HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text Full Text (PDF) CME Test (opens in a new window) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kiyosue, H. Articles by Mori, H. Search for Related Content PubMed PubMed Citation Articles by Kiyosue, H. Articles by Mori, H. Related Collections Neuroradiology

Treatment of Intracranial Dural Arteriovenous Fistulas: Current Strategies Based on Location and Hemodynamics, and Alternative Techniques of Transcatheter Embolization¹

¹ From the Department of Radiology, Oita Medical University, 1–1 Hasama, Oita, 879–55, Japan (H.K., Y.H., M.O., S.T., Y.S., S.M., H.M.); and the Department of Neurosurgery, Nagatomi Neurosurgical Hospital, Oita, Japan (H.N.). Recipient of a Cum Laude award for an education exhibit at the 2003 RSNA scientific assembly. Received March 1, 2004; revision requested April 20 and received June 3; accepted June 3. All authors have no financial relationships to disclose. Address correspondence to H.K. (e-mail: hkiyosue@med.oita-u.ac.jp).

View larger version (53K): [in a new window]   Figure 1a.  Drawings (a = lateral view, b = anteroposterior view) illustrate the most common locations of dural AVFs: 1 = cavernous sinus (CS) (20%-40% of cases), 2 = transverse-sigmoid sinus (TS, SS) (20%-60%), 3 = tentorium (12%-14%), 4 = superior sagittal sinus (SSS) (8%), and 5 = anterior fossa (2%-3%). IPS = inferior petrosal sinus, ISS = inferior sagittal sinus, JV = jugular vein, MS = marginal sinus, OS = occipital sinus, SPS = superior petrosal sinus.

View larger version (67K): [in a new window]   Figure 1b.  Drawings (a = lateral view, b = anteroposterior view) illustrate the most common locations of dural AVFs: 1 = cavernous sinus (CS) (20%-40% of cases), 2 = transverse-sigmoid sinus (TS, SS) (20%-60%), 3 = tentorium (12%-14%), 4 = superior sagittal sinus (SSS) (8%), and 5 = anterior fossa (2%-3%). IPS = inferior petrosal sinus, ISS = inferior sagittal sinus, JV = jugular vein, MS = marginal sinus, OS = occipital sinus, SPS = superior petrosal sinus.

View larger version (165K): [in a new window]   Figure 2a.  Complication associated with subdural hematoma from TVE. (a) Left external carotid arteriogram shows a transverse sinus dural AVF fed by the left occipital, superficial temporal, and middle meningeal arteries. The AVF drains into the left jugular vein and cortical veins. (b) Left internal carotid arteriogram shows two dural AVFs (arrows) fed by the left ascending pharyngeal artery and the meningohypophyseal artery, respectively. The AVFs drain into the superior petrosal sinus (arrowheads). (c) Fluoroscopic image obtained during placement of a coil into the superior venous pouch contiguous with the superior petrous sinus demonstrates that the distal edge of the coil did not form a loop (arrow). As a result, the coil probably penetrated the venous wall. The transverse sinus and inferior venous pouch around the superior petrous sinus were already packed with coils. (d) Computed tomographic (CT) scan obtained 1 day after embolization shows a subdural hematoma at the left cerebral convexity and the falx. The patient complained of headache for a few days but fortunately did not have any neurologic symptoms. (e) Follow-up angiogram of the left external carotid artery shows complete obliteration of the transverse-sigmoid sinus dural AVF. (f) Left internal carotid arteriogram shows complete obliteration of the dural AVFs involving the superior petrosal sinus.

