Safety evaluation of sinus patency after stereotactic radiosurgery for transverse-sigmoid sinus dural arteriovenous fistulas: implications of treatment options for patients with Borden type I fistulas.

OBJECTIVE: This study aimed to assess the efficacy and safety of stereotactic radiosurgery (SRS) in treating transverse-sigmoid sinus dural arteriovenous fistulas (TSS DAVFs), and to investigate post-SRS sinus patency, focusing on the risk factors associated with treated sinus occlusion. METHODS: Data from 34 patients treated with SRS between January 2006 and April 2023 were analyzed. Detailed angioarchitecture was confirmed using digital subtraction angiography before SRS. Angiography of the ipsilateral internal carotid artery and vertebral artery was performed to evaluate whether the involved side of the TSS was used for normal venous drainage. TSS stenosis was defined as sinus diameter < 50% of the normal proximal diameter. DAVF shunt obliteration, TSS occlusion, neurological status, and adverse events were also evaluated. RESULTS: Of the 34 patients, 21 had Borden type I and 14 had Borden type II DAVFs. The median age at SRS was 64 years (interquartile range 54-71 years), and the follow-up period was 31 months (interquartile range 15-94 months). Complete shunt obliteration was achieved in 24 (70.6%) patients. The cumulative 2-, 3-, and 5-year shunt obliteration rates were 49.6%, 71.2%, and 86.0%, respectively. Borden type I had higher obliteration rates (60.5%, 83.1%, and 94.4%, respectively) than Borden type II (41.7%, 51.4%, and 75.7%, respectively; p = 0.034). TSS occlusion occurred in 5 patients (14.7%). The cumulative 1-, 5-, and 10-year TSS occlusion rates were 2.9%, 8.3%, and 23.6%, respectively, across the entire cohort. All occlusions occurred exclusively in the sinuses that were not used for normal venous drainage. Cox proportional analyses revealed that TSS stenosis and the sinus not being used for normal venous drainage were significantly associated with a greater risk of TSS occlusion after SRS (HR 9.44, 95% CI 1.01-77.13; p = 0.049). CONCLUSIONS: SRS is effective and safe for TSS DAVF and results in favorable shunt obliteration, symptom improvement, and low complication rates. TSS occlusion after SRS is asymptomatic and is limited to sinuses that are not used for normal venous drainage.

Torcular dural AVF: Transvenous onyx embolisation with sinus reconstruction.

Transvenous onyx (Microtherapeutics, Irvine, CA, USA) embolization with sinus reconstruction using a venous balloon is a novel technique to embolise dural arterial venous fistula while preserving the sinus. We elucidate the technical tips and tricks that were employed to treat this torcular dural AVF in an elderly male with visual disturbances secondary to papilledema. Right external carotid artery injection revealed a type 2c fistula along the torcula with feeders from the right parietal & petrosal branches of the middle meningeal artery and dural branches of the posterior auricular and the occipital artery. The right distal transverse and the sigmoid were occluded with retrograde flow into the superior sagittal sinus and the cortical veins. XPER CTA analysis revealed the fistula point to be along the wall of the torcula. Through right femoral artery access, a neuron max (Penumbra inc.USA) was placed in the right common carotid artery. An eclipse (Balt Extrusion, France) 6 × 12 mm single lumen balloon was placed in the proximal ECA to achieve flow reduction. Thereafter, through bilateral femoral venous approach, two neuron max 8 F (Penumbra inc.USA) were placed into the left jugular vein. A Copernic RC balloon 10×80 mm (Balt Extrusion, France) was placed from the left to the right transverse sinus. Further, two microcatheters, 1.5 F Marathon (Medtronic, Minneapolis, MI, USA) were navigated into the feeding arteries from the venous end. Microcatheter injections were taken with inflation of the venous balloon to determine the point at which sinus and cortical vein reflux is absent. Following that onyx 18 was injected under biplane fluoroscopy with an adequately inflated arterial and venous balloon. We could achieve retrograde permeation of the onyx into the fistula and the arterial feeders resulting in complete occlusion while preserving the sinus. Careful analysis of the angioarchitecture of the fistula and evaluating for delayed cerebral venous drainage is the key to determining the right strategy to achieve complete occlusion of the fistula.

