Sinus Recanalization & TVE of a Complex Torcular DAVF-Part 1

Review

History

• 61 y/o female.

• Suffered from blurred vision, transient amaurosisn and mild pulsatile tinnitus for 4 months.

• Previous medical history: cerebral hemorrhage in July 2023, HTN for 10 years, gastric carcinoma resection in April 2021, aplastic anemia since Jan 2022.

• Medical imaging: MRV in local hospital demonstrated CVST.

• Lumbar puncture:

CSF pressure 380mmH₂O in June in 2024.

CSF pressure >500mmH₂O in July in 2024.

• PE:

Normal muscle strength; left temporal vessel engorgement.

Bilateral vision field deficit.

MMSE 29/30, MOCA 25/30 (primary school).

THI 36/100.

• 61岁女性。

• 双眼模糊伴一过性黑蒙、轻度搏动性耳鸣4月。

• 既往史：2023年6月脑出血，高血压10年，2021年4月行胃癌切除术，2022年1月诊断再生障碍性贫血。

• 影像学：MRV提示静脉窦血栓。

• 腰穿：

2024年6月腰穿压力380mmH₂O。

2024年7月腰穿压力>500mmH₂O。

• 查体：

四肢肌力正常；左侧颞部血管扩张。

双侧视野缺损。

认知评分：MMSE 29/30，MOCA 25/30 (小学学历)。

耳鸣妨碍量表 36/100。

Medical imaging

Figure 1. MRI (2023-08) showed cerebral hemorrhage with mild SAH.

图 1. MRI (2023-08) 示脑出血及少许蛛网膜下腔出血。

Figure 2. Enhanced MR (2023-09) showed right hemisphere swelling without enhancement. MRA depicted left sigmoid sinus occlusion.

图 2. 增强MR (2023-09) 示右侧大脑半球肿胀，无强化。MRA示左侧乙状窦闭塞。

Figure 3. Enhanced MR (2023-11) showed hyperintensity in the left sigmoid sinus on the T1WI, considered as subacute thrombosis formation.

图 3. 增强MR T1WI(2023-11) 示左侧乙状窦高信号，考虑左侧乙状窦亚急性血栓形成。

Figure 4 GIF. SWI (2024-07) before admission demonstrated a new hemorrhage at right temporal lobe and deep venous ectasia.

图 4 GIF. 入院前SWI (2024-07)示右侧颞叶新发出血，深静脉扩张。

Figure 5 GIF. Right PMA and MMA joined the medial tentorial vein and converged to the torcular sinus. The fistula refluxed to the left branch of the SSS and drained to the right lateral sinus. Severe stenosis was revealed at right transverse-sigmoid junction, left sigmoid sinus occluded.

图 5 GIF. 右侧颈外动脉造影示右侧脑膜后动脉、脑膜中动脉参与供血，在天幕内侧汇合向窦汇引流，然后逆流至上矢状窦左侧分支后经右侧侧窦引流。右侧横乙交界区狭窄，左侧乙状窦闭塞。

Figure 6 GIF. Cerebral drainage via the SSS and straight sinus was occupied by the competitive fistulous flow. The cerebral drainage compensated via the ventral emissary vein and pterygoid plexus. The right vein of Labbe emptied into the sigmoid sinus.

图 6 GIF. 右侧颈内动脉造影示上矢状窦和直窦的引流被动静脉瘘竞争性占据，脑引流主要经腹侧导静脉和翼丛。右侧Labbe静脉汇入乙状窦。

Figure 7 GIF. The left petrosal branch of the MMA and occipital artery fed the fistula, which converged to the conjunction between the left branch of the SSS and transverse sinus. The fistula refluxed to the left vein of Labbe and straight sinus.

图 7 GIF. 左侧颈外动脉造影示左侧脑膜中动脉岩支及枕动脉参与动静脉瘘供血，汇入上矢状窦左侧分支和横窦交界处，经左侧Labbe和直窦逆流。

Figure 8 GIF. The left MHT joined the medial tentorial vein and drained to the torcular.

图 8 GIF. 左侧颈外动脉造影示左侧脑膜垂体干汇入天幕内侧静脉后向窦汇引流。

Figure 9 GIF. The fistula fed by the PMA and occipital branch of the VA converge to the conjunction between the left branch of the SSS and transverse sinus. The fistula refluxed to the straight sinus. The left sigmoid sinus was occluded while the left IJV was demonstrated.

