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A 68-year-old man was referred to our clinic for sensory aphasia. Head CT revealed an intracranial hemorrhage located in left temporal and occipital lobes (Fig. 1). Angiography was initially performed from the right femoral artery. Safe manipulation could not be achieved using several catheters, including Cathex 4Fr OK2M 125 cm (CATHEX, Osaka, Japan) and a Simmons catheter 130 cm (Medikit, Tokyo, Japan) with a 0.035-inch 150 cm Radifocus guidewire (Terumo, Tokyo, Japan). Angiography was completed only that of the left common carotid artery. Findings from DSA and enhanced CT confirmed the existence of a right-sided aortic arch with an aberrant left subclavian artery (Fig. 2). Angiography and MRI revealed a left transverse-sigmoid sinus dural arteriovenous fistula (TSdAVF), suggesting that reflux into the Vein of Labbé led to the intracranial hemorrhage (Fig. 3a). Two days after admission, neuroendovascular therapy was initiated for obliteration of the fistula from the right femoral artery. Safe introduction of 6Fr Envoy (Cordis, Miami Lakes, FL) into the left common carotid artery could not be achieved and only partial occlusion of the left occipital artery with coils was possible. Flow reduction from the left occipital artery was restored but cortical venous reflux persisted. Since superfluous irritation against Kommerell’s diverticulum might cause a rupture, we planned direct sinus packing seven days after admission.

A Right-sided Aortic Arch with an Aberrant Left Subclavian Artery in a Patient with a Transverse-sigmoid Sinus Dural Arteriovenous Fistula