Transarterial embolization for cranial vault dural arteriovenous fistula: a case report

A 70-year-old man presented with a rare case of a dural arteriovenous fistula (dAVF) at the cranial vault manifesting as headache. Cerebral angiography disclosed that multiple feeding arteries were immediately draining into the right parietal cortical vein without communication to the superior sagittal sinus, and this dAVF was classified as Borden type III and Cognard type IV. Transarterial embolization was performed using particles of polyvinyl alcohol and glue of n-butyl 2-cyanoacrylate. After embolization, the dAVF had completely disappeared and the patient was discharged without any symptom. Angiogram one year after embolization showed no recanalization of dAVF. Transarterial glue embolization is a safe and effective treatment of dAVF with cortical venous reflux.     

Use of a wedged microcatheter for curative transarterial embolization of complex intracranial dural arteriovenous fistulas: indications,endovascular technique,and outcome in 21 patients

OBJECT: The aim of this study was to describe the application of a novel transarterial approach to curative embolization of complex intracranial dural arteriovenous fistulas (DAVFs). This technique is particularly useful in patients harboring high-grade DAVFs with direct cortical venous drainage or for whom transvenous coil embolization is not possible because of limited sinus venous access to the fistula site due to thrombosis or stenotic changes. METHODS: Twenty-three DAVFs in 21 patients were treated using a transarterial N-butyl cyanoacrylate (NBCA) embolization technique with the aid of a wedged catheter. In all patients, definitive treatment involved two critical steps: 1) a microcatheter was wedged within a feeding artery, establishing flow-arrest conditions within the catheterized vessel distal to the microcatheter tip; and 2) NBCA was injected under these resultant flow-arrest conditions across the pathological arteriovenous connection and into the immediate draining venous apparatus, definitively occluding the fistula. Patient data were collected in a retrospective manner by reviewing office and inpatient charts and embolization reports, and by directly analyzing all procedural and diagnostic angiograms. Eight patients presented with the principal complaint of tinnitus/bruit, five with intracranial hemorrhage, four with cavrnous sinus syndrome, and one each with seizures, ataxia, visual field loss, and hiccups. The parent (recipient) venous structure of the DAVFs in this study included 11 leptomeningeal veins, eight transverse/sigmoid sinuses, three cavernous sinuses, and one sphenoparietal sinus. The NBCA permeated the arteriovenous shunt, perifistulous network, and proximal draining vein in all DAVFs. Occlusion was confirmed on postembolization angiography studies. No complication occurred in any patient in this series. There has been no recurrence during a mean follow up of 18.7 months (range 2-46 months). CONCLUSIONS: Transarterial NBCA embolization with the aid of a wedged catheter in flow-arrest conditions is a safe and an effective treatment for intracranial DAVFs.     

Dural arteriovenous fistula of the sphenobasilar sinus with concomitant meningioma: case report and review of the literature

Dural arteriovenous fistula of the sphenobasilar sinus is a true but rare lesion that connects the meningeal arteries from both the external and internal carotid arteries to the superficial middle cerebral vein (SMCV) and dural sinus. It must be distinguished from other dural arteriovenous fistulas (DAVFs) of the middle cranial fossa, such as cavernous DAVFs and sphenoparietal sinus DAVF, because of differences in the treatment and outcome between these DAVFs. Two patients with sphenobasilar sinus DAVFs reported in the literature have been identified, but they did not simultaneously harbor intracranial meningiomas. To the best of the authors’ knowledge, the patient described here is the first case that concomitantly harbors a sphenobasilar sinus DAVF and intracranial meningioma. A 42-year-old man presented with acute subarachnoid hemorrhage. Angiography demonstrated a DAVF of the sphenobasilar sinus with a giant venous aneurysm of the SMCV. After transarterial embolization, the fistula was successfully obliterated and the giant venous aneurysm was resected microsurgically. A fortuitous small meningioma at the anterior clinoid was found and removed during the operation. The patient recovered excellently and resumed his normal activities. The relevant literature is reviewed and discussed.     

