title: Complete endovascular occlusion of a cranial dural fistula using a venous "to the point" approach.
abstract: OBJECTIVE
  Cranial dural arteriovenous fistulas are commonly treated using an endovascular method. In comparison to intracerebral arteriovenous malformations, it is important to reach the venous part of these malformations to maintain a complete occlusion. Therefore, often the venous side is totally occluded using coils and∕or glue.
  
  
  METHODS
  We describe a patient with an initially Type IIab (Cognard classification) left occipital cranial fistula. The patient suffered from an intense pulsate tinnitus. Therefore, the first embolization was performed using an approach via the dilated left middle meningeal artery using Onyx. The shunt of the fistula was reduced significantly but total occlusion was impossible. Therefore, the venous approach was used. Over a guiding catheter in the sigmoid sinus, the venous side of the fistula could be reached with a microcatheter. This part of the fistula was then completely occluded using coated and bare coils, without occluding the adjacent sinus. Control angiography of all previous feeders showed a complete occlusion of the fistula (used classification: Cognard).
  
  
  RESULTS
  The fistula was entirely occluded. The patient's outcome was excellent. The patient did not develop any symptoms and no complication occurred due to the treatment.
  
  
  CONCLUSIONS
  Direct occlusion of the venous part of an arteriovenous cranial fistula can be an option before an occlusion of the sinus has to be performed. This approach can lead to reduction of risk during the endovascular procedure and risk reduction in long-term follow-up.
authors.affiliation: University Hospital Essen, Department of Diagnostic and Interventional Radiology and Neuroradiology, Essen, Germany. elke.gizewski@radiol.med.uni-giessen.de
authors.forename: E R
authors.initials: ER
authors.lastname: Gizewski
authors.forename: S L
authors.initials: SL
authors.lastname: Göricke
authors.forename: N
authors.initials: N
authors.lastname: Özkan
authors.forename: A E
authors.initials: AE
authors.lastname: Grams
authors.forename: M E
authors.initials: ME
authors.lastname: Ladd
authors.forename: U
authors.initials: U
authors.lastname: Sure
authors.forename: M
authors.initials: M
authors.lastname: Forsting
mesh_terms: D015901:Angiography, Digital Subtraction; D000925:Anticoagulants / Q000627:therapeutic use; D020785:Central Nervous System Vascular Malformations / Q000601:surgery*; D002533:Cerebral Angiography; D004388:Dura Mater / Q000601:surgery*; D004621:Embolization, Therapeutic; D057510:Endovascular Procedures / Q000379:methods*; D005260:Female; D006493:Heparin / Q000627:therapeutic use; D006801:Humans; D018810:Magnetic Resonance Angiography; D008279:Magnetic Resonance Imaging; D008875:Middle Aged; D009778:Occipital Lobe / Q000473:pathology / Q000601:surgery; D014012:Tinnitus / Q000209:etiology
chemical_list: D000925:Anticoagulants; D006493:Heparin