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.

Can occipital lobe bending, Gibraltar sign of superior sagittal sinus groove and jugular foramen dimensions predict transverse sinus dominance?

BACKGROUND: Asymmetry between the transverse sinuses (TS) is quite common. We sought to test the possible hypothesis that certain anatomical features - namely, occipital lobe bending, Gibraltar sign of superior sagittal sinus groove (SSS) and jugular foramen (JF) dimensions - can predict dominance of the transverse sinuses on routine axial T1- and T2-weighted images. MATERIALS AND METHODS: One hundred consecutively acquired combined MRI-MRV studies of brain were reviewed. On non-contrast axial T1WI, each reviewer assessed the occipital lobe bending, and Gibraltar sign of SSS groove; on axial T2-weighted images, JF dimensions were measured. TS cross-sectional area was measured on non-contrast sagittal 2-dimensional phase contrast MRV images and served as the reference standard. RESULTS: Of the 51 subjects with right-dominant TS, 37 had occipital bending to the right side and 35 showed sloping of the Gibraltar sign to right side. Of the 18 subjects with left dominant TS, 10 had occipital bending to left side and 13 showed left-sided sloping of the Gibraltar sign. Of the 31 subjects with co-dominant TS, 15 had no occipital bending and 20 showed no sloping of the Gibraltar sign. Mean right and left JF dimensions were higher in the right and left dominant TS respectively with no significant differences in patients with co-dominant sinus (p < 0.02). CONCLUSION: Right occipital bending had a good association with right TS dominance. The other two parameters- Gibraltar sign of superior sagittal sinus groove and jugular foramen dimensions - did not have a very good association with respect to TS dominance.

A new method for assessing transverse sinus stenosis with CT venography based on the venous trans-stenotic pressure gradient.

BACKGROUND: Evaluation of the transverse sinus stenosis (TSS) is essential for TSS-related diseases. OBJECTIVE: To investigate a new method for the quantitative assessment of TSS based on the correlation between TSS and trans-stenotic pressure gradient (TPG). METHODS: Patients with unilateral pulsatile tinnitus with or without idiopathic intracranial hypertension were retrospectively included. All patients underwent CT venography and venous manometry and were confirmed to have TSS. The cross-sectional diameter/area of TSS, the poststenotic and prestenotic segments, and the superior sagittal sinus (SSS) were measured. The degree of TSS was calculated by dividing the diameter/area of TSS by the diameter/area of the poststenotic segment (M1/M2), prestenotic segment (M3/M4), and SSS (M5/M6). Partial correlation analysis (controlling for the effect of age, sex, outflow laterality, and contralateral stenosis) was performed to evaluate the correlation between M1-M6 and the TPG. Receiver operating characteristic curve analysis of M1-M6 for diagnosing a significant TPG (≥8 mm Hg) was performed. RESULTS: Ninety-nine patients met the inclusion criteria. The partial correlation coefficients between M1-M6 and the TPG were 0.60, 0.61, 0.43, 0.48, 0.39, and 0.54, respectively. The areas under the curve (AUCs) of M1-M6 for diagnosing a significant TPG were 0.81, 0.86, 0.68, 0.69, 0.64, and 0.72, respectively. The AUC of M2 was significantly larger than that of M3 (P=0.002), M4 (P<0.001), M5 (P=0.001), and M6 (P<0.001). CONCLUSIONS: Quantitatively assessing TSS by taking the ratio of the cross-sectional area of TSS to that of the poststenotic segment might be a more efficient method for predicting the TPG.

Outflow Patency Correlates with Radiosurgical Outcomes of Lateral Sinus Dural Arteriovenous Fistula.