View larger version (142K): [in a new window]   Figure 2b.  Complication associated with subdural hematoma from TVE. (a) Left external carotid arteriogram shows a transverse sinus dural AVF fed by the left occipital, superficial temporal, and middle meningeal arteries. The AVF drains into the left jugular vein and cortical veins. (b) Left internal carotid arteriogram shows two dural AVFs (arrows) fed by the left ascending pharyngeal artery and the meningohypophyseal artery, respectively. The AVFs drain into the superior petrosal sinus (arrowheads). (c) Fluoroscopic image obtained during placement of a coil into the superior venous pouch contiguous with the superior petrous sinus demonstrates that the distal edge of the coil did not form a loop (arrow). As a result, the coil probably penetrated the venous wall. The transverse sinus and inferior venous pouch around the superior petrous sinus were already packed with coils. (d) Computed tomographic (CT) scan obtained 1 day after embolization shows a subdural hematoma at the left cerebral convexity and the falx. The patient complained of headache for a few days but fortunately did not have any neurologic symptoms. (e) Follow-up angiogram of the left external carotid artery shows complete obliteration of the transverse-sigmoid sinus dural AVF. (f) Left internal carotid arteriogram shows complete obliteration of the dural AVFs involving the superior petrosal sinus.

View larger version (122K): [in a new window]   Figure 2c.  Complication associated with subdural hematoma from TVE. (a) Left external carotid arteriogram shows a transverse sinus dural AVF fed by the left occipital, superficial temporal, and middle meningeal arteries. The AVF drains into the left jugular vein and cortical veins. (b) Left internal carotid arteriogram shows two dural AVFs (arrows) fed by the left ascending pharyngeal artery and the meningohypophyseal artery, respectively. The AVFs drain into the superior petrosal sinus (arrowheads). (c) Fluoroscopic image obtained during placement of a coil into the superior venous pouch contiguous with the superior petrous sinus demonstrates that the distal edge of the coil did not form a loop (arrow). As a result, the coil probably penetrated the venous wall. The transverse sinus and inferior venous pouch around the superior petrous sinus were already packed with coils. (d) Computed tomographic (CT) scan obtained 1 day after embolization shows a subdural hematoma at the left cerebral convexity and the falx. The patient complained of headache for a few days but fortunately did not have any neurologic symptoms. (e) Follow-up angiogram of the left external carotid artery shows complete obliteration of the transverse-sigmoid sinus dural AVF. (f) Left internal carotid arteriogram shows complete obliteration of the dural AVFs involving the superior petrosal sinus.

View larger version (139K): [in a new window]   Figure 2d.  Complication associated with subdural hematoma from TVE. (a) Left external carotid arteriogram shows a transverse sinus dural AVF fed by the left occipital, superficial temporal, and middle meningeal arteries. The AVF drains into the left jugular vein and cortical veins. (b) Left internal carotid arteriogram shows two dural AVFs (arrows) fed by the left ascending pharyngeal artery and the meningohypophyseal artery, respectively. The AVFs drain into the superior petrosal sinus (arrowheads). (c) Fluoroscopic image obtained during placement of a coil into the superior venous pouch contiguous with the superior petrous sinus demonstrates that the distal edge of the coil did not form a loop (arrow). As a result, the coil probably penetrated the venous wall. The transverse sinus and inferior venous pouch around the superior petrous sinus were already packed with coils. (d) Computed tomographic (CT) scan obtained 1 day after embolization shows a subdural hematoma at the left cerebral convexity and the falx. The patient complained of headache for a few days but fortunately did not have any neurologic symptoms. (e) Follow-up angiogram of the left external carotid artery shows complete obliteration of the transverse-sigmoid sinus dural AVF. (f) Left internal carotid arteriogram shows complete obliteration of the dural AVFs involving the superior petrosal sinus.

View larger version (146K): [in a new window]   Figure 2e.  Complication associated with subdural hematoma from TVE. (a) Left external carotid arteriogram shows a transverse sinus dural AVF fed by the left occipital, superficial temporal, and middle meningeal arteries. The AVF drains into the left jugular vein and cortical veins. (b) Left internal carotid arteriogram shows two dural AVFs (arrows) fed by the left ascending pharyngeal artery and the meningohypophyseal artery, respectively. The AVFs drain into the superior petrosal sinus (arrowheads). (c) Fluoroscopic image obtained during placement of a coil into the superior venous pouch contiguous with the superior petrous sinus demonstrates that the distal edge of the coil did not form a loop (arrow). As a result, the coil probably penetrated the venous wall. The transverse sinus and inferior venous pouch around the superior petrous sinus were already packed with coils. (d) Computed tomographic (CT) scan obtained 1 day after embolization shows a subdural hematoma at the left cerebral convexity and the falx. The patient complained of headache for a few days but fortunately did not have any neurologic symptoms. (e) Follow-up angiogram of the left external carotid artery shows complete obliteration of the transverse-sigmoid sinus dural AVF. (f) Left internal carotid arteriogram shows complete obliteration of the dural AVFs involving the superior petrosal sinus.

