J Neurol Surg B Skull Base 2021; 82(S 03): e278-e284
DOI: 10.1055/s-0040-1710514
Original Article

Transvenous Onyx Embolization of Carotid-Cavernous Fistulas: Mid- and Long-Term Outcomes

1   Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois, United States
,
Krishna C. Joshi
1   Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois, United States
,
Bledi Brahimaj
1   Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois, United States
,
Demetrius K. Lopes
2   Advocate Aurora Health, Cerebrovascular Neurosurgery and Comprehensive Stroke Center, Chicago, Illinois, United States
› Author Affiliations
Funding Demetrius Lopes—Medtronic: proctor and advisory board; Stryker: proctor and advisory board.

Abstract

Objective Endovascular treatment of carotid-cavernous fistulas (CCFs) has been consistently shown to give excellent results and is currently the mainstay of treatment of these complex vascular pathologies. Onyx is currently the most widely used agent, but there has been concern over high rates of cranial nerve (CN) deficits seen in patients with CCF treated with Onyx and paucity of data on long-term outcomes.

Methods This is a retrospective analysis of patients who underwent transvenous Onyx embolization between 2011 and 2018. The data collected included demographics, comorbidities, presenting symptoms, CCF morphology, degree of obliteration, procedure-related complications, clinical outcomes, and follow-up.

Results A total of seven patients (five females) were included. The median age was 66 years (range: 15–79 years). Median duration of symptoms before treatment was 4 weeks (range: 1–24 weeks). There were three direct and four indirect CCFs. Barrow classification is as follows: A-3; B-3; C-0; and D-1. Immediate complete occlusion was achieved in all cases. There was also one case of immediate postoperative change in CN function (new partial CN VI deficit) that resolved completely at 1-month follow-up. The mean length of stay was 3 days (±2). The preoperative extraocular movement CN deficits had the following outcomes: three resolved; two improved; and one persisted. Proptosis, chemosis, conjunctival injection, and tinnitus were resolved in all patients. The median follow-up was 34 months (range: 10–91 months).

Conclusion Transvenous Onyx embolization is a safe and effective treatment of CCFs when technical aspects to reduce complications are performed diligently. Our technique demonstrates safety of the Onyx as a stand-alone embolization for the treatment of CCF.



Publication History

Received: 07 September 2019

Accepted: 19 March 2020

Article published online:
15 May 2020

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 
  • References

  • 1 Barrow DL, Spector RH, Braun IF, Landman JA, Tindall SC, Tindall GT. Classification and treatment of spontaneous carotid-cavernous sinus fistulas. J Neurosurg 1985; 62 (02) 248-256
  • 2 Ringer AJ, Salud L, Tomsick TA. Carotid cavernous fistulas: anatomy, classification, and treatment. Neurosurg Clin N Am 2005; 16 (02) 279-295 , viii
  • 3 Hassan T, Rashad S, Aziz W, Sultan A, Ibrahim T. Endovascular modalities for the treatment of cavernous sinus arteriovenous fistulas: a single-center experience. J Stroke Cerebrovasc Dis 2015; 24 (12) 2824-2838
  • 4 Chen T, Kalani MY, Ducruet AF, Albuquerque FC, McDougall CG. Development of syndrome of inappropriate antidiuretic hormone secretion (SIADH) after Onyx embolisation of a cavernous carotid fistula. BMJ Case Rep 2016; 2016: bcr2015012104
  • 5 Barber SM, Rangel-Castilla L, Zhang YJ, Klucznik R, Diaz O. Mid- and long-term outcomes of carotid-cavernous fistula endovascular management with Onyx and n-BCA: experience of a single tertiary center. J Neurointerv Surg 2015; 7 (10) 762-769
  • 6 Santos-Franco JA, Lee A, Zenteno M, Gil-Ortiz C, Vega-Montesinos S. Carotid-cavernous fistula treatment with ethylene vinyl alcohol (onyx) exclusively through anterior venous approach. Vasc Endovascular Surg 2012; 46 (04) 332-337
  • 7 Elhammady MS, Wolfe SQ, Farhat H, Moftakhar R, Aziz-Sultan MA. Onyx embolization of carotid-cavernous fistulas. J Neurosurg 2010; 112 (03) 589-594
  • 8 Akutsu H, Kreutzer J, Fahlbusch R, Buchfelder M. Transsphenoidal decompression of the sellar floor for cavernous sinus meningiomas: experience with 21 patients. Neurosurgery 2009; 65 (01) 54-62
  • 9 Zanaty M, Chalouhi N, Tjoumakaris SI, Hasan D, Rosenwasser RH, Jabbour P. Endovascular treatment of carotid-cavernous fistulas. Neurosurg Clin N Am 2014; 25 (03) 551-563
  • 10 Lewis AI, Tomsick TA, Tew Jr JM. Management of 100 consecutive direct carotid-cavernous fistulas: results of treatment with detachable balloons. Neurosurgery 1995; 36 (02) 239-244
  • 11 Bink A, Goller K, Lüchtenberg M. et al. Long-term outcome after coil embolization of cavernous sinus arteriovenous fistulas. AJNR Am J Neuroradiol 2010; 31 (07) 1216-1221
  • 12 Joshi KC, Singh D, Tandon MS. Intrafistula pressure measurement in traumatic carotid cavernous fistulas--key to increasing safety and effectiveness of endovascular coiling. Acta Neurochir (Wien) 2014; 156 (09) 1695-1700
  • 13 Debrun G, Lacour P, Vinuela F, Fox A, Drake CG, Caron JP. Treatment of 54 traumatic carotid-cavernous fistulas. J Neurosurg 1981; 55 (05) 678-692
  • 14 Arat A, Cekirge S, Saatci I, Ozgen B. Transvenous injection of Onyx for casting of the cavernous sinus for the treatment of a carotid-cavernous fistula. Neuroradiology 2004; 46 (12) 1012-1015
  • 15 Suzuki S, Lee DW, Jahan R, Duckwiler GR, Viñuela F. Transvenous treatment of spontaneous dural carotid-cavernous fistulas using a combination of detachable coils and Onyx. AJNR Am J Neuroradiol 2006; 27 (06) 1346-1349
  • 16 Lv X, Jiang C, Li Y, Wu Z. Results and complications of transarterial embolization of intracranial dural arteriovenous fistulas using Onyx-18. J Neurosurg 2008; 109 (06) 1083-1090
  • 17 Windrum P, Morris TC. Severe neurotoxicity because of dimethyl sulphoxide following peripheral blood stem cell transplantation. Bone Marrow Transplant 2003; 31 (04) 315
  • 18 Hoyt R, Szer J, Grigg A. Neurological events associated with the infusion of cryopreserved bone marrow and/or peripheral blood progenitor cells. Bone Marrow Transplant 2000; 25 (12) 1285-1287
  • 19 Bakar B, Kose EA, Sonal S, Alhan A, Kilinc K, Keskil IS. Evaluation of the neurotoxicity of DMSO infused into the carotid artery of rat. Injury 2012; 43 (03) 315-322
  • 20 Pamuk AG, Saatci I, Cekirge HS, Aypar U. A contribution to the controversy over dimethyl sulfoxide toxicity: anesthesia monitoring results in patients treated with Onyx embolization for intracranial aneurysms. Neuroradiology 2005; 47 (05) 380-386
  • 21 Zenteno M, Santos-Franco J, Rodríguez-Parra V. et al. Management of direct carotid-cavernous sinus fistulas with the use of ethylene-vinyl alcohol (Onyx) only: preliminary results. J Neurosurg 2010; 112 (03) 595-602