Complete endovascular occlusion of a cranial dural fistula using a venous "to the point" approach

Cranial dural arteriovenous fistulas are commonly treated using an endovascular method. In comparison to intracerebral arteriovenous malformations, it is important to reach the venous part of these malformations to maintain a complete occlusion. Therefore, often the venous side is totally occluded using coils and∕or glue.

We describe a patient with an initially Type IIab (Cognard classification) left occipital cranial fistula. The patient suffered from an intense pulsate tinnitus. Therefore, the first embolization was performed using an approach via the dilated left middle meningeal artery using Onyx. The shunt of the fistula was reduced significantly but total occlusion was impossible. Therefore, the venous approach was used. Over a guiding catheter in the sigmoid sinus, the venous side of the fistula could be reached with a microcatheter. This part of the fistula was then completely occluded using coated and bare coils, without occluding the adjacent sinus. Control angiography of all previous feeders showed a complete occlusion of the fistula (used classification: Cognard).

The fistula was entirely occluded. The patient's outcome was excellent. The patient did not develop any symptoms and no complication occurred due to the treatment.

Direct occlusion of the venous part of an arteriovenous cranial fistula can be an option before an occlusion of the sinus has to be performed. This approach can lead to reduction of risk during the endovascular procedure and risk reduction in long-term follow-up.