Neurol Med Chir (Tokyo) 42, 217¿220, 2002

Dural Arteriovenous Fistula Involving the Superior Sagittal
Sinus Following Sinus Thrombosis
—Case Report—
Akimasa NISHIO, Kenji OHATA, Kazuyuki TSUCHIDA, Naohiro TSUYUGUCHI,
Mitsuhiro HARA, Masaki KOMIYAMA*, Takashi TSURUNO**,
and Takaho MURATA**
Department of Neurosurgery, Osaka City University Medical School, Osaka;
*Department of Neurosurgery, Osaka City General Hospital, Osaka;
**Department of Neurosurgery, Suisyo-kai Murata Hospital, Osaka

Abstract
A 57-year-old woman presented with a dural arteriovenous fistula (AVF) involving the superior sagittal
sinus (SSS) based upon serial radiological examinations. Her chief complaints were headache and
vomiting. Cerebral angiography and magnetic resonance (MR) venography revealed the sinus thrombosis involving the SSS, the bilateral transverse sinuses (TSs), and the right sigmoid sinus. Her symptoms
disappeared after anticoagulant therapy. Follow-up MR venography revealed almost complete recanalization of the occluded sinuses, followed by restenosis of the SSS and the left TS and occlusion of the
right TS without symptoms. She developed transient right hemiparesis 13 months after the initial onset. Cerebral angiography revealed a dural AVF involving the SSS with cortical reflux into the left
frontoparietal region. The dural AVF was occluded by transarterial and transvenous embolization.
Her symptom disappeared during the follow-up period.
Key words:

dural arteriovenous fistula,

sinus thrombosis,

superior sagittal sinus

Introduction

Case Report

Intracranial dural arteriovenous fistulas (AVFs) account for 10–15% of all intracranial arteriovenous
lesions in which meningeal and extracranial arteries
shunt blood directly into the dural sinuses or, less
commonly, into the meningeal or pial veins.9) Dural
AVFs usually involve the transverse-sigmoid sinus
or the cavernous sinus, but may occur in the tentorial incisura, the superior sagittal sinus (SSS), the torcular Herophili, the anterior cranial fossa, the superior petrosal sinus, and the foramen magnum.
Dural AVFs of the SSS account for 8–11% of intracranial dural fistulas.2,4) The etiology of dural
AVFs is still unclear. The present case radiologically
documents the development of dural AVF in a
patient with recurrent sinus thrombosis.

A 57-year-old woman suffered sudden onset of severe headache and vomiting in December 1998.
There was no history of trauma, previous surgery, or
medical treatment. Protein-S and protein-C levels
were within the normal ranges. Neurological examination revealed no deficits. Computed tomography
on admission revealed no subarachnoid blood.
Cerebral angiography and magnetic resonance (MR)
venography revealed occlusion of the SSS and the
bilateral transverse sinuses (TSs), and stenosis of the
left sigmoid sinus (Figs. 1 and 2A). She was treated
with anticoagulants for sinus thrombosis. Headache
and vomiting subsided within 48 hours. MR
venography 5 days after the initial onset revealed
partial recanalization of the sinuses (Fig. 2B). MR
venography in February 1999 revealed nearly
complete recanalization of the occluded sinuses
(Fig. 2C). Follow-up MR venography in August 1999
revealed restenosis of the SSS and the left TS, and
occlusion of the right TS (Fig. 2D). However, she
was asymptomatic. She had developed transient mo-

Received
2002

October 1, 2001;

Accepted

March 19,

217

218

Fig. 1

A. Nishio et al.

Right (upper row) and left (lower row) common carotid angiograms, anteroposterior
view (left column) and lateral view (right
column), on first admission showing subtotal occlusion of the superior sagittal sinus
and occlusion of the bilateral transverse
sinuses without arteriovenous shunting.

tor weakness in the limbs on the right in January
2000, but recovered completely within few minutes.
She was re-admitted for further evaluation in May
2000. Neurological examination revealed no deficits. Cerebral angiography revealed a dural AVF involving the SSS fed by the bilateral superficial temporal arteries, the frontal branches of the middle
meningeal arteries, the bilateral parietal branches of
the middle meningeal arteries, and the occipital arteries (Fig. 3). The dural AVF drained into the cortical
veins of the frontoparietal region on the left through
shunt points located in the anterior third of the SSS
and in the posterior third of the SSS.
Transarterial
embolization
with
N-butyl
cyanoacrylate was performed from the bilateral middle meningeal arteries followed by transvenous embolization of the involved SSS with interlocking
detachable coils (Target Therapeutics, Fremont,
Calif., U.S.A.). Nearly complete occlusion of the
fistula was achieved (Fig. 4). At one-year follow up,
she had no neurological problem or further episode
of transient motor weakness and follow-up an-

