case_images: PMC10927206_01
case_images: (a) A time-of-flight magnetic resonance angiography image demonstrates a left transverse-sigmoid dural arteriovenous fistula (DAVF) with cortical venous reflux (white arrow). (b) Left external carotid artery angiography (lateral view) demonstrates multiple feeding arteries of a DAVF from the mastoid branches of the occipital artery (OA) and petrosquamous branches of the middle meningeal artery directly draining into the vein of Labbe (VOL) (black arrow). The shunting point was suspected to be limited to the transverse sinus (TS) wall with no venous drainage into the dural sinus. (c) Transarterial Onyx embolization was performed through the mastoid branch of the OA with a DeFrictor microcatheter (Medico's Hirata, Osaka, Japan) and achieved successful penetration into the VOL. A SHOURYU HR (Kaneka Medics, Kanagawa, Japan) 7 x 7-mm balloon catheter was placed on standby in the TS for Onyx penetration into the sinus; however, the shunting point was completely isolated from the TS (black arrow). (d) Final view after Onyx embolization; complete occlusion of the arteriovenous shunt. (e) The venous phase of internal carotid artery angiography demonstrates that the left TS was intact. (f) Heavy T2-weighted magnetic resonance imaging before Onyx embolization demonstrates the existence of arachnoid granulation (AG) in the shunting point of the left TS (white arrowhead). (g and h) The sagittal view of postoperative digital subtraction angiography and computed tomography fusion image shows that the Onyx cast demonstrated that multiple feeders (white arrows) aggregated into the AG (white arrow) and a dilated draining vein launched from the shunt point (white arrowhead).
case_images: SNI-15-43-g001.jpg
case_images: PMC10927206_01_SNI-15-43-g001.jpg
case_images: F1
case_images: Magnetic resonance imaging revealed no lesions responsible for his symptoms; however, time-of-flight magnetic resonance angiography demonstrated venous reflux into the vein of Labbe (VOL), suggesting a TS-DAVF [Figure 1a]. Digital subtraction angiography (DSA) showed that the TS-DAVF was supplied by the occipital artery (OA) and the middle meningeal artery (MMA) [Figure 1b]. Neurovascular, Irvine, CA) was injected to achieve successful penetration into the VOL, including the shunt point, without neurological complications [Figure 1c-e]. No Onyx penetration into the TS was observed. Postoperative three-dimensional-DSA and computed tomography (CT) fusion imaging revealed that the Onyx cast successfully showed the embolized multiple feeders from the occipital and middle meningeal arteries aggregated into the AG and a dilated draining vein launched from the shunt point [Figure 1f-h] [Video 1].
case_images: PMC10927206_02
case_images: (a) Contrast-enhanced computed tomography (CT) demonstrates cortical venous reflux, indicating a left transverse-sigmoid dural arteriovenous fistula (DAVF). (b) Left external carotid artery angiography (lateral view) demonstrates multiple feeding arteries of a DAVF from the petrosquamous branches of the middle meningeal artery (MMA) and transosseous branches of the occipital artery (OA) directly draining into the cortical vein. The shunting point was suspected to be limited to the transverse sinus (TS) wall with no venous drainage into the dural sinus (black arrow). (c) Transarterial Onyx embolization was performed through the petrosquamous branch of the MMA with a DeFrictor microcatheter (Medico's Hirata, Osaka, Japan) and achieved successful penetration into the cortical vein. A Scepter C (Terumo, Tokyo, Japan) 4x10-mm balloon catheter was placed and inflated on the proximal side of the OA, with flow reduction during Onyx injection. (d) Final view after Onyx embolization; complete occlusion of the arteriovenous shunt. (e) The venous phase of internal carotid artery angiography demonstrates that left the TS was intact with no Onyx penetration. (f) Heavy T2-weighted magnetic resonance imaging before Onyx embolization demonstrates the existence of arachnoid granulation (AG) in the shunting point of the left TS (white arrowhead). (g and h) The sagittal view of postoperative digital subtraction angiography and CT fusion image shows that the Onyx cast demonstrated that multiple feeders (white arrows) aggregated into the AG (white arrow) and a dilated draining vein launched from the shunt point (white arrowhead).
case_images: SNI-15-43-g002.jpg
case_images: PMC10927206_02_SNI-15-43-g002.jpg
case_images: F2
case_images: A 54-year-old man was incidentally suspected of having a TS-DAVF with cerebral cortical venous reflux on contrast-enhanced CT for examination of thyroid disease [Figure 2a]. TS-DAVF supplied by the MMA and OA [Figure 2b]. The shunt point was suspected to be limited to the TS wall, with no involvement of the dural sinus (Borden type III, Cognard type IV). A Scepter C (Terumo, Tokyo, Japan) 4 x 10-mm balloon catheter was placed and inflated on the proximal side of the OA to reduce blood flow during Onyx injection. A total of 1.47 mL of Onyx18 was injected to achieve successful penetration into the cortical vein, including the shunt point on the TS wall, without neurological complications [Figure 2c-e]. In postoperative fusion images, the Onyx cast showed multiple feeders aggregated into the AG and a dilated draining vein similarly [Figure 2f-h] [Video 2].