PMC10370528_01
A 49-year-old, right-handed female presented to our hospital with motor aphasia. (A and B) Images obtained with MRI-FLAIR showing high-intensity area in the left temporal and occipital lobes involving a small hemorrhage. (C and D) Anterior-posterior and lateral views of left ECA angiogram showing the arteriovenous fistula shunting at the left TS (black arrow), which is fed by OA mastoid branch and drained into the cortical veins retrogradely. (E) Anterior-posterior view of left VA angiogram showing the left TS occlusion. (F) Multiplanar reformation images of con-beamed CT obtained from left ECA 3D rotational angiography showing the shunting area at the middle part of the transvers sinus (white arrow) and draining into the cortical veins retrogradely via lateral tentorial sinus (white arrowhead). ECA: external carotid artery; OA: occipital artery; TS: transverse sinus; VA: vertebral artery
jnet-17-61-g001.jpg
PMC10370528_01_jnet-17-61-g001.jpg
F1
MRI revealed congestion in the left temporal and occipital lobes, with a small hemorrhage (Fig. 1A and 1B). TS was occluded; however, the fistula drained into the cortical veins of the temporal and occipital lobes through the patent part of the sinus (Fig. 1C-1F). Transvenous embolization was initially attempted, but the microcatheter could not reach the fistula. Therefore, TAE was performed via the mastoid branch of the left OA, which was the main feeder artery, under general anesthesia.
(A) Lateral view of the left ECA posttreatment angiogram showing partial occlusion of OA and the DAVF disappearance. (B) Lateral view of the left ECA follow-up angiogram showing residual shunt, which was fed by the OA muscle branch and posterior convexity of the left MMA. (C) Lateral view of selective angiogram of the OA muscle branch showing the connection with the OA distal mastoid branch, which was occluded with the first treatment. DAVF: dural arteriovenous fistula; ECA: external carotid artery; MMA: middle meningeal artery; OA: occipital artery
jnet-17-61-g002.jpg
PMC10370528_01_jnet-17-61-g002.jpg
F2
Although it was a proximal occlusion without the glue penetration into the shunt point, angiography after embolization showed disappearance of the DAVF (Fig. 2A), and the patient's symptom improved. An eight-day follow-up angiography showed a residual shunt (Fig. 2B), and an additional TAE was performed. OA muscle branch revealed that the muscle branch was connected to the OA distal mastoid branch, which was occluded with the first treatment (Fig. 2C). Our treatment plans were occlusion of the muscle branch and embolization of DAVF via MMA with NBCA.
(A and B) Anterior-posterior view of blank roadmap and fluoroscopic images showing the migrated NBCA glue (white arrowheads) to VA through the OA muscle branch (black arrowheads) at the C1 level. (C) Postembolization CT showing the OA muscle branch (black arrowhead) occluded by NBCA glue at the C1 level. (D) Anterior-posterior view of left VA angiogram showing severe stenosis and the migrated NBCA glue (white arrowhead). NBCA: N-butyl-2-cyanoacrylate; OA: occipital artery; VA: vertebral artery
jnet-17-61-g003.jpg
PMC10370528_01_jnet-17-61-g003.jpg
F3
After embolization, it was observed that part of the NBCA glue migrated into the left VA via muscle branch anastomosis (Fig. 3A-3C). A left VA angiogram revealed severe VA stenosis and floating NBCA glue (Fig. 3D).
(A) Fluoroscopic image showing retrieval of the migrated NBCA glue using Trevo (black arrow) and Penumbra ACE68 (black arrowhead) under inflation of the balloon-guiding catheter (white arrowhead). (B) Image of the NBCA glue caught on the outside of the stent. (C) Postretrieval left VA angiogram showing recanalization without stenosis and slow flow. NBCA: N- butyl-2-cyanoacrylate; VA: vertebral artery
jnet-17-61-g004.jpg
PMC10370528_01_jnet-17-61-g004.jpg
F4
Trevo and Penumbra devices were carefully withdrawn under continuous aspiration (Fig. 4A). The NBCA glue was removed, but the NBCA glue got trapped at the tip of the guiding catheter outlet due to its large size. Therefore, the guiding catheter was pulled out slowly maintaining continuous aspiration using a 50-cc syringe. Thus, the NBCA glue was successfully retrieved, and an after- retrieval angiogram revealed VA recanalization without slow flow and distal embolization (Fig. 4B and 4C).
(A) Lateral view of left ECA angiogram showing no DAVF after embolization. (B and C) Images obtained with MRI-FLAIR showing no abnormal signals after embolization. DAVF: dural arteriovenous fistula; ECA: external carotid artery
jnet-17-61-g005.jpg
PMC10370528_01_jnet-17-61-g005.jpg
F5
Additionally post- intervention MRI showed no signs of intracranial hemorrhage and infarction (Fig. 5).