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Journal Information
Vol. 31. Issue 7.
Pages 505-507 (September 2016)
Vol. 31. Issue 7.
Pages 505-507 (September 2016)
Letter to the Editor
DOI: 10.1016/j.nrleng.2014.11.001
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Transcranial puncture using Onyx for endovascular embolisation of dural arteriovenous fistula
Punción transcraneal arterial microselectiva e inyección de Onyx para el cierre endovascular de fístula arteriovenosa dural
N. Gonzaloa,
Corresponding author

Corresponding author.
, P. Naviab, J.A. Larreab, J. Massób
a Servicio de Neurología, Hospital Universitario Donostia, Donostia-San Sebastián, Guipúzcoa, Spain
b Servicio de Neurorradiología Intervencionista, Hospital Universitario Donostia, Donostia-San Sebastián, Guipúzcoa, Spain
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Dear Editor:

Dural arteriovenous fistulas (AVF) account for 10% to 15% of all intracranial vascular malformations.1,2 The overall annual risk of bleeding is approximately 1.5%.3 According to the Cognard classification,4–6 dural AVFs associated with leptomeningeal venous drainage or venous ectasia are considered to pose a high risk of haemorrhage.

Malignant dural AVFs, which are associated with cortical venous reflux, usually have an aggressive presentation, with a 35% risk of rebleeding within the first 2 weeks after the haemorrhage.7

Dural AVFs can be treated with surgery (endovascular treatment) or radiotherapy, the former being the treatment of choice in most cases.8,9 The direct transcranial approach through the parietal and mastoid foramina was developed by Houdart et al.10 Other authors11 have also described different surgical routes, including the dural sinus after craniectomy, the superior ophthalmic vein prior to surgical exposure, the cavernous sinus via the foramen rotundum, and the extracranial segment of the occipital arteries.

We present the case of a 56-year-old man with grade IV dural AVF according to the Cognard classification who displayed subarachnoid haemorrhage secondary to a ruptured flow-related aneurysm in the ascending artery (Fig. 1). The fistula, located near the tentorium, was supplied by both occipital arteries, the meningeal branches of the vertebral arteries, and the meningeal branches of the right internal carotid artery and the left superior cerebellar artery (the location of the aneurysm undergoing endovascular repair). The arteriovenous shunt was located medial to the attachment of the falx to the tentorium. We found large-calibre veins with retrograde flow draining to the straight sinus and signs of bilateral cortical reflux draining to the superior sagittal sinus.

Figure 1.

(A) Cranial CT scan: subarachnoid haemorrhage at symptom onset. (B) 3D reconstruction based on CT: flow-related aneurysm in the left external carotid artery. (C) Aneurysm embolisation. (D) Angiography: arterial supply from the meningeal branches of the external carotid artery; the point where the occipital artery becomes intracranial can be seen. (E) Angiography: thick drainage veins with blood flow inversion and draining to the straight sinus.


In view of the technical difficulties of performing distal catheterisation (marked elongation of the arteries ascending to the fistula and the tortuosity of the vein), we decided to perform a transcranial puncture of the right occipital artery through the parietal foramen (Fig. 2). After general anaesthesia was administered, the patient was placed in a prone position and the puncture was guided radiographically and angiographically. With an 18-gauge needle guided by direct fluoroscopy, a Marathon microcatheter (Covidien) was advanced to the arteriovenous shunt. After microcatheterisation we injected Onyx,8,12 which achieved complete occlusion of the AVF. The procedure was performed without incidents; at discharge, the patient remained asymptomatic.

Figure 2.

(A) Angiography: transcranial puncture of the occipital artery. (B) Fistula occluded with Onyx. (C) Surgical field with patient in a prone position. (D) Follow-up cranial CT scan.


In line with other studies,11,13 our case supports the hypothesis that the transcranial route is safe and effective when endovascular access is not viable due to blood vessel tortuosity.

In our view, a transcranial approach reduces treatment risks; in fact, it avoids the need for craniectomy. It also lowers the duration of the procedure and makes it easier to advance the microcatheter to reach the shunt location, which permits greater control over the injected liquid embolic agent.8,14 A possible complication specific to transcranial access is the formation of epidural or epicranial haematomas. The risk can be reduced by conducting a previous CT study of the foramen and performing the puncture using a map delivered by a catheter placed in the carotid.

