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