Torcular pseudomass is frequently detected on fetal magnetic resonance imaging and reduces with gestational age.

BACKGROUND: The torcular pseudomass is an incidental extra-axial midline mass located between the venous sinuses and the occipital squama in the pediatric population. Although this structure is presumed to be a developmental feature, it has not been characterized on fetal MRI. OBJECTIVE: To determine the frequency, imaging features and longitudinal in utero evolution of torcular pseudomass using fetal MRI. MATERIALS AND METHODS: We present a single-center retrospective study of fetal MRI performed at a tertiary hospital. Two independent reviewers first ordinally scored torcular pseudomass as absent, focal, crescentic or bulky based on morphology. We reviewed available follow-up fetal and postnatal MRI and further classified torcular pseudomass as stable, involuted or progressive. We also collected clinical and demographic data from electronic charts and compared them among categories, corrected for multiple comparisons. RESULTS: This study included a total of 219 fetuses with median gestational age of 28 weeks (interquartile range [IQR]: 23-32 weeks). Torcular pseudomass was absent in 8% (n=17) and present as a focal mass in 15% (n=33), crescentic in 45% (n=98) and bulky in 32% (n=71) of the cases. Median gestational age was statistically different among torcular pseudomass categories and inversely associated with size. Follow-up fetal MRI was available in 9.6% (n=21) of cases (median interval 4 weeks; IQR: 2-9 weeks) and torcular pseudomass in these cases was classified as stable in 67% (n=14), involuted in 29% (n=6) and progressive in 5% (n=1). Postnatal MRI was available in 5% (n=12) of fetuses (median interval 11.5 months, IQR: 3-17 months), and among these cases torcular pseudomass was classified as stable in 33% (n=4) and involuted in 67% (n=8). CONCLUSION: Torcular pseudomass is highly prevalent in the fetal population and shows a natural tendency to involute, even in utero, although it sometimes persists during early infanthood.

Absence of the torcular, review of venous sinus anatomy, and the simplified dural sinus classification.

BACKGROUND: Classically, the torcular Herophili is described as the symmetric junction between the superior sagittal sinus (SSS), transverse sinuses (TSs), and straight sinus (SS). However, finding this pattern in practice is not standard. Anatomical variations are common, and different drainage patterns should be expected. Existing literature proposes highly detailed descriptions and classifications of this region. Still, a simplified and practical categorization is not available. METHODS: We present an anatomical finding of the torcular Herophili discovered on a cadaveric dissection. Then, we conducted a retrospective study examining the 100 most recent cranial magnetic resonance venographies (MRVs) from the Mayo Clinic, labeling them with a new proposed dural sinus classification system. Images were initially classified by two authors and further validated by a board-certified neurosurgeon and a board-certified neuroradiologist from our institution. To measure consistency in image identification, two additional international neurosurgeons were asked to classify a subset of the same MRV images, and their answers were compared. RESULTS: Of the MRV cohort, 33 patients were male and 67 were female. Their ages ranged from 18 to 86 years, with a mean of 47.35 years and a median of 49 years. Upon examination, 53 patients presented as confluent (53%), 9 as SSS divergent (9%), 25 as SS divergent (25%), 11 as circular (11%), and 2 as trifurcated (2%). The inter-rater reliability ranked very good; agreement between the two neurosurgeons was 83% (κ = 0.830, p < 0.0005). CONCLUSION: The confluence of the venous sinuses is a highly variable anatomical area that is rarely evaluated with neuroimaging before surgery. The classic textbook configuration is not the rule. Using a simplified classification system may increase awareness and hopefully patient safety by preparing the physician for anatomical variations that they will encounter in a surgical or clinical scenario.

Low torcular Herophili position and large brainstem-tentorium angle in fetuses with open spinal dysraphism at 11-13 weeks' gestation.

