• Yusuke Iki, Yoichi Morofuji, Chika Somagawa, Susumu Yamaguchi, Jumpei Hamabe, Nobutaka Horie, Tsuyoshi Izumo, Kazuhiko Suyama, and Takayuki Matsuo.
• Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan. Electronic address: yusuke.nagasaki1119@gmail.com.
• World Neurosurg. 2020 May 1; 137: 18-23.

BackgroundCavernous sinus dural arteriovenous fistulas (CS dAVFs) occasionally behave aggressively (e.g., intracranial hemorrhage, venous infarction, seizures) depending on the drainage flow and presence of a collateral route of cortical or basal cerebral venous drainage. When a CS dAVF with aggressive behavior is encountered, a radical cure is required to avoid catastrophic deficits. However, conventional transvenous cavernous sinus (CS) embolization via the inferior petrosal sinus does not always achieve shunt obliteration. We herein report a case of surgical venous drainage disconnection in an 83-year-old woman with a CS dAVF.Case DescriptionThe patient presented with coma and anisocoria due to intracranial hemorrhage. Because of the patient's critical condition, we had no choice but to perform emergency decompressive craniectomy and hematoma evacuation without detailed preoperative hemodynamic information obtained by digital subtraction angiography. Postoperative digital subtraction angiography showed a CS dAVF with retrograde venous drainage of the deep middle cerebral vein (DMCV) and varix formation in the affected DMCV, causing hemorrhagic episodes. Five days after admission, the patient's neurologic state worsened because of rebleeding from the varix, which had increased in size. The percutaneous transvenous approach failed because of compartmentalization within the CS. Open surgery was performed; the deep vasculature was exposed by the transsylvian approach, and the arterialized DMCV was permanently clipped at its proximal segment with disconnection from the venous varix and fistulous point. Shunt obliteration was successfully achieved.ConclusionsSurgical venous drainage disconnection from the fistulous point may be an alternative radical therapy for CS dAVFs with aggressive behaviors.Copyright © 2020 Elsevier Inc. All rights reserved.

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