Management strategies for anterior cranial fossa (ethmoidal) dural arteriovenous fistulas with an emphasis on endovascular treatment

OBJECT: Dural arteriovenous fistulas (DAVFs) of the anterior cranial fossa are rare lesions that can cause intracranial hemorrhage. Authors of previous reports mostly have described open surgical treatment for this fistula type. The authors' purpose in the present study was to describe their experience with anterior cranial fossa DAVFs, including their endovascular treatment. METHODS: All patients with anterior cranial fossa DAVFs diagnosed and treated in 3 separate institutions during the last 23 years were retrospectively identified. Clinical charts, imaging studies, and procedural notes were evaluated. RESULTS: Twenty-four patients (22 males and 2 females), ranging in age from 3 to 77 years, harbored 24 DAVFs in the anterior cranial fossa. Eleven patients were primarily treated with surgical disconnection and 2 with radiosurgery. Eleven patients were treated endovascularly; 7 of these patients (63.6%) were cured. In 4 cases of failed embolization, final disconnection was achieved through surgery. In fact, surgery was effective in disconnecting the fistula in 100% of cases. All endovascular procedures consisted of transarterial injections of diluted glue (N-butyl cyanoacrylate [NBCA]), and there were no complications. Brain edema developed around the venous pouch and confusion was apparent after venous disconnection in 1 surgically treated patient. No patient suffered a hemorrhage during the follow-up period. CONCLUSIONS: Disconnection of an anterior cranial fossa DAVF by using transarterial catheterization through the ophthalmic artery and subsequent injection of NBCA is possible with a reasonable success rate and low risk for complications. In patients with good vascular access this procedure could be the treatment of choice, to be followed by open surgery in cases of embolization failure.     

Surgical treatment of intracranial dural arteriovenous fistulas

BACKGROUND: When considering the treatment strategies for dural arteriovenous fistulas (DAVFs), it is important to clarify the exact location of the fistula and venous drainage route from both DAVFs and normal brain tissue. DAVFs with leptomeningeal retrograde venous drainage carry a high risk of neurological deficits and require aggressive treatment. When AVFs involve the dural sinus, transvenous embolization via the transfemoral approach is usually the first choice of treatment. For DAVFs draining directly into the cortical veins without dural sinus involvement, transarterial embolization may be a curative treatment. However, when embolization is technically difficult or results in incomplete occlusion, surgical treatment is required. The purpose of the present study was to review our experience with surgical treatment of DAVFs. METHODS: The present series included 17 patients; 9 had DAVFs involving the dural sinus with leptomeningeal retrograde venous drainage and 8 had DAVFs draining directly into the cortical veins. For DAVFs involving the sinus, embolization of the diseased sinus by direct surgical exposure was performed in 8 patients, and surgical excision in one. For DAVFs draining directly into the cortical veins, interruption of the draining veins close to DAVFs was undertaken in 7 and surgical excision in 1. RESULTS: Complete obliteration of DAVFs was demonstrated in 16 patients. At final follow-up, 15 patients were asymptomatic and the other 2 showed clinical improvement. CONCLUSIONS: For DAVFs involving the dural sinus, direct operative sinus packing is indicated. For DAVFs directly draining into the cortical veins, surgical interruption of the draining veins is indicated.     

Transcranial embolization of a transverse-sigmoid sinus dural arteriovenous fistula carried out through a decompressive craniectomy

Summary We report a case of dural arteriovenous fistula (DAVF) of the transverse-sigmoid sinus presenting with intraventricular hemorrhage. Cerebellar infarction developed after transarterial embolization, and decompressive craniectomy was performed to relieve the mass effect. Through the bone window of the decompressive craniectomy, transcranial puncture of thetransverse sinus and coil occlusion of the fistula were successfully performed. Decompressive craniectomy may provide an opportunity to occlude DAVFs which cannot be occluded by the transarterial or transvenous approach.     

Resection of the transverse sinuses and confluence of sinuses for treatment of multiple dural arteriovenous fistulas. Case report

Dural arteriovenous fistulas (DAVFs) occurring simultaneously at two or more separate locations are not frequent. In fact, the incidence of multiple DAVFs is 7 to 8% of all DAVFs. Patients harboring multiple DAVFs have a higher incidence of hemorrhage, venous infarction, and neurological deficits due to a greater frequency of leptomeningeal venous drainage. To the authors' knowledge only a few cases of DAVFs involving both transverse sinuses (TSs) have been reported. These patients underwent various combined treatments (transarterial embolization, transvenous obliteration, surgical isolation, resection, and radiosurgery). Treatments performed that do not include resection of the involved sinuses do not always guarantee a cure. The authors present a patient who harbored multiple DAVFs of the TSs, both distally occluded with secondary reflux into the superior sagittal sinus (SSS), the straight sinus, the deep venous system, and the leptomeningeal veins of both hemispheres. An en bloc removal of the portions including the fistulas of the TSs, the confluence of sinuses, and the distal parts of the SSS, and straight sinus allowed for the patient to be cured. The fact is emphasized that despite the progress of endovascular treatment and radiosurgery this kind of DAVF must be surgically treated. The operation may be complex and dangerous.     

