title: Direct access to the middle meningeal artery for embolization of complex dural arteriovenous fistula: a hybrid treatment approach.
abstract: Endovascular embolization has become increasingly favored over microsurgical resection for treatment of complex dural arteriovenous fistulas (DAVFs). However, endovascular treatment can be restricted by tortuous transarterial access and a transvenous approach is not always feasible. We present a Borden III DAVF treated by direct access to the middle meningeal artery (MMA) and Onyx embolization performed in a hybrid operating room-angiography suite. A middle-aged patient with pulsatile headaches was found to have left transverse sinus occlusion and DAVF with retrograde cortical venous drainage fed by multiple external carotid artery (ECA) feeders. Endovascular attempts via conventional transvenous and transarterial routes were unsuccessful, and the major MMA feeder was accessed directly after temporal craniotomy was performed under neuronavigation. Onyx embolization was performed; complete occlusion of the fistula was achieved. Three-month follow-up angiography showed no residual filling; the patient remains complication-free. A combined surgical-endovascular technique in a hybrid operating room-angiography suite can be an effective treatment for DAVFs complicated by inaccessible arterial and transvenous approaches.
authors.affiliation: Department of Neurosurgery, University at Buffalo, State University of New York, Buffalo, New York, USA.
authors.forename: Ning
authors.initials: N
authors.lastname: Lin
authors.affiliation: Department of Neurosurgery, University at Buffalo, State University of New York, Buffalo, New York, USA.
authors.forename: Adam M
authors.initials: AM
authors.lastname: Brouillard
authors.affiliation: Department of Neurosurgery, University at Buffalo, State University of New York, Buffalo, New York, USA.
authors.forename: Maxim
authors.initials: M
authors.lastname: Mokin
authors.affiliation: Department of Neurosurgery, University at Buffalo, State University of New York, Buffalo, New York, USA.
authors.forename: Sabareesh K
authors.initials: SK
authors.lastname: Natarajan
authors.affiliation: Departments of Neurosurgery and Radiology and Toshiba Stroke Research Center, University at Buffalo, State University of New York, Buffalo, New York, USA.
authors.forename: Kenneth V
authors.initials: KV
authors.lastname: Snyder
authors.affiliation: Departments of Neurosurgery and Radiology and Toshiba Stroke Research Center, University at Buffalo, State University of New York, Buffalo, New York, USA.
authors.forename: Elad I
authors.initials: EI
authors.lastname: Levy
authors.affiliation: Departments of Neurosurgery and Radiology and Toshiba Stroke Research Center, University at Buffalo, State University of New York, Buffalo, New York, USA.
authors.forename: Adnan H
authors.initials: AH
authors.lastname: Siddiqui
mesh_terms: D020785:Central Nervous System Vascular Malformations / Q000000981:diagnostic imaging* / Q000628:therapy*; D003131:Combined Modality Therapy / Q000379:methods; D004121:Dimethyl Sulfoxide / Q000008:administration & dosage; D004621:Embolization, Therapeutic / Q000379:methods*; D005500:Follow-Up Studies; D006801:Humans; D008576:Meningeal Arteries / Q000000981:diagnostic imaging* / Q000601:surgery*; D008875:Middle Aged; D011145:Polyvinyls / Q000008:administration & dosage; D011859:Radiography; D016896:Treatment Outcome
chemical_list: C450660:Onyx copolymer; D011145:Polyvinyls; D004121:Dimethyl Sulfoxide
keywords: Artery; Fistula; Intervention; Technique; Vascular Malformation