TECHNICAL CASE REPORT
Transarterial N-Butyl-2-cyanoacrylate Embolization of an Intraosseous Dural Arteriovenous Fistula Associated With Acute Epidural Hematoma: Technical Case Report Shotaro Yoshioka, MD Kazuyuki Kuwayama, MD, PhD Junichiro Satomi, MD, PhD Shinji Nagahiro, MD, PhD Department of Neurosurgery, The University of Tokushima Graduate School, Tokushima, Japan Correspondence: Shotaro Yoshioka, MD, Department of Neurosurgery, The University of Tokushima Graduate School, 3-18-15, Kuramoto-cho, Tokushima, 770-8503 Japan. E-mail: [email protected] Received, January 15, 2015. Accepted, March 16, 2015. Published Online, April 11, 2015. Copyright © 2015 by the Congress of Neurological Surgeons.
BACKGROUND AND IMPORTANCE: Intraosseous dural arteriovenous fistulae (DAVF) are rare, especially those with drainage into the diploic venous system. The clinical presentation depends on the location of the lesion. This is the first report of an intraosseous DAVF associated with acute epidural hematoma. CLINICAL PRESENTATION: A 25-year-old man presented with headache and nausea. Imaging of the brain revealed abnormal signals indicative of acute epidural hematoma in the right frontal convexity. Angiography demonstrated a DAVF in the region of the frontal bone. Right external carotid artery angiography showed that the DAVF was fed mainly by the right middle meningeal artery with drainage into diploic veins. Immediately after embolization of the middle meningeal and the distal internal maxillary artery with 17% N-butyl-2-cyanoacrylate, the shunt was completely occluded. The patient was discharged 4 days later without clinical complications. CONCLUSION: Intraosseous DAVF can be treated by surgical resection or endovascular embolization. Curative treatment requires careful inspection of the angiographic architecture and microsurgical anatomy. KEY WORDS: Acute epidural hematoma, Diploic venous system, Intraosseous dural arteriovenous fistula, Meningeal-dural, Periosteal-dural, Transarterial embolization Operative Neurosurgery 11:E468–E471, 2015
C
ommon clinical presentations of dural arteriovenous fistulae (DAVF) are tinnitus, headache, and, to a lesser extent, venous congestion, increased intracranial pressure, and intracranial hemorrhage.1 They depend on the location of the DAVF. To our knowledge, ours is the first patient with an intraosseous DAVF presenting with acute epidural hematoma. Although DAVF are typically located within the dura adjacent to a venous sinus, they can arise at extrasinusal locations including the cranial base, tentorium, and intraorbital area.1-7 Intraosseous DAVF are rare, especially those with drainage into the diploic venous system.2-7
CLINICAL PRESENTATION A 25-year-old man presented with headache and nausea. He had no history of severe trauma, ABBREVIATION: DAVF, dural arteriovenous fistulae
E468 | VOLUME 11 | NUMBER 3 | SEPTEMBER 2015
DOI: 10.1227/NEU.0000000000000773
infection, or surgery and he was not on any medications. Computerized tomography and magnetic resonance imaging scans of the brain revealed abnormal signals indicative of acute epidural hematoma at the right frontal convexity. There were no abnormal signals in the subdural, subarachnoid, and parenchymal regions (Figure 1). Three-dimensional rotation angiography demonstrated a DAVF in the area of the frontal bone (Figure 2). Right external carotid artery angiography showed that it was fed mainly by the frontal and parietal branches of the right middle meningeal artery with drainage into the diploic veins (Figure 3). There was no evidence of venous drainage directly into the cortical veins or dural sinus. Immediately after embolization of the middle meningeal and the distal internal maxillary artery with 17% N-butyl-2-cyanoacrylate, the shunt was completely occluded (Figures 4A and 4B). The patient was discharged 4 days later without clinical complications.
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Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited
TRANSARTERIAL EMBOLIZATION OF INTRAOSSEOUS DAVF
FIGURE 1. Preoperative magnetic resonance imaging revealed abnormal signals indicative of acute epidural hematoma at the right frontal convexity (white arrow). There were no abnormal signals in subdural, subarachnoid, and parenchymal regions.
