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Biomedical subjects

G M Debrun

Publications and source records attributed to G M Debrun.

At least 19 recordsLinked to original sources
PubMed2002

Spontaneous disappearance of vein of galen malformation and posterior fossa venous pouch.

Cerebrovascular anomalies remain an issue of controversy regarding diagnosis, classification, and treatment. We report the first case of total and asymptomatic regression and disappearance of a vein of Galen malformation associated with a posterior fossa venous pouch. Different aspects of the vein of Galen are discussed together with emphasis on the underlying mechanisms of spontaneous thrombosis and regression.A 4-month-old boy presented with macrocrania and signs of intracranial hypertension. Computerized tomography disclosed two masses, the first was a giant aneurysmal dilatation in the posterior fossa, and the second was a gigantic pouch at the level of the vein of Galen. Hydrocephalus was treated by ventriculo-peritoneal shunting. Two months later, the shunt was revised, and posterior fossa was explored without active treatment. Both abnormalities regressed spontaneously. No recurrence occurred, and the child remained neurologically intact. Total disappearance of the masses as well as normal brain and cerebrovascular anatomy were confirmed by angiography, MRI, and MRA. Over a follow-up period of 17 years, the patient did not develop complications. He had perfect clinical tolerance and resumed a normal life.

Cerebral Veins↗
PubMed2001

Guglielmi detachable coiling for intracranial aneurysms: the story so far.

Spontaneous rupture of cerebral aneurysms typically results in subarachnoid hemorrhage. The primary goal of treatment of cerebral aneurysms is to prevent future rupture. Surgical clipping had been the mainstay of treatment of both ruptured and unruptured cerebral aneurysms. In 1991, Guglielmi detachable coil (GDC) embolization was introduced as an alternative method for treating selected patients with aneurysm. The goal of the treatment is prevent the flow of blood into the aneurysm sack by filling the aneurysm with coils and thrombus. Theoretically, there are several advantages of GDC over surgery. These procedures are performed under general anesthesia with the standard transfemoral approaches used in diagnostic angiography. Since its inception, GDC embolization has evolved as a result of both clinical experience and the introduction of technological improvements. We are now better at selecting aneurysms appropriate for coiling, which also have wide necks. Advances in GDC technology have also improved this method of treatment. Over the last several years, the number of coil sizes has been increased, multidimensional coils allowing safer initial coil placement have become available, and, more recently, softer coils have been introduced. Our current approach is to have both surgical and endovascular options for patients.

Cerebral Hemorrhage↗
PubMed2000

Intracranial percutaneous transluminal angioplasty for arteriosclerotic stenosis.

BACKGROUND: Patients with intracranial arteriosclerotic disease have significant morbidity and mortality rates, and some are unresponsive to medical treatment and have unacceptable surgical risks. Percutaneous transluminal angioplasty of the intracranial vessels is a possible alternative to surgery. OBJECTIVES: To present our experience with percutaneous transluminal angioplasty and to summarize our data. PATIENTS AND METHODS: Sixteen patients underwent intracranial percutaneous transluminal angioplasty for high-grade arteriosclerotic stenosis based on strict inclusion and exclusion criteria. All patients had symptoms referable to the stenosis except one. Angioplasty was performed in 6 intracranial vertebral arteries, 3 basilar arteries, 5 middle cerebral arteries, and 3 distal internal carotid arteries. One patient had concomitant stent placement. RESULTS: There was 1 treatment failure secondary to tortuous vascular anatomy. Vessel caliber was increased to more than 80% of normal in 6 patients and to 50% to 70% of normal in 6 patients, with a reduction of symptoms. Three intimal dissections occurred during angioplasty; one of these, in a precavernous segment of the internal carotid artery, was stented. One patient restenosed within 1 month of treatment. The remaining treated arteries remained patent during follow-up of 3 months to 2 years. Stroke as a complication occurred in 2 patients, 1 mild and 1 severe. There was no mortality. CONCLUSIONS: Occlusive arteriosclerotic disease involving the intracranial cerebral vessels can be managed medically with antiplatelet and anticoagulant drug therapy or surgically. However, in patients who are unresponsive to medical therapy or who have unacceptable surgical risks, percutaneous transluminal angioplasty is an attractive alternative that can be performed in selected patients with relatively low risk and good clinical outcome.

Adult↗
PubMed2000

Endovascular treatment of paraclinoid aneurysms.

