PMC9020868_01
Preoperative angiography.. The white arrow indicates the varix. R indicates the right. P indicates the posterior. A: Early phase anterior-posterior view of left external carotid angiography showing arteriovenous fistula. B: Late phase anterior-posterior view of left external carotid angiography showing much venous reflux. C: Lateral view of left external carotid angiography showing that the varix exists at the origin of the uncal vein. D: Reconstructed three-dimensional image showing the vasculature.
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The main feeders were the left middle meningeal artery, left accessory meningeal artery (AMA), and the left artery of the foramen rotundum (Fig. 1).
Curved multiplanar reconstruction images of the left accessory meningeal artery (AMA).. A: At the origin of the AMA from the internal maxillary artery. B: At the foramen ovale. C: At the shunting point from the AMA to the venous side.
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AMA looked thick enough to approach the venous side from the arterial side (Fig. 2). Aquarius iNtuition (TeraRecon Inc., Durham, NC, USA) was used for neuroimaging analysis.
Intraoperative images.. The asterisk indicates the lateral cavernous sinus (CS). The white arrows indicate the shunting point. The white arrowheads indicate the tip of the microcatheter. A: Lateral view of a roadmap image showing the microcatheter advancing in the accessory meningeal artery (AMA). P indicates the posterior. B: Oblique view of a roadmap image showing that the microcatheter is inside the lateral CS. C: The black arrowhead indicates the first coil in the superficial middle cerebral veins. The tip of the distal access catheter is passed through the shunting point. D: The final coil configuration showing that the coil was filled up to the end of the AMA.
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AMA using a Chikai 14 black microguidewire (Asahi Intecc, Aichi, Japan). A 3.2/3.4-Fr GuidePost 120-cm (Tokai Medical Products, Aichi, Japan) was coaxially used as a distal access catheter (Fig. 3).
Postoperative images.. R indicates the right. P indicates the posterior. A: Anterior-posterior view of the left common carotid angiography. B: Lateral view of the left common carotid angiography showing complete obliteration of the fistula. C, D: Magnetic resonance images showing the coil mass in the lateral cavernous sinus and affected veins (white arrows).
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Finally, the shunt completely disappeared (Fig. 4).