Adaptive Multimodal Management of Tentorial Dural Arteriovenous Fistula: Cure Achieved via Transvenous Embolization following Transarterial Embolization and Stereotactic Radiosurgery: A Case Report.

Objective: Tentorial dural arteriovenous fistula (TDAVF) is a rare subtype of DAVF, and most cases are classified as Borden type III. Due to its aggressive clinical course, therapeutic intervention is frequently required. Treatment modalities include endovascular therapy, direct surgical intervention, and stereotactic radiosurgery. While cases with a simple vascular architecture may be curable with a single treatment modality, a multimodal approach is often needed for those with a complex vascular structure. However, a standardized treatment strategy has yet to be established. Case Presentation: A 63-year-old male patient presented with mild neurological symptoms, but had TDAVF with a large venous varix compressing the brainstem and multiple arterial feeders. Despite undergoing transarterial embolization, direct surgical disconnection, and stereotactic radiosurgery, complete obliteration was not achieved. After shunt flow decreased and the venous varix shrank, transvenous embolization (TVE) was performed, ultimately resulting in the disappearance of TDAVF. Conclusion: The direct surgical interruption of the draining vein has traditionally been performed for TDAVF with a large venous varix. However, when adjacent normal veins preclude the disconnection and an accessible dural sinus is not present, TVE is not the preferred 1st-line option. TVE via the varix or deep veins, combined with flow reduction, may still be a viable alternative for these cases when other treatments are not feasible.