BACKGROUND: Paraclinoid aneurysms include those that are distal to the cavernous segment of the internal carotid artery and proximal to the posterior communicating artery. The purpose of this study was to review our experience with the endovascular treatment of this group of aneurysms, which are difficult to treat surgically. METHODS: Between June 1994 and April 1999, 66 patients (56 female, 10 male) with a mean age of 50.1 years (range 13-75, median 51) underwent endovascular treatment for 71 paraclinoid aneurysms. The mean size of the dome was 8.9 mm (range 3-25 mm, median 7) and the of neck was 3.8 mm (range 1.4-8 mm, median 4). Thirteen patients presented with acute subarachnoid hemorrhage, and 4 with previous subarachnoid hemorrhage. Six aneurysms produced mass effect with visual symptoms, 4 presented with transient ischemic attacks, and 44 were incidental. Nine patients had had previous unsuccessful surgery. All procedures were performed under general anesthesia and with systemic heparinization. RESULTS: Ninety endovascular procedures were performed on 71 aneurysms: GDC coiling in 78 (including 45 with the remodeling technique), permanent balloon occlusion in 9, and 3 had both GDC coiling and permanent balloon occlusion. In ten aneurysms it was not possible to place coils in the lumen of the aneurysm with the available technology and balloon occlusion was not indicated. Five of these were treated surgically and 5 remain untreated. All patients had immediate post procedure angiography. Of the 61 aneurysms that were treated, 46 (75%) have angiographic follow-up of 6 months or more. Morphological outcome following endovascular therapy for 61 aneurysms at last available follow-up showed > 95% occlusion in 52/61 (85.2%) and <95% in 9/61 (14.8%). Eight patients required surgery, 2 for partial coiling, 2 for refilling of a neck remnant, 2 for persistent mass effect and 2 for coil protrusion. In the 90 procedures performed, 2 (2.2%) patients had major permanent deficits (1 monocular blindness, 1 hemiparesis), 1 (1.1%) had a minor visual field cut, and 2 (2.2%) patients died from major embolic events. CONCLUSION: Properly selected paraclinoid aneurysms can be successfully treated by endovascular technology. The morbidity and mortality rate of the endovascular approach in our experience is equal to or better than the published surgical series of similar aneurysms. We recommend that the endovascular approach be given primary consideration in the treatment of paraclinoid aneurysms.

Adolescent↗
PubMed2000

Surgery following endovascular coiling of intracranial aneurysms.

BACKGROUND: Surgery for intracranial aneurysms that have been treated by endovascular coiling is a new challenge for neurosurgeons and the need for it will undoubtedly continue to increase. The indications for, timing, and technique of surgery in our experience are described. METHODS: We have reviewed our experience with 11 patients who underwent surgery following endovascular coiling with Guglielmi detachable coils (GDCs) of an aneurysm. We analyzed the indications for surgery, surgical techniques used, and patient outcome. RESULTS: There were nine female and two male patients. The mean age was 49 years (range 13 to 67 years). The intervals between coiling and surgery were 1, 2, 3, 4, 7, 7, 10, and 14 days, 6 weeks, 2, 18, and 25 months. The indications for surgery were partial treatment (3), growth of residual neck (2), persistent mass effect of a giant aneurysm (1), mass effect from the coil ball (2), coil migration (2), and coil protrusion with embolic event (1). The coils were removed at the time of surgery from 9 of 11 aneurysms before clipping. In two cases it was possible to place a clip across the neck of the aneurysm without removing the coils, as the coils no longer occupied the neck. There were two permanent deficits directly related to the endovascular procedures. Two other patients who presented with subarachnoid hemorrhage had residual neurological deficits post surgery and one patient with a giant aneurysm had persistent visual loss. CONCLUSION: Surgery remains a viable option at any time for treating aneurysms that have been previously treated by GDC placement. The operative approach is determined by the need for coil removal and the duration since coiling.

Adolescent↗
PubMed2000

Techniques of coiling cerebral aneurysms.