Transarterial approach for selective intravenous coil embolization of a benign dural arteriovenous fistula. Case report

Transarterial particulate embolization is indicated for benign intracranial dural arteriovenous fistulas (DAVFs) that have no dangerous venous reflux. This treatment, however, does not cure these lesions. In this case report the authors describe a spontaneously occurring DAVF that was treated by implanting coils through a transarterial microcatheter into the affected venous channel. The channel was separate from the normal dural sinuses. The pathological architecture of the fistula and the usefulness of this approach are discussed.     

Onyx embolization of cavernous sinus dural arteriovenous fistulas via direct transorbital puncture under the guidance of three-dimensional reconstructed skull image (reports of six cases)

Backgrond

Because of complex angioarchitecture, the transarterial or venous pathway is not feasible for some cavernous sinus dural arteriovenous fistulas (CS DAVFs). We present six cases in which onyx embolization of a CS DAVFs was made possible through direct transorbital puncture.

Methods

In the present study, all patients were penetrated through one third of the medial-lateral of the inferior orbital rim under the guidance of fluoroscopy superimposed on the three-dimensional reconstructed skull image to complete embolization (onyx with or without coils). The records of patient demographics, clinical manifestation, fistula features, procedures, clinical outcome and angiographic outcome were reviewed and analyzed.

Results

In our series of six patients, the immediate angiographic result showed complete occlusion in all patients. The six patients experienced retrobulbarhematoma and eye swelling right after embolization, while the swelling significantly subsided after 3–5 days of conservative treatment. During the postoperative angiography and clinical follow-up (4–10 months), one of the patients had decreased visual acuity; the other five patients did not have neurological dysfunction.

Conclusions

Onyx embolization via direct transorbital puncture provides a method to be considered to treat CS DAVFs when the conventional transvenous approaches are inaccessible.     

Multiple spinal and cranial dural arteriovenous fistulas

Synchronous multiplicity of cranial and spinal dural arteriovenous fistulas (DAVFs) is known but uncommon. The authors report on a patient with the unusual finding of multiple cranial and multiple separate spinal DAVFs. The patient initially presented with vague visual symptoms in 2004. A cranial DAVF was identified along the left transverse sinus with cortical venous reflux and another DAVF was identified along the posterior part of the superior sagittal sinus with no cortical venous reflux. The first DAVF was treated both endovascularly and surgically and the second was left untreated. The follow-up angiogram showed multiple spinal DAVFs at the levels of C-1, C-2, and C-6 on the left side and at the C-3 level on the right side along with another cranial DAVF along the anterior part of the superior sagittal sinus with cortical venous reflux. A retrospective analysis of the digital subtraction angiogram and MR images suggested that the cervical spinal DAVFs were already present in 2004 (6 years previously). Multiple DAVFs, although rare, do exist and it is important to look for any evidence of their presence when evaluating patients with symptoms suggestive of arteriovenous fistulas.     

Treatment of dural arteriovenous fistula using ethylene vinyl alcohol (onyx) arterial embolization as the primary modality: short-term results

OBJECT: A dural arteriovenous fistula (DAVF) typically involves meningeal feeding arteries and can cause clinical symptoms ranging from tinnitus to rupture of draining cortical or parenchymal veins. Surgical treatment may be technically demanding. Ethylene vinyl alcohol (Onyx, ev3 Neurovascular) has several properties that make it potentially useful as a primary treatment agent for DAVF. Onyx is expected to be a permanent embolic agent. It should have a decreased risk of catheter retention when compared with other permanent embolic materials. METHODS: The authors report a series of six patients with symptomatic DAVF who were treated initially with transarterial Onyx embolization and other endovascular techniques. RESULTS: Five patients had complete occlusion of their DAVF noted on the follow-up angiogram obtained between 2 and 4 months. One patient had residual filling via a small arterial branch that was stable on follow-up angiography. None of the patients had worsening of neurological function. One case was complicated by a retained catheter fragment. CONCLUSIONS: Transarterial Onyx embolization and other endovascular methods can angiographically obliterate DAVF. In some cases, embolization allowed occlusion of multiple arterial feeding arteries from a single arterial injection. Technically, the embolization was optimized when a microcatheter position immediately adjacent to the point(s) of fistulization was achieved.     

