PMC4553663_01
Preoperative angiogram. Right external carotid artery angiogram (a and c: Early phase, b and d: Late phase) showing a transverse-sigmoid sinus dural arteriovenous fistula with occlusive changes in both the right sigmoid sinus and the left transverse sinus. Marked retrograde venous drainage was directed toward the deep venous system through the straight sinus and toward the cerebral hemisphere via the superior sagittal sinus
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F1
The tentorial artery arose from the right internal carotid artery also fed the fistulae [Figure 1a and c]. A reverse flow was primarily observed in the dilated left superficial middle cerebral vein toward the cavernous sinus and vein of Labbe toward the left sigmoid sinus [Figure 1b and d].
Preoperative computed tomography venography precisely showing occlusive part of the right sigmoid sinus. The dotted lines indicate the presumed occluded sinus. The white asterisk indicates the partially thrombosed right jugular bulb
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F2
Considering the sinus restoration strategy, we performed computed tomography (CT) venography preoperatively, which precisely revealed an occluded segment [Figure 2] and the right jugular bulb and internal jugular vein were both patent.
(a) Following preliminary balloon angioplasty, restoration of the antegrade venous flow was observed on a left external carotid angiogram. (b) Subsequent balloon angioplasty with a peripheral balloon catheter achieved a further improvement in the antegrade venous flow; however, the retrograde sinus flow persisted. (c) Next, a self-expanding stent was successfully deployed, and the retrograde venous flow completely disappeared; the Cognard Type IV dural arteriovenous fistula was converted to a Type I
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F3
A subsequent angiogram showed that antegrade venous flow was restored [Figure 3a], and an additional balloon angioplasty (Bandicoot RX 6 mm x 40 mm; Kaneka, Osaka, Japan) was performed at the lower part of the sigmoid sinus [Figure 3b]. Next, a self-expanding stent (Precise 8 mm x 40 mm; Codman, Raynham, MA) was deployed between the sigmoid sinus and jugular bulb, which resulted in complete restoration of the venous flow in the occluded right sigmoid sinus [Figure 3c]; the Cognard Type II DAVF was converted to a Type I.
(a) Preoperative left internal carotid angiogram showing severe venous flow impairment. Markedly dilated cortical veins were observed, the cerebral blood flow narrowly returned through either the superficial middle cerebral vein or the vein of Labbe and retrograde venous drainage due to dural arteriovenous fistula was noted. (b) Angiogram obtained 12 months after sinus reconstruction showing a remarkable improvement in the cerebral venous return. The treated right sigmoid sinus was patent
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F4
TSS DAVF and bilateral venous sinus occlusion [Figure 4a]. The clinical symptoms of the patient were considered to be due to this cerebral circulatory insufficiency, and therefore sinus restoration may be a more preferable treatment than TAE or TVE to improve the cerebral venous return. Bilateral internal carotid angiograms showed a remarkable improvement in cerebral perfusion [Figure 4b].