Burr-hole assisted direct transcranial Onyx embolization of an isolated transverse sinus dural arteriovenous fistula

Introduction

Treating dural arteriovenous fistulas (DAVFs) with endovascular embolization has proven to be effective. However, in cases where the DAVF is isolated or inaccessible via conventional endovascular methods, a combined surgical and endovascular approach may be necessary. This strategy provides a direct approach to the venous system and bypasses the site of sinus occlusion.

Methods

In this report, we present a case of direct Onyx embolization after navigated cannulation of the transverse sinus (TS) for the treatment of a left TS DAVF, along with a review of the literature on transcranial endovascular treatment of DAVF.

Results

The isolated TS was embolized with Onyx, filling both supratentorial and infratentorial draining cortical varices. The patient tolerated the procedure well, and follow-up angiography revealed no DAVF recurrence.

Discussion

Onyx has been used in very few case reports for transcranial DAVF embolization, even though its higher viscosity characteristics offer better control over distal migration at the possible cost of decreased penetration of the targeted lesion. When using coils, the sinus exposure must be long enough to allow for puncture at a certain distance from the DAVF. The superficial location of the isolated TS allowed us to use a syringe filled with Onyx to directly obliterate the sinus during a single burr-hole craniotomy.

Conclusions

This combined strategy might be a practical and efficient way to treat DAVFs with sinus occlusion. It can serve as the primary treatment option when addressing a DAVF involving a superficial sinus with drainage disconnected from both internal jugular veins.