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Background: The Onyx™ Liquid Embolic System is a non-adhesive liquid embolic agent, which has been proved by the US FDA for embolization of lesions in the peripheral and neurovasculature since 2005. We reported a case of ischemic optic neuropathy after using Onyx-18 to embolize the anterior ethmoid arteries that feeding dural arteriovenous fistulas (DAVF)., Case Presentation: A 57-year-old Asian male presented with anterior cranial fossa DAVF underwent embolotherapy by delivering Onyx-18 through a microcatheter into the anterior ethmoid arteries under angiography guidance. The interventional procedure was successful and no clear evidence was found pointing to untargeted occlusive embolus. But after the surgery the patient experienced delayed painless vision loss in the right eye (RE). The fundoscopy showed unilateral papilledema with pale optic disc in RE, accompanied by significant edema and thickening in the retinal nerve fiber layer (RNFL) of macula. The fundus fluorescence angiography showed that most of the optic disc in RE had postponed or absent fluorescence filling. Visual evoked potential (VEP) confirmed that the amplitude of the P100 component was decreased in RE without significant prolongation of the latency. The patient was diagnosed with anterior ischemic optic neuropathy, but immediate pulse steroid therapy failed to rescue his vision., Conclusion: Preoperative evaluation of the patient's hemodynamic status and fundus examination are essential for assessing the risk of ischemic ocular complications, and the non-adhesive liquid embolic agent Onyx-18 should be used cautiously during endovascular embolization of intracranial artery., (© 2024. The Author(s).)

Background: Dual-lumen balloon microcatheters allow for controlled anterograde flow of Onyx while providing proximal flow arrest, thereby obviating the need for a second microcatheter or Onyx plug formation. We sought to assess the safety and efficiency of the Scepter dual-lumen balloon microcatheter in trans arterial Onyx embolization of intracranial dural arteriovenous fistulas (DAVFs)., Methods: We conducted a retrospective study of 36 patients with cranial DAVFs in which a Scepter balloon microcatheter was used between 2016 and 2023., Results: Our study comprised 36 patients, mostly male (n = 23, 63.8%) with a mean age of 60.8 years. Most DAVFs were in the occipital lobe (n = 24, 66.7%), and 50% had external carotid artery supply from the occipital artery. Eighteen (50%) of DAVFs were Cognard type III and IV, respectively. About one third (33.3%, n = 12) of the DAVFs drained into the transverse sigmoid junction, and 27.7% (n = 10) had direct cortical venous drainage into supratentorial or posterior fossa veins. Complete occlusion was obtained in 22 (61.1%) patients while partial occlusion was observed in 14 (38.9%) patients. One patient (2.8%) developed a retroperitoneal hematoma. At final follow-up, complete occlusion was observed in 21 (77.8%) and partial occlusion was observed in 8 (22.2%). Recurrence was observed in 4/30 (13.3%) patients, and retreatment was required in 6 (18.75%) cases., Conclusions: At midterm follow-up, our study showed low morbidity and modest complete occlusion rates using the Scepter for transarterial Onyx embolization of high-grade DAVFs., (Copyright © 2024. Published by Elsevier Inc.)

Isolated sinus dural arteriovenous fistulas (DAVFs) involve a dural sinus with occlusion on both sides of the diseased sinus segment. Because of venous drainage refluxing from the isolated sinus into the cortical veins, all isolated sinus DAVFs are Borden type III or Cognard type Ⅲ/Ⅳ. Venous drainage typically involves temporo-occipital cortical veins or the superior petrosal sinus and tributaries of the petrosal vein. However, drainage veins involving the perimedullary venous system are extremely rare. Here, we present a case of Cognard type V isolated sinus DAVF successfully treated with balloon catheter and Onyx., (Copyright © 2023. Published by Elsevier Inc.)