Treatment of dural arteriovenous fistulas

Opinion statement  The treatment of a dural arteriovenous fistula (DAVF) depends on the severity of the symptoms, its angiographic characteristics, and the risk it presents for intracranial hemorrhage. In many instances, therapy may involve a combination of more than one modality. Low-risk DAVFs, either incidental or with minimal symptoms, can be treated conservatively (observation, blood pressure control, manual carotid compressions). If the patient does not tolerate the symptoms, definite or palliative treatment can be offered. All high-risk DAVFs (Borden Grade II or III) should receive treatment because they carry a high probability of intracranial hemorrhage or neurologic deterioration. For small, well-circumscribed fistulas, radiosurgery can have excellent results, but thrombosis can occur many months after the treatment. For large DAVFs with severe symptoms (vision deterioration, ophthalmoplegia with diplopia, seizures, or neurologic deficit) or with high risk for hemorrhage (cortical venous drainage or venous varices), the first treatment option should be endovascular embolization. With the combination of modern materials and techniques, this procedure can yield a high rate of cure with minimal complications. In patients not amenable to embolization or after incomplete embolization, surgery should be considered if the DAVF is located in an easily accessible area, because of its immediate and definite results. Surgery can be facilitated by preoperative embolization of the fistula to reduce the arterial supply and minimize intraoperative bleeding. Radiosurgery can also be used adjunctively after embolization or surgery has significantly reduced the size of large DAVFs.     

Tentorial dural arteriovenous fistula presenting with various visual symptoms related to anterior and posterior visual pathway dysfunction: case report

OBJECTIVE AND IMPORTANCE: Dural arteriovenous fistulae (DAVFs) not directly shunting into the cavernous sinus are an infrequent cause of visual dysfunction. An unusual case of a tentorial DAVF associated with visual symptoms related to dysfunction of the anterior and posterior visual pathway is presented. CLINICAL PRESENTATION: A 38-year-old woman with a history of long-standing bilateral proptosis experienced a sudden onset of headache and visual disturbances. Ocular examination revealed bilateral episcleral and retinal venous congestion, optic disc paleness, right superior homonymous quadrantanopsia in both eyes, and concentric narrowing of the visual field of the right eye. Angiography revealed a DAVF supplied by a falx branch arising from the left vertebral artery and both middle meningeal arteries, which drained directly into the markedly dilated vein of Galen via the basal vein of Rosenthal and the cavernous sinus into both superior ophthalmic veins. INTERVENTION: Endovascular treatment was performed in two consecutive sessions by transarterial embolization with n-butylcyanoacrylate, which resulted in occlusion of the fistula and complete clinical cure, confirmed at the 6-month follow-up examination. CONCLUSION: Various neuro-ophthalmological findings may be caused by an arteriovenous lesion remote from the optic organ as a result of rerouting of venous drainage compromising the visual pathway at different locations. Transarterial embolization of a DAVF may result in complete cure if advantageous arterial anatomy allows for flow control and occlusion of the fistulous connection with liquid adhesives.     

Single stage transcranial exposure of large dural venous sinuses for surgically-assisted direct transvenous embolization of high-grade dural arteriovenous fistulas: technical note

Background  

High-grade dural arteriovenous fistulas (DAVFs) with retrograde cortical leptomeningeal drainage are formidable lesions because of their risk for intracranial hemorrhage. Treatment is aimed at occluding venous outflow to achieve obliteration of the fistula. In DAVFs that involve a large dural venous sinus (transverse sigmoid sinus or superior sagittal sinus), occluding venous outflow can be accomplished endovascularly with transvenous embolization. However, in some cases of DAVFs with reflux into cortical leptomeningeal veins, there may be venous restrictive disease downstream, such as occlusive thrombosis, which can prohibit endovascular access via the transfemoral or transjugular routes. In these instances, a transcranial approach can be performed to expose the large dural venous sinus distal to the site of occlusion for direct catheterization of the venous outflow for transvenous embolization. This combined surgical and endovascular strategy provides direct access to the venous outflow and bypasses the site of thrombotic obstruction.     

