The Neuroradiology Journal 20: 726-729, 2007

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Transarterial and Transvenous Embolization of a Tentorial Dural Arteriovenous Fistula. A Case Report

CHUHAN JIANG, XIANLI LV, YOUXIANG LI, ZHONGXUE WU Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University; Beijing, China

Key words: dural arteriovenous fistula, tentorium, transvenous embolization

SUMMARY – Various treatments of tentorial dural arteriovenous fistulas have been assessed, but there are only two pertinent literature reports on percutaneous transvenous coil embolization. We describe the case of a patient with tentorial dural arteriovenous fistula coiled transvenously.

Introduction The treatment strategy for tentorial dural arteriovenous fistulas (DAVF) is still debated because of the rich variety of DAVF flow types and the surgical difficulty for such deeply seated lesions 2,6,10,11. Surgery has proved risky and unnecessary and stereotactic radiosurgery is not indicated 6,13 . Transarterial embolization alone is rarely successful 1,2,7,9,13. We present a case of tentorial DAVF well treated by transarterial embolization with sutures and transvenous embolization with platinum coils. Case Report A 70-year-old man presented with a headache of sudden onset and vomiting. Computed tomography demonstrated diffuse subarachnoid hemorrhage and a venous aneurysm at the right petrous apex. Selective right external and internal carotid angiography revealed a dural fistula supplied by branches of the right middle meningeal artery, ascending pharyngeal artery and tentorial branches of the right internal carotid artery. The fistula drained in the region of the right petrosal venous complex and thence into the basal vein to the straight sinus. There was a 726

venous aneurysm appropriately 1 cm in diameter on the basal vein. We initially attempted external carotid artery embolization. A microcatheter was placed in the posterior branch of the right middle meningeal artery and embolizing with 5-0 (1.0-1.5 cm long) sutures. The external carotid suppliers were occluded. But the fistula was still persistent and fed by the branches of the right ascending pharyngeal artery and right internal carotid artery. We therefore decided on endovascular treatment using a transvenous approach. A microcatheter was placed in the right jugular vein which was catheterized and a microcatheter was directed through the straight sinus into the basal vein. The venous varix was crossed with care and the tip of the microcatheter was placed at the site of the fistula in the petrosal venous complex. Using the venous catheter, five EDCs were then placed at the site of the fistula via the transvenous microcatheter. Angiography revealed complete occlusion of the fistula on both the external and internal carotid injections. The patient made an uneventful recovery. After four months, the follow-up angiograms of bilateral common carotids arteries confirmed the complete obliteration and the patient demonstrated no symptoms.

Chuhan Jiang

Transarterial and Transvenous Embolization of a Tentorial Dural Arteriovenous Fistula

Discussion Tentorial DAVFs are located in the cerebellar tentorium and are fed primarily by branches of the meningohypophyseal trunk, the middle meningeal artery and occipital artery. Although venous drainage varies greatly and depends on the tentorial location of the fistula, they typically drain into deep leptomeningeal veins (2,5-7). Thus, tentorial DAVFs are aggressive, 80%-90% presenting with hemorrhage 2,3,6-9, as illustrated by our patient. These lesions require complete treatment as partial therapy is not fully protective 2. Tentorial DAVFs can be treated with transarterial or transvenous embolization 1,2,7,9, stereotactic radiosurgery 5,10,11, surgical resection 3,5,6,9,12 , or some combination of these strategies 4,9,14 . Surgical division of the tentorial DAVF is extremely difficult because of the deep locations of the lesions, with surrounding vital structures such as the deep venous system 3,6,10. Complete interruption of a DAVF must be confirmed intraoperatively by visual inspection, intraoperative angiography and intraoperative microvascular Doppler monitoring 4. Previously, embolization by a transarterial approach that used flow control via a single remaining feeder after occluding all other contributing pedicles seemed to be the best option 1,9. Treatment with gamma knife is also reported to be effective, but the risk of bleeding remains until a cure is

obtained 5,10,11. Although intravascular embolization is the procedure of choice, few reports have indicated that embolization results in complete and permanent lesion obliteration 7. In previous cases, 19 patients were treated by transarterial embolization but only three fistulas were completely occluded 8. Several cases of tentorial DAVF have been treated by transvenous embolization 2: the venous approach through the elongated, ectactic and potentially fragile pial veins is considered difficult and risky. In our case, we started the procedure with: the softest EDC to fit the draining leptomeningeal vein and to minimize the risk of damage and rupture of the leptomeningeal vein. After the delivery of five coils, the DAVF became obliterated, which emphasizes the role of the draining vein in the hemodynamics and treatment of DAVFs. Four months follow-up angiographic study shows complete obliteration and the patient demonstrates no symptoms. Conclusion Our experience with this patient indicates that transarterial and transvenous embolizations might offer an efficacious treatment of DAVFs of the tentorium. The transvenous technique may still play a role in the management of this condition.

