Abstract

BackgroundNon-sinus type parasagittal dural arteriovenous fistula (DAVF) is associated with a high incidence of cortical venous reflux and is susceptible to the development of progressive symptoms, including venous infarction and cerebral hemorrhage. Well-developed superficial temporal arteries (STAs) and/or occipital arteries (OAs) are frequently involved, which present a challenge in controlling liquid embolic material when injecting liquid embolic material from the middle meningeal artery (MMA). We developed a method to control the feeding from cutaneous vessels using a circular plastic disc and a rubber band.

Case DescriptionWe present a case of a 48-year-old male with upper and lower extremity paralysis and diminished sensation in the left lower extremity. Imaging studies revealed a non-sinus type parasagittal DAVF (Borden type III, Cognard type IV) with bilateral MMAs and transosseous feeders from the STA and OA. To control blood flow from cutaneous feeders during Onyx embolization, we used a circular plastic disc and a rubber band to compress the feeders. The DAVF was successfully occluded without any complications. Cutaneous vessels were preserved after embolization.

ConclusionOur technique, which employs a circular plastic disc and rubber band to physically compress the cutaneous feeders and regulate blood flow during transarterial embolization for non-sinus type parasagittal DAVF, represents a valuable approach to preserving the cutaneous vessels and promptly assessing complete occlusion following the procedure. At the same time, it avoids the potential risks of radiation exposure to the surgical assistant.

Keywords: Dural arteriovenous fistula, Flow control, Onyx, Superficial temporal artery, Transarterial embolization

INTRODUCTION

Non-sinus type parasagittal dural arteriovenous fistula (DAVF) is associated with a high incidence of cortical venous reflux and is susceptible to the development of progressive symptoms, including venous infarction and cerebral hemorrhage.[ 2 , 8 ] Treatment options for non-sinus type parasagittal DAVF include direct surgery[ 3 , 8 ] and endovascular treatment.[ 1 , 4 , 6 , 7 ] However, in recent years, endovascular treatment has emerged as the preferred option when an accessible feeder is present.

The middle meningeal artery (MMA) is the main feeder for shunting[ 6 ], and a well-developed superficial temporal artery (STA) and/or occipital artery (OA) is frequently involved.[ 8 ] This presents a challenge in controlling liquid embolic material when injecting the material from the MMA. We have previously reported a case of tumor embolization of a meningioma involving a well-developed STA. In this previous case, manual compression around the parietal foramen of the STA inflow using a circular plastic disc and injection of n-butyl-2-cyanoacrylate from the MMA controlled the blood flow from the STA and achieved good embolization.[ 5 ] Manual compression by an assistant using lead gloves was necessary, and radiation exposure to the assistant was a problem. In this study, we developed a method to effectively block blood flow from developed cutaneous vessels without exposing the assistant to radiation. This was achieved using a circular plastic disc and a rubber band. Using this method, we report a case of transarterial embolization (TAE) using Onyx to cure a non-sinus type parasagittal DAVF.

CASE DESCRIPTION

A 48-year-old male experiencing difficulty ambulating was promptly transported to our medical facility. He was alert and oriented. However, he displayed evidence of upper and lower extremity paralysis and diminished sensation in the left lower extremity. Diffusion-weighted-imaging (DWI) showed a high intensity area in the right parietal lobe, and T2* showed no dilated vessels in the brain parenchyma [ Figures 1a and b ]. We considered the possibility of an acute cerebral infarction and administered tissue plasminogen activator. Subsequently, his symptoms improved. The next day, DWI demonstrated an improvement in the high intensity area observed the previous day. T2* exhibited a flow void in the right parietal lobe [ Figures 1c and d ]. Cerebral angiography revealed a DAVF with a shunt pouch in close proximity to the superior sagittal sinus (SSS) on angiography from the bilateral external carotid artery (ECA). The left STA was observed to flow into the right parietal foramen, which was connected to the dural vessels, and subsequently into the shunt. The right OA was also noted to flow through a small foramen posterior to the right parietal foramen, connected to the dural vessels, and ultimately into the shunt. The drainers were two right parietal cortical veins. One of the two cortical veins had a varix. There was no direct connection between the shunt pouch and the SSS. A diagnosis of non-sinus type parasagittal DAVF (Borden type III, Cognard type IV) was established [ Figures 1e - h ]. We performed TAE using Onyx.

