J Cerebrovasc Endovasc Neurosurg.  2017 Jun;19(2):106-110. 10.7461/jcen.2017.19.2.106.

Fluoroscopy-guided Combined (Surgical/Endovascular) Treatment of Dural Arteriovenous Fistula

Affiliations
  • 1Department of Neurosurgery, College of Medicine, Yeungnam University, Daegu, Korea. sofesofe@hanmail.net

Abstract

For dural arteriovenous fistula (DAVF), when the usual endovascular or neurosurgical approaches are difficult to treat, multi-modal treatment can be helpful. We present a case of a 71-year-old woman with DAVF, who presented with an intracerebral haemorrhage. Digital subtraction angiography revealed a DAVF of the transverse sinus, with cortical venous reflux. Transvenous and transarterial approaches for coil embolization failed. In the operating room, a small craniotomy was performed, and coil embolization was done under fluoroscopy. Transcranial venous embolization might be a useful method to occlude DAVF in a case that is difficult to access by usual surgical or endovascular approaches.

Keyword

Arteriovenous fistula; Transverse sinuses; Endovascular procedures; Neurosurgical procedures

MeSH Terms

Aged
Angiography, Digital Subtraction
Arteriovenous Fistula
Central Nervous System Vascular Malformations*
Craniotomy
Embolization, Therapeutic
Endovascular Procedures
Female
Fluoroscopy
Humans
Methods
Neurosurgical Procedures
Operating Rooms
Transverse Sinuses

Figure

  • Fig. 1 Axial non-contrast brain computed tomography shows an intracerebral haemorrhage on left parieto-occipital area.

  • Fig. 2 Digital subtraction angiography, left external carotid artery injection, anteroposterior (A) and lateral (B) views. Angiogram revealing an isolated left transverse sinus and dural arteriovenous fistula fed by left middle meningeal artery and occipital artery with ectatic venous drainage.

  • Fig. 3 Illustration of coil embolization under C-arm image guiding after craniotomy. (A) Arterial pulsation was observed in vein of transverse sinus at transcranial Doppler. (B) An angiocath needle was placed in the isolated sinus and preparation for coil embolization was performed through the needle. (C) The isolated sinus was punctured with an angiocath needle and coils were inserted. (D) The sinus was punctured at the opposite side with another angiocath needle and coils were inserted. (E) Coil masses were met from both sides. (F) Sketch demonstrated the isolated sinus packed with coils, two punctured angiocath needles and feeding arteries (left middle meningeal artery and left occipital artery).

  • Fig. 4 DSA, left external carotid artery injection, anteroposterior (A) and lateral (B) views. A week after treatment, follow-up DSA revealing complete obliteration of the DAVF on left parieto-occipital area. DSA = digital subtraction angiography; DAVF = dural arteriovenous fistula.


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