a 36-year - old man with repeatedly paroxysmal headache was admitted to our hospital . the patient suffered a severe head trauma in a car accident 21 days prior to the accident .
he was admitted to hospital with periorbital soft tissue swelling , ct scanning revealed a skull fracture in sss area . before he was transferred to our hospital , computerized tomographic angiography ( cta ) revealed vascular malformation and venous congestion of the sss , which was considered to be secondary to the trauma .
left internal carotid artery angiogram revealed a davf supplied by the anterior falx artery ( figure 1a ) .
left lateral ( figure 1b ) , anteroposterior ( figure 1c ) and right lateral ( figure 1d ) view of left external carotid artery ( eca ) angiogram showed the sss davf with bilateral cortical venous reflux .
endovascular treatment for a patient with posttraumatic dural arteriovenous fistula ( davf ) of the superior sagittal sinus ( sss ) .
a ) left internal carotid artery angiogram before embolization showing the davf supplied by the anterior falx artery ; b , c and d ) lateral ( b&d ) and anteroposterior ( c ) view of left external carotid artery ( eca ) angiogram before embolization showing the davf of sss with bilateral cortical venous reflux ; e ) unsubtracted image showing the scepter balloon catheter navigated close to the fistulous point for onyx injection ( arrow head indicating the balloon markers , arrow indicating the distal tip ) ; f ) unsubtracted image showing the onyx cast extending to the proximal draining vein after embolization ; g ) post - embolization angiogram of the left common carotid artery showing complete disappearance of the fistula .
h ) post - embolization angiogram of the right eca showing complete disappearance of the fistula .
( 415 mm , microvention , tustin , california , usa ) was placed at the most distal segment of the left middle meningeal artery ( mma ) and contrast medium was injected into the balloon .
unsubtracted image showed the scepter balloon catheter navigated close to the fistulous point for onyx injection ( figure 1e ) . in order to occlude any residual fistula , onyx-18 ( ev3 , irvine , california , usa )
was then injected through the dual lumen balloon catheter positioned in one branch of the mma .
unsubtracted image showed the onyx cast extending to the proximal draining vein after embolization ( figure 1f ) . with the balloon inflated , a total of 1.2 ml of onyx-18 was delivered with thorough penetration into the malformation slowly , after which , angiogram of both the left common carotid artery and the right external carotid artery ( eca ) showed complete disappearance of the fistula ( figures 1g - h ) .
the balloon was deflated by syringe suction without difficulty . at the end of the procedure
, the catheter was removed under constant aspiration without any noticeable adherence to the onyx cast .
discussion dural arteriovenous fistula account for 10%15% of intracranial arteriovenous malformations.6 davfs in sss are extremely rare .
a small percentage of patients have a history of previous trauma , they have been well reported.7 the common characteristic of davfs happened when a patient suffered skull fraction , or other trauma , not long after a head injury with progressive symptoms such as , exophthalmos , swelling of the eyelids , bruit , and so forth .
this scenario most likely accounts for the findings in our patient , and we believe that his davfs probably were secondary to the head injury rather than a congenital anomaly .
so far , the first - line treatment for davfs is embolization by using transarterial , transvenous , or occasionally , combined approaches.1 - 8 this approach proved to be effective comparable with davf obliteration in preventing neurologic morbidity with lower levels of procedural risk .
the use of onyx has been increasingly reported for the treatment of davfs.2 - 10 using reflux as a plug , operator creates a forward flow of onyx , which is called the  plug and push technique .
 the dual lumen balloon microcatheter served a dual purpose : the onyx-18 injection was allowed through the dual lumen balloon catheter and a mechanical barrier was provided to prevent the onyx reflux at the same time .
this technique is an option during extracranial embolic embolization in a few select cases . in this case
, a patient with a post - traumatic davf of the sss was effectively treated .
it is appropriate to select a dual lumen balloon microcatheter for complex dural arteriovenous fistulas .
using a dual lumen balloon microcatheter helps prevent onyx reflux and improves its penetration during onyx embolization of davfs .
thus , this is a feasible and effective alternative approach for the management of post - traumatic davfs .
 dural arteriovenous fistula ( davfs ) induced by trauma in the superior sagittal sinus ( sss ) are rare and difficult to treat because of their unique midline location , multiplicity of arterial feeders , and critical venous drainage . 
 we report a case of an endovascular treatment using dual lumen balloon microcatheter on a patient with post - traumatic sss davf . by the use of dual lumen scepter balloon microcatheter , proximal onyx reflux was prevented . in this case , 
 complete embolization of the davfs was achieved and the outcome of the patient was fairly good . 