A case of multiple dural arteriovenous fistulas treated by multiple modalities

The authors report a rare case of multiple intracranial dural arteriovenous fistulas (DAVF) at separate sinuses. A 70-year-old man was introduced to our hospital complaining of visual disturbance due to bilateral choked disk, headache, and tinnitus. Initial angiography showed DAVFs involving the superior sagittal sinus and bilateral transverse-sigmoid sinuses, and the occlusion of the right jugular vein. The patient developed progressive impairment of visual activity and had high intracranial pressure (ICP) caused by venous hypertension. No cerebral alteration was seen on magnetic resonance imaging. To decrease the high ICP, surgical sinus isolation of the superior sagittal sinus was performed. After the surgery, transvenous embolization was performed to the right transverse-sigmoid sinus DAVF. Headache and tinnitus improved after these treatments, but visual activities rapidly declined and he experienced blindness in just a few months. Gamma knife radiosurgery was performed to the residual DAVFs. We discussed the etiology and treatment of the multiple DAVF, and reviewed past literatures.     

Transarterial NBCA embolization with transvenous partial outflow obstruction for superior petrosal sinus dural arteriovenous fistula: a case report

We encountered a case of superior petrosal sinus dural arteriovenous fistula (SPS DAVF) which was treated by a combination of a transvenous and a transarterial approach after the failure of the transvenous approach alone. A 69-year-old man presented with a complaint of progressive left bulbar conjunctival conjestion, exophthalmos, and impaired vision. Cerebral angiography revealed a left SPS DAVF fed by the left middle meningeal artery, the meningeal branches of the left internal carotid artery and the left posterior meningeal artery. Venous drainage proceeded through the cavernous sinus (CS) toward the left superior ophthalmic vein (SOV). Transvenous embolization via the SOV was indicated because the left ipsilateral inferior petrosal sinus contributed to the normal venous return. However the microcatheter to the CS couldn't go through the tortuous SOV. Next a transarterial NBCA (n-butyl-cyanoacrylate) embolization of the affected sinuses was performed under arterial flow control with balloons and the partial coil embolization of the origin of the SOV. The coils in the SOV trapped NBCA and the sinuses were filled slowly with NBCA. The postoperative angiogram confirmed complete obliteration of the DAVF and the patient's ocular symptoms disappeared. DAVF is usually difficult to treat by transarterial embolization with NBCA because of its multiple feeders and high flow drainage. We should therefore carefully observe its structure and the blood flow change with 3D-DSA and the selective angiography while embolizing the DAVE.     

Multiple dural arteriovenous fistulas involving both the cavernous sinus and the posterior fossa: report of two cases and review of the literature]

Multiple dural arteriovenous fistulas (DAVFs) are rare, accounting for 7% of all intracranial DAVFs. The authors describe two cases of multiple DAVFs involving both the cavernous sinus and the posterior fossa. The first patient was a 45-year-old man who presented with visual disturbance, chemosis, exophthalmus, and tinnitus. Angiograms demonstrated DAVFs involving the right cavernous sinus and the ipsilateral sigmoid sinus. Soon after transarterial embolization via the right occipital artery, the patient's symptoms completely disappeared. Six months later, follow-up angiograms showed disappearance of the cavernous DAVF and a subtle opacification of the sigmoid sinus DAVF. The patient has been free from symptoms for four years. The second patient was a 75-year-old woman who presented with progressive tinnitus two years after stereotactic radiosurgery for right cavernous DAVF. Angiograms showed a new lesion in the contralateral transverse and sigmoid sinuses. Transvenous embolization (TVE) of the affected sinuses was successful and the patient's symptoms disappeared. The patient's course has been uneventful after treatment, and follow-up MR angiograms have not shown any recurrence of lesions. To our knowledge, 25 cases of multiple DAVFs have been reported in the literature, of which we reviewed 12 cases of multiple DAVFs affecting the cavernous sinus. The patients' ages ranged from 43 to 75 years with a mean of 57.4 and their distribution showed female predominance. Other DAVFs occurred mostly in the transverse and sigmoid sinuses. With the exception of our case (second patient), the posterior fossa lesions were located on the same side as the cavernous sinus DAVF. Multiple DAVFs were detected simultaneously in 5 of the 12 cases with the initial angiograms. In the other 7 cases, cavernous DAVFs had been treated, but were followed by posterior fossa lesions occurring after various intervals (4 months to 2.5 years). All the patients presented with ocular signs due to cavernous DAVFs. Based upon our review of the literature, we discuss here three possible hypotheses. The first possibility for formation of multiple DAVFs concerns their primary etiology, viz. that they develop after a huge sinus thrombosis involving several sinuses and its recanalization. A second possibility is the secondary formation of DAVFs. Preexisting cavernous sinus DAVFs induce sinus thrombosis and/or venous hypertension, which results in the formation of multiple lesions. A third possibility is that they are due to other factors, including increased angiogenic activity and some technical problems associated with TVE. Our review indicates that careful follow-up for several years should be made after treatment of cavernous DAVFs.     

