Falcotentorial dAVF with Hydrocephalus: Review of a Rare Case with a Strategic Embolization to Prevent Progression of...

Dural arteriovenous fistula is an abnormal shunt between arteries and veins located within or around the dural venous sinuses, comprising 10%-15% of cerebrovascular malformations. Falcotentorial dural arteriovenous fistula with hydrocephalus is extremely rare, with only a few cases reported. This paper presents the technical approach to managing such a condition.

A 56-year-old man presented with gait disturbance and cognitive decline for 3 months. Magnetic resonance angiography revealed hydrocephalus and a vascular malformation near the third ventricle. Digital subtraction angiography confirmed a falcotentorial dural arteriovenous fistula with multiple arterial feeders and deep venous drainage. Trans-arterial embolization was performed, achieving complete occlusion of the fistula while preserving the venous varices. The patient tolerated the procedure well, with both clinical and radiological improvement.

Hydrocephalus in dural arteriovenous fistula is often caused by aqueductal compression from dilated venous structures. Treating hydrocephalus before addressing the fistula may risk hemorrhage due to fragile leptomeningeal vessels. In this case, embolization was performed with particular attention to preserving the venous varix located caudally at the fistula site. Embolizing this pouch could have led to acute thrombosis and worsening hydrocephalus. Following embolization, ventricular dilation regressed, and the patient's symptoms improved.

Falcotentorial dural arteriovenous fistula with hydrocephalus is exceptionally rare. During embolization, preserving the venous ectasia compressing the Sylvian aqueduct may help prevent the aggravation of hydrocephalus and support progressive ventricular size reduction.