OBJECTIVE: To evaluate whether in fetuses with open spina bifida (OSB) the tentorium can be seen to be displaced downwards and vertically oriented by the time of the 11-13-week scan and whether this is reflected in an alteration of the brainstem-tentorium (BST) angle. METHODS: The study population was recruited between 2015 and 2020 from three fetal medicine referral centers and comprised a control group and a study group of pregnancies with OSB. The control group was recruited prospectively and included singleton pregnancies with a normal sonographic examination after first-trimester combined screening for chromosomal abnormalities and normal outcome. The study group was selected retrospectively and included all cases with OSB between 2015 and 2020. All cases underwent detailed ultrasound assessment at 11 + 0 to 13 + 6 weeks' gestation. The position of the torcular Herophili (TH) was identified in the midsagittal view of the fetal brain with the use of color Doppler and was considered as a proxy for the insertion of the tentorium on the fetal skull. The BST angle was calculated in the same view and was compared between the two groups. RESULTS: Sixty normal fetuses were included in the control group and 22 fetuses with OSB in the study group. In both groups, the BST angle was found to be independent of gestational age or crown-rump length (P = 0.8815, R2 = 0.0003861 in the controls, and P = 0.2665, R2 = 0.00978 in the OSB group). The mean BST angle was 48.7 ± 7.8° in controls and 88.1 ± 1.18°, i.e. close to 90°, in fetuses with OSB. Comparison of BST-angle measurements between the control group and cases with OSB showed a statistically significant difference (P = 0.0153). In all fetuses with OSB, the downward displacement of the TH and tentorium was clearly visible at the 11-13-week scan. CONCLUSIONS: In fetuses with OSB, the BST angle is significantly larger than in normal controls, with the tentorium being almost perpendicular to the brainstem. This sign confirms the inferior displacement of the tentorium cerebelli with respect to its normal insertion on the occipital clivus as early as the first trimester of pregnancy and is useful in the diagnosis of Chiari-II malformation at this early stage. In fetuses with OSB, the low position of the tentorium and TH is clearly visible, even subjectively, at the 11-13-week scan. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Torcular pseudomass in newborns and its association with delivery: follow up or leave it alone?

PURPOSE: The cranial epidural space (ES) is a potential space and is not generally recognized unless there is underlying pathology. With MRI in newborns, we have frequently observed T2 hyperintense thickening of the ES posterior to the confluence of sinuses, also referred to as "torcular pseudomass" (TP). We aim to identify the frequency of TP and possible associations with delivery. METHODS: Retrospectively, brain MRIs of 194 neonates obtained within the first 2 weeks of life were evaluated. If TP was present, imaging characteristics and thickness were assessed by two observers, using fat-suppressed T2WI/FLAIR, T1WI, and SWI. Exclusion criteria were motion artifact, lack of sagittal T2WI, and lack of clinical data. Medical records were evaluated for demographic and clinical data. Follow-up exams were evaluated if available. Patients with TP and without were compared using Student t and chi-square tests. RESULTS: TP was present in 64/158 (40%). No difference was found between the groups regarding sex, gestational age, birth weight, delivery type, fetal presentation during delivery, birth difficulty, and neurological sequelae (p > 0.05). Eight patients with TP underwent follow-up imaging, and in 6/8, TP completely resolved. Two patients showed persistent TP, improving from 3.2 to 1 mm in one child and from 3.2 to 2.8 mm in the other within a week. CONCLUSION: TP frequently occurs in early newborns. TP does not appear to be associated with factors related to delivery, shows complete resolution in most cases with a follow-up, and is likely of no clinical importance.

A hugely elevated torcular Herophili.

The torcular Herophili is formed by the joining of the major dural venous sinuses including the superior sagittal sinus, transverse sinuses, straight sinuses, and the occipital sinus. Surgically, knowledge of the position of the torcular Herophili is vitally important to avoid catastrophic hemorrhage. Here, we present a case report of an elevated torcularia found on radiological imaging. Such an anatomical variation should be kept in mind by clinicians and anatomists alike.

Torcular dural sinus malformations: a grading system proposal.

BACKGROUND: Torcular dural sinus malformations (tDSMs) are congenital complex vascular anomalies often referred as a single unit. Nevertheless, they possess distinct anatomical features, clinical diversity, and markedly different outcomes. OBJECTIVE: On the basis of our institutional experience and analysis of published data, we propose a grading system. METHODS: We have identified 44 papers to which we added our four institutional cases for a total of 126 patients. Eight predictor variables were studied. In order to assess their individual impact on mortality and possible correlations, a logistic regression model was constructed through a stepwise forward process. RESULTS: Overall mortality was 22.1%. Mortality was higher in tDSM patients diagnosed postnatally, 40.7% versus a 15.6% in prenatally found cases (p = 0.007). We divided the patients into four grades. Grade I comprised patients with no feeder evidence and possessed the best outcomes (mortality of 7.55%). Mortality rose for grades II and III defined respectively by scarce and multiple feeders. Brain damage was the defining feature of grade IV. A mortality of 75% could be observed within this grade. Grade IV was further divided into grades IVa (antenatal) and IVb (postnatal cases). Furthermore, our logistic regression model found that brain damage (OR 11.3, p < 0.001, 95% CI 2.97-42.91) and patent feeders (OR 4, p = 0.03, 95% CI 1.15-13.86) were major determinants of poor outcome (area under ROC curve of 81.44%). CONCLUSION: The grading system (tDSM-GS) streamlines classification into four different grades facilitating both diagnosis, clinical decision-making, and proper prognostication.