OBJECTIVE: To explore the impact of outflow patency on radiosurgical outcomes of lateral sinus dural arteriovenous fistulas (DAVFs). METHODS: We retrospectively examined 83 lateral sinus DAVFs treated with Gamma Knife radiosurgery (GKRS) between 1995 and 2020. Two neuroradiologists blinded to the therapeutic outcomes served as imaging evaluators on pre-GKRS digital subtraction angiography and magnetic resonance images. The sinovenous outflow of lateral sinus DAVF was scored using combined conduit score (CCS), ranging from 0 (total occlusion) to 8 (full patency). The patients' follow-up magnetic resonance and digital subtraction angiography images were used to validate the radiosurgical outcomes (obliteration or non-obliteration) of lateral sinus DAVF. Cox regression and Kaplan-Meier analyses were performed to determine the correlations between the variables and outcomes. RESULTS: Among the 83 cases, 60 (72%) lateral sinus DAVFs achieved obliteration after a GKRS at a median latency period of 24.5 months. After adjustment for aggressive presentation, cortical venous reflux, straight sinus reflux, and optic nerve sheath enlargement, a CCS of >6 was independently associated with lateral sinus DAVF obliteration (hazard ratio: 2.335, P = 0.007). The estimated 36-month probabilities of obliteration were 80% versus 53.6% for lateral sinus DAVFs with a CCS of >6 versus ≤6. CONCLUSIONS: Lateral sinus DAVFs with a CCS of >6, indicating a nearly patent sinovenous outflow, were more likely to be obliterated after GKRS. Sinovenous outflow patency is a factor associated with therapeutic outcomes in radiosurgery for lateral sinus DAVFs.

Sinovenous outflow in lateral sinus dural arteriovenous fistulas after stereotactic radiosurgery: a retrospective longitudinal imaging study.

PURPOSE: To investigate sinovenous outflow restriction (SOR) in lateral sinus dural arteriovenous fistulas (LSDAVFs) after Gamma Knife radiosurgery (GKRS) and its association with complete obliteration. METHODS: We retrospectively (1995-2019) enrolled 39 patients with LSDAVFs who had undergone GKRS alone and evaluated their angiography and magnetic resonance imaging (MRI) before and after GKRS. The LS conduits ipsilateral and contralateral to the DAVFs were scored using a 5-point scoring system, with scores ranging from 0 (total occlusion) to 4 (fully patent). SOR was defined by a conduit score < 2. Demographics, imaging features, and outcomes were compared between patients with and without ipsilateral SOR after GKRS. Logistic regression analysis was performed to estimate the odds ratio (OR) for obliteration with the imaging findings. RESULTS: After a median angiographic follow-up of 28 months for the 39 patients, the ipsilateral LS became more restrictive (median conduit score before and after GKRS: 2 vs. 1, p = .011). Twenty-one patients with ipsilateral SOR after GKRS had a significantly lower obliteration rate (52.4% vs. 94.4%, p = .005) than those without SOR. Follow-up SOR was independently associated with a lower obliteration rate (OR 0.05, p = .017) after adjustment for age, cortical venous reflux, and absent sinus flow void on MRI. CONCLUSION: This study demonstrates a restrictive change of outflow in LSDAVFs after GKRS and a lower obliteration rate in patients with SOR. Follow-up imaging for SOR may help predict outcomes of these patients.

Crouzon's Syndrome with a Dominant Sinus Pericranii Draining Transverse Sinus: Report of a Rare Association and Review of Literature.

INTRODUCTION: Crouzon's syndrome and sinus pericranii (SP) are rare entities. Only few cases having both the features are reported. SP most commonly drains in relation to superior sagittal sinus and their communication to major posterior dural sinuses is rare. CASE REPORT: We report a rare case of Crouzon's syndrome with SP at a suboccipital location with termination of left transverse sinus into the SP draining further through the extracranial suboccipital and extravertebral cervical venous plexi into external jugular veins. Distal transverse sinus and sigmoid sinus on the left side were absent. CONCLUSION: Crouzon's syndrome with SP is an extremely rare entity. SP with communication to major posterior dural venous sinuses is also rare and mostly associated with multi-suture craniosynostosis. Management depends on the volume of venous blood they are draining. Most of them are dominant type and their occlusion is not feasible. Preoperative diagnosis of a dominant SP is essential for proper surgical planning as it needs to be preserved mandatorily to prevent cerebral venous infarction.

