Combined Surgical and Endovascular Management of a Complex Posttraumatic Dural Arteriovenous Fistula of the Tentorium and Straight Sinus

Diagnosis and management of a complex tentorial dural arteriovenous fistula (DAVF) of the straight sinus with vein of Galen aneurysmal dilatation is presented. A 65-year-old woman with remote history of cranial gunshot lapsed into coma after months of progressive neurological decline. Computed tomography brain scan showed cerebellar hemorrhage while arteriography demonstrated a complex arteriovenous fistula of an isolated straight sinus and tentorium with extensive arterial supply. First extracranial then intracranial arterial feeders to the fistula were occluded in separate procedures following initial presentation. Eleven days after presentation, an occipital burr-hole craniotomy was performed, the isolated straight sinus was cannulated under fluoroscopic guidance, and the fistula eradicated with multiple thrombogenic fibered platinum and Gugliemi detachable coils. Staged embolization now represents the standard of care for many complex DAVFs. A multi-disciplinary surgical and endovascular approach is a valuable combination to cure deep lesions with limited surgical or transvascular access.