Acute Sinus Recanalization for the Urgent Treatment of an Isolated Transverse-sigmoid Sinus Dural Arteriovenous Fistula with Hemorrhagic Presentation: Case Report.

Dural arteriovenous fistula can present with cerebral venous sinus thrombosis and retrograde leptomeningeal venous drainage. Given the associated intracranial hemorrhage risk, immediate retrograde leptomeningeal venous drainage obliteration is desirable. Herein, we report a case of dural arteriovenous fistula with acute cerebral venous sinus thrombosis and intracranial hemorrhage that was successfully managed using sinus thrombectomy alone. A 76-year-old woman was admitted to our hospital with a sudden headache. Radiological assessments showed a subarachnoid hemorrhage in the left cerebellopontine cistern, Borden type III (Cognard type III) dural arteriovenous fistula with cerebral venous sinus thrombosis in the left transverse-sigmoid sinus, and retrograde leptomeningeal venous drainage in the superficial middle cerebral vein, the vein of Labbé, and the petrosal vein. To prevent re-bleeding, we performed an acute thrombectomy of the transverse-sigmoid sinus, aiming to obliterate retrograde leptomeningeal venous drainage. Following the procedure, the dural arteriovenous fistula was downgraded to Borden type I (Cognard type IIa). In this case, a simple thrombectomy alone prevented the re-bleeding of a dural arteriovenous fistula without direct fistula access. Understanding the relative contributions of the fistula and cerebral venous sinus thrombosis to retrograde leptomeningeal venous drainage in transverse-sigmoid sinus dural arteriovenous fistula is essential for refining the treatment strategy. Sinus thrombectomy is a tentative treatment, and this strategy is the emergency procedure to reduce re-bleeding risk. However, it may be a viable approach to prevent re-bleeding by improving venous outflow in dural arteriovenous fistula cases complicated by acute cerebral venous sinus thrombosis and intracranial hemorrhage.