Gradual dilatation of an occluded transverse sinus associated with dural arteriovenous fistula after balloon angioplasty with sinus packing: A case report.

BACKGROUND: There is no consensus as to whether balloon angioplasty alone or stent placement is effective for sinus occlusion associated with dural arteriovenous fistula (DAVF). Herein, we first report a case of transverse sinus occlusion associated with DAVF in which gradual sinus dilatation was observed after balloon angioplasty with embolization of the affected sinus with shunt flow. CASE PRESENTATION: A 69-year-old man presented with executive dysfunction. Magnetic resonance imaging revealed left transverse sinus-sigmoid sinus DAVF with occlusion of the left jugular vein and right transverse sinus. Before endovascular treatment, the patient had symptomatic epilepsy and subarachnoid hemorrhage. Retrograde leptomeningeal venous drainage disappeared with packing of the left transverse sinus-sigmoid sinus. Subsequently, balloon angioplasty of the right occluded transverse sinus was performed to maintain the normal venous drainage and remaining shunt outflow. Dilatation of the right transverse sinus was poor immediately after surgery. However, angiography after 10 days and 6 months revealed gradual dilatation of the right transverse sinus. CONCLUSION: Sinus occlusion, which is thought to be caused by sinus hypertension associated with DAVF rather than chronic organized thrombosis or thrombophilia, may dilate over time after balloon angioplasty and shunt flow reduction if occluded sinus is necessary for facilitating normal venous drainage.

Bilateral absence of the transverse sinuses with fenestrated superior sagittal sinus draining through enlarged occipital and marginal sinuses.

The endothelial-lined dural venous sinuses collect blood from the brain, meninges, and calvaria and drain it to the internal jugular veins. The adult drainage pathway of the venous sinuses confluent is commonly via the transverse and sigmoid sinuses to the jugular bulb. The occipital (OS) and marginal (MS) sinuses are well-represented before birth, in most cases. During a retrospective study of the computed tomography angiograms of a 64-year-old female was found a rare combination of variants of the posterior fossa sinuses. The confluence of the dural venous sinuses was rhomboidal and drained superiorly the superior sagittal sinus, and inferiorly a well-represented OS. The transverse sinuses were aplastic, on the right side, and hypoplastic on the opposite side. The OS further drained into the MS which, on each side, emptied into the respective jugular bulb. On each side a condylar vein left the junction of the sigmoid sinus and jugular bulb. Such posterior fossa drainage, exclusively on the OS-MS pathway, should be kept in mind when transections of the venous sinuses are intended during neurosurgical approaches of the foramen magnum. The OS-MS drainage is rather a persisting foetal pattern. The bilateral anatomical exclusion of the transverse sinuses is an added condition to spare the OS and MS.

Dural Venous Sinus Variations in Idiopathic Subarachnoid Hemorrhage: A New Indicator of the Venous Origin with Diagnostic Usefulness?

