arteriovenous malformations (bAVMs) between acute and delayed cerebral digital subtraction angiography (DSA) obtained after hemorrhage, and to examine bAVM characteristics predicting change.
This is a retrospective study of a prospective institutional bAVM database. The authors included all patients with ruptured bAVMs who had DSA in both acute and delayed phases, with no interval treatment of their bAVM, between January 2000 and April 2017. The authors evaluated the existence or absence of angioarchitectural changes. Demographic data, radiological characteristics of hemorrhages, and angioarchitectural features of the bAVMs of the two patients’ groups were analyzed. Univariate and multivariate logistic analyses were performed to identify predictors of angioarchitectural change.
A total of 42 patients were included in the series. Seventeen (40.5%) patients had angioarchitectural changes including bAVM only visible on the delayed DSA study (n = 8), spontaneous thrombosis of the AVM (n = 3), or alteration of the size or the opacification of the nidus (n = 6). The factors associated with angioarchitectural changes were a small nidus (3.8 ± 7.9 ml vs 6.1 ± 9.5 ml, p = 0.046), a superficial location (94.1% vs 5.9%, p = 0.016), and a single superficial draining vein (58.8% vs 24.0%, p = 0.029).
Angioarchitectural changes can be seen in 40% of ruptured bAVMs between the acute- and delayed-phase DSA. A small nidus, a superficial location, and a single superficial draining vein were statistically associated with the occurrence of angioarchitectural changes. These changes included either enlargement or spontaneous occlusion of the bAVM, as well as subsequent diagnosis of a bAVM following an initial negative DSA study.