Bilateral Thalamic Edema Caused by Tentorial Galenic Dural Arteriovenous Fistula and Sinus Thrombosis: Successful Endovascular Therapy.

Bilateral thalamic edema is commonly caused by vascular, toxic/metabolic, neoplastic, and infectious factors. However, dural arteriovenous fistulas (DAVFs) are a relatively rare and often overlooked cause, with an incidence rate of about 8%. Tentorial dural arteriovenous fistulas (TDAVFs) represent a rare subtype. Cerebral angiography often shows TDAVFs with reflux into cortical or subarachnoid veins and retrograde deep drainage through the vein of Galen, which is associated with a high risk of hemorrhage?97% of cases involve hemorrhage and exhibit aggressive neurological behavior. Venous sinus thrombosis, high-flow arteriovenous malformations, or a combination of both can result in venous hypertension, leading to bilateral thalamic dysfunction. The arterial supply to TDAVFs is complex, involving meningeal arteries from the vertebral and internal carotid arteries, which are difficult to cannulate, increasing the risk of complications due to retrograde embolic flow compared to external carotid artery (ECA) feeders. Transvenous navigation to deep lesions around the tentorium is also challenging. Additionally, TDAVFs often drain into subarachnoid or cortical veins rather than their associated sinus (Borden Type ?), making transvenous embolization impossible. The middle meningeal artery, which supplies more than two-thirds of the cranial dura, is the primary dural feeder. In this article, we presented a unique case of symptomatic bilateral thalamic edema caused by both a tentorial galenic DAVF and straight sinus thrombosis of the cerebral deep venous system, and we detailed our treatment approach and experience.