View larger version (156K): [in a new window]   Figure 2f.  Complication associated with subdural hematoma from TVE. (a) Left external carotid arteriogram shows a transverse sinus dural AVF fed by the left occipital, superficial temporal, and middle meningeal arteries. The AVF drains into the left jugular vein and cortical veins. (b) Left internal carotid arteriogram shows two dural AVFs (arrows) fed by the left ascending pharyngeal artery and the meningohypophyseal artery, respectively. The AVFs drain into the superior petrosal sinus (arrowheads). (c) Fluoroscopic image obtained during placement of a coil into the superior venous pouch contiguous with the superior petrous sinus demonstrates that the distal edge of the coil did not form a loop (arrow). As a result, the coil probably penetrated the venous wall. The transverse sinus and inferior venous pouch around the superior petrous sinus were already packed with coils. (d) Computed tomographic (CT) scan obtained 1 day after embolization shows a subdural hematoma at the left cerebral convexity and the falx. The patient complained of headache for a few days but fortunately did not have any neurologic symptoms. (e) Follow-up angiogram of the left external carotid artery shows complete obliteration of the transverse-sigmoid sinus dural AVF. (f) Left internal carotid arteriogram shows complete obliteration of the dural AVFs involving the superior petrosal sinus.

View larger version (58K): [in a new window]   Figure 3.  Drawing shows venous drainage of cavernous sinus dural AVFs. 1 = anterior drainage into superior ophthalmic vein (SOV) and inferior ophthalmic vein (IOV), which can lead to ocular symptoms (eg, exophthalmos and chemosis); 2 = posteroinferior drainage into inferior petrous sinus (IPS), basilar plexus, and pterygoid plexus, leading to bruit and cranial nerve deficits; 3 = posterior drainage into superior petrous sinus (SPS), leading to bruit; 4 = cortical reflux into sphenoparietal sinus and superficial middle cerebral vein (SMV), leading to venous infarction and hemorrhage; 5 = cerebellar (spinal) drainage into petrous vein (PV), leading to ataxia and hemorrhage; and 6 = deep drainage into deep middle cerebral vein and uncal vein, leading to hemorrhage. JV = jugular vein, SS = sigmoid sinus, STV = superficial temporal vein.

View larger version (153K): [in a new window]   Figure 4a.  Cavernous sinus dural AVF with dominant cerebellar venous drainage. (a) Right external carotid arteriogram shows a cavernous sinus dural AVF draining into the superior ophthalmic vein and cerebellar veins via the superior petrosal sinus (arrow). (b) Right external carotid arteriogram obtained after TVE through an occluded inferior petrosal sinus shows obliteration of the dural AVF.

View larger version (142K): [in a new window]   Figure 4b.  Cavernous sinus dural AVF with dominant cerebellar venous drainage. (a) Right external carotid arteriogram shows a cavernous sinus dural AVF draining into the superior ophthalmic vein and cerebellar veins via the superior petrosal sinus (arrow). (b) Right external carotid arteriogram obtained after TVE through an occluded inferior petrosal sinus shows obliteration of the dural AVF.

View larger version (165K): [in a new window]   Figure 5a.  Spontaneous regression of a cavernous sinus dural AVF with posterior drainage. (a) T2-weighted magnetic resonance (MR) image shows multiple flow voids in the posterior cavernous sinus (arrows). (b) Left external carotid arteriogram shows a cavernous sinus dural AVF with posterior drainage into the inferior and superior petrosal sinuses (arrows). (c) Follow-up MR image shows resolution of the flow voids.

View larger version (203K): [in a new window]   Figure 5b.  Spontaneous regression of a cavernous sinus dural AVF with posterior drainage. (a) T2-weighted magnetic resonance (MR) image shows multiple flow voids in the posterior cavernous sinus (arrows). (b) Left external carotid arteriogram shows a cavernous sinus dural AVF with posterior drainage into the inferior and superior petrosal sinuses (arrows). (c) Follow-up MR image shows resolution of the flow voids.