DISCUSSION Classic DAVF are located in the dura mater that contains the dural sinuses.1-7 They can arise at other locations without any
direct relationship with the venous sinus.2-7 From a microsurgical anatomic point of view, the term “dura” as used here is not accurate. The meninges comprise a system of membranes, the dura, arachnoid, and pia mater, which envelops the whole central nervous system. The dura mater is the thickest and outermost of these membranes; it consists of 2 separate layers, an outer periosteal layer (periosteal dura) and an inner meningeal layer (dura propria) that are split to form sinuses.8-10 The periosteal dura adheres to the inner surface of the skull and turns over the outer surface of the skull along the emissary foramen, optic canal, or foramen magnum. In our patient, imaging demonstrated that the fistula was located in the frontal bone and that the shunt drained into the diploic veins. This indicated that the intraosseous DAVF was situated around the periosteal dura and that the hematoma was located in the epi-meningeal-dural space. Therefore, we think that its location is best described as meningeal-dural or periosteal-dural. Intraosseous DAVF located at the skull base, hypoglossal canal, condylar veins, and around the foramen magnum have been reported,2-7 and the meningeal structures harboring the arteriovenous shunt in those cases and our patient are similar. Intraosseous DAVF can be treated curatively by surgical resection or endovascular procedures.3-7 Because hematoma did not grow chronologically and the patient demonstrated no
FIGURE 2. Axial contrast-enhanced CT scans (bone window setting) revealed an arteriovenous shunt (white arrow) in the diploic space with drainage into diploic veins (white arrowheads). CT, computed tomography.
OPERATIVE NEUROSURGERY
VOLUME 11 | NUMBER 3 | SEPTEMBER 2015 | E469
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited
YOSHIOKA ET AL
deterioration, we chose an endovascular procedure aiming at shunt occlusion under local anesthesia. The transvenous approach may be better for complete occlusion of the fistula than transarterial embolization, which requires the catheterization of multiple feeders.3,6,7 In our patient, the fistula and the main draining vein were located at the emissary foramen in the frontal bone without a direct relationship with the venous sinus. Because the transvenous approach required retrograde catheterization involving a long and winding route, we chose the transarterial approach. We carefully analyzed the multiple feeders and the venous drainage pattern and, under digital subtraction angiography guidance, embolization with 17% N-butyl-2-cyanoacrylate was completed and the patient was discharged 4 days after the procedure without clinical complications. It has been suggested that DAVF are acquired lesions arising after trauma, infections, intracranial surgery, and sinus thrombosis.5,11 Central to this hypothesis is the concept of an opening up of physiological arteriovenous shunts in the dura mater as a result of traumatic disruption or compensatory hypertrophy after sinus thrombosis. In our patient, there was no evidence of cranial bone fracture nor a history of infection, intracranial surgery, or sinus thrombosis. As is true for most DAVF, the etiology of our patient’s intraosseous DAVF is not known.
CONCLUSION Intraosseous DAVF are rare vascular malformations that involve the diploic venous system. They are associated with acute epimeningeal-dural hematoma and can be treated safely and curatively with the endovascular approach. For curative treatment, the angiographic architecture and microsurgical anatomy must be analyzed carefully. FIGURE 3. Preoperative diagnostic cerebral angiography of the right external carotid artery (A, anteroposterior projection; B, lateral projection) in the early and late arterial phase. There is a connection between the right middle meningeal artery and diploic veins.
Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.
FIGURE 4. Intra- and postoperative angiograms (lateral projection). A, embolization with 17% NBCA was performed through a microcatheter in the branches of the right middle meningeal artery. The NBCA cast is seen in the diploic space of the frontal bone. B, postembolization right external angiogram confirms complete obliteration of the arteriovenous shunt. NBCA, N-butyl-2-cyanoacrylate.
