PMC9399927_01
Preoperative images in case 1. (A) CT showing right cerebellar hemorrhage (asterisk). (B) Maximum intensity projection of CTA showing a tangle of abnormal vessels (frame) at the right margin of the tentorium; a DAVF was suspected. (C) Three-dimensional reconstruction of CTA showing a tortuous draining vein (multiple arrows) along the cerebellopontine fissure, the surface of inferior cerebellar hemisphere, and inferior vermin, went into the torcular herophili, with varix (triangle) at the beginning. (D) DSA of the right ICA showing that the MHT was the main feeding artery, and there was varix on the draining vein (triangle). (E) DSA of the right ECA showing that the petrous branch of the MMA was a minor feeding artery, and varix (triangle) was indicated. (F) DSA of the VA showing that the artery of Wollschlaeger and Wollschlaeger of the SCA was the minor feeding artery. CT, computed tomography; CTA, CT angiography, DAVF, dural arteriovenous fistula; DSA, digital subtraction angiography; ECA, external carotid artery; ICA, internal carotid artery; MHT, meningohypophyseal trunk; MMA, middle meningeal artery; R, right; SCA, superior cerebellar artery; VA, vertebral artery.
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F1
CT showed cerebellar hematoma, subarachnoid hemorrhage (SAH), and hydrocephalus (Figure 1A). DAVF of the tentorial margin, and a tortuous draining vein with varix was shown clearly, draining to the torcular herophili (Figures 1B,C). Digital subtraction angiography (DSA) confirmed the TDAVF and that the feeding arteries included the MHT, MMA, and artery of Wollschlaeger and Wollschlaeger of the SCA, in which the MHT was the main feeder (Figures 1D-F). The DAVF was Cognard Type IV and ruptured.
Operative images in case 1. (A) Three-dimensional reconstruction of DSA of the right ICA showing the diameters of the feeding artery to the TDAVF. The MHT origin was 2.3 mm, and the MTA of Bernasconi-Cassinari was 1.1 mm in diameter. (B) Road map of the ICA showing a Marathon microcatheter placed in the lower MTA. The MHT trunk with an aneurysmal dilation was coiled to produce the mass effect. (C) X-ray film showing the coils and casting Onyx. Onyx reflux reached the coils (arrow) but did not extend beyond the coils. (D) Three-dimensional reconstruction of Xper-CT showing the location of the Onyx casting (frame) at the margin of the tentorium. (E,F) DSAs of the right carotid artery (E) and VA (F) show complete obliteration of the DAVF. DAVF, dural arteriovenous fistula; DSA, digital subtraction angiography; ICA, internal carotid artery; MHT, meningohypophyseal trunk; R, right; MTA, medial tentorial artery; VA, vertebral artery.
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F2
Three-dimensional reconstruction of the internal carotid artery (ICA) showed the best projection degree of the MHT and MTA of Bernasconi-Cassinari (Figure 2A). The proximal MHT trunk with an aneurysmal dilation was embolized with coils [Axium Prime 3.5 mm x 10 cm, 2 mm x 8 cm (Medtronic, Irvine, CA, USA)] to produce a mass effect to prevent Onyx reflux (Figure 2B). Then, the Onyx casting penetrated the fistula into the draining vein (Figures 2C,D). DSA of the carotid artery and vertebral artery confirmed that the TDAVF was completely obliterated (Figures 2E,F).
PMC9399927_02
First EVT via MTA in case 2. (A) CT showing left cerebellar hemorrhage (asterisk). (B) DSA of the left ICA showing that the MTA of Bernasconi-Cassinari was the feeding artery to a DAVF (asterisk). (C) Three-dimensional DSA showing that double MTAs should share the common trunk with the ILT of the cavernous ICA; the arrow indicates the origin of these vessels. (D) Superselective angiogram via a Marathon microcatheter showing the TDAVF angioarchitecture. The arrow indicates the dilated beginning of the MTA, the asterisk indicates the fistula point, and the triangles indicate draining veins. (E) X-ray film showing Onyx casting. The arrow indicates the beginning of the MTA, the asterisk indicates that Onyx casting reached the fistula point via the MTA, and the Onyx also went into the ILT. (F) DSA of the left ICA showing that the DAVF was not seen. CT, computed tomography; DAVF, dural arteriovenous fistula; DSA, digital subtraction angiography; EVT, endovascular treatment; ICA, internal carotid artery; ILT, inferior lateral trunk; L, left; MTA, medial tentorial artery.
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F3
CT showed cerebellar hematoma, intraventricular hemorrhage, and hydrocephalus (Figure 3A). Double MTAs shared the common trunk with the inferior lateral trunk (ILT) of the cavernous ICA (Figures 3B,C). First, a Marathon microcatheter tried to go into the distal MTA, but it could only be placed at the tortuous MTA beginning (Figure 3D). Then, Onyx-18 was cast (Figures 3E,F).
Second EVT via MMA in case 2. (A) DSA of the left external carotid artery showing that the MMA and AphA still supplied the DAVF. (B) Superselective angiogram of the MMA via a Marathon microcatheter showing the DAVF angioarchitecture. The asterisk indicates the fistula point, and the triangle indicates the draining vein. (C) DSA of the left carotid artery showing that the DAVF was completely embolized after Onyx casting via the MMA. D-E: Lateral view (D) and anteroposterior (E) unsubtracted DSA showing the casting Onyx; the asterisk indicates the fistula point. (F) Three-dimensional reconstruction of Xper-CT showing Onyx casting. The asterisk indicates the fistula point at the margin of the tentorium. AphA, ascending pharyngeal artery; DAVF, dural arteriovenous fistula; DSA, digital subtraction angiography; EVT, endovascular treatment; ICA, internal carotid artery; L, left; MMA, middle meningeal artery.
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F4
TDAVF (Figures 4A,B). The second Onyx casting was performed by a Marathon microcatheter via the MMA, and the TDAVF was cured (Figures 4C-F).