PMC10126350_01
A timeline of events beginning with initial discovery of papilledema, outpatient visits related to the dAVF, angiography, embolization events, adverse events, and follow-up.
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fig1
A timeline of events from initial presentation through treatment and follow-up can be found in Figure 1.
(A) Lateral projection of the right ICA demonstrating early shunting from the tentorial branch of the MHT (purple arrow) and distal ACA (blue arrow) filling the dilated vein of Galen (red arrow). (B) Lateral projection of the right ECA showing retrograde venous drainage and occlusion of the straight sinus (black asterisk). (C) Lateral projection of the right occipital artery. (D) Lateral projection of right ECA, late venous phase, demonstrating generalized venous congestion.
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A cerebral angiogram (Figures 2A-D) was obtained which demonstrated a complex dAVF with the fistulous connections at the vein of Galen (Lawton et al.
(A) Lateral projection of the right ECA again demonstrating an occluded straight sinus with retrograde deep drainage. (B) Un-subtracted lateral view showing the microcatheter in the straight sinus. (C) Venogram from the straight sinus showing that the vein of Galen had not been catheterized yet with delayed antegrade venous drainage through the channel created by the microcatheter. (D) Un-subtracted lateral view showing the microcatheter in the vein of Galen. (E) Venogram from the vein of Galen. (F) Lateral projection of the R ECA after the first coil placement (black arrow). (G) Lateral projection of the R ECA after the last coil (black arrow) in the late arterial phase. (H) Lateral projection of the R ECA after final coil placement and preservation of the internal cerebral veins with no residual shunting.
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Follow-up superselective and external carotid angiograms demonstrated a minor reduction in arterial venous shunting (Figures 3A-D). The microcatheter and wire were advanced through the occluded straight sinus to the level of the vein of Galen (Figures 3B,C). The microcatheter and wire were then advanced distally to the level of the fistula (Figures 3D,E). Intermittent angiograms were obtained to evaluate for occlusion of the fistula (Figures 3F,G). Final follow-up arteriograms were obtained from the right external carotid artery (Figure 3H), left vertebral artery and left common carotid artery which demonstrated no residual arteriovenous shunting.
(A) Lateral projection of the left ICA, arterial phase, showing no shunting. (B) Lateral projection of the left ICA, venous phase, showing improvement in the overall venous congestion. (C) Lateral projection of the right ECA showing mild shunting from the falcine artery. (D) Lateral projection of the right vertebral artery, early venous phase, showing mild shunting from the posterior choroidal artery with venous drainage through the basal vein of Rosenthal and left superior ophthalmic vein.
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A follow-up angiogram was obtained 6  months after the transvenous embolization which demonstrated significantly improved venous drainage pattern with greatly reduced venous congestion (Figures 4A-C). There was minimal residual arteriovenous shunting from the falcine artery and posterior choroidal artery with venous drainage through the basal vein of Rosenthal and left superior ophthalmic vein (Figure 4D).