Objective: In contrast to high-grade dural arteriovenous fistula (dAVF), low-grade dAVF is mainly associated with tinnitus and carries a low risk of morbidity and mortality. It remains unclear whether the benefits of active interventions outweigh the associated risk of complications in low-grade dAVF., Methods: The authors conducted a retrospective single-center study that included all consecutive patients diagnosed with an intracranial low-grade dAVF (Cognard type I and IIa) during 2012-2022 with DSA. The authors analyzed symptom relief, symptomatic angiographic cure, treatment-related complications, risk for intracerebral hemorrhage (ICH), and mortality. All patients were followed up until the end of 2022., Results: A total of 81 patients were diagnosed with a low-grade dAVF. Of these, 48 patients (59%) underwent treatment (all primary endovascular treatments), and 33 patients (41%) did not undergo treatment. Nine patients (19%) underwent retreatments. Angiographic follow-up was performed after median (IQR) 7.7 (6.1-24.1) months by means of DSA (mean 15.0, median 6.4 months, range 4.5-83.4 months) or MRA (mean 29.3, median 24.7 months, range 5.9-62.1 months). Symptom control was achieved in 98% of treated patients after final treatment. On final angiographic follow-up, 73% of patients had a completely occluded dAVF. There were 2 treatment-related complications resulting in 1 transient (2%) and 1 permanent (2%) neurological complication. One patient showed recurrence and progression of a completely occluded low-grade dAVF to an asymptomatic high-grade dAVF. No cases of ICH- or dAVF-related mortality were found in either treated patients (median [IQR] follow-up 5.1 [2.0-6.8] years) or untreated patients (median [IQR] follow-up 5.7 [3.2-9.0] years)., Conclusions: Treatment of low-grade dAVF provides a high rate of symptom relief with small risks for complications with neurological sequela. The risks of ICH and mortality in patients with untreated low-grade dAVF are minimal. Symptoms may not reveal high-grade recurrence, and radiological follow-up may be warranted in selected patients with treated low-grade dAVF. An optimal radiographic follow-up regimen should be developed by a future prospective multicenter registry.

Background: Endovascular treatment is the primary treatment modality for dural arteriovenous fistulas (DAVFs). We performed a retrospective analysis of DAVFs treated in our hospital to determine if high-quality endovascular treatment can be provided in a medium-volume vascular center., Methods: From 2007 to 2021, 69 DAVF treatments were undertaken in our hospital. Of these DAVFs, 55 were endovascular, 11 were open surgical procedures, and 3 were Gamma Knife treatments. Of the endovascular treatments, 10 (18.2%) were in ruptured DAVFs. The most common location of endovascularly treated DAVFs was at the transverse/sigmoid sinus (32.7%) and at the cavernous sinus (25.5%). Of the endovascularly treated DAVFs, 38.2% were low-grade fistulas (Cognard I/IIa), whereas 61.8% were high-grade fistulas (Cognard ≥IIb). 58.2% of fistulas were treated transarterially. DAVFs located in the cavernous sinus were treated using coils alone, whereas most other DAVFs were treated with liquid embolics alone or in combination with coils., Results: Complete or near-complete cure was achieved in 74.5% of treatments, whereas 18.2% of treatments resulted in downgrading of the fistula. Twelve patients were retreated once (9 endovascularly) and 1 patient was retreated twice. After retreatment, complete or near-complete cure was achieved in 86.4% of patients. 72.7% of treatments were performed without any remnant or retreatment. There were no procedure-related deaths. One patient experienced a complication resulting in permanent neurologic deficits. Seven other complications (12.7%) were recorded, all asymptomatic or causing only temporary symptoms., Conclusions: Based on our findings, we conclude that high-quality treatment of DAVFs can be provided in a medium-volume vascular center., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Dural arteriovenous fistulas (DAVFs) are direct shunts between extracranial or meningeal arteries and dural sinuses, dural veins, or cortical veins. They account for 10%-15% of all intracranial vascular malformations. DAVFs are classified according to two classification systems, Borden and Cognard, both of which are based on the venous drainage pathway and presence of antegrade or retrograde venous flow. A multidisciplinary approach using endovascular techniques has become the mainstay of treatment. We present two cases of DAVF with cortical venous drainage (Borden type 3) that were successfully treated using a transvenous approach via the draining subarachnoid veins.

