Staged management of bilateral DAVFs-Part One

Review

History

• 46 y/o, male.

• Suffered from transient repeated headache and bilateral pulsatile tinnitus for 3 years. The pulsatile tinnitus relieved spontaneously after COVID infection (2023-12). While headache aggravated accompanied with nausea and vomiting, persisting for several minutes and relieving spontaneously.

• PE: normal muscle strength

mild cognitive disorder: MMSE 25/30, MoCA 23/30
THI 0/100

• Pre-operative medication: Rivaroxaban 10mg QD; ticagrelor 90mg BID.

• 46岁，男性。

• 主诉反复发作性头痛伴双侧搏动性耳鸣3年。近期（2023-12）COVID感染后颅内杂音消失，但出现头痛发作频次及程度加重，每次持续数分钟伴有恶心呕吐，可自行缓解。

• 神经系统查体：肢体肌力正常，视力正常。

认知功能轻度下降：MoCA 23/30，MMSE 25/30。
耳鸣致残量表 0/100。

• 术前用药：利伐沙班 10mg QD；替格瑞洛90mg BID。

Figure 1. MRA revealed increased dilated vessels at the bilateral lateral sinuses. SWI did not detect any obvious micro-bleedings.

图 1. MRA提示双侧侧窦区增多增粗血管影。SWI未见明显微出血灶。

Figure 2 GIF. Right MMA and occipital feeders converged to the right transverse-sigmoid junction (Cognard I), while the sinus septum could be identified on the proximal side. Right TS was not revealed via RECA. The MMA was regraded as “golden access” for trans-arterial embolization.

图 2 GIF. 右侧脑膜中动脉及枕动脉向横-乙交界区硬膜静脉端汇聚，这一部分由脑膜中动脉黄金通道供血，经动脉栓塞到位容易。右侧乙状窦内可见静脉间隔，右侧横窦未见显影。从右侧颈外动脉造影上，该右侧侧窦区DAVF为Cognard I。

Figure 3 GIF. Right posterior meningeal artery medial branches fed DAVFs at the bilateral lateral sinuses (yellow arrows). And right posterior meningeal artery lateral branches converged to right transverse-sigmoid junction yellow circle), the region Onyx difficult to diffuse into.

图 3 GIF. 右侧椎动脉发出的脑膜后动脉的内侧支向双侧侧窦区DAVF供血(黄箭)。右侧脑膜后动脉外侧支沿乙状窦向横-乙交界区共同静脉端汇聚（黄色圆圈)，这是Onyx胶最终比较难以弥散的部位。

Figure 4 GIF. RECA fusion 3D reconstruction, revealed fistulae concentrated to the transverse-sigmoid junction. (internal maxillary artery (purple) and occipital artery (yellow); internal maxillary artery (white) and right vertebrate artery (green)).

图 4 GIF. 右侧颈外动脉的融合重建，不同来源的供血动脉向横-乙交界区共同静脉端的汇聚。颌内动脉（紫）和枕动脉（黄）；右侧颌内动脉（白）与右侧椎动脉（绿）的融合重建。

Figure 5 GIF. Fistula located at left transverse-sigmoid junction, emptied to the TS, SSS, SS, right TS and cortical veins (Cognard 2a+b). The LEFT sigmoid sinus occluded, while the right transverse-sigmoid junction also obstructed (red lines).
图 5 GIF. 左侧颈外动脉分支向左侧横-乙交界区的汇聚，再通过左侧横窦向窦汇、上矢状窦、直窦以及右侧横窦残端引流（Cognard 2a+b）左侧乙状窦闭塞（红虚线）位于DAVF下游；右侧横-乙交界区闭塞（位于DAVF上游）。

Figure 6 GIF. The sinus occluded at right transverse-sigmoid junction (X).

图 6 GIF. 右侧（紫）横-乙交界处闭塞（X）。

Bilateral DAVFs angioarchitecture analysis

Angioarchitecture of the right lateral sinus DAVF

1. Cognard I, sinus type;

2. Feeders arose from MMA, PMA and occipital artery converged to the right transverse-sigmoid junction;

3. Right sigmoid sinus septum (still patent);

4. Right transvers-sigmoid junction sinus occlusion.

Angioarchitecture of left transverse-sigmoid junction DAVF

1. Cognard IIa+b, sinus type；

2. Left sigmoid sinus occlusion;

3. Left ECA converged to the left transverse-sigmoid junction;

4. Retrograde drainage of pial veins interfered the judgement of focal angioarchitecture.

右侧侧窦区DAVF血管构筑

1. Cognard I，窦型；

2. 右侧脑膜中动脉、脑膜后动脉及枕动脉向横-乙交界区硬膜静脉端汇聚；

3. 右侧乙状窦通畅，内可见静脉间隔；

4. 右侧横-乙状窦交界区静脉窦闭塞。

左侧横-乙交界区DAVF的血管构筑

1. Cognard IIa+b，窦型；

2. 左侧乙状窦闭塞；

3. 左侧颈外动脉分支向左侧横-乙交界区的汇聚；

4. 经横窦向软膜静脉窦逆流，静脉结构迂曲扩张，干扰对局部动静脉瘘血管构筑的判断。

Figure 7. Cerebral venous angioarchitecture. Normal venous drainage to the SSS and SS was occupied by the fistula, compensated via the ventral and deep venous compensation.

