Case Courtesy Dr. Peter Kim Nelson

Another example of dural fistula arising seemingly from a random dural point, not directly associated with a venous sinus.  The explanation is that these fistulas form in a dural venous channel that connects a cortical vein to the nearby sinus (see Dural Venous Channels page).  When connection between the channel and sinus is lost, the only way fistula can drain is retrogradely into brain.  Thus fistulas which do not directly involve a sinus are more likely to be or become high grade

In this case the fistula is in the posterior temporal/lateral occipital region, above the transverse sinus.  Typical region supply of MMA and ascending pharyngeal neuromeningeal trunk branches. Drainage is directly into occipital vein which finds egress into the superior sagittal sinus

Stereo views

Vert injection with the frequently seen tentorium cerebelli artery (part of posterior meningeal system) contributing to shunt

Mild venous congestion in the shunt region below

MMA micro prior to glue.  excellent position

Despite plenty of nBCA in the vein, fistula is still alive.  The position below is not good for injection due to risk of cranial nerve injury

Petrosal branch of MMA is a bit better. Micro injections are on left, nBCA cast on right.  More glue penetration into vein has been achieved

Post embo ECA and vert injections with no residual fistula

Improved congestion

More dural venous channel cases — see Cases section

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