Middle Cranial Fossa Sphenoidal Region Dural Arteriovenous Fistulas: Anatomic and Treatment Considerations

Patient 8. Cerebral angiograms show a fistula (arrow) along the lesser sphenoid wing, primarily fed by the right MMA and draining into the right cavernous sinus, bilateral inferior petrosal sinuses, and the right superior ophthalmic vein. A, Anteroposterior view of the right ECA angiogram. B, Lateral view of the right ECA angiogram.

Patient 5. The ECA (A, lateral view; B, anteroposterior view) and ICA (C, lateral view) angiograms show that the high-flow fistula is fed by multiple branches of the ICA and the ECA, and there is venous drainage into the basal vein of Rosenthal and subsequently the vein of Galen, as well as into the Sylvian and Trolard veins (arrow) into the superior sagittal sinus. A triaxial system with a guide catheter inserted into the internal jugular vein, an intervening Tracker-38 catheter (Boston Scientific) placed in the transverse sinus near the torcula—and, in this, a longer microcatheter was navigated to the exact fistula site through the straight sinus, the vein of Galen, and the basal vein of Rosenthal—and transvenous embolization of the fistula was performed using coils. Postembolization angiograms of the ECA (D, lateral view) and ICA (E, anteroposterior view; F, lateral view) show complete obliteration of the fistula.

Patient 3. Anteroposterior (A) and lateral (B) view of the left ECA angiograms during transarterial coil embolization show that the fistula site involves the sphenobasal sinus (arrow) draining to the left cavernous sinus and SOV. Five-month follow-up angiogram of the left common carotid artery (C, anteroposterior view; D, lateral view) demonstrates durable complete obliteration of the fistula by Onyx and coils.