Multidisciplinary Approach to Recalcitrant Dural AV Fistula

Dural arteriovenous fistulas (DAVF) most commonly arise from the junction of the transverse and sigmoid sinuses. Interventions typically include endovascular occlusion, open surgical management, and/or radiosurgical treatment. Endovascular intervention is often adequate for definitive management, but open surgical approaches may be required for more extensive disease. We present a case of 49-year-old male with an extensive left transverse-sigmoid junction DAVF (Cognard's II a + b) status post–two failed endovascular interventions and one failed hybrid approach who presented with symptoms of pulsatile tinnitus, headache, left eyelid ptosis, and evidence of persistent fistula on angiography. The patient underwent revision craniotomy via transtemporal approach to the posterior fossa. Drilling of the temporal bone was complicated by high flow vascular channels and vessels throughout. Ultimately, successful embolization of the fistula was performed using Onyx via direct access to the transverse sigmoid junction. Postoperative angiography showed complete resolution of arteriovenous shunting. This case highlights a complex, recalcitrant DAVF that required a hybrid approach among multiple surgeons for successful treatment.

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No conflict of interest has been declared by the author(s).

Publication History

Article published online:
12 February 2021