Figure 1:

(a) Diffusion-weighted imaging (DWI) at the initial examination demonstrated a high-intensity area in the right parietal lobe. (b) T2* at the initial examination exhibited no dilated vessels. (c) DWI on the day following the onset of symptoms indicated that the high-intensity area in the right parietal lobe had diminished. (d) T2* on the day following onset displayed dilated vessels in the right parietal lobe. (e) Cerebral angiography performed on the day following the onset of symptoms revealed the presence of a right middle meningeal artery (MMA) as a feeder with a dural arteriovenous fistula in the early phase imaging of the right external carotid artery (ECA). The shunt was located in close proximity to the superior sagittal sinus and drained into two cortical veins. A varix was observed in the drainage vein that ran medially to the right parietal lobe. (f) The late phase of cerebral angiography from the right ECA showed the right occipital artery (OA) (white arrowhead) flowing through the foramen into the shunt. (g) Angiography from the left ECA showed the left MMA and the left superficial temporal artery (STA) feeding the shunt. The left STA (white arrow) passed through the right parietal foramen to the dural vessels and flowed into the shunt. (h) Three-dimensional rotational angiography of the left ECA revealed a dilated left STA flowing into the right parietal foramen (black arrow). Additionally, a foramen (white arrowhead) with inflow of the right OA was observed posterior to the right parietal foramen.

Endovascular procedure

We administered general anesthesia to the patient for the duration of the procedure. The patient was administered heparin intravenously, and the activated clotting time was maintained at 200–250 s. A 7F sheath was inserted into each bilateral femoral artery, and a 7Fr Roadmaster guiding catheter (Goodman, Nagoya, Japan) was introduced into the right and left ECAs, respectively. A 4.2 Fr FUBUKI (ASAHI Intec, Seto, Japan) was advanced from the Roadmaster in the left ECA to the proximal left MMA. A 4.2 Fr FUBUKI was then guided to the proximal portion of the right MMA. A SHOURYU 3 × 5 mm balloon catheter (KANEKA MEDIX, Osaka, Japan) was guided from a 4.2F FUBUKI to the left MMA, which was subsequently expanded to control blood flow from the left MMA. The blood flow from the left MMA was successfully regulated. A circular plastic disc [ Figures 2a and b ] was placed around both the right parietal foramen, into which the left STA flowed, and the foramen, into which the right OA flowed. A rubber band was then wrapped around the disc in a plane passing through the compression area and mandible in order to secure it [ Figure 2c ]. Furthermore, the disc was reinforced with tape to prevent any potential shifting [ Figure 2d ]. The successful occlusion of blood flow from the cutaneous vessels was confirmed [ Figure 2e ]. A Marathon microcatheter (Medtronic, Minneapolis, Minnesota, USA) was then guided into the right MMA from the 4.2F FUBUKI placed in the right MMA origin. Onyx 18 (Medtronic, Minneapolis, Minnesota, USA) was injected through the right MMA, resulting in a retrograde flow of casts into the feeders from the right OA and left STA [ Figure 2f ]. The Onyx injection was continued, yet the shunt remained incompletely occluded. Onyx was injected from Marathon, and Onyx was injected into the left MMA. On injection from Marathon, the shunt was fully occluded. Following the release of the compression, no shunt was observed [ Figure 2g ].

Figure 2:

(a) A SHOURYU 3 × 5 mm balloon catheter (white arrowhead) was expanded in the left middle meningeal artery (MMA) for flow control from the left MMA. A plastic disc (black arrow) was fixed around the two foramina in which the cutaneous feeders were inflowing. (b) The plastic disc utilized as a protective cap for the contrast agent, with an approximate diameter of 3 cm. (c) Image of our method using a skull model. (d) A photograph of the procedure was presented. The rubber band exhibited instability in its fixation and was reinforced with tape. (e) Angiography from the left external carotid artery (ECA), conducted after balloon expansion and disc fixation, demonstrated that the inflow from the left superficial temporal artery (STA) into the shunt had stopped. (f and g) Image after Onyx injection from the right MMA showed that feeders from the right OA (white arrowhead) and the left STA (black arrowhead) were occluded retrogradely. (h) Subsequent to embolization and the removal of the plastic disc, final angiography from the left ECA demonstrated the absence of feeding from the left STA. The shunt was no longer evident.