OBJECTIVE: Venous hypertension associated with a primitive basal vein of Rosenthal (BVR) has been noted as the most likely cause of idiopathic subarachnoid hemorrhage (iSAH). Other types of venous drainage variations have been scarcely studied but may further explain the cases not associated with a BVR anomaly. Our aim was to investigate if dural venous sinus (DVS) anomalies are related with iSAH. METHODS: A total of 76 patients diagnosed with iSAH were identified from a prospectively maintained database and their angiographic findings compared with 76 patients diagnosed with aneurysmal subarachnoid hemorrhage. RESULTS: On top of the BVR variations, our data showed a higher prevalence of transverse sinus hypoplasia (47.4% vs. 28.9%; P = 0.019), superior petrosal sinus hypoplasia (32.9% vs. 13.2%; P = 0.003), and clival plexus hyperplasia (65.8% vs. 43.4%; P = 0.005) in patients with iSAH. Analyzing by total number of angiograms, the iSAH group showed also a higher prevalence of inferior petrosal sinus hyperplasia (36.2% vs. 25%; P = 0.003). Of the patients with iSAH without a primitive BVR, 84% harbored ≥1 perimesencephalic DVS variation and the overall number of venous drainage variations was significantly higher in patients with iSAH. CONCLUSIONS: In addition to the well-documented BVR anomalies, there seems to be a significant relationship of other DVS variations in patients with iSAH. Transverse sinus hypoplasia, superior petrosal sinus hypoplasia, inferior petrosal sinus hyperplasia, and clival plexus hyperplasia were significantly more frequent in patients with iSAH. The presence of ≥3 of those variations would increase the suspicion of a nonaneurysmatic subarachnoid hemorrhage and could help avoid a second angiogram.

Navigability of a long sheath in the lateral dural sinuses facilitated by the pilot balloon technique: technical note.

Dural sinus stenting is an increasingly recognized intervention for the treatment of lateral sinus stenosis. This procedure can be challenging in tortuous anatomy and in the presence of intraluminal septa because of poor trackability and crossability of long sheath commonly used for stenting. We report a technique using a pilot angioplasty balloon positioned at the distal end of the long sheath that improves its navigability in dural sinuses and facilitated the intervention.

Intracranial venous sinus stenting for the treatment of lateral sinus stenoses: An analysis of 200 patients.

PURPOSE: The purpose of this study was to analyze the long-term efficacy and safety of intracranial venous sinus stenting in a large cohort of patients with any type of presentation of primary lateral venous sinus stenosis (VSS). MATERIALS AND METHODS: A retrospective cohort study was performed including patients treated by venous sinus stenting for symptomatic VSS from 2012 to 2019. Successful primary resolution of symptoms without adjunctive treatment or recurrence, and complications after stenting were analyzed at the last follow-up time point. RESULTS: Two-hundred patients were included. There were 14 men and 186 women with a mean age of 39±14 (SD) years (age range: 13-75 years). Presenting symptoms included venous pulsatile tinnitus in 168 patients (168/200; 84%), idiopathic intracranial hypertension in 100 patients (100/200; 50%) and/or spontaneous cerebrospinal fluid leak in 35 patients (35/200; 17%). The overall rate of successful primary resolution of any typical presenting symptoms was 79% (95% CI: 73-85%). This rate ranged from 74% to 93% depending on the symptom with no significant difference between patients with and those without idiopathic intracranial hypertension (P=0.08). Recurrence rate was 10% (95% CI: 6-14%). No death or permanent morbidity were observed during a median follow-up of 2.2 years (Q1, Q3: 1.4, 3.3; range: 1-7.7 years). CONCLUSION: Our study shows that venous sinus stenting has a low morbidity and high success rate at long-term follow-up for the treatment of idiopathic intracranial hypertension, venous pulsatile tinnitus or spontaneous cerebrospinal fluid leak associated with VSS. The excellent safety suggests considering this treatment as first-line treatment when medical management is ineffective or poorly tolerated.

State of the Art: Venous Causes of Pulsatile Tinnitus and Diagnostic Considerations Guiding Endovascular Therapy.

Venous variants and pathologic abnormalities are the most common causes of pulsatile tinnitus. These conditions include causes of turbulence within normally located veins and sinuses, and abnormally enlarged or abnormally located veins in close transmissive proximity to the conductive auditory pathway. Such disorders include pathologic abnormalities of the lateral sinus (transverse sinus stenosis and sigmoid sinus wall anomalies), abnormalities and variants of the emissary veins, and anomalies of the jugular bulb and jugular vein. Despite being the most common causes for pulsatile tinnitus, venous variants and pathologic abnormalities are often overlooked in the workup of pulsatile tinnitus. Such oversights can result in delayed patient care and prolonged patient discomfort. Advances in both cerebrovascular imaging and endovascular techniques allow for improved diagnostic accuracy and an increasing range of endovascular therapeutic options to address pulsatile tinnitus. This review illustrates the venous causes of pulsatile tinnitus and demonstrates the associated endovascular treatment. © RSNA, 2021.

