Transarterial packing of an isolated superior sagittal sinus dural arteriovenous fistula using a combined coiling and Onyx casting technique

Isolated superior sagittal sinus (SSS) dural arteriovenous fistulas (DAVFs) represent a rare subtype of DAVF. Endovascular treatment can be effective; however, this remains technically challenging. Studies on the treatment of isolated SSS DAVFs through SSS packing with combined coiling and Onyx casting are limited. Such a case is reported here. A previously healthy 55-year-old female patient presented with an epileptic attack. The physical examination was unremarkable. Computed tomography showed multiple frontal lobe calcifications. Digital subtraction angiography revealed an isolated SSS DAVF fed by the bilateral middle meningeal and superficial temporal arteries and the right anterior cerebral artery, with cortical venous drainage (Cognard III classification). Endovascular treatment was performed as follows. Initially, the microcatheter was navigated through the left middle meningeal artery and across the sinus wall defect to access the isolated SSS segment, which was subsequently packed by coiling. Thereafter, transarterial embolization by Onyx casting via the bilateral middle meningeal arteries was conducted to achieve nearly complete obliteration of the isolated SSS DAVF. The postoperative course was unremarkable, with no new neurological deficits. ‌Six-month follow-up angiography confirmed the resolution of the DAVF without epileptic events. This case demonstrates that trans-middle meningeal artery packing with combined coil embolization and Onyx casting can effectively treat an isolated SSS DAVF by using a microcatheter to traverse the sinus wall defect to access the isolated SSS segment.