Postoperative course

The patient had a good postoperative course and was discharged home on postoperative day 3 without neurological deficits. Cerebral angiography at 3 months postoperatively showed that the shunt had remained occluded.

DISCUSSION

Miyake et al.[ 8 ] delineated three key characteristics of non-sinus parasagittal DAVF: The shunt is located just below the lambdoid or coronal suture, there is no communication with the SSS and direct drainage to the cortical veins, and the draining vein is exclusively ipsilateral to the shunt point, whereas the feeding arteries demonstrated a bilateral flow. This case was classified as a non-sinus type parasagittal DAVF as it fulfilled all the aforementioned characteristics.

When performing TAE of DAVF, it is important to control blood flow from feeders other than the feeder into which the liquid embolic material is injected. If blood flow from other feeders is strong, the embolizing material may not be able to remain in the shunt and may be dispersed. Blood flow from other feeders may also push back the embolic material, preventing it from reaching the shunt and leading to proximal occlusion. In DAVFs with shunts in the midline, such as non-sinus type parasagittal DAVFs, cutaneous vessels frequently become feeders.[ 6 , 10 ] In cases where well-developed cutaneous vessels are present as feeders, it is essential to regulate their blood flow. However, the tortuosity of cutaneous vessels can present a challenge when attempting to navigate the catheter in close proximity to the shunt. This can potentially lead to proximal occlusion. It has been documented that extensive embolization of cutaneous vessels using a liquid embolic material from a site distant from the shunt can result in cutaneous ischemia and infection.[ 10 ] It is preferable to utilize reversible occlusion rather than irreversible occlusion of cutaneous vessels through the deployment of coils or liquid embolic materials.

Methods to control blood flow in well-developed cutaneous vessels feeding the shunt have been reported.[ 7 , 9 , 11 ] Omura et al. used a balloon catheter to block the high flow cutaneous feeder during the treatment of transverse-sigmoid DAVF and injected Onyx from the main feeder.[ 9 ] The same methodology was employed in this instance, whereby the high-flow feeder from the left MMA was temporarily occluded with a balloon catheter following the injection of Onyx from the right MMA. Yamauchi et al. employed subcutaneous infiltration of lidocaine containing epinephrine to regulate blood flow from the cutaneous feeders into the shunt.[ 11 ] Kotsugi et al. controlled blood flow from the cutaneous feeders by temporarily obstructing bilateral ECAs with a balloon guiding catheter.[ 7 ]

When cutaneous vessels such as STA and OA feed into the DAVF, they invariably enter through the foramen. Furthermore, these cutaneous vessels are anastomosed to each other[ 12 ] and proximal occlusion of the feeder has only a limited effect on blood flow reduction due to abundant collateral blood flow. Consequently, we employed a circular plastic disc surrounding the foramen to regulate blood flow.[ 5 ] The benefit of our method in DAVF is that complete occlusion of the shunt can be immediately confirmed following embolization by removing the pressure of the circular plastic disc.

There is no set indication of how much pressure should be applied to the skin and for how long with our method. There is a concern about the possibility of skin ischemia if the skin is compressed with high pressure for a long time. We addressed this issue by loosening the band except during angiography to confirm whether the cutaneous vessels were occluded by pressure, and also during injection to minimize the compression time. We believe that it is desirable to keep the amount of pressure to the minimum necessary to occlude the cutaneous vessel. The patient did not complain of postoperative skin ischemia or pain.

This method can be used on other DAVFs near the midline, including non-sinus type parasagittal DAVFs. However, when cutaneous feeders flow into the shunt through multiple foramina,[ 7 , 10 ] ingenuity is required. A large-diameter disc may not fit flush to the outside of the skull and, therefore, may not adequately compress the cutaneous feeders. Therefore, it may be necessary to use a 3D printer to customize the disc to fit the curves of the skull. This is an issue that will need to be addressed in the future.

CONCLUSION

Our technique, which employs a circular plastic disc and rubber band to physically compress the cutaneous feeders and regulate blood flow during TAE for non-sinus type parasagittal DAVF, represents a valuable approach to preserving the cutaneous vessels and promptly assessing complete occlusion following the procedure while avoiding the potential risks associated with radiation exposure for the assistant.

Acknowledgment

We acknowledge the assistance of editorial services that provide language help.

Ethical approval

The Institutional Review Board approval is not required.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

Disclaimer

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.

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