图 7. 脑静脉回流血管构筑。正常至上矢状窦和乙状窦的引流被瘘口引流静脉占据，经腹侧和深部引流静脉代偿。

First stage strategies

Flow reduction and venous sinus reconstruction

1. The main target for the bilateral transverse-sigmoid junction DAVFs with bilateral occluded sinuses was sinus recanalization in order to reconstruct anterograde drainage instead of simple fistula obliteration.

2. Right transverse-sigmoid sinus recanalization:

The occluded segment was located in the upstream of the fistula, which was a protective factor for right DAVF while aggravated left side drainage disorder. Therefore the occluded sinus should be recanalized.
Consider the short obstructed segment on the right side, the recanalization might be technically easier.
Antegrade recanalization from right to the left side was technically preferable.
Transvenous access route can obliterate the shunted pouch effectively.

3. Left sigmoid sinus recanalization:

Consider the dominant size of the left sinus, sinus reconstruction was prior to sacrifice.
Left jugular foramen was involved, therefore retrograde recanalization through left internal jugular vein was technically difficult.
The long-term risk of jugular foramen intra-stent stenosis was high.
If the left sinus reconstruction failed, the left sinus sacrificed and right sinus reconstruction can provide enough venous drainage capacity.

1. 双侧横-乙交界区DAVF伴有双侧静脉窦闭塞，重建静脉窦的正向回流是主要目标，而非单纯闭塞动静脉瘘；

2. 右侧横-乙交界区闭塞再通：

静脉窦闭塞段位于动静脉瘘汇聚区的上游，是相对右侧DAVF的保护性因素，但导致左侧DAVF的静脉回流障碍进一步加重，仍有干预的指征；
右侧静脉入路相对更稳定，横-乙交界静脉窦闭塞节段短，再通重建的技术难度相对于左侧低，静脉窦远期通畅率高；
右侧入路正向开通左侧闭塞乙状窦技术成功率更高；
右侧静脉入路可能直接进入动静脉瘘硬膜血管汇集区，可以经静脉途径高效地靶向栓塞DAVF。

3. 左侧乙状窦闭塞再通：

左侧侧窦优势侧，仍倾向于静脉窦重建优于闭塞静脉窦；
左侧闭塞段累及乙状窦颈静脉孔段，经左侧颈内静脉逆行开通技术难度大；
左侧乙状窦经静脉孔段支架远期再狭窄风险；
双侧静脉窦至少需要确保重建一侧的正向回流，当左侧静脉窦再通失败时，经静脉途径闭塞静脉窦也是备用方案。

Figure 8 GIF. The venography revealed two shunted pouches:

Red circle on the lateral side was fed by the ECA feeders and trans-arterial embolization through MMA was technically not too hard;
Yellow dot line indicated the PMA fed torcular fistula. Large balloon to protect sinus was required if MMA was selected, which will increase the risk of normal drainage vein obliteration and onyx refluxing to arteries.
The 3D roadmap can separate the right TS (blue dot lines)from the fistulous veins.

图 8 GIF. 通过静脉窦直接造影，可以将右侧横-乙交界区的窦前共同静脉端进一步分解为两部分：

外侧静脉腔隙（红圈）由颈外动脉分支主要参与供血，可以通过脑膜中动脉入路闭塞，技术难度最低；
内侧静脉腔隙（黄色虚线）通过脑膜后动脉供血。如果经通过脑膜中动脉，则需要静脉窦大球囊保护，增加Onyx胶沿球囊闭塞功能引流静脉或向动脉端危险返流的风险。
通过双侧颈外动脉三维容积成像的融合，可以显示上游的横窦的走行（蓝色虚线）。

Figure 9. Left ECA arterial + right sigmoid venous roadmap

Best overall perspective of venous structure;
Three retrograde transvenous routes:
1. dural veins from PMA (green)
2. veins from MMA (lateral)
3. occluded sinus (blue)
Torcular fistula would be difficult to manage via bilateral MMA routes. Therefore TVE of the torcular fistula is preferred.

图 9. 左侧颈外动脉+右侧静脉窦联合路途

动-静脉联合路途显示整体血管构筑;
经静脉逆行有三个路径：
1. 脑膜后动脉来源的硬膜静脉（绿）
2. 脑膜中动脉来源（外侧）
3. 闭塞的静脉窦（蓝）；
脑膜后动脉的供血来源（绿色）经动脉栓塞相对困难，而经静脉可以靶向闭塞静脉汇聚区。

Sequence of TVE, TAE and sinus recanalization:

1. The TVE aimed to decrease flow instead of occluding sinus.

2. MMA is the golden route for second staged trans-arterial embolization.

3. Right occluded sinus recanalized first to reconstruct left/bilateral cerebral drainage veins.

1. TVE靶向栓塞的目的是减流，不应当影响闭塞静脉窦重建的通路；

2. MMA是二期经动脉治愈性栓塞的最优通路；

3. 右侧静脉窦再通重建左侧/全脑的静脉回流。

Figure 10 GIF. Two Echelon-10 microcatheters were advanced into torcular primary veins via a Transend softip-205. Then inserted 6 coils through proximal microcatheter and injected Onyx-18 through distal microcatheter. Never embolized excessively and preserved sinus reconstruction route (blue circle). Right VA angiograms showed blood flow of the fistula decreased.