图 9 GIF. 左侧椎动脉造影示左侧脑膜后动脉及枕动脉参与动静脉瘘供血，汇入上矢状窦左侧分支和横窦交界处。动静脉瘘有经直窦逆流。尽管左侧乙状窦闭塞，左侧颈内静脉仍可见显影。

Figure 10 GIF. Cerebellar venous compensation via the SPS to the IPS.

图 10 GIF. 岩上窦、岩下窦代偿小脑的静脉引流。

The keys points of structural analysis of the fistulae

Figure 11. There existed two major shunted pouches, medial tentorial (orange circle ) and left SSS-TS conjunction (purple circle), which were connected.

图 11. 存在两个主要的动静脉瘘口汇集区，即天幕内侧(橘色圆圈所指)和左侧上矢状窦及横窦交界区(紫色圆圈所指)，且两个汇集区相沟通。

Figure 12. Left sigmoid sinus occlusion and right lateral sinus stenosis.

图 12. 左侧乙状窦闭塞，右侧横窦狭窄。

Figure 13. General heparization was performed. Pre-operative sinus pressure measurements.

图 13. 全身肝素化后行术前静脉窦测压。

Strategy

1. Treatment target:

a. Two major shunted pouches, medial tentorial and left SSS-TS conjunction, which were connected.

b. A clear and accessible shunted pouch can be treated via TVE and venous pressure cooker technique. It can obliterate the complex DAVF effectively.2. Sinus reconstruction: Right lateral sinus stenosis induced significant pressure gradient, which should be relieved first.
3. Alternative methods:
a. TAE: Bilateral MMA routes are available.
b. If the left retrograde access failed, reconstruction of the right side and the residual left lateral sinus could be sacrificed.
1. 治疗靶点：
a. 存在两个主要的动静脉瘘口汇集区，天幕内侧和左侧上矢状窦及横窦交界区，且两个汇集区相沟通。
b. 经静脉栓塞联合高压锅技术可以精准高效栓塞动静脉瘘口汇集区。2. 静脉窦重建：静脉窦压力差主要是由于右侧侧窦狭窄所导致的，所以应先开通右侧侧窦。
3. 备选方案：
a. 经动脉栓塞：可经双侧脑膜中动脉栓塞。
b. 如果经左侧逆行入路失败，可牺牲右侧和左侧残余侧窦的重建。
重点难点是动静脉瘘不直接向左侧小脑幕组桥静脉逆流，而是直接进入静脉窦，所以tve靶向栓塞不会闭塞邻近桥静脉，适用液体栓塞材料避免过度弥散。

Operation

Figure 14. Deployed a Precise 7*40mm stent, then dilated a Litepac 5*30mm 6-8 ATM for 30s.

图 14. 选用Precise 7*40mm支架在右侧横窦狭窄处释放，然后Litepac 5*30mm球囊以6-8 ATM扩张狭窄段30s。

Figure 15 GIF. SSS reflux decreased and superior cerebral venous (arrow) reflux diminished. While left vein of Labbe still refluxed due to left sigmoid sinus occlusion.

图 15 GIF. 复查左侧颈外造影，上矢状窦逆流减少，大脑上静脉（箭头所指）消失，由于左侧乙状窦闭塞，左侧Labbe仍有逆流。

Figure 16. ΔP across right TS stenosis decreased from 23mmHg to 3mmHg. The SSS and torcular sinus pressure almost recovered to normal.

图 16. 再以测压导丝按需测压，右侧横窦狭窄段压力差从术前23mmHg 下降至3mmHg，上矢状窦和窦汇区压力基本恢复正常。

Figure 17 GIF. 6F 65cm Terumo was placed into left IJV. Advanced 0.035 wire into the posterior condylar vein first. Navigated Envoy DA across the jugular foramen. Gateway 4*9mm was navigated into the left sigmoid sinus via a Transend-205. Gateway 4*9mm was dilated 8ATM, 3min for each segment (from occlude sigmoid sinus to jugular foramen).