BACKGROUND: More than 200 aneurysms have been coiled at the UIC Medical Center within the last 5 years. We describe in detail the technical factors that increase the chance of complete occlusion of a cerebral aneurysm with coils. Aneurysms selected for coiling have good geometry or are in a location that is difficult to reach surgically. Patients with medical conditions that preclude surgical treatment may also undergo coiling. METHODS: Patients with aneurysms, either ruptured or unruptured, are treated under general anesthesia, fully anticoagulated and deeply paralyzed. Coiling is done under simultaneous biplane roadmapping. After the first coil has created a mesh, the aneurysm is densely packed with soft coils of decreasing diameter, until no more coils can be deployed into the aneurysm. RESULTS: The morbidity and mortality rates associated with the coiling procedure have continuously decreased over the last 5 years. The morphological outcomes have improved, due to extensive use of the remodeling technique and to advancements in materials, such as refinements in the coils themselves or the availability of over-the-wire balloon catheters in different sizes and hydrophilic wires with complex tip configurations. Twenty-one percent of the aneurysms were considered to be incompletely occluded immediately after coiling. Of this group, one-third of the aneurysms were found to be completely occluded on follow-up angiograms by 6 months; these have remained occluded. One-third were more than 95% occluded after the coiling procedure; in these patients, the dome was completely occluded, but there was a small neck remnant, which has remained stable in all patients on control angiograms obtained at 6 months and 1, 2, and 4 years; none have rebled. These patients are followed medically. The remaining one-third of the aneurysms in this subgroup were less than 95% occluded, although the dome was completely thrombosed. None of them have rebled, but the neck remnant in most has regrown over a period ranging from 6 months to 2 years. These patients have undergone a second treatment-either surgical clipping, permanent occlusion of the parent vessel, or repeat coiling using the remodeling technique. The overall rebleeding rate of incompletely occluded aneurysms is extremely low (less than 1%). CONCLUSION: The low morbidity and mortality rates and the good morphological outcome obtained in most cases make coiling a reasonable alternative to surgical clipping in properly selected cases.

Embolization, Therapeutic↗
PubMed2000

Role of magnetic resonance imaging and diagnostic and interventional angiography in vascular and neoplastic diseases of the skull base associated with vestibulocochlear symptoms.

There are many vascular and neoplastic diseases as well as normal variants that produce the vestibulocochlear symptoms of pulsatile tinnitus, hearing loss, dizziness, and ataxia. Magnetic resonance imaging may be diagnostic, and magnetic resonance angiography/magnetic resonance venography have added to the ability of magnetic resonance to image vascular abnormalities. The extent of neoplasms is accurately assessed and complication of vascular lesions are clearly seen. However, detailed vascular anatomy requires high-quality selective angiography. This enables optimal treatment planning. Endovascular therapeutic intervention has a major role to play in conjunction with surgery of skull base lesions and may be curative in certain conditions, avoiding major surgical procedures. The interventionalist, however, must have an excellent knowledge of the external carotid circulation and all of its potential communications with the internal circulation to avoid serious embolic complications.

Angiography↗
PubMed2000

What percentage of surgically clipped intracranial aneurysms have residual necks?

OBJECTIVE: To determine the angiographically proven rate and persistence of occlusion of intracranial aneurysms after surgical clipping as reported in the literature. This should establish a basis for comparing surgery with new endovascular methods of treatment. METHODS: We reviewed the literature published during the period from 1979 through 1999, dividing the articles into two groups. The first group of articles reported patients undergoing surgical treatment with immediate postoperative angiography. The second group of articles documented symptomatic recurrence or regrowth of aneurysms that were surgically treated previously. The data from these articles are presented for analysis. RESULTS: During the period 1979 to 1999, six series of patients undergoing surgical treatment of aneurysms with immediate postoperative angiography were reported. These reported series comprised a total of 1,397 patients, of whom 1,370 underwent postoperative angiography demonstrating 1,569 clipped aneurysms. Residual filling was found in 82 aneurysms (5.2%) on postoperative angiography. Of the 1,370 patients, only 124 patients with 169 aneurysms were reported to have had any long-term angiographic follow-up. The second group consisted of 226 patients representing six reported groups of patients, who either presented up to 24 years after aneurysm clipping with recurrent symptoms of hemorrhage or mass effect, or had important findings on intraoperative and postoperative angiograms. CONCLUSION: The lack of information regarding both the frequency of residual filling or regrowth and long-term angiographic follow-up of patients with surgically treated aneurysms makes meaningful comparison between surgical treatments and new treatment methods for intracranial aneurysms difficult or impossible. Detailed analysis with high-quality angiography should be performed to determine the success of surgical treatment.

Cerebral Angiography↗
PubMed2000

The remodeling technique of balloon-assisted Guglielmi detachable coil placement in wide-necked aneurysms: experience at the University of Illinois at Chicago.