How I do it: endoscopic supracerebellar infratentorial approach for torcular meningioma removal.

BACKGROUND: Torcular meningioma is a rare type of brain tumor with few reports regarding the appropriate resection approach for this disease. In cases without sinus occlusion, surgeons are advised to spare the sinus; however, the sinus may interfere with the visual field. METHOD: Endoscopic supracerebellar infratentorial approach for removal of torcular meningioma was performed in the prone position. The tumor attachment to sinus or confluence was removed or coagulate safely due to an optimal look-up view with the 0° and 30° endoscope. CONCLUSION: Endoscopic supracerebellar infratentorial approach for infratentorial torcular meningioma is a safe and less invasive technique.

Supra- and infra-torcular double occipital encephalocele.

An encephalocele is a protrusion of the brain and/or meninges through a defect in the skull that is closed or covered with skin. Occipital encephaloceles are the most frequent type in North America and Western Europe, where about 85% of encephaloceles take this form. To the best of our knowledge, there are only three other reported cases of double occipital encephaloceles in the literature. The current study reports a double and both supra- and infra-torcular occipital encephalocele in a neonate and discusses the importance of preoperative neuroimaging studies to optimize the outcome. The patient was a 1-day-old male child who was identified by prenatal ultrasound to have two occipital encephaloceles. The patient underwent a closure of the occipital encephalocele on the second postnatal day. The infant tolerated the procedure well and was extubated on the first postoperative day. The child continues to do well during follow-up.

The effect of the occipital sinus on the torcular Herophili and neighboring structures.

Objective: The occipital sinus (OS) has many variations. It is unknown whether OS can change the angioarchitecture of torcular Herophili. Therefore, we performed magnetic resonance venography (MRV) in a cohort of Han Chinese individuals to determine whether OS can change the angioarchitecture of torcular Herophili. Methods: Participants were divided into a normal OS group and a hyperplastic OS group. Parameters of the OS and torcular Herophili and its neighboring structures were recorded. Statistical analysis was used to determine the effects of OS on torcular Herophili and neighboring structures. Results: One hundred forty-five healthy participants were enrolled. One hundred patients were in the normal OS group, and 45 were in the hyperplastic OS group. In the normal OS group, the diameters at the transverse sinus (TS) origin were 5.8 ± 2.3 mm on the left side and 7.5 ± 2.2 mm on the right side. In the hyperplastic OS group, the diameters at the TS origin were 6.0 ± 2.1 mm on the left side and 7.0 ± 2.7 mm on the right side. Fenestration was observed in 33% of the torculars in the normal OS group and 6.7% of the torculars in the hyperplastic group. An unpaired t-test revealed a significant difference between bilateral TSs in the normal OS group (P < 0.05) but no difference in the hyperplastic OS group. The chi-square test revealed a significant difference in torcular Herophili fenestration between the normal and hyperplastic OS groups (P < 0.05). Conclusions: Hyperplastic OS makes bilateral TSs equal in diameter and weakens the predominance of the right TS. A hyperplastic OS reduces the occurrence of torcular Herophili fenestration.

Prenatal Three-Dimensional Ultrasound Diagnosis of Dural Sinus Arteriovenous Malformation: An Unusual Case Report.

BACKGROUND: Dural sinus arteriovenous malformation is an uncommon intracranial vascular malformation. The affected cases may suffer from severe neurological injury. Prenatal ultrasound has been used to diagnose fetal intracranial vascular abnormality, but prenatal three-dimensional (3D) ultrasound presents a very rare anomaly; an arteriovenous malformation of the dural sinus has not been reported. OBJECTIVE: This study aimed to emphasize the diagnostic value of 3D ultrasound in the fetus with dural sinus arteriovenous malformation. CASE PRESENTATION: A 38-year-old woman was referred for targeted fetal ultrasonography at 37 weeks of gestation due to an ultrasound that showed a cystic lesion in the posterior cranial fossa. The fetus demonstrated obvious dilatation of the torcular herophili, bilateral transverse sinuses, and bilateral sigmoid sinuses, appearing as a novel bull's horn sign on 3D ultrasound. After birth, cerebral angiography confirmed the diagnosis of dural arteriovenous fistula (DAVF) in the occipital sinus region. CONCLUSION: 3D ultrasound is an appealing method for prenatal diagnosis of dural sinus arteriovenous malformation.

