Direct packing of the isolated sinus in patients with dural arteriovenous fistulas of the transverse—sigmoid sinus

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Object. The goal of this study was to evaluate the efficacy of direct packing of the isolated sinus (occluded both distally and proximally) in patients with dural arteriovenous fistulas (AVFs) of the transverse—sigmoid sinus.

Methods. Eight patients were included in this study. There were seven men and one woman, ranging in age from 47 to 75 years (mean 60.4 years). Five patients presented with intracranial hemorrhage or venous infarction, one with convulsions, and two with pulsatile tinnitus. Prominent retrograde cortical venous drainage due to sinus isolation was angiographically demonstrated in all patients. All patients were treated by a small craniotomy and direct sinus packing with microcoils; the procedure was performed with the aid of digital subtraction angiography. Five patients were pretreated with transarterial embolization to reduce arterial inflow before the procedure, and intrasinus pressure and sinus blood gases were monitored throughout the operation. Postsurgery, the dural AVF was completely obliterated in all patients. The sinus pressure was 29 to 58% of systemic blood pressure, and sinus blood gas levels were purely arterial before packing. There was no morbidity related to direct sinus packing; however, one patient died as a result of acute myocardial infarction. Over a follow-up period ranging from 1 to 5 years, a faint asymptomatic dural AVF recurred in one patient on the cortex adjacent to the occluded sinus but regressed spontaneously within 1 year.

Conclusions. Direct sinus packing was found to be highly effective for the treatment of dural AVFs that empty into the isolated sinus. Measurement of changes in sinus pressure and sinus blood gas levels was useful for monitoring the progress of direct sinus packing.

Article Information

Address reprint requests to: Naoya Kuwayama, M.D., Department of Neurosurgery, Toyama Medical and Pharmaceutical University, 2630 Sugitani, Toyama 930–01 Japan. email: kuwayama@ms.toyama-mpu.ac.jp.

© AANS, except where prohibited by US copyright law.

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Figures

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    Case 2. Left: Right carotid angiogram obtained before treatment. Note the isolated transverse—sigmoid sinus and retrograde cortical drainage into the vein of Labbé. Center: Cranial radiograph obtained after direct sinus packing demonstrating coils in the affected sinus. Right: Right carotid angiogram obtained 17 days posttreatment revealing obliteration of the dural AVF.

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    Case 4. Angiograms. Upper: Early (left) and late (right) phases of left external carotid injection administered at admission demonstrating a dural AVF involving the isolated transverse sinus and prominent retrograde cortical drainage. Lower: Early (left) and late (right) phases of left external carotid injection after transarterial embolization. Note the marked decrease in arterial inflow.

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    Case 4. Left: Cranial radiograph obtained after direct sinus packing showing the region of craniotomy and coils in the affected transverse sinus. Center and Right: Angiograms showing early arterial (center) and late arterial (right) phases of left carotid injection administered 7 days after direct sinus packing. Note the complete obliteration of the dural AVF and retrograde cortical drainage.

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    Case 8. Angiograms obtained before treatment. Upper: Early arterial (left), late arterial (center), and venous (right) phases of right carotid injection. Lower: Early arterial (left), late arterial (center), and venous (right) phases of left carotid injection. Note the dural AVF involving the right transverse—sigmoid sinus with vigorous retrograde venous drainage into the straight sinus and cortical veins. The right transverse—sigmoid sinus is isolated and the left transverse sinus is thrombosed. The posterior half of the superior sagittal sinus is also thrombosed, resulting in marked intracranial venous congestion. The cerebral venous drainage includes scalp veins, the patent left sigmoid, and the sphenoparietal sinuses.

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    Case 8. Left: Cranial radiograph obtained after direct sinus packing. Note the small craniotomy and microcoils in the affected right transverse sinus and torcular herophili. Center and Right: Angiograms with right carotid (lateral view) and left carotid (anteroposterior view) injection obtained 1 day posttreatment, demonstrating complete obliteration of the dural AVF that involved the transverse—sigmoid sinus.

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