From the Guidelines
Yes, coil embolization of the transverse sinus in the treatment of a dural arteriovenous fistula (DAVF) can potentially cause cerebellar ischemia. This complication occurs because the transverse sinus is a major venous drainage pathway for the cerebellum. When the transverse sinus is occluded during embolization procedures, it can disrupt normal venous outflow from the cerebellum, leading to venous congestion and subsequent ischemia of cerebellar tissue. According to the American Heart Association Council on Cardiovascular Radiology and Intervention, stroke council, council on cardiovascular surgery and anesthesia, interdisciplinary council on peripheral vascular disease, and interdisciplinary council on quality of care and outcomes research 1, dural arteriovenous fistulas are acquired artery-to-vein shunts within the dura mater, often without a distinctive vascular nidus, and symptoms depend on the location of the fistula.
Key Considerations
- The risk of cerebellar ischemia is particularly significant if the patient has limited collateral venous drainage pathways or if the contralateral transverse sinus is hypoplastic or absent.
- Before proceeding with transverse sinus occlusion, neurointerventionalists should carefully evaluate the patient's venous anatomy through angiography to assess collateral drainage capacity, as suggested by the indications for the performance of intracranial endovascular neurointerventional procedures 1.
- Temporary balloon occlusion testing may be performed to evaluate tolerance to sinus occlusion.
- Alternative treatment strategies such as selective embolization of feeding arteries or partial sinus occlusion might be considered in high-risk cases to minimize the chance of cerebellar venous infarction.
Post-Procedural Care
- Patients undergoing this procedure should be monitored closely for symptoms of cerebellar dysfunction including ataxia, nystagmus, and vertigo in the post-procedural period.
From the Research
Coil Embolization of the Transverse Sinus in DAVF Treatment
- Coil embolization of the transverse sinus is a treatment option for dural arteriovenous fistula (DAVF) [(2,3)]
- This procedure can be performed via a transarterial or transvenous approach, depending on the difficulty of the approach and the location of the DAVF [(2,3,4)]
Risks of Cerebellar Ischemia
- Cerebellar ischemia is a potential complication of coil embolization of the transverse sinus, particularly if the procedure results in overembolization or migration of the coils 4
- The risk of cerebellar ischemia may be higher in cases where the transverse sinus is occluded or hypoplastic, as this can affect the drainage of blood from the cerebellum 5
Alternative Treatment Options
- In cases where coil embolization of the transverse sinus is not feasible or safe, alternative treatment options such as transarterial embolization with liquid materials or surgical interruption of the shunt may be considered [(4,5)]
- Stent graft placement with or without transarterial embolization may also be an effective treatment option in certain cases, particularly where there is hypoplasia of the contralateral venous sinuses 5