title: Selective image-guided venous sinus exposure for direct embolization of dural arteriovenous fistula: technical case report.
abstract: BACKGROUND
  Transcranial approaches for transsinusal endovascular therapy of DAVF have been sporadically reported by large craniectomies. Large craniectomies carry nevertheless a risk of postembolization extradural hematoma, reduced by delaying the endovascular procedure. We report a 1-session technique of SIGC for percutaneous transvenous DAVF embolization.
  
  
  METHODS
  This 58-year-old woman developed a right-sided cerebellar hematoma in relation with a high-grade left transverse and sigmoid sinus DAVF. The DAVF was fed by branches from the left vertebral artery, left internal, and left external carotid arteries, draining into the transverse sinus with retrograde flow in cortical veins. Transvenous retrograde embolization was not feasible either through the left internal jugular vein because of thrombosis, or through the right one because of torcular septa. During the same anaesthetic session, a 5-cm-length selective craniectomy was shaped under magnetic resonance image guidance navigation according to the left transverse sinus with high-speed drill. Thereafter, back in the angiography room, the transverse sinus was taped and coiled resulting in a complete exclusion of the DAVF.
  
  
  CONCLUSIONS
  Selective image-guided craniectomy is efficient and safe for direct percutaneous transvenous embolization of DAVF in a single anesthetic session. Leaving bone beside the sinus prevents a parenchymal traumatic puncture. This bone has nevertheless to be drilled to allow an adequate sharp puncture angle. Doing so, postoperative hematoma is prevented by the small bone opening, the natural adherence of the dura matter and the possibility of direct compression.
authors.affiliation: Department of Neurosurgery, Hôpital Erasme, Université Libre de Bruxelles, Brussels 1070, Belgium. mbruneau@ulb.ac.be
authors.forename: Michaël
authors.initials: M
authors.lastname: Bruneau
authors.forename: Boris
authors.initials: B
authors.lastname: Lubicz
authors.forename: Benoit
authors.initials: B
authors.lastname: Pirotte
authors.forename: Nordeyn Oulad Ben
authors.initials: NO
authors.lastname: Taib
authors.forename: David
authors.initials: D
authors.lastname: Wikler
authors.forename: Jacques
authors.initials: J
authors.lastname: Brotchi
authors.forename: Marc
authors.initials: M
authors.lastname: Levivier
mesh_terms: D020785:Central Nervous System Vascular Malformations / Q000000981:diagnostic imaging / Q000473:pathology / Q000628:therapy*; D003399:Craniotomy / Q000379:methods*; D004621:Embolization, Therapeutic / Q000379:methods*; D005260:Female; D006801:Humans; D008875:Middle Aged; D011859:Radiography; D025321:Surgery, Computer-Assisted