Transarterial Sinus Embolization for a Dural Arteriovenous Fistula in a Sinus of the Lesser Sphenoid Wing: A Case Report

Abstract

Dural arteriovenous fistula (DAVF) in a sinus of the lesser sphenoid wing (SLSW) is rarely reported. Here, we report a case of an isolated SLSW DAVF treated by coils placed into the sinus through the feeding artery. A 68-year-old man was admitted to our hospital with headache. Magnetic resonance images and an angiogram showed a varix in the right middle cranial fossa. A DAVF, consisting of three main feeders and the isolated SLSW, was diagnosed based on the angiogram findings. Retrograde leptomeningeal venous drainage to the deep middle cerebral vein was observed. Given the remarkable extent of cortical venous ectasia together with the presence of headache and right abducens nerve paralysis, endovascular treatment was initiated. A transvenous approach through the right inferior petrosal sinus was not feasible because of difficulty associated with inserting the microcatheter into the SLSW. Thus, we tried a transarterial approach and were able to advance the microcatheter beyond the fistula into the isolated SLSW, through the artery of the foramen rotundum. The isolated sinus and feeding arteries were embolized with coils. The postoperative angiogram showed the total occlusion of the SLSW DAVF. This case demonstrates the feasibility of transarterial sinus packing for an isolated SLSW DAVF.

Dural arteriovenous fistula in the sphenoid bone lesser wing region: Endovascular adjuvant techniques of treatment and literature review

“…Currently, there are fewer than 20 case reports of a DAVF in the sphenoid bone lesser wing area. [1][2][3][4][5][6][7][8][9][10][11][12][13][14] The fistula is fed by branches of the ECA (middle and accessory meningeal arteries) and by the ICA (branches of the inferolateral trunk, recurrent meningeal branch of the ophthalmic artery). The location and anatomical relationship between the two venous systems (superficial middle cerebral vein and sphenoparietal sinus) determine the characteristics of venous drainage.…”

“…We were able to find 13 publications, reporting a total 18 cases of DAVF in the given location. [1][2][3][4][5][6][7][8][9][10][11][12][13][14] The analysis of published cases allowed us to divide these clinical observations into fistulas of the sphenoid bone lesser wing sinus and the superficial middle cerebral vein (Table 1) *Two case reports of AV-fistulas in the lesser sphenoid wing region with drainage exclusively into the basal vein can be considered equivalent to the AV-fistula of the superficial middle cerebral vein. For example, according to Watanabe et al (2015) an exclusion of the bridging vein, which was draining into the basal vein, in direct proximity to the confluence led to a change in the blood flow, redirecting the reflux into the superficial medial cerebral vein.…”

“…We were able to find 13 publications, reporting a total 18 cases of DAVF in the given location. 1–14 The analysis of published cases allowed us to divide these clinical observations into fistulas of the sphenoid bone lesser wing sinus and the superficial middle cerebral vein (Table 1), based on the pattern of venous drainage. In two cases, direct drainage to the basal vein was noted.…”

Endovascular treatment for sphenoidal region dural arteriovenous fistula

“…The most complete TAEs for sphenoidal region DAVFs via MMA and AMA can be found in reports by Rezende et al ( 40 ), Unterhofer et al ( 4 ), Fukuda et al ( 39 ), Macdonald et al ( 2 ), Yako et al ( 29 ), Park et al ( 54 ), Kandyba et al ( 17 ), and Shimizu et al ( 52 ). In addition, on rare occasions, complete TAE for sphenoidal region DAVFs can be achieved via the artery of the foramen rotundum ( 39 , 58 ). During TAE via the MMA or AMA, other large feeding arteries can be occluded with coils or balloons to reduce blood flow and facilitate liquid embolic agent casting ( 39 ).…”

“…Only occlusions of the distal feeding artery and fistula cannot cure sphenoidal region DAVFs; although angiography confirmed no residual DAVF, recanalization can occur ( 66 ). Occlusions of distal feeding arteries, fistula connections, and the very proximal segment of the draining vein can lead to obliteration of DAVFs and a good clinical outcome via TAE or TVE ( 1 , 15 , 17 , 39 , 40 , 54 , 58 ). For instance, in Lv et al’s report, 7 LCS DAVFs were completely embolized, and good outcomes were achieved ( 67 ).…”