Fig 2.

Sample case of a DAVF presenting with angioarchitectural features with a negative influence on the treatment success. A DAVF is located at the transverse and sigmoid sinus with antegrade flow in the sinus (Cognard type I) in a 46-year-old man who presented with severe pulsatile tinnitus (A). Multiple feeders supply the DAVF, including the middle meningeal artery (black arrows in A), the occipital artery (white arrows in A), and the ascending pharyngeal artery (black arrowheads in A). The DAVF was treated by transarterial Onyx embolization in combination with transvenous balloon-assisted protection of the venous sinus (B). The DAVF could not be occluded completely, due to small branches of the middle meningeal artery (black arrows in C) and of the occipital artery (white arrows in C), and particularly because of multiple persistent feeders from the ascending pharyngeal artery (black arrowheads in C), which could not be catheterized distal enough because of their small size and their tortuosity. The patient’s symptoms were declining but still persistent at the latest follow-up.