Purpose: Endovascular treatment represents the first-line therapy for cavernous sinus dural arteriovenous fistulas (CS-dAVF); however, different approaches and embolic agents as well as occlusion rates, complications and clinical outcomes are reported among the published series. In this study we performed a comprehensive meta-analysis to investigate clinical and radiological outcomes after endovascular treatment of CS-dAVFs., Methods: PubMed, Ovid Medline, Ovid EMBASE, Scopus, and Web of Science were screened for a comprehensive literature review from 1990 to 2020 regarding series of patients treated for CS-dAVF with endovascular approaches. We performed a proportion meta-analysis estimating the pooled rates of each outcome also including data of patients treated in our center., Results: A total of 22 studies reporting 1043 patients and 1066 procedures were included. Chemosis was reported in 559 out of 1043 patients (45.9%), proptosis in 498 (41.5%), and ophthalmoplegia in 344 (23.5%). A transvenous embolization was preferred in 753 cases (63.2%) and coils were used in 712 out of 1066 procedures (57.8%). Overall, 85% (95% confidence interval, CI 69.5-96.1%) of patients had a complete resolution of symptoms, while complications occurred in 7.75% (95% CI 3.82-12.7%) with minimal permanent deficits (0.15%). The mortality rate was 1 out of 1043 patients (< 0.001)., Conclusion: A transvenous coiling is the most common endovascular approach for CS-dAVF, achieving a high percentage of radiological and clinical resolution and low complication rates. Transvenous approaches show less complications than transarterial ones, and coils appear safer than liquid embolic agents., (© 2021. The Author(s).)

Asystole or bradycardia is a relatively uncommon side effect seen in patients undergoing endovascular embolization using dimethylsulfoxide based liquid embolic agents. We present a case of a patient who underwent dural arteriovenous fistula embolization and experienced bradycardia during Onyx injection but was stabilized and the procedure was completed successfully.

A 75-year-old man presented with bilateral frontal hematomas owing to a dural arteriovenous fistula involving an isolated segment of the superior sagittal sinus. After an unsuccessful attempt of transarterial endovascular embolization of the dural arteriovenous fistula, the fistula was occluded using a transvenous approach through recanalization of the occluded superior sagittal sinus., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Cranial dural arteriovenous fistulas (dAVFs) are rare acquired neurovascular disorders that have the potential to profoundly alter the local and global cerebral venous drainage. Factors such as location, angioarchitecture, degree of shunting, and mode of presentation all appear to have some bearing on the natural history of dAVFs, which can vary from almost entirely benign to life-threatening. Accurate and evidence-based risk stratification is, therefore, key to informing important management decisions. The treatment strategies are nuanced and, for an already rare entity, can vary tremendously from 1 fistula to another. It is only through a thorough understanding of their behavior and the treatment options available that we will be able to deliver tailored treatment to the correct dAVF and the correct patient. We aimed to provide an up-to-date summary of the reported data on the natural history and predictors of aggressive behavior for cranial dAVFs in general, followed by site-specific management considerations., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Introduction: Dural arteriovenous fistulae (DAVF) are vascular lesions with arteriovenous shunting that may be treated with surgical obliteration or endovascular embolization. Some DAVF, such as anterior cranial fossa DAVF (AC-DAVF) derive their arterial supply from ophthalmic artery branches in nearly all cases, and trans-arterial embolization carries a risk of vision loss. We determined the efficacy and safety of trans-ophthalmic artery embolization of DAVF., Materials and Methods: We performed a retrospective cohort study of all patients with DAVF treated by trans-ophthalmic artery embolization from 2012 to 2020. Primary outcome was angiographic cure of the DAVF. Secondary outcomes included vision loss, visual impairment, orbital cranial nerve injury, stroke, modified Rankin Scale at 90-days, and mortality., Results: 12 patients met inclusion criteria (9 males; 3 females). 10 patients had AC-DAVF. Patient age was 59.7  ±  9.5 (mean ± SD) years. Patients presented with intracranial hemorrhage (4 patients), headache (4 patients), amaurosis fugax (1 patients), or were incidentally discovered (2 patients). DAVF Cognard grades were: II (1 patient), III (6 patients), and IV (5 patients). DAVF were embolized with Onyx (10 patients), nBCA glue (1 patient), and a combination of coils and Onyx (1 patient). DAVF cure was achieved in 11 patients (92%). No patients experienced vision loss, death, or permanent disability. One patient experienced a minor complication of blurry vision attributed to posterior ischemic optic neuropathy. 90-day mRS was 0 (10 patients) and 1 (2 patients)., Conclusions: Trans-ophthalmic artery embolization is an effective and safe treatment for DAVF.

