J Korean Neurosurg Soc.  2015 Jan;57(1):54-57. 10.3340/jkns.2015.57.1.54.

Transcranial Direct Middle Meningeal Artery Puncture for the Onyx Embolization of Dural Arteriovenous Fistula Involving the Superior Sagittal Sinus

• Oh JS
• Yoon SM
• Shim JJ
• Bae HG

• KMID: 2067092
• DOI: http://doi.org/10.3340/jkns.2015.57.1.54

Abstract

A 66-year-old woman presented with intermittent paraparesis and generalized tonic-clonic seizure. Cerebral angiography demonstrated dural arteriovenous fistula (AVF) involving superior sagittal sinus (SSS), which was associated with SSS occlusion on the posterior one third. The dural AVF was fed by bilateral middle meningeal arteries (MMAs), superficial temporal arteries (STAs) and occipital arteries with marked retrograde cortical venous reflux. Transfemoral arterial Onyx embolization was performed through right MMA and STA, but it was not successful, which resulted in partial obliteration of dural AVF because of tortuous MMA preventing the microcatheter from reaching the fistula closely enough. Second procedure was performed through left MMA accessed by direct MMA puncture following small decortications of cranium overlying the MMA using diamond drill one week later. Microcatheter could be located far distally to the fistula through 5 F sheath placed into the MMA and complete obliteration of dural AVF was achieved using 3.9 cc of Onyx.

Keyword

Dural arteriovenous fistula; Superior sagittal sinus; Transcranial; Middle meningeal artery; Onyx embolization

MeSH Terms

Aged
Arteries
Central Nervous System Vascular Malformations*
Cerebral Angiography
Diamond
Female
Fistula
Humans
Meningeal Arteries*
Paraparesis
Punctures*
Seizures
Skull
Superior Sagittal Sinus*
Temporal Arteries
Diamond

Figure

• 

  Fig. 1 Brain magnetic resonance image showing multiple microbleeding (arrowheads) along the sulci of cerebral convexities on gradient echo image (A) and multiple vascular signals (arrows) on both centrum semiovale on gadolinium enhanced T1-weighted image (B).

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  Fig. 2 Angiography depicting dural arteriovenous fistulas on superior saggittal sinus (SSS) fed by both middle meningeal arteries (arrowheads), superficial temporal arteries (arrows) and occipital arteries (A) and draining into the occluded SSS retrograde fashion, then marked reflux to bilateral superficial cortical veins (B). There was no feeder from both internal carotid arteries and most cerebral venous outflow was drained into deep venous system through internal cerebral vein and straight sinus to transverse sigmoid sinus (C).

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  Fig. 3 Radiologic images obtained during first embolization session. Lateral view of roadmap image showing the tortuous turning point (arrow) beyond the foramen spinosum level (A). Postoperative skull radiographs showing the Onyx cast after incomplete embolization (B). Postoperative angiogram showing the incomplete obliteration of dAVFs (C). dAVFs : dural arteriovenous fistulas.

• 

  Fig. 4 Roadmap image showing the dilling point of MMA (A). Intraoperative photograph demonstrating decortication of temporal bone using diamond drill and dilated MMA after verapamil injection (B). MMA : middle meningeal artery.

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  Fig. 5 Photograph showing the placement of 5 F micropuncture sheath in the MMA and fixation with black silk tie to prevent accidental removal during the procedures (A). Microcatheter angiogram showing the dAVFs clearly (B). MMA : middle meningeal artery, dAVFs : dural arteriovenous fistulas.

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  Fig. 6 Postoperative angiograms showing the completer obliteration of dAVFs without cortical venous reflux (A and B). Postoperative skull radiographs showing the Onyx cast after complete obliteration of dAVFs (C and D). dAVFs : dural arteriovenous fistulas.

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