Demonstration of physiologic, clinical and angiographic improvement of dural arteriovenous fistula via primary transverse sinus stenting.

A healthy, middle-aged man presented with acute on chronic progressive photophobia, headache and visual impairment. Clinical workup demonstrated advanced papilledema, tortuous optic nerves, flattened globes and intracranial pressure of >55 cm H2O. Diagnostic cerebral angiogram demonstrated a Cognard IIA tentorial dural arteriovenous fistula (dAVF) associated with transverse sinus stenosis. Venous manometry demonstrated a pressure gradient of 28 mm Hg across the stenosis. Given acute symptoms of elevated intracranial pressure and significant functional gradient, venous sinus balloon angioplasty and stenting were performed, which resulted in near resolution of functional gradient, immediate improvement of symptoms and resolution of retrograde venous flow, thus downgrading his dAVF to Cognard I. At 3-month follow-up, angiographic improvement in dAVF grade was maintained, with durable improvement in papilledema and headaches.