Endovascular embolization of arteriovenous malformations (AVMs) and dural arteriovenous fistulas (DAVFs) has become the mainstay in treatment for these pathologies. Traditional techniques required the formation of a proximal plug of Onyx around the microcatheter prior to embolization to avoid reflux. Recently, dual-lumen balloon catheters have been introduced as a potential solution to this issue. We sought to compare our institutional experience with dual-lumen balloons to traditional microcatheters in the endovascular embolization of AVMs and DAVFs. A retrospective analysis of consecutive patients treated with Scepter between 2016 and 2020 was obtained. A control cohort treated with Marathon between 2012 and 2020 was also obtained. Variables collected included patient demographics, procedure times, pedicles treated, operative complications, obliteration rate, and retreatment rate. A total of 44 trial (30 DAVFs and 14 AVMs) and 25 control (15 DAVFs and 10 AVMs) subjects were identified. Average Scepter procedure times were 66.0 and 68.0 min for DAVFs and AVMs, respectively. Average Scepter volume of Onyx injected was 2.2 and 1.4 mL for DAVFs and AVMs, respectively. Complete angiographic occlusion Scepter rate was 86.7% and 50.0% for DAVFs and AVMs, respectively. The Scepter retreatment rate was 13.3% and 50.0% for DAVFs and AVMs, respectively. Predictors of angiographic occlusion included the number of pedicles (OR 0.54, 95%CI 0.30-0.97, p = 0.04). Predictors of retreatment included DAVF (OR 0.16, 95%CI 0.04-0.66, p = 0.01) and Marathon (OR 3.34, 95%CI 1.00-11.56, p = 0.05). Our study shows that dual-lumen balloon catheters are a viable option in the embolization of DAVFs and AVMs., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Dural arteriovenous fistulas (DAVF) are commonly encountered lesions that can be treated both transvenously, transarterially or using a combined approach., Objective: Transvenous coil embolization of DAVF is a recognized treatment option but can be challenging. In this context this article presents clinical experience using the Kaneka ED10 ExtraSoft coils in combination with the Marathon microcatheter to treat high grade DAVF. The physical properties of these coils and the microcatheter were also determined., Material and Methods: All patients with high grade DAVF treated with the Marathon and the Kaneka ED COIL ∞10 ExtraSoft coils were retrospectively identified. The clinical presentation, location, grade of the lesion, clinical and radiological follow-up data were recorded. Bench side studies were performed to determine the physical properties of the Marathon catheter in comparison to the SL10 and Headway Duo as well the maximum width of the Kaneka pusher wire in comparison to Hypersoft, Target and Axium Prime coils., Results: A total of 8 patients with 9 DAVF with 3 Cognard 3 and 6 Cognard 4 lesions were identified. All the DAVF's were occluded either at the end of the procedure or on follow-up imaging. On bench side tests the Marathon microcatheter had the most flexible distal tip and distal shaft in comparison to the SL10 and Headway Duo. The proximal shaft of the Marathon was stiffer than the SL10. The Kaneka ED COIL ∞10 ExtraSoft had the smallest distal width and were the only coils tested that could be deployed through a Marathon microcatheter., Conclusion: The combination of the Marathon microcatheter and Kaneka ED COIL ∞10 ExtraSoft is useful for the treatment of high grade DAVF.

