Intracranial dural arteriovenous fistulas (DAVFs) draining into an isolated sinus segment constitute a specific entity within the spectrum of cranial dural AV shunts, with under-reporting of their optimal treatment.To describe the multimodal treatment approach to isolated sinus DAVFs in a large single-center cohort.Retrospective analysis of adult patients with an isolated sinus DAVF treated at our institution between 2004 and 2020 was performed. Cases were analyzed for demographics, clinical presentation, angiographic findings, treatment techniques, angiographic and clinical outcomes, and complications.Of 317 patients with DAVFs, 20 (6.3%) with an isolated sinus DAVF underwent treatment. Transarterial embolization was performed through the middle meningeal artery in 9 of 12 procedures, with a success rate of 66.7%. Transarterial glue embolization proved successful in two of five procedures (40%) and Onyx in six of seven procedures (85.7%). Transvenous embolization (TVE) with navigation via the occlusion into the isolated sinus was successful in seven out of nine procedures (77.8%). All three open TVE and one pure open surgical procedure gained complete closure of the fistula. There were two major complications. Complete occlusion of the fistula was eventually obtained in all cases (100%).Isolated sinus DAVFs are always aggressive and require a multimodal approach to guarantee closure of the shunt. Transarterial treatment with Onyx achieves good results. Transvenous treatment appears equally successful, navigating into the occluded segment across the occlusion or via burr hole as backup.

Single Center

Sinus (botany)

10.1136/neurintsurg-2021-017652

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Citations (12)

Tumefactive Perivascular Spaces Causing Obstructive Hydrocephalus

Radiology (2022)

Daniel Loh Saravana Kumar Swaminathan

Obstructive hydrocephalus

Perivascular space

Neuroradiology

Cerebral aqueduct

10.1148/radiol.221724

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Citations (1)

Cerebral contrast staining mimicking parenchymal haemorrhage in a stroke patient

BMJ Case Reports (2020)

Elvin Yuan Ting Lim Saravana Kumar Swaminathan

A 75-year-old female patient presented with signs and symptoms of a right hemispheric syndrome. A CT scan of the brain with angiogram showed an acute infarct in the right middle cerebral artery (MCA) territory secondary to thromb-occlusion of the M1 segment of the right MCA. A follow-up CT scan 2 weeks later showed a large hyperdense region in the infarcted area. With the aid of a dual-energy CT scan, this was eventually shown to be due to contrast staining from an earlier administration of iodinated contrast on the same day, rather than frank haemorrhagic conversion of the recent right MCA infarct.

Iodinated contrast

Stroke

Parenchyma

Brain infarction

10.1136/bcr-2020-236400

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Citations (2)

When Two Is Better than One

Clinical Neuroradiology (2021)

Tomas Dobrocky Hubert Lee Patrick Nicholson Ronit Agid Jeremy Lynch

Delivery of most flow diverters (FD) requires larger, and thus stiffer microcatheters (0.021-0.027in.) which can pose challenges to intracranial navigation. The concomitant use of two microwires within one microcatheter, also known as the buddy-wire technique, may be helpful for navigation and support in challenging situations.We analyzed all flow diverter procedures in our prospectively collected database. We recorded all patient-related, anatomical and procedural information. We performed univariate statistics and technical descriptions.In total, 208 consecutive patients treated with a FD at our institution between July 2014 and August 2020 were retrospectively analyzed. In 17 patients the buddy-wire technique was used (mean age 63 years, range 31-87 years: 16 female). Aneurysms were located at the petrous, cavernous, supraophthalmic internal carotid artery, and a proximal M2 branch in 2, 7, 7 and 1 patient(s), respectively. In all cases a 0.027in. microcatheter was used for device deployment. In 14 patients with a wide-necked aneurysm the buddy-wire provided additional support to advance the microcatheter and mitigated the ledge between the aneurysm neck and the parent artery or a side branch. In two giant cavernous aneurysms treated with telescoping FDs, the buddy-wire was used to re-enter the proximal end of the foreshortened FD.The buddy-wire is a useful technique in FD procedures to prevent herniation of the microcatheter into the aneurysm sack, in wide-necked aneurysms to mitigate the ledge effect between the aneurysm neck and the parent artery where the microcatheter tip may get stuck, or to enable re-entry into a foreshortened FD.

Concomitant

Flow diverter

Anterior communicating artery

Posterior communicating artery

10.1007/s00062-021-01053-x

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Citations (4)

Headache and optic disc oedema revealing autoimmune GFAP-astrocytopathy

QJM (2024)

Chai Ching Ng Mervyn Qi Wei Poh Su Ann Lim Saravana Kumar Swaminathan Tianrong Yeo

Learning points for clinicians1. Causes of optic disc (OD) oedema extend beyond papilloedema which is OD swelling due to raised intracranial pressure (ICP) -clinicians should also consider inflammatory and infective aetiologies.Investigations should encompass brain imaging and cerebrospinal fluid (CSF) examination.2. Autoimmune glial fibrillary acidic protein-antibody astrocytopathy (GFAP-astrocytopathy) is a newly described inflammatory disorder involving the central nervous system (CNS).Antibody testing in CSF has higher sensitivity and specificity compared to serum.

10.1093/qjmed/hcae007

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Dilated MMA sign in cDAVF and other arterial feeders on 3D TOF MRA

The Neuroradiology Journal (2021)

Sin Yee Foo Saravana Kumar Swaminathan Timo Krings

Among the varied causes of pulsatile tinnitus, the condition that can cause severe mortality and morbidity is a cranial dural arteriovenous fistula (cDAVF). This study aimed to assess the diagnostic accuracy of the dilated middle meningeal artery on three-dimensional time-of-flight magnetic resonance angiography in cranial dural arteriovenous fistula and to identify other feeders that can aid in the detection of these lesions.Magnetic resonance angiography and digital subtraction angiography data of all patients with cranial dural arteriovenous fistula treated in a single tertiary referral center between 2007-2020 were included. The middle meningeal artery and other feeders recorded from digital subtraction angiography were assessed on magnetic resonance angiography.The overall agreement between readers in identifying the dilated middle meningeal artery was substantial (κ = 0.878, 95% confidence interval: 0.775-0.982). The dilated middle meningeal artery indicated the presence of a cranial dural arteriovenous fistula with a sensitivity of 79.49% (95% confidence interval: 66.81-92.16), specificity of 100% (95% confidence interval: 100.00-100.00), and negative predictive value of 94.56% (95% confidence interval: 90.89-98.02). An area under the curve of 0.8341 was observed for the ipsilateral middle meningeal artery, with a sensitivity of 92.2% and a specificity of 75.0% at a cut-off of 0.30 mm for identifying a cranial dural arteriovenous fistula. Of 73 other feeders, the occipital, meningohypophyseal trunk, ascending pharyngeal, and posterior meningeal arteries contributed to a large proportion visualized on magnetic resonance angiography (83.6% (41/49)).The dilated middle meningeal artery sign is useful for identifying a cranial dural arteriovenous fistula. Dilatation of the occipital and ascending pharyngeal arteries and meningohypophyseal trunk should be assessed to facilitate the detection of a cranial dural arteriovenous fistula, particularly in the transverse-sigmoid and petrous regions.

Digital subtraction angiography

Magnetic resonance angiography

Middle meningeal artery

10.1177/19714009211041530

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Citations (5)