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Follow the case of a 27-year-old woman with von Willebrand disease presenting with right-sided tinnitus, evolving into pulsatile tinnitus. Delve into the diagnostic journey through MRI and DSA, revealing multiple fistulas originating from various arterial branches. Explore the challenge of microcatheter support at the skull base and the innovative solution using Sofia 5F for distal support in the MMA trunk.
TOF MRI imaging of the brain demonstrated abnormal vessels along the right skull base. Most of the feeding arteries seem to come from external carotid artery.
ECA DSA showing multiple fistulas arising from right MMA and maxillaris interna branches. There are feeding vessels from right ophtalmic artery as well as from cavernous ICA through the skull base. Drainage is direct to a large venous structure that extends through the skull base.
The patient is strongly bothered by her symptoms.
The fistula carries a risk for bleeding and local expansion.
Patient in general anesthesia.
Right radial approach:
There appears to be a ”three lane highway” leading directly from MMA to the large venous pouch
Lots of devices, effort and sweat to reach the target
Problem arose at the distal loops at the skull base level, causing the microcatheter to prolapse to the main maxillaris interna trunk.
The microcatheter lacked support at skull base level where the feeding arteries traversed the bone, making it impossible to reach the fistula.
We tried with various different microcatheters and wires. The key point was to find adequate distal support. This was reached with Sofia 5F distally in the MMA, that was soft and navigable enough to be placed distally in the MMA trunk.