Balloon anchoring to traverse the sigmoid sinus for delivery of large-caliber venous stents: A technical note.

BACKGROUND: In the reconstruction of the superior sagittal sinus or transverse sinus, it is desirable to place a large-diameter guiding catheter into the transverse sinus to introduce the stent delivery system smoothly. The utility of an anchoring technique with a percutaneous transluminal angioplasty (PTA) balloon for navigating an 8 F guiding catheter into the transverse sinus is demonstrated.Case Descriptions: Two dural arteriovenous fistula (dAVF) cases (Cognard type II a +b, Borden type II) that underwent sinus stenting are presented. In both cases, when the 8 F guiding catheter was placed in the jugular vein, the stent delivery system could not enter the transverse sinus because it could not pass through the transverse-sigmoid sinus junction. Introduction of an 8 F guiding catheter into the transverse sinus was attempted but failed. An 8-mm or 9-mm PTA balloon was used as a distal anchor, and this technique allowed easier guiding of catheter advancement into the transverse sinus. In both cases, Carotid WALLSTENTS were placed in the sinus easily, with no complications. CONCLUSION: Balloon anchoring in the venous system is useful for achieving large-caliber catheter access across difficult anatomy and is technically feasible.

Hydroacoustic analysis and extraluminal compression surgical insights of venous pulsatile tinnitus.

OBJECTIVE: This study aimed to quantitatively and qualitatively evaluate the hydroacoustic changes from "presence" to "disappearance" of pulsatile tinnitus (PT) with the extraluminal compression surgical technique. The recent issues of concern pertaining to the hydroacoustic characteristics of sigmoid sinus wall anomalies and distal transverse sinus stenosis (dTSS) were discussed. METHODS: This study was based on a retrospective case series. Seventy-seven patients with PT and transverse-sigmoid sinus enlargement with or without transverse-sigmoid sinus junction anomalies and transverse sinus stenosis (TSS) who had undergone extraluminal compression surgery under local anesthesia were included. Management of intractable intraoperative challenges and techniques for reversal extraluminal compression were introduced. Anatomical measurements, intraoperative color-coded Doppler ultrasonography, spectro-temporal analysis, and computational fluid dynamics were employed to analyze the hydroacoustic characteristics of PT. RESULTS: The efficacy of the extraluminal compression technique was evident with the significant reduction in peak turbulent kinetic energy, vorticity, and mean pressure gradient at the transverse-sigmoid junction, resulting in over 20% reduction in PT amplitude. dTSS is a common finding in patients with PT exhibiting transverse-sigmoid sinus enlargement. Patients with dTSS presented with significant differences in hemodynamic characteristics as compared to those without. Linear regression analysis showed that the flow disturbance (turbulent kinetic energy and vorticity) was closely associated with the degree of dTSS, whereas the flow amplitude was not related to the degree or location of TSS. Low-pulsatory vortex flow at the transverse-sigmoid junction was visualized during an intraoperative color-coded Doppler examination, and the displayed low-frequency PT sound corresponded to the patients' subjective perception of PT. CONCLUSION: (1) A reduction of over 20% of the flow-induced noise is the therapeutic goal of extraluminal compression technique. Since reductions in the magnitude of hemodynamic parameters, including turbulent kinetic energy, vorticity, and mean pressure gradient, render the flow-induced noise inaudible, besides sigmoid sinus wall anomalies, it is likely that PT develops from the aggregation of flow-based pathologies. (2) Although dTSS and diverticulum may greatly affect the hemodynamics at the transverse-sigmoid junction, in contrast to dehiscence, dTSS and diverticulum may not be the limiting factors for PT development.

