Dural AVF Draining into an Isolated Sac: Embolization Technique
A 38-year-old female presented with progressive headache followed by drowsiness and quadriparesis. At the time of presentation, she had papilloedema and her GCS was E3M4V2. The MRI revealed diffuse white matter edema along with dilated vessels in the subarachnoid space (Fig. 64.1a, b). Small areas of bleed were seen in the right occipital and frontal regions. Prominence of left transverse sinus was observed (Fig. 64.1c, d). Cerebral DSA revealed a high flow dural AVF with feeders from left middle meningeal and occipital arteries, the meningohypophyseal trunk of left ICA, and posterior meningeal branch of left posterior inferior cerebellar artery. It was draining into left sigmoid sinus and retrogradely into the straight sinus, superior sagittal sinus, and cortical and deep veins (Fig. 64.2a–d). There was a sharp kink in the left middle meningeal artery (MMA) (Fig. 64.2e). Both sigmoid sinuses were occluded. The case was planned for transarterial onyx embolization.