Cortical Venous Approach for Transvenous Embolization of a Greater Sphenoid Wing Dural Arteriovenous Fistula: A Case Report.

Abstract

Objective: Dural arteriovenous fistulas (dAVFs) in the paracavernous sinus of the sphenoid wing often present challenges for transvenous access because of their complex venous drainage patterns. Herein, we report the successful diagnosis and treatment of a greater sphenoid wing dAVF using a percutaneous transvenous approach via the Labbé vein.

Case presentation: A 48-year-old woman presented with tinnitus and was diagnosed with a greater sphenoid wing dAVF. The dAVF was fed by multiple meningeal arteries from the accessory meningeal artery. Shunted blood drained retrogradely into the superficial middle cerebral vein (SMCV) and bilateral inferior petrosal sinus (IPS) via the cavernous sinus (CS). Although communication was observed between the shunt pouch and the lateral part of the CS, the tortuous and narrow nature of this connection suggests difficulty in accessing the shunt pouch via the IPS. Conversely, the SMCV, which served as the primary outflow pathway, was adequately connected to the vein of Labbé with minimal difficulty, facilitating the passage of the microcatheter. The percutaneous transvenous approach via the Labbé vein successfully reached the SMCV and achieved complete obliteration with selective transvenous embolization (TVE) using coils. The symptoms of the patient improved postoperatively, and the patient was discharged without complications.

Conclusion: Greater sphenoid wing dAVFs often rely on the SMCV as the major drainage route, making venous approaches challenging. The route via the vein of Labbé through the cortical veins to reach the SMCV proved to be a valuable access route for TVE of greater sphenoid wing dAVFs.