OBJECT: Reports in the literature have offered discussions of the feasibility, efficacy, and safety of balloon-assisted Guglielmi detachable coil (GDC) placement in wide-necked intracranial aneurysms, which was first described by Jacques Moret as the "remodeling technique." In this article the authors summarize their results in a subset of aneurysms treated with GDCs using the remodeling technique. METHODS: This report contains a retrospective analysis of 72 patients with 75 aneurysms who underwent 79 endovascular procedures performed using the remodeling technique. Morphological outcome was determined at the end of each procedure and by reviewing available follow-up angiograms. Clinical assessments and outcomes are reported using a modified Glasgow Outcome Scale. Coils were placed in 66 (88%) of 75 aneurysms selected for treatment. In eight aneurysms (11%) treatment failures occurred due to the tortuosity of the vessel used to reach the aneurysms or because of balloon inadequacies. Incorporating all available follow-up data the authors found that 50 (78%) of 64 aneurysms were completely or subtotally (> 95%) occluded and eight (12%) of 64 were incompletely (< 95%) occluded. Since the time of coil placement, eight aneurysms have progressed to complete occlusion and another five have exhibited progressive thrombosis on follow-up angiograms. In three aneurysms there has been neck remnant growth. Surgical clipping was performed to treat six aneurysms after an initial coil placement procedure. Permanent incidences of morbidity were limited to four patients and there were three deaths directly related to the procedure. CONCLUSIONS: The remodeling technique shows promise in increasing the number of cerebral aneurysms amenable to treatment by endovascular coil placement, and offers an alternative approach to aneurysms that have met with failed surgical treatment or are surgically inaccessible. Long-term follow-up review is needed to determine the final outcome of aneurysms treated by this technique.

Adult↗
PubMed1998

Selection of cerebral aneurysms for treatment using Guglielmi detachable coils: the preliminary University of Illinois at Chicago experience.

OBJECTIVE: We present our initial experience with Guglielmi detachable coils (GDCs). The aim of this study was to determine the criteria for aneurysms, ruptured or unruptured, that are suitable for this technique. The importance of aneurysm geometry and its impact on the final results are discussed. METHODS: A retrospective analysis of 329 patients with 339 cerebral aneurysms that were treated at the University of Illinois Hospital at Chicago from May 1994 to June 1997 was conducted. One hundred eighty-five patients were treated surgically, and 144 were selected for treatment using GDCs. Of the 144 patients selected for GDC treatment, 55 patients with 55 aneurysms were admitted during the acute phase of subarachnoid hemorrhage and 89 patients with 97 aneurysms had nonruptured aneurysms or were treated after clinical recovery of previously ruptured aneurysms. All procedures were performed with the patients under general anesthesia and with systemic heparinization using live simultaneous biplane roadmapping, with the exception of the first four patients. These patients were treated before the installation of the biplane system. The percentage of aneurysm occlusion was determined at the end of each procedure. Follow-up angiography was scheduled to be performed at 6 months, 1 year, and 2 years after treatment. PATIENT SELECTION: For the initial 25 patients (Group 1), selection for coiling was restricted to nonsurgical candidates or patients in whom coiling was thought to be the best treatment choice, based on medical condition and location of the aneurysm. The geometry of the aneurysm was not considered to be an important factor in the selection for coiling. The remaining patients (Group 2) were selected for coiling based on aneurysm geometry, as determined by pretherapeutic angiography. Aneurysms that were considered to be favorable for coiling included those that had a dome-to-neck ratio of at least 2 and an absolute neck diameter less than 5 mm. RESULTS: The initial 25 patients (Group 1) were treated from May 1994 to February 1995. There were high morbidity and mortality rates, with 56% of the treated aneurysms occluded at 6 months. The remaining patients (Group 2) consisted of 119 patients with 123 aneurysms. There was no mortality directly related to the coiling procedure, and permanent morbidity was limited to 1.0%. Three patients (2.5%) developed transient neurological deficits secondary to the procedure, and seven patients (5.8%) experienced periprocedural complications that did not result in neurological sequelae. The morphological results were strongly correlated to the geometry of the aneurysms, with a complete occlusion rate of 72% among the acutely ruptured aneurysms and 80% among the nonacute aneurysms, when patients were selected for treatment based on the geometry of the aneurysms and the dome-to-neck ratio was at least 2. The occlusion rate dropped to 53% when selection was not based on aneurysm geometry and the dome-to-neck ratio was less than 2. A summary of the morphological outcomes for the Group 2 patients shows that 86% of the aneurysms that initially underwent coiling using GDCs were completely occluded (78% by coils alone, 3.0% in conjunction with surgery, and 5.0% with parent artery occlusion). Residual small neck remnants were present in 11% of the Group 2 aneurysms (3.0% were scheduled for surgical treatment of residual neck remnant growths not amenable to further endovascular treatment, and 8% were scheduled for initial 6-mo follow-up examinations). Death resulting from unrelated causes before initial follow-up occurred in 3.0% of the patients. CONCLUSION: These preliminary results suggest that using GDCs is a safe technique resulting in low morbidity and mortality rates for the treatment of intracranial aneurysms in appropriately selected patients. The percentage of complete aneurysm occlusion is related to the density of coil packing, which is strongly dependent on the geometry of the aneurysm. Optim

Acute Disease↗
PubMed1998

Aneurysm geometry: an important criterion in selecting patients for Guglielmi detachable coiling.

