J Cerebrovasc Endovasc Neurosurg.  2024 Mar;26(1):71-78. 10.7461/jcen.2023.E2023.05.009.

Navigation guided small craniectomy and direct cannulation of pure isolated sigmoid sinus for treatment of dural arteriovenous fistula

• Shim JH
• Yun GY
• Ann JM
• Park JH
• Oh HJ
• Shim JJ
• Yoon SM

• KMID: 2554049
• DOI: http://doi.org/10.7461/jcen.2023.E2023.05.009

Abstract

Dural arteriovenous fistula (DAVF) is a rare condition affecting approximately 1.5% of 1,000,000 individuals annually. It frequently occurs in the transsigmoid and cavernous sinuses. An isolated sigmoid sinus is extremely rare and is treated by performing transfemoral transvenous embolization along the opposite transverse sinus. A 69-year-old woman presented with asymptomatic Borden type III/Cognard type III DAVF involving an isolated sigmoid sinus. She underwent a staged operation in which a navigation system was used to expose the sigmoid sinus in the operating room before transferring the patient to the angio suite for transvenous embolization. Various modalities have been used to treat DAVF, including surgical disconnection, transarterial embolization, transvenous embolization, and stereotactic radiosurgery. However, treating DAVF cases where the affected sinus is isolated can be challenging because an easily accessible surgical route may not be available. In this case, direct sinus cannulation and transvenous embolization were the most effective treatments.

Keyword

Central nervous system vascular malformations; Arteriovenous fistula; Embolization; Onyx

Figure

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  Fig. 1. Preoperative MRI and MRA. (A) Brain MRI T2 image showing multiple areas with low signal intensity in the subarachnoid space without other abnormal findings in the brain parenchyma. (B) MRA demonstrating an irregular and tortuous vascular structure around the right sigmoid sinus. MRI, magnetic resonance imaging; MRA, magnetic resonance angiography

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  Fig. 2. Preoperative transfemoral angiography. (A and B) External carotid angiogram showing the DAVF. The sigmoid sinus appears in the early arterial phase with multiple feeding occipital artery branches, the parietal branch of the middle meningeal artery, and cortical vein refluxes. (C and D) Delayed venous phase angiogram demonstrating extensive cortical vein refluxes without opacification of the ipsilateral transverse sinus or jugular vein, indicating an isolated sigmoid sinus. DAVF, dural arteriovenous fistula

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  Fig. 3. Intraoperative photograph demonstrating. (A) Planning the craniectomy using a neuronavigation system. (B) Exposure of the sigmoid sinus (black arrowhead) after creating a small craniectomy.

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  Fig. 4. Intraoperative photograph and right common carotid angiogram. (A) Photograph demonstrating the position of the microcatheter and micropuncture sheath. (B and C) Navigation of the microcatheter over a microwire into the right isolated sigmoid sinus under fluoroscopic guidance.

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  Fig. 5. (A and B) Angiogram showing partial occlusion of the isolated sigmoid sinus with the feeding artery after adding nine packing coils. (C) Sequential Onyx cast filling the sigmoid sinus and feeding artery, with a remnant fistula point. (D) Final early and late phase angiogram demonstrating complete obliteration of the DAVF. DAVF, dural arteriovenous fistula

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