case_images: PMC4323506_01
case_images: 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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case_images: PMC4323506_01_jkns-57-54-g001.jpg
case_images: F1
case_images: Whole spine magnetic resonance image (MRI) demonstrated no abnormal findings, but brain MRI revealed multiple signal void lesions on both fronto-parietal convexity suggesting vascular lesion (Fig. 1), which was not visible on previous MRI performed 3 years ago.
case_images: 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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case_images: F2
case_images: Because the SSS was occluded at the posterior one third, most cerebral venous outflow was drained into deep venous system through internal cerebral vein and straight sinus to transverse sigmoid sinus (Fig. 2).
case_images: 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.
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case_images: F3
case_images: Initially, Echelon-10 (ev3 Neurovascular, Irvine, CA, USA) microcatheter was navigated through the 6 F guiding catheter, but it was very difficult to navigate the tortuous turning point beyond the foramen spinosum level (Fig. 3A). However, the infiltration of Onyx into the fistula was not successful from these vessels (Fig. 3B, C).
case_images: 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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case_images: F4
case_images: Under the roadmap guidance, exact location of MMA to be punctured was marked with drill tip (Fig. 4A). After a small semilunar shaped scalp incision was made, decortication of temporal bone using diamond drill was performed on the distal part of turning point of MMA (Fig. 4B).
case_images: 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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case_images: PMC4323506_01_jkns-57-54-g005.jpg
case_images: F5
case_images: This sheath was fixed with black silk tie to prevent accidental removal during the procedures (Fig. 5).
case_images: 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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case_images: F6
case_images: AVF without remnant (Fig. 6). And on post operative angiogram, AVF from both STAs and OAs was also completely obliteration.