Flow control-assisted transarterial embolization of a high-flow superior sagittal sinus dural arteriovenous fistula: An illustrative case.

BACKGROUND: Dural arteriovenous fistulas (DAVFs) with high-flow shunts pose a technical challenge for transarterial embolization (TAE) because a pronounced arteriovenous pressure gradient can limit penetration of liquid embolic agents and increase the risk of reflux or nontarget embolization. Flow control has been proposed as an adjunctive strategy to address these challenges in selected cases. CASE DESCRIPTION: A 66-year-old man presented with cognitive decline. Cerebral angiography demonstrated a high-flow superior sagittal sinus DAVF (SSS-DAVF) supplied by multiple bilateral external carotid and ophthalmic artery branches, with cortical and deep venous reflux. Given the presence of venous congestion and cortical venous reflux, treatment was indicated because of the associated hemorrhagic risk. TAE using Onyx was performed under flow control achieved by bilateral external carotid artery balloon occlusion, allowing controlled delivery of the embolic agent. CONCLUSION: Flow control-assisted TAE enabled effective obliteration of a high-flow SSS-DAVF by mitigating the adverse arteriovenous pressure gradient. Selective use of flow control may improve the safety and reliability of TAE in carefully selected high-flow DAVF cases.