Therapy of a DAVF Cognard 2a: Transvenous embolization of a sigmoid sinus collector

Patient presentation

• 72-year-old, female patient
• Left-sided pulse-synchronous tinnitus
• Headache 

DAVF Cognard 2a

Feeder: racemous arteries of the left occipital artery and ascending pharyngeal artery

Drainage: left sigmoid sinus (distally thrombosed!), nuchal veins

Left-sided ECA injection (lateral projection)

left-sided ICA injection (lateral projection)

Treatment chosen

• Due to severe symptoms: endovascular treatment of the DAVF
• Transvenous embolization of non-functional sigmoid sinus preferred (multiple feeders, avoid the risk of embolization of vasa nervorum)

Intervention

• Via right transverse sinus depiction of the left sigmoid-sinus-compartment draining the DAVF:

Coiling of the left sigmoid sinus

• Post-coiling: still multiple feeders detectable

Left CCA-series (lateral projection)

X-ray

Post-coiling DSA

Arterialized sigmoid sinus collector

• Drainage of the collector via the left inferior petrosal sinus

Route to left inferior petrosal sinus

• contralateral cavernous sinus → intercavernous sinus → ipsilateral cavernous sinus

• Microcatheter-injection confirms the location of the collector

Complete occlusion of the DAVF

• Left-sided ECA-series (lateral + p.a.-projection)

• Complete regression of symptoms shortly after the intervention

Final control

After supposedly save TVE:

• Potential collectors might be inaccessible via the initial route
• Possible upgrading of a DAVF when the collector is not occluded

Prior localization of collectors (which might be difficult)

• Comprehension of anatomical positional relations to the collector
• Planning of alternative, possibly more challenging routes

Embolization of the arterialized collector is crucial for DAVF occlusion!