E470 | VOLUME 11 | NUMBER 3 | SEPTEMBER 2015
www.operativeneurosurgery-online.com
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited
TRANSARTERIAL EMBOLIZATION OF INTRAOSSEOUS DAVF
REFERENCES 1. Geibprasert S, Pereira V, Krings T, et al. Dural arteriovenous shunts: a new classification of craniospinal epidural venous anatomical bases and clinical correlations. Stroke. 2008;39(10):2783-2794. 2. Piske RL, Lasjaunias P. Extrasinusal dural arteriovenous malformations: report of three cases. Neuroradioloy. 1988;30(5):426-432. 3. Jung C, Kwon BJ, Kwon OK, et al. Intraosseous cranial dural arteriovenous fistula treated with transvenous embolization. AJNR Am J Neuroradiol. 2009;30 (6):1173-1177. 4. Malik GM, Mahmood A, Mehta BA. Dural arteriovenous malformation of the skull base with intraosseous vascular nidus: report of two cases. J Neurosurg. 1994; 81(4):620-623. 5. Kim MS, Oh CW, Han DH, Kwon OK, Jung HW, Han MH. Intraosseous dural arteriovenous fistula of the skull base associated with hearing loss: case report. J Neurosurg. 2002;96(5):952-955.
OPERATIVE NEUROSURGERY
6. Nerva JD, Hallam DK, Ghodke BV. Percutaneous transfacial direct embolization of an intraosseous dural arteriovenous fistula. Neurosurgery. 2014;10(suppl 1):E178-E182. 7. Shim JH, Yoon SM, Shim JJ, Kim RS. A case of intraosseous dural arteriovenous fistulas involving diploic vein treated with transarterial onyx embolization. J Korean Neurosurg Soc. 2011;50(3):260-263. 8. Mori K, Yamamoto T, Nakao Y, Esaki T. Surgical simulation of extradural anterior clinoidectomy through the trans-superior orbital fissure approach using a dissectable three-dimensional skull base model with artificial cavernous sinus. Skull Base. 2010;20(4):229-236. 9. Mori K, Yamamoto T, Nakao Y, Esaki T. Development of artificial cranial base model with soft tissues for practical education: technical note. Neurosurgery. 2010; 66(6 suppl operative):339-341. 10. Sikora A, Kedzia A. A quantitative comparison of dura mater tissue structures measured with atomic force microscopy. Adv Clin Exp Med. 2012;21(4):487-493. 11. Chaudhary MY, Sachdev VP, Cho SH, et al. Dural arteriovenous malformation of the major venous sinuses: an acquired lesion. AJNR Am J Neuroradiol. 1982;3(1):13-19.
VOLUME 11 | NUMBER 3 | SEPTEMBER 2015 | E471
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited
Transarterial N-Butyl-2-cyanoacrylate Embolization of an Intraosseous Dural Arteriovenous Fistula Associated With Acute Epidural Hematoma: Technical Case Report Shotaro Yoshioka, MD Kazuyuki Kuwayama, MD, PhD Junichiro Satomi, MD, PhD Shinji Nagahiro, MD, PhD Department of Neurosurgery, The University of Tokushima Graduate School, Tokushima, Japan Correspondence: Shotaro Yoshioka, MD, Department of Neurosurgery, The University of Tokushima Graduate School, 3-18-15, Kuramoto-cho, Tokushima, 770-8503 Japan. E-mail: [email protected] Received, January 15, 2015. Accepted, March 16, 2015. Published Online, April 11, 2015. Copyright © 2015 by the Congress of Neurological Surgeons.
BACKGROUND AND IMPORTANCE: Intraosseous dural arteriovenous fistulae (DAVF) are rare, especially those with drainage into the diploic venous system. The clinical presentation depends on the location of the lesion. This is the first report of an intraosseous DAVF associated with acute epidural hematoma. CLINICAL PRESENTATION: A 25-year-old man presented with headache and nausea. Imaging of the brain revealed abnormal signals indicative of acute epidural hematoma in the right frontal convexity. Angiography demonstrated a DAVF in the region of the frontal bone. Right external carotid artery angiography showed that the DAVF was fed mainly by the right middle meningeal artery with drainage into diploic veins. Immediately after embolization of the middle meningeal and the distal internal maxillary artery with 17% N-butyl-2-cyanoacrylate, the shunt was completely occluded. The patient was discharged 4 days later without clinical complications. CONCLUSION: Intraosseous DAVF can be treated by surgical resection or endovascular embolization. Curative treatment requires careful inspection of the angiographic architecture and microsurgical anatomy. KEY WORDS: Acute epidural hematoma, Diploic venous system, Intraosseous dural arteriovenous fistula, Meningeal-dural, Periosteal-dural, Transarterial embolization Operative Neurosurgery 11:E468–E471, 2015
C
ommon clinical presentations of dural arteriovenous fistulae (DAVF) are tinnitus, headache, and, to a lesser extent, venous congestion, increased intracranial pressure, and intracranial hemorrhage.1 They depend on the location of the DAVF. To our knowledge, ours is the first patient with an intraosseous DAVF presenting with acute epidural hematoma. Although DAVF are typically located within the dura adjacent to a venous sinus, they can arise at extrasinusal locations including the cranial base, tentorium, and intraorbital area.1-7 Intraosseous DAVF are rare, especially those with drainage into the diploic venous system.2-7
