34 1

Embolization of a Dural Arteriovenous Malformation Using Gianturco Coils Soo Sung Han,1 Carolyn E. Parry,1 and Frederick A. Simeone2

A patient had a congenital dural arteri ovenous malforma­tion in the supraorbital and subfrontal regions . The malfor­mation was successfully embolized using both a percuta­neous approach with transcatheter embol ization of a Gian­turco co il , and a direct approach with embolization of coils through an 18 gauge needle after surgical exposure of the aneurysmal venous sac .

Case Report

A 16-year-old girl was seen by a local ophthalmolog ist because of diplopia and fullness of the right eye. Exam ination revealed visual acuity of 20/20 in both eyes with a 2-3 mm proptosis of the right eye. The right eye was also displaced downward with restri c tion of upward gaze and redness of the right canthus. There was a ma­chine- li ke bruit over the right eye and a thrill over the right supraor­bital reg ion. The patient was admitted to the hospital for further evaluation and treatment.

Right-sided selective internal and external angiog raphy revealed a dural arteriovenous malformation in the supraorbital and subfron­tal regions. The major feed ing arteries were the middle deep tem­poral and middle meningeal arteries from the internal maxillary artery and , a lesser contribution, th e ethmoidal meningeal artery from a branch of the ophthalmic artery (fig . 1).

Because the external carotid artery was the major feeding artery of the large dural arteriovenous malformation, superselective cath­eterizat ion was done and a 3 mm mini Gianturco coil was introduced through a size 5 French catheter. Postembolization extern al carot id arteriography revealed a complete occlusion of th e middle menin­geal artery as well as the distal part of the intern al maxillary artery (fig. 2A). A postembolization selecti ve internal carotid arteriogram revealed filling of the aneurysmal dilated venous sac from the ethmoidal branch of the ophthalmic artery. Ph ysical examinat ion at that time revealed a decreased orbital bruit and improvement of the diplopia.

Five days later, a frontotemporal craniotomy was performed and the residual dural arteriovenous malformation was exposed . An 18 gauge need le was direct ly inserted into the aneurysmal venous sac and 8 mm Gianturco coils were introduced . After this, the medium (5 mm) and mini (3 mm) coils were injected. A total of 18 coils were introduced until there was no blood return through the needle. The craniotomy was closed and the postoperative course was unevent­ful. Postoperative arteriography revealed the dural arteriovenous malformation (AVM) to be completely occluded by the coils in the

Received April 15, 198 1; accepted after revision November 25, 1981

supraorbital and subfrontal reg ions (fig. 2B). The patient was com­pletely asymptomatic with no orbital bruits . One month later th e patient remained asymptomatic with normal vision and no diplopia.

Discussion

Interventional radiology has become increasingly impor­tant in the past decade as newer or less traumati c methods of therapy are developed for various diseases. The first neurologic embolization was performed by Brooks in 1930 when he embolized a posttraumatic carotid-carvernous fis­tula with a muscle embolus [1). Since that time other con­ditions such as AVMs, aneurysms, intractable epistax is, and vascular tumors of the head and neck have proved to be amendable to embolizati on [2-19).

The ideal transcatheter embolization material shou ld be nonantigenic, noninflammatory, noncarcinogenic , easi ly in­troduced, and permanent. Autologous clots , muscle em­bolus, and gelfoam are not permanent agents [19, 20). Silicone spheres, Ivalon, isobutyl-2-cyanoacryl ate and Gian­turco co ils are permanent agents [2-1 2, 21, 22). In thi s case, Gianturco coils were used for the treatment. Although extracranial meningeal branches were embolized by the catheter technique, the ethmoidal meningeal branches of the ophthalmic artery could not be embolized. The large venous sac could also not be catheterized and embolized because the blood flow in the large ophthalmic vein would carry embolic material to the heart and result in a pu lmonary embolism. A detachable balloon [16-18] might be consid­ered for occlusion of the meningeal arteries, but was not thought to be suitable for this patient. Surgical removal of the AVM was not considered appropriate in this case be­cause of a large venous drainage through the ophthalmic vein.

Considerable experience in embolization of vascular le­sions with Gianturco coils in extracranial locations has been reported [23-26). In our case of a large dural AVM , a combined catheter and direct approach using the coil s was used. As a first step , med ium and small branches of the extracranial meningeal arteries were occluded. The second step was a direct exposure of the venous sac and direct

I Department of Radiology, Pennsylvania Hospital , 8 th and Spruce Streets, Philade lph ia, PA 19107 . Address repri nt requests to S. S. Han. 2 Department of Neurosurgery, Pennsylvania Hospital, Philadelphia, PA 19 107.

AJNR 3:341-343, May/ June 1982 0195-6108/ 82 / 0303-0341 $00.00 © American Roentgen Ray Society

342 HAN ET AL. AJNR: 3 , May I June 1982

A B

Fig. 1.-Lateral view arteriog rams. A, Extern al ca rotid artery. Dura l arte­riovenous malformation (AVM) fed by middle meningeal artery (arrows) and middle deep temporal artery (arrowheads ). B, Superselective view of middle

A B

introduction of large coi ls that were trapped in the malfor­mation.

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c deep temporal artery. Dural AVM filled. C, Intern al carotid artery. Dural AVM filled by ethmoidal meningeal artery (arrowheads ) originating from ophthalmic artery.

Fig. 2. - A, Postembolizati on external ca rotid arte riog ram. Lateral view. Meningeal arteri es and intern al max illary artery completely occluded us­ing single 3 mm Gianturco coil (arrows) with no filling of dural arteriovenous malformati on. B, Post­operative intern al carot id arteriogram. Lateral view. Aggregated co ils introduced after exposure of dural venous sac. Dural arteriovenous malfor­mation no longer fill s from ethmoidal branch of ophthalmic artery.

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