Elsevier

World Neurosurgery

Volume 107, November 2017, Pages 1050.e1-1050.e7
World Neurosurgery

Case Report
Medial Tentorial Dural Arteriovenous Fistula Embolization: Single Experience with Embolic Liquid Polymer SQUID and Review of the Literature

https://doi.org/10.1016/j.wneu.2017.08.050Get rights and content

Background

Tentorial dural arteriovenous fistulas (DAVFs) are uncommon, complex fistulas located between the leaves of the tentorium cerebelli with a specific anatomic and clinical presentation characterized by high hemorrhagic risk. We present a rare case of a medial tentorial DAVF successfully managed via transarterial embolization using SQUID liquid polymer.

Case Description

A 60-year-old woman presented with a history of left progressive hearing loss and tinnitus for >1 year. Cerebral angiography demonstrated the presence of a medial tentorial DAVF with multiple arterial feeders, including the artery of Davidoff and Schechter; reverse venous outflow was observed in the inferior sagittal sinus and in multiple cortical veins. The patient underwent transarterial embolization with SQUID liquid polymer, an embolic agent that provides 2 different viscous formulations to cast the DAVF. The procedure went well without any complication, and the patient regained her preoperative status. In the postprocedural period, the patient experienced complete resolution of tinnitus. At 6 months, she remained asymptomatic, and cerebral angiography confirmed complete, stable occlusion of the fistula and normalization of cerebral deep venous outflow.

Conclusions

Medial tentorial DAVFs are considered the most complex DAVFs because of their location and extensive vascular supply. Our literature review focused on endovascular treatment of tentorial DAVFs to highlight the usefulness of new embolic agents in management of these diseases. To our knowledge, we report the first successful use of SQUID liquid polymer in management of a tentorial DAVF.

Introduction

Tentorial dural arteriovenous fistulas (DAVFs) are uncommon, complex lesions characterized by an arteriovenous (AV) shunt located within the leaves of the tentorium cerebelli. Tentorial DAVFs constitute only 4%–8.4% of all AV cerebral dural fistulas, and they are considered the most complex type because of their location and the extensive vascular supply. Tentorial DAVFs have a very high incidence of hemorrhagic transformation compared with DAVFs in other locations, probably owing to their distinctive cortical venous drainage associated with intracranial venous hypertension.1 The treatment of tentorial DAVFs is focused on the precise disconnection of the fistula point; both surgical and endovascular therapeutic options are challenging because of the location of the AV shunt and the extensive arterial supply from dural and pial branches. In this article, we describe a successful transarterial embolization of a rare case of a medial tentorial DAVF achieved with a single injection of a novel liquid polymer from the middle meningeal artery (MMA), and we review the related literature.

Section snippets

Case Description

A 60-year-old woman was admitted to our hospital with a history of left progressive hearing loss and tinnitus for >1 year. The patient was referred to an ear, nose, and throat specialist. Dizziness or balance disorders were not present, and audiometry demonstrated only a left low-frequency hearing loss. Physical examination did not reveal any pulse murmur over the left mastoid region.

Brain magnetic resonance imaging showed a markedly enlarged cerebellar vein and abnormal prominent deep vessels (

Discussion

The incidence of tentorial DAVFs is 4%–8.4% among all cerebral AV dural fistulas, and DAVFs are considered to be the most complex type because of their location and extensive vascular supply.6 Compared with DAVFs in other locations, tentorial DAVF manifests the most aggressive neurologic behavior; the occurrence of intracranial hemorrhage is 60%–75%,1 including a fatal bleed in the posterior fossa.7 Consequently, tentorial DAVF must be treated aggressively when diagnosed, even in patients

Conclusions

To our knowledge, this is the first reported experience of management of a tentorial DAVF with SQUID liquid polymer. Transarterial embolization with SQUID in our limited experience showed a good durable angiographic result and postoperative outcome. Although it was unnecessary in our case, the use of SQUID 12, with a lower viscosity formulation, represents a potential advantage enabling better penetration compared with SQUID 18 or Onyx formulation. Low metallic artifacts were confirmed on

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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