View larger version (159K): [in a new window]   Figure 5c.  Spontaneous regression of a cavernous sinus dural AVF with posterior drainage. (a) T2-weighted magnetic resonance (MR) image shows multiple flow voids in the posterior cavernous sinus (arrows). (b) Left external carotid arteriogram shows a cavernous sinus dural AVF with posterior drainage into the inferior and superior petrosal sinuses (arrows). (c) Follow-up MR image shows resolution of the flow voids.

View larger version (177K): [in a new window]   Figure 6a.  TVE via an occluded inferior petrosal sinus with changes in the drainage pattern of a cavernous sinus dural AVF. (a) Left external carotid angiogram shows a cavernous sinus dural AVF draining mainly into the inferior petrosal sinus (arrows) and pterygopharyngeal plexus (arrowheads). (b) Follow-up angiogram obtained 3 months later shows significant changes in the drainage pattern. The inferior petrosal sinus is occluded, and the dural AVF now drains into the superior ophthalmic vein (arrows) and the superficial middle cerebral vein (arrowheads). Although the patient’s symptoms (mild chemosis, proptosis, diplopia) were unchanged during follow-up, occlusion of the dural AVF was indicated because of the change into a dangerous drainage pattern. (c) Superselective venogram shows the tip of a microcatheter that has been introduced into the cavernous sinus outlets to the superficial middle cerebral vein. (d) Superselective venogram shows that the tip of the microcatheter has been introduced into the outlets to the superior ophthalmic vein. Note that the microcatheter has been advanced through the occluded sinus. (e) Left common carotid angiogram obtained after TVE shows complete occlusion of the dural AVF. Before placement of the coils, it is important to determine whether a microcatheter can be introduced into all outlets of the cavernous sinus.

View larger version (173K): [in a new window]   Figure 6b.  TVE via an occluded inferior petrosal sinus with changes in the drainage pattern of a cavernous sinus dural AVF. (a) Left external carotid angiogram shows a cavernous sinus dural AVF draining mainly into the inferior petrosal sinus (arrows) and pterygopharyngeal plexus (arrowheads). (b) Follow-up angiogram obtained 3 months later shows significant changes in the drainage pattern. The inferior petrosal sinus is occluded, and the dural AVF now drains into the superior ophthalmic vein (arrows) and the superficial middle cerebral vein (arrowheads). Although the patient’s symptoms (mild chemosis, proptosis, diplopia) were unchanged during follow-up, occlusion of the dural AVF was indicated because of the change into a dangerous drainage pattern. (c) Superselective venogram shows the tip of a microcatheter that has been introduced into the cavernous sinus outlets to the superficial middle cerebral vein. (d) Superselective venogram shows that the tip of the microcatheter has been introduced into the outlets to the superior ophthalmic vein. Note that the microcatheter has been advanced through the occluded sinus. (e) Left common carotid angiogram obtained after TVE shows complete occlusion of the dural AVF. Before placement of the coils, it is important to determine whether a microcatheter can be introduced into all outlets of the cavernous sinus.

View larger version (167K): [in a new window]   Figure 6c.  TVE via an occluded inferior petrosal sinus with changes in the drainage pattern of a cavernous sinus dural AVF. (a) Left external carotid angiogram shows a cavernous sinus dural AVF draining mainly into the inferior petrosal sinus (arrows) and pterygopharyngeal plexus (arrowheads). (b) Follow-up angiogram obtained 3 months later shows significant changes in the drainage pattern. The inferior petrosal sinus is occluded, and the dural AVF now drains into the superior ophthalmic vein (arrows) and the superficial middle cerebral vein (arrowheads). Although the patient’s symptoms (mild chemosis, proptosis, diplopia) were unchanged during follow-up, occlusion of the dural AVF was indicated because of the change into a dangerous drainage pattern. (c) Superselective venogram shows the tip of a microcatheter that has been introduced into the cavernous sinus outlets to the superficial middle cerebral vein. (d) Superselective venogram shows that the tip of the microcatheter has been introduced into the outlets to the superior ophthalmic vein. Note that the microcatheter has been advanced through the occluded sinus. (e) Left common carotid angiogram obtained after TVE shows complete occlusion of the dural AVF. Before placement of the coils, it is important to determine whether a microcatheter can be introduced into all outlets of the cavernous sinus.

