Single-session hematoma removal and transcortical venous approach for coil embolization of an isolated transverse-sigmoid sinus dural arteriovenous fistula in a hybrid operating room: illustrative case

Abstract

Background: Dural arteriovenous fistula (DAVF) can present with massive hematoma, which sometimes requires emergent removal. Therefore, a surgical strategy for single-session hematoma removal and shunt occlusion in the same surgical field is important.

Observations: A 73-year-old man was transferred to the authors' hospital with a headache. Brain computed tomography (CT) revealed an intracerebral hematoma in the right temporoparietal lobe (hematoma volume 12 ml). A cerebral angiogram revealed a right isolated transverse-sigmoid sinus (TSS)-DAVF fed by the occipital artery and middle meningeal artery. There was cortical venous reflux into the Labbé vein and posterior parietal vein. Percutaneous transarterial and transvenous embolization were unsuccessful. The following day, his consciousness level acutely declined with a headache, and brain CT showed hematoma expansion (hematoma volume 41 ml) with a midline shift. Therefore, the authors performed single-session hematoma removal and a transcortical venous approach for coil embolization of an isolated TSS-DAVF in a hybrid operating room. His postoperative course was uneventful. No recurrence was observed 3 months postoperatively on cerebral angiography.

Lessons: Single-session hematoma removal and a transcortical venous approach for coil embolization of an isolated TSS-DAVF is considered in cases with massive hematoma. This strategy is useful, considering recent developments in hybrid operating rooms.

Keywords: CT = computed tomography; CVR = cortical venous reflux; DAVF = dural arteriovenous fistula; TAE = transarterial embolization; TSS = transverse-sigmoid sinus; TVE = transvenous embolization; cerebral hemorrhage; dural arteriovenous fistula; transcortical venous approach; transverse sinus.

FIG. 1.

A: Brain CT performed on the day of hospitalization showing an intracerebral hematoma in the temporoparietal lobe with slight subdural hematoma and subarachnoid hemorrhage. B: Right external carotid artery angiogram showing isolated TSS-DAVF with feeding vessels from the occipital and middle meningeal arteries. The fistula drains into the vein of Labbé (arrow) and posterior parietal vein (arrowhead).

FIG. 2.

Preoperative brain CT (A) showing hematoma enlargement with midline shift. Postoperative CT (B) showing temporoparietal craniotomy with U-shaped skin incision. Intraoperative photograph (C) and intra-arterial superselective indocyanine green video angiography (D) show the arterialized vein of Labbé (arrow) and posterior parietal vein (arrowhead) as seen on cerebral angiogram. The arterialized vein of Labbé was isolated for direct puncture (E). An 18-gauge needle was placed into the vein of Labbé, and 5-0 silken thread was tied (F).

FIG. 3.

A: Intraoperative external carotid angiography (ECAG) showing right TSS-DAVF with cortical venous reflux. Arrow indicates the puncture point of the vein of Labbé. Arrowhead points to the shunt pouch adjacent to the transverse sinus. B: The microcatheter was advanced into the shunt pouch via the Labbé vein, and coil embolization was performed. C: Intraoperative ECAG showing disappearance of arteriovenous shunt. D: Plain angiogram, lateral view, showing the coils in the shunt pouch.

FIG. 4.

The arterialized vein of Labbé with extensive hyperplasia of media on hematoxylin and eosin staining (A) and Elastica van Gieson staining (B). Bars = 500 µm.