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. 2016 Jun 3;7(Suppl 14):S410-4.
doi: 10.4103/2152-7806.183518. eCollection 2016.

Onyx removal after embolization of a superior sagittal sinus dural arteriovenous fistula involving scalp artery

Jun Watanabe  1 , Jun Maruya  1 , Keiichi Nishimaki  1 , Yasushi Ito  2
Affiliations

Onyx removal after embolization of a superior sagittal sinus dural arteriovenous fistula involving scalp artery

Jun Watanabe et al. Surg Neurol Int. .

Abstract

Background: Most dural arteriovenous fistula (DAVF) in superior sagittal sinus (SSS) requires multimodal treatment. Onyx embolization is useful for DAVF; however, scalp artery embolization has cast extrusion risk.

Case description: A 59-year-old male presented with involuntary movements of both legs and progressive dementia. Cerebral angiography demonstrated the DAVF in the SSS fed by bilateral superficial temporal, occipital, and middle meningeal arteries. The posterior SSS was thrombosed, and the main drainers were cortical veins. Combined treatment with transarterial embolization using Onyx and transvenous embolization using coils was performed. Although symptoms were improved, a small DAVF remained. Two months later, Onyx cast extrusion through the scalp was observed, requiring removal and debridement because of infection at the extrusion sites. Surgery for the residual DAVF would be difficult because of scalp condition; therefore, an additional endovascular treatment was conducted, completely occluding DAVF.

Conclusion: Onyx embolization is useful for DAVF; however, scalp artery embolization has cast extrusion risk. Therefore, scalp infection should be considered because it may preclude additional surgical procedures.

Keywords: Complication; Onyx; dural arteriovenous fistula; scalp artery; superior sagittal sinus.

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Figures

Figure 1
Figure 1
(a) Preoperative T2-weighted magnetic resonance image revealing multiple aberrant medullary veins. (b) Magnetic resonance angiography revealing expanded bilateral occipital arteries and superficial. (c) Iodine-123-N-isopropyl-p-iodoamphetamine single-photon emission computed tomography revealing hypoperfusion of bilateral vertex sides of the frontal, parietal, and occipital lobules
Figure 2
Figure 2
Angiographic images (lateral view). (a) Preoperative right external carotid angiography showing a dural arteriovenous fistula in the superior sagittal sinus fed by the right superficial temporal artery and thin middle meningeal artery. (b) Preoperative right external carotid angiography in the venous phase showing occlusion of the posterior one-third of superior sagittal sinus. The dural arteriovenous fistula is drained via anterograde flow by cortical and medullary veins into the vein of Labbe or deep venous system and subsequently into the vein of Galen. (c) Preoperative right occipital artery angiography showing the dural arteriovenous fistula fed by occipital artery
Figure 3
Figure 3
Angiographic images (anteroposterior view). (a) After the first embolization, right occipital artery angiography showing a residual dural arteriovenous fistula after left occipital artery and superficial temporal artery embolization using Onyx. (b) After the second embolization, right carotid artery angiography showing a reduction of the shunt and remaining drainer. Right occipital artery is occluded by Onyx. The proximal segment of the right occipital artery is highly tortuous. Compared to the left occipital artery, the right occipital artery is occluded from the proximal segment. The fistulous portion of superior sagittal sinus is packed using coils of various sizes. (c) After the third embolization, right external carotid angiography showing complete obliteration of the dural arteriovenous fistula. Residual dural arteriovenous fistula is occluded by Onyx. The Onyx cast in the right occipital artery was extruded
Figure 4
Figure 4
(a) A photograph showing regions of scalp erosion and swelling above occipital artery. (b) An intraoperative photograph showing naked Onyx casts
See this image and copyright information in PMC

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