View larger version (154K): [in a new window]   Figure 6d.  TVE via an occluded inferior petrosal sinus with changes in the drainage pattern of a cavernous sinus dural AVF. (a) Left external carotid angiogram shows a cavernous sinus dural AVF draining mainly into the inferior petrosal sinus (arrows) and pterygopharyngeal plexus (arrowheads). (b) Follow-up angiogram obtained 3 months later shows significant changes in the drainage pattern. The inferior petrosal sinus is occluded, and the dural AVF now drains into the superior ophthalmic vein (arrows) and the superficial middle cerebral vein (arrowheads). Although the patient’s symptoms (mild chemosis, proptosis, diplopia) were unchanged during follow-up, occlusion of the dural AVF was indicated because of the change into a dangerous drainage pattern. (c) Superselective venogram shows the tip of a microcatheter that has been introduced into the cavernous sinus outlets to the superficial middle cerebral vein. (d) Superselective venogram shows that the tip of the microcatheter has been introduced into the outlets to the superior ophthalmic vein. Note that the microcatheter has been advanced through the occluded sinus. (e) Left common carotid angiogram obtained after TVE shows complete occlusion of the dural AVF. Before placement of the coils, it is important to determine whether a microcatheter can be introduced into all outlets of the cavernous sinus.

View larger version (182K): [in a new window]   Figure 6e.  TVE via an occluded inferior petrosal sinus with changes in the drainage pattern of a cavernous sinus dural AVF. (a) Left external carotid angiogram shows a cavernous sinus dural AVF draining mainly into the inferior petrosal sinus (arrows) and pterygopharyngeal plexus (arrowheads). (b) Follow-up angiogram obtained 3 months later shows significant changes in the drainage pattern. The inferior petrosal sinus is occluded, and the dural AVF now drains into the superior ophthalmic vein (arrows) and the superficial middle cerebral vein (arrowheads). Although the patient’s symptoms (mild chemosis, proptosis, diplopia) were unchanged during follow-up, occlusion of the dural AVF was indicated because of the change into a dangerous drainage pattern. (c) Superselective venogram shows the tip of a microcatheter that has been introduced into the cavernous sinus outlets to the superficial middle cerebral vein. (d) Superselective venogram shows that the tip of the microcatheter has been introduced into the outlets to the superior ophthalmic vein. Note that the microcatheter has been advanced through the occluded sinus. (e) Left common carotid angiogram obtained after TVE shows complete occlusion of the dural AVF. Before placement of the coils, it is important to determine whether a microcatheter can be introduced into all outlets of the cavernous sinus.

View larger version (183K): [in a new window]   Figure 7a.  TVE with an anterior approach via the superficial temporal vein. (a) Left carotid angiogram shows a cavernous sinus dural AVF draining into the superior ophthalmic vein, the facial vein (arrowheads), and the superficial temporal vein (arrows). Note the occlusion of the inferior petrosal sinus. (b) Superselective venogram shows a microcatheter that has been advanced through the superficial temporal and superior ophthalmic veins into the posterior compartment of the cavernous sinus. The dural AVF was completely obliterated with subsequent coil embolization.

View larger version (154K): [in a new window]   Figure 7b.  TVE with an anterior approach via the superficial temporal vein. (a) Left carotid angiogram shows a cavernous sinus dural AVF draining into the superior ophthalmic vein, the facial vein (arrowheads), and the superficial temporal vein (arrows). Note the occlusion of the inferior petrosal sinus. (b) Superselective venogram shows a microcatheter that has been advanced through the superficial temporal and superior ophthalmic veins into the posterior compartment of the cavernous sinus. The dural AVF was completely obliterated with subsequent coil embolization.

