Department of Neurosurgery, State University of New York Upstate Medical University, Syracuse, New York, USA.
Department of Neurosurgery, State University of New York Upstate Medical University, Syracuse, New York, USA.
World Neurosurg. 2022 Nov;167:4. doi: 10.1016/j.wneu.2022.08.004. Epub 2022 Aug 9.
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.
经颅入路直接接触硬脑膜动脉（MMA）以栓塞硬脑膜动静脉瘘（dAVF）已有报道，但关于其设置、设备和技术的信息有限。我们在破裂的 Cognard 分级 IV 幕顶 dAVF （视频 1）的情况下介绍了这种混合入路的详细信息。患者为成年女性，表现为恶心、呕吐和头晕，被发现患有小脑出血。导管血管造影显示幕顶 dAVF 由双侧脑膜中动脉、左脑膜后动脉和左枕动脉供血。通过这些动脉进行的经动脉栓塞尝试均未成功。左 MMA 是主要供血动脉，但由于近端迂曲，无法进行远端微导管放置。因此，我们尝试在迂曲的近端进行经颅 MMA 入路。使用 roadmap 血管造影定位 MMA，并在动脉上方完成颞骨切除术。放置 4-French 鞘管，并进行超选择性血管造影，显示瘘。将微导管导航至瘘管并使用 Onyx 栓塞。术后血管造影显示瘘管闭塞。患者保持神经基线，出院回家。经颅 MMA 入路是一种有用的技术，可以克服传统血管内技术无法通过的迂曲。
