Neurointervention.  2013 Feb;8(1):34-40. 10.5469/neuroint.2013.8.1.34.

A Unique Type of Dural Arteriovenous Fistula at Confluence of Sinuses Treated with Endovascular Embolization: A Case Report

• Gupta R
• Miyachi S
• Matsubara
• Izumi T
• Naito T
• Haraguchi
• Wakabayashi T

• KMID: 2052079
• DOI: http://doi.org/10.5469/neuroint.2013.8.1.34

Abstract

Dural arteriovenous fistula (DAVF) is classically defined as abnormal arteriovenous connections located within the dural leaflets. Though the exact etiology is still not clear, they are generally accepted as acquired lesions. However, some DAVFs formed as the congenital disorders are called dural arteriovenous malformations and these lesions with a marked cortical venous reflux are considered to be aggressive and warrant an early intervention. The authors describe a case of 35-year-old man presented with unique type of DAVF. The fistula was located adjacent to the confluence of venous sinuses with multiple feeders. The feeders drained into a large venous pouch just anterior to the confluence which had a bilateral venous drainage. This was associated with multiple cerebellar venous ectasia along the draining cortical vein. It was managed by staged endovascular procedures and complete cure could be achieved. The pathogenesis and technique of embolization of this complex fistula/malformation are also discussed.

Keyword

Dural arteriovenous fistula; Confluence of sinuses; Embolization; Cortical reflux; Varix

MeSH Terms

Arteriovenous Malformations
Central Nervous System Vascular Malformations
Congenital, Hereditary, and Neonatal Diseases and Abnormalities
Dilatation, Pathologic
Drainage
Early Intervention (Education)
Endovascular Procedures
Fistula
Varicose Veins
Veins

Figure

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  Fig. 1 T2 weighted MR images (A, B) showing large varix near the torcula (double arrows), multiple cerebellar varices (black arrows) and draining cortical cerebellar veins (arrow heads).

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  Fig. 2 Preoperative angiograms. A, B. Right external carotid angiogram of anterior-posterior (A-P) view: early phase (A) and late phase (B). C-F. Left external carotid angiogram: A-P view in early phase (C) and late phase (D). Lateral view in early phase (E) and late phase (F). Multiple feeders from both ECAs are demonstrated. Main feeders are bilateral ascending pharyngeal and occipital arteries. Right transverse sinus is dominant and enlarged. Large varix near the torcula (double arrows), cerebellar varices (arrow) and abnormaly dilated draining cortical cerebellar veins (arrow heads) are apparently shown on angiograms in late phase.

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  Fig. 3 A. Skull X-ray during procedure in anterior-posterior (A-P) view showing coil mass placed in dilated cerebellar cortical vein. Tip of 4Fr guiding catheter in transverse sinus (arrow) and the course of microcatheter in the venous system (multiple arrows) are also displayed. B. Angiogram acquired after coil embolization of abnormal cerebellar vein. Cortical venous reflux of cerebellum disappeared although large varix near the torcula still remained. C, D. Skull X-ray A-P (C) and lateral (D) views showing coil mass filling that varix (double arrows) and cortical vein. E, F. Left external carotid angiogram after embolization in A-P (E) and lateral views (F) showing complete occlusion of DAVF.

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  Fig. 4 Postprocedural T2 weighted MR images (A, B) showing metal artefacts in large varix (arrows) and thrombosis of cerebellar varices and draining vein (arrow heads).

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