Torcular herophili dural arteriovenous fistula of the brain – Balloon-assisted flow-controlled embolisation with venous sinus preservation

Abstract

Dural arteriovenous fistulas (DAVF) are rare acquired vascular malformations of the brain with varied clinical presentations based on the location and pattern of venous drainage. Aggressive management of DAVF is predominantly endovascular with open surgical obliteration reserved for a few selected cases. DAVF around the trocular herophili are challenging as we need to preserve the superficial and deep venous channels for the normal drain drainage. We describe a case of complex DAVF centered around torcula herophili and left transverse sinus with complete obliteration of left sigmoid sinus and stenosis of the left transverse sigmoid sinus. The DAVF had retrograde venous drainage through the superficial and deep venous sinuses, cortical veins, competing with normal venous drainage of the brain with significant venous hypertension and cognitive impairment. Our goal was complete obliteration of all the feeders with preservation of the venous sinuses and reduction of venous hypertension to achieve cognitive improvement. Endovascular embolisation by transarterial route was done with flow control on the venous side using dimethyl sulfoxide compatible balloon. We have described the technical challenges and strategy to achieve complete obliteration of all the feeders around the sinus, with preservation of torcula using balloon inflation. Venous system flow was restored to the normal pattern and anti-coagulated for 24 h. Endovascular embolisation is the mainstay treatment for DAVF. To achieve cure, strategising the approach and extent of obliteration based on anatomy and venous drainage pattern of the brain is essential. Torcular DAVF pose a specific challenge, at it is the confluence of the superficial and deep venous system. Transvenous Balloon-assisted embolisation is a safe and effective method to achieve complete obliteration of DAVF with preservation of the venous sinuses.