Usefulness of Super-Selective Three-Dimensional Digital Subtraction Angiography in Endovascular Embolization of an Intracranial Dural Arteriovenous Fistula : Case report

Three-dimensional digital subtraction angiography (3D-DSA) provides better comprehension of vascular lesion archi- tecture. We report the usefulness of super-selective 3D-DSA for endovascular treatment of cavernous sinus dural arteriovenous fistula (dAVF). Case: A 65-year-old female patient suffered from a three-month history of right chemosis, exophthalmos and visual disturbance. Carotid angiogram revealed a right cavernous sinus dural arteriovenous fistula fed by many feeders branching from right external carotid artery. Draining veins drain mainly into the left inferior petrosal sinus (contra- lateral side) through the intercavernous sinus and partially into the right superior orbital vein. Intervention: Endovascular transvenous embolization (TVE) was performed. Rotational ascending pharyngeal angio- gram was performed, and a 3D image was reconstructed. Super-selective 3D-DSA clearly demonstrated feeding arteries, fistula point and draining veins, which were the approach route for the catheterization of TVE. By rotating the super-selective 3D-DSA images in the workstation, the best working angle for manipulating a microcatheter to the fistula point was selected. The microcatheter was successfully man ipulated very close to the fistula point. Then target embolization of the fistula was performed by only a little coil. Since a very tiny fistula remained after TVE, additional transarterial embolization of the feeding arteries was done. Finally, complete obliteration of the fistula was achieved. Conclusion: Super-selective 3D-DSA proved very useful for better understanding the complex vascular architecture of intracranial dAVF to select the best working angles for catheterization and develop an appropriate therapeutic strategy for endovascular treatment (especially for target embolization) for dAVF. Its usefulness assures good opera- tive and clinical outcomes.