Indication: Patient with a large left basal ganglia haemorrhage extension to the ventricles and right sided weakness. CTA no convincing AVM or DAVF. Patient was transferred from ICU intubated after placement of EVD for diagnostic angiography with view to intervention.
Technique & Findings:
A left parietal DAVF at the left lateral wall of the superior sagittal sinus is identified receives supply predominantly from middle meningeal branches of the left > right with a compact nidus of fistulas, and rapid arteriovenous shunting with drainage to the dilated cortical veins including vein of trolard & then to the superior sagittal sinus. No other significant external carotid supply. No supply from the internal carotids or vertebral arteries bilaterally. No aneurysms or evidence of arteriovenous malformations. Conventional aortic arch.
The lesion was distal to the site of bleeding but given the high grade Davf and risk of further bleeding for onyx embolisation. A 6Fr guiding catheter was placed in the external carotid artery, Apollo microcatheter navigated over microwire into the left MMA feeder just proximal to the nidus. Single pedicle Onyx 34 injection achieved angiographic complete obliteration. Superior sagittal sinus continue to fill normally.