Presentation A 35 year-old lady presented with headache, tinnitus and papilloedema. LP showed raised CSF pressure. Acetazolamide was commenced for presumed idiopathic intracranial hypertension with atypical phenotype but papilloedema persisted despite increasing dosage.
CTV showed a non-occlusive right sigmoid sinus filling defect with bilateral transverse sinus stenosis. Prominent, tortuous veins straddled the tentorium, indicating venous hypertension.
Angiography identified a dural A-V fistula involving the torcula and right transverse sinus. Tributaries included bilateral MMA and occipital artery branches, bilateral posterior meningeal branches via vertebral arteries, tentorial PCA branches, meningo-hypophyseal/inferolateral trunk and distal PCA branches. The transverse sinus, posterior aspect of superior sagittal sinus and straight sinus drained the fistula exclusively.
Intervention The fistula was embolised in two stages. At first stage, detachable coils were deployed along the right transverse sinus and Onyx18 was injected trans-arterially into the right middle meningeal and occipital feeders. At second stage, Onyx18 was injected into the right occipital artery feeders with good fistula/feeder penetration and satisfactory angiographic result.
Follow-Up Headaches and tinnitus due to fistula-induced raised ICP initially resolved but headaches recurred after a few months, again with raised CSF pressure. Angiography showed fistula resolution but with regression of the collateral venous outflow back to the normal sigmoid/jugular pattern. At this point, raised ICP was deemed secondary to left sigmoid stenosis, the right transverse sinus having been endovascularly occluded. The left transverse-sigmoid stenosis pressure gradient was 22mHg and a sinus stent was therefore inserted. CTV demonstrated satisfactory stent placement and disc swelling resolved.
Disclosure of Interest Nothing to disclose
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