Surgical Outcome of Torcula Herophili Meningioma: An Institutional Experience.

INTRODUCTION: Resection of meningiomas (THMs) at the torcular Herophili poses challenges to surgeons due to complex regional anatomy. The current study aims to evaluate factors affecting the extent of resections, progression-free survival, and the role of radiation. METHODS: We did a retrospective study of all the THM patients treated at our institute between May 1987 and June 2022. The demographic data, signs and symptoms, surgical notes, postoperative details, and radiotherapy were gathered retrospectively. Survival analysis was done with Kaplan-Meier tests along with predictors of the extent of resection as well as recurrence. RESULTS: A total of 39 patients qualified to be included in the study, with 10 male patients (male:female 1:2.9) and an average age of 50.8 years. The average follow-up duration was 75.9 months. Simpson's grade 2 excision was achieved in 19 (48.7%) patients, followed by Simpson's grade 3 excision in 17 patients (43.6%). Progression-free survival in subtotal resection was 60 months, and 100 months in gross total resection. Statistically, the extent of the resection was determined by the involvement of sinuses/torcula and the number of quadrants involved around torcula. A total of 16 patients received radiosurgery for the residual or small reccurrence of the lesion. Follow-up revealed reccurrence in 5 cases. CONCLUSIONS: Torcular meningiomas are relatively uncommon, described in few reports, and represent a therapeutic dilemma. Though some experts recommend complete removal of tumor and reconstruction of the sinus, others suggest maximum safe resection, followed by radiosurgery. The present study reflects reasonable control of the residual lesion with radiosurgery after maximum safe resection.

Prenatal diagnosis of torcular herophili thrombosis: report of 2 cases and review of the literature.

Prenatally diagnosed thrombosis of the torcular herophili is very rare, and it is sometimes misdisgnosed due to unfamiliarity. Sonography with color Doppler imaging is the key imaging modality for prenatal diagnosis of torcular herophili thrombosis. Typical prenatal sonographic findings include a well-defined triangular anechoic collection in the occipital region and an echogenic structure within the collection, which represents the thrombus. Fetal magnetic resonance imaging is usually used as an adjunctive modality for prenatal diagnosis, as it confirms the diagnosis by providing more precise anatomic information and better characterization of the lesion. We present 2 cases of thrombosis of an ectatic torcular herophili with serial sonographic and magnetic resonance imaging examinations, as well as a review of the literature regarding the prenatal diagnosis of torcular herophili thrombosis.

Cognard Type â ¤ Torcular Dural Arteriovenous Fistula: A Rare Entity.

Tentorial dural arteriovenous fistulas (DAVFs) are a dangerous subtype of fistula. Lawton et al classified this type of fistula into 6 categories based on specific operative strategies. Clinical manifestations of 6 types of tentorial DAVFs vary to some extent. Cognard type V DAVFs in the tentorial region are usually petrosal/superior petrosal sinus DAVFs. DAVFs with perimedullary venous drainage around the torcular herophili are rare. The veins of the posterior fossa are intricate and variable. There are anatomic communications between the perimedullary vein and cerebellar vein or veins of the brainstem. Almost all of the Cognard type V DAVFs are found in the posterior fossa. Here, we present a Cognard type V DAVF with a fistula located around the torcular herophili.

A retrospective study of 78 adult tentorial middle line region dural arteriovenous fistulae.