Dural arteriovenous fistula (dAVF) accounts for approximately 10% of all intracranial vascular malformations. While they can be benign lesions, the presence of retrograde venous drainage and cortical venous reflux makes the natural course of these lesions aggressive high risk of haemorrhage, neurological injury and mortality. Endovascular treatment is often the first line of treatment for dAVF. Both transarterial and transvenous approaches are used to cure dAVF. The selection of treatment approach depends on the angioarchitecture of the dAVF, the location, the direction of venous flow. Surgery and, to a lesser extent, stereotactic radiosurgery are used when endovascular approaches are impossible or unsuccessful., Competing Interests: Competing interests: GPC is a consultant for Medtronic, Stryker and MicroVention. ALC is a consultant for Medtronic, Stryker, MicroVention and InNeuroCo., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

There are fewer than 20 published case reports of bradycardia or asystole during intracranial embolisation procedures. These are well described in open neurosurgical procedures, particularly involving the skull base. We present a case of a 59-year-old male patient who presented for elective embolisation of a dural arteriovenous fistula. During the injection of Onyx, the patient experience sudden asystole, which recurred after a second Onyx injection. Following successful treatment, a third injection proceeded without incident.

Endovascular management of dural arteriovenous fistulas has become a mainstay of treatment. In particular, modern techniques have allowed greater fistula penetration and likelihood of complete obliteration. However, the efficacy of newer agents has not been quantified outside of predominantly small case reports and case series. Furthermore, the Australian experience with fistula embolization has yet to be reported in the literature. To this aim, we performed a retrospective review of our endovascular management of a large cohort of cranial dural arteriovenous fistulas in the liquid embolic era. This retrospective case series included ninety-six consecutive patients of any Cognard grade, treated between 2005 and 2016. Liquid embolic agents were used exclusively in eighty-three cases. The overall complete obliteration rate was 89.6% with a residual fistula rate of 2%, and complication rate of 8.3%. This Sydney, Australia cohort demonstrates excellent treatment effect and safety outcomes and thus supports the primary treatment of this condition by endovascular means., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

OBJECTIVE Many small series and technical reports chronicle the evolution of endovascular techniques for cranial dural arteriovenous fistulas (dAVFs) over the past 3 decades, but reports of large patient series are lacking. The authors provide a thorough analysis of clinical and angiographic outcomes across a large patient cohort. METHODS The authors reviewed their endovascular database from January 1996 to September 2015 to identify patients harboring cranial dAVFs who were treated initially with endovascular approaches. They extracted demographic, presentation, angiographic, detailed treatment, and long-term follow-up data, and they evaluated natural history, initial angiographic occlusion, complications, recurrence, and symptomatic resolution rates. RESULTS Across a cohort of 251 patients with 260 distinct dAVFs, the overall initial angiographic occlusion rate was 70%; recurrence or occult residual lesions were seen on subsequent angiography in 3% of cases. The overall complication rate was 8%, with permanent neurological complications occurring in 3% of cases. Among 102 patients with dAVFs without cortical venous reflux, rates of resolution/improvement of pulsatile tinnitus and ocular symptoms were 79% and 78%, respectively. Following the introduction of Onyx during the latter half of the study period, the number of treated dAVFs doubled; the initial angiographic occlusion rate increased significantly from 60% before the use of Onyx to 76% after (p = 0.01). In addition, during the latter period compared with the pre-Onyx period, the rate of dAVFs obliterated via a transarterial-only approach was significantly greater (43% vs 23%, p = 0.002), as was the number of dAVFs obliterated via a single arterial pedicle (29% vs 11%, p = 0.002). CONCLUSIONS Overall, in the Onyx era, the rate of initial angiographic occlusion was approximately 80%, as was the rate of meaningful clinical improvement in tinnitus and/or ocular symptoms after initial endovascular treatment of cranial dAVFs.

