Where is this fistula?
Presentation is with progressive mental status decline — attributed to a very long, very progressive COVID…
![](https://www.neuroangio.org/wp-content/uploads/Archives/Dural_Fistula/Tentorial-small-supply-big-hemorrhage/Tentorial-fistula-trapped-tentorial-sinus-small-supply-big-hemorrhage-01.png)
![](https://www.neuroangio.org/wp-content/uploads/Archives/Dural_Fistula/Tentorial-small-supply-big-hemorrhage/Tentorial-fistula-trapped-tentorial-sinus-small-supply-big-hemorrhage-02.png)
![](https://www.neuroangio.org/wp-content/uploads/Archives/Dural_Fistula/Tentorial-small-supply-big-hemorrhage/Tentorial-fistula-trapped-tentorial-sinus-small-supply-big-hemorrhage-03.png)
![](https://www.neuroangio.org/wp-content/uploads/Archives/Dural_Fistula/Tentorial-small-supply-big-hemorrhage/Tentorial-fistula-trapped-tentorial-sinus-small-supply-big-hemorrhage-04.png)
![](https://www.neuroangio.org/wp-content/uploads/Archives/Dural_Fistula/Tentorial-small-supply-big-hemorrhage/Tentorial-fistula-trapped-tentorial-sinus-small-supply-big-hemorrhage-05.png)
![](https://www.neuroangio.org/wp-content/uploads/Archives/Dural_Fistula/Tentorial-small-supply-big-hemorrhage/Tentorial-fistula-trapped-tentorial-sinus-small-supply-big-hemorrhage-06.png)
![](https://www.neuroangio.org/wp-content/uploads/Archives/Dural_Fistula/Tentorial-small-supply-big-hemorrhage/Tentorial-fistula-trapped-tentorial-sinus-small-supply-big-hemorrhage-07.png)
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.
![](https://www.neuroangio.org/wp-content/uploads/Archives/Dural_Fistula/Tentorial-small-supply-big-hemorrhage/Tentorial-fistula-trapped-tentorial-sinus-small-supply-big-hemorrhage-08.png)
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
![](https://www.neuroangio.org/wp-content/uploads/Archives/Dural_Fistula/Tentorial-small-supply-big-hemorrhage/Tentorial-fistula-trapped-tentorial-sinus-small-supply-big-hemorrhage-09.png)
Another decent one above — connected to the supratentorial compartment.
![](https://www.neuroangio.org/wp-content/uploads/Archives/Dural_Fistula/Tentorial-small-supply-big-hemorrhage/Tentorial-fistula-trapped-tentorial-sinus-small-supply-big-hemorrhage-10.png)
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
![](https://www.neuroangio.org/wp-content/uploads/Archives/Dural_Fistula/Tentorial-small-supply-big-hemorrhage/Tentorial-fistula-trapped-tentorial-sinus-small-supply-big-hemorrhage-11.png)
Post
![](https://www.neuroangio.org/wp-content/uploads/Archives/Dural_Fistula/Tentorial-small-supply-big-hemorrhage/Tentorial-fistula-trapped-tentorial-sinus-small-supply-big-hemorrhage-12.png)
![](https://www.neuroangio.org/wp-content/uploads/Archives/Dural_Fistula/Tentorial-small-supply-big-hemorrhage/Tentorial-fistula-trapped-tentorial-sinus-small-supply-big-hemorrhage-13.png)
Movie of the whole case below
Excellent clinical recovery so far