Article Figures & Data
Figures
- FIG 1.
A, Cerebral DSA (patient 3) via a left vertebral artery injection demonstrating arterial supply to a superior sagittal sinus dural AVF by enlarged bilateral arteries of Davidoff and Schechter. Anterior-posterior projection in the arterial phase shows a bilateral enlarged ADS arising from the superior aspect of the P1–2 junctions of the posterior cerebral arteries and converging (black arrows) into an enlarged falcine artery at the falcotentorial junction, with early venous filling of the superior sagittal sinus. Note the presence of cortical venous reflux. B, Lateral projection shows a bilateral enlarged ADS (black arrows) extending posteriorly along the free edges of the tentorium cerebelli and converging adjacent to the falcotentorial junction.
- FIG 2.
A, Cerebral DSA and endovascular treatment (patient 1) of a falcotentorial dural AVF supplied by the bilateral arteries of Davidoff and Schechter. Anterior-posterior projection of a right vertebral artery injection in the arterial phase shows an enlarged left ADS (black arrow) with early filling of the vein of Galen. Note the mildly enlarged right ADS arising from the right P1–2 junction (white arrow) and the infratentorial venous reflux. B, Axial MIP reconstruction of a 3D rotational angiogram performed via right vertebral artery injection shows the bilateral origins of the ADS from the P1–2 junctions of the posterior cerebral arteries (white arrows). C, Anterior-posterior projection of a microcatheter injection within the right ADS shows early venous filling along the straight and left transverse sinuses. D, Lateral projection of a microcatheter injection within the right ADS shows the course of the vessel along the free edge of the tentorium to the falcotentorial junction, with early venous filling into the vein of Galen. E, Nonsubtracted anterior-posterior projection during right vertebral artery injection after a second-stage transvenous embolization shows no residual early venous filling, with an Onyx cast filling the vein of Galen. F, Spot lateral radiograph of the skull shows the Onyx cast following transarterial and transvenous embolizations.
- FIG 3.
A, Cerebral DSA and endovascular treatment (patient 2) of a falcotentorial dural AVF supplied by the bilateral arteries of Davidoff and Schechter. Lateral projection of a left vertebral artery injection shows supply to the dural AVF by the left posterior meningeal artery (white arrow) and faint supply from the ADS (black arrow). B, Lateral projection of a left vertebral artery injection after embolization using Onyx from the posterior meningeal artery shows the residual ADS supply (black arrow) to the inferior surface of the vein of Galen more clearly, with reduced competitive flow. C, Anterior-posterior projection of a microcatheter injection via the left ADS distally shows the remnant fistulous flow to the junction of the vein of Galen and straight sinus at the falcotentorial junction. D, Lateral projection of a microcatheter injection via the left ADS distally shows the residual supply to the dural AVF with deep venous reflux. E, Anterior-posterior projection of a left vertebral artery injection in the arterial phase shows the residual supply to the dural AVF by the enlarged left ADS (black arrow). F, Anterior-posterior projection of a right vertebral artery injection after embolization of the left ADS distal supply using coils and Onyx shows no residual early venous filling with cure of the AVF.
Tables
Category Risk-Reduction Strategy Patients Treated Anatomic assessment; to identify supply from ADS Magnified high-frame-rate angiography 1–6 3D rotational angiography with multiplanar reconstructions 1–6 Transarterial embolization; strategies to avoid reflux across ADS Initial embolization from non-ADS arterial supplies (to reduce competitive flow) 1–6 Close monitoring for linear reflux anteriorly from the vein of Galen (along the expected course of ADS) 1–6 Embolization directly via ADS; strategies to treat via ADS while avoiding reflux Direct cannulation of ADS with embolization if distal access achieved (pressure-cooker technique to minimize reflux) 2 Aborting embolization attempts from ADS if distal access not achieved (insufficient safety margin) 1 Strategies for residual ADS supply Staged embolization over multiple sessions as required 1, 3, 5 Transvenous approach (eg, reverse pressure-cooker technique) 1
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