The study was aimed determine the criteria for treating cerebral aneurysms, ruptured and unruptured, suitable for endovascular Guglielmi detachable coiling (GDC) with least morbidity and mortality. We will discuss the importance of knowledge of the geometry of cerebral aneurysm and its impact on the results of coiling. We have treated 324 patients with cerebral aneurysms at the University of Illinois Hospital from May 1, 1994 to June 1997. During this period 139 patients were treated with GDC and 185 patients were treated surgically. Of 139 patients treated with coils 54 patients with 54 aneurysms were ruptured and the remaining 85 patients with 90 aneurysms were unruptured. For initial 25 patients, the selection of aneurysms for coiling was random and the geometry of the aneurysm was not considered as an important factor in the selection for coiling, however, in the later series of 114 patients with 119 aneurysms were selected for coiling only when the geometry looked favorable in the angiogram. With time we realized that the dome/neck ratio more than or equal to 2/1 and the diameter of the neck not exceeding 5 mm were most suitable for coiling. The initial series of 25 patients (May 1994 to February 1995) treated without taking geometry of the aneurysms as an important criteria for coiling led to high morbidity and mortality and less than 50% of these aneurysms were angiographically occluded at 6-month follow-up. In the second series of 114 patients (March 1995 to June 1997) with 119 aneurysms we had 0% mortality related to the coiling and only 1.8% permanent morbidity. We found complete aneurysm occlusion in 78% of the subarachnoid hemorrhage and 76% of unruptured group when the dome/neck ratio was more than or equal to 2/1. However, the occlusion rate dropped to 50% when the dome/neck ratio was less than 2/1. This preliminary experience suggests that GDC is a safe technique with low mortality-morbidity for the treatment of intracranial aneurysms in appropriately selected patients. The percentage of complete occlusion of the aneurysm following tight and dense packing is strongly dependent on the geometry of the aneurysm and we conclude that the best results are achieved when the dome/neck ratio is more than or equal to 2/1.

Adult↗
PubMed1998

Management of pericentral arteriovenous malformations.

Pericentral arteriovenous malformations (AVMs) have more often been deemed inoperable lesions because of their complexity, owing to their critical locations and dismal outcome. This study discusses the management of this group of patients with a variety of treatments which includes surgery, nidus embolization, and radiosurgery. Out of 89 patients treated for AVMs in our institute over a period of 30 months (1992 through May 1995), we present a case series of 34 patients who had AVMs located in the pericentral region. All the treated AVMs were Spetzler and Martin grade III (6 patients), grade IV (13 patients), and grade V (15 patients). The neurological outcome remained, normal or improved from baseline in 68% of patients following treatments; of the remaining 32%, 19% remained in the same condition (with continuing preoperative deficits) and 10% showed some deterioration from their pretreatment condition. Thus 87% were unchanged or improved after the treatment regime. There was a 3% mortality (one patient who died as result of initial hemorrhage) in the series. Our multimodality treatment for this group of AVMs confirms the efficacy of the practiced strategies for their management. The results derived from the experience with this selected group of patients with AVMs lead us to recommend treating these patients with multimodality regimen rather than awaiting the natural history of the disease in the best interest of the patients.

Adolescent↗
PubMed1997

Embolization of the nidus of brain arteriovenous malformations with n-butyl cyanoacrylate.

