Endovascular treatment of a grade IV transverse sinus dural arteriovenous fistula by sinus recanalization, angioplasty, and stent placement: Technical case report

OBJECTIVE AND IMPORTANCE: The frequent association of dural arteriovenous fistulae (DAVFs) and dural sinus thrombosis may render the treatment of these complex lesions difficult. We report a case of DAVF eradicated by recanalization of the chronically thrombosed transverse sinus (TS) and sigmoid sinus followed by balloon angioplasty and stent deployment at the site of the fistula. CLINICAL PRESENTATION: A 52-year-old man presented with a Type IV DAVF of the left TS with widespread white matter changes secondary to venous hypertension. Arterial feeders arose from the left internal carotid, external carotid, and vertebral arteries. The distal segment of the left TS, the left sigmoid sinus, and the proximal segment of the right TS were occluded. Reverse flow was observed in the deep venous system and in the superior sagittal sinus. INTERVENTION: Endovascular access was gained through the left internal jugular vein. Mechanical recanalization of the thrombosed left TS and sigmoid sinus was followed by balloon angioplasty and placement of six overlapping stents extending from the TS to the proximal internal jugular vein. Angiograms performed after surgery showed resaturation of antegrade venous drainage as well as complete eradication of the fistulous connections. The patient was discharged with an improving clinical status. CONCLUSION: Recanalization of a chronically occluded dural venous sinus through a jugular approach is feasible. In addition to eradicating cerebral venous hypertension by reestablishing antegrade venous drainage, balloon angioplasty and stent deployment at the DAVF site produced complete closure of the fistula. This may prove to be a new therapeutic strategy for management of DAVF.