OBJECTIVE: Dural arteriovenous fistulae (DAVF) in the tentorial middle line region are uncommon with specific features and more cognitive disorders than any other region. The purpose of this study is to present clinical characteristics and our experience with endovascular treatment in this specific region. METHODS: During a 20-year period, 94.9% of patients (74/78) underwent endovascular treatment (36 in galenic, 48.6%) (12 in straight sinus, 16.2%) (26 in torcular, 35.1%). There were 63 males and 15 females with mean age of 50 (50 ± 12) years in total of 78 patients. The clinical presentation, angiographic features, treatment strategy, and clinical outcomes were recorded. RESULTS: Transarterial embolization (TAE) was performed in 89.2% of the 74 patients (66/74), transvenous embolization alone in one patient and mixed approach in seven. Complete obliteration of the fistulas was obtained in 87.5% of the patients (64/74). 71 patients (mean, 56 months) had phone, outpatient, or admission follow-up. The digital subtraction angiography (DSA) follow-up period (25/78, 32.1%) was 13.8 (6-21) months. Two of them (2/25, 8%) had fistula recurrences after complete embolization and were embolized again. The phone follow-up period (70/78, 89.7%) was 76.6 (40-92.3) months. Pre-embolization and post-embolization mRS ≥ 2 were in 44 patients (44/78) and 15 (15/71) patients, respectively. DAVF with internal cerebral vein drainage (OR 6.514, 95% Cl 1.201-35.317) and intracranial hemorrhage (OR 17.034, 95% Cl 1.122-258.612) during TAE were the risk factors for predicting poor outcomes (followed up mRS ≥ 2). CONCLUSIONS: TAE is the first-line treatment for tentorial middle line region DAVF. When pial feeders' obliteration is difficult to achieve, it should not be forced due to the poor outcomes after intracranial hemorrhage. The cognitive disorders caused by this region were not reversible as reported. It is imperative to enhance the care provided to these patients with cognitive disorders.

Spontaneous Resolution of Congenital Dural Venous Sinus Ectasia Associated With Polymicrogyria-Case Report.

Dural venous sinus ectasia belongs to a rare group of venous sinus malformations of unknown origin and uncertain prognosis. We report the first patient with idiopathic congenital ectasia of the confluence of sinuses with thrombosis associated with bilateral polymicrogyria. It may highlight the causative relation between ischemia within the central nervous system due to torcular herophili ectasia with thrombosis in early pregnancy and the development of cortical malformations in neonates. We also highlight the role of MR neuroimaging in the diagnosis of these entities.

Torcular pseudomass in a 14-month-old child: illustrative case.

BACKGROUND: "Torcular pseudomass," or redundant soft tissue in the torcular region, is not an infrequent incidental finding on advanced imaging of the brain in infants and young children. It was recently codified among pediatric neuroradiologists; however, its report in the pediatric neurosurgical community has not previously been elucidated. OBSERVATIONS: The authors present a case of a 14-month-old child who presented with fever and a first-time seizure. Computed tomography of the head suggested an epidural abscess; however, magnetic resonance imaging characteristics of the lesion were consistent with torcular pseudomass, a normal variant. At the 3-month follow-up, the child was continuing to do well and had not had another seizure. There have been no indications for surgical intervention or additional radiographic surveillance. LESSONS: The differential diagnosis for torcular pseudomass includes dural venous sinus thrombosis, dermoid cysts, occipital encephalocele, eosinophilic granuloma, and primary and metastatic tumors, such as neuroblastoma. The management of each of these disorders in the differential diagnosis may be much more invasive than continued observation in the case of torcular pseudomass. Therefore, it is important for pediatric neurosurgeons to become familiar with this developmental anomaly of the dura and occipital skull.

Contralateral Supracerebellar-Transtentorial Approach for Posterior Mediobasal Temporal Cavernous Malformation Resection.

Cerebral cavernous malformations are abnormal clusters of thin-walled sinusoidal vascular channels without intervening brain parenchyma. The most common presenting symptom is seizure, which results from hemosiderin deposition in surrounding tissues. Early surgical resection of these malformations confers the greatest likelihood of long-term seizure freedom. This operative video demonstrates the resection of a posterior mediobasal temporal cavernous malformation through a contralateral supracerebellar-transtentorial (cSCTT) approach. The patient, a 65-year-old woman, presented with a complex partial seizure with secondary generalization. On preoperative evaluation, she was neurologically intact. The risks and benefits of treatment alternatives, including observation, were explained to her. She consented to proceed with surgery to remove the cavernous malformation. The patient was placed in the sitting position with neck flexion to flatten the angle of the tentorium. A torcular craniotomy was performed to expose the confluence of the sagittal and transverse sinuses. Gravity retraction of the cerebellum plus contralateral supracerebellar arachnoid dissection allowed generous exposure of the ambient cistern and incisura with no brain retraction or transgression. The tentorium was opened, and the cavernous malformation was then circumferentially dissected and removed en bloc. Postoperative magnetic resonance imaging findings indicated complete resection without cortical injury. The patient remained free of seizures through the 6-month follow-up. Video 1 demonstrates the cSCTT approach to lesions of the posterior mediobasal temporal lobe without the need for retraction or transcortical dissection. The cSCTT approach extends the reach of the ipsilateral, infratentorial approach laterally, which is nearly 2 cm off midline, more than is possible without cutting the tentorium.

Torcular Herophili: A Review of the History of the Term and Synonyms.

