Purpose Dural arteriovenous fistulas (dAVF) are rare vascular malformations with increased risk of hemorrhage with higher Cognard grading. Transarterial and transvenous embolizations are commonly used in their treatment. Embolization of the common collector arterial channel within the sinus wall allows for minimal disruption of surrounding vessels. Complete eradication of shunting is quite challenging in high‐grade dAVF given multiple arterial feeders into the venous system (1). Here we present a case of a 64‐year‐old woman who underwent successful embolization of high‐grade dural AVF by directly accessing the common collector site. Materials/Methods A 64‐year‐old woman with no medical history presented with left hemibody numbness and was found to have a right thalamic hemorrhage. Her symptoms acutely worsened with new left‐sided weakness, somnolence, and left eye esotropia. Imaging demonstrated increasing hemorrhage with enlargement of the supratentorial ventricles with obstructive hydrocephalus in the setting of extensive complex cerebrovascular malformation with a bilobed thrombosed aneurysm along the vein of Rosenthal with mass effect on the right midbrain and thalamus. Results Emergent digital subtraction angiography (DSA) demonstrated Cognard grade IV dural arteriovenous fistula with arterial feeders from both middle meningeal arteries predominantly, occipital arteries, Bernosconi and Cassinari, and posterior meningeal arteries with large venous varices of the vein of Galen and basal vein of Rosenthal. The dAVF was treated with Onyx embolization through the right parietal branch of the middle meningeal artery (MMA) by identifying the common collector channel, traversing it and reaching the straight sinus. As embolization material was being translocated due to high flow, a different branch of parietal MMA was chosen and embolized despite its diminutive caliber. Despite great penetration, early venous drainage was noted. A trial run of the external carotid artery performed to attempt catheterization of the petrosquamosal branch of the MMA demonstrated no residual shunting, possibly representing a delayed thrombosis of the fistula, completing the procedure successfully. Patient recovered and motor strength improved to 4/5 on the left hemibody at the time of discharge compared to 3/5 day of arrival and sensation remained same. Repeat evaluation at 3 months demonstrated return to neurologic baseline and delayed angiography demonstrated no residual arteriovenous shunting. Conclusion Dural arteriovenous fistulas can present with rapidly evolving neurologic symptoms and transarterial embolization of the strategically identified common collector site can result in successful, precise embolization with minimal collateral impact, even in high‐grade fistulas. This reinforces the importance of direct access of the common collector site for the arterial feeds as a target for successful embolization. 1. Shapiro, M., Raz, E., Litao, M., Becske, T., Riina, H., & Nelson, P. K. (2018). Toward a Better Understanding of Dural Arteriovenous Fistula Angioarchitecture: Superselective Transvenous Embolization of a Sigmoid Common Arterial Collector. AJNR. American journal of neuroradiology, 39(9), 1682‐1688. https://doi.org/10.3174/ajnr.A5740
Daniel A. Tonetti (Sat,) studied this question.