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Case report
Direct access to the middle meningeal artery for embolization of complex dural arteriovenous fistula: a hybrid treatment approach
  1. Ning Lin1,
  2. Adam M Brouillard1,
  3. Maxim Mokin1,
  4. Sabareesh K Natarajan1,
  5. Kenneth V Snyder2,
  6. Elad I Levy2,
  7. Adnan H Siddiqui2
  1. 1Department of Neurosurgery, University at Buffalo, State University of New York, Buffalo, New York, USA
  2. 2Departments of Neurosurgery and Radiology and Toshiba Stroke Research Center, University at Buffalo, State University of New York, Buffalo, New York, USA
  1. Correspondence to Adnan H Siddiqui MD PhD, University at Buffalo Neurosurgery, 100 High Street, Suite B4, Buffalo, NY 14203, USA; asiddiqui{at}ubns.com

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.

  • Vascular Malformation
  • Fistula
  • Intervention
  • Technique
  • Artery

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