图 17 GIF. 6F 65cm Terumo长鞘置于左侧颈静脉，0.035微导丝置于髁后静脉，Envoy DA置于左侧颈静脉孔区闭塞盲端内。Gateway 4*9mm球囊在Transend-205微导丝导引下通过闭塞段进入乙状窦内。Gateway球囊以8ATM逐段扩张闭塞乙状窦至颈静脉孔段（每次持续3min）。

Figure 18 GIF. Used the Gateway balloon to advance the Envoy DA to the transverse sinus. Deployed a Precise 6*40mm at the left branch of SSS.

图 18 GIF. 以球囊将Envoy DA通过闭塞段置于左侧横窦，Precise 6*40mm支架置于上矢状窦后部左侧支内。

Figure 19. Two Echelon-10 45º (C tipped) was advanced into the punch. Inserted 3 coils and coils packed in the dorsal portion of the shunted pouch.

图 19. 选用2根Echelon-10 45º 微导管（塑C型）穿支架置于窦前间隙。经近端微导管填入3枚弹簧圈，弹簧圈位于动静脉汇集区的背侧部分。

Figure 20. Inserted one coil through the distal microcatheter. The injected Onyx-34/18 via two microcatheters. A little of onyx penetrated into the stent.

图 20. 经远端微导管填入一枚弹簧圈，位置满意。经2根微导管交替注入Onyx-34和18。少许液体胶进入静脉窦。

Figure 21 GIF. Most of the fistula was obliterated, and the sinus was still patent.

图 21 GIF. 复查造影动静脉瘘大部分栓塞，右侧侧窦引流通畅。

Figure 22 GIF. Looped 0.035 wire advanced through the stent demonstrated Onyx migrated into the sinus. Litepac 5*30mm 6ATM for 1min. Precise 6*30mm was deployed to ensure the sinus patent.

图 22 GIF. 0.035微导丝头端成圈通过支架时有阻力，提示打胶时静脉窦内有Onyx液体胶进入。Litepac 5*30mm球囊以6ATM于静脉窦扩张，选用Precise 6*30mm支架予部分重叠释放确保左侧横窦通畅。

Figure 23. Deployed a Precise 6*40mm and dilated Litepac 5*30mm 6-8 ATM for 3 min at the left sigmoid sinus. Consider the re-stenotic rate, a stent was not placed at jugular foramen. Litepac 5*30mm dilated at the left jugular foramen 6ATM for 3min.

图 23. 左侧闭塞乙状窦段释放Precise 6*40mm支架后Litepac 5*30mm以6-8 ATM扩张3min。左侧颈静脉孔区考虑支架释放后再狭窄率高，予Litepac 5*30mm以6ATM扩张3min。

Figure 24 GIF. Left ECA angiography showed the fistula was almost obliterated and left sigmoid-jugular drained patent. Nimodipine 1ml and Tirofiban 5ml were administered.

图 24 GIF. 复查左侧颈外动脉造影示动静脉瘘大部分栓塞，静脉窦再通满意，左侧乙状窦-颈静脉引流通畅。经导引导管给予尼莫地平1ml和替罗非班5ml。

Figure 25 GIF. Straight sinus and SSS returned to antegrade flow from left ICA angiography.

图 25 GIF. 左侧颈内动脉造影示直窦、上矢状窦恢复正向引流。

Figure 26 GIF. Bilateral lateral sinus and SSS drained smoothly.

图 26 GIF. 双侧侧窦、上矢状窦引流顺畅。

Figure 27. Sinus pressure returned to normal after first-stage embolization and sinus recanalization. The residual fistula was planned second stage treatment.

图 27. 一期栓塞+静脉窦再通后静脉窦压力恢复正常。残余少许动静脉瘘计划二期治疗。

Post-operation

• NE: GCS 15, pulsatile tinnitus disappeared, bilateral muscle strength normal, without facial paralysis.

• Medication: Nadroparin 4100iu q12h for 3 days, Aspirin and Clopidogrel were prescribed.

• 神经查体：GCS 15，搏动性耳鸣消失，双侧肌力正常，无面瘫。

• 药物：那曲肝素4100iu q12h皮下注射3天，阿司匹林和氯吡格雷长期口服。

Figure 28. No edema nor acute infarction was detected.

图 28. 术后4天复查磁共振未见水肿及新发脑梗死。

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