Direct access to the middle meningeal artery for embolization of complex dural arteriovenous fistula: a hybrid treatment approach

J Neurointerv Surg. 2015 Jul;7(7):e24. doi: 10.1136/neurintsurg-2014-011256.rep. Epub 2014 Jun 10.

Abstract

Endovascular embolization has become increasingly favored over microsurgical resection for treatment of complex dural arteriovenous fistulas (DAVFs). However, endovascular treatment can be restricted by tortuous transarterial access and a transvenous approach is not always feasible. We present a Borden III DAVF treated by direct access to the middle meningeal artery (MMA) and Onyx embolization performed in a hybrid operating room-angiography suite. A middle-aged patient with pulsatile headaches was found to have left transverse sinus occlusion and DAVF with retrograde cortical venous drainage fed by multiple external carotid artery (ECA) feeders. Endovascular attempts via conventional transvenous and transarterial routes were unsuccessful, and the major MMA feeder was accessed directly after temporal craniotomy was performed under neuronavigation. Onyx embolization was performed; complete occlusion of the fistula was achieved. Three-month follow-up angiography showed no residual filling; the patient remains complication-free. A combined surgical-endovascular technique in a hybrid operating room-angiography suite can be an effective treatment for DAVFs complicated by inaccessible arterial and transvenous approaches.

Keywords: Artery; Fistula; Intervention; Technique; Vascular Malformation.

Publication types

  • Case Reports
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Central Nervous System Vascular Malformations / diagnostic imaging*
  • Central Nervous System Vascular Malformations / therapy*
  • Combined Modality Therapy / methods
  • Dimethyl Sulfoxide / administration & dosage
  • Embolization, Therapeutic / methods*
  • Follow-Up Studies
  • Humans
  • Meningeal Arteries / diagnostic imaging*
  • Meningeal Arteries / surgery*
  • Middle Aged
  • Polyvinyls / administration & dosage
  • Radiography
  • Treatment Outcome

Substances

  • Onyx copolymer
  • Polyvinyls
  • Dimethyl Sulfoxide