The eponymous term torcular Herophili has been used for the confluence of sinuses. Although no original writings of Herophilus are extant, his accomplishments and descriptions live on in the writings of such authors as Galen. However, in regard to the torcular Herophili, there are some inconsistencies in the secondary sources and their translations regarding what was actually originally described by Herophilus. Herein, we review the history of the term torcular Herophili, which is so often used in clinical medicine.

Herophilus-Galen line as a predictor of extent of resection in the occipital interhemispheric transtentorial approach to pineal tumors in children.

OBJECTIVE: The goals of this study were to evaluate the extent of resection (EOR) obtained with an occipital interhemispheric transtentorial approach (OITA) in a series of pediatric patients with pineal region tumors and to define preoperative radiological factors predictive of the EOR. METHODS: This is a retrospective cohort study of a series of pediatric patients with pineal tumors who underwent surgery through a microsurgical OITA performed by the senior author during the period from January 2006 to January 2020. The tumor volume was measured preoperatively, and then on sagittal midline cuts the authors identified the most cranial point of the torcular Herophili (defined as the "Herophilus point") and the lowest point of the inferior profile of the vein of Galen (defined as the "Galen point"). The line joining these two points (defined as the "Herophilus-Galen line" [H-G line]) was used to identify the "Herophilus-Galen plane" (H-G plane) perpendicular to the sagittal plane. Tumor volumes located below and above this plane were measured. EOR was evaluated by measuring residual tumor volume visible on T1 volumetric injected sequences of immediate postoperative MRI. RESULTS: Thirty patients were selected for study inclusion. The preoperative mean tumor volume was 15.120 cm3 (range 0.129-104.3 cm3). The mean volumes were 2.717 cm3 (range 0-31 cm3) above the H-G plane and 12.40 cm3 (median 5.27 cm3, range 0.12-72.87 cm3) below the H-G plane. Three patients underwent only biopsy. Of the remaining 27 patients, gross-total resection (GTR; 100% tumor volume) was achieved in 20 patients (74%). In the remaining 7 patients, the mean residual tumor volume was 7.3 cm3 (range 0.26-17.88 cm3). In 3 of these patients, GTR was accomplished after further surgical procedures (1 in 2 patients, 3 in 1 patient) for an overall GTR rate of 85.18%. Larger tumor volume was significantly associated with incomplete resection (p < 0.001). A tumor volume ≤ 2 cm3 above the H-G plane (p = 0.003), linear extension ≤ 1 mm above the H-G line, and pineal histology were predictive of GTR at first OITA procedure (p = 0.001). CONCLUSIONS: The H-G line is an intuitive, easy-to-use, and reliable indicator of the superior anatomical limit of visibility during the microsurgical OITA. This anatomical landmark may be useful as a predictor of EOR for pineal tumors performed through this approach. The main limitations of this study are the small number of patients and the exclusively pediatric age of the patient population.

Ultrasound-guided transjugular embolization of ruptured huge venous ectasia of a Cognard IV tentorial dural arteriovenous fistula as a first-stage lifesaving procedure: Review of the literature.

Tentorium is a rare location of the brain dural arteriovenous fistulae (DAVF) consisting <4% of cases. Hemorrhagic clinical presentation is common, as cortical venous reflux consists a usual characteristic of tentorial DAVF's angioarchitecture. We present a case of transvenous, transjugular embolization of a ruptured huge venous ectasia of a Cognard IV tentorial middle-line DAVF, as a first step life-saving procedure. Initially, a transarterial antegrade embolization attempt was performed but failed due to the tortuous course of arterial feeders. Subsequently, the internal jugular vein (IJV) was directly catheterized under ultrasound (U/S) guidance and a 6F guiding catheter was placed at the ipsilateral transverse sinus. A microcatheter was navigated inside the venous ectasia and eventually, coils were deployed inside causing complete occlusion of the huge venous ectatic aneurysm. In this way, initial occlusion of the venous ectatic ruptured point has been achieved as a first-stage lifesaving treatment. Subsequently, the patient underwent stereotactic radiosurgery for the DAVF 4 months after embolization. Angiographic control with digital subtraction angiography 2 years after embolization and additional stereotactic radiosurgery revealed complete occlusion of the tentorial DAVF. The patient experienced complete neurological recovery. Direct puncture of the IJV under U/S guidance may assist transvenous embolization of ruptured venous ectasia in case of complex tentorial middle-line DAVFs type IV when the ecstatic venous aneurysm is recognized as the bleeding source.