Direct sinus packing of dural arteriovenous fistula at torcular herophili: A case report and review of the literature

A 65-year-old male with a past history of superior sagittal sinus thrombosis, presented 6 years later with general convulsions. On admission, he displayed dementia (HDS-R score of 13) and left hemiparesis. A computed tomography (CT) scan revealed a subcortical hemorrhage at the right temporal lobe. Angiography revealed a dural arteriovenous fistula (DAVF) at the torcular herophili. The bilateral transverse sinus and superior sagittal sinus distal to the fistula were occluded and there was retrograde venous drainage through the straight sinus to the basal vein of Rosenthal. Transarterial embolization (TAE) was performed for the bilateral middle meningeal artery and occipital artery. After the TAE, general anesthesia was induced in the patient and direct sinus packing using portable digital subtraction angiography (DSA) was performed successfully. Postoperative angiography showed the complete obliteration of the DAVF and the HDS-R score improved to 28. Direct sinus packing is a significant and effective treatment for DAVF's that empty into the isolated sinus.