CLINICAL PRESENTATION A 25-year-old man presented with headache and nausea. He had no history of severe trauma, ABBREVIATION: DAVF, dural arteriovenous fistulae
E468 | VOLUME 11 | NUMBER 3 | SEPTEMBER 2015
DOI: 10.1227/NEU.0000000000000773
infection, or surgery and he was not on any medications. Computerized tomography and magnetic resonance imaging scans of the brain revealed abnormal signals indicative of acute epidural hematoma at the right frontal convexity. There were no abnormal signals in the subdural, subarachnoid, and parenchymal regions (Figure 1). Three-dimensional rotation angiography demonstrated a DAVF in the area of the frontal bone (Figure 2). Right external carotid artery angiography showed that it was fed mainly by the frontal and parietal branches of the right middle meningeal artery with drainage into the diploic veins (Figure 3). There was no evidence of venous drainage directly into the cortical veins or dural sinus. Immediately after embolization of the middle meningeal and the distal internal maxillary artery with 17% N-butyl-2-cyanoacrylate, the shunt was completely occluded (Figures 4A and 4B). The patient was discharged 4 days later without clinical complications.
www.operativeneurosurgery-online.com
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited
TRANSARTERIAL EMBOLIZATION OF INTRAOSSEOUS DAVF
FIGURE 1. Preoperative magnetic resonance imaging revealed abnormal signals indicative of acute epidural hematoma at the right frontal convexity (white arrow). There were no abnormal signals in subdural, subarachnoid, and parenchymal regions.
DISCUSSION Classic DAVF are located in the dura mater that contains the dural sinuses.1-7 They can arise at other locations without any
direct relationship with the venous sinus.2-7 From a microsurgical anatomic point of view, the term “dura” as used here is not accurate. The meninges comprise a system of membranes, the dura, arachnoid, and pia mater, which envelops the whole central nervous system. The dura mater is the thickest and outermost of these membranes; it consists of 2 separate layers, an outer periosteal layer (periosteal dura) and an inner meningeal layer (dura propria) that are split to form sinuses.8-10 The periosteal dura adheres to the inner surface of the skull and turns over the outer surface of the skull along the emissary foramen, optic canal, or foramen magnum. In our patient, imaging demonstrated that the fistula was located in the frontal bone and that the shunt drained into the diploic veins. This indicated that the intraosseous DAVF was situated around the periosteal dura and that the hematoma was located in the epi-meningeal-dural space. Therefore, we think that its location is best described as meningeal-dural or periosteal-dural. Intraosseous DAVF located at the skull base, hypoglossal canal, condylar veins, and around the foramen magnum have been reported,2-7 and the meningeal structures harboring the arteriovenous shunt in those cases and our patient are similar. Intraosseous DAVF can be treated curatively by surgical resection or endovascular procedures.3-7 Because hematoma did not grow chronologically and the patient demonstrated no
FIGURE 2. Axial contrast-enhanced CT scans (bone window setting) revealed an arteriovenous shunt (white arrow) in the diploic space with drainage into diploic veins (white arrowheads). CT, computed tomography.
OPERATIVE NEUROSURGERY
VOLUME 11 | NUMBER 3 | SEPTEMBER 2015 | E469
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited
YOSHIOKA ET AL
deterioration, we chose an endovascular procedure aiming at shunt occlusion under local anesthesia. The transvenous approach may be better for complete occlusion of the fistula than transarterial embolization, which requires the catheterization of multiple feeders.3,6,7 In our patient, the fistula and the main draining vein were located at the emissary foramen in the frontal bone without a direct relationship with the venous sinus. Because the transvenous approach required retrograde catheterization involving a long and winding route, we chose the transarterial approach. We carefully analyzed the multiple feeders and the venous drainage pattern and, under digital subtraction angiography guidance, embolization with 17% N-butyl-2-cyanoacrylate was completed and the patient was discharged 4 days after the procedure without clinical complications. It has been suggested that DAVF are acquired lesions arising after trauma, infections, intracranial surgery, and sinus thrombosis.5,11 Central to this hypothesis is the concept of an opening up of physiological arteriovenous shunts in the dura mater as a result of traumatic disruption or compensatory hypertrophy after sinus thrombosis. In our patient, there was no evidence of cranial bone fracture nor a history of infection, intracranial surgery, or sinus thrombosis. As is true for most DAVF, the etiology of our patient’s intraosseous DAVF is not known.
