PMC8326100_01
Magnetic resonance imaging on admission. (a) Magnetic resonance angiography shows abnormal clusters of numerous blood vessels in the area of the left transverse sinus-sigmoid sinus junction (white arrow). (b) Fluid-attenuated inversion recovery imaging reveals no abnormal changes.
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Magnetic resonance angiography (MRA) on admission showed a cluster of abnormal blood vessels in the area of the left TS-SS junction [Figure 1a]. Fluid-attenuated inversion recovery imaging on magnetic resonance imaging revealed no abnormal changes [Figure 1b].
Preoperative cerebral angiography. (a) Left external carotid angiography (a-1: anterior posterior view, a-2: lateral view) showing shunt flow to the junction of TS-SS via the left middle meningeal artery and left occipital artery. (b) Left internal carotid angiography (b-1: anterior posterior view; b-2: lateral view) revealing fistula to the same area through the left meningohypophyseal trunk in the early phase. In the late venous phase (c-1: anterior posterior view; c-2: lateral view), the draining venous flows mainly into the right TS, but the left SS is partially used for normal venous perfusion. Retrograde flow in the ectatic cortical vein is not recognized. TS: Transverse sinus, SS: Sigmoid sinus.
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Cerebral angiography demonstrated a d-AVF at the left TS-SS junction, supplied mainly by the left middle meningeal artery (MMA), left occipital artery, left meningohypophyseal trunk, left posterior meningeal artery, and meningeal branch of the left superior cerebellar artery [Figures 2 and 3]. On the other hand, no retrograde flow was recognized in the ectatic cortical vein [Figures 2 and 3].
Preoperative cerebral angiography. (a) Left vertebral artery angiography (a-1: anterior posterior view; a-2: lateral view) showing the shunt flow to the same portion through left posterior meningeal artery and the meningeal branch of the left superior cerebellar artery in the early arterial phase. In the late venous phase (b-1: anterior posterior view; b-2: lateral view), venous flow drains mainly into the right TS, but the left SS is partially used for normal venous perfusion. Retrograde flow is not apparent in the ectatic cortical vein. TS: Transverse sinus, SS: Sigmoid sinus.
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Cerebral angiography demonstrated a d-AVF at the left TS-SS junction, supplied mainly by the left middle meningeal artery (MMA), left occipital artery, left meningohypophyseal trunk, left posterior meningeal artery, and meningeal branch of the left superior cerebellar artery [Figures 2 and 3]. On the other hand, no retrograde flow was recognized in the ectatic cortical vein [Figures 2 and 3].
Endovascular surgery by transarterial embolization. (a and b) Cerebral angiography shows a Headway DUO microcatheter navigated to the near shunt point at the junction of the TS and SS (white arrow: Headway DUO; black dashed arrow: 4.2-Fr FUBUKI). (c) SHOURYU is placed and inflated in the left TSSS junction near the shunt point. (d) Embolization using Onyx 18 is performed while preventing embolic material from straying into the TS-SS (d-1, d-2: Digital subtraction angiography; d-3: Conventional angiography). TS: Transverse sinus, SS: Sigmoid sinus.
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SS [Figure 4a and b]. Second, a 6-Fr Launcher guiding catheter was introduced into the femoral vein and advanced to the right internal carotid vein (ICV), then a SHOURYU (Kaneka Medics, Kanagawa, Japan) was placed in the left TS-SS junction near the shunt point through the right TS over the confluence of bilateral transverse sinuses. To avoid migration of Onyx into the TS-SS junction and preserve antegrade sinus flow, we inflated the SHOURYU at the same site [Figure 4c], and consequently performed embolization using Onyx 18 to prevent embolic material from straying into the TS-SS [Figure 4d].
Postoperative cerebral angiography and MRA findings. (a-c) Digital subtraction angiography (a: left ECAG; b: left VAG; c-1: left ICAG) (lateral view) in the early arterial phase confirms complete disappearance of shunt flow. In the late venous phase, good antegrade venous perfusion of the left TS and SS to the left internal carotid vein is identified (c-2) left ICAG) (anterior-posterior view). (d) Follow-up MRA 12 months later shows left TS-SS venous flow has been well reconstructed and that the d-AVF has completely disappeared. MRA: Magnetic resonance angiography, ECAG: External carotid angiography, VAG: Vertebral artery angiography, ICAG: Internal carotid angiography, TS: Transverse sinus, SS: Sigmoid sinus, d-AVF: Dural arteriovenous fistula.
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TS and SS to the left ICV [Figure 5a-c]. The patient was discharged home on postoperative day 7. TS-SS, and complete disappearance of the d-AVF [Figure 5d]. The clinical study of this report was approved by the ethics committee of the authors' institution, and informed consent was obtained from the patient prior to initiating the study.