Where is this fistula?

Presentation is with progressive mental status decline — attributed to a very long, very progressive COVID…

So, where is this fistula?

No point in going transarterially… the only reasonable supply is via the neuromeningeal trunk

Transvenous is best — it is usually possible to go through the occluded portion of the sinus (what sinus?) and get to the fistula — the target is the large pouch.

Above is a good place — but not the best one. see there is all that cerebellar congestion — we are in the part of the venous outflow directed towards the cerebellum. we need to be in the venous pouch

Another decent one above — connected to the supratentorial compartment.

Now we are in a good place — see above — catheter curled in the pouch — to protect against kickback during coiling

Below is post coil and onyx

Post

Movie of the whole case below

Excellent clinical recovery so far

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