PMC10481809_01
(a) Left oblique and (b) lateral projections of the left internal carotid artery angiogram show the dural arteriovenous fistula at the anterior cranial fossa feeding by the left ophthalmic artery and venous reflux in the left frontal cortical veins drained into the anterior third of the superior sagittal sinus.
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F1
Magnetic resonance angiography incidentally revealed findings suggestive of ACF dAVF, which was confirmed by cerebral angiography [Figure 1].
(a) A fusion image of a three-dimensional bilateral internal carotid angiogram shows the anterior cranial fossa dural arteriovenous fistula with a drainage vein associated with a laminar flow (yellow arrow). (b) Computed tomography angiography reveals that it is the confluence of the affected drainage vein and the normal frontal cortical vein (yellow arrow). Both veins merge and form a common trunk that drains into the superior sagittal sinus.
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F2
We planned TAE with n-butyl-2-cyanoacrylate (NBCA); however, precise evaluation of angiograms revealed that the drainage vein had a laminar flow [Figure 2a, yellow arrows], which was the confluence of the normal cortical vein perfused from the left frontal lobe. Computed tomography angiography (CTA) revealed that both merged to form a common trunk that drained into the SSS [Figure 2b, yellow arrows].
(a) The procedure is performed under general anesthesia using transfemoral artery (yellow arrow head) and transvenous internal jugular vein (yellow arrow) approaches. (b) Parent Plus45 (28 cm) is placed into the right internal jugular vein (yellow arrow). (c) Retrograde transvenous access from the right internal jugular vein to the superior sagittal sinus, and an intermediate catheter TACTICS PLUS reaches to the bifurcation base of the left frontal vein (yellow arrow). (d and e) TACTICS PLUS insertion into an internal carotid artery cavernous portion (yellow arrowhead), with Marathon being advanced over a microwire to the adjacent fistulae (green arrowhead). Excelsior SL-10 being advanced over a microwire to the foot of the vein (green arrow) supported by TACTICS PLUS at the base of the left frontal vein (yellow arrow).
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F3
The endovascular procedures were performed under general anesthesia using transfemoral artery and transinternal jugular vein approaches [Figure 3a]. Parent Plus45 at 28 cm (Medikit, Tokyo, Japan) was placed into the right internal jugular vein under ultrasound guidance [Figure 3b]. Aichi, Japan), was advanced into the SSS and carefully inserted into the left frontal cortical vein [Figure 3c]. TACTICS PLUS (Technocrat) insertion into the ICA cavernous portion, a microcatheter Marathon (Covidien, Irvine, CA, USA) was immediately advanced adjacent to the fistula [Figures 3d and e]. Transvenous outlet occlusion was done with a total of 9 cm of three i-ED coils (Kaneka, Osaka, Japan) placed at the foot of the vein [Figures 4a-d].
A series of angiograms and illustrations during the procedure. (a and b) Selective angiogram from the microcatheter placed in the left anterior ethomoidal artery. Note the tip of the microcatheter for transvenous embolization placement near the shunt. (c and d) Coils are placed in the foot of the vein for flow control. (e-h) Low-concentration n-butyl-2-cyanoacrylate (14%) is injected from the arterial side without fragmentation into the venous drainage. Note the glue penetration of the fistulous point without extending to the confluence of the normal frontal cortical vein.
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F4
TACTICS PLUS (Technocrat) insertion into the ICA cavernous portion, a microcatheter Marathon (Covidien, Irvine, CA, USA) was immediately advanced adjacent to the fistula [Figures 3d and e]. Transvenous outlet occlusion was done with a total of 9 cm of three i-ED coils (Kaneka, Osaka, Japan) placed at the foot of the vein [Figures 4a-d]. A low concentration of NBCA (14%) was injected under careful inspection using continuous fluoroscopy [Figures 4e and f]. We confirmed the glue penetration of the fistulous point without extending to the confluence of the normal frontal cortical vein and completed the occlusion of the shunt [Figures 4g and h].
(a) Frontal and (b) lateral projections of the left internal carotid artery angiogram obtained at the end of session show the complete occlusion of the anterior cranial fossa dural arteriovenous fistula. Magnified oblique view of the left internal carotid angiogram(c and d) show the complete occlusion of the shunt with the preservation of the left frontal cortical vein (yellow arrows).
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F5
The final left ICA angiograms showed complete occlusion of the ACF dAVF [Figures 5a and b] with the preservation of the left frontal cortical vein [Figures 5c and d, yellow arrows].