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Direct superior sagittal sinus puncture via a surgical burr hole for curative embolization of the complex transverse-sigmoid sinus dural arteriovenous fistula: How I do it

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Abstract

Background

Transvenous embolization of high-grade dural arteriovenous fistulas (dAVFs) is challenging particularly when the direct sinus access is favorable due to the complex venous anatomy which prohibits endovascular access via the transfemoral approach.

Method

The procedure was conducted in the hybrid operating suite, where a burr hole was performed, followed by direct catheterization of the superior sagittal sinus. Coil embolization was then executed to achieve complete obliteration of the fistula.

Conclusion

The direct puncture of the superior sagittal sinus is a safe and effective method for treating complex dAVFs. This approach grants access to the fistula channel which facilitates curative embolization.

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Data availability

Not applicable.

Code availability

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Abbreviations

CT:

Computed tomography

DSA:

Digital subtraction angiography

ECA:

External carotid artery

ICA:

Internal carotid artery

dAVF:

Dural arteriovenous fistula

SSS:

Superior sagittal sinus

TSS:

Transverse-sigmoid sinus

TVE:

Transvenous embolization

References

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Author information

Authors and Affiliations

  1. Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Thammasat University, Thammasat University Hospital, Pathum Thani, 12120, Thailand

    Gahn Duangprasert & Dilok Tantongtip

Authors
  1. Gahn Duangprasert
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  2. Dilok Tantongtip
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Contributions

Gahn Duangprasert: conceptualization, investigation, data curation, writing an original draft, revise the manuscript. Dilok Tantongtip: supervision. All authors reviewed and approved the final version of the manuscript.

Corresponding author

Correspondence to Gahn Duangprasert.

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Ethics approval

The research project was conducted following the principles outlined in the Declaration of Helsinki. The ethics approval was waived by the local university hospital review board according to an anonymized presentation of a single case.

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Key points

1. Malignant dAVFs carry a high risk of intracranial bleeding secondary to the cortical venous reflux; therefore, complete fistula obliteration is mandatory despite the complexity of the venous access.

2. To determine the most suitable venous access for transvenous embolization, the anatomy of venous drainage must be comprehensively assessed prior to the procedure.

3. Transcranial approach should be considered for direct sinus puncture when the transfemoral approach is not feasible due to the complex venous anatomy.

4. The hybrid operating room facilitates the combined approach of surgical and endovascular procedures.

5. A variety of techniques can be employed to precisely localize the sinus, such as indocyanine green videography, neuronavigation, and fluoroscopy.

6. In order to prevent complications such as sinus perforation, which may result in intracranial bleeding, cautious cannulation is required when performing direct sinus access.

7. Since the affected sinus typically divides into several compartments, complete embolization would be achieved if the venous drainage route is directly accessed.

8. Superior sagittal sinus puncture should be performed as anteriorly as possible to avoid venous complications in cases where sinus sacrification is required.

9. While coils are widely used due to their durability and controllability, liquid embolic materials may also be utilized in conjunction with coils to ensure that the fistulas are completely occluded.

10. Particular cases of dAVFs might benefit from a combined endovascular and surgical approach, making this a crucial skill for hybrid neurovascular surgeons.

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Duangprasert, G., Tantongtip, D. Direct superior sagittal sinus puncture via a surgical burr hole for curative embolization of the complex transverse-sigmoid sinus dural arteriovenous fistula: How I do it. Acta Neurochir 166, 131 (2024). https://doi.org/10.1007/s00701-024-06020-2

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