图 10 GIF. 将两根Echelon-10微导管在Transend softip-205微导丝导引下逆行置于天幕区硬膜初级静脉内，微导管确认到位后，经近端微导管填入6弹簧圈，远端微导管注入Onyx-18。计划性减流，不过度栓塞，保留静脉窦重建的通路（蓝圈）。右椎动脉造影示动静脉瘘流量减低。

Figure 11 GIF. Gateway 3*15mm balloon was advanced into right transverse sinus via a Transend softip-205 microwire. Exchanged to a Floppy-300 wire, then dilated the balloon 8ATM at right transverse-sigmoid junction. Dilated LitePAC 4*20mm 6-8ATM at the right transverse-sigmoid junction.

图 11 GIF. Gateway 3*15mm球囊在Transend softip-205微导丝导引下穿过狭窄段间隔进入横窦，造影证实球囊位于真腔。更换Floppy-300交换导丝，回撤球囊于右侧横-乙交界区以8ATM 逐段扩张。交换LitePAC 4*20mm球囊于横-乙交界区以6-8ATM扩张。

Figure 12. Gateway 3*15mm 8-10 ATM and LitePAC 5*30mm 6-8 ATM dilated at the left jugular foramen. Then deployed Precise 6*30mm at the left jugular foramen, Precise 8*30mm at the left sigmoid sinus. Dilated LitePACA 6*30mm at the stenosis. Precise 8*40mm was deployed at the left transverse-sigmoid segment to compress the meningeal venules.

图 12. Gateway 3*15mm球囊以8-10ATM、LitePAC 5*30mm球囊以6-8ATM扩张颈静脉孔段。选用Precise 6*30mm置于左侧乙状窦颈静脉孔段，Precise 8*30mm置于左侧乙状窦内。LitePAC 6*30mm球囊扩张残余狭窄段。Precise 8*40mm至于左侧横乙交界区与前一枚支架部分重叠释放并覆盖动静脉瘘。

Figure 13 GIF. The pre-operative Cognard 2a+b DAVF transferred to a benign Cognard 1 fistula after proximal recanalization.

图 13 GIF. 左侧静脉窦重建后，Cognard IIa+b DAVF转变为低分级Cognard I级。

Figure 14. Precise 7*30mm and 7*40mm stents were deployed at the right transverse-sigmoid segment. LitePac 6*30mm 6-8ATM dilated to make stents well-adherent to vascular wall.

图 14. Precise 7*30mm和7*40mm支架于右侧横乙交界区释放。LitePac 6*30mm球囊以6-8ATM扩张支架使支架贴壁良好。

Figure 15 GIF. Left LECA angiograms showed the residual fistula draining to left sigmoid sinus without retrograde pial veins drainage (Cognard I). A suspected SSS DAVF should be followed up.

图 15 GIF. 复查左侧颈外动脉造影示残余动静脉瘘经乙状窦正向引流，无软膜静脉逆流(Cognard I)。上矢状窦区可疑硬脑膜动静脉瘘建议随访。

Video 1. The right residual fistula drained to right sigmoid sinus (Cognard I).

视频 1. 复查右侧颈外、椎动脉造影见残余动静脉瘘经右侧乙状窦正常引流(Cognard I)。

Video 2. The cerebral drainage pattern partially reversed to an antegrade direction, while the high flow of the fistula still occupying the sinus. Therefore fistulous flow deduction was scheduled in a short period.

视频 2. 双侧颈内动脉造影示软膜静脉部分恢复至经上矢状窦正向引流，尽管仍有高流量的瘘占据静脉窦。因此短期内需进行二次手术。

Post-operation

• NE: GCS 15, pulsatile tinnitus disappearance, bilateral pupils movement and light reflux normal, bilateral muscle strength V, normal swallowing.

• Pre-operative MMSE 25/30, Post-operative MMSE 29/30

• Pre-operative MoCA 23/30, Post-operative MoCA 26/30

• Medication: aspirin and clopidogrel.

• 神经查体：GCS 15, 搏动性耳鸣消失，双侧瞳孔运动正常，对光反射灵敏，双侧肌力正常，吞咽正常。

• 术前MMSE 25/30, 术后 MMSE 29/30

• 术前 MoCA 23/30, 术后 MoCA 26/30

• 药物：口服阿司匹林和氯吡格雷。

声明：脑医汇旗下神外资讯、神介资讯、脑医咨询、Ai Brain 所发表内容之知识产权为脑医汇及主办方、原作者等相关权利人所有。

投稿邮箱：NAOYIHUI@163.com

未经许可，禁止进行转载、摘编、复制、裁切、录制等。经许可授权使用，亦须注明来源。欢迎转发、分享。

投稿/会议发布，请联系400-888-2526转3。