Combined transvenous and transarterial embolization of a tentorial—incisural dural arteriovenous malformation followed by primary stent placement in the associated stenotic straight sinus

Abstract

Dural arteriovenous malformations (AVMs) involving the tentoria-incisura are associated with an aggressive clinical course characterized by subarachnoid and intracranial hemorrhage (ICH). In these lesions, venous outflow obstruction precipitates leptomeningeal venous drainage, resulting in the arterialization of pial veins and the formation of venous aneurysms, both of which are prone to hemorrhage. Stenotic lesions of the dural sinuses also contribute to the development of retrograde leptomeningeal drainage, which is responsible for the aggressive clinical course of the dural AVM. Endovascular approaches are successful in the treatment of these lesions and of any potential venous outflow obstruction caused by stenosis of a dural sinus. The authors report on a patient with a tentorial-incisural dural AVM and an accompanying stenotic venous sinus. A combined transvenous and transarterial embolization procedure was performed, resulting in complete obliteration of the dural AVM, followed by primary stent placement across a stenotic segment of the straight sinus and normalization of venous outflow. The authors conclude that dural AVMs can be treated safely by using a combined transarterial and transvenous approach and that an extensive search for venous outflow obstruction often reveals stenosis of a draining sinus. Consideration should be given to primary stent placement in the stenotic sinus to protect against ICH.

Dural arteriovenous fistula presenting as thalamic dementia

“…In this case, with arterialization of the straight sinus that becomes dysplastic, increment of venous pressures can promote the formation of venous aneurysms, thereby augmenting the potential for intracranial hemorrhage 7,18 . On the basis of researchers' findings, it is now generally accepted that the venous drainage prototype of dural AVF is the most predictive factor that predispose to the risk of these aggressive dural AVF symptoms, with focal neurologic deficits or hemorrhage 12 .…”

Treatment of Intracranial Dural Arteriovenous Fistulas: Current Strategies Based on Location and Hemodynamics, and Alternative Techniques of Transcatheter Embolization

“…† Numbers in parentheses indicate percentages of cases. (15,18,21,29,30,(53)(54)(55)(56)(57)(58). The efficacy, potential risk, and difficulty of these options are described in Table 7.…”

Intracranial Dural Arteriovenous Fistulae

“…This technique may treat DAVF by restoring normal venous flow, as well as by closing arteriovenous shunts in the dural sinus wall. [64][65][66] Although endovascular embolization has generally been shown to be safe and effective, potential complications include nontarget embolization resulting in stroke or blindness, vessel injury, and intracranial hemorrhage. 63,66 Because DAVF often involve branches of the external carotid artery, it is imperative that treating physicians remain cognizant of potential dangerous anastomoses between the external and the internal carotid artery systems, as well as the normal external carotid artery supply to cranial nerves.…”