Transarterial Embolization of Dural Arteriovenous Fistula in Superior Sagittal Sinus Under Bilateral External Carotid Artery Flow Control: Technical Note

Abstract Transarterial embolization (TAE) using liquid embolic material is a standard treatment for non-sinus-type dural arteriovenous fistula (DAVF). However, to reach embolic material over a shunt point for complete obliteration of DAVF is often difficult. We present a technical case report of an efficacy of bilateral external carotid artery (ECA) flow control for the TAE of superior sagittal sinus (SSS) DAVF. A 64-year-old man presented with dizziness and left hemiparesis. Computed tomography imaging showed right parietal subcortical hemorrhage, and cerebral angiography revealed a DAVF in the superior sagittal sinus (SSS) fed by bilateral occipital artery (OA), bilateral superficial temporal artery (STA) and bilateral middle meningeal artery (MMA), with cortical venous reflux and without connection to the SSS. We therefore planned TAE using glue via MMA under bilateral ECA flow control. A 7Fr. balloon guide catheter (GC) was positioned in the bilateral ECA origins, and a microcatheter was introduced distal to the MMA. Heated 20 % n-butyl-2-cyanoacrylate (NBCA) was slowly injected via the left MMA under bilateral ECA origin flow control. The NBCA reached the shunt point and obliterated the shunt in a single session. The patient was discharged without neurological symptoms. Bilateral ECA flow control using balloon GC is safe and effective for a DAVF in the SSS with multiple and tortuous scalp feeders. (213 words)