Abstract
A 52-year-old woman presented to her general practitioner with enervating pulsatile tinnitus on the left-hand side. She was referred for a cranial MRI examination, which remained nonconclusive. A DSA examination 8 months later revealed a dural arteriovenous fistula (DAVF) of the left sigmoid sinus. The fistula was being supplied by the ipsilateral posterior meningeal, tentorial, occipital, and middle meningeal artery. The drainage was direct through the left sigmoid sinus to the internal jugular vein in an anterograde direction (Borden type I, Cognard type I). The “benign” nature of this DAVF was explained to the patient, together with the options for further management (conservative observation, open surgery, stereotactic irradiation, endovascular occlusion). The patient asked for treatment, hoping to get rid of the pulsatile bruit. Under general anesthesia, transosseous supply branches from the left occipital artery were embolized with nBCA/ethiodized oil. Since a transarterial occlusion of all branches involved was not feasible, the temporal branch of the left middle meningeal artery was catheterized with a microcatheter. Via transvenous access, a compliant balloon catheter was inserted into the left sigmoid sinus. Under roadmap guidance, “Precipitating Hydrophobic Injectable Liquid” (PHIL 25%, MicroVention) was transarterially injected via the microcatheter with the venous balloon fully inflated. The PHIL created a proximal cast around the distal end of the microcatheter and then propagated distally. The precipitating liquid embolic agent created a jacket around the inflated compliant balloon and entered the orifices of the supplying dural arteries in a retrograde direction. After several cycles of balloon inflation and deflation with gentle PHIL injection when the balloon was inflated, the arteriovenous shunt was eventually halted. The patient recognized that her tinnitus had ceased upon recovering from general anesthesia. Follow-up MRA confirmed the patency of the left sigmoid sinus. The endovascular treatment of DAVFs with the combination of transarterial embolization and transvenous balloon protection is the main topic of this chapter.
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Hellstern, V., Dukiewicz, M., Serna Candel, C., Ganslandt, O., Henkes, H. (2021). Sigmoid Sinus Dural Arteriovenous Fistula: Transarterial Embolization with PHIL Under Transvenous Balloon Protection of the Sinus, With Occlusion of the Dural Arteriovenous Fistula and Good Clinical Outcome. In: Henkes, H., Lylyk, P., Ganslandt, O. (eds) The Arteriovenous Malformations and Fistulas Casebook. Springer, Cham. https://doi.org/10.1007/978-3-030-51200-2_14-1
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DOI: https://doi.org/10.1007/978-3-030-51200-2_14-1
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