case_images: PMC11723842_01
case_images: Initial head computed tomography (CT) of the patient, revealed several relatively high-density mass lesions in quadrigeminal cistern, resulting in occlusive hydrocephalus (A: axial view, B: coronal view, C: sagittal view)
case_images: 701_2024_6418_Fig1_HTML.jpg
case_images: PMC11723842_01_701_2024_6418_Fig1_HTML.jpg
case_images: Fig1
case_images: Initial head computed tomography (CT) showed several relatively high-density mass lesions in the quadrigeminal cistern causing occlusive hydrocephalus (Fig. 1A-C).
case_images: Digital subtraction angiography (DSA) revealed a tentorial dural AVF (Cognard type IV, Borden typeIII). The left external carotid angiogram showed left falcine artery and branches of MMA making arteriovenous shunt at the falcotentorial junction, draining to vein of Galen and making a large varix at the draining route (A: AP view and B: Lat view). Right vertebral angiogram showed branches of bilateral posterior cerebral artery, making arteriovenous shunt at the falcotentorial junction, draining to vein of Galen and making a large varix at the draining route (C: AP view and D: Lat view). First, we performed n-butyl-2-cyanoacrylate (NBCA) trans-arterial embolization (TAE) of left MMA petrosal branch (E: Lat view). However, post-TAE vertebral angiography showed left PCA peripheral flow reduction (F: AP view). Next, second NBCA TAE of right falcine artery was performed (G: AP view) 8 weeks after the first NBCA TAE. Postoperative DSA showed the angiographical disappearance of falco-tentorial dural AVF and recanalization of left PCA peripheral artery (H: AP view and I: Lat view)
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case_images: PMC11723842_01_701_2024_6418_Fig2_HTML.jpg
case_images: Fig2
case_images: Moreover, digital subtraction angiography (DSA) confirmed a tentorial dural AVF (Cognard type IV, Borden type III) (Fig. 2A-I). We first performed n-butyl-2-cyanoacrylate (NBCA) transarterial embolization (TAE) of the petrosal branch of the left middle meningeal artery (MMA) (Fig. 2e). PCA peripheral flow reduction (Fig. 2f). Post-TAE FLAIR image showed left occipital high signal intensity lesion and clinically mild right-side hemianopia was observed (Fig. 4a). Additional NBCA TAE of the right falcine artery was performed 8 weeks later (Fig. 2g). Postoperative DSA revealed angiographic disappearance of the falcotentorial dural AVF and recanalization of left PCA peripheral artery (Fig. 2h, i).
case_images: Initial brain magnetic resonance (MRI) showed a dilated varix of the dural AVF stenosed the aqueduct (red arrow) in the sagittal A and axial view B. Four days after the second TAE treatment of the dural AVF, disturbance of the consciousness worsened, hydrocephalus was worse on brain MRI A, showing the more dilated varix by the thrombus formation causing the occlusion of aqueduct (red arrow) in sagittal view C and axial view D. Six months after the TAE treatment, his brain MRI showed the shrinking of the dilated varix by the complete thrombus formation re-opening of the occluded aqueduct (red arrow) in sagittal view E and axial view F
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case_images: PMC11723842_01_701_2024_6418_Fig3_HTML.jpg
case_images: Fig3
case_images: Brain magnetic resonance imaging (MRI) showed dilated varix of the dural AVF, that stenosed the aqueduct, causing occlusive hydrocephalus (Fig. 3A, B). Four days after the second TAE treatment for the dural AVF, he presented with a disturbance of consciousness and his brain MRI revealed worsening hydrocephalus caused by the complete occlusion of the aqueduct by the dilated and thrombosed varix of the dural AVF (Figs. 3c, d and 4a). At six-month follow-up, no recurrence of the dural AVF nor hydrocephalus was observed on brain MRI (Fig. 3e, f).
case_images: Four days after the second TAE treatment of the dural AVF, disturbance of the consciousness worsened, hydrocephalus was worse on his brain MRI A. Emergent endoscopic third ventriculostomy (ETV) was performed. Right foramen of Monro was dilated B. Puncture was made at the midpoint between the bilateral mammillary bodies and infundibular recess C, D. Puncture hole was dilated with balloon catheter E, making clearly visible to the quadrigeminal cistern F. Aqueductal occlusion due to the varix of the dural AVF was observed G. Post-ETV MRI showed the improvement of the hydrocephalus H
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case_images: PMC11723842_01_701_2024_6418_Fig4_HTML.jpg
case_images: Fig4
case_images: PCA peripheral flow reduction (Fig. 2f). Post-TAE FLAIR image showed left occipital high signal intensity lesion and clinically mild right-side hemianopia was observed (Fig. 4a). Four days after the second TAE treatment for the dural AVF, he presented with a disturbance of consciousness and his brain MRI revealed worsening hydrocephalus caused by the complete occlusion of the aqueduct by the dilated and thrombosed varix of the dural AVF (Figs. 3c, d and 4a). Emergent ETV was performed (Fig. 4b-g), resulting in improved consciousness and hydrocephalus on brain MRI (Fig. 4h).