Multimodal Treatment Of Occipital Tentorial Dural Arteriovenous Fistula Cognard III.

Abstract

Dural arteriovenous fistulas (dAVF) are rare vascular malformations of uncertain pathophysiology. If associated with cortical venous reflux, they present a significant risk of hemorrhage. We present a 69 year old patient who presented with spontaneous right sided symptomatic chronic subdural hematoma which was evacuated via burr hole. Due to lack of history of prior trauma, a CTA was performed which showed dilated convoluted vessels in right occipital region and enlarged right posterior cerebral artery, suspected of AVM or dAVF. Subsequent angiography demonstrated occipital tentorial dAVF with primary cortical venous reflux ( Cognard III) and reflux into transverse sinus, fed primarily from petrosquamous branch of middle meningeal artery and neuromeningeal trunk. The fistula was initially treated by transarterial endovascular embolization of the occipital artery and neuromeningeal trunk with Onyx, achieving complete obliteration. However follow-up angiography demonstrated recurrence of the lesion fed from contralateral middle meningeal artery and pial branches of enlarged right posterior cerebral artery. Given the recruitment of contralateral supply from the left middle meningeal artery and ipsilateral posterior cerebral artery, we felt that surgical disconnection of the fistula was the best option for the patient. An occipital craniotomy with disconnection of the fistula without isolation of the transverse sinus performed, as published literature demonstrated lower intraoperative risk with disconnection only. Perioperative course was uneventful. Immediate postoperative and follow-up angiography demonstrated complete occlusion of the fistula.