View larger version (38K): [in a new window]   Figure 8.  Drawings illustrate a classification scheme for transverse-sigmoid sinus dural AVFs that is based on venous drainage patterns: Grade 1, antegrade sinus drainage without venous restriction or cortical venous reflux; Grade 2, antegrade and retrograde sinus drainage with or without cortical venous reflux; Grade 3, retrograde sinus drainage with cortical venous reflux; and Grade 4, cortical venous reflux only. (Reprinted, with permission, from reference 11.)

View larger version (163K): [in a new window]   Figure 9a.  Recanalization of a grade 3 transverse-sigmoid sinus dural AVF after TVE. (a) Early arterial phase left common carotid angiogram shows a Grade 3 transverse-sigmoid sinus dural AVF. (b) Late arterial phase left common carotid angiogram shows that the left sigmoid sinus is occluded (arrow) and the dural AVF drains mainly into cortical veins and the posterior condylar vein (arrowheads). (c) Superselective venogram shows a microcatheter that has been advanced via the posterior condylar vein (arrowheads) into the affected sinus. (d) Left common carotid angiogram obtained after TVE shows disappearance of the AVF. (e) CT scan obtained 2 months after TVE shows a massive hemorrhage in the left temporal lobe. (f) Left common carotid angiogram shows recanalization of the dural AVF at the retrograde cortical drainage outlet (arrows).

View larger version (163K): [in a new window]   Figure 9b.  Recanalization of a grade 3 transverse-sigmoid sinus dural AVF after TVE. (a) Early arterial phase left common carotid angiogram shows a Grade 3 transverse-sigmoid sinus dural AVF. (b) Late arterial phase left common carotid angiogram shows that the left sigmoid sinus is occluded (arrow) and the dural AVF drains mainly into cortical veins and the posterior condylar vein (arrowheads). (c) Superselective venogram shows a microcatheter that has been advanced via the posterior condylar vein (arrowheads) into the affected sinus. (d) Left common carotid angiogram obtained after TVE shows disappearance of the AVF. (e) CT scan obtained 2 months after TVE shows a massive hemorrhage in the left temporal lobe. (f) Left common carotid angiogram shows recanalization of the dural AVF at the retrograde cortical drainage outlet (arrows).

View larger version (169K): [in a new window]   Figure 9c.  Recanalization of a grade 3 transverse-sigmoid sinus dural AVF after TVE. (a) Early arterial phase left common carotid angiogram shows a Grade 3 transverse-sigmoid sinus dural AVF. (b) Late arterial phase left common carotid angiogram shows that the left sigmoid sinus is occluded (arrow) and the dural AVF drains mainly into cortical veins and the posterior condylar vein (arrowheads). (c) Superselective venogram shows a microcatheter that has been advanced via the posterior condylar vein (arrowheads) into the affected sinus. (d) Left common carotid angiogram obtained after TVE shows disappearance of the AVF. (e) CT scan obtained 2 months after TVE shows a massive hemorrhage in the left temporal lobe. (f) Left common carotid angiogram shows recanalization of the dural AVF at the retrograde cortical drainage outlet (arrows).

View larger version (179K): [in a new window]   Figure 9d.  Recanalization of a grade 3 transverse-sigmoid sinus dural AVF after TVE. (a) Early arterial phase left common carotid angiogram shows a Grade 3 transverse-sigmoid sinus dural AVF. (b) Late arterial phase left common carotid angiogram shows that the left sigmoid sinus is occluded (arrow) and the dural AVF drains mainly into cortical veins and the posterior condylar vein (arrowheads). (c) Superselective venogram shows a microcatheter that has been advanced via the posterior condylar vein (arrowheads) into the affected sinus. (d) Left common carotid angiogram obtained after TVE shows disappearance of the AVF. (e) CT scan obtained 2 months after TVE shows a massive hemorrhage in the left temporal lobe. (f) Left common carotid angiogram shows recanalization of the dural AVF at the retrograde cortical drainage outlet (arrows).

