title: Transcortical venous approach for direct embolization of a cavernous sinus dural arteriovenous fistula:  technical case report.
abstract: BACKGROUND
  Dural arteriovenous fistulas (dAVFs) represent 10% to 15% of all intracranial arteriovenous malformations. Most often, embolization is accomplished with transfemoral catheter techniques. We present a case in which embolization of a cavernous sinus dAVF was made possible through transcranial cannulation of a cortical draining vein.
  
  
  METHODS
  An 82-year-old woman presented with diplopia, left sixth cranial nerve palsy, intraocular hypertension, and bilateral chemosis. Angiography revealed a complex cavernous dAVF with cortical venous reflux, supplied by both external carotid arteries and the left meningohypophyseal trunk. Percutaneous transvenous access failed, and only partial occlusion was achieved by transarterial embolization. A frontotemporal craniotomy was performed to access the superficial middle cerebral vein in the left sylvian fissure. Under fluoroscopic guidance, a microcatheter was advanced through this vein to the floor of the middle cranial fossa and into the dAVF, permitting coil occlusion.
  
  
  CONCLUSIONS
  This transcranial vein technique may be a useful adjunct in dAVF therapy when percutaneous transarterial or transvenous approaches fail or are not possible.
authors.affiliation: Department of Clinical Neurological Sciences, London Health Sciences Centre, London, Ontario, Canada. nchaudh3@uwo.ca
authors.forename: Navjot
authors.initials: N
authors.lastname: Chaudhary
authors.forename: Stephen P
authors.initials: SP
authors.lastname: Lownie
authors.forename: Miguel
authors.initials: M
authors.lastname: Bussière
authors.forename: David M
authors.initials: DM
authors.lastname: Pelz
authors.forename: David
authors.initials: D
authors.lastname: Nicolle
mesh_terms: D000369:Aged, 80 and over; D002404:Catheterization / Q000295:instrumentation / Q000379:methods; D020226:Cavernous Sinus Thrombosis / Q000000981:diagnostic imaging / Q000473:pathology / Q000628:therapy*; D020785:Central Nervous System Vascular Malformations / Q000000981:diagnostic imaging / Q000473:pathology / Q000628:therapy*; D002550:Cerebral Veins / Q000601:surgery*; D004621:Embolization, Therapeutic / Q000295:instrumentation / Q000379:methods*; D005260:Female; D006801:Humans; D011859:Radiography; D012086:Reoperation / Q000379:methods