Embolization of a Dural Arteriovenous Fistula Using Transcranial Middle Meningeal Artery Access: 2-Dimensional Operative Video.

The transcranial approach for direct middle meningeal artery (MMA) access to embolize dural arteriovenous fistulas (dAVF) has been described, but limited information regarding the setup, equipment, and technique is available. We present the details of this hybrid approach in the setting of a ruptured Cognard grade IV tentorial dAVF (Video 1). The patient was an adult female who presented with nausea, vomiting, and dizziness and was found to have a cerebellar hemorrhage. Catheter angiography revealed a tentorial dAVF fed by bilateral middle meningeal, left posterior meningeal, and left occipital arteries. Attempted transarterial embolizations through each of these were unsuccessful. The left MMA was a primary source of supply, but distal microcatheter placement was not possible due to proximal tortuosity. Therefore transcranial MMA access distal to this tortuosity was pursued. The MMA was localized using roadmap angiography and a temporal craniectomy was completed over the artery. A 4-French sheath was placed, and super selective angiography was performed, demonstrating the fistula. A microcatheter was navigated to the fistula and it was embolized with Onyx. Postoperative angiogram demonstrated fistula occlusion. The patient remained at her neurologic baseline and was discharged home. Transcranial MMA access is a useful technique to overcome tortuosity that cannot be navigated with traditional endovascular techniques.