Transcranial embolization of a superficial DAVF: an alternative technique after unsuccessfull conventional approaches

CASE PRESENTATION

• A patient on her/his 70s
• CT and CTA: superficial SAH, midline DAVF
• Conventional approaches failed (partial embolization)
• Persistent headaches, no neurological deficits, GSC 15

PREOPERATIVE IMAGES 

DSA, Injection from right ECA:

• Images show a midline, superficial, parasagittal DAVF
• Previous embolizations attempts were unsuccessful to reach the foot of the vein (blue arrow). Considering the superficial location, and the tiny/tortuous afferent arteries, a transcranial puncture was proposed.

Preoperative marker, DSA guided:

• A surgical staple was placed into the skin at the level of the mid-portion of the draining vein(X), as a marker to perform the burr hole

• Once the burr hole was done (dotted circle), puncture was performed using a 22 G spinal needle (arrow)
• We punctured out of the skin incision (blue circle) for achieving a more stable position of the needle
• A Y-connector was used to avoid blood reflux, allowing also a comfortable microcatheter insertion

PROCEDURAL IMAGES

• Puncture was performed under road-map wearing radioprotective gloves.

• AP view, for the initial tip orientation, and lateral view, for the needle angulation/advance. Target was the foot of the vein.

• DSA, lateral view: after obtaining blood reflux, a contrast injection confirmed the correct position of the needle. A marathon microcatheter was inserted through the needle

• Once the Marathon microcatheter (Medtronic) reached the foot of the Vein, we deployed Barricade coils (Balt Extrusion) through it

• Image setup illustrating the needle and the microcatheter location

• DSA, lateral view, needle contrast injection: after coils deployment, contrast distributed anterogradely into the vein

• 2 cc of Onyx-34 were gently injected through the Marathon microcatheter from the coils, to the anterior venous side  

• Onyx cast: complete obliteration of the foot of the vein and the draining vein

• DSA, lateral view showing complete occlusion of the fistula

• Dyna CT reconstruction showing the midline location of the Coils/Onyx cast, the needle (white arrow), and the burr hole (blue arrow) over the vein.

RESULTS

• After the needle removal, a gentle manual compression was applied during 5 minutes, and the skin incision was closed with staples.
• DSA ruled out local complications, confirming the complete occlusion of the DAVF.
• Patient was extubated 2 hours later, without complications.
• Patient was discharged 48 hours later, without headaches and no neurological deficits.