title: Combined covered stent and onyx treatment for complex dural arteriovenous fistula involving the clivus and cavernous sinus.
abstract: BACKGROUND
  Complex DAVFs involving both the clivus and cavernous sinus are rare, especially when associated with brainstem compression from a large varix. In this report, we describe the use of a covered stent in combination with a liquid embolic agent to cure a complex clival-cavernous DAVF.
  
  
  METHODS
  A 46-year-old man presented with 6 months of dizziness, dysphagia, and progressive dysarthria. Magnetic resonance imaging showed tortuous and enlarged right cavernous and preclival flow voids. There were also bilateral prepontine varices compressing the ventral pons, which led to marked dorsal pontine edema. A cerebral angiogram revealed a clival DAVF supplied by multiple branches of the right ECA, as well as the MHT of the right ICA.
  
  
  RESULTS
  An endovascular cure was achieved by deploying a covered stent in the right cavernous ICA, followed by transarterial embolization of the feeding arteries originating from the ECA with Onyx (ev3, Irvine, Calif). This combined approach resulted in complete occlusion of the fistula. His 1-month follow-up angiogram confirmed persistent occlusion of the fistula and preserved patency of the right ICA. The patient made a full recovery without any new symptoms, and he remained neurologically intact at 18-month follow-up.
  
  
  CONCLUSIONS
  The combined technique of covered stent placement and Onyx transarterial embolization is valuable for the management of complex DAVFs supplied by branches of both the external and internal carotid arteries.
authors.affiliation: Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China.
authors.forename: Zhong-Song
authors.initials: ZS
authors.lastname: Shi
authors.forename: Tie-Wei
authors.initials: TW
authors.lastname: Qi
authors.forename: Nestor R
authors.initials: NR
authors.lastname: Gonzalez
authors.forename: Jordan
authors.initials: J
authors.lastname: Ziegler
authors.forename: Zheng-Song
authors.initials: ZS
authors.lastname: Huang
mesh_terms: D002426:Cavernous Sinus / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D003388:Cranial Fossa, Posterior / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D004121:Dimethyl Sulfoxide / Q000627:therapeutic use*; D004621:Embolization, Therapeutic / Q000379:methods*; D006801:Humans; D002538:Intracranial Arteriovenous Malformations / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000379:methods*; D011145:Polyvinyls / Q000627:therapeutic use*; D011859:Radiography; D015607:Stents; D014656:Vascular Surgical Procedures / Q000379:methods*
chemical_list: C450660:Onyx copolymer; D011145:Polyvinyls; D004121:Dimethyl Sulfoxide