Traumatic MMA-Orbitofrontal Dural AVF Treated with Coils and Liquid Embolization

Middle meningeal artery fistulas are rare and few case reports and series have been reported in the literature (Almefty et al. 2016, Kim et al 2020)Freckmann classification of MMA AVFs (Freckmann 1981):

• Performed 446 cerebral angiograms for trauma patients and found MMA fistulas in 8 patients (1.8%)
• Type 1 drainage via the middle meningeal vein to the pterygoid plexus
• Type 2 drainage via the sphenoparietal sinus or other meningeal vein to saggital sinus
• Type 3 drainage via the sphenoparietal sinus to cavernous sinus
• Type 4 drainage via the MMV and the superior petrosal sinus to cavernous sinus or the basilar plexus
• Type 5 drainage via diploic vein
• Type 6 drainage via bridging vein to superior sagittal sinus

Kim et al JKNS 2020

• The patient is a 59-year-old male with unknown past medical history, who presented as a trauma, after being found down on a bike trail.
• CT head revealed bilateral temporal contusions, traumatic subarachnoid hemorrhage and bilateral acute subdural hematomas, and right tentorial subdural hematoma.
• Admission GCS 13, E3 V4 M6 but declined and was intubated.
• EVD on admission, with elevated ICPs and bradycardia.
• Left-sided craniectomy on post-injury day #1 for left temporal intracerebral hemorrhage evacuation.

NCCT on admission

CTA on admission

Cerebral Angiography showing MMAF with complex venous drainage

DynaCT

Procedure

• Standard radial access with 6F sheath
• 5 French Glidecath catheter was introduced over a 035 Glidewire for angiography
• Echelon 10 microcatheter , Aristotle 14 microwire Glidewire for MMAE
• Ethylene vinyl alcohol and DMSO was used as the liquid embolic agent
• 1.0mm x 2cm helical finishing coils (x2)
• 2.0mm x 8cm helical finishing coils (x4)

Embolization

Post-embolization DynaCT

Outcome

• Angiographically successfully occluded
• No evidence of recurrence or hemorrhage on follow-up imaging

• Unique case of traumatic MMA fistula with venous drainage eventually to superior sagittal sinus, orbital venous plexus, sphenopalatine sinus and inferior petrosal sinus
• Liquid embolic agent was used for distal anterior MMA embolization and coils in proximal MMA and recurrent MMA to prevent non-target embolization of the ophthalmic artery
• MMAVFs should be considered as high-risk vascular lesions
• CTA should be carefully evaluated in patients with skull base fractures
• Have been amenable to endovascular technique in recent literature
• Open surgery with ligation or clipping could be considered but not as first line treatment in this patient

References

1. Almefty RO, Kalani MY, Ducruet AF, Crowley RW, McDougall CG, Albuquerque FC. Middle meningeal arteriovenous fistulas: A rare and potentially high-risk dural arteriovenous fistula. Surg Neurol Int. 2016 Apr 1;7(Suppl 9):S219-22. doi: 10.4103/2152-7806.179575. PMID: 27127711; PMCID: PMC4828950.
2. 2.Kim HS, Song JH, Oh JK, Ahn JH, Kim JH, Chang IB. Endovascular Treatment of Traumatic Arteriovenous Fistula in Young Adults with Pulsatile Tinnitus. J Korean Neurosurg Soc. 2020 Jul;63(4):532-538. doi: 10.3340/jkns.2019.0233. Epub 2020 Mar 5. PMID: 32126747; PMCID: PMC7365271.
3. 3.Freckmann N, Sartor K, Herrmann HD. Traumatic arteriovenous fistulae of the middle meningeal artery and neighbouring veins or dural sinuses. Acta Neurochir (Wien). 1981;55(3-4):273-81. doi: 10.1007/BF01808443. PMID: 7234533.