Staged Arterial and Venous Embolizations in Treatment of Type IV Intraosseous Dural Arteriovenous Fistula.

Objective: This is a case report of an adult male with complex type IV intraosseous DAVF causing severe venous hypertension and bony destruction, presenting with severe hemotympanum, and a novel way of staged arterial and venous embolizations to treat the emergent symptoms.

Methods: First and second stages were direct selective arterial embolizations using Onyx liquid agent. Goal was to reduce flow into the fistula by embolizing the feeder branch and distal penetration of the nidus with Onyx. The third stage was performed through the venous route: the transverse sinus and the sigmoid sinus were embolized using Penumbra Ruby coils and Onyx, two microcatheters were used and two large coils were placed simultaneously to form a stable coil mass, and the entire sinus was embolized using Coils and Onyx.

Results: Patient's venous hypertension and degree of hydrocephalus had significantly decreased after the procedure. He was able to return to work, but was instructed to avoid heavy lifting and placing anything in and around his right ear.

Conclusions: Multiple step arterial and venous embolization procedures were successful in decreasing the frequency of hemotympanum, degree of hydrocephalus, and improving quality of life of this patient.