Objectives: Dural arteriovenous fistulas (DAVFs) are a challenging condition in vascular neurosurgery. Disease natural history and its management is still debated. In the present paper we report our center series on DAVFs over a period of 10 years. Our data were compared with relevant literature., Patient and Methods: Our series includes 45 cases: 14 cavernous sinus, 11 transverse-sigmoid, 8 patients tentorial, 6 anterior cranial fossa, 5 patients spinal, 1 patient foramen magnum., Results and Conclusions: DVAFs distribution, clinical presentation and hemorrhagic risk are discussed. Cavernous sinus DAVFs are the most common site in our series. Other locations in order of frequency are transverse-sigmoid sinus, tentorial, anterior cranial fossa, spinal and foramen magnum. The majority of patients presented with non-aggressive symptoms. 18% presented with intracranial hemorrhage: all the hemorrhages occurred in high-grade DAVFs. For most patients, endovascular treatment, transarterial or transvenous, was the first option. Surgery was performed for the anterior cranial fossa DAVFs and other complex lesions draining mostly transverse-sigmoid sinus and tentorium. In 7% of cases a combination of endovascular+surgical treatment was used. Our series has been carefully analyzed in comparison 'side by side' with most relevant literature on DVAFs, focusing particularly on management strategies, therapeutic options and risks related to treatment., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Open surgical disconnection has long been the treatment of choice for dural arteriovenous fistulas (dAVFs) of the anterior cranial fossa. However, advanced patient age and the presence of medical comorbidities can substantially increase the risk of craniotomy and favor a less invasive endovascular approach. Optimal positioning within the distal ophthalmic artery, beyond the origin of the central retinal branch, is achievable using current microcatheter technology and embolic materials. Here we present the case of an 88-year-old female with an incidentally discovered dAVF of the anterior cranial fossa. Angiographic cure was achieved with one-stage Onyx embolization. The video can be found here: http://youtu.be/KVE0fUIECQM .

Dural arteriovenous fistulae (dAVF) with direct cortical venous drainage (CVD, Borden Type III) have a high risk of hemorrhage, particularly when symptomatic. Stereotactic radiosurgery is therefore not recommended, and endovascular treatment can be limited by access, incomplete obliteration, and recanalization. Of 70 cerebral dAVF seen at our institution over the past 8 years, 35 were Borden Type III (50%). Twenty-four were treated via microsurgery (69%). Presentation included hemorrhage in nine patients (38%), nonhemorrhagic neurologic deficits in five (21%), asymptomatic in five (21%), headache in three (13%), and seizure in two patients (8%). Only eight of 19 patients with symptomatic dAVF were independent (modified Rankin Scale [mRS] 0-2) preoperatively (42%). The dAVF location was tentorial in six patients (25%), petrosal in six (25%), superior sagittal sinus in four (17%), torcular in two (7%), floor of the anterior fossa in two (7%), and sphenoid ridge, transverse-sigmoid, inferior sagittal sinus and jugular in one patient each (4%). Four patients had failed endovascular therapy (17%). The angiographic obliteration rate was 96%. The combined permanent morbidity and mortality rate was 17%. After a mean follow-up of 2.1 years, 13 patients improved (54%), seven were the same, (29%) and four were worse (17%). Thirteen patients were asymptomatic (mRS 0, 54%), and 18 were independent (mRS 0-2, 75%). Our results reinforce that surgical treatment of dAVF with direct CVD is associated with a high angiographic cure rate with acceptable morbidity and mortality, particularly in light of the lesions' natural history., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objective: Dural arteriovenous fistulas (DAVFs) are arteriovenous shunts from a dural arterial supply to a dural venous channel, typically supplied by pachymeningeal arteries and located near a major venous sinus. A retrospective review was conducted to present the results of endovascular obliteration of DAVFs, with particular emphasis of newer liquid embolic agents, including Onyx-18 (MV3, Irvine, California, USA)., Methods: A review of the literature was performed, and a presentation of the number of treatments, complications, and outcomes is included here. The number of arterial embolizations and need for transvenous embolization, open surgery, and radiosurgery was assessed as well as normalization of retrograde cortical venous drainage., Results: Thirty-nine patients (22 men and 17 women) underwent endovascular treatment of DAVFs at our institution from 2001 to 2009. Ages ranged from 39 to 71 years (mean, 48 years). Seventy-nine percent of patients had retrograde cortical venous drainage. The average number of embolizations in all patients was 2.1. Twelve patients underwent 40 embolization treatments with Onyx, with an obliteration rate of 75% and cortical venous drainage obliteration rate of 85%. Seventy-one percent (28/39) of patients had complete treatment of the fistula: 21 by purely endovascular treatment and 7 with endovascular therapy followed by craniotomy, as well as seven patients who underwent stereotactic radiosurgery after embolization., Conclusions: Endovascular management of DAVFs is a safe and effective method of treating these complex lesions., (Copyright © 2013 Elsevier Inc. All rights reserved.)