Endovascular treatment of tentorial dural arteriovenous fistulae

Abstract

Tentorial dural arteriovenous fistula (DAVF) is a rare vascular disease, which accounts for less than 4% of all cases of intracranial DAVF. Because of the high risk of intracranial hemorrhage, patients with tentorial DAVF need aggressive treatment. Management approaches are still controversial, and endovascular treatment has emerged as an effective alternative. In the current work, we describe our experience with the endovascular approach in the treatment of these deep and complex DAVF of the tentorium. Eight patients were treated between January 2006 and July 2009. Six patients (75%) presented with intracranial hemorrhage related to the DAVF rupture. Four patients (50%) had subarachnoid bleeding and two had intraparenchymal hematoma. Endovascular treatment was performed via the transarterial route alone in five cases (62.5%), by the transvenous approach in two cases (25.0%) and in a combined procedure using both arterial and venous routes in one patient (12.5%). Complete obliteration of the fistula was achieved in all cases. The outcome at 15 months was favorable (modified Rankin scale 0-3) in seven (87.5%) patients. Complete cure of the lesion was confirmed in these cases. This paper reports on the effectiveness of endovascular treatment in tentorial DAVF management. The choice of the venous versus the arterial approach is determined by regarding different anatomical dispositions.

Figure 1

A) Vertebral artery angiogram (lateral view) revealing a tentorial dural arteriovenous fistula, with feeding arteries arising from the posterior meningeal artery. B) Venous phase, showing retrograde venous pial drainage to the Vermian veins. C) Transarterial embolization (anteroposterior view): a microcatheter was positioned through the middle meningeal artery to the fistulous zone. A total of 1.8 ml of Onyx^® was injected across the shunt to the venous side, leading to total occlusion of the shunt. D) Left vertebral artery injection (anteroposterior view, post-procedure), demonstrating complete obliteration of the fistula.

Figure 2

A) Brain MRI (axial FLAIR) depicting abnormal flow voids, which represent dilated veins in the cerebellopontine angle and along the medial border of the temporal lobe. B) Right internal carotid artery angiogram (lateral view) revealing a tentorial dural arteriovenous fistula, with feeding arteries arising from the internal carotid artery (marginal tentorial artery), and drainage into the leptomeningeal veins. C) Transvenous embolization: the microcatheter was positioned through the superior petrous sinus into the venous pouch, and coil occlusion was achieved. D) Right internal carotid artery angiogram, post-procedure, demonstrating obliteration of the fistula.