Onyx embolization of carotid-cavernous fistulas

Clinical article

Mohamed Elhammady, Stacey Quintero Wolfe, Hamad Farhat, Roham Moftakhar, Mohammad Ali Aziz-Sultan

Research output: Contribution to journalArticle

51 Citations (Scopus)

Abstract

Object. The authors conducted a study to determine the safety and efficacy of embolization of carotid-cavernous fistulas (CCFs) with the ethylene vinyl alcohol copolymer, Onyx. Methods. They prospectively collected data in all patients with CCFs who underwent Onyx-based embolization at their institution over a 3-year period. The type of fistula, route of embolization, viscosity of Onyx, additional use of coils, extent of embolization, procedural complications, and clinical follow-up were recorded. Results. A total of 12 patients (5 men and 7 women who were age 24-88 years) underwent embolization in which Onyx was used. There were 1 Barrow Type A, 1 Type B, 3 Type C, and 7 Type D fistulas. Embolization was performed via a transvenous route in 8 cases and a transarterial route in 4 cases. Onyx 34 was used in all but 2 cases: a direct Type A fistula embolized with Onyx 500 and an indirect Type C fistula embolized with Onyx 18. Adjuvant embolization with framing coils was performed in 7 cases. All procedures were completed in a single session. Immediate fistula obliteration was achieved in all cases. Clinical resolution of presenting symptoms occurred in 100% of the patients by 2 months. Neurological complications occurred in 3 patients. One patient developed a complete cranial nerve (CN) VII palsy that has not resolved. Two patients developed transient neuropathies - 1 a Horner syndrome and partial CN VI palsy, and 1 a complete CN III and partial CN V palsy. Radiographic follow-up (mean 16 months, range 4-35 months) was available in 6 patients with complete resolution of the lesion in all. Conclusions. Onyx is a liquid embolic agent that is effective in the treatment of CCFs but not without hazards. Postembolization cavernous sinus thrombosis and swelling may result in transient compressive cranial neuropathies. The inherent gradual polymerization properties of Onyx allow for casting of the cavernous sinus but may potentially result in deep penetration within arterial collaterals that can cause CN ischemia/infarction. Although not proven, the angiotoxic effects of dimethyl sulfoxide may also play a role in postembolization CN deficits.

Original languageEnglish
Pages (from-to)589-594
Number of pages6
JournalJournal of Neurosurgery
Volume112
Issue number3
DOIs
StatePublished - Mar 1 2010

Fingerprint

Fistula
Cranial Nerve Diseases
Cranial Nerves
Cavernous Sinus Thrombosis
Abducens Nerve Diseases
Oculomotor Nerve
Horner Syndrome
Cavernous Sinus
Trigeminal Nerve
Facial Nerve
Dimethyl Sulfoxide
Viscosity
Polymerization
Infarction
Ischemia
Safety

Keywords

  • Carotid-cavernous fistula
  • Embolization
  • Endovenous treatment
  • Onyx
  • Surgical technique

ASJC Scopus subject areas

  • Clinical Neurology
  • Surgery

Cite this

Elhammady, M., Wolfe, S. Q., Farhat, H., Moftakhar, R., & Aziz-Sultan, M. A. (2010). Onyx embolization of carotid-cavernous fistulas: Clinical article. Journal of Neurosurgery, 112(3), 589-594. https://doi.org/10.3171/2009.6.JNS09132

Onyx embolization of carotid-cavernous fistulas : Clinical article. / Elhammady, Mohamed; Wolfe, Stacey Quintero; Farhat, Hamad; Moftakhar, Roham; Aziz-Sultan, Mohammad Ali.

In: Journal of Neurosurgery, Vol. 112, No. 3, 01.03.2010, p. 589-594.

Research output: Contribution to journalArticle

Elhammady, M, Wolfe, SQ, Farhat, H, Moftakhar, R & Aziz-Sultan, MA 2010, 'Onyx embolization of carotid-cavernous fistulas: Clinical article', Journal of Neurosurgery, vol. 112, no. 3, pp. 589-594. https://doi.org/10.3171/2009.6.JNS09132
Elhammady M, Wolfe SQ, Farhat H, Moftakhar R, Aziz-Sultan MA. Onyx embolization of carotid-cavernous fistulas: Clinical article. Journal of Neurosurgery. 2010 Mar 1;112(3):589-594. https://doi.org/10.3171/2009.6.JNS09132
Elhammady, Mohamed ; Wolfe, Stacey Quintero ; Farhat, Hamad ; Moftakhar, Roham ; Aziz-Sultan, Mohammad Ali. / Onyx embolization of carotid-cavernous fistulas : Clinical article. In: Journal of Neurosurgery. 2010 ; Vol. 112, No. 3. pp. 589-594.
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N2 - Object. The authors conducted a study to determine the safety and efficacy of embolization of carotid-cavernous fistulas (CCFs) with the ethylene vinyl alcohol copolymer, Onyx. Methods. They prospectively collected data in all patients with CCFs who underwent Onyx-based embolization at their institution over a 3-year period. The type of fistula, route of embolization, viscosity of Onyx, additional use of coils, extent of embolization, procedural complications, and clinical follow-up were recorded. Results. A total of 12 patients (5 men and 7 women who were age 24-88 years) underwent embolization in which Onyx was used. There were 1 Barrow Type A, 1 Type B, 3 Type C, and 7 Type D fistulas. Embolization was performed via a transvenous route in 8 cases and a transarterial route in 4 cases. Onyx 34 was used in all but 2 cases: a direct Type A fistula embolized with Onyx 500 and an indirect Type C fistula embolized with Onyx 18. Adjuvant embolization with framing coils was performed in 7 cases. All procedures were completed in a single session. Immediate fistula obliteration was achieved in all cases. Clinical resolution of presenting symptoms occurred in 100% of the patients by 2 months. Neurological complications occurred in 3 patients. One patient developed a complete cranial nerve (CN) VII palsy that has not resolved. Two patients developed transient neuropathies - 1 a Horner syndrome and partial CN VI palsy, and 1 a complete CN III and partial CN V palsy. Radiographic follow-up (mean 16 months, range 4-35 months) was available in 6 patients with complete resolution of the lesion in all. Conclusions. Onyx is a liquid embolic agent that is effective in the treatment of CCFs but not without hazards. Postembolization cavernous sinus thrombosis and swelling may result in transient compressive cranial neuropathies. The inherent gradual polymerization properties of Onyx allow for casting of the cavernous sinus but may potentially result in deep penetration within arterial collaterals that can cause CN ischemia/infarction. Although not proven, the angiotoxic effects of dimethyl sulfoxide may also play a role in postembolization CN deficits.

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