Treatment of cavernous sinus dural arteriovenous fistula using different surgical approaches: Analysis of 32 consecutive cases

OBJECTIVE: Transarterial and transvenous embolization methods are considered effective and safe approaches for the treatment of cavernous sinus dural arteriovenous fistula (CSDAVF). Here., we report the angioarchitectural features and clinical outcomes of CSDAVF in patients treated with either the inferior arterial approach (IAA) or the inferior petrosal sinus approach (IPSA). METHODS: The clinical data of 32 patients with CSDAVF treated at our institution from May 2008 to May 2014 were retrospectively analyzed. All patients underwent routine diagnostic digital subtraction angiography (DSA) before surgery. Embolization was performed using the IPSA through the internal jugular vein or IAA, based on angioarchitectural features. RESULTS: Of the 32 patients with CSDAVF, 24 underwent embolization treatment through the internal jugular vein-IPSA and 8 patients underwent treatment through IAA. Nineteen patients in the IPSA group experienced mild headache, which improved after specific treatment. The immediate postembolization angiographic results revealed complete occlusion in 26 cases (18 IPSA and 8 IAA) and almost complete occlusion in 6 cases (IPSA). Complications that occurred during the procedure included abducens nerve palsy (n = 1, IPSA) and prosopoplegia (n = 1, IAA). One patient developed tinnitus, which was diagnosed as anterior cranial fossa new-onset dural arteriovenous fistula on DSA, whereas the symptoms of other patients all improved with no recurrence. CONCLUSIONS: On the basis of the angioarchitectural features of CSDAVF, IAA can be considered the primary treatment when the blood-supplying artery and fistula are relatively singular, and when the microcatheter can easily reach the fistula through the artery. The venous approach should be selected as the primary approach when the fistula is indistinguishable and blood is supplied by multiple arteries through small plexiform vessels. Choosing the optimal surgical approach may increase the success rate of intravascular CSDAVF surgery and may help avoid complications.