title: Combined surgical and endovascular access of the superficial middle cerebral vein to occlude a high-grade cavernous dural arteriovenous fistula: case report.
abstract: BACKGROUND
  High-grade cavernous sinus (CS) dural arteriovenous fistulae with cortical venous drainage often have a malignant presentation requiring urgent treatment. In the absence of a venous access to the lesion, transarterial embolization can potentially cure these lesions; however, the high concentration of eloquent arterial territories adjacent to the fistula creates a precarious risk of arterial-arterial reflux. In such cases, a combined surgical and endovascular approach may provide the least invasive option.
  
  
  METHODS
  We describe a patient presenting with a venous hemorrhagic infarct caused by a high-grade CS dural arteriovenous fistula (Barrow type D caroticocavernous fistula) with isolated drainage via the superficial middle cerebral vein into engorged perisylvian cortical veins. No transfemoral or ophthalmic strategy was angiographically apparent, and the posterior location of the involved CS compartment mitigated a direct puncture. The patient underwent direct puncture of the superficial middle cerebral vein via an orbitozygomatic craniotomy and the CS was catheterized under fluoroscopic guidance. The CS was coil-embolized back into the distal superficial middle cerebral vein with complete obliteration of the fistula. The patient did well with no new deficits and made an uneventful recovery.
  
  
  CONCLUSIONS
  This novel combined open surgical and endovascular approach enables obliteration of a CS dural arteriovenous fistula with isolated cortical venous drainage and avoids the additional manipulation with direct dissection and puncture of the CS itself.
authors.affiliation: Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA.
authors.forename: Michael C
authors.initials: MC
authors.lastname: Hurley
authors.forename: Rudy J
authors.initials: RJ
authors.lastname: Rahme
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Fishman
authors.forename: H Hunt
authors.initials: HH
authors.lastname: Batjer
authors.forename: Bernard R
authors.initials: BR
authors.lastname: Bendok
mesh_terms: D000368:Aged; D002426:Cavernous Sinus / Q000473:pathology* / Q000601:surgery; D020785:Central Nervous System Vascular Malformations / Q000150:complications / Q000601:surgery*; D002543:Cerebral Hemorrhage / Q000209:etiology / Q000601:surgery; D002550:Cerebral Veins / Q000601:surgery; D003924:Diabetes Mellitus, Type 2; D004621:Embolization, Therapeutic / Q000379:methods; D057510:Endovascular Procedures / Q000379:methods*; D005260:Female; D006801:Humans; D006949:Hyperlipidemias / Q000150:complications; D006973:Hypertension / Q000150:complications; D002538:Intracranial Arteriovenous Malformations / Q000150:complications / Q000601:surgery*; D019635:Neurosurgical Procedures / Q000379:methods*