Transarterial embolization of clival dural arteriovenous fistulae using liquid embolic agents

OBJECTIVE: Dural arteriovenous fistulae (DAVFs) rarely involve the clivus. This report examines the clinical presentation, angiographic findings, endovascular management, and outcome of clival DAVFs. Particular attention was given to safety and efficacy of transarterial embolization using liquid embolic agents. METHODS: We reviewed the clinical and radiological data of 10 patients with spontaneous clival DAVFs who were treated endovascularly at the University of California at Los Angeles Medical Center between 1992 and 2006. RESULTS: Nine patients presented with ocular symptoms and one patient experienced pulsatile tinnitus. Cerebral angiograms showed that these clival DAVFs were supplied by multiple branches of the internal and external carotid arteries. The patterns of venous drainage were from the clival veins to the cavernous sinus and superior ophthalmic vein in nine patients and to the inferior petrosal sinus in two patients. Six clival DAVFs were embolized transarterially through the clival branches of the ascending pharyngeal artery. Onyx 18 (Micro Therapeutics Inc., Irvine, CA) was used in three patients and n-butyl cyanoacrylate was used in three patients. Immediate complete angiographic obliteration was achieved in three patients. All six patients experienced an angiographic and clinical cure without any complications at 3 months. Two patients were incompletely treated using particles and coils for the relief of the symptoms. Two other patients were completely treated after the recipient clival venous structures were occluded transvenously with coils. CONCLUSION: Clival DAVFs can be misdiagnosed as dural cavernous sinus fistulae. The best treatment is transarterial embolization of the dural feeders using liquid embolic agents. Transvenous occlusion of the cavernous sinus is unnecessary in most cases.