View larger version (133K): [in a new window]   Figure 9e.  Recanalization of a grade 3 transverse-sigmoid sinus dural AVF after TVE. (a) Early arterial phase left common carotid angiogram shows a Grade 3 transverse-sigmoid sinus dural AVF. (b) Late arterial phase left common carotid angiogram shows that the left sigmoid sinus is occluded (arrow) and the dural AVF drains mainly into cortical veins and the posterior condylar vein (arrowheads). (c) Superselective venogram shows a microcatheter that has been advanced via the posterior condylar vein (arrowheads) into the affected sinus. (d) Left common carotid angiogram obtained after TVE shows disappearance of the AVF. (e) CT scan obtained 2 months after TVE shows a massive hemorrhage in the left temporal lobe. (f) Left common carotid angiogram shows recanalization of the dural AVF at the retrograde cortical drainage outlet (arrows).

View larger version (154K): [in a new window]   Figure 9f.  Recanalization of a grade 3 transverse-sigmoid sinus dural AVF after TVE. (a) Early arterial phase left common carotid angiogram shows a Grade 3 transverse-sigmoid sinus dural AVF. (b) Late arterial phase left common carotid angiogram shows that the left sigmoid sinus is occluded (arrow) and the dural AVF drains mainly into cortical veins and the posterior condylar vein (arrowheads). (c) Superselective venogram shows a microcatheter that has been advanced via the posterior condylar vein (arrowheads) into the affected sinus. (d) Left common carotid angiogram obtained after TVE shows disappearance of the AVF. (e) CT scan obtained 2 months after TVE shows a massive hemorrhage in the left temporal lobe. (f) Left common carotid angiogram shows recanalization of the dural AVF at the retrograde cortical drainage outlet (arrows).

View larger version (158K): [in a new window]   Figure 10a.  Type IV tentorial dural AVF with intracranial hemorrhage. (a) Unenhanced CT scan shows intracranial hemorrhage in the left occipital lobe and the lateral ventricle. (b) Left external carotid angiogram shows a tentorial dural AVF (arrowheads) with leptomeningeal-cortical venous drainage and venous ectasia (arrow). (c) Digital subtraction angiogram obtained during the injection of diluted n-butyl-2 cyanoacrylate demonstrates the tip of a microcatheter (arrow). (d) Left common carotid angiogram obtained after TAE shows complete obliteration of the AVF.

View larger version (128K): [in a new window]   Figure 10b.  Type IV tentorial dural AVF with intracranial hemorrhage. (a) Unenhanced CT scan shows intracranial hemorrhage in the left occipital lobe and the lateral ventricle. (b) Left external carotid angiogram shows a tentorial dural AVF (arrowheads) with leptomeningeal-cortical venous drainage and venous ectasia (arrow). (c) Digital subtraction angiogram obtained during the injection of diluted n-butyl-2 cyanoacrylate demonstrates the tip of a microcatheter (arrow). (d) Left common carotid angiogram obtained after TAE shows complete obliteration of the AVF.

View larger version (149K): [in a new window]   Figure 10c.  Type IV tentorial dural AVF with intracranial hemorrhage. (a) Unenhanced CT scan shows intracranial hemorrhage in the left occipital lobe and the lateral ventricle. (b) Left external carotid angiogram shows a tentorial dural AVF (arrowheads) with leptomeningeal-cortical venous drainage and venous ectasia (arrow). (c) Digital subtraction angiogram obtained during the injection of diluted n-butyl-2 cyanoacrylate demonstrates the tip of a microcatheter (arrow). (d) Left common carotid angiogram obtained after TAE shows complete obliteration of the AVF.

View larger version (135K): [in a new window]   Figure 10d.  Type IV tentorial dural AVF with intracranial hemorrhage. (a) Unenhanced CT scan shows intracranial hemorrhage in the left occipital lobe and the lateral ventricle. (b) Left external carotid angiogram shows a tentorial dural AVF (arrowheads) with leptomeningeal-cortical venous drainage and venous ectasia (arrow). (c) Digital subtraction angiogram obtained during the injection of diluted n-butyl-2 cyanoacrylate demonstrates the tip of a microcatheter (arrow). (d) Left common carotid angiogram obtained after TAE shows complete obliteration of the AVF.

