Middle cranial fossa sphenoidal region dural arteriovenous fistulas: anatomic and treatment considerations

• Published in: American journal of neuroradiology : AJNR Vol. 34; no. 2; pp. 373 - 380
• Main Authors: Shi, Z-S, Ziegler, J, Feng, L, Gonzalez, N R, Tateshima, S, Jahan, R, Martin, N A, Viñuela, F, Duckwiler, G R
• Format: Journal Article
• Language: English
• Published: United States 01-02-2013
• Subjects: Adult; Aged; Carotid Artery, External - anatomy & histology; Carotid Artery, External - diagnostic imaging; Central Nervous System Vascular Malformations - diagnostic imaging; Central Nervous System Vascular Malformations - surgery; Central Nervous System Vascular Malformations - therapy; Cerebral Angiography; Cerebral Arteries - anatomy & histology; Cerebral Arteries - diagnostic imaging; Cerebral Hemorrhage - prevention & control; Cerebral Veins - anatomy & histology; Cerebral Veins - diagnostic imaging; Cranial Fossa, Middle - anatomy & histology; Cranial Fossa, Middle - diagnostic imaging; Dura Mater - anatomy & histology; Dura Mater - diagnostic imaging; Embolization, Therapeutic - methods; Endovascular Procedures; Female; Follow-Up Studies; Humans; Male; Middle Aged; Phlebography; Retrospective Studies; Sphenoid Bone - anatomy & histology; Sphenoid Bone - diagnostic imaging; Treatment Outcome
• ISSN: 0195-6108; 1936-959X
• DOI: 10.3174/ajnr.A3193

DAVFs rarely involve the sphenoid wings and middle cranial fossa. We characterize the angiographic findings, treatment, and outcome of DAVFs within the sphenoid wings.
We reviewed the clinical and radiologic data of 11 patients with DAVFs within the sphenoid wing that were treated with an endovascular or with a combined endovascular and surgical approach.
Nine patients presented with ocular symptoms and 1 patient had a temporal parenchymal hematoma. Angiograms showed that 5 DAVFs were located on the lesser wing of sphenoid bone, whereas the other 6 were on the greater wing of the sphenoid bone. Multiple branches of the ICA and ECA supplied the lesions in 7 patients. Four patients had cortical venous reflux and 7 patients had varices. Eight patients were treated with transarterial embolization using liquid embolic agents, while 3 patients were treated with transvenous embolization with coils or in combination with Onyx. Surgical disconnection of the cortical veins was performed in 2 patients with incompletely occluded DAVFs. Anatomic cure was achieved in all patients. Eight patients had angiographic and clinical follow-up and none had recurrence of their lesions.
DAVFs may occur within the dura of the sphenoid wings and may often have a presentation similar to cavernous sinus DAVFs, but because of potential associations with the cerebral venous system, may pose a risk for intracranial hemorrhage. Curative embolization through a transarterial or transvenous approach is the primary therapeutic strategy for these lesions. In incompletely embolized patients, exclusion of any refluxing cortical veins is necessary.