gms | German Medical Science

Objective: Dural arteriovenous fistulas of the transverse and sigmoid sinus represent a therapeutic conundrum. Transarterial or transvenous embolization is sometimes not possible, while surgical treatment options for a complete cure are equally limited. Direct transcranial access and embolization of the affected sinus has been described previously as a potential treatment method. We present our experience with this method.

Method: Four patients with dural arteriovenous fistulas (dAVF, Cognard types I, IIb, III and IV) in the transverse and sigmoid sinuses presented with subdural hematoma (grade IIb), pulse-synchronous tinnitus in two cases (grades I, III) and syncope. The patients were treated by surgical exposure of the diseased sinus, and after transfer in the angiography suite by subsequent catheterization and endovascular embolization. In three patients conventional transarterial or -venous embolization had failed previously.

Results: Complete embolization of the fistula could be achieved in three of the four patients using a combined surgical access and coil embolization treatment. In the fourth case, catheterization of the sinus was not possible. Patient 1: after having prepared the surgical access the fistula was found to be completely occluded due to previous transarterial treatment. Patient 2: because of previous endovascular treatment the flow in the sinus was significantly reduced and coils in the sinus prevented direct catheter access. The definite occlusion of the sinus was achieved by opening and packing the sinus in addition to repeated transarterial embolization via the middle meningeal artery. Patient 3: a parasagittal fistula of the transverse sinus which was not previously treated could be occluded via transcranial access to the isolated superior sagittal sinus and coil embolization. Patient 4: catheter access to the diseased sinus failed via the burr hole provided. Retreatment is scheduled.

Conclusions: Direct transcranial embolization of dural arteriovenous fistulas is feasible in patients in whom embolization via conventional venous or arterial access is found to be impossible. However, this highly individualized treatment needs meticulous interdisciplinary planning. Adequate exposure of the dural surface overlying the sinus is essential thus small craniotomies were preferred over burr hole trepanations.