View larger version (139K): [in a new window]   Figure 11a.  Type IV tentorial dural AVF. (a) Left external carotid angiogram shows a tentorial dural AVF with leptomeningeal-cortical venous drainage and venous ectasia. (b) Lateral radiograph shows the planned radiation field. Because of the poor general condition of the patient, the AVF was treated with conventional irradiation (total dose, 30 Gy). (c) Left common carotid angiogram obtained 8 months after radiation therapy shows complete obliteration of the tentorial dural AVF.

View larger version (118K): [in a new window]   Figure 11b.  Type IV tentorial dural AVF. (a) Left external carotid angiogram shows a tentorial dural AVF with leptomeningeal-cortical venous drainage and venous ectasia. (b) Lateral radiograph shows the planned radiation field. Because of the poor general condition of the patient, the AVF was treated with conventional irradiation (total dose, 30 Gy). (c) Left common carotid angiogram obtained 8 months after radiation therapy shows complete obliteration of the tentorial dural AVF.

View larger version (170K): [in a new window]   Figure 11c.  Type IV tentorial dural AVF. (a) Left external carotid angiogram shows a tentorial dural AVF with leptomeningeal-cortical venous drainage and venous ectasia. (b) Lateral radiograph shows the planned radiation field. Because of the poor general condition of the patient, the AVF was treated with conventional irradiation (total dose, 30 Gy). (c) Left common carotid angiogram obtained 8 months after radiation therapy shows complete obliteration of the tentorial dural AVF.

View larger version (179K): [in a new window]   Figure 12a.  Superior sagittal sinus dural AVF. (a) Right external carotid angiogram shows a dural AVF with cortical reflux and occlusion of the superior sagittal sinus. (b) Right external carotid angiogram obtained during transarterial sinus embolization shows a microcatheter that has been advanced into the superior sagittal sinus via the right middle meningeal artery (arrows). (c) Right external carotid angiogram obtained after embolization shows obliteration of the AVF.

View larger version (148K): [in a new window]   Figure 12b.  Superior sagittal sinus dural AVF. (a) Right external carotid angiogram shows a dural AVF with cortical reflux and occlusion of the superior sagittal sinus. (b) Right external carotid angiogram obtained during transarterial sinus embolization shows a microcatheter that has been advanced into the superior sagittal sinus via the right middle meningeal artery (arrows). (c) Right external carotid angiogram obtained after embolization shows obliteration of the AVF.

View larger version (164K): [in a new window]   Figure 12c.  Superior sagittal sinus dural AVF. (a) Right external carotid angiogram shows a dural AVF with cortical reflux and occlusion of the superior sagittal sinus. (b) Right external carotid angiogram obtained during transarterial sinus embolization shows a microcatheter that has been advanced into the superior sagittal sinus via the right middle meningeal artery (arrows). (c) Right external carotid angiogram obtained after embolization shows obliteration of the AVF.

View larger version (161K): [in a new window]   Figure 13a.  Anterior fossa dural AVF. (a) Unenhanced CT scan shows intracranial hemorrhage at the frontal base. (b) Left internal carotid angiogram shows a dural AVF (arrow) that is fed by the ethmoidal artery and drains into the leptomeningeal vein, which demonstrates varices (arrowheads). (c) Left internal carotid angiogram obtained after clipping of the draining vein shows disappearance of the AVF.

View larger version (191K): [in a new window]   Figure 13b.  Anterior fossa dural AVF. (a) Unenhanced CT scan shows intracranial hemorrhage at the frontal base. (b) Left internal carotid angiogram shows a dural AVF (arrow) that is fed by the ethmoidal artery and drains into the leptomeningeal vein, which demonstrates varices (arrowheads). (c) Left internal carotid angiogram obtained after clipping of the draining vein shows disappearance of the AVF.

View larger version (183K): [in a new window]   Figure 13c.  Anterior fossa dural AVF. (a) Unenhanced CT scan shows intracranial hemorrhage at the frontal base. (b) Left internal carotid angiogram shows a dural AVF (arrow) that is fed by the ethmoidal artery and drains into the leptomeningeal vein, which demonstrates varices (arrowheads). (c) Left internal carotid angiogram obtained after clipping of the draining vein shows disappearance of the AVF.