CONCLUSION Intraosseous DAVF are rare vascular malformations that involve the diploic venous system. They are associated with acute epimeningeal-dural hematoma and can be treated safely and curatively with the endovascular approach. For curative treatment, the angiographic architecture and microsurgical anatomy must be analyzed carefully. FIGURE 3. Preoperative diagnostic cerebral angiography of the right external carotid artery (A, anteroposterior projection; B, lateral projection) in the early and late arterial phase. There is a connection between the right middle meningeal artery and diploic veins.
Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.
FIGURE 4. Intra- and postoperative angiograms (lateral projection). A, embolization with 17% NBCA was performed through a microcatheter in the branches of the right middle meningeal artery. The NBCA cast is seen in the diploic space of the frontal bone. B, postembolization right external angiogram confirms complete obliteration of the arteriovenous shunt. NBCA, N-butyl-2-cyanoacrylate.
E470 | VOLUME 11 | NUMBER 3 | SEPTEMBER 2015
www.operativeneurosurgery-online.com
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited
TRANSARTERIAL EMBOLIZATION OF INTRAOSSEOUS DAVF
REFERENCES 1. Geibprasert S, Pereira V, Krings T, et al. Dural arteriovenous shunts: a new classification of craniospinal epidural venous anatomical bases and clinical correlations. Stroke. 2008;39(10):2783-2794. 2. Piske RL, Lasjaunias P. Extrasinusal dural arteriovenous malformations: report of three cases. Neuroradioloy. 1988;30(5):426-432. 3. Jung C, Kwon BJ, Kwon OK, et al. Intraosseous cranial dural arteriovenous fistula treated with transvenous embolization. AJNR Am J Neuroradiol. 2009;30 (6):1173-1177. 4. Malik GM, Mahmood A, Mehta BA. Dural arteriovenous malformation of the skull base with intraosseous vascular nidus: report of two cases. J Neurosurg. 1994; 81(4):620-623. 5. Kim MS, Oh CW, Han DH, Kwon OK, Jung HW, Han MH. Intraosseous dural arteriovenous fistula of the skull base associated with hearing loss: case report. J Neurosurg. 2002;96(5):952-955.
OPERATIVE NEUROSURGERY
6. Nerva JD, Hallam DK, Ghodke BV. Percutaneous transfacial direct embolization of an intraosseous dural arteriovenous fistula. Neurosurgery. 2014;10(suppl 1):E178-E182. 7. Shim JH, Yoon SM, Shim JJ, Kim RS. A case of intraosseous dural arteriovenous fistulas involving diploic vein treated with transarterial onyx embolization. J Korean Neurosurg Soc. 2011;50(3):260-263. 8. Mori K, Yamamoto T, Nakao Y, Esaki T. Surgical simulation of extradural anterior clinoidectomy through the trans-superior orbital fissure approach using a dissectable three-dimensional skull base model with artificial cavernous sinus. Skull Base. 2010;20(4):229-236. 9. Mori K, Yamamoto T, Nakao Y, Esaki T. Development of artificial cranial base model with soft tissues for practical education: technical note. Neurosurgery. 2010; 66(6 suppl operative):339-341. 10. Sikora A, Kedzia A. A quantitative comparison of dura mater tissue structures measured with atomic force microscopy. Adv Clin Exp Med. 2012;21(4):487-493. 11. Chaudhary MY, Sachdev VP, Cho SH, et al. Dural arteriovenous malformation of the major venous sinuses: an acquired lesion. AJNR Am J Neuroradiol. 1982;3(1):13-19.
VOLUME 11 | NUMBER 3 | SEPTEMBER 2015 | E471
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited
