Fig 2.

Type IIa transverse-sigmoid sinus dural arteriovenous fistulas with multiple shunted pouches. The DAVFs were associated with paraganglioma at the ipsilateral carotid bifurcation. A, Lateral view of right external carotid angiography shows DAVFs involving the transverse and sigmoid sinuses. The DAVFs are fed by the middle meningeal artery, the posterior auricular artery, and the occipital artery and drain into the right jugular vein and the contralateral transverse sinus. B, The axial reformatted images show multiple SPs (SP 1–3), which are located at the sigmoid-jugular junction (SP1), mediodorsal to the vertical portion of the sigmoid sinus (SP2), and at the transverse-sigmoid junction (SP3), respectively. The transosseous feeders from the stylomastoid branches (SMB) of the posterior auricular arteries supply the SP1; the transosseous branch (TOB) of the occipital artery and the posterior auricular artery supply the SP2. The petrosal branch (PB), the petrosquamous branch (PSB), and the posterior convexity branch (Post B) of the middle meningeal artery supply the SP3. C, Anterior oblique view of selective angiography of the middle meningeal artery during the embolization procedure shows a shunted pouch (arrows) that is located medial to the transverse-sigmoid junction. Multiple branches of the middle meningeal artery converge on the shunted pouch. A microcatheter is advanced into the shunted pouch with a transvenous approach. D, Fluoroscopic image after selective embolization shows a coil mass in the shunted pouch. Minimal shunt through the coil mass remains after selective transvenous embolization. E, Angiography during injection of diluted n-butyl 2-cyanoacrylate (33% n-BCA-lipiodol mixture) via the petrosquamous branch shows sufficient filling of the n-BCA into the residual part of the shunted pouch without migration into the main lumen of the sinus. F, Lateral view of right external carotid angiography after embolization shows marked regression of DAVFs with their disappearance at the transverse-sigmoid junction. Small residual AVFs were seen at the vertical portion of the sigmoid sinus (SP2) and the sigmoid-jugular junction (SP1). These residual shunted pouches were not treated because they seemed to be too small to catheterize and were supplied by dangerous feeders of stylomastoid branch and a petrosal branch of the middle meningeal artery. G, Frontal view of common carotid angiography at the venous phase shows that normal blood flow via the right transverse-sigmoid sinus is preserved. Arrows indicate staining of the paraganglioma at the carotid bifurcation.