Introduction Venous embolization is an effective alternative to arterial embolization in treating dAVF, but optimal operative route determination can be difficult. We present cases of skull base dAVF treated with venous embolization and highlight multimodality image segmentation (MMIS) in preprocedural planning and postprocedural visualization of dAVF treatment.

Materials and Methods We reviewed four cases of dAVF and one dAVM treated with transvenous embolization. MMIS was performed prior to or after treatment for optimized visualization and/or planning.To create the MMIS files, DICOM files with slice thicknesses ≤ 1mm were moved into 3D Slicer for registration. The segmentations were performed using Vitrea and exported in STL format. STL files were registered on Slicer combined using Blender. The models were then visualized using Sketchfab.

Results Four cases of dAVF and one case of dAVM were identified (table 1). In Case 1, a staged vermian dAVF embolization was performed. A traditional arterial route was planned for the second stage, however, significant tortuosity of the proximal posterior meningeal artery initially noted on catheter angiography led the treatment team to choose the transvenous approach based on MMIS (figure 1) for successful embolization of the fistula. In case 2, MMIS helped identify the single fistulous point at the junction of the right superior ophthalmic vein and cavernous sinus as target for venous embolization. In case 3, MMIS was performed as follow up to characterize the anatomy more accurately. In case 4, a complex MCF dAVM with venous ectasia, MMIS helped map the retrograde venous route through the superior petrosal sinus to two large venous varices near the fistulous point. In case 5, an intraosseous dAVF presenting with tinnitus, MMIS was useful in pre-procedural and determination of optimal treatment to symptom resolution given the extent of the fistula along the transverse sinus.

Conclusion MMIS is useful in the preprocedural planning and postprocedural analysis of dAVF treatment, especially in cases involving tortuous vasculature and difficulty localizing the fistulous zone as it combines MRI and angiography in a way that can overcome the traditional spatial and temporal dissociation of draining veins and normal venous structures on catheter angiography alone.

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Abstract E-213 Figure 1

3D segmentation of the vermian dAVF in case 1. The segmentation demonstrates the tortuosity of the proximal middle meningeal artery making an arterial approch difficult. Labels: 1. posterior meningeal artery, 2. coils, 3. petrosal branch of MMA, 4. MVP, 5. nBCA glue, 6. transosseous occipital dAVF feeder, 7. superior vermian vein, 8. tentorial tributary to torcula, 9. torcula

Disclosures B. Pinsky: None. M. Rhee: None. A. Park: None. L. Lin: None. D. Vollhaber: None. N. Chaudhary: None. Z. Wilseck: 2; C; Penumbra Neurovascular. A. Pandey: None. J. Gemmete: None.