Fatal progression of posttraumatic dural arteriovenous fistulas refractory to multimodal therapy. Case report

The authors report the case of a man who suffered from progressive, disseminated posttraumatic dural arteriovenous fistulas (DAVFs) resulting in death, despite aggressive endovascular, surgical, and radiosurgical treatment. This 31-year-old man was struck on the head while playing basketball. Two weeks later a soft, pulsatile mass developed at his vertex, and the man began to experience pulsatile tinnitus and progressive headaches. Magnetic resonance imaging and subsequent angiography revealed multiple AVFs in the scalp, calvaria, and dura, with drainage into the superior sagittal sinus. The patient was treated initially with transarterial embolization in five stages, followed by vertex craniotomy and surgical resection of the AVFs. However, multiple additional DAVFs developed over the bilateral convexities, the falx, and the tentorium. Subsequent treatment entailed 15 stages of transarterial embolization; seven stages of transvenous embolization, including complete occlusion of the sagittal sinus and partial occlusion of the straight sinus; three stages of stereotactic radiosurgery; and a second craniotomy with aggressive disconnection of the DAVFs. Unfortunately, the fistulas continued to progress, resulting in diffuse venous hypertension, multiple intracerebral hemorrhages in both hemispheres, and, ultimately, death nearly 5 years after the initial trauma. Endovascular, surgical, and radiosurgical treatments are successful in curing most patients with DAVFs. The failure of multimodal therapy and the fulminant progression and disseminated nature of this patient's disease are unique.     

Development of a complex dural arteriovenous fistula next to a cerebellar developmental venous anomaly after resection of a brainstem cavernoma. Case report and review of the literature

Developmental venous anomalies (DVAs) are common abnormalities of intracranial venous drainage, which may occur in conjunction with other cerebral vascular malformations and are known for their benign natural history. The authors present the case of a 16-year-old boy who experienced a spontaneous brainstem hemorrhage due to a cavernoma. Preoperative angiography findings revealed a large DVA draining the right cerebellar hemisphere. The patient underwent suboccipital surgery for cavernoma resection and recovered completely from his neurological symptoms. Fourteen months later he returned with progressive symptoms. Repeated angiography demonstrated a complex dural arteriovenous fistula (DAVF) of the transverse sinus, which had developed next to the DVA. Several transarterial and transvenous embolizations were ineffective. Common causes of acquired DAVFs and the potential role of the DVA in the development of the DAVF in this case are discussed on the basis of the pertinent literature.     

Treatment of dural arteriovenous fistula presenting as typical symptoms of hydrocephalus caused by venous congestion: case report

A 76-year-old woman presented with a dural arteriovenous fistula (DAVF) manifesting as typical symptoms of normal pressure hydrocephalus such as progressive dementia, gait disturbances, and urinary incontinence. The cerebrospinal fluid pressure during lumbar puncture was 120 mmH(2)O. Computed tomography and magnetic resonance imaging showed ventricular dilation and diffuse white matter changes, which were consistent with the symptoms of hydrocephalus. Cerebral angiography revealed a DAVF in the transverse-sigmoid sinuses with severe cortical venous reflux into the superior sagittal sinus. Transarterial embolization of the feeding arteries reduced the venous flow from the cortical veins into the superior sagittal sinus. Her symptoms improved with reduction in ventricle size. However, she suffered recurrence of the same symptoms several months later. Computed tomography and magnetic resonance imaging demonstrated ventricular dilation associated with hydrocephalus. Angiography revealed a fistulous channel in the left transverse-sigmoid junction. Transvenous embolization was performed resulting in complete obliteration of the fistula. Magnetic resonance image findings such as ventricular dilation and diffuse white matter disappeared and the symptoms of hydrocephalus improved. Although DAVFs often present as venous hypertensive encephalopathy, this case presented with ventricular dilation and diffuse white matter changes, which are the typical neurological signs of normal-pressure hydrocephalus. Venous hypertension associated with the DAVF in the transverse-sigmoid sinuses may have been caused by normal pressure hydrocephalus.