Transvenous Coil Embolization of a Transverse-Sigmoid Sinus Dural Arteriovenous Fistula: 2-Dimensional Operative Video.

This case is a 66-yr-old woman with a 2-mo history of left-sided tinnitus. Workup with magnetic resonance angiography showed early opacification of the left sigmoid sinus and internal jugular vein as well as asymmetric and abundant opacification of the left external carotid artery branches, suspicious for a dural arteriovenous fistula (dAVF). Diagnosis was confirmed with cerebral angiography, consistent with a left-sided Cognard type I dAVF.1 Initial treatment attempt was made with transarterial 6% ethylene-vinyl alcohol copolymer (Onyx 18) embolization of feeders from the occipital and middle meningeal arteries. However, embolization was not curative and there was a recurrence of a highly bothersome tinnitus 3 wk following treatment. Angiography redemonstrated the transverse sinus dAVF with new recruitment arising from several feeders, including the left external carotid artery, middle meningeal artery, and superficial temporal artery, now Cognard type IIa. Definitive treatment through a transvenous coil embolization provided permanent obliteration of the fistula without recrudescence of symptoms on follow-up. In this video, the authors discuss the nuances of treating a dAVF via a transvenous embolization. Patient consent was given prior to the procedure, and consent and approval for this operative video were waived because of the retrospective nature of this manuscript and the anonymized video material.

Direct Transverse Sinus Cannulation for Coil Embolization of a Transverse-Sigmoid Sinus Dural Arteriovenous Fistula: 2-Dimensional Operative Video.

A 65-yr-old male presented 2 mo after an episode of acute-onset headache associated with altered mental status. Imaging workup with cerebral angiography revealed a Cognard type IV right-sided transverse-sigmoid junction dural arteriovenous fistula (dAVF). The patient was treated with endovascular embolization of several pedicles from the middle meningeal (MMA) and occipital arteries. Residual filling and cortical venous reflux were noted on follow-up imaging. Therefore, definitive treatment of the persistent fistula was offered with a combined open and endovascular embolization approach.1 This would provide direct access into the sinus followed by embolization of the fistula. In the accompanying video, we present the case in detail and provide a discussion of the rational and treatment nuances associated with this approach. Patient consent was given prior to the procedure and consent and approval for this operative video were waived due to the retrospective nature of this manuscript and the anonymized video material.

Associations Between Doppler Internal Jugular Vein Blood Flow and Transverse Sinus Stasis Detected by Magnetic Resonance Imaging.

OBJECTIVES: This study aimed to compare the estimated internal jugular vein (IJV) volume flow with Doppler ultrasound in patients with slow flow in the transverse sinuses and normal transverse sinuses on brain magnetic resonance imaging (MRI). METHODS: Eighty patients between the ages of 18 and 80 years who did not have any signs of sinus vein thrombosis on brain MRI were included. On MRI, cases with hyperintensity due to a signal void loss in the transverse sinuses in coronal fluid attenuation inversion recovery sequences were included in the slow-flow group. The presence of sinus thrombosis was excluded with other MRI pulse sequences and clinical findings. The participants were divided into 2 groups as having normal and slow flow according to MRI findings. Then bilateral IJV volume flow measurements were made by Doppler ultrasound. Bilateral volume flow was estimated by time-averaged blood flow velocities sampled in the center of the IJV, and IJV cross-sectional areas were measured. We defined the dominant IJV as the one having the higher estimated volume flow of the 2 sides. RESULTS: Total estimated IJV blood flow was lower (P < .001) in patients with slow flow on MRI (546 mL/min) compared to those without (768 mL/min). A similar finding was seen for the nondominant IJV. In a receiver operating characteristic analysis, the cutoff value for the total estimated IJV volume flow was determined to be 590 mL/min, and the cutoff value for nondominant estimated IJV volume flow was determined to be 202 mL/min to distinguish between the groups. CONCLUSIONS: Low estimated volume blood flow in the IJV is associated with MRI evidence of stasis in the ipsilateral transverse sinus.