Fig. 2

Magnetic resonance (MR) venograms on
admission (A) showing occlusion of the superior sagittal sinus (SSS) and the bilateral
transverse sinuses (TSs), and stenosis of the
left sigmoid sinus, and 5 days later (B) showing partial recanalization of the sinuses.
Follow-up MR venograms 2 months after
admission (C) showing almost complete
recanalization of the occluded sinuses, and
8 months after admission (D) showing restenosis of the SSS and left TS, and occlusion
of the right TS.

giography showed no remarkable change.

Discussion
Serial radiological studies demonstrating the evolution of dural AVF are rare. Previously, five case
reports have included angiographic demonstration
of sinus occlusion prior to the development of dural
AVF.1,6,7) Initial angiography demonstrated occlusion of a dural sinus prior to subsequent angiographic demonstration of a typical dural AVF in the same
or an immediately adjacent sinus in three cases.6,7)
Angiography performed prior to and soon after head
injury revealed no evidence of dural AVF whereas
follow-up angiography demonstrated typical dural
AVF in two cases.1)
Serial angiography in our case showed that sinus

Neurol Med Chir (Tokyo) 42, May, 2002

Dural AVF After the Sinus Thrombosis

Fig. 4

Fig. 3

Right external carotid angiograms, anteroposterior view (A) and lateral view (B),
on second admission 17 months after the initial onset showing a dural arteriovenous
fistula (AVF) involving the superior sagittal
sinus (SSS) fed by the middle meningeal artery, the occipital artery, and the superficial
temporal artery with cortical reflux into the
frontoparietal region on the left, occlusion
of the right transverse sinus (TS), and stenosis of the left TS, with two shunt points
(arrows). Left external carotid angiograms,
anteroposterior view (C) and lateral view
(D), also showing the dural AVF involving
the SSS fed by the middle meningeal artery
and superficial temporal artery with the
same shunt point (arrow) as seen in the right
external carotid angiograms.

thrombosis preceded the development of dural AVF
and follow-up MR venography a few days after the
initial onset showed recanalization probably due to
the increase of secondary fibrinolysis. Thereafter,
sinus thrombosis occurred again possibly resulting
in long-standing venous hypertension and then
dural AVF development.
Possible etiologies of sinus thrombosis include infection, head trauma, Behçhet's disease, oral contraceptives, lupus erythematosus, antithrombotic III
deficiency, carcinoma, nephritic syndrome, and
protein-S or protein-C deficiency, but our patient
had no known cause of sinus thrombosis. The etiolo-

Neurol Med Chir (Tokyo) 42, May, 2002

219

Left common carotid angiogram after the
embolization showing nearly complete occlusion of the fistula, but a minimal shunt
persisting in the anterior portion of the
superior sagittal sinus (SSS) fed by the falx
artery draining into the SSS anteriorly
without cortical reflux.

gy of dural AVF is unclear, although many cases
have been associated with sinus occlusion and/or sinus stenosis. Sinus thrombosis may not always lead
to the development of dural AVF, whereas venous
hypertension may be an essential condition for the
formation of dural AVF.5,10)
Treatment of dural AVFs includes oral drug therapy, direct surgical resection or isolation of the involved sinus, and endovascular treatment.3,4) The involved sinuses may be part of the normal drainage
route, even if only marginal. In this situation, total
resection or total occlusion of the sinus could result
in venous infarction. Therefore, feeder embolization, feeder coagulation, or occlusion of shunt site
should be performed if the sinus is patent.8) If the involved sinus does not participate in normal venous
drainage, total resection or total occlusion can be
safely performed. Normal cortical venous flow may
drain via the sinus wall rather than the sinus. In this
situation, endovascular occlusion of the involved sinus should be performed safely with preservation of
drainage in this sinus wall because total resection of
the involved sinus including the sinus wall will
cause venous infarction. The involved SSS was not
part of the normal drainage route in our case, so we
selected embolization of the involved SSS. This case
indicates that patients with sinus thrombosis should
be followed up to detect the development of dural
AVF.

A. Nishio et al.

220

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Address reprint requests to: A. Nishio, M.D., Department
of Neurosurgery, Osaka City University Medical
School, 1–4–3 Asahi–machi, Abeno–ku, Osaka
545–8585, Japan.
e-mail: m3275727＠med.osaka-cu.ac.jp.

Neurol Med Chir (Tokyo) 42, May, 2002