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Case Report: Direct Burr Hole Access for Embolization of Dural Arteriovenous Fistula

Key findings

  • High-grade dural arteriovenous fistulas (DAVFs) present a risk of intracranial hemorrhage and should be treated; transarterial and/or transvenous embolizations are often the preferred initial options, but these approaches aren't always possible
  • This report describes direct cannulation of the left transverse sinus through a burr hole for treatment of a transverse–sigmoid junction DAVF in a 73-year-old man after several attempts at percutaneous transfemoral venous access were unsuccessful
  • Post-procedure angiography showed the DAVF was cured, without residual shunting, and there was no evidence of complications
  • Imaging performed two weeks post-procedure did not show evidence of hemorrhage or infarction, and at the one-year visit, the patient and his spouse reported substantial improvement in his symptoms

Dural arteriovenous fistulas (DAVFs)—relatively rare vascular lesions within the cranial cavity—are characterized by abnormal shunting between dural arteries and veins. Symptoms, if present, are influenced by anatomical location and may include pulsatile tinnitus, bruits, headache, visual changes, cranial nerve palsies, motor or sensory deficits, mental status changes, seizures, or myelopathy.

DAVFs can lead to intracranial hemorrhage and death, so higher-grade lesions require treatment, conventionally with transarterial and/or transvenous embolization. In some cases, however, percutaneous access is impossible.

A multidisciplinary team at Massachusetts General Hospital has described in Brain Sciences the evaluation and treatment of a patient who ultimately required burr hole access to the left transverse sinus for treatment of a DAVF.

The report's authors are Robert W. Regenhardt, MD, PhD, neurointerventionalist and instructor at Mass General, Christopher J. Stapleton, MD, neurosurgeon and assistant program director of Neurosurgery Residency Program, and Aman B. Patel, MD, director of the Cerebrovascular Surgery Program in the Department of Neurosurgery.

Introduction to the Case

The patient was a 72-year-old man whose presenting primary complaint was a persistent headache for two months. He also reported "brain fog" and fatigue that had progressed over the past several years and left-sided pulsatile tinnitus that had been subtle for several years but worsened over the past two months.

Imaging Results

Head and neck CT and CT angiography showed possible early filling of the right cavernous sinus, increased vascularity around the left sigmoid–transverse sinus junction, and dilated bilateral cortical veins, more notable on the left.

Digital subtraction angiography (DSA) showed a left transverse–sigmoid junction DAVF with cortical venous reflux and retrograde flow involving the dural sinus. Such DAVFs are aggressive and present a high risk of intracranial hemorrhage.

Attempts at Access

Regardless of modality, DAVF treatment aims to occlude arteriovenous shunting by obliterating the fistula. The patient was initially treated with transarterial Onyx embolization of the occipital artery, which reduced shunting by 30%. The patient reported improved tinnitus and headache but persistent fatigue and anxiety.

Four weeks later, several attempts were made to access the fistula during transvenous embolization. However, accessing the left transverse sinus fistula site was impossible because there was no communication across the torcula from the right transverse sinus and the left inferior sigmoid–jugular bulb was occluded.

The next day, a single burr hole was drilled and direct access to the DAVF was achieved with a micropuncture needle under neuronavigational guidance. The left transverse–sigmoid sinus junction was then embolized with coils. The paper gives details of the procedure.


Post-procedure angiography showed the DAVF was cured without residual shunting. There was no evidence of complications, and the patient was discharged after two days of hospital monitoring.

He presented with delirium at his two-week follow-up appointment, and his spouse reported a "change in his personality." Imaging did not show evidence of hemorrhage or infarction. His delirium gradually resolved, and at the one-year visit, he and his spouse reported significant improvement in his memory.

Learn more about the Cerebrovascular Surgery Program at Mass General

Refer a patient to the Department of Neurosurgery

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