References 1 Benndorf G, Schmidt S, Sollman WP et Al: Tentorial dural arteriovenous fistula presenting with various visual symptoms related to anterior and posterior visual pathway dysfunction: case report. Neurosurgery 53: 222-227, 2003. 2 Deasy NP, Gholkar AR, Cox TCS et Al: Tentorial dural arteriovenous fistulae: endovascular treatment with transvenous coil embolization. Neuroradiology 41: 308312, 1999. 3 Deshmukh VR, Maughan PH, Spetzler RF: Resolution of hemifacial spasm after surgical obliteration of a tentorial arteriovenous fistula: case report. Neurosurgery 58: 202, 2006. 4 Fujita A, Tamaki N, Nakamura M et Al: A tentorial dural arteriovenous fistula successfully treated with interruption of leptomeningeal venous drainage using

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microvascular Doppler sonography: case report. Surg Neurol 56: 56-61, 2001. Iwamuro Y, Nakahara I, Higashi T et Al: Tentorial dural arteriovenous fistula presenting symptoms due to mass effect on the dilated draining vein: case report. Surg Neurol 65: 511-515, 2006. Jesus OD, Rosado JE: Tentorial dural arteriovenous fistula obliteration using the petrosal approach. Surg Neurol 51: 164-167, 1999. Kajita Y, Miyachi S, Wakabayashi T et Al: A dural arteriovenous fistula of the tentorium successfully treated by intravascular embolization. Surg Neurol 52: 294-298, 1999. Kallmes DF, Jensen ME, Kassell NF et Al: Percutaneous transvenous coil embolization of a Djindjian type 4 tentorial dural arteriovenous malformation. Am J Neuroradiol 18: 673-676, 1997.

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Transarterial and Transvenous Embolization of a Tentorial Dural Arteriovenous Fistula

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9 Kim MS, Han DH, Han MH et Al: Posterior fossa hemorrhage caused by dural arteriovenous fistula: case reports. Surg Neurol 59: 512-517, 2003. 10 Masahiro S, Hiroki K, Masao T et Al: Stereotactic radiosurgery for tentorial dural arteriovneous fistulae draining into the vein of Galen: reports of two cases. Neurosurgery 46: 730, 2000. 11 Matsushige T, Nakaoka M, Ohta K et Al: Tentorial du-

ral arteriovenous malformation manifesting as trigeminal neuralgia treated by stereotactic radiosurgery: a case report. Surg Neurol 66: 519-523, 2006. 12 Pannu Y, Shownkeen H, Nockels RP et Al: Obliteration of a tentorial dural arteriovenous fistula causing spinal cord myelopathy using the cranio-orbital zygomatic approach. Surg Neurol 62: 463-467, 2004. 13 Patrik RT, Harry JC, Akihiko K et Al: Evolution of the

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The Neuroradiology Journal 20: 726-729, 2007

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Figure 1 A) Lateral DSA of right external carotid artery shows the fistula supplied by branches of the right middle meningeal artery and asending pharyngeal artery. B) Lateral DSA of the right common carotid artery shows the meningohypophyseal trunk supplying the DAVF and the suppliers from the right meningeal artery were occluded. C) During the procedure, the skull X-ray film shows the delivery of the detachable coils. Postprocedure angiograms of right common carotid artery, frontal (D) and lateral (E), demonstrated complete obliteration of the fistula. Four months after endovascular treatment, lateral DSAs of the right common carotid artery (F) and left common carotid artery (G) show permanent occlusion of DAVF.

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management of tentorial dural arteriovenous malformations. Neurosurgery 52: 750-762, 2003. 14 Troffkin NA, Graham CB, Berkman T et Al: Combined transvenous and transarterial embolization of a tentorial-incisural dural arteriovenous malformation followed by primary stent placement in the associated stenotic straight sinus. Case report. J. Neurosurg 99: 579-583, 2003.

Wu Zhongxue, MD Beijing Neurosurgical Institute Beijing Tiantan Hospital Capital Medical University 6,Tiantan Xili 100050 Beijing, Heibei, China Tel: 86-10-67098850 E-mail: [email protected]

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Transarterial and transvenous embolization of a tentorial dural arteriovenous fistula. A case report.

Various treatments of tentorial dural arteriovenous fistulas have been assessed, but there are only two pertinent literature reports on percutaneous t...
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