Development of sigmoid dural arteriovenous fistulas after transvenous embolization of cavernous dural arteriovenous fistulas.

A 54-year-old woman presented with left proptosis, chemosis, ophthalmoplegia, and tinnitus in March 1989. Angiography demonstrated a left cavernous DA VF. The feeding arteries from the left external carotid artery were embolized. Her symptoms were relieved for a while but soon recurred . On May 2, she was referred to us for treatment. Angiography revealed that all the branches of the left external carotid artery were recanalized and fed the DA VF (Fig 1 A). In addition, the DA VF was also fed by the branches of the right external carotid artery and by the dural branches of the left internal carotid artery. A 5-F catheter was placed in the left external carotid artery and a Tracker-18 catheter (Target Therapeutics Inc, San Jose, Calif) was advanced coaxially within it. The middle meningeal artery and the internal maxillary artery were occluded with coils (Hila! embolization microcoils, Cook, 489 Bloomington, lnd) (Fig 1B). Her ocular symptoms were greatly alleviated, but tinnitus remained. The DAVF was still supported by the left internal carotid angiogram. One month later, the remnant fistula was occluded with coils introduced through the left inferior petrosal sinus from a jugular vein access. The DAVF disappeared angiographically, and the patient's clinical symptoms disappeared as well (Fig 1 C). In May 1990, the patient again presented with left tinnitus. There were no ocular signs. Angiography revealed a new DA VF involving the left sigmoid sinus, which was fed by the occipital artery, the retroauricular artery, and the ascending pharyngeal artery of the left external carotid artery (Fig 1 D), and the clival branch of the meningohypophyseal trunk of the left internal carotid artery (Fig 1E). Because there were no signs of increased intracranial pressure and no cortical venous reflux, only some of the feeding arteries were occluded with coils. Her tinnitus was lessened.