Endovascular Treatment of Medial Tentorial Dural Arteriovenous Fistula Through the Dural Branch of the Pial Artery

Case report: Onyx embolization of tentorial dural arteriovenous fistula via the meningohypophyseal trunk and medial tentorial artery of Bernasconi-Cassinari

For tentorial dural arteriovenous fistula (TDAVF), the meningohypophyseal trunk (MHT), and medial tentorial artery (MTA) of Bernasconi-Cassinari are rarely used as transarterial paths to perform the successful endovascular treatment (EVT). We reported a TDAVF mainly fed by the MHT. Onyx-18 casting in the MTA of Bernasconi-Cassinari under the assistance of coil embolization in proximal MHT was performed. The technique was reported in case 1. At the same time, case 2 with a similar TDAVF was chosen as a control. In case 1, a 52-year-old man suffered a cerebellar hemorrhage. A TDAVF was confirmed by computed tomography angiography and digital subtraction angiography. The feeding arteries included the MHT, middle meningeal artery (MMA), and the artery of Wollschlaeger and Wollschlaeger of the superior cerebellar artery. The MHT and MTA of Bernasconi-Cassinari were hypertrophied. First, a Marathon microcatheter was placed in the MTA to wait for Onyx casting, and then an Echelon-10 microcatheter was placed in the proximal MHT trunk with an aneurysmal dilation to perform coiling to prevent Onyx reflux. Then, Onyx casting obliterated the TDAVF. Case 2 was a 75-year-old woman with TDAVF, and the MTA of Bernasconi-Cassinari was the main feeder. First, the TDAVF experienced incomplete EVT with Onyx casting via the MTA under no assistance of coil embolization in the proximal MTA. The second EVT had to be performed via MMA. Then, Onyx casting obliterated the TDAVF. Therefore, for selected TDAVFs with hypertrophied MHT, under the assistance of coil embolization in proximal MHT, Onyx casting via MHT can finish the complete EVT.

Analysis of the Pial Arterial Supply as a Cause of Intraprocedural Hemorrhage During Transarterial Liquid Embolization of Tentorial Dural Arteriovenous Fistulas

OBJECTIVE

Tentorial dural arteriovenous fistulas (AVFs) are bridging vein shunts, and are therefore sometimes supplied by the pial artery as well as the dural artery. Recently, intraprocedural hemorrhage from the pial artery was reported, and we experienced 2 tentorial dural AVFs with the same complication. Pure pial artery has a glomus-like structure and forms direct shunts along the draining vein, and is likely to bleed after restriction of the draining vein caused by the transarterial embolization. This study investigated the characteristics of the pial arterial supply as a cause of hemorrhage.

METHODS

Twenty-six tentorial dural AVFs in 25 patients treated in our institute were retrospectively investigated and the characteristics of the pial feeders responsible for bleeding were analyzed.

RESULTS

Thirteen pial arterial feeders (pure pial feeder in 7, dilated dural branch of the pial artery in 4, and undefined in 2) were identified in 10 of the 26 tentorial dural AVFs. Pure pial feeders were responsible for bleeding in 2 tentorial dural AVFs.

CONCLUSIONS

To prevent intraprocedural hemorrhage, differentiation of the pure pial supply from the dural branch of the pial artery is important. The infratentorial artery will supply supratentorial fistula as the dural branch after passing through the tentorium. In contrast, the supratentorial artery can supply supratentorial fistula not only as a dural branch but also as a pure pial feeder. Therefore, attribution of the fistula and the pial supply, supratentorial or infratentorial, is useful in identifying pure pial supply.