PMC5691552_01
DSA profile view showing FAVD supplied by branches of the LECA and direct drainage into the sigmoid sinus
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F1
Digital subtraction angiography revealed DAVF with afferents from the left external carotid artery (LECA), notably with the occipital and middle meningeal arteries draining into the ipsilateral sigmoid sinus, without leptomeningeal cortical retrograde venous drainage, and grade I of the Cognard classification [Figure 1].
Unsuccessfully attempt of embolization through transvenous approach due to left sigmoid sinus isolated
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F2
Thus, two sessions of transarterial embolization were performed 2 months apart [Figure 2].
(a) Selective micro catheterization of the left occipital artery showing the fistulous point. (b) Final control of the first session, after embolization of the left occipital artery
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F3
During the first session, the fistulous branch of the left occipital artery was occluded with Onyx  [Figure 3a and b].
(a) Selective micro catheterization of the left middle meningeal artery showing the fistulous point. (b) Final control of the second session, after embolization of the left middle meningeal artery
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F4
During the second session conducted with Onyx , the feeder branch of the left middle meningeal artery was occluded [Figure 4a and b].
DSA final control, showing complete closure of FAVD by Onyx
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F5
Angiography revealed complete exclusion of the fistula and successful embolization [Figure 5].
Left peripheral facial palsy House-Brackmann grade 4 on the first postoperative day
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F6
On the first day postoperatively, the patient presented with ipsilateral peripheral facial palsy, House Brackmann grade 4 [Figure 6], and no other physical or neurological signs.
Computed tomography image (axial view) showing large amount of artifact corresponding to Onyx in the embolized vessels in close proximity to the facial nerve route (opacities at the left side)
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F7
Tomography showed no ischemic or hemorrhagic complications [Figure 7].
Spontaneous resolution of peripheral facial paralysis after 4 days of embolization
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F8
The patient received 4 mg of intravenous dexamethasone every 6 h and showed progressive improvement with complete recovery in 4 days [Figure 8].