OBJECTIVE: To demonstrate that nidus embolization of brain arteriovenous malformations (AVMs) with Histoacryl (B. Braun, Melsungen, Germany) is effective and yields low morbidity and mortality rates. METHODS: We present a retrospective analysis of 54 brain AVMs treated at the University of Illinois at Chicago from April 1994 to December 1995. Treatment modalities included embolization in all cases and then surgical resection or radiosurgery. INSTRUMENTATION: The nidus was reached with the combined use of a Magic microcatheter (Balt, Montmorency, France) and a Terumo 0.010-inch guidewire. TECHNIQUE: Embolization was performed only when the tip of the microcatheter was wedged into the nidus of the AVMs with no reflux of contrast proximally. The embolization was performed using simultaneous biplane roadmapping with the patient under general anesthesia without Amytal testing. RESULTS: Twenty-six of 54 patients are still waiting for more radical treatment. Two deaths and two minor and one severe permanent neurological deficit occurred. Three patients were cured with embolization alone; 11 patients were cured after surgical resection. Three patients underwent radiosurgery, with one cure after 1 year. CONCLUSION: Nidus embolization with Histoacryl is an effective technique that permits complete cure of a large number of brain AVMs, with or without surgical resection and/or radiosurgery.

Adolescent↗
PubMed1997

Arteriovenous malformation nidus catheterization with hydrophilic wire and flow-directed catheter.

Arteriovenous malformation nidus catheterization with a flow-directed catheter at times can be difficult owing to tortuosity of the intracranial vasculature and distal location of the nidus. Since January 1995, hydrophilic wire has been used in conjunction with the 1.8F flow-directed microcatheter in over 150 vessel embolizations with cyanoacrylate glue for brain and spinal arteriovenous malformations at our institution. This technique has improved our success rate in achieving superselective catheterization of the nidus and has shortened the overall procedure time. To date, only one complication has occurred that was directly related to wire manipulation.

Adult↗
PubMed1996

Transcranial cerebral oximetry in endovascular treatment of carotid-cavernous fistula.

The transcranial cerebral oximeter is a reliable, low-cost, noninvasive device that provides real-time evaluation of regional brain oxygen saturation during endovascular treatment of cerebrovascular diseases. We discuss three patients with carotid-cavernous fistulae treated by endovascular balloon occlusion, each monitored continuously before, during, and after the procedure with transcranial cerebral oximetry. The cerebral oxygen saturation measured was directly related to the side of the venous drainage of the fistula, being 15-20% higher on that side. Following endovascular occlusion of the fistula, oxygen saturation gradually became equal on the two sides.

Adult↗
PubMed1996

Three cases of spontaneous direct carotid cavernous fistulas associated with Ehlers-Danlos syndrome type IV.

We are reporting three cases of spontaneous direct carotid cavernous fistulas (CCFs) associated with Ehlers-Danlos syndrome (EDS) out of a series of 147 direct CCFs. The internal carotid artery could be preserved in only one case. Two patients had severe bilateral irregularities of caliber of both internal carotid arteries. Two patients had recurrence of their symptoms after a first balloon was detached in the cavernous sinus (CS) necessitating a second treatment. Two patients died several months later from complications associated with their disease. The treatment of direct CCFs associated with Ehlers-Danlos syndrome is more difficult and more risky than most direct CCFs. The permanent occlusion of the ICA, which may be difficult to avoid, increases the risks of development of aneurysm on the contralateral side.

Adult↗
PubMed1996

Transverse sinus dural fistula: combined surgical and endovascular approach: a case report.

BACKGROUND: The treatment of a large dural sinus fistula can be very difficult and complicated. The very extensive and complex nature of these malformations may require a combination therapy in the form of surgery and multistaged embolization. The transverse sinus fistula in our patient was fed by multiple large high-flow feeders and was draining retrograde into the superior sagittal sinus (SSS) and the cortical veins. The SSS did not fill in the late venous phase of the carotid angiogram, suggesting increased venous pressure. METHODS: A case of transverse sinus dural fistula is described that was managed by a combination of surgery and embolization. The complex nature of this malformation encouraged us to adopt a combination of multistaged embolization and surgery for the management and clinical control. The patient underwent embolization of multiple feeders from the branches of the external carotid artery. After this procedure, the patient underwent endovascular occlusion of the transverse sinus via the SSS. Throughout the endovascular treatment, the patient had concomitant intracranial pressure monitoring and SSS pressure monitoring, along with transcranial cerebral oximetry (TCCO). Despite this aggressive endovascular intervention, the fistula could not be completely closed. The patient then underwent surgical excision of the transverse sinus along with duraplasty and cranioplasty. RESULTS: The patient had a good recovery and posttreatment angiogram revealed normal antegrade flow in the SSS with no evidence of the fistula. The combined surgical and endovascular techniques are described and their use in clinical practice is discussed. CONCLUSIONS: The complexity of certain large dural sinus fistulae should not be underestimated. They may require a prolonged multistaged treatment for their total obliteration. Also, despite the large size and complexity of the disease, complete cure can be achieved.

Adult↗