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● Abstract● Objective: We report a case of dural arteriovenous fistula (DAVF) of the sinus confluence treated with surgical transvenous embolization by direct puncture of the superior sagittal sinus (SSS). Case presentation: A 34-year-old man complained of tinnitus and diplopia. Cerebral angiography showed aggressive DAVF involving the bilateral transverse-sigmoid sinus, the SSS, and the sinus confluence with severe cortical and deep venous reflux. We performed transarterial and transvenous embolization for the transverse-sigmoid sinus lesions at first. The feeding posterior meningeal arteries were collected into the sinus pouch of the confluence with the strong upward blood flow to the SSS in a retrograde fashion. A catheter from the femoral vein never got into the sinus pouch. Therefore we performed a small craniotomy on the frontal midline and the distal SSS was directly punctured to navigate a microcatheter to the pouch, which was obliterated completely with coils. Thus the shunt flow was significantly decreased. Conclusion: This surgical transvenous approach with a direct puncture of the SSS was a unique and an effective way for the treatment of DAVF of the confluence.

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Surgical transvenous embolization by direct puncture of the superior sagittal sinus for the treatment of dural arteriovenous fistula of the sinus confluence