Elsevier

Surgical Neurology

Volume 69, Issue 2, February 2008, Pages 192-196
Surgical Neurology

Technique
Selective image-guided venous sinus exposure for direct embolization of dural arteriovenous fistula: technical case report

https://doi.org/10.1016/j.surneu.2006.11.059Get rights and content

Abstract

Background

Transcranial approaches for transsinusal endovascular therapy of DAVF have been sporadically reported by large craniectomies. Large craniectomies carry nevertheless a risk of postembolization extradural hematoma, reduced by delaying the endovascular procedure. We report a 1-session technique of SIGC for percutaneous transvenous DAVF embolization.

Case Description

This 58-year-old woman developed a right-sided cerebellar hematoma in relation with a high-grade left transverse and sigmoid sinus DAVF. The DAVF was fed by branches from the left vertebral artery, left internal, and left external carotid arteries, draining into the transverse sinus with retrograde flow in cortical veins. Transvenous retrograde embolization was not feasible either through the left internal jugular vein because of thrombosis, or through the right one because of torcular septa. During the same anaesthetic session, a 5-cm-length selective craniectomy was shaped under magnetic resonance image guidance navigation according to the left transverse sinus with high-speed drill. Thereafter, back in the angiography room, the transverse sinus was taped and coiled resulting in a complete exclusion of the DAVF.

Conclusion

Selective image-guided craniectomy is efficient and safe for direct percutaneous transvenous embolization of DAVF in a single anesthetic session. Leaving bone beside the sinus prevents a parenchymal traumatic puncture. This bone has nevertheless to be drilled to allow an adequate sharp puncture angle. Doing so, postoperative hematoma is prevented by the small bone opening, the natural adherence of the dura matter and the possibility of direct compression.

Introduction

Dural arteriovenous fistulas account for 10% to 15% of all intracranial arteriovenous lesions [4]. Their venous pattern of drainage determines the risk of neurologic complication. This risk increases in the presence of venous reflux into a main sinus and leptomeningeal vessels [2], [4], [5].

The goal of the treatment is the complete exclusion of the lesion. Surgery can be associated with a high complication rate. Nowadays, transvenous embolization has proven to be efficient and the first treatment option in some location [6], [10]. Nevertheless, this treatment is sometimes not applicable because the venous access can be prevented by the sinus thrombosis often associated or by previous treatments. In such cases, surgical exposure of the sinus is an elegant option to permit further transvenous DAVF occlusion [4]. In their experience, Houdart et al [4] advised to perform a large craniectomy owing to the failure of the subsequent endovascular treatment after small ones.

To avoid the disadvantages and complications associated with large craniectomies in cases of DAVF, we have performed an SIGC. We detail our surgical technique and discuss its advantages and pitfalls.

Section snippets

Case report

This 58-year-old woman has a 2-year history of left pulsatile tinnitus. She was admitted after an abrupt neurologic deterioration. Neurologic examination revealed a deep coma. Computed tomography scan showed a right-sided cerebellar hematoma responsible for hydrocephalus. The patient was brought in the operating room for cerebrospinal fluid tap and hematoma drainage. Surgery was associated with profuse and unusual bleedings all over the procedure. The patient's neurologic condition improved

Discussion

The transcranial approach was first described by Mickle and Quisling [7] in 1986 for the transtorcular embolization of vein of Galien aneurysms. The transcranial access has then been reported to catheterize the transverse sinus and the superior sagittal sinus [1], [3], [4], [8]. Based on the largest published experience, Houdart et al [4] advocated performing large craniectomies. In fact, 7 of their 10 patients needed to be reoperated on to enlarge a craniectomy because it was either too small

Conclusion

Selective image-guided craniectomy allows the direct percutaneous transvenous embolization of DAVF in the same anesthetic session. The bone beside the sinus borders has to be drilled to allow an adequate sharp puncture angle but must be left in place to prevent traumatic parenchymal puncture. Doing so, postoperative hematoma is prevented by the small bone opening, the natural adherence of the dura matter, and the possibility of direct compression.

References (10)

  • S.L. Barnwell et al.

    Complex dural arteriovenous fistulas. Results of combined endovascular and neurosurgical treatment in 16 patients

    J Neurosurg

    (1989)
  • C. Cognard et al.

    Cerebral dural arteriovenous fistulas: clinical and angiographic correlation with a revised classification of venous drainage

    Radiology

    (1995)
  • V.V. Halbach et al.

    Transvenous embolization of dural fistulas involving the transverse and sigmoid sinuses

    AJNR

    (1989)
  • E. Houdart et al.

    Transcranial approach for venous embolization of dural arteriovenous fistulas

    J Neurosurg

    (2002)
  • P. Lasjaunias et al.

    Neurological manifestations of intracranial dural arteriovenous malformations

    J Neurosurg

    (1986)
There are more references available in the full text version of this article.

Cited by (0)

View full text