A case of dural arteriovenous malformation (AVM) in the posterior fossa in the region of the transverse sigmoid sinus (TSS), which had a total of eight feeders, was reported. It required four surgical procedures until the clinical symptoms completely disappeared.
The patient was a 51-year old male who had been a professional bicycle racer for 10 years. He had hit his head many times while racing. With sudden onset, headache and tinnitus occured at the end of March, 1980. Loud bruit was heard on the left side of his neck and was the only symptom of neurological deficit. Six-vessel study showed a dural AVM in the region of the left transverse sigmoid sinus, which was supplied by (1) the middle meningeal artery, (2) the posterior meningeal branch of the occipital artery, (3) the posterior meningeal branch of the ascending pharyngeal artery, (4) the posterior auricular artery, (5) the parietal branch of the superficial temporal artery (STA) via the left external carotid artery, (6) the posterior meningeal branch of the right occipital artery via the right external carotid artery and (7) the artery of Bernasconi and Cassinari of the meningohypophyseal trunk via the left internal carotid artery. The sigmoid sinus showed marked stenosis.
First step on July 2, 1980: The left occipital artery, STA and internal maxillary artery were embolized using a detachable balloon. Bruit ceased for only five days. Second step on Aug. 12: The left external carotid artery was ligated at its origin. But bruit was not stopped by this proce-dure. Third step on Sept. 5: Left occipital and suboccipital craniectomy was performed. Separation of the periostium from the occipital bone and dural resection above and below the left transverse sinus was undertaken. The superior petrosal sinus was cut off. Bruit was stopped for three months. The posterior meningeal branches of the right occipital artery via the right external carotid artery and (8) the same branches of the left occipital artery via the left vertebral artery were still active and drained into the left TSS.
Fourth step on March 20, 1981: Left occipital and suboccipital craniectomy was done again. Ligation and cut of the transverse sinus at its origin and endpoint were performed without any cocomplications. Bruit ceased completely. Various surgical treatments have been considered for the management of TSS dural AVM. Intravascular embolization would not be sufficient and a radical procedure would be required in such a severe case, supplied not only by the ipsilateral external carotid artery, but also by the ipsilateral internal carotid and vertebral arteries and the contralateral external carotid and vertebral arteries.
