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