Direct Puncture Feasibility for Diffuse Type IV Transverse Sinus Dural Arteriovenous Fistula

Background: We report a case of a Cognard type IV DAVF located diffusely on both transverse sinus (TS) treated in 2 sessions. Complete cure by transarterial embolization via occipital feeders or transvenous embolization through the femoral vein would not have been possible.

Case: A middle-aged men presented with progressive cognitive decline. Because of repetitive thrombophlebitis he was under continuous anticoagulant therapy. Retrograde superior sagittal sinus (SSS) and cortical venous reflux was depicted on cerebral angiography with the right TS occluded and the left TS subocclusive. In addition, 50% of the fistula could be treated the first time by direct left cervical puncture. The second treatment was managed by direct puncture of the SSS as both TS were occluded. A small craniotomy was performed at the vertex and a 6F sheath was inserted to the SSS. A triaxial system helped to navigate the microcatheter to the right TS which was successfully excluded by coils and Squid. Follow-up DSA did not show any fistulous residue and MRI also normalized. Neurological symptoms resolved.

Discussion: We discuss indications, different technical options and also direct puncture treatment related tips and tricks. We also review potential pitfalls and difficulties related to such a treatment.

Publication History

Article published online:
09 February 2023