In conclusion, transcranial puncture for the treatment of dural AVFs may be considered an effective endovascular technique when arterial or venous access is impossible or extremely complex.

Conflicts of interest

The authors have no conflicts of interest to declare.

A. Lussenhop.
Dural arteriovenous malformations and intracraneal hemorrhage.
Neurosurgery, pp. 1473-1477
T.H. Newton, S. Cronqvist.
Involvement of dural arteries in itracranial arteriovenous malformations.
Radiology, 93 (1969), pp. 1071-1078
R.D. Brown Jr., D.O. Wiebers, D.A. Nichols.
Intracranial dural arteriovenous fistulae: angiographic predictors of intracranial hemorrhage and clinical outcome in nonsurgical patients.
J Neurosurg, 81 (1994), pp. 531-538
C. Cognard, Y.P. Gobin, L. Pierot, A.L. Bailly, E. Houdart, A. Casasco, et al.
Cerebral dural arteriovenous fistulas: clinical and angiographic correlation with a revised classification of venous drainage.
Radiology, 194 (1995), pp. 671-680
J.A. Borden, J.K. Wu, W.A. Shucart.
A proposed classification for spinal and cranial dural arteriovenous fistulous malformations and implications for treatment.
J Neurosurg, 82 (1995), pp. 166-179
S. Geibprasert, V. Pereira, T. Krings, P. Jiarakongmun, F. Toulgoat, S. Pongpech, et al.
Dural arteriovenous shunts: a new classification of craniospinal epidural venous anatomical bases and clinical correlations.
Stroke, 39 (2008), pp. 2783-2794
H. Duffau, M. Lopes, V. Janosevic, J.P. Sichez, T. Faillot, L. Capelle, et al.
Early rebleeding from intracranial dural arteriovenous fistulas: report of 20 cases and review of the literature.
J Neurosurg, 90 (1999), pp. 78-84
C. Cognard, A.C. Januel, N.A. Silva Jr., P. Tall.
Endovascular treatment of intracranial dural arteriovenous fistulas with cortical venous drainage: new management using Onyx.
Am J Neuroradiol, 29 (2008), pp. 235-241
A. Santillan, M. Nanaszko, J.K. Burkhardt, A. Patsalides, Y.P. Gobin, H.A. Riina.
Endovascular management of intracranial dural arteriovenous fistulas: a review.
Clin Neurol Neurosurg, 115 (2013), pp. 241-251
E. Houdart, J.P. Saint-Maurice, R. Chapot, A. Ditchfield, A. Blanquet, G. Lot, et al.
Transcranial approach for venous embolization of dural arteriovenous fistulas.
J Neurosurg, 97 (2002), pp. 280-286
R. Chapot, J.P. Saint-Maurice, A.P. Narata, A. Rogopoulos, J.J. Moreau, E. Houdart, et al.
Transcranial puncture through the parietal and mastoid foramina for the treatment of dural fistulas. Report of four cases.
J Neurosurg, 106 (2007), pp. 912-915
R.G. Nogueira, G. Dabus, J.D. Rabinov, C.J. Eskey, C.S. Ogilvy, J.A. Hirsch, et al.
Preliminary experience with Onyx embolization for the treatment of intracranial dural arteriovenous fistulas.
AJNR Am J Neuroradiol, 29 (2008), pp. 91-97
P. Saura, J. Saura, A. Pérez-Higueras, M. Martínez-Galdámez.
Direct transforaminal Onyx embolization of intracranial dural arteriovenous fistulas: technical note and report of five cases.
J Neurointerv Surg, 6 (2014), pp. 500-504
J.M. Van Dijk, K.G. terBrugge, R.A. Willinsky, M.C. Wallace.
Clinical course of cranial dural arteriovenous fistulas with long-term persistent cortical venous reflux.
Stroke, 33 (2002), pp. 1233-1236

Please cite this article as: Gonzalo N, Navia P, Larrea JA, Massó J. Punción transcraneal arterial microselectiva e inyección de Onyx para el cierre endovascular de fístula arteriovenosa dural. Neurología. 2016;31:505–507.

Copyright © 2014. Sociedad Española de Neurología
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