Transarterial Wedged-catheter, Flow-arrest, N-butyl Cyanoacrylate Embolization of Three Dural Arteriovenous Fistulae in a Single Patient

Abstract

The pathogenesis of dural arteriovenous fistulas (DAVFs) is currently unknown, with multiple DAVFs being rare. For patients with limited venous access secondary to sinus thrombosis, or for patients where parent sinus occlusion would not be tolerated, transvenous embolization may not be possible and other treatment methods must be considered. A 69-year-old female patient with a two-year history of progressive headaches, memory loss, and unsteady gait underwent cerebral angiography that revealed three separate DAVFs with congested cortical venous drainage overlying both frontal lobes. Using an application of a transarterial wedged-catheter, flow-arrest technique, N-butyl cyanoacrylate was deposited across all three pathologic arteriovenous connections providing a definitive cure. Transarterial NBCA embolization may provide curative treatment of DAVFs, and is of particular utility in situations where access to the draining venous structures is limited.

Figure 1

Pre-embolization right common carotid injection, frontal (A) and lateral (B) projections, demonstrating three separate DAVFs with direct cortical venous drainage. The location of each fistula is indicated (black arrows). A selective right external carotid injection, frontal (C) and lateral (D) projections, characterizes the arterial feeders and venous drainage of each fistula. In the frontal projection (C), DAVF #1 (anterior falcial) is fed by the right anterior falcial artery (large white arrows) and drains into left hemisphere cortical veins (large black arrows). DAVF #2 (right parasagittal) is fed by a branch of the right middle meningeal artery (small white arrows) and drains into a right hemisphere cortical vein (small black arrows). DAVF #3 (right middle frontal) is fed by a branch of the right middle meningeal artery (white arrowheads) and drains into a right hemisphere cortical vein (black arrowheads) and then into a right Sylvian vein. In the lateral projection (D), the arterial feeder (white arrowheads) and venous drainage (black arrowheads) of DAVF #3 is evident. The location of DAVF #1 (white star) and DAVF #2 (black star) is also illustrated. (E) Lateral projection, selective left ophthalmic artery injection demonstrates arterial supply to DAVF #1 via the anterior falcial artery (black arrows). The pathological arteriovenous connection is evident (black star), as is the microcatheter in the ophthalmic artery (white arrows). (F) Lateral projection, selective left middle meningeal injection, demonstrates additional arterial supply (black arrows) to DAVF #1 from the left middle meningeal artery (white arrows).

Figure 2

(A) Microinjection with the catheter wedged in an ethmoidal branch of the right ophthalmic artery, lateral projection, just prior to NBCA injection. The following structures are demonstrated: microcatheter within an ethmoidal artery (black arrowheads), anterior falcial artery (black arrows), pathological arteriovenous connection of DAVF #1 (white star), and cortical venous drainage (white arrows). (B) NBCA glue cast from the same microcatheter wedged in an ethmoidal division of the right ophthalmic artery, lateral projection radiograph. NBCA fills the ethmoidal branch distal to the wedged catheter tip, the anterior falcial artery (black arrows) and the proximal portion of the cortical draining vein (white arrows). The microcatheter track is also visible (black arrowheads). (C-F) Post-embolization control angiography following obliteration of all three DAVFs using flow-arrest NBCA injections from wedged-catheter positions. Right common carotid injection, lateral projection, early (C) and late (D) arterial phases. Left common carotid injection, lateral projection, early (C) and late (D) arterial phases. No evidence of arteriovenous shunting is present.

Figure 3

DAVF embolization techniques. (A) Schematic of a DAVF. (B) Proximal feeding artery occlusion with particulate embolization (no cure). (B) Transvenous coil embolisation of the parent venous structure (cure). (D) Transarterial wedged-catheter NBCA injection under flow-arrest conditions across the fistula entering the parent venous structure (cure).