PMC10158667_01
The preoperative imaging. (a and b) Sagittal and axial MRI. A massively dilated torcular herophili (blue arrow) and transverse sinuses are visualized (white arrows). (c) A 3D reconstruction of the CTA with arterial feeders from the posterior circulation (green arrow). (d) A sagittal T1 MRI showing the thinned corpus callosum (orange arrow), the compressed aqueduct of Sylvius and fourth ventricle (white arrow) and herniation of the tonsils through the foramen magnum (blue arrow). MRI: Magnetic resonance imaging, 3D: Three-dimensional, CTA: Computer tomography angiography,
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F1
The superior sagittal sinus was massively dilated. There was a large cystic flow void involving the whole confluence of sinuses and proximal parts of both transverse sinuses measuring 47 mm x 30 mm x 51 mm [Figure 1].
Angiography performed during embolization showing the fistula with multiple feeding arteries (black arrow) and the venous drainage into the torcular (blue arrow). It is noted that the major afferents of the DAVF came from the vertebral system (white arrows) with other minor feeders from the carotid system through the choroidal arteries (orange arrow) and the meningeal branches of the external carotid artery. DAVF: Dural arteriovenous fistulas
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F2
Preembolization angiogram showed the multiple feeders of the DAVF and the dilated torcular [Figure 2].
(a and b) Following microcatheters superselective catheterization and embolization with n-Butyl cyanoacrylate (blue arrows). (c and d) The embolization was >80% with partial filling of the DAVF and sinuses (black arrows) from the branches of the choroidal arteries and small meningeal arteries (green arrows) seen on the postembolization angiogram. DAVF: Dural arteriovenous fistulas
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F3
(a) Postoperative image at 3 months compared to the preoperative imaging, the tonsilar herniation has almost completely reversed on the sagittal view (blue arrow). The torcula diameter had significantly reduced (white arrow) and the fourth ventricle appears normal with no signs of compression (green arrow). (b) No features of increased ICP were seen on the axial scan. ICP: Intracranial pressure
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F4
The CSF dynamics were greatly improved with a significant reduction in